GP OSCE Flashcards
CVS risk calculation consultation
QRISK2 score (>10% is high)
Modifiable - smoking, hypertension, high cholesterol, exercise, diabetes, diet. SHHEDD
Non-modifyable - age, sex, ethnicity, family history, RA, migraines.
‘I am worried about blood pressure’
We are going to measure your blood pressure now. Oh, its above 140/90. I am going to repeat it again. It’s raised again? I will offer you HBPM - it means taking three readings in the morning and three at night for a week.
To assess your further risk of cardiovascular disease, I’d like to put your info into the QRISK2 score. I’d also like to take some blood to look at the levels of lipid, how your kidneys are working and also whether you are diabetic.
If >180 –> hospital
We can work together to manage your hypertension if we can get you to exercise more, stop smoking/drinking, and eat less salt.
I would also like to start you on a medication: ACEi or amlodipine Both Indapamide Alpha, beta, diuretic
Ideally, we want your blood pressure to be below 140/90. (>80 is 150/90, diabetic 130/90, diabetic with organ damage 130/80)
‘I want to check out my cholesterol’
To assess your further risk of cardiovascular disease, I’d like to put your info into the QRISK2 score. I’d also like to take some blood to look at the levels of lipid, how your kidneys are working and also whether you are diabetic.
Ideally, your lipid should be below 5.2.
QRISK2 > 10%?
I am going to start you on a lipid lowering medication called a statin. I must warn you that it can cause GI upset +/- muscle cramps in some people. Let me know if that happens and we can think about other types.
Starting you on this medication means I have to check how your liver is doing now, at 3 and at 6 months., which means blood tests.
If you get bad muscle cramps, let me know and we may need to do a blood test or stop it if it is causing you lots of trouble.
?breast cancer
You are 30 and have a lump (or 50 and have only skin changes).
Your history makes me suspicious and therefore I am gong to need to examine the breast.
I am also going to refer you to a special clinic called a 2ww. They will perform a ‘triple assessment’, where they will repeat the breast examination, but also perform a breast ultrasound and mammography.
?colon cancer
Your history makes me suspicious of cancer, since you are over 50 and have blood in your stools.
I am therefore going to request a 2ww colonoscopy in order to visualise if there are any problems. It may also be a good idea to take some blood to see if your blood count is ok and whether there are any infection markers present.
It is worth mentioning that 90% of people referred for this do not have cancer. It may be normal, or there may be things like polyps acting up and causing some bleeding.
?lung cancer
Since you are a smoker and have 2 of (haemoptysis, weight loss, SOB, fatigue, appetite loss) I am suspicious of cancer.
I want to refer you for a 2ww chest X-ray. Depending on the results, I may ask for a CT scan as well.
Depending on the results of the scan, I may send you to a specialised clinic in hospital.
prostate cancer
You have some symptoms of an enlarged prostate (LUTS). You don’t have any symptoms of local spread (erectile dysfunction, haematuria) or metastasis (back pain, weight loss), however I want to be sure this isn’t something suspicious.
I therefore want to do a PR examination, for which I will bring in an observing assistant.
I will also do a blood test for a special protein that the protein produces more of if there is an issue, called the PSA.
If the PR examination is abnormal or if the PSA is above your age-specific range, I will refer you to a special clinic in hospital.
Red flags for headache
early morning worst ever/rapid onset wakes you up at night personality change seizure focal neurological deficit rash/fever/neck stiffness vomiting TMJ pain
many mornings or nights, people start to fiercly vomit
depression history taking
Core 3 for >2 weeks
low mood
fatigue
loss of interest
physical Sx
poor sleep
poor concentration
poor appetite
psychological Sx
guilt
worthlessness
self-esteem
risk
to self, to others, from others
ask about alcohol/drugs
exclude bipolar/anxiety/psychosis
depression I and M
PHQ-9 assessment + ensure not suicidal
In terms of management, there are non-medical and medical things we can do to help.
In terms of non-medical things, there are things you can do for yourself, and things we can do together.
Counselling and problem solving therapy is very helpful, and I can refer you for that. There is also CBT which re-wires how you think and is very helpful.
There are also things you can do to help yourself, including exercise, sleep hygiene and mindfulness.
We can trial this as management for a couple months, and if it doesn’t work there are medical treatments to supplement the therapy. SSRIs such as fluoxetine are first line. They take 4 weeks to kick in and we should continue them for 6 months after the symptoms resolve, so it’s a bit of a commitment.
I want to review you every week until you are stable, and then we can reduce the amount we see each other.
?gastroenteritis
I will need to take a stool sample from you and send to the lab, to look for any bugs or any parasites that may be causing your diarrhoea.
Gastroenteritis is usually something that clears itself. Therefore I don’t want to give you antibiotics just yet because they have risks of their own.
However, I do want you to stay very hydrated (2L/day + ORS). You can consider using loperamide as well.
We must stop any ACEi/diuretics/NSAIDs until it has settled.
I will receive the results from the stool sample in 48-72 hours, and at this point, if the symptoms haven’t settled, I will want to see you again and will consider Abx then.
?heartburn
From your history, it sounds like you may have some heartburn. It is reassuring that you don’t have any ALARMS symptoms.
I am happy to not send you for an endoscopy, but let me know if you do get any of those ALARMS symptoms.
In terms of management, there are a number of things we can do for you. Firstly, it would help you to stop drinking any alcohol, avoid fatty foods and smoking. Try not to lie down after meals either. I also want to start you on something to reduce the amount of acid in the stomach, called omeprazole.
Let’s meet in 1 month time, and if it hasn’t resolved we can test you for a bug in the stomach which we can treat with antibiotics.
Migraine
I am happy with the clinical diagnosis of a migraine. However, if any new symptoms arise, please don’t hesitate to get in touch.
In terms of management, there are a number of things which you can do to help yourself. This includes stress reduction and avoidance of triggers (cheese/chocolate)
There are two types of active management: acute treatment and prophylaxis. Since you are getting more than 2 a month, I want to give you both.
Acute treatment involves NSAIDS/paracetamol/triptan
Prophylaxis is propranolol, and topiramate if asthmatic. We can try acupuncture if this doesn’t help.
non-specific lower back pain (not chronic)
There aren’t too many investigations for back pain of this nature. X-rays aren’t helpful, and MRIs are reserved for serious things.
The best thing you can do for yourself is to carry on doing the things that you normally do, in the knowledge that 80% resolve within 6 weeks. I will refer you to a physiotherapist i you’d like who can give advice about core and back exercises that may provide seem relief.
I will also give you medication in the form of NSAID + naproxen + omeprazole
Simple sore throat
FeverPAIN score fever pus on tonsils attends <3days inflamed tonsils no coryza
0-1 = no antibiotics 2-3 = delayed antibiotics (give to use 3-5 days later) 4-5 = amox
