Osce Questions

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Introduction to NAC OSCE

General Information... Registration for NAC OSCE... Fees... Examination station... NAC OSCE scoring... Sample of Therapeutic written test... Sample clinical case station... Therapeutic Guidelines Medicine

Cardiology... Dermatology... Endocrinology... Gastroentermogy... Hematology... Infectious Diseases... Neurology... Otolaryngology... Pulmonology... Rheumatology... Nephrology/Urology... Emergency Medicine... Counseling (smoking/alcohol)... Obstetrics & Gynecology

Sexually transmitted infections... Urinary tract infection... Vulvovaginitis... Pelvic inflammatory disease... Dysfunctional uterine bleeding... Dysmenorrhea... Endometriosis... Hormone replacement therapy... Emergenqr contraception... Group B Streptococcus in pregnancy... Pregnancy induced hypertension... Ectopic pregnancy... Hyperemesis gravidarum... Drugs contraindicated in pregnancy... Pediatrics

Acute bronchiolitis... Acute otitis media... Asthma... Bacterial tracheitis... Bacterial pneumonia... Croup (Laryngotracheobronchitis)... Epiglottitis... Streptococcal pharyngitis (Group A streptococcus)... Whooping cough (Pertussis)... Bacterial meningitis... Febrile seizures... Urinary tract infection... Allergic reaction... Anemia... Dose of tylenol... Immunization schedule...

1 Introduction to NAC OSCE

General Information

The National Assessment Collaboration, or NAC OSCE, was established to provide a system that streamlines the assessment of IMG medical knowledge and clinical skills throughout Canada. Many international medical graduates (IMGs) find that the path to obtaining a medical license in Canada challenging and difficult to navigate. Different provinces and territories have their own system for assessing IMG medical knowledge and clinical skills.

Comprised of a number of federal and provincial assessment and educational stakeholders, the NAC OSCE aims to streamline the evaluation process through which an IMG must navigate to obtain a license to practice medicine in Canada. Through such a system, an IMGs path to licensure would be the same, regardless of the jurisdiction in which he or she is being assessed. The NAC OSCE has replaced C EH PE As Clinical Examination 1 (CEI), which was unique to Ontario.

Registration for NAC OSCE

Registration for the NAC OSCE in Ontario starts in November, with the deadline in January the next year. Candidates are advised to complete their registration within this time-frame. Once the deadline is over, the candidate will not be able to register for the NAC OSCE for the entire year. The exams are scheduled for March, June, August and September.

Visit www.mcc.ca and www.cehpea.ca for updated information. Fees

Application Fee: $200 which is non-refundable, NAC OSCE Fee in Ontario: $1850 and Exam Date Change Fee: $100

All fees are in (CAD) Canadian Dollars. Examination station

The format for the National Assessment Collaboration (NAC) Objective Structured Clinical Examination (OSCE) consists of 12 stations based on presentations of clinical scenarios. For a given administration, each candidate rotates through the same series of stations. Each station is 10 minutes in length with two minutes between stations.

At each station, a brief written statement introduces a clinical problem and outlines the candidate's tasks (e.g. take a history, do a physical examination, etc.). In each station, there is at least one standardized patient and a physician examiner. Standardized patients have been trained to consistently portray a

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patient problem. Candidates should interact with standardized patients as they would with their own patients.

The physician examiner observes the patient encounter. For most stations, the candidate will be asked to respond to a series of standardized oral questions posed by the physician examiner after seven minutes with the standardized patient. There are no rest stations.

Orientation videos http://www.mcc.ca/en/video/QEII-Orientation/index.html 2 NAC OSCE | A Comprehensive Review

The examination includes a separate written test of candidates' therapeutic knowledge. This component lasts 45 minutes and consists of 24 short-answer questions testing the candidates' knowledge of

therapeutics for patients across the age spectrum and related to pharmacotherapy, adverse effects, disease prevention and health promotion.

NAC OSCE scoring

The candidate's total examination score will be determined by combining the scores on the OSCE

component with the scores on the therapeutics component. The OSCE score contributes 75 per cent of the total score and the therapeutics score contributes 25 per cent of the total score. For reporting purposes, the NAC total examination scores are reported on a scale with a distribution ranging from 0 to 100 with a fixed passing mark of 65.

Number of times candidates can take the examination

Starting in 2011, the NAC OSCE can be attempted once per Canadian Resident Matching Service (CaRMS) cycle. If you pass the examination, you can register for the examination a maximum of two additional times if your eligibility is maintained. Regardless of whether you pass or fail, you can only take the examination three times. If you take the examination more than once, the most recent result will be the only valid result.

Sample of Therapeutic written test

Question: An otherwise healthy 65 year old woman presents with a 3 week history of aching and morning stiffness in both shoulders with difficulty dressing. She has no temporal artery tenderness, headache, jaw pain or visual disturbance. Her ESR (Erythrocyte sedimentation rate) is 100 and you have made the diagnosis of POLYMYALGIA RHEUMATICA (PMP).

What would you choose as the drug of first choice for initial medical therapy? (Drug, dose, route of administration and duration are required.)

Answer:_______________________________________________________ Answer key the marker receives:

PREDNISONE 7.5 - 20 mg PO od for 2-4 weeks following resolution of symptoms

Question: An otherwise healthy 55 year old male with a history of childhood “chickenpox" presents with a 2 day history of painful unilateral vesicular eruption in a restricted dermatomal distribution. You make a diagnosis of HERPES ZOSTER (shingles).

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

Answer:__________________________________________________________ Answer key the marker receives:

VALACYCLOVIR (VALTREX ®) 1000 mg PO tid X 7 days OR FAMCICLOVIR (FAMVIR ®) 500 - 750 mg PO tid X 7 days OR ACYCLOVIR (ZORIVAX ®) 800 mg PO 5X / day X 7 days)

Introduction to NAC OSCE | General Info 3 Sample Clinical Case Station

Example instruction written outside the station

David Thompson, 59 years old, presents to your office complaining of jaundice. In the next 7 minutes, obtain a focused and relevant history.

After the 7 minutes, you will be asked to answer questions about this patient. Example of post encounter questions

Ql.The abdominal examination of David Thompson revealed no organ enlargement, no masses and no tenderness. What radiologic investigation would you first order to help discriminate the cause of the jaundice?

Q2. If the investigations revealed that this patient likely had a post-hepatic obstruction, what are the two principal diagnostic considerations?

Q3. What radiologic procedure would you consider to elucidate the level and nature of the obstruction?

Therapeutic Guidelines

This isa

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Therapeutic Guidelines Medicine

1. Cardiology

Acute Myocardial Infarction : Immediate management in ER 1. Beta blockers: Inj Metoprolol 2.5-5 mg rapid IV q2-5 min, upto 15 mg over 10-15 minutes, then 15 minutes after receiving 15 mg IV. 2. Then 50 mg PO q6h x 48 hours, then 50-100 mg PO BID.

3. Inj Morphine Sulfate IV 2-5 mg every 5-30 min prn (If pain not relieved with 3 Sublingual Nitroglycerins) 4. Oxygen by nasal cannula at 4 liters per minute

5. Sublingual Nitroglycerin 0.3-0.6 mg q5min up to 3 times. 6. Non-enteric coated Aspirin 325 mg PO.

7. Cardiology Consultation Post MI drugs Drugs Benefits Side effects Cofitraliidiiiil Wi ACE Inhibitors

Ramipril - 10mg hs Lisinopril - lOmgod Enalapril - 20mg od Captopril - 50 mg tid 1 mortality

Prevents ventricular remodelling 1 proteinuria

Hypotension/dizziness Hyperkalemia Angioedema Renal insufficiency Cough, taste changes Bilateral renal artery stenosis

Hx of angioedema Pregnancy ARB

Valsartan - 160mgbid Candesartan - 32 mg od 1 mortality 1 proteinuria

Angioedema Cough, taste changes Beta Blocker

Metoprolol - lOOmg bid Atenolol - lOOmg od Carvedilol - 25mg bid Propranolol - 60-80 tid 1 mortality

1 sudden death, reinfarction & arrhythmias

Cardioselective : preferred for mild asthma and diabetes

Decreases BP&HR Dizziness, fatigue Sexual dysfunction May mask hypoglycemia Increase risk of cardiogenic shock Severe/poorly controlled asthma 2nd/3rd degree heart block

HR<50, SBP<90 Cocaine use Statins

Atorvastatin - 10mgod Simvastatin - 20-40mg od 1 mortality in post Ml patients with high cholesterol

Gl upset, muscle aches, myopathy, rhabdomyo- lysis, Impotence Active liver disease, alcoholics, pregnancy

Anti-platelets

ASA - 80-162mg od Clopidogrel - 75mgod Warfarin - 1-10mgod 1 vascular events

Gl upset, hypersensitivity Gl bleed Recent/active

bleeding

Gl intolerance or ASA allergy

MNEMONIC B : Beta Blockers M : Morphine Sulphate 0:0xygen N : Nitroglycerin A : Aspirin 8 NAC OSCE | A Comprehensive Review

Atrial Fibrillation 1. To control rate:

• Inj Metoprolol 5 mg bolus IV, followed by infusion at 0.05 mg/kg/min, increasing as needed to 0.2 mg/kg/min.

