2018 June Osce Flashcards
Station 1: A 28 year old woman who has being married for 3 years present to hospital clinic complaining of inability to get pregnant. Take a detailed history.
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:
Inability to get pregnant
How long have you been trying to conceive?
Have you ever been pregnant?
Do you live with your partner?
How often do you have sexual intercourse?
Do you have vaginal penetrative sex?
Do you have protected or unprotected sexual intercourse?
Does your partner ejaculate or release inside your vagina after sex?
Do vou douche after sex?
Are you from monogamous or polygamous marriage?
Causes:
Do you see your menses every month?
Do you have a normal regular menstrual cycle?
Have you ever been pregnant before?
Any history of use of contraceptives (which type, how long)
Any history of cold/heat intolerance?
Hx of Excessive sweat, weight gain or weight loss?
Hx of milky discharge from the nipple?
Any hx of abnormal hair distribution on your body, (r/o hirsutism)
Hx of repeated Dilatation & Curettage
Any hx of excessive blood loss in your previous pregnancy?
Any hx of lower abdominal pain, fever & vaginal discharge?
Any hx of abdominal mass & abdominal distension?
Hx of abdomino-pelvic surgery
Hx of typhold perforation or peritonitis
Complications:
Since the onset of this problem have you had any complications like:
Feeling Depressed
Having problems in your marriage (r/o marital discoid)
Pressure and stress from inlaws
Suicidal thoughts
People laughing at you or mocking you (r/o Social stigma)
Feeling of not woman enough (r/o Low self-esteem.)
Care received so far:
Since the onset of this did you use any herbal medication?
Did you take any medication from the pharmacy?
Did you go to the hospital?
When you went to the hospital what did they do for you?
Did they do any investigations like semen analysis, hormonal profile, abdomino-pelvic USS, CTScan etc.?
Did they prescribe any drugs like clomiphene citrate, metformin etc.?
Did they do IVF, ZIFT or GIFT?
Past. gyneHX, Past. obst.HX, PM&S HX , FHX, SHx, Drug& allergy Hx, systemic review.
- Lab test Urinalysis:Glucose 34.0mmol/L, ketones +++, nitrate ++ Electrolytes are normal CBC: high neutrophils. Diagnosis?
*Diabetic ketoacidosis
List 2 Complications of diabetes keto acidosis
Shock
Cerebral edema
State other investigations you can do in DK
Arterial blood gas
Serum uric acid level
Fasting lipid profile
Chest X-ray
Electrocardiography
Management of diabetes keto acidosis
ABCD of resuscitation
Fluid therapy with strict input and output monitoring: IV 0.9% normal saline
Electrolyte replacement: K levels need to be monitored, though initial level might not be low, insulin lead to K uptake.
Insulin therapy:loading dose of 10IU IV, 10IU IM stat
Maintain at 6IU IV or IM hourly
Treat underlying cause
Treat complications
24 year old woman present with anterior neck swelling, weight loss, and palpitation. Which system is affected?
Endocrine system
Write 10 symptoms for the system affected. Endocrine
Amenorrhea, heat intolerance, hirsutism, impotence, insomnia, tremor,
restlessness,
Irritability,
decreased libido,
coarse skin.
List the level of prevention.
Primary level : Health promotion and specific prophylaxis
Secondary level: Early diagnosis and treatment
Tertiary level: Limiting disability and rehabilitation
Apply the level of prevention on Tuberculosis.
General health promotion
Educate the people through mass media about
Disease(infectious granulomatous disease)
Cause( M.TB)
Riskfactors(overcrowding, unpasteurized milk,unvaccinated kids)
Good nutrition and sanitation
Avoid overcrowding and maintain proper ventilation
RIAI
Use of face mask and other PPEs
Specific Prophylaxis
Immunization with BCG(Bacillus-Calmatte-Guerin) vaccine
Screening of high risk people for TB
Early diagnosis and treatment
Fast acid bacilli
Chest X ray
Ziehl Nielsen
Sputum culture
Tuberculin test
Symptoms: Chronic cough, drenching night sweats, weight loss
Treatment
RIPES(rifampycin,isoniazid,pyrazinamide,
ethambutol,streptomycin)
Limiting disability
Antibiotics for Meningitis
Surgery for Pott’s deformity
Monitor using Walgreens timetable,
Regular eye exam
Rehabilitation
Vocational therapy(retrain for another job)
Physiotherapy (Prosthetics)
Psychosocial (support from community and family members).
List 5 causes of postpartum hemorrhage.
Uterine atony
Abruptio placenta
Retained placenta
Placenta previa
Cesarean section
List the steps of management of the 3rd stage of labor.
Administration of 10 IU of oxytocin IM within 1 min of delivery of the baby.
Delayed cord clamping
Delivery of placenta by controlled cord traction
Intermittent uterine massage quarter hourly for 2 hours
A patient present with pain in his abdomen. Perform an abdominal examination on the patient.
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
SPECIAL SIGNS TO KNOW
Appendicitis
• Pointing sign
• Rebound tenderness
• Rovsing sign
• Psoas sign
• Obturator sign
Cholecystitis
• Murphy sign
• Boas sign
Nephrolithiasis/Pyelonephritis:
• Pasternatsky
Gastric Outlet Obstruction
Succussion splash
A patient present with signs of acute appendicitis. Perform an abdominal examination on the patient.
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)
Appendicitis:
• Pointing sign
• Rebound tenderness
• Rovsing sign
• Psoas sign
• Obturator sign
Thank the patient and the examiner
Station 7: A woman with a 4 year old boy having recurrent hand and foot pains. The boy’s genotype is SS and his mother wants to know what can be done for him to avoid future reoccurrences. Counsel her.
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.
June 2018
8. List 2 differential diagnosis of peptic ulcer
Ulcerative colitis
Crohn’s disease
