medicine osces - organized

8/15/2019 Medicine OSCEs - Organized

1/23

TIPS

• Introduce yourself

• Always confirm age, occupation

• Allow patient to state their chief complaint

•Always ask about: pmh, meds, allergies, smoking, alcohol, family history

Don’t forget to drape

Cardio/vascular

1. htn2. calf claudication

. rd degree heart block

!. post "I mgmt#. chest pain

$. palpitations%arrythmia

&'A"I(& 2) *.+ &"A-& I/0 0*&/&(3I+(&: DD', I(4&3/I5A/I+(3, 0A/ /+ D+ I *+6 I(4&3/I5A/I+(3 A&

(+"A-

&'A"I(& "A( I/0 7A- 7-A6DI7A/I+(

&: I(/&&/ &85, I38 A7/+3, I(4&3/I5A/I+(3

709 "ed. ) yo lady collapses at mall, -+7, brought to & by ambulance, granddaughter with

her to answer ;uestions. 9 )%!), 0 !). "anage.

Findings: patient complained of shortness of breath, heart pounding, dizziness justbefore fainting. Has history of hypertension, no other cardiac history. EKG shows third

degree heart bloc. Granddaughter mentions that she!s on digo"in, but the nurse

wouldn!t gi#e me the le#el. $ou!re supposed to treat this as an acute coronary%&'() station.

57 yo man one month post MI

History

< chest pain < +=3/, pleuritic, same type as before>

< e?ercise tolerance and 773%(*0A class @based on B 2 blocks on flat surfaceC

< palpitations, 3+9, orthopnea, (D, diaphoresis, (?%4?

< cardioascular risk factors < D", 0/(, smoking, pre "I, fam h? "I, incr. chol also

ask re: obesity, sedentary lifestyle, depression

< medications < compliance with meds, difficulty in taking meds>


2/23


3/23

• Associated 3ymptoms

• (, 4, diaphoresis, palpitations, dyspnea, orthopnea, (D

• 7AD isk factors

• 3moking, D", 0/(, hyperlipidemia, fam h? @first degree relatie H male## yo, female$) yoC

• "0• Also, preious cardiac disease

• "eds

#oman $ith acute MI complains o% chest pain

0istory

• chest pain

• associated symptoms: nausea, omiting, 3+9, diaphoresis

• preious history of chest pain

• cardiac risk factors

• past medical history

• family medical history

• medications, allergies

• social: smoking, alcohol

hysical &?am

• general appearance

• itals

• chest e?am

• cardiac e?am

Inestigations

• 797, lytes, 96(, 7r, A3/, -D0, 9ili, /, //

• 78%78

• 7 B1) min of chest compressions within weeks

• pregnancy

Indications for Angioplasty

• trend toward lower mortality, less reinfarction, fewer strokes when compared to

thrombolysis


4/23

• as effectie but not superior to thrombolysis plus A3A

• considered for those in which contraindications e?ist for thrombolysis

• emergent in all patients with shock

&' yo $ith palpitations! irre"ular rhythm and %ati"ue ( h)

0I:


5/23

*esp

1. 3+9 and sputum

2. hi with 3+9

. pneumonia!. & post s?

#. 7oumadin mgmt

$. deeloped hemoptysis, on coumadin for afib, wants another doctor @cleoC

K. resp e?am H emphysema, consolidation, dec lung olume

/A8& 0I3/+* +" "A( I/0 3+9 A(D 36/6"

&: & ', I(4&3/I5A/I+(3, AD4I7& &: &4&(/I+(

A. 0I4 patient with increasing e?ercise intolerance and dyspnea, now dyspneic at rest.

hysical e?am.9: interpret 7'ay, Dd?, ?

neumonia "ed

!. !2 year old male presents with cough, temp and pleuritic pain on right side of chest.Do focused physical.

indings: itals stable e?cept high temp. Decreased breath sounds on right, no tenderness

to palpation.=uestions: interpret 7' @"- consolidationC. hat is diagnosis and what is etiology

@7A, 3. pneumoniaeC> rite a script.

) " presents with cough, sputum, pleuritic chest pain. Do physical e)am+&: @1C Interpret 7' @"- infiltrateC

@2C hat is the diagnosis @7AC@C hat is the most likely pathogen @). pneumoniaeC

emale $ years old ! days post 5I surgery with 1# minutes of 3+9. hysical e?am.

oman in $)Es discharged ! days ago from hospital with &. as on # mg of coumadin

+D, discharged with I( of 2.). I( today 1.). 7ounsel and manage.

#$ " presents with hemoptysis. +n coumadin for A fib. 0as long standing hemoptysis

but now worse. &?