• Inj Diltiazem 20 mg bolus. Maintenance infusion of 5-15 mg/hr. • Inj Verapamil 5-10 mg IV over 2-3 min, repeated once after 30 mins. • Tab Amiodarone (in case of heart failure):

• Loading dose: 800 - 1600 mg PO in divided doses until response; till max 1000 mg/day divided bid-tid. • Maintenance: 200 mg PO od.

2. To prevent thromboembolism: Assess with CHADS 2 score • No risk: Tab Aspirin 81-325 mg PO od.

• 1 moderate risk: Tab Aspirin 81-325 mg PO od or Tab Warfarin 2-15 mg PO od to maintain INR 2-3. • >1 moderate risk or very high risk: Tab Warfarin 2-15 mg PO od to maintain INR 2-3.

3. To control rhythm:

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• Tab Sotalol 80-160 mg PO bid. ( Second choice) • Tab Amiodarone (in case of heart failure):

• Loading dose: 800 - 1600 mg PO in divided doses until response; till max 1000 mg/day divided bid-tid. • Maintenance: 200 mg PO od.

• Electrical Cardioversion: 100-360 joules.

Congestive Cardiac Failure : Immediate management in the ER • Oxygen by nasal cannula at 4 liters per minute.

• Inj Furosemide (Lasix) 10 mg IV stat.

• Inj Morphine sulfate IV 2-5 mg every 5-30 min prn. • Sublingual Nitroglycerin 0.3-0.6 mg q5min up to 3 times. • Position of patient > 45 degrees.

Non pharmacological management of Heart Failure • Exercise : Regular physical activity

• Salt restriction : symptomatic HF - 2-3g salt/day (Vfc tsp/day) no added salt in diet. HF with fluid retention : l-2g salt/day (V4 tsp/day)

• Fluid intake : 1.5/2L per day in patients with fluid retention or HF not controlled by diuretics. • Daily weight measurement.

• Education.

• Aggressive risk reduction (BP, glucose, lipids). • Lifestyle modifications, influenza vaccination. Off TREATMENT MNEMONIC L: Lasix

M : Morphine Sulphate N : Nitroglycerin 0:0xygen

P : Positive airway pressure P : Position > 45 degrees D : Dopamine (indicated in cardiogenic shock and hypotension)_________ Therapeutic Guidelines | Medicine 9

Dyslipidemia

1. HMG Co A Inhibitors:

• Atorvastatin : Tab Lipitor 10-80 mg qhs • Rosuvastatin : Tab Crestor 10-40mg qhs

• S/E: Gl symptoms, rash, pruritus, increased liver enzymes, myositis. • C/I: active liver disease, muscle disease, pregnancy.

2. Fibrates: increased TG (triglycerides) • Fenofibrate : Tab Lipidil 67-200 mg/d 3. Bile acid sequestrants : increased LDL • Tab Colestipol 5-30g/day

4. Cholesterol absorption inhibitors: • Tab Ezetimibe lOmg /day.

Lipid Risk LDL Total cholesterol/HDL HIGH (lOyrCAO >20%) Target LDL-<2.0 Target <4

MODERATE (10yr CAD > 10-19%) Treat if LDL- >3.5

Treat if >5

LOW (10yr CAD <10%) Treat if LDL ->5 Treat if >6

High Risk : All with CAD, CVD, most diabetes cases & chronic renal disease.

Hypertension

Non pharmacological treatment :

• Smoking cessation: smoking aggravates hypertension and remains the major contributor to cardiovascular disease in people under 65 years.

• Weight reduction : Maintain BMI<27, particularly in patients with glucose intolerance • Alcohol restriction.

• Sodium restriction <150mmol/day. Blood pressure risk factors

Consider treatment if BP BP target

No risk factors >160/100 <140/90

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SBP>160 SBP<140

Moderate-High risk patient >140/90

<140/90

Diabetes or Renal disease >130/80

<130/80

10 NAC OSCE | A Comprehensive Review Commonly used anti-hypertensive drugs : Drug

Indication Side Effect Diuretics

Hydrochlorothiazide HCT - 12.5-25mgod Spironolactone - 25-50mg od

Uncomplicated HTN, Diabetes with normal albuminuria, LVH and isolated systolic HTN Rash, allergic rxn, pancreatitis, sexual dysfunction. HCT contraindicated in gout. Beta Blockers

Metoprolol - 50mg bid or 100mg SR od Propranolol - 80mg bid Atenolol - 50-100mgod Stable angina, Ml, LVH, uncomplicated HTN <60 years,

Fatigue, insomnia, 1 HR, impotence, dizziness. C/I - asthma/COPD, 2"<,/3,,, degree heart block, uncompensated HF severe PAD ACE Inhibitors

Ramipril - 10mghs Lisinopril - 10mgod Enalapril - 10-20mgod Captopril - 25-50 mg bid

Heart failure, diabetes, post Ml, uncomplicated HTN, LVH, prior CVA/TIA, renal disease, all coronary artery disease pts. Cough, loss of taste, rash, angioedema, renal failure, IBP

C/I - b/l renal artery stenosis, Hx of angioedema, pregnancy Angiotensin II Receptor Blockers

Losartan - 25-50mg od Valsartan - 80-160mgod Candesartan - 8-16mgod

Diabetes, uncomplicated HTN, isolated systolic HTN, LVH, patients unable to tolerate ACEI. Fatigue, headache, rash, angioedema, i BP, t K+, pancreatitis.

C/I - b/l renal artery stenosis, Hx of angioedema, pregnancy Calcium Channel Blockers

Amlodipine - 2.5-10mgod Nefidipine- 10mgtid Verapamil - 40-80mg tid Diltiazem - 30-60mgtid Uncomplicated HTN, LVH, Angina, Isolated systolic HTN, diabetes without nephropathy

Dizziness, headache, rash, edema, gingival hypertrophy, worsen HF C/I - hypotension, recent Ml with pulmonary edema, sick sinus syndrome, 2nd/3rd AV block

Methyldopa - 125mg bid to 500mgqid First-line for hypertension in pregnancy

Sedation, dry mouth, hepatotoxic, lupus like symptoms.

Infective Endocarditis Prophylaxis • Inj Ampicillin 2g IV q4h x 4weeks.

• Inj Gentamicin 1 mg/kg IV q8h x 4 weeks.

• Prophylaxis: Dental/respiratory/esophageal procedure: Tab Amoxicillin 2g PO 30-60 min prior; Tab Clindamycin 600mg PO, if allergic to penicillin.

Rheumatic Heart Disease (EHD)

• Tab Erythromycin 500 mg tid PO x lOdays. • Tab Penicillin VK 500 mg PO bid x 10 days. Therapeutic Guidelines | Medicine 11

2. Dermatology Acne

Mild : <20 comedones (whiteheads/blackheads) or <15 inflammatory papules, or a lesion count <30 Moderate : 15-50 papules and pustules with comedones, cysts are rare, lesion count ranges from 30-125 Severe : Primarily nodules and cysts,also present are comedones, papules and pustules, scarring is present, lesion count >125

T 0 P

i

Benzoyl Peroxide (Antibacterial/Keratolytlc) Dose : apply to entire affected area qhs or bid

Indication: 1st line medication for mild- moderate acne. S/E : contact dermatitis, dryness, erythema, burning & pruritis

c

A

Tretinoin (Retinoid) 1st line treatment for mild-S/E : erythema, dryness,

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L

Dose : qhs, apply 30-45 minutes after wash moderate comedones acne.

burning, photosensitivity. Oral antibiotics

Indicated for moderate-S/E : Gl upset, nausea,

Tetracycline - initial 500mg bid then 250-500mg od severe acne.

vomiting, candidiasis. Doxycydine - 100mgod

Erythromycin - initial 500mg bid then 250-500mg od Acne on chest, back & shoulders

C/I : liver disease

S

Combined Oral Contraceptive Females with moderate-C/I : Smoking, migraine with

Y

5

Diane 35/Yasmin/Alesse : od x 21 days, 7 days severe acne + seborrhea +

aura, seizures

T

off/cycle

hirsutism, late onset acne

E M

Isotretinoin

Severe nodulocystic acne, Teratogenicity : ocular

1

Accutane : 0.5-1 mg/kg/day x 16-20 weeks acne with scarring, failure to

effects - conjunctivitis,

c

"Important : Tests for pregnancy 30 days prior to starting Accutane, before each refill. Patient has to sign an informed consent.

respond to other treatments

1 night vision, premature epiphyseal closure, t LFTs, pseudomotor cerebri, mucocutaneous effects, myalgias. Photosensitivity.

Bums

• Initial assessment of ABCs , consider the need for early intubation if airway is compromised. • Humidified 02 if any suspicion for inhalational injury.

• Oxygen 100% if known carbon monoxide exposure of fire in an enclosed space. (Half life of hemoglobin will drop from 330 to 90 mins).

• Establish IV access.

• Fluid resuscitation : Parkland formula 4mL/kg/%BSA burn, Vi over 8 hours and rest over 16 hours • Nasogastric tube drainage for ileus.

• Bladder catheterization to monitor urinary output, minimum lmL/kg/hr.

• Tetanus prophylaxis : 0.5 mL tetanus toxoid IM in previously immunized and 250 units TIG IM if unimmunized.

