OSCE PRO III Trial Answer

Onn Azli bin Puade

Question 1

A 25 years old male presented with X was temporarily put on exhibit Y 1. State 3 characteristic of X (3 marks) 2. What is the most likely nerve affected? (2 marks) 3. State the location of lesion and give 2 reasons (3 marks) 4. Name exhibit Y (2 marks)

Question 1
State 3 characteristic of X (3 marks)
There is wrist and finger drops of the right upper limbs The right triceps muscle is intact No evidence of other nerve injury such as claw hands and pointing finger

What is the most likely nerve affected? (2 marks)

Radial nerve

State the location of lesion and give 2 reasons (3 marks)

High/ Middle lesion lesion is located in between brachioradialis and radial groove of the humerus as there are evidence of dysfuction of all the wrist extensor (ECRB, ECRL and ECU) with intact triceps function

Name exhibit Y (2 marks)

Banjo splint

Question 1
Other spotted PRO question (Clinical short case or OSCE)
Ulnar paradox (FDP and lumbricals) Pointing finger (Extensor indices) Carpal tunnel syndrome (median nerve palsy)

Question 2
A 5 years old came to you with vomiting and diarrhoea for 1 day duration. Initial assessment found out that the child was lethargy, dry mucous membrane and pulse rate was 152 beats/minute. Outline the fluid resuscitation in this patient (10 marks)

Dehydration

Answer question 2
25 years old - unable to tolerate orally (no ORS, give intravenous fluids) Fluid requirement = Maintenance + Deficit + Ongoing loss Set 2 intravenous line = one for deficit, one for maintenance Deficit
Lethargy, dry mucous membrane and tachycardia moderate dehydration (~5.1 9.9 %) Took halfway in between 5.1 9.9% = 7.5 % Calculate the fluid requirement
o 7.5/100 x (patients bodyweight = 60,000 g) = 4500 mls of fluid deficit o Replace 4500 ml in 24 hours
First 8 hours (1/2 of total deficit) = 2250 mls (4.5 pint) Second 8 hours (1/4 of total deficit) = 1125 mls (2.25 pint) Final 8 hours (1/4 of total deficit) = 1125 mls (2.25 pint)

o Use normal saline 0.9% or Haartmans solution

Answer question 2
Maintenance
40 mls per kilogram in adult 60 kg patient needs = 60 x 40 = 2400 mls per day (~ 5 pint per day) Choice of fluids depending upon the sodium requirement in this patient
Assuming sodium requirement is normal Na+ requirement = 2 4 mmol/ kg/ day Thus, 60 kg patient needs = 120 240 mmols per day 1 pint of normal saline 0.9 % contains 75 mmols of sodium (150 mmols/liter) Thus, this patient needs = 2 3 pint of normal saline 0.9% Another 2 pint = Dextrose 5% So, this patient need 2 pints of NS 0.9% with 3 pints of Dextrose 5% or 3 pints of NS 0.9% with 2 pints of D5%

Question 2
Other spotted PRO question (Clinical short case or OSCE) Fluid requirement in paediatric patient
1st 10 kg = 100 mls/kg/ day 2nd 10 kg = 50 mls/kg/day Remaining kg = 20 mls/kg/day Fluid for resuscitation = Na 0.18 Fluid for maintenance = Na 0.18 Dextrose 4.3%

Question 3

An 18 years old male with visual disturbance and deafness came to see you for follow up 1. State 4 findings in the above picture (4 marks) 2. State 1 provisional diagnosis (2 marks) 3. State 3 visual disturbances experienced by the patient (3 marks) 4. State 1 pharmacological treatment in this patient (1 mark)

Answer Question 3
State 4 findings in the above picture (4 marks)
Bony spicules appearance at all 4 quadrant of retina Waxy pallor of the optic disc Attenuation of retinal artery Preservation of the macula with peripheral ring of depigmentation

State 1 provisional diagnosis (2 marks)

Retinitis pigmentaosa + Deafness = Usher syndrome/ Dystrophia retinae dysacusis syndrome

Answer Question 3
State 3 visual disturbances experienced by the patient (3 marks)
Nyctalopia Tunnel vision Poor colour separation Photopsia Visual loss

State 1 pharmacological treatment in this patient (1 mark)

Vitamin A

Question 3
Other spotted PRO question (Clinical short case or OSCE)
Diabetic retinopathy (last year PRO question) Corneal ulcer Orbital cellulitis vs Periorbital cellulitis

Question 4
A 56 years old female with underlying diabetes mellitus came to see you at dermatology clinic 1. Describe 3 characteristics of the lesion (3 marks) 2. State the most likely diagnosis (1 mark) 3. Name 4 other skin lesions seen in diabetic patient (4 marks) 4. Outline your treatment (2 marks)

Answer Question 4
Describe 3 characteristics of the lesion (3 marks)
Presence of well-defined rashes at anterior shins Erythematous border with central yellowish tint Multiple dilated veins

State the most likely diagnosis (1 mark)

Necrobiosis lipoidica diabeticorum

Answer Question 4
Name 4 other skin lesions seen in diabetic patient (4 marks)
Eruptive xanthomata Lipoatrophy or lipohypertrophy Diabetic foot ulcer Acanthosis nigricans Peripheral anhidrosis Granuloma annulare

Outline your treatment (2 marks)

Good diabetic control Whirpool therapy, occlusive dressing and aspirin Excision and skin grafting

Question 4
Other spotted PRO question (Clinical short case or OSCE)
Lipoatrophy Scabies (last year PRO) Erythema multiforme Linchen planus Livedo reticularis

Question 5
A 35 years old gentleman were called to infertility clinic for Seminal fluid analysis. Explain to the patient regarding the procedure (10 marks)

Answer Question 5
Greet the patient, maintain privacy (1 mark) Explanation of the procedure (2 marks)
collect seminal fluid analyzed under microscope and laboratory to detect the quantity and the quality of sperms

Explanation precollection of the sperm(3 marks)

Abstain for ejaculation for at least 2 days and no more than 10 days Avoid medications = cimetidine, nitrofurantoin, testosterone hormone (androgel) for at least 2 days duration Avoid smoking, caffeine and alcohol Sample needed to be arrived at the hospital in less than 24 hours after collection if the patient insist to take the sample at home

Answer Question 5
Explanation on how to collect the sample (3 marks)
Wash hands and genital area before masturbating Ejaculate directly into the sterile container provided (avoid contaminating the container by touching inside it) Store the sample at body temperature (in pockets) before delivering it to the hospital) Do not use condoms to collect the samples

Offer the patient with any question (1 mark)

Question 6
Other spotted PRO question (Clinical short case or OSCE)
Breastfeeding counselling Partogram charting

Question 6

A 56 years old gentleman who suffered from loss of consciousness was brought to a accident and emergency clinic. Cardiac monitoring found was done and revealed the above diagram 1. State your diagnosis (1 mark) 2. Outline your management (4 marks)

Subsequently, after 5 minutes of resuscitation, the rhythm change to the above diagram 1. State your diagnosis (1 mark) 2. Outline your management (4 marks)

Answer Question 6
State your diagnosis (1 mark)
Ventricular fibrillation

Outline your management (4 marks)

Defibrillate the patient (200 J = Biphasic defibrillator) Commenced CPR for 2 minutes, get Intravenous or intraosseous access Assess the rhythm back, if rhythm is shockable, defibrillate the patient again (200 J) Give the patient epinephrine and intubate the patient with CPR continuously for another 2 minutes

Answer Question 6
State your diagnosis (1 mark)
Asystole

Outline your management (4 marks)

Asystole protocol = check leads placement, reduce machine amplitude sensitivity Commenced CPR and assessed rhythm after 2 minutes of CPR Consider reversible causes (5H and 5T) and treat accordingly

Question 6
Other spotted PRO question (Clinical short case or OSCE)
5H and 5T treatment Acute management of stroke Acute management of increase ICP

Question 7

A 50 years old female with mental retardation and seizure 1. Name exhibit G and H (2 marks) 2. Name the triad of mental retardation, seizure and exhibit G (2 marks) 3. State your diagnosis (2 marks) 4. State 4 other lesion cause by the disease you stated above (2 marks) 5. Outline your treatment (2 marks)

Answer - Question 7
Name exhibit G and H (2 marks)
G Adenoma Sebaceum H Ash leaf macules

Name the triad of mental retardation, seizure and exhibit G (2 marks)

Vogt triad

State your diagnosis (2 marks)

Tuberous sclerosis

Answer Question 7

Answer Question 7
State 4 other lesion cause by the disease you stated above (2 marks)
CNS hamartomas (cortical tubers, subependymal hamartomas) Renal angiomyolipomas Cardiac rhabdomyomas and pulmonary myomas Liver, renal and pancreatic cyst

Outline your treatment (2 marks)

Anticonvulsant depending on the types of seizure the patient had (generalized seizure sodium valproate and focal seizure carbamezepine)

Question 7
Other spotted PRO question (Clinical short case or OSCE)
Neurofibromatosis I and II Dystrophia myotonica

Question 8

Regarding exhibit Y and Z 1. Name exhibit Y (2 marks) 2. State 1 indication and 1 contraindication of exhibit Y (2 marks) 3. Name exhibit Z (1 mark) 4. State 2 uses of Z (2 marks) 5. Name 3 ways to detect the correct placement of Z (3 marks)

Answer Question 8
Name exhibit Y (2 marks)
Sengstaken Blakemore Tube

State 1 indication and 1 contraindication of exhibit Y (3 marks)

Indication UGIB secondary to bleeding oesophageal varices Contraindication known oesophageal stricture

Name exhibit Z (1 mark)

Ryles tube/ Nasogastric tube

Answer Question 8
State 2 uses of Z (2 marks)
Feeding in unconscious patient Gastric decompression

Name 3 ways to detect the correct placement of Z (3 marks)

Litmus paper acidic Aspirate the tube fluids Submerge in the water bubbling in lung placement Chest radiograph

Question 8
Other spotted PRO question (Clinical short case or OSCE)
Chest tube and its placement Diathermy (unipolar and bipolar) Scalpel, needle holder, artery forceps

Question 9
D

C B

Regarding picture above 1. Name exhibit A and B (2 marks) 2. State 2 uses of exhibit A (3 marks) 3. Name exhibit C and D (2 marks) 4. List 2 complications of insertion of C and D (3 marks)

Answer Question 9
Name exhibit A (2 marks)
A is Balkans frame B is Monkey bar

State 2 uses of exhibit A (3 marks)

For patients mobility and exercise to prevent the complications of prolonged immobilization For site of attachment of orthopaedic devices

Answer Question 9
1.Name exhibit C and D (2 marks)
- Steinmen pin - Stirrup

2.List 2 complications of insertion of C and D (3 marks)

- Nerve palsy - Pin tract infections

Question 9
Other spotted PRO question (Clinical short case or OSCE)
Thomas splint (complete and incomplete ring) Skin traction Bohler-Braun frame Cast, figure of 8

Question 10

An 8 years old patient with known case of thalassaemia came for blood transfusion. His current haemoglobin was 10 g/dL and he was currently on desferoxamine 1. State 2 abnormalities in this patient skull radiograph (2 marks) 2. Calculate the amount of blood to transfuse in this patient (8 marks)

Answer Question 10
State 2 abnormalities in this patient skull radiograph (2 marks)
Hair on end appearance Frontal bossing

Answer Question 10
Calculate the amount of blood to transfuse in this patient (8 marks)
Estimate bodyweight in this patient
(Age + 4) x 2 = (8 +4) x 2 = 24 kg

Blood transfusion formula (packed cell transfusion)

On iron chelation therapy
(14 current Hb level) x BW x (3.5 to 4) [HUSM use 3.5) (14 10) x 24 x (3.5 to 4) 336 ml to 384 ml over 4 hours Diuretics (furosemide) at the end of transfusion

Question 10
Other spotted PRO question (Clinical short case or OSCE)
Remember the formula for packed cell transfusion
On iron chelation
(14 current Hb level) x BW x 3.5 to 4

Without iron chelation

(12 current Hb level) x BW x 3.5 to 4

For whole blood transfusion in Exchange transfusion

(2 x BW x 80) ml

For whole blood transfusion in Acute blood loss

(haemoglobin rise) x BW x 6

Question 11
A 56 years old female with underlying psychiatric illness and on antipsychotic 1. State your diagnosis (2 marks) 2. Name 1 drug which is commonly associated with above diagnosis (2 marks) 3. Name 4 other complications of antipsychotic (4 marks) 4. State one pharmacological treatment (2 marks)

Answer Question 11
State your diagnosis (2 marks)
Acute dystonia secondary to antipsychotic ingestion

Name 1 drug which is commonly associated with above diagnosis (2 marks)

Haloperidol (Typical antipsychotic)

Name 4 other complications of antipsychotic (4 marks)

Extrapyramidal side effects Akathisia, Tardive dyskinesia, parkinsonism Anticholinergic side effects dry mouth, blurred vision Adrenergic antagonist postural hypertension Cortex and limbic system mental confusion, drowsiness

Answer Question 11
State one pharmacological treatment (2 marks)
Dopamine agonist Bromocriptine Dopamine Levo-Dopa

Question 11
Other spotted PRO question (Clinical short case or OSCE)
Interview technique video Phenomenology based on MSE DSM IV classification
Axis I Psychiatric illness Axis II Mental retardation/ Personality disorder Axis III GMC Axis IV Social problem Axis V Activity of daily living

Question 12

A 2 days old neonate was born with respiratory distress syndrome. Examination reveals a fasciculation at upper limbs and tongue 1. State 3 features of the patient (3 marks) 2. State the most possible diagnosis (2 marks) 3. State 1 blood investigation for diagnosis (2 marks) 4. State the prognosis for this child (2 marks)

Answer - Question 12
State 3 features of the patient (3 marks)
Patient is on opisthothonic posture Bilateral CTEV, left knee is hyperextended Patient was on nasogastric tube and nasal prong

State the most possible diagnosis (2 marks)

Spinal muscular atrophy 0 (Arthrogryphosis Multiplex congenita)

State 1 blood investigation for diagnosis and the expected findings (2 marks)
Genetic testing show bi-allelic deletion of exon 7 of the SMN 1 gene

Prognosis of the child

Prognosis is very poor as this condition were incompatible for life

Question 12
Other spotted PRO question (Clinical short case or OSCE)
Spinal muscular atrophy types Approach to floppy infant (muscle, NMJ, Peripheral nerve, Anterior Horn Cell)

Question 13
A 65 years old patient with bilateral knee pain for 3 months duration 1. State 2 findings in the knee radiograph (2 marks) 2. State your diagnosis (1 mark) 3. State 1 other view of radiograph you would like to order in this patient to asses the patellofemoral joint (1 mark) 4. State 2 pharmacological treatment in this patient (2 marks) 5. State 1 surgical intervention you would like to offer the patient (1 mark) 6. State 3 complications of the operation you stated above (3 marks)

Answer Question 13
State 2 findings in the knee radiograph (2 marks)
Narrowing of medial joint space of bilateral knee joint Marginal osteophytes

State your diagnosis (1 mark)

Bilateral knee osteoarthritis

State 1 other view of radiograph you would like to order in this patient to asses the patellofemoral joint (1 mark)
Skyline view, Lateral view

Answer Question 13
State 2 pharmacological treatment in this patient (2 marks)
Tablet NSAIDs T Glucosamine Sulphate

State 1 surgical intervention you would like to offer the patient (1 mark)
Bilateral knee arthroplasty

State 3 complications of the operation you stated above (3 marks)

Patella fracture, Patella maltracking Arthrofibrosis Deep Vein thrombosis, Pulmonary embolisme

Question 13
Other spotted PRO question (Clinical short case or OSCE)
Hip osteoarthritis Hip avascular necrosis total hip arthroplasty

Question 14
Picture above showing the medication used in the labour room. Explain how would you titrate and calculate how would you give the patient with this medication (10 marks)

Answer Question 14
Induction
4g of MgSO4 over 10 - 15 minutes 10 mls vial contains 5 g of MgSO4
Thus, 1 ml solution contains 0.5 g of MgSO4 Use, 8 ml solution (4 g of MgSO4) add dilute in 12 mls of Normal Saline 0.9% or Dextrose 5% Total of 20 mls with 4g of MgSO4 given in 10-15 minutes

Answer Question 14
Maintenance
Aim = 1 g per hour with a rate of 5mls per hour Take 20 mls vial (contains 10 g of MgSO4) dilute in 30 mls of Normal Saline 0.9% or Dextrose 5% Total of 50 mls of solution with 10 g of MgSO4 So, 5mls contains 1 g of MgSO4 Infuse the patient with 5 mls per hour

Question 14
Other spotted PRO question (Clinical short case or OSCE)
Titration of Pitocin Drugs MgSo4, Antihypertensive in pregnancy, Tocolytics (side effects and precautions)

Question 15
Mr S, a 36 years old Malay man with newly diagnosed hypertension since 1 year ago, came to your clinic for 3rd follow up. He is a businessman who is busy travelling, and thus always forgot to take his medication. He is currently on nifedipine 10mg TDS. His latest BP was 160/90mmHg. Please counsel him on compliance towards medication

Answer Question 15
Greet the patient, build rapport Explain the hypertension control in this patient
Not controlled Aim is systolic <140mmHg and diastolic <85 mmHg Complications which may arise in the patient

Ask about the medication

Ask the reason why he kept forgetting to take the medication Give the patient alternatives, one that needs to be taken BD dosing or OD dosing Give strategy to remember to take the medication (e.g safe on the handphone, bring to work etc)

Question 15
Other spotted PRO question (Clinical short case or OSCE)
Pap smear counseling and performing the procedures Prescription drugs Short history and diagnosis Contraception counselling

Question 16

A 34 years old gentleman was referred to you with palpitations 1. State 4 features in the ECG (4 marks) 2. State your diagnosis (2 marks) 3. Outline the treatment in this patient (3 marks)

Answer Question 16
State 4 features in the ECG (4 marks)
Absent of P wave in all leads Widened QRS complex Tall T wave Evidence of sine wave

State your diagnosis (2 marks)

Hyperkalaemia

Outline the treatment in this patient (3 marks)

Insulin and nebulize salbutamol Calcium gluconate Calciun resonium

Question 16
Other spotted PRO question (Clinical short case or OSCE)
Hypokalaemia (tall P wave, ST segment depression, U wave) Acute myocardial infarction and PCI

Question 17

A newborn with syndromic features 1. State 3 features of the patient (3 marks) 2. State your diagnosis (2 marks) 3. State 3 other system that can be involved in the disease you stated above (3 marks)

Answer Question 17
State 3 features of the patient (3 marks)
Cleft lip and palate Polydactyly Omphalocele

State your diagnosis (2 marks)

Trisomy 13 Patau Syndrome

State 3 other system that can be involved in the disease you stated above (3 marks)
Central nervous system myelomeningocele, microcephaly, mental retardation Cardiovascular system VSD, ASD and PDA Skin Cutis aplasia Urogenitalia Undescended testis

Question 17
Other spotted PRO question (Clinical short case or OSCE)
Downs syndrome Marfans syndrome Turner syndrome Congenital Adrenal Hyperplasia

Question 18
Mdm K, a 43 years old Para 7 just underwent emergency C-section due to macrocosmic baby. Her last child birth was 1 year ago. Counsel the patient prior to discharge

Answer Question 18
Greet the patient, build rapport Wound care avoid water contact, came to hospital if bleeding and any discharge Breasfeeding exclusive breastfeeding until 6 months and continue up to 2 years of babys age Importance of spacing give at least 2 years Advise on contraception
Risk of grand multipara Risk of advance age pregnancy Choice of contraception

Discharge the patient with letter to local public health nurse (follow up at 6 weeks) Sexual intercourse wait until 4 weeks Any symptoms of pervaginal discharge, fever please came to hospital immediately