High yield OSCE topics for comms skill Flashcards
Tension (or tension-type) headache - Management
- Conservative –> reassurance +/- simple analgesia + lifestyle advice (avoid triggers)
- Chronic TTH (prophylaxis) –> Amitriptyline
Sinusitis - management of prolonged cases
- steroid nasal spray
- antibiotics (phenoxymethylpenicillin 1st line)
Types of migraine
- Migraine without aura
- Migraine with aura
- Silent migraine (aura but NO headache)
- Hemiplegic migraine
. - Chronic migraine - pt experiences for more than 15 days per month for at least 3 months
Migraines - Acute management + Prophylactic management
Acute management:
(pts may go into a dark, quiet room)
1. Triptan (eg. sumatriptan) +/- NSAID +/- paracetamol
2. Anti-emetic (eg. metoclopramide/ondansetron/prochlorperazine)
.
Prophylactic management:
1. Propranolol OR Topiramate OR Amitriptyline
2. Conservative –> avoid triggers
What medication should NOT be given to pts with migraines (eg. acute attack)
Opiates - can make condition worse
What can patients with migraines and other chronic headache conditions do to help identify triggers and assess response to treatment?
Headache diary
Cluster headaches - Acute management + Prophylactic management
Acute management:
1. High-flow 100% oxygen
2. Subcutaneous triptan
.
Prophylactic management:
1. Verapamil (Ca channel blocker)
(can use oral prednisolone during clusters of attacks)
2. Avoid triggers –> alcohol is a common trigger
Encephalitis - Investigations + Management
- LP (CSF viral PCR) +/- MRI brain
- IV Aciclovir
- Supportive care
Meningococcal septicaemia - what is it and what symptom on the skin is often associated with it?
- When the meningococcus bacterial infection is in the bloodstream
- non-blanching rash
Which lobe would the tumour be in if the pt has an unusual change in personality and behavior?
Frontal lobe
- the frontal lobe is responsible for personality and higher-level decision-making
Brain abscesses - Management
- Surgery - craniotomy –> abscess cavity debrided
- IV antibiotics
- Intracranial pressure management (eg. dexamethasone)
Label the cerebral arteries.
- Which arteries supply anterior brain
- Which arteries supply posterior brain
- Blood is delivered to brain through 4 main arteries, two internal carotid arteries (anterior supply), and two vertebral arteries (posterior supply to the brain)
- Anterior supplied by internal carotid arteries which form the ACA and MCA
- Anterior connects with Posterior via posterior communicating artery
- Posterior supplied by vertebral arteries which combine to form the Basilar artery
(The brain also has a venous drainage system which drain into the venous sinuses)
What are the 3 main arteries that form the Circle of Willis?
- What is function of Circle of Willis?
- Formed by basilar artery, internal carotid artery, and middle cerebral artery
- Safeguards the oxygen supply from interruption by arterial blockage
- For example, if there is stenosis in one artery then other source arteries to the Circle of Willis can provide an alternative blood flow (collateral circulation)
Key function of brain lobes
- Frontal
- Parietal
- Temporal
- Occipital
- Frontal - thinking, planning, problem-solving
- Parietal - sensory info (touch, temp. pain), spatial relationships
- Temporal - sesnory info (hearing, smell, taste), primary auditory cortex
- Occipital - primary visual cortex
Symptoms of an MCA infarct
- Affects frontal, parietal, and temporal lobes affected
. - hemiparesis - arm worse than leg
- sensory loss
- facial weakness
- dysphasia
- hemianopia
Broca’s aphasia vs Wernicke’s aphasia
- Broca’s –> expressive dysphasia
- Wernicke’s –> receptive dysphasia
If a right-hand dominant patient has Broca’s or Wernicke’s aphasia then which side is the stroke?
