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OSCE 3 > Clinical Reasoning > Flashcards

Clinical Reasoning Flashcards

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1
Q

What are the 3 components of triple assessment for a breast lump?

A

Clinical examination
Mammogram
Fine needle aspiration

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2
Q

The patient has - distended abdomen, hyper-resonance on percussion and shifting dullness. What does this indicate?

A

Ascites

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3
Q

These are the ascitic tap results - cloudy, SAAG <1.1, neutrophils >250. What is the diagnosis?

A

Infection - spontaneous bacterial peritonitis

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4
Q

What are the symptoms of myasthenia gravis?

A 
Ptosis
Fatigability 
Diplopia 
Dysphonia
Dysarthria
Dysphagia
Facial weakness
Proximal and axial muscle weakness
Breathlessness
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5
Q

What investigation could be carried out to diagnose myasthenia gravis?

A

Anti-Ach receptor antibody
Muscle-specific tyrosine kinase antibody
Electromyography
CT imagine (exclude thymoma)

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6
Q

What would suggest a myasthenic crisis?

A

Breathlessness - life-threatening weakness of respiratory muscles

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7
Q

How is a myasthenic crisis treated?

A 
Ventilatory support 
Plasmapheresis/IVIg 
Identify trigger (medication, infection)
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8
Q

What is the initial management of bacterial pneumonia?

A 
Oral antibiotics (amoxicillin/doxycycline)
Oral steroids (prednisolone)
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9
Q

How would you manage an acute deterioration in a patient with pneumonia?

A

A-E assessment
Senior help
Escalate antibiotics
Re-scan

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10
Q

What investigation would you do if you suspected critical limb ischaemia?

A

ABPI

Doppler US

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11
Q

What surgical option is available for critical limb ischaemia?

A

Bypass

Balloon angioplasty

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12
Q

What is Charcot’s triad?

A

Symptoms of ascending cholangitis

RUQ pain, jaundice and fever/rigors

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13
Q

What is Reynold’s pentad?

A

Charcot’s triad (RUQ pain, jaundice and fever/rigor)
Shock (low BP, tachycardia)
Altered mental state

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14
Q

How is an MI initially managed?

A 
Aspirin 
Morphine
GTN
Oxygen
Clopidogrel
Call PCI centre
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15
Q

How is an MI definitively managed?

A

Primary percutaneous coronary intervention

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16
Q

Who is the breast screening service for?

A

50-70 year old women every 3 years

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17
Q

What are the symptoms of breast cancer?

A 
Skin dimpling
Nipple retraction/discharge/bleeding/eczema 
Tethering of skin around areola
Mass in axilla/breast 
Peau d’orange
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18
Q

What are the treatment options for breast cancer?

A

Surgery (masectomy, lumpectomy)

Neo-adjuvant (chemotherapy, radiotherapy, endocrine therapy, HER2 therapy)

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19
Q

What are the indications for masectomy?

A

More than 1 tumour
Diffuse DCIS
Large tumour in small breast
Recurrence after lumpectomy

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20
Q

What is the pathophysiology of myasthenia gravis?

A

Antibodies created against the acetylcholine receptors at the postsynaptic neuromuscular junction

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21
Q

How is myasthenia gravis managed?

A

Pyridostigmine (anti-acetylcholine esterase)

Steroids, IVIg (immunosuppressants)

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22
Q

What conditions is myasthenia gravis associated with?

A

Thymoma/thymic hyperplasia
Pernicious anaemia
T1DM

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23
Q

What is the pathophysiology of Guillain-Barre?

A

After an infection (campylobacter, CMV, EBV), the imune system attacks the part of the myelin sheath which resembles the pathogen

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24
Q

What are the symptoms of Guillain Barre?

