OSCE

Question 1

Vital signs

Answer 1

1. pulse oximeter (O2 saturation)
2. thermometer (temperature)
3. Sphygmomanometer (BP)
4. pulse
5. respiratory rate

Question 2

CPR

Answer 2

1. D - DANGER
2. R - RESPONSE
3. S - SEND FOR HELP
4. A - AIRWAY
5. B- BREATHING
6. C - CPR
7. D - DEFIBRILLATOR

Question 3

Oxygen devices

Answer 3

Question 4

Cardiovascular History Taking

Answer 4

Presenting Complaint

• What has brought you to the doctor today?
• Chest pain
  
  • SOCRATES
  • Frequency
  • Relieving factors such as changes in posture
• Shortness of breath
  
  • On exertion or not
  • When sleeping
    
    • Can’t lie flat (uses pillows)
    • Suddenly wakes up out of breath
  • Associated symptoms of cough, sputum, fevers
• Ankle Swelling
  
  • When is it worse or better
  • Symmetrical or asymmetrical
• Palpitations
  
  • Get to tap it out
  • Slow, fast, irregular or missed beat
  • Onset and what makes it stop
• Syncope/dizziness
  
  • Lose consciousness
  • Circumstances and recovery
  • If collapse rule out neuro (vertigo, seizure, incontinence) and hypoglycaemia
• Intermittent claudication - distance they can walk
• Fatigue
• Any weight changes? - increase oedema, decrease hypovolaemia
• Atypical chest pain
  
  • Fatigue
  • Nausea
  • Pale and clammy
• Other symptoms at all?

Past Medical Hx

• Have you ever had any medical, dental or cosmetic procedures?
• Have you ever been diagnosed with any medical conditions?
• Have you ever had any stays in the hospital?
• How often do you see your dentist in a year?

Allergies

• Are you allergic to anything? if so find out what and the nature of the allergy

Medication Hx

• Are you currently taking any medications?
• Have you recently started or stopped any medications?
• Do you take any over the counter or herbal medications?
• What about any medication devices, drops, puffers, patches or creams?

Family Hx

• Tell about your parents and siblings medical history

Social Hx

• SNAP
  
  • Have you ever smoked?
  • On average, how many standard drinks of alcohol do you consume in a week?
  • Have you ever taken any recreational drugs?
  • What are some typical meals you eat during the week?
  • On average how much physical activity you undertake in a day?
• Have you had any recent life stressors?
• Occupational Hx
  
  • Who do you live with?
  • Are you working at the moment?
    
    • If retired ask about hobbies, etc
    • If student ask about part-time work and exam stress

Question 5

Central Cardiovascular Examination

Answer 5

Introduction and greeting

Check if the patient has any injuries

• especially neck, shoulders, back or legs due to small body movements during the examination

Position patient at 45 degrees

• Ask to pull gown down and inspect

Hands and Arm

• Nails - splinter haemorrhages
• Capillary Return
• Clubbing
• Palms
• Radial pulses (compare both sides)
• Collapsing pulse
• Measure BP/comment on vitals

Face and Mouth

• Eyes
• Mouth and tongue

Neck

• JVP + hepatojugular reflex
• Palpate Carotids (one at a time)
• Auscultate Carotids

Chest

• Inspect
• Palpate
  
  • Heaves with Heels of hands (L & R Ventricular Hypertrophy)
  • Thrills (palpable murmurs for all four valves)
  • Count down 5th ICS midline to palpate apex beat
• Percuss
  
  • Borders of liver if suspect hepatomegaly
• Auscultate
  
  • Listen to
    
    • Mitral valve at apex (diaphragm and bell)
    • Tricuspid at 4th ICS LSE (diaphragm and bell)
    • Pulmonary at 2nd ICS LSE (diaphragm)
    • Aortic Valve at 2nd ICS RSE (diaphragm)

Dynamic Manoeuvres

• Roll patient to left lateral position
  
  • Palpate for thrills at apex
  • Auscultate (bell and diaphragm) at apex and in the axilla for mitral murmurs
• Ask patient to sit and lean forward
  
  • Palpate for thrills and the base of the heart
  • Auscultate for pulmonary valve (on inspiration) and aortic valve (on expiration)

Back and Lungs

• Percuss lungs - compare sides
• Auscultate lungs - compare sides
• Check for sacral oedema (over sacrum)

Lower limbs

• Inspect
• Feel temperature, swelling, calf tenderness
• Check for pitting oedema over distal tibia above ankle (hold for 30 seconds)
• Palpate dorsalis pedis and posterior tibial arteries

Closing

• Make sure patient dressed and comfortable
• Conclusion and thank the patient

If I had time, to conduct a complete cardiovascular exam I would also:

• check any chest X-rays
• do a peripheral vascular exam
• 12-lead ECG
• Urine dipstick
• Bedside BSL

Question 6

Peripheral Vascular Disease Examination

Answer 6

Introduction and greeting

Check if the patient has any injuries

Position patient at 45 degrees

• Ask to pull gown down and inspect

Hands and Arm

• Nails - splinter haemorrhages
• Capillary Return
• Clubbing
• Palms
• Radial pulses (compare both sides)
• Collapsing pulse
• Brachial pulse
• Measure BP (in PVD exam measure lying and standing)/ comment on vitals
  
  • If we have time later we’ll do a BP reading lying down and standing

Face and Mouth

• Eyes
• Mouth and tongue

Neck

• JVP
• Palpate Carotids (one at a time)
• Auscultate Carotids

Chest

• Inspect
• Palpate
  
  • Heaves with Heels of hands (L & R Ventricular Hypertrophy)
  • Thrills (palpable murmurs for all four valves)
  • Count down 5th ICS midline to palpate apex beat
• Auscultate
  
  • Listen to
    
    • Mitral valve at apex (diaphragm and bell)
    • Tricuspid at 4th ICS LSE (diaphragm and bell)
    • Pulmonary at 2nd ICS LSE (diaphragm)
    • Aortic Valve at 2nd ICS RSE (diaphragm)

Back and Lungs

• Percuss lungs - compare sides
• Auscultate lungs - compare sides
• Check for sacral oedema (over sacrum)

Abdomen

• Lie patient flat and palpate abdominal aorta

Lower limbs

• Inspect
• Palpate
  
  • Feel temperature,
  • swelling,
  • calf tenderness
• Check for pitting oedema over distal tibia above ankle (hold for 30 seconds)
• Pulses
  
  • Femoral pulses and radial femoral delay
  • Popliteal artery pulses
  • Dorsalis pedis and posterior tibial arteries
• Capillary return on toes
• Buerger’s Test - hold for 1-2 mins

Closing

• Make sure patient dressed and comfortable
• Conclusion and thank the patient

For completeness sake of a peripheral vascular exam I would also check any Chest X-rays for pulmonary oedema and cardiac changes

Question 7

Anthropometry and Explaining Cardiac Risk Chart

Answer 7

Introduction and greeting

Check if the patient has any injuries

• especially neck, shoulders, back or legs due to small body movements and standing during the examination

Patient preparation

• Check patient has voided before weighing
• Ask patient to remove their shoes, heavy outer garments, and hair ornaments (for height)

Height:

• Ask patient to stand, feet together, with his/her back to the height rule.
• The back of the head, back, buttocks, calves and heels should be touching the wall.
• The top of the external auditory meatus (ear canal) should be level with the inferior margin of the bony orbit (eye socket).
• Ask the patient to look straight ahead.
• Pull the height rule down to touch the head and read the height.
• Record height in meters.

Weight:

• Assist patient to step on scales (if necessary).
• Ask patient to stand still, face forward, place arms at the side & wait until asked to step off.
• Read the weight off the display.
• Record weight in kilograms.

Waist circumference:

• Ask patient to stand comfortably, with arms hanging loosely at the sides, weight evenly on both feet (separated about 25-30 cm)
• Palpate the inferior margin of the lowest rib and the crest of the ilium, and find the midpoint.
• Measurement is taken in the mid-axillary line at the midpoint, directly over skin, at the end of normal expiration.
• The tape should be snug, but should not compress underlying soft tissues.
• Read the waist circumference off the tape.
• Record waist measurement in centimetres.

Calculate body mass index:

• Calculation: weight in kilograms divided by the square of the height in metres. Units are kg/m2 .

Concluding with patient:

• Thank the patient
• Explain findings to patient
• Record finding in medical notes
• Ensure patient is dressed and comfortable
• Attend to hand hygiene

NOTE

Cardio risk chart - there are two diff ones (only one attached). One is for patient without diabetes and the other is for patients with diabetes. Make sure you ask and pick the right one.

Charts found here : (https://www.heartfoundation.org.au/getmedia/dbb102e3-850f-41da-afbe-2776d8d4b97e/Absolute-CVD-Risk-Quick-Reference-Guide_2018.pdf?fbclid=IwAR02gak_GrE4Hnlw-h52Zyj-rWtkVDyaR35JGYUP_0reUuHQJoSl_I_SYXM)

Health is at risk if waist circumference according to Heart Foundation is:

• Males over 94 cm (about 37 inches)
• Females over 80cm (about 31.5 inches)

Question 8

Identify the features of this normal chest X-ray

Answer 8

Review slides attached to LAO of Cardio CS titles “Chest X-rays”

Question 9

Identify the features of this normal chest X-ray

Answer 9

Question 10

• *ECG**
• *Not sure if examinable but can review LAO**

Answer 10

Can review attached to LAO of Cardio CS titled “Recording an ECG”

Question 11

Examples of ECG

Answer 11

Know what STEMI, Non-STEMI, BBB, Arrythmias look like

Question 12

Respiratory Examination

Answer 12

Introduction and greeting

Check if the patient has any injuries

• especially neck, shoulders, back or legs due to small body movements during the examination

Position patient at 45 degrees

• Ask to pull gown down and inspect
  
  • Check rate. depth and pattern of breathing
• Ask patient to cough

Hands and Arm

• Flapping tremor (hold for a minute or so)
• Nails - splinter haemorrhages
• Capillary Return
• Clubbing
• Palms
• Radial pulses (compare both sides)
• Respiratory rate
• Measure BP/ comment on Vitals

Face and Mouth

• Eyes
• Sinuses
• Mouth, back of throat and tongue

Neck

• JVP
• Tracheal position

Back and lungs

• Inspect
  
  • Palpate chest expansion from back
• Palpate lymph nodes
  
  • shrug shoulders
• Ask patient to cross arms at the front
• Percuss lungs comparing both sides
• Auscultate both sides comparing
  
  • deep breath in and out through the mouth
  • vocal resonance “99”
• Sacral oedema

Anterior chest

• Inspect
• Percuss
  
  • apices of chest comparing both sides
• Auscultate both sides comparing
  
  • deep breath in and out through the mouth
  • vocal resonance “99”

Lower limbs

• Inspect
• Palpate
  
  • Feel temperature,
  • swelling,
  • calf tenderness
• Check for pitting oedema over distal tibia above ankle (hold for 30 seconds)
• Capillary refill and dorsalis pedis pulse

Closing

• Make sure patient dressed and comfortable
• Conclusion and thank the patient

For a complete respiratory examination I would also:

• check any Chest X-rays
• CVR exam for ruling out heart failure
• Spirometry for Lung Function
• ENT exam

Question 13

Respiratory History Taking

Answer 13

Presenting Complaint

• What has brought you to the doctor today?
• Cough
  
  • SOCRATES
  • Character - moist vs dry, coughing fits and any sputum
• Sputum
  
  • Amount/volume
  • Colour and presence of blood
  • Purulent or thin/frothy
• Blood in cough
  
  • Frequency
  • Duration
  • Amount - massive or streaks
  • Fresh blood or dark
• Shortness of breath
  
  • Onset
  • Duration and time course
  • Functional ability
  • Exacerbating/relieving factors
  • Triggers
  • Worse when lying down?
• Chest pain
  
  • SOCRATES (resp pleuritic pain is sharp, worse on inspiration or coughing)
• Breath sounds - wheeze, stridor
• Snoring/Sleep apnoea
• Signs of infection
  
  • Fevers
  • Rigors
  • Night sweats
  • Malaise
  • Myalgias
• Hoarseness of voice
• Any weight changes or night sweats
• Nausea, vomiting or loss of appetite
• Other symptoms at all?

Past Medical Hx

• Have you ever had any medical, dental or cosmetic procedures?
• Have you ever been diagnosed with any medical conditions?
• Have you ever had any stays in the hospital?
• Other
  
  • Are all your vaccines up to date?
  • Have you ever had something like TB, Pneumonia, childhood asthma or any issues with the lungs or your airways?

Allergies

• Are you allergic to anything? if so find out what and the nature of the allergy

Medication Hx

• Are you currently taking any medications?
• Have you recently started or stopped any medications?
• Do you take any over the counter or herbal medications?
• What about any medication devices, drops, puffers, patches or creams

Family Hx

• Tell about your parents and siblings medical history

Social Hx

• Work/Occupational Hx
  
  • What do you do for work?
  • Do you notice a difference in symptoms at home and at work?
  • Is it better when you are away from work?
  • Any one else around you have similar symptoms?
  • Do you use protective gear at work?
  • Have they been any incidents at works causing a spill or exposure to chemicals, etc?
  • What other jobs have you done in your life?
  • Have you or any of your family members work with or been exposed to asbestos?
  • Do you work or live with any animals? Any pets?
• SNAP
  
  • Have you ever smoked?
    
    • 20 cigs a day for 10 years = 10 pack years
    • 1 bong = 5 cigarettes
  • On average, how many standard drinks of alcohol do you consume in a week?
  • Have you ever taken any recreational drugs?
  • What is your diet like? What are some typical meals you eat during the week?
  • How active are you? Do you get a chance to do any physical activity?
• Check allergy triggers
  
  • Dust
  • Pollen
  • Mould
• Occupational Hx
  
  • Who do you live with?
  • Are you working at the moment?
    
    • Ask about hobbies, etc

Question 14

Peak flow meter explanation and counselling

Answer 14

The measure of peak expiratory flow rate is useful in the monitoring of asthma severity. PEFR varies depending on the level of control and severity of disease. It is more accurate than subjective symptoms in assessing asthma control and severity.

Measurement of peak expiratory flow gives an idea of how narrow or obstructed a person’s airways are by measuring the maximum (or peak) rate at which they can blow air into a peak flow meter after a deep breath.

Patients with asthma may benefit from regular peak flow monitoring to establish a baseline, predict flares and monitor response to treatment. When monitoring is recommended, it is usually done in addition to reviewing asthma symptoms and frequency of reliever medication use (according to an asthma action plan).

Procedure:

• Standard Precautions
• Sit patient upright in a chair
• Attach mouthpiece to meter
• Push pointer on meter to zero mark
• Give meter to patient
• Ensure fingers are not blocking/holding the pointer
• Ask patient to take deep full breath in
• Ask patient to seal lips around mouthpiece
• Immediately blast out air as hard and fast as possible
• Read where the pointer has landed
• Reset pointer to zero and repeat process two more times
• Record the highest of these three readings on the peak flow chart

Peak Flow Charts:

Peak flow measurements are most useful if they are displayed on a chart or graph rather than just written down as a list. A peak flow chart allows the doctor and the person with asthma to recognise the pattern of that person’s asthma and see how it changes over time. Many different charts are available in Australia for recording peak flow – the best recognised is that developed by the Woolcock Institute of Medical Research and the Asthma Centre at Royal Prince Alfred Hospital.

Using the peak flow chart:

1. Write the start date at the top of each page.
2. For each day there is a white column for morning peak flow and a grey column for evening peak flow
3. Twice a day, record the highest of three peak flows
4. Use the box at the bottom to record the total number of puffs of reliever medication (e.g. Ventolin) used in the last 24 hours.

Question 15

Peak flow chart interpretation

Answer 15

Measure height of patient:

• Ask patient to stand, feet together, with his/her back to the height rule.
• The back of the head, back, buttocks, calves and heels should be touching the wall.
• The top of the external auditory meatus (ear canal) should be level with the inferior margin of the bony orbit (eye socket).
• Ask the patient to look straight ahead.
• Pull the height rule down to touch the head and read the height.
• Record height in meters.

Question 16

Explain/interpret Spirometry chart

(Difference between obstructive vs restrictive lung disease - see resp lung function and devices LAO)

Answer 16

Question 17

Asthma Action Plan and Asthma First Aid

Answer 17

Question 18

Asthma Device Counselling

Answer 18

Each device has a specific technique (see “device specific checklists”). A general guide is:

• Remove inhaler cap (if applicable)
• Check dose counter (if applicable)
• Prime the device (if applicable)
• Load cartridge (if applicable)
• Shake device before each dose (if applicable)
• Breathe out gently, away from the inhaler
• Put mouthpiece between teeth (without biting) for a good seal
• When to press the delivery button varies
• Breathe in strongly and deeply. Hold breath for 5 seconds.
• Breathe out gently, away from the inhaler
• Wipe down the mouthpiece of the inhaler with a dry cloth
• Rinse mouth (if applicable)

Spacers are recommended to be utilised in addition to MDIs. MDI drug delivery depends on good hand-breath coordination and respiratory effort to inhale the particles correctly. This optimises the delivery of medication to the lungs and avoids deposition in the mouth, reducing side effects such as hoarseness and thrush.

Checklist for spacer use:

• Assemble spacer (if necessary)
• Remove inhaler cap
• Hold upright and shake well
• Insert inhaler mouthpiece upright into spacer
• Close lips to form good seal around spacer mouthpiece
• Press down on inhaler canister once
• Immediately take 3-4 normal breaths or one deep, slow breath (and hold breath for 5 sec after)
• Repeat these 2 steps if required
• Clean the spacer once monthly in warm water and detergent. Allow to airdry without rinsing (avoids static which makes medication stick to the sides)

Question 19

Interpretation of Chest X-Ray (DRS ABCDE)

Answer 19

Review slides attached to LAO of Cardio CS titles “Chest X-rays”

Question 20

Gastrointestinal History Taking

Answer 20

Presenting Complaint

• What has brought you to the doctor today?
• Abdominal pain
  
  • SOCRATES
  • Site - ask patient to point and where it radiates
  • Character - colicky or constant
• Dysphagia
  
  • Difficulty swallowing
  • Associated with other GI symptoms e.g. acid regurgitation
  • Pain on swallowing (odynophagia)
  • Sensation of lump in throat (globus)
• Nausea/anorexia/loss of appetite
  
  • Check if associated with pregnancy, dizziness, taste or smells, headaches
  • Time of day e.g. morning after taking meds
• Fever and night sweats
• Weight changes
• Vomiting
  
  • Qty, frequency, associated with diarrhoea
  • Eaten any “high risk foods”
  • Been around anyone else with it
  • Dry retching
  • Contents - what is vomited out
• Haematemesis
  
  • Coffee grounds appearance
  • Frank blood - bright or dark
  • Amount and frequency
  • Bright blood on repeat vomiting (Mallory Weis tear)
• Reflux/dyspepsia
  
  • Associated with belching (burping)
  • Burning pain
  • SOCRATES
  • Differentiate from cardiac pain
• Altered bowel habit
  
  • Constipation/diarrhoea
  • Stool consistency - colour, solidity, smelly, mucous, blood, floating in toilet/difficult to flush
  • Flatus
• Bloating/distension
  
  • 6Fs - fat, foetus, flatus, fluid, food, faeces; check for organomegaly
  • Fluctuating or constant
• Melaena or rectal bleeding
  
  • Dark tarry stools
  • Blood in stool
  • Blood on toilet paper or in toilet bowl
• Haemorrhoids/rectal prolapse
• Tenesmus
  
  • When was the last time you got a bowel cancer screening test done
• Pain with defecation
• Jaundice
  
  • Recent travel, or illness in contact
  • Rash
  • Bruising easily
  • Associated pale stools/dark urine
  • Drug and alcohol use
• Other symptoms at all?

Past Medical Hx

• Have you ever had any medical, dental or cosmetic procedures?
• Have you ever been diagnosed with any medical conditions?
• Have you ever had any stays in the hospital?
• Other
  
  • Are all your vaccines up to date? Have you had vaccines for Hep B, Hep A?
  • Have you ever had your appendicitis?

Allergies

• Are you allergic to anything? if so find out what and the nature of the allergy

Medication Hx

• Are you currently taking any medications?
• Have you recently started or stopped any medications?
• Do you take any over the counter or herbal medications?
• What about any medication devices, drops, puffers, patches or creams

Family Hx

• Tell about your parents and siblings medical history
  
  • IBD, familial polyps or colorectal cancer, Coealiac etc

Social Hx

• SNAP
  
  • Have you ever smoked?
    
    • 20 cigs a day for 10 years = 10 pack years
    • 1 bong = 5 cigarettes
  • On average, how many standard drinks of alcohol do you consume in a week?
  • Have you ever taken any recreational drugs?
  • What is your diet like? What are some typical meals you eat during the week?
  • How active are you? Do you get a chance to do any physical activity?
• Recently travelled anywhere?
• Work/Occupational Hx
  
  • What do you do for work?
    
    • Childcare worker, food handling, health care worker
    • Do you work or live with any animals? Any pets or farm?
• Personal Hx
  
  • Who do you live with?
  • Do you currently have a partner?
  • Flesh out if any male to male sexual contact
  • Ask about hobbies, etc

Question 21

Gastrointestinal and renal exam

Answer 21

Introduction and greeting

Check if the patient has any injuries

• especially neck, shoulders, back or legs due to small body movements during the examination

Inspect Body Habitus

Positioning and exposure

• 45 degrees angle with a single pillow
• hip and knees flexed to relax abdo muscles - expose from xiphoid process to suprapubic area

Inspect

• Have you been experiencing any confusion at all?
• Bruising/scratch marks, colour
• Body Habitus

Hands and arms

• Hepatic flap (hold for 15 secs)
• Clubbing, leuconycia, koilonycia
• Hands
• Check pulse and comment on vitals

Face and neck

• Eyes
• Mouth
  
  • Breath, lips, gums, mouth, tongue, teeth
• Palpate
  
  • Salivary glands (parotid and submandibular)
  • Lymph nodes
• JVP

Chest - RENAL

• Auscultate - pericardial rubs and heart sounds
• Palpate - skin turgor, renal angle, sacral oedema

Abdomen

• Lie patient flat - bring bed down
• Inspect
  
  • Ask patient to take deep breaths
  • Observe from the side
  • If checking for Hernia ask patient to bring chin to chest and cough
• Palpate 9 regions - deep and superficial
• Liver and spleen palpation
• Liver, spleen and bladder percussion
• Shifting dullness
• Palpate for AA
• Balloting of the kidneys - RENAL
• Auscultate for AA bruits, renal bruits, bowel sounds

Lower limbs

• Inspect Bruising
• Check for pitting oedema

Conclusion and thank the patient

In order to conduct a complete GIT examination I would also do:

• BP (lying and standing). Standing BP should not be performed in an acute abdomen or if patient is already hypotensive lying down.
• Pulse rate and temperature
• Measurement of height, weight, waist circumference, BMI
• Auscultation for friction rubs over liver and spleen
• Examination of the male genitals and rectal examination
• Examination of relevant other systems (eg PNS in ETOH-induced liver disease)
• Urinalysis should also be performed.

Question 22

Alcohol audit

Answer 22

Your alcohol score indicates possible dependence. What are your thoughts when you hear this?

We’ll take baby steps to help you cut back.

Possible services to involve according to RACGP:

• Psychosocial interventions
  
  • Motivational interviewing
  • Relapse prevention
  • CBT Therapy
• Pharmacotherapy
  
  • Naltrexone
  • Disulfuram
  • Acamprosate
• Self help
  
  • Alcoholics Anonymous
  • SMART recovery Australia
  • Local Drug and Alcohol Service

Question 23

Hernia sites and presentations

Answer 23

Question 24

Scenario 1 (AXR 2 – plain film)

Explain X-Ray

• 86 year old man presents with generalised abdominal pain over the past 24 hours, with vomiting and profuse watery diarrhoea
• Past medical history – hypertension, IHD, PVD, CVA 3 years ago with residual left hemiplegia, moderate dementia
• Ex-Smoker – 50 pack years – quit 15 years ago
• Nursing home resident
• OE – generalised abdominal tenderness

Answer 24

Check LAO for features of abdominal X-ray (under GI CS skills) to help you read it

Question 25

Scenario 2 (AXR 3 – plain film)

• 42 year old man presents with 12 hours of severe left flank pain - colicky in nature and radiating to his groin, with associated nausea and vomiting
• Past medical history – appendicectomy age 18
• Medications – nil regular
• OE – Pt. is tachycardic and hypertensive

Answer 25

See LAO of GI CS for more examples

Question 26

Scenario 3 (AXR 4 – plain films x 2)

• 67 year old woman presents with 24 hours of bilious vomiting, colicky abdominal pain and bloating. She had diarrhoea yesterday but has not opened her bowels for the past 24 hours.
• Past Medical history – abdominal hysterectomy 7 years ago (fibroids), 3 caesarean deliveries, recurrent DVT (Factor V Leiden), IHD – AMI with VF arrest age 62
• Medications – perindopril, atorvastatin, warfarin
• OE – Abdomen moderately distended

Answer 26

See LAO in GI CS for more examples

Question 27

Review of Dental Health SSG

(unlikely to be an OSCE station given COVID but just in case have a quick scan through it)

Answer 27

There is also a detailed powerpoint with examples under the Dental Health LAO in GI CS - can review it

Question 28

Hydration assessment

Answer 28

Attached to GI/Liver exam 2 LAO

Question 29

Bedside Urine Analysis

Answer 29

Attachment can be found LAO of GI Examination 2

Introduction and consent

Hand hygiene and wear gloves

Sample collection:

• Give patient sterile specimen container and saline wipe and carefully instruct:
  
  • Take to toilet
  • Spread the labia/retract the foreskin
  • Prior to urination cleans urethral meatus with saline-soaked gauze, wipe in a downwards motion FRONT TO BACK, then dry
  • Instruct patient to collect midstream specimen in sterile container after passing a small amount of urine into the toilet, and then finish passing urine

Procedure:

• Attend hand hygiene, don non-sterile gloves
• Retrieve specimen jar (yellow top, clear) from patient
• Mix specimen well immediately before using
• Confirm that the test strips are within the expiration date on the bottle
• Remove one strip from the bottle and replace the cap immediately
• Inspect the strip. If reagent areas are discoloured, do not use the strip
• Gold standard is to draw up urine into sterile syringe and drop onto reagent squares carefully. Alternatively, dip the test strip into the urine up to the last test pad for no more than 1 second – note this can potentially contaminate the urine for M/C/S
• On drawing the strip out of the sample, run its edge over the rim of the container to remove excess liquid or blot on paper towel
• After 60 seconds (60–120 seconds for leukocytes) compare the reaction colour in the test area against the colour scale on label
• Discard urine in contaminated waste
• Remove gloves, wash hands
• Record results in patient notes

Important Points:

• Avoid tipping test strip on to its end as the fluid and colour may run affecting interpretation capabilities
• If the tests cannot be done within two hours of urine collection, keep the specimen in a refrigerator at +4°C

Question 30

Pregnancy test

Answer 30

Review LAO for procedure

Question 31

Renal and Urology History Taking

Answer 31

Presenting Complaint

• What has brought you to the doctor today?
• Pain
  
  • SOCRATES
  • Kidney – pain in loin or flank, dull or sharp, continuous or with movement/position
  • Ureter – colicky from flank to loin to groin
  • Bladder – generalised lower abdominal, suprapubic, association with micturition
  • Urethra –dysuria (burning or stinging passing urine)
• Changes in urination patterns
  
  • Frequency (passing more often but no increase in overall quantity)
  • Polyuria (increase in the quantity of urine passed +/- polydypsia)
  • Urgency (strong urge to urinate even with small amounts of urine in bladder)
  • Nocturia (How often? Pattern changing?)
  • Oliguria (decrease in quantity produced: <400ml urine/24hrs)
  • Anuria (no urine output) eg. acute renal failure
• Changes in urinary stream
  
  • Incontinence (stress or urge)
  • Urinary retention +/- overflow o Hesitancy (bladder outlet obstruction)
  • Leaking or postmicturition dribbling
  • Double voiding
  • Strangury (slow flow +/- pain)
• Changes in urine
  
  • Colour (concentrated urine is darker – ?dehydration)
  • Vitamins, medications and food colourings often discolour urine
  • Urine cloudy and or smelly suggesting pyuria
  • Frothy urine suggesting proteinuria
  • Port wine colouration (Porphyria cutanea tarda-rare)
• Haematuria
  
  • Small amount blood – urine is pinkish, brownish or cloudy
  • Heavy bleeding – frank blood or clots
  • Bleeding at start or end of stream
  • Painful (stones, infection, papillary necrosis)
  • Painless (infection, neoplasia, acute glomerulonephritis, menstruation or vaginal cause)
• Urethral discharge
  
  • Amount, odour, colour, blood, pus, pain
  • History of STIs and recent sexual history
• Systemic systems
  
  • Constitutional: fever, anorexia, weight loss, night sweats, malaise
  • Infection: chills, rigors, malaise, sore throat, sepsis (post-streptococcal glomerulonephritis)
  • Neoplasia: symptoms associated with metastasis – bone pain, headache, confusion, shortness of breath
  • Autoimmune/systemic inflammatory diseases (eg SLE, vasculitis): arthralgia, myalgia, rash, purpura, alopecia, eye and respiratory symptoms
• Chronic Kidney Disease
  
  • Oliguria
  • Anorexia, malaise, vomiting, hiccups, fatigue, insomnia
  • Itching, bruising
  • Oedema, breathlessness
  • Restless leg syndrome
  • Parasthesia, bone pain
  • Symptoms due to anaemia
• Other symptoms at all?

Dialysis History if relevant

• Type of dialysis
  
  • haemodialysis or peritoneal
• Duration on dialysis
• Type of dialysis access
  
  • AV fistula or Vascath for haemodialysis
  • peritoneal catheter for peritoneal dialysis
• Complications associated with dialysis
  
  • Haemodialysis
    
    • blocked access (thrombosed fistula, blocked Vascath),
    • Vascath infection,
    • cardiovascular instability (intradialysis hypotension, arrhythmia from electrolyte shift),
    • bleeding from intradialytic heparin use
  • Peritoneal dialysis
    
    • peritonitis,
    • peritoneal catheter exit site infection,
    • catheter displacement or blockage,
    • abdominal hernias,
    • hydrothorax from pleuroperitoneal fistula/leak
• Check if patient has had previous kidney transplant or if patient is on the renal transplant waiting list
• Check whether dialysis is affecting patient’s activities
• Check whether patient is depressed

Past Medical Hx

• Have you ever had any medical, dental or cosmetic procedures?
• Have you ever been diagnosed with any medical conditions?
• Have you ever had any stays in the hospital?
• Other
  
  • In women with bladder symptoms, ask about obstetric history, pelvic surgery, other gynaecological symptoms
  • In men with symptoms of bladder outlet obstruction, ask about history of prostate disease, family history of prostate cancer, past PSA screening, prostate examination or imaging

Allergies

• Are you allergic to anything? if so find out what and the nature of the allergy

Medication Hx

• Are you currently taking any medications?
• Have you recently started or stopped any medications?
• Do you take any over the counter or herbal medications?
• What about any medication devices, drops, puffers, patches or creams
• Other
  
  • Medications taken to treat kidney disease or reduce risk factors eg antihypertensives
  • Nephrotoxic medications eg NSAIDs, aminoglycoside antibiotics
  • Medications that are renally excreted and may require dose adjustment in renal failure eg some antibiotics, oral hypoglycaemics

Family Hx

• Tell about your parents and siblings medical history
  
  • Polycystic kidney disease
  • Ureteric abnormalities
  • Hypertension, gout and diabetes
  • Renal impairment or disease of any kind
  • Bladder, kidney or prostate cancer
  • Deafness, iritis (rare genetic causes of renal disease- Alport syndrome)

Social Hx

• SNAP
  
  • Have you ever smoked?
    
    • 20 cigs a day for 10 years = 10 pack years
    • 1 bong = 5 cigarettes
  • On average, how many standard drinks of alcohol do you consume in a week?
  • Have you ever taken any recreational drugs?
  • What is your diet like? What are some typical meals you eat during the week?
  • Fluid intake - amount and type
  • How active are you? Do you get a chance to do any physical activity?
• Recently travelled anywhere?
  
  • Travel (schistosomiasis and other infections)
• Work/Occupational Hx
  
  • What do you do for work? Particularly possible toxin exposure (eg dyes associated with bladder cancer
• Personal Hx
  
  • Who do you live with?
  • Do you currently have a partner?
  • Flesh out sexual history as relevant
  • Obstetric history for female if relevant

Question 32

Thyroid Examination

Answer 32

Introduction and greeting

Check if the patient has any injuries

Inspect Body Habitus

Hands and Arms

• Cap refill
• Palmar erythema
• Clubbing
• Check for tremor with paper on hands
• Radial pulse
• Pemberton’s sign

Eyes

• Front (follow finger with eyes)
• Scrunch eyes to see lid lag
• Inspect eyes from side and above

Neck and thyroid

• Inspect from front and ask to sip water, ask patient to stick tongue out
• Locate cricoid cartilage and check position for trachea
• Lymph nodes
• Palpate thyroid from behind
• Ask patient to swallow water whilst palpating thyroid
• Percuss manubrium
• Auscultate over the thyroid and listen for bruits

Legs

• Reflexes - bicep, knee
• Oedema on tibia + malleoli
• Standing test for proximal muscle strength

(If I had time I would also examine the chest for gynaecomastia, systolic flow murmurs and CCF)

Question 33

Upper Limb PNS Exam

Answer 33

Introduction and greeting

Inspect Body Habitus

Check if the patient has any injuries

• especially neck, shoulders, back or legs due to small body movements during the examination

Gait

• Walk normal + back figure 8
• Walk heel to toe
• Walk up on toes
• Walk on heels
• Squat
• Romberg test: eyes closed + arms out + support if needed

Upper Limb

Motor: inspect, tone, power, coordination + reflexes

• Inspect and compare
• Tone
  
  • Wrist: rotation
  • Elbows: flexion/extension + supination
• Power (resisted)
  
  • Shoulder: abduction/adduction
  • Elbow: flexion/extension
  • Wrist: flexion/extension
  • Fingers: flexion/extension + abduction/adduction
  • Thumb: abduction/adduction + opposition
• Coordination
  
  • Drift test - Close eyes, palms up and fingers splayed - push up see drift
  • Finger-nose test
  • Hand flip test- Rapid alternation one hand on another palm to dorsal
• Reflexes
  
  • Biceps
  • Triceps
  • Radial
  • Fingers

Sensory

• Soft touch
• Pain
• Proprioception
• Temperature
• Vibration

Question 34

Lower Limb PNS exam

Answer 34

Introduction and greeting

Inspect Body Habitus

Check if the patient has any injuries

Gait

• Walk normal + back figure 8
• Walk heel to toe
• Walk up on toes
• Walk on heels
• Squat
• Romberg test: eyes closed + arms out + support if needed

Lower Limb

Motor: inspect, tone, power, coordination + reflexes

• Inspect and compare
• Tone
  
  • Knee
  • Ankle
• Clonus
  
  • Knee
  • Ankle
• Power (resisted)
  
  • Hip: Flexion/Extension + abduction/adduction
  • Knee: flexion/extension
  • Ankle: plantarflexion/dorsiflexion
  • Foot: inversion/eversion (isolate heel)
  • Big toe: abduction/adduction + opposition
• Coordination
  
  • Heel-shin test
  • Foot-tapping test
• Reflexes
  
  • Knee
  • Achilles heel
  • Plantar (C shape on sole of heel to toe)

Sensory

• Soft touch
• Pain
• Proprioception
• Temperature
• Vibration

Question 35

Cranial Nerve Examination

Answer 35

Introduction and greeting

Inspect Body Habitus

Check if the patient has any injuries

• especially neck, shoulders, back or legs due to small body movements during the examination

CNI - Olfactory

• Any change or loss of smell

CNII - Optic

• Snellen Chart (with glasses on)
• Visual fields
• Blind spot

CNIII/IV/VI - Oculomotor, Trochlear + Abducens

• Pupils - inspect, light (direct + consensual)
• H pattern
• Accommodation

CNV - Trigeminal

• Corneal reflex
• Soft touch forehead, cheek, chin
• Pain prick forehead, cheek, chin
• Clench teeth + palpate masseters + open jaw resist
• Reflex jaw jerk

CNVII - Facial

• Resisted eyebrow raise
• Resisted eye scrunch
• Resisted cheek puff out
• Show teeth

CNVIII - Vestibulocochlear

• Whisper test with opposite ear closed
• Rinne’s - tuning fork on mastoid process till no longer heard then placed alongside ear canal
• Weber’s - tuning fork placed on head and asked if equal

CNIX/CNX - Glossopharyngeal + Vagus

• Inspect mouth and say “Ahh” for palatal arches
• Swallow water
• Cough test

CNXII - Hypoglossal

• Inspect tongue
• Poke out tongue
• Assess tongue power by pushing through cheek

CNXI - Accessory

• Resisted shrug
• Resisted left + right head rotation - look to both sides

Question 36

Upper Limb MSK examination

Answer 36

• Introduction and greeting
• Check if patient has any injuries
  
  • especially neck, shoulders, back or legs due to small body movements during the examination

-NB. for entire session, watch the Patient’s expression-

Gait + Stance (for pathologies involving thoracolumbar spine)

• Inspect + compare sides
• Walk
• Squat
• Trendelenburg sign - stand on one leg

CERVICAL SPINE

• Inspect
• Palpate: spinous processes + facet joints + paraspinal muscles + temp

Cervical Spine Active Movements

Observe from side:

• Flexion: chin to chest
• Extension: look up

Observe from front:

• Rotation: Look to side
• Lateral flexion: Tilt ear to shoulder

THORACOLUMBAR SPINE

• Inspect
• Palpate: Temp + spinous processes + facet joints + paravertebral & ilio-lumbar muscles
• Gentle thumping down and up spine

Thoracolumbar Spine Active Movements

Observe from side:

• Extension: Bend forward & touch toes
• Flexion: Bend backward (supporting pt.’s back)

Observe from behind:

• Lateral flexion: Bend sideways - reach hand to knee w/out moving pelvis
• Rotation: sit pt. on bed w/ arms crossed → rotate trunk and look to side w/out moving pelvis

SHOULDER

• Inspect
• Ask pt. to show painful areas & demonstrate limited/painful ROM
• Palpate: Temp + sternum + clavicle + acromion + coracoid process + + bicipital groove + scapula

Shoulder Active Movements

Observe from behind w/ pt. standing:

• Flexion/extension: raise straight arms forward & up + down & back
• Abduction/adduction: Hands from side to top (like a jumping jack) & back down
  
  • Do a 2nd time & palpate scapula during movement
• Internal/External rotation: rotate flexed elbow (90 deg) in & out, NB. for internal rotation, hand must go behind back

Shoulder Special Tests

Rotator cuff:

• Empty can test: hold arms straight out, 30 degrees lateral + thumbs down (pouring out cans) → Push downwards on their arms & ask patient to resist
• Take off test: Hand behind back (palm facing outwards) and Dr pushes inwards against it as pt. pushes out
• Driving test: elbow @ 90 deg with palms facing each other → Push in against and out

Shoulder impingement:

• Jumping Jack test: abduct the arm and watch for painful arc between 60 & 120 deg
• Hawkins test: Dr places palm on pt. shoulder + pt. arm rests over inner elbow of Dr → Push forearm down (twisting hinge)

ELBOW

Pt. standing:

• Inspect + assess carrying angle
• Ask pt. to locate painful areas & demonstrate limited/painful ROM
• Palpate: Temp + inner elbow + olecranon + ulnar nerve + medial & lateral ligaments

Elbow Active Movements

• Flexion/extension: robot arms up & down (palms facing in)
• Internal/external rotation: robot arms cross at front and out
• Supination/pronation: elbow @ 90 deg → rotate palms up & down

Elbow Special Tests

• Tennis elbow test: hold under pt’s distal forearm (elbow bent @ 90 deg with palm down) → push down on hand as pt extends wrist up
• Golfers elbow test- as above → Flex wrist down against pressure

WRIST + HANDS + FINGERS + THUMB

• Inspect
• Palpate: Temp + radial pulse + cap refill + wrist + hand + fingers

Active Movements

Wrist: flexion, extension, abduction and adduction

Fingers: bend at MCP flexion/extension (flat fingers) + fingers splayed + claw hand fist (bend at PIP & DIP)

Thumbs: flexion/extension + abduction/adduction + opposition

Hand Special Tests

• Carpal tunnel test: namaste praying & reverse
• De Quervain’s test - wrap thumbs under fist and bend wrist down

Question 37

Lower Limb MSK Examination

Answer 37

• Introduction and greeting
• Check if patient has any injuries
  
  • especially neck, shoulders, back or legs due to small body movements during the examination

-NB. for entire session, watch the Patient’s expression-

Gait + Stance (for pathologies involving thoracolumbar spine + lower limb)

• Inspect + compare sides
• Walk
• Squat
• Trendelenburg sign - stand on one leg
• Heel raise on one leg
• Optional: Thessaly Test for knee menisci (one leg standing rotation)

HIP

• Lay pt. flat
• Inspect
• Ask pt. to locate painful areas & demonstrate limited/painful ROM
• Measure leg lengths (umbilicus/ASIS/greater trochanter to medial malleoli)
• Palpate: greater trochanter + inguinal area

Hip Active Movements

• Flexion: bring knee to chest
• Internal & external rotation: rotate bent leg in and out
• Abduction + adduction: straight leg medial cross and lateral
• Extension: Roll pt. over + fix hips + straight leg extension
• Optional: Apley’s test (knee grind)

KNEE

• Inspect
• Ask pt. to locate painful areas & demonstrate limited/painful ROM
• Measure circumference of thighs 20cm above tibial tuberosity
• Palpate: patella, patellar tracking, ligaments, muscles

Knee Active Movements

• Extension: heel to buttock
• Flexion: flip pt. to front and bend knee + grinding test (if not already done)

Knee Special Tests

• Oedema ‘milk fluid down’ test: Patellar tap + Bulge push both sides
• Collateral knee ligaments test: bend knee & abduct and adduct lower leg
• ACL + PCL test: Sit on pt. foot w/ knee bent & jerk lower leg forward & backwards

ANKLE + TOES

• Inspect
• Ask pt. to locate painful areas & demonstrate limited/painful ROM
• Palpate ankle, foot and toes

Ankle Active movements

• Dorsiflexion + Plantarflexion: point foot forward/backward
• Inversion + Eversion: fix heels + point sole of foot in/out

Toe Active movements

• Flexion + Extension: curl + splay toes

Question 38

MSK History Taking

Answer 38

Presenting Complaint

• Confirm if it is both sides
• Bones
  
  • pain (SOCRATES and inc or dec with weight bearing)

Swelling

• Joints –
• joint pain (arthralgia)
• stiffness – where? worse in the morning?
• swelling or deformity - soft/hard (Fluctuant -> effusion Spongy/boggy -> synovitis, haemorrhage Hard/immobile -> osteophyte/ subchondral bone thickening)
• locking - suggests loose bodies or torn cartilages
• instability – ‘giving away’ (suggests dislocation, subluxation, torn tendons or ligaments)
• noises and redness – clicks, clunks, grating sensations
• loss of function – ASK ABOUT IMPACT ON LIFE!
• Systemic manifestations (connective tissue disease and seronegative arthropathies)
• Vasculitis (any fever? Fatigue? Weight loss?)
• Skin
  
  • Rash (photosensitive, burning? does it blanch? Itchy, distribution)
  • Skin thickening
  • Ulcers
  • Raynaud’s phenomenon (triphasic colour change in feet or fingers in cold – white, blue, red)
• Head and face
  
  • Alopecia
  • Headaches
  • Visual disturbances
  • Sicca symptoms (dry eyes and/or mouth) OR red, painful eyes
  • Jaw claudication
• Neck and chest
  
  • Dysphagia or odynophagia (painful swallowing)
  • Pleuritis (sharp chest or abdominal pain)
  • Dyspnoea, haemoptysis, wheezing, chest tightness, hoarse voice, sinusitis
• Abdomen
  
  • Abdominal discomfort or dragging sensation in abdomen (heapto/splenomegaly)
  • Postprandial abdominal pain
• Testicular pain
• Muscle pain/weakness
• Neuropathy – motor and/or sensory
• Ask about how it is impacting their life (sleep, work, recreational activities, future, etc)

Past medical history

• Previous joint injury, surgery, or treatment of any kind?
• Nerve, muscle, tendon injury/surgery
• Diabetes (peripheral neuropathy)
• Gout
• Peptic/duodenal ulcer
• OA (increase steroid use = RF for OA)
• Menopause?
• Obesity (past or present)
• Stress/depression (psychosomatic problems)

Medications

• Pain relief
• NSAIDs
• Statins (rhabdomyalgia – muscle pain)
• Immunosuppressives including azathioprine, cyclosporine, methotextrate, cyclophosphamide
• Corticosteroids
• Hydroxychloroquine (plaquenil)
• Hydralazine
• Procainamide
• Anti-thyroid meds

Allergies

NSAIDs, immunosuppressive meds, analgesia

Family history

RA, arthritis, lupus, scleroderma, sjoren’s syndrome, OA, OP, gout

Social history

Occupational – overuse of joint

Sporting – Have you had any injuries?

Diet (RF for gout - high purine diet)

Exercise (What is your exercise regimen like?)

Smoking and alcohol

Question 39

Gynaecology History Taking

Answer 39

Presenting Complaint

• What has brought you to the doctor today?
• Menstruation
  
  • Menstrual History
    
    • Menarche- age at first period
    • Age of menopause (if relevant)
    • Frequency/regularity and duration of cycles including cycle length expressed as days of menstruation/cycle length eg 3/27
    • Heaviness of flow - number of tampons/pads used on Day 1, clots
    • Date of last menstrual period (LMP) -always expressed as 1st day of cycle
    • Dysmenorrhoea (painful menstruation) -onset (at menarche or later), duration, intensity, location and radiation, relieving factors (eg do NSAIDs relieve pain?)
    • Pre-menstrual tension/dysphoria -mood changes, breast tenderness, bloating
  • Non menstrual bleeding
    
    • Intermenstrual bleeding (IMB)/breakthrough bleeding (BTB) if on hormonal contraception
    • Post-coital bleeding (PCB) -after sexual intercourse
    • Post-menopausal bleeding (PMB)
• Obstetric (details important if currently pregnant or planning a pregnancy)
  
  • Gravida -total number of pregnancies (including miscarriages and terminations with gestation reached), include current pregnancy if relevant
  • Parity -number of births (live or stillbirths)
    
    • Gravida and parity are expressed as GxPx eg G3P2 is three pregnancies, two births
  • Birth details
    
    • Gestational ages at birth in weeks (ie 32, 36, 42 etc)
    • Induction of labour/spontaneous
    • Duration of labour
    • Type of delivery- vaginal vs. Caesarean (planned or emergency), forceps, tears/episiotomies
    • Birth weight, sex of babies, Apgar scores
  • Pregnancy complications: GDM, hypertension, pre-eclampsia, other medical problems
  • Neonatal complications or abnormalities, multiple births (twins, triplets)
  • Blood group and Rh factor, history of anti-D immunisations
  • HIV, Hepatitis B or Hepatitis C infection
• Gynaecological
  
  • Past and current contraception and any problems with these
  • Cervical screening history
    
    • Date of last pap smear/cervical screen - result
    • Any abnormal tests in the past
  • Genital symptoms
    
    • Vaginal discharge- all women have physiological vaginal discharge- need to determine if abnormal for her- colour, quantity, odour, irritation, onset, time course, any past diagnoses eg recurrent thrush
    • Dyspareunia (painful intercourse)- superficial (at the vaginal entrance) or deep
    • Other genital symptoms eg ulcers, lesions, lumps, rashes, itching
  • Micturition/urinary tract symptoms
    
    • Frequency, dysuria, stress or urge incontinence particularly if past pregnancies
    • Past urinary tract infections
  • Bowel symptoms- constipation/diarrhoea, pain with defecation, difficulty defecating
  • Menopausal history (if relevant)
    
    • Peri-menopausal -current pattern of bleeding (as in menstrual history)
    • Post-menopausal -date of final period
    • Hot flushes and night sweats -frequency and severity
    • Other symptoms associated with menopause and their effect on life such as: vaginal dryness, mood changes, joint aches and pains, insomnia, loss of libido
  • Any past gynaecological diagnoses or surgery eg treatment of endometriosis
  • Other - May need to sensitively ask about past genital mutilation/surgery in women from high risk countries or if suspected on examination
• Sexual History
  
  • Current relationship, length of relationship, monogamous or not
  • Most recent unprotected sex and number of casual partners in last 12 months if relevant
  • Male or female partners or both
  • Use of condoms
  • Any past sexually transmitted infections, especially past genital herpes, syphilis or chlamydia and treatment details
  • Previous STI testing
  • Sexual difficulties may be disclosed and may be relevant to the presenting illness eg vaginismus (difficulty with vaginal penetration), painful sex after previous childbirth.
• Changes in weight?
• Any fevers, nausea or vomiting?
• Other symptoms at all?

Past Medical Hx

• Have you ever had any medical, dental or cosmetic procedures?
• Have you ever been diagnosed with any medical conditions?
• Have you ever had any stays in the hospital?
• Other
  
  • Mental health history: depression especially postnatal depression, anxiety, any other psychiatric illness, treatment

Allergies

• Are you allergic to anything? if so find out what and the nature of the allergy

Medication Hx

• Are you currently taking any medications?
• Have you recently started or stopped any medications?
• Do you take any over the counter or herbal medications?
• What about any medication devices, drops, puffers, patches or creams
• Other
  
  • Contraception -current and past use (will be covered in detail in next session)
  • HRT (if relevant) -current or past use and duration of use
  • Alternative remedies/herbal medicines
  • Vitamin supplements, especially iron, iodine & folic acid if pregnant
  • Immunisations
    
    • Gardasil in younger women (was the full course of 3 injections completed?)
    • Varicella (chicken pox- at least one month prior to pregnancy, cannot be given in pregnancy)
    • Rubella (at least 1 month prior to pregnancy or postnatally, cannot be given in pregnancy)
    • Hepatitis B (especially if not Australian born)
    • Fluvax (can have when pregnant- protects mother and newborn)
    • Pertussis (can have when pregnant- protects newborn)

Family Hx

• Tell about your parents and siblings medical history
  
  • Gynaecological cancers -ovarian, endometrial
  • Breast cancer- number of first degree relatives affected at what age
  • Genetic conditions
  • Pre-eclampsia
  • Postnatal depression
  • Twins

Social Hx

• SNAP
  
  • Have you ever smoked?
    
    • 20 cigs a day for 10 years = 10 pack years
    • 1 bong = 5 cigarettes
  • On average, how many standard drinks of alcohol do you consume in a week?
  • Have you ever taken any recreational drugs?
  • What is your diet like? What are some typical meals you eat during the week?
  • How active are you? Do you get a chance to do any physical activity?
• Work/Occupational Hx
  
  • What do you do for work?
  • Who do you live with?
  • Do you currently have a partner?
  • If pregnant:
    
    • Smoking- high risk for premature and small babies, document amount smoked, attempts to quit and motivation to quit, refer to Quit Clinic
    • Nutrition- varied, balanced diet high in iron important, avoid foods with risk of Listeria monocytogenes (eg soft cheeses, unpasteurised milk products, salad bars), avoid high levels of caffeine (more than one strong espresso coffee per day)
    • Alcohol- current recommendations are no alcohol in pregnancy, refer for support if problematic
    • Physical activity- moderate exercise is beneficial, supportive back exercises, avoid intense new exercise
    • Any drug use particularly intravenous drugs (potential risk of hepatitis C)
    • Social supports- partner, extended family, friendships, preschool and school contacts, cultural group etc

Question 40

Nervous System History Taking

Answer 40

Higher Cortical Functions (intelligence, complex problems etc)

Levels of Consciousness

Fits, epilepsy, funny turns

Headache, neck pain, facial pain

Cranial nerves (sight, smell, balance, face sensations. pain etc)

PNS - gait, back pian etc

Question 41

geriatric assessment