12 NAC OSCE | A Comprehensive Review

Psoriasis

Topical Preparations : 1. Topical Corticosteroids :

• High Potency Topical Steroids (Usually indicated) • Very high potency: e.g. Clobetasol (Temovate) • High potency: e.g. Fluocinonide (Lidex)

• Low Potency Topical Steroids (Alclometasone dipropionate) usually indicated in • Face

• Genitals

• Maintenance Therapy 2. Vitamin D based topicals : • Calcipotriene (Dovonex)

• Used in combination with Topical Corticosteroids 3. Retinoid based topicals :

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• More irritating than Calcipotriene 4. Immunosuppressant based topicals :

• Tacrolimus 0.1% or Pimecrolimus 0.1% creams Effective in facial and intertriginous Psoriasis 5. Adjunctive agents in combination with above :

• Topical Salicylic Acid (Keratolytic Agent)

6. Poorly tolerated topicals (use Calcipotriene instead) : • Historically used with UVB light exposure

• Anthralin (Anthra-Derm) • Coal Tar (e.g. Zetar) Ultraviolet light

• Risk of non-Melanoma skin cancer • Protocols

• Ultraviolet B exposure alone

• Ultraviolet A exposure with psoralen (PUVA) Increased risk of non-Melanoma skin cancer Systemic agents (most are for higher risk) • Immunosuppressants

• Etretinate • Cyclosporine

• Methotrexate (unclear efficacy) Therapeutic Guidelines | Medicine 13 • Biological agents

• Tumor necrosis factor (TNF) receptor blockers Etanercept (Enbrel)

Infliximab (Remicade) • Other mechanisms Alefacept (Amevive) Efalizumab (Raptiva)

• Thiazolidinedione (Avandia, Actos) - experimental • Appears effective in Psoriasis even in non-diabetics • Only small trials support to date

Cellulitis

• Cause : P Hemolytic Streptococcus , Staphylococcus • Treatment : Tab Cloxacillin 500mg PO qid x 10-14 days

If patient is allergic to penicillin : Tab Cephalexin 500mg PO qid 10-14 days OR Tab Clindamycin 300mg PO qid x 10-14 days

Pediculosis

• Permethrin 1% - wash hair with regular shampoo, then apply permethrin and leave for 10 mins then rinse • Pyrethrins with piperonyl butoxide

• Lindane 1% C/I in neonates, young children and pregnant women, causes neurotoxicity • Wash all clothes and linen in hot water, then machine dry.

Scabies

• Permethrin 5% - massage into all skin areas, from the top of the head to the soles of the feet, leave for 8-14 hours then wash off.

• Crotamiton 10%

• Scabene (aerosol spray)

• Lindane : used only if allergic to permethrin. • Treat family and contacts.

• Wash all clothes and linen in hot water, then machine dry. Tinea Cruris/Pedis (Jock itch/Athlete's foot)

• Clotrimazole 1% cream apply bid • Ketoconazole 2% cream apply bid 14 NAC OSCE | A Comprehensive Review 3. Endocrinology

Diabetes Mellitus Blood glucose target

A1C q3-6 months Target <7 Normal range<6 Fasting plasma glucose Target 4-7mmol/L Normal range 4-6mmol/L

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Post prandial blood glucose 2h Target 5-10mmoi/L

Normal range 5-8mmol/L

Approach to management of diabetes mellitus 1. Lifestyle modification & patient education

2. Oral hypoglycemic monotherapy :

• Biguanides (Metformin) - 250-500mg PO bid-tid (if obese or overweight) • Sulfonylureas (Glyburide) - 80mg PO bid

• Thiazolidinedione (Pioglitazone) - 15mg PO od; Rosiglitazone - 4mg PO od • Alpha glucosidase inhibitors (Acarbose) - 50mg PO tid

3. Oral combination therapy (2 agents often needed; after 3 years 50%, after 9 years 75%) 4. Insulin therapy +/- oral hypoglycemics

Diabetic Ketoacidosis Management • Fluid replacement

• Initial : Give 1 liter NS bolus over first 45 minutes, repeat fluid bolus until shock corrected.

• Next : Replace first 50% volume deficit in first 8 hours, use Normal Saline or Lactated Ringers. Replace remaining 50% deficit over next 16 hours, use D5 1/2 NS at 150-250 ml per hour.

• Insulin (Hypokalemia must be corrected prior to Insulin) • Initial

i. Give IV bolus of 0.15 units/kg ii. Start 0.1 units/kg/hour Insulin Drip • Maintenance

i. Anticipate Serum Glucose drop of 50-70 mg/dl/hour • If inadequate drop, then increase drip

a) Increase Insulin Infusion rate by 50-100% b) Continue at increased rate until adequate ii. When Serum Glucose <200-250 mg/dl a) Keep Serum Glucose at 150 to 200 mg/dl b) Decrease rate by 50% (to 0.05 units/kg) or c) Discontinue Insulin Drip and start SC dosing Therapeutic Guidelines | Medicine 15

• Potassium

Do not administer Insulin until potassium >3.3 • Give KC1 40 mEq/hour IV until corrects • Serum Potassium 3.3 to 5.0 mEq/L

i. Standard replacement: 20-30 mEq per liter • Serum Potassium >5.0 mEq/L

i. Do not administer any potassium ii. Monitor every 2 hours until <5.0 • Bicarbonate

Indications

i. ABG pH < 6.9 to 7.0 after initial hour of hydration ii. Other contributing factors

• Shock or Coma • Severe Hyperkalemia Hyperthyroidism

• Tab Propylthiouracil(PTU) 100 mg PO tid, to max 150 mg 6-8 hours. • Tab Methimazole 10-30 mg PO od.

• Medications associated with Hyperthyroidism:

Excess Thyroid hormone intake Dietary Iodine Amiodarone Hypothyroidism

• Tab L-Thyroxine 0.05-0.2 mg/day

• Medications associated with Hypothyroidism: i. Inorganic iodine

ii. Iodide iii. Amiodarone iv. Lithium

Hyperprolactinemia

• Tab Bromocriptine 1.25-2.5 mg PO od, increase by 2.5 mg/day q3-7days to max 15 mg/day.

• Tab Cabergoline 0.25 mg PO twice weekly, may increase by 0.25 mg q4weeks up to max lmg twice weekly.

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16 NAC OSCE | A Comprehensive Review Medications causing hyperprolactinemia a) Benzodiazepines b) Buspirone c) MAOI d) SSRI e) TCA f) Valproic acid g) Methyldopa h) Verapamil i) Atenolol j) Danazol k) Estrogen 1) Depo-Provera m) OCPs n) Metoclopromide o) Amphetamines P) Cannabis Impotence

• Tab Sildenafil 25-lOOmg per dose, to take half an hour to 4 hours prior to intercourse. S/E: flushing, headache, indigestion C/I: don't take with Nitrates.

4. Gastroenterology Appendicitis

Perioperative for 24hrs • Inj Ampicillin l-2g IV q4-6h. • Inj Flagyl 500mg IV bid.

• Inj Gentamicin 3-5mg/kg/day q8h (monitor creatinine levels). • NPO

Acute Gastroenteritis

• Tab Flagyl 500 mg PO bid x 5 days.

• Tab Ciprofloxacin 500 mg PO bid x 3 days. • Tab Norfloxacin 400 mg PO bid x 3 days. • Oral rehydration solution.

Acute Gastroenteritis Causes (Watery diarrhea)

E. Coll (Traveler's diarrhea) CMV Cryptosporidium Giardia lamblia

Therapeutic Guidelines | Medicine 17

Acute Pancreatitis • NPO

• Inj Flagyl 400 mg IV q8h

• Inj Meperidine 75-lOOmg IV q2-3h • I VF

• NG tube

• Replace calcium Crohn’s Disease

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1. Mild to moderate:

• Tab Mesalamine 800 mg PO tid. Maintenance dose 3.2 - 4g per day.

• Tab Sulfasalazine 250 mg per day and increase up to 2 g per day. Maintenance dose is 500- 1000 mg PO qid with food.

2. Moderate to severe:

• Tab Prednisone 40 mg PO qid x 8-12 weeks and taper gradually.

• Tab Azathioprine 2-2.5 mg/kg/day. Used for maintenance while tapering corticosteroids. Diverticulitis • Inj Flagyl 500mg IV bid.

• Inj Ciprofloxacin 500mg IV bid. Helicobacter Pylori

1. HP-PAC (7 blister pack) 7-14 days • Tab Lansoprazole 30mg PO bid + • Tab Clarithromycin 500mg PO bid + • Tab Amoxicillin lg bid

2. 2nd LINE Quadruple : 14 days • Tab Lansoprazole 30mg PO bid • Tab Flagyl 500mg PO bid • Tab Tetracycline 500mg bid • Tab Bismuth 525mg PO qid

18 NAC OSCE | A Comprehensive Review Hepatitis B post exposure prophylaxis 1. Known HBsAg Positive Source: i. Unvaccinated exposed patient:

• Hepatitis B Immunoglobulin (HBIG) 0.06 ml/kg and • Hepatitis B Vaccine 0,land 6 months.

ii. Exposed patient with known response to vaccine: • No treatment.

iii. Exposed patient with known failed response to vaccine: • Patient has not yet completed second 3-dose series: • Hepatitis B Immunoglobulin (HBIG) 0.06 ml/kg and • Hepatitis B Vaccine (complete second 3-dose series) • Patient has completed two prior 3-dose series: • Hepatitis B Immunoglobulin (HBIG) 0.06 ml/kg • Second Hepatitis B Immunoglobulin dose.

iv. Exposed patient with unknown response to vaccine: • Test for Antibody to HBsAg

• Adequate Antibody (HBsAg Positive): No treatment • Inadequate Antibody (HBsAg Negative)

• Hepatitis B Immunoglobulin (HBIG) 0.06 ml/kg and • Hepatitis B Vaccine booster dose:

2. Known HBsAg Negative Source:

i. Administer Hepatitis B Vaccine Series if unvaccinated ii. No treatment otherwise needed.

3. Unknown HBsAg Source Status: i. Unvaccinated exposed patient • Hepatitis B Vaccine Series

ii. Exposed patient with known response to vaccine • No treatment

iii. Exposed patient with known failed response to vaccine • Treat source as HBsAg positive if high risk

iv. Exposed patient with unknown response to vaccine • Test for Antibody to HBsAg

• Adequate Antibody (HBsAg Positive): No treatment • Inadequate Antibody (HBsAg Negative)

• Hepatitis B Vaccine initial and booster dose • Recheck titer in 1 to 2 months

4. Infant with HBsAg Positive Mother:

i. Hepatitis B Immunoglobulin (HBIG) 0.5 ml within 12 hours of birth.

ii. Hepatitis B vaccine: Dose 1 within 12 hours of birth, Dose 2 at age 1 months, Dose 3 at age 6 months. iii. Repeat HBsAg and HbsAb at 9 months &c 15 months.

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Peptic ulcer disease

• Tab Omeprazole 20mg PO od. • Tab Ranitidine 150 mg PO bid. Ulcerative Colitis

• Tab Sulfasalazine 250 mg per day and increase up to 2 g per day. Maintenance dose is 500-1000 mg PO qid with food.

• Tab Mesalamine 800 mg PO tid. Maintenance dose 3.2 - 4g per day. • Rectal suppositories preferred for proctitis.

Acute Cholecystitis (Perioperative) • Inj Cefazolin 0.5-1.5mg IV q6h • NPO • I VF • NG Tube 5. Hematology Anemia

• Iron Deficiency Anemia : Tab Ferrous fumarate(Palafer) 300 mg PO qd OR Tab Ferrous Sulfate 325 mg PO qd

• Megaloblastic Anemia : Tab Ferrous Fumarate 300mg PO qd + Tab Folic acid l-5mg PO qd + Inj B12 1000 meg q monthly or 1000 - 2000 microgram PO.

6. Infectious Diseases

Prophylaxis for opportunistic infections in HIV patients

• Pneumocystis carinii: CD4 count< 200 cells/mm3 or oral candidiasis. - Tab TMP/SMZ DS PO OD till CD4 counts rises.

• Toxoplasma gondii: IgG antibody positive and CD4 count < 100 cells/mm3 - Tab TMP/SMZ DS PO OD till CD4 counts rises.

• Mycobacterium tuberculosis: Man toux > 5 mm in immunocompromised or contact with active TB. - Tab Isoniazid 300 mg PO OD x 9 months along with

- Tab Pyridoxine 50 mg PO OD.

• Mycobacterium avium complex: CD4 counts < 50 cells/mm3. - Tab Azithromycin 1200 mg PO once a week.

- Tab Clarithromycin 500 mg PO once a week.

• Varicella zoster virus: Recent exposure to chicken pox or shingles. - Varicella zoster immune globulin within < 96 hours of exposure. 20 NAC OSCE | A Comprehensive Review

HI V post exposure prophylaxis

• Start within hours of exposure (under 24 to 48 hours). • Triple Therapy for 4 weeks:

1. First two medications: AZT and 3TC (or Combivir) i. Tab Zidovudine (AZT) 300 mg PO bid and

ii. Tab Lamivudine (3TC) 150 mg PO bid. 2. Third medication (choose one): i. Tab Indinavir (IDV) 800 mg PO tid or ii. Tab Nelfinavir (Viracept) 750 mg PO tid or iii. Tab Efavirenz 600 mg PO qhs.

• Obtain baseline labs to monitor for adverse reaction: 1. Pregnancy Test

2. Complete Blood Count with differential and platelets 3. Urinalysis

4. Renal Function Tests 5. Liver Function Tests Malaria

1. Treatment for active infection:

i. Tab Chloroquine 1 g PO stat, then 500 mg PO 6-8 hours later, then 500 mg PO at 24 hours & 48 hours after initial dose.

ii. Tab Mefloquine 1250 mg stat dose.

iii. Tab Primaquine 15 mg base PO od x 14 days. 2. Chemoprophylaxis:

i. Tab Chloroquine 500 mg PO once a week. ii. Tab Mefloquine 250 mg PO once a week. Pulmonary tuberculosis

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2 months.

2. Continuation Phase: Tab Isoniazid 300 mg + Tab Rifampin 600 mg for 4 months. 3. Add Tab Pyridoxine (Vit B6) 50 mg PO OD.

Rabies

Post exposure prophylaxis:

• Wash wound with soap and water.

• Human Rabies Immunoglobulin 20 IU/kg IM stat and half dose into the wound. • Rabies vaccine 1 ml IM on days 0,3,7,14,28.

• Inform Public Health.

• Capture animal & observe x 10 days, then examine brain for negri bodies. Therapeutic Guidelines | Medicine 21

Tetanus Prophylaxis : Based upon Tetanus immunization status -History of tetanus Immunization

Clean, minor wounds All other wounds Td or Tdap* 0.5ml Tig** 250U Td or Tdap* Tig

Uncertain or < 3 doses of an immunization Yes

No Yes Yes

> 3 doses received in an immunization Not

No No§ No

* Adult-type combined tetanus and diphtheria toxoids or a combined preparation of diphtheria, tetanus and acellular pertussis. If the patient is < 7 years old, a tetanus toxoid-containing vaccine is given as part of the routine childhood immunization. ** Tetanus immune globulin, given at a separate site from Td (or Tdap) t Yes, if > 10 years since last booster.

§ Yes, if > 5 years since last booster. More frequent boosters not required and can be associated with increased adverse events. The bivalent toxoid, Td, is not considered to be significantly more reactogenic than T alone and is recommended for use in this circumstance. The patient should be informed that Td (or Tdap) has been given.

7. Neurology Seizures

1. Acute Management:

• Inj Diazepam 5-10mg IV q2-3mins till seizure stops. • Inj Phenytoin 20mg/kg IV at 50mg per min.

• Inj Phénobarbital 20mg/kg IV at 50-75mg/min • If all fails then rapid sequence intubation. 2. Primary Generalized & Partial seizures:

• Tab Phenytoin: Loading 300mg PO q4h x 3 doses, then 300mg PO qhs. • Tab Valproate: Loading 15mg/kg/day, increments by

5-10mg/kg/day qweekly, till seizures are controlled.

• Tab Carbamazepine: Start 100-200mg PO od-bid, increments by 200mg/per q2d, if needed till max 800mg-1200mg per day.

3. Absence Seizures:

• Tab Ethosuximide 500mg PO daily in divided doses, increments by 250mg/day q4-7d pm till max 1500mg per day.

Meningitis

• Investigations : CT then LP, CSF analysis, blood C&S, neurology consult

• Empirical adult antibiotics : 3rd generation cephalosporins + vancomycin + ampicillin Inj Ceftriaxone 2g IV ql2h

Inj Dexamethasone lOmg q6h IV x 4 days for pneumococcal meningitis Meningococcal: give contacts Tab Rifampin 600mg PO ql2h x 4 doses

IP: P~450 Interactions H: Hirsutism E: Enlarged gums N: Nystagmus Y; Yellow-browning of skin T: Teratogenicity 0: Osteomalacia I: Interference with folic acid absorption {hence anemia) N: Neuropathies: vertigo, ataxia, headache

CSF Findings : Normal

Bacterial Viral

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Fungai/TB

Pressure (cmMsO)

5-20 >30

Normal or mildly increased

Appearance Normal Turbid Clear Fibrin web Protein {g/U 0.18-0.45 >1 <1 0.1-0.5 Glucose (mmol/l) 25-3.5 <2.2 Normal 1.6-2.5 Gram stain Normal 60-90% Positive Normal

Glucose - CSF^enim Ratio

0.6 <0.4 >0.6 <0.4 WCC <3 >500 <1000 100-500 Other 90% PMN

Monocytes 10% have >90% PMN 30% have >50% PMN Monocytes

Cluster headache

• Tab Triptan and Tab Prednisone at the beginning of the cycle and prophylactic treatment with Tab Lithium(300-600mg daily initially then monitor serum levels)

• Dihydroergotamine nasal spray 4mg per 1 ml. One spray each nostril and repeat ql5mins. Migraine

1. Mild - Moderate -► NSAIDS • Tab Ibuprofen 200mg tid • Tab Aspirin 600mg PO q4h 2. Moderate - Severe -► TRIPTANS

• Tab Sumatriptan 25mg PO & repeat q 2hrs prn • Tab Metoclopramide lOmg PO stat

3. Prophylaxis:

• Tab Propranolol 60mg PO daily • Tab Amitriptyline 10-25mg PO qhs. Tension headache

Tab Tylenol 500mg PO 4-6hrs prn. Therapeutic Guidelines | Medicine 23

Myasthenia Gravis

1. Anticholinesterase (Cholinergic)

• Tab Mestinon (Neostigmine and Pyridostigmine): 60-120 mg q3-4h. 2. Immunosuppressive therapy

• Tab Prednisone: Start at 20 mg qd, increase gradually by 5 mg every 3 days to 60mg. Continue for 3 months or until clinical improvement stops or declines. Taper gradually to every other day

• Tab Azathioprine (Imuran) 2 mg/kg/day. Effective when given with Prednisone. Effect not seen for 6 months or more. Monitor CBC and LFTs.

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Response rate: 70%. Parkinson’s disease

• Tab Carbidopa/Levodopa 25/100 mg PO bid-qid, increase as needed to max 200/2000mg/day. • Tab Bromocriptine 1.25 mg PO bid.

• Tab Pergolide 0.05 mg PO od, titrate q2-3 days to the desired effect. Maintenance dose is 3-6 mg/day in divided doses.

• Tab Premipexole 0.125 mg PO tid, increase to 1.5 - 4.5 mg/day in divided doses. • Tab Ropinirole 0.25 mg PO tid, increase weekly to max dose 24 g/day.

• Tab Amantadine 100 mg PO od to max 100 mg PO qid. • Tab Selegiline 5 mg PO bid.

• Tab Benztropine 0.5-6 mg/day PO in divided doses.

• Tab Entacapone 200 mg given concurrently with Carbidopa/Levodopa. 8. Otolaryngology

Acute Sinusitis

• Tab Amoxicillin 500mg tid PO x 10 days. • Decongestant: Tab Sudafed 60mg PO q6h • Nasal saline.

Acute Pharyngitis

• Group A 6 Hemolytic Strep: Tab Penicillin V 300mg PO tid x lOdays

Penicillin /ülctuk : lab Erydiromycia 500rnu rid x 10 days

24 NAC OSCE | A Comprehensive Review 9. Pulmonology

Asthma

1. Intermittent Asthma: Short acting beta-agonist - Salbutamol (Ventolin) Inhaler 1-2 puffs q4-6h pm. 2. Mild Intermittent Asthma:

• Long acting beta agonist - Salmeterol Inhaler 1-2 puffs bid. • Inhaled steroids:

i. Fluticasone (Flovent) 2-4 puffs bid. ii. Budesonide (Pulmicort) 2 puffs bid.

iii. Beclomethasone (Vanceril) 1-4 puffs (40|ig) bid or 1-2 puffs (80pg) bid. 3. Moderate Persistent Asthma:

• Inhaled steroids:

i. Fluticasone (Flovent) 2-4 puffs bid. ii. Budesonide (Pulmicort) 2 puffs bid.

iii. Beclomethasone (Vanceril) 1-4 puffs (40pg) bid or 1-2 puffs (80|ig) bid. • Long acting beta agonist - Salmeterol Inhaler 1-2 puffs bid.

• Leukotriene Receptor Antagonist: • Tab Montelukast 10 mg PO qhs. • Tab Zileuton 600 mg PO qid. 4. Severe Persistent Asthma: • High dose Inhaled steroids. • Long acting beta agonist.

• Leukotriene Receptor Antagonist. • Systemic Steroids:

i. Tab Prednisone 2 mg/kg/day PO (max 60 mg/day).

ii. Inj Methylprednisolone (Depo-medrol) 2mg/kg IV, then 0.5 mg/kg q6h x 5days. Acute exacerbation of COPD

• Admit with nasal 02.Keep saturation between 88-92%. If silent chest/GCS < 8 or decreased LOC then intubate.

• Elevated bed > 45 degrees. • I VF.

• MDI : 8 puffs of Ventolin (Salbutamol) alternate with 8 puffs of Atrovent (Ipratropium) back to back every 20 mins 3 times.

• Nebulizer : 2cc Ventolin + lcc Atrovent in 3cc NS q20 mins x 3 times. • Inj Hydrocortisone 125mg IV stat, if severe.

• Inj Ceftriaxone 1-2 g IV q24h along with • Inj Piperacillin-Tazobactam 3.375 g IV q6h.

• Inj Methylprednisolone 2mg/kg IV, then 0.5 mg/kg q6h x 5 days. Therapeutic Guidelines | Medicine 25

Community Acquired Pneumonia 1. Outpatient management:

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• Tab Doxycycline 100 mg PO bid x 7-10 days. • Tab Erythromycin 250 - 500 mg bid x 7-10 days. • Tab Azithromycin 500 mg PO od x 5 days. • Tab Levofloxacin 500 mg PO od x 7-10 days. • Tab Augmentin 500 mg/ 125 mg PO q8h x 5days. 2. Inpatient management:

• Inj Ceftriaxone 1-2 g IV bid along with • Inj Levofloxacin 500 mg IV od x 7-10 days.

• Inj Azithromycin 50 mg IV over 1 hour od x 1-2 days. Pulmonary Embolism

1. Investigations

• V/Qscan, spiral CT or D-dimer (if unlikely Wells' score < 4) • CBC, INR, PTT, BUN, creatinine, ALT, AST.

2. Management: Initiation

• Start Warfarin (Coumadin) concurrent with Heparin.

• Contraindicated in pregnancy. (If contraindicated may put IVC filter)

• Start Tab Warfarin at 5 mg PO daily on Day 1-2 and Heparin 5000 UIV bolus followed by continuous infusion 20 U/kg/hour, titrate to INR 2-3 then stop heparin within 24 hours.

• Check INR in 3-5 days.

• Therapeutic INR: 2.0 to 3.0 IU.

• Oxygen, and if pain give morphine or NSAID. 3. Management: Duration of Anticoagulation • Very low risk: 6-12 weeks

• Symptomatic isolated calf vein thrombosis. • Low risk patient: 3-6 months

• Reversible thromboembolism risk (transient risk such as post-operative PE). • Upper extremity Deep Vein Thrombosis.

• Moderate risk patient: 6-12 months • First idiopathic DVT or PE.

• High risk patient: 12 months or lifetime Anticoagulation • Recurrent DVT or PE or Thrombophilia.

26 NAC OSCE | A Comprehensive Review 10. Rheumatology

Osteoporosis

• Tab Calcium (I500mg/day) and Tab Vitamin D (800 IU/day) intake in diet or as supplements. • Bisphosphonates: Alendronate, Risedronate or Raloxifene.

• Hormone Replacement Therapy • Calcitonin

• Recombinant Parathyroid Hormone

• Lifestyle modifications: Weight bearing exercises, smoking and alcohol cessation. Osteoarthritis • Tab Tylenol 500 mg PO tid.

• Tab Ibuprofen 200-600 mg PO tid. • Tab Naproxen 125-500 mg PO bid. • Tab Celecoxib 200 mg PO od. • Other treatment:

• Tab Acetaminophen + Tab Codeine. • Intra-articular corticosteroid injection. • Intra-articular hyaluron injection. • Topical NSAIDs.

• Capsaicin cream. • Glucosamine sulfate. Rheumatoid Arthritis 1. First Choice:

• Tab Naproxen 500 mg PO bid. • Tab Ibuprofen 300-800 mg PO qid.

• Tab Indomethacin 25-50 mg PO bid or tid.

2. Analgesics: Tab Acetaminophen 500 mg PO tid prn. 3. Corticosteroids: given intra-articular

i. Small Joints:

• Inj Hydrocortisone 8-20 mg. • Inj Methylprednisolone 2-5 mg.

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• Inj Betamethasone 0.8 - 1.0 mg. ii. Large Joints:

• Inj Hydrocortisone 40 100 mg. • Inj Methylprednisolone 10-25 mg. • Inj Betamethasone 2-4 mg.

Therapeutic Guidelines | Medicine 27

4. Disease Modifying Antirheumatic Drugs (DMARDs): Start within 3 months of diagnosis to reduce disease progression.

i. Mild disease:

• Tab Hydroxychloroquine 200 mg PO bid. • Tab Sulfasalazine 500 mg PO bid to tid. ii. Moderate disease:

• Tab Methotrexate 10-15 mg PO once weekly, then increase to 20 mg PO once weekly. • Combination therapy:

• Methotrexate + Sulfasalazine + Hydroxychloroquine. • Methotrexate + Cyclosporine.

• Methotrexate + Etanercept (biological DMARD). iii. Biological DMARDs: used in persistent disease: • Etanercept SC. • Infliximab IV. • Anakinra SC. • Adalimumab SC. • Abatacept IV. • Rituximab IV. NOTE:

• If Corticosteroids are used for> 3 months, do baseline DEXA and start bisphosphonate therapy. • S/E of Corticosteroids: Osteoporosis, cataracts, glaucoma, peptic ulcer disease, avascular necrosis, hypertension, increased infection rate, hypokalemia, hyperglycemia, hyperlipidemia.

• C/I to Corticosteroids: Active infection, hypertension, diabetes mellitus, gastric ulcer, osteoporosis. Gout

1. Acute Gout:

i. NSAIDs: Tab Indomethacin 25-50 mg PO tid x 10-14 days. ii. Tab Naproxen 500 mg PO bid x 4-10 days.

iii. Tab Colchicine 0.6 mg PO qlh till pain relief (max 4-6 doses), then bid x 3-5 days. iv. Systemic Steroids: (rule out Septic Arthritis)

• Inj Methylprednisolone 40 mg IV single dose • Inj Depo-Medrol 80-120 mg IM single dose.

