Professional Documents
Culture Documents
A Comprehensive Review
First Edition
Copyright @ 2011, Canadaprep.
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Care has been taken to confirm the accuracy of the information presented and to describe generally accepted
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consequences from application of the information in this book and make no warranty, expressed or implied,
with respect to the contents of the publication. The authors, editors, and publishers have exerted every effort
to ensure that drug selection and dosage set forth in this text are in accordance with the current
recommendations and practices at the time of publication. However, in view of ongoing research, changes in
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the reader is urged to check the package insert for each drug for any change in indications and dosage and
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This publication has not been authored, reviewed or supported by the Medical Council of Canada, nor is it
endorsed by the Medical Council as a review material for the NAC OSCE.
PREFACE
This book was written due to the lack of preparation material available for the National Assessment
Collaboration (NAC) Objective Structured Clinical Examination (OSCE). As an International Medical
Graduate (IMG) preparing for clinical and written exams in Canada, there is no comprehensive review
textbook available for the NAC OSCE. Due to the lack of resource materials, many students are forced to
study from sources that are not relevant to the NAC OSCE. This eventually hampers the candidate's score
in the examination.
This book aims to guide you through the steps of the NAC OSCE and ensures that you are well prepared
and a step ahead of the competition. A great effort has been put into collecting and organizing relevant
content for both the clinical OSCE stations and the written therapeutic exam.
Written by medical graduates who are oriented to the NAC OSCE, this comprehensive review can be used
as a framework, complementing your clinical skills and therapeutic knowledge as you prepare for the
examination.
This book is dedicated to all the IMGs preparing for the medical licensing examinations in Canada.
“And most important, have the courage to follow your heart and intuition. They somehow already know what you
truly want to become. Everything else is secondary.” - Steve Jobs
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TABLE OF CONTENTS
General Information
The National Assessment Collaboration, or NAC OSCE, was established to provide a system that streamlines
the assessment of IMG medical knowledge and clinical skills throughout Canada. Many international medical
graduates (IMGs) find that the path to obtaining a medical license in Canada challenging and difficult to
navigate. Different provinces and territories have their own system for assessing IMG medical knowledge and
clinical skills.
Comprised of a number of federal and provincial assessment and educational stakeholders, the NAC OSCE
aims to streamline the evaluation process through which an IMG must navigate to obtain a license to practice
medicine in Canada. Through such a system, an IMG’s path to licensure would be the same, regardless of the
jurisdiction in which he or she is being assessed. The NAC OSCE has replaced CEHPEA’s Clinical
Examination 1 (CE1), which was unique to Ontario.
Fees
Application Fee: $200 which is non-refundable, NAC OSCE Fee in Ontario: $1850 and Exam Date Change
Fee: $100
All fees are in (CAD) Canadian Dollars.
Examination station
The format for the National Assessment Collaboration (NAC) Objective Structured Clinical Examination
(OSCE) consists of 12 stations based on presentations of clinical scenarios. For a given administration, each
candidate rotates through the same series of stations. Each station is 10 minutes in length with two minutes
between stations.
At each station, a brief written statement introduces a clinical problem and outlines the candidate’s tasks (e.g.
take a history, do a physical examination, etc.). In each station, there is at least one standardized patient and a
physician examiner. Standardized patients have been trained to consistently portray a patient problem.
Candidates should interact with standardized patients as they would with their own patients.
The physician examiner observes the patient encounter. For most stations, the candidate will be asked to
respond to a series of standardized oral questions posed by the physician examiner after seven minutes with the
standardized patient. There are no rest stations.
Orientation videos http://www.mcc.ca/en/video/QEII-Orientation/index.html
2 NAC OSCE | A Comprehensive Review
The examination includes a separate written test of candidates’ therapeutic knowledge. This component lasts
45 minutes and consists of 24 short-answer questions testing the candidates’ knowledge of therapeutics for
patients across the age spectrum and related to pharmacotherapy, adverse effects, disease prevention and health
promotion.
Question: An otherwise healthy 55 year old male with a history of childhood “chickenpox”
presents with a 2 day history of painful unilateral vesicular eruption in a restricted
dermatomal distribution. You make a diagnosis of HERPES ZOSTER (shingles).
What would you choose as the drug of first choice to promote healing and lessen the
neuropathic pain? (Drug, dose, route of administration and duration are required.)
Answer:___________________________________________________________
Answer key the marker receives:
VALACYCLOVIR (VALTREX ®) 1000 mg PO tid X 7 days OR
FAMCICLOVIR (FAMVIR ®) 500 - 750 mg PO tid X 7 days OR
ACYCLOVIR (ZORIVAX ®) 800 mg PO 5X / day X 7 days)
Introduction to NAC OSCE | General Info 3
Q1. The abdominal examination of David Thompson revealed no organ enlargement, no masses and no
tenderness. What radiologic investigation would you first order to help discriminate the cause of the
jaundice?
Q2. If the investigations revealed that this patient likely had a post-hepatic obstruction, what are
the two principal diagnostic considerations?
Q3. What radiologic procedure would you consider to elucidate the level and nature of the
obstruction?
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Therapeutic Guidelines
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Therapeutic Guidelines | Medicine 7
Therapeutic Guidelines
Medicine
1. Cardiology
Acute Myocardial Infarction : Immediate management in ER
ACUTE MI TREATMENT
1. Beta blockers: Inj Metoprolol 2.5-5 mg rapid IV q2-5 min, upto MNEMONIC
15 mg over 10-15 minutes, then 15 minutes after receiving 15 mg IV. B : Beta Blockers
2. Then 50 mg PO q6h x 48 hours, then 50-100 mg PO BID. M : Morphine Sulphate
3. Inj Morphine Sulfate IV 2-5 mg every 5-30 min prn O : Oxygen
N : Nitroglycerin
(If pain not relieved with 3 Sublingual Nitroglycerins) A : Aspirin
4. Oxygen by nasal cannula at 4 liters per minute
5. Sublingual Nitroglycerin 0.3-0.6 mg q5min up to 3 times.
6. Non-enteric coated Aspirin 325 mg PO.
7. Cardiology Consultation
Post MI drugs
Statins ↓ mortality in post MI patients GI upset, muscle aches, Active liver disease,
Atorvastatin – 10mg od with high cholesterol myopathy, rhabdomyo- alcoholics, pregnancy
lysis, Impotence
Simvastatin – 20-40mg od
Anti-platelets ↓ vascular events GI upset, Recent/active
ASA – 80-162mg od hypersensitivity bleeding
Clopidogrel – 75mg od GI bleed GI intolerance or ASA
allergy
Warfarin – 1-10mg od
8 NAC OSCE | A Comprehensive Review
Atrial Fibrillation
1. To control rate:
• Inj Metoprolol 5 mg bolus IV, followed by infusion at 0.05 mg/kg/min, increasing as needed
to 0.2 mg/kg/min.
• Inj Diltiazem 20 mg bolus. Maintenance infusion of 5-15 mg/hr.
• Inj Verapamil 5-10 mg IV over 2-3 min, repeated once after 30 mins.
• Tab Amiodarone (in case of heart failure):
• Loading dose: 800 – 1600 mg PO in divided doses until response; till max 1000
mg/day divided bid-tid.
• Maintenance: 200 mg PO od.
2. To prevent thromboembolism: Assess with CHADS 2 score
• No risk: Tab Aspirin 81-325 mg PO od.
• 1 moderate risk: Tab Aspirin 81-325 mg PO od or Tab Warfarin 2-15 mg PO od to maintain
INR 2-3.
• > 1 moderate risk or very high risk: Tab Warfarin 2-15 mg PO od to maintain INR 2-3.
3. To control rhythm:
• Tab Flecainide 300-400 mg PO bolus dose, maintenance: 50-150 mg PO bid. (First choice)
• Tab Sotalol 80-160 mg PO bid. ( Second choice)
• Tab Amiodarone (in case of heart failure):
• Loading dose: 800 – 1600 mg PO in divided doses until response; till max 1000
mg/day divided bid-tid.
• Maintenance: 200 mg PO od.
• Electrical Cardioversion: 100-360 joules.
Dyslipidemia
High Risk : All with CAD, CVD, most diabetes cases & chronic renal disease.
Hypertension
• Smoking cessation: smoking aggravates hypertension and remains the major contributor to
cardiovascular disease in people under 65 years.
• Weight reduction : Maintain BMI<27, particularly in patients with glucose intolerance
• Alcohol restriction.
• Sodium restriction <150mmol/day.
Beta Blockers Stable angina, MI, LVH, Fatigue, insomnia, ↓HR, impotence,
nd rd
Metoprolol – 50mg bid or 100mg SR od uncomplicated HTN ≤60 years, dizziness. C/I – asthma/COPD, 2 /3
Propranolol – 80mg bid degree heart block, uncompensated HF
Atenolol – 50-100mg od severe PAD
ACE Inhibitors Heart failure, diabetes, post MI, Cough, loss of taste, rash, angioedema,
Ramipril – 10mg hs uncomplicated HTN, LVH, prior renal failure, ↓BP
Lisinopril – 10 mg od CVA/TIA, renal disease, all C/I – b/l renal artery stenosis, Hx of
Enalapril – 10-20mg od
coronary artery disease pts. angioedema, pregnancy
Captopril - 25-50 mg bid
Angiotensin II Receptor Blockers Diabetes, uncomplicated HTN, Fatigue, headache, rash, angioedema,
Losartan - 25-50mg od isolated systolic HTN, LVH, ↓BP, ↑K+, pancreatitis.
Valsartan – 80-160mg od patients unable to tolerate ACEI. C/I – b/l renal artery stenosis, Hx of
Candesartan – 8-16mg od angioedema, pregnancy
Calcium Channel Blockers Uncomplicated HTN, LVH, Angina, Dizziness, headache, rash, edema,
Amlodipine – 2.5-10mg od Isolated systolic HTN, diabetes gingival hypertrophy, worsen HF
Nefidipine - 10mg tid without nephropathy C/I – hypotension, recent MI with
Verapamil - 40-80mg tid pulmonary edema, sick sinus
nd
Diltiazem – 30-60mg tid syndrome, 2 /3rd AV block
Methyldopa – 125mg bid to 500mg qid First-line for hypertension in Sedation, dry mouth, hepatotoxic,
pregnancy lupus like symptoms.
2. Dermatology
Acne
Mild : <20 comedones (whiteheads/blackheads) or <15 inflammatory papules, or a lesion count <30
Moderate : 15-50 papules and pustules with comedones, cysts are rare, lesion count ranges from 30-125
Severe : Primarily nodules and cysts,also present are comedones, papules and pustules, scarring is present,
lesion count >125
st
T Benzoyl Peroxide (Antibacterial/Keratolytic) Indication: 1 line S/E : contact dermatitis,
O
Dose : apply to entire affected area qhs or bid medication for mild- dryness, erythema, burning
P
I moderate acne. & pruritis
C st
A Tretinoin (Retinoid) 1 line treatment for mild- S/E : erythema, dryness,
L Dose : qhs, apply 30-45 minutes after wash moderate comedones acne. burning, photosensitivity.
Burns
• Initial assessment of ABCs , consider the need for early intubation if airway is compromised.
• Humidified O2 if any suspicion for inhalational injury.
• Oxygen 100% if known carbon monoxide exposure of fire in an enclosed space. (Half life of
hemoglobin will drop from 330 to 90 mins).
• Establish IV access.
• Fluid resuscitation : Parkland formula 4mL/kg/%BSA burn, ½ over 8 hours and rest over 16 hours
• Nasogastric tube drainage for ileus.
• Bladder catheterization to monitor urinary output, minimum 1mL/kg/hr.
• Tetanus prophylaxis : 0.5 mL tetanus toxoid IM in previously immunized and 250 units TIG IM if
unimmunized.
12 NAC OSCE | A Comprehensive Review
Psoriasis
Topical Preparations :
1. Topical Corticosteroids :
• High Potency Topical Steroids (Usually indicated)
• Very high potency: e.g. Clobetasol (Temovate)
• High potency: e.g. Fluocinonide (Lidex)
• Low Potency Topical Steroids (Alclometasone dipropionate) usually indicated in
• Face
• Genitals
• Maintenance Therapy
2. Vitamin D based topicals :
• Calcipotriene (Dovonex)
• Used in combination with Topical Corticosteroids
3. Retinoid based topicals :
• Tazarotene (Tazorac)
• More irritating than Calcipotriene
4. Immunosuppressant based topicals :
• Tacrolimus 0.1% or Pimecrolimus 0.1% creams
Effective in facial and intertriginous Psoriasis
5. Adjunctive agents in combination with above :
• Topical Salicylic Acid (Keratolytic Agent)
6. Poorly tolerated topicals (use Calcipotriene instead) :
• Historically used with UVB light exposure
• Anthralin (Anthra-Derm)
• Coal Tar (e.g. Zetar)
Ultraviolet light
• Immunosuppressants
• Etretinate
• Cyclosporine
• Methotrexate (unclear efficacy)
Therapeutic Guidelines | Medicine 13
• Biological agents
• Tumor necrosis factor (TNF) receptor blockers
Etanercept (Enbrel)
Infliximab (Remicade)
• Other mechanisms
Alefacept (Amevive)
Efalizumab (Raptiva)
• Thiazolidinedione (Avandia, Actos) - experimental
• Appears effective in Psoriasis even in non-diabetics
• Only small trials support to date
Cellulitis
Pediculosis
• Permethrin 1% - wash hair with regular shampoo, then apply permethrin and leave for 10 mins then
rinse
• Pyrethrins with piperonyl butoxide
• Lindane 1% C/I in neonates, young children and pregnant women, causes neurotoxicity
• Wash all clothes and linen in hot water, then machine dry.
Scabies
• Permethrin 5% - massage into all skin areas, from the top of the head to the soles of the feet, leave for
8-14 hours then wash off.
• Crotamiton 10%
• Scabene (aerosol spray)
• Lindane : used only if allergic to permethrin.
• Treat family and contacts.
• Wash all clothes and linen in hot water, then machine dry.
3. Endocrinology
Diabetes Mellitus
• Fluid replacement
• Initial : Give 1 liter NS bolus over first 45 minutes, repeat fluid bolus until shock corrected.
• Next : Replace first 50% volume deficit in first 8 hours, use Normal Saline or Lactated
Ringers. Replace remaining 50% deficit over next 16 hours, use D5 1/2 NS at 150-250 ml per
hour.
• Insulin (Hypokalemia must be corrected prior to Insulin)
• Initial
i. Give IV bolus of 0.15 units/kg
ii. Start 0.1 units/kg/hour Insulin Drip
• Maintenance
i. Anticipate Serum Glucose drop of 50-70 mg/dl/hour
• If inadequate drop, then increase drip
a) Increase Insulin Infusion rate by 50-100%
b) Continue at increased rate until adequate
ii. When Serum Glucose <200-250 mg/dl
a) Keep Serum Glucose at 150 to 200 mg/dl
b) Decrease rate by 50% (to 0.05 units/kg) or
c) Discontinue Insulin Drip and start SC dosing
Therapeutic Guidelines | Medicine 15
• Potassium
Do not administer Insulin until potassium >3.3
• Give KCl 40 mEq/hour IV until corrects
• Serum Potassium 3.3 to 5.0 mEq/L
i. Standard replacement: 20-30 mEq per liter
• Serum Potassium >5.0 mEq/L
i. Do not administer any potassium
ii. Monitor every 2 hours until <5.0
• Bicarbonate
Indications
i. ABG pH < 6.9 to 7.0 after initial hour of hydration
ii. Other contributing factors
• Shock or Coma
• Severe Hyperkalemia
Hyperthyroidism
Hypothyroidism
Hyperprolactinemia
• Tab Bromocriptine 1.25-2.5 mg PO od, increase by 2.5 mg/day q3-7days to max 15 mg/day.
• Tab Cabergoline 0.25 mg PO twice weekly, may increase by 0.25 mg q4weeks up to max 1mg twice
weekly.
16 NAC OSCE | A Comprehensive Review
Impotence
• Tab Sildenafil 25-100mg per dose, to take half an hour to 4 hours prior to intercourse.
S/E: flushing, headache, indigestion
C/I: don’t take with Nitrates.
4. Gastroenterology
Appendicitis
Acute Gastroenteritis
Acute Gastroenteritis Causes
(Watery diarrhea)
• Tab Flagyl 500 mg PO bid x 5 days.
E. Coli (Traveler's diarrhea)
• Tab Ciprofloxacin 500 mg PO bid x 3 days.
CMV
• Tab Norfloxacin 400 mg PO bid x 3 days. Cryptosporidium
• Oral rehydration solution. Giardia lamblia
Therapeutic Guidelines | Medicine 17
Acute Pancreatitis
• NPO
• Inj Flagyl 400 mg IV q8h
• Inj Meperidine 75-100mg IV q2-3h
• IVF
• NG tube
• Replace calcium
Crohn’s Disease
1. Mild to moderate:
• Tab Mesalamine 800 mg PO tid. Maintenance dose 3.2 – 4g per day.
• Tab Sulfasalazine 250 mg per day and increase up to 2 g per day. Maintenance dose is 500-
1000 mg PO qid with food.
2. Moderate to severe:
• Tab Prednisone 40 mg PO qid x 8-12 weeks and taper gradually.
• Tab Azathioprine 2-2.5 mg/kg/day. Used for maintenance while tapering corticosteroids.
Diverticulitis
Helicobacter Pylori
Ulcerative Colitis
• Tab Sulfasalazine 250 mg per day and increase up to 2 g per day. Maintenance dose is 500-1000 mg
PO qid with food.
• Tab Mesalamine 800 mg PO tid. Maintenance dose 3.2 – 4g per day.
• Rectal suppositories preferred for proctitis.
5. Hematology
Anemia
6. Infectious Diseases
Malaria
Pulmonary tuberculosis
1. Initiation Phase: Tab Rifampin 600 mg + Tab Isoniazid 300 mg + Tab Pyrazinamide 2 g for
2 months.