A

Progressive ascending weakness
Flaccid quadraparesis
Areflexia
Respiratory/bulbar/autonomic involvement

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25
How is Guillain Barre treated?
IVIg or apheresis
26
What investigations could be used to confirm Guillain Barre?
Lumbar puncture - CSF has high protein | Nerve conduction studies - delayed impulse
27
What are the symptoms of multiple sclerosis?
Central - fatigue, cognitive impairment, depression Visual - nystagmus, optic neuritis, diplopia Throat - dysarthria, dysphagia MSK - weakness, spasms, ataxia Sensation - pain, paraesthesia Bowel - incontinence Urinary - incontinence, retention, frequency
28
What is optic neuritis?
Painful vision loss which develops over days | Blurred vision and loss of colour vision
29
What is transverse myelitis?
Inflammation of the spinal cord causing weakness and sensory loss
30
How is multiple sclerosis diagnosed?
Evidence of 2 or more episodes of demyelination disseminated in time and space
31
How do symptoms of multiple sclerosis present?
Focal neurological deficits which develop gradually, last more than 24 hours and may improve over days/weeks
32
What investigations could help to confirm multiple sclerosis?
MRI brain Lumbar puncture (oligoclonal bands) Visual evoked potentials
33
How is multiple sclerosis managed?
``` Steroids Physiotherapy Occupational therapy Disease modifying therapies Alemtuzumab Natalizumab Fingolimod Dimethyl fumarate ```
34
What are the symptoms of a stroke?
Right sided weakness Dysphagia Visual disturbance Light-headedness
35
How are ischaemic strokes managed?
``` IV thrombolysis (alteplase)/thrombectomy/aspirin Stroke unit ```
36
How are haemorrhagic strokes managed?
Reversal of anticoagulant/BP control | Stroke unit
37
What are the cardiovascular risk factors for stroke?
``` Hypertension Obesity Physical inactivity Hyperlipidaemia Smoking ```
38
How is a further stroke prevented?
``` Smoking cessation Anti-platelets (aspirin, clopidogrel) BP management (ACEi) Statin Diabetic control Atrial fibrillation management ```
39
What are the symptoms of a subarachnoid haemorrhage?
``` Sudden onset thunderclap headache Photophobia Meningism Loss of consiousness Seizures Visual/speech/limb disturbance Sentinel headache weeks before ```
40
What investigations would be used to diagnose subarachnoid haemorrhage?
``` CT brain (and angiography) Lumbar puncture ```
41
How is subarachnoid haemorrhage managed?
Fluids Nimodipine (calcium channel antagonist - neuronal protection) Analgesia Surgical clipping/endovascular coil
42
What are the complications of subarachnoid haemorrhage?
Rehaemorrhage Delayed ischaemia Hydrocephalus Hyponatraemia
43
What are the symptoms of meningitis?
``` Headache Neck stiffness Reduced GCS Fever Petechial rash Photophobia ```
44
How is meningitis diagnosed?
PCR | Lumbar puncture - high WCC, low glucose, high protein
45
What are the 2 main bacterial caused of meningitis?
Pneumococcus (+ve) - streptococcus pneumoniae | Meningococcus (-ve) - neisseria meningitides
46
How is meningitis treated?
IV ceftriaxone Add amoxicillin if listeria Add dexamethasone if bacterial
47
What are the symptoms of heart failure?
``` Breathlessness (dyspnoea, orthopnoea, PND) Exercise intolerance Fluid retention Fatigue Cough ```
48
What investigations can be used to confirm heart failure?
ECG Chest x-ray Echo Natriuretic peptides (BNP)
49
How is heart failure managed?
``` Beta-blocker (bisoprolol) and ACEi (enalapril) MRA (spironolactone) Valsartan Ivabradine/ICD Digoxin LVAD/transplant ```
50
How is an acute deterioration of heart failure managed?
``` A-E assessment Inotropes Ventilatory support Diuretics Investigate trigger (infection, ischaemia, PE) ```
51
