Heart Failure

Heart Failure(HF)

1. intro

2. pathophysio

3. Signs and Symptoms

4. Classifications: NYHA

5. Investigations

6. Management

HF is a structural or physiological abnormality of the heart resulting in its inability to meet the metabolic demands of the body or its ability to do so only at higher than normal filling pressure

Population:

EF <40% HFrEF

EF>50% HRpEF

EF: 40-50: HFmrEF

Pathophysio

Acute heart failure Signs and Symtoms

4 types of symptoms to show which type of HF belongs to. 

• warm and wet: adequate perfusion but congested (lungs/peripheral) - volume overload
• cold and dry - hypoperfuse, dehydrated - pump failure
• cold and wet - hypoperfuse and congested
• ward and dry - adequate perfusion and dehydrated - mild HF/ compensated stage of HF

what is reperfusion? The restoration of blood back into tissue

- Elevated jugular venous pressure 

• is a manifestation of abnormal right heart dynamics, mostly commonly reflecting elevated pulmonary capillary wedge pressure from left heart failure. This usually implies fluid overload, indicating the need for diuresis.

Left and Right sided heart failure differences:

NYHA: 

I- no limitation , 

II: slight limitation, comfortable at rest, activity causes fatigue 

III: dmarked limitation: less than ordinary activity causes sx 

IV: unable to carry out physical activity without discomfort.

Imvestigations (Ix):

• ECG
• - access HR, rhythm, 
• QRS morphology /durarion/voltage, 
• evidence of ischemia, LVhypertrophy/ arrthymia
• chest radiography: 
• pulmonary congestion, cardiomegaly , or other lung pathology
• Echo 
• to determine type of HF
  - assess LV chamber size, thicknesss
  - diastolic fx
  myocardial ischemia test: treadmill exercise, stress echocardio,
• invasive: 
• coronary angiography
• others: holter, pulmonary function test

Blood Ix: 

• FBC
• RP
• LFT
• CBS
• FLP
• HbA1c
• Natiuretic Peptides/BNP: 
• peptide hormones synthesized by the heart, brain and other organs. to reduce arterial pressure by decreasing blood volume and systemic vascular resistance

- the higher the number= heart could not pump the way it should

- release when cardiac myocytes are strained

- useful to rule out acute dypsnea

- NP can increase also when pt have AF/ CRF/ age/ obese/ ARNI

- significant if >400, age >50: >450, age 50-75 :>900, age>75: >1800

• CK: 
• inflammation of muscle, indicates level of damage or disease of skeletal muscle
• TFT
• infective screening
• iron study,
•  - to check Tsat: Fe/TIBC x100, if <20% : inadequate iron supply
• urine test: UFEME/ C+S
• blood gas:

- hypoxemia: paO2<60

- hypercapnia: PaCO2>50

- Acidosis: pH<7.35

Management(Mx): 

Acute HF:

1. stabilise hemodynamics
2. maintain o2 and perfusion of organs
3. relieve symptoms and signs
4. treat u/l cause or aggravating factors

Treatments:

1. non pharma, pharma

• Diuretics
• ACEI
• ARB
• Beta blockers
• MRA
• Statins

2. Surgery

3. Device therapy

- catheter ablation/pacemaker therapy

Common drugs used:

• dopamine: improve renal perfusion and promote diuresis / increase BP
• dobutamine: peripheral hypoperfusion n pulmonary congestion
• Ivabradine: slows the heart rate to allow more perfusion to the heart
• thiazides: hydrochlorothiazides: promote natiuresis and diuresis

ROF : 1-1.5L/day

To watch out for

- worsen symptoms, readmission rate

- increase in cardiovascular event rate

- increase in bleeding risk and stroke rate

- adverse effects due to pharmacotherapy

References:

1. Malaysia CPG for HF

Abdomen examination

Basic Abdomen Examination

In this post I will also add in a sample OSCE questions for EPR. Hopefully you will understand the structure and question style of EPR part II. 

Physical examination video. 

1; check from the end of the bed first  

(include RR, age, confusion, pain, scars, septic looking, pallor )

then... check 

--> the hand(palm, finger clubbing and straighten hand)

--> arms and axilla

--> face+mouth

-->lymph node 

--> chest (spider naevi>5 is significant)

2. Abdomen

--> observation

--> palpation of 9 segment! light palpation and deep palpation-

-> access the location, size, shape, surface, consistency, mobility

--> palpate the liver: liver edge then percuss from up to down 

--> the gall bladder (murphy sign)

--> palpate the spleen start diagonally (look for rib 11, splenic notch)then percuss to confirm

--> ballot the kidney (make sure your hand is symmetrical)

--> palpate the aorta (2cm side and up, on the corners)

--> palpate the bladder

--> percussion for shifting dullness

--> auscultation for bowel sounds- bruits

3. peripheral check up

- check limbs (pitting edema)

Investigations

1. FBC

- WBC: high/low any infection

- Hb: anemia, bleeding, IDA

- PLT: low - spleen issue

2. coag

- PT prolong - if its high to suspect some liver damage/ vit K usage/ anticoagulant usage/ liver disease

- APTT - prolong ppt --> liver disease

3. LFT

- AST : in the blood may indicate hepatitis, cirrhosis, mononucleosis, or other liver diseases. High AST levels can also indicate heart problems or pancreatitis. 

- ALT : high--> might be acute hepatits/ viral hepatitis infection

- ALP: can indicate liver disease or bone disorders

4. viral screening

- Hep B and Hep C (HbsAg, ANTI-HCV)

5. for differential diagnosis

- malignancy, tumor, abscess - to confirm with fnac/biopsy

- infection

- autoimmune disease

- thrombosis

- myeloma

- primary biliary cirrhosis

 

Sample cases for OSCE:

Sample Answer: 

English to Malay terms

References:

https://www.moh.gov.my/index.php/pages/view/168

CPG management of upper GI bleeding

CPG Acute variceal bleeding management

ATLS overview (OSCE)

Definition: 

1. ATLS : life threatening with pulse
2. ACLS(cardiac): life threatening, no pulse

Common emergency cases:  (ATOMTC)

• Airway obstruction
• Tension pneumothorax - silent chest, trachea deviated

• Open wound

• Massive hemothorax

• Tracheobronchio dissociation/ fistula
• empysema
• crepitus, poor air entry
• corrective surgery
• do X-ray - is it hyperventilated?

• Cardiac tamponade - JVP, increase HR, muffled heart sound
• Pericardial effusion?

OSCE ATLS steps: 

1. What to do when the patient came in with emergency? (DR. AVPU)

1. Danger
• access the situation, ensure you are safe first
2. Response & role
• check for patient response and 
• ask someone around you(assistants)to help
• prepare airway apparatus +cervical support
• chest tube, needle tube, SP02
• IV line - for fluid & BT & crossmatch

    Check their response to... 

1. Alert
2. Verbal
3. Pain
4. Unconscious

2. If all above indicates emergency case signs proceed with   ABCDE

Airway       - jaw thrust - open the mouth and inspect for foreign substances (yonker suction could help 

                       removing them) - check for gag reflex - 

                   - cervical support - can be confirmed by using the NEXUS criteria 

                  

 https://www.grepmed.com/images/3860/management-clearance-algorithm-cervical-canadian-mnemonic-imaging

 (cervical spine evaluation in trauma)

             

Breathing   - ventilation,

• inspection: check for ATOMTC (common emergency cases, in first paragraph)
• palpation: trachea location, rib intact? fracture?
• percussion: hyper-resonance? dull?
• auscultation: Air entry? Heart rhythm, HR?                        

                    - check Respiratory rate

                    - intubate if needed

Circulation - bleeding

• IV 2 large bonula
• IL warm NS
• BT urgent panel
• inspect head to toe for bleeding
• EENT, abdomen (peritonitis), pelvis(spring fracture), genitalia (hematoma, scrotum, perianal bleeding, urethral)
• peripheral bleeding (fracture)

Disability   - pupil

• GCS scale!   
•       

Exposure    - environmental - do they need a blanket? (hypothermia?)

• log roll for back examination (examine the spine - stepping sign)/ rectoperitoneal bleeding / prostate high riding / pelvic injury / abdominal injury / thoracolumbar injury
• DRE? anal tone lac? 

Simple Management mnemonic:

2(CBD, NG tube)

+

2(X-ray : chest and pelvic)

+

2(drugs and analgesia IPTT)

+

2 investigation(ECG, FAST u/s)

other links:

https://www.researchgate.net/figure/ATLSR-algorithm-and-spine-trauma-assessment-In-Step-A-cervical-spine-C-Spine_fig4_24174239

Breaking bad news: Down syndrome

How to explain to the parents about Down Syndrome?

First, you will need to know what is the problem and understand before explaining to them.

The parents will be worried, anxious and some might even cry upon receiving the news. Be ready to comfort them and help them through this journey of hardship but understanding their children together. 

As a doctor, you are to tell them the truth and at the same time, comfort and reassurance. 

Resources are from: https://canadiem.org/breaking-bad-news/

So.. how should you start your conversation?

1: Express your concern

- Greet the parents, introduce who you are and why are you here. 

Setting

- Before telling them about their child's condition, 

    ask if they need someone to accompany them or if their family member is here (if they are alone).

Example: Before we go ahead, can I just ask, would you like to be with someone now? 

 

Perception

- Ask what they realise that is abnormal about their child.

    - This helps us to understand how much they know about the situation, so we know where to start.

Invitation

Tell them about the news:

Example: Unfortunately, I do not have good news, I am sorry to tell you that... ...

*wait for them to react before you continue your explanation*

👇

2. Explain and educate

Knowledge

- Explain the nature of down syndrome. definition, symptoms and signs

- Genetic Issue

- Intellectual Aspect

- Health Aspect

    - To tell them their child would probably need a lot of follow up on potential health issues

    - TO explain the prognosis is poor

        - average lifespan is around 50-60years old, 

        -possible health issues of the heart, gastrointestinal, eyes and bones, 

👇

3. Advice the parents

- Their character and behaviour infront of the child

    - try to be encouraging to the child

    - be patient and kind

-To discover the child's talent

    - the child might not do well in studying but might excel in cooking, music or sports

- Diet

    - to ensure good nutrition provided and not neglect the child

    - they need the same/ more attention compare to normal children of the same age. 

- Advice to look for special care school

    - there are special school's which teaches kids who have the same problem

    - opportunity to know other parents who face the same issue and share experiences

👇

4. Future follow up 

- to come regularly for normal vaccination

- to check calcium development regularly

- ensure proper growth and reach their age milestone

- Series of check up for their child in the future : Eye checkup, bone density, X-ray, echocardiogram, etc. 

👇

5. Encourage the parents to join a parents group

Summary

- we can give them leaflets (if available) to understand down's syndrome better

- provide reliable sources (websites) so they can read to help with the understanding

- encourage them to not give up and keep persevering till the end. the child is a gift from god, and we are to take care of them with love and care. 

Example: Don't blame yourself. There is nothing that could have been done to stop this from happening. What you need to do now is to... ... 

👇

-Reassurance

Example: 

    - I understand you are worried but...

    - Do you need some time to rest?

    - We will keep an eye on your child for his (results), so we can provide the treatment earlier. 

    - The doctor/professor who is in charge of your child is an expert on this syndrome and would try 

       his/her best to help your child. 

    - I will give you a follow up date with us in the clinic, will you be available on the ... ...?

👇

6. Empathy (throughout the whole session)

** Always ask if they understand what you are trying to say before going to the next point.

**ask if they have questions to ask you concerning their child and their worries. 

Example: Do you understand what I am trying to explain? 

                Do you have any questions?

- Look them in the eye while you are talking and show that you care about them.

- If there is a break down (crying), pause the conversation and try to offer tissue or suggest them to come at a later date with their family/support.

- Have empathy and to try answer their questions at the same time.  

Consent for Bone Marrow Aspiration - Peds

Pediatrics Consultation Session

1: Ask for a chaperone

2: Talk to the parents/ guardian who bring the children

    - Ask if they know about bone marrow aspiration

    - what are their concern

    - will they need another person to sit in and listen

3. Describe reasons for having a bone marrow aspiration

    - to confirm diagnosis

    - to check iff there are any blast cell

    - after retrieving the samples, it will be sent for culture, biochemical test... ...

4. The way procedure was done

    - Sedation for kids? 

    - local anesthesia?

    - are parents allowed to be in the room

    - any media distraction for the child while procedure is ongoing

      

5.  Time and Cost

    - how long is the procedure

    - the cost, and ask if parents are able to pay for the procedure

    - recovery time after procedure 

6. Any complication?

    - possibilities of infection if not deal with care

    - child need to be put in a position that can be uncomfortable.

    - try to reassure the mother/father about the success rate of bone marrow aspiration

            - that it is safe

            - eg. cases like this are common

7. Ask if they have any questions

    - be patient and confident in what you say (make sure it is right)

    - try to comfort the parents

    - no big medical term.

    - always ask if they understand what you say

8. Ask for consent and permission

    - Do you agree?......

This template can be useful for lumbar puncture for children after a few minor changes.

TQ and good luck!

 

OSCE VIDEO 1 (epr malaysia)

This is a sample video which can be helpful for you to imagine how it is like during the exam.

Just for your reference, 

and

credits to the students, doctors and the volunteer from IMU. 

Thank you for making this video. 

Question in the video

**P/s: this is exactly what happens to my OSCE exam when I took EPR OSCE on 2019. Although the venue is different (in USM), the way they conduct the exam is the same.

There will always be a doctor in each room to evaluate your performance and ask you questions after you finish the task.

Make sure you organise your time well. For sample questions you can refer to my other posts here.



Good luck!

Will EPR exam be postponed?

To all readers,

I am sure a lot of you are wondering if Examination of Provisional Registration (EPR) will be postponed this year.
Let me tell you the trend, usually the first batch who took step 1 on March will have their OSCE on July while the 2nd batch is on September and December for step 1 and step 2 respectively. 

It is almost the end of May 2020 now, and there is still no news of the examination date for EPR OSCE. So, there is a high possibility that it could be delayed. Furthermore, with the PKPB - pergerakan rentas negeri restrictions, I don't think students will be able to cross state borders to take the exam if they wanted to host it by July this year.

News about PKPB

Reference: https://umno-online.my/2020/05/16/jangan-rentas-negeri-patuh-sop-pkpb/

https://www.hmetro.com.my/mutakhir/2020/05/580354/jangan-ambil-kesempatan-rentas-negeri-polis

I suspect they could delay the exam and host it around the end of the year (December) or next year on 2021. Just a wild guess since SPM is delayed to the first quarter of year 2021 (news on April 15th).
In the end it is still best for you to ask the person in charge from the MMC office. 

• For any queries kindly contact Ms Fatim Nasuha Badaruddin at fatim.mmc@gmail.com

https://www.thestar.com.my/news/nation/2020/04/15/pt3-upsr-cancelled-spm-stpm-3rd-semester-exam-pushed-to-q1-2021

Since there would not be any OSCE exam soon in the next few months, the hope of having the EPR Step 1 for batch 2 graduates are very slim. 
So there is no confirmation if there will be another theory session this year EITHER.

However all this are subjected to change based on how the Covid-19 situation goes.


What we can do now is pray to God that everything can goes smoothly under this new normal, 
and grab this opportunity to study more and be prepared when the time comes. 

(Those who are not prepared should start preparing soon.😁) 


Stay Safe and Stay home!

EPR OSCE sample - I

In this post I would like to share some examples of how the OSCE will be asked during Examination for Provisional Registration (EPR) part II.

Start practicing with your friends and think how will you manage your time to answer the question within 10 minutes.

Station 1

Answers - S1

Station 2

Station 3

Answers to S2 & S3

Station 4


Answers-S4

Their respective answer can be found after you finish reading the questions.

It can be quite difficult to try practicing this by yourself as you have no real patient, so it would be good if you can find friends who could play the role as the patient and the examiner.

This is for your reference only, to help you get prepared for the exam. 

References: IMU OSCE 2008 

Obstetric Examination Checklist

Obstetric Abdominal Examination Checklist

What should we do when we have a pregnant lady that needs physical examination?

The checklist below is a guidance to what you must do to make sure both the mum and baby are healthy and safe.😌

However every hospital have a different checklist, you need to make sure you do what the professor is expecting you to do. 

In all Physical Examination checklist there must be 5 aspects be done from

1. Introduction and consent

2. Inspection

3. Palpation

4. Auscultation

5. Presentation

If you panic during the exam, always think of this 4 aspects, and you will remember what you need to do.

Introduction

• Introduce yourself 
• Explain why are you here (to examine her and her baby's well being)
• Ask the patient to get ready. eg: to have proper exposure of her tummy and lie on her back facing upwards.
• Wash your hands and prepare instruments needed for the checkup

Inspection checklist

• Abdominal distension (is it normal distension or abnormal)
• Shape of uterus
• Scar / Linea nigrae/ Striae
• take note of the surgical scar (can be from C-section)
• Is it healed? or keloid form?
• Any fetal movements visible?

Palpation

• Superficial
• Tenderness?
• Fetal movements
• SFH - symphysis fundal height 
• Important to determine if there are any abnormalities, eg. :
• Big: multiple pregnancy, growth restriction, polyhydramious
• Small: FGR, oligohydramious
• Fundal grip
• Lateral grip
• Pelvic grip

• Fetal Lie
• transverse? longitudinal? or oblique?

• Palpate the fetus size softly to determine his position by checking:
• upper pole - is it round? soft?
• lower pole - hard? globular?
• Left side - soft broad curved structure? (back)
• Right side - Irregular structure? (limbs)

• Confirm any head engagement
• Are there adequate liquor 

Auscultation

• check fetal heart rate using fetoscope

Presentation - what to explain

Step 1

• Uterine contraction presence
• Uterus correspond to date
• Any breech? and explain

• type of lie, usually longitudinal.
• cephalic presentation?
• head engagement?
• adequate liquor ?

 For example: The fetal lie was longitudinal with a cephalic presentation noted to be 4/5th palpable on abdominal examination.

Step 2

• present SFH eg. the measurements

Step 3

• Fetal HR
• surgical scar 
• EFW
• Liquor volume

Step 4

• Gather information about delivery history
• successful vaginal delivery? c-section? what are the indications/ complications? weight of the previous baby.
• Suggest further assessment
• ultrasound to confirm location
• cardiotocogram - exclude fetal compromise
• vaginal examination
• give appropriate counsel
• eg: on VBAC benefits, success, complication compare to LSCS
• reassure patient and thank them. 

A video to help you understand better:
https://www.youtube.com/watch?v=-pkkgBX7OFQ

2019 OSCE past year - EPR

OSCE Question 2019 - EPR Part II

HI again, this is the PART II for past year questions on 2019. The Part I post only explains the past year questions that I took during December 2019 in Hospital USM December.

In this is the post I will talk about the past year OSCE (Examination for Provisional Registration Malaysia) from USM - February session and IMU- July session. 

I am still wondering why there are 3 session of osce on year 2019, but its good news for us unemployed graduates. Not sure if it will be the same for this year 2020, but unlikely. 

P/S:
It would not be as detail as the last post, as I wasn't taking exams for these two session.
But I would like to thank the one who shared his/her experience and topics with us the next batch.
Thank you💓

USM EPR II (Feb 2019)

1, ECG. Describe findings - Atrial fibrillation

- further investigation and management

2. OGTT. 

- explain procedure to patient and interpret the result

3. Postnatal discharge. advice the mother

4. Dengue (with blood result)

 - describe findings

 - diagnosis, what test to confirm (at least 3))

- other 3 Differential diagnosis

- management

5. Measure BP of 8 year old boy, with family history of hypertension

 - demo: which cuff, and why

 - explain how you do the whole procedure

 - BP 125/80, is it normal or hypertensive? 

6. Insert ET tube in manikin. name all instruments, explain and demo, contradictions

7. Primary support (Basic trauma life support)

8. X- ray (Small Intestinal Obstruction)

9. PTSD (a victim who survived in a flood) - interview the patient and give diagnosis

10.Demo Cathether insertion

 - take chief complain and diagnose patient (BPH)

11. Insert Ryle's tube on manikin

 - steps, how do you know if the tube is rightly placed?

12. CTG- cardiotopography

 - describe (FHR, variability, acceleration and deceleration)

- next management

13. Bimanual examination

 - describe suprapubic mass

14.X ray (Galaezi fracture) and label

15: perform lower limb neuro examination

16. Perform eye movement test (H test)

 - any squint, ptosis, diplopia?

- Diagram was given, describe finding (Lateral rectus palsy) 

IMU (July 2019)

1. CPR
2. Febrile seizure
3. Nephritis for children
4. Rib Fracture
5. Posterior Cruciate Ligament (PCL) reconstruct
6. Abdominal pain - peritonitis
7. ECT - Electroconvulsive therapy
8. third degree heart block
9. Thalassemia
10. Deep Vein Thrombosis (DVT)
11. Abortion
12. Pregnancy Full Physical Examination
13. Tuberculosis (TB) radiology interpretation
14. Cholesteatoma
15. Suture
16. Back pain differential diagnosis


So,  that is all the questions I get from year 2017, 2018 and 2019. You can click on the link to go back to the page where they are shared.
2017: https://yu4med.blogspot.com/2020/03/past-year-for-epr-osce-2017.html
2018: https://yu4med.blogspot.com/2020/03/past-year-epr-osce-2018.html
2019 Part I : https://yu4med.blogspot.com/2020/03/past-year-osce-topics-usm-2019.html

Good luck Doctors!

USM OSCE - EPR 2019 Dec

Past Year Topics for USM OSCE - 2019 - Part I

Hi all, in this post I am going to share the topics they have on year 2019 for Examination for Provisional Registration-/EPR. (the year I took my exams😁Thank God I passed)

** EPR is a special exam where International Medical Graduates must take to get full licence to work in Malaysia. 

So I will provide more details on how the questions were asked and what I experienced specifically for the USM December 2019 session. However I won't be able to recall the questions fully word by word, but will try my best to explain what was being asked.
The other session for 2019 are USM-Feb  and IMU-July will be posted in another post.

Reminder:

You have 1 minute to read the questions outside the room and once the bell rang, you have 9 minutes to finish the station. the second bell will ring, and you will have to move to the next station quickly to read the next question.

USM (December 2019)

Emergency medicine
1. Patient involve in motor vehicle accident, access the patient and do immediate management
   - Emergency management of Pneumothorax
   - Name all the equipment needed in ED (we have to name the equipments shown on the table)
   - explain the safe triangle position in detail
   - perform the procedure from the safe triangle


Orthopedics
2. Patient involve in motor vehicle accident and have problem walking, you are require to do a lower limb PE
  -  identify short limb gait (at least that is what I think it is) ** real patient walking
  - so I proceed with full lower limb physical examination and LLD(Limb Length Discrepancy) diagnosis
  - Physical examination necessary to identify LLD

3. Hip X-ray with a problem, patient short history provided
   -  Describe the X-ray, give a diagnosis and explain your further management
   - identify all structures shown in the picture and explain their functions.

P/S: remember to check patient name and date


Internal medicine
4. Patient with chest pain and SOB, take the history and explain further management if needed
  - history taking and I suspect its AMI

5. Interpret chest X-ray and give diagnosis with treatment + physical examination of the chest
   - Tips: there is a mass in the chest x-ray

P/S: treatment plan must be specific***


Surgery
6. Patient present with mass at inguinal area, diagnose and focus physical examination
  - Inguinal Hernia - after history taking, ask for permission to do examination
  - physical examination is done on the manikin. (you can refer to this to understand the scoring)

** The examiner asked the differences of direct and indirect hernia physical examinations and their respective treatments.

7. Pneumoperitoneum - X- ray interpretation and management plan
  - management is specific

Tips: if you plan to have iv fluid, what do you want to do? (is it fluid bolus? how much you want to give? how long you plan to administer the fluid? etc.)


Pediatrics

8. Growth Chart interpretation
  - scenario given was about short stature. (explain the cause, QOL, management)

 Tips: calm the child down first so they can cooperate

9. Lumbar Puncture Consent from Parents
  - get the consent is the aim. make sure you explain all about lumbar puncture from the cause to the treatment values.
   - reassure the patient


OBGYN

10. Bimanual Examination
   - there is a huge mass in the manikin.
   - explain your examination specifically on inspection and palpation,
  - the examiner will ask for your diagnosis and your management plan for the patient

11. Patient complain is stomach pain and discomfort (a little aggitated)
  - After history taking, i suspect its a Placenta Abruption case.
  - the examiner asked for our diagnosis
  - present your case from history taking
remember to include: Gestational age calculation, GPO - all OBGYn necessary history
  - treatment plan

*P/S: I finish this station when the bell rang for us to leave the room. We only have 9 minutes to do all the above, make sure you manage your time well. 


Anesthesiology

12. Patient need to prep for surgery, as a junior doctor apply adequate oxygenation before anesthesiologist arrive.

  - full airway assessment and use the Bag valve mask (if  you observe well, you will see it lying on the table beside the manikin) -explain the indication and possible complications.

*P/S:   - the procedure was easy as i did a lot during my internship in china (finish smoothly in a few minutes), but the examiner asked a lot of questions and fully utilized the 9 minutes. Be ready to answer a lot of questions and make sure you know what and why you do what you have done.


Psychiatry

13. The patient is very sad and depressed. If you have good observation, you will see a plaster on her wrist.

 - The patient has history of suicide, so after accessing the patient and confirm it is related to suicide, I used the suicide risk assessment to confirm the diagnosis.
 - the examiner will ask how you come out with your diagnosis, luckily i still remember the specific components for the assessment. (the examiner asked how I get the score)


ENT

14. ASOM
 - acute suppurative otitis media

* I am very thankful to be able to work as a clinic assistant for an ENT doctor for almost a year. 
Really grateful I know how to use the equipment, give diagnosis, explain the cause, complication and management to the patient very quickly and specifically. I spend a lot of time sitting outside the station to wait for the next bell to ring.😄Thank you Doctor Koay! 


Radiology

15. Two CT was showed
 - I suspect it's a CT with Epidural hematoma and subdural hematoma
 - we are require to explain the CT in detail to support our diagnosis

 *P/S: this is the only station I don't know if what i did is right or wrong. because he is not satisfied with the answer i gave, and when I asked the other students, they say the same thing.. 
 Until now I still don't know what the doctor showed us, because I forgot how the CT looks like... (sad)


Community Medicine

16. Consultation on family planning
 -  asking for pregnancy advice and how to have a healthy

*P/S: the patient has diabetes after minutes of asking... So I have to quickly brief her the pros and cons on the complication of pregnancy while having an uncontrolled diabetes situation. 


If you have more questions can leave a comment below, I will try to reply as soon as possible.
Good luck!

2018 OSCE Past Year for EPR

Past year OSCE 2018

This is the past year topics asked in USM 2018 and specifically for those who took the examination for provisional registration. I didnt have the past years from those who took the exam in IMU, so if there is anyone who took the exam that year and would like to share, you are welcome to share it in the comments.^^



If you are interested in what they asked in 2017, refer to the previous post.

USM EPR OSCE questions 2018

Gynecology
1. COCP
2. Speculum Examination and high vaginal swab

Pediatrics
3. ORS usage advice for children
4. G6PD counseling

Orthopedics
5. neurovascular examination (lower limbs)
6. Elbow Joint Dislocation (interpret the X-ray)

Psychiatry
7. PTSD

Emergency Medicine
8. CPR
9. Mallampati classification + Airway assessment

Internal Medicine
10. Hypertension
11. GI perforation
12. Pneumoperitonium

Opthamology
13. Visual Acuity Test (patient with hypertension and diabeter)

Surgery
14. DRE
15. Colonoscopy consent

Others
16. ABG interpretation and Heart attack evaluation

2017 OSCE Past year

Past Year Questions Year 2017

The topics below are the topics from the students who took the  Examination for Provisional Registration(EPR) OSCE on 2017. I do not have the specific questions but having a main topic is sufficient for me to prepare for exam after knowing the rating rubrics for osce.

Study each topic in detail to make sure you get it.
&
Hopefully it is helpful for you!

P/S: For reference only!

IMU July 2017 OSCE

1. Hemiplegia
2. IDA
3. Cataract
4. AOM (Acute Otitis Media)
5. Rib Fracture
6. Diabetis Mellitus foot ulcer
7. MMSE + Bipolar
8. Constitutional Small gestational Age (SGA)
9. Thalassemia
10. Hepatomegaly
11. PUD
12. Contraceptive methods
13. Nephrotic Syndrome
14. Gall bladder Stone
15. Break bad news (Patient diagnosed cancer)

USM Jan 2017 OSCE

1. Schizophrenia
2. Bipolar
3. GCS and its usage
4. Snellen Chart
5. Nephritis
6. Hepatomegaly
7. Septal Deviation
8. Hemiplegia
9. COPD and Lipoma
10. choledolithiasis
11. Diverticulitis
12. HPN + IUCD
13. Fundal height (Prenatal check up)
14. Dysfunctional Uterine bleeding
15. Knee Physical Examination

Good luck!

How is your OSCE graded for EPR - Part II

The Rating Rubrics of OSCE (Part 2) - for EPR Malaysia

Notes: 

• BOLD: Must do
• Underline: clinical related

Lets continue from what we left in the last post 😁

Part 2 - History Examination

• Uses a structured, fluent and focused approach to history taking, relevant to the station
• Uses a combination of open question and closed questions where appropriate
• Respond to information given by the patient, rather than strictly appearing to follow a standard/ guided formula of questions.
• Obtains key an relevant information and shows the ability to use the information appropriately
• Question reflect the depth of understanding of the clinical condition/ pathology, where applicable.
• Repeats, reflects, summaries and clarifies any misconceptions as necessary
• Allows the patient to ask questions and endaevours to answer those
• Able to ask the patients to give more information missed earlier.
• Avoid premature or false reassurance

Part 3 - Physical Examination

• Wash your hands before starting
• Seeks permission to examine and explains the nature of the examination 
• Asks for chaperone where appropriate
• Does not distress, embarrass or hurt the patient unduly
• Respect patient's modesty
• Asks the patient if any areas to be palpated or moved are painful
• Positions the patient correctly and comfortably
• Uses a methodical and fluent approach indicating familiarity with the examination skill.
• Examines/suggests examining all the relevant areas with the correct technique.
• Completes the task in the allocated time, thanks the patient and covers up the exposed areas.

Part 4 - Procedural Skills

• Introduces and explains the procedure and gains consent
• Ensure privacy - asks for chaperone where appropriate
• Prepares the patient with correct exposure and position for the procedure
• Checks that all relevant equipment are available, appropriate and functioning
• Ensures aseptic precautions and correct methods are taken.
• Ensures correct and safe placement of equipment wherever necessary
• Avoids any unnecessary/ dangerous steps
• Disposes equipment appropriately and safely.
• Thanks the patient.
• Document and/or labels the process or samples appropriately.
• Completes the task in the allocated time. 

Part 5 - Professional Skills

• Explores patient's understanding before providing information.
• Encourages the patient to ask questions and responds appropriately.
• Provides correct information and options without the use of jargon.
• Discover the impact of the problem on the patient's life and acknowledge concerns.
• Respects the patient's autonomy and negotiates with the patient appropriately.
• Reviews the patient's understanding during the interview - clarifies and summaries where appropriate.
• Appears to have a grasp of the issue and its ramifications - minimizing conflict.
• Acts assertively and within the codes of practice and law.
• Reaches and agreement with the patient about a strategy to progress.

Part 6 - Content Knowledge

• Systematic approach in collecting and/or understanding the data/ scenario/ information presented.
• Able to interpret the data or information provided and correlate it with clinical relevant context.
• Able to identify and recognize the pattern of the underlying problem.
• Able to integrate the information provided.
• Able to make a conclusion/ diagnosis / differential diagnosis if applicable.
• Able to apply knowledge to the problem presented such as listing possible complications and management. 

So these are the 5 details that are important and vital for your exam preparation. 

Once you fully understand these, don't forget to practice with the questions in the books (Question samples can be found in sams) !!!