2019 November Osce

Question 1

A 29 old woman present with swelling in her anterior neck. Her Lab investigation was as follows TSH =0.1 normal (4-9) T3 =9 normal(2-7) T4 =279 normal (40-90). mention two differential diagnosis

Answer 1

Grave’s disease

Toxic Adenoma

Question 2

Mention three symptoms the patient might present with

Answer 2

Weight loss

Heat intolerance

Excessive sweating

Question 3

Mention 3 clinical sign that might be present in the patient

Answer 3

Exophthalmos

Palmar erythema

Acropachy

Question 4

Mention two surgical options for this patient

Answer 4

Thyroidectomy

Lobectomy

Question 5

A primipara present with 26 weeks cyeisis. Take a detail focus history.

Answer 5

Greetings

Introduction

Take consent

Establish rapport

Language

Biodata - NASTROMA-L

Reproductive profile:
Gravity-How many times have you been pregnant whether you deliver the baby or not?

Parity-How many pregnancy have you carried pass 28 weeks?

LMP-When was your first day of last menstrual period?

Last confinement -When did you gave birth to your last child?

Presenting Complaint:
Ask her what brought her to the hospital.

History of index pregnancy
Is this your first booking or routine antenatal visit?

Is the pregnancy planned or not?

When, where and how was the pregnancy confirmed?

Is this assisted conception like IVF or not?

Indications for booking:
1#Enquire for pregnancy symptoms:

Do you have early morning nausea and vomiting?

Is your breast full and tender?

Do you have increased frequency of urination?

What about weird cravings and mood swings?

Do you feel tired throughout the day?

Have you gained weight?

Do you have vaginal discharge?

Can you feel fetal movements?

2#Investigations: as for routine visit ask if she has done some test and show you the result.

As for the patient doing her booking let her know that she will be doing these tests:

Ultrasound (1st trimester)

PCV (Anemia)

HIV screening

Hepatitis B& C test

Venereal disease research laboratory test (VDRL)

Blood group - rhesus compatibility

Genotype

Urinalysis

RBS (diabetes)

Malaria parasite test (Malaria)

Weight /height

Blood pressure

3# Treatment: as for routine visit ask the patient if she has been taking her medicine.

As for the patient booking tell her you will be giving her:

Routine antenatal drugs (Fersolate, multivitamins, folic acid)

Ask about shot of Tetanus Toxoid (TT)

Ask about intermittent preventive therapy for Malaria (fansidar)

Enquire about other drugs the woman is taking like oral hypoglycemic drugs, anti hypertensive, anticonvulsants.

Past obstetric history-at least 2 questions each
Antenatal:

Were you booked for antenatal care in your previous pregnancies?

Were you treated for Malaria?

Did you carry all pregnancies to term?

Have you had any miscarriage or preterm delivery?

Natal:

Were the labor spontaneous or induced?

Were the labor prolonged or not?

Were your previous pregnancies delivered by you pushing the baby out or did the drs cut and delivered your baby?

Was their any complications in your previous deliveries like excessive bleeding or injury to the baby or giving birth to a baby who is not alive?

Postnatal:

Was their any complications after delivery like excessive bleeding?

Birth weight and sex of the children?

How long were you admitted in the hospital afterwards?

Any complications so far as regard to the children?

How many are alive and how many have passed away?

How many of them did you exclusively breastfed?

Gynaecological history-ask at least 5 questions
At what age did you start your menstrual period?

What is the average duration of your period and cycle length? Is it 28 or 30 days cycle?

Have you been experiencing any irregular periods?

Any excessive menstruation or scanty flow?

Any pain during menstruation or during sex?

Do you know about contraceptives? Have you ever used any?

Have you had any abortion? What were the outcomes and any complications?

Do you know about pap smear? When was the last time you had pap smear done?

Do you have any history of STD?

