Answer:Fixed oval dilated pupil & corneal edema n haziness & injected conjuctivaAcute angle closure glaucomaHyperopia, female, >60, family hx, shallow ant chamber, mature cataractc) Signs:Reduced visual acuity d2 corneal edema n vsual fieldElevated IOP (50-100 mmHg)Shallowant chamber Harder eye on gentle palpationGonioscopy – complete peripheral iridocorneal contactOphthalmoscopy – optic disc odema and hyperaemiad) Irreversible loss of vision & permanent peripheral anterior synechiaee) EMERGENCY TX!!!!!!i.vacetazolamide 500 mg (carbonic anhydrase to reduce aquoes formation), pilocarpine drop (cholinergic drug to constrict pupil). Both are to reduce IOP immediately to preserve vision.f) Laser iridotomy/ surgical iridectomy
Hazy cornea, hypopyon, injected conjunctivaCorneal ulcerFluorescein dye staining: the de-epitheliazed area stains greenTrauma, contact lens wear, topical steroid toxicity, infection (bact, viral,fungal,protozoa)Ocular emergency! Topical antibiotic but do culture 1st, topical cytoplegic drug to reduce ciliary spasm.
Optic disc swollen with blurred disc margin, hyperemia, engorged vessel + some areas of haemorrhage and cotton wool spot + macular starPapilloedemaIncreased ICP d2: Severe hypertension/malignant hypertension, space occupying lesionCT scan of head
a) Nasal cannulas should only be used in patients who breathe adequately through their nostril .It is for obligatory nasal breather ie: newborn & for adult who req minimal O2 enrichment.b). Use of cannulae is not indicated in patients who have severe hypoxia, poor respiratory effort, blocked nasal passages, apnea, or are mouth breathers.c) comfortable,can eat n drinks, cheap, well toleratedd) Pressure sore, dry nasal mucosa, epistaxis, can only deliver low concentrations of oxygen (It can deliver from 24% to 40% oxygen at a flow rate of 0.26-1.58 gal (1-6 L) per minute)
Oropharyngeal airway/ guedel airway.To protect airway (airway adjunct) by preventing the tongue fall backwards to obstruct the hypopharynx in unconscious pt.Do not use in conscious pt who hv intact gag reflex that can cause vomiting and aspiration.Wash hand, put on glove – choose correct size (tragus of ear to angle of mouth) – open mouth by chin lift manouver – insert it in reverse position – as it advanced to back of mouth, rotate it.
Nasopharyngeal airwayFor pt with gag reflex and lower facial traumaNasal obstruction n base skull # is suspectedWash hand and put on glove – choose correct size (lumen size = size of pt finger) – lubricate the tip with KY gel – insert the tip into nostril downward – until flange rest on nostril – ventilate with bag and mask device
CombitubeUsed in pt with difficult airways secondary to severe facial burns, trauma, upper airway bleeding and vomiting where there was an inability to visualize the vocal cords.The Combitube is a twin lumen device designed for use in emergency situations and difficult airways. It can be inserted without the need for visualization into the oropharynx, and usually enters the esophagus. It has a low volume inflatable distal cuff and a much larger proximal cuff designed to occlude the oro- and nasopharynx (1-4). If the tube has entered the trachea, ventilation is achieved through the distal lumen as with a standard ETT. More commonly the device enters the esophagus and ventilation is achieved through multiple proximal apertures situated above the distal cuff. In the latter case the proximal and distal cuffs have to be inflated to prevent air from escaping through the esophagus or back out of the oro- and nasopharynx.increased incidence of sore throat, dysphagia and upper airway hematoma,esophageal ruptureKnown esophageal disease
Sims speculumUse: 1)To visualize vaginaesp in gynae cases. Useful for visualising fistula (abnormal holes or connections) and prolapse (protrusion) of the rectum or bladderinto the vagina. In sims position, abdominal viscera fall away from back and pelvis and allowing full inspection of vagina) – 2)High Vaginal Swab for C&S 3)Pap smear 4)D&CSims position:A position where a patient is on the left side with the right knee flexed against the abdomen and the left knee slightly flexed.Not self-retaining,therefore require assistant.
a) Secondary arrest labour (cessation of cervical dilatation after initial normal active phase) b) Cephalo-pelvic disproportionc) If amniotic membrane not ruptured yet, rupture it artificially. Then give I.V oxytocin to manipulate the ‘power’ to increase uterine activity and promote cervical dilatation (Augmentation of labour). Hydration is important also.However, most pt in secondary arrest will end up with CS.d)Epidural analgesia: bcoz augmentation with oxytocin is > painful compared to spontaneous contraction.
Progesterone-only long acting reversiblehormonal contraceptivebirth control drug (depo-medroxyprogesterone acetate, injected every 3 months)Primary action: inhibit follicular development and prevent ovulation. Secondary action:of all progestogen-containing contraceptives is inhibition of sperm penetration by changes in the cervical mucus (thicker) Other: prevent implantation (causes the endometrium to become thin and atrophic)c) Very effective (PI<1)Good compliance once injectedInfrequent visit to doctorCan be use during lactationNo estrogen. No increased risk of deep vein thrombosis (DVT), pulmonary embolism (PE), stroke, or myocardial infarction.Decreased risk of endometrial cancer.d) Nausea, weight gain, headache, breast tenderness, acne,moodinessOccasional breakthrough bleedingAmenorrheaDelay in return of fertility of up to 4 months once stoppedOffers no protection against Sexually transmitted diseases (STDs). e) Pearl index<1
Right: Neville-Barnes Forcep (mid cavity&outlet), Left: WrigleysForcep (outlet)To assist 2nd stage of labour.Indication: Maternal (maternal exhaustion,cardiacds in pregnancy, prev scar) , Fetal (fetal distress, breech,malposition:not for forcep)FORCEPS: Fully dilated os/Fetus head engaged, Occiput anterior, Ruptured membrane, traction applied at height of Contraction, Episiotomy must be done/Empty bladder&rectum, Pain relief (adequate), Station low/Skilled doctor.Maternal: Genital tract trauma (3rd degree tear),vulva hematoma Fetus: fetal injury like damaged eyes,cranial bones, ICB
Ventouse (kiwi, metal cup,silicon cup)Prerequisites: same as forcep EXCEPT it can be applied when: a) cervical os not fully dilated , b) Fetal head in any position.Maternal: same with forcep Fetus: cephalohaematoma,ICBc) As mentioned in (a),it can be used when cervical os not fully dilated and fetal head in any position.