- Left MCA
- Broca’s and Wernicke’s area are found in the dominant cerebral hemisphere
- left side for right-handed
- right side for left-handed
Symptoms of ACA infarct
- Affects frontal and parietal lobes
. - hemiparesis - leg worse than arm
- behavioural –> apathy / disinhibition
Lacunar stroke symptoms
- Pure motor /sensory / sensorimotor (eg. hemiparesis with contralateral sensory impairment)
Symptoms of PCA infarct
- Mainly affects occipital
. - hemianopia (with macular sparing)
- amnesia
- sensory loss (thalamus)
What syndrome occurs if basilar artery affected in stroke
Locked in syndrome
- quadriplegia
- resp. muscles paralysed too –> ventilation
Longer-term management of ischaemic stroke
- Aspirin 300mg daily –> for 2 weeks (start aspirin 24hrs after thrombolysis and once repeat CT confirms no haemorrhage)
- After the 2 weeks –> Clopidogrel 75mg –> lifelong
- Atorvastatin 20-80mg (after 48hrs) –> lifelong
- Address modifiable risk factors –> smoking, diabetes control, AF control (if ECG showed AF to be the cause), exercise
Indications for carotid endarterectomy
- If carotid artery doppler ultrasound confirms > 50% carotid stenosis
- (risk of clot embolising and causing stroke)
How would you manage a patient who has had an ischaemic stroke and they have atrial fibrillation?
Anticoagulants should not be started until brain imaging has excluded haemorrhage, and not until 14 days after the onset of an ischaemic stroke
Management of crescendo TIAs
Aspirin 300mg and review in TIA clinic within 24hrs
Stroke/TIA –> DVLA guidelines for car drivers
- Must stop driving immediately
- Must stop for 1 month
- Must inform DVLA if after 1 month you still have –> weakness in arms or legs, eyesight problems (visual filed loss or double vision), or problems with balance, memory, or understanding –> or if doctor says not safe to drive
Stroke/TIA –> DVLA guidelines for bus/lorry drivers
- stop driving immediately
- Must stop driving for at least one year, can only restart when doctor says it is safe
Facial nerve palsy (bell’s palsy) - Management
Most pts recover over several weeks:
- Prednisolone (if pt present within 72hrs of onset) +/- antivirals
- Lubricating eye drops (to prevent eye from drying out)
(if eye pain - refer to ophthalmology for potential exposure keratopathy)
Glasgow Coma Scale (GCS) - what is measured + scores given and what score would indicate intubation?
GCS measures level of consciousness
- GCS ≤ 8 –> intubation (needs airway support as risk of airway obstruction or aspiration, leading to hypoxia and brain injury)
Mainstay of treatment for hydrocephalus
Ventriculoperitoneal shunt (VP shunt)
- drains CSF from ventricles into another body cavity (peritoneal cavity usually used)
What are the 3 main patterns of multiple sclerosis?
- Relapsing-remitting MS (RRMS)
- 85% of cases
- relapses are followed by periods of neurological stability between episodes
- RMMS often progresses to SPMS - Secondary progressive MS (SPMS)
- A progressive neurological disability after an initial RRMS course - Primary progressive MS (PPMS)
- Steady progressive worsening of neurological symptoms from onset
Multiple sclerosis - Investigations/diagnosis
- MRI scans - demonstrate typical lesions
- Lumbar puncture - oligoclonal bands in CSF
Multiple sclerosis - Management
- acute relapse
- longer term management
.
Specific problems: spasticity/fatigue/oscillopsia/depression
Specialist MDT manages MS:
1. Acute relapse - High-dose steroids IV or oral for 5 days (also improves optic neuritis)
2. Reducing long-term remission - DMARDS (eg. natalizumab, ocrelizumab)
Specific problems:
3. Spasticity - baclofen or gabapentin
4. Fatigue - amantadine
5. Oscillopsia - gabapentin
6. Depression - antidepressants (eg. SSRIs)
Motor neuron disease - Management
There are no effective treatment for halting or reversing the progression of the disease
1. Riluzole - can slow progression of the disease (used in ALS)
- Respiratory care - NIV (BiPAP) used at night
- Palliative care
Symptom control:
4. Spasticity - baclofen
5. Excess saliva - antimuscarinic
6. Breathlessness (worsened by anxiety) - benzodiazepines
What do pts with MND usually die of?
Respiratory failure (due to weakened resp. muscles)
Subacute combined degeneration of spinal cord (SCD) - treatment
- High-dose vitamin B12 supplementation
(caused by B12 def.)
Describe tonic-clonic seizures
- Tonic –> muscle tensing/stiffening
- Clonic –> muscle jerking
Describe partial/focal seizures
- in isolated region of brain –> usually temporal lobe
- pts remain awake, but can get aware/impaired subtypes
- symptoms –> deja vu, strange smells/tastes/unusual emotions/behaviours
Describe atonic seizures
- “drop attacks” –> sudden loss of muscle tone, pt usually falls
Investigations for seizures/epilepsy
- EEG (electroencephalogram) –> can do prolonged to ‘capture’ the seizure
- MRI brain –> look for structural abnormalities
(blood glucose –> rule out hypoglycaemia)
(ECG –> rule out arrhythmias)
Conservative management of Epilepsy / seizures
- Showers not baths
- Caution with swimming, heights, etc.
- DVLA –> removed until seizure-free for 1 year
How does sodium valproate work (MOA)?
+ what is the main side effect to be aware of?
- Increases activity of GABA (gamma-aminobutyric acid), which has a calming effect on the brain
- Teratogenic (harmful in pregnancy)
Parkinson’s disease - Management
No cure - treatment is aimed at controlling symptoms:
1. Levodopa + carbidopa
(Carbidopa is given along with levodopa (Co-careldopa) as it reduces the breakdown of levodopa peripherally, leading to a better therapeutic effect)
- Monoamine oxidase-B (MAO-B) inhibitors –> reduces dopamine degradation
- Dopamine agonists (bromocriptine, cabergoline) –> mimic action of dopamine in basal ganglia
- Adjuvant therapy: physiotherapy + speech therapy + occupational therapy
Huntington’s disease (Huntington’s chorea) - Management
Management involves an MDT approach, there is no treatment for slowing or stopping the progression of the disease:
1. Tetrabenazine: used for chorea symptoms
2. Antidepressants (eg. SSRIs): for depression
(MDT: Physio, SLT, OT, palliative care)
What % chance does a child of somebody with Huntington’s disease have of inheriting the faulty gene?
50% chance
- Huntington’s is an autosomal dominant condition
Charcot-Marie-Tooth disease - Management
Management is supportive (cannot stop progression) and requires an MDT approach:
1. MDT: neurologists + geneticists, physio, OT, podiatrist
2. Analgesia - for neuropathic pain (eg. amitriptyline)
3. Orthopaedic surgeons - for severe joint deformities
Guillain-Barre syndrome - Management
- Supportive care + VTE prophylaxis (PE is a leading cause of death)
- IV immunoglobulins (IVIG) –> 1st-line
- Plasmapheresis (is an alternative to IVIG)
(if resp. failure –> intubate/ventilate (FVC is monitored regularly))
Acute epiglottitis (aka. supraglottitis) - Aetiology + what group is at risk?
Usually a bacterial infection (Strep. pneumonia, group A streptococci, and Staph. aureus)
- Epiglottitis is now rare due to the HiB vaccine - be suspicious in unvaccinated children
Acute epiglottitis - Clinical features
- Sore throat, stridor, and drooling
- Muffled voice (‘hot potato’ voice) - characteristic change
- Respiratory distress - tachypnoea +/- use of accessory muscles
- Tripod position
- High-grade fever (if bacterial)
Acute epiglottitis - Management
- Keep pt calm + DO NOT examine throat (risk of airway closure)
- Call for senior pediatrician + anaesthesist + ENT surgeon
- Steroids (dexamethasone) +/- oxygen
- Monitor in ICU and intubation/tracheostomy (if need) +/- adrenaline
(5. If bacterial –> IV antibiotics - empiric broad-spectrum (eg. ceftriaxone) –> adjust based on culture + local guidelines)
(6. Vaccination - HiB vaccine to prevent paediatric cases of acute epiglottitis)
Tonsillitis - what are the 2 criterias used to assess whether the tonsilitis is bacterial and therefore antibiotics should be given
CENTOR criteria (≥ 3):
- Fever over 38ºC
- Tonsillar exudates
- Absence of cough
- Tender anterior cervical lymph nodes (lymphadenopathy)
.
