3. Describe what u see Diagnosis Name 1 simple clinical examination to confirm diagnosis Name 2 risk factors for this condition Name 2 likely causative organisms 2 investigations How would u treat?
6. Exopthalmos, lid retraction, conjuctivitis Thyroid eye disease-grave disease Mechanical compression(optic neuropathy), ischemia, corneal ulceration( exposure keratitis), Restrictive myopathy (compress the muscle) Orbital swelling
7. Examine the fundus Diagnosis What u want to do to complete the examination?
8. venous tortuosity and dilatation flame-shaped and ‘dot-blot’ haemorrhages retinal haemorrhages cotton-wool spots disc oedema,swollen (actually, just throw in everything know) CRVO Check the other eye? may develop neurovascular glaucoma-check tonometer? check for predisposing factors -Glaucoma, diabetes, hypertension, increased blood viscosity, and elevated Hct such RBS, BP, FBC? no answer is available
9. Corneal ulcer Symptoms Pain Photophobia f/b sensation, tearing Signs: epithelial defect stained with fluorescein Look for foreign body beneath upper lid conjunctival injection 1. Shield the eye 2. IV antibiotics 3. Refer Ophthalmologist 4. NBM 5. IM A.T.T. 6. X-ray / CT scan of the orbits 7. Rule out other injuries *sorry, no proper question is available…
11. Pale optic disc,0.8 CDR, disc margin well dermarcated Optic neuritis(MS) , glaucoma, compression of optic nerve, ischemic optic neuropathy Visual acuity loss , RAPD positive, colour vision loss, visual field defect, painful extra ocular muscle normal(in MS),
12. Diabetic retinopathy ( no question again) -blurred vision -black spots -flashing lights in the field of vision -sudden severe vision loss -floater -halo 3 stages NPDR PDR Diabetic maculopathy Invx : Clinical diagnosis Fluorescien angiography( to find the bleeding site)
13. Non Proliferative 1st signs - venous dilation and small red dots Later - dot and blot retinal hemorrhages, hard exudates, and cotton-wool spots Microaneurism Exudate Blot haemorrhage
17. TREATMENT Control of diabetes and BP Injection of intravitreal or periocular corticosteroids – macular edema LASER: Light Amplification by the Stimulated Emission of Radiation Focal -when macular edema in NPDR Panretinal photocoagulation -nonproliferative retinopathy becomes severe Vitrectomy in vitreous hemorrhage
18. Complication : Non clearing vitreous hemorrhage Traction retinal hemorrhage
19. OPTHALMOSCPE EXAMINATION Intro and explain procedure (+ greet) Request to dim light Instruct patient to look straight Use right hand and right eye Stand on the right side of the patient Move in from an angle of 45o from the right side Describe findings - optic disc, blood vessel, macula Examiner show fundus picture and ask for diagnosis Examiner ask what u wanna do next - check the other eye la, aiyo! -
20. Visual Acuity Intro and inform procedure (+greet) Instruct patient to read the letters on snellen chart (ask 2 question-can read or not, wear glass or not) Check eye seperately Ensure tested eye is open and the other eye properly closed with occluder Ensure patient reads from the top line to the smallest letters she can read by pointing to the letters systematically Intruct patient to look through pinhole Bring patient forward by 1 metre each time when patient is unable to read at 6 metres distance Let patient count fingers held in front of the eye Correct findings for R visual acuity noted Correct findings for the left eye +MAX MARK of 2/10 if fail to occlude 1 eye *the bracketed sentences are added points by author, not in the marking scheme
21. Torchlight examination Intro, explain Eyelids appear normal,no ptosis,MRD 4mm Lid margin appear normal,no extropian/extropian No lumps and bumps Look left and right,both tarsal and bulbar conjunctiva not injected Corneal clear,no pus/haemorhage No defecton iris Both lens present,no gross cataract Pupil round,both direct and concensual reflex intact
22. Visual Field Intro and inform procedure (+greet) Sit the patient in front at the same eye level Make sure his head is still Ask patient to close 1 eye(your right eye against his right eye) Use pin Pin from the superior and laterally until the patient can see the pin Make sure the hand don’t cross the middle meridian of the eye (use the left hand for the left side of the same eye) Repeat on the other eye Diagnosis (please memorise the slide below)
23. 1 = central scotoma-secondary to optic neuritis (does not respect the vertical meridian) 2 = Total blindness of the right eye -complete lesion of the optic nerve 3 = Bitemporalhemianopia -complete lesion of the optic chiasm 4 = Right nasal hemianopia -perichiasmal lesion 5 = Right homonymous hemianopia-complete left optic tract lesion 6 = Right homonymous superior quadrantopia-involvement of the optic radiation in the left temporal lobe (Meyer's loop) 7 = Right homonymous inferior quadrantopia -partial involvement of the optic radiation in the left parietal lobe 8 = Right homonymous hemianopia -complete lesion of the left optic radiation 9 = Right homonymous hemianopia (with macular sparing) -posterior cerebral artery occlusion causing ischemia of the calcarine cortex of the occipital lobe
24. Extra Ocular Muscle Intro and inform procedure (+greet) Sit the patient in front at the same eye level Make sure his head is still Use pin Move in a H-manner Make sure your hand don’t cross the middle meridian line Look for any paralysis and nystagmus Nth to write so say thank you maybe…courtesy ma
30. Fingers clubbing Fattened appearance of distal phalynx with loss of angle between proximal edge of nail and skin. Associated with (but not pathognomonic for) COPD, cystic fibrosis, hypoxia, and a number of other disease states. Causes 1. Infective endocarditis 2. lung abscess 5. chronic liver disease 4. Bronchectaisis 3. lung carcinoma Grades 1. loss of angle 2. loss of angle + fluctuation 3. Drum stick appearanc 4.Hypertrophic pulmonary osteoarthropathy proliferation of tissue
31. Splinter hemorrhage تراها تنشاف باي اصبع مو بس هنا small linear splinter hemorrhage is seen here subungually on the left thumb the Linear hmg. Is parallel to the long axis of nails Causes 1. vasculitis “trauma” 2. Infective endocarditis
32. Xanthomata “also xantheolasma” Localised deposition of the lipid in the tendon of the palm of the hand Yellow deposits apparent above and below eyes, due to infiltration with fat laden cells Yellow deposits on the “area” Caused by intracutanaus cholesterol deposits *indicate type I or II hyperlipidemia Tendon =type II hyperlipidemia pallor and tuboeruptive=Type III hyperlipidemia Fat deposition in the knees
33. Pitting Edema Swelling in the limb and if you press the swelling there will be slor & Redill Causes: 1. right sided heart failure 2. hepatic cirrhosis 3. GI “malabsorption” 4-nephrotic syndrome pitting unilateral: lower limb edema: DVT – Compression on large vans by tumor or enlarged L.N
34. pectus excavatum . Localized depression of the low end of sternum give cosmetic effects the cause could be due to lung restriction or due chronic child respiratory illness or rickets
35. Carcinoma of the Breast elevation of the breast and retraction of the nipple
36. Peutz-Jegher Syndrome discrete, brown-black lesion around the mouth and buccal mucosa it indicates hamartomatous polyps of the Bowel and colon inherited Autosomal dominant
37. Hereditary hemorrhagic telangictasia . multiple small hmg. Involving the lips _associated mostly with Osler-weloer synd. It is autosomal dominant and mostly associate with arteriovenous malformation in the liver and GI bleeding
38. prophyria cutanea trada Porphyria cutanea tarda can be inherited as a dominant trait or acquired due to liver disease. Sun exposed areas develop blistering (vesicles and bullae), erosions and ulcerations, fragile skin, pigmentary changes, and scarring. The cause mostly is: _ prophyrine metabolism disorder as in alcoholism and Hepatitis
39. Spider nevi numerous small vessels look like spider legs distributed over the chest founding Neck, arm, chest. causes 1. liver cirrhosis 2. viral hepatitis 3. pregnancy DDX1. Campbell de Morgan bodies 2. hereditary Hmg telangectaisia *spider nevi opposite venous stars
40. Sclera Icterus Yellow discoloration of the sclera occurs in tissue containing elastin causes 1 . hemolysis 2. obstructive Jaundice when Billirubin level exceed 2-5 mg/dl
41. Periorbital purpura black-red discoloration in the peri orbital area (amyloidosis)
43. Caput medusa Dilated, tortuous, superficial veins radiating upwards from the umbilicus. Portal hypertension has caused recanalization of the umbilical vein, allowing the formation of this collateral DDx :inferior vena cava obstruction
44. Spleenomegaly Massively enlarged spleen, the result of extramedullary hematopoiesis, is outlined above.This patient's left upper quadrant appears more full than the corresponding area on the right causes 1.infection, hepatitis 2.hemlaytic anemia 4. portal hypertension 3. SLE
46. Thrombocytopenic purpura hmg into the skin causes: 1-increase platelets destruction as, in : a-immuno thrompocytopenic pupura b-loss of blood 2- decrease in platelet formation as Bone marrow Aplasia *found in liver diseases and hemophilia
47. Rheumatoid arthritis Chronic inflammation of the MCP joints has lead to theirdeformity, with deviation of fingers towards the ulnar aspect of the upper extremity Fingers 1.swan neck deformity 2. Z deformity of thumb 3.Bounyonnirtr deformity Wrist : 1. ulnar deviation of metacarpophalangeal Joints 2. palmar subluxation of fingers
54. Exophthalmus protrusion of the eye ball from the orbits Complications: 1.chemosis 2. conjunctivitis 3. corneal ulcer 4.optic atrophy 5. opthalmoplegia Causes: 2. Graves disease 1. tumor of the orbit
55. Cushing Syndrome 1.moon face 2. central "truncal" obesity 3.Brusing 4.Buffalo hump 5.erythema & acne causes : 1. exogenous ACTH administration 2. congenital Adrenal hyperplasia 3. ACTH 2nry to hyperpituitarisim
56. Striae Broad, slightly pigmented, linear marks associated with multiple clinicalconditions. In this case, the axillary region striae are related to prior weight loss Most common cause is cushing’s syndrome(increase the steroid) and in steroidal therapy
58. Down Syndrome 1. oblique orbital fissures 2. small simple ears 3. mouth hanging open. 4. protruded tongue 5. short hand and broad
59. Rickets 1. frontal Bossing 2. Bowing of ulna and femur Causes: 1. vit. D deff. 2. hypophosphatemia
60. Facial Palsy 1. dropping of mouth corner 2. flattened nasolabial fold 3. sparing of the forehead Cause: Upper motor neuron lesion due to tumor or vascular lesion .