Past medical & Surgical history: Diabetes, Asthma, epilepsy, Tuberculosis, HTN
Family history: Diabetes, HTN, Epilepsy
Social History
Drug and allergy history
Review of system - at least 2 from each

Question 6

List 10 endemic diseases in Nigeria

Answer 6

Malaria,
Lassa fever,
typhoid,
Tuberculosis,
polio,
HIV,
Gonorrhoea,
Schistosomiasis,
yellow fever,
Cholera

Question 7

Which ones are vaccine preventable?

Answer 7

Malaria,
Polio,
Tuberculosis
, Typhoid,
Yellow fever,
Cholera

Question 8

Apply the level of prevention to Malaria

Answer 8

General health promotion
Educate the masses using TV/radio, seminars (community and service provider partnership) that malaria is an endemic caused by plasmodium species, transmitted by female anopheles mosquito, risk factors living in riverine areas/close to bushes, stagnant water, sleeping without insecticide treated nets)

Specific prophylaxis
Mosquirix vaccine

Proguanil (Sickle Cell Disease Patients)

Sulfadoxine-Pyrimethamine (for pregnant women)

avoid risk factors, good hygiene and sanitation, clearing of grasses, use of IT, do away with stagnant water, mosquitoes.

repellants

Early diagnosis and prompt treatment
Screen for symptoms: intermittent fever, nausea, chills, rigors, vomiting, malaise Investigations: rapid diagnostic test, thick and thin test, quantitative buffy coat test Treatment: artemisinin-based combination therapy

ACT (arthemeter+ lumefantrine),

antipyretics

Limiting disability
Ensure compliance with drugs, anticonvulsants (seizures), IV Artesunate (severe malaria), antipyretics, rehydration therapy (oral/IV),

Blood transfusion (anemia), antibiotics (infections)

Rehabilitation
Psychotherapy, physiotherapy, vocational therapy, family and guidance support, nutritional support review by specialist

Question 9

List 6 childhood killer diseases

Answer 9

Measles,
Pertussis,
Poliomyelitis,
diphtheria,
Tetanus,
Tuberculosis

Question 10

Which one has been eradicated

Answer 10

Small pox

Question 11

Which is about to be eradicated

Answer 11

Polio

Question 12

List the NPI immunization schedule in Nigeria

Answer 12

At birth: BCG / OPV0 / Hep B

6 weeks: Pentavalent1 (DPT, Hep B, hemophilus influenza type B) / PCV1 / 0PV1 /Rota1

10 weeks: Pentavalent 2/ PCV2 / OPV2 / Rota 2

14 weeks: Pentavalent 3/ PCV3/ OPV3/ IPV

6 months: Vit A 1st dose (100,000IU)

9 months: Measles 1/ Yellow fever / meningitis

15 months: Vit A 2nd dose (200,000IU) / Measles 2

Question 13

A 5 year old present with fever diarrhea and vomiting for 5 days . Mother complain that he was unable to pass urine for the past 2 days . His Lb investigation are as follows ;Na=120 k=6.9 cl =97 urea =8 creatinine =279 full blood count , PCV=23% wbcs =18000 neutrophils=74% esoniphols =2% monocytes =4% lymphocytes =20% . Mention 6 abnormalities from the lab investigation.

Answer 13

Low Na,
high k,
Urea based on the unit could high or normal,
high Creatinine,
low PCV,

Question 14

Which among them is the most threatening to the patient’s life.

Answer 14

Hyperkalemia

Question 15

What is the most likely diagnosis?

Answer 15

Acute Kidney Injury

Question 16

A 25 year old nuliparous woman wants to undergo a fibroid surgery. Counsel her.

Answer 16

Greet examiner, Greet patient

Introduce self

Take/obtain consent: (Like sir/ma I have been asked to counsel you on your condition, can I proceed or do I have your permission etc.)

Establish a rapport: sir/ma how are you today? Don’t worry everything will be alright. We are here for you and we will do our best to see that you are well managed.

Biodata: NASTROMA-L (For a female patient add reproductive profile) Please what’s your name, age, are you married, occupation, your religion, where do you live, tribe and level of education.

Setting: Please ma/sir is English your preferred language, is it okay for us to continue? Are you comfortable talking to me? Is the environment comfortable for you? Do you need anybody to be here with you?Do you need a glass of water?

Confidentiality: I want to assure you that whatever we discuss will strictly stay between us, so I want you to feel free to talk to me.

Ask:Ma/Sir, please do you know why you are here? What do you know about uterine fibroid? Okay, I will enlighten you a bit on why we are having this session. You have been diagnosed of this and I know it not an easy news to take but I want you to know that knowing more about this and getting treated on time will be the best for you and we want the best for you.

Tell:

Myomectomy is the surgical procedure to remove fibroid from the womb.

Fibroid is a non-cancerous growth in the womb.

Physiopathology: It is the most common non-cancerous growth in women of reproductive age because of estrogen production.

Risk factors : Black race, women who hasn’t given birth before, family history, previous history, drugs(OCPs, tamoxifen), obesity etc

Reasons for removal of fibroid:

To relieve Pelvic pain

To reduce heavy menstrual bleeding

To stop irregular bleeding

To stop pressure symptoms like frequent urination, difficulty passing stool, loose stool etc

To give a proper pregnancy outcome

I will suggest we do myomectomy because you might want to give birth in the future. Is that OK with you Ma?

Types of myomectomy :

Abdominal myomectomy is when a surgeon cut the abdomen to remove fibroid. It’s indicated for large fibroids

Laparoscopic myomectomy is minimal procedure where a small hole is made on the abdomen for removal of fibroid. It’s indicated for small fibroids

In hysteroscopic myomectomy a special instrument is required to pass through vagina or cervix for removal of the fibroid. It’s indicated for smaller fibroids and fibroids that are contained in the womb

Preoperative care :

Medication to reduce the size of the fibroid like buserelin, leuprolide

Preoperative tests like blood test, ECG, Pelvic ultrasound

Ask the patient if they are on any medication or do they have any existing disease

Intra operative care :During surgery we will maintain good aseptic environment, continue anesthesia and monitor vital signs.

Post operative care:

After the surgery we will keep you for a while to monitor your vitals signs and you should have a proper rest.

Proper rehydration

Antibiotics for infection

Antipyretics for pain reliever

Monitor urine output

Complications: Infection /adhesion /blood loss / damage to oragns /child birth complications

Strategies to prevent complications: Iron supplements /vitamins /hormonal therapy /proper Preoperative and post operative care

Do you understand everything I have said? Do you have any questions?

Can you repeat what I have said in your own words?

Ma do you agree to proceed with this surgery? OK Ma you have made the right decision, please go through the consent form and sign it in front of my senior colleague.

Don’t forget to show empathy throughout the counselling session.

Thank patient and examiner

Question 17

A 3 year old child present to the emergency paediatrics unit with fever diarhea vomitting and wight loss . He has the following parameters ;weight =7kg length =70cm mid arm circumference =11 cm . Take a detail focus history and write as well .

Answer 17

Greet the examiner

Greet the patient, introduce yourself and establish rapport

Take consent

Relationship to the child: Who are you to this child?

Biodata: Name, Age, Sex, Class, Family setting, Address, Religion, Tribe, Occupation,Educational status

Presenting Complaints
Fever:

When did the fever start? How did it start - sudden on gradual? How long has it lasted? Is it high grade on low grade? Is it constant or intermittent? How often have you had the episode of fever? Does the fever worsen in the morning, day or night, or it’s not affected by the time? Does it affect your daily activities? Does it relieve with tepid sponging or drugs?

Diarrhea (Watery or Loose stool):

When did it start? Was it sudden or gradual? How long has it lasted? Has it been continuous or intermittent since onset? Has it worsened, improved or staved the same since onset? How many times do you visit the toilet in a day? When do you usually have the diarthea - morning, afternoon, night or always? Is te stool copious or scanty? (Estimate the volume using household utensit like cap or containers) Does it contain undigested food particles? An specific odor? Is it odorless or malodorous? What is the color of the stool - pale, greenish, dark, rice-water, brown, etc.? Does it contain pus, blood, mucus or slime? Does the watery stool alternate with constipation? What triggers or relieves the watery stool?

Vomiting:

When did it first start? Was it gradual or sudden? Is it projectile (forceful) or effortless? Has it worsened, gotten better or remained unchanged since onset? Does it occur more in the morning, afternoon or night? How many times do you vomit in a day? Is the vomiting constant or intermittent? What does the vomitus contain - digested food, undigested food, mucus or fluid? What is the color - bright red, coffee appearance, bile-stained? Any specific odor - foul smell or odorless? What is the volume in each episode? (Estimate the volume in liters or ml with containers or cups around) Is there anything that triggers (aggravates) or relieves it?

Weight loss:

Duration and Onset- when did you notice the inability of the child to gain weight, how did you know the child is not gaining weight? Was it evidenced by loose fitting cloths, visible bony prominence, sagging buttocks? Course - Have you been noticing it gradually or it started suddenlv? Since you became aware of the child’s symptom, have he/her lost more weight, gained weight or remained the same? Timing - This failure to gain weight is it related to a particular time? Not feeding properly, Communal clash or unrest or it’s at all times.

O-R- Any other association like: Loss of appetite, vomiting, abdominal pain, diarrhea, weakness,pallor, dehydration.

Mx of Causes/ risk factors/ differentials:Prior to you noticing/having all this symptoms:

Was this baby exclusive breastfed? Hx of early or faulty weaning? When was the child introduced to formula or family food? Did the child receive all necessary immunizations like BCG, Rota virus vaccine, measles vaccine, DPT, and Vitamin A supplement. Is the child eating well? Exhaust FADU properly Did you receive malaria prophylaxis in pregnancy or does the child sleep under IN (r/o malaria infection) Any hx of communal clash, herdsmen attack, etc. Any hx of drenching night sweat, chronic cough or contact with person with chronic cough (r/o TB) Any hx of fever, passage of loose stool (r/o gastroenteritis) Hx of kind of housing or environment of living, income of parents (r/o low social economic status) Any hx of fever, diarrhea, weight loss or HIV infection in parents or sexual abuse (r/o HIV) Any hx of fever, associated rash, nasal or eye discharge (r/o measles)

Hx of Complication: Since you noticed this condition have you had any complications like?

Hx of weakness, fatigue & pallor (r/o Anemia) Hx of feeling of cold than normal (hypothermia) Hx confusion, irritability (r/o hypoglycemia) Hx of high fever, chest pain, fast breathing (r/o pneumonia) Hx of loss of consciousness, convulsion or seizure (r/o encephalopathy) Hx of decrease urine output, loin pain (r/o AKI) Hx of dyspnea, weakness, chest pain & palpitation (r/o heart failure) Hx of weight loss (r/o malnutrition) Is the child growing well compared to his peers Hx protuberant abdomen and thin limbs

Care Received:

What home remedies, if any, has the patient taken? Has the patient been to any hospital for this condition? Has the patient undergone any surgery for this condition? What investigations have been carried out? What treatments has the patient received?T

reatment; vaccines (BCG, Measles, DPT), malaria prophylaxis, folic acid, vitamin A, antibiotics,IV fluids, blood transfusion, anti-diarrhea.

Past Medical History
Prenatal, Natal and Postnatal history
Nutritional and Developmental History
Immunization history
Family and Social history
Drug and allergy history
Systemic review

Question 18

A 30 year old man present with a 14 day history of cough and fever. Take a focused history.

