MEDICINE OSCE COMPILED AND SOLVED

1. Hx of chest pain :
2. Diagnosis of chest pain, types of angina,management and treatment
Chest pain can be differentiated into heart-related and non heart related chest pain
Cardiac chest pain is called angina pectoris. Some causes of noncardiac chest pain
include gastrointestinal, musculoskeletal, or lung issues.
DD; cardiovascular
A blockage of coronary arteries can lead to a heart attack
Acute coronary syndrome
Stable or unstable angina
Illustration depicting angina

Stable angina
Also known as 'effort angina', this refers to the classic type of angina related to myocardial
ischemia. A typical presentation of stable angina is that of chest discomfort and associated
symptoms precipitated by some activity (running, walking, etc.) with minimal or non-
existent symptoms at rest or after administration of sublingual nitroglycerin.[4] Symptoms
typically abate several minutes after activity and recur when activity resumes. In this way,
stable angina may be thought of as being similar to intermittent claudication symptoms.
Other recognized precipitants of stable angina include cold weather, heavy meals,
and emotional stress.
Unstable angina]
Unstable angina (UA) (also "crescendo angina"; this is a form of acute coronary syndrome)
is defined as angina pectoris that changes or worsens.[5]
It has at least one of these three features:

1. it occurs at rest (or with minimal exertion), usually lasting more than 10 minutes
2. it is severe and of new onset (i.e., within the prior 4–6 weeks)
3. it occurs with a crescendo pattern (i.e., distinctly more severe, prolonged, or
frequent than before).
UA may occur unpredictably at rest, which may be a serious indicator of an impending
heart attack. What differentiates stable angina from unstable angina (other than
symptoms) is the pathophysiology of the atherosclerosis. The pathophysiology of unstable
angina is the reduction of coronary flow due to transient platelet aggregation on apparently
normal endothelium, coronary artery spasms, or coronary thrombosis. The process starts
with atherosclerosis, progresses through inflammation to yield an active unstable plaque,
which undergoes thrombosis and results in acute myocardial ischemia, which, if not
reversed, results in cell necrosis (infarction).[7] Studies show that 64% of all unstable
anginas occur between 22:00 and 08:00 when patients are at rest.[7][8]
In stable angina, the developing atheroma is protected with a fibrous cap. This cap may
rupture in unstable angina, allowing blood clots to precipitate and further decrease the
area of the coronary vessel's lumen. This explains why, in many cases, unstable angina
develops independently of activity.
 Myocardial infarction ("heart attack") - People usually complained of a pressure or
squeezing sensation over the chest. Other associated symptoms are: excessive
sweating, nausea, vomiting, and weakness. Chest pain is more commonly associated
with anterior infarction because of left ventricular impairment; inferior infarction is
more commonly associated with nausea, vomitng, and excessive sweating due to
irritation of vagus nerve; lateral infarction is associated with left arm pain.

• Prinzmetal's angina - Chest pain is caused by coronary vasospasm. More common in

women younger than 50 years. Person usually complain of chest pain at rest. It may
occur early in the morning which awaken person from sleep
• Cocaine abuse - This condition is suspected when a person with few or no risk
of arteriosclerosis presented with non-traumatic chest pain. Ingestion of cocaine can
cause vasoconstriction of coronary arteries, thus producing chest pain similar to heart
attack. Symptoms can appear within one hour of cocaine use.
• Aortic stenosis - This condition happens when the person has underlying
congenital bicuspid valve, aortic sclerosis, or history of rheumatic fever. Chest pain
usually happens during physical activity. Syncope is a late symptom. Signs and
symptoms of heart failure may also present. On auscultation, loud ejection systolic
murmur can be best heard at the right second intercostal space and radiates to the
carotid artery in the neck. Splitting of second heart sound is heard in severe stenosis.
• Hypertrophic cardiomyopathy - It is the hypertrophy of interventricular septum that
causes outflow obstruction of left ventricle. Dyspnea and chest pain commonly occurs
during daily activities. Sometimes, syncope may happen. On physical examination,
significant findings include: loud systolic murmur and palpable triple apical impulse
due to palpable presystolic fourth heart sound.
• Aortic dissection- is characterized by severe chest pain that radiates the back. It is
usually associated with Marfan's syndrome and hypertension. On examination, murmur
of aortic insufficiency can be heard with unequal radial pulses.
• Pericarditis - This condition can be the result of viral infection such as coxsackie
virus and echovirus, tuberculosis, autoimmune disease, uremia, and after myocardial
infarction (Dressler syndrome). The chest pain is often pleuritic in nature (associated
with respiration) which is aggravated when lying down and relieved on sitting forward,
sometimes, accompanied by fever. On auscultation, pericardial friction rub can be
heard.
• cardiac tamponade
• Arrhythmia - atrial fibrillation and a number of other arrhythmias can cause chest
pain.
• Myocarditis
• Mitral valve prolapse syndrome - Those affected are usually thin females presented
with chest pain which is sharp in quality, localized at the apex, and relieved when lying
down. Other symptoms include: shortness of breath, fatigue, and palpitations. On
auscultation, midsystolic click followed by late systolic murmur can be heard, louder
when person is in standing position.
• Aortic aneurysm