FeverPAIN score (≥ 4):
- Fever during previous 24hrs
- P - Purulence (pus on tonsils)
- A - Attended withing 3 days of onset of symptoms
- I - Inflamed tonsils (severely inflamed)
- N - No cough or coryza
Management of tonsillitis
- Usually self-limiting –> reassure + safety net (can give paracetamol/NSAIDs for pain/fever)
- Use CENTOR or FeverPAIN to see if antibiotics needed
- Penicillin V 10 day course (can give delayed prescription)
(pen-allergic –> erythromycin)
Chronic rhinosinusitis - Management
Medical:
1. Nasal saline irrigation - clears nasal secretions and improves mucociliary function
2. Intranasal steroids
3. Oral corticosteroids (for severe cases)
(4. Antibiotics - if evidence of bacterial infection - Staph. A)
Surgical:
5. Functional endoscopic sinus surgery (FESS)
Allergic rhinitis - Management
- Allergen avoidance
- Oral/Intranasal antihistamines
- Non-sedating - cetirizine, loratadine, and fexofenadine
- Sedating - chlorphenamine and promethazine - Nasal corticosteroid sprays - eg. fluticasone and mometasone
Referral criteria for laryngeal cancer (2-week wait)
- Persistent unexplained hoarseness
- OR an unexplained lump in the neck
Which salivary glands are usually affected in salivary gland stones + symptoms of salivary gland stones?
Submandibular glands
.
Symptoms:
- pain and swelling (usually triggered when salivary flow is stimulated - eg. eating or chewing)
- can be asymptomatic
- can present with a hard, palpable lump within the salivary duct or orifice
Salivary gland stones - management
- Advise pt to remain well hydrated
- Stop medications (if able to) that impair saliva flow - eg. amitriptyline
- Encourage saliva flow - suck on citrus fruits/sweets
- NSAIDs - to relieve pain
Nasal polyps - Management
- Medical management:
- intranasal tpoical steroid drops (to reduce inflammation)
- intranasal saline irrigations (can provide symptomatic relief) - Surgical intervention:
- Intranasal polypectomy - used when polyps are visible close to the nostrils
- Endoscopic nasal polypectomy - used where the polyps are further in nose/sinuses
(NOTE: Unilateral polyps - refer to exclude malignancy)
What is a peritonsillar abscess (quinsy) + symptoms
a serious complication of tonsilitis or can arise on its own
- a collection of pus in the tissue surrounding the tonsils, usually caused by a bacterial infection
- symptoms - trismus, “hot potatoes voice”, swelling/ertythema
Peritonsillar abscess (quinsy) - management
- Antibiotics - empirical antibiotics (eg. co-amoxiclav)
- Analgesia - eg. NSAIDs or paracetamol
- Needle aspiration OR surgical incision and drainage - to remove pus from abscess
(4. Recurrent cases - quinsy tonsillectomy)
Indications for tonsillectomy (ie. how many episodes of acute sore throat per year in 1 year/2 years/3 years + other reasons for tonsillectomy)
No. episodes of acute sore throat:
- 7 or more in 1 year
- 5 per year for 2 years
- 3 per year for 3 years
.
