OSCE stems Flashcards
Knife cut on forearm near thumb, initial bleeding has stopped.
Tasks:
Examine and assess injury
Explain nature of injury and management
- Examine the thumb - extensor mechanisms damaged
- Know thumb extensors (Extensor pollicus longus and Extensor Pollicus brevis) affecting interphalangeal and metacarpophalangeal joints
- Referal for surgery
- Abx prophylaxis with cefazolin or broad spectrum
- Clean/contaminated wound
25 year at 35 weeks gestation wants to know about breast feeding vs formula as her mum thinks formula fed babies gain weight better
Tasks:
- advantages and disadvantages of BF and Formula feeding
- steps involved in safe formula feeding
Reasons that may prevent breast feeding may be:
- illness of mother
- failure to establish lactation
- illness of baby e.g, cleft palate
- prematurity which may require mother to express regularly to maintain supply
- previous breast surgery of the mother
- heightened anxiety of mother
Formula feeding is safe and an effective alternative, although components difficult to exactly replicate. No advantage over breast feeding
Advantages of breast feeding:
- practical advantage
- immunological benefit
- establoshes a closer connection to baby
Response to mum’s comment that weight gain is not the only criteria - excess weight gain in forst 12 months can be detrimental later in life
Optimal formula feeding:
- sterility in preparing bottle feeds is essential
- use of bottle brush to clean milk residues
- using sterilisation tablets like milton to soak in but ensure rinsing after
- use FBC water for rinsing and making the formula
- ensure to follow formula feed making instructions exactly and not to add extra scoops
- do not make more than a day’s worth in advance and all should be stored in the fridge
- make excess of 30ml per feed and discard excess
Young couple come to GP expecting their child and want to know about neonatal circumcision if boy.
Tasks
- discuss risks and benefits of neonatal circumcision
Perceived advantages:
- reduced incidence of UTI but not routine practice to do as preventative. Can always selectively chose to do so if issue on a later date
- Reduction of STI - inconclusive in literature
- Treatment of phimosis as a result of inappropriate foreskin care. Foreskin care should be minimal until age of 5 when easily retractable.
- Minimising risk of carcinoma of the penis. HPV is major contributor and cancer rarely seen in men who can retract and clean the foreskin
Complications and disadvantages:
- haemorrhage
- infection
- ulceration of the glans
- damage to the urethra
- unsatisfactory appearance
- anaesthetic complications
- secondary phimosis
Contraindiacations:
- lack of expertise at hand
- congenital anomalies of the penis
- chordee
- buried penis
- sick infants
- family history of blood disorders
Procedure
Freeing the foreskin from the glans
* Excising the foreskin
* Providing haemostasis
* Facilitating wound healing.
No evidence of benefits outwieghing the risk according to Paediatric division of RACP
Suspected hearing loss in 10 month old child
In addition of full paeds Hx, add in:
- Does baby respond to sounds?
- Does she respond when her name is called?
- Does she turn towards the source of the sound
- Respond to TV?
Management:
- Referral to paediatric audiologist for formal audiogram
- Return for review after audiogram
- If normal, review hearing and ealry development after 3 months
- If abnormal, referral to paediatric ENT scpecialist
Counselling a family after SIDS
SIDS:
- frequency has falled from 1 in 500 to 1 in 1000
- peak incidence occurs are 4 months of age
- unknown cause
There can be other causes such as severe overwhelming infection but there is no suggestion in Andrew’s case medical treatment for snuffles would have changed the outcome.
- police and coroner must be notified by law as cause of death was unexplained and sudden
- role of police officer is to assist the coroner - all people involved are interviewed including the GP
- need for autopsies in all cases and done by experienced pathologists to find out what causes SIDS and if there was any other reason
- tissues samples are taken for furthe rinvestigation under microscope
- Happy to contact coroner with initial findings of they can wait for the coroner to contact them
- coroner will decide if an inquest needs to be held but generally not the case for SIDS
- SIDS support group
- keep in contact and review/offer to contact relatives or anyone else that needs the support
Patchy hair loss in male
Alopecia areata - chronically relapsing autoimmune disease with variable history. Genetic factors, febrile illness and sudden stress may be causes
- will be improvement or return to normal but very unpredicatable
Management:
3-6 months of
- topical strong corticosteroids
- intralesional corticosteroids
- minoxidil 5% topical
- referral to dermatologist for immunotherapy or UV phototherapy
- consideration of using a wig
Acute angle glaucoma examination signs and treatment
- Red eye, headaches, nausea, fixed dialted pupil, corneal haze, blurry vision
- Hard eye on palpation
- coloured halos around lights
- IOP >30mmHg
Ix
- Gonioscopy and tonometry
- Visual field and acuity
Management
- analgesia + anti-nausea
- lie patient flat
- IV/oral acetazolamide
- timolol
- Latanoprost
- Pilocarpine
- Topical steroids
- Laser iridotomy
30 yr old man presents to GP with throat problem. Smoker + drinks 2-3 drinks on weekends. Feels a lump in throat.
Task:
1. Focused Hx
2. What investigations?
History
- Rule out dysphagia, voice hoarseness and airway issues
- Psychological stressors - in this case cousin died from cancer of a larynx
-diagnosis after normal exam is globus disorder subject to laryngoscopy
Investigations
- Laryngoscopy and pharyngoscopy
- Chest X-ray with thoracic inlet views and barium swallow can be done
- Upper GI endoscopy can be done
Pain in testes following mumps in a 25 yr old
Counsel and give info
- Viral aetiology related to mumps virus
- Pain relief with codeine, scrotal support and application of heat will help but not abx
- Usually only affects one testicle and unlikely to cause sterility or affect both testes. Won’t affect fertility or sexual function
- Affected testicle may reduce in size
- can return to work 7-10 days time
- Infectivity of mumps 6 days prior to 9 days after swelling so can contract to unimmunised family members
- Complications of mumps orchitis, meningitis, encephalitis, arthritis, pancreatitis or oophoritis
- Mumps does not pre-dispose to testicular malignancy
Contraception advice to 24 year old
Tasks
1. History
2. Recommendations
History
- Mensturation Hx
- Obstretic Hx
- Sexual History
- Previous + current contraception
- Pap Smear
- Hx of DVT, liver disease, breast cancer, bleeding disorders
- Hx of HTN, Migraines and is she a smoker?
- BMI?
- Taking any other medications e.g anti-epileptics
20 year old rape victim that doesn’t want to report to police as the perpetrator is known to the family
Tasks:
Counsel and manage
- PMOSC, LMP and on any contraceptive?
- Any other assault? Was there any bleeding?
- Was there ejaculation in the vagina?
- Med Hx, allergies and SHx
- Exam of the vulva and vagina with speculum
- Swabs for STI and forensic analysis
- Bloods for HIV and syphilis
- Cervical smear (or urine ) for gonoccocus and chlamydia culture
- Azithromycin and doxycycline given prophylactically
- BHcg done first for previous preg and then pregnancy prevention with emergency contraception of one pill stat
- Review 3 weeks for results and repeat BHcg
- Repeat HIV and syphilis screening in 1-3 months time
- Refer for sexual assault crisis team/centre and forensic medicine
- Document all injuries
- no mandatory reporting but encourage the patient to make a statement (they can make the decision to pursue issue later)
Left colon adenocarcinoma counselling for a 60 year old man reluctant to get surgery
- If untreated tumour will become evident due to bleeding, bowel obstruction of spread of the cancer
- Untreated will cause partial obstruction with increasing constipation interspersed with diarrhea
- Acute complete obstruction will lead to distension and pain required urgent surgery to prevent rupture. Surgery may require a temporary colostomy.
DUKES scoring for 5 year survival:
Stage A - carcinoma confined to mucosa = >95% survival
Stage B - involves muscle of colonic wall = 75-80% survival
Stage C - Lymph node involvement = 50% survival
Stage D - spread to peritoneal or elsewhere = 25-35% survival
Pre-operative investigations:
- Fitness of anaesthesia
- absence of anaemia
- Normal renal function
- Abdo CT
- Prophylactic abx prior to surgery
Pre-operative assessment
- Anesthetics Hx
- airway/vascular access
- complications i.e. anaphylaxis or hyperthermia
- Post operative nausea or vomiting (PONV)
- FHx of anesthetic complications - Surgical Hx
- Name of operation, side and site
- Indication of surgery
- Symptoms and duration - Cardiovascular Hx
- Current disease e.g. chest pain, palpitations, SOB
- PMHx CVD - Respiratory Hx
- Snoring, wheeze, chest infection, SOB
- Exercise tolerance (2 flights of stairs) - Remain systems review
- diabetes
- contact lenses
- false teeth
- GORD
- Liver/renal disease
- bleeding disorders
- pregnancy if female - Rx, allergies, SHx and physical examination (cardio-resp and abdo)
- Investigations:
- Bedside ECG and BGL
- Bloods: FBC, UEC, Coags (INR)
- Imaging: surgeon dependent
Post-op fever
5 Ws
Wind: rule out pneumonia
Water/waterway: rule out UTI e.g. IDC, dysuria, etc. rule out IV lines, central lines, cellulitis
Wound: Pain/discharge, tenderness, erythema, risk factors such as smoking, T2DM, bleeding
Walking/Veins: DVT or PE
Wonder drugs: drug fever or reaction to transfusion
Thalassaemia minor counselling
- Recessive inherited trait give thalassaemia minor
- Need to get partner tested for trait as implications for future kids to have thalassaemia major
Diagnosis:
- symptomless hypochromic microcytic anaemia, reduced MCV but normal RBC
- serum electrophoresis (elevated HbA2)
- anaemia does not respond to iron supplementation unless iron deficient which is rare
Counselling:
- reassure and iron supplementation is not needed
- 1mg folic acid supplementation for mildly increased cell turnover
- Fiance also of Greek descent needs to be tested as carrier by his own doctor so both can get referred to genetic counselling or haematologist for future planning of children if both carriers
- Thalassaemia major needs life long transfusion but can be detected at 12-14 weeks in utero for early termination
Pre-pregnancy advice to 28 year old with previous thrombo-embolism - had DVT few days after giving birth
- Complete Hx of DVT, when it happened, how it was diagnosed and how it was treated
- Is she still on anticoagulants
- Screen for current DVT symptoms e.g. SOB, calf or leg tenderness and risk factors
- Family history of clotting disorders
- Birthing Hx
Management
- In consultation with haematologist and obs/gyn
- Clotting/thrombophilia screen which includes anticardiolupin, lupus anticoagulant, Protein C, Protein S, Factor V leiden and anti-thrombin 3. If positive then anticoagulation throughout pregnancy and puerperium is advised
- For this lady with negative thrombophilia screen anticoags atleast peurperium but safer to do from 14 weeks pregnancy to 4-6 weeks postpartum
- LMWH 20-40mg bd
- Increased mobilisation + compression stockings
- Controlled delivery at 38-39 weeks
- Does not cross placenta so nil effects to foetus
- Continue folic acid supplementation
Pre-pregnancy advice for 24 year old with Type 1 diabetes
Commence with:
- History of diabetes i.e. initial diagnosis, current glucose control, hypoglycaemic events and last review
- Issues with UTI or vaginal infetions
- Vision and renal function normal?
