OSCE : DHF History Taking

Particulars of the Patient
Name, age, residence etc as usual. Age is important for disease occurance..
Residence is important in this case because of possible outbreak. Anyone with similar illness in the neighborhood should be enquired

Chief complaints
Fever and flulike symptoms
Muscle and bone aches
red spots
vomitting, coffee-ground vomiting, black stools
abdominal pain
headache and periorbital pain
rash

Symptom Analysis

Fever
-onset- acute, ask the exact day the fever first appeared because it is useful for management.
The disease is worst in day 3 to 6. If the continuous monitoring including haematocrit traces good, patient can be discharged at day 7.
nature-continuous,
any associations-flulike symptoms +, headache, periobital pain, etc

Muscle and Bone Aches

Bleeding manifestations
-(spots appear on the body, leading questions are avoided if possible.)
-(do you notice anything appears on your body? is appropriate)
-if the child reponse is a lot of spots appears, you should specify what kind of spots are there -by asking more questions on them. --day of appearance, type of spots
-petechiae?, Pupura?, Echymosis?, Rash?
-Epistasis? Is there any blood coming out from your body, example nasal bleeding?
-Do you vomit? What color is the vomitus?
- Are they coffee ground colored?
-If the response is yes, you have to prove that it is not due to having coffee before vomiting?
You should specify that by asking whether he took coffee or not before vomiting.
-Malena ? What is the color of your poo-poo? (Is it black? is a leading question that may give false positives and not encouraged in children because they may easily nod their head.)
The malena stool is tarry black. Should be distinguished from brown color asking in details.

Abdominal pain
onset, usually 3 to 7 days after onset of fever, vague discomfort, dull in nature, tense right hypochondrium.

Urine color
May be pink to red in severe disease. If it presents, urinary becomes an issue to go details.
Bleeding at the end of voiding or before the start is likely from urithera , prostate and bladder neck.
Mixure of blood with urine with red, pink or strawberry color is likely from the upper urinary tract . Other urinary symptoms needs to be excluded.

Associated symptoms and complications needs to be asked

Conversions,
Sweating and faint, common in frequent vomiting
Paler with rashes
Lethergy,etc

Recovery Rash

It is typical confluent rash with whorls of pales and reds usually in the leg appearing at the recovery phase usually from Day 6 to Day 10.
It indicates that the disease is at the recovery phase.
It is retrospectively diagnotic of Dengue Fever.

The rash should be asked about if the child is at day 6 or later, however children may not notice though care giver may find them while tepid sponging.

Interview

After History taking, the examinor may interview you.

About epidermiology, natural history of disease, life cycle of Aedes,etc
About investigations and observation
About treatment, including fluid caculations and DSS emergency management
About prevention
About recovery rash and its clinical importance

The END. GOOD LUCK

Multiple Choice Questions for Final Part II-(Medicine)

Sample MCQ only...........

1. In tricuspid incompetence, the following signs are present:
(a) Very high jugular venous pressure
(b) Prominent 'a' wave in the neck
(c) Pulsatile liver
(d) Ascites
(e) Pansystolic murmur in the tricuspid area

2. Atrial fibrillation is commonly due to:
(a) Mitral stenosis
(b) Pulmonary stenosis
(c) Ischaemic heart disease
(d) Thyrotoxicosis
(e) Addison's disease

3. Pericardial effusion is characterized by:
(a) Sinus tachycardia
(b) Pulsus alternans
(c) Small volume pulse
(d) Wide pulse pressure
(e) Reduced cardiac impulse

4. The following are features of infective endocarditis:
(a) Pallor
(b) Splenomegaly
(c) Clubbing of the fingers
(d) Heberden's node
(e) Erythema marginatum

5. Beta-blockers are contraindicated in:
(a) Bronchial asthma
(b) Peripheral vascular disease
(c) Migraine
(d) Ischaemic heart disease
(e) Pregnancy

