Osce Questions

Introduction to NAC OSCE General Information............................................................... Registration for NAC OSCE................................................ Fees......................................................................................... Examination station............................................................... NAC OSCE scoring.............................................................. Sample of Therapeutic written test........................................ Sample clinical case station.................................................... Therapeutic Guidelines Medicine Cardiology.............................................................................. Dermatology........................................................................... Endocrinology........................................................................ Gastroentermogy.................................................................... Hematology............................................................................ Infectious Diseases................................................................. Neurology............................................................................... Otolaryngology...................................................................... Pulmonology.......................................................................... Rheumatology........................................................................ Nephrology/Urology.............................................................. Emergency Medicine.............................................................. Counseling (smoking/alcohol).............................................. Obstetrics & Gynecology Sexually transmitted infections.............................................. Urinary tract infection............................................................ Vulvovaginitis......................................................................... Pelvic inflammatory disease................................................... Dysfunctional uterine bleeding............................................. Dysmenorrhea........................................................................ Endometriosis........................................................................ Hormone replacement therapy.............................................. Emergenqr contraception....................................................... Group B Streptococcus in pregnancy.................................... Pregnancy induced hypertension........................................... Ectopic pregnancy.................................................................. Hyperemesis gravidarum........................................................ Drugs contraindicated in pregnancy...................................... Pediatrics Acute bronchiolitis................................................................. Acute otitis media.................................................................. Asthma................................................................................... Bacterial tracheitis.................................................................. Bacterial pneumonia............................................................... Croup (Laryngotracheobronchitis)........................................ Epiglottitis.............................................................................. Streptococcal pharyngitis (Group A streptococcus).............. Whooping cough (Pertussis)................................................. Bacterial meningitis................................................................ Febrile seizures....................................................................... Urinary tract infection............................................................ Allergic reaction...................................................................... Anemia................................................................................... Dose of tylenol....................................................................... Immunization schedule..........................................................

TABLE OF CONTENTS ...1 ...1 ...1 ...1 ...2 ...2

...3 ...7

.11 .14 .16 .19 .19 .21

.23 .24 .26 .29 .30 .35 .38 .39 .39 .40 .40 .40 .40 .41 .41 .41 .41 .42 .42 .42 .45 .45 .45 .45 .46 .48 .48 .48 .48 .49 .49 .49 .50 .50 .50 .50 Psychiatry Delerium.....................................................................................................................................52 Mania..........................................................................................................................................53 Panic disorder..............................................................................................................................53 Social phobia...............................................................................................................................54 General anxiety disorder.............................................................................................................54 Obsessive compulsive disorder....................................................................................................55 Post traumatic stress disorder......................................................................................................55 Dementia.....................................................................................................................................55 Depression...................................................................................................................................56 Psychosis......................................................................................................................................56 Mood stabilizers..........................................................................................................................57 Medications causing sexual dysfunction.....................................................................................58 Substance abuse...........................................................................................................................59 Clinical Examination Abdominal ..................................................................................................................................63 Cardiovascular ............................................................................................................................65

Peripheral vascular ......................................................................................................................67 Respiratory examination.............................................................................................................69 Central nervous system ..............................................................................................................71 Upper limb neurological .............................................................................................................73 Lower limb neurological ............................................................................................................75 Musculo-skeletal system : Spine/Back........................................................................................77 Hip..............................................................................................................................................79 Knee.............................................................................................................................................81 Foot and ankle.............................................................................................................................83 Shoulder......................................................................................................................................85 Elbow..........................................................................................................................................87 Hand and wrist............................................................................................................................88 Breast examination......................................................................................................................90 Thyroid........................................................................................................................................91 Mini Mental State Examination.................................................................................................93 Clinical cases Protocol for history taking..........................................................................................................99 Medicine Atrial fibrillation.......................................................................................................................102 Asthma......................................................................................................................................103 Congestive heart failure.............................................................................................................104 Cerebrovascular attack..............................................................................................................105 Dieoxin toxicity.........................................................................................................................106 Infectious mononucleosis (sore throat).....................................................................................107 Impotence..................................................................................................................................108 Meningitis.................................................................................................................................109 Migraine (Headache)................................................................................................................110 Myocardial Infarction(Chest pain)............................................................................................Ill Pneumonia.................................................................................................................................112 Post exposure prophylaxis for HIV...........................................................................................113 Pulmonary embolism................................................................................................................114 Seizure disorder.........................................................................................................................115 Temporal arteritis......................................................................................................................116 Viral hepatitis............................................................................................................................117 Obstetrics and Gynecology Abortion....................................................................................................................................118 Antenatal visit...........................................................................................................................119 Ectopic pregnancy.....................................................................................................................120

TABLE OF CONTENTS

Infertility....................................................................................................................................121 OCP counseling.........................................................................................................................122 Pelvic inflammatory disease.......................................................................................................123 Placenta previa...........................................................................................................................124 Pre eclampsia..............................................................................................................................125 Pediatrics Failure to thrive..........................................................................................................................126 Febrile seizure............................................................................................................................127 Measles......................................................................................................................................128 Neonatal jaundice.......................................................................................................................129 Primary nocturnal enuresis........................................................................................................130 Pyloric stenosis...........................................................................................................................131 Speech delay...............................................................................................................................132 Psychiatiy Anorexia.....................................................................................................................................133 Bulimia.......................................................................................................................................134 Delirium.....................................................................................................................................135 Dementia....................................................................................................................................136 Depression..................................................................................................................................137 Mania.........................................................................................................................................138 Panic attack................................................................................................................................139 Schizophrenia.............................................................................................................................140

Suicide........................................................................................................................................141 Surgery Back Pain....................................................................................................................................142 Basal cell carcinoma...................................................................................................................143 Benign prostatic hyperplasia......................................................................................................144 Carpal Tunnel Syndrome...........................................................................................................145 Deep Vein Thrombosis..............................................................................................................146 Diabetic foot..............................................................................................................................147 Difficulty swallowing (Ca oesophagus )....................................................................................148 Hematemesis..............................................................................................................................149 Neck swelling.............................................................................................................................150 Pain abdomen.............................................................................................................................151 Peripheral vascular disease.........................................................................................................152 Post operative fever....................................................................................................................153 Solitary lung nodule...................................................................................................................154 Thyroid mass..............................................................................................................................155 Trauma.......................................................................................................................................156 Counseling Breast feeding.............................................................................................................................159 Child abuse................................................................................................................................160 Domestic violence......................................................................................................................161 Hormone replacement therapy..................................................................................................161 Mammogram.............................................................................................................................163 Immunization.............................................................................................................................164 Obesity.......................................................................................................................................165 Smoking.....................................................................................................................................167

TABLE OF CONTENTS

Introduction to NAC OSCE | General Info 1

Introduction to NAC OSCE General Information The National Assessment Collaboration, or NAC OSCE, was established to provide a system that streamlines the assessment of IMG medical knowledge and clinical skills throughout Canada. Many international medical graduates (IMGs) find that the path to obtaining a medical license in Canada challenging and difficult to navigate. Different provinces and territories have their own system for assessing IMG medical knowledge and clinical skills. Comprised of a number of federal and provincial assessment and educational stakeholders, the NAC OSCE aims to streamline the evaluation process through which an IMG must navigate to obtain a license to practice medicine in Canada. Through such a system, an IMGs path to licensure would be the same, regardless of the jurisdiction in which he or she is being assessed. The NAC OSCE has replaced C EH PE As Clinical Examination 1 (CEI), which was unique to Ontario.

Registration for NAC OSCE Registration for the NAC OSCE in Ontario starts in November, with the deadline in January the next year. Candidates are advised to complete their registration within this time-frame. Once the deadline is over, the candidate will not be able to register for the NAC OSCE for the entire year. The exams are scheduled for March, June, August and September. Visit www.mcc.ca and www.cehpea.ca for updated information.

Fees

Application Fee: $200 which is non-refundable, NAC OSCE Fee in Ontario: $1850 and Exam Date Change Fee: $100 All fees are in (CAD) Canadian Dollars.

Examination station The format for the National Assessment Collaboration (NAC) Objective Structured Clinical Examination (OSCE) consists of 12 stations based on presentations of clinical scenarios. For a given administration, each candidate rotates through the same series of stations. Each station is 10 minutes in length with two minutes between stations. At each station, a brief written statement introduces a clinical problem and outlines the candidate's tasks (e.g. take a history, do a physical examination, etc.). In each station, there is at least one standardized patient and a physician examiner. Standardized patients have been trained to consistently portray a

patient problem. Candidates should interact with standardized patients as they would with their own patients. The physician examiner observes the patient encounter. For most stations, the candidate will be asked to respond to a series of standardized oral questions posed by the physician examiner after seven minutes with the standardized patient. There are no rest stations. Orientation videos http://www.mcc.ca/en/video/QEII-Orientation/index.html

2 NAC OSCE | A Comprehensive Review

The examination includes a separate written test of candidates' therapeutic knowledge. This component lasts 45 minutes and consists of 24 short-answer questions testing the candidates' knowledge of therapeutics for patients across the age spectrum and related to pharmacotherapy, adverse effects, disease prevention and health promotion.

NAC OSCE scoring

The candidate's total examination score will be determined by combining the scores on the OSCE component with the scores on the therapeutics component. The OSCE score contributes 75 per cent of the total score and the therapeutics score contributes 25 per cent of the total score. For reporting purposes, the NAC total examination scores are reported on a scale with a distribution ranging from 0 to 100 with a fixed passing mark of 65.

Number of times candidates can take the examination Starting in 2011, the NAC OSCE can be attempted once per Canadian Resident Matching Service (CaRMS) cycle. If you pass the examination, you can register for the examination a maximum of two additional times if your eligibility is maintained. Regardless of whether you pass or fail, you can only take the examination three times. If you take the examination more than once, the most recent result will be the only valid result.

Sample of Therapeutic written test

Question: An otherwise healthy 65 year old woman presents with a 3 week history of aching and morning stiffness in both shoulders with difficulty dressing. She has no temporal artery tenderness, headache, jaw pain or visual disturbance. Her ESR (Erythrocyte sedimentation rate) is 100 and you have made the diagnosis of POLYMYALGIA RHEUMATICA (PMP). What would you choose as the drug of first choice for initial medical therapy? (Drug, dose, route of administration and duration are required.) Answer:_______________________________________________________ Answer key the marker receives: PREDNISONE 7.5 - 20 mg PO od for 2-4 weeks following resolution of symptoms Question: An otherwise healthy 55 year old male with a history of childhood “chickenpox" presents with a 2 day history of painful unilateral vesicular eruption in a restricted dermatomal distribution. You make a diagnosis of HERPES ZOSTER (shingles). What would you choose as the drug of first choice to promote healing and lessen the neuropathic pain? (Drug, dose, route of administration and duration are required.) Answer:__________________________________________________________ Answer key the marker receives: VALACYCLOVIR (VALTREX ®) 1000 mg PO tid X 7 days OR FAMCICLOVIR (FAMVIR ®) 500 - 750 mg PO tid X 7 days OR ACYCLOVIR (ZORIVAX ®) 800 mg PO 5X / day X 7 days)

Introduction to NAC OSCE | General Info 3 Sample Clinical Case Station

Example instruction written outside the station David Thompson, 59 years old, presents to your office complaining of jaundice. In the next 7 minutes, obtain a focused and relevant history. After the 7 minutes, you will be asked to answer questions about this patient. Example of post encounter questions Ql.The abdominal examination of David Thompson revealed no organ enlargement, no masses and no tenderness. What radiologic investigation would you first order to help discriminate the cause of the jaundice? Q2. If the investigations revealed that this patient likely had a post-hepatic obstruction, what are the two principal diagnostic considerations? Q3. What radiologic procedure would you consider to elucidate the level and nature of the obstruction?

Therapeutic Guidelines This isa

Therapeutic Guidelines | Medicine 7

Therapeutic Guidelines Medicine 1. Cardiology Acute Myocardial Infarction : Immediate management in ER 1. Beta blockers: Inj Metoprolol 2.5-5 mg rapid IV q2-5 min, upto 15 mg over 10-15 minutes, then 15 minutes after receiving 15 mg IV. 2. Then 50 mg PO q6h x 48 hours, then 50-100 mg PO BID. 3. Inj Morphine Sulfate IV 2-5 mg every 5-30 min prn (If pain not relieved with 3 Sublingual Nitroglycerins) 4. Oxygen by nasal cannula at 4 liters per minute 5. Sublingual Nitroglycerin 0.3-0.6 mg q5min up to 3 times. 6. Non-enteric coated Aspirin 325 mg PO. 7. Cardiology Consultation Post MI drugs Drugs Benefits Side effects Cofitraliidiiiil Wi ACE Inhibitors Ramipril - 10mg hs Lisinopril - lOmgod Enalapril - 20mg od Captopril - 50 mg tid 1 mortality Prevents ventricular remodelling 1 proteinuria Hypotension/dizziness Hyperkalemia Angioedema Renal insufficiency Cough, taste changes Bilateral renal artery stenosis Hx of angioedema Pregnancy ARB Valsartan - 160mgbid Candesartan - 32 mg od 1 mortality 1 proteinuria Angioedema Cough, taste changes Beta Blocker Metoprolol - lOOmg bid Atenolol - lOOmg od Carvedilol - 25mg bid Propranolol - 60-80 tid 1 mortality 1 sudden death, reinfarction & arrhythmias Cardioselective : preferred for mild asthma and diabetes Decreases BP&HR Dizziness, fatigue Sexual dysfunction May mask hypoglycemia Increase risk of cardiogenic shock Severe/poorly controlled asthma 2nd/3rd degree heart block HR<50, SBP<90 Cocaine use Statins Atorvastatin - 10mgod Simvastatin - 20-40mg od 1 mortality in post Ml patients with high cholesterol Gl upset, muscle aches, myopathy, rhabdomyo- lysis, Impotence Active liver disease, alcoholics, pregnancy Anti-platelets ASA - 80-162mg od Clopidogrel - 75mgod Warfarin - 1-10mgod 1 vascular events Gl upset, hypersensitivity Gl bleed Recent/active bleeding Gl intolerance or ASA allergy MNEMONIC B : Beta Blockers M : Morphine Sulphate 0:0xygen N : Nitroglycerin A : Aspirin


Atrial Fibrillation 1. To control rate: • Inj Metoprolol 5 mg bolus IV, followed by infusion at 0.05 mg/kg/min, increasing as needed to 0.2 mg/kg/min. • Inj Diltiazem 20 mg bolus. Maintenance infusion of 5-15 mg/hr. • Inj Verapamil 5-10 mg IV over 2-3 min, repeated once after 30 mins. • Tab Amiodarone (in case of heart failure): • Loading dose: 800 - 1600 mg PO in divided doses until response; till max 1000 mg/day divided bid-tid. • Maintenance: 200 mg PO od. 2. To prevent thromboembolism: Assess with CHADS 2 score • No risk: Tab Aspirin 81-325 mg PO od. • 1 moderate risk: Tab Aspirin 81-325 mg PO od or Tab Warfarin 2-15 mg PO od to maintain INR 2-3. • >1 moderate risk or very high risk: Tab Warfarin 2-15 mg PO od to maintain INR 2-3. 3. To control rhythm: • Tab Flecainide 300-400 mg PO bolus dose, maintenance: 50-150 mg PO bid. (First choice)

• Tab Sotalol 80-160 mg PO bid. ( Second choice) • Tab Amiodarone (in case of heart failure): • Loading dose: 800 - 1600 mg PO in divided doses until response; till max 1000 mg/day divided bid-tid. • Maintenance: 200 mg PO od. • Electrical Cardioversion: 100-360 joules. Congestive Cardiac Failure : Immediate management in the ER • Oxygen by nasal cannula at 4 liters per minute. • Inj Furosemide (Lasix) 10 mg IV stat. • Inj Morphine sulfate IV 2-5 mg every 5-30 min prn. • Sublingual Nitroglycerin 0.3-0.6 mg q5min up to 3 times. • Position of patient > 45 degrees. Non pharmacological management of Heart Failure • Exercise : Regular physical activity • Salt restriction : symptomatic HF - 2-3g salt/day (Vfc tsp/day) no added salt in diet. HF with fluid retention : l-2g salt/day (V4 tsp/day) • Fluid intake : 1.5/2L per day in patients with fluid retention or HF not controlled by diuretics. • Daily weight measurement. • Education. • Aggressive risk reduction (BP, glucose, lipids). • Lifestyle modifications, influenza vaccination. Off TREATMENT MNEMONIC L: Lasix M : Morphine Sulphate N : Nitroglycerin 0:0xygen P : Positive airway pressure P : Position > 45 degrees D : Dopamine (indicated in cardiogenic shock and hypotension)_________


Dyslipidemia 1. HMG Co A Inhibitors: • Atorvastatin : Tab Lipitor 10-80 mg qhs • Rosuvastatin : Tab Crestor 10-40mg qhs • S/E: Gl symptoms, rash, pruritus, increased liver enzymes, myositis. • C/I: active liver disease, muscle disease, pregnancy. 2. Fibrates: increased TG (triglycerides) • Fenofibrate : Tab Lipidil 67-200 mg/d 3. Bile acid sequestrants : increased LDL • Tab Colestipol 5-30g/day 4. Cholesterol absorption inhibitors: • Tab Ezetimibe lOmg /day. Lipid Risk LDL Total cholesterol/HDL HIGH (lOyrCAO >20%) Target LDL-<2.0 Target <4 MODERATE (10yr CAD > 10-19%) Treat if LDL- >3.5 Treat if >5 LOW (10yr CAD <10%) Treat if LDL ->5 Treat if >6 High Risk : All with CAD, CVD, most diabetes cases & chronic renal disease.

Hypertension Non pharmacological treatment : • Smoking cessation: smoking aggravates hypertension and remains the major contributor to cardiovascular disease in people under 65 years. • Weight reduction : Maintain BMI<27, particularly in patients with glucose intolerance • Alcohol restriction. • Sodium restriction <150mmol/day. Blood pressure risk factors Consider treatment if BP BP target No risk factors >160/100 <140/90 isolated systolic hypertension

SBP>160 SBP<140 Moderate-High risk patient >140/90 <140/90 Diabetes or Renal disease >130/80 <130/80


Commonly used anti-hypertensive drugs : Drug Indication Side Effect Diuretics Hydrochlorothiazide HCT - 12.5-25mgod Spironolactone - 25-50mg od Uncomplicated HTN, Diabetes with normal albuminuria, LVH and isolated systolic HTN Rash, allergic rxn, pancreatitis, sexual dysfunction. HCT contraindicated in gout. Beta Blockers Metoprolol - 50mg bid or 100mg SR od Propranolol - 80mg bid Atenolol - 50-100mgod Stable angina, Ml, LVH, uncomplicated HTN <60 years, Fatigue, insomnia, 1 HR, impotence, dizziness. C/I - asthma/COPD, 2"<,/3,,, degree heart block, uncompensated HF severe PAD ACE Inhibitors Ramipril - 10mghs Lisinopril - 10mgod Enalapril - 10-20mgod Captopril - 25-50 mg bid Heart failure, diabetes, post Ml, uncomplicated HTN, LVH, prior CVA/TIA, renal disease, all coronary artery disease pts. Cough, loss of taste, rash, angioedema, renal failure, IBP C/I - b/l renal artery stenosis, Hx of angioedema, pregnancy Angiotensin II Receptor Blockers Losartan - 25-50mg od Valsartan - 80-160mgod Candesartan - 8-16mgod Diabetes, uncomplicated HTN, isolated systolic HTN, LVH, patients unable to tolerate ACEI. Fatigue, headache, rash, angioedema, i BP, t K+, pancreatitis. C/I - b/l renal artery stenosis, Hx of angioedema, pregnancy Calcium Channel Blockers Amlodipine - 2.5-10mgod Nefidipine- 10mgtid Verapamil - 40-80mg tid Diltiazem - 30-60mgtid Uncomplicated HTN, LVH, Angina, Isolated systolic HTN, diabetes without nephropathy Dizziness, headache, rash, edema, gingival hypertrophy, worsen HF C/I - hypotension, recent Ml with pulmonary edema, sick sinus syndrome, 2nd/3rd AV block Methyldopa - 125mg bid to 500mgqid First-line for hypertension in pregnancy Sedation, dry mouth, hepatotoxic, lupus like symptoms.

Infective Endocarditis Prophylaxis • Inj Ampicillin 2g IV q4h x 4weeks. • Inj Gentamicin 1 mg/kg IV q8h x 4 weeks. • Prophylaxis: Dental/respiratory/esophageal procedure: Tab Amoxicillin 2g PO 30-60 min prior; Tab Clindamycin 600mg PO, if allergic to penicillin. Rheumatic Heart Disease (EHD) • Tab Erythromycin 500 mg tid PO x lOdays. • Tab Penicillin VK 500 mg PO bid x 10 days.

Therapeutic Guidelines | Medicine 11 2. Dermatology

Acne Mild : <20 comedones (whiteheads/blackheads) or <15 inflammatory papules, or a lesion count <30 Moderate : 15-50 papules and pustules with comedones, cysts are rare, lesion count ranges from 30-125 Severe : Primarily nodules and cysts,also present are comedones, papules and pustules, scarring is present, lesion count >125 T 0 P

i Benzoyl Peroxide (Antibacterial/Keratolytlc) Dose : apply to entire affected area qhs or bid Indication: 1st line medication for mild- moderate acne. S/E : contact dermatitis, dryness, erythema, burning & pruritis c A

Tretinoin (Retinoid) 1st line treatment for mildS/E : erythema, dryness,

L

Dose : qhs, apply 30-45 minutes after wash moderate comedones acne. burning, photosensitivity. Oral antibiotics Indicated for moderateS/E : Gl upset, nausea, Tetracycline - initial 500mg bid then 250-500mg od severe acne. vomiting, candidiasis. Doxycydine - 100mgod Erythromycin - initial 500mg bid then 250-500mg od Acne on chest, back & shoulders C/I : liver disease S Combined Oral Contraceptive Females with moderateC/I : Smoking, migraine with Y 5

Diane 35/Yasmin/Alesse : od x 21 days, 7 days severe acne + seborrhea + aura, seizures T

off/cycle hirsutism, late onset acne E M

Isotretinoin Severe nodulocystic acne, Teratogenicity : ocular 1

Accutane : 0.5-1 mg/kg/day x 16-20 weeks acne with scarring, failure to effects - conjunctivitis, c "Important : Tests for pregnancy 30 days prior to starting Accutane, before each refill. Patient has to sign an informed consent. respond to other treatments 1 night vision, premature epiphyseal closure, t LFTs, pseudomotor cerebri, mucocutaneous effects, myalgias. Photosensitivity.

Bums • Initial assessment of ABCs , consider the need for early intubation if airway is compromised. • Humidified 02 if any suspicion for inhalational injury. • Oxygen 100% if known carbon monoxide exposure of fire in an enclosed space. (Half life of hemoglobin will drop from 330 to 90 mins). • Establish IV access. • Fluid resuscitation : Parkland formula 4mL/kg/%BSA burn, Vi over 8 hours and rest over 16 hours • Nasogastric tube drainage for ileus. • Bladder catheterization to monitor urinary output, minimum lmL/kg/hr. • Tetanus prophylaxis : 0.5 mL tetanus toxoid IM in previously immunized and 250 units TIG IM if unimmunized.


Psoriasis Topical Preparations : 1. Topical Corticosteroids : • High Potency Topical Steroids (Usually indicated) • Very high potency: e.g. Clobetasol (Temovate) • High potency: e.g. Fluocinonide (Lidex) • Low Potency Topical Steroids (Alclometasone dipropionate) usually indicated in • Face • Genitals • Maintenance Therapy 2. Vitamin D based topicals : • Calcipotriene (Dovonex) • Used in combination with Topical Corticosteroids 3. Retinoid based topicals : • Tazarotene (Tazorac)

• More irritating than Calcipotriene 4. Immunosuppressant based topicals : • Tacrolimus 0.1% or Pimecrolimus 0.1% creams Effective in facial and intertriginous Psoriasis 5. Adjunctive agents in combination with above : • Topical Salicylic Acid (Keratolytic Agent) 6. Poorly tolerated topicals (use Calcipotriene instead) : • Historically used with UVB light exposure • Anthralin (Anthra-Derm) • Coal Tar (e.g. Zetar) Ultraviolet light • Risk of non-Melanoma skin cancer • Protocols • Ultraviolet B exposure alone • Ultraviolet A exposure with psoralen (PUVA) Increased risk of non-Melanoma skin cancer Systemic agents (most are for higher risk) • Immunosuppressants • Etretinate • Cyclosporine • Methotrexate (unclear efficacy)


• Biological agents • Tumor necrosis factor (TNF) receptor blockers Etanercept (Enbrel) Infliximab (Remicade) • Other mechanisms Alefacept (Amevive) Efalizumab (Raptiva) • Thiazolidinedione (Avandia, Actos) - experimental • Appears effective in Psoriasis even in non-diabetics • Only small trials support to date Cellulitis • Cause : P Hemolytic Streptococcus , Staphylococcus • Treatment : Tab Cloxacillin 500mg PO qid x 10-14 days If patient is allergic to penicillin : Tab Cephalexin 500mg PO qid 10-14 days OR Tab Clindamycin 300mg PO qid x 10-14 days Pediculosis • Permethrin 1% - wash hair with regular shampoo, then apply permethrin and leave for 10 mins then rinse • Pyrethrins with piperonyl butoxide • Lindane 1% C/I in neonates, young children and pregnant women, causes neurotoxicity • Wash all clothes and linen in hot water, then machine dry. Scabies • Permethrin 5% - massage into all skin areas, from the top of the head to the soles of the feet, leave for 814 hours then wash off. • Crotamiton 10% • Scabene (aerosol spray) • Lindane : used only if allergic to permethrin. • Treat family and contacts. • Wash all clothes and linen in hot water, then machine dry. Tinea Cruris/Pedis (Jock itch/Athlete's foot) • Clotrimazole 1% cream apply bid • Ketoconazole 2% cream apply bid

14 NAC OSCE | A Comprehensive Review 3. Endocrinology Diabetes Mellitus Blood glucose target A1C q3-6 months Target <7 Normal range<6 Fasting plasma glucose Target 4-7mmol/L Normal range 4-6mmol/L

Post prandial blood glucose 2h Target 5-10mmoi/L Normal range 5-8mmol/L

Approach to management of diabetes mellitus 1. Lifestyle modification & patient education 2. Oral hypoglycemic monotherapy : • Biguanides (Metformin) - 250-500mg PO bid-tid (if obese or overweight) • Sulfonylureas (Glyburide) - 80mg PO bid • Thiazolidinedione (Pioglitazone) - 15mg PO od; Rosiglitazone - 4mg PO od • Alpha glucosidase inhibitors (Acarbose) - 50mg PO tid 3. Oral combination therapy (2 agents often needed; after 3 years 50%, after 9 years 75%) 4. Insulin therapy +/- oral hypoglycemics Diabetic Ketoacidosis Management • Fluid replacement • Initial : Give 1 liter NS bolus over first 45 minutes, repeat fluid bolus until shock corrected. • Next : Replace first 50% volume deficit in first 8 hours, use Normal Saline or Lactated Ringers. Replace remaining 50% deficit over next 16 hours, use D5 1/2 NS at 150-250 ml per hour. • Insulin (Hypokalemia must be corrected prior to Insulin) • Initial i. Give IV bolus of 0.15 units/kg ii. Start 0.1 units/kg/hour Insulin Drip • Maintenance i. Anticipate Serum Glucose drop of 50-70 mg/dl/hour • If inadequate drop, then increase drip a) Increase Insulin Infusion rate by 50-100% b) Continue at increased rate until adequate ii. When Serum Glucose <200-250 mg/dl a) Keep Serum Glucose at 150 to 200 mg/dl b) Decrease rate by 50% (to 0.05 units/kg) or c) Discontinue Insulin Drip and start SC dosing


• Potassium Do not administer Insulin until potassium >3.3 • Give KC1 40 mEq/hour IV until corrects • Serum Potassium 3.3 to 5.0 mEq/L i. Standard replacement: 20-30 mEq per liter • Serum Potassium >5.0 mEq/L i. Do not administer any potassium ii. Monitor every 2 hours until <5.0 • Bicarbonate Indications i. ABG pH < 6.9 to 7.0 after initial hour of hydration ii. Other contributing factors • Shock or Coma • Severe Hyperkalemia Hyperthyroidism • Tab Propylthiouracil(PTU) 100 mg PO tid, to max 150 mg 6-8 hours. • Tab Methimazole 10-30 mg PO od. • Medications associated with Hyperthyroidism: Excess Thyroid hormone intake Dietary Iodine Amiodarone Hypothyroidism • Tab L-Thyroxine 0.05-0.2 mg/day • Medications associated with Hypothyroidism: i. Inorganic iodine ii. Iodide iii. Amiodarone iv. Lithium Hyperprolactinemia • Tab Bromocriptine 1.25-2.5 mg PO od, increase by 2.5 mg/day q3-7days to max 15 mg/day. • Tab Cabergoline 0.25 mg PO twice weekly, may increase by 0.25 mg q4weeks up to max lmg twice weekly.


Medications causing hyperprolactinemia a) Benzodiazepines b) Buspirone c) MAOI d) SSRI e) TCA f) Valproic acid g) Methyldopa h) Verapamil i) Atenolol j) Danazol k) Estrogen 1) Depo-Provera m) OCPs n) Metoclopromide o) Amphetamines P) Cannabis Impotence • Tab Sildenafil 25-lOOmg per dose, to take half an hour to 4 hours prior to intercourse. S/E: flushing, headache, indigestion C/I: don't take with Nitrates.

4. Gastroenterology

Appendicitis Perioperative for 24hrs • Inj Ampicillin l-2g IV q4-6h. • Inj Flagyl 500mg IV bid. • Inj Gentamicin 3-5mg/kg/day q8h (monitor creatinine levels). • NPO Acute Gastroenteritis • Tab Flagyl 500 mg PO bid x 5 days. • Tab Ciprofloxacin 500 mg PO bid x 3 days. • Tab Norfloxacin 400 mg PO bid x 3 days. • Oral rehydration solution. Acute Gastroenteritis Causes (Watery diarrhea) E. Coll (Traveler's diarrhea) CMV Cryptosporidium Giardia lamblia

Therapeutic Guidelines | Medicine 17 Acute Pancreatitis • NPO • Inj Flagyl 400 mg IV q8h • Inj Meperidine 75-lOOmg IV q2-3h • I VF • NG tube • Replace calcium Crohn’s Disease

1. Mild to moderate: • Tab Mesalamine 800 mg PO tid. Maintenance dose 3.2 - 4g per day. • Tab Sulfasalazine 250 mg per day and increase up to 2 g per day. Maintenance dose is 500- 1000 mg PO qid with food. 2. Moderate to severe: • Tab Prednisone 40 mg PO qid x 8-12 weeks and taper gradually. • Tab Azathioprine 2-2.5 mg/kg/day. Used for maintenance while tapering corticosteroids. Diverticulitis • Inj Flagyl 500mg IV bid. • Inj Ciprofloxacin 500mg IV bid. Helicobacter Pylori 1. HP-PAC (7 blister pack) 7-14 days • Tab Lansoprazole 30mg PO bid + • Tab Clarithromycin 500mg PO bid + • Tab Amoxicillin lg bid 2. 2nd LINE Quadruple : 14 days • Tab Lansoprazole 30mg PO bid • Tab Flagyl 500mg PO bid • Tab Tetracycline 500mg bid • Tab Bismuth 525mg PO qid

18 NAC OSCE | A Comprehensive Review Hepatitis B post exposure prophylaxis 1. Known HBsAg Positive Source: i. Unvaccinated exposed patient: • Hepatitis B Immunoglobulin (HBIG) 0.06 ml/kg and • Hepatitis B Vaccine 0,land 6 months. ii. Exposed patient with known response to vaccine: • No treatment. iii. Exposed patient with known failed response to vaccine: • Patient has not yet completed second 3-dose series: • Hepatitis B Immunoglobulin (HBIG) 0.06 ml/kg and • Hepatitis B Vaccine (complete second 3-dose series) • Patient has completed two prior 3-dose series: • Hepatitis B Immunoglobulin (HBIG) 0.06 ml/kg • Second Hepatitis B Immunoglobulin dose. iv. Exposed patient with unknown response to vaccine: • Test for Antibody to HBsAg • Adequate Antibody (HBsAg Positive): No treatment • Inadequate Antibody (HBsAg Negative) • Hepatitis B Immunoglobulin (HBIG) 0.06 ml/kg and • Hepatitis B Vaccine booster dose: 2. Known HBsAg Negative Source: i. Administer Hepatitis B Vaccine Series if unvaccinated ii. No treatment otherwise needed. 3. Unknown HBsAg Source Status: i. Unvaccinated exposed patient • Hepatitis B Vaccine Series ii. Exposed patient with known response to vaccine • No treatment iii. Exposed patient with known failed response to vaccine • Treat source as HBsAg positive if high risk iv. Exposed patient with unknown response to vaccine • Test for Antibody to HBsAg • Adequate Antibody (HBsAg Positive): No treatment • Inadequate Antibody (HBsAg Negative) • Hepatitis B Vaccine initial and booster dose • Recheck titer in 1 to 2 months 4. Infant with HBsAg Positive Mother: i. Hepatitis B Immunoglobulin (HBIG) 0.5 ml within 12 hours of birth. ii. Hepatitis B vaccine: Dose 1 within 12 hours of birth, Dose 2 at age 1 months, Dose 3 at age 6 months. iii. Repeat HBsAg and HbsAb at 9 months &c 15 months.


Peptic ulcer disease • Tab Omeprazole 20mg PO od. • Tab Ranitidine 150 mg PO bid. Ulcerative Colitis • Tab Sulfasalazine 250 mg per day and increase up to 2 g per day. Maintenance dose is 500-1000 mg PO qid with food. • Tab Mesalamine 800 mg PO tid. Maintenance dose 3.2 - 4g per day. • Rectal suppositories preferred for proctitis. Acute Cholecystitis (Perioperative) • Inj Cefazolin 0.5-1.5mg IV q6h • NPO • I VF • NG Tube

5. Hematology Anemia • Iron Deficiency Anemia : Tab Ferrous fumarate(Palafer) 300 mg PO qd OR Tab Ferrous Sulfate 325 mg PO qd • Megaloblastic Anemia : Tab Ferrous Fumarate 300mg PO qd + Tab Folic acid l-5mg PO qd + Inj B12 1000 meg q monthly or 1000 - 2000 microgram PO.

6. Infectious Diseases

Prophylaxis for opportunistic infections in HIV patients • Pneumocystis carinii: CD4 count< 200 cells/mm3 or oral candidiasis. - Tab TMP/SMZ DS PO OD till CD4 counts rises. • Toxoplasma gondii: IgG antibody positive and CD4 count < 100 cells/mm3 - Tab TMP/SMZ DS PO OD till CD4 counts rises. • Mycobacterium tuberculosis: Man toux > 5 mm in immunocompromised or contact with active TB. - Tab Isoniazid 300 mg PO OD x 9 months along with - Tab Pyridoxine 50 mg PO OD. • Mycobacterium avium complex: CD4 counts < 50 cells/mm3. - Tab Azithromycin 1200 mg PO once a week. - Tab Clarithromycin 500 mg PO once a week. • Varicella zoster virus: Recent exposure to chicken pox or shingles. - Varicella zoster immune globulin within < 96 hours of exposure.

20 NAC OSCE | A Comprehensive Review HI V post exposure prophylaxis • Start within hours of exposure (under 24 to 48 hours). • Triple Therapy for 4 weeks: 1. First two medications: AZT and 3TC (or Combivir) i. Tab Zidovudine (AZT) 300 mg PO bid and ii. Tab Lamivudine (3TC) 150 mg PO bid. 2. Third medication (choose one): i. Tab Indinavir (IDV) 800 mg PO tid or ii. Tab Nelfinavir (Viracept) 750 mg PO tid or iii. Tab Efavirenz 600 mg PO qhs. • Obtain baseline labs to monitor for adverse reaction: 1. Pregnancy Test 2. Complete Blood Count with differential and platelets 3. Urinalysis 4. Renal Function Tests 5. Liver Function Tests Malaria 1. Treatment for active infection: i. Tab Chloroquine 1 g PO stat, then 500 mg PO 6-8 hours later, then 500 mg PO at 24 hours & 48 hours after initial dose. ii. Tab Mefloquine 1250 mg stat dose. iii. Tab Primaquine 15 mg base PO od x 14 days. 2. Chemoprophylaxis: i. Tab Chloroquine 500 mg PO once a week. ii. Tab Mefloquine 250 mg PO once a week. Pulmonary tuberculosis 1. Initiation Phase: Tab Rifampin 600 mg + Tab Isoniazid 300 mg + Tab Pyrazinamide 2 g for

2 months. 2. Continuation Phase: Tab Isoniazid 300 mg + Tab Rifampin 600 mg for 4 months. 3. Add Tab Pyridoxine (Vit B6) 50 mg PO OD. Rabies Post exposure prophylaxis: • Wash wound with soap and water. • Human Rabies Immunoglobulin 20 IU/kg IM stat and half dose into the wound. • Rabies vaccine 1 ml IM on days 0,3,7,14,28. • Inform Public Health. • Capture animal & observe x 10 days, then examine brain for negri bodies.


Tetanus Prophylaxis : Based upon Tetanus immunization status History of tetanus Immunization Clean, minor wounds All other wounds Td or Tdap* 0.5ml Tig** 250U Td or Tdap* Tig Uncertain or < 3 doses of an immunization Yes No Yes Yes > 3 doses received in an immunization Not No No§ No * Adult-type combined tetanus and diphtheria toxoids or a combined preparation of diphtheria, tetanus and acellular pertussis. If the patient is < 7 years old, a tetanus toxoid-containing vaccine is given as part of the routine childhood immunization. ** Tetanus immune globulin, given at a separate site from Td (or Tdap) t Yes, if > 10 years since last booster. § Yes, if > 5 years since last booster. More frequent boosters not required and can be associated with increased adverse events. The bivalent toxoid, Td, is not considered to be significantly more reactogenic than T alone and is recommended for use in this circumstance. The patient should be informed that Td (or Tdap) has been given.

7. Neurology

Seizures 1. Acute Management: • Inj Diazepam 5-10mg IV q2-3mins till seizure stops. • Inj Phenytoin 20mg/kg IV at 50mg per min. • Inj Phénobarbital 20mg/kg IV at 50-75mg/min • If all fails then rapid sequence intubation. 2. Primary Generalized & Partial seizures: • Tab Phenytoin: Loading 300mg PO q4h x 3 doses, then 300mg PO qhs. • Tab Valproate: Loading 15mg/kg/day, increments by 5-10mg/kg/day qweekly, till seizures are controlled. • Tab Carbamazepine: Start 100-200mg PO od-bid, increments by 200mg/per q2d, if needed till max 800mg-1200mg per day. 3. Absence Seizures: • Tab Ethosuximide 500mg PO daily in divided doses, increments by 250mg/day q4-7d pm till max 1500mg per day. Meningitis • Investigations : CT then LP, CSF analysis, blood C&S, neurology consult • Empirical adult antibiotics : 3rd generation cephalosporins + vancomycin + ampicillin Inj Ceftriaxone 2g IV ql2h Inj Dexamethasone lOmg q6h IV x 4 days for pneumococcal meningitis Meningococcal: give contacts Tab Rifampin 600mg PO ql2h x 4 doses IP: P~450 Interactions H: Hirsutism E: Enlarged gums N: Nystagmus Y; Yellow-browning of skin T: Teratogenicity 0: Osteomalacia I: Interference with folic acid absorption {hence anemia) N: Neuropathies: vertigo, ataxia, headache

22 NAC OSCE | A Comprehensive Review CSF Findings : Normal Bacterial Viral

Fungai/TB Pressure (cmMsO) 5-20 >30 Normal or mildly increased

Appearance Normal Turbid Clear Fibrin web

Protein {g/U 0.18-0.45 >1 <1 0.1-0.5

Glucose (mmol/l) 25-3.5 <2.2 Normal 1.6-2.5

Gram stain

Normal 60-90% Positive Normal

Glucose - CSF^enim Ratio 0.6 <0.4 >0.6 <0.4 WCC <3 >500 <1000 100-500

Other

90% PMN Monocytes 10% have >90% PMN 30% have >50% PMN Monocytes

Cluster headache • Tab Triptan and Tab Prednisone at the beginning of the cycle and prophylactic treatment with Tab Lithium(300-600mg daily initially then monitor serum levels) • Dihydroergotamine nasal spray 4mg per 1 ml. One spray each nostril and repeat ql5mins. Migraine 1. Mild - Moderate -► NSAIDS • Tab Ibuprofen 200mg tid • Tab Aspirin 600mg PO q4h 2. Moderate - Severe -► TRIPTANS • Tab Sumatriptan 25mg PO & repeat q 2hrs prn • Tab Metoclopramide lOmg PO stat 3. Prophylaxis: • Tab Propranolol 60mg PO daily • Tab Amitriptyline 10-25mg PO qhs. Tension headache Tab Tylenol 500mg PO 4-6hrs prn.


Myasthenia Gravis 1. Anticholinesterase (Cholinergic) • Tab Mestinon (Neostigmine and Pyridostigmine): 60-120 mg q3-4h. 2. Immunosuppressive therapy • Tab Prednisone: Start at 20 mg qd, increase gradually by 5 mg every 3 days to 60mg. Continue for 3 months or until clinical improvement stops or declines. Taper gradually to every other day • Tab Azathioprine (Imuran) 2 mg/kg/day. Effective when given with Prednisone. Effect not seen for 6 months or more. Monitor CBC and LFTs. 3. Plasmapheresis (Plasma Exchange) and IV Ig: Indicated for emergent worsening/crisis.

Response rate: 70%. Parkinson’s disease • Tab Carbidopa/Levodopa 25/100 mg PO bid-qid, increase as needed to max 200/2000mg/day. • Tab Bromocriptine 1.25 mg PO bid. • Tab Pergolide 0.05 mg PO od, titrate q2-3 days to the desired effect. Maintenance dose is 3-6 mg/day in divided doses. • Tab Premipexole 0.125 mg PO tid, increase to 1.5 - 4.5 mg/day in divided doses. • Tab Ropinirole 0.25 mg PO tid, increase weekly to max dose 24 g/day. • Tab Amantadine 100 mg PO od to max 100 mg PO qid. • Tab Selegiline 5 mg PO bid. • Tab Benztropine 0.5-6 mg/day PO in divided doses. • Tab Entacapone 200 mg given concurrently with Carbidopa/Levodopa.

8. Otolaryngology

Acute Sinusitis • Tab Amoxicillin 500mg tid PO x 10 days. • Decongestant: Tab Sudafed 60mg PO q6h • Nasal saline. Acute Pharyngitis • Group A 6 Hemolytic Strep: Tab Penicillin V 300mg PO tid x lOdays Penicillin /ülctuk : lab Erydiromycia 500rnu rid x 10 days

24 NAC OSCE | A Comprehensive Review 9. Pulmonology Asthma 1. Intermittent Asthma: Short acting beta-agonist - Salbutamol (Ventolin) Inhaler 1-2 puffs q4-6h pm. 2. Mild Intermittent Asthma: • Long acting beta agonist - Salmeterol Inhaler 1-2 puffs bid. • Inhaled steroids: i. Fluticasone (Flovent) 2-4 puffs bid. ii. Budesonide (Pulmicort) 2 puffs bid. iii. Beclomethasone (Vanceril) 1-4 puffs (40|ig) bid or 1-2 puffs (80pg) bid. 3. Moderate Persistent Asthma: • Inhaled steroids: i. Fluticasone (Flovent) 2-4 puffs bid. ii. Budesonide (Pulmicort) 2 puffs bid. iii. Beclomethasone (Vanceril) 1-4 puffs (40pg) bid or 1-2 puffs (80|ig) bid. • Long acting beta agonist - Salmeterol Inhaler 1-2 puffs bid. • Leukotriene Receptor Antagonist: • Tab Montelukast 10 mg PO qhs. • Tab Zileuton 600 mg PO qid. 4. Severe Persistent Asthma: • High dose Inhaled steroids. • Long acting beta agonist. • Leukotriene Receptor Antagonist. • Systemic Steroids: i. Tab Prednisone 2 mg/kg/day PO (max 60 mg/day). ii. Inj Methylprednisolone (Depo-medrol) 2mg/kg IV, then 0.5 mg/kg q6h x 5days. Acute exacerbation of COPD • Admit with nasal 02.Keep saturation between 88-92%. If silent chest/GCS < 8 or decreased LOC then intubate. • Elevated bed > 45 degrees. • I VF. • MDI : 8 puffs of Ventolin (Salbutamol) alternate with 8 puffs of Atrovent (Ipratropium) back to back every 20 mins 3 times. • Nebulizer : 2cc Ventolin + lcc Atrovent in 3cc NS q20 mins x 3 times. • Inj Hydrocortisone 125mg IV stat, if severe. • Inj Ceftriaxone 1-2 g IV q24h along with • Inj Piperacillin-Tazobactam 3.375 g IV q6h. • Inj Methylprednisolone 2mg/kg IV, then 0.5 mg/kg q6h x 5 days.

Therapeutic Guidelines | Medicine 25 Community Acquired Pneumonia 1. Outpatient management:

• Tab Doxycycline 100 mg PO bid x 7-10 days. • Tab Erythromycin 250 - 500 mg bid x 7-10 days. • Tab Azithromycin 500 mg PO od x 5 days. • Tab Levofloxacin 500 mg PO od x 7-10 days. • Tab Augmentin 500 mg/ 125 mg PO q8h x 5days. 2. Inpatient management: • Inj Ceftriaxone 1-2 g IV bid along with • Inj Levofloxacin 500 mg IV od x 7-10 days. • Inj Azithromycin 50 mg IV over 1 hour od x 1-2 days. Pulmonary Embolism 1. Investigations • V/Qscan, spiral CT or D-dimer (if unlikely Wells' score < 4) • CBC, INR, PTT, BUN, creatinine, ALT, AST. 2. Management: Initiation • Start Warfarin (Coumadin) concurrent with Heparin. • Contraindicated in pregnancy. (If contraindicated may put IVC filter) • Start Tab Warfarin at 5 mg PO daily on Day 1-2 and Heparin 5000 UIV bolus followed by continuous infusion 20 U/kg/hour, titrate to INR 2-3 then stop heparin within 24 hours. • Check INR in 3-5 days. • Therapeutic INR: 2.0 to 3.0 IU. • Oxygen, and if pain give morphine or NSAID. 3. Management: Duration of Anticoagulation • Very low risk: 6-12 weeks • Symptomatic isolated calf vein thrombosis. • Low risk patient: 3-6 months • Reversible thromboembolism risk (transient risk such as post-operative PE). • Upper extremity Deep Vein Thrombosis. • Moderate risk patient: 6-12 months • First idiopathic DVT or PE. • High risk patient: 12 months or lifetime Anticoagulation • Recurrent DVT or PE or Thrombophilia.

26 NAC OSCE | A Comprehensive Review 10. Rheumatology Osteoporosis • Tab Calcium (I500mg/day) and Tab Vitamin D (800 IU/day) intake in diet or as supplements. • Bisphosphonates: Alendronate, Risedronate or Raloxifene. • Hormone Replacement Therapy • Calcitonin • Recombinant Parathyroid Hormone • Lifestyle modifications: Weight bearing exercises, smoking and alcohol cessation. Osteoarthritis • Tab Tylenol 500 mg PO tid. • Tab Ibuprofen 200-600 mg PO tid. • Tab Naproxen 125-500 mg PO bid. • Tab Celecoxib 200 mg PO od. • Other treatment: • Tab Acetaminophen + Tab Codeine. • Intra-articular corticosteroid injection. • Intra-articular hyaluron injection. • Topical NSAIDs. • Capsaicin cream. • Glucosamine sulfate. Rheumatoid Arthritis 1. First Choice: • Tab Naproxen 500 mg PO bid. • Tab Ibuprofen 300-800 mg PO qid. • Tab Indomethacin 25-50 mg PO bid or tid. 2. Analgesics: Tab Acetaminophen 500 mg PO tid prn. 3. Corticosteroids: given intra-articular i. Small Joints: • Inj Hydrocortisone 8-20 mg. • Inj Methylprednisolone 2-5 mg.

• Inj Betamethasone 0.8 - 1.0 mg. ii. Large Joints: • Inj Hydrocortisone 40 100 mg. • Inj Methylprednisolone 10-25 mg. • Inj Betamethasone 2-4 mg.

Therapeutic Guidelines | Medicine 27 4. Disease Modifying Antirheumatic Drugs (DMARDs): Start within 3 months of diagnosis to reduce disease progression. i. Mild disease: • Tab Hydroxychloroquine 200 mg PO bid. • Tab Sulfasalazine 500 mg PO bid to tid. ii. Moderate disease: • Tab Methotrexate 10-15 mg PO once weekly, then increase to 20 mg PO once weekly. • Combination therapy: • Methotrexate + Sulfasalazine + Hydroxychloroquine. • Methotrexate + Cyclosporine. • Methotrexate + Etanercept (biological DMARD). iii. Biological DMARDs: used in persistent disease: • Etanercept SC. • Infliximab IV. • Anakinra SC. • Adalimumab SC. • Abatacept IV. • Rituximab IV. NOTE: • If Corticosteroids are used for> 3 months, do baseline DEXA and start bisphosphonate therapy. • S/E of Corticosteroids: Osteoporosis, cataracts, glaucoma, peptic ulcer disease, avascular necrosis, hypertension, increased infection rate, hypokalemia, hyperglycemia, hyperlipidemia. • C/I to Corticosteroids: Active infection, hypertension, diabetes mellitus, gastric ulcer, osteoporosis. Gout 1. Acute Gout: i. NSAIDs: Tab Indomethacin 25-50 mg PO tid x 10-14 days. ii. Tab Naproxen 500 mg PO bid x 4-10 days. iii. Tab Colchicine 0.6 mg PO qlh till pain relief (max 4-6 doses), then bid x 3-5 days. iv. Systemic Steroids: (rule out Septic Arthritis) • Inj Methylprednisolone 40 mg IV single dose • Inj Depo-Medrol 80-120 mg IM single dose. • Oral: Tab Prednisone 40 mg PO od x 5days, then gradually taper the dose. v. Intra- Articular Corticosteroid: used in large single joints & refractory cases. • Inj Betamethasone 7 mg or Inj ACTH 40-80IU. 2. Recurrent Gout: Treat for 3-6 months. i. Over producers: Tab Allopurinol 100-300 mg/day PO. ii. Under-excreters: Tab Probenecid 250 mg PO bid (max:1500 mg bid) or Tab Sulfapyrizine 50 mg PO bid (max: 1000 mg bid). iii. Concurrently start with Tab Colchicine 0.6 mg PO bid x 3-6 months.


Temporal arteritis • Start high dose Tab Prednisone 60 mg PO od until symptoms subside and ESR normal • Then 40 mg PO od for 4-6 weeks • Then taper to 5-10 mg PO od for 2 years (relapses occur in 50% if treatment is terminated before 2 years). Treatment does not alter biopsy results if the sample is taken within 2 weeks. • Monitor ESR regularly. • If visual symptoms are present, or develop during treatment, the patient is admitted and given Inj Prednisolone 1000 mg IV ql2h for 5 days. Polymyalgia Rheumatica Management 1. General measures • Consider concurrent Temporal Arteritis (See above) • NSAIDs 2. Prednisone (key to management) • See Corticosteroid Associated Osteoporosis • Efficacy: 90% response

Dramatic improvement in first 48 hours If no response to steroids - reconsider diagnosis Reconsider diagnosis Consider Methotrexate • Polymyalgia alone Dose: 15-20 mg PO qd • Polymyalgia with Temporal Arteritis Dose: 40-60 mg PO qd Symptoms and signs remit within 1 month Decrease dose by 10% each week after improvement • Course • Initial: Maintain starting dose for 1 month • First steroid taper (depends on clinical response) Taper by 2.5 mg per month down to 10 mg/day then Taper 1 mg per 4-6 weeks down to 5 to 7.5 mg/day • Final steroid taper Indicated when symptom free for 6-12 months Do not taper until sedimentation rate normalizes Taper by 1 mg every 6-8 weeks until done • Anticipate 2-6 year course of steroids Relapse common in first 18 months of steroid use Patients off steroids at 2 years: 25%

Therapeutic Guidelines | Medicine 29 Fibromyalgia 1. ANTIDEPRESSANTS : Benefits • Assists with local pain, stiffness and sleep • Does not affect Tender Points 2. Tricyclic Antidepressants • Amitriptyline (Elavil) i. First week: 10 mg PO qhs ii. Next three weeks: 25 mg PO qhs iii. Later: 50 mg PO qhs • Nortriptyline (Pamelor) 3. Novel Antidepressants • Venlafaxine (Effexor) • Duloxetine (Cymbalta) 4. Selective Serotonin Reuptake Inhibitors (SSRI) • Combination: Fluoxetine and Amitriptyline Septic Arthritis • Gonococcal: Inj Ceftriaxone lg IV q24h x 2-4 days, then switch to Tab Ciprofloxacin 500 mg PO bid x 7 days. • Non-Gonococcal: Inj Naficillin 2g IV q4h x 2 weeks, then switch to Tab Ciprofloxacin 500 mg PO bid x 24weeks.

11. Urology/Nephrology Urinary tract infection (UTI) 1. Acute uncomplicated UTI: outpatient • Tab Bactrim DS PO bid x 3 days. • Tab Nitrofurantoin (Macrobid) 100 mg PO bid x 5 days. 2. Drug resistant UTI: outpatient • Tab Ciprofloxacin 500 mg bid x 3 days. • Tab Norfloxacin 400 mg PO bid x 3 days. • Tab Ofloxacin 200 mg PO bid x 3 days. 3. Acute complicated UTI: inpatient • Inj Ampicillin 1-2 g IV q4-6h and Inj Gentamicin 2mg/kg IV loading dose followed by 1.7 mg /kg q8h IV OD • Inj Ciprofloxacin 400 mg IV bid. • Switch to oral antibiotics upon improvement for a total course of 14-21 days.

30 NAC OSCE | A Comprehensive Review Acute Pyelonephritis 1. Outpatient management: For acute uncomplicated cases • Tab Ciprofloxacin 500 mg PO bid x 10 days. • Tab Gatifloxacin 400 mg PO daily x 10 days. • Tab Moxifloxacin 400 mg PO daily x 10 days. • Tab Levofloxacin 250 mg PO daily x 10 days. • Tab Augmentin bid x 14 days. • Tab Bactrim bid x 14 days.

2. Inpatient management: IV for 48-72 hours, then switch to oral agents. Total duration of treatment for 14 days. • Inj Ceftriaxone (Rocephin) 1-2 grams IV q24 hours. • Inj Cefotaxime (Claforan) 1 gram IV ql2 hours. • Inj Ampicillin 2 g IV q6h with Inj Gentamicin 2mg/kg IV loading dose , then 1.7mg/kg q8h. Inj Piperacillin 3.375g IV q6h.

12. Emergency Medicine/Poisoning

Acetaminophen Intoxication • Toxic level dose is more than 7.5g • Investigations : Monitor drug level stat and then q4h (Acetaminophen nomogram), LFT, INR, PTT, BUN, Creatinine, ABG, Glucose • Rx : Charcoal/Gastric lavage as per presentation N-acetyl cysteine 140mg/kg PO, then 70mg/kg q4h for 18 doses Alcohol withdrawal • Treatment : Inj Diazepam 10-20mg IV Inj Thiamine lOOmg IM then 50-100mg/day Fluid resuscitation with D5W l-2mL/kg IV Allergic Reaction 1. Severe: Inj Epinephrine 0.3-0.5 mg SC/IM stat 2. Mild: Tab Benadryl 25-50mg PO q6h x 3d 3. Tab Prednisone 60mg PO od x 3d Anaphylaxis • Epinephrine autoinjector (EpiPen) if available • Epinephrine IV or ETT : 1ml of 1:10,000 in adults • Inj Diphenhydramine (Benadryl) 50mg IV or IM q4-6 h • Inj Methylprednisone 50-lOOmg IV according to severity • If wheezing or spasm present : Salbutamol via nebulizer.

Therapeutic Guidelines | Medicine 31 Arrhythmias Arrhythmias due to 2nd degree and 3rd degree heart block : Inj Atropine 0.5mg IV while waiting for transcutaneous pacing. Transcutaneous pacing first (give Inj Midazolam 2mg for sedation) Admit for transvenous pacing Unstable patients (hypotensive systolic BP < 90, chest pain, SOB, altered mental status or unconscious) : CARDIOVERT! Stable patient : Atrial fibrillation : either chemical cardioversion (Amiodarone) or electrical (Synchronized DC cardioversion) Ventricular tachycardia : DC cardioversion or Inj Lidocaine/Amiodarone 150mg IV over 10 mins. Ventricular fibrillation : Always defibrillate! Synchronized cardioversion not useful because there is no QRS complex to synchronize with. PSVT : Valsalva or carotid massage (after checking for bruit), Inj Adenosine 6mg rapid IV push. If no response then Metaprolol, Diltiazem. ASA Intoxication Investigations : Drug levels, electrolytes, ABG, BUN, Creatinine Rx : Gastric lavage/Charcoal Alkalinize urine with D5W, KC1 and NaHC03 Aim : urine pH > 7.5 Diabetic ketoacidosis Estimated daily basal glucose requirement is 0.5U/kg Investigations : Blood glucose, electrolytes, ABG, serum ketones, osmolar gap, anion gap, BUN, creatinine. Look of the cause : Urinalysis, blood C&S, chest x-ray, ECG. Monitor : Urine output, extra-cellular fluid volume, electrolytes, ABG, creatinine, capillary blood glucose and level of consciousness every 1-2 hours. Management : Rehydration : NS lL/h in first 2 hours followed by 0.45% NS 500cc/h then switch to maintain blood glucose 13.9-16.6mmol/L to avoid rapid decrease of osmolality. K+ replacement : As acidosis is corrected, hypokalemia may develop. If K+ is 3.3-5.0 mmol/L, add KC120-30 mEq/L to keep it within this range. Correct acidosis : If pH < 7.0/hypotension/coma then give 3 amp NaHCOs (150mEq/L) Reduce blood glucose : Start Insulin therapy with 0.15U/kg bolus and maintain 0.1U/kg/h until acidosis and blood glucose resolve. Treat underlying precipitant.


Digoxin Intoxication • Investigations : Plasma digoxin/digitoxin levels, ECG, electrolytes, BUN, Cr ( levels > 2.6 indicate

intoxication) • Rx : Treat arrhythmias (common with digoxin intoxication; vfib, vtach, conduction blocks) Gastric lavage / Charcoal (lg/kg) for ingestion NaHC03 or glucose and insulin Ventricular tachycardia : Digibind 10-20 vials if dose unknown Chronic toxicity : then Digibind 3-6 vials IV over 30 mins. Follow ECG, K+ Mg+, Digoxin levels every 6 hours. Hypertensive emergency • Systolic BP > 180mmHg and Diastolic BP > 120mmHg (with signs of acute organ damage) • Investigations : CBC, electrolytes, BUN, Creatinine, ABG, Urinalysis, CXR, ECG, BP in all four limbs, Fundoscopy, Cardiology consult. • 1st Line : Inj Sodium nitroprusside 0.3 mcg/kg/min IV OR Inj Labetalol 20mg IV bolus q 10 mins. • Aortic dissection : Sodium nitroprusside + Beta blocker (esmolol) • Catecholamine excess : Inj Phentolamine 5-l5mg IV q 5-15 mins • Ml/Pulmonary edema : Inj Nitroglycerin 5-20mcg/min IV, increase by 5mcg/min every 5 min till symptoms improve. Hypoglycemia • Investigations : Baseline blood glucose, insulin and C-peptide, check glucose ql5 mins until > 5mmol/L • Rx : If patient can eat/drink : give I5g carbohydrate if BG < 4mmol/L (15g glucose tabs or ZA caps of juice or 3 spoons of sugar in water.) NPO : give 25g carbohydrate if BG < 4mmol/L ( D50W 50cc IV push 1 amp OR D10W 500cc IV OR glucagon l-2mg IM/SC ) Methanol/Ethylene glycol intoxication • Investigations : CBC, electrolytes, glucose, methanol level. • Rx : Ethanol 10mg/kg over 30 mins OR Inj Fomepizole 15mg/kg IV over 30 mins.

Therapeutic Guidelines | Medicine 33 Opioid Intoxication • Mental status effects include euphoria, sedation, decreased anxiety, a sense of tranquility and indifference to pain produced by mild-to-moderate intoxication. Severe intoxication can lead to delirium and coma. • Physiological effects include the following: Respiratory depression (may occur while the patient maintains consciousness) Alterations in temperature regulations Hypovolemia (true as well as relative), leading to hypotension Miosis Soft tissue infection Increase sphincter tone (can lead to urinary retention) • Treatment IV glucose : 50% Dextrose 50ml Inj Nalaxone 0.4mg upto 2mg IV for reversal of opioid intoxication. Inj Thiamine lOOmg IM stat & OD x 3days 02, intubation &, mechanical ventillation Shock (Cardiogenic/Neurogenic) • Dopamine : l-3mcg/kg/min is the renal dose; 4-10mcg/kg/min is the inotropic dose • Dobutamine : 2.5-5mcg/kg/min Sprain (Ankle) RICE • Rest • Ice : using bag of ice, apply during the day for 5-20 mins every 2 hours. • Compression : Tensor bandage or special supports. • Elevation : Elevate the ankle as much as possible. • Analgesics as needed. • Crutches if too painful to bear weight. Stroke • Investigations : CBC, electrolytes, BUN, glucose, creatinine, INR/PTT, lipids, ECG, carotid doppler if suspecting TIA, ABG, Non contrast urgent CT scan. • Treatments : NPO, Foley catheter, DVT prophylaxis, Neurology consult Rule out contraindications for thrombolytic treatment. Urgent neurology consult. Thrombolysis : rTPA within 3 hours of symptoms Anti-coagulation : Low dose Heparin 5000 U bid, start Warfarin within 3 days, monitor INR/PTT If unable to thrombolyse or anti-coagulate then : Tab ASA 50-325mg od or Tab Clopidogrel 75mg od

BP control : decrease slowly, IV Labetalol (First line treatment) Bed rest, analgesics, mild sedation and laxatives, avoid hyperglycemia.


TCA Intoxication • Patients who present to the ED following psychotropic drug overdose with GCS < 8 should undergo intubation at the earliest opportunity to prevent hypoventilation and aspiration pneumonia. • Investigations : Drug levels, ECG, ABG, electrolytes, LFTs, RFTs. • Rx : Activated charcoal lgm/kg via NG Diazepam for seizures Wide QRS/Seizures : NaHCOa ( 1-2 mEq/kg bolus dose and then 100-150 mEq in 1L D5/0.45% NaCl infused 100-200 ml/h IV) Upper Gl Bleed • Stabilize patient with IVF, cross & type, 2 large bore IV cannulas. • Investigations : CBC, platelets, INR, BUN, creatinine, PTT, electrolytes, LFTs • Management : NG tube, NPO, blood transfusion if needed, upper Gl endoscopy Inj Octreotide 50mcg loading and 50mcg per hour (for varices) SC/I V Inj Pantoprazole 50mg IV stat and 50mg q8h (gastric ulcer) Lower Gl Bleed • Stabilize patient with IVF, cross & type, 2 large bore IV cannulas. • Investigations : CBC, platelets, INR/PTT, BUN, creatinine, electrolytes. • Management : NG tube, NPO, blood transfusion if needed, sigmoidoscopy, colonoscopy, angiogram (for angiodysplasia) Warfarin Intoxication • Treatment according to INR levels INR < 5 : Stop warfarin, observation, serial INR/PTT INR 5-9 : If no risk factors for bleeding, hold warfarin x 1-2 days & reduce maintenance dose. OR Vitamin K 1-2 mg PO, if patient at increased risk or FFP for active bleeding. INR 9-20 : Stop warfarin, Vitamin K 2-4 mg PO, serial INR/PTT then additional Vitamin K if needed or FFP for active bleeding. INR > 20 : FFP 10-15ml/kg, Inj Vitamin K lOmg IV over 10 min, increase dose of Vitamin K (q4h) if needed.

Therapeutic Guidelines | Medicine 35 13. Counselling Smoking cessation 1. 2.

3. 4. Nicotine gums: 2mg if < 25 cig/day, 4mg if > 25cig/day • 1 piece ql-2h for l-3mths Nicotine patch: • 21 mg per day for 4 weeks • 14mg per day for 2 weeks • 7mg per day for 2 weeks Nicotine inhaler: 6-16 cartridges per day upto 12 weeks Bupropion(Zyban): • 150mg qAM x 3days, then 150mg bid for 7- 12 weeks • Maintenance 150mg bid for upto 6 months. • General Stop smoking during second week of medication Stop Bupropion if unable to quit by 7 weeks Minimum of 8 hours between doses More is not better Swallow pills whole (not crushed, divided or chewed). Alcohol cessation Protocol: Alcohol Dependence • Lab markers Serum Gamma glutamyl transferase or Carbohydrate deficient Transferrin 1.Initial Management • Tab Thiamine 100 mg PO qd • Tab Folate 1 mg PO qd • Multivitamin qd • Treat Hypomagnesemia if present • Seizure precautions 2.Long-Term Abstinence Programs • Alcoholics Anonymous

• Detoxification centers • Halfway House CAGE Questionnaire C : Have you ever felt the need to CUT down on your drinking? A : Have you ever felt ANNOYED at criticism of your drinking? & : Have you ever felt GUILTY about your drinking? E : Have you ever had a drink first thing in the morning (EYE OPENER}?


3.Adjunctive Medications for abstinence 1.First line (consider Naltrexone with Campral) • Tab Naltrexone Blocks Opioid receptors Decreases pleasure from Alcohol Dosing: 50 mg orally daily Effective in short-term, but not in long-term • Tab Campral (Acamprosate) Balances GABA and glutamate neurotransmitters Reduces anxiety from abstinence Dosing: 2 tabs PO tid 2.Second line agents to consider • Selective Serotonin Reuptake Inhibitors (SSRI) Consider especially if comorbid depression Prozac often used, but other SSRIs effective • Topiramate (Topamax) Decreases Alcohol use severity and binge drinking Improves well being, quality of life in Alcoholics 3.Agents to avoid • Antabuse Taken 250 to 500 mg orally daily Not recommended due to risk and uncertain benefit • Delirium Tremens General Protocol (Requires ICU observation) • Tab Diazepam (Valium) Dose: 10-25 mg PO qlh prn while awake Endpoint: until adequate sedation • Inj Lorazepam (Ativan) Dose: 1-2 mg IV qlh prn while awake for 3-5 days Endpoint: until adequate sedation • Librium (Chlordiazepoxide) Dose: 50 to 100 mg PO/IM/IV q4h (max: 300 mg/day) Endpoint: until adequate sedation

NOTES


Obstetrics & Gynecology

1. Sexually Transmitted Infection a. Chlamydia: Tab Azithromycin lg PO stat or Tab Doxycycline lOOmg PO bid x 7 days If pregnant: Tab Erythromycin SOOmg PO tid x 7 days. Treat partner, Reportable disease. b. Gonorrhea: Inj Ceftriaxone 125mg IM stat + Tab Doxycycline lOOmg bid x 7 days. If pregnant : Inj Spectinomycin 2g IM stat Treat partner, Reportable disease. c. Syphilis: Primary, Secondary, Latent Syphilis (duration less 1 year ): Inj Benzathine Penicillin G 2.4 MU IM for 1 dose Treat partner, Reportable disease. If allergic to Penicillin: Tab Doxycycline 100 mg PO bid for 14 days. Late latent, Cardiovascular (duration over 1 year) Inj Benzathine Penicillin G 2.4 MU IM once a week for 3 weeks If Penicillin allergic : Tab Tetracycline 500 mg PO qid for 4 weeks or Tab Doxycycline 100 mg PO bid for 4 weeks Neurosyphilis : Inj Aqueous Penicillin G 34 MU IM every 4 hours for 10-14 days. d. Genital herpes: First episode: Tab Acyclovir 400mg PO tid x 10 days or Tab Famciclovir 250 mg tid x 10 days or Tab Valacyclovir 1 g bid x 10 days Recurrent: Tab Acyclovir 400mg PO tid x 5 days or Tab Famciclovir 120 mg bid x 5 days or Tab Valacyclovir 500 mg bid x 5 days Suppression: if more than 6 episodes per year Tab Acyclovir 400mg PO bid x 12 months Severe episode: Inj Acyclovir 5-10 mg/kg q8h x 5-7 days e. Genital warts (HPV): Local treatment with LIQUID NITROGEN repeat every 1-2 weeks Podophyllotoxin 0.5% gel bid x 3days,then 4 days off - to be repeated for 4 weeks.

Prophylaxis for HPV (for Cervical CA & warts) - Inj Gardasil IM 0,2 and 6 months.

Therapeutic Guidelines | Obstetrics & Gynecology 39 GENERAL INSTRUCTIONS for all sexually transmitted infections: • Treat all partners • Avoid sexual intercourse till treatment completion. • Barrier contraception/ educate about safe sex practices. • Rescreening in 3 months. SIDE EFFECTS: • DOXYCYCLINE: Drug induced PHOTOSENSITIVITY, use sun screen • ACYCLOVIR: headache, Gl upset, impaired renal function, tremors, agitation, lethargy, confusion, coma 2. Urinary Tract Infection Uncomplicated: Tab Bactrim DS PO bid x 3 days or Tab Nitrofurantoin lOOmg PO qid x 5days. (with food) In pregnancy: Treat asymptomatic UTI Tab Amoxicillin 250mg PO tid or Tab Macrobid lOOmg PO bid x 10 days. Pyelonephritis: Acute Uncomplicated: Tab Ciprofloxacin 500mg PO bid x 10 days or Tab Augmentin 625mg PO bid x 14 days. Inpatient: Inj Ceftriaxone lg IV bid for 48 hours then switch to oral drugs + Inj Gentamicin 50mg IV q8h for 24 hours. 3. Vulvovaginitis a. Candidiasis: Tab Miconazole 200mg PV qhs x 3 days or Tab Nystatin (100,00 unit) vaginal tab PV qhs x 14 days or Tab Fluconazole I50mg PO stat dose. Prophylaxis: 4 or more infection per year - Tab Fluconazole 150mg PO every 3days for 3 doses. Maintenance: Tab Fluconazole 150mg PO each week. Monitor liver enzymes every 1-2 months. b. Bacterial vaginosis: Tab Flagyl 500mg PO bid x 7days.(with food) c. Trichomonas vaginalis: Tab Flagyl 2g PO for 1 dose, or Tab Flagyl 500mg PO bid x 7days.(with food), treat partner. d. Atrophic vaginitis: Topical Estrogen cream 0.5 to 2g daily to be applied locally.

40 NAC OSCE | A Comprehensive Review 4. Pelvic Inflammatory Disease (PID) a. Outpatient: Inj Ceftriaxone 250mg IM stat dose + Tab Doxycycline lOOmg PO bid x 14days. b. Inpatient: Inj Cefoxitin 2g IV q6h + Inj Doxycycline lOOmg IV ql2h. Continue IV for 48 hrs & then tab Doxycycline lOOmg PO bid x 14 days. Reportable disease, treat partners, rescreening after 4-6 weeks incase of documented infection. 5. Dysfunctional Uterine Bleeding (DUB) a. Mild DUB: • NSAIDs - Tab Mefenamic acid 500mg PO tid x 5 days, • Anitfibrinolytics - Tranexamic acid 500mg PO tid x 5 days, Combined OCPS • Mirena / Provera • Tab Progestin one tab OD in first 10-14days. b. Severe DUB: • Inj Premarin 25mg IV q4h + Tab Gravol 50mg PO q4h. • With Tab Ovral PO tid till bleeding stops (24hrs),THEN bid for 2 days, THEN od for 3days. • Continue conventional OCPs if pregnancy not desired. 6.Dysmenorrhea • Tab Ibuprofen 400mg PO qid from 1st day of menstrual cycle. • Oral Contraceptive Pills. • Important to rule out secondary causes of dysmenorrhea. 7. Endometriosis a) NSAIDs : Tab Ibuprofen 400 mg PO qid till symptoms last. b) Oral Contraceptive pills. c) Tab Provera 10-20 mg PO OD. d) Tab Danazol 600-800 mg PO OD for 6 months. e) GnRH Agonist: Inj Leuprolide 3.75 mg IM once a month for 6 months. Inj Goserelin 3.6 mg SC every 28 days for 6 months.

Use GnRH Agonist along with Estrogen/Progesterone add back therapy. (To reduce the side effects of bone loss.)

Therapeutic Guidelines | Obstetrics & Gynecology 41

8. Hormone Replacement Therapy (HRT) a) Only Estrogen - Tab Premarin 0.625mg PO OD ( only estrogen) b) Cyclic Dose - Tab Premarin 0.625mg PO OD and Tab Provera S-10mg PO OD from days 1-14. c) Standard dose - Tab Prempro (premarin 0.625mg and provera 2.5mg) combination pill PO OD. d) Pulsatile - Tab Premarin 0.625mg PO OD and Low dose Tab Provera 1.5 mg PO OD. Given as 3 days on and 3 days off. e) Transdermal : Estradiol transdermal patch twice daily and Tab Provera 2.5 mg PO OD. 9. Emergency contraception • OTC no prescription needed. Take within 72 hours of unprotected intercourse. • Tab Ovral 2 tabs PO ql2h x 2 doses (has Levonorgestrel 0.5mg/dose + estrogen O.lmg/dose) + Tab Benadryl lOmg 1 hr before dose (emesis induced by Estrogen). • Plan B ( Tab Levonorgestrel 0.75mg/tab) one tab ql2hrs x 2 doses. 10. Group B Streptococcus (GBS) in pregnancy • Inj Penicillin G 5 MU IV then 2.5 MU IV q4h till delivery. • Penicillin allergic: Inj Cefazolin 2 g IV then 1 g q8h or Inj Clindamycin 900 mg IV q8h or Inj Erythromycin 500 mg IV q6h. 11. Pregnancy Induced Hypertension (PIH) a. Initial: To maintain DBP<100 • Inj Labetalol 20mg IV bolus every 10-20 mins prn. (C/I asthma,CHF) • Tab Nifedipine XL lOmg PO very 20-30 mins prn. • Inj Hydralazine 5mg or lOmg IM every 20 mins pm, then 5 or lOmg every 3 hrs pm. (S/E: fetal tachycardia, maternal headache, palpitations) b. Maintenance: • Tab Methyldopa 250-500mg PO bid - qid. • Tab Metoprolol 25-lOOmg PO bid. • Tab Labetalol 100-400mg PO qid. c. Anticonvulsant therapy: • Inj Magnesium sulfate 4g IV bolus over 20 min, followed by maintenance of 2-4 g/hour. • Monitor signs of Magnesium toxicity - depressed deep tendon reflexes, decreased respiratory reflex, anuric, hypotonic, CNS or cardiac depression. • Antagonist to Magnesium sulfate: Calcium gluconate(10%) 10 ml IV over 2 minutes. d. Avoid these antihypertensives: • ACE(-) & ARBs - neonatal renal failure, teratogenic, IUGR. • Atenolol - IUGR Thiazide diuretics - maternal fluid depletion.

42 NAC OSCE | A Comprehensive Review 12. Ectopic Pregnancy a) Inj Methotrexate 50mg/m2 BSA IM stat dose. b) Repeat beta hCG levels weekly till <1. c) Contraception till beta hcg returns to 5mIU/ml or less. d) Do CBC, LFTs. 13. Hyperemesis Gravidarum Tab Diclectin (10 mg Doxylamine with 10 mg Pyridoxin) started as 1 tab qAM + 1 tab qPM + 2 tabs qhs. Maximum 8 tabs per day. 14. Drugs contraindicated in pregnancy • Chloramphenicol: Gray baby syndrome • Erythromycin: Maternal liver damage (used only if allergic to penicillin). • Fluoroquinolones: Cartilage damage. • Metronidazole: Anti-metabolite, high risk in 1st trimester and breast feeding. Can lead to miscarriage. • Sulfa drugs: Miscarriage in 1st trimester and kernicterus in 3rd trimester. • Tetracyclines: Staining of teeth in children. • ACE inhibitors: IUGR, oligohydraminos, fetal renal defects. • Anticonvulsants: i) Phenytoin: Fetal hydantoin syndrome - IUGR, facial dysmorphogenesis, cardiovascular defects, congenital anomalies of hand & foot, umbilical hernia and congenital anomalies. ii) Valproic acid: Lumbosacral spina bifida with meningomyelocele or meningocele, often accompanied by midfacial hypoplasia, deficient orbital ridge, prominent forehead, congenital heart disease, and decreased postnatal growth.

iii) Carbamazepine: Unique facial appearance and underdevelopment of the fingers, toes, and nails; developmental delay. iv) Phénobarbital: Cleft palate/lip, congenital heart disease, intra-cranial hemorrhage. • DES: Vaginal adenosis, adenocarcinoma, uterine malformations in female fetuses. • Lithium: Ebsteins cardiac anomaly, goiter, hyponatremia. • Misoprostol: Congenital facial paralysis with or without limb defects (Mobius syndrome) and Neural tube defects. • Retinoids: Deformities of the cranium, ears, face, limbs, and liver, hydrocephalus, microcephaly, heart defects, cognitive defects, craniofacial alteration, cleft palate, neural tube defects, cardiovascular malformations and kidney alterations.

Therapeutic Guidelines | Obstetrics & Gynecology 43

Warfarin: High risk of spontaneous abortion, stillbirths, IUGR. Fetal Warfarin Syndrome: Deformities of the axial and appendicular skeleton, hypoplastic nose, optic atrophy, mental retardation, brachydactyly, scoliosis, mental retardation, intracranial hemorrhage. Alcohol: High incidence of abortion and still births, IUGR. Fetal Alcohol Syndrome: Decreased muscle tone and coordination, cognitive impairment, ASD/VSD, narrow small eyes with large epicanthal folds, small head, small mid-face, indistinct philtrum, thin upper lip. Cigarette smoking: IUGR, placental abruptio/ previa, spontaneous abortion. Cocaine: IUGR, microcephaly, prematurity, mental retardation.

NOTES

Therapeutic Guidelines | Pediatrics 45

Pediatrics

1. Acute Bronchiolitis a. Mild distress: oral/IV hydration, antipyretics for fever, humidified 02, VENTOLIN 0.03cc in 3ml NS by face mask q20min and then qlhr. b. Moderate to severe distress: all the above + Ribavirin in high risk groups like congenital lung disease, congenital heart disease, bronchopulmonary dysplasia, immunodeficient patients. c. Antibiotics, ipratropium, systemic corticosteroids have no use. 2. Acute Otitis Media (AOM) a) First line: Tab Amoxicillin 80-90mg/kg/day PO divided q8h for lOd. If allergic - Tab Azithromycin 10mg/kg/day OD for 3 days. To be given if child > 6months old. b) Second line: Tab Augmentin 90mg/kg/day divided ql2h for 10 days or Tab Cefuroxime 30mg/kg/day divided bid for 10 days. Avoid FLUOROQUINOLONES under 16 years age. 3. Asthma 9 Classification (NIH recommendations) a) Intermittent Asthma- Occasional exacerbations (Less than twice per week). b) Mild Persistent Asthma- Frequent exacerbations (>twice weekly, but not daily). c) Moderate Persistent Asthma- Daily symptoms with daily Beta Agonist use d) Severe Persistent Asthma- Continuous Symptoms and frequent exacerbations. • Acute Management i. 02 (to maintain 02 saturation > 90%). ii. Fluids, if dehydrated. iii. P2 Agonist : Salbutamol (Ventolin)- 0.03 cc/kg in 3cc NS every 20 minutes for 3 doses then 0.15-0.3 mg/kg (not to exceed 10 mg) every 1-4 hours as needed or 0.5 mg/kg/hour by continuous nebulization. iv. If Severe - Ipratropium bromide (Atrovent) lcc added to each of first 3 salbutamol masks. v. Steroids: Inj Prednisone 2mg/kg in ER, then lmg/kg PO OD x 4d. 4. Bacterial Tracheitis • Airway management, keep child calm. • Humidified 02 • Nebulized racemic epinephrine(l:1000 solution) in 3ml NS, 1-3 doses, ql-2h. • Inj Ceftriaxone 75-100mg/kg/day q24hrs + Inj Vancomycin 40mg/kg/day in divided doses every 6-8h.

46 NAC OSCE | A Comprehensive Review 5. Bacterial Pneumonia Newborn (under 3 weeks old) 1. Admit all newborns with Pneumonia.

2. Antibiotic regimen (Use 2-3 antibiotics combined) a) Antibiotic 1: Ampicillin i. Age <7 days • Weight <2 kg: 50-100 mg/kg divided ql2h. • Weight >2 kg: 75-150 mg/kg divided q8h. ii. Age >7 days • Weight <1.2 kg: 50-100 mg/kg divided ql2h • Weight 1.2-2 kg: 75-150 mg/kg divided q8h. • Weight >2 kg: 100-200 mg/kg divided q6h. b) Antibiotic 2: Gentamicin (dosing below if >37 weeks old) • Age <7 days: 2.5 mg/kg repeated ql2h. • Age >7 days: 2.5 mg/kg repeated q8h. c) Antibiotic 3: Cefotaxime (optional) • Age <7 days: 100 mg/kg divided ql2h. • Age >7 days: 150 mg/kg divided q8h. 3. Organisms requiring additional antibiotic coverage i. Methicillin Resistant Staphylococcus Aureus (MRSA)-Vancomycin a) Age < 7 days : • Weight < 1.2 kg : 15 mg/kg IV OD. • Weight 1.2 - 2 kg : 10-15 mg/kg IV ql2-18h. • Weight > 2 kg 10-15 mg/kg IV q8-12h. b) Age > 7days , weight > 2 kg : 45-60 mg/kg/day in divided IV q8h. ii. Chlamydia trachomatis-Erythromycin 30-50 mg/kg/d PO divided q8h. Management: Age 3 weeks to 3 months 1. Outpatient (if afebrile without respiratory distress) i. Azithromycin 10 mg/kg day 1,5 mg/kg days 2-5 PO. ii. Erythromycin 30-40 mg/kg/day PO divided q6h xlOdays. 2. Inpatient (if febrile or hypoxic) i. Inj Erythromycin 40 mg/kg/day IV divided q6h and ii. One of the following antibiotics if febrile: • Inj Cefotaxime 200 mg/kg/day IV divided q8h. • Inj Cefuroxime 150 mg/kg/day IV divided q8h. 3. Critically ill i. Inj Cefotaxime as above and Inj Cloxacillin or ii. Inj Cefuroxime alone as above

Therapeutic Guidelines | Pediatrics 47 Management: Age 3 months to 5 years 1. Outpatient (if afebrile without respiratory distress) a) Consider initial parenteral antibiotic at diagnosis: • Inj Ceftriaxone 50 mg/kg/day up to 1 gram IM xl dose. • Start oral antibiotics concurrently as below. b) First-line oral agents: • Amoxicillin 90 mg/kg/day PO divided q8h x7-10d. c) Alternative oral agents: • Amoxicillin-Clavulanic Acid (Augmentin). • Erythromycin. • Clarithromycin. • Azithromycin. 2. Inpatient (if febrile or hypoxic): a) Inj Cefotaxime 150 mg/kg/day IV divided q6h. b) Inj Cefuroxime 150 mg/kg/day IV divided q8h. c) If confirmed Pneumococcal Pneumonia: • Inj Ampicillin alone 200 mg/kg/day IV divided q8h. 3. Critically ill: a) Option 1 • Inj Cefotaxime 150 mg/kg/day IV divided q6h and • Inj Erythromycin 40 mg/kg/day IV divided q6h. b) Option 2 • Inj Cefuroxime 150 mg/kg/day IV divided q8h and • Inj Cloxacillin 150-200 mg/kg/day IV divided q6h. Management: Age 5 to 18 years

1. Outpatient: a) First-line oral agents: i. Erythromycin 40 mg/kg/day PO divided q6h x 7-10d. ii. Clarithromycin 15 mg/kg/day PO divided ql2h x 7-10d. iii. Azithromycin • Day 1:10 mg/kg day 1 PO (maximum 500 mg). • Days 2-5: 5 mg/kg/day PO (maximum 250 mg). b) Pneumococcal Pneumonia confirmed: i. Amoxicillin 90 mg/kg/day PO divided q8h x 7-10d. 2. Inpatient: a) First line and in critical illness: i. Inj Cefuroxime 150 mg/kg/day IV divided q8h and ii. Inj Erythromycin 40 mg/kg/day IV divided q6h. b) Pneumococcal Pneumonia confirmed: i. Inj Ampicillin 200 mg/kg/day IV divided q8h.

48 NAC OSCE | A Comprehensive Review 6. Croup (Laryngotracheobronchitis) a) Humidified 02 b) Nebulized racemic epinephrine(l:1000 solution) in 3ml NS, 1-3 doses, ql-2h : • Child < 6mths: 0.25ml • Child > 6mths: 0.5ml • Adolescent: 0.75ml c) Dexamethasone 0.6mg/kg IM/IV/PO, max dose lOmg, given as a single dose. 7. Epiglottitis • Suspect epiglottitis if child has fever, ill looking, dyspnea, dysphonia, loss of voice, stridor, sudden in onset. • Investigations : Pharyngeal swab and culture Blood culture Lateral X-ray neck (Thumbprint sign) ABG, CBC Endoscopy in ER • Treatment : Intubation IV fluid IV Cefuroxime 8. Streptococcal Pharyngitis (Group A Streptococcus) Mclsaac Criteria - no cough, tender anterior cervical lymph nodes, erythematous tonsils with exudate, fever > 38°C, age 3-14 years. a) If 1 symptom only - no culture or antibiotics needed. b) If > 1 symptom, culture positive - treat with antibiotics: Penicillin V 40 mg/kg/day PO divided bid x 10 days. Erythromycin 40mg/kg/day PO divided tid x 10 days. Acetaminophen for fever or pain. c) Invasive GAS: needs admission Inj Clindamycin 40 mg/kg divided into 3-4 doses and Inj Penicillin 250 000 - 400 000 U/kg/day divided into 6 doses x 10 days. 9. Whooping Cough (Pertussis) a) Erythromycin 40-50mg/kg/day PO divided qid x lOd. b) Azithromycin lOmg/kg/PO OD dayl, 5mg/kg PO OD day2 to day5. (preferred) c) Isolate for 5 days of treatment. d) Erythromycin to all the household members.

Therapeutic Guidelines | Pediatrics 49 10. Bacterial Meningitis (Reportable disease) a) Inj Dexamethasone 0.6 mg/kg/day IV in 4 divided doses. Start within 1 hour of 1st antibiotic dose.. b) Ampicillin: i. Age< 1 month - SO mg/kg IV q8-12h. ii. Age>l month - 50 mg/kg IV q6h. c) Cefotaxime: i. Age < 1 month - 50 mg/kg IV q8-12h. ii. Age>l month - 200 mg/kg/day IV divided q6-8h. d) Ceftriaxone: i. Age< 1 month - 50-75 mg/kg IV divided ql2-24h. ii. Age> 1 month - 100 mg/kg/d IV divided ql2h. e) Gentamycin: 2-2.5 mg/kg IV q8h.

f) Vancomycin: 15 mg/kg q6h IV x 7-14 days. g) Prophylaxis for contacts: i. H. \nfluenzae : Rifampin 20 mg/kg/day up to 4 days. ii. N. Meningitides : • Rifampin • Children: 10 mg/kg PO ql2h x 2 days (max 600 mg). • Adults: 600 mg PO ql2h x 2 days. • Ciprofloxacin (adults) 500mg PO for one dose. • Ceftriaxone : • Age 15 years: 250 mg IM for one dose. 11. Febrile Seizures a) In ER : Inj Diazepam 0.2 - 0.5mg/kg IV ql5mins till seizure stops. b) Home : Diazepam rectal suppository. c) Investigate & treat the cause of fever. 12. Urinary^ 1. Oral Treatment- for 7-14 days. i. Cefixime (Suprax) 8 mg/kg PO divided bid or ii. Cefpodoxime ( Vantin) 10 mg/kg PO divided bid or iii. Cefprozil (Cefzil) 30 mg/kg PO divided bid or iv. Cephalexin (Keflex) 50-100 mg/kg PO divided qid. 2. IV antibiotics i. Inj Cefotaxime 50-150mg/kg/day divided q4-6h or ii. Inj Ceftriaxone 50-75mg/kg/day divided ql2-24h. 3. UTI Prophylaxis i. Bactrim (2mgTMP/10mg SMZ per kg) at bedtime qhs.


13. Allergic reaction a) General Measures: ABC management. i. Oxygen. ii. IVF. iv. Nebulised beta-agonist (Albuterol). b) Anaphylaxis with airway compromise: Epinephrine (1:1000 solution) 0.01ml/kg SC/IM(upto 0.3ml) c) Urticaria, Pruritus or Flushing: Inj Diphenhydramine 25-50mg IM/IV every 6hrs prn. Orally same dose q6h x 3days. d) Prevention: Medical alert bracelet. Strict avoidance of allergen. EpiPen. Allergy testing and desensitization therapy. i. ii. iii. iv. 14. Anemia in children • 6mg/kg/day elemental iron bid-tid. • Investigate the cause of anemia. 15. Dose ofTylenol in children a) 40-60 mg/kg/day PO divided q6hr prn (not to exceed 5 doses/24 hours). b) Neonates: 10-15 mg/kg PO q6-8hr prn. 16. Immunization Schedule for Infants and Children in Canada I: Routine likinttinteation Schedule for infants and Children àgB at vaccination 0Taf*~ IPV Hit≫ mmm m PneuC*7 Men~C Tdap HPV

inf 8ifth 2 months m

m

im 4 months

m m

îm 6 12 ≪WRES ! § mmmthm m

m

♦ ■ m Mmmm ,, M i\ n -

IJUK and m* 8~23 WES m 1-2 4~S jjWMTSi -

m !■■■ %Z ^ t||f|

NOTES 52 NAC OSCE | A Comprehensive Review

Psychiatry

1. Agitation & Aggression Agitation can be defined as excessive verbal and/or motor behavior. It can readily escalate to aggression, which can be either verbal (vicious cursing and threats) or physical (toward objects or people). Goals of treatment (Nonpharmacological treatment) • Create a safe environment for treatment • Decrease stimulation • Permit patient to ventilate his or her feelings, but this may need to be cut short if the degree of agitation is escalating and there is clear danger to self and others. • Behavioral approaches include never turning your back to an agitated patient, talking softly rather than shouting, and inquiring about what specific needs the patient may have • Prevent further episodes of agitation or aggression Delirium • Delirium or acute confusional state is a common and severe neuropsychiatric syndrome with core features of acute onset and fluctuating course, attentional deficits and generalized severe disorganization of behavior. Treatment of delirium requires treatment of the underlying causes. • Antipsychotics are first-line treatment. Haloperidol is the most effective medication for decreasing agitation in delirious patients. First generation antipsychotic Loxapine and second generation (atypical) antipsychotics such as Olanzapine,Risperidone and Quetiapine can also be used. Benzodiazepines should be reserved for cases of alcohol withdrawal. First-generation Antipsychotics (FGA) • Haloperidol : 0.5-2.5 mg PO/IM bid • Loxapine : 12.5-50 mg/day PO Second generation (atypical) antipsychotics (SGA) • Olanzapine : 5-10 mg/day PO, 2.5-10 mg IM (repeat 2h and 6h prn to max of 30 mg/24 h) • Risperidone : 0.5-2 mg/day PO • Quetiapine : 25-100 mg/day PO Benzodiazepines • Lorazepam : 0.5-1 mg PO/IM q6-8h • Oxazepam : 10-15 mg PO tid

ANnpsYCHoncss/e FGA>SGA Extrapyramidal S/E - Acute dystonia, Parkinsonism, akathasia, Tardive dyskinesia. Neuroleptic Malignant Syndrome (NMS) Sedation Weight gain, diabetes and dyslipidemia Hyperprolactinemia and sexual dysfunction.

Therapeutic Guidelines | Psychiatry 53

Mania • Mania is a state of abnormally elevated or irritable mood, arousal, and/ or energy levels. Treatment of mania involves both acute control of severe agitation by a mood stabilizer and long term mood stabilizers. Initially atypical antipsychotics such as Risperidone, Olanzapine or Quetiapine are effective. First-generation Antipsychotics • Haloperidol : 5-10 mg/day PO/IM Atypical antipsychotics • Risperidone : 2-3 mg/day PO • Olanzapine : 5-20 mg/day PO, 2.5-10 mg IM (repeat 2h and 6h prn to max of 30 mg/24 h) • Quetiapine : start with 100 mg/day PO; increase by 100 mg/day as needed to 300-600 mg/day divided BID

2. Anxiety Disorders • Anxiety disorders are a group of conditions with exaggerated anxiousness and worry about a number of concerns persists for an extended period of time. Goals of treatment (Nonpharmacologic treatment) • Stress reduction and relaxation techniques such as meditation and low impact yoga is often helpful. • Cognitive behavioral therapy (CBT) • Reduction of consumption of caffeine and other stimulants. • Minimize use of alcohol Panic disorder • Panic attack or panic disorder involves sudden anxiety that occurs without warning. Symptoms can include chest pain, heart palpitations, sweating, shortness of breath, feeling of unreality, trembling, dizziness, nausea, hot flashes or chills, a feeling of losing control, or a fear of dying. Panic attacks are extremely common - 10% to 20% of the population experience a panic attack at some point in their life. Some people start to avoid situations that might trigger a panic attack; this is called panic attack with agoraphobia. Panic disorder refers to recurring feelings of terror and fear, which come on unpredictably without any clear trigger. • SSRIs and SNRIs are the first choice in the treatment of panic disorders. Selective serotonin reuptake inhibitors (SSRIs) like Citalopram, Escitalopram, Fluoxetine, Paroxetine and Sertraline are all effective in reducing panic attacks. Serotonin norepinephrine reuptake inhibitor (SNRIs) eg. Venlafaxine is also used in panic disorder. • There is a delay in the onset of response to these drugs which may be accompanied by initial agitation. Combining SSRI or SNRI with a brief course of low dose benzodiazepine can increase adherence to medication and produce rapid response. • Other medication include Tricyclic antidepressants (TCAs) eg. Imipramine, Desipramine and Clomipramine and Monoamine oxidase inhibitors (MAOIs) eg. Phenelzine, Tranylcypromine.

54 NAC OSCE | A Comprehensive Review Selective serotonin reuptake inhibitors (SSRIs) • Paroxetine : 20-60 mg/day PO • Fluoxetine : 20-80 mg/day PO • Sertraline : 50-200 mg/day PO • Citalopram : 20-60 mg/day PO • Escitalopram : 10-20 mg/day PO Serotonin norepinephrine reuptake inhibitor (SNRIs) • Venlafaxine : 37.5-22.5 mg/day Tricyclic antidepressants (TCAs) • Clomipramine : 75-225 mg/day • Desipramine : 75-300 mg/day • Imipramine : 75-300 mg/day Benzodiazepines • Alprazolam : 0.25 mg tid-qid, up to 1 mg PO qid • Clonazepam : 0.25-0.5 mg PO bid Monoamine oxidase inhibitors (MAOIs) • Phenelzine : 45-90 mg/day • Tranylcypromine : 20-60 mg/day Social Phobia • Social anxiety, also known as social phobia, involves excessive anxiety in social situations where people fear being embarrassed or made fun of. Situations that can trigger social anxiety include small group discussions, dating, going to a party, and playing sports. Common symptoms of social anxiety include

blushing, sweating, and dry mouth. People with social phobia often avoid social situations that cause anxiety. • SSRI and SNRI are mainstay drugs for the treatment for social phobia. Escitalopram, Fluvoxamine, Paroxetine, Sertraline and Venlafaxine may be used for milder cases. • Simple stage fright or fear of public speaking may respond to low dose Propranolol lOmg taken 30 minutes before the event. General Anxiety Disorder • Generalized anxiety disorder (GAD) is associated with continual excessive anxiety and worry about a number of things (e.g., work, money, children, and health). There is no specific source of fear. Symptoms can include muscle tension, trembling, shortness of breath, fast heartbeat, dizziness, dry mouth, nausea, sleeping problems, and poor concentration. CBT is the most effective psychosocial treatment but often takes 20 or more sessions to be effective. • SSRIs and SNRIs have become established as first line treatments for GAD. Bupropion and Pregabalin are further choices. Low dose benzodiazepines can be used but dependence is a problem. Buspirone has a low abuse potential and is less sedating than benzodiazepines. • Buspirone : 5mg bid-tid, up to 60 mg/day

smmnmsmmom

Confusion, disorientation, agitation, fever, diaphoresis, sinus tachycardia, HTN, mydriasis, tachypnea, myoclonic jerks, hyperreflexia, muscle rigidity, tremor, ataxia, incoordination. TREATMENT: Benzodiazepines (1 line), Serotonin Antagonists : Cyproheptadine, Methysergide, Propranolol*


• Pregabalin : Initial 150 mg/day in 2-3 divided doses, may be increased to 150 mg bid after 1 week if necessary • Bupropion (Wellbutrin, Zyban): Use : Smoking cessation, second line Antidepressant. Antidepressant: Start 100 mg bid x 4 days 100 m g tid. Obsessive-compulsive disorder (OCD) • OCD involves recurring unpleasant thoughts (obsessions) and/or repetitive behaviours (compulsions). The thoughts may be connected to the repetitive behaviours. For example, people who fear getting an infection may constantly wash their hands. At times, however, there’s no connection at all between the thoughts and the behaviours. • CBT is the psychotherapy of choice. SSRIs : Fluoxetine, Fluvoxamine, Paroxetine and Sertraline, in the usual antidepressant dosing range are the drugs of choice in Canada. It may take 6-8 weeks for symptoms to improve. Second line drugs include Clomipramine, Venlafaxine, Citalopram and Mirtazapine. Post-traumatic stress disorder (PTSD) • PTSD is associated with extreme anxiety that appears after a traumatic experience. Symptoms usually start within 3 months of the traumatic event but may take years to start. PTSD can be associated with sleep problems, nightmares, irritability, and anger. Feelings of guilt and unworthiness are common with PTSD. Traumatic experiences that can trigger PTSD include wars, plane crashes, natural disasters (e.g., hurricane, earthquake), and violent crimes (e.g., rape, abuse). • SSRI and SNRI antidepressants have been shown to be effective in reducing the symptoms of PTSD. Fluoxetine, Paroxetine, Sertraline and Venlafaxine are first line options.

3. Dementia

Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging. Dementia is not a single disease, but rather a non-specific illness syndrome in which affected areas of cognition may be memory, attention, language, and problem solving. It is normally required to be present for at least 6 months to be diagnosed. The most common causes of dementia are Alzheimer’s disease and vascular dementia. It affects about 1% of people aged 60-64 years and as many as 30-50% of people older than 85 years. Benzodiazepines must be used cautiously in the elderly patients due to increase risk of falls and impaired cognition. «DUMBI* Dressing Eating Ambulation Toilet Hygiene Shopping Housekeeping Accounting Food Making Transportation

56 NAC OSCE | A Comprehensive Review 4. Depression Nonpharmacological treatment

• Cognitive behavioral and interpersonal psychotherapy are as effective as antidepressants in mild to moderate depression. Pharmacological treatment • Take medication daily, antidepressant must be taken for 2 to 4 weeks for effect to be noticeable. Medication must be taken even if patient is feeling better. SSRI • Paroxetine (Paxil): Start 20 mg qhs, increase lOmg every 2wks, max 60mg per day. • Fluoxetine (Prozac): Start 20mg PO qd, avoid increasing more often than monthly, max 80mg PO per day • Sertraline (Zoloft): Start 50mg PO qAM, increase 50mg every 2 weeks, max 200mg per day • Fluvoxamine (Luvox): Start 25mg PO qhs x 3 days -> 50mg PO qhs x 7 days -> titrate 150-250 mg daily divided doses bid. • Citalopram (Celexa): Start 20mg PO qd, max 60mg. • Escitalopram (Lexapro): Start lOmg PO qd Monoamine Oxidase Inhibitor (MAO inhibitor): Use in Atypical depression, Refractory depression. • Isocarboxazid (Marplan) - 10 mg PO bid, max 60 mg per day. • Phenelzine (Nardil) - 15 mg PO tid, max 90 mg per day. • Tranylcypromine (Parnate) - 10-40 mg per day in divided doses, max 60 mg per day. Complication: Hypertensive crisis, Serotonin syndrome. Interaction with tyramine containing foods to be avoided strictly. Serotonin Norepinephrine Reuptake Inhibitors(SNRI) not used these days • Tricyclic Antidepressants: Amitriptyline 25 mg qhs, Nortriptyline (Pamelor) S/E: Anti-cholinergic - dry mouth, constipation, blurred vision, Anti-histaminergic - sedation, weight gain; Serotonergic - sexual dysfunction; Orthostatic hypotension; Sinus tachycardia, SVT, Ventricular tachycardia, Prolonged QT interval, heart block; Withdrawal symptoms. Other : Venlafaxine (Effexor) 37.5 mg PO od.

6. Psychosis

In acutely psychotic individuals, short-acting parenteral antipsychotics either alone or in combination with a parenteral benzodiazepine may be recommended. Liquid formulations of atypical antipsychotics may be used as an alternative to intramuscular injections, Risperidone and Olanzapine are examples. Atypical antipsychotics : • Clozapine - 12.5 mg PO qd or bid, titrate slowly upwards in increments of25-50 mg/day Target dose : 300 - 450 mg/day, max 900 mg/day. S/E: Agranulocytosis, Diabetes mellitus, hypertriglyceridemia. NOT 1st LINE Anti-psychotic. Order weekly blood counts for 1 month and then q2 weeks.


• Olanzapine (Zyprexa) - Start 5-10 mg PO qd, increase in 5 mg increments weekly as tolerated, max 20 mg/day. S/E: Mild sedation, insomnia, dizziness, early AST & ALT elevation, resdessness, weight gain, increased risk of diabetes mellitus and hyperlipidemia. • Quetiapine (Seroquel) - Start 25 mg PO bid - tid, increase in 25- 50 mg/day increments, target 300-400 mg/day divided doses bid- tid, max 750 mg/day. S/E: Headache, sedation, dizziness, constipation. • Risperidone (Risperdal) - Start 1 mg PO bid, slow titration 2-4 mg PO daily or divided doses bid, max 16 mg/day. S/E: Insomnia, agitation, EPS, headache, anxiety, hyperprolactenemia, postural hypotension, constipation, dizziness, weight gain. Typical antipsychotics: • Haloperidol (Haldol)- 5-10 mg PO, IM, IV. May repeat q30-60mins, max 300 mg per day. • Fluphenazine (prolixin) - 2.5 mg PO bid, max 40 mg per day. S/E - EXTRA PYRAMIDAL SIDE EFFECTS: Akinesia - treat with Benztropine 2mg PO /IM/IV OD Dystonie reaction - treat with Lorazepam or benztropine. Dyskinesia Akathesia - treat with Lorazepam, Propranolol or Diphenhydramine. Perioral tremor Neuroleptic malignant Syndrome - Muscle rigidity, tremor, delirium, high fever, diaphoresis, hypertension. Discontinue drug. Give symptomatic treatment and supportive care. Treatment with Dantrolene or bromocriptine. Tardive dyskinesia - Blinking, lip smacking, sucking, chewing, grimaces, choreoathetoid movements, tonic contractions of neck / back.

Treatment - Clozapine.

7. Mood stabilizers : Used in Bipolar disorder. • Lithium bicarbonate - Start 300 mg PO bid, then increase to 900 - 1800 mg per day divided doses. Serum levels - 0.6 -1.2 mEq/1, monitor RFTs,TFTs. S/E: tremor, polydipsia, hypothyroidism, weight gain, nausea/vomiting, diarrhea, ataxia, slurred speech, lack of coordination. Treatment of Lithium toxicity: Discontinue lithium. Check serum lithium levels, BUN, electrolytes. IV fluids - Normal saline. Hemodialysis in case Li > 2 mmol/L, coma, shock, severe dehydration, deterioration, unresponsive to treatment. Life* threatening neurological disorder presents with muscle Elevated creatine phosphokinase Rx : dantrolene sodium


• Divalproex (Epival) 300-1600 mg/day PO bid. Monitor LFTs weekly x 1 month, then monthly. S/E: Liver dysfunction, nausea/vomiting, diarrhea, ataxia, drowsiness, tremor, sedation, hair loss, weight gain thrombocytopenia, neural tube defects in early pregnancy. • Carbamazepine (Tegretol) 750- 3000 mg/day PO tid. Monitor weekly CBC due to risk of agranulocytosis. S/E: Nausea/vomiting, hepatic toxicity, ataxia, drowsiness, confusion, nystagmus, diplopia, transient leukopenia, agranulocytosis, drug reaction (SJS), neural tube defect in early pregnancy.

8. Medications causing sexual dysfunction 1. Antiandrogen Medications • Spironolactone • Ketoconazole • Finasteride 2. Antihypertensives • Centrally acting sympatholytics (e.g. Clonidine) • Peripherally acting sympatholytics (e.g. Guanadrel) • Beta Blockers • Thiazide Diuretics 3. Antidepressant Medications • Selective Serotonin Reuptake Inhibitors (SSRI) • Tricyclic Antidepressants • MAO inhibitors 4. Sedative-Hypnotic Medications • Barbiturates • Benzodiazepines 5. Drug Abuse • Alcohol Abuse • Heroin abuse • Marijuana abuse • Methadone • Tobacco abuse 6. Other Medications • Anticholinergic Medications • Antipsychotic Medications • H2 Receptor Blockers

Therapeutic Guidelines | Psychiatry 59 9. Substance abuse • Alcohol withdrawal: • Tab Diazepam 20 mg PO ql-2h prn . • Observe for 1-2 hours and re-assess. • Inj Thiamine 100 mg IM then 100 mg PO OD x 3 days. • Maintain hydration. • If oral Diazepam not well tolerated then switch to Inj Diazepam 2-5 mg IV/min - maximum 10-20 mg qlh, or S/L Lorazepam.

• If severe liver dysfunction ,severe asthma, respiratory failure or age> 65 years present - Lorazepam PO/SL/IM 1-4 mg q l-2h. • Hallucination present - Haloperidol 2-5 mg IM/PO ql-4h - max 5 doses/day along with Diazepam 20 mg x 3 doses as seizure prophylaxis. • Wernickes syndrome:Thiamine 100 mg PO OD x 1-2 weeks. • Korsakoffs syndrome: Thiamine 100 mg PO bid/tid x 3-12 months. • Opioid Intoxication: • ABCs • IV Glucose • Inj Naloxone (Narcan) 0.4 mg - 2mg IV. • Intubation and mechanical ventilation may be required for decreased level consciousness. • Cocaine Overdose: • ABCs • Inj Diazepam 2-5 mg IV/min - maximum 10-20 mg qlh ( to control seizures). • Propranolol or labetalol to treat hypertension and arrhythmia. • Hallucinogens: LSD, mescaline, psilocybin, MDMA. • Symptomatic treatment and supportive care. • Decreased stimulation. • Benzodiazepines or antipsychotics might be required. • Phencyclidine: • Room with minimal stimulation. • Inj Diazepam IV for muscle spasms or seizures. • Haloperidol to suppress psychotic behavior.

NOTES

Clinical Examination Clinical Examination 63 Abdominal Examination 1. Steps before beginning examination • Introduce yourself : “I am Dr._______, your attending physician and I’ll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.” • Wash/Sanitize hands • Explain to the patient what you are about to do and gain informed consent. • Look for medical equipment/therapies (e.g. drains, colostomy/ileostomy bags). • Verbalize the steps of the examination and your findings. • Use proper draping techniques. 2. Inspection • General inspection of the patient : Is patient comfortable at rest? Do they appear to be tachypnoeic? • Examine the patient’s hands for presence of koilonhychia (iron deficiency), leukonychia (hypoalbuminemia), clubbing (IBD, coeliac disease, cirrhosis), palmar erythema, tar staining or Dupuytren’s contracture. • Ask the patient to hold their hands out in front of them looking for a any tremor and then get them to extend their wrists up towards the ceiling keeping the fingers extended and look for flapping (asterixis in hepatic encephalopathy). • Examine the face, check the conjunctiva for pallor. Also check the sclera for jaundice. Look at the buccal mucosa for any obvious ulcers which could be a sign of Crohn’s disease, B12 or iron deficiency. Also look at the tongue. If it is red and fat it could be another sign of anaemia, as could angular stomatitis. Check state of dentition - pigmentation of oral mucosa (Peutz-Jegher’s syndrome), telangectasia, candidiasis. • Examine the neck for an enlarged left supraclavicular lymph node. A palpable enlarged supraclavicular (Virchow’s) node is known as Troisier’s Sign, may be a sign of malignancy. Virchow’s node drains the thoracic duct and receives lymphatic drainage from the entire abdomen as well as the left thorax. Therefore, enlargement of this node may suggest metastatic deposits from a malignancy in any of these areas. • Examine the chest, in particular look for gynaecomastia in men and the presence of 5 or more spider naevi. These are both stigma of liver pathology.

• Inspect the abdomen and comment on any obvious abnormalities such as scars, masses and pulsations. Also note if there is any abdominal dis tension/ascites. Look for distended veins, striae, Cullen’s/GreyTurner’s signs (pancreatitis), Sister Mary Joseph's nodule (widespread abdominal cancer)

64 NAC OSCE | A Comprehensive Review 3. Auscultation • Listen with the diaphragm next to the umbilicus for up to 30 seconds. • Listen for bowel sounds - absent (e.g. Ileus, peritonitis), tinkling (bowel obstruction) 4. Palpation • Palpation of the abdomen should be performed in a systematic way using the 9 named segments of the abdomen: right and left hypochondrium, right and left flank, right and left iliac fossa, the umbilical area, the hypochondrium and the suprapubic region. • If a patient has pain in one particular area you should start as far from that area as possible. The tender area should be examined last as they may start guarding making the examination very difficult. • Initial examination should be superficial using one hand.Once you have examined all 9 areas superficially, you should examine deeper. This is performed with two hands, one on top of the other. • Feel for organomegaly, particularly of the liver, spleen and kidneys. Palpation for the liver and spleen is similar, both starting in the right iliac fossa. For the liver, press upwards towards the right hypochondrium. You should try to time the palpation with the patient's breathing as this presses down on the liver. If the liver is distended, its distance from the costal margin should be noted. • Palpating for the spleen is as for the liver but in the direction of the left hypochondrium. The edge of the spleen which may be felt if distended is more nodular than the liver. • To feel for the kidneys you should place one hand under the patient in the flank region and the other hand on top. You should then try to ballot the kidney between the two hands. 5. Percussion Percussion over the abdomen is usually resonant, over a distended liver it will be dull. Percussion can also be used to check for 'shifting dullness' - a sign of ascites. With the patient lying flat, start percussing from the midline away from you. If the percussion note changes, hold you finger in that position and ask the patient to roll towards you. Again percuss over this area and if the note has changed then it suggests presence of fluid such as in ascites. It is also appropriate at this time to check for pedal edema. 6. You should mention to the examiner at this point that you would like to finish the examination with an examination of the hernial orifices, the external genitalia and also a rectal examination. 1

/l\ I

HYPO* / : ' HYPO CHONORWl/ ; CHOMORIAL EPKÎWWmW LUMBAf t ILIAC UMBi(JCAL OASTRJUM

\ Clinical Examination 65 Cardiovascular Examination

1. Steps before beginning examination • Introduce yourself : “I am Dr.________, your attending physician and I'll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.” • Wash/Sanitize hands • Explain to the patient what you are about to do and gain informed consent. • Look for medical equipment/therapies (e.g. GTN spray, ECG pads, oxygen) • Verbalize the steps of the examination and your findings. 2. Inspection • Start by observing the patient from the end of the bed. You should note whether the patient looks comfortable. Are they cyanosed or flushed? • Respiratory rate, rhythm and effort of breathing. • Chest shape, chest movements with respration (symmetrical/assymetrical), skin (scars/nevi) • Inspect the nails for clubbing, splinter hemorrhages (infective endocarditis), koilonychia (iron deficiency anemia).

• Inspect fingers for capillary refill time, peripheral cyanosis, osier's nodes (infective endocarditis) and nicotine staining. • Inspect palms for palmar erythema,Janeway lesions and xanthomas. • Take the radial pulse, assess the rate and rhythm.At this point you should also check for a collapsing pulse - a sign of aortic incompetence. Locate the radial pulse and place your palm over it, then raise the arm above the patient’s head. A collapsing pulse will present as a knocking on your palm. At this point you should say to the examiner that you would like to take the blood pressure. They will usually tell you not to and give you the value. • Inspect the sclera for any signs of jaundice, anaemia and corneal arcus. You should also look for any evidence of xanthelasma. • Whilst looking at the face, check for any malar facies, look in the mouth for any signs of anaemia such as glossitis, check the colour of the tongue for any cyanosis, and around the mouth for any angular stomatitis - another sign of anaemia. • Assess jugular venous pressure ( JVP), ask patient to turn their head to look away from you. Look across the neck between the two heads of sternocleidomastoid for a pulsation then measure the JVP. • Examine the chest, or praecordium for any obvious pulsations, abnormalities or scars, remembering to check the axillae as well.

66 NAC OSCE | A Comprehensive Review 3. Palpation • Palpate praecordium trying to locate the apex beat and describe its location anatomically. The normal location is in the 5th intercostals space in the mid-clavicular line. • Palpate for any heaves or thrills. A thrill is a palpable murmur whereas a heave is a sign of left ventricular hypertrophy. Feel for these all over the praecordium. 4. Auscultation • Mitral valve - where the apex beat was felt. • Tricuspid valve - on the left edge of the sternum in the 4th intercostal space. • Pulmonary valve - on the left edge of the sternum in the 2nd intercostal space. • Aortic valve - on the right edge of the sternum in the 2nd intercostal space. How many heart sounds are heard? Are the heart sounds normal in character? Any abnormal heart sounds? If you hear any abnormal sounds you should describe them by when they occur and the type of sound they are producing. Are there any murmurs? Can you hear any rub? Feeling the radial pulse at the same time can give good indication as to when the sound occurs - the pulse occurs at systole. Furthermore, if you suspect a murmur, check if it radiates. Mitral murmurs typically radiate to the left axilla whereas aortic murmurs are heard over the left carotid artery. • To further check for mitral stenosis you can lay the patient on their left side, ask them to breathe in, then out and hold it out and listen over the apex and axilla with the bell of the stethoscope. • Aortic incompetence can be assessed in a similar way but ask the patient to sit forward, repeat the breathe in, out and hold exercise and listen over the aortic area with the diaphragm. 5. With patient sitting up percuss back for pleural effusion (cardiac failure) 6. Finally assess for any pedal & sacral oedema. 7. Finish by thanking the patient and ensuring they are comfortable and well covered.

Clinical Examination 67

Peripheral Vascular Examination 1. Steps before beginning examination • Introduce yourself : “I am Dr._______, your attending physician and I’ll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.” • Wash/Sanitize hands • Explain to the patient what you are about to do and gain informed consent. • Look for medical equipment/therapies (e.g. GTN spray, ECG pads, oxygen) • Verbalize the steps of the examination and your findings. 2. Inspection • General observation of the patient, arms from the finger tips to the shoulder and legs from the groin and buttocks to the toes. Comment on the general appearance of the arms and legs, size, swelling, symmetry, skin color, hair, scars, pigmentation including any obvious muscle wasting. Note colour and texture of nails. • Any signs of gangrene or pre-gangrene such as missing toes or blackening of the extremities. • The presence of any ulcers - ensure you check all around the feet including behind the ankle. These may be venous or arterial - one defining factor is that venous ulcers tend to be painless whereas arterial are painful.

• Any skin changes such as pallor, change in colour (eg purple/black from haemostasis or brown from haemosiderin deposition), varicose eczema or sites of previous ulcers, atrophic changes and hair loss. • Presence of any varicose veins - often seen best with the patient standing. 3. Palpation • Assess the skin temperature. Starting distally, feel with the back of your hand and compare each limb to the other noting any difference. • Check capillary return by compressing the nail bed and then releasing it. Normal colour should return within 2 seconds. If this is abnormal, perform Buerger’s Test. This involves raising the patient’s feet to 45°. In the presence of poor arterial supply, pallor rapidly develops. Following this, place the feet over the side of the bed, cyanosis may then develop. • Any varicosities which you noted in the observation should now be palpated. If these are hard to the touch, or painful when touched, it may suggest thrombophlebitis. • Palpate peripheral pulses. These are: Carotid - only palpate one carotid at a time Radial - use the pad of three fingers Brachial - may use thumb to palpate Femoral - feel over the medial aspect of the inguinal ligament.


Popliteal - ask the patient to flex their knee to roughly 60° keeping their foot on the bed, place both hands on the front of the knee and place your fingers in the popliteal space. Posterior tibial - felt posterior to the medial malleolus of the tibia. Dorsalis pedis -feel on the dorsum of the foot, lateral to the extensor tendon of the great toe. You should compare these on both sides and comment on their strength. • Check for radio-femoral delay. Palpate both the radial and femoral pulses on one side of the body. The pulsation should occur at the same time. Any delay may suggest coarctation of the aorta. 4. Auscultation : listen for femoral and abdominal aortic bruits 5. Special Tests • Allen Test : Ask the patient to make a tight fist and elevate the hand. Occlude the radial and ulnar arteries with firm pressure. The hand is then opened. It should appear blanched (pallor can be observed at the finger nails). Release either the Ulnar or radial artery pressure and the color should return in 7 seconds. If the palm does not redden immediately, this suggests arterial insufficiency. • Straight Leg Raise and Refill Test (Buerger's Test) : Raise the leg 45° to 60° for 30 seconds until pallor of the feet develops and observe empty veins. Sit the patient upright and observe the feet. In normal patients, the feet quickly turn pink (within 10-15 seconds). If, pallor persists for more than 10- 15s or there is development of a dusky cyanosis (rubor), this suggests of arterial insufficiency. • Test for incompetent Saphenous Vein : Ask the patient to stand and note the dilated varicose veins. Compress the vein proximally with one hand and place the other hand 10-15 cm distally. Briskly compress and decompress the distal site. Normally, the hand at the proximal site should feel no impulse, however with varicose veins a transmitted pulse may be felt. • Trendelenburg Maneuver (Retrograde filling) : Ask the patient to lie down. Elevate the leg, and empty the veins by massaging distal to proximal. Using a tourniquet, occlude the superficial veins in the upper thigh. Ask the patient to stand. If the tourniquet prevents the veins from re-filling rapidly, the site of the incompetent valve must be above this level i.e. at the sapheno-femoral junction. If the veins re-fill, the communication must be lower down. Observing the same protocol, proceed down the leg until the tourniquet controls re-filling. As necessary, test: • above the knee - to assess the mid-thigh perforator • below the knee - to assess competence between the short saphenous vein and popliteal vein If re-filling cannot be controlled, the communication is probably by one or more distal perforating veins.

Clinical Examination 69 Respiratory Examination 1. Steps before beginning examination • Introduce yourself : “I am Dr.________, your attending physician and I'll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.” • Wash/Sanitize hands • Explain to the patient what you are about to do and gain informed consent. • Look for medical equipment/therapies (e.g. inhalers, oxygen). • Verbalize the steps of the examination and your findings. 2. Inspection

• General look of the patient. Check whether they are comfortable at rest, is patient tachypnoeic? Are they using accessory muscles? Are there any obvious abnormalities of the chest? Check for any clues around the bed such as inhalers, oxygen masks or cigarettes. • Inspect the hands, hot, pink peripheries may be a sign of carbon dioxide retention. Look for any signs of clubbing, cyanosis, hypertrophic pulmonary osteoarthropathy, dupytren's contacture and nicotine staining. Assess for carbon dioxide retention flap/salbutamol tremor. • Take the patient’s pulse. After you have taken the pulse it is advisable to keep your hands in the same position and subtly count the patient’s respiration rate. • Inspect the face, ask the patient to stick out their tongue and note its colour - checking for cyanosis. - Horner's sydrome (Pancoast tumour), plethora (polycythemia). • Look for any use of accessory muscles such as the sternocleidomastoid muscle. Also palpate for the left supraclavicular node (Virchow's Node) as an enlarged node (Troisier's Sign) may suggest metastatic lung cancer. • Examine the chest and back. Observe the chest for any deformities (barrel chest, kyphoscoliosis, pectus excavatum, pectus carinatum), symmetry of expansion, dilated veins, intercostal recession. 3. Palpation • Palpate the chest. Feel between the heads of the two clavicles for the trachea, see if it is deviated. • Feel for chest expansion. Place your hands firmly on the chest wall with your thumbs meeting in the midline. Ask the patient to take a deep breath in and note the distance your thumbs move apart. Normally this should be at least 5 centimetres. Measure this at the top and bottom of the lungs as well as on the back.

70 NAC OSCE | A Comprehensive Review 4. Percussion • Percussion should be performed on both sides, comparing similar areas on both sides. Start by tapping on the clavicle which gives an indication of the resonance in the apex. Then percuss normally for the entire lung fields. Hyper-resonance may suggest a collapsed lung where as hypo-resonance or dullness suggests consolidation such as in infection or a tumour. Be sure to perform this on the back as well. 5. Vocal Fremitus Check for tactile vocal fremitus. Place the medial edge of your hand on the chest and ask the patient to say ‘99\ Do this with your hand in the upper, middle and lower areas of both lungs. 6. Auscultation • Do this in all areas of both lungs and on front and back comparing the sides to each other. Listen for any reduced breath sounds, or added sounds such as crackles, wheezes or rhonchi. Tracheal Percussion Tactile Vocal Fremitus Breath Sounds OtherSounds Effusion Away Dull Decreased Decreased Bronchial sounds +/- egophony at edge

ComoMatton Central Dull Increased Bronchial Occasional crackles

Pneumothorax Away Hyper-resonant Decreased Absent Nil

Atelectasis Towards lesion Dull Increased Decreased Nil

Fibrosis Central Resonant (normal) Normal Decreased if severe Late inspiratory crackles

7. Finish by examining the lymph nodes in the head and neck. Start under the chin with the submental nodes, move along to the submandibular then to the back of the head at the occipital nodes. Next palpate the pre and post auricular nodes. Move down the cervical chain and onto the supraclavicular nodes.