- Pre-pregnancy bloods like FBC, blood group, antibody screen, MMR, Varicella, Hep B, Hep C, HIV, syphilis serology, cervical screening
Diabetes specific advice:
- First trimester really important for blood glucose levels to be between 5-7mmol/L to reduce risk of fetal malformation. To reduce risks such as macrosomia and miscarriage other trimesters too
- insulin requirement may increase during pregnancy but will return back to pre-pregnancy levels after birth
- Referral to diabetic physician to ensure no peripheral neuropathy, renal function and opthal review for optic fundi
- If all normal can commence trying and take folic acid supplementation of 0.5-1mg daily (is part of pregnancy multivitamins)
- Midstream urine test to rule out UTI and also ensure not already pregnant
- will be considered high risk pregnancy and will require more frequent monitoring (12 weeks, 18 weeks and 32 weeks)
- will have to plan for possible early delivery
Information of risks to consider before going ahead
- Increased risk of pre-eclampsia, macrosomia and polyhydramnios
- increased risk of unexplained fetal death in utero late pregnancy and respiratory distress at birth
Counsel results to 25 year old primigravida with anencephalic foetus diagnosed on US at 18 weeks with increased alpha fetoprotein
Focused Hx
- regular periods prior to pregnancy
- How was foetus due date calculated
- Taken folic acid in early pregnancy
- FHx of neural tube defects?
- Blood group
- Medical conditions Hx
Diagnosis
- Fetal anencephaly is a defect of the brain that occurs at 6-8 weeks gestation. Condition is always fatal soon after birth.
- Pt has option to terminate or continue until labour occurs (the latter can lead to pre-term labour due to polyhydramnios)
- Medical termination is Mifeprostone on day 1, followed by Misoprostol day 2. Day 2-4 will experience cramping and passage of pregnancy material/clots.
-Pt must be within 2hrs of medical facility, no IUD in utero and not an ectopic pregnancy - D&C not first choice after 16 weeks due to cervical incompetence and must be done in expert hands
Review post medical termination with BHcg and ultrasound
Risk of recurrence of neural tube defects is 2-5% so needs to take 5mg of folic acid daily. When pregnant next time test maternal alpha fetoprotein at 16 weeks, ultrasound at 11-12 weeks
Counsel 65 year old on duodenal ulcer found on colonoscopy following epigastric pain and NSAID use for arthritis
- Contributing factors could be H.Pylori infection (common in duodenal ulcers) or it could be NSAID use
- Await biopsy results and if H.Pylori present treat with triple therapy of PPI + clarithro + ampxycillin and repeat urease breath test at 6 weeks
- Stop NSAID use and swap to paracetamol to aid mucosal healing
- If left untreated can lead to bleeding, perforation and gastric outlet obstruction requiring surgery
- Continue PPI treatment for 4-8 weeks
- tobacco and EtOH impair wound healing
- unlikely to be a malignancy
Autologous blood transfusion on a man awaiting elective surgery
- Will take 2L of blood over a period of 2-5 weeks (approx 450mL each week)
- Blood will start regenerating immediately and back to base line in few weeks
- Blood is good for up to 5 weeks stored at 4 degrees
- Reduces the risk of blood incompatibilities or transmission of blood infections
- Donation doesn’t increase any risks in surgery and the slight low Hb and thinning of blood may assist in small reduction in clot risk
- Risk of needing more blood in which case would need to use blood bank stores.
- Run the risk of surgery being cancelled and blood being unable to be used
Criteria is:
- planned surgery with known date
- expected blood loss
- Hb count > 110 g/L
Smoking cessation in 30 year old man
Questions to ask:
- How many cigarettes a day
- How soon after waking up is the first cigarette
- Do you find it difficult not to smoke in non-smoking areas
- Is first cigarette of the day hardest to give up?