What are the symptoms of an MI?
``` Chest pain Indigestion Sweatiness Shortness of breath None (dementia/diabetes) ```
52
How is an MI managed?
``` A-E assessment Aspirin Heparin Morphine Anti-emetic Clopidogrel/ticagrelor ```
53
What are the symptoms of atrial fibrillation?
``` Asymptomatic Palpitations Breathlessness Chest pain Syncope Stroke ```
54
How is atrial fibrillation diagnosed?
Irregular pulse ECG Echo
55
What are the major risk factors for stroke in atrial fibrillation?
Previous stroke TIA/embolism Age >75
56
How is atrial fibrillation managed?
Anticoagulation - warfarin/dabigatran/rivaroxaban/apixaban | Rhythm control - cardioversion, antiarrythmic drugs (flecainide), catheter ablation
57
How is hypertension defined?
BP of >140/90 mmHg
58
What are the risk factors for hypertension?
Age, gender, ethnicity, genetics, diet, physical activity, obesity, alcohol, stress
59
How is hypertension managed?
ACEi or calcium channel blocker (>55, black) Both together Add thiazide diuretic Add another diuretic or alpha/beta blocker
60
What are the symptoms of endocarditis?
Fever Murmur Fatigue
61
How is endocarditis investigated?
Blood cultures | Echo
62
What is Duke's criteria for endocarditis?
2 major/1 major 3 minor/5 minor criteria Major - 2 blood cultures, echo, new valve Minor - predisposition, fever, vascular, immunological
63
How is endocarditis managed?
IV antibiotics for 4-6 weeks
64
What are the symptoms of alcoholic liver disease?
``` Malaise Nausea Hepatomegaly Fever Jaundice Sepsis Encephalopathy Ascites Renal failure Death ```
65
What are the signs of portal hypertension?
``` Hypersplenism Oesophageal varices Encephalopathy Ascites Hepato-renal syndrome ```
66
How is ascites managed?
Low salt diet | Diuretic (spironolactone, furosemide)
67
How is encephalopathy managed?
Lactulose
68
What are the symptoms of hepatitis?
``` Malaise Fever Headaches Anorexia Nausea Vomiting RUQ pain Dark urine Jaundice ```
69
How is hepatitis managed?
Interferon | Tenofovir/entecavir
70
How can hepatitis B be prevented?
Education Immunisation Mother to child
71
How is hepatitis C cured?
Direct acting antivirals for 8-12 weeks
72
How is pancreatitis diagnosed?
Classic pain (central to back, eases on leaning forward) Blood amylase 3x upper limit of normal Characteristic CT
73
What are the causes of pancreatitis?
``` Gallstones Alcohol Trauma (ERCP) Drugs Autoimmune Viral ```
74
How is pancreatitis treated?
``` A-E assessment Fluids Oxygen Allow body to recover Treat cause Necrosectomy ```
75
What are the complications of pancreatitis?
Pseudocyst Fistula Necrosis Diabetes
76
What are the symptoms of cholecystitis (gallstones)?
RUQ pain Fever Raised WCC Normal amylase
77
How is coeliac disease managed?
Gluten free diet
78
What are the histological features of coeliac disease?
Atrophy of villi Crypt hyperplasia Intraepithelial lymphocytes
79
What are the symptoms of coeliac disease?
``` Diarrhoea/constipation Flatulence Nausea and vomiting Recurrent stomach pain Cramping/bloating. Tiredness ```
80
What are the symptoms of critical limb ischaemia?
``` Severe pain or Numbness in the legs and feet Decrease in the temperature Toe or foot sores/infections/ulcers Gangrene Shiny, smooth, dry skin Thickening of the toenails Absent or diminished pulse ```
81
How is critical limb ischaemia treated?
Angioplasty and shunt | Bypass
82
What are the symptoms of an upper GI bleed?
Haematemesis Coffee-ground vomit Melaena
83
How is an upper GI bleed managed?
``` A-E assessment Resuscitation - fluids, oxygen Endoscopy Blood transfusion Antibiotics, beta-blocker and terlipressin TIPS/banding/balloon tamponade (varices) ```
84
What are the symptoms of asthma?
``` Wheeze Cough Breathlessness Exercise intolerance Trigger ```
