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NAC OSCE COMPREHENSIVE REVIEW PDF

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NAC OSCE A Comprehensive Review - resourceone.info - Free download as PDF File .pdf), Text File .txt) or read online for free. NAC OSCE - A . Download Nac Osce Comprehensive Review Description. TABLE OF CONTENTS Introduction to NAC OSCE General Information. Download NAC OSCE – A Comprehensive Review 1st Edition. NAC OSCE – A Comprehensive Review is a detailed study guide for the Canadian NAC OSCE.


Nac Osce Comprehensive Review Pdf

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Feelings of guilt and unworthiness are common with PTSD. Traumatic experiences that can trigger PTSD include wars, plane crashes, natural disasters e.

Fluoxetine, Paroxetine, Sertraline and Venlafaxine are first line options. Dementia Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging. Dementia is not a single disease, but rather a non-specific illness syndrome in which affected areas of cognition may be memory, attention, language, and problem solving.

It is normally required to be present for at least 6 months to be diagnosed. Benzodiazepines must be used cautiously in the elderly patients due to increase risk of falls and impaired cognition. Medication must be taken even if patient is feeling better.

Start 20 mg qhs, increase lOmg every 2wks, max 60mg per day. Start 20mg PO qd, max 60mg. Use in Atypical depression, Refractory depression. Hypertensive crisis, Serotonin syndrome. Interaction with tyramine containing foods to be avoided strictly. Anti-cholinergic - dry mouth, constipation, blurred vision, Anti-histaminergic - sedation, weight gain; Serotonergic - sexual dysfunction; Orthostatic hypotension; Sinus tachycardia, SVT, Ventricular tachycardia, Prolonged QT interval, heart block; Withdrawal symptoms.

Venlafaxine Effexor Psychosis In acutely psychotic individuals, short-acting parenteral antipsychotics either alone or in combination with a parenteral benzodiazepine may be recommended. Nac Osce Comprehensive Review Liquid formulations of atypical antipsychotics may be used as an alternative to intramuscular injections, Risperidone and Olanzapine are examples. Atypical antipsychotics: Agranulocytosis, Diabetes mellitus, hypertriglyceridemia. Order weekly blood counts for 1 month and then q2 weeks.

Headache, sedation, dizziness, constipation. Insomnia, agitation, EPS, headache, anxiety, hyperprolactenemia, postural hypotension, constipation, dizziness, weight gain. Typical antipsychotics: May repeat qmins, max mg per day. Dyskinesia Akathesia - treat with Lorazepam, Propranolol or Diphenhydramine. Discontinue drug. Give symptomatic treatment and supportive care. Treatment with Dantrolene or bromocriptine.

Treatment - Clozapine. Mood stabilizers: Used in Bipolar disorder. Serum levels - 0. Treatment of Lithium toxicity: Discontinue lithium. Check serum lithium levels, BUN, electrolytes. IV fluids - Normal saline. Monitor LFTs weekly x 1 month, then monthly. Monitor weekly CBC due to risk of agranulocytosis. Medications causing sexual dysfunction 1. Thiamine mg PO OD x weeks.

Cocaine Overdose: At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there. Verbalize the steps of the examination and your findings. Use proper draping techniques. Is patient comfortable at rest? Do they appear to be tachypnoeic? Ask the patient to hold their hands out in front of them looking for a any tremor and then get them to extend their wrists up towards the ceiling keeping the fingers extended and look for flapping asterixis in hepatic encephalopathy.

Examine the face, check the conjunctiva for pallor. Also check the sclera for jaundice. Also look at the tongue. If it is red and fat it could be another sign of anaemia, as could angular stomatitis. Examine the neck for an enlarged left supraclavicular lymph node. Therefore, enlargement of this node may suggest metastatic deposits from a malignancy in any of these areas.

Examine the chest, in particular look for gynaecomastia in men and the presence of 5 or more spider naevi. These are both stigma of liver pathology. Inspect the abdomen and comment on any obvious abnormalities such as scars, masses and pulsations. Listen for bowel sounds - absent e.