- What is your pattern of smoking throughout the day
- Do you smoke even if you are so ill you can’t get out of bed?
- Have you tried smoking for good in the past but found you could not?
Nicotine withdrawal
- Depression
- insomnia
- restlessness and anxiety
- increased cravings for cigarettes and also sweet things
- weight gain expected of up to 3kg in next 12 months
- Peak withdrawals first 4 days
- most other symptoms improve in another month
- hunger and weight gain for up to a year
Success rate is 45%
QUIT plan
- set a quit date and total abstinence
- trouble shoot previous attempts of quitting
- inform family, friends and other smokers
- Avoid triggers such as a alcohol and caffeine
- Practice problem solve what if scenarios
- schedule regular follow up and QUIT line
- exercise and good diet to be generally healthier
NRT
- check not pregnant or CVD
- overall does will be 40% of what you get from cigarettes but without the carcinogens and will assist in the cravings and withdrawal symptoms
- Patches covered under PBS, but gum and inhalers OTC and can be more expensive (but not as expensive as cigarettes!)
- Gum - 2 or 4 mg chew and when tingling sensation tuck in cheek - can chew every 30 minutes up to 10 times
- Patches - 16mg or 24mg depending on early morning cigarette and used for 8-12 weeks rotating sites to prevent irritation
- alternatively can use buproprion which works on addiction pathways. Currently out of stock in Australia
Counselling excessive alcohol in a 45 year old man
Explain blood results suggesting liver damage of
- elevated GGT
- AST: ALT ration > 1.5 to 2
- Elevated MCV (macrocytosis)
Effects of excessive drinking:
- Affect the gut, cardiovascular system and central nervous system
- Linked with HTN and weight gain
- long term can also damage the part of the brain responsible for balance
- Can contribute to family problems, work issues, minor accidents and sexual performance
- can cause target organ damage
- Compliment him for seeking help
CAGE
- Have you ever felt the need to cut down your drinking?
- Do you get annoyed by criticism of your drinking?
- Have you ever felt guilty for drinking?
- Have you ever needed a drink first thing in the morning?
Normal drinking:
- Not more than 4 standards in one sitting and not more than 10 stds in a week
- A standard is 10grm of alcohol so as strength increases, volume decreases.
- Can give a pictogram to assess his own drinking
- show test results show he is drinking excessively
Dependency
- Social
- Psychological
- Physical dependence
Physical dependency
- Increasing alcohol tolerance
- Withdrawal symptoms of tremor, sweating, agitation, hyperarousal and in worse cases a condition called delireum tremens
- Relief from withdrawal symptoms by further alcohol use or using benzodiazepines
- Explain we want to protect him from social, emotional, behavioral and cognitive sequelae or drinking
Management
- Initial we test his abstinence with being available to assess the degree of withdrawal and symptom management for withdrawals
- Prescribe thiamin daily
- We can use benzos as a short term withdrawal management if needed
- He needs to make the decision and we come up with a plan
- Engage with alcoholics anonymous and happy to talk to his wife
- Offer psychological support and encourage healthy behaviors such as exercise and nutrition focused eating
- Can refer to a dietitian
- Follow up appointment
- EMPHASISE driving under the influence
Type 1 diabetes in 9 year old boy
- need for injections once or twice daily for a lifetime
- Injection by parents and can educate older sibling or other carers
- blood glucose monitor before each meal and at night. Also give ketone test strips for use when sugars consistently high
- informing school and ensuring all carers know what to do in case of a hypoglycaemic event
- Encourage parents to attend school camp as camp parents or ensure school has a policy on how to manage children with diabetes. Want to ensure child has as normal a life as possible
- Sleepovers should be close to parents so can administer insulin and monitor levels and ensure other carers are aware of condition and how to care for the child
- Child can play most sports but insulin dose may need to be adjusted due to increased glucose use.
Request for vasectomy from 36 year old
BEFORE PROCEDURE
- ask background of fertility
- preferable to have consent from wife too (or discussed with wife)
- Not 100% effective - recanalisation can occur
PROCEDURE
- clamping and cutting of the vas deferens
- will affect the sperm but no effect on semen so will still ejaculate
AFTER PROCEDURE
- Semen analysis showing no spermatozoa after 20 ejaculations and the test repeated at least on 2 occasions
- Ensure additional contraception till sperm count is clear
- Reversal success is uncertain and even after microsurgery infertility can persist due to sperm antibodies
- After surgery can experience discomfort, bruising, haematoma and wound infection
- Sexual function can resume once recovered and no effect on libido or function
Day 8 jaundiced baby that had phototherapy on day 2-5 who is breast fed and otherwise well. Serum bilirubin is elevated and nil history of blood or other complications
- Ask about the feeding
- Urine and bowel motions
- Normal weight gain or not?
