2021 May Osce Flashcards
Identify the instrument. It has a tube used for GIT
Nasogastric tube
indication of use nasogastric tube
Gastric decompression
Gastric lavage
Feeding
Taking specimen from stomach
Upper GI bleeding
Complications of nasogastric tube
Trauma of nasal mucosa
Epistaxis
Sore throat
Kinking of the tube
Esophageal perforation
Other materials used with nasogastric tube
KY gel, sterile gloves, plaster, syringe, water, stethoscope, galley pot, nasogastric collection bag.
Ways to confirm entry of the tube
Put the end of the tube in water and observe for bubbles (multiple bubbles indicate that the tube is in the lungs) OR
Aspirate stomach contents and test with litmus paper (it should turn blue litmus paper red) OR
Do an abdominal X-ray
Contractions time when partograph was opened?
What is the distance in time between action and alert line?
4 hrs
Take a focused history from a woman that presented to a gynecological clinic with mass protruding from her vagina.
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 give birth to your last child?
Presenting Complaint:
Protruding mass per vagina
When and how did you notice it?
Was it sudden or gradual?
How long has it been?
Has it gotten better, worse or remained the same?
Is it reducible or not?
Is it painful to touch?
Is it related with any particular timing like during coughing or defecating?
Is it associated with other symptoms like low back pain, dyspareunia, vaginal bleeding, dysuria etc
Causes:
Hx of chronic cough
Hx of chronic constipation
Hx of prolonged labor
Hx of instrumental vaginal delivery
Hx of high parity with short birth spacing
Hx of pelvic surgery
Complications:
Marital discord
Depression, social Apathy
Low self esteem
Painful sexual intercourse
Recurrent infection
Care received:
Have you visited any religious home or herbalist, hospital?
Any investigation done like USS, MRI, cystoscopy, E/Ur/Cr, urinalysis, FBC
Gynecological history
When was your first menstrual period?
What is the average duration of your period and cycle length? Is it a 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 obstetric history
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:
Was 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 deliver your baby?
Was there 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 there 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 regards the children?
How many are alive and how many have passed away?
How many of them did you exclusively breastfed?
Drug history
Any current medications on
Any known drug allergies?
Past medical and surgical
Is the patient a known DM, Hypertension, Sickle Cell Disease, Asthma or Epileptic patient.
Family history and social
Any hereditary disease in the family
History of drinking and smoking
Review of system
Central nervous system: headache, dizziness
Cardiovascular: chest pain, palpitation
Respiratory: cough, runny nose
Gastrointestinal: Abdominal swelling, abdominal pain
genitourinary: any discharge, dysuria
endocrinology: excessive weight gain or weight loss
Musculoskeletal: joint pain, muscle ache
haematology: rashes, bruises
A 45 year old man presented to the ER complaining of right iliac fossa pain for 3 days, pain is sharp and stabbing in nature. Perform an abdominal examination on the patient.
Always look at the patient when you palpitating
A. 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
Appendicial signs
• Pointing sign
• Rebound tenderness
• Rovsing sign
• Psoas sign
• Obturator sign
A mother brought in her 2 year old baby with cough and difficulty breathing and fever. Perform a respiratory examination.
A. 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 (tell patient to take off shirt or singlet).
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.
The Anterior Chest Wall:
B. INSPECTION:
Inspect from the side to the foot of the bed or from head to toe.
Points to note:
• Symmetry of the chest wall
• Any deformity (pectus excavatum, pectus carinatum, etc.)
• Chest wall movements (use of accessory muscles)
• Chet tube in-situ, endotracheal tube, etc.
C. PALPATION:
• Respiratory rate (hold the patient’s hand as a distraction while you count the
respiratory rate)
• Check for trachea deviation
• Check for chest expansion (three lung zones: upper, middle and lower)
• Check for tactile fremitus
− Tell patient to say 99
− Must be done bilaterally and comparatively
D. PERCUSSION:
Must be done bilaterally and comparatively
Start by tapping the clavicle with a finger (lung apex)
Percuss the three lung zones (upper, lower and middle zones)
Percuss the axilla (two zones: upper and lower)
E. AUSCULTATION:
Must be done bilaterally and comparatively
Auscultate the three lung zones (upper, lower and middle zones)
Tell the patient to breath in and out
Auscultate the axilla (two zones: upper and lower)
Check for vocal fremitus (tell the patient to say 99)
The Posterior Chest Wall
A. INSPECTION:
Inspect the back of the patient.
Points to note:
Curvature of the vertebrae (scoliosis, kyphosis, etc.)
Any other deformity
Scarification marks
B. PALPATION:
Check for chest expansion (three lung zones: upper, middle and lower)
Check for tactile fremitus
Tell patient to say 99
Must be done bilaterally and comparatively
C. PERCUSSION:
Must be done bilaterally and comparatively
Percuss the three lung zones (upper, lower and middle zones)
D. AUSCULTATION:
Must be done bilaterally and comparatively
Auscultate the three lung zones (upper, lower and middle zones)
Tell the patient to breath in and out
Check for vocal fremitus (tell the patient to say 99)
Thank the patient and the examiner.
May 2021
A patient present with 4 weeks history of cough and weight loss. Perform a chest examination.
• 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.
• expose my patient (tell patient to take off shirt or singlet, lower limbs must be
exposed too).
• place my patient in cardiac position (45º angle).
• sanitize or wash my hands with running water and soap.