6/23

.7 yo man to e e)mained %or decreased lun" volume in le%t hemithora) ( %ocus

posterior chest

Physical E)amination -

Inspection < resp. distress @>parido?icalC, cyanosis, indrawing, tracheal tug, chestmoement @symmetryC, use of accessory muscles

alpation < tactile fremitus


7/23

• (eck H accessory muscles

• 7hest H A dia., deformities, indrawing, assymetry

• esp rate and pattern

• 0ands H clubbing @not seen in emphysemaC, nicotine stains

• alpation

• /rachea H position and mobility

• 7hest e?cursion

• Diaphragmatic e?cursion

• /actile fremitus

• ercussion

• -ungs H hyperresonant> H compare sides

• -oss of cardiac dullness

• &uscultation

• 9reath sounds

• 4ocal resonance

• &/: normal indiiduals can empty their chest from full inspiration in ! seconds or less. /he end

point of &/ is detected by auscultating oer the trachea in the suprasternal notch. rolongation

of the &/ to more than $ seconds indicates airflow obstruction

• Don’t’ forget middle lobe, anterior and posterior chest

*espiratory e)am – consolidation

3ee L$ aboe for more complete e?am

3alient features:

• urulent sputum

• /achypnea

• educed moement of affected side

• /rachea central

• Impaired percussion note

• 9ronchial breath sounds• crackles

ost*e"am probe: " ((( cracles

• 7ongestie heart failure

• +bstructie lung disease

• Interstitial fibrosis

• neumonia

• Atelectasis

• ulmonary embolus

• 9ronchogenic carcinoma

• 9ronchitis

• 9ronchiectasis

• (on


8/23

• Inspect: cyanosis, accessory muscle use, A diameter

• alpate: tracheal deiation, respiratory e?cursion

• ercussion: diaphragmatic e?cursion, lung areas

• Auscultate

• 3pecial tests: tactile fremitus, whisper pectorilo;uy, egophony

PEP

• crackles at bases: atelectasis, pneumonia, upper border of effusion, pulmonary edema

• pneumonia < community ac;uired

• not seere, $# years: ). pneumoniae, /ycoplasma, 'hlamydia

• treatment: macrolides, or tetracycline%do?ycycline

• not seere, B $# years M%< comorbid: &bo#e 0 H. flu, Klebsiella, )taph,

(egionella

• treatment: e?tended gm negatie coerage N cefuro?ime,

clarithromycin

• treat i. until afebrile !


9/23


10/23

• 5eneral appearance

• 4itals

• 7(3 status: alert or decreasing -+7

• Abdomen: M *ECTA1 for melena, +9 positie blood

• 3igns of chronic lier disease

2. yo man re3uires a 1iver E)amination

E)amination o% the liver-

6pon inspection


11/23

• Icterus, cyanosis, parotid enlargement, fetor hepaticus

• 'hest

• 3pider nei, loss of a?illary hair, gynecomastia

• &bdomen

• 3plenomegaly, ascites, hepatomegaly, caput medusae

• G2

• /esticular atrophy, loss of pubic hair

• (eg edema

Melena – history

• 3ee upper 5I bleed

.5 year old $ith ado cramps and diarrhea %or $ee6s ( History

ID:0I:

history of diarrhea:

;uantify: olume, fre;uency @is it really diarrhea> defn: increase in fluidity and%fre;uencyC

;uality: colour, consistency, presence of melena, hematocheFia @blood N catharticC

associated symptoms: tenesmus, relief with defecation, urgency, nausea%omiting

history of cramps: +=3/

+nset: sudden s gradual

osition: where are the crampsroocating%alleiating factors: foods, @chocolate, peppermint, caffeineC, alcohol, drugs,

stress, actiity, etc.

=uality: what do the cramps feel like @true crampy pain s sharp%dull, etcC

adiation of pain3ymptoms associated: feer, myalgias, weight loss, chills @and those aboeC

/emporal profile: progression of symptoms with time

risk factors for infectious: daycare worker%children at daycare, outbreaks

! mechanisms of diarrheaabnormal intestinal motility

increased permeability causing fluid%electrolyte secretion

impaired intestinal absorptionintraluminal nonadsorbable osmotically actie solutes

&tiology of Acute diarrhea:Infectious

bacterial @salmonella, shigella, campylobacter, ibrio cholerae, enteropathogenic &coli,

7.diff, yersinia, 4ibrio parahemolyticusC4iral @enteroirus, hepatitis


12/23

rotoFoal @giardia lamblia, entamoeba histolytica, cryptosporidium, Isospora belli,

blastocystis hominisC

0elminthic/o?ic

bacterial to?in @food poisoningC: staph, clostridia, &.coli, pseudomonas

chemical poisons: lead, mercury, mushrooms, arsenicDietary

irritating foods, alcohol, drugs, nonabsorbable sugar substitutes @sorbitol, mannitolC

"iscellaneousappendicitis, dierticulitis, 5I hemorrhage, pseudomembranous colitis, fecal impaction,

ischemic colitis, 03, 3teens


13/23


14/23

9ephro

1. oliguria H renal failure

.5 yo %emale $ith h) o% oli"uria ( ie *enal 4ailure

/hink pre


15/23

• oor cardiac output @70, tamponade, "I, &C

• 3?:>D+&, orthopnea, (D, ankle edema

• recipitants: "I, 0/(, alular heart disease, congenital heart disease, pericardial disease,

cardiomyopathy, &, fluid oerload, sodium retention, salt oerload, dysrhythmia, beta

blocker, renal disease, anemia, feer and infection, pregnancy, noncompliance with meds or

diet.