6. Risk factors for the development of IHD include:
(a) Cigarette smoking
(b) Alcohol drinking
(c) High HDL cholesterol level
(d) Physical inactivity
(e) Hypertension

7. Acute pulmonary oedema is usually treated with:
(a) Intravenous mannitol
(b) Intravenous frusemide
(c) Intravenous morphine
(d) Intravenous digoxin
(e) Sublingual glyceryltrinitrate

8. Features of malignant hypertension include:
(a) Renal failure
(b) Diastolic BP above 130 mmHg
(c) Retinal haemorrhages
(d) Ptosis
(e) headache

9. Left ventricular failure is diagnosed by:
(a) Pulsus bigeminus (coupled beats)
(b) Widespread crepitations both lungs
(c) Fixed splitting of the second heart sound
(d) Raised jugular venous pressure
(e) Ascites

10. Secondary hypertension should be considered in a patient presenting with the following features:
(a) Young age with severe hypertension
(b) Bilateral palpable kidneys
(c) Left ventricular hypertrophy
(d) Renal bruit
(e) Variable blood pressures with sweating, tachycardia and tremors

11. Risk factors for cardiovascular disease include:
(a) Female gender
(b) Hypercholesterolaemia
(c) Positive family history
(d) Diabetes mellitus
(e) Hyperuricaemia

12. ECG can be of help in the diagnosis of:
(a) Acute pulmonary oedema
(b) Acute myocardial infarction
(c) Cardiac arrhythmias
(d) Thrombus in the left ventricle
(e) Complete heart block

13. The following are causes of acute aortic regurgitation:
(a) Infective endocarditis
(b) Rheumatic fever
(c) Marfan's syndrome
(d) Aortic dissection
(e) Ankylosing spondylitis

14. The following are major criteria of rheumatic fever:
(a) Raised ASO titre
(b) Erythema nodosum
(c) Arthralgia
(d) Chorea
(e) Carditis

15. Extracardiac manifestations of infective endocarditis include:
(a) Femoral bruit (Duroziez's sign)
(b) Haematuria
(c) Roth's spots
(d) Osler's nodes
(e) Palmar erythema

16. Recognized clinical features of constrictive endocarditis include:
(a) Ascites
(b) Hepatomegaly
(c) Dependent oedema
(d) Kussmaul's sign
(e) Pulsus paradoxus

17. The following are recognized complications of myocardial infarction:
(a) Aortic regurgitation
(b) Hypertrophic cardiomyopathy
(c) Ventricular septal defect
(d) Cerebral embolism
(e) Atrial fibrillation

18. In aortic stenosis, the following symptoms are common:
(a) Angina on exertion
(b) Syncopal attacks
(c) Paroxysmal nocturnal dyspnoea
(d) Large pleural effusion
(e) Acidotic respiration

19. Rheumatic fever may be diagnosed by the presence of:
(a) Carditis
(b) Erythema multiforme
(c) Migratory joint pain
(d) Subcutaneous nodules
(e) Facial rash

20. Angina pectoris: (a) Is commonly due to coronary artery disease
(b) May be caused by rheumatic pericarditis
(c) Is ofteociated with ischaemic changes in the ECG
(d) May be due to tight mitral stenosis
(e) May be relieved with nitroglycerine

21. In acute left ventricular failure:
(a) Morphine is beneficial
(b) Bilateral basal crepitations are usually present
(c) Triple rhythm may be present
(d) Liver enlargement is usually present
(e) Bilateral pedal oedema is a common finding
GI and Hepatobiliary diseases

22. Dysphagia may result from:
(a) Bulbar and pseudobulbar palsy
(b) Painful conditions of the mouth and pharynx
(c) Extensive compression from goiter
(d) Oesophageal varices
(e) Carcinoma of the oesophagus

23. The characteristic features of a DU are:
(a) Occurrence in females much commoner than in males (b) Relationship to high acidity of the stomach
(c) Relationship of the pain to food
(d) Association with stress
(e) Hunger pain

