2017 Osce November Flashcards
Station 1
You are asked to Counsel a woman who brought her 2 year old boy whose genotype is SS. I c
Greet examiner and patient
Ask for her relationship with the child and permission, preferred language and confidentiality.
Tell:
What can you tell me about sickle cell anemia? Alright thank you ma, I will like to tell you some important things about It.
Sickle cell disease Is a blood disorder due to mutation of beta-globin chain characterized by two abnormal hemoglobin alleles. The mode of inheritance is autosomal recessive type and has the typical HbSS unlike the normal hemoglobin which is HbAA. It means that both parents have to at least be carrier for the sickle cell gene which will lead to a 25% chance of having a sickle cell disease child from each pregnancy.
This mutation causes a change of adenine to thymine at the 6 codon of beta globin chain and glutamine being replaced by valine. This mutation means that the hemoglobin has a sickled shape instead of the normal doughnut biconcave-disk shape. Because of this sickling, the ability of the hemoglobin to carry sufficient oxygen throughout the body is limited. This makes sickle cell patients to have typical clinical features such as jaundice, long & thin extremities; frontal & parietal bossing, enlarged abdomen, pallor, digital clubbing, gnathopathy, swelling of hand and feet, stunted growth and so on.
Sickle cell disease can have crisis states outside of the steady state which is the pain-free period between two crises. The sickle cell crisis states are the vaso-occlusive crisis which is the commonest where the patient can have hand and foot swelling, hyper-hemolytic crisis due to rabid breakdown of red blood cells, aplastic crisis caused by parvo virus B19, splenic sequestration crisis from the pulling of blood into the spleen and the rare megaloblastic crisis which is due to enzyme deficiencies like thalassemia.
Trigger factors for sickle cell crisis such as stress, cold weather, and infection like malaria, dehydration, hypoxia from high altitudes, acidosis and drugs.
Especially in children, poor handling of the sickle cell disease condition can lead to complications like hepatosplenomegaly, blindness, transient ischemic attack, priapism, impotence, acute chest syndrome etc
As overwhelming as all these may seem I want to assure you that several similar cases have been handled by our more-than-qualified staff and you can be sure that you are in the right place.
There are certain investigations that can be done for this condition depending on the period of time one comes to the hospital. Prenatal investigations are chorionic villous sampling & amniocentensis; natal investigations such as sickling & solubility test. The commonest investigation is the hemoglobin electrophoresis.
For the management of this condition, we have the conservative plan and the pharmacological methods.
Conservative management include ensuring that this child doesn’t miss any of his vaccinations with good hygiene, proper rehydration, malaria prophylaxis for proguanil,avoiding extreme weather conditions/stress/high altitudes/or the use of drugs, regular routine check-up.
I will also recommend your child being in a day-school to ensure that you have time to monitor this child. Pharmacological methods is where we give drugs such as antibiotics, analgesics, blood transfusion, hydroxyurea to increase fetal hemoglobin in circulation, folic acid and the newly developed drug called oxbryta.
The definite management for this condition is Bone Marrow transplant but at this time it is quite expensive and highly experimental in this part of the world with chances of failure.
Do you have any questions for me? Did you follow all we’ve said? Can you repeat what I’ve told you in one or two words?
I commend your efforts in going all-out to see your child healthy and I want to assure you that should you have any further concerns; doctors will always be available here to attend to you.
We have dinic days on Wednesdays where we give special time to attend to similar cases.
Thank you very much for your time and have a good day.
station 2
A patient came in with chest pain. Perform a precordium 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
Station 3: A patient complain of difficulty passing urine. Take a detailed history.
Greet examiner
Introduce yourself to the patient
Bio data : NASATROMA_L
Presenting Complaint:
Difficulty passing urine
When did it start? Sudden or gradual
How long has it been
Has it gotten better, worse or remained the same
Continuous or on and off
Does it occur during the day or night
Related symptoms: FUN WISH RIDO
(Frequency, urgency, nocturia, weak streams, intermittence, stricture, hesitancy, retention, incomplete voiding, terminal dribbling, overflow incontinence)
How many times a day do you urinate?
Do you feel you can’t hold urine?
Do you feel you might leak urine if you do not reach the toilet soon?
How often do you wake up at night?
Does the stream go far or it drops in front of you
While urinating do you stop and start again
Do you force yourself before urine comes out
Any delay in initiating urination
Do you feel like you retain urine
After urinating does urine still come out in drops
Do you wet your clothes with urine
Associated symptoms:blood in urine, pain during urination, Abd pain, fever, weight loss
Causes:
Previous history of BPH
Family history of prostate cancer
Hx of urethral surgeries, instrumentation
Excessive appetite, thirst or increased urination
Fever and painful urination
Hx of STD
Complications:
Weakness, dizziness
Back pain
LOC, cold extremities
Headache, LOC, seizure
Umbilical or groin swelling
Care received:
Traditional or religious home
Hospital :FBC, PSA, Abd pelvic x-ray, prostate biopsy, txt~Prazozin, prostatectomy
Drug Hx, PMH, FH, SH and Review of systems
Station 4
*List the level of prevention
*Apply the level of prevention on monkey pox.
1: Primary level : Health promotion and specific prophylaxis
Secondary level: Early diagnosis and treatment
Tertiary level: Limiting disability and rehabilitation
2: General health promotion
Educate masses using Mass media
Organism (monkey pox virus)
Vector (macaque monkey, giant Gambia rats, squirrels)
Similar to small pox but milder.
Transmitted from wild animals and person to person
Spread is via direct contact with blood and body fluids of infected persons
Specific Prophylaxis
vaccine : Jynneos and Mpox
small pox vaccine covers immunity but no longer available
Early diagnosis and treatment
Using scrapes from rashes or enanthem for viral culture and microscopy
Polymerase chain reaction
Symptoms: fever, headeache, myalgia rash that starts from face
Treatment
Acyclovir
Cidofovir
Anlagesics
Antipyretics
Limiting disability
Give antibiotics to limit secondary bacterial infecetion
treat pneumonia with antibiotics
limit corneal ulceration by vitamin A supplementation
calamine lotion for itching
Rehabilitation
Vocational therapy
Physiotherapy
psychotherapy and social therapy