Levonogestrel (progestogen) Intrauterine contraceptive devicePrevent fertilization n implantation, inhibit ovulation3) For Menorrhagia, Uterine Fibroids,Adenomyosis,Dysmenorrhea,Progestogenic opposition of HRT, Endometrial Hyperplasia4) Rapid return to fertility , long acting (up to 5 years), got non contraceptive effect as mentioned in (c)5) Risk of PID & Ectopic Pregnancy High expulsion rate and risk of perforation Need specialist for insertion,infection during insertion6)Pearl index:0.14 pregnancies / 100 women
Vaginal ring pessaryTo hold the pelvic organ in the correct position & to support areas of pelvic organ prolapse(UV/recto/entero/cystocoele)Discomfort, vaginal discharge/bleeding,Infection, pressure necrosis *change every 3 month
a)Pipelle & endometrial samplingb) Abnormal per vaginal bleeding in >40 y/o, post menopausal bleeding, abnormal bleeding in young woman with high risk like PCOS,obese,anovulation, woman on tamoxifen.c) bleeding, pain,infection, uterine perforation
a)Uterine soundb) -for probing a woman's uterus through the cervixz: to measure the length and direction of the cervical canal and uterus to determine the level of dilation to induce further dilation.c) Uterine sounding prior to embryo transfer/prior to insertion of an intrauterine device (IUD) to prevent uterine perforation.
Amniotic hook/amniotic membrane perforaterAmniotomy (artificial rupture of membrane)Fetal: Cord prolapse, intrauterine fetal infection, conversion of unstable lie to tranverse obstructed lie with prolapse of arm. Maternal: Trauma to genital tract n LS of uterus, maternal infection, abruptio placenta (if sudden rupture in polyhydramnion),
Face presentation (mento-posterior position)Submento-bregmatic:9.5 cmComplication: Prolong labour d2 late engagement of headEmergency LSCS
Brow presentationMento-vertex: 13.5Complication: Arrested labourLSCS (incompatible with vaginal delivery bcoz it will not engaged!)
a)130 bpmb) About 10 bpmc) Type 2 decelerationd) Fetal distress due to: cord round neck,meconeum aspiration, cord prolapse etcNOTES:Baseline fetal heart rate (FHR) is the mean level of the FHR when this is stable, excluding accelerations and decelerations. It is determined over a time period of 5-10 minutes, expressed as beats per minute (bpm)1. Preterm fetuses tend to have values towards the upper end of the normal range.Baseline variability is the minor fluctuation in baseline FHR. It is assessed by estimating the difference in bpm between the highest peak and lowest trough of fluctuation in one minute segments of the trace1.Accelerations are transient increases in FHR of 15bpm or more above the baseline and lasting 15 seconds. Accelerations in preterm fetuses may be of lesser amplitude and shorter duration1.Decelerations are transient episodes of decrease of FHR below the baseline of more than 15 bpm lasting at least 15 seconds, which are:Early – uniform, repetitive decrease of FHR with slow onset early in the contraction and slow return to baseline by the end of the contraction1Variable – repetitive or intermittent decreasing of FHR with rapid onset and recovery. Time relationships with contraction cycle may be variable but most commonly occur simultaneously with contractions1.Complicated variable decelerations - the following additional features indicate the likelihood of fetal hypoxia:Rising baseline rate or fetal tachycardiaReducing baseline variability Slow return to baseline FHR after the end of the contractionLarge amplitude (by 60bpm or to 60bpm) and /or long duration (60 seconds)Loss of pre and post deceleration shouldering (abrupt brief increases in FHR baseline).Presence of post deceleration smooth overshoots (temporary increase in FHR above baseline)1Prolonged decelerations - decrease of FHR below the baseline of more than 15 bpm for longer than 90 seconds but less than 5 minutes1.Late decelerations - uniform, repetitive decreasing of FHR with, usually, slow onset mid to end of the contraction and nadir more than 20 seconds after the peak of the contraction and ending after the contraction1. 3. Classification of CTGs3.1 Normal antenatal CTG trace: The normal antenatal CTG is associated with a low probability of fetal compromise and has the following features:Baseline fetal heart rate (FHR) is between 110-160 bpmVariability of FHR is between 5-25 bpmDecelerations are absent or earlyAccelerations x2 within 20 minutes.3.2 Normal intrapartum CTG trace:The normal intrapartum CTG is associated with a low probability of fetal compromise and has the following features:Baseline FHR is between 110-160 bpmVariability of FHR is between 5-25 bpmDecelerations are absent or early The significance of the presence or absence of accelerations is unclear. Therefore, exclude accelerations during interpretation.3.3 Non-reassuring CTG trace is where one of the following features is present:The following features are unlikely to be associated with significant fetal compromise when occurring in isolation. The presence of two or more features is considered abnormal as these may be associated with fetal compromise and require further action (see 3.4).Baseline FHR is between 100-109 bpm or between 161-170 bpmVariability of FHR is reduced (3-5 bpm for >40 minutes)Decelerations are variable without complicating featuresDo not consider the absence of accelerations in intrapartum interpretation as abnormal.3.4 Abnormal CTG trace is where:The following features are very likely to be associated with significant fetal compromise and require further action:Two of the features described in non-reassuring CTG trace are present, ORBaseline FHR is <100 bpm or >170 bpmVariability is absent or <3 bpmVariability is sinusoidalDecelerations are prolonged for >3 minutes / late / have complicated variables
Polycistic ovarian syndrome (multiple cyst :string of pearl’s sign)-Serum LH:FSH ratio= 2-3:1 (normal=1:1) - High free testosterone and low sex hormone binding globulin, high androstenedione - High fasting plasma insulinc) Progestogen only pilld) Endometrial hyperplasia (then lead to endometrial ca), Cardiovascular disease d2 metabolic syndrome n DM, Sub/infertility
HysterosalpingographyBlockage of left fallopian tube.Subfertility d2 tubal blockageTubal damage/adhesion secondary to PID or endometriosisTell her that she still has chance to become pregnant bcoz the right tube is still patent. Investigate her husband (semen analysis). At the same time, advise her to reduce weight (if overweight la), take folic acid, regular unprotected sexual intercourse.
Cervical DiaphragmPrevent sperm from reaching cervical canal-Size must be appropriate to fit,therefore require trained person - Infection during insertion
- no p wave, irregular base line - Irregular QRS complex- Normally shaped QRS complex- AtrialfibrilationPalpitation, tachycardia, irregularly irregular pulse rate“I have a fib” xpress - IHD, HyperThyroid, Acute Pericarditis, Valvular HD, Embolus, ASD, Failure, Infection (pneumonia), booze.thrombo-embolism event, L vent failure, exacerbation of angina.
There is area of opacity in the R upper zone, there is airbronchogram seen, cavitation(imagine ajelaaa k heheheeeeakxjumpe chest xrayygadecavitation) There is chronic granulomatousinflamatory reaction characterise by central granular caseation, surrounded by epithelioid and multinucleated giant cellsPulmonary TuberculosisMycobectrium TuberculosisMantoux test, sputum smear for acid fast bacilli, culture in Lowenstein-Jensen mediumIsoniazid, rifampicin, prazinamide, ethambutolPlueral effusion, lung fibrosis, dessiminatedtb,
HeadacheYes , it is low. Normally =/>60% of plasma glucoseLow glucose, high protein, high wcc (polymorph), turbid appearance & pressure is elevatedBacterial meningitisIntravenous antibioticBrain abscess hydrocephalus, seizure, visual/hearing loss
Partially compensated metabolic acidosis, low pH 7.31, with low HCO3- and low PaCO2 –hyperventilate MUDPILES & HARDUPS – Methanol, Uremia, DKA, Paraldehyde, Isoniazid, Lactic acidosis, Ethanol, Salicylate. Hyperalimentation, Acetazolamide, Renal Tubular Acidosis,Diarrhea, Uretero-Pelvic Shunt,Post-Hypocapnia,Spironolactone(Na+K) – (Cl+HCO3) (140+4)-(102+18) =24 High anion gap [normal : 6-12]MUDPILES
Symptoms of anaemiaShortness of breath, drowsiness, decrease effort tolerance, letharyHperthyroidSweating, LOW despite increase appetite, hot intolerance, neck swelling,Anxiety Stress, worried,OthersCaffine, recreational drugs
Midline neck swellingThyroid storm- Triage patient to red zone - O2 with high flow mask 10-15L/min - ECG to exclude spectrum of ACS - Monitor ECG, vital signs and pulse oxymetry every 10-15 min - establish peripheral line - fluid maintenance with dextrose saline by slow infusion - blood investigations (TFT, FBC, BUSE/Creatinine, LFT - urinalysis for evidence of UTI - relieve fever by PCM, tepid sponging and other cooling method. - avoid aspirin as it will release T4 and T3 from its protein bound - anti thyroid meds:i) beta blocker (IV propanolol 1-2mg slowly for 4-6hourly) ii) PTU 600mg stat OR carbimazole 60-1200mg/day in 3 divided dose iii) steroids to inhibit release of thyroid hormone and peripheral conversion of T4 to T3 (IV dexamethasone 2mg 6hrly) - treat underlying heart problem -refer patient to endocrinologist or internal medicine team
IntraosseouscannulaTemporary measure for rapid vascular access in critically ill or injured paediatric patient (3-4 hrs only)ContraindicationAbsolute: fracture of tibia or long bones which are potential site for insertionRelative:Cellulitis overlying the insertion siteIVC injuryPrev attempt on the same leg boneOsteogenesisimperfectaOsteoporosisChildren ages more than 6 yearsWhere to insert the intrumentPreferably tibia bone (2-3cm inferior to proximal tibia tuberosity and 2-3cm medial to it with needle being advanced inferiorly)Distal femur ( anterior midline, above the external epicondyles, 1-3cm above the femoral plateau)ASISSternumUlnar boneComplicationExtravasation of fluidCompartment syndromeNecrosis of the muscle due to extravasation of hypertonic or caustic medications like sodium bicarbonate, dopamine, or calcium chloride
Xray findingLeft thorax radiolucent suggestive of massive pneumothoraxLeft lung collapsed, evidence by left mediastinal shiftTrachea shifted to the leftTraumatic pneumothorax of the left lungManagementTriage patient to the red zone with cardiac and oxygen saturation monitoringSecure the airway, breathing and circulationPut patient on high flow mask with oxygen 10-15L/minThis patient may require intubation if unconscious in order to protect the airway if O2 fails to reach >95% on high flow maskComplete the primary and secondary surveyInsert chest tube to the left thorax at safe triangleRepeat the thorax xray post chest tube insertionBlood investigation (FBC, GSH, PT/aPTT, ABG)Anaelgesic ( IV morphine 10-15 mg tat) with antiemetic (IV metochlopramide 10mg stat)Patient may require sedation with midazolam if intubated or restlessRefer patient to surgical team
The ECG showsST elevation in lead II, III, AVFReciprocal ST depression in lead I, AVLReciprocal T inversion in lead V1 and V2Normal sinus rhythmInferior myocardial infarctionRisk factorMale sexAge more than 55 y/oSmoker Management in EDTriage the patient to the red zone with cardiac monitoringSecure the airway, breathing and circulationIf ABC is not compromised, give oxygen via nasal prong 3L/minSublingual GTN 0.3-0.5mg (can be repeated every 5min for 3x if no HPT)Aspirin 300mg statClopidogrel 300mg statAnaelgesic 10-15mg IV slow bolus with IV metoclopramide 10mgIf patient still in pain, put patient on IV infusion morphine 1mg/kg in 50ml water for injectionBlood investigatio: cardiac enzyme (CK, Trop T) FBCFluid resuscitation (crucial in inferior MI)Consider giving thrombolytic agent, particularly streptokinase (1.5 million unit in 100ml normal saline infused over 60min). Make sure there is no contraindication to streptokinaseReght sided ECG to exclude RV involvementRefer to cardiologist r internal medicine team
Comment on picturePartial flex, adducted and internally rotated of the right hip jointShortening of the right limbSlight flexion of the right knee jointTraumatic right posterior hip dislocationManagementTriage the patient to yellow zoneEnure airway, breathing and circulation ha securedXray of the pelvis, right femur and right tibia fibularAdequate anaelgesicClosed reduction under general anaesthesiaXray of pelvis post reductionInform the orthopaedic team. If reduction fail, or unstable hip dislocation require admission to the orthopaedic ward
Fasciotomyb) Swelling of the muscle – usually as a result of post-traumatic bleeding and oedema.o Initially only venous flow is disturbed, and arterial flow (due to its greater pressure) still occurs.o Eventually, the pressure within the compartment exceeds the arterial pressure, and the muscle begins to undergo ischaemia. § The main arteries in the compartment have a higher pressure than the arterioles, and thus these may not be occluded until late on, if at all§ Other structures close by are also affected by the ischaemia – e.g. nerves, but the nerves are not affected until the pressure is very high!§ This means that distal pulses and neurological exam are usually normal until VERY LATE ON! · If there are reduced or absent pulses, then it is likely the diagnosis is too late to stop severe ischaemic damage. c) Permanent nerve damageInfectionLoss of limbDeathCosmetic deformity from fasciotomy
a) Posteroanterior (PA) radiograph of the hand reveals narrowing, osteophytes, and subchondral cysts affecting the distal interphalangeal joints; this finding is typical of osteoarthritis.