On the basis of the above, a number of tests may be ordered:

• An electrocardiogram (ECG)
• Chest radiograph or chest x rays are frequently performed
• Echocardiography can be useful in patients with known cardiac disease or aortic
dissection
• CT scanning is used in the diagnosis of aortic dissection
• V/Q scintigraphy or CT pulmonary angiogram (when a pulmonary embolism is
suspected)
• Blood tests:
• Troponin I or T (to indicate myocardial damage)
• Complete blood count
• Electrolytes and renal function (creatinine)
• Liver enzymes
• Creatine kinase (and CK-MB fraction in many hospitals)
• D-dimer (when suspicion for pulmonary embolism is present but low)
• serum lipase to exclude acute pancreatitis
Management: ANTI ANGINAL THERAPY
nitrates (glyceryl trinitratd GTN)
beta blockers (metprolol)
calcium channel blocker
potassium channel activation(nicorandil)
If channel antagonists (ivabradine)
3. Cxr of cardiomegaly:

Cardiothoracic ratio =
where,[4]
MRD = greatest perpendicular diameter from midline to right heart border
MLD = greatest perpendicular diameter from midline to left heart border
ID = internal diameter of chest at level of right hemidiaphragm
If the cardiac thoracic ratio is greater than 50%, pathology is suspected
# possible causes include:
The most common causes of Cardiomegaly are congenital (patients are born with the
condition based on a genetic inheritance), high blood pressure which can enlarge the left
ventricle causing the heart muscle to weaken over time, and coronary artery disease

Heart Valve Disease, Cardiomyopathy (disease to the heart muscle),

Pulmonary Hypertension, Pericardial Effusion (fluid around the heart), Thyroid Disorders,
Hemochromatosis (excessive iron in the blood), Other rare diseases like Amyloidosis, Viral
infection of the heart, Pregnancy, with enlarged heart developing around the time of
delivery (peripartum cardiomyopathy), Kidney disease requiring dialysis, Alcohol or
cocaine abuse
Medications: Diuretics, Angiotensin-converting enzyme (ACE) inhibitors, Angiotensin
receptor blockers (ARBs) , Beta blockers, Digoxin, Anticoagulants, Anti-arrhythmics
Medical devices to regulate the heartbeat :

• Pacemaker: Coordinates the contractions between the left and right ventricle. In
people who may be at risk of serious arrhythmias, drug therapy or an implantable
cardioverter-defibrillator (ICD) may be used.

• ICDs: Small devices implanted in the chest to constantly monitor the heart rhythm and
deliver electrical shocks when needed to control abnormal, rapid heartbeats. The
devices can also work as pacemakers.
Surgical procedures: Heart valve surgery, Coronary bypass surgery, Left ventricular assist
device , Heart transplant.
4. Ct scan of intracranial bleeding.

causes : Hypertension (high blood pressure), Diabetes mellitus, Menopause, Cigarette

smoking, Excessive alcohol consumption, Severe migraine, impaired level of consciousness,
vomiting, headache ,focal neurological deficit