Breastmilk jaundice
- self limiting condition requiring no treatment
- not necessary but if mother is very concerned can suspend breast feeding for a day and two before remeasuring bilirubin levels but mother will have to keep expressing milk to maintain milk supply
- Nothing wrong with the milk and no phototherapy necessary
- may be a few days to up to 3 months and reassure the parent
A first convulsion in a 14 month old boy who has been sick with a fever
Complete hx of convulsion
- Fever
- Current status of child
- Focal neurological deficits such as clumsiness
- Paeds BINDS Hx
- FHx
Febrile convulsion
- 3% of population has seizure as reaction to fever
- Generally benign condition
- commonly runs in family
- Fever is almost always caused by a virus
- Seizures do not cause brain damage or subsequent epilepsy
- 30% chance of recurrence in first 24 hours so when running temp useful for tepid sponging and antipyretics
- Very unlikely to be epilepsy given lack of family history, no prolonged convulsions, focal element and no abnormal development before seizure)
- If any concerns can return for review
- If happens again keep child safe
Loud and disruptive behavior of a 6 year old boy
Hx should include
- Hyperactivity symptoms
- Sleeping patterns
- Frustration
- School progress i.e. interruptions, friendships, class work
- Home situation - lack of attention, attention seeking, sibling relationship and stable home environment
- Family Hx
Hearing and vision - ALWAYS CHECK
ADHD - must explore other causes first
Management
- Refer for psychometric testing
- May require input from paediatric psychiatrist or paediatrician to get diagnosis and try stimulant medication
- Ensure all other causes are excluded
Tremor in 40 year old man
Targeted history should ask:
- how long has it been there for and when has it started becoming a problem
- Is it just hands or head shakes as well?
- How does it affect activities of daily living? Can you do up buttons, can you cook, can you hold cup of tea without spilling?
- What makes the shakes better?
- Worse in the morning or when going to bed?
- Any hand particularly worse
- Any stiffness or trouble moving from one position to another?
- Any issues with walking?
- Can you stop the shakes by gripping something or someone holding onto your hands?
- Is voice affected?
- Are you a stressed or nervy person? Does stress make it worse?
- Full systems review
- FHx
- Alcohol history
- Smoking history
DDx
- Benign tremor
- Tremor associated with heavy drinking
- Anxiety
- Parkinsonism
- Thyrotoxicosis
Physical signs
- Hepatomegaly, stigmata chronic liver disease, cerebellar signs, increased muscle tone, tachycardia, cardiomegaly
Ix
FBC, LFTs, TFTs
Headache in a 35 year old
Hx
- SOCRATES
- Rule out VIVID (vascular, infective, vision changes, raised ICP and carotid dissection)
- Recent change in chronicity
- Acute Pt concern
- Identify triggers/life stressors
- PMOSC
- MHx, Rx, FHx, SHx
Physical examination
- Inspection of head and neck testing for neck stiffness
- Neurological exam including ophthalmoscope
- Cardiovascular including blood pressure
DDx
- Tension Headache
- Migraines
- Cluster headache
- Raised ICP
- Cervical spondylosis
Pt education and reassurance
Arrange follow up
Lethargy in 50 year old woman
Hypothyroidism questions
- slow and tired
- weak in muscles and body
- Put on weight
- Constipation
- Changes to voice
- Concentration
- mood
Physical exam
- Thyroid exam
Ix
- FBC (rule out anaemia and blood disorders), iron studies, B12, CRP/ESR , TFTs
DDx
Spontaneous atrophic hypothyroidism which will respond to thyroxine
Syncope in a 52 year old man
Hx
- Confirm loss of consciousness
- event before, during and after
- Any previous dizzy or fainting spells
- Any convulsions, vertigo, numbness/tingling, loss of vision, headache, palpitations or heart beating abnormally?
- Loss of bladder or bowel?
- SOB, PND, Orthopneoa, chest pain, dizziness, ankle swelling?
- Systems review
- Last time cholesterol was checked?
- MHx, Rx, FHx, SHx
Examination
- Cardiovascular exam
- Neuro exam
Aortic stenosis
Syncope (exertional)
Angina
Dypsnoea
Aortic stenosis management
- ECG and ECHO
- Chest-Xray
- FBC
- Referral to cardiologist
Painful penile rash in 23 year old
Hx
- Complete HOPC
- Sexual Hx
- Med Hx, Rx, SHx
DDx
- Herpes simplex virus
Ix
- Pt education and explanation
- Confirm diagnosis with viral swab
- Consent for STI screening of chlamydia, gonorrhoea, syphilis, HIV swabbing from oral, genital and anal regions and bloods for serology
- Antiviral treatment such as aciclovir or valaciclovir for treatment (and recurrence)
- topical povidone-iodine and lignocaine cream
- salt baths, ice packs, loose fitting clothing
other info
- first attack lasts 2 weeks
- recurrence rate is 50% often at times of stress and associated with shooting pain in buttocks and legs
- Regular STI screening and use of condoms
Primary amenorrhoea in 18 year old
Hx
- Growth spurt when? (approx 3 years ago)
- Breast changes
- Pubic hair
- Mother had period at 17 years of age
- Sister hasn’t started breast development at 14
- Never been sexually active
Examination
- BMI?
- Tanner stage for breast and pubic hair?
- BP?