Other indications:
- Recurrent tonsillar abscesses (2 episodes)
- Enlarged tonsils causing difficulty breathing, swallowing, or snoring
Laryngopharyngeal reflux - management
- Lifestyle measures:
- avoid dietary triggers - eg. fatty foods, caffeine, chocolate, and alcohol - Proton pump inhibitor - eg. omeprazole
- Sodium alginate liquids - eg. Gaviscon
Investigations for any suspicious head/neck/mouth lump
- FNAC
- CT/MRI
- ? USS
Otitis media - Management
(Most cases will resolve without antibiotics within around 3 days)
- Simple analgesia (eg. paracetamol or ibuprofen) - for pain and fever
- Antibiotics (immediate or delayed prescription):
- Amoxicillin 1st-line (5-7 day course)
- (erythromycin or clarithromycin if pen allergy)
Otitis externa - Management`
(Keep ear dry)
- MILD: acetic acid 2% - has antifungal and antibacterial effects
- MODERATE: Topical antibx + Steroid
- eg. Neomycin + dexamethasone + acetic acid (eg. Otomize spray) - SEVERE: oral antibx
(4. Ear wick (contains topical treatment, eg. antibxs + steroids) - used if ear canal is very swollen)
(5. Fungal infections - clotrimazole ear drops)
What is malignant otitis externa and which groups of people are most at risk?
- a severe and potentially life-threatening form of otitis external where the infection spreads to the bones surrounding the ear canal and skull
- it progresses to osteomyelitis of the temporal bone of the skull
.
At risk groups: - Diabetes (most common)
- Immunosuppressed (eg. chemotherapy or HIV)
Meniere’s disease - Management + driving info
- Symptomatic: Prochlorperazine OR antihistamines
(symptomatic treatment for up to 3 days)
- Prophylaxis - Betahistine
(Inform DVLA and stop driving until symptoms are controlled)
Describe the basic structures of the ear (from outside in)
- Pinna - the external portion of the ear
- External auditory canal - the tube into the ear
- Tympanic membrane - the eardrum
- Eustachian tube - connects the middle ear with the throat to equalise pressure
- Malleus, incus and stapes (ossicles) - the small bones in the middle ear that connect the tympanic membrane to the structures of the inner ear
- Semicircular canals - responsible for sensing head movement (the vestibular system)
- Cochlea - responsible for converting the sound vibration into a nervous signal
- Vestibulocochlear nerve - transmits nerve signals from the semicircular canals and cochlea to the brain
Presbycusis - Diagnosis and Management
- Audiometry - sensorineural pattern (with worse hearing loss at higher frequencies)
.
1. Hearing aids
2. Cochlear implants (if hearing aids are not sufficient)
(3. Lifestyle adaptations)
Otosclerosis - Management
- Conservative: hearing aids
- Surgical: stapedectomy or stapedotomy
.
(Stapedectomy = removing entire stapes bone and replacing with prosthesis)
(Stapedotomy = removing part of the stapes bone and leaving the base of the stapes (the footplate) attached to the oval window)
Impacted ear wax (cerumen) - Management
(Avoid inserting cotton buds into ear as can press wax in further and cause impaction)
- Ear drops: olive oil or sodium bicarbonate 5%
- Ear irrigation: squirting water in ears to clean away wax
(do not irrigate if perforation of tympanic membrane suspected) - Microsuction
Main side effect of dopamine agonists (eg. bromocriptine, cabergoline)?
Gambling, hypersexuality
Main side effect of prostaglandin analogues (eg. latanoprost)
eyelash growth, iris pigmentation
Glaucoma - management + definitive management
- Prostaglandin analogues (latanoprost) OR 360 selective laser therapy
- IOP-lowering medications –> eg. timolol
- Trabeculectomy (alternative outflow)
Parkinson’s medication is very time-sensitive, how would you administer medication in a pt who is nil by mouth
Rotigotine patch (transdermal)
What anti-emetic would you give in a pt with Parkinson’s?
Ondansetron
(metoclopramide, prochlorperazine, and domperidone are contraindicated as they are dopamine antagonists)
Hypoglycaemia, what is management in community (no IV access) + what is management if there is IV access
- IM Glucagon
- IV Dextrose 10% 200ml (15 mins)
- IV Dextrose 20% 100ml (15 mins)
Presbycusis management
- Conservative –> avoid loud noise + crowded areas + support groups
1. Hearing aids –> amplify speech
2. Cochlear implants (further management)
Epilepsy management
- generalised tonic/clonic
- partial (focal)
- myoclonic
- tonic and atonic
- absence