Clinical Examination 71 Central Nervous System Examination

1. Steps before beginning examination • Introduce yourself : “I am Dr._______, your attending physician and I’ll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.” • Wash/Sanitize hands • Explain to the patient what you are about to do and gain informed consent. • Look for medical equipment/therapies (e.g. walking aids). • Verbalize the steps of the examination and your findings. 2. Cranial Nerve Examination 1) The Olfactory nerve (CN I) is simply tested by offering something familiar for the patient to smell and identify - for example coffee or vinegar. 2) The Optic nerve (CN II) is tested in five ways: • The acuity is easily tested with Snellen charts. This should be assessed both with the patient wearing any glasses or contact lenses they usually wear and without them. • Colour vision is tested using Ishara plates, these identify patients who are colour blind. • Visual fields are tested by asking the patient to look direcdy at you and wiggling one of your fingers in each of the four quadrants. Ask the patient to identify which finger is moving. Visual inattention can be tested by moving both fingers at the same time and checking the patient identifies this. • Visual reflexes comprise direct and concentric reflexes. Place one hand vertically along the nose to block any light from entering the eye not being tested. Shine a pen torch into one eye and check that the pupils on both sides constrict. This should be tested on both sides. • Finally fundoscopy should be performed on both eyes. 3) Eye movements: Oculomotor nerve (III), Trochlear nerve (IV) and Abducent nerve (VI) are involved in movements of the eye. Asking the patient to keep their head perfecdy still direcdy in front of you, you should draw two large joining Hs in front of them using your finger and ask them to follow your finger with their eyes. It is important the patient does not move their head. Always ask if the patient experiences any double vision and if so when is it worse. Also look for ptosis and assess saccadic eye movements. 4) The Trigeminal nerve (CN V) is involved in sensory supply to the face and motor supply to the muscles of mastication. Initially test the sensory branches by lightly touching the face with a piece of cotton wool and then with a blunt pin in three places on each side - around the jawline, on the cheek and on the forehead. The corneal reflex should also be examined as the sensory supply to the cornea is from this nerve. This is done by lighdy touching the cornea with the cotton wool. This should cause the patient to shut their eyelids. For the motor supply, ask the patient to clench their teeth together, observing and feeling the bulk of the masseter and temporalis muscles. Then ask them to open their mouth against resistance. Finally perform the jaw jerk on the patient by placing your left index finger on their chin and striking it with a tendon hammer. This should cause slight protrusion of the jaw.

72 NAC OSCE | A Comprehensive Review 5) The Facial nerve (CN VII) supplies motor branches to the muscles of facial expression. Therefore, this nerve is tested by asking the patient to crease up their forehead (raise their eyebrows), close their eyes and keep them closed against resistance, puff out their cheeks and show you their teeth. 6) The Vestibulocochlear nerve (CN VIII) provides innervation to the hearing apparatus of the ear and can be used to differentiate conductive and sensori-neural hearing loss using the Rinne and Weber tests. For the Rinne test, place a sounding tuning fork on the patient’s mastoid process and then next to their ear and ask which is louder, a normal patient will find the second position louder. For Weber’s test, place the tuning fork base down in the centre of the patient’s forehead and ask if it is louder in either ear. Normally it should be heard equally in both ears. 7) The Glossopharyngeal nerve (CN IX) provides sensory supply to the palate. It can be tested with the gag reflex or by touching the arches of the pharynx.

8) The Vagus nerve (CN X) provides motor supply to the pharynx. Asking the patient to speak gives a good indication to the efficacy of the muscles. You should also observe the uvula before and during the patient saying aah’. Check that it lies centrally and does not deviate on movement. 9) The Accessory nerve (CN XI) gives motor supply to the sternocleidomastoid and trapezius muscles. To test it, ask the patient to shrug their shoulders and turn their head against resistance. 10) The Hypoglossal nerve (CN XII) provides motor supply to the muscles of the tongue. Observe the tongue for any signs of wasting or fasciculations. Then ask the patient to stick their tongue out. If the tongue deviates to either side, it suggests a weakening of the muscles on that side. 3. Cerebellar Examination Gait: • Ask the patient to stand up. Observe the patient's posture and whether they are steady on their feet. • Ask the patient to walk, e.g. to the other side of the room, and back. If the patient normally uses a walking aid, allow them to do so. • Observe the different gait components (heel strike, toe lift off). Is the gait shuffling / waddling / scissoring/ swinging? • Observe the patients arm swing and take note how the patient turns around as this involves good balance and co-ordination. • Ask the patient to walk heel-to-toe to assess balance. • Perform Romberg’s test by asking the patient to stand unaided with his eyes closed. If the patient sways or loses balance this test is positive. Stand near the patient in case he falls. Co-ordination: • Look for a resting tremor in the hands. • Test tone in the arms (shoulder, elbow, wrist) • Test for dysdiadochokinesis by showing the patient to clap by alternating the palmar and dorsal surfaces of the hand. Ask to do this as fast as possible and repeat the test with the other hand. • Perform the finger-to-nose test by placing your index finger about two feet from the patients face. Ask him to touch the tip of his nose with his index finger then the tip of your finger. Ask him to do this as fast as possible while you slowly move your finger. Repeat the test with the other hand. • Perform the heel-to-shin test. Have the patient lying down for this and get him to run the heel of one foot down the shin of the other leg and then to bring the heel back up to the knee and start again. Repeat the test with the other leg.

Clinical Examination 73 Upper Limb Neurological Examination

1. Steps before beginning examination • Introduce yourself : aI am Dr.________, your attending physician and I'll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.” • Wash/Sanitize hands • Explain to the patient what you are about to do and gain informed consent. • Use proper draping techniques, verbalize the steps of the examination and your findings. 2. Inspection • General inspection of patient: general comfort, abnormal posture/movements, muscle wasting. • The upper body should be exposed for this examination. Observe the patient's arms, look for any muscle wasting, fasciculations or asymmetry. 3. Tone • Examine the tone of the muscles. Start proximally at the shoulder, feeling how easy the joint is to move passively. Then move down to the elbow, wrist and hand joints again assessing each one's tone in turn. • Assess for spastic catch, clasp-knife rigidity, led-pipe or cog-wheel rigidity. 4. Power • Next assess the power of each of the muscle groups. - Shoulder abduction (C5) & Shoulder adduction (C5/C6/C7) - Elbow flexion (C5/C6) & Elbow extension (C7) - Wrist flexion (C8) & Wrist extension (C8) - Finger flexion (C8), Finger abduction (Tl), Finger adduction (Tl) - Thumb abduction (C8) 5. Reflexes • There are three reflexes in the upper limb - the biceps, triceps and supinator reflexes. • The biceps reflex (C5/C6) is tested by supporting the patient's arm, with it flexed at roughly 60°, placing your thumb over the biceps tendon and hitting your thumb with the tendon hammer. It is vital to get your patient to relax as much as possible and for you to take the entire weight of their arm. • The triceps reflex (C6/C7) is elicited by resting the patient's arm across their chest and hitting the triceps tendon just proximal to the elbow.

• Finally, with their arm rested on their abdomen, locate the supinator tendon (C5/C6) as it crosses the radius, place three fingers on it and hit the fingers. This should give the supinator reflex. If you struggle with any of these reflexes, asking the patient to clench their teeth should exaggerate the reflex.

74 NAC OSCE | A Comprehensive Review 6. Sensation This is tested in a number of ways. You should test light touch, pin prick, vibration and joint position sense and proprioception. Ask the patient to place their arms by their sides with their palms facing forwards. Lighdy touch the patient's sternum with a piece of cotton wool so that they know how it feels. Then, with the patient's eyes shut, lightly touch their arm with the cotton wool. The places to touch them should test each of the dermatomes. Tell the patient to say yes every time they feel the cotton wool as it felt before. Then repeat this using a light pin prick. To assess vibration you should use a sounding tuning fork. Place the fork on the patient's sternum to show them how it should feel. Then place it on the bony prominence at the base of their thumb and ask them if it feels the same. If it does, there is no need to check any higher. If it feels different you should move to the radial stylus and then to the olecranon until it feels normal. Finally, proprioception. Hold the distal phalanx of the thumb on either side so that you can flex the interphalangeal joint. Show the patient that when you hold the joint extended, that represents 'Up' whereas when you hold it flexed that represents 'Down'. Ask the patient to close their eyes and, having moved the joint a few times hold it in one position - up or down. Ask the patient which position the joint is in. 7. Coordination • Pronator drift - Ask patient to extend arms in front of them in supination and to close their eyes. A positive result occurs when the arm falls downwards and pronates (cerebral damage), in cerebellar lesions the arms may rise. • Assess for dysdiadochokinesia • Assess for finger to nose coordination and intentional tremor. 8. Function is a very important part of any neurological examination as this is the area which will affect people's day to day lives the most. For upper limb you should ask people to touch their head with both hands and then ask them to pick up a small object such as a coin which each hand. 9. Finish by thanking the patient and ensuring they are comfortable and well covered.

Clinical Examination 75 Lower Limb Neurological Examination 1. Steps before beginning examination • Introduce yourself : “I am Dr._______, your attending physician and I'll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I’ll stop the examination right there.” • Wash/Sanitize hands • Explain to the patient what you are about to do and gain informed consent. • Verbalize the steps of the examination and your findings. • Make sure patient is adequately exposed, use proper draping techniques 2. Inspection • Observe the patient's legs, look for any muscle wasting, fasciculations or asymmetry. 3. Tone • Start by examining the tone of the muscles. Roll the leg on the bed to see if it moves easily and pull up on the knee to check its tone. Also check for ankle clonus by placing the patients leg turned outwards on the bed, moving the ankle joint a few times to relax it and then sharply dorsiflexing it. Any further movement of the joint may suggest clonus. 4. Power • Next assess the power of each of the muscle groups. - Hip flexion (L1/L2) & Hip extension (L5/S1) - Hip abduction (L2/L3) & Hip adduction (L2/L3) - Knee flexion (L5/S1) & Knee extension (L3/L4) - Ankle dorsiflexion (L4/L5) & Ankle plantar flexion (S1/S2) - Big toe flexion (S1/S2) 5. Reflexes • Test the patient's reflexes. There are three reflexes in the lower limb - the knee reflex, the ankle jerk and the plantar reflex - elicited by stroking up the lateral aspect of the plantar surface.

• The knee reflex (L3/L4) is tested by placing the patient's leg flexed at roughly 60°, taking the entire weight of their leg with your arm and hitting the patellar tendon with the tendon hammer. It is vital to get your patient to relax as much as possible and for you to take the entire weight of their leg. • The ankle jerk (S1/S2) is elicited by resting the patient's leg on the bed with their hip laterally rotated. Pull the foot into dorsiflexion and hit the calcaneal tendon. • Finally, with their leg out straight and resting on the bed, run the end of the handle of the tendon hammer along the outside of the foot. This gives the plantar reflex (Si). An abnormal reflex would see the great toe extending. If you struggle with any of these reflexes, asking the patient to clench their teeth should exaggerate the reflex.

76 NAC OSCE | A Comprehensive Review 6. Sensation The final test is sensation. However, this is tested in a number of ways. You should test light touch, pin prick, vibration and joint position sense and proprioception. Ask the patient to place their legs out straight on the bed. Lightly touch the patient's sternum with a piece of cotton wool so that they know how it feels. Then, with the patient's eyes shut, lightly touch their leg with the cotton wool. The places to touch them should test each of the dermatomes - make sure you know these! Tell the patient to say yes every time they feel the cotton wool as it felt before. Then repeat this using a light pin prick. To assess vibration you should use a sounding tuning fork. Place the fork on the patient's sternum to show them how it should feel. Then place it on their medial malleolus and ask them if it feels the same. If it does, there is no need to check any higher. If it feels different you should move to the tibial epicondyle and then to the greater trochanter until it feels normal. Finally, proprioception. Hold the distal phalanx of the great toe on either side so that you can flex the interphalangeal joint. Show the patient that when you hold the joint extended, that represents 'Up' whereas when you hold it flexed that represents 'Down'. Ask the patient to close their eyes and, having moved the joint a few times hold it in one position - up or down. Ask the patient which position the joint is in. Anterior

7. Function is a very important part of any neurological examination as this is the area which will affect people’s day to day lives the most. For the lower limb you should assess the patient's walking. Observe their gait and check for any abnormalities. Whilst they are standing you should perform Romberg's test. Ask the patient to stand with their feet apart and then close their eyes. Stand next to the patient in case he falls. Any swaying may be suggestive of a posterior column pathology. 8. Finish by thanking the patient and ensuring they are comfortable and well covered.

Clinical Examination 77 Musculo-skeletal system : Spine/Back 1. Steps before beginning examination • Introduce yourself : aI am Dr.________, your attending physician and I'll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.” • Wash/Sanitize hands • Explain to the patient what you are about to do and gain informed consent. • Ensure patient is adequately exposed. • Look for medical equipment/therapies • Show empathy. • Verbalize the steps of the examination and your findings. 2. Inspection • Ask for patient’s vitals • Observe patient : Is patient sitting comfortably? Gait? Position of comfort. • Observe the patient from behind : - Pelvic and shoulder symmetry, palpate the pelvic brim to check for symmetry. - Scoliosis - Gibbus (dorsal spines abnormally prominent) • Observe patient from side : - Kyphosis - Increased lumbar lordosis • Check the spine for SEADS : S: Swelling, E: Erythema, ecchymosis, A: Atrophy/asymmetry (muscle bulk), D: Deformity, S: Skin changes/scars/bruising 3. Range of Motion

• Flexion : In the standing position by asking the patient to touch the toes. Normal - 90° .The normal spine should lengthen more than 5 cm in the thoracic area and more than 7.5 cm in the lumbar area on forward flexion. • Extension : Stabilize the patient, ask the patient to bend backwards. Normal - 30°. • Lateral flexion : ask the patient to slide their hand straight down the thigh, first on the right and then on the left, keeping the hips straight. • Observe for restricted movement and loss of symmetry. • Test for facet joint disease : Ask patient to extend their back as far as possible and to rotate (pain suggests facet joint pathology). 4. Palpation • Examine the back and palpate for areas of muscle spasm and tenderness (paraspinal muscles). • Palpate spinous processes with thumb for tenderness • Sacroiliac joints, sacro iliac dimples, ask for tenderness.

78 NAC OSCE | A Comprehensive Review 5. Ankylosing spondylitis tests • Chest expansion : Measure with a tape measure (should be >5cm) • Schober'sTest : Draw a horizontal line 10cm above and one 5cm below the dimples of Venus (the distance between these lines should increase to >20cm during lumbar flexion - in ankylosing spondylitis the distance will not increase to >20cm) • Distance of tragus to wall when patient is standing with their back to the wall (useful for monitoring). 6. Cervical and thoracic movements (patient sitting on edge of bed) • Cervical movements - Flexion (ask patient to touch chin to chest) - Extension (ask patient to look to the ceiling as far back as possible) - Lateral flexion (ask patient to touch their ear to the shoulder keeping the shoulder still) - Spurling Maneuver : Extend head back & bring ear towards shoulder. Give gentle axial pressure on the head. If patient complains of pain radiating from head to ipsilateral arm - diagnosis of Radiculopathy is made. - Rotation (ask patient to look over the left and right shoulder) - Perform these movements passively if active movements are restricted. • Thoracic rotation : ask patient to fold their arms and twist around. 7. Tests with patient lying on their back • Straight leg raising test : ask the patient to lie with the spine on the table and to relax completely. With the knee fully extended, first one leg and then the other is slowly lifted and flexed at the hip. This produces stretch on the sciatic nerve, at which point sciatic pain is produced. If this maneuver produces pain in the hip or low back with radiation in the sciatic area, the test is considered positive for nerve root irritation. The angle of elevation of the leg from the table at the point where pain is produced should be recorded. • FABER (Flexion Abduction External Rotation) : Ask the patient to lie supine on the exam table. Place the foot of the affected side on the opposite knee. Pain in the groin area indicates a problem with the hip and not the spine. Press down gently but firmly on the flexed knee and the opposite anterior superior iliac crest. Pain in the sacroiliac area indicates a problem with the sacroiliac joints. • Bowstring test: Once the level of pain has been reached, flex the knee slighdy and apply firm pressure with the thumb in the popliteal fossa over the stretched tibial nerve. Radiating pain and paraesthesiae suggest nerve root irritation. 8. Tests with patient lying on their abdomen • Lasegue's sign: With the patient supine and hip flexed, dorsiflexion of the ankle causes pain or muscle spasm in the posterior thigh if there is lumbar root or sciatic nerve irritation. • Femoral stretch test:With the patient prone and the anterior thigh fixed to the couch, flex each knee in turn. This causes pain in the appropriate distributions by stretching the femoral nerve roots in L2- L4.The pain produced is normally aggravated by extension of the hip. The test is positive if pain is felt in the anterior compartment of thigh.

Clinical Examination 79 Hip Examination

1. Steps before beginning examination • Introduce yourself : “I am Dr.________, your attending physician and I'll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.” • Wash/Sanitize hands • Explain to the patient what you are about to do and gain informed consent. • Ensure patient is adequately exposed. • Look for medical equipment/therapies

• Ask which hip is painful, show empathy. • Verbalize the steps of the examination and your findings. 2. Inspection of hip (with patient standing up) • While the patient is standing, check the hip for SEADS : S: Swelling, E: Erythema, ecchymosis, A: Atrophy/asymmetry (muscle bulk), D: Deformity, S: Skin changes (erythema/scars/abscess/sinuses) • Leg length discrepancy • Whilst the patient is still standing, perform the Trendelenberg test. This is done by asking the patient to alternately stand on one leg. Stand behind the patient and feel the pelvis. It should remain at level or rise slightly. If the pelvis drops markedly on the side of the raised leg, then it suggests abductor muscle weakness on the leg the patient is standing on. 3. Gait - ask patient to walk across the floor. Look for any abnormalities, hip, knee, foot movements, length of stride. 3. Inspection & Palpation of hip (with patient lying down) • Inspection for hip and groin swellings (hernia, lymphadenopathy, saphenous varix, effusion) • Inspect for obvious fixed flexion • Palpate anterior hip for lumps and tenderness. • Palpate the greater trochanter for any tenderness which might suggest trochanteric bursitis. 4. Leg-length difference • Make an approximate judgment by aligning the medial malleoli and looking for discrepancy. • Measure true and apparent leg-length if appropriate. True leg length discrepancy is found by measuring from the anterior superior iliac spine to the medial malleolus. Apparent leg length discrepancy is measured from the umbilicus to the medial malleolus.

wresoFGAfr

Antalgic ~ Trauma, OA Trendelenberg - weakness of hip adductors Festlnating - Parkinson's ds. High stepping - Polio, MS Scissor Spastic cerebral palsy Stomping - Friedreich's ataxia, tabes dorsalis Spastc - Brain tumor, sturge Weber's, cerebral palsy


5. Active and passive movements • Assess active flexion, extension, abduction and adduction. - Flexion : Flex the knee to 90 degrees and passively flex the hip by pushing the knee towards the chest. - Extension : is performed by placing your hand under the patient’s ankle and asking them to push your hand into the bed. • Passively assess internal and external rotation of the hip (with hips at 90° flexion) - Internal rotation : performed with the knee flexed and by everting the knee for internal rotation - External rotation : performed with the knee flexed and inverting it for external rotation. 6. Special tests • Thomas test : Place your hand under the patient's lumbar spine to stop any lumbar movements and fully flex one of the hips. Observe the other hip, if it lifts off the couch then it suggests a fixed flexion deformity of that hip. • FABER (Flexion Abduction External Rotation) : Ask the patient to lie supine on the exam table. Place the foot of the affected side on the opposite knee. Pain in the groin area indicates a problem with the hip and not the spine. Press down gendy but firmly on the flexed knee and the opposite anterior superior iliac crest. Pain in the sacroiliac area indicates a problem with the sacroiliac joints.

Clinical Examination 81 Knee Examination 1. Steps before beginning examination • Introduce yourself : “I am Dr.________, your attending physician and I'll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.” • Wash/Sanitize hands • Explain to the patient what you are about to do and gain informed consent. • Ensure patient is adequately exposed (up to above knees). • Look for medical equipment/therapies • Ask about knee locking, giving way and pain, show empathy. • Verbalize the steps of the examination and your findings. 2. Inspection • Gait : Ask the patient to walk for you. Observe any limp or obvious deformities such as scars or muscle wasting. Check if the patient has a varus (bow-legged) or valgus (knock-knees) deformity. Also observe from behind to see if there are any obvious popliteal swellings such as a Baker's cyst. • While the patient is lying on the bed, make a general observation. Look for symmetry, redness, muscle wasting, scars, rashes or fixed flexion deformities.

3. Palpation • Check the temperature using the backs of your hands, comparing it with other parts of the leg. • Palpate the border of the patella for any tenderness, behind the knee for any swellings, along all of the joint lines for tenderness and at the point of insertion of the patellar tendon. Finally, tap the patella to see if there is any effusion deep to the patella. • Landmarks of the knee : Tibial tuberosity, patellar tendon, quadriceps tendon, medial and lateral femoral condyles. • Peripatellar area : push patella medially and rub right underneath the medial facet of patella and look for tenderness ( Patellar - femoral stress S°). • Joint line tenderness : bend the knee 90°, palpate medial and lateral joint line. • Patella apprehension test - Move patella around and observe patient's face for pain. 4. Range of Motion • Active flexion and extension of knee - Observe for restricted movement and for displacement of patella. • Passive flexion and extension of knee - feel for crepitus. • Straight leg raise - assessment of extensor apparatus.

82 NAC OSCE | A Comprehensive Review 5. Special tests Tests to Detect Arthritis: • Crepitus: Crepitus is the sensation that is felt when rough cartilage or exposed bone is rubbing as the knee is bent. The examiner will feel, and may hear, this grinding as the knee is bent back and forth. • Deformity: As the knee cartilage is worn away, the knees may become progressively knock-kneed or bow-legged. • Limited Motion: The range of motion of the knee typically becomes limited if arthritis, bone spurs, and swelling prevents normal mobility. Tests to Detect a Tom Meniscus: • Joint Line Tenderness Joint line tenderness is a very non-specific test for a meniscus tear. The area of the meniscus is felt, and a positive test is considered when there is pain in this area. • McMurrays Test McMurray’s test is performed with the patient lying flat on his back and the examiner bending the knee. A click is felt over the meniscus tear as the knee is brought from full flexion to full extension. Tests to Detect an ACL Tear: • Lachman Test The Lachman test is the best test to diagnose an ACL tear. With the knee slighdy bent, the examiner stabilizes the thigh while pulling the shin forward. A tom ACL allows the shin to shift too far forward. • Anterior Drawer Test This test is also performed with the patient lying flat on his back. The knee is bent 90 degrees and the shin is pulled forward to check the stability of the ACL. Tests to Detect Other Ligament Injuries: • Posterior Drawer Test The posterior drawer is performed similarly to the anterior drawer test. This test detects injury to the PCL. By pushing the shin backward, the function of the PCL is tested. • Collateral Ligament Stability Side-to-side stability of the knee detects problems of the collateral ligaments, the MCL and LCL. With the patient lying flat, and the knee held slightly bent, the shin is shifted to each side. Damage to the LCL or MCL will allow the knee to "open up" excessively, a problem called varus (LCL) or valgus (MCL) instability. Tests to Detect Kneecap Problems: • Patellar Grind The patient lies supine with the leg extended. The examiner reproduces the patient's knee pain by pushing the kneecap down and asking the patient to flex his thigh muscles. Damaged cartilage can cause a grinding sensation called crepitus. • Patellar Tenderness The examiner can slightly lift up the kneecap and place direct pressure on the under surface of the kneecap. By doing so, the examiner is looking for sensitive regions of cartilage. • Patellar Apprehension This is a sign of an unstable kneecap. While the examiner places pressure on the kneecap, the patient may complain of the sensation that the kneecap is going to 'pop out' of its groove.

Clinical Examination 83 Foot and Ankle Examination

1. Steps before beginning examination • Introduce yourself : “I am Dr._______, your attending physician and I'll be examining you today. At

any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.” • Wash/Sanitize hands • Explain to the patient what you are about to do and gain informed consent. • Ensure patient is adequately exposed (up to above knees). • Look for medical equipment/therapies • Ask if patient is able to bear weight, show empathy. • Verbalize the steps of the examination and your findings. 2. Inspection • Gait : watch the patient walk, observing for a normal heel strike, toe-off gait. Also look at the alignment of the toes for any valgus or varus deformities. Assess ability to weight-bear on affected side. • While patient is standing check the foot arches checking for pes cavus (high arches) or pes planus (flat feet). • Inspection of the foot with patient sitting and feet overhanging - Check the foot and ankle for SEADS : S: Swelling, E: Erythema, ecchymosis, A: Atrophy/asymmetry (muscle bulk), D: Deformity, S: Skin changes/scars/bruising. - Check the symmetry, nails (psoriasis), skin, toe alignment, look for toe clawing, joint swelling and plantar and dorsal calluses. • Finally you should look at the patient’s shoes, note any uneven wear on either sole and the presence of any insoles. 3. Palpation of ankle/foot • Feel each foot for temperature, comparing it to the temperature of the rest of the leg. • Feel for distal pulses. • Squeeze over the metatarsophalangeal joints observing the patient's face for any pain. • Palpate over the midfoot, ankle and subtalar joint lines for any tenderness. Feel the Achilles tendon for any thickening or swelling. Palpate medial and lateral malleoli for any tenderness.

84 NAC OSCE ) A Comprehensive Review

4. Range of Motion • Assess all active and passive movements of the foot. These movements are inversion, eversion, dorsiflexion and plantarflexion. - Subtalar joint - inversion and eversion - Ankle joint - dorsiflexion and plantar flexion - Big toe - dorsiflexion and plantar flexion - Mid-tarsal joints - which are tested by fixing the ankle with one foot and inverting and everting the forefoot with the other. 5. Special tests • Ankle Anterior Drawer Test - assesses for lateral ankle sprain Patient is seated, stabilize the tibia with one hand while grasping heel and pulling it anteriorly with the other. Greater than 3 mm anterior movement may be significant. 1 cm is significant and indicates anterior talofibular ligament rupture. Positive Test - laxity in the ligament with exaggerated anterior translation • Talar Tilt Test - assesses integrity of the deltoid ligament/lateral ankle sprain Patient is seated, stabilize the leg and foot while adducting and inverting the calcaneus apply a varus force. The calcaneus is then abducted and everted applying a valgus force. Positive Test - pain or laxity in the ligament • Thompson’s Test - assesses for Achilles' tendon rupture Patient is prone, squeeze the gastrocnemius and soleus muscles while noting any movement at the ankle and foot Positive Test - no movement or plantarflexion at all indicates a 3rd degree strain of the Achilles' tendon • Plantar Fasciitis Test - assesses for inflammation of the plantar fascia Patient is supine, dorsiflex the ankle and extends all toes then press in the medial border of the plantar fascia Positive Test - pain is consistent with plantar fasciitis Ottawa Ankle rules For taking ankle series x-rays(AP and lateral ankle) • X-ray if there is pain over the malleolar zone AND tenderness on palpation of the medial/lateral malleolar tip and posterior aspect of medial/lateral malleolus OR • Patient unable to bear weight immediately and in ER. For foot series (AP and Lateral foot) • X-ray if there is pain in midfoot zone AND bony tenderness over the navicular or base of 5th metatarsal OR Unable to bear weight immediately and in ER


Shoulder Examination 1. Steps before beginning examination • Introduce yourself : “I am Dr.________, your attending physician and I'll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.” • Wash/Sanitize hands • Explain to the patient what you are about to do and gain informed consent. • Look for medical equipment/therapies, ensure patient is adequately exposed. • Ask which shoulder is painful. Verbalize the steps of the examination and your findings. 2. Inspection • Start by exposing the joint and observe the shoulder joint looking from the back, side and front for any scars, deformities or muscle wasting (SEADS). Also compare both sides for symmetry. • With the patient standing, ask the patient to place their hands behind their head and behind their back and observe for and deformities. 3. Palpation • Feel over the joint and its surrounding areas for the temperature of the joint as raised temperature may suggest inflammation or infection in the joint. • Systematically feel along both sides of the bony shoulder girdle. Start at the sternoclavicular joint, work along the clavicle to the acromioclavicular joint • Feel the acromion and then around the spine of the scapula. • Feel the anterior and posterior joint lines of the glenohumeral joint and finally the muscles around the joint for any tenderness. 4. Range of Motion • The movements of the joint should start being performed actively. • Ask the patient to bring their arm forward (flexion), bend their arm at the elbow and push backwards (extension), • Bring their arm out to the side and up above their head (abduction). When testing adduction perform the scarf test (The scarf test is performed with the elbow flexed to 90 degrees, placing the patient's hand on their opposite shoulder and pushing back, again look for any discomfort. ) • Rotation - Internal rotation : Ask the patient to place hands in the small of their back, and slide them up the back as far as possible. - External rotation : Ask patient to rotate their arms outwards, keeping the elbows flexed and by the side of the body. • Once all of these movements have been performed actively, you should perform them passively and feel for any crepitus whilst moving the joints.


5. Special Tests Tests for Rotator Cuff i. Supraspinatus • Empty Can Test ( tests integrity of Supraspinatus) : The patient stands with arms extended at the elbows and abducted in the scapular plane and with thumbs pointed to the floor. The examiner applies downward pressure to the arms and the patient attempts to resist. Positive test : Pain, muscle weakness or both. • Apley's Scratch Test- Reach over shoulder to "scratch" between scapula. Measure to which vertebrae thumb can reach. ii. Infraspinatus • External Rotation Lag Sign : The elbow is passively flexed to 90 degrees, and the shoulder is held at 20 degrees abduction (in the scapular plane) and near maximal external rotation by the examiner. The patient is then asked to actively maintain the position of external rotation in abduction as the examiner releases the wrist while maintaining support of the limb at the elbow. The sign is positive when a lag, or angular drop occurs. The magnitude of the lag is recorded to the nearest 5 degrees. iii. Subscapularis • Gerber Lift-OfFTest : With the patient’s hand on the small of the back, the arm is extended and internally rotated. The examiner then passively lifts the hand off the small of the back, placing the arm in maximal internal rotation. The examiner then releases the hand. If the hand falls onto the back because the subscapularis is unable to maintain internal rotation, the test result is positive. Patients with subscapularis tears have an increase in passive external rotation and a weakened ability to resist internal rotation. Tests for Shoulder Instability

• Apprehension Sign for Anterior Instability : The test is performed by abducting the shoulder to 90 degrees, and then slowly externally rotating the shoulder toward 90 degrees. A patient with anteriorinferior instability will usually become "apprehensive" either verbally or with distressing facial expressions. Tests for Subacromial Impingement • Neer Impingement Sign : Place one hand on the posterior aspect of the scapula to stabilize the shoulder girdle, and, with the other hand, take the patient's internally rotated arm by the wrist, and place it in full forward flexion.If there is impingement, the patient will report pain in the range of 70 degrees to 120 degrees of forward flexion as the rotator cuff comes into contact with the rigid coracoacromial arch. • Hawkins Impingement Sign : The examiner places the patient's arm in 90 degrees of forward flexion and forcefully internally rotates the arm, bringing the greater tuberosity in contact with the lateral acromion. A positive result is indicated if pain is reproduced during the forced internal rotation. Tests for Long Head of the Biceps • Speed's Maneuver : The patient's elbow is flexed 20 degrees to 30 degrees with the forearm in supination and the arm in about 60 degrees of flexion. The examiner resists forward flexion of the arm while palpating the patient's biceps tendon over the anterior aspect of the shoulder. • Yergason test : The patient's elbow is flexed to 90 degrees with the thumb up. Forearm is in neutral. The examiner grasps the wrist, resisting attempts by the patient to actively supinate the forearm and flex the elbow. Pain suggests biceps tendonitis.

Clinical Examination 87 Elbow Examination

1. Steps before beginning examination • Introduce yourself : “I am Dr._______, your attending physician and I'll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.” • Wash/Sanitize hands • Explain to the patient what you are about to do and gain informed consent. • Look for medical equipment/therapies, ensure patient is adequately exposed. • Verbalize the steps of the examination and your findings. 2. Inspection • SEADS : S: Swelling, E: Erythema, ecchymosis, A: Atrophy/asymmetry (muscle bulk), D: Deformity, S: Skin changes/scars/bruising. Check for a fixed flexion deformity. Look at the underside of the elbows to check for any psoriatic plaques, cysts or rheumatoid nodules. 3. Palpation • Feel the elbow, assessing the joint temperature relative to the rest of the arm. • Palpate the olecranon process as well as the lateral and medial epicondyles for tenderness (medial for golfer’s elbow and lateral for tennis elbow), and cubital fossa for tenderness. • Palpate joint line with elbow flexed to 90° for tenderness and swelling. 4. Range of Motion • The movements at the elbow joint are all fairly easy to describe and assess. These are flexion, extension, pronation and supination. Once these have been assessed actively they should be checked passively checking for power and crepitus. • Test for varus / valgus instability. 5. Neurological Examination of hand Motor - Median nerve (thumb abduction) - Radial nerve (wrist extension) - Ulnar nerve (finger abduction) 6. Special Tests • Tennis Elbow : Tennis elbow localises pain over the lateral epicondyle, particularly on active extension of the wrist with the elbow bent. • Golfer's Elbow : Golfer's elbow pain localises over the medial epicondyle and is made worse by flexing the wrist. Sensory - Median nerve (pulp of index finger) - Radial nerve (1st dorsal interosseous space) - Ulnar nerve (pulp of 5th finger)

88 NAC OSCE | A Comprehensive Review Hand and Wrist Examination

1. Steps before beginning examination • Introduce yourself : “I am Dr.________, your attending physician and I'll be examining you today. At

any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.” • Wash/Sanitize hands • Explain to the patient what you are about to do and gain informed consent. • Look for medical equipment/therapies • Verbalize the steps of the examination and your findings. 2. Inspection • Inspect hands : - Skin (rashes, Gottron's patches, nodules, Raynaud's phenomenon, sclerodactyly, scars, skin atrophy) - Nails (pitting, onycholysis, splinter haemorrhages, clubbing) - Muscles (swelling, wasting) - Joints (swellings, subluxation / deviation of wrist, swan neck / Boutoniere's deformity, Heberden's/Bouchard's nodes, Z deformity of thumb) - Inspect palm (palmar erythema, pallor, cyanosis), muscle wasting. • Inspect elbows : - Psoriatic skin lesions - Rheumatoid nodules - Scars 3. Palpation • Assess the temperature over the joint areas and compare these with the temperature of the forearm. • Start proximally and work towards the fingers, feeling the radial pulses and the wrist joints. Then feel the muscle bulk in the thenar and hypothenar eminences. In the palms, feel for any tendon thickening and assess the sensation over the relevant areas supplied by the radial, ulnar and median nerves. • Squeeze over the row of metacarpophalangeal joints whilst watching the patient's face for any discomfort. • Bi-manually palpate MCP and interphalangeal joints.


4. Range of Motion • Ask the patient to perform the following movements in the sequence mentioned below and observe for range of movement : - Make a fist - Pronate wrist - Extend little finger (extensor digiti minimi is usually the first tendon to rupture in rheuatoid arthritis) - Extend all fingers • Assess function - Pinch grip - Opposition (touch thumb to each finger) - Power grip (ask patient to squeeze your fingers) - Froment's test (for ulnar nerve palsy). In this test the patient attempts to grip a paper with thumb and index finger while the examiner tries to pull the paper out of the patient's grip. - Ask patient to write something / undo a button. • Assess power - Wrist extension (radial nerve) - Thumb abduction (median nerve) - Finger abduction (ulnar nerve) 5. Neurovascular Examination Nerve Sensation Motor Median Lateral portions of the pulp of the index and middle fingers Resisted palmar abduction of the thumb Ulnar Lateral pulp areas of the little finger Abduction of the fingers against resistance Radial Web space between the thumb and index finger (anatomical snuff box) Wrist extension

6. Special Tests • Phalen's test : Forced flexion of the wrist, either against the other hand or by the examiner for 60 seconds will recreate the symptoms of carpal tunnel syndrome.

• Finkelstein’s test is used to diagnose DeQuervain's tenosynovitis. Patient is told to flex the thumb and clench the fist over the thumb followed by ulnar deviation. If there is an increased pain in the radial styloid process and along the length of the extensor pollicis brevis and abductor pollicis longus tendons, then the test is positive for De Quervains syndrome. • Tinel's sign : Use the index finger to tap over the carpal tunnel at the wrist. A positive test results when the tapping causes tingling or paresthesia in the area of the median nerve distribution, which includes the thumb, index finger, and middle and lateral half of the ring finger. A positive Tinel's sign at the wrist indicates carpal tunnel syndrome.

90 NAC OSCE | A Comprehensive Review Breast Examination

• Introduce yourself : “I am Dr._______, your attending physician and I'll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.” • Wash/Sanitize hands • Explain to the patient what you are about to do and gain informed consent. • Verbalize the steps of the examination and your findings. Ask which side the problem is. • Make sure patient is adequately exposed, use proper draping techniques 1. General Inspection (with patient sitting on side of bed) • Inspect with : - Patient's arm by their sides. - Patient’s arms behind their head (tenses skin) - Patient's hands on their hips (tenses pectoralis major) These manoeuvers test forT4 disease - invasion of chest wall / skin. Inspect for : - Obvious masses - Scars - Radiotherapy tattoos - Skin changes - Peau d'orange - Dimpling - Nipple retraction - Paget's disease. 2. Inspection (with patient lying down) - Breasts size, symmetry and contour. - Areola pigmentation, nipple pigmentation, shape, ulceration and discharge. - Skin color, thckening, venous pattern and edema. 3. Palpate - Palpate normal breast followed by abnormal breast. - Palpate all quadrants, nipple and axillary tail of each breast. - Describe any masses : position, size shape, mobility, number, tenderness, consistency. - Palpate axillary, supraclavicular and infraclavicular lymph nodes. 4. Auscultate lungs.

Clinical Examination 91 Thyroid Examination 1. Steps before beginning examination • Introduce yourself : “I am Dr._______, your attending physician and I'll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.” • Wash/Sanitize hands • Explain to the patient what you are about to do and gain informed consent. • Ensure patient is adequately exposed. • Look for medical equipment/therapies • Show empathy. • Verbalize the steps of the examination and your findings. 2. Inspection • Ask for patient’s vitals. • Observe patient : Is patient anxious? Weight gain/loss? Note hoarseness of voice. • Feel pulse - rate/rhythm/volume • Face : Facial expression ( dull in hypothyroidism) Periorbital myxedema Loss of l/3rd of eyebrows Hair - texture/alopecia Exophthalmos (look from behind patient), lid lag Ophthalmoplegia (ask patient to follow your finger then ask for diplopia)

Chemosis (redness and watering of eyes) • Hands : Temperature, moist palms, texture, color. Assess for fine tremors, palmar eythema Pemberton's sign - is the development of facial flushing, distended neck and head superficial veins, inspiratory stridor and elevation of the jugular venous pressure (JVP) upon raising of the patient’s both arms above his/her head simultaneously. (Thoracic inlet obstruction - e.g. due to goitre) Carpal Tunnel Syndrome (Tinel’s and Phalen's Test) - associated with hypothyroidism. Arm reflexes - brisk in hyperthyroidism. • Neck : Stand in front of the patient, inspect for neck swellings/goitre - scars, sinuses, dilated vessels.

92 NAC OSCE | A Comprehensive Review 3. Examination of the Thyroid gland and cervical lymph nodes. • Swallow tests - Ask patient to swallow water and observe for movement of any masses. • Tongue protrusion - Thyroglossal cyst moves on tongue protrusion. • Stand behind the patient and palpate. Assess size, texture, smoothness, margins and mobility of the thyroid gland (including when swallowing). Note the temperature over gland and adjacent skin. • Palpate cervical lymph nodes. • Percuss over sternum - Retrosternal goitre. • Auscultate for thyroid bruit - Grave's disease. 4. Examination of legs. • Prétibial myxoedema • Peripheral edema due to congestive cardiac failure. • Delayed relaxation of ankle reflex in hypothyroidism. 5. Thank the patient after the examination.

