The H Book for 4th Year OSCE 2013

Preface
Years to years, stations are repeated in 4th year OSCE. This is because

1. The faculty has to find enough patients with the same medical conditions or signs (E.g. Usually 8 for the morning group and another 8 for the afternoon
group). Therefore, you can only expect to see common signs and conditions. Also, cranial nerves examination wont be tested due to difficulties in
getting patients with the same palsy. Exception in supplementary exam where only 1-2 patients are needed.
2. The patients have to be physically well enough. Therefore, you wont see acute signs. E.g. Central cyanosis, Use of accessory muscles. You wont get a
patient with acute decompensated heart failure or AAA. But you may get a stale patient with HF and less likely, an AAA repair scar.
3. Common things are common. It is easy to get 8 patients with aortic stenosis than to get 8 patients with mitral stenosis. (very rare and very soft murmur).
So it is unlikely that you will be asked questions about uncommon conditions such as mitral stenosis.
4. Only basic knowledge will be tested. Dont spend lots of time memorizing uncommon conditions.
It is not difficult to make a reasonable prediction as to what will be tested in the 4th year OSCE. In fact, the majority of stations are repeated every year. 6 out
of 8 stations will be repeated. Every year the faculty tends to introduce 2 slightly different or new stations. But of course they will be of common conditions.
You can expect:
General Med

1st Stations

2nd stations

Upper/Lower Neuro Examination

Cardio/Resp Examination

Fixed, that means 99.9% you will get it

Surgery

Vascular
- Fixed, that means 99.9% you will get it

ID

Case Discussion
-

Lab result interpretation

Fixed, that means 99.9% you will get it
Every year is pretty much the same and straight forward

Psy

History Taking
- Fixed, that means 99.9% you will get it

Geriatrics

History Taking or Functional/ Gait Assessment

Fixed, that means 99.9% you will get it

This is the station that tends to vary year from year.

- This could be an ENT station (neck lump, eardrum), abdominal
chest XR, CT
- An abdominal or thyroid examination is in fact unlikely, but
possible

Musculo

Fixed, that means 99.9% you will get it

This is another stations that tends to vary year from year

- Years ago it used to be an examination station, but not
anymore
- Now, you are likely be given a XR, can be pelvis, back
(mainly) or other parts of the body (less likely)
- Conditions: Fracture, Multiple myeloma, Arthritis

In summary, there are usually 3 examination stations, 2 history taking stations and 3 case discussion stations. It sounds scary. But 6 out of 8 stations are very
expectable and predictable and we are going to go through them one by one.
Examination Stations Patient + Examiner
Cardio

Respiratory

Upper/Lower Neuro

Aortic stenosis, Aortic regurgitation, Mitral

regurgitation

Vascular
-

Bypass scar, +ve Buergers sign, Venous or

arterial insufficiency
Rarely: Ulcers, Varicose veins

Bronchiectasis, Emphysema/COPD, Pulmonary

fibrosis, Pneumonectomy

Stroke, Peripheral polyneuropathy,

Parkinsons, Cerebral ataxia

These 4 stations are pretty much fixed and the conditions tested tend to reappear in every year. They
are very predictable.

History Stations Patient + Examiner

Psy
-

Geriatrics
Manic episode, Depression, Over treating
depression
Rarely: Borderline personality

These 2 stations are again very predictable.

MMSE, Falls, Incontinence (History +

Discussion only)
Functional Assessment, Assessment of Gait
(history, simple examination, discussion
included)

Case Discussion Stations

ID Examiner only, you wont see a patient

Musculo - Examiner only, a patient is unlikely

Surgery A patient may or may not be present

Quite straight forward

Usually not a problem to pass

XR interpretation
Examination is possible, but unlikely

Highly variable, Usually a new station

But again, a common condition

Table of Content

Chapter 1 - Cardio
-

In station, you always (yes, 100% sure) get to hear a murmur

Murmur tested: Ejection systolic murmur, Pansystolic murmur and Early diastolic (go to youtube and search to hear the murmur)
Mitral stenosis (Mid-diastolic murmur) wont be tested because it is quite rare
Make sure you know how to describe the murmur including heart sound, radiation, intensity, area heard
E.g. S1 (soft/loud/normal) and S2 (soft/loud/normal) are heard with an ejection systolic murmur, Loudest over the aortic area, Radiation to the carotid
arteries, Normal intensity
Remember to do all the maneuvers

Core Knowledge Must Know to Pass

DDx of Murmur
Ejection Systolic
(Heard in the Aortic Area)

Maneuvres
-

Aortic Stenosis (Pressure loaded apex

beat)
Pulmonary Stenosis
Hypertrophic cardiomyopathy (Double
impulses apex beat)

1. Leaning Forward and Deep Expiration

- Aortic Regurgitation (Early diastolic murmur) will be louder
2. Right Side Murmur and Left Side Murmur
- Inspiration increase in venous return Right side murmur louder
3. Hand Grip

May be innocent in children and pregnancy

Mitral Regurgitation (Volume Loaded Apex

Beat)
Tricuspid Regurgitation
Ventricular Septal Defect

- Mitral Regurgitation (Pancyctolic murmur) Louder on hand grip

4. Valsalva
- Hypertrophic Cardiomyopathy (Ejection systolic murmur) Louder

Mitral Valve Prolapse

Early Diastolic Murmur

(Heard in Aortic Area)

Aortic Regurgitation
Pulmonary Regurgitation

Mid-Diastolic Murmur
(Heard in Mitral Area)

Mitral Stenosis

Pansystolic Murmur
(Heard in Mitral Area)

Late Systolic Murmur +/Midsystolic Click

(Heard in Mitral Area)

Heart Sounds

Pulses Rate and Rhythm

1st Closure of the mitral and tricuspid valve

Rate

2nd

Closure of the aortic and pulmonary valve

3rd
- Normal if age <30
- High Pitch Constrictive Pericarditis, Restrictive Cardiomyopathy
- Low Pitch Dilated left ventricle with rapid ventricular filling or poor left
ventricular function
th
4 Always abnormal, atrial contractions against a stiff ventricle

Tachycardia Fever, Exercise, Emotion, Pain, Anemia, Heart failure,

Shock, Hyperthyroidism, Alcohol
- Bradycardia Sick sinus syndrome, Hypothyroidism, Beta-blockers, Sleep,
Hypothermia, Athletes
Rhythm
- Irregularly Irregular AF
- Regularly Irregular Sinus arrhythmias, Second degree heart block

Pulse - Characteristics
Normal

Small and Weak Pulses

Large and Bounding

Pulses

Causes: Aortic stenosis, Shock, Pericardial effusion

Forceful pulses that quickly disappers

- Causes: Heart Failure, Aortic Regurgitation, Patent ductus arteriosus

Bisferiens Pulses

Causes: Combined aortic stenosis and regurgitation

Pulsus Alternans

Causes: LVF

Slowing Rising /

Causes: Aortic stenosis

Causes: Aortic regurgitation, AV malformation, Patent ductus arteriosus

Anacrotic Pulses
Collapsing

Core Conditions Must Know to Pass

Cardiac Failure Left Ventricular Failure

Cardiac Failure Left Ventricular Failure

Symptoms
- External dyspnea, Orthopnea, Paroxysmal nocturnal dyspnea
Signs
- General: Tachypnea, Central cyanosis (due to pulmonary edema),
Cheyne-stokes breathing, Peripheral cyanosis (due to low cardiac
output)
- Pulse: Tachycardia, Low pulse pressure, Pulsus alternan

Signs
- Ankle, Sacral edema, Abdominal swelling
- Peripheral edema
- Pulse: Low volume
- JVP: Large v wave, Raised
- Apex Beat: Right ventricular heave
- Auscultation: Pansystolic murmur tricuspid

- Apex Beat: Displaced

- Auscultation: Left ventricular S3, Mitral regurgitation
- Lungs: Basal inspiratory crackles (pulmonary congestion)
Causes
- Ischemic heart disease, Cardiomyopathy, Valvular diseases, Aortic or
mitral regurgitation, Hypertension
- Precipitating Causes: Anemia, Thyrotoxicosis, AF
Aortic Stenosis

Aortic Regurgitation

Restricted left ventricular outflow, imposes a pressure load on the left

ventricle
Symptoms: Exertional chest pain, Exertional dyspnea, Exertional syncope
General Signs: May be nothing remarkable
Pulse: Small volume
Systolic thrill at the base of the heart

Auscultation: Ejection systolic murmur, Loudest over the aortic area,

Radiation to carotid arteries, Associated aortic regurgitation is common
Causes
- Degenerative calcification, Rheumatic fever, Congenital bicuspid valve,
HTN
- DM can speed up the process

Symptoms: in late stages of diseases Exertional dyspnea, Fatigue,

Palpitation, Exertional angina
General signs: Marfans syndrome
Pulse: Collapsing pulse, Bisferiens pulse (Severe aortic regurgitation with
aortic stenosis)
Neck: Prominent carotid pulsation

- Palpation: Apex beat displaced and hyperkinetic

- Auscultation: Early diastolic murmur
Causes
- Rheumatic fever, Congenital bicuspid, Ankylosing spondylitis, Marfans
syndrome

Mitral Regurgitation

Tricuspid Regurgitation (Not common in the exams)

Imposing a volume load on both left atrium and ventricle

Symptoms: Dyspnea, Fatigue
Pulse: AF is common
Palpitation: The apex beat is displaced, diffuse and dynamic, a
pansystolic thrill
Auscultation: S1 soft or absent, Left ventricular S3, Pansystolic murmur
loudest at the apex beat and usually radiating to the axilla

- Signs of pulmonary HTN

Causes
- Mitral valve prolapse, Degenerative changes, Rheumatic fever, Papillary
muscle dysfunction, Cardiomyopathy (Hypertrophic, Dilated,
Constrictive), Marfans, RA, Ankylosing spondylitis

JVP: Large v wave

Right ventricular heave
Pansystolic murmur maximal at the lower end of the sternum, Increases
in inspiration
- Abdomen: Pulsatile, Ascites, Pleural effusion
- Legs
Causes
Functional, Rheumatic fever, IE, Tricuspid valve prolapse, Right ventricular
papillary muscle infarction

Other examination to Do
- Urinalysis, Temperature chart, Fundoscopy (Roth spots in IE, or Diabetes/Hypertension), Lying and standing BP
-

Isometric hand grip: The murmur get louder (in mitral regurgitation) except aortic stenosis, hypertrophic cardiomyopathy, mitral valve prolapse
Learning forward: Aortic regurgitation, pericardial rub
Valsalva maneuver: Assess left-sided heart failure, murmur decrease in aortic stenosis, tricuspid regurgitation, Increased in hypertrophic cardiomyopathy,
mitral valve prolapse
Common Questions to be asked:
- 1. Is it a systolic or diastolic murmur?
- 2. What are you 3 DDx for the murmur?
-

3. What are the causes of the aortic stenosis/pulmonary stenosis.? (whatever DDx that you have mentioned)
4. What are the signs and symptoms if the patient is in a heart failure?

5. What are the differences between JVP and carotid pulses? (1. Fill from above 2. Double pulsation 3. Not palpable 4. Changes in posture 5. Heaptojugular reflex)
6. You may be asked about the classification of intensity of murmur.

Important Signs (some are not common, but good to know)

Hands

Clubbing
- Respiratory Causes: Cystic fibrosis,
Bronchiectasis, Lung carcinoma, TB,
-

Mesothelioma
Cardiac Causes: Endocarditis
GI Causes: IBD, Cirrhosis, Esophageal
carcinoma
Others: Hyperthyroidism

Splinter Hemorrhage
- Cardiac: Endocarditis
- Autoimmune: Scleroderma, SLE, RA,

Antiphospholipid syndrome, Psoriatic nail

trauma
Trauma (most common)

Osler Nodes
- Painful, Red nodules, Raised
- Causes: Endocarditis

Abnormal Radial Pulses (in the exam just say

normal, unless you are really certain)
- Irregularly irregular AF due to MI, Valvular
diseases, HTN, Thyrotoxicosis
- Jerky Pulse: Aortic regurgitation
- Anacrotic (small volume): Aortic stenosis
- Radiofemoral Delay: Coarctation of the aorta
- Radio-Radio Delay: Blockage of the
subclavian artery
Janeway Lesion
- Flat, Painless lesions
- Causes: Endocarditis
Head

Xanthomata
- Hyperlipidemia

Franks Sign / Earlobe Crease

Xanthelasmata

Mitral Facies

Signs of cardiovascular diseases

Associated with DM (diabetes mellitus)

High Palate
- Marfans syndrome
-

Hyperlipidemia

Mucous Petechiae
- Infective endocarditis

Associated with aortic and mitral

regurgitation

JVP - Normally less than 8cm

- a wave = Atrial contraction
-

Kussmauls Sign

Elevated JVP

Rise of JVP on Inspiration

- Constrictive pericarditis
- Cardiac Tamponade
- Right ventricular infarction

Causes
- Right ventricular failure, Tricuspid stenosis /
Regurgitation, Constrictive pericarditis, SVC
obstruction, Fluid overload

Chest
Forceful, Pressure Loaded Apex Beat

Double Impulse Apex Beat

Rosy Cheeks with a Bluish Tinge

Dilatation of the malar capillaries
Causes: Mitral stenosis, Pulmonary HTN

c wave = Contraction of the right ventricle

causing the tricuspid valve to bulge
x trough = Atrial relaxation
v wave = Venous filling
y wave = Emptying of atrium into the
ventricle

Causes
-

Aortic stenosis, HTN

Hypertrophic cardiomyopathy

Chapter 2 Respiratory
-

Make sure you know the DDx of different signs. The following signs are commonly seen or asked in the OSCE
Common Signs in the Respiratory Station: Wheeze, Crackles, Scars, Barrel chest, Reduced chest expansion
The following 4 conditions are used in OSCE not only because they are common (so very easy to find enough number of patients with the same
condition), but also they have really obvious and good signs
Common Conditions in the Respiratory Stations: Bronchiectasis, Emphysema/COPD, Pulmonary fibrosis, Pneumonectomy, so make sure you know the
meaning, signs and symptoms about them

Core Knowledge Must Know to Pass

Dull Percussion DDx

Hyper-resonant Percussion DDx

Consolidation
Pleural effusion (Stony dull)
Fibrosis
Collapse
Pleural Thickening

Pneumothorax
Hyperinflation E.g. COPD

Breath Sounds DDx

Added Sound DDx

Breath Sounds

Added Sounds

Bronchial Breathing: Hollow quality, Gap between inspiration and

expiration, occurs with tissue become firm/solid E.g. Consolidation,
Localized fibrosis, Above pleural effusion, Next to a pericardial effusion
Diminished Breath Sound: Asthma, COPD, Bronchial obstruction,
Pneumothorax, Pleural effusion
Silent Chest: Life threatening asthma

Wheeze: Asthma, COPD, Tumor, also in Cardiac asthma = LVF

Pulmonary edema
- Stridor: Inspiratory wheeze, high pitched, Tracheal obstruction
Crackles:
- Early inspiratory crackles COPD, Heart Failure
- Low Pitch Bronchiectasis
-

High Pitch Pulmonary edema, Lung fibrosis

Vocal Resonance

Sputum

Increased in Consolidation
Decreased in pleural effusion

Yellow/Green Infection E.g. Pneumonia, Bronchiectasis

Pink + Smelly Pulmonary edema
Bloody Malignancy, TB, Infection, Trauma
Black Carbon Specks Smoking

Pink Pulmonary edema (not really sputum, but hemoptysis)

Signs of Respiratory Distress

Different Pattern of Breathing

Tachypnea
Nasal flaring
Tracheal tug
Use of accessory muscle (Sternocleidomastoid, Scalene)
Intercostal recession
Pulsus Paradoxus (Pulmonary Causes: PE, Tension Pneumothorax,

Cheyne-Stokes Respiration
- Progressive deeper, then gradually decrease, then temporary stop
- Causes: Brain stem lesions, Heart failure, Pulmonary edema, High
altitude, Chronic hypoxemia
Kussmaul Breathing
- Stimulation of the respiratory center by acidosis

Cardiac Causes: Cardiac tamponade, Constrictive pericarditis, Pericardial

Effusion, Cardiogenic shock)

- Causes: Metabolic acidosis, Diabetic ketoacidosis

Biots Breathing
- Breathing that is irregular in timing and depth

Tracheal Deviation

Vocal Resonance

Towards collapse, pneumothorax

Always from pleural effusion, tension pneumothorax, pneumonectomy

Increased in consolidated lungs

Decrease in pleural effusion?