• Oral: Tab Prednisone 40 mg PO od x 5days, then gradually taper the dose. v. Intra- Articular Corticosteroid: used in large single joints & refractory cases. • Inj Betamethasone 7 mg or Inj ACTH 40-80IU.

2. Recurrent Gout: Treat for 3-6 months.

i. Over producers: Tab Allopurinol 100-300 mg/day PO.

ii. Under-excreters: Tab Probenecid 250 mg PO bid (max:1500 mg bid) or Tab Sulfapyrizine 50 mg PO bid (max: 1000 mg bid).

iii. Concurrently start with Tab Colchicine 0.6 mg PO bid x 3-6 months. 28 NAC OSCE | A Comprehensive Review

Temporal arteritis

• Start high dose Tab Prednisone 60 mg PO od until symptoms subside and ESR normal • Then 40 mg PO od for 4-6 weeks

• Then taper to 5-10 mg PO od for 2 years (relapses occur in 50% if treatment is terminated before 2 years). Treatment does not alter biopsy results if the sample is taken within 2 weeks.

• Monitor ESR regularly.

• If visual symptoms are present, or develop during treatment, the patient is admitted and given Inj Prednisolone 1000 mg IV ql2h for 5 days.

Polymyalgia Rheumatica Management 1. General measures

• Consider concurrent Temporal Arteritis (See above) • NSAIDs

2. Prednisone (key to management)

• See Corticosteroid Associated Osteoporosis • Efficacy: 90% response

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Dramatic improvement in first 48 hours If no response to steroids - reconsider diagnosis Reconsider diagnosis Consider Methotrexate

• Polymyalgia alone Dose: 15-20 mg PO qd

• Polymyalgia with Temporal Arteritis Dose: 40-60 mg PO qd

Symptoms and signs remit within 1 month

Decrease dose by 10% each week after improvement • Course

• Initial: Maintain starting dose for 1 month

• First steroid taper (depends on clinical response)

Taper by 2.5 mg per month down to 10 mg/day then Taper 1 mg per 4-6 weeks down to 5 to 7.5 mg/day • Final steroid taper

Indicated when symptom free for 6-12 months Do not taper until sedimentation rate normalizes Taper by 1 mg every 6-8 weeks until done

• Anticipate 2-6 year course of steroids

Relapse common in first 18 months of steroid use Patients off steroids at 2 years: 25% Therapeutic Guidelines | Medicine 29

Fibromyalgia

1. ANTIDEPRESSANTS : Benefits

• Assists with local pain, stiffness and sleep • Does not affect Tender Points

2. Tricyclic Antidepressants • Amitriptyline (Elavil) i. First week: 10 mg PO qhs

ii. Next three weeks: 25 mg PO qhs iii. Later: 50 mg PO qhs

• Nortriptyline (Pamelor) 3. Novel Antidepressants • Venlafaxine (Effexor) • Duloxetine (Cymbalta)

4. Selective Serotonin Reuptake Inhibitors (SSRI) • Combination: Fluoxetine and Amitriptyline Septic Arthritis

• Gonococcal: Inj Ceftriaxone lg IV q24h x 2-4 days, then switch to Tab Ciprofloxacin 500 mg PO bid x 7 days.

• Non-Gonococcal: Inj Naficillin 2g IV q4h x 2 weeks, then switch to Tab Ciprofloxacin 500 mg PO bid x 2-4weeks.

11. Urology/Nephrology

Urinary tract infection (UTI)

1. Acute uncomplicated UTI: outpatient • Tab Bactrim DS PO bid x 3 days.

• Tab Nitrofurantoin (Macrobid) 100 mg PO bid x 5 days. 2. Drug resistant UTI: outpatient

• Tab Ciprofloxacin 500 mg bid x 3 days. • Tab Norfloxacin 400 mg PO bid x 3 days. • Tab Ofloxacin 200 mg PO bid x 3 days. 3. Acute complicated UTI: inpatient

• Inj Ampicillin 1-2 g IV q4-6h and Inj Gentamicin 2mg/kg IV loading dose followed by 1.7 mg /kg q8h IV OD • Inj Ciprofloxacin 400 mg IV bid.

• Switch to oral antibiotics upon improvement for a total course of 14-21 days. 30 NAC OSCE | A Comprehensive Review

Acute Pyelonephritis

1. Outpatient management: For acute uncomplicated cases • Tab Ciprofloxacin 500 mg PO bid x 10 days.

• Tab Gatifloxacin 400 mg PO daily x 10 days. • Tab Moxifloxacin 400 mg PO daily x 10 days. • Tab Levofloxacin 250 mg PO daily x 10 days. • Tab Augmentin bid x 14 days.

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2. Inpatient management: IV for 48-72 hours, then switch to oral agents. Total duration of treatment for 14 days.

• Inj Ceftriaxone (Rocephin) 1-2 grams IV q24 hours. • Inj Cefotaxime (Claforan) 1 gram IV ql2 hours.

• Inj Ampicillin 2 g IV q6h with Inj Gentamicin 2mg/kg IV loading dose , then 1.7mg/kg q8h. Inj Piperacillin 3.375g IV q6h.

12. Emergency Medicine/Poisoning Acetaminophen Intoxication • Toxic level dose is more than 7.5g

• Investigations : Monitor drug level stat and then q4h (Acetaminophen nomogram), LFT, INR, PTT, BUN, Creatinine, ABG, Glucose

• Rx : Charcoal/Gastric lavage as per presentation

N-acetyl cysteine 140mg/kg PO, then 70mg/kg q4h for 18 doses Alcohol withdrawal

• Treatment : Inj Diazepam 10-20mg IV

Inj Thiamine lOOmg IM then 50-100mg/day Fluid resuscitation with D5W l-2mL/kg IV Allergic Reaction

1. Severe: Inj Epinephrine 0.3-0.5 mg SC/IM stat 2. Mild: Tab Benadryl 25-50mg PO q6h x 3d 3. Tab Prednisone 60mg PO od x 3d

Anaphylaxis

• Epinephrine autoinjector (EpiPen) if available • Epinephrine IV or ETT : 1ml of 1:10,000 in adults • Inj Diphenhydramine (Benadryl) 50mg IV or IM q4-6 h • Inj Methylprednisone 50-lOOmg IV according to severity • If wheezing or spasm present : Salbutamol via nebulizer. Therapeutic Guidelines | Medicine 31

Arrhythmias

Arrhythmias due to 2nd degree and 3rd degree heart block : Inj Atropine 0.5mg IV while waiting for transcutaneous pacing. Transcutaneous pacing first (give Inj Midazolam 2mg for sedation) Admit for transvenous pacing

Unstable patients (hypotensive systolic BP < 90, chest pain, SOB, altered mental status or unconscious) : CARDIOVERT!

Stable patient :

Atrial fibrillation : either chemical cardioversion (Amiodarone) or electrical (Synchronized DC cardioversion) Ventricular tachycardia : DC cardioversion or Inj Lidocaine/Amiodarone 150mg IV over 10 mins. Ventricular fibrillation : Always defibrillate! Synchronized cardioversion not useful because there is no QRS complex to synchronize with.

PSVT : Valsalva or carotid massage (after checking for bruit), Inj Adenosine 6mg rapid IV push. If no response then Metaprolol, Diltiazem.

ASA Intoxication

Investigations : Drug levels, electrolytes, ABG, BUN, Creatinine Rx : Gastric lavage/Charcoal Alkalinize urine with D5W, KC1 and NaHC03 Aim : urine pH > 7.5

Diabetic ketoacidosis

Estimated daily basal glucose requirement is 0.5U/kg

Investigations : Blood glucose, electrolytes, ABG, serum ketones, osmolar gap, anion gap, BUN, creatinine. Look of the cause : Urinalysis, blood C&S, chest x-ray, ECG.

Monitor : Urine output, extra-cellular fluid volume, electrolytes, ABG, creatinine, capillary blood glucose and level of consciousness every 1-2 hours.

Management : Rehydration : NS lL/h in first 2 hours followed by 0.45% NS 500cc/h then switch to maintain blood glucose 13.9-16.6mmol/L to avoid rapid decrease of osmolality. K+ replacement : As acidosis is corrected, hypokalemia may develop.

If K+ is 3.3-5.0 mmol/L, add KC120-30 mEq/L to keep it within this range. Correct acidosis : If pH < 7.0/hypotension/coma then give 3 amp NaHCOs (150mEq/L)

Reduce blood glucose : Start Insulin therapy with 0.15U/kg bolus and maintain 0.1U/kg/h until acidosis and blood glucose resolve.

Treat underlying precipitant.

32 NAC OSCE | A Comprehensive Review Digoxin Intoxication

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intoxication)

• Rx : Treat arrhythmias (common with digoxin intoxication; vfib, vtach, conduction blocks) Gastric lavage / Charcoal (lg/kg) for ingestion NaHC03 or glucose and insulin

Ventricular tachycardia : Digibind 10-20 vials if dose unknown Chronic toxicity : then Digibind 3-6 vials IV over 30 mins.

Follow ECG, K+ Mg+, Digoxin levels every 6 hours. Hypertensive emergency

• Systolic BP > 180mmHg and Diastolic BP > 120mmHg (with signs of acute organ damage) • Investigations : CBC, electrolytes, BUN, Creatinine, ABG, Urinalysis, CXR, ECG, BP in all four limbs, Fundoscopy, Cardiology consult.

• 1st Line : Inj Sodium nitroprusside 0.3 mcg/kg/min IV OR Inj Labetalol 20mg IV bolus q 10 mins. • Aortic dissection : Sodium nitroprusside + Beta blocker (esmolol)

• Catecholamine excess : Inj Phentolamine 5-l5mg IV q 5-15 mins

• Ml/Pulmonary edema : Inj Nitroglycerin 5-20mcg/min IV, increase by 5mcg/min every 5 min till symptoms improve.

Hypoglycemia

• Investigations : Baseline blood glucose, insulin and C-peptide, check glucose ql5 mins until > 5mmol/L

• Rx : If patient can eat/drink : give I5g carbohydrate if BG < 4mmol/L (15g glucose tabs or ZA caps of juice or 3 spoons of sugar in water.)

NPO : give 25g carbohydrate if BG < 4mmol/L ( D50W 50cc IV push 1 amp OR D10W 500cc IV OR glucagon l-2mg IM/SC )

Methanol/Ethylene glycol intoxication

• Investigations : CBC, electrolytes, glucose, methanol level.

• Rx : Ethanol 10mg/kg over 30 mins OR Inj Fomepizole 15mg/kg IV over 30 mins. Therapeutic Guidelines | Medicine 33

Opioid Intoxication

• Mental status effects include euphoria, sedation, decreased anxiety, a sense of tranquility and

indifference to pain produced by mild-to-moderate intoxication. Severe intoxication can lead to delirium and coma.

• Physiological effects include the following:

Respiratory depression (may occur while the patient maintains consciousness) Alterations in temperature regulations

Hypovolemia (true as well as relative), leading to hypotension Miosis

Soft tissue infection

Increase sphincter tone (can lead to urinary retention) • Treatment

IV glucose : 50% Dextrose 50ml

Inj Nalaxone 0.4mg upto 2mg IV for reversal of opioid intoxication. Inj Thiamine lOOmg IM stat & OD x 3days

02, intubation &, mechanical ventillation Shock (Cardiogenic/Neurogenic)

• Dopamine : l-3mcg/kg/min is the renal dose; 4-10mcg/kg/min is the inotropic dose • Dobutamine : 2.5-5mcg/kg/min

Sprain (Ankle) RICE • Rest

• Ice : using bag of ice, apply during the day for 5-20 mins every 2 hours. • Compression : Tensor bandage or special supports.

• Elevation : Elevate the ankle as much as possible. • Analgesics as needed.

• Crutches if too painful to bear weight. Stroke

• Investigations : CBC, electrolytes, BUN, glucose, creatinine, INR/PTT, lipids, ECG, carotid doppler if suspecting TIA, ABG, Non contrast urgent CT scan.

• Treatments : NPO, Foley catheter, DVT prophylaxis, Neurology consult Rule out contraindications for thrombolytic treatment.

Urgent neurology consult.

Thrombolysis : rTPA within 3 hours of symptoms

Anti-coagulation : Low dose Heparin 5000 U bid, start Warfarin within 3 days, monitor INR/PTT If unable to thrombolyse or anti-coagulate then : Tab ASA 50-325mg od or Tab Clopidogrel 75mg od

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BP control : decrease slowly, IV Labetalol (First line treatment)

Bed rest, analgesics, mild sedation and laxatives, avoid hyperglycemia. 34 NAC OSCE | A Comprehensive Review

TCA Intoxication

• Patients who present to the ED following psychotropic drug overdose with GCS < 8 should undergo intubation at the earliest opportunity to prevent hypoventilation and aspiration pneumonia.

• Investigations : Drug levels, ECG, ABG, electrolytes, LFTs, RFTs. • Rx : Activated charcoal lgm/kg via NG

Diazepam for seizures

Wide QRS/Seizures : NaHCOa ( 1-2 mEq/kg bolus dose and then 100-150 mEq in 1L D5/0.45% NaCl infused 100-200 ml/h IV)

Upper Gl Bleed

• Stabilize patient with IVF, cross & type, 2 large bore IV cannulas.

• Investigations : CBC, platelets, INR, BUN, creatinine, PTT, electrolytes, LFTs • Management : NG tube, NPO, blood transfusion if needed, upper Gl endoscopy

Inj Octreotide 50mcg loading and 50mcg per hour (for varices) SC/I V Inj Pantoprazole 50mg IV stat and 50mg q8h (gastric ulcer)

Lower Gl Bleed

• Stabilize patient with IVF, cross & type, 2 large bore IV cannulas. • Investigations : CBC, platelets, INR/PTT, BUN, creatinine, electrolytes.

• Management : NG tube, NPO, blood transfusion if needed, sigmoidoscopy, colonoscopy, angiogram (for angiodysplasia)

Warfarin Intoxication

• Treatment according to INR levels

INR < 5 : Stop warfarin, observation, serial INR/PTT

INR 5-9 : If no risk factors for bleeding, hold warfarin x 1-2 days & reduce maintenance dose. OR Vitamin K 1-2 mg PO, if patient at increased risk or FFP for active bleeding.

INR 9-20 : Stop warfarin, Vitamin K 2-4 mg PO, serial INR/PTT then additional Vitamin K if needed or FFP for active bleeding.

INR > 20 : FFP 10-15ml/kg, Inj Vitamin K lOmg IV over 10 min, increase dose of Vitamin K (q4h) if needed. Therapeutic Guidelines | Medicine 35

13. Counselling Smoking cessation 1. 2

.

3. 4.

Nicotine gums: 2mg if < 25 cig/day, 4mg if > 25cig/day • 1 piece ql-2h for l-3mths Nicotine patch:

• 21 mg per day for 4 weeks • 14mg per day for 2 weeks • 7mg per day for 2 weeks

Nicotine inhaler: 6-16 cartridges per day upto 12 weeks Bupropion(Zyban): • 150mg qAM x 3days, then 150mg bid for 7- 12 weeks

• Maintenance 150mg bid for upto 6 months. • General

Stop smoking during second week of medication Stop Bupropion if unable to quit by 7 weeks Minimum of 8 hours between doses More is not better

Swallow pills whole (not crushed, divided or chewed). Alcohol cessation

Protocol: Alcohol Dependence • Lab markers

Serum Gamma glutamyl transferase or Carbohydrate deficient Transferrin 1.Initial Management

• Tab Thiamine 100 mg PO qd • Tab Folate 1 mg PO qd • Multivitamin qd

• Treat Hypomagnesemia if present • Seizure precautions

2.Long-Term Abstinence Programs • Alcoholics Anonymous

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• Detoxification centers • Halfway House

CAGE Questionnaire

C : Have you ever felt the need to CUT down on your drinking?

A : Have you ever felt ANNOYED at criticism of your drinking? & : Have you ever felt GUILTY about your drinking?

E : Have you ever had a drink first thing in the morning (EYE OPENER}?

36 NAC OSCE | A Comprehensive Review 3.Adjunctive Medications for abstinence 1.First line (consider Naltrexone with Campral) • Tab Naltrexone

Blocks Opioid receptors

Decreases pleasure from Alcohol Dosing: 50 mg orally daily

Effective in short-term, but not in long-term • Tab Campral (Acamprosate)

Balances GABA and glutamate neurotransmitters Reduces anxiety from abstinence Dosing: 2 tabs PO tid 2.Second line agents to consider

• Selective Serotonin Reuptake Inhibitors (SSRI)

Consider especially if comorbid depression Prozac often used, but other SSRIs effective • Topiramate (Topamax)

Decreases Alcohol use severity and binge drinking Improves well being, quality of life in Alcoholics 3.Agents to avoid

• Antabuse

Taken 250 to 500 mg orally daily

Not recommended due to risk and uncertain benefit • Delirium Tremens

General Protocol (Requires ICU observation) • Tab Diazepam (Valium)

Dose: 10-25 mg PO qlh prn while awake Endpoint: until adequate sedation • Inj Lorazepam (Ativan)

Dose: 1-2 mg IV qlh prn while awake for 3-5 days Endpoint: until adequate sedation • Librium (Chlordiazepoxide)

Dose: 50 to 100 mg PO/IM/IV q4h (max: 300 mg/day) Endpoint: until adequate sedation

NOTES

Obstetrics & Gynecology

1. Sexually Transmitted Infection a. Chlamydia:

Tab Azithromycin lg PO stat or Tab Doxycycline lOOmg PO bid x 7 days If pregnant: Tab Erythromycin SOOmg PO tid x 7 days.

Treat partner, Reportable disease. b. Gonorrhea:

Inj Ceftriaxone 125mg IM stat + Tab Doxycycline lOOmg bid x 7 days. If pregnant : Inj Spectinomycin 2g IM stat Treat partner, Reportable disease. c. Syphilis:

Primary, Secondary, Latent Syphilis (duration less 1 year ):

Inj Benzathine Penicillin G 2.4 MU IM for 1 dose Treat partner, Reportable disease. If allergic to Penicillin: Tab Doxycycline 100 mg PO bid for 14 days.

Late latent, Cardiovascular (duration over 1 year)

Inj Benzathine Penicillin G 2.4 MU IM once a week for 3 weeks If Penicillin allergic : Tab Tetracycline 500 mg PO qid for 4 weeks or Tab Doxycycline 100 mg PO bid for 4 weeks Neurosyphilis : Inj Aqueous Penicillin G 3-4 MU IM every 3-4 hours for 10-13-4 days.

d. Genital herpes:

First episode: Tab Acyclovir 400mg PO tid x 10 days or Tab Famciclovir 250 mg tid x 10 days or Tab Valacyclovir 1 g bid x 10 days Recurrent: Tab Acyclovir 400mg PO tid x 5 days or Tab Famciclovir 120 mg bid x 5 days or Tab Valacyclovir 500 mg bid x 5 days Suppression: if more than 6 episodes per year Tab Acyclovir 400mg PO bid x 12 months Severe episode: Inj Acyclovir 5-10 mg/kg q8h x 5-7 days e. Genital warts (HPV):

Local treatment with LIQUID NITROGEN repeat every 1-2 weeks Podophyllotoxin 0.5% gel bid x 3days,then 4 days off - to be repeated for 4 weeks.

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Prophylaxis for HPV (for Cervical CA & warts) - Inj Gardasil IM 0,2 and 6 months. Therapeutic Guidelines | Obstetrics & Gynecology 39

GENERAL INSTRUCTIONS for all sexually transmitted infections: • Treat all partners

• Avoid sexual intercourse till treatment completion. • Barrier contraception/ educate about safe sex practices. • Rescreening in 3 months.

SIDE EFFECTS:

• DOXYCYCLINE: Drug induced PHOTOSENSITIVITY, use sun screen

• ACYCLOVIR: headache, Gl upset, impaired renal function, tremors, agitation, lethargy, confusion, coma 2. Urinary Tract Infection

Uncomplicated:

Tab Bactrim DS PO bid x 3 days or

Tab Nitrofurantoin lOOmg PO qid x 5days. (with food) In pregnancy: Treat asymptomatic UTI

Tab Amoxicillin 250mg PO tid or Tab Macrobid lOOmg PO bid x 10 days. Pyelonephritis: Acute Uncomplicated:

Tab Ciprofloxacin 500mg PO bid x 10 days or Tab Augmentin 625mg PO bid x 14 days. Inpatient: Inj Ceftriaxone lg IV bid for 48 hours then switch to oral drugs +

Inj Gentamicin 50mg IV q8h for 24 hours. 3. Vulvovaginitis

a. Candidiasis:

Tab Miconazole 200mg PV qhs x 3 days or

Tab Nystatin (100,00 unit) vaginal tab PV qhs x 14 days or Tab Fluconazole I50mg PO stat dose.

Prophylaxis: 4 or more infection per year - Tab Fluconazole 150mg PO every 3days for 3 doses. Maintenance: Tab Fluconazole 150mg PO each week. Monitor liver enzymes every 1-2 months. b. Bacterial vaginosis:

Tab Flagyl 500mg PO bid x 7days.(with food) c. Trichomonas vaginalis:

Tab Flagyl 2g PO for 1 dose, or

Tab Flagyl 500mg PO bid x 7days.(with food), treat partner. d. Atrophic vaginitis:

Topical Estrogen cream 0.5 to 2g daily to be applied locally. 40 NAC OSCE | A Comprehensive Review

4. Pelvic Inflammatory Disease (PID)

a. Outpatient: Inj Ceftriaxone 250mg IM stat dose + Tab Doxycycline lOOmg PO bid x 14days. b. Inpatient: Inj Cefoxitin 2g IV q6h + Inj Doxycycline lOOmg IV ql2h.

Continue IV for 48 hrs & then tab Doxycycline lOOmg PO bid x 14 days. Reportable disease, treat partners, rescreening after 4-6 weeks incase of documented infection.

5. Dysfunctional Uterine Bleeding (DUB) a. Mild DUB:

• NSAIDs - Tab Mefenamic acid 500mg PO tid x 5 days,

• Anitfibrinolytics - Tranexamic acid 500mg PO tid x 5 days, Combined OCPS • Mirena / Provera

• Tab Progestin one tab OD in first 10-14days. b. Severe DUB:

• Inj Premarin 25mg IV q4h + Tab Gravol 50mg PO q4h.

• With Tab Ovral PO tid till bleeding stops (24hrs),THEN bid for 2 days, THEN od for 3days. • Continue conventional OCPs if pregnancy not desired.

6.Dysmenorrhea

• Tab Ibuprofen 400mg PO qid from 1st day of menstrual cycle. • Oral Contraceptive Pills.

• Important to rule out secondary causes of dysmenorrhea. 7. Endometriosis

a) NSAIDs : Tab Ibuprofen 400 mg PO qid till symptoms last. b) Oral Contraceptive pills.

c) Tab Provera 10-20 mg PO OD.

d) Tab Danazol 600-800 mg PO OD for 6 months.

e) GnRH Agonist: Inj Leuprolide 3.75 mg IM once a month for 6 months. Inj Goserelin 3.6 mg SC every 28 days for 6 months.

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Use GnRH Agonist along with Estrogen/Progesterone add back therapy. (To reduce the side effects of bone loss.)

Therapeutic Guidelines | Obstetrics & Gynecology 41

8. Hormone Replacement Therapy (HRT)

a) Only Estrogen - Tab Premarin 0.625mg PO OD ( only estrogen)

b) Cyclic Dose - Tab Premarin 0.625mg PO OD and Tab Provera S-10mg PO OD from days 1-14. c) Standard dose - Tab Prempro (premarin 0.625mg and provera 2.5mg) combination pill PO OD. d) Pulsatile - Tab Premarin 0.625mg PO OD and Low dose Tab Provera 1.5 mg PO OD.

Given as 3 days on and 3 days off.

e) Transdermal : Estradiol transdermal patch twice daily and Tab Provera 2.5 mg PO OD. 9. Emergency contraception

• OTC no prescription needed. Take within 72 hours of unprotected intercourse.

• Tab Ovral 2 tabs PO ql2h x 2 doses (has Levonorgestrel 0.5mg/dose + estrogen O.lmg/dose) + Tab Benadryl lOmg 1 hr before dose (emesis induced by Estrogen).

• Plan B ( Tab Levonorgestrel 0.75mg/tab) one tab ql2hrs x 2 doses. 10. Group B Streptococcus (GBS) in pregnancy

• Inj Penicillin G 5 MU IV then 2.5 MU IV q4h till delivery. • Penicillin allergic: Inj Cefazolin 2 g IV then 1 g q8h or

Inj Clindamycin 900 mg IV q8h or Inj Erythromycin 500 mg IV q6h. 11. Pregnancy Induced Hypertension (PIH)

a. Initial: To maintain DBP<100

• Inj Labetalol 20mg IV bolus every 10-20 mins prn. (C/I asthma,CHF) • Tab Nifedipine XL lOmg PO very 20-30 mins prn.

• Inj Hydralazine 5mg or lOmg IM every 20 mins pm, then 5 or lOmg every 3 hrs pm. (S/E: fetal tachycardia, maternal headache, palpitations)

b. Maintenance:

• Tab Methyldopa 250-500mg PO bid - qid. • Tab Metoprolol 25-lOOmg PO bid.

• Tab Labetalol 100-400mg PO qid. c. Anticonvulsant therapy:

• Inj Magnesium sulfate 4g IV bolus over 20 min, followed by maintenance of 2-4 g/hour.

• Monitor signs of Magnesium toxicity - depressed deep tendon reflexes, decreased respiratory reflex, anuric, hypotonic, CNS or cardiac depression.

• Antagonist to Magnesium sulfate: Calcium gluconate(10%) 10 ml IV over 2 minutes. d. Avoid these antihypertensives:

• ACE(-) & ARBs - neonatal renal failure, teratogenic, IUGR. • Atenolol - IUGR

Thiazide diuretics - maternal fluid depletion. 42 NAC OSCE | A Comprehensive Review

12. Ectopic Pregnancy

a) Inj Methotrexate 50mg/m2 BSA IM stat dose. b) Repeat beta hCG levels weekly till <1.

c) Contraception till beta hcg returns to 5mIU/ml or less. d) Do CBC, LFTs.

13. Hyperemesis Gravidarum

Tab Diclectin (10 mg Doxylamine with 10 mg Pyridoxin) started as 1 tab qAM + 1 tab qPM + 2 tabs qhs. Maximum 8 tabs per day.

14. Drugs contraindicated in pregnancy • Chloramphenicol: Gray baby syndrome

• Erythromycin: Maternal liver damage (used only if allergic to penicillin). • Fluoroquinolones: Cartilage damage.

• Metronidazole: Anti-metabolite, high risk in 1st trimester and breast feeding. Can lead to miscarriage. • Sulfa drugs: Miscarriage in 1st trimester and kernicterus in 3rd trimester.

• Tetracyclines: Staining of teeth in children.

• ACE inhibitors: IUGR, oligohydraminos, fetal renal defects. • Anticonvulsants:

i) Phenytoin: Fetal hydantoin syndrome - IUGR, facial dysmorphogenesis, cardiovascular defects, congenital anomalies of hand & foot, umbilical hernia and congenital anomalies. ii) Valproic acid: Lumbosacral spina bifida with meningomyelocele or meningocele, often

accompanied by midfacial hypoplasia, deficient orbital ridge, prominent forehead, congenital heart disease, and decreased postnatal growth.

Osce Questions

TABLE OF CONTENTS

TABLE OF CONTENTS

TABLE OF CONTENTS

1

Introduction to NAC OSCE

Therapeutic Guidelines

Therapeutic Guidelines Medicine

.

NOTES

Obstetrics & Gynecology