Feed Your OSCE Skills (2014)

Feed Your OSCE Skills (Total of 99 Stations)

OSCE Study Guide [4th Year Medicine] Goal: This exam tests history taking, physical examination, patient education, communication, diagnostic/management decisions (incl prescriptions, referral, admission to hospital). YOU ARE the family doctor! Overal Competency Includes: 1. Introduction of self. Define objective. Be respectful. 2. Body language is important: eye contact, appropriate speech and expressions 3. Listening skills: encourages discussion, interrupts only when needed 4. Use open-ended questions but when required uses closed-ended questions to attain data 5. Logical organization of interview 6. Summarizes each interview by Hans April 2014

Section I The Bread and Peanut Butter Stations (60 Stations)

Notes:  These are the stations that you should have down cold. The majority of the stations will likely come from these examples.  Questions were culled from the CFPC 99 Topics of Family Medicine

Combined Stations (7 Stations) 65yo F comes in with a decrease in hearing. Take a hx and px. Conductive vs Sensorineural hearing loss: obstruction, otitis media, TM perforation, presbycusis, noise, ototoxic drugs (aminoglycosides, furosemide), Meniere's dz (min-hrs; triad of tinnitus, hearing loss, vertigo), MS, CVA, congenital (TORCH)

1. HPI  Onset, sudden/gradual, both ears  Hearing voice not understanding, men's voice easier than women's  Pain/fullness, discharge, ringing, vertigo  Congestion, headache  Dry eyes/mouth, oral ulcers, joint pain 2. Meds/OTC/Allergies  Aminoglycosides, furosemide 3. PMHx/Surgery/Hospitalization  DM, HTN  Head injuries, stroke  Ear syringed, hearing test, ear infections 4. Social Hx  Smoking/ETOH/IVDU  Occupation, noise exposure, ear protection 5. Family Hx  Hearing loss, Meniere's dz, MS Physical Examination  Vital signs 1. Inspection  Asymmetry, bruising, mass, tenderness, rash  Nasopharynx masses 2. Ear Exam  Otoscope  Finger rub test, Weber's (lateralization), Rinne's (AC>BC) 3. CN Exam  II, III/IV/VI, V (corneal reflex), VII [cerebellopontine angle ]  Pronator drift, finger-to-nose, repetitive movements 25yo M sprain ankle while running. Do a focused hx and px exam. Anterior/posterior talofibular, calcaneofibular strain, fibular #, tibial avulsion #, metarsal/calcaneal stress #, base of 5th metatarsal #, arthritis, tendonitis (posterior tibial, peroneal), plantar fasciitis, tarsal tunnel syndrome, bony heel spur, Morton's neuroma

1. HPI  Mechanism of injury, previous injury, wt bearing, pain (PQRSTPP)  Swelling, skin changes, stiffness/locking/grinding  Head injury, vertigo, visual changes

 CP/SOB, palpitations 2. Meds/OTC/Allergies  Steroids, pain killers 3. PMHx/Surgery/Hospitalization  DM, HTN  Previous falls  Bleeding d/o, osteoporosis 4. Social Hx  Smoking/ETOH/IVDU, occupation, handedness Physical Exam 1. Inspection  Examine hands for nodes (Heberden's DIP and Bouchard's) and OA  Exposes up to knee, gait, heel/toe walk,  Swelling, Erythema, Atrophy, Deformity (symmetry of feet, toe alignment, foot arches, heel alignment [varus/valgus], Achilles tendon), Skin (color, warmth, scars, lesions, wounds) 2. Palpation  Compare temperature, pulses,  Squeeze MTPs, palpate Achilles tendon  Lateral/medial malleoli, proximal fibula, base of 5th metatarsal, navicular  Ankle joint, tarsal joint, subtalar (talocalcaneal joint) joint, 3. ROM  Plantar/dorsiflexion, inversion/eversion  Toe flexion, extension, adduction, abduction  Anterior drawer test (ATFL), Thompson test  Examine Knee/Hip 4. Neuro  Tone, Motor (L2 – hip flexion; L3 – knee extension; L4 – inversion of foot; L5 – extension of great toe; S1 – eversion of foot)  Sensory (L2 – lateral thigh; L3 – middle knee; L4 – middle ankle; L5 – 1st web space; S1 – lateral foot) [light touch, pin-prick, vibration]  Reflexes (L4 – patellar; S1 – achilles, Babinski, clonus) PEP Questions  What are the 3 views of the ankle? AP, lateral, mortice  What is the most common ankle sprain? Lateral, anterior talofibular ligament  Weber Type A (below ankle joint, syndesmosis intact), Type B (at ankle joint, oblique, syndesmosis intact or slightly torn), Type C (above ankle joint, syndesmosis disrupted, requires ORIF) Ottawa Ankle/Foot Rules (Not for use in patients30 cm ROM), SLR (r/o disc herniation), cross-SLR (r/i disc herniation), Lasegue sign,  FABER (SI joint pain) 4. Neuro  Tone, Motor (L2 – hip flexion; L3 – knee extension; L4 – inversion of foot; L5 – extension of great toe; S1 – eversion of foot)  Sensory (L2 – lateral thigh; L3 – middle knee; L4 – middle ankle; L5 – 1st web space; S1 – lateral foot) (light touch, pin-prick, vibration, proprioception)  (L4 – patellar; S1 – achilles, Babinski, clonus) 5. Counselling  Back pain is very common, most episodes resolve without tx (acute resolves 90% w/in 1 month)  Continue regular activities modified  PT and exercise, supportive devices, massage, acupuncture PEP Questions

 

What sx would make you worry about cauda equina? Saddle anesthesia, anal tone decreased, fecal incontinence, urinary retention, bilateral lower leg weakness. If it is determined to be mechanical in nature, how long should one wait until following up? 4 weeks.

75yo M comes in with facial drooping on the right side. Do a hx and px. Ischemic (thrombosis, embolism, hypoperfusion), hemorrhagic (intracerebral vs subarachnoid), TIA ( transbronchial. DDX: TB, granulomatous disease (sarcoid, Wegeners), malignancy, fungal infection.  Common cold (rhinovirus 50%, coronavirus 15%, influenza 15%, unknown 20%),  Acute pharyngitis (viral 90%, GAS, beta-hemolytics strep, N. Gonorrhea),  Sinusitis (viral, S. pneumoniae, H. influenza, M. catarrhalis, anaerobes if chronic).  If asthmatic, PFTs: ventolin (250mg 2 puffs BID), fluticasone (125mg 2 puffs BID), ipratropium.  Community acquired (S. pneumoniae, M. pneumoniae, C. pneumoniae, Chlamydia, H. influenzae, M. catarrhalis, S. aureus, viral)

65yo M with abdominal pain/jaundice. Do a hx. Based on location: gastroenteritis, biliary, hepatitis (infection, autoimmune, hemachromatosis, Wilson's, drugs), pancreatitis, appendicitis, diverticulitis, GERD/gastritis, esophagitis, obstruction. PBC/PSC, IBD, sigmoid volvulus, abscess (subdiaphragmatic, splenic), mesenteric adenitis, salpingitis, pericarditis, porphyria, lead poisoning

1. HPI  Onset, duration, timing, night pain, severity, quality (burning, tearing, colicky), radiation (shoulder pain, R subscap, back), provoking/palliating (eating, BM, urination, position)  N/V, diarrhea, constipation, last bowel movement, bloody stools  Fever, chills, night sweats, wt loss/appetite, abdominal mass  Jaundice, pruritus, confusion, dark urine/pale stools  Cough/blood, bruising, waist size, ankle swelling  Joint pain, rashes, skin bronzing 2. Meds/OTC/Allergies  Tylenol, OCPs 3. PMHx/Surgery/Hospitalization  Liver/gallbladder dz, cancer  IBD, RA, autoimmune

 Blood transfusions 4. Social Hx  Smoking/ETOH/IVDU, tattoo  Travel/sexual hx (STD)  Occupation (HCW) 5. Family Hx  IBD, cancer, hemachromatosis PEP Questions  What can you see on AXR? Bowel obstruction, volvulus, pneumatosis, biliary tree air, calcification, colitis  What blood tests would you consider? CBC, lytes, BUN/Cr, glucose, betahcg, AST, ALT, ALP, bili, lipase, U/A, culture  What would US show? AAA, gallbladder, renal dz, pancreatitis, venous thrombosis, peritonitis, pelvic dz, indicated for pregnancy.  Primary billiary cirrhosis (PBC) - autoimmune dz; destruction of intra hepatic bile ducts; seen mainly in women. Associated with RA , Sjogren. AMA found in 95%.  Primary sclerosis cholangitis (PSC) – focal dz; destruction of intrahepatic and extrahepatic ducts; seen mainly in males. Associated with IBD. ERCP see characteristic strictures.  Acute abdominal pain and jaundice. List the 5 most important questions to ask in your history: IVDU, ETOH, blood transfusion, tattoos, asian ethnicity.  What is your differential diagnosis? Hepatocellular, cholestatic, CHF, nephrotic sx, malignancy.  What investigations would you order in this patient? CBC, LFTs, lytes, abdo U/S, CT, liver biopsy, diagnostic paracentesis

35yo M comes in with melena/bloody stools. Take a focused history. Painful - PUD, IBD, fissure, Mallory-Weiss tear, gastritis, esophagitis, hemorrhoids. Painless – polyps/cancer, diverticulosis, esophageal varices, AVM.

1. HPI  Onset, duration, previous episode, color (red/tarry), volume of blood, on wiping/stool/toilet bowl, abdominal pain, straining, constipation, diarrhea, stool changes, last bowel movement  Acid reflux, dysphagia, cough, SOB/CP  Jaundice, ascites, edema (esophageal varices)  Nose bleed, bleeding gums, bruising, petechiae  Fever, chills, night sweats, wt loss  Rashes, joint pain, dry eyes, dry mouth  Fatigue, tachycardia, light-headedess 2. Meds/OTC/Allergies  NSAIDs, anticoagulants, steroids,  Pepto-Bismol, beets, iron supplements 3. PMHx/Surgery/Hospitalization  GERD/PUD, IBD, liver dz, hemmorhoids  Transfusions 4. Social Hx

 Smoking/ETOH/IVDU  Travel/sexual Hx 5. Family Hx  IBD, colorectal cancer, other cancer PEP Question  How do you treat H. Pylori? Clarithromycin 500mg BID and metronidazole 500mg BID and omeprazole 20mg BID x14days  How do you R/O UGIB? NG aspirate  Endoscopy (sigmoidoscopy/colonoscopy), Gastroscopy (upper GI bleed)  Non-variceal bleed: bolus 80mg IV pantoprazole, then run 8mg/hr x72hrs  If variceal bleed: 50mcg IV octreotide, then drip 50mcg/hr

45yo M comes in with a history of diarrhea. Take a history. IBD/IBS, celiac, cancer, lactose intolerance, hyperthhyroidism, Addison's, uremia, pancreatitis, carcinoid, infection.

1. HPI  Onset, duration, frequency, quantity, quality (bloody/tarry, watery/mucous, foul smelling/floats), urgency (rectal), provoking/palliating (fasting = secretory, wheat, milk)  N/V, abdominal pain, bloating, gas  Fever, chills night sweats, wt loss  Sore throat, cough  Joint pain, rashes, red eyes, mouth ulcers  Palpitation, heat intolerance, sweating  Food (poultry, spoiled dairy, hamburger, seafood), 2. Meds/OTC/Allergies  Abx, chemotherapy, laxatives  Metformin, colchicine 3. PMHx/Surgery/Hospitalization  IBD/IBS, celiac  Hyperthyroidism, Addison's,  Short-gut syndrome (previous surgery) 4. Social Hx  Smoking/ETOH/IVDU  Travel/sexual hx  Occupation/HCW, childcare 5. FamHx  Colon cancer, IBD, celiac dz PEP Question  What special tests would you consider? Anti-TTG, IgA levels. TSH  Organisms: small bowel/watery (salmonella, cholera, C. diff, campylobacter, yersinia), colonic/bloody (shigella, EHEC, Campylobacter, Yersinia). Noro/rotavirus. Cryptosporidium, Giardia.

35yo F comes in complaining of vomiting. Take a history. Gastroenteritis, obstruction, appendicitis, pancreatitis, GERD. Pregnancy, meningitis, vertigo, DKA, adrenal insufficiency, migraine, uremia, hyperthyroidism. Bulimia, anxiety, depression, MI, HTN emergency.

1. HPI  Onset, duration, frequency, content (blood, coffee grounds, food, bilious), amount, projectile vomiting, provoking/palliating factors (meals, food, time, lying)  Abdominal pain (PQRSTPP), constipation/diarrhea, last bowel movement, flatus, last ate/drank  Fever, chills, night sweats, wt loss  Headaches, vertigo, photophobia, neck stiffness  Heat intolerance, sweating, palpitations  LMP, pregnancy  Stressors, mood, suicide, anxiety  Anorexia, guilt, early satiety  Polyuria/decrease (uremia), postural hypotension, CP/SOB 2. Meds  Opioids, steroids, NSAIDs 3. PMHx/Surgery/Hospitalization  DM, pancreatitis, IBD  Hernias, colon cancer  Depression, anxiety 4. Social Hx  Smoking/ETOH/IVDU,  Occupation Note:  

Go into room, withdrawn pale woman. Vague history of abdo pain and vomiting, non specific. She is depressed/adjustment disorder. Her father recently died.

25yo F, first prenatal visit/GA36wks with BP150/90 or GDM. Do a hx. Fetal movements, pre-eclampsia, bleeding, cramping.

1. HPI    

GTPAL, planned/unplanned, LMP Breast tenderness, N/V, urinary frequency, wt gain Fetal movements, cramping, discharge/bleeding Headaches/drowsiness, blurred/double vision/amourosis/flashing lights, SOB/CP, abdo pain, edema, urine output  U/S: dating (10-13wks), detailed (18-20wks)  Prenatal care: HTN, GDM, infection, CBC 2. Meds/OTC/Allergies  Contraception, vitamins (iron/folic acid)  Anti-hypertensives 3. PMHx/Surgery/Hospitalization

  

HTN, DM, kidney dz HIV, chicken pox Previous pregnancy: GDM/HTN, infection, bleeding, fever/GBS, UTI, GA/delivery, NICU, metabolic screen, complication (fever/shock/seizure/distress), meconium.  Health of child now  Last PAP smear 4. Social Hx  Smoking/ETOH/IVDU  STD history  Occupation/husband, support system  Asks about delivery, if severe pre-eclampsia->hospital->Obs consult. 5. Family Hx  Genetic conditions, CF 6. Counselling 1st Trimester (wk1-12) 2nd Trimester (wk13-28) Detailed US at 18-20wks. Regular monthly visits to week 28 Smoking/ETOH/drugs, folic acid, iron, Subsequent visits 24-28wks: support system. CBC, GDM screen, (24-28wk) Initial Labs: beta-hcg, CBC, blood blood type and antibodies type/Rh, rubella, varicella, HBsAg, VDRL, HIV, gonorrhea/chlamydia 3rd Trimester (wk29-40) screen, urine dip GBS swab at 36wks Dating U/S 10-12 wks Women >40yrs: CVS 10-12wks (1-2% SA) , Amnio 15-16wks (0.5% SA) Screening Explain DS: Tri21, genetic defect, causes mental impairment and physical abnormalities. Each person different. No cure, but resources available.  Screening = risk, not diagnostic. E.g. 1/100  Detection rate of ~85% and false positive rate of 35y can get IPS (includes NT), If >40 = amniocentesis. NIPT which is private pay (>10wks). Next step is diagnostic (CVS, amnio) SIPS (MSP)

IPS (>35)

FTS (varies)

Amnio (>40)

NIPT ($800)

Tr21/18, NTD

Tr21/18, NTD

Tr21/18/13

All

Tri21/18/13++

2 draws

2 draws+1 US

1 draw+1 US

Invasive

1 draw

10-14+15-21w

10-14+15-21w

11-14w

>15w

>10w

DR >85%

87%

83%

100%

99.9%

FP 4.4%

1.9%

5.0%

0%

0.2%

No risk

No risk

No risk

1/200 SA

No risk

PEP Questions:  What was most concerning? Visual changes, headache, abdominal pain,  Severe pre-eclampsia: cerebral/visual distrubance, hepatic (abdo pain, LFTs), BP>160/110, low PLT, renal abnormality, pulmonary edema.  How would you dx? SBP> 140/90 AND Proteinuria >0.3g/24h or signs of end-organ dysfunction (PLT, Cr, AST, ALT)  Complication? Seizures, growth restriction, preterm delivery, abruptio placentae, stillbirth.  3 Procedures/Investigations? US, BPP, BW  Medication? Labetolol or Hydralazine or PO Nifedipine AND MgSO4  Sugar in urine, need to do more tests. Risk of diabetes in the future. Risk to fetus include macrosomia, shoulder dystocia, requires surgery. Reassure mother.

25yo F comes in complaining of missing her periods. Take a history Pregnancy, anorexia/stress/exercise, prolactinoma/hypothalamic tumor, Kallman's syndrome, Sheehan's vs. PCOS, menopause/premature ovarian failure (Turner's, radiation, chemotherapy), Ashermans, hypothyroidism, Cushing's

1. HPI  Onset, duration, previous episodes, LMP (menarche, regularity, length of cycle/menses, #pads), dysmenorrhea  Breast tenderness, N/V, bloating  Hot flushes, night sweats, vaginal dryness, mood changes  Diet, wt loss, exercise, stress  Wt gain, cold/heat intolerance, dry/wet skin, sleeping  Headache, visual changes, galactorrhea, smelling problems  Hirsutism, balding, acne 2. Meds/OTC/Allergies  OCP/IUD, anti-psychotics 3. PMHx/Surgery/Hospitalization  Pregnancy/infertility, hemorrhage  Breast feeding/failure  Cancer treatment  Abortion, D&C 4. Social Hx  Smoking/ETOH/IVDU  Sexual Hx (#/concurrent, sex for money/drugs, oral/vaginal/anal)  STD hx  Stressors (relationship, school, work)

5. Family Hx  PCOS, DM, thyroid dz PEP Questions  What blood work would you order? B-HCG, FSH, LH estradiol, testosterone, androstenedione, DHEA  What imaging would you do? U/S transvaginal, MRI head, if suspicion: hysterosalpingogram, hysteroscopy  What other tests would you consider doing? Progesterone challenge test, karyotype, 24h-urine cortisol

25yo F who is pregnant. Experienced vaginal bleeding. Take a history. 1st trimester (Nonviable: SA [20%], ectopic, molar; Viable: normal implantation [33%], cervical polyp, rectum/bladder). 2/3rd trimester: (placenta previa [painless], vasa previa, abruption [painful, dark blood], bloody show, cervical/vaginal lesion)

1. HPI  Onset, duration, trauma, previous bleeding, color (dark = abruption), underwear/wiping/urine, frequency of changing pad/tampon, passage of tissue/clots, post-coital bleeding  Fetal movements  Cramping/contractions, back pain  LMP, U/S results (ectopic/twins)  Prenatal care (BP, blood type) 2. Meds/OTC/Allergies  OCPs, IUD, anticoagulants 3. PMHX/Surgeries  Bleeding disorder, liver dz  Previous C/S  Previous pregnancy: GDM/HTN, infection, bleeding, fever/GBS, UTI, GA/delivery, NICU, metabolic screen, complication (fever/shock/seizure/distress), meconium.  Health of child now  Last PAP smear 4. Social Hx  Smoking/ETOH/IVDU, cocaine  STD hx  Support at home, occuptation/husband, plans for pregnancy PEP Questions  Placenta previa RF: grand multip, twins, age>35, uterine scar - Tx: cerclage.  Placenta abruption RF: previous abruption, HTN/preeclampsia, trauma, PROM, smoking, cocaine.  How would you manage the bleeding? ABC, Rhogam, transvaginal U/S, CBC, serial betaHCG  How would you manage ectopic? Stable = methotrexate (betaHCG decrease 15%/week), unstable = laparoscopy. Perform U/S at 7 weeks to ensure no recurrence (10%)

 

In normal pregnancies beta-HCG doubles q48-72 hours until 10,00020,000mIU/ml. At betaHCG of 1500-1800mIU/ml (transvaginal U/S), with abdo U/S (6000-6500mIU/mL) Betamethasone x2 if GA 7days, >1pad q2hrs), metrorrhagia (irregular, between cycles), menometrorrhagia (metrorrhagia that is prolonged), polymenorrhea (35d cycle),

1. HPI  Onset, duration, previous episode, LMP (menarche, regularity, length of cycle/menses), frequency of changing pad/tampon (q1-2 hours too much), color, passage of tissue/clots, post-coital bleeding  Fever, chills, night sweats, pain, discharge  Abdominal mass, bloating, early satiety  Breast tenderness, N/V, urinary frequency  Cold/heat intolerance, wt gain/loss, palpitations  Wt gain, hirsutism, acne 2. Meds/OTC/Allergies  OCP/IUDs  Anticoagulants 3. PMHx/Surgery/Hospitalization  Fibroids, PCOS  Thyroid dz, bleeding disorder  PAP smear results, previous cancer 4. Social Hx  Smoking/ETOH/IVDU  STI Hx 5. Family Hx  Cancer PEP Questions:  What for ovulatory menorrhagia? NSAIDS (onset, q6-8hrs PRN)  What surgical procedure? D&C, endometrial ablation, hysterectomy

55yo F comes in complaining of dysuria. Take a history. UTI/cystitis, urethritis, prostatisis, epididymitis, orchitis, pyelonephritis

1. HPI  Onset, duration, previous episodes, pain (PQRSTPP), frequency, discharge, urine color, does urinating make the pain go away  Flank/back pain, abdo fullness, incontinence  Fever, chills, night sweats, N/V  Urethral/vaginal discharge, joint pain, skin rash, lesion/swelling  LMP (menopause)

2. Meds/OTC/Allergies  Abx, contraception  Anticholinergics (antihistamines, antidepressants) 3. PMHx/Surgery/Hospitalization  Prolapse, GTPAL  Menopause  DM, kidney stones, BPH, incontinence 4. Social Hx  Smoking/ETOH/IVDU  Sexual Hx (#/concurrent, sex for money/drugs, oral/vaginal/anal)  STD hx 5. FamHx  Cancer PEP Questions  UTI - KEEPSS: Klebsiella, E.coli [95%], Enterococcus faecalis, Proteus mirabilis, Pseudomonas, Staph saprophyticus, Serratia marcesence; Urethritis: gonorrhea, chlamydia, trichomonas vaginalis, HSV  What is the treatment for cystitis? Septra DS 1tab PO BID x3d OR Nitrofurantoin 100mg PO bid x5d. If male Septra DS 1tab PO bid x7d  What is the treatment for recurrent cystitis? Low dose or post-coital Abx: Septra 1tab PO daily, or post-coital only.  Do you treat asymptomatic bacteruria? Only if pregnant  How would you treat prostatitis? Cipro 500mg PO q12h x2-4wks or Septra 1 tab PO BID x2-4wk

25yo F with lower abdominal/pelvic pain. Take a focused history. Dysmenorrhea, ectopic, PID, endometriosis, fibroids, ovarian torsion/hemorrhage/rupture, prolapse, UTI vs. appendicitis, diverticulitis, obstruction, renal stone, ruptured AAA, mesenteric ischemia, IBD, cancer, hernia, hip arthritis, shingles.

1. HPI  Onset, duration, pattern (cyclical), progression, location, quality, radiation, provoking/palliating (BM/voiding, menses, sex, NSAIDs)  Fever, chills, night sweats, wt loss  Discharge, itchiness, irritation, odor, bleeding  Dysuria, back pain  LMP (regularity, length cycle/menses), breast tenderness, N/V, cramping, bloating, pregnancy test  Last bowel movement, diarrhea/constipation, bloody stools 2. Meds/OTC/Allergies  OCP/IUD 3. PMHx/Surgery/Hospitalization  PID, previous pregnancy, infertility, PAP  Appendicitis, IBD 4. Social Hx  Smoking/ETOH/IVDU

 Sexual Hx (#/concurrent, sex for money/drugs, oral/vaginal/anal)  STD hx 5. Family Hx  Fibroids, endometriosis  Breast, ovarian, colon, endrometrial cancer PEP Questions:  Ectopic vs. PID, she was having periods so PID.  Antibiotics for inpatient? Cefoxitin (2g IV q6h, D/C after 24hr clinical improvement) and doxycycline (100mg PO BID x14days)  Antibiotics for outpatient? Ceftriaxone (250mg IMx1) plus doxycycline (100mg BID 14 days) plus metronidazole (500mg BID 14 days)  Indications for hospital? Pregnancy, non-adherence, N/V, fever, pelvic abscess.

25yo F comes in complaining of vaginal discharge. Take a history. UTI vs Vaginal infection: bacterial vaginosis, candidiasis, trichomoniasis, atrophic vaginitis [R/O PID]

1. HPI  Onset, duration, previous episode, quantity, frequency, color, consistency (milky:vaginosis, thick:candidiasis, frothy:trichomonas), odor (fishy:vaginosis), provoking/palliating (menses/sexual activity)  Pain, itchiness, irritation, lesions  Fever, chills, night sweats, abdominal pain  LMP (menarche, regularity, length of cycle/menses)  Dysuria, urinary frequency, nocturia, smelly urine  Douching, foreign body 2. Meds/OTC/Allergies  OCP/IUD  Antiobiotics, immunosuppressants 3. PMHx/Surgery/Hospitalization  DM, HIV  Pregnancy, PAP smear 4. Social Hx  Smoking/ETOH/IVDU  Sexual Hx (#/concurrent, sex for money/drugs, oral/vaginal/anal),  STD hx PEP Questions:  On a pelvic exam what would you look for? Vulvar erythema, atrophy, lesions, cervix friability.  What tests would you do? pH, whiff test, wet-mount, gram-stain, GC screen. Consider VDRL, HIV, HepB  BV: metronidazole 500mg PO bid x7d or clindamycin cream;  Trichomoniais: metronidazole 2g PO x1dose  Candidiasis: fluconazole 150mg PO x1dose  Gonorrhea: cefexime 800mg PO x1dose or ceftriaxone 250mg IM x1  Chlamydia: doxycycline 100mg PO BID x7d or azithromycin 1g PO x1

75yo F has fatigue/anemia. Take a history. Anemia (normocytic: blood loss, HIV, malignancy, autoimmune, chronic infection, early Fe deficiency, hypothyoidism, alcoholism, liver dz, sickle cell, chronic renal dz, hemolysis; Microcytic (TAILS): thalassemia, anemia of chronic dz, Fe deficiency, lead poisining, sideroblastic anemia; Macrocytic: B12/folate deficiency, chronic liver dz, AIHA, myelodysplasia, pernicious anemia, chemotherapy, antiviral meds, hypothyroidism. CHF, hypothyroidism, depression, CFS, OSA, DM, substance abuse, cancer, HIV, medication/toxin.

1. HPI  Onset, duration, progression, timing, weakness/pain, provoking/palliating factors (exertion, rest)  Bloody stools, melena, bloody urine, lightheadedness/syncope  Nutrition/appetite, dysphagia, dental health  Fevers, chills, night sweats, wt loss  Headaches, weakness, dysarthria, ataxia, visual changes, vertigo  CP, palpitations, orthopnea/PND, abdo swelling, edema  SOB, wheeze, cough, blood  Cold intolerance, dry skin, constipation  Stressors, mood, concentration  Sleep, snoring, refreshed 2. Meds/OTC/Allergies  Beta-blockers, ACEi, diuretics  Antidepressants 3. PMHx/Surgery/Hospitalization  DM, CAD, COPD,  Sleep disorder, OSA  Hypothyroidism, cancer  Depression, anxiety 4. Social Hx  Smoking/ETOH/IVDU  Travel Hx, tick bites  STD Hx 5. FamHx  Cancer PEP Questions:  What labs would you order: CBC, retic count, peripheral smear (schistocytes – MAHA, target cell – liver dz; hypersegmented neutrophils – b12; tear rop – thalassemia; Howell Jolly – asplenia, sickle) lytes, BUN, Cr, glucose, LFTs, TSH, B12, iron studies, CXR, ECG, urinalysis, sleep study, colonoscopy for >50y Normocytic: Bilirubin/haptoglobin/LDH (hemolysis), retic count, INR, PTT, fibrinogen (DIC), DAT

Microcytic: Ferritin, Fe, TIBC, FE saturation (Fe deficiency, anemia of chronic dz), anti-

Macrocytic: RBC folate, B12, TSH (hypothyroid),

(hemolysis), SPEP/UPEP (multiple myeloma), creatining (renal failure), TSH, AST/ALT/bilirubin/INR/PTT/albu min (liver dz)

TTG/IgA (Celiac), Hb electrophoresis (thalassemia), serum Pb/erythrocyte protophorphyrin (lead poisoning)

AST/ALT/ALP bilirubin, INR/PTT albumin (liver dz)

Heart Failure Systolic HF (poor emptying): CAD/MI, HTN, dilatedCM, viral/toxins, aortic stenosis Diastolic HF (poor filling): hypertrophic/restrictiveCM, mitral sten., pericardial dz High Output Failure: anemia, Beriberi, thyroid, pregnancy, Paget's Dz, AV fistula Arrythmia/Conduction: SVT, AF, AV block NYHA HF Classification I – No SOBw/ N activity II – @rest OK, SOB w/ N III – N activities limited IV – SOB at rest

CXR Findings for CHF Alveolar Edema (LR+6) Edema: Kerley B lines, periBronchial cuffing, vascular markings (LR+12) Cardiomegaly (LR+3.3, LR-0.33) Dilated upper lobe vessel (pulm. veno. congestion LR+12) Pleural effusion (LR+3.2)

Management EKG, Echo, Angiogram, MIBI, urinalysis (proteinuria) ACEi/ARB, beta blocker (hydralazine/nitrate if no ACEi, black, NYHA III/I) Consider aldosterone antagonist Symptom relief: nitrates, digoxin

75yo M experienced an episode of syncope/fall. Please take a history. Orthostatic, vasovagal, carotid sinus, TIA/stroke, seizures, hypoglycemia, hypovolemia, adrenal insuffienciency (postural), MI, VT/VF, afib, aortic dissection, AS, HOCM, sick sinus/AV block, migraine, muscle weakness, vertigo, vision problem

1. HPI  Onset, duration, previous episode, memory of event, LOC  Pre – standing up, emotional stimulus, lightheaded/diaphoresis, N/V, urinating/defecating/coughing, head turning/putting on shirt/shaving, reaching for object, exertion (AS/HOCM)  Headache, visual problem, dysarthria, dysphagia, ataxia, vertigo  CP/SOB, back pain, palpitations  Tonic-clonic, incontinence, tongue biting  Automatisms (lateralizations)  Post – confusion, headache, imbalance  Bloody stool, diarrhea  Use of cane/walker 2. Meds/OTC/Allergies  BP meds/nitrates, antihistamine, diet pills 3. PMHx/Surgery/Hospitalization  DM (autonomic neuropathy), HTN, stroke, heart dz  Epilepsy, Parkinson's, anxiety

4. Social Hx  Smoking/ETOH/IVDU  Occupation, driving 5. Family Hx  Heart disase, neurological dz, osteoporosis PEP Questions:  What blood tests would you do?CBC, lytes, Mg, Ca, BUN/Cr  What other investigations ? EKG, EEG, CT head, Echocardiogram

55yo M with headache. Take a focused history. Stroke, SAH, subdural, migraine, cluter/tension, temporal arteritis, glaucoma, CO poisoning, meningitis, brain abscess, brain tumor.

 Offer turn down light (photophobia) 1. HPI  Onset, duration, trauma, timing (AM/PM), severity, quality (throbbing, dull, sharp, tight), location (unilatera/bilateral), progression, radiation, provoking/palliating (exertion, light, sound, motion, NSAIDs)  Visual problems, aura, tinnitus, N/V  Dysarthria/dysphagia/ataxia/weakness, vertigo  Fever, chills, night sweats, neck stiffness, drowsiness  Scalp tenderness, jaw claudication  Low back pain (PMR = TA), sciatica 2. Meds/OTC/Allergies  Anticoagulants, nitrates, OCPs  Analgesics (rebound h/a) 3. PMHx/Surgery/Hospitalization  HTN, glaucoma, PMR  Head trauma 4. Social Hx  Smoking/ETOH/IVDU, occupation 5. Family Hx  Stroke, polycystic kidney dz, Marfan's, neurofibromatosis 55yo M complaining of dizziness/vertigo. Take a focused history. Central vs peripheral vertigo: Central vertigo (often with neuro sx): tumor, stroke, migraine, multiple sclerosis, Parkinson's; Peripheral vertigo: BPPV (sec-min), labrinthitis (days), Meniere's dz (min-hrs; triad of tinnitus, hearing loss, vertigo). Aortic stenosis, arrhythmia, orthostatic.

 Asks if they need to lie down 1. HPI  Onset, duration, spinning, previous episode, timing (AM/PM), provoking/palliating (standing up, looking up, closing eyes, staying still)  Tinnitus, hearing loss, relationship to vertigo, N/V  Fever, chills, night sweats, wt loss, ear/resp infection

 Headache, double vision, dysarthria, dysphagia, ataxia  CP, SOB, back pain, palpitations, syncope  Bleeding, bloody stools, bruising 2. Meds/OTC/Allergies  ASA, NSAIDs  Aminoglycosides, furosemide  Anticonvulsants 3. PMHx/Surgeries  DM, HTN, dLp, stroke, CAD  CHF, afib, aortic stenosis  Migraine, Parkinson's, MS  LMP, pregnancy 4. Social Hx  Smoking/ETOH/IVDU 5. Family Hx  Stroke, Meniere's dz Mnemonics BE SKIM (>3sx for 6mo): blank mind, easy fatigue, sleep, keyed up, irritable, muscle tensions MSIGECAPS (>5sx for 2wk): mood, sleep, interest, guilt, energy, concentration, appetite, psychomotor, suicide; [post-partum, psychosis, stressors, seasonal, bereavement (3sx for 7d): grandiosity, sleep, talkative, pleasure, activity, ideas, distractibility TRAUMA (>1mo): traumatic event, re-experience, avoidance, unable to function, 1 month, arousal increased. OCD: unwanted obsessions, compulsions, insight CAGE: cut down, annoyance, guilt, eye-opener

25yo M “going crazy and can't take it anymore”. Do a hx. GAD, OCD, panic disorder, PTSD, social/specific phobia/agoraphobia, depression, psychosis, somatoform d/o. R/O hyperthyroid, drug w/d, substance-induced, pheochromocytoma

1. HPI  What he means, onset, duration, frequency, progression  BESKIM: Blank mind, energy, sleep, keyed up, irritable, muscle tensions; panic attacks, phobia/social  OCD: Obsessions (recurring thoughts/worries), compulsions (hand washing, repetitive patterns, checking doors/ovens/taps), special order, concern about contamination, intrusivessness, insight into thoughts,  SIGECAPS: Mood, SI/HI, self-harm, stressors, hallucinations  GSTPAID: grandiosity, sleep, talkative, pleasure, activity, ideas, distractibility  TRAUMA: Trauma, flashbacks, nightmares



CP/SOB, diaphoresis, flushing, wt loss, palpitations, heat intolerance  How is it affecting his life? 2. Meds/OTC/Allergies  Levothyroxine, SSRIs, ADD meds, decongestants 3. PMHx/Surgery/Hospitalization  Thyroid dz, CAD/CHF  Psychiatric hx 4. Social Hx  Smoking/ETOH/IVDU, MJ, cocaine, MDMA  Relationships, legal problems, work problems  Sexual hx (STDs) 5. Counselling  SSRI: takes 6 weeks. Trial 1 year. Escitalopram 10-20mg OD. A/E nausea, diarrhea, libido. Assurance of effectiveness. Can do CBT.  PTSD: CBT, exposure, supportive.  OCD: SSRIs, clomipramine (TCA) w/ CBT, exposure and response prevention  GAD: SSRIs/SNRIs, buspirone, buproprion w/ CBT 14 yo suicidal teen w/ bilateral bandages on wrists. Take a history. Depression, anxiety, psychosis, substance abuse, eating disorder, personality disorder, delirium, chronic pain, medication side effect.

 Asks if they feel safe 1. HPI  Thoughts: onset, duration, frequency, stressors  Behaviors: Cutting/burning/scratching, letters/notes, wills, giving away possessions  Actions: previous attempts, plans/rehearsal, firearms, why they are thinking of it  SIGECAPS: Hopelessness, mood, loss of interest, sleep, appetite, decrease concentration, wt loss/gain, energy  GSTPAID: grandiosity, sleep, talkative, pleasure, activity, ideas, distractibility  TRAUMA: Trauma, flashbacks, nightmares  Anxiety, panic attacks, hallucinations/commands  Cold intolerance, constipation, wt gain 2. Meds/OTC/Allergies  Tylenol, TCAs, MAOIs 3. PMHx  Chronic dz/pain, cancer  Depression, psychosis, schizophrenia, personality d/o 4. Social Hx  Home: lives with parents, marital status (HEADSS)

 Education: grade, like the teachers, feel safe  Activities: hobbies, extracurricular, clubs, sports  Drugs: smoking, MJ, IVDU  Safety: at home, any worry about abuse, suicide, self-harm  Sexuality: currently active, partners, condom use  Friends: anyone she can talk to  Legal Hx, violence, childhood abuse 5. FamHx  Suicide in family, psychiatric illness, substance abuse 25yo F comes in w/ rash. Treatment has not worked. Do a hx. Acne, eczema/psoriasis, seborrheic keratosis, tinea, cellulitis, folliculitis, hives, vitiligo, bullous pemphigoid, alopecia. R/O actinic keratosis, basal cell carcinoma, melanoma, Steven-Johnson, TEN, necrotizing fasciitis, pemphigus vulgaris.

1. HPI  Onset, duration, location, spread/change, seasonal changes, provoking/palliating (heat, cold, sun, exercise)  Itch, pain, color, raised, scaling  Fever, chills, night sweats, wt loss  Joint/back pain, oral ulcers, hair/nail changes  Dysphagia, Raynaud's, SOB (CREST) 2. Meds/OTC/Allergies  Steroids, NSAIDs  Topicals 3. PMHx  Eczema/psoriasis, skin cancer  DM, HIV, autoimmune 4. Social Hx  Smoking/ETOH/IVDU  Travel hx, sun exposure, tanning beds  Sexual hx (STIs)  Pets/hobbies 5. Family Hx  Skin cancer hx  Eczema, psoriasis PEP Questions:  Tinea corporis, how would you diagnose and treat? KOH scraping is diagnostic. Fungal culture can also be taken. Topical azoles (ketoconazole, clotrimazole, miconazole) for 2 weeks applied OD or BID.  Tinea: red with central clearing, maculopapular, oval-round, commonly on trunk or face.

25yo M has a mole on his back. Take a history. Melanoma, pigmented basal cell carcinoma, squamous cell carcinoma, seborrheic keratoses, atypical moles, warts

1. HPI  Onset, change, asymmetry, border, color, diameter  Previous mole removal  Pain/itching/bleeding  >20 moles, freckling, sun burn/tanning  Fever, chills, night sweats, wt loss  CP/SOB 2. Meds/OTC/Allergies  NSAIDs  Psoriasis treatment 3. PMHx  Lesions (lentigo maligna), non-melanoma cancer, pancreatic ca  HIV, immunosuppression  Previous cancer treatment, previous psoriasis treatment 4. Social Hx  Smoking/ETOH/IVDU  Travel hx: sunny regions, sunscreen use. 5. Family Hx  Skin cancer (melanoma in 1st degree = 8x risk), mole syndromes 6. Counselling  Wear loose clothing, hat, sunglasses during summer, avoid noon sun, high SPF screen, avoid tanning beds  Warn that during winter, especially skiing, still vulnerable  Suggest have someone look for moles and track them  Bad: irregular shape, bleeding, painful, not uniform color, ulcerating PEP Questions:  What are the important characteristics about this lesion? ABCDE  What is the most important prognostic factor? Depth of lesion  Describe your management? Excision (possibly imiquimod or cryotherapy) followed for 3 years q3months. If spread to Lns, chemo. If spread to bones, radiotherapy.

3yo M is with a “seizure” witnessed by his mom. Take a history. Febrile seizures (5Fs: fever, 5mo to 5 years, less than 15min, non-focal=generalized, family history), epilepsy (>2 unprovoked), hypoglycemia, hypovolemia, meningitis, breath-holding spells, migraine

1. HPI    

Onset, duration, previous episode, LOC Fever, cough, runny/stuffy nose Nutrition/hydration, bleeding, head trauma, toxins Pre – standing up, emotional stimulus, N/V, urinating/defecating/coughing, turning head, exertion (AS/HOCM)

   

Pre – anxious, irritable, drowsy, stomach ache (epigastric) CP/SOB, back pain, palpitations Tonic-clonic, incontinence, tongue biting Automatisms (lateralizations): eye movements, staring, hand movements, lip smacking (make sure generalized, both sides)  Post – confusion, headache, imbalance, weakness, lethargy, paralysis (Todd's), behavioral changes (crying, aggressive) 2. Meds/OTC/Allergies  Abx 3. PMHx (Pediatric)  Previous seizures, unprovoked  Developmental hx, infections, brain injury  Prenatal: U/S, GDM, HTN, infection, IUGR, smoking/ETOH/drugs  GBS status, maternal UTI/fever, GA/delivery, APGARS, wt  NICU, metabolic screen, fever/shock/seizure/respiratory distress, meconium 4. Social Hx  Parents occupation, marital status, safety at home, day care 5. Family Hx  Epilepsy, developmental delay 6. Counselling  Febrile seizure, no meds (except Tylenol)  If >5 min call 911, 160/90), severe hypercholesterolemia (also CI for progesterone only), thrombophilia/famhx, valvular heart dz, smoker >35y (>15cigs/d), breast or endometrial cancer, abnormal vaginal bleeding, abnormal liver function, pregnancy (also CI for progesterone only), migraine with aura;

1. Sexual Hx  Previous use, current knowledge, personal preference  LMP, pregnancy  Vaginal discharge/bleeding, pain, itching, redness, abdo pain  Menarche, regular, length of cycle/menses, irregular bleeding,  Sexual activity, sexual debut, number of partners presently/past/concurrent, men/women/both, oral/vaginal/anal, current relationship, age of partner 2. PMHx  HTN, CAD, DVT/PE, liver dz/gallbladder  Cancer, clotting d/o, migraine with aura  Gynecological procedures, pregnancy, abortions  Past PAP results, last PAP, STIs 3. Meds  Antibiotics, anticonvulsants 4. Social Hx  Smoking/ETOH/IVDU  HEADSS  Childbearing goals? What you would do if you got pregnant 5. FamHx  Clotting d/o, cancer 6. Counselling  COCP and POP Pills 99% effective.  IUD 99% (lasts for 5 years). STI check before. Check for string monthly.  C-OCP Pros: regulates periods, decreases risk of endometrial/ovarian/GI cancer, helps with acne. CONS: vaginal spotting first few cycles, bloating, weight changes.  POP CONS: compliance issue, must be taken same time each day.  IUD Pros: simple, long-lasting. CONS: uterine perforation.  COCP missed pill (if12hrs need to take for 7 days until covered again. Use condoms at this time.  POP missed pill (if3 hrs take for 7 days.  Depo provera (every 3 months) shot option.  States that surgical sterilization is also an option, regret rate is 30%  F/u in 3 months  Most women get pregnant 3 months after stopping pills. May take up to a year.

65yo F, “personal and sensitive” dyspareunia matter. Do a hx. Superficial – vaginal atrophy, vaginal spasm, vestibulodynia, candidiasis, chlamydia, UTI, vaginal cancer, rectal cancer, endometriosis. Deep dyspareunia – PID, cervicitis, endometriosis, adenomyosis

 

Obtains consent and stresses confidentiality “I understand that this may be distressing, and I appreciate you coming to talk about it” “Sexual difficulties are quite common in otherwise healthy people”

 1. HPI  Onset (during/after coitus), duration (lifelong, other relationships), quality (burning, aching, itchy), entry/deep, frequency of intercourse, provoking/palliating factors (lubrication, position)  Vaginal spasm/dryness/discharge/bleeding, itching, redness, sores  Fever, chills, night sweats, abdominal pain/pelvic  LMP (menarche/regular/length), fatigue, hot flashes, mood, energy, appetite, wt loss, sleep  Dysuria, constipation 2. Meds/OTC/Allergies  Viagra, HRT  SSRIs, beta-blockers 3. PMHx/Surgeries  DM, eczema  Anxiety  Fibroids/endometriosis, PID  PAP smear, infertility  Pregnancy, lacerations/episiotomies/trauma 4. Social Hx  Smoking/ETOH/IVDU  Sexual debut, # partners/concurrent, men/women/both, oral/vaginal/anal, desire/arousal/orgasm  How they feel about their partner being involved, are they able to discuss with them, are they happy  “Because sexual violence is an enormous problem in our society and can affect a person's health and well being, I now ask all my patients about sexual health”  Arguments, tensions, forced to have sex, sexually assaulted 5. Counselling She has dyspareunia. Talk about hormone creams and reassure her.  Atrophic vaginitis due to lack of estrogen  First line treatment is estrogen replacement  Contraindications: breast/endometrial cancer, end-stage liver failure, past history of estrogen-related throboembolization  Adverse events include: breast tenderness, vaginal bleeding, slight increase in breast/endometrial cancer.  Routes of administation include oral, cream, transdermal.

   

Oral has benefit of preventing bone loss, and alleviation of hot flushes. But may not alleviate vaginal dryness in 25% of patients Transvaginal cream: very effective. Decreases UTI, lower hormone amount. Increase in risk of endometrial cancer. Transvaginal ring also possible. Moisturizers and lubricants can be used in conjunction

14yo brought in by mom due to being withdrawn at home. Do a hx. 1. HPI  Onset, stressors: home, friends, school, what is the mom worried about. Will have to speak to daughter alone in a bit.  SIGECAPS: mood, sleep, interests, guilt, energy, concentration, appetite, wt gain/loss,  Anxiety, hallucinations  Home: lives with parents, marital status (HEADSS)  Education: grade, like the teachers, feel safe  Activities: hobbies, extra-curricular, clubs, sports Asks mom to leave politely Stresses confidentiality, unless you are at harm to yourself or others  Drugs: smoking/ETOH/IVDU, MJ  Safety: at home, abuse, suicide, self-harm  Sexuality: currently active, partners, condom use 2. PMHx  PAP smears, STI screening 3. Counselling Elicits patient is worried about STD because of unprotected sex Chlamydia, gonorrhea, HPV, HSV, HepB, syphilis, HIV, chancroid  Sexual debut, number of partners, concurrent, men/women/both, oral/vaginal/anal, condom/OCP  Tattoos/IVDU, sex for money/drugs  Vaccine: HepA/B, HPV  Abdominal pain, discharge, itchiness, dysuria, lumps, red eyes  Sore throat, rashes, joint pain  LMP, cramping, pregnancy  Tells patient that betahcg will be done for pregnancy  Screen for syphilis, HIV, HBsAg, HepC Ab, endocervical swab (GC)  That if positive in Canada we HAVE to report chlamydia, gonorrhea, syphilis, HIV. It is BC Law. Will be confidential.  Counsel patient on safe sex practices  Follow-up in 2 weeks

5yo M diagnosed w/ asthma/discharged w/ asthma meds. Counsel. Encourages question, ensure understanding, ensure's mother's willingness and ability to following

                  

Airways very sensitive, causing narrowing and difficulty breathing. Etiology: family history and environmental factors Triggers: URTI, allergens, smoking, NSAIDS, emotional stress, cold air, exercise. Treatment is to manage not cure, most kids grow out of it, but can be lifelong Symptoms: night-time couging, difficulty breathing, wheezing. Lifestyle: exercise, avoid allergens (pets, dander), avoid infections Puffers: reliever meds (dilate airways, short-acting), controller meds (inhaled steroids, help prevent attacks) Steroids are not absorbed systemically, not to worry about S/E Signs of attacks: difficulty breathing, pale/blue, fatigue, can't speak, wheeze, change in mental status During attacks give reliever puffers and come to ER if not improved Ventolin for acute treatment: TID x1 week, then PRN Ventolin's S/E: N/V, muscle aches, fine motor tremor, palpitations, restlessness, throat irritation Fluticasone for prevention: BID, everyday Fluticasone's S/E: N/V, abdominal pain, diarrhea, headaches, dizziness, nasal irritation/bleeding Prednisone for decreasing inflammation: OD x 2 days Prednisones S/E: N/V, mood changes, candidiasis, avascular necrosis of the femoral head Offers pamphlets and support groups Books f/u to do PFTs Instructs the mother about a follow-up visit

25yo F, sister dx w/ breast Ca. She is worried. Take a hx and counsel. Cyst, fibroadenoma, fibrocystic changes, breast cancer, infection

1. HPI  Onset, number, size, association with menses, nipple discharge (blood = benign intraductal papilloma), spontaneous/bilateral discharge, skin changes/dimpling, pain  Fever, chills, night sweats, wt loss, anorexia, bone pain  SOB/CP, hemoptysis  LMP, menarche (55 is late), first pregnancy (>30y late), breast feeding (protective) 2. Meds/OTC/Allergies  OCP/HRT (>5yr @ risk) 3. PMHx/Surgeries

 Previous mammograms/bx, radiation, breast cancer  Ovarian/endometrial/colon cancer 4. Social Hx  Smoking/ETOH/IVDU  High fat diet, exercise 5. Family Hx  Breast cancer, colon/ovarian/endometrial cancer 6. Counselling  I'll do a breast exam and teach you how to perform self breast exams. [few days after cycle, offer chaperone if examining]  Discuss your sisters results with her  Mammography start screening at 50y q2yrs. For those with strong family history start at 40y or 10 years prior to age of onset in first degree relative PEP Questions  Triple assessment: clinical exam, biopsy, imaging  Is the FNA diagnostic? NO. If non-bloody, and lump disappears = benign cystic dz. If bloody, send for cytology.  What imaging would you consider? Diagnostic mammography, breast U/S (identifying benign cysts) and guided core bx, MRI maybe for difficult lesions  What genetic tests would you consider? BRCA1/2 if family hx. Her-2 and hormone receptor testing if mass is cancer.  Early stage: lumpectomy or mastectomy +/- RT then adjuvant therapy may be offered based size, grade, lymph nodes, ER/PR/HER2  Breast Conserving Therapy: Lumpectomy + RT (preclude: multicentric dz, large tumor size relative to breast, diffuse malignant-appearing calcifications on imagin, prior hx of chest wall RT, pregnancy, persistent positive margins)  Mastectomy for those not candidates for BCT:  Medical tx: radiation, chemotherapy, or combined. Hormone and biologic for hormone receptor +ve.

35yo F comes in asking about breast-feeding. Counsel her. 1. General  WHO recommends up to 6 months  Premature q2-3h, term q4h, q5h @ night until 4.5kg or 2-3 month 2. Benefits (ABCDEFGH)  ALLERGIC conditions reduced, BEST food for infants, CLOSE relationship, DEVELOPMENT of IQ/jaw/mouth, ECONOMICAL, FITNESS of mom (return to normal wt), GUARD against breast/ovarian/uterine cancer, HEMORRHAGE reduction  Risk of HIV transfer 3. Contraindications  HIV/AIDS/active TB/herpes in breast  Heavy ETOH/illicit drugs  Chemo/rad compounds



Diazepam, metronidazole, lithium, tetracycline, bromocriptine, chloramphenicol, ergots, gold, cyclophosphamide, antimetabolites  NOT C/I: mastitis, OCP, CMV, hepatitis 4. Complications  Sore/cracked nipples, engorgement, mastitis, poor wt gain, oral candidiasis  Breast feeding jaundice, breast milk jaundice, 16yo M, Diabetes Type 1 is non-compliant with insulin regimen. 1. HEADSS  Home: lives with parents, marital status  Education: grade, like the teachers, feel safe  Activities: hobbies, extra-curricular, clubs, sports  Drugs: smoking, MJ, IVDU  Safety: at home, any worry about abuse, suicide, self-harm  Sexuality: currently active, partners, condom use Elicits confession that they are a raging alcoholic 2. HPI  Mood, suicide  CAGE; Cutting down, Angry at criticism, Guilty, Eye-opener  Amount/week, types of alcohol, drinking more, drinking with friends  Effect on family/friends, trouble with police  W/D: tremor, mood changes, sweating, hallucinations 3. Counselling  Would they like to reduce amount?  Benefits: reduced risk of dz, improved mood, improvement in function  Groups available -> Referal to alcohol team  Detoxification in community (Chlordiazepoxide over 1 week, reduces symptoms) vs. in hospital Reportable diseases in BC Must be reported. Helps public health determine trends and monitors effectiveness of interventions. It is mandated by BC law.

Gonorrhea, syphilis, chlamydia, HIV, Hep A/B/C, TB HCP also needs to notify sexual partners.

45M comes in with results. Please counsel. SPIKES: setting, perception, invitation, knowledge, empathy, summarize

Postive TB sputum cx. Homeless. Postive HIV test. Married. 1. Setting Puts on mask

Are you comfortable?

2. Perception (“before you tell, ask”)  Is it ok to share important news  If they want someone here  Their knowledge of the test 3. Invitation (obtaining patient's invitation) “Would you like me to give you all the information or sketch out the results and spend more time discussing the treatment plan?” 4. Knowledge (“Unfortunately I've got some bad news to tell you”) Tested +ve for TB: infects lungs causing cough and hemoptysis HPI: cough, mucus, blood, fever Patient asks “how did I get it?”: homeless, alcohol dependent, immunosuppressed are at risk Do you know anyone else with TB? There is a cure, 6 months of meds Initial phase is 2 months (INH, RIF, PZA, EMB), then AFB smears, then 4 months (INH and RIF) A/E: liver dmg, vision rash, drug fever Long-term hospitalization for treatment. Also Portland Hotel Society. Reportable, BC Law, confidential.

HIV test positive, not AIDS HIV is a viral infection that attacks the immune system and causes you to have other infections HPI: fever, lumps/bumps, thrush, urethral discharge, pelvic pain, skin rash, cough, mucus, blood, N/V, diarrhea. Patient asks “how did I get it?”: sexual activity, sharing needles Asks patient if they know how they got it (IVDU, MSM, paying for sex) No cure, treatments to keep virus under control Reportable, BC Law, confidential. Any questions?

5. Empathy “I can see how upsetting this is to you.” 6. Summarize TB is reportable. How do you feel? Summarize Offers more information Follow-up visit

HIV is reportable, inform wife/sexual contacts, offer to help, wife should be tested (public health) Safe sex/abstinence to stop trans. How do you feel? Summarize Offer more information Follow-up visit

DNR Discussion (SPIKE) 1. Setting  “I have something I would like to discuss with you”  About your medical options, this is something I discuss with all my patients.  Would you like someone present?