- Can do vaginal inspection but no bimanual or speculum
Ix
- Abdo/Pelvic US (NOT transvaginal)
- FSH, LH, Prolactin and oestradiol
- If tests above normal don’t need to do chromosomal test for turners
Management
- Reassurance and period starts 2-3 years after breast development
- Review in 12 months if still no period at which oestradiol levels will be repeated
Skin lesion on cheek of 50 year old male
ulcerated BCC
- ensure sun exposure history
- Skin excision with wide margin - on face so can refer to plastics if needed
- avoiding direct sunlight, be sun smart wearing broad rimmed hat, long sleeved shirt and sunscreen
Pigmented mole on the trunk of a 30 year old woman
Dark mole changed over last few months
Ask if itchy, bleeding, ulcerated etc
Should suspect a dysplastic naevus requiring an excisional biopsy
Itchy rash on hands of 19 year old
HOPC
- SOCRATES
- Worse with hot water or heat
- Alleviated with what?
- anyone else with same symptoms?
Examination
- Skin scrapings taken if suspect scabies
Management
- Pt education and counselling that not serious and partner needs to be treated
- Apply lyclear cream from jawline down on every surface
- no scrubbing or scratching before
- Treat household contacts even if asymptomatic
- wash clothing and bedding in hot water and dry in sun (can use hot iron after too)
- Repeat treatment in a week if infestation is severe and avoid sexual contact until everyone is treated
- itch may persist even after treatment
Red painful dry hands in 30 year old brick layer
Concrete worker and hands better when on holiday
Allergic contact dermatitis
- Soap free wash
- moisturise at every opportunity
- use gloves and barrier creams - can use tough hands designed for cement workers
- topical steroids when bad
- if signs of infection will need antibiotics
- can use wraps at night to help heal the hands if really bad
Swelling of both ankles in 53 year old
HX
- bilateral or unilateral
- Pain, redness or discoloration
- SOB, dizziness, palpitations, PND, orthopnoea, OSA, chest pain
- symptoms on exertion and ADLs atm
- Fevers or resp symptoms
- system review
- Med Hx Rx, Allergies, Fhx, SHx
- last time did a medical check up?
Examination
- Cardioresp
- abdo for liver or kidney stigmata
Ix
- Urine analysis
- ECG, ECHO, Chest X-ray
- Wells Criteria
- FBC, UEC, LFTS, Trops and BNP
HF Acute = frusemide + dobutamine
HF GP setting = Cardiologist directed ACE, A2RB, betablocker, spiranolactone and SGLT2 inhibitor, entresto + frusemide for symptomatic relief
Assessment of a comatose patient
GCS
Eyes (4)
- spontaneous,
- sound,
- pain
- none
Verbal (5)
- Oriented
- Confused
- Words
- Sounds
- none
Motor (6)
- Obeys commands
- Localising to pain
- Withdrawal from pain
- Abnormal flexion (decorticate posturing)
- Extension (decerebrate posturing)
- none
Examination
- A to E assessment
- General examination for evidence of injury
- Examine eyes and pupils
- GCS
- neck stiffness
- Check arms for IV drug abuse
- check BGL
Differentials
- drug overdose
- meningitis
- head injury
- hypoglycaemia
Ix
- vitals
- ECG
- Brain CT/MRI
- Chest X-ray
- Consider lumbar puncture
- FBC, UEC, LFTs , CRP
- UA and tox screen
Recent onset of poor distance vision in 17 year old male
- exclude serious eye disease on examination
- snellen chart
- explain findings
Exclude serious eye disease
- Change in eyelids (ptosis, lid retraction)
- conjunctiva (injection, pallor, chemosis)
- cornea (ulcer)
- anterior chamber (pus or blood)
- sclera (jaundice)
- orbit (tenderness, parasthesia)
- eyeball (IOP, glaucoma)
Would use opthalmoscope for:
- red reflex
- examine retina (for detachment, exudates, haemorrhage, new blood vessels)
- optic disc (bulging, blurring of margins)
- macula (exudates)
Would complete with flouroescene, slit lamp visualisation, dilatation of pupil, tonometry and pin hole
Pinhole test - see through 1mm and if visual acuity is not improved then issue is not refractory error and could be cataract, glaucoma or macular degeneration
Visual acuity
6 metres from snellen chart
Myopic has better vision at near distance
Hyperopic has better far distance vision
Numerator is always 6 and denominator changes
6/6 = normal vision
6/12 = vision required for drivers licence
6/60 = legal blindness
MYOPIA
- Commonly inherited condition due to axis of eyeball being too long
- vision corrected by using concave lenses (minus) prescription
- will worsen in early adult life and then improve
- Refer to optometrist and regular follow up to ensure screening for glaucoma
Painful rash on the trunk of 45 year old child-care worker
Hx
- SOCRATES of rash
- Constitutional symptoms (rule out malignancy)
- Systems review
Dx:
Herpes zoster (shingles)
Mx:
- symptomatic treatment with zostrix cream, calamine, cold compress
- pain relief +/- codeine
- if within 72 hrs valaciclovir
- monitor for postherpetic neuralgia
- malignancy screening (complete examination and bloods)
- contagious so exclusion from work at childcare and avoid contact with immunosuppressed and pregnant women
Acute low back pain in 30 year old
Hx
- SOCRATES of back pain
- numbness/tingling down legs
- saddle anesthesia or incontinence?