Answer 18

Greet the examiner Greet the patient, introduce yourself and establish rapport Take consent Biodata: Name, Age, Sex, Class, Family setting, Address, Religion, Tribe, Occupation, Educational status Presenting Complaints

Fever :When did the fever start? How did it start - sudden on gradual? How long has it lasted? Is it high grade on low grade? Is it constant or intermittent? How often have you had the episode of fever? Does the fever worsen in the morning, day or night, or it’s not affected by the time? Does it affect your daily activities? Does it relieve with tepid sponging or drugs?

Cough: When did the cough start Was the onset sudden or gradual? How long has it based? Is it episodic or persisent Is this a barking or whooping cough? How frequent are the coughing spells? How long does each coughing spell last? Has the cough worsened, remained the same or improved since onset Does is produce sputum? What’s the color of the sputum - yellowish, whitish, greenish, rose, browni What is the consistency - thick, ielly-like or frothy? What is the odor like - foul-smelling or odorless? What time of the day or night is the cough on sputum production reas severe? How much sputum is produced - copious or little? Does the sputum have traces of blood? Any associated chest pain and/or breathlessness with this cough?

Other Possible Symptoms: Have you noticed any loss of body weight (weight loss)? Do you cough up blood (hemoptysis)? Do you often lose appetite (anorexia)? Do you experience general body weakness or tiredness (fatigue)?

Causes/ Risk factors: History of contact with someone who has prolonged cough? Does the patient live in oyercrowded environment? History of BCG vaccination at birth? Is the patient homeless? Does the patient consume unpasteurized milk? History of cigarette smoking? Is the patient a known diabetic? Is the patient a known HIV patient? Any long-term use of steroids? Is the patient on any chemotherapeutic drugs? History of travel to a TB-endemic region?

Complications: Brain tuberculoma: History of headache with vomiting, seizure, and irrational behaviors. Abdominal tuberculosis: Any abdominal pain, distension or change in bowel habits. Renal tuberculosis: Any change in urine volume and frequency, blood in urine or painful urination. Pott’s disease: Any joint pain or swelling of the back, lower limb, muscle weakness. Genital tuberculosis: History of infertility, menstrual irregularity. Pulmonary edema: History of breathlessness, feeling of drowning.

Care received: What home remedies or care has the patient received? What hospital has the patient visited and what investigations have been done (Chest X-ray, Mantoux test, CBC, Urinalysis, etc.)? Any drug treatment (rifampicin, isoniazid, pyrazinam ethambutol)? Was it through Directly Obsen Therapy or Home administration

D. DRUG HISTORY: What current medication is patient on? An known drug allergies?

E. PAST MEDICAL HISTORY: Is the patient hypertensive, diate sickle-cell anemic, asthmate, epileptic? Any previous transfusions: Any past surgeries?

F. FAMILY AND SOCIAL HISTORY: History of hereditary disease Is familv Does the patient drink alcohol Does the patient smoke cigarette

G. SYSTEMIC REVIEW (At least one or two questions on each of the systems): Central Nervous System, Endocrine System, Respiratory System, Cardiovascular System, Digestive System, Genito-urinary System, Hematologic System, Musculoskeletal System

Question 19

Examine the abdomen of a man with abdominal pain.