85
How is asthma diagnosed?
Serial peak flow measurements | Spirometry reversibility
86
How is asthma managed?
SABA and ICS
87
How is an acute asthma attack managed?
``` A-E assessment Oxygen Salbutamol nebuliser Ipratropium bromide nebuliser Prednisolone (oral/IV) Magnesium sulphate infusion ```
88
What are the 2 pathophysiological components of COPD?
Chronic bronchitis - sputum most days for 3 months in 2 years Emphysema - permanently enlarged airspaces
89
What are the symptoms of COPD?
``` Exertional breathlessness Chronic cough Regular sputum production Frequent winter bronchitis Wheeze ```
90
How is COPD managed?
Bronchodilators (SABA, LABA) Corticosteroids Oxygen therapy Mucolytics
91
What is a blue bloater and pink puffer?
BB - chronic bronchitis, type 2 respiratory failure | PP - emphysema, type 1 respiratory failure
92
What are the symptoms of a pneumothorax?
``` Pleuritic chest pain Breathlessness Respiratory distress Reduced air entry Hyper-resonance Tracheal deviation ```
93
What investigations may aid diagnosis of pneumothorax?
X-ray | CT
94
What are the management options for a pneumothorax?
Observation Aspiration Intercostal drain
95
Where would you aspirate gas from a pneumothorax?
2nd intercostal space mid clavicular line
96
What are the symptoms of extrinsic allergic alveolitis/hypersensitivity pneumonitis?
``` Flu-like Cough Fever Chills Dyspnoea Malaise Chest tightness Myalgia Sputum production Weight loss ```
97
How is extrinsic allergic alveolitis/hypersensitivity pneumonitis managed?
Avoid trigger Corticosteroids Cytotoxics Oxygen
98
What are the symptoms of pulmonary fibrosis?
Breathlessness Hacking dry cough Fatigue and weakness Appetite and weight loss
99
What are the signs of pulmonary fibrosis?
Finger clubbing Bibasal crackles Subpleural honeycombing
100
How is pulmonary fibrosis investigated?
High resolution CT | Video assisted thoracoscopic surgery (biopsy)
101
How is pulmonary fibrosis managed?
Symptomatic Oxygen Pulmonary rehabilitation Transplant
102
What are the 3 types of skin cancer?
Basal cell carcinoma Squamous cell carcinoma Malignant melanoma
103
How is basal cell carcinoma managed?
Surgical excision with 3-4mm margin
104
How is squamous cell carcinoma managed?
Surgical excision with 4mm margin
105
What are the risk factors for melanoma?
``` Genetics Family history UV radiation Sunburn Fair skin History of melanoma High socioeconomic status Immunosuppression ```
106
What classification is used to determine prognosis of melanoma?
Breslow depth
107
How is malignant melanoma treated?
Surgical excision with 1-2cm margin | Immunotherapy (ipilimumab)
108
What types of eczema are there?
Atopic Seborrhoeic Varicose Contact
109
How is eczema managed?
``` Emollients Topical steroids Antihistamines Antibiotics/antivirals/antifungals Immunosuppressants Biologic agents Avoid triggers ```
110
What is the Koebner phenomenon?
Psoriasis develops at site of trauma/scars
111
What are the symptoms of psoriasis?
Salmon pink plaques on extensor surfaces Onycholysis Pitting/thickened/dystrophic nails Psoriatic arthritis
112
How is psoriasis managed?
``` Topical moisturiser, steroid, vitamin D analogue, retinoids UV phototherapy Oral retinoids Methotrexate/cyclosporin Biologics (abalumimab) ```
113
What are the symptoms of hyperthyroidism?
``` Weight loss Irritability/restlessness Malaise Itching Sweating Breathlessness Palpitations Heat intolerance Muscle weakness Stiffness Tremor Diarrhoea Eye changes Oligomenorrhoea Loss of libido ```
114
What are the symptoms of hypothyroidism?
``` Tiredness Weight gain Cold intolerance Depression Poor memory Dry/brittle hair Dry/course skin Arthralgia Myalgia Muscle weakness Constipation Menorrhagia ```