2. Perception (“before you tell, ask”)  “What do you know about your disease”  What do you expect out of your medical care, your goals for the future.  What are things you would like to be able to do? 3. Invitation  Can we talk about CPR? 4. Knowledge  Do you know what CPR is?  CPR involved chest compressions to start your heart again  Most of the time it does not work  If you were to die suddenly would you like CPR?  What would be a reasonable quality of life that you would like to live with 5. Empathy  What are your feelings around this topic?  We don't need to make our decision now, revisit this topic later 6. Summarize  If we place your status as DNR it does not mean withdraw care  In fact we would like to make you as comfortable as possible  I know this is a very difficult discussion, thank you for allowing me to discuss it with you  We will talk again soon. Geriatric Giant Screen 1. Drugs What drugs/reason, S/E, forget 2. Delirium Confusion, day/night, hallucination 3. Dementia Forgetfulness, difficulty paying bills, making meals, driving 4. Depression (MSIGECAPS)

5. Sleep Sleep through, feel rested, snoring 6. Constipation BMs, frequency, painful/hard 7. Urinary Retention Incontinence, frequency, pain 8. Vision/Hearing Visual problems, hearing speech

9. Falls Falls, unsteady, lightheaded

10. Supports Friends/family, fun/hobby

11. Functionality: ADLs: feeding, grooming, washroom; IADLs: cooking, grocery, shopping, bills, driving 24yo F had labs show high chol. Counsel her.  Heart disease: arteries supply blood to the heart, sometimes they can get clogged with plaque leading to a heart attack  TC, HDL, LDL, TG; high HDL is correlated with decreased CAD; high LDL is correlated with increased CAD

  

Risk factors: male >45, female >55, DM/HTN, high cholesterol/low HDL, obesity, smoking, FAMHx 18 if(angina, DM, HTN, smoking, obesity, FMHx, CKD, SLE, atherosclerosis) Signs of hyperlipidemia: atheromata, xanthoma, tendinous xanthoma, corneal arcus

1. HPI  CP/SOB(OE), orthopnea/PND  DM: Polyuria/polydipsia/polyphagia/wt loss  Cold intolerance, dry skin, constipation  RUQ pain, jaundice, frothy urine 2. Meds/OTC/Allergies  Steroids, beta-blockers 3. PMHx/Surgery/Hospitalization  DM/HTN, CKD, autoimmune  Pregnancy, GDM 4. Social Hx  Smoking/ETOH/IVDU 5. Family Hx  CAD 2 office visits  Can be white coat hypertesion, thus can also do ambulatory BP  Cause is likely artery hardening (but unknown), other secondary causes are (Cushing's, pheo, aldosteronism, hyperthyroidism, cocaine, aortic coarctation, renal artery stenosis)  Risk factors: age, obesity, sedentary lifestyle, stress, smoking, ETOH, high salt, family Hx

 Complications: stroke, blindness, heart attack, kidney failure 1. HPI  History of BP, previous treatment  Headache, weakness, visual problems, CP/SOB, claudication  Snoring, daytime somnolence, morning headaches (OSA)  Sweating, tremor, muscle weakness, tachycardia (pheo)  Heat intolerance, sweating palpitations, diarrhea (thyroid)  Thinning of skin (Cushing's), flank pain (kidney dz) 2. Meds/OTC/Allergies  NSAIDs, cocaine, sodium 3. PMHx/Surgery/Hospitalization  Sleep apnea  DM, high cholesterol  Afib, heart failure, MI 4. Social Hx  Smoking/ETOH/IVDU, cocaine  Work schedule 5. FamHx 6. Counselling:  Lifestyle changes x3months (exercises, salt, smoking/ETOH cessation, stress reduction)  Lab work: HbA1c, creatinine/GFR, lipids, U/A, uACR, ECG  First line HCTZ or ACEi: diuretic that prevent body from retaining too much salt  S/E: urination, dizziness, may increase blood sugars  F/U every 3 months 45yo F new to clinic with a history of Diabetes. Take a history. 1. HPI  Type I/II, when diagnosed, glucometer, levels in AM/PM, HbA1c  Hunger, dizziness, tingling, concentration  Polydipsia, polyuria, nocturia, polyphagia, wt loss  Blurred vision, impotence, constipation, bloating (gastroparesis), orthostatic, feeling in feet  CP/SOB, claudication 2. Meds/OTC/Allergies  Insulin use 3. PMHx/Surgery/Hospitalization  Foot/eye care  Retinopathy, nephropathy, neuropathy  CAD/CVD, stroke, HTN, dLp  PCOS, gestational diabetes  Hospitalizations for DKA 4. Social Hx

 Smoking/ETOH/IVDU, occupation, diet, exercise 5. FamHx  DM 6. Counselling  Diabetes is a disease of glucose dysregulation  What are risk factors? First degree relative, high risk population, hx of IGT/GDM. Vascular dz, overweight, HTN, dLp, PCOS, acanthosis nigricans.  Lifestyle trial for 3 months, then medications.  Firstline antihyperglycemic agents? Metformin, sulphonylurea, alpha-glucosidase inhibitor.  Increases sensitvity of cells to insulin. OD/BID.  A/E include nausea, diarrhea, abdo pain, weight loss, lactic acidosis  C/I: kidney dz, low BMI  What are complications of diabetes? Neuropathy (impotence, constipation, diarrhea, gastroparesis, orthostatic hypotension, paresthetic feet), Retinopathy, Nephropathy, CVS, foot care, hospitalizations (DKA, hyperosmolar nonketotic coma, hypoglycemia). PEP Questions  What are screening guidelines? q3yrs >40yrs no risk factors.  Diabetes: Symptoms + random glucose >11.1; FPG > 7.0; HbA1c > 6.5%

1yr M brought in by mother to discuss immunzations. Counsel her. 1. Education  Prevent serious illnesses. It is safe, majority of babies get it.  Also prevents spread of disease. E.g. smallpox eliminated  “Does this make sense?” “Do you have any questions?”  Inj: cry, irritable, low-grade fever, local reaction. Fluids+Tylenol  If large swelling, or around lips/mouth, rash, call doctor immediately.  Rare: 1/1000 high-grade fever, seizure, call 911. 1/500,000 anaphylaxis.  “The disease is more srs than the complication, thus we vaccinate.” 2. MMR and Autism  Paper published in 1990s in NEJM. Since been discredited.  The study was very small and the outcomes were biased.  Several large-scale epidemiological studies found no evidence. 3. Summarize  With your consent, you child will be vaccinated for these vaccines. The reason is to benefit your baby and prevent any harm, as well as for the interest of public health.  Vaccines are safe. There are minor side-effects such as slight fever and irritability, use Tyelnol. If baby has severe reaction call doctor.  “Does this make sense?” “Do you have any questions?”

65yo M dx with Alzheimer's. Inform the patient and counsel him. 4 A's of Alzheimer's: amnesia, aphasia, apraxia, agnosia SPIKES: setting, perception, invitation, knowledge, empathy, summarize

1. Setting 2. Perception (“before you tell, ask”)  Is it ok to share important news, if they want someone here, their knowledge of the test 3. Invitation (obtaining patient's invitation)  “Would you like me to give you all the information or sketch out the results and spend more time discussing the treatment plan?” 4. Knowledge: “Unfortunately I've got some bad news to tell you”  Positive for Alzheimer's, form of dementia: memory loss, confusion, word finding difficulties, concentration, problems with paying bills, getting lost etc..  Later changes include behavioral changes (sometimes aggressive, sometimes passive), hallucinations, needing help with eating/bathing/dressing, incontinence, driving will become dangerous/cooking  Patient asks “how did I get it?”  Unknown mechanism, deposits in the brain, risks: age and family hx  No cure, medications improve memory, slow progression >10 years  Death is due to other illness (pneumonia, bladder/kidney infection, complication of fall)  Meds are trialed for 8 weeks and monitored for side effects  For other symptoms such as depression we have SSRIs  Asks patient if he has any questions Empathy  “I can see how upsetting this is to you.”  “I guess anyone might have that same reaction.”  Asks patient about social supports (family, friends)  Offers to help tell family Summarize  Advises patient to think about getting financial affairs in order  Advises patient to think about drawing up an advanced directive  There are also support groups available for you and your family  F/U q3 months 35yo F wants to quit smoking. Counsel her. 1. HPI  Quantify cigarette use, previous attempts, health concerns, why they want to quite (pre-contemplative, contemplative, preparation, action, maintenance, relapse) 2. Knowledge



Pts knowledge of health risk; educates risks of smoking (stroke, heart attack, sexual impotence, COPD, lung cancer, infections, other cancers, costs)  Benefits of quitting (heart health, costs, better exercise tolerance, better breathing) 3. Treatment  Counsels on quitting with friends or joining support groups; Reassures the patient that it won't be easy; Advises that patient takes on another activity (chew gum)  If failed, can try medications (Champix, wellbutrin, patch) Stages of Change Precontemplation No intention to change behavior (4R's: reluctance, rebellion, resignation, rationalizations). Tx: provide information and raise doubt Contemplation Aware of problem, not made commitment (ambivalent) Tx: explore the “good and less good” things Preparation Intending to change withing next month Tx: help patient create their own plan and reinforce pros of changing Action Making modifications to life Tx: focus on success, reaffirm commitment Maintenance Prevent relapse Tx: manage crises by reviewing progress that has been made

SECTION II The Strawberry­Jam Stations (33 Stations)

Note: These are examples of the stations that usually occur in a couple stations during the OSCE. They make you think “oh S$!T”

Combined Stations (4 Stations) 65yo M, transient loss/strain of vision L eye. Take a hx and px. Closed/open angle glaucoma, vitreous hemorrhage, retinal artery/vein occlusion, retinal detachment, cataracts, DM retinopathy, macular degeneration, optic neuritis, migraine, CVA, temporal arteritis, trauma. HTN.

1. HPI  Onset, duration, bilateral, central/peripheral, total/partial, flashing lights, floaters, lines  Pain, trauma, headache/temporal, dysarthria/dysphagia/ataxia  Weakness/paralysis/urinary incontinence (MS)  Red eyes, itchy, discharge 2. Meds/OTC/Allergies  Eye drops, heart medications 3. PMHx/Surgery/Hospitalization  DM, HTN, glaucoma,  Stroke, migraines, MS 4. Social Hx  Smoking/ETOH/IVDU  Occupation, driving 5. FamHx  Stroke, DM, migraines, eye dz Physical Examination  Vital signs (commenting on afib) 1. Inspection  Symmetry, gaze, ptosis, trauma 2. Palpation  Carotid artery ausculation/palpation  Temporal artery (pain/beading), scalp tenderness, TMJ/open close mouth (claudication pain)  Press on eye for pain (glaucoma) 3. Auscultation  Heart (S1,S2,S3,S4,murmurs) 4. Neuro  CNII: Visual acuity, color vision (decreased in optic neuropathies), visual fields, pupils (PERL, RAPD),  Fundoscopy (papilledema, hemorrhage, vascular occlusion, cup-todisc ratio 0.5)  CNIII/IV/VI: EOM (nystagmus, dysconjugate gaze),  CNV, VII, VIII, IX/X, XI/XII  Finger-to-nose, repetitive movements, pronator drift  Tone, Motor/sensory/reflex, Babinski, clonus PEP Questions:  What are the risk factors? Ocular hx, DM, HTN

  

What are some etiologies of vision loss? Glaucoma, retinal artery/vein occlusion, optic neuritis, retinal detachment, temporal arteritis, retinopathy, cataracts. What imaging modality can be used? CT head scan if central process suspected. Carotid doppler if suspicious for occlusion. Picture shows hemorrhages, provide a differential? HTN retinopathy, vein occlusion, papilledema, glaucoma, DM, trauma, macular degeneration,

45yo M comes in complaining of problems swallowing. Take a history. Mechanical/motor/initiation. Stricture/Schatzki's Ring, esophageal carcinoma, eosinophilic esophagitis vs. achalasia, esophageal spasm, scleroderma, GERD vs. stroke, MS, myasthenia gravis, Parkinson's

1. HPI  Onset, duration, previous episode, progression (solids:mechanical, liquids:motility), coughing/drooling/choking (initiation), food getting stuck, pain, provoking/palliating factors (cold liquid:spasm)  Hoarseness, halitosis, heart burn/vomiting, regurgitation (Zenker's)  Fever, chills, night sweats, wt loss, appetite  SOB/cough, wheezing  Heat intolerance, sweating, anxiety, palpitations, diploplia  Joint pain/rash/skin thickening, Raynaud's (CREST)  Tremor, gait, balance, weakness/paralysis/incontinence (MS)  Fatigue with prolonged speaking, food in mouth after swallowing. 2. Meds/OTC/Allergies  Bisphosphanates, NSAIDs 3. PMHx/Surgery/Hospitalization  GERD (investigations), DM, cancer  Myasthenia gravis, scleroderma (CREST)  Stroke, MS, Parkinson's 4. Social Hx  Smoking/ETOH/IVDU, occupations  Suicide/caustic ingestion 5. FamHx  Cancer, MS, autoimmune Physical Examination 1. Inspection  Distress, emaciation, oral cavity (dentition, abscess, pharynx), skin (rashes, nodules/sclerosis), muscle (wasting/fasciculations) 2. HEENT  Palpate nodes, thyroid (nodules/goiters) 3. Chest  Tactile fremitus (aspiration = consolidation)  Auscultate lungs (vesicular, GAEB) [R/O aspiration pneumonia] 4. Neuro  Sit-to-stand (proximal), heel/toe walk, Romberg's  Easy fatigue: peek test = close eyes gently for 30 sec (MG)

  

Tone: hand tremor/cogwheeling/rigidity CN V, IX/X, XI, XII, (no need for eye tests) Pronator drift, finger to nose, repetitive movements

45 yo M w/ an incidental finding of hypercalcemia. Do a hx and px. 90% are malignant (lung, breast, myeloma, leukemia, lymphoma), hyperparathyroidism (primary, lithium related, familial). Vitamin D related disorders (toxicity, sarcoidosis), bone turnover (thiazides, hyperthyroidism, vitamin A intoxication), renal failure (milk-alkali), thiazides, familial.

1. HPI (stones, bones, abdominal moans, psychic groans)  Onset, duration, lethargy, weakness, confusion  Polyuria, nocturia, polydipsia, flank pain/stones  Constipation, abdominal pain, nausea, anorexia  Fever, chills, night sweats, wt loss, appetite  Chronic cough  Syncope  Heat intolerance, palpitations, sweating, diarrhea  Amount of milk they drink. 2. Meds/OTC/Allergies  Vitamin D, vitamin A/tretinoin/acne,  Thiazide/diuretic, lithium  Calcium supplements 3. PMHx  Cancer, thyroid dz 4. Social Hx  Smoking/ETOH/IVDU 5. Family Hx  Parathyroid disorder, pancreatic cancer, thyroid cancer  MEN syndromes Physical Examination 1. General  Confusion (AAOx3), band keratopathy (calcium precipitation), skin turgor  Inspect thyroid, palpate for nodules  Palpate lymph nodes 2. CNS  Tone (low) and reflexes (sluggish) 3. CVS/RESP  JVP, heart auscultation,  Chest percussion and auscultation 4. Abdo Exam  Bruising (Grey-Turner's/Cullen's sign), bulging flanks,  Auscultates (BS, tinkling), aortic/renal bruits, venous hums,  Percuss liver, Castell's sign, shifting dullness, bladder distension,

 

Palpation: light/deep, rebound, liver edge, spleen, AAA Testicular exam/pelvic exam

PEP Questions:  Lab tests: calcium, phosphorus, renal function, PTH, TSH, CBC, ACE levels;  Imaging: CXR, bone scan

25yo M with a history of IVDU/traveled comes in with fevers. Do a px. Infectious endocarditis (fever, track marks, heart murmur, heart failure, stroke, PE, splenomegaly), cellulitis

1. HPI  Onset, duration, variations, fever, chills, night sweats, sweating, myalgia, fatigue  Headache, neck stiffness, dysphagia/dysarthria/ataxia  New lumps/bumps  N/V, diarrhea  Cough, SOB/CP, stuffy/runny nose  Dysuria/discharge, back pain  Joint pain/back pain, skin rash, bloody stools  Abdominal pain/mass, jaundice  Heat intolerance, palpitations  Pregnancy 2. Meds/OTC/Allergies  Abx use, vaccinations 3. PMHx/Surgery/Hospitalization  TB, HIV, immunosuppression  RA, autoimmune dz 4. Social Hx  Smoking/ETOH/IVDU  Travel: where, when, activities, sick contacts, mosquitoes/ticks, animal exposure (sheep, cattle, goats = Q fever: atypical pneumonia, hepatitis)  Sexual hx, STD  Occupation (HCW, ID clinic) Physical Examination 1. General  Distress, facial symmetry, jaundice  Janeway lesions, Osler's nodes, splinter hemorrhages, track marks  Palpates pulses in arm/feet 2. H/N  Lymph nodes, conjuctival hemorrhages  CNII-XII: EOM, pupils, fundoscopy =Roth Spot's  Finger-to-nose, repetitive movements, pronator drift 3. Cardiac/Resp

 Auscultate carotids/palpate (bruits)  JVP  Thrills, apex beat, auscultate heart (murmurs)  Auscultates lungs 4. Abdo Exam  Angiomata, masses, bulging flanks, bruising  Auscultate for bruits and venous hum over liver  Palpate for hepatomegaly/splenomegaly, nodules, masses PEP Questions  What are the immune complex signs? Osler nodes, roth spots  What are the vascular phenomena? Splinter hemorrhages, janeway lesions, conjuctival hemorrhages  What are the organisms? Staph aureas (IVDU), streptococcus viridans and staph epidermidis (prosthetic valve), enterococcus, HACEK and Candida.  What abx? PenG and Gentamicin (for streptococcus viridans and enterococcus); Clox/Vanco and Gentamicin for staph aureus.  What 3 investigations? CBC, serial blood cultures, TEE  CXR, loculated opacity in RUL. What test would you order? AFB sputum, sputum culture, thick and thin smear, Needle aspiration or biopsy > transbronchial  Ddx: TB, granulomatous disease (sarcoid, Wegeners), malignancy, fungal infection.

Physical Examination (5 Stations) Pelvic Exam  Explain process and offers chaperone 1. Position  Feet in footrest, buttock at edge, drape mid abdomen to knee 2. Inspection of Externa  Labia majora/minora, urethral meatus, clitoris, vaginal introitus, perianal region (inflammation, ulcers, warts, pustules, swelling, discoloration, atrophy) 3. Internal Exam  Speculum: size, lubrication  Cervix: location, color, os, ulcers, lesions, bleeding, discharge  PAP smear  On removal assess for cystocele/prolapse 4. Bimanual Exam  Lubricate index/middle finger, palpate cervix, motion tenderness, palpates uterus (bimanual) (size, shape, mobility), palpates ovaries (size, shape, mobility). 5. Pelvirectal Exam  Tell patient and verifies consent  Middle finger into recturm (posterior vaginal wall = masses) 25yo M comes in with ear pain. Do a HEENT examination. 1. Head  Symmetry, size, shape, masses  Hair: quantity, distribution, loss, scalp redness, scaling, lumps, scars  Face: expression, hair, pigmentation, lesions  Palpates: scalp/skull for tenderness, temporal arteries (thickening, tenderness, beading) 2. Eyes  Inspect: alignment, eyebrows, conjuctiva, sclera, cornea  Visual acuity (Snellen's), visual fields, EOM, PERLA  Fundoscopy (optic disc/cup, arterioles/veins, macula, fovea) 3. Ears  Auricle (size, position, symmetry), lumps, inflammation, discharge  Otoscopy (red/white, transparent/opaque, retracted/neutral/bulging, cone of light, handle of malleus 4. Nose  Deformities, asymmetry, mucosa for swelling, exudate, ulcers, polyps, septal deviation, inflammation, perforation  Palpates sinuses, performs transillumination 4. Throat

      

Lips: symmetry, color, crack, ulcers Mucosa: color, ulcer, white patches Gum: inflammation, ulceration, swelling Teeth: missing, color Tongue: movement, symmetry, ulcers Uvula: “ah”, midline, symmetrical Pillars: tonsils, color, symmetry, swelling, exudations, ulcerations

25yo M comes in to ER c/o severe left leg pain. IVDU. XR -ve. Do a px. Septic arthritis vs osteomyelitis. Compartment syndrome: 6Ps - Pain out of proportion, Paraesthesia, Pallor, Pulseless, Polar, Paralysis

 ABCs 1. Inspection  Swelling, Erythema, Atrophy, Deformity (hip abduction, length of leg), Skin (red, skin breaks, petechiae, surgical scars [CABG, femoral-arterial bypass]) 2. Palpation  Temperature, capillary refill, pulses, Baker's cyst  Effusion swipe test  Hip, femur, patella, tibial plateau, tibial tubercle, fibular head, femoral head, tibia/femur. 3. ROM  If septic, will be limited due to swelling 4. Neuro  Tone, Motor (L2 – hip flexion; L3 – knee extension; L4 – inversion of foot; L5 – extension of great toe; S1 – eversion of foot)  Sensory (L2 – lateral thigh; L3 – middle knee; L4 – middle ankle; L5 – 1st web space; S1 – lateral foot) (light touch, pin-prick, vibration)  Reflexes (L4 – patellar; S1 – achilles, Babinski, clonus) PEP Questions:  What test would you do? Bone scan. Management of Fractures  Life before limb (ABCs), reduce fracture (prevent neurovascular injury then XR and re-check status)  Irrigation/debridement/Abx for open fractures  Analgesics, immobilization/aids if required, tetanus prophylaxis  May require fixation, manipulation, arthroscopy  Red flags for f/u if: swelling, cyanosis, increased pain, decreased sensation  Complications: nonunion, malunion, joint stiffness, AVN, osteomyelitis

55yo F with claudicating pain/leg ulcer/tingling in feet. Do a px. Spinal stenosis (radiating pain, worse w/ standing/walking, better w/ bending forward/sitting). Arterial: vasculitis, popliteal (painful, rest pain, worse w/ walking, better w/ rest, RF: smoking, HTN, dLp, CAD, MS, obesity). Venous (minimal pain, pigmentation, marked edema, ulcer @ankles)



Comments on discomfort

 Vital signs (BP in both arms, normal 40pyh w/ hemotypsis  Consult thoracic surgery

65yo M is a new patient with a history of COPD. Take a history. FEV1/FVC 4 red flag]  SOB: blocks/stairs walked, any SOB at rest  CP (rest/activity), orthopnea, PND, edema, wt gain  Fevers, chills, night sweats, wt loss

 Facial fullness/pain, runny/stuffy nose, ear pain  Asthma, nasal polyps, ASA sensitivity (Samter's triad)  Eczema, rashes  Oral thrush 2. Meds/OTC/Allergies  Puffer use (>3x/week red flag), steroids, O2  Pneumococcal/influenza vaccine 3. PMHx/Surgery/Hospitalization  ER visits, ICU admissions 4. Social Hx  Smoking [>40pyh LR=12]/ETOH/IVDU  Missed work, pets, age of home, occupation  Social supports, activities  Plans for future, traveling, advanced directives 5. Family Hx  Atopy, CF 35yo M comes in with hematemesis. Take a focused history. Peptic ulcer, esophagal varices, Mallory-Weiss tear, AVM, gastritis, esophagitis, cancer, nose bleed, hemotypsis.

1. HPI  Onset, duration, episodes, frequency, content (coffee grounds, food, bilious), strenuous vomiting, provoking/palliating factors  Epigastric pain (PQRSTPP), acid reflux, dysphagia  Jaundice, ascites, edema, dark urine/pale stools, itching  Nose bleed, bleeding gums, bruising, petechiae, bloody stools  Fever, chills, night sweats, wt loss,  Cough, CP/SOB,  Fatigue, tachycardia, light-headedess 2. Meds/OTC/Allergies  Anticoagulants, steroids, NSAIDs 3. PMHx  Liver dz, bleeding disorder  Surgery, hospitalization 4. Social Hx  Smoking/ETOH/IVDU PEP Questions  Managements: IVx2, CBC, INR/PTT, group/x-match, lytes, LFTs  Monitor urine output  Endoscopy on unstable patients. Stable patients within 24 hours  Variceal bleeding (band ligation, sclerotherapy, tamponade).  Ulcer (endoclips w/ adrenaline, thermal coagulation, fibrin/thrombin)  Pantoprazole 80 mg IV bolus, followed by 8 mg/hour infusion 72 hrs postendoscopy. NPO for 8-12 hours post endoscopy.

65yo M comes in with a history of jaundice Take a history. Pre-hepatic, hepatic, post-hepatic: spherocytosis, G6PD, sickle cell, HUS/TTP/DIC, PBC, PSC, gallstones, pancreatic cancer, biliary cancer, infection (HepABC)

1. HPI  Onset, duration, previous episodes, itchiness, pale stool/dark urine, ascites, confusion, hematemesis, bruising, melena  Abdominal pain (PQRSTPP), constipation/diarrhea  Fever, chills, night sweats, appetite, wt loss (ascending cholangitis)  Joint pain/skin bronzing (hemachromatosis), rash  SOB (alpha-1-antitrypsin) 2. Meds/OTC/Allergies  Statins, blood transfusions  Immunizations 3. PMHx/Surgery/Hospitalization  Liver dz, gallstones, RBC dz  Hemachromatosis, Wilson's  HIV, IBD 4. Social Hx  Smoking/ETOH/IVDU, tattoos  Sexual Hx, STDs  Travel history 5. Fam Hx  Liver dz, blood cell dz, hemachromatosis 65yo M comes in complaining of an abdominal mass. Take a history. Cancer, abscess, hernia, cholecystitis, hepato/splenomegaly, hepatitis, pancreatitis, AAA, ectopic, pregnancy, ovarian cyst, diverticular abscess, fibroids, bladder distension, stool.

1. HPI  Onset, duration, size/progression, reducibility, location, pain (changes with BM),  N/V, bloating, constipation/diarrhea, bloody stools/melena  Fever, chills, night sweats, wt loss  Dysphagia, early satiety, bone pain  Jaundice, fatigue, shoulder pain, dysuria/straining  LMP/pregnancy  SOB, cough, sore throat (splenomegaly) 2. Meds/OTC/Allergies 3. PMHx/Surgery/Hospitalization  Cancer, liver dz 4. Social Hx  Smoking/ETOH/IVDU  Travel hx 5. FamHx

 Cancer, cysts, IBD 6. Counselling for CRC Screening  NO FamHx colonoscopy q10yrs @ 50yo OR FIT q1yr  If 1st degree relative 50yo then FOBT q1yrs + colonoscopy q10yrs starting @ 50yo  HNPCC: q1-2yrs colonoscopy @ 20yrs  FAP: q1yrs sigmoidoscopy @ 10yrs 45yo M comes in complaining of a neck lump. Take a history. 1 lump = cystic hygroma, congenital dermoid cyst, branchial cyst, carotid body tumor, carotid artery aneurysm, salivary gland stone/tumor, thyroglossal cysts, single thyroid nodule, goitre, pharyngeal pouch. If bilateral = chronic parotitis, mumps, Sjogren/Mikulicz syndrome. If multiple = sebaceous cysts, lipomata, lymph nodes, multinodular goitre

1. HPI  Onset, duration, location, number, growth, pain  Fever, chills, night sweats, wt loss  Dysphagia, odynophagia, hoarseness, halitosis  SOB/CP, cough, hemoptysis, wheezing, runny/stuffy nose  Palpitations, diploplia, heat intolerance,  Kidney stones, constipation, polyuria, fatigue  Ear pain 2. Meds/OTC/Allergies  Beta-blockers, lithium, thyroxine 3. PMHx/Surgery/Hospitalization  Pregnancy, thyroid dz, skin lesion (melanoma)  Radiation, cancer 4. Social Hx  Smoking/ETOH/IVDU  Travel: camping (lyme, fungal), developing countries (TB)  Sexual Hx, STD (HIV)  Cat scratches 5. FamHx  Thyroid dz/cancer, neurofibromatosis 65yo M comes in complaining of weakness UMN vs LMN vs NMJ vs muscle (myopathy); Fatigue (weakness without an anatomic or temporal pattern) vs Weakness (specific pattern with objective findings). MS, myasthenia gravis, Eaton-Lambert, Guillain-Barre, ALS, spinal cord injury, hypokalemia, hypercalcemia, hypo/hypernatremia, b12, hypothyroidism, Cushing's, steroids, statins, ETOH, cocaine, interferon, infection (flu/EBV/CMV/lyme/HIV), polymyositis, dermatomyositis, lupus, stroke/TIA.

1. HPI



Onset, duration, pain, fluctuation, distribution (diffuse, focal, one side, proximal/distal), severity (rising from chair/brushing hair), provoking/palliating (exercise [worsens with MG, improves with Eaton-Lambert], heat [worsens with MS]), blocks you can walk  Numbness, tingling  Fever, chills, night sweats, wt loss, preceding illness (GBS)  Speech getting worse with prolonged speaking, drooling, chewing, difficulty swallowing (MG: LR+4.5 LR-0.61)  Dysphagia, dysarthria, diploplia, CP/SOB (stroke/ALS)  Skin rash (SLE, dermatomyositis), joint pain  Cold intolerance, wt gain, dry skin, eye irritation  Mood, anxiety, suicide, sleep, hopelessness, stressors 2. Meds/OTC/Allergies  Steroids, statins, interferon 3. PMHx/Surgery/Hospitalization  Hypothyroidism, DM, adrenal, malignancy  CMV, HIV  Depression 4. Social Hx  Smoking/ETOH/IVDU,  Occupation (organophosphates in farming), lead exposure 5. Family Hx  MG, muscular dystrophy, autoimmune dz, collagen vascular dz, ALS 75yo F, refill on sleeping pills, do a hx and counsel her. RLS, sleep apnea, pain/noise, bereavement/stress/depression/anxiety, dementia, ETOH abuse, Parkinson's disease

1. HPI  Onset, trouble falling/staying/awakening from sleep, feeling refreshed, leg twitching, snoring, nocturia  Medications, how much/how long, tried anything else  Mood, stressors, guilt, energy, concentration, suicide, confusion, memory, incontinence, constipation, fall, pain, weakness  Elicits that patient's husband died 3 months ago and she started having sleeping problems then.  Tells patient that she likely needs the medication for now 2. Meds/OTC/Allergies 3. PMHx  Lung dz, previous stroke  Myasthenia gravis 4. Social Hx  Smoking/ETOH/IVDU  Previous susbstance abuse 5. Counselling



Regular sleep schedule, avoid caffeine after lunch. ETOH/smoking in evening, exercise before 7pm  DO NOT go to bed hungry/daytime naps/force sleep (get up after 20 min)  Use bed only for sleeping  Try some relaxation before bed  DO NOT use antihistamines Medications  Benzodiazepines, non-benzo (zoplicone), trazadone (antidepressant), melatonin agonists  These medications may be habit forming  Can try for 4 weeks then reassess  Talk to doctor before you stop taking it [avoid withdrawal]  C/I in liver dz, avoid driving, avoid ETOH/sedatives/pain meds, antihistamines  Side effects include: lightheaded, fatigue, weakness, change in balance, blurred vision, confusion, dry mouth. 2wk old infant, fever of 38.8. Take a hx and counsel the mom. Pneumonia, gastroenterits, UTI, meningitis, TORCH, autoimmune

1. HPI  Onset, duration, pattern, Tmax, thoughts of cause, lethargy, seizure  Coughing, SOB, wheezing, cyanosis, choking/poor feeding  N/V, diarrhea, foul smelling urine  Rashes, joint swelling  Jaundice, breastfeeding  Fluid intake/appetite, wet diapers, wt gain/loss,  Hearing/vision (TORCH) 2. Meds/OTC/Allergies  Immunizations 3. Pediatric Hx  Jaundice  Developmental hx, infection, prenatal care (U/S, GDM, HTN, infection, bleeding), smoking/ETOH/drugs,  IUGR, GBS status/fever/maternal UTI, PROM  GA, delivery, birth wt, APGARS  NICU, metabolic screen, fever/shock/seizure/respiratory distress, meconium 4. Past ObsGyn Hx  Previous, delivery, gender, wt, complications 5. FamHx  Congenital deformities, immunodeficiencies, sickle cell PEP Questions:  What to do next? Find out no urine output for last 12 hours. Send to ER.

   

What three causes of sepsis in 10yrs): neuropathy, retinopathy, renal failure, CAD; Annual eye screening/foot checks 35yo F is pregnant, her sister had kid with Down's Syndrome. Counsel. 1. Counselling  Her chances are not increased by sister  Due to her age change is 1/350  Genetic counselling is available/financial support 2. HPI  Most common chromosomal condition (~1/800 births), screening options (SIPS, IPS, FTS, NIPT[$800]), screening options not perfect  Diagnosis is by karyotyping  Increased materal age associated with DS  Facial features (upslanted eyes, protruding tongue, short neck), palmar creases, hypotonic  Risk of cataracts, hearing loss, ear infections, cardiac anomolies, OSA, GI tract anomolies, celiac dz, hypothyroidism, infertility, short stature, obesity, leukemia  Developmentally delayed, behavioral problems, early Alzheimer's 3. Management  Multidisciplinary approach, most are born healthy but they need close monitoring  Specialists include cardiologists and ophthalmologists, speech therapist, dietitian, occupation and physiotherapists  Give child a normal of a life as possible  Support groups available 4. Prognosis



Despite the initial mortality rate being increased in the first year of life, most children with Down’s syndrome can expect to live until 5055 years.

Alice, daughter of your patient. Her mother has had Vfib, needed resuscitation in ICU, and was comatose for a few days. Now AAOx3. Alice wants a DNR.  Point out mother is alert, discuss with mother life-sustaining treatments, point out mother's preference, it is mother's right to decide.  Put herself in mother's shoes, she may welcome the discussion, can be handled in sensitive way, daughter can be present during discussion  Refuses to write DNR order, only with mother's consent, mother has rights  Explain what the DNR order states.  What concerns she has? e.g. care-giver burden. Why does she want her mother to be DNR? Also what does she think her mother would want? 25yo F nurse stuck herself with a needle. Counsel her. 1. HPI  “This must be a difficult to deal with, but I assure you it happens quite often”  Rinse with water (10min), disposed needle safely, reassure chances of transmission are low  HIV (0.3%), HepB (30%), HepC (1.8%)  Depth of needle, blood on needle, patient IVDU/sexual hx  HepB vaccination, tested for HIV before  Consent patient and nurse for HepB/C, HIV testing  Talk to Worksafe  If nurse is vaccinated but no booster in last 6 months, give booster  If donor is at risk for HIV, start prophylaxis