61. Facial palsy 3 ABNORMALITIES: 1-loss of forehead wrinkle 2-LOSS ability to close eye 3-decreased naso-labial fold prominence on left 4-LOSS ability to raise corner of mouth CLINICAL IMPRESSION: LMN OF LEFT 7TH CRANIAL NERVE
62. Jonway lesion Flat, painless, erythematous lesions seen on the palm of this patient's hand Frequently Seen in infective endocarditis
72. Horner's Syndrome: Loss of sympathetic nervous system input to (in this case)left eye. Note that left pupil is smaller than right. Also that left eyelid covers a greater portion of eye than on right (known as ptosis). The etiology in this case was itiopathic, though it can be associated with tumors occurring at the apex of the lung, among other things.
73. PALMER ERYTHEMA Redness of thinner and hypothinner with whitish appearance in the middle of the palm Causes : pregnancy,thyrotoxicosis,chronic liver disease……etc
76. Arcus senilis puple Deposition of the lipid in the corneal stroma The cause is Hyperlipidemia
77. Dupuytren’s contraction thickening of the palmar facia. In this case severe enough thatit limits finger extensions Causes: alcoholic cirrhosis , pancreatitis or occupitional
79. gynecomastia . Breast development in men, often related to relative increase in estrogen levels. In this case, associated with advanced liver disease or androgen decrease .
83. Question 1 (a) 66 y/o man – headache & L sided weakness for 1 day. No history of trauma. Non-contrasted CT scan of brain performed List 3 abnormalities seen Hyperdensity at R side of brain parenchyma Hyperdensity in the ventricle Hydrocephalus Oedema
84. Question 1 What is the diagnosis Intraparenchymal haemorrhage What is the most likely underlying cause for this condition hypertension
85. Question 1 (b) 25 y/o male construction worker – fever & cough for 3 weeks. CXR taken. List 2 abnormalities seen Miliary nodules in the lungs R sided pleural effusion What is the most likely diagnosis Miliary TB What is the mode of dissemination of this condition in the body Haematogenous/blood-borne
86. Question 2 A 56 y/o female pt is brought from the OT after major pelvic surgery. 4 hours later she complains of crushing pain in her chest and the nurse informs you that she has collapsed. Follow the examiner’s instruction
89. Question 2 What are the possible causes of collapse in this pt? Haemorrhage eg. intraperitoneal bleeding MI How would you manage this collapsed pt? Establish unresponsiveness; activate Emergency Medical Service System Open Airway (head tilt, chin lift) Check breathing (look, listen, feel) Give 2 slow breaths (1.5 to 2 sec) Watch chest rise Allow for exhalation in between breaths Check carotid pulse (5 sec) Examiner prompts: no pulse
90. Question 2 Demonstrate position on chest to perform chest compression Complete 1 full cycle of 30:2 Examiner asks: how many cycles? After 5 cycles, check pulse Examiner prompts: pt has non pulse but ECG shows this. What is this? Exhibit A Broad complex ventricular tachycardia Examiner prompts: how do you treat? Defibrillation Examiner prompts: after defib, ECG reverts to this rhythm. What is this> Exhibit B Ventricullar fibrillation Examiner prompts: how do you treat? Defibrillation with DC shocks of 200J,
91. Question 3 Tina, 30 y/o lady – tiredness 4 months. She is a strict vegetarian. Her menses are normal. Explain the results and diagnosis to her Explain to her how you would manage her
98. Question 3 Explaination of diagnosis (3m) Low hb Low iron and ferritin – iron stores are depleted Relation of symptoms to anemia Dietary history (1m) One day dietary recall Dietary details Management of anemia (6m) Balanced diet: increase iron containing food eg spinach, green leafy vege, fortified bread/flour Iron supplements to be prescribed Duration Dosage and frequency Side-effects
99. Question 4 Picture of thyroid eye disease Elicit 3 signs Exophthalmus Lid retraction chemosis Diagnosis Thyroid eye disease-grave’s disease Explain 2 causes of visual loss Mechanical compression Ischaemia Corneal ulceration CT orbital Orbital swelling
100. Question 5 Measure and interpret this pt’s peak flow reading Move indicator to base Stand up Put mouthpiece into mouth Take a deep breath Blow as hard as possible Take reading 3 times, take the highest Demonstrated by student Ask pt for weight & height Plot on chart
101. Question 5 B) peak flow readings on the chart provided Showing high peak flow readings on weekends and low on weekdays Diagnosis? Work related asthma
104. Question 1 Greet patient Consent Preparation of the equipment Glove Lightning Absorbable synthetic material (Dexon/Vicryl Rapid 2/0) Find the apex Suture starts from 1cm above the apex continue suture at the level fourchette,appose the vaginal mucosa n tie off at the junction – CONTINUOuS SUTURE The perineal muscle is closed with INTERRUPTED suture The vaginal skin is closed with INTERRUPTED or continuous subcuticular suture Inspect for PPH and estimate blood lost Monitor vital sign
105. Question 2 Name all the measurement of the head of the baby Which one are suitable for delivery and complication
106. Question 3 Pap Smear Introduce & consent Lithotomy position Gloves, speculum, lightning, alcohol 90%, NS, 3 slides with patient & ID, pap smear instrument Lubricate speculum with NS not KY jelly Inspect labia, cervix Use ayer’s spatula Swab 360 degrees Spread smear on slide Put slide in alcohol Remove speculum
107. Question 4 You are given the pelvis and head of baby Demonstrate the mechanism of labour Engagement of the head Fetal head enters pelvic brim ROT/LOT FLEXION DESCENT INTERNAL ROTATION FURTHER DESCENT & EXTENSION RESTITUTION EXTERNAL ROTATION Ant.shoulder slips under pubis, post sholder is born
108. Question 5 60 years old come with PV bleed. Please examine her cervix using speculum. Introduce and consent Glove. Check speculum function or not? Lightning, Normal saline, KY jelly Inspect labia majora & minora Lubricate the speculum Separate labia with your L hand put speculum in 90 degrees first then once it enter vagina rotate into 180 degree Open speculum and make sure u fix it Describe the cervix (nulli/multi, pointed ant/post, dischage, mass)
109. Question 6 Combined oral contraceptive Mechanism of action Prevent ovulation Thickened mucus Benefits Rx for menorrhagia & dysmenorrhea Regulate menses in PCOS Content Progestogen lenavogestrel Contraindication Hpt Heart problem Thromboembolism DVT
110. Question 7 Male condom COC IUCD Advantages & Disadvantages Choose one of the methods and tell us how u use it? What if the patient miss pill Less than 12 hr (take delay pill, continue the rest) More than 12 hr (take most recent pill, discard missed pill and use condom) Complication of IUCD
111. I m not so sure whether question 8 to are pass yr or not. I got them from senior. Quite a tough one.
112. Question 8 Routine u/s show a dilated fetal renal pelvis at 24 weeks gestation. How would you counsel the parents? Mother ask: Is my baby normal? What happens now? What will happen after my baby is born?
