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NAC OSCE A Comprehensive Review First Edition

Copyright @ 2011, Canadaprep. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher. Reproducing passages from this book without such written permission is an infringement of copyright law. Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the authors, editors, and publishers are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the contents of the publication. The authors, editors, and publishers have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practices at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug. This publication has not been authored, reviewed or supported by the Medical Council of Canada, nor is it endorsed by the Medical Council as a review material for the NAC OSCE.

PREFACE This book was written due to the lack of preparation material available for the National Assessment Collaboration (NAC) Objective Structured Clinical Examination (OSCE). As an International Medical Graduate (IMG) preparing for clinical and written exams in Canada, there is no comprehensive review textbook available for the NAC OSCE. Due to the lack of resource materials, many students are forced to study from sources that are not relevant to the NAC OSCE. This eventually hampers the candidate's score in the examination. This book aims to guide you through the steps of the NAC OSCE and ensures that you are well prepared and a step ahead of the competition. A great effort has been put into collecting and organizing relevant content for both the clinical OSCE stations and the written therapeutic exam. Written by medical graduates who are oriented to the NAC OSCE, this comprehensive review can be used as a framework, complementing your clinical skills and therapeutic knowledge as you prepare for the examination. This book is dedicated to all the IMGs preparing for the medical licensing examinations in Canada. “And most important, have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary.” - Steve Jobs

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TABLE OF CONTENTS Introduction to NAC OSCE General Information ...............................................................................................................1 Registration for NAC OSCE ..................................................................................................1 Fees ........................................................................................................................................1 Examination station ................................................................................................................1 NAC OSCE scoring ...............................................................................................................2 Sample of Therapeutic written test ..........................................................................................2 Sample clinical case station .....................................................................................................3 Therapeutic Guidelines Medicine Cardiology ..............................................................................................................................7 Dermatology ........................................................................................................................11 Endocrinology ......................................................................................................................14 Gastroenterology ..................................................................................................................16 Hematology ..........................................................................................................................19 Infectious Diseases ................................................................................................................19 Neurology .............................................................................................................................21 Otolaryngology .....................................................................................................................23 Pulmonology ........................................................................................................................24 Rheumatology ......................................................................................................................26 Nephrology/Urology .............................................................................................................29 Emergency Medicine ............................................................................................................30 Counseling (smoking/alcohol) ...............................................................................................35 Obstetrics & Gynecology Sexually transmitted infections ..............................................................................................38 Urinary tract infection ...........................................................................................................39 Vulvovaginitis .......................................................................................................................39 Pelvic inflammatory disease ...................................................................................................40 Dysfunctional uterine bleeding ..............................................................................................40 Dysmenorrhea ......................................................................................................................40 Endometriosis ......................................................................................................................40 Hormone replacement therapy ..............................................................................................41 Emergency contraception ......................................................................................................41 Group B Streptococcus in pregnancy .....................................................................................41 Pregnancy induced hypertension ...........................................................................................41 Ectopic pregnancy ................................................................................................................42 Hyperemesis gravidarum .......................................................................................................42 Drugs contraindicated in pregnancy ......................................................................................42 Pediatrics Acute bronchiolitis ................................................................................................................45 Acute otitis media .................................................................................................................45 Asthma .................................................................................................................................45 Bacterial tracheitis ................................................................................................................45 Bacterial pneumonia .............................................................................................................46 Croup (Laryngotracheobronchitis) ........................................................................................48 Epiglottitis ...........................................................................................................................48 Streptococcal pharyngitis (Group A streptococcus) ................................................................48 Whooping cough (Pertussis) .................................................................................................48 Bacterial meningitis ..............................................................................................................49 Febrile seizures .....................................................................................................................49 Urinary tract infection ...........................................................................................................49 Allergic reaction ....................................................................................................................50 Anemia .................................................................................................................................50 Dose of tylenol .....................................................................................................................50 Immunization schedule .........................................................................................................50

TABLE OF CONTENTS Psychiatry Delerium ..............................................................................................................................52 Mania ...................................................................................................................................53 Panic disorder .......................................................................................................................53 Social phobia ........................................................................................................................54 General anxiety disorder .......................................................................................................54 Obsessive compulsive disorder ...............................................................................................55 Post traumatic stress disorder ................................................................................................55 Dementia .............................................................................................................................55 Depression ............................................................................................................................56 Psychosis ..............................................................................................................................56 Mood stabilizers ...................................................................................................................57 Medications causing sexual dysfunction .................................................................................58 Substance abuse ....................................................................................................................59 Clinical Examination Abdominal ...........................................................................................................................63 Cardiovascular .....................................................................................................................65 Peripheral vascular ................................................................................................................67 Respiratory examination ........................................................................................................69 Central nervous system ........................................................................................................71 Upper limb neurological .......................................................................................................73 Lower limb neurological .......................................................................................................75 Musculo-skeletal system : Spine/Back ...................................................................................77 Hip .......................................................................................................................................79 Knee .....................................................................................................................................81 Foot and ankle ......................................................................................................................83 Shoulder ...............................................................................................................................85 Elbow ...................................................................................................................................87 Hand and wrist .....................................................................................................................88 Breast examination ................................................................................................................90 Thyroid ................................................................................................................................91 Mini Mental State Examination ............................................................................................93 Clinical cases Protocol for history taking .....................................................................................................99 Medicine Atrial fibrillation .................................................................................................................102 Asthma ...............................................................................................................................103 Congestive heart failure .......................................................................................................104 Cerebrovascular attack .........................................................................................................105 Digoxin toxicity ..................................................................................................................106 Infectious mononucleosis (sore throat) .................................................................................107 Impotence ...........................................................................................................................108 Meningitis ..........................................................................................................................109 Migraine (Headache) ..........................................................................................................110 Myocardial Infarction(Chest pain) .......................................................................................111 Pneumonia ..........................................................................................................................112 Post exposure prophylaxis for HIV ......................................................................................113 Pulmonary embolism ..........................................................................................................114 Seizure disorder ...................................................................................................................115 Temporal arteritis ................................................................................................................116 Viral hepatitis .....................................................................................................................117 Obstetrics and Gynecology Abortion .............................................................................................................................118 Antenatal visit .....................................................................................................................119 Ectopic pregnancy ...............................................................................................................120

TABLE OF CONTENTS Infertility ............................................................................................................................121 OCP counseling ..................................................................................................................122 Pelvic inflammatory disease .................................................................................................123 Placenta previa ....................................................................................................................124 Pre eclampsia ......................................................................................................................125 Pediatrics Failure to thrive ...................................................................................................................126 Febrile seizure .....................................................................................................................127 Measles ...............................................................................................................................128 Neonatal jaundice ................................................................................................................129 Primary nocturnal enuresis ..................................................................................................130 Pyloric stenosis ....................................................................................................................131 Speech delay .......................................................................................................................132 Psychiatry Anorexia .............................................................................................................................133 Bulimia ...............................................................................................................................134 Delirium .............................................................................................................................135 Dementia ............................................................................................................................136 Depression ..........................................................................................................................137 Mania .................................................................................................................................138 Panic attack .........................................................................................................................139 Schizophrenia .....................................................................................................................140 Suicide ................................................................................................................................141 Surgery Back Pain ............................................................................................................................142 Basal cell carcinoma ............................................................................................................143 Benign prostatic hyperplasia ................................................................................................144 Carpal Tunnel Syndrome .....................................................................................................145 Deep Vein Thrombosis ........................................................................................................146 Diabetic foot .......................................................................................................................147 Difficulty swallowing (Ca oesophagus ) ...............................................................................148 Hematemesis ......................................................................................................................149 Neck swelling ......................................................................................................................150 Pain abdomen .....................................................................................................................151 Peripheral vascular disease ...................................................................................................152 Post operative fever .............................................................................................................153 Solitary lung nodule ............................................................................................................154 Thyroid mass ......................................................................................................................155 Trauma ...............................................................................................................................156 Counseling Breast feeding .....................................................................................................................159 Child abuse .........................................................................................................................160 Domestic violence ...............................................................................................................161 Hormone replacement therapy ............................................................................................161 Mammogram ......................................................................................................................163 Immunization .....................................................................................................................164 Obesity ...............................................................................................................................165 Smoking .............................................................................................................................167

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Introduction to NAC OSCE | General Info

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Introduction to NAC OSCE General Information The National Assessment Collaboration, or NAC OSCE, was established to provide a system that streamlines the assessment of IMG medical knowledge and clinical skills throughout Canada. Many international medical graduates (IMGs) find that the path to obtaining a medical license in Canada challenging and difficult to navigate. Different provinces and territories have their own system for assessing IMG medical knowledge and clinical skills. Comprised of a number of federal and provincial assessment and educational stakeholders, the NAC OSCE aims to streamline the evaluation process through which an IMG must navigate to obtain a license to practice medicine in Canada. Through such a system, an IMG’s path to licensure would be the same, regardless of the jurisdiction in which he or she is being assessed. The NAC OSCE has replaced CEHPEA’s Clinical Examination 1 (CE1), which was unique to Ontario. Registration for NAC OSCE Registration for the NAC OSCE in Ontario starts in November, with the deadline in January the next year. Candidates are advised to complete their registration within this time-frame. Once the deadline is over, the candidate will not be able to register for the NAC OSCE for the entire year. The exams are scheduled for March, June, August and September. Visit www.mcc.ca and www.cehpea.ca for updated information. Fees Application Fee: $200 which is non-refundable, NAC OSCE Fee in Ontario: $1850 and Exam Date Change Fee: $100 All fees are in (CAD) Canadian Dollars. Examination station The format for the National Assessment Collaboration (NAC) Objective Structured Clinical Examination (OSCE) consists of 12 stations based on presentations of clinical scenarios. For a given administration, each candidate rotates through the same series of stations. Each station is 10 minutes in length with two minutes between stations. At each station, a brief written statement introduces a clinical problem and outlines the candidate’s tasks (e.g. take a history, do a physical examination, etc.). In each station, there is at least one standardized patient and a physician examiner. Standardized patients have been trained to consistently portray a patient problem. Candidates should interact with standardized patients as they would with their own patients. The physician examiner observes the patient encounter. For most stations, the candidate will be asked to respond to a series of standardized oral questions posed by the physician examiner after seven minutes with the standardized patient. There are no rest stations. Orientation videos http://www.mcc.ca/en/video/QEII-Orientation/index.html

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NAC OSCE | A Comprehensive Review

The examination includes a separate written test of candidates’ therapeutic knowledge. This component lasts 45 minutes and consists of 24 short-answer questions testing the candidates’ knowledge of therapeutics for patients across the age spectrum and related to pharmacotherapy, adverse effects, disease prevention and health promotion. NAC OSCE scoring The candidate’s total examination score will be determined by combining the scores on the OSCE component with the scores on the therapeutics component. The OSCE score contributes 75 per cent of the total score and the therapeutics score contributes 25 per cent of the total score. For reporting purposes, the NAC total examination scores are reported on a scale with a distribution ranging from 0 to 100 with a fixed passing mark of 65. Number of times candidates can take the examination Starting in 2011, the NAC OSCE can be attempted once per Canadian Resident Matching Service (CaRMS) cycle. If you pass the examination, you can register for the examination a maximum of two additional times if your eligibility is maintained. Regardless of whether you pass or fail, you can only take the examination three times. If you take the examination more than once, the most recent result will be the only valid result. Sample of Therapeutic written test Question: An otherwise healthy 65 year old woman presents with a 3 week history of aching and morning stiffness in both shoulders with difficulty dressing. She has no temporal artery tenderness, headache, jaw pain or visual disturbance. Her ESR (Erythrocyte sedimentation rate) is 100 and you have made the diagnosis of POLYMYALGIA RHEUMATICA (PMP). What would you choose as the drug of first choice for initial medical therapy? (Drug, dose, route of administration and duration are required.) Answer: ________________________________________________________ Answer key the marker receives: PREDNISONE 7.5 – 20 mg PO od for 2-4 weeks following resolution of symptoms Question: An otherwise healthy 55 year old male with a history of childhood “chickenpox” presents with a 2 day history of painful unilateral vesicular eruption in a restricted dermatomal distribution. You make a diagnosis of HERPES ZOSTER (shingles). What would you choose as the drug of first choice to promote healing and lessen the neuropathic pain? (Drug, dose, route of administration and duration are required.) Answer:___________________________________________________________ Answer key the marker receives: VALACYCLOVIR (VALTREX ®) 1000 mg PO tid X 7 days OR FAMCICLOVIR (FAMVIR ®) 500 - 750 mg PO tid X 7 days OR ACYCLOVIR (ZORIVAX ®) 800 mg PO 5X / day X 7 days)

Introduction to NAC OSCE | General Info Sample Clinical Case Station Example instruction written outside the station David Thompson, 59 years old, presents to your office complaining of jaundice. In the next 7 minutes, obtain a focused and relevant history. After the 7 minutes, you will be asked to answer questions about this patient.

Example of post encounter questions Q1. The abdominal examination of David Thompson revealed no organ enlargement, no masses and no tenderness. What radiologic investigation would you first order to help discriminate the cause of the jaundice? Q2. If the investigations revealed that this patient likely had a post-hepatic obstruction, what are the two principal diagnostic considerations? Q3. What radiologic procedure would you consider to elucidate the level and nature of the obstruction?

3

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Therapeutic Guidelines

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Therapeutic Guidelines | Medicine

7

Therapeutic Guidelines Medicine 1. Cardiology Acute Myocardial Infarction : Immediate management in ER 1. Beta blockers: Inj Metoprolol 2.5-5 mg rapid IV q2-5 min, upto 15 mg over 10-15 minutes, then 15 minutes after receiving 15 mg IV. 2. Then 50 mg PO q6h x 48 hours, then 50-100 mg PO BID. 3. Inj Morphine Sulfate IV 2-5 mg every 5-30 min prn (If pain not relieved with 3 Sublingual Nitroglycerins) 4. Oxygen by nasal cannula at 4 liters per minute 5. Sublingual Nitroglycerin 0.3-0.6 mg q5min up to 3 times. 6. Non-enteric coated Aspirin 325 mg PO. 7. Cardiology Consultation

ACUTE MI TREATMENT MNEMONIC B : Beta Blockers M : Morphine Sulphate O : Oxygen N : Nitroglycerin A : Aspirin

Post MI drugs Drugs

Benefits

Side effects

Contraindication

ACE Inhibitors Ramipril – 10mg hs Lisinopril – 10 mg od Enalapril – 20mg od Captopril - 50 mg tid

↓ mortality Prevents ventricular remodelling ↓ proteinuria

Hypotension/dizziness Hyperkalemia Angioedema Renal insufficiency Cough, taste changes

Bilateral renal artery stenosis Hx of angioedema Pregnancy

ARB Valsartan – 160mg bid Candesartan – 32 mg od

↓ mortality ↓ proteinuria

Angioedema Cough, taste changes

Beta Blocker Metoprolol – 100mg bid Atenolol – 100mg od Carvedilol – 25mg bid Propranolol – 60-80 tid

↓ mortality ↓ sudden death, reinfarction & arrhythmias Cardioselective : preferred for mild asthma and diabetes

Decreases BP & HR Dizziness, fatigue Sexual dysfunction May mask hypoglycemia Increase risk of cardiogenic shock

Severe/poorly controlled asthma nd 2 /3rd degree heart block HR 45 degrees.

CHF TREATMENT MNEMONIC L : Lasix M : Morphine Sulphate N : Nitroglycerin O : Oxygen P : Positive airway pressure P : Position > 45 degrees D : Dopamine (indicated in cardiogenic shock and hypotension)

Non pharmacological management of Heart Failure • Exercise : Regular physical activity • Salt restriction : symptomatic HF – 2-3g salt/day (½ tsp/day) no added salt in diet. HF with fluid retention : 1-2g salt/day (¼ tsp/day) • Fluid intake : 1.5/2L per day in patients with fluid retention or HF not controlled by diuretics. • Daily weight measurement. • Education. • Aggressive risk reduction (BP, glucose, lipids). • Lifestyle modifications, influenza vaccination.

Clinical Examination

Clinical Examination

91

Thyroid Examination 1. Steps before beginning examination •

• • • • • •

Introduce yourself : “I am Dr. ________, your attending physician and I'll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.” Wash/Sanitize hands Explain to the patient what you are about to do and gain informed consent. Ensure patient is adequately exposed. Look for medical equipment/therapies Show empathy. Verbalize the steps of the examination and your findings.

2. Inspection •

Ask for patient's vitals.

•

Observe patient : Is patient anxious? Weight gain/loss? Note hoarseness of voice.

•

Feel pulse – rate/rhythm/volume

•

Face :

•

•

Facial expression ( dull in hypothyroidism) Periorbital myxedema Loss of 1/3rd of eyebrows Hair – texture/alopecia Exophthalmos (look from behind patient), lid lag Ophthalmoplegia (ask patient to follow your finger then ask for diplopia) Chemosis (redness and watering of eyes) Hands : Temperature, moist palms, texture, color. Assess for fine tremors, palmar eythema Pemberton's sign - is the development of facial flushing, distended neck and head superficial veins, inspiratory stridor and elevation of the jugular venous pressure ( JVP) upon raising of the patient's both arms above his/her head simultaneously. (Thoracic inlet obstruction – e.g. due to goitre) Carpal Tunnel Syndrome (Tinel's and Phalen's Test) – associated with hypothyroidism. Arm reflexes – brisk in hyperthyroidism. Neck : Stand in front of the patient, inspect for neck swellings/goitre - scars, sinuses, dilated vessels.

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3. Examination of the Thyroid gland and cervical lymph nodes. • • • • • •

Swallow tests – Ask patient to swallow water and observe for movement of any masses. Tongue protrusion – Thyroglossal cyst moves on tongue protrusion. Stand behind the patient and palpate. Assess size, texture, smoothness, margins and mobility of the thyroid gland (including when swallowing). Note the temperature over gland and adjacent skin. Palpate cervical lymph nodes. Percuss over sternum – Retrosternal goitre. Auscultate for thyroid bruit – Grave's disease.

4. Examination of legs. • • •

Pretibial myxoedema Peripheral edema due to congestive cardiac failure. Delayed relaxation of ankle reflex in hypothyroidism.

5. Thank the patient after the examination.

Clinical Cases

Clinical Cases – Protocol for history taking

99

Protocol for history taking A candidate gets 2 minutes outside the station to read the clinical case senario on the door before entering. It is essential to get yourself organised in these 2 minutes. •

Read the question properly, understand the requirement and follow instructions (e.g. if you are asked to do a physical examination, do not start taking history. You will be losing valuable time)

• • • • •

You will be given a pencil and a booklet with blank pages. It is a good practice to jot down notes. Write the name, age, sex and chief complaint of the patient. For history of present illness, you can use the mnemonic OCDPQRSTUV+AAA. Past and Social History : PAM HUGS FOSS Write down your differential diagnosis.

So your note should look something like this : Name of the patient, age, sex and chief complaints O - Onset C - Course D - Duration P - Place Q - Quality R - Radiation S - Severity T - Timing U – You (associated with your daily activities) V – Deja vu (Has it happened before?) A – Aggravating factors A – Alleviating factors A – Associated symptoms

P – Past medical history A - Allergies M - Medication H – Hospitalizations U – Urinary problems G – GIT problems S - Sleep F – Family history O – Obstetrical history S – Social history S – Sexual history

Differential diagnosis :

•

Knock the door before entering, relax, take a deep breath, smile and enter the room with confidence. Hand over the stickers to the physician examiner.

•

Introduce yourself to the patient : e.g. “Good morning/afternoon/evening, Mr./Miss ______, I am Dr. _____ and I'm your attending physician today.” “So, Mr./Miss _____, what complaint has brought you here today?” Show empathy : “Oh! I am sorry to hear that, I shall try my best to help you.”

• •

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Tammy Robbins, a 48 years old lady presented with heart racing and chest discomfort for the past 3 days. Take a focused history and perform focused physical examination. Vitals: BP - 90/70 mm Hg, HR - 146/min, irregular, RR - 12/min, Temp - 37.5°C Clinical Info: Ms Tammy Robbins is a known hypertensive with CAD for the past 10 years, who presented with sudden onset of palpitations and chest discomfort for the past 3 days. Her symptoms are worsening for the past 24 hours. She has dyspnea. She has dizziness for the past 12 hours. Pedal edema is 2 +. She had 2 vessel angioplasty done 5 years ago. ECG shows absent P waves with irregular narrow QRS complexes. Bilateral basal rales present on lung auscultation. Clinical Case : Atrial Fibrillation (examination on page 65) HOPI • OCD PQRST UV + AAA • How did it start? Sudden or gradual. • Is it getting worse/better or no changes in the symptoms? • Duration of palpitations? • Associated with chest discomfort? • Describe the type of chest discomfort? • Do you have chest pain? • Any shortness of breath? • Any dizziness/light headedness? • Any fever/cough/nausea/vomiting? • Any hemoptysis? • Any chills/night sweats? • Any malaise/fatigue/weakness? • Any swelling of feet? • Any numbness/paresthesias? • Any visual problems? • Any relieving factors? • Any aggravating factors? • Any recent trauma? • List of current medications/compliance?

Past History • Do you have any medical illnesses? • Are you allergic to any medications? • Any surgeries in the past? • Past h/o recurrent infections?

Differential Diagnosis Atrial fibrillation secondary to: 1. Congestive heart failure. 2. Ischemic heart disease. 3. Hypertension. 4. Thyroid disease.

Management • Treat the primary cause. • Admit in cardiac care unit. • Rate control by beta blockers, calcium channel blockers or digoxin. • Anticoagulation with heparin, then warfarin. • Rhythm control by electro or medical cardioversion. • Assess Stroke risk by using CHADS2 score.

Investigations • CBC, electrolytes, glucose. • LFT, RFT, TSH. • CK, LDH, Cardiac enzymes. • 12 lead ECG. • Echocardiogram. • Chest X ray.

Family and Social History • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration & frequency. • Do you take any recreational drugs? • Any family history of cancers/ medical illnesses?

Clinical Cases - Counseling

161

Nancy Alfredo, a 30 years old woman presented to your clinic with a black eye and multiple bruises on her arms. Take history and address her concerns. Counseling Case : Domestic violence HOPI • • • • • • • • • • • • • • • •

• Who are the biological parents of the How did the injury occur? children? When did the injury occur? • Do the children witness physical abuse? Location of injury/injuries? • Ask about violence to the children, sexual Circumstances in which the injury occurred? abuse? Describe violent episode, what triggered it? • Is the boyfriend willing to seek help? Were objects used as weapons? • Any stressors at home/work? Was the boyfriend remorseful afterward? History of previous episodes of violence or Family and Social History loss of temper by boyfriend? • Do you smoke? Amount/frequency. What was the patient's response? • Do you consume alcohol? Has patient been in an abusive relationship Amount/frequency. before? • Do you use recreational drugs? TRAPPED. Is the boyfriend controlling? • Does the partner abuse alcohol or other Does he restrict her activities? drugs? Question her excessively after she has been • Economic situation? out? • Any family history of physical abuse? Engages in verbal abuse or threats? Is the violence increasing in severity? Are there children in the house?

Counseling for domestic violence • Explain that the boyfriend hitting the patient is a criminal assault and an example of domestic violence. • Domestic violence tends to increase over time unless the victim leaves, or the abuser and couple seek therapy. • Very often, women don't leave their abusive partner until they are seriously hurt. • Domestic violence between adult partners tends to be reflected in future behavior of children who are exposed to it and there is a risk of violence to the children. • Child abuse is a criminal act and if suspected, is reportable to police by law. • Spousal abuse is also a criminal act but is not reportable by law. • Recommend that the patient not return to the abuser if there is risk to her safety (e.g. not the first assault, abuser not remorseful). • If the patient does return, an exit plan should be developed to ensure patient safety. • Document all evidence of abuse (pictures, sketches) and related visits; quote patient directly in chart. • Alternatively, the patient can contact the police to obtain a restraining order on the abuser. • Develop a plan with the patient to seek alternate living arrangements (women's shelter). • Enlist the help of patient's support structure (friends, other family members). • Contact the police (patient should be informed that, if contacted, the police will lay charges whether the patient wants to or not). • Counsel patient on how to enter into a controlled, safe environment & contact with the abuser to discuss possible therapy for anger management and controlling behaviors. • Social worker referral and provide info about community resources. • Arrange follow up.

Alphabetical Index Abortion - clinical case........................................118 Acetaminophen ....................................................30 Acne.....................................................................11 Acute Bronchiolitis...............................................45 Acute Cholecystitis...............................................19 acute confusional state...........................................52 Acute Gastroenteritis............................................16 Acute Myocardial Infarction....................................7 Acute Otitis Media ..............................................45 Acute Pancreatitis..................................................17 Acute Pharyngitis..................................................23 Acute Pyelonephritis.............................................30 Acute Sinusitis......................................................23 Alcohol.................................................................35 Alcohol withdrawal..........................................30, 59 Allen Test..............................................................68 Allergic reaction....................................................50 Allergic Reaction...................................................30 Anaphylaxis...........................................................30 Anemia............................................................19, 50 Ankle Anterior Drawer Test .................................84 Anorexia - clinical case........................................133 Antenatal Visit - clinical case...............................119 Anterior Drawer Test............................................82 anti-hypertensive drugs.........................................10 Apley's Scratch Test..............................................86 Appendicitis..........................................................16 Apprehension Sign................................................86 Arrhythmias..........................................................31 ASA.....................................................................31 Asthma............................................................24, 45 Asthma - clinical case..........................................103 Athlete's foot........................................................13 Atrial Fibrillation.............................................8, 102 Atrial Fibrillation - clinical case...........................102 Atrophic vaginitis..................................................39 Back Pain - clinical case.......................................142 Bacterial Meningitis..............................................49 Bacterial Pneumonia .............................................46 Bacterial Tracheitis................................................45 Bacterial vaginosis.................................................39 Basal Cell Carcinoma - clinical case.....................143 Benign Prostatic Hyperplasia - clinical case..........144 Bipolar disorder.....................................................57 Bowstring test.......................................................78 Breast Feeding - counseling.................................159 Buerger's Test........................................................68 Bulimia - clinical case..........................................134 Burns....................................................................11 Ca Oesophagus - clinical case..............................148 Candidiasis...........................................................39 Carpal Tunnel Syndrome - clinical case................145 Cellulitis...............................................................13 Cerebrovascular Attack - clinical case..................105 Chest Pain - clinical case.....................................111 Child abuse - counseling......................................160 Chlamydia............................................................38 Cluster headache...................................................22 Cocaine Overdose.................................................59

Collateral Ligament Stability.................................82 Community Acquired Pneumonia.........................25 Congestive Cardiac Failure......................................8 Congestive Heart Failure - clinical case................104 COPD..................................................................24 Crohn’s Disease.....................................................17 Croup...................................................................48 Deep Vein Thrombosis - clinical case...................146 Delirium...............................................................52 Delirium - clinical case........................................135 Delirium Tremens.................................................36 Dementia..............................................................55 Dementia - clinical case.......................................136 Depression............................................................56 Depression - clinical case.....................................137 Diabetes Mellitus..................................................14 Diabetic Foot - clinical case.................................147 Diabetic ketoacidosis.............................................31 Diabetic Ketoacidosis............................................14 Digoxin.................................................................32 Digoxin Toxicity - clinical case............................106 Diverticulitis.........................................................17 Domestic violence - counseling............................161 Dysfunctional Uterine Bleeding.............................40 Dyslipidemia...........................................................9 Dysmenorrhea.......................................................40 Ectopic Pregnancy.................................................42 Ectopic Pregnancy - clinical case.........................120 Emergency contraception......................................41 Empty Can Test ...................................................86 Endometriosis.......................................................40 Epiglottitis............................................................48 Ethylene glycol .....................................................32 Examination - Abdominal.....................................63 Examination - Back/Spine.....................................77 Examination - Breast.............................................90 Examination - Cardiovascular................................65 Examination - Central Nervous System ................71 Examination - Elbow ...........................................87 Examination - Foot and Ankle .............................83 Examination - Hand and Wrist ............................88 Examination - Hip ...............................................79 Examination - Knee .............................................81 Examination - Lower Limb Neurological .............75 Examination - Mini Mental State .........................93 Examination - Peripheral Vascular ........................67 Examination - Respiratory ....................................69 Examination - Shoulder........................................85 Examination - Thyroid .........................................91 Examination - Upper Limb Neurological ..............73 External Rotation Lag Sign...................................86 FABER...........................................................78, 80 Failure to thrive - clinical case..............................126 Febrile Seizures.....................................................49 Febrile seizures - clinical case...............................127 Femoral stretch test...............................................78 Fibromyalgia.........................................................29 Finkelstein's test....................................................89 General Anxiety Disorder......................................54

Alphabetical Index Genital herpes.......................................................38 Genital warts ........................................................38 Gerber Lift-Off Test.............................................86 GI Bleed...............................................................34 Golfer's Elbow......................................................87 Gonorrhea............................................................38 Gout.....................................................................27 Group A Streptococcus.........................................48 Group B Streptococcus..........................................41 Hallucinogens.......................................................59 Hawkins Impingement Sign..................................86 Headache - clinical case.......................................110 Heart Failure...........................................................8 Helicobacter Pylori................................................17 Hematemesis - clinical case.................................149 Hemothorax - clinical case..................................156 Hepatitis B............................................................18 HIV......................................................................19 Hormone Replacement Therapy............................41 HRT - counseling...............................................162 Horner's sydrome..................................................69 Hyperemesis Gravidarum......................................42 Hyperprolactinemia............................................15p. Hypertension.....................................................9, 32 Hyperthyroidism...................................................15 Hypoglycemia.......................................................32 Hypothyroidism....................................................15 Immunization - counseling..................................164 Immunization Schedule.........................................50 Impotence.............................................................16 Impotence - clinical case......................................108 Infectious Mononucleosis - clinical case...............107 Infective Endocarditis............................................10 Infertility - clinical case.......................................121 Lachman Test.......................................................82 Laryngotracheobronchitis......................................48 Lasegue's sign.......................................................78 Malaria.................................................................20 Mammogram - counseling...................................163 Mania...................................................................53 Mania - clinical case............................................138 McMurray's Test...................................................82 Measles - clinical case..........................................128 Meningitis............................................................21 Meningitis - clinical case.....................................109 Migraine...............................................................22 Mood stabilizers....................................................57 Myasthenia Gravis................................................23 Neck Swelling - clinical case................................150 Neer Impingement Sign........................................86 Neonatal Jaundice - clinical case..........................129 Obesity - counseling............................................165 Obsessive-compulsive disorder ..............................55 OCP Counseling - clinical case...........................122 Opioid..................................................................33 Opioid Intoxication...............................................59 Osteoarthritis........................................................26 Osteoporosis.........................................................26 Ottawa Ankle rules...............................................84

Pain Abdomen - clinical case...............................151 Panic attack...........................................................53 Panic Attack - clinical case..................................139 Panic disorder........................................................53 Parkinson’s disease.................................................23 Patellar Apprehension...........................................82 Patellar Grind.......................................................82 Pediculosis............................................................13 Pelvic Inflammatory Disease..................................40 Pelvic inflammatory disease - clinical case............123 Pemberton's sign...................................................91 Peptic ulcer disease................................................19 Peripheral Vascular Disease - clinical case............152 Pertussis................................................................48 Phalen's test .........................................................89 Phencyclidine........................................................59 Placenta Previa - clinical case...............................124 Plantar Fasciitis Test..............................................84 Pneumonia - clinical case.....................................112 Polymyalgia Rheumatica........................................28 Post exposure - clinical case.................................113 Post Operative fever - clinical case.......................153 Post-traumatic stress disorder ...............................55 Posterior Drawer Test............................................82 Pre Eclampsia - clinical case................................125 Pregnancy Induced Hypertension..........................41 Primary nocturnal enuresis - clinical case.............130 Psoriasis................................................................12 Psychosis...............................................................56 Pulmonary Embolism............................................25 Pulmonary Embolism - clinical case....................114 Pulmonary tuberculosis..........................................20 Pyelonephritis.......................................................39 Pyloric stenosis - clinical case..............................131 Rabies...................................................................20 Rheumatic Heart Disease......................................10 Rheumatoid Arthritis............................................26 Romberg’s test.......................................................72 Scabies..................................................................13 Schizophrenia - clinical case................................140 Schober's Test.......................................................78 Seizure disorder - clinical case.............................115 Seizures.................................................................21 Septic Arthritis.....................................................29 sexual dysfunction.................................................58 Sexually Transmitted Infection..............................38 Shock....................................................................33 Smoking...............................................................35 Smoking - counseling..........................................167 Social Phobia........................................................54 Solitary lung nodule - clinical case.......................154 Speech delay - clinical case..................................132 Speed's Maneuver.................................................86 Sprain...................................................................33 Straight leg raising test..........................................78 Streptococcal Pharyngitis......................................48 Stroke...................................................................33 Substance abuse.....................................................59 Suicide - clinical case...........................................141

Alphabetical Index Syphilis.................................................................38 Talar Tilt Test.......................................................84 TCA.....................................................................34 Temporal arteritis..................................................28 Temporal Arteritis - clinical case.........................116 Tennis Elbow .......................................................87 Tension headache..................................................22 Tetanus.................................................................21 Thomas test..........................................................80 Thompson's Test...................................................84 Thyroid mass - clinical case.................................155 Tinea Cruris.........................................................13 Tinel's sign............................................................89 Trendelenberg test.................................................79

Trendelenburg Maneuver.......................................68 Trichomonas vaginalis...........................................39 Troisier's Sign.......................................................69 Tylenol..................................................................50 Ulcerative Colitis...................................................19 Urinary tract infection...........................................29 Urinary Tract Infection....................................39, 49 Viral Hepatitis - clinical case...............................117 Virchow's Node.....................................................69 Vocal fremitus.......................................................70 Vulvovaginitis........................................................39 Warfarin...............................................................34 Whooping Cough ................................................48 Yergason test.........................................................86