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294 Passive Range of Movements Check passive movements while you are moving the shoulder through abduction, forward flexion, extension, external rotation, and internal rotation (test with the elbow flexed to 90°). Muscle power: While the patient is performing the above movements, check for power. A normal passive ROM with limited active motion can be due to a rotator cuff tear, nerve injuries, or severe impinge-ment syndrome. Any limitation in passive ROM indicates mechanical blocks as seen in frozen shoulder with an unre-duced shoulder dislocation, or advanced shoulder osteoarthritis. Special Tests: Impingement: Painful Arc: First check abduction with palms facing downward; then repeat with palms facing upward (Fig. 10. 13). Note any increase in range of movement with less pain. Test will be positive with impingement. Pain should start after 60-90° and resolve after 120°. Hawkins Test: Performed with the patient in a relaxed sitting position. The examiner passively moves the arm to be tested such that the arm is in 90° of forward flexion and the elbow is flexed at 90°. In the starting position, the examiner forcefully moves the patient's shoulder into internal rotation to the end of range of motion or until reports of pain (Fig. 10. 14a, b). The Hawkins test is con-sidered positive if the patient experiences pain in the superior lateral aspect of the shoulder. Neer Test: The examiner performs maximal passive abduction in the scapula plane, with internal rotation, while stabilizing the scapula with his other hand (Fig. 10. 15a, b). The Neer test is considered to be positive if the patient experiences pain in the subacromial space or on the anterior edge of the acromion. ab Fig. 10. 14 Hawkins test. (a) Starting position. (b) Internal rotation of shoulder Fig. 10. 13 Clinical examination of the shoulder region: active abduc-tion. The shaded areas show typical painful arcs and their causes. (Reprinted with permission from da Silva JAP, Woolf AD. Regional Syndromes The Painful Shoulder. In: Rheumatology in Practice. Springer, London, UK: Springer. 2010; 81-94) M. S. Saravi and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
295 Complete Rotator Cuff Tear: Drop Arm Test: Performed with the patient standing or sitting. The examiner holds and supports the patient's arm to be tested and abducts it to 90°. The patient is asked to actively lower their arm from abduction to their side in a slow and controlled manner (Fig. 10. 16a, b). The test is considered positive if the patient is unable to smoothly control the lowering of their arm or has the inability to hold their arm in 90° of abduction. There may or may not be pain reported. Pain alone is not a positive test. Acromioclavicular Joint: Scarf Test: Performed with the arm to be tested in 90° of elbow flexion and 90° of shoulder flexion (forward elevation). The patient then cross adducts/horizontally adducts, resting the hand on top of the opposite shoul-der. The examiner pushes the arm into further horizontal adduction (Fig. 10. 17). The position and movement mimic throwing a scarf over the shoulder, hence the name of the test. A positive test is indicated by localized pain over the acromioclavicular joint. A positive test commonly indicates a-c joint osteoarthritis or a-c joint ligament injury such as a ligament sprain or joint separation. Biceps: Yergason Test: Patient sits, while the examiner stands in front of them. The patient's elbow is flexed to 90°, and the forearm is in a pronated position while holding the upper ab Fig. 10. 15 (a, b) The Neer test 10 The Musculoskeletal System | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
296 arm at the side. Patient is instructed to supinate arm, while examiner concurrently resists forearm supination at the wrist (Fig. 10. 18). Localized pain at the bicipital groove indicates a positive test. Speeds Test: The patient's arm is flexed to 90°, and then the patient is asked to resist an eccentric movement into extension, first with the arm supinated and then pronated. The test is considered to be positive if there is an increased tenderness in the bicipital groove, especially with the arm supinated. Supraspinatus: The Empty Can and Full Can Tests (Jobe Supraspinatus Test): The examiner passively elevates the patient's shoulder to 90° of abduction with internal rotation (empty can) and pushes the arm down against the patient's resis-tance (Fig. 10. 19). Provoked pain and demonstrated weakness are considered as positive result. The full can test is performed at the same position but with external rotation, which is a less painful posture for the patient allowing for the assessment of power. Drop Arm Test: Already described (see Fig. 10. 16). Infraspinatus and Teres Minor External Rotation Resistance Test: Tries to verify the external rotation power of the shoulder. Shoulder is placed at 0° of abduction and 30° of external rotation with the elbow held in 90° of flexion. The examiner pushes the arms into internal rotation against the patient's resistance (Fig. 10. 20). It can be performed on both sides simultane-ously for comparison. Subscapularis: Lift-Off Test: The examiner stands either beside or behind the patient. The patient stands and places the dorsum of the hand against their mid-lumbar spine. The patient then lifts his hand away from the back (Fig. 10. 21). An inability to perform this action indi-ab Fig. 10. 16 (a, b) Drop arm test Fig. 10. 17 Scarf test M. S. Saravi and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
297 cates a lesion of the subscapularis muscle. Abnormal motion of the scapula during the test may indicate scap-ular instability. Belly-Press Test: The examiner places a hand on the abdo-men so that the he or she can feel how much pressure the patient is applying to the abdomen. The patient places his or her hand of the shoulder being tested on the examiner's hand and pushes as hard as he or she can into the stomach. The patient also attempts to bring the elbow forward in the scapular plane causing greater medial shoulder rotation (Fig. 10. 22). It is a positive test if the patient is unable to maintain the pressure on the examiner's hand while moving the elbow forward or if the patient extends the shoulder. Tests for shoulder instability Anterior Apprehension and Relocation: The exam-iner stands either behind or at the involved side, grasps the wrist with one hand, and passively externally rotates the humerus to end range with the shoulder in 90° of Fig. 10. 18 Yergason test Fig. 10. 19 The empty can and full can tests (Jobe supraspinatus test) Fig. 10. 20 External rotation resistance test Fig. 10. 21 Lift-off test 10 The Musculoskeletal System | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
298 abduction. Forward pressure is then applied to the pos-terior aspect of the humeral head by the examiner or the table (if the patient is in supine) (Fig. 10. 23a, b). A positive test for anterior instability is if apprehension is pre-sented by the patient or if the patient reports pain. Then repeat the test by supporting the anterior aspect of the shoulder while increasing the external rotation. Now, the patient does not report any pain or apprehension. Tell the patient that you will also examine the joint above and below and would also like to compare with the other side. If time permits, continue examining the elbow and hand motions rapidly by asking your patient to bend their elbows, make fists, and spread their fingers. These are important as combined motion limitation in upper extrem-ities usually originates from brachial plexus injuries. Sulcus Sign: An orthopedic evaluation test for glenohu-meral instability of the shoulder. With the arm straight and relaxed to the side of the patient, the elbow is grasped by the examiner and traction is applied in an inferior direction (Fig. 10. 24). With excessive inferior translation, a depression occurs just below the acromion indicating a positive test. Neurovascular Assessment: Sensory: Check the sensation of the skin over the deltoid (axillary nerve), lateral elbow (C5), thumb (C6), middle finger (C7), little finger (C8), and medial elbow (T1). Motor: Resisted shoulder abduction, elbow flexion and extension, wrist extension, finger flexion, and abduction. Reflexes: Biceps and triceps reflexes. Pulse: Radial. Tell the patient that you will also examine the joint above and below and would also like to compare with the other side. If the examiner asks what you will do next, say that you will check for referred pain or will do a hand examination. Thank the patient and tell them that they can now cover up. Wrap up your findings with the examiner or the patient. Wrap-Up Question: Describe the diagnosis Answer: Based on history and physical examination, the usual diagnoses for OSCE exams will be either: Fig. 10. 22 Belly-press test ab Fig. 10. 23 (a, b) Anterior apprehension and relocation M. S. Saravi and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
299 Impingement syndrome Rotator cuff rupture Frozen shoulder Shoulder instability Question: What will you do next? Answer : The usual first diagnostic step is a shoulder X-ray. MRI is the best diagnostic modality that should be used with an intra-articular injection of gadolinium (magnetic resonance angiogram [MRA]) for detecting labral injuries in patients with shoulder instability. Question: What is your management plan? Answer : The common conservative treatment for most shoulder pathologies consists of NSAIDS, local steroid injection, and physiotherapy. This is suitable for impingement syndrome and frozen shoulder. Physiotherapy is the main part of treatment for the subtle shoulder instability. Give the patient some information about your manage-ment plan, the pathology, the follow-up plan, or possible referral for surgery. Offer her some sources for further information. Referring the patient for surgery is indicated for failed conservative treatment, for recurrent gross shoulder dislocation, or for complete post-traumatic rota-tor cuff tears. Checklist: Shoulder Examination See Table 10. 7 for a checklist that can be used as a quick review before the exam. History and Physical Examination: Elbow Candidate Information: A 25-year-old male presents with right elbow pain for 2 weeks. Vital Signs: HR, 71/min, regular; BP, 120/65 mm Hg; temp, 36. 8; RR, 14/min; O2 saturation, 98% Please take a brief history, perform a focused elbow examination, and address patient concerns at the end. Please do not perform rectal, genitourinary, or breast examination. Differential Diagnoses A) Lateral Elbow Pain : Lateral elbow pain is the hallmark of lateral epicondylitis or tennis elbow -one of the most common musculoskeletal disorders found in everyday practice. A typical scenario will be a middle-aged patient with a history of elbow pain for a few weeks, which gets worse with physical activities that involve repeated supina-tion and pronation with an extended elbow (Fig. 10. 25 ). Upon physical examination, the only positive findings will be point tenderness on the lateral epicondyle and pain with passive flexion of the wrist in full pronation or resisted dor-siflexion of the wrist. Radial Tunnel Syndrome : This is caused by pressure on the deep radial nerve at around the radial head and must be considered in all presumed cases of lateral epi-condylitis -especially recalcitrant cases. The clinical clues are the point of maximal tenderness, which will be Fig. 10. 24 Sulcus sign test. (Reprinted with permission from Steinfeld et al. [ 7]. © Mayo 1998) 10 The Musculoskeletal System | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
300 about 1 inch distal to the lateral epicondyle, and accentua-tion of the pain with resisted dorsiflexion of the middle finger. In chronic cases, weakness of finger dorsiflexion and radial deviation of the wrist after active dorsiflexion can be noticed. Osteoarthritis of the Lateral Compartment of Elbow: This condition is characterized by some limitation of motion and crepitation on passive movement. Comment on absence of these signs for ruling out this condition. B) Lateral and medial elbow pain are the titles for two main groups of the elbow pain, please emphasize that by some changes in the font size or some number or letters, inside these group we have some differentials, for medial elbow pain, f. g, as you see we have cubical tunnel syndrome and osteoarthritis of elbow. Medial Elbow Pain: Pain at the medial elbow is the chief complaint of patients suffering from medial epicondylitis or “golf elbow. ” A typical scenario will be a middle-aged patient who presents with medial elbow pain that gets worse with physical activity. These patients have no positive findings at physical examination except for point tenderness on medial epicondyle and increasing pain with active resisted wrist flexion and pronation. Cubital Tunnel Syndrome: This is an entrapment neu-ropathy caused by pressure on the ulnar nerve at or around the cubital tunnel. The patient usually presents with pares-thesia in the ulnar nerve supply area -on the medial one and half digits and sometimes with medial elbow pain. It might be associated with elbow deformities, such as cubitus valgus, and in chronic established cases of motor deficits related to the ulnar nerve, such as clawing of the medial two digits or atrophy of the interosseous muscles. However, in early pre-sentation, the only positive sign could be a Tinel's sign over the cubital tunnel, which makes it an appealing case for an OSCE exam. Osteoarthritis of the Elbow: This condition is character-ized by limitation of motion, crepitation, and possibly remote history of trauma. Comment on the absence of these signs for ruling out this diagnosis. History: Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Table 10. 7 Checklist for shoulder examination Starting the station Knock on the door Enter the station Hand-wash/alcohol rub Greet the examiner and the patient Give stickers to the examiner if required or show your ID badge Now sit on the chair or stand on the right side of the patient and start the interview Opening Introduction Greet, explain, position, and expose/drape Ask for vital signs -interpret General physical examination (may skip these questions if it is a history and physical station)Check for alertness and orientation Look for any abnormal findings in: Hands Face (eyes, nose, lips, and mouth) Neck Inspection Position and observe the anterior, posterior, and lateral aspects of the shoulder and compare to other side Look for SEADS Joint palpation Explain to the patient what to expect from the examination Palpate the sternoclavicular joint, clavicle, acromioclavicular joint, acromion, spine and body of the scapula, coracoclavicular joint, greater tubercle of humerus, humeral head, glenohumeral joint, supraspinatus, infraspinatus, deltoid, and biceps Note and feel for: tenderness, effusion, swelling, temperature, crepitus, and atrophy Active range of movement (ROM)Check for flexion, extension, abduction, adduction, internal, and external rotation Passive ROM Check for passive movements in flexion, extension, abduction, adduction, internal and external rotation Power Check for power in all of the above movements Special tests Impingement Hawkins and Neer AC joint Scarf sign Bicep Yergason and speed test Supraspinatus Jobe and drop arm test Infraspinatus and Teres Minor External rotation resistance test Subscapularis Lift-off and belly-press test Shoulder instability Anterior apprehension test and Sulcus sign Check neck for referred pain Mention that you would examine the joint above and below and would also compare to the other side Wrap-up Thank the patient and tell them that they can now cover up Wrap up your findings and ask if the patient has any concerns M. S. Saravi and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
301 Opening: “Good morning/good afternoon. I am Dr... I am your attending physician. Are you Mr... ? Are you 25 years old?” “Is it alright if I ask you few questions about your elbow pain? I would also like to do a relevant physical examination. It will involve manipulating and watching your elbows and arm as well as some movement or tests that might be uncom-fortable. At any time if you have severe pain, please let me know and I will stop immediately. Once I've finished, we will discuss the plan. ” Elbow Pain First establish the location of the pain. It should be in the question stem; otherwise ask the patient to show you where they feel the pain. Then, go through the pain questions and the rest of the history as outlined in the history details of this chapter. Elbow Examination: Vitals: Start by commenting on the vitals given at the door. (It should include pulse rate, blood pressure, respiratory rate, temperature, and O2 saturation. ) “Mr... vital signs are nor-mal” or mention if there are any abnormal findings. Inspection: Comment on: General: Joint posture, any dressings or casts, and any abnormal movements. Position: Inspect the elbow in its resting position (the normal carrying angle is 5-20°) (Fig. 10. 26). Expose both arms from shoulder to fingers. Properly drape the rest of the body. Joint Inspection: Inspect the joint from anterior and posterior angles. Compare to the other side, and then verbalize if you do not see any swelling, erythema, atro-phy, deformity, or skin changes/rash/scar marks (SEADS). Palpation: Inform the patient again that you are going to feel their elbow and to inform you if they feel any pain. Feel for: tenderness, effusion, swelling, temperature, crepitus, fluctuance, and atrophy. Palpate olecranon, medial, and lateral condyles of the humerus, extensor, and flexor surfaces of the forearm and the radial head (about 1 cm distal to lateral epicondyle). Palpate for elbow effusion in the elbow triangle radial head, lateral condyle, and olecranon. Palpate the ulnar nerve between the medical and lateral epicondyles. Motion: Active Range of Movements: Ask the patient to stand and mimic your movements. Check movements in flexion, exten-sion, supination, and pronation. Either show the movements and let the patient repeat these or ask the patient to bend their elbows until they can touch their shoulders (flexion). Then tell them to place their arms back down (extension). Ask the patient to keep their arms at their side with the elbow flexed and then to turn the palm up (supination) and down (pronation). Ask the patient to hold a pencil in their fist during these movements to help determine the range of movement in degrees. Passive ROM: Check for passive movements in flexion, extension, supination, and pronation. Test Power: While the patient is performing flexion, extension, supination, and pronation. EXTENSIONSUPINA TIONFLEXION140° 0°80° 80° PRONATIONFig. 10. 25 Range of motion of the elbow joint. (Reprinted with permission from Malagelada et al [8]. © Pau Golano) 10 The Musculoskeletal System | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
302 Special Tests: Tennis Elbow: Passively flex the patient's elbow to 90°, pronate it, and flex the wrist before passively extending the elbow. This maneuver stretches the wrist extensors causing pain. Check for tenderness over the common extensor insertion at the lateral epicondyle. Pain over lateral epicondyle is a positive test for tennis elbow (Fig. 10. 27). Golfer' Elbow: Passively supinate the forearm and then extend the elbow and wrist. It may increase pain over the medial epicondyle. Check for tenderness over the common flexor insertion at the medical epicondyle. Pain over the medial epicondyle is a positive test for golfer's elbow. Neurovascular Assessment: Sensory: Check the sensation of the skin over the deltoid (axillary nerve), lateral elbow (C5), thumb (C6), middle finger (C7), little finger (C8), and medial elbow (T1). Motor: Elbow movements already checked. Check wrist extension, finger flexion, and abduction. Lateral Elbow Pain: You need to test the posterior interosseous nerve and the deep motor branch of the radial nerve, which is trapped in radial tunnel syndrome. You should also test wrist and fingers in resisted extension. For Medial Elbow Pain: You need to do a sensory and motor test for the ulnar nerve to rule out cubical tunnel syndrome. Reflexes: Biceps, triceps, and brachioradialis. Pulse: Radial. Tell the patient that you will also examine the joint above and below and will compare it with the other side. Wrap-Up: Describe the diagnosis. Further laboratory and radiology tests: For a typical case, no further evaluation is needed. However, an X-ray would be helpful if you are suspicious of any structural abnor-malities like osteoarthritis, and an EMG/NCV is indicated if you think entrapment neuropathies are possible. Management plan (pain medication, NSAIDs, and/or ste-roids), physiotherapy. Further information, Websites/brochures/support groups or societies. Follow-up. Fig. 10. 26 Carrying angle Fig. 10. 27 Tennis elbow. By Bruce Blaus -Own work, CC BY-SA 4. 0, https://commons. wikimedia. org/w/index. php?curid=44923322 M. S. Saravi and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
303 Checklist: Elbow Examination See Table 10. 8 for a checklist that can be used as a quick review before the exam. History and Physical Examination: Wrist and Hand Candidate Information: A 45-year-old female comes in with right hand pain and a tingling sensation that presented 3 weeks ago. She delivered a baby 2 months ago with no complications. She wakes at night due to her pain. She has noticed recently that things like glasses of water tend to fall from her hand. Vital Signs: HR, 71/min, regular; BP, 120/65 mm Hg; temp, 36. 8; RR, 14/min; O2 saturation, 98% Please take a brief history and perform a focused right hand examination (Figs. 10. 28a-e, considering the left hand to be the normal side, and address patient concerns at the end. Please do not perform a rectal, genitourinary, or breast examination. Differential Diagnosis of Wrist and Hand Pain: Carpal Tunnel Syndrome (CTS): This is a classic sce-nario for carpal tunnel syndrome. The typical OSCE sce-nario for CTS is easy to recognize, so the lion share of the scores would probably go to considering differential diag-noses or in the physical exam (pregnancy, diabetes, rheu-matoid arthritis, acromegaly, and hypothyroidism). Pronator Syndrome: This is quite similar to CTS and is caused by pressure on the median nerve in the proximal part of the forearm, probably due to muscle hypertrophy. The important clues are a history of heavy weight lift-ing, body building, or repetitive resisted pronation. Involvement of the palmar cutaneous branch of the median nerve is apparent by having symptoms on the palms and a positive compression test on the proximal volar forearm. Scaphoid Nonunion: Presents with mild to moderate pain on the radial side, no obvious swelling, history of old trauma, worse with activity, and tenderness on snuff box. De Quervain Disease: Found in middle-aged females who have severe pain on the radial side of their wrists. It is mostly developed postpartum, with maximum tender-ness on the volar border of the snuff box showing a posi-tive Finkelstein test. Kienbock Disease: Found in young men with dorsal wrist pain, probably with remote trauma and tenderness on the lunate bone. To find the lunate, you first need to touch the Lister tubercle. The area of the wrist joint distal to this is the scapholunate joint. Trapeziometacarpal Joint Arthrosis: Found in middle- to old-aged women with pain in the radial side of the wrist, associated with tenderness and swelling at the base of first metacarpal. Table 10. 8 Checklist for elbow examination Starting the station Knock on the door Enter the station Hand-wash/alcohol rub Greet the examiner and the patient Give stickers to the examiner if required or show your ID badge Now sit on the chair or stand on the right side of the patient and start the interview Opening Introduction Greet, explain, position, and expose/ drape Ask for vital signs -interpret General physical examination (may skip these questions if it is a history and physical station)Check for alertness and orientation Look for any abnormal findings in: Hands Face (eyes, nose, lips, and mouth) Neck Inspection Posture: Carrying angle 5-20° Position: Sitting with both elbows exposed shoulder downward Look for SEADS Joint palpation Explain to the patient what to expect from the examination Palpate olecranon, medial and lateral condyles of the humerus, the radial head, the forearm and humerus, elbow effusion, and the ulnar nerve Note and feel for tenderness, effusion, swelling, temperature, crepitus, and atrophy Active range of movement (ROM)Check for flexion, extension, abduction, adduction, pronation, and supination Passive ROM Check for passive movements in flexion, extension, abduction, adduction, pronation, and supination Power Check for power in all of the above movements Neurovascular assessment Special tests Forced wrist extension Tennis elbow, lateral epicondyle tenderness Forced wrist flexion Golfer's elbow, medial epicondyle tenderness Mention that you would examine the joint above and below and would also compare to the other side Wrap-up Thank the patient and tell them that they can now cover up Wrap up your findings and ask if the patient has any concerns 10 The Musculoskeletal System | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
304 History: Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr... I am your attending physician. Are you Miss... ? Are you 45 years old?” “Is it alright if I ask you few questions about your hand pain? I would also like to do a relevant physical examination. It will include manipulating and observing your hand and wrist and some movement or tests that might be uncomfort-able. Is that OK? At any time if you have severe pain, please let me know, and I will stop immediately. In the end, we will discuss the plan. ” ab c de Fig. 10. 28 Thumb movements. (a) Extension or reposition. (b) Flexion. (c) Opposition. (d) Adduction. (e) Abduction M. S. Saravi and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
305 In hand and wrist scenarios, these are important questions that need to be asked: 1. “Are you right handed or left handed?” 2. “What do you do for living?” 3. “Do you often work with computers?” 4. “Have you recently given birth?” (CTS is very common during or after a recent pregnancy. ) 5. “Do you feel cold all the time? Have you noticed exces-sive dryness and progressive thinning of your hair? How are your bowel movements?” (Considering hypothy-roidism, especially for bilateral cases. ) 6. Associated symptoms: “Have you noticed any weakness in your hand?” 7. “Have you noticed any changes in the size of your shoes or rings?” (acromegaly) 8. “Have you ever been diagnosed with kidney disease or a chronic infection?” (amyloidosis) 9. “Have you previously had multiple joint swelling or rheumatoid diseases?” (rheumatoid arthritis) 10. “Have you ever fractured this hand?” (You are cover-ing CTS as a complication of a distal radius fracture. ) 11. “Do you have neck pain too?” (You are showing the examiner that you are considering cervical radiculopa-thy in your differential diagnoses. ) 12. “Have you had any work-related injuries recently?” 13. “How has this affected your daily activities?” Some Clues About CTS At first establish the location of the pain. “Can you show me where you feel the pain?” -Expect the patient to present the pain in three and a half radial digits. In practice, the second and third digits are mainly involved. Radiation of the pain -commonly up to the elbow and sometimes up to the shoulder. Nature of pain -usually burning and tingling. CTS can be presented with mild, moderate, or severe pain. “How did it start?” Sudden or gradual onset is a clue of CTS. “What time of the day does your pain feel the worst?” - typically at night. “Does it interfere with your sleep?” -it will in typical cases. “What tends to lessen your pain?” -rubbing, shaking, dangling, and pain medicines. Please complete the history as mentioned in the history details of this chapter. Hand and Wrist Examination: Vitals: Start by commenting on the vitals given at the door. (This should include pulse rate, blood pressure, respiratory rate, temperature, and O2 saturation. ) “Mrs... vital signs are normal” or mention any abnormal findings. Inspection: Position: Patient should be sitting with both hands exposed up to their elbows. You can put both of their hands on a pillow (if available) (Fig. 10. 29). Drape the rest of the body. Inspect both the dorsal and volar aspects of the hands. Compare to the other side, and then verbalize if you do not see any swelling, erythema, atrophy (thenar and hypothe-nar), deformities, and skin changes/rash/scar marks. Look for Mallet finger, Boutonniere, Swan neck defor-mity, Heberden's nodes, and Bouchard's nodes: Mallet Finger/Thumb Flexed Distal Interphalangeal Joints: Caused by damage to extensor tendon due to trauma or rheumatoid arthritis (RA). Boutonniere: Hyperextended distal interphalangeal and flexed proxi-mal interphalangeal joint: caused by detachment of the central slip of the extensor tendon from the middle pha-lanx due to trauma or RA. Swan Neck: Flexed distal interphalangeal and hyperextended proxi-mal interphalangeal joint: caused by RA and others. Heberden's Nodes: Hard dorsolateral nodules of distal interphalangeal may associate with deviation of the distal phalanx: caused by osteoarthritis. Bouchard's Nodes: Hard dorsolateral nodules of proximal interphalangeal joint may associate with deviation of the proximal inter-phalangeal joint: caused by osteoarthritis Dupuytren's contracture Flexion deformity of the fingers at MCP and IPs with nodular thickening of the palm: caused by diabetes mel-litus, epilepsy, alcoholism, hereditary causes, and repeti-tive trauma. Fig. 10. 29 Hand and wrist inspection 10 The Musculoskeletal System | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
306 Palpation: Inform the patient again that you are going to feel their hands and to let you know if they feel pain. Feel for tenderness, effu-sion, swelling, temperature, crepitus, fluctuance, and atrophy. Palpate using your thumb and index fingers. Palpate the distal radius, ulna, carpel bones, radial and ulnar styloid processes, distal radioulnar articulations, and anatomical snuff box. 1. Ask the patient to extend her thumb. The borders of the ana-tomical snuff box will become more apparent. The dorsal border is the tendon of the extensor pollicis longus (EPL), which is the third wrist extensor compartment. The volar border, which is the first wrist compartment, comprises the tendons of the abductor pollicis longus (APL) and the exten-sor pollicis brevis (EPB). Tenderness in this compartment at the proximal half of snuff box is a sign of de Quervain dis-ease. Try to touch the elements of the snuff box floor from proximal to distal. Some ulnar deviation of the wrist will help you to distinguish these elements. Tenderness of: The styloid of radius is caused by a chauffeur fracture. The waist of the scaphoid is caused by a scaphoid frac-ture or nonunion. The trapezium. Trapeziometacarpal joint is caused by arthrosis. 2. Now try to find the Lister tubercle on the dorsum of the wrist. Ask the patient to extend their thumb, which makes the tendon of extensor pollicis longus (EPL) prominent. Follow the tendon of EPL with the pulp of your thumb to reach the distal radius. Now you can feel Lister tubercle. The importance of finding this tubercle is because of its relation to the scapholunate joint. If you slide your thumb distally from the Lister tubercle and place it distal to the dorsal border of the distal radius, you will find the scaph-olunate joint, the proximal pole of the scaphoid, and the lunate, which are the sites of ganglion cysts, scaphoid fractures, and Kienbock disease, respectively. 3. On the most ulnar side of the dorsum of the wrist, find the prominent ulnar head. Check the stability of the distal radioulnar joint by pushing over the ulnar head. Check the presence of tenderness on the soft spot distal to the ulnar head, which is compatible with injury to the triradi-ate fibrocartilage complex (TFCC). 4. On the volar aspect of the wrist, first find the wrist flexion crease. There are two touchable bony prominences on the radial and ulnar ends of this crease: the scaphoid tuberosity and the pisiform. They are the proximal attachments of the transverse carpal ligament; the distal attachments of this ligament are also palpable. On the ulnar side, slide your thumb 1. 5-2 cm distally and a little radially to feel the hook of hamate between the hypothenar muscles. On the radial side, move your thumb from the tuberosity of the scaphoid distally and radially to feel the trapezium. You can feel the firmness of the TCL under the skin between these 4 points. Range of Motion: Active Range of Movements: Quick assessment: Show the patient how to move both wrists in flexion, extension, ulnar, and radial deviations. Check both wrists and compare them to yours, allowing you to comment on abnormal restriction of movement without having to memorize the normal range. Passive ROM: As usual, check passive movement if the reciprocal active movement is limited. Power: While patient is performing the above movements. Neurovascular Assessment: Sensory: Median, ulnar, and radial nerves (Fig. 10. 30). The test can be done with a piece of cotton. You are going to test lateral three and half digits to reveal hypoesthesia and lack of hypoesthesia on the fifth finger, over thenar and hypothenar prominences. Reflexes: Biceps, triceps, and brachioradialis. Pulse: Radial. Special Tests: Tinel's Sign: Percuss the volar aspect of the wrist over the median nerve (Fig. 10. 31). Numbness or paresthesia in the distribution of the median nerve is suggestive of carpel tunnel syndrome. Finkelstein's Test: Consider this test if you have found tenderness around the volar aspect of the snuff box. Have the patient place their thumb in the palm of their closed fist. Ask the patient to deviate the wrist in the ulnar direc-tion (Fig. 10. 32a, b). This test stretches the extensor pol-licis brevis and abductor pollicis longus and produces pain in patients with de Quervain tenosynovitis. This test is not needed if your history has led you toward CTS. It is mostly helpful if the patient has located their pain on the lateral side of the wrist. Phalen Test: Have the patient bring the backs of both hands together in front of you, and let the hands hang down for about 60 s (Fig. 10. 33). If they feel tingling, numbness, or pain in the fingers within 60 s, it may be due to carpal tunnel syndrome. Examination for the Differential RA: Comment that there is no hand deformity or joint swelling indicative of RA. Pronator Syndrome: Put pressure on the proximal volar forearm, and ask the patient if they feel tingling in their hand, which is a sign of pronator syndrome. M. S. Saravi and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
307 Cervical Discopathy: Spurling test, neurological test for the nerve roots. Hypothyroidism: Comment that there is no facial changes compatible with it and no goiter present. Wrap-Up: Question: What is your diagnosis? Answer: “Carpel tunnel syndrome. ” Question: Describe the diagnosis. Answer: “It is a painful condition involving the hand. It can be in one or both hands and it is caused by pressure on the median nerve. This nerve passes through the wrist, under a tunnel. This tunnel is formed by a membrane sheet and is attached to the wrist bones. This tunnel keeps nerves, arteries, veins, and tendons in place. If it becomes thick-ened, it can put pressure on nerves, thus resulting in symptoms. ” Question: What is the management plan? Answer: “I need to arrange to have some lab work done and then some investigations. ” Question: What investigations will you order? Answer: “Blood work to get a CBC differential, blood sugar, urea and electrolyte levels, and possibly TSH. I will also order nerve conduction studies. ” Question: What is the treatment? Answer: “The symptoms may resolve without any treat-ment. Pain medication gives temporary relief. ” “In pregnancy, a wrist splint is advised to be worn dur-ing the night until the baby is born. The symptoms usually resolve after the baby is delivered. A night wrist splint is also useful for elderly patients. In some patients, liquid pills or a steroid injection into the tunnel gives relief of the symptoms. ” Referral for Surgery: “In failure of conservative manage-ment or in cases of severe carpal tunnel syndrome, surgery is advised. The surgery will involve cutting through the tunnel membrane and relieving the pressure on the nerve by creat-ing more space. ” Fig. 10. 30 The cutaneous innervation of the right hand Fig. 10. 31 Tinel's sign 10 The Musculoskeletal System | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