24. The familial occurrence of jaundice should suggest the possibilities of:
(a) Gilbert's disease
(b) Primary biliary cirrhosis
(c) Dubin Johnson syndrome
(d) Rotor syndrome
(e) Chronic active hepatitis

25. The complications of intestinal amoebiasis include:
(a) Haemorrhage
(b) Carcinoma
(c) Perforation
(d) Hepatitis
(e) Granuloma formation

26. Chronic active hepatitis:
(a) Is common among males
(b) May be associated with positive ANF
(c) May have positive HBsAg
(d) Corticosteroids may be tried
(e) Ultimately cirrhosis develops

27. Primary biliary cirrhosis is characterized by:
(a) Predominantly affect women
(b) Pruritus may be the initial symptom
(c) Jaundice
(d) Abdominal pain and discomfort
(e) Osteosclerosis

28. Chronic diarrhea may be a manifestation of:
(a) Worm infestations
(b) Malabsorption syndrome
(c) HIV infection
(d) Hypothyroidism
(e) Duodenal ulcer

29. In cirrhosis of the liver:
(a) Spider telangiectasia and bleeding tendency are indicative of portal hypertension
(b) Hepatitis A virus infection is the commonest cause of the disease
(c) The use of spironolactone can induce hypokalaemia
(d) Serum alkaline phosphatase level is of particular prognostic value
(e) Increasing jaundice suggests progressive liver disease

30. Regarding obstructive jaundice:
(a) It is an unconjugated hyperbilirubinaemia
(b) It is characterized by dark urine and clay colored stool
(c) It can be caused by oral contraceptive pills
(d) A palpable gallbladder indicates acute cholecystitis
(e) Very high alkaline phosphatase level is a feature

31. The following are typical of type B viral hepatitis (HBV) infection:
(a) Myalgia and conjunctival suffusion
(b) History of exposure to unsafe sex or drug abuse
(c) The liver is enlarged, hard and nodular
(d) Hepatitis illness more severe than with type A virus infection
(e) Absence of progression to chronic hepatitis

32. Zollinger-Ellison syndrome is characterized by:
(a) Peptic ulceration
(b) Colonic polyposis
(c) Decreased gastrin levels
(d) Diarrhoea
(e) Pancreatic adenoma

33. Features of portal hypertension include:
(a) Jaundice
(b) Ascites
(c) Haemorrhoids
(d) Hepatomegaly
(e) Oesophageal varices

34. Common causes of ascites are:
(a) Portal hypertension
(b) Congestive cardiac failure
(c) Amoebic liver abscess
(d) Chronic pancreatitis
(e) Tuberculosis of the abdomen

35. Diarrhoea may be a presenting symptom in:
(a) Hyperthyroidism
(b) Prolonged antibiotic therapy
(c) Obstructive jaundice
(d) Diabetic neuropathy
(e) Chronic cholecystitis

36. Haematemesis may be due to:
(a) Oesophageal varices
(b) Acute alcoholism
(c) Acute pancreatitis
(d) Achalasia cardia
(e) Ingestion of Non-steroidal anti-inflammatory durgs

37. Duodenal ulcer may be associated with:
(a) Helicobacter pylori infection
(b) Malignant changes in chronic cases
(c) Zollinger-Ellison syndrome
(d) Epigastric pain following meals
(e) Pylorospasm

38. The following conditions may present with abdominal pain:
(a) Lead poisoning
(b) Acute intermittent porphyria
(c) Tabes dorsalis
(d) Diabetic ketoacidosis
(e) Giardiasis

39. The following are true of chickenpox:
(a) It is spread by droplet infection
(b) It is spread by contamination from the discharge from ruptured skin lesions
(c) It can be caused by contact with herpes zoster
(d) It is common in the adults
(e) It is a notifiable disease

40. The clinical features of typhoid fever are:
(a) The temperature rises in a step ladder fashion
(b) Haemoptysis
(c) Slight enlargement of the spleen
(d) Relative bradycardia
(e) Appearance of rose spots on the abdomen

41. The complications of roundworm infestation are:
(a) Diarrhoea
(b) Lung abscess
(c) Intestinal obstruction
(d) Acute pancreatitis
(e) Löffler's syndrome

42. Manifestations of scrub typhus include:
(a) Small intestinal ulceration
(b) Lymphadenopathy
(c) Maculopapular rashes
(d) Ptosis
(e) The presence of eschar

43. Measles:
(a) Is a viral disease
(b) Is diagnosed by the presence of Koplik's spots on the mucous membrane of the mouth
(c) May be complicated by secondary bacterial infection
(d) Is commonly spread by the bite of mosquitoes
(e) Is common over 40 years of age

44. Complications of malaria due to Plasmodium falciparum include:
(a) Severe anaemia
(b) Splenic rupture
(c) Hyperglycaemia
(d) Respiratory acidosis
(e) Jaundice

45. Clinical features of symptomatic HIV disease include:
(a) Weight loss
(b) Splenomegaly
(c) Jaundice
(d) perianal herpes
(e) Oral hairy leukoplakia

46. The following are recognized complications of typhoid fever:
(a) Osteomyelitis
(b) Cholecystitis
(c) Suppurative lymphadenitis
(d) Myocarditis
(e) Pneumonia

47. Recognized features of meningococcaemia include:
(a) Purpuric rash
(b) Shock
(c) Disseminated intravascular coagulation
(d) Coma
(e) Arthritis

48. The following are characteristic features of plague:
(a) Incubation period less than seven days
(b) the patient's expectorates are highly infectious
(c) Pneumonic plague is more common than bubonic plague
(d) Rigors, severe headache and painful lymphadenopathy are the usual presentation
(e) Penicillin is the drug of choice

49. Features of shigellosis include:
(a) Bloody diarrhea
(b) Liver abscess
(c) Haemolytic uraemic syndrome
(d) Colonic perforation
(e) Arthritis

50. The following organisms can cause food poisoning:
(a) Staphylococcus aureus
(b) Corynebacterium diphtheriae
(c) Streptococcus viridans
(d) Yersinia enterocolitica
(e) Clostridium perfringes

51. The following features are typical of lepromatous leprosy:
(a) The affected person is not infective
(b) Organisms are scanty in number in the skin smears
(c) Lepromin test is strongly positive
(d) Peripheral nerves are thickened
(e) Anaesthetic, hypopigmented skin macules and plaques are present

52. The following worms are associated with the respective pathological conditions in man:
(a) Taenia saginata Cysticercosis
(b) Echinococcus
granulosa Hydatid cyst
(c) Wucheria bancrofti Pulmonary eosinophilia
(d) Enterobius
vermicularis Enterocolitis
(e) Ankylostoma Megaloblastic
duodenale anaemia

53. Correct statements about amoebiasis include:
(a) The causative organism is Entamoeba coli
(b) Metronidazole therapy is effective both in the liver and colonic disease
(c) The cysts are eradicated with mebendazole
(d) Liver abscesses are best identified with plain X-ray abdomen
(e) Right lobe liver abscess often leads to pericardial tamponade

54. The following statements regarding rabies are correct:
(a) It can be transmitted by cat bite
(b) It can cause ascending paralysis
(c) Prognosis is poor if symptoms develop
(d) Lacerated wounds resulting from rabid dog bite should be immediately cleaned and stitched
(e) Antirabies vaccine is given in the anterolateral aspect of the thigh in the adults

55. Gonorrhoea:
(a) Is due to a Gram-negative diplococcus
(b) May be asymptomatic in the female
(c) Usually presents as epididymo- orchitis in the male
(d) Is treated with penicillin
(e) May lead to sterility

56. The following statements regarding Pneumocystis carinii infection in an HIV patient are correct:
(a) It is the commonest cause of respiratory failure in Myanmar patients
(b) It is characterized by copious sputum production
(c) It is characterized by widespread pulmonary crackles
(d) It is more likely to occur when the CD4 count is less than 200/mm3
(e) It is treated with high doses of benzylpenicillin