MBBS UM (malaya) EXTENDERS: OSCE

Showing posts with label OSCE. Show all posts

5/01/2009 10:37:00 AM | Author: fadzly

Okay, because today is holiday, i'll continue happily typing the 2nd question for you all.. haha

Note: This question basically a short answer question, which might come out in the END OF POSTING test, OSCE, and also long case exam.

Mrs. Wee a 56 years old clerk has hypertension for the pass 1 year. She's currently comes for follow-up. She on tab amlodipine 10 mg daily. His blood pressure (BP) is 150/100 mmhg. Discuss the management of this patient. (10 marks)

So like always address the issues first! So what are the issues here?

Hypertension (HPT) for the pass 1 year. So we need to assess her IDEA about the HPT.

Her BP was 150/100. What do you think this is? Basically in any disease (i mean any medical or psychiatric illness) when the disease is not improving, there are 3 things to bear in mind.

1) COMPLIANCE
2) DOSAGE
3) WRONG DIAGNOSIS

So we need to assess all this three things first. In this case, usually the compliance and the dosage are all we talk about.

Then the other issues are to establish the degree of control of disease process

Then is there any complication from the disease?

And is there any co-morbid condition such as Diabetes, Obesity

Then after addressing the issues we tackle it one by one.. ok?

So answer should be like this

- I would like to assess this patient Idea about Hypertension. How much the patient knows about hypertension? How much the patient concern about the disease affect to his life, family, work?
- Then i would give top up the information and re-educate him so that the patient knows adequately about HPT, such as complication of the HPT. I would also like to tackle the biopsychosocial problems accordingly.
- I would like to assess this patient compliance. Did the patient compliance to medication? Did the patient compliance to the advice?
- If not why? Is there a problem? - Side effect? no access to medication such as patient poor, home is far, no transport, no clinic nearby? No one take care of him? Traditional medicine
- If compliance is the problem managed accordingly by giving education on medication, emphasis again about pharmacology and non pharmacology management, stop the traditional medicine.
- If the patient can’t tolerate the medication, such as side effect, change other type of drugs. If SE is not a problem, i would try to increase the dosage of the drug.
- Assess the patient compliance to advice and clinics. Did the patient go for follow up regularly? Did the patient have BP monitoring at home?
- I would like to emphasis on Non pharmacology management such as exercise regularly 30 minutes a day 3 times per week, eat healthy diet, less sugar, less fat diet, etc
- I would like to referred the patient to dietician
- I would like to assess any complication from HPT by doing CVS examination, EYE- ophthalmoscope and also do some investigation such as Urine dipstick, UrineFEME for protienuria, ECG for ECG changes.
- I would also want to assess this patient co morbidity such as DM or obesity by doing BMI, FBS, and cholesterol level.
- I would like to follow up the next 3 months or 4 months to monitor the progression.

I do agree with it's a bit wordy and difficult. Dr Sajar said, we just need a lot of training, that’s all. Good luck in your study! Till we meet at the next question! haha

Dr Sajar, Long Case, OSCE, PCM, Question | comments (2) |

The 10th day of my 6 months

4/29/2009 05:47:00 PM | Author: fadzly

Woke up early?

So? What i do today? Got up early in the morning. i mean not early, 9.10 am.. In my timetable given by department, class start at 9.30. I'm not in a rush anyway, because hospital was just nearby my college. Then later when i came, Dr Sajar was there. She claims that she was there waiting us at 8.00.. owh.. so pity.. we all except Syud was coming at 9.30am. Then the dept get one of our phone number so that in case of something happen, they will call us.. Sorry Dr Sajar, she was so busy this week because of the ongoing Master's Exam now. That's why a lot of unknown people in the college currently.

Class

This time she managed to get us a past year questions.. It seems to be simple, but i thought it was challenging. There is 3 scenario question, basically all of them can be in the paper, OSCE or long case. Ok i managed to get the question in my note, roughly let see the question!

Question One

Mrs Tan 38 years old teacher present to the clinic with a 6 months history of lower abdominal pain, bloated, increased flatulance and diarrhoea. She stated that she can pass up to three loose bowel movement per day. There is no fever loss of wt(LOW) and loss of appetite(LOA). She was recently diagnose to have diabetes melitus and is on regular follow up and treatment.

1) What futher hx would you elicit and give reason? (8 marks)
2) Give 3 differential diagnoses (3 marks)

On physical examination, she looks well, in pink, not febrile and not in pain. Her height is 163 cm, and her weight is 67 kg. Abdomen was soft and there was very mild generalized tenderness.

3) What other physical examination and investigation would you like to do? (7 marks)
4) She has went to 4 different GP for the past 6 months and on antacids and antibiotics for her current condition. She request for a scope to be done. How do you respond to her request? (4 marks)
5) Outline the management for this patient (8 marks)

Discussion

This is a typical question in paper 1 for PCM every year. It just so typical that the question will start by asking, what futher hx u would elicit and what are the differentials?

So how to answer?

Read the questions first! Patient having chronic diarrhoea for the past 6 months. What do u think in your mind? Although the first question is what futher hx you want to take, but i usually start the 2nd question. So it will be easier for me to answer the 1st question, isn't it?

The DDx in mind are:
Irritable Bowel Syndrome (IBS)
SE of drugs such antibiotics, antacids, acarbose
DM
Hyperthyroidism
Diverticulosis

So the next things is to elicit history from the DDx above, rite?
Just answer like Steps on History Taking so you wouldn't miss a thing.

History presenting Illness
1) Characteristic of the stools, is it watery, mucous, blood, malaena, soft stool?
2) Any aggravating/relieving factor such as food stressor?
3) Any associated symptom such as nausea or vomiting
4) Patient malnurish? Assess the symptom of hydration status such as cramps, very weak or lethargy, thirsty, reduce urine output.
5) Symptom of thyrotoxicosis such as heat intolerance, increase appetite, reduce weight, eye problems

Then go to past medical and past surgical hx.
DM, HPT? any thyroid surgery - past hyperthyroidism

Drugs Hx
DM- what type of drugs? acarbose, metformin can cause diarrhoea
Antibiotics? Antacids? - can cause diarrhoea also

Dietary Hx?

Family Hx - any GI malignancy in the the first degree relatives?

Social Hx - any stress event occur? such as financial prob, increase workload as a teacher? - stress can induce diarrhoea

So basically, it complete. eventhough u might miss something, but hey, the above answers already make u have 8 out of 8.

Ok 3rd question.

The question already done Abdominal, take her BMI(overweight skit). What other PE?
Hehe.. simple la.. Same principle. Start with vital sign. Temperature, BP, pulse. Then do the Hydration status such as reduce capillary refils, skin turger, sunken eye etc..
Thyroid examination jgn lupa aaa..- Goiter, thyroid eye disease, pulse - AF, thyroid acropathy, proximal myopathy and etc.
Per rectal examination!!
and because patient has DM - check the eyes, peripheral neuropathy
Investigation such as - stools for culture, ova and cyst!!
then DM - we do, urine dipstick, UFEME, renal profile etc.
Haha.. 7 marks already~!

4th question.

4 marks means 4 point to be inserted... This question basically testing your generals knowledge. Even a layman can answer it.. If you meet this type of question, it means, it is a PCM question.

TIPS: PCM will always ask about this and the answer will always rejecting the patient request! The answer should be basically like this:

Firstly i would like to like to assess the patient consern about why she want to do scope? What does the patient thinks? Did she thinks about GI malignancy?
I would tell her that currently patient is not indicated for scope yet.(be in mind what are the indications for endoscopy)
Tell her about the complication if she done the scope such as bleeding, perforation etc, and it is costly wasting your money
But, if after stopping the antibiotic and antacid, patient still having diarrhoea then we can discuss about doing the scope later

Nice isn't it? If you have another type of answer pls do not hesitate to give it at the comment section.
Last.. Outline the management.

Outline management means make it simple. First of all address the issues that the patient having now.
Issues are Diarrhoea, DM, Overweight, Stress, Multiple GP, anxious about malignancy

Diarrhoea can be settle by non pharmaco and pharmaco. Non pharmaco such as stop triggering factors and takes care of her diet and takes plenty of water. Anti-diarrhoea can be given to her.
DM - Compliance to medication, healthy lifestyle, reduce intake of sugar, fats, eat a lot of fibres, reffered her to dietician.
Overweight - Lose weight, excersize regularly 30 minutes and 3 times a week.
Stress - Reduce stress by plan management, sleep adequately.
Reassure again that this is not due to malignancy and give simple explanation about symptom of GI malignancies.

That its.. Penat menaip.. 2nd and 3rd questions will coming.. later.. i nak eat first...