308 Checklist: Hand and Wrist Examination for Carpal Tunnel Syndrome See Table 10. 9 for a checklist that can be used as a quick review before the exam. History and Physical Examination: Hip Candidate Information: A 63-year-old male comes in with right-sided hip pain, which has been bothering him for the last 8 weeks. Vital Signs: HR, 71/min, regular; BP, 120/65 mm Hg; temp, 36. 8; RR, 14/min; O2 saturation, 98% Please take a brief history and perform a focused hip examination and address patient concerns at the end. Please do not perform a rectal, genitourinary, or breast examination. ab Fig. 10. 32 Finkelstein's test for de Quervain tenosynovitis. (a) Patient places thumb inside closed fist. (b) Patient tilts hand down Table 10. 9 Checklist for carpal tunnel syndrome (CTS) examination Starting the station Knock on the door Enter the station Hand-wash/alcohol rub Greet the examiner and the patient Give stickers to the examiner if required or show your ID badge Now sit on the chair or stand on the right side of the patient and start the interview Opening Introduction Greet, explain, position, and expose/drape Ask for vital signs -interpret General physical examination (may skip these questions if it is a history and physical station)Check for alertness and orientation Look for any abnormal findings in: Hands Face (eyes, nose, lips, and mouth) Neck Inspection Inspect the dorsal and palmar aspects of the hand Compare to the other side and comment if you see any SEADS Joint palpation Tell the patient that you are going to feel their hands and to tell you if they feel pain Try to locate a tender point No specific point: CTS Center of snuff box: scaphoid or nonunion fracture Proximal to the base of the first metacarpal bone (volar border of snuff box): de Quervain disease Dorsum of the wrist distal to the Lister tubercle: scapholunate injuries, ganglion cysts, Kienbock disease Active range of movement (ROM)Check at the wrist, MCP, PIP, and DIP (fingers) and at the thumb Fig. 10. 33 Phalen test for carpal tunnel syndrome M. S. Saravi and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
309 Differential Diagnosis Hip Pain: Hip cases are rarely adapted for the OSCE exam. However, be ready for the occasional appearance of a hip pain case requiring combined history taking and a physical exam. The usual causes of hip pain in adults that must be consid-ered are: Osteoarthritis Avascular necrosis (A VN) Septic arthritis Fractures Stress fracture Dislocations Trochanteric bursitis Bone tumors In relatively younger patients: Slipped capital femoral epiphysis Developmental dysplasia of hip Legg-Calvé-Perthes disease Considering the relative prevalence of these pathologies, it is logical to choose osteoarthritis as your main diagnosis for middle-aged or older patients and A VN among the younger patients. You may also need to rule out lumbar radiculopathies. History: Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician. Are you Mr....? Are you 63 years old?” “Is it alright if I ask you few questions about your hip pain? I would also like to do a relevant physical examination. It will involve watching and manipulating your hip as well as some tests that might be uncomfortable. Is that OK? At any time if you have severe pain, please let me know, and I will stop immediately. After this we will discuss the treatment plan. ” Hip Pain First establish the location of the pain. It should be in the question stem; otherwise ask the patient. Location: “Can you show me where you feel the pain?” Then go through the pain questions and the rest of the his-tory as mentioned in the history details of this chapter. Onset: “Can you tell me how this pain started?” Except for with septic arthritis, the pain of other hip disorders starts and worsens gradually. Duration: “How long have you had this pain?” Expect long duration for hip osteoarthritis, shorter course for tumors, A VN, and stress fractures and very acute presen-tation for septic arthritis. Severity: Ask about the quality or severity of the pain, although this will not help you in finding the cause of the hip pain. Referred pain: “Can you show me where exactly you feel this pain?” Pain originating from the hip is usually felt on the inguinal region and sometimes referred to as the anteromedial aspect of the knee. The pain of trochanteric bursitis is laterally located, and buttock pain may be due to gluteal bursitis or referred from the lumbar spine. Radiation: “Does this pain shoot anywhere else? To your knee? To your ankle?” Timing: “At what time of the day is your pain the worst?” Pain of osteoarthritis, A VN, stress fractures, and some kinds of pain related to tumors are activity related and are worse during the day. Pain of bone tumors is sometimes more both-ersome at night. Aggravating Factors: “What makes your pain worse and what makes it better?” Walking or resting? Associated Symptoms: Ask about fever, night sweats, and weight loss. Tumors and infections. Rheumatologic Disorders: Associated A VN of the proximal humerus and femoral condyles Heel pain, eye pain, and back pain or stiffness (spondyloarthropathies) Weakness and numbness (radiculopathies)Power Check for power using the same movements as active ROM Neurovascular assessment Sensory: median, ulnar, and radial nerves Reflexes: biceps, triceps, and brachioradialis Pulse: radial Special tests Tinel's sign Phalen test Wrap-up Thank the patient and tell them that they can now cover up Wrap up your findings and ask if the patient has any concerns 10 The Musculoskeletal System | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
310 Past Medical History : It is extremely important in our evaluation. Past history for trauma (for OA and A VN), medi-cations such as glucocorticoids (for A VN), diseases such as SLE, sickle cell anemia (ANN), diabetes, or any form of decreased immunity (for septic arthritis). Please complete the history as mentioned in the history details of this chapter. Hip Examination “I am going to examine your hip now. I will be looking at the right side only (if right side is the troubling side) assuming that the left side is normal. Should we start?” Vitals Start by commenting on the vitals given at the door. (It should include pulse rate, blood pressure, respiratory rate, temperature, and O2 saturation. ) “Mr... vital signs are nor-mal” or mention any abnormal findings. Inspection: General: Joint posture, any dressings or casts, and any abnormal movement Posture Standing and lying supine Joint Inspection Inspect the joint from the anterior, lat-eral, and posterior angles. Compare to the other side, and then verbalize if you do not see any swelling, erythema, atrophy, deformity, and skin changes/rash/scar marks (SEADS). Gait Always start with walking unless the patient is in acute pain, lying on the bed, and you are suspicious of septic arthritis or fractures. Ask your patient to walk a few steps and check for any limping and antalgic gait. Trendelenburg Sign To detect weak hip abductors. Stand behind the patient and ask him to stand on one leg and then on the other (Fig. 10. 34 ). Note any change in the level of the iliac crests or gluteal folds during this maneuver. If the iliac crest drops toward the non-weight-bearing side, it is indicative of weakness of the hip abductors in the weight-bearing limb. Joint Palpation Inform the patient again, “I am going to feel your hip, if you feel pain, please let me know. ” Feel for tenderness, swelling, temperature, crepitus, and atrophy. Palpate around the hip joint, pelvis, anterior superior iliac supine, posterior superior iliac supine, iliac crest, and greater trochanter of the femur. Palpate for tenderness over and pos-terior to the greater trochanter as a sign of trochanteric bursitis. Check for Leg Length Discrepancy Ask the patient to lie down on the bed in a supine position. An apparent leg length can be measured with a measuring tape from the umbilicus to the medial malleoli of the ankle (usually medial malleolus) (Fig. 10. 35 ). Discrepancies in length of the lower limbs are seen in pelvic tilt or adduction abnormalities. A true leg length is measured from the anterior superior iliac spine to the medial malleolus seen in hip joint patholo-gies (Fig. 10. 35 ). Hip ROM can be checked in standing or lying (supine and prone) positions. If the patient seems to be strong and in no acute pain, you can check the active ROM rapidly in standing position after checking his gait, but in other cases check it on the table. A good time-sparing strategy is this: When the patient is in supine position, ask him to bend his hip (active flexion). If the movement is limited, try to bend it yourself (passive hip flexion). Now reduce the hip flexion to a little less than full active flexion, and ask the patient to bend it again against your resistance (checking the power). Fig. 10. 34 Positive Trendelenburg's sign, as illustrated in the first description. (Source: H.-P. Haack https://commons. wikimedia. org/wiki/ File:Erstausgaben_f%C3%BCr_Wikipedia_IV_002. jpg ) (Reprinted under terms of Creative Commons Attribution-Share Alike 3. 0 Unported license https://creativecommons. org/licenses/by-sa/3. 0/deed. en ) M. S. Saravi and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
311 When the hip is flexed as close to 90° as possible and the knee is flexed at 90°, ask the patient to rotate his hip inter-nally and externally. Check the passive movement too, but be gentle as these movements are painful in most hip pathologies. Now check the Thomas test to verify the presence of any flexion contracture. Thomas Test: Ask the patient to bend the other healthy hip fully and hold it in that position with both hands (Fig. 10. 36). That will eliminate any lumbar lordosis that can obscure hip flexion contractures. Check absence of lumbar lordosis with your hand. Now measure the flexion of the diseased hip. If there is no flexion contracture, you need to check the hip extension in the lateral decubitus position. Finally, ask the patient to lie on his stomach and check and compare internal and external rotation in hip extension. Neurovascular Assessment: Motor: Hip flexion L2, knee extension L3-L4, ankle dor-siflexion L4-L5, great toe dorsiflexion L5, and ankle plan-tar flexion S1. Sensory: Check sensation on the medial side of the knee L3, medial malleoli L4, dorsum of the third toe L5, and lateral heel S1. Reflexes: Achilles and patellar tendon reflexes, Babinski, and clonus Pulse: Dorsalis pedis and posterior tibial (usually not done) Straight Leg Raising: Already described in the back examination Ask the Patient to Lie on His Side: If the Thomas test was negative (no flexion contracture detected), you want to check the hip extension in this posi-tion (Fig. 10. 37). Ask Patient to Lie Prone: Check for internal and external rotation in hip extension and compare it with the other side (Fig. 10. 38). Apparent method True method Fig. 10. 35 Methods for checking leg length discrepancy Fig. 10. 36 Thomas test. Red arrow shows flexion contracture 10 The Musculoskeletal System | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
312 Patient Prone: Femoral stretch L2 and L4, hip and knee in extension. Motor exam S1 -gluteus maximus, backward lift leg against resistance (Fig. 10. 39). Thank the patient and tell the patient that they can now cover up. Wrap-Up: Describe the diagnosis. Question: What further tests will you order? Answer: X-ray of the hip joint or possibly MRI. Question: What will be your management plan? Answer: Pain medication -NSAIDs, physiotherapy, referral for surgery Further information, Websites/brochures/support groups or societies Follow-up Checklist: Hip Physical Examination See Table 10. 10 for a checklist that can be used as a quick review before the exam. History and Physical Examination: Knee Candidate Information: A 21-year-old female comes in with right knee pain. Vital Signs: HR 78/min, regular; BP, 120/65 mm Hg; temp, 36; RR, 14/min; O2 saturation, 98% Please take a brief history and perform a focused knee examination. Give your differentials. Please do not perform rectal, genitourinary, or breast examination. Knee Pain Overview: We can classify knee pain cases into two broad groups based on the presence or absence of sport injuries. Main Diagnosis: Osteoarthritis (OA) is a common musculoskeletal disor-der in general medical practice. The knee joint is the most Fig. 10. 37 If Thomas test is negative, check hip extension while patient lies on side Fig. 10. 38 Check internal and external rotation in hip extension while patient lies prone Fig. 10. 39 Backward lift leg against resistance while patient lies prone M. S. Saravi and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
313 common joint involved with osteoarthritis, and it is often chosen as the primary diagnosis for knee pain in older patients. In patients younger than 30 years of age, patel-lofemoral pain syndrome will be the top differential diagnosis. For patients with a sports injury, consider meniscal or anterior cruciate ligament (ACL) tears as your main diagno-ses and put osteoarthritis and patellofemoral pathologies in your list of secondary differentials. These patients may seek medical advice just after the injury, which makes the diag-nostic process more straightforward. They may also come in later with residual symptoms. Sometimes the history of a sport injury is not related to current complaints, and we need to look at other differentials as discussed before. Secondary Differentials: Knee arthritis Patellofemoral pain syndrome Tendinitis (quadriceps tendon or patellar tendon) Bursitis (prepatellar, subpatellar, pes anserinus) Bone tumors (primary or secondary) History Clues for Knee Pain: History of Trauma: It is important to ask about trauma early in the process of history taking, as the response will deter-mine your differentials. “Have you ever fractured any bones around your knee? What kind of fracture? What kind of treatment did you have for that?” A history of an old fracture is compatible with develop-ment of osteoarthritis. “Are you participating in any kind of sports? Have you ever had any sports-related knee injuries?” If so: “What happened? Were you able to continue play-ing after it occurred? Did you notice any knee swelling after that? How long after that injury did your knee start swelling?” A history of sports injury raises suspicion for meniscal and ligamentous injuries, especially a rupture of the ante-rior cruciate ligaments. Age: This is the most important piece of information for our thought process. It will usually be given in the question stem so you can build a structure in your mind before enter-ing the room: An old patient with knee pain: knee osteoarthritis A young patient with knee pain: chondromalacia patella Onset: “How did your pain start?” Duration: “How long have you had this knee pain?” A sudden onset is not precluding OA as the cause of the pain. OA is a chronic condition that might force the patient to seek medical advice after an acute pain episode caused by sudden synovitis or simply due to more physical activity than usual. However, the course of the disease is fluctuating pain epi-sodes with or without underlying daily pain. The same can Table 10. 10 Checklist for hip physical examination Starting the station Knock on the door Enter the station Hand-wash/alcohol rub Greet the examiner and the patient Give stickers to the examiner if required or show your ID badge Now sit on the chair or stand on the right side of the patient and start the interview Opening Introduction Greet, explain, position, and expose/drape Ask for vital signs -interpret General physical examination (may skip these questions if it is a history and physical station)Check for alertness and orientation Look for any abnormal findings in: Hands Face (eyes, nose, lips, and mouth) Neck Inspection General: joint posture, dressings or casts, any abnormal movement Posture: standing Gait and Trendelenburg sign Look for SEADS Joint palpation Posture: supine. Explain to the patient what to expect from the examination Palpate for hip, pelvis, anterior superior iliac spine, posterior superior iliac spine, iliac crest, and greater trochanter of the femur Check for leg length discrepancy Active range of movement (ROM)Flexion, extension, abduction, adduction, external and internal rotation Passive ROM Flexion, extension, abduction, adduction, external and internal rotation Power Check power while the patient performs the above movements Neurovascular assessment Reflexes: Achilles and patellar tendon reflexes, Babinski, and clonus Special tests Thomas test Straight leg raising test Wrap-up Mention that you would examine the lumbar spine and the knee jot and would also compare to the other side Thank the patient and tell them that they can now cover up Wrap up your findings and ask if the patient has any concerns 10 The Musculoskeletal System | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
314 be said about chondromalacia patella: chronic disorders with acute presentation. In dealing with a hyper-acute knee with severe pain, you need to rule out septic arthritis and gout. Bone tumors have more indolent course unless complicated with a pathologic fracture. Location: “Can you show me where you feel the pain?” OA pain can be centered behind the patella or medial or lateral joint line depending on the involved compartment. The pain related to a Baker's cyst is felt on the posterior or posteromedial side of the knee. Anterior knee pain due to patellofemoral pain syndrome is behind the knee cap. Quadriceps tendinitis causes pain at the superior margin of the patella, while localized pain at the inferior margin of the patella or superior aspect of the tibial tubercle is due to patellar tendinitis. Severity of Pain: “How would you rate your pain on scale of 1-10?” A very severe constant pain of the knee should raise suspicion for septic arthritis and gout. The other causes can be scored variably from mild to severe, based on the time and the pain tolerance of the patient. Quality of Pain: “How would you describe the pain?” The quality of the pain is not very helpful for decision; how-ever, very sharp pain might be due to a pathologic fracture. Referred Pain: “Does the pain shoot anywhere else?” Knee pain itself might be a referral pain coming from the hip, but knee pain does not radiate anywhere. Timings: “What time of the day is your pain the worst?” Morning pain brings rheumatologic disorder up on our list of differentials. OA pain is activity related, so it will be worse in the evening or afternoon. Night pain is notoriously associ-ated with a bone tumor or bone infection. Aggravating Factors: “What makes your pain worse and what makes it better?” Activities (which may provoke the pain) like walking, especially on a slope, and climbing up and down the stairs. The anterior knee pain of patellofemoral pain syndrome a gets worse with prolonged sitting (movie sign). The pain of septic arthritis is so intense even at rest that the patient will refuse to bear weight or even range his or her knee. Associated Symptoms: These associated symptoms are extremely important for diagnosing meniscal or ACL inju-ries and should be checked in all cases, especially those with a previous sports injury: 1. Giving way or sudden buckling “Have you ever noticed your knee suddenly buckling? How often does this happen? What were you doing at that time?” Giving way is not a specific symptom and can be seen in every condition associated with quadriceps weakness. Recurrent giving way is usually associated with meniscal injuries when the patient has a sudden change in direction during walking and with patello-femoral pain syndrome when going down stairs. 2. Locking “Have you ever had an episode of locked knee -a con-dition that you couldn't make your knee straight from a bent position?” Locking is an uncommon but characteristic sign of a bucket handle tear of the menisci. Temporary locking episodes happen also in those knees with loose bodies. 3. Giving out or instability “Have you ever felt that your knee goes out of its place?” A significant complaint of instability is most commonly expressed by patients suffering from an ACL tear. 4. Swelling “Have you noticed any swelling in your knee? When?” It is crucially important to ask about the timing of swelling if there is a history of sports injury. A new effusion that develops in the first 2 h after trauma is hemarthrosis, and a hemarthrosis after a sports injury is caused by ACL injury in 70% of cases. Other causes of hemarthrosis, such as intra-articular fractures, usu-ally have more acute presentations that make them unsuitable for the OSCE exam. If effusion develops overnight after a knee injury, it is reactive effusion by the synovium, which usually her-alds the presence of a meniscal injury. Complete the rest of the history as described in the mus-culoskeletal history taking. Knee Examination: “I am going to examine your right knee now. ” Mention here: “I will be examining the right side only (if right side is the troubling side) assuming that the left side is normal. Should we start?” Vitals: Start with commenting on the vitals given at the door. (It should include pulse rate, blood pressure, respiratory rate, temperature and O2 saturation. ) “Miss... vital signs are normal” or mention if there are any abnormal findings. Inspection: General: Joint posture, any dressings or casts, and any abnormal movement. Position: Standing, then lying down on the bed. Expose both knees from mid-thigh to toes. Properly drape the rest of the body. Ask the patient to walk a few steps and then walk back. Look for any limping. Inspect the joint from the anterior, lateral, and posterior angles. Compare to the other side, and then verbalize if you M. S. Saravi and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
315 do not see any swelling, erythema, atrophy, and skin changes/ rash/scar marks. Check the general lower extremities alignment: genu varum, genu valgum, and genu recurvatum. Check for varicose veins. Comment on the presence or absence of quadriceps atrophy when the patient lies down on the bed. Do this by pointing out and comparing the prominence of vastus medialis muscles on both knees superomedial to the superior border of the patella. Joint Palpation: Inform the patient again, “I am going to feel your knee, if you feel pain, please let me know. ” Position: Lying down. Feel for: Tenderness, effusion, swelling, temperature, and crepitus. Palpate the patella, tibial tuberosity, tibial and femoral condyles, quadriceps, patella tendon, medial/lateral liga-ment, meniscus, and bursa (pre patellar bursa, anserine bursa, and semimembranosus bursa). Feel for swelling in the popli-teal area (Baker's cyst). Search for Point Tenderness: Superior pole of the patella: Quadriceps tendinitis Inferior pole of patella and tibial tubercle: Patellar tendinitis Medial and lateral joint lines: Meniscal injuries or col-lateral ligaments injuries Superior-medial aspect of tibia and posterior-medial to the tibial tubercle: Pes anserinus tendinitis Examine the Knee in Search of Effusion: Bulge Sign: Immobilize the patella with the thumb and index finger. Use the free hand to milk the medial aspect of knee (upward strokes). If a downward stroke is used on the lateral aspect of the knee, fluid will be displaced and may be visible as a medial bulge known as the bulge sign. Patellar Ballottement Test: It is complementary to the bulge sign. Just after milking the suprapatellar pouch and commenting on the presence or absence of a bulge around the patella, push the patella down and comment on the presence or absence of ballottement. Range of Motion: Active Range of Movements: Flexion -150 Extension -0 Check active movements in flexion and extension when the patient lies down on the table. If there is any limitation of active movement, check the passive movement too; otherwise you may skip these. It is very important to compare both sides. Any limitation of extension must be commented on as it may be due to locking caused by displaced bucket handle meniscal tears or a massive knee effusion. Patients with severe osteoar-thritis may also have some variable limitation in exten-sion or flexion. Passive Range of Movements: Check if the active motion is restricted. Test Power: While the patient is performing the ROM movements, check for power. Neurovascular Assessment: Sensory: Check the sensation of the skin over the thigh and leg. Reflexes: Knee and ankle jerk. Pulses: Dorsalis pedis and posterior tibial. Special Tests: Anterior Drawer Test: The patient should lie supine. Flex the hip to 45° and then flex the knees 90° with the feet flat on the table (Fig. 10. 40). You can position your-self by sitting on the examination bed in front of the knee you are examining. Grasp the tibia just below the joint line of the knee. Place your fingers in the patient's popli-teal fossa and your thumbs along the joint line on either side of the patellar tendon. Then pull the tibia forward. A positive palpable step formed with anterior force indi-cates a positive anterior draw test. It is indicative of either a sprain of the anteromedial bundle or complete tear of the ACL. Posterior Sag Sign: This test is performed in the same position used for the anterior drawer test. Before perform-ing that test, check the position of the anterior border of the medial tibial plateau relative to the medial femoral condyle; it should be anterior. If these two structures lie at the same level or the latter is more anterior, that means there is posterior sagging of the tibia due to a torn poste-rior cruciate ligament (PCL). Posterior Drawer Test: This test is done in a same way as the anterior drawer test, but now you apply a backward force on the tibia (Fig. 10. 41). A displacement of the tibia posteriorly is a positive posterior drawer test. It is indica-tive of a tear in the posterior cruciate ligament. Lachman Test: Ask the patient to lie supine on the bed. Place the patient's knee in about 20-30° of flexion. Place one hand behind the tibia and the other on the patient's thigh. Place your thumb on the tibial tuberosity. Pull the tibia anteriorly. An intact ACL should prevent forward translational movement of the tibia on the femur. Anterior 10 The Musculoskeletal System | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
316 translation of the tibia associated with a soft or a mushy end-feel indicates a positive test. Collateral Ligament Stress Test: The patient is supine. The test is performed in two positions, knee extended and then flexed to 30° (Fig. 10. 42a, b). You should palpate the medial joint line and then apply a valgus force to the patient's knee. A positive test occurs when pain or excessive gaping occurs. Next, a varus force is applied with the knee in a neutral (0° of flexion) position. A positive test occurs when pain or gaping is produced. There should be no gaping at 0°. This same test is repeated with valgus force while observing the lateral joint line for excessive gaping or opening that will indicate lateral collateral ligament injury. Mc Murray Test: The patient should be in a supine position. The knee to be tested is fully flexed. You should hold the sole of the foot with one hand and palpate the medial or lateral aspect of the knee with your other hand. This test is used to determine damage to either the lateral or medial meniscus. Then you palpate the side of the joint being tested. First, check the medial meniscus by palpating the pos-teromedial aspect of the knee while simultaneously extending the knee and externally rotating the tibia (Fig. 10. 43a). A valgus stress is also applied. The second step is to check the lateral meniscus (Fig. 10. 43b). Palpate the posterolateral joint line and extend the knee while internally rotating the tibia. A varus stress is also applied. If pain is felt by the patient or a click is felt by you or the patient, the test is considered to be positive. Apley Grinding Test: Ask the patient to lie on her stom-ach (prone position). Flex the knee at 90° (Fig. 10. 44). The patient's thigh is then held fixed to the examining table with the examiner's knee. Rotate the tibia medially and laterally, first with dis-traction and then with applied compression. Note any restriction, excessive movement, or discomfort. The lesion will be ligamentous if there is more pain on rota-tion with distraction. It will be a meniscus injury if the rotation with compression is more painful. Wrap-Up: Comment that you will also do the examination of the hip and ankle and would also like to compare with the other side. Thank the patient and tell the patient that they can now cover up. Wrap up your findings with the examiner or the patient. Checklist: Knee Examination See Table 10. 11 for a checklist that can be used as a quick review before the exam. History and Physical Examination: Ankle Candidate Information A 27-year-old male comes in with pain in the right ankle for the past 8 weeks. Vital Signs: HR, 71/min, regular; BP, 120/65 mm Hg; temp, 36. 8; RR, 14/min; O2 saturation, 98% Please take a brief history, perform a focused ankle exam-ination, and address patient concerns at the end. Please do not perform a rectal, genitourinary, or breast examination. Differential Diagnosis Ankle Pain Ankle cases are mostly presented in pure physical exam sta-tions; however, a general knowledge of basic differential diagnoses of ankle pain is a necessity for arranging a focused physical exam. Fig. 10. 40 Anterior drawer test Fig. 10. 41 Posterior drawer test M. S. Saravi and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
317 Acute Post-traumatic Ankle Pain: The main diagnosis is an ankle sprain, which usually involves some comments of lateral collateral ligaments. It presents with sudden swelling and pain on the lateral side of ankle after an inversion injury of ankle. The differential diagnoses: 1. Achilles' tendon rupture-Clue: sudden onset of pain and swelling mainly at the back of the ankle after hearing a pop during sports. Upon physical examination, a palpable ab Fig. 10. 42 Collateral ligament stress test: (a) lateral stress, (b) medial stress ab Fig. 10. 43 Mc Murray test. (a) Check the medial meniscus. (b) Check the lateral meniscus 10 The Musculoskeletal System | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
318 defect near the Achilles insertion, ecchymosis, and a posi-tive Thompson squeeze test can be found (Fig. 10. 45a-c). A rapid test for an Achilles rupture is to ask the patient to stand on his toes. It will be impossible for them. 2. Malleolar fractures-The presence of any bony tender-ness over the malleoli is indicative of a fracture making taking X-rays a mandatory next step. 3. Jones fracture-Tenderness over the base of fifth meta-tarsal is the clue for asking for foot X-rays. 4. Fracture of the anterior process of the calcaneus- Point tenderness about 1 cm distal and 1 cm anterior to the tip of the lateral malleoli. 5. Osteochondral fracture of the talus-Hard to diag-nose with a physical exam. It should be considered especially in cases of continued pain after an ankle sprain. 6. Rupture of the extensor digitorum brevis muscle- Significant local swelling anterior to the tip of lateral mal-leoli with a negative stress test in a patient that can bear weight after an inversion injury 7. Arthritis-Widespread swelling around the ankle with-out history of trauma can be due to various types of arthri-tis, especially gout. 8. Perineal tendon dislocation-Similar to the usual ankle sprain but with a tenderness that is mainly posterior to the lateral malleoli and followed by recurrent popping of the dislocated tendon. Chronic Ankle and Heel Pain: 1. Peroneal tendinitis -Findings: swelling and tenderness over the peroneal tendons especially posterior to the lat-eral malleoli. 2. Tibialis posterior tendinitis -Findings: swelling and tenderness over the course of the tibialis posterior tendon posterior and inferior to medial malleoli, with or without unilateral flat foot. Fig. 10. 44 Apley grinding test. (Reprinted with permission from Mc Hale et al. [9])Table 10. 11 Checklist for knee examination Starting the station Knock on the door Enter the station Hand-wash/alcohol rub Greet the examiner and the patient Give stickers to the examiner if required or show your ID badge Now sit on the chair or stand on the right side of the patient and start the interview Opening Introduction Greet, explain, position, and expose/drape Ask for vital signs -interpret General physical examination (may skip these questions if it is a history and physical station)Check for alertness and orientation Look for any abnormal findings in: Hands Face (eyes, nose, lips, and mouth) Neck Inspection Position and observe the anterior, posterior and lateral aspects of the knee and compare to the other side Look for SEADS Joint palpation Tell the patient what to expect from the examination Note and feel for: patella, tibial tuberosity, tibial condyles, femoral condyles, patella tendon Feel for effusions (bulge sign) Active range of movement (ROM)Check for flexion and extension Passive ROM Check for passive movements in flexion and extension Power Check for power in the above movements Neurovascular assessments Special tests Anterior and posterior drawer tests Lachman test Collateral ligament stress test Mc Murray's test Apley grinding test Wrap-up Mention that you would also examine the hip and ankle joints and would also like to compare with the other side Thank the patient and tell them that they can now cover up Wrap up your findings and ask if the patient has any concerns M. S. Saravi and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
319 3. Achilles tendinitis -Findings: tenderness over the Achilles tendon just superior to its insertion. 4. Plantar fasciitis -Clues: gradual onset of heel pain which is worse with the first steps after rest and improves gradually with walking is the pathognomonic feature of plantar fasciitis. Findings: the only positive finding in a physical exam is point tenderness on the center of heel. First take a focused history as mentioned in the start of this chapter. Then continue with the ankle examination. Ankle Examination Vitals: Start by commenting on the vitals given at the door. (It should include pulse rate, blood pressure, respiratory rate, temperature, and O2 saturation. )“Mr... vital signs are normal” or mention if there are any abnormal findings. Inspection: Exposure: knees to toes. Drape the rest of the body. Patient posture: ask the patient to walk a few steps and to walk back. Is the patient able to bear weight or not? Then ask the patient to stand while bearing weight and then in sitting for examining sole of the foot and back of the ankle. Compare to the other side, and then ver-balize if you do not see any swelling, erythema, atro-phy, deformity, ecchymosis, and skin changes/rash/ scar marks. Check the longitudinal arch for heel valgus or varus. Now ask the patient to stand on his toes. If he can, the Achilles tendon is intact. ab c Fig. 10. 45 (a) Finger points to a palpable gap consistent with a tear in the Achilles tendon in the right foot. Thompson squeeze test: (b) An intact Achilles tendon leads to plantarflexion of the unaffected left foot on calf squeeze. (c) However, there is no plantar flexion on calf squeeze of the right foot due to a ruptured Achilles tendon. (Photos reprinted with permission from Mahmood and Maffulli [10]) 10 The Musculoskeletal System | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
320 Palpation: Inform the patient again, “I am going to feel your feet, if you feel pain, please let me know. ” Feel for: tenderness, effusion, swelling, temperature, crepitus, and atrophy. Palpate: These spots must be touched one by one for ten-derness: medial malleolus, lateral malleolus, base of the fifth metatarsal bone, navicular bone, anterior process of the calcaneus, Achilles tendon (for defect or tenderness), deltoid ligament, anterior talofibular ligament, calcaneo-fibular ligament, metatarsals, and MTP joints and toes. Evaluate for the Ottawa ankle rule if the case history suggests trauma: Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus Inability to bear weight both immediately and in the emergency department for four steps Evaluate for the Ottawa foot rule if the case history sug-gests trauma: Bone tenderness at the base of the fifth metatarsal Bone tenderness at the navicular bone Inability to bear weight both immediately and in the emergency department for four steps Motion: Active Range of Movements: in dorsiflexion, plantarflexion, inversion, eversion and flexion and extension of the big toe. Passive ROM: in dorsiflexion, plantarflexion, inversion, eversion, flexion and extension of the big toe. Power as in active range of movements. Neurovascular Assessment: Sensory Examination of the Foot: Upper part of the upper leg -L2 Lower-medial part of the upper leg -L3 Medial lower leg -L4 Lateral lower leg -L5 Sole of the foot -S1 Special Tests: Anterior Draw Test: The test is performed in either a supine or sitting position. Stabilize the anterior side of dis-tal leg with one hand and then grasp the patient's heel and rear foot with the other hand. Place the patient's foot into 10-15° of plantar flexion and push the rear foot anteriorly (Fig. 10. 46). The test will be positive if the talus translates forward. The positive tests are often graded on a scale of 0-3, with 0 indicating no laxity and 3 indicating gross lax-ity. This test primarily assesses the strength of the anterior talofibular ligament and the anteromedial capsule. Inversion Stress Test (Lateral Stress): The knee is flexed at 90°. The heel is held from below by one hand, while the other hand holds the lower leg. The hand on the heel is placed somewhat inferior and lateral and is used to push the calcaneus and talus into inversion. Meanwhile, the other hand grips the lower leg medially and pushes later-ally (Fig. 10. 47). Note an end point. It will test the calca-neofibular ligament and the anterior talofibular ligament. Eversion Stress (Medial Stress): Knee is flexed at 90°. The heel is held from below by one hand, while the other hand holds the lower leg. The hand on the heel is placed somewhat inferior and medial and is used to push the cal-caneus and talus into eversion, while the other hand grips the lower leg laterally and pushes medially (Fig. 10. 48). It is performed to test the deltoid ligament. Squeeze Test: This test is performed by squeezing the bones together firmly and slowly just above the anterior tibiofibular ligament, then holding, and quickly releasing (Fig. 10. 49). If there is pain upon release at the area of the anterior tibiofibular ligament, then a sprain of that liga-ment is highly suspected. External Rotation (Kleiger Test): The foot is held in a neutral position with the lower leg stabilized. Then the foot is externally rotated. If this produces pain, it will indicate a tear of the anterior tibiofibular ligament. Depending on the severity, the interosseous membrane may be involved. Pain will be at the site of the anterior tibiofibular ligament. Wrap-Up: Thank the patient and tell them that they can now cover up. Wrap up your findings and ask the patient if they have any concerns. Quick Assessment: Ankle Sprain A 20-year-old male sprained his right ankle. Please assess and manage. Differential Diagnoses The differential diagnoses ankle traumatic injury: 1. Achilles tendon rupture 2. Malleolar fractures 3. Jones fracture 4. Fracture of the anterior process of the calcaneus 5. Osteochondral fracture of the talus 6. Rupture of the extensor digitorum brevis muscle 7. Perineal tendon dislocation M. S. Saravi and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
321 Fig. 10. 47 Inversion stress test Fig. 10. 48 Eversion stress test Fig. 10. 46 Anterior draw test Fig. 10. 49 Squeeze test Show empathy and offer pain medicine before proceed-ing. Please complete the history as mentioned in the history details of this chapter. Focus on mechanism and duration of injury. Ask about the position of ankle and foot at the time of the trauma. Ankle Assessment Vitals: Start by commenting on the vitals given at the door. (It should include pulse rate, blood pressure, respiratory rate, temperature, and O2 saturation. ) “Mr... vital signs are normal” or mention if there are any abnormal findings. Inspection: Exposure: Knees to toes. Drape the rest of the body. Patient posture: Is the patient able to bear weight or not? Then standing while bearing weight and while sit-ting, examine the sole of the foot and the back of the ankle. Compare to the other side, and then verbalize if you do not see any swelling, erythema, atrophy, defor-mity, ecchymosis, and skin changes/rash/scar marks (SEADS). Palpation (Very Important): Inform the patient again, “I am going to feel your feet; if you feel pain, please let me know. ” Feel for tenderness, effusion, swelling, temperature, crepitus, fluctuance, and atrophy. Palpate: These spots must be touched one by one for ten-derness: medial malleolus, lateral malleolus, base of the fifth metatarsal bone, navicular bone, anterior process of the calcaneus, Achilles tendon (for defect or tenderness), deltoid ligament, anterior talofibular ligament, calcaneo-fibular ligament, metatarsals, and MTP joints and toes. Evaluate for the Ottawa ankle rule if the case history suggests trauma: Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus 10 The Musculoskeletal System | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
322 Inability to bear weight both immediately and in the emergency department for four steps Evaluate for the Ottawa foot rule if the case history sug-gests trauma: Bone tenderness at the base of the fifth metatarsal Bone tenderness at the navicular bone Inability to bear weight both immediately and in the emergency department for four steps Motion Make sure that the patient is not in acute pain. If the patient does not allow certain movements, skip it and move on. Mention to the examiner. Active Range of Movements In dorsiflexion, plan-tarflexion, inversion, eversion, flexion, and extension of the big toe. Passive ROM In dorsiflexion, plantarflexion, inversion, eversion, flexion, and extension of the big toe. Power As in active range of movements. Neurovascular Assessment: Sensory Examination of the Foot: Upper part of the upper leg -L2 Lower-medial part of the upper leg -L3 Medial lower leg -L4 Lateral lower leg -L5 Sole of the foot -S1 Special Tests: Anterior draw test Inversion stress test Eversion stress (medial stress) Squeeze test External rotation (Kleiger test) Wrap-Up: Thank the patient and tell them that they can now cover up. Wrap up your findings and ask the patient if they have any concerns. Question: What you will do next? Answer: X-ray: PA view, lateral and mortise Severity of Ankle Sprain: First degree: stretching of ligament fibers Second degree: partial tear with pain and swelling Third degree: complete ligament separation Control the Swelling First Tell the patient, “Use an elastic bandage to attach an ice pack or immerse the foot in ice water for 15-20 min at a time. You can do this every 3-4 h as needed up to 72 h. When you're awake, elevation of the foot may help. ” Offer analgesics. First-and Second-Degree Ankle Sprain: Repeat ice pack -after 72 h and then change to hot soak. Elastic bandage for 1-2 weeks in a neutral/slight everted position. Partial weight-bearing using a crutch until no pain is present. Non-weight-bearing exercise started after 2-3 days including plantar flexion, dorsal flexion, toe flexion, inversion, and eversion. After pain and swelling subside, can bear weight with a sprain brace. Third-Degree Ankle Sprain: Surgical repair. Cast immobilization for 4-8 weeks. Refer to orthopedics. References 1. Mc Rae R. Ch 1. General principals in the examination of a patient with an orthopaedic problem. In: Clinical orthopaedic examination, 4th ed. UK: Churchill Livingstone. 1998. p. 7. 2. Keegan JJ, Garrett FD. The segmental distribution of the cutaneous nerves in the limbs of man. Anat Rec. 1948;102:409. 3. Ch 9. The musculoskeletal exam. In: Hall J, Piggott K, V ojvodic M, Zaslavsky K (eds). Essentials of clinical examination handbook, 6th ed. New York, USA: Thieme. 2010. p 159-161. 4. Hurley KF. Ch 6. Musculoskeletal system, cervical spine: exami-nation. In: OSCE and Clinical skills handbook, 2nd ed. Toronto: Elsevier Canada. 2011. p. 185-188 5. Della-Giustina D. Acute low back pain: recognizing the “red flags” in the workup. Consultant. 2013;53(6):436-40. 6. Houghton KM. Review for the generalist: evaluation of low back pain in children and adolescents. Pediatr Rheumatol. 2010;8:28. 7. Steinfeld R, Valente RN, Stuart MJ. A commonsense approach to shoulder problems. Mayo Clin Proc. 1999;74(8):785-94. 8. Malagelada F, Dalmau-Pastor M, Vega J, Golano P. Elbow anatomy. In: Doral MN, Karlsson J, editors. Sports injuries: prevention, diag-nosis, treatment and rehabilitation, vol. 2E. Berlin: Springer; 2015. p. 527-53. 9. Mc Hale KJ, Park MJ, Tjoumakaris FP. Ch 2. Physical examina-tion for meniscus tears. In: Kelly JDIV, editor. Meniscal injuries: management and surgical techniques. New York: Springer Science + Business Media; 2014. 10. Mahmood A, Maffulli N. Ch 6. Acute repairs of the Achilles tendon by the percutaneous technique. In: Nunley JA, editor. The Achilles tendon. New York: Springer Science + Business Media; 2008. p. 55-65. M. S. Saravi and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
323 © Springer Nature Switzerland AG 2019 M. H. Sherazi, E. Dixon (eds. ), The Objective Structured Clinical Examination Review, https://doi. org/10. 1007/978-3-319-95444-8_11Obstetrics and Gynecology Mubashar Hussain Sherazi and Uzma Bukhari Common Gynecology and Obstetric Symptoms for the Objective Structured Clinical Examination Bleeding between periods Bleeding lasting longer than 7 days Passing blood clots Bleeding after intercourse Painful, excessively heavy, or abnormal bleeding Spotting or bleeding between periods or after menopause Pain or pressure in the pelvis that differs from menstrual cramps Pelvic discomfort or pressure Abdominal tenderness or cramps Backache or pain Painful intercourse Feeling heaviness or pressure in the pelvis or constant abdominal pressure Infertility Swelling or bloating Feeling of pressure on the bladder or rectum Slipping or dropping of the vagina or uterus Frequent and urgent need to urinate or a burning sensation during urination Itching, burning, swelling, redness, or soreness in the vaginal area Sores or lumps in the genital area Vaginal discharge with an unpleasant or unusual odor or of an unusual color Increased vaginal discharge History Overview: Obstetrics and Gynecology In the objective structured clinical examinations (OSCE), one can expect one station from gynecology and one from obstetrics. This is usually a history-taking station with coun-seling or discussing a management plan with the patient. You would not be asked to perform a pelvic, breast, rectal, or vaginal examination. This chapter outlines a few common gynecology-and obstetric-related topics important for OSCEs. An overview of the history taking is given in Table 11. 1. Detailed History: Obstetrics and Gynecology Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your identification (ID). Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Miss/Mrs... ? Are you ... years old?” Chief Complaint: Chief complaint or the reason the patient is visiting the clinic. “What brings you in today?” or “Tell me about your symptoms. ” Listen to the patient, let her describe the chief complaint, and tailor your list of questions in your mind. In obstetrics and gynecology cases, the patient's privacy is M. H. Sherazi ( *) Mallacoota Medical Centre, Mallacoota, VIC, Australia U. Bukhari General Practitioner, Sahiwal, Pakistan11 | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
324 very important. Establish confidence and rapport. Offer a chaperon. History of Present Illness: Ask these questions for each symptom: Onset: “When did the symptom start? Was the onset acute or gradual?” Course: “Is the symptom worsening, improving, or con-tinuing to fluctuate?” Duration: “How long has it been going on?” Severity: “How severe are the symptoms?” For example, if there is pain, then how severe on a scale of 1-10? Intermittent or continuous? “Are the symptoms present all the time or do they come and go?” Precipitating factors: “Are there any obvious triggers for the symptom?” Relieving factors: “Does anything appear to improve the symptoms?” Associated features: “Are there other symptoms that appear associated; e. g., fever/malaise?” Previous episode: “Have you experienced these symp-toms before?” Systemic review: Just ask a few questions from each system. This can pick up any symptoms that the patient may have not mentioned before in the presenting complaint. -Gastrointestinal (GI): Nausea, vomiting, appetite, dys-phagia, weight loss, abdominal pain, and bowel routine -Cardiovascular system: Chest pain, palpitations, dys-pnea, syncope, orthopnea, and peripheral edema -Respiratory system: Cough, wheeze, sputum, hemop-tysis, and chest pain -Central nervous system (CNS): Problems with vision, headache, motor or sensory loss, loss of conscious-ness, and confusion -Musculoskeletal: Bone point, joint pain, and muscular pain Table 11. 1 Quick review of history taking for obstetrics and gynecology Introduction Name and age Chief complaint In patient's own words History of present illness Analysis of chief complaint Onset, course, duration Contributing factors Aggravating factors Alleviating factors Related symptoms (see common symptoms in detailed history) Associated symptoms Predisposing factors Aggravating and relieving factors Red flags/risk factors Rule out differential diagnosis Review of systems Respiratory Cardiovascular Gastrointestinal Neurology Musculoskeletal Constitutional symptoms Anorexia, chills, night sweats, fever, and weight loss Past medical history and surgical history Medical illnesses Any previous or recent medical issues History of previous surgery/operation, especially relevant to the area of concern Any related anesthetic/surgical complication Hospitalization history or emergency admission history Medications history Current medications (prescribed, over the counter, and any herbal) Vaccination (Gardasil) Allergic history/triggers Any known allergies Family history Family history of any long-term or specific medical illness Home situation Occupation history What do you do for a living? Social history Smoking Alcohol Street drugs Sexual history If adult female: Menstrual history (LMP) Gynecology history Obstetric history If teen female: Home Education Employment Table 11. 1 (continued) Activities Drugs Sexual activity Wrap-up Describe the diagnosis Management plan Possible medical treatment Duration of treatment and side effects Red flags Laboratory tests Further information websites/brochures/support groups or societies/toll-free numbers Follow-up M. H. Sherazi and U. Bukhari | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
325 -Dermatology: Rashes, ulcers, or lesions -Kidney disease: Systemic symptoms of acute kidney injury or chronic kidney disease such as anorexia, vomiting, fatigue, pruritus, and peripheral edema Constitutional symptoms: Fatigue, malaise, night sweats, fever, and weight loss History of the Current Pregnancy: Is this the first pregnancy? How was the pregnancy confirmed? -Home testing kit, human chorionic gonadotropin (h CG) blood test, or ultrasonography (USG) scan. Dating scan or anomaly scan. Growth of the fetus. Placental location. Last menstrual period (LMP): First day of the LMP. Was the patient using contraception? Oral pill, implant, or coil? Estimated date of delivery (EDD): If known, estimated by scan or via dates. -Calculating the due date (three steps) [1]: Step 1 -determine the first day of the patient's last menstrual period. Step 2 -count back three calendar months from that date. Step 3 -add 1 year and 7 days to that date. This will be the EDD. Symptoms to Ask a Pregnant Patient: Nausea and vomiting Abdominal pain Vaginal bleeding Dysuria or urinary frequency Fatigue Preeclampsia: Headache, visual changes, or swelling Fetal movements: Usually experienced at around 18-20 weeks gestation Labor pains: More relevant in the third trimester Planned method of delivery: Vaginal or cesarean delivery Medical illness during pregnancy: If any hypertension, gestational diabetes, and vaginal bleeding Previous Obstetric History: Details of Each Pregnancy: Date of delivery? Length of pregnancy? Single, twins, or more? Mode of delivery? Spontaneous labor or induced? Weight of babies? Current health of babies? Complications of previous pregnancies: -Ectopic pregnancy? -Any miscarriages or terminations? -How many unsuccessful pregnancies? -Intrauterine growth retardation (IUGR), hyperemesis gravidarum, hypertension, preeclampsia, eclampsia, gestational diabetes, HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count). -Labor: Failure to progress, shoulder dystocia, perineal tears. -Postnatal: Postpartum hemorrhage, retained products of conception. Gynecological History: Menstrual History: Age at menarche? If there is any concern about abnormal puberty, need to consider precocious puberty or delayed puberty. Ask about the onset of other secondary sexual characteristics and the onset of breast development. Ask about the pattern of the menstrual cycle: -When was the last normal menstrual period? -When was the first day of last normal menstrual period? -How many days of blood loss? -The duration or length of the cycle? -Whether blood loss was heavy? If yes, then ask about the number of tampons and/or pads. Ask further about passing clots? -What form of contraception is being used? -Any other vaginal discharge other than the menses? The normal menstrual cycle: -Each cycle usually ranges between 21 and 35 days, with an average of 28. -Most healthy and fertile women have regular cycles with 1 or 2 days of variation. -Blood loss is 50-200 mls with an average of 70 mls. Passage of large clots suggests excessive bleeding. Different abnormal patterns of bleeding: -Polymenorrhea: Unusually frequent periods. -Oligomenorrhea: Unusually infrequent or scanty periods. -Menorrhagia: Unusually heavy periods. -Menometrorrhagia: Prolonged, excessive, and irregu-lar uterine bleeding. -Intermenstrual bleeding: Bleeding between periods. -Breakthrough bleeding: Patient is on the pill. Diseases of the uterus and cervix: -Mucosal disorders. -Postcoital bleeding (usually local cervical or uterine disease). 11 Obstetrics and Gynecology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
326 Postmenopausal bleeding: bleeding occurring more than 12 months after amenorrhea of menopause. Dysfunctional uterine bleeding: Abnormal bleeding that cannot be ascribed to pelvic pathology. Regular pattern will suggest that ovulation is occurring. Irregular pattern suggests no ovulation or anovulatory cycles. Previous Gynecological Problems and Treatments: Sexually transmitted diseases (STDs) Pelvic inflammatory disease (PID) Vaginal discharge Ask about the vaginal discharge: -Color -Amount -Consistency -Odor -Presence of blood -Any itching, burning, or fever -Use of gels, douches, or perfumed bath additives -Any associated localized tenderness (Bartholinitis) Urethral discharge: -Color -Amount -Consistency -Odor -Presence of blood -Any itching or burning Amenorrhea Gynecological diseases: Polyps or cysts Previous cervical smear Current contraception: Oral contraceptive pill, Depot, implant or implanted uterine device Sexual History: Ask about sexual activity. Inform the patient that you need to ask few questions about her sexual history to make a diagnosis: The first question should be: “Are you sexually active?” If yes, then ask, “With whom do you live?” “How long have you been together?” Coital history: “How often do you have intercourse?” “Do you practice safe sex -using condoms?” “When did you start to be sexually active?” “How many partners have you had in the last years?” “What is your sexual preference?” “What type of sexual activity do you practice?” “Have you ever been diagnosed with PID?” “Any vaginal discharge?” “How about your partner? Does he have any symptoms?” “Have you ever been screened for human immunodefi-ciency virus (HIV)?” Genital Ulcers: Ask questions similar to those asked for sexually transmitted disease. Dyspareunia: Determine if this is superficial (vaginismus or coming from an episiotomy scar), or if it is deep, then it can be uterine, cervical, or possibly an adnexal origin. Ask if it is intermittent/recurrent or always present. Ask if it occurs on penetration/preventing penetration or full intercourse. Note whether there is radiation of the pain. Discuss positional factors. Any relationship to menses. Ask if libido and foreplay are sufficient. Note whether the patient is postmenopausal. Ask if there is dryness/atrophy. Ask if there is any rash. Establish the degree of distress. Assess for any mood disorder. Abnormal Vaginal Bleeding: Passing clots or flood of blood. Discuss relationship to menses -intermenstrual? Relationship to coitus -postcoital bleeding? Establish periodicity. Ask about possibility of pregnancy? Past Medical History: “Do you have any other health issues?” Gestational diabetes: Tight blood sugar control is essen-tial and risk of congenital defects. Risk of macrosomia with complications during labor. Thromboembolic disease: High risk for further events in following pregnancy. Epilepsy: Some antiepileptics are teratogenic -needs neurology input. Hypothyroidism: Thyroid function tests (TFTs) need close monitoring -risk of congenital hypothyroidism. Previous preeclampsia: Higher risk to develop it in the current pregnancy. Past Hospitalization: “Have you had any previous hospitalization?” Medication History: “Are you taking any medications prescribed, over the counter, or herbal? If so, have there been any side effects?” M. H. Sherazi and U. Bukhari | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
327 Pregnancy medications: Folic acid, iron, antiemetics, and antacids. Teratogenic drugs: Angiotensin-converting enzyme (ACE) inhibitors, sodium valproate, methotrexate, reti-noids, and trimethoprim. Vaccination (Gardasil). Document all regular medications. Surgical History: Previous abdominal and gynecological surgery of relevance Allergic History: “Do you have any known allergies?” Social History: “Do you smoke? Or does anyone else in your home or close proximity at work smoke?” “Do you drink alcohol?” If yes, then ask further ques-tions: “How much? Daily? How long?” “Have you ever tried any recreational drugs? If yes, which ones? How long? When?” Specifically ask about intrave-nous (IV) drug use. Family History: Marital status, number of children, any significant history in first-degree relatives Self-Care and Living Condition: “What do you do for a living?” “Working status and occupation?” “Educational status?” “Who lives with you?” Light duties or maternity leave Support: “Do you have good support from your family and friends?” Functional status or severity or impact on life activities. If a Teenager, Then Add Questions Regarding: Home, education, employment, activities, drugs, and sexual activity If the Patient Is More Than 65 Years Old, Add These Questions: “Any problem with balance?” “Any difficulty with peeing/urination?” “Any issues sleeping?” “Any change in vision/hearing?” “Any recent change in memory?” “Are you taking any regular medications? Do you have any prescribed medicine? Are you taking any over-the- counter medicine?”Wrap-Up: Describe the diagnosis. Laboratory tests. Management plan. Duration of treatment and side effects. Red flags. Further information websites/brochures/support groups or societies. Follow-up. Physical Examination: Female Genital Tract Examination It is highly unlikely to be asked to perform a female pel-vic examination. You must be familiar with the main steps and the how to verbalize these. The examiner may ask you to verbalize these steps or you may be asked to per-form an examination on a manikin. Details of female gen-ital tract physical examination are given in Chap. 8: Genitourinary. A checklist is provided in Table 11. 2 as a quick review. Table 11. 2 Checklist for female genital tract examination Starting the station Knock on the door Enter the station Hand-wash/alcohol rub Greet the examiner and the patient Give stickers to the examiner if required or show your ID badge Now sit on the chair or stand on the right side of the patient and start the interview Opening Introduction, greet, explain, position, and exposure/drape Introduce/offer chaperone General physical examination Ask for vital signs -interpret the vital signs Look for any abnormal findings in hands, face, neck, heart, chest, and abdomen Pelvic examination Positioning Inspection external genitalia: examine labia majora and labia minora, perineum, clitoris, and urethra Speculum examination: examine the vestibule, vagina, and cervix Palpation: internal examination of the uterus: uterus and adnexa Rectal examination Position: left lateral Look for pain, occult blood, masses, hemorrhoids, anal fissures, and sphincter tone Wrap-up Thank the patient Ask patient to dress Describe your findings to the examiner 11 Obstetrics and Gynecology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
328 History and Counseling: Primary Amenorrhea Candidate Information: You are seeing an 18-year-old woman with primary amenor-rhea. Her secondary sexual characteristics have been present for the past 3 years. She wants to start a relationship. Please take a focused history and make a diagnostic and manage-ment plan for her. Differential Diagnosis: Primary amenorrhea is an absence of menses at the age of 15 years in the presence of normal growth and secondary sexual characteristics. The evaluation of primary amenorrhea should begin at age 13 years if no menses have occurred and there is a complete absence of secondary sexual characteris-tics. Some girls with secondary sexual characteristics may present before age 15 years with amenorrhea and cyclic pel-vic pain. These girls should be evaluated for possible outflow tract obstruction. Primary amenorrhea is usually the result of a genetic or ana-tomical abnormality. It is important to consider that all causes of secondary amenorrhea can also present as primary amenorrhea. Secondary amenorrhea is considered to be present when a girl has previously had a menstrual cycle but stops having menstrual periods for three cycles in a row or for a time period of 6 months or more and is not pregnant. Major Causes of Primary and Secondary Amenorrhea See Tables 11. 3 and 11. 4 for causes of amenorrhea [2]. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Miss... ?” Presenting Complaint: “What brings you in today?” History of Presenting Illness: Ensure confidentiality. Offer to bring in a chaperone. Primary Versus Secondary Amenorrhea: New problem? Confirm if she has ever had any menstrual flow. How is her health otherwise? Inform her that you need to ask about her body and sexual characteristics to come to a diagnosis. “How about your growth spurt (recently 2-3 years)?”Table 11. 3 Common causes of primary amenorrhea Category Approximate frequency (%) Breast development 30 Müllerian agenesis 10 Androgen insensitivity 9 Vaginal septum 2 Imperforate hymen 1 Constitutional delay 8 No breast development: high FSH 40 46 XX 15 46 XY 5 Abnormal 20 No breast development: low FSH 30 Constitutional delay 10 Prolactinomas 5 Kallman syndrome 2 Other CNS 3 Stress, weight loss, anorexia 3 PCOS 3 Congenital adrenal hyperplasia 3 Other 1 Reprinted with permission from The Practice Committee of the American Society for Reproductive Medicine [2] FSH follicle-stimulating hormone, CNS central nervous system, PCOS polycystic ovarian syndrome Table 11. 4 Common causes of secondary amenorrhea Category Approximate frequency (%) Low or normal FSH 66 Weight loss/anorexia Non-specific hypothalamic Chronic anovulation including PCOS Hypothyroidism Cushing's syndrome Pituitary tumor, empty sella, Sheehan syndrome Gonadal failure: high FSH 12 46 XX Abnormal karyotype High prolactin 13 Anatomic 7 Asherman syndrome Hyperandrogenic states 2 Ovarian tumor Nonclassic CAH Undiagnosed Reprinted with permission from The Practice Committee of the American Society for Reproductive Medicine [2] FSH follicle-stimulating hormone, PCOS polycystic ovarian syndrome, CAH congenital adrenal hyperplasia M. H. Sherazi and U. Bukhari | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
329 “Do you think your breasts have developed?” “How about axillary and pubic hair?” “How is your height when you compare it to your friends?” Chronic illness? Pregnancy: Sexual activity? Any breast tenderness? Early morning sickness? Functional Hypothalamic Amenorrhea: “Are you on a special diet?” “Do you do excessive exercise?” “Do you take laxatives or induce vomiting?” “Do you consider yourself overweight?” “How do you feel when you look at yourself in the mirror?” “Psycho-social stress?” Thyroid Disease: “Any change in your weight?” “Do you have any weather preferences? Temperature intolerance?” “Any lump in your neck or change in your voice?” “How about your bowel motion? Diarrhea? Constipation?” “Palpitations, tremor, depression, skin changes?” Pituitary Tumor: Galactorrhea -“Have you noticed any milk secretions from your breast?” Significant headaches or vision changes? Symptoms of Hormone Excess: Hirsutism, acne, polycystic ovarian syndrome (PCOS), ovarian or adrenal tumor, Cushing syndrome Imperforate Hymen: “Do you experience cyclical abdominal pain every month?” Constitutional Delay of Puberty: Family history of early or delayed menarche? Chemotherapy or Radiation: Impairment of specific organ (brain, pituitary, ovary)? Illicit or Prescription Drug Use: Consider effects on prolactin level. Past Medical History: “Do you have any other health issues?” Past Hospitalization: “Have you had any previous hospitalization?”Medication History: “Are you taking any medications pre-scribed, over the counter, or herbal? If so, have there been any side effects?” Surgical History: Previous abdominal and gynecological surgery of relevance Allergic History: “Do you have any known allergies?” Social History: “Do you smoke? Or does anyone else in your home or close proximity at work smoke?” “Do you drink alcohol?” If yes, then ask further questions: “How much? Daily? How long?” “Have you ever tried any recreational drugs? If yes, which ones? How long? When?” Specifically ask about intrave-nous drug use (IVDU). Adolescents (Patient 18 Years Old): HEEADDSSS Home: “With whom do you live?” Education: Which grade? School performance? Grades? Recent changes in grades? Employment or future career aspirations? Activities, hobbies, exercise? -Hobbies: (in case of epilepsy -ask about risky activities) Diet: Any specific diet? Drugs and alcohol: “Do you smoke? Recreational drugs? IVDU?” -“A lot of people of your age might experiment with drugs? How about you?” Sexual activity or relationships. Suicidal ideation (“Have you tried hurting yourself?”) or mood? Family History: It should include age at menarche and presence of chronic disease. Self-Care and Living Condition: “What do you do for a living? Working status and occupation? Educational status? Who lives with you?” Support: “Do you have good support from your family and friends?” Functional status or severity or impact on life activities. Wrap-Up Question: “What will you do next?” (Questions may be asked by the patient or the examiner. ) Answer: “I will perform a thorough physical examination”: 11 Obstetrics and Gynecology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
330 Vital signs Height, weight, and body mass index (BMI) (high in PCOS and low in functional hypothalamic amenorrhea) Skin examination General Physical Examination: -Evaluate body habitus. -Skin: Look for color, texture and moisture, male pat-tern baldness, increased facial hair, acne (hyperan-drogenism, PCOS, ovarian or adrenal tumor, Cushing syndrome). -Hands: Feel the hands for any sweating. -Look for any tremors. -Head, eyes, ears, nose, and throat (HEENT): Thyroid swelling. -Dysmorphic features: Webbed neck, short stature, or low hairline may suggest Turner syndrome. -Breast: Breast development. -Look for axillary hair. -Chest and heart examination. -Abdomen: Suprapubic mass (imperforate hymen). -Pelvic exam: Inspect external genitalia Speculum examination: Look for imperforate hymen, presence of transverse vaginal septum (out-flow tract obstruction). -Tanner staging. Question: “What laboratory test will you consider?” Answer: See Fig. 11. 1 [3]. Complete blood count and metabolic panel abnormalities -Chronic disease Pregnancy test -Positive in pregnancy and ectopic pregnancy Estradiol -Low, poor endogenous estrogen production (sugges-tive of poor ovarian function) Follicle-stimulating hormone (FSH) and luteinizing hor-mone (LH) -High in primary ovarian insufficiency, Turner syndrome -Low in functional hypothalamic amenorrhea -Normal in PCOS, Asherman syndrome, multiple others Free and total testosterone, dehydroepiandrosterone sulfate -High in hyperandrogenism, PCOS, ovarian or adrenal tumor, CAH, Cushing syndrome Prolactin -High in pituitary adenoma, medications, hypothyroid-ism, other neoplasms Thyroid-stimulating hormone -High: Hypothyroidism History and physical exam Order: Pregnancy test Serum LH, FSH, TSH and prolactin levels Pelvic ultrasound Other tests if indicated Results: Positive pregnancy test-patient is pregnant (exclude ectopic pregnancy) TSH-if abnormal, order thyroid function tests, treat thyroid disease Prolactin-if abnormal, order MRI of the pituitary to exclude adenoma; consider medications Does patient have a uterus? No 46,XX Müllerian agenesis (Mayer-Rokitansky-Küster-Hauser syndrome): Expect female-range serum testosterone levels46,XY Androgen insensitivity syndrome: Expect male-range serum testosterone levels Yes Low FSH and LH Functional amenorrhea Constitutional delay of puberty Rare cases: primary gonadotropin-releasing hormone deficiency Normal FSH and LH Consider: Outflow tract obstruction All other causes of amenorrhea with normal gonadotropin levels High FSH and LH Primary ovarian insufficiency Order karyotype to evaluate: Turner syndrome or Presence of Y chromatin Determine karyotype Check free and total testosterone levels FSH and LH Levels Fig. 11. 1 Diagnosis of primary amenorrhea. LH -luteinizing hormone, FSH -follicle-stimulating hormone, TSH -thyroid-stimulating hormone, MRI -magnetic resonance imaging. (Adapted from [3]) M. H. Sherazi and U. Bukhari | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
331 -Low: Hyperthyroidism Karyotype -Abnormal in Turner syndrome, rare chromosomal disorders Diagnostic imaging -Magnetic resonance imaging (MRI) of the head -If a pituitary tumor is suspected (microadenoma) -Pelvic ultrasonography -To find out morphology of pelvic organs and the pres-ence or absence of a uterus and can identify structural abnormalities of reproductive tract organs Question: “What will be the treatment?” Answer: “Treatment is determined by the cause. Treatment goals should be to relieve the symptoms second-ary to hormonal imbalance, establish menstruation, prevent complications, and/or to achieve fertility: In anatomical abnormalities: Surgery may be recommended. Functional hypothalamic amenorrhea: Try to find the spe-cific cause and then treat. Gaining weight. Reduction in intense exercise. Nutritional counseling may be of benefit. In premature ovarian failure: Hormone therapy. Polycystic ovary syndrome: Benefit from treatments that reduce the level or activity of male hormones, or androgens. Dopamine agonist medications: Bromocriptine can reduce elevated prolactin levels, which may be respon-sible for amenorrhea. Consequently, medication levels may be adjusted by the person's physician if appropriate. Assisted reproductive technologies and the administra-tion of gonadotropin medications that stimulate follicle maturation in the ovaries can be appropriate for women with some types of amenorrhea who wish to attempt to become pregnant. ” History and Counseling: Secondary Amenorrhea Candidate Information: You are seeing a 27-year-old female with a 2-year history of no menstruation. Please take a focused history and make a diagnostic and management plan for her. Differentials: (See list under previous heading, History and Counseling: Primary Amenorrhea. )Secondary amenorrhea is the absence of menstrual bleeding in a woman who had been menstruating but later stops menstruating for 3 or more months in the absence of pregnancy, lactation, cycle suppression with systemic hor-monal contraceptive pills, or menopause. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Miss... ?” Presenting Complaint: “What brings you in today?” History of Presenting Illness: Ensure confidentiality. Offer to bring in a chaperone. Primary Versus Secondary Amenorrhea: New problem? Confirm if she has ever had any menstrual flow. “Can you please tell me when was your last menstrual period?” “Did your period stop suddenly or gradually?” Menstrual periods: “Menarche? Were they regular? How long is the cycle? How long is the bleeding time? Did you have excessive bleeding or pain during periods? Spotting in between periods?” “How is your health otherwise?” Inform her that you need to ask about her body and sexual characteristics to come to a diagnosis: “How about your growth spurt (recently 2-3 years)?” “Do you think your breasts have developed?” “How about axillary and pubic hair?” “How is your height when you compare it to your friends?” “Chronic illness?” Pregnancy: Partner: “Are you sexually active? Are you in a stable relationship?” “Any breast tenderness or early morning sickness?” 11 Obstetrics and Gynecology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
332 Functional Hypothalamic Amenorrhea: “Are you on a special diet?” “Do you do excessive exercise?” “Do you take laxatives or induce vomiting?” “Do you consider yourself overweight?” “How do you feel when you look at yourself in the mirror?” “Psycho-social stress?” Thyroid Disease: “Any change in your weight?” “Do you have any weather preferences? Temperature intolerance?” “Any lump in your neck or change in your voice?” “How about your bowel motion? Diarrhea? Constipation?” “Palpitations, tremor, depression, skin changes?” Pituitary Tumor: Galactorrhea -“Have you noticed any milk secretions from your breast?” “Significant headaches or vision changes?” Symptoms of Hormone Excess: Hirsutism, acne, polycystic ovarian syndrome (PCOS), ovarian or adrenal tumor, Cushing syndrome Constitutional Delay of Puberty: Family history of early or delayed menarche Chemotherapy or Radiation: Impairment of specific organ (brain, pituitary, ovary) Illicit or Prescription Drug Use: Consider effect on prolactin. Pills: “Do you use any form of contraception? Which type?” Pap Smear: When? Results? Menopausal Symptoms: “Hot flashes? Dryness of vagina? Is intercourse painful?” Past Medical History: “Do you have any other health issues?” Past Hospitalization: “Have you had any previous hospitalization?” Medication History: “Are you taking any medications pre-scribed, over the counter, or herbal? If so, have there been any side effects?”Surgical History: Previous abdominal and gynecological surgery of relevance Allergic History: “Do you have any known allergies?” Social History: “Do you smoke? Or does anyone else in your home or close proximity at work smoke?” “Do you drink alcohol?” If yes, then ask further ques-tions: “How much? Daily? How long?” “Have you ever tried any recreational drugs? If yes, which ones? How long? When?” Specifically ask about IV drug use. Family History: Presence of chronic disease Self-Care and Living Condition: “What do you do for a living? Working status and occupation? Educational status? Who lives with you?” Support: “Do you have good support from your family and friends?” Functional status or severity or impact on life activities. Wrap-Up Question: “What is the management plan?” Answer: See Fig. 11. 2 [3]. Question: “How will you deal with a patient with Asherman syndrome after miscarriage?” Answer: “I will take a detailed history including history of pregnancy and miscarriage”: Detailed physical examination Order pregnancy test to exclude pregnancy Order FSH, LH, estradiol, prolactin, thyroid-stimulating hormone (TSH) to exclude different causes Pelvic USG Counseling: If Asherman syndrome is confirmed, then I will give her more information about it: “According to your history you most likely have secondary amenorrhea due to Asherman syndrome. It is the formation of adhesion or scar tissues inside the uterus. It is a well-recognized complication of curettage. During the pregnancy the ability of the inner lining of the uterus to recover is reduced. The surgical procedure also contributes to the formation of scar tissue inside the uterus. ” “But there is treatment for this condition. I need to refer you to a gynecologist. The gynecologist will perform exami-nation under anesthesia. The examination is called a hyster-oscopy in which a small flexible optic tube is placed through the cervix into the uterine cavity. It helps to see intrauterine adhesions and cut these. Sometimes it is not possible to see M. H. Sherazi and U. Bukhari | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
333 inside the uterus, so a contrast may be required and X-ray will be taken to locate the uterine cavity and to define the scar tissues. After the procedure, the gynecologist will pre-scribe estrogen to increase the repair of the inner lining. As with any surgical procedure, hysteroscopy carries some risks. Complications are uncommon but it includes anesthe-sia risk, infection, bleeding, and, rarely, perforation. ” “It is an effective treatment and most likely you can get preg-nant again. Success depends on the extent of the disease and how difficult is the treatment. Replacement of estrogen is also given in form of oral contraceptives (OCP) or hormone replacement therapy (HRT). These hormones will reduce your symptoms. ” Question: “How will you manage a patient with second-ary amenorrhea due to polycystic ovarian syndrome?” Answer: “I will take a detailed history”: Anovulatory cycles (prolonged >40 days and irregular). Detailed physical examination:-General appearance, hirsutism, acne, and high BMI -Vital signs -Visual field, thyroid and breast exam -Abdominal examination -Pelvic exam: size of the uterus, adnexal masses, and tenderness -Urine dipstick and urine PT Order pregnancy test to exclude pregnancy. Order FSH, LH, estradiol, prolactin, and TSH to exclude different causes. -Increased LH, increased androgen (androstenedione) converted to testosterone -Decreased FSH and increased insulin secretion -LH: FSH ratio = 3:1 Pelvic USG for PCOS: Necklace appearance. Counseling: If PCOS is confirmed, then I will counsel the patient: “You most likely have secondary amenorrhea second-Order : Pregnancy test Ser um LH, FSH, TSH and prolactin le vels Pelvic ultrasound Other tests if indicated Review medications, include: contraceptiv es illegal dr ugs Results: Positive pregnancy test-patient is pregnant (exclude ectopic pregnancy) TSH-if abnor mal, order th yroid function tests, treat th yroid disease Prolactin-if abnor mal, order MRI of the pituitary to e xclude adenoma; consider medications Elevated FSH and LH Normal or Low FSH and LH Repeat test in 1 month Consider seru m estradio l Primary ovarian insufficiency or Natural menopause Order kary otype to ru le out Turner syndrome, especially in short-statured patient Disordered eating Poor nutr ition Excessiv e exe rcise Likely functional amenorrhea Also consider chronic illness High intracranial pressure Symptoms: Headache Vomiting Vision changes Consider head MRI to ev aluate fo r neoplasm Hyperandrogenism Order tests: Ser um testosterone DHEA S 17-h ydroxyprogesterone History of Ob/Gyn procedures Consider : Inducing withdr awal bleeding or Hysteroscopy to chec k for Asher man syndrome Elevated le vels of 17-hydroxprogesterone Possib le late-onset congenital adrenal hyperplasia Meets PCOS cr iteria Metabolic syndrome: Screen Treat Consider tumor if rapid onset of symptoms, or ve ry high seru m androgen: Order adrenal and ovarian imaging History and Physical Exam Fig. 11. 2 Diagnosis of secondary amenorrhea. LH -luteinizing hormone, FSH -follicle-stimulating hormone, TSH -thyroid-stimulating hor-mone, MRI -magnetic resonance imaging, Ob/Gyn -obstetrics/gynecology, PCOS -polycystic ovary syndrome. (Adapted from [3]) 11 Obstetrics and Gynecology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
334 ary to polycystic ovarian syndrome. PCOS is a condition that causes irregular menstrual cycles because monthly ovulation is not occurring and levels of androgens or male hormones are elevated. It is a very common condition. The cause of PCOS is not yet completely understood. It is believed that abnormal levels of the pituitary hormone LH and high level of androgen interfere with normal function of the ovary. PCOS symptoms include absent or irregular periods, abnormal hair growth, scalp hair loss, acne, weight gain, and difficulty becoming pregnant. Although PCOS is not completely reversible, there are a number of treatments that can reduce symptoms: Periods and hirsutism: -Lifestyle modification such as healthy diet and regular exercise help. -Use oral contraceptives for 6 months. -Hair treatment such as laser therapy or electrolysis. -If these are not effective, then OCP plus antiandrogen (spironolactone or cyproterone acetate). Pregnancy: -Lifestyle modification. -Try to have a regular sexual life for 6 months. -If will not be successful, then refer to gynecologist for specific treatment: Metformin (improves insulin resistance and weight loss) Clomiphene citrate FSH injection In vitro fertilization (IVF)” History and Counseling: Vaginal Discharge Candidate Information: A 34-year-old female presented in your practice with foul- smelling vaginal discharge, mild lower abdominal pain, and fever. Please take a detailed history and counsel the patient about the management plan. Differentials: Abdominal Pain: Acute appendicitis Pelvic inflammatory disease (PID) Ectopic pregnancy Ruptured ovarian cyst Torsion of ovary Urinary tract infection (UTI) Vaginal Discharge: Infections not associated with sex: Group B streptococcal vaginitis, bacterial vaginosis, Candida albicans [4]. Noninfectious causes: Hormonal contraception, physio-logical, cervical ectropion and cervical polyps, malig-nancy, foreign body (e. g., retained tampon), dermatitis, fistulae, allergic reaction, erosive lichen planus, desqua-mative inflammatory vaginitis, atrophic vaginitis in lac-tating and postmenopausal women [4]. Sexually transmitted infections (STIs): Chlamydia trachomatis, Mycoplasma genitalium, Neisseria gon-orrhea, Trichomonas vaginalis, herpes simplex virus [4]. Common Causes of Vaginal Discharge with Symptoms: See Table 11. 5 for some of the common symptoms and causes of vaginitis [5-7]. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Miss... ?” Presenting Complaint: “How can I help you today?” Ensure confidentiality. Offer to bring in a chaperone. History of Present Illness: There are three presenting complaints: vaginal discharge, low abdominal pain, and fever. You must ask questions about each symptom: Vaginal Discharge: Onset: When did this start? Was the onset acute or gradual? Amount: How much coming out? Pads? Just staining? Course: Is it worsening, improving, or continuing? Duration: How long has it been going on? Intermittent or continuous? Are the symptoms present all the time, or do they come and go? Consistency: Describe the consistency (sticky or watery)? Color: What is the color of the discharge? Smell: Is there any smell? Blood: Is it blood stained? Precipitating factors: Are there any obvious triggers for the symptom? M. H. Sherazi and U. Bukhari | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
335 Associated features: Are there other symptoms that appear associated, e. g., fever/malaise? Any itching, burning, or fever? -“How are your waterworks? Burning? Frequency on urination?” -Use of gels, douches, or perfumed bath additives? -Any associated localized tenderness (Bartholinitis)? -Any relation to periods? Relieving factors: Does anything appear to improve the symptoms? Previous episode: Have you experienced these symptoms before? Urethral discharge: Any associated urethral discharge? -Color -Amount -Consistency -Odor -Presence of blood Fever: -Onset -Severity -Continuous or intermittent -Any relieving factors? Abdominal pain: -Onset -Course -Duration -Nature -Intensity (1-10)-Location -Progression -Radiation -Timing Constitutional symptoms: Fatigue, malaise, night sweats, fever, and weight loss You should be able to identify to the examiner that you have tried to rule out appendicitis, cystitis, pregnancy, inflammatory bowel disease, and PID. Gynecological History: Menstrual History Age at menarche? When was the last normal menstrual period? How many days of blood loss? The duration or length of the cycle? Whether blood loss was heavy? If yes, then ask about number of tampons and/or pads. Ask further about pass-ing clots. Previous Gynecological Problems and Treatments: Sexually transmitted diseases (STDs)? Pelvic inflammatory disease (PID)? Previous cervical smear? What form of contraception is being used?Table 11. 5 Symptoms and causes of vaginitis [5-7] Symptoms Type of vaginitis Cause Pain Discharge/appearance Pruritus (itching) Burning on contact, soreness Minimal discharge More likely in allergic reactions Contact irritation or allergic reaction Irritant or allergic contact dermatitis Not a primary symptom Clear, white, or gray discharge Not a primary symptom Bacterial vaginosis Bacteria: Malodorous/fishy smell Gardnerella vaginalis Mycoplasma hominis Prevotella species Mobiluncus species Burning, painful urination, painful intercourse White, thick (“cottage cheese-like”), odorless discharge Frequent Candidiasis Yeast: Candida albicans Candida krusei Candida glabrata Painful intercourse, vaginal soreness, painful urination Frothy yellow-green discharge May be present, but not a primary symptom Trichomoniasis Protozoan parasite: Trichomonas vaginalis Malodorous Vulvovaginal erythema “Strawberry” cervix Vaginal dryness, painful intercourse Yellow-green, odorless discharge Rare Atrophic vaginitis Estrogen deficiency Intense pain, painful intercourse, bleeding after intercourse Gray or yellow discharge Intense Erosive lichen planus Unknown cause 11 Obstetrics and Gynecology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
336 Current contraception: Oral contraceptive pill, depot, implant, or implanted uterine device? Coital history: “How often do you have intercourse?” Sexual History: (Important for this station) Ask about sexual activity. Inform the patient that you need to ask a few questions about her sexual history to make a diagnosis: The first question should be: “Are you sexually active?” If yes, then, “With whom do you live?” “How long have you been together?” “Do you practice safe sex -using condoms?” “When did you start to be sexually active?” “How many partners you had last years?” “What is your sexual preference?” “How about your partner? Does he have any symptoms? Have you ever been screened for HIV?” Dyspareunia-only ask further questions if she mentions this. Otherwise skip. Abnormal vaginal bleeding-only ask if she mentions; otherwise skip this. Past Medical History: “Do you have any other health issues?” Past Hospitalization: “Have you had any previous hospitalization?” Medication History: “Are you taking any medications pre-scribed, over the counter, or herbal? If so, have there been any side effects?” Previous use of antibiotics for PID. Vaccination (Gardasil). Surgical History: Previous abdominal and gynecological surgery of relevance Allergic History: “Do you have any known allergies?” Social History: “Do you smoke? Or does anyone else in your home or close proximity at work smoke?” “Do you drink alcohol?” If yes, then ask further questions: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” If yes, “Which ones? How long? When?” Specifically ask about IV drug use. Family History: Presence of chronic disease Self-Care and Living Condition: “What do you do for a living? Working status and occupation? Educational status? Who lives with you?” Support: “Do you have good support from your family and friends?” Functional status or severity or impact on life activities. Wrap-Up Question: “What will you do next?” Answer: “I will perform a detailed physical examination”: Vital signs. General appearance. Chest and heart auscultation. Abdominal examination: -Palpation: Tenderness or mass. -Rebound tenderness. -Examine the liver and spleen. -Digital rectal examination. Pelvic examination: -Inspection of the pelvic area: Bleeding, discharge (color, quantity, and smell), warts -Bimanual palpation: Adnexal mass. Cervical excitation. Observe the size and position of the uterus and cervix. Sterile speculum examination: Note for source of discharge from the cervix or vagina? Take swabs and send for culture and wet mount. Get urine dipstick/finger BSL/PT. Question: “Your patient has been diagnosed with trichomoniasis. Counsel her. ” Answer: “Most likely from the history and physical examination done today, it looks like you have a vaginal infection called trichomoniasis. It is a common STI. It is caused by a parasite called Trichomonas vaginalis. It is transmitted through sexual contact. Many females carry the organism without signs and symptoms. The common symptoms are itching, burning of urine, watery greenish discharge with a fishy smell. Most of the infected males are asymptomatic. Diagnosis is by visualizing the organism within the vaginal secretion under the microscope. I will give you a prescription of Metronidazole (confirm drug allergy). ” “When someone is diagnosed with one STI then there are higher chances of developing other STIs. So I would recom-mend that we should test you for other STIs as well. ” M. H. Sherazi and U. Bukhari | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
337 Recommend Precautions: Practice good genital hygiene, wash vaginal area before and after intercourse Do not share towels Remember to shower after swimming Practice safe sex with condoms Advise to bring partner for consultation and treatment Question: What investigations will you order? Answer: Full blood count Urine for microscopy culture sensitivities (MCS) Blood sugar, urea, and electrolytes USG abdomen and pelvis STD screening Urine polymerase chain reaction (PCR) for chlamydia and herpes High vaginal swab for wet film preparation for Trichomonas Endocervical swab for chlamydia and gonorrhea Syphilis with venereal disease research laboratory (VDRL) and rapid plasma reagin (RPR) Pap smear Hepatitis B serology HIV Throat swab or anorectal swab if indicated Urethral swab if indicated Checklist: Oral Contraceptive Pill (OCP) Counseling Candidate Information: A 23-year-old female presents to your GP clinic. She is ask-ing for an OCP prescription. Take a brief history and counsel the patient. No examination is required. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair and start the interview. Opening: “Good morning/good afternoon. I am Dr..., and you are... ? How can I help you today?” Ensure confidentiality. Offer to bring in a chaperone. Reason: Reason why she is asking for the pill. Take Sexual History: How long sexually active? Is she practicing safe sex? Condoms? How many partners? Any previous STDs? What contraception used so far? Is this a new partner? Gynecology History: Menarche Regularity of periods Amount of bleeding (number of day and pads) Any excessive bleeding or clots Regular periods or irregular Pain with periods Last menstrual period (LMP) Last Pap smear Obstetrics History: Pregnancy before? How many? When was the last time she was pregnant? Any abortion? Premature baby? Term baby? Live children? Ask Specifically About Contraindications for OCP: History of estrogen-dependent cancer: Breast, uterus, liver Any abnormal vaginal bleeding Cardiovascular disorder Clots in the lungs, vessels, legs High blood pressure Migraine headache Smoking Family history of breast, uterine, and liver cancers The rest of the history should be very brief. Do not repeat the questions already asked. Past Medical History: “Do you have any other health issues?” Past Hospitalization: “Have you had any previous hospitalization?” Medication History: “Are you taking any medications prescribed, over the counter, or herbal? If so, have there been any side effects?” Vaccination (Gardasil). Surgical History: Previous abdominal and gynecological surgery of relevance 11 Obstetrics and Gynecology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
338 Allergic History: “Do you have any known allergies? Social History: “Do you smoke? Or does anyone else in your home or close proximity at work smoke?” “Do you drink alcohol?” If yes, then ask further questions: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” If yes, “Which ones? How long? When?” Specifically ask about IV drug use. Family History: Presence of chronic disease Discuss About Benefits of OCPs: It will eliminate the pain during periods. There will be less blood loss during periods. It will prevent bone loss (osteoporosis). Their failure rate is very low. These also help to reduce the symptoms of premenstrual syndrome (PMS). Warnings: OCP and smoking will increase heart attack. OCP cannot not protect from STDs (need to use condoms all the time). Packages: 21-day pack 28-day pack Agree to prescribe OCP if no contraindication. Ask Her if She Wants to Know About the Mechanism of Action of OCP: Standard preparations of OCP contain estrogen and proges-terone or just progesterone. These prevent ovulation by interfering with feedback of hormone signals from the brain. Progestin-containing contraceptives may also inhibit sperm penetration through the cervix into the uterus by decreasing the amount of and increasing the viscosity of the cervical mucus [8]. Symptoms to watch and when to seek immediate medical attention while on the pill: Headache Chest pain Shortness of breath Vision changes Drug Interaction: “If you want to take any new medication while on the pill, always let your doctor know first. ”Wrap-Up: Pap smear: Encourage to get one done if not yet done or due. Answer any concerns or questions. Ensure confidentiality. Checklist: Hormone Replacement Therapy (HRT) Counseling Candidate Information: A 52-year-old female presents to your GP clinic. She is ask-ing for a prescription for hormone replacement therapy (HRT). Take a brief history and counsel the patient. No examination is required. Starting the Interview: Knock the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair and start the interview. Opening: Good morning/good afternoon. I am Dr..., and you are... ? How can I help you today? Ensure confidentiality. Offer to bring in a chaperone. Reason: Reason why she is asking for HRT? Or how she heard about HRT? Screen for Symptoms of Menopause: Urogenital symptoms: Irregular periods, vaginal dryness, soreness, superficial dyspareunia (pain in intercourse), urinary frequency, and urgency Vasomotor symptoms: Sweating, hot flushes, palpitation Neurological symptoms: Mood swings, sleep distur-bances, depression, anxiety Skin thinning Duration of symptoms Bone pain and easy fracture (osteoporosis) Screened for Risk Factors for Osteoporosis: Physical inactivity or immobilization Chronic steroids use Using heparin Low calcium diet High caffeine intake M. H. Sherazi and U. Bukhari | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
339 High alcohol Smoking Gynecology History: Early menarche Regularity of periods Last menstrual period Late menopause Last Pap smear Current sexual activity Obstetrics History: Pregnancy before? How many? Nullipara? Age of first and last pregnancy? Any abortion? OCP? No breastfeeding. Past Medical History: “Do you have any other health issues? Ask about stroke, hypertension and heart problems. ” Past Hospitalization: “Have you had any previous hospitalization?” Medication History: “Are you taking any medications pre-scribed, over the counter, or herbal? If so, have there been any side effects?” Surgical History: Previous abdominal and gynecological surgery of relevance Allergic History: “Do you have any known allergies?” Social History: “Do you smoke? Or does anyone else in your home or close proximity at work smoke?” “Do you drink alcohol?” If yes, then ask further ques-tions: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” If yes, “Which ones? How long? When?” Family History: Presence of chronic disease Ask specifically about contraindications of HRT: Undiagnosed vaginal bleeding History of breast and endometrial cancers Thromboembolic disease (clots in the lungs, vessels, legs) Acute liver disease Uncontrolled hypertension Diabetes mellitus Obesity Migraine headache Discuss about benefits of HRT: It will keep your bones strong. It will reduce menopausal symptoms. It will help with vaginal dryness. Reduce pain during sex. Discuss about side effects of HRT: Nausea and vomiting Fluid retention Weight gain Abnormal vaginal bleeding Breast tenderness Will increase the risk of heart attack Increase risk of stroke Increase risk of clots Heartburn in the first few days Mood swings Advise of lifestyle modifications: Drink milk Regular exercise Required baseline investigations: Full blood count Urinalysis Blood sugar, electrolytes and urea ECG Pap test USG for endometrial thickness and ovarian volume Mammography If she is a good candidate to receive HRT, then agree to give her a prescription, but let her decide if she still wants HRT after today's discussion. Wrap-Up: Inform her that you will perform a physical examination. Discuss and encourage to get a Pap smear and mammogram. Any concerns or questions. Checklist: Breastfeeding Counseling Candidate Information: A 27-year-old female presents to your GP clinic. She is ask-ing to get information about breastfeeding. She is 36/40 11 Obstetrics and Gynecology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
340 pregnant. Her pregnancy-related visits are all up to date and seem to be without any complication. Take a brief history and counsel the patient. No examination required. Starting the Interview: Knock the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair and start the interview. Opening: “Good morning/good afternoon. I am Dr... ? Are you Miss... ? How can I help you today?” Ensure confidentiality. Offer to bring in a chaperone. Congratulate her on her pregnancy. Encourage her that it was her good decision to come in today, and discuss about breastfeeding. Ask her if she wants to get general information about breastfeeding or if she has some specific concerns. Say to her, “Before we proceed further, I will like to make sure that if you are a good candidate for breastfeeding. I need to ask you a few questions about your current preg-nancy and general health. Should we start?” “Have you ever been pregnant before?” “Have you ever breastfed before?” “How is your pregnancy?” “When was your last pregnancy follow-up?” “When is your due date?” Past Medical History: “Do you have any other health issues?” “Do you have any long-term diseases?” Endocrinopathies. Psychiatric problems. “Have you been screened for tuberculosis (TB) or HIV?” “Do you plan chemotherapy or radiation therapy?” Past Hospitalization: “Have you had any previous hospitalization?” Medication History: “Are you taking any medications prescribed, over the counter, or herbal? If so, have there been any side effects?” Vaccination (Gardasil). Surgical History: Previous abdominal and gynecological surgery of relevance Allergic History: “Do you have any known allergies?” Social History: “Do you smoke? Or does anyone else in your home or close proximity at work smoke?” “Do you drink alcohol?” If yes, then ask further ques-tions: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” If yes, “Which ones? How long? When?” If she shows her concerns and asks, “Will there be pain while breastfeeding?” Address this here: “There should not be pain while breast-feeding. It is a natural physiological process. However, sometimes it might cause some discomfort. Difficulties with breastfeeding are common, especially in the first week after birth. It is common for the breasts to become engorged early on. In some women, a few days after delivery, the milk sup-ply comes on so quickly that the breasts become swollen, hard, and sore. This is called engorgement. There is an increased supply of blood and other fluids in the breast as well as milk. It can be easily managed at home, the lactation nurse/breastfeeding clinic will guide you. ” “If there is pain then we should find out the cause. Most of those causes are treatable: Cracks and fissures in the nipples. These are caused because of not proper care of the nipple. You have to make sure that they are moist, clean them, and do not use soap. Retracted nipple and inflammation of the breast (mastitis) you can still continue to breastfeed. Localized condition, such as abscess, we still recommend to continue to feed from the breast on the other side. ” Encourage the pregnant mother to initiate and continue the breastfeeding relationship at least through the first 12 months of age. Compare between breast milk and formula milk: “The reason we recommend breastfeeding is that we can-not match it with formulas. Supplemental feedings of water or infant formula are unnecessary as breast milk provides ideal nourishment for the infant. ” “A mother's breast milk has the perfect combination of nutrients needed for her infant's growth and development. The first 24 h secretion is called colostrum, which is a special kind of milk. It has a lot of protective immuno-globulin and essential amino acids. ” “With time the milk becomes more mature and suits the needs of your baby. It has the right amount of carbohy-drates and fat. The quality of the fat is better. It has more whey relative to casein. The iron is less than cow's milk but is more available. ” M. H. Sherazi and U. Bukhari | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
341 “There is less load on the kidneys. ” “It develops an emotional connection between the mother and the infant, which is important to both of you. ” “Babies who are breastfed have less chances of having allergies, less ear infections, less chance of having diar-rhea, and less chance of being obese. ” “There are some benefits for you (the mother)”: -“It helps to lessen the postpartum bleeding. ” -“Helps you to regain the figure you had prior to pregnancy. ” -“It is clean and readily available. ” -“It is always at the right temperature. ” -“It is economical and you do not have to pay for it. ” -“It is one of the most important things you can give your child. ” At the beginning the breastfeeding is on demand. “With time it regulates and you may need to breastfeed about 8-12 h in 1 day. ” At least 10 min from each breast. Monitor weight gain to ensure that the baby is adequately fed. Occasionally the baby may be jaundiced and sometimes stool may be loose. “If you choose to breastfeed you need to be careful when-ever you take medications or alcohol. ” If she shows concern about going back to work: “You can go back to work, after the maternity leave. ” Breastfeeding can be continued. “You can use special pumps to pump the milk and store it properly to be used later. Make sure you keep the pumps always clean. Don't put it in the microwave for heating. ” What about contraception?: “Breastfeeding is not reliable method of contraception. I will prescribe you a mini pill or you can use barrier method. ” If she chooses to breastfeed: “I will send you to a lactation clinic, breastfeeding clinic, or lactation nurse, who will teach you and guide you about breastfeeding. ” Provide educational materials on breastfeeding. Give further information about breast pumps, breast shells, or nursing supplementers. Help support the initiation and continuation of breastfeeding. Checklist: Antenatal Counseling Candidate Information: A 26-year-old female presents to your GP clinic. She has missed her period for 4 weeks and a home pregnancy test was positive. Take a detailed history and give her necessary advice about her pregnancy. No physical examination is required. Starting the Interview: Knock the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair and start the interview. Opening: “Good morning/good afternoon. I am Dr.... Are you 26 years old? How can I help you today?” (Please read your regional guidelines. ) She has missed her period for about 4 weeks, and a home urine pregnancy test was positive. Start with questions about pregnancy: “Was this a planned pregnancy?” “What is your feeling about it?” “How is your partner feeling about it?” If she looks happy, then offer congratulations on becom-ing an expectant parent. Encourage her by saying, “This is a very exciting time in everyone's life. Pregnancy is a normal event in the lifecycle and usually goes smoothly. We are here to help you and provide you with regular medical care for yourself and your baby. ” Start with symptoms related to pregnancy: “Do you have nausea or have you vomited?” “Do you have any breast tenderness?” “Do you have abdominal pain?” “How is your water work?” “Do you have regular bowel function?” “Do you have unusual vaginal discharge or bleeding?” “Do you feel tired?” Ask about LMP and calculate the expected date of deliv-ery. Nagele's rule: LMP -3 months +7 days +1 year. 11 Obstetrics and Gynecology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
342 If She Shows Concern About Why She Has to Come for Regular Antenatal Checkups: Tell her, “It is important to have regular checkups during pregnancy. There are many problems that can potentiality harm you or your baby during pregnancy. Most of these problems need to be detected early and can be treated. One of these problems is pregnancy-induced hypertension, which can lead to a serious condition called preeclampsia or tox-emia of pregnancy. It can cause weight gain, high blood pres-sure, and proteins in the urine. This will require urgent treatment. ” What other things can cause problems during pregnancy? Infections such as rubella, varicella, and genital herpes Diabetes High blood pressure Smoking (retards fetus growth) Alcohol -causes abnormalities, including mental retardation Continue with a brief medical history: “Because this is your first visit, I will need to ask you a few questions about your general health. ” Obstetrics History: Pregnancy before? How many? When was the last time she was pregnant? Any abortion? Premature baby? Term baby? Live children? Gynecology History: Menarche Regular periods or irregular Last Pap smear Take Sexual History (Not Usually Asked for This Station): How long sexually active? Is she practicing safe sex? Condoms? Any previous STDs? Past Medical History: “Do you have any other health issues?” Hypertension, diabetes, kidney disease, heart disease, exposure to chicken pox as a child, hepatitis B virus (HBV), HIV, and blood group and Rh group. Past Hospitalization: “Have you had any previous hospitalization?”Medication History: “Are you taking any medications prescribed, over the counter, or herbal? If so, have there been any side effects?” Vaccination (Gardasil). Surgical History: Previous abdominal and gynecological surgery of relevance Allergic History: “Do you have any known allergies?” Social History: “Do you smoke? Or does anyone else in your home or close proximity at work smoke?” “Do you drink alcohol?” If yes, then ask further ques-tions: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” If yes, “Which ones? How long? When?” Specifically ask about IV drug use. Family History: Presence of chronic disease. Family his-tory of complicated pregnancies, abortions, genetic, or con-genital abnormalities. Pregnancy Plan: Complete the pregnancy-related health chart (electronic or paper). Document today's visit. Visits: “I need to see you on scheduled visits every 4 weeks till the 28th week, then every 2 weeks till the 36th week and then every week thereafter until delivery. ” “Today we will do a physical examination including pelvic examination. ” “We need to order some routine lab tests to identify any current issue that needs immediate attention and for a healthy outcome of your pregnancy”: Full blood count to exclude anemia. Iron levels. Lytes. Urea and creatinine. VDRL (syphilis). Blood group-“If you are Rh-ve then we need to give you anti-D immunoglobin prophylactically to prevent prob-lems in future pregnancy. We will also need to repeat the antibody test in 26 weeks. ” Rubella antibodies status if you are not immunized to rubella, I recommend you receive rubella vaccination after delivery (contraindication during the pregnancy). We will also do Hepatitis B and C and HIV screening. M. H. Sherazi and U. Bukhari | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
343 Vitamin D level. Midstream urine to check urinary tract infection. Sometimes it can be asymptomatic but needs to be treated in pregnancy; 30% of asymptomatic UTI can become symptomatic. Down syndrome screening test: See Table 11. 6 for the risk of Down syndrome [9]. -“We recommend Integrated Prenatal Screening (IPS), which is a series of tests that are done during pregnancy. These tests tell you what the chances are that the baby will have a birth defect such as Down syndrome or spina bifida. Would you like to do it?” -First trimester (IPS I 11-14 weeks): PAPP-A, beta human chorionic gonadotropin (h CG), ultrasound (USG for nuchal translucency at 12 weeks) -Second trimester Quad Test (15-18 weeks): Beta h CG, alpha-fetoprotein (AFP), estradiol, inhibin A “Then if required the results can be confirmed with amniocentesis”: Amniocentesis: USG-guided transabdominal extraction of amniotic fluid for identification of genetic anomalies at 15-16 weeks. Poses a 0. 5% risk of spontaneous abortion and risk of fetal limb injury. Anatomy USG -at 20 weeks mid-pregnancy ultrasound to make sure baby develops properly and to look for position of the placenta. At 28 weeks we screen for gestational diabetes: Sweet drink test/glucose challenge test. At 36 weeks you will need to be advised to do a low vagi-nal swab to check for a bacterial infection called Group B streptococcus (GBS). If found, you will be given antibiot-ics prophylactically during delivery. “You need to eat a well-balanced diet. Your diet is impor-tant; it should include foods rich in protein, dairy, starch, and plenty of fruits and vegetables. Best avoid a lot of sugary, salty, and fatty foods. Food such as uncooked meat, egg, soft cheese, shellfish, sugar, refined carbohydrates (sweets, cakes, biscuits, soft drinks), polyunsaturated margarine, butter, oil, and cream should be avoided. I will give you printed guide-lines about your diet in pregnancy. ” “You need to take folic acid 0. 4-5 mg for the first 3 months of pregnancy because it decreases the occurrence of neural tube defects. ” “Moderate exercise is good for you because it improves cardiovascular and muscle strength. The best exercises are low-impact aerobics, swimming, walking, and yoga. No con-tact sports because of the risk of trauma. ” “Weight gain should be around 11-16 kg during preg-nancy. But it all depends on your pre-pregnancy state. ” “Avoid smoking, alcohol, and drugs. ” If the patient asks, “What about my sexual life?” Tell her, “A sexual life is acceptable and normal during pregnancy. Just follow your normal desires. ” Breastfeeding is highly recommended. Contact a local lactation or breastfeeding mothers' group guidance. Traveling: Avoid standing in trains. Avoid international air travel after 28 weeks. Immediate seek medical attention if: Unusual abdominal pain or cramps. Bleeding or large amount of fluid loss from the vagina before the baby is due. If the baby is less active than usual. Wrap-Up: Ask if she has any questions or concerns. Offer brochures; connect to support groups and classes for pregnant women. Table 11. 6 Risk of child born with Down syndrome based on moth-er's age [9] Mother's age Frequency of Down syndrome per births 20 1/2000 21 1/1700 22 1/1500 23 1/1400 24 1/1300 25 1/1200 26 1/1100 27 1/1050 28 1/1000 29 1/950 30 1/900 31 1/800 32 1/720 33 1/600 34 1/450 35 1/350 36 1/300 37 1/250 38 1/200 39 1/150 40 1/100 41 1/80 42 1/70 43 1/50 44 1/40 45 1/30 46 1/25 47 1/20 48 1/15 49 1/10 11 Obstetrics and Gynecology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
344 History and Counseling: First Trimester Vaginal Bleeding Candidate Information: A 28-year-old female, known to be 10-week pregnant, pres-ents to the emergency department with lower abdominal cramps and pain with vaginal bleeding. Take a detailed his-tory. No physical examination is required. Differentials: Abdominal Pain: Acute appendicitis Pelvic inflammatory disease Ruptured ovarian cyst Torsion of ovary Urinary tract infection Vaginal Bleeding: Some amount of light bleeding or spotting during preg-nancy occurs in about 20% of pregnancies, and most of these women go on to have healthy pregnancies. Spontaneous abortion (Table 11. 7) [10]. Complete abortion, incomplete abortion, inevitable abor-tion, or septic abortion. Threatened miscarriage. Ectopic pregnancy (Table 11. 8) [11]. Subchorionic hemorrhage. Vanishing twin. Molar pregnancy. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... Are you 28 years old? How can I help you today?” Chief Complaint: Abdominal Pain: Onset Course Duration Nature Intensity (1-10) Location Progression Radiation Timing -Abdominal cramps -Uterine contractions -Signs of peritonitis Estimate Blood Loss: How much? Color? Number of pads soaked? Any clots? Presence of any tissue? Heavier than normal menstrual period? Associated Symptoms: Fever, chills, and rigors (sepsis) Presyncope, shortness of breath, palpitation Syncope, feeling dizzy while standing (hemorrhagic shock) Abdominal size too big for gestational age (molar pregnancy)Table 11. 7 Risk factors for spontaneous abortion [10] Advanced maternal age Alcohol, tobacco, illicit drug use Chronic maternal diseases: thyroid disease, diabetes, autoimmune diseases (antiphospholipid syndrome, lupus) Exposure to radiation Exposure to toxins -e. g., arsenic, lead, ethylene glycol, carbon disulfide, polyurethane, heavy metals, organic solvents Genetic aneuploidy History of previous miscarriage Intrauterine device Maternal infections -e. g., chlamydia, gonorrhea, herpes, listeria, mycoplasma, syphilis, toxoplasmosis, etc. Medications Multiple previous elective abortions Uterine -congenital anomalies Table 11. 8 Risk factors for ectopic pregnancy [11] History of genital infection -e. g., pelvic inflammatory disease, chlamydia, or gonorrhea History of in utero exposure to diethylstilbestrol In vitro fertilization Infertility Intrauterine device Previous ectopic pregnancy Tobacco use Tubal surgery -tubal ligation or re-anastomosis of tubes M. H. Sherazi and U. Bukhari | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
345 Other sites of bleeding (bleeding disorder) Urinary symptoms Bowel symptoms Vaginal intercourse or penetration (local trauma) Obstetrics History: LMP? Was she under an obstetrician so far? Pregnancy before? How many? Any abortion? Premature baby? Term baby? Live children? Route of delivery (vaginal or cesarean delivery) Past Medical History: “Do you have any other health issues?” Ectopic pregnancy? PID? Intrauterine device? Fertility treatment? Hypertension? Diabetes? Kidney disease? Heart disease? Bleeding disorder? Ovarian cyst? Endometriosis? Past Hospitalization: “Have you had any previous hospitalization?” Medication History: “Are you taking any medications prescribed, over the counter, or herbal? If so, have there been any side effects?” Aspirin or blood thinners? Surgical History: Previous abdominal and gynecological surgery of relevance Allergic History: “Do you have any known allergies?” Social History: “Do you smoke? Or does anyone else in your home or close proximity at work smoke?” “Do you drink alcohol?” If yes, then ask further questions: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” If yes, “Which ones? How long? When?” Specifically ask about IV drug use. Family History: Presence of chronic disease Family history of complicated pregnancies, abortions, and genetic and congenital abnormalities Management Plan Question: “What will you do next?” Answer: “I will do a physical examination with pelvic and speculum examination”: General appearance Vital signs (postural drop) Abdominal examination: Distention, tenderness espe-cially on the right iliac fossa (RIF) and left iliac fossa (LIF). Any mass or hernia. Pelvic examination: Amount of bleeding, color of blood, clots, discharge or signs of trauma Speculum examination -Check os -whether open or closed -Product of conception -Any mass or lesion over the cervix -Bimanual examination checking for size, shape, and position of the uterus, adnexal tenderness or mass, and cervical excitation. Order: Urine dipstick and pregnancy test, h CG, blood sugar Differential Diagnosis Ectopic pregnancy: per vaginal (PV) bleeding + b-h CG (positive) + os closed + empty uterus Threatened miscarriage: PV bleeding + b-h CG (positive) + os closed + intrauterine pregnancy Incomplete abortion: b-h CG (positive) + os open + intra-uterine pregnancy + POC on examination Question: “How will you counsel for threatened abortion?” Answer: If the most likely diagnosis is threatened abor-tion, then counsel the patient as: “Your pregnancy test is positive and you are having bleeding. We need to admit you to the hospital to do some further blood tests including blood group. We also need to get an ultrasound of the pelvis to look for the presence of a fetal sac within the uterus and to check for cardiac activity. I will consult the obstetrician and, depending upon the results, they might advise you to take rest. Sometimes, because of the attachment of the placenta to the womb, some bleeding can happen. In a majority of cases (90-95%), this bleeding is quite harmless. It will stop on its own within a few days. Your pregnancy will continue with-out any problems, but you need to avoid stress, anxiety, and rigorous physical activity for the rest of your pregnancy. We do not need to give you any medications as it has not shown to alter the outcome in any way. If the bleeding continues, we 11 Obstetrics and Gynecology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
346 will repeat serial ultrasound to check for fetal viability, but you will need to stay in the hospital until the bleeding stops. ” Question: How will you counsel for incomplete abortion? Answer: Refer to obstetrics and gynecology unit. Patient needs to be admitted under obstetrics. Start IV fluids. Take blood for routine tests and grouping and cross matching Inform the patient: “Based on the history and examina-tion, I am sorry to say that this is a miscarriage. Most of the miscarriages occur without any obvious reason. Most likely in the first 14 weeks, the reason of miscarriage is due to chromosomal abnormalities. I have admitted you, informed the registrar, and sent all the bloods for neces-sary investigations. They will probably take you to the theater and do a procedure called 'curettage. ' They will empty whatever is left in the uterus to prevent any compli-cations. We will wait for your blood group report to come and if it is negative, we will give you an injection called anti-D. ” Show empathy. “I know it is a very hard time for you. Do you want me to call anyone for you?” History and Counseling: Third Trimester Vaginal Bleeding Candidate Information: A 28-year-old female, known to be 36-week pregnant, pres-ents to the emergency department with painless bleeding. Take a detailed history. No physical examination is required. Make a management plan for the patient. Differentials: Placenta previa Vasa previa Placenta abruption Trauma or lesion of the external genitalia Cervical polyp Cervical malignancy Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... Are you Miss/ Mrs..., and are you 28 years old? How can I help you today?” Chief Complaint: Estimate blood loss: -How much? (Vasa previa: If it is fetal blood then it can be catastrophic. ) -Color? -Number of pads soaked? -Any clots? -Presence of any tissue? -Heavier than normal menstrual period? “Have you had previous bleeding that stopped spontane-ously with no abdominal pain or tenderness?” (Placenta previa) “Have you had abdominal pain and tenderness along with dark blood?” (Placenta abruption) Associated Symptoms: Abdominal cramps or uterine contractions (frequency and length) (labor)? Broken water bag? “Did you have water gush” (premature rupture of membranes)? Change in fetal movement? Hand or face swelling? Headache? Fever, chills, and rigors (sepsis)? Presyncope, shortness of breath, palpitation? Syncope, feeling dizzy while standing (hemorrhagic shock)? Abdominal size too big for gestational age (molar pregnancy)? Other sites of bleeding (bleeding disorder)? Vaginal intercourse or penetration (local trauma)? Is there anything that slows the bleeding? Does anything make the bleeding worse? Obstetrics History: LMP? Was she under an obstetrician so far? “Did you have an ultrasound examination during this pregnancy?” Pregnancy before? How many? Any abortion? Premature baby? Term baby? Live children? Route of delivery (vaginal or cesarean section)? Any complication with previous pregnancies? M. H. Sherazi and U. Bukhari | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
347 Past Medical History: “Do you have any other health issues?” “What is your blood group?” Hypertension? Liver disease? Urogenital malignancy? Abnormal Pap smear? Bleeding disorder? Past Hospitalization: “Have you had any previous hospitalization?” Medication History: “Are you taking any medications prescribed, over the counter, or herbal? If so, have there been any side effects?” Aspirin or blood thinners. Surgical History: Previous abdominal and gynecological surgery of relevance Allergic History: “Do you have any known allergies?” Social History: “Do you smoke?” “Do you drink alcohol?” If yes, then ask further questions: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” If yes, “Which ones? How long? When?” Specifically ask about IV drug use. Family History: Presence of chronic disease Family history of complicated pregnancies, abortions, and genetic and congenital abnormalities Management Plan Question: “What will you do next?” Answer : “I will do a physical examination with pelvic and speculum examination”: General appearance. Vital signs (postural drop). Check capillary refill. Obstetric vitals : Fetal heart rate and its trends (beat-to- beat variability and accelerations). Listen to the lungs and heart. Abdominal examination: Distention, tenderness espe-cially on the RIF and LIF. Any mass or hernia. At 36 weeks the uterus occupies nearly all of the palpable abdomen. In placental abruption the uterus is exquisitely tender. Pelvic examination : Measure the fundal height from the pubic symphysis (Fig. 11. 3). Use the Leopold maneuvers to determine the position, presentation, and lie of infant (Fig. 11. 4)[12, 13]. In placenta previa, the presenting part is high riding and not engaged in the pelvis. Speculum examination : Check os whether open or closed, amount of bleeding or any discharge, color of blood, clots, or signs of trauma. Observe for any lesions, product of conception, or any mass. Discuss with obstetrics before doing a vaginal examination because this may cause severe bleeding if placenta previa or vasa previa is present. Question: “What will be your management plan for placenta previa?” Answer: Total placenta previa: Completely obstructs the cervical os (Fig. 11. 5 stage IV) [ 14] Fig. 11. 3 The height of the fundus at comparable gestational dates varies greatly from patient to patient. Those shown are the most com-mon. A convenient rule of thumb is that at 5-month gestation, the fun-dus is usually at or slightly above the umbilicus. (Reprinted with permission from Augustin G. Acute appendicits. In: Acute Abdomen During Pregnancy. Cham, Switzerland: Springer. 2014;3-43) 11 Obstetrics and Gynecology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
348 ac bd Fig. 11. 4 Leopold maneuvers. (a) First maneuver: fundal grip. Palpate the upper abdomen with both hands to determine the size, consistency, shape, and mobility of the fetus. (b) Second maneuver: umbilical grip. Palpate to determine the location of the fetal back. (c) Third maneuver: first pelvic grip. Determine the part of the fetus at the inlet. (d) Fourth maneuver: second pelvic grip. Determine the location of the fetus' brow and degree of fetal extension into the pelvis. (Reprinted with permis-sion from Ludwig H. Christian Gerhard Leopold (1846-1911): Nicht nur der Lehrmeister der Geburtshilfe. In: Der Gynäkologe. 2004;37(10): 961. (Illustrations originally from: Leopold CG, Spörlin N. Die Leitung der regelmäßigen Geburt nur durch äußere Untersuchung. Arch Gynäkol. 1894; 45: 337-368)) M. H. Sherazi and U. Bukhari | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
349 Stage I Stage II Stage III Classifications Classical Type I Type II Type IIIMarginal Lateral Central Minor Major Type IVUltrasound Contemporar y Stage IV Fig. 11. 5 Placenta previa. (Reprinted with permission from Calleja-Agius et al. [14]) 11 Obstetrics and Gynecology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
350 Partial placenta previa: Partially obstructing the cervical os (Fig. 11. 5 stage III) [14] Marginal: Just at the beginning of the os (Fig. 11. 5 stage II) [14] Low-lying placenta (Fig. 11. 5 stage I) [14] Risk Factors: Smoking Previous placenta previa Previous cesarean section Multiparity Advanced maternal age Management: IV lines. Admit to the hospital. Take blood for routine, blood grouping and cross match-ing, and coagulation profile. Urgent obstetrics and gynecology consult. Cardiotocography (CTG) monitoring and check the status of the baby. Arrange an urgent USG to see the position of the placenta. Reassure the patient. Counsel the Patient About Placenta Previa: According to the Victoria State Government's Better Health Channel, “During pregnancy, the placenta provides the growing baby with oxygen and nutrients from the mother's bloodstream. Placenta previa means the placenta has implanted at the bottom of the uterus, covering the cervix. When a baby is ready to be born, the cervix (neck of the womb) dilates (opens) to allow the baby to move out of the uterus and into the vagina. When a woman has placenta pre-via (the placenta has implanted at the bottom of the uterus, over the cervix or close by), the baby can't be born vaginally. 'Partial placenta previa' means the cervix is partly blocked, while 'complete placenta previa' means the entire cervix is obstructed” [15]. Possible Complications: Placenta previa is an obstetric complication that occurs in the second half of pregnancy. It can cause serious complications in both the mother and fetus [15]: Major hemorrhage for the mother Shock from blood loss Fetal distress from lack of oxygen Premature labor or delivery Health risks to the baby, if born prematurely Emergency cesarean delivery Hysterectomy, if the placenta fails to come away from the uterine lining Fetal blood loss Death Further Management: Total or partial placenta previa: Admit under obstetrics and stay until delivery and most cases deliver via cesarean section. Marginal or low-lying placenta previa, with minor bleed-ing and bleeding has stopped: Discharge home but needs to stay close to the hospital. Specialist needs to decide whether to book a cesarean delivery. Placenta previa with severe bleeding and fetal compro-mise: Immediate cesarean delivery. Question: “How will you counsel patient on placenta abruption?” (Patient is in emergency department and you are an emergency physician. ) Answer: “I will inform the patient about placenta abrup-tion and immediate management plan”: “Unfortunately, it looks like you came in with a serious condition called placental abruption. In placenta abruption, a part of the placenta starts detaching from the wall of the womb. The exact cause is unknown. There are certain known risk factors such as trauma, smoking, high blood pressure in the mom, diabetes, previous history of placental abruption, high parity, poor nutrition, and sometimes it is unexplained. This condition can be quite serious as there is a high risk of fetal demise, preterm rupture of membranes, maternal shock, acute renal failure, and sometimes can cause mother or fetal death. ” “I will consult an Obstetrician to come and examine you. We will put IV lines and take blood for cross matching. If required, we may need to transfuse you. Will you be alright with that? I will discuss with you a blood transfusion consent form soon. We need to prepare for possible premature deliv-ery. I will inform the theater to prepare for emergency cesar-ean section. We will give you steroids to help with the maturation of baby's lungs. If the baby is non-viable, if you are stable, we will induce and deliver the baby. But if not, emergency cesarean section is performed. ” Ask if she wants to inform someone. Ask if she has any questions or concerns. History and Counseling: Dysfunctional Uterine Bleeding Candidate Information: A 45-year-old female presents with painless heavy men-strual bleeding for the last 5 months. She has four children. Take a detailed history. No physical examination is required. Differentials: Dysfunctional uterine bleeding (DUB) is defined as exces-sively heavy, prolonged, or frequent bleeding of uterine ori-gin that is not due to pregnancy or any recognizable pelvic or M. H. Sherazi and U. Bukhari | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
351 systemic disease. It is, therefore, a diagnosis of exclusion. The mechanisms for DUB are largely unknown. Uterine Causes: Endometrial polyps Hyperplasia Endometrial carcinoma (may also cause intermenstrual bleeding) Uterine fibroids Adenomyosis Endometriosis Intrauterine device (IUD) Miscarriage and ectopic pregnancy Systemic Causes: Hypothyroidism Coagulopathy Drugs (anticoagulants, estrogen-containing preparations) Trauma Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... Are you 45 years old? How can I help you today?” Chief Complaint: Estimate Blood Loss: Since when? How much? Color? Number of pads soaked? Any clots? Presence of any tissue? Heavier than normal menstrual period? Gynecology History: Menarche Regularity of periods Last menstrual period Last Pap smear Current sexual activity Any spotting or bleeding in between periods Any pain during periods Associated Symptoms: The presence of signs of anemia or iron deficiency (pallor, fatigue, shortness of breath). “Do you have symptoms such as nausea, vomiting, headache, irritability, swelling of your body before periods?” Pre-syncope, shortness of breath, palpitation. Syncope, feeling dizzy while standing (hemorrhagic shock). Other sites of bleeding (bleeding disorder). Urinary symptoms. Bowel symptoms. Vaginal intercourse or penetration (local trauma). Sexual History: “Are you sexually active?” “Are you in a stable relationship?” “May I ask, do you have any problems related to inter-course such as pain or bleeding?” “What contraception do you use?” “What type and since when?” “Have you used an intrauterine contraceptive device (IUCD)?” “Have you ever been diagnosed with STIs or other pelvic infections?” Obstetrics History: LMP Number of pregnancies Any abortion Premature baby Term baby Live children Route of delivery (vaginal or cesarean delivery) Past Medical History: “Do you have any other health issues?” Bleeding disorder? PID? Intrauterine device? Hypothyroidism? Diabetes? Kidney disease? Endometriosis? Past Hospitalization: “Have you had any previous hospitalization?” Medication History: “Are you taking any medications prescribed, over the counter, or herbal? If so, have there been any side effects?” Aspirin or blood thinners. 11 Obstetrics and Gynecology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
352 Surgical History: Previous abdominal and gynecological surgery of relevance Allergic History: “Do you have any known allergies?” Social History: “Do you smoke? Or does anyone else in your home or close proximity at work smoke?” “Do you drink alcohol?” If yes, then ask further questions: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” If yes, “Which ones? How long? When?” Specifically ask about IV drug use. Family History: Presence of chronic disease Wrap-Up: Question: “What will you do next?” Answer: “I will do a physical examination with pelvic and speculum examination”: General appearance: Pallor, jaundice, dehydration, BMI. Skin: Bruises or purpura. Vital signs (postural drop). Perform a thyroid examination. Abdominal examination: Distention, tenderness espe-cially on the RIF and LIF. Any mass or hernia. Pelvic examination: Amount of bleeding, color of blood, clots, discharge, or signs of trauma? Speculum examination: Look for any signs of trauma, ulceration, lesions, and polyps. Take swabs from the vagina and cervix. Perform a bimanual examination checking for size, shape, and position of the uterus, adnexal tenderness or mass, and cervical excitation. Question: “What investigations will you order?” Answer: Full blood examination Serum ferritin Urea, creatinine, and electrolytes Coagulation profile such as von Willebrand disease Blood grouping Liver function test Thyroid function tests b-h CG Pap smear Transvaginal ultrasound Referral to gynecology and obstetrics Counseling: If DUB is confirmed, then I will counsel my patient: “From your history, physical examination and other investigations it looks like that you have a condition called DUB. In DUB the patient has bleeding without an apparent cause in spite of all the investigations. It is a very common condition with an unknown cause. It is suggested that disturbances of the nor-mal brain axis leads to hormonal changes or there is a prob-lem within the lining of the uterus (there is reduced vasoconstriction of endometrial vessels and increased pros-taglandin E1 and prostacyclin). It is a diagnosis of exclusion. We offer a step-ladder approach. We will start with medical management. ” Medical Treatment: Give iron supplements Nonsteroidal anti-inflammatory drugs (NSAIDs) or anti-prostaglandins reduce prostaglandin (mefenamic acid) Tranexamic acid Progestogen-releasing intrauterine device Combined oral contraceptive pill Progestogens Other therapies Danazol Gestrinone Gonadotropin-releasing hormone (Gn RH) agonists Surgical Treatment: Surgical treatment is reserved for resistant cases. Dilation and curettage with hysteroscopy are a diagnostic investigation, not a treatment for DUB. Endometrial ablation or resection is a procedure to destroy the endometrium by either a form of diathermy or removal. First-generation techniques (including laser ablation, roller ball diathermy, or resection) and second- generation techniques including microwave ablation are all very effective when performed. History and Counseling: Bleeding After Menopause Candidate Information: A 55-year-old female presents in the GP practice with vagi-nal bleeding. It started as brownish staining of her under-pants a week ago, and she came to get a checkup. She has had painless heavy menstrual bleeding for the last 5 months. She has four children. Take a detailed history. No physical examination is required. Differentials: Bleeding After Menopause: In about 90% of cases, the cause of bleeding after meno-pause remains unknown. According to The Royal Women's Hospital, Victoria, Australia, “Most of the time, postmeno-pausal bleeding is caused by: M. H. Sherazi and U. Bukhari | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
353 Inflammation and thinning of the lining of your vagina (called atrophic vaginitis) Thinning of the lining of your uterus Growths in the cervix or uterus (called polyps) which are usually not cancerous Thickened endometrium (called endometrial hyperpla-sia) often because of hormone replacement therapy (HRT) Abnormalities in the cervix or uterus “These are generally not serious problems and can be cured relatively easily. However, about 10% of the time, post-menopausal bleed-ing is linked to cancer of the cervix or uterus and so it is very important to have it investigated. ” [16] Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... Are you 55 years old? How can I help you today?” Chief Complaint: Estimate Blood Loss: Since when? How much? Color? Number of pads soaked? Any clots Presence of any tissue? Gynecology History: Menarche? What age? Last menstrual period? Vaginal discharge? Last Pap smear? Current sexual activity? Vaginal intercourse or penetration (local trauma)? Intercourse at early age? HPV? Multiple partners? Associated Symptoms: The presence of signs of anemia or iron deficiency (pallor, fatigue, shortness of breath) Symptoms of menopause: Hot flushes, mood swings, vaginal dryness. Easy bruising. Other sites of bleeding (bleeding disorder). Pelvic pain. Presyncope, shortness of breath, palpitation. Urinary symptoms. Bowel symptoms. “May I ask, do you have any problems related to inter-course such as pain or bleeding?” “Have you ever been diagnosed with STIs or other pelvic infections?” Vaginal discharge? Fever, chills, or weight loss? Obstetrics History: Number of pregnancies? Any abortion? Live children? Route of delivery (vaginal or cesarean delivery) Past Medical History: “Do you have any other health issues?” Bleeding disorder? PID? Hypothyroidism? Diabetes? Kidney disease? Endometriosis? Pelvic instrumentation? History of cervix, uterine, or vaginal cancer? Past Hospitalization: “Have you had any previous hospitalization?” Medication History: “Are you taking any medications prescribed, over the counter, or herbal? If so, have there been any side effects?” Aspirin or blood thinners? Surgical History: Previous abdominal and gynecological surgery of relevance Allergic History: “Do you have any known allergies?” Social History: “Do you smoke? Or does anyone else in your home or close proximity at work smoke?” “Do you drink alcohol?” If yes, then ask further questions: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” 11 Obstetrics and Gynecology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
354 Family History: Presence of chronic disease? Family history of cervical/uterine or vaginal cancer? Family history of premature menopause? Wrap-Up: Question: “What will you do next?” Answer: “I will do a physical examination with pelvic and speculum examination”: General appearance: Pallor, jaundice, dehydration, BMI Skin: Bruises or purpura Vital signs (postural drop) Perform a thyroid examination Abdominal examination: Distention, tenderness espe-cially on the RIF and LIF. Any mass or hernia. Pelvic examination: Amount of bleeding, color of blood, clots, discharge, or signs of trauma? Speculum examination: Look for any signs of trauma, ulceration, polyps, discharge, lesions, warts, scratch, and atrophic change. Take swabs from the vagina and cervix. Perform a bimanual examination checking for size, shape, and position of the uterus, adnexal tenderness or mass, and cervical excitation. Question: “What investigations will you order?” Answer: Full blood examination Urea, creatinine, and electrolytes Coagulation profile Liver function test Thyroid function tests Pap smear USG pelvis and transvaginal ultrasound Book a follow-up visit. References 1. Johns Hopkins Medicine. Calculating a due date. https://www. hop-kinsmedicine. org/healthlibrary/conditions/pregnancy_and_child-birth/calculating_a_due_date_85,p01209. Accessed 17 Apr 2018. 2. The Practice Committee of the American Society for Reproductive Medicine. Current evaluation of amenorrhea. Fertil Steril. 2008;90(5):S219-25. http://www. fertstert. org/article/ S0015-0282(08)03527-9/fulltext. 3. Klein DA, Poth MA. Amenorrhea: an approach to diagnosis and management. Am Fam Physician. 2013;87(11):781-788. https:// www. aafp. org/afp/2013/0601/p781. html. Accessed 17 Apr 2018. 4. Australian STI management guidelines for use in primary care. Vaginal discharge. http://www. sti. guidelines. org. au/syndromes/ vaginal-discharge#possible-causes. Accessed 17 Apr 2018. 5. Candida Hub. What does a yeast infection smell like? How a yeast infection smells (candida odor). https://candidahub. com/Candida-Odor/What-Does-a-Yeast-Infection-Smell-Like. Accessed 17 Apr 2018. 6. Hainer BL, Gibson MV. Vaginitis: diagnosis and treatment. Am Fam Physician. 2011;83(7):807-15. 7. Johnson NR. Vaginitis and vulvitis. Obgyn key. 6 June 2016. https:// obgynkey. com/vaginitis-and-vulvitis/. Accessed 17 Apr 2018. 8. Rivera R, Yacobson I, Grimes D. The mechanism of action of hor-monal contraceptives and intrauterine contraceptive devices. Am J Obstet Gynecol. 1999;181(5 Pt 1):1263-9. 9. National Down Syndrome Society (NDSS). What is down syn-drome. https://www. ndss. org/about-down-syndrome/down-syn-drome/. Accessed 17 Apr 2018. 10. Griebel CP, Halvorsen J, Golemon TB, Day AA. Management of spontaneous abortion. Am Fam Physician. 2005;72(7):1243-50. 11. Deutchman M, Tubay AT, Turok DK. First trimester bleeding. Am Fam Physician. 2009;79(11):985-92. 12. Ludwig H. Christian Gerhard Leopold (1846-1911): Nicht nur der Lehrmeister der Geburtshilfe. Gynakologe. 2004;37(10):961. 13. Leopold CG, Spörlin N. Die Leitung der regelmäßigen Geburt nur durch äußere Untersuchung. Arch Gynakol. 1894;45:337-68. 14. Calleja-Agius J, Custo R, Brincat MP, Calleja N. Placental abrup-tion and placenta praevia. Eur Clin Obstet Gynaecol. 2006;2:121-7. 15. Victoria State Government. Placenta previa. Better health channel. Aug 2014. https://www. betterhealth. vic. gov. au/health/healthyliv-ing/placenta-previa. Accessed 17 Apr 2018. 16. The Royal Women's Hospital, Victoria, 1928 Australia. Bleeding after menopause. https://www. thewomens. org. au/health-infor-mation/periods/periods-overview/bleeding-after-menopause. Accessed 17 Apr 2018. M. H. Sherazi and U. Bukhari | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
355 © Springer Nature Switzerland AG 2019 M. H. Sherazi, E. Dixon (eds. ), The Objective Structured Clinical Examination Review, https://doi. org/10. 1007/978-3-319-95444-8_12Pediatrics Umair Khalid and Mubashar Hussain Sherazi Common Pediatric Symptoms for the Objective Structured Clinical Examination Common symptoms in pediatrics: Fevers Funny turns Cough Dehydration Irritable Rash Crying baby V omiting and diarrhea Painful ear Painful abdomen Child “not their usual self” Injuries/head injuries Jaundice Anaphylaxis Not gaining weight/failure to thrive Behavioral issues Not meeting developmental milestones History Overview: Pediatrics In the objective structured clinical examinations (OSCE), you are likely to get at least one and often two stations, on a pediatric case scenario. This will include a detailed history, possibly a discussion of an examination (the need to examine a child in the OSCE setting is unlikely), and likely to end in counseling and/or discussing a management plan with the child's parents. Pediatric cases can be highly varied, and this chapter will aim to cover the most common topics. You will most likely be taking a history from the child's parents (role player) and may need to discuss a physical exam-ination with the examiner in the room. In most cases, the sta-tion will be approximately 10 minutes; one should try to keep the history and examination discussion to 5 minutes, leaving 5 minutes to counsel and discuss a plan with the parents. This chapter outlines common pediatric-related topics important for an OSCE. There is an overview of the history taking required for pediatric stations (Table 12. 1), followed by several common and important pediatric presentations with detailed histories and counseling discussions. In pediat-ric cases, it is important to develop skills in communication to be able to counsel and reassure the child's parents. Detailed History: Pediatrics Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) or show your identification (ID) badge. Sit on the chair or stand on the right side and start the interview. U. Khalid ( *) Child & Adolescent Unit, Mackay Base Hospital, Mackay, Queensland, Australia M. H. Sherazi Mallacoota Medical Centre, Mallacoota, Victoria, Australia12 | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
356 Introduction: Identify the historian: parent or relative? Child's name and age. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Mr. /Mrs....? Are you the parents of... ? And he/she is... years old?” Chief Complaint: Chief complaint or the reason the patient is visiting the clinic. “What has brought your child/the child in today?” or “Tell me about their symptoms or your main concern. ” Allow the historian to answer, while trying not to inter-rupt or direct the conversation. Try to facilitate the historian to expand on the presenting complaint if required. For exam-ple: “So tell me more about that. ” During a pediatric history and examination, remember to remain vigilant to discrepancies between histories as well as between a history and an examination. These discrepancies are red flags for child safety concerns and should always be kept in mind. History of Presenting Illness: When was the child (last well)? What happened and when? Analysis of the chief complaint: -Onset. -Course. -Duration. -Predisposing factors. -Aggravating and relieving factors. -Red flags/risk factors. -Impact on body. -Constitutional symptoms. -Rule out differential diagnosis. -Management/treatment so far. Associated symptoms: nausea, vomiting, diarrhea, con-stipation, urinary, jaundice, sweating, fever, weight loss/ gain. Review of Systems: Respiratory Genitourinary (GU) Cardiovascular Table 12. 1 Quick review of history taking for pediatric stations Introduction (Identify the historian: parent or relative?) Child's name and age Confirm the historian's relationship to the child Chief complaint Presenting complaint/parent's concern History of present illness When was the child (last well)? What happened and when? Analysis of chief complaint Onset/course/duration Predisposing factors Aggravating and relieving factors Red flags/risk factors Constitutional symptoms Rule out differential diagnosis Associated symptoms: nausea, vomiting, diarrhea, constipation, smell to urine, jaundice, sweating, fever, weight loss/gain Review of systems Respiratory Genitourinary Cardiovascular Neurology Gastroenterology Past medical and surgical history Baby health visits Medical illnesses Any previous or recent surgery Hospitalization history or emergency visits, accidents, frequent trauma Medications/allergic history/triggers If a child Birth history Immunization Nutrition Development Emergency room visits Home situation With whom does the child live? If an adolescent (HEEADS) Home Education Employment Activities Drugs Sexual activity Family history Family history of same symptoms; or any other conditions Social history Ask for parent's socioeconomic status, marriage, job, ethnic background Wrap-up Describe the diagnosis Management plan Possible medical treatment Duration of treatment and side effects Table 12. 1 (continued) Red flags Laboratory tests Further information: websites/brochures/support groups or societies/toll-free numbers Counseling, safety netting, and follow-up U. Khalid and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
357 Neurology Gastroenterology Hydration status (tears, wet nappies/diapers, oral intake, lethargy) Past Medical and Surgical History: Baby health visits, medical illnesses, any previous or recent surgery Hospitalization history or emergency visits, accidents, frequent trauma Medications/Allergic History/Triggers: Current medications that the child is taking including pre-scribed medications, over the counter (OTC) medication, herbal remedies, and vitamins. Does the child have any allergies to any medications or any other general allergies? Any specific triggers known to cause certain symptoms. Child (BINDES): Birth history Immunizations Nutrition Development Environment Social Birth History: Birth history includes prenatal, natal, and postnatal histories. You need to tailor the prenatal, natal, and postnatal questions accord-ing to context. If the birth history is not relevant to the presenta-tion of the child, then one general question will be sufficient such as “Any issues with the pregnancy/birth of the child?” Prenatal: -“Was it a planned pregnancy?” -“Did you have any regular follow-up?” -“Did you have any ultrasonography (USG) scans? Was it normal or not?” -“During your pregnancy did you have any fevers or skin rash?” -“Any contact with sick person or cats?” -“Any medication/smoking/drugs/alcohol?” -“Screened for human immunodeficiency virus (HIV), syphilis, Group B Streptococcus (GBS), hepatitis B? Blood group?” Natal (delivery): -“Term baby or not?” -“What was the route? Cesarean section (C/S), sponta-neous vaginal delivery (SVD), or assisted vacuum delivery (A VD)?” -“How long was the labor/delivery?” (18 h is normal for primi, 12 h for multi)-“Early gush of water?” (Premature rupture of membranes) -“Any need for augmentation/induction?” -“What was the Apgar score?” (1 and 5 min) -“Did the baby cry immediately?” -“Did your baby need any special attention or admis-sion to special care?” -“Any bulging or bruising on the baby's body?” -“When were you sent home?” (C/S 3 days, SVD 1 day) -“After delivery did you have any fever/vaginal dis-charge/on any medication?” -“Were you told that your baby had any congenital deformity?” Natal (birth): -Vaginal or CS? -Spontaneous or assisted labor (i. e., forceps delivery)? -Premature rupture of membranes (PROM) or fever? -Baby: full term/preterm, weight at birth, Apgar score if known -Did the child need any resuscitation at birth? Postnatal or newborn period: -Mom: fever, bleeding, or any other complication -Baby: jaundice, screening tests, congenital anomalies, suckling, and weight gain Immunization: If they state that the child is not immunized, you need to inquire for the reason. If the child is not vaccinated due to a reason that points toward neglect, then look for child abuse red flags. Inquire further about weight gain and developmen-tal milestones. If it is due to religious beliefs, you do not have to inquire further. Otherwise, move onto nutrition. Nutrition: Mom's medications Complications during pregnancy such as diabetes, bleed-ing, hypertension Multiple pregnancy Infections such as TORCH: toxoplasmosis, other (syphi-lis, varicella-zoster, parvovirus B19), rubella, cytomega-lovirus (CMV), and herpes Mom's age Planned or unplanned pregnancy Weight -What is the current weight? -Birth weight -Maximal weight Is the child breastfed? Or bottle-fed? -Frequency, amount, supplement, formula fortified, weaning, and if formula, then ask about type/brand. Growth charts (height/weight/head circumference) 12 Pediatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
358 Feeding -Formula When did you start the formula? Was baby ever breastfed? If yes, then why stopped? Did you consider breastfeeding? What type of formula do you use? -“Has there been any changes in the feeding? Did you add any solid food or supplements (any fortified serials or iron)?” -If any diarrhea, when did it start (before the solid food or after)? Development History: Gross motor, fine motor, vision, hearing/speech, and social Are they developing according to their milestones? For example: -6 months: head control, grasp a toy, generalized reac-tions, smiles, and babbles -18 months: sitting without support, walking/running, good fine motor control (swapping objects/turning pages), 1-15 words, and have self-awareness -30 months: jump, go up/down stairs without assis-tance, symbolic thought Are they growing along growth centiles? How do they compare to their siblings? Any comments from their teachers at school or daycare? Environment: “With whom does the child live at home?” “Any other children?” “Relation between your child and others?” “Who spends most of the time with the child?” “Financially how do you support yourself?” “Do you live in your own house?” “Anyone at home drinks or uses drugs?” Building Basement (mold) Old house (lead poisoning) Children Attending School: School performance: comparing the grades between now and previous Adolescents (HEEADDSS): Home: “With whom do you live?” Education: which grade? School performance? Grades? Recent changes in grades? Employment/future career aspirations? Activities, hobbies, exercise? -Hobbies (in case of epilepsy -ask for the risky activities) Diet -any specific diet? Drugs and alcohol -“Do you smoke? Recreational drugs? Intravenous drug use (IVDU)?” -“A lot of people of your age might experiment with drugs. How about you?” Sexual activity/relationships Suicidal ideation (“Have you tried hurting yourself?”)/ mood? Social History: Smoking Alcohol Street drugs Sexual history (male, female, both) Family History: Family history of the same/similar symptoms. Any other family history? Family tree (genetic conditions) Consanguinity Wrap-Up: Describe the diagnosis/condition. Management plan. Possible medical treatment. Duration of treatment and side effects. Red flags. Laboratory tests. Further information websites/brochures/support groups or societies/toll-free numbers. Parental counseling/reassurance/safety net/follow-up. History and Counseling: Fever Candidate Information A 3-year-old boy is brought into the emergency department (ED) by his parents due to having a fever and feeling unwell. Take a detailed history from the parents and counsel the par-ents on fevers in children. No physical examination is required for this station. Differential Diagnosis: Respiratory tract infections Viral illness Ear infections Exanthematous diseases Meningitis Urinary tract infections Gastroenteritis Fever is one of the most common reasons for children to present to a doctor and often causes great concern for parents. U. Khalid and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
359 Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) or show your identification (ID) badge. Sit on the chair or stand on the right side and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Mr. /Mrs....? Are you the parents of... ? And he is... years old?” Presenting Complaint: “What brings you to the ED today?” History of Presenting Illness: When was the child last well? Fever: onset, course, and duration. Predisposing factors (unwell contacts), aggravating and relieving factors. Rule out differential diagnosis (with systems review). Management/treatment so far. Any seizures? Associated Symptoms: Ask about any cough, ear discharge, nasal discharge, or pain anywhere. Ask about vomiting. Ask about urine and bowel problems. Ask about any exposure to infected individuals. Any his-tory of travel? Ask about rashes. Neck stiffness? Ask about oral intake. Feeding? Fluids? Wet nappies? Urinary output? Lethargy? Past Medical and Surgical History: Baby health visits Medical illnesses Any previous or recent surgery Hospitalization history or emergency visits, accidents, frequent trauma Past ear infections, convulsions, urinary tract infections, respiratory infections Medications/Allergic History/Triggers: Any known allergies Any regular medications (prescribed, over the counter, herbal/vitamins)Child (BINDES): Birth/pregnancy history, immunization status, nutrition/ weight gain, developmental history/meeting milestones, environment, and social history Family History: Anyone else in the family having similar symptoms? Any conditions that run in the family? Wrap-Up: Mention that once you complete the history, you would then examine the child. Question: “How will you counsel the parents?” (Questions may be asked by the patient or the examiner. ) Answer: “Fevers are very common among children and are not harmful within themselves but rather show that the child's immune system is fighting an infection. There is a small chance (1 in 25) that the febrile child may have a seizure, which within itself is short lived and does no long-term harm. ” (Febrile con-vulsions are discussed in more detail in the next section. ) “It is best to treat the discomfort rather than the fever itself. If the child is irritable with a fever, one may try paracetamol or ibuprofen to bring down the fever. ” “Fevers are usually caused by viral infections; however, it is important to rule out more serious bacterial causes. A child with a fever often needs to take in more fluid than usual; and it is important to keep an eye on their hydration status. If at any point, your child looks sick enough to cause a level of concern, then you should bring them in to the doctors. ” “It is important to return to the hospital if your child looks very sick (lethargic, poorly responsive), has a stiff neck, has a rash, is in respiratory distress, having difficulty swallow-ing, decreased urine output/wet nappies, has a limp/not using a limb, has severe abdominal pain, any redness/swelling on their body or if they have a seizure. ” Questions: “How to assess hydration status?” Answer: Vitals (heart rate, respiratory rate), mucus mem-branes, urine output, skin turgor, sunken eyes, fontanelles, tears, capillary refill, irritable/lethargy/reduced consciousness level As per the Royal Children's Hospital Melbourne clinical guidelines [1]: -Mild (<4%) dehydration -may have no clinical signs -Moderate (4-6%) -delayed capillary refill, increased respiratory rate (RR), mild decreased tissue turgor -Severe (≥7%) -very delayed capillary refill, signs of shock (tachycardia, irritable, reduced conscious level, hypotension), deep (acidotic) breathing, decreased tis-sue turgor 12 Pediatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
360 Question: “When would you recommend that the par-ents bring the child back to hospital?” Answer: “If the child looks very sick (lethargic, poorly responsive), has a stiff neck, has a rash, is in respiratory distress, having difficulty swallowing, decreased urine output/wet nap-pies, has a limp/not using a limb, has severe abdominal pain, any redness/swelling on their body, or if they have a seizure. ” History and Counseling: Febrile Convulsion Candidate Information: A 2-year-old girl is brought into the ED by her parents due to having an episode of body stiffening followed by sharp jerky movements of the arms and legs. This is on a background of having a runny nose and a cough. Take a detailed history from the parents and counsel the parents on this condition. No physical examination is required for this station. Differential Diagnosis: Epileptic seizure Generalized seizure Breath holding spell Febrile convulsion Differential for cause of fever: -Respiratory tract infections, ear infections, exanthem-atous diseases, meningitis, urinary tract infections, gastroenteritis, or viral illness In a presentation of a febrile convulsion, one needs to deal with the convulsion as well as to find the foci of infection causing the fever. Febrile convulsions are seizures that occur in children between 6 months and 5 years of age, within a setting of a fever. They are normally associated with simple viral illnesses and are benign. Most often the convulsion occurs at the onset of an illness, when there is the greatest increase in temperature. Simple versus complex febrile seizures [2, 3]: Simple: generalized, tonic-clonic convulsions lasting less than 15 min and that do not reoccur within the same febrile illness Complex: one or more of the following: focal features with the seizure, >15 min, reoccurrence of the seizure within the same illness, and incomplete recovery within 1 h Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) or show your ID. Sit on the chair or stand on the right side and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Mr. /Mrs....? Are you the parents of... ? And she is... years old?” Presenting Complaint: “What brings you in to the ED today?” History of Presenting Illness: When was the child last well? Was this a witnessed episode/seizure? Whole body shaking? Tongue biting? Wet themselves? Eyes rolling? Any neurological signs before/after the seizure? How long did it last? Did it stop on its own or did it require medical intervention? Has this happened before? Immunization status? Recent sick contacts? Fever: onset, course, and duration. Predisposing factors (unwell contacts), aggravating and relieving factors. Rule out differential diagnosis (with systems review). Management/treatment so far. Associated Symptoms: Ask about any cough, ear discharge, nasal discharge, or pain anywhere. Ask about vomiting. Ask about urine and bowel problems. Ask about any exposure to infected individuals. Any his-tory of travel? Ask about rashes. Neck stiffness? Ask about oral intake. Feeding? Fluids? Wet nappies? Urinary output? Lethargy? Past Medical and Surgical History: Baby health visits Medical illnesses Any previous or recent surgery Hospitalization history or emergency visits, accidents, frequent trauma Past convulsions, urinary tract infections, respiratory infections, ear infections Medications/Allergic History/Triggers: Any known allergies Any regular medications (prescribed, OTC, herbal/ vitamins) U. Khalid and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
361 Child (BINDES): Birth/pregnancy history, immunization status, nutrition/ weight gain, developmental history/meeting milestones, environment, and social history Family History: Anyone else in the family having similar symptoms? Any conditions that run in the family? Any epilepsy? Seizures? Febrile seizures? Wrap-Up: Mention that once you complete the history, you would then examine the child. Question: “How will you counsel the patient/parents?” Answer: “Most children who have a simple febrile convul-sion do not have any long-term sequelae; however, if your child is having repeated or complex febrile convulsions, it is advisable to follow-up with a pediatrician. It is important to find the cause of the fever and to rule out serious infections such as meningitis or sepsis. ” “Treatment of a fever, with paracetamol or ibuprofen, does not necessarily prevent a febrile seizure; in fact, noth-ing can be done to prevent a febrile convulsion. It can be very scary for parents who experience this; however, they can be reassured that there are no long-term health effects. If there is a focus of infection found on examination, no further investigations are required. ” “Your child can be discharged and return to a normal rou-tine, and no medications are required on discharge. After a simple febrile convulsion, no further follow-up or investiga-tions are required. However, in the case of a complex febrile convulsion, consider observation in hospital as well as pos-sible outpatient pediatrician follow-up. ” “If your child has another convulsion at home, you should be up to date with basic first aid procedures. This includes firstly ensuring the child is safe (will not fall off a bed/around dangerous objects); roll them on to their side and call for help. Parents should be up to date with first aid and cardio-pulmonary resuscitation (CPR) certification. ” History and Counseling: Respiratory Tract Infection Candidate Information: An 8-month-old boy is brought into the ED by his parents due to being in respiratory distress (intercostal recession, nasal flaring, and grunting) with a decreased oral intake on a background cough of 1 week. Differential Diagnosis: Reactive airway disease/wheeze/asthma Bronchiolitis Pneumonia Pharyngitis/tonsillitis Acute otitis media Croup Whooping cough (Pertussis) Cystic fibrosis 1. Productive: bronchiectasis, bronchitis, abscess, bacterial pneumonia, tuberculosis (TB) 2. Nonproductive: viral infections, interstitial lung disease, anxiety, allergy 3. Wheezy: suggests bronchospasm, asthma, allergy 4. Nocturnal: asthma, congestive heart failure (CHF), post-nasal drip, gastroesophageal reflux disease (GORD or GERD), or aspiration 5. Barking: epiglottal disease (croup) 6. Positional: abscess, tumor Respiratory conditions account for a majority of acute pediatric presentations and can be broken down into condi-tions that compromise the airway vs. conditions that com-promise the parenchyma. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) or show your ID badge. Sit on the chair or stand on the right side and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Mr. /Mrs....? Are you the parents of... ? And he is... years old?” Presenting Complaint: “What brings you in to the ED today?” History of Presenting Illness: When was the child last well? Start with questions related to the cough -Onset of cough? -Nature of cough? -Chronicity? -Time of day/night of cough? 12 Pediatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
362 -Duration? -Contributing factors? -What makes the cough worse/better? Any treatment so far? -Productive cough? Color and quantity of sputum? -Prodromal illness? Fever/malaise/lethargy? Rhinorrhea? Shortness of breath? -Any triggers for the cough (allergies/dust/pollution/ cold/smoke/exercise)? Allergies? Allergic symptoms (red eyes/itching)? Immunizations up to date? Predisposing factors (sick contacts)? Does the child go to school or daycare? Management/treatment so far? Associated Symptoms: Ask about any ear discharge, nasal discharge, or pain anywhere. Ask about vomiting. Ask about urine and bowel problems. Ask about any exposure to infected individuals. Any his-tory of travel? Ask about rashes. Neck stiffness? Ask about oral intake. Feeding? Fluids? Wet nappies? Urinary output? Lethargy? Past Medical and Surgical History: Baby health visits Medical illnesses Any previous or recent surgery Hospitalization history or emergency visits, accidents, frequent trauma Past respiratory infections, ear infections Medications/Allergic History/Triggers: Any known allergies Any regular medications (prescribed, OTC, herbal/ vitamins) Child (BINDES): Birth/pregnancy history, immunization status, nutrition/ weight gain, developmental history/meeting milestones, environment, and social history Family History: Anyone else in the family having similar symptoms? Any conditions that run in the family? Asthma? Respiratory conditions? Wrap-Up: Mention that once you complete the history, you would then examine the child. Question: “How will you counsel the parents?” Answer: “A very common condition in children under 2 years of age is bronchiolitis. It is a condition of the small airways that is caused by a virus -the most common being respiratory syncytial virus. It often starts with general cold- like symptoms, and over a few days, they may worsen in terms of their cough, and you may hear a wheeze. The child may appear to be in respiratory discomfort and often will begin to have difficulty feeding due to the labored breathing. ” “Bronchiolitis is a viral infection and thus your child will not need antibiotics. It usually peaks at 2-4 days of the onset of symptoms and then gradually improves. Most children are back to their normal selves in 7-10 days. The two reasons why we might choose to admit your baby to hospital is if (1) the baby is requiring oxygen therapy and (2) the baby is not able to feed and thus will require nasogastric tube feeds or intravenous fluid. It is advised to the parents to cease smok-ing around the child. ” Question: The parents ask you if they should use Ventolin. Answer: “Ventolin may be tried for older children as it can be quite difficult to tell the difference between bronchiolitis and reactive airways disease. ” See reactive airway disease/ wheeze action plan (Fig. 12. 1) [4]. History and Counseling: Ear Pain Candidate Information: An 18-month-old girl is brought into the GP clinic by her parents due to having fevers and constantly pulling at her ears. Differential Diagnosis: Acute otitis media Otitis media with effusion Mastoiditis Otitis externa Hearing loss Foreign body Acute otitis media is a very common problem in child-hood, with at least 90% of children having at least one episode prior to going to school. Viral causes account for 25% of cases, whereas bacterial sources account for the majority of cases (Streptococcus pneumoniae, 35%; Haemophilus influenzae, 25%; and Moraxella catarrhalis, 15%) [5 ]. U. Khalid and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
363 Fig. 12. 1 Wheeze action plan (Reprinted under terms of Creative Commons Attribution 4. 0 International license (CC BY 4. 0) from Queensland Government Children's Health Queensland Hospital and Health Service. https://www. childrens. health. qld. gov. au/wp-content/ uploads/PDF/wheeze-action-plan. pdf [4]) 12 Pediatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
364 Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) or show your identification (ID) badge. Sit on the chair or stand on the right side and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Mr. /Mrs....? Are you the parents of... ? And she is... years old?” Presenting Complaint: “What brings you in today?” History of Presenting Illness: When was the child last well? Is the child complaining of a painful ear? Onset? Nature? Location? Duration? Aggravating and alleviating factors? Any treatment so far? Any discharge? Color? Smell? Fevers? Lethargy? Irritability? Any concerns with hearing? Any previous history of ear infections? Associated Symptoms: Ask about any nasal discharge or pain anywhere. Ask about vomiting. Ask about urine and bowel problems. Ask about any exposure to infected individuals. Any his-tory of travel? Ask about rashes. Neck stiffness? Ask about oral intake. Feeding? Fluids? Wet nappies? Urinary output? Lethargy? Past Medical and Surgical History: Baby health visits Medical illnesses Any previous or recent surgery Hospitalization history or emergency visits, accidents, frequent trauma Past respiratory infections, ear infections Medications/Allergic History/Triggers: Any known allergies Any regular medications (prescribed, OTC, herbal/ vitamins)Child (BINDES): Birth/pregnancy history, immunization status, nutrition/ weight gain, developmental history/meeting milestones, environment, and social history Family History: Anyone else in the family having similar symptoms? Any conditions that run in the family? Asthma? Respiratory conditions? Wrap-Up: Mention that once you complete the history, you would then examine the child. Question: “How will you counsel the parents?” Answer: “It is very common for children to have ear infec-tions. In fact, 90% of children will have at least one episode before going to school. It is common to occur after a viral respiratory tract infection. Hearing loss is noticeable at the time of infection, especially if bilateral; however, it should self-resolve. If concerns for ongoing hearing loss after infec-tion resolves, a review with the GP should occur. ” “There are a number of measures to prevent recurring epi-sodes of acute otitis media including limiting exposure to viral infections (daycares, etc. ) and reducing exposure to cigarette smoke. If episodes continue to occur, a referral can be made to an ear, nose, and throat (ENT) clinic to consider an insertion of a grommet. Grommets are small tubes that are inserted into the eardrum to allow air into the middle ear and thus prevent a fluid build-up. ” History and Counseling: Rash Candidate Information: A 6-year-old girl is brought into the ED by her parents due to having fevers with an associated rash on the face. Differential Diagnosis [6]: Impetigo Scarlet fever Chickenpox Virus (coxsackieviruses and enteroviruses) Meningococcemia Lyme disease Kawasaki disease Toxic shock syndrome There are many causes for rashes in children, including but not limited to reaction to skin irritants, drug reactions, infec-tions, or an allergic reaction. Rashes can represent a benign viral U. Khalid and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
365 infection or could be a sign of a life-threatening emergency. The key to an accurate diagnosis is a very careful and detailed his-tory followed by a judicious examination of the rash. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) or show your ID badge. Sit on the chair or stand on the right side and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Mr. /Mrs....? Are you the parents of... ? And she is... years old?” Presenting Complaint: “What brings you in to the ED today?” History of Presenting Illness: When was the child last well? When did the rash start? Where is the rash? Is it generalized or localized? Has the rash changed over time? Does the rash look the same now or how it did initially? Has the child had this rash before? Is it getting worse? Is there anything that makes the rash better or worse? Is the rash itchy? Is there any pain or abnormal sensations? Any treatment so far (tried any ointments or creams)? Any fevers? Any infective symptoms (cough/runny nose/sore throat/ vomiting/diarrhea)? Any sick contacts? Daycare? Any recent travel out of the country? Has the child started any new medications recently? Recent immunizations? Any skin products changed at home recently (soaps/ shampoos/washing detergents/lotions etc. )? Associated Symptoms: Ask about any ear discharge, nasal discharge, or pain anywhere. Ask about vomiting. Ask about urine and bowel problems. Ask about any exposure to infected individuals. Any his-tory of travel? Ask about rashes. Neck stiffness? Ask about oral intake. Feeding? Fluids? Wet nappies? Urinary output? Lethargy? Past Medical and Surgical History: Baby health visits Medical illnesses Any previous or recent surgery Hospitalization history or emergency visits, accidents, frequent trauma Past ear infections, convulsions, urinary tract infections, respiratory infections, asthma, allergies Medications/Allergic History/Triggers: Any known allergies Any regular medications (prescribed, OTC, herbal/ vitamins) Child (BINDES): Birth/pregnancy history, immunization status, nutrition/ weight gain, developmental history/meeting milestones, environment, and social history Family History: Anyone else in the family having similar symptoms? Any conditions that run in the family? Anyone in the family with asthma or atopy? Wrap-Up: Mention that once you complete the history, you would then examine the child (including a thorough examination of the rash). Question: “How will you counsel the parents?” Answer: “The most important thing to do is to reassure the parents that the rash is not sinister or a sign of a serious dis-ease. If the child is not lethargic, peripherally cold, and tachycardic/tachypneic, is alert and interactive, has a blanch-ing rash, and does not look clinically sick, then it is unlikely that the rash is serious. ” “The rash associated with a fever, with no obvious focal signs of infection, is most likely due to a viral illness. Viral infections are common in children and often present with a low-grade fever and a rash. These rashes are harmless and will go away on their own. There are some viral rashes that have very distinctive appearances (viral exanthems) including hand, foot, and mouth disease, roseola infantum, and slapped cheek syndrome. ” “Rashes can have very different appearances and present in many different ways. The viruses are usually spread by direct contact. The rash and fever will often coincide; how-ever, the fever will either present before the rash, before the illness, or at the same time as the rash. ” 12 Pediatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
366 “If your child becomes quite unwell, lethargic, unable to tolerate oral intake, or unable to produce adequate urine and/ or has a rash that does not turn white (blanch) when pushed, then return to the hospital. ” History and Counseling: Anaphylaxis and Epi Pen Counseling Candidate Information: A 10-year-old girl is brought into the ED by ambulance due to severe facial and tongue swelling, respiratory distress with associated stridor, and vomiting after ingesting peanuts in school. Differential Diagnosis: Anaphylaxis Angioedema Asthma exacerbation Ingestion of foreign body Panic attack Excess histamine syndromes Anaphylaxis is a life-threatening condition and is treated as an emergency unlike a generalized allergic reaction. Anaphylaxis is a rapidly evolving generalized multi-system allergic reaction that is characterized by symptoms/signs of respiratory and cardiovascular involvement and may also include symptoms/signs of other systems such as the gastro-intestinal tract and/or skin. The clinical manifestations of anaphylaxis may include hypotension, bronchospasm, and upper airway obstruction [7]. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) or show your ID badge. Sit on the chair or stand on the right side and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Mr. /Mrs....? Are you the parents of......? And she is... years old?” Presenting Complaint: “What brings you in to the ED today?” History of Presenting Illness: When was the child last well? What happened? Events? Any known triggers? Have triggers been removed? Was she eating something at the onset of symptoms? New medication commenced? Known to have anaphylaxis? What symptoms occurred and how have they progressed? Has she had any treatment yet? Any cough? Wheeze? Swelling around tongue and lips? Change in voice? Trouble swallowing? Any palpitations? Was there any loss of consciousness? Headache? Dizzy? Confusion? Nausea? V omiting? Diarrhea? Abdominal pain? Rashes? Any foreign bodies ingested? Any history of asthma? Any fevers? Past Medical and Surgical History: Baby health visits Medical illnesses Any previous or recent surgery? Hospitalization history or emergency visits, accidents, frequent trauma Known anaphylactic triggers? Allergies? Asthma? Atopy? Medications/Allergic History/Triggers: Any known allergies Any regular medications (prescribed, OTC, herbal/ vitamins) Child (BINDES): Birth/pregnancy history, immunization status, nutrition/ weight gain, developmental history/meeting milestones, environment, and social history Family History: Anyone else in the family having similar symptoms? Any conditions that run in the family? Anyone in the family with asthma or atopy? Wrap-Up: Mention that once you complete the history, you would then examine the child. Question: “How will you counsel the parents?” Answer: “Anaphylaxis is basically a hypersensitivity or severe allergic reaction. It is a multi-system allergic reaction characterized by a sudden onset development of symptoms typically including skin features plus respiratory, cardiovas-cular, and/or gastrointestinal symptoms. Usual triggers to anaphylaxis may be food, medications, or chemicals -in this case being peanuts. ” U. Khalid and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
367 “At a certain stage, the immune system starts to inter-act with elements of the peanut, called antigens. From now on, when your daughter will be exposed to the same antigens (peanuts), it will lead to a release of chemicals that will affect the skin and will widen the blood vessels causing them to become leaky. This will result in swelling around the body and especially can become serious if there is swelling around the neck, which can obstruct the airway. ” “The best treatment for this condition is future preven-tion. You will need to be careful and check the ingredients of all foods to ensure they are peanut free. It will be best to ensure that the child's siblings are made aware of this condi-tion as well as her friends and school environment. ” “She will now need to carry what is called an Epi Pen with her as treatment if she is to be exposed to peanuts and has a similar reaction in the future. The Epi Pen is a special pen with a needle on it that is capped and only activated once applied with pressure to the thigh for 10 seconds (Figs. 12. 2 and 12. 3) [8, 9]. This pen contains adrenaline, which is the treatment for anaphylaxis. ” “This will maintain the blood pressure for about 20 minutes longer, and thus she will still need to present her-self to the emergency department. You should get a prescrip-tion for two pens at a time, one to be kept at home and one to be carried daily to school. I will also do a referral to an allergy specialist for you. ” History and Counseling: Vomiting Candidate Information: A 5-week-old girl is brought into the ED by her parents due to recurrent projectile vomits shortly after feeding. She has inadequate weight gain for her age. Differential Diagnosis: Sepsis/infection (meningitis, pneumonia, urinary tract infection, necrotizing enterocolitis) Obstruction (malrotation, volvulus, intestinal atresia, incarcerated hernia) Hiatal hernia Pyloric stenosis GORD Neurologic (increased intracranial pressure secondary to hydrocephalus, hemorrhage, tumor, or trauma) Renal Metabolic Milk/soy protein allergy Overfeeding V omiting is a very common symptom in children and is most often due to gastroenteritis; however, it may also be an initial symptom of a more sinister medical condition that would require further work-up and investigation to rule out. It is a symptom that is often mistaken due to a baby “spitting up” shortly after a feed. The major concerns with a child vomiting are, firstly, whether it is a presentation of a sinister condition; secondly, whether the child is dehydrated; and, lastly, if any electrolyte disturbances have occurred second-ary to the vomiting. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) or show your ID badge. Sit on the chair or stand on the right side and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Mr. /Mrs....? Are you the parents of... ? And she is... weeks old?” Presenting Complaint: “What brings you in to the ED today?” History of Presenting Illness: When was the child last well? Age of onset of vomiting? Duration? Severity? Association of vomiting with feeding? Certain body positions? Description of force of vomiting? V olume of vomitus? Color? Composition (bilious, fecal, blood, regurgitant)? Is it getting worse or better? Is the child still hungry after she vomits? Or does she settle down? Fig. 12. 2 Epi Pen®. Source: Tokyogirl79. https://en. wikipedia. org/wiki/ Epinephrine_autoinjector. (Reprinted under terms of Attribution-Share Alike 4. 0 International (CC BY-SA 4. 0)) 12 Pediatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
368 Fig. 12. 3 How to administer an adrenaline autoinjector (Epi Pen®) (Reprinted with permission from Allergy & Anaphylaxis Australia. https:// allergyfacts. org. au/allergy-management/risk/ change-to-instructions-on-epipen-administration) U. Khalid and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
369 Does she cough or gag while feeding? Any associated diarrhea or constipation? Fevers? Weight loss? Lethargy? Abdominal distension? Any other sick contacts? Any recent trauma/head injury? Associated Symptoms: Ask about any ear discharge, nasal discharge, coughs. Ask about vomiting. Ask about urine and bowel problems. Ask about any exposure to infected individuals. Any his-tory of travel? Ask about rashes. Neck stiffness? Ask about oral intake. Feeding? Fluids? Wet nappies? Urinary output? Lethargy? Developmental History: Age and weight normograms Feeding history: quantity, frequency, breast vs. bottle (which formula?) Colic? Feeding issues? Past Medical and Surgical History: Baby health visits Medical illnesses Any previous or recent surgery Hospitalization history or emergency visits, accidents, frequent trauma Medications/Allergic History/Triggers: Any known allergies Any regular medications (prescribed, OTC, herbal/ vitamins)Child (BINDES): Birth/pregnancy history, immunization status, nutrition/ weight gain, developmental history/meeting milestones, environment, and social history Family History: Anyone else in the family having similar symptoms? Any conditions that run in the family? Wrap-Up: Mention that once you complete the history, you would then examine the child. Question: “How will you counsel the patient/parents?” Answer: “Pyloric stenosis is a thickening of the gastric out-let, which ultimately results in the obstruction of the gastric outlet (Fig. 12. 4). The cause is unclear; however, there is a possible genetic link. It is common to present between 2 and 6 weeks of age. There is a concern for metabolic complica-tions with this condition due to vomiting resulting in a loss of gastric fluid. Babies with pyloric stenosis will need careful rehydration to prevent complications such as cerebral edema and hypernatremia” [10]. “A referral to the surgical team will be done; however, pyloric stenosis is not a surgical emergency, and the focus is on the careful correction of the dehydration. Surgery will be performed once the baby is safely rehydrated and there are no coexisting biochemical/electrolyte abnormalities. ” “The surgeon will further discuss the surgery with you. At 6 h post surgery, small feeds will be commenced. Your baby may still have small vomits; however, this should start to resolve. Once your baby is adequately feeding, they will be able to be safely discharged home. ” Esophagus Stomach Enlarged pylorus Duodenum Normal anatomy Pyloric stenosis Fig. 12. 4 Pyloric stenosis (Reprinted with permission from Yemen and Stemland [22]) 12 Pediatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
370 “If the baby is still having ongoing vomiting at home, and not gaining adequate weight, she will need to be brought back to the emergency department. ” History and Counseling: Diarrhea Candidate Information: A 2-year-old boy is brought into the ED by his parents due to a number of episodes of diarrhea over 2 days, associated with vomiting, fevers, and lethargy. His older brother and sister have similar symptoms. Differential Diagnosis: Enteral infections: bacterial/viral/parasitic gastroenteritis, hemolytic uremic syndrome, pseudomembranous colitis (antibiotic associated) Parenteral infections: UTI, otitis media, pneumonia, sep-sis, etc. Inflammatory: allergy (cow's milk, soy, etc. ), inflamma-tory bowel disease, necrotizing enterocolitis Malabsorption: lactase deficiency, celiac disease, pancre-atic insufficiency (CF), bile deficiency (biliary atresia, etc. ), short gut syndrome Feed related (overfeeding) Immune deficiency related Toxin related: antibiotics, toxin ingestion, chemotherapy, radiotherapy Surgical: intussusception, malrotation, bowel obstruction, appendicitis Endocrine and neoplastic Diarrhea is a very common symptom in children and is most often due to gastroenteritis or food intolerance. However, it may also be an initial symptom of a more sinister medical condition that would require further work-up and investigation to rule out. There are many causes of diarrhea, which can be broadly grouped by their causes: osmotic, secretory, inflammatory, and diarrhea due to motility disor-ders. One of the major concerns of diarrhea in children is dehydration and electrolyte disturbances. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) or show your ID badge. Sit on the chair or stand on the right side and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Mr. /Mrs....? Are you the parents of... ? And he is... years old?” Presenting Complaint: “What brings you in to the ED today?” History of Presenting Illness: When was the child last well? When did the diarrhea start? How many bowel move-ments per day? What is the normal pattern for this child? Are there normal bowel movements between the episodes of diarrhea? Has the child ever had this before? What is the child's dietary history? Did he eat anything before that could have been off? What is the consistency of the stool? What is the volume of the stool the child is passing? Is there blood, pus, or mucus within the stool? Is it very foul smelling? Does it contain “oil droplets”? Does the child have a fever? Is there associated vomiting? Any abdominal pain? What is the urine output? How many wet nappies? Are they eating and drinking as per normal? What is the child's weight today compared to last measured? Anyone else sick who the child has been exposed to? Any recent overseas travel? Any recent use of antibiotics? Associated Symptoms: Ask about any ear discharge, nasal discharge, coughs. Ask about vomiting. Ask about urine and bowel problems. Ask about any exposure to infected individuals. Any his-tory of travel? Ask about rashes. Neck stiffness? Ask about oral intake. Feeding? Fluids? Wet nappies? Urinary output? Lethargy? Past Medical and Surgical History: Baby health visits Medical illnesses Any previous or recent surgery Hospitalization history or emergency visits, accidents, frequent trauma Past ear infections, convulsions, urinary tract infections, respiratory infections, asthma, allergies U. Khalid and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
371 Medications/Allergic History/Triggers: Any known allergies Any regular medications (prescribed, OTC, herbal/ vitamins) Child (BINDES): Birth/pregnancy history, immunization status, nutrition/ weight gain, developmental history/meeting milestones, environment, and social history Family History: Anyone else in the family having similar symptoms? Any conditions that run in the family? Wrap-Up: Mention that once you complete the history, you would then examine the child. Question: “How will you counsel the patient/parents?” Answer: “Gastroenteritis is an illness caused by an infec-tious agent in the stomach/bowels and may include a virus, bacteria, or parasite. Gastroenteritis causes diarrhea and may also be associated with vomiting, fevers, abdominal pain, and cramps. It is usually self-limiting and resolves on its own after a few days; however, the child will remain infectious so long as they have diarrhea and vomiting. ” “Treatment for gastroenteritis is largely conservative with fluid and electrolyte replacement as well as paracetamol being used if fevers are a source of discomfort. Antibiotics and antiemetics are rarely of use. If the history and symp-toms point toward a bacterial source, then antibiotics may be of use. However, this is often commenced upon a positive stool microscopy growing a certain bacterial organism. ” “The main concerns and principles of management for gastroenteritis in a child are rehydration and electrolyte dis-turbances caused by both diarrhea and vomiting. Early rein-troduction of normal diet is advised as soon as the dehydration is corrected. ” “Firstly, a trial of oral rehydration will be commenced; and if that fails, then consideration will be given to nasogas-tric or intravenous rehydration. ” Question: “What are ways to prevent this from happen-ing in the future?” Answer: “Good hand-washing techniques and frequent hand-washing are important for everyone in the family. It is important for all to wash hands thoroughly after going to the bathroom, after changing a diaper or helping the child go to the bathroom and before preparing and eating food. It will be important to disinfect the toys, bathrooms, and any surfaces that the child may have been in contact with. Lastly, it will be important to keep the child with gastroenteritis out of school or daycare until the symptoms resolve. ” History and Counseling: Anemia Candidate Information: A 2-year-old girl is referred to the ED by her GP for having a low hemoglobin (Hb) level associated with fatigue, pallor, and inadequate weight gain over the last few months. Differential Diagnosis: Microcytic -Iron deficiency -Thalassemia -Lead poisoning -Sideroblastic anemia Normocytic -Anemia of chronic disease -Acute blood loss/hemorrhage -Hemolysis -Transient erythroblastopenia of childhood -Mixture of nutritional (iron and B12 deficiency) -Aplastic anemia/marrow infiltration Macrocytic -Drugs -Thyroid disease -Myelodysplasia/Fanconi's anemia -B12/folate anemia B12: -Maternal B12 deficiency: autoimmune gastritis, vegetarian (dietary), inflammatory bowel dis-ease (IBD), ileal resection, Helicobacter pylori, drugs -Malabsorption (terminal ileal disease, Crohn's disease) -Metabolic (inborn errors of metabolism) -Genetic Anemia is defined as having a hemoglobin level that is less than the lower limit of the normal range for the specific age. There are three main mechanisms for a low hemoglo-bin level. These include inadequate production, excessive destruction, and, lastly, excessive blood loss. Inadequate production of red blood cells may cause anemia either from a lack of stimulation of production or from a loss of precur-sor availability (bone marrow level). Excessive or prema-ture red cell destruction may be caused by hemolysis (red cell breakdown) prior to their normal turnover. Lastly, excessive blood loss may occur due to hemorrhage or trauma. 12 Pediatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
372 Anemia is classified as either microcytic, normocytic, or macrocytic and is based on the mean corpuscular vol-ume (MCV). Anemia in children is most commonly due to nutritional deficiency followed by primary hematologic processes. The most common nutritional deficiency caus-ing anemia is an iron deficiency causing a microcytic anemia. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) or show your ID badge. Sit on the chair or stand on the right side and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Mr. /Mrs....? Are you the parents of... ? And she is... years old?” Presenting Complaint: “What brings you in to the ED today?” History of Presenting Illness: “When was the child last well?” “What symptoms have you noticed?” “Any pallor? Lethargy? Weakness? Fast heart rate?” “Is the child losing interest in her normal activities?” “What is the child's diet like?” “Is she eating iron-containing foods? Which foods and how much?” “What does the child drink? What kind of milk and how much?” “How was the child fed in the first year of life? Breast milk vs. formula?” “Timing of the introduction of solids? Timing of transi-tion from breast milk/formula to milk?” “Does your child get the desire to eat non-food items such as dirt, clay, or ice?” “Does the child have any chronic medical conditions?” “What is the child's growth pattern? Weight and height normograms?” “Is the child on any regular medications or any exposure to possible toxins such as lead or radiation?” “Does the child have any fevers, unexplained weight loss, or night sweats?” “Is the child prone to bruising and bleeding?” “Does the child get severe or frequent infections?” “Any recent illness with infective symptoms such as coughs and colds, rashes, vomiting, or diarrhea?” “Urine output?” “Any recent transfusions?” “Is there any recent travel history, specifically to malaria endemic countries?” “Family history of anemia?” “Any obvious blood loss or trauma?” “Any blood in stool or black, tarry melaena?” “Any mucosal bleeding (gums/nose bleeds)?” Past Medical and Surgical History: Baby health visits Medical illnesses Any previous or recent surgery Hospitalization history or emergency visits, accidents, frequent trauma Medications/Allergic History/Triggers: Any known allergies Any regular medications (prescribed, OTC, herbal/ vitamins) Child (BINDES): Birth/pregnancy history, immunization status, nutrition/ weight gain, developmental history/meeting milestones, environment, and social history Detailed dietary history Family History: Anyone else in the family having similar symptoms? Any conditions that run in the family? Wrap-Up: Mention that once you complete the history, you would then examine the child. Question: “How will you counsel the parents?” Answer: “Iron deficiency is the most common cause of anemia in children. In children, iron deficiency is most often nutritional in nature including but not limited to insufficient red meat, fish, chicken, green vegetables, or excessive cow's milk. It is rarely due to other causes such as malabsorption or gastrointestinal bleeding. Iron is one of the important build-ing blocks for hemoglobin, and a lack of it causes insuffi-cient production of red blood cells (Fig. 12. 5) [11]. ” “Risk factors for iron deficiency include prematurity, low birth weight, multiple pregnancy, excessive breastfeeding after 6 months, and excessive cow's milk, as well as a low socioeconomic status. At birth, children generally have ade-quate iron stores, and they are able to live exclusively on breast milk and/or formula without developing iron defi-ciency. Beyond these 6 months, stores begin to run out, and it is important to include iron-rich foods into the diet. Often these are the children who drink excessive amounts of milk or are picky eaters. ” U. Khalid and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
373 “Iron deficiency anemia is quite simple to manage. We can start the child on oral iron supplementation. We can empirically treat and then test the blood again in a few weeks, and if we see an increase in hemoglobin, then we know that the cause of anemia is iron deficiency. ” “Even if the hemoglobin increases to the normal range, it is important to continue iron supplementation for 3 months in order to replenish iron stores. Iron deficiency in the absence of an anemia may lead to reduced cognitive and psy-chomotor performance. ” “The decision for a transfusion will be based on the sever-ity, the symptoms, the cause, and lastly whether it is an acute or chronic anemia. If the hemoglobin levels do not increase with iron supplementation, we will then need to investigate for other causes and treat accordingly” [11]. History and Counseling: Short Stature Candidate Information: An 11-year-old boy has been brought in to the GP clinic by his parents due to concerns of growth. He is otherwise well, but his parents state, “He is much shorter than everyone else in his class at school. ”Differential Diagnosis: Constitutional delay of growth and puberty Familial short stature Intrauterine -Placental insufficiency, Russell-Silver syndrome Skeletal -Bone dysplasia, spinal irradiation Nutritional -Malabsorption (celiac, short gut), rickets, protein- calorie malnutrition Chronic illness -Renal failure, IBD, cystic fibrosis (CF), inborn errors of metabolism Iatrogenic -Long-term corticosteroid therapy Chromosomal/Genetic -Turner, Down, Noonan, Cornelia de Lange Endocrine -Hypothyroidism, growth hormone deficiency, Cushing syndrome/disease, pubertal delay/arrest, pseudohypo parathyroidism Psychosocial deprivation/child protection concerns Short stature describes a height that is significantly below the average height for a person's age, sex, ethnicity, and Anemia? Chec k mean cor puscular v olume (MCV) Normocytic (normal MCV) Reticulocyte count Hemolysis or Blood loss Marro w hypoplasia Leuk emia Infiltrationincreased not increased or abnor malities of other parameters Microcytic (decreased MCV) Serum fe rritin Iron deficiency Hemoglobin electrophoresis Thalassemia minorlow normal Macrocytic (increased MCV) Serum fo late Red b lood cells f olate Vitamin B12 le vel Folate deficiency B12 deficiency Fig. 12. 5 Anemia algorithm. MCV mean corpuscular volume, RBC red blood cell, Hb hemoglobin (Adapted from The Royal Children's Hospital [11]) 12 Pediatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
374 family background. Short stature may be a normal variant or genetically linked; however, it may also be a sign of an organic medical condition. Stature must be assessed within the context of parental heights and the child's pubertal status and bone age. Apart from average height, growth velocity must also be compared to average for age, sex, and ethnicity. There are several factors that affect longitudinal growth, including but not limited to familial growth patterns, nutri-tional status, general medical health, bone health, and several endocrine-related conditions including the growth hormone axis, adrenal function, thyroid status, and the individual effects of insulin and sex steroids. When assessing a child brought in due to concerns of short stature, there are two questions you need to keep in mind: (1) is the child short in relation to other children of the same age and (2) is the child unexpectedly short for the family? Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) or show your ID badge. Sit on the chair or stand on the right side and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Mr. /Mrs....? Are you the parents of... ? And he is... years old?” Presenting Complaint: “What brings you in to the office today?” History of Presenting Illness: Who is mainly concerned that there is a problem with the child's height (child themselves, parents, and/or others)? Is there a family history of growth problems? What are the heights of the child's parents and siblings? Are the parents related to each other? What was the child's birth weight and height? What has their pattern of growth been throughout life? At what gestational age was the child born? Were there any issues during the pregnancy or delivery? -Mode of delivery? -Did the child require any time in special care? -Any major physical issues after delivery? Did the child breast or bottle-feed? Were there any diffi-culties with feeding? Detailed dietary history? Do they consume a normal var-ied diet? Any symptoms suggestive of an eating disorder? Do they take any special supplements? Did the child meet all their normal developmental milestones? Does the child go to school? How are they coping at school? Has the child shown signs of the start of puberty? Systems Review: Any problems with breathing/issues with their lungs? Any bowel issues? Constipation or diarrhea? Abdominal pain? Does the patient have a normal sense of smell (Kallmann's syndrome)? Any dental problems? Any problems with the kidney? Any symptoms of history of thyroid dysfunctions [12]? Any history of vascular abnormalities? Any hearing problems? Any learning difficulties? Or mental health issues? Has the child lost or gained weight? Any changes in body shape? Has he had any testicular surgery, testicular torsion/ trauma, mumps, or maldescent of the testis? Any symptoms of pituitary hormone deficiency [13]? Any cardiac problems? Any liver problems? Any infections? Fevers? Night sweats? Lethargy? Past Medical and Surgical History: Baby health visits Medical illnesses Any previous or recent surgery Hospitalization history or emergency visits, accidents, frequent trauma Medications/Allergic History/Triggers: Any known allergies Any regular medications (prescribed, OTC, herbal/ vitamins) Length of time been taking any regular medications? Child (BINDES): Birth/pregnancy history, immunization status, nutrition/ weight gain, developmental history/meeting milestones, environment, and social history Detailed dietary history Growth pattern history Family History: Anyone else in the family having similar symptoms? Any conditions that run in the family? Any family members who have had late or absent puberty, infertility, or never had children? U. Khalid and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
375 Any family members with dental or palatal problems, kid-ney abnormalities, or anosmia? Wrap-Up: Mention that once you complete the history, you would then examine the child. Question: “How will you counsel the parents?” Answer: “Management of the condition largely depends on the cause for the short stature. Constitutional growth delay is the most common cause of short stature and puber-tal delay. Children who have constitutional growth delay will often have had slowed linear growth within the first 3 years of life. Their growth then resumes at a normal rate; these children will grow along the lower growth percen-tiles at a normal velocity for the prepubertal years. Consequently, at the expected time of puberty, the height of children with constitutional delay will begin to drift fur-ther from the growth curve due to a delay in the pubertal growth spurt. There is reassurance with constitutional delay of growth in that there will be a delayed onset of puberty and growth spurt; however, there will be normal growth to a normal adult. Constitutional delay of growth is a transient state of hypogonadotropic hypogonadism. This diagnosis of constitutional delay in growth can only be made after excluding other causes that cause hypogonado-tropic hypogonadism, which unfortunately cannot be diag-nosed till late. ” “You can be referred to an endocrinologist who can dis-cuss with you further in regard to treatment options for con-stitutional delay in growth as well as investigations that can be done to exclude other causes. ” “The most common drug used to treat this condition is depot testosterone injections. The use of testosterone will need to be done carefully to induce puberty and optimize skeletal growth without inducing premature fusion of the growth plate and without adversely affecting fertility. Another option is growth hormone replacement. ” Question: “What are some further investigations that might be done with the endocrinologist?” Answer: “The investigations that are done will largely be based on the history and examination findings, but the fol-lowing will be considered: Full blood count Erythrocyte sedimentation rate (ESR) Thyroid function tests Renal function tests Serum calcium/phosphate/alkaline phosphatase (ALP) Celiac antibodies Karyotypes for various genetic syndromes Skeletal survey “Depending on the history, further investigations for the assessment of the growth hormone axis may need to be done, including insulin-like growth factor 1 (IGF1), luteinizing hormone, and follicle-stimulating hormone. Lastly, a mag-netic resonance imaging (MRI) of the pituitary gland may be considered. ” History and Counseling: Jaundice Candidate Information: A 2-day-old baby has been brought to your attention due to having a yellow tinge to the skin and conjunctiva. The baby has otherwise been well but has a serum bilirubin 220 μ(mu) mol/L (ref. Max 200 μ[mu]mol/L). Differential Diagnosis: Unconjugated -Physiological neonatal jaundice -Hemolytic ABO Rh incompatibility Neonatal sepsis Splenomegaly Hereditary spherocytosis G6PD -Nonhemolytic Breast milk jaundice Breakdown of cephalohematoma Polycythemia Sepsis Gilberts syndrome Crigler-Najjar syndrome Hypothyroidism Conjugated -Bowel obstruction -Bile duct obstruction/biliary atresia/choledochal cyst -Neonatal hepatitis -Galactosemia -Drug-induced Jaundice is quite common in the newborn period and is almost always caused by unconjugated hyperbilirubinemia. Almost 60% of term and 80% of preterm babies develop jaundice in the first week of life [14]. Jaundice is a sign of elevated levels of bilirubin in the blood; and the baby presents with a yellowish appearance of the skin, mucus membranes, and then conjunctiva. Hyperbilirubinemia occurs when there is an imbalance between bilirubin production, conjugation, and elimination. The breakdown of red blood cells (RBC) and hemoglobin 12 Pediatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
376 cause unconjugated bilirubin to accumulate in the blood. Unconjugated bilirubin binds to albumin and is transported to the liver where it is converted to conjugated bilirubin. Conjugated bilirubin is water soluble and able to be elimi-nated via urine and feces. Unbound unconjugated bilirubin is lipid soluble and can cross the blood-brain barrier [14]. Jaundice needs to be taken seriously because the conse-quence of an untreated high bilirubin level may lead to brain damage (kernicterus). Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) or show your ID badge. Sit on the chair or stand on the right side and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Mr. /Mrs....? Are you the parents of... ? And he is... days old?” Presenting Complaint: “What seems to be the problem?” A yellow tinge to the skin and conjunctiva History of Presenting Illness: When did the mom notice it? If it is early in the second day, is it pathological? Make sure that the baby is stable: “Where did you notice it first?” “Is it spreading to the whole body?” “Did it reach the legs?” “Is it getting darker with time?” “Did you notice any darker urine?” “Is he passing pale/gray stools?” (In biliary atresia, pale stool from the beginning) Ask about associated symptoms: Fever Cough Discharge from eyes/ears Diarrhea V omiting Foul smelling urine Rash Irritability or lethargy Dehydration: how many diapers? Any tears?Ask about these three red flags: High-pitched cry Poor feeding and poor sucking Floppy baby If these three signs are present, tell the mom that you need to examine the newborn and will need a pediatric review and likely admission. Maternal/Obstetric History: GTPAL (number of gestations, term pregnancies, prema-ture births, abortions, live children)? History of previous pregnancies (neonatal jaundice)? Maternal medical history (including liver disease, illness during pregnancy, diabetes, preeclampsia, rubella, toxo-plasmosis, herpes, cytomegalovirus (CMV), medication use during pregnancy)? Any drugs, medications, or alcohol used during pregnancy? Maternal blood type? Any complications of the current pregnancy? Gestational hypertension? Gestational diabetes? Hyper-/hypothyroid-ism? Hypercoagulation? Family history of neonatal jaundice? Liver problems? Group B strep status? Any swab done? Any fevers during delivery? Newborn History: Gestational age at birth? Cesarean delivery versus spontaneous vaginal delivery? Prolonged rupture of membranes? Artificial rupture of membranes? Any fetal distress post-delivery? Forceps or vacuum delivery? Meconium present? What were the Apgar scores at 1 minute and 5 minutes? Was there any resuscitation required? Any admission to special care required for any reason? Any initial blood work done? For what reason? What were results? Is the baby breastfeeding? How often? And how well? What was the color of the first stool? Color of the urine? Past Medical and Surgical History: Baby check Any medical/surgical issues post-delivery Hospitalization history or emergency visits Medications/Allergic History/Triggers: Any known allergies Any regular medications (prescribed, OTC, herbal/ vitamins) U. Khalid and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
377 Child (BINDES): Birth/pregnancy history, immunization status, nutrition/ weight gain, developmental history/meeting milestones, environment, and social history Family History: Anyone else in the family having similar symptoms? Any conditions that run in the family? Any family history of neonatal jaundice? Any family history of liver issues? Wrap-Up: Mention that once you complete the history, you would then examine the child. Question: “How will you counsel the patient/parents?” Answer: “One of the most common causes of jaundice in a baby presenting after 24 h and resolving early is physiologi-cal neonatal jaundice. Physiological jaundice is transient and a mild unconjugated hyperbilirubinemia. It is often caused due to an immature liver with reduced enzyme activity as well as there are increased bilirubin levels secondary to an increase in the amount of red blood cells and a decrease in their life span. It will usually resolve within the first week of life. If it is prolonged, we will then need to investigate for other causes. ” “We can be reassured that the jaundice is physiological if the jaundice appeared on day 2-4, the baby is well (no signs of sepsis/infection and feeding well), the baby is passing normal-colored stools and urine, and there are no other abnormalities. ” “It usually requires no treatment, but if the bilirubin levels are above the treatment threshold, then the baby may require phototherapy. The aim of treatment is to decrease bilirubin and prevent kernicterus. Kernicterus is the deposition of bili-rubin in the brain stem and basal ganglia, which may lead to intellectual disability, cerebral palsy, hearing loss, and paral-ysis of upward gaze. ” “We can reassure the parents that physiological jaundice is self-limiting and resolves by day 7-10 and usually requires no treatment. If there are any other symptoms or jaundice does not resolve after 10 days, then further investigations will need to be done to search for underlying disease. ” History and Management: Failure to Thrive Candidate Information: A 12-month-old baby has been referred to your clinic by the GP due to a weight-for-age decline from the 30th percentile to the 10th centile. Differential Diagnosis: Poor intake: -Inadequate nutrition (breast milk/formula and/or food) -Breastfeeding difficulties -Restricted diet -Structural causes of poor feeding (cleft palate) -Persistent vomiting -Early (<4 months) or delayed introduction of solids Inadequate absorption: -Celiac disease -Chronic liver disease -Pancreatic insufficiency (cystic fibrosis) -Chronic diarrhea -Cow's milk protein intolerance Excessive caloric utilization: -Chronic illness -UTI -Chronic respiratory disease (cystic fibrosis) -Congenital heart disease -Diabetes mellitus -Hyperthyroidism Psychosocial factors: -Parental depression, anxiety, or other mood disorders -Parent/parents substance abuse -Attachment difficulties -Disability/chronic illness of parent/parents -Coercive feeding -Difficulties at meal times -Poverty -Behavioral disorders -Poor social support -Poor carer understanding -Exposure to traumatic incident/family violence -Neglect -Current or past child protection involvement Failure to thrive (FTT) is a condition that indicates insuf-ficient weight gain or inappropriate weight loss. A slight weight loss, up to 10% of birth weight, after birth is normal, and most babies return to their birth weight over about 3 weeks. FTT is a vague term that is not a disorder within itself, but rather a sign of undernourishment; however, it can be a sign of a serious underlying disorder. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) or show your ID badge. Sit on the chair or stand on the right side and start the interview. 12 Pediatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
378 Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Mr. /Mrs....? Are you the parents of... ? And he is... old?” Presenting Complaint: “What brings you in today?” History of Presenting Illness: When was the child last well? What is the current weight and height? What was the birth weight and height? Breastfeeding: -Any difficulties? Timing of feeds? Number and vol-ume of feeds per day? Duration of feeds? -Is the baby “settled” with breastfeeds? -Any vomits after feeds? -Breast milk supply? -Time taken to feed? -Mother's perception of the breast milk supply? Formula feeding: -Is the formula made up correctly? Correct dilution? -V olumes? Any recent changes to formula brands? -Any vomiting or diarrhea associated with feeds? Solids: -When were solids introduced? What types have been given? What is the interaction between baby and parent when feeding? “Do you ever feel like you need to force feed?” Are feeding times pleasant or unpleasant? Does the infant accept solids readily? Age when three meals and two snacks per day has been achieved? Composition and quantity of meals? What does a meal encompass of? Variety in food groups? Any behavioral issues or fussing around at meal times? What is the meal time routine? What is the total milk volume over 24 h? Detailed birth history: -Any antenatal complications? -Maternal health issues? -Birth weight/height and head circumference? Systems Review: Any significant intercurrent illnesses coinciding with onset of poor growth? Any vomiting and diarrhea? Frequency? V olume? Consistency? Any blood/bile? Abdominal pain? Recurrent ear infections? Urine output: number of wet nappies? Urinary tract infections? Developmental delay, regression, or syndromal features? Fevers? Lethargy? Irritability? Past Medical and Surgical History: Baby health visits Medical illnesses Any previous or recent surgery Chronic and current illness Hospitalization history or emergency visits, accidents, frequent trauma Medications/Allergic History/Triggers: Any known allergies Any regular medications (prescribed, OTC, herbal/ vitamins) Child (BINDES): Birth/pregnancy history, immunization status, nutrition/ weight gain, developmental history/meeting milestones, environment, and social history Detailed dietary history Growth pattern history Family History: Anyone else in the family having similar symptoms? Any conditions that run in the family? Social History: “Is there a lack of financial resources for food requirements?” “Where do you live? And how many people are in the household?” “How many siblings does the baby have?” “Do you have extended family in the area whom you are close with?” “Have you recently immigrated from overseas? What is your ethnic background?” “Any mental health problems in the family?” “Do you see the GP regularly for the baby?” “Are you engaging with community services?” “Any previous involvement with child protection for any reason?” Wrap-Up: Mention that once you complete the history, you would then examine the child. Question: “How will you manage the case?” Answer: “Ultimately, the management of the child will depend on the cause for the FTT. However, the child will require admis-sion to hospital if any of the following exist: severe under nutri-tion/dehydration, failed outpatient management, there is U. Khalid and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
379 suspicion or confirmed child neglect or abuse, psychosocial concerns, and, lastly, if there is extreme parental anxiety or depression. In all the preceding reasons, admission will allow us to further assess feeding techniques and routines, the interaction between the parents and the child, as well as allow a holistic approach with a multidisciplinary team. ” “While in hospital, it will be important to ensure there are no organic causes for the failure to thrive. At the same time, if there are any feeding concerns, a lactation consultant and a dietician can be involved. If there are any concerns for child neglect, it will be appropriate to involve a social worker who may also be able to comment on the interaction between the parent and the child. ” “In the majority of cases, further investigations are not required. ” “However, depending on the history and physical exami-nation, one may consider to order the following investiga-tions: full blood count, erythrocyte sedimentation rate (ESR), electrolytes, liver function tests, iron studies, calcium/phos-phate, thyroid function tests, blood glucose, urine micros-copy/culture, celiac screen (if on solids and containing gluten), stool microscopy and culture, and, lastly, to look at the stool for fat globules and fatty acid crystals. ” “A clear follow-up plan should be made at the time of discharge. The timing and frequency of follow-up will largely depend on the child's weight, weight gain/velocity, age, and psychosocial situation. There should be close com-munication with the general practitioner, the community health nurse for the baby, and the pediatrician. If outpatient appointments are consistently being missed, then there should be a strong suspicion for child neglect, and a referral should be made to child protection. ” History and Counseling: Vaccination Candidate Information: A young mother presented with her 8-week-old baby. The woman has recently immigrated from Kenya and English is her second language. She was referred to you for her child's 2-month vaccinations and is unsure whether she should have her child vaccinated and would like to discuss it with you. General Principles of Counseling in This Case: Firstly, to be aware of communication barriers such as language difficulties and cultural differences. You need to understand the patient's fears, concerns, and preconceptions and to respond and deal with these in an empathetic, nonjudgmental way. You need to transmit information in a way that is consistent with the patient's expectations and in a way that is understandable to them. Always remember to encourage questions and feedback from the patient. This is an important case to practice closed-loop communication. Immunization from an early age is highly recommended for all children. This helps to protect them from the most serious childhood infections, some of which can be life-threatening. Routine childhood immunizations help to protect the child against diphtheria, tetanus, whooping cough (pertussis), polio, meningococcal C disease, pneumococcal disease, hepatitis B, Haemophilus influenzae, rotavirus, chickenpox, measles, mumps, and rubella. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) or show your ID badge. Sit on the chair or stand on the right side and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Mr. /Mrs....? Are you the parents of... ? And he/she is... old?” Presenting Complaint: “What brings you in today?” Ask the mother if she would prefer someone to translate (family member or an official translator). History of Presenting Illness: Ask if the child has been well. Does she have any current concerns about the child's physical health? Any rashes? Coughs? Abdominal pain? V omiting? Diarrhea? Fevers? Lethargy? Feeding well? Wet nappies? What are her concerns with vaccinations? What would she like to know and why? Has the child had any prior vaccines? Any reactions? If yes, which ones? If no, why not? Systems Review: Any fevers? Lethargy? Night sweats? Any allergies? 12 Pediatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
380 Received any blood products in the past? Any chronic illness? Past Medical and Surgical History: Baby health visits Medical illnesses Any previous or recent surgery Chronic and current illnesses that may lower immunity (leukemia, cancer, human immunodeficiency virus [HIV], acquired immunodeficiency syndrome [AIDS]) or treat-ment that may lower immunity (oral steroid therapy, radio-/chemotherapy) Hospitalization history or emergency visits, accidents, frequent trauma Medications/Allergic History/Triggers: Any known allergies Any regular medications (prescribed, OTC, herbal/ vitamins) Child (BINDES): Birth/pregnancy history, immunization status, nutrition/ weight gain, developmental history/meeting milestones, environment, and social history Family History: Anyone in the family with a disease or is having treatment that causes lower immunity (leukemia, cancer, HIV, AIDS, oral steroid medication, radiotherapy, or chemotherapy)? Social History: Financial resources to support the family? “Where do you live? And how many people are in the household?” “How many siblings does the baby have? Have they been vaccinated?” “Do you have extended family in the area whom you are close with?” “Have you recently immigrated from overseas? What is your ethnic background?” “Do you see the GP regularly for the baby?” “Are you engaging with community services?” “Any previous involvement with child protection for any reason?” Wrap-Up: Question: “How will you counsel the parents?” Answer: Empathize and be nonjudgmental while address-ing the patient's concerns and pick up on their cues. Try to further explore their beliefs. Begin counseling the patient by explaining the benefits versus risks of vaccinations: “There are many benefits of immunizing your child, and this includes preventing serious diseases that may have severe and life-threatening conse-quences. These severe diseases that are largely preventable include diphtheria, tetanus, whooping cough (pertussis), polio, meningococcal C disease, pneumococcal disease, hep-atitis B, Haemophilus influenzae, rotavirus, chickenpox, measles, mumps, and rubella. Another benefit of immuniza-tion is to maintain the eradication of these diseases that can kill and disable millions of children if an outbreak is to occur. It is ultimately much safer to have the vaccines than not to have them. Vaccines are very safe and undergo many safety procedures in the labs prior to being used. However, as with all medications used to treat diseases, vaccines can have side effects. However, these side effects are rarely serious and generally last short term. Some of the side effects include local effects such as swelling, redness, a lump, fever, an allergic reaction, and, rarely, anaphylaxis. ” Discuss some of the contraindications to vaccination: “There are some circumstances where we would either post-pone a vaccination or recommend that it is not safe for a child to have a vaccination. This includes if your child is unwell or has a fever, the vaccine should be postponed. If the child is immunocompromised (has a disease such as leuke-mia, cancer, HIV/AIDS, or is being treated with oral ste-roids, radiotherapy, or chemotherapy), we would recommend avoiding live vaccines such as MMR (measles, mumps, and rubella) and BCG (Bacillus Calmette-Guérin/tuberculosis). If there is a known anaphylaxis reaction to a certain ingredi-ent within the vaccine, it would be advisable to avoid it. ” Explain the national immunization program and the process of vaccination to the parent. For example: “There is a national immunization program that is used Australia-wide and provides an outline of what vaccinations should be administered at specific ages. Here is a copy of the schedule for your information (see Figs. 12. 6, 12. 7a, b, 12. 8a, b and Table 12. 2) [15-18]. At the current age of 8 weeks, it would be recommended for baby to have the diphtheria/tetanus/ pertussis, hepatitis B, pneumococcal, and rotavirus vaccinations. ” “The vaccination will be given as an injection, usually in the thigh. It is normal for the baby to be a bit upset and cry at the time. The child might be irritable for a couple days after the vaccination and may also have a low-grade fever. The child may also have a sore arm, with some redness or a lump around the injection site. The low-grade fever and sore arm may both be treated by some Panadol (paracetamol/acetaminophen) and/or ibuprofen. If any more serious reactions develop, then you will need to bring the child back to the doctor. ” Summary The reason for the vaccinations is both to benefit the baby and reduce any risk of contracting a life-threatening disease, as well as in the interest of public health to reduce the spread of disease and protect those that are unable to be vaccinated. Vaccines are generally safe and may have some minor side effects. U. Khalid and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
381 Symbols with brackets around them imply that these doses may not be required, depending upon the age of the child or adult. Diphtheria, tetanus, acellular pertussis and inactivated polio virus vaccine (DTa P-IPV): DTa P-IPV(± Hib) vaccine is the preferred vaccine for all doses in the vaccination series, including completion of the series in children who have received one or more doses of DPT (whole cell) vaccine (eg, recent immigrants). The 4-to 6-year dose can be omitted if the fourth dose was given after the fourth birthday. Haemophilus influenzae type b conjugate vaccine (Hib): the Hib schedule shown is for the Haemophilus b capsular polysaccharide-polyribosylribitol phosphate (PRP) conjugated to tetanus toxoid (PRP-T). For catch up, the number of doses depends on the age at which the schedule is begun. Not usually required past the age of 5. Measles, mumps and rubella vaccine (MMR): a second dose of MMR is recommended for children at least one month after the first dose for the purpose of better measles protection. For convenience, options include giving it with the next scheduled vaccination at 18 months of age or at school entry (4 to 6 years of age) (depending on the provincial/territorial policy) or at any intervening age that is practical. In the catch-up schedule, the first dose should not be given until the child is ≥ 12 months old. Varicella vaccine (Var): children aged 12 months to 12 years should receive 1 dose of varicella vaccine. Hepatitis B vaccine (HB): hepatitis B vaccine can be routinely given to infants or pre-adolescents, depending on the provincial/territorial policy. For infants born to chronic carrier mothers, the first dose should be given at birth (with hepatitis B immunoglobulin), otherwise the first dose can be given at 2 months of age to fit more conveniently with other routine infant immunization visits. The second dose should be administered at least 1 month after the first dose, and the third at least 2 months after the second dose, but these may fit more conveniently into the 4-and 6-month immunization visits. Pneumococcal conjugate vaccine-7-valent (Pneu-C-7): recommended for all children under 2 years of age. The recommended schedule depends on the age of the child when vaccination is begun. Meningococcal C conjugate vaccine (Men-C): recommended for children under the age of 5, adolescents and young adults. The recommended schedule depends on the age of the individual and the conjugate vaccine used. At least 1 dose in the primary infant series should be given after 5 months of age. If the provincial/territorial policy is to give Men-C to persons ≥ 12 months of age, 1 dose is sufficient. Influenza vaccine (Inf): recommended for all children 6 to 23 months of age and all persons ≥ 65 years of age. Previously unvaccinated children < 9 years of age require 2 doses of the current season's vaccine with an interval of at least 4 weeks. The second dose within the same season is not required if the child received 1 or more doses of Influenza vaccine during the previous Influenza season. Age at Vaccination DTa P-IPVHib MMR Var H B Pneu-C-7Men-C Tdap Inf Birth 2 months 4 months 6 months 12 months 18 months 4-6 year s Infanc y 3 doses or Pre-teen/ teen 2-3 doses12-15 monthsif not ye t givenor6-23 months 1-2 doses or( ) ( ) Fig. 12. 6 Canada's routine immunization schedule for infants and chil-dren. https://www. canada. ca/en/public-health/corporate/publications/ chief-public-health-officer-reports-state-public-health-canada/report-on-state-public-health-canada-2009/appendix-b. html. © All rights reserved. The Chief Public Health Officer's Report on the State of Public Health in Canada, 2009 -Routine Immunization Schedule for Infants and Children -Appendix B. Public Health Agency of Canada, 2009 (Adapted and reproduced with permission from the Minister of Health 2018) 12 Pediatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
382 History and Counseling: Enuresis Candidate Information: The parents of a 6-year-old boy have brought him into the practice due to concerns of his night-time bedwetting. He has never had a period of consistent night-time dryness. He has no other symptoms. Differential Diagnosis: Constipation Diabetes Congenital abnormality of the urinary tract -Ectopic ureter, ureterocele, and urethral valves Detrusor overactivity Detrusor areflexia Emotional disturbances Neurological disorder leading to voiding dysfunction -Spina bifida, epilepsy Urinary tract infection Bedwetting is a problem for many school-aged children and their families. Nocturnal enuresis affects 20% of 5-year-olds, 5% of 10-year-olds, and 1% of those over 18 years old [19]. Enuresis can be divided into primary versus secondary enuresis, and monosymptomatic versus nonmonosymptomatic enuresis. Primary enuresis is when a child has never achieved 6 months of continuous dry nights, whereas secondary enuresis is when a child has previously attained at least 6 months of night-time dryness but who has relapsed. Monosymptomatic enuresis refers to enuresis where the only symptom present is nighttime bedwetting. Nonmonosymptomatic enuresis refers to enuresis alongside daytime lower urinary tract symptoms such as urgency, frequency, dribbling, incomplete emptying and often daytime incontinence, dysuria, and a display of vari-ous holding maneuvers. Starting the Interview: Knock on the door. Enter the station. Fig. 12. 7 (a, b) U. S. Centers for Disease Control and Prevention: 2018 recommended immunization schedules for children from birth through 6 years old (Reprinted from US Centers for Disease Control and Prevention. https://www. cdc. gov/vaccines/schedules/easy-to-read/ index. html [16]) a U. Khalid and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
383 Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) or show your ID badge. Sit on the chair or stand on the right side and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Mr. /Mrs....? Are you the parents of... ? And he is... old?” Presenting Complaint: “What seems to be the problem?” History of Presenting Illness: Is the child bothered by the bedwetting? Onset of bedwetting? How long has it been going on for? Has the child previously been dry at night without assis-tance for 6 months? Or has this been an ongoing issue? Has any treatment or therapies been tried before? What is the frequency of the enuresis (days per week and episodes per night)? When during the night, do the episodes occur? What is the quantity of urine? Are pants soaked? Does the child have a large first-morning void despite enuresis? What are the child's daytime drinking habits? Especially in the afternoon and evening? Are there any daytime symptoms (incontinence, urgency, frequency, dribbling, incomplete emptying, straining, weak stream, leakage)? Are there any holding maneuvers (crossing legs, tiptoe-ing, etc. )? How many times during the day does the child void? Any dysuria (pain on urinating)? Does the child have a history of urinary tract infections? Does the child have behavioral problems? Does the child have daytime somnolence? Does the child snore? Any history of motor or learning difficulties? Delayed development? b Fig. 12. 7 (continuted) 12 Pediatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
384 Any psychosocial concerns? Any recent stressors? Recent events in their life? Systems Review: Does the child have constipation? Fecal incontinence? Does the child have polydipsia, polyuria, or weight loss? Fevers? Night sweats? Rigors? V omiting? Nausea? Diarrhea? Abdominal pain? Past Medical and Surgical History: Baby health visits Medical illnesses Any previous or recent surgery Chronic and current illness Hospitalization history or emergency visits, accidents, frequent trauma Medications/Allergic History/Triggers: Any known allergies Any regular medications (prescribed, OTC, herbal/vitamins)Child (BINDES): Birth/pregnancy history, immunization status, nutrition/ weight gain, developmental history/meeting milestones, environment, and social history Home environment, siblings, school environment, and performance Family History: Anyone else in the family having similar symptoms? Any conditions that run in the family? Social History: “Where do you live? And how many people are in the household?” “How many siblings does the child have?” “Any mental health problems in the family?” “Any stressors in the child's life?” Assess the family dynamic and whether the family has been supportive in any past treatments. School environment. Does the child enjoy going to school? School performance? Fig. 12. 8 (a, b) US Centers for Disease Control and Prevention: 2018 recommended immunization schedules for children 7-19 years old (Reprinted from US Centers for Disease Control and Prevention. https://www. cdc. gov/vaccines/schedules/easy-to-read/index. html [17]) a U. Khalid and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
385 Wrap-Up: Mention that once you complete the history, you would then examine the child. Question: “How will you counsel the parents?” Answer: “Both the parents and the child should be reas-sured that primary monosymptomatic enuresis is a very com-mon condition and it usually will resolve spontaneously in most children. This usually will motivate the child and par-ents to consider behavioral management and defer the need for medical management. There are a few simple comorbid conditions that contribute to enuresis and that can be treated quite easily. These include constipation, obstructive sleep apnea, and urinary tract infections. Constipation, if present, should be adequately managed prior to even addressing enuresis. It will also be advisable to target any behavioral issues as well as any psychosocial stressors. ” “The first step in management, after organic causes have been excluded, is behavioral changes. It is important to involve the child in this process. Most children will already be motivated and won't need a rewards system to take part in management. The prospect of a dry bed will be enough. It will be helpful to have a calendar that is marked with wet or dry each night. You can encourage the child to make the cal-endar and use stickers for dry nights or whatever suits their interests. It is not advisable to restrict fluid intake, as the child needs to remain well hydrated; however, avoid caffein-ated drinks at night such as coffee, tea, hot chocolate, or soft drinks in the evening and onward. Waking the child at night to urinate may be helpful. Cleanliness training, where you make the child change the sheets and make the bed each time they have an episode, may alter their habits. ” “Apart from basic behavioral modification, bed alarms are currently the most effective treatment available. A bed alarm has a moisture sensor, which is placed either in the child's underwear or as a pad underneath the child and is connected by a wire to a loud alarm. When moisture is detected, a loud alarm is signaled, with the intention that the child is woken up at the beginning of an episode and will ultimately control b Fig. 12. 8 (continuted) 12 Pediatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
386 Table 12. 2 Australian health department national immunization program schedules for children and adolescents Age Disease Vaccine Comments Childhood schedule (birth to 4 years) Birth An injection for hepatitis Ba (usually offered in hospital)H-B-Vax® II pediatric or Engerix B -pediatric Hepatitis B vaccine should be given to all infants as soon as practicable after birth. The greatest benefit is if given within 24 h, and must be given within 7 days 2 months (vaccines can be given from 6 weeks of age)A combined injection for diphtheria, tetanus, whooping cough (pertussis), hepatitis B, polio, Hib (Haemophilus influenzae type b)Infanrix® hexa None An injection for pneumococcal Prevenar 13® None Oral drops for rotavirus Rotarix® Oral dose of rotavirus vaccine 6-14 weeks of age 4 months A combined injection for diphtheria, tetanus, whooping cough (pertussis), hepatitis B, polio, Hib (Haemophilus influenzae type b)Infanrix® hexa None An injection for pneumococcal Prevenar 13® None Oral drops for rotavirus Rotarix® Oral dose of rotavirus vaccine 10-24 weeks of age 6 months A combined injection for diphtheria, tetanus, whooping cough (pertussis), hepatitis B, polio, Hib (Haemophilus influenzae type b)Infanrix® hexa None An injection for pneumococcal Prevenar 13® None 6 months and over with medical risk factors Injection for influenza Refer to the current edition of The Australian Immunisation Handbook for all medical risk factor conditions 12 months A combined injection for measles, mumps, rubella M-M-R® II or Priorix® None A combined injection for Hib (Haemophilus influenza type b), meningococcal CMenitorix® None An injection for pneumococcal Prevenar 13® Medically at-risk children only Refer to the current edition of The Australian Immunisation Handbook for all medical risk factor conditions 18 months A combined injection for measles, mumps, rubella, chickenpox (varicella)Priorix-Tetra® or Pro Quad®None A combined injection for diphtheria, tetanus, whooping cough (pertussis)Infanrix® or Tripacel® None 4 years A combined injection for diphtheria, tetanus, whooping cough (pertussis), polio Infanrix® IPV or Quadracel®None An injection for pneumococcal Pneumovax 23® Medically at-risk children only Refer to the current edition of The Australian Immunisation Handbook for all medical risk factor conditions Adolescent and adult schedule (10 years and older) 10-15 years (school programs)Injections for HPV (human papillomavirus) (2 doses)Gardasil® 9 Contact the state or territory health service for details on the school grade eligible for vaccination A combined injection for diphtheria, tetanus, whooping cough (pertussis)Boostrix® Contact the state or territory health service for details on the school grade eligible for vaccination Adapted from Australian Government Department of Health [18] U. Khalid and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
387 their urination, switch off the alarm, and go to the toilet to finish urinating. This process is time-consuming and can take up to a few months and thus will require the parents to be motivated to invest their time into this behavioral modifi-cation intervention. ” “If all the above fails, the next step is to consider pharma-cological therapy. This includes the use of a drug called des-mopressin. This ultimately decreases the amount of urine produced overnight. This medication is safe to use, so long as instructions are followed. “It is important to be patient and supportive of your child who is going through management for enuresis. It is impor-tant to make sure you do not punish or make fun of your child as this may only worsen the problem. It is important that the child's siblings are aware of this too. It is vitally important to have the child involved in their treatment plan and work together with them. ” Phone Call: History and Counseling, Child Swallowed A Cleaning Agent Candidate Information: You receive a phone call in the ED from a very anxious mother stating that her 2-year-old girl swallowed some household cleaning agent. Take a history over the phone and then advise her on what to do next. Most incidents of accidental ingestion poisoning occur among 1-to 3-year-olds; and it should be considered in any young child presenting with symptoms that cannot be other-wise explained. Most ingestions are insignificant. However, there are a few agents that are highly toxic, and sometimes a low toxic agent is ingested in quite a large quantity. In older children, intentional poisoning must be taken very seriously. These children should be admitted into the hospital with psy-chiatry reviews. Suicide should always be considered even in children; and at the same time, non-accidental injury should be considered in young children. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) or show your ID badge. Sit on the chair or stand on the right side and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am the attend-ing physician for today. ”Confirm who is on the phone and their relationship to the child. Presenting Complaint: “What is your name? Child's name? Date of birth/age of child?” “What seems to be the problem?” “I understand that you are calling because your child has swallowed some medication. I know that you are stressed and it is a difficult time for you. I need your phone num-ber now, and it is important, because if we get discon-nected then I will call you back. ” “How far away from the hospital are you?” “Try and stay calm. ” “I will give you some instructions and you need to follow them. First I will ask you a few questions about his condition:” -“When did it happen?” -“How long was he alone?” -“What is the child's current condition? Conscious? Airway open? Breathing? Talking?” -“Is he crying?” -“Is he breathing?” -“What is his color? Pink?” -“Try to hold him and check his mouth; if there are chemical/medications there, remove them. ” -“What is the agent ingested?” (Ask the parent to read the hazard label on the agent. ) -“Any chance there were multiple substances ingested?” -“Route of ingestion (ingested, inhaled, topical exposure)?” -“What was the time of the incident?” -“What is the weight of the child?” -“Amount of agent ingested? Estimate?” “We will send the ambulance for you. ” Systems Review: Loss of consciousness? Seizures? Loss of tone? Stiff? Paralysis? Neurological signs? Feel the pulse racing or very slow? Pale? Dizzy? Cold? Difficulty breathing? Abdominal pain? V omiting? Nausea? Diarrhea? Constipation? Fevers? Urinary symptoms? Sweats? Rigors? Past Medical and Surgical History: Baby health visits Medical illnesses Any previous or recent surgery Chronic and current illness Hospitalization history or emergency visits, accidents, frequent trauma 12 Pediatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
388 Medications/Allergic History/Triggers: Any known allergies Any regular medications (prescribed, OTC, herbal/ vitamins) Child (BINDES): To Be Asked Once the Child Arrives at the Hospital (No Need to Ask over the Phone) Birth/pregnancy history, immunization status, nutrition/ weight gain, developmental history/meeting milestones, environment, and social history Mention that once you complete the history, you would then examine the child (once they arrive at the hospital). The OSCE can pose a similar scenario in which the child has taken a family member's prescribed medicines. The following questions need to be asked: “Which medications did he take?” “Whose medications did he take?” “Do you have the container?” “Don't go to the next room to bring them. When the para-medics arrive then you can go and get the container. ” “Do you know for what condition these medications were prescribed for? Was it vitamins, sleeping pills, or any other?” “How much did he ingest?” “Don't use any ipecac. Do not induce vomiting. ” “Has it happened before?” Then in the management, you need to call the poison con-trol center to get the management guidelines. Wrap-Up: Question:“How will you counsel the parents?” Answer: “Firstly, it will be important to reassure the mother and to keep her calm. Inform her that accidental ingestion is common, and mostly it is insignificant. Explain to the mother that if it was a very minimal amount ingested and the child is well with no signs and symp-toms of poisoning, then the child can remain at home. However, if a large amount was ingested, the child is dis-playing any signs or symptoms, or if the mother is con-cerned at all to bring the child in. If she is unable to drive over to the ED, then we will call an ambulance for her. While we are waiting for the child to head over, we will contact the poisons information center to get any further advice from them. ” “When the child presents to the ED, we would need to do an initial emergency assessment (ABC), while concurrently obtaining any further history that wasn't obtained over the phone. We would first assess that there was a patent airway, normal breathing/saturations and lastly that circulation is intact in terms of being hemodynamically stable and having a regular rhythm. We would then ensure there were no sei-zures or drug-induced syndromes (malignant hyperthermia, serotonin syndrome, neuroleptic malignant syndrome) and lastly check the blood glucose level. ” “Next, we would look at if there was any way to decrease the exposure to the poison. If contamination to the eyes or skin, we would advise copious irrigation. On recommenda-tion from the toxicologist, activated charcoal, gastric lavage, or whole bowel irrigation may be considered. If any specific drugs were ingested, then consideration for an antidote would be given. ” “Lastly, some further investigations may be required. These include full blood count, electrolytes, urea, kidney function tests, liver function tests, serum ketones/glucose, venous/arterial blood gas, and if the substance was unknown, then a toxicology screen may add some benefit. ” “The child will likely be kept in the emergency depart-ment for a period of observation. ” History and Management: Child Abuse Candidate Information: A 4-year-old girl is brought in to the ED by her mother due to a painful arm. Some bruising is also noticed on both arms. She is otherwise well and recently moved in with her moth-er's new boyfriend. Differential Diagnosis: Infection -Septic arthritis, osteomyelitis, reactive arthritis, synovitis Trauma/overuse -Fracture (accidental vs. non-accidental injury), soft tissue injury, hypermobility Malignancy -Leukemia, neuroblastoma, bone tumors Hematologic -Hemophilia, sickle cell anemia Inflammatory -Juvenile idiopathic arthritis, systemic lupus erythema-tosus (SLE), Henoch-Schönlein purpura (HSP) Non-inflammatory -Growing pains, fibromyalgia, conversion reaction Non-accidental injury is a significant cause of morbidity and mortality among children. Doctors should always con-sider the possibility of abuse or neglect when they assess an injured child and when they interact with a child who appears vulnerable to abuse and neglect. In most states, there is a legal requirement for doctors to notify child protection if U. Khalid and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
389 there is a suspicion of abuse or neglect. There are various forms of child abuse, including physical abuse, sexual abuse, emotional abuse, and, lastly, neglect, which is the failure of the caregiver to adequately provide for and take care of the child's well-being and safety. The following are features on the history that may raise suspicion of non-accidental injury [20]: No story is offered to account for the injuries. Inconsistent story from the same individual. Inconsistent story between multiple individuals (without an explanation). Story is inconsistent with the child's developmental skills. The mechanism of injury involves a young sibling or other child. An unexplained delay between the time of injury and the time of presentation. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) or show your ID badge. Sit on the chair or stand on the right side and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Mr. /Mrs....? Are you the parents of... ? And she is... old?” Presenting Complaint: “What brings you in today?” History of Presenting Illness: “When was the child last well?” “When did the pain start? Was there a specific mechanism of injury?” Determine when, where, and how the injury occurred. “What is the nature of the pain?” “What is the intensity of the pain, on a scale of 0-10?” “Where exactly is the pain? Does it radiate?” Ask the child to point to where it hurts. “How long has it been going on for?” “What makes the pain better or worse?” “Any inciting event that causes the pain?” “Any associated symptoms?” “Have you tried any treatment or medication so far?” “Is the pain activity related?” “Is the pain bad enough to prevent the child from their activities, sports/play, or school?” “Does the pain wake her at night?” “Any previous injuries? Any history of easy bruising? Any past fractures?” “Is the child gaining appropriate weight?” “Meeting developmental milestones?” Note Make sure to note who told this story and where the information is coming from. Try to assess whether anyone witnessed the events that caused the injury, and try to contact the witness to see if their story matches with the initial his-tory. Concurrently, try to assess the child's developmental capabilities. Systems Review: Any fevers? Rashes? Weight loss? Change in activity? Decreased appetite? Lethargy? Changes in sleep patterns? Any generalized bruising on the body? Abrasions? Lacerations? Other injuries? And previous burns? Any problems with lungs? Prior infections? Past Medical and Surgical History: Baby health visits Medical illnesses Any previous or recent surgery Chronic and current illness Hospitalization history or emergency visits, accidents, frequent trauma Medications/Allergic History/Triggers: Any known allergies Any regular medications (prescribed, OTC, herbal/vitamins) Child (BINDES): Birth/pregnancy history, immunization status, nutrition/ weight gain, developmental history/meeting milestones, environment, and social history Performance at school, extracurricular activities Child's growth and weight gain Family History: Anyone else in the family having similar symptoms? Any conditions that run in the family? Any bleeding disorders? Any bone disorders? Social History: “Financial resources to support the family?” “Where do you live? And how many people are in the household?” 12 Pediatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
390 “How many siblings does the child have? Are they well?” “Do you have extended family in the area with whom you are close?” “Do you see the GP regularly for the child?” “Methods of disciplining children?” “Any behavioral issues with the child?” “Do any of the parents/caregivers use substances/drugs or abuse alcohol? Smoke?” “Any previous involvement with child protection for any reason?” Wrap-Up: Mention that once you complete the history, you would then examine the child. Question: “How will you manage the case?” Answer: “If there is a concern for the safety of the child and/or if medically required, the child should be admitted to the hospital. Further investigations should be done for the arm pain and bruising, to rule out medical causes, espe-cially if there is a suspicion of non-accidental injury” (Fig. 12. 9) [21]. “There are a few findings on history and examination that will generate suspicion for a non-accidental cause for injury. During the history taking you may suspect non-accidental injury if there is no explanation for the injury, an inconsistent story between an individual or between multiple people, if there is an inconsistency of the injury and the child's devel-opmental capability, or if there was a delay between the time of injury and the presentation. ” “During the examination and assessment, there are a few findings that should raise suspicion for non-accidental injury. These include bruising/fractures in an immobile child, bruises away from bony prominences, patterned bruising, unexplained encephalopathy in a child <2 years, unexplained intracranial bleed, metaphyseal fractures at the ends of long bones, and, lastly, immersion-patterned burns. ”Suspected Non-Accidental Injur y of a Child Suspicious: Stor y Symptoms Signs Document yo ur findings and concern s Consult senior medical staff Persistent suspicion of non-accidental injur y No Yes Consult a Pe diatric Fo rensic Medicine specialist Any concer n about psychosocial r isk?Continuing suspicion of non-accidental injur y Refer to Social Worker Refer to: Pediatric Fo rensic Medicine specialist and Social Worker In-depth ev aluation by Pediatr ic Fo rensic Medicine specialist Social Worker Evaluation and Suppor t Forensic Evaluation of: Cause Risk to child Treat injur y Arrange ongoing care Is there reason to belie ve the child needs protection? Repor t to child protectiv e ser vices Is there reason to be concer ned about the child' s wellbeing ? Refer to child welf are ser vice No No Yes No No And Yes Yes Fig. 12. 9 Suspected non-accidental injury algorithm (Adapted from Victorian Forensic Paediatric Medical Service [21]) U. Khalid and M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
391 “Further investigations for the unexplained bruising would include a full blood count and a coagulation profile. If there are any suspicions of a medical cause, then you can consider a full clotting/thrombophilia screen. Further inves-tigations for the arm pain would firstly include a basic X-ray to look for fractures. If there is a suspicion of previously undiagnosed fractures, then you can consider a skeletal sur-vey and a bone scan. ” “A referral can then be done to child protection services if there is a suspicion that there has been child abuse or neglect. ” History and Management: Limping Child Candidate Information: A 5-year-old boy has been brought into the ED by his parents because they have noticed he has been walking funny over the past week. Differential Diagnosis: Toddlers (1-4 years old): -Developmental dysplasia of the hip -Toddlers fracture -Transient synovitis of the hip -Child abuse Child (4-10 years old): -Transient synovitis of the hip -Perthes disease Adolescent (>10 years): -Slipped upper femoral epiphysis (SUFE) -Overuse syndromes/stress fractures All ages: -Infections (septic arthritis, osteomyelitis, myositis, etc. ) -Trauma (fractures, sprains, strains) -Malignancy (leukemia, bone tumors) -Rheumatological disorders (reactive arthritis) -Acute abdomen (e. g., appendicitis) -Inguinoscrotal conditions (e. g., testicular torsion) -Vasculitis -Child abuse/non-accidental injury -Functional disorder At some time or the other, almost all children will develop a limp. Most will be due to a minor injury that is self-limiting. However, occasionally it may be due to a more serious con-dition and will need further investigation and treatment. A limp is defined as a deviation in the normal walking pattern for a child's age. It should always be remembered that the gait itself undergoes orderly stages of development, and this must be taken into consideration. Limp is not a diagnosis but rather a clinical presentation of conditions that vary across different age groups. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the parents/patient. Give stickers to the examiner (if required) or show your ID badge. Sit on the chair or stand on the right side and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Mr. /Mrs....? Are you the parents of... ? And he is... old?” Presenting Complaint: “What brings you in today?” History of Presenting Illness: How long has the child been limping/walking like this? Acute vs. subacute vs. chronic Painful or non-painful? -Onset of pain? Location? Duration? Intensity (on a scale of 0-10)? Nature of the pain? Specific times (night vs. day)? Any aggravating or alleviating factors? Any radia-tion? Associated symptoms? Any treatment tried so far? Course of the limp since onset? Course of the limp throughout the day? Worse in the morning or at night? Unilateral or bilateral? Recent trauma? Recent infections? Any prior episodes like this? Ability to weight bear? Any morning stiffness? What position is the leg held in? Does joint movement or bony pressure cause pain? Is there a limitation of movement (active and passive)? Systems Review: Any fevers? Weight loss? Night sweats? Rashes? Joint pain? Back pain? Muscular pain? Bowel and urination issues? Recent coughs? Colds? Runny nose? Ear ache? Nausea? V omiting? Diarrhea? Constipation? Any unexplained bruising or other body pains? Past Medical and Surgical History: Baby health visits Medical illnesses Any previous or recent surgery Chronic and current illness Hospitalization history or emergency visits, accidents, frequent trauma 12 Pediatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
392 Medications/Allergic History/Triggers: Any known allergies Any regular medications (prescribed, OTC, herbal/ vitamins) Child (BINDES): Birth/pregnancy history, immunization status, nutrition/ weight gain, developmental history/meeting milestones, environment, and social history Child's growth and weight gain Family History: Anyone else in the family having similar symptoms? Any conditions that run in the family? Any bleeding disorders? Any bone disorders? Any auto-immune conditions? Social History: “Financial resources to support the family?” “Where do you live? And how many people are in the household?” “How many siblings does the child have? Are they well?” “Do you see the GP regularly for the child?” “Any previous involvement with child protection for any reason?” Wrap-Up: Mention that once you complete the history, you would then examine the child. Question: “How will you manage the case?” Answer: “Ultimately, after a thorough history and exami-nation, the management will depend on the underlying cause. Most presentations for a limp will be due to a minor injury that is self-limiting; however, there are a few red flags to be aware of. These include but are not limited to a very young child (under 3 years old), an unwell/febrile child, a child who can't weight bear at all, those with painful restricted hip movements, an immunosuppressed child, and, lastly, any suspicion of a non-accidental injury. ” “One of the most common reasons for a limp in a child of this age is irritable hip (transient tenosynovitis); however, this is also a diagnosis of exclusion. The usual presentation of irritable hip is a child who is well with a limp/difficulty walk-ing and may or may not have a painful hip. The usual clinical features of this condition include having a recent history of a viral illness, no history or evidence of trauma, child is able to weight bear (but with pain), child is afebrile and well, and there is minimal decrease in range of movement due to pain. ” “As this is a diagnosis of exclusion, if there is suspicion of a more sinister cause, then further investigations should be conducted. These include a full blood count with a differen-tial, erythrocyte sedimentation rate (ESR) and a C-reactive protein (CRP), a plain X-ray of the joint/limb, an ultrasound of the hip, and, lastly, a bone scan may be considered. ” “The treatment for irritable hip (transient tenosynovitis) comes down to conservative management, rest and analgesia as required. The more a child can rest, the quicker they will recover. If they return to activity too quickly, they may have a relapse with a return of symptoms. If this is a problem, then one may consider admission for the child. ” References 1. The Royal Children's Hospital. Clinical practice guidelines. Dehydration. www. rch. org. au/clinicalguide/guideline_index/ Dehydration/. Accessed 5 Apr 2018. 2. The Royal Children's Hospital. Clinical practice guidelines. Febrile convulsion. https://www. rch. org. au/clinicalguide/guideline_index/ Febrile_convulsion/. Accessed 5 Apr 2018. 3. Children's Health Queensland Hospital and Health Service. Febrile convulsions. https://www. childrens. health. qld. gov. au/wp-content/ uploads/PDF/factsheets/chifs-febrile-conv. pdf. Accessed 5 Apr 2018. 4. Queensland Government Children's Health Queensland Hospital and Health Service. Wheeze action plan. https://www. childrens. health. qld. gov. au/wp-content/uploads/PDF/wheeze-action-plan. pdf. Accessed 5 Apr 2018. 5. The Royal Children's Hospital. Clinical practice guidelines. Acute otitis media. https://www. rch. org. au/clinicalguide/guideline_index/ Acute_otitis_media/. Accessed 5 Apr 2018. 6. Phillips R, Orchard D. Chapter 17. Dermatologic conditions. In: Gwee A, Rimer R, Marks M, Royal Children's Hospital Melbourne, editors. Pediatric handbook. 9th ed. Victoria, Australia: Wiley-Blackwell; 2015. p. 251. 7. Australian Society of Clinical Immunology and Allergy (ASCIA). ASCIA guidelines for adrenaline auto injector prescription. 2016. https://www. allergy. org. au/health-professionals/anaphylaxis-resources/adrenaline-autoinjector-prescription. Accessed 5 Apr 2018. 8. Australian Society of Clinical Immunology and Allergy (ASCIA). How to give Epi Pen®. https://www. allergy. org. au/health-profes-sionals/anaphylaxis-resources/how-to-give-epipen-in-english-and-other-languages Accessed 5 Apr 2018. 9. Allergy & Anaphylaxis Australia. How to administer an adrenaline autoinjector. https://allergyfacts. org. au/allergy-management/risk/ change-to-instructions-on-epipen-administration. Accessed 5 Apr 2018. 10. Mayo Clinic. Pyloric stenosis. https://www. mayoclinic. org/dis-eases-conditions/pyloric-stenosis/symptoms-causes/syc-20351416. Accessed 5 Apr 2018. 11. The Royal Children's Hospital. Clinical practice guidelines. Anemia. https://www. rch. org. au/clinicalguide/guideline_index/ Anaemia_Guideline/ Accessed 5 Apr 2018. 12. Zacharin M, Cameron F, Werther G, O'Connell M. Chapter 13. The endocrine system. In: Gwee A, Rimer R, Marks M, The Royal Children's Hospital Melbourne, editors. Paediatric handbook. 9th ed. Victoria, Australia: Wiley-Blackwell; 2015. p. 193-4. 13. Sinnott B. Hypopituitarism. BMJ Best Practice. 2016. http://best-practice. bmj. com/topics/en-us/521. Accessed 5 Apr 2018. 14. Queensland Clinical Guidelines. Maternity and neonatal clinical guideline: neonatal Jaundice. 2017. https://www. health. qld. gov. au/__data/assets/pdf_file/0018/142038/g-jaundice. pdf. Accessed 5 Apr 2018. U. Khalid and M. H. 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393 15. Government of Canada. Appendix B: The Chief Public Health Officer's report on the State of Public Health in Canada, 2009 - Routine immunization schedule for infants and children. https:// www. canada. ca/en/public-health/corporate/publications/chief-public-health-officer-reports-state-public-health-canada/report-on-state-public-health-canada-2009/appendix-b. html. Accessed 5 Apr 2018. 16. U. S. Centers for Disease Control and Prevention. Immunization schedule for infants and children (birth through 6 Years). 2018 immunization schedule. https://www. cdc. gov/vaccines/schedules/ easy-to-read/child. html. Accessed 5 Apr 2018. 17. U. S. Centers for Disease Control and Prevention. Immunization Schedule for Preteens and Teens (7 through 18 Years). 2018 immu-nization schedule. https://www. cdc. gov/vaccines/schedules/easy-to-read/preteen-teen. html. Accessed 5 Apr 2018. 18. Australian Government Department of Health. National immunisation program schedule. https://beta. health. gov. au/topics/immunisation/ immunisation-throughout-life/national-immunisation-program-schedule. Accessed 5 Apr 2018. 19. Walker AM, Huston J, O'Brien M, Grover S. Chapter 10. Genitourinary conditions. In: Gwee A, Rimer R, Marks M, Royal Children's Hospital Melbourne, editors. Pediatric handbook. 9th ed. Victoria, Australia: Wiley-Blackwell; 2015. p. 126-7. 20. Smith A. Chapter 29. Forensic medicine. In: Gwee A, Rimer R, Marks M, Royal Children's Hospital Melbourne, editors. Pediatric hand-book, vol. 419. 9th ed. Victoria, Australia: Wiley-Blackwell; 2015. 21. Victorian Forensic Paediatric Medical Service. VFPMS guide-lines for forensic evaluation of suspected child abuse. The Royal Children's Hospital Melbourne. https://www. rch. org. au/vfpms/ guidelines/VFPMS_guidelines_for_forensic_evaluation_of_sus-pected_child_abuse/ Accessed 5 Apr 2018. 22. Yemen TA, Stemland C. Pediatric anesthesia. In: Sikka P, Beaman S, Street J, editors. Basic clinical anesthesia. New York: Springer; 2015. 12 Pediatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |