2B. OBJETIVOS ESPECÍFICOS
III. MATERIALES Y MÉTODOS
3. GENERACIÓN DE RATONES KO
Maternal: Primigravida or new paternity, Family hx of Preeclampsia, Diabetes Mellitus, Obesity, Maternal age >40 years, Preexisting Hypertension, Anti-Phospholipid Antibody syndrome.
126 NAC OSCE | A Comprehensive Review Michael Walter a 18 months old boy brought to your office by his mother regarding poor weight gain. Take history from the mother & address nis concerns.
Clinical Info: Michael's mother is concerned regarding poor weight gain for his age & height. He has no fever/nausea/vomiting/cough. No h/o recurrent infections. No urinary or bowel complaints. He's picky eater who gets distracted while eating food. His diet consists of excessive juice & milk. No family stress present. Clinical Case Diagnosis: Failure to thrive due to inadequate dietary intake.
HOPI
• OCD PQRST UV + AAA • Duration of poor weight gain? • Sudden or gradual decline in weight? • Quality ana Quantity of food? • Who feeds the child?
• Does the child feed self(e.g. spoon, cup)? • Psychosocial events around feeding time. • Is the child distracted or not supervised? • Are there food battles or food refusal? • Discuss food preparation (e.g. formula too
dilute).
• Beverages (e.g. Milk, juice, water, soda). • Stool habits (e.g. frequency and consistency). • Pica history.
• Detailed nursing or breast feeding history. • Infrequent brief feedings.
• Current weight & heignt? • Highest weight?
• Any fever/nausea/vomiting/cough? • Any diarrhea/constipation? • Any urinary complaints? • H/o recurrent infections?
• Maternal ingestion of alcohol/diuretics. • Inadequate milk supply.
• Inadequate milk let down.
• Maternal malnutrition.
• Maternal exhaustion or Major Depression. • Any stress at home?
• Any signs of physical/psychological/family abuse?
• Family history of short stature/FTT in siblings.
• Any developmental delay? Birth history
• Gestational age at birth and birth weight. • Mode of delivery: cesarean, induction,
forceps or vacuum delivery.
• Any fetal distress?Was meconium passed in utero?
• APGAR score at birth, 1 minute & 5 minute?
• Was resuscitation required? • When was breast feeding started? • Color of 1st stool, when was 1st stool
passed?
• Color of urine, when was 1st urine passed? • Any antenatal/post partum complications. • Immunization history.
• Developmental milestones. • Detailed dietary history. Differential Diagnosis
• Physiologic cause-Familial short stature. • Organic cause-Cleft palate, Choanal atresia,
GÉRD, Celiac ds, Giardiasis, Protein losing enteropathy, Milk protein allergy, Liver ds. • Chronic diarrhea.
• Hyperthyroidism, Immunodeficiency. • Prenatal causes-Intrauterine infection,
maternal malnutrition,Fetal alcohol syndrome.
• Chromosomal disorders. Investigations
• CBC,ESR, electrolytes, RFT, LFT.
• Blood sugar,TSH,Se Ferritin,Sweat chloride. • Urinalysis-routine microscopy, C/S.
• Stool for fat content,ova & parasites. • Se Calcium, Phosphate, Albumin.
• Karyotype. • Wrist A ray. Management
• Complete physical examination. • Reassure parents.
• Height & weight measurement. • Head circumference.
• Assess feeding process & parent-child interaction.
• Determine & treat underlying etiology. • Institute nutritional therapy.
• Eat in a comfortable, stress free environment with positive reinforcement.
• Consume food from all four food groups. • Maintain dietary intake diary.
Clinical Cases - Pediatrics 127 Benjamin Smith a 15 months old boy has been brought to the ER with fever and 2 episodes of seizures. He is stabilized now. Take history & address the concerns of an over anxious mother.
Clinical Info: Beniamin Smith was having a runny nose and high grade fever for the past 3 days. His fever did not subside with Tylenol. He had 1st episode of tonic-clonic seizure 6 hours ago at home. This was the first occurrence. He haa no other symptoms. No family history of seizures. No complications during birth or development so far. Immunization is up to date.
No signs of child abuse. Diagnosis: Febrile seizures.
HOPI • History of problems during the pregnancy
• OCD PQRST UV + AAA and birth.
• Describe seizure duration? • Developmental history. • Child's medical history. • What body parts are affected and in what
order, premonitory signs? • Immunization history.
