OSCE SPOTTER STATIONS Final Year Revision. By Dr Mehreen Jameel (FY1 General Medicine). Parkinson’s Disease Paget’s Disease Stomas AV Fistulas Neurofibromatosis Atrial Fibrillation Duputyren’s Contracture. Myeloma Ankle Oedema Hypercholesterolemia Dermatology Spotters.
OSCE SPOTTER STATIONSFinal Year Revision By Dr Mehreen Jameel (FY1 General Medicine)
Parkinson’s Disease Paget’s Disease Stomas AV Fistulas Neurofibromatosis Atrial Fibrillation Duputyren’s Contracture Myeloma Ankle Oedema Hypercholesterolemia Dermatology Spotters Past Spotters
History ADLs, handwriting, buttons & shoes, turning over in bed Inspection Tremor, masked face, posture, blink rate, drooling, walking aids Examine Rigidity- cog wheeling Tremor reinforced Bradykinesia by Loss of postural reflexessynkinesis Glabellar Tap Gait Festinant gait, reduced arm swinging, flexed posture, difficulty starting and stopping, turning, retropulsion Other tests Micrographia Parkinson’s Disease
Triad- tremor, rigidity, bradykinesia Differential Vascular events-strokes Orthostatic hypotension+ atonic bladder= MSA Dementia + vertical gaze= SRO Syndrome Kayser Fleisher rings = Wilsons disease Apraxic gait= communication hydrocephalus Antipsychotics, antiemetics Management MDT Approach Assess disability/cognition eg time to walk 10m, dress alone Medication when QoL affected eg L-Dopa + Dopa Decarboxylase Inhibitor, MR forms, newer drugs eg D agonist- Ropinirole, carbergoline Anticholinergics (help motor symptoms) Modafinil- daytime sleepiness (all in OHCM) Parkinson’s Continued
Briefly Examine legs Inspection: Sabre Tibia, lateral bowing of femur Feel: Warmth Complete examination by: Examine skull appearance (>55cm abnormal) Hearing defect (conductive- ossicles or VIII nerve compression OA involvement Raised JVP (HF, Hyperdy Circ) Kyphosis (Auscultate vertebral bodies for bruits) Diagnosis Normal Ca & Phosphate ALP Urinary hydroxyproline secretion Complications Bone- #’s, sarcomatous change 1% in 10 yrs Neurology- CN palsies, cord compression, headache, fits Cardiac- high output HF Management Symptomatic- analgesia, bisphosphonates, calcitonins Surgical- for OA Paget’s Disease
Radiological Features: Local bony enlargement, patchy cortical thickening, scelrosis, osteolysis, deformity Skull- “Honeycomb, Cotton wool” Vertebra- “Picture frames” sclerotic changes Pelvis- “Brim Sign”, thickening iliopectineal line, enlargement of pubic and ischial bones Paget’s Continued
Complications Early Haemorrhage Stoma Ischaemia High Output Obstruction (adhesions) Stoma retraction Delayed Dermatitis, Stoma Prolapsed Parastomal hernia Fistulae Obstruction Prepare for surgery Psychosocial, physical prep and support Clinical stoma nurse specialist Counselling How to manage stomas Stoma site avoided: Bony areas, umbilicus, scars, waistline skin fold & creases Stomas Continued
Dual Lumen Tunnelled Cuffed Catheters AV Fistulas Brachio-cephalic, Radio-cephalic, ulna-basilic 2-3 months arterialised “matured” Examination Scar, dilated veins, thrill, bruit Complications Venous stenosis, Thrombosis, Distal Ischaemia, infection, aneurysm. Types of dialysis Haemodialysis, haemofiltration, CAPD Indications Acidosis Electrolyte imbalance Ingestion Overload Uraemia ARF/CRF RRT
Renal Transplantation ESRF Cadaver/ live donor Lifelong immunosuppression CI- HIV, Cancer, Severe heart disease Complications Acute Rejection 3-6 mths Chronic Rejection > 6 mths Peritoneal dialysis Tenkoff catheter Complications Peritonitis Infection around catheter site Constipation Pleural effusions CI- Peritoneal adhesions, stoma, hernia, intra-abdo RRT Continued
NF1 (AD Ch 17) 1:2500 ≥ café au lait macules >5mm (prepubertal) >15mm (post-pubertal ≥ 2 neurofibromas or 1 plexiform Freckling Optic glioma ≥2 lisch nodules Osseous lesions First degree relative affected Management MDT Annual BP & cutaneous survey Genetic counselling Removal of dermal neurofibromas NF2 (AD Ch 22) 1:35000 Bilateral vestibular schwannomas First degree relative affected or Unilateral vestibular schwanoma Neurofibroma, meningioma, glioma, jeuvenille cataract Management Annual hearing test and MRI from puberty Clear scan 30 yr- unlikely inherited Neurosurgery Complication, hearing loss, facial palsy Neurofibromatosis
Examine pulse & comment: Radial-rate/rhythm Carotid- character/volume Discrepancy in radial and apical rate Examine CVS Differential- AF/ Multiple Ventricular Ectopics Causes: CARDIAC- Hypertension, HF, cardiomyopathy, mitral valve disease RESP- pneumonia, lung ca, sarcoidosis Other- hyperthyroidism, post-op, alcohol, PE Diagnosis + tests: ECG, U&Es, TFTs, Cardiac enzymes, echo Complications: Embolic Stroke, Intestinal Ischaemia, Acute Limb Ischaemia Management: Treat cause eg MI, PE, Pneumonia Are they Haemodynamically Stable? DC cardioversion or Drug Cardioversion. Acute AF/ Chronic AF (OHCM) ANTICOAGULATION, Warfarin (INR 2-3 / Aspirin 300mg + PPI), Warfarin CI. Ablative therapy Atrial Fibrillation
Screen CHD/ risk f/h CHD or 65yr <CHD Xanthomata, xanthelasmata 50yr <Corneal arcus Primary Hyperlipidaemia Pls be aware of 5 types (OHCM) Secondary Lipidaemia DM, Alcohol, renal failure, nephrosis, cholestasis, hypothyroidism Management Exclude familial/2º hyperlipidaemias Lifestyle advice, BMI, Omega3, exercise 1st Statins CI porphyria, myositis, LFTs (decrease synthesis) 2nd Fibrates (decreases absorption) Hypertriglyceridaemia, fibrates, nicotinic acid, fish oils Residual plaques- excision, cryotherapy Hypercholesterolemia
Inspection Swollen, bi/unilateral, hyperkeratosis, discoloured nails Palpate Pitting/ non-pitting Inguinal lymphadenopathy Completion Signs of right HF, JVP Hepatomegaly, fluid overload Differential swollen legs CENTRAL- RHF, hypoalbuminaemia, nephrotic syn, hypothyroidism PERIPHERAL- DVT, venous insufficiency 1º/2º lymphoedema 1º-congenital disease eg Milroy’s 2º- malignancy, infection, post surgery/radiotherapy Management Non Surgical- Stockings, elevation, Rx cellulitis Surgical- rare, done when occlusion of lymphatics Ankle Oedema
Progressive painless thickening of palmar fascia, skin puckering & teathering Ring + little finger Bilateral Hueston’s Table Tops Test +ve Causes Genetic (AD), Alcoholism, antiepileptics, DM, Peyronies Management Physio, splinatege Fasciectomy Fasciotomy Dermofasciectomy Complications Bleeding, scarring, recurrence, infection, neurovascular complications Duputyren’s Contracture
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