115
How is hypothyroidism managed?
Levothyroxine
116
How is hyperthyroidism managed?
Beta-blocker Carbimazole/propylthiouracil Radioactive iodine
117
What antibodies are involved in thyroid disease?
TSH receptor antibody - Grave's | TPO antibody - Hashimoto's
118
What are the symptoms of diabetes?
``` Excessive thirst and hunger Frequent urination Weight loss Fatigue Irritability Blurred vision Slow-healing wounds Nausea Skin infections Acanthosis nigricans Fruity/sweet/acetone breath Tingling or numbness in the hands or feet ```
119
What are the x-ray features of osteoarthritis?
Narrowed joint space Osterophytes Subchondral sclerosis Subchondral cysts
120
What are the joint features of rheumatoid arthritis?
``` Boutonniere deformity Swan neck deformity Z-thumb Subluxation of wrist Ulnar deviation of digits Radial deviation of wrist Piano key ulnar head ```
121
What investigations can be used to diagnose rheumatoid arthritis?
Rheumatoid factor Anti-CCP ANA Imaging - x-ray
122
How is rheumatoid arthritis managed?
Occupational/physiotherapy NSAIDs/analgesia DMARDs (methotrexate, sulfasalazine) Biologics (anti-TNF infliximab, anti-CD20 rituximab, anti-IL6 tocilizumab)
123
How is a hot, swollen joint investigated?
Synovial fluid aspirate Gram stain and culture Polarised microscopy Blood culture
124
What are the symptoms of reactive arthritis?
Non-gonococcal urethritis, post-infectious arthritis, conjunctivitis
125
How are gout and pseudogout differentiated using polarised light microscopy?
Gout - negatively bifringent, needle shaped crystals of sodium urate Pseudogout - weakly positive birefringent rhomboidal crystals of sodium pyrophosphate
126
How is gout managed?
Acute - NSAIDs, colchicine | Chronic - urate lowering therapy (e.g. allopurinol, xanthine oxidase inhibitor)
127
What investigations are used for diagnosing disseminated intravascular coagulation?
Look for underlying cause Coagulation panel D-dimer FBC and blood film
128
How is isseminated intravascular coagulation managed?
Fresh frozen plasma | Platelets
129
What is the most common pathogen to cause pneumonia?
Streptococcus pneumoniae
130
What are the symptoms of bacterial pneumonia?
Abrupt cough Pleuritic chest pain High fever
131
What are the signs of bacterial pneumonia?
Consolidation (dull percussion) Coarse crepitations Increased vocal resonance
132
How is bacterial pneumonia treated?
Penicillin | doxycycline if allergy
133
What is the CURB65 score?
``` Clinical assessment of pneumonia - >2 severe C - confusion U - urea (>7) R - respiratory rate (>30) B - BP <90/<60 mmHg 65 - age >65 ```
134
How can pneumonia be investigated?
ABG Chest x-ray Blood/sputum culture
135
How is TB treated?
Rifampicin Isoniazid (prophylactic pyridoxine) Pyrazinamide Ethambutol
136
What is the most likely STI to cause urethral discharge?
Gonorrhoea (neisseria gonnorhoea)
137
How is gonorrhoea treated?
Ceftriaxone IM and azithromycin oral
138
How is chlamydia treated?
Doxycycline
139
What are the symptoms of syphilis?
``` Macropapular rash Patchy alopecia Lip/anal chancre Ophthalmic Aortic root dissection ```
140
How is syphilis treated?
Penicillin IM
141
How are genital warts treated?
Topical podophyllotoxin Aldara immune modulator Liquid nitrogen
142
How is herpes treated?
Aciclovir
143
What are the symptoms of HIV?
``` Macropapular rash Glandular fever Weight loss Mouth sores Myalgia Fever Nausea and vomiting Headache Diarrhoea Oesophageal candida ```
144
How is HIV treated?
HAART - highly active antiretroviral treatment (triple therapy)
145
When can a person with HIV have unprotected sex?
Viral load undetectable (<200) for >6 months - untransmissible

OSCE 3 (3 decks)

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