OSCE PRACTICE

From: NorFadhillah Mahdah

OPHTALMOLOGY

1)

Scenario: 61 y/o Chinese lady presented with painful red eye a/w blurring of vision for 1 day.

a) name 2 findings (1)b) what is your provisional diagnosis (2)c) Name 2 risk factors (2)d) name 2 other signs u would like to elicit(3)e) name 2 complication (2m)f) name 2 drugs u would give and what are they for (2)g) what is the definitive tx (1)

OPHTALMOLOGY

2)

A 35 y/o lady came with c/o red eye a/w progressively worsening blurring of vision, pain and teary eyes.

a) Describe what u see? (3m)b) What is ur dx? (1m)c) How to confirm ur dx? (1m)d) What are the predisposing factors? (3m)e) How to manage her? (3m)

OPHTALMOLOGY

3)

A 46 y/o man came with severe headache and vomiting for 1 day. This is the image seen through his fundus.

a) Describe what u see? (3m)b) What is the likely diagnosis? (1m)c) What are the aetiologies? (2m)d) How would u investigate this man? (1m)

ANAESTHESIOLOGY

1)

a) Who is this for?b)When not to use the above device? (3m)c) What are the advantages? (2m)d) What are the disadvantages? (2m)

ANAESTHESIOLOGY

2)

a) Name the above pic. (1m)b) What it is used for? (1m)c) What is the CI and why? (2m)d) How to insert? (3m)

ANAESTHESIOLOGY

3)

a) Name the above pic. (1m)b) When it is used for? (2m)c) What is the CI? (2m)d) How to insert? (3m)

ANAESTHESIOLOGY4)

a) Name the above picture. (1m)b) When to use it? (3m)c) How does it f(x)? (3m)d) What are the CX? (2m)e) What is the contraindication? (1m)

O&G1)

a) Name the above picture. (1m)b) What it is used for? (3m)c) How to position the pt in order to insert it? (1m)d) Disadvantage? (1m)

O&G2) 25 y/o pregnant lady in labour. The following is the

result of her partogram: (sorry, I could not find picture of partogram)

Cervical os:

a) What is ur diagnosis? c)How do you manage her?b) What is the likely cause? d) what we can offer her?

O&G3)

a) What is it?b) Mechanism of action?c) Advantage?d) Disadvantage?e) Failure rate?

O&G

4)

a) Name picture (right & left).b) What is the function?c) What are the indications?d) What are the prerequisites? e) What are the CX?

O&G

5)

a) What are the prerequisites?b) What are the CX?c) What are the advantages compared to Q(4)?

O&G

6)

a) Name it?b) What are the mechanism of action?c) Non-contraceptive uses?d) Advantage?e) Disadvantage?f) Failure rate?

O&G

7)

a) Name the picture.b) What is the function?c) What are the side effects?

O&G

9)

a) Name the picture.b) What are the indications?c) Complications?

O&G

10)

a) What is this?b) What are the functions?c) Uses?

O&G

11)

a) Name it?b) What it is used for?c) What are the possible complications of the

procedure in (b)?

O&G

12)

a) Diagnosis?b) Presenting diameter?c) Complications?d) Mode of delivery?

O&G

13)

a) Diagnosis?b) Presenting diameter?c) Complications?d) Mode of delivery?

O&G

16)

a) Diagnosis?b) Give 3 predisposing factors?c) Complications?d) Mode of delivery?

O&G

17)

a) Baseline heart rate?b) Variability?c) Diagnosis?d) Causes?

O&G18)

25 y/o lady with oligomenorrhoea. US of ovary.a) Provisional diagnosis?b) Name 2 other investigations to confirm dx?c) What treatment u would give for the menstrual problem?d) What complications may arise from this problem?

O&G19)

This is an imaging taken from 30 y/o, para 1 lady who wants to get pregnant since 5 years ago.

a) What imaging modality is this?b) Describe what u see?c) What is ur provisional diagnosis?d) What is the likely cause for the condition u mentioned in (b)?e) What is ur next plan for this lady?

O&G

20)

a) What is that?b) Actions?c) What are the side effects?

Question 1An 8 year old child complained PAIN during micturation- Urine bottle was given. Inspect and state AbnormalitiesColor• Cloudy- proteinuria• Bubble-frothy• Blood- smoky –Haematuria

Urine Test• Wash hands before and after• Assemble equipments- liner, record sheet, gloves, urine bottle, test strip• Check expiratory date• Wear gloves• Take test strip from bottle and close• Read time 2 minutes• Immerse test strip from bottle and wipe excess urine on edge of container• Hold strip horizantally• Wait recommended time• Compare test strip with color scale on container label• Write result in record sheet and interpret• Discard urine properly

Question 2

Anthropometry chart

• Plot growth parameter-with •-ask DOB –chronological-ask whether preterm –correct age

• Comment-microcephalyHead circumference below 2nd centile

• Causes-familial –normal development-Autosomal recessive – developmental delay- Acquired after insult and developing brain –perinatal hypoxia, hypoglycaemia, meningitis, CP,

seizures

Question 39 months old baby. Worsening on breathing. (headphones & Vclip)

• What do you see?Suprasternal recessionSubcostal recessionInspiratory stridor

• What is your diagnosis?Foreign body inhalationCroupAcute epiglottis

• ManagementMask with O2FB removalIntubation- nasotracheal tube, endotracheal tube

• Monitor?Pulse oximetry- to measure oxygen saturationIndications- heart failure, respiratory failure, monitor dring intubation procedure, post extubation, preterm babies

• ProcedurePut on finger/ thumb/ earSwitch onWait reading stabiliseTake reading and record

• Factors affect readingMovement- nervousHypothermisHypoperfusion - severe hypovolaemiaAbnormal Hb – carboxy Hb, metHbSevere cardiac failure

Question 4Mom with diarrhoeal child. Advice on ORS

• Intro and greet• Assess cause of diarrhoeaJust change breastfeed to formula milk (lactose intolerance)Boiled water? (in preparation of milk)Pacifier usage? Hygiene?

• Explain AGE to momMost are self-limitingBut can be serious if superimposed with dehydration and malnutritionCan cause diarrhoea, vomiting, ab pain, seizure/convulsionn, fever, malaise

• Assess severityHistory-Frequency of diarrhoea

Volume of stool Reduce urine output Reduce weight Fever Convulsion

Examination - Hydration status

• Advice on ORSDissolve 1 sachet in 250ml drinking water (boiled/cold water in bottle)Feed baby everytime diarrhoeaContinue breastfeed

• If baby breastfeeding but suggested to have lactose intoleranceChange to lactose free milk / semi-elemental formula

• If baby already weaning-allow semi-solid foodDrink a lot water!

• Advice mom to keep good hygiene on milk preparation

• Advice mom to monitor baby’s progression,- If show dehydration – convulsion, weak, crying, not feeding- Bring to hospital!

• Any questions mommy??

Question 5Mother brought daughter 10 month old,suspect measles? Missed immunisation scheduled at 5 months.

• Greet and introduce• Asses immunisation schedule• Ask problem- Mom says she’s afraid of her daughter nfected with measles from neighbour’s child

• Assess why missed immunisation-education level, finance, transport

• Explain the importance of immunisation-antibodies for infectious disease

• Ask the child condition-fever, rash?

• Explain to mom about injection- Can still get the injection-baby may have fever, rash – but don’t worry, only once infected, mild, no more next time

• Advice mom to bring daughter back after injection, when daughter is healthy and well to get next injection that misssed.• If daughter unwell, bring to hospital for further management• Ask mom’s understanding• Ask mom if there are any other question she wants to ask?

ECG 1

ECG

1. Describe the above ECG and the diagnosis (4m)

2. Name 2 clinical presentation of this condition (2m)

3. Give 4 causes for the above condition (2m)

4. Name 2 complication of above (2m)

Chest XR

20 year-old male with fever and haemoptysis for 3 weeks

1. Describe the abnormal findings in chest x-ray above (3m)

2. Describe the histological feature of the above slide (3m)

3. What is the possible diagnosis (1m)4. What is the name of the organism (1m)5. Give 2 other investigation to confirm diagnosis

(2m)6. Name 2 drugs that is used to treat the above

condition (2m)7. Name 2 complication of this disease (2m)

Interpret results

Appearance Cloudy

Organism -

WBC 257/mm3

RBC 2/mm3

Glucose 1.6mmol/L (plasma glucose -5.5mmol/L)

Total Protein 0.94g/L (plasma total protein -0.43g/L)

Pressure 21mmH2O

A 17y/o complains of headache. Lumbar puncture was performed.

1. What are the commonest s/e after LP was performed (1m)

2. In this CSF, is the plasma glucose ratio is of concern? (1m)

3. Summarize the CSF abnormalities (3m)4. What is the likely diagnosis? (1m)5. What immediate treatment is required? (2m)6. Name 2 complications (2m)

Revision – CSF!

http://www.osceskills.com/subjects/topics/csf%20interpretation/csfinterpretation.htm

Interpret resultspH 7.31

PaO2 90mmHg

PaCO2 32mmHg

HCO3- 18

1. Interpret the above ABG (2m)2. Name 4 causes of above condition (4m)3. Following are the renal profile

• Na – 140mmol/L• K – 4mmol/L• Cl – 102 mmol/L

4. Calculate the anion gap (2m)5. Name 2 causes for above result (2m)

p/s : aku reka jee the numbers so if xlogic sorry hehehee

History

• Puan Siti, 32y/o teacher came in with chief complaint of palpitation. Take a focus history

Q1) 34 y/o malay lady presented to A&E with complaint of high grade fever and palpitation. Vital sign shows high grade fever (T=40C), BP 103/90, HR 140bpm, RR 16bpm

a) Comment on the picture (2m)b) What is your provisional diagnosis (2m)c) Outline your management of this patient (6m)

Q2 paediatrics resuscitation

1. Name the instrument (1m)2. Indication of the instrument (2m)3. Contraindication for usage of the instrument (2m)4. Where to insert the instrument (2m)5. Complication of the procedure (3m)

24 y/o malay man was brought in to casualty by EMD after receiving a call from public saying that he was involved in motorbike vs car accident1. Comment on the xray (3m)2. What is your radiological diagnosis (1m)3. Outline your management in ED (6m)

52 y/o malay man, smoker for 20 years who presented to casualty with complaint of left sided chest tightness for 2 hours which is associated with giddiness and palpitation

1. Comment on ECG strip (2m)2. What is your diagnosis based on history and ECG strip (1m)3. What is the risk factor that you can elicit in the history, related to the

diagnosis in 2 (2m)4. Outline your management in ED for the patient

24 y/o chinese lady alleged fall from escalator and sustain pain over right lower limb and was brought to casualty by her partner

1. Comment on the above picture (3m)2. What I your provisional diagnosis (2m)3. Outline your management in ED (5m)

Question 1A. Name the procedure done (1m)B. Explain the pathophysiology of

the condition (5m)C. Complication of the condition?

(4m)

Question 2A. Interpret the changes seen in the

xray? (3m)B. Indications for surgery?C. Take consent for patient if they

have to undergone surgery.

Question 3A. Diagnosis?B. Take consent for thr.

Question 4a) Diagnosisb) Explain about what u r going to do

and advice the patient.

Question 5a) explain the diagnosis to ptnt?

***need to apply POPb) POP care to the ptnt

Question 6a) Pathophysiology ?b) Common sites?c) Sequalae?

Question 7a) What is the different of fractures

in children compare to adult

Question 8

A 60 years old obese female presented to your clinic after cannot bear the pain of the knee joint. The pain has been present since 2 years ago, gradually increase in intensity and associated with morning stiffness. Bilateral lower limb X ray was taken.

A. What other history you would like to obtain?

B. Name three differential diagnosisC. Name two abnormalities in

picture AD. What other clinical signs you

would like to elicit?E. Outline the radiological finding in

picture BF. Name two management for this

patient

Question 9Approach to an ulcer

a) Explain the abnormalities seen in the picture (4m)

b) Give one most possible causes of the abnormality and the Pathophysiology for the condition (3m)

c) Name one complication of the abnormality (1m)

d) Outline the management for this patient. (2m)

Approach to an ulcer • Basically it is divided into 3 steps. Inspection, palpation and focal examination.

Inspection 1) Size and shape 2) Number 3) Location 4) Margin (Healing, Inflammed, Fibrosed) 5) Edge (Sloping, punched, everted, undermined, everted, raised) 6) Floor (Granulation tissue, slough, discharge) 7) surrounding skins (inflammation, pigmentation, scars&puckering, hypopigmentation)

Palpation 1) Surrounding skins (Temperature, tenderness) 2) Edge of the ulcer (soft: healing ulcer, firm: non healing, hard:malignant) 3) Floor of ulcer (Consistency, underlying structure) 4) Test the fixity (skin, muscle, bone)

.

• Focal examination 1) Lymph node 2) Arteries, venous circulation, nerves 3) Movement of neighboring joint

******Grading of ulcer (especially for ulcer foot) Grade 0 — No ulcer in a high risk foot. Grade 1 — Superficial ulcer involving the full skin thickness but not underlying tissues • Grade 2 — Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation • Grade 3 — Deep ulcer with cellulitis or abscess formation, often with osteomyelitis • Grade 4 — Localized gangrene. • Grade 5 — Extensive gangrene involving the whole foot

Question 10a) Name the procedures shown in

the above picturesb) What is the indication for the

proceduresc) Name the complication of the

above procedures

Question 11a) What is the procedures done to

the patientb) What is the principles of the

proceduresc) Gives indications for the

procedured) Name the complication of the

procedures

Question 12a) Comment on the above picture

(3m)b) What is your provisional diagnosis

(2m)c) Outline your management at A&E

department (5m)

Question 1329 years old Malay man involves in MVA and brought to ED with GCS 9 (M5, E2,V2). Below is his hip x ray. Outline your management to this patient

Short case..

• c/o: 40 years old Malay lady presented with painful swelling of right ring finger. please examine her.

1) Position

the most important for hand examination is to position both hands correctly. put the hands on top of a pillow with the patient in sitting position. ask the patient to abduct the fingers as maximum as she can because from this position, we can already detect any neurological disorder related to the hands, specifically motor disorder.

• 2) Inspection (look)

inspection is divided into 2, towards the pathology (mass) itself, as well as towards the hand as a whole. 1st, compare both hands, don't take too much time doing this, just inspect surfacely because the examiner can be annoyed if korang sibuk2 nak pegang2 ke, angkat2 ke, or give excessive attention to the normal hand.

then, check for any signs of wasting or skin discoloration, or any obvious changes related to the hand.

for the mass or swelling, inspect it just like you inspect any lump and bump in surgery. do not forget to include the edge, border, size, site, character of the mass (fungating, etc), surface, and any discharge noted. for the site, describe precisely where is the origin of the mass. don't forget to check fo any associated deformity, such as nail deformity or finger deformity.

• 3) Palpation (feel)

begin with soft palpation, in order to detect any tenderness associated with the mass, xkesahlah at the mass itself or the area surrounding the mass. then, don't forget to check for circulatory status, i.e. CRT and pulse, as well as the sensation whether it is intact or not.

• 4) Movement (move)

for movement, just test for active movement first and examine the ROM. assess the ROM of all fingers of the hand, not just the affected finger, because others can be affected too. for example, ring finger share the same tendon with the little finger, so, if one is affected, the other might be affected too.

• 5) Ending

complete your examination by checking the lymph node, other features of malignancy, or any relevant examination related to your differentials.

Ya Allah! Permudahkanlah aku untuk menuntut ilmuMu, Memahaminya, Mengingati dan Menyebarkannya. Berkatilah ilmu itu dan

tambahkanlah Ia. Ameen!

Credits to: http://jacknaimsnotes.blogspot.com

Q1

A 68y/o woman is admitted to surgical ward with the result of LFT as follows:

result Normal range

T. bilirubin 99

AST 31

ALT 34

ALP 196

GGT 100

albumin 41

1. What would be observed on examining this patient? discolouration of the skin-jaundice (1m)2. What might be the patient complain of? -skin discolouration(1m)

-itchiness(1m)-pale stool & dark coloures urine(1m)

3. What specific biochemical abnormality does the patient have?obstructive jaundice (2m)

4. What investigation should be performed next?ultasound of the abdomen (1m)

5. Give 3 causes of this abnormality.-intraluminal-bile duct stone-intramural- bile duct stricture

-ampullary carcinoma -cholangiocarcinoma

-extraluminal-head of pancreas carcinoma -porta hepatis LN

6. What tumour marker might one considered measuring?CA 19-9 (associated with pancreatic carcinoma) (1m)

Q2 A 67y/o woman is admitted directly to surgical ward with

persistent vomiting and has not passed bowel motion for

4 days. An abdominal x-ray is performed:

1.What further question would you like to ask about her constipation? is it an absolute constipation? Does she pass flatus?(flatus-partial obstruction)(1m)

2. What would you expect her bowel sound to be like?tinkling bowel sound (high pitch in nature) (1m)

3. Describe the findings in AXR-dilated small bowel loops -stack of coins appearance-located in the centre of the film-valvulae conniventes seen and thickened-no gas seen in rectum/large bowel

4. What is the diagnosis?small bowel obstruction(1m)

5. Give 3 causes of this condition.intraluminal-foreign body

- ascaris lumbricoides - gallstones in the small bowel

intramural-bowel strictures-inflammatory(crohn’s) -drug induced(NSAIDS)

-tumours -lymphomas -intussusceptions

ertraluminal-adhesions -tumour(mets) -hernia

6. What are the treatment options?

-surgical laparotomy-to identify the cause and rectify the problem- relieve obstruction

-surgical stenting- to relieve obstruction(in case of tumours)

otoscopy should includes inspection of the external ear and pinna INSPECT THE EXTERNAL MEATUS --discharge,blood or pus -masses -on insertion of speculum inspect the canal -skin -discharge -swelling -wax OTOSCOPY POSITION pt should be positioned e the head flexed laterally away from the examiner the external auditory canal has a bend which normally restricts the examiner,s view the pinna of the ear to be examined is held firmly and gently pulled upwards and backwards to straighten the canal using the hand not holding the otoscope HOLDING THE INSTRUMENT otoscope is held in the same hand as the ear being examined the speculum should be as wide as possible to comforttably fit into the ear canal holding the otoscope (like a pen) horizontally provides a secure cradle for the instrument the curled fingers can rest against the cheek and the handle will not catch the shoulder (as it may if held vertically) in addition this position will help protect against accidently pushing too deeply into the outer ear TYMPANIC MEMBRANE inspect the tympanic membrane identify the normal structure any insignificant variation in normal appearance report ur findings to examiner

1. Name the syndromeRamsay Hunt syndrome

2. Name the causative organismVarizella zoster virus

3. Name the other areas where rashes can be seen in this syndromeAnterior 2/3 of tongue, soft palate, external auditory canal, and pinna

• Name the various eye care procedures which should be followed in treating the patient at the previous station

• 1. Wearing of eye glasses to prevent corneal damage

• 2. Instilling moisturizing eye drops to prevent exposure keratitis

• Name the instrument• Siegle's pneumatic aural speculum• Name it uses• 1. Examination of ear drum• 2. Testing the mobility of the ear drum• Write down its magnification factor• 2.5 times

• Examine the right ear of this patient• 1. Describe the lesion• Cotton wool like mass seen occluding the external

auditory canal. Black spots are also seen• 2. What could be the probable diagnosis ?• Otomycosis• 3. What could be the causative organisms?• Aspergillus Niger - black spots• Candida - Cotton wool like mass

• Comment on the ear drum• 1. Loss of light reflex• 2. Prominence of handle of malleus• 3. Loss of mobility of ear drum• 4. Retracted ear drum

• Name the structures numbered• 1. Round window• 2. Stapedial tendon• 3. Pyramid• 4. Long process of incus

• Write down the possible causes of bilateral retracted ear drum

• 1. Nasopharyngeal carcinoma• 2. Following adenotonsillectomy (Iatrogenic)• 3. Cleft palate

• Comment on ear discharge of this patient• What could be the possible diagnosis ?• 1. Scanty• 2. Foul smelling• 3. Blood tinged (sometimes)• 4. CSOM with attic cholesteatoma

• Name this condition seen on the ear drum• Enumerate 3 causes for it• 1. Tympanosclerosis• 2. Due to resolved otitis media• 3. Trauma• 4. Grommet insertion (Iatrogenic)

• 65 years old man• Known diabetic for 15 years on poor glycemic control• c/o pain left ear - 1 month• Blood stained discharge from left ear - 1 month• Tragal tenderness left side - 15 days• Inability to close left eye - 10 days• Otoscopic finding:• 1. What could be the possible diagnosis ?• 2. Name the probable causative organism• 3. Name the choice of antibiotic• Malignant otitis externa• Psuedomonas aeruginosa is the probable causative organism• Carbenicillin / IV generation cephalosporins

• Enumerate Levenson's criteria for malignant otitis externa

• 1. Refractory otitis externa• 2. Severe nocturnal otalgia• 3. Purulent otorrhoea• 4. Granulation tissue in external canal• 5. Growth of pseudomonas aeruginosa in specimen

cultured from external canal• 6. Presence of diabetes mellitus / other

immunocompromised states

• 5 years old child• c/o excrutiating pain in right ear - 6 hours• H/O URI - 2 days• Otoscopy showed:• Name the diagnosis• Name the various stages of this disorder• Acute otitis media• Stages of acute otitis media:• 1. Stage of hyperemia• 2. Stage of exudation• 3. Stage of suppuration• 4. Stage of resolution

• Name the surgery performed in AOM• Indication for surgery in AOM• Myringotomy• AOM which does not respond to adequate

medical managment within 48 hours

• Post surgical otoscopic finding of a patient with AOM• Name the instrument used for this surgical procedure• Name the possible surgical complications of

myringotomy• Myringotomy knife• Complications include:• 1. Dislocation of incudostapedial joint• 2. Injury to corda tympani nerve• 3. Persistent perforation

• Differential diagnosis of this lesion:• This is a red drum• Could be due to:• 1. AOM - associated with otalgia• 2. High jugular bulb - Normal variant. CT scan

shows intact jugular foramen• 3. Glomus jugulare - associated with pulsatile

tinnitus, conductive deafness, positive Brown's sign. CT scan shows eorsion of jugular foramen.

• 40 years old male patient• C/O swelling behind left ear - 7 d• Pain in left ear - 4 days• H/O ear discharge - 8 years• What differential diagnosis you can offer ?• 1. Subperiosteal abscess• 2. Suppurated retroauricular lymph node

• Perform three finger test on this patient• Greet the patient first• Explain the procedure• Reassure the patient• Three fingers are used to perform this test.• Middle finger is used to apply pressure over the well of the

concha - Tenderness in this area indicates tenderness over the antral area

• Index finger is used to apply pressure over mastoid process - Tenderness indicates mastoiditis

• Thumb is used to apply pressure over mastoid tip - Tenderness indicates mastoid emissary vein thrombophlebitis

• 30 years old male patient came with c/o• Pain right ear - 1 week• Blocking sensation right ear - 10 days• Mild discharge from right ear - 1 week• Otoscopy shows:• Enumerate otoscopic findings• Mention the possible diagnosis• Mention in brief the pathophysiology of this disorder• Whitish mass admixed with wax can be seen in the external canal• The external canal appears widened• Probable diagnosis - Keratosis obturans• Kertosis obturans occur due to faulty epithelial migration of external canal skin.

This movement occurs in a reverse direction in these patients (i.e. towards the ear drum)

• Name the type of pinna seen here• Name some drugs which when ingested

during pregnancy would cause this condition• Microtia• Warfarin, Folic acid antagonists like

methotrexate and aminopterin

• 22 year male patient came with c/o swelling over right pinna - 4 days

• Mild pain ++• No h/o fever• Name the possible pathology• How will you manage this condition ?• Aural seroma• Needle aspiration with application of compression

dressing to prevent reaccumulation.

• Why is this external auditory canal narrow ?• What could be the cause ?• What could be the clinical problems faced by the patient ?• What surgery should be performed in this patient ?• Exostosis of external auditory canal.• It is common in swimmers.• These patients have conductive deafness, cerumen

impaction.• Cerumen impaction is caused by abnormal self cleansing

mechanism of the skin lining external canal in these patients.• Canalplasty

• 30 years old female patient came to the OPD with c/o:• Hard of hearing both sides – 4 years

Tinnitus on and off left ear – 6 months• O/e:• Ear drum on both sides appeared normal. They also showed normal

mobility on siegalization.• Given below is the audiogram of the patient:• What could be the probable diagnosis?

What do you see in the audiogram?• This patient is probably suffering from otosclerosis.• The audiogram shows carharts notch. It is classically seen in bone

conduction audiogram of patients as a dip centered around 2000Hz.