2018 October Osce Flashcards
Image of an x ray of pleural effusion mention 3 findings
Homogeneous opacities
Meniscus sign
Blunting of costophrenic angle and cardiophrenic angle
Possible cause of pleural effusion
Lobar pneumonia
2.A patient presents with breathlessness and tiredness especially on exertion. Take a focused history.
A. Introduction: Greet examiner, greet patient, introduce yourself, establish rapport and obtain consent.
B. Biodata: Name, Age, Occupation, Marital Status, Address, Religion, Tribe, Level of Education.
C. Presenting Complaints:
(Shortness of breath (dyspnea) and easy fatigability on exertion)
Chief Complaint and Course
Breathlessness/Shortness of breath
• When was it first noticed?
• Did it start suddenly or gradually?
• For how long have you been
experiencing this?
• Is it continuous or intermittent?
• Has it worsened, improved or
remained the same since onset?
• Does it worsen on rest or exertion?
• Does it worsen on mild, moderate or severe exertion?
• Are there any specific aggravating or relieving factors?
• Does it worsen at any particular
time of the day, e.g. in the morning, afternoon or night?
• Does it interfere with your day today activity?
• Is it associated with cough, chest pain, chest tightness, dizziness, wheezing, etc.?
Easy Fatigability
• When was it first noticed?
• Did it start suddenly or gradually?
• For how long has the patient had this?
• Has it been worsening, improving or remained the same since onset?
• Is it continuous or intermittent?
• Is it related to physical activity?
• Is it dependent on the time of the day?
Other Symptoms:
• Any feeling of the heart seeming to beat out of the chest (palpitation)?35
• Do you run out of breath while lying down (orthopnea)?
• Any chest pain or tightness?
• Do you wake up at night gasping for air/breath (paroxysmal nocturnal dyspnea)?
• Have you been losing weight?
• Do you have cough with frothy sputum?
• Do you urinate more at night (nocturia)?
• Do you feel full too soon while eating ?
• Have you been losing weight?
• Do you have cough with frothy sputum?
• Do you urinate more at night (nocturia)?
• Do you feel full too soon while eating
• Any swelling of body parts,especially the lower limb?
Causes/Risk factors:
Any family history of heart diseases (Hypertrophic cardiomyopathy)?
Are you a hypertensive patient (poorly controlled hypertension)?
Are you a diabetic patient?
Any history of intravenous drug use (infective endocarditis)?
Any history of myocardial infection?
Any history of thyroid diseases?
Are you a heavy drinker of alcohol?
Do you have a sedentary lifestyle?
Do you know how much you weigh (obesity)?
Do you smoke cigarette?
Any history of sore throat with fever
(rheumatic heart disease)?
Any history of kidney problems?
Any ingestion of herbal concoction?
Complications:
Any loss of consciousness, limb paralysis or weakness (stroke)?
Any feeling of drowning (pulmonary edema)?
Any intermittent claudication i.e. pain when you walk or exercise (peripheral artery disease)?
Any pain in the sides with decreased volume of urine (kidney disease)?
Any yellow discoloration of the eyes or skin (liver disease)?
Care received
What has been done since the onset of the condition?
Has the patient visited any hospital, chemist or herbalist?
What investigations have been carried out (ECG, echocardiography, FBC, urinalysis, liver function test, chest X-ray, etc.)?
Any drug treatment received (thiazides, diuretics, etc.)?
Drug History:
What current medication is the patient on?
Any known drug allergies?
Past Medical History
Are you hypertensive?
Are you Asthmatic?
Do you have peptic Ulcer disease?
Have you been admitted in the hospital before?
If yes, when? Why? And how long did you stay?
Have you had surgery before? If yes, what procedure was that and when?
Have you been transfused with blood before? If yes, when?
Family & Social History
Monogamous or polygamous setting?
What is your level of education?
Do you smoke cigarette?
Do you drink alcohol?
If yes, how often do you take them?
How many rooms do your apartment have?
How many windows per room and how many occupants in a room?
What’s your source of drinking water? Well, borehole, stream or spring?
What method of refuse disposal do you adopt?
What method of sewage (faecal matter) disposal do you adopt?
Review of Systems
CNS:
✓ Do you have headache?
✓ Any dizziness?
✓ Any hearing or vision imbalance?
CVS:
✓ Do you have difficulty breathing?
✓ Do you find it difficult to sleep 37
without pillows (orthopnea)?
✓ Do you wake up in the middle of the night with chest compression (Paroxysmal Nocturnal dyspnea)?
Respiratory:
✓ Do you have cough?
✓ Any wheezing?
✓ Any chest pain?
✓ Any night sweats?
GIT:
✓ Do you experience vomiting?
✓ Any Diarrhoea?
✓ Constipation?
✓ Any stomach pains?
Urogenital Tract:
✓ Do you experience difficulty passing urine?
✓ Do you urinate more frequently than usual?
✓ Did you notice any change in the colour of your urine?
✓ Do you experience bleeding per vagina?
Thank your patient and examiner
A 34 year old woman present with fibroid, council her on the available treatment options for her.