Core Conditions Must Know to Pass

Bronchiectasis

Emphysema

Meaning
- Irreversible dilatation of the bronchial tree resulting in an impaired
clearance of mucus and chronic infection
- A history of chronic and purulent sputum since childhood is virtually
diagnostic
Signs

Meaning
- Dilatation of the alveoli / air sac
Signs
- Pink puffer (result from hyperinflation)
- Barrel chest
- Pursed lip breathing (decrease the end-expiratory pressure, helps to

Systemic Signs: Fever, Cachexia, Sinusitis

minimize air trapping)

Clubbing and Cyanosis (if severe)

Sputum: Large amount, purulent, Foul smelling
Low pitch coarse inspiratory crackles over the affected lobe
Signs of Severe Bronchiectasis: Copious sputum, Hemoptysis, Clubbing,
Widespread crackles, Signs of respiratory failure, Cor pulmonale (signs of
right heart failure)
Causes

- Use of accessory muscles

- Palpation: Reduced chest expansion, Hyper-inflated chest
- Percussion: Hyperresonant
- Breath Sounds: Decreased, Early inspiratory crackles
- Wheeze is often absent
- Signs of right heart failure in very late stage
Causes

Congenial: Cystic fibrosis, Primary ciliary dyskinesia

Acquired: Infections in childhood (whooping cough, Pneumonia,
Measles), TB, A bronchial adenoma

Smoking
Occasionally alpha-1-antitrpsin deficiency

Pulmonary Fibrosis

Pneumonectomy

Meaning
- Scarring of lung

Meaning
- Removal of lungs

Signs
- Cyanosis, Dyspnea

- Lobectomy = Removal of one lobe of lung

Indications

Clubbing may be present

Dull percussion
High pitch inspiratory crackles over the affected lobes

- Lung cancer
- In the past: TB
Symptoms

Signs of associated connective tissue disease E.g. RA, SLE, Scleroderma

Shortness of breath

Causes

- Counterclockwise rotation of the heart and great vessels

- Compression of bronchi
- Pulmonary hyperplasia and hyperinflation, Diaphragmatic elevation
Signs
- Tracheal deviation is almost always in Pneumonectomy, deviated
away from the side of surgery
- Expansion will be reduced over the side of surgery

Upper Lobe: Schart (Silicosis, Sarcoidosis, Coal workers

pneumoconiosis, Histiocytosis, Ankylosing spondylitis, Radiation, TB)
Lower Lobe: Rasco (RA, Asbestosis, Scleroderma, Cryptogenic fibrosing
alveolitis, Medications: Methotrexate, Cyclophosphamide,
Nitrofurantoin)

Changes in mediastinum position (shift to the operated side)

- Percussion Hyperresonant over the side of surgery

- Breath sounds harsher over the side of pneumonectomy
Differences between signs of Lobectomy and Pneumonectomy
- Signs of lobectomy are confined to lobe which is removed and tracheal is
central
Other examinations included sputum, O2 saturation, temperature chart, peak expiratory flow, forced expiratory time (normally <3 seconds)
Common Questions to be asked
-

1. What are the DDx of crackles? Lung fibrosis, Bronchiectasis, COPD, Heart Failure
2. What are the signs that suggest of the DDx? (Especially for HR)
3. What are the causes of the Lung fibrosis, Bronchiectasis, COPD?

Important Signs

Clubbing
- Respiratory Causes: Cystic fibrosis,
Bronchiectasis, Lung carcinoma, TB,
Mesothelioma

Asterixis/Flapping Tremor
- Liver damage abnormal ammonia
metabolism Hepatic encephalopathy E.g.
Liver failure, Cirrhosis

Cardiac Causes: Endocarditis

GI Causes: IBD, Cirrhosis, Esophageal
carcinoma
Others: Hyperthyroidism

Carbon dioxide retention E.g. COPD

Muscle Wasting of Hands

- Compression of the brachial plexus by a lung
tumor

Horners Syndrome
- Ptosis, Anhydrosis (Loss of sweating), Pupillary miosis (Constricted pupils)
- Causes: Pancoast tumor (a tumor of the pulmonary apex) presses on the sympathetic chain
Other Causes
- Central Causes: Lateral medullary syndrome, Multiple sclerosis, Brain tumors, Cervical cord tumors,
-

Syringomyelia
Peripheral Causes: Carotid aneurysm, Internal jugular vein cannulation, Carotid dissection, Neck
Trauma

Nasal Polyps
- Associate with asthma

Pigeon Chest
- Chronic childhood respiratory disease

Funnel Chest/Pectus Excavatum

- Causes: Congenital
- Usually an aesthetic problem, may cause
impairment of function of cardiovascular
system

Barrel Chest
- COPD, Asthma

Chapter 3 Upper and Lower Neuro Examination

- In this station, you are likely to get patients with stroke, Peripheral polyneuropathy, Parkinsons, Cerebral ataxia
- Very hard for them to find patients with other conditions, brain tumor patient is possible
- This is one of the hardest stations of the exam as you need to memorize a lot of basic knowledge to be safe to pass.
3 Questions that they will definitely ask
- 1. Is this a lower or upper motor neuron lesion? Why?
- 2. What is the location of the lesion? Why?
- 3. What are the possible causes?
Core Knowledge Must Know to Pass (Just memorize)
Answering Q1
Upper Motor Neuron Lesion

Lower Motor Neuron Lesions

Caused by Lesions from the cortex, through the internal capsule, brain
stem, spinal cord to the anterior horn cells
Increased tone (spasticity), Increased reflexes
Babinski sign = Plantars are upgoing

Caused by lesions from anywhere from the anterior horn cells, nerve
roots, plexi to the peripheral nerves
Muscular wasting and fasciculation
Decreased tone

Clonus

Reduced reflexes

Arm drifting E.g. Cerebellar signs

Note: Can mimic LMN lesion in the first few hours before the hyper-reflexia
and increased tone develops

Note: In primary muscle disease, there is a symmetrical loss and no

sensory loss

Answering Q2 (just memorize the following)

Upper Motor Neuron Lesion

Lower Motor Neuron Lesions

Further history and physical examination are required for me to accurately

Further history and physical examination are required for me to

locate the lesion, For example

If the lesion is on the Cortex, I would expect
- Cortical sensory loss E.g. Agraphasthesia, Astereognosia, Loss of 2 points
discrimination
- Arms flexion, External rotation of the leg
If the lesion is on the Internal Capsule, I would expect

accurately to locate the lesion, For example

If the lesion is on the peripheral nerve, I would expect
- Radial Nerve: Wrist drop, loss of sensation over the anatomical snuff
box
- Median Nerve: Weakness of the abduction of thumb, loss of
sensation of the palmar side of the thumb, index ginger and middle

Hemiplegia

finger and lateral half of the ring finger

Ulnar Nerve: Claw 4th and 5th finger, loss of sensation of the little
finger and the medial half of the ring finger
Brachial Plexus:
Complete: LNM signs of the whole limb, sensory loss of the whole
limb, Horners syndrome
Upper Lesion: Waiters tip, Sensory loss over the lateral aspect of the
arm

- Arm and legs are equally affected and are quite weak
If the lesion is on the Thalamus, I would expect
- Unilateral loss of all form of sensation E.g. Loss of sensation of the same
side of the head and the body
If the lesion is on the Brainstem, I would expect
- Mid-Brain: CN3,4 Ptosis, Diplopia, Non-reactive pupil
- Pons: CN5,6,7 LMN facial weakness

Medulla: CN8,9,10,11,12 Abnormalities of these cranial nerves, Medullary

syndrome
If the lesion is on the Cerebellum, I would expect
- Head: Nystagmus
- Hands: Dysdiadochokinesia, Past pointing, Arm drifting
- Leg: Ataxia, Hypotonia, Heel shin coordination
If the lesion is on the Basal Ganglia, I would expect

whole leg and lateral side of the lower leg, Motor: Footdrop
- Common Peroneal Nerve: Loss of sensation of the dorsum side of the
foot, Footdrop
If the lesion is on the nerve root (E.g. Nerve root compression), I would
expect
- A sharp shooting pain in the dermatomical distribution
- If only a single nerve root is affected may not have sensory loss

Bradykinesia, Rigidity, Tremor

Postural instability, +ve Glabellar reflex, Lack of facial expression,
Micrographia

Lower Lesion: True claw hand, Sensory loss over the ulnar side of the
hand and forearm, Horners syndrome
Lateral Cutaneous nerve of the Thigh: Loss of sensation on the lateral
side of the thigh, No motor loss
Femoral Nerve: Loss of the sensation on the inner thigh and leg,
Motor: Weakness of keen extension, Absent knee jerk
Sciatic Nerve (L45, S12): Loss of sensation of the posterior side of the

because of the overlapping of the sensory distribution

Could it be a spinal cord compression? (good to know, but I dont think you will How to work out the location of a brain tumor? (good to know, but I dont
be asked)
think you will be asked)
-

A spinal cord compression causes LMN signs at the lesion level and UMN
signs below the level

Parietal Lobe Dominant Signs

Acalculia, Agraphia

There are sensory and motor changes

Sensory Changes
Complete Transaction: Loss of all sensation below the level

Left-Right disorientation
Finger agnosia Inability to name the fingers
Parietal Lobe Non-Dominant Signs

Hemi-Section (Brown Sequard Syndrome): Loss of vibration and

Agraphaesthesia Inability to recognize the number written on skins

proprioception on the same side as the lesion, Loss of temperature and

Astereognosia Inability to recognize objects in hands

pain on the opposite side of the lesion

- Posterior Column: Proprioception and vibration loss
Motor Changes
Motor Changes in Cervical Compression
- For cervical fracture autonomic dysreflexia = abnormal increase in BP,
sweating
- C1-C2: often result in loss of breathing mechanical ventilation or phrenic

Tactile Extinction Inability to feel the touch on both sides at the

same time
Dressing Apraxia Inability to dress
Constructional Apraxia Inability to copy a drawn object
Lower Quadrant Homonymous Hemianopia
Frontal Lobe
Skilled movements, Planned movements, Voluntary movements

nerve pacing
C3: Loss of diaphragm function and require use of a ventilator
C4: Significant loss of function of the biceps and shoulders
C5: Complete loss of function at the wrist and hands
C6: Limited wrist control, Complete loss of hand function
C7 and T1: Some movement of the hands and fingers, typically cannot
handle daily living

Emotion changes, Memory problems

Judgment
Disinhibition
Careless about personal hygiene
Grasp reflex
Palmomental reflex Contraction of the mentalis muscle
Pout and snout reflex

Motor Changes in Thoracic Compression UMN signs of the lower limbs

- Result in paraplegia
- Functions of the hands, arms, necks and breathing are usually not affected
- T1-T8: Inability to control the abdominal muscles, Trunk instability, the
lower the level the less severe the effects
- Typically lesion above T6 can result in autonomic dysreflexia
- T9-T12: Partial loss of trunk and abdominal muscle control

Anosmia
Gait Apraxia Feet typically as if glued to the floor
Temporal Lobe
Upper quadrant hemianopia
Short and long term memory
Dysphasia
Occipital Lobe

Motor Changes in Lumosacral Compression

- Decrease control of the legs, hips, urinary system and anus
- Sexual dysfunction (S2) is with sacral spinal segments, also with bowel and
bladder control E.g. Urinary retention and fecal incontinence
- Hip Flexion: L2, L3
- Hip Extension: L5, S1, S2
- Hip Abduction: L4, L5, S1

Alexia Inability to read

Homonymous hemianopia

Hip Adduction: L2, L3, L4

Knee Flexion: L5, S1

Knee Extension: L3, L4
Plantar Flexion: S1, S2
Dorsiflexion: L4, L5
Ankle Eversion: L5, S1
Ankle Inversion: L5, S1 (E.g. Stop me turning your food outwards)

Sensory Pattern (I dont think you will be asked, just skip this, unless you are that hard-working)
-

Glove and stocking loss

- Peripheral polyneuropathy
Causes
- See below

Radial Nerve: Wrist drop, Loss of sensation over

the anatomical snuff box
Medical Nerve: Weakness of the abductor pollicis
brevis of the thumb, Loss of sensation on the
palmar side of the thumb, index finger and
middle finger, and lateral half of the ring finger
Ulnar Nerve: Claw 4th and 5th finger, Loss of

sensation of the little finger and the medial half

of the ring finger
Brachial Plexus:
- Complete: Rare, LMN signs of the whole limb,
Sensory of the whole limb, Horners syndrome
- Upper Lesions: Waiters tip, Sensory loss over the
lateral aspect of the arm
-

Lower Lesions: True claw hand, Sensory loss over

the ulnar side of hand and forearm, Horners
syndrome

Lateral Cutaneous Nerve of Thigh: Loss of

sensation on the lateral side of the thigh,
No motor loss
Femoral Nerve: Loss of sensation on the
inner thigh and leg, Motor: Weakness of
knee extension, Absent keen jerk
Sciatic Nerve (L4,L5,S1,S2): Loss of
sensation of the posterior side of the
whole leg and lateral side of the lower leg,
Motor: Footdrop
Common Peroneal Nerve: Loss of
sensation of the dorsum side of the foot
drop
Causes: DM, Entrapment, RA, Vasculitis

Bilateral loss of all forms of sensation below a definite

level
- Complete spinal transection
- If only pain and temperature loss anterior cord
lesion

Saddle loss in
cauda equina

Loss of vibration and proprioception on the

same side of the lesion, loss of pain and
temperature to the opposite side
- Brown Sequard Syndrome
Central Cord Syndrome

Posterior Cord Syndrome

- Loss of vibration and proprioception only

+ Loss of pain and temperature

Anterior Cord Syndrome

- Loss of motor function below the level of injury, Loss

Central Cord Syndrome

- Greater motor impairment in the upper
arm to the lower limbs
- Loss of sensation below the level of injury

of pain and temperature

Preservation of the touch and proprioception

(Dorsal column is spared)
Causes: Anterior spinal artery occlusion

Cause = Syringomyelia

Thalamus or upper brainstem lesions

- Unilateral loss of all form of sensation

Urinary retention is common

Lateral medullary syndrome

-

Pain and temperature loss on one side of

the face and opposite side of body

Sacral Sparing,
Loss of sensation of many segments
- Intrinsic cord compression

Answering Q3
Causes of Hemiplegia

Causes of Space Occupying Lesion

Vascular: Cerebral hemorrhage, Stroke

Tumors

Traumatic: Cerebral laceration, Subdural hematoma

Neoplastic: Glioma-meningioma
Infective: Encephalitis, Meningitis, Brain abscess
Congenital: Cerebral palsy
Demyelination: Disseminated sclerosis

Vascular: Aneurysm, Embolism, Thrombosis

Intracranial bleeding
Abscesses
Traumatic

Causes of Nerve Peripheral Nerve Lesions

Causes of Peripheral Polyneuropathy

Entrapment

Idiopathic

DM
Vasculitis

Genetic: Charcot-Marie-Tooth Disease

Alcohol
DM, Chronic renal failure
Guilian Barre Syndrome
Vitamin B Deficiency
Connective tissue disease: Lupus, Sarcoidosis, Multiple sclerosis
Drugs E.g. Phenytoin. Nitrofurantoin

Causes of Nerve Root Compression

Disc herniation
Bony compression
Malignancy
Infection
Aneurysm

Power Grading

Reflexes

0: Paralysis

Biceps Jerk: C5, C6

1: Flicker of contraction
2: Movement when no Gravity
3: Movement Against Gravity
4: Movement Against Resistance
5: Normal Power

Triceps: C7, C8
Brachioradialis: C5, C6
Knee Jerk L3-L4
Ankle Jerk S1-S2
Plantar Reflex L5, S1, S2

Parkinsons Disease

Cerebral Ataxia

- Death of the dopamine generating cells in the substantia nigra

Signs and Symptoms
- Motor: Resting tremor, Bradykinesia, Rigidity, Postural instability
(typical in the late stages, leading to impaired balance and frequent
falls), +ve glabellar reflux, Lack of facial expression, Micrographia
- Neuropsychiatric: Disorders of speech, cognition (Executive

- Gross lack of coordination of muscles movements

- Types: Cerebellar, Sensory and Vestibular
Cerebellar
- Dysfunction of vestibulocerebellum: Impairs the balance and the
control of eye movements, postural instability, tend to separate the
feet on standing, +ve Rombergs test unstable even with eyes

dysfunction, fluctuations in attention, memory), mood behaviors,

open

thought, Depression, Anxiety, Apathy, 4% of patients with

hallucination or delusions
- Others: Sleep problems (Disturbances in REM sleep), alterations in
the autonomic nervous systems
Managements
- Levodopa
- Dopamine agonists

- Dysfunction of the spinocerebellum: Wide based drunken sailor gait,

uncertain starts and stops, lateral deviation
- Dysfunction of the cerebrocerebellum: Intention tremor, Writing
abnormalities (large, unequal letters), Dysarthria (slurred speech,
sometime with explosive variation in voice intensity),
Dysdiadochokinesia,
Sensory Ataxia

- Anticholinergics
- COMT inhibitors
- MAO-B inhibitors
Gait and Movement
- Shuffling: small steps, difficulty in initiating, difficulty stopping, lack
of normal hand swing
- Braykinesia: Decrease in speed, may be the result of a lesion in the

- Due to loss of proprioception, caused by dysfunction of the dorsal

columns of spinal cord, also dysfunctions of cerebellum, Rarely in
thalamus and parietal loes
Causes 3 types of ataxia have overlapping causes
- Focal lesions: Stroke, Brain tumors, MS
- Exogenous substances: Alcohol
- Radiation poisoning

nigrostriatal movements, difficulty getting out of chair

Tremor
- Resting tremor, often asymmetrical, pill rolling
Tone
- Cogwheel rigidity, tone in increased with an interrupted nature
- Signs are often asymmetrical early in the course of Parkinsons
disease

- Vitamin B12 deficiency

- If isolated sensory ataxia peripheral neuropathies
- Hereditary
- Wilsons disease
Treatments
- Physiotherapy, OT
- Depression

Face
- Lack of facial expression, absence of blinking
- Speech is monotonus, soft and faint, lacking intonation
- Isolated failure of upward gaze is a feature
Writing
- Micrographia
Causes of Parkinsons Syndrome

Idiopathic = Parkinsons disease

Drugs E.g. Methyldopa

Post-encephalitis (very rare)
Wilsons disease
Syphilis

Peripheral Neuropathy

Hemiplegia

Causes of Neuropathy (Peripheral Neuropathy)

- Idiopathic

- In elderly, strokes are the most common cause

- In children, majority has no identified causes
Causes
- Stroke (Hemipleia is common when the stroke affects corticospinal
tract)
- A lesion that results in hemiplegia occurs in brain or spinal cord
- Features: Weakness, decreased movement control, clonus, spasticity,

Alcohol
DM
Guilian-Barre Syndrome
Vitamin B12 Deficiency
Connective tissue disease
Heavy Metals
Drugs E.g. Phenytoin

Total paralysis of the arm, leg and trunk on the same side of the body
More severe than hemiparesis less marked weakness

Who Gets Neuropathy

- Risk Factors: DM, Autoimmune disease, HIV (immune suppression),
Poor nutrition (Vitamin B deficiency)
Symptoms
- Motor Muscle weaknes
- Sensory Glove and stocking distribution
- Autonomic Abnormal pressure and HR, constipation, bladder

exaggerated reflexes
- Vascular Stroke
- Infective Meningitis
- Neoplastic Glioma-meningioma
- Traumatic
- Congential Cerebral palsy
- Disseminated MS

dysfunction, diarrhea, Incontinence, Sexual dysfunction

Signs

Pathogenesis
- Corticospinal tract is damaged

- Injury manifested on the opposite side of the body

Signs and Symptoms
- Difficulty with gait, balance, standing

Bilateral Footdrops
Gloves and stocks loss of sensation
Weakness of ankle

Diagnosis

Difficulty with motor activity

Medical history, examination, nerve conduction studies E.g.

Electromyography
Treatment
- Antidepressants Relieve neuropathic pain
- Anticonvulsants
- Opoids

Muscle spasms

- Difficulty with speech

- Dysphagia
- Depression
Treatments
- Physiotherapists
- Occupational therapists
- Lack of mobility, complications can occur E.g. Loss of fitness, joint
stiffness, bed sores, DVT
Prognosis
- Not a progressive disorder
- Many have limited recovery

Blood Supply of the Brain

Good to know

Chapter 4 Vascular
- Things to know: Venous and arterial insufficiency (signs and symptoms), Ulcer types, Absence pulses
- Usually a patient with + Buergers test, scars from previous surgery
- Need to know about the vascular anatomy and the anatomy of palpation E.g. able to describe the location you are palpating for the pulse
- This is quite an easy station to pass
Commonly Asked Questions:
- 1. Is it a venous or arterial insufficiency? Or both?
- 2. Where is the location of the blockage? (need to know the vascular anatomy)
-

3. Does he require surgery? (only if pain at rest)

4. How to tell between different types of ulcers?
5. What are the DDx of a swollen leg?

Core Knowledge Must Know to Pass (make sure you know the vascular anatomy)
Venous Ulcer

Arterial Ulcer

Result from valve incompetence, thrombosis or

vein thrombophlebitis, failed calf pump

A contraindication to compression therapy

Result from an inadequate blood supply more common on pressure

Venous hypertension ischemia

Usually superficial
Moderate to heavy exudate
More proximal
Irregular
Surround skin: Hyperpigmentation, dermatitis
May be painless

points E.g. lateral

malleolus
Pain at rest
More distal
Regular
Surrounding skin: Blanched, Shiny, Tight
Punched out, Very painful, Demarcated

Note: Know what is ankle brachial index

Venous Insufficiency (Signs)

Arterial Insufficiency

Dark bluish/purple discoloration,

Long standing stasis leads to deposition of hemosiderin dark color

Pale skin due to underperfusion

In Buergers test, gravity enhances the arterial inflow and the skin
become red
Gangrene may be seen

Shiny skin and loss of hair indication of arterial insufficiency

Cellulitis will cause skin to appear bright red

AAA

Different Types of Ulcers

Exceeding the normal diameter by more than 50 percent

90% below the level of kidney
Can extend to include iliac arteries
Common between age 65-75, Men, Smokers,
Surgery is >5.5 cm in diameter

Venous Leg Ulcers

- 70% of all leg ulcers are venous ulcers, leg is swollen, skin surround ulcer
is dry, itchy, sometimes brownish in color, Eczema may appear, usually
painless unless infected, often located just above the ankle, typically on
the medial side

Signs and Symptoms: Asymptomatic, If expands (pain in chest,

pulsating sensations), Complications (rupture, embolization, fistula
to the IVC or duodenum), Abdominal mass, Bruits, If ruptured
(hypovolemic shock, tachycardia, cyanosis, Grey Turners sign)
Causes: Smoking, Genetics, Atherosclerosis, Infection, Trauma,
Arteritis
Diagnosis: US, CT, MRI

Screening: US in men age 65-75, 4.5-5.4 cm (screen every 3 months)

Management: Conservative (smoking, surveillance), Medications (BP,
Lipids), Surgery (open surgery symptomatic or ruptured aneurysms,
endovascular aneurysm repair insertion of a Y shaped stent)

Arterial Ulcers
- 10% of all leg ulcers
- Feet and legs often feel cold, may be pale or bluish, shiny appearance,
can be painful
- Causes: Narrowed arteries
Diabetic Ulcer
- Painless and are associated with reduced sensation in the surrounding

Causes: Venous hypertension (valve incompetence)

Preventions: Regular exercise, Sit with legs raised, Avoid sitting with legs
crossed, Compression stocking
Diagnosis: Ankle brachial pressure index (<0.9 = arterial disease, False
ve in stiff arteries)
Treatment: Cleaning, Dressing, Compression dressings, Elevation
(Vascular surgery for arterial ulcers)

skin
Others things you may want to know
Diabetic Neuropathy and Diabetic Foot Care
- Amputation is common
- Signs: Examine foot regularly, Ischemia (absent dorsalis pedis pulse,
critical toes), Neuropathy (Ulcer, Infection)

Varicose Veins
- Veins that are enlarged and tortuous
- Most common in the superficial veins of legs
- Often itchy

Neuropathy: Decreased sensation with a glove and stocking

distribution, absent ankle jerks, claw toes, loss of transverse arch
Ischemia: Foot examination on mirror, Removal of callus, Treat fungal
infection
Foot ulceration: Usually painless, Punched out, Area of thick callus,
Superadded infection, can cause cellulitis, abscesses, osteomyelitis
Management: Removal of callus (thick skin in response to irritation),
Relieve high pressure area (E.g. Bed rest, Shoes), Infection
(Benzylpenicillin + Flucoxacillin +/- Metronidazole), Surgical
debridement
Diabetic Neuropathies: Pain relief, Mononeuritis multiplex (E.g. III
and VI cranial nerve, treat with corticosteroids), Autonomic
neuropathy (Posture BP drop, urinary retention, erectile dysfunction,
diarrhea, Fludrocortisone used for orthostatic hypotension)

Non-surgical treatment include: Sclerotherapy, Stockings, Elevation

of legs, Exercise, Tradition surgery (remove the affected veins),
Newer less invasive treatments (Seal the main leaking vein on the
thigh)
Signs and Symptoms: Heavy legs, Ankle swellings, Brownish-blue
shiny skin discoloration, Itch
Complications: Pain, Heaviness, Inability to walk, Dermatitis, Ulcers,
Bleeding from trauma, Blood clotting, Fat necrosis
Causes: More common in women, Linked to genetics, pregnancy,
obesity, aging, menopause, prolonged standing, crossing legs
Treatment: Conservative (Elevating the legs, exercise, compression
stockings, Ibuprofen for superficial thrombophlebitis) Surgical
(Stripping = Removal of part of the saphenous main trunk) Nonsurgical (Sclerotherapy, Endovenous thermal ablation)

Loss of pain repeat joint injury

Deep Vein Thrombosis

- Commonly affect femoral veins, popliteal veins or deep veins of the
pelvis
- Symptoms: Painful, swollen, red, warm, superficial vein may be
engorged
- Most serious complications: PE

If varicose presence
1. Auscultation
2. Trendelenburgs test: Lie the patient and empty the vein by asking to
raise the legs, Place 2 fingers on the saphenofemoral junction (or put
a tourniquet), Ask to stand (If the vein refills rapidly when remove
the fingers = +ve indication of SF incompetence), If not do the

A late complications: Post-thrombotic syndrome = edema, pain or

Perthes test

discomfort
Virchows triad = Stasis, Hypercoagulability, Injury to endothelium
Causes: Compression of the veins, Physical trauma, cancer, infection,
stroke, HF, Nephrotic syndrome
Risk: Surgery, hospitalization, immobilization, orthopedic casts,
prolonged flight, smoking, obesity, age, estrogen, pregnancy
Most common test of DVT: D-dimer, Doppler US

3. Tourniquet test: Instead of using the finger, a tourniquet is used, By

putting it at different levels, the level of incompetence can be
identified
4. Perthes test: Tourniquet placed in the mid-thigh, the patient walks
for 5 mins (If the saphenous veins collapse deep veins and
communicating veins are patent)
5. Tap test: Ask the patient to stand, place 2 fingers on the

Signs and symptoms: Pain, swelling, redness, leg can be pale, cool or
cyanosed, important to consider PE
History: Ask use of oral contraceptives, flight, IVDU, History of
miscarriage (antiphospholipid syndrome)
Causes: Surgery (heparin prophylaxis), Tobacco usage and air travel
Diagnosis: Intravenous venography (rarely performed), Doppler US,
D-dimer, Coagulation studies

saphenofemoral junction, Tap on the varicose vein, If impulses

transmitted to the fingers = Incompetence of superficial valves
6. Cough Impulse Test Put fingers in the great saphenous opening
(medial to the femoral vein) and ask to cough a fluid thrill is felt if
the saphenofemoral valve is incometent

Management: Anticoagulants, Thrombolysis (reserved for extensive

clot), Thrombectomy, Compression stockings, IVC filter

Important Signs

Chronic Arterial Insufficiency with ulcers

- Shiny, Hairless appearance (seen with arterial insufficiency)

Asymmetric Leg, Swelling due to Deep Venous Thrombosis

Nail thickening and deformity, occurs with arterial insufficiency, also

Venous Insufficiency

with fungal infections

Venous Stasis Ulcer

Important to check the sole and between the toes

To examine (My consultant suggested me to use 6 finger to feel for it E.g. Middle 3 finger from each hand, so you definitely wont miss it, and it looks
professional according to him)

Chapter 5 Geriatrics
-

Things will be tested: MMSE, Falls, Incontinence, Assessment of Gait, Functional Assessment
Generally this is not a difficult station to pass, just make sure you know all the above topics
There will usually be a patient, you will take a history and have a brief discussion with the examiners
In the assessment of gait, only task to do is to assess the gait, then spend 6 mins to discuss the gait (that mean they focus more on discussion, rather
than history taking), please read carefully and follow the instruction written
Make sure you know how to describe the gait and talks about different types of gait

Core Knowledge Must Know to Pass

Fall Risk Assessment

Assessment of Gait

1. Fall Risk Assessment

DDx: Vasovagal Syncope (emotion, fear, standing too long), Cough syncope,
Micturition syncope, Orthostatic hypotension, Epilepsy, Arrhythmias, Drop
attacks, Hypoglycemia, Loss of balance (Parkinsons, Alzheimers, Peripheral
neuropathy), Vertigo
- My name is Anthony. Can I have your name please? I know that you have

2. Assessment of Gait
Gait
General inspection (with shoes taken off):
- Normal standing posture, Muscular wasting, Scars, Valrus or valgus
deformity, Erythema, Swelling, Pigmentation, Loss of hair, No ulcers
Walking:

recently had a fall. And I have been asked to come to take a history of it.
Is that alright?
Background
- When did it happen? Where did it happen?
- How did it happen? Did you trip over?
- Did you lose your consciousness? Or a fall to the ground without losing
consciousness?

What were you doing when you fall?

Any warning signs? For example, dizziness? Closing of the vision?
Anything may have triggered the fall? For example, getting up from
sitting? Standing for too long? Coughing? Micturition? Too hunger?
After the Fall
- What happen after the fall? Were you able to get up quikly?

There is no difficulty in initiating the gait

Unlikely to be a hemiplegic gait Arms are not in flexion and legs are not
in extension, No circumduction while walking
Unlikely to be a diplegic gait Hips and knees are not flexed, Legs are not
internally rotated, No circumduction of legs
Unlikely to be a neuropathic gait There is no footdrop or high stepping
Unlikely to be a myopathic gait Pelvis dropping to the non-weight
bearing gait
Unlikely to be a Parkinsonian Gait / Festinating Gait There is no rigidity,
bradykinesia. No difficulty in initiation, steps are not small, turning like a
statue
Unlikely to be a cerebellar ataxic gait Feet are not widely separated,
There is no unsteadiness, Body does not tend to bend forward or

Did you injure yourself because of the fall?

backward, Uncertain starts and stops

When you recover, do you have any bladder incontinence? Were you
confused?
- How long did it take for you to get up?
Past History of Fall
- Is this your first time that you have fallen?
- How many times have you fallen in the past year?
- Have you had more than 2 falls in the last 6 months?

Normally, under what circumstances do you fall? For example, fall at

night due to poor lighting?
- Do you have any vision problems?
- Do you feel like the world is spinning around you
- Do you have difficulty balancing your body?
- Do you have difficulty walking?
Past Medical History

Other Physical Examination

- Neurological examination Power, Tone, Reflexes, Sensation
- Peripheral vascular examination Feel for pulses
- Sitting and standing BP Orthostatic BP
- Cardiovascular examination Arrhythmias, Bradicardia, Cartoid bruits
- Musculoskeletal examination
- Vision

Heart Disease, Stroke, Arthritis, DM (Peripheral neuropathy), Menieres

disease, Depression, Epilepsy, Osteoporosis
Medications: Diuretics, Anticonvulsants, Antidepressants,
Antihypertensives, Beta-blockers, Antipsychotics, Benzo

Unlikely to be a sensory ataxic gait There is slamming the foot in order

to feel it.
Up and Go Test
- Have the person sit on the chair stand up and walk a distance of 3m
turn back walk back to the chair and sit
- If >20s, impaired mobility
- Normal = around 10s

Hearing
History: Fall risk assessment How many falls in the past 6 months?
Under what circumstances the person is likely to fall?
Px medical
Fx
Daily activities assessment
Home assessment

Fx
- Family of Parkinsons or Alzheimers
Social History

- Smoke, Alcohol, Exercise, Diet, Occupation

Physical Examination
- Postural BP
- Chest Crackles, dullness
- Cardiac Murmur, Arrhythmia
- Extremities Leg ulcers, shoes
- Neuro Visual acuity, eye movements, nystagmus, visual field, hearing,

Investigations
- FBC Anemia, Infection
- U&E Volume status
- Glucose Hypoglycemia, DM
- Renal function test
- CXR Heart failure
- CT head scan If a vascular dementia

Proprioception and vibration, Up and go test

Management

Investigations
- FBC Infection, Anemia
- U&E Volume status
- Glucose Hypoglycemia, DM
- Calcium Delirium in hypercalcemia
- Thyroid function test
- Urinalysis

Review of medications
Pressure stocking for orthostatic hypotension
OT assessment E.g. Home assessment for environmental hazards
Physio assessment E.g. Strength and balance training
Visual correction
Personal alarm
Podiatrists

- Echocardiogram MI, Arrhythmia

- CXR CCF, Pneumonia
- CT head Tumor
- Bone density
Management
- Review of medications
- Pressure stocking for orthostatic hypotension

Hip protector
Regular exercise
Diet

OT assessment E.g. Home assessment for environmental hazards

Physio assessment E.g. Strength and balance training
Visual correction
Personal alarm
Podiatrists
Hip protector
Regular exercise

Diet

Incontinence

Cognition

3. Incontinence
History
- When do you first experience it?

4. Cognition
History
- Have you been being forgetful recently?

How many times a day? (>8 times Urge incontinence)

Sudden onset? Gradual onset? Progressively worse?

Stress, Urge, Overflow, Functional, Reflex

Short term or long term memory?

Difficulty reading? Difficulty understanding language? Difficulty

speaking?
Difficulty writing?
Attention? Loss of concentration?
Problems solving skills? Make decision? Problems handling money?
How are you handling the daily activates?
Are you depressed?

When did it usually occur? Any leakage when cough, laughing or lifting
heavy things? (Laugh? Coughing? Stress incontinence)
Sudden urge to pass urine? (Urge incontinence)
Any dripping at the end? (Overflow incontinence)
Any difficult in reaching the toilet? Often have to rush to use the toilet?
Sometimes not make it to the toilet in time? (Functional)
Does it affect you at night?

Others
- Any difficulty in starting the flow? (Urinary obstruction)
- Any change in the size of the stream of urine? (Urinary obstruction)
- Do you have the desire to pass urine again even though you have just
done so? (Urinary obstruction)
- Do you need to pass small amount of urine frequently? (polyuria = UTI
or DM)

Px
- Stroke? Head injury? Epilepsy?
- Medications: Recent changes in the medications
Fx
- Parkinsons, Alzheimers
Social
- Alcohol, Smoking

MMSE
- What the day? Date? Month? Year? Season? 5
- Where are we now? The name of the hospital? Which floor? What is the
address? What country? What state? What suburb? 5
- Name 3 objects? Can you repeat them? 3
- Can you subtract 7 from 100? 5
- Can you repeat the objects I have just asked you? 3

Have you been feeling thirsty? (Diuretics, DM, Kidney failure)

Any change in the appearance of the urine? Cloudy? Bloody? (UTI)
Pain when passing urine? (UTI)
Any pain on your tummy or back?
Fecal incontinence?
Because of the incontinence, any change in the daily activities? How
does it affect your life?

- What do you think is causing this?

Past Medical History
- Injury to your back? (Reflex)
- UTI, Diabetes
- Strokes Urge incontinence
- Any difficulties giving birth?
- Prostate problems?

Can you name 2 objects? 2

Can you repeat No ifs, ands or buts? 1
Can you use the right index finger to touch your nose, and touch you left
ear? 3
Write Close your eyes, can you do it? 1
Can you please write a sentence? 1
Draw the pattern, can you copy? 1

Injury to the back?

>25 normal

Medications causing incontinence:

- Diuretics
- Anti-hypertensives: Prazosin, Terazosin, Doxazosin
- Anxiolytics: Benzo
- Anti-psychotics
Social Hx
- Drink Coffee

- 10-24 mild to moderate impairment

- <10 severe impairment
Clock Drawing
- I want you to draw a clock.
- Draw a circle and put the numbers. Lastly, set the time at 10 minutes
after eleven.
Frontal Assessment Battery

- Smoking
- Alcohol
- Exercise
Stress continence
- Leakage of small amount of urine when you cough, sneeze, laugh, strain,
lift or play sports
- Causes: Age, Pregnancy, Childbirth, after Prostate surgery Weakened

- Total score of 18
- Similarities between a banana and orange
- Words beginning with letter S
- Following instruction
- Repetition of observed movements
Examination
- Neurological

pelvic muscle
Urge continence
- Sudden strong urge to urinate
- Causes: Stroke, Parkinsons, Enlarged prostate, Overactive bladder
more than 8 times a day, Bladder stones, Bladder Infection,
Constipation
Overflow continence

- Cardiovascular
Investigations
- Cognitive Testing: Clocking drawing test, Frontal Assessment Battery,
IQCODE
- Laboratory Testing: FBC, Thyroid function, ESR, U&E, Calcium, Renal
function, Vitamin deficiency, Liver functions (Alcohol)
- Imaging: CT, MRI

DDx
- Dementia, Pseuodementia, Delirium
Dementia
- A progressive decline in the cognition, despite a normal level of alertness
- Altered functions E.g. Intelligence, Language, Problem solving, Memory,
Learning, Attention, Judgement
Causes

Cannot stop their bladder E.g. constant dribbling, slow stream of urine,
hesitance
- Causes: Enlarged prostate
Functional continence
- A persons ability to reach toilet is impaired E.g. physically, mentally,
environmentally
- Causes: Reduced mobility, Poor coordination, Loss of memory

Reflex continence

Alzheimers Disease (most common)

- Result from damage to the nerves which control the bladder

- Causes: spinal injuries
Fecal incontinence
- Causes: muscle weakness, severe diarrhea (gastroenteritis, IBS, IBD,
diverticulitis, side effect of medications), constipation and impaction,
disorders of nervous system, disorder of lower bowel (cancer, fistula,
hemorrhoids)

Vascular Dementia (many small strokes)

Lewy Body Dementia (Histology with Lewy body in brainstem and cortex,
Later develop Parkinsonism)
Frontal-Temporal Dementia: Disinhibition, Behavioral or personality
changes, Executive impairment
Rare Causes: Alcohol, Repeated head trauma, Huntingtons, Parkinsons,
Picks Disease

Investigations
- Stress test As the person to cough and look for urinary incontinence
- Urinalysis Infection
- Blood test FBC, infection
- US Bladder, Ureters
- Cytoscopy
- Urodynamics testing Post-void residual volume, Uroflowmetry (how

- Important DDx: Delirium, Dementia

General Management
- A care coordinator
- Power of Attorney
- Day services: Meal on wheel
- Medications in packages
- Depression

fast the patient can empty the bladder), EMG electromyography

(Measure the strength of the sphincter contraction)
Management
- Pelvic muscle exercise (work the muscle that you use to stop urinating),
- Timed voiding (you urinate in a set schedule)??
- Life style changes (losing weight, quit smoking, avoid alcohol, drink less
coffee, tea, prevent lifting heavy objects),

Delirium
- Acute onset of fluctuating cognitive impairment and a disturbance of
consciousness
- A syndrome, not a disease
Causes
- Systemic Infection: Pneumonia, Malaria, UTI
- Intracranial Infection: Encephalitis, Meningitis

- Drugs: Opiates, Sedatives, Anti-convulsants

- Alcohol withdrawal
- Metabolic: Anemia, Hypoglycemia
- Head injury
- Nutritional
Core Features
- Altered consciousness, Altered attention, Disorientation, Decreased

Absorbent pads,
Medications E.g. Urge continence: Oxybutynin 5mg orally, 2-3 times a
day,
- Catheterization,
- Surgery for prostate
Drugs Treating Urge Incontinence = Overactive Bladder
- Anti-cholinergic = Anti-muscarinics: Oxybutynin, Solifenacin,

Darifenacin, Tolterodine
Drugs Treating Obstruction
- Alpha blockers: Prazosin, Tamsulosin, Terazosin
- 5 alpha reductase inhibitor: Finasteride

memory, Rapid onset, Brief duration (days to weeks), Fluctuations,

Sometimes worse at night (sundowning), Disorganization of thought,
Perceptual disturbances (illusions/hallucinations), Disruption of sleep,
Mood alterations, Altered neurological function

5. Functional Assessment
My name is Anthony. I am a medical student. I have been asked to come to take a history to see how well you are managing with your daily living. Is that
alright?
Activities of Daily Living Deatth
- Dressing? Are you able to dress yourself independently?
- Eating? Are you able to feed yourself independently?
- Ambulation? Are you able to walk without any difficulty?
- Transfer? How about transferring? I mean for example, you get up in the morning were you able to get out of bed and go to the chair or toilet?
- Toilet? Are you able to use the toilet? Incontinence issue?
- Hygiene? Any problems with grooming? Like take a shower, brushing your teeth, washing your face?
- Stairs? Are you able to climb up stairs?
Instrumental Activities SCCUM
- Shopping? Do you do the shopping?
- Cleaning the house?
- Cooking?
- Use of technology? Use of television? Use of phone? Use of a computer?
- Managing money?
Barthel Index
- A full score of 100
Other Examination
- Up and go test
- Assessment of gait
- Cognitive function: MMSE, clock-drawing test, Frontal battery assessement

Neurological examination, Cranial nerve examination

- Cardiovascular examination
- Vision, Hearing
- Standing and sitting BP
- ACAT assessment, OT, Physio assessment, Geriatrician assessment
Residential Care
- To enter residential care, have to be assessed by ACAS Aged Care and Assessment Services
- Home and Community Care packages are an alternative to entering a nursing home, providing up to 12 hours assistance a week (17 hours with
Extended Assistance Care)
- Dependency requiring assistance with transfers (or sometimes with continence) is generally indication for a nursing home placement, otherwise
hostel (usually reasonable mental state)
- 28% of patients in hostels and 60% of patients in nursing homes had a diagnosis of dementia
- After dementia, walking difficulty and poor self-rated health are the strongest predictors of nursing home admission
Members of an ACAT Team
- Doctors: Geriatrician, referred is often provided by the GP
- Social Workers: Referral to other services, Power of attorney, Guardianship
- Speech therapist: Communication, eating, swallowing
- OT: Home modification, community aids and equipment
- Physiotherapist
Dieticians
Do a youtube search to have a look of the gait
1. Hemiplegic Gait (Spastic Gait)
-

Unilateral weakness and spasticity

Upper extremity held in flexion and the lower extremity in extension

The foot is too long will have to circumduct to step forward

Seen with a UMN lesion
Causes of Hemiplegia: Stroke (Most common), Infective (Meningitis, Abscess), Neoplastic, Traumatic,
Congenital (cerebral Palsy), MS

Hemiplegic

With mild hemiparesis, loss of normal swing and slight circumduction may be the only abnormalities

2. Diplegic Gait
Spasticity in the lower extremities greater than the upper extremities
Hips and knees are flexed, Ankle extended and internally rotated
Both lower extremities are circumducted
Upper extremities in a low guard position
Legs are more affected than arms because the corticospinal tract going to the legs are close to the
ventricles

Causes: Bilateral periventricular lesions, Cerebral palsy

3. Neuropathic Gait (Steppage Gait)
Foot dorsiflexion is weak
High stepping gait to avoid dragging the toe on the groud
Causes of unilateral FootDrop: Compression of peroneal nerve, L5 radiculopathy
Bilateral: Peripheral polyneuropathy, Charcot-Marie-Tooth disease
4. Myopathic Gait (Waddling Gait)
Muscular disease, the proximal pelvic girdle muscles are usually the weakest
Pelvis tilt toward the non-weight bearing leg
Causes: Muscular Dystrophy, Congenital dislocation of hips
5. Parkinsonian Gait (Festinating Gait)
Rigidity, Bradykinesia
Trunk is bent forward, Gait initiation is slow, Steps are slow
Turning like a statue
Causes: Parkinsons disease
Causes of Parkinsonism: Medications, Idiopathic, Vascular, Repeated trauma
6. Ataxic Gait (Cerebellar Gait)
Wide-based
Unsteadiness, Body tends to bend forward-backward
Irregularity of steps, Uncertain starts and stops
Lateral deviation

Diplegic

Neuropathic

Myopathic

Parkinson

Resemble gait of acute alcohol intoxication

Causes: Lesion of cerebellum, Vit B12 Def., Radiation, Hereditary, Wilsons, Alcohol
7. Sensory Gait (Sensory Ataxia)
Slam the foot onto the ground in order to sense it
Severe form resemble cerebellar gait: Wide-based, Irregularity of steps (impairment of joint position)
Different from cerebellar gait: 1. Marked worsening of coordination when eyes are closed 2. +ve Rombergs
test (In cerebellar ataxia, unstable even when eyes opened)
8. Choreiform Gait

Irregular, jerky, involuntary movements in both upper and lower extremities

Causes: Certain types of basal ganglia disorders E.g. Huntington Disease,
Sydenham chorea

Ataxic

Choreiform

Chapter 6 Psy
- Commonly tested: Depression, Over treating depression, Manic episode
- This station focus a lot on the history and a brief discussion.
- Knowing how to take an efficient psy history is the key to pass this station. (see history taking notes below)
- In the history taking, make sure you screen for other psy disorders even though the diagnosis is apparent
- Know your DSM4 or 5 criteria
Commonly Asked Questions
- What do you think is happening? Why?
-

What are the possible DDx?

Knowledge Must Know to Pass

Side Effects of SSRI
- Common Insomnia, Agitation, Sedation, GI Distresses, Sexual
Dysfunction
- Beware for the first 2 weeks increase in suicidal ideation particularly
in young patients

Treatment for Schizophrenia

- Pharmacological: 1. Antipsychotics 2. If become agitated, 1st generation
(E.g. Haloperidol, most sedating, low-potency) 3. Have to monitor fasting
glucose level due to risk of metabolic syndrome
- Psychosocial: 1. CBT 2. Group therapy 3. Family therapy 4. Supportive

Pregnancy Paroxetine in the first trimester has been linked to cardiac

defects, Fluoxetine has been linked to spontaneous abortion and
premature labor, 20-30% of neonates will experience a syndrome
resembling serotonergic overstimulation
Side Effects of Venlafaxine
- Common Sleep changes, GI distress
- Higher doses may cause hypertension, monitor BP frequently

psychotherapy (NOT insight-orientated) 5. Case management

Treatment for Mania
- Mood Stabilizer: Lithium, Sodium valproate, Carbamazepine, continue
for prophylaxis
- Bipolar depression?
Tretment for Anxiety
- Pharmacological: Benzo, SSRI, TCA, Beta blockers

Side Effects of TCA

- Drowsiness, Insomnia, Hypotension, Weight gain

- Fatal if overdose
- Considered the drug of choice in severe depression during pregnancy
Side Effects of Lithium

Treatment for Depression

- Pharmacology: 1st line (Fluoxetine, Sertaline, Citalopram, Paroxetine), 2nd
(Venlafaxine, TCA), Beware the first 2 weeks (May need Benzo to cover),

Common Metallic taste, GI distress, Acne, Psoriasis, Benign T wave on

Psychological: Supportive psychotherapy, Insight-orientated

psychotherapy, Behavioral therapy, Cognitive therapy, Group therapy

If responds well continue at least half a year to a year, the tampering

ECG

the dose but watch for withdrawal symptoms

High serum level required for acute mania

Watch for toxicity Ataxia, Vomiting, Disorientation, Muscle twitches
Considered as a 1st line treatment in pregnant women with severe
bipolar disorder, but linked to fetal abnormalities need fetal echo
- But still not commonly recommended during pregnancy, slowly withdraw
lithium before conception occurs
Side Effects of Sodium Valproate / Carbamazepine

- Psychological: CBT, Supportive psychotherapy, Group, Family

Treatment for Alcohol
- Alcohol detoxification: Benzodiazepine
- Supplements: Thamine, Mg, Other vitamins
- Disulfiram: Develop an unpleasant reaction when they ingest even small
amounts of alcohol E.g. Flushing, headache, hyperventilation,
tachycardia, hypotension

Valproate (Loss of scalp hair, GI distress, Blurred vision), can lead to

abnormal liver function test
- Carbamazepine, can lead to Leucopenia, Thrombocytopenia, Abnormal
liver function test
- Valproate and Carbamazepine increases the risk of spina bifida
- If use get enough B9 folic acid
Side Effect of the 1st generation anti-psychotics

Treatment for Delirium - Not Really Important

- Depends on the cases
- Should not be sensory deprived or overly stimulated
- Pharmacology: Psychosis (Haloperidol), Insomina (benzo)
Treatment for Dementia - Not Really Important
- Generally supportive, Maintain proper nutrition, exercise and activities
- Environment with frequent cues for orientation to day, date, place and

Common: Sedation, EPSE (treated with Benztropine), Hypotension,

Tachycardia, Blurred vision, GI symptoms
Infrequent: Neuroleptic malignant syndrome, Metabolic Syndrome
Extrapyramidal SE: Highest with Haloperidol, lower with Chlorpromazine,
Akathisia (inability to remain motionless), Tardive dyskinesia (Involuntary
movement of the face, mouth or tongue), Parkinsonism (Tremor, rigidity
or bradykinesia)

Side Effect of the 2nd generation anti-psychotics

- Similar to above

Naltrexone: To reduce the craving for alcohol, worked by inhibiting

release of endogenous opioids associated with drinking
Insight orientated psychotherapy: Help the patient to recognize the
problems
Group Therapy
CBT

time
- Nursing home may be necessary
- Psychological: Supportive, Group therapy, Referral to organizations
- Pharmacology: Barbiturates and Benzodiazepines should be avoided as
they can worsen cognition, Haloperidol for agitation
Treatment for Alzheimers Disease Important in Gere, not in Psy
Cholinesterase Inhibitors

Can maintain the cognition at or above baseline for up to 12 months

- Do not modify the underlying progression of pathology

- Adverse effect: GI SE can prevent the use of these drugs in some patients
- Donepezil
- Galantamine
- Rivastigmine (Transdermally)
NMSA Antagonist
- Memantine
- Moderate to severe alzheimers disease
Treatment for Somatization Disorder - Not Really Important
- Pharmacology: Anxiety depression (causes the disorder or caused by the
disorder)
- Psychological: Insight or supportive psychotherapy, prevent unnecessary
procedures and diagnostic tests
Alcohol Related Problems
Liver: Fatty liver, Hepatitis, Cirrhosis, Liver failure
CNS: Memory loss, Encephalopathy
GIT: Pancreatitis, Peptic ulcer
Heart: Arrhythmias, Cardiomyopathy
Skeleton: Disrupt calcium metabolism, risk of osteoporosis
Sperm: Decrease in sperm motility

Clozapine
- Atypical antipsychotics
- Indications: Schizophrenia in people unresponsive to, or intolerant of,
other antupsychotics
- SE: Agranulocytosis = dangerous leukopenia (Low WCC), most commonly
of neutrophils
Extrapyramidal Symptoms

Social: Crime, Suicide

ECT
Commonly indicated for depression and catatonia, Also schizophrenia or

Delusion
- Persecutory

mania

Akinesia (inability to initiate movement)

Akathisia (Inability to remain motionless)
Acute dystonic reactions

Jealous

Indications

Erotomanic

Resistant to medications
A good response to previous ECT
Need for rapid and definitive response (E.g. Risk of suicide)
Patients preference
Severity of illness

Somatic Grandiose
Shared delusional disorder

Most common side effects: Confusion (usually disappears after a few

hours) and memory loss

It can be tolerated by pregnant women
Very cautious in people in epilepsy provokes small tonic-clonic
seizures
Likely not given to a person whose epilepsy is not well controlled

History
Presenting Compliant
- What is the reason for coming?
History of Presenting Compliant The most important part
- 1. Depression: When did it first start? How often? Do you feel it particularly in the morning? How bad is it? Anything may have triggered it?
Have you lost interest in things? Have you lost concentration? Sleep/Appetite/Energy level? Guilty? Feeling of slowing down in your movement
or thinking? How does it affect your daily life? Do you have fatigue?
- 2. Anxiety: Do you feel anxious? When did it first start? Do you have it in the past? When do you feel it? What were you doing when you feel it?
Do you feel anxiety all day? Anything would make it worse or better? What would you do when you feel anxious? Do you avoid the situation or
any repetitive behaviors? Do you have fear about dying/going crazy? Do you worry about have additional attacks? Do you have any physical

symptoms? (hyperventilation, sweating, palpitation, tremor)? Fatigue? Concentration? Irritable? Sleep? Restlessness? Muscle tensions? Any
things happen recently may have triggered it?
3. Mania: Thoughts are racing? Increased activity? Talkative? Decreased sleep? Difficulty concentrating? Make mistakes? Grandiosity?

4. Psychotic Disorder: Do you have any thoughts or idea that the others may tell you is not true? Do you feel like you are persecuted by the

others? Do you feel like you are better than the others? Do you think people around you are talking to you?

Do you ever have a feeling that somebody may insert or take out thoughts from you? Or you thoughts are made available to the others so that
the other can read your mind? Do you hear voices even though no one is around you? What are the voices about? Do they tell you to do
something? Do you see something that the others tell you is actually not there?
5. Substance Abuse: How long have you been using the substance? How often do you use it? Where do you use it? Do you use it with the
others? Do you end up using more than you intend to? Do you use it more often in order to get the desired effect? What do you do after using
the substance? Risky behaviors? Do you spend a great deal of time in using or getting the substance? How does it affect your life? Have you
relationship/job been affected? What happens if you stop taking it? Are you aware of any related health problems? Any legal problems? Do you
use other drugs such as amphetamine, opioids or cannabis? Have you decide to give up? Why do you take it? Any difficulties when cutting it off?
Drugs used, Age of first use, Age first dependent, Pattern of use over time, Recent use (Quantity, Frequency), Method of use, What happens
when use is stopped, Complications from use, Problems from use
6. Alcohol Abuse: Similar to above
Suicide: Sometimes people with your issue (Alcohol, Depression, Anxiety) may think of harming themselves? Have you ever had any thoughts of
harming yourself or even committing suicide? Have you made any plan? Have you done anything? What happened? How about now? Do you
have any suicidal thoughts?

- Stressors
Past Psychiatric History
- Do you have any psychiatric disorder? Compliance
- Any admissions to hospital because of psychiatric disorder?
- Received any treatment?
Past Medical History Keep it brief
- Any illnesses? DM? Hypertension?
- Medications? Compliance
- Allergies?
Substance Abuse History
- Alcohol/Smoking/Amphetamine/Opioids/Cannabis
- Reason?
- Ask about dependence, withdrawal, tolerance, abuse
- Refer above

Forensic History Keep it brief

- Legal issues
- Speeding tickets
Family History Keep it brief
- Family history of psy disorders
- Mum and Dad
- Sisters and brothers? Close relationship with them?
- Anyone in the family committed suicide?
Personal History Keep it very brief, choose 2 to ask only!!
- Pregnancy
- Childhood? Physical or sexual abuse?
- School? Issues with teachers or students? No problems in learning. Average
- Relationship with family?
- Friends?
- Are you in a relationship?
- Job? Stress?
- Hobbies?
Premorbid Personality
- When you last feel well?

Chapter 7 ID
-

Common Topics Tested: Pneumonia, Return travelers (E.g. STD, Malaria, Diarrhea), Meningitis, UTI, Post-Operative infection
Make sure you know the signs and symptoms, investigation and management of these conditions
Less Likely Topics: Endocarditis, Skin infections, Osteomyelitis, Septicemia, Foreign devices
This station usually start with a questions asking to give the top 3 DDx with reasoning
In generally this is not a hard station to pass

Meningitis
Clinical Features
-

Headache, Fever, Neck stiffness, Confusion, Photophobia, Irritability

Kernigs signs Hip is flexed, inability to extend the knee
Brudzinskis sign Lift the head of a lying patient involuntary lifting of the legs

Neisseria meningitidis, a spreading petechial rash may precede other symptoms, rash may also be seen in mucous membrane, non-blanching, glass test
for petechiae

DDx
- Malaria, Encephalitis, Septicemia, Subarachnoid, Dengue, Tetanus
Introduction
- Commonest causes of bacterial meningitis Neisseria meningitidis (Gram -ve), Streptococcus pneumoniae (Gram +ve diplococci),
- Non-vaccinated young children Haemophilus influenzae type b

In babes < 3 months of age Streptococcus agalactiae, Escherichia coli

Immunocompromised and > 50 yrs of age Listeria monocytogenes, Cryptococcal meningitis (Cryptococcus neoformans Treat with amphotericin B
and fluconazole), Viral meningitis (Herpes simplex, Varicella zoster)
Investigation
- Blood culture
- CSF examination Gram stain, Nucleic acid testing NAT
- CT scan has shown no evidence of increased ICP or focal lesions that indicate a lumbar puncture may be hazardous, also localized infection in the
lumbar region, bleeding tendency
-

Management
- Due to poor penetration into the CSF, aminoglucosides, clindamycin, erythromycin and earlier cephalosporins are not effective
- Early treatment with dexamethasone to improve outcomes with suspected acute bacterial meningitis, which needs to be given before or with the first
dose of antibiotic
Management before Hospitalization
- Collect blood cultures
- Aspirate or swabs from skin lesions (if meningococci) Fever + Rash
- Empirical treatment for meningococcal Benzylpenicillin
Immediate and Early Hospital Management

Blood cultures, swabs or aspirates of punctured skin lesions NAT, CSF

- Dexamethasone + Empirical antibiotics

- Indications for CT scan: Adults with history of CNS disease, focal neurological signs
Empirical Treatment
- Dexamethasone + Ceftriaxone
- To cover Listeria monocytogenes Benzylpenicillin
- Consider adding Vancomycin if Gram +ve diplococcic are seen (In case of resistant Streptococcus pneumoniae)
Directed Treatment As directed by the culture result
- Neisseria meningitidis = Benzylpenicillin
- Streptococcus pneumoniae = Benzylpenicillin
Prophylaxis
- Pregnancy Ceftriaxone IM
- Adult and children 12 years or older Ciprofloxacin orally
- Children Rifampicin orally
Important
- Meningococcal rash = Septicemia caused by Neisseria meningitidis (intracellular, culture on a chocolate agar plate)
- A purpuric (red or purple discolorations, do not blanch on applying pressure) rash that is non-blanching, Put a glass and does not lose its colors
- About 50% mortality rate over a few hours from initial onset
- Can cause multi-organ failure and DIC Disseminated Intravascular Coagulation
- Neisseria meningitidis, endotoxin on the outer member
DIC
-

Activation of the coagulation mechanism that happens in response to a variety of disease clotting in small blood vessel (affect organ functioning)
consume all the clotting factors bleeding occurs in the skin

Pneumonia
Community Acquired Pneumonia
Introduction
- Who are not in hospital, or in hospital for less than 2 weeks

Most common bacterial pathogen Streptococcus pneumonia

- Hemophilus infleunzae is responsible for less than 5% cases of CAP, mainly in patients with chronic obstructive pulmonary disease
- Other causes Mycoplasma pneumoniae, Chlamydophila and Legionella pneumoniae
- Choice of antibiotic is usually empirical as standard microbiological tests have a relatively low yield
Clinical Assessment
- History and examination
- Acute respiratory symptoms Cough, Sputum, Pleuritic chest pain, Fever
- In some patients, diarrhea, headache, particularly in elderly
Investigation
- Chest X-ray
- Oxygen sat in room air, Arterial blood gases in severely ill patients
- Sputum gram stain and culture, provided specimens are collected before commencing treatment, good quality = few squamous epithelial cells
- Blood culture 5-10% yield, in patients who are unwell
- Others: Urinary antigen assay
- Nose and throat swabs for NAT
- Mycoplasma serology
- Bronchoalveolar lavage, considered in severely ill patients
Assessing Pneumonia Severity
- Pneumonia Severity Index To assess the mortality, identify patients for outpatient care
- Scoring system CORB
- C = Acute confusion
- O = Oxygen Sat <90%
- R = Respiratory Rate >30 breaths per mintute
- B = Systolic blood pressure less than 90mmHg
- Interpretation = At least 2
- Scoring system SMART-CRP, total score of 11, assess the need for intensive care
Rational for Antibiotic Use
- Doxycycline or a macrolide (Oral Clarithromycin or IV Azithromycin) to treat atypical organisms E.g. Mycoplasma pneumoniae, Chlamydophila
pneumoniae, Legionella species, these drugs are also active against Streptococcus pneumoniae

IV Benezylpenicillin for Hemophilus influenzae, but amoxicillin is preferred if taken orally due to better absorption

- Penicillin resistant Streptococcus pneumoniae and Hemophilus influenzae are currently uncommon in Australia
In Patient Treatment
Moderate CAP
- In non-tropical regions: Benzylpenicillin + Doxycycline
- In tropical regions: Risk for Burkholderia pseudomallei and Acinetobacter baumannii Ceftriaxone + Gentamicin
Severe CAP
- Non-Tropical Regions: Ceftriaxone + Azithromycin
- Tropical regions: Imipenem + Azithromycin
Outpatient Treatment
- Amoxycillin or Doxycycline or Clarithromycin
? Use of Corticosteroid
Aspiration Pneumonia
- Often due to anaerobes
-

Assess the development of lung abscess

Treatment: Benzylpenicillin + Metronidazole

Hospital Acquired Pneumonia

- Longer than 48 hours after hospitalization
- Most occurs by aspiration of bacterial in the oropharynx or upper GIT
Diagnosis and Potential Pathogens
- Classic respiratory symptoms are mild, Frequent extrapulmonary manifestations E.g. Mental confusion
- Frequently develop from bacteria in oropharynx
- MRSA, Pseudomonas aeruginosa, Stenotrophomonas maltophilia
- Legionella, Aspergillis species, Respiratory viruses
- Treatment depends of the low risk ward or high risk ward (ICU) Commonly (Gentamicin + Benzylpenicillin)
Immunocompromised
- Pneumocystis jiroveci pneumonia

Treatment: Trimethoprim + Sulfamethoxazole

Travellers

Malaria West Africa, Nigeria, Solomon Islands, Ghana, Papua New Guinea
Dengue Vectors of Aedes albopictus, Clues (short incubation of 4-7 days, maculopapular rash, thrombocytopenia, leukopenia), but last 3 features
also in HIV seroconversion, Q fever, measles, Rubella
Enteric Fever (Typhoid and paratyphoid fever)
Fever in the returned traveller
- In all returned travellers, think about Malaria and Dengue. Also pneumonia and meningitis.
Malaria
- 4 species: Plasmodium falciparum, vivax, ovale, malariae
- Transmitted by the bite of the female Anopheles mosquito
- Highest transmission occurs at dawn and dusk
-

Highest transmission rates occur in Oceania and Sub-Saharan Africa

Symptoms
- Fever is universal in non-immune patients
- Chills, Sweats
- Headache, Myalgia, Diarrhea are common
- Complications: Anemia, Thrombocytopenia, Splenomegaly, Rarely splenic rupture
Plasmodium falciparum
- Most severe form, high mortality
- Cerebral malaria, Renal failure, Blackwater fever (hemoglobinuria), Pulmonary edema, Hypoglycemia, Anemia and bleeding
- Presents within 6 weeks of infection
- Can lead to death in 48 hours
- Mortality from 0.6-3.8%
Plasmodium Vivax
- May take several months before symptoms commence
- Has latent phase in liver, may recur after years
Diagnostic Methods (they will show you a film and ask is it a thick or thin blood, also ask you to identify the type E.g. Falciparum)
- Thick and thin blood films

Antigen detection

- PCR
Treatment
- Non-Falciparum: Chloroquine (resistance problem), Primaquine (Eradicates liver phase of vivax/ovale)
- Falciparum: Mefloquine (Neuropsychtatric), Malarone (expensive)
- Severe Falciparum: Artemisin derivatives (not widely available), Quinine (tolerance issue), Doxycycline
Prophylaxis
- Choice depends on: Countries to be visited and for how long, Previous reaction, other medical problems
- Chloroquine (limited usage), Doxycycline (side effects), Mefloquine (neurological problems), Malarone (cost)
Non-Drug Management
- Insecticide impregnated bed nets
- Mosquito repellent
- Covering arms and legs at time of greatest biting activity
Dengue Fever
- Mosquito borne infection (Aedes aegypti)
- Worldwide distribution in tropics and temperate
- >100 countries
- 25,000 deaths p.a.
- Occurs as 4 serotypes
- Infection leads to life-long immunity to the infecting serotype
Presentations
- Non-specific febrile illness
- Classic dengue
- Dengue hemorrhagic fever
- Dengue hemorrhagic fever with shock
- Other: Encephalopathy, Fulminant liver failure
Clinical Features
- 2-7 days after bitten Severe myalgia, Fever, Retro-orbital headache, transient rash predominantly on trunk, Usually defervesces within a
week, Thrombocytopenia universal finding

Major complications: Dengue hemorrhagic fever

Usually children in endemic region

Can lead to Dengue shock syndrome

Diagnosis
- Decreased platelet, lymphocytes
- Serology Demonstrates IgM response or seroconversion
- PCR
Treatment
- Supportive only
- Correction of clotting in severe hemorrhage
- A vaccine is not currently available commercially
Prevention
- Personal protection, Vector control, Environmental control, Vaccine development
Dengue in Australia
- Not endemic
- Epidemics initiated by tourists or returning resident
- Corresponds with distribution of Ae. aegypti
Typhoid Fever
- Caused by Salmonella typhi and paratyphi
- Acute generalized infection of reticuloendothelial system
- A bacteraemic illness, not a diarrheal illness
- Inflammatory destruction of the intestine and other organs
- Distributed globally, but worse on the Indian Subcontinent, 600,000 deaths worldwide annually
- Ingestion of contaminated food/water

In endemic countries: Food prepared out of home, Food from street vendors, Poor hygiene and housing

Salmonella typhi
- Member of Enterobacteriaceae
- Intracellular pathogen
- Humans the only animal reservoir
- Serologically +ve for LPS antigen, flagellar antigen, capsular polysaccharide antigen Vi (the major virulence factor)
Pathogenesis
- Vi antigen major virulence factor
- Low gastric pH important host defence
- Survive in mononuclear phagocytic cells of lymphoid follicles, liver and spleen
- Incubation period 7-14 days
- Common sites of secondary infection: Liver, Spleen, Bone marrow, Gall bladder, Peyers patches of terminal ileum
- Mortality from treated typhoid 1%
Clinical Features
- 1st week: Fever, chills, headache, malaise, Abdominal discomfort, Dry cough, Few physical signs, Relative bradycardia
- 2nd week: Sustained fever (39-40oC), Constipation > diarrhea, Neuropsychiatric features, Hb, WBC, platelet count normal, Rose spots
- 3rd week: The week of complications, Intestinal bleeding and perforation, Septic shock, Altered level of consciousness
- Relapse rate 1-5%
- Untreated typhoid 10% excrete for up to 3 months, 1-4% long term carriers
- Risk factors for chronic carriage Women>men, Elderly, Cholelithiasis
Diagnosis
- Blood cultures 60-80% sensitivity, Culture of large blood volume improves sensitivity
- Bone marrow culture 80-95% sensitivity
- Urine and stool cultures Usually ve early in illness, +ve 2nd week
- Widals test
Treatment
- Fluoroquinolones (E.g. Ciprofloxacin) Most effective, Rapid fever clearance, Low relapse and chronic carriage, Short course therapy effects
(<5d)
- Alternatives: Chloramphenicol, Ampicillin, IV Ceftriaxone, Azithromycin

Antibiotic Resistance
-

Chloramphenicol resistance since 1950

Reduced susceptibility to Quinolones especially SE Asia

STD
- Common Presentation: Dysuria, Discharge
- Diagnosis: Urethritis
- Most common causes: Chlamydia trachomatis (can be asymptomatic) (intracellular), Neisseria gonorrheae, less common: Mycoplasma
-

genitalium
Even less common: Ureaplasma urealyticum, Herpes simplex virus, Trichomonas vaginalis (protozoan)
Most important complications (in the patient or partner): Pelvic inflammatory disease, Infertility, Uncommonly disseminated gonococcal
infection and epididymo-orchitis
Tests: Nucleic acid test NAT on First voided urine, Discharge culture, Genital swab to examine under a microscope
Empirical Treatment: Azithromycin for Chlamydia, Ceftriaxone IM for Neisseria (Ciprofloxacin is no longer recommended due to resistance)
If resistant to treatment Consider Mycoplasma Genitalium

Common Investigations for STD

- Chalmydia or Gonorrhea Genital swab examined under a microscopy, NAT on the first void urine
- HIV Blood test (ELISA to detect antibodies to HIV), or immunofluorescence assay (labeled antibodies binds to the virus)
- Genital Herpes PCR (polymerase chain reaction), Culture
- Syphilis Dark ground microscopy (testing must be done within 10 mins), PCR to detect the presence of specific syphilis genes
- Trichomoniasis Examine under microscope
- HPV Visual diagnosis, Pap smear
Common
- Gonorrhea, Chlamydia, Syphilis, Herpes simplex, Genital warts
Less common
- Chancroid, Donovanosis, LGV
HIV testing Widow Period
- Infected but immune system not yet produce antibodies

Window period few weeks to 6 months

Vaginal Discharge
- Vaginal causes Bacterial vaginosis, Candidiasis, Trichomoniasis, Desquammative inflammatory vaginitis, Foreign body, Atrophic vaginitis, Nonspecific vaginitis
- Cervical causes Gonorrhea, Chlamydia, Carcinoma, Mucopurulent cervicitis
- Upper genital tract causes Gonorrhea, Chlamydia, Bacterial vaginosis
Testing: Urethra, Cervix, Vagina MCS and PCR, Rectal and throat MCS for gonorrhea, PCR for chlamydia
Medical History
-

Type of discharge, duration, dyspareunia (painful intercourse), Dysuria, Pelvic pain, menstrual history, symptoms in partner, Number of sexual
partners, STD history, missed contraception
Bacterial Vaginosis
- Imbalance in the normal flora
- Often confused with candidiasis Trichomonas vaginalis
- Diagnosis: Thin, white, yellow discharge, Fishy odor (on adding KOH solution), Loss of acidity, Presence of clue cells
- Treatment: Metronidazole, Clindamycin 2% vaginal cream
-

Normal flora: Lactobacillus species, Streptococcus agalactiae

UTI
- Young women, fever, rigors, dysuria, tenderness in RUQ
- Diagnosis based on the symptoms
- Confirmed by bacteriuria
- Usually associate with pyuria
- Uncomplicated UTI: Non-pregnant, no anatomical abnormalities of the urinary tract, no diabetes, Escherichia coli (Gram ve, Rod shaped)
causes 70% to 95%, Staphylococcus saprophyticus 5% to 10%
- If complicated: E coli 20% to 50%, but others E.g. Proteus, Kebisella, Enterococci, Streptococcus agalactiae are more common
Acute Pyelonephritis
- Urine cultures are collected before the administration of the antibioitcs
- Blood culture should be performed
- Mild Infection (low fever, no N+V): Trimethoprim or Cephalexin

Severe Infection (Sepsis or Vomiting): Gentamicin + Amoxycillin

Acute Cystitis
- Urine alkalinizing agents may relieve symptoms of UTI
- Uncomplicated: Trimethoprim 300mg or Cephalexin
- Quinolone (E.g. Ciprofloxacin) reserved for Pseudomonas aeruginosa
Recurrent Urinary Tract Infections
- Cranberry juice
- For prophylaxis Trimethoprim or Cephalexin
Osteomyelitis/Septic arthritis
Introduction
- Infection in bone may arise from hematogenous spread
- E.g. Inoculation following trauma or surgery, spread a structure for example a joint
- E.g. Spread from pneumonia, abscesses
- In children, hematogenous osteomyelitis usually affect long bones
- In adult, more likely to involve the axial skeleton
- Causes: Staphylococcus aureus for more than 80%, some enteric Gram ve for vertebral osteomyelitis in adults (E. coli, Pseudomonas)
- Others: Salmonella in sickle cell disease
- Think about TB (Zn stain, Mantoux +ve) or malignancy
- Chronic infection is difficult to treat
- Sequestra, dead bone, require surgical removal in chronic infection
Clinical Features
- Pain, Tenderness, Warmth, Erythema, Unwilling to move, Signs of systemic infection
Risk Factors
- Diabetes, Vascular disease, Impaired immunity, Surgical prostheses, Open fractures
Investigations
- Blood culture (+ve in60%), Radiological changes not apparent for 10-14 days (show haziness and loss of density), Sequestrum and involucrum
(new bone that form around sequestrum) may be seen, MRI, Cloacae (a hole in the cortex), Sequestrum culture if removed in surgery
Treatment

Drainage of abscesses

- Empirical Treatment: Flucloxacillin IV

- MRSA: Vancomycin IV
- Duration in adults (acute): IV for 4 weeks, 2 weeks of oral
- Duration in children (acute): IV for 3 days, 4 weeks oral
Complications
- Septic arthritis, Fracture, Deformity, Chronic osteomyelitis

This is the lumbar spine x-ray of the patient, taken on 5th of November.
This is a lateral view.
-

There is no obvious broken bones, dislocation or foreign objects present

The spine is normally curved, no scoliosis
The line-up of the vertebra seems to be normal
The shape and size of the vertebra seems to be normal, No squaring of the body
No narrowed joint space
No bone spurs
No soft tissue swelling

No osteopenia

Septic arthritis
- Generally a monoarticular arthritis
- Joint aspirate, Blood cultures
- Drainage of the pus, wash out are important
- Septic arthritis of the hip in children is an emergency necrosis of the femoral head
Think about hematogenous (E.g. Lungs)
DDx
- Osteomyelitis, Trauma, Gout
Empirical Treatment
- Same for osteomyelitis
Risk Factors
- Pre-existing joint disease E.g. RA
- Diabetes

Immunosuppression

- Prosthetic joints
Investigation
- Joint aspiration for synovial fluid microscopy and culture
- Plain x-ray can be normal
- Blood cultures
Monoarthritis

Oligoarthritis <5

Polyarthritis

Septic

Crystal

RA

Crystal (Gout and CPPD)

OA
Trauma

Psoriatic
Reactive (Yersinia,
Salmonella, Campylobacter)
OA
Ankylosing spondylitis

OA
Reactive
Psoriatic
Viruses (Hepatitis, mumps)

Immunocompromise and major opportunistic infections neutropenic, asplenic, HIV patients

HIV and CD4
-

HIV infects many cells, CD4 bear brunt + T helper lymphocytes

CD4 falls by 40-80 cells/ul per year

Impaired cell mediated immunity
Opportunistic infections appear at count <200 cells/ul
Will present clinically about 6-10 years after diagnosis
Aim to start treatment before this (200-350)

>500, Candidal vaginitis, Persistent generalized lymphadenopathy, GBS, Aseptic meningitis, Myopathy
200-500, Pneumococcal pneumonia, TB, HSV, VZV, Esophageal candidiasis, OHL, Cryptosporidiosos, KS, Cervical ca, Hodkins/B cell lymphoma,
ITP, anemia
<200, PCP, Disseminated HSV, Toxoplasmosis, Cryptococcosis, Microsporidiosis, Cryptosporidiosis, Esophageal candidiasis, PML, Pneumocystis

pneumonia
- <50, Disseminated CMV, Disseminated non-tuberculous mycobacterial infection E.g. MAI
PCP
- Pneumocystis pneumonia
- Caused by Pneumocystis jiroveci (Carinii), a fungus
- Only a problem with immunosuppression
- Can be B or T cells
TB
-

Infections occurs early in life, airborne transmission

Re-infection can occur
Up to 80% TB co-infected with HIV
New infection and reactivation
10% reactivation per year
Increased risk of drug resistant TB

Clinically: chest pain, cough, fever, sweats, extra pulmonary common

Cryptococcal Meningitis
- Cryptococcus neoformans, Yeast like fungus, CD4 <50
- Presentation: Headache due to raised ICP, fever, mental change, coma
- Investigations: CSF India ink, CrAg, Blood CrAg and cultures
- Treatment: Amphotericin + Flucytosine, then Fluconazole
Cerebral toxoplasmosis
- Toxoplasma gondii: Protozoal, cat faeces, meat, cysts dormant in brain, CD4 <100
- Presentation: Fever, confusion, headache, focal neurology, seizures
- Investigation: Ring enhancing lesions (>5), serology not helpful
- Treatment: Sulphadiazine + Pyrimethamine
Kaposis Sarcoma

Human Herpes Virus 8

Vertical and horizontal transmission
Increased prevalence in gay men
Proliferation of spindle cells

- Often mucocutaneous, all organs except brain

- Treatment: HAART, Liposomal doxorubicin
Neutrophil Defects
- Examples: Acute leukemia, Chemotherapy, Bone Marrow treatment
- Risk of bacteria and fungi infection
CMI Cell Mediated Immunity Defects
- Examples: Lymphoma, Chemotherapy, Bone marrow treatment, renal, liver, cardiac treatment, HIV

Risk of bacteria, fungi, parasite and viruses infection

Globulin Defects
- Examples: Hypogamm, Splenectomy, Multiple myeloma, HIV, GVHD
- Risk of bacteria and parasite infection
Interrupted Integument
- Examples: IV lines, TPN Total parenteral nutrition, Urinary catheters, Tracheostomy, Mucositis
- Risk of bacteria and fungi infection
Neutropenia
- Site of infections: Septicemia, Pneumonia, Pharyngitis, Perianal lesions, Skin lesions, Esophagitis
- Diagnosis: Blood cultures, IV line site, Sputum, Throat swabs, Biopsy/Bronchoscopy
Febrile Nuetropenia
- 20-40% mortality rate with Pseudomonas aeruginosa
- Viridans Streptococcal Infection: acute respiratory distress syndrome, acute encephalopathy, rash with skin desquamation
- Empirical therapy: Broad spectrum antibiotics, include antipseudomonal agent, better outcome with dual therapy (beta lactam +
amnioglycoside) for Gram ve, Monotherapy with CTZ (Ceftazidime), PIP (Piperacillin), Gram +ve cover not necessary in initial regimen
- Prevention: Modified environment, modified diet, Meticulous line management, Prophylactic antibtiotics/antifungals
Cellular Immune Dysfunction
- Congenital or acquired (E.g. Lymphoma, Hodkins, Drugs cytotoxics, steroids, Infection EBV, TB, CMV, HIV)
- Site of Infection: Pneumonia, Nonspecific fever, CNS infection, Pharyngitis, Esophagitis, Hepatosplenic
- disease, GIT, Skin
- CMV manifestations: fever, nonspecific symptoms, leucopenia, thrombocytopenia, hepatitis, gastroenteritis, interstitial pneumonia
- Diagnosis: culture/ microscopy of blood (listeria, mycobacteria), CFS (listeria, cryptococcus), Sputum (legionella, myobacteria, pneumocystis,
-

nocardia, aspergillus), Bronchoscopy specimens, Skin, GIT (CMV, myobacteria, strongyloides, salmonella), urine (adenovirus)
Antigen detection Cryptococcus, CMV, Legionella
PCR Myobacteria, Pneumocystis, CMV, Legionella, Parvovirus B19
Serology CMV, toxoplasma, legionella
Treatment: Antibacterial, Antifungal (E.g. Fluconazole, Itraconazole), Antiparasitic (Cotrimoxazole, Pentamidine), Antiviral (Acycclovir,
Ganciclovir)
Prevention: CMV, antifungal, HIV associated infections

CMV Prevention: CMV seronegative blood products, leucocyte depleted blood products, acyclovir/Ganciclovir prophylaxis, immunoglobulin,

early treatment
- Do not vaccinate with live vaccines
Humoral Immune Dysfunction
- Primary or secondary
- Site of infection Pneumonia/Chronic bronchitis, Sinuses, GIT, Bacteria
- Splenectomy Vaccination most important, Pneumococcal vaccine, conjugate vaccine, meningococcal vaccine, haemophilus influenzae type B,
booster doses necessary
Spleen
Function
- Red pulp Mechanical filtration of red blood cells
- White pulp Active immune response through humoral and cell-mediated pathways (Lymphoid follicles rich in B-cells, Lymphoid sheaths rich in
T-cells)
- Other functions: Production of red cells until the fifth mouth of gestation, Storage of red cells, Opsonization
Effect of Removal
- Increase in circulating white blood cells, platelets (risk of thrombosis)
- Diminished responsiveness to some vaccines
- Increased susceptibility to infection by bacteria and protozoa
Risk
- Spesis from polysaccharide encapsulated bacteria
- Particularly at risk of Pneumococcus, Hemophilus influenza, Meningococcus (350 fold)
Management
-

Antibiotic prophylaxis
Vaccination Pneumococcal vaccine, Hemophilus influenzae, Meningococcal vaccine, Influenzae vaccine

Nosocomial Infections
- Common sources: Hospital environment, Surgical equipment, Hospital bedding, Protective clothing, Staff and patients (Patients to patients
assisted by hospital staff)
- Transmission: Direct or indirect contact, Airborne, Ingestion, Transfusion

Example: Medical procedures which breach the epidermis, in-dwelling device

Types of Nosocomial Infections

- UTI is the commonest type > Surgical wound infections > Pneumonia
- Others: Hospital acquired diarrhea and vomiting Listeria monocytogens, Clostridium difficile (Antibiotic associated, switch antibiotics to
Metronidazole)
- Common agents: Staphylococcus aureus, Pseudomonas aeruginosa, Klebsiella pneumoniae
Infectious Control
Standard Precautions
-

Hand Hygiene
Personal Protective Equipment: Clean gloves
Handling and disposing of sharps
Routine management of the physical environment
Reprocessing of reusable instruments and equipment
Aseptic technique
Waste management

Infection control team: Medical microbiologist, Infection control nurse, Lab staff
Isolation of the patients
Regular surveillance activities, inspection of the facilities

Blood Culture
1. Explanation to patients
2. Put a cannula
3. Use a syringe to take blood
4. Change needle
5. Remove the plastic cap on the blood culture

6. Injection blood into the blood culture bottle

7. After the procedure, dispose needles into yellow bin
8. Wash hands
9. Label
Contamination of the Blood Culture
- Blood drawn from vascular devices or lines (the arterial lines may have been colonized by bacteria)
- Bottle preparation: Clean the tops of the culture bottles (should not use iodine, may cause erosion of the rubber stopper)
- Site preparation: Clean site with alcohol or iodine based antiseptics
- Collection enough volume
Outbreak Control Steps
1. Preparation (Meeting Set up a team, Surveillance system, Lab support, Plans for isolation wards)
2. Detection (Take clinical specimen, is there an outbreak?)
3. Response Confirmation (The number of cases higher than expected), Investigation (Confirm diagnosis, Formulate hypothesis for
transmission, sources), Control (Contact tracking, Preventative measures, Vaccination)
4. Evaluation Assess effectiveness of the measure, Chang policy, Write report
Sources of Infection
- Procedures, Environment, Patients, Health workers
Sources of Infectious Agents
- People, Patients, Environment, Equipment
- Routes: Airborne, Hands, Equipment
- Transmission: Airborne, Droplet, Direct/Indirect contact, Vehicle (Food)
Standard Precautions
-

Aseptic technique
Personal hygiene practices
Disposal of sharps
Disposal of clinical waste
Patient equipment
Environmental controls
Laundry and food services

Management of an Exposure
- First aid
- Report to infection control officer
- Assessment
- Intervention required? E.g. Immediate intervention for HIV prevention
- Reporting
- Follow-up
Body Fluids that do not Pose a Risk for HBV, HBC and HIV
- Tears, Sweat, Saliva, Urine, Stool, Vomitus, Nasal secretions, Sputum
High Risk Deep injury, blood filled needle
At Risk Injury with a device visibly contaminated with blood
Low Risk Superficial injury, not causing bleedin
Needle Injury
- HIV 0.3%
- Hep C 3%
-

Hep B 30%

Endocarditis
- Inflammation of the endocardium
- Usually involve heart valves
- Characterized by vegetation = mass of platelets, fibrin, and the micro-organism, may involve a granulomatous tissue in subacute infective
endocarditis
- Poor blood supply to the valve bacteria may attaches to the valve and not detected by the immune defense, attachment risk increased if
damaged by rheumatic fever (If on abnormal valve tend to have a subacute course)
- But 50% of endocarditis occurs in normal valves
- Chief cause: Staphylococcus aureus
- Risk factors: IV injection, Dermatitis, Renal failure (?dialysis), Operation
- Tricuspid valve in IVDU
Infective Endocarditis

Acute: Likely to be Staphylococcus aureus, more virulent

- Subacute: Like to be Streptococci

- Rare causes: HACEK, Fungal, Coxiella
Signs and Symptoms
- Fever, New or changing heart murmur (due to vegetation of the valve damage)
- Septic embolism (Gangrene of fingers, Janeway lesion, splinter hemorrhages, Renal infarcts, Infarct spleen, Intracranial bleed)
- Immune complex deposition Oslers nodes (painful, red, raised), Roths spots, Glomerulonephritis
Duke Criteria
-

Major criteria 1. Positive blood culture (Organisms in 2 separate cultures / Persistent +ve culture) 2. Positive Echo (vegetation, abscess) or new
murmur
- Minor criteria High fever, Evidence of embolism (Janeway lesion, conjunctival hemorrhage), Immunological problems (glomerulonephritis,
Oslers nodes)
Investigation
- Blood cultures: Do 3 at 3 different sites at peak of fever
- Urinalysis for hematuria
- CXR
- ECG
- Echo
Empirical Treatment
- Benzylpenicillin + Flucloxacillin + Gentamicin

Chapter 8 Musculo + 2nd Surgical Station

-

These 2 stations are usually new stations (E.g. Not in the past OSCE), so be prepared and dont be surprised
Please refer to the outcomes of the guidebook and think about topics that are common and important
Last Year (2012): Musculo XR showing fracture of the back/pelvis, 2nd Surgical XR showing bowel obstruction
2011: Musculo XR showing fracture of the pelvis, 2nd Surgical Neck lump / Audiometry

Musculo: Make sure you know how to read XR of a pelvis and back (they are most likely in the exam)
Core Knowledge Must Know to Pass
Fracture, OA, RA, Dislocation, Osteoporosis
Types of Fractures
A: Transverse Fracture
B: Oblique
C: Spiral Fracture
D: Comminuted Fracture
E: Segmental Fracture
F: Buckle
G: Greenstick Fracture

Location of the Fracture

Salter-Harris Classification (this type of fracture commonly occur in children)

1: Proximal third
2: Mid-shaft / Mid third
3: Distal third
Others
- Neck of femur

I: Epiphyseal only
II: Triangular bit above the epiphyseal (entire epiphysis and part of metaphysis)

III: Triangular bit below the epiphyseal (part of epiphysis)

IV: Bony attachments on both sides of the epiphyseal
V: Damage to the epiphyseal plate (compression injury)
Displacement

Angulation
A: No displacement
B: 50% dorsal/ventral
displacement
C: Complete displacement

A: 30 degrees angulation
B: 30 degrees angulation with complete
displacement
C: 30 degrees angulation

Open Injury

Management of Fractures

ABC
Analgesia and initial splitting
- Usually IV or IM
- Nerve blocks
Examination and radiology

Class I: <1cm in length, usually from penetration of bone

Class II: >1cm, not associated with flaps or excessive soft tissue
injuries
Class III: Extensive soft tissue injury or loss

Reduction (may not be required in simple cases)

- Urgent if neurovascular or skin compromise
- Correct shortening by traction
Treat complications
- Antibiotics in open injuries
- Compartment syndromes

Splinting and immobilization

-

Sling, Plaster, Splint, Internal or external fixation, Traction

Signs and Symptoms of Fractures

Complication of Fractures

Immediate
- Compartment syndrome
- Embolization
- Nerve and vascular injury
- Necrosis

Symptoms: Pain, Loss of function, Non weight bearing

Pain elsewhere

Long Term
- Non-union, Mal-union, Delayed union
- Joint stiffness
Immediate Internal bleeding, external bleeding, organ injury, nerve
injuries, vessel injuries, Compartment syndrome, Crush syndrome
- Later local Skin necrosis, gangrene, Pressure sores, Infection, nonunion, mal-union
- Later generalized Embolism, Pneumonia, Compartment and crush
syndrome
How would you assess?

Healing Time of a Fracture

History
- Mechanism of injury
- Degree of force
- Landing surface

- Symptoms: Pain, Loss of function, Non weight bearing

- Pain elsewhere
- Signs: Swelling, Deformity, Crepitus, Erythema, Open fracture
Physical Examination
- Signs of fracture
- Examination of other possible associated joints

A closed, pediatric, metaphyseal, upper limb simplest, will heal in 3

weeks
Complicating factors (doubles the healing time) E.g. Adult (6 weeks),
diaphyseal (12), open (24), tibia (48)

Complications E.g. Vascular, Neurological, Compartment

syndrome
Immediate Management
- ABC
- Pain relief and splinting
Investigation
- XR
- Show get at least 2 views + Joints below and above the
-

suspected fracture
If unclear, consider CT/MRI

Indications for Surgical Correction

-

Joint articular involvement open reduction, reconstruction

and fixation
Open reduction internal fixation indications: Open, Intraarticular,

Cancellous bone: Usually 6 weeks

Cortical bone: Tibial shaft 16 weeks, Humerus shaft 10 weeks,
Carpals/tarsals/phalanges 5 weeks
Young children may half the time

Failed conservative, 2 fractures in 1 limb

Carpal Tunnel Syndrome

-

Immobilization Time

Medial nerve entrapment causing pins and needles, pain,

RA
-

A chronic systemic inflammatory disease

wasting of thenar eminence

Causes: Unknown causes, associate with other disease E.g. RA,

DM, Hypothyroidism, Pregnancy
Diagnosis: Phalens maneuver (flexing the wrist), Tinels sign
(tappingthe skin over the flexor retinaculum)
Treatments: Localized corticosteroid injections, Immobilizing
braces, Surgery
Contents of carpal tunnel: 4 tendons of flexor digitorum

- Peak onset 50-60 years

- HLD DR4 linked, associated with increased severity
Presentation
- Typically: Symmetrical swelling, painful, stiff small joints of hands and feet,
worse in the morning
- Less common: Sudden onset, Monoarthritis (often knee, hip, shoulder)
Signs

profundus, 4 tendons of flexor digitorum superficialis, 1 tendon

of flexor pollicis longus, median nerve

Symmetrical and peripheral polyarthritis

Early: Inflammation, no joint changes, swollen MCP, PIP, wrist, MTP joints
Later: Ulnar deviation of the fingers, boutonniere, swan neck deformity, Zdemority
Extra-articular: Nodules (elbows, lungs), lymphadenopathy, vasculitis, pleural
and pericardial effusion, Raynauds, carpal tunnesyndrome, splenomegaly
(5%), Feltys syndrome (1%, splenomegaly, RA, Neutropenia), scleritis,
Conjunctivitis, Osteoporosis

Investigations
- Rheumatoid factors +ve in70%, a high titre is associated with severe disease,
erosions and extra-articular disease
- Anti-CCP Highly specific
- Often anemia of chronic disease, increase in ESR/CRP
- X-rays: Soft tissue swelling, Juxta-articular osteopenia, decrease in joint
space, erosion
Diagnostic Criteria
- 4 out of 7: Morning stiffness, >2 joints, hand joints, symmetrical, rheumatoid
nodules, +ve RF, radiological changes
Management
- Non-Pharmacological: Regular exercise, Physio, Occupational
- Pharmacological: NSAIDs (No effects on disease progression), Simple
analgesics, Disease Modifying Anti-rheumatic drug (Methotrexate,

Hydroxychloroquine, slow down disease progression), TNF inhibitors

(Infliximab), Steroid
OA
-

Osteoporosis
Commonest joint conditions
F:M = 3:1
Typically >50yrs
Usually primary (generalized) or secondary to joint disease =
localized (Obesity, occupational, hemochromatosis)

1.
2.
3.
4.
5.

What is osteoporosis and osteopenia?

What are the causes?
What are the common clinical features?
What are the investigations?
What are the managements?

Signs and Symptoms

- Localized: Usually knee or hip, pain on movements, crepitus,
worse at the end of day, background pain at rest, stiffness after
resting,
- Generalized: Heberdens nodes (DIP joint), Bouchards nodes (PIP
joint)
Investigations

6. Give 3 common fracture sites.

Ans
1. Osteoporosis = Low bone density T score < -2.5, Osteopenia = loss of
bone density, but not severe enough
2. Primary (Post-menopausal, Age-related), Secondary (Celiac disease,
Osteomalacia Vit D deficiency, Cirrhosis, Malignancy,
Hyperparathyroidism, Medications)

3. Asymptomatic until a fracture occurs, Loss of height

4. Bloods for Ca++, parathyroid, X-ray of spine, Bone scan
5. Increase vit D and Ca++ intake, check eye sight, Regular exercise,
Stop smoking, Home modification, Hip protectors, Bisphosphonates
(Indicated if patients have had previous fractures E.g. Alendronate)
6. Spine, Wrist, Hip

X-ray: Loss of joint space, subchondral sclerosis (bone density is

increased) and cysts, and marginal osteophytes
- CRP may be slightly elevated
Management
- Exercise, Quadriceps exercise in knee, hydrotherapy in hip
- Glucosamine and chondroitin
- Paracetamol, codeine, NSAID (is paracetamol not effective), Main
SE of NSAIDs (GI bleeding, Renal impairment, COX-2 selective
only used in past medical history of peptic ulcer)
-

Steroid injection
Joint replacement (Risk: DVT, Hemorrhage, infection, Dislocation,
PE)

Common Upper Fractures

Colles Fracture
Description
- This is the x-ray of left wrist the patient x, which was taken on 4th of Jan 2014
- There is a transverse fracture located of the distal end of radius
- With minimal dorsal angulation and displacement
- The x-ray findings are suggestive of a colles fracture
-

Most commonly caused by falling onto a hard surface with outstretched arms

Smiths Fracture
- The opposite to the colles fracture
- E.g. Ventral angulation and displacement of the distal end of the radius
- Most commonly caused by falling onto a flexed wrist
- Less common than the colles

A 68 years old female falls on her outstretched arm and has

Common Questions

immediate pain in her wrist which is swollen and deformed.

Description of XR
History, Physical examination, Investigation, Management, Complications
Description
- This is the XR of the right wrist of patient X taken on
18th June 2001.
- 2 fractures are shown
- There is a transverse fracture located at the distal end

of the radius, with severe dorsal displacement and

angulation of about 60 degrees
There is another transverse fracture located at the
distal end of the ulna, with severe dorsal displacement
and angulation of about 60 degrees

A 17 years male fell off his skateboard 2 days ago onto his

outstretched right upper limb. He has ongoing mild pain in his wrist
and is unable to di his normal physical activity due to poor grip.
Description
- This is the XR of the right wrist of patient X, taken on.
- There is a transverse fracture located on the body of the scaphoid

A 17 years old male is involved in a drunken brawl and sustains a

punching injury. He has pain and swelling in his hand and is unable
to do his normal physical activity due to poor hand grip.
Description
- This is the XR of the right hand of patient x taken
on xxxx
- There is a transverse fracture located on the distal
end of the metacarpal joint
-

Associated with mild to moderate ventral

displacement and about 30 degrees of ventral
angulation

18 years old male is involved in a drunken brawl and is struck on his

right forearm by a metal bar.

Description
- Transverse fracture located on the distal
third of the radius
- Associated with mild ventral
displacement and moderate ventral
angulation of about 50 degrees

A 48 years old female falls on her outstretched arm and has

immediate pain in her elbow. She has difficult moving her elbow
and has minimal lateral swelling.
Description
- This is the XR of the left elbow of patient x taken on xxxxx
- There is a avulsion fracture of the head of the radius with one
complete bone fragment
- The bone fragment and the main bone are close together E.g.
They are not far apart

Fat Pad Sign in elbow fracture goggle it if you want to know it

A heavy metal bar falls onto the left arm of a 37 years old male factory

worker. He has pain and significant swelling of his arm. He is reluctant to

move his upper limb.
Description
- Spiral fracture, Mid-shaft.
Mid-shaft fracture may damage the radial nerve (signs and symptoms???
Check the neurological station notes)

A 77 years old female falls off her bed onto her left shoulder. She has pain

and swelling in her anterior shoulder, supports the elbow and is reluctant to
move her upper limb.
Description
- Oblique fracture at the surgical neck of the humerus
(very likely to have axillary nerve damage paralysis
of the deltoid and teres minor + loss of sensation of
the lateral upper arm)

A 17 years old males fall off his skateboard onto his outstretched right limb.

He has pain in his anterior shoulder, supports his elbow and is reluctant to
move his shoulder.
Description

Indications for Surgery in Clavicle Fracture

- Open fracture
-

Communicated
Severe shortening
Nervous and vascular trauma E.g. Brachial plexus
Non-union after 3-6 months
Distal third fracture high risk of non-union (which is in
this case)

Common Lower Limb Fracture

Femur Fractures (hip fracture is commonly asked, make sure you know the anatomy of the pelvis and femur)
A 77 years old falls off her bed onto her left side. She has pain in her anterior
hip and is unable to walk. She has pain on any movement of her hip.

Description
- Lesser trochanter fracture?
Important to talk about fall prevention

A 74 years old male with a known right hip prosthesis trips over his dog and has

sudden onset of pain and immobility in his right hip.

Description
- Dislocation

A 34 years old male runs into a car whilst riding his motorbike.

Description
- Looks like a comminuted fracture
- Need a knee veiw
Important
- Management: Always ABC and resuscitation
- Check for GCS score
- Whole body examination
-

US for internal injury

A 47 years old female slips over on uneven pavement. She has pain in her

knee and is unable to walk. She has pain on any movement of her lower
limb.
Description
- Transverse fracture
- Severe displacement
- 30 degrees angulation

A 17 years old male is jumping around with friends when his knee suddenly

gives way. He has pain and deformity and is reluctant for you to touch.
Description
- Patella dislocation

A 77 years old female slips over on uneven pavement. She has pain in her

knee and is unable to walk. She has moderate swelling in her knee.
Description
- A avulsion fracture located on the lateral condyle of the tibia
- The bone fragment and the main bone are close together E.g. They are
not far apart

A 34 years old man runs into a car whilst riding his motorbike.

Description
- There are 2 fractures
- There is a segmental fracture located on the distal third of the tibia
- The segmental section is about 10 cm in length, associated with 50%
displacement and no significant angulation
- There is another spiral fracture located on the mid-shaft of the fibula,
with complete displacement of 1cm shortening and mild angulation

A 34 years old male suffers from an inversion injury to his right ankle.

A 35 years old male develops sudden onset of pain in his right heel while
jumping off a high wall.

A 34 years old man suffers an inversion injury to his right ankle.

Transverse fracture of the proximal end of the
5th metatarsal

Important Signs (unlikely to be an examination station)

Hands

Clubbing
- Respiratory Causes: Cystic fibrosis,
Bronchiectasis, Lung carcinoma, TB,
Mesothelioma
- Cardiac Causes: Endocarditis
- GI Causes: IBD, Cirrhosis, Esophageal
-

carcinoma
Others: Hyperthyroidism

Leukonychia
- Complete Whitening: Hypoalbuminemia by
nephrotic syndrome/liver failure/ protein malabsorption
- Bands or Lines: Cirrhosis, Injury, Chemotherapy
- Spots: Physical injury (biting), Lack of Zinc

Koilonychia
- Iron Deficiency

Heberdens Nodes
- Swelling of the DIP
- OA

Bouchards Nodes
- Swelling of the PIP
- OA

4th Finger
- Boutonnieres deformity RA
5th Finger
- Swan neck deformity RA

Ulnar Deviation
- RA

Z-Deformity
- RA

Rheumatoid Nodules

Left
- Finger adduction
Right

Left
- Thumb extension
Right

Left
- Thumb adduction
Right

Finger abduction

Thumb flexion

Thumb abduction

Crest Syndrome
- C Calcinosis
- R Raynauds
- E Esophageal dysmotility
- S Sclerodactyly = thickening and tightness of
skin of finger or toes
-

Tinels Test
- Carpal tunnel syndrome

Sjogrens Syndrome
- Autoimmune disease that attacks the exocrine
glands

T - Telangiectasia

2nd Surgical: Please read the outcomes in the guidebook, Common things are common, Check for disease prevalence if not sure

Chapter 9 Abdominal Examination

- Abdominal examination dont really come out in the 4th year OSCE. More likely an Abdominal XR or CT, Neck Lump or ENT station
- Option: Skip it
Reasons
- Important signs in abdo examination such as splenomegaly, hepatomegaly, spleno-hepatomegaly, ascites and lumps are not common, it is difficult to
find enough patients for the OSCE
- Abdominal scars are common and easy to find in community, but it is just a general inspection finding and not really testing the examination skills
- You wont see jaundice patients, they will be on ward and they cant find enough jaundice patients. Same for polycystic kidneys and hernia.
-

If you think about it, they can at most find a patient with an abdominal scar and ask about the DDx of it.

Core Knowledge Must Know to Pass (if it does come out in OSCE, but unlikely)
DDx of Hepatomegaly

DDx of Splenomegaly

Massive
- Metabolic/Infiltrative: Hemochromatosis, Amyloid, Sarcoidosis, Fatty
liver, Alcohol
- Neoplastic: Hepatocellular carcinoma, Metastases, Lymphoma, Chronic

leukemia
Abnormal Blood Flow: Right heart failure, Biliary obstruction
Infective: Hepatitis, HIV infection, Malaria, Abscesses, Hydatid cyst

Infiltration: Amyloidosis, Leukemia, Lymphoma, Sarcoidosis

Infection: Malaria, Abscess, mononucleosis
Hematological: Sickle cell anemia, Thalassemia, Autoimmune hemolytic
anemia

Causes of Portal Hypertension

- Pre-hepatic: Portal vein thrombosis, Congenital atresia
- Intra-hepatic: Cirrhosis, Hemochromatosis, Wilsons disease
- Post-hepatic: Hepatic vein thrombosis, Inferior vena cava thrombosis

DDx of Hepatosplenomegaly

Lumps on Abdomen

Infection: CMV, Malaria, EBV

Hematological: Leukemia, Myeloproliferative disease, Lymphoma

- DDx: Fat, Fetus, Flatus, Fluid, Faeces, Cancer

Description

Metabolic: Gauchers disease

Infiltration: Amyloidosis, Sarcoidosis

Site, Tenderness, Size, Shape, Edge, Surface (regular, irregular),

Consistency, Mobility with inspiration, Pulsatile

Signs of Portal Hypertension

Cause of Liver Failure

Acute Liver Failure

- Paracetamol overdose, Hepatitis, Ingestion of poisonous wild
mushrooms

Ascites
Hepatic encephalopathy flapping tremors
Splenomegaly

Carput medusa (extremely rare now)

Chronic Liver Failure

Esophageal varices

Hepatitis B,C, Long term alcohol consumption, Cirrhosis,

Hemochromatosis, Wilson disease, Primary biliary cirrhosis,
Autoimmune hepatitis, HELLP syndrome in pregnancy, Alpha-1antitrypsin deficiency

Signs of Liver Failure

Differences in Palpation of Spleen and Kidneys

Hands: Clubbing, Leuconychia, Palmar erythema, Brusing, Asterixis

Face: Jaundice, Scratch marks, Spider naevia, Fetor hepaticus

Spleen
- Cannot get above it, ribs overlie its top

Chest: Gymecomastia, Loss of body hair, Spider naevi, Bruising

Abdomen: Hepatosplenomegaly, Ascites, Signs of portal hypertension,
Testicular atrophy
Legs: Edema, Bruising
Lungs: Pulmonary edema crackles

Complications of Liver Failure

-

Ascites, also at risk of spontaneous bacterial peritonitis

Esophageal variceal bleeding

Bleeding disorders Clotting factors

Hypoglycemia
Hepatic encephalopathy
Hepatorenal syndrome
Pulmonary edema from low albumin protein

Dull to percussion in spleen, resonant in kidney because of overlying

bowel
Moves more with inspiration
May have a palpable notch

Scars

1. Subcostal scar: Cholecystectomy

2. Right paramedian scar: Laparotomy
3.
4.
5.
6.
7.
8.

Midline scar: Laparotomy

Nephrectomy scar: Renal surgery
Gridiron scar: Appendectomy
Laparoscopic scar: Laparoscopy
Left paramedian scar: Anterior rectal resection
Transverse suprapubic: Hysterectomy, Pelvic surgery

9. Hernia Incision Scars

More Scars
Red
- Bi-subcostal scar: Surgery on
the proximal GIT, Liver or
pancreas
Blue
-

Vertical midline scar: Surgery

on the colon, bladder
Orange
- Appendicectomy

Core Condition Must Know to Pass

Hernia
Indirect Hernia
- Common 80%
- Protrudes through the deep inguinal ring
- Just above the mid-point of the inguinal ligament
- If large may descend to the scrotum
- Can strangulate
Direct Hernia
- Pushes into the inguinal canal posteriorly through a weakness called
Hesselbachs triangle
- Reduced easily
- Rarely strangulate
Clinically very difficult to differentiate, often determined only at time of
operation

Femoral Hernia
- More frequently in females
- Frequently strangulate and not reducible
- Commonly do not exhibit cough impulse
- On the medial thigh on the groin crease
- Commonly mistaken for an inguinal lymph node
Incisional Hernia
- Management: Avoid straining
- Mesh
Immediate, Short term, Long term
- Watch for recurrence
Signs
General

Jaundice
- Pre-Hepatic: Blood group incompability, G6PD
deficiency, Thalassemia, Sickle cell anemia
- Hepatic: Hepatitis, Cirrhosis, Alcoholic liver,
Toxins, Hemochromatosis, Primary biliary
hepatitis

Cachexia
- Malignancy
- Alcohol related malnutrition
- Mal-absorption

Skin Pigmentation
- Hemochromatosis
- Addisons disease
(wont see in the exam)

Post-Hepatic: Gallstones, Pancreatitis,

Carcinoma of the head of pancreas
Genetic: Gibert syndrome, Crigler-Najjar
syndrome, Rotor syndrome, Dubin-Johnson
syndrome

Acanothosis Nigricans

Seen in Prophyria

Palmar Erythema

- Chronic Liver Diseases Elevated estrogen

level
- Also in pregnancy, RA, Thyrotoxicosis, RA,
polycythaemia
- Can be a normal finding

GI Carcinom
Lymphoma
Acromegaly
Diabetes

Sun exposed area develops blistering/erosions,

heal with scarring
Urine is dark

Blue Lunulae
- Wilsons disease

Spider Naevi
- Elevated estrogen level
- Normal in pregnancy
- Disappear under compression
- Finding of more than 2/3 is likely to be

Dupuytrens Contracture
Contraction of the palmar fascia causing
permanent flexion of the ring finger
- Often bilateral
- Occasionally affect feet

abnormal
- Can be caused by alcoholism, cirrhosis,
hepatitis
DDx
- Venous stars (due to elevated venous pressure,
no change on pressure),
- Telangiectasia

- Associate with alcoholism, diabetes, liver

diseases, epilepsy

Asterixis Flapping Tremor

- Due to impaired proprioception of the brain
- Hepatic Encephalopathy, Liver Failure
- Also seen in cardiac, respiratory and renal
failure
- And hypoglycemia, hypokalaemia,

Bruising
- Clotting abnormalities E.g. Hepatic damaged
impaired production of clotting factors
- Impaired absorption of vitamin K reduced
production of vitamin K dependent clotting
factors E.g. Obstructive jaundice,

hypomagnesaemia
-

malabsoprtion
Anti-coagulants

Scratch Mark
Due to severe itch
Associate with obstructive or cholestatic
jaundice
- Common in primary biliary cirrhosis before
other signs are apparent

Parotid Enlargement
- Bilateral Enlargement can be due to fatty
-

infiltration in alcoholism
Parotiditis, Parotid carcinom

Geographical Tongue
- Can be a sign of B12 deficiency or normal

Leukoplakia
- Pre-malignant lesion

Mouth Ulcers

Angular Stomatitis

Gynaecomastia

Normal
But associate with Crohns disease, celiac
disease, HIV infection

Striae
- Pregnancy, Cushings disease

Iron or vitamin B deficiency

Kayser-Fleischer Rings
- Green ring at the periphery of the cornea
-

Typically found in Wilsons Disease

Also in cholestatic liver disease

Cirrhosis, Chronic hepatitis

Use of spironolactone
Alcoholics damage the Leydig cells
Breast cancer

Good Luck for Your OSCE!!!

Please send me a copy of the OSCE at the end of this year: hiuhunglam@hotmail.com