113. Question 8 Introduction Put pt at ease Listens attentively Explain condition Dilated renal pelvis Intrauterine v-u reflux From maternal hormone on fetal renal tract Uses plain english or simple malay Follows verbal and non verbal clues Explains intended actions Repeat u/s at 24, 28 and 34 wks Postnatally, MCUG to exclude vesico-ureteric reflux Antibiotic Renogram to exclude partial obstruction Appropriate eye contact
114. Question 9 Routine cervical smear show HGSIL How would you manage and advise pt?
115. Question 9 Introduction Etiology Intercourse Wart virus infection Explain the result Not cancer but indicate moderate/severe dysplasia Only 1.5% develops cancer in 24 months Less than 45 % in 10 years Can be eliminated with simple treatment after confirmation with colposcopy Need colposcopic examination & biopsy Colposcope A viewing device similar to binoculars Does not hurt Examine the cervix for abnormalities
116. Question 9 Explain punch biopsy and treatment LLETZ/cone S/E discomfort, bleeding, serosanguinous vaginal discharge, pelvic infection Procedure is 95% effective It may come back, so need f/up. Repeat pap smear and colposcopy in 4-6 months after LEEP/LLETZ proceduce, then annually after 3 normal smears for 10 years
117. Question 10 This is Vimala Devi’s videocystography report (42 years old) Initial flow rate 18ml/s Volume voided 230ml Residual 30ml Early first desire to void at 180ml Urgency reported at 350ml Maximum cystometric capacity was 490ml Stable bladder, with normal compliance Detrusor pressure at end of filling :11cm H20 Bladder outline normal with no reflux Bladder base low at rest, with further descent on coughing Marked incontinence seen Voiding pressure mounted was 25cmH20 Difficulty in ‘stopping mid-stream’, voided with flow rates of 23ml/s and residual of 50ml
118. Question 10 What is the diagnosis in this case? Genuine stress incontinence If a conservative approach to management is adopted: What would be the improvenment rate? 50-70% How long would it take to see an improvement? 4-6 months
119. Question 10 State 4 surgical treatment options available Vaginal anterior repair Colposuspension Stamey/raz/perera Vesica bladder stabilization procedure Periurethral collagen injections Transvaginal tape What is a pad test? Test that allows one to quantify the urine loss. Pads are worn for 24 hours and weighted (both dry and wet) to allow calculation
120. Question 11 Pn TSK is 37 years old and has just presented at your antenatal clinic 10 weeks pregnanat. She is very concerned about having a Down Syndrome baby.
121. Question 11 What would you estimate her risk to be, based on her age alone? 1:190 to 1:250 (dependent on age at delivery) What 2 important factors in her past history would significantly increase this risk? Family history Previous down baby In counseling this patient before embarking on amniocentesis: Name 2 widely available tests which would further determine her risk factor other than her age alone Maternal alpha fetoprotein Leeds/Barts/Triple test At what stage in pregnancy is each of these routinely performed? 14-18 weeks
122. Question 11 What further test is currently being evaluated as a Down marker? Nuchal fold thickness What advantage does this test offer over the others? Can be performed earlier i.e. at 11 weeks What single specific piece of advice would you give this lady about the interpretation of these results? These tests only offer a probability, not a definite diagnosis If Pn TSK opts for amniocentesis, what is her risk of miscarriage following the procedure if it is performed at 16 weeks gestation? 1%
123. Question 12 Mr and Mrs Tan attend your gynaecological clinic to discuss sterilization. Mr Tan is aged 36 and Mrs Tan 30. They have 3 children aged 6, 4 and 16months, all of them are well. Mrs Tan is a diabetic and therefore they feel that Mr Tan should be the one to be sterilized.
124. Question 12 List 3 advantages of male sterilization Performed under local analgesia Significant operation morbidity and mortality are virtually non existent Easy procedure to perform Cheaper Usually involves less disruption to family than female sterilization No inpatient stay Out-patient proceduce/day care
125. Question 12 How long will Mr Tan need to be off work if: he is an office worker? Just the day of procedure he does heavy manual work? 2/3 days How will you confirm that the procedure is effective? Negative seminal analysis 12 and 16 weeks after the vesectomy List 2 short term complications Scrotal hematoma or bleeding Wound infection or epididymitis What advice might given to reduce these 2 short-term complications Wear a good, firm scrotal support, night and day for the first 2 weeks Maintain good hygiene Sexual activity may be resumed as soon as there is no further discomfort
126. Question 13 The modern management of ectopic pregnancies has changed with better investigative and surgical techniques available
127. Question 13 What level of sensitivity does the beta-hCG urine test offer? Sensitivity greater than 50iu At what week gestation can a fetal heart be detected: On an abdominal probe ultrasound? 6-7 weeks On a vaginal probe ultrasound? 5-6 weeks Given that the urinary pregnancy test is positive but the ultrasound showed an empty uterine cavity and you are monitoring the patient by serial beta-hCG levels: What is the normal rise of serum beta-hCG in pregnancy? Beta-hCG doubles in 48 hours At what level would you decide that a laparoscopy was indicated? Greater than 1000 i.u.
128. Question 13 Many units are now performing laparoscopic salpingotomy instead of open surgery. List 3 advantages to the patient: Smaller scar Better cosmetic results Less analgesic required Early discharge from hospital (2 days) Early return to work (after 2-3 weeks) Less chance of pelvic adhesions More chance of future conception
129. Question 13 What is the tubal patency rate after laparoscopic salpingotomy? 70% Is the intrauterine pregnancy rate higher after laparoscopic or formal salpingotomy? Laparoscopic salpingotomy
131. 2006 (1) 1 yr old child had diarhoea for 6 times in a day. Clinical examination was normal. A diagnosis of AGE was made. Treat with ORS. The patient has mild dehydration. Vital sign stable. Explain to mother the diagnosis: What food can be taken: Explain about ORS and how to prepare:
132. Ans 2006 (1) Introduction and greet Assess causes: Changing of breastfeeding to formula milk (lactose intolerance) Boiled water for milk preparation Pacifier usage and hygience Explain: AGE, usually self limiting, complication (dehydration, malnutrition), cause (diarrhoea, vommiting, abd pain, seizure, fever, malaise) Assess severity Frequency of diarrhoea, volume of stool, urine output reduction, loss of weight, fever, convulsion, P/e: hydration status.
133.
134. Dissolve 1 sachet in 250ml drinking water (boiled/cooked water of estimated 1 glass)
138. If baby already weaning (allow semi-solid food, drink water a lot) Advice mother to keep good hygience on milk preparation Advice mother to monitor baby’s progression If show dehydration (convulsion, weak, crying, not feeding) Ask mother for any question?
139. 2006 (2) Patient is schedule for chelecsystectomy. However, an emergency operation on liver laceration had to be done and her operation was postponed. All operation on that day has been cancelled. As houseman, break the bad news to her.
140. 2005 (1) Consultation with patient. Patient, fever for 3 days and generalised body ache. Investigation results showed tarchycardia (120bpm), low Bp(80/70mmHg), febrile (38oC), thrombocytopenia(30), neutropenia, high haematrocrit. Suspected dengue fever. Advice patient for admission. However patient refused. Try to counsel her.
141. Ans 2005 (1) Intro: greeting, introduction Explain the diagnosis : Dengue fever Review the investigation result Emphasis the severity, sympathy Advise admission with reason: severity, risk of bleeding and shock, need close monitoring, immediate resuscitation if needed Access patient social circumstances: house-hospital distance, access to hospital, family member (other children)
142. Cont ans 2005 (1) Emphasis the need of admission, but express respect on patient’s autonomy Reiterate possible complication Give overview, what will be done in ward (iv fluid, frequent blood taking)
143. 2005 (2) Patient has asthma. You need to start her on beclomethasone inhaler 2 puff bd (MDI). Explain to her about your plan of management. Teach the patient how to use the inhaler and what you should advice the patient.