Introduction:
• Greet examiner
• Greet patient
• Establish rapport and introduce yourself
• Assure her of confidentiality
• Obtain consent
Ask:
• Language of preference
• Settings
• Quick biodata (confirm name, age and occupation)
• Quick history (symptomatic fibroid, risk factors)
• Knowledge on uterine fibroid. What do you know about uterine fibroid?
Tell:
Definition: Uterine fibroid is a benign mass that arise from the smooth muscles of the womb (uterus). Include nulliparity, obesity, black ethnicity, family history, polycystic ovarian syndrome, diabetes and hypertension.
Risk factors
− Black race
− Nulliparity
− Obesity
− Reproductive age (25-45 years)
− Positive family history
Clinical Presentation
Presentation commonly depends on the size of the fibroid. Possible findings include:
− No symptoms
− Abdominal swelling
− Cramps
− Menorrhagia
− Pressure symptoms
Bladder: increased frequency of urination
Rectum: constipation
Lymphatic vessels: swelling of limbs
Complications
− If symptomatic fibroid is left untreated, it can lead to
− Anemia
− Infection
− Womb stone
− Degenerative changes (hyaline, red, cystic, fatty, atrophy, calcification)
− Foetal malpresentation
− Infertility
Investigations
− Full blood count, clotting factors
− Electrolyte, urea and creatinine test
− Intravenous urogram especially in larger fibroids (mass more than 20 weeks old)
− Abdomino-pelvic ultrasound, abdominal X-ray, MRI, CT-scan
Treatment
• Expectant: If mass is less than 12 weeks and asymptomatic
• Medical treatment: Used to relieve/reduce symptoms of fibroid. Examples: mifepristone, danazol and GnRH analogs such as Goserelin and burserelin (but they are expensive).
• Surgical: This is the mainstay treatment of fibroids.
− Myomectomy
− Hysterectomy
− Polypectomy
− Uterine Artery Embolization
Help:
Ask the following questions:
• Do you understand everything I have explained?
• Is there any question you may have?
• Would you like to proceed with the test?
Explain/Empathy:
You are to answer in clear terms all questions the patient may have for you. Answering these questions is very important. Be understanding of the patient’s state of mind.
Retell/Return
Ask the patient to repeat in their own words what they understood from all you have told them. Gain their consent to proceed with the investigations and treatment.
Thank the patient and the 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.
Mention five epidemic diseases currently in Nigeria
*Lassa fever, *
yellow fever,
*monkeypox,
*measles,
*cerebrospinal meningitis
*, Cholera,
*Ebola
Lassa fever mode of transmission
Contamination from infected Multimammate rate (mastomys natalensis)
State the level of prevention of lassa fever
Primordial:
Measures typically include laws and government policy.
Primary:
General Health Promotion:
Health promotion on causative agent (mastomys natalensis) and how to avoid it. Educate the public on proper hygiene and sanitation, about spread through undercooked bush meats, fluids of infected persons (blood, sweat, semen, etc.), to avoid living in overcrowded places (e.g. camps) and maintain wellventilated spaces.
Specific Prophylaxis:
Use rat poisons, discourage hunting of wild animals, discourage deforestation, proper storage of grains in rodent-proof containers, personal protective gears for healthcare personnel (masks, gloves, gowns, googles), proper disposal of dead bodies of infected persons (buried far from residential areas or adequate cremation).
Secondary:
Early Diagnosis and Treatment:
Screen suspected patients for symptoms including haemorrhaging in gums, eyes, nose, fever, myalgia, respiratory distress, vomiting and so on. In addition, laboratory investigation – ELISA to detect IgM, IgG and Lassa antigen, reverse transcription-polymerase chain reaction (RT-PCR), blood
culture for virus (in 7 to 10 days)
Treatment – I.V. ribavirin. Supportive – maintenance of good fluid and electrolyte balance (oral and IV), antipyretics, analgesics.
Tertiary:
Limiting Disability
Monitor electrolytes, urea and creatinine every 5 days or as required; monitorPCV and transfuse when necessary; monitor viral load, prophylaxis for sepsis, ACEI and rehydration, dialysis (in case of acute kidney injury), organ transplant (in case of liver or kidney failure).
Quanternary:
Rehabilitation:
Measures to aid recovery from disease and prevent disability such as active physiotherapy which may include prosthesis (to prevent stroke), social and emotional sup286
port (to prevent social stigmatization), vocational therapy (help
patient return to job by retraining or providing letter of recovery), counselling of family members to provide social support.
Ways to eradicate rats
● Inspect for signs of rat activity
● Remove food sources and nesting materials
● Seal the gaps and cracks rats use to access your home
● Place multiple traps and food poison in rat runways
What is the most characteristic way this presents? For subdural hematoma
*Headache that keeps getting worse
Pathological findings of subdural hematoma
Cerebral atrophy as a result of greater tension to the cortical bridging veins which will make the brain shrink gradually. It can also rises the intracranial pressure.
What does the image indicate?
Chronic subdurak hematoma
A patient present with anterior neck swelling. Take a history.