Ask to perform a quick general examination:
Points to note: Hair texture, sclera jaundice, conjunctival pallor, peripheral cyanosis,
finger clubbing, lymphadenopathy, etc.
The Precordium
a. Inspection: (focus should be on the precordium)
Look out for: precordial hyperactivity, cardiac impulses, bulge, etc.
b. Palpation:
Apex beat:
Palpate the apex beat.
Localize the apex beat with the middle finger.
Indicate, with the fingers, the position of the apex beat (5th intercostal space,
midclavicular line).
Thrills:
Using the flat of your right hand, check for thrills on the four valve areas:
Mitral valve area (apex beat)
Tricuspid valve area (lower left sternal edge)
Pulmonary valve area (left 2nd intercostal space)
Aortic valve area (right 2nd intercostal space)
Heaves:
Using the heel of the hand, check for heaves on the:
Mitral valve area (left ventricular hypertrophy)
Left parasternal area (right ventricular hypertrophy)
c. Auscultation:
Listen for heart sounds over the four valve areas using the diaphragm of the
stethoscope
Mitral valve area
Tricuspid valve area
Pulmonary valve area
Aortic valve area
Listen for heart murmurs over the four valve areas using the bell of the stethoscope
Mitral valve area
Tricuspid valve area
Pulmonary valve area
Aortic valve area
The Back and Leg
Auscultate the lung bases for fine crackles (heart failure)
Check for sacral edema
Check for pedal edema
Thank the patient and examiner
What is epidemic?
Epidemic refers to sudden increase in the number of cases of a disease above what is normally expected in that population in that area which is clearly in excess of the usual expectancy.
Epidemic we have been experiencing since November 2020
Lassa fever,
Ebola,
Yellow fever,
Monkeypox,
measles
Apply the level of prevention to yellow fever
General health promotion
Educate the people about the epidemic
Yellow fever(viral hemorrhagic fever)
it’s caused by an arbovirus of the flavirus origin
transmitted from person through mosquito bite.(aedes egypti)
Good hygiene and sanitation(use of insecticide treated net, avoid staying in bush
Specific Prophylaxis
yellow fever vaccine (one dose of 0.5ml at 9month sc)
use of insecticide rx nets and mosquito repellent
Early diagnosis and treatment
symptoms include;
Bleeding from orifices, fever, muscular pain,fever headache,
nausea and vomiting, jaundice, decreased urine output.
Labs, serology for viral culture and isolation.
Treatment
Standard support(rehydration oral and IV)
Pain management
analgesic, antipyretic,, blood transfusion
Limiting disability
patient should be well rehydrated
dialysis for renal failure,
nasogastric tube for feeding for patient that cannot tolerate oral feeding,
intubation,
blood transfusion to prevent haemorrhagic shock due to blood loss.
Rehabilitation
Vocational therapy(retrain for another job)
Physiotherapy (Prosthetics)
Social (support from community and family members).
A 23 year old woman presented in the children’s outpatient unit with her one week old child who has jaundice and signs of bilirubin encephalopathy. Counsel the mother on causes,treatment and possible outcome for her baby.
Greet examiner and patient
Ask for permission, preferred language and confidentiality.
Tell:
Definition- Bilirubin encephalopathy is a rare neurological condition that occurs in some newborns with severe jaundice.
Bilirubin encephalopathy is caused by very high levels of bilirubin. Bilirubin is a yellow pigment that is created as the body gets rid of old red blood cells. High levels of bilirubin in the body can cause the skin to look yellow.
Causes-If the level of bilirubin is very high or a baby is very ill, the substance will move out of the blood and collect in the brain tissue if it is not bound to protein in the blood. This can lead to problems such as brain damage and hearing loss. The term kernicterus refers to the yellow staining caused by bilirubin. This is seen in parts of the brain on autopsy.
This condition most often develops in the first week of life, but may be seen up until the third week. Some newborns with Rh hemolytic disease are at high risk for severe jaundice that can lead to this condition.
Symptoms- The symptoms depend on the stage of BE. Not all babies with kernicterus on autopsy have had definite symptoms.
Early stage:
Extreme jaundice
Absent startle reflex
Poor feeding or sucking
Extreme sleepiness (lethargy) and low muscle tone (hypotonia)
Middle stage:
High-pitched cry
Irritability
May have arched back with neck hyperextended backwards, high muscle tone (hypertonia)
Poor feeding
Late stage:
Stupor or coma
No feeding
Shrill cry
Muscle rigidity, markedly arched back with neck hyperextended backwards
Seizures
Complications- Complications may include:
Permanent brain damage
Hearing loss
Death
Investigations- A blood test will show a high bilirubin level (greater than 20 to 25 mg/dL). However, there is not a direct link between bilirubin level and degree of injury.
FBC, U&E, LFTS, Coomb’s test, sepsis screen.
Treatment- Treatment depends on how old the baby is (in hours) and whether the baby has any risk factors (such as prematurity). It may include:
Light therapy (phototherapy)
Exchange transfusions (removing the child’s blood and replacing it with fresh donor blood or plasma)
Help: Please have you understood all I have said? Do you have any questions?
Empathy :it should be throughout the counseling session.
Retell: Can you tell me in your own words what you have understood so far?
Thank patient and examiner
What are the levels of Prevention
Primary level : Health promotion and specific prophylaxis
Secondary level: Early diagnosis and treatment
Tertiary level: Limiting disability and rehabilitation