Colles’ #Introduce. Explain to patient that from the xray of hand it shows displaced left distal radius and ulnar # (colles #). *can be due to trauma (FOOSH). Also can be cause by osteoporosis (weakening of bone d2 low calcium level). CMR will be done. it will be under pain reliever (anaesthesia). We will give you through iv (iv midazolam)temporarily unconscious (only for few hours). Hand will be in a cast. After 10 days will need to come back for x-ray to see the position. If still displaced will need remanipulate. Risk involve is risk of anaesthesia (respiratory depression, rashes). After procedure will also give u painkiller. Benefit of cmr, it will reduce the pain, reduce deformity, reduce dysfunction.***must check either ptnt understand or not and if they have any question. Then sign the consent form.
Pathophysiology1) Urate crystal deposited in minute clumps in the connective t/s and articular cartilage (commonest sites are the small joints of the hands and feet)2) They can remain inert for month or years.3) Possibly as a result of local trauma, the crystal can disperse into the joints and surrounding t/s which excite inflammatory rxn.4) Clumps or tophi vary in size. It may destroy cartilage and periarticular bone and penetrate the skinCommon sitesType of t/s:- Joints- Periarticular t/s- Tendons- BursaeSites:- Metatarsophalengeal joints of big toe (adasorang pt harituada swelling and discharge at both feet)- Finger joints- Ankle- Achilles tendon- Olecranonbursae- Pinnae of earsSequlae1) Cartilage degeneration.2) Renal dysfunction.3) Uric acid kidney stone.
In very young children à bone ends are largely cartilaginous & therefore do not show in x-ray è Fracture at these sites are difficult to diagnoseChildren bone less brittle à more liable to plastic deformity compare to adult. Incomplete fractures – torus fracture (buckling of the cortex)& greenstick fractures are common in children compare to adultPeriosteum is thicker than in adult bones; this may explain why fracture displacement is more controlledCellular activity of periosteum is more active, which is why children’s fracture heal more rapidly than adult (the younger the quicker rate of union)Non-union is very unusualBone growth involves modeling & remodeling à fracture deformity can be reshape to normal over time (except rotational deformity)Damage to growth plate can have serious effect compare to adult
Answer Is it aggravated by movement (OA worsen with movement, RA relieve by movement)Any family history of rheumatoid arthritis? Occupational involving handling heavy object?Any pain on climbing stairs (rule out involvement of patellofemoral joint)Any history of infection with TB (rule out tuberculous arthritis)Osteoarthritis (most common in elder female+obese)Rheumatoid arthritisSeptic arthritisBilateral knee joint swellingGenuvalrusJoint crepitusLimited range of movement on knee.Osteophytes formation (Irregular and protuberant feeling at edge of articular ligament)Antalgic gaitDecreased joint space at weight beiring siteOsteophytes formationSubchondral cyst (not seen in this x ray)Subchondral sclerosisLoose bodies (calcified cartilage, free lying bone in joint space; also not seen in this x ray)Depend whether mild, moderate or severeAnalgesic (NSAIDS, opiods, opiods+paracetamol)Load reduction (weight loss, cane)GlucosamineArthroscopic debridementArthroplasty
AnwerGrade one single ulcerPlantar surface of big toeHealing marginPunched edgeFloor filled with granulation tissueTrophic ulcer due to uncontrolled diabetis mellitusUncontrolled DM --> peripheral neuropathy -->motor damage + sensory damage + autonomic damage --> ulcer formation without realizing it --> will extend and complicate the ulcer.OsteomyelitisDebridementRelieve the pressureAntibiotic if present with infection.
AnswerSkeletal traction with Bohler Stirrup.Indication for the proceduresLong term treatment of fracture or dislocation for more than two weeks (eg; fractured femur, fractured tibia, open fractures)Hold the fracture after reductionTraction more than 5 kg or 10% of body weight.ComplicationPin tract infectionOver distraction causing delayed/ non unionSoft tissue injuryIschemic necrosis of skin around the pinDamage to the epiphyseal growth plate when used in children
AnswerExternal fixation (Ilizarov Fixation)Immobilization/ hold of the limbIndication for the proceduresFracture with severe soft tissue injury for daily inspection, dressing and definitive coverageSevere communited @ unstable fractureFracture associated with neurovascular damageInfected fractureNon union fractureLimb lengthening procedurePelvic fracture that cannot be controlled by other methodsComplication of the proceduresDamage to the soft tissue component (nerve, vessels, ligaments)Over-distractionPin tract infection.
AnswerComment of the picturePartial flex, adducted and internally rotated of the right hip jointShortening of the right limbSlight flexion of right knee joint.Traumatic right posterior hip dislocationA&E management to this patientTriage the patient to the yellow zoneEnsure that airway, breathing and circulation has securedX ray of the pelvis, right femur and right tibia-fibularAdequate analgesicClosed reduction under general anaesthesiaX ray of the pelvis post reduction.Inform the orthopedic team. If reduction fail, or unstable hip dislocation, then may require admission to the orthopedic ward.
