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03.28.08 (3 months ago)
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hi bandula, i dont know if this comes too late for you...but i can give you the 7 sisters mmaterial which contains a lot of general medicine as well as other OSCE
's-here is the complete 7 sisters...i can also help you with any other OSCE
's u need-i have been studying for 1 month now-& i had to write many of the OSCE
's myself with help from the site which is very valuable! i mean that i had to 'organise' the OSCE
's so tht i will remember it when i go for the exam..
it's easier when you do things systematically in order!
i have only visited this site since end of feb-so sorry i didnt answer ur post before this!
Q.1: IDDM: Annual Check up.
1. Measure Body Weight.
2. Examine the eyes:
a. Xanthelasma and arcus.
b. Visual acuity (maculopathy).
c. Test eye movements (Mononeuritis multiplex, III, IV, VI CN).
d. Ophthalmoscopy (cataract, rubeosis iridis, retinopathy, vitrous haemorrhage).
3. Mouth: candidiasis.
4. Neck: listen for carotid bruit (atherosclerosis).
5. Upper limb:
a. Blood pressure (sitting and standing for postural hypotension, and hypertension).
b. Radial pulse (for resting tachycardia).
c. Inspect hand for wasting of thenar (carpal tunnel syndrome), hypothenar and interossei muscles (ulnar nerve palsy). Index for infection of prick site, ask the patient to do prayer sign (joint contracture).
6. Chest: auscultate for signs of TB, pneumonia, or CCF.
7. Examine lower limb:
a. Inspection:
i. Foot for ulcer, gangrene, callus, infection at prick site. In between toes and look for small muscle wasting, pes cavus, claw toes.
ii. Ankle: for deformity (charcot joint, OHCS, 5th ed. p668)
iii. Leg: for muscle wasting.
iv. Knee: for deformity (charcot joint).
v. Thigh: for injection sites (infection, lipo-atrophy, lipo-hypertrophy), muscle wasting (especially quadriceps for diabetic amyotrophy).
b. Foot pulses:
i. Dorsalis pedis: on dorum of foot just lateral to extensor hallucis tendon
ii. Posterior tibial: 1-2cm below and behind medial malleolus
c. Tendon reflexes:
i. Ankle jerk (S1): lower limb flexed at knee and extended at ankle by hand of examiner and ankle put at dorsum of opposite foot (can be abscent in elderly)
ii. Knee jerk (L3, L4): lower limb flexed at knee to 60° and carried by hand.
iii. Plantar reflex (S1, S2): rake with blunt object along lateral border of foot from heel to little toe (can be extended in Diabetic amyotrophy).
d. Sensory exam:
i. Joint position: ask the patient to close eyes. Show him up and down positions first. Then start form interphalangeal (IP) joint of hallux holding proximal and moving distal phalanx. If sensation is impaired, move to metatarso-phalangeal (MP) joint, ankle and knee.
ii. Vibration: ask the patient to close eyes, apply tuning fork to sternum, to establish baseline sensation. Test base of big toe, medial malleolus, tibial shaft and tuberus of anterior iliac crest.
iii. Touch: ask the patient to close eyes, use cotton piece. Ask the patient to respond verbally. Examine segments in turn and compare.
iv. Pain: Ask the patient to close eyes and to respond verbally. Use disposable pin, establish baseline sensation at the sternum. Test segments in turn and compare. Ask patient to report if quality of sensations changes (hypo or hyper-aesthesia).
v. Temperature: ask the patient to close eyes. Use two containers of warm and cool water; or use a cold subject (e.g. tuning fork). And ask the patient about quality of sensation (test segments in turn and compare).
vi. Deep pain: ask the patient to close eyes. Apply firm pressure to nail or squeeze the calf belly. And ask the patient to report pain.
e. Power (motor system): Test from proximal to distal.
i. Flex, extend, abduct, and adduct hip joint.
ii. Flex, and extend knee joint.
iii. Dorsiflex (L5), plantarflex (S1), invert, and evert foot.
iv. Flex, and extend toes.
f. Sensory loss in DM
:
i. Early: vibration, deep pain, and temperature.
ii. Later: joint position sensation.
g. Investigations:
i. Glycosylated Hb (HbA1c): relates to BLOOD GLUCOSE level over 6-8 weeks (normal: 2.3-6.5%).
ii. Glycosylated plasma proteins (fructosamine): relates to BLOOD GLUCOSE level over 1-3 weeks.
iii. Urine for glucose, Ketones, and Albumin (macro and micro-albuminuria).
iv. Blood for plasma creatinine, and lipids.
h. Questions to ask:
i. Review of self-monitoring results and injection techniques.
ii. Review of eating habit.
iii. Ask about symptoms of hypoglycemia.
iv. Talk about general and specific problems.
v. Education.
Q.2: Examine the lower limbs of a diabetic patient.
Introduction, and then you may say: “As far as I know you have high glucose level, I would like to examine your legs. Can you please slip off cloths from your bottom half to your underwear?”
1. Observe patient's gait.
2. Inspection:
a. Foot: for ulcer, gangrene, infection, callus at prick sites (heel and heads of metatarsals). And look for small muscle wasting, pes cavus, claw toes, loss of hair, and trophic (waxy) changes.
b. Ankle: for deformity (charcot joint).
c. Leg: for muscle wasting.
d. Knee: deformity (charcot joint).
e. Thigh: for injection sites (lipo-atrophy, lipo-hypertrophy, infection). Quadriceps (diabetic amyotrophy).
3. Palpation:
a. Pulses: (always compare bilaterally)
i. Dorsalis pedis: on dorsum of foot, just lateral to extensor hallucis tendon.
ii. Posterior tibial: 1-2cm below and behind medial malleolus.
iii. Popliteal: flex knee to 30°, press firmly with thumbs in front, and four fingers of both hands posteriorly over popliteal artery below knee.
iv. Femoral: midway between anterior superior iliac spine and pubic tubercle (lateral extension of pubic hair).
b. Palpate for temperature changes, with dorsum of hand.
c. Palpate hind foot, mid foot, and fore foot (MP, IP joints). Compress fore foot for tenderness.
d. Reflexes:
i. Ankle jerk (S1): lower limb is slightly flexed at knee, and extended at ankle, which is placed on the dorsum of opposite foot.
ii. Knee jerk (L3, L4): lower limb is flexed at knee to 60º, and held by hand of examiner.
iii. Plantar reflexes (S1, S2): rake, with blunt object, lateral border of foot. (extension is noted in amyotrophy).
e. Sensory:
i. Joint position: show the patient up and down and then ask him/her to close eyes. Start from IP of big toe. Hold the proximal part and move the distal one, if impaired then move downwards to MP, ankle, knee.
ii. Vibration: ask the patient to close eyes, and apply TF to sternum for baseline sensation. Test base of big toe, medial malleolus, tibial shaft, tibial tuberosity, and anterior iliac crest.
iii. Touch: ask the patient to close eyes. Use cotton piece. Examine segments in turn.
iv. Pain: ask the patient to close eyes. Use disposable pins and start from sternum for baseline sensation. Test segments in turn and ask the patient to report if quality of sensation changes (hypo-, or hyper-aesthesia).
v. Temperature: ask the patient to close eyes. Use two containers of warm and cool water. Or you may use cold object (e.g. TF). And ask the patient about quality of sensation he/she felt. Test segments in turn.
vi. Deep pain: ask the patient to close eyes. Apply firm pressure to toe nail and squeeze calf belly. Ask the patient to report pain.
f. Motor System:
i. Power:
• Flex, extend, abduct, and adduct hip joint.
• Flex, and extend knee joint.
• Dorsiflex (L5), plantar flexion (S1), invert and evert foot.
• Flex, and extend toes.
ii. Tone:
• Rotate the foot (ask the patient to relax).
• Rotate the leg, internally and externally, with knee extended.
• Flex and extend knee.
For segment distribution, dermatomes check OHCM, 4th Ed, p 410.
Q.3: Diabetic coma (M. X.). Explain to examiner.
1. Hypoglycemia:
a. BLOOD GLUCOSE <2.5 mmol/L.
b. Clinical Findings: autonomic symptoms (sweating, TREMOR , pallor). Neurological symptoms (irritablity, abnormal behaviour, drowsiness, convulsion, focal neurological sings, and coma). None specific symptoms like nausea, tiredness, and headache.
c. Management: if in doubt, take blood sample for test and give glucose bolus injection before results are out. (50 ml 50% Dextrose IV, followed by Normal Saline flushing. Or give Glucagone 1mg IM).
2. Diabetic Ketoacidosis(DKA):
a. Clinical findings: nausea, vomiting, abdominal pain. Signs of dehydration. Hyperventilation (Kussmall Breathing). Ketotic (acetone) breath smells. Neurological symptoms (confusion, stupor, coma).
b. Management:
i. Insulin: 10 u IV stat, then by pump according to Insulin sliding scale. If no pump available 10 u IM stat, then 6 u IM/hr.
ii. Fluid: 1L N/S over ½ hr, 1L /1hr, 1L /2hrs, 1L /4hrs, 1L /6hrs, till when BLOOD GLUCOSE < 15 mmol/L then change to 4% Dextrose, 0. 18% N/S.
iii. Add KCL 20 mmol to all fluid except the first liter (Contraindicated in Renal Failure, and if K+ >6)
iv. Before starting treatment take blood for glucose, U & E, Osmolality, Blood Gases, FBC, Blood C/S, urine for Ketones and C/S. Then measure BLOOD GLUCOSE and U & E hourly.
v. Insert N/G tube. Chart vital signs, B. Glucose, coma level, Input/Output.
vi. Consider cathetrisation if no urine for 4 hours.
vii. Treat infections with antibiotics.
viii. Shift to SC Insulin and allow by mouth intake when Ketones level <1+.
Differences between Hypoglycemia and DKA coma:
Hypoglycemia DKA
Moist SKIN and tongueFull pulseNormal, or high blood pressureNormal breathingHyper-reflexia Dry SKIN and mouthWeak pulseLow blood pressureHyper-ventilationHypo-reflexia
3. Hyperosmolar Non-Ketotic Coma:
a. Clinical findings: typically affects elderly NIDDM, severe dehydration, no acidosis, focal neurological signs may be found, increased risk of DVT.
b. Management:
i. Fluid: N/S half rate of fluid given in DKA.
ii. Insulin: wait after fluid correction, since insulin may not be needed then. But, if needed give 1 u/hr.
iii. Heparin: prophylactic for DVT risk.
Q.4 A 24 year-old female patient presents with vaginal bleeding and 8 weeks of secondary amenorrhea. Take history, make a diagnosis, and discuss management plan.
Introduce yourself. And you may, then, start by saying: ” As far as I know, you didn’t have your periods for the last 8 weeks, and now you have bleeding from down below. I would like to ask you some questions, and then I will explain to you what we will do”. (You may ask her if it is ok, then proceed with your questions).
When did the bleeding happen? (Or you may ask) when did you first notice the bleeding? Can you describe the bleeding for me? Is it bright red? (Abortion). Or dark red or brown? (Ectopic pregnancy). Is it heavy bleeding with clots? Or just slight blood loss? Have you felt any pain in your tummy? (Site, and character). Have you always had regular periods? Do you think you might be pregnant?
Do you feel sick? Is there any pain in your breasts? Did you notice if your breasts enlarged lately?
Do you use any contraceptive method? What kind you use? IUCD, pills? (IUCD, Progesteron Only Pill risk ectopic pregnancy).
Have you ever had ectopic pregnancy? Have you ever had previous miscarriages? Have you ever had vaginal discharge? Any recurrent pain in the lower part of your tummy? (PID).
Have you ever had any previous operation in your tummy? (appendectomy,C/S).
How have you been feeling in yourself recently? Any stress in job or at home?
Have you experienced any pain between shoulder blades?
Do you have any pain when passing water? Any burning sensation?
How is your bowel motion?
Do you have any medical problem? Do take any medication?
Do you have any bleeding from other sites?
Have you suffered any dizziness? Have you fainted?
After finishing the History taking, you may proceed by saying: “Now I would like to examine you, and after exam we need to run some tests especially pregnancy test to make sure if you are pregnant or not. And we need to do ultrasound examination (ask the patient if she knows what U/S is about, and shortly explain if necessary) to be sure that the possible pregnancy is in the right place, which is in your womb”.
Don’t worry, you will be all right, we will look after you.
Q.5 A young lady presenting with vaginal bleeding and left iliac fossa pain. Take history, and establish differential diagnosis.
Introduce yourself, and you may continue by saying: “As far as I know, you have bleeding from your down below, and you feel pain in the left lower part of your tummy. I would like to ask you a few questions about your condition”.
Can you describe the bleeding for me? Is it bright red? (Miscarriage). Or dark red or brown? (Ectopic pregnancy). Is it heavy bleeding with clots? How many tampons (or pad) you use? Is it heavy bleeding (miscarriage), or slight blood loss? (Ectopic pregnancy).
Can you tell exactly where the pain is? Can you tell what it feels like? Did the pain started before bleeding? (Ectopic pregnancy). Or you saw bleeding before feeling pain? (Miscarriage).
How was your periods? Regular, irregular?
Have you ever had unprotected sexual contact? Do you think you are pregnant? Do you feel sick? Is there any breast discomfort, pain, or enlargement?
Do you use contraception? What kind? (IUCD & progesterone only pills® Ectopic pregnancy).
Have you ever had ectopic pregnancy before? Any miscarriages?
Have you ever had vaginal discharges before? Or recurrent pain in lower part of your tummy? Have you ever had any operation before, especially in your tummy (ask about appendectomies, Cesarean section).
Differential diagnosis:
1. Ectopic pregnancy
2. Miscarriage (Threatened or Inevitable).
3. Chronic PID.
4. Dysfunctional Uterine Bleeding.
Q.6 Amenorrhoea of nine months, Take history to reach a diagnosis.
Introduce yourself, and then you may say: “As far as I have been told, you did not have your periods for the last nine months. I would like to ask you few questions about your condition”.
How old were you when you had your first period? Were your periods regular before? Have you become pregnant before? How many times? When was the last time? Have you ever had miscarriages before? Have you ever had problems during your pregnancies? Have you ever had any kind of Termination Of Pregnancy? Any D&C? (think of Ascherman Syndrome).
Were your deliveries normal? Any difficulties? Any bleeding following deliveries? (Sheehan Syndrome.).
Do you use contraception? What kind do you use? (Post pill amenorrhea and amenorrhea after injectables).
Do you feel tired, sleepy? Have you had any (temperature) fever recently? (General illness).
Did you notice any change in weight? Are you on any kind of diet? (Decreased in Anorexia Nervosa, general illness, increased in Polycystic Ovary Syndrome).
Any recent dislike of hot weather, sweating, TREMOR , diarrhoea? (Hyperthyroidism).
Any recent increase in hair growth in your face, on your breasts or on your tummy? Did you notice any deepening of your voice? (Virilization).
Have you notice any milky discharge from nipple recently? Any disturbance of vision? (Hyperprolactinoma).
How have you been feeling in yourself for the last year? Any stress in job or at home? Any change of environment? (Stress may cause amenorrhoea).
Are you on any medication? Do you feel any mass in your tummy?
Differential diagnosis:
1. Ectopic pregnancy.
2. Miscarriage (Threatened, inevitable).
3. Chronic PID.
4. Dysfunctional Uterine Bleeding.
Q.7 Hormone Replacement Therapy (HRT): Counseling.
Introduction, then you may begin by saying: “I have heard that you are here to discuss HRT. You know every woman goes through the menopause. This occurs when a woman’s ovaries produce no more the female sex hormones, which are oestrogen and progesterone. Oestrogen has an effect on every cell in the body, whether it is in the SKIN , bone, blood vessels, womb and vagina. So when the level of oestrogen in the body fall, women get features of hot flushes, night sweats, mood changes, forgetfulness, sleep disturbances, and loss of concentration. In addition, lack of oestrogen causes a type of protein, called collagen, to be gradually lost from the SKIN , so the SKIN become thinner, drier, and easily bruised. Also the vagina becomes thinner, less flexible, drier leading to painful sexual intercourse, and less resistant to infections. But the most important effect of oestrogen lack, is on the bones causing what we call osteoporosis, which means that the bones loose mass so they become weak, brittle, and much more likely to break causing number of minor injury such as a fall. Another important effect is on the heart, where before menopause women rarely get heart diseases, while after menopause, the possibility of getting heart attack increases. And within 10 years they catch up with the heart attack incidence in men. Fortunately, there is an effective way of dealing with the problem that is the use of HRT, which consists of these lacking hormones, oestrogen and progesterone.
There are many ways of taking HRT; the first is tablets, which are taken by mouth every day, the second is patches that stick to the SKIN and should be changed twice weekly. Another way is implants that are inserted under the SKIN under local Anaesthesia
and their effect lasts for 3-6 months. The fourth way is the gel, which is applied to the SKIN daily. But you should not bath after application for 1 hour. If vaginal dryness is the main problem, we could give you cream or pessary to place inside the vagina.
With HRT, hot flushes usually disappear within few weeks. It also helps dryness of vagina, improves mood, and sleep disturbances. And the most important effect of HRT is that it can dramatically decrease the risk of osteoporosis, hence fractures. And substantially decreases the risk of heart attacks.
There are very few reasons why a woman cannot take HRT, such as in liver disease, cancer of the womb, or cancer of the breast, and in case of abnormal bleeding from vagina that has no obvious cause. Like any other medication HRT has some side effects, most of them are minor and often disappear if you stop the treatment. Some women feel sick, that is with tablets. Some may put on weight, some may get breast pain and mood changes before periods, which will re-appear with HRT. Some may get SKIN irritation with the usage of patches. With the use of oestrogen hormone there is a slight increased risk of womb cancer and to decrease that risk we add progesterone, which has protective effect on the womb. Therefore, in women who have had their womb removed this combination of drug is not necessary. The most common reason people are worried about in HRT, is breast cancer, however if you use HRT for five years the risk still minimal. But once you get beyond that e.g. 10-15years then risk tends to increase bit more and we usually teach women how to do self-examination of the breast. Also, we tell them to report, immediately, any vaginal bleeding if happens. One more thing is that HRT is not a contraception method and the woman should continue to use her usual contraception method for one year after the last menstrual period.
Patches, implants, and gel can be taken with liver disease.
Q.8 a female patient asks for permanent sterilization. Take history & counsel her.
Introduction, then you may say: “As far as I know you want to do permanent sterilization. I would like to ask you a few questions, and discuss the condition with you.
How old are you? Do you have children? How many? Do you have a partner? Does he know about your decision? Does he agree?
Why do you want to be sterilized? Do you know about contraception methods available, such as OCP, coils, condoms, diaphragm and cups?
Female sterilization is a procedure by which the fallopian tubes that are the tubes between the womb and ovaries are cut, sealed or blocked. This stops eggs moving down them to meet sperms. The operation can be done in several ways; the most common method is by the use of laparoscopy. This is usually done with the use of General Anaesthesia
, where you will be put to sleep; a doctor will make two tiny cuts, one just below your navel and the other and the other just above the bikini line in the lower part of your tummy, they will then insert a laparoscope which is a thin telescope-like instrument with magnifying lenses to look at your reproductive organs. The second way is by what we call it mini-laporatomy, usually done under General Anaesthesia
, the doctor will make a small cut in your tummy, just below the bikini line to reach the Fallopian Tubes. The third way is to reach the reproductive organs through the vagina. The fallopian tubes are then blocked either by tying (ligation), or by removal of a small piece, and then sealed by heat, Or by applying clips or rings.
The period you need to stay in hospital depends on type of Anaesthesia
and operation. It is usually around couple of days. After operation if you have General Anaesthesia
you may feel unwell for few days and you may have some bleeding and pain, which are slight. You must consider sterilization as permanent method of contraception.
However, there is an operation to reverse sterilization, but it is complicated and may not work. The failure rate of female fertilization is 1-3 per 1000. Pregnancy rate after reversal is around 50% with high risk of ectopic pregnancy.
The advantage is that it does not interfere with sex; your womb and ovaries will remain in place. Ovaries will still release an egg every month. Your sex drive and enjoyment will not be affected. Actually they may improve, as fear of pregnancy is no more an issue. Occasionally some women find their periods to be heavier, but it is usually because of their age and stopping contraceptive pills. You can start sex as soon as comfortable. You must continue contraception until time of operation and if you use ICUD, it should be left till the next period. You should contact your doctor if you think that you are pregnant, of if you missed a period and especially it’s accompanied with tummy pain.
Q.9 A girl on the pills. Explain.
Introduction, I have heard that you are here to discuss OCP. There are two main types of OCP.
The first type is Combined Oral Contraceptives (COP): Where the tablet contains two hormones, Oestrogen and Progesterone. This type stops woman releasing an egg each month.
Advantages: A very reliable method of contraception with less than 1/100 will get pregnant in a year. It does not interrupt sex, often decreases bleeding, period pain and Premenstrual Tension. It also protects against cancer of womb and ovaries.
Disadvantages: The most important disadvantages are the risk of vascular diseases as clot in the leg, heart attack, and stroke. That is why it should not be given to women at risk of these diseases. Women with cardiac diseases, liver diseases, some cases of migraine, gross obesity and immobility also abnormal vaginal bleeding. It should be stopped in a smoker at age of 30 yrs and should not be used by breast-feeding mothers.
How to take the pills: they should be taken daily for 21 days, and stopped then for 7 days. Taking pills should starts on the first day of cycle (the first day when blood is seen), on the day of Termination Of Pregnancy, 3 weeks postpartum (if the mother is not breast-feeding the baby), and 2 weeks after major surgery (if the patient is immobilized). If the pills are forgotten for more then 12 hrs, you should keep taking the pills as usual thereafter, but you should use another type of contraception for seven days. This is also applied in case of diarrhea where you should use another type of contraception on the day of diarrhea and for another 7 days thereafter. It is also applied in case of taking of drugs known to interfere in the action of Combined Oral Contraceptive pills like anticonvulsants, and antibiotics.
If you start taking OCP you have to come for follow up every 6 months to check your BP, and do Breast exam (if >35 yrs).
OCP should be stopped in case of severe headache, severe chest pain, and tummy pain.
The second type is POP (Progesterone Only Pills): this type contains only the Progesterone hormone which causes changes making it difficult for sperm to enter the womb or for womb to accept a fertilized egg, and in some women it prevents the release of eggs.
Advantages: it is a reliable method, with careful use; the failure rate is 1/100 per year. It does not interrupt sex. It is useful for women who smoke and those who cannot take COP for any cause. Also it can be taken in breast-feeding mothers.
Disadvantages: it has some side effects like headache, acne, putting on weight. The periods may be irregular with some bleeding in between. And it is less reliable than COP.
How to take the pill: the same as COP, and should be taken at the same time of everyday. If you miss by 3 hours, you should use another type of contraception for a week and also if you get diarrhea, use another type of contraception for the period of diarrhea and for one week thereafter.
Any woman on OCP should have every 6 months check of: BP, breast exam, cervical smear.
Q.10 Vasectomy, explain the operation and the side effects.
Introduction, then you may say: “As far as I know you asked about sterilization that is what we call vasectomy.
Vasectomy is the procedure by which tubes that carry sperms from your testicles to the penis are cut and blocked. This operation is usually done under local Anaesthesia
. That is the type of Anaesthesia
that numbs the (sac) scrotal area. So you will be awake during the procedure but you will not feel pain. The doctor will make a small cut in the SKIN of the scrotum, which is the sac of the testicle to reach the tubes, then will remove a small piece of each tube and close the ends.
The cuts will be very small and you may not need any stitch, but if needed, dissolvable stitches will be used. The operation takes 10-15 minutes and you will be able to leave the hospital shortly afterward. But you should not drive yourself home; you should rest for the remainder of the day. The stitches used are dissolvable and will disappear within a week. After the operation the scrotum may feel bruised, swollen and painful. You can help that by wearing tight-fitting underpants to support your scrotum day and night for one week. Avoid heavy exercise for at least a week.
Some men may get bleeding or infections. If this happens you should contact your doctor. You can have sex after the operation as soon as it is comfortable; however, you have to use another method of contraception until sperms disappear from your seminal fluid, and this may take up to 2-3 months. We have to have 2 clear semen tests so that you can rely on vasectomy for contraception. Your testicle will continue to produce male hormone as before, your sex drive, ability to have erection and climax will not be affected. The appearance and amount of semen should be the same as before. There is a suggestion about link between vasectomy and cancer of testicle and prostate but it is not yet proven.
You should consider vasectomy as a permanent method of contraception. Reversal is complicated and may not work. Failure rate is 1/1000-2000 and reversal rate is as 50%.
You should not attempt vasectomy if you are not sure that you don’t want more children and you should discuss it carefully with your partner as well as the possibility of the use of available method of contraception.
It doesn’t protect against STD.
Q.11 a 30 years old with cervical smear results of severe dyscaryosis (CIN-III). Counsel, give explanation and advice about colposcopy, and biopsy
Introduction, then you may start as follows: “Now we have had the results of your cervical smear test back and it showed some changes in the lower part of your womb, that is the neck of your womb.
Now we need to do further exam called colposcopy, which is a simple exam that allows the doctor to have a closer look at the changes on the neck of your womb. You will lie comfortably on bed, and the doctor will gently insert a speculum into your vagina just as when you had your cervical smear done. After that the doctor will look by a colposcope that is a specially adapted type of microscope. It is just a large magnifying glass with a light source attached to it. It does not touch you nor gets inside you. The doctor will then dab liquids onto the neck of your womb, which helps the area with changes to appear white and if any such area appears then the doctor will take a sample of tissue (which is just a size of pin head). The exam takes about 15 minutes it should not be painful, may be a bit uncomfortable. You may feel a slight stinging during the tissue sample taking.
After colposcopy, if you have had a biopsy, you may have a light blood stained discharge for few days, this is nothing to worry about and should clear by itself and it is better to avoid sexual intercourse for 5 days to allow site to heal.
You will get the results back of your biopsy after one or two weeks, they will tell you about that. If the result showed any condition that needs treatment, the doctor will tell you about the treatment, which is simple, and virtually 100% effective. The treatment is usually carried out with the use of colposcopy and the procedure is similar to your initial exam. There are several ways of treatment, either to apply heat or freeze the area or apply laser. All treatment types aim at destroying the cells with changes. After treatment you may need to have blood stained discharge for 2-4 weeks during which and with periods you will need to use sanitary towels rather than tampons and it is better to avoid heavy exercise and sexual intercourse to allow the area to heal.
The treatment will have little or no effect on your further fertility, nor on risk of having miscarriages. After treatment you will have a follow up visit after 6 months during which you will have a cervical smear and colposcopy exam and if everything is satisfactory you will have a follow up smears every year for the follow
ing 4-5 years.
NB: you are welcome to arrange for a friend or relative to come with you for colposcopy. You may need to bring a sanitary towel with you just in case some discharge appears.
Intercourse does not make the condition worse, enjoy sex as usual but use effective contraception, it is important not to get pregnant until the condition is dealt with. This is because hormones during pregnancy make treatment more difficult. You cannot pass changes or abnormal cells to your partner.
Abnormal smear does not mean cancer, it is very common 1/12, it is just a warning sign and the treatment is simple and virtually 10
0% effective.
Colposcopy is performed in lithotomy position and liquid used is 5% acetic acid.
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HERE IS COMPLETE SEVEN SISTERS MATERIAL Posted on 12.11.03 #1
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Q.12/A A patient is diagnosed to have ectopic pregnancy. You decided to do laparoscopy. Explain that to her.
Introduction, then you may start by saying: “Now, we have had a good look at your tests that we run. And according to the results of the tests, the examination, and what you complained of, there is a high possibility that you have what we call ectopic pregnancy that is a pregnancy outside your womb. This can be in the tubes between your womb and ovaries as in most cases, or at the ovary or inside the tummy, which is very rare.
And since the pregnancy is not in the usual place, it cannot continue to term. In addition, it may bleed suddenly or even cause damage to the tube, which could cause you some harm.
To avoid these problems, we have first to be sure that you have ectopic pregnancy and the best way to do this is by laparoscope. That is the procedure by which we insert a tube with lenses within a small incision in your tummy, after we put you into sleep. So we could look at your womb and tubes. And to treat the condition, there are two ways. Either by laparoscopy, where we could either, inject a medication called methotrexate or remove the pregnancy by incision. The second way to deal with this condition is by operation to remove the pregnancy. And in either ways of treatment we will try to conserve the tube, but if it is damaged by this condition, then the only way to deal with it, is to remove the tube.
Is everything clear or do you want me to repeat anything for you?
Are there any questions that you would like to ask me?
You will remain for 2-3 days in the hospital.
You can return to work after 6 weeks (sick leave).
The doctor will make 2 incisions, one just below the navel and the second above the bikini line.
Q.12/B a female patient with left lower abdominal pain with vaginal bleeding, suspected to have ectopic pregnancy. You want to do investigation, and the patient wants to go home. Counsel her.
Introduction, then you may begin by saying: “According to what you complain of and the examination, there is a high possibility that you have what we call it ectopic pregnancy, which is a pregnancy outside the normal place that is the womb. And this could be either in the tube between the womb and ovaries or less commonly on the ovaries or inside the tummy. And the pregnancy in these positions could not go to term and what is important is that it could bleed suddenly or even cause tear to the tube with bleeding inside your tummy. And these conditions could be avoided by early treatment.
So first, we have to confirm ectopic pregnancy, so we want you to do pregnancy test on sample of your urine. Then we would arrange ultrasound of your tummy and we might need to do laparoscopy, which is a tube passed inside your tummy through small incisions to look at your womb and tubes.
There are 2 ways to deal with this condition by laparoscopy with injection of medication called methotrexate or removal of pregnancy. The second way is to remove the pregnancy by operation and in either ways we try to conserve the tube but if it is so damaged then we need to remove it.
Is everything clear or do you want me to repeat anything for you?
Are there any questions that you would like to ask me?
You will remain in hospital for 2-3 days.
Return to work in 6 weeks.
The doctor will do 2 incisions, one just below the navel, and the second above the bikini line.
Q.13 Baby Blues, and Post natal depression, take history and do counseling.
Introduction, then you may start with: “I have heard that you are finding life a bit difficult; tell me about what has been going on.
Is this your first pregnancy? How do you feel in yourself? Do you feel tired? Do you cry often? How is your sleep? How is your appetite? Do you enjoy things you used to enjoy before (TV, films, visiting friends, etc.)? Do you have any concern about your health or your baby’s health? Do you think life is worth living now a days? Do you think that someone else or yourself may harm the baby?
Have you had any problem during your pregnancy? Was it normal delivery? Any difficulties?
Do you have any pain in your breast or in your down below?
Do you have a partner? How is your relation with him? Did you try to get help from your mother or sister? How have you been feeling in yourself before? Have you felt like this after previous pregnancies?
Do you have any problem at home? Or at work? With your partner’s work?
Then in case of Baby Blues:
(It is commonest in first 3-4 days after delivery and lasts for few days). You may explain: “Well, Mrs. (the patient) what you have is what we call Baby Blues, it is a very common condition, occurs in more than one of every 2 mothers after delivery, what you need is just rest, try to have more sleep, eat healthy food with lot of vegetables and fruit and try to get out with your partner. Have fun with him and you will be OK in few days, and as for the child the doctor has seen/will see him/her and said that nothing is wrong with him/her, so there is nothing to worry about, and you can contact us at any time you feel the need to”.
In case of Post Natal Depression:
(It is commonest in the first month up to 6 months). You may start by saying: “Well Mrs. (the patient), what you have is what we call Post Natal Depression, we will refer you to another department in this hospital, they will give you some medication. You will get better, but it takes some time and meanwhile we will arrange support for you. It is common condition and can be treated so don’t worry about it.
Q.14 A patient will undergo an operation for ovarian cyst removal. Explain, and do counseling.
Introduction. And then: “I have heard that you will have an operation to take out a cyst from your ovary. Do you know anything abut cysts in the ovaries?
Well, cysts in the ovaries are quiet common, a cyst is a fluid filled sac that arises from the ovary, and it is important to take it out as infection may happen, blood might get collected into it, it might became twisted or even burst, so this could affect health.
The operation to take out the ovarian cyst is usually done under General Anaesthesia
, that is we are going to put you to sleep, the doctor is going to make a cut, take out the cyst and leave the ovary in place, and we can arrange for you to have what we call subcuticular suturing so that the scar will be faint and will fade away with time. The operation with the Anaesthesia
will take around one hour. And you will stay in hospital for 4 days and return to work in 6 weeks.
Don’t worry Mrs. (the patient) you are in good hands. One more thing, this condition will not affect your future fertility.
Is everything clear, or do you want me to repeat anything for you?
Are there any questions that you would like to ask me?
We will try not to take the ovary out, but in very rare conditions we might be obliged to do, so we have to take your consent for that.
Some complications: Bleeding, infection.
Vertical cut.
Q.15 Sexually Transmitted Diseases (STD). Counseling.
Introduction. Then you may say: “I have heard that you are here to discuss STD. They are infections that can pass from one person to another during sexual contact; anyone can get STD from an infected partner if no protection has been taken. There are several types of STD:
Some are common: genital warts, genital herpes, chlamydia, none specific urethritis, gonococal infection.
Less common: trichomonas vaginalis, syphilis (the pox), HIV (the virus that causes AIDS), hepatitis B & C, infestations like scabies , and pubic lice (crabs).
Method of spread: STDs usually spread when an infected blood, semen, or vaginal fluid comes into contact with another person during sex, but some infections can be transmitted by blood or sharing needles as AIDS or Hepatitis. Some of them like none specific urethritis, gonorrhea, hepatitis and HIV spread by penetrative sex, some as trichomonas vaginalis by vaginal sex, some as warts, herpes, and syphilis by body contact.
Safe sex: this can be achieved by preventing infected person’s blood, semen, or vaginal fluid from getting inside their partner’s body. This can be done by use of male or female condom, which can even protect from AIDS. When using condom be sure if you want to use a lubricant to use water-based ones as KY jelly or boots lubricant jelly. And do not use oil-based lubricants such as Vaseline. For anal sex use stronger condom as Durex, and plenty of water-based lubricant.
How do I know if I have STD?
There are some features to look for:
1. Unusual thick, cloudy or smelling discharge from vagina.
2. Discharge from penis.
3. Itchy, rash, sores, blisters, or pain in genital area.
4. Pain or burning sensation when passing water.
5. Passing water more than usual with little quantity.
6. Pain during sex.
But remember that STD can have no feature at all, or features that may not appear for months. Some features may disappear and you may still have the disease, and this could lead to many problems if untreated.
The patient may ask: Where can I go for help?
You can go to Genitourinary Medicine Clinics; they offer free check-up and treatment of STD. All information is kept strictly confidential; you can go to any clinic anywhere in the country. You will complete a registration form and they will give you a number to retain your anonymity. A full sexual health check includes:
1. Examination of your genitals and sometimes the lower part of your body, mouth, and SKIN .
2. Taking swabs, which is a type of cotton bud used to take sample from any secretion or discharge from genitalia.
3. Urine sample for examination.
4. Blood test for syphilis
You also may be offered:
1. HIV test with your consent.
2. Cervical smear in women.
3. Blood test for hepatitis B & C.
It better not to have sex until it is all clear. When you have STD it is important to tell your sexual partner so he/she can have a sexual health check up too.
Incubation Period:
• Gonorrhea: 2-10 days
• Syphilis: 9-90 days
• None specific urethritis: few days to few weeks.
• Hepatitis B: 2-6 months
• HIV, take sample at 3-6-8 months.
Q.16 A patient with low back pain, examine the back.
Introduction, then you may start: “I am going to examine your back, please get undressed to your underwear, and stand up so that your back is in front of me.
1. Inspection: with patient standing, observe from behind for scoliosis, and from the side checking that there is normal lordosis.
2. Palpation: palpate with fingers for tenderness on spinous processes and paraspinal muscles. Then perform light percussion with the fist to elicit bone tenderness.
3. Movement: Ask the patient to extend backward, bend forward with leg straight, then on each side trying to touch side of knee. Then ask the patient to sit on couch and rotate to right and left with fixed hips.
4. Tests:
a. Straight leg raising test (SLR): the patient is lying supine. With knee flexed. Check passive hip flexion. With knee extended, raise leg on unaffected side by lifting the heel with right hand while preventing knee flexion with left hand. Repeat this on the affected side asking the patient to report any pain or paraesthesia. (Normal straight leg raising test are 90º). When this limit is reached, now gently dorsiflex the ankle if the patient feels pain, Bragaard test is positive.
b. Bow string sign: perform SLR test at the limit, flex the knee, reducing tension on the sciatic roots and hamstrings. Now further flex the hip to 90º. Gently extend the knee until pain is once again reproduced (Lasegue’s sign). Apply firm pressure with thumb first over the hamstring nearest the examiner, then in the middle of the popliteal fossa and finally over the other hamstring tendon. Ask the patient which maneuvre exacerbates the pain. The test is positive if the second manoeuvre is painful and if the resultant pain radiates from the knee to the back.
c. Sitting test: Ask the patient to sit up from the lying position, ostensibly to inspect the back. Only in the absence of sciatic nerve irritation will the patient be able to sit up straight with legs flat on the bed.
d. Flip test: Ask the patient to sit with hips and knees flexed to 90º on the edge of the couch and test the knee reflexes. Then extend the knee, ostensibly to examine the ankle jerk. When there is genuine root irritation the patient will flip backwards to relieve the tension. The malingerer, distracted by attention to the ankle jerk test, may permit full extension of the knee, which is the equivalent of full 90º SLR.
The accompanying neurological signs of L5 and S1 nerve root irritation are: (L5): weakness of dorsiflexion of ankle, big toe and inability to walk on heel. Numbness on dorsum of foot and lateral aspect of calf. (S1): weakness of plantarflexion, and inability to walk on toes. Numbness of sole and 5th toe. Weakness of ankle jerk.
e. Femoral stretch test: ask the patient to lie prone, or on the unaffected side if there is a painful flexion deformity of hip. Flex the knee slowly asking the patient to report onset of pain. If this fails to produce pain gently extend the hip with the knee still flex.
The accompanying neurological deficit in femoral roots compression: numbness on anteromedial aspect of the thigh and weakness of knee jerk.
Examine sacroiliac joint with patient in prone position, apply firm pressure over the sacrum.
Femoral nerve: L2, L3, L4
Sciatic nerve: L4, L5, S1, S2, S3
Useful language: I’m going to tap your back (percussion)
For prone position: lie on your front, or tummy.
Q.17 Painful knee, examine the knee.
Introduction, then you may say: “ I’m going to examine your knee, please undress your bottom half to your underwear, and stand up for me (Slip your trousers and leave your underwear/ don't worry about it).
Inspection: with the patient erect, then supine for limb alignment, bony contour, erythema, swelling, muscle wasting, and any genu valgus or varus.
Measures: muscle girth at 10 cm above patella (both sides).
Palpation: with knee extended palpate soft tissue, collateral ligaments for tenderness and temperature with dorsum of your hand. With knee flexed palpate along the joint line anterior and posterior for tenderness.
Movement: with patient supine, put your left hand on the knee to detect crepitation; ask the patient to fully flex knee and then to extend it. With patient in prone position, thigh supported on the couch and legs projecting from couch. Observe level of heels (test minor limitation of extension).
Test:
1. Massage test: (for effusion) with knee extended, massage any fluid in the anterior compartment of thigh into suprapatellar pouch. Then firmly stroke the lateral side of the joint with the palm of your hand. Observe any fluid impulse on medial side of the joint.
2. Patellar tap: (for effusion) with knee extended, empty suprapatellar pouch with pressure from the palm of your left hand. And with index of right hand, press patella firmly against femur.
3. Patellar apprehension test: (stability of patella) with knee extended, apply pressure with both your both thumbs on medial border of patella, and maintain pressure while slowly flexing the knee passively to 30º.
4. Anterior and posterior draw test: (cruciate ligament test) flex the knee and sit on the patient foot. Grasp upper tibia with your both hands and try to draw it forward (anterior cruciate ligament). Try to push it backward (posterior cruciate ligament).
5. Lachman test: (isolated cruciate ligament tear with intact collateral ligament) flex the knee to 20º, push the lower part of thigh in one direction and pull tibia in other direction, then reverse directions.
6. Collateral ligament test: with knee fully extended, hold the patient ankle between your elbow and side with both hands on upper tibia and attempt to abduct and adduct femur on tibia with knee straight.
7. Pivot shift test: (rotation in stability) with knee extended, hold the patient’s heel with right hand and fully internally rotate foot and tibia while apply valgus pressure to knee with your left hand. Flex the knee from 0º-30º to detect palpable or visible reduction.
8. McMurray test: (for menisci) flex the hip and knee to 90º, hold the patient’s heel with your right hand and hold the knee steady with your left hand. Externally rotate the tibia and slowly extend the knee. Repeat with internal rotation. If positive, clunk can be felt with some discomfort to the patient.
Q.18 Painful and stiff shoulder. Examine the shoulder.
Introduction, then you may say: “I’m going to examine your shoulder, if you don’t mind expose your top half, please”.
Inspection: inspect the shoulder from the front, side and back for deformity, swelling, muscle wasting, and SKIN lesion.
Palpation: swelling, tenderness in anterior aspect, bicepital groove, tip of shoulder, subacromial space and sternoclavicular joint.
Movement: ask the patient to place the palms at the base of neck with elbows pointing laterally. Then put arms down and reach between shoulder blades with dorsum of hands. Ask the patient to flex elbow to 90º and to do external and internal rotation of shoulder joint.
Test:
1. Glenohumeral joint movement: firmly hold tip of scapula. Ask the patient to flex arm (normally it can be flexed to 90º), and ask the patient to abduct the arm (normally it can be flexed to 90º).
2. If cannot abduct the arm, passively abduct it to 40º, the patient should now be able to abduct it (supraspinatus rupture).
3. Test for painful arc: (40º-120º) passively abduct arm. Ask the patient for any pain during this movement, and then ask him/her to bring the arm down.
4. Elicit impingement pain by passively flexing the shoulder to 90º, and then internally rotate it (Hawkin sign).
5. Test for bicepital tendonitis by asking patient to do flexion, and supination of elbow against resistance.
Q.19 A patient with right hip pain, examine the hip joint.
Introduction, then you may say: “ I’m going to examine your hip, please undress your bottom half to your underwear and stand for me”.
Inspection:
1. Ask the patient to walk and inspect the gait. In fixed flexion deformity, the buttock is prominent. And in abduction deformity, the patient swings the apparent long leg out and round with each step.
2. Ask the patient to stand up and inspect from back for scoliosis. From side for pelvic tilt which may conceal hip deformity.
3. Trendelenburg test: ask the patient to stand on one leg with flexing the lifted knee to 90º and observe. In normal conditions the pelvis is tilted up on the lifted side. In abnormal conditions, the pelvis is tilted down.
4. Ask the patient to lie on couch in supine position with pelvic brim at right angle to spine and inspect for deformity (abduction, adduction, flexion), swelling or redness, muscle wasting, and sinus formation. Compare.
Palpation: palpate for local tenderness over front of hip and greater trochanter.
Measurement of leg length: in case of apparent shortening. With legs parallel, do the measurement from xyphosternum to medial malleolus. In case of true shortening, place the normal leg in comparable position of abduction or adduction to abnormal one and measure from anterior superior iliac spine to medial malleolus.
Movement:
1. Stabilize iliac crest with left hand and use right hand to flex hip with knee flexed to 90º and note range of movement. The normal range is 0º-120º.
2. Thomas’ test: place one hand between patient lumbar spine and the couch. Flex the unaffected hip to its limit and continue to push to straighten lumbar spine. In normal condition, the opposite leg will remain flat, whereas in abnormal one the leg will rise from the couch and the degree of rise is the amount of flexion deformity.
3. Stabilize the opposite iliac crest with left hand, then abduct with right hand (normal is 45º) and adduct (normal is 25º).
4. Roll each leg on couch and measure range of rotation of foot as indicator (90º).
5. Flex hip and knee to 90º and rotate internally, the normal is 30º. And rotate it internally, the normal is 45º.
Q.20 A patient with Rheumatoid Arthritis, examine the hand.
Introduction, then you may start: “I’m going to examine your hand”.
Inspection:
1. Nails: for splinter hemorrhage, and nail fold infarcts.
2. SKIN : colour changes, pallor or cyanosis (Raynauld’s phenomenon).
3. Subcutaneous tissue: for nodules.
4. Tendons: for swelling.
5. Joints: for deformity (swan neck, Boutonniere, Z deformity of the thumb), ulnar deviation at MP, wrist, and sublaxation of MP and wrist.
6. Muscles: for wasting of s.m.s of hand.
Palpation:
1. Joints of hand, wrist, and periarticular tissue for tenderness, osteophytes and swelling.
2. Savill pinch test: pinch SKIN at palmar aspect of proximal phalanx. In normal condition it is lax and can be pinched, whereas in synovitis it is firm and tense.
3. Fell for local swelling and thickening of flex tendons at base of fingers while asking the patient to flex and extend the fingers.
Movement:
1. Ask the patient to grip two of examiners fingers and make a pinch.
2. Ask the patient to put hands in position of prayer and then lower the hands (wrist dorsiflexion).
3. Ask the patient to place backs of hands together and raise hands (wrist flexion).
4. Ask the patient to flex DIP while holding finger in extension at PIP (Flexor Digitorum Profondus).
5. Ask the patient to flex PIP while other fingers held in full extension (Flexor Digitorum Sublimis).
6. Ask the patient to extend IP while MP held in flexion (lumbricals).
7. Ask the patient to grip a card between two fingers while the examiner attempts to pull it (palmar interossei, adduction).
8. Ask the patient to spread fingers and press sides of index fingers against each other (dorsal interossei, abduction).
9. Ask the patient to abduct thumb and maintain against resistance; and to touch the terminal phalanx of little finger with thumb and maintain against resistance (thenar muscles, median nerve).
10. Ask the patient to hold a card between radial sides of index fingers and extend thumbs (adductor pollicis). The normal condition is when the thumb is extended, whereas it flexes if muscles are weak.
11. Ask the patient to place palm on flat surface and to lift the thumb like a hitchhiker. The patient is only able to do this if the tendon is intact (extensor pollicis longus).
Carpal tunnel syndrome:
1. Phalen’s sign is positive if pain is symptoms are increased when flexing the wrist passively for a minute or two.
2. Tinel’s test: is positive if percussion over carpal tunnel increases symptoms.
Finkelstein test for De Quervian’s tenosynovitis (tendon of abductor pollicis longus, and extensor pollicis brevis): move the wrist passively into ulnar deviation while patient holds thumb clenched into palm, if he/she feels pain the test is positive.
Test sensation: (check the dermatomes from any clinical examination book).
Q.21 a 25 year old patient fell on outstretched hand, now he/she complains of pain in the right wrist. Examine, look at x-ray, put a diagnosis, and do management.
Introduction, then you may say: “As far as I know you have pain in your right hand since yesterday”.
Ask about site, radiation, and aggravating and relieving factors. Any associated symptoms and severity.
Inspection: any swelling, deformity or bruises on the radial side of wrist.
Palpation: palpate for tenderness over the carpal bones in general, then in the anatomical snuff box, and apply axial pressure on the extended thumb or index finger.
Movement: ask the patient to flex and extend the wrist. Look for pain.
Investigation: request x-ray: anteroposterior, lateral, and 2 oblique views.
Diagnosis: FRACTURE of scaphoid bone.
Management: if the FRACTURE appears on the x-ray, then immobilize in scaphoid plaster from below the elbow to beyond knuckle including the thumb to base of nail until union occurs, which is usually around 8 weeks.
If no FRACTURE appears on x-ray, and scaphoid FRACTURE is strongly suggested on clinical ground then apply scaphoid plaster for 2 weeks. Repeat x-ray, then, which may show the FRACTURE as bone resorption occurs in that period. If FRACTURE is detected, then use plaster for 8 weeks. If FRACTURE does not appear and if bone scan is available, then we may use it. Also give the patient analgesic for pain relief. Some surgeon prefer internal fixation.
Complication:
1. Malunion: managed by bone graft or internal fixation.
2. Avascular necrosis of proximal fragment, which gets its blood supply from distal part. May cause osteoarthritis of wrist later on.
Check x-ray of wrist.
Q.22/A An overweight patient with severe pain in big toe, take history.
Introduction, then you may say: “As far as I know you have pain in your foot, I would like to ask you a few questions about your condition.
How long has the pain been there? (Duration). Is it there all the time or does it come and go? (Periodicity). Can you tell me exactly where the pain is? (Site). Does it spread? (Radiation). Do you have pain in other joints? Do you feel any heat over the toe? (Septic arthritis). Any SKIN rash? (SLE). Any redness of eye or pain on passing water? (Reiter’s syndrome)
Associated features: Have you had a similar pain before? Ask about predisposing factors to gout: have you had any injury or surgery recently? Do you have any disease, blood disease? Any recent illness? Are you on any medication? Aspirin? Do you eat a lot of red meat? Are you on any diet? Do you drink at all? How much of alcohol? Has anyone else in your family had similar condition? Do you have any tummy pain? Any kind of problem? Is it painful when you touch it, any swelling, and any redness?
Q.22/B A patient with knee pain and history of pain in big toe. Take history.
Introduction, then you may say: “As far as I know you have pain in your right knee. I would like to ask you a few questions and then I will explain to you what we will do.
How long has the pain been there? It is the first time? Is it there all the time or does it come and go? Have you sought medical advice in the first time? Did the doctor then, tell you what was it? Can you tell me exactly where the pain is? Does it go anywhere else? (Radiation) What brings on the pain? (Precipitating factors). Does anything seem to make the pain better or worse? Do you have pain in other joints (elbow, wrist, hand, back)? Is the pain worse when you get up in the morning and becomes better at the end of the day, or better in the morning and gets worse at the end of the day?
For gout ask:
Did you have any accident injury or surgery? Do you have any disease (blood disease, Rheumatoid Arthritis, Osteoarthritis)? Do you have any kind of problem, passed stone before with water? Are you on any medication? Aspirin? Do you eat a lot of red meat? Are you on any diet? Do you drink at all? How much of alcohol?
Q.23 A patient who feels dizzy on standing up. Measure blood pressure.
Introduction, then you may start by saying: “I’m going to measure your blood pressure. I will wrap this cuff around your arm and inflate it. This will cause you to feel your arm squeezed a little bit. Then I will deflate the cuff and get your blood pressure figures from this device. Then I would like/need to take it when you are standing up. Now would you tuck/pull the sleeve of your shirt up please.
Choose the right cuff and wrap it around the upper arm. Palpate brachial artery to put your stethoscope later. Put your hand on radial pulse and inflate cuff until pulse disappears (rough estimate of systolic pressure). Now inflate cuff another 10 mmHg and apply stethoscope over brachial artery. Deflate cuff and record systolic and
diastolic blood pressure (deflate by 1mm/Sec) Ask the patient to stand up (nurse will support you) and repeat the procedure. Or ask the examiner to hold the device for you while the patient is standing.
N.B.: cuff size (child 5cm, adult 15cm, obese 20cm, thigh 25cm) Sphygmomanometer should be at the same level of eye , support arm with your thumb on stethoscope and fingers around the back of elbow at about the heart level.
In normal individuals the systolic pressure measured on standing decreases by less than 20mmHg from the bp measured on sitting. And the diastolic pressure increases by less then 10mmHg. If the systolic pressure decreases by more then 20mmHg then the patient is having postural hypotension, which has several possible causes:
1. Hypovolaemia (haemorrhage, dehydration, diarrhoea).
2. Autonomic neuropathy (DM
, amyloidosis).
3. Drugs (Tricyclic Antidepressant, Ca channel blockers, ACE inhibitors).
4. Prolonged bed rest.
Treatment: stop or decrease the dose of the drug, teach the patient to stand in steps, compression stockings, drugs (NSAIDs, fludrocortisone).
Q.24 Blood pressure of 170/ 90mmHg. Comment.
British Hypertension Society defined a patient to be hypertensive if he/she has 3 readings of high blood pressure (systolic ³140mmHg, diastolic ³90mmHg) each a week apart. And suggests that treatment is needed when blood pressure measurements are:
1. Systolic ³200mmHg
2. Diastolic ³100mmHg
3. Systolic ³160mmHg + diastolic ³95mmHg
4. Systolic ³160mmHg + end organ damage
5. Diastolic ³90mmHg + end organ damage or other risk factors
So in this case we must exclude other risk factors:
1. Ask about family history, smoking, DM
, hyperlipidaemia and look for obesity.
2. End organ damage: ask about, dyspnoea, chest pain or discomfort upon exertion (heart failure, angina, etc.).
3. Past history of MI.
4. Tiredness, lethargy, facial and foot swelling (right heart failure).
5. Past history of stroke.
6. Pain in the limb on walking (intermittent claudication)
If no end organ damage nor other risk factor: follow up for 3-6months, if systolic pressure remains ≥ 160mmHg, give medical treatment.
Exclude secondary causes of hypertension:
1. Renal:
a. Renal artery stenosis: listen to renal bruit.
b. Chronic pyelonephritis: past history of loin pain, burning micturation or haematuria, stones.
c. Glomerulonephritis: face or foot swelling, change in the colour of urine.
2. Endocrine: Cushing syndrome (change in weight, redness of SKIN ). Pheochromocytoma (recurrent headache, sweating, palpitation).
Treatment of hypertension:
1. No drug treatment:
a. Stop smoking.
b. Optimize weight and healthy diet.
c. Encourage exercise.
d. Cut alcohol to nearly 1 U/day
e. Reduce stress.
2. Drug treatment: needs long term treatment, and compliance.
Thiazide diuretic: side effects: hyperuricaemia, hyperglycemia, hyperlipidaemia, hypokalaemia, hypomagnesaemia. Beta blockers: side effects: bradycardia, bronchospasm, fatigue, cold extremities, bad dreams, hallucination. Ca channel blockers: side effects: headache, flushing, ankle oedema. ACE inhibitors: side effects: postural hypotension, renal impairment, cough.
Q.26 A patient with central chest pain given 5mg Diamorphine by GP. You are given ECG, CXR, choose from drugs on table the ones you would use. & Management. (Contraindiction to Thrombolysis).
1. ECG: Changes of anterolateral MI (leads V1, V6 with leads aVL and I). ST elevation within hours. Formation of Q wave and inversion of T wave within days. Normalisation of ST segment with persistence of Q wave over months. (ECG changes depend on time from onset of infarct, generally:
a. Wide spread ST segment elevation.
b. T wave changes with Q wave appearance.
c. Bifid QRS complex.
2. CXR: Pulmonary oedema: hilar opacity, distended upper lobe veins, Kerly B lines, effusion at costophrenic angles, and cardiomegaly.
3. Management:
a. Manage the patient in CCU.
b. Continuous ECG monitoring.
c. Sit the patient up.
d. O2 %100, by face mask (if no lung diseases).
e. Insert IV cannula, give Frusemide 40-80mg IV Slow infusion.
f. Anti-emetic: Metoclopromide 10mg IV or Cyclizine 50mg IV.
g. GTN Nitroglycerine: 2 puffs sl or 2 tablets of 0.3mg Sl
h. If fast AF: Digoxin 0.5mg PO or IV.
i. If blood pressure > 110 Systolic. give Isosorbide DN IV infusion
j. If blood pressure < 100 Systolic, give Dobutamine 2.5-10 μg/Kg/min. If worse, venesection 500ml and ventilation.
k. Monitoring: Frequently blood pressure, PR, heart sounds, Input/Output (every 4 hrs). Daily: ECG, U&E, weight, and cardiac enzymes.
l. Aspirin 300mg.+ Thrombolysis (if indicated)
Thrombolysis:
Indication:
a. Chest pain within 12 hrs + ST elevation (> 2mm on chest leads, > 1mm on limbs leads) or R wave + ST depression in V1-V3 (post MI).
b. 12-24 hrs with chest pain and ECG evidence of evolving MI.
Contraindication:
a. Risk of Bleeding:
i. General: thrombocytopenia, heamophilia, severe liver disease, patients on warfarin with INR > 3.
ii. Local: recent stroke (within weeks), recent surgery (within weeks), trauma, Resucitation, eye bleeding (vitrous heamorrhage), peptic ulcer, GI bleeding, pregnancy, severe vaginal bleeding, tooth extraction, TB with cavitation (STREPT).
b. Hypertension: systolic > 200mmHg, diastolic > 120 mmHg.
c. Thrombus which might embolise, like in endocarditis, aortic aneurysm,
Warn the patient of %1 of possibility of stroke. Side effects: hypotension, anaphylaxis. If no response, consider angiography + angioplasty or CABG.
Q.27 A patient with chest pain. Take history and examine.
Introduction, then you may say: “As far as I know, you have pain in y | |
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