• Post-ictal state (decrease in level of • Family history of seizure disorder. consciousness, headache, weakness). • Screen for signs of child abuse. • Previous seizure?
• Events during the seizure time? • How did the seizure stop?
• Onset of fever? Sudden or gradual? • Duration of fever?
• Type of fever-continuous, remittent, intermittent.
• Any nausea/vomiting?
• Any ear/eye discharge/runny nose? • Any rash?
• Any cough/sore throat/difficulty swallowing? • Any difficulty breathing?
• Any bowel or urinary complaints? • Any sick contacts?
• Ask about preceding trauma or illness or medications taken?
Differential Diagnosis Management
• Febrile seizure. • Symptomatic treatment.
• Meningitis. • Antipyretics for fever prn.
• Encephalitis. • Maintain hydration.
Investigations • • Counseling & reassurance for parents.Recurrence - rectal or sublingual Lorazepam. • CBC, electrolytes, RFT. • Treat underlying cause of fever.
• ABG, Blood glucose. • Urinalysis.
• Blood culture &c sensitivity.
128 NAC OSCE | A Comprehensive Review Nick Chang is a 15 years old boy brought by his mother with fever and rash for the past 2 days.
Take history & address her concerns.
Clinical Info: Nick has high fever for the past 2 days. He has developed a diffuse rash in the last 24 hours which is spreading from head to trunk. He also has cough, sore throat and redness of eyes. He has no altered level of consciousness/irritability. He is alert and feeding well. Has h/o sick contacts with similar complaints in the day care. His immunization is up to date.
Diagnosis: Measles.
HOPI
• OCD PQRST UV + AAA • Onset of fever- sudden or gradual? • Duration of fever?
• Type of fever-
continuous,remittent,intermittent? • Highest recorded temperature? • Relieving factors for the fever? • Onset of rash?
• Type of rash? • Location of rash?
• Rash becoming better or worse? • Any vesicles noticed with the rash? • Any swelling in the body?
• Any ear/eye discharge?
• Any excessive crying/irritability? • Any changes in alertness of the child? • Any cough/sore throat/runny nose?
• Any nausea/vomiting/difficulty swallowing? • Any changes in urinary/bowel habits? • Feeding well or not?
• Any seizures?
• Any recent sick contacts? • Any travel?
Differential Diagnosis Management
• Measles. • Symptomatic treatment.
• Rubella. • Maintain adequate hydration.
• Varicella zoster. • Rest.
• Erythema infectiosum. • Antipyretics for fever prn.
• Educate parents about complications. Investigations
• CBC with differential.
Immunization history till date? Any recurrent infections? Development milestones for age? Any similar symptoms in the past?
Clinical Cases - Pediatrics 129 Marie Jones delivered baby Anthony 36 hours old and now the newborn has jaundice, lethargy and crying. The serum bilirubin is 220 mmol ( N < 200). Take history & address her concerns.
Clinical Info: Anthony was born to a primigravida by normal vaginal delivery. Mother noticed yellowish discoloration of his eyes in the morning. She had no antenatal complications. She had premature rupture of membranes prior to onset of labor at 38 weeks. She was put on antibiotics. Her labor was 18 hours long. The labor was induced. Apgar was 9/10. Baby is a little lethargic and not feeding well. Has no fever/altered consciousness. No seizures.
Clinical Case Diagnosis: Neonatal Jaundice due to Sepsis. HOPI
Mother's obstetrical history:
• GTPAL
• H/o neonatal jaundice in past pregnancies. • Maternal medical history esp. liver disease. • Illness during pregnancy esp. diabetes,
rubella, toxoplasmosis, hemes, CMV. • Teratogenic medications during pregnancy. • Radiation exposure in pregnancy?
• Drug and alcohol use during pregnancy? • Any pets in the house?
• Maternal & Paternal blood type. • Complications of present pregnancy.
- Gestational hypertension or diabetes, hyper/hypothyroid, hypercoagulation. • Any antenatal/post partum complications? Newborn history:
• Gestational age at birth,
• Mode of delivery: cesarean, induction, forceps or vacuum delivery.
• Duration of rupture of membranes (ROM)? • Was ROM artificial or prolonged?
• Any fetal distress?Was meconium passed in utero?
• APGAR score at birth, 1 minute & 5 minutes?
• Was resuscitation required? • When was breast feeding started? • Is the baby feeding well?
• Color of 1st stool, when was 1st stool passed?
• Color of urine, when was 1st urine passed? • Any vomiting/regurgitation?
• Decreased neonatal muscle tone? • Any fever, irritability, lethargy,seizure? • Past History
• Do you have diabetes or hypertension? • Are you on any medications?
• Are you allergic to any medications? • Any surgeries in the past?
• Past h/o recurrent infections? 9 Family and Social History • Social support.
• Any family history of medical illnesses?
Differential Diagnosis • Sepsis.
• Breast feeding jaundice. • Hemolysis.
• Physiologic jaundice. Investigations
• CBC with reties,electrolytes, RFT.
• Se bilirubin(conjugated & unconjugated) & albumin.
• Blood group (maternal, paternal & neonatal).
• Coomb's test.
• Blood & urine culture. • TSH, G6PD.
• Chest X Ray, LP.
Management
Prevent kernicterus. Treat underlying cause. Monitor neonatal vitals. Maintain hydration. Initiate phototherapy. Reassurance for parents.
130 NAC OSCE | A Comprehensive Review Sean Radcliffe is a 8 years old boy whose parents have concern about bed wetting. Take history from the father Sc address his concerns.
Clinical Info: Sean has been wetting his bed since the last 3 years. He never had bladder control. He has no fever/vomiting. No h/o recurrent infections. He wets bed 2-3 times in the night. No day time wetting present. No encoparesis. Parents have not taken any treatment so far and have tried toilet training in past with no success. No stresses at home or school.
Clinical Case Diagnosis: Primary nocturnal enuresis.
HOPI
• OCD PQJtST UV + AAA
• Type of voiding - Involuntary or intentional. • Number of times wets bed in the night? • Has the child ever been dry?(primary or
secondary)
• Is there aaytime Enuresis?(complicated Enuresis)
• Wetting pattern - day±night or night only. • Any dysuria/pyuria/foul smelling urine? • Involuntary passage of stool in the sleep? • Functional bladder disorder signs like
- Voids >7 times per day with urgency Sc in small volumes.
- Withholds urine until last minute, wets more than once nightly.
• Has enuresis on only a few nights per week? • Voids large volumes when enuresis occurs? • Bowel or bladder habit changes recently. • Infrequent or difficult stool passage? • Any changes in appetite/weight? • Any fever/nausea/vomiting? • Any recurrent infections?
• Amount of fluid intake prior to sleep? • Any neurological disorders?
• Any genitourinary surgeries?
• Enuresis in other siblings? • Any stresses at home or school?
• Any new habits or regression to old habits? • Trial of toilet training in the past?
• Any treatment in the past for enuresis? Birth history
• Gestational age at birth and birth weight. • Mode of delivery: cesarean, induction,
forceps or vacuum delivery.
• Any fetal distress?Was meconium passed in utero?
• APGAR score at birth, 1 minute Sc 5 minute?
• Was resuscitation required? • When was breast feeding started? • Color of 1st stool, when was 1st stool
passed?
• Color of urine, when was 1st urine passed? • Any antenatal/post partum complications. • Immunization history.
Differential Diagnosis
• Primary nocturnal enuresis. • Urinary tract infection.
• Urinary tract anomalies like small bladder. • Psychological (death in the family, sexual
abuse). Investigations • CBC,electrolytes, RFT, LFT. • Blood sugar. • Urinalysis-routine microscopy, C/S. • Ultrasound abdomen. Management
• Complete physical examination. • Reassure parents.
• Schedule voiding times. • Bed wetting alarm. • Void before bedtime.
• Limit fluids 1 hour before bedtime. • Voiding diary to be maintained. • Positive reinforcement for dry nights. • Pharmacological therapy like
Clinical Cases - Pediatrics 131 Ally Singer's 6 weeks old baby boy Alex is vomiting for the past 2 days. Take history 8c address her concerns. Clinical Info: Alex had 4 episodes of projectile non bilious vomiting in the past 48 hours. He vomits after feeding. No fever. Looks lethargic 8c dehydrated but alert. No seizures. Had only one bowel movement in last 24 hours. No sick contacts. O/E: Palpable abdominal mass in the right hypochondrium.
Clinical Case Diagnosis : Pyloric stenosis.
HOPI
• OCD PQRST UV + AAA • Number of episodes of vomiting? • Duration of vomiting?
• Type of vomiting - projectile/non projectile? • Color/contents of vomitus?
• Any excessive crying?
