OSCE Reviewer

2014 Edition

ORAL REVALIDA REVIEWER ACUTE APPENDICITIS SURGERY  Etiology o E.coli & Bacteroides fragilis  Clinical Manifestations o Abdominal pain – cramping, severe, steady at the lower epigastric, within 4-6hrs localizes at RLQ (may vary from different locations of pain of the appendix) o Anorexia o Vomiting  Signs: o Direct and Indirect tenderness o Rovsing's sign—pain in the RLQ when palpatory pressure is exerted in the LLQ (indicates site of peritoneal irritation) o Psoas sign – have patient lay on the left side as the examiner slowly extends the right thigh, thus stretching the iliopsoas muscle (indicates an irritative focus proximal to that muscle) o Obturator sign – passive internal rotation of the flexed right thigh with the patient supine  Laboratory Findings: o CBC – mild leukocytsis, 10,000-18,000 cells/mm3 (acute uncomplicated AP) o Urinalysis – to rule out UTI  Imaging Studies o Barium Enema – if barium fills the appendix, it is excluded o Plain films o Chest radiograph – if referred pain for right lower lobe pneumonic process o CT scan – has minimal advantage (dye in the presence of vomiting) o Laparoscopy – in lower abdominal complaints; in differentiating gynecologic problem  The Avogardo Scale for Diagnosing Appendicitis Manifestations Value Migration of pain 1 Symptoms Anorexia 1 Nausea/vomiting 1 RLQ tenderness 2 Signs Rebound 1 Elevated temperature 1 Leukocytosis 2 Laboratory values Left shift 1 Total: 10 3 o Note: Rupture should be suspected in the presence of elevated temperature (>39°C) and a WBC of >18,000cells/mm  Differential Diagnosis: o Acute Mesenteric Adenitis – URTI is present, pain is diffuse, tenderness is not sharply localized as in AP; voluntary guarding and diarrhea are present; laboratory values are normal o Pelvic Inflammatory Disease – right tube inflammation may mimic AP; nausea and vomiting are present in 50% of PID o Ovarian Cyst – ruptured right sided cyst may have similar manifestations of AP, patients develop RLQ pain, tenderness, rebound, fever and leukocytosis o Ruptured Ectopic Pregnancy – rupture of right tubal and ovarian pregnancies can mimic AP, development of RLQ pain may be the first symptoms, hematorcit falls due to internal abdominal hemorrhage o Urinary Tract Infection – Acute pyelonephritis, on the right side particularly, may mimic a retroileal acute appendicitis. Chills, right costovertebral angle tenderness, pyuria, and bacteriuria are usually sufficient to make the diagnosis. o Peptic Ulcer Disease – Perforated peptic ulcer closely simulates appendicitis if the spilled gastroduodenal contents gravitate down the right gutter to the cecal area and if the perforation spontaneously seals, minimizing upper abdominal findings  Treatment Plan: o For possible operation, Adequate hydration should be ensured; electrolyte abnormalities corrected; and pre-existing cardiac, pulmonary, and renal conditions should be addressed o Administer antibiotics to all patients with suspected appendicitis. If simple acute appendicitis is encountered, there is no benefit in extending antibiotic coverage beyond 24 hours. If perforated or gangrenous appendicitis is found, antibiotics are continued until the patient is afebrile and has a normal white blood cell count. o Open Appendectomy  McBurney (oblique) or Rocky-Davis (transverse) incision o Laparoscopic Appendectomy  Under general anesthesia, use of 3-4 ports  Advantages: decreased operative pain, shorter duration of hospital stay, good wound healing, minimal incision

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2014 Edition

ORAL REVALIDA REVIEWER ACUTE and CHRONIC CHOLECYSTITIS

SURGERY

ACUTE CHOLECYSTITIS Charcot’s Triad: 1. Fever  Clinical Manifestations: 2. RUQ Pain o RUQ or epigastric pain that may radiate to the right upper part of the back or the 3. Jaundice interscapular area Reynold’s Pentad: o It is usually more severe than the pain associated with uncomplicated biliary colic 1. Fever o Fever, anorexia, nausea, vomiting are present; patient is reluctant to move, as the 2. RUQ Pain inflammatory process affects the parietal peritoneum. 3. Jaundice o On PE: focal tenderness and guarding at the RUQ; a mass, the gallbladder and adherent 4. Shock omentum, is occasionally palpable; however, guarding may prevent this. 5. Changes in sensorium o Murphy's sign, an inspiratory arrest with deep palpation in the right subcostal area, is characteristic of acute cholecystitis.  Laboratory Findings: 3 o mild to moderate leukocytosis (12,000 to 15,000 cells/mm ); but some patients may have a normal WBC o high WBC (>20,000) is suggestive of a complicated form of cholecystitis such as gangrenous cholecystitis, perforation, or associated cholangitis o Serum liver chemistries are usually normal, but a mild elevation of serum bilirubin, < 4 mg/mL, may be present along with mild elevation of alkaline phosphatase, transaminases, and amylase. o Severe jaundice is suggestive of common bile duct stones or obstruction of the bile ducts by severe pericholecystic inflammation secondary to impaction of a stone in the infundibulum of the gallbladder that mechanically obstructs the bile duct (Mirizzi's syndrome).  Differential Diagnosis: o peptic ulcer with or without perforation, pancreatitis, appendicitis, hepatitis, pleuritis CHRONIC CHOLECYSTITIS (Biliary Colic)  Clinical Manifestations: o Recurrent attacks of pain, episodic o Pain is constant and increases in severity over the first half hour or so, typically lasts 1-5 hours. It is located in the epigastrium or right upper quadrant and frequently radiates to the right upper back or between the scapula o Pain is occurs typically during the night or after a fatty meal o Often associated with nausea and vomiting o On PE: RUQ tenderness during an episode of pain  Laboratory Findings: o WBC count and liver function tests are usually normal in uncomplicated gallstones o Ultrasound – standard diagnostic test for gallstones o CT scans – show extrahepatic biliary tree status and adjacent structures o Endoscopic retrograde cholangiography (ERCP) and Endoscopic ultrasound – rarely needed for uncomplicated gallstones but for the stones in the common bile duct, in particular when associated with obstructive jaundice, cholangitis or gallstone pancreatitis.  Management: o For symptomatic gallstones, elective laparoscopic cholecystectomy is the procedure of choice. o Diabetic patients with symptomatic gallstones should undergo cholecystectomy promptly as they are prone to develop acute cholecystitis nd o In pregnant women, elective laparoscopic cholecystectomy is allowed during the 2 trimester

CHOLEDOCHOLITHIASIS SURGERY “Common bile duct stones” RUQ tenderness, nausea, vomiting Symptoms such as pain and jaundice may be intermittent  Imaging Studies: o Magnatic Resonance Cholangiography (MRC) – provides excellent anatomic detail and has a sensitivity and specificity of 95 and 89%, respectively o Ultrasonography o Endoscopic cholangiography is the gold standard for diagnosing common bile duct stones  Management: o Endoscopic cholangiogram o Sphincterotomy and ductal clearance of stones followed by laparoscopic cholecystectomy