NORMAL TYMPANIC MEMBRANE
otoscopy slides Monday 2nd of August 2004 04:44:34 PM (6 years ago) #1NORMAL TYMPANIC MEMBRANE NORMAL EAR WAX IN EAR
ACUTE OTITIS MEDIA E EFFUSION
otoscopy slides Monday 2nd of August 2004 04:44:34 PM (6 years ago) #1NORMAL TYMPANIC MEMBRANE NORMAL EAR WAX IN EAR ACUTE OTITIS MEDIA E EFFUSION ACUTE MIDDLE EAR INFECTION E EFFUSION
otoscopy slides Monday 2nd of August 2004 04:44:34 PM (6 years ago) #1NORMAL TYMPANIC MEMBRANE NORMAL EAR WAX IN EAR ACUTE OTITIS MEDIA E EFFUSION ACUTE MIDDLE EAR INFECTION E EFFUSION SEROUS OTITIS MEDIA
FLUID BEHIND THE EAR DRUM
otoscopy slides Monday 2nd of August 2004 04:44:34 PM (6 years ago) #1NORMAL TYMPANIC MEMBRANE NORMAL EAR WAX IN EAR ACUTE OTITIS MEDIA E EFFUSION ACUTE MIDDLE EAR INFECTION E EFFUSION SEROUS OTITIS MEDIA FLUID BEHIND THE EAR DRUM TYMPANOSCLEROSIS CENTRAL PERFORATION OF EAR DRUM
otoscopy slides Monday 2nd of August 2004 04:44:34 PM (6 years ago) #1NORMAL TYMPANIC MEMBRANE NORMAL EAR WAX IN EAR ACUTE OTITIS MEDIA E EFFUSION ACUTE MIDDLE EAR INFECTION E EFFUSION SEROUS OTITIS MEDIA FLUID BEHIND THE EAR DRUM TYMPANOSCLEROSIS CENTRAL PERFORATION OF EAR DRUM GROMMET
A typical audiogram comparing normal and impaired hearing. The dip or notch at 4 kHz as shown, or at 6 kHz, is a symptom of noise-induced hearing loss.
Presbycusis curves for women and men, showing the average threshold shift for pure tones as a function of age
OSCE PRACTICEFrom: NorFadhillah Mahdah
OPHTALMOLOGY1)Scenario: 61 y/o Chinese lady presented with painful red eye a/w blurring of vision for 1 day.a) name 2 findings (1)b) what is your provisional diagnosis (2)c) Name 2 risk factors (2)d) name 2 other signs u would like to elicit(3)e) name 2 complication (2m)f) name 2 drugs u would give and what are they for (2)g) what is the definitive tx (1)
OPHTALMOLOGY2)A 35 y/o lady came with c/o red eye a/w progressively worsening blurring of vision, pain and teary eyes.a) Describe what u see? (3m)b) What is ur dx? (1m)c) How to confirm ur dx? (1m)d) What are the predisposing factors? (3m)e) How to manage her? (3m)
OPHTALMOLOGY3)A 46 y/o man came with severe headache and vomiting for 1 day. This is the image seen through his fundus.a) Describe what u see? (3m)b) What is the likely diagnosis? (1m)c) What are the aetiologies? (2m)d) How would u investigate this man? (1m)
ANAESTHESIOLOGY1)a) Who is this for?b)When not to use the above device? (3m)c) What are the advantages? (2m)d) What are the disadvantages? (2m)
ANAESTHESIOLOGY2)a) Name the above pic. (1m)b) What it is used for? (1m)c) What is the CI and why? (2m)d) How to insert? (3m)
ANAESTHESIOLOGY3)a) Name the above pic. (1m)b) When it is used for? (2m)c) What is the CI? (2m)d) How to insert? (3m)
ANAESTHESIOLOGY4)a) Name the above picture. (1m)b) When to use it? (3m)c) How does it f(x)? (3m)d) What are the CX? (2m)e) What is the contraindication? (1m)
O&G1)a) Name the above picture. (1m)b) What it is used for? (3m)c) How to position the pt in order to insert it? (1m)d) Disadvantage? (1m)
O&G2) 25 y/o pregnant lady in labour. The following is the result of her partogram: (sorry, I could not find picture of partogram)Cervical os:a) What is ur diagnosis? c)How do you manage her?b) What is the likely cause? d) what we can offer her?
O&G3)a) What is it?b) Mechanism of action?c) Advantage?d) Disadvantage?e) Failure rate?
O&G4)a) Name picture (right & left).b) What is the function?c) What are the indications?d) What are the prerequisites?e) What are the CX?
O&G5)a) What are the prerequisites?b) What are the CX?c) What are the advantages compared to Q(4)?
O&G6)a) Name it?b) What are the mechanism of action?c) Non-contraceptive uses?d) Advantage?e) Disadvantage?f) Failure rate?
O&G7)a) Name the picture.b) What is the function?c) What are the side effects?
O&G9)a) Name the picture.b) What are the indications?c) Complications?
O&G10)a) What is this?b) What are the functions?c) Uses?
O&G11)a) Name it?b) What it is used for?c) What are the possible complications of the procedure in (b)?
O&G12)a) Diagnosis?b) Presenting diameter?c) Complications?d) Mode of delivery?
O&G13)a) Diagnosis?b) Presenting diameter?c) Complications?d) Mode of delivery?
O&G16)a) Diagnosis?b) Give 3 predisposing factors?c) Complications?d) Mode of delivery?
O&G18)25 y/o lady with oligomenorrhoea. US of ovary.a) Provisional diagnosis?b) Name 2 other investigations to confirm dx?c) What treatment u would give for the menstrual problem?d) What complications may arise from this problem?
O&G19)This is an imaging taken from 30 y/o, para 1 lady who wants to get pregnant since 5 years ago.a) What imaging modality is this?b) Describe what u see?c) What is ur provisional diagnosis?d) What is the likely cause for the condition u mentioned in (b)?e) What is ur next plan for this lady?
O&G20)a) What is that?b) Actions?c) What are the side effects?