A. INTRODUCTION: Greet examiner, greet patient, introduce yourself, establish rapport and obtain consent.
B. BIODATA: Name, Age, Occupation, Marital Status, Address, Religion, Tribe, Level of Education.
C. PRESENTING COMPLAINT: (Anterior neck swelling)
Section A. (Symptom Analysis) “Chief Complaint and Course”
Anterior Neck Swelling:
When was it first noticed?
How was it noticed or who noticed it?
Was it rapid or gradual in development?
How long have you had it?
How has the swelling been progressing; worsened, lessened, unchanged?
Is it tender to touch or painful?
Is the swelling warm to touch?
What is the consistency – hard, fluctuant or soft?
Is there any aggravating or relieving factor such as change in position, movement or rest?
Is it mobile?
Is there associated:
− Painful swallowing
− Difficulty in swallowing
− Voice hoarseness
− Loss of sensation
Other symptoms:
Cold/heat intolerance
Constipation/loose stool
Somnolence/insomnia
Weight/weight loss
Hair loss
Profuse sweating
Tremors
Dry skin, etc.
Section B (Diagnosis/Differential Diagnosis)
“Causes, Complications and Care Received”
Causes/Risk factors:
Does the patient consume large amounts of cassava, cabbage (goitrogens)?
Any history of fever and pain (thyroiditis)?
Any family history of anterior neck mass?
Any previous history of neck mass?
Any skin changes, vitiligo (autoimmune)?
Does the patient smoke?
Does the patient drink alcohol?
Does the patient live in a mountainous area?
Does the patient consume locally made salt?
Any history of neck surgery?
Any history of exposure to radiation?
Does the patient use drugs like amiodarone, lithium?
Is there a history of drug use to lose weight?
History of chronic cough, with night sweating (TB adenitis)
Complications:
Any blurring of vision, bulging eyes?
Any history of yellow discoloration of the eyes or skin with abdominal distention?
Any history of cough with hemoptysis?
Any history of seizures?
Any history of bone pain?
Any history of menstrual irregularities, inability to conceive?
Any lower limb swelling, easy fatigability?
Care Received:
What the patient has done since the onset of the condition, investigations carried out and treatments received in the course of the disease are as well important to ascertain. Questions directed to the patient include:
What home remedies, if any, has the patient taken?
Has the patient been to any hospital for this condition?
Has the patient undergone surgery for this condition?
What investigations have been carried out?
− General: full blood count, Urinalysis, liver function test
− Specific: Hormone assay (T3, T4 and TSH)
− Chest X-ray
What treatments has the patient received?
DRUG HISTORY: Any drug allergies? All current medications including herbal concoction.
PAST SURGICAL AND MEDICAL HISTORY:
History of previous surgeries?
Any history of blood transfusion?
Diabetes, hypertension, epilepsy, asthma, sickle cell, blood transfusion, tuberculosis, any recent surgeries, etc.
FAMILY AND SOCIAL HISTORY: Any hereditary disease in the family? What is the living condition? Smoking history and alcohol consumption history.
SYSTEMIC REVIEW:
Central Nervous System
Endocrine System
Respiratory System
Cardiovascular System
Digestive System
Genito-Urinary System
Hematologic System
Musculoskeletal System
Thank your patient and examiner
A) Write the levels of prevention in exact words
Health promotion and education
● Specific prophylaxis
● Early diagnosis and prompt treatment
● Limiting disability
● Rehabilitation
B) Apply the levels of prevention in accordance to Tuberculosis
TUBERCULOSIS
• Level 1: General Health Promotion
Health education should be done using fliers and other means to educate the public about tuberculosis and how it spreads. Promote good nutrition, avoid overcrowding, good ventilation, proper etiquette when sneezing, use of personal protective equipment (face masks, gloves, etc.).
• Level 2: Specific Prophylaxis
Vaccination with BCG (Bacillus-Calmette-Guerin) vaccine, chemoprophylaxis to exposed individuals (isoniazid), control of animal tuberculosis, isolate infected persons.
• Level 3: Early Diagnosis and Treatment
Screening of high-risk groups for symptoms such as long-standing night sweats, cough and weight loss. Investigations with mantoux/tuberculin skin test, sputum test (acid-fast bacilli/ Ziehl-Neelsen stain), chest x-ray.
Treatment - Directly Observed Therapy (DOT), RIPES (rifampicin, isoniazid, pyrazinamide, ethambutol, streptomycin) for 2 months and RI (rifampicin, isoniazid) for 4 months.
• Level 4: Limiting Disability
Prevent complications by treating multi-resistant tuberculosis. The patient needs antibiotics for meningitis, surgery for Pott’s deformity.
Conservative: Good hygiene, balanced diet, enough exercise, smoking and alcohol cessation.
• Level 5: Rehabilitation
Measures to aid recovery from disease and prevent disability – active physiotherapy (may include prosthetics), vocational therapy (help patient return to job by retraining or providing letter of recovery), counselling of relatives and community to break down prejudices, social support from community and family members.
