Osce Questions

Introduction to NAC OSCE General Information............................................................... Registration for NAC OSCE................................................ Fees......................................................................................... Examination station............................................................... NAC OSCE scoring.............................................................. Sample of Therapeutic written test........................................ Sample clinical case station.................................................... Therapeutic Guidelines Medicine Cardiology.............................................................................. Dermatology........................................................................... Endocrinology........................................................................ Gastroentermogy.................................................................... Hematology............................................................................ Infectious Diseases................................................................. Neurology............................................................................... Otolaryngology...................................................................... Pulmonology.......................................................................... Rheumatology........................................................................ Nephrology/Urology.............................................................. Emergency Medicine.............................................................. Counseling (smoking/alcohol).............................................. Obstetrics & Gynecology Sexually transmitted infections.............................................. Urinary tract infection............................................................ Vulvovaginitis......................................................................... Pelvic inflammatory disease................................................... Dysfunctional uterine bleeding............................................. Dysmenorrhea........................................................................ Endometriosis........................................................................ Hormone replacement therapy.............................................. Emergenqr contraception....................................................... Group B Streptococcus in pregnancy.................................... Pregnancy induced hypertension........................................... Ectopic pregnancy.................................................................. Hyperemesis gravidarum........................................................ Drugs contraindicated in pregnancy...................................... Pediatrics Acute bronchiolitis................................................................. Acute otitis media.................................................................. Asthma................................................................................... Bacterial tracheitis.................................................................. Bacterial pneumonia............................................................... Croup (Laryngotracheobronchitis)........................................ Epiglottitis.............................................................................. Streptococcal pharyngitis (Group A streptococcus).............. Whooping cough (Pertussis)................................................. Bacterial meningitis................................................................ Febrile seizures....................................................................... Urinary tract infection............................................................ Allergic reaction...................................................................... Anemia................................................................................... Dose of tylenol....................................................................... Immunization schedule..........................................................

TABLE OF CONTENTS ...1 ...1 ...1 ...1 ...2 ...2

...3 ...7

.11 .14 .16 .19 .19 .21

.23 .24 .26 .29 .30 .35 .38 .39 .39 .40 .40 .40 .40 .41 .41 .41 .41 .42 .42 .42 .45 .45 .45 .45 .46 .48 .48 .48 .48 .49 .49 .49 .50 .50 .50 .50 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 Dieoxin toxicity.........................................................................................................................106 Infectious mononucleosis (sore throat).....................................................................................107 Impotence..................................................................................................................................108 Meningitis.................................................................................................................................109 Migraine (Headache)................................................................................................................110 Myocardial Infarction(Chest pain)............................................................................................Ill 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 Psychiatiy 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

TABLE OF CONTENTS

Introduction to NAC OSCE | General Info 1

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 IMGs path to licensure would be the same, regardless of the jurisdiction in which he or she is being assessed. The NAC OSCE has replaced C EH PE As Clinical Examination 1 (CEI), 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

2 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 3 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 Ql.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?

Therapeutic Guidelines This isa

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 Post MI drugs Drugs Benefits Side effects Cofitraliidiiiil Wi ACE Inhibitors Ramipril - 10mg hs Lisinopril - lOmgod Enalapril - 20mg od Captopril - 50 mg tid 1 mortality Prevents ventricular remodelling 1 proteinuria Hypotension/dizziness Hyperkalemia Angioedema Renal insufficiency Cough, taste changes Bilateral renal artery stenosis Hx of angioedema Pregnancy ARB Valsartan - 160mgbid Candesartan - 32 mg od 1 mortality 1 proteinuria Angioedema Cough, taste changes Beta Blocker Metoprolol - lOOmg bid Atenolol - lOOmg od Carvedilol - 25mg bid Propranolol - 60-80 tid 1 mortality 1 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 2nd/3rd degree heart block HR 45 degrees. Non pharmacological management of Heart Failure • Exercise : Regular physical activity • Salt restriction : symptomatic HF - 2-3g salt/day (Vfc tsp/day) no added salt in diet. HF with fluid retention : l-2g salt/day (V4 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. Off TREATMENT MNEMONIC L: Lasix M : Morphine Sulphate N : Nitroglycerin 0:0xygen P : Positive airway pressure P : Position > 45 degrees D : Dopamine (indicated in cardiogenic shock and hypotension)_________

Therapeutic Guidelines | Medicine 9

Dyslipidemia 1. HMG Co A Inhibitors: • Atorvastatin : Tab Lipitor 10-80 mg qhs • Rosuvastatin : Tab Crestor 10-40mg qhs • S/E: Gl symptoms, rash, pruritus, increased liver enzymes, myositis. • C/I: active liver disease, muscle disease, pregnancy. 2. Fibrates: increased TG (triglycerides) • Fenofibrate : Tab Lipidil 67-200 mg/d 3. Bile acid sequestrants : increased LDL • Tab Colestipol 5-30g/day 4. Cholesterol absorption inhibitors: • Tab Ezetimibe lOmg /day. Lipid Risk LDL Total cholesterol/HDL HIGH (lOyrCAO >20%) Target LDL-3.5 Treat if >5 LOW (10yr CAD 5 Treat if >6 High Risk : All with CAD, CVD, most diabetes cases & chronic renal disease.

Hypertension Non pharmacological treatment : • Smoking cessation: smoking aggravates hypertension and remains the major contributor to cardiovascular disease in people under 65 years. • Weight reduction : Maintain BMI 3 months, do baseline DEXA and start bisphosphonate therapy. • S/E of Corticosteroids: Osteoporosis, cataracts, glaucoma, peptic ulcer disease, avascular necrosis, hypertension, increased infection rate, hypokalemia, hyperglycemia, hyperlipidemia. • C/I to Corticosteroids: Active infection, hypertension, diabetes mellitus, gastric ulcer, osteoporosis. Gout 1. Acute Gout: i. NSAIDs: Tab Indomethacin 25-50 mg PO tid x 10-14 days. ii. Tab Naproxen 500 mg PO bid x 4-10 days. iii. Tab Colchicine 0.6 mg PO qlh till pain relief (max 4-6 doses), then bid x 3-5 days. iv. Systemic Steroids: (rule out Septic Arthritis) • Inj Methylprednisolone 40 mg IV single dose • Inj Depo-Medrol 80-120 mg IM single dose. • Oral: Tab Prednisone 40 mg PO od x 5days, then gradually taper the dose. v. Intra- Articular Corticosteroid: used in large single joints & refractory cases. • Inj Betamethasone 7 mg or Inj ACTH 40-80IU. 2. Recurrent Gout: Treat for 3-6 months. i. Over producers: Tab Allopurinol 100-300 mg/day PO. ii. Under-excreters: Tab Probenecid 250 mg PO bid (max:1500 mg bid) or Tab Sulfapyrizine 50 mg PO bid (max: 1000 mg bid). iii. Concurrently start with Tab Colchicine 0.6 mg PO bid x 3-6 months.

28 NAC OSCE | A Comprehensive Review

Temporal arteritis • Start high dose Tab Prednisone 60 mg PO od until symptoms subside and ESR normal • Then 40 mg PO od for 4-6 weeks • Then taper to 5-10 mg PO od for 2 years (relapses occur in 50% if treatment is terminated before 2 years). Treatment does not alter biopsy results if the sample is taken within 2 weeks. • Monitor ESR regularly. • If visual symptoms are present, or develop during treatment, the patient is admitted and given Inj Prednisolone 1000 mg IV ql2h for 5 days. Polymyalgia Rheumatica Management 1. General measures • Consider concurrent Temporal Arteritis (See above) • NSAIDs 2. Prednisone (key to management) • See Corticosteroid Associated Osteoporosis • Efficacy: 90% response

Dramatic improvement in first 48 hours If no response to steroids - reconsider diagnosis Reconsider diagnosis Consider Methotrexate • Polymyalgia alone Dose: 15-20 mg PO qd • Polymyalgia with Temporal Arteritis Dose: 40-60 mg PO qd Symptoms and signs remit within 1 month Decrease dose by 10% each week after improvement • Course • Initial: Maintain starting dose for 1 month • First steroid taper (depends on clinical response) Taper by 2.5 mg per month down to 10 mg/day then Taper 1 mg per 4-6 weeks down to 5 to 7.5 mg/day • Final steroid taper Indicated when symptom free for 6-12 months Do not taper until sedimentation rate normalizes Taper by 1 mg every 6-8 weeks until done • Anticipate 2-6 year course of steroids Relapse common in first 18 months of steroid use Patients off steroids at 2 years: 25%

Therapeutic Guidelines | Medicine 29 Fibromyalgia 1. ANTIDEPRESSANTS : Benefits • Assists with local pain, stiffness and sleep • Does not affect Tender Points 2. Tricyclic Antidepressants • Amitriptyline (Elavil) i. First week: 10 mg PO qhs ii. Next three weeks: 25 mg PO qhs iii. Later: 50 mg PO qhs • Nortriptyline (Pamelor) 3. Novel Antidepressants • Venlafaxine (Effexor) • Duloxetine (Cymbalta) 4. Selective Serotonin Reuptake Inhibitors (SSRI) • Combination: Fluoxetine and Amitriptyline Septic Arthritis • Gonococcal: Inj Ceftriaxone lg IV q24h x 2-4 days, then switch to Tab Ciprofloxacin 500 mg PO bid x 7 days. • Non-Gonococcal: Inj Naficillin 2g IV q4h x 2 weeks, then switch to Tab Ciprofloxacin 500 mg PO bid x 24weeks.

11. Urology/Nephrology Urinary tract infection (UTI) 1. Acute uncomplicated UTI: outpatient • Tab Bactrim DS PO bid x 3 days. • Tab Nitrofurantoin (Macrobid) 100 mg PO bid x 5 days. 2. Drug resistant UTI: outpatient • Tab Ciprofloxacin 500 mg bid x 3 days. • Tab Norfloxacin 400 mg PO bid x 3 days. • Tab Ofloxacin 200 mg PO bid x 3 days. 3. Acute complicated UTI: inpatient • Inj Ampicillin 1-2 g IV q4-6h and Inj Gentamicin 2mg/kg IV loading dose followed by 1.7 mg /kg q8h IV OD • Inj Ciprofloxacin 400 mg IV bid. • Switch to oral antibiotics upon improvement for a total course of 14-21 days.

30 NAC OSCE | A Comprehensive Review Acute Pyelonephritis 1. Outpatient management: For acute uncomplicated cases • Tab Ciprofloxacin 500 mg PO bid x 10 days. • Tab Gatifloxacin 400 mg PO daily x 10 days. • Tab Moxifloxacin 400 mg PO daily x 10 days. • Tab Levofloxacin 250 mg PO daily x 10 days. • Tab Augmentin bid x 14 days. • Tab Bactrim bid x 14 days.

2. Inpatient management: IV for 48-72 hours, then switch to oral agents. Total duration of treatment for 14 days. • Inj Ceftriaxone (Rocephin) 1-2 grams IV q24 hours. • Inj Cefotaxime (Claforan) 1 gram IV ql2 hours. • Inj Ampicillin 2 g IV q6h with Inj Gentamicin 2mg/kg IV loading dose , then 1.7mg/kg q8h. Inj Piperacillin 3.375g IV q6h.

12. Emergency Medicine/Poisoning

Acetaminophen Intoxication • Toxic level dose is more than 7.5g • Investigations : Monitor drug level stat and then q4h (Acetaminophen nomogram), LFT, INR, PTT, BUN, Creatinine, ABG, Glucose • Rx : Charcoal/Gastric lavage as per presentation N-acetyl cysteine 140mg/kg PO, then 70mg/kg q4h for 18 doses Alcohol withdrawal • Treatment : Inj Diazepam 10-20mg IV Inj Thiamine lOOmg IM then 50-100mg/day Fluid resuscitation with D5W l-2mL/kg IV Allergic Reaction 1. Severe: Inj Epinephrine 0.3-0.5 mg SC/IM stat 2. Mild: Tab Benadryl 25-50mg PO q6h x 3d 3. Tab Prednisone 60mg PO od x 3d Anaphylaxis • Epinephrine autoinjector (EpiPen) if available • Epinephrine IV or ETT : 1ml of 1:10,000 in adults • Inj Diphenhydramine (Benadryl) 50mg IV or IM q4-6 h • Inj Methylprednisone 50-lOOmg IV according to severity • If wheezing or spasm present : Salbutamol via nebulizer.

Therapeutic Guidelines | Medicine 31 Arrhythmias Arrhythmias due to 2nd degree and 3rd degree heart block : Inj Atropine 0.5mg IV while waiting for transcutaneous pacing. Transcutaneous pacing first (give Inj Midazolam 2mg for sedation) Admit for transvenous pacing Unstable patients (hypotensive systolic BP < 90, chest pain, SOB, altered mental status or unconscious) : CARDIOVERT! Stable patient : Atrial fibrillation : either chemical cardioversion (Amiodarone) or electrical (Synchronized DC cardioversion) Ventricular tachycardia : DC cardioversion or Inj Lidocaine/Amiodarone 150mg IV over 10 mins. Ventricular fibrillation : Always defibrillate! Synchronized cardioversion not useful because there is no QRS complex to synchronize with. PSVT : Valsalva or carotid massage (after checking for bruit), Inj Adenosine 6mg rapid IV push. If no response then Metaprolol, Diltiazem. ASA Intoxication Investigations : Drug levels, electrolytes, ABG, BUN, Creatinine Rx : Gastric lavage/Charcoal Alkalinize urine with D5W, KC1 and NaHC03 Aim : urine pH > 7.5 Diabetic ketoacidosis Estimated daily basal glucose requirement is 0.5U/kg Investigations : Blood glucose, electrolytes, ABG, serum ketones, osmolar gap, anion gap, BUN, creatinine. Look of the cause : Urinalysis, blood C&S, chest x-ray, ECG. Monitor : Urine output, extra-cellular fluid volume, electrolytes, ABG, creatinine, capillary blood glucose and level of consciousness every 1-2 hours. Management : Rehydration : NS lL/h in first 2 hours followed by 0.45% NS 500cc/h then switch to maintain blood glucose 13.9-16.6mmol/L to avoid rapid decrease of osmolality. K+ replacement : As acidosis is corrected, hypokalemia may develop. If K+ is 3.3-5.0 mmol/L, add KC120-30 mEq/L to keep it within this range. Correct acidosis : If pH < 7.0/hypotension/coma then give 3 amp NaHCOs (150mEq/L) Reduce blood glucose : Start Insulin therapy with 0.15U/kg bolus and maintain 0.1U/kg/h until acidosis and blood glucose resolve. Treat underlying precipitant.

32 NAC OSCE | A Comprehensive Review

Digoxin Intoxication • Investigations : Plasma digoxin/digitoxin levels, ECG, electrolytes, BUN, Cr ( levels > 2.6 indicate

intoxication) • Rx : Treat arrhythmias (common with digoxin intoxication; vfib, vtach, conduction blocks) Gastric lavage / Charcoal (lg/kg) for ingestion NaHC03 or glucose and insulin Ventricular tachycardia : Digibind 10-20 vials if dose unknown Chronic toxicity : then Digibind 3-6 vials IV over 30 mins. Follow ECG, K+ Mg+, Digoxin levels every 6 hours. Hypertensive emergency • Systolic BP > 180mmHg and Diastolic BP > 120mmHg (with signs of acute organ damage) • Investigations : CBC, electrolytes, BUN, Creatinine, ABG, Urinalysis, CXR, ECG, BP in all four limbs, Fundoscopy, Cardiology consult. • 1st Line : Inj Sodium nitroprusside 0.3 mcg/kg/min IV OR Inj Labetalol 20mg IV bolus q 10 mins. • Aortic dissection : Sodium nitroprusside + Beta blocker (esmolol) • Catecholamine excess : Inj Phentolamine 5-l5mg IV q 5-15 mins • Ml/Pulmonary edema : Inj Nitroglycerin 5-20mcg/min IV, increase by 5mcg/min every 5 min till symptoms improve. Hypoglycemia • Investigations : Baseline blood glucose, insulin and C-peptide, check glucose ql5 mins until > 5mmol/L • Rx : If patient can eat/drink : give I5g carbohydrate if BG < 4mmol/L (15g glucose tabs or ZA caps of juice or 3 spoons of sugar in water.) NPO : give 25g carbohydrate if BG < 4mmol/L ( D50W 50cc IV push 1 amp OR D10W 500cc IV OR glucagon l-2mg IM/SC ) Methanol/Ethylene glycol intoxication • Investigations : CBC, electrolytes, glucose, methanol level. • Rx : Ethanol 10mg/kg over 30 mins OR Inj Fomepizole 15mg/kg IV over 30 mins.