• isk: 7AD, 0/(, cardiomyopathy• 3hock%sepsis H feer, chills, focus of infection

• enal

• 5lomerular nephritides

• /ubular interstitial H pyelo, hypercalcemia

• A/( H recent surgery

• (ephroto?ic agents H antibiotics, contrast dye, anaesthetics, (3AIDs, chemo

• 4ascular problems H emboli, renal essel thrombosis

• ost


16/23

Heme

1. purpura%epista?is

2. low blood counts M peripheral neuropathy

. haemolytic transfusion reaction%error !. lymph node e?am, lymphoma

#. asymptomatic anemia

$. spleen e?am, read peripheral smears and protein electrophoresis

&'A"I(& *+6(5 +"A( I/0 66A A(D &I3/A'I3

&: 0', D', I(4&3/I5A/I+(3

(euro%heme topic:

$) yo m came to "D a few days ago (. *our office partner did a

797 "74 12), anemic, low 97, low plts. /ake a releant h?. +%&: eripheralneuropathy, probs walking at night. /ingling. 3ome mental symptoms.

(o consitutional illnesses as far as I can remember. (o &/+0. ritten: gie most likelyd?, gie 2 other possibilities for the neuropathy @I said peripheral neuropathy 2ndary to

lymphoma, gastric, causing b12 deficiency, or D"C. 5ie 2 tests you want. t tells youhe is a bus drier and he has forgotten to make 2 pickups this week. 0ow do you counsel

him>

0emolytic transfusion reaction % error

Head and 9ec6 E)am / E)amine 1ymph 9odes aove the diaphra"m

E)amination o% 19;s aove diaphra"m

< e?amine the following


17/23

II < two or more -(Es on the same side of the diaphragm

III < -( on both sides of the diaphragm, spleen may be inoled

I4 < diffuse inolement of e?tra


18/23

chemical agent @drugC

infection @malaria, septicemiaC

neoplasm @especially lymphomaCconnectie tissue disease @lupusC

splenomegaly

immuniFation @newborn, transfusionC

0I3/+*

ID: age, se?, occupation

0I: how was anemia picked up @i.e. why had 797 doneC


19/23

microcytic anemia: with target cells suggests thalassemia

hemolytic anemia: macrocytes and microspherocytes with polychromasia @more purpleC

sickle cellaplastic anemia @marrow full of fat cellsJlooks emptyC

hypersegmented "(s @B!


20/23

*heum

1. back pain

2. Goint pain

-


21/23

Supine


22/23

• +": actie, passie, against resistance @ to detect lesions in tendons and to measure powerC

• 3upporting 3tructures: look for instability

• Also: neuro, power, ascular, skin lesions

55 year old $oman $ith 8oint pain ( history

•

Goint pain: location, onset%duration, swelling, function of Goint, AD-s• characteristics: morning stiffness, worse after rest%actiity

• course: hae you eer had it before @chronic%subacute%acuteC

• pattern of Goint inolement: other Goints

• e?tra articular features: skin, eyes, bowel, kidney, lung inolement, urethritis,

cericitis, 3I Goints, enthesitis

• constitutional symptoms


• family history @arthritis, collagen ascular diseasesC


•

social history: smoking, alcohol, se?ual historyPEP

• comment on ?


23/23

• course: hae you eer had it before @chronic%subacute%acuteC

• pattern of Goint inolement: other Goints

• e?tra articular features: skin, eyes, bowel, kidney, lung inolement, urethritis,

cericitis, 3I Goints, enthesitis

• constitutional symptoms

• se?ual history


• family history @arthritis, collagen ascular diseasesC


• social history: smoking, alcohol

PEP

• ?ray: periarticular osteopenia, erosions

• management of A

• patient education, e?ercise, /, +/

• symptomatic treatment: (3AIDs, corticosteroids @intraarticular%systemicC

• D"ADs

• 0ydro?ychloro;uine @antimalarialC: dose !)) mg%day

• si? month trial

• hyperpigmentation, myopathy, rash, diarrhea, retinal to?icity

• baseline +phthalmologic e?am ; months

• "ethotre?ate @folic acid antagonistC

• starting dose K.#mg%week p.o., inGection, increased to

2#mg%week

• response within $

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