Answer 19

INTRODUCTION
• Greet the examiner.
• Greet the patient.
• Introduce yourself and establish rapport.
• Confirm patient’s identity.
• Briefly explain what the examination is about.
• Obtain consent.
• Ask for a chaperone
To the examiner:
I would like to:
• screen my patient for privacy.
• adequately expose my patient (e.g. from nipple line to mid-thigh).
• place my patient in an anatomical position (e.g. with the body supine, the arms at the
sides and the palms facing upwards).
• sanitize or wash my hands with running water and soap.
Ask to perform a quick general examination.
Points to note: Sclera jaundice, conjunctival pallor, peripheral cyanosis, finger clubbing,
cervical lymphadenopathy, etc.
B. INSPECTION:
Inspect the abdomen from the side to the foot of the bed.
Points to note:
• Is the abdomen flat, scaphoid or distended?
• Does it move with respiration?
• Is umbilicus everted or inverted?
• Is the patient calm or restless?
• Is the patient obese or wasted?
• Are there scars, lumps, rashes, ulcers, dilated veins, etc.?
• Are there colostomy bags, gastrostomy tubes, Intravenous cannula, catheters, etc.?
• Check for visible cough impulse from hernia orifices (ask the patient to turn head to
the left).
C. PALPATION
Before you proceed to palpate, ask for any area of tenderness. If any, ask patient to
point with a finger.
Light palpation: start from the left iliac region, checking for tenderness (if there is pain,
start away from the site of pain).
Deep palpation: repeat the same palpation but going deeper this time checking for
masses.
Organ palpation:
Liver (hepatomegaly): begin by placing the right hand on the right iliac fossa and
palpating upwards as the patient breaths in and out.
Spleen (Splenomegaly): starting from the right iliac fossa, palpate diagonally upwards
to the projection of an enlarged spleen.
Kidney (hydronephrosis): ballot the kidney by placing the left hand behind the patient at
the level of the 12th rib. Place your right hand on the abdomen at the right or left flank
and palpate with these two hands, feeling for an enlarged kidney
D. PERCUSSION
Liver span:
• Start from the midclavicular line at the 2nd or 3rd intercostal space and percuss
downwards until the point of dullness (upper border).
• Resume percussion from right iliac fossa upwards until the point of dullness (inferior
border).
• Measure the liver span in centimeters (with the inch side facing you to avoid bias).
Ascites: Shifting dullness:
• Percuss from the umbilicus to the flank (about 3 zones), checking for dullness.
• Keep your finger on the spot and ask the patient to roll onto the opposite side.
• Keep the patient on this position for about 10seconds (to allow for fluid redistribution).
• Repeat the percussion, but this time towards the umbilicus.
• If the flank becomes resonant after a change in patient’s position, it is positive for
ascites.
E. AUSCULTATION
• Bowel sounds: best heard at the Mcburney’s point.
• Aortic bruits: best heard above the umbilicus.
• Renal bruits: best heard above the umbilicus, slightly lateral to the midline.
• Hepatic bruits: best heard over the right upper quadrant.
Ask to perform a Digital Rectal Examination (DRE)

Thank the patient and the examiner
NOTE: If any of the signs are indicated, carry it out immediately after superficial palpation Appendicitis; Pointing, Roving, Rebound tenderness Obturator, Psoas signs Cholecystitis; murphy’s, Boas signs Gastric outlet obstruction (GOO); Succussions splash

Question 20

November 2019
10. A diabetic man presented to the hospital clinic complaining of weakness of his legs. Perform a lower motor examination on him.

Answer 20

Greet the examiner.

• Greet the patient.

• Introduce yourself and establish rapport.

• Confirm patient’s identity.

• Briefly explain what the examination is about.

• Obtain consent.

• Ask for a chaperone.

To the examiner:

I would like to:

• screen my patient for privacy.

• adequately expose my patient (properly expose the leg).

• position my patient (e.g. with the body supine, the arms at the sides and the palms

facing upwards).

• sanitize or wash my hands with running water and soap.

B. INSPECTION:

Inspect the lower limb from side to foot of the bed.

Points to note:

Any deformities?

Any muscle wasting?

Presence of fasciculations?

Any hair loss, scarification marks, etc.?

C. PALPATION:

Elicit Fasciculation

Muscle Bulk:

Choose a reference point (knee).

Then measure the muscle mass for each point of the limb.

Tone:

This is the movement across joints (rotation, flexion, extension).

Hip (Ball and Socket joint)

Knee (hinge joint)

Ankle (hinge joint)

Power:

This is assessed across muscle groups (adduction, abduction, flexion, extension, etc.).

Reflexes:

Knee reflex, Ankle reflex

Plantar response

Ankle Clonus

Gait :ask patient to walk in a straight line and return

Coordination: Heel to shin