- Trigger?
- Constitutional symptoms
L5/S1 Herniation of disc after heavy lifting
- Explain slipped disc with diagram (or bulging disc)
- Very common when lifting heavy load
- With adequate rest can go back to work in 1-2weeks. If pain doesn’t settled will do a back MRI
- No chiropractor but can see physio if needed to strengthen core and remove load off back
- no specialist, no operation and it should resolve
- pain relief of NSAIDS and temp Panadeine forte
- lack of resolution may involve ortho, neuro or rheum
REASSESS
- essential in 2-3 days
PREVENTATIVE
- back strenthening
- stretching
- correct lifting techniques
- walking and swimming
Fever and recent rash in 42 year old
Complete systems review
Sexual History
Consent for:
Blood tests, viral panels and a complete STI screen including HIV screening
DDx:
HIV
CMV
EBV
syphilis
Rubella
toxoplasmosis
Hepatitis A-E
Gonorrhoea
Management:
PPE
Cardio-resp-abdo-Haem/immune exam
Vitals
Bloods for Ddx above and LFTs
PEP/treatment with antiretrovirals
Pt education on safe sex and consent
Heart murmur in 4 year old boy
Soft cardiac midsystolic murmur (2/6) in otherwise normal and healthy child with no symptoms is considered to be normal
Reassurance
- 50% of normal 4 year olds have an innocent murmur
- child is otherwise well and can continue to be active
- if patient shows concern can refer to cardiologist but unnecessary
- can do chest-x-ray and ECG to reassure parents
- continue monitoring child expecting murmur to disappear between ages 5-7
Focused examination of knife wound in the wrist of a 25 year old
- Loss of sensation to palmar surface, back of fingers, over the nails and end of joint
- Nil flexion of fingers or thumb
- Extension of fingers intact
- Nil wrist flexion
- Wrist extension intact
Extensive injury to:
- Median nerve
- ulnar nerve
- arteries (although not affected viability of the hand)
Affected tendons are:
- wrist flexors (flexor carpi radialis, ulnaris)
- finger flexors (flexor digitorum superficialis and profundus)
- thumb flexors (flexor pollicus longus)
Neurological effects:
Paralysis of thenar and hypothenar muscles preventing:
- Palmar abduction of thumb (abductor pollicus brevis - median nerve)
- abduction of little finger (abductor digiti minimi - ulnar nerve)
- flexion of MP joints fingers and thumb (ulnar and median nerve)
- ab/adduction of fingers - ulnar nerve
- opposition - median and ulnar nerve
- adduction of thumb - ulnar nerve
Sensation - median and ulnar nerve injury
Dorsal cutaneous branch of ulnar nerve has been spared
Multiple skin lesions in a QLD family
Pictures
1. SCC of lip
2. 50 yr BCC of neck
3. Father seborrheic keratosis
4. wife malignant melanoma of leg
5. 52 yr benign spider naevus on chest
6. benign melanocytic dermal naevus of face
Examination of the knee with recurrent painful swelling after an injury
Complete knee exam plus quads strength
Compare both knees
Test ligament strength
Dx
- medial meniscus injury/tear
- traumatic osteochondritis/synovitis
Assessment of hearing loss first noticed at pregnancy of 35 year old
Otoscopy, rinnes and weber test
- Refer to audiologist and ENT
- suspicion for otosclerosis
Examination of a 20 year old who dislocated her shoulder 6 months ago
Shoulder examination
- Shoulder dislocation always examine axillary nerve
- Can return to basketball but likelihood of recurrence so need to get physio to strap the shoulder before each game to reduce the likelihood
Assessment of groin lump in 40 yr old
Hernia exam
- Ask patient to reduce hernia if they can
- Standing and lying down is better
Eye problems in an aboriginal community
- Chlamydia trachomatis transmitted by flies, hand contact and fomites
- most common cause of infective blindness and most common in poverty stricken areas and marginalised sections of society
- recurrent infection causes conjunctival inflammation and scarring of tarsal plate distorting eyelash growth and causing corneal abrasions, infections and damage to eyes
Treatment is:
- surgery
- azithromycin abx treatment
- facial cleanliness
- environmental upgrade
Positive test for Hepatitis C in 26 year old
Hx
Method of transmission
- Sexual Hx
- IV drug use
- Blood transfusion
- Travel overseas and use of a sex worker
- Current profession (needlestick injusry)
- Tattoos or body piercing
- Any family history of hepatitis
Systems review and signs of hepatitis
Pregnancy or family planning
Ix
- LFTS
- HCV PCR to see if infection is cleared by body
If ALT is persistently normal (3 times over 6 months) then prognosis is good and no long term effects to liver
If ALT is elevated will need to refer to Hepatologist for biopsy, complete liver assessment and commencement of antiviral treatment. Ultimately liver failure and liver transplant will be needed if untreated and high risk of HCC
Pregnancy should not be allowed for next 6 months whilst undergoing treatment due to tertogenicity. There is a 5% chance of vertical transmission to baby with a positive PCR test.
Further information
- notifiable disease with confidentiality maintained and contact tracing
- prevention of spreading by blood to blood transmission including not sharing razors or toothbrushes
Diagnosis of brain death prior to organ donation
Law in australia to certify death is by either of two methods:
1. permanent and irreversible cessation of heart beat and loss of cardiac function
2. permanent and irreversible loss of brain function
When brain dead -> can’t breath and permanent death of brain stem the organs are artificially kept alive artifically and organs have a time window
Brain death has to be confirmed by 2 doctors and nil responses present
Breast biopsy concerns in 20 year old with family history of breast cancer
- reassurance of fibroadenoma
- Reassurance it is benign
- Very common, do not require excision, not cancerous and do not become cancerous
- Reassurance that biopsy takes several representative pieces and can save unnecessary surgery
- homogenous lesion like this a biopsy can be relied on for diagnosis
- sympathy for pt concern and regular monitoring and noninvasiveness of US
- Whatever patient decideds periodic followup and routine screening
Elbow injury in 11 year old girl
- Fractured the arm bone (humerus) just above the elbow but there is no displacement and no complications so she will get full functional movement back
- back slab/plaster/splint for 4-6 weeks with paracetamol as pain relief when needed
- Needs to report immediately if hand or fingers swell
- Follow up next day to ensure plaster etc is comfortable
- sleep with arm supported on pillow
- Subsequent unrestricted use of hand and fingers
- can write as soon as can use fingers and back to school in a day or two
Screen for brachial artery injury - 6 Ps of limb
Sudden onset of chest pain and breathlessness in 20 year old
A spontaneous pneumothorax with collapse of right lung
25-30% collapse and symptomatic = drain insertion but can admit for observation
35% recurrence rate on same side and 10% on opposite side
Information
- causes is rupture of bleb on surface of lung
Investigation for male factor infertility in 25 year old
Hx
- Occupation
- contact with chemicals
- surgery or trauma to groin
- smoking and alcohol
- medications
- recreational drugs
- anabolic steroid use
- mumps or other viral infections
- any illnesses or use of abx in last 3 months
Counselling
- one specimen is insufficient and ideally need 3 samples 3 months apart
- unlikely a cause of abnormal sperm can be found
- FSH and testosterone levels to be tested.
- IVF with intracytoplasmic sperm injection has a 40% chance of fertility each cycle but expensive process
- can also use sperm donor but might not be palatable to couple
Acute chest pain in 60 year old
Morphine, Oxygen, Aspirin, GTN
ECG repeated 0 and 2 hrs with trops and every 30 mins
CXR
Return to cardio questions 65 and 66
Muscle weakness and urinary symptoms in 60 year old
identify weakness, prostatism, fear of cancer and new medication thiazide
Exam
Vitals + neuro + PR
Ix
ECG, Urine dipstick, Urine MC , FBC, UEC, PSA
Aches and pains in 62 year old
Polymyalgia rheumatica
Examination
- Vitals
- Neck, shoulder trunk muscles movement
- Power tone and reflex
- examination of joints
- lymph nodes, abdo and resp exam
Further tests
- ECG
- FBC, UEC, CMP, ESR, CK, CRP, Urine bence jones protein, anti-CCP, RF, ANA
Lack of energy in 56 year old sun tanned man
Haemachromatosis exam
- joints
- vitals
- skin discolouration
- abdomen - liver
- genetalia - smaller
- Urine dipstick - diabetes
Ddx
Haemachromatosis
Cushings
Addison
Chronic renal failure
hyperthyroidism
drug toxicity e.g amiadarone
Ix
FBC
Iron studies
ESR
UEC
LFTS
TFTs
Hemochromatosis gene
Haematemesis of 50 year old man
A to E assessment
Vitals
Complete abdomen exam for chronic alcoholic liver disease
PR exam looking for maleana
Anaemia in 28 year old pregnant woman
find reason for anaemia
- menstrual loss
- multiple pregnancies close to each other
- thalassemia minor (mediterrenean back ground?)
- been bleeding at all?
Ix
Iron studies
FBC
Haemaglobin electrophoresis
Mx
Iron supplementation and review - no need for blood transfusion
6 week old vaccinations information station
NHMRC immunisation guidelines
Birth = Hep B
2 & 4 months:
- DTP
- HiB
- Polio
- Hep B
- rotavirus
- Pneumococcal
6 months:
- DTP
- Polio
- Hep B
- Hib
12 months
- HiB
- MMR
- Meningococcal ACWY
- Pneumococcal
18 months
- DTP
- MMR
- Varicella
- Hib
PSGN after impetigo
Mx
admission to hospital
Strict fluid balance
Regular 4 hry BP and vitals and urine test
Daily weight
High carb, low protein, low salt diet
Antihypertensive treatment
Penicillin therapy under renal physician
Future
- on going BP and renal function
- regular urine analysis
- long term prognosis is good