• Feeding pattern in the last 48 hours? • Decreased neonatal muscle tone? • Any fever, irritability, lethargy,seizure? • Last bowel movement?
• Foul smelling urine 8c color of urine? • Current weight.
• Any sick contacts. Newborn history
• Gestational age at birth and birth weight. • Mode of delivery: cesarean, induction,
forceps or vacuum delivery.
• Any fetal distress? Was meconium passed in utero?
• APGAR score at birth, 1 minute 8c 5 minute?
• Was resuscitation required? • When was breast feeding started? • H/o neonatal jaundice.
• Color of 1st stool, when was 1st stool passed?
• Color of urine, when was 1st urine passed?
Mother's obstetrical history
• GTPAL
• Maternal medical history esp. liver disease. • Illness during pregnancy esp. diabetes,
rubella, toxoplasmosis, herpes, CMV. • Teratogenic medications during pregnancy. • Radiation exposure in pregnancy.
• Drug and alcohol use auring pregnancy. • Complications of present pregnancy.
- Gestational hypertension or diabetes, - hyper/hypothyroid, hypercoagulation. • Any antenatal/post partum complications?
Differential Diagnosis • Pyloric stenosis. • Tracheo-esophageal fistula. • Duodenal atresia. • Malrotation of gut. • Gastro-esophageal reflux. Investigations • CBC,electrolytes, RFT, LFT. • ABG. • Urinalysis. • Ultrasound abdomen. • Abdominal X ray. Management • Admit.
• Urgent Pediatric surgery consult. • IVF to maintain hydration. • Surgery - Pyloromyotomy.
132 NAC OSCE | A Comprehensive Review John Andrews is a 3 years old boy who is not speaking well. Take history & address his father's concerns. Clinical Info: John Andrews has h/o recurrent ear infections. He had 3 episodes in the last 6 months. He has runny nose and mild cough too. He can speak in sentence of 3-4 words. He can count to 5. But for the past 3 months he is not learning new words or numbers. He responds to loud sounds. No other complaints. Social interaction is very good. No birth or developmental complications till date.
Diagnosis: Speech delay secondary to recurrent otitis media.
• Duration of speech delay? • Who noticed it first?
• Any ear discharge/runny nose? • Any recurrent infections? • Any fever/cough/sore throat?
• Does the child wake up in response to sounds? • Startle to loud sounds?
• Comes when called?
• Understands spoken instructions? • Ask about swimming.
• Enquire about verbal cues.
• How many languages are spoken in the household? • Child's social interaction with others.
• Does the child talk less in particular situations? • How many words are spoken by the child? • Detailed developmental history.
• Was the child screened for hearing at birth? • Any regression in habits?
• Immunization history till date. • Family history of speech delay.
• Any complications during pregnancy or birth? • Detailed birth history.
• Exposure to toxins during pregnancy? • Any ototoxic drugs used in infancy? • Screen for signs of child abuse.
Differential Diagnosis Management
• Hearing loss secondary to Otitis media. • Reassurance for parents. • Selective mutism.
• Expressive speech delay.
• Complete physical assessment. • ENT referral.
• Autism. • Speech therapy.
• Positive reinforcement & encouragement. Investigations
Clinical Cases - Psychiatry 133 Gabriella Anderson, a 18 years old girl came to your office with complaints of gaining weight. Take history 8c counsel.
Clinical Info: Ms Gabriella Anderson presented with gaining 5 lbs in the last 1 month. She looks underweight for her age and height. She is exercising 3 times a day. She doesn’t binge or induce vomiting. Lately she is taking small portions of meals due to fear of gaining weight. She has no medical illnesses. No past nistory of psychiatric illness. Currently not taking any medications.
Clinical Case : Anorexia HOPI
• When did you notice the change in weight? • Duration of symptoms?
• Amount of weight gain?
• Lowest and highest weight you had? • Are you afraid of gaining weight? • How do you try to control your weight? • How do you think your body looks? • Does your body weight 8c shape have an
impact on your self opinion? • Last menstrual period / regularity /
complications?
• Any abdominal pain/nausea/vomiting? • Bowel and bladaer habits?
• Any skin changes?
• Any intolerance to temperature changes? • Any recent stressors at nome or work? • Changes in sleep pattern?
• Feeling of guilt / hopelessness / helpless / worthless?
• Changes in mood?
• Any thoughts of harming self/suicide? • Any thoughts of harming someone else? • Any plans at the moment?
• Do you feel persistently cheerful/high? • Do you have any medical/surgical illnesses?
Ask details.
• Do you take any medications? Ask details. • Do you consume alcohol?
Amount/frequency?
• Do you use recreational drugs? Ask TRAPPED.
Past Psychiatric History
• Any similar symptoms in past?
• Any h/o mania / depression / delusion / delirium?
• Any contacts with mental health professionals?
• Any past problems with law? Family Histoiy
• Any family history of similar complaints? • Any family history of other psychiatric
illnesses?
• Any family history of suicide/alcohol/drug abuse?
Social History
• Support system at home/work? • Current living situation? • Relationship nistory? • Education nistory?
• Any risk of physical/sexual/mental abuse?
Differential Diagnosis • Anorexia nervosa. • Bulimia nervosa. • Mood disorders.
• Medical cause of weight loss. • Body Dysmorphic disorder. Investigations
• CBC, electrolytes, renal 8c Liver function tests.
• TSH, blood glucose, ECG. • Urine toxicology screen. • Beta HCG, LH,FSH.
Management
• Complete physical assessment. • Antiaepressants.
• Suj3j|>ortive psychotherapy. • Make plans for weight gain.
• Community resources for eating disorders. • Educational brochures.
• Admit if weight <85% of ideal weight. HR < 40 bpm.
Hypovolemia. Hypokalemia Hypoglycemia. Hypothermia.
134 NAC OSCE | A Comprehensive Review Amanda Sawyer, a 20 years old girl brought to your office by her mother for vomiting and weight loss. Take history & counsel.
Clinical Info: Ms Amanda Sawyer presented with vomiting after meals. She has fear of weight gain. H/o binging & induced vomiting present. H/o laxative abuse and excessive exercise. She has no apparent psycho motor or suicidal ideation. Sne has no medical illnesses. No past history of psychiatric illness. Currendy not taking any medications.
Clinical Case : Bulimia
HOPI
• Onset of vomiting? • Duration of symptoms? • Type of vomitus/contents? • Projectile/non projectile? • H/o abdominal pain/site/type? • Do you force yourself to vomit? • Do you binge large amount of food? • Amount of weight gain/loss? • Lowest and highest weight you had? • How do you try to control your weight? • Does your body weight & shape have an
impact on your self opinion? • Last menstrual period / regularity /
complications? • Any skin changes?
• Any intolerance to temperature changes? • Any recent stressors at nome or work? • Changes in sleep pattern?
• Feeling of guilt / hopelessness / helpless / worthless?
• Changes in mood?
• Any thoughts of harming self/suicide? • Any thoughts of harming someone else? • Do you feel persistently cheerful/high? • Do you have any medical/surgical illnesses?
Ask details.
• Do you take any medications? Ask details. • Do you consume alcohol?
Amount/frequency?
• Do you use recreational drugs? Ask TRAPPED.
Past Psychiatric History
• Any similar symptoms in past?
• Any h/o mania / depression / delusion / delirium?
• Any contacts with mental health professionals?
• Any past problems with law? Family Histoiy
• Any family history of similar complaints? • Any family history of other psychiatric
illnesses?
• Any family history of suicide/alcohol/drug abuse?
Social History
• Support system at home/work? • Current living situation? • Relationship nistory? • Education nistory?
• Any risk of physical/sexual/mental abuse?
Differential Diagnosis • Bulimia nervosa. • Anorexia nervosa. • Mood disorders.
• Medical cause of weight loss. • Body Dysmorphic disorder. Investigations
• CBC, electrolytes, renal & Liver function tests.
• TSH, blood glucose, ECG. • Urine toxicology screen. • Beta HCG, LH,FSH.
Management
• Complete physical assessment. • Antidepressants.
• Suj3|)ortive psychotherapy.
• Make plans for weight gain.
• Community resources for eating disorders. • Educational brochures.
• Admit if weight <85% of ideal weight. HR < 40 bpm.
Hypovolemia. Hypokalemia Hypoglycemia. Hypothermia.
Clinical Cases - Psychiatry 135 Derek Paul, a 65 years old man admitted in surgical floor presented with strange behavior for the past 4 hours. You are on call surgical resident for the shift. Take nistory & counsel.
Clinical Info: Mr Derek Paul had partial right hip replacement 3 days ago. His post op recovery till now has been uneventful. Evening shift nurse noticed significant change in his behavior. He is agitated, resdess with