OSCE Flashcards
Examination for syphilis
Primary-
anogenital- chancre, follman’s balanitis
Secondary
Eyes- retinitis, uveitis, optic neuropathy
Scalp- patch alopecia
Mouth- mucous matches
Signs of meningism
Cranial nerves (incl 8 - deafness, facial palsy)
Skin- maculopapular rash, palms/soles
Liver edge
Splenomegaly
Genitals- mucous patches, condylomata lata
Lymphatics (incl tonsils, epitrochlear)
LATE CV examination- AR BP, difference for aneurysm Bilateral upper-extremity blood pressures should be measured in patients with AAAs. Upper-extremity blood pressures that differ from each other by more than 30 mm Hg indicate subclavian artery stenosis,
Collapsing pulse
Neurological
General paresis- dysarthria, hypotonia, intention tremor
Tabes dorsalis- argyl robinson pupil, impaired reflexes, impaired vibration and joint position sense, rhomberg’s
Examination for congenital syphilis- early
Rash Bloody snuffles Generalised LNs Hepatosplenomegaly Osteochondritis Periostits Pseudoparalysis
Examination for late syphilis?
Interstitial keratitis (blurred vision) Cluttons joints (symmetrical joint swelling) Hutchinsons incisors Mulberry molars High palatal arch Rhagades (periorbital fissures) Sensorineural deafness Frontal bossing Short maxilla Protuberance of mandible Saddle nose deformity CN palsies Learning difficulty
Explaining resistance HIV ARV
Resistance occurs when the virus starts to make changes (mutations) to its genetic make-up (RNA) that are resistant to certain HIV drugs, or classes of HIV drugs.
This can happen either as a result of a prolonged period of time on treatment, or more commonly, as a result of suboptimal treatment adherence.
These new mutations make copies of themselves, gradually increasing the level of the virus in the person living with HIV – meaning treatment may no longer be effective
Explaining viral mutations HIV
When HIV first enters the body, it will actively go about replicating. But retroviruses such as HIV have a high mutation rate, so every now and then, the virus will reproduce a copy with errors.
‘Wild type’ viruses – the naturally-occurring, non-mutated forms of the virus – are most susceptible to ART, but mutated forms of the virus may be less so. When antiretroviral treatment is given in inadequate levels, we are allowing for these drug resistant mutations to be selected out and multiplied to the point that drug resistant virus becomes the primary population in the viral pool.
Depending on the specific mutation, it is possible for people to become resistant to a drug they have never taken – this is called ‘cross-resistance’. This is because some mutations affect the efficacy of different drugs within the same drug class.
Even when taking ART optimally, small populations of virus still replicate. Over time, due to mutations, the population of viruses in an individual may contain fewer viral strains susceptible to HIV treatment, and more strains that are drug resistant.8 This is when viral load may become higher and detectable – and the prescribing healthcare provider would consider switching out a different drug or drug class.
Male genital exam
explain to the patient what the examination will involve
Verbal consent
Wash hands/gloves/chaperone
Ask to remove clothing-knees to umbilicus.
Look in the mouth - assess mouth for ulceration, mucus patches or snail track ulcers as these may occur in secondary syphilis.
Inspection- evidence of infestation, infection or skin conditions
I would like to examine your testicles. Do you ever check your testicles?
I’ll talk you through what to do and we would advise 1 x month in shower checking.
“You roll each testicle between thumb and first two fingers in order to palpate the testicles for texture, tenderness, swelling or lumps.
Palpate the epididymii where sperm are made for texture, tenderness, swelling or cysts”
If the testicle enlarged, torch ?transillumination suggestive of a hydrocele.
If cord-like structures are palpable above the testicle, examine for varicocele of the scrotum. Ask the patient to stand up, the varicocele feels ‘like a bag of worms’!
Visually examine the skin of the groin.
‘Do want to pull your foreskin back or shall I?’
Retract the foreskin to examine the glans and subpreputial area.
Observe if urethral discharge at the meatal opening. If not, “it would be useful to try see if I can express some discharge by applying some pressure to the base of the penis”
Microscopy-
fine urethral swab or small plastic loop into the meatus and distal urethra.
Lift the discharge onto the swab or loop or rotate the urethral swab in the distal urethra to collect material from the mucosa.
Spread a thin layer of the swab material onto a microscope slide, which can then be Gram stained to look for pus cells and intracellular diplococci.
Also take a swab for gonococcal culture and antibiotic sensitivity testing.
Ask for urine sample for GC/CT/mycoplasma genitalium
Perianal examination MSM
explain to the patient what the examination will involve
“Would like to do a proctoscopic examination. Involves putting a tube up your bottom to look for any inflammation, ulcers, warts. Have you ever had this done?”
Need you to lie on your left side
Knees up to elbows
Verbal consent
Wash hands/gloves/chaperone
Left lateral
Ask to remove clothing-knees to umbilicus.
OBSERVATION: Inflammation Fissures Ulcers Warts Skin rashes or erythema extending along the natal cleft
Disposable plastic proctoscope
Lubricant to the proctoscope to ease its passage through the anal canal
Insert instrument carefully asking patient to take deep breath
Push gently aiming towards the patient’s umbilicus initially, then into the curve of the sacrum
Remove introducer
Shine light along plastic proctoscope and
Assess rectal mucosa for erythema, oedema, ulceration, pus and discharge – take swabs
Green viral HSV and ?mycoplasma
Yellow- GC/CT and LGV
GC culture
Loop for microscopy
Gently withdraw visualising anal canal for lesions including warts
Urine - gc/ct/?mycoplasma if NGU
(hold pee 30 mins before and first catch)
Throat GC/CT
Bloods HIV /STS and hep a /b/c depending on vaccine hx
Examination of a woman with discharge
Vagina
- Microscopy of stained slide of vaginal discharge for BV or candida
- wet mount microscopy- Test for TV
- TV NAAT if available ?green or TV culture
- GC/CT vulvovaginal
Cervix - mop
- microscopy plus
GC culture if GC strongly suspected
Mycoplasma genitalium if PID
HPV?
Not one way No better treatment Topical or ablative Combined treatment MAY work bette Can get recurrence