144. Ans 2005 (2) Greeting and introduction Reiterate diagnosis Explain what medication you prescribed :steroid MDI Explain purpose: frequent attack, reduce frequency of attack, prophylaxis, improve quality of life Give the patient the beclomethasone inhaler and you have the placebo inhaler Explain and demonstrate to the patient the technique (ask the patient to observe first):
145. CONtans 2005 (2) Technique: Shake well Exhale to expiratory reserve volume Put inhaler into mouth (over tongue, well into mouth), no leakage Press 1 puff (press top of cannister firmly between forefinger and thumb) inhale quickly and deeply at the same time Hold breath for 10 s/as long as comfortable Take out the inhaler from mouth, Pause between 1st and 2nd puff (10s for becotide, 1 min for ventolin) shake again, repeat for 2nd puff Ask the patient to demonstrate Emphasis the need of regular use despite absence of attack Inform the side effect: oral thrush, hoarseness of voice
146. 2004 Consent and Demo on how to take blood culture (aseptic) Demo handwash
147. Ans 2004 Blood CnS: Universal precaution Wear gloves (aseptic glove) Do not recap Proper sharp disposal handwash Assemble equipment Syringe (10ml) Special container Blue cap (aerobic) Black cap (anaerobic) 2 needles Aseptic garments Povidone Cotton swab forcep
148. Cont ans 2004 Site Antecubital fossa Emphasis not poking around Steps Wear mask, aseptic gloves Apply povidone to cotton swab (use forcep, apply on puncture site) Apply aseptic garment on antecubital fossa Puncture and take about 10ml blood Change needle Remove cap from culture and sensitivity bottle and swab with alcohol Puncture blood in syringe with changed needle into each bottle -5ml each Apply sticker for dx, date and signature
160. Ans 2003 (2)Sexual history Introduce, comfortable Try to keep confidential Explain the use of sexual history Ask few sensitive questions to be able to help you Age at first coitus, last coitus How many sexual partners Protected/unprotected (condom); contraception Homosexuality Pregnancy history PV discharge, growth, other constitutional Sx Sexual abuse
178. Insulin injection (Novopen) Wash hand with soap and clean Open casing, take out the pen Turn and pull off cap, unscrew penfill holder, insert penfill, screw it back Turn pen upside down before injection x10 Uniformly cloudy: insulatard/mixtard only Remove cap, if new x4 units, inject to expel air Choose a site and inject Count to 10 before withdrawal of pen (if not, insulin wasted) Used needles ( limited to 3-4 usage) throw into (metal)bin with label Actrapid yellow, insulatard green, mixtard brown What to do after penfill finish? Overturn dose req?Cx of insulin injection
190. Cont Breaking bad news Major: terminal illness, handicap, chronic progressive ds Minor: no bed, case notes misplaced, cancel op Personal preparation: emotion, presence of relative for patient Physical setting: privacy eg. Room, position, no distraction Talking to patients Establish rapport and trust Empathy What does patient already know Find out what they want to know
191. Cont Breaking bad news Give info: incrementally (start with facts and add), conclude what they mean Check understanding Respond to question and concerns Elicit own resource for copy Instill realistic hope Arrange for follow up and referal
192.
193. Setting up: quiet room, less interruptions, support present, eyes contact, 2 support persons
230. Thanks for seeing this patient, mr_____, age___, race_____, gender______, who has c/o:_______, since________.
231. From hx_____, p/e______, Ix_______, found that ________, impression_______. Medication her is on now __________. No other medical illness. The patient requested surgical removal (intention) and further mx from you.
242. Work: mar return to work after 2 mths, unless pilot, air traffic controller, diver or driver of public transport or heavy goods vehicles; heavy manual labour should seek lighter job
243. Diet: high in oily fish, fruit, vegetable, fibres, low in saturated food
247. Review at 5 weeks: angina, dyspnoea, palpitation-if angina recur, treat conventionally and consider angioplasty
248.
249. Counselling station How to give ORS Breaking bad news Elicit alcohol dependence, CAGE Sexual history Advice on contraceptive Care of diabetic foot Informed consent Smoking cessation Dietary history Diet advice (DM, hpt, hypercholesterolemia, gout, renal failure, obesity Teenage pregnancy Advice for hospital admission AIDS: pre and post testing counselling Alcohol cessation
251. Miss K diagnosed to have a psychotic illness for the past 2 years.Assess her insight towards her illness and compliance to treatment. Communication Skills Greet/ intro - 1/2 m Explain - 1/2 m Non-verbal communication - 1/2 m Clarity of language - 1/2 m Insight Awareness of mental illness - 1 m (FAILED if not elicited) Awareness of abnormal symptom - 6 m Recognition of problem assoc Others see as ill Agree that treatment/ admission needed Understand purpose of treatment/ admission Full compliance (when, how, S/E, f/up) Examiner ask: degree of insight (good) - 1/2 m Proper termination - 1/2 m
252. Miss B, 38 year-old lady has been experiencing depression for the past 4 weeks. Assess her risk factors for suicide. (10 m) Sex Age Depression/ other psy illness Previous attempt Ethanol substance abuse Rational thinking loss Suicide in family Organized plan/ intent No support/ employment Sickness (co-morbid) Communication Skills Greet/ intro - 1/2 m Explain - 1/2 m Non-verbal communication - 1/2 m Clarity of language - 1/2 m Suicidal assessment (SAD PERSONS) Suicidal intention + past suicide - 2 m (FAILED if not elicited) - Divorced/ widow/ separated - 5 m - Unemployed - Chronic medical problem - Loss of rational thinking - No social support - Family history of suicide - Specific plan for suicide (SAMPAH - high risk) Diagnosis: high/ moderate/ low risk + MDD - 1/2 m Proper termination - 1/2 m Suicidal note Avoid detection Method Plan Arrangement Hint
253. Patient emotionally disturbed for 2 months. Assess mood (depression) Communication Skills Greet/ intro (open qn: how are you today?) - 1/2 m Explain - 1/2 m Non-verbal communication - 1/2 m Clarity of language - 1/2 m Depression assessment Low mood (in most days esp morning) + ahedonia - 2 m (FAILED if not elicited) - Fatigue - 5 m - Low concentration - Appetite/ weight change (>5% body weight) - Sleep pattern change (early morning awakening > 2H, difficult initiating sleep) - Hopelessness - Suicidal ideation - Psychotic symptoms (hallucination, delusion) Diagnosis: Severe major depressive disorder - 1/2 m Proper termination - 1/2 m
254. Patient emotionally irritable. Assess the mood (bipolar) Communication Skills Greet/ intro (open qn: how are you today?) - 1/2 m Explain - 1/2 m Non-verbal communication - 1/2 m Clarity of language - 1/2 m Depression assessment Elevated mood & full of energy (> 1 week) - (FAILED if not elicited) - Distractibility - Insomnia (decreased need for sleep) - Grandiosity - Flight of ideas - Activity (goal-directed) - Speech (pressured) - Thoughtlessness (spending spree, gambling, drinking, sex, investment) Previous history: past PSY, previous depression, family, premorbid personality Diagnosis: Bipolar mood disorder in manic phase Proper termination
255. This patient was diagnosed to have schizophrenia. Elicit his delusions. (NOT hallucinations). Communication skill: greet, introduction, non-verbal, clarity of language, proper closing = 2 m Schneider’s 1st rank symptoms: Auditory hallucinations (3rd person, commentary, inner voice spoken aloud) Somatic hallucinations (body not functioning/ rotting?) Delusion of thought: Thought insertion: thought implanted from outside… Thought withdrawal: taken away… Thought broadcasting: heard by others; broadcasted thru’ TV/ radio Thought echo: hear own thought aloud Delusion of control: controlled by someone, eg with remote control Delusional perception: people hinting/ giving clue through minor action; arrangement of surrounding indicates life is threatened etc. Other delusions: persecutory (others try to harm), reference (newspaper/ TV talking about you), grandiosity (special power), nihilistic (world is ending), guilt (cause troubles to others), jealousy (spouse unfaithful), bizarre
256. 38 years old patient come with confusion and hallucinations. Elicit her hallucinations (NOT delusions). Communication skill: greet, introduction, non-verbal, clarity of language, proper closing = 2 m Schneider’s 1st rank symptoms: Auditory hallucinations (3rd person, commentary, inner voice spoken aloud) Somatic hallucinations (body not functioning/ rotting?) Delusion of thought: Thought insertion: thought implanted from outside… Thought withdrawal: taken away… Thought broadcasting: heard by others; broadcasted thru’ TV/ radio Thought echo: hear own thought aloud Delusion of control: controlled by someone, eg with remote control Delusional perception: people hinting/ giving clue through minor action; arrangement of surrounding indicates life is threatened etc. Visual hallucinations Tactile hallucinations (things crawling on hand) Olfactory hallucinations Taste hallucinations
257. Mini Mental State Assessment in dementia patient Communication skill: greet, introduction (open-ended question first), non-verbal, clarity of language, proper closing = 2 m Orientation Orientation to time (date/ month/ year/ day/ time) 5 Orientation to place (ward/ hospital/ city/ state/ country) 5 Registration Name three objects (car, tree, ball) 3 Attention & Concentration Attention (serial-7, digit span test) 5 Memory 5-mins recall 3 objects 3 Language Show and name 2 objects: pen, ruler 2 Follow saying (no ‘if’s, ‘and’s, ‘but’s; 四首狮, tak mungkin dan memang mustahil) 1 3-step command: take pen in right hand, put in left hand, place on table 3 “Close your eye”; write a sentence; copy design 1 each < 25 out of 30 (ie 24 and below) = dysfunction. Must correlate with pt’s education level
258. Elderly noted to have poor memory recently. Differentiate dementia VS pseudodementia Communication Skills Greet/ intro (open qn: how are you today?); explain; non-verbal communication; clarity of language; proper termination - 2 m Dementia Pseudodementia Onset Insidious (can’t pinpoint) Acute (able to tell) (can you recall when you started to experience memory loss?) Problem awareness Unaware Aware (do you think you are suffering from memory loss?) Memory assessment Confabulation, cooperative “Don’t know”, not cooperative Emphasize accomplishment Emphasize failure (can you recall where you study for primary school etc…) (can you recall what did you have for dinner yesterday?) Eye contact Usually good Poor Depression symptom Absent/ present Present Anti-depressant effect Do not help Memory improve
259. Addicted to alcohol. Assess. Communication Skills Greet/ intro (open qn: how are you today?); explain; non-verbal communication; clarity of language; proper termination - 2 m CAGE (screening for abuse > 2/4) Desire to Cut down drinking Annoyed by criticism Feel Guilty about drinking Take as Eye-opener? (early morning crave, relief of withdrawal) Edward’s criteria of alcohol dependence Narrowing repertoire (to 1 type of alcohol) Priority of drinking over other activities Tolerance of effect (increasing amount to satisfy need) Repeated withdrawal (tremor, palpitation, sweating, nausea/vomit, anxiety, seizure) Relief of withdrawal symptoms by drinking Compulsion to drink Reinstatement after abstinence (difficult to quit)
260. Patient is on lithium. Give counseling. Communication Skills Greet/ intro (open qn: how are you today?); explain; non-verbal communication; clarity of language; proper termination - 2 m Lithium counseling Lithium is effective in controlling mood symptoms However it has various side effects and some may be life-threatening: GIT : nausea/vomit, diarrhoea Renal : thirst, polyuria, dehydration, lethargy Thyroid : hypothyroidism, goitre Neuro : tremor, ataxia, dysarthria, seizure, mild parkinsonism CVS : arrythmias Increasing lethargy, drowsiness, confusion & hyper tonicity Before starting need to take blood (renal function, TFT) and ECG. If female, ask LMP +/- UPT to confirm not pregnant (risk of cardiac defect eg Ebstein’s anomaly) Monitoring: Weekly blood test till lithium level stabilized (0.4 - 1 mmol/L), thereafter 1- 3 monthly. If symptoms of intoxication appears, stop and consult doctor immediately Usual dose: 300mg tab tds. Lower dose in elderly (especially if renal impaired) Drug interaction, lifestyle and diet Total body water and sodium level main factors. Factors that cause sodium depletion is dangerous as predispose to intoxication: low sodium diet, excessive sweating/ dehydration, concurrent use of diuretics esp. thiazide If go for ECT, need to stop at least 3 days :- can prolong seizure & cause post-ictal delirium common intoxication
261. Give psychoeducation to patient & family (schizophrenia) Communication Skills Greet/ intro (open qn: how are you today?); explain; non-verbal communication; clarity of language; proper termination - 2 m Psychoeducation Illness - mental illness, common (1%), cause unknown but treatable - assess insight (sick? how others view? Medication needed?) Drug - anti-psychotic, treat symptom (hallucination, delusion) - side effects (HAM, EPS, metabolic syndrome) - emphasize compliance & adherence Relapse - early S&S (agitated, symptoms reappear) - what to do (contact consulting psychiatrist/ nurse ASAP) General health - physical (quit drug/ smoking/ alcohol; control co-morbid, diet - mental (coping strategy, stress/ anger management) - social (family support, employment)
262. Patient recommended for ECT. Take consent. Communication Skills Greet/ intro (open qn: how are you today?); explain; non-verbal communication; clarity of language; proper termination - 2 m Electroconvulsive therapy What is ECT? :- safe, commonly performed procedure. Small amount of electrical current is sent to brain via electrodes on scalp. Produce seizure that affect entire brain, including centre that affect thinking, mood, appetite & sleep. Why do I need ECT? :- treat severe depression, schoziphrenia & bipolar disorder; faster recovery needed; or when drugs ineffective/ unable to tolerate S/E. S/E of ECT? :- transient headache, confusion, memory loss & muscle ache Will I die from ECT? :- very low risk (1 in 50,000; 0.02%); lower than childbirth Explain the procedure :- (pre-ECT) fast for > 8 hours, remove jewellery, dentures etc. Will need to take blood and ECG. (during ECT) anaesthetist will give injection to make you sleep and relax muscle. Once you’re sleeping we will pass the electric current. (after ECT) may feel confused/ headache but transient. Observe in ward. Explain that procedure need patient consent (sign papers; valid for 2 weeks) and that it is voluntary (can revoke any time during course of treatment)
263. 40 year-old male with fever and haemoptysis for 2 months Opacities seen in both lungs esp upper lobes Cavitations Diagnosis: Active TB (post-primary
264. 20 year-old male with fever and haemoptysis for 3 weeksOpacities with air bronchogramDiagnosis: Tuberculosis (primary)Parenchymal changes are similar to typical pneumonia
266. 65 year-old female with SOB for 2 monthsOpacity occupying almost the whole of right hemithorax with meniscal levelDiagnosis: Pleural effusionNote that trachea is not shifted to the left indicating some amount of collapse in the right lung
267. 35 year-old femalewith dyspnoea, Fever and cough for 1weekOpacity in right upper lobe bordered by the horizontal fissureAir bronchogramDiagnosis: Lobar pneumoniaCommon agent: Strep. pneumoniae
268. Post trauma with headache and impaired consciousnessCrescent shape-hyperdense left frontal collection with mass effect = acute subdural haematoma
269. Man with sudden onset of right sided weaknessCT: Wedge shaped hypodense lesion affecting the white and grey matter = Acute left MCA infarction
270. 52 year old female with abdominal distension and vomiting for 2 daysPrevious history of appendicectomy
271.
272. Small bowel obstruction Due to adhesions from the previous appendicectomy Note the multiple air fluid levels on the erect AXR On the supine radiograph – dilated loops of air filled small bowel How do you differentiate dilated small and large bowel ?
273. Look for the bowel folds Small bowel folds extend from one end of the bowel wall to the other Large bowel folds- Haustra extend about one third of the way Small bowel is also more central in position in the abdomen
275. Topics Nasogastric tube insertion Airway management ALCS ATLS Trauma leading to neurogenic shock CPR and defibrillation CBD insertion Putting a cervical collar Log roll Endotracheal Intubation Chest tube insertion CVP insertion Oxygen therapy Hypovolaemic shock Anaesthesia- Respiratory acidosis Set drips Needle thoracocentesis Secondary survey
276. Nasogastric tube insertion Choose correct tube-1 Explain and reassure patient-1 Prepare NG tube Measure from nose-tragus-stomach-1 Lubricate-1 Inspect nasal passage, no blocking/swollen mucosa/bleeding-0.5 Thumb and forefinger of freehand to push the tip of the nose backward and the other hand pass the NG tube along floor of the nose-0.5 Ask the patient to swallow once the NG tube reach oropharynx-2 When NG tube in place: Test aspirated content with litmus paper(acid-blue to pink)-1.5 Inject 40-50 cc air into the stomach and auscultate for 'bubbling' sound in epigastric region-1.5 Total: 10 marks
277. Airway management Nurse tells you patient in the ward stop breathing, give your first instruction Assess patient's responsiveness Tell the nurse: Call for help and bring resuscitation trolley and equipment Oxygen Self inflated bag Mask Oral airway Suction Intubation equipment Total: 2 marks Patient not breathing, looking blue but pulse can be felt, perform correct manoeuvres Look, listen, and feel for spontaneous breathing-1 Head tilt, chin lift/jaw thrust-1 Insertion of oropharygeal airway-2 Correct assembly of bag-valve mask-1 Application of the bag-valve to the face-1 Squeezing the bag to obtain chest inflation-1 Observation of the chest for inflation-1 Total: 10 marks
278. ACLS Scenario -70 y/o, male, sudden chest pain, collapse How do you manage this collapsed patient? -Establish unresponsiveness, call for help-1 -Open airway-1 -Check breathing-1 -Give 2 slow breaths (1.5-2sec/breath),watches chest rise, allow exhalation in between breaths-1 -Check carotid pulse-1 No pulse -Show position on chest to perform chest compression(mid sternum, depth-4.5cm)-1 -Initiate cycles of 30 chest compressions followed by 2 slow breaths(complete 1 cycle of 2:30)-1 No pulse, ECG show this rhythm, interpret -Ventricular fibullation-2 How do you treat this rhythm? -Defibrillation-1 Total: 10 marks
283. ATLS Scenario: 30y/o, MV, multiple injuries In emergency unit, he is in class IV hypovolemic shock (>40% blood loss) Q-Name the 8 signs of hypovolemic shock: Low volume pulse, tachycardia, pallor and cool skin, delayed capillary refilling time, reduced pulse pressure, altered mental state, reduced urine output, hypotension (0.25 marks each, total:2marks) Q-What first aid procedure would you do to the compound fracture of the leg? Providone dressing Apply direct pressure dressing Immobilization and elevation Check distal pulse, tissue perfusion, motor and sensory deficit and after procedure (perform all points:2 marks, describe all points:2marks, Total: 4 marks) Q-what IV access would you obtain and where? More then 2 IV lines-0.5 14G IV cannulation-0.5 Large vein in cubital fossa-0.5 Venous cut-down if unable to get venous puncture-0.5 (total:2 marks) Q-What blood investigation would you order? GXM whole blood-0.5 FBC, BUSE, RBS, ABG-0.5 (total:1 mark) Q-What IV fluid would you transfuse this patient? Group O negative-0.5 Sodium lactate solution-0.25 Colloid-0.25 (total:1 mark) Total: 10 marks
284. Trauma leading to neurogenic shock Scenario: 35y/o, fell from third storey building, multiple injuries Primary survey reviewed neurogenic shock and requires in-line immobilization Q- Name the 8 signs of neurogenic shoch Hypotensio0n, bradycardia, flaccid paralysis, altered sensorium, peripheral vasodilatation, warm peripheries, pain and neck tenderness and loss of anal tone. (0.5 mark each, Total: 4marks) Q- What instruments do you use to maintain in-line immobilizatioon? Stiff cervical collar-1 Head immobilizer-0.5 Spinal Board-0.5 Q-Demonstrate how would you apply this stiff cervical collar? Moulding collar ( insert fastener into table)-1 Measure patient (Key dimension [distance between an imaginary line drawn across the top of the shoulder and the bottom plane of the patient's chin] on patient)-1 Size collar-1 Supine application and tightening of collar-1 Total: 10marks
285. CPR and defibrillation Scenario: You are the HO in Gynae ward. 56y/o, operated, 4 hours later complains of crushing pain in her chest, nurse informs that she has collapsed. Q-What are the possible causes of collapse in this patient? Haemorrhage-0.5 MI-0.5 Q-How would you manage this collapsed patient? Establish unresponsiveness, call for help-0.5 Open airway and check breathing-1 Give 2 slow breaths and watch for chest rise-1 Check carotid pulse-0.5 No pulse Demonstrate position on chest to perform chest compression-1 Initiate cycle of 30 chest compressions followed by 2 slow breaths-0.5 How many cycle you have to do? After 4 cycles of 30:2, check pulse Q-No pulse. ECG shows this rhythm. What rhythm is this? Broad complex ventricular tachycardia Q-How do you treat? Defibrillation Q-After defibrillation, the ECG reverts to this rhythm, what rhythm is this? Ventricular fibrillation Q-How do you treat this rhythm? Defibrillation with DC shock of 200J, 200J, 360J
286. CBD insertion Explain to patient tube being inserted into penis to help urination, mild discomfort but not painful, analgesic will be given Prepare 14F CBD, urine bag, lignocaine 2% in syringe, KY jelly-10ml, water for injection in syringe, gloves and apron, hypafix, cotton balls, forcep Wash hand and wear glove Check balloon Right hand: Forcep, cotton in cetrimide, clean perineum and penis Drape Left hand hold penis and retract foreskin, right hand clean again Right hand: Syringe with lignocaine injection and wait 2 minutes Left hand: Hold penis 90 degrees to body Continue inserting whole CBD, see urine flow Inject water and pull CBD still stop Reposition foreskin Tape tube of urine back to thigh Send patient to ward.
287. Putting a cervical collar Q- What are the indications for cervical collar? Fall from a 5m height Velocity>40km/h Roll over of vehicle Victim thrown from crash site Unconscious Neck pain Focal deficit Abnormal neck position Injury above clavicle Q-What are the signs of cervical spine Injury? Flaccid paralysis Sensory loss Hypotension Bradycardia Vasodilatation Priapism Q-What equipments are used to protect cervical spine? Cervical collar Spinal board Head immobilizer Q-Demonstrate how would you apply this stiff cervical collar? Moulding collar ( insert fastener into table)-1 Measure patient (Key dimension [distance between an imaginary line drawn across the top of the shoulder and the bottom plane of the patient's chin] on patient)-1 Size collar-1 Supine application and tightening of collar-1 1 person technique: use knees to pin head 2 person technique: trapezius lift ( hands on shoulder, elbow 90 degrees, use forearm to pin head together against ears)
288. Log roll Objective: To maintain correct anatomical alignment in order to prevent the possibility of further, catastrophic neurologic injury and the prevention of pressure sores. At least four staff members will be required to assist in the log roll procedure as outlined below: 1 staff member to hold the patient's head 2 staff members to support the chest, abdomen and lower limbs. An additional staff member may be also required when log rolling trauma patients who are obese, tall, or have lower limb injuries. 1 staff member to perform the required procedure (ie. assessment of the patient's back) The log rolling procedure is implemented at various stages of the trauma patient's management including: as part of the primary and secondary survey to examine the patient's back as part of a bed to bed transfer (such as in radiology) to apply cervical collar care or pressure area care to facilitate chest physiotherapy etc.
289. The steps in the spinal log roll procedure are as follows: 1. Explain the procedure to the patient regardless of conscious state and ask the patient to lie still and to refrain from assisting. Ensure that the collar is well fitting prior to commencement. 2. If applicable, ensure that devices such as indwelling catheters, intercostal catheters, ventilator tubing etc. are repositioned to prevent overextension and possible dislodgement during repositioning. 3. If the patient is intubated or has a tracheostomy tube, airway suctioning prior to log rolling is suggested, to prevent coughing which may cause possible anatomical malalignment during the log rolling procedure. 4. The bed must be positioned at a suitable height for the head holder and assistants. 5. The patient must be supine and anatomically aligned prior to commencement of log rolling procedure. 6. The patient’s proximal arm must be adducted slightly to avoid rolling onto monitoring devices eg. arterial or peripheral intravenous lines. The patient’s distal arm should be extended in alignment with the thorax and abdomen (Fig 1), or bent over the patient’s chest if appropriate ie. if the arm is uninjured. A pillow should be placed between the patient’s legs. 7. Assistant 1, the assistant supporting the patient’s upper body, places one hand over the patient’s shoulder to support the posterior chest area, and the other hand around the patient’s hips (Fig 1). 8. Assistant 2, the assistant supporting the patient’s abdomen and lower limbs, overlaps with assistant 1 to place one hand under the patient’s back, and the other hand over the patient’s thighs (Fig 1). 9. On direction from the head holder, the patient is turned in anatomical alignment in one smooth action (Fig 2). 10. On completion of the planned activity, the head holder will direct the assistants to either return the patient to the supine position or to support the patient in a lateral position with wedge pillows. The patient must be left in correct anatomical alignment at all times. Fig 1 Fig 2
301. CVP insertion RATIONALE FOR USE Measurement of central venous pressure (indicator of heart’s effectiveness as a pump, circulating blood volume, patient’s vascular tone, and patient’s response to treatment) Diagnosis (e.g. evidence of underlying cardiac pathology such as cardiac failure) Drug administration of preparations harmful to smaller lumen peripheral veins (e.g. potassium chloride and dopamine) CENTRAL VENOUS LINE INSERTION Sites: Subclavian vein, Jugular vein, Brachial vein, Femoral vein Explanations and reassurance must begiven to the patient prior to and during the procedure. Lying the patient flat and raising the foot of the bed (to promote upper venous engorgement making it easier to puncture the vessel). A strict aseptic technique is used for the procedure of insertion. The catheter is fixed in place with sutures and the entry site covered with a clear dressing, to allow easy observation without increasing the risk of Infection. The catheter’s position is verified by X-ray – catheters have a radio-opaque strip for this purpose.
302. CVP insertion MEASURING CVP Measurements can be taken at two points at the sternal angle at the mid axilla point. Position: Lying flat At a 45 degree angle. Measurements are in centimetres of water using a graduated water manometer. The procedure for measurement is: Zero the manometer (to remove extraneouspressures and equalise with atmospheric pressure) Fill manometer with solution (eg. normal saline) using a three-way tap Close off tap from solution bag Open tap to patient Observe the falling fluid level in the manometer Record the mean level (the fluid level will ‘swing’ between a high and a low level and the middle point is usually taken as the central venous system pressure). Normal CVP range is: 0-8 cm H2O. COMPLICATIONS Pnuemo- or haemo pneumothorax caused by puncture of lung (via subclavian or jugular vein) Cardiac tamponade caused by puncture of heart Cardiac dysrhythmia from over-insertion of catheter tip into right atrium causing irritation Misplacement (during insertion or subsequent use) causing problems with fluid infusion or CVP measurement. Problems occurring during use: Infection Air emboli can develop if any connection is loose Abnormal cardiac rhythms can result from rapid Infusion of cold fluid Haemorrhage, especially in patients receiving, or who have received, thrombolytic therapy.
303.
304. Simple face mask (5-15L/min, concentration is between 35% and 50% )
305.
306. Extra-Classes of Hemorrhage Class I hemorrhage (loss of 0-15%) In the absence of complications, only minimal tachycardia is seen. Usually, no changes in BP, pulse pressure, or respiratory rate occur. A delay in capillary refill of longer than 3 seconds corresponds to a volume loss of approximately 10%. Class II hemorrhage (loss of 15-30%) Clinical symptoms include tachycardia (rate >100 beats per minute), tachypnea, decrease in pulse pressure, cool clammy skin, delayed capillary refill, and slight anxiety. The decrease in pulse pressure is a result of increased catecholamine levels, which causes increase in peripheral vascular resistance and a subsequent increase in the diastolic BP. Class III hemorrhage (loss of 30-40%) By this point, patients usually have marked tachypnea and tachycardia, decreased systolic BP, oliguria, and significant changes in mental status, such as confusion or agitation. In patients without other injuries or fluid losses, 30-40% is the smallest amount of blood loss that consistently causes a decrease in systolic BP. Most of these patients require blood transfusions, but the decision to administer blood should be based on the initial response to fluids. Class IV hemorrhage (loss of >40%) Symptoms include the following: marked tachycardia decreased systolic BP, narrowed pulse pressure (or immeasurable diastolic pressure), and markedly decreased (or no) urinary output, depressed mental status (or loss of consciousness), and cold and pale skin. This amount of hemorrhage is immediately life threatening.
307. Anaesthesiology Scenario: Patient has undergone total knee replacement in recovery room, become confused and cyanosed. Patient removed the nasal prong. pH↓ pO ↓ pCO↑ HCO ↑ BE +2 Q- Initial management (2marks) Primary survey: ABC Replaced the nasal prong with high flow mask and give high flow oxygen Q-Interpret ABG (3marks) Respiratory acidosis Q-Give 5 ways to assess his condition after the initial treatment (5marks) Vital signs Pulse oximetry Recheck ABG hourly Secondary survey: Look for the cause of sudden deterioration
308. Placing IV cannulae (set drips) Set up a tray (swab, cannula, cotton-wool, tape, flush, tourniquet) Set up a 'drip-stand' with NS/HM/Dextrose Explain the procedure to the patient Place tourniquet around the arm Search hard for the best vein Rest the arm below the level of heart to aid filling Ask patient to clench and unclench their fist Tap the vein to make it prominent Clean the skin using local anesthetic Insert the cannula Connect fluid tube, check flow Fix the cannula firmly with tape Bandage a loop of the tube to the arm If the tube is across a joint, use a splint Check the flow speed Write a fluid chart
309. Needle thoracocentesis Procedure: Introduce yourself Explain the procedure Determine second intercostals space in mid-clavicular line Sterilize the skin of the chest Local anesthesia usually not necessary Position patient upright if cervical spine injury excluded Insert an over needle catheter (14/16G, 3-6cm long) into skin with needle directed just above rib into the intercostal space Puncture parietal pleural and remove Luer-lock to listen for sudden escape of air to indicate the tension pneumothorax has been relieved Remove the needle and connect a 3-way tap for intermittent release during chest tube insertion procedure Now prepare for chest tube insertion Remove initial catheter after chest tube has been inserted Obtain chest X-ray Complications: Local cellulitis Local haematoma Pleural infection, empyema
310. Secondary survey The secondary survey commences once the primary survey is complete, and it entails a meticulous head-to-toe evaluation. Head Examine the scalp, head, and neck for lacerations, contusions, and evidence of fractures. Examine the eyes before eyelid oedema makes this difficult. Look in the ears for cerebrospinal fluid leaks, tympanic membrane integrity, and to exclude a haemotympanum. Thorax (look for signs of bruising, lacerations, ECG, Chest X ray) deformity, and asymmetry. Abdomen (Examine the abdomen for bruising and swelling. Carefully palpate each of the four quadrants) Limb These should be examined for tenderness, bruising, and deformity. A careful neurological and vascular assessment must be made and any fractures reduced and splinted. Spinal colume Spine tenderness. Sensory and motor deficits, priapism, and reduced anal tone will indicate the level of any cord lesion. Neurogenic shock is manifest by bradycardia and hypotension, the severity of which depends on the cord level of the lesion. Neurological status can be assessed using the simple AVPU mnemonic: ● Alert ● Responds to voice ● Responds to pain ● Unconscious Emergency: AMPLE History A: Allergy/Airway M: Medications P: Past medical history L: Last meal E: Event - What happened?
312. Adam is a 10 year old schoolboy who fell from a swing at school. He started crying immediately and complained of right wrist pain What is the radiological diagnosis? Closed displaced fracture of the distal right radius and ulna (1) Proceed to talk to Adam’s mother Greet & introduce yourself (1)
313. Adam is a 10 year old schoolboy who fell from a swing at school. He started crying immediately and complained of right wrist pain What is wrong with my son? There is a fracture of the right wrist It is displaced (2) What are you going to do for him? It needs to be reduced and the fracture should be immbilised with a slab or plaster of paris (2) Is this going to hurt my son? (2) Consent taken for sedation Respiratory rate need to be monitored after the procedure for 4-6 hours (observation) He cannot go home immediately During the procedure, he may still experience some pain as he cannot be fully anesthetized What problems should i look out for when Adam goes home? (2) Circulation needs to be checked (colour of fingers) Swelling, blistering (skin ischaemia if POP too tight) Arm need to be in sling and not in dependent position (to reduce swelling) Parents need to know when to return to see doctor if they see any of the above sign i.e. not to wait for follow-up appointment
314. 2003 You are the orthopaedic house officer – take consent from patient for above knee amputation. He has a gangrenous right leg secondary to infected diabetic ulcer Introduce yourself Explain the condition Gangrenous right leg and its cause (infected diabetic ulcer) Reassurance of the probelm he had From my examination this infection on the right leg become extensive due to DM – cannot be controlled by antibiotic Explain the possible complications without treatment Infection can go to blood Sepsis, life threatening Explain the recommended treatment AKA How is it done, cost & timing and progression Under GA with vital signs monitored
315. 2003 You are the orthopaedic house officer – take consent from patient for above knee amputation. He has a gangrenous right leg secondary to infected diabetic ulcer Explain the advantages and disadvantages Benefits: limit the infection as it can be life threatening anaesthesia risk, massive bleeding in surgery, complications (stump infection) Explain alternatives Debridement, daily dressings, antibiotic Hyperbaric oxygen therapy Its advantage & disadvantage Can ask for 2nd opinion Can change mind Check patient understanding Ask the patient to tell you what she understands Ask if she has any question for you regarding the procedure
316. 2003 (supp) Obtaining Consent from a patient who had ankle fracture Introduce yourselfExplain the condition Ankle fracture Explain the possible complications Malunion & nonunion, shortening Explain the recommended treatment ORIF How is it done, cost & timing and progression Under GA with vital signs monitored Explain the advantages and disadvantages Benefits: helps maximal healing, prevent deformity anaesthesia risk, massive bleeding & complications (infection) Explain alternatives POP Its advantage & disadvantage Can ask for 2nd opinion Can change mind Check patient understanding Ask the patient to tell you what she understands Ask if she has any question for you regarding the procedure
317. X-ray: Complete fracture of the right distal radius and ulna (1) 2004
318. 1. Explain the diagnosis and the relation between the signs and symptoms to the diagnosis Explain the diagnosis Distal fracture of radius & ulna (fracture at the wrist joint) Explain the signs & symptoms to the diagnosis Pain & swelling at the right wrist joint Inability to move / restricted movement of the right wrist joint Dinner fork deformity 2004
319. 1. Explain the diagnosis and the relation between the signs and symptoms to the diagnosis Explain the management & plan As he is a child, good and fast healing and remodelling is expected Therefore, close reduction & application of POP above elbow will be sufficient Respiratory rate need to be monitored after the procedure for 4-6 hours (observation) He cannot go home immediately During the procedure, he may still experience some pain as he cannot be fully anesthetized Analgesics will be given for pain relief 2004
320. 2. Get consent for POP Explain the condition and why POP is necessary Fractures of ulna and radius of right arm 1 POP is prevent malunion so that maximum healing in a proper position can occur Explain the possible complications without treatment 1 Malunion / nonunion with deformity Explain the complications of POP Compartment syndrome (if too tight) 1 Allergic reaction, uncomfortability Explain alternatives No treatment (leave it and let it heal by itself) 1 Can ask for 2nd opinion ½ Can change mind ½ Check patient understanding Ask the patient to tell you what she understands ½ Ask if she has any question for you regarding the procedure ½ 2004
321. 2. Explain & advice on POP care Circulation needs to be checked (colour of fingers) Swelling, blistering (skin ischaemia if POP too tight) Arm need to be in sling and not in dependent position (to reduce swelling) Parents need to know when to return to see doctor if they see any of the above sign i.e. not to wait for follow-up appointment Do not expose POP cast to extreme heat or moisture Do not insert anything underneath the cast Cover while taking bath Come back immediately if there is any swelling, bluish discolouration, pain/numbness or if the cast cracks 2004
322. Child with distal radial-ulna fractureExplain to mother about diagnosis, management and possible complications to look for Diagnosis Fracture of the radial shaft with distal radial-ulna junction injury Management Close manual reduction under sedation followed by POP cast Take consent for CMR and POP cast under sedation Respiratory rate need to be monitored after the procedure for 4-6 hours (observation) He cannot go home immediately During the procedure, he may still experience some pain as he cannot be fully anesthetized Analgesics prescribed for pain relief Should advice patient’s mother for POP care 2005
323. Child with distal radial-ulna fractureExplain to mother about diagnosis, management and possible complications to look for 2005 Consent for CMR Introduce yourself Explain the condition Fracture of the radial shaft Explain the possible complications Malunion & nonunion Explain the recommended treatment CMR with POP cast Anaesthesia will be given (midazolam) – temporarily unconscious for few hours In cast for next 10 days X-ray, if position not good remanipulate Explain the advantages and disadvantages Benefits: reduce pain, deformity and dysfunction Disadvantage: May fail and have to repeat, pain, anaesthesia risk Explain alternatives No treament Its advantage & disadvantage Can ask for 2nd opinion Check patient understanding Ask the patient to tell you what she understands Ask if she has any question for you regarding the procedure
324. 5 yrs old child had a fall and fractured his radius. A closed reduction under anaesthesia is going to be done and a POP is going to be applied 2006 Explain to the mother about the procedure Introduce yourself Explain the condition Fracture of the radial bone Explain the possible complications Malunion & nonunion Explain the recommended treatment CMR under anaesthesia with POP cast Anaesthesia will be given (midazolam) – temporarily unconscious for few hours In cast for next 10 days X-ray, if position not good remanipulate Explain the advantages and disadvantages Benefits: reduce pain, deformity and dysfunction Disadvantages: May fail and have to repeat, pain, anaesthesia risk Explain alternatives No treament Its advantage & disadvantage Can ask for 2nd opinion Check patient understanding Ask the patient to tell you what she understands Ask if she has any question for you regarding the procedure
325. 5 yrs old child had a fall and fractured his radius. A closed reduction under anaesthesia is going to be done and a POP is going to be applied 2. Advice given for POP application Do not expose POP cast to extreme heat or moisture Do not insert anything underneath the cast-may injure the skin Cover while taking bath If the cast gets wet skin underneath may become macerated Seek immediate advice if any article falls into or becomes lodged inside the cast, or a discharge appears on the surface of the cast, or an unpleasant odour becomes apparent If the casted limb becomes increasingly painful, the fingers or toes change colour to a dusky or white shade, become cold, lose motion or sensation, or there is increasing pain on passive extension of the digits, seek help immediately, day or night The only treatment for this condition is to split the cast to relieve the pressure on the limb and enable normal circulation to return Follow up in 5 weeks time 2006
326. 48 years old patient with history of uncontrolled DM come to clinic with swelling of big toe and ulcer of constant pain Greet & introduce yourself What is wrong with my toe? It is infected and unhealthy with ulcer It is a complication of DM Can you do something about it? Clean the wound by debridement and antibiotic will be given If it is extensive may need amputation Check the blood sugar to see how well is his DM control / look for infection I don’t want amputation. 1st: treated with daily dressing and antibiotic If wellno need amputation If not well and progresses amputation Explain about advantage : limit the infection Disadvantage: infection spread to blood septicaemia (life-threatening)
327. 48 years old patient with history of uncontrolled DM come to clinic with swelling of big toe and ulcer of constant pain Is it painful? We will do it under general anesthesia which means we will put you into sleep so that you will not feel the pain On awakening up, there may be pain but we will provide you with painkiller Can it be cured? Depend on how well is your DM controlled How to prevent further progress? Control sugar Compliance to medication Wear shoes rather than slippers
328. Patient had right fracture of hipTake consent for operation. Talk to the daughter What is the diagnosis for the X-ray given? Fracture of the femoral neck of the right hip Talk to the daughter Introduce yourself Explain the condition Fracture of the femoral neck of the right hip Common in elderly Explain the possible complications Malunion & nonunion Pain, deformity, shortening Explain the recommended treatment ORIF under GA Anaesthesia - temporarily unconscious for few hours
329. Patient had right fracture of hipTake consent for operation. Talk to the daughter Talk to the daughter Explain the advantages and disadvantages Benefits: reduce pain, deformity and dysfunction Disadvantage: May fail and have to repeat, pain, anaesthesia risk, bed sore Explain alternatives No treatment Its advantage & disadvantage Can ask for 2nd opinion Check patient understanding Ask the patient to tell you what she understands Ask if she has any question for you regarding the procedure
330. Patient complains of pain at the right shin. X-ray shows transverse fracture of tibia What is the diagnosis for the X-ray given? Fracture of the tibia Talk to the daughter Introduce yourself Explain the condition Fracture of the tibia Explain the possible complications Malunion & nonunion Pain, deformity, shortening Explain the recommended treatment ORIF under GA Anaesthesia - temporarily unconscious for few hours
331. Patient complains of pain at the right shin. X-ray shows transverse fracture of tibia Talk to the daughter Explain the advantages and disadvantages Benefits: reduce pain, deformity and dysfunction Disadvantage: May fail and have to repeat, pain, anaesthesia risk, bed sore Explain alternatives No treatment Its advantage & disadvantage Can ask for 2nd opinion Check patient understanding Ask the patient to tell you what she understands Ask if she has any question for you regarding the procedure
335. 2005 INTERACTIVE STATION What machine is this? Pulse Oximeter (1) What is it used for? To measure oxygen saturation (1) Give 4 indications for this machine (4) Heart failure Respiratory failure Monitoring a patient during a procedure Post-extubation monitoring Monitoring of pre-term baby or any ill patient Apply the instrument on me and give me your result (2) Apply on either finger/thumb/earlobe Switch machine on Ensure result stabilises before taking reading Give 4 factors that may affect the result in a clinical setting (2) Movement ½ Shock, poor perfusion state ½ Abnormal HB (methaemoglbin) ½ Hypothermia ½
336. Measure the head circumference of this childPlot it together with the child’s given weight and height on the chart provided Candidate’s approach / bedisde manners (1) Correct method of measurement: Correct placement of the measuring tape (above eyebrow and at occipital prominence) (2) 3 measurements done, then average reading taken (2) Ask mother for date of birth (1) Calculate chronogical age Ask mother if child is preterm, to correct age (1) Candidate plots measurements on anthropometric charts (1) What is your impression? (1) microcephaly
337. A 9 month old boy is brought by his mother with a 24 hour history of worsening breathingFollow the examiner’s instructions: Describer 3 physical signs: Inspiratory stridor (2) Sternal recession (2) Subcostal recession (2) What may cause these signs? Upper airway obstruction (2) Acute epiglotitis Croup Foreign body inhalation Other cause of upper airway obstruction What is the immediate next step in management? (2) Resuscitation (airway, breathing, circulation) Give oxygen Mask =/- bagging Intubation
338. Baby boy: weight 5.2kg, length 57.0cm, head circumference 42.8cm Age??? Plot the growth parameter on anthropometric charts Comment on the charts
340. A dummy with a central venous line What does it measure? (1) Measure the central venous pressure (blood pressure in vena cava and right atrium) Normal Value (1) 2-6 mmH2O Complications (2) Pneumothorax, Infection, Haemorrhage, arrhythmia Situation giving a false reading (1) Position of the manometer is not at the same level of the right atrium (sternal angle) Situation giving a low reading (1) hypovolemic shock from hemorrhage, fluid shift, dehydration negative pressure breathing which occurs when the patient demonstrates retractions or mechanical negative pressure which is sometimes used for high spinal cord injuries What is the CVP reading on the dummy? (4)
341. This patient requires a central venous catheter to be inserted in the antecubital fossa Demonstrate the standard landmarks for insertion of the catheter in the antecubital fossa (2) At point in the cephalic vein, lateral to brachial artery at the antecubital fossa Demonstrate your aseptic technique before inserting the catheter (4) Wear mask, Remove wrist watch, bangles, rings Wash hands and forearms to elbows Dry hands Put on sterile gloves Demonstrate the sterile preparation of the skin area for catheter insertion (4) Open dressing pack Apply povidone-soaked cotton ball to skin using circular motion radiating outward from the insertion site Place a sterile ‘perineal’ paper towel over the insertion site
342. CBD insertion Which catheter would you choose? 18 French gauge for male Which lubricant? Lignocaine gel Which fluid for inflation of balloon? water Demo how you know the catheter is in the bladder Urine flows out Drag the balloon
Notas del editor
Not sheathed, terminal nuclei, uncountable nuclei, stained with Giemsa, kinking
