OSCE clin skills Flashcards
Which diabetes drugs cause weight gain
Sulphonylureas
Insulin
Which diabetes drugs cause weight loss
SGLT2i
Incretins
Which diabetes drugs cause hypos
Sulphonylureas
Insulin
First line management for all diabetes patients
Metformin
What does second line management for diabetes depend on
CKD or HF
History of atherosclerotic CVD
Weight gain should be avoided
Risk of hypo should be avoided
Second line management for diabetes if history of atherosclerotic heart disease
SGLT2i
GLP 1
Second line management for diabetes if history of CKD or HF
SGLT2i
Second line management for diabetes if hypos should be avoided
Anything from
- GLP 1
- SGLT2i
- DPP4i
- TZD
What is another name for for thiazolidinediones
Glitazones
Second line for management of diabetes if weight gain should be avoided
GLP1
SGLT2i
Main side effect of GLP 1 agonists
Diarrhoea and feel sick
Main side effects of gliptins
Pancreatitis risk
Retinopathy
Main side effects of metformin
Diarrhoea
Lactic acidosis
When is metformin contraindicated
Liver failure
Severe renal disease
Chronic HF
Side effects of SGLT2i
Genital infections
When does someone move between different diabetes therapies
If after 3 months Hba1c doesnt reach target
What metformin is given initially
Standard release
What is given if standard release metformin not tolerated
Modified release metformin
If a patient is on a drug that can cause hypos on monotherapy what is target Hba1c
53
What is target Hba1c for metformin
48
When on dualtherapy for T2DM what is target Hba1c
53
When Hba1c rises to what do you move up a therapy
58
Causes of slow AF
Hypothermia
Digoxin toxicity
Some anti-arrythmics
What does an OT do
Looks for things that can help a person go home- help and improve peoples daily life by allowing them to function as best they can- very individualised
What does a physio do
Make sure muscles are strong allowing you to carry on normal daily life- for example getting from bed to chair. We dont want you to be falling again so theyre going to make sure your legs have good balance and can support you
Questions to ask in scenario where someone is going home and need to advise them about physio and OT
Whos at home with you
Do you have any neighbours, children and friends who can help you
Do you live in a flat
Are there any stairs/ is there a lift
What does a normal day look like
What are some things you like to do in a day
How to explain sulphonylurea, gliptin and incretin to a patient
They increase insulin production
How to explain SGLT2i to a patient
Wee out more glucose
How to explain metformin to a patient
It helps activate insulin and makes sure more of it acts as that door
How to structure an explaining station
BUCES Brief history Understanding of patient Concerns Explanation Summarise
How to structure the explaining part of a station
Normally we can probably manage Normal physiology What disease is Causes Problems of it Management
Brief history qs for diabetes
Whats brought you in today? Have you had any symptoms? Feeling thirsty? Weeing out more water than usual? Tired? Infections of your genitals? Past medical history? What is your diet like? What is your daily activity like? What job do you do?
Understanding question to ask?
From what youve been told so far/What do you know about X?
Explaining diabetes
So normally when we eat our body breaks it down into sugar and this enters the blood to go around the body for cells to use it as energy. However sugar cant just enter cells it needs a gateway into them so when we eat we also produce a hormone called insulin that goes into blood that acts as a door allowing the sugar into cells
In type 2 diabetes that you have some of the insulin doesnt work so not all glucose can get into cells meaning that it builds up and damages some of our blood vessels
Just to check that you understand would you be able to just run me through what you understand so far?
In terms of what causes it, its often a mix of both sometimes people are born with faulty insulin so and as they get older waht they eat that contain lots of sugar it causes this insulin to be faulty and the cells dont respond
Do you have any questions at this point
So with diabetes it can lead to everyday symptoms such as feeling tired, going to toilet more or can often get infections on your penis which can be uncomfortable but the main problem with diabetes is that silently when youre totally unaware of it your all this sugar is damaging certain parts of your body and what that leads to
In your eyes can lead to vision loss
In your nerves can lead to not be able to feeling your hands and feet
In your kidney causing kidney failure
In your brain increasing risk of stroke
In your heart leading to heart attacks
So im sure at this point thats all sounding very scary but this can be managed and even in the early stages can be reversed through a variety of lifestyle modifications and medicines
How to do MSU sample explaining
Good afternoon my names owen vineall etc
Can i just confirm your name and DOB please
Ive been asked by the doctor today to come and explain to you how to take whats called a mid stream urine sample is that ok with you?
Have you ever had this before?
From what youve been told so far what do you uderstand about this procedure?
Ok so what were doing is taking a sample of your urine and then its gonna go off to the lab who are going to look for an signs of infection and then youll get the results back in a few days the doctor will call you
So whats important about this sample is that we dont get it contaminated with any of the germs on your skin so waht you do is so you take this cup to the toilet with you and before you start weeing take the cap off having it ready at the side taking special care to make sure you dont touch the inside of the lid and cup. So you start weeing with the cup in your hand or on the side then after a bit of weeing put the cup in front of your stream to catch some of it and before you finish weeing put the bottle on the side and finsh your wee then when youre done flush wash your hands and put the cap back on the cup making special care again not to touch inside of lid and cap.
then its gonna go off to the lab who are going to look for an signs of infection and then youll get the results back in a few days the doctor will call you
AF management advice station
Brief history for AF
Have you ever had it before?
SOB, chest pain, palpitations, fainting- when started
Heart problems in the past
Any illness in the past
Any medications
What lifestyle like active?
Do you understand
ICE
Explain about irregular rythm, blood pools can form clumps of cells that cause stroke, fast want to reduce work on heart, rythm return will increqse CO helping activity
Management start anticoagulation, depends on factors if start rate or rythm management
4 factors that influence if move up asthma scale
Symptoms at night
Using reliever inhaler more than 3 times a week
Symptoms interfering with daily activities
Number of hospitilisations
How to explain MDI use
Introduce self- explain why here
How are you feeling- any chest pain or SOB
What inhalers?
Ask about understanding of inhalers
Explain what inhalers are for
Go through parts of inhaler with patient and check expiration date
Explain procedure by demonstrating
Mention washing out mouth if steroids
Explain some potential side effects
- salbutamol heart racing and tremor
- steroids can get sore mouth so wash mouth
Safety net about when to use in an excacerbation and if doesn’t work after 10 call 999
Check if have any concerns
Any questions?
What is difference between clean, aseptic and sterile
Clean- clear from any marks and stains
Aseptic- clear from any pathogens
Sterile- free of all microorganisms
Contraindications for venepuncture
Burns area
Limb damaged by stroke, hemiplegic
Sited for surgical procedure
Suspected fracture
What do cannula gauges run from
14-24
Indications for taking blood
Diagnostic levels
Monitor drugs
Sample for group and save
Monitor treatment
What goes in purple bottle
FBC
ESR
Blood film
Hba1c
What goes in blue bottle
INR
Clotting
D-dimer
What goes in yellow bottle
U&Es LFTs Calcium Lipids Troponin TFTs Phosphate Magnesium
What goes in grey bottle
Glucose
Lactate
Complications of cannula and venepuncture
Systemic infection Syncope Allergic reaction Haematoma Air embolism
Venepuncture- whole thing
Introduce self
Been asked by the doctor take your blood today is that ok?
Ok great so this is to look at the levels of x which will help doctor have more of an idea of whats going on, this will involve just putting a small needle into your arm does that sound ok?
Have you had your blood taken before?
How are you with needles?
Are you in any pain at the moment?
Any recent surgeries?
Any allergies?
Any medications?
Ok so im going to go and get my equipment ready I will see you in a minute
Needle
Cap
Gauze
Alcohol wiples gloves
Blood bottles
Tape
Tourniquet
REMEMBER TO HAVE GAUZE READY
Ok so thats all done how was that?
So try and keep that on for 30 mins and avoid any heavy lifting
Some things to look out for around this site and redness and if it becomes hot so if that does happen seek medical assistance as soon as possible
So now im going to write this all up it will go off to lab and the doctor will contact you with the results
Thank you for your time today
Questions before for venepuncture and cannulation?
Have you had your blood taken before? How are you with needles? Are you in any pain at the moment? Any allergies? Any medications?
What is contained within grey blood tube
Sodium fluoride
What is contained within pink and purple bottles
EDTA
What bottle is EDTA in
Purple- FBC etc
What is contained within blue blood bottle
Sodium citrate
When do you put gloves on in bloods
After collecting all equipment and returning to patient
What would make you avoid a particular vein
If its hard as suggest phlebitis
How do you check for second flashback in cannula
Withdraw needle a little bit when have advanced tube a little bit
Cannulation full station
Introduce self Im just going to be putting a small plastic tube into your arm to deliver some fluids is that ok with you Have you had your blood taken before? How are you with needles? Are you in any pain at the moment? Any recent surgeries? Any allergies? Any medications? PREPARE AND DO PROCEDURE Ok so thats all done someone will come and change it in 2 days but if you think the site gets very hot, red and painful let a member of staff know and theyll come and change it Do you have any questions for me?
What is only time invert blood bottles 4 times
Blue
How many times do you invert blue bottle
3-4
How many times do you invert yellow bottle
5
How many times do you invert purple and most bottles
8-10
Suturing full procedure
Introduce self
Today ive been asked to come and stitch up your wound to close it and hopefully relieve some pain does that sound OK?
Identity
This will just involve me using a small needle to put some stitches in does that sound alright?
How did the cut happen?
Has someone been along to put some anaesthetic in?
Do you have any allergies?
Have you had your tetanus jab?
Are you on any medication?
DO PROCEDURE
Ok so thats all done how was that?
Ok so in terms of managing the wound now make sure you look out for any redness and discharge if this does happen go to one of our walk in clinics
Try and keep it nice and dry so avoid swimming and when youre in the shower hold it away from water
You can get your stitches removed in around x days if ask GP
Any questions?
What happens if havent had tetanus jab?
Must get booster
What must ask if have had glass in wound
X rayed
How long for all the stitches based on site to be removed
- Stitches inserted on the head can be removed in about 5 days. This is due to the good blood supply to this region of the body.
- Stitches over joints must be present for 10-14 days. This is because these areas are usually under a lot of stress due to the continuous movements which stretch the skin.
- Stitches on other body parts can be removed in in 7-10 days
What is documented on cannula sheet
Identity etc Time Reason Batch Size Site Number of attempts
How is patient position for an ECG
Sitting at 45 degrees legs supported
Where do chest leads go
V1- 4th intercostal space right sternal border
V2- 4th intercostal space left sternal border
V3- halfway between V2 and 4
V4- 5th ICS MCL
V5- halfway between V4 and 6
V6- MAL horizontal to V4
Where do limb leads go
Red- right arm
Yellow- left arm
Green- left foot
Black- right foot
What should ECG be calibrated to
25mm/second
10mm/mv sensitivity
What to do with lead sites before placing them
Clean with paper
Towel
If required use alcohol wipes
If hairy shave after gaining consent from patient
What colour needle is used for ID and sub cut injections
Orange
What colour needle is used for IM injections
green or blue
Difference in administration technique between normal sub cut and insulin
For insulin in must be at 90
Normal is at 45
Technique used for intradermal injection
Pull skin taut with thumb and forefiner of free hand
Key when documenting an injection
Get the signature of a supervisor
How is heparin normally given
Sub cut
What needles are used to draw up from glass ampules
Big purple ones as have glass filters these will have big red sheath
When drawing up a drug from container where are they normally stored beforehand
Fridge
What should be done before drawing up the drug from rubber ampule that draw from
Clean the top of it
Do you need to clean skin before su cut
Don’t have to depends on guidelines but in OSCE safe to do it
Where give IM injection
Gluteus maximus or shoulder
What type of injection is local anaesthetic
Intra dermal
How to do a local anaesthetic injection
Done intradermally
Go around the site in multiple areas pulling out whilst injecting- called continuous technique
When is only time use big syringe for injections
IM
Procedure for infusion
Introduce self
can i just check your name and DOB
ive been asked today to come and set up a drip for you is that ok this will just involve me hooking up some fluids to your cannula there which will…..
How are you doing today are you in any pain?
Do you have any allergies
examiner will act as my chaperone
Check cannula site, for example date of cannula and VIP score
Collect equipment and prescribing chart- note prescription and see if matches up to bag you have
Remove fluid bag and check expiration date, drip factor and if any punctures etc
Place fluid bag on side
Remove infusion bag port and ensure roller clamp closed
Remove cap from spike and infusion bag
Insert into bag and hang up
Open roller clamp ensuring fluid into collection chamber at least half full or up to drawing line while squeezing in
Open end and see if fluid coming out then close roller clamp
Now check cannula so clean it and flush to check primed
Insert into octopus port
Adjust drip rate to prescription- check correct with examiner
Thank patient and let them know to let medical team if start feeling unwell
What document for an infusion
•Date and time,•Patient name, hospital no.•Your name and grade•Chaperone name and grade•Prescription/name of fluid•Batch number•Fluid checked against prescription, for expiry, leakages, clarity of solution. All clear.•Attached to cannula in [location] which was deemed appropriate. •Cannula to be changed on:•Time started, time to finish•Volume•Duration of infusion•Drip rate•Sign and print name•Chaperone sign and print name•Complete fluid balance char
What ask before hand infusion
Allergies
About cannula
What are 5 rs for infusion and injection
Right time Right patient Right drug Right dose Right route
What is equation for infusions
Work out ml/min then multiply by drop factor
Why do you rotate sub cut sites
Avoids abscesses and lipid hypertrophy
How long should sub cut injections be given over
10-30 seconds
Injection general procedure
Introduce self
State purpose and consent
Gather equipment
Draw up drug using filterless blunt needle for rubber bungs and filtered one for glass bottles
CLEAN BUNG
Take off drawing up needle and dispose of it
Put on correct needle and administer
When taking out the needle apply pressure
Tell them what to look out for- red and discharge seek medical attention
Where can subcut injections be given
Lateral part of arms Sides of back Anterior tummy area Thighs anteriorly Lower loins
3 sites can administer IM injection
Deltoid
Ventrogluteal
Dorsogluteal
How to present a CXR
Rotation- equidistant clavicle from spinous processes Inspiration- 6 ribs anteriorly and 10 posteriorly Penetrated- can you see spinous process behind cardiac shadow Exposure Airway - trachea central - bronchi changes (diversion mainly) Breathing - work from apices to base - opacity - lung volume Cardiac - cardiomegaly - aortic knuckle - mediastinal shift Diaphragm - flat? - air - costophrenic angles visible Everything else - bones - soft tissue such as breast - surgical emphysema - any tubes etc
How to do fundoscopy
Introduce self
Ive been asked today to come and examine your eyes today does that sound ok
Thats gonna involve me having a look in your eyes through this fundoscope which has a light and a window for me to look through. Im also going to have to dim the lights a bit to help me see better is that ok
Can i ask do you use glasses or contacts
Say to examiner id ideally use tropicamide eye drops to dilate the eyes
Start by inspecting the eyes without fundoscope
Do red reflex by asking patient to look into distance at a point
I’m gonna put my hand on your shoulder to make sure we dont bump into eachother
Examine right eye first using right hand for fundoscope and put other hand on shoulder
Zoom in to a very high plus
Start off looking at a vessel then follow up to optic disc
Examine the rest of vessels coming off the optic disc
Move on to examine macula
Clean hands and thank patient
Present to doctor
What need to think when examining the optic disc
The colour, size and margins
How does normal optic disc appear
Well defined margins yellow in appearance with paler center
In fundoscopy what is yellow part of eye
Optic disc
In fundoscopy what is the dark part of the eye
Macula
If doctor has glasses how is fundoscopy set up when doing red reflex
Start on your prescription- ie -3
How to turn light on in fundoscope
Turn part at bridge between grey and black part
What is hypermetropia
Long sightedness
What is miopia
Short sightedness
What 2 things must do before remove needle in bloods
Remove tourniquet
Get gauze ready
Looking around the bed cardio
Warfarin bracelets Medications- diabetes eg Defib pads GTN spray Oxygen masks
Signs on hands cardio
Splinter haemorrhages
Janeway lesions
Clubbing
Osler nodes
What are janeway lesions
Non-painful flat lesions
What causes janeway lesions
Septic micro emboli
Features of clubbing
Drum sticking of fingers- thing phalangeals
Curvature of nailbed
Loss of angle between nail beds- luverbonds
Cardiac causes of clubbing
Infective endocarditis Atrial myxoma Malignancy Congenital cyanotic heart disease Teratology of fallot
What are osler nodes
Painful raised nodes
What causes osler nodes
Immunological reaction
What causes splinter haemorrhages
Septic emboli
What causes tendon xanthomata
High cholesterolaemia
What is difference between CO2 retention and asterixis
In CO2 retention is symmetrical
In asterixis is asymmetrical flapping
Why is irregular pulse not pathological
Can be related to difference with breathing
What other than aortic regurg can cause collapsing pulse
VSD
Persistent ductus arteriosus
What is corrigans pulse the same as
Waterhammer pulse
Collpasing pusle
What is positive waterhammer pulse sign
Feel the pulse properly bounding- dont have to just feel the pulse put hand around it
What is pulsus paradoxus
Difference in pulse strength depending on inspiration vs expiration
What causes pulsus paradoxus
Pericardial effusion
Constrictive pericarditis
Anything affecting hearts ability to contract
In pulsus paradoxus is pulse greater in inspiration or expiration
In expiration as in inspiration when you reduce thoracic pressure more blood flows into right side of heart putting pressure on left ventricle which reduces its CO
What does pulsus alternans occur in
Anything causing LVD Aortic stenosis Hypertension Dilated cardiomyopathy IHD
Signs in face of cardio
Malar flush Corneal arcus Xanthelasma Conjunctival pallor Central cyanosis High arch palate
Difference between malar flush and malar rash
Malar flush in mitral stenosis
Malar rash in SLE
What causes high arch palate
Downs syndrome
Ehlers Danlos
Downs syndrome
Which jugular vein are you examining
Internal
What is pathological JVP
Raised above 4cm
Causes of raised JVP
Fluid overload RHF Tamponade Constrictive pericarditis Tricuspid regurg
Physiologically should JVP fall on inspiration
Should fall
What is it called when JVP rises on inspiration or stays the same
Kussmauls
What is kussmauls breathing seen in
Metabolic acidosis not just DKA
What is kussmauls sign seen in
Cardiac tamponade
Constrictive pericarditis
Restrictive cardiomyopathy
How to tell difference between JVP and carotid pulse
JVP double wave form
Carotid single
What are 3 normal JVP waves
A wave then followed by little c waves and finally second V wave
What is a wave indicative of
Atrial contractoin
What causes C wave
Tricsupid bulge from ventricular constriction
What causes V wave
Passive atrial filling
Canon a waves seen in
3rd degree HB
Large V waves seen in what
Tricuspid regurg
Slow Y descent seen in what
Tricuspid stenosis
What is Y wave
Descent of V wave
What is raised JVP with no pulsation seen in
SVC syndrome
Where are thoracotomy scars
Either on the front or back
Will be curve shaped
How to describe a thoracotomy scar
For example left anterior thoracotomy
Posterolateral
What is clam shell scar seen in
Lung transplant
What is pacemaker scar called
Left subclavicular
What are 5 cardiac scars
Midline sternotomy Left/right anterior thoracotomy Lateral posterior thoracotomy Clam shell scar Left subclavicular
What can midlline sternotomy suggest
CABG
Valve replacements
What looking for inspection of chest cardio
Pacemakers
Scars
Chest deformities
Angiomas
What part of hands do you feel thrills with
Joints just under fingers
What do you feel heave with
Bottom of hands and so when feeling for heave make sure use that part of the hand
What part of heart makes up most of anterior chest wall
Right ventricle
Where is RV heave best felt
4th ICS left sternal edge
What does heave felt on left side of chest suggest
Right ventricle hypertophy
How to feel for thrills
Go over all locations using bottom of fingers
What is S1
Mitral valve closure
What is S2
Aortic valve closure
What is S3
Turbulent ventricular filling
What is S4
atria contracting against stiff ventricles
How to remember S3
Kentucky
How to remember S4
Tennesse
Difference between S3 and S4
S3 is early diastole whereas S4 is late diastole
How to tell difference between aortic stenosis and sclerosis
Stenosis radiates to carotids
What is aortic sclerosis
Thickening of aortic valve
How to describe aortic stenosis
Crescendo decrescendo murmur heard best at 2nd ICS left sternal edge
Radiates to carotid
Louder on expiration
How to describe aortic regurg murmur
Decrescendo diastolic murmur heard best with patient leaning forward on expiration
How to describe mitral stenosis murmur
Mid diastolic murmur
Loud S1
Cresecendo decrescendo
Heard best on expiration
What causes mitral stenosis
Rheumatic fever
Calcium deposits
Congenital defect
What causes mitral regurg
IE
Rheumatic fever
MI
Mitral valve prolapse
What to look for in leg of cardion exam
CAGB
Swelling
How to present cardio exam
Today i performed a cardiovascular examination on a 22yo male
On general inspection he was breathing comfortably on room air and was no medical paraphenalia around the bed indicative of cardiovascular disease
There was no stigmata of cardiovascular disease in the hands or face and his HR was x RR was X BP X all within normal range
His JVP was not riased and general inspection of the chest was ubremarkable
The apex beat was palpated in the 5th ICS MCL with no heaves or thrills detected
HS 1 and 2 were auscultated with no murmurs or added sounds
The lung bases were clear and was no sacral or pedal oedema
In summary this was a normal cardiovascular examination of a 22 yo male
To complete my examination id like to take a full history do resp and vascular exam
Do fundoscopy get a urine dip and an ECG
General inspection of resp exam
Inhalers Oxygen Mobility aids Extra pillows Central line How comfortably breathing the patient is Use of accessory muscles Cigarettes
Inspection of hands in resp
Clubbