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395 © 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_13The Endocrine System Mubashar Hussain Sherazi Introduction The thyroid history and examination is one very important topic for the objective structured clinical examination (OSCE). It is frequently repeated. It is very important to practice focused history and thyroid examination well before the examination. When I used to practice with my colleagues for OSCE, I found it very difficult to complete both the his-tory and examination of the thyroid in 8-10 min. Diabetes is also a very important topic for the OSCE. Diabetes-related topics can come in many different forms: a simple first visit history and examination, a diabetic foot examination, a teenage patient with diabetes, or with atypical presentations, for example, fatigue. This chapter will outline a few common topics related to the thyroid and diabetes. History and Physical Examination: Hypothyroidism Candidate Information: A 58-year-old female presents with a husky voice, cold intol-erance, facial swelling, and tiredness for a few days. She is known to have hypothyroidism. Please take a focused history and perform a relevant physical examination. Differentials: Hypothyroidism [1, 2]: Thyroid destruction after thyroidectomy (surgery), radio-active thyroid ablation Metabolic: hypopituitarism or hypothalamic disease Autoimmune/allergic: Hashimoto thyroiditis Medicines: lithium, amiodarone, interferon Severe iodine deficiency Lymphocytic thyroiditis (which may occur after hyperthyroid) Idiopathic/iatrogenic: idiopathic atrophy of the thyroid Starting the Interview: Knock on the door. Enter the station. Handwash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your identification (ID) badge. 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 Mrs... ? Are you 58 years old?” Chief Complaint Chief complaint or the reason patient is visiting the clinic. “What brings you in today?” The patient will tell about her symptoms. Ask Questions About Symptoms Associated with Hypothyroidism: Fatigue/weakness Weight gain or increased difficulty losing weight Coarse/dry hair Dry/rough pale skin Hair loss Husky voice Cold intolerance Muscle cramps and frequent muscle aches Myofibrosis M. H. Sherazi Mallacoota Medical Centre, Mallacoota, VIC, Australia13 | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
396 Myalgia Joint effusion Constipation Depression Irritability Memory loss Abnormal menstrual cycles Decreased libido Slowed speech (severe cases) Jaundice (severe cases) Increase in tongue size (severe cases) Past Medical History: “Do you have any previous health issues?” Ask about cardiac ischemia, cardiomegaly, pericardial effusion, bradycardia, hyperlipidemia, galactorrhea, goi-ter, infertility, neuropathy, nerve entrapment, ataxia. Patients at risk of hypothyroidism are those with: -Previous Graves' disease -Autoimmune disorder (rheumatoid arthritis, type 1 diabetes) -Down syndrome -Turner syndrome -Previous thyroid or neck surgery -Previous radioactive iodine treatment of the thyroid Hospitalization History or Emergency Admission History: “Do you have any previous hospitalization or pre-vious surgery?” Medications History: Current medications? Use of lithium, amiodarone, interferon Prescribed, over the counter, and any herbal? Allergic History: “Do you have any known allergies?” Family History: “Has anyone in your family had similar symptoms or similar health problem?” 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?” Relationships: “Are you sexually active? Do you have sex-ual preferences?”Self-Care and Living Condition: “What do you do for liv-ing? Who lives with you?” Support: “Do you have good family and friends support?” Impact on Life/Disability and Adaptation: “Effects on life?” “Any effect on your daily activity?” Physical Examination: “Now, I will start the examination. ” Comment on the vital sign findings: check for presence of bradycardia. Check level of consciousness, alertness, and orientation. General Physical Examination: Evaluate body habitus, nervous/depressed and observe for dull facial expressions. Skin: Look for color, texture, and moisture. (Dry, coarse, yellow -red pigmentation on palms or soles or brittle nails) Hair: Coarse, brittle, loss of lateral one-third of the eye-brows (Queen Anne's eyebrows). Face: Edema around the eyes and macroglossia. Thyroid Examination: Inspection: Neck: -Observe the whole neck, but pay particular attention to the area of the thyroid gland. Inspect the neck from the front and side, and look for any obvious abnormalities, scars, or swellings. -Hand the patient a glass of water, and observe them as they take a drink. Watch the movement of any swellings as they drink as this can help to differentiate between different causes. -Comment on size, symmetry, and visible nodule in the neck. Palpation: (Be very gentle with the patient -so many people have already examined her at the day of your examination) Next feel the gland: -The approach is from behind so always tell the patient what you will be doing and that you will be behind her. Warn her again the moment before you actually touch her neck. M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
397 -Palpate the entire length of both lobes of the gland as well as the isthmus. Note any swellings or abnormal lumps. Comment on the shape and consistency of any lumps as well as whether they are tender or mobile. Also examine while the patient drinks to assess whether the lump moves with swallowing. -While still behind the patient, take the opportunity to examine the cervical lymph nodes. -Examine the eyes from behind and above to look for any exophthalmos. Percuss: Percuss for substernal extension of the thyroid. Auscultate: Auscultate over the lateral lobes with a bell to detect a bruit. Check neck lymph nodes and trachea. Check for pretibial edema (non-pitting). Cardiovascular Examination: Palpate peripheral pulses -Note: pulse volume, contour, and rhythm Auscultate (bradycardia and for any murmur) -Muffled heart sounds and an elevated jugular venous pressure -pericardial effusion Respiratory System: Inspection: Check chest expansion and percussion. Auscultate: Breath sounds and adventitious sounds. Nervous Examination: Note for tremors Motor power Muscle tone Sensations Reflexes (delayed relaxation phase or brisk) Wrap-Up: Thank the patient and ask the patient to cover up. Wrap up your findings with the examiner or the patient. Question: “What tests will you order?” (Questions may be asked by the patient or the examiner. ) Answer: Thyroid function test Thyroxine (T4): subnormal Thyroid-stimulating hormone (TSH): elevated Serum cholesterol Anemia: normocytic may be macrocytic Electrocardiogram (ECG): Sinus bradycardia Question: “What are a few complications if hypothyroid is not treated?” Answer: Untreated hypothyroidism can lead to [3]: Goiter Heart problems. Hypothyroidism may also be associated with an increased risk of heart disease, primarily because high levels of low-density lipoprotein (LDL) cholesterol. Hypothyroidism can also lead to an enlarged heart and heart failure. Mental health issues. Depression. Hypothyroidism can also cause slowed mental functioning. Peripheral neuropathy. Long-term uncontrolled hypo-thyroidism can cause damage to your peripheral nerves, the nerves that carry information from your brain and spi-nal cord to the rest of your body, for example, your arms and legs. Signs and symptoms of peripheral neuropathy may include pain, numbness, and tingling in the area affected by the nerve damage. It may also cause muscle weakness or loss of muscle control. Myxedema. This rare, life-threatening condition is the result of long-term, undiagnosed hypothyroidism. Its signs and symptoms include intense cold intolerance and drowsiness followed by profound lethargy and uncon-sciousness. A myxedema coma may be triggered by seda-tives, infection, or other stress on your body. If you have signs or symptoms of myxedema, you need immediate emergency medical treatment. Infertility. Low levels of thyroid hormone can interfere with ovulation, which impairs fertility. Birth defects. Babies born to women with untreated thyroid disease may have a higher risk of birth defects than babies born to healthy mothers. These children are also more prone to serious intellectual and developmental problems. Infants with untreated hypothyroidism present at birth are at risk of serious problems with both physical and mental development. But if this condition is diagnosed within the first few months of life, the chances of normal development are excellent. History and Physical Examination: Hyperthyroidism Candidate Information A 29-year-old female presents with heat intolerance, weak-ness, sweaty skin, and weight loss. Please take a focused his-tory and perform a relevant physical examination. 13 The Endocrine System | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
398 Differentials: Hyperthyroidism: Graves' disease Subacute thyroiditis Hashimoto's thyroiditis Toxic multinodular goiter Toxic adenoma Iatrogenic and factitious (exogenous thyroid hormones, excessive iodine ingestion) Anxiety disorder Pheochromocytoma Premenopausal state Metastatic neoplasm Starting the Interview: Knock on the door. Enter the station. Handwash/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... ? Are you 29 years old?” Chief Complaint “Can you please describe your symptoms to me?” The patient will tell about her symptoms. “How long has it been going on?” “How was these problems come about?” (suddenly versus gradual) “When did you first notice these symptoms?” “Are these progressing?” “Which symptoms are getting worse?” “How often do you notice these symptoms?” (intermittent versus constant) Ask Questions About Symptoms Associated with Hyperthyroidism: “Have you notice any swelling in the neck?” (goiter) “Weight loss?” “How much? Over what duration of time?” “Do your clothes still fit you?” “How is your appetite?” (Usually good or even increased). “Heat intolerance? How severe?” “Accelerated heart rate or palpitations?” “Do you feel irritable?” “Do you find difficulty in getting to sleep? Sleeping difficulties?” “Muscle weakness and trembling?” “Have you noticed that your hands shake or do you have tremors in your hands?” “Have you noticed any change in bowel habits? Diarrhea?” “Sweating?” “Nervousness, agitation, and anxiety?” “Changes in menstruation, including scantier flow and increased cycle length?” “Last menstrual period?” “Do you have any swelling in your legs?” (pretibial myxedema) “Itching?” “Did you notice any change in your eyes? Bulging?” “Did you notice any change in your vision? Double vision? Staring gaze?” “Does anything make your symptoms better? Or worse?” Constitutional Symptoms: Fever, chills, night sweats, anorexia Past Medical History: “Do you have any previous health issues?” Ask about thyroid disease, any treatment for thyroid dis-ease, radiation delivered to the neck, or radiation exposure. Hospitalization History or Emergency Admission History: “Have you had any previous hospitalization or previous surgery?” Medications History: Current medications? Use of thyroid replacement therapy, iodine, lithium, ami-odarone, interferon, propylthiouracil, cold and cough remedies, antiepileptics. Prescribed, over the counter, and any herbal? Allergic History: “Do you have any known allergies?” Family History: “Has anyone in your family had similar symptoms or similar health problems?” Social History: “Do you smoke? Do you drink alcohol?” If yes, then further ask: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” Relationships: “Are you sexually active? Do you have sex-ual preferences? Man, woman or both?” M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
399 Self-Care and Living Condition: “What do you do for liv-ing? Who lives with you?” Support: “Do you have good family and friend support?” Impact on Life/Disability and Adaptation: “Affects on your life?” “Any effect on your daily activity?” Physical Examination: “Now, I will start the examination. ” Comment on the vital sign findings: check for presence of tachycardia, heart rhythm, and respiratory rate. Atrial fibrillation? Fever? Check level of consciousness, alertness, and orientation. General Physical Examination: Evaluate body habitus and nervous/anxious, and observe for anxious facial expressions. Skin: Look for color, texture, and moisture. Hands: Feel the hands for any sweating. Look for any tremors: Placing a piece of paper on the back of the patient's outstretched hands. Look for tremors (Fig. 13. 1). Check the nails for any thyroid acropachy: Clubbing (Fig. 13. 2), or onycholysis, where the nail comes away from the nail bed. Observe for palmar erythema (Fig. 13. 3). Next you should feel the pulse (Fig. 13. 4). It may be tachycardiac. Inspect eyes: Eye protrusion, lid retraction, or lid lag or exophthalmos. Thyroid Examination: Inspection: Neck: -Observe the neck as a whole, but pay particular atten-tion to the area of the thyroid gland. Inspect the neck from front and side and looking for any obvious abnor-malities, scars, or swellings. -Hand the patient a glass of water, and observe them as they take a drink. Watch the movement of any swell-ings as they drink as this can help to differentiate between different causes. -Comment on size, symmetry, and visible nodule in the neck. Palpation: (Be very gentle with the patient -so many people have already examined her at the day of your examination). Fig. 13. 1 Looking for tremors Fig. 13. 2 Checking for clubbing Fig. 13. 3 Hand examination 13 The Endocrine System | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
400 Next feel the gland. -The approach is from behind, so always tell the patient what you will be doing and that you will be behind them. Warn them again the moment before you actu-ally touch their neck. -Palpate the entire length of both lobes of the gland as well as the isthmus. Note any swellings or abnormal lumps. Comment on the shape and consistency of any lumps as well as whether they are tender or mobile. Also examine while the patient drinks to assess whether the lump moves with swallowing. -While still behind the patient, take the opportunity to examine the cervical lymph nodes. -Examine the eyes from behind and above to look for any exophthalmos. Percuss: Percuss for substernal extension of the thyroid. Auscultate: Auscultate over the lateral lobes with a bell to detect a bruit (Fig. 13. 5). Pretibial edema (non-pitting) Cardiovascular Examination: Palpate peripheral pulses Note: pulse volume, contour, and rhythm Auscultate (tachycardia and for any murmur) Respiratory System: Inspection: Check chest expansion and percussion. Auscultate: Breath sounds and adventitious sounds. Nervous Examination: Note for tremors. Motor power. Muscle tone (proximal myopathy). Sensations. Reflexes (hyperreflexia may be present). Mention that you will also perform a fundoscopic exami-nation to note any papilledema. Wrap-Up: Thank the patient and ask the patient to cover up. Wrap up your findings with the examiner or the patient. Question: “What tests will you order?” Answer: Thyroid function test TSH (low) T4 and triiodothyronine (T3) (elevated) Thyroid antibodies (checked to differentiate Graves' and toxic multinodular goiter) Imaging -Radioisotope scan Increased uptake in overactive thyroid and decreased in thyroiditis and iatrogenic T4 ingestion. Uptake is homogeneous in Graves, heterogeneous in multinodular goiter, and single focus in a hot nodule. Question: “What treatment will be advised?” Answer: Antithyroid drugs: propylthiouracil (PTU) and methima-zole (MMI, Tapazole) -Inhibit thyroid hormone synthesis (block thyroid per-oxidase); inhibit peripheral conversion of T4 to T3. -Most useful in young, nonpregnant patients with small glands and mild disease. Fig. 13. 4 Checking radial pulse Fig. 13. 5 Auscultate with a bell M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
401 -Patients should be seen every 1-3 months until euthy-roid and then q 3-4 months while remaining on medication. B-blockers: propranolol for symptomatic control Medical ablation: -Radioactive iodine: It is given in Graves' when PTU or MMI fail to produce remission. Usually require life-long thyroid hormone replacement. Surgical ablation: -Subtotal thyroidectomy History and Physical Examination: Diabetic Patient First Visit Candidate Information: A 46-year-old male presents to your GP clinic with concerns of high blood sugar levels, which were checked in a medical awareness camp. Please take a focused history and perform a relevant physical examination. Starting the Interview: Knock on the door. Enter the station. Handwash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID badge. 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 Mr... ? Are you 46 years old?” Chief Complaint: “I understand, you came today to discuss about your blood results. Is it alright if I ask you a few questions about your blood test and general health? Then we will discuss about it. I would be happy to address any concerns you may have. ” “Why was the blood test done?” “When was the blood done?” “Who ordered it?” “What were the results?” “Have you ever had blood sugar levels done before? When?” Continue with symptoms related to diabetes/hyperglyce-mia. Ask about: Being excessively thirsty Passing more urine “How is your urine? Is it frothy or cloudy?” Feeling tired and lethargic Always feeling hungry Having cuts that heal slowly Itching, skin infections “Have you ever had an eye check?” “When was the last time you saw an ophthalmologist?” Any retinal complications? Blurred vision or vision changes? Any history of heart attack? Gradually putting on weight Mood swings Headaches Feeling dizzy “How are your feet?” Any feet ulcers? Leg cramps “Do you have tingling or numbness?” Past Medical History: “Do you have any previous health issues?” Hospitalization History or Emergency Admission History: “Have you had any previous hospitalization or previous surgery?” Medications History: Current medications? Prescribed, over the counter, and any herbal? Allergic History: “Do you have any known allergies?” Family History: Diabetes? Social History: “Do you smoke? Do you drink alcohol?” If yes, then further ask: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” Relationships: “Are you sexually active? Do you have sex-ual preferences? Man, woman, or both?” Self-Care and Living Condition: “What do you do for liv-ing? Who lives with you?” Support: “Do you have good family and friend support?” Impact on Life/Disability and Adaptation: “Effects on life?” “Any effect on your daily activity?” 13 The Endocrine System | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
402 Physical Examination: “Now, I will start the examination. ” Comment on the vital signs. General Physical Examination: Ask for patient height and weight with body mass index (BMI). Check level of consciousness, alertness, and orientation. General appearance. Head and neck exam: -Oral: hygiene, thrush, and caries -Nose -Mouth and throat -Thyroid assessment -Cervical lymph nodes Cardiovascular Examination: Palpate peripheral pulses Note: pulse volume, contour and rhythm Auscultate Pedal edema Respiratory System: Inspection: Check chest expansion and percussion. Auscultate: Breath sounds and adventitious sounds. Abdominal Examination: Inspection Palpation Nervous Examination: Note for tremors. Motor power. Muscle tone. Sensations (proprioception, vibration, light touch). Reflexes (delayed relaxation phase or brisk). Skin: Fungal infections Cutaneous infection Signs of dyslipidemia Examination of Hand and Feet Wrap-Up: Thank the patient and ask the patient to cover up. Wrap up your findings with the examiner or the patient. Question: What tests will you order? Answer: Full blood count Hemoglobin A1c (Hb A1c) Fasting lipid profile Urea and creatinine Electrolyte Estimated glomerular filtration rate (e GFR) Urine dip ECG Ophthalmologist referral for eye exam (check your regional guidelines) Question: What will you do next? Answer: Referral to diabetic clinic Diabetic education Information on healthy diet (food guide) Information about regional diabetic resources Question (Patient): “Doctor, please tell me more about type 1 diabetes. ” Answer: “Type 1 diabetes represents about 10% of all cases of diabetes and is one of the most common chronic child-hood conditions. Type 1 diabetes is an autoimmune condi-tion in which your immune system is activated to destroy the cells in the pancreas that produce insulin. We do not know what causes this autoimmune reaction. Type 1 diabetes is not linked to modifiable lifestyle factors. There is no cure and it cannot be prevented. Its onset is usually abrupt and the symptoms obvious. It is managed with insulin injections sev-eral times a day or the use of an insulin pump. ” Question: “What happens if people with type 1 diabetes do not receive insulin?” Answer: “If the patient will not get insulin, the body will start burning its own fats as a substitute, which releases chemical substances in the blood. Without ongoing injec-tions of insulin, the dangerous chemical substances will accumulate and can be life-threatening if it is not treated. This is a condition called ketoacidosis”[4]. Question (Patient): “Doctor, please tell me more about type 2 diabetes. ” Answer: “Type 2 diabetes represents about 85-90% of all cases of diabetes. It is a progressive condition in which the body becomes resistant to the normal effects of insulin and or gradually loses the capacity to produce enough insulin in the pancreas. It usually develops in adults over the age of 45 years but is increasingly occurring in younger age groups. We do not know what causes type 2 diabetes. It is also likely in people with a family history of type 2 diabetes or from particular ethnic backgrounds. Some patient may present with a complication of diabetes such as a heart attack, vision M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
403 problems, or a foot ulcer. It is managed with a combination of regular physical activity, healthy eating, and weight reduc-tion. Because type 2 diabetes is often progressive, most peo-ple will need to take oral medications and/or insulin injections in addition to lifestyle changes over a period of time” [5]. Question: “What is hypoglycemia?” Answer: Hypoglycemia, or low blood sugar, occurs when a person's blood glucose level drops too low -lower than 4 mmol/L. It can make a person very unwell, so it is very important to treat it as quickly as possible. A person may experience the following symptoms: Light-headedness Dizziness Sweating Hunger Shaking, trembling, or weakness Paleness Headache Pins and needles around mouth Fitting/seizures Loss of consciousness Question: “How do you treat hypoglycemia?” Answer: If hypoglycemia is suspected, immediately check blood sugar level. Or seek help to get someone to check it for you. If your blood sugar level is below 4 mmol/L, take 15 g of a fast-acting carbohydrate. For example, one of these: Six to seven jelly beans Half a can of regular soft drink Half a glass of fruit juice Three teaspoons of sugar or honey Glucose tablets equivalent to 15 g carbohydrate After this, please wait for 15 min and then recheck the blood glucose levels to see if the blood sugar level has risen above 4 mmol/L. If the blood sugar level has not risen, then take another 15 g of a fast-acting carbohydrate as above. If blood sugar has improved, then eat a snack or meal. History: Diabetic Follow-Up Visit Candidate Information: A 39-year-old male, who is a known diabetic, presented to your GP clinic for a routine checkup. Please take a detailed history. No physical examination is required. Starting the Interview: Knock on the door. Enter the station. Handwash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID badge. 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 Mr... ? Are you 39 years old? You are here for your diabetic follow-up. As I am seeing you for the first time, I will ask you a few ques-tions about diabetes and then your general health. If you have any question or concern, please ask me. ” Chief Complaint “What type of diabetes do you have?” “How long have you been diagnosed with diabetes? Or how old were you when you were diagnosed to have diabetes?” “How was it diagnosed?” “What treatment you are taking?” “Who does the follow-ups?” “When was the last time you had Hb A1c checked?” “When was the last time your lipid profile was checked?” “When was the last time you had a urine screen for microalbuminuria?” “Do you see a diabetic educator/nurse?” “Do you see a dietitian/nutritionist?” “Have you seen an endocrinologist?” “How often do you monitor blood sugar?” “How are the numbers?” “How well is your blood sugar under control?” “Did you ever have an episode of diabetic ketoacidosis?” Ask About Symptoms of Hyperglycemia: Being excessively thirsty Passing more urine “How is your urine? Is it frothy or cloudy?” Feeling tired and lethargic Always feeling hungry Ask About Symptoms of Hypoglycemia: “Do you have episodes of hypoglycemia?” Pallor Sweating Palpitations 13 The Endocrine System | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
404 Tremor Headache Hunger Abdominal pain Decrease level of consciousness Fainting “Have you ever had an eye check?”: “When was the last time you saw an ophthalmologist?” “Any retinal complications?” “Blurred vision or vision changes?” Past Medical History: “Do you have any previous health issues?” Eye problems Infections Hypertension Ischemic heart disease Nephropathy: microalbuminuria and renal failure Peripheral neuropathy or mononeuropathy Hospitalization History or Emergency Admission History: “Have you had any previous hospitalization or previous surgery?” Medications History: Current medications? Insulin (dose, frequency, and mode of delivery). Prescribed, over the counter, and any herbal? Allergic History: “Do you have any known allergies?” Family History: Diabetes? Vascular disease? Social History: “Do you smoke? Do you drink alcohol?” If yes, then further ask: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” Relationships: “Are you sexually active? Do you have sex-ual preferences?” Self-Care and Living Condition: “What do you do for liv-ing? Who lives with you?” Support: “Do you have good family and friends support?” Impact on Life/Disability and Adaptation: “Effects on life?” “Any effect on your daily activity?”Wrap-Up Question: “What tests will you order?” Answer: Full blood count Hb A1c Fasting lipid profile Urea and creatinine and (Urine albumin to creatinine ratio ACR) Electrolyte e GFR Urine dip ECG Fundoscopy Ophthalmologist referral for eye exam (check your regional guidelines) History and Counseling: Child with Diabetes Candidate Information: A 10-year-old male, known to be diabetic, is brought by his father to your GP clinic for a checkup. Please take a detailed history. No physical examination is required. (Make sure you remember throughout the station that you are asking ques-tions of the patient's father. ) Starting the Interview: Knock on the door. Enter the station. Handwash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID badge. 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 Mr... ? You are... 's father? How can I help you today?” Chief Complaint “You are here for his checkup. Is there anything in par-ticular that you are worried about?” “Is he doing well in school?” “Is he not looking well?” “Is he not playing well and looks tired?” “As, I am seeing him for the first time, I am going to ask a few questions about his diabetes and then about his general health. ” M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
405 “How long has he been diagnosed with diabetes? Or how old was he when diagnosed to have diabetes?” “How was it diagnosed?” “What treatment was he taking?” “When was the last follow-up?” “Who does the follow-ups?” “When was the last time that his Hb A1c was checked?” “When was the last time he had a urine screen for microalbuminuria?” “Does he follow-up with a diabetic educator/nurse?” “Does he see a dietitian/nutritionist?” “Does he see an endocrinologist?” “How often do you monitor his blood sugar?” “What are his numbers like?” “Did he ever have an episode of diabetic ketoacidosis?” Ask About Symptoms of Hyperglycemia Being excessively thirsty? Passing more urine? “How is his urine? Is it frothy or cloudy?” Feeling tired and lethargic? Always feeling hungry? Ask About Symptoms of Hypoglycemia “Does he have episodes of hypoglycemia?” Pallor Sweating Palpitations Tremor Headache Hunger Abdominal pain Decrease level of consciousness Fainting Ask About His Insulin “Does he take insulin himself or does somebody else give it to him?” “Does he take it regularly and all on time?” “Does he skip doses?” “Does he need any help to take insulin?” “Do you record his blood sugar levels?” “Do you maintain a log book of his blood sugar levels?” Past Medical History: “Does he have any previous health issues?” Eye problems? Infections? Heart problem? Nephropathy: microalbuminuria and renal failure? Hospitalization History or Emergency Admission History: “Has he had any previous hospitalization or previ-ous surgery?” Medications History: Current medications? Insulin (dose, frequency, and mode of delivery). Prescribed, over the counter, and any herbal? Allergic History: “Does he have any known allergies?” Child (BINDES): Birth/pregnancy history, immunization status, nutrition/weight gain, developmental history/meeting milestones, environment and social history Family History: Diabetes? Vascular disease? Wrap-Up Question:“What tests will you order?” Answer: Full blood count Hb A1c Fasting lipid profile Urea and creatinine and (Urine albumin to creatinine ratio ACR) Electrolyte e GFR Urine dip ECG Fundoscopy Ophthalmologist referral for eye exam (check your regional guidelines) Question: “Tell me more about his diabetes. ” Answer: Ask the patient's father about his understanding about diabetes. Then explain, “when we eat food containing sugar, it is absorbed in our intestine. The sugar goes to the blood and from there to different parts of our body. Sugar acts like a fuel in our body. We require insulin in order for our body to use this energy. Patients having diabetes do not have enough insulin. Sugar will built up in the blood. The body tries to get rid of it by peeing extra sugar. This will lead to increasing thirst and tiredness. ” “This can be avoided by controlling the blood sugar. If the blood sugars are well controlled, these symptoms can be avoided. If blood sugars are not controlled, it may end up in diabetic ketoacidosis and with serious consequences. ” “Always be aware of hypoglycemic symptoms: loss of consciousness, sweating, heart racing, hungry. It is advised 13 The Endocrine System | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
406 that your son should carry a medical alert card or a bracelet that will clarify that he has diabetes. ” Physical Examination: Diabetic Foot Candidate Information: A 51-year-old male, who is a known diabetic, presents to your GP clinic. Please perform a diabetic foot examination. Starting the Interview: Knock on the door. Enter the station. Handwash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Stand on the right side of the patient and start the examination. Equipment: Monofilament Tuning fork (128 Hz) Tendon hammer Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Mr... ? Are you 51 years old? Today, I shall be doing a detailed examination of your feet. Are you alright with that? During the examina-tion, if you feel uncomfortable please let me know. ” Inspection: Inspect legs from front, side, and behind. Inspect feet, both dorsal and planter aspects, and in between toes. Color of foot: Pallor, cyanosis, erythema (looking for ischemia and cellulitis). Skin: -Look for dry, shiny, and hair loss (looking for periph-eral vascular disease [PVD]). -Eczema or hemosiderin staining (venous disease). Ulcers: -Venous ulcers: (venous insufficiency or varicose veins). -Moderate to no pain, ulcers may be larger or shallow. -Arterial ulcers (diabetes mellitus or peripheral vascu-lar disease). -Usually very painful, deep punched out appearance. Swelling: -Edema: venous insufficiency or heart failure -Deep vein thrombosis: tender on palpation Planter arch:-Observe for loss of planter arch. Toes: -Look for clawing of toes due to neuropathy. Calluses: -Check weight-bearing area for callus. May indicate incorrectly fitting shoes. Venous filling: -Guttering of veins or reduced visibility suggests PVD. Deformity caused by neuropathy: -Charcot arthropathy Palpation: Temperature: -Feel the temperature with the back of your hand and compare both sides. -Cool (PVD). -Hot (cellulitis). Capillary refill time: -Normal: <2 s. -Prolongation suggests PVD. Pulses: -Dorsalis pedis artery. -Posterior tibial artery. -Absence of peripheral pulses is suggestive of periph-eral vascular disease. Sensations: -Monofilament: Guide the patient by touching the monofilament to the patient's arm or sternum and letting him acknowledge the sensation. Ask the patient to close his eyes, place the mono-filament on the hallux and metatarsal heads. Press firmly so that the filament bends. Hold the monofilament against the skin for 1-2 s, and ask the patient to tell you when he feels it. Avoid touching at the areas of calluses and scars as these will likely have a reduced level of sensation, which is not representative of the surrounding nor-mal tissue. -Vibration sensation: With the patient's eye closed, tap a 128 Hz tuning fork. Place it on the patient's sternum and confirm that the patient can feel it buzzing. Ask the patient to inform you when he can feel it on his foot and to tell you when it stops buzzing. Assess sensation by placing the vibrating tuning fork onto the distal phalanx of the great toe. Repeat on the other side and compare. If sensations are intact, he should mention that he can feel the tuning fork buzzing. You should then gently place your hand onto the tuning fork to stop it vibrating. If the patient's sen-M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
407 sation is intact, then he should state that the vibra-tion has now stopped. If sensation is impaired, continue to assess more proximally, e. g., proximal phalanx. Repeat assessment on the other leg. -Proprioception Hold the distal phalanx of the great toe by its sides. Demonstrate movement of the toe upward to the patient. Then ask the patient to close his eyes and state whether you are moving the toe up or down. If the patient is unable to correctly identify direc-tion of movement, move to a more proximal joint: to ankle, knee, and then hip. Gait: Observe the patient walking while assessing. -Symmetry and balance -Turning: quick, slow, or staggered -Abnormalities: broad-based gait, foot drop, or antalgia Examine the footwear (just mention that you will also have a look on the patient's shoes): -Note pattern of wear on the soles. -Look for asymmetrical wearing (for gait abnormality). -Ensure the shoes are the correct size for the patient. -Note holes and material inside the shoes that could cause foot injury. Ankle jerk reflex: Ankle jerk reflex may be absent in advanced peripheral neuropathy. To Complete the Examination Mention you will also examine lower limb neurological examination and peripheral vascular examination. Thank the patient. Ask him to cover up. Sum up your findings to the examiner. History and Management: Diabetic Ketoacidosis (DKA) Candidate Information: You are working in an emergency room when a 24-year-old male is brought by ambulance because of drowsiness, cough, fever, diffuse abdominal pain, and vomiting for 2 days. He is known to be type 1 diabetic. Manage this case. There is a nurse in the room to carry out the orders. Differential Diagnosis of Diabetic Ketoacidosis: Hyperglycemic hyperosmolar state (HHS) Abdominal pain differentials Cough with fever differentials Other causes of raised anion gap metabolic acidosis Alcohol “MUDPILES”: Methanol, uremia, DKA, paraldehyde, isoniazid, lactate, ethylene glycol, salicylates Carbon monoxide/cyanide This scenario can be divided into two parts: History and examination Management Starting the Interview: Knock on the door. Enter the station. Handwash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Stand on the right side of the patient and start. Opening: The nurse may give you the blood result report as you walk in to see the patient [6]: Hemoglobin: 13. 3 g/dl (133 g/L) WBC: (19. 0) 19,000/μ(mu)l Hematocrit: 49% Glucose: 450 mg/dl (25. 0 mmol/L) Urea: 60 mg/dl (10. 2 mmol/L) Creatinine: 1. 4 mg/dl (123. 7 μ[mu]mol/L) Na+: 142 m Eq/L K+: 5. 3 m Eq/L Cl-: 110 mmol/L Arterial p H: 7. 23 PO2: 95 mm Hg PCO2: 28 mm Hg HCO3: 9 m Eq/L O2 sat: 98%. Strip for ketone bodies in urine: strongly positive Urinalysis: glucose 800 mg/dl and Specific gravity: 1030 Interpret quickly: hyperglycemia, ketosis, and metabolic acidosis. “He has DKA. ” Triage Immediately: Call the patient's name and check his response. Or gently shake his shoulder or hand. Check for response and immediately tell the examiner about your findings. If the patient is conscious and stable, then introduce your-self to the patient: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Mr... ? Are you 24 years old?” Ask the nurse for vital signs -interpret the vital signs: 13 The Endocrine System | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
408 Temp: 39 °C Heart rate (HR): 110 Blood pressure (BP): 90/60 Respiratory rate (RR): 27 Mention to the examiner: “I will start primary survey (ABCD)” Airway Is the airway patent? Comment on the airway. If the patient is talking well, then mention that the airway is patent. Breathing Is the patient breathing? Check respiratory rate. Pulse oximetry. Deliver high flow oxygen 15 L/min via reservoir mask and titrate to achieve oxygen saturations (S p O2) 94-98%. Listen to the chest and heart. The examiner may inform you that the patient has dry mucous membranes, poor skin turgor, and decreased air entry with rales in the right lower chest. Circulation Check pulse, BP Ask the nurse to please pass two large bore cannula (G14/ G16), one on each arm. Ask the nurse to prepare 1 L normal saline 0. 9% to start infusing as the first liter in 1 h. Ask the nurse to prepare continuous monitoring with car-diac monitoring/12-lead ECG. Add blood cultures and urine cultures in the investigations. Portable chest X-ray. (Remember that the patient has cough and fever -order it here. Many times candidates miss it later in the history). D: Disability and neurological status: Rapid neurological assessment should be done next. During the primary survey, a basic neurological assess-ment is made, known by A VPU (an acronym for “alert, voice, pain, unresponsive”). Pupils: size, symmetry, and reaction. Any lateralizing signs. History: You need to ask questions about abdominal pain, cough, and fever. (Do not go into too much detail as this is a manage-ment station, and there is too much still to cover. Select ques-tions from the following list. ) Pain Questions: Onset: “When did the pain start?” Course: “How did it start?” (Suddenly or gradually) Duration: “How long have you had this pain?” Location: “Where does the pain start?” Then clarify the area: right upper quadrant (RUQ), right left quadrant (RLQ), left upper quadrant (LUQ), left lower quadrant (LLQ), suprapubic, epigastrium, or flanks. Character: “What is the pain like?” Progression: “Is the pain progressing?” Severity: “From 0 to 10, 10 being the worst pain and 0 as no pain, how is your pain now?” Aggravating: “Anything that increases the pain?” Alleviating: “Anything that relieves the pain?” Cough Questions: “When did your cough start?” 2 days back “Did it start gradually or suddenly?” “Is it continuous or does it come and go?” “Is the cough present all the time or does it come on at a specific time?” “Does your cough come with certain positions? Lying down?” “Is it getting worse with time?” “How long does each bout of coughing last?” “What increases/decreases this cough?” “Is it accompanied by phlegm?” “Consistency?” “Odor?” “Color?” “Amount?” “Any blood?” “Do you become short of breath?” “Have you noticed any difficulty in breathing? Not enough air, chest pain, chest tightness, or wheezing?” Fever: “When and how much? Did you take anything for it?” Past Medical History: “Any previous health issues? Previous DKA, previous hospital admissions?” Medication History: Insulin glargine 28 IU at bedtime and a rapid-acting insulin analog before each meal. Social History: Smoking, alcohol, drugs, sexual history Now Back to Management: (Check your regional and hos-pital guidelines. ) M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
409 Fluid Resuscitation: The rates should be adjusted according to urine outpatient and patient condition. Aim for a urine output of >0. 5 ml/ kg/h; insert a urethral catheter if necessary. 0. 9% saline 1 L intravenous (IV) over 1 h. 0. 9% saline 1 L IV over 2 h. 0. 9% saline 1 L IV over 4 h. 0. 9% saline 1 L IV over 6 h. Use 5% dextrose when blood glucose is <10 mmol [ 7]. Insulin Intravenous Infusion: Ask the nurse to draw up 50 units of actrapid in 50 ml of 0. 9% saline (1 unit/ml) and run at 0. 1 unit/kg/h, for exam-ple, 8 units/h for a 80 kg individual. Ketone levels should fall by 0. 5 m M/h. If it does not, then increase the infusion rate by 0. 1 unit/h increments until the target rate is achieved. Insulin rates that will be adequate to switch off ketogen-esis usually make patients hypoglycemic, so start glucose 10% IV at 125 ml/h once glucose <14 m M. Continue long-acting insulin therapy at the usual dose and timing. Potassium Replacement: Potassium levels may be high on arrival; they will fall rap-idly once the fixed rate insulin IV infusion commences. The supplementation suggested below should be added to the resuscitation fluid: Potassium >5. 5 mmol requires no supplementation. Add when potassium <3. 5 mmol: give 20 mmol with each liter infusion and give 10 mmol/h when potassium = 3. 5-5 mmol. Monitoring [ 8]: Blood glucose and ketones: hourly VBG should be done: 0, 2, 6 h Creatinine: 0, 6, 12, 24 h Bicarbonate: 0, 1, 2, 3, 6, 12, 24 h The examiner may hand you an X-ray (Fig. 13. 6) This is right-sided pneumonia. Mention you will chart broad-spectrum antibiotics. Consult the medical unit and critical care. Thank the patient and describe your findings to the examiner. Question: “What are complications of DKA?” Answer: Hyperkalemia Hypokalemia Hypoglycemia from fixed rate insulin IV infusion without glucose supplementation Cerebral edema Pulmonary edema Death References 1. Hurley KF. Ch 9. Endocrinology. In: OSCE and clinical skills hand-book. 2nd ed. Toronto: Elsevier; 2011. p. 271-2. 2. Mathur R. Hypothyroidism symptoms, diet, natural and medical treatments, and tests. Medicine Net. com. https://www. medicinenet. com/hypothyroidism/article. htm. Accessed 11 Apr 2018. 3. Mayo Clinic. Hypothyroidism (underactive thyroid). https://www. mayoclinic. org/diseases-conditions/hypothyroidism/symptoms-causes/syc-20350284. Accessed 11 Apr 2018. 4. Diabetes Australia. Type 1 diabetes. https://www. diabetesaustralia. com. au/type-1-diabetes. Accessed 11 Apr 2018. 5. Diabetes Australia. Type 2 diabetes. https://www. diabetesaustralia. com. au/type-2-diabetes. Accessed 11 Apr 2018. 6. Diabetes in Control. Diabetic emergencies, part 5: DKA case stud-ies. 2012. http://www. diabetesincontrol. com/diabetic-emergencies-part-5-dka-case-studies/. Accessed 11 Apr 2018. 7. Longmore M, Wilkinson IB, Davidson EH, Foulkes A, Mafi AR. Diabetic ketoacidosis. In: Oxford handbook of clinical medicine. 8th ed. Pakistan: Oxford University Press; 2010. p. 842-3. 8. Gale EAM, Anderson JV. Diabetic metabolic emergencies. In: Kumar P, Kumar CM, editors. Clark's clinical medicine. 9th ed. Netherland: Elsevier; 2017. p. 1261-4. 9. Liang L. Infections atypical pneumonia. In: Li H, editor. Radiology of infectious diseases: volume 1. Dordrecht: Springer; 2015. Fig. 13. 6 On day 1 of pneumonia, the chest X-ray shows subpleural flakes of blurry shadow at the right lower lung. (Reprinted with permis-sion from Liang [ 9]) 13 The Endocrine System | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
410 Further Reading Hypothyroidism 10. Haugen BR. Drugs that suppress TSH or cause central hypothyroid-ism. Best Pract Res Clin Endocrinol Metab. 2009;23(6):793-800. https://www. ncbi. nlm. nih. gov/pmc/articles/PMC2784889/ 11. Hurley KF. Ch 9. Endocrinology. In: OSCE and clinical skills handbook. 2nd ed. Toronto: Elsevier; 2011. p. 271-2. 12. Mathur R. Hypothyroidism symptoms, diet, natural and medical treatments, and tests. Medicine Net. com. https://www. medicinenet. com/hypothyroidism/article. htm 13. Mayo Clinic. Hypothyroidism (underactive thyroid). https:// www. mayoclinic. org/diseases-conditions/hypothyroidism/ symptoms-causes/syc-20350284. Hyperthyroidism 14. Murtagh J. Ch 82: asthma: dangerous signs. In: John Murtagh's general practice. 6th ed. North Ryde: Mc Graw-Hill Australia Pty Ltd; 2015. p. 227-38. Diabetes Mellitus 15. Diabetes Australia. Type 1 diabetes. https://www. diabetesaustralia. com. au/type-1-diabetes. 16. Diabetes Australia. Type 2 diabetes. https://www. diabetesaustralia. com. au/type-2-diabetes. Diabetic Detoacidosis 17. Oxford Medical Education. Diabetic ketoacidosis (DKA). http:// www. oxfordmedicaleducation. com/endocrinology/dka/. 18. Diabetes in Control. Diabetic emergencies, part 5: DKA case studies. 2012. http://www. diabetesincontrol. com/ diabetic-emergencies-part-5-dka-case-studies/. 19. Longmore M, Wilkinson IB, Davidson EH, Foulkes A, Mafi AR. Diabetic ketoacidosis. In: Oxford handbook of clinical medi-cine. 8th ed: Oxford University Press; 2010. p. 842-3. 20. Ch 27. Diabetes mellitus. Diabetic metabolic emergencies. In: Kumar P, Clark M. Kumar and Clark's clinical medicine, 9th edn. Elsevier; 2017. p. 1261-4. M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
411 © 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_14Hematology Mubashar Hussain Sherazi History Overview: General History Hematology I have brought these few blood-related topics together in one hematology chapter. In the objective structured clinical examinations (OSCE), you may or may not have one of these scenarios. The general structure of going through these sce-narios in OSCE will generally be similar to the other medical scenarios. These will often come as a history-taking station with counseling. If you will be asked to perform an examina-tion, it will be either limited to focus on one system examina-tion or a general physical examination. See Table 14. 1 for an overview of the pattern of history- taking required for hematology stations. Checklist: Physical Examination Hematology See Table 14. 2 for a checklist that can be used as a quick review before the exam. History and Counseling: Warfarin Candidate Information: A 60-year-old male presents in your GP clinic with concerns of his international normalized ratio (INR) being 1. 0 today. Please take a detailed but relevant history and counsel the patient accordingly. Vital Signs: Heart rate (HR), 62/min, regular; blood pres-sure (BP), 140/80 mm Hg; temp, 36. 8 °C; respiratory rate (RR), 18/min; O2 saturation, 100%. No physical examination is required for this station. 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. Now 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 Mr... ? Are you 60 years old?” History of Present Illness: “I understand you came today to discuss your blood results. Is it alright if I ask you a few questions about your blood test and general health? Then we will discuss about it. I'd be happy to address if you have any concerns. ” “Why was the blood test done?” “When was the blood test done?” “Who ordered it?” The patient may explain that he was diagnosed with pul-monary embolism (PE) or deep vein thrombosis (DVT) a few months back and was put on warfarin (Coumadin). He has been coming for regular checkups until last week to another GP. “How was it diagnosed?” “What investigations were done?” “Were you admitted to the hospital? How many days?” “What were the symptoms at that time?” “Was there any pain and swelling?” “Was there shortness of breath? Chest pain?” “Which were the medicines that you were treated with?”M. H. Sherazi Mallacoota Medical Centre, Mallacoota, Victoria, Australia14 | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
412 “What was the target INR set?” “Is INR done on a regular basis?” “What was your last INR and when?” “What was the level?” 1. 0 “I want to find out why it is 1. 0. ” Check for compliance: “Do you take your medications on a regular basis?” “Do you take your medicines by yourself or do you need help?” “Was there any chance that you skipped a dose?” “Did you start any new medications or antibiotics?” “Are you eating a lot of spinach?” “Are you recently taking any vitamin K supplements?” He may tell that he stopped taking warfarin because of some particular reason; for example, he was told by a friend that it may cause stroke! Or he may mention any other side effects, such as skin necrosis/bleeding! “I need to ask you more questions before answering this concern”: “Did you notice any blood from your gums, nose, bruises in body, coughing up blood?” “Do you have any stomachache?” “Did you vomit? Blood in vomit?” “Did you pass black tarry stools?” Ask about any neurological symptoms. Table 14. 1 Quick review of history taking required for hematology stations Introduction Name and age Chief complaint In patient's own words History of present illness Analysis of chief complaint Onset Course Duration If pain Nature Intensity (1-10) Location Progression Frequency Quality Radiation Severity (1-10) Timing Contributing factors Aggravating/alleviating factors Related symptoms Associated symptoms: nausea, vomiting, change in bowel habits, appetite, blood in vomiting/feces/urine Predisposing factors Aggravating and relieving factors Red flags/risk factors Rule out differential diagnosis Review of systems Respiratory Cardiovascular Neurology Musculoskeletal Constitutional symptoms: anorexia, chills, night sweats, fever, lumps/bumps, 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 Medication history Current medications (prescribed, over the counter, and any herbal) 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 Table 14. 1 (continued) Street drugs Sexual history If adult female Menstrual history (LMP) Gynecology history Obstetric history If teen Home Education Employment 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 | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
413 “Since you stopped warfarin, I want to ensure that there is no relapse of your DVT/PE”: “Do you have any swelling of your calf?” “Did you have any calf pain?” “Did you have shortness of breath?” “Have you had any heart racing?” “Did you notice any chest tightness?” Ask about fever. Past Medical History: “How is your health otherwise? Any other medical problems? Diabetes mellitus (DM), hypertension (HTN), history of kidney/liver disease? Stroke? Bleeding disorder?” Past Hospitalization and Surgical History: “Have you had any previous hospitalization or previous surgery?” Medication History: “Are you taking any medication?” If he says no, then continue to the next question. “Over-the-counter or herbal medications and any side effects?” Allergic History: “Do you have any known allergies?” Family History: “Any family history of stroke, blood dis-orders, liver and kidney disorders?” Social History: “Do you smoke? Do you drink alcohol? Do you take any recreational drugs?” Self-Care and Living Condition: “What do you do for liv-ing? Who lives with you?” Work Conditions and Financial Status? Support: “Do you have good family and friends support?”Table 14. 2 Checklist for hematology 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 identification (ID) badge Now sit on the chair or stand on the right side of the patient and start the examination Opening Introduction, greet, explain, position, and exposure/drape Ask for vital signs -interpret the vital signs Ask for orthostatic blood pressure (BP) General physical examination Check for alert and orientation. Look for any abnormal findings in Face: characteristic face Eyes: palpebral conjunctival pallor, jaundice Mouth: mucosal bleeding, gum bleeding, strawberry tongue, cheilosis Palms: pallor in creases, petechia, cold, clammy Fingers: nail changes or clubbing Cervical lymph nodes palpation Axillary lymph nodes palpation Sternal tenderness: press and ask for bone pain Skin Thinning and dry skin Evidence of delayed healing (multiple scars or unresolved wounds) Look for any bruise or rash Record the distribution, number, site, and size of bruising together with any petechiae, ecchymoses, and subcutaneous hematoma Examine the pattern of bruising In dependent areas: thrombocytopenia or stasis factor Only on the arms or legs: possible trauma Around the eyes: connective tissue disorder In atypical areas such as back, buttocks, arms, and abdomen: bleeding disorder or non-accidental injury Typically over extensor surfaces of forearms: suspect senile purpura Palpate bruise: raised above the surface, tenderness, blench on touch Abdominal examination Inspection Auscultation: bowel sounds and bruits Palpation: Superficial/light palpation Deep palpation Liver palpation Spleen palpation Kidney palpation Inguinal lymph nodes palpation Rectal examination Mention Table 14. 2 (continued) Chest examination Auscultate (murmurs) Respiratory system Auscultate Nervous examination Motor power Muscle tone Sensations Reflexes Legs examination Petechia on legs, bruises, check of position sense, and vibration sense Wrap-up Thank the patient and ask the patient to cover up Wrap up your findings with the examiner or the patient 14 Hematology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
414 Wrap-Up Counseling: Ask him about his understanding of DVT or PE? (But do not go into too much details. Remember it is a warfarin scenario. ) Question: “Why does he require treatment?” (Questions may be asked by the patient or the examiner. ) Answer: “The main reason about the treatment about DVT or PE is that if not treated, there is a high chance that relapse may recur. In high-risk patients or recurrent DVT or PE, life-long treatment will be required. In addition, these clots formed in your legs may dislodge and may travel all the way to your heart and then to lungs. This can be serious and even can cause sudden death. ” Question: “Why is blood clotting important?” Answer: “Blood clotting or coagulation, which is the process of forming of clots, is an important function of the body, espe-cially when we get a cut and need to stop bleeding. However, clots forming inside blood vessels are dangerous because they can travel to potentially any organ of the body, especially the heart, lung, and brain. In the brain it can cause a stroke. If it travels to the heart, it can cause a coronary attack. ” Question: “What treatment will you advise to this patient now?” Answer: “Because you stopped warfarin, we need to start both heparin and warfarin. We need to bridge heparin until you have adequate INR, then we will stop heparin and con-tinue with warfarin. ” Question: “What about missing a warfarin tablet?” Answer: “It is important to take warfarin at around the same time each day. If you miss a dose, do not take a double dose, but take your next dose when it is due and contact your doctor. ” Question: “What factors can affect warfarin?” Answer: “Your diet: There should be some dietary restriction while taking warfarin. Some foods may contain vitamin K that may interact with warfarin. Spinach, collard greens, Brussels sprouts, parsley, kale, and chard need to be avoided. Some drinks may change warfarin's effects, such as cranberry juice and green tea. Alcohol may interact with warfarin. Use it in moderation and avoid binge drinking. Medications enhancing the warfarin effects: Antibiotics, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), cimetidine, allopurinol, amiodarone, anabolic steroids, met-ronidazole, omeprazole, phenytoin, quinine, and thyroxine. Medications decreasing the effect of warfarin: Antacids, antihistamines, barbiturates, diuretics, haloper-idol, estrogen, oral contraceptives, and vitamin C. ” History and Counseling: Anemia Candidate Information: A 40-year-old male presents to your GP clinic with a blood report showing hemoglobin of 8. 0 gm/dl. Please take a detailed history and determine what is the most likely cause. Discuss your differentials with the examiner. What investiga-tions would be helpful? Differentials: Pathophysiology: 1. Decreased production 2. Increased loss 3. Increased destruction Microcytic: -Anemia of chronic disease -Iron deficiency -Thalassemia -Lead poisoning -Sideroblastic anemia -defects in heme biosynthesis Normocytic: -Acute blood loss -Bone marrow failure -Chronic disease -Destruction (hemolysis) High reticulocyte count: Hemolysis: -Inherited: hemoglobinopathy (sickle cell) -Membrane: spherocytic -Metabolic: hexose monophosphate (HMP) shunt, gly-colytic pathway Acquired: -Microangiopathic hemolytic anemia: Disseminated intravascular coagulation (DIC), thrombotic thrombo-cytopenic purpura (TTP), hemolytic-uremic syndrome (HUS), HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) -Immune: Coombs positive, drug-related, cold agglutinin M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
415 -Infection: Malaria -Oxidative/drug-related Bleeding: Gastrointestinal (GI), genitourinary (GU), or other Low reticulocyte count: Decreased production (retics <2%) Pancytopenia: Aplastic anemia, myelofibrosis, leuke-mia, drugs (chemotherapy) Non-pancytopenia: Anemia of chronic disease, renal/ liver disease Macrocytic: -Megaloblastic: B12 and/or folate deficiency: Metformin, proton pump inhibitor (PPI), H2 blocker, methotrexate, sulfa, chemotherapy, bacteria over-growth at terminal ileum, pernicious anemia -Non-megaloblastic: Alcoholism, liver disease, hypothyroidism 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. Now 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 Mr... ? Are you 40 years old?” “I understand, you came today to discuss your blood results. Is it alright, first, if I ask you a few questions about your blood test and general health? Then we will discuss about it. I would be happy to address any of your concerns. ” History of Present Illness: “Why was the blood test done?” “When was the blood test done?” “Who ordered it?” The patient may explain that he was feeling tired/recent trauma/bleeding. He visited another GP in the same clinic who ordered this blood test, and now the other GP is on vaca-tion. Tell him that you are covering the other GP and you are seeing the other GP's patients in his absence. Ask about symptoms to rule out differentials: Fatigue Malaise Weakness Shortness of breath Easy bruising Pallor Fever Loss of appetite Night sweats Bone pain Bumps and lumps Weight loss Nose bleeding Gum bleeding Heart burns Black stool (GI bleeding) Jaundice (hemolysis) Tingling and numbness (B12 deficiency) Diarrhea Change in bowel habits Rash Joint pain Nail changes Brittle hair Trouble swallowing Heart racing Orthostatic changes: -Feeling dizzy while standing up suddenly from sitting or lying -Blackout episodes when standing Recent accident/trauma leading to bleeding Systemic Review (Only Ask if Not Asked Before): GI: Nausea, vomiting, appetite, weight loss, abdominal pain, and bowel routine Cardiovascular system: Chest pain, dyspnea Respiratory system: Cough, hemoptysis, and chest pain Central nervous system: Headache, loss of consciousness, and confusion Musculoskeletal: Bone point, joint pain, and muscular pain Constitutional Symptoms (only ask if not asked before in the history): Fatigue and malaise, night sweats, fever, weight loss Diet Restrictions: Vegetarian? Past Medical History: “Do you have any other health issues?” Ask in particular about: Bleeding disorder Previous anemia History of thalassemia History of sickle cell anemia 14 Hematology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
416 History of cancer History of radiotherapy History of chronic disease Mechanical heart valve History eating disorders Previous history of transfusion Past Hospitalization and Surgical History: “Have you had any previous hospitalization or surgeries (bowel resection)?” Medication History: “Are you taking any medication pre-scribed, over the counter, or herbal? If so, have there been any side effects?” (Pain killer, blood thinners, methyldopa, chloramphenicol, phenytoin) Allergic History: “Do you have any known allergies?” Social History: “Do you smoke?” “Do you drink alcohol?” “Have you ever tried any recreational drugs?” Family History: Any family history of chronic disease, thalassemia, sickle cell anemia, or bleeding disorder? Relationships: “Are you sexually active? Do you have sex with men, women, or both?” Self-Care and Living Condition: “What do you do for liv-ing? 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 would like to perform a physical examination. I will order further blood tests, according to history and physi-cal examination findings”: Hemoglobin and hematocrit Red cell indices Reticulocyte count Iron studies -serum iron, total iron-binding capacity (TIBC), ferritin, transferrin Serum B12 and folate Haptoglobin Lactate dehydrogenase (LDH) Schilling test Hemoglobin electrophoresis Question: “What is the treatment?” Answer: “Once iron deficiency has been diagnosed and its underlying cause addressed, the next challenge is restoration of the iron supply. Assuming an average absorption of 10% of the iron in a medicinal form, the daily elemental iron requirement is 10 mg in children, adult males, and post-menopausal women (to provide 1 mg to the body); 20 mg in young nonpregnant women; and 30 mg in pregnant women. Of course, patients who do not absorb iron well, such as those who have undergone gastric bypass, will require higher doses” [1]. Iron Therapy Oral ferrous iron salts are the most economical and effective medications for the treatment of iron deficiency anemia. Of the various iron salts available, ferrous sulfate is the one most commonly used. Iron Supplements To improve your body's ability to absorb the iron in the tablets [2]: For best results, take iron tablets on an empty stom-ach. However, because iron tablets may cause stomach upset, you may need to take the tablets with food. Avoid taking iron with antacids. Antacids can interfere with the absorption of iron. Take iron 2 h before or 4 h after taking antacids. Take iron tablets with vitamin C, which improves the absorption of iron. Your doctor might recommend taking the tablets with a glass of orange juice or with a vitamin C supplement [2]. History and Counseling: Needle Stick Injury Candidate Information: You are working in an emergency department, and a 27-year- old female hospital nurse presents after having a needle stick injury about 10 min ago. Please take a detailed history and counsel her about your plan of action. Differentials: More than 25 blood-borne viruses have been reported to be caused by needle stick injuries [3]. The major blood-borne pathogens of concern associated with needle stick injury [3]: Human immunodeficiency virus (HIV) Hepatitis B Hepatitis C M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
417 Other pathogens [4]: Human T-lymphotropic retroviruses I (HTLV-I) and II (HTLV-II) Hepatitis D virus (HDV -or delta agent), which is acti-vated in the presence of HBV GB virus C (GBV-C) -formerly known as hepatitis G virus (HGV) Cytomegalovirus (CMV) Epstein-Barr virus (EBV) Parvovirus B19 Transfusion-transmitted virus (TTV) West Nile virus (WNV) Malarial parasites Prion agents such as those associated with transmissible spongiform encephalopathies (TSEs) Determine Risk by: Exposure risk Source risk 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. Now 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... ? And are you 27 years old? I just read that you are one of our nurses. How can I help you today?” She will mention that she was drawing blood or giving some IV medication and got a needle stick injury. History of Present Illness: Questions related to event: What happened? When did it happen? Show empathy. (Please do not say that it was her fault and she should have been careful. ) Ask about: Used or new needle. Size of needle. What was gauge of needle? Blunt or hollow. Any visible blood on the needle? How deep was the injury? Where was the location of the prick? Any bleeding after that? Was she wearing gloves? What did she do immediately? Is it the first time? Ask about body fluid if it was a splash or patient spitted/ vomited. What was done after the puncture? (washing, alcohol scrub, or Betadine wash) Source Risk: Was the patient admitted to the hospital? Was the patient's HIV status known? If yes, then when was it tested -viral loads, CD4 lev-els, any previous or current treatments and its responses. Was the patient hepatitis B and C status known? Did someone inform the patient about the needle stick injury? Did someone obtain the patient's permission or consent for further testing? -If not, then tell the nurse, “We need to obtain consent. Without consent I will not be able to order any tests from the source. ” -If consent has already been taken, then order the required blood tests. Past Medical History: “How is your health otherwise? Any other medical problems?” “Being a health-care provider”: -“Have you been vaccinated before for hepatitis A and B?” -“How many doses?” -“When was the last dose?” -“Liver disease: Have you ever been yellowish? Itchiness? Dark urine? Pale stool? Bruises in body?” -“Repeated infections?” -“Chronic diarrhea?” “I am going to ask you some questions if you were exposed before for any of the viruses previously mentioned”: -Any travel outside the country? -Any recent surgery? -Any blood transfusions? -Any tattoos/piercings? Past Hospitalization and Surgical History: “Have you had any previous hospitalization or previous surgery?” Medication History: “Are you taking any medication?” If she says no, then continue to next question. “Over-the- counter or herbal medications and any side effects?” 14 Hematology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
418 Allergic History: “Do you have any known allergies?” Social History: “Do you smoke? Do you drink alcohol? Do you take any recreational drugs?” Wrap-Up: Counseling: Tell her to write an incident report. Consult infectious diseases department/consultant. Give her the risks of being infected with needle stick injury: -HIV: 0. 3% -Hepatitis C: 3% -Hepatitis B: 30% Laboratory Studies (Please check with your regional and hospital guidelines) Source patient (only after consent being given): -HIV testing -Hepatitis B antigen -Hepatitis C antibody Health-care worker/exposed individuals: -Hepatitis B surface antibody -HIV testing at time of incident and again at 6 weeks, 3 months, and 6 months -Hepatitis C antibody at time of incident and again at 2 weeks, 4 weeks, and 8 weeks Laboratory tests before initiating retroviral therapy: -Pregnancy test -Complete blood count (CBC) with differential and platelets -Serum creatinine/blood urea nitrogen (BUN) levels -Urinalysis with microscopic analysis -Aspartate transaminase/alanine transaminase (AST/ ALT) levels -Alkaline phosphatase level -Total bilirubin level Question: “What will be the management plan?” Answer: According to the US Centers for Disease Control and Prevention [5]: “Exposure Management Treatment of an exposure site: Wounds and skin sites that have been in contact with blood or body fluids should be washed with soap and water; mucous membranes should be flushed with water. There is no evidence that the use of antiseptics for wound care or expressing fluid by squeez-ing the wound further reduces the risk for HIV transmis-sion. However, the use of antiseptics is not contraindicated. The application of caustic agents (e. g., bleach) or the injection of antiseptics or disinfectants into the wound is not recommended [5]. ” “Evaluation of Exposure. The exposure should be evalu-ated for potential to transmit HIV based on the type of body substance involved and the route and severity of the exposure. Exposures to blood, fluid containing visible blood, or other potentially infectious fluid (including semen; vaginal secretions; and cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids) or tis-sue through a percutaneous injury (i. e., needle stick or other penetrating sharp-related event) or through contact with a mucous membrane are situations that pose a risk for blood-borne transmission and require further evalua-tion [5]” (Fig. 14. 1). “For screening, we need to send bloods today, and then: HIV testing again at 6 weeks, 3 months, and 6 months Hepatitis C antibody again at 2 weeks, 4 weeks, and 8 weeks” Prophylaxis: Recommended 28-day prophylaxis-Tenofovir 300 mg daily plus emtricitabine 200 mg daily plus either raltegra-vir 400 mg BID or dolutegravir 50 mg daily. Hepatitis B prophylaxis: -Patients who have been previously vaccinated with known response to vaccine: No further therapy required. -Patients previously vaccinated without known response to vaccine: Send anti-Hep Bs titer; administer prophy-laxis (one dose of HBIG); booster is required. -Unvaccinated: Provide one dose of HBIG and initiate vaccination series. Hepatitis C prophylaxis -There is no known effective postexposure prophylaxis for hepatitis C. History and Physical Examination: Easy Bruising Candidate Information: A 20-year-old male presents in your GP clinic with easy bruising and epistaxis for the past 2 months. Please take a relevant history and perform a focused examination. What investigations you will order to reach to a diagnosis? or A 20-year-old female presents to your GP clinic with recurrent episodes of bleeding from her nose. Please take a focused history and perform a focused examination. M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
419 Differentials [ 6]: Platelet disorders (quantitative): Idiopathic thrombocy-topenic purpura, thrombotic thrombocytopenic purpura, malignancy, viral disease Platelet disorders (functional): Glycoprotein disor-ders (Bernard-Soulier syndrome, Glanzmann throm-basthenia), storage pool disease, von Willebrand's disease Hemophilia type A or B (factor VIII or IX deficiency) or other factor deficiencies: Classically presents with joint or soft-tissue bleeding; family history of bleeding in men (skipped generations) Hereditary hemorrhagic telangiectasia: Telangiectasias over lips, tongue, nasal cavity, and skin. Epistaxis Vasculitis or cryoglobulinemia: Neuropathy; pulmonary- renal involvement; purpura Leukemia: Abnormal complete blood count or peripheral blood smear Disseminated intravascular coagulation: Bleeding from multiple sites Prolonged prothrombin time and par-tial thromboplastin time Vitamin K deficiency: Malabsorption (bacterial over-growth, celiac disease, chronic pancreatitis, inflamma-tory bowel disease, short-gut syndrome), poor diet Fig. 14. 1 Determining the need for HIV postexposure prophylaxis (PEP) after an occupational exposure. (Reprinted from Centers for Disease Control and Prevention [ 5]) 14 Hematology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
420 (alcoholism, total parenteral nutrition), or drugs that bind vitamin K Alcohol abuse: Social history Abuse (including child abuse): Atypical pattern of bruis-ing or bleeding. Bruises that pattern after objects; bruises in children who are not yet mobile. History that is incon-sistent with the patient's injuries Senile purpura: Dark ecchymosis in aged, thin skin; typically over extensor surfaces of forearms Cushing's disease: Facial plethora, hirsutism, hypergly-cemia, hypertension, poor wound healing, stria Marfan's syndrome: Enlarged aortic root; eye involve-ment; mitral valve prolapse; scoliosis; pectus excava-tum; stretch marks; tall and slim, with long limbs and digits Vitamin C deficiency (scurvy): Dietary history Ehlers-Danlos syndrome or connective tissue disease: Atrophic scarring or joint dislocation, hypermobile joints, skin hyperextensibility Medications that can cause bleeding and bruising [6]: Common causes: -Aspirin -Clopidogrel -Heparin -NSAIDs -Warfarin Rare causes: -Cephalosporins -Ginkgo biloba -Gold -Interferon -Penicillins -Selective serotonin reuptake inhibitors (SSRIs) 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. Now 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 Mr... ? Are you 20 years old? I am going to ask you questions about the bruising and nasal bleeding. I would also like to perform a focused examination. Should we start?”History of Present Illness: Start with bruising: Onset Course Duration (from birth or just presently) Location: where? Size: how big? Color? After trauma or spontaneously? How frequent? Ask a few questions about epistaxis: Onset Course Duration (from birth or just presently) After trauma or spontaneously? How frequent? How much blood? What measure taken to stop bleeding? Did he visit the hospital? Was he admitted? Any blood tests done? Show empathy. Ask about symptoms to rule out differentials: Bleeding too long from small cuts (platelet problem) Fatigue Malaise Weakness Shortness of breath Pallor Fever Loss of appetite Night sweats Bone pain Joint swelling (hemarthrosis -hemophilia) Bumps and lumps Weight loss Gum bleeding Heart burns Black stool (GI bleeding) Jaundice (hemolysis) Tingling and numbness (B12 deficiency) Diarrhea Change in bowel habits Rash Joint pain Nail changes M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
421 Brittle hair Trouble swallowing Heart racing Orthostatic changes: -Feeling dizzy while standing up suddenly from sitting or lying -Blackout episodes when standing Systemic Review (Only Ask if Not Asked Before): GI: Nausea, vomiting, appetite, weight loss, abdominal pain, and bowel routine Cardiovascular system: Chest pain, dyspnea Respiratory system: Cough, hemoptysis, and chest pain Central nervous system: Headache, loss of consciousness, and confusion Musculoskeletal: Bone point, joint pain, and muscular pain Constitutional Symptoms (only ask if not asked before in the history): Fatigue and malaise, night sweats, fever, weight loss Diet Restrictions: Vegetarian? Past Medical History: “Do you have any other health issues?” Ask in particular about: -Bleeding disorder. -Previous anemia. -History of chronic disease. -Childhood illness: Chemotherapy or radiation therapy for childhood malignancies may later lead to treatment- related bleeding from bone marrow disorders such as myelodysplasia or leukemia. -Autoimmune disorders that may affect the blood vessels. -Renal disease: Causing platelet dysfunction. -Hepatic disorders: May affect the numbers of platelets, platelet function, quantity of coagulation proteins, or the quality of the skin and connective tissue. Past Hospitalization and Surgical History: “Have you had any previous hospitalization or surgeries (bowel resection)?” Medication History: “Are you taking any medication pre-scribed, over the counter, or herbal? If so, have there been any side effects?” (Pain killer, blood thinners, aspirin)Allergic History: “Do you have any known allergies?” Social History: “Do you smoke?” “Do you drink alcohol?” “Have you ever tried any recreational drugs?” Family History: “Any family history of chronic dis-ease, thalassemia, sickle cell anemia, or bleeding disorder?” Relationships: “Are you sexually active? Do you have sex with men, women, or both?” Self-Care and Living Condition: “What do you do for liv-ing? 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. Physical Examination: “Now, I will start the examination. ” Comment on the vital sign findings if there are any men-tionable findings, otherwise state that vitals are normal. Check level of consciousness, alertness, and orientation. General Physical Examination: Look for any abnormal findings in: -Face: Characteristic face. -Eyes: Palpebral conjunctival pallor, jaundice. -Mouth: Mucosal bleeding, gum bleeding, strawberry tongue, cheilosis. -Nose: Check for clots or any fresh bleed. -Palms: Pallor in creases, petechia, cold, clammy. -Fingers: Brittle nails -due to nutritional factors, aging, and thyroid diseases. -Cervical lymph nodes palpation. -Axillary lymph nodes palpation. -Sternal tenderness: Press and ask for bone pain. Skin: -Thinning and dry skin -Evidence of delayed healing (multiple scars or unre-solved wounds) Look for any bruise or rash: 14 Hematology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
422 -Record the distribution, number, site, and size of bruis-ing together with any petechiae, ecchymoses, and sub-cutaneous hematoma -Examine the pattern of bruising: In dependent areas: Thrombocytopenia or stasis factor Only on the arms or legs: Possible trauma Around the eyes: Connective tissue disorder In atypical areas such as back, buttocks, arms, and abdomen: Bleeding disorder or non-accidental injury Typically over extensor surfaces of forearms: sus-pect senile purpura -Palpate bruise: Raised above the surface, tenderness, blench on touch Abdominal Examination: Inspection Palpation: -Superficial/light palpation -Deep palpation -Liver palpation -Spleen palpation -Kidney palpation -Inguinal lymph nodes palpation (mention) Rectal Examination (mention) Chest Examination: Auscultate (murmurs) Respiratory System: Auscultate. Comment on your findings. Thank the patient and tell the patient to cover up. Ask the patient if they have any questions or concerns. Wrap-Up Question: “What will you do next?” Answer: “I will order further blood tests according to history and physical examination findings: Full blood count (FBC) and differentials Hemoglobin and hematocrit Red cell indices Reticulocyte count Coagulation panel Iron studies (serum iron, TIBC, ferritin, transferrin) Serum B12 and folate Hemoglobin electrophoresis Coagulation screen”Partial Thromboplastin Time and Prothrombin Time The partial thromboplastin time (PTT) is the measure of the factors of the intrinsic and common pathways. Lack of these factors, including factor VIII (hemophilia A) and factor IX (hemophilia B), will prolong the value of PTT. Factor VIII levels may also be low in patients with von Willebrand's dis-ease. In these patients there will be prolonged PTT [6]. Prothrombin time (PT) is the measure of the factors of the extrinsic and common pathways. Deficiencies of these fac-tors, most commonly factor VII, will prolong the value of PT. Vitamin K is essential for the synthesis of these factors. So patients with vitamin K deficiency will have a prolonged PT (Fig. 14. 2) [6, 7]. History and Management: Acetaminophen Intoxication You are working in an emergency room when a 25-year-old female was brought in after taking pills of paracetamol. She recently broke up with her boyfriend. She was brought in by an ambulance. Please manage the patient. There is also a bedside nurse to help you carry out orders. This scenario can be divided into three parts: History and examination Management Psychiatric evaluation of the patient So try to complete and cover all three of these. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner, nurse, and the patient. Give stickers to the examiner (if required) and/or show your ID. Now stand on the right side of the patient and start the examination. Opening: Triage immediately. Call the patient's name and check the patient's response. Or gently shake shoulder or hand. Check for response and immediately tell the examiner about your findings. If the patient is conscious and stable, then introduce your-self to the patient: “Good morning/good afternoon. I am Dr... I am your attending physician for today. Are you Miss... ? Are you 25 years old?” M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
423 Ask the nurse for vital signs -interpret the vital signs. Mention to the Examiner: “I will start primary survey (ABCD)”: A. Airway Is the airway patent? Comment on airway. If the patient is talking well, then mention that the air-way is patent. B. Breathing Is the patient breathing? Check respiratory rate. Pulse oximetry to keep Sa O 2 >95% C. Circulation Check pulse, BP. Ask the nurse to please pass two large-bore cannula (G14/G16), one on each arm. Draw blood for: -CBE -Liver function tests (LFTs) -Electrolytes -Paracetamol level -Coagulation profile -Lactate -Amylase -Blood alcohol Urine toxicology/pregnancy test Mention that you will send a paracetamol level at 4 h of ingestion. Ask the nurse to put continuous monitoring with car-diac monitoring/12-lead electrocardiogram (ECG). D. Disability and neurological status Rapid neurological assessment should be done next. During the primary survey, a basic neurological assessment is made, known as A VPU: -Alert -Verbal stimuli response -Painful stimuli response -Unresponsive Or by using the Glasgow Coma Scale (GCS). Pupils: size, symmetry, and reaction. Any lateralizing signs. Ask for a blood glucose level (finger prick). Give dex-trose if hypoglycemia. Body Language and Clues: Ask the patient what happened. The patient will describe the events and her circumstances leading her to the decision to attempt suicide. In this particular station, it is very important to show empathy and support. The patient may look sad or low and may avoid eye contact. If so then one should offer support and help. Offer social worker's support. You must encour-age the patient by saying it is a good thing she called the Patient History and Examination and Bleeding Score (if available) Medication Review Identify possib le medication(s) that could cause bl eeding Consider stopping medication(s)Laboratory Tests: CBC PT a PTT Normal Test Results Abnormal Test Results PT/a PTT CBC (thrombocytopenia)Histor y of Bleeding No Bleeding Histor y or History of Minor Bleeding Workup Coagulation Fa ctors and/or von Willebrand Factor Assa y Peripheral Smear and Further Workup (based on suspected diagnosis)Platelet Aggregation and Electron Microscop y and Consider : von Willebrand F actor Assa y and/or F actor XIII Workup Consider : Bleeding Time and/or Platelet Function Analysis Observ ation Fig. 14. 2 Easy bruising algorithm. PT prothrombin time, a PTT activated partial thromboplastin time, CBC complete blood count. (Adapted from Wang and Kraut [7]) 14 Hematology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
424 emergency number to seek help. You and your team are here to help her. Ask the nurse if a collateral history available: Ask for the empty pill bottles to confirm the drug, how many pills, when taken, concurrent ingestion of alcohol or other drugs. Where was the patient found? Was there a period of unconsciousness? How long did this last? Suicide History (customize according to time): “What happened?” “When did it happen?” “Did you have thoughts of hurting yourself?” “How long have you been thinking about suicide?” “When did you plan it? What was the method?” “How long you have been planning on it? How often do you have these thoughts?” “How severe are your thoughts? Do these suicidal thoughts affect your activities of daily life? Have you ever been hospitalized?” “What made you decide to act on today's event? Any recent event or stressor precipitated in these thoughts?” Or may ask, “What made you want to kill yourself?” “Did you leave a note?” “Did you make a will?” “Did you tell someone?” “Did you give away your belongings?” “Did you select a date or specific time? Any particular place?” “Did you buy a weapon? How did you get the gun/pills?” “Did you try stopping these thoughts? Did you seek help?” “Is there anything that has held you from executing the suicide plan? Family, friends, religion?” “Did it happen before? When?” “Do you still have a plan to kill yourself? What are your plans?” “Any time lag between the suicide attempt and arrival in emergency?” “What do you feel to survive from the attempt you made?” Assessment: Modified SAD PERSONS scale score of greater or equal to 6 shows need for emergency psych consult (Table 14. 3). Psychiatric Symptoms Screening Depression Screening: Low mood: -“How is your mood nowadays? Have you been feeling low/sad/down or depressed these days? Is your mood always low or does it alternate?”-“How were you feeling before this?” -“How long have you been feeling like this?” Loss of Interest: “What kind of activities do you do for pleasure? Do you still enjoy them? Or do you enjoy social activities and relationships you used to enjoy?” Lack of Sleep: “How is your sleep? Do you have prob-lems with going to sleep or maintaining sleep? Do you wake up early in the morning and then find it difficult to go back to sleep? Do you feel you are sleeping for a lon-ger duration than before?” Guilt: “Do you feel guilty/hopeless/worthless?” Decreased Energy: “Do you feel lack of energy? Do you feel tired?” Inability to Concentrate: “Do you have difficulty in concentrating?” Loss of Appetite: “Has your appetite changed recently?” Psychomotor Retardation: “Do you think that you have slowed down in your usual pace?” Suicide Ideas (Very Important in This Station): “Do you have any plan to hurt yourself or others? Any previ-ous attempt? Recurrent thoughts? Left a note?” Screen for Anxiety: Just one question Screen for Mania: Just one or two questions Screen for Psychosis: Just one question about delusions and one for hallucinations Past Medical History: Any previous health issues? Past Psychiatric History: Diagnosis, treatments, admis-sions, follow-ups, previous suicide attempts Medication History: Antidepressant, anxiolytics, antipsy-chotics, or any other medications and any side effects Family History and Family Psychiatric History Social History: Smoking, alcohol, drugs, sexual history Self-Care, Living Condition, and Relationships Work Conditions and Financial Status Support: Family and friends Table 14. 3 Modified SAD PERSONS scale Sex male 1 Age <19 or >45 1 Depression 2 Previous attempt 1 Excessive alcohol 1 Rational thinking loss 2 Separated 1 Organized plan 2 No support 1 Stated future intent 2 M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
425 Physical Examination: Tell the patient that you will be doing a physical examination. Review vital signs with the examiner. Exposure: Stand on the right side of the bed and tell the patient (indirectly to the examiner), “Miss..., I am start-ing my examination now. During the examination if you feel uncomfortable at any point please do let me know. ” Position: Supine, arms on the side, legs uncrossed. General Physical Examination: Check for alert and orien-tation. Look for any abnormal findings in the hands, face, neck, and chest. Chest: Listen to the chest (respiration and heart sounds). Abdominal Examination: Inspection and palpation. Thank the patient and describe your findings to the examiner. Wrap-Up: Question: “What are the clinical features?” Answer: Stage 1 (0-24 h): Asymptomatic or GI upset only Stage 2 (24-48 h): Resolution or nausea and vomiting, right upper quadrant (RUQ) pain and tenderness, and pro-gressive elevation of transaminases, bilirubin, PT Stage 3 (48-96 h): Hepatic failure (jaundice, coagulopa-thy, encephalopathy) Stage 4: Death from hepatic failure or normalization of LFTs and complete resolution of hepatic architecture by 3 months [8]. Question: “What will be your further management plan?” (Please check your local and regional guidelines for paracetamol overdose. ) Answer: You need to consult: Psychiatrist Medical unit Intensive care unit (ICU) (if unstable) Poison control This patient needs to be admitted for observation and fur-ther management. According to the patient condition, patient weight, number of pills ingested, and time duration, assess if acti-vated charcoal and/or N-acetyl cysteine (NAC) needs to be given. Decontamination with activated charcoal is recommended in cooperative adults within 2 h of ingestion of (solid) immediate-release forms or within 4 h of ingestion of either modified-release forms or greater than 30 g of acetamino-phen (paracetamol). See Figs. 14. 3 and 14. 4 for clinical guidelines in single acute ingestion of paracetamol. Question: “What if the patient has ingested tricyclic antidepressants?” Answer: “Most of the management will be the same as of the aforementioned patient. ” “The main effects of overdose are on the cardiovascular system, central nervous system, and peripheral autonomic nervous system [9 ]. The initial side effects, which can be mild, usually develop within 2 h of overdose. Common symptoms Single acute ingestion >200 mg/kg or unkno wn dose No Yes <4 h post ingestion Paracetamol le vel at 4 hours. Plot on nomogra m and treat if indicated4-8 h post ingestion immediate paracetamol level. Plot on nomogram, treat if indicated>8 h post ingestion Commence NAC, immediate paracetamol le vel and AL T: Continue NA C if paracetamol level abo ve treatment line. Cease NA C if belo w treatment line and nor mal ALT. Seek advice if paracetamol level belo w treatment line and raised AL TNo treatment required Fig. 14. 3 Paracetamol ingestion flowchart. (Republished, with permission, from resources at the Royal Children's Hospital, Melbourne, Australia. https:// www. rch. org. au/clinicalguide/ guideline_index/ Paracetamol_poisoning/) 14 Hematology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
426 may include tachycardia, dilated pupils, confusion, agitation, drowsiness, dry mouth, urinary retention, nausea and vomit-ing, headache, fatigue, anxiety, blurry vision, and dizziness. Additional signs of overdose may include palpitations, hyper-tension, tremors, confusion, delirium, and lethargy” [10]. “The signs of severe poisoning include life-threatening cardiac rhythm and conduction disturbances, changes in level of consciousness, coma, convulsions, hypotension, and pulmonary complications” [10]. Decontamination Charcoal is generally contraindicated due to risk of aspiration. However, patients who have ingested more than 10-15 mg/kg should be given charcoal following intubation [11]. Specific Treatments: If QRS is widened or there is ventricular arrhythmia, com-mence alkalization with sodium bicarbonate (bolus 2 mmol/ kg). Repeat boluses may be given in addition to consider-ation of intubation and hyperventilation in order to bring p H to 7. 5 [11]. Ongoing Care and Monitoring: Cardiac monitoring and regular ECGs Contact the ICU if the patient is in an altered state of con-sciousness, GCS <12, having seizures, widened QRS, or arrhythmia. Treat seizures with benzodiazepines -avoid phenytoin as it has sodium channel blockade activity. If asymptomatic: Follow investigation procedures, observe for 6 h, and discharge if ECG remains normal [11]. References 1. Alleyne M, Horne MK, Miller JL. Individualized treatment for iron deficiency anemia in adults. Am J Med. 2008;121(11):943-8. https://www. ncbi. nlm. nih. gov/pmc/articles/PMC2582401/. 2. Mayo Clinic. Iron deficiency anemia. https://www. mayoclinic. org/ diseases-conditions/iron-deficiency-anemia/diagnosis-treatment/ drc-20355040. Accessed 12 Mar 2018. 3. Tarigan LH, Cifuentes M, Quinn M, Kriebel D. Prevention of needle-stick injuries in healthcare facilities: a meta-analysis. Infect Control Hosp Epidemiol. 2015;36(7):823-9. 4. Henderson R. Needlestick injury. Patient. 2016. https://patient. info/ doctor/needlestick-injury-pro. Accessed 12 Mar 2018. 5. Centers for Disease Control and Prevention. Public health service guidelines for the management of health-care worker exposures to HIV and recommendations for postexposure prophylaxis. MMWR Recommen Rep. 1998;47(RR-7):1-34. 6. Ballus M, Kraut EH. Bleeding and bruising: a diagnostic work-up. Am Fam Physician. 2008;77(8):1117-24. https://www. aafp. org/ afp/2008/0415/p1117. html 7. Wang T-F, Kraut EH. Assessment of easy bruising. BMJ Best Pract. http://bestpractice. bmj. com/topics/en-gb/1208. 8. Nickson C. Acute paracetamol toxicity. 2016. Life in the Fastlane. https://lifeinthefastlane. com/ccc/acute-paracetamol-toxicity/. Accessed 12 Mar 2018. 9. Kerr GW, Mc Guffie AC, Wilkie S. Tricyclic antidepressant over-dose: a review. Emerg Med J. 2001;18:236-41. 10. Woolf AD, Erdman AR, Nelson LS, Caravati EM, Cobaugh DJ, Booze LL, et al. Tricyclic antidepressant poisoning: an evidence- based consensus guideline for out-of-hospital management. Clin Toxicol. 2007;45(3):203-33. 11. The Royal Children's Hospital Melbourne. Clinical practice guide-lines: tricyclic antidepressant (TCA) poisoning. https://www. rch. org. au/clinicalguide/guideline_index/Tricyclic_Antidepressant_ (TCA)_Poisoning/. Accessed 12 Mar 2018. 12. Bateman DN. Acetaminophen (Paracetamol). In: Brent J, Burkhart K, Dargan P, Hatten B, Megarbane B, Palmer R, editors. Critical care toxicology. Cham: Springer; 2016. p. 1-25. 200 Treatment lines150 100 50 10 5 1 48 12 Hours post ingestion Plasma acetaminophon concentration (mcg/m L) Plasma acetaminophen concentration (µmol/L) 16 20 24102030507010020030050070010001300 Potential fo r toxicity Toxicity unlikel y Prescott Nomogram Rumac k-Matthe w Nomogram UK-Ir ish Nomogra m Fig. 14. 4 Acetaminophen (paracetamol) treatment nomograms. Treatment is recommended if the plasma acetaminophen concentration is above the solid (150 mg/L at 4 h) line in North America and Australia. In the UK and Ireland the dotted-dashed line (100 mg/L at 4 h) is used to determine therapy with acetylcysteine. (Reprinted with permission from Bateman [12]) M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
427 Additional Readings Easy Bruising/Bleeding Assessment Rodeghiero F, Tosetto A, Abshire T, Arnold DM, Coller B, James P, et al. Supplementary material to the official communication of the SSC. 2011. https://c. ymcdn. com/sites/www. isth. org/resource/ resmgr/ssc/isth-ssc_bleeding_assessment. pdf. Paracetamol Poisoning Burns MJ, Friedman SL, Larson AM. Acetaminophen (paracetamol) poisoning in adults: pathophysiology, presentation, and diagnosis. Up To Date. 2017. https://www. uptodate. com/contents/acetamino-phen-paracetamol-poisoning-in-adults-pathophysiology-presenta-tion-and-diagnosis. Farrell SE. Acetaminophen toxicity. Medscape. 2018. https://emedi-cine. medscape. com/article/820200-overview. Heard K, Newton A. Paracetamol overdose. BMJ Best Pract. 2017. http://bestpractice. bmj. com/topics/en-gb/337. Henderson R. Paracetamol poisoning. Patient. 2016. https://patient. info/doctor/paracetamol-poisoning. The Royal Children's Hospital Melbourne. Clinical practice guide-lines: paracetamol poisoning. https://www. rch. org. au/clinicalguide/ guideline_index/Paracetamol_poisoning/. TCA Poisoning Dargan PI, Colbridge MG, Jones AL. The management of tricyclic antidepressant poisoning: the role of gut decontamination, extra-corporeal procedures and fab antibody fragments. Toxicol Rev. 2005;24(3):187-94. Salhanick SD. Tricyclic antidepressant poisoning. Up To Date. 2018. https://www. uptodate. com/contents/ tricyclic-antidepressant-poisoning. Weingart S. Podcast 98 -cyclic (tricyclic) antidepressant overdose. EMCrit RACC. 2013. https://emcrit. org/racc/ tricyclic-antidepressant-overdose/. 14 Hematology | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
429 © 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_15Skin Mubashar Hussain Sherazi History Overview: The Skin There are only a few skin cases that are important for the objective structured clinical examination (OSCE). Besides inquiring about the skin problem, it is equally important to complete the rest of the history just as for other systems. Occupation and residence histories are very important. Exposure to allergens, sun, and other triggering factors are essential questions in skin scenarios. It becomes difficult for some candidates to diagnose skin diseases due to limited experience in this particular field. This chapter will outline a few common skin issues and will outline how to go through these in the OSCE. See Table 15. 1 for an overview of the pattern of history taking required for skin stations. Please do not forget to seek help from experts: the dermatologists. Common Signs and Symptoms for the OSCE For the skin, common presenting symptoms are: Rash Itching Blisters Hives Ulcers Pigmentation Moles Scaly rash (psoriasis) Erythema Hair problems Nail problems Detailed History: The Skin 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 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 Mr/Mrs/Miss... ? And you are... years old?” Gender, Age, and Skin Conditions: See Tables 15. 2 and 15. 3 [1]. Chief Complaint Chief complaint or the reason the patient is visiting the clinic. “What brings you in today?” History of Present Illness Chief Complaint: Onset Course Duration Progression Severity of symptoms Skin lesions (Fig. 15. 1) [2]: -What did the initial lesions look like? -How have they evolved and extended? -Which part of the body involved? -Is the nails or hair involved? -What did patient do to relieve the symptoms? M. H. Sherazi Mallacoota Medical Centre, Mallacoota, Victoria, Australia15 | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
430 Describe the lesion: -Asymmetry -Border -Color -Diameter -Elevation Description of skin lesions: Lesion Type (Primary Morphology): -Macules are nonpalpable flat lesions that are smaller than 1 cm in diameter in size. These look like just a change in color and the skin surface is not raised or depressed [3]. -A patch is a relatively larger macule. Examples include freckles, flat moles, port wine stains, the rashes of rubella, and measles [3]. -Papules are small, solid, rounded bumps rising from the skin. Usually, a papule is less than 1 cm in diame-ter. The term “papule” is derived from the Latin pap-ula, meaning a pimple. Examples include warts, nevi, insect bites, actinic keratoses, and skin cancers [3, 4]. -Nodules are firm lesions that extend into the dermis or subcutaneous tissue, for example, cysts and lipomas [3 ]. -Plaques are palpable lesions more than 1 cm in diam-eter that are elevated or depressed compared to the skin surface. These can be flat topped or rounded. For example, lesions of psoriasis and granuloma annulare commonly form plaques [3]. Table 15. 1 Quick review of history taking for the skin stations Introduction Name and age Chief complaint In patient's own words History of present illness Analysis of chief complaint Onset (when, where, and how the skin problem started?) Course Duration Progression Skin lesion What did the initial lesion look like? How have they evolved and extended? Describe the lesion Asymmetry Border Color Diameter Elevation Associated symptoms: itching, pain, bleeding, nausea, vomiting, urine changes, jaundice, chills, sweating, fever, weight loss Predisposing factors Aggravating and relieving factors (sunlight, rest, antihistamines) Constitutional symptoms Review of systems Respiratory Genitourinary Cardiovascular Neurology Impact on the body Rule out differential diagnosis Past medical and surgical history Medical illnesses (similar symptoms, atopy, skin lesions, systemic diseases, for example, rheumatoid arthritis, celiac disease) Any previous or recent surgery (skin related) Hospitalization history or emergency admission history Medication history Current medications New drugs, antibiotics, immunosuppressants Prescribed, over the counter, and any herbal Allergic history/triggers Any known allergies? Family history Family history of same symptoms (scabies) Any long-term disease, any genetic skin problem -neurofibromatosis Home situation With whom do you live in? Occupation history What kind of work do you do? Does the problem improve when away from work/home or hobbies? Social history Smoking Alcohol Street drugs Sexual history Tattoos Table 15. 1 (continued) If adult female Menstrual history (LMP) Gynecology history Obstetric history If teen Home Education Employment Activities Drugs Sexual activity If child Birth history Immunization Nutrition Development 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 | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
431 -Skin plaques can have defined borders or not, and they can take on many different shapes, including [5]: Annular (ring-shaped) Arcuate (half-moon) Polygonal (varied and not geometric) Polymorphic (varied shapes) Serpiginous (snake-shaped) Poikilodermatous (variegated) [5] -Vesicles are fluid-filled clear lesions with diameter less than 0. 5 cm. These are seen in impetigo, contact dermati-tis, and insect bites. -Bullae are clear fluid-filled lesions with a diameter more than 1 cm. These may be caused by burns, bullous pem-phigoid, pemphigus, dermatitis herpetiformis, or chronic bullous dermatosis.-Pustules are fluid-filled vesicles containing pus, for example, acne vulgaris, rosacea, and folliculitis. -Scale is epidermal cells produced by abnormal kerati-nization of the skin that have died and then been shed. Examples are fungal infections, psoriasis, and sebor-rheic dermatitis. -Urticaria (wheals or hives) are raised lesions caused by localized edema. Wheals are red and pruritic. These are seen in stings and bites or hypersensitivity to drugs [3 ]. -Crusts (scabs) are dried collections of serum and cel-lular exudates, for example, impetigo. -Ulcers are a discontinuation of an epithelial lining extending into the epidermis/dermis. For example: Arterial ulcer caused by ischemia and usually located on the lateral aspect of the ankle or distal ends of the digits of the lower limbs Venous ulcer due to valvular insufficiency of the veins Neuropathic ulcer related to sensory loss in the lower limbs -most common in diabetes [6] -Petechiae, purpura, and ecchymosis: These are all terms that refer to bleeding that occurs in the skin. Petechiae generally refer to smaller lesions, while pur-pura and ecchymoses are used to describe larger lesions. Petechiae, ecchymoses, and purpura do not blanch when pressed. Sometimes, purpura may be pal-pable [7]. Examples of petechiae can be seen in throm-bocytopenia, platelet dysfunction, vasculitis, and infections such as meningococcemia. If pain then go through pain questions: -Onset: “When did the pain start?” -Course: “How did it start?” (suddenly or gradually) -Duration: “How long have you had this pain?”Table 15. 2 Age and skin conditions (Modified from Simon et al. [1]) Age Some common skin conditions based on age Child Atopic eczema Epidermolysis bullosa Erythropoietic porphyria Head lice Ichthyosis Bacterial infection, e. g., impetigo Infantile seborrheic dermatitis Port wine stain Strawberry nevus Urticaria pigmentosa Viral infection, e. g., chicken pox, warts, molluscum contagiosum Early adult Dermatitis herpetiformis Lichen planus Lupus erythematosus Pityriasis versicolor Psoriasis Seborrheic dermatitis Vitiligo Middle age Lichen planus Mycosis fungoides Pemphigus vulgaris Porphyria cutanea tarda Rosacea Skin cancers: basal cell carcinoma, malignant melanoma Venous ulceration Old age Asteatotic eczema Bullous pemphigoid Cherry angioma (Campbell de Morgan spot) Herpes zoster Seborrheic warts Senile pruritus Skin cancers: basal cell carcinoma, squamous cell carcinoma Solar elastosis Solar keratosis Venous and arterial ulcers Table 15. 3 Gender and skin conditions (Modified from Simon et al. [1 ]) Sex Some common skin conditions based on sex Female Dermatitis artefacta Lichen sclerosus Lupus erythematosus Malignant melanoma Morphea Palmoplantar pustulosis Rosacea Systemic sclerosis Venous ulceration Male Dermatitis herpetiformis Mycosis fungoides Polyarteritis nodosa Porphyria cutanea tarda Pruritus ani Seborrheic dermatitis Squamous cell carcinoma Tinea cruris Tinea pedis 15 Skin | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
432 -Location: “Where does the pain start?” -Character: “What is the pain like?” -Progression: “Is the pain progressing?” -Severity: “From 0-10, 10 being the worst pain and 0 as no pain, how is your pain now?” Associated symptoms: -Itching, pain, bleeding, nausea, vomiting, urine changes, jaundice, chills, sweating, fever, or weight loss -Other lesions Aggravating and relieving factors -sunlight, rest, or antihistamines Review of Systems: Nervous system: Headache or vision changes Urine: Hematuria, change in color of urine, dysuria, polyuria, change in frequency of urine, nocturia, or anuria Eyes: Iritis, scleritis, or conjunctivitis Mouth: Ulceration or erosion Respiratory system: Shortness of breath, cough, or chest pain Gastroenterology: Malabsorption, change in bowel hab-its like constipation alternating to diarrhea, or just constipation Liver disease: Nausea, vomiting, anorexia, abdominal dis-tension, blood in vomiting or blood with bowel movements, easy bruising, impotence, change in normal sleep pattern, confusion, bad taste, or jaundice (yellowness of eyes or skin) Bone pain Enlarged lymph nodes Past Medical History: “Do you have any previous health issues?” Similar symptoms, atopy, skin lesions, systemic diseases, for example, rheumatoid arthritis (RA), celiac disease. Any previous or recent surgery (skin related). Hospitalization history or emergency admission history. Medication History: Current medications? New drugs (antibiotics or immunosuppressants) Prescribed, over the counter, and any herbal? Past Hospitalization and Surgical History: “Have you had any previous hospitalizations or any previous surgeries?” Allergic History: “Do you have any known allergies?” Family History: “Has anyone in your family had similar symptoms or similar health problem?” Family history of any long-term or specific medical ill-ness? (Inflammatory bowel disease) Social History: “Do you smoke? Do you drink alcohol?” “Have you ever tried any recreational drugs?” If yes, then further ask, “How much? Daily? How long?” Relationships: “Are you sexually active? Do you have sex-ual preferences? Man, woman, or both?” Self-Care and Living Condition: “What do you do for liv-ing? Who lives with you?” Support: “Do you have good family and friends support?”Patient presents with skin anomaly Rash Single or multiple discrete lesions What is the color? Red, v ascular Flesh-colored Pigmented: brown, bl ack, blue Subepider mal (belo w the skin)Papule (raised, <1 cm)Macule (flat, <1 cm)Plaque (raised, >1 cm)Fig. 15. 1 Common benign skin lesion algorithm. (Adapted from Henry [2]) M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
433 Impact on Life/Disability and Adaptation: Affects on life? “Any effect on your daily activity?” If patient is a teenager, then add these questions: Home, education, employment, activities, drugs, and sexual activity If patient is an adult female, then ask these questions: Menstrual history (LMP) Gynecology history Obstetrics history If patient is more than 65 years old, add these questions here: Any problem with balance? Any difficulty in peeing/urination? Any issues with sleeping? Any change in vision/hearing? Any recent change in memory? Any regular medication? Prescribed or over the counter? Skin Examination: Distribution of skin lesions. Try to identify lesion morphology (using a magnifying glass will be helpful): -Are lesions monomorphic (one form) or pleomorphic? -Are there secondary changes on top of primary lesions, for example, excoriation? -How are lesions grouped locally, for example, ring shaped? Check hair, nails, and mucous membranes. Complete a general examination. Wrap-Up: Describe the diagnosis. Laboratory tests. Management plan. Duration of treatment and side effects. Describe the red flags. Further information: Websites/brochures/support groups or societies. Follow-up. History and Counseling: Changing Mole Candidate Information: A 28-year-old male comes to your clinic concerned about the mole/skin lesion on his back. Please take a detailed history and perform a relevant physical examination. Differentials [8]: Vascular: -Pyogenic granuloma -Thrombosed or irritated hemangioma Neoplastic: -Malignant melanoma -Pigmented basal cell carcinoma -Dysplastic nevus -Seborrheic keratosis Congenital/genetic: Irritated congenital or compound nevus [8] 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 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 Mr... ? Are you 28 years old?” Chief Complaint: “What brings you in today?” The patient will tell about a mole on his back that recently has increased in size. History of Present Illness: “I am going to ask you few questions about the mole and then about your general health. I will also like to perform a physical examination. Should we start?” “When noticed?” “Did you have it before or you noticed it for the first time?” “What is the size of it?” “Is it growing in size?” “What is the color?” “Is the color changing?” “How are the borders?” (irregular vs. regular) “Is it itchy?” “Did you notice any bleeding?” (spontaneously or after scratch) “Any other mole on your body?” “How is the surface above it?” (raised or flat) “Do you have any pain in it?” “Is it tender on touch?” “Have you noticed such lesions around eyes or genital area?” 15 Skin | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
434 “Do you have any vision problems?” “Are the nails or hair involved?” Associated Symptoms (If Have Not Asked Before): Itching, pain, bleeding, nausea, vomiting, urine changes, jaundice, chills, sweating, fever, or weight loss Other lesions Aggravating and relieving factors (sunlight, rest, or antihistamines) Risk Factors: Factors associated with increased risk of melanoma [9]: Changing or persistently changing mole One or several irregularly pigmented lesions Atypical mole Congenital mole White race (Caucasian) Previous melanoma Melanoma in parents, children, or siblings Immunosuppression Multiple moles Sun sensitivity, tans poorly, burns easily, had multiple or severe sunburns Excessive sun exposure, particularly during childhood Review of Systems: Nervous system: Headache or vision changes Urine: Hematuria, change in color/frequency of urine Eyes: Iritis, scleritis, or conjunctivitis Mouth: Ulceration/erosion Respiratory system: Shortness of breath, cough, or chest pain Gastroenterology: Malabsorption, change in bowel habits like constipation alternating to diarrhea, or constipation Liver disease: Nausea, vomiting, anorexia, or abdominal distension Bone pain Enlarged lymph nodes Past Medical History: “Do you have any previous health or skin issues?” Any previous or recent surgery (skin related). Hospitalization history or emergency admission history. Medication History: Current medications? Prescribed, over the counter, and any herbal? Allergic History: “Do you have any known allergies?” Family History: “Does anyone in your family have similar symptoms or a similar health problem?”Social History: “Do you smoke? Do you drink alcohol? Have you ever tried any recreational drugs?” Relationships: “Are you sexually active? Do you have sex-ual preferences? Man, woman, or both?” Physical Examination: (Run through the examination part. Remember to leave 1-2 min for wrap-up. ) “Now, I will start the examination. ” Comment on the vital sign findings: State if there are any mentionable findings; otherwise state that vitals are normal. General Appearance Head and neck exam: -Nose -Mouth and throat (limitations to intubation) -Cervical lymph nodes Skin: Look for any rash. The examiner may show a pic-ture or a model (Figs. 15. 2 and 15. 3) [10]. Skin examination: -Distribution of skin lesions. -Try to identify lesion morphology (just tell that you will use a magnifying glass to examine the lesion). -Comment on: Asymmetry Border Color Diameter Elevation Check hair, nails, and mucous membranes. Chest examination. Inspection, auscultation, palpation, and percussion. Cardiovascular examination: -Auscultation for heart sounds Fig. 15. 2 Stage I. The asymmetric shape, scalloped borders, and vari-ety of colors typical of a superficial spreading melanoma are seen on this patient's shoulder. (Reprinted with permission from Naylor [10]) M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
435 Abdominal examination: -Inspection and palpation Comment on your findings. Thank the patient and tell the patient to cover up. Wrap-Up: Question: “How will you describe the diagnosis?” (Melanoma) (Questions may be asked by the patient or the examiner. ) Answer: “Melanoma is the most serious type of skin cancer. It affects young adults as well as older people. Melanoma is a form of cancer that develops in the skin's pigment cells called melanocytes. Melanocytes produce melanin, which helps protect the skin from ultraviolet (UV) radiation, i. e., sunlight. When melanocyte cells aggregate together in the skin during childhood or adolescence they form a mole. Most moles are quite safe, however sometimes the mela-nocytes in a mole begin to grow and divide in an uncon-trolled way. If they start to grow in a unregulated way, either expanding outward or down into the lower layers of the skin, they can become a melanoma. Melanoma is the most serious form of skin cancer and grows very quickly if left untreated. It can spread to the lower part of your skin (dermis), enter the lymphatic system or bloodstream, and then spread to other parts of the body, e. g., lungs, liver, brain, or bone. ” Question: “What causes melanoma?” Answer: “The main preventable cause of melanoma is over-exposure to UV radiation from the sun or things such as solarium tanning machines (sunbeds). There are many risk factors that increase the chances of melanoma, including people with fair skin, a high mole count, family history and a pattern of sunburns throughout life, especially during childhood. Importantly, melanoma can occur anywhere on the skin, even in areas that receive little or no sun exposure, e. g., inside the mouth or on the soles of your feet” [11]. Question: “How is a melanoma diagnosed?” Answer: “If a melanoma is suspected then your doctor is likely to advise an excisional biopsy. In this procedure, the entire abnormal area of skin is removed by a minor opera-tion. (Local anesthetic is injected into the skin to make this painless. ) This tissue is looked at under the microscope. This is to: Confirm the diagnosis -abnormal melanoma cells can be seen. To assess the melanoma's thickness (how deep it has spread into the skin). The thickness of the melanoma helps to guide treatment and the need for further assess-ment” [12]. “Further investigations may include shave biopsy, senti-nel lymph node biopsy, a baseline chest X-ray and serial lac-tate dehydrogenase (LDH)” [9]. “Further treatment for primary melanoma should include wide local excision and regular follow-up” [9]. “Treatment of metastatic disease may include radiation, immunotherapy and chemotherapy” [9]. Further information: Websites/brochures/support groups or societies. Book a follow-up. History and Counseling: Face Lesion Candidate Information: A 62-year-old male presents to your clinic with a small bump on his face that he has had for about 5 months. He noticed some bleeding while shaving. Please take a detailed history and perform a relevant physical examination. Differetntials: Basal cell carcinoma (BCC) Squamous cell carcinoma (SCC) Benign hemangioma Excoriated nevus Irritated nevus Keratoacanthoma Sebaceous gland hyperplasia Seborrheic keratosis Actinic keratosis Rosacea Folliculitis Fig. 15. 3 Stage II. A nodular melanoma is apparent on the back of this middle-aged male. (Reprinted with permission from Naylor [10]) 15 Skin | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
436 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 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 Mr... ? Are you 62 years old?” Chief Complaint: Chief complaint or the reason patient is visiting the clinic. “What brings you in today?” The patient will tell about a small bump on his face. History of Present Illness: “I am going to ask you few questions about the bump on your face and then about your general health. I would also like to do a physical examination. Should we start?” “When did you notice the bump?” “Did you have it before or did you notice it for the first time?” “Was it long-standing but now changing?” “How did the lesion appear when you first noticed it?” What is the size of it? -Is it a papule? -Ulcer like? (BCC or SCC) -Scaly plaque? (actinic keratosis) “Is it growing in size?” What is the color? -Is it a flesh-color papule present with associ-ated inflammation of surrounding skin? (irri-tated nevus) “Is the color changing?” How are the borders? (irregular vs. regular) -Does it have shiny, pearly quality with associated tel-angiectasia? (BCC) How is the surface above it? -Is it flat, rough, and scaly with ill-defined borders? (actinic keratosis) Does the lesion have a stuck-on appearance? (seborrheic keratosis) Are there multiple soft, yellow, umbilicated papules pres-ent? (sebaceous hyperplasia) “Is it itchy?” “Did you notice any bleeding?” (spontaneously or after scratch) (BCC or SCC) “Is there any other similar bump on the body?” -“Is the lesion painful?” “Is it tender on touch?” “Nail or hair involvement?” Associated Symptoms (If These Have Not Been Asked Before in the History): Itching, pain, bleeding, nausea, vomiting, urine changes, jaundice, chills, sweating, fever, or weight loss Aggravating and relieving factors (sunlight, rest, or antihistamines) Review of Systems: Nervous system: Headache or vision changes Eyes: Iritis, scleritis, or conjunctivitis Mouth: Ulceration/erosion Respiratory system: Shortness of breath, cough, or chest pain Gastroenterology: Nausea or vomiting Bone pain Enlarged lymph nodes Past Medical History: “Do you have any previous health or skin issues?” “Previous skin cancers?” “Any previous or recent surgery (skin related)?” Hospitalization history or emergency admission history Medication History: Current medications? Aspirin and other blood thinners (the lesion bleeds on shaving?) Prescribed, over the counter, and any herbal? Allergic History: “Do you have any known allergies?” Family History: “Does anyone in your family have similar symptoms or a similar health problem?” Social History: “Do you smoke? Do you drink alcohol? Have you ever tried any recreational drugs?” Relationships: “Are you sexually active? Do you have sex-ual preferences? Man, woman, or both?” Physical Examination: (Go through the examination part. Remember to leave 1-2 min for wrap-up. ) “Now, I will start the examination. ” Comment on the vital sign findings: State if there are any mentionable findings; otherwise state that vitals are normal. M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
437 General Appearance Head and neck exam: -Nose -Mouth and throat (limitations to intubation) -Cervical lymph nodes Skin: Look for the lesion. The examiner may show a pic-ture (Figs. 15. 4 and 15. 5a, b). Skin examination: Describe the lesion in picture (Fig. 15. 5a): -It is about... x... cm shiny, pearly skin nodule. -It has irregular borders. -It is pink to red in color. Check hair, nails, and mucous membranes. Chest examination: -Inspection and auscultation Cardiovascular examination: -Auscultation for heart sounds Abdominal examination: -Inspection and palpation Thank the patient and tell the patient to cover up. Comment on your findings: “It appears to be a basal cell carcinoma. ” Wrap-Up: Question: “What is basal cell carcinoma?” Answer: “Basal cell carcinoma is the most common skin cancer. About 75% of all skin cancers are BCCs. It is usually the least dangerous. If treated, it will be almost always com-pletely curable. BCCs are slowly growing and almost never spread to other parts of the body. These can destroy and dam-age the overlying skin and surrounding tissues. ” Question: “What causes BCC?” Answer: “There are many factors that lead to the develop-ment of most cancers. However, sun exposure is by far the most important factor in the development of BCCs. This excessive sun exposure usually occurred many years before the BCC develops. Those who are at a greater risk of devel-oping a basal cell carcinoma include people with fair skin, people with a strong family history of BCC, and those with a Celtic background” [13]. “Diagnosis is often based on skin examination and con-firmed by tissue biopsy. ” Question: “What does a BCC look like?” Answer: “BCCs usually start with a subtle change on the skin—often a small bump or a flat red patch. BCCs develop very slowly over months and years, steadily becoming larger and more obvious. Eventually they may appear as a non- healing sore. BCCs are often not noticed until relatively well developed and their appearance can be confused with that of Fig. 15. 4 A basal carcinoma on the proximal helix. Prior to removal by Mohs surgery, a reservoir of laxity was identified at the preauricular sulcus and relaxed skin tension lines marked. (Reprinted with permis-sion from Humphreys [16]) a b Fig. 15. 5 (a) Basal cell carcinoma at alar base and junction with the cheek. (b) Large basal cell carcinoma of nasal tip. (Reprinted with per-mission from Humphreys [16]) 15 Skin | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
438 a mole, patch of dermatitis, or a scar. A lesion that bleeds on the face is quite suspicious of BCC. ” Question: “What types of BCC are there?” Answer: Superficial Nodular Infiltrating Question: “What is the treatment for BCC?” Answer: A biopsy is taken and sent to a pathology labora-tory. The specimen will be then examined under a micro-scope to confirm the diagnosis. In the treatment of BCC in a particular patient, the follow-ing factors are considered: Patient age Size of lesion Site of lesion Depth of the lesion Patient's general health Type of BCC Various treatment options include: Serial cryotherapy Standard surgical excision (removal) Mohs micrographic surgery Curettage and cautery Photodynamic therapy Topical immunotherapy Radiotherapy Question: “What sort of follow-up is needed?” Answer: “The general recommendation after removal of a BCC is to undergo regular skin follow-ups every 6-12 months. It is important that the skin be self-examined and any suspi-cious new lesions reported” [13]. History and Counseling: Eczema Flare-Up Candidate Information: A 9-year-old male is brought by his parents to your GP clinic with a flare-up of his eczema. He is in the waiting area. His mother is in the consultation room. Please take a detailed history. No examination is required for this station. Differentials: Flare-up with physical factors: -Summer weather-Heat -Humidity -Intense exercise Atopic dermatitis with secondary Staphylococcus aureus infection Eczema herpeticum Atopic dermatitis Allergic contact dermatitis Drug reaction 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 or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... Are you... 's mother? How can I help you today?” Mom will tell about her kid's eczema flare-up. Chief Complaint: “I am going to ask you a few questions about his eczema and his general health. Then I would like to bring him in for an examination. Should we start?” History of Present Illness: When noticed? How long has it been going on? Did this flare-up develop suddenly or progressively? Previous flare-ups? What were the triggering factors? Previous treatments given? How often are the topical moisturizers or medicated oint-ment applied? Any regular follow-ups? Dermatologists? Is this something new? What does the eczema look like? -Dry or scaly? -Is the skin very dry? How is the skin involved? Thickened? Which part of the body is involved? Is it progressing? Is any new area involved? Localized or generalized? Is it flexor surfaces mostly? (antecubital and popliteal fos-sae? -common areas of eczema) Is it itchy? Is it painful, umbilicated vesicles present in a generalized or widespread distribution? (eczema herpeticum) M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
439 Are there small, deep, intensely itchy vesicles present within the eczema? (more acute flare-up) Are the lesions crusting and oozing? (secondary bacterial infection with S. aureus) How is the eczema affecting the child's life? Associated Symptoms (If These Have Not Been Asked Before in the History): Itching, pain, bleeding, nausea, vomiting, chills, sweat-ing, fever, weight loss Aggravating and relieving factors (sunlight, rest, antihis-tamines, dust, pets, or wool?) Past Medical History: “Do you have any previous health or skin issues?” Previous hospital admission for eczema or use of oral antibiotics to treat secondary infection? History of asthma or rhinitis? Any previous or recent surgery (skin related)? Medication History: Current medications? Creams/moisturizers? Prescribed, over the counter, or any herbal? Allergic History: “Do you have any known allergies? Skin allergy testing?” Family History: “Does anyone in your family have similar symptoms or similar health problem? Atopic dermatitis, asthma?” Social History: Do you smoke? Do you drink alcohol? Do you take any recreational drugs? Birth History: “Any problems during or after birth?” Immunization: “Are his immunizations up to date?” Developmental History: “Any concerns about his growth? How is he doing in school?” Thank the patient's mother and tell her that you would like to see the child now. Wrap-Up Question: “How will you describe eczema to the patient?” Answer: “Eczema or atopic dermatitis is an inherited, chronic inflammatory skin condition. Most cases first develop in children under the age of 5 years. It is unusual to develop atopic eczema for the first time after the age of 20. Patches of skin will become itchy, scaly, and red. At times small blisters containing clear fluid can form and the affected areas of skin can weep. Weeping is a sign that the dermatitis has become infected, usually with the bacterium Staphylococcus aureus (“golden staph”). Eczema is not contagious. Eczema can vary in severity and symptoms may flare up or subside from day to day. If your eczema becomes worse, disrupts sleep, or becomes infected, see your doctor. “Using moisturizers and cortisone-based ointments can help ease the symptoms. It is also important to avoid skin irritants, such as soap, hot water, and synthetic fabrics. “Children with eczema have a higher risk of developing food allergies, asthma, and hay fever later in childhood” [14]. Question: “What causes eczema?” Answer: “The cause is unknown. It is more seen in children whose family members have eczema, asthma, or hay fever. ” Triggering factors: Skin dryness Overheated Irritation from soaps or detergents Allergies to dust mites Allergies to plant pollens Allergies to animal fur Food allergies Question: “Will the treatment cure eczema?” Answer: “Eczema can be well controlled in most children by: Identifying and avoid the triggers Skin care and avoiding dryness Reducing the itchiness by wet dressings and cool compresses A good quality moisturizer can be used as often as necessary. To control the itch and redness, your doctor may prescribe a cortisone-based cream or ointment. Cortisone is a natural hormone that is produced by the body. Cortisones are very effective in controlling eczema and are safe if used as directed. Weaker cortisones should be used on the face and stronger cortisones are used for the body. ” Try to control the itch as scratching makes the eczema worse and can cause infection: Try applying a soft, cool wet towel to the itchy area for immediate relief and leave on for 5-10 min. Remove the wet dressing and apply a thick layer of moisturizer. Distract your child when he/she is scratching. 15 Skin | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
440 Avoid overheating your child, particularly in bed or on long car trips. Keep your child's fingernails short and clean. Avoid heat. Keep your child cool at all times. If there are signs of skin infection, antibiotics will be required. If the child has a severe infected rash, the child may need to be referred to nearest hospital for treat-ment [ 15]. Checklist: Physical Examination Psoriasis Candidate Information: A 29-year-old male with known psoriasis presents to your clinic for a follow-up examination. Please perform a relevant physical examination. See Table 15. 4 for a checklist that can be used as a quick review before the exam. References 1. Simon C, Everitt H, van Dorp F, Burke M, Llewelyn H, Ang HA, et al. Chapter 17, Dermatology. In: Oxford handbook of general practice. 4th ed. Oxford: Oxford University Press; 2014. p. 589. 2. Henry GI. Benign skin lesions. Medscape. January 26, 2018. https:// emedicine. medscape. com/article/1294801-overview. Accessed 12 Feb 2018. 3. Page EH. Description of skin lesions. MSD Manual Professional Version. http://www. msdmanuals. com/en-au/professional/derma-tologic-disorders/approach-to-the-dermatologic-patient/descrip-tion-of-skin-lesions. Accessed 12 Feb 2018. 4. Medicine Net. com. Medical definition of papules. https://www. medicinenet. com/script/main/art. asp?articlekey=14075. Accessed 27 Mar 2018. 5. Brannon H. Understanding skin plaque causes. Verywell health. March 25, 2018. https://www. verywell. com/understanding-plaque-1069366 Accessed 27 Mar 2018. 6. https://www. fastbleep. com/medical-notes/other/4/310. Accessed 27 Mar 2018. 7. Williams G, Katcher M. Primary care dermatology module: nomen-clature of skin lesions. Madison: The University of Wisconsin Madison. https://web. pediatrics. wisc. edu/education/derm/text. html. Accessed 27 Mar 2018 8. Hurley KF. Chapter 7, Dermatology. In: OSCE and clinical skills handbook. 2nd ed. Toronto: Elsevier Canada; 2011. p. 237. 9. Shuja F, Zoghbi ZW. Chapter 40, Skin cancer. In: Arndt KA, Hsu JTS, Alam M, Bhatia AC, Chilukuri S, editors. Manual of derma-tologic therapeutics. 8th ed. Philadelphia: Lippincott Williams & Wilkins; 2014. p. 303-9. 10. Naylor MF. Chapter 15, Practical management of melanoma. In: Mac Farlane D, editor. Skin cancer management: a practi-cal approach. New York: Springer Science + Business Media; 2010. 11. Melanoma Institute Australia. What is melanoma? https://www. melanoma. org. au/understanding-melanoma/what-is-melanoma/. Accessed 12 Feb 2018. 12. Tidy C. Melanoma skin cancer. Patient. December 4, 2017. https:// patient. info/health/skin-cancer-types/melanoma-skin-cancer. Accessed 12 Feb 2018. Table 15. 4 Checklist for psoriasis 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 Ask for vital signs -interpret the vital signs Vitals Start by commenting on the vitals given at the door. (It should include pulse rate, blood pressure, respiratory rate, temperature, and O 2 saturation) “Vital signs are within normal range. ” Or comment if they are not General examination Exposure: Expose patient's upper body and then lower body. Drape him accordingly Inspection Examine the entire skin area Just mention that you will also examine the anogenital area Examine scalp Look for typical silvery scales Examine the face, mucous membranes, and neck Examine nails Pitting Onycholysis Oil drop sign (yellow to red discoloration of nail bed) Examine for Koebner's phenomenon Linear or traumatized area involvement Palpation Observe for raised plaques versus erythema only (treated psoriasis) Observe for Auspitz sign Pinpoint bleeding that occurs on a psoriatic plaque with physical removal of scale Examine for large joints (hip and lumbosacral spine) Tenderness Range of movements Examine hands Swelling (sausage digits) Tenderness Range of movements Chest examination Inspection and auscultation Cardiovascular examination Auscultation for heart sounds Abdominal examination Inspection and palpation Comment on your findings Thank the patient and tell the patient to cover up Wrap-up Thank patient and cover the arms Wrap up your findings and ask the patient if he has any concerns M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
441 13. The Australasian College of Dermatologists. Basal cell carcinoma (BCC). https://www. dermcoll. edu. au/atoz/basal-cell-carcinoma-bcc/. Accessed 12 Feb 2018. 14. Better Health. Eczema (atopic dermatitis). https://www. better-health. vic. gov. au/health/conditionsandtreatments/eczema-atopic-dermatitis. Accessed 12 Feb 2018. 15. The Royal Children's Hospital Melbourne. Kids health info: eczema. https://www. rch. org. au/kidsinfo/fact_sheets/Eczema/. Accessed 12 Feb 2018. 16. Humphreys T. Chapter 12, Cutaneous flaps. In: Mac Farlane D, editor. Skin cancer management: a practical approach. New York: Springer Science + Business Media; 2010. Further Reading Murtagh J. Part 9: Problems of the skin. In: John Murtagh's general practice. 6th ed. North Ryde: Mc Graw-Hill Australia Pty Ltd. ; 2015. p. 1289-406. Starr O. Atopic eczema. Patient. April 18, 2018. https://patient. info/ health/atopic-eczema. 15 Skin | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
443 © 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_16Geriatrics Mubashar Hussain Sherazi History Overview: The Geriatrics In OSCE, geriatric stations are important and frequently repeated stations. These are usually history-taking and coun-seling stations. Please see Table 16. 1 for an overview of the pattern of history taking required for geriatric stations. Common Geriatrics Signs and Symptoms for the Objective Structured Clinical Examination Common presenting symptoms are: Headache Vertigo Hearing loss Weakness or sensory/motor loss Confusion Delirium Depressed level of consciousness Falls Head injury Abuse Dementia Dizziness Urine related symptoms History and Counseling: Falls Candidate Information: A 66-year-old female was brought to the emergency room by ambulance after having a fall at home. Please take a detailed history and counsel the patient. No external injury was found. The patient's Glasgow Coma Scale (GCS) is 15/15 and vitals are within the normal range. No examination is required for this station. (A similar topic “frequent falls” has been discussed in the chapter on the nervous system. ) Differentials: Fall secondary to medical conditions: -Low blood pressure/orthostatic hypotension -Polypharmacy -Hypovolemia Poor intake V omiting/diarrhea Recent bleeding -Cardiovascular disease -Poor diabetic control/hypoglycemia -Psychological conditions (depression) -Dementia or delirium -Stroke -Parkinson's disease -Epilepsy -Vision problems (impaired vision/cataract) -Arthritis -Foot disorders -Balance disorders -Impaired lower limb strength Social conditions: -Elder abuse Environmental factors: -Poor lighting -Slippery surfaces (wet floors, wet toilets, slippery shower/bath area) -Loose objects on floor -Poorly fitting footwear -Loose rugs and mats -Uneven floors or paving -No handrails on stairs M. H. Sherazi Mallacoota Medical Centre, Mallacoota, VIC, Australia16 | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
444 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 or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attend-ing physician. Are you Ms....? Can I confirm that you are 66 years old?” History of Present Illness: “Is it alright if I ask you a few questions about your fall? During the history if you have any questions or if you feel any discomfort please let me know. Should we start?” Please divide the history into three parts: About the fall Before the fall After the fall About the fall: “When did the fall occur?” “Can you recall what happened?” “Where did it occur? Home or outside?” “What were you doing at the time?” “Were you alone? Did someone witness the fall?” If she says yes, then just mention that you need to take a collat-eral history later. “How did you fall?”Table 16. 1 Quick overview of geriatric history taking Introduction: Name and age Chief complaint: In patient's own words History of present illness: Analysis of chief complaint: Onset Course Duration If pain -pain questions Associated symptoms: nausea, vomiting, diarrhea, constipation, change in bowel habits, reflux, appetite, blood in vomiting/feces/ urine Predisposing factors Aggravating and relieving factors Red flags/risk factors Constitutional symptoms: anorexia, chills, night sweats, fever, weight loss Review of systems: Respiratory Genitourinary Cardiovascular Neurology Rule out differential diagnosis Specific geriatric questions: Any problems with balance? Any difficulty in urination? Any issues with sleeping? Any change in vision/hearing? Any recent change in memory? Past medical and surgical history: Medical illnesses Any previous or recent surgery Hospitalization history or emergency admission history Medications history: Current medications (prescribed, over the counter, and any herbal) Ask if the patient has brought the list of prescribed medicines Allergic history/triggers Any known allergies? Family history: Family history of any long-term or specific medical illness In some cases, may need to ask about substitute decision maker or next of kin or power or attorney Acute resuscitation plan (ARP) status? Social history: Smoking Alcohol Street drugs Sexual history Home situation: further explore Activities of daily living (ADLs) Walking Transferring Dressing and grooming Feeding Bathing Toileting Table 16. 1 (continued) Instrumental activities of daily living (IADLs) Finances Transportation Shopping and meal preparation House cleaning Communication Medications: obtaining medications and taking them as required 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 | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
445 “Did you trip or just feel your legs give way?” “Did you or someone else notice any shaking/jerky move-ments when you had the fall?” “Did you wet yourself?” “Did you turn blue or turn stiff?” “Did you bite your tongue?” “How do you feel now?” “Did you hurt yourself? Any previous fall injuries?” “Do you need any urgent attention? Pain control?” Before the fall: “How were you feeling before the fall?” “Did you feel light headed or your head spinning?” “Did you feel hungry? Did you notice your heart racing? Was there any sweating?” (Hypoglycemia) “Did you have chest pain? Did you have palpitations? Did you notice shortness of breath?” (Cardiovascular) “Did you experience lights flashing, a strange smell, or strange feeling in body?” (Seizure) “Did you have any weakness, numbness, difficulty find-ing words, or visual disturbances?” (Stroke) Ask about environmental factors: -“Was the lighting good?” -Tight or loose shoes? -Slippery/wet or uneven floors? -Loose rugs? -Slippery/wet or uneven stairs, lighting on stairs? -“How is your vision?” -“Is your footwear comfortable?” After the fall: “Did you hit your head on the ground?” “Did you lose consciousness?” “Any other obvious injury?” “Could you get up by yourself?” “When did the help arrive?” “Did you have any nausea or vomiting?” “Did you notice any weakness?” “Did you have any difficulty in finding words?” “Did you have any vision problems?” “Did you have loss of sensation in the arms or legs?” “Did you have ringing in your ears?” “Did you seek medical help?” “What were you advised?” Past Medical History: “How is your health otherwise? Do you have any previous health issues?” History of stroke, transient ischemic attack (TIA), heart attacks, chest pain, hypertension (HTN), diabe-tes mellitus (DM), atrial fibrillation, and neurological dis-ease (seizures, head trauma, migraine, multiple sclerosis (MS), aneurysms, depression, gastrointestinal bleeding and dementia). Past Hospitalization and Surgical History: “Have you had any previous hospitalizations or any previous surgery?” Medication History: “Are you taking any medication (pre-scribed, over the counter, or herbal)? Was there any side effects?” If patient says no, then continue to the next question. Antihypertensives, diuretics -Ask for any recent changes in the doses. Polypharmacy -Ask if the patient has a list of her medi-cations. She may hand over a list. Read it carefully before commenting on the medications. Allergy History: “Do you have any known allergies?” Personal History: “Please tell me about yourself. ” (Can be asked in any sequence: marital status, occupation, religion, education, type of residence, living conditions. ) Social History: “Do you smoke? Do you drink alcohol?” Self-Care and Living Condition: “What do you do for a living? Working status and occupation? Educational status? Who lives with you? Do you have good family and friends support?” Functional status or severity or impact on life activities? Activities of Daily Living (ADLs) Walking: Getting around the home or outside, also labeled as ambulating. Transferring: Being able to move from one body position to another. This includes being able to move from a bed to a chair, or into a wheelchair. Dressing and grooming: Selecting clothes, putting them on, and managing one's personal appearance. Feeding: Being able to get food from a plate into one's mouth. Bathing: Washing one's face and body in the bath or shower. Toileting: Getting to and from the toilet, using it appropri-ately, and cleaning oneself. Instrumental Activities of Daily Living (IADLs) Finances: Paying bills and managing financial assets. Transportation: Driving or organizing other means of transport. 16 Geriatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
446 Shopping and meal preparation: Getting a meal on the table. This includes shopping for clothing and other items required for daily life. Housecleaning: Cleaning kitchen after cooking/eating, keeping one's living space clean and tidy. Keeping up with home maintenance. Communication: Using telephone and mail. Medications: Obtaining medications and taking them as required. Wrap-Up: Wrap up your findings and ask the patient if they have any concerns. Question: “What will you do next?” (Questions may be asked by the patient or the examiner. ) Answer: “I would like to do a detailed physical examination. ” Question: “What will you observe for in a physical examination?” Answer: “I shall observe for: Postural changes in vital signs. Check for visual problems. Presence of arrhythmia. Listen for carotid bruits. Check for lower extremity strength and joint function. Check for gait and balance abnormalities. A neurologic evaluation looking for focal deficits. Assessment of lower extremity peripheral nerves, pro-prioception, and vibration sense. Tests for cerebellar functions. Timed up and go test: Observe patient for unsteadiness as the patient gets up from a chair without using the arms, walks 10 ft (~3 m), turns around, walks back, and resumes a seated position. Timing the process, which should take less than 16 s, enhances the sensitivity of this test. Patient difficulties performing this test indicate an increased risk for falling and the need for further comprehensive evaluation. ” Question: “What tests will you order?” Answer: “CBC, electrolytes, blood urea nitrogen (BUN), creatinine, glucose, thyroid function, and vitamin B12 levels. Syncope evaluation may include an electrocar-diogram (ECG), an echocardiography, a Holter monitor-ing, and a possible consult to a cardiologist. Consider brain imaging if the history suggests a cerebral cause and lastly a physiotherapy (PT) and occupational therapy (OT) review. ”Question: “What will you do next?” Answer: Fall risk counseling Adjusting medications Safety-related skills Environmental hazard reduction: Home safety assess-ment and modifications Exercise and physical training: Improve balance and pro-gressive muscle strengthening A walking plan: Appropriate use of assistive devices by an occupational therapist Question: “What will you tell your patient if the cause of the fall was orthostatic hypotension; resulting from polypharmacy?” Answer: “I will explain to my patient that based on our dis-cussion and my examination, the most likely reason of your fall is a condition called orthostatic hypotension. Have you ever heard about it? Do you want to know more about it?” “In a normal person, when you change your position from lying to sitting or standing, the blood pools to the legs and blood vessels narrow to maintain your blood pressure. ” “In patients with orthostatic hypotension -due to age, medication, and other medical problems such as diabetes mellitus -the body might fail to react with a change in pos-ture and blood pools in the legs causing a fall in blood pres-sure. There won't be enough blood reaching the brain, which will lead to dizziness or a feeling that you may pass out. ” “There is a possibility that this may occur again. From now on, I would like to recommend to you that whenever you change your position from lying down to standing, do it slowly, and sit at the edge of the bed and gradually stand up. ” “I also need to review your home medications, which may require modifications in the dosage of some of your blood pressure medications or a change in them altogether. ” “Do you have any questions?” Thank the patient and the examiner. History and Counseling: Dizziness Candidate Information: A 66-year-old female is brought to your GP practice with dizziness since this morning. Please take a detailed history and counsel the patient. Vitals are within normal range. No examination is required for this station. Dizziness: Dizziness can be classified into four groups [1]: M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
447 Vertigo (spinning sensation) Disequilibrium (feeling of imbalance) Light-headedness (sensation of giddiness) Presyncope (sensation of feeling faint) Differentials: Neurologic and Otologic Causes [2]: Peripheral vestibular -Benign paroxysmal positional vertigo -Meniere's disease -Vestibular neuronitis -Labyrinthitis -Otitis media -Acoustic neuroma Central vestibular causes -Cardiovascular accident -Vertebrobasilar ischemia -Cerebellopontine angle mass -Brain tumor -Motion sickness Cardiovascular causes -Arrhythmias -Orthostatic hypotension -Hypovolemia -Anemia -Myocardial ischemia -Hypoxia -Valvular heart disease -Vasovagal episode Hypoglycemia Hormonal -Thyroid disease -Menstruation -Pregnancy Psychiatric (hyperventilation or anxiety) -Panic disorder -Hyperventilation -Anxiety -Depression Age related -Diminished visual -Balance and perception of spatial orientation abilities Medications Associated with Dizziness from Orthostatic Hypotension [2]: Cardiac medication -Alpha-blockers (doxazosin, terazosin) -Alpha-/beta-blockers (carvedilol, labetalol) -Clonidine (Catapres) -Angiotensin-converting enzyme inhibitors -Diuretics (Furosemide)-Hydralazine -Methyldopa -Nitrates (sublingual nitroglycerin) Central nervous system medications -Parkinsonian drugs (bromocriptine, levodopa/ carbidopa) -Antipsychotics (chlorpromazine, clozapine, thioridazine) -Opioids -Skeletal muscle relaxants (baclofen) -Tricyclic antidepressants (e. g., amitriptyline, doxepin, trazodone) Urologic medications -Phosphodiesterase type 5 inhibitors (sildenafil) -Urinary anticholinergics (oxybutynin) 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 or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attend-ing physician. Are you Ms....? Are you 66 years old?” History of Present Illness: “Is it alright if I ask you a few questions about your dizzi-ness? During the history if you have any question or if you feel any discomfort, please let me know. Is this alright? How can I help you today?” “Can you please describe your dizziness more?” “When did it start?” (gradual versus sudden) “How long has it been going on?” “Is it progressing?” “Was there any triggering factor?” Ask about associated symptoms: “Did you black out?” (Syncope) “Did you feel dizzy when standing up from sitting or lying?” (Vasovagal) “Did you feel light-headed or the head spinning?” (Vertigo) “Did you have ringing in ears?” (Tinnitus) “Did you notice any problem with your ears? Fullness of ears?” “Any recent hearing problem?” 16 Geriatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
448 “Did you lose balance?” “Did you have any vision difficulties?” “Any change in your vision? Transient one-eye blind-ness?” (TIA) “Transient hand or leg weakness?” “Did you find difficulty in finding words? Slurred speech?” “Did you have any weakness, numbness, difficulty find-ing words or visual disturbances?” (Stroke) “Did you feel hungry? Did you notice heart racing? Were you sweating?” (Hypoglycemia) “Did you have chest pain? Did you have heart racing/pal-pitations? Did you notice shortness of breath?” (Cardiovascular) “Did you experience lights flashing, strange smell, or strange feeling in the body?” (Seizure) “Did you have any nausea or vomiting?” “Did you have epigastric pain?” (Upper gastrointestinal bleed) “Did you pass any tarry stool (melena) or blood in stool?” “Did you notice shortness of breath?” (Panic attack) “Feeling of shock?” “Tingling and numbness in hands and feet?” “Have you ever been screened for thyroid problems?” Past Medical History: “How is your health otherwise? Do you have any previous health issues?” Past Hospitalization and Surgical History: “Have you had any previous hospitalization or previous surgery? History of stroke, TIA, heart attacks, chest pain, HTN, DM, atrial fibrillation, neurological disease (seizures, head trauma, migraine, MS, aneurysms), depression, gastrointestinal bleeding, or dementia. Thyroid problems?” Medication History: “Are you taking any medication - prescribed, over the counter, or herbal -and are there any side effects?” If patient says no, then continue to the next question. Antihypertensives or diuretics -Ask for any recent changes in the doses. Polypharmacy -Ask if the patient has a list of her medi-cations. She may hand over a list. Read it carefully before commenting on the medications. Allergic History: “Do you have any known allergies?” Personal History: “Please tell me about yourself. ” (Can be asked in any sequence: marital status, occupation, religion, education, type of residence, living conditions. ) Social History: “Do you smoke? Do you drink alcohol?”Self-Care and Living Condition: “What do you do for a living? Working status and occupation? Educational status? Who lives with you? Do you have good family and friends support?” Functional status or severity or impact on life activities? Activities of Daily Living (ADLs) Walking: Getting around the home or outside, also labeled as ambulating. Transferring: Being able to move from one body position to another. This includes being able to move from a bed to a chair, or into a wheelchair. Dressing and grooming: Selecting clothes, putting them on, and managing one's personal appearance. Feeding: Being able to get food from a plate into one's mouth. Bathing: Washing one's face and body in the bath or shower. Toileting: Getting to and from the toilet, using it appropri-ately, and cleaning oneself. Instrumental Activities of Daily Living (IADLs) Finances: Such as paying bills and managing financial assets. Transportation: Driving or organizing other means of transport. Shopping and meal preparation: Getting a meal on the table. It includes shopping for clothing and other items required for daily life. Housecleaning: Cleaning kitchens after eating, keeping one's living space clean and tidy. Keeping up with home maintenance. Communication: Using telephone and mail. Medications: Obtaining medications and taking them as required. Wrap-Up: Wrap up your findings and ask the patient if they have any concerns. Thank the patient. Question: “What will you do next?” Answer: “I would like to do a detailed physical examination. ” Blood pressure lying and standing: Measure blood pressure while the patient is lying on the bed, and then recheck at least 1 min after the patient stands up. A sys-tolic blood pressure decrease of 20 mm Hg, diastolic blood pressure decrease of 10 mm Hg, or pulse increase M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
449 of 30 beats per minute is indicative of orthostatic hypotension. The Dix-Hallpike maneuver: It is diagnostic for benign par-oxysmal positional vertigo (BPPV) if positive. It will not rule out BPPV if negative. The maneuver is performed on a flat examination table. While the patient is in a seated position, the physician turns the patient's head 45° to one side, then rapidly lays the patient into a supine position with the head hanging about 20° over the end of the table, and observes the patient's eyes for approximately 30 s. The maneuver is repeated with the head turned to the opposite side. Nystagmus is diagnostic of vestibular debris in the ear that is facing down, closest to the examination table. There is usually a latent period of a few seconds before the patient develops nystag-mus and a sensation of vertigo for up to 1 min. The sensitivity of the Dix-Hallpike maneuver is 50-88% for BPPV. Cardiovascular examination and ECG: Further testing may be required if a cardiac cause is suspected, for exam-ple, Holter monitor testing and carotid Doppler testing. After obtaining the patient's history, the physician can tai-lor the physical examination to best fit the differential diag-nosis. One approach to the initial evaluation of patients with dizziness is presented in Fig. 16. 1 [2]. Question: “What tests will you order?” Answer: Laboratory testing and radiography are not benefi-cial in the work-up of patients with dizziness when no other neurologic abnormalities are present. Complete blood count, electrolytes, BUN, creatinine, glucose, thyroid function, and vitamin B 12 levels can be ordered. History and Counseling: Elder Abuse Candidate Information: A 71-year-old male presented to your GP clinic with pain in the left forearm for 3 days. He tried taking pain medications Dizziness Yes No Yes No Yes No Ask patient about: Medications Caffeine, nicotine, alcohol use Any history of head trauma or whiplash Ask patient to describe symptoms Spinning sensation or false motion Feeling off balance or wobbly Feeling faint or blacking out Vague symptoms May feel disconnected from surroundings Vertigo Dysequilibrum Presyncope Lightheaded Migraine Hearing loss Confirm diagnosis of migraine-associated vertigo when patient: Has a history of episodic vertigo plus a current migraine, or Has a history of migraine and at least 2 episodes of vertigo along with 1 of these symptoms: Migraine Photophobia Phonophobia, or Aura Investigate possible underlying conditions (eg, Parkinson disease or peripheral neuropathy) Check patient medications, especially for older patients Check gait and vision, Romberg test, neuropathy screening Any history of arrhythmias or myocardial infarction? Check patient medications, especially for older patients Check orthostatic blood pressure Any history of anxiety or depression? Hyperventilation provocation test Consider cardiac testing for high-risk patients Episodic vertigo? Episodic vertigo? Labyrinthitis Meniere disease Benign paroxysmal positional vertigo Vestibular neuritis Dix-Hallpike maneuver Fig. 16. 1 Algorithm for evaluating a patient with dizziness. (Adapted from [2]) 16 Geriatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
450 and put his arm in a sling, but the pain continued. He was brought today by a neighbor. Please take a detailed history. No examination is required for this station. Differentials: Elder abuse has been used as an all-inclusive term that is often used to represent physical abuse. So, that already indi-cates that there are differences in the way elder abuse is interpreted. It may involve relationships between spouses, adult children, other relatives, maybe friends, and anyone else in whom the older person has placed trust. Other behav-ior that is considered abusive may depend on its duration, its frequency, its intensity, its intentionality, and the conse-quences [3 ]. Elder abuse can be: Physical Psychosocial Financial Sexual Neglect Physical abuse [4] Inappropriate physical restraints Inappropriate chemical restraints Slapping, hitting, pushing, shaking, shoving, or restraining Harm created by over or under medicating Psychosocial abuse [4] Threaten to hurt Threatened with eviction or moving to a nursing home or age care facility Threaten to damage your belongings Threatened to stop seeing the family or friends Being harassed, humiliated, or intimidated Threatened to attend regular activities Financial abuse [4] Being denied access to your own funds Misuse of an enduring power of attorney Pension money skimmed Money stolen or taken from your bank account Your belongings taken away or sold without permission Your property taken improperly Being forced to change your Will Sexual abuse [4] Someone making unwanted sexual approaches or behav-ing indecently toward you No consent, or consent given by using force or threats Neglect [4] Not being allowed to get essential care services Physical, medical, or emotional needs not taken care of Red flags [5] Unexplained physical injuries Depression, fear, anxiety, passivity Dehydration, malnutrition, or lack of food Poor hygiene, rashes, pressure sores Oversedation Delay in seeking medical care Disparity in histories Frequent emergency room visits Presentation of functionally impaired patient without des-ignated caregiver Lab findings inconsistent with history Victim risk factors [5] Greater frailness Older age (80 and above) Female gender Dependence on the abuser Cognitive impairment or disability in activities of daily living Living in isolation Perpetrator risk factors [5] Suffering from caregiver stress Poor mental health or psychiatric illness Alcohol or drug dependence Financial dependence on the victim Male gender 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 or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... Are you Mr....? Are you 71 years old?” History of Present Illness: “How can I help you today?” (It is very important to listen carefully about the mechanism of injury and the reasoning M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
451 for delayed presentation. Also check for poor eye contact from the patient. ) The patient may describe the pain: The pain started about 3 days back when he had a fall on his outstretched left hand. His son gave him paracetamol and put his arm in a sling. His pain persisted. Today his neighbor found him to be in pain and then brought him to your clinic. Did he have any other injury? No Loss of consciousness before or after the fall? No Where is the pain? The pain is in the upper and middle part of the forearm, increases with any movement. Any visible swelling or deformity? Yes, in the same area where pain is. Any paralysis or loss of sensation? None Why the delay in seeking medical attention? The patient may avoid eye contact and will look worried. His son did not bring him to a clinic or hospital because he was busy. He also did not let him seek help. Show empathy and offer pain medication. Assure him about his privacy, confidentiality, and safety. Delayed pre-sentation should raise a red flag for elder abuse. But do not forget to rule out radius and ulna fracture. Rule out previous physical abuse (as mentioned earlier): Inappropriate physical restraints Inappropriate chemical restraints Slapping, hitting, pushing, shaking, shoving, or restraining Harm created by over-or under-medication Rule out psychosocial abuse Threatened to hurt Threatened with eviction or moving to a nursing home or age care facility Threatened to damage your belongings Threatened to stop seeing the family or friends Being harassed, humiliated, or intimidated Threatened to attend regular activities Rule out sexual abuse Someone making unwanted sexual approaches or behav-ing indecently toward you No consent, or consent given by using force or threats Rule out neglect Not being allowed to get essential care services Physical, medical, or emotional needs not taken care of History of Previous Attacks The frequency and severity of previous attacks? Previous threats? The presence of weapons in the home. What is the degree of physical violence? Rule out red flags Unexplained physical injuries Depression, fear, anxiety, passivity Dehydration, malnutrition, or lack of food Poor hygiene, rashes, pressure sores Oversedation Delay in seeking medical care Disparity in histories Frequent ER visits Presentation of functionally impaired patient without des-ignated caregiver Lab findings inconsistent with history Rule out perpetrator risk factors Suffering from caregiver stress Poor mental health or psychiatric illness Alcohol or drug dependence Financial dependence on the victim Male gender Past Medical History: “How is your health otherwise? Do you have any previous health issues?” Patients with psychi-atric complaints, especially suicide attempts, ideation, or gestures, always should be questioned about current or past domestic violence. Past Hospitalization and Surgical History: “Have you had any previous hospitalization or previous surgery?” Medication History: “Are you taking any medication - prescribed, over the counter, or herbal -and are there any side effects?” If patient says no, then continue to the next question. Allergic History: “Do you have any known allergies?” Personal History: “Please tell me about yourself. ” (Can be asked in any sequence: marital status, occupation, religion, education, type of residence, living conditions. ) Social History: “Do you smoke? Do you drink alcohol?” None. Self-Care and Living Condition: “Who lives with you?” His son only. “Do you have good family and friends support?” None. Functional status or severity or impact on life activities? 16 Geriatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
452 Activities of Daily Living (ADLs) Walking: Getting around the home or outside, also labeled as ambulating. Transferring: Being able to move from one body position to another. This includes being able to move from a bed to a chair, or into a wheelchair. Dressing and grooming: Selecting clothes, putting them on, and managing one's personal appearance. Feeding: Being able to get food from a plate into one's mouth. Bathing: Washing one's face and body in the bath or shower. Toileting: Getting to and from the toilet, using it appropri-ately, and cleaning oneself. Instrumental Activities of Daily Living (IADLs) Finances: Such as paying bills and managing financial assets. Transportation: Driving or organizing other means of transport. Shopping and meal preparation: Getting a meal on the table. It includes shopping for clothing and other items required for daily life. Housecleaning: Cleaning kitchens after eating, keeping one's living space clean and tidy. Keeping up with home maintenance. Communication: Using telephone and mail. Medications: Obtaining medications and taking them as required. Wrap-Up: Wrap up your findings and ask the patient if he has any concerns. Question: “What will you do next?” Answer: “I would like to do a detailed physical examination. ” Question: “What will you observe in the physical examination?” Answer: “I shall observe for vital signs, skin examination, extremities examination, cardiovascular, respiratory, and GI examination. ” Make a record of any visible injuries. Question: “What will be your management plan?” Answer: “I will establish the patient's concerns and ask him about his decisions. I will assure him of confidentiality. I will explain about the sources of support. Establish if he has any friend or family member that knows or could support him. I will tell him that elder abuse needs to be reported (check with your local and regional guidelines about elder abuse reporting)” [6, 7]. “I will need to send him to the nearest the emergency department for an X-ray and possible management of his forearm fracture. He will require orthopedic consultation (cast versus open reduction and internal fixation). ” The patient may require: Admitting to the hospital. Obtaining a court protective order. Placing the patient in a safe home. Permitting return home if the patient has the capacity to make an informed decision and refuses intervention. Referral to social services and adult protective services. Seeking support and assistance from family members or friends, caregivers, health care providers, social services, senior centers, police, legal professionals, and/or mem-bers of faith communities. Management of sexual or physical assault -If you are given permission by the patient, or you are satisfied that there are grounds to believe that the patient has been abused sexually or physically, you may want to notify the police. Once it is established by the police that abuse has occurred, they will conduct any further notification or questioning. In criminal cases you should document all injuries and consider photographing injuries before initiating treat-ment. You will need to gain consent from the patient to photograph injuries. In the case of sexual assault, evi-dence may need to be collected by forensic examination. Question: “What recommendations you will give to patient?” Answer: “The patient may or may not want to leave the situation or take action, but it is important to know the options and that help is available. ” “To seek help, one should [8]: Tell someone trusted about what is happening. Ask others for help if you need it. Turn to the police for help if someone is hurting you or you do not feel safe. Talk with people to learn more about resources and ser-vices available in your community. Find out your options to take care of your personal needs and financial security. Make a safety plan in case you have to leave quickly. ” Safety Planning Checklist One may want to consider putting together an emergency kit with [8]: M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
453 Emergency phone numbers written out and stored in a safe place Emergency money (e. g., for a taxi, hotel, or payphone) Extra clothing A list of medications, name, and phone number of phar-macy and at least 3 days' worth of medications Glasses, hearing aids, and other assistive devices such as cane, walker, or wheelchair A safe place to go in the event of an emergency (both in and outside your home) An escape route from your home Keys for home, car, and safety deposit box Copies of relevant documents History and Counseling: Syncope Candidate Information: A 71-year-old female is brought to the emergency depart-ment after passing out for a brief period of time at a nearby shopping mall. Please take a detailed history. The patient's GCS is 15/15 and vitals are within the normal range. No examination is required for this station. Differentials: Major life-threatening causes of syncope: Cardiovascular -Arrythmias -Ventricular tachycardia -Supraventricular tachycardia -Long QT syndrome -Brugada syndrome -Bradycardia: Mobitz II or 3° heart block -Acute coronary syndrome (ACS) -Myocardial infarction (MI) -Structural abnormalities -Valvular heart disease -Cardiomyopathy -Atrial myxoma -Cardiac tamponade -Aortic dissection Non-cardiovascular -Significant hemorrhage -Trauma with significant blood loss -GI bleed -Pulmonary embolism -Subarachnoid hemorrhage Other common causes of syncope: Orthostatic hypotension (drug induced) Reflex mediated (vasovagal) Neurogenic Situational (cough/post-micturition) Psychogenic Metabolic (hyperventilation) Medications: Medicines causing long QT: Sotalol, Cisapride, Amoidarone, Erythromycin, Terfenadine, Quinidine, Clarithromycin, Haldol, Fluxetine. Drugs causing orthostatic hypotension: -Alpha-blockers (doxazosin, terazosin) -Alpha-/beta-blockers (carvedilol, labetalol) -Clonidine (Catapres) -Angiotensin-converting enzyme inhibitors -Diuretics (furosemide) -Hydralazine -Methyldopa -Nitrates (sublingual nitroglycerin) Central nervous system medications -Parkinsonian drugs (bromocriptine, levodopa/carbidopa) -Antipsychotics (chlorpromazine, clozapine, thioridazine) -Tricyclic antidepressants (e. g., amitriptyline, doxepin, trazodone) Urologic medications -Phosphodiesterase type 5 inhibitors (sildenafil) -Urinary anticholinergics (oxybutynin) 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 or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attend-ing physician. Are you Ms....? Are you 71 years old?” History of Present Illness: Express empathy: -“Did you hurt yourself?” -“How do you feel right now?” -“I am glad that you are alright. ” “What happened?” “When did it happen?” “How long did you remain unconscious?” “What were you doing?” -Standing up from sitting? -Coughing? 16 Geriatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
454 “Did someone witness the event?” “What brought it on?” “Did you ever have this before?” Ask about associated symptoms: -“Did you black out?” (Syncope) -“Did you feel dizzy when standing up from a sitting or lying position?” (Vasovagal) -“Did you feel light headed or was your head spin-ning?” (Vertigo) -“Did you have ringing in your ears?” -“Did you notice any problem with your ears? Fullness of ears?” -“Any recent hearing problem?” -“Did you lose balance?” -“Did you have any vision difficulties?” -“Any change in your vision? Transient one-eye blind-ness?” (TIA) -“Transient hand or leg weakness?” -“Did you find difficulty in finding words? Slurred speech?” -“Did you have any weakness, numbness, difficulty finding words, or visual disturbances?” (Stroke) -“Did you feel hungry? Did you notice your heart rac-ing? Were you sweating?” (Hypoglycemia) -“Did you have chest pain? Did you have heart racing/ palpitations? Did you notice shortness of breath?” (Cardiovascular) -“Did you experience lights flashing, strange smell, or strange feeling in body?” (Seizure) -“Did your body get stiff?” -“Did you have any nausea or vomiting?” -“Did you have epigastric pain?” (Upper GI bleed) -“Did you pass any tarry stool (melena) or blood in stool?” -“Nausea/vomiting?” Past Medical History: “How is your health otherwise? Do you have any previous health issues?” “Previous syncopal episodes?” “History of stroke, TIA, heart attacks, chest pain, HTN, DM, atrial fibrillation, neurological disease (seizures, head trauma, migraine, MS, aneurysms), depression, gas-trointestinal bleeding, or dementia. Thyroid problems?” Past Hospitalization and Surgical History: “Have you had any previous hospitalization or previous surgery?” Medication History: “Are you taking any medication -pre-scribed, over the counter, or herbal -and are there any side effects?” If patient says no, then continue to the next question. Antihypertensives, diuretics -Ask for any recent changes in the doses. Polypharmacy -Ask if the patient has a list of her medi-cations. She may hand over a list. Read it carefully before commenting on the medications. Allergic History: “Do you have any known allergies?” Personal History: “Please tell me about yourself. ” (Can be asked in any sequence: marital status, occupation, religion, education, type of residence, living conditions). Social History: “Do you smoke? Do you drink alcohol?” Self-Care and Living Condition: “What do you do for liv-ing? Working status and occupation? Educational status? Who lives with you? Do you have good family and friends support?” Functional status or severity or impact on life activities? Activities of Daily Living (ADLs) Walking: Getting around the home or outside, also labeled as ambulating. Transferring: Being able to move from one body position to another. This includes being able to move from a bed to a chair, or into a wheelchair. Dressing and grooming: Selecting clothes, putting them on, and managing one's personal appearance. Feeding: Being able to get food from a plate into one's mouth. Bathing: Washing one's face and body in the bath or shower. Toileting: Getting to and from the toilet, using it appropri-ately, and cleaning oneself. Instrumental Activities of Daily Living (IADLs) Finances: Such as paying bills and managing financial assets. Transportation: Driving or organizing other means of transport. Shopping and meal preparation: Getting a meal on the table. It includes shopping for clothing and other items required for daily life. Housecleaning: Cleaning kitchens after eating, keeping one's living space clean and tidy. Keeping up with home maintenance. Communication: Using telephone and mail. Medications: Obtaining medications and taking them as required. M. H. Sherazi | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
455 Wrap-Up: Wrap up your findings and ask the patient if they have any concerns. Thank the patient. Question: “What will you do next?” Answer: “I would like to do a detailed physical examination. ” Vitals signs including lying and standing blood pressure General physical examination Complete cardiovascular and respiratory system examination Neurological and abdominal examination Ask for an ECG: The examiner may give you an ECG (you must be familiar with the ECG changes). Question: “What will be the plan for this patient?” Answer: “According to physical examination findings, blood tests results, and ECG, I will consult the cardiology or medical unit or both. Most likely the patient will require admission for observation and further investigations. ” References 1. Dommaraju S, Perera E. An approach to vertigo in general practice. Aust Fam Physician. 2016;45(4):190-4. https://www. racgp. org. au/ afp/2016/april/an-approach-to-vertigo-in-general-practice/. 2. Post RE, Dickerson LM. Dizziness: a diagnostic approach. Am Fam Physician. 2010;82(4):361-8. https://www. aafp. org/afp/2010/0815/ p361. html. 3. Wolf R. Appendix C. Elder abuse and neglect: history and concepts. National Research Council (US) panel to review risk and prevalence of elder abuse and neglect. In: Bonnie RJ, Wallace RB, editors. Elder mistreatment: abuse, neglect, and exploitation in an aging America. Washington: National Academies Press; 2003. https://www. ncbi. nlm. nih. gov/books/NBK98805/. 4. NSW Elder Abuse Helpline & Resource Unit. What is elder abuse? http://www. elderabusehelpline. com. au/for-everyone/what-is-elder-abuse. Accessed 16 Feb 2018. 5. OSCE Notes. Elder abuse. 2018. http://www. oscenotes. com/table-of-contents/family-medicine/elder-abuse/. Accessed 16 Feb 2018. 6. RACGP. Clinical guidelines. Section 10. 1 Elder abuse. https://www. racgp. org. au/your-practice/guidelines/whitebook/chapter-10-spe-cific-vulnerable-populations-the-elderly-and-disabled/section-101-elder-abuse/. Accessed 16 Feb 2018. 7. Government of Canada. Provincial and territorial resources on elder abuse. https://www. canada. ca/en/employment-social-development/ campaigns/elder-abuse/resources-province-territory. html. Accessed 16 Feb 2018. 8. Ontario. Information about elder abuse. https://www. ontario. ca/ page/information-about-elder-abuse. Accessed 16 Feb 2018. Further Reading 9. Gao Z-H, Ng D. OSCE & LMCC-II: review notes. Brush Education, Canada; 2009. 10. Jugovic PJ, Bitar R, Mc Adam LC. Fundamental clinical situations: a practical OSCE study guide. Elsevier Saunders, Canada; 2003. 11. Hurley KF. Geriatric. In: OSCE and clinical skill handbook. 2nd ed. Toronto: Elsevier Saunders; 2011. 12. Drislane FW, Acosta J, Caplan L. Blueprints neurology, 4th edn. Wolters Kluwer, USA; 2013. 13. Murtagh J. Chapter 8: the elderly patient. In: John Murtagh's gen-eral practice. 6th ed. North Ryde: Mc Graw-Hill Australia Pty Ltd; 2015. p. 49-64. 16 Geriatrics | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
457 © Springer Nature Switzerland AG 2019 M. H. Sherazi, E. Dixon (eds. ), The Objective Structured Clinical Examination Review, https://doi. org/10. 1007/978-3-319-95444-8Index A Abdomen, 245, 247 Abdominal girth, 202-203 Abdominal pain first trimester vaginal bleeding, 344 management abdominal examination, 260, 261 allergic history, 260 candidate information, 259 differentials, 259 family history, 260 IV line and draw bloods, 261 interview, starting, 259 management, 261 medication history, 260 opening, 260 past hospitalization and surgical history, 260 past medical history, 260 physical examination, 260 present illness, history of, 260 rule out differentials, questions to, 260 social history, 260 Abdominal wall hernias, 186 Abdominopelvic quadrants, 182 Abduction, 18 Abductor digiti minimi, 19 Abductor pollicis longus, 20 Abnormal vaginal bleeding, 222, 326 Accessory nerve, 42 Accommodation reflex, 37 Acetaminophen (paracetamol) intoxication ABCD survey, 423 clinical features, 425 clinical presentation, 422 decontamination, 426 ingestion flowchart, 425 ongoing care and monitoring, 426 overdosage management, 425 patient history, 424 physical examination, 425-426 psychiatric symptoms screening, 424 risk factors, 425 SAD PERSONS scale score, 424 sucidal history, 423-424 treatment, 426 Acromioclavicular joint osteoarthritis, 292 Active abduction, 294 Activities of daily living (ADLs), 9, 62 Acute diverticulitis, 11 Acute post-traumatic ankle pain, 317 Acute retroviral syndrome, 146 Adductor of hip, 27Adhesive capsulitis, 291, 293 Advance Trauma Life Support (ATLS), 245 Airway, breathing and circulation (ABCD), 119, 124 Alcohol intoxication, 65-66 Amenorrhea primary adolescents, 329 allergic history, 329 candidate information, 328 causes of, 328 differential diagnosis, 328 family history, 329 interview, starting, 328 laboratory test, 330, 331 medication history, 329 opening, 328 past hospitalization, 329 past medical history, 329 presenting complaint, 328 presenting illness, history, 328, 329 self-care and living condition, 329 social history, 329 support, 329 surgical history, 329 treatment, 331 wrap-up, 329, 330 secondary allergic history, 332 Asherman syndrome after miscarriage, 332 candidate information, 331, 332, 334 differentials, 331 family history, 332 interview, starting, 331 management, 332, 333 medication history, 332 opening, 331 past hospitalization, 332 past medical history, 332 polycystic ovarian syndrome, 333 presenting complaint, 331 presenting illness, history of, 331, 332 self-care and living condition, 332 social history, 332 support, 332 surgical history, 332 Anaphylaxis, 366-367 Anemia, 371-373 clinical presentation, 414 differential diagnosis, 414-415 patient history, 415-416 physical examination, 416 treatment of, 416 | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
458 Ankle, 27 acute post-traumatic ankle pain, 317 chronic pain, 318 differential diagnosis, 316 examination, 319 neurovascular assessment, 320 range of motion, 320 tests, 320 Ankle clonus, 29 Ankle edema, 117 Ankle jerk, 29 Ankle jerk reflex, 407 Ankle jerk test, 29 Ankle sprain assessment, 321 differential diagnoses, 320 first-and second-degree, 322 inspection, 321 neurovascular assessment, 322 palpation, 321 range of motion, 322 severity, 322 tests, 322 third-degree, 322 Ankylosing spondylitis, 288 Anorexia nervosa, 97 Antenatal counseling allergic history, 342 candidate information, 341, 342 checkups, 342 family history, 342 gynecology history, 342 interview, starting, 341 medication history, 342 obstetrics history, 342 opening, 341 past hospitalization, 342 past medical history, 342 pregnancy plan, 342 pregnancy, cause, 342 social history, 342 surgical history, 342 take sexual history, 342 traveling, 343 visits, 342, 343 wrap-up, 343 Anterior apprehension test, 297, 298 Anterior draw test, 315, 316, 320, 321 Anterolateral infarction, 121 Antiepileptic drugs (AEDs), 55 Antiretroviral therapy (ART), 214 Antithyroid drugs, 400 Anxiety, 71, 74 delirium, 103 dementia, 101 drug seeker, 98 history and counseling, 81-82 mania, 78 psychosis/schizophrenia, 93 suicide, 100 Apley grinding test, 316, 318 Appendicectomy, 253 Appendicitis abdominal examination, 251 allergic history, 251 appendix, 252candidate information, 250 causes, 252 differential diagnosis, 250 family history, 251 gynecology history, 251 interview, starting, 250 medication history, 251 opening, 251 past hospitalization and surgical history, 251 past medical history, 251 present illness, history of, 251 problem, 252 sexually active, 251 social history, 251 test, 252 travel history, 251 treatment, 253 vital signs, 250 Appendix, 252 Aricept, 102 Arm tone, 17 Arousal, 72 Arterial pulse, 276 Asherman syndrome, 332 Asthma action plans, 164 associated symptoms, 162 clinical investigations, 163 closed-mouth technique, 165 definition, 163 diagnosis, 163 differential diagnosis, 161 family and friend support, 163 follow-up, 166 functional status, 163 history of, 162-163 management, 163 medical treatment, 165 patient interview, 161 precipitating/aggravating factors, 162 puffer (MDI)/inhalers, 165 relationships, 163 self-care and living condition, 163 shortness of breath, 161 signs and symptoms, 165 spacer device, 165 Asymmetrical oligoarthritis, 273 Atypical pneumonia, 146, 150 associated symptoms, 152 causes, 153 clinical investigations, 153 common pathogens, 153 complications, 154 diagnosis, 153 differential diagnosis, 151 family and friend support, 153 follow up, 154 history of present illness, 152 outpatient treatment, 154 patient history, 153 patient instructions, 154 physical findings, 153 precipitating/aggravating factors, 152 prevention, 154 relieving factors, 153 risk factors, 152 Index | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
459 self-care and living condition, 153 treatment at home, 154 Auscultation, 115, 251 Australian Medical Council Clinical Examination, 1 B Bacterial meningitis, 53 Basal cell carcinoma (BCC) alar base and cheek, 437 biopsy, 437 causes of, 437 characteristics of, 437 follow-up, 438 on proximal helix, 437 skin cancer, 437 skin examination, 437 treatment of, 438 types, 438 Basic Life Support (BLS), 245 B-blockers, 401 BCC, see Basal cell carcinoma Bell's palsy, 46 antiviral agents, 47 candidate information, 45 cause of, 46 clinical diagnosis, 47 cranial imaging, 47 differential, 45 eye care, 47 inspection, 46 interview, starting, 45 neurologic findings, 47 opening, 45 outcome, 47 physical therapy, 47 reference, 47 site of, 46 treatment, 47 vital signs, 45, 46 wrap-up, 46 Belly-press test, 297, 298 Benign paroxysmal positional vertigo causes of, 58 examination, 57 family history, 57 history and examination, 56 interview, starting, 56 medication history, 57 neuroimaging, 57 opening, 56 past history, 57 past hospitalization and surgical history, 57 pathophysiology, 58 personal/social history, 57 present illness, history of, 56, 57 referral, 58 wrap-up, 57 Benign prostatic hyperplasia (BPH), see Urinary hesitancy Benzodiazepam, 87 Benzodiazepines, 55 Biceps, 18 Biceps reflex, 20 Biceps tendinitis, 292 Big toe extension, 29 Big toe flexion, 29Bilateral cerebellar lesion, causes of, 32 Bipolar disorder, 71, 78 allergies, 80 candidate information, 78 chief complaint, 79 contract, 80 differentials, 78 follow-up appointment, 80 interview, starting, 79 mania, 80 medication history, 80 opening, 79 organic, 80 past medical history, 80 psychiatric symptoms screening, 80 safety check, 80 social history, 80 support, 80 treatment, 80 vital signs, 78 wrap-up, 80 Bleeding after menopause allergic history, 353 associated symptoms, 353 candidate information, 352 chief complaint, 353 differentials, 352, 353 family history, 354 gynecology history, 353 interview, starting, 353 investigations, 354 medication history, 353 obstetrics history, 353 opening, 353 past hospitalization, 353 past medical history, 353 physical examination, 354 social history, 353 surgical history, 353 Blood clotting, 414 Blood pressure, 128 Boas' sign, 254 Bowel obstruction, management of, 263 abdominal examination, 262, 263 allergic history, 262 candidate information, 261 counselling, 263 differential diagnosis, 261 family history, 262 interview, starting, 261 medication history, 262 opening, 261 past hospitalization and surgical history, 262 past medical history, 262 physical examination, 262 present illness, history, 262 rule out differentials, questions to, 262 social history, 262 Brain death, 206 Brainstem tumors, 59 Breakthrough bleeding, 325 Breast lump allergic history, 264 candidate information, 263 differential diagnosis, 263 family history, 264 Index | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
460 Breast lump (cont. ) fibroadenoma, 266 fibrocystic disease, 266 interview, starting, 263 mammogram, 266 medication history, 264 menstrual, gynecology, and obstetric history, 264 metastasis, signs of, 264 opening, 263 past hospitalization and surgical history, 264 past medical history, 264 physical examination, 264, 265 present illness, history of, 263, 264 risk factors, 264, 265 self-examination, 266 signs and symptoms, 265 social history, 264 treatment, 265 wrap-up, 265 Breastfeeding counseling, 343 allergic history, 340 breast vs. formula milk, 340, 341 candidate information, 339 contraception, 341 interview, starting, 340 medication history, 340 opening, 340 past hospitalization, 340 past medical history, 340 social history, 340 surgical history, 340 Bronchial breath sounds, 136 Bronchiolitis, 362 Bronchodilators, 167 Bronchovesicular breath sounds, 136 Brudzinki's sign, 52 Bulge sign, 315 Burning micturition constitutional symptoms, 238 differential diagnosis, 238 family and friend support, 239 foreign travel, 239 history of present illness, 238 patient history, 239 physical examination, 239 preventive measures, 240 relationships, 239 self-care and living condition, 239 C Caloric test, 42 Capillary refill, 276 Cardiac auscultation, 116 Cardiovascular system history and management, 111, 112 acute chest pain, 118-120 heart failure, 123-126 hypertension, 126-129 palpitation, 120, 122, 123 present illness, history of, 119, 120 physical examination candidate information, 111 capillary refill, 113 chest, 115-118 face, 113general physical examination, 112, 113 hands, 113 JVD/JVP, 114 neck, 113, 114 vital signs, 111, 112 wrap-up, 118 symptoms, 111 volume status examination, 129 Carotid bruit, 117 Carotid pulse, 117, 118 Carpal tunnel syndrome (CTS), 303, 307 Castell's sign, 184 Cauda equina syndrome, 285 Cerebellar dysarthria, 34 Cerebellar syndromes, 59 physical examination additional examination, 33, 34 bilateral cerebellar lesion, causes of, 32 candidate information, 31 clinical diagnosis, 35 diagnosis, 34 differential diagnosis, 31 Friedreich's ataxia, 32 gait, 34 interview, starting, 32 observe walking and standing, 33 opening, 32 remember, 34 unilateral cerebellar lesion, causes of, 32 vital signs, 31, 33 wrap-up, 34 Cervical discopathy, 307 Cervical myelopathy, 278 Cervical radiculopathy, 278 Cervical spine active movement, 279 checklist, 281 clinical investigation, 281 compression test, 280 differential diagnosis, 278 history of present illness, 278, 279 inspection, 279 joint palpation, 279 Lhermitte sign, 280 management, 281 neurological examination, 279 occiput-to-wall distance, 280 passive movements, 279 patient interview, 278 power assessment, 279 Spurling's sign, 280 vital signs, 278, 279 Cervical spondylosis, 278 Chemotherapy, 329, 332 Chest auscultation, 136 cardiovascular system, 115-118 expansion, 133 history and management ABCD, 119 allergic history, 120 candidate information, 118, 119 differentials, 118, 119 ECG, 120 family history, 120 medication history, 120 Index | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
461 NSTEMI/ STEMI, 120 opening, 119 past medical history, 120 risk factors, 120 social history, 120 starting the station, 119 Chest wall palpation, 114 Child abuse, 388-391 Child Swallowed A Cleaning Agent, 387-388 Cholecystitis, acute abdominal examination, 254 allergic history, 254 biliary colic and, 254 candidate information, 253 differential diagnosis, 253 family history, 254 gallbladder, function of, 254 gallstones, 254 interview, starting, 253 medication history, 253 opening, 253 past hospitalization and surgical history, 253 past medical history, 253 present illness, history of, 253 sexual history, 254 social history, 254 test, 254 travel history, 254 treatment, 255 ultrasound, 255 vital signs, 253 Chronic obstructive pulmonary disease (COPD) associated symptoms, 166 constitutional symptoms, 166 differential diagnosis, 166 exacerbation, 168 family and friend support, 167 follow up, 168 functional status, 167 history of present illness, 166 interview, 166 management, 167 medications, 167 patient history, 166 relationships, 167 relieving factors, 166 risk factors, 166 self-care and living condition, 167 Closed-Mouth Technique, 165 CN-IV palsy, 38 CN-VI palsy, 38 Codeine, 98 Collateral ligament stress test, 316, 317 Colostrum, 340 Combined oral contraceptives (COCs), 55 Common cold allergic history, 139 causes, 138 differential diagnosis, 138 family history, 139 follow-up, 140 functional status, 139-140 history of present illness, 138 medication history, 139 past hospitalization and surgical history, 139 past medical history, 139precipitating or aggravating factors, 138 self-care and living condition, 139 social history, 139 symptoms, 139 vital signs, 138 warning signs, 140 Communication, 5 Community-acquired pneumonia, 150 Compression test, 280, 281 Conjugate movements, 37 Conjugated bilirubin, 376 Consensual pupillary reflex, 37 Constipation associated symptoms, 196 causes, 197 constitutional symptoms, 196 counseling, patient, 197 definition, 197 differential diagnosis, 195 family and friends support, 196 fiber, 197 history of present illness, 196 interview, 195 management plan, 196 patient history, 196 relationships, 196 risks, 197 self-care and living condition, 196 Constitutional symptoms, 76 Contract bipolar disorder, 80 mania, 78 Conversion disorder, 89-90 Corticosteroid, 167 Costovertebral angle (CV A) tenderness, 184, 185 Cough asthma, history of, 162 checklist, 159 clinical investigations, 158 constitutional symptoms, 158 diagnosis, 158 differential diagnosis, 157 follow-up, 159 friends and family support, 158 functional status, 158 heart failure, 124 history of present illness, 157 management, 159 patient history, 158 precipitating/aggravating factors, 158 relationships, 158 relieving factors, 158 self-care and living condition, 158 work conditions and financial status, 158 Courvoisier's sign, 183 Crackles, 136 Cranial nerves accessory nerve, 42 candidate information, 35 color vision, 36 equipment, 35 facial, 39 fundoscopy, 36 glossopharyngeal nerve, 42 hypoglossal nerve, 42 inspection, 35 Index | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
462 Cranial nerves (cont. ) interview, starting, 35 jaw jerk, 39 light touch (posterior column) sensation, 38, 39 motor, 39 opening, 35 pinprick (spinothalamic) sensation, 39 testing eye movements, 37 testing pupils, 37, 38 vagus nerve, 42 vestibulocochlear nerve, 39-41 visual acuity, 35 visual field, 36 vitals, 35 wrap-up, 42 Crossed straight leg raising test, 285, 287 Cubital Tunnel syndrome, 300 Cushing's syndrome, 127 D De Quervain disease, 303 de Quervain tenosynovitis, 308 Death before survival, 205, 206 Deep tendon reflexes, 275 Deep vein thrombosis (DVT), 411 cause of death, 414 prophylaxis, 248 Delirium, 250 history anxiety, 103 blood work, 104 candidate information, 102, 104 causes, 104 chief complaint, 103 diagnosis, 104 differentials, 102, 103 follow-up, 104 interview, starting, 103 management, 104 medication history, 104 mood, 103 opening, 103 organic, 103 past medical history, 103 past psychiatric history, 104 present illness, history of, 103 psychosis, 103 social history, 104 support, 104 Deltoid, 17 Dementia, 100-102 Depression, 70, 208 anxiety, 81 checklist, 76 generalized anxiety disorder, 86 history and counseling allergic history, 75 anxiety, 74, 75 body language and clues, 74 candidate information, 73 differentials, 73 family history, 75 interview, starting, 73 investigations, 75 management, 75 mania, 74medication history, 75 opening, 74 organic causes, 74 past hospitalization and surgical history, 75 past medical, 75 present illness, history of, 74 presentations of, 75 psychiatric symptoms screening, 74 psychosis, 74 relationships, 75 self-care and living condition, 75 social history, 75 starting with sleep problems, 76 support, 75 wrap-up, 75 Derealization, 105 Dermal segmentation, 22, 276 Diabetes, 248, 395 cheif complaints, 401 in children, 404 prediabetic counseling for parents, 405 insulin injection, 405 hypoglycemia symptoms, 405 hyperglycemia symptoms, 405 history, 405 diagnostic and imaging studies, 405 chief complaints, 404 clinical presentation, 401 complications of, 402 diagnostic and imaging studies of, 402 examination, 402 foot examination, 406 ankle jerk reflex, 407 equipment for, 406 foot wear, 407 inspection, 406 neurological examination, 407 palpation, 406-407 hypoglycemia (see Hypoglycemia) patient history, 401 prediabetic counseling, 402 routine checkup for cheif complaints, 403 diagnostic and imaging studies, 404 hyperglycemia, 403 hypoglycemia, 403 patient history, 404 symptoms, 401 Diabetic ketoacidosis (DKA), 402, 405 ABCD survey, 408 blood result report, 407 chest X-ray, 409 clinical presentation, 407 complications of, 409 differential diagnosis of, 407 fluid resuscitation, 409 insulin intravenous infusion, 409 patient history, 408 potassium replacement, 409 vital signs, 408 Diaphragm, 135, 136 Diarrhea, 370-371 associated symptoms, 198 constitutional symptoms, 198 definition, 199 dehydration, 198 diagnosis, 199 Index | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
463 differential diagnosis, 197 family and friends support, 199 history of present illness, 197, 199 interview, 197 management, 199 patient history, 198 physical examination, 199 relationships, 198 risk factors, 199 self-care and living condition, 198 treatment, 199 Diphtheria, 146 Direct pupillary reflex, 37 Distal interphalangeal (DIP) joints, 20 Diverticulitis, acute abdominal examination, 256 allergic history, 256 candidate information, 255 causes, 257 complications, 256 differential diagnosis, 255 diverticulosis vs., 256 family history, 256 gynecology history, 256 interview, starting, 255 management, 256, 257 medication history, 255 opening, 255 past hospitalization and surgical history, 255 past medical history, 255 physical examination, 256 present illness, history of, 255 sexually active, 256 social history, 256 surgery, 257 test, 256 travel history, 256 vital signs, 255 Dix-Hallpike maneuver, 58 Dizziness activities of daily living, 448 algorithm for (see Benign paroxysmal positional vertigo) classification, 446 clinical presentation, 446 diagnostic studies, 449 differential diagnosis, 447 instrumental activities of daily living, 448 medication associated with, 447 patient history, 447-448 physical examination, 448-449 Dorsalis pedis artery, 118 Dorsiflexion of ankle, 27, 28 Down syndrome screening test, 343 Drop arm test, 295, 296 Drug seeker anxiety, 98 candidate information, 97 chief complaint, 97 differential diagnosis, 97 follow-up, 99 interview, starting, 97 management, 99 mania, 98 medication history, 98 opening, 97 organic, 98 past medical history, 98past psychiatric history, 98 present illness, history of, 97, 98 psychiatric symptoms screening, 98 psychosis, 98 questions regarding tylenol, 98 social history, 98 support, 98 wrap-up, 98 Dysdiadochokinesia test, 23, 24, 34 Dysfunctional uterine bleeding (DUB), 326 history and counseling allergic history, 352 associated symptoms, 351 candidate information, 350 chief complaint, 351 counseling, 352 differentials, 350, 351 family history, 352 gynecology history, 351 interview, starting, 351 investigations, 352 medical treatment, 352 medication history, 351 obstetrics history, 351 opening, 351 past hospitalization, 351 past medical history, 351 sexual history, 351 social history, 352 surgical history, 352 surgical treatment, 352 wrap-up, 352 Dyspareunia, 222, 326 Dysphagia associated symptoms, 188 constitutional symptoms, 188 diagnosis, 189 differential diagnosis, 187 history of present illness, 188 interview, 188 patient history, 188, 189 relationships, 189 relieving factors, 188 self-care and living condition, 189 weight loss, 188 E Ear pain, 362-364 Easy bruising algorithm, 423 chest and abdominal examination, 422 clinical presentation, 418 differential diagnosis, 419-420 medications causes of, 420 partial thromboplastin time and prothrombin time factors, 422 patient history, 420-421 physical examination, 421-422 respiratory system, 422 Eating disorder anxiety, 96 candidate information, 94 contract, 97 differentials, 95, 96 follow-up, 97 interview, starting, 95 management plan, 97 Index | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
464 Eating disorder (cont. ) mania, 96 menstrual history, 96 opening, 95 organic, 96 physical examination, 96, 97 present illness, history of, 95, 96 psychiatric symptoms screening, 96 psychosis, 96 wrap-up, 97 Ectopic pregnancy, 344 Eczema flare-up chief clients, 438 children, 439 clinical presentation, 438 differential diagnosis, 438 patient history, 438-439 treatment of, 439-440 triggering factors for, 439 Eighth cranial nerve, 46 Elbow, 18 checklist, 303 cubital tunnel syndrome, 300 examination, 301 Golfer' elbow, 302 lateral elbow pain, 299 medial elbow, 300 neurovascular assessment, 302 osteoarthritis, 300 patient history, 300 radial tunnel syndrome, 299 range of motion, 301 tennis elbow, 302 Elder abuse activities of daily living, 452 counseling for, 452 differential diagnosis, 450 finanacial abuse, 450 instrumental activities of daily living, 452 management of, 452 neglect, 450 patient history, 450-451 physical abuse, 450 physical examination, 452 psychosocial abuse, 450 red flags, 450 risk factors, 450 safety planning checklist, 453 sexual abuse, 450 Empathy, 5, 67 Empty can and full can tests, 296, 297 Engorgement, 340 Enuresis BINDES, 384 differential diagnosis, 382 family history, 384 history of presenting illness, 383 interview, 382 medications/allergic history/triggers, 384 monosymptomatic, 382 nonmonosymptomatic, 382 parent counseling, 385 past medical and surgical history, 384 presenting complaint, 383 primary vs. secondary, 382 social history, 384 systems review, 384Enzyme immunoassays (EIA), 212 Epigastric pain clinical investigations, 193 constitutional symptoms, 192 diagnosis, 192 differential diagnosis, 191-193 factors, 193 history of present illness, 192 interview, 191 management, 193 abdominal examination, 258 allergic history, 258 candidate information, 257 diagnosis, 259 differentials, 257 family history, 258 interview, starting, 257 management, 258, 259 medication history, 258 opening, 257 order, 258 pancreas, 259 past hospitalization and surgical history, 258 past medical history, 258 present illness, history of, 257 rule out differentials, questions, 257 social history, 258 X-ray, 258 patient history, 192 physical examination, 193 relationships, 192 self-care and living condition, 192 urea breath test, 193 work conditions and financial status, 192 Epilepsy, 55, 326 Epi Pen, 366-367 Erectile dysfunction (ED) anxiety screening, 236 definition, 237 differential diagnosis, 235 history of present illness, 236 mood screening, 236 patient counseling, 237 patient history, 236 physical examination, 237 relationships, 237 treatment options, 237 Ethics brain death, 206 confidentiality, 208-209 death before survival, 205, 206 decision-making, 209-210 forgo treatment, 207, 208 Marijuana, son's bag, 215-217 medical errorwrong blood transfusion, 214-215 organ donation, 206, 207 pharmacist refusal, 210 positive HIV test, 213, 214 pre-HIV test, 211, 212 surrogate decision-maker, 210 truth telling, 211 Eversion stress test, 320, 321 Exercise, 343 Extensor carpi radialis longus, 19 Extensor carpi ulnaris, 19 Extensor digitorum, 19 Extensor hallucis longus, 28 Index | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
465 External genitalia, 226 External rotation resistance test, 296, 297 External rotation test, 320 Eye movements, 37, 41 F Faber test, 285, 288 Face lesion basal cell carcinoma (see Basal cell carcinoma) chief complaint, 436 clinical presentation, 435 differential diagnosis, 435 patient history, 436 physical examination, 436-437 Facial nerve, 39 Failure to thrive (FTT) BINDES, 378 case management, 378 differential diagnosis, 377 family history, 378 history of presenting illness, 378 interview, 377 medications/allergic history/triggers, 378 past medical and surgical history, 378 presenting complaint, 378 social history, 378 systems review, 378 Falls activities of daily living, 445 clinical presentation, 443 diagnostic test, 446 differential diagnosis, 443 instrumental activities of daily living, 445 management of, 446 patient history, 444-445 physical examination, 446 Febrile conversion, 360-361 Female genital tract examination, 327 Female genitourinary system abdominal examination, 225, 226 abnormal vaginal bleeding, 222 cervix examination, 226 checklist, 227, 228 common symptoms, 219 dyspareunia, 222 external genitalia, 226 interview, 225 pelvic examination, 226 physical examination, 225 rectal examination, 227 uterus examination, 227 vaginal discharge, 222 Femoral artery pulse, 117 Fever, 358-360 Fibroadenoma, 266 Fibrocystic disease, 266 Fifth cranial nerve, 46 Finger, 19, 20 Finger abduction, 20 Finger extension, 19 Finger flexion, 20 Finger-to-nose test, 21, 23, 34 Finkelstein's test, 306, 308 First dorsal interosseous, 19 First trimester vaginal bleeding allergic history, 345candidate information, 344 chief complaint, 344, 345 differential diagnosis, 344, 345 family history, 345 incomplete abortion, counsel for, 346 interview, starting, 344 management plan, 345 medication history, 345 obstetrics history, 345 opening, 344 past hospitalization, 345 past medical history, 345 social history, 345 surgical history, 345 threatened abortion, counsel for, 345, 346 Fistula test, 42 Flexor carpi radialis, 19 Flexor digitorum superficialis, 19 Flexor hallucis longus, 28 Flip test, 285, 286 Flu and pneumonia shots, 168 Folic acid, 343 Forced expiratory time, 137 Forgo treatment, 207, 208 Frequent falls history ADLs, 64 allergic history, 64 differentials, 63 IADLs, 64 interview, starting, 63 medication history, 64 opening, 63 past hospitalization and surgical history, 64 personal history, 64 present illness, history of, 63, 64 self-care and living condition, 64 social history, 64 wrap-up, 64 physical examination, 64 Friedreich's ataxia, 32 Frozen shoulder, 291 Functional hypothalamic amenorrhea, 329, 332 Functional status, 49 Fundoscopy, 36 Fundus height, 347 G Gait, 25, 26, 34, 62, 310 Galactorrhea, 332 Gastroesophageal reflux disease, 191 Gastrointestinal (GI) system, 252 abdominal girth, 202-203 constipation, 195-197 diarrhea, 197-199 dysphagia, 187-189 epigastric pain, 191-193 history adult female, 179 allergic history, 179 chief complaint, 177 constitutional symptoms, 179 family and friends support, 179 family history, 179 history of present illness, 177 interview, 177 Index | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
466 Gastrointestinal (GI) system (cont. ) life/disability and adaptation, 179 malignancy symptoms, 179 medications history, 179 older adult, 180 past medical history, 179 relationships, 179 self-care and living condition, 179 social history, 179 teen age, 179 jaundice, 199-202 lower gastrointestinal bleeding, 193-195 physical examination abdominal examination, 181 asterixis, 180 auscultation, 181 bruits, 182 checklist, 187 chest, 180 face, 180 hands, 180 hernia examination, 185, 187 neck, 180 palpation, 182-184 percussion, 185 pulse, 180 signs and symptoms, 177 upper gastrointestinal bleeding, 189-191 General surgery abdomen, 245, 247 history and physical examination acute appendicitis, 250-253 acute cholecystitis, 253-255 acute diverticulitis, 255-257 breast lump, 263-266 candidate information, 246 postoperative fever, 248-250 preoperative visit, 245, 247, 248 history taking, 245, 246 management abdominal pain, 259-261 bowel obstruction, 261-263 epigastric pain, 257-259 candidate information, 257 Generalized anxiety disorder, 71, 86-87 Genital ulcers, 222, 326 Genitourinary system associated symptoms, 221 burning micturition/UTI, 238-240 chief complaints, 220, 221 constitutional symptoms, 221 erectile dysfunction, 235-237 family and friends support, 223 in female vaginal discharge, 222 psychosexual history, 224 physical examination, 224-227 obstetric history, 224 menstrual history, 224 dyspareunia, 222 common symptoms, 219 abnormal vaginal bleeding, 222 foreign travel, 223 hematuria, 232-235 history of present illness, 221 increase frequency of urination, 240-242in male common symptoms, 219 genital ulcers, 222 infertility, 222 physical examination, 227-229 testicular pain, 222 urethral discharge, 222 older adults, 224 overview, 220 patient history, 223 patient interview, 220 relationships, 223 renal, 221 self-care and living condition, 223 urinary hesitancy, 229-231 uterovaginal prolapse and urinary incontinence, 242-244 Geriatrics abuse (see Elder abuse) dizziness (see Dizziness) falls (see Falls) overview of, 444 symptoms, 443 syncope (see Syncope) Gestational diabetes, 326 Glabellar tap, 62 Glandular fever associated Symptoms, 141 differential diagnosis, 140 functional status, 141-142 history of present illness, 140 patient history, 141 precipitating or aggravating factors, 141 self-care and living condition, 141 Glasgow coma score, 60 Glenohumeral osteoarthritis, 292 Glossopharyngeal nerve, 42 Gluteus maximus, 27 Gluteus medius, 27 Gluteus minimus, 27 Golfer' elbow, 302 Gonococcal pharyngitis, 145 Granulomas, 173 Group A Beta Hemolytic Strep (GABHS), 144, 145 Gynecology checklist antenatal counseling, 341-343 breastfeeding counseling, 339-341 HRT counseling, 338, 339 OCP counseling, 337, 338 history, 323 abnormal vaginal bleeding, 326 allergic history, 327 bleeding after menopause, 352-354 chief complaint, 323 current pregnancy, 325 dysfunctional uterine bleeding, 350-352 dyspareunia, 326 family history, 327 first trimester vaginal bleeding, 344-346 genital ulcers, 326 history taking, 323, 324 interview, starting, 323 medication history, 326 menstrual, 325, 326 opening, 323 past hospitalization, 326 Index | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
467 past medical history, 326 present illness, history of, 324, 325 primary amenorrhea, 328-331 problems and treatments, 326 secondary amenorrhea, 331-334 self-care and living condition, 327 sexual history, 326 65 years old, 327 social history, 327 support, 327 surgical history, 327 teenager, 327 third trimester vaginal bleeding, 346, 347, 350 vaginal discharge, 334-337 wrap-up, 327 objective structured clinical examination, 323 physical examination, 327 H Hallpike's maneuver, 42 Hallucination, 105 Haloperidol, 93 Hawkins test, 294 Headache, 48-50 Heart failure, 126 history and physical examination, 125 ABCD, 124 abdomen, 126 acute onset, 124 allergic history, 125 associated symptoms, 124 candidate information, 123 cardiovascular examination, 125 causes of, 123 constitutional symptoms, 125 cough, 124 differentials, 123 family history, 125 general physical examination, 125 gradual onset, 124 hospitalization history, 125 interview, starting, 123 investigations, 126 life/disability and adaptation, 125 medication history, 125 past medical history, 125 precipitating/aggravating factors, 125 present illness, history of, 124 relationships, 125 relieving factors, 125 respiratory system, 126 risk factors, 125 self-care and living condition, 125 social history, 125 support, 125 triage immediately, 123 wrap-up, 126 Heart sound auscultation, 115, 116 in supine position, 117 in upright position, 116 Heaves, 115 Heel-to-shin test, 31, 32, 34 Hematology pattern of history, 411, 412 physical examination checklist, 411, 413Hematuria clinical investigations, 234 constitutional symptoms, 234 diagnosis, 234 etiology, 232 family and friend support, 234 foreign travel, 234 history of present illness, 233 key related symptoms, 232, 233 management plan, 235 painless/painful hematuria, 232, 233 patient history, 234 physical examination, 234 relationships, 234 self-care and living condition, 234 Hemoptysis associated symptoms, 160 clinical investigations, 161 differential diagnosis, 159 family and friend support, 161 functional status, 161 history of present illness, 160 management, 161 patient history, 160, 161 relationships, 161 risk factors, 160 self-care and living condition, 161 Hemothorax, 170-171 Hepatitis, 200 Hepatitis B prophylaxis, 418 Hepatitis C prophylaxis, 418 Hepatojugular reflex, 114 Hip, 26 causes, 309 checklist, 312 diagnosis, 312 differential diagnosis, 309 examination, 310 history, 309-310 leg length discrepancy, 310 management, 312 neurovascular assessment, 311 pulse, 311 reflexes, 311 straight leg, 311 thomas test, 311 Hip adduction, 28 Hip extension, 27 Hip flexion, 27 Hormone excess, 329, 332 Hormone replacement therapy (HRT), 338-339 Hospital-acquired pneumonia, 150 Human immunodeficiency virus (HIV), 154-157, 214 See also Needle stick injury Hyperbilirubinemia, 375 Hyperglycemia, 403, 405 Hypertension, 248 history and physical examination abdominal examination, 127 allergic history, 127 blood pressure values, 128 candidate information, 126 cardiovascular examination, 127 chief complaint, 126, 127 counsel patient, 128 family history, 127 Index | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
468 Hypertension (cont. ) general physical examination, 127 hospitalization history, 127 interview, starting, 126 life/disability and adaptation, 127 medication history, 127 neurology examination, 128 opening, 126 past medical history, 127 respiratory system, 127 risk factors, 127, 128 self-care and living condition, 127 social history, 127 support, 127 symptoms, 127 tests, 128 treatment, 128 various conditions, 128 wrap-up, 128 Hyperthyroidism, 127 associated symptoms, 398 cheif complaints, 398 clinical presentation, 397 constitutional symptoms, 398 diagnositic and imaging studies of, 400 differential diagnosis, 398 examination, 399-400 patient history, 398-399 treatment for, 400-401 Hypoglossal nerve, 34, 42 Hypoglycemia, 403 Hypothyroidism, 127, 307, 326 associated symptoms, 395-396 cheif complaints, 395 complications of, 397 diagnostic test, 397 differential diagnosis, 395 examination auscultate, 397 cardiovascular, 397 fundoscopic, 400 neck, 396 neck lymph nodes and trachea, 397 nervous, 397 palpation, 396 percuss, 397 physical, 396 pretibial edema, 397 respiratory system, 397 patient history, 396 risk of, 396 Hypotonia, 34 I Iliopsoas, 26 Illusion, 105 Imperforate hymen, 329 Impingement syndrome, 290, 293 Incidental solitary lung nodule, 171 Infectious granulomas, 173 Infertility, 222 Influenza associated symptoms, 143 differential diagnosis, 142 functional status, 143-144 history of present illness, 143patient history, 143 precipitating or aggravating factors, 143 Instrumental activities of daily living (IADLs), 9 Intention tremors, 34 Intermenstrual bleeding, 325 Inversion stress test, 320, 321 Iron deficiency anemia, 373 J Jaundice associated symptoms, 200 BINDES, 377 causes, 377 checklist, 201 clinical investigations, 201 constitutional symptoms, 200 differential diagnosis, 199, 201, 375 failure to thrive, 377-379 family history, 377 follow up, 201 history of present illness, 200, 376 maternal/obstetric history, 376 medications/allergic history/triggers, 376 newborn history, 376 past medical and surgical history, 376 patient history, 200 patient interview, 199, 376 patient/parents counseling, 377 physical examination, 201 presenting complaint, 376 relationships, 200 self-care and living condition, 200 signs, 375 Jobe supraspinatus test, 296 Jugular vein distention (JVD), 114 Jugular venous pressure (JVP), 114, 129 K Kernig's sign, 52 Kidney palpation, 185 Kienbock disease, 303 Kleiger test, 320 Knee, 27 checklist, 316 diagnosis, 312 differential diagnosis, 313 effusion, 315 examination, 314-315 history, 313-314 neurovascular assessment, 315 range of motion, 315 tenderness, 315 tests, 315 Knee extension, 28 Knee flexion, 28 Knee jerk test, 29 Kussmaul sign, 114 L Lachman test, 315 Lamotrigine, 55 Lasègue's sign, 285 Lateral elbow pain, 299 Latissimus dorsi, 17 Index | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
469 Leopold maneuvers, 347, 348 Leriche syndrome, 235 Lhermitte sign, 280 Lift-off test, 296, 297 Light touch sensation, 21, 22, 30, 38, 39 Limping child BINDES, 392 case management, 392 differential diagnosis, 391 family history, 392 history of presenting illness, 391 interview, 391 medications/allergic history/triggers, 392 past medical and surgical history, 391 presenting complaint, 391 social history, 392 systems review, 391 Liver disease, 201 Liver palpation, 183 Liver percussion, 184 Lobar pneumonia, 150 Low back pain, 288 See also Lumbar spine Lower gastrointestinal bleeding, 193-195 Lower limbs candidate information, 24 checklist, 31, 33 coordination, 31 equipment, 24 exposure, 25 gait, 25, 26 general, 25 inspection, 26 interview, starting, 24 light touch (posterior column) sensation, 30 opening, 24 pinprick (spinothalamic) sensation, 30 position sense, 30 power, 26, 27, 29 sensation, 30 tone, 26 vibration sensation, 30 vital signs, 24 wrap-up, 31 Lumbar spine age, 282 aggravating factors, 283 associated symptoms, 283 cauda equina syndrome, 285 checklist, 286 differential diagnoses, 282 duration, 282 inspection and palpation, 284, 285 location, 282 neurovascular assessment, 285 onset of pain, 282 patient history, 284 patient interview, 282 radiation, 282 red flags, 283 relieving factors, 283 sciatica, 282 severity, 282 timings, 283 vital signs, 282 Lung cancer associated symptoms, 174clinical investigations, 175 diagnosis, 175 differential diagnosis, 174 follow-up, 176 friends and family support, 175 history of present illness, 174 patient history, 175 patient interview, 174 relationships, 175 risk factors, 175 self-care and living condition, 175 staging workup, 175 Lung nodule associated symptoms, 172 benign lesions, 173 constitutional symptoms, 172 definition, 173 differential diagnosis, 171 family and friend support, 173 features, benign lesions, 173 follow-up, 173, 174 history of present illness, 172 malignant, 173 malignant lesion, 173 patient history, 172 patient, interview, 172 physical examination, 173 relationships, 173 risk factors, 172 self-care and living conditions, 173 work conditions and financial status, 173 M Male genitourinary system abdominal examination, 229 benign prostatic hypertrophy, 222 common symptoms, 219 genital ulcers, 222 infertility, 222 neurological examination, 229 pelvic examination, 229 prostate cancer, 222 testicular Pain, 222 urethral discharge, 222 Mammogram, 266 Mania, 70, 74 anxiety, 81 bipolar disorder, 80 checklist, 78, 79 drug seeker, 98 eating disorder, 96 generalized anxiety disorder, 86 history, 77-78 screening, 71 suicide, 100 Mc Burney' point, 182, 183 Mc Murray test, 316, 317 Melanocytes, 435 Melanoma causes of, 435 development of, 435 diagnosis of, 435 nodular, 434, 435 risk factors, 434 superficial spreading, 434 treatment of, 435 Index | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
470 Ménière's disease, 58 Meningitis allergic history, 51 associated symptoms, 51 candidate information, 50 causes, 53 contraindications, 52 differentials, 50 environmental risk factors, 51 examination, 51 family history, 51 functional status, 51 interview, starting, 51 management, 52 medication history, 51 opening, 51 past hospitalization and surgical history, 51 past medical history, 51 precipitating/aggravating factors, 51 present illness, history of, 51 relationships, 51 risk factors, 51 self-care and living condition, 51 social history, 51 symptoms, 53 systems review, 51 vaccine, 53 vital signs, 50-52 wrap-up, 52 Menometrorrhagia, 325 Menorrhagia, 325 Mental status examination (MSE), 104-106 Mesenteric infarction, see Abdominal pain Metastatic tumor lesions, 292 Metered dose inhalers (MDIs), 165 Methimazole, 400 Migraine, see Headache Mini-mental status examination (MMSE), 106-107 Modified SAD PERSONS scale, 99, 100, 102 Mole associated symptoms, 434 clinical presentation, 433 differential diagnosis, 433 melanoma (see Melanoma) patient history, 433-434 physical examination, 434-435 Monoarthritis, 273 Monosymptomatic enuresis, 382 Mood, 70 delirium, 103 dementia, 101 Motor nerve, 42 Murmurs, 116 Murphy's sign, 183, 252, 254 Muscle tone, 17 Musculoskeletal system ankle, 320-322 ankylosing spondylitis, 288 cervical spine, 278-281 checklist, 277 elbow, 299-303 hip pain, 308-312 history, taking details of adult female, 274 allergy, 274 chief complaint, 271constitutional symptoms, 273 family and friend support, 274 functional status, 274 inflammatory, 273 life, disability, and adaptation, 273 mechanical, 273 medication, 274 noninflammatory, 273 older adults, 274 pain, 271 past hospitalization and surgical, 274 past medical, 274 patient interview, 271 pattern of joint involvement, 273 present illness, 271 relationships, 274 self-care and living condition, 274 seronegative, 273 seropositive, 273 social, 274 systems and extra-articular features, 273 teenage patient, 274 knee pain, 312-316 low back pain, 288 lumbar spine, 281-288 overview, 271, 272 physical examination, 274-277 shoulder pain, 290-299 wrist and hand, 303-307 Mycoplasma pneumonia, 154 Myocardial infarction (MI), 248 N National immunization program, 380, 386 Neck pain, see Cervical pain Needle stick injury clinical presentation, 416 counseling, 418 determined risk, 417 differential diagnosis, 416 laboratory studies, 418 management of, 418 patient history, 417-418 postexposure prophylaxis, 418, 419 Neer test, 294, 295 Nerve and brain disorders, 235 Nervous system, 13 history, 13, 14 for adult female, 16 allergic history, 15 benign paroxysmal positional vertigo, 56-58 chief complaint, 14 constitutional symptoms, 15 family history, 15 frequent falls, 63-65 headache, 48-50 interview, starting, 14 medication history, 15 Ménière's disease, 58 meningitis, 50-53 pain questions, asking, 15 Parkinson's disease, 61, 62 past hospitalization and surgical history, 15 past medical history, 15 present illness, history of, 14, 15 Index | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
471 relationships, 15 seizures, 53-56 self-care and living condition, 15 social history, 15 support, 15 systems review, 15 for teenager, 15 vestibular neuronitis, 58 wrap-up, 16 physical examination, 16 Bell's palsy, 45-47 cerebellar syndromes, 31-35 checklist, 24 cranial nerves, 35-39, 41, 42 equipment, 16 exposure, 16 general, 16 grading power, 17, 20, 21 inspection, 16 interview, starting, 16 lower limbs, 24-27, 29-31 opening, 16 power, 17 pronator drift, 17 stroke/transient ischemic attack, 42-45 tone, 17 vitals, 16 wrap-up, 24 symptoms, 13 unresponsive patient, 59, 60 Neurovascular assessment, 275 Nixon's sign, 184 Nonmonosymptomatic enuresis, 382 Nystagmus, 34 O Objective structured clinical examination (OSCE), 1, 131 advantages, 1 books and course, 2 candidate information/doorway information, 3 consists of, 1 day of examination, 2, 3 document writing admission orders, 11, 12 candidate information, 10 scenario, starting, 10, 11 exam security, 3 fail, 11 good interview, conduct, 5, 6 history taking, details of, 4 activities, 9 ADLs, 9 alcohol, 9 allergic history, 7 birth history, 7, 8 character, 6 constitutional symptoms, 7 course, 6 development history, 8 diet, 9 drugs, 9 duration, 6 education, 9 employment, 9 environment, 8events associated, 6 family history, 7 foreign travel, 7 frequency, 6 home, 8 IADLs, 9 immunization, 8 medication history, 7 nutrition, 8 onset, 6 past psychiatry history, 7 personal history, 7 precipitating factors/aggravating factors, 6 quick recap, 6 relationships, 7 relevant associated symptoms, 6 relieving factors, 6 risk factors, 7 rule out, 6 self-care and living condition, 7 setting, 6 sexual activity, 9 social history, 7 suicide, 9 support, 7 systems review, 7 timings, 6 wrap up, 9 interview, 2, 4 navigating, 10 patient interaction, 4 patient rapport, building, 5 physical examination, tips for, 9, 10 plan, making, 3 preparation, 2 quick checklist, 3 registration and orientation, 3 stations, 2 study plan, 2 Obsessive compulsive disorder, 71, 82-84 Obstetrics checklist antenatal counseling, 341-343 breastfeeding counseling, 339-341 HRT counseling, 338, 339 OCP counseling, 337, 338 history, 323 abnormal vaginal bleeding, 326 allergic history, 327 bleeding after menopause, 352-354 chief complaint, 323 current pregnancy, 325 dysfunctional uterine bleeding, 350-352 dyspareunia, 326 family history, 327 first trimester vaginal bleeding, 344-346 genital ulcers, 326 history taking, 323, 324 interview, starting, 323 medication history, 326 opening, 323 past hospitalization, 326 past medical history, 326 pregnant patient, symptoms to ask, 325 present illness, history of, 324, 325 previous history, 325 Index | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
472 Obstetrics (cont. ) primary amenorrhea, 328-331 secondary amenorrhea, 331-334 self-care and living condition, 327 sexual history, 326 social history, 327 support, 327 surgical history, 327 teenager, 327 third trimester vaginal bleeding, 346, 347, 350 vaginal discharge, 334-337 wrap-up, 327 objective structured clinical examination, symptoms for, 323 physical examination, 327 Obturator's sign, 183, 184, 252 Oculomotor nerve, 36 Olfactory nerve, 35 Oligomenorrhea, 325 Optic nerve, 35 Oral contraceptive pill (OCP) counseling, 337-338 Organic disease, 72, 74 anxiety, 81 bipolar disorder, 80 conversion disorder, 90 delirium, 103 dementia, 101 drug seeker, 98 eating disorder, 96 generalized anxiety disorder, 86 post-traumatic stress disorder, 88 psychosis/schizophrenia, 93 somatization disorder, 91 suicide, 100 Orthostatic hypotension, 446 Osteoarthritis (OA), 300, 312 Ottawa ankle rule, 320, 321 Ottawa foot rule, 320, 322 Oxygen therapy, 168 P Painful arc test, 294 Palpable heart sounds, 115 Palpation, 115, 252 Palpitation allergic history, 122 associated symptoms, 122 candidate information, 120, 122 cardiovascular examination, 123 chief complaint, 122 differentials, 120 family history, 122 general physical examination, 123 hospitalization history/emergency admission history, 122 interview, starting, 122 life/disability and adaptation, 123 medication history, 122 neurology examination, 123 opening, 122 past medical history, 122 physical examination, 123 presenting illness, history of, 122 relationships, 122 respiratory system, 123self-care and living condition, 123 social history, 122 support, 123 Pancreas, 259 Pancreatitis, chronic, see Epigastric pain Panic disorder, 71, 84-86 Paracetamol, 250 Paraneoplastic syndrome, 175 Parkinson's disease gait problems in, 63 history and physical examination, 62 ADLs, 62 allergic history, 61 associated symptoms, 61 candidate information, 61 differential, 61 family history, 61 general appearance, 62 IADLs, 62 inspection, 62 interview, starting, 61 medication history, 61 opening, 61 past hospitalization and surgical history, 61 personal history, 61 present illness, history of, 61 relationships, 61 self-care and living condition, 61 social history, 61 speech, 62 support, 61 vital signs, 61 vitals, 62 wrap-up, 62 Partial thromboplastin time (PTT), 422 Patellar Ballottement test, 315 Pectoralis major, sternal head of, 17 Pediatrics anaphylaxis, 366-367 anemia, 371-373 child abuse, 388-391 child swallowed A cleaning agent, 387-388 common symptoms, 355 diarrhea, 370-371 ear pain, 362-364 enuresis, 382-387 Epi Pen, 366-367 febrile conversion, 360-361 fever, 358-360 history, 355 allergies, 357 BINDES, 357 birth, 357 chief complaint, 356 development history, 358 environment, 358 family, 358 HEEADDSS, 358 immunization, 357 medications, 357 nutrition, 357 past medical and surgical, 357 presenting illness, 356 review of systems, 356 school performance, 358 social, 358 Index | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
473 jaundice, 375-377 limbing child, 391-392 overview, 356 rash, 364-366 respiratory tract infection, 361-362 short stature, 373-375 vaccinations, 379-380 vomiting, 367-370 Pelvic abscess, 250 Pendular knee jerk, 34 Peptic ulcer disease, 190, 191 Perforated peptic ulcer, see Epigastric pain Peripheral bruit, 116 Peripheral edema, 116 Peripheral pulses, 117 Peroneus longus, 28 Peyronie's disease, 235 Phalen test, 306, 308 Pheochromocytoma, 127 Phobic disorder, 71 Pinprick (spinothalamic) sensation, 21, 30, 39 Pinprick sensation, 22, 30 Pituitary tumor, 329, 332 Placenta abruption, 350 Placenta previa, 347, 349, 350 Plantar response, 29 Plantarflexion of ankle, 27 Pleural rub, 136 Pneumonia antibiotics, 151 associated symptoms, 149 atypical, 151-154 causes, 151 diagnosis, 150 differential diagnosis, 149 duration of therapy, 151 family support, 150 follow up, 151 history of present illness, 149 patient history, 149-150 physical findings, 150 precipitating/aggravating factors, 149 prevention, 151 relieving factor, 149 risk factors, 149 self-care and living condition, 150 treatment at home, 151 treatment at hospital, 151 Pneumothorax, 168-170 Polycystic ovarian syndrome (PCOS), 333 Polymenorrhea, 325 Popliteal artery pulse, 117 Position sense, 21, 30 Positive Trendelenburg's sign, 310 Posterior drawer test, 315, 316 Posterior sag sign, 315 Posterior tibial artery, 117 Postexposure prophylaxis (PEP), 419 Postmenopausal bleeding, 326 Postoperative fever allergic history, 249 before surgery, 250 candidate information, 248, 250 delirium, 250 diagnoses, 249-250 Post-traumatic stress disorder, 87-89Preoperative visit allergic history, 248 candidate information, 245 family history, 248 follow-up, 248 general appearance, 248 interview, starting, 245 investigations, 248 medication history, 248 opening, 245 past hospitalization and surgical history, 247 past medical history, 247 physical examination, 248 preoperative assessment, 245 self-care and living condition, 248 social history, 248 surgery, questions, 246 wrap-up, 248 Prescription drug use, 329, 332 Previous preeclampsia, 326 Profundus, 19 Progesterone-only contraceptives, 55 Pronator drift, 17, 18, 57 Pronator syndrome, 303, 306 Propylthiouracil (PTU), 400 Prostate cancer, 222 Prostate gland, 231 Prothrombin time (PT), 422 Proton-pump inhibitors (PPIs), 193 Pseudoseizure, 56 Psoas sign, 183, 252, 254 Psoriasis, checklist for, 440 Psychiatry, 67 depression, checklist, 76 history and counseling, 67-69 anxiety, 81, 82 bipolar disorder, 78-80 chief complaint, 69 conversion disorder, 89, 90 course, 69 delirium, 102-104 dementia, 100-102 depression, 73-76 drug seeker, 97-99 eating disorder, 94-97 duration, 69 empathy, 67 events associated, 69 generalized anxiety disorder, 86, 87 interview, starting, 69 mania, 77, 78 obsessive compulsive disorder, 82-84 onset, 69 opening, 69 panic disorder, 84-86 post-traumatic stress disorder, 87-89 precipitating factors/aggravating factors, 70 psychosis/schizophrenia, 92-94 relevant associated symptoms, 70 relieving factors, 70 risk of, 104 rule out, 70 setting, 69 somatization disorder, 90-92 stress, 69 suicide, 99, 100 Index | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
474 Psychiatry (cont. ) support, 67 timings, 69 validation, 67, 69 MMSE, 106, 107 MSE, 104-106 symptoms screening adult female, 73 allergic history, 73 anxiety, 71 arousal, 72 associated events, 71 avoidance, 72 constitutional symptoms, 72 course, 70 developmental history, 73 duration, 70 family history, 73 mania, 70 medication history, 73 mood, 70 onset, 70 organic, 72 past hospitalization and surgical history, 73 past medical history, 72 personal history, 73 re-experience, 72 relationships, 73 review of, 72 safety check, 72 self-care and living condition, 73 show empathy, 72 social history, 73 support, 73 teenager, 73 traumatic event, 71 unable to function, 72 wrap-up, 73 Psychosis, 72, 74 anxiety, 81 delirium, 103 dementia, 101 drug seeker, 98 eating disorder, 96 generalized anxiety disorder, 86 mania, 78 suicide, 100 Psychosis/schizophrenia anxiety screening, 93 body language and clues, 92 candidate information, 92 checklist, 94, 95 chief complaint, 94 differential diagnosis, 92, 94 disorganized behavior, 93 disorganized speech, 93 interview, starting, 92 investigations, 94 management, 93 medical treatment, 93 medication history, 93 mood screening, 93 negative symptoms, 93 opening, 92 organic, 93past medical history, 93 past psychiatric history, 93 present illness, history of, 92 social history, 93 support, 93 wrap-up, 93 Puberty, 329, 332 Pulmonary embolism (PE), 411, 414 Pursuit movements, 37 Pyloric stenosis, 369 Q Quadriceps, 27 R Radial artery, 118 Radial pulse, 117, 118 Radial tunnel syndrome, 299 Radiation, 329, 332 Radioactive iodine, 401 Rash, pediatrics, 364-366 Rebound phenomenon, 34 Rebound tenderness, 182, 252, 254 Reflexes, 20, 21, 29, 275 Relocation test, 297, 298 Renal symptoms, 127 Respiratory system asthma, 161-166 atypical pneumonia, 151-154 COPD, 166-168 cough for 4 weeks, 157-159 heart failure, 126 hemoptysis, 159-161 hemothorax, 170-171 history, 131 HIV, 154-157 hypertension, 127 lung cancer, 174-176 lung nodule, 171-174 physical examination checklist, 137 chest, 133 chest auscultation, 136 chest expansion, 133 diaphragm, 135, 136 face, 133 forced expiratory time, 137 hands, 133 neck, 133 palpation, 133 tactile fremitus, 134 vital signs, 131, 132 vocal fremitus, 137 pneumonia, 148-151 pneumothorax, 168-170 shortness of breath, 146-148 sore throat (see Sore throat) Respiratory tract infection, 361-362 Rhonchi, 136 Rinne's test, 40, 41 Risperidone, 93 Romberg's test, 26, 33, 41, 57 Rotator cuff, 291, 292 Rovsing's sign, 182, 183, 252, 254 Index | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
475 S Saccades, 37 Saccadic pursuits, 33-34 Sacral edema, 117 Scaphoid nonunion, 303 Scarf test, 295, 296 Schober's test, 284 Sciatica, 282 Seizures history and counseling allergic history, 54 candidate information, 53 chances of children, 55 contraceptives, 55 differentials, 53 driving, 55 epilepsy, 55 family history, 54 functional status, 54 interview, starting, 53 medication history, 54 opening, 54 past medical history, 54 pregnant, 55 present illness, history of, 54 relationships, 54 risk to fetus, 55 rule out differentials, 54 social history, 54 wrap-up, 54 and pseudoseizure, 56 syncope and, 56 Sensation, 21 Sensory test, 30 Septic arthritis, 292 Seventh nerve palsy, 39 Sexually transmitted infections (STIs), 334 Short stature, 373-375 Shortness of breath acute onset, 147 associated symptoms, 147 asthma, 161 with cough, 147 differential diagnosis, 146 functional status, 148 gradual onset, 147 history of present illness, 146 patient history, 147-148 precipitating/aggravating factors, 147 self-care and living condition, 148 support, 148 work conditions and financial status, 148 Shoulder, 17 acromioclavicular joint, 295 anatomy, 290 anterior dislocation, 297 biceps, 295 checklist, 299 complete rotator cuff tear, 295 diagnosis, 298 differential diagnosis, 290 examination, 293 impingement, 294 infraspinatus and teres minor, 296 inspection, 293 instability, 291joint palpation, 293 management, 299 movements, 290, 291 neurovascular assessment, 298 patient history, 292-293 physical findings, 293 range of motion, 293 subscapularis, 296 supraspinatus, 296 Sixth nerve palsy, 46 Skin cancer, see Melanoma Skin diseases age and skin condition, 429, 431 chief complaint, 429 eczema (see Eczema flare-up) examination, 433 gender and skin condition, 429, 431 lesion (see Face lesion) moles (see Moles) patient history, 429-433 pattern of history, 429, 430 signs and symptoms, 429 Skin lesions, 429, 432 Smoking, 248 Somatization disorder, 90-92 Sore throat common cold allergic history, 139 causes, 138 differential diagnosis, 138 family history, 139 follow-up, 140 functional status, 139-140 history of present illness, 138 medication history, 139 past hospitalization and surgical history, 139 past medical history, 139 precipitating/aggravating factors, 138 self-care and living condition, 139 social history, 139 symptoms, 139 vital signs, 138 warning signs, 140 glandular fever associated symptoms, 141 differential diagnosis, 140 functional status, 141-142 history of present illness, 140 patient history, 141 precipitating factors or aggravating factors, 141 self-care and living condition, 141 influenza associated symptoms, 143 differential diagnosis, 142 functional status, 143-144 history of present illness, 143 patient history, 143 precipitating or aggravating factors, 143 Spatial ability, testing, 107 Speeds test, 296 Spinal Stenosis, 285 Spleen palpation, 184, 185 Spontaneous abortion, 344 Spurling test, 280 Spurling's sign, 280 Square wave jerks, 33 Index | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
476 Squeeze test, 320, 321 Staphylococcus aureus, 439 Status epilepticus, 60 Sternocleidomastoid muscles, 42 Straight Leg Raising (SLR), 285 Stress incontinence, 221 Stridor, 136 Stroke/transient ischemic attack, 59 allergic history, 44 associated symptoms, 44 candidate information, 42 cerebellar examination, 45 cranial nerve examination, 45 differentials, 43 family history, 44 general appearance, 44 illness, history of, 44 inspection, 45 interview, starting, 43 medication history, 44 muscle power, 45 muscle tone, 45 opening, 43 past hospitalization and surgical history, 44 personal history, 44 reflexes, 45 relationships, 44 risk factors, 44 self-care and living condition, 44 sensory, 45 social history, 44 support, 44 vital signs, 43, 44 wrap-up, 45 Subtotal thyroidectomy, 401 Suicide, 99-100 Sulcus sign test, 298, 299 Supinator reflex, 18, 21 Symmetrical large joint polyarthritis, 273 Symmetrical small joints polyarthritis, 273 Syncope, 56 activities of dialy living, 454 clinical presentation, 453 diagnostic test, 455 differential diagnosis, 453 instrumental activities of daily living, 454 medications, 453 patient history, 453-454 physical examination, 455 T Tactile fremitus, 134 Talk therapy, 78 Temporal arteritis (TA), 50 Tennis elbow, 302 Tenofovir, 418 Tensor fasciae latae, 27 Teres major, 17 Testicular pain, 222 Testing eye movements, 37 Third trimester vaginal bleeding allergic history, 347 associated symptoms, 346 candidate information, 346, 347 chief complaint, 346differentials, 346 family history, 347 interview, starting, 346 management, 347, 350 medication history, 347 obstetrics history, 346 opening, 346 past hospitalization, 347 past medical history, 347 placenta abruption, 350 placenta previa, 347, 350 possible complications, 350 risk factors, 350 social history, 347 surgical history, 347 Thomas test, 311 Thompson squeeze test, 319 Thromboembolic disease, 326 Thyroid disease, 329, 332 Thyroid function test, 397, 400 Tibialis posterior, 28 Tinel's sign, 306, 307 Tolerance, 98 Tongue, 43 Tracheal breath sounds, 136 Trapeziometacarpal joint arthrosis, 303 Trapezius, 42 Traube's space, 184 Trauma patient checklist assessment, 266 candidate information, 266 vital signs, 269 primary survey for, 266-268 secondary survey for, 266, 269 Trendelenburg sign, 310 Triceps, 18, 19 Triceps reflex, 21 Trichomonas vaginalis, 336 Trichomoniasis, 336 Trigeminal nerve, 38 Triple therapy, 193 Tumor spread disease, 175 Tylenol, 98 Type 1 diabetes, 402 U Unconjugated bilirubin, 376 Unilateral cerebellar lesion, causes of, 32 Unilateral palatal palsy, 42 Upper gastrointestinal bleeding associated symptoms, 190 case management, 191 constitutional symptoms, 190 differential diagnosis, 189 history of present illnes, 189 interview, 189 liver problems, 190 patient history, 190 work conditions and financial status, 191 Upper limbs, 16 checklist, 24 equipment, 16 exposure, 16 general physical examination, 16 grading power, 17, 20, 21 Index | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
477 inspection, 16 interview, starting, 16 opening, 16 physical examination, 25 power, 17 pronator drift, 17 tone, 17 vitals, 16 wrap-up, 24 Urea breath test, 193 Urethral discharge, 222 Urge incontinence, 221, 244 Urinary hesitancy associated symptoms, 231 clinical investigations, 232 constitutional symptoms, 231 diagnosis, 232 differential diagnosis, 230 family and friends support, 231 history of present illness, 230 initial treatment, 232 patient history, 231 relationships, 231 risk factors, 232 self-care and living condition, 231 Urinary incontinence clinical investigations, 243 differential diagnosis, 242 follow up, 244 history of present illness, 242 management plan, 244 patient counseling, 244 patient history, 243 physical examination, 243 risk factors, 243 Urinary tract infections (UTIs) constitutional symptoms, 238 differential diagnosis, 238 family and friend support, 239 foreign travel, 239 history of present illness, 238 patient history, 239 physical examination, 239 preventive measures, 240 relationships, 239 risk factor, 239 self-care and living condition, 239 treatment, 239 Urination, increase frequency of, 240-242 Uterovaginal prolapse clinical investigations, 243 differential diagnosis, 242 follow up, 244 history of present illness, 242 management plan, 244 patient counseling, 244 patient history, 243 physical examination, 243 risk factors, 243 V Vaccinations benefits vs. risks, 380 BINDES, 380 communication barriers, 379contraindications, 380 family history, 380 history of presenting illness, 379 immunization, 379 interview, 379 medications/allergic history/triggers, 380 national immunization program, 380 past medical and surgical history, 380 presenting complaint, 379 social history, 380 systems review, 379 Vaccine, 53 Vaginal bleeding, 344 Vaginal discharge, 222 allergic history, 336 candidate information, 334 causes of, 334, 335 diagnosed with trichomoniasis, 336, 337 differentials, 334 family history, 336 gynecological history, 335, 336 interview, starting, 334 investigations, 337 medication history, 336 opening, 334 past hospitalization, 336 past medical history, 336 physical examination, 336 present illness, history of, 334, 335 presenting complaint, 334 self-care and living condition, 336 social history, 336 support, 336 surgical history, 336 Vagus nerve, 42 Vesicoureteric reflux, 239 Vesicular breath sounds, 136 Vestibular neuronitis, 58 Vestibulocochlear nerve, 39 auditory testing, 40 vestibular testing, 41 Vestibulo-ocular reflex tests, 57 Vibration sensation, 21, 30 Violent patient checklist, 108 Visual field test, 36 V ocal fremitus, 137 V olume status examination, 129 V omiting, 367-370 W Walking pneumonia, see Atypical pneumonia Warfarin (Coumadin), 411 for blood clotting, 414 clinical presentation, 411 counseling, 414 factors affecting, 425-426 heparin and, 414 missed dosage, 414 patient history, 411-413 risk for stroke, 412 side effects, 412 Weber's test, 40, 41 Weight gain, 343 Wheeze action plan, 363 Wheezes, 136 Index | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |
478 Wrist and hand, 19 checklist, 308 clinical investigations, 307 diagnosis, 307 differential diagnosis, 303, 306 examination, 305 history, 304-305 management, 307 neurovascular assessment, 306 palpation, 306range of motion, 306 referral for surgery, 307 treatment, 307 Wrist extension, 19 Wrist flexion, 19 Y Yergason test, 295, 297 Index | Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf |