MFOP OSCE Flashcards
Parkinsons
I need to ask you to do some special things to better understand what’s going on.
- micrographia (spiral, clock)
- bradykinesia (finger tap, leg stomping)
- arm swing, tremor, en bloc (gait assessment)
I think this may be Parkinson’s. Since it is better to be 100% sure, it is worth doing some investigations. This will involve two types of scans: DAT scan and MRI. The first looks at dopamine uptake and the second will rule out any P+ syndromes.
There are 3 types of things we can do for Parkinson’s: conservative, medical, surgical.
Conservative management involves support groups such as Parkinson’s UK, OT for adapting to tremor and physio for falls prevention classes. Exercise helps too.
Since Parkinsons is largely caused by too little dopamine, medical treatment aims to restore dopamine levels. First we will try carbidopa/levodopa. If this doesn’t work, we can use dopamine agonists +/- MAOB/COMTi which prolongs effects of levodopa by about an hour.
Surgery is a last line form of treatment, but involves DBS and duodopa.
SEs of Parkinson’s medication
Fluctuations are common with any of the drugs (where symptoms worse just before dose and SEs high just after dose)
Some SEs are specific to the medication, but some SEs are common to them all.
Any of the drugs can exacerbate postural hypotension or increase confusion. Also, if you stop any of the meds suddenly, there is a small risk of developing a condition called neuroleptic malignant syndrome
The dopamine agonists must be used with caution, because they increase impulsive and compulsive behaviour (gambling, shopping, eating, sex), and so you must sign a special consent form. Hallucinations are also more common.
Levodopa is safer in that respect, but it can cause you to wriggle at rest (dyskinesia). It can also cause nausea.
COMTi causes orange urine and extreme diarrhoea.
dizziness
To try and figure out where this dizziness is coming from, it is worth doing a number of special examinations. This includes your blood pressure (standing and lying), as well as full examinations of balance organs (ears, cerebellum, peripheral neuro). It is also worth doing an ECG to check your heart is ok. We should also do a blood test to make sure your sugar levels are ok and that you aren’t dehydrated.
The management will depend on the problem:
dehydration –> rehydrate
BPPV –> Epley
Meniere’s –> buccal prochlorperazine acute, betahistine/vestibular rehab for prevention.
syncope
We need to figure out whether what happened was due to your heart or due to something else. So we need to do an ECG. I also need to examine your blood pressure lying down, standing up, and whilst I massage your neck. If you have any murmurs I will send you for an echo.
This sounds like a vasovagal syncope. To prevent this from happening again, you should avoid triggers (blood, stress etc), stay well hydrated and keep salt intake up. I will review your medication to see if you are on any diuretics/antihypertensives that may contibute to this.
You must inform the DVLA who will have the final say as to whether you can drive or not.
falls
I need to thoroughly examine you to try and figure out what, if anything, caused this fall. The main systems to think about are your heart and your balance organs (Ears, cerebellum, nervous system), so I will examine all of these.
I will also do some investigations including ECG, blood tests (U/Es, glucose, FBC). Imaging if fracture suspected.
It may be a good idea to refer you to a falls clinic. Here they do a full multifactorial risk assessment and achieve about 30% reduction in falls. It has a multidisciplinary team with a PT strength programme and an OT for home hazard reduction.
As an adjunct to this, we should use the FRAX tool to assess you for osteoporosis and treat that with Ca2+, vita, alendronate if present.
TIA
We need to assess whether this is likely to happen again or whether you are likely to have a stroke:
- age
- blood pressure
- clinical features (unilateral weakness or speech)
- duration >60m
- diabetes
Furthermore, we should do an ECG to see whether your heart might be to blame, an ultrasound of your neck to see if your carotid artery is to blame, as well as a series of screening blood tests (FBC, clotting, glucose, lipids, UEs)
I need to give you 300mg aspirin immediately and you need to be admitted for assessment by one of the consultants. In 2 weeks time, you will be started on clopidogrel 75mg for the rest of your life.
To minimise risk of future events, we will look at whether you need blood pressure +/- lipid medication
stroke
we must arrange an immediate CT head before anything else to see whether this is a bleed or ischaemia
Furthermore, we should do an ECG to see whether your heart might be to blame, an ultrasound of your neck to see if your carotid artery is to blame, as well as a series of screening blood tests (FBC, clotting, glucose, lipids, UEs)
It is likely to be ischaemic, in which case i need to give you 300mg aspirin right now. Since it has been <4.5 hours since onset of symptoms, we are going to send you for thrombolysis (alteplase). Before I do so, I must check that:
- you haven’t had a previous brain bleed
- you haven’t recently had a lumbar puncture
- you don’t have brain cancer
- you don’t have active bleeding or any varices
Since the swallow is often affected by strokes, it is important that one of the SALT specialists come and make sure it is safe for you to have food and drink.
In two weeks time, we will assess your risk of future strokes. We will put you on 75mg clopidogrel forever and look at your modifiable risk factors such as blood pressure and lipid levels.
swallowing
The best investigation is video fluoroscopy, however it is quite invasive.
FEES is often used, which stands for fibreoptic endoscopic examination of the swallow, which uses coloured food so we can see whether food ends up somewhere it shouldn’t.
Often, the most practical way to assess the swallow is for the SALT specialists to come and do it at the bedside
Since we are worried about your swallow, we need to keep you NBM with a temporary NG tube until the SALT therapy has made a real effect.
dementia
By the sounds of the MAPLEV history, it looks like there is an element of dementia.
I will perform an AMTS and if that shows a reduced score then I will refer to neuropsychological testing to confirm.
Whilst dementia is irreversible and progressive, it is worth excluding any reversible causes and so we will do a brain CT and a full array of blood tests to look at all your organs, to check if there are any infections (syphilis), to check B12/folate.
There are a number of conservative things all people with dementia will benefit from: support groups, OT/PT, sorting out acting power of attorney, informing DVLA and stopping driving.
There are also some medical treatment depending on the type of dementia:
AD –> cholinesterase i
VD –> CV risk management
DLB –> rivastigmine + anti-parkinsonism meds
delirium
since the causes of delirium are very broad, so too is the net we cast in terms of investigations.
We will do a broad set of blood tests (literally everything you can think of, including culture), as well as a CXR, ECG, urine dip. depending on the history, we may even need to do an AXR for constipation or a wound swab culture.
it is important to treat the underlying cause which hopefully we will ellicidate through these investigations.
The mainstay of treatment for now is supportive, by reducing the risk of pressure sores, falls, clots.
We will liaise carefully with the specialist nurses, who will try and make this room suitable for someone recovering from delirium. They will organise a routine, ensure regular staffing and ensure peace and quiet especially at night. It would be helpful to bring in family pictures as well to help the patient remain orientated. regular visiting is also helpful.
hypothermia
We will measure the temperature using a rectal thermometer, as it is more accurate in this range.
we will do a set of blood tests to look for any cause of the hypothermia (thyroid, culture for cause of neglect) as U/Es to assess level of resulting dehydration.
We will do an ECG to check the strain on the heart the cold is causing (J waves, long QT)
It is important to re-warm from the inside out (warmed fluids) at a rate of 0.5/hour
pressure sores
we must examine you everywhere to see if we’re missing anything and to grade any existing sores.
We must prevent any from forming by turning you every 2 hours + using air mattresses + nutrition.
If there are any sores currently, we must debride them (by covering, by using streptokinase, by surgery) and them keep them moist in order to promote healing
urinary incontinence
Bladder diaries for >3days Urine dipstick Renal function bloods Post-void bladder USS for incomplete emptying Urodynamic studies (cystometry) AXR for constipation
Rationalise drugs especially diuretics
Urge incontinence
1st: bladder retraining 6 weeks + avoid
caffeine + avoid fluid before bed
2nd: antimuscarinics (oxybutynin,
tolterodine)
3rd = Botulinum
Stress incontinence
C = Pelvic floor muscle training (8
contractions 3x/day for 3 months)
M = nil
S = Retropubic mid-urethral tape
Can consider indwelling catheter in elderly
perform an AMTS
—Oriented in self, time and place + quiz—
What is your age
What is your DOB
Remember ‘42 West street’
What is the time
What is the year
Which hospital are we in
Who am I (doctor) and who is that (nurse)
When did WW2 end
Who is the current monarch
Count backwards from 10-1
What was that address I said