Diagnosis: non contrast CT scan, MRI, angiography

MANAGEMENT: Tracheal intubation is indicated in people with decreased level of
consciousness or other risk of airway obstruction.
IV fluids are given to maintain fluid balance, using isotonic rather than hypotonic fluids
Frozen plasma, vitamin K, protamine, or platelet transfusions are given in case of
a coagulopathy
elevate bed and anti seizure prophylaxis
BP control less than 140
surgical decompression .
6- meningitis case, an adult present with high grade fever, headache, neck stiffness,
photophobia, altered consciousness, nausea, vomit, and seizures

signs: nuchal rigidity, kerning sign, and brudzinski sign

diagnosis: lumber puncture (m a)
and CT scan first in case of FCPS
MANAGEMENT: ceftriaxone 2g iv 12hourly + vancomycin
steroids therapy
COMPLICATION: deafness, cerebral edema, hydrocephalus, hyponatremia.

7- Crushing chest pain.

Tests to confirm causes : ECG, blood tests, chest xray, CT-coronary angiogram, stress test.
management: Nitroglycerin, Aspirin, Thrombolytic drugs, blood thinners.

8- Resp examination, asthma and status asthmatic treat :

DEFINATION: asthma failed to resolve with therapy within 24h
or acute severe asthma
TRIGERS: viral, moulds and pollens
PEF: 33-35%
heart rate : 110
RR : 25
inability to complete 1 sentence
MANAGEMENT: oxygen (pa02 92%), bronchodilator , steroids
endotracheal intubation.
9- HIV COUNCELLING :
11-cardio exam:
Q: mitral regurg murmur,
Q: where it radiate :
Q: othr cause of pansystolic murmur: (VSD, MR, TR)
Q: left ventricular hypertrophy causes: hypertension, Aortic valve stenosis. , Hypertrophic
cardiomyopathy, Athletic training.
Q: treatment : The enlargement is not permanent in all cases, and in some cases the growth
can regress with the reduction of blood pressure
Surgery: Implantable defibrillator
dual chamber pacing and transplant.
11. ABDOMINAL EXAMINATION :
Station 1: perform reflexes of lower limb and babinski :

After completing the examination, examiner ask the question about positive findings,

Q: D/f btw upper and lower motor and causes of upper and lower motor:

Q : Causes:
Station2: female present with joint pain and stiffness in morning,there is
erythromatous rash over her cheeks.

Q1:diagnosis: SLE

Q2: 5 investigations : CBC ( leukopenia, lymphopenia, thrombocytopenia) ESR & CRP (

raised), UCE & Urinalysis( proteinuria, cellular cast), complement levels( C3 and C4
(decreased) , autoantibodies( AnA, anti-DsDNA, Anti-smith antibodies

Q3:treatment: avoid sun exposure, analgesics , nsaids, hydoxychloroquine, belimumab(for

arthritis, serositis, skin disease), Acute flares ( I/v steroids + I/v cyclophosphamide

High dose steriods+mycophenolate for lupus nehpritis

Maintenance therapy: Oral steroids + immunosupressants ( azathioprine, methotraxate,

mycophenolate)
STATION-3 : HX OF COUGH :
Station 4: pt present with severe chest pain more thn 30 minutes_____nt remeber:p
(but it was case of MI)

Q1:what is the emegency managment of tertiary care centres? Mona therapy

Morphine , oxygen, nitrates(sublingual Gtn), Aspirin and Clopidogrel, CBC, biochemistry,

glucose, ECG, beta blockers( metaprolo and carvidalol), if primary PCI available then give
Gp IIb/IIIa inhibitors, give thrombolytics alternatively. (DO CHECK ANS )

Q2:management of unstable angina and NSTEM?

Withi n 12 hrs : I/v opiates (morphine), i/v metaclopromide,.

Anti platelet therapy: aspirin, clopidogrel, ticagrelor, prasugrel, abciximab, eptifibatide,

tirofiban.

Antithrombin therapy : with unfractioned heparin, fondaprinux,or subcutaneous

enoxaparin.

Anti anginal therapy: with nitrates and beta blockers.

Station 05 : lfts was given and patient present with mild jaundice and tender
hepatomegaly and resident of hostle

Q1:definitive diagnosis : hep A/ acute hepatitis.

Q2:modes of transmission : feco oral

Q3:vaccination schedule :
for individuals between ages 1 and 18 years : Give vaccine I/Min two doses of 0.5 ml..
separated by 6-12 months, then booster 0.5ml after 6-12months

For individuals older than 18 years : high vaccine dose of 1ml then, booster dose of 1ml
6-12 months following initial dose

Q4:furthur investigations to make the diagnosis : Anti HAV IgM and Anti HAV IgG.
1. Station 6 : DM COUNCELLING :
1- Chest xray pleural effusion :
Q: Findings?

Q: 4 condition that lead to this?

TRASUDATIVE (CHF, nephrotic, cirrhosis and atelectasis)
EXUDATIVE (malignancy, emboli, mesothelioma and tb)

Q: Further test to find cause? fluid analysis (lights criteria)

Q: treatment: antibiotics, drainage , pleurodesis and surgery.
2- Case of copd observed
a 50 year old single :p smoker presents SOB, LOW, chronic cough, dyspnea on
exertion, hyper resonance, increased expiration phase, ronchi, wheeze and headache

Q: Management? Smoking cessation and LTOT

Q: Test? PFT, methacholine test, DLCO , CBC, ECG and CXR
Q: Food habits?
Q: Exacerbations? increase symptoms and deterioration of lung function and health
status.
Q: What you can find apart from copd? asthma, TB, pneumothorax.

3- Abdominal examination observed

Q: Clinical findings in diarrhea? Dehydration, dry mouth (eager to drink), sunken eyes,
LOW
Q; Test for diarrhea? CBC, blood and stool culture and sigmoidscopy
Q: Most common cause of diarrhea in our setup? Parasites such as Giardia lamblia and
cryptosporidium can cause diarrhea. Common bacterial causes of diarrhea include
campylobacter, salmonella, shigella and Escherichia
Q: Giardiasis drug of choice? metronidazole
Q: Difference between acute and chronic diarrhea :
ACUTE less than14 days
chronic more than14 days
4- Perform relevent examination for patient with hx of headache
Q: d/d?

Q: what is trigeminal neuralgia?

Trigeminal neuralgia (TN or TGN) is a chronic pain disorder that affects
the trigeminal nerve. There are two main types: typical and atypical trigeminal neuralgia.
The typical form results in episodes of severe, sudden, shock-like pain in one side of the
face that lasts for seconds to a few minutes.
Q:Conditions in which patient has headache (ear conditions) test?
Q: Management?
abortive therapy: NSAIDS
preventive: BETA Blockers, calcium channel blockers and TCA
5- HX OF FEVER :
6. Related to previous HX taking

Q: What you think pt has? PUO.

Q: Define PUO? Fever of unknown origin (FUO), pyrexia of unknown origin (PUO) or febris
e causa ignota (febris E.C.I.) refers to a condition in which the patient has an elevated
temperature (fever) but despite investigations by a physician no explanation has been
found.
Q: Specific test for PUO:
Q: Management :

7- Xray pulmonary embolism

sudden onset of SOB and pleuritic chest pain and hemoptysis

syncope (tachycardia tachypnea and S4)
causes: DVT
ECG: ST-T waves changes
CT- angiography and D-dimer (diagnostic)
MANAGEMENT: heparin and oxygen , anticoagulation (warfarin), thrombolytics.
8- HX OF BLOOD IN STOOL :
9- COUNCELLING OF CLD
10. CVS exam and viva on CCF (obs)
heart unable to pump at required rate of body.

a) systolic (ischemia, HTN, dilated crdiomopathy, alcohol)

B) diasystolic (LVH , hypertrophic, restrictive, cardiac tamponade)
1) left heart failure: mc (dyspnea, orthopnea and PND) S3
2) right heartfailure : (JVD, ascites and edema)
ECHO: diagnosis and BNP
MANAGEMENT: lifestyle modification
PHARMA: ACEI, ARDS, beta blockers, spironolactone, hydralazine, nitrates.
NON PHARMA: CRT and ICD

11- Aortic Regurgitation(un-obs)

Dx:
causes: rheumatic, infection
Tx: valve replacement
Investigations: ECHO
physical findings: pulmonary edema, hypotension and cardiogenic shock.
 ECGS FROM PREVIOUS YEARS

SA NODE PROBLEMS:

1. Sinus Bradycardia: SA node fires too slow.

Rate : 30 bpm
Cause: MI, inc: vagal tone, hypothermia, hypothyroidism, hypoxia, raise intracranial
pressure, drugs(b-blocker, Ca Channel blockers, amiodarone.)
Management : asymptomatic : no treatment
symptomatic : atropine (initial), pacemaker (effective)

2. Sinus Tachycardia: SA node fires too fast.

Rate : 130 bpm

Causes: Anxiety, fever, anemia, HF, thyrotoxicosis, drugs B-agonists.
Management : beta blockers.
ATRIAL CELLS PROBLEMS :

1. NSR with premature atrial contraction: Atrial cells fire occasionally from a focus.

Rate : 70 bpm
causes : caffeine.

2. Atrial flutter (saw tooth): Atrial cell fire continuously from a loop re-entrant circuit.

Rate : 70 bpm
causes : Ischemia
Management : beta blockers , calcium channel blockers, electrical cardioversion
3. Atrial fibrillation: Atrial cells fire continuously from multiple foci. (OR) From multiple
micro re-entrant wavelets.

Rate : 100 bpm

Causes: (PIRATES): Pulmonary embolism, IHD, RHD, atrial myxoma, thyrotoxicosis,

ethanol and sepsis.
Management : beta blockers , calcium channel blockers, electrical cardioversion
VENTRICULAR CELL PROBLEMS:

1. NSR with 1 premature venricular contraction: Ventricular cells fires occasionally

from single or multiple foci.

Rate : 60 bpm
causes : alcohol , antihistamines, tobacco
Management : amiodarone, flecainide.

2. ventricular tachycardia: Ventricular cells fire continuously due to looping re-entrant

circuit.

Rate : 160 bpm

Causes: Coronary artery disease with prior MI(most common), cardiomyopathy, prolonged
QT syndrome and drug toxicity.
Management :
pulseless : unsynchronized cardioversion + CPR
hemodynamically unstable : unsynchronized cardioversion + amiodarone
hemodynamically stable : amiodarone, procainamide + synchronized cardioversion
3. ventricular fibrillation: Ventricular cells fire continuously from multiple foci.

Rate : not regonizable none

Causes: IHD(most common)
Management : CPR + deliver shock + CPR
AV JUNCTIONAL PROBLEMS:

1.Paroxymal supraventricular tachycardia: AV junction fires continuously due to

looping re-entrant circuit.

Rate : 74-148 bpm

AV Juntional Block: AV junction blocks impulses coming from SA node.

2. 1st degree AV block

Rate : 60 bpm
PR interval : >0.20
Causes: AV nodal disease, inc: vagal tone, acute inferior MI and electrolyte imbalance.
Management : asymptomatic : no treatment
symptomatic : atropine (initial), pacemaker (effective).
3. 2nd degree AV block (mobitz type-I)

Rate : 50 bpm
causes : Mi, myocarditis, mitral valve surgery , athletes.
Management : asymptomatic : no treatment
symptomatic : atropine (initial), pacemaker (effective)

PR interval progressively lengthens then impulse is completely blocked (P wave not

followed by QRS complex)

4. 2nd degree AV block (mobitz type-II)

Rate : 40 bpm
Occasionally P waves are completely blocked
causes : ant : wall MI, degeneration of conductive system, aortic valve surgery
management : asymptomatic : parmanant pacemaker
symptomatic : parmanant pacemaker
5. 3rd degree AV block

Rate : 40 bpm
P waves are completely blocked and no relation with QRS complex
Causes: MI, severe hyperkalemia, cardiomyopathy, congenital with SLE mothers, acute and
chronic inflammations.
Management : asymptomatic : parmanant pacemaker
symptomatic : parmanant pacemaker
MYOCARDIAL INFARCTION

# MI dignosed by ST segment elevation in ECG.

MI on V1, V2, V3 bcoz ST segment elevation i.e anterior wall MI

 Lateral portion
of the heart

Anterior portion
of the heart

Inferior portion
of the heart
# Anterior wall seen through (V1-V4).

# Lateral wall MI (I, aVL, V5, V6)

# Inferior wall MI (II, III, aVF)

# Posterior wall MI (V5, V6)

# Extensive wall MI (Lateral + Anterior wall MI)