Ileus, peritonitis , tinkling bowel obstruction 4. If a patient has pain in one particular area you should t ILIAC start as far from that area as possible. Initial examination should be superficial using one hand. Once you have examined all 9 areas superficially, you should examine deeper. This is performed with two hands, one on top of the other. Feel for organomegaly, particularly of the liver, spleen and kidneys.

Palpation for the liver and spleen is similar, both starting in the right iliac fossa. For the liver, press upwards towards the right hypochondrium. You should try to time the palpation with the patient's breathing as this presses down on the liver. If the liver is distended, its distance from the costal margin should be noted. Palpating for the spleen is as for the liver but in the direction of the left hypochondrium.

The edge of the spleen which may be felt if distended is more nodular than the liver. To feel for the kidneys you should place one hand under the patient in the flank region and the other hand on top. You should then try to ballot the kidney between the two hands. Percussion Percussion over the abdomen is usually resonant, over a distended liver it will be dull.

Percussion can also be used to check for 'shifting dullness' - a sign of ascites.

With the patient lying flat, start percussing from the midline away from you. If the percussion note changes, hold you finger in that position and ask the patient to roll towards you. Again percuss over this area and if the note has changed then it suggests presence of fluid such as in ascites. It is also appropriate at this time to check for pedal edema. You should mention to the examiner at this point that you would like to finish the examination with an examination of the hernial orifices, the external genitalia and also a rectal examination.

You should note whether the patient looks comfortable. Are they cyanosed or flushed? Respiratory rate, rhythm and effort of breathing. Inspect fingers for capillary refill time, peripheral cyanosis, osier's nodes infective endocarditis and nicotine staining. Inspect palms for palmar erythema,Janeway lesions and xanthomas. Take the radial pulse, assess the rate and rhythm.

At this point you should also check for a collapsing pulse - a sign of aortic incompetence. A collapsing pulse will present as a knocking on your palm. At this point you should say to the examiner that you would like to take the blood pressure.

They will usually tell you not to and give you the value. You should also look for any evidence of xanthelasma. Whilst looking at the face, check for any malar facies, look in the mouth for any signs of anaemia such as glossitis, check the colour of the tongue for any cyanosis, and around the mouth for any angular stomatitis - another sign of anaemia.

Assess jugular venous pressure JVP , ask patient to turn their head to look away from you.

Look across the neck between the two heads of sternocleidomastoid for a pulsation then measure the JVP. Examine the chest, or praecordium for any obvious pulsations, abnormalities or scars, remembering to check the axillae as well. The normal location is in the 5th intercostals space in the mid-clavicular line. Palpate for any heaves or thrills.

A thrill is a palpable murmur whereas a heave is a sign of left ventricular hypertrophy. Feel for these all over the praecordium. Tricuspid valve - on the left edge of the sternum in the 4th intercostal space. Pulmonary valve - on the left edge of the sternum in the 2nd intercostal space. Aortic valve - on the right edge of the sternum in the 2nd intercostal space.

How many heart sounds are heard? Are the heart sounds normal in character? Any abnormal heart sounds? If you hear any abnormal sounds you should describe them by when they occur and the type of sound they are producing. Are there any murmurs? Can you hear any rub? Feeling the radial pulse at the same time can give good indication as to when the sound occurs the pulse occurs at systole. Furthermore, if you suspect a murmur, check if it radiates. Mitral murmurs typically radiate to the left axilla whereas aortic murmurs are heard over the left carotid artery.

Aortic incompetence can be assessed in a similar way but ask the patient to sit forward, repeat the breathe in, out and hold exercise and listen over the aortic area with the diaphragm. With patient sitting up percuss back for pleural effusion cardiac failure 6. Finish by thanking the patient and ensuring they are comfortable and well covered.

Comment on the general appearance of the arms and legs, size, swelling, symmetry, skin color, hair, scars, pigmentation including any obvious muscle wasting. Note colour and texture of nails.

Any signs of gangrene or pre-gangrene such as missing toes or blackening of the extremities. The presence of any ulcers - ensure you check all around the feet including behind the ankle.

These may be venous or arterial - one defining factor is that venous ulcers tend to be painless whereas arterial are painful. Presence of any varicose veins - often seen best with the patient standing.

Starting distally, feel with the back of your hand and compare each limb to the other noting any difference. Check capillary return by compressing the nail bed and then releasing it. Normal colour should return within 2 seconds. In the presence of poor arterial supply, pallor rapidly develops. Following this, place the feet over the side of the bed, cyanosis may then develop. Any varicosities which you noted in the observation should now be palpated. If these are hard to the touch, or painful when touched, it may suggest thrombophlebitis.

Palpate peripheral pulses. These are: Carotid - only palpate one carotid at a time Radial - use the pad of three fingers Brachial - may use thumb to palpate Femoral - feel over the medial aspect of the inguinal ligament.

Posterior tibial - felt posterior to the medial malleolus of the tibia. Dorsalis pedis -feel on the dorsum of the foot, lateral to the extensor tendon of the great toe. You should compare these on both sides and comment on their strength. Palpate both the radial and femoral pulses on one side of the body.

The pulsation should occur at the same time.

Nac Osce Comprehensive Review.rar

Any delay may suggest coarctation of the aorta. Ask the patient to make a tight fist and elevate the hand. Occlude the radial and ulnar arteries with firm pressure. The hand is then opened. It should appear blanched pallor can be observed at the finger nails. Release either the Ulnar or radial artery pressure and the color should return in 7 seconds. Sit the patient upright and observe the feet.

In normal patients, the feet quickly turn pink within seconds. If, pallor persists for more than s or there is development of a dusky cyanosis rubor , this suggests of arterial insufficiency. Ask the patient to stand and note the dilated varicose veins. Compress the vein proximally with one hand and place the other hand cm distally.

Briskly compress and decompress the distal site. Normally, the hand at the proximal site should feel no impulse, however with varicose veins a transmitted pulse may be felt. Ask the patient to lie down. Elevate the leg, and empty the veins by massaging distal to proximal.

Using a tourniquet, occlude the superficial veins in the upper thigh. Ask the patient to stand. If the tourniquet prevents the veins from re-filling rapidly, the site of the incompetent valve must be above this level i. If the veins re-fill, the communication must be lower down.

Observing the same protocol, proceed down the leg until the tourniquet controls re-filling. As necessary, test: Check whether they are comfortable at rest, is patient tachypnoeic? Are they using accessory muscles?

Are there any obvious abnormalities of the chest? Check for any clues around the bed such as inhalers, oxygen masks or cigarettes. Inspect the hands, hot, pink peripheries may be a sign of carbon dioxide retention.

Look for any signs of clubbing, cyanosis, hypertrophic pulmonary osteoarthropathy, dupytren's contacture and nicotine staining. Inspect the face, ask the patient to stick out their tongue and note its colour - checking for cyanosis.

Nac osce comprehensive review pdf

Look for any use of accessory muscles such as the sternocleidomastoid muscle. Also palpate for the left supraclavicular node Virchow's Node as an enlarged node Troisier's Sign may suggest metastatic lung cancer. Examine the chest and back. Observe the chest for any deformities barrel chest, kyphoscoliosis, pectus excavatum, pectus carinatum , symmetry of expansion, dilated veins, intercostal recession. Feel between the heads of the two clavicles for the trachea, see if it is deviated. Feel for chest expansion.

Place your hands firmly on the chest wall with your thumbs meeting in the midline. Any recent trauma? Past History Do you have any medical illnesses? Are you allergic to any medications? Any surgeries in the past? Differential Diagnosis Atrial fibrillation secondary to: Congestive heart failure.

Ischemic heart disease. Thyroid disease. Management Treat the primary cause. Admit in cardiac care unit. Rate control by beta blockers, calcium channel blockers or digoxin. Anticoagulation with heparin, then warfarin. Rhythm control by electro or medical cardioversion.

Investigations CBC, electrolytes, glucose. Chest X ray. Family and Social History Do you smoke? Do you consume alcohol? Do you take any recreational drugs?

Nancy Alfredo, a 30 years old woman presented to your clinic with a black eye and multiple bruises on her arms. Take history and address her concerns. Counseling Case: Domestic violence HOPI. Who are the biological parents of the How did the injury occur? When did the injury occur? Do the children witness physical abuse? Ask about violence to the children, sexual Circumstances in which the injury occurred? Describe violent episode, what triggered it? Is the boyfriend willing to seek help?

Were objects used as weapons? Was the boyfriend remorseful afterward? History of previous episodes of violence or Family and Social History loss of temper by boyfriend?

Do you smoke? What was the patient's response? Do you use recreational drugs? Is the boyfriend controlling? Does the partner abuse alcohol or other Does he restrict her activities? Question her excessively after she has been Economic situation? Any family history of physical abuse? Engages in verbal abuse or threats? Is the violence increasing in severity? Are there children in the house? Counseling for domestic violence Explain that the boyfriend hitting the patient is a criminal assault and an example of domestic violence.

The best way to prepare for the National Assessment Collaboration.

Domestic violence tends to increase over time unless the victim leaves, or the abuser and couple seek therapy. Very often, women don't leave their abusive partner until they are seriously hurt. Domestic violence between adult partners tends to be reflected in future behavior of children who are exposed to it and there is a risk of violence to the children.

Child abuse is a criminal act and if suspected, is reportable to police by law. Spousal abuse is also a criminal act but is not reportable by law. Recommend that the patient not return to the abuser if there is risk to her safety e. If the patient does return, an exit plan should be developed to ensure patient safety. Document all evidence of abuse pictures, sketches and related visits; quote patient directly in chart. Alternatively, the patient can contact the police to obtain a restraining order on the abuser.

Develop a plan with the patient to seek alternate living arrangements women's shelter. Enlist the help of patient's support structure friends, other family members. Contact the police patient should be informed that, if contacted, the police will lay charges whether the patient wants to or not. Social worker referral and provide info about community resources. Arrange follow up.

Alphabetical Index Abortion - clinical case Collateral Ligament Stability Alphabetical Index Genital herpes Pain Abdomen - clinical case Alphabetical Index Syphilis Trendelenburg Maneuver Flag for inappropriate content. Related titles. Jump to Page. Search inside document. Congestive Cardiac Failure: Immediate management in the ER Oxygen by nasal cannula at 4 liters per minute. Dopamine indicated in cardiogenic shock and hypotension Non pharmacological management of Heart Failure Exercise: Steps before beginning examination Introduce yourself: Inspection Ask for patient's vitals.

Observe patient: Is patient anxious? Note hoarseness of voice. Examination of the Thyroid gland and cervical lymph nodes. Examination of legs. Thank the patient after the examination. You will be losing valuable time You will be given a pencil and a booklet with blank pages.

Clinical Cases - Counseling Nancy Alfredo, a 30 years old woman presented to your clinic with a black eye and multiple bruises on her arms.

Emad Mergan. Vijay Mg. Marc Tarcu. Hassan R.

Darin Boyd. Burton Mohan. Al Imari. Through such a system, an IMGs path to licensure would be the same, regardless of the jurisdiction in which he or she is being assessed. Candidates are advised to complete their registration within this time-frame.

The exams are scheduled for March, June, August and September. Visit www. Fees Application Fee: For a given administration, each candidate rotates through the same series of stations.

Each station is 10 minutes in length with two minutes between stations. At each station, a brief written statement introduces a clinical problem and outlines the candidate's tasks e. In each station, there is at least one standardized patient and a physician examiner. Standardized patients have been trained to consistently portray a patient problem.

Candidates should interact with standardized patients as they would with their own patients. The physician examiner observes the patient encounter. For most stations, the candidate will be asked to respond to a series of standardized oral questions posed by the physician examiner after seven minutes with the standardized patient. There are no rest stations. Orientation videos http: This component lasts 45 minutes and consists of 24 short-answer questions testing the candidates' knowledge of therapeutics for patients across the age spectrum and related to pharmacotherapy, adverse effects, disease prevention and health promotion.

The OSCE score contributes 75 per cent of the total score and the therapeutics score contributes 25 per cent of the total score. For reporting purposes, the NAC total examination scores are reported on a scale with a distribution ranging from 0 to with a fixed passing mark of If you pass the examination, you can register for the examination a maximum of two additional times if your eligibility is maintained.

Regardless of whether you pass or fail, you can only take the examination three times. If you take the examination more than once, the most recent result will be the only valid result. Sample of Therapeutic written test Question: An otherwise healthy 65 year old woman presents with a 3 week history of aching and morning stiffness in both shoulders with difficulty dressing. She has no temporal artery tenderness, headache, jaw pain or visual disturbance.

What would you choose as the drug of first choice for initial medical therapy? Drug, dose, route of administration and duration are required. What would you choose as the drug of first choice to promote healing and lessen the neuropathic pain?

In the next 7 minutes, obtain a focused and relevant history. After the 7 minutes, you will be asked to answer questions about this patient. Example of post encounter questions Ql. The abdominal examination of David Thompson revealed no organ enlargement, no masses and no tenderness. What radiologic investigation would you first order to help discriminate the cause of the jaundice? If the investigations revealed that this patient likely had a post-hepatic obstruction, what are the two principal diagnostic considerations?

What radiologic procedure would you consider to elucidate the level and nature of the obstruction? Cardiology Acute Myocardial Infarction: Immediate management in ER 1. Beta blockers: Inj Metoprolol 2. Oxygen by nasal cannula at 4 liters per minute 5. Sublingual Nitroglycerin 0. Non-enteric coated Aspirin mg PO. Beta Blockers M: Morphine Sulphate 0: Nitroglycerin A: Lasix M: Morphine Sulphate N: Nitroglycerin 0: Positive airway pressure P: HF with fluid retention: Gl symptoms, rash, pruritus, increased liver enzymes, myositis.

Hypertension Non pharmacological treatment: Weight reduction: Osteoporosis, cataracts, glaucoma, peptic ulcer disease, avascular necrosis, hypertension, increased infection rate, hypokalemia, hyperglycemia, hyperlipidemia. Active infection, hypertension, diabetes mellitus, gastric ulcer, osteoporosis. Gout 1. Acute Gout: Tab Indomethacin mg PO tid x days. Tab Naproxen mg PO bid x days. Tab Colchicine 0. Systemic Steroids: Tab Prednisone 40 mg PO od x 5days, then gradually taper the dose.

Intra- Articular Corticosteroid: Recurrent Gout: Treat for months. Over producers: Tab Probenecid mg PO bid max: Concurrently start with Tab Colchicine 0. Treatment does not alter biopsy results if the sample is taken within 2 weeks. Monitor ESR regularly. If visual symptoms are present, or develop during treatment, the patient is admitted and given Inj Prednisolone mg IV ql2h for 5 days.

Polymyalgia Rheumatica Management 1. First week: Next three weeks: Acute uncomplicated UTI: Drug resistant UTI: Acute complicated UTI: Outpatient management: Inpatient management: IV for hours, then switch to oral agents.

Total duration of treatment for 14 days. Inj Piperacillin 3. Inj Epinephrine 0. Salbutamol via nebulizer. Therapeutic Guidelines Medicine 31 Arrhythmias Arrhythmias due to 2nddegree and 3rddegree heart block: Inj Atropine 0.

Transcutaneous pacing first give Inj Midazolam 2mg for sedation Admit for transvenous pacing Unstable patients hypotensive systolic BP 7. Look of the cause: Urine output, extra-cellular fluid volume, electrolytes, ABG, creatinine, capillary blood glucose and level of consciousness every hours. As acidosis is corrected, hypokalemia may develop. Correct acidosis: Digibind vials if dose unknown Chronic toxicity: Inj Sodium nitroprusside 0.

Aortic dissection: CBC, electrolytes, glucose, methanol level. Severe intoxication can lead to delirium and coma. Physiological effects include the following: Respiratory depression may occur while the patient maintains consciousness Alterations in temperature regulations Hypovolemia true as well as relative , leading to hypotension Miosis Soft tissue infection Increase sphincter tone can lead to urinary retention Treatment IV glucose: Tensor bandage or special supports.

Elevate the ankle as much as possible. Analgesics as needed. Crutches if too painful to bear weight. Urgent neurology consult. Counselling Smoking cessation 1. Nicotine gums: Alcohol cessation Protocol: Have you ever felt the need to CUT down on your drinking? Adjunctive Medications for abstinence 1. SexuallyTransmitted Infection a. Treat partner, Reportable disease. If pregnant: Primary, Secondary, Latent Syphilis duration less 1 year: Inj Benzathine Penicillin G 2.

If allergic to Penicillin: Tab Doxycycline mg PO bid for 14 days. Genital herpes: First episode: Genital warts HPV: Urinary Tract Infection Uncomplicated: Acute Uncomplicated: Vulvovaginitis a. Tab Fluconazole mg PO each week.

Monitor liver enzymes every months. Bacterial vaginosis: Tab Flagyl mg PO bid x 7days. Trichomonas vaginalis: Atrophic vaginitis: Topical Estrogen cream 0. Reportable disease, treat partners, rescreening after weeks incase of documented infection.

Mild DUB: Severe DUB: Oral Contraceptive Pills. Important to rule out secondary causes of dysmenorrhea. Tab Ibuprofen mg PO qid till symptoms last. Oral Contraceptive pills. GnRH Agonist: Inj Leuprolide 3. Inj Goserelin 3. To reduce the side effects of bone loss. Standard dose - Tab Prempro premarin 0.

Pulsatile - Tab Premarin 0. Given as 3 days on and 3 days off. Estradiol transdermal patch twice daily and Tab Provera 2. Take within 72 hours of unprotected intercourse. Tab Ovral 2 tabs PO ql2h x 2 doses has Levonorgestrel 0. Plan B Tab Levonorgestrel 0. Penicillin allergic: To maintain DBPtwice weekly, but not daily. Acute Management i. Fluids, if dehydrated. P2 Agonist: Salbutamol Ventolin - 0.

If Severe - Ipratropium bromide Atrovent lcc added to each of first 3 salbutamol masks. Bacterial Pneumonia Newborn under 3 weeks old 1. Admit all newborns with Pneumonia. Antibiotic regimen Use antibiotics combined a Antibiotic 1: Ampicillin i.

Organisms requiring additional antibiotic coverage i. Age 3 weeks to 3 months 1. Outpatient if afebrile without respiratory distress i. Inpatient if febrile or hypoxic i. One of the following antibiotics if febrile: Critically ill i. Inj Cefotaxime as above and Inj Cloxacillin or ii. Age 3 months to 5 years 1. Outpatient if afebrile without respiratory distress a Consider initial parenteral antibiotic at diagnosis: Inpatient if febrile or hypoxic: Critically ill: Age 5 to 18 years 1.

Croup Laryngotracheobronchitis a Humidified 0 2 b Nebulized racemic epinephrine l: Acetaminophen for fever or pain. Erythromycin to all the household members. Therapeutic Guidelines Pediatrics Bacterial Meningitis Reportable disease a Inj Dexamethasone 0.

Start within 1 hour of 1st antibiotic dose.. Febrile Seizures a In ER: Inj Diazepam 0. Diazepam rectal suppository. Oral Treatment- for days. IV antibiotics i. UTI Prophylaxis i. Allergic reaction a General Measures: ABC management. Nebulised beta-agonist Albuterol. Epinephrine 1: Orally same dose q6h x 3days.

Medical alert bracelet. Strict avoidance of allergen. Allergy testing and desensitization therapy. Investigate the cause of anemia. It can readily escalate to aggression, which can be either verbal vicious cursing and threats or physical toward objects or people. Treatment of delirium requires treatment of the underlying causes. Antipsychotics are first-line treatment.

Haloperidol is the most effective medication for decreasing agitation in delirious patients.

First generation antipsychotic Loxapine and second generation atypical antipsychotics such as Olanzapine,Risperidone and Quetiapine can also be used. Benzodiazepines should be reserved for cases of alcohol withdrawal. Treatment of mania involves both acute control of severe agitation by a mood stabilizer and long term mood stabilizers. Initially atypical antipsychotics such as Risperidone, Olanzapine or Quetiapine are effective.

Cognitive behavioral therapy CBT Reduction of consumption of caffeine and other stimulants. Symptoms can include chest pain, heart palpitations, sweating, shortness of breath, feeling of unreality, trembling, dizziness, nausea, hot flashes or chills, a feeling of losing control, or a fear of dying. Some people start to avoid situations that might trigger a panic attack; this is called panic attack with agoraphobia.

Panic disorder refers to recurring feelings of terror and fear, which come on unpredictably without any clear trigger. Serotonin norepinephrine reuptake inhibitor SNRIs eg. Venlafaxine is also used in panic disorder. There is a delay in the onset of response to these drugs which may be accompanied by initial agitation.

Other medication include Tricyclic antidepressants TCAs eg. Phenelzine, Tranylcypromine. Benzodiazepines 1 line , Serotonin Antagonists: Situations that can trigger social anxiety include small group discussions, dating, going to a party, and playing sports. Common symptoms of social anxiety include blushing, sweating, and dry mouth.

People with social phobia often avoid social situations that cause anxiety. Escitalopram, Fluvoxamine, Paroxetine, Sertraline and Venlafaxine may be used for milder cases.

Simple stage fright or fear of public speaking may respond to low dose Propranolol lOmg taken 30 minutes before the event. There is no specific source of fear. Symptoms can include muscle tension, trembling, shortness of breath, fast heartbeat, dizziness, dry mouth, nausea, sleeping problems, and poor concentration. CBT is the most effective psychosocial treatment but often takes 20 or more sessions to be effective. Bupropion and Pregabalin are further choices.

Low dose benzodiazepines can be used but dependence is a problem. Buspirone has a low abuse potential and is less sedating than benzodiazepines. Smoking cessation, second line Antidepressant. Start mg bid x 4 days m g tid. The thoughts may be connected to the repetitive behaviours.

For example, people who fear getting an infection may constantly wash their hands. CBT is the psychotherapy of choice. Fluoxetine, Fluvoxamine, Paroxetine and Sertraline, in the usual antidepressant dosing range are the drugs of choice in Canada. It may take weeks for symptoms to improve. Second line drugs include Clomipramine, Venlafaxine, Citalopram and Mirtazapine. Symptoms usually start within 3 months of the traumatic event but may take years to start. PTSD can be associated with sleep problems, nightmares, irritability, and anger.

Feelings of guilt and unworthiness are common with PTSD. Traumatic experiences that can trigger PTSD include wars, plane crashes, natural disasters e. Fluoxetine, Paroxetine, Sertraline and Venlafaxine are first line options. Dementia Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging.

Dementia is not a single disease, but rather a non-specific illness syndrome in which affected areas of cognition may be memory, attention, language, and problem solving. It is normally required to be present for at least 6 months to be diagnosed. Benzodiazepines must be used cautiously in the elderly patients due to increase risk of falls and impaired cognition.

Medication must be taken even if patient is feeling better. Start 20 mg qhs, increase lOmg every 2wks, max 60mg per day. Start 20mg PO qd, max 60mg. Use in Atypical depression, Refractory depression. Hypertensive crisis, Serotonin syndrome.

Interaction with tyramine containing foods to be avoided strictly. Anti-cholinergic - dry mouth, constipation, blurred vision, Anti-histaminergic - sedation, weight gain; Serotonergic - sexual dysfunction; Orthostatic hypotension; Sinus tachycardia, SVT, Ventricular tachycardia, Prolonged QT interval, heart block; Withdrawal symptoms.

Venlafaxine Effexor Psychosis In acutely psychotic individuals, short-acting parenteral antipsychotics either alone or in combination with a parenteral benzodiazepine may be recommended. Liquid formulations of atypical antipsychotics may be used as an alternative to intramuscular injections, Risperidone and Olanzapine are examples.

Atypical antipsychotics: Agranulocytosis, Diabetes mellitus, hypertriglyceridemia. Order weekly blood counts for 1 month and then q2 weeks. Headache, sedation, dizziness, constipation. Insomnia, agitation, EPS, headache, anxiety, hyperprolactenemia, postural hypotension, constipation, dizziness, weight gain.

Typical antipsychotics: May repeat qmins, max mg per day. Dyskinesia Akathesia - treat with Lorazepam, Propranolol or Diphenhydramine. Perioral tremor Neuroleptic malignant Syndrome - Muscle rigidity, tremor, delirium, high fever, diaphoresis, hypertension. Discontinue drug. Give symptomatic treatment and supportive care. Treatment with Dantrolene or bromocriptine. Treatment - Clozapine. Mood stabilizers: Used in Bipolar disorder.

Serum levels - 0. Treatment of Lithium toxicity: Discontinue lithium. Check serum lithium levels, BUN, electrolytes. IV fluids - Normal saline. Monitor LFTs weekly x 1 month, then monthly. Monitor weekly CBC due to risk of agranulocytosis.

Medications causing sexual dysfunction 1. Thiamine mg PO OD x weeks. Cocaine Overdose: At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there. Verbalize the steps of the examination and your findings. Use proper draping techniques. Is patient comfortable at rest?

Do they appear to be tachypnoeic? Ask the patient to hold their hands out in front of them looking for a any tremor and then get them to extend their wrists up towards the ceiling keeping the fingers extended and look for flapping asterixis in hepatic encephalopathy. Examine the face, check the conjunctiva for pallor. Also check the sclera for jaundice.

Also look at the tongue. If it is red and fat it could be another sign of anaemia, as could angular stomatitis. Examine the neck for an enlarged left supraclavicular lymph node. Therefore, enlargement of this node may suggest metastatic deposits from a malignancy in any of these areas. Examine the chest, in particular look for gynaecomastia in men and the presence of 5 or more spider naevi.

These are both stigma of liver pathology. Inspect the abdomen and comment on any obvious abnormalities such as scars, masses and pulsations. Listen for bowel sounds - absent e. Ileus, peritonitis , tinkling bowel obstruction 4. If a patient has pain in one particular area you should t ILIAC start as far from that area as possible. Initial examination should be superficial using one hand. Once you have examined all 9 areas superficially, you should examine deeper.

This is performed with two hands, one on top of the other. Feel for organomegaly, particularly of the liver, spleen and kidneys. Palpation for the liver and spleen is similar, both starting in the right iliac fossa.

For the liver, press upwards towards the right hypochondrium. You should try to time the palpation with the patient's breathing as this presses down on the liver.

If the liver is distended, its distance from the costal margin should be noted. Palpating for the spleen is as for the liver but in the direction of the left hypochondrium. The edge of the spleen which may be felt if distended is more nodular than the liver. To feel for the kidneys you should place one hand under the patient in the flank region and the other hand on top. You should then try to ballot the kidney between the two hands.

Percussion Percussion over the abdomen is usually resonant, over a distended liver it will be dull. Percussion can also be used to check for 'shifting dullness' - a sign of ascites.

NAC OSCE - A Comprehensive Review 1E (2011)[PDF][Koudiai] VRG

With the patient lying flat, start percussing from the midline away from you. If the percussion note changes, hold you finger in that position and ask the patient to roll towards you. Again percuss over this area and if the note has changed then it suggests presence of fluid such as in ascites.

It is also appropriate at this time to check for pedal edema. You should mention to the examiner at this point that you would like to finish the examination with an examination of the hernial orifices, the external genitalia and also a rectal examination. You should note whether the patient looks comfortable. Are they cyanosed or flushed? Respiratory rate, rhythm and effort of breathing. Inspect fingers for capillary refill time, peripheral cyanosis, osier's nodes infective endocarditis and nicotine staining.

Inspect palms for palmar erythema,Janeway lesions and xanthomas. Take the radial pulse, assess the rate and rhythm. At this point you should also check for a collapsing pulse - a sign of aortic incompetence. A collapsing pulse will present as a knocking on your palm. At this point you should say to the examiner that you would like to take the blood pressure. They will usually tell you not to and give you the value. You should also look for any evidence of xanthelasma.Any surgeries in the past?

Wast it normal? Observe the patient's posture and whether they are steady on their feet. Observe any limp or obvious deformities such as scars or muscle wasting. Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices.

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