May 2015, OSCE

(12 interactive and 1 non-interactive station and 7 rest stations)

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Case:-1
Patient got whiplash (neck injury) in car accident and Dr. prescribed Percocet (Combination of
OXYCODONE HYDROCHLORIDE 2.5mg & ACETAMINOPHEN 325mg) tab that were
stopped 6 months back after the course of given duration. Dr. told the patient to take Tylenol #1
(contains acetaminophen 300 mg, caffeine 15 mg, and codeine phosphate 8 mg). Patient did not
stop taking Tylenol #1 and has been taking up to now. Patient is taking 20 tab per day,
complaining of hot and cold sweats and shakiness and wants Tylenol #1 from pharmacy.
Think of overdose of Tylenol #1 — 6 grams of acetaminophen per day.
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Case:-2
A mother got mastitis on right breast, prescribed cloxacillin 1 tab QID for 10 days. She breast
feeds 2 year old son who is solely on breast feed. Check appropriateness of the Rx and counsel
her. There were some OTC products as well on the table including lanolin cream.
Concern: is cloxacillin harmful to my baby? Or should I stop breastfeeding?
Ans: From eCPS, Nursing Women

Based on the knowledge that some penicillins are excreted in breast milk, it should be expected
that cloxacillin is as well. Although possible effects on a nursing infant include alteration of the
gut flora (potentially resulting in oral thrush or diarrhea), obscured diagnosis of fever and
hypersensitivity reactions, cloxacillin is generally considered to be compatible with breast-
feeding.

So you may tell her for inspecting white patches in baby’s mouth and diarrhea as well!

Case:-3

A young male patient hospitalized for bipolar disorder. He wants to know whether he should
keep taking quetiapine or no. He was worried about the side effects of the drug. Because he is an
artist (painter, guitarist) by profession and quetiapine may affect his career in future.

According to eCPS: Yes, Quetiapine has Tardive Dyskinesia (TD) and Extrapyramidal
Symptoms (EPS) side effects.
Tardive Dyskinesia is a syndrome of potentially irreversible, involuntary, dyskinetic movements
that may develop in patients treated with antipsychotic drugs including quetiapine. Although the
prevalence of the syndrome appears to be highest among the elderly, especially elderly women, it
is impossible to rely upon estimates to predict which patients are likely to develop the syndrome.
So we can say, yes it may affect your art in future. Possibly, best response would be that Dr. has
prescribed good medicine that suitable for you as per his expertise! Furthermore, it is more
common in elder patient so youngers are not as much as at risk comparatively. But if you still
think that it may affect then talk to your doctor for better option!

Case:-4

A medical intern came to get your recommendation about Lantus for the patient whose blood
glucose is not controlled with short and intermediate acting insulin. And patient’s A1C reading
was also going high. Patient’s eating habits have also changed for two weeks because of change
in her job. Dr. asked what dose of Lantus (long acting) should be started in this patient?
Give recommendation based on her A1C level (how many units of Lantus) and inform doctor
about patient to change her life style.

Case:-5

Dr. came for your recommendation for 8 year old asthmatic patient who needs to take 4 times
Ventolin (salbutamol) inhaler for his exercise induced asthma. Pt also takes Flovent (fluticasone)
inhaler regularly. Upon probing, inhalation techniques were ok. Dr. has not tried LABA and
increased dose of ICS yet! Dr. wants to prescribe Zafirlukast for this patient. Give your
recommendation.

Zafirlukast is not recommended in < 12 year old children. He may try for LABA and/or increase
dose of ICS or go for Montelukast.

Case:-6

Patient is about to discharge from hospital after hip replacement surgery. He was on Tramacet
(contains tramadol 37.5 mg and acetaminophen 325 mg) for pain and Arixtra (Fondaparinaux)
infusion to prevent blood clots. Now Dr. wants to stop Arixtra (Fondaparinaux) and want to
switch him on Xarelto (Rivaroxaban). Patient has prescription of Xarelto and he did not know
how and when he should start Xarelto?
It was a counselling case on Xeralto.

Case:-7

A father came for OTC recommendation for his 3 years old son who got constipated. There were
no red flags. He takes diet rich in fiber.
You may ask for toilet (potty) training!

Case:-8

Dr. needs your recommendation for his 73 year old female patient who is diagnosed with mono
articular osteoarthritis of right knee. She is taking multiple medications for bad cholesterol and
hypertension. Dr wants to know if fever (devil’s) claw (herbal) would be good and if not then
what else do you recommend.
Devil’s clove is not good for heart condition.

Case:-9

A gentle man came to get some pain killers for his mother who is 80 year old. She fell down this
morning and went to hospital for emergency help. She did not get any fracture and ER sent her
home saying that she just need to take any pain killer for pain from the pharmacy. Upon probing,
she was not able to sleep after her husband's death last week. She was taking Benadryl tab for
sleep since one week. She stopped Benadryl (diphenhydramine) 2-3 days before.

Critical thinking and Ans: Showing sympathy. She fell down because of Benadryl! Geriatric
patient should avoid as much as possible anticholinergic drugs. If she has still trouble having
sleep then you may refer for sleep only. And explain about not to take any OTC medicine
without any health care’s consultation. Give her some pain killers and counsel about the
medication and why fall happened!
Case:-10

A patient came for refill of tacrolimus, mycophenolate and prednisone. He had kidney transplant
3 months ago. He was doing well after transplant with medicines. He was given 3 months’
supply but came after 5 months. He was not taking medication regularly. He says his mother died
about 1 month ago and she was reminding him to take the medicines. Now he forgets to take
medication regularly. He was drinking 6-7 alcohol drinks per week.
Refer because of missing immunosuppressive dose and offer dosette or blister pack. And counsel
not to drink alcohol because of his condition and show some sympathy for her mother.

Case11:-

A 30 year old female patient came for OTC recommendation for cough. She was taking
adalimumab, methotrexate and folic acid for rheumatoid arthritis. Now she had cough with green
sputum and temp 39.5 degree *C.
Refer because of cough, could be due to methotrexate side effect (chest infection).

Case:-12

A 60 year old female patient came with a prescription for Herpes zoster vaccine (zostavax). The
vaccine was to be given by the Dr. She was taking Acyclovir for cold sore that started yesterday.
Tell her to finish all antiviral (acyclovir) medicine and wait for 24 hours and take zostavax.

Case: -13
non-interactive