Question 1An 8 year old child complained PAIN during micturation- Urine bottle was given. Inspect and state AbnormalitiesColor• Cloudy- proteinuria• Bubble-frothy• Blood- smoky –HaematuriaUrine Test• Wash hands before and after• Assemble equipments- liner, record sheet, gloves, urine bottle, test strip• Check expiratory date• Wear gloves• Take test strip from bottle and close• Read time 2 minutes• Immerse test strip from bottle and wipe excess urine on edge of container• Hold strip horizantally• Wait recommended time• Compare test strip with color scale on container label• Write result in record sheet and interpret• Discard urine properly
Question 39 months old baby. Worsening on breathing. (headphones & Vclip)• What do you see?Suprasternal recessionSubcostal recessionInspiratory stridor• What is your diagnosis?Foreign body inhalationCroupAcute epiglottis• ManagementMask with O2FB removalIntubation- nasotracheal tube, endotracheal tube• Monitor?Pulse oximetry- to measure oxygen saturationIndications- heart failure, respiratory failure, monitor dring intubation procedure, post extubation, preterm babies
• ProcedurePut on finger/ thumb/ earSwitch onWait reading stabiliseTake reading and record• Factors affect readingMovement- nervousHypothermisHypoperfusion - severe hypovolaemiaAbnormal Hb – carboxy Hb, metHbSevere cardiac failure
Question 4Mom with diarrhoeal child. Advice on ORS• Intro and greet• Assess cause of diarrhoeaJust change breastfeed to formula milk (lactose intolerance)Boiled water? (in preparation of milk)Pacifier usage? Hygiene?• Explain AGE to momMost are self-limitingBut can be serious if superimposed with dehydration and malnutritionCan cause diarrhoea, vomiting, ab pain, seizure/convulsionn, fever, malaise• Assess severityHistory-Frequency of diarrhoea Volume of stool Reduce urine output Reduce weight Fever ConvulsionExamination - Hydration status
• Advice on ORSDissolve 1 sachet in 250ml drinking water (boiled/cold water in bottle)Feed baby everytime diarrhoeaContinue breastfeed• If baby breastfeeding but suggested to have lactose intoleranceChange to lactose free milk / semi-elemental formula• If baby already weaning-allow semi-solid foodDrink a lot water!• Advice mom to keep good hygiene on milk preparation• Advice mom to monitor baby’s progression,- If show dehydration – convulsion, weak, crying, not feeding- Bring to hospital!• Any questions mommy??
Question 5Mother brought daughter 10 month old,suspect measles? Missed immunisation scheduled at 5 months.• Greet and introduce• Asses immunisation schedule• Ask problem- Mom says she’s afraid of her daughter nfected with measles from neighbour’s child• Assess why missed immunisation-education level, finance, transport• Explain the importance of immunisation-antibodies for infectious disease• Ask the child condition-fever, rash?• Explain to mom about injection- Can still get the injection-baby may have fever, rash – but don’t worry, only once infected, mild, no more next time• Advice mom to bring daughter back after injection, when daughter is healthy and well to get next injection that misssed.• If daughter unwell, bring to hospital for further management• Ask mom’s understanding• Ask mom if there are any other question she wants to ask?
ECG1. Describe the above ECG and the diagnosis (4m)2. Name 2 clinical presentation of this condition (2m)3. Give 4 causes for the above condition (2m)4. Name 2 complication of above (2m)
Chest XR20 year-old male with fever and haemoptysis for 3 weeks
1. Describe the abnormal findings in chest x-ray above (3m)2. Describe the histological feature of the above slide (3m)3. What is the possible diagnosis (1m)4. What is the name of the organism (1m)5. Give 2 other investigation to confirm diagnosis (2m)6. Name 2 drugs that is used to treat the above condition (2m)7. Name 2 complication of this disease (2m)
Interpret resultsAppearance CloudyOrganism -WBC 257/mm3RBC 2/mm3Glucose 1.6mmol/L (plasma glucose -5.5mmol/L)Total Protein 0.94g/L (plasma total protein -0.43g/L)Pressure 21mmH2OA 17y/o complains of headache. Lumbar puncture was performed.
1. What are the commonest s/e after LP was performed (1m)2. In this CSF, is the plasma glucose ratio is of concern? (1m)3. Summarize the CSF abnormalities (3m)4. What is the likely diagnosis? (1m)5. What immediate treatment is required? (2m)6. Name 2 complications (2m)
1. Interpret the above ABG (2m)2. Name 4 causes of above condition (4m)3. Following are the renal profile • Na – 140mmol/L • K – 4mmol/L • Cl – 102 mmol/L4. Calculate the anion gap (2m)5. Name 2 causes for above result (2m)p/s : aku reka jee the numbers so if xlogic sorry hehehee
History• Puan Siti, 32y/o teacher came in with chief complaint of palpitation. Take a focus history
Q1) 34 y/o malay lady presented to A&E with complaintof high grade fever and palpitation. Vital sign showshigh grade fever (T=40C), BP 103/90, HR 140bpm, RR16bpma) Comment on the picture (2m)b) What is your provisional diagnosis (2m)c) Outline your management of this patient (6m)
Q2 paediatrics resuscitation1. Name the instrument (1m)2. Indication of the instrument (2m)3. Contraindication for usage of the instrument (2m)4. Where to insert the instrument (2m)5. Complication of the procedure (3m)
24 y/o malay man was brought in to casualty by EMDafter receiving a call from public saying that he wasinvolved in motorbike vs car accident1. Comment on the xray (3m)2. What is your radiological diagnosis (1m)3. Outline your management in ED (6m)
52 y/o malay man, smoker for 20 years who presentedto casualty with complaint of left sided chest tightnessfor 2 hours which is associated with giddiness andpalpitation1. Comment on ECG strip (2m)2. What is your diagnosis based on history and ECG strip (1m)3. What is the risk factor that you can elicit in the history, related to the diagnosis in 2 (2m)4. Outline your management in ED for the patient
24 y/o chinese lady alleged fall from escalator andsustain pain over right lower limb and was brought tocasualty by her partner1. Comment on the above picture (3m)2. What I your provisional diagnosis (2m)3. Outline your management in ED (5m)
Question 1A. Name the procedure done (1m)B. Explain the pathophysiology of the condition (5m)C. Complication of the condition? (4m)
Question 2A. Interpret the changes seen in the xray? (3m)B. Indications for surgery?C. Take consent for patient if they have to undergone surgery.
Question 3A. Diagnosis?B. Take consent for thr.
Question 4a) Diagnosisb) Explain about what u r going to do and advice the patient.
Question 5a) explain the diagnosis to ptnt?***need to apply POPb) POP care to the ptnt
Question 6a) Pathophysiology ?b) Common sites?c) Sequalae?
