100 Clinical Cases and OSCEs in Medicine
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The evaluation will be objective based on logbook as to whether the candidate has achieved certain competencies as outlined. Each formative evaluation score will be carried on and added to the internal assessment mark for final examination. Summative Evaluation: This will be conducted by the University and will consist of three parts. The part I examination will be conducted by the end of first year. A maximum of three attempts will be allowed.
Candidates failing in the third attempt will be dropped from the course. Thesis should be submitted by the second year and there will be external and internal examiners. The candidates will not be allowed to sit or final examination without approval of the thesis. The candidates who pass the examination will be awarded the degree of Doctor of medicine MD in Internal Medicine by Tribhuvan University. Young player on South African Market, Thunderbolt is one of the most valuable gambling establishments in Teaching Hospital B.
MD in Internal Medicine This is a three-year residency programme started in Course Objectives To train specialists in Internal medicine with adequate knowledge, attitude and skills to enable them to function as consultants in Internal medicine. To develop qualities of having the initiatives creativity, sound judgement and logical deduction so as to provide academic leadership in medicine.
To develop skills of critical analysis of scientific literature. Be conversant with recent advances in medicine. To develop skill in thesis writing. To develop skills in clinical research. Full registration with Nepal Medical Council. A one-year work experience in any institution approved by IOM for such purpose. Passing of post graduate entrance examination and selection as per the merit list of the result.
Selection for Admission An entrance examination will be conducted for selection into the different post graduate programme. Enrollment of four students annually will be done strictly on merit basis. Candidates are registered for the course will not be allowed to enter other PG programmes during the course. Methods of training The postgraduate students will go through a 3 year full time residential training programme.
A preceptor will be designated to each student. The PG students will be encouraged towards self-directed learning. There are five ma in precipitat in g causes:. The amount of exercise that causes the pa in varies from. The distance the patient can walk on the flat or the number. After a meal the metabolic rate in creases and there is in creased. Beware of the. Patients who have ang in a are more likely to experience. Occasionally patients are awakened from sleep by chest.
This is probably due to an attack of ang in a be in g precipitated dur in g. There are no signs specific to ang in a, but there may be cl in ical signs present. Classically, ST. Extension of ischaemia in to the in terventricular septum is in dicated by ST-segment. Occasionally myocardial ischaemia results in ST-segment elevation in the.
They ma in ly reduce peripheral resistance, and some also have a. Sometimes a s in gle agent is sufficient to control the pa in , but often a comb in ation of. Myocardial in farction occurs when there is an area of myocardial necrosis result in g. It is usually due to thrombosis or embolism from a clot form in g on an atheromatous. There is a sudden onset of severe, crush in g, central chest pa in that usually lasts for.
The pa in may radiate to the arms or lower jaw. It is often associated with sweat in g,. On exam in ation the patient looks shocked and unwell, with an ashen complexion,. They usually have a fast, weak pulse and may. Classic ECG changes occur in a sequential fashion in the st and ard and chest leads.
This enzyme is fairly. The level of CKMB rises rapidly in the blood. The total level of creat in e k in ase in the blood is. Recently, a number of more specific tests have become available. These in volve the measurement of various tropon in s, which are part of the. If the tropon in level is elevated, this. Classically, the pattern of rise and fall of these enzymes was used to confirm the.
Patients with myocardial in farction usually require opiate analgesics such as morph in e. The patient should be given oxygen to breathe, and any complications. Intramuscular in jections should be. If you are asked how to. In the absence of any contra in dication see Table 2 , all patients with acute. The drugs used are either.
MD in Internal Medicine
Both have been shown to significantly. Active gastro in test in al bleed in g or past history of peptic ulceration. Streptok in ase treatment — should not be used if it has been given with in the past. The complications of an in farct can be classified as immediate, early or late, and all. This condition is commonly used in OSCEs for history-tak in g on shortness of breath.
It is a condition in which there is impaired function of the left ventricle, result in g in. The most prom in ent symptom is dyspnoea due to a comb in ation of pulmonary.
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The degree and rate of progression of. For example, if there is a. Because of compensatory fluid retention and the redistribution of fluid in the. Although orthopnoea can also occur in respiratory disorders, PND is pathognomonic of. On cl in ical exam in ation, the presence of f in e crepitations heard. The most helpful in vestigation is the chest X-ray, which shows the follow in g four.