Clinical Examination 93 Mini Mental State Examination 1. ORIENTATION Maximum score = 10 What is today's date? 1 What is the year? 1 What is the month? 1 What is the day today? 1 Can you tell me what season it is? 1 Can you also tell me the name of the location we are in? (Hospital/clinic) 1 What floor are we on? 1 What city are we in? 1 What country are we in? 1 What state are we in? 1 II. IMMEDIATE RECALL Maximum score = 3 Ask the patient if you may test his/her memory. Say the words "ball" , "flag" , "tree" clearly and slowly. Then ask the patient to repeat the words. Check for each correct response. The first repetition determines the score. If the patient does not repeat all three correctly, keep saying them up to six tries until the patient can repeat them. Ball 1 Flag 1 Tree 1 Number of Trials :__ III. ATTENTION AND CALCULATION A. Counting Backwards Test Record each response Maximum score = 5

Ask the patient to begin with 100 and count backwards by 7. Record each response. Check one box at right for each correct response. The score is the number of correct subtractions. 93 1 86 1 79 1 72 1 65 1 B. Spelling Backwards Test Ask the patient to spell the word "WORLD" backwards. Record each response. Use the instructions to determine which are correct responses, and check one box at right for each correct response. D 1 L 1 R 1 0 1 W 1


C. Final Score Compare the scores of the Counting Backwards and Spelling Backwards tests. Write the greater of the two scores in the box labeled FINAL SCORE at right, and use it in deriving the TOTAL SCORE. Final Score : (Max of 5 or Greater of the two scores) IV. RECALL Maximum score = 3 Ask the patient to recall the three words you previously asked him/her to remember. Check the Box at right for each correct response. Ball 1 Flag 1 Tree 1 V. LANGUAGE Maximum score = 9 Naming Watch 1 Show the patient a wrist watch and ask him/her what it is. Repeat for a pencil. Pencil 1 Repetition Ask the patient to repeat "No ifs, ands, or buts." Correct repetition 1 Three - Stage Command Establish the patient's dominant hand. Give the patient a sheet of blank paper and say, 'Take the paper in your right/left hand, fold it in half and put it on the floor." Takes paper in hand 1 Folds paper in half 1 Puts paper on the floor 1 Reading Hold up the card that reads, "Close your eyes." So the patient can see it clearly. Ask him/her to read it and do what it says. Check the box at right only if he/she actually closes his/her eyes. Closes eyes 1 Writing

Give the patient a sheet of blank paper and ask him/her to write a sentence. It is to be written spontaneously. If the sentence contains a patient and a verb, and is sensible, check the box at right. Correct grammar and punctuation are not necessary. Writes sentence 1 Copying Show the patient the drawing of the intersecting pentagons. Ask him/her to draw the pentagons (about one inch each side) on the paper provided. If ten angles are present and two intersect, check the box at right. Ignore tremor and rotation. Copies pentagons 1


""i DERIVING THE TOTAL SCORE Add the number of correct responses. The maximux is 30. 23-30 Normal 23-19 Borderline Less than 19 Impaired

This is a blank page

Clinical Cases This is a blank page

Clinical Cases - Protocol for history taking 99 Protocol for history taking A candidate gets 2 minutes outside the station to read the clinical case senario on the door before entering. It is essential to get yourself organised in these 2 minutes. • Read the question properly, understand the requirement and follow instructions (e.g. if you are asked to do a physical examination, do not start taking history. You will be losing valuable time) • You will be given a pencil and a booklet with blank pages. It is a good practice to jot down notes. • Write the name, age, sex and chief complaint of the patient. • For history of present illness, you can use the mnemonic OCDPQRSTUV+AAA. • Past and Social History : PAM HUGS FOSS • Write down your differential diagnosis. So your note should look something like this : Name of the patient, age, sex and chief complaints O - Onset C - Course D - Duration P - Place Q_- Quality R - Radiation S - Severity T - Timing U - You (associated with your daily activities) V - Deja vu (Has it happened before?) A - Aggravating factors A - Alleviating factors A - Associated symptoms Differential diagnosis : P - Past medical history A - Allergies M - Medication H - Hospitalizations U - Urinary problems G - GIT problems S - Sleep F - Family history O - Obstetrical history S - Social history S - Sexual history • Knock the door before entering, relax, take a deep breath, smile and enter the room with confidence. Hand over the stickers to the physician examiner. • Introduce yourself to the patient : e.g. “Good morning/afternoon/evening, Mr./Miss______, I am Dr._____and I’m your attending physician today.” • “So, Mr./Miss_____, what complaint has brought you here today?” • Show empathy : “Oh! I am sorry to hear that, I shall try my best to help you.”


Data Collection : OCDPQRSTUV+AAA • Onset : When did it start? Sudden? Gradual? • Course : Is it getting worse, better or just the same? • Duration : You said it started......ago, does it come and go? How often does it come? For how long does it stay each time? • Place : Show me exactly where it hurts? • Quality : Tell me how it feels like? Is it sharp/burning/dull/crampy? • Radiation : Does it travel to anywhere? • Severity : On a scale from 1 to 10, with 1 being the mildest and 10 the worst pain, how bad is it? • Timing : Is it worse at a particular time of the day?

• U (You) your daily activities : Does it interfere in your day to day activities? Does it change with your daily activities like posture, rest, eating, exertion? • V (Deja vu) : Has it happened before? When? What happened then? What medication? • Aggravating factors : What makes it worse? • Alleviating factors : What make it better? • Associated symptoms : Have you noticed anything that occurs with it? • Al : Associated constitutional symptoms like fever, shortness of breath, cough, nausea, vomiting, diarrhea, headache, fatigue (FSC NVD HF) • A2 : Associated symptoms to particular system Respiratory : Chest pain, shortness of breath, cough, sputum, wheezing, runny nose, post nasal drip, contact with ill person, night sweats, questions for pulmonary embolism (leg pain, long travel, surgery and OCP use in females) CVS : chest pain, orthopnea, paroxysmal nocturnal dyspnea, palpitations, tachycardia. GIT : pain in abdomen, stool, bowel movements, vomiting, jaundice, blood in stools, diet, travel. Neurology : headache, loss of consciousness, weakness, paresthesias Higher Mental Function : orientation, memory, consciousness. Motor : weakness of limbs. Sensory : tingling sensation. Cerebellum : gait, balance. Cranial Nerves : speech, swallowing, vision, hearing. PAM HUGS FOSS • “Ok, Mr./Miss_____, Now I need to ask you about your health in general. Is that okay with you?” • Past Medical History : What other medical problems do you have? (Diabetes/Hypertension/Asthma / Cancer?) • Allergies : Do you have any allergies? Are you allergic to any drugs?

Clinical Cases - Protocol for history taking 101 • Medication : Do you take medicines at present? • Hospitalizations : (medical/surgical/trauma) • Urinary problem : burning sensation while passing urine? Blood in urine? • GIT : bowel movements? Loose stools? Constipation? Blood in stools? • Sleep? • “lam going to ask you a few personal questions that will help me in my diagnosis. Is that okay with you? Let me begin by asking you about your family health.” • Family history : similar complaints in the family? Cancer in the family? Depression? Suicide? • Obstetrical History : When was your last pap smear? Wast it normal? Any history of STIs? • “Now I need to ask you about your sexual health. Whatever you tell me will be kept confidential. Is that okay with you?” • Sexual History : Are you in a physical relationship? How long? Do you practice safe sex? Any risk of STIs? • Social History : Smoking, how many packs? Alcohol, amount? Recreational drugs? • “Is there anything else that you want to share?” • WRAP UP T : Treatment history R: Route A : Addictlon/toxicity/amount P: Pattern of use P: Prior abstinence E: Effects of the drug D: Duration of use


Tammy Robbins, a 48 years old lady presented with heart racing and chest discomfort for the past 3 days. Take a focused history and perform focused physical examination. Vitals: BP - 90/70 mm Hg, HR - 146/min, irregular, RR - 12/min,Temp - 37.5°C Clinical Info: Ms Tammy Robbins is a known hypertensive with CAD for the past 10 years, who presented with sudden onset of palpitations and chest discomfort for the past 3 days. Her symptoms are worsening for the past 24 hours. She has dyspnea. She has dizziness for the past 12 hours. Pedal edema is 2 +. She had 2 vessel angioplasty done 5 years ago. ECG shows absent P waves with irregular narrow QRS complexes. Bilateral basal rales present on lung auscultation. Clinical Case : Atrial Fibrillation (examination on page 65) HOPI • OCD PQRST UV + AAA • How did it start? Sudden or gradual. • Is it getting worse/better or no changes in the symptoms? • Duration of palpitations?

• Associated with chest discomfort? • Describe the type of chest discomfort? • Do you have chest pain? • Any shortness of breath? • Any dizziness/light headedness? • Any fever/cough/nausea/vomiting? • Any hemoptysis? • Any chills/night sweats? • Any malaise/fatigue/weakness? • Any swelling of feet? • Any numbness/paresthesias? • Any visual problems? • Any relieving factors? • Any aggravating factors? • Any recent trauma? • List of current medications/compliance? Past History • Do you have any medical illnesses? • Are you allergic to any medications? • Any surgeries in the past? • Past h/o recurrent infections? Family and Social History • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration oc frequency. • Do you take any recreational drugs? • Any family history of cancers/ medical illnesses? Differential Diagnosis Management Atrial fibrillation secondary to: • Treat the primary cause. 1. Congestive heart failure. • Admit in cardiac care unit. 2. Ischemic heart disease. • Rate control by beta blockers, calcium 3. Hypertension. channel blockers or digoxin. 4. Thyroid disease. • Anticoagulation with heparin, then warfarin. • Rhythm control by electro or medical Investigations cardioversion. • CBC, electrolytes, glucose. • Assess Stroke risk by using CHADS2 score. • LFT, RFT,TSH. • CK, LDH, Cardiac enzymes. • 12 lead ECG. • Echocardiogram. • Chest X ray.

Clinical Cases - Medicine 103

Simon Charles, a 20 years old male presented to your clinic with shortness of breath for the past 24 hours. Take a focused history and perform focused physical examination. Vitals: BP - 110/80 mm Hg, HR - 110/min, RR - 22/min,Temp - 37.5°C. Clinical Info: Mr Simon Charles has a h/o of Asthma since the past 10 years. He recently cleaned his basement 1 day ago and his asthma symptoms exacerbated. He is having wheezing, chest tightness,cough and SOB. He is currently on inhalers with no night symptoms. On examination, he has dyspnea and wheezing present in all lung fields. He has mild exacerbation of his symptoms and needs only outpatient treatment. Clinical Case : Asthma (examination on page 69) HOPI OCD PQRST UV + AAA How did it start? Sudden or gradual. Is it getting worse/better or no changes in the symptoms? Do you wake up in night with shortness of breath?

Do you have noisy breathing? H/o fever/sore throat/rash? Any night time cough? Any sputum production? Any cnest pain with deep inspiration? Any recent activity whicn worsened your svmptoms? Any exposure to cold air/dust/mites? Any pets at home? Any changes in bowel & urinary habits? Any contact with a sick person? Any recent travel? Any recurrent episodes? Do symptoms affect your daily activities? Past History • Do you have asthma/other allergies? • Are you on any medications ana compliance? • Are you allergic to any medications? • Any hospitalizations for asthma? • H/o any other medical illness? Family and Social History • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration & frequency. • Do you use recreational drugs? TRAPPED. • Any family history of asthma/allergies? Differential Diagnosis Management • Asthma. • Ventolin 2-4 puffs MDI q4-6h. • Fluticasone 2-4 puffs bid(Inhaled steroids) • Acute bronchitis. • GERD. • Asthma education: • Pneumonia. Inhaler use. Investigations • CBC. Spacer and holding chamber use. Symptom monitoring. Early recognition of exacerbation. • Pulmonary function tests. Avoid environmental allergens. • Peak flow meter. Encase mattress and pillow in • Chest X ray. impermeable cover. Reduce indoor humidity to <50%.


Larry Edwards, a 55 years old man presented with blood in sputum and shortness of breath for the past 5 days. Take a focused nistory and perform focused physical examination. Vitals: BP - 160/110 mm Hg, HR - 96/min, RR - 18/min,Temp - 37.5°C. Clinical Info: Mr Larry Edwards is a known hypertensive who presented with shortness of breath and blood in sputum for 5 days. It is gradual in onset. He has chest pain also. No fever or recurrent pneumonia. He is non compliant with his medications. He is on Losartan, Aspirin, Atorvas, multi vitamins. He has not taken his anti-hypertensives for 4 weeks. Has paroxysmal nocturnal dyspnea and orthopnea. Clinical Case : Congestive Heart Failure (examination on page 65) HOPI • OCD PQRST UV + AAA • How did it start? Sudden or gradual. • Is it getting worse/better or no changes in the symptoms? • Duration of blood in sputum? • Amount / color of blood of sputum? • Any of shortness of breath? • Present at rest or with exertion?

• H/o orthopnea? • H/o paroxysmal nocturnal dyspnea? • Any chest pain/palpitations? • Type of pain - sharp or dull? • Does the pain radiate or shoot anywhere? • Severity of pain on a scale of 1-10. • Do your symptoms change with time?? • H/o fever/cough/sore throat/rash? • Any chills/nignt sweats? • Any swelling of face or feet? • Any change in weight/appetite? • Any bruises on the body? • Any trauma recendy? Past History • Do you have diabetes or hypertension? • Are you on any medications? • Compliance with medications? • Are you allergic to any medications? • Any surgeries in the past? • Past h/o recurrent infections? Family and Social History • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration & frequency. • Do you use recreational drugs? TRAPPED. • Any family history of cancers/ medical illnesses? • Any family history of heart disease? Differential Diagnosis Management • Pulmonary Edema due to CHF. • Symptomatic treatment. • Pulmonary embolism. • Admit in cardiac care unit. • Bronchiectasis. • Inj Lasix 40 mg IV stat. • Beta blockers & ACE inhibitors. • Drug induced coagulopathy. • Pneumonia. • Inj Morphine 2-4 mg IV. Investigations • Nasal oxygen. • Sublingual Nitroglycerines. • CBC, electrolytes, glucose. • Position - 45 degree elevation of head end. • LFT, RFT. • PT, PTT, INR. • 12 lead ECG. • Echocardiogram. • Chest X Ray.


Jack Allen, a 65 years old man presented with sudden onset of right arm weakness 4 hours ago. Take a focused history and perform focused physical examination. Vitals: BP - 160/90 mm Hg, HR - 96/min, RR - 12/min,Temp - 37.5°C. Clinical Info: Mr Jack Allen presented with sudden onset of right arm weakness with numbness and paresthesias 4 hours ago. He has slurring of speech, blurring ofvision and mild headache. He has no nausea,vomiting or head trauma. No weakness of lower limbs or left arm. No incontinence. He is hypertensive for the past 10 years and non compliant to medications. Clinical Case : Cerebrovascular Attack (examination on page 71) HOPI • OCD PQRST UV + AAA • How did it start? Sudden or gradual. • Is it getting worse/better or no changes in the symptoms?

• Duration of weakness? • Where is the weakness located? • Is there any associated pain in the arm? • Any numbness/tingling/paresthesias? • Any limitations in right arm movements? • Any abnormal position of right arm? • Do your symptoms change with time? • Any changes in vision? • Any changes in speech? • Any difficulty swallowing/drooling of saliva? • Any headache/trauma? • Any weakness of left arm or lower limbs? • Any seizures? • Any changes in facial expression? • H/o fever/cough/sore throat/rash? • Any chest pain/shortness of breath? • Any changes in bowel & urinary habits? Past History • Do you have diabetes or hypertension? • Are you on any medications/compliance? • Are you allergic to any medications? • Any surgeries in the past? Family and Social Histoiy • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration & frequency. • Do you use recreational drugs? TRAPPED. • Any family history of cancers/ medical illnesses? Differential Diagnosis Management • Cerebrovascular Attack. • Admit urgently. • Transient Ischaemic Attack. • Urgent neurological consult. • Sub Arachnoid Hemorrhage. • Neurovitals q 1 hourly. Investigations • Nasal oxygen. • Tab Aspirin 325 mg PO OD. • CBC, ESR, Glucose. • Blood pressure control. • Lipid profile, RFT. • PT, PTT, INR. • Thrombolysis to be done only if presented within 3 hours of onset of symptoms. • ECG. • CT ± MRI Head. • Echo, Carotid doppler.

106 NAC OSCE | A Comprehensive Review Allan Smith, a 70 years old man presented with light headedness and dizziness for 2 days. Take a focused history and perform focused physical examination. Vitals: BP - 110/80 mm Hg, HR - 56/min, irregular, RR - 12/min,Temp - 37.0°C. Clinical Info: Mr Allan Smith is a known hypertensive for the past 20 years on medications. He is experiencing light headedness and dizziness for the past 2 days. He has palpitations and mild chest pain for 2 weeks. He is breathless on exertion. Has 2+ pedal edema. No fainting episode. No trauma recently. No visual changes or limb weakness. He is on Losartan, Ramipril, Digoxin, Atorvas, Aspirin, Nexium and Calcium. ECG shows Type 2 Second Degree AV block. Clinical Case : Digoxin Toxicity (examination on page 65) HOPI • OCD PQRST UV + AAA • How did it start? Sudden or gradual. • Is it getting worse/better or no changes in the symptoms?

• Duration of dizziness? • Any relieving factors? • Any aggravating factors? • Any episode of fainting? • Any weakness/tingling/paresthesias of limbs? • Any chest pain/palpitations? • Any shortness of breath? • Any visual changes/headache? • Any hearing loss/ear discharge? • Any excessive sweating? • Any fever/cough/vomiting? • Any abdominal pain/loss of appetite? • Any changes in bowel/urinary habits? • Any swelling of ankles? • Do your symptoms vary with change in head position? • List of current medications & compliance? • Any changes in medications & dosages? • Any recent trauma? Past History • Do you have diabetes or hypertension? • Are you allergic to any medications? • Any surgeries in the past? • Past h/o recurrent infections? Family and Social History • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration oc frequency. • Do you use recreational drugs? TRAPPED. • Any family history of cancers/ medical illnesses? Differential Diagnosis • Digoxin toxicity. • Arrhythmia. • TIA. • Anxiety disorder. • Medication induced bradycardia. Investigations • Serum Digoxin level. • CBC, electrolytes, RFT. • INR/PTT, glucose. • ECG, 24 hour Holter monitor. • Echocardiogram,Carotid Doppler. Management • Admit in cardiac care unit. • Stop Digoxin. • Start Digibind in case of massive overdose or refractory toxicity. • External Pacemaker.

Clinical Cases - Medicine 107 Lisa Giroux, a 25 years old lady presented with lump in the neck for the past 7 days. Take a focused history and perform focused physical examination. Vitals: BP - 120/88 mm Hg, HR - 96/min, RR - 12/min,Temp - 38.5°C. Clinical Info: Ms Lisa Giroux noticed 2 lumps on the right side of her neck below the mandible. She has positive history of fever for 5 days,sore throat and fatigue. On examination she has 2 enlarged, tender submandibular lymph nodes. Monospot test is positive. Clinical Case : Infectious Mononucleosis (Sore throat ) HOPI OCD PQRST UV + AAA How did it start? Sudden or gradual. Is it getting worse/better or no changes in the symptoms? Since how long have you noticed the lumps? Where are the lumps located? How does the lumps feel like? Is there any pain associated with the lumps? Type of pain - sharp or dull pain? Does the pain radiate or shoot anywhere? Severity of pain on a scale of 1-10. Do your symptoms change with time?

H/o fever/cough/sore throat/rash? Any chest pain/shortness of breath? Any abdominal pain? Any weakness or myalgia? Any chills/night sweats? Any change in voice? Any change in appetite? Any change in weight? Any changes in bowel & urinary habits? Any contact with a sick person? Recent travel? Past History • Do you have diabetes or hypertension? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? • Past h/o recurrent infections? Family and Social History • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration & frequency. • Do you use recreational drugs? TRAPPED. • Any family history of cancers/ medical illnesses? Differential Diagnosis Management • Infectious mononucleosis. • Symptomatic treatment. • Acute bacterial pharyngitis. • Maintain adequate hydration. • Acute viral pharyngitis. • Rest. • Lymphoma. • Toxoplasmosis. • Analgesics for pain. • Treat Streptococcal pharyngitis, if coexists. • Avoid active sports. Investigations • Steroids used only for severe symptoms. • CBC. • Monospot test. • Throat swab for gram stain, culture 8c sensitivity.


Jason Hardinge, a 26 years old university student wants to discuss confidential issues with a doctor. Take focused history and address his concerns. Vitals: BP - 120/88 mm Hg, HR - 88/min, RR - 12/min,Temp - 37.5°C Clinical Info: Mr Jason Hardinge is having difficulty in maintaining erection duringintercourse for the past 4 months. He is currently in a monogamous relationship with his girlfriend. He is on raroxetin for his mood disorder for 6 months. No other medical illnesses. Girlfriend is very understanding. He has no morning or night tumescence. Has no erection with self stimulation. He is very anxious about this issue. Clinical Case : Impotence HOPI • OCD PQRST UV + AAA • How did it start? Sudden or gradual. • Is it getting worse/better or no changes in the symptoms? • Duration of impotence? • Course & frequency of impotence? • Description of the problem: no erection at all, cannot sustain erection, ejaculate too quickly to satisfy partner? • Cannot achieve orgasm or orgasm without ejaculation? • Any retrograde ejaculation? • Circumstances under which impotence occurs only with certain partners, only at certain times or locations, what percentage of the time?

• Is impotence related to lack of sexual desire? • Presence and firmness of morning or nocturnal erections. • Can sustain erections with self stimulation? • Associated problems: anxiety attacks, anhedonia/aepression, perineal or peripheral numbness, poor peripheral circulation. • Sexual orientation - heterosexual/homosexual/bisexual? • Current relationship? • Performance anxiety? • Any stresses in the relationship? • Any stresses at home or school? • Sexual partner's expectations? • Are you on any medications? • Compliance/type of medications - details? Past History • Do you have diabetes or hypertension? • Are you allergic to any medications? • Any surgeries in the past? • Any trauma in the past? • Past h/o recurrent infections? Family and Social Histoiy • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration oc frequency. • Do you use recreational drugs? TRAPPED. • Any family history of cancers/medical illnesses? Impotence secondary to antidepressants. of impotence : (IMPOTENCE) lie, Mechanical, Psychological, Causes imp Iatrogenic, Occlusive vascular, Trauma, Extra factors, Neurogenic, Chemical, Endocrine. Investigations • CBC, blood glucose,TSH. • Se Testosterone. • Urinalysis. • Endocrine lab tests, if indicated: FSH,LH, Prolactin. Management • Complete physical exam. • Reassurance, counseling both patient & partner. • Inform that symptoms are due to side effects of anti-depressants. • Symptoms are reversible by changing the dose or the type of drug. • Substitute with another anti-depressant: Minimal to no sexual dysfunction Nefazodone (Serzone) Bupropion (Wellbutrin) Low risk of sexual dysfunction (10-15%) Fluvoxamine (Luvox) Citalopram (Celexa) Venlafaxine (Effexor) • Avoid alcohol/s molting. • Medical treatment: Tab Sildenafil 25-50 mg PO 0.5 to 4 hours prior to coitus.

Clinical Cases - Medicine 109 Taylor Jackson, a 18 years old boy presented with fever, neck stiffness and photophobia to the ER.Take a focused history and perform focused physical examination. ’ - 90/70 mm Hg, f Vitals: BP,HR - 110/min, RR - 12/min,Temp - 39.0°C. Clinical Info: Mr Taylor Jackson has high grade fever for the past 3 days alone with neck stiffness. He has photophobia for the past 1 day. He is alert & conscious. No seizures. Has heaaache with nausea & vomiting. No ear discharge. Has a purpuric rash on chest and lower limbs. No recent trauma. Has h/o contact with sick

Srson with similar symptoms. O/E: Febrile, Brudzinski's and Kernig's sign are positive, linical Case : Meningitis (examination on page 71) HOPI

OCD PQRST UV + AAA How did fever start? Sudden or gradual. Is it getting worse/better or no changes in the symptoms? Duration of fever? Continuous/intermittent/remittent? Duration of neck stiffness? Associated with headache/nausea/vomiting? Any photophobia/phonophobia? Any fatigue/malaise? Any fainting/seizures/confusion/irritability? H/o fever/cough/sore throat/rash? Any chills/night sweats? Any chest pain/shortness of breath? Any abdominal pain? Any changes in bowel & urinary habits? Any contact with a sick person? Recent travel? Recent head trauma? Past History • Do you have medical illnesses? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? • Past h/o recurrent infections? Family and Social History • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration & frequency. • Do you use recreational drugs? TRAPPED. • Any family history of cancers/ medical illnesses? Differential Diagnosis • Bacterial Meningitis • Encephalitis. • Intra-cerebral abscess. Investigations • CBC, electrolytes, glucose. • RFT, ABG. • Lumbar puncture - gram stain, microscopy, culture/sensitivity (rule out papilledema). • Blood culture/sensitivity, gram stain. • Urinalysis. • CT scan head. • Chest X Ray. Management • Admit under isolation. • Start empiric antibiotics prior to LP. Inj Cefotaxime 2 g IV q4h + Inj Ampicillin 50 mg/kg IV q6h. Inj Dexamethasone 10 mg q6h IV x 4 days. • Treat all close contacts.

110 NAC OSCE | A Comprehensive Review James Irwin a 30 years old man presented to your clinic with symptoms of headache. Take a focused history and address his concerns. Vitals: BP - 120/88 mm Hg, HR - 96/min, RR - 12/min,Temp - 37.5°C. Clinical Info: Mr James Irwin presented with unilateral, pulsating headache, grade 7/10 for the past 6 months. He experiences aura prior to the onset of headache. Associated with nausea,vomiting and photophobia. Stimulated by stress and excessive caffeine intake. One episode lasts for 8-12 hours. He had 6 attacks in past 6 months. Currently on Advil prn. Clinical Case : Headache (Migraine) HOPI OCD PQRST UV + AAA How did it start? Sudden or gradual. Location of pain? Is it getting worse/better or no changes in the symptoms? Since how long have you noticed the pain? Number of episodes of headache till now? How many hours pain lasts? How does the pain feel like? Does the pain radiate or shoot anywhere? Severity of pain on a scale of 1-10. Any provoking factors like food, alcohol, caffeine, chocolate, wine, stress. How does the pain decrease?

Do your symptoms change with time? H/o fever/cough/sore throat/nasal stuffiness? Any excessive lacrimation? Any visual changes prior to onset of headache? Any neck pain/rigidity/seizures? Any weakness/muscle pain/paresthesias? Any mood changes/decreased sleep/energy? Past History • Do you have diabetes or hypertension? • Any head trauma in the past? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? • Past h/o recurrent infections? Family and Social Histoiy • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration &c frequency. • Do you use recreational drugs? TRAPPED. • Any family history of cancers/ medical illnesses? Differential Diagnosis • Migraine with Aura. • Tension Headache. • Cluster Headache. • Temporal Arteritis Investigations • CBC, ESR Management • Symptomatic treatment. • Avoid triggers. • Mild attack - ASA, Ibuprofen. • Moderate attack - Anti-emetics, Ibuprofen, Triptans, ergots. • Severe attack - Anti-emetics, Ergotamines, Triptans. • Migraine prophylaxis - Propranolol, Amitriptyline, Verapamil.

Clinical Cases - Medicine 111 Michael Smith, a 55 years old man presented with chest discomfort for the past 1 hour. Take a focused history and perform focused physical examination. Vitals: BP - 160/90 mm Hg, HK - 96/min, RR - 12/min,Temp - 37.5°C. Clinical Info: Mr Michael Smith presented with left sided chest discomfort for the past 1 hour. He has pain in his left shoulder and jaw. He has shortness of breath along with palpitations. He is a known hypertensive and diabetics on oral medications. His wife states he is non-compfiant with his medications. ECG shows ST elevation in leads II,III and avF. Clinical Case : Chest Pain (Myocardial Infarction) (examination on page 65) HOPI • OCD PQRST UV + AAA • How did it start? Sudden or gradual. • Is it getting worse/better or no changes in the symptoms? • Duration of chest discomfort? • Location of chest discomfort? • How does the discomfort feel like? • Any pain associated with chest discomfort? • Does the pain radiate or shoot anywhere? • Severity of pain on a scale of 1-10. • Any shortness of breath? • Any palpitations/diaphoresis/dizziness? • Do your symptoms become change with time? • H/o fever/cough/sore throat/rash? • Any hemoptysis? • Any heart burn? • Any abdominal pain? • Any weakness or myalgia? • Any changes in bowel & urinary habits?

• Any swelling of feet? • Any relieving factors? • Any aggravating factors? Past History • Do you have diabetes or hypertension? • Are you on any medications/compliance? • Are you allergic to any medications? • Any surgeries in the past? • Past h/o recurrent infections? Family and Social History • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration Sc frequency. • Do you use recreational drugs? TRAPPED. • Any family history of cancers/ medical illnesses? Differential Diagnosis Management • Myocardial Infarction. • Admit to cardiac care unit. • Unstable Angina. • Urgent cardiology consult. • Pericarditis. • Nasal oxygen. • Panic Attack. • Tab Aspirin 160-325 mg chewable stat. Inj Morphine 2-4 mg IV stat & pm. Investigations • • Sublingual Nitroglycerin 0.4 mg stat, repeat • CBC, electrolytes, glucose. 3 times. • INR/PTT. • Ini Atenolol 5 mg IV bolus over 5 mins, then • Serial CK-MB & Troponin q8h X 3. repeat. Then switch to oral Atenolol 50 mg. ABG. • CXR. • Cardiac monitoring every 30 minutes-1 • 12 lead ECG. hour. • Bed rest. • Consider PCI, in case of no contraindications.


Adam Sawyer, a 18 years old male presented with fever, cough for 1 week along with shortness of breath. Take a focused history and perform focused physical examination. Vitals: BP - 110/70 mm Hg, HR - 96/min, RR - 20/min,Temp - 38.5°C. Clinical Info: Adam Sawyer has fever and expectorant cough for the past 1 week. He has wheezing and shortness of breath for 2 aays. On auscultation of chest, there is decreased breath sounds on left side with rales present. Clinical Case : Pneumonia (examination on page 69) HOPI • OCD PQRST UV + AAA • How did it start? Sudden or gradual.

• Is it getting worse/better or no changes in the symptoms? • Duration of cough? • Type of cough - dry or expectorant? • Is there any chest pain? • Location of chest pain? • Type of pain - sharp or dull? • Does the pain radiate or shoot anywhere? • Severity of pain on a scale of 1-10. • Pain present with deep breathing? • Onset of shortness orbreath? • Any noisy breathing present? • Any chills/night sweats? • Any changes in bowel & urinary habits? • Any contact with a sick person? • Recent travel? Past History • Do you have diabetes or hypertension? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? • Past h/o recurrent infections? Family and Social History • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration & frequency. • Do you use recreational drugs? TRAPPED. • Any family history of cancers/ medical illnesses? Differential Diagnosis • Community Acquired Pneumonia. • Acute exacerbation of COPD. • Acute bronchitis. • Asthma. Investigations • CBC. • Sputum gram stain with culture/sensitivity. • Electrolytes. • Renal function tests. • Chest X Ray. Management • Outpatient treatment. • Tab Doxycycline 100 mg PO bid x 7 days. • Tab Azithromycin 500 mg PO OD x 5 days. • Rest and adequate hydration. • Symptomatic treatment. • Inpatient treatment for 48-72 hours. • Tab Levofloxacin 750 mg PO q24h. • Tab Amoxicillin 1000 mg PO aid + • Tab Clarithromycin 500 mg PO bid.

Clinical Cases - Medicine 113 Helen Solazzo is an ICU nurse who had a needle stick injury 30 minutes ago while drawing blood sample from a patient .Take a focused history and address her concerns. Vitals: bP - 120/88 mm Hg, HR - 86/min, RR - 12/min,Temp - 37.0°C. Clinical Info: Ms Helen Solazzo had a needle stick injury in the ICU 30 minutes ago. She was drawing blood sample at that time. She was wearing gloves. She has no nigh risk behavior. Her immune status for HIV/HCV/HBsAg is negative as of 1 year ago. Patient's immune status is unknown as of now. Physician examiner states that the patient's result come back positive for HIV. Clinical Case Diagnosis: Post exposure prophylaxis for HIV. HOPI Mechanism of injury. Was the nurse wearing gloves? Were adequate occupational precautions taken? (like gloves, mask.) Depth of needle penetration?

Type of needle- hollow or solid? Needle gauge? Was any blood present on the tip of needle? Any contact with patient's body fluids? Steps taken after injury? Immune status of tne nurse? When was the last immune status checked? Immunization for Hepatitis A and Hepatitis Any high risk behavior like unprotected sex? Any similar incident in the past? Is the immune status of the patient known? Patient's medical history? Past History • Do you have medical illnesses? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? • Past h/o recurrent infections? Family and Social History • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration & frequency. • Do you use recreational drugs? TRAPPED. • Any family history of cancers/ medical illnesses? Investigations For Healthcare professional: • CBC, electrolytes. • RFT, LFT. • HIV, HCV, HBsAg. For the patient: inform the pt. • CBC, electrolytes. • HIV, HCV, HBsAg. • In case of positive HIV/HCV/HBsAg do viral loads & CD 4 counts. Management • Reassurance. • Refer to Infectious Disease clinic. • Report to occupational health dept within 72 hours & every 2 weekly. • Certify to worker's compensation board for file claim. • Advise about safe sex practices. • Avoid pregnancy/breast feeding. • Repeat blood work 6 weeks,12weeks,6 months and 12 months. • Patient HIV + then start the nurse on post exposure prophylaxis for 4 weeks. • Counsel about side effects of medications.


Jacob Sandler, a 50 years old man presented with hemoptysis and right sided calf swelling for the past 2 days. He had knee replacement surgery 1 week ago. Take a focused history and perform focused examination. Vitals: BP - 140/80 mm Hg, HR - 110/min, RR - 18/min,Temp - 37.5°C. Clinical Info: Mr Jacob Sandler had a right knee replacement 1 week ago. He now presented with 2 episodes of hemoptysis and right calf swelling witn tenderness. He has no fever or infection of surgical wound. Homan’s sign is positive with ECG showing S1Q3T3 pattern. Clinical Case : Pulmonary Embolism (examination on page 69) HOPI OCD PQRST UV + AAA How did it start? Sudden or gradual. Is it getting worse/better or no changes in the symptoms? Duration of blood in sputum? Amount / color of blood of sputum? Onset of shortness of breath/chest pain? Present at rest or with exertion? H/o orthopnea? H/o paroxysmal nocturnal dyspnea? Duration of leg swelling? Where is the leg swelling located? Any leg pain associated with swelling? Type of pain - sharp or dull pain? Does the pain radiate or shoot anywhere? Severity of pain on a scale of 1-10. Any pain during rest? Any pain in the night time? Any skin discoloration of legs/nail changes? Any skin ulceration of legs?

Any fever/cough/cold? Any headache/dizziness? Any weakness/muscle pain? Any prolonged immobilization? Any pain/discharge from the wound? Any pre-op or intra-op complications? Past History • Do you have diabetes or hypertension? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? • Past h/o recurrent infections? Family and Social Histoiy • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration &, frequency. • Do you use recreational drugs? TRAPPED. • Any family history of cancers/ medical illnesses? Differential Diagnosis Management • Pulmonary embolism. • Admit in Intensive care unit. • Deep Vein Thrombosis. • Elevate head end to 45 degree. • Pulmonary edema due to CHF • Nasal oxygen. • Myocardial infarction. • Give chewable ASA 160-325 mg immediately. Investigations • Secure IV access, bolus IV Lasix 40 mg. • CBC, RFT. • Ventolin if wheezes are heard. • Electrolytes, glucose. • Serial CK-MB and Troponin q8h X 3. • Sublingual nitro spray, if blood pressure is adequate. • Inj Morphine 1 mg IV. • Arterial blood gases. • D-dimer, PT, PTT, INR, factor assay. • Inj Heparin 7500 UIV bolus, then infuse at 1200 U/h, then switch to warfarin. • ECG, Echocardiogram. • Chest X Ray. • Continue anticoagulation for 3 months. • PET Scan or VQscan. • Doppler of lower limbs.

Clinical Cases - Medicine 115 Jasper Preudhomme, a 16 years old boy is a known epileptic presented to your clinic for the first time. Take a focused history and address his concerns. Vitals: BP - 120/88 mm Hg, HR - 96/min, RR - 12/min,Temp - 37.0°C. Clinical Info: Mr Jasper Preudhomme is a known epileptic for the past 6 years. He is on regular antiepileptics and is non-compliant. His last seizure was 2 months ago. He recently started consuming alcohol with friends. His main concern is to get a driver's license. Clinical Case : Seizure disorder HOPI Age of onset. Précipitants: Sleep deprivation, drugs, alcohol, TV screen,emotional upset. Describe type of seizures. Salivation, cyanosis, tongue biting, incontinence, automatisms, motor vs. visual/gustatory/olfactory. Frequency & duration of seizures. What body parts affected and in what order? Premonitory signs (presence of aura: implies focal attack).

Post-ictal state (decrease in level of consciousness, headache, sensory phenomena, tongue soreness, limb pains, Todd's paralysis - hemiplegia) Degree of control achieved with medications. Was a CT scan done when seizures were first diagnosed? Number and description of recent seizures. Are they different from previous seizures? Is the patient having any new symptoms like headache, vomiting, new neurological deficits? Side effects of antiepileptics: drowsiness, poor concentration, poor performance in school, ataxias, peripheral neuropathy, acne, nystagmus, dysarthria, hypertrichosis, gingival hypertrophy. Past History • Do you have diabetes or hypertension? • Any surgeries in the past? • Past h/o recurrent infections? Family and Social History • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration & frequency. • Do you use recreational drugs? TRAPPED. • Any family history of cancers/ medical illnesses? Diagnosis Management • Seizure Disorder • Discuss compliance of medications. • Regular follow up. Investigations • Avoid alcohol consumption/smoking. • CBC, electrolytes. • Avoid recreational drugs. • Inform to the patient Ministry of • Serum drug levels. • EEG. Transportation regulations require patient to be seizure free for 1 year or more. • Notify Ministry of Transportation as required by law.

116 NAC OSCE | A Comprehensive Review Samantha Ho, a 56 years old woman presented to your clinic with symptoms of headache and blurry vision. Take a focused history and address her concerns. Vitals: BP - 130/88 mm Hg, HR - 86/min, RR - 12/min,Temp - 37.5°C. Clinical Info: Ms Samantha Ho presented with unilateral, left temporal side pulsating headache, grade 7/10 for the past 2 weeks. She experiences headache while chewing and combine her hair. Associated with blurring of vision and diplopia. One episode lasts for 30 minutes. Currendy on advilprn, atenolol 50 mg OD and multivitamins. Clinical Case : Temporal Arteritis HOPI OCD PQRST U V + AAA How did it start? Sudden or gradual. Location of pain? Is it getting worse/better or no changes in the symptoms? Since how long have you noticed the pain? Number of episodes of headache till now? For how long the pain lasts? How does the pain feel like? Does the pain radiate or shoot anywhere? Severity of pain on a scale of 1-10. Any provolang factors like food, alcohol, caffeine, chocolate, stress, combing hair. How does the pain decrease? Do your symptoms change with time? H/o fever/cough/sore throat/nasal stuffiness? Any excessive lacrimation? Any visual changes with headache? Any neck pain/rigidity/seizures? Any weakness/muscle pain/paresthesias? Any mood changes/decreased sleep/energy? Past History • Do you have diabetes or hypertension? • Any head trauma in the past? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past?

• Past h/o recurrent infections? Family and Social Histoiy • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration & frequency. • Do you use recreational drugs? TRAPPED. • Any family history of cancers/ medical illnesses? Differential Diagnosis Management • Temporal arteritis. • Migraine. • TIA. • High dose corticosteroids. • Tab Prednisone 60 mg PO OD until symptoms subside and ESR is normal, then 40 mg PO OD for 4-6 weeks. Then taper to Investigations 5-10 mg PO OD for 2 years. • CBC, ESR, CRP, LFT. • Relapses occur in 50% if treatment is • Temporal artery biopsy. stopped before 2 years. • Visual acuity. • Monitor ESR regularly. • Fundoscopy. • If visual symptoms present, then admit & start Inj Prednisolone 1000 mg IV ql2h for 5 days.


Jason Scott, a 30 years old manjpresented with yellowish discoloration of eyes and skin for the past 1 week. Take a focused history and perform focused physical examination. Vitals: BP - 120/88 mm Hg, HR - 96/min, RR - 12/min,Temp - 38.0°C. Clinical Info: Mr Jason Scott presented with yellowish discoloration of eves and skin for the past 1 week. It has progressed gradually. He has right upper quadrant abdominal pain. He has loss of appetite, malaise, nausea and vomiting. His urine is high colored and stool is pale colored. He has low graae fever. He has few tattoos on his body along with body piercing. He is a chronic alcoholic, smoker and fv drug user for the past 10 years. Clinical Case : Viral Hepatitis (examination on page 63) HOPI • OCD PQRST UV + AAA • How did it start? Sudden or gradual. • Is it getting worse/better or no changes in the symptoms? • Duration of yellowish discoloration? • Any fever/chills/night sweats? • Any abdominal pain/location/duration? • Any nausea/vomiting? • Any pruritus/rash? • Any bruises/spontaneous bleeding? • Any loss of appetite/weight? • Any bowel complaints/color of stools? • Any urinary complaints/color of urine? • Any fatigue/malaise? • Any confusion/irritability/seizures? • Any aggravating factors? • Any relieving factors? • Any contact with sick person? • Any recent travel? Past History • Do you have medical illnesses? • Are you on any medications? • Are you allergic to any medications? • Any surgeries/dental procedures in the past? • Past h/o recurrent infections? Family and Social History • Do you smoke? Duration & frequency.

• Do you consume alcohol? Duration & frequency. • Do you use recreational drugs? TRAPPED. • Any tattoos/body piercing? • Are you in a sexual relationship? • Do you practice safe sex? • Are you at risk of sexually transmitted infections? • Any family history of medical illnesses? • Immunization history. Differential Diagnosis • Acute viral Hepatitis. • Alcoholic hepatitis. • Bacterial hepatitis. Investigations • CBC, electrolytes, glucose. • LFT, RFT. • INR, PT, PTT. • HAV, HBsAg, HCV, HIV serology. • Ultrasound abdomen. Management • Symptomatic treatment. • Treat the primary cause. • Educate about safer sex practices. • Notify public health in case of HAV, HBsAg,HCV or HIV positive serology.

118 NAC OSCE | A Comprehensive Review Anna Levy, a 32 years old lady presented with lower abdominal pain and vaginal spotting for 2 days.. Take a focused history. Vitals: BP - 120/80 mm Hg. HR - 90/min. RR - 12/min.Temp - 37.5°C Clinical Info: Ms Anna Levy presented with h/o lower abdominal pain and vaginal spotting for 2 days. LMP: 6 weeks ago. Bi-manual exam has cervical motion tenderness with open os and bleeding +++. Clinical Case : Abortion HOPI • OCD PQRST UV + AAA • How did it start? Sudden or gradual. • Is it getting worse/better or no changes in the symptoms? • Since how long have you noticed the pain? • Where is the pain located? • Sharp or dull pain? • Does the pain radiate or shoot anywhere? • Severity of pain on a scale of 1-10. • Type 8c amount of vaginal bleeding? • Number of pads changed? • Passage of clots per vagina? • Do your symptoms change with time? • H/o fever/nausea/vomiting? • Any changes in bowel 8c urinary habits? • Date of last menstrual period? • Last intercourse? • Blood group? Gynecological History • Age of onset of menses • Regular/irregular? • Duration of menses? • Amount of bleeding/passage of clots? • Any dysmenorrhea? Obstetrical History • Do you have children? If yes, then ask for Gravidity, Term/Premature deliveries, Abortions, Live/Multiple births, complications in pregnancy. • H/o ectopic pregnancy? Past History • Do you have diabetes or hypertension? • Are you on any medications?

• Are you allergic to any medications? • Any surgeries in the past? • Past h/o sexually transmitted infections? Family and Social History • Do you smoke or consume alcohol? • Do you use recreational drugs? • Currendy in a relationship? How long? • Sexual orientation? • Are you at risk of abuse? • Any family history of cancers? Differential Diagnosis • Spontaneous abortion. • Incomplete abortion. • Ectopic pregnancy. • Implantation bleed. • Postcoital trauma Investigations • CBC, electrolytes, renal function tests. • Beta HCG • Pelvic ultrasound. • Blood group 8c type. Management • Admit. Dilatation 8c curettage in case of incomplete abortion. IVF for hemodynamic stability. Serial Beta HCG till levels
Clinical Cases - Obstetrics & Gynecology 119 Rachel Owens, a 42 years old primigravida who is 9 weeks pregnant. She came to your office to know about her genetic risks. Take a focused history and address her concerns. Clinical Info: Ms Rachel Owens conceived naturally and this is her first pregnancy. She is sure of her dates. She didn't have any antenatal visit yet. This is her first visit. Her home pregnancy test was positive twice. No family history of genetic disorders. She is only taking prenatal vitamins. No h/o medical illnesses. She does not smoke or consume alcohol. Clinical Case : Antenatal Visit HOPI • Congratulate the patient. • When was your last period? • Conceived naturally or with treatment? • Any antenatal visits till date? • Any blood tests and ultrasound done? • Any lower abdominal pain? • Any bleeding per vagina? • Any radiation exposure till now? • Any medication taken in the past 2 months? • Any fever/nausea/vomiting? • Any vaginal discharge? • Intake of folic acid prior to conception? • Blood group? Gynecological History • Age of onset of menses • Regular/irregular? • Duration of menses? • Amount of bleeding/passage of clots? • Any dysmenorrhea? Obstetrical History • Do you have children? If yes, then ask for Gravidity, Term/Premature deliveries, Abortions, Live/Multiple births, complications in pregnancy. • H/o ectopic pregnancy? • Past History • Do you have diabetes or hypertension? • Are you on any medications?

• Are you allergic to any medications? • Any surgeries in the past? • Past h/o sexually transmitted infections? • When was your last PAP test & results? Family and Social History • Do you smoke or consume alcohol? • Do you use recreational drugs? • Currendy in a relationship? How long? • Are you at risk of abuse? • Any family history of cancers? • Any family history of genetic disorders? • Any h/o genetic aisorders in the partners family? • Support system at home? • Any stressors at work or home? Investigations • CBC • Urine culture/sensitivity, microscopy. • Beta HCG • ABO Rh, type. • Blood sugar,TSH. • Measles,Mumps,Rubella,Varicella, VDRL. • HIV,HBsAg,HCV. • Pelvic ultrasound. Management • Give antenatal brochures. • Discuss about genetic screening & Counseling. • Referral to an obstetrician and prenatal genetics screening. • Nutrition &c exercise in pregnancy. • Avoid alcohol/smoking/teratogenic medications. • Discuss about risk of Down's/Turner's & other genetic disorders in elderly primigravida.


Lisa Raymond, a 28 years old lady presented to the ER with lower abdominal pain on the left side for the past 12 hours. Take a focused history and perform a focused examination (Page 63). Vitals: BP - 100/70 mm Hg. HR - 98/min. RR - 16/min.Temp - 37.5°C Clinical Info: Ms Lisa Raymond, presented with h/o left side lower abdominal pain for 12 hours with mild spotting. LMP: 2 months ago. Bi-manual exam has cervical motion tenderness & left adnexal fullness. Clinical Case : Ectopic Pregnancy HOPI • OCD PQRST UV + AAA • How did it start? Sudden or gradual. • Is it getting worse/better or no changes in the symptoms? • Since how long have you noticed the pain? • Where is the pain located? • Sharp or dull pain? • Does the pain radiate or shoot anywhere? • Severity of pain on a scale of 1-10. • Type Sc amount of bleeding per vagina? • Do your symptoms change with time? • H/o fever/nausea/vomiting? • Any changes in bowel & urinary habits? • Date of last menstrual period? • Any trauma recendy? • When was your last meal? • Blood group. Gynecological History • Age of onset of menses • Regular/irregular? • Duration of menses? • Amount of bleeding/passage of clots? • Any dysmenorrhea? Obstetrical History

• Do you have children? If yes, then ask for Gravidity, Term/Premature deliveries, Abortions, Live/Multiple births, complications in pregnancy. • H/o ectopic pregnancy? Past History • Do you have diabetes or hypertension? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? • Past h/o sexually transmitted infections? • When was your last PAP test & results? Family and Social History • Do you smoke or consume alcohol? • Do you use recreational drugs? • Currendy in a relationship? How long? • Sexual orientation? • Are you at risk of abuse? • Any family history of cancers? Differential Diagnosis • Ectopic pregnancy. • Threatened abortion. • Pelvic Inflammatory Disease. • Ovarian torsion. • Endometriosis. Investigations • CBC. • Blood group, type and cross match. • Beta HCG • Electrolytes, Renal function tests. • Pelvic ultrasound. Management • Admit • IVF • Urgent gynecology consult • Rhogam if needea. Medical treatment: • Inj Methotrexate 50 mg/m2 given IM as stat dose. • Serial Beta HCG till levels drop to <1. • Contraception advice till completion of treatment. • Surgical treatment : Laparoscopy/ Laparotomy.

Clinical Cases - Obstetrics & Gynecology 121 Cathy Davies, a 32 years old lady presented with inability to conceive for the past 3 years. Take a focused history and address her concerns. Vitals: BP - 120/80 mm Hg. HR - 88/min. RR - 12/min.Temp - 37.0°C Clinical Info: Ms Cathy Davies has been unable to conceive for the past 3 years with unprotected intercourse. She has not taken any treatment so far. Her periods are irregular witn prolonged intervals. She has weight gain for past 2 years and hirsutism. She is in a monogamous relationship. No other stressors. She has a 5 years old daughter conceived naturally. No other medical illnesses. Clinical Case : Infertility HOPI • Since how long trying to conceive? • Frequency of sexual intercourse? • Awareness of ovulation period? • Any difficulty /pain during/after intercourse? • Any bleeding after intercourse? • Any weight gain recendy? • Any excessive hair growth? • Any vaginal discharge/type/duration? • Any abdominal pain/back pain? • Any swelling/masses noticed in the body? • Any heat/ccSd intolerance? • Any nipple discharge/type/duration?

• H/o repetitive infections? • H/o fever/nausea/vomiting? Male Partner History: • Any difficulty during intercourse? • H/o premature ejaculation? • H/o difficulty maintaining ejaculation? • Any abdominal surgeries? • Any trauma to the pelvic area in the past? • Any medical illnesses? • H/o mumps in childhood? • Are you on any medications/allergies? • Do you smoke or consume alcohol? • Do you use recreational drugs? • H/o sexually transmitted infections? • Any stressors at home or work? • H/o of conception in past relationships? Gynecological History • Last menstrual period? • Age of onset of menses • Regular/irregular? • Duration of menses? • Amount of bleeding/passage of clots? • Any dysmenorrhea? Obstetrical • Do you have children? If yes, then ask for Gravidity, Term/Premature deliveries, Abortions, Live/Multiple births, complications in pregnancy. Past History • Do you have diabetes/hypertension/thyroid diseases? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? • Past h/o sexually transmitted infections? • When was your last PAP test & results? Family and Social History • Do you smoke or consume alcohol? • Do use recreational drugs? • Are you at risk of abuse? • Any family history of cancers? Diagnosis • Secondary infertility. Investigations • CBC,FBS,TSH. • Day 3 FSH,LH,PRL±DHEAS,Free testosterone. • Day 21-23 Progesterone. • Basal body temperature monitoring. • Pelvic ultrasound • Hystero-salphingogram. • Laparoscopy. • Semen analysis Management • Complete physical examination of both the partners. • Treat the cause. • Supportive counseling. • Timing of the intercourse in relation to ovulation. • Referral to infertility specialist.

122 NAC OSCE | A Comprehensive Review Alyssa Jones, a 18 years old girl came to your office requesting for contraceptive pills. Take a focused history and address her concerns. Vitals: BP - 120/80 mm Hg. HR - 80/min. RR - 12/min.Temp - 37.0°C

Clinical Info: Ms Alyssa Jones is a 18 years old student with no significant history of medical illnesses. She is in an active sexual relationship for the past 4 months. Had one episode of STI 6 months ago. LMP was 1 week ago. No family history of cancers. Currently using barrier contraception. Clinical Case : OCP Counseling HOPI • When was the last menstrual period? • Do you get headaches often? • Do you nave any bleeding disorders? • Any thromboembolic events? • Any liver disease? • Any uncontrolled high blood pressure? • Any heart disease? • Any mass in the breast? • Any abnormal vaginal bleeding? • Any history of sexually transmitted infections? • Any abnormal PAP results? • When was the last PAP done? • Sexual orientation? • Currently in a relationship? How long? • Number of sexual partners? • Do you practice safe sex? • Do you smoke or consume alcohol? • Do you use recreational drugs? • Are you on any medications? • Are you allergic to any medications? Gynecological History • Age of onset of menses • Regular/irregular? • Duration of menses? • Amount of bleeding/passage of clots? • Any dysmenorrhea? • Current contraception use? Obstetrical History • Have you been pregnant before? If yes, then ask for Gravidity, Term/Premature deliveries, Abortions, Live/Multiple births, complications in pregnancy. • H/o ectopic pregnancy? Past History • Any hospitalizations? • Any surgeries in the past? Family History • Family history of hypertension/diabetes? • Family history of breast/ovarian/endometrial cancers? • Family history of bleeding disorders? Investigations • PAP test & complete physical. • Vaginal & Cervical swabs, culture/sensitivity. Benefits of OCP • Prevention of unwanted pregnancy. • Reduced blood loss. • Decreased dysmenorrhea. • Cycle regularization. • Decreased risk of breast/ovarian/endometrial cancers. • Decreased acne. • Decreased osteoporosis. • Decreased PMS symptoms. • Reversible contraception. Management • Tab Yasmin one tab OD for 28 days. • Begin pill on first Sunday after onset of Menses • If Menses start on Sunday, then start pill Day 1

• • • •

Use barrier Contraception for Days 1-7 If pill started after Day 5: OCP may not suppress Ovulation for first cycle Use barrier Contraception for first month. Follow up 6 weeks after the start of the pill.

Clinical Cases - Obstetrics & Gynecology 123

Maria Santosa, a 28 years old lady presented with lower abdominal pain, dyspareunia and vaginal discharge for 1 week. Take a focused history and perform focused examination. Vitals: BP - 120/80 mm Hg. HR - 90/min. RR - 12/min.Temp - 38.5°C Clinical Info: Ms Maria Santosa presented with h/o lower abdominal pain for 1 week with dyspareunia and foul smelling vaginal discharge. She has mild fever for 2 days. H/o unprotected intercourse +. H/o of past infection 3 months ago. LMr: 1 week ago. Bi-manual exam has cervical motion tenderness & right adnexal fullness. Clinical Case : Pelvic Inflammatory Disease (examination on page 63) HOPI • OCD PQRST UV + AAA • How did it start? Sudden or gradual. • Is it getting worse/better or no changes in the symptoms? • Since how long have you noticed the pain? • Where is the pain located? • Sharp or dull pain? • Does the pain radiate or shoot anywhere? • Severity of pain on a scale of 1-10. • H/o painful intercourse? • Type & amount of vaginal discharge? • Do your symptoms change with time? • H/o fever/cough/rash/vomiting? • Any chills/night sweats? • Any changes in bowel & urinary habits? • Any spotting per vagina? • Date of last menstrual period? • Do you practice safe sex? • Number of sexual partners? Gynecological History • Age of onset of menses • Regular/irregular? • Duration of menses? • Amount of bleeding/passage of clots? • Any dysmenorrhea? lntra uterine devices? Obstetrical History • Do you have children? If yes, then ask for Gravidity, Term/Premature deliveries, Abortions, Live/Multiple births, complications in pregnancy. • H/o ectopic pregnancy? Past History • Do you have diabetes or hypertension? • Did you suffer from any diseases in the past like tuberculosis? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? • Past h/o sexually transmitted infections? • When was your last PAP test & results? Family and Social History • Do you smoke or consume alcohol? • Do you use recreational drugs? • Currently in a relationship? How long? • Sexual orientation? • Are you at risk of abuse? • Any family history of cancers? Differential Diagnosis • Pelvic Inflammatory Disease caused due to sexually transmitted infections, IUDs. • Ovarian cyst. • Endometriosis.

• Ovarian torsion. • Acute appendicitis. Investigations • CBC • Vaginal & Cervical swabs, culture/sensitivity. • Urine culture/sensitivity. Beta HCG • Pelvic ultrasound. Management • Inj Ceftriaxone 250 mg IM stat dose with • Tab Doxycycline 100 mg PO bid x 14 days. • Reportable disease. • Treat partners. • Avoid intercourse till completion of treatment. • Practice safe sex. • Retest with cervical swabs after 4-6 weeks.


Julia Marshall, a 30 years old lady presented to the ER with bright red vaginal bleeding for the past 1 hour. She is 36 weeks pregnant. Take a focused history and address her concerns. Vitals: BP - 100/70 mm Hg. HR - 100/min. RK - 14/min.Temp - 37.5°C Clinical Info: Ms Julia Marshall is G2 Tl PO AO Ll at 36 weeks gestation. She has painless vaginal bleeding for the past 1 hour. Has no contractions. Fetal heart rate is 130/minute. She has a previous history of cesarean section. Clinical Case : Placenta Previa HOPI • OCD PQRST UV + AAA • How did it start? Sudden or gradual. • Is it getting worse/better or no changes in the symptoms? • Since how long have you noticed the bleeding? • Amount of bleeding? • Color of bleeding? • Number of pads changed? • Any passage of clots? • Any leaking noticed per vagina? • Any trauma recendy? • Are fetal movements felt? • Any abdominal pain? • Any fever/nausea/vomiting? • Any changes in bowel & urinary habits? • When was the last intercourse? • Date of last menstrual period? • Anv complications in the antenatal period? • When was the last antenatal visit? • Any bleeding episode during pregnancy? • Blood group? Gynecological History • Regular/irregular menses? Obstetrical History • Do you have children? If yes, then ask for Gravidity, Term/Premature deliveries, Abortions, Live/Multiple births, complications in pregnancy. • H/o ectopic pregnancy? • H/o placenta previa/ abruptio placentae? • H/o of cesarean section and the reason? • Any surgeries on the uterus? Past History • Do you have diabetes or hypertension? • Are you on any medications? • Are you allergic to any medications? Family and Social History • Do you smoke or consume alcohol? • Do you use recreational drugs?

• Are you at risk of abuse? • Any family history of medical illnesses? Differential Diagnosis • Placenta previa. • Vasa previa. • Abruptio placentae. • Blooay show. Investigations • CBC, electrolytes, renal function tests. • Fetal ultrasound. • Blood group, type and cross match. Management • Admit in the hospital. • Left lateral decubitus position. • Electronic fetal heart monitoring. • IVF. • Maternal vital monitoring. • Inj Rhogam, if needed. • GA < 37 weeks - mild bleeding - admit & observation. • GA > 36 weeks - profuse bleeding with feto- maternal compromise - Urgent Cesarean section.

Clinical Cases - Obstetrics & Gynecology 125

Elaine Abraham, a 32 years old lady primigravida, at 34 weeks gestation presented to the ER with headache, abdominal pain and blurring of vision. Take a focused history and address her concerns. Vitals: BP - 150/100 mm Hg. HR - 90/min. RR - 14/min.Temp - 37.0°C. FHR - 148/min. Clinical Info: Ms Elaine Abraham has a history of pregnancy induced hypertension since 28 weeks. Her BP is controlled by dietary restrictions and low salt intake, ohe has epigastric pain, blurring and headache for the

East 4-6 hours. She has facial and ankle edema ++. There are no contractions. Fetal movements are felt. No leeding. Urine dipstick is positive for proteinuria. Clinical Case : Pre Eclampsia HOPI • OCD PQRST UV + AAA • How did it start? Sudden or gradual. • Is it getting worse/better or no changes in the symptoms? • Since how long have you noticed the pain? • Where is the pain located? • Sharp or dull pain? • Does the pain radiate or shoot anywhere? • Severity of pain on a scale of 1-10. • Onset of headache? • Location of headache? • Type of headache? • Onset of blurring of vision? • Do your symptoms change with time? • H/o fever/cough/rash/vomiting? • Any changes in bowel & urinary habits? • Any bleeding per vagina? • Any swelling of the body? • Fetal movements? • Any contractions/ leaking per vagina? • Total weight gain in the pregnancy? • Any antenatal complications like high blood pressure/diabetes/ seizures? Gynecological History • Regular/irregular? Obstetrical History • Do you have children? • If yes, then ask for Gravidity, Term/Premature deliveries, Abortions, Live/Multiple births, complications in pregnancy. • H/o ectopic pregnancy? • Last antenatal visit?

Past History • Do you have diabetes or hypertension? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? Family and Social History • Do you smoke or consume alcohol? • Do you use recreational drugs? • Are you at risk of abuse? • Any family history of hypertension/diabetes? Diagnosis • Gestational hypertension with Preeclampsia. Investigations • CBC, electrolytes, renal function tests. • Urinalysis, 24 hour urinary protein, liver function tests, uric acid, Ll)H, albumin. • INR, PTT, Fibrinogen. • Non stress test, Bio-physical profile. • Fetal ultrasound. Management • Admit in the hospital. • Electronic Fetal monitoring. • Bed rest in left lateral decubitus position. • Hourly maternal vital signs with intake/output charting. • Inj Magnesium sulphate 4 mg IV bolus over 20 min,then 2-4g/h for maintenance. • Monitor signs for magnesium toxicity. • Inj Labetalol 20-50 mg IV qlOminutes till Br< 140/90 mmHg. • Deliver the baby. RISK FACTORS FOR PIH: Maternal: Primigravida or new paternity, Family hx of Preeclampsia, Diabetes Mellitus, Obesity, Maternal age >40 years, Preexisting Hypertension, Anti-Phospholipid Antibody syndrome. Fetal: IUGR, Oligohydraminos, Gtn. hydrops, Multiple pregnancy.


Michael Walter a 18 months old boy brought to your office by his mother regarding poor weight gain. Take history from the mother & address nis concerns. Clinical Info: Michael's mother is concerned regarding poor weight gain for his age & height. He has no fever/nausea/vomiting/cough. No h/o recurrent infections. No urinary or bowel complaints. He's picky eater who gets distracted while eating food. His diet consists of excessive juice & milk. No family stress present. Clinical Case Diagnosis: Failure to thrive due to inadequate dietary intake. HOPI • OCD PQRST UV + AAA • Duration of poor weight gain? • Sudden or gradual decline in weight? • Quality ana Quantity of food? • Who feeds the child? • Does the child feed self(e.g. spoon, cup)? • Psychosocial events around feeding time. • Is the child distracted or not supervised? • Are there food battles or food refusal? • Discuss food preparation (e.g. formula too dilute). • Beverages (e.g. Milk, juice, water, soda). • Stool habits (e.g. frequency and consistency). • Pica history. • Detailed nursing or breast feeding history. • Infrequent brief feedings. • Current weight & heignt? • Highest weight? • Any fever/nausea/vomiting/cough? • Any diarrhea/constipation? • Any urinary complaints? • H/o recurrent infections? • Maternal ingestion of alcohol/diuretics. • Inadequate milk supply.

• Inadequate milk let down. • Maternal malnutrition. • Maternal exhaustion or Major Depression. • Any stress at home? • Any signs of physical/psychological/family abuse? • Family history of short stature/FTT in siblings. • Any developmental delay? Birth history • Gestational age at birth and birth weight. • Mode of delivery: cesarean, induction, forceps or vacuum delivery. • Any fetal distress?Was meconium passed in utero? • APGAR score at birth, 1 minute & 5 minute? • Was resuscitation required? • When was breast feeding started? • Color of 1st stool, when was 1st stool passed? • Color of urine, when was 1st urine passed? • Any antenatal/post partum complications. • Immunization history. • Developmental milestones. • Detailed dietary history. Differential Diagnosis • Physiologic cause-Familial short stature. • Organic cause-Cleft palate, Choanal atresia, GÉRD, Celiac ds, Giardiasis, Protein losing enteropathy, Milk protein allergy, Liver ds. • Chronic diarrhea. • Hyperthyroidism, Immunodeficiency. • Prenatal causes-Intrauterine infection, maternal malnutrition,Fetal alcohol syndrome. • Chromosomal disorders. Investigations • CBC,ESR, electrolytes, RFT, LFT. • Blood sugar,TSH,Se Ferritin,Sweat chloride. • Urinalysis-routine microscopy, C/S. • Stool for fat content,ova & parasites. • Se Calcium, Phosphate, Albumin. • Karyotype. • Wrist A ray. Management • Complete physical examination. • Reassure parents. • Height & weight measurement. • Head circumference. • Assess feeding process & parent-child interaction. • Determine & treat underlying etiology. • Institute nutritional therapy. • Eat in a comfortable, stress free environment with positive reinforcement. • Consume food from all four food groups. • Maintain dietary intake diary.

Clinical Cases - Pediatrics 127 Benjamin Smith a 15 months old boy has been brought to the ER with fever and 2 episodes of seizures. He is stabilized now. Take history & address the concerns of an over anxious mother. Clinical Info: Beniamin Smith was having a runny nose and high grade fever for the past 3 days. His fever did not subside with Tylenol. He had 1st episode of tonic-clonic seizure 6 hours ago at home. This was the first occurrence. He haa no other symptoms. No family history of seizures. No complications during birth or development so far. Immunization is up to date. No signs of child abuse. Diagnosis: Febrile seizures. HOPI • History of problems during the pregnancy • OCD PQRST UV + AAA and birth. • Describe seizure duration?

• Developmental history. • Child's medical history. • What body parts are affected and in what order, premonitory signs? • Immunization history. • Post-ictal state (decrease in level of • Family history of seizure disorder. consciousness, headache, weakness). • Screen for signs of child abuse. • Previous seizure? • Events during the seizure time? • How did the seizure stop? • Onset of fever? Sudden or gradual? • Duration of fever? • Type of fever-continuous, remittent, intermittent. • Any nausea/vomiting? • Any ear/eye discharge/runny nose? • Any rash? • Any cough/sore throat/difficulty swallowing? • Any difficulty breathing? • Any bowel or urinary complaints? • Any sick contacts? • Ask about preceding trauma or illness or medications taken? Differential Diagnosis Management • Febrile seizure. • Symptomatic treatment. • Meningitis. • Antipyretics for fever prn. • Encephalitis. • Maintain hydration. Investigations • Counseling & reassurance for parents. • Recurrence - rectal or sublingual Lorazepam. • CBC, electrolytes, RFT. • Treat underlying cause of fever. • ABG, Blood glucose. • Urinalysis. • Blood culture &c sensitivity. • LP-gram stain, culture Sc sensitivity.


Nick Chang is a 15 years old boy brought by his mother with fever and rash for the past 2 days. Take history & address her concerns. Clinical Info: Nick has high fever for the past 2 days. He has developed a diffuse rash in the last 24 hours which is spreading from head to trunk. He also has cough, sore throat and redness of eyes. He has no altered level of consciousness/irritability. He is alert and feeding well. Has h/o sick contacts with similar complaints in the day care. His immunization is up to date. Diagnosis: Measles. HOPI • OCD PQRST UV + AAA • Onset of fever- sudden or gradual? • Duration of fever? • Type of fevercontinuous,remittent,intermittent? • Highest recorded temperature? • Relieving factors for the fever? • Onset of rash? • Type of rash? • Location of rash?

• Rash becoming better or worse? • Any vesicles noticed with the rash? • Any swelling in the body? • Any ear/eye discharge? • Any excessive crying/irritability? • Any changes in alertness of the child? • Any cough/sore throat/runny nose? • Any nausea/vomiting/difficulty swallowing? • Any changes in urinary/bowel habits? • Feeding well or not? • Any seizures? • Any recent sick contacts? • Any travel? Differential Diagnosis Management • Measles. • Symptomatic treatment. • Rubella. • Maintain adequate hydration. • Varicella zoster. • Rest. • Erythema infectiosum. • Antipyretics for fever prn. • Educate parents about complications. Investigations • CBC with differential. Immunization history till date? Any recurrent infections? Development milestones for age? Any similar symptoms in the past?

Clinical Cases - Pediatrics 129

Marie Jones delivered baby Anthony 36 hours old and now the newborn has jaundice, lethargy and crying. The serum bilirubin is 220 mmol ( N < 200). Take history & address her concerns. Clinical Info: Anthony was born to a primigravida by normal vaginal delivery. Mother noticed yellowish discoloration of his eyes in the morning. She had no antenatal complications. She had premature rupture of membranes prior to onset of labor at 38 weeks. She was put on antibiotics. Her labor was 18 hours long. The labor was induced. Apgar was 9/10. Baby is a little lethargic and not feeding well. Has no fever/altered consciousness. No seizures. Clinical Case Diagnosis: Neonatal Jaundice due to Sepsis. HOPI Mother's obstetrical history: • GTPAL • H/o neonatal jaundice in past pregnancies. • Maternal medical history esp. liver disease. • Illness during pregnancy esp. diabetes, rubella, toxoplasmosis, hemes, CMV. • Teratogenic medications during pregnancy. • Radiation exposure in pregnancy? • Drug and alcohol use during pregnancy? • Any pets in the house? • Maternal & Paternal blood type. • Complications of present pregnancy. - Gestational hypertension or diabetes, hyper/hypothyroid, hypercoagulation. • Any antenatal/post partum complications? Newborn history: • Gestational age at birth, • Mode of delivery: cesarean, induction, forceps or vacuum delivery. • Duration of rupture of membranes (ROM)? • Was ROM artificial or prolonged? • Any fetal distress?Was meconium passed in utero? • APGAR score at birth, 1 minute & 5 minutes? • Was resuscitation required? • When was breast feeding started? • Is the baby feeding well?

• Color of 1st stool, when was 1st stool passed? • Color of urine, when was 1st urine passed? • Any vomiting/regurgitation? • Decreased neonatal muscle tone? • Any fever, irritability, lethargy,seizure? • Past History • Do you have diabetes or hypertension? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? • Past h/o recurrent infections? 9 Family and Social History • Social support. • Any family history of medical illnesses? Differential Diagnosis • Sepsis. • Breast feeding jaundice. • Hemolysis. • Physiologic jaundice. Investigations • CBC with reties,electrolytes, RFT. • Se bilirubin(conjugated & unconjugated) & albumin. • Blood group (maternal, paternal & neonatal). • Coomb's test. • Blood & urine culture. • TSH, G6PD. • Chest X Ray, LP. Management Prevent kernicterus. Treat underlying cause. Monitor neonatal vitals. Maintain hydration. Initiate phototherapy. Reassurance for parents.


Sean Radcliffe is a 8 years old boy whose parents have concern about bed wetting. Take history from the father Sc address his concerns. Clinical Info: Sean has been wetting his bed since the last 3 years. He never had bladder control. He has no fever/vomiting. No h/o recurrent infections. He wets bed 2-3 times in the night. No day time wetting present. No encoparesis. Parents have not taken any treatment so far and have tried toilet training in past with no success. No stresses at home or school. Clinical Case Diagnosis: Primary nocturnal enuresis. HOPI • OCD PQJtST UV + AAA • Type of voiding - Involuntary or intentional. • Number of times wets bed in the night? • Has the child ever been dry?(primary or secondary) • Is there aaytime Enuresis?(complicated Enuresis) • Wetting pattern - day±night or night only. • Any dysuria/pyuria/foul smelling urine? • Involuntary passage of stool in the sleep? • Functional bladder disorder signs like - Voids >7 times per day with urgency Sc in small volumes. - Withholds urine until last minute, wets more than once nightly. • Has enuresis on only a few nights per week? • Voids large volumes when enuresis occurs? • Bowel or bladder habit changes recently. • Infrequent or difficult stool passage? • Any changes in appetite/weight? • Any fever/nausea/vomiting? • Any recurrent infections? • Amount of fluid intake prior to sleep? • Any neurological disorders? • Any genitourinary surgeries? • Enuresis in other siblings?

• Any stresses at home or school? • Any new habits or regression to old habits? • Trial of toilet training in the past? • Any treatment in the past for enuresis? Birth history • Gestational age at birth and birth weight. • Mode of delivery: cesarean, induction, forceps or vacuum delivery. • Any fetal distress?Was meconium passed in utero? • APGAR score at birth, 1 minute Sc 5 minute? • Was resuscitation required? • When was breast feeding started? • Color of 1st stool, when was 1st stool passed? • Color of urine, when was 1st urine passed? • Any antenatal/post partum complications. • Immunization history. Differential Diagnosis • Primary nocturnal enuresis. • Urinary tract infection. • Urinary tract anomalies like small bladder. • Psychological (death in the family, sexual abuse). Investigations • CBC,electrolytes, RFT, LFT. • Blood sugar. • Urinalysis-routine microscopy, C/S. • Ultrasound abdomen. Management • Complete physical examination. • Reassure parents. • Schedule voiding times. • Bed wetting alarm. • Void before bedtime. • Limit fluids 1 hour before bedtime. • Voiding diary to be maintained. • Positive reinforcement for dry nights. • Pharmacological therapy like Imipramine/DDAVP.

Clinical Cases - Pediatrics 131 Ally Singer's 6 weeks old baby boy Alex is vomiting for the past 2 days. Take history 8c address her concerns. Clinical Info: Alex had 4 episodes of projectile non bilious vomiting in the past 48 hours. He vomits after feeding. No fever. Looks lethargic 8c dehydrated but alert. No seizures. Had only one bowel movement in last 24 hours. No sick contacts. O/E: Palpable abdominal mass in the right hypochondrium. Clinical Case Diagnosis : Pyloric stenosis. HOPI • OCD PQRST UV + AAA • Number of episodes of vomiting? • Duration of vomiting? • Type of vomiting - projectile/non projectile? • Color/contents of vomitus? • Any excessive crying? • Feeding pattern in the last 48 hours? • Decreased neonatal muscle tone? • Any fever, irritability, lethargy,seizure? • Last bowel movement? • Foul smelling urine 8c color of urine? • Current weight. • Any sick contacts. Newborn history • Gestational age at birth and birth weight. • Mode of delivery: cesarean, induction, forceps or vacuum delivery. • Any fetal distress? Was meconium passed in utero? • APGAR score at birth, 1 minute 8c 5 minute?

• Was resuscitation required? • When was breast feeding started? • H/o neonatal jaundice. • Color of 1st stool, when was 1st stool passed? • Color of urine, when was 1st urine passed? Mother's obstetrical history • GTPAL • Maternal medical history esp. liver disease. • Illness during pregnancy esp. diabetes, rubella, toxoplasmosis, herpes, CMV. • Teratogenic medications during pregnancy. • Radiation exposure in pregnancy. • Drug and alcohol use auring pregnancy. • Complications of present pregnancy. - Gestational hypertension or diabetes, - hyper/hypothyroid, hypercoagulation. • Any antenatal/post partum complications? Differential Diagnosis • Pyloric stenosis. • Tracheo-esophageal fistula. • Duodenal atresia. • Malrotation of gut. • Gastro-esophageal reflux. Investigations • CBC,electrolytes, RFT, LFT. • ABG. • Urinalysis. • Ultrasound abdomen. • Abdominal X ray. Management • Admit. • Urgent Pediatric surgery consult. • IVF to maintain hydration. • Surgery - Pyloromyotomy.

132 NAC OSCE | A Comprehensive Review John Andrews is a 3 years old boy who is not speaking well. Take history & address his father's concerns. Clinical Info: John Andrews has h/o recurrent ear infections. He had 3 episodes in the last 6 months. He has runny nose and mild cough too. He can speak in sentence of 3-4 words. He can count to 5. But for the past 3 months he is not learning new words or numbers. He responds to loud sounds. No other complaints. Social interaction is very good. No birth or developmental complications till date. Diagnosis: Speech delay secondary to recurrent otitis media. • Duration of speech delay? • Who noticed it first? • Any ear discharge/runny nose? • Any recurrent infections? • Any fever/cough/sore throat? • Does the child wake up in response to sounds? • Startle to loud sounds? • Comes when called? • Understands spoken instructions? • Ask about swimming. • Enquire about verbal cues. • How many languages are spoken in the household? • Child's social interaction with others. • Does the child talk less in particular situations? • How many words are spoken by the child? • Detailed developmental history. • Was the child screened for hearing at birth? • Any regression in habits? • Immunization history till date. • Family history of speech delay. • Any complications during pregnancy or birth?

• Detailed birth history. • Exposure to toxins during pregnancy? • Any ototoxic drugs used in infancy? • Screen for signs of child abuse. Differential Diagnosis Management • Hearing loss secondary to Otitis media. • Reassurance for parents. • Selective mutism. • Expressive speech delay. • Complete physical assessment. • ENT referral. • Autism. • Speech therapy. • Positive reinforcement & encouragement. Investigations • Hearing test like Pure Tone Audiometry.

Clinical Cases - Psychiatry 133 Gabriella Anderson, a 18 years old girl came to your office with complaints of gaining weight. Take history 8c counsel. Clinical Info: Ms Gabriella Anderson presented with gaining 5 lbs in the last 1 month. She looks underweight for her age and height. She is exercising 3 times a day. She doesn’t binge or induce vomiting. Lately she is taking small portions of meals due to fear of gaining weight. She has no medical illnesses. No past nistory of psychiatric illness. Currently not taking any medications. Clinical Case : Anorexia HOPI • When did you notice the change in weight? • Duration of symptoms? • Amount of weight gain? • Lowest and highest weight you had? • Are you afraid of gaining weight? • How do you try to control your weight? • How do you think your body looks? • Does your body weight 8c shape have an impact on your self opinion? • Last menstrual period / regularity / complications? • Any abdominal pain/nausea/vomiting? • Bowel and bladaer habits? • Any skin changes? • Any intolerance to temperature changes? • Any recent stressors at nome or work? • Changes in sleep pattern? • Feeling of guilt / hopelessness / helpless / worthless? • Changes in mood? • Any thoughts of harming self/suicide? • Any thoughts of harming someone else? • Any plans at the moment? • Do you feel persistently cheerful/high? • Do you have any medical/surgical illnesses? Ask details. • Do you take any medications? Ask details. • Do you consume alcohol? Amount/frequency? • Do you use recreational drugs? Ask TRAPPED. Past Psychiatric History • Any similar symptoms in past? • Any h/o mania / depression / delusion / delirium? • Any contacts with mental health professionals? • Any past problems with law? Family Histoiy • Any family history of similar complaints? • Any family history of other psychiatric illnesses? • Any family history of suicide/alcohol/drug abuse? Social History

• Support system at home/work? • Current living situation? • Relationship nistory? • Education nistory? • Any risk of physical/sexual/mental abuse? Differential Diagnosis • Anorexia nervosa. • Bulimia nervosa. • Mood disorders. • Medical cause of weight loss. • Body Dysmorphic disorder. Investigations • CBC, electrolytes, renal 8c Liver function tests. • TSH, blood glucose, ECG. • Urine toxicology screen. • Beta HCG, LH,FSH. Management • Complete physical assessment. • Antiaepressants. • Suj3j|>ortive psychotherapy. • Make plans for weight gain. • Community resources for eating disorders. • Educational brochures. • Admit if weight <85% of ideal weight. HR < 40 bpm. Hypovolemia. Hypokalemia Hypoglycemia. Hypothermia.

134 NAC OSCE | A Comprehensive Review Amanda Sawyer, a 20 years old girl brought to your office by her mother for vomiting and weight loss. Take history & counsel. Clinical Info: Ms Amanda Sawyer presented with vomiting after meals. She has fear of weight gain. H/o binging & induced vomiting present. H/o laxative abuse and excessive exercise. She has no apparent psychomotor or suicidal ideation. Sne has no medical illnesses. No past history of psychiatric illness. Currendy not taking any medications. Clinical Case : Bulimia HOPI • Onset of vomiting? • Duration of symptoms? • Type of vomitus/contents? • Projectile/non projectile? • H/o abdominal pain/site/type? • Do you force yourself to vomit? • Do you binge large amount of food? • Amount of weight gain/loss? • Lowest and highest weight you had? • How do you try to control your weight? • Does your body weight & shape have an impact on your self opinion? • Last menstrual period / regularity / complications? • Any skin changes? • Any intolerance to temperature changes? • Any recent stressors at nome or work? • Changes in sleep pattern? • Feeling of guilt / hopelessness / helpless / worthless? • Changes in mood? • Any thoughts of harming self/suicide? • Any thoughts of harming someone else? • Do you feel persistently cheerful/high? • Do you have any medical/surgical illnesses? Ask details. • Do you take any medications? Ask details.

• Do you consume alcohol? Amount/frequency? • Do you use recreational drugs? Ask TRAPPED. Past Psychiatric History • Any similar symptoms in past? • Any h/o mania / depression / delusion / delirium? • Any contacts with mental health professionals? • Any past problems with law? Family Histoiy • Any family history of similar complaints? • Any family history of other psychiatric illnesses? • Any family history of suicide/alcohol/drug abuse? Social History • Support system at home/work? • Current living situation? • Relationship nistory? • Education nistory? • Any risk of physical/sexual/mental abuse? Differential Diagnosis • Bulimia nervosa. • Anorexia nervosa. • Mood disorders. • Medical cause of weight loss. • Body Dysmorphic disorder. Investigations • CBC, electrolytes, renal & Liver function tests. • TSH, blood glucose, ECG. • Urine toxicology screen. • Beta HCG, LH,FSH. Management • Complete physical assessment. • Antidepressants. • Suj3|)ortive psychotherapy. • Make plans for weight gain. • Community resources for eating disorders. • Educational brochures. • Admit if weight <85% of ideal weight. HR < 40 bpm. Hypovolemia. Hypokalemia Hypoglycemia. Hypothermia.