Question 7a) What is the different of fractures in children compare to adult
Question 8A 60 years old obese female presentedto your clinic after cannot bear thepain of the knee joint. The pain hasbeen present since 2 years ago,gradually increase in intensity andassociated with morning stiffness.Bilateral lower limb X ray was taken.A. What other history you would like to obtain?B. Name three differential diagnosisC. Name two abnormalities in picture AD. What other clinical signs you would like to elicit?E. Outline the radiological finding in picture BF. Name two management for this patient
Question 9Approach to an ulcera) Explain the abnormalities seen in the picture (4m)b) Give one most possible causes of the abnormality and the Pathophysiology for the condition (3m)c) Name one complication of the abnormality (1m)d) Outline the management for this patient. (2m)
Approach to an ulcer• Basically it is divided into 3 steps. Inspection, palpation and focal examination. Inspection 1) Size and shape 2) Number 3) Location 4) Margin (Healing, Inflammed, Fibrosed) 5) Edge (Sloping, punched, everted, undermined, everted, raised) 6) Floor (Granulation tissue, slough, discharge) 7) surrounding skins (inflammation, pigmentation, scars&puckering, hypopigmentation) Palpation 1) Surrounding skins (Temperature, tenderness) 2) Edge of the ulcer (soft: healing ulcer, firm: non healing, hard:malignant) 3) Floor of ulcer (Consistency, underlying structure) 4) Test the fixity (skin, muscle, bone) .
• Focal examination 1) Lymph node 2) Arteries, venous circulation, nerves 3) Movement of neighboring joint ******Grading of ulcer (especially for ulcer foot) Grade 0 — No ulcer in a high risk foot. Grade 1 — Superficial ulcer involving the full skin thickness but not underlying tissues • Grade 2 — Deep ulcer, penetrating down to ligaments and muscle, but no bone involvement or abscess formation • Grade 3 — Deep ulcer with cellulitis or abscess formation, often with osteomyelitis • Grade 4 — Localized gangrene. • Grade 5 — Extensive gangrene involving the whole foot
Question 10a) Name the procedures shown in the above picturesb) What is the indication for the proceduresc) Name the complication of the above procedures
Question 11a) What is the procedures done to the patientb) What is the principles of the proceduresc) Gives indications for the procedured) Name the complication of the procedures
Question 12a) Comment on the above picture (3m)b) What is your provisional diagnosis (2m)c) Outline your management at A&E department (5m)
Question 1329 years old Malay man involves inMVA and brought to ED with GCS 9(M5, E2,V2). Below is his hip x ray.Outline your management to thispatient
Short case..• c/o: 40 years old Malay lady presented with painful swelling of right ring finger. please examine her. 1) Position the most important for hand examination is to position both hands correctly. put the hands on top of a pillow with the patient in sitting position. ask the patient to abduct the fingers as maximum as she can because from this position, we can already detect any neurological disorder related to the hands, specifically motor disorder.
• 2) Inspection (look) inspection is divided into 2, towards the pathology (mass) itself, as well as towards the hand as a whole. 1st, compare both hands, dont take too much time doing this, just inspect surfacely because the examiner can be annoyed if korang sibuk2 nak pegang2 ke, angkat2 ke, or give excessive attention to the normal hand. then, check for any signs of wasting or skin discoloration, or any obvious changes related to the hand. for the mass or swelling, inspect it just like you inspect any lump and bump in surgery. do not forget to include the edge, border, size, site, character of the mass (fungating, etc), surface, and any discharge noted. for the site, describe precisely where is the origin of the mass. dont forget to check fo any associated deformity, such as nail deformity or finger deformity.
• 3) Palpation (feel) begin with soft palpation, in order to detect any tenderness associated with the mass, xkesahlah at the mass itself or the area surrounding the mass. then, dont forget to check for circulatory status, i.e. CRT and pulse, as well as the sensation whether it is intact or not.
• 4) Movement (move) for movement, just test for active movement first and examine the ROM. assess the ROM of all fingers of the hand, not just the affected finger, because others can be affected too. for example, ring finger share the same tendon with the little finger, so, if one is affected, the other might be affected too.
• 5) Ending complete your examination by checking the lymph node, other features of malignancy, or any relevant examination related to your differentials.
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Q1A 68y/o woman is admitted to surgical ward with the result of LFT as follows: result Normal range T. bilirubin 99 AST 31 ALT 34 ALP 196 GGT 100 albumin 41
1. What would be observed on examining this patient? discolouration of the skin-jaundice (1m)2. What might be the patient complain of? -skin discolouration(1m) -itchiness(1m) -pale stool & dark coloures urine(1m)3. What specific biochemical abnormality does the patient have? obstructive jaundice (2m)4. What investigation should be performed next? ultasound of the abdomen (1m)5. Give 3 causes of this abnormality. -intraluminal-bile duct stone -intramural- bile duct stricture -ampullary carcinoma -cholangiocarcinoma -extraluminal-head of pancreas carcinoma -porta hepatis LN6. What tumour marker might one considered measuring? CA 19-9 (associated with pancreatic carcinoma) (1m)
Q2A 67y/o woman is admitted directly to surgical ward with persistent vomiting and has not passed bowel motion for 4 days. An abdominal x-ray is performed:
1.What further question would you like to ask about her constipation? is it an absolute constipation? Does she pass flatus? (flatus-partial obstruction)(1m)2. What would you expect her bowel sound to be like? tinkling bowel sound (high pitch in nature) (1m)3. Describe the findings in AXR -dilated small bowel loops -stack of coins appearance -located in the centre of the film -valvulae conniventes seen and thickened -no gas seen in rectum/large bowel4. What is the diagnosis? small bowel obstruction(1m)5. Give 3 causes of this condition. intraluminal-foreign body - ascaris lumbricoides - gallstones in the small bowel intramural-bowel strictures-inflammatory(crohn’s) -drug induced(NSAIDS) -tumours -lymphomas 6. What are the treatment options? -intussusceptions -surgical laparotomy-to identify the cause and rectify the ertraluminal-adhesions problem- relieve obstruction -tumour(mets) -hernia -surgical stenting- to relieve obstruction(in case of tumours)
otoscopy should includes inspection of the external ear and pinna INSPECT THE EXTERNAL MEATUS --discharge,blood or pus -masses -on insertion of speculum inspect the canal -skin -discharge -swelling -wax OTOSCOPY POSITION pt should be positioned e the head flexed laterally away from the examiner the external auditory canal has a bend which normally restricts the examiner,s view the pinna of the ear to be examined is held firmly and gently pulled upwards and backwards to straighten the canal using the hand not holding the otoscope HOLDING THE INSTRUMENT otoscope is held in the same hand as the ear being examined the speculum should be as wide as possible to comforttably fit into the ear canal holding the otoscope (like a pen) horizontally provides a secure cradle for the instrument the curled fingers can rest against the cheek and the handle will not catch the shoulder (as it may if held vertically) in addition this position will help protect against accidently pushing too deeply into the outer ear TYMPANIC MEMBRANE inspect the tympanic membrane identify the normal structure any insignificant variation in normal appearance report ur findings to examiner
1. Name the syndrome Ramsay Hunt syndrome 2. Name the causative organism Varizella zoster virus 3. Name the other areas where rashes can be seen in this syndromeAnterior 2/3 of tongue, soft palate, external auditory canal, and pinna
• Name the various eye care procedures which should be followed in treating the patient at the previous station• 1. Wearing of eye glasses to prevent corneal damage• 2. Instilling moisturizing eye drops to prevent exposure keratitis
• Name the instrument• Siegles pneumatic aural speculum• Name it uses• 1. Examination of ear drum• 2. Testing the mobility of the ear drum• Write down its magnification factor• 2.5 times
• Examine the right ear of this patient• 1. Describe the lesion• Cotton wool like mass seen occluding the external auditory canal. Black spots are also seen• 2. What could be the probable diagnosis ?• Otomycosis• 3. What could be the causative organisms?• Aspergillus Niger - black spots• Candida - Cotton wool like mass
• Comment on the ear drum• 1. Loss of light reflex• 2. Prominence of handle of malleus• 3. Loss of mobility of ear drum• 4. Retracted ear drum
• Name the structures numbered• 1. Round window• 2. Stapedial tendon• 3. Pyramid• 4. Long process of incus
• Write down the possible causes of bilateral retracted ear drum• 1. Nasopharyngeal carcinoma• 2. Following adenotonsillectomy (Iatrogenic)• 3. Cleft palate
• Comment on ear discharge of this patient• What could be the possible diagnosis ?• 1. Scanty• 2. Foul smelling• 3. Blood tinged (sometimes)• 4. CSOM with attic cholesteatoma
• Name this condition seen on the ear drum• Enumerate 3 causes for it• 1. Tympanosclerosis• 2. Due to resolved otitis media• 3. Trauma• 4. Grommet insertion (Iatrogenic)
• 65 years old man• Known diabetic for 15 years on poor glycemic control• c/o pain left ear - 1 month• Blood stained discharge from left ear - 1 month• Tragal tenderness left side - 15 days• Inability to close left eye - 10 days• Otoscopic finding:• 1. What could be the possible diagnosis ?• 2. Name the probable causative organism• 3. Name the choice of antibiotic• Malignant otitis externa• Psuedomonas aeruginosa is the probable causative organism• Carbenicillin / IV generation cephalosporins
• Enumerate Levensons criteria for malignant otitis externa• 1. Refractory otitis externa• 2. Severe nocturnal otalgia• 3. Purulent otorrhoea• 4. Granulation tissue in external canal• 5. Growth of pseudomonas aeruginosa in specimen cultured from external canal• 6. Presence of diabetes mellitus / other immunocompromised states
• 5 years old child• c/o excrutiating pain in right ear - 6 hours• H/O URI - 2 days• Otoscopy showed:• Name the diagnosis• Name the various stages of this disorder• Acute otitis media• Stages of acute otitis media:• 1. Stage of hyperemia• 2. Stage of exudation• 3. Stage of suppuration• 4. Stage of resolution
• Name the surgery performed in AOM• Indication for surgery in AOM• Myringotomy• AOM which does not respond to adequate medical managment within 48 hours
• Post surgical otoscopic finding of a patient with AOM• Name the instrument used for this surgical procedure• Name the possible surgical complications of myringotomy• Myringotomy knife• Complications include:• 1. Dislocation of incudostapedial joint• 2. Injury to corda tympani nerve• 3. Persistent perforation
• Differential diagnosis of this lesion:• This is a red drum• Could be due to:• 1. AOM - associated with otalgia• 2. High jugular bulb - Normal variant. CT scan shows intact jugular foramen• 3. Glomus jugulare - associated with pulsatile tinnitus, conductive deafness, positive Browns sign. CT scan shows eorsion of jugular foramen.
• 40 years old male patient• C/O swelling behind left ear - 7 d• Pain in left ear - 4 days• H/O ear discharge - 8 years• What differential diagnosis you can offer ?• 1. Subperiosteal abscess• 2. Suppurated retroauricular lymph node
• Perform three finger test on this patient• Greet the patient first• Explain the procedure• Reassure the patient• Three fingers are used to perform this test.• Middle finger is used to apply pressure over the well of the concha - Tenderness in this area indicates tenderness over the antral area• Index finger is used to apply pressure over mastoid process - Tenderness indicates mastoiditis• Thumb is used to apply pressure over mastoid tip - Tenderness indicates mastoid emissary vein thrombophlebitis
• 30 years old male patient came with c/o• Pain right ear - 1 week• Blocking sensation right ear - 10 days• Mild discharge from right ear - 1 week• Otoscopy shows:• Enumerate otoscopic findings• Mention the possible diagnosis• Mention in brief the pathophysiology of this disorder• Whitish mass admixed with wax can be seen in the external canal• The external canal appears widened• Probable diagnosis - Keratosis obturans• Kertosis obturans occur due to faulty epithelial migration of external canal skin. This movement occurs in a reverse direction in these patients (i.e. towards the ear drum)
• Name the type of pinna seen here• Name some drugs which when ingested during pregnancy would cause this condition• Microtia• Warfarin, Folic acid antagonists like methotrexate and aminopterin
• 22 year male patient came with c/o swelling over right pinna - 4 days• Mild pain ++• No h/o fever• Name the possible pathology• How will you manage this condition ?• Aural seroma• Needle aspiration with application of compression dressing to prevent reaccumulation.
• Why is this external auditory canal narrow ?• What could be the cause ?• What could be the clinical problems faced by the patient ?• What surgery should be performed in this patient ?• Exostosis of external auditory canal.• It is common in swimmers.• These patients have conductive deafness, cerumen impaction.• Cerumen impaction is caused by abnormal self cleansing mechanism of the skin lining external canal in these patients.• Canalplasty
• 30 years old female patient came to the OPDwith c/o:• Hard of hearing both sides – 4 years Tinnitus on and off left ear – 6 months• O/e:• Ear drum on both sides appeared normal. They also showed normal mobility on siegalization.• Given below is the audiogram of the patient:• What could be the probable diagnosis? What do you see in the audiogram?• This patient is probably suffering from otosclerosis.• The audiogram shows carharts notch. It is classically seen in bone conduction audiogram of patients as a dip centered around 2000Hz.