When us in g diuretic drugs it. Their effect is primarily. This is most likely to occur in. Also, some patients with left-sided failure. It is therefore underst and able that a patient who has acute. The cl in ical features that. One should always suspect LVF in any middle-aged or elderly patient who develops. This usually occurs as a consequence of left ventricular failure, and when the two. The most prom in ent symptoms. As a result of in creased blood volume, raised hydrostatic pressure in. The ma in stay of treatment is diuretic therapy to reduce the total blood volume and. This is a relatively common OSCE station used ma in ly for history tak in g, although.
ECGs with common or life-threaten in g forms of arrhythmias are also used for data. The symptom usually in volves a rapid or irregular heartbeat, but there can be a. Syncope is a sudden loss of consciousness that results from a drop in systolic blood. Syncopal attacks are precipitated by anyth in g that reduces the systolic blood.
They may be due to a. At some time in their life everyone experiences the subjective feel in g of their heart. These are physiological palpitations, and they. It is important to be able to. Pathological palpitations may lead to more serious or life-threaten in g arrhythmias and. These palpitations are usually fast and regular in rhythm.
They gradually in crease in. Although they may be associated with feel in gs of anxiety, such as tremor and. Dur in g an episode the ECG rhythm. These palpitations may be associated with a slow, fast or irregular rate and rhythm. They often commence and term in ate abruptly. They are more likely to be associated. A variety of. When the rate is rapid, atrial fibrillation is experienced as an irregular beat in g in the. The condition usually responds to digox in or amiodarone therapy, but. This type of case is used in the cl in ical exam in ation station, as some older patients.
Mitral stenosis is a narrow in g of the mitral valve and is usually a sequel to rheumatic.
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It is more common in women than in men, with a female:male ratio of The cl in ical features usually appear in early adult life, approximately 10—12 years. This may be paroxysmal at first, but. There is also an in creased risk of recurrent. On cl in ical exam in ation, in spection of the patient may reveal a classic malar flush.
The pulse is small-volume, and on auscultation of the. There is a mid- to late diastolic murmur, and if the. This accentuation of the murmur is due to left atrial contraction, and is absent. The severity of the murmur is in versely proportional to the in terval between the. In other words, the shorter the in terval.
The loudness of. Treatment in cludes prophylactic antibiotic therapy prior to any procedure, to prevent. Atrial fibrillation, if present, should be treated with digox in ,. Patients should undergo. This common cardiac valvular defect is frequently used in cl in ical exam in ations. Mitral in competence is a cardiac valvular defect in which the mitral valve allows blood. This defect is more common in men than in women, and it may be secondary to left.
The cl in ical features are in creas in g shortness of breath on exertion, usually occurr in g.
A palpable systolic thrill may be felt over the apex, and there will be a. The first heart sound will be soft due to failure of closure. The diagnosis can be confirmed by echocardiography, and a chest X-ray will show the. Medical therapy in volves treat in g any left ventricular failure or rhythm disturbance. This is def in ed as a narrow in g of the aortic valve. This condition is more. It usually presents. The symptoms that occur in this condition are due to decreased cardiac output.
Ang in a pectoris,. The first symptom that patients often describe is general tiredness and reduced. The cont in ued obstruction to outflow of the left. This in crease in muscle mass in the left. The development of left ventricular failure is a s in ister sign in aortic stenosis. Occasionally, sudden. On cl in ical exam in ation, the characteristic signs are as follows:. On ECG there will be marked left ventricular hypertrophy, and left bundle branch.
If left. Echocardiography will confirm the diagnosis and may also give some in dication as to. This condition is frequently used in cl in ical exam in ation stations, when the student is. Aortic in competence is a condition in which the aortic valve fails to close completely. The cl in ical features result from the comb in ed in crease in pressure and volume load. Shortness of breath is the most prom in ent symptom, and this is due to left. Ang in a pectoris usually develops approximately two years after the. Patients may have symptoms or signs of the underly in g.
On cl in ical exam in ation there are several signs which may classically be present in. Auscultat in g over the femoral arteries may elicit two cl in ical signs:. Chest X-ray may. The diagnosis is. Medical therapy in volves the treatment of any underly in g cause, if present. Treat the. Patients with aortic in competence also have a reduced life expectancy. If untreated,. Pulmonary valve diseases are rare, although occasionally patients may have in creased.
The most prom in ent symptom of pulmonary stenosis is shortness of breath on. The second. Pulmonary in competence is extremely rare. It may occur as a consequence of. The symptoms are shortness of breath on exertion. On exam in ation, an early diastolic murmur is heard at the left sternal edge, and the. The ma in diagnostic tests for pulmonary valve disease are echocardiography and. Many of the causes are potentially life-threaten in g, and therefore chest pa in is commonly used in the history-tak in g part of the exam in ation to assess the ability of the student to take a history which will help to differentiate between the major causes.
These can be classified as follows: The patient with chest pa in Cardiovascular disorders 1 cardiovascular causes — ang in a pectoris, myocardial in farction, pericarditis, aortic aneurysm, pulmonary embolism 2 respiratory causes — associated with chest in fection, pleurisy, tumours mesothelioma, bronchogenic carc in oma 3 musculoskeletal causes — bone, muscle 4 neurological causes — herpes zoster sh in gles. However, it is important to remember a few general po in ts when try in g to differentiate between them.
No matter what part of the body is affected, if a patient compla in s of pa in there are eight features of the pa in that must be ascerta in ed. By us in g these discrim in at in g features it is possible to reach a diagnosis relatively easily. The patient should be asked about the exact position of the pa in — for example whether it is central or peripheral.
There are many types of pa in sharp, crush in g, burn in g, pressure, crampy, etc. The exact character of the pa in often gives an important clue about its cause. Non-verbal cues are also helpful when the patient is asked to describe the type of pa in they have been experienc in g. Patients use a po in t in g f in ger when they mean a sharp pa in , a closed fist rest in g on the sternum when their pa in was felt as a pressure or heav in ess, or they grip the sides of their chest with their h and s and squeeze when the pa in is of a tight or crush in g nature.
This can be done by ask in g the patient to state on a scale of 0 to 10 how severe the pa in felt — where 0 is no pa in and 10 is the worst pa in the patient has ever experienced. Pa in from in ternal organs is represented and experienced on the body surface. It often radiates or moves in a characteristic way. For example, renal colic due to a stone in the ureter causes pa in in the lo in , which radiates around the flank and down in to the gro in in gu in al region. The patient should be asked to state how long the pa in lasted, in m in utes or hours. This is unhelpful as it is fairly mean in gless, so the patient should be politely asked to state in seconds, m in utes or hours for how long the longest episode of pa in was present.
This question is particularly helpful when try in g to differentiate between chest pa in due to ang in a pectoris and that due to myocardial in farction. Ang in a pa in seldom persists for more than 20 m in utes, whereas the pa in of a heart attack usually lasts for more than 30 m in utes. CASE 1 6 Onset. Patients should be asked to describe what they were do in g or had recently been do in g at the time of onset of the pa in. Ang in a pa in classically comes on dur in g exercise, but it may occur after a meal, dur in g an argument or awaken the patient from sleep see ang in a decubitus.
The pa in of myocardial in farction more often occurs after exercise or when the patient is at rest. These differ from onset but give similar in sight in to the cause of pa in. The pa in of myocardial in farction does not abate with rest or nitrates and is usually only relieved by opiate analgesics such as morph in e or hero in given by in jection. Severe pa in by itself can cause the patient to feel nauseated and vomit. Therefore if the patient has these symptoms this gives an in dication of pa in severity.
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Chest pa in due to ang in a pectoris is usually less severe and less likely to cause associated symptoms. On the other h and , the severe pa in of myocardial in farction is often associated with vomit in g. Patients may develop shortness of breath due to the development of venous congestion in the lungs, or they may experience symptoms of sympathetic nervous system over-activity, such as sweat in g, palpitations and The patient with chest pa in 5 a feel in g of panic or impend in g doom which is due to the hypotension and shock associated with myocardial muscle necrosis.
With a knowledge of these eight features of chest pa in it is possible to differentiate between the major causes and arrive at an accurate diagnosis in most cases. While the classic features of these conditions are described in the case studies, Table 1, on page 7 shows how the discrim in at in g features of chest pa in can be used to determ in e the most likely cause. Respiratory causes of chest pa in The lung parenchyma has no pa in sensory fibres, and therefore pa in is only associated with respiratory disease if other tissue is in volved.
Cardiovascular disorders 1 Tracheitis. If there is in fection or in flammation of the trachea, the patient experiences a sharp retrosternal pa in that is associated with and exacerbated by cough in g.
There may also be other signs of in fection, such as fever and purulent sputum. Infection or in flammation of the pleura, which can either occur in isolation or spread from underly in g lung disease, causes sharp chest pa in s that are usually felt in a localised area overly in g the area of in flammation. They can vary in severity, are made worse by deep in spiration or cough in g, and are eased by spl in t in g the ribs.
On auscultation a friction rub is heard over the site of the pa in. The rub has a squeak in g character, sometimes likened to the noise of chamois leather be in g rubbed. It is heard dur in g the same phase of in spiration and expiration, is not altered after the patient coughs, and will disappear if an effusion develops as the fluid separates the parietal and visceral layers of the pleura and this prevents them from rubb in g together. Pleurisy can be caused by viral or bacterial in fection, in filtration with tumours, or granulomatous disease such as sarcoidosis.
It can also occur in association with autoimmune disease eg rheumatoid arthritis. As mentioned above, tumours can metastasise to the pleura and cause pleuritic pa in. Mesothelioma is a primary malignancy that arises in the pleura, is usually slow-grow in g and is only associated with pa in when the tumour beg in s to erode in to the ribs or in volve in tercostal nerves.
Bronchogenic cancers in the early stages are completely pa in less and , like mesothelioma, will only cause pa in if they spread to in volve surround in g tissues such as pleura, ribs, vertebrae, pericardium or in tercostal nerves. CASE 1 6 Cl in ical Cases and OSCEs in Medic in e Cardiovascular disorders Musculoskeletal causes of chest pa in Chest pa in of musculoskeletal orig in is felt as a pleuritic-type pa in — that is, it is localised to one area of the chest, it does not radiate, and it is usually made worse by deep in spiration and cough in g.
The ma in features that help to differentiate it from pleurisy are as follows: 1 usually there is a history of trauma or exercise which caused the bone damage or caused muscle fibres to tear 2 pa in is elicited when the patient uses the muscle groups around the site of pa in 3 there is acute local tenderness — a feature that is not usually present in pleurisy. Neurological causes of chest pa in The commonest neurological cause of chest pa in is herpes zoster sh in gles. It is felt as a peripheral pa in , usually start in g in the back and radiat in g around the side of the chest in the classic unilateral distribution of a dermatome.
After four days a vesicular sk in eruption appears in the same area and eventually resolves. However, pa in and discomfort can persist in this area for up to 2 years post-herpetic neuralgia and may be very severe. On exam in ation, areas of depigmentation can often be seen which in dicate the site of the previous vesicular eruption. Def in ition Ang in a pectoris is a transient chest pa in that is due to myocardial ischaemia brought on by exercise and relieved by rest or subl in gual glyceryl tr in itrate GTN.
Causes Ang in a is most commonly caused by arteriosclerosis of one or more of the coronary arteries. Cl in ical features There is episodic central chest pa in that is characteristically felt as a tightness or crush in g sensation, or as a weight or heav in ess. The pa in is of variable severity and normally lasts for less than 20 m in utes. Acute attacks are relieved by rest or subl in gual nitrates. The amount of exercise that causes the pa in varies from one patient to another and is determ in ed by the severity of the coronary artery narrow in g. The distance the patient can walk on the flat or the number of stairs they can climb before the onset of pa in is known as their exercise tolerance.
After a meal the metabolic rate in creases and there is in creased dem and for blood flow in the splanchnic circulation. If in dividuals with myocardial ischaemia become excited, emotional or stressed, the in creased heart rate and peripheral resistance result in in creased oxygen dem and in the left ventricular muscle. Cardiovascular disorders 4 Cold temperature.
Patients who have ang in a are more likely to experience episodes of chest pa in in cold weather, due to in creased peripheral resistance. Occasionally patients are awakened from sleep by chest pa in. This is probably due to an attack of ang in a be in g precipitated dur in g rapid eye movement REM sleep. There are no signs specific to ang in a, but there may be cl in ical signs present associated with risk factors, such as obesity, hypertension, xanthelasma or cl in ical features of diabetes.
Investigations Dur in g episodes of pa in the ECG will show alterations in the ST segments in the st and ard and chest leads correspond in g to the area of ischaemia. Extension of ischaemia in to the in terventricular septum is in dicated by ST-segment depression in V1 to V3, and extension in to the lateral wall is in dicated by changes in V4 to V6. CASE 2 10 Cl in ical Cases and OSCEs in Medic in e Cardiovascular disorders Treatment 1 The patient should be given general advice about reduc in g risk, such as weight reduction, stopp in g cigarette smok in g and reduc in g cholesterol levels by switch in g to a low-fat diet together with lipid-lower in g drugs if in dicated.
These drugs reduce the peripheral resistance and thus reduce oxygen dem and in the cardiac muscle. This group of drugs slows the heart rate and reduces the force of contraction of the myocardial muscle fibres negative in otropic effect. This causes a reduction in the rate and force of contraction of the ventricles and therefore a decrease in oxygen dem and.
These drugs have a dual action. They ma in ly reduce peripheral resistance, and some also have a negative in otropic effect on the heart. Sometimes a s in gle agent is sufficient to control the pa in , but often a comb in ation of drugs is required. At the history-tak in g station 1 Ask all of the discrim in at in g questions for chest pa in see Case 1.