Therapeutic Guidelines | Medicine 33 Opioid Intoxication • Mental status effects include euphoria, sedation, decreased anxiety, a sense of tranquility and indifference to pain produced by mild-to-moderate intoxication. Severe intoxication can lead to delirium and coma. • Physiological effects include the following: Respiratory depression (may occur while the patient maintains consciousness) Alterations in temperature regulations Hypovolemia (true as well as relative), leading to hypotension Miosis Soft tissue infection Increase sphincter tone (can lead to urinary retention) • Treatment IV glucose : 50% Dextrose 50ml Inj Nalaxone 0.4mg upto 2mg IV for reversal of opioid intoxication. Inj Thiamine lOOmg IM stat & OD x 3days 02, intubation &, mechanical ventillation Shock (Cardiogenic/Neurogenic) • Dopamine : l-3mcg/kg/min is the renal dose; 4-10mcg/kg/min is the inotropic dose • Dobutamine : 2.5-5mcg/kg/min Sprain (Ankle) RICE • Rest • Ice : using bag of ice, apply during the day for 5-20 mins every 2 hours. • Compression : Tensor bandage or special supports. • Elevation : Elevate the ankle as much as possible. • Analgesics as needed. • Crutches if too painful to bear weight. Stroke • Investigations : CBC, electrolytes, BUN, glucose, creatinine, INR/PTT, lipids, ECG, carotid doppler if suspecting TIA, ABG, Non contrast urgent CT scan. • Treatments : NPO, Foley catheter, DVT prophylaxis, Neurology consult Rule out contraindications for thrombolytic treatment. Urgent neurology consult. Thrombolysis : rTPA within 3 hours of symptoms Anti-coagulation : Low dose Heparin 5000 U bid, start Warfarin within 3 days, monitor INR/PTT If unable to thrombolyse or anti-coagulate then : Tab ASA 50-325mg od or Tab Clopidogrel 75mg od

BP control : decrease slowly, IV Labetalol (First line treatment) Bed rest, analgesics, mild sedation and laxatives, avoid hyperglycemia.

34 NAC OSCE | A Comprehensive Review

TCA Intoxication • Patients who present to the ED following psychotropic drug overdose with GCS < 8 should undergo intubation at the earliest opportunity to prevent hypoventilation and aspiration pneumonia. • Investigations : Drug levels, ECG, ABG, electrolytes, LFTs, RFTs. • Rx : Activated charcoal lgm/kg via NG Diazepam for seizures Wide QRS/Seizures : NaHCOa ( 1-2 mEq/kg bolus dose and then 100-150 mEq in 1L D5/0.45% NaCl infused 100-200 ml/h IV) Upper Gl Bleed • Stabilize patient with IVF, cross & type, 2 large bore IV cannulas. • Investigations : CBC, platelets, INR, BUN, creatinine, PTT, electrolytes, LFTs • Management : NG tube, NPO, blood transfusion if needed, upper Gl endoscopy Inj Octreotide 50mcg loading and 50mcg per hour (for varices) SC/I V Inj Pantoprazole 50mg IV stat and 50mg q8h (gastric ulcer) Lower Gl Bleed • Stabilize patient with IVF, cross & type, 2 large bore IV cannulas. • Investigations : CBC, platelets, INR/PTT, BUN, creatinine, electrolytes. • Management : NG tube, NPO, blood transfusion if needed, sigmoidoscopy, colonoscopy, angiogram (for angiodysplasia) Warfarin Intoxication • Treatment according to INR levels INR < 5 : Stop warfarin, observation, serial INR/PTT INR 5-9 : If no risk factors for bleeding, hold warfarin x 1-2 days & reduce maintenance dose. OR Vitamin K 1-2 mg PO, if patient at increased risk or FFP for active bleeding. INR 9-20 : Stop warfarin, Vitamin K 2-4 mg PO, serial INR/PTT then additional Vitamin K if needed or FFP for active bleeding. INR > 20 : FFP 10-15ml/kg, Inj Vitamin K lOmg IV over 10 min, increase dose of Vitamin K (q4h) if needed.

Therapeutic Guidelines | Medicine 35 13. Counselling Smoking cessation 1. 2.

3. 4. Nicotine gums: 2mg if < 25 cig/day, 4mg if > 25cig/day • 1 piece ql-2h for l-3mths Nicotine patch: • 21 mg per day for 4 weeks • 14mg per day for 2 weeks • 7mg per day for 2 weeks Nicotine inhaler: 6-16 cartridges per day upto 12 weeks Bupropion(Zyban): • 150mg qAM x 3days, then 150mg bid for 7- 12 weeks • Maintenance 150mg bid for upto 6 months. • General Stop smoking during second week of medication Stop Bupropion if unable to quit by 7 weeks Minimum of 8 hours between doses More is not better Swallow pills whole (not crushed, divided or chewed). Alcohol cessation Protocol: Alcohol Dependence • Lab markers Serum Gamma glutamyl transferase or Carbohydrate deficient Transferrin 1.Initial Management • Tab Thiamine 100 mg PO qd • Tab Folate 1 mg PO qd • Multivitamin qd • Treat Hypomagnesemia if present • Seizure precautions 2.Long-Term Abstinence Programs • Alcoholics Anonymous

• Detoxification centers • Halfway House CAGE Questionnaire C : Have you ever felt the need to CUT down on your drinking? A : Have you ever felt ANNOYED at criticism of your drinking? & : Have you ever felt GUILTY about your drinking? E : Have you ever had a drink first thing in the morning (EYE OPENER}?

36 NAC OSCE | A Comprehensive Review

3.Adjunctive Medications for abstinence 1.First line (consider Naltrexone with Campral) • Tab Naltrexone Blocks Opioid receptors Decreases pleasure from Alcohol Dosing: 50 mg orally daily Effective in short-term, but not in long-term • Tab Campral (Acamprosate) Balances GABA and glutamate neurotransmitters Reduces anxiety from abstinence Dosing: 2 tabs PO tid 2.Second line agents to consider • Selective Serotonin Reuptake Inhibitors (SSRI) Consider especially if comorbid depression Prozac often used, but other SSRIs effective • Topiramate (Topamax) Decreases Alcohol use severity and binge drinking Improves well being, quality of life in Alcoholics 3.Agents to avoid • Antabuse Taken 250 to 500 mg orally daily Not recommended due to risk and uncertain benefit • Delirium Tremens General Protocol (Requires ICU observation) • Tab Diazepam (Valium) Dose: 10-25 mg PO qlh prn while awake Endpoint: until adequate sedation • Inj Lorazepam (Ativan) Dose: 1-2 mg IV qlh prn while awake for 3-5 days Endpoint: until adequate sedation • Librium (Chlordiazepoxide) Dose: 50 to 100 mg PO/IM/IV q4h (max: 300 mg/day) Endpoint: until adequate sedation

NOTES

38 NAC OSCE | A Comprehensive Review

Obstetrics & Gynecology

1. Sexually Transmitted Infection a. Chlamydia: Tab Azithromycin lg PO stat or Tab Doxycycline lOOmg PO bid x 7 days If pregnant: Tab Erythromycin SOOmg PO tid x 7 days. Treat partner, Reportable disease. b. Gonorrhea: Inj Ceftriaxone 125mg IM stat + Tab Doxycycline lOOmg bid x 7 days. If pregnant : Inj Spectinomycin 2g IM stat Treat partner, Reportable disease. c. Syphilis: Primary, Secondary, Latent Syphilis (duration less 1 year ): Inj Benzathine Penicillin G 2.4 MU IM for 1 dose Treat partner, Reportable disease. If allergic to Penicillin: Tab Doxycycline 100 mg PO bid for 14 days. Late latent, Cardiovascular (duration over 1 year) Inj Benzathine Penicillin G 2.4 MU IM once a week for 3 weeks If Penicillin allergic : Tab Tetracycline 500 mg PO qid for 4 weeks or Tab Doxycycline 100 mg PO bid for 4 weeks Neurosyphilis : Inj Aqueous Penicillin G 34 MU IM every 4 hours for 10-14 days. d. Genital herpes: First episode: Tab Acyclovir 400mg PO tid x 10 days or Tab Famciclovir 250 mg tid x 10 days or Tab Valacyclovir 1 g bid x 10 days Recurrent: Tab Acyclovir 400mg PO tid x 5 days or Tab Famciclovir 120 mg bid x 5 days or Tab Valacyclovir 500 mg bid x 5 days Suppression: if more than 6 episodes per year Tab Acyclovir 400mg PO bid x 12 months Severe episode: Inj Acyclovir 5-10 mg/kg q8h x 5-7 days e. Genital warts (HPV): Local treatment with LIQUID NITROGEN repeat every 1-2 weeks Podophyllotoxin 0.5% gel bid x 3days,then 4 days off - to be repeated for 4 weeks.

Prophylaxis for HPV (for Cervical CA & warts) - Inj Gardasil IM 0,2 and 6 months.

Therapeutic Guidelines | Obstetrics & Gynecology 39 GENERAL INSTRUCTIONS for all sexually transmitted infections: • Treat all partners • Avoid sexual intercourse till treatment completion. • Barrier contraception/ educate about safe sex practices. • Rescreening in 3 months. SIDE EFFECTS: • DOXYCYCLINE: Drug induced PHOTOSENSITIVITY, use sun screen • ACYCLOVIR: headache, Gl upset, impaired renal function, tremors, agitation, lethargy, confusion, coma 2. Urinary Tract Infection Uncomplicated: Tab Bactrim DS PO bid x 3 days or Tab Nitrofurantoin lOOmg PO qid x 5days. (with food) In pregnancy: Treat asymptomatic UTI Tab Amoxicillin 250mg PO tid or Tab Macrobid lOOmg PO bid x 10 days. Pyelonephritis: Acute Uncomplicated: Tab Ciprofloxacin 500mg PO bid x 10 days or Tab Augmentin 625mg PO bid x 14 days. Inpatient: Inj Ceftriaxone lg IV bid for 48 hours then switch to oral drugs + Inj Gentamicin 50mg IV q8h for 24 hours. 3. Vulvovaginitis a. Candidiasis: Tab Miconazole 200mg PV qhs x 3 days or Tab Nystatin (100,00 unit) vaginal tab PV qhs x 14 days or Tab Fluconazole I50mg PO stat dose. Prophylaxis: 4 or more infection per year - Tab Fluconazole 150mg PO every 3days for 3 doses. Maintenance: Tab Fluconazole 150mg PO each week. Monitor liver enzymes every 1-2 months. b. Bacterial vaginosis: Tab Flagyl 500mg PO bid x 7days.(with food) c. Trichomonas vaginalis: Tab Flagyl 2g PO for 1 dose, or Tab Flagyl 500mg PO bid x 7days.(with food), treat partner. d. Atrophic vaginitis: Topical Estrogen cream 0.5 to 2g daily to be applied locally.

40 NAC OSCE | A Comprehensive Review 4. Pelvic Inflammatory Disease (PID) a. Outpatient: Inj Ceftriaxone 250mg IM stat dose + Tab Doxycycline lOOmg PO bid x 14days. b. Inpatient: Inj Cefoxitin 2g IV q6h + Inj Doxycycline lOOmg IV ql2h. Continue IV for 48 hrs & then tab Doxycycline lOOmg PO bid x 14 days. Reportable disease, treat partners, rescreening after 4-6 weeks incase of documented infection. 5. Dysfunctional Uterine Bleeding (DUB) a. Mild DUB: • NSAIDs - Tab Mefenamic acid 500mg PO tid x 5 days, • Anitfibrinolytics - Tranexamic acid 500mg PO tid x 5 days, Combined OCPS • Mirena / Provera • Tab Progestin one tab OD in first 10-14days. b. Severe DUB: • Inj Premarin 25mg IV q4h + Tab Gravol 50mg PO q4h. • With Tab Ovral PO tid till bleeding stops (24hrs),THEN bid for 2 days, THEN od for 3days. • Continue conventional OCPs if pregnancy not desired. 6.Dysmenorrhea • Tab Ibuprofen 400mg PO qid from 1st day of menstrual cycle. • Oral Contraceptive Pills. • Important to rule out secondary causes of dysmenorrhea. 7. Endometriosis a) NSAIDs : Tab Ibuprofen 400 mg PO qid till symptoms last. b) Oral Contraceptive pills. c) Tab Provera 10-20 mg PO OD. d) Tab Danazol 600-800 mg PO OD for 6 months. e) GnRH Agonist: Inj Leuprolide 3.75 mg IM once a month for 6 months. Inj Goserelin 3.6 mg SC every 28 days for 6 months.

Use GnRH Agonist along with Estrogen/Progesterone add back therapy. (To reduce the side effects of bone loss.)

Therapeutic Guidelines | Obstetrics & Gynecology 41

8. Hormone Replacement Therapy (HRT) a) Only Estrogen - Tab Premarin 0.625mg PO OD ( only estrogen) b) Cyclic Dose - Tab Premarin 0.625mg PO OD and Tab Provera S-10mg PO OD from days 1-14. c) Standard dose - Tab Prempro (premarin 0.625mg and provera 2.5mg) combination pill PO OD. d) Pulsatile - Tab Premarin 0.625mg PO OD and Low dose Tab Provera 1.5 mg PO OD. Given as 3 days on and 3 days off. e) Transdermal : Estradiol transdermal patch twice daily and Tab Provera 2.5 mg PO OD. 9. Emergency contraception • OTC no prescription needed. Take within 72 hours of unprotected intercourse. • Tab Ovral 2 tabs PO ql2h x 2 doses (has Levonorgestrel 0.5mg/dose + estrogen O.lmg/dose) + Tab Benadryl lOmg 1 hr before dose (emesis induced by Estrogen). • Plan B ( Tab Levonorgestrel 0.75mg/tab) one tab ql2hrs x 2 doses. 10. Group B Streptococcus (GBS) in pregnancy • Inj Penicillin G 5 MU IV then 2.5 MU IV q4h till delivery. • Penicillin allergic: Inj Cefazolin 2 g IV then 1 g q8h or Inj Clindamycin 900 mg IV q8h or Inj Erythromycin 500 mg IV q6h. 11. Pregnancy Induced Hypertension (PIH) a. Initial: To maintain DBPtwice weekly, but not daily). c) Moderate Persistent Asthma- Daily symptoms with daily Beta Agonist use d) Severe Persistent Asthma- Continuous Symptoms and frequent exacerbations. • Acute Management i. 02 (to maintain 02 saturation > 90%). ii. Fluids, if dehydrated. iii. P2 Agonist : Salbutamol (Ventolin)- 0.03 cc/kg in 3cc NS every 20 minutes for 3 doses then 0.15-0.3 mg/kg (not to exceed 10 mg) every 1-4 hours as needed or 0.5 mg/kg/hour by continuous nebulization. iv. If Severe - Ipratropium bromide (Atrovent) lcc added to each of first 3 salbutamol masks. v. Steroids: Inj Prednisone 2mg/kg in ER, then lmg/kg PO OD x 4d. 4. Bacterial Tracheitis • Airway management, keep child calm. • Humidified 02 • Nebulized racemic epinephrine(l:1000 solution) in 3ml NS, 1-3 doses, ql-2h. • Inj Ceftriaxone 75-100mg/kg/day q24hrs + Inj Vancomycin 40mg/kg/day in divided doses every 6-8h.

46 NAC OSCE | A Comprehensive Review 5. Bacterial Pneumonia Newborn (under 3 weeks old) 1. Admit all newborns with Pneumonia.

2. Antibiotic regimen (Use 2-3 antibiotics combined) a) Antibiotic 1: Ampicillin i. Age 7 days • Weight 2 kg: 100-200 mg/kg divided q6h. b) Antibiotic 2: Gentamicin (dosing below if >37 weeks old) • Age 7 days: 2.5 mg/kg repeated q8h. c) Antibiotic 3: Cefotaxime (optional) • Age 7 days: 150 mg/kg divided q8h. 3. Organisms requiring additional antibiotic coverage i. Methicillin Resistant Staphylococcus Aureus (MRSA)-Vancomycin a) Age < 7 days : • Weight < 1.2 kg : 15 mg/kg IV OD. • Weight 1.2 - 2 kg : 10-15 mg/kg IV ql2-18h. • Weight > 2 kg 10-15 mg/kg IV q8-12h. b) Age > 7days , weight > 2 kg : 45-60 mg/kg/day in divided IV q8h. ii. Chlamydia trachomatis-Erythromycin 30-50 mg/kg/d PO divided q8h. Management: Age 3 weeks to 3 months 1. Outpatient (if afebrile without respiratory distress) i. Azithromycin 10 mg/kg day 1,5 mg/kg days 2-5 PO. ii. Erythromycin 30-40 mg/kg/day PO divided q6h xlOdays. 2. Inpatient (if febrile or hypoxic) i. Inj Erythromycin 40 mg/kg/day IV divided q6h and ii. One of the following antibiotics if febrile: • Inj Cefotaxime 200 mg/kg/day IV divided q8h. • Inj Cefuroxime 150 mg/kg/day IV divided q8h. 3. Critically ill i. Inj Cefotaxime as above and Inj Cloxacillin or ii. Inj Cefuroxime alone as above

Therapeutic Guidelines | Pediatrics 47 Management: Age 3 months to 5 years 1. Outpatient (if afebrile without respiratory distress) a) Consider initial parenteral antibiotic at diagnosis: • Inj Ceftriaxone 50 mg/kg/day up to 1 gram IM xl dose. • Start oral antibiotics concurrently as below. b) First-line oral agents: • Amoxicillin 90 mg/kg/day PO divided q8h x7-10d. c) Alternative oral agents: • Amoxicillin-Clavulanic Acid (Augmentin). • Erythromycin. • Clarithromycin. • Azithromycin. 2. Inpatient (if febrile or hypoxic): a) Inj Cefotaxime 150 mg/kg/day IV divided q6h. b) Inj Cefuroxime 150 mg/kg/day IV divided q8h. c) If confirmed Pneumococcal Pneumonia: • Inj Ampicillin alone 200 mg/kg/day IV divided q8h. 3. Critically ill: a) Option 1 • Inj Cefotaxime 150 mg/kg/day IV divided q6h and • Inj Erythromycin 40 mg/kg/day IV divided q6h. b) Option 2 • Inj Cefuroxime 150 mg/kg/day IV divided q8h and • Inj Cloxacillin 150-200 mg/kg/day IV divided q6h. Management: Age 5 to 18 years

1. Outpatient: a) First-line oral agents: i. Erythromycin 40 mg/kg/day PO divided q6h x 7-10d. ii. Clarithromycin 15 mg/kg/day PO divided ql2h x 7-10d. iii. Azithromycin • Day 1:10 mg/kg day 1 PO (maximum 500 mg). • Days 2-5: 5 mg/kg/day PO (maximum 250 mg). b) Pneumococcal Pneumonia confirmed: i. Amoxicillin 90 mg/kg/day PO divided q8h x 7-10d. 2. Inpatient: a) First line and in critical illness: i. Inj Cefuroxime 150 mg/kg/day IV divided q8h and ii. Inj Erythromycin 40 mg/kg/day IV divided q6h. b) Pneumococcal Pneumonia confirmed: i. Inj Ampicillin 200 mg/kg/day IV divided q8h.

48 NAC OSCE | A Comprehensive Review 6. Croup (Laryngotracheobronchitis) a) Humidified 02 b) Nebulized racemic epinephrine(l:1000 solution) in 3ml NS, 1-3 doses, ql-2h : • Child < 6mths: 0.25ml • Child > 6mths: 0.5ml • Adolescent: 0.75ml c) Dexamethasone 0.6mg/kg IM/IV/PO, max dose lOmg, given as a single dose. 7. Epiglottitis • Suspect epiglottitis if child has fever, ill looking, dyspnea, dysphonia, loss of voice, stridor, sudden in onset. • Investigations : Pharyngeal swab and culture Blood culture Lateral X-ray neck (Thumbprint sign) ABG, CBC Endoscopy in ER • Treatment : Intubation IV fluid IV Cefuroxime 8. Streptococcal Pharyngitis (Group A Streptococcus) Mclsaac Criteria - no cough, tender anterior cervical lymph nodes, erythematous tonsils with exudate, fever > 38°C, age 3-14 years. a) If 1 symptom only - no culture or antibiotics needed. b) If > 1 symptom, culture positive - treat with antibiotics: Penicillin V 40 mg/kg/day PO divided bid x 10 days. Erythromycin 40mg/kg/day PO divided tid x 10 days. Acetaminophen for fever or pain. c) Invasive GAS: needs admission Inj Clindamycin 40 mg/kg divided into 3-4 doses and Inj Penicillin 250 000 - 400 000 U/kg/day divided into 6 doses x 10 days. 9. Whooping Cough (Pertussis) a) Erythromycin 40-50mg/kg/day PO divided qid x lOd. b) Azithromycin lOmg/kg/PO OD dayl, 5mg/kg PO OD day2 to day5. (preferred) c) Isolate for 5 days of treatment. d) Erythromycin to all the household members.

Therapeutic Guidelines | Pediatrics 49 10. Bacterial Meningitis (Reportable disease) a) Inj Dexamethasone 0.6 mg/kg/day IV in 4 divided doses. Start within 1 hour of 1st antibiotic dose.. b) Ampicillin: i. Age< 1 month - SO mg/kg IV q8-12h. ii. Age>l month - 50 mg/kg IV q6h. c) Cefotaxime: i. Age < 1 month - 50 mg/kg IV q8-12h. ii. Age>l month - 200 mg/kg/day IV divided q6-8h. d) Ceftriaxone: i. Age< 1 month - 50-75 mg/kg IV divided ql2-24h. ii. Age> 1 month - 100 mg/kg/d IV divided ql2h. e) Gentamycin: 2-2.5 mg/kg IV q8h.

f) Vancomycin: 15 mg/kg q6h IV x 7-14 days. g) Prophylaxis for contacts: i. H. \nfluenzae : Rifampin 20 mg/kg/day up to 4 days. ii. N. Meningitides : • Rifampin • Children: 10 mg/kg PO ql2h x 2 days (max 600 mg). • Adults: 600 mg PO ql2h x 2 days. • Ciprofloxacin (adults) 500mg PO for one dose. • Ceftriaxone : • Age 15 years: 250 mg IM for one dose. 11. Febrile Seizures a) In ER : Inj Diazepam 0.2 - 0.5mg/kg IV ql5mins till seizure stops. b) Home : Diazepam rectal suppository. c) Investigate & treat the cause of fever. 12. Urinary^ 1. Oral Treatment- for 7-14 days. i. Cefixime (Suprax) 8 mg/kg PO divided bid or ii. Cefpodoxime ( Vantin) 10 mg/kg PO divided bid or iii. Cefprozil (Cefzil) 30 mg/kg PO divided bid or iv. Cephalexin (Keflex) 50-100 mg/kg PO divided qid. 2. IV antibiotics i. Inj Cefotaxime 50-150mg/kg/day divided q4-6h or ii. Inj Ceftriaxone 50-75mg/kg/day divided ql2-24h. 3. UTI Prophylaxis i. Bactrim (2mgTMP/10mg SMZ per kg) at bedtime qhs.

50 NAC OSCE | A Comprehensive Review

13. Allergic reaction a) General Measures: ABC management. i. Oxygen. ii. IVF. iv. Nebulised beta-agonist (Albuterol). b) Anaphylaxis with airway compromise: Epinephrine (1:1000 solution) 0.01ml/kg SC/IM(upto 0.3ml) c) Urticaria, Pruritus or Flushing: Inj Diphenhydramine 25-50mg IM/IV every 6hrs prn. Orally same dose q6h x 3days. d) Prevention: Medical alert bracelet. Strict avoidance of allergen. EpiPen. Allergy testing and desensitization therapy. i. ii. iii. iv. 14. Anemia in children • 6mg/kg/day elemental iron bid-tid. • Investigate the cause of anemia. 15. Dose ofTylenol in children a) 40-60 mg/kg/day PO divided q6hr prn (not to exceed 5 doses/24 hours). b) Neonates: 10-15 mg/kg PO q6-8hr prn. 16. Immunization Schedule for Infants and Children in Canada I: Routine likinttinteation Schedule for infants and Children àgB at vaccination 0Taf*~ IPV Hit≫ mmm m PneuC*7 Men~C Tdap HPV

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NOTES 52 NAC OSCE | A Comprehensive Review

Psychiatry

1. Agitation & Aggression Agitation can be defined as excessive verbal and/or motor behavior. It can readily escalate to aggression, which can be either verbal (vicious cursing and threats) or physical (toward objects or people). Goals of treatment (Nonpharmacological treatment) • Create a safe environment for treatment • Decrease stimulation • Permit patient to ventilate his or her feelings, but this may need to be cut short if the degree of agitation is escalating and there is clear danger to self and others. • Behavioral approaches include never turning your back to an agitated patient, talking softly rather than shouting, and inquiring about what specific needs the patient may have • Prevent further episodes of agitation or aggression Delirium • Delirium or acute confusional state is a common and severe neuropsychiatric syndrome with core features of acute onset and fluctuating course, attentional deficits and generalized severe disorganization of behavior. Treatment of delirium requires treatment of the underlying causes. • Antipsychotics are first-line treatment. Haloperidol is the most effective medication for decreasing agitation in delirious patients. First generation antipsychotic Loxapine and second generation (atypical) antipsychotics such as Olanzapine,Risperidone and Quetiapine can also be used. Benzodiazepines should be reserved for cases of alcohol withdrawal. First-generation Antipsychotics (FGA) • Haloperidol : 0.5-2.5 mg PO/IM bid • Loxapine : 12.5-50 mg/day PO Second generation (atypical) antipsychotics (SGA) • Olanzapine : 5-10 mg/day PO, 2.5-10 mg IM (repeat 2h and 6h prn to max of 30 mg/24 h) • Risperidone : 0.5-2 mg/day PO • Quetiapine : 25-100 mg/day PO Benzodiazepines • Lorazepam : 0.5-1 mg PO/IM q6-8h • Oxazepam : 10-15 mg PO tid

ANnpsYCHoncss/e FGA>SGA Extrapyramidal S/E - Acute dystonia, Parkinsonism, akathasia, Tardive dyskinesia. Neuroleptic Malignant Syndrome (NMS) Sedation Weight gain, diabetes and dyslipidemia Hyperprolactinemia and sexual dysfunction.

Therapeutic Guidelines | Psychiatry 53

Mania • Mania is a state of abnormally elevated or irritable mood, arousal, and/ or energy levels. Treatment of mania involves both acute control of severe agitation by a mood stabilizer and long term mood stabilizers. Initially atypical antipsychotics such as Risperidone, Olanzapine or Quetiapine are effective. First-generation Antipsychotics • Haloperidol : 5-10 mg/day PO/IM Atypical antipsychotics • Risperidone : 2-3 mg/day PO • Olanzapine : 5-20 mg/day PO, 2.5-10 mg IM (repeat 2h and 6h prn to max of 30 mg/24 h) • Quetiapine : start with 100 mg/day PO; increase by 100 mg/day as needed to 300-600 mg/day divided BID

2. Anxiety Disorders • Anxiety disorders are a group of conditions with exaggerated anxiousness and worry about a number of concerns persists for an extended period of time. Goals of treatment (Nonpharmacologic treatment) • Stress reduction and relaxation techniques such as meditation and low impact yoga is often helpful. • Cognitive behavioral therapy (CBT) • Reduction of consumption of caffeine and other stimulants. • Minimize use of alcohol Panic disorder • Panic attack or panic disorder involves sudden anxiety that occurs without warning. Symptoms can include chest pain, heart palpitations, sweating, shortness of breath, feeling of unreality, trembling, dizziness, nausea, hot flashes or chills, a feeling of losing control, or a fear of dying. Panic attacks are extremely common - 10% to 20% of the population experience a panic attack at some point in their life. Some people start to avoid situations that might trigger a panic attack; this is called panic attack with agoraphobia. Panic disorder refers to recurring feelings of terror and fear, which come on unpredictably without any clear trigger. • SSRIs and SNRIs are the first choice in the treatment of panic disorders. Selective serotonin reuptake inhibitors (SSRIs) like Citalopram, Escitalopram, Fluoxetine, Paroxetine and Sertraline are all effective in reducing panic attacks. Serotonin norepinephrine reuptake inhibitor (SNRIs) eg. Venlafaxine is also used in panic disorder. • There is a delay in the onset of response to these drugs which may be accompanied by initial agitation. Combining SSRI or SNRI with a brief course of low dose benzodiazepine can increase adherence to medication and produce rapid response. • Other medication include Tricyclic antidepressants (TCAs) eg. Imipramine, Desipramine and Clomipramine and Monoamine oxidase inhibitors (MAOIs) eg. Phenelzine, Tranylcypromine.

54 NAC OSCE | A Comprehensive Review Selective serotonin reuptake inhibitors (SSRIs) • Paroxetine : 20-60 mg/day PO • Fluoxetine : 20-80 mg/day PO • Sertraline : 50-200 mg/day PO • Citalopram : 20-60 mg/day PO • Escitalopram : 10-20 mg/day PO Serotonin norepinephrine reuptake inhibitor (SNRIs) • Venlafaxine : 37.5-22.5 mg/day Tricyclic antidepressants (TCAs) • Clomipramine : 75-225 mg/day • Desipramine : 75-300 mg/day • Imipramine : 75-300 mg/day Benzodiazepines • Alprazolam : 0.25 mg tid-qid, up to 1 mg PO qid • Clonazepam : 0.25-0.5 mg PO bid Monoamine oxidase inhibitors (MAOIs) • Phenelzine : 45-90 mg/day • Tranylcypromine : 20-60 mg/day Social Phobia • Social anxiety, also known as social phobia, involves excessive anxiety in social situations where people fear being embarrassed or made fun of. Situations that can trigger social anxiety include small group discussions, dating, going to a party, and playing sports. Common symptoms of social anxiety include

blushing, sweating, and dry mouth. People with social phobia often avoid social situations that cause anxiety. • SSRI and SNRI are mainstay drugs for the treatment for social phobia. Escitalopram, Fluvoxamine, Paroxetine, Sertraline and Venlafaxine may be used for milder cases. • Simple stage fright or fear of public speaking may respond to low dose Propranolol lOmg taken 30 minutes before the event. General Anxiety Disorder • Generalized anxiety disorder (GAD) is associated with continual excessive anxiety and worry about a number of things (e.g., work, money, children, and health). There is no specific source of fear. Symptoms can include muscle tension, trembling, shortness of breath, fast heartbeat, dizziness, dry mouth, nausea, sleeping problems, and poor concentration. CBT is the most effective psychosocial treatment but often takes 20 or more sessions to be effective. • SSRIs and SNRIs have become established as first line treatments for GAD. Bupropion and Pregabalin are further choices. Low dose benzodiazepines can be used but dependence is a problem. Buspirone has a low abuse potential and is less sedating than benzodiazepines. • Buspirone : 5mg bid-tid, up to 60 mg/day

smmnmsmmom

Confusion, disorientation, agitation, fever, diaphoresis, sinus tachycardia, HTN, mydriasis, tachypnea, myoclonic jerks, hyperreflexia, muscle rigidity, tremor, ataxia, incoordination. TREATMENT: Benzodiazepines (1 line), Serotonin Antagonists : Cyproheptadine, Methysergide, Propranolol*

Therapeutic Guidelines | Psychiatry 55

• Pregabalin : Initial 150 mg/day in 2-3 divided doses, may be increased to 150 mg bid after 1 week if necessary • Bupropion (Wellbutrin, Zyban): Use : Smoking cessation, second line Antidepressant. Antidepressant: Start 100 mg bid x 4 days 100 m g tid. Obsessive-compulsive disorder (OCD) • OCD involves recurring unpleasant thoughts (obsessions) and/or repetitive behaviours (compulsions). The thoughts may be connected to the repetitive behaviours. For example, people who fear getting an infection may constantly wash their hands. At times, however, there’s no connection at all between the thoughts and the behaviours. • CBT is the psychotherapy of choice. SSRIs : Fluoxetine, Fluvoxamine, Paroxetine and Sertraline, in the usual antidepressant dosing range are the drugs of choice in Canada. It may take 6-8 weeks for symptoms to improve. Second line drugs include Clomipramine, Venlafaxine, Citalopram and Mirtazapine. Post-traumatic stress disorder (PTSD) • PTSD is associated with extreme anxiety that appears after a traumatic experience. Symptoms usually start within 3 months of the traumatic event but may take years to start. PTSD can be associated with sleep problems, nightmares, irritability, and anger. Feelings of guilt and unworthiness are common with PTSD. Traumatic experiences that can trigger PTSD include wars, plane crashes, natural disasters (e.g., hurricane, earthquake), and violent crimes (e.g., rape, abuse). • SSRI and SNRI antidepressants have been shown to be effective in reducing the symptoms of PTSD. Fluoxetine, Paroxetine, Sertraline and Venlafaxine are first line options.

3. Dementia

Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging. Dementia is not a single disease, but rather a non-specific illness syndrome in which affected areas of cognition may be memory, attention, language, and problem solving. It is normally required to be present for at least 6 months to be diagnosed. The most common causes of dementia are Alzheimer’s disease and vascular dementia. It affects about 1% of people aged 60-64 years and as many as 30-50% of people older than 85 years. Benzodiazepines must be used cautiously in the elderly patients due to increase risk of falls and impaired cognition. «DUMBI* Dressing Eating Ambulation Toilet Hygiene Shopping Housekeeping Accounting Food Making Transportation

56 NAC OSCE | A Comprehensive Review 4. Depression Nonpharmacological treatment

• Cognitive behavioral and interpersonal psychotherapy are as effective as antidepressants in mild to moderate depression. Pharmacological treatment • Take medication daily, antidepressant must be taken for 2 to 4 weeks for effect to be noticeable. Medication must be taken even if patient is feeling better. SSRI • Paroxetine (Paxil): Start 20 mg qhs, increase lOmg every 2wks, max 60mg per day. • Fluoxetine (Prozac): Start 20mg PO qd, avoid increasing more often than monthly, max 80mg PO per day • Sertraline (Zoloft): Start 50mg PO qAM, increase 50mg every 2 weeks, max 200mg per day • Fluvoxamine (Luvox): Start 25mg PO qhs x 3 days -> 50mg PO qhs x 7 days -> titrate 150-250 mg daily divided doses bid. • Citalopram (Celexa): Start 20mg PO qd, max 60mg. • Escitalopram (Lexapro): Start lOmg PO qd Monoamine Oxidase Inhibitor (MAO inhibitor): Use in Atypical depression, Refractory depression. • Isocarboxazid (Marplan) - 10 mg PO bid, max 60 mg per day. • Phenelzine (Nardil) - 15 mg PO tid, max 90 mg per day. • Tranylcypromine (Parnate) - 10-40 mg per day in divided doses, max 60 mg per day. Complication: Hypertensive crisis, Serotonin syndrome. Interaction with tyramine containing foods to be avoided strictly. Serotonin Norepinephrine Reuptake Inhibitors(SNRI) not used these days • Tricyclic Antidepressants: Amitriptyline 25 mg qhs, Nortriptyline (Pamelor) S/E: Anti-cholinergic - dry mouth, constipation, blurred vision, Anti-histaminergic - sedation, weight gain; Serotonergic - sexual dysfunction; Orthostatic hypotension; Sinus tachycardia, SVT, Ventricular tachycardia, Prolonged QT interval, heart block; Withdrawal symptoms. Other : Venlafaxine (Effexor) 37.5 mg PO od.

6. Psychosis

In acutely psychotic individuals, short-acting parenteral antipsychotics either alone or in combination with a parenteral benzodiazepine may be recommended. Liquid formulations of atypical antipsychotics may be used as an alternative to intramuscular injections, Risperidone and Olanzapine are examples. Atypical antipsychotics : • Clozapine - 12.5 mg PO qd or bid, titrate slowly upwards in increments of25-50 mg/day Target dose : 300 - 450 mg/day, max 900 mg/day. S/E: Agranulocytosis, Diabetes mellitus, hypertriglyceridemia. NOT 1st LINE Anti-psychotic. Order weekly blood counts for 1 month and then q2 weeks.

Therapeutic Guidelines | Psychiatry 57

• Olanzapine (Zyprexa) - Start 5-10 mg PO qd, increase in 5 mg increments weekly as tolerated, max 20 mg/day. S/E: Mild sedation, insomnia, dizziness, early AST & ALT elevation, resdessness, weight gain, increased risk of diabetes mellitus and hyperlipidemia. • Quetiapine (Seroquel) - Start 25 mg PO bid - tid, increase in 25- 50 mg/day increments, target 300-400 mg/day divided doses bid- tid, max 750 mg/day. S/E: Headache, sedation, dizziness, constipation. • Risperidone (Risperdal) - Start 1 mg PO bid, slow titration 2-4 mg PO daily or divided doses bid, max 16 mg/day. S/E: Insomnia, agitation, EPS, headache, anxiety, hyperprolactenemia, postural hypotension, constipation, dizziness, weight gain. Typical antipsychotics: • Haloperidol (Haldol)- 5-10 mg PO, IM, IV. May repeat q30-60mins, max 300 mg per day. • Fluphenazine (prolixin) - 2.5 mg PO bid, max 40 mg per day. S/E - EXTRA PYRAMIDAL SIDE EFFECTS: Akinesia - treat with Benztropine 2mg PO /IM/IV OD Dystonie reaction - treat with Lorazepam or benztropine. Dyskinesia Akathesia - treat with Lorazepam, Propranolol or Diphenhydramine. Perioral tremor Neuroleptic malignant Syndrome - Muscle rigidity, tremor, delirium, high fever, diaphoresis, hypertension. Discontinue drug. Give symptomatic treatment and supportive care. Treatment with Dantrolene or bromocriptine. Tardive dyskinesia - Blinking, lip smacking, sucking, chewing, grimaces, choreoathetoid movements, tonic contractions of neck / back.

Treatment - Clozapine.

7. Mood stabilizers : Used in Bipolar disorder. • Lithium bicarbonate - Start 300 mg PO bid, then increase to 900 - 1800 mg per day divided doses. Serum levels - 0.6 -1.2 mEq/1, monitor RFTs,TFTs. S/E: tremor, polydipsia, hypothyroidism, weight gain, nausea/vomiting, diarrhea, ataxia, slurred speech, lack of coordination. Treatment of Lithium toxicity: Discontinue lithium. Check serum lithium levels, BUN, electrolytes. IV fluids - Normal saline. Hemodialysis in case Li > 2 mmol/L, coma, shock, severe dehydration, deterioration, unresponsive to treatment. Life* threatening neurological disorder presents with muscle Elevated creatine phosphokinase Rx : dantrolene sodium

58 NAC OSCE | A Comprehensive Review

• Divalproex (Epival) 300-1600 mg/day PO bid. Monitor LFTs weekly x 1 month, then monthly. S/E: Liver dysfunction, nausea/vomiting, diarrhea, ataxia, drowsiness, tremor, sedation, hair loss, weight gain thrombocytopenia, neural tube defects in early pregnancy. • Carbamazepine (Tegretol) 750- 3000 mg/day PO tid. Monitor weekly CBC due to risk of agranulocytosis. S/E: Nausea/vomiting, hepatic toxicity, ataxia, drowsiness, confusion, nystagmus, diplopia, transient leukopenia, agranulocytosis, drug reaction (SJS), neural tube defect in early pregnancy.

8. Medications causing sexual dysfunction 1. Antiandrogen Medications • Spironolactone • Ketoconazole • Finasteride 2. Antihypertensives • Centrally acting sympatholytics (e.g. Clonidine) • Peripherally acting sympatholytics (e.g. Guanadrel) • Beta Blockers • Thiazide Diuretics 3. Antidepressant Medications • Selective Serotonin Reuptake Inhibitors (SSRI) • Tricyclic Antidepressants • MAO inhibitors 4. Sedative-Hypnotic Medications • Barbiturates • Benzodiazepines 5. Drug Abuse • Alcohol Abuse • Heroin abuse • Marijuana abuse • Methadone • Tobacco abuse 6. Other Medications • Anticholinergic Medications • Antipsychotic Medications • H2 Receptor Blockers

Therapeutic Guidelines | Psychiatry 59 9. Substance abuse • Alcohol withdrawal: • Tab Diazepam 20 mg PO ql-2h prn . • Observe for 1-2 hours and re-assess. • Inj Thiamine 100 mg IM then 100 mg PO OD x 3 days. • Maintain hydration. • If oral Diazepam not well tolerated then switch to Inj Diazepam 2-5 mg IV/min - maximum 10-20 mg qlh, or S/L Lorazepam.

• If severe liver dysfunction ,severe asthma, respiratory failure or age> 65 years present - Lorazepam PO/SL/IM 1-4 mg q l-2h. • Hallucination present - Haloperidol 2-5 mg IM/PO ql-4h - max 5 doses/day along with Diazepam 20 mg x 3 doses as seizure prophylaxis. • Wernickes syndrome:Thiamine 100 mg PO OD x 1-2 weeks. • Korsakoffs syndrome: Thiamine 100 mg PO bid/tid x 3-12 months. • Opioid Intoxication: • ABCs • IV Glucose • Inj Naloxone (Narcan) 0.4 mg - 2mg IV. • Intubation and mechanical ventilation may be required for decreased level consciousness. • Cocaine Overdose: • ABCs • Inj Diazepam 2-5 mg IV/min - maximum 10-20 mg qlh ( to control seizures). • Propranolol or labetalol to treat hypertension and arrhythmia. • Hallucinogens: LSD, mescaline, psilocybin, MDMA. • Symptomatic treatment and supportive care. • Decreased stimulation. • Benzodiazepines or antipsychotics might be required. • Phencyclidine: • Room with minimal stimulation. • Inj Diazepam IV for muscle spasms or seizures. • Haloperidol to suppress psychotic behavior.

NOTES

Clinical Examination Clinical Examination 63 Abdominal 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. • Look for medical equipment/therapies (e.g. drains, colostomy/ileostomy bags). • Verbalize the steps of the examination and your findings. • Use proper draping techniques. 2. Inspection • General inspection of the patient : Is patient comfortable at rest? Do they appear to be tachypnoeic? • Examine the patient’s hands for presence of koilonhychia (iron deficiency), leukonychia (hypoalbuminemia), clubbing (IBD, coeliac disease, cirrhosis), palmar erythema, tar staining or Dupuytren’s contracture. • Ask the patient to hold their hands out in front of them looking for a any tremor and then get them to extend their wrists up towards the ceiling keeping the fingers extended and look for flapping (asterixis in hepatic encephalopathy). • Examine the face, check the conjunctiva for pallor. Also check the sclera for jaundice. Look at the buccal mucosa for any obvious ulcers which could be a sign of Crohn’s disease, B12 or iron deficiency. Also look at the tongue. If it is red and fat it could be another sign of anaemia, as could angular stomatitis. Check state of dentition - pigmentation of oral mucosa (Peutz-Jegher’s syndrome), telangectasia, candidiasis. • Examine the neck for an enlarged left supraclavicular lymph node. A palpable enlarged supraclavicular (Virchow’s) node is known as Troisier’s Sign, may be a sign of malignancy. Virchow’s node drains the thoracic duct and receives lymphatic drainage from the entire abdomen as well as the left thorax. Therefore, enlargement of this node may suggest metastatic deposits from a malignancy in any of these areas. • Examine the chest, in particular look for gynaecomastia in men and the presence of 5 or more spider naevi. These are both stigma of liver pathology.

• Inspect the abdomen and comment on any obvious abnormalities such as scars, masses and pulsations. Also note if there is any abdominal dis tension/ascites. Look for distended veins, striae, Cullen’s/GreyTurner’s signs (pancreatitis), Sister Mary Joseph's nodule (widespread abdominal cancer)

64 NAC OSCE | A Comprehensive Review 3. Auscultation • Listen with the diaphragm next to the umbilicus for up to 30 seconds. • Listen for bowel sounds - absent (e.g. Ileus, peritonitis), tinkling (bowel obstruction) 4. Palpation • Palpation of the abdomen should be performed in a systematic way using the 9 named segments of the abdomen: right and left hypochondrium, right and left flank, right and left iliac fossa, the umbilical area, the hypochondrium and the suprapubic region. • If a patient has pain in one particular area you should start as far from that area as possible. The tender area should be examined last as they may start guarding making the examination very difficult. • Initial examination should be superficial using one hand.Once you have examined all 9 areas superficially, you should examine deeper. This is performed with two hands, one on top of the other. • Feel for organomegaly, particularly of the liver, spleen and kidneys. Palpation for the liver and spleen is similar, both starting in the right iliac fossa. For the liver, press upwards towards the right hypochondrium. You should try to time the palpation with the patient's breathing as this presses down on the liver. If the liver is distended, its distance from the costal margin should be noted. • Palpating for the spleen is as for the liver but in the direction of the left hypochondrium. The edge of the spleen which may be felt if distended is more nodular than the liver. • To feel for the kidneys you should place one hand under the patient in the flank region and the other hand on top. You should then try to ballot the kidney between the two hands. 5. Percussion Percussion over the abdomen is usually resonant, over a distended liver it will be dull. Percussion can also be used to check for 'shifting dullness' - a sign of ascites. With the patient lying flat, start percussing from the midline away from you. If the percussion note changes, hold you finger in that position and ask the patient to roll towards you. Again percuss over this area and if the note has changed then it suggests presence of fluid such as in ascites. It is also appropriate at this time to check for pedal edema. 6. You should mention to the examiner at this point that you would like to finish the examination with an examination of the hernial orifices, the external genitalia and also a rectal examination. 1

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\ Clinical Examination 65 Cardiovascular 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. • Look for medical equipment/therapies (e.g. GTN spray, ECG pads, oxygen) • Verbalize the steps of the examination and your findings. 2. Inspection • Start by observing the patient from the end of the bed. You should note whether the patient looks comfortable. Are they cyanosed or flushed? • Respiratory rate, rhythm and effort of breathing. • Chest shape, chest movements with respration (symmetrical/assymetrical), skin (scars/nevi) • Inspect the nails for clubbing, splinter hemorrhages (infective endocarditis), koilonychia (iron deficiency anemia).

• Inspect fingers for capillary refill time, peripheral cyanosis, osier's nodes (infective endocarditis) and nicotine staining. • Inspect palms for palmar erythema,Janeway lesions and xanthomas. • Take the radial pulse, assess the rate and rhythm.At this point you should also check for a collapsing pulse - a sign of aortic incompetence. Locate the radial pulse and place your palm over it, then raise the arm above the patient’s head. A collapsing pulse will present as a knocking on your palm. At this point you should say to the examiner that you would like to take the blood pressure. They will usually tell you not to and give you the value. • Inspect the sclera for any signs of jaundice, anaemia and corneal arcus. You should also look for any evidence of xanthelasma. • Whilst looking at the face, check for any malar facies, look in the mouth for any signs of anaemia such as glossitis, check the colour of the tongue for any cyanosis, and around the mouth for any angular stomatitis - another sign of anaemia. • Assess jugular venous pressure ( JVP), ask patient to turn their head to look away from you. Look across the neck between the two heads of sternocleidomastoid for a pulsation then measure the JVP. • Examine the chest, or praecordium for any obvious pulsations, abnormalities or scars, remembering to check the axillae as well.

66 NAC OSCE | A Comprehensive Review 3. Palpation • Palpate praecordium trying to locate the apex beat and describe its location anatomically. The normal location is in the 5th intercostals space in the mid-clavicular line. • Palpate for any heaves or thrills. A thrill is a palpable murmur whereas a heave is a sign of left ventricular hypertrophy. Feel for these all over the praecordium. 4. Auscultation • Mitral valve - where the apex beat was felt. • Tricuspid valve - on the left edge of the sternum in the 4th intercostal space. • Pulmonary valve - on the left edge of the sternum in the 2nd intercostal space. • Aortic valve - on the right edge of the sternum in the 2nd intercostal space. How many heart sounds are heard? Are the heart sounds normal in character? Any abnormal heart sounds? If you hear any abnormal sounds you should describe them by when they occur and the type of sound they are producing. Are there any murmurs? Can you hear any rub? Feeling the radial pulse at the same time can give good indication as to when the sound occurs - the pulse occurs at systole. Furthermore, if you suspect a murmur, check if it radiates. Mitral murmurs typically radiate to the left axilla whereas aortic murmurs are heard over the left carotid artery. • To further check for mitral stenosis you can lay the patient on their left side, ask them to breathe in, then out and hold it out and listen over the apex and axilla with the bell of the stethoscope. • Aortic incompetence can be assessed in a similar way but ask the patient to sit forward, repeat the breathe in, out and hold exercise and listen over the aortic area with the diaphragm. 5. With patient sitting up percuss back for pleural effusion (cardiac failure) 6. Finally assess for any pedal & sacral oedema. 7. Finish by thanking the patient and ensuring they are comfortable and well covered.

Clinical Examination 67

Peripheral Vascular 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. • Look for medical equipment/therapies (e.g. GTN spray, ECG pads, oxygen) • Verbalize the steps of the examination and your findings. 2. Inspection • General observation of the patient, arms from the finger tips to the shoulder and legs from the groin and buttocks to the toes. Comment on the general appearance of the arms and legs, size, swelling, symmetry, skin color, hair, scars, pigmentation including any obvious muscle wasting. Note colour and texture of nails. • Any signs of gangrene or pre-gangrene such as missing toes or blackening of the extremities. • The presence of any ulcers - ensure you check all around the feet including behind the ankle. These may be venous or arterial - one defining factor is that venous ulcers tend to be painless whereas arterial are painful.

• Any skin changes such as pallor, change in colour (eg purple/black from haemostasis or brown from haemosiderin deposition), varicose eczema or sites of previous ulcers, atrophic changes and hair loss. • Presence of any varicose veins - often seen best with the patient standing. 3. Palpation • Assess the skin temperature. Starting distally, feel with the back of your hand and compare each limb to the other noting any difference. • Check capillary return by compressing the nail bed and then releasing it. Normal colour should return within 2 seconds. If this is abnormal, perform Buerger’s Test. This involves raising the patient’s feet to 45°. In the presence of poor arterial supply, pallor rapidly develops. Following this, place the feet over the side of the bed, cyanosis may then develop. • Any varicosities which you noted in the observation should now be palpated. If these are hard to the touch, or painful when touched, it may suggest thrombophlebitis. • Palpate peripheral pulses. These are: Carotid - only palpate one carotid at a time Radial - use the pad of three fingers Brachial - may use thumb to palpate Femoral - feel over the medial aspect of the inguinal ligament.

68 NAC OSCE | A Comprehensive Review

Popliteal - ask the patient to flex their knee to roughly 60° keeping their foot on the bed, place both hands on the front of the knee and place your fingers in the popliteal space. Posterior tibial - felt posterior to the medial malleolus of the tibia. Dorsalis pedis -feel on the dorsum of the foot, lateral to the extensor tendon of the great toe. You should compare these on both sides and comment on their strength. • Check for radio-femoral delay. Palpate both the radial and femoral pulses on one side of the body. The pulsation should occur at the same time. Any delay may suggest coarctation of the aorta. 4. Auscultation : listen for femoral and abdominal aortic bruits 5. Special Tests • Allen Test : Ask the patient to make a tight fist and elevate the hand. Occlude the radial and ulnar arteries with firm pressure. The hand is then opened. It should appear blanched (pallor can be observed at the finger nails). Release either the Ulnar or radial artery pressure and the color should return in 7 seconds. If the palm does not redden immediately, this suggests arterial insufficiency. • Straight Leg Raise and Refill Test (Buerger's Test) : Raise the leg 45° to 60° for 30 seconds until pallor of the feet develops and observe empty veins. Sit the patient upright and observe the feet. In normal patients, the feet quickly turn pink (within 10-15 seconds). If, pallor persists for more than 10- 15s or there is development of a dusky cyanosis (rubor), this suggests of arterial insufficiency. • Test for incompetent Saphenous Vein : Ask the patient to stand and note the dilated varicose veins. Compress the vein proximally with one hand and place the other hand 10-15 cm distally. Briskly compress and decompress the distal site. Normally, the hand at the proximal site should feel no impulse, however with varicose veins a transmitted pulse may be felt. • Trendelenburg Maneuver (Retrograde filling) : Ask the patient to lie down. Elevate the leg, and empty the veins by massaging distal to proximal. Using a tourniquet, occlude the superficial veins in the upper thigh. Ask the patient to stand. If the tourniquet prevents the veins from re-filling rapidly, the site of the incompetent valve must be above this level i.e. at the sapheno-femoral junction. If the veins re-fill, the communication must be lower down. Observing the same protocol, proceed down the leg until the tourniquet controls re-filling. As necessary, test: • above the knee - to assess the mid-thigh perforator • below the knee - to assess competence between the short saphenous vein and popliteal vein If re-filling cannot be controlled, the communication is probably by one or more distal perforating veins.

Clinical Examination 69 Respiratory 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. • Look for medical equipment/therapies (e.g. inhalers, oxygen). • Verbalize the steps of the examination and your findings. 2. Inspection

• General look of the patient. Check whether they are comfortable at rest, is patient tachypnoeic? Are they using accessory muscles? Are there any obvious abnormalities of the chest? Check for any clues around the bed such as inhalers, oxygen masks or cigarettes. • Inspect the hands, hot, pink peripheries may be a sign of carbon dioxide retention. Look for any signs of clubbing, cyanosis, hypertrophic pulmonary osteoarthropathy, dupytren's contacture and nicotine staining. Assess for carbon dioxide retention flap/salbutamol tremor. • Take the patient’s pulse. After you have taken the pulse it is advisable to keep your hands in the same position and subtly count the patient’s respiration rate. • Inspect the face, ask the patient to stick out their tongue and note its colour - checking for cyanosis. - Horner's sydrome (Pancoast tumour), plethora (polycythemia). • Look for any use of accessory muscles such as the sternocleidomastoid muscle. Also palpate for the left supraclavicular node (Virchow's Node) as an enlarged node (Troisier's Sign) may suggest metastatic lung cancer. • Examine the chest and back. Observe the chest for any deformities (barrel chest, kyphoscoliosis, pectus excavatum, pectus carinatum), symmetry of expansion, dilated veins, intercostal recession. 3. Palpation • Palpate the chest. Feel between the heads of the two clavicles for the trachea, see if it is deviated. • Feel for chest expansion. Place your hands firmly on the chest wall with your thumbs meeting in the midline. Ask the patient to take a deep breath in and note the distance your thumbs move apart. Normally this should be at least 5 centimetres. Measure this at the top and bottom of the lungs as well as on the back.

70 NAC OSCE | A Comprehensive Review 4. Percussion • Percussion should be performed on both sides, comparing similar areas on both sides. Start by tapping on the clavicle which gives an indication of the resonance in the apex. Then percuss normally for the entire lung fields. Hyper-resonance may suggest a collapsed lung where as hypo-resonance or dullness suggests consolidation such as in infection or a tumour. Be sure to perform this on the back as well. 5. Vocal Fremitus Check for tactile vocal fremitus. Place the medial edge of your hand on the chest and ask the patient to say ‘99\ Do this with your hand in the upper, middle and lower areas of both lungs. 6. Auscultation • Do this in all areas of both lungs and on front and back comparing the sides to each other. Listen for any reduced breath sounds, or added sounds such as crackles, wheezes or rhonchi. Tracheal Percussion Tactile Vocal Fremitus Breath Sounds OtherSounds Effusion Away Dull Decreased Decreased Bronchial sounds +/- egophony at edge

ComoMatton Central Dull Increased Bronchial Occasional crackles

Pneumothorax Away Hyper-resonant Decreased Absent Nil

Atelectasis Towards lesion Dull Increased Decreased Nil

Fibrosis Central Resonant (normal) Normal Decreased if severe Late inspiratory crackles

7. Finish by examining the lymph nodes in the head and neck. Start under the chin with the submental nodes, move along to the submandibular then to the back of the head at the occipital nodes. Next palpate the pre and post auricular nodes. Move down the cervical chain and onto the supraclavicular nodes.

Clinical Examination 71 Central Nervous System 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. • Look for medical equipment/therapies (e.g. walking aids). • Verbalize the steps of the examination and your findings. 2. Cranial Nerve Examination 1) The Olfactory nerve (CN I) is simply tested by offering something familiar for the patient to smell and identify - for example coffee or vinegar. 2) The Optic nerve (CN II) is tested in five ways: • The acuity is easily tested with Snellen charts. This should be assessed both with the patient wearing any glasses or contact lenses they usually wear and without them. • Colour vision is tested using Ishara plates, these identify patients who are colour blind. • Visual fields are tested by asking the patient to look direcdy at you and wiggling one of your fingers in each of the four quadrants. Ask the patient to identify which finger is moving. Visual inattention can be tested by moving both fingers at the same time and checking the patient identifies this. • Visual reflexes comprise direct and concentric reflexes. Place one hand vertically along the nose to block any light from entering the eye not being tested. Shine a pen torch into one eye and check that the pupils on both sides constrict. This should be tested on both sides. • Finally fundoscopy should be performed on both eyes. 3) Eye movements: Oculomotor nerve (III), Trochlear nerve (IV) and Abducent nerve (VI) are involved in movements of the eye. Asking the patient to keep their head perfecdy still direcdy in front of you, you should draw two large joining Hs in front of them using your finger and ask them to follow your finger with their eyes. It is important the patient does not move their head. Always ask if the patient experiences any double vision and if so when is it worse. Also look for ptosis and assess saccadic eye movements. 4) The Trigeminal nerve (CN V) is involved in sensory supply to the face and motor supply to the muscles of mastication. Initially test the sensory branches by lightly touching the face with a piece of cotton wool and then with a blunt pin in three places on each side - around the jawline, on the cheek and on the forehead. The corneal reflex should also be examined as the sensory supply to the cornea is from this nerve. This is done by lighdy touching the cornea with the cotton wool. This should cause the patient to shut their eyelids. For the motor supply, ask the patient to clench their teeth together, observing and feeling the bulk of the masseter and temporalis muscles. Then ask them to open their mouth against resistance. Finally perform the jaw jerk on the patient by placing your left index finger on their chin and striking it with a tendon hammer. This should cause slight protrusion of the jaw.

72 NAC OSCE | A Comprehensive Review 5) The Facial nerve (CN VII) supplies motor branches to the muscles of facial expression. Therefore, this nerve is tested by asking the patient to crease up their forehead (raise their eyebrows), close their eyes and keep them closed against resistance, puff out their cheeks and show you their teeth. 6) The Vestibulocochlear nerve (CN VIII) provides innervation to the hearing apparatus of the ear and can be used to differentiate conductive and sensori-neural hearing loss using the Rinne and Weber tests. For the Rinne test, place a sounding tuning fork on the patient’s mastoid process and then next to their ear and ask which is louder, a normal patient will find the second position louder. For Weber’s test, place the tuning fork base down in the centre of the patient’s forehead and ask if it is louder in either ear. Normally it should be heard equally in both ears. 7) The Glossopharyngeal nerve (CN IX) provides sensory supply to the palate. It can be tested with the gag reflex or by touching the arches of the pharynx.

8) The Vagus nerve (CN X) provides motor supply to the pharynx. Asking the patient to speak gives a good indication to the efficacy of the muscles. You should also observe the uvula before and during the patient saying aah’. Check that it lies centrally and does not deviate on movement. 9) The Accessory nerve (CN XI) gives motor supply to the sternocleidomastoid and trapezius muscles. To test it, ask the patient to shrug their shoulders and turn their head against resistance. 10) The Hypoglossal nerve (CN XII) provides motor supply to the muscles of the tongue. Observe the tongue for any signs of wasting or fasciculations. Then ask the patient to stick their tongue out. If the tongue deviates to either side, it suggests a weakening of the muscles on that side. 3. Cerebellar Examination Gait: • Ask the patient to stand up. Observe the patient's posture and whether they are steady on their feet. • Ask the patient to walk, e.g. to the other side of the room, and back. If the patient normally uses a walking aid, allow them to do so. • Observe the different gait components (heel strike, toe lift off). Is the gait shuffling / waddling / scissoring/ swinging? • Observe the patients arm swing and take note how the patient turns around as this involves good balance and co-ordination. • Ask the patient to walk heel-to-toe to assess balance. • Perform Romberg’s test by asking the patient to stand unaided with his eyes closed. If the patient sways or loses balance this test is positive. Stand near the patient in case he falls. Co-ordination: • Look for a resting tremor in the hands. • Test tone in the arms (shoulder, elbow, wrist) • Test for dysdiadochokinesis by showing the patient to clap by alternating the palmar and dorsal surfaces of the hand. Ask to do this as fast as possible and repeat the test with the other hand. • Perform the finger-to-nose test by placing your index finger about two feet from the patients face. Ask him to touch the tip of his nose with his index finger then the tip of your finger. Ask him to do this as fast as possible while you slowly move your finger. Repeat the test with the other hand. • Perform the heel-to-shin test. Have the patient lying down for this and get him to run the heel of one foot down the shin of the other leg and then to bring the heel back up to the knee and start again. Repeat the test with the other leg.

Clinical Examination 73 Upper Limb Neurological Examination

1. Steps before beginning examination • Introduce yourself : aI 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. • Use proper draping techniques, verbalize the steps of the examination and your findings. 2. Inspection • General inspection of patient: general comfort, abnormal posture/movements, muscle wasting. • The upper body should be exposed for this examination. Observe the patient's arms, look for any muscle wasting, fasciculations or asymmetry. 3. Tone • Examine the tone of the muscles. Start proximally at the shoulder, feeling how easy the joint is to move passively. Then move down to the elbow, wrist and hand joints again assessing each one's tone in turn. • Assess for spastic catch, clasp-knife rigidity, led-pipe or cog-wheel rigidity. 4. Power • Next assess the power of each of the muscle groups. - Shoulder abduction (C5) & Shoulder adduction (C5/C6/C7) - Elbow flexion (C5/C6) & Elbow extension (C7) - Wrist flexion (C8) & Wrist extension (C8) - Finger flexion (C8), Finger abduction (Tl), Finger adduction (Tl) - Thumb abduction (C8) 5. Reflexes • There are three reflexes in the upper limb - the biceps, triceps and supinator reflexes. • The biceps reflex (C5/C6) is tested by supporting the patient's arm, with it flexed at roughly 60°, placing your thumb over the biceps tendon and hitting your thumb with the tendon hammer. It is vital to get your patient to relax as much as possible and for you to take the entire weight of their arm. • The triceps reflex (C6/C7) is elicited by resting the patient's arm across their chest and hitting the triceps tendon just proximal to the elbow.

• Finally, with their arm rested on their abdomen, locate the supinator tendon (C5/C6) as it crosses the radius, place three fingers on it and hit the fingers. This should give the supinator reflex. If you struggle with any of these reflexes, asking the patient to clench their teeth should exaggerate the reflex.

74 NAC OSCE | A Comprehensive Review 6. Sensation This is tested in a number of ways. You should test light touch, pin prick, vibration and joint position sense and proprioception. Ask the patient to place their arms by their sides with their palms facing forwards. Lighdy touch the patient's sternum with a piece of cotton wool so that they know how it feels. Then, with the patient's eyes shut, lightly touch their arm with the cotton wool. The places to touch them should test each of the dermatomes. Tell the patient to say yes every time they feel the cotton wool as it felt before. Then repeat this using a light pin prick. To assess vibration you should use a sounding tuning fork. Place the fork on the patient's sternum to show them how it should feel. Then place it on the bony prominence at the base of their thumb and ask them if it feels the same. If it does, there is no need to check any higher. If it feels different you should move to the radial stylus and then to the olecranon until it feels normal. Finally, proprioception. Hold the distal phalanx of the thumb on either side so that you can flex the interphalangeal joint. Show the patient that when you hold the joint extended, that represents 'Up' whereas when you hold it flexed that represents 'Down'. Ask the patient to close their eyes and, having moved the joint a few times hold it in one position - up or down. Ask the patient which position the joint is in. 7. Coordination • Pronator drift - Ask patient to extend arms in front of them in supination and to close their eyes. A positive result occurs when the arm falls downwards and pronates (cerebral damage), in cerebellar lesions the arms may rise. • Assess for dysdiadochokinesia • Assess for finger to nose coordination and intentional tremor. 8. Function is a very important part of any neurological examination as this is the area which will affect people's day to day lives the most. For upper limb you should ask people to touch their head with both hands and then ask them to pick up a small object such as a coin which each hand. 9. Finish by thanking the patient and ensuring they are comfortable and well covered.

Clinical Examination 75 Lower Limb Neurological 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. • Verbalize the steps of the examination and your findings. • Make sure patient is adequately exposed, use proper draping techniques 2. Inspection • Observe the patient's legs, look for any muscle wasting, fasciculations or asymmetry. 3. Tone • Start by examining the tone of the muscles. Roll the leg on the bed to see if it moves easily and pull up on the knee to check its tone. Also check for ankle clonus by placing the patients leg turned outwards on the bed, moving the ankle joint a few times to relax it and then sharply dorsiflexing it. Any further movement of the joint may suggest clonus. 4. Power • Next assess the power of each of the muscle groups. - Hip flexion (L1/L2) & Hip extension (L5/S1) - Hip abduction (L2/L3) & Hip adduction (L2/L3) - Knee flexion (L5/S1) & Knee extension (L3/L4) - Ankle dorsiflexion (L4/L5) & Ankle plantar flexion (S1/S2) - Big toe flexion (S1/S2) 5. Reflexes • Test the patient's reflexes. There are three reflexes in the lower limb - the knee reflex, the ankle jerk and the plantar reflex - elicited by stroking up the lateral aspect of the plantar surface.

• The knee reflex (L3/L4) is tested by placing the patient's leg flexed at roughly 60°, taking the entire weight of their leg with your arm and hitting the patellar tendon with the tendon hammer. It is vital to get your patient to relax as much as possible and for you to take the entire weight of their leg. • The ankle jerk (S1/S2) is elicited by resting the patient's leg on the bed with their hip laterally rotated. Pull the foot into dorsiflexion and hit the calcaneal tendon. • Finally, with their leg out straight and resting on the bed, run the end of the handle of the tendon hammer along the outside of the foot. This gives the plantar reflex (Si). An abnormal reflex would see the great toe extending. If you struggle with any of these reflexes, asking the patient to clench their teeth should exaggerate the reflex.

76 NAC OSCE | A Comprehensive Review 6. Sensation The final test is sensation. However, this is tested in a number of ways. You should test light touch, pin prick, vibration and joint position sense and proprioception. Ask the patient to place their legs out straight on the bed. Lightly touch the patient's sternum with a piece of cotton wool so that they know how it feels. Then, with the patient's eyes shut, lightly touch their leg with the cotton wool. The places to touch them should test each of the dermatomes - make sure you know these! Tell the patient to say yes every time they feel the cotton wool as it felt before. Then repeat this using a light pin prick. To assess vibration you should use a sounding tuning fork. Place the fork on the patient's sternum to show them how it should feel. Then place it on their medial malleolus and ask them if it feels the same. If it does, there is no need to check any higher. If it feels different you should move to the tibial epicondyle and then to the greater trochanter until it feels normal. Finally, proprioception. Hold the distal phalanx of the great toe on either side so that you can flex the interphalangeal joint. Show the patient that when you hold the joint extended, that represents 'Up' whereas when you hold it flexed that represents 'Down'. Ask the patient to close their eyes and, having moved the joint a few times hold it in one position - up or down. Ask the patient which position the joint is in. Anterior

7. Function is a very important part of any neurological examination as this is the area which will affect people’s day to day lives the most. For the lower limb you should assess the patient's walking. Observe their gait and check for any abnormalities. Whilst they are standing you should perform Romberg's test. Ask the patient to stand with their feet apart and then close their eyes. Stand next to the patient in case he falls. Any swaying may be suggestive of a posterior column pathology. 8. Finish by thanking the patient and ensuring they are comfortable and well covered.

Clinical Examination 77 Musculo-skeletal system : Spine/Back 1. Steps before beginning examination • Introduce yourself : aI 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 sitting comfortably? Gait? Position of comfort. • Observe the patient from behind : - Pelvic and shoulder symmetry, palpate the pelvic brim to check for symmetry. - Scoliosis - Gibbus (dorsal spines abnormally prominent) • Observe patient from side : - Kyphosis - Increased lumbar lordosis • Check the spine for SEADS : S: Swelling, E: Erythema, ecchymosis, A: Atrophy/asymmetry (muscle bulk), D: Deformity, S: Skin changes/scars/bruising 3. Range of Motion

• Flexion : In the standing position by asking the patient to touch the toes. Normal - 90° .The normal spine should lengthen more than 5 cm in the thoracic area and more than 7.5 cm in the lumbar area on forward flexion. • Extension : Stabilize the patient, ask the patient to bend backwards. Normal - 30°. • Lateral flexion : ask the patient to slide their hand straight down the thigh, first on the right and then on the left, keeping the hips straight. • Observe for restricted movement and loss of symmetry. • Test for facet joint disease : Ask patient to extend their back as far as possible and to rotate (pain suggests facet joint pathology). 4. Palpation • Examine the back and palpate for areas of muscle spasm and tenderness (paraspinal muscles). • Palpate spinous processes with thumb for tenderness • Sacroiliac joints, sacro iliac dimples, ask for tenderness.

78 NAC OSCE | A Comprehensive Review 5. Ankylosing spondylitis tests • Chest expansion : Measure with a tape measure (should be >5cm) • Schober'sTest : Draw a horizontal line 10cm above and one 5cm below the dimples of Venus (the distance between these lines should increase to >20cm during lumbar flexion - in ankylosing spondylitis the distance will not increase to >20cm) • Distance of tragus to wall when patient is standing with their back to the wall (useful for monitoring). 6. Cervical and thoracic movements (patient sitting on edge of bed) • Cervical movements - Flexion (ask patient to touch chin to chest) - Extension (ask patient to look to the ceiling as far back as possible) - Lateral flexion (ask patient to touch their ear to the shoulder keeping the shoulder still) - Spurling Maneuver : Extend head back & bring ear towards shoulder. Give gentle axial pressure on the head. If patient complains of pain radiating from head to ipsilateral arm - diagnosis of Radiculopathy is made. - Rotation (ask patient to look over the left and right shoulder) - Perform these movements passively if active movements are restricted. • Thoracic rotation : ask patient to fold their arms and twist around. 7. Tests with patient lying on their back • Straight leg raising test : ask the patient to lie with the spine on the table and to relax completely. With the knee fully extended, first one leg and then the other is slowly lifted and flexed at the hip. This produces stretch on the sciatic nerve, at which point sciatic pain is produced. If this maneuver produces pain in the hip or low back with radiation in the sciatic area, the test is considered positive for nerve root irritation. The angle of elevation of the leg from the table at the point where pain is produced should be recorded. • FABER (Flexion Abduction External Rotation) : Ask the patient to lie supine on the exam table. Place the foot of the affected side on the opposite knee. Pain in the groin area indicates a problem with the hip and not the spine. Press down gently but firmly on the flexed knee and the opposite anterior superior iliac crest. Pain in the sacroiliac area indicates a problem with the sacroiliac joints. • Bowstring test: Once the level of pain has been reached, flex the knee slighdy and apply firm pressure with the thumb in the popliteal fossa over the stretched tibial nerve. Radiating pain and paraesthesiae suggest nerve root irritation. 8. Tests with patient lying on their abdomen • Lasegue's sign: With the patient supine and hip flexed, dorsiflexion of the ankle causes pain or muscle spasm in the posterior thigh if there is lumbar root or sciatic nerve irritation. • Femoral stretch test:With the patient prone and the anterior thigh fixed to the couch, flex each knee in turn. This causes pain in the appropriate distributions by stretching the femoral nerve roots in L2- L4.The pain produced is normally aggravated by extension of the hip. The test is positive if pain is felt in the anterior compartment of thigh.

Clinical Examination 79 Hip 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

• Ask which hip is painful, show empathy. • Verbalize the steps of the examination and your findings. 2. Inspection of hip (with patient standing up) • While the patient is standing, check the hip for SEADS : S: Swelling, E: Erythema, ecchymosis, A: Atrophy/asymmetry (muscle bulk), D: Deformity, S: Skin changes (erythema/scars/abscess/sinuses) • Leg length discrepancy • Whilst the patient is still standing, perform the Trendelenberg test. This is done by asking the patient to alternately stand on one leg. Stand behind the patient and feel the pelvis. It should remain at level or rise slightly. If the pelvis drops markedly on the side of the raised leg, then it suggests abductor muscle weakness on the leg the patient is standing on. 3. Gait - ask patient to walk across the floor. Look for any abnormalities, hip, knee, foot movements, length of stride. 3. Inspection & Palpation of hip (with patient lying down) • Inspection for hip and groin swellings (hernia, lymphadenopathy, saphenous varix, effusion) • Inspect for obvious fixed flexion • Palpate anterior hip for lumps and tenderness. • Palpate the greater trochanter for any tenderness which might suggest trochanteric bursitis. 4. Leg-length difference • Make an approximate judgment by aligning the medial malleoli and looking for discrepancy. • Measure true and apparent leg-length if appropriate. True leg length discrepancy is found by measuring from the anterior superior iliac spine to the medial malleolus. Apparent leg length discrepancy is measured from the umbilicus to the medial malleolus.

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Antalgic ~ Trauma, OA Trendelenberg - weakness of hip adductors Festlnating - Parkinson's ds. High stepping - Polio, MS Scissor Spastic cerebral palsy Stomping - Friedreich's ataxia, tabes dorsalis Spastc - Brain tumor, sturge Weber's, cerebral palsy

80 NAC OSCE | A Comprehensive Review

5. Active and passive movements • Assess active flexion, extension, abduction and adduction. - Flexion : Flex the knee to 90 degrees and passively flex the hip by pushing the knee towards the chest. - Extension : is performed by placing your hand under the patient’s ankle and asking them to push your hand into the bed. • Passively assess internal and external rotation of the hip (with hips at 90° flexion) - Internal rotation : performed with the knee flexed and by everting the knee for internal rotation - External rotation : performed with the knee flexed and inverting it for external rotation. 6. Special tests • Thomas test : Place your hand under the patient's lumbar spine to stop any lumbar movements and fully flex one of the hips. Observe the other hip, if it lifts off the couch then it suggests a fixed flexion deformity of that hip. • FABER (Flexion Abduction External Rotation) : Ask the patient to lie supine on the exam table. Place the foot of the affected side on the opposite knee. Pain in the groin area indicates a problem with the hip and not the spine. Press down gendy but firmly on the flexed knee and the opposite anterior superior iliac crest. Pain in the sacroiliac area indicates a problem with the sacroiliac joints.

Clinical Examination 81 Knee 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 (up to above knees). • Look for medical equipment/therapies • Ask about knee locking, giving way and pain, show empathy. • Verbalize the steps of the examination and your findings. 2. Inspection • Gait : Ask the patient to walk for you. Observe any limp or obvious deformities such as scars or muscle wasting. Check if the patient has a varus (bow-legged) or valgus (knock-knees) deformity. Also observe from behind to see if there are any obvious popliteal swellings such as a Baker's cyst. • While the patient is lying on the bed, make a general observation. Look for symmetry, redness, muscle wasting, scars, rashes or fixed flexion deformities.

3. Palpation • Check the temperature using the backs of your hands, comparing it with other parts of the leg. • Palpate the border of the patella for any tenderness, behind the knee for any swellings, along all of the joint lines for tenderness and at the point of insertion of the patellar tendon. Finally, tap the patella to see if there is any effusion deep to the patella. • Landmarks of the knee : Tibial tuberosity, patellar tendon, quadriceps tendon, medial and lateral femoral condyles. • Peripatellar area : push patella medially and rub right underneath the medial facet of patella and look for tenderness ( Patellar - femoral stress S°). • Joint line tenderness : bend the knee 90°, palpate medial and lateral joint line. • Patella apprehension test - Move patella around and observe patient's face for pain. 4. Range of Motion • Active flexion and extension of knee - Observe for restricted movement and for displacement of patella. • Passive flexion and extension of knee - feel for crepitus. • Straight leg raise - assessment of extensor apparatus.

82 NAC OSCE | A Comprehensive Review 5. Special tests Tests to Detect Arthritis: • Crepitus: Crepitus is the sensation that is felt when rough cartilage or exposed bone is rubbing as the knee is bent. The examiner will feel, and may hear, this grinding as the knee is bent back and forth. • Deformity: As the knee cartilage is worn away, the knees may become progressively knock-kneed or bow-legged. • Limited Motion: The range of motion of the knee typically becomes limited if arthritis, bone spurs, and swelling prevents normal mobility. Tests to Detect a Tom Meniscus: • Joint Line Tenderness Joint line tenderness is a very non-specific test for a meniscus tear. The area of the meniscus is felt, and a positive test is considered when there is pain in this area. • McMurrays Test McMurray’s test is performed with the patient lying flat on his back and the examiner bending the knee. A click is felt over the meniscus tear as the knee is brought from full flexion to full extension. Tests to Detect an ACL Tear: • Lachman Test The Lachman test is the best test to diagnose an ACL tear. With the knee slighdy bent, the examiner stabilizes the thigh while pulling the shin forward. A tom ACL allows the shin to shift too far forward. • Anterior Drawer Test This test is also performed with the patient lying flat on his back. The knee is bent 90 degrees and the shin is pulled forward to check the stability of the ACL. Tests to Detect Other Ligament Injuries: • Posterior Drawer Test The posterior drawer is performed similarly to the anterior drawer test. This test detects injury to the PCL. By pushing the shin backward, the function of the PCL is tested. • Collateral Ligament Stability Side-to-side stability of the knee detects problems of the collateral ligaments, the MCL and LCL. With the patient lying flat, and the knee held slightly bent, the shin is shifted to each side. Damage to the LCL or MCL will allow the knee to "open up" excessively, a problem called varus (LCL) or valgus (MCL) instability. Tests to Detect Kneecap Problems: • Patellar Grind The patient lies supine with the leg extended. The examiner reproduces the patient's knee pain by pushing the kneecap down and asking the patient to flex his thigh muscles. Damaged cartilage can cause a grinding sensation called crepitus. • Patellar Tenderness The examiner can slightly lift up the kneecap and place direct pressure on the under surface of the kneecap. By doing so, the examiner is looking for sensitive regions of cartilage. • Patellar Apprehension This is a sign of an unstable kneecap. While the examiner places pressure on the kneecap, the patient may complain of the sensation that the kneecap is going to 'pop out' of its groove.

Clinical Examination 83 Foot and Ankle 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 (up to above knees). • Look for medical equipment/therapies • Ask if patient is able to bear weight, show empathy. • Verbalize the steps of the examination and your findings. 2. Inspection • Gait : watch the patient walk, observing for a normal heel strike, toe-off gait. Also look at the alignment of the toes for any valgus or varus deformities. Assess ability to weight-bear on affected side. • While patient is standing check the foot arches checking for pes cavus (high arches) or pes planus (flat feet). • Inspection of the foot with patient sitting and feet overhanging - Check the foot and ankle for SEADS : S: Swelling, E: Erythema, ecchymosis, A: Atrophy/asymmetry (muscle bulk), D: Deformity, S: Skin changes/scars/bruising. - Check the symmetry, nails (psoriasis), skin, toe alignment, look for toe clawing, joint swelling and plantar and dorsal calluses. • Finally you should look at the patient’s shoes, note any uneven wear on either sole and the presence of any insoles. 3. Palpation of ankle/foot • Feel each foot for temperature, comparing it to the temperature of the rest of the leg. • Feel for distal pulses. • Squeeze over the metatarsophalangeal joints observing the patient's face for any pain. • Palpate over the midfoot, ankle and subtalar joint lines for any tenderness. Feel the Achilles tendon for any thickening or swelling. Palpate medial and lateral malleoli for any tenderness.

84 NAC OSCE ) A Comprehensive Review

4. Range of Motion • Assess all active and passive movements of the foot. These movements are inversion, eversion, dorsiflexion and plantarflexion. - Subtalar joint - inversion and eversion - Ankle joint - dorsiflexion and plantar flexion - Big toe - dorsiflexion and plantar flexion - Mid-tarsal joints - which are tested by fixing the ankle with one foot and inverting and everting the forefoot with the other. 5. Special tests • Ankle Anterior Drawer Test - assesses for lateral ankle sprain Patient is seated, stabilize the tibia with one hand while grasping heel and pulling it anteriorly with the other. Greater than 3 mm anterior movement may be significant. 1 cm is significant and indicates anterior talofibular ligament rupture. Positive Test - laxity in the ligament with exaggerated anterior translation • Talar Tilt Test - assesses integrity of the deltoid ligament/lateral ankle sprain Patient is seated, stabilize the leg and foot while adducting and inverting the calcaneus apply a varus force. The calcaneus is then abducted and everted applying a valgus force. Positive Test - pain or laxity in the ligament • Thompson’s Test - assesses for Achilles' tendon rupture Patient is prone, squeeze the gastrocnemius and soleus muscles while noting any movement at the ankle and foot Positive Test - no movement or plantarflexion at all indicates a 3rd degree strain of the Achilles' tendon • Plantar Fasciitis Test - assesses for inflammation of the plantar fascia Patient is supine, dorsiflex the ankle and extends all toes then press in the medial border of the plantar fascia Positive Test - pain is consistent with plantar fasciitis Ottawa Ankle rules For taking ankle series x-rays(AP and lateral ankle) • X-ray if there is pain over the malleolar zone AND tenderness on palpation of the medial/lateral malleolar tip and posterior aspect of medial/lateral malleolus OR • Patient unable to bear weight immediately and in ER. For foot series (AP and Lateral foot) • X-ray if there is pain in midfoot zone AND bony tenderness over the navicular or base of 5th metatarsal OR Unable to bear weight immediately and in ER

Clinical Examination 85

Shoulder 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. • Look for medical equipment/therapies, ensure patient is adequately exposed. • Ask which shoulder is painful. Verbalize the steps of the examination and your findings. 2. Inspection • Start by exposing the joint and observe the shoulder joint looking from the back, side and front for any scars, deformities or muscle wasting (SEADS). Also compare both sides for symmetry. • With the patient standing, ask the patient to place their hands behind their head and behind their back and observe for and deformities. 3. Palpation • Feel over the joint and its surrounding areas for the temperature of the joint as raised temperature may suggest inflammation or infection in the joint. • Systematically feel along both sides of the bony shoulder girdle. Start at the sternoclavicular joint, work along the clavicle to the acromioclavicular joint • Feel the acromion and then around the spine of the scapula. • Feel the anterior and posterior joint lines of the glenohumeral joint and finally the muscles around the joint for any tenderness. 4. Range of Motion • The movements of the joint should start being performed actively. • Ask the patient to bring their arm forward (flexion), bend their arm at the elbow and push backwards (extension), • Bring their arm out to the side and up above their head (abduction). When testing adduction perform the scarf test (The scarf test is performed with the elbow flexed to 90 degrees, placing the patient's hand on their opposite shoulder and pushing back, again look for any discomfort. ) • Rotation - Internal rotation : Ask the patient to place hands in the small of their back, and slide them up the back as far as possible. - External rotation : Ask patient to rotate their arms outwards, keeping the elbows flexed and by the side of the body. • Once all of these movements have been performed actively, you should perform them passively and feel for any crepitus whilst moving the joints.

86 NAC OSCE | A Comprehensive Review

5. Special Tests Tests for Rotator Cuff i. Supraspinatus • Empty Can Test ( tests integrity of Supraspinatus) : The patient stands with arms extended at the elbows and abducted in the scapular plane and with thumbs pointed to the floor. The examiner applies downward pressure to the arms and the patient attempts to resist. Positive test : Pain, muscle weakness or both. • Apley's Scratch Test- Reach over shoulder to "scratch" between scapula. Measure to which vertebrae thumb can reach. ii. Infraspinatus • External Rotation Lag Sign : The elbow is passively flexed to 90 degrees, and the shoulder is held at 20 degrees abduction (in the scapular plane) and near maximal external rotation by the examiner. The patient is then asked to actively maintain the position of external rotation in abduction as the examiner releases the wrist while maintaining support of the limb at the elbow. The sign is positive when a lag, or angular drop occurs. The magnitude of the lag is recorded to the nearest 5 degrees. iii. Subscapularis • Gerber Lift-OfFTest : With the patient’s hand on the small of the back, the arm is extended and internally rotated. The examiner then passively lifts the hand off the small of the back, placing the arm in maximal internal rotation. The examiner then releases the hand. If the hand falls onto the back because the subscapularis is unable to maintain internal rotation, the test result is positive. Patients with subscapularis tears have an increase in passive external rotation and a weakened ability to resist internal rotation. Tests for Shoulder Instability

• Apprehension Sign for Anterior Instability : The test is performed by abducting the shoulder to 90 degrees, and then slowly externally rotating the shoulder toward 90 degrees. A patient with anteriorinferior instability will usually become "apprehensive" either verbally or with distressing facial expressions. Tests for Subacromial Impingement • Neer Impingement Sign : Place one hand on the posterior aspect of the scapula to stabilize the shoulder girdle, and, with the other hand, take the patient's internally rotated arm by the wrist, and place it in full forward flexion.If there is impingement, the patient will report pain in the range of 70 degrees to 120 degrees of forward flexion as the rotator cuff comes into contact with the rigid coracoacromial arch. • Hawkins Impingement Sign : The examiner places the patient's arm in 90 degrees of forward flexion and forcefully internally rotates the arm, bringing the greater tuberosity in contact with the lateral acromion. A positive result is indicated if pain is reproduced during the forced internal rotation. Tests for Long Head of the Biceps • Speed's Maneuver : The patient's elbow is flexed 20 degrees to 30 degrees with the forearm in supination and the arm in about 60 degrees of flexion. The examiner resists forward flexion of the arm while palpating the patient's biceps tendon over the anterior aspect of the shoulder. • Yergason test : The patient's elbow is flexed to 90 degrees with the thumb up. Forearm is in neutral. The examiner grasps the wrist, resisting attempts by the patient to actively supinate the forearm and flex the elbow. Pain suggests biceps tendonitis.

Clinical Examination 87 Elbow 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. • Look for medical equipment/therapies, ensure patient is adequately exposed. • Verbalize the steps of the examination and your findings. 2. Inspection • SEADS : S: Swelling, E: Erythema, ecchymosis, A: Atrophy/asymmetry (muscle bulk), D: Deformity, S: Skin changes/scars/bruising. Check for a fixed flexion deformity. Look at the underside of the elbows to check for any psoriatic plaques, cysts or rheumatoid nodules. 3. Palpation • Feel the elbow, assessing the joint temperature relative to the rest of the arm. • Palpate the olecranon process as well as the lateral and medial epicondyles for tenderness (medial for golfer’s elbow and lateral for tennis elbow), and cubital fossa for tenderness. • Palpate joint line with elbow flexed to 90° for tenderness and swelling. 4. Range of Motion • The movements at the elbow joint are all fairly easy to describe and assess. These are flexion, extension, pronation and supination. Once these have been assessed actively they should be checked passively checking for power and crepitus. • Test for varus / valgus instability. 5. Neurological Examination of hand Motor - Median nerve (thumb abduction) - Radial nerve (wrist extension) - Ulnar nerve (finger abduction) 6. Special Tests • Tennis Elbow : Tennis elbow localises pain over the lateral epicondyle, particularly on active extension of the wrist with the elbow bent. • Golfer's Elbow : Golfer's elbow pain localises over the medial epicondyle and is made worse by flexing the wrist. Sensory - Median nerve (pulp of index finger) - Radial nerve (1st dorsal interosseous space) - Ulnar nerve (pulp of 5th finger)

88 NAC OSCE | A Comprehensive Review Hand and Wrist 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. • Look for medical equipment/therapies • Verbalize the steps of the examination and your findings. 2. Inspection • Inspect hands : - Skin (rashes, Gottron's patches, nodules, Raynaud's phenomenon, sclerodactyly, scars, skin atrophy) - Nails (pitting, onycholysis, splinter haemorrhages, clubbing) - Muscles (swelling, wasting) - Joints (swellings, subluxation / deviation of wrist, swan neck / Boutoniere's deformity, Heberden's/Bouchard's nodes, Z deformity of thumb) - Inspect palm (palmar erythema, pallor, cyanosis), muscle wasting. • Inspect elbows : - Psoriatic skin lesions - Rheumatoid nodules - Scars 3. Palpation • Assess the temperature over the joint areas and compare these with the temperature of the forearm. • Start proximally and work towards the fingers, feeling the radial pulses and the wrist joints. Then feel the muscle bulk in the thenar and hypothenar eminences. In the palms, feel for any tendon thickening and assess the sensation over the relevant areas supplied by the radial, ulnar and median nerves. • Squeeze over the row of metacarpophalangeal joints whilst watching the patient's face for any discomfort. • Bi-manually palpate MCP and interphalangeal joints.

Clinical Examination 89

4. Range of Motion • Ask the patient to perform the following movements in the sequence mentioned below and observe for range of movement : - Make a fist - Pronate wrist - Extend little finger (extensor digiti minimi is usually the first tendon to rupture in rheuatoid arthritis) - Extend all fingers • Assess function - Pinch grip - Opposition (touch thumb to each finger) - Power grip (ask patient to squeeze your fingers) - Froment's test (for ulnar nerve palsy). In this test the patient attempts to grip a paper with thumb and index finger while the examiner tries to pull the paper out of the patient's grip. - Ask patient to write something / undo a button. • Assess power - Wrist extension (radial nerve) - Thumb abduction (median nerve) - Finger abduction (ulnar nerve) 5. Neurovascular Examination Nerve Sensation Motor Median Lateral portions of the pulp of the index and middle fingers Resisted palmar abduction of the thumb Ulnar Lateral pulp areas of the little finger Abduction of the fingers against resistance Radial Web space between the thumb and index finger (anatomical snuff box) Wrist extension

6. Special Tests • Phalen's test : Forced flexion of the wrist, either against the other hand or by the examiner for 60 seconds will recreate the symptoms of carpal tunnel syndrome.

• Finkelstein’s test is used to diagnose DeQuervain's tenosynovitis. Patient is told to flex the thumb and clench the fist over the thumb followed by ulnar deviation. If there is an increased pain in the radial styloid process and along the length of the extensor pollicis brevis and abductor pollicis longus tendons, then the test is positive for De Quervains syndrome. • Tinel's sign : Use the index finger to tap over the carpal tunnel at the wrist. A positive test results when the tapping causes tingling or paresthesia in the area of the median nerve distribution, which includes the thumb, index finger, and middle and lateral half of the ring finger. A positive Tinel's sign at the wrist indicates carpal tunnel syndrome.

90 NAC OSCE | A Comprehensive Review Breast 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. • Verbalize the steps of the examination and your findings. Ask which side the problem is. • Make sure patient is adequately exposed, use proper draping techniques 1. General Inspection (with patient sitting on side of bed) • Inspect with : - Patient's arm by their sides. - Patient’s arms behind their head (tenses skin) - Patient's hands on their hips (tenses pectoralis major) These manoeuvers test forT4 disease - invasion of chest wall / skin. Inspect for : - Obvious masses - Scars - Radiotherapy tattoos - Skin changes - Peau d'orange - Dimpling - Nipple retraction - Paget's disease. 2. Inspection (with patient lying down) - Breasts size, symmetry and contour. - Areola pigmentation, nipple pigmentation, shape, ulceration and discharge. - Skin color, thckening, venous pattern and edema. 3. Palpate - Palpate normal breast followed by abnormal breast. - Palpate all quadrants, nipple and axillary tail of each breast. - Describe any masses : position, size shape, mobility, number, tenderness, consistency. - Palpate axillary, supraclavicular and infraclavicular lymph nodes. 4. Auscultate lungs.

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 l/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.

92 NAC OSCE | A Comprehensive Review 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. • Prétibial myxoedema • Peripheral edema due to congestive cardiac failure. • Delayed relaxation of ankle reflex in hypothyroidism. 5. Thank the patient after the examination.

Clinical Examination 93 Mini Mental State Examination 1. ORIENTATION Maximum score = 10 What is today's date? 1 What is the year? 1 What is the month? 1 What is the day today? 1 Can you tell me what season it is? 1 Can you also tell me the name of the location we are in? (Hospital/clinic) 1 What floor are we on? 1 What city are we in? 1 What country are we in? 1 What state are we in? 1 II. IMMEDIATE RECALL Maximum score = 3 Ask the patient if you may test his/her memory. Say the words "ball" , "flag" , "tree" clearly and slowly. Then ask the patient to repeat the words. Check for each correct response. The first repetition determines the score. If the patient does not repeat all three correctly, keep saying them up to six tries until the patient can repeat them. Ball 1 Flag 1 Tree 1 Number of Trials :__ III. ATTENTION AND CALCULATION A. Counting Backwards Test Record each response Maximum score = 5

Ask the patient to begin with 100 and count backwards by 7. Record each response. Check one box at right for each correct response. The score is the number of correct subtractions. 93 1 86 1 79 1 72 1 65 1 B. Spelling Backwards Test Ask the patient to spell the word "WORLD" backwards. Record each response. Use the instructions to determine which are correct responses, and check one box at right for each correct response. D 1 L 1 R 1 0 1 W 1

94 NAC OSCE | A Comprehensive Review

C. Final Score Compare the scores of the Counting Backwards and Spelling Backwards tests. Write the greater of the two scores in the box labeled FINAL SCORE at right, and use it in deriving the TOTAL SCORE. Final Score : (Max of 5 or Greater of the two scores) IV. RECALL Maximum score = 3 Ask the patient to recall the three words you previously asked him/her to remember. Check the Box at right for each correct response. Ball 1 Flag 1 Tree 1 V. LANGUAGE Maximum score = 9 Naming Watch 1 Show the patient a wrist watch and ask him/her what it is. Repeat for a pencil. Pencil 1 Repetition Ask the patient to repeat "No ifs, ands, or buts." Correct repetition 1 Three - Stage Command Establish the patient's dominant hand. Give the patient a sheet of blank paper and say, 'Take the paper in your right/left hand, fold it in half and put it on the floor." Takes paper in hand 1 Folds paper in half 1 Puts paper on the floor 1 Reading Hold up the card that reads, "Close your eyes." So the patient can see it clearly. Ask him/her to read it and do what it says. Check the box at right only if he/she actually closes his/her eyes. Closes eyes 1 Writing

Give the patient a sheet of blank paper and ask him/her to write a sentence. It is to be written spontaneously. If the sentence contains a patient and a verb, and is sensible, check the box at right. Correct grammar and punctuation are not necessary. Writes sentence 1 Copying Show the patient the drawing of the intersecting pentagons. Ask him/her to draw the pentagons (about one inch each side) on the paper provided. If ten angles are present and two intersect, check the box at right. Ignore tremor and rotation. Copies pentagons 1

Clinical Examination 95

""i DERIVING THE TOTAL SCORE Add the number of correct responses. The maximux is 30. 23-30 Normal 23-19 Borderline Less than 19 Impaired

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Clinical Cases This is a blank page

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 Differential diagnosis : 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 • 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.”

100 NAC OSCE | A Comprehensive Review

Data Collection : OCDPQRSTUV+AAA • Onset : When did it start? Sudden? Gradual? • Course : Is it getting worse, better or just the same? • Duration : You said it started......ago, does it come and go? How often does it come? For how long does it stay each time? • Place : Show me exactly where it hurts? • Quality : Tell me how it feels like? Is it sharp/burning/dull/crampy? • Radiation : Does it travel to anywhere? • Severity : On a scale from 1 to 10, with 1 being the mildest and 10 the worst pain, how bad is it? • Timing : Is it worse at a particular time of the day?

• U (You) your daily activities : Does it interfere in your day to day activities? Does it change with your daily activities like posture, rest, eating, exertion? • V (Deja vu) : Has it happened before? When? What happened then? What medication? • Aggravating factors : What makes it worse? • Alleviating factors : What make it better? • Associated symptoms : Have you noticed anything that occurs with it? • Al : Associated constitutional symptoms like fever, shortness of breath, cough, nausea, vomiting, diarrhea, headache, fatigue (FSC NVD HF) • A2 : Associated symptoms to particular system Respiratory : Chest pain, shortness of breath, cough, sputum, wheezing, runny nose, post nasal drip, contact with ill person, night sweats, questions for pulmonary embolism (leg pain, long travel, surgery and OCP use in females) CVS : chest pain, orthopnea, paroxysmal nocturnal dyspnea, palpitations, tachycardia. GIT : pain in abdomen, stool, bowel movements, vomiting, jaundice, blood in stools, diet, travel. Neurology : headache, loss of consciousness, weakness, paresthesias Higher Mental Function : orientation, memory, consciousness. Motor : weakness of limbs. Sensory : tingling sensation. Cerebellum : gait, balance. Cranial Nerves : speech, swallowing, vision, hearing. PAM HUGS FOSS • “Ok, Mr./Miss_____, Now I need to ask you about your health in general. Is that okay with you?” • Past Medical History : What other medical problems do you have? (Diabetes/Hypertension/Asthma / Cancer?) • Allergies : Do you have any allergies? Are you allergic to any drugs?

Clinical Cases - Protocol for history taking 101 • Medication : Do you take medicines at present? • Hospitalizations : (medical/surgical/trauma) • Urinary problem : burning sensation while passing urine? Blood in urine? • GIT : bowel movements? Loose stools? Constipation? Blood in stools? • Sleep? • “lam going to ask you a few personal questions that will help me in my diagnosis. Is that okay with you? Let me begin by asking you about your family health.” • Family history : similar complaints in the family? Cancer in the family? Depression? Suicide? • Obstetrical History : When was your last pap smear? Wast it normal? Any history of STIs? • “Now I need to ask you about your sexual health. Whatever you tell me will be kept confidential. Is that okay with you?” • Sexual History : Are you in a physical relationship? How long? Do you practice safe sex? Any risk of STIs? • Social History : Smoking, how many packs? Alcohol, amount? Recreational drugs? • “Is there anything else that you want to share?” • WRAP UP T : Treatment history R: Route A : Addictlon/toxicity/amount P: Pattern of use P: Prior abstinence E: Effects of the drug D: Duration of use

102 NAC OSCE | A Comprehensive Review

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? Family and Social History • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration oc frequency. • Do you take any recreational drugs? • Any family history of cancers/ medical illnesses? Differential Diagnosis Management Atrial fibrillation secondary to: • Treat the primary cause. 1. Congestive heart failure. • Admit in cardiac care unit. 2. Ischemic heart disease. • Rate control by beta blockers, calcium 3. Hypertension. channel blockers or digoxin. 4. Thyroid disease. • Anticoagulation with heparin, then warfarin. • Rhythm control by electro or medical Investigations cardioversion. • CBC, electrolytes, glucose. • Assess Stroke risk by using CHADS2 score. • LFT, RFT,TSH. • CK, LDH, Cardiac enzymes. • 12 lead ECG. • Echocardiogram. • Chest X ray.

Clinical Cases - Medicine 103

Simon Charles, a 20 years old male presented to your clinic with shortness of breath for the past 24 hours. Take a focused history and perform focused physical examination. Vitals: BP - 110/80 mm Hg, HR - 110/min, RR - 22/min,Temp - 37.5°C. Clinical Info: Mr Simon Charles has a h/o of Asthma since the past 10 years. He recently cleaned his basement 1 day ago and his asthma symptoms exacerbated. He is having wheezing, chest tightness,cough and SOB. He is currently on inhalers with no night symptoms. On examination, he has dyspnea and wheezing present in all lung fields. He has mild exacerbation of his symptoms and needs only outpatient treatment. Clinical Case : Asthma (examination on page 69) HOPI OCD PQRST UV + AAA How did it start? Sudden or gradual. Is it getting worse/better or no changes in the symptoms? Do you wake up in night with shortness of breath?

Do you have noisy breathing? H/o fever/sore throat/rash? Any night time cough? Any sputum production? Any cnest pain with deep inspiration? Any recent activity whicn worsened your svmptoms? Any exposure to cold air/dust/mites? Any pets at home? Any changes in bowel & urinary habits? Any contact with a sick person? Any recent travel? Any recurrent episodes? Do symptoms affect your daily activities? Past History • Do you have asthma/other allergies? • Are you on any medications ana compliance? • Are you allergic to any medications? • Any hospitalizations for asthma? • H/o any other medical illness? Family and Social History • Do you smoke? Duration & frequency. • Do you consume alcohol? Duration & frequency. • Do you use recreational drugs? TRAPPED. • Any family history of asthma/allergies? Differential Diagnosis Management • Asthma. • Ventolin 2-4 puffs MDI q4-6h. • Fluticasone 2-4 puffs bid(Inhaled steroids) • Acute bronchitis. • GERD. • Asthma education: • Pneumonia. Inhaler use. Investigations • CBC. Spacer and holding chamber use. Symptom monitoring. Early recognition of exacerbation. • Pulmonary function tests. Avoid environmental allergens. • Peak flow meter. Encase mattress and pillow in • Chest X ray. impermeable cover. Reduce indoor humidity to 7 times per day with urgency Sc in small volumes. - Withholds urine until last minute, wets more than once nightly. • Has enuresis on only a few nights per week? • Voids large volumes when enuresis occurs? • Bowel or bladder habit changes recently. • Infrequent or difficult stool passage? • Any changes in appetite/weight? • Any fever/nausea/vomiting? • Any recurrent infections? • Amount of fluid intake prior to sleep? • Any neurological disorders? • Any genitourinary surgeries? • Enuresis in other siblings?

• Any stresses at home or school? • Any new habits or regression to old habits? • Trial of toilet training in the past? • Any treatment in the past for enuresis? Birth history • Gestational age at birth and birth weight. • Mode of delivery: cesarean, induction, forceps or vacuum delivery. • Any fetal distress?Was meconium passed in utero? • APGAR score at birth, 1 minute Sc 5 minute? • Was resuscitation required? • When was breast feeding started? • Color of 1st stool, when was 1st stool passed? • Color of urine, when was 1st urine passed? • Any antenatal/post partum complications. • Immunization history. Differential Diagnosis • Primary nocturnal enuresis. • Urinary tract infection. • Urinary tract anomalies like small bladder. • Psychological (death in the family, sexual abuse). Investigations • CBC,electrolytes, RFT, LFT. • Blood sugar. • Urinalysis-routine microscopy, C/S. • Ultrasound abdomen. Management • Complete physical examination. • Reassure parents. • Schedule voiding times. • Bed wetting alarm. • Void before bedtime. • Limit fluids 1 hour before bedtime. • Voiding diary to be maintained. • Positive reinforcement for dry nights. • Pharmacological therapy like Imipramine/DDAVP.

Clinical Cases - Pediatrics 131 Ally Singer's 6 weeks old baby boy Alex is vomiting for the past 2 days. Take history 8c address her concerns. Clinical Info: Alex had 4 episodes of projectile non bilious vomiting in the past 48 hours. He vomits after feeding. No fever. Looks lethargic 8c dehydrated but alert. No seizures. Had only one bowel movement in last 24 hours. No sick contacts. O/E: Palpable abdominal mass in the right hypochondrium. Clinical Case Diagnosis : Pyloric stenosis. HOPI • OCD PQRST UV + AAA • Number of episodes of vomiting? • Duration of vomiting? • Type of vomiting - projectile/non projectile? • Color/contents of vomitus? • Any excessive crying? • Feeding pattern in the last 48 hours? • Decreased neonatal muscle tone? • Any fever, irritability, lethargy,seizure? • Last bowel movement? • Foul smelling urine 8c color of urine? • Current weight. • Any sick contacts. Newborn history • Gestational age at birth and birth weight. • Mode of delivery: cesarean, induction, forceps or vacuum delivery. • Any fetal distress? Was meconium passed in utero? • APGAR score at birth, 1 minute 8c 5 minute?

• Was resuscitation required? • When was breast feeding started? • H/o neonatal jaundice. • Color of 1st stool, when was 1st stool passed? • Color of urine, when was 1st urine passed? Mother's obstetrical history • GTPAL • Maternal medical history esp. liver disease. • Illness during pregnancy esp. diabetes, rubella, toxoplasmosis, herpes, CMV. • Teratogenic medications during pregnancy. • Radiation exposure in pregnancy. • Drug and alcohol use auring pregnancy. • Complications of present pregnancy. - Gestational hypertension or diabetes, - hyper/hypothyroid, hypercoagulation. • Any antenatal/post partum complications? Differential Diagnosis • Pyloric stenosis. • Tracheo-esophageal fistula. • Duodenal atresia. • Malrotation of gut. • Gastro-esophageal reflux. Investigations • CBC,electrolytes, RFT, LFT. • ABG. • Urinalysis. • Ultrasound abdomen. • Abdominal X ray. Management • Admit. • Urgent Pediatric surgery consult. • IVF to maintain hydration. • Surgery - Pyloromyotomy.

132 NAC OSCE | A Comprehensive Review John Andrews is a 3 years old boy who is not speaking well. Take history & address his father's concerns. Clinical Info: John Andrews has h/o recurrent ear infections. He had 3 episodes in the last 6 months. He has runny nose and mild cough too. He can speak in sentence of 3-4 words. He can count to 5. But for the past 3 months he is not learning new words or numbers. He responds to loud sounds. No other complaints. Social interaction is very good. No birth or developmental complications till date. Diagnosis: Speech delay secondary to recurrent otitis media. • Duration of speech delay? • Who noticed it first? • Any ear discharge/runny nose? • Any recurrent infections? • Any fever/cough/sore throat? • Does the child wake up in response to sounds? • Startle to loud sounds? • Comes when called? • Understands spoken instructions? • Ask about swimming. • Enquire about verbal cues. • How many languages are spoken in the household? • Child's social interaction with others. • Does the child talk less in particular situations? • How many words are spoken by the child? • Detailed developmental history. • Was the child screened for hearing at birth? • Any regression in habits? • Immunization history till date. • Family history of speech delay. • Any complications during pregnancy or birth?

• Detailed birth history. • Exposure to toxins during pregnancy? • Any ototoxic drugs used in infancy? • Screen for signs of child abuse. Differential Diagnosis Management • Hearing loss secondary to Otitis media. • Reassurance for parents. • Selective mutism. • Expressive speech delay. • Complete physical assessment. • ENT referral. • Autism. • Speech therapy. • Positive reinforcement & encouragement. Investigations • Hearing test like Pure Tone Audiometry.

Clinical Cases - Psychiatry 133 Gabriella Anderson, a 18 years old girl came to your office with complaints of gaining weight. Take history 8c counsel. Clinical Info: Ms Gabriella Anderson presented with gaining 5 lbs in the last 1 month. She looks underweight for her age and height. She is exercising 3 times a day. She doesn’t binge or induce vomiting. Lately she is taking small portions of meals due to fear of gaining weight. She has no medical illnesses. No past nistory of psychiatric illness. Currently not taking any medications. Clinical Case : Anorexia HOPI • When did you notice the change in weight? • Duration of symptoms? • Amount of weight gain? • Lowest and highest weight you had? • Are you afraid of gaining weight? • How do you try to control your weight? • How do you think your body looks? • Does your body weight 8c shape have an impact on your self opinion? • Last menstrual period / regularity / complications? • Any abdominal pain/nausea/vomiting? • Bowel and bladaer habits? • Any skin changes? • Any intolerance to temperature changes? • Any recent stressors at nome or work? • Changes in sleep pattern? • Feeling of guilt / hopelessness / helpless / worthless? • Changes in mood? • Any thoughts of harming self/suicide? • Any thoughts of harming someone else? • Any plans at the moment? • Do you feel persistently cheerful/high? • Do you have any medical/surgical illnesses? Ask details. • Do you take any medications? Ask details. • Do you consume alcohol? Amount/frequency? • Do you use recreational drugs? Ask TRAPPED. Past Psychiatric History • Any similar symptoms in past? • Any h/o mania / depression / delusion / delirium? • Any contacts with mental health professionals? • Any past problems with law? Family Histoiy • Any family history of similar complaints? • Any family history of other psychiatric illnesses? • Any family history of suicide/alcohol/drug abuse? Social History

• Support system at home/work? • Current living situation? • Relationship nistory? • Education nistory? • Any risk of physical/sexual/mental abuse? Differential Diagnosis • Anorexia nervosa. • Bulimia nervosa. • Mood disorders. • Medical cause of weight loss. • Body Dysmorphic disorder. Investigations • CBC, electrolytes, renal 8c Liver function tests. • TSH, blood glucose, ECG. • Urine toxicology screen. • Beta HCG, LH,FSH. Management • Complete physical assessment. • Antiaepressants. • Suj3j|>ortive psychotherapy. • Make plans for weight gain. • Community resources for eating disorders. • Educational brochures. • Admit if weight