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2014 Edition

ORAL REVALIDA REVIEWER MYOCARDIAL INFARCTION (ST-SEGMENT ELEVATION) MEDICINE May precipitate various physical exercise, emotional stress or a medical or surgical illness Chest pain – deep and visceral, heavy, squeezing and crushing Similar to discomfort of angina pectoris, occurs at rest but more severe, lasts longer Accompanied by weakness, sweating, nausea and vomiting, anxiety and a sense of impending doom, pallor, substernal chest pain of more >30 minutes Pericardial friction rub is usually heard  Laboratory Findings: o ECG – ST elevation, Q wave  Transmural MI is present if the ECG demonstrates Q wave and loss of K waves  Nontransmural MI is considered if ECG shows only transient ST segment and T wave changes o Serum Cardiac Biomarkers  Cardiac-specific troponin-T and troponin-I are biochemical markers which usually rise in patients with STEMI not seen in healthy individuals. o MB isoenzymes of CK – more specific but not diagnostic of a myocardial rather than a skeletal muscle source of ↑CKMB o Non-specific reaction to myocardial injury is associated with PMN leukocytosis, WBC often reaches 12,00-15,00; ESR rises more slowly than WBC o 2D-Echo cardiac imaging – provides abnormalities of wall motion o High-resolution MRI –contrast agent (gadolinium) is administered, and images are obtained after a 10-minute delay; a bright contrast appears in areas of infarction  Differential Diagnosis: o Acute Pericarditis  Chest discomfort radiating from trapezius is not seen in STEMI o Pulmonary Embolism  STEMI may present with sudden onset of breathlessness that may progress to pulmonary edema and embolism  Initial Management: o Pre-hospital Care  Patient may manifest arrhythmias or mechanical complications (pump failure)  May cause sudden ventricular fibrillation o Management in Emergency Department  Aspirin in suspected STEMI causes inhibitin of cyclooxygenase I followed by reduction of thromboxane A2  If there is hypoxemia, O2 administration with nasal cannula or face mask at 2-4L/min o Control of Chest Discomfort  Nitroglycerine (sublingual) up to 3 doses of 0.4mg at about 5mins interval should be administered, or IV nitroglycerine if with ongoing ST segment ischemia shifts.  IV β-blockers – diminishes O2 demand  Hospital Phase Management: o Activity – ambulation should be encouraged if without complication o Diet – diet rich in potassium, magnesium and fiber but not sodium o Bowel – use of stool softener o Sedation – diazepam or lorazepam (adverse effect: delirium)  Pharmacotherapy: o Antithrombotic Agents – its role is to maintain patency of infarct related artery and reduce thrombosis that can lead to embolization  Clopidogrel – reduces risk of clinical events, reinfarction, stroke and death  Heparin + Aspirin – may help about 6 liver per 1000 patients o Beta-adrenergic blocker – improves the myocardium O2 demand, reduces pain, reduces infarct site, reduces arrhythmias o Inhibition of RAAS – reduces mortality rate; reduction in ventricular remodeling with subsequent reduction in the risk of CHF, indolent to ACE inhibitors

NORMAL SPONTANEOUS DELIVERY (NSD) 1. Secure consent for procedure 2. Transfer patient to OR 3. Wear cap and mask 4. Place patient in dorsal lithotomy position 5. Asepsis, antiseptic technique 6. Straight catheterization 7. IE (fully dilated cervix, fully effaced, cephalic, intact BOW, station?) 8. Apply sterile drapes 9. Infuse 5cc lidocaine at right mediolateral (RML) wall of vagina, aspirate before infusing

OB-GYN

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2014 Edition

ORAL REVALIDA REVIEWER 10. 11. 12. 13. 14. 15. 16. 17. 18. 19.

Do RML episiotomy Once baby’s head is out, rotate gently then pull upward and downward then slide head on fetal back and hold fetal legs Clamp the cord, place one clamp 2cms above the umbilicus, another Deliver placenta using Ritgen’s maneuver Once placenta is out, inspect cotyledon Give oxytocin, check BP first Do episiorapphy Do final IE Final asepsis and antisepsis Monitor VS q15 for 1 hour then q30 for the next hour, and then q4 thereafter

DENGUE HEMORRHAGIC FEVER  Clinical Manifestations: o Fever of 2-7 days o Headache, muscle and joint pain o Nausea and vomiting o Rashes (Herman’s rash)  Laboratory Findings: 3 o Low platelet count (20% from baseline) o Low albumin o Pleural or other effusions  Dengue Shock Syndrome o 4 criteria for DHF, plus:  Evidence of circulatory failure  Rapid and/or weak pulse  Narrow pulse pressure  Cold clammy skin o Shock  Differential Diagnosis: o Typhoid fever, measles, rubella  Management: o Rehydration management o Palliative treatment, antipyretics o Monitor vital signs, hematocrit, platelet count, level of consciousness

PEDIATRICS

PCAP – PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA PEDIATRICS  Clinical Manifestations: o 3mos-5yrs – fever, tachypnea and chest indrawing o 5-12yrs – fever, tachypnea, crackles o 12yrs and above – fever, tachypnea, tachycardia, at least one abnormal chest finding of diminished breath sounds, rhonchi, crackles or wheezes 

Classification: Variables

PCAP-A Minimal Risk

PCAP-B Low Risk

PCAP-C Moderate Risk

PCAP-D High Risk

Comorbid illness Compliant caregiver Ability to follow-up (+)Dehydration Ability to feed Age Respiratory rate, age 2-12mos Respiratory rate, age 1-5 yrs Respiratory rate, age >5 yrs

None Yes Possible None Able >11 mos ≥50/min ≥40/min ≥30/min

Present Yes Possible Mild Able >11 mos >50/min >40/min >30/min

Present No Not possible Moderate Unable 60/min ≥50/min ≥35/min

Present No Not possible Severe Unable 70/min >50/min >35/min

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2014 Edition

ORAL REVALIDA REVIEWER 

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Signs of Respiratory Failure: PCAP-A PCAP-B PCAP-C PCAP-D Retraction None None Intercostals/subcostal Supraclavicular Head bobbing None None Present Present Cyanosis None None Present Present Grunting None None None Present Apnea None None None Present Sensorium Awake Awake Irritable Lethargic/Stupurous/Comatose Respiratory Complications None None Present Present Action Plan OPD OPD Admit to regular ward Admit to PICU Diagnostics: o PCAP A & B – Clinical o PCAP C & D:  CXR PA-Lateral  WBC count  Pleural fluid C/S  Blood C/S for PCAP-D  Tracheal aspirate upon initial intubation  Blood gas and pulse oximetry  Sputum C/S for older children Treatment: o For PCAP A or B – DOC: oral amoxicillin (40-50mg/kg/day in 3 divided doses) o For PCAP C and D:  (+)HiB vaccine – pen G (100,000u/kg/day in q4)  (-)Hib vaccine – IV ampicillin (100mg/kg/day q4)

SEPSIS NEONATORUM PEDIATRICS  Characteristics: o temperature instability, hypotension, poor perfusion with pallor and mottling of skin, metabolic acidosis, tachycardia or bradycardia, apnea, respiratory distress, grunting, cyanosis, irritability, lethargy, seizures, feeding intolerance, abdominal distention, jaundice, petechiae, purpura, bleeding.  Initial S/S in Newborn Infants: o General – fever, temperature instability, poorly feeding, edema o Gastrointestinal – abdominal distention, vomiting, diarrhea, hepatomegaly o Respiratory – apnea, dyspnea, tachypnea, retractions, flaring, grunting, cyanosis o Cardiovascular – pallor, mottling, cold, clammy skin, tachycardia, hypotension, bradycardia o Renal – oliguria o CNS – irritability, lethargy, tremors, seizure, hyperreflexia, hypotonia, abnormal Moro reflex, irregular respirations, bulging fontanels, high pitched cry o Hematologic system – jaundice, splenomegaly, pallor, petechiae, purpura, bleeding  Differential Diagnosis: o Respiratory Distress Syndrome o Aspiration Pneumonia – amniotic fluid, meconium or gastric content  Laboratory Studies: o Blood and CSF culture o Antigen detection (urine, CSF) o Autopsy  Evidence of Inflammation: o Leukocytosis, ↑immature/total neutrophil count ratio o Acute-phase reactions; ESR, CRP o Cytokines, interleukins o Pleocytosis in CSF  Treatment: o Initial treatment with ampicillin and aminoglycoside (gentamicin) o Nosocomial infections – methicillin or nafcillin for S.aureus (antistaphylococcal drugs, or) vancomycin for CONS or MRSA o Pseudomonas infections – piperacillin, ticarcillin, ceftazidine or an aminoglycoside o Antifungal therapy in infants with very low birth weight rd o Most gram(-) enteric bacteria – ampicillin and an aminoglycoside or 3 gen cephalosporin (Cefotaxime or Ceftazidine) o Enterococci – penicillin (ampicillin or piperacillin) + an aminoglycoside o Anaerobic infections – clindamycin or metronidazole o GBS – penicillin

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2014 Edition

ORAL REVALIDA REVIEWER

TYPHOID FEVER PEDIATRICS / FAMILY MEDICINE  Salmonella typhi (etiologic agent)  Acquired through contaminated foods and water or close contact with infected person  Clinical Manifestations: o High grade fever (39-40°C) o Headache o Rose spots on chest and abdomen o Cough, epistaxis o Abdominal pain, with either constipation or diarrhea o Weakness and fatigue o Severely ill patients may experience delirium, shock, and intestinal hemorrhage  Diagnosis: o Culture – blood, urine, stool st  1 week – blood (+) 40% in the first week nd  2 week – urine and stool, highly (+)  Bone marrow – single most sensitive test, (+) in 85-90%, less sensitive if influenced by prior antimicrobial therapy o Typhi Dot IgM IgG Interpretation (+) (-) Acute infection (+) (+) Recent infection (-) (+) Equivocal  Management: o Susceptible strains – 14 day-treatment  Chloramphanicol 50-60mg/kg/day in 4 divided doses, or  Cotrimoxazole 800/160 1 tab BID, or  Ampicillin or Amoxicillin 100mg/kg/day in 3-4 divided doses o Resistant strains  Ceftriaxone, 7-10 days, 3gm TIV, or  Ciprofloxacin (507 days) 500mg tab BID o Chronic Carrier  High dose IV ampicillin or oral amoxicillin with probenecid for 4-6 weeks  For adult carriers: Ciprofloxacin

MENINGITIS  Etiology: o First 2 months – groups B and D Streptococci, Gram (-) enteric bacilli, and Listeria monocytogenes o 2 months to 12yrs – S.pneumoniae, N.meningitidis, H.influenza type B  Epidemiology: o Close contact (e.g. household, daycare centers, military barracks), crowding, poverty, male gender  Transmission: o Person to person contact through respiratory tract secretions or droplets  Clinical Manifestations: o Several days of fever o Upper GI or respiratory symptoms o Meningeal irritation – nuchal rigidity, back pain, Kernig sign, Brudzinski sign o Headache, vomiting, cranial nerve neuropathies (10-20%) o Seizures due to cerebritis, infarction or electrolyte disturbances (20-30%)  Diagnosis: o CSF analysis o CBC, platelet count, blood C/S, ESR, ABG o Na, K, BUN, Creatinine, RBS o Urinalysis, Urine G/S, C/S o Stool, throat, nasal C/S o Viral cultures (Coxsakie, Echinococcus, Mumps, EBV, HSV, CMV, Arbovirus) o CXR, ECG, CT scan, MRI, EEG

PEDIATRICS

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2014 Edition

ORAL REVALIDA REVIEWER

Normal Pressure (mmH2O)

3

Leukocytes (mm )

CHON (mg/dL) Glucose (mg/dL)

Others



50-80

Cerebrospinal Fluid Analysis Acute Bacterial Viral TB Meningitis Meningitis Meningitis Usually high Normal or Usually (100-300) slightly high elevated

75, ≥75% lymphocytes

100 to 10,000 or more; usually 3002000 PMN

20-45

100-500

>50

1000 cells

30-100 Generally normal HSV, encephalitis by focal CT scan findings

10-500, PMN early, then lymphocytes predominates in most cases 100-3000