Clinical Cases - Psychiatry 135

Derek Paul, a 65 years old man admitted in surgical floor presented with strange behavior for the past 4 hours. You are on call surgical resident for the shift. Take nistory & counsel. Clinical Info: Mr Derek Paul had partial right hip replacement 3 days ago. His post op recovery till now has been uneventful. Evening shift nurse noticed significant change in his behavior. He is agitated, resdess with acute memory loss. He is disoriented to time, place 8c person. He is having delusional thoughts of ants crawling. He is on oral antibiotics, antihypertensives, blood thinners. He is a chronic alcohol abuser. Clinical Case : Delirium HOPI • When did you notice the change in behavior? • Duration of symptoms? • Symptoms have worsened or improved? • Do you feel persistently cheerful/high? • Do you sense things that others around you don t? • Do you hear any voices? • Do you feel restless/agitated? • Any changes in memory? • Orientation to time/place/person? • Any fever/nausea/vomiting?

• Any chest pain/ abdomind pain? • Any changes in bowel/urinary habits? • Last meal? • Any changes in mood? • Any thoughts of harming self/suicide? • Any thoughts of harming someone else? • Any plans at the moment? • Do you have any medical/surgical illnesses? Ask details. • Do you take any medications? Ask details. • List of current medications. • Do you consume alcohol? Amount/frequency? • Do you smoke? Duration/frequency? • Do you use recreational drugs? Ask TRAPPED. Past Psychiatric History • Any similar symptoms in past? • Any h/o mania / depression / delusion / delirium? • Any contacts with mental health professionals? • Any past problems with law? Family History • Any family history of similar complaints? • Any family history of other psychiatric illnesses? • Any family history of suicide/alcohol/drug abuse? Social History • Support system at home/work? • Current living situation? • Relationship nistory? • Education history? • Any risk of physical/sexual/mental abuse? T : Treatment history R : Route A : Addiction / toxicity / Amount P : Pattern of use P : Prior abstinence E : Effects of drug D: Duration of use Differential Diagnosis • Acute Delirium. • Alcohol withdrawal. • Medication induced delirium. • Sepsis. Investigations • CBC, electrolytes, renal function tests. • TSH, blood glucose, blood gases. • Urinalysis with toxicology screen. • Blood alcohol levels. • MSE/MMSE. Management • Complete physical examination. • Re-evaluate current medications. • Maintain hydration. • Avoid sedatives,narcotics,BZD. • Place in a quiet, well lit room. • Vital qlhourly. • Inj Haloperidol 5 mg IM stat with Inj Lorazepam 2mg IJVlstat. • Reassurance.


Claire Wiggins, a 72 years old lady brought to your office by her son with strange behavior. Take history from the patient and address her concerns. Clinical Info: Ms Claire Wiggins is forgetting things and daily tasks for the past 1 year. Her symptoms have become worse for the last 6 months. Recently she forgot her way back home. She lives alone. Son has noticed changes in her dressing and poor hygiene. She has no apparent psycho-motor or suicidal ideation. She has hypertension. No past history of psychiatric illness. Currently on oral antihypertensives, statins, zoloft, multivitamins. Clinical Case : Dementia HOPI • When did you notice the change in behavior?

• Duration of symptoms? • Have you found yourself forgetting things? (establish onset, duration, degree) • Do you ever get confused or disorientated? • Do you have trouble understanding what people say to you? • Do you have trouble finding the right words to say? • Symptoms getting gradually worse over months? • Have you seen, heard or felt anything that other people told you didn’t exist? • Have you noticed a change in your sense of smell? • Have you had any incontinence? • Any cnanges in gait? • Any mood changes? • Any fever/nausea/vomiting/abdominal pain? • Has there been a change in personality? • Do you have any medical/surgical illnesses? Ask details. • Do you take any medications? Ask details. • Do you consume alcohol? Amount/frequency? • Do you smoke? Duration/frequency? • Do you use recreational drugs? Ask TRAPPED. Past Psychiatric History • Any similar symptoms in past? • Any h/o mania/ depression/ delusion/ delirium? • Any contacts with mental health professionals? • Any past problems with law? Family History • Any family history of similar complaints? • Any family history of other psychiatric illnesses? • Any family history of suicide/alcohol/drug abuse? Social History • Support system at home/work? • Current living situation? • Relationship nistory? • Education history? • Any risk of physical/sexual/mental abuse? • Activities of daily living & Instrumental Activities of daily living. Differential Diagnosis • Alzheimer's disease. • MRI/CT Head. • MSE/MMSE. • Multi-Infarct dementia. • Dementia with Lewy bodies. Management • Depression. • Complete physical examination. Involve social worker. • Polypharmacy. • • Living environment assessment. Investigations • Educational brochures. • CBC, electrolytes, renal function tests. • Access to community resources. • Liver function tests,Vit B12 levels. • Orientation cues: clocks,calendars,notes. • TSH, blood glucose, ECG. • Urinalysis, urine toxicology screen.

• Resources for the family. • Acetylcholinesterase inhibitors. • Safely home registry.


Julian Smith, a 56 years old lady brought to your office by her husband with strange behavior. Take history & counsel. Clinical Info: Ms Julian Smith has h/o of change in mood for the past 1 month after loosing her job. She has changes in mood, sleep and appetite. She has lost 10 lbs in the last 1 month. She has lack ofinterest in social activities. She has no apparent psycho-motor or suicidal ideation. She has no medical illnesses. No past history ofpsychiatric illness. Currently not taking any medications. Clinical Case : Depression HOPI • When did you notice the change in behavior? • Duration of symptoms? • Symptoms have worsened or improved? • Any recent stressors at home or work? • Changes in sleep pattern? • H/o lack of interest recendy? • Feeling of guilt/hopelessness/ helpless/worthless? • Lack of energy? • Changes in mood? • Are you crying a lot? • Is your mood always low or it alternates? • Any changes in concentration? • Any changes in appetite? • Any changes in weight? • Any changes in memory? • Do you feel slowed down? • Do you feel resdess/agitated? • Any thoughts of harming self/suicide? • Any thoughts of harming someone else? • Any plans at the moment? • Do you feel persistendy cheerful/high? • Do you sense things that others around you dont? • Do you have any medical/surgical illnesses? Ask details. • Do you take any medications? Ask details. • Do you consume alcohol and smoke? Amount/frequency? • Do you use recreational drugs? Ask TRAPPED. Past Psychiatric History • Any similar symptoms in past? • Any h/o mania/depression/delusion/ delirium? • Any contacts with mental health professionals? • Any past problems with law? Family History • Any family history of similar complaints? • Any family history of other psychiatric illnesses? • Any family history of suicide/alcohol/ drug abuse? Social History • Support system at home/work? • Current living situation? • Relationship history? • Education history? • Any risk of physical/sexual/mental abuse? Differential Diagnosis • Major Depressive Episode. • Adjustment disorder with depressed mood. • Bipolar affective disorder. • Anxiety disorder.

Investigations • CBC, electrolytes, renal function tests. • TSH, blood glucose, urinalysis. • MSE/MMSE. Management • Start SSRI. • Psychotherapy/CBT. • Educational brochures about depression. • Info about the side effects of medications. • Emphasis on long term management,follow up and compliance. • Referral to community resources. • Contract: Pt to contact you/family doctor/ nearest emergency/friend/family/crisis help line in case of suicidal or homicidal ideation.

138 NAC OSCE | A Comprehensive Review David Rosenberg, a 26 years old man brought to the ER by the police because he was throwing stones at a public building. Take history & counsel. Clinical Info: Mr David Rosenberg presented with irrational behavior for the past 10 days. He is having racing thoughts, increased activity, decreased sleep and increased vocalization. He has constant flight ofideas during the interview with easy distractibility. He is restless while sitting and at times agitated. No medical illnesses but is a chronic cocaine abuser. Clinical Case : Mania HOPI • When did you notice the behavioral changes? • Duration of symptoms? • Symptoms have worsened or improved? • Any recent stressors at home or work? • Do you get easily distracted while talking or working? • Did you have reckless driving & drinking episode? • Have vou gone for shopping sprees/ gambling/ excessive spending? • Do you feel like a special person with special talent, power or on a mission? • Do people say you jump from topic to topic? • Did anyone say that you have increased activity/ energy/appetite/ resdess/agitation? • Changes in Seep pattern? • Did anyone say that you are more talkative than usual? • H/o lack of interest recendy? • Feeling of guilt/hopelessness/helplessness/ worthlessness? • Changes in mood? • Any thoughts of harming self/suicide? • Any thoughts of harming someone else? • Any plans at the moment? • Do you sense things that others around you don t? • Do you have any medical/surgical illnesses? Ask details. • Do you take any medications? Ask details. • Do you consume alcohol and smoke? Amount/frequency? • Do you use recreational drugs? Ask TRAPPED. Past Psychiatric History • Any similar symptoms in past? • Any h/o mania/depression/delusion/ delirium? • Any contacts with mental health professionals? • Any past problems with law? Family Histoiy • Any family history of similar complaints? • Any family history of other psychiatric illnesses? • Any family history of suicide/alcohol/drug abuse? Social History • Support system at home/work? • Current living situation? • Relationship history? • Education history? • Any risk of physical/sexual/mental abuse? Differential Diagnosis

• Cocaine induced Maniac episode. • Bipolar disorder. • Personality disorder. • Substance abuse. Investigations • CBC, electrolytes, renal function tests. • TSH, blood glucose, urinalysis. • VDRL, HI vT • Urine toxicology screen. • Urgent psychiatric consult. Management • Start Mood stabilizers - Lithium/ Valproate / CBZ. • Psychotherapy/CBT. • Admit in case of acute mania. • Info about the side effects of medications. • Emphasis on long term management,follow up and compliance. • Referral to community resources. • Contract: Pt to contact you/ family doctor/ nearest emergency/friend/family/crisis help line in case of suicidal or homicidal ideation.


Brad Daniels, a 22 years old man came to your office with light headedness, trembling and chest pain for the past 4 hours. Take nistory & counsel. Clinical Info: Mr Brad Daniels is a university student who presented with sudden onset of light headedness, trembling of body and chest pain prior to his presentation in class. He also complaints of palpitations and shortness of breath. He had similar episodes in the past. No past history of psychiatric or medical illnesses. Not taking any medications currently. Clinical Case : Panic Attack HOPI • When did you notice the symptoms? • Duration of symptoms? • Symptoms have worsened or improved? • Any recent stressors at home or work? • Do you have excessive sweating? • Do you experience tremors? • Do you have unsteadiness/dizziness? • Do you sense things that others around you don t? (Derealization) • Do you ever feel you are outside of yourself? (Depersonalization) • Do you have excessive heart rate? • Nausea/vomiting? • Any tingling/paresthesias? • Any shortness of breath? • Any fear of dying/loosing control/going crazy? • Do you have chest pain? • Do you have chills/choking sensation? • Changes in sleep pattern? • Feeling of guilt/ hopelessness/ helplessness/ worthless? • Any changes in mood? • Any changes in concentration? • Any changes in appetite/weight? • Any changes in bowel habits? • Any changes in memory? • Do you feel slowed down? • Do you feel restless/agitated? • Amount of caffeine intake? • Any anticipatory anxiety? • Worry about consequences of another attack? • Any thoughts of harming self/suicide? • Any thoughts of harming someone else? • Do you have any medical/ surgical illnesses? • Do you take any medications? Ask details.

• Do you consume alcohol/smoke? Amount/frequency? • Do you use recreational drugs? Ask TRAPPED. Past Psychiatric History • Any similar symptoms in past? • Any h/o mania/ depression/ delusion/ delirium? • Any contacts with mental health professionals? • Any past problems with law? Family Histoiy • Any family history of similar complaints? • Any family history of other psychiatric illnesses? • Any family history of suicide/alcohol/drug abuse? Social History • Support system at home/work? • Current living situation? • Relationship nistory? • Education history? • Any risk of physical/sexual/mental abuse? Differential Diagnosis Management • Panic Attack. • Start SSRI. • Panic disorder. • Anxiety disorder. • • Psychotherapy/CBT. Educational brochures about anxiety attacks. • Mood disorder. • Info about the side effects of medications. Investigations • Emphasis on long term management,follow up and compliance. • CBC, electrolytes, renal function tests. • Muscle relaxation, deep breathing & • TSH, blood glucose, urinalysis. biofeedback. • ECG. • Contract: Pt. to contact you/family doctor/ nearest emergency/friend/family/crisis help line in case of suicidal or homicidal ideation.


Liam Pinkerton, a 24 years old male was brought to the ER with complaints of alien attacks . Take history & counsel. Clinical Info: Mr Liam Pinkerton is brought by police with complaints of being attacked by aliens in the last 48 hours. He is talking to himself and avoiding direct eye contact. He is restless and agitated and feels threatened. He is hearing strange voices for the past 1 month along with disorganized speech and behavior. He is a chronic cocaine user for the past 3 years and increased consumption in last 48 hours. Clinical Case : Schizophrenia HOPI Thought phenomena: • Think your thoughts are interfered with in any way? • Think others can read your thoughts? • Think an outside entity is affecting your thoughts? • Hear echo's of your thoughts like a voice? Delusions: • Anything bothering you at the moment? • Ever felt that someone is out to get you?

• Different understanding of things to other people? • Do you get any special information from things which happen? • Do you get special messages or communication from newspapers, radio, television or any other source? • Delusions of control; influence or passivity: • Do you feel that a force can control or influence you? • Think that some of your actions or thoughts are not being controlled by you? Hallucinations: • Hear voices when there is no one present? • Does someone talk to you? • How many? Who are they? What do they say? • Do they ever tell you to harm/kill yourself or others? • How often do you hear voices? • How does it make you feel? • Can you control or stop them? • Blunted affect / Apathy, loss of drive? • Get emotional or excited about things you are used to? • Have drive and ambition for anything at the moment? • Any mood changes recendy? • Do you feel restless/agitated? • Any changes in appetite/weight? • Any fever/nausea/vomiting/trauma? • Currendy on any medications? • Do you consume alcohol? Amount/frequency? • Do you smoke? Duration/frequency? • Do you use recreational drugs? TRAPPED? Past Psychiatric History • Any similar symptoms in past? • Any h/o mania/ depression/ delusion/ delirium? • Any contacts with mental health professionals? • Any past problems with law? Family History • Any family history of similar complaints? • Any family history of other psychiatric illnesses? • Any family history of suicide/alcohol/drug abuse? Social History • Support system at home/work? • Current living situation? • Relationship nistory? • Education nistory? • Any risk of physical/sexual/mental abuse? Differential Diagnosis • Schizophrenia. • Substance induced Acute Psychosis. • Acute Delusional disorder. • Schizoaffective disorder. Investigations • CBC, electrolytes, renal function tests. • Liver function test, blood gases. • Blood glucose, urinalysis. • Urine toxicology screen. Management • Admit in hospital under FORM 1. • Start Anti-Psvchotics. • Inj Haloperiaol 5mg IM stat. • Urgent psychiatric consultation. • Detoxification program. • Involve social worker.

Clinical Cases - Psychiatry 141 Erica McCain is a 16 years old girl brought to the ER with ASA overdose. She is stabilized now. Take history & counsel. Clinical Info: Ms Erica McCain a 16 years old school going girl took 30 tabs of Aspirin after smashing her

Earents car in a tree. She attempted to commit suicide to prevent embarrassment. She went to her friend's ouse after the accident. Her grandma brought her to the ER. Has h/o previous attempt 1 year ago. Is currendv consulting a psychiatrist on a regular basis. Presendy on antidepressants. Show EMPATHY! Clinical Case : Suicide HOPI • Analyze the attemptVv hen / What method / Source of method / Circumstances which lead to the attempt • What were your thoughts while hurting yourself? • What did you think would be the outcome? • Changes in mood? • H/o lack of interest recently? • Feeling of guilt/hopelessness/helplessness/ worthlessness? • Lack of energy/concentration? • Is your mooa always low or it alternates? • Any changes in appetite/weight? • Do you feel restless/agitated? • Any thoughts of harming someone else? • Any plans at the moment? • Do you sense things that others around you dont? • Do you have any medical/surgical illnesses? Ask details. • Do you take any medications? Ask details. • Do you consume alcohol? Amount/frequency? • Do you smoke? Frequency/duration? • Suicidal Attempt. Investigations • CBC, electrolytes, renal function tests. • Liver function tests, Blood gases. • Se. salicylate levels q2h till levels fall. • Blood glucose, urinalysis. Management • Admit under FORM 1. • Gastric Lavage. • Urine alkalinization. • Urgent psychiatric evaluation. • Arrange family meeting and involve social worker. • Start Lithium or Clozapine. • Do you use recreational drugs? Ask TRAPPED. Past Psychiatric History • Any similar attempts in the past? Outcome/admission, if any? • Treatment given for such attempts? • Any h/o mania/ depression/ delusion/ delirium? • Any contacts with mental health professionals? • Any past problems with law? Family Histoiy • Any family history of suicidal attempts? • Any family history of other psychiatric illnesses? • Any family history of suicide/alcohol/drug abuse? Social History • Support system at home/work? • Current living situation? • Relationship nistory? • Education history? • Any risk of physical/sexual/mental abuse? Assess Suicidal risk: SAD PERSONS Sex - Male> female Age - Bimodal: 15-25 years and > 65 years. Depression Previous attempts Ethanol use Rational thinking Suicide in family

Organized plan No support Sickness Based on the score from the scale: 0-2 - Send home with family. 3-4 - Close follow up, consider admission. 5-6 - Strongly consider admission. 7-10 - Admit.

142 NAC OSCE | A Comprehensive Review Brandon Rodrigues, 28 young man comes with recent onset of back pain and limp. Take focused history and preform a focused examination. Clinical info: Mr Brandon Rodrigues had a sudden onset of sharp lower back pain 2 days ago after lifting heavy boxes at home. Pain is located in the lumbar area, grade 8/10 and is constandy present. He has numbness and paresthesias present in his left leg for the past 12 hours. No weakness or loss of sensation in the lower limbs. No urinary retention or bowel incontinence. He does not smoke or consume alcohol. O/E there is tenderness in the L4 - L5 area & decreased sensation in the L4 - L5 dermatomal distribution. Clinical Case : Back Pain HOPI • OCD PQRST UV + AAA • How did it start? Sudden or gradual. • Is it getting worse/better or no changes in the symptoms? • Since how long have you noticed the back pain? • Where is the pain located? (Pain worse in back than in buttocks or legs suggests mechanical back pain. Pain worse in buttocks suggests radiculopathy) • Type of pain -sharp or dull? • Does the pain radiate or shoot anywhere? • Severity of pain on a scale of 1-10. • Do your symptoms change with time? • Any aggravating or relieving factors? (Pain worse lying down and bilateral leg weakness suggests spinal stenosis or ankylosing spondylosis, ) • Effect on activities of daily living, functional limitation? • H/o fever/ fatigue / weight loss/night sweats? • Burning micturation, joint pain, uveitis? • Morning stiffness? Associated numbness, weakness? • Bladder retention /bowel incontinence? Past History • Do you have diabetes or hypertension? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? Family and Social History • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration oc frequency. • Do you use recreational drugs? TRAPPED. • Any family history of cancers/ medical illnesses? • Erectile dysfunction (Cauda equina syndrome) RED FLAGS (BACKPAIN) Bowel or Bladder dysfunction Anesthesia (Saddle; - perineal numbness Constitutional Symptoms - Malignancy K : Chronic disease Paresthesias Age > 50 IV drug users Neuromotor deficits Differential Diagnosis Management • Disc herniation. • Reassurance and education if no cause (70% • Spondyloarthropathy. improve in 2 weeks, 90% in 6 weeks) • Radiculopathy.

• Limited bed rest. • Mechanical back pain. • Activity modification. • Heat/Cold therapies. Investigations • Low stress aerobic activities in first 2 weeks. • Lumbo-sacral X-ray. • Encourage early return to work/ activities. • MRI lumbo-sacral area • NSAIDS/ Acetaminophen. Surgery indicated in • Cauda Equina. • Worsening neurological deficit. • Intractable pain not responding to conservative treatment.

Clinical Cases - Surgery________________________________________________________ 143 Nicole Davy, a 75 years old lady presented with enlarging mole on her nose .Take a focused history and perform focused physical examination. Vitals: BP - 120/88 mm Hg, HR - 86/min, RR - 12/min,Temp - 37.0°C Clinical Info: Ms Nicole Davy has an enlarging mole on her nose which is changing in color and shape over the past 1 month. She is a Caucasian retired woman who spends 6 months in Florida during winters in Canada. Recently noticed irregular edges of her mole and got concerned. She worked as a radiation technician for 30 years prior to retirement. She had a similar mole which was cancerous and removed 10 vears ago. O/E: There is a small 0.5 x 0.5 cm pearly papule on her lateral left side of nose, with irregular rollea out margins and minimal discharge. Clinical Case Diagnosis: Basal Cell Carcinoma. HOPI • OCD PQRST UV + AAA • How did it start? Sudden or gradual. • Is it getting worse/better or no changes in the symptoms? • Duration of the mole? • Location of the mole? • What changes have you noticed in the mole? • Any itching? • Any ulceration? • Any discharge or bleeding noticed? • Any change in color of the mole? • Any other suspicious moles elsewhere? • Amount of sun exposure? • Any radiation exposure? • Any swelling noticed in the body? • Any fever/nausea/vomiting/decreased appetite? • Any weight loss/night sweats? • Any headache/chest pain/bony pain? • Any visual changes? • Any changes in bowel & urinary habits? Past History • Do you have diabetes or hypertension? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? • Past h/o recurrent infections? Family and Social History • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration & frequency. • Do you use recreational drugs? TRAPPED. • Any family history of cancers/ medical illnesses? • Occupation? Differential Diagnosis Management • Basal Cell Carcinoma.

• Complete physical examination. • Squamous Cell Carcinoma. • Electrodessication & curettage. • Nodular malignant melanoma. • Surgical excision ± microscopically • Intradermal melanocytic nevus. controlled surgery. • Cryotherapy. Investigations • 95% cure rate in lesions less than 2 cm. • Punch/excision biopsy. • Life long follow up. • Imiquimod 5% cream locally, if surgical treatment not possible.


Jacob Simpson, 62 year old man presents to the Emergency Department with 12 hours suprapubic discomfort and inability to urinate. Take a focused history & perform a focused examination. Clinical Info: Mr Jacob Simpson presented with acute urinaiy retention for the past 12 hours. He is having difficulty passing urine for the past 4 months, which has gradually increased. He has hesitancy, urgency, increased frequency and weak stream. No hematuria or UTI. O/E there is a palpable supra-pubic mass. Catheterization[yields 1200cc urine. Clinical Case : Benign Prostatic Hyperplasia HOPI • OCD PQRST UV + AAA • How did it start? Sudden or gradual. • Is it getting worse/better or no changes in the symptoms? • Duration of inability to pass urine? • Any pain associated? • Location of pain? • Type of pain - sharp or dull? • Severity of pain on a scale of 1-10. • Do your symptoms change with time? • Difficulty initiating or maintaining urinary stream? • H/O weak/interrupted urinary stream. • Feeling of incomplete bladder emptying? • Any nocturia/ urgency/ increased frequency? • Color of urine? Any blood in urine? • H/O recurrent urinary infections? • H/O renal pain or groin pain? • H/O fever, night sweats, weight loss, fatigue? • Any bowel complaints? • Any perineal numbness / leg weakness? Past History • Do you have diabetes or hypertension? • Are you on any medications? • Are you allergic to any medications? • Previous renal colic / diagnosed prostate hypertrophy? • H/O prostate cancer, prostatism, nephrolithiasis, UTIs? H/O pelvic radiation? • Any h/o past surgeries? TURP? Family and Social History • Any family history of cancer / similar complaints? • Currendy in a relationship? • Practicing safe sex? • Do you think you are at risk of getting STIs? • Do you smoke? Duration & frequency.

• Do you consume alcohol? Duration oc frequency. • Do you use recreational drugs? TRAPPED. Differential Diagnosis • Benign rrostatic Hyperplasia. • Urinary Tract Infection. • Prostatitis. • Prostate Cancer. Investigations • Urea / Creatinine. • Urinalysis, culture & sensitivity. • Prostate Specific Antigen (PSA). • Renal and pelvic ultrasound. • Cystoscopy. Management • DRE (Digital rectal examination). • Watchful waiting ( 50% resolve spontaneously). • Lifestyle modifications - evening fluid restrictions, planned voiding. • Urological consultation. • Medication - Alpha-adrenergic antagonists (Terazosin, Doxazosin, Tamsulosin). • 5-alpha-reductase inhibitors ( Finasteride). • Surgery (TURP, open prostatectomy). • Minimally invasive (Stents, Microwave therag^, Laser ablation, Cryotherapy, HIFU,

Clinical Cases - Surgery 145

Lydia Jones, a 30 years old office lady presented to your office with right hand numbness and weakness for 2 months. Take a focused history and address her concerns. Clinical info: Ms Lydia Jones presented with gradual onset of right hand numbness and weakness for the past 2 months. Her symptoms have worsened. Associated with paresthesias and pain in fingers at the end of the day. She has difficulty opening jars, turning keys and night pains. She has no medical illness. Not on any medications. She is an office administrator. Clinical Case : Carpal Tunnel Syndrome HOPI • OCD PQRST UV + AAA • Handedness - left or right? • How did it start? Sudden or gradual. • Is it getting worse/better or no changes in the symptoms? • Duration of numbness? • Location of numbness? • Any paresthesias/tingling/swelling? • Any weakness or muscle pain? • Is mere any associated pain? • Any difficulty opening jars/turning keys? • Any symptoms in night time? • Any abnormal position of the hand? • Any neck pain/upper arm weakness? • Similar symptoms in other parts of the body? • Do your symptoms change with time? • Any changes in vision/speech/headache? • Any changes in gait? • Occupation? Past History • Do you have diabetes or hypertension? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? Family and Social Histoiy • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration & frequency. • Any family history of thyroid disease? • Any family history of cancers/ medical illnesses? Differential Diagnosis • Carpal Tunnel Syndrome.

• Cervical radiculopathy. • TIA. Investigations • CBC, blood glucose, electrolytes. • C-spine X ray. • Nerve conduction studies. Management • Modify manual work. • Wrist splint (often worn at night). • NSAIDs, local corticosteroid injections. • Control underlying systemic contributors (e.g. diabetes, hypothyroidism, arthritis). • Surgical decompression via flexor retinaculum release. • Orthopedic or Plastic surgery consult.

146 NAC OSCE | A Comprehensive Review Ruth Gagnon, a 60 years old woman presented to your office with right sided calf swelling for the past 2 days. Take a focused history and perform focused examination. Vitals: BP - 140/80 mm Hg, HR - 86/min, RR - 12/min,Temp - 37.5°C Clinical Info: Ms Ruth Gagnon is having right calf swelling and redness for the past 2 days. She has leg pain also. She is a known hypertensive on medications. She recendy traveled for 20 hours in an overnight flight. She is compliant with her medications. She has past history of breast cancer treatment 5 years ago with no complications. Clinical Case : Deep Vein Thrombosis HOPI OCD PQRST UV + AAA How did it start? Sudden or gradual. Is it getting worse/better or no changes in the symptoms? Duration of leg swelling? Where is the leg swelling located? Any leg pain associated with swelling? Type of pain - sharp or dull pain? Does the pain radiate or shoot anywhere? Severity of pain on a scale of 1-10. Any pain during rest? Any pain in the night time? Any skin discoloration of legs/nail changes? Any skin ulceration of legs? Any fever/cough/cold? Any chest pain/ shortness of breath? Any headache/dizziness? Any weakness/muscle pain? Any recent travel? Any prolonged immobilization? Past History • Do you have diabetes or hypertension? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? • Past h/o recurrent infections? Family and Social History • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration & frequency. • Any family history of thyroid disease? • Do you take any recreational drugs? • Any family history of cancers/medical illness? Differential Diagnosis • Deep Vein Thrombosis. • Ruptured Baker's Cyst. • Cellulitis. • Unilateral lymphedema. Investigations • CBC, ESR, Lipid profile, RFT. • D-dimer. • PT, PTT, INR, factor assay. • Deficiency of Antithrombin III, protein C or S.

• Lupus anticoagulant. • Doppler of lower limbs. • Impedance plethysmography. Management • Urgent medicine consult. • Low molecular weight heparin x 3 days. • Then switch to Warfarin. • IVC filters (only if anticoagulation is contradicted).


Mathew Hobbs, a 55 years old man presented with numbness in his both feet. He is a known diabetic. Take a focused history and perform focused physical examination. Vitals: BP - 130/90 mm Hg, HR - 86/min, RR - 14/min,Temp - 38.5°C. Clinical Info: Mr Mathew Hobbs is a known diabetic for the past 15 years. He is on oral hypoglycemics. His last fasting glucose was 7.6 mmol/L. On examination, both feet were normal. Clinical Case : Diabetic Foot HOPI OCD PQRST UV + AAA How did numbness start? Sudden or gradual. Is it getting worse/better or no changes in the symptoms? Duration of numbness? Location of numbness? Is there any pain associated with numbness? Type of pain - sharp or dull pain? Does the pain radiate or shoot anywhere? Severity of pain on a scale of 1-10. Do your symptoms change with time? H/o tingling? Any recent injury to feet? Any blisters/calluses on the feet? Any swelling of feet? Any changes in vision? H/o dizziness / LOC? H/o chest pain/orthopnea? H/o excessive sweating? Any changes in appetite? Any changes in weight? Any changes in bowel Sc urinary habits? Last fasting blood sugar, eye ana foot exam? Past History • Do you have diabetes or hypertension? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? • Past h/o recurrent infections? Family and Social History • Do you smoke? Duration and frequency. • Do you consume alcohol? If yes, duration, amount and frequency. • Do you use recreational drugs? TRAPPED • Any family history of cancers/medical illnesses? • Exercise schedule. • Dietary restrictions for diabetes. • Compliance with medications? Diagnosis • Diabetic foot Investigations • Fasting blood glucose. • HbAlC. • Fasting lipids, Renal function tests. • ECG. • Fundoscopy. • Urinalysis with urine dip. Management • Self foot exam daily.

• • • • • • • •

Foot examined regularly at physician visits. Perform Peripheral Neuropathy Testing. Check for pedal pulses. Evaluate Sc aggressively treat new foot wound. Avoid foot trauma Do not walk barefoot. Cut nails carefully. Avoid excessive heat or chemicals.


Wayne Singer, 68 year old man presented with difficulty swallowing for the past 4 months. Take a focused history and perform a focused examination. Clinical Info: Mr Wayne Singer has difficulty swallowing for the past 4 months. It has gradually increased from solids to liquids. He feels a lump in the throat. He has chest pain when he eats food. He has noticed weight loss, night sweats and decreased appetite in the last 3 months. He is a chronic smoker for the past 30 years. Clinical Case : Difficulty Swallowing ( Ca Oesophagus) HOPI • OCD PQRST UV + AAA • How did it start? Sudden or gradual. • Is it getting worse/better or no changes in the symptoms? • Duration of difficulty swallowing? • Is there difficulty transferring food from mouth to esophagus (suggestive of oropharyngeal dysphagia) or further down (suggestive of esophageal dysphagia)? • Is me problem worse with solids (suggests mechanical obstruction) or liquids (suggests neuromuscular dysfunction, often can't swallow both solids and liquids)? • Is there a sensation of lump in the throat (globus hystericus)? • Progression of difficulty swallowing solids to difficulty in swallowing liquid? (Suggests a worsening stricture of growing tumor) • Any swelling the neck? • Aggravating, relieving factors? The association of intermittent obstruction and chest pain suggests esophageal spasm. • H/O peptic ulcer, reflux, hiatus hernia? • H/O fever, night sweats, weight loss, fatigue, hematemesis, black stools? Past History • Do you have diabetes or hypertension? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? • Any history of goitre or thyroid problems? • Any radiation exposure? Family and Social History • Do you smoke? Duration &, frequency. • Do you consume alcohol? Duration & frequency. • Any family history of thyroid disease? • Any family history of cancers/ medical illnesses? Differential Diagnosis • Esophageal Cancer. • Stricture due to GERD/Trauma. • Neuromuscular obstruction - achalasia, cranial nerve palsy, MS, supranuclear palsy, stroke, motor neuron disease, myasthenia gravis, muscular dystrophy. Investigations • Endoscopy with biopsy. • Upper Gl series. • CT chest (for mediastinal and lymph node involvement). • Chest X-ray. • LFTs, RFT. • Abdominal ultrasound. • CBC. Management • Urgent surgical consult.

Clinical Cases - Surgery________________________________________________________ 149

Brad Chisolm, a 35 years old man presented with bloody vomiting to the ER for the past 2 hours. Take a focused history and perform focused physical examination. Vitals: BP - 90/60 mm Hg, HR - 116/min, RR - 12/min,Temp - 37.0°C Clinical Info: Mr Brad Chisolm presented with acute onset of blood in vomitus, 2 episodes in 2 hours ago. He has no history of trauma. Non alcoholic, non smoker. He has been having chronic knee pain after a skateboarding accident 2 weeks ago. He is taking Ibuprofen for the past 2 weeks 4-5 times a day. Has moderate epigastric pain. No hemoptysis, hematuria or hematochezia. No surgeries/ medical illnesses. Clinical Case : Hematemesis HOPI OCD PQRST UV + AAA How did it start? Sudden or gradual. Is it getting worse/better or no changes in the symptoms? Duration of blood in vomitus? Amount of blood? Color of blood? Number of episodes? Is there any abdominal pain? Type of pain - sharp or dull pain? Does the pain radiate or shoot anywhere? Severity of pain on a scale of 1-10. Do your symptoms change with time? Any blood wnile coughing? Any blood in stools/last bowel movement? Any blood in urine? Any trauma to abdomen? Any fever recently? Any dizziness/fainting? Currently on any médications? Last meal? Any allergic reactions? Past History • Do you have medical illnesses? • Any surgeries in the past? Family and Social History • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration & frequency. • Any family history of cancers/ medical • Do you take any recreational drugs? • Any family history of cancers/ medical illnesses? Differential Diagnosis Management • Gastric ulcer. • ABC. • Acute Esophagitis. • Admit. • Acute gastritis. • NPO. • Drug induced coagulopathy. • NG tube. • IVF via large bore cannulas. Investigations • CBC, electrolytes, glucose. • Inj Ranitidine 50 me IV bolus and q8h. • In case of perforated ulcer - surgery consult. • LFT, RFT. • PT, PTT, INR. • Blood group & cross match. • Urgent endoscopy. • Upright abdominal X Ray.

150 NAC OSCE | A Comprehensive Review Mary Laplante, a 40 years old lady presented with swelling in the neck for the past 1 month. Take a focused history and perform focused physical examination. Vitals: BP - 120/88 mm Hg, HR - 96/min, RR - 12/min,Temp - 37.5°C.

Clinical info: Ms Mary Laplante noticed this swelling in the anterior neck with no other prominent symptoms. On examination, there is 2cm x 2cm mobile, non tender thyroid enlargement in the left lobe. Clinical Case : Neck Swelling HOPI • OCD PQRST UV + AAA • How did it start? Sudden or gradual. • Is it getting worse/better or no changes in the symptoms? • Since how long have you noticed the lump? • Where is the lump located? • How does the lump feel like? • Is there any pain associated with the lump? • Type of pain - sharp or dull pain? • Does the pain radiate or shoot anywhere? • Severity of pain on a scale of 1-10. • Do your symptoms change with time? • H/o fever/cough/sore throat? • Any weakness or myalgia? • Any change in voice? • Any change in vision? • Any change in appetite? • Any change in weight? • Any changes in bowel & urinary habits? • Any temperature intolerance? • Any palpitations or tremors? • Any swelling of face or feet? • Last menstrual period? • Any changes in menstrual cycles? Past History • Do you have diabetes or hypertension? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? • Any history of goitre or thyroid problems? • Any radiation exposure? Family and Social History • Do you smoke? Duration and frequency. • Do you consume alcohol? If yes, duration, amount and frequency. • Any family history oi thyroid disease? • Any family history of cancers/medical illnesses? Differential Diagnosis • Toxic nodular goitre. • Hashimoto’s thyroiditis. • Thyroid cyst. • Thyroid adenoma. • Thyroid lymphoma. Investigations • TSH. • Free T3 and T4. • Thyroid ultrasound. • Thyroid biopsy. • Antimicrosomal & anti-thyroglobulin abs. Management • Refer to an endocrinologist.

Clinical Cases - Surgery________________________________________________________ 151 Judy Frances, a 25 year old female presented to your office with lower abdominal pain for the past 1 day. Take a focused history and perform a focused examination. Clinical Info: Ms Judy Frances had a gradual onset of right lower abdominal pain 24 hours ago. The pain has gradually increased in intensity, grade 7/10. She has fever, nausea and vomiting since morning. No bowel or urinary complaints. No trauma. Her LMP was one week ago. O/E peritoneal signs are present and tenderness at Mcfeurney's point. Clinical Case : rain Abdomen /Acute Abdomen

HOPI OCD PQRST UV + AAA How did it start? Sudden or gradual. Is it getting worse/better or no changes in the symptoms? Duration of abdominal pain? Where is the pain located? Type of pain - sharp or dull? Does the pain radiate or shoot anywhere? Severity of pain on a scale of 1-10. Do your symptoms change with time? Any aggravating or relieving factors (change in position/food intake)? Effect on activities of daily living, functional limitation? H/o fever, nausea/vomiting, dizziness / fainting? Any urinary complaints? Loose stools /black stools or blood in stools? Change in stool caliber? Females : LMP? Pain associated with periods? Vaginal discharge? Past History • Do you have diabetes or hypertension? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? Family and Social Histoiy • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration & frequency. • Do you use recreational drugs? TRAPPED. • Any family history of cancers/ medical illnesses? Differential Diagnosis Management • Appendicitis. • Admit. • surg*cal consultation. • Renal colic due to nephrolithiasis. • PID. • IV Antibiotics. • Ectopic pregnancy. • Ruptured Ovarian cyst or ovarian torsion. • Mittelschmerz syndrome. Investigations • Abdominal X-ray 3 views • Abdominal 8c pelvic ultrasound • CBC, Electrolytes, Urea, Creatinine • INR/PTT, Glucose, beta HCG • Urinalysis • Stool for occult blood • Cervical swabs for culture/ PAP smear • NPO, NG tube.

152 NAC OSCE | A Comprehensive Review Ronald Mandel, a 65 years old man presented to your office with bilateral leg pain for the past 2 weeks. Take a focused history and perform focused examination. Vitals: BP - 140/90 mm Hg, HR - 86/min, RR - 12/min,Temp - 37.5°C Clinical Info: Mr Ronald Mandel is a known hypertensive for 15 years. He was diagnosed with CAD 5 years ago. He is having bilateral lower leg pain for the past 2 weeks. Pain starts only when he has walked for 1015 minutes. Pain subsides after taking rest. He has paresthesias too. No weakness or night pain. He is a chronic smoker and alcoholic for 20 years. Clinical Case : Peripheral Vascular Disease (Examination on page - 67) HOPI OCD PQRST UV + AAA How did it start? Sudden or gradual. Is it getting worse/better or no changes in the symptoms? Duration of leg pain? Where is the leg pain located?

Type of pain - sharp or dull pain? Does the pain radiate or shoot anywhere? Severity of pain on a scale of 1-10. Distance or time walked before pain starts. Speed of walking before pain starts. Degree of incline walked. Any pain during rest? Any pain in the night time? Any skin discoloration of legs/nail changes? Any skin ulceration of legs? Any chest pain/ shortness of breath? Any headache/dizziness? Any weakness/muscle pain? Do the symptoms come back with exertion? H/o impotence? Past History • Do you have diabetes or hypertension? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? • Past h/o recurrent infections? Family and Social History • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration & frequency. • Any family history of thyroid disease? • Do you take any recreational drugs? • Any family history of cancers/medical illnesses? Differential Diagnosis Management • Peripheral Vascular Disease. • Symptomatic treatment. • Tab Aspirin 75-150 mg OD. • Osteoarthritis. • Neurogenic claudication. • Clopidogrel. • Baker's cyst. • Vascular surgery opinion. • Reduction of CAE) risk factors. Investigations • CBC, Lipid profile. • Serum Homocysteine, Apolipoprotein A. • Serum Creatinine. • Hemoglobin AlC ,fasting glucose. • Urinalysis. • Ankle brachial index, Doppler of lower limbs. • CT Angiography. • Alcohol & smoking cessation.

Clinical Cases - Surgery 153 Alex Pereira, a 45 years old man presented with high grade fever with chills on day 3 after his abdominal surgery. Take a focused history and perform focused physical examination. Vitals: BP - 110/80 mm Hg, HR - 96/min, RR - 12/min,Temp - 38.5°C. Clinical Info: Mr Alex Pereira was operated 3 days ago for acute appendicitis. The morning shift nurse noticed temperature of 39.8° C. He is complaining of chills , rigors and nausea. He has pain at the wound site. No burning in urine. Had one bowel movement in the morning. No chest pain or shortness of breath. IV antibiotics were stopped on post op day 2. No other complications. O/E: Wound site is tender, erythematous with yellowish discharge. Clinical Case : Post Operative fever secondary to wound infection HOPI • OCD PQRST UV + AAA • How did it start? Sudden or gradual. • Associated with any chills/rigors? • Duration of fever? • Fever pattern- continuous,intermittent, remittent? • H/o cough/sore throat/rash? • Any chest pain/shortness of breath?

• Any abdominal pain? • Any burning in urine/cloudy urine? • Any dysuria/hematuria? • Last bowel movement? • Any pain at the wound site? • When was the wound dressing changed? • Any pain at the IV site? • Any pain in calves? • Any leg swelling? • Current list of medications? • Any changes in medications? • Last meal? • Reason for surgery? • Any pre-op/intra-op surgical complications? Past History • Do you have diabetes or hypertension? • Are you allergic to any medications? • Any surgeries in the past? • Past h/o recurrent infections? Family and Social History • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration & frequency. • Do you take any recreational drugs? • Any family history of cancers/ medical illnesses? Differential Diagnosis • Post op wound infection. • Urinary tract infection. • Intra-abdominal abscess. • Septic thrombophlebitis. Investigations • CBC, electrolytes, glucose. • LFT, RFT. • Urine routine and culture/sensitivity. • Wound swab, culture/sensitivity, gram stain. • Blood culture/sensitivity. • Ultrasound abdomen. Management • Start IV Antibiotics & Antipyretics. • Wound drainage. • Wound dressing for healing by secondary intention. • Vitals q4n till fever subsides.

154 NAC OSCE | A Comprehensive Review Diane Richardson, a 55 years old woman presented with incidental finding of lung nodule on chest x ray. Take a focused history and perform focused physical examination. Vitals: BP - 120/80 mm Hg, HR - 86/min, RR - 18/min,Temp - 37.5°C. Clinical Info: Ms Diane Richardson has chronic cough for 2 months. It was gradual in onset. No fever or recurrent pneumonia. A routine chest X ray revealed solitary nodule in the right middle lobe. She is a known smoker for the past 30 years. She is a chronic alcoholic also. Clinical Case : Solitary lung nodule HOPI • Why was the chest X ray done? • OCD PQRST UV + AAA • How did cough start? Sudden or gradual. • Is it getting worse/better or no changes in the symptoms? • Duration of cough? • Type of cough - dry/expectorant? • Amount / color of cough? • Any of shortness of breath? • Present at rest or with exertion? • H/o orthopnea? • H/o paroxysmal nocturnal dyspnea?

• Any chest pain/palpitations? • Does the pain radiate or shoot anywhere? • Severity of pain on a scale of 1-10. • Do your symptoms change with time? • H/o fever/chills/night sweats? • Any change in weight/appetite? • Any recent travel? • Any contact with sick person? • Any pets at home? Past History • Do you have diabetes or hypertension? • Are you on any medications? • Compliance with medications? • Are you allergic to any medications? • Any surgeries in the past? • Past h/o recurrent infections? Family and Social History • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration & frequency. • Any family history of cancers/ medical illnesses? • Occupation? • Exposure to carcinogenic substances? Differential Diagnosis • Lung Carcinoma. Management • Symptomatic treatment. • Solitary granuloma. • Comparison with older chest X rays. • Pulmonary tuberculosis. • Urgent respirology consult. • TB skin test. Investigations • CT guided biopsy. • CBC, electrolytes, glucose. • Bronchoscopy. • LFT, RFT. • Chest X Ray. • CT Chest. • Sputum cytology.


Elaine Jones, a 60 years old lady presented with swelling in the neck for the past 4 months. Take a focused history and perform focused physical examination. Vitals: BP - 120/80 mm Hg, HR - 88/min, RR - 12/min,Temp - 37.5°C. Clinical info: Ms Elaine Jones presented with a solitary swelling in the right lobe of the thyroid for the past 4 months. The swelling has increased in size. She has no fever, cough or sore throat. She has decreased appetite and 5 kg weight loss in the past 3 months. She has hoarseness of voice. Clinical Case : Thyroid mass HOPI Past History • OCD PQRST UV + AAA • Do you have diabetes or hypertension? • How did it start? Sudden or gradual. • Are you on any medications? • Is it getting worse/better or no changes in • Are you allergic to any medications? the symptoms? • Any surgeries in the past? • Since how long have you noticed the • Any history of goitre or thyroid problems? swelling? • Any radiation exposure? • Where is the swelling located?

• How does the swelling feel like? • Is there any pain associated with the Family and Social History • Do you smoke? Duration & frequency. swelling? • Do you consume alcohol? Duration & • Type of pain - sharp or dull pain? frequency. • Does the pain radiate or shoot anywhere? • Any family history of thyroid disease? • Severity of pain on a scale of 1-10. • Any family history of cancers/ medical • Do your symptoms change with time? illnesses? • H/o fever/cough/sore throat? • Any weakness or myalgia? • Any change in voice? • Any change in vision? • Any change in appetite? • Any change in weight? • Any changes in bowel & urinary habits? • Any temperature intolerance? • Any palpitations or tremors? • Any swelling of face or feet? Differential Diagnosis • Thyroid adenoma. Management • Urgent surgical opinion. • Multinodular goitre. • Radioiodine in case of hyperthyroidism • Chemo/radiotherapy in case or anaplastic • Thyroid cyst. • Parathyroid adenoma. tumor. • Benign nodule. • Surgical removal in cases other than Investigations anaplastic tumor or lymphoma. • TSH. • Free T3 and T4. • Radioactive thyroid uptake scanHot nodule : Hypo/Hyperthyroidism. Cold nodule: Thyroid malignancy. • Thyroid ultrasound. • Thyroid biopsy and cytology. • Neck CT.


Joseph Quinton, a 25 years old male was brought to the ER after a motor vehicle accident with the following vitals: BP - 80/50 mm Hg, HR - 116/min, RK - 10/min,Temp - 37.0°C, 02 sat - 80%. Manage the patient with a nurse. Clinical Info : Mr Joseph Quinton had a MVA 1 hour ago. He is conscious, alert and responding to verbal commands. He is in excruciating pain & complains of difficulty breathing. He can move all limbs. On auscultation, there are decreased breath sounds on right side oi chest with dullness on percussion. Diagnosis: Trauma - Right sided hemothorax. Introduce yourself. Call out the patient's name and assess verbal response. Follow universal precautions - mask,wash hands,wear gloves. Ask for patient's vitals. Ask the patient to be connected to monitors: cardiac monitor, BP cuff, pulse oximeter, temperature probe. rlace cervical collar with in-line traction. AIRWAY - Open mouth & check airway for any loose body/dentures/bleeding. Mention any specific smell. BREATHING - LOOK - cyanosis/pallor/icterus/nasal flaring/chest movements/respiratory rate/neck venous engorgement.

- FEEL - flow of air/tracheal shift/chest wall for crepitus/flail segments/sucking chest wounds/subcutaneous emphysema. - LISTEN - sounds of obstruction/breath sounds/symmetry of air entry/air escaping/noisy breathing. CIRCULATION - feel for peripheral pulses/ assess for shock-capillary refill,cool extremeities. DISABILITY GCS/pupillary reaction. Order primary INVESTIGATIONS - CBC, differentials, electrolytes, RFTs, LFTs, ABG, INR, PTT, 12 lead ECG, urinalysis, urine toxicology screen, portable chest X ray, C-spine X ray, Blood group, type & cross match, blood glucose. Place large bore IV cannulas both arms & IVF 11 normal saline bolus stat. Attach to 100 % oxygen through mask/nasal cannulas. Ask for vitals again. Ask for orientation to time/place/person, mechanism of injury/ any eye witnesses/ any loss of consciousness/ vomiting/ pain anywhere in the body/ last meal/ any arug allergies/ TAMPLE or SAMPLE. EXPOSURE/ SECONDARY SURVEY - Assess for: - Skull/cranium fractures. - Injuries to the face. - Hemotympanum/ otorrhea/ rhinorrhea/ epistaxis/ batde's sign/ racoon eyes. - Check upper extremities for fractures/ bruises/ lacerations/ tattoos/ needle track marks/ medic alert bracelet/ scars/ wounds. - Check abdomen for movements/ scars/ wounds/ bruises/ rigidity/ masses, bowel sounds. - Check lower extremities for fractures/ bruises/ wounds/ tattoos/needle track marks. - Pelvic compression to rule out pelvic fracture. - Deep tendon reflexes of upper & lower extremities. - Sensory examination of upper & lower extremities. - Motor examination of upper & lower extremities. - Genital examination. - Spinal examination - log roll with help to look for fracture/ step deformity. - Digital rectal examination. - Change rigid board to semi rigid board.

Clinical Cases - Surgery 157 • Give SECONDARY ORDERS: - Ask for vitals again. - Results of the investigation ordered earlier. - Request for needle thoracostomy with 16 G needle in 2nd intercostal space. - Ask what do you see - air or blood, (nurse or physician examiner will respond) - Urgent cardio-thoracic consult for chest tube. - Order 2L blood transfusion. - Foley's catheter. - Naso-gastric tube. - Measure intake/output. Management for specific trauma case scenarios Management for tension pneumothorax • Large bore IV needle in 2nd intercostal space in the mid-clavicular line. • Cardio-thoracic consult. • Chest tube to be inserted in the 5th intercostal space in the anterior axillary line. Management of open pneumothorax • 3 sided sealea dressing. • Cardio-thoracic consult. • Chest tube to be inserted in the 5th intercostal space in the anterior axillary line. Management of flail chest • Nasal oxygen. • IV fluids. • Pain control with Inj Morphine 2-4 mg IV. • Positive pressure ventilation. • Cardio-thoracic consult. Management of pericardial tamponade • Nasal oxygen. • IV fluids. • Cardio-thoracic consult. • Pericardiocentesis. Management of increased intracranial pressure

• Raise head end of the bed to 30-45 degrees. • Maintain neck in a neutrahsosition. • Hyperventilate to target pC02 30-35 mmHg. • Osmolar diuresis - Inj Mannitol 20% IV 1-1.5 g/kg, then 0.25 g/kg q6h to achieve serum osmolarity of 315-320. • Sedation. • Paralysis with vecuronium. • Oxygen to maintain p02 >60 mmHg. • Urgent neurosurgery consult. • Order CT scan of tne head.


Management of open fracture • Remove debris and wound irrigation with normal saline. • Sterile dressing and splint the fracture. • Check the neurovascular status of the limb. • Order X ray of the fracture with 1 joint above and 1 joint below. • Start IV analgesics. • IV antibiotics. • Tetanus shot, if not immunized in the last 5 years. • NPO. • Urgent orthopedic consult. Management of anterior shoulder dislocation • Posture of the arm - Abducted & externally rotated. • Order X rays: AP, trans-scapular, axillary views. • Urgent orthopedic consult. • Closed reduction with IV sedation & muscle relaxation. • Obtain post reduction x rays. • Check post-reduction neurovascular status. • Sling for 3 weeks, followed by shoulder rehabilitation. Management of ankle sprain • Follow Ottawa ankle rules to order X rays. • Ankle X rays - AP, lateral, mortise views. • Rest to the joint. • Ice to be used for 5-20 minutes every 2 hours. • Compression with a tensor bandage. • Elevate the limb. • Analgesics. • Urgent orthopedic consult. • Reduce weight bearing with help of crutches. Glasgow Coma Scale t 2 3 4 5 6 Eyes Does not open eyes Opens eyes in response to painful stimuli Opens eyes in response to voice Opens eyes spontaneously N/A N/A

Verbal

Makes no sounds Incomprehensible sounds Utters inappropriate words Confused, disoriented Oriented,

converses normally N/A

Motor

Makes no movements Extension to painful stimuli (decerebrate response) Abnormal flexion to painful stimuli (decorticate response) Flexion / Withdrawal to painful stimuli Localizes painful stimuli Obeys commands Generally, brain Injury is classified as Severe : GCS < 8, Moderate : GCS 9-12 and Minor : GCS > 13.

Clinical Cases - Counseling 159

Allison George, a 28 years old primigravida came to your clinic for her antenatal visit. She wants info for breast feeding. Take a focused history and address her concerns. Counseling Case : Breast Feeding HOPI Current gestational age? Any complications in the current pregnancy? GTPAL : Gravidity, Term pregnancies, Prematurity, Abortion, Living children. Last fetal ultrasound. Any maternal screening till date for genetic disease? Any genetic disorder in family ? Any Breast feeding issues in previous pregnancies? Any recurrent infections of the breast? Any h/o HIV/HCV/HBsAg/active HSV? Past History • Do you have any medical illnesses? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? • Any h/o cancer in the past? Family and Social History • Do you smoke? Amount/frequency. • Do you consume alcohol? Amount/frequency. • Do you use recreational drugs? TRAPPED. • Any family history of cancers (esp breast cancer)? Counseling for Breast Feeding • Breast feeding has to be initiated immediately after birth. • Initial clear breast milk called COLOSTRUM is full of nutrients and immunoglobulins. • It is beneficial for developing immunity in the newborn. • Full milk production starts by 3-7 days. • Exclusive breast feeding is recommended during the first 4 months. • Breast milk is easily digested with minimal renal load. • Breast milk has low allergic potential than cow's milk protein. • Lower pH promotes growth of lactobacillus in the Gl tract. • Creates parent - child bonding. • Breast fed babies require following supplements: Vitamin K, Vitamin D, Iron (from 4months to 12 months), Fluoride(after 6 months). • Contraindications to breast feeding- Mother receiving chemotherapy. - Mother with HlV/AIDS, active TB, herpes in the breast region. - Mother consuming alcohol/illicit drugs. - Mother on drugs contraindicated for breast feeding like antimetabolites, bromocriptine, chloramphenicol, metronidazole, tetracycline, lithium, cyclophosphamide. • Complications of breast feeding - sore/cracked nipples, breast engorgement, mastitis, breast feeding jaundice, breast milk jaundice, oral thrush in baby. • Breast feeding helps in losing pregnancy weight. • Lactational amenorrhea protects against future pregnancy. • Give educational info for breast feeding.


Rachel Marshall is a 20 months old girl brought to the ER with excessive crying. She has signs of fracture of right humerus. You also observe some old healed bruises elsewhere on her body. She is now stable. Take history from the mother and address her concerns. Counseling Case : Child abuse HOPI • How did the injury occur? • When did the injury occur? • Location of injury? • What was the child doing at the moment of injury? • Any loss of consciousness? • Any abnormal position or posture of the body? • Any seizures after the trauma? • Any vomiting? • Any excessive crying? • Any bleeding or discharge from nose/ears/ mouth? • Who are the child's care givers? • Who lives in the house or comes in contact with the child? • How did the child get the bruises? • What happened with the other fractures? • Any other injuries in the past? • Is the child accident prone or difficult to handle? • What is the child's personality: open vs. withdrawn? • Are there other children in the house? • Have they had broken bones or other injuries? • Was this child a planned pregnancy? • Problems with pregnancy, birth history? detailed history. • Developmental milestones. Detailed history. • What is the typical response of caregivers when the child cries or misbehaves? Family and Social History • Do you smoke? Amount/frequency. • Do you consume alcohol? Amount/frequency. • Do you use recreational drues? TRAPPED. • Alcoholism/smoking/drug abuse by other caregivers? • Economic condition of the family? • Any problems with the law? • Were the caregivers abused as children? • Is there spousal abuse, sexual abuse or incest? • Has the Children's Aid Society been involved with this child or other children? Counseling for child abuse Do a complete physical examination of the baby. Document and/or photograph all injuries: type, location, size, shape, color, pattern. Inform parents or care takers about the suspicion of child abuse. Order blood tests to rule out medical causes of presenting symptoms. Sexually transmitted infection work up. Skeletal survey/bone scan. CT/MRI. Fundoscopy. Report all suspicious cases to the CHILDREN'S AID SOCIETY. Admit for serious injuries. Involve social worker and other community resources. Inform that you are legally obliged to inform the Children's Aid Society. Your duty to report overrides patient's confidentiality. Evaluate the risk factors for chi * ild abuse: - Environmental factors- Social isolation, poverty, domestic violence. - Caregiver factors- Parents were abused as children, psychiatric illnesses, substance abuse, single parent family, poor social & vocational skills, below average intelligence. - Child factors- difficult temperament, disability, special needs(eg developmental delay), premature.

Clinical Cases - Counseling 161 Nancy Alfredo, a 30 years old woman presented to your clinic with a black eye and multiple bruises on her arms. Take history and address her concerns.

Counseling Case : Domestic violence HOPI • How did the injury occur? • When did the injury occur? • Location of injury/injuries? • Circumstances in which the injury occurred? • Describe violent episode, what triggered it? • Were objects used as weapons? • Was the boyfriend remorseful afterward? • History of previous episodes of violence or loss of temper by boyfriend? • What was the patient's response? • Has patient been in an abusive relationship before? • Is the boyfriend controlling? • Does he restrict her activities? • Question her excessively after she has been out? • Engages in verbal abuse or threats? • Is the violence increasing in severity? • Are there children in the house? • Who are the biological parents of the children? • Do the children witness physical abuse? • Ask about violence to the children, sexual abuse? • Is the boyfriend willing to seek help? • Any stressors at home/work? Family and Social History • Do you smoke? Amount/frequency. • Do you consume alcohol? Amount/frequency. • Do you use recreational drugs? TRAPPED. • Does the partner abuse alcohol or other drugs? • Economic situation? • Any family history of physical abuse? Counseling for domestic violence • Explain that the boyfriend hitting the patient is a criminal assault and an example of domestic violence. • Domestic violence tends to increase over time unless the victim leaves, or the abuser and couple seek therapy. • Very often, women don't leave their abusive partner until they are seriously hurt. • Domestic violence between adult partners tends to be reflected in future behavior of children who are exposed to it and there is a risk of violence to the children. • Child abuse is a criminal act and if suspected, is reportable to police by law. • Spousal abuse is also a criminal act but is not reportable by law. • Recommend that the patient not return to the abuser if there is risk to her safety (e.g. not the first assault, abuser not remorseful). • If the patient does return, an exit plan should be developed to ensure patient safety. • Document all evidence of abuse (pictures, sketches) ana related visits; quote patient direcdy in chart. • Alternatively, the patient can contact the police to obtain a restraining order on the abuser. • Develop a plan with the patient to seek alternate living arrangements (women's shelter). • Enlist die help of patient's support structure (friends, other family members). • Contact the police (patient should be informed that, if contacted, the police will lay charges whether the patient wants to or not). • Counsel patient on how to enter into a controlled, safe environment & contact with the abuser to discuss possible therapy for anger management and controlling behaviors. • Social worker referral and provide info about community resources. • Arrange follow up.


Sara Chang, a 55 years old lady came to your clinic to get info about Hormone Replacement Therapy. She is menopausal for the past 2 years. She is having significant hot flushes, mood fluctuations and vaginal dryness. It is significantly affecting her quality of life. Take a focused nistory and address her concerns. Counseling Case : Hormone replacement therapy HOPI • Menopausal since when? • Any post menopausal bleeding/spotting?

• Any hot flushes? • Any vaginal discharge/itchiness/dryness? • Any dysparuenia? • Any night sweats/sleep disturbances? • Any chest pain/palpitations? • Any h/o breast lump/mass? • Any nipple discharge? • Any weight loss/gain? • Any bony pains? • Any bowel/urinary changes? • Any mood changes/irritability/decreased libido? • GTPAL - Gravidity, Term pregnancies, Prematurity, Abortions, Living children. • When was last PAP test done? • When was the last breast exam and mammogram done? • Any h/o fibroids? • Any headaches/migraines? • Any liver/gallbladder disease? • Any blood clotting disorders? Past History • Do you have medical illnesses? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? • Any h/o cancer in the past? Family and Social History • Do you smoke? Amount/frequency. • Do you consume alcohol? Amount/frequency. • Do you use recreational drugs? TRAPPED. • Any family history of cancers (esp breast/encfometrial cancer)? Counseling for hormone replacement therapy • HRT is recommended for significant vasomotor symptoms of menopause. • Low dose of hormones is given for a short duration of < 5 years. • Types of HRT - Oral, Transdermal (patch, gel), Combined estrogen & progestin. • Give information brochures about HRT. • Compliance to medication dose is very important. • Encourage annual physical examination with a family physician. • Side effects: Abnormal uterine bleeding, mastodynia. edema, bloating, heartburn, nausea, mood changes. • Contraindications to HRT: Pre-existing uncontrolled hypertension. Uterine fibroids, endometriosis, migraine. Family h/o estrogen dependent cancers. Chronic thrombophlebitis, diabetes mellitus. Impaired liver function/ gall bladder disease. Hypertriglyceridemia, fibrocystic disease of the breasts. • HRT is protective against osteoporotic fractures and colon cancers. • HRT increases risk for: Invasive breast cancer. Coronary heart disease. Deep vein thrombosis or pulmonary embolism. Stroke. Dementia and mild cognitive impairment.

Clinical Cases - Counseling 163 Nadia Solanski, a 45 years old lady came to your clinic to get info about mammogram. Take a focused history and address her concerns. Counseling Case : Mammogram

HOPI • Any h/o breast lump/mass? • Any breast discharge? • Any nipple discharge?

• Any trauma to the Breast? • Any abnormal skin discoloration of breast? • Any breast surgeries/biopsies? • Any fever/night sweats/weight loss? • Any bony pains? • Any bowel/urinary changes? • When was your first menstrual period? • When was the last menstrual period? • Any irregularity in the menses? • Any dysmenorrhea/ menorrhagia/ oligomenorrhea? • Any passage of clots? • GTPAL - Gravidity, Term pregnancies, Prematurity, Abortions, Living children. • Age at which 1st child delivered? • H/o breast feeding? • When was the last PAP test done? • When was the last breast exam done? Past History • Do you have medical illnesses? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? • Any h/o cancer in the past? Family and Social History • Do you smoke? Amount/frequency. • Do you consume alcohol? Amount/frequency. • Do you use recreational drugs? TRAPPED. • Any family history of cancers (esp breast cancer)? Counseling for Mammogram • Mammogram is an annual screening test for the early detection of breast cancer. • Breast cancer is the second leading cause of cancer mortality in women. • Every 1 in 9 women in Canada are diagnosed with breast cancer. • It is recommended after the age of 40 years or more for every women. • It is done annually or every 2 years as a routine preventive test. • If there is a strong family nistory of breast cancer or genetic pre-disposition to breast cancer, then mammogram is done 5-10 years prior to the age of the relative detected with cancer. • There are two types of mammogram - Screening and Diagnostic. • Diagnostic mammogram is done in cases of breast mass/lumps/suspicion of breast cancer. • Mammogram is a special X ray of the breast done in a diagnostic radiology clinic. • The procedure mignt cause slight discomfort or pain which lasts only few seconds. • It can take upto 20 minutes to do a mammogram. • Images are interpreted by an experienced radiologists. • In case of any abnormality, further tests will be arranged. • Ideally mammogram should be done after your period has stopped, to avoid discomfort. • Give information brochures for mammogram. • Encourage annual physical examination with a family physician.

164 NAC OSCE | A Comprehensive Review Jenna Martin is a 28 year old mother who has concerns about the immunization for her 2 months old son. Take history and address her concerns. Counseling Case : Immunization

Any h/o egg allergies? Any allergies to medications? Feeding pattern? Developmental history? Any fever/vomiting/irritability? Any bowel complaints? Any urinary complaints? Any neonatal jaundice? Hearing & vision tests for the newborn? Any issues during newborn examination? Any h/o complications after immunization in the family? Counseling for immunization

• Ask about the patient’s concerns? • What does she want to know and why? • Immunization (vaccination) is a way of creating immunity to certain diseases by using small amounts of a killed or weakened microorganism that causes the particular disease. • Explain that vaccines protect children from diphtheria, tetanus, pertussis, polio (DPTP), mumps, measles, rubella (MMR), influenza (Hib) and nepatitis B (Hep B). • All of which were once common and caused serious, sometimes fatal illness in Canada, and now these diseases are hardly ever seen because of vaccines. • Explain that the vaccines stimulate the immune system. • Infants are fully capable of generating protective numoral Sc cellular immune responses to multiple vaccines simultaneously. • The timing of vaccines is important; some vaccines are most effective when given to children at a particular age or in combination with other vaccines. • Every batch of vaccine is tested for safety and quality in Canada before it is released for public use. • Some children have a temporary sore arm (with induration and tenderness) at the injection site, malaise, mild fever or rash. • Allergic reactions to vaccines also occur including urticaria, rhinitis, anaphylaxis. • It is very rare to have a more serious reaction (seizures, encephalopathy have been reported). • Standard modern vaccines are not known to cause disease or to have long-term deleterious effects. • The risks of vaccinations are small compared with the health risks associated with the diseases they're intended to prevent. • Explain the recommended immunization schedule : Give the patient some information pamphlets, invite further questions and ask her to return in two weeks for the child's first immunization. HOPI Take detailed prenatal/antenatal history? Any complications during pregnancy? Any complications during delivery time?

Clinical Cases - Counseling 165 James Hendrik is a 40 years old man who came to your office today to discuss his weight issues. His current weight is 250 lbs, Height 5 feet 7 inches, BMI 39.2. Take history and address his concerns. Counseling Case : Obesity HOPI • Duration of weight gain? • Amount of weight gain? • Dietary habits: frequency of meals, snacking, eating at night, foods eaten, binge eating, guilt about food, hoarding, concealing eating from others. • Estimated daily caloric intake. • Exercise history. • Diseases associated with weight gain: hypothyroidism, DM type II, Cushing's, major depression, anxiety disorder, some medications (TCA, steroids, OCP). • Problems associated with overweight: gout, sleep apnea, cholecystitis, back pain, cardiovascular disease, hemorrhoids, lower limb joint pain and osteoarthritis. • Why is patient seeking medical help for this now? • Past attempts to lose weight, successes, obstacles, goals. • Crisis in patient's life, stress, anxiety? • Assess patient's self-image: does the patient feel underweight, overweight or normal? • Does the patient feel that weight interferes with health, activities? • Screen for eating disorders. Past History • Do you have medical illnesses? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? Family and Social History • Do you smoke? Amount/frequency. • Do you consume alcohol? Amount/frequency. • Do you use recreational drugs? TRAPPED. • Any family history of cancers? • Any overweight relatives? Counseling for Obesity

• Motivation: how would being at ideal body weight improve the patient's life? • Emphasize health, lifestyle, self esteem, relationship benefits. • Discuss nutrition-related problems: heart disease, obesity, hypertension, osteoporosis, anemia, dental decay, cancer, gastrointestinal disorders, respiratory compromise, high lipids, diabetes, sleep apnea, osteoarthritis. • Discuss diets tried and why these failed. • Fad diets involve unusual or extreme eating patterns and are not designed to be maintained for a lifetime therefore these should be discouraged. • Weight loss agent Pondéral no longer available. • SSRIs such as Paxil may assist with weight loss, unfortunately, when the drug is discontinued, most people regain weight. • Explain mat the brain has a satiety set point which can be reset over time with reduction in caloric intake. • Warn that the body's ability to determine caloric content is very good, and will not be fooled by so- called diet products. • Recommend a balanced diet consisting of ordinary foods, with three distinct meals per day of small size. • No eating at night and be careful of snacks. • Inform patient that he will be hungry for at least the first two weeks of reduced intake. • Suggest visualization techniques, redirection of interests, and to think of hunger as a sign of positive progress on weight loss. • Group support can be beneficial too: Weight watchers, overeaters anonymous etc.

166 NAC OSCE | A Comprehensive Review • Behavior modification and positive outlook is vital for weight loss regime. • Dietary recommendations: reduce fat to 20% of caloric intake. 1200-1600 kcal/day for males. • Ideal caloric intake can be estimated at 10-12 Cal/lbs (ideal weight) in males. • Emphasize that caloric intake is more important for weight loss than food composition (i.e. excessive calories lead to weight gain even if they are non-fat). • Exercise recommendations: 30 minutes of moderate intensity exercise, 4-5 days/week. • Sudden intense exercise in sedentary patient unwise. • More vigorous exercise can be initiated when weight is lost. • Behavioral modifications, self control, rewards on achieving goals. • Arrange regular follow-up for body mass monitoring and counseling.

Clinical Cases - Counseling 167 Peter Harper is a 35 years old man, who is a chronic smoker for the past 10 years. He came to your office today because he wants to quit smoking. Take history and address his concerns. Counseling Case : Smoking

HOPI • Duration of smoking? • Frequency of smoking in a day? • At what age did you start smoking? • What type of tobacco do you smoke- cigarette/ cigars/ pipe/filter/non filter? • When do you have your first cigarette of the day? • If you do not smoke for a while, do you experience cravings or withdrawal symptoms? • Which symptoms do you experience - weak & tired? - sad or blue? - irritable or cranky? - difficulty concentrating? - restlessness? - anxious or jittery? • What people,places or events make you crave a cigarette? • How does smoking help you? • Does smoking help or harm your relationships? Counseling for smoking cessation • Do not judge the patient. • Recognize the readiness of the patient to quit smoking. • Be sympathetic to the patient. • Respect the patient’s decision. • Be familiar with the relevant information and resources for smoking cessation. • Encourage all efforts taken.

• Stress that many smokers have successfully stopped smoking. • Emphasize that smoking is a single most preventable cause of illness & death. • Talk about 5 R's for quitting: Relevance to health. Risks of smoking. Rewards of quitting. Road blocks in quitting. Repetition of motivational intervention at each visit. • Quit plan - STAR Set a quit date. Tell family &c friends. Anticipate challenge. Remove tobacco products. • Methods of smoking cessation: Nicotine replacement therapy - gum/patch/inhaler/nasal spray. Tab Bupropion SR. Tab Varenicline. • How many times have you tried to quit smoking? • If you tried to quit before, what methods you used? • What challenges you faced while quitting? • What methods helped you in the plan? • What is your motivation to quit on the scale of 1-10? Past History • Do you have medical illnesses? • Are you on any medications? • Are you allergic to any medications? • Any surgeries in the past? • Any h/o cancer in the past? Family and Social History • Do you consume alcohol? Amount/frequency. • Do you use recreational drugs? TRAPPED. • Any family history of cancers? • Occupation?

NOTES

mms Alphabetical Index

Abortion - clinical case................................... 118 Collateral Ligament Stability......................... Community Acquired Pneumonia................ , 82 Acetaminophen.............................................. 30 , 25 Acne................................................................. 11 Congestive Cardiac Failure............................ ...........8 Acute Bronchiolitis.......................................... 45 Congestive Heart Failure - clinical case........ COPD............................................................ ....104 Acute Cholecystitis......................................... 19 24 acute confusional state..................................... 52

Crohns Disease.............................................. .........17 Acute Gastroenteritis...................................... ........16 48 Acute Myocardial Infarction.......................... 7 Deep Vein Thrombosis - clinical case........... ,,146 Acute Otitis Media........................................ 45 52 Acute Pancreatitis............................................ 17 Delirium - clinical case.................................. ,135 Acute Pharyngitis............................................ 23 Delirium Tremens.......................................... 36 Acute Pyelonephritis....................................... , . .30 Dementia........................................................ , 55 Acute Sinusitis................................................ 23 Dementia - clinical case................................. .,136 Alcohol............................................................ ,, .35 Depression...................................................... ..........56 Alcohol withdrawal......................................... 30,59 Depression - clinical case............................... 137 Allen Test........................................................ ,68 Diabetes Mellitus........................................... .........14 Allergic reaction.............................................. Allergic Reaction............................................. 50 Diabetic Foot - clinical case........................... ,147 ,30 Diabetic ketoacidosis..................................... , 31 Anaphylaxis..................................................... ........30 Diabetic Ketoacidosis..................................... 14 Anemia............................................................ 19,50 32 Ankle Anterior Drawer Test......................... ........84 Digoxin Toxicity - clinical case...................... ,106 Anorexia - clinical case................................... 133

Diverticulitis................................................... 17 Antenatal Visit - clinical case......................... 119 Domestic violence - counseling..................... ......161 Anterior Drawer Test...................................... ........82 Dysfunctional Uterine Bleeding.................... .........40 anti-hypertensive drugs................................... Apley s Scratch Test........................................ ........10 Dyslipidemia.................................................. ...........9 ........86 Dysmenorrhea................................................ 40 Appendicitis.................................................... 16 Ectopic Pregnancy......................................... 42 Apprehension Sign......................................... ,86 Ectopic Pregnancy - clinical case.................. .......120 Arrhythmias.................................................... ........31 Emergency contraception.............................. .........41 ASA............................................................... , ,31 Empty Can Test............................................ Endometriosis................................................ ,, 86 Asthma............................................................ 24,45 ...... 40 Asthma - clinical case..................................... 103 Epiglottitis..................................................... 48 Athlete’s foot................................................... 13 Ethylene glycol.............................................. , 32 Atrial Fibrillation............................................ ...8,102 Examination - Abdominal............................. 63 Atrial Fibrillation - clinical case..................... 102 Examination - Back/Spine............................ 77 Atrophic vaginitis............................................ , .39 Examination - Breast..................................... .........90 Back Pain - clinical case.................................. ......142 Examination - Cardiovascular.......................

65 Bacterial Meningitis........................................ 49 Examination - Central Nervous System...... .......71 Bacterial Pneumonia...................................... 46 Examination - Elbow.................................... , 87 Bacterial Tracheitis.......................................... 45 Examination - Foot and Ankle.................... ..........83 Bacterial vaginosis........................................... Basal Cell Carcinoma - clinical case.............. 39 Examination - Hand and Wrist................... .........88 ......143 Examination - Hip........................................ 79 Benien Prostatic Hyperplasia - clinical case... Bipolar disorder............................................... 144 Examination - Knee...................................... , 81 57 Examination - Lower Limb Neurological.... 75 Bowstring test................................................. 78 Examination - Mini Mental State............... 93 Breast Feeding - counseling............................ , , 159 Examination - Peripheral Vascular.............. ,67 Buerger’s Test.................................................. ........68 Examination - Respiratory........................... ..........69 Bulimia - clinical case..................................... 134 Examination - Shoulder................................ 85 Burns............................................................... 11 Examination - Thyroid................................. .........91 Ca Oesophagus - clinical case........................ 148 Examination - Upper Limb Neurological.... External Rotation Lag Sien.......................... ..........73 Candidiasis...................................................... 39 .........86 Carpal Tunnel Syndrome - clinical case......... Cellulitis.......................................................... .......145 FABER.......................................................... 78,80 , , 13

Failure to thrive - clinical case....................... , . ,126 Cerebrovascular Attack - clinical case............ 105 Febrile Seizures.............................................. , .49 Chest Pain - clinical case................................ 111 Febrile seizures - clinical case........................ ,127 Child abuse - counseling................................ 160 Femoral stretch test......................................., , ,.78 Chlamydia....................................................... 38 Fibromyalgia.................................................. Finkelstein's test............................................ ,, 29 Cluster headache............................................. 22 89 Cocaine Overdose........................................... 59 General Anxiety Disorder............................. 54 Genital herpes..........................................................38 Genital warts...........................................................38 Gerber Lift-OfFTest................................................86 Gl Bleed...................................................................34 Golfer's Elbow.........................................................87 Gonorrhea................................................................38 Gout.........................................................................27 Group A Streptococcus...........................................48 Group B Streptococcus............................................41 Hallucinogens..........................................................59 Hawkins Impingement Sign....................................86 Headache - clinical case.........................................110 Heart Failure..............................................................8 Helicobacter Pylori..................................................17 Hematemesis - clinical case...................................149 Hemothorax - clinical case....................................156 Hepatitis B...............................................................18 HIV..........................................................................19 Hormone Replacement Therapy.............................41 HRT - counseling..................................................162 Horner's sydrome.....................................................69 Hyperemesis Gravidarum........................................42 Hyperprolactinemia..............................................I5p. Hypertension........................................................9,52 Hyperthyroidism......................................................15 Hypoglycemia..........................................................32 Hypothyroidism.......................................................15 Immunization - counseling...................................164 Immunization Schedule...........................................50 Impotence................................................................16 Impotence - clinical case........................................108 Infectious Mononucleosis - clinical case...............107 Infective Endocarditis..............................................10 Infertility - clinical case.........................................121 Lachman Test..........................................................82

Laryngotracheobronchitis........................................48 Lasegue’s sign..........................................................78 Malaria.....................................................................20 Mammogram - counseling....................................163 Mania.......................................................................53 Mania - clinical case..............................................138 McMurray's Test......................................................82 Measles - clinical case............................................128 Meningitis................................................................21 Meningitis - clinical case.......................................109 Migraine..................................................................22 Mood stabilizers......................................................57 Myasthenia Gravis...................................................23 Neck Swelling - clinical case.................................150 Neer Impingement Sign..........................................86 Neonatal Jaundice - clinical case...........................129 Obesity - counseling..............................................165 Obsessive-compulsive disorder...............................55 OCP Counseling - clinical case.............................122 Opioid......................................................................33 Opioid Intoxication.................................................59 Osteoarthritis...........................................................26 Osteoporosis............................................................26 Ottawa Ankle rules..................................................84 Alphabetical Index

Pain Abdomen - clinical case.................................151 Panic attack..............................................................53 Panic Attack - clinical case....................................139 Panic disorder...........................................................53 Parkinson’s disease....................................................23 Patellar Apprehension..............................................82 Patellar Grind...........................................................82 Pediculosis................................................................13 Pelvic Inflammatory Disease....................................40 Pelvic inflammatory disease - clinical case............123 Pemberton's sign......................................................91 Peptic ulcer disease...................................................19 Peripheral Vascular Disease - clinical case.............152 Pertussis....................................................................48 Phalen's test.............................................................89 Phencyclidine...........................................................59 Placenta Previa - clinical case................................124 Plantar Fasciitis Test................................................84 Pneumonia - clinical case.......................................112 Polymyalgia Rheumatica..........................................28 Post exposure - clinical case...................................113 Post Operative fever - clinical case........................153 Post-traumatic stress disorder.................................55 Posterior Drawer Test..............................................82 Pre Eclampsia - clinical case..................................125 Pregnancy Induced Hypertension............................41 Primary nocturnal enuresis - clinical case..............130 Psoriasis....................................................................12 Psychosis...................................................................56 Pulmonary Embolism..............................................25 Pulmonary Embolism - clinical case.....................114 Pulmonary tuberculosis............................................20 Pyelonephritis...........................................................39 Pyloric stenosis - clinical case................................131 Rabies.......................................................................20 Rheumatic Heart Disease........................................10

Rheumatoid Arthritis...............................................26 Romberg's test..........................................................72 Scabies......................................................................13 Schizophrenia - clinical case..................................140 Schober'sTest...........................................................78 Seizure disorder - clinical case...............................115 Seizures....................................................................21 Septic Arthritis.........................................................29 sexual dysfunction....................................................58 Sexually Transmitted Infection................................38 Shock........................................................................33 Smoking...................................................................35 Smoking - counseling............................................167 Social Phobia............................................................54 Solitary lung nodule - clinical case........................154 Speech delay - clinical case....................................132 Speed's Maneuver....................................................86 Sprain.......................................................................33 Straight leg raising test............................................78 Streptococcal Pharyngitis........................................48 Stroke.......................................................................33 Substance abuse........................................................59 Suicide - clinical case.............................................141 Alphabetical Index

Syphilis.....................................................................38 Talar Tilt Test...........................................................84 TCA.........................................................................34 Temporal arteritis.....................................................28 Temporal Arteritis - clinical case...........................116 Tennis Elbow..........................................................87 Tension headache.....................................................22 Tetanus.....................................................................21 Thomas test..............................................................80 Thompson's Test......................................................84 Thyroid mass - clinical case...................................155 Tinea Cruris.............................................................13 Tinel's sign...............................................................89 Trendelenberg test....................................................79 Trendelenburg Maneuver.........................................68 Trichomonas vaginalis..............................................39 Troisier's Sign...........................................................69 Tylenol......................................................................50 Ulcerative Colitis......................................................19 Urinary tract infection..............................................29 Urinary Tract Infection.......................................39,49 Viral Hepatitis - clinical case.................................117 Virchow s Node........................................................69 Vocal fremitus...........................................................70 Vulvovaginitis...........................................................39 Warfarin...................................................................34 Whooping Cough...................................................48 Yergason test.............................................................86

Osce Questions

Recommend Documents