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