2. Continuation Phase: Tab Isoniazid 300 mg + Tab Rifampin 600 mg for 4 months.
3. Add Tab Pyridoxine (Vit B6) 50 mg PO OD.
Rabies
7. Neurology
Seizures
1. Acute Management:
• Inj Diazepam 5-10mg IV q2-3mins till seizure stops. PHENYTOIN S/E
• Inj Phenytoin 20mg/kg IV at 50mg per min. P: P-450 interactions
• Inj Phenobarbital 20mg/kg IV at 50-75mg/min H: Hirsutism
E : Enlarged gums
• If all fails then rapid sequence intubation. N: Nystagmus
2. Primary Generalized & Partial seizures: Y: Yellow-browning of skin
T: Teratogenicity
• Tab Phenytoin: Loading 300mg PO q4h x 3 doses, O : Osteomalacia
I: Interference with folic acid
then 300mg PO qhs.
absorption (hence anemia)
• Tab Valproate: Loading 15mg/kg/day, increments by N: Neuropathies: vertigo,
5-10mg/kg/day qweekly, till seizures are controlled. ataxia, headache
• Tab Carbamazepine: Start 100-200mg PO od-bid,
increments by 200mg/per q2d, if needed till max
800mg-1200mg per day.
3. Absence Seizures:
• Tab Ethosuximide 500mg PO daily in divided doses, increments by 250mg/day q4-7d prn
till max 1500mg per day.
Meningitis
CSF Findings :
Cluster headache
• Tab Triptan and Tab Prednisone at the beginning of the cycle and prophylactic treatment with
Tab Lithium(300-600mg daily initially then monitor serum levels)
• Dihydroergotamine nasal spray 4mg per 1 ml. One spray each nostril and repeat q15mins.
Migraine
Tension headache
Myasthenia Gravis
1. Anticholinesterase (Cholinergic)
• Tab Mestinon (Neostigmine and Pyridostigmine): 60-120 mg q3-4h.
2. Immunosuppressive therapy
• Tab Prednisone: Start at 20 mg qd, increase gradually by 5 mg every 3 days to 60mg.
Continue for 3 months or until clinical improvement stops or declines. Taper gradually to
every other day
• Tab Azathioprine (Imuran) 2 mg/kg/day. Effective when given with Prednisone. Effect not
seen for 6 months or more. Monitor CBC and LFTs.
3. Plasmapheresis (Plasma Exchange) and IV Ig: Indicated for emergent worsening/crisis.
Response rate: 70%.
Parkinson’s disease
8. Otolaryngology
Acute Sinusitis
Acute Pharyngitis
9. Pulmonology
Asthma
1. Intermittent Asthma: Short acting beta-agonist - Salbutamol (Ventolin) Inhaler 1-2 puffs q4-6h prn.
2. Mild Intermittent Asthma:
• Long acting beta agonist - Salmeterol Inhaler 1-2 puffs bid.
• Inhaled steroids:
i. Fluticasone (Flovent) 2-4 puffs bid.
ii. Budesonide (Pulmicort) 2 puffs bid.
iii. Beclomethasone (Vanceril) 1-4 puffs (40µg) bid or 1-2 puffs (80µg) bid.
3. Moderate Persistent Asthma:
• Inhaled steroids:
i. Fluticasone (Flovent) 2-4 puffs bid.
ii. Budesonide (Pulmicort) 2 puffs bid.
iii. Beclomethasone (Vanceril) 1-4 puffs (40µg) bid or 1-2 puffs (80µg) bid.
• Long acting beta agonist – Salmeterol Inhaler 1-2 puffs bid.
• Leukotriene Receptor Antagonist:
• Tab Montelukast 10 mg PO qhs.
• Tab Zileuton 600 mg PO qid.
4. Severe Persistent Asthma:
• High dose Inhaled steroids.
• Long acting beta agonist.
• Leukotriene Receptor Antagonist.
• Systemic Steroids:
i. Tab Prednisone 2 mg/kg/day PO (max 60 mg/day).
ii. Inj Methylprednisolone (Depo-medrol) 2mg/kg IV, then 0.5 mg/kg q6h x 5days.
• Admit with nasal O2. Keep saturation between 88-92% . If silent chest/GCS < 8 or decreased LOC
then intubate.
• Elevated bed > 45 degrees.
• IVF.
• MDI : 8 puffs of Ventolin (Salbutamol) alternate with 8 puffs of Atrovent (Ipratropium) back to back
every 20 mins 3 times.
• Nebulizer : 2cc Ventolin + 1cc Atrovent in 3cc NS q20 mins x 3 times.
• Inj Hydrocortisone 125mg IV stat, if severe.
• Inj Ceftriaxone 1-2 g IV q24h along with
• Inj Piperacillin-Tazobactam 3.375 g IV q6h.
• Inj Methylprednisolone 2mg/kg IV, then 0.5 mg/kg q6h x 5 days.
Therapeutic Guidelines | Medicine 25
1. Outpatient management:
• Tab Doxycycline 100 mg PO bid x 7-10 days.
• Tab Erythromycin 250 – 500 mg bid x 7-10 days.
• Tab Azithromycin 500 mg PO od x 5 days.
• Tab Levofloxacin 500 mg PO od x 7–10 days.
• Tab Augmentin 500 mg/ 125 mg PO q8h x 5days.
2. Inpatient management:
• Inj Ceftriaxone 1-2 g IV bid along with
• Inj Levofloxacin 500 mg IV od x 7-10 days.
• Inj Azithromycin 50 mg IV over 1 hour od x 1-2 days.
Pulmonary Embolism
1. Investigations
• V/Q scan, spiral CT or D-dimer (if unlikely Wells' score < 4)
• CBC, INR, PTT, BUN, creatinine, ALT, AST.
2. Management: Initiation
• Start Warfarin (Coumadin) concurrent with Heparin.
• Contraindicated in pregnancy. (If contraindicated may put IVC filter)
• Start Tab Warfarin at 5 mg PO daily on Day 1-2 and Heparin 5000 U IV bolus followed by
continuous infusion 20 U/kg/hour, titrate to INR 2-3 then stop heparin within 24 hours.
• Check INR in 3-5 days.
• Therapeutic INR: 2.0 to 3.0 IU.
• Oxygen, and if pain give morphine or NSAID.
3. Management: Duration of Anticoagulation
• Very low risk: 6-12 weeks
• Symptomatic isolated calf vein thrombosis.
• Low risk patient: 3-6 months
• Reversible thromboembolism risk (transient risk such as post-operative PE).
• Upper extremity Deep Vein Thrombosis.
• Moderate risk patient: 6-12 months
• First idiopathic DVT or PE.
• High risk patient: 12 months or lifetime Anticoagulation
• Recurrent DVT or PE or Thrombophilia.
26 NAC OSCE | A Comprehensive Review
10. Rheumatology
Osteoporosis
• Tab Calcium (1500mg/day) and Tab Vitamin D (800 IU/day) intake in diet or as supplements.
• Bisphosphonates: Alendronate, Risedronate or Raloxifene.
• Hormone Replacement Therapy
• Calcitonin
• Recombinant Parathyroid Hormone
• Lifestyle modifications: Weight bearing exercises, smoking and alcohol cessation.
Osteoarthritis
Rheumatoid Arthritis
1. First Choice:
• Tab Naproxen 500 mg PO bid.
• Tab Ibuprofen 300-800 mg PO qid.
• Tab Indomethacin 25-50 mg PO bid or tid.
2. Analgesics: Tab Acetaminophen 500 mg PO tid prn.
3. Corticosteroids: given intra-articular
i. Small Joints:
• Inj Hydrocortisone 8-20 mg.
• Inj Methylprednisolone 2-5 mg.
• Inj Betamethasone 0.8 – 1.0 mg.
ii. Large Joints:
• Inj Hydrocortisone 40 100 mg.
• Inj Methylprednisolone 10 – 25 mg.
• Inj Betamethasone 2 - 4 mg.
Therapeutic Guidelines | Medicine 27
4. Disease Modifying Antirheumatic Drugs (DMARDs): Start within 3 months of diagnosis to reduce
disease progression.
i. Mild disease:
• Tab Hydroxychloroquine 200 mg PO bid.
• Tab Sulfasalazine 500 mg PO bid to tid.
ii. Moderate disease:
• Tab Methotrexate 10-15 mg PO once weekly, then increase to 20 mg PO once
weekly.
• Combination therapy:
• Methotrexate + Sulfasalazine + Hydroxychloroquine.
• Methotrexate + Cyclosporine.
• Methotrexate + Etanercept (biological DMARD).
iii. Biological DMARDs: used in persistent disease:
• Etanercept SC.
• Infliximab IV.
• Anakinra SC.
• Adalimumab SC.
• Abatacept IV.
• Rituximab IV.
NOTE:
• If Corticosteroids are used for> 3 months, do baseline DEXA and start bisphosphonate therapy.
• S/E of Corticosteroids: Osteoporosis, cataracts, glaucoma, peptic ulcer disease, avascular necrosis,
hypertension, increased infection rate, hypokalemia, hyperglycemia, hyperlipidemia.
• C/I to Corticosteroids: Active infection, hypertension, diabetes mellitus, gastric ulcer, osteoporosis.
Gout
1. Acute Gout:
i. NSAIDs: Tab Indomethacin 25-50 mg PO tid x 10-14 days.
ii. Tab Naproxen 500 mg PO bid x 4-10 days.
iii. Tab Colchicine 0.6 mg PO q1h till pain relief (max 4-6 doses), then bid x 3-5 days.
iv. Systemic Steroids: (rule out Septic Arthritis)
• Inj Methylprednisolone 40 mg IV single dose
• Inj Depo-Medrol 80-120 mg IM single dose.
• Oral: Tab Prednisone 40 mg PO od x 5days, then gradually taper the dose.
v. Intra-Articular Corticosteroid: used in large single joints & refractory cases.
• Inj Betamethasone 7 mg or Inj ACTH 40-80 IU.
2. Recurrent Gout: Treat for 3-6 months.
i. Over producers: Tab Allopurinol 100-300 mg/day PO.
ii. Under-excreters: Tab Probenecid 250 mg PO bid (max:1500 mg bid) or Tab Sulfapyrizine 50
mg PO bid (max: 1000 mg bid).
iii. Concurrently start with Tab Colchicine 0.6 mg PO bid x 3-6 months.
28 NAC OSCE | A Comprehensive Review
Temporal arteritis
• Start high dose Tab Prednisone 60 mg PO od until symptoms subside and ESR normal
• Then 40 mg PO od for 4-6 weeks
• Then taper to 5-10 mg PO od for 2 years (relapses occur in 50% if treatment is terminated before 2
years). Treatment does not alter biopsy results if the sample is taken within 2 weeks.
• Monitor ESR regularly.
• If visual symptoms are present, or develop during treatment, the patient is admitted and given
Inj Prednisolone 1000 mg IV q12h for 5 days.
1. General measures
• Consider concurrent Temporal Arteritis (See above)
• NSAIDs
2. Prednisone (key to management)
• See Corticosteroid Associated Osteoporosis
• Efficacy: 90% response
Dramatic improvement in first 48 hours
If no response to steroids – reconsider diagnosis
Reconsider diagnosis
Consider Methotrexate
• Polymyalgia alone
Dose: 15-20 mg PO qd
• Polymyalgia with Temporal Arteritis
Dose: 40-60 mg PO qd
Symptoms and signs remit within 1 month
Decrease dose by 10% each week after improvement
• Course
• Initial: Maintain starting dose for 1 month
• First steroid taper (depends on clinical response)
Taper by 2.5 mg per month down to 10 mg/day then
Taper 1 mg per 4-6 weeks down to 5 to 7.5 mg/day
• Final steroid taper
Indicated when symptom free for 6-12 months
Do not taper until sedimentation rate normalizes
Taper by 1 mg every 6-8 weeks until done
• Anticipate 2-6 year course of steroids
Relapse common in first 18 months of steroid use
Patients off steroids at 2 years: 25%
Therapeutic Guidelines | Medicine 29
Fibromyalgia
1. ANTIDEPRESSANTS : Benefits
• Assists with local pain, stiffness and sleep
• Does not affect Tender Points
2. Tricyclic Antidepressants
• Amitriptyline (Elavil)
i. First week: 10 mg PO qhs
ii. Next three weeks: 25 mg PO qhs
iii. Later: 50 mg PO qhs
• Nortriptyline (Pamelor)
3. Novel Antidepressants
• Venlafaxine (Effexor)
• Duloxetine (Cymbalta)
4. Selective Serotonin Reuptake Inhibitors (SSRI)
• Combination: Fluoxetine and Amitriptyline
Septic Arthritis
• Gonococcal: Inj Ceftriaxone 1g IV q24h x 2-4 days, then switch to Tab Ciprofloxacin 500 mg PO
bid x 7 days.
• Non-Gonococcal: Inj Naficillin 2g IV q4h x 2 weeks, then switch to Tab Ciprofloxacin 500 mg PO
bid x 2-4weeks.
11. Urology/Nephrology
Acute Pyelonephritis
Acetaminophen Intoxication
Alcohol withdrawal
Allergic Reaction
Anaphylaxis
Arrhythmias
ASA Intoxication
Diabetic ketoacidosis
Digoxin Intoxication
• Investigations : Plasma digoxin/digitoxin levels, ECG, electrolytes, BUN, Cr ( levels > 2.6 indicate
intoxication)
• Rx : Treat arrhythmias (common with digoxin intoxication; vfib, vtach, conduction blocks)
Gastric lavage / Charcoal (1g/kg) for ingestion
NaHCO3 or glucose and insulin
Ventricular tachycardia : Digibind 10-20 vials if dose unknown
Chronic toxicity : then Digibind 3-6 vials IV over 30 mins.
Follow ECG, K+, Mg+, Digoxin levels every 6 hours.
Hypertensive emergency
• Systolic BP ≥ 180mmHg and Diastolic BP ≥ 120mmHg (with signs of acute organ damage)
• Investigations : CBC, electrolytes, BUN, Creatinine, ABG, Urinalysis, CXR, ECG, BP in all four
limbs, Fundoscopy, Cardiology consult.
• 1st Line : Inj Sodium nitroprusside 0.3 mcg/kg/min IV OR Inj Labetalol 20mg IV bolus q 10 mins.
• Aortic dissection : Sodium nitroprusside + Beta blocker (esmolol)
• Catecholamine excess : Inj Phentolamine 5-15mg IV q 5-15 mins
• MI/Pulmonary edema : Inj Nitroglycerin 5-20mcg/min IV, increase by 5mcg/min every 5 min till
symptoms improve.
Hypoglycemia
• Investigations : Baseline blood glucose, insulin and C-peptide, check glucose q15 mins
until > 5mmol/L
• Rx : If patient can eat/drink : give 15g carbohydrate if BG < 4mmol/L (15g glucose tabs or ¾ caps
of juice or 3 spoons of sugar in water.)
NPO : give 25g carbohydrate if BG < 4mmol/L ( D50W 50cc IV push 1 amp OR
D10W 500cc IV OR glucagon 1-2mg IM/SC )
Opioid Intoxication
• Mental status effects include euphoria, sedation, decreased anxiety, a sense of tranquility and
indifference to pain produced by mild-to-moderate intoxication. Severe intoxication can lead to
delirium and coma.
• Physiological effects include the following:
Respiratory depression (may occur while the patient maintains consciousness)
Alterations in temperature regulations
Hypovolemia (true as well as relative), leading to hypotension
Miosis
Soft tissue infection
Increase sphincter tone (can lead to urinary retention)
• Treatment
IV glucose : 50% Dextrose 50ml
Inj Nalaxone 0.4mg upto 2mg IV for reversal of opioid intoxication.
Inj Thiamine 100mg IM stat & OD x 3days
O2, intubation & mechanical ventillation
Shock (Cardiogenic/Neurogenic)
• Rest
• Ice : using bag of ice, apply during the day for 5-20 mins every 2 hours.
• Compression : Tensor bandage or special supports.
• Elevation : Elevate the ankle as much as possible.
• Analgesics as needed.
• Crutches if too painful to bear weight.
Stroke
• Investigations : CBC, electrolytes, BUN, glucose, creatinine, INR/PTT, lipids, ECG, carotid doppler
if suspecting TIA, ABG, Non contrast urgent CT scan.
• Treatments : NPO, Foley catheter, DVT prophylaxis, Neurology consult
Rule out contraindications for thrombolytic treatment.
Urgent neurology consult.
Thrombolysis : rTPA within 3 hours of symptoms
Anti-coagulation : Low dose Heparin 5000 U bid, start Warfarin within 3 days,
monitor INR/PTT
If unable to thrombolyse or anti-coagulate then : Tab ASA 50-325mg od or
Tab Clopidogrel 75mg od
BP control : decrease slowly, IV Labetalol (First line treatment)
Bed rest, analgesics, mild sedation and laxatives, avoid hyperglycemia.
34 NAC OSCE | A Comprehensive Review
TCA Intoxication
• Patients who present to the ED following psychotropic drug overdose with GCS ≤ 8 should undergo
intubation at the earliest opportunity to prevent hypoventilation and aspiration pneumonia.
• Investigations : Drug levels, ECG, ABG, electrolytes, LFTs, RFTs.
• Rx : Activated charcoal 1gm/kg via NG
Diazepam for seizures
Wide QRS/Seizures : NaHCO3 ( 1-2 mEq/kg bolus dose and then 100-150 mEq in
1L D5/0.45% NaCl infused 100-200 ml/h IV)
Upper GI Bleed
• Stabilize patient with IVF, cross & type, 2 large bore IV cannulas.
• Investigations : CBC, platelets, INR, BUN, creatinine, PTT, electrolytes, LFTs
• Management : NG tube, NPO, blood transfusion if needed, upper GI endoscopy
Inj Octreotide 50mcg loading and 50mcg per hour (for varices) SC/IV
Inj Pantoprazole 50mg IV stat and 50mg q8h (gastric ulcer)
Lower GI Bleed
• Stabilize patient with IVF, cross & type, 2 large bore IV cannulas.
• Investigations : CBC, platelets, INR/PTT, BUN, creatinine, electrolytes.
• Management : NG tube, NPO, blood transfusion if needed, sigmoidoscopy, colonoscopy, angiogram
(for angiodysplasia)
Warfarin Intoxication
13. Counselling
Smoking cessation
Alcohol cessation
• Delirium Tremens
b. Gonorrhea:
Inj Ceftriaxone 125mg IM stat + Tab Doxycycline 100mg bid x 7 days.
If pregnant : Inj Spectinomycin 2g IM stat
Treat partner, Reportable disease.
c. Syphilis:
Primary, Secondary, Latent Syphilis (duration less 1 year ):
Inj Benzathine Penicillin G 2.4 MU IM for 1 dose
Treat partner, Reportable disease.
If allergic to Penicillin: Tab Doxycycline 100 mg PO bid for 14 days.
Late latent, Cardiovascular (duration over 1 year)
Inj Benzathine Penicillin G 2.4 MU IM once a week for 3 weeks
If Penicillin allergic : Tab Tetracycline 500 mg PO qid for 4 weeks or
Tab Doxycycline 100 mg PO bid for 4 weeks
Neurosyphilis : Inj Aqueous Penicillin G 3-4 MU IM every 4 hours for 10-14 days.
d. Genital herpes:
First episode: Tab Acyclovir 400mg PO tid x 10 days or
Tab Famciclovir 250 mg tid x 10 days or
Tab Valacyclovir 1 g bid x 10 days
Recurrent: Tab Acyclovir 400mg PO tid x 5 days or
Tab Famciclovir 120 mg bid x 5 days or
Tab Valacyclovir 500 mg bid x 5 days
Suppression: if more than 6 episodes per year
Tab Acyclovir 400mg PO bid x 12 months
Severe episode: Inj Acyclovir 5-10 mg/kg q8h x 5-7 days
SIDE EFFECTS:
• DOXYCYCLINE: Drug induced PHOTOSENSITIVITY, use sun screen
• ACYCLOVIR: headache, GI upset, impaired renal function, tremors, agitation, lethargy,
confusion, coma
Uncomplicated:
Tab Bactrim DS PO bid x 3 days or
Tab Nitrofurantoin 100mg PO qid x 5days. (with food)
In pregnancy: Treat asymptomatic UTI
Tab Amoxicillin 250mg PO tid or
Tab Macrobid 100mg PO bid x 10 days.
Pyelonephritis: Acute Uncomplicated:
Tab Ciprofloxacin 500mg PO bid x 10 days or
Tab Augmentin 625mg PO bid x 14 days.
Inpatient: Inj Ceftriaxone 1g IV bid for 48 hours then switch to oral drugs +
Inj Gentamicin 50mg IV q8h for 24 hours.
3. Vulvovaginitis
a. Candidiasis:
Tab Miconazole 200mg PV qhs x 3 days or
Tab Nystatin (100,00 unit) vaginal tab PV qhs x 14 days or
Tab Fluconazole 150mg PO stat dose.
Prophylaxis: 4 or more infection per year – Tab Fluconazole 150mg PO every
3days for 3 doses.
Maintenance: Tab Fluconazole 150mg PO each week. Monitor liver enzymes every 1-2
months.
b. Bacterial vaginosis:
Tab Flagyl 500mg PO bid x 7days.(with food)
c. Trichomonas vaginalis:
Tab Flagyl 2g PO for 1 dose. or
Tab Flagyl 500mg PO bid x 7days.(with food), treat partner.
d. Atrophic vaginitis:
Topical Estrogen cream 0.5 to 2g daily to be applied locally.
40 NAC OSCE | A Comprehensive Review
a. Outpatient: Inj Ceftriaxone 250mg IM stat dose + Tab Doxycycline 100mg PO bid x 14days.
b. Inpatient: Inj Cefoxitin 2g IV q6h + Inj Doxycycline 100mg IV q12h.
Continue IV for 48 hrs & then tab Doxycycline 100mg PO bid x 14 days.
Reportable disease, treat partners, rescreening after 4-6 weeks incase of documented
infection.
a. Mild DUB:
• NSAIDs – Tab Mefenamic acid 500mg PO tid x 5 days,
• Anitfibrinolytics – Tranexamic acid 500mg PO tid x 5 days, Combined OCPS
• Mirena / Provera
• Tab Progestin one tab OD in first 10-14days.
b. Severe DUB:
• Inj Premarin 25mg IV q4h + Tab Gravol 50mg PO q4h.
• With Tab Ovral PO tid till bleeding stops (24hrs),THEN bid for 2 days, THEN od for
3days.
• Continue conventional OCPs if pregnancy not desired.
6.Dysmenorrhea
7. Endometriosis
9. Emergency contraception
Tab Diclectin (10 mg Doxylamine with 10 mg Pyridoxin) started as 1 tab qAM + 1 tab qPM +
2 tabs qhs. Maximum 8 tabs per day.
Pediatrics
1. Acute Bronchiolitis
a. Mild distress: oral/IV hydration, antipyretics for fever, humidified O2, VENTOLIN 0.03cc in 3ml NS
by face mask q20min and then q1hr.
b. Moderate to severe distress: all the above + Ribavirin in high risk groups like congenital lung disease,
congenital heart disease, bronchopulmonary dysplasia, immunodeficient patients.
c. Antibiotics, ipratropium, systemic corticosteroids have no use.
a) First line:
Tab Amoxicillin 80-90mg/kg/day PO divided q8h for 10d.
If allergic – Tab Azithromycin 10mg/kg/day OD for 3 days. To be given if child > 6months
old.
b) Second line:
Tab Augmentin 90mg/kg/day divided q12h for 10 days or
Tab Cefuroxime 30mg/kg/day divided bid for 10 days.
Avoid FLUOROQUINOLONES under 16 years age.
3. Asthma
4. Bacterial Tracheitis
• Airway management, keep child calm.
• Humidified O2
• Nebulized racemic epinephrine(1:1000 solution) in 3ml NS, 1-3 doses, q1-2h.
• Inj Ceftriaxone 75-100mg/kg/day q24hrs + Inj Vancomycin 40mg/kg/day in divided doses every
6-8h.
46 NAC OSCE | A Comprehensive Review
5. Bacterial Pneumonia
6. Croup (Laryngotracheobronchitis)
a) Humidified O2
b) Nebulized racemic epinephrine(1:1000 solution) in 3ml NS, 1-3 doses, q1-2h :
• Child < 6mths: 0.25ml
• Child > 6mths: 0.5ml
• Adolescent: 0.75ml
c) Dexamethasone 0.6mg/kg IM/IV/PO, max dose 10mg, given as a single dose.
7. Epiglottitis
• Suspect epiglottitis if child has fever, ill looking, dyspnea, dysphonia, loss of voice, stridor, sudden in
onset.
• Investigations : Pharyngeal swab and culture
Blood culture
Lateral X-ray neck (Thumbprint sign)
ABG, CBC
Endoscopy in ER
• Treatment : Intubation
IV fluid
IV Cefuroxime
McIsaac Criteria – no cough, tender anterior cervical lymph nodes, erythematous tonsils with exudate,
fever > 38°C, age 3-14 years.
a) If 1 symptom only – no culture or antibiotics needed.
b) If > 1 symptom, culture positive – treat with antibiotics:
Penicillin V 40 mg/kg/day PO divided bid x 10 days.
Erythromycin 40mg/kg/day PO divided tid x 10 days.
Acetaminophen for fever or pain.
c) Invasive GAS: needs admission –
Inj Clindamycin 40 mg/kg divided into 3-4 doses and
Inj Penicillin 250 000 – 400 000 U/kg/day divided into 6 doses x 10 days.
a) Inj Dexamethasone 0.6 mg/kg/day IV in 4 divided doses. Start within 1 hour of 1st antibiotic
dose..
b) Ampicillin:
i. Age< 1 month – 50 mg/kg IV q8-12h.
ii. Age>1 month – 50 mg/kg IV q6h.
c) Cefotaxime:
i. Age < 1 month – 50 mg/kg IV q8-12h.
ii. Age>1 month – 200 mg/kg/day IV divided q6-8h.
d) Ceftriaxone:
i. Age< 1 month – 50-75 mg/kg IV divided q12-24h.
ii. Age> 1 month – 100 mg/kg/d IV divided q12h.
e) Gentamycin: 2-2.5 mg/kg IV q8h.
f ) Vancomycin: 15 mg/kg q6h IV x 7-14 days.
g) Prophylaxis for contacts:
i. H. Influenzae : Rifampin 20 mg/kg/day up to 4 days.
ii. N. Meningitides :
• Rifampin
• Children: 10 mg/kg PO q12h x 2 days (max 600 mg).
• Adults: 600 mg PO q12h x 2 days.
• Ciprofloxacin (adults) 500mg PO for one dose.
• Ceftriaxone :
• Age<15 years: 125 mg IM for one dose.
• Age> 15 years: 250 mg IM for one dose.
a) General Measures:
i. ABC management.
ii. Oxygen.
iii. IVF.
iv. Nebulised beta-agonist (Albuterol).
b) Anaphylaxis with airway compromise: Epinephrine (1:1000 solution) 0.01ml/kg SC/IM(upto 0.3ml)
c) Urticaria, Pruritus or Flushing: Inj Diphenhydramine 25-50mg IM/IV every 6hrs prn. Orally same
dose q6h x 3days.
d) Prevention:
i. Medical alert bracelet.
ii. Strict avoidance of allergen.
iii. EpiPen.
iv. Allergy testing and desensitization therapy.
Psychiatry
Delirium
• Delirium or acute confusional state is a common and severe neuropsychiatric syndrome with core
features of acute onset and fluctuating course, attentional deficits and generalized severe
disorganization of behavior. Treatment of delirium requires treatment of the underlying causes.
• Antipsychotics are first-line treatment. Haloperidol is the most effective medication for decreasing
agitation in delirious patients. First generation antipsychotic Loxapine and second generation
(atypical) antipsychotics such as Olanzapine,Risperidone and Quetiapine can also be used.
Benzodiazepines should be reserved for cases of alcohol withdrawal.
Mania
• Mania is a state of abnormally elevated or irritable mood, arousal, and/ or energy levels. Treatment of
mania involves both acute control of severe agitation by a mood stabilizer and long term mood
stabilizers. Initially atypical antipsychotics such as Risperidone, Olanzapine or Quetiapine are effective.
First-generation Antipsychotics
• Haloperidol : 5-10 mg/day PO/IM
Atypical antipsychotics
• Risperidone : 2-3 mg/day PO
• Olanzapine : 5-20 mg/day PO, 2.5-10 mg IM (repeat 2h and 6h prn to max of 30 mg/24 h)
• Quetiapine : start with 100 mg/day PO; increase by 100 mg/day as needed to 300-600 mg/day
divided BID
2. Anxiety Disorders
• Anxiety disorders are a group of conditions with exaggerated anxiousness and worry about a number of
concerns persists for an extended period of time.
• Stress reduction and relaxation techniques such as meditation and low impact yoga is often helpful.
• Cognitive behavioral therapy (CBT)
• Reduction of consumption of caffeine and other stimulants.
• Minimize use of alcohol
Panic disorder
• Panic attack or panic disorder involves sudden anxiety that occurs without warning. Symptoms can
include chest pain, heart palpitations, sweating, shortness of breath, feeling of unreality, trembling,
dizziness, nausea, hot flashes or chills, a feeling of losing control, or a fear of dying. Panic attacks are
extremely common - 10% to 20% of the population experience a panic attack at some point in their
life. Some people start to avoid situations that might trigger a panic attack; this is called panic attack
with agoraphobia. Panic disorder refers to recurring feelings of terror and fear, which come on
unpredictably without any clear trigger.
• SSRIs and SNRIs are the first choice in the treatment of panic disorders. Selective serotonin reuptake
inhibitors (SSRIs) like Citalopram, Escitalopram, Fluoxetine, Paroxetine and Sertraline are all
effective in reducing panic attacks. Serotonin norepinephrine reuptake inhibitor (SNRIs) eg.
Venlafaxine is also used in panic disorder.
• There is a delay in the onset of response to these drugs which may be accompanied by initial agitation.
Combining SSRI or SNRI with a brief course of low dose benzodiazepine can increase adherence to
medication and produce rapid response.
• Other medication include Tricyclic antidepressants (TCAs) eg. Imipramine, Desipramine and
Clomipramine and Monoamine oxidase inhibitors (MAOIs) eg. Phenelzine, Tranylcypromine.
54 NAC OSCE | A Comprehensive Review
Social Phobia
• Social anxiety, also known as social phobia, involves excessive anxiety in social situations where people
fear being embarrassed or made fun of. Situations that can trigger social anxiety include small group
discussions, dating, going to a party, and playing sports. Common symptoms of social anxiety include
blushing, sweating, and dry mouth. People with social phobia often avoid social situations that cause
anxiety.
• SSRI and SNRI are mainstay drugs for the treatment for social phobia. Escitalopram, Fluvoxamine,
Paroxetine, Sertraline and Venlafaxine may be used for milder cases.
• Simple stage fright or fear of public speaking may respond to low dose Propranolol 10mg taken 30
minutes before the event.
• Generalized anxiety disorder (GAD) is associated with continual excessive anxiety and worry about a
number of things (e.g., work, money, children, and health). There is no specific source of fear.
Symptoms can include muscle tension, trembling, shortness of breath, fast heartbeat, dizziness, dry
mouth, nausea, sleeping problems, and poor concentration. CBT is the most effective psychosocial
treatment but often takes 20 or more sessions to be effective.
• SSRIs and SNRIs have become established as first line treatments for GAD. Bupropion and
Pregabalin are further choices. Low dose benzodiazepines can be used but dependence is a problem.
Buspirone has a low abuse potential and is less sedating than benzodiazepines.
• Buspirone : 5mg bid-tid, up to 60 mg/day
Therapeutic Guidelines | Psychiatry 55
• Pregabalin : Initial 150 mg/day in 2-3 divided doses, may be increased to 150 mg bid after 1 week if
necessary
• Bupropion (Wellbutrin, Zyban): Use : Smoking cessation, second line Antidepressant.
Antidepressant: Start 100 mg bid x 4 days 100 m g tid.
• OCD involves recurring unpleasant thoughts (obsessions) and/or repetitive behaviours (compulsions).
The thoughts may be connected to the repetitive behaviours. For example, people who fear getting an
infection may constantly wash their hands. At times, however, there's no connection at all between the
thoughts and the behaviours.
• CBT is the psychotherapy of choice. SSRIs : Fluoxetine, Fluvoxamine, Paroxetine and Sertraline, in
the usual antidepressant dosing range are the drugs of choice in Canada. It may take 6-8 weeks for
symptoms to improve. Second line drugs include Clomipramine, Venlafaxine, Citalopram and
Mirtazapine.
• PTSD is associated with extreme anxiety that appears after a traumatic experience. Symptoms usually
start within 3 months of the traumatic event but may take years to start. PTSD can be associated with
sleep problems, nightmares, irritability, and anger. Feelings of guilt and unworthiness are common with
PTSD. Traumatic experiences that can trigger PTSD include wars, plane crashes, natural disasters
(e.g., hurricane, earthquake), and violent crimes (e.g., rape, abuse).
• SSRI and SNRI antidepressants have been shown to be effective in reducing the symptoms of PTSD.
Fluoxetine, Paroxetine, Sertraline and Venlafaxine are first line options.
3. Dementia
4. Depression
Nonpharmacological treatment
• Cognitive behavioral and interpersonal psychotherapy are as effective as antidepressants in mild to
moderate depression.
Pharmacological treatment
• Take medication daily, antidepressant must be taken for 2 to 4 weeks for effect to be noticeable.
Medication must be taken even if patient is feeling better.
SSRI
• Paroxetine (Paxil): Start 20 mg qhs, increase 10mg every 2wks, max 60mg per day.
• Fluoxetine (Prozac): Start 20mg PO qd, avoid increasing more often than monthly, max 80mg PO per
day
• Sertraline (Zoloft): Start 50mg PO qAM, increase 50mg every 2 weeks, max 200mg per day
• Fluvoxamine (Luvox): Start 25mg PO qhs x 3 days -> 50mg PO qhs x 7 days -> titrate 150-250 mg
daily divided doses bid.
• Citalopram (Celexa): Start 20mg PO qd, max 60mg.
• Escitalopram (Lexapro): Start 10mg PO qd
Monoamine Oxidase Inhibitor (MAO inhibitor): Use in Atypical depression, Refractory depression.
• Isocarboxazid (Marplan) – 10 mg PO bid, max 60 mg per day.
• Phenelzine (Nardil) – 15 mg PO tid, max 90 mg per day.
• Tranylcypromine (Parnate) – 10-40 mg per day in divided doses, max 60 mg per day.
Complication: Hypertensive crisis, Serotonin syndrome. Interaction with tyramine containing foods to
be avoided strictly.
Serotonin Norepinephrine Reuptake Inhibitors(SNRI) not used these days
• Tricyclic Antidepressants: Amitriptyline 25 mg qhs, Nortriptyline (Pamelor)
S/E: Anti-cholinergic – dry mouth, constipation, blurred vision, Anti-histaminergic – sedation, weight
gain; Serotonergic – sexual dysfunction; Orthostatic hypotension; Sinus tachycardia, SVT, Ventricular
tachycardia, Prolonged QT interval, heart block; Withdrawal symptoms.
Other : Venlafaxine (Effexor) 37.5 mg PO od.
6. Psychosis
In acutely psychotic individuals, short-acting parenteral antipsychotics either alone or in combination
with a parenteral benzodiazepine may be recommended. Liquid formulations of atypical antipsychotics may be
used as an alternative to intramuscular injections, Risperidone and Olanzapine are examples.
Atypical antipsychotics :
• Clozapine – 12.5 mg PO qd or bid, titrate slowly upwards in increments of 25-50 mg/day
Target dose : 300 – 450 mg/day, max 900 mg/day.
S/E: Agranulocytosis, Diabetes mellitus, hypertriglyceridemia.
NOT 1st LINE Anti-psychotic. Order weekly blood counts for 1 month and then q2 weeks.
Therapeutic Guidelines | Psychiatry 57
Typical antipsychotics:
• Haloperidol (Haldol)– 5-10 mg PO, IM, IV. May repeat q30-60mins, max 300 mg per day.
• Fluphenazine (prolixin) – 2.5 mg PO bid, max 40 mg per day.
2. Antihypertensives
• Centrally acting sympatholytics (e.g. Clonidine)
• Peripherally acting sympatholytics (e.g. Guanadrel)
• Beta Blockers
• Thiazide Diuretics
3. Antidepressant Medications
• Selective Serotonin Reuptake Inhibitors (SSRI)
• Tricyclic Antidepressants
• MAO inhibitors
4. Sedative-Hypnotic Medications
• Barbiturates
• Benzodiazepines
5. Drug Abuse
• Alcohol Abuse
• Heroin abuse
• Marijuana abuse
• Methadone
• Tobacco abuse
6. Other Medications
• Anticholinergic Medications
• Antipsychotic Medications
• H2 Receptor Blockers
Therapeutic Guidelines | Psychiatry 59
9. Substance abuse
• Alcohol withdrawal:
• Tab Diazepam 20 mg PO q1-2h prn .
• Observe for 1-2 hours and re-assess.
• Inj Thiamine 100 mg IM then 100 mg PO OD x 3 days.
• Maintain hydration.
• If oral Diazepam not well tolerated then switch to Inj Diazepam 2-5 mg IV/min – maximum
10-20 mg q1h, or S/L Lorazepam.
• If severe liver dysfunction ,severe asthma, respiratory failure or age> 65 years present –
Lorazepam PO/SL/IM 1-4 mg q 1-2h.
• Hallucination present – Haloperidol 2-5 mg IM/PO q1-4h – max 5 doses/day along with
Diazepam 20 mg x 3 doses as seizure prophylaxis.
• Wernicke’s syndrome: Thiamine 100 mg PO OD x 1-2 weeks.
• Korsakoff ’s syndrome: Thiamine 100 mg PO bid/tid x 3-12 months.
• Opioid Intoxication:
• ABCs
• IV Glucose
• Inj Naloxone (Narcan) 0.4 mg – 2mg IV.
• Intubation and mechanical ventilation may be required for decreased level consciousness.
• Cocaine Overdose:
• ABCs
• Inj Diazepam 2-5 mg IV/min – maximum 10-20 mg q1h ( to control seizures).
• Propranolol or labetalol to treat hypertension and arrhythmia.
• Hallucinogens: LSD, mescaline, psilocybin, MDMA.
• Symptomatic treatment and supportive care.
• Decreased stimulation.
• Benzodiazepines or antipsychotics might be required.
• Phencyclidine:
• Room with minimal stimulation.
• Inj Diazepam IV for muscle spasms or seizures.
• Haloperidol to suppress psychotic behavior.
NOTES
Clinical Examination
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Clinical Examination 63
Abdominal Examination
• Introduce yourself : “I am Dr. ________, your attending physician and I'll be examining you today. At
any point of the examination you feel uncomfortable, please let me know and I'll stop the examination
right there.”
• Wash/Sanitize hands
• Explain to the patient what you are about to do and gain informed consent.
• Look for medical equipment/therapies (e.g. drains, colostomy/ileostomy bags).
• Verbalize the steps of the examination and your findings.
• Use proper draping techniques.
2. Inspection
• General inspection of the patient : Is patient comfortable at rest? Do they appear to be tachypnoeic?
• Examine the patient's hands for presence of koilonhychia (iron deficiency), leukonychia
(hypoalbuminemia), clubbing (IBD, coeliac disease, cirrhosis), palmar erythema, tar staining or
Dupuytren's contracture.
• Ask the patient to hold their hands out in front of them looking for a any tremor and then get them
to extend their wrists up towards the ceiling keeping the fingers extended and look for flapping
(asterixis in hepatic encephalopathy).
• Examine the face, check the conjunctiva for pallor. Also check the sclera for jaundice. Look at the
buccal mucosa for any obvious ulcers which could be a sign of Crohn's disease, B12 or iron deficiency.
Also look at the tongue. If it is red and fat it could be another sign of anaemia, as could angular
stomatitis. Check state of dentition – pigmentation of oral mucosa (Peutz-Jegher's syndrome),
telangectasia, candidiasis.
• Examine the neck for an enlarged left supraclavicular lymph node. A palpable enlarged supraclavicular
(Virchow's) node is known as Troisier's Sign, may be a sign of malignancy. Virchow's node drains the
thoracic duct and receives lymphatic drainage from the entire abdomen as well as the left thorax.
Therefore, enlargement of this node may suggest metastatic deposits from a malignancy in any of
these areas.
• Examine the chest, in particular look for gynaecomastia in men and the presence of 5 or more spider
naevi. These are both stigma of liver pathology.
• Inspect the abdomen and comment on any obvious abnormalities such as scars, masses and pulsations.
Also note if there is any abdominal distension/ascites. Look for distended veins, striae, Cullen's/Grey-
Turner's signs (pancreatitis), Sister Mary Joseph's nodule (widespread abdominal cancer)
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3. Auscultation
4. Palpation
5. Percussion
Percussion over the abdomen is usually resonant, over a distended liver it will be dull. Percussion can also
be used to check for 'shifting dullness' - a sign of ascites. With the patient lying flat, start percussing from
the midline away from you. If the percussion note changes, hold you finger in that position and ask the
patient to roll towards you. Again percuss over this area and if the note has changed then it suggests
presence of fluid such as in ascites. It is also appropriate at this time to check for pedal edema.
6. You should mention to the examiner at this point that you would like to finish the examination with an
examination of the hernial orifices, the external genitalia and also a rectal examination.
Clinical Examination 65
Cardiovascular Examination
• Introduce yourself : “I am Dr. ________, your attending physician and I'll be examining you today. At
any point of the examination you feel uncomfortable, please let me know and I'll stop the examination
right there.”
• Wash/Sanitize hands
• Explain to the patient what you are about to do and gain informed consent.
• Look for medical equipment/therapies (e.g. GTN spray, ECG pads, oxygen)
• Verbalize the steps of the examination and your findings.
2. Inspection
• Start by observing the patient from the end of the bed. You should note whether the patient looks
comfortable. Are they cyanosed or flushed?
• Respiratory rate, rhythm and effort of breathing.
• Chest shape, chest movements with respration (symmetrical/assymetrical), skin (scars/nevi)
• Inspect the nails for clubbing, splinter hemorrhages (infective endocarditis), koilonychia (iron
deficiency anemia).
• Inspect fingers for capillary refill time, peripheral cyanosis, osler's nodes (infective endocarditis) and
nicotine staining.
• Inspect palms for palmar erythema, Janeway lesions and xanthomas.
• Take the radial pulse, assess the rate and rhythm.At this point you should also check for a collapsing
pulse – a sign of aortic incompetence. Locate the radial pulse and place your palm over it, then raise
the arm above the patient’s head. A collapsing pulse will present as a knocking on your palm.
At this point you should say to the examiner that you would like to take the blood pressure. They will
usually tell you not to and give you the value.
• Inspect the sclera for any signs of jaundice, anaemia and corneal arcus. You should also look for any
evidence of xanthelasma.
• Whilst looking at the face, check for any malar facies, look in the mouth for any signs of anaemia such
as glossitis, check the colour of the tongue for any cyanosis, and around the mouth for any angular
stomatitis – another sign of anaemia.
• Assess jugular venous pressure ( JVP), ask patient to turn their head to look away from you. Look
across the neck between the two heads of sternocleidomastoid for a pulsation then measure the JVP.
• Examine the chest, or praecordium for any obvious pulsations, abnormalities or scars, remembering to
check the axillae as well.
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3. Palpation
• Palpate praecordium trying to locate the apex beat and describe its location anatomically. The normal
location is in the 5th intercostals space in the mid-clavicular line.
• Palpate for any heaves or thrills. A thrill is a palpable murmur whereas a heave is a sign of left
ventricular hypertrophy. Feel for these all over the praecordium.
4. Auscultation
How many heart sounds are heard? Are the heart sounds
normal in character? Any abnormal heart sounds? If you hear any abnormal sounds you should describe
them by when they occur and the type of sound they are producing. Are there any murmurs? Can you hear
any rub? Feeling the radial pulse at the same time can give good indication as to when the sound occurs –
the pulse occurs at systole. Furthermore, if you suspect a murmur, check if it radiates. Mitral murmurs
typically radiate to the left axilla whereas aortic murmurs are heard over the left carotid artery.
• To further check for mitral stenosis you can lay the patient on their left side, ask them to breathe in,
then out and hold it out and listen over the apex and axilla with the bell of the stethoscope.
• Aortic incompetence can be assessed in a similar way but ask the patient to sit forward, repeat the
breathe in, out and hold exercise and listen over the aortic area with the diaphragm.
5. With patient sitting up percuss back for pleural effusion (cardiac failure)
7. Finish by thanking the patient and ensuring they are comfortable and well covered.
Clinical Examination 67
• Introduce yourself : “I am Dr. ________, your attending physician and I'll be examining you today. At
any point of the examination you feel uncomfortable, please let me know and I'll stop the examination
right there.”
• Wash/Sanitize hands
• Explain to the patient what you are about to do and gain informed consent.
• Look for medical equipment/therapies (e.g. GTN spray, ECG pads, oxygen)
• Verbalize the steps of the examination and your findings.
2. Inspection
• General observation of the patient, arms from the finger tips to the shoulder and legs from the groin
and buttocks to the toes. Comment on the general appearance of the arms and legs, size, swelling,
symmetry, skin color, hair, scars, pigmentation including any obvious muscle wasting. Note colour and
texture of nails.
• Any signs of gangrene or pre-gangrene such as missing toes or blackening of the extremities.
• The presence of any ulcers – ensure you check all around the feet including behind the ankle. These
may be venous or arterial – one defining factor is that venous ulcers tend to be painless whereas
arterial are painful.
• Any skin changes such as pallor, change in colour (eg purple/black from haemostasis or brown from
haemosiderin deposition), varicose eczema or sites of previous ulcers, atrophic changes and hair loss.
• Presence of any varicose veins – often seen best with the patient standing.
3. Palpation
• Assess the skin temperature. Starting distally, feel with the back of your hand and compare each limb
to the other noting any difference.
• Check capillary return by compressing the nail bed and then releasing it. Normal colour should return
within 2 seconds. If this is abnormal, perform Buerger’s Test. This involves raising the patient’s feet
to 45º. In the presence of poor arterial supply, pallor rapidly develops. Following this, place the feet
over the side of the bed, cyanosis may then develop.
• Any varicosities which you noted in the observation should now be palpated. If these are hard to the
touch, or painful when touched, it may suggest thrombophlebitis.
• Palpate peripheral pulses. These are:
Carotid – only palpate one carotid at a time
Radial – use the pad of three fingers
Brachial – may use thumb to palpate
Femoral – feel over the medial aspect of the inguinal ligament.
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Popliteal – ask the patient to flex their knee to roughly 60º keeping their foot on the bed,
place both hands on the front of the knee and place your fingers in the popliteal space.
Posterior tibial – felt posterior to the medial malleolus of the tibia.
Dorsalis pedis –feel on the dorsum of the foot, lateral to the extensor tendon of the great toe.
You should compare these on both sides and comment on their strength.
• Check for radio-femoral delay. Palpate both the radial and femoral pulses on one side of the body. The
pulsation should occur at the same time. Any delay may suggest coarctation of the aorta.
5. Special Tests
• Allen Test : Ask the patient to make a tight fist and elevate the hand. Occlude the radial and ulnar
arteries with firm pressure. The hand is then opened. It should appear blanched (pallor can be
observed at the finger nails). Release either the Ulnar or radial artery pressure and the color should
return in 7 seconds. If the palm does not redden immediately, this suggests arterial insufficiency.
• Straight Leg Raise and Refill Test (Buerger's Test) : Raise the leg 45o to 60o for 30 seconds until
pallor of the feet develops and observe empty veins. Sit the patient upright and observe the feet. In
normal patients, the feet quickly turn pink (within 10-15 seconds). If, pallor persists for more than 10-
15s or there is development of a dusky cyanosis (rubor), this suggests of arterial insufficiency.
• Test for incompetent Saphenous Vein : Ask the patient to stand and note the dilated varicose veins.
Compress the vein proximally with one hand and place the other hand 10-15 cm distally. Briskly
compress and decompress the distal site. Normally, the hand at the proximal site should feel no
impulse, however with varicose veins a transmitted pulse may be felt.
• Trendelenburg Maneuver (Retrograde filling) : Ask the patient to lie down. Elevate the leg, and
empty the veins by massaging distal to proximal. Using a tourniquet, occlude the superficial veins in
the upper thigh. Ask the patient to stand. If the tourniquet prevents the veins from re-filling rapidly,
the site of the incompetent valve must be above this level i.e. at the sapheno-femoral junction. If the
veins re-fill, the communication must be lower down.
Observing the same protocol, proceed down the leg until the tourniquet controls re-filling. As
necessary, test:
• above the knee - to assess the mid-thigh perforator
• below the knee - to assess competence between the short saphenous vein and popliteal vein
If re-filling cannot be controlled, the communication is probably by one or more distal perforating
veins.
Clinical Examination 69
Respiratory Examination
• Introduce yourself : “I am Dr. ________, your attending physician and I'll be examining you today. At
any point of the examination you feel uncomfortable, please let me know and I'll stop the examination
right there.”
• Wash/Sanitize hands
• Explain to the patient what you are about to do and gain informed consent.
• Look for medical equipment/therapies (e.g. inhalers, oxygen).
• Verbalize the steps of the examination and your findings.
2. Inspection
• General look of the patient. Check whether they are comfortable at rest, is patient tachypnoeic? Are
they using accessory muscles? Are there any obvious abnormalities of the chest? Check for any clues
around the bed such as inhalers, oxygen masks or cigarettes.
• Inspect the hands, hot, pink peripheries may be a sign of carbon dioxide retention. Look for any signs
of clubbing, cyanosis, hypertrophic pulmonary osteoarthropathy, dupytren's contacture and nicotine
staining. Assess for carbon dioxide retention flap/salbutamol tremor.
• Take the patient’s pulse. After you have taken the pulse it is advisable to keep your hands in the same
position and subtly count the patient’s respiration rate.
• Inspect the face, ask the patient to stick out their tongue and note its colour – checking for cyanosis.
- Horner's sydrome (Pancoast tumour) , plethora (polycythemia).
• Look for any use of accessory muscles such as the sternocleidomastoid muscle. Also palpate for the
left supraclavicular node (Virchow's Node) as an enlarged node (Troisier's Sign) may suggest
metastatic lung cancer.
• Examine the chest and back. Observe the chest for any deformities (barrel chest, kyphoscoliosis,
pectus excavatum, pectus carinatum), symmetry of expansion, dilated veins, intercostal recession.
3. Palpation
• Palpate the chest. Feel between the heads of the two clavicles for the trachea, see if it is deviated.
• Feel for chest expansion. Place your hands firmly on the chest wall with your thumbs meeting in the
midline. Ask the patient to take a deep breath in and note the distance your thumbs move apart.
Normally this should be at least 5 centimetres. Measure this at the top and bottom of the lungs as well
as on the back.
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4. Percussion
• Percussion should be performed on both sides, comparing similar areas on both sides. Start by tapping
on the clavicle which gives an indication of the resonance in the apex. Then percuss normally for the
entire lung fields. Hyper-resonance may suggest a collapsed lung where as hypo-resonance or dullness
suggests consolidation such as in infection or a tumour. Be sure to perform this on the back as well.
5. Vocal Fremitus
Check for tactile vocal fremitus. Place the medial edge of your hand on the chest and ask the patient to say
‘99’. Do this with your hand in the upper, middle and lower areas of both lungs.
6. Auscultation
• Do this in all areas of both lungs and on front and back comparing the sides to each other. Listen for
any reduced breath sounds, or added sounds such as crackles, wheezes or rhonchi.
7. Finish by examining the lymph nodes in the head and neck. Start under the chin with the submental
nodes, move along to the submandibular then to the back of the head at the occipital nodes. Next
palpate the pre and post auricular nodes. Move down the cervical chain and onto the supraclavicular
nodes.
Clinical Examination 71
• Introduce yourself : “I am Dr. ________, your attending physician and I'll be examining you today. At
any point of the examination you feel uncomfortable, please let me know and I'll stop the examination
right there.”
• Wash/Sanitize hands
• Explain to the patient what you are about to do and gain informed consent.
• Look for medical equipment/therapies (e.g. walking aids).
• Verbalize the steps of the examination and your findings.
1) The Olfactory nerve (CN I) is simply tested by offering something familiar for the patient to smell
and identify – for example coffee or vinegar.
2) The Optic nerve (CN II) is tested in five ways:
• The acuity is easily tested with Snellen charts. This should be assessed both with the patient
wearing any glasses or contact lenses they usually wear and without them.
• Colour vision is tested using Ishara plates, these identify patients who are colour blind.
• Visual fields are tested by asking the patient to look directly at you and wiggling one of your
fingers in each of the four quadrants. Ask the patient to identify which finger is moving.
Visual inattention can be tested by moving both fingers at the same time and checking the
patient identifies this.
• Visual reflexes comprise direct and concentric reflexes. Place one hand vertically along the
nose to block any light from entering the eye not being tested. Shine a pen torch into one eye
and check that the pupils on both sides constrict. This should be tested on both sides.
• Finally fundoscopy should be performed on both eyes.
3) Eye movements: Oculomotor nerve (III), Trochlear nerve (IV ) and Abducent nerve (VI) are
involved in movements of the eye. Asking the patient to keep their head perfectly still directly in front
of you, you should draw two large joining H’s in front of them using your finger and ask them to
follow your finger with their eyes. It is important the patient does not move their head. Always ask if
the patient experiences any double vision and if so when is it worse. Also look for ptosis and assess
saccadic eye movements.
4) The Trigeminal nerve (CN V) is involved in sensory supply to the face and motor supply to the
muscles of mastication. Initially test the sensory branches by lightly touching the face with a piece of
cotton wool and then with a blunt pin in three places on each side – around the jawline, on the cheek
and on the forehead. The corneal reflex should also be examined as the sensory supply to the cornea is
from this nerve. This is done by lightly touching the cornea with the cotton wool. This should cause
the patient to shut their eyelids.
For the motor supply, ask the patient to clench their teeth together, observing and feeling the bulk of
the masseter and temporalis muscles. Then ask them to open their mouth against resistance. Finally
perform the jaw jerk on the patient by placing your left index finger on their chin and striking it with
a tendon hammer. This should cause slight protrusion of the jaw.
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5) The Facial nerve (CN VII) supplies motor branches to the muscles of facial expression. Therefore,
this nerve is tested by asking the patient to crease up their forehead (raise their eyebrows), close their
eyes and keep them closed against resistance, puff out their cheeks and show you their teeth.
6) The Vestibulocochlear nerve (CN VIII) provides innervation to the hearing apparatus of the ear and
can be used to differentiate conductive and sensori-neural hearing loss using the Rinne and Weber
tests. For the Rinne test, place a sounding tuning fork on the patient’s mastoid process and then next
to their ear and ask which is louder, a normal patient will find the second position louder. For Weber’s
test, place the tuning fork base down in the centre of the patient’s forehead and ask if it is louder in
either ear. Normally it should be heard equally in both ears.
7) The Glossopharyngeal nerve (CN IX) provides sensory supply to the palate. It can be tested with the
gag reflex or by touching the arches of the pharynx.
8) The Vagus nerve (CN X) provides motor supply to the pharynx. Asking the patient to speak gives a
good indication to the efficacy of the muscles. You should also observe the uvula before and during
the patient saying ‘aah’. Check that it lies centrally and does not deviate on movement.
9) The Accessory nerve (CN XI) gives motor supply to the sternocleidomastoid and trapezius muscles.
To test it, ask the patient to shrug their shoulders and turn their head against resistance.
10) The Hypoglossal nerve (CN XII) provides motor supply to the muscles of the tongue. Observe the
tongue for any signs of wasting or fasciculations. Then ask the patient to stick their tongue out. If the
tongue deviates to either side, it suggests a weakening of the muscles on that side.
3. Cerebellar Examination
Gait:
• Ask the patient to stand up. Observe the patient's posture and whether they are steady on their feet.
• Ask the patient to walk, e.g. to the other side of the room, and back. If the patient normally uses a
walking aid, allow them to do so.
• Observe the different gait components (heel strike, toe lift off ). Is the gait shuffling / waddling /
scissoring / swinging?
• Observe the patients arm swing and take note how the patient turns around as this involves good
balance and co-ordination.
• Ask the patient to walk heel-to-toe to assess balance.
• Perform Romberg’s test by asking the patient to stand unaided with his eyes closed. If the patient
sways or loses balance this test is positive. Stand near the patient in case he falls.
Co-ordination:
• Look for a resting tremor in the hands.
• Test tone in the arms (shoulder, elbow, wrist)
• Test for dysdiadochokinesis by showing the patient to clap by alternating the palmar and dorsal
surfaces of the hand. Ask to do this as fast as possible and repeat the test with the other hand.
• Perform the finger-to-nose test by placing your index finger about two feet from the patients face. Ask
him to touch the tip of his nose with his index finger then the tip of your finger. Ask him to do this as
fast as possible while you slowly move your finger. Repeat the test with the other hand.
• Perform the heel-to-shin test. Have the patient lying down for this and get him to run the heel of one
foot down the shin of the other leg and then to bring the heel back up to the knee and start again.
Repeat the test with the other leg.
Clinical Examination 73
• Introduce yourself : “I am Dr. ________, your attending physician and I'll be examining you today. At
any point of the examination you feel uncomfortable, please let me know and I'll stop the examination
right there.”
• Wash/Sanitize hands
• Explain to the patient what you are about to do and gain informed consent.
• Use proper draping techniques, verbalize the steps of the examination and your findings.
2. Inspection
• General inspection of patient: general comfort, abnormal posture/movements, muscle wasting.
• The upper body should be exposed for this examination. Observe the patient's arms, look for any
muscle wasting, fasciculations or asymmetry.
3. Tone
• Examine the tone of the muscles. Start proximally at the shoulder, feeling how easy the joint is to
move passively. Then move down to the elbow, wrist and hand joints again assessing each one's tone in
turn.
• Assess for spastic catch, clasp-knife rigidity, led-pipe or cog-wheel rigidity.
4. Power
• Next assess the power of each of the muscle groups.
– Shoulder abduction (C5) & Shoulder adduction (C5/C6/C7)
– Elbow flexion (C5/C6) & Elbow extension (C7)
– Wrist flexion (C8) & Wrist extension (C8)
– Finger flexion (C8), Finger abduction (T1), Finger adduction (T1)
– Thumb abduction (C8)
5. Reflexes
• There are three reflexes in the upper limb - the biceps, triceps and supinator reflexes.
• The biceps reflex (C5/C6) is tested by supporting the patient's arm, with it flexed at roughly 60º,
placing your thumb over the biceps tendon and hitting your thumb with the tendon hammer. It is
vital to get your patient to relax as much as possible and for you to take the entire weight of their arm.
• The triceps reflex (C6/C7) is elicited by resting the patient's arm across their chest and hitting the
triceps tendon just proximal to the elbow.
• Finally, with their arm rested on their abdomen, locate the supinator tendon (C5/C6) as it crosses the
radius, place three fingers on it and hit the fingers. This should give the supinator reflex. If you
struggle with any of these reflexes, asking the patient to clench their teeth should exaggerate the
reflex.
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6. Sensation
• This is tested in a number of ways. You should test
light touch, pin prick, vibration and joint position
sense and proprioception.
7. Coordination
• Pronator drift – Ask patient to extend arms in front of them in supination and to close their eyes. A
positive result occurs when the arm falls downwards and pronates (cerebral damage), in cerebellar
lesions the arms may rise.
• Assess for dysdiadochokinesia
• Assess for finger to nose coordination and intentional tremor.
8. Function is a very important part of any neurological examination as this is the area which will affect
people's day to day lives the most. For upper limb you should ask people to touch their head with both
hands and then ask them to pick up a small object such as a coin which each hand.
9. Finish by thanking the patient and ensuring they are comfortable and well covered.
Clinical Examination 75
2. Inspection
• Observe the patient's legs, look for any muscle wasting, fasciculations or asymmetry.
3. Tone
• Start by examining the tone of the muscles. Roll the leg on the bed to see if it moves easily and pull
up on the knee to check its tone. Also check for ankle clonus by placing the patients leg turned
outwards on the bed, moving the ankle joint a few times to relax it and then sharply dorsiflexing it.
Any further movement of the joint may suggest clonus.
4. Power
• Next assess the power of each of the muscle groups.
– Hip flexion (L1/L2) & Hip extension (L5/S1)
– Hip abduction (L2/L3) & Hip adduction (L2/L3)
– Knee flexion (L5/S1) & Knee extension (L3/L4)
– Ankle dorsiflexion (L4/L5) & Ankle plantar flexion (S1/S2)
– Big toe flexion (S1/S2)
5. Reflexes
• Test the patient's reflexes. There are three reflexes in the lower limb - the knee reflex, the ankle jerk
and the plantar reflex - elicited by stroking up the lateral aspect of the plantar surface.
• The knee reflex (L3/L4) is tested by placing the patient's leg flexed at roughly 60º, taking the entire
weight of their leg with your arm and hitting the patellar tendon with the tendon hammer. It is vital
to get your patient to relax as much as possible and for you to take the entire weight of their leg.
• The ankle jerk (S1/S2) is elicited by resting the patient's leg on the bed with their hip laterally rotated.
Pull the foot into dorsiflexion and hit the calcaneal tendon.
• Finally, with their leg out straight and resting on the bed, run the end of the handle of the tendon
hammer along the outside of the foot. This gives the plantar reflex (S1). An abnormal reflex would see
the great toe extending. If you struggle with any of these reflexes, asking the patient to clench their
teeth should exaggerate the reflex.
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6. Sensation
• The final test is sensation. However, this is tested in a number
of ways. You should test light touch, pin prick, vibration and
joint position sense and proprioception.
• Ask the patient to place their legs out straight on the bed.
Lightly touch the patient's sternum with a piece of cotton wool
so that they know how it feels. Then, with the patient's eyes
shut, lightly touch their leg with the cotton wool. The places to
touch them should test each of the dermatomes - make sure
you know these! Tell the patient to say yes every time they feel
the cotton wool as it felt before. Then repeat this using a light
pin prick.
• To assess vibration you should use a sounding tuning fork.
Place the fork on the patient's sternum to show them how it
should feel. Then place it on their medial malleolus and ask
them if it feels the same. If it does, there is no need to check
any higher. If it feels different you should move to the tibial
epicondyle and then to the greater trochanter until it feels
normal.
• Finally, proprioception. Hold the distal phalanx of the great toe
on either side so that you can flex the interphalangeal joint.
Show the patient that when you hold the joint extended, that represents 'Up' whereas when you hold
it flexed that represents 'Down'. Ask the patient to close their eyes and, having moved the joint a few
times hold it in one position - up or down. Ask the patient which position the joint is in.
7. Function is a very important part of any neurological examination as this is the area which will affect
people's day to day lives the most. For the lower limb you should assess the patient's walking. Observe
their gait and check for any abnormalities. Whilst they are standing you should perform Romberg's
test. Ask the patient to stand with their feet apart and then close their eyes. Stand next to the patient
in case he falls. Any swaying may be suggestive of a posterior column pathology.
8. Finish by thanking the patient and ensuring they are comfortable and well covered.
Clinical Examination 77
2. Inspection
• Ask for patient's vitals
• Observe patient : Is patient sitting comfortably? Gait? Position of comfort.
• Observe the patient from behind :
– Pelvic and shoulder symmetry, palpate the pelvic brim to check for symmetry.
– Scoliosis
– Gibbus (dorsal spines abnormally prominent)
• Observe patient from side :
– Kyphosis
– Increased lumbar lordosis
• Check the spine for SEADS : S: Swelling, E: Erythema, ecchymosis, A: Atrophy/asymmetry (muscle
bulk), D: Deformity, S: Skin changes/scars/bruising
3. Range of Motion
• Flexion : In the standing position by asking the patient to touch the toes. Normal - 90o .The normal
spine should lengthen more than 5 cm in the thoracic area and more than 7.5 cm in the lumbar area
on forward flexion.
• Extension : Stabilize the patient, ask the patient to bend backwards. Normal – 30o.
• Lateral flexion : ask the patient to slide their hand straight down the thigh, first on the right and then
on the left, keeping the hips straight.
• Observe for restricted movement and loss of symmetry.
• Test for facet joint disease : Ask patient to extend their back as far as possible and to rotate (pain
suggests facet joint pathology).
4. Palpation
• Examine the back and palpate for areas of muscle spasm and tenderness (paraspinal muscles).
• Palpate spinous processes with thumb for tenderness
• Sacroiliac joints, sacro iliac dimples, ask for tenderness.
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Hip Examination
TYPES OF GAIT
3. Gait – ask patient to walk across the floor. Look for any abnormalities,
Antalgic – Trauma, OA
hip, knee, foot movements, length of stride. Trendelenberg – weakness
of hip adductors
Festinating – Parkinson's ds.
High stepping – Polio, MS
3. Inspection & Palpation of hip (with patient lying down) Scissor – Spastic cerebral
palsy
• Inspection for hip and groin swellings (hernia, lymphadenopathy, Stomping – Friedreich's
saphenous varix, effusion) ataxia, tabes dorsalis
Spastc – Brain tumor, sturge
• Inspect for obvious fixed flexion weber's, cerebral palsy
• Palpate anterior hip for lumps and tenderness.
• Palpate the greater trochanter for any tenderness which might
suggest trochanteric bursitis.
4. Leg-length difference
• Make an approximate judgment by aligning the medial malleoli and looking for discrepancy.
• Measure true and apparent leg-length if appropriate. True leg length discrepancy is found by
measuring from the anterior superior iliac spine to the medial malleolus. Apparent leg length
discrepancy is measured from the umbilicus to the medial malleolus.
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6. Special tests
• Thomas test : Place your hand under the patient's lumbar spine to stop any lumbar movements and
fully flex one of the hips. Observe the other hip, if it lifts off the couch then it suggests a fixed flexion
deformity of that hip.
• FABER (Flexion Abduction External Rotation) : Ask the patient to lie supine on the exam table.
Place the foot of the affected side on the opposite knee. Pain in the groin area indicates a problem
with the hip and not the spine. Press down gently but firmly on the flexed knee and the opposite
anterior superior iliac crest. Pain in the sacroiliac area indicates a problem with the sacroiliac joints.
Clinical Examination 81
Knee Examination
2. Inspection
• Gait : Ask the patient to walk for you. Observe any limp or obvious deformities such as scars or
muscle wasting. Check if the patient has a varus (bow-legged) or valgus (knock-knees) deformity.
Also observe from behind to see if there are any obvious popliteal swellings such as a Baker's cyst.
• While the patient is lying on the bed, make a general observation. Look for symmetry, redness, muscle
wasting, scars, rashes or fixed flexion deformities.
3. Palpation
• Check the temperature using the backs of your hands, comparing it with other parts of the leg.
• Palpate the border of the patella for any tenderness, behind the knee for any swellings, along all of the
joint lines for tenderness and at the point of insertion of the patellar tendon. Finally, tap the patella to
see if there is any effusion deep to the patella.
• Landmarks of the knee : Tibial tuberosity, patellar tendon, quadriceps tendon, medial and lateral
femoral condyles.
• Peripatellar area : push patella medially and rub right underneath the medial facet of patella and look
for tenderness ( Patellar – femoral stress So).
• Joint line tenderness : bend the knee 90o , palpate medial and lateral joint line.
• Patella apprehension test – Move patella around and observe patient's face for pain.
4. Range of Motion
• Active flexion and extension of knee – Observe for restricted movement and for displacement of
patella.
• Passive flexion and extension of knee – feel for crepitus.
• Straight leg raise – assessment of extensor apparatus.
82 NAC OSCE | A Comprehensive Review
5. Special tests
• Introduce yourself : “I am Dr. ________, your attending physician and I'll be examining you today. At
any point of the examination you feel uncomfortable, please let me know and I'll stop the examination
right there.”
• Wash/Sanitize hands
• Explain to the patient what you are about to do and gain informed consent.
• Ensure patient is adequately exposed (up to above knees).
• Look for medical equipment/therapies
• Ask if patient is able to bear weight, show empathy.
• Verbalize the steps of the examination and your findings.
2. Inspection
• Gait : watch the patient walk, observing for a normal heel strike, toe-off gait. Also look at the
alignment of the toes for any valgus or varus deformities. Assess ability to weight-bear on affected
side.
• While patient is standing check the foot arches checking for pes cavus (high arches) or pes planus
(flat feet).
• Inspection of the foot with patient sitting and feet overhanging
– Check the foot and ankle for SEADS : S: Swelling, E: Erythema, ecchymosis,
A: Atrophy/asymmetry (muscle bulk), D: Deformity, S: Skin changes/scars/bruising.
– Check the symmetry, nails (psoriasis), skin, toe alignment, look for toe clawing, joint swelling and
plantar and dorsal calluses.
• Finally you should look at the patient's shoes, note any uneven wear on either sole and the presence of
any insoles.
3. Palpation of ankle/foot
• Feel each foot for temperature, comparing it to the temperature of the rest of the leg.
• Feel for distal pulses.
• Squeeze over the metatarsophalangeal joints observing the patient's face for any pain.
• Palpate over the midfoot, ankle and subtalar joint lines for any tenderness. Feel the Achilles tendon
for any thickening or swelling. Palpate medial and lateral malleoli for any tenderness.
84 NAC OSCE | A Comprehensive Review
4. Range of Motion
• Assess all active and passive movements of the foot. These movements are inversion, eversion,
dorsiflexion and plantarflexion.
– Subtalar joint – inversion and eversion
– Ankle joint – dorsiflexion and plantar flexion
– Big toe – dorsiflexion and plantar flexion
– Mid-tarsal joints - which are tested by fixing the ankle with one foot and inverting and everting
the forefoot with the other.
5. Special tests
Shoulder Examination
• Introduce yourself : “I am Dr. ________, your attending physician and I'll be examining you today. At
any point of the examination you feel uncomfortable, please let me know and I'll stop the examination
right there.”
• Wash/Sanitize hands
• Explain to the patient what you are about to do and gain informed consent.
• Look for medical equipment/therapies, ensure patient is adequately exposed.
• Ask which shoulder is painful. Verbalize the steps of the examination and your findings.
2. Inspection
• Start by exposing the joint and observe the shoulder joint looking from the back, side and front for
any scars, deformities or muscle wasting (SEADS). Also compare both sides for symmetry.
• With the patient standing, ask the patient to place their hands behind their head and behind their
back and observe for and deformities.
3. Palpation
• Feel over the joint and its surrounding areas for the temperature of the joint as raised temperature may
suggest inflammation or infection in the joint.
• Systematically feel along both sides of the bony shoulder girdle. Start at the sternoclavicular joint,
work along the clavicle to the acromioclavicular joint
• Feel the acromion and then around the spine of the scapula.
• Feel the anterior and posterior joint lines of the glenohumeral joint and finally the muscles around the
joint for any tenderness.
4. Range of Motion
5. Special Tests
Elbow Examination
• Introduce yourself : “I am Dr. ________, your attending physician and I'll be examining you today. At
any point of the examination you feel uncomfortable, please let me know and I'll stop the examination
right there.”
• Wash/Sanitize hands
• Explain to the patient what you are about to do and gain informed consent.
• Look for medical equipment/therapies, ensure patient is adequately exposed.
• Verbalize the steps of the examination and your findings.
2. Inspection
3. Palpation
• Feel the elbow, assessing the joint temperature relative to the rest of the arm.
• Palpate the olecranon process as well as the lateral and medial epicondyles for tenderness (medial for
golfer's elbow and lateral for tennis elbow), and cubital fossa for tenderness.
• Palpate joint line with elbow flexed to 90o for tenderness and swelling.
4. Range of Motion
• The movements at the elbow joint are all fairly easy to describe and assess. These are flexion,
extension, pronation and supination. Once these have been assessed actively they should be checked
passively checking for power and crepitus.
• Test for varus / valgus instability.
6. Special Tests
• Tennis Elbow : Tennis elbow localises pain over the lateral epicondyle, particularly on active extension
of the wrist with the elbow bent.
• Golfer's Elbow : Golfer's elbow pain localises over the medial epicondyle and is made worse by
flexing the wrist.
88 NAC OSCE | A Comprehensive Review
• Introduce yourself : “I am Dr. ________, your attending physician and I'll be examining you today. At
any point of the examination you feel uncomfortable, please let me know and I'll stop the examination
right there.”
• Wash/Sanitize hands
• Explain to the patient what you are about to do and gain informed consent.
• Look for medical equipment/therapies
• Verbalize the steps of the examination and your findings.
2. Inspection
• Inspect hands :
– Skin (rashes, Gottron's patches, nodules, Raynaud's phenomenon, sclerodactyly, scars, skin
atrophy)
– Nails (pitting, onycholysis, splinter haemorrhages, clubbing)
– Muscles (swelling, wasting)
– Joints (swellings, subluxation / deviation of wrist, swan neck / Boutoniere's deformity,
Heberden's/Bouchard's nodes, Z deformity of thumb)
– Inspect palm (palmar erythema, pallor, cyanosis), muscle wasting.
• Inspect elbows :
– Psoriatic skin lesions
– Rheumatoid nodules
– Scars
3. Palpation
• Assess the temperature over the joint areas and compare these with the temperature of the forearm.
• Start proximally and work towards the fingers, feeling the radial pulses and the wrist joints. Then feel
the muscle bulk in the thenar and hypothenar eminences. In the palms, feel for any tendon thickening
and assess the sensation over the relevant areas supplied by the radial, ulnar and median nerves.
• Squeeze over the row of metacarpophalangeal joints whilst watching the patient's face for any
discomfort.
• Bi-manually palpate MCP and interphalangeal joints.
Clinical Examination 89
4. Range of Motion
• Ask the patient to perform the following movements in the sequence mentioned below and observe
for range of movement :
– Make a fist
– Pronate wrist
– Extend little finger (extensor digiti minimi is usually the first tendon to rupture in rheuatoid
arthritis)
– Extend all fingers
• Assess function
– Pinch grip
– Opposition (touch thumb to each finger)
– Power grip (ask patient to squeeze your fingers)
– Froment's test (for ulnar nerve palsy). In this test the patient attempts to grip a paper with thumb
and index finger while the examiner tries to pull the paper out of the patient's grip.
– Ask patient to write something / undo a button.
• Assess power
– Wrist extension (radial nerve)
– Thumb abduction (median nerve)
– Finger abduction (ulnar nerve)
5. Neurovascular Examination
Median Lateral portions of the pulp of the Resisted palmar abduction of the
index and middle fingers thumb
Ulnar Lateral pulp areas of the little finger Abduction of the fingers against
resistance
6. Special Tests
• Phalen's test : Forced flexion of the wrist, either against the other hand or by the examiner for 60
seconds will recreate the symptoms of carpal tunnel syndrome.
• Finkelstein's test is used to diagnose DeQuervain's tenosynovitis. Patient is told to flex the thumb
and clench the fist over the thumb followed by ulnar deviation. If there is an increased pain in the
radial styloid process and along the length of the extensor pollicis brevis and abductor pollicis longus
tendons, then the test is positive for De Quervain’s syndrome.
• Tinel's sign : Use the index finger to tap over the carpal tunnel at the wrist. A positive test results
when the tapping causes tingling or paresthesia in the area of the median nerve distribution, which
includes the thumb, index finger, and middle and lateral half of the ring finger. A positive Tinel's sign
at the wrist indicates carpal tunnel syndrome.
90 NAC OSCE | A Comprehensive Review
Breast Examination
• Introduce yourself : “I am Dr. ________, your attending physician and I'll be examining you today. At
any point of the examination you feel uncomfortable, please let me know and I'll stop the examination
right there.”
• Wash/Sanitize hands
• Explain to the patient what you are about to do and gain informed consent.
• Verbalize the steps of the examination and your findings. Ask which side the problem is.
• Make sure patient is adequately exposed, use proper draping techniques
• Inspect with :
– Patient's arm by their sides.
– Patient's arms behind their head (tenses skin)
– Patient's hands on their hips (tenses pectoralis major)
These manoeuvers test for T4 disease – invasion of chest wall / skin. Inspect for :
– Obvious masses
– Scars
– Radiotherapy tattoos
– Skin changes
– Peau d'orange
– Dimpling
– Nipple retraction
– Paget's disease.
3. Palpate
– Palpate normal breast followed by abnormal breast.
– Palpate all quadrants, nipple and axillary tail of each breast.
– Describe any masses : position, size shape, mobility, number, tenderness, consistency.
– Palpate axillary, supraclavicular and infraclavicular lymph nodes.
4. Auscultate lungs.
Clinical Examination 91
Thyroid Examination
• Introduce yourself : “I am Dr. ________, your attending physician and I'll be examining you today. At
any point of the examination you feel uncomfortable, please let me know and I'll stop the examination
right there.”
• Wash/Sanitize hands
• Explain to the patient what you are about to do and gain informed consent.
• Ensure patient is adequately exposed.
• Look for medical equipment/therapies
• Show empathy.
• Verbalize the steps of the examination and your findings.
2. Inspection
• Swallow tests – Ask patient to swallow water and observe for movement of any masses.
• Tongue protrusion – Thyroglossal cyst moves on tongue protrusion.
• Stand behind the patient and palpate. Assess size, texture, smoothness, margins and mobility of the
thyroid gland (including when swallowing). Note the temperature over gland and adjacent skin.
• Palpate cervical lymph nodes.
• Percuss over sternum – Retrosternal goitre.
• Auscultate for thyroid bruit – Grave's disease.
4. Examination of legs.
• Pretibial myxoedema
• Peripheral edema due to congestive cardiac failure.
• Delayed relaxation of ankle reflex in hypothyroidism.
W 1
94 NAC OSCE | A Comprehensive Review
C. Final Score
Compare the scores of the Counting
Backwards and Spelling Backwards Final Score : ____
tests. Write the greater of the two (Max of 5 or Greater of
scores in the box labeled FINAL the two scores)
SCORE at right, and use it in
deriving the TOTAL SCORE.
IV. RECALL Maximum score = 3
Ask the patient to recall the three Ball 1
words you previously asked him/her
Flag 1
to remember. Check the Box at right
for each correct response. Tree 1
V. LANGUAGE Maximum score = 9
Naming Watch 1
Show the patient a wrist watch and ask Pencil 1
him/her what it is. Repeat for a pencil.
Repetition
Ask the patient to repeat “No ifs, ands, or Correct repetition 1
buts.”
Three – Stage Command
Establish the patient's dominant hand. Give Takes paper in hand 1
the patient a sheet of blank paper and say,
Folds paper in half 1
"Take the paper in your right/left hand, fold
it in half and put it on the floor." Puts paper on the floor 1
Reading
Hold up the card that reads, “Close your
eyes." So the patient can see it clearly. Ask
him/her to read it and do what it says. Closes eyes 1
Check the box at right only if he/she
actually closes his/her eyes.
Writing
Give the patient a sheet of blank paper and
ask him/her to write a sentence. It is to be
written spontaneously. If the sentence Writes sentence 1
contains a patient and a verb, and is
sensible, check the box at right. Correct
grammar and punctuation are not
necessary.
Copying
Show the patient the drawing of the
intersecting pentagons. Ask him/her to
draw the pentagons (about one inch each Copies pentagons 1
side) on the paper provided. If ten angles
are present and two intersect, check the
box at right. Ignore tremor and rotation.
Clinical Examination 95
23 - 30 Normal
23 - 19 Borderline
Less than 19 Impaired
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Clinical Cases
This is a blank page
Clinical Cases – Protocol for history taking 99
A candidate gets 2 minutes outside the station to read the clinical case senario on the door before entering. It is
essential to get yourself organised in these 2 minutes.
• Read the question properly, understand the requirement and follow instructions (e.g. if you are asked
to do a physical examination, do not start taking history. You will be losing valuable time)
• You will be given a pencil and a booklet with blank pages. It is a good practice to jot down notes.
• Write the name, age, sex and chief complaint of the patient.
• For history of present illness, you can use the mnemonic OCDPQRSTUV+AAA.
• Past and Social History : PAM HUGS FOSS
• Write down your differential diagnosis.
• Knock the door before entering, relax, take a deep breath, smile and enter the room with confidence.
Hand over the stickers to the physician examiner.
• “Ok, Mr./Miss _____, Now I need to ask you about your health in general. Is that okay with you?”
• Past Medical History : What other medical problems do you have? (Diabetes/Hypertension/Asthma /
Cancer?)
• Allergies : Do you have any allergies? Are you allergic to any drugs?
Clinical Cases – Protocol for history taking 101
• Hospitalizations : (medical/surgical/trauma)
• Sleep?
• “ I am going to ask you a few personal questions that will help me in my diagnosis. Is that okay with
you? Let me begin by asking you about your family health.”
• Family history : similar complaints in the family? Cancer in the family? Depression? Suicide?
• Obstetrical History : When was your last pap smear? Wast it normal? Any history of STIs?
• “Now I need to ask you about your sexual health. Whatever you tell me will be kept confidential. Is
that okay with you?”
Tammy Robbins, a 48 years old lady presented with heart racing and chest discomfort for the past 3 days.
Take a focused history and perform focused physical examination.
Vitals: BP - 90/70 mm Hg, HR - 146/min, irregular, RR - 12/min, Temp - 37.5°C
Clinical Info: Ms Tammy Robbins is a known hypertensive with CAD for the past 10 years, who presented
with sudden onset of palpitations and chest discomfort for the past 3 days. Her symptoms are worsening for
the past 24 hours. She has dyspnea. She has dizziness for the past 12 hours. Pedal edema is 2 +. She had 2
vessel angioplasty done 5 years ago. ECG shows absent P waves with irregular narrow QRS complexes.
Bilateral basal rales present on lung auscultation.
Clinical Case : Atrial Fibrillation (examination on page 65)
Simon Charles, a 20 years old male presented to your clinic with shortness of breath for the past 24 hours.
Take a focused history and perform focused physical examination.
Vitals: BP - 110/80 mm Hg, HR – 110/min, RR – 22/min, Temp – 37.5°C.
Clinical Info: Mr Simon Charles has a h/o of Asthma since the past 10 years. He recently cleaned his
basement 1 day ago and his asthma symptoms exacerbated. He is having wheezing, chest tightness,cough and
SOB. He is currently on inhalers with no night symptoms. On examination, he has dyspnea and wheezing
present in all lung fields. He has mild exacerbation of his symptoms and needs only outpatient treatment.
Clinical Case : Asthma (examination on page 69)
Larry Edwards, a 55 years old man presented with blood in sputum and shortness of breath for the past 5
days. Take a focused history and perform focused physical examination.
Vitals: BP - 160/110 mm Hg, HR - 96/min, RR - 18/min, Temp – 37.5°C.
Clinical Info: Mr Larry Edwards is a known hypertensive who presented with shortness of breath and blood
in sputum for 5 days. It is gradual in onset. He has chest pain also. No fever or recurrent pneumonia. He is
non compliant with his medications. He is on Losartan, Aspirin, Atorvas, multi vitamins. He has not taken
his anti-hypertensives for 4 weeks. Has paroxysmal nocturnal dyspnea and orthopnea.
Clinical Case : Congestive Heart Failure (examination on page 65)
Jack Allen, a 65 years old man presented with sudden onset of right arm weakness 4 hours ago. Take a focused
history and perform focused physical examination.
Vitals: BP - 160/90 mm Hg, HR - 96/min, RR - 12/min, Temp – 37.5°C.
Clinical Info: Mr Jack Allen presented with sudden onset of right arm weakness with numbness and
paresthesias 4 hours ago. He has slurring of speech, blurring of vision and mild headache. He has no
nausea,vomiting or head trauma. No weakness of lower limbs or left arm. No incontinence. He is hypertensive
for the past 10 years and non compliant to medications.
Clinical Case : Cerebrovascular Attack (examination on page 71)
Allan Smith, a 70 years old man presented with light headedness and dizziness for 2 days. Take a focused
history and perform focused physical examination.
Vitals: BP - 110/80 mm Hg, HR - 56/min, irregular, RR - 12/min, Temp – 37.0°C.
Clinical Info: Mr Allan Smith is a known hypertensive for the past 20 years on medications. He is
experiencing light headedness and dizziness for the past 2 days. He has palpitations and mild chest pain for 2
weeks. He is breathless on exertion. Has 2+ pedal edema. No fainting episode. No trauma recently. No visual
changes or limb weakness. He is on Losartan, Ramipril, Digoxin, Atorvas, Aspirin, Nexium and Calcium.
ECG shows Type 2 Second Degree AV block.
Clinical Case : Digoxin Toxicity (examination on page 65)
Investigations
• Serum Digoxin level.
• CBC, electrolytes, RFT.
• INR/PTT, glucose.
• ECG, 24 hour Holter monitor.
• Echocardiogram,Carotid Doppler.
Clinical Cases - Medicine 107
Lisa Giroux, a 25 years old lady presented with lump in the neck for the past 7 days. Take a focused history
and perform focused physical examination.
Vitals: BP - 120/88 mm Hg, HR – 96/min, RR – 12/min, Temp – 38.5°C.
Clinical Info: Ms Lisa Giroux noticed 2 lumps on the right side of her neck below the mandible. She has
positive history of fever for 5 days,sore throat and fatigue. On examination she has 2 enlarged, tender
submandibular lymph nodes. Monospot test is positive.
Clinical Case : Infectious Mononucleosis (Sore throat )
Jason Hardinge, a 26 years old university student wants to discuss confidential issues with a doctor. Take
focused history and address his concerns.
Vitals: BP - 120/88 mm Hg, HR - 88/min, RR - 12/min, Temp - 37.5°C
Clinical Info: Mr Jason Hardinge is having difficulty in maintaining erection during intercourse for the past 4
months. He is currently in a monogamous relationship with his girlfriend. He is on Paroxetin for his mood
disorder for 6 months. No other medical illnesses. Girlfriend is very understanding. He has no morning or
night tumescence. Has no erection with self stimulation. He is very anxious about this issue.
Clinical Case : Impotence
Diagnosis Management
Impotence secondary to antidepressants. • Complete physical exam.
• Reassurance, counseling both patient &
Causes of impotence : (IMPOTENCE) partner.
Iatrogenic, Mechanical, Psychological, • Inform that symptoms are due to side effects
Occlusive vascular, Trauma, Extra factors, of anti-depressants.
Neurogenic, Chemical, Endocrine. • Symptoms are reversible by changing the
dose or the type of drug.
Investigations • Substitute with another anti-depressant:
• CBC, blood glucose, TSH. Minimal to no sexual dysfunction
• Se Testosterone. Nefazodone (Serzone)
• Urinalysis. Bupropion (Wellbutrin)
• Endocrine lab tests, if indicated: Low risk of sexual dysfunction (10-15%)
FSH,LH, Prolactin. Fluvoxamine (Luvox)
Citalopram (Celexa)
Venlafaxine (Effexor)
• Avoid alcohol/smoking.
• Medical treatment: Tab Sildenafil 25-50 mg
PO 0.5 to 4 hours prior to coitus.
Clinical Cases - Medicine 109
Taylor Jackson, a 18 years old boy presented with fever, neck stiffness and photophobia to the ER. Take a
focused history and perform focused physical examination.
Vitals: BP - 90/70 mm Hg, HR - 110/min, RR - 12/min, Temp – 39.0°C.
Clinical Info: Mr Taylor Jackson has high grade fever for the past 3 days along with neck stiffness. He has
photophobia for the past 1 day. He is alert & conscious. No seizures. Has headache with nausea & vomiting.
No ear discharge. Has a purpuric rash on chest and lower limbs. No recent trauma. Has h/o contact with sick
person with similar symptoms. O/E: Febrile, Brudzinski's and Kernig's sign are positive.
Clinical Case : Meningitis (examination on page 71)
James Irwin a 30 years old man presented to your clinic with symptoms of headache. Take a focused history
and address his concerns.
Vitals: BP - 120/88 mm Hg, HR - 96/min, RR - 12/min, Temp - 37.5°C.
Clinical Info: Mr James Irwin presented with unilateral, pulsating headache, grade 7/10 for the past 6
months. He experiences aura prior to the onset of headache. Associated with nausea,vomiting and
photophobia. Stimulated by stress and excessive caffeine intake. One episode lasts for 8-12 hours. He had 6
attacks in past 6 months. Currently on Advil prn.
Clinical Case : Headache (Migraine)
Michael Smith, a 55 years old man presented with chest discomfort for the past 1 hour. Take a focused
history and perform focused physical examination.
Vitals: BP - 160/90 mm Hg, HR - 96/min, RR - 12/min, Temp – 37.5°C.
Clinical Info: Mr Michael Smith presented with left sided chest discomfort for the past 1 hour. He has pain
in his left shoulder and jaw. He has shortness of breath along with palpitations. He is a known hypertensive
and diabetics on oral medications. His wife states he is non-compliant with his medications. ECG shows ST
elevation in leads II,III and avF.
Clinical Case : Chest Pain (Myocardial Infarction) (examination on page 65)
Adam Sawyer, a 18 years old male presented with fever, cough for 1 week along with shortness of breath. Take
a focused history and perform focused physical examination.
Vitals: BP - 110/70 mm Hg, HR – 96/min, RR – 20/min, Temp – 38.5°C.
Clinical Info: Adam Sawyer has fever and expectorant cough for the past 1 week. He has wheezing and
shortness of breath for 2 days. On auscultation of chest, there is decreased breath sounds on left side with
rales present.
Clinical Case : Pneumonia (examination on page 69)
Helen Solazzo is an ICU nurse who had a needle stick injury 30 minutes ago while drawing blood sample
from a patient . Take a focused history and address her concerns.
Vitals: BP - 120/88 mm Hg, HR - 86/min, RR - 12/min, Temp - 37.0°C.
Clinical Info: Ms Helen Solazzo had a needle stick injury in the ICU 30 minutes ago. She was drawing blood
sample at that time. She was wearing gloves. She has no high risk behavior. Her immune status for
HIV/HCV/HBsAg is negative as of 1 year ago. Patient's immune status is unknown as of now.
Physician examiner states that the patient's result come back positive for HIV.
Clinical Case Diagnosis: Post exposure prophylaxis for HIV.
Investigations Management
For Healthcare professional: • Reassurance.
• CBC, electrolytes. • Refer to Infectious Disease clinic.
• RFT, LFT. • Report to occupational health dept within 72
• HIV, HCV, HBsAg. hours & every 2 weekly.
For the patient: inform the pt. • Certify to worker's compensation board for
• CBC, electrolytes. file claim.
• HIV, HCV, HBsAg. • Advise about safe sex practices.
• In case of positive HIV/HCV/HBsAg do • Avoid pregnancy/breast feeding.
viral loads & CD 4 counts. • Repeat blood work 6 weeks,12weeks,6
months and 12 months.
• Patient HIV + then start the nurse on post
exposure prophylaxis for 4 weeks.
• Counsel about side effects of medications.
114 NAC OSCE | A Comprehensive Review
Jacob Sandler, a 50 years old man presented with hemoptysis and right sided calf swelling for the past 2 days.
He had knee replacement surgery 1 week ago. Take a focused history and perform focused examination.
Vitals: BP - 140/80 mm Hg, HR - 110/min, RR - 18/min, Temp – 37.5°C.
Clinical Info: Mr Jacob Sandler had a right knee replacement 1 week ago. He now presented with 2 episodes
of hemoptysis and right calf swelling with tenderness. He has no fever or infection of surgical wound.
Homan's sign is positive with ECG showing S1Q3T3 pattern.
Clinical Case : Pulmonary Embolism (examination on page 69)
Jasper Preudhomme, a 16 years old boy is a known epileptic presented to your clinic for the first time. Take a
focused history and address his concerns.
Vitals: BP - 120/88 mm Hg, HR - 96/min, RR - 12/min, Temp – 37.0°C.
Clinical Info: Mr Jasper Preudhomme is a known epileptic for the past 6 years. He is on regular anti-
epileptics and is non-compliant. His last seizure was 2 months ago. He recently started consuming alcohol
with friends. His main concern is to get a driver's license.
Clinical Case : Seizure disorder
Diagnosis Management
• Seizure Disorder • Discuss compliance of medications.
• Regular follow up.
Investigations • Avoid alcohol consumption/smoking.
• CBC, electrolytes. • Avoid recreational drugs.
• Serum drug levels. • Inform to the patient Ministry of
• EEG. Transportation regulations require patient to
be seizure free for 1 year or more.
• Notify Ministry of Transportation as
required by law.
116 NAC OSCE | A Comprehensive Review
Samantha Ho, a 56 years old woman presented to your clinic with symptoms of headache and blurry vision.
Take a focused history and address her concerns.
Vitals: BP - 130/88 mm Hg, HR - 86/min, RR - 12/min, Temp - 37.5°C.
Clinical Info: Ms Samantha Ho presented with unilateral, left temporal side pulsating headache, grade 7/10
for the past 2 weeks. She experiences headache while chewing and combing her hair. Associated with blurring
of vision and diplopia. One episode lasts for 30 minutes. Currently on advil prn, atenolol 50 mg OD and
multivitamins.
Clinical Case : Temporal Arteritis
Jason Scott, a 30 years old man presented with yellowish discoloration of eyes and skin for the past 1 week.
Take a focused history and perform focused physical examination.
Vitals: BP - 120/88 mm Hg, HR - 96/min, RR - 12/min, Temp – 38.0°C.
Clinical Info: Mr Jason Scott presented with yellowish discoloration of eyes and skin for the past 1 week. It
has progressed gradually. He has right upper quadrant abdominal pain. He has loss of appetite, malaise,
nausea and vomiting. His urine is high colored and stool is pale colored. He has low grade fever. He has few
tattoos on his body along with body piercing. He is a chronic alcoholic, smoker and IV drug user for the past
10 years.
Clinical Case : Viral Hepatitis (examination on page 63)
Anna Levy, a 32 years old lady presented with lower abdominal pain and vaginal spotting for 2 days.. Take a
focused history.
Vitals: BP - 120/80 mm Hg. HR - 90/min. RR - 12/min. Temp - 37.5°C
Clinical Info: Ms Anna Levy presented with h/o lower abdominal pain and vaginal spotting for 2 days. LMP:
6 weeks ago. Bi-manual exam has cervical motion tenderness with open os and bleeding +++.
Clinical Case : Abortion
Investigations
• CBC, electrolytes, renal function tests.
• Beta HCG
• Pelvic ultrasound.
• Blood group & type.
Clinical Cases – Obstetrics & Gynecology 119
Rachel Owens, a 42 years old primigravida who is 9 weeks pregnant. She came to your office to know about
her genetic risks. Take a focused history and address her concerns.
Clinical Info: Ms Rachel Owens conceived naturally and this is her first pregnancy. She is sure of her dates.
She didn't have any antenatal visit yet. This is her first visit. Her home pregnancy test was positive twice. No
family history of genetic disorders. She is only taking prenatal vitamins. No h/o medical illnesses.
She does not smoke or consume alcohol.
Clinical Case : Antenatal Visit
Obstetrical History
• Do you have children? If yes, then ask for
Gravidity, Term/Premature deliveries,
Abortions, Live/Multiple births,
complications in pregnancy.
• H/o ectopic pregnancy?
•
Investigations Management
• CBC • Give antenatal brochures.
• Urine culture/sensitivity, microscopy. • Discuss about genetic screening &
• Beta HCG Counseling.
• ABO Rh, type. • Referral to an obstetrician and prenatal
• Blood sugar,TSH. genetics screening.
• Measles,Mumps,Rubella,Varicella,VDRL. • Nutrition & exercise in pregnancy.
• HIV,HBsAg,HCV. • Avoid alcohol/smoking/teratogenic
• Pelvic ultrasound. medications.
• Discuss about risk of Down's/Turner's &
other genetic disorders in elderly
primigravida.
120 NAC OSCE | A Comprehensive Review
Lisa Raymond, a 28 years old lady presented to the ER with lower abdominal pain on the left side for the
past 12 hours. Take a focused history and perform a focused examination (Page 63).
Vitals: BP - 100/70 mm Hg. HR - 98/min. RR - 16/min. Temp - 37.5°C
Clinical Info: Ms Lisa Raymond, presented with h/o left side lower abdominal pain for 12 hours with mild
spotting. LMP: 2 months ago. Bi-manual exam has cervical motion tenderness & left adnexal fullness.
Clinical Case : Ectopic Pregnancy
Cathy Davies, a 32 years old lady presented with inability to conceive for the past 3 years. Take a focused
history and address her concerns.
Vitals: BP - 120/80 mm Hg. HR - 88/min. RR - 12/min. Temp - 37.0°C
Clinical Info: Ms Cathy Davies has been unable to conceive for the past 3 years with unprotected intercourse.
She has not taken any treatment so far. Her periods are irregular with prolonged intervals. She has weight
gain for past 2 years and hirsutism. She is in a monogamous relationship. No other stressors. She has a 5 years
old daughter conceived naturally. No other medical illnesses.
Clinical Case : Infertility
Diagnosis • Hystero-salphingogram.
• Secondary infertility. • Laparoscopy.
• Semen analysis
Investigations
• CBC,FBS,TSH. Management
• Day 3 FSH,LH,PRL±DHEAS,Free • Complete physical examination of both the
testosterone. partners.
• Day 21-23 Progesterone. • Treat the cause.
• Basal body temperature monitoring. • Supportive counseling.
• Pelvic ultrasound • Timing of the intercourse in relation to
ovulation.
• Referral to infertility specialist.
122 NAC OSCE | A Comprehensive Review
Alyssa Jones, a 18 years old girl came to your office requesting for contraceptive pills. Take a focused history
and address her concerns.
Vitals: BP - 120/80 mm Hg. HR - 80/min. RR - 12/min. Temp - 37.0°C
Clinical Info: Ms Alyssa Jones is a 18 years old student with no significant history of medical illnesses. She is
in an active sexual relationship for the past 4 months. Had one episode of STI 6 months ago. LMP was 1
week ago. No family history of cancers. Currently using barrier contraception.
Clinical Case : OCP Counseling
Investigations Management
• PAP test & complete physical. • Tab Yasmin one tab OD for 28 days.
• Vaginal & Cervical swabs, culture/sensitivity. • Begin pill on first Sunday after onset of
Menses
Benefits of OCP • If Menses start on Sunday, then start pill
• Prevention of unwanted pregnancy. Day 1
• Reduced blood loss. • Use barrier Contraception for Days 1-7
• Decreased dysmenorrhea. If pill started after Day 5:
• Cycle regularization. • OCP may not suppress Ovulation for first
• Decreased risk of breast/ovarian/endometrial cycle
cancers. • Use barrier Contraception for first month.
• Decreased acne. • Follow up 6 weeks after the start of the pill.
• Decreased osteoporosis.
• Decreased PMS symptoms.
• Reversible contraception.
Clinical Cases – Obstetrics & Gynecology 123
Maria Santosa, a 28 years old lady presented with lower abdominal pain, dyspareunia and vaginal discharge
for 1 week. Take a focused history and perform focused examination.
Vitals: BP - 120/80 mm Hg. HR - 90/min. RR - 12/min. Temp - 38.5°C
Clinical Info: Ms Maria Santosa presented with h/o lower abdominal pain for 1 week with dyspareunia and
foul smelling vaginal discharge. She has mild fever for 2 days. H/o unprotected intercourse +. H/o of past
infection 3 months ago. LMP: 1 week ago. Bi-manual exam has cervical motion tenderness & right adnexal
fullness.
Clinical Case : Pelvic Inflammatory Disease (examination on page 63)
Julia Marshall, a 30 years old lady presented to the ER with bright red vaginal bleeding for the past 1 hour.
She is 36 weeks pregnant. Take a focused history and address her concerns.
Vitals: BP - 100/70 mm Hg. HR - 100/min. RR - 14/min. Temp - 37.5°C
Clinical Info: Ms Julia Marshall is G2 T1 P0 A0 L1 at 36 weeks gestation. She has painless vaginal bleeding
for the past 1 hour. Has no contractions. Fetal heart rate is 130/minute. She has a previous history of cesarean
section.
Clinical Case : Placenta Previa
Elaine Abraham, a 32 years old lady primigravida, at 34 weeks gestation presented to the ER with headache,
abdominal pain and blurring of vision. Take a focused history and address her concerns.
Vitals: BP - 150/100 mm Hg. HR - 90/min. RR - 14/min. Temp - 37.0°C. FHR - 148/min.
Clinical Info: Ms Elaine Abraham has a history of pregnancy induced hypertension since 28 weeks. Her BP
is controlled by dietary restrictions and low salt intake. She has epigastric pain, blurring and headache for the
past 4-6 hours. She has facial and ankle edema ++. There are no contractions. Fetal movements are felt. No
bleeding. Urine dipstick is positive for proteinuria.
Clinical Case : Pre Eclampsia
Diagnosis Management
• Gestational hypertension with Pre- • Admit in the hospital.
eclampsia. • Electronic Fetal monitoring.
• Bed rest in left lateral decubitus position.
Investigations • Hourly maternal vital signs with
• CBC, electrolytes, renal function tests. intake/output charting.
• Urinalysis, 24 hour urinary protein, liver • Inj Magnesium sulphate 4 mg IV bolus over
function tests, uric acid, LDH, albumin. 20 min,then 2-4g/h for maintenance.
• INR, PTT, Fibrinogen. • Monitor signs for magnesium toxicity.
• Non stress test, Bio-physical profile. • Inj Labetalol 20-50 mg IV q10minutes till
• Fetal ultrasound. BP< 140/90 mmHg.
• Deliver the baby.
RISK FACTORS FOR PIH:
Maternal: Primigravida or new paternity, Family hx of Preeclampsia, Diabetes Mellitus, Obesity, Maternal age >40 years,
Preexisting Hypertension, Anti-Phospholipid Antibody syndrome.
Fetal: IUGR, Oligohydraminos, Gtn. hydrops, Multiple pregnancy.
126 NAC OSCE | A Comprehensive Review
Michael Walter a 18 months old boy brought to your office by his mother regarding poor weight gain. Take
history from the mother & address his concerns.
Clinical Info: Michael's mother is concerned regarding poor weight gain for his age & height. He has no
fever/nausea/vomiting/cough. No h/o recurrent infections. No urinary or bowel complaints. He's picky eater
who gets distracted while eating food. His diet consists of excessive juice & milk. No family stress present.
Clinical Case Diagnosis: Failure to thrive due to inadequate dietary intake.
Benjamin Smith a 15 months old boy has been brought to the ER with fever and 2 episodes of seizures. He is
stabilized now. Take history & address the concerns of an over anxious mother.
Clinical Info: Benjamin Smith was having a runny nose and high grade fever for the past 3 days. His fever did
not subside with Tylenol. He had 1st episode of tonic-clonic seizure 6 hours ago at home. This was the first
occurrence. He had no other symptoms. No family history of seizures. No complications during birth or
development so far. Immunization is up to date.
No signs of child abuse.
Diagnosis: Febrile seizures.
Nick Chang is a 15 years old boy brought by his mother with fever and rash for the past 2 days.
Take history & address her concerns.
Clinical Info: Nick has high fever for the past 2 days. He has developed a diffuse rash in the last 24 hours
which is spreading from head to trunk. He also has cough, sore throat and redness of eyes. He has no altered
level of consciousness/irritability. He is alert and feeding well. Has h/o sick contacts with similar complaints
in the day care. His immunization is up to date.
Diagnosis: Measles.
Marie Jones delivered baby Anthony 36 hours old and now the newborn has jaundice, lethargy and crying.
The serum bilirubin is 220 mmol ( N < 200). Take history & address her concerns.
Clinical Info: Anthony was born to a primigravida by normal vaginal delivery. Mother noticed yellowish
discoloration of his eyes in the morning. She had no antenatal complications. She had premature rupture of
membranes prior to onset of labor at 38 weeks. She was put on antibiotics. Her labor was 18 hours long. The
labor was induced. Apgar was 9/10. Baby is a little lethargic and not feeding well. Has no fever/altered
consciousness. No seizures.
Clinical Case Diagnosis: Neonatal Jaundice due to Sepsis.
Sean Radcliffe is a 8 years old boy whose parents have concern about bed wetting. Take history from the
father & address his concerns.
Clinical Info: Sean has been wetting his bed since the last 3 years. He never had bladder control. He has no
fever/vomiting. No h/o recurrent infections. He wets bed 2-3 times in the night. No day time wetting present.
No encoparesis. Parents have not taken any treatment so far and have tried toilet training in past with no
success. No stresses at home or school.
Clinical Case Diagnosis: Primary nocturnal enuresis.
Ally Singer's 6 weeks old baby boy Alex is vomiting for the past 2 days. Take history & address her concerns.
Clinical Info: Alex had 4 episodes of projectile non bilious vomiting in the past 48 hours. He vomits after
feeding. No fever. Looks lethargic & dehydrated but alert. No seizures. Had only one bowel movement in last
24 hours. No sick contacts. O/E: Palpable abdominal mass in the right hypochondrium.
Clinical Case Diagnosis : Pyloric stenosis.
Newborn history
• Gestational age at birth and birth weight.
• Mode of delivery: cesarean, induction,
forceps or vacuum delivery.
• Any fetal distress? Was meconium passed in
utero?
• APGAR score at birth, 1 minute & 5
minute?
• Was resuscitation required?
• When was breast feeding started?
• H/o neonatal jaundice.
• Color of 1st stool, when was 1st stool
passed?
• Color of urine, when was 1st urine passed?
Investigations
• CBC,electrolytes, RFT, LFT.
• ABG.
• Urinalysis.
• Ultrasound abdomen.
• Abdominal X ray.
132 NAC OSCE | A Comprehensive Review
John Andrews is a 3 years old boy who is not speaking well. Take history & address his father's concerns.
Clinical Info: John Andrews has h/o recurrent ear infections. He had 3 episodes in the last 6 months. He has
runny nose and mild cough too. He can speak in sentence of 3-4 words. He can count to 5. But for the past 3
months he is not learning new words or numbers. He responds to loud sounds. No other complaints. Social
interaction is very good. No birth or developmental complications till date.
Diagnosis: Speech delay secondary to recurrent otitis media.
Gabriella Anderson, a 18 years old girl came to your office with complaints of gaining weight. Take history &
counsel.
Clinical Info: Ms Gabriella Anderson presented with gaining 5 lbs in the last 1 month. She looks
underweight for her age and height. She is exercising 3 times a day. She doesn't binge or induce vomiting.
Lately she is taking small portions of meals due to fear of gaining weight. She has no medical illnesses. No
past history of psychiatric illness. Currently not taking any medications.
Clinical Case : Anorexia
Amanda Sawyer, a 20 years old girl brought to your office by her mother for vomiting and weight loss. Take
history & counsel.
Clinical Info: Ms Amanda Sawyer presented with vomiting after meals. She has fear of weight gain. H/o
binging & induced vomiting present. H/o laxative abuse and excessive exercise. She has no apparent psycho-
motor or suicidal ideation. She has no medical illnesses. No past history of psychiatric illness. Currently not
taking any medications.
Clinical Case : Bulimia
Derek Paul, a 65 years old man admitted in surgical floor presented with strange behavior for the past 4
hours. You are on call surgical resident for the shift. Take history & counsel.
Clinical Info: Mr Derek Paul had partial right hip replacement 3 days ago. His post op recovery till now has
been uneventful. Evening shift nurse noticed significant change in his behavior. He is agitated, restless with
acute memory loss. He is disoriented to time, place & person. He is having delusional thoughts of ants
crawling. He is on oral antibiotics, antihypertensives, blood thinners. He is a chronic alcohol abuser.
Clinical Case : Delirium
Claire Wiggins, a 72 years old lady brought to your office by her son with strange behavior. Take history from
the patient and address her concerns.
Clinical Info: Ms Claire Wiggins is forgetting things and daily tasks for the past 1 year. Her symptoms have
become worse for the last 6 months. Recently she forgot her way back home. She lives alone. Son has noticed
changes in her dressing and poor hygiene. She has no apparent psycho-motor or suicidal ideation. She has
hypertension. No past history of psychiatric illness. Currently on oral antihypertensives, statins, zoloft,
multivitamins.
Clinical Case : Dementia
Julian Smith, a 56 years old lady brought to your office by her husband with strange behavior. Take history &
counsel.
Clinical Info: Ms Julian Smith has h/o of change in mood for the past 1 month after loosing her job. She has
changes in mood, sleep and appetite. She has lost 10 lbs in the last 1 month. She has lack of interest in social
activities. She has no apparent psycho-motor or suicidal ideation. She has no medical illnesses. No past
history of psychiatric illness. Currently not taking any medications.
Clinical Case : Depression
David Rosenberg, a 26 years old man brought to the ER by the police because he was throwing stones at a
public building. Take history & counsel.
Clinical Info: Mr David Rosenberg presented with irrational behavior for the past 10 days. He is having
racing thoughts, increased activity, decreased sleep and increased vocalization. He has constant flight of ideas
during the interview with easy distractibility. He is restless while sitting and at times agitated. No medical
illnesses but is a chronic cocaine abuser.
Clinical Case : Mania
Brad Daniels, a 22 years old man came to your office with light headedness, trembling and chest pain for the
past 4 hours. Take history & counsel.
Clinical Info: Mr Brad Daniels is a university student who presented with sudden onset of light headedness,
trembling of body and chest pain prior to his presentation in class. He also complaints of palpitations and
shortness of breath. He had similar episodes in the past. No past history of psychiatric or medical illnesses.
Not taking any medications currently.
Clinical Case : Panic Attack
Liam Pinkerton, a 24 years old male was brought to the ER with complaints of alien attacks . Take history &
counsel.
Clinical Info: Mr Liam Pinkerton is brought by police with complaints of being attacked by aliens in the last
48 hours. He is talking to himself and avoiding direct eye contact. He is restless and agitated and feels
threatened. He is hearing strange voices for the past 1 month along with disorganized speech and behavior.
He is a chronic cocaine user for the past 3 years and increased consumption in last 48 hours.
Clinical Case : Schizophrenia
Erica McCain is a 16 years old girl brought to the ER with ASA overdose. She is stabilized now. Take
history & counsel.
Clinical Info: Ms Erica McCain a 16 years old school going girl took 30 tabs of Aspirin after smashing her
parents car in a tree. She attempted to commit suicide to prevent embarrassment. She went to her friend's
house after the accident. Her grandma brought her to the ER. Has h/o previous attempt 1 year ago. Is
currently consulting a psychiatrist on a regular basis. Presently on antidepressants. Show EMPATHY!
Clinical Case : Suicide
Brandon Rodrigues, 28 young man comes with recent onset of back pain and limp. Take focused history and
preform a focused examination.
Clinical info: Mr Brandon Rodrigues had a sudden onset of sharp lower back pain 2 days ago after lifting
heavy boxes at home. Pain is located in the lumbar area, grade 8/10 and is constantly present. He has
numbness and paresthesias present in his left leg for the past 12 hours. No weakness or loss of sensation in
the lower limbs. No urinary retention or bowel incontinence. He does not smoke or consume alcohol. O/E
there is tenderness in the L4 – L5 area & decreased sensation in the L4 – L5 dermatomal distribution.
Clinical Case : Back Pain
Surgery indicated in
• Cauda Equina.
• Worsening neurological deficit.
• Intractable pain not responding to
conservative treatment.
Clinical Cases - Surgery 143
Nicole Davy, a 75 years old lady presented with enlarging mole on her nose . Take a focused history and
perform focused physical examination.
Vitals: BP - 120/88 mm Hg, HR - 86/min, RR - 12/min, Temp - 37.0°C
Clinical Info: Ms Nicole Davy has an enlarging mole on her nose which is changing in color and shape over
the past 1 month. She is a Caucasian retired woman who spends 6 months in Florida during winters in
Canada. Recently noticed irregular edges of her mole and got concerned. She worked as a radiation technician
for 30 years prior to retirement. She had a similar mole which was cancerous and removed 10 years ago. O/E:
There is a small 0.5 x 0.5 cm pearly papule on her lateral left side of nose, with irregular rolled out margins
and minimal discharge.
Clinical Case Diagnosis: Basal Cell Carcinoma.
Jacob Simpson, 62 year old man presents to the Emergency Department with 12 hours suprapubic discomfort
and inability to urinate. Take a focused history & perform a focused examination.
Clinical Info: Mr Jacob Simpson presented with acute urinary retention for the past 12 hours. He is having
difficulty passing urine for the past 4 months, which has gradually increased. He has hesitancy, urgency,
increased frequency and weak stream. No hematuria or UTI. O/E there is a palpable supra-pubic mass.
Catheterization yields 1200cc urine.
Clinical Case : Benign Prostatic Hyperplasia
Lydia Jones, a 30 years old office lady presented to your office with right hand numbness and weakness for 2
months. Take a focused history and address her concerns.
Clinical info: Ms Lydia Jones presented with gradual onset of right hand numbness and weakness for the
past 2 months. Her symptoms have worsened. Associated with paresthesias and pain in fingers at the end of
the day. She has difficulty opening jars, turning keys and night pains. She has no medical illness. Not on any
medications. She is an office administrator.
Clinical Case : Carpal Tunnel Syndrome
Ruth Gagnon, a 60 years old woman presented to your office with right sided calf swelling for the past 2 days.
Take a focused history and perform focused examination.
Vitals: BP - 140/80 mm Hg, HR - 86/min, RR - 12/min, Temp - 37.5°C
Clinical Info: Ms Ruth Gagnon is having right calf swelling and redness for the past 2 days. She has leg pain
also. She is a known hypertensive on medications. She recently traveled for 20 hours in an overnight flight.
She is compliant with her medications. She has past history of breast cancer treatment 5 years ago with no
complications.
Clinical Case : Deep Vein Thrombosis
Mathew Hobbs, a 55 years old man presented with numbness in his both feet. He is a known diabetic. Take a
focused history and perform focused physical examination.
Vitals: BP - 130/90 mm Hg, HR – 86/min, RR – 14/min, Temp – 38.5°C.
Clinical Info: Mr Mathew Hobbs is a known diabetic for the past 15 years. He is on oral hypoglycemics. His
last fasting glucose was 7.6 mmol/L. On examination, both feet were normal.
Clinical Case : Diabetic Foot
Diagnosis Management
• Diabetic foot • Self foot exam daily.
• Foot examined regularly at physician visits.
Investigations • Perform Peripheral Neuropathy Testing.
• Fasting blood glucose. • Check for pedal pulses.
• HbA1C. • Evaluate & aggressively treat new foot
• Fasting lipids, Renal function tests. wound.
• ECG. • Avoid foot trauma
• Fundoscopy. • Do not walk barefoot.
• Urinalysis with urine dip. • Cut nails carefully.
• Avoid excessive heat or chemicals.
148 NAC OSCE | A Comprehensive Review
Wayne Singer, 68 year old man presented with difficulty swallowing for the past 4 months. Take a focused
history and perform a focused examination.
Clinical Info: Mr Wayne Singer has difficulty swallowing for the past 4 months. It has gradually increased
from solids to liquids. He feels a lump in the throat. He has chest pain when he eats food. He has noticed
weight loss, night sweats and decreased appetite in the last 3 months. He is a chronic smoker for the past 30
years.
Clinical Case : Difficulty Swallowing ( Ca Oesophagus)
Investigations
• Endoscopy with biopsy.
• Upper GI series.
• CT chest (for mediastinal and lymph node
involvement).
Clinical Cases - Surgery 149
Brad Chisolm, a 35 years old man presented with bloody vomiting to the ER for the past 2 hours. Take a
focused history and perform focused physical examination.
Vitals: BP - 90/60 mm Hg, HR - 116/min, RR - 12/min, Temp - 37.0°C
Clinical Info: Mr Brad Chisolm presented with acute onset of blood in vomitus, 2 episodes in 2 hours ago.
He has no history of trauma. Non alcoholic, non smoker. He has been having chronic knee pain after a
skateboarding accident 2 weeks ago. He is taking Ibuprofen for the past 2 weeks 4-5 times a day. Has
moderate epigastric pain. No hemoptysis, hematuria or hematochezia. No surgeries/ medical illnesses.
Clinical Case : Hematemesis
Mary Laplante, a 40 years old lady presented with swelling in the neck for the past 1 month. Take a focused
history and perform focused physical examination.
Vitals: BP - 120/88 mm Hg, HR – 96/min, RR – 12/min, Temp – 37.5°C.
Clinical info: Ms Mary Laplante noticed this swelling in the anterior neck with no other prominent
symptoms. On examination, there is 2cm x 2cm mobile, non tender thyroid enlargement in the left lobe.
Clinical Case : Neck Swelling
Management
• Refer to an endocrinologist.
Clinical Cases - Surgery 151
Judy Frances, a 25 year old female presented to your office with lower abdominal pain for the past 1 day. Take
a focused history and perform a focused examination.
Clinical Info: Ms Judy Frances had a gradual onset of right lower abdominal pain 24 hours ago. The pain has
gradually increased in intensity, grade 7/10. She has fever, nausea and vomiting since morning. No bowel or
urinary complaints. No trauma. Her LMP was one week ago. O/E peritoneal signs are present and tenderness
at McBurney's point.
Clinical Case : Pain Abdomen /Acute Abdomen
Investigations
• Abdominal X-ray 3 views
• Abdominal & pelvic ultrasound
• CBC, Electrolytes, Urea, Creatinine
• INR/PTT, Glucose, beta HCG
• Urinalysis
• Stool for occult blood
• Cervical swabs for culture/ PAP smear
152 NAC OSCE | A Comprehensive Review
Ronald Mandel, a 65 years old man presented to your office with bilateral leg pain for the past 2 weeks. Take
a focused history and perform focused examination.
Vitals: BP - 140/90 mm Hg, HR - 86/min, RR - 12/min, Temp - 37.5°C
Clinical Info: Mr Ronald Mandel is a known hypertensive for 15 years. He was diagnosed with CAD 5 years
ago. He is having bilateral lower leg pain for the past 2 weeks. Pain starts only when he has walked for 10-15
minutes. Pain subsides after taking rest. He has paresthesias too. No weakness or night pain. He is a chronic
smoker and alcoholic for 20 years.
Clinical Case : Peripheral Vascular Disease (Examination on page - 67)
Alex Pereira, a 45 years old man presented with high grade fever with chills on day 3 after his abdominal
surgery. Take a focused history and perform focused physical examination.
Vitals: BP - 110/80 mm Hg, HR - 96/min, RR - 12/min, Temp – 38.5°C.
Clinical Info: Mr Alex Pereira was operated 3 days ago for acute appendicitis. The morning shift nurse
noticed temperature of 39.8º C. He is complaining of chills , rigors and nausea. He has pain at the wound site.
No burning in urine. Had one bowel movement in the morning. No chest pain or shortness of breath. IV
antibiotics were stopped on post op day 2. No other complications. O/E: Wound site is tender, erythematous
with yellowish discharge.
Clinical Case : Post Operative fever secondary to wound infection
Diane Richardson, a 55 years old woman presented with incidental finding of lung nodule on chest x ray. Take
a focused history and perform focused physical examination.
Vitals: BP - 120/80 mm Hg, HR - 86/min, RR - 18/min, Temp – 37.5°C.
Clinical Info: Ms Diane Richardson has chronic cough for 2 months. It was gradual in onset. No fever or
recurrent pneumonia. A routine chest X ray revealed solitary nodule in the right middle lobe. She is a known
smoker for the past 30 years. She is a chronic alcoholic also.
Clinical Case : Solitary lung nodule
Elaine Jones, a 60 years old lady presented with swelling in the neck for the past 4 months. Take a focused
history and perform focused physical examination.
Vitals: BP - 120/80 mm Hg, HR – 88/min, RR – 12/min, Temp – 37.5°C.
Clinical info: Ms Elaine Jones presented with a solitary swelling in the right lobe of the thyroid for the past 4
months. The swelling has increased in size. She has no fever, cough or sore throat. She has decreased appetite
and 5 kg weight loss in the past 3 months. She has hoarseness of voice.
Clinical Case : Thyroid mass
Joseph Quinton, a 25 years old male was brought to the ER after a motor vehicle accident with the following
vitals: BP - 80/50 mm Hg, HR - 116/min, RR - 10/min, Temp - 37.0°C, O2 sat - 80%.
Manage the patient with a nurse.
Clinical Info : Mr Joseph Quinton had a MVA 1 hour ago. He is conscious, alert and responding to verbal
commands. He is in excruciating pain & complains of difficulty breathing. He can move all limbs. On
auscultation, there are decreased breath sounds on right side of chest with dullness on percussion.
Diagnosis: Trauma - Right sided hemothorax.
• Introduce yourself.
• Call out the patient's name and assess verbal response.
• Follow universal precautions - mask,wash hands,wear gloves.
• Ask for patient's vitals.
• Ask the patient to be connected to monitors: cardiac monitor, BP cuff, pulse oximeter, temperature
probe.
• Place cervical collar with in-line traction.
• AIRWAY - Open mouth & check airway for any loose body/dentures/bleeding. Mention any
specific smell.
• BREATHING -
- LOOK - cyanosis/pallor/icterus/nasal flaring/chest movements/respiratory rate/neck venous
engorgement.
- FEEL - flow of air/tracheal shift/chest wall for crepitus/flail segments/sucking chest
wounds/subcutaneous emphysema.
- LISTEN - sounds of obstruction/breath sounds/symmetry of air entry/air escaping/noisy
breathing.
• CIRCULATION - feel for peripheral pulses/ assess for shock-capillary refill,cool extremeities.
• DISABILITY - GCS/pupillary reaction.
• Order primary INVESTIGATIONS - CBC, differentials, electrolytes, RFTs, LFTs, ABG, INR,
PTT, 12 lead ECG, urinalysis, urine toxicology screen, portable chest X ray, C-spine X ray, Blood
group, type & cross match, blood glucose.
• Place large bore IV cannulas both arms & IVF 1 l normal saline bolus stat.
• Attach to 100 % oxygen through mask/nasal cannulas.
• Ask for vitals again.
• Ask for orientation to time/place/person, mechanism of injury/ any eye witnesses/ any loss of
consciousness/ vomiting/ pain anywhere in the body/ last meal/ any drug allergies/ TAMPLE or
SAMPLE.
• EXPOSURE/ SECONDARY SURVEY - Assess for:
- Skull/cranium fractures.
- Injuries to the face.
- Hemotympanum/ otorrhea/ rhinorrhea/ epistaxis/ battle's sign/ racoon eyes.
- Check upper extremities for fractures/ bruises/ lacerations/ tattoos/ needle track marks/ medic
alert bracelet/ scars/ wounds.
- Check abdomen for movements/ scars/ wounds/ bruises/ rigidity/ masses, bowel sounds.
- Check lower extremities for fractures/ bruises/ wounds/ tattoos/ needle track marks.
- Pelvic compression to rule out pelvic fracture.
- Deep tendon reflexes of upper & lower extremities.
- Sensory examination of upper & lower extremities.
- Motor examination of upper & lower extremities.
- Genital examination.
- Spinal examination - log roll with help to look for fracture/ step deformity.
- Digital rectal examination.
- Change rigid board to semi rigid board.
Clinical Cases - Surgery 157
1 2 3 4 5 6
Eyes Does not open Opens eyes in Opens eyes in Opens eyes N/A N/A
eyes response to response to spontaneously
painful stimuli voice
Generally, brain injury is classified as Severe : GCS ≤ 8 , Moderate : GCS 9 - 12 and Minor : GCS ≥ 13.
Clinical Cases - Counseling 159
Allison George, a 28 years old primigravida came to your clinic for her antenatal visit. She wants info for
breast feeding.
Take a focused history and address her concerns.
Rachel Marshall is a 20 months old girl brought to the ER with excessive crying. She has signs of fracture of
right humerus. You also observe some old healed bruises elsewhere on her body. She is now stable. Take
history from the mother and address her concerns.
Nancy Alfredo, a 30 years old woman presented to your clinic with a black eye and multiple bruises on her
arms. Take history and address her concerns.
Sara Chang, a 55 years old lady came to your clinic to get info about Hormone Replacement Therapy. She is
menopausal for the past 2 years. She is having significant hot flushes, mood fluctuations and vaginal dryness.
It is significantly affecting her quality of life.
Take a focused history and address her concerns.
Nadia Solanski, a 45 years old lady came to your clinic to get info about mammogram.
Take a focused history and address her concerns.
• Mammogram is an annual screening test for the early detection of breast cancer.
• Breast cancer is the second leading cause of cancer mortality in women.
• Every 1 in 9 women in Canada are diagnosed with breast cancer.
• It is recommended after the age of 40 years or more for every women.
• It is done annually or every 2 years as a routine preventive test.
• If there is a strong family history of breast cancer or genetic pre-disposition to breast cancer, then
mammogram is done 5-10 years prior to the age of the relative detected with cancer.
• There are two types of mammogram - Screening and Diagnostic.
• Diagnostic mammogram is done in cases of breast mass/lumps/suspicion of breast cancer.
• Mammogram is a special X ray of the breast done in a diagnostic radiology clinic.
• The procedure might cause slight discomfort or pain which lasts only few seconds.
• It can take upto 20 minutes to do a mammogram.
• Images are interpreted by an experienced radiologists.
• In case of any abnormality, further tests will be arranged.
• Ideally mammogram should be done after your period has stopped, to avoid discomfort.
• Give information brochures for mammogram.
• Encourage annual physical examination with a family physician.
164 NAC OSCE | A Comprehensive Review
Jenna Martin is a 28 year old mother who has concerns about the immunization for her 2 months old son.
Take history and address her concerns.
HOPI
• Take detailed prenatal/antenatal history?
• Any complications during pregnancy?
• Any complications during delivery time?
• Any post partum complications?
• Any h/o genetic disorders in the family?
• Any h/o egg allergies?
• Any allergies to medications?
• Feeding pattern?
• Developmental history?
• Any fever/vomiting/irritability?
• Any bowel complaints?
• Any urinary complaints?
• Any neonatal jaundice?
• Hearing & vision tests for the newborn?
• Any issues during newborn examination?
• Any h/o complications after immunization in the family?
James Hendrik is a 40 years old man who came to your office today to discuss his weight issues. His current
weight is 250 lbs, Height 5 feet 7 inches, BMI 39.2.
Take history and address his concerns.
• Motivation: how would being at ideal body weight improve the patient's life?
• Emphasize health, lifestyle, self esteem, relationship benefits.
• Discuss nutrition-related problems: heart disease, obesity, hypertension, osteoporosis, anemia, dental
decay, cancer, gastrointestinal disorders, respiratory compromise, high lipids, diabetes, sleep apnea,
osteoarthritis.
• Discuss diets tried and why these failed.
• Fad diets involve unusual or extreme eating patterns and are not designed to be maintained for a
lifetime therefore these should be discouraged.
• Weight loss agent Ponderal no longer available.
• SSRIs such as Paxil may assist with weight loss, unfortunately, when the drug is discontinued, most
people regain weight.
• Explain that the brain has a satiety set point which can be reset over time with reduction in caloric
intake.
• Warn that the body's ability to determine caloric content is very good, and will not be fooled by so-
called diet products.
• Recommend a balanced diet consisting of ordinary foods, with three distinct meals per day of small
size.
• No eating at night and be careful of snacks.
• Inform patient that he will be hungry for at least the first two weeks of reduced intake.
• Suggest visualization techniques, redirection of interests, and to think of hunger as a sign of positive
progress on weight loss.
• Group support can be beneficial too: Weight watchers, overeaters anonymous etc.
166 NAC OSCE | A Comprehensive Review
• Behavior modification and positive outlook is vital for weight loss regime.
• Dietary recommendations: reduce fat to 20% of caloric intake. 1200-1600 kcal/day for males.
• Ideal caloric intake can be estimated at 10-12 Cal/lbs (ideal weight) in males.
• Emphasize that caloric intake is more important for weight loss than food composition (i.e. excessive
calories lead to weight gain even if they are non-fat).
• Exercise recommendations: 30 minutes of moderate intensity exercise, 4-5 days/week.
• Sudden intense exercise in sedentary patient unwise.
• More vigorous exercise can be initiated when weight is lost.
• Behavioral modifications, self control, rewards on achieving goals.
• Arrange regular follow-up for body mass monitoring and counseling.
Clinical Cases - Counseling 167
Peter Harper is a 35 years old man, who is a chronic smoker for the past 10 years. He came to your office
today because he wants to quit smoking.
Take history and address his concerns.