OSCE counselling Flashcards
HPI for woman who got PAP results with moderate dyskaryosis
last pap and results
vaginal discharge/bleeding, itching, redness, abdo pain
menarche, regularity, length of cycle/menses, irregular bleeding
sexual activity, sexual debut, number of partners presently/past/currently, men/women/both, oral/vaginal/anal sex
meds to ask for woman who got PAP results with moderate dyskaryosis
contraception
condoms
HPV vaccine
pmhx to ask for woman who got PAP results with moderate dyskaryosis
STIs, HIV, PID, warts, cancer
gyne procedures, pregnancy, abortions
social hx to ask for woman who got PAP results with moderate dyskaryosis
smoking
etoh
ivdu
how should you start counselling for woman who got PAP results with moderate dyskaryosis
there are many types of HPV, some cause warts, some cause cancer, some you can have and never know you have it at all
HPV infection with high risk types cause over 99% of cervical cancers
most HPV infections go away without treatment
can HPV be transmitted thru non penetrative sex
yes, due to contact with anogenital region
viral shedding
what are the high risk HPV types
16 and 18
will HPV always be found on PAP
no because may be latent
what types of HPV does guardasil protect against
16 and 18–cancer
6 and 11–warts
when should PAP screening begin
start at age 25 and screen every 3 years
when should you increase frequency of paps
HSIL, AIS, cervical cancer or immunosuppression
how should you follow up ASC-US and LSIL
every 6 months for one year… if continue to be abnormal then refer for colposcopy
how should you follow up ASC-H, HSIL, AGC, AIS
colposcopy
how should you follow up SCC, adenocarcinoma
consult
how to prevent HPV
reduce sexual partners
avoid concurrent partners
use condoms
HPV vaccine
stop smoking
get regular PAPs
OCP absolute contraindications
previous PE/CVA/DVT
CAD
HTN above 160/90
severe hypercholesterolemia (also C/I for progesterone only pill)
thrombophilia/family hx
valvular heart dz
smoker older than 35
breast or endometrial cancer
abnormal vaginal bleeding
abnormal liver function
pregnancy
migraine with aura
what should you ask about in a sexual history
previous use, current knowledge, personal preference
LMP, pregnancy
vag discharge, bleeding, pain, itching, redness, abdo pain
menarche, regularity, length of cycle/menses, irregular bleeding
sexual activity, debut, number of partners, men/women/both, oral/vaginal/anal, current relationship, age of partner
what to ask about on pmhx for 16 year old girl coming in for birth control
HTN
CAD
DVT, PE
liver or gallbladder disease
cancer, clotting disorder, migraine with aura
gyne procedures, pregnancy, abortions
past PAP results, last PAP, STIs
meds to ask for 16 year old girl coming in for birth control
antibiotics
anticonvulsants
social hx to ask for 16 year old girl coming in for birth control
smoking, etoh, ivdu
HEADSS
childbearing goals? what would you do if you got pregnant?
what is the effectiveness of the OCP
99% when used correctly
what is the effectiveness of the IUD
99%, lasts 5 years
STU check before and check for string monthly
pros of the combined OCP
regulates periods
decreases risk of endometrial/ovarian/GI cancers
helps with acne
cons of the combined OCP
compliance issues
must be taken at same time each day
IUD pros
simple, long lasting
IUD cons
risk of uterine perforation
what should you discuss with for 16 year old girl coming in for birth control
surgical sterilization is an option
30% regret rate
how long does it take to get pregnant after stopping pills
most women get pregnant 3 mo after stopping
may take up to a year
causes of superficial dyspareunia
vaginal atrophy
vagina spasm
vestibulodynia
candidiasis
chlamydia
UTI
vaginal cancer
rectal cancer
endometriosis
causes of deep dyspareunia
PID
cervicitis
endometriosis
adenomyosis
when discussing dyspareunia/sensitive matters, what should you do first
obtain consent and stress confidentiality
“sexual difficulties are quite common in otherwise healthy people”
HPI for dyspareunia
onset (during/after coitus)
duration (lifelong, other relationships)
quality (burning, aching, itching)
entry vs deep
frequency of intercourse
provoking/palliating factors (lubrication, position)
itching, redness, sores
fever, chills, night sweats, abdo pain/pelvic
LMP, fatigue, hot flashes, mood, energy, appetite, wt loss, sleep
dysuria, constipation
meds to ask for dyspareunia
viagara, HRT
SSRIs, beta blockers
pmhx to ask for dyspareunia
DM
eczema
fibroids, endometriosis
PID
PAP smear
infertility
pregnancy, lacerations, episiotomies, trauma
social hx for dyspareunia
smoking, etoh, ivdu
sexual debut, partners etc…
how would they feel about their partner being involved, are they able to discuss their concerns with their partner, are they happy in the relationship
“because sexual violence is an enormous problem in our society, and can affect a person’s health and wellbeing, I now ask all my patients about sexual health and safety”
arguments, tensions, forced to have sex, sexually assaulted
what causes atrophic vaginitis
lack of estrogen
first line tx for atrophic vaginitis
estrogen repalcement
contraindications for estrogen replacement
breast, endometrial cancer
end stage liver failure
past history of estrogen related thromboembolism
adverse events associated with estrogen replacement
breast tenderness
vaginal bleeding
slight increase in breast, endometrial cancer risk
routes of administration for estrogen
oral, cream, transdermal
pros and cons of oral estrogen replacement
prevents bone loss and alleviates hot flashes
doesnt alleviate vag dryness in 25% of patients
pros and cons of transvaginal cream
very effective for vag dryness
decreases UTI risk
has lower hormone amount
increases risk of endometrial cancer
what else can be used to help vag dryness
moisturizers and lubricants
what should you do if a parent brings their kid into see you?
speak to them together then ask to speak to the kid alone
stress to the kid that things are confidential unless danger to self or others
HEADSS
for STD screens, say that certain diseases are reportable but confidential still
asthma counseling: what causes asthma
airways are very sensitive and can cause narrowing and difficulty breathing
asthma counseling: asthma etiology
family history and environmetnal factors
asthma counseling: triggers for asthma
URTI
allergens
smoking
NSAIDs
emotional stress
cold air
exercise
asthma counseling: treatment/management
treatment is to manage it is not a cure
but most kids grow out of it, though can be lifelong
symptoms of asthma
night time coughing
difficulty breathing
wheezing
asthma counseling: lifestyle changes
exercise
avoid allergens like pet dander
avoid infections
asthma counseling: what do puffers do
one type are reliever medications–> dilate airways, are short acting
one type are controller medications–> are inhaled steroids and can help prevent attacks
*steroids not absorbed systemically so side effects are not as much of a concern
asthma counseling: signs of an attack
difficulty breathing
pale/blue
fatigue
cant speak
wheeze
change in mental status
asthma counseling: what to do during an attack
give puffers and come to ER if not improved
asthma counseling: ventolin use and dosing
used for acute treatment
TID for one week then PRN
asthma counseling: ventolin side effects
nausea, vomiting muscle aches fine motor tremor palpitations restlessness throat irritation
asthma counseling: fluticasone use and dosing
for prevention
BID every day
asthma counseling: fluticasone side effects
nausea, vomiting
abdo pain
diarrhea
headaches
dizziness
nasal irritation, bleeding
asthma counseling: prednisone use and dosing
decreases inflammation
once daily for two days for attacks
prednisone side effects
nausea and vomiting
mood changes
candidiasis
avacular necrosis of the femoral head
what should you do at the end of an asthma counseling session
offer pamphlets and support groups
book f/u to do PFTs
instruct mother about a follow up
what can cause breast lumps
cyst
fibroadenoma
fibrocystic changes
breast cancer
infection
what are the guidelines for mammography screening
start at 5 years q2 years
for those with strong family history start at 40 or 10years prior to earliest diagnosis
what is the “triple assessment” for breast cancer
clinical exam, biopsy, imaging
is a breast FNA diagnostic?
NO
if non bloody and lump disappears then it was benign cystic disease
if bloody, send for pathology
what imaging you do consider in a breast lump
diagnostic mammography
breast u/s (for cysts)
guided core bx
MRI maybe for difficult lesions
what genetic tests do you consider for a breast lump
BRCA 1/2 if family hx
Her-2 and hormone receptor testing if mass is cancer
management of early stage breast cancer
lumpectomy or mastectomy with or without RT then adjuvant therapy may be offered mased on size, grade, lymph nodes, genetic testing
what is breast conserving therapy for breast ca
lumpectomy with RT
must preclude multicentric disease, large tumour size relative to breast, diffuse malignant appearing calcifications on imaging, prior hx of chest wall RT, pregnancy, persistent positive margins
how long does WHO recommend breastfeeding
6 mo
how often should you breastfeed
every 2 hours for premature
every 4 hours for term baby
every 5 hours at night until 4/5 kgs or 2-3 months old
benefits of breastfeeding (mnemonic)
ALLERGIC conditions reduced
BEST food for infants
CLOSE bond
DEVELOPMENT of IQ/jaw/mouth
ECONOMICAL
FITNESS of mom (return to normal weight)
GUARD against breast, ovarian, uterine cancer
HEMORRHAGE reduction
**risk of HIV transfer
contraindications for breastfeeding
HIV/AIDS/active TB/herpes in breast
heavy EtOH or illicit drug use
chemo/rad compounds
diazepam, metronidazole, lithium, tetracycline, mrocopriptine, ergots, gold, cyclophosphamide
are mastitis, OCP, CMV or hepatitis contraindications to breastfeeding
no
complications associated with breastfeeding
sore/cracked nipples
engorgement
mastitis
poor weight gain
oral candidiasis
breast feeding jaundice
breast milk jaundice
what should you ask about in a teen who, after HEADSS, admits they’re an alcoholic
mood, suicide
CAGE
amount/week, types, drinking more, drinking with friends
effects on family, friends, trouble with police
withdrawal symptoms–mood, sweating, hallucinations
what should do you do etoh counseling in a teen
would they like to reduce the amount?
benefits–> reduced risk of disease, improved mood, improvement in function
groups available–> refer to etoh team
detox in the community–> chlordiazepoxide over 1 week, reduces symptoms vs in hospital
BC reportable illnesses
gonorrhea syphilis chlamydia HIV hep a/b/c TB
HCP also needs to notify sexual partners
what is the SPIKES mnemonic for counseling bad news (i.e positive TB in homeless person or positive HIV in married person)
setting
perception–> is it okay to share important news, do you want someone here, their knowledge of the test
invitation–> would you like all information or more focus on treatment plan?
knowledge–>unfortunately ive got some bad news, test came back +
emphathy–>I can see how this is upsetting to you
summarize
TB counselling: what is TB
infects lungs and causes cough and hemoptysis
ask about htese sx
TB counselling: how do you get it
homeless
etoh dependent
immunosuppressed are at risk
TB counselling: treatment
there is a cure
6 months of meds
initial phase 2 mo, then AFB smears, then another 4 months
TB counselling: risks of treatment
liver damage
vision
rash
drug fever
TB counselling: housing for treatment
can get long term hospitalization or portland hotel society
TB counselling: importnat points
reportable, confidential
HIV counseling: what is it
viral infection that attacks immune system and causes you to have other infections
HPI
HIV counseling: how did they get it
sexual activity, sharing needles
ask patient if they know how they got it (IVDU, MSM, paying for sex)
HIV counseling: treatment
no cure
treatment keeps illness under control
HIV counseling: important points
reportable, confidential
inform partner, offer to help, partner should be tested
mnemonic for DNR discussion
SPIKE
what do you know about your disease
what do you expect of your medical care
what are your goals for your care
can we talk about CPR
do you know what CPR is
–chest compressions
–usually doesnt work
if you were to die suddenly would you want CPR
what is a reasonable quality of life that you would like to live with
what are your feelings around this topic
dont need to decide now, make decision later
DNR status does not mean withdraw care, we would like to make you as comfortable as possible
what are the geriatric giants
drugs delirium dementia falls sleep constipation urinary retention vision/hearing supports functionality
ADLs
feeding, grooming, washroom
IADLs
cooking, groceries, shopping, bills, driving
risk factors for heart disease
males above 45 females above 55 DM HTN high cholesterol obesity smoking family hx under age 60 inflammatory biomarkers
physical signs of hyperlipidemia
atheromata
xanthoma
tendinous xanthoma
corneal arcus
lifestyle changes for hypercholestrolemia
3 month trial
decraese SAFA increase fibre exercise weight loss smoking cessation moderation of alcohol
management of hyperlipidemia
treat HTN and DM
lab tests for DM and end organ function
what are statins
slow cholesterol formation
dose of atorvastatin
10-80 mg po daily
side effects of statins
less than 5% get myalgias
some hepatotoxicity
monitoring for statins
ALT, AST, CK at baseline then 6 weeks then every 6 months
follow up for hypercholesterolemia
every 3 months
waht does systolic BP represent
pressures of the contracting heart (versus relaxing heart in dBP)
define HTN
above 140/90 (cutoffs different for DM and renal disease)
what are the most likely causes of hTN
artery hardening (but not known for sure)
secondary causes: cushings pheo aldosteromism hyperthyroid cocaine aortic coarctation renal artery stenosis
risk factors for htn
age obesity sedentary lifestyle stress smoking alcohol high salt family history
complications of htn
stroke
blindness
heart attack
kidney failure
ask about OSA in htn assessment
lalala
management of HTN
lifestyle changes trial for 3 mo
–exercise, salt, smoking, alcohol, stress reduction
labs
–HbA1c, creatinine, GFR, lipids, UA, urine ACR, ECG
first line
–HCTZ or ACEi
what are HCTZ/ACEi
diuretics that prevent the body from retianing too much salt and thus water
side effects of diuretics
urination
dizziness
may increase BG
follow up for HTN
3 mo
risk factors for diabetes
first degree relative high risk population hx IGT, GDM vascular disease overweight HTN dLP PCOS acanthosis nigricans
management of diabetes
lifestyle for 3 month then meds
first line antihyperglycemic agents
metformin, sulphonylurea, aalpha-glucosidase inhibitor
what do antihyperglycemic agents do
make cells more sensitive to insulin
taken once or twice daily
side effects of antihyperglycemic agents
nausea diarrhea abdo pain weight loss lactic acidosis
contraindications to antihyperglycemic agents
kidney disease
low BMI
compliations of diabetes
neuropathy (impotence, constipation, diarrhea, gastroparesis, orthostatic hypotension, paresthesias in feet)
retinopathy
nephropathy
CVS
foot ulcers
hospitalizations (DKA etc)
screening guidelines for diabetes
every 3 years once over 40 if no risk factors
how do you diagnose diabetes
symptoms plus random glucose above 11.1
-or-
fasting blood glucose above 7
or-
HbA1c above 6.5%
why should you vaccinate kids
prevents serious illness
safe
majority of babies get it
prevents spread of disease i.e smallpox
adverse events with injections
crying, irritable, low grade fever, local reaction
can treat with tylenol and fluids
rare 1/1000 high grade fever, seizure, call 911
1/500 000 anaphylaxis
“disease is more serious than the complication, thus we vaccinate”
what to watch out for with vaccines
if large swelling, or swelling around lips or mouth, rash, call doctor
what are the links between autism and MMR
none
paper from 1990s has since been disredicted
study very small and outcomes biased
several large scale epidemiological studies found no evidence
what are the 4 As of alzheimers
amnesia
aphasia
apraxia
agnosia
what is alzheimers
form of memory loss, form of dementia
memory loss, confusion, word finding difficulties, concentration, problems with paying bills, getting lost etc
later changes can include behavioral changes (sometimes aggressive, sometimes passive), hallucinations, needing help with eating, bathing, dressing, incontinence, driving and cooking will become dangerous
how does someone get alzheiemrs
unknown mechanism
deposits in the brain
risks are age and family history
how do you manage alzheimers
no cure
medications improve memory and slow progression for more than 10 years sometimes
meds trialled for 8 weeks, monitor for SEs
can treat other sx like depression with SSRIs
does alzheimers kill you
death is from other illnesses like pna or falls
what should you advise patients to do after an alzheimer’s diagnosis
get financial affairs in order
advise to draw up advanced care directives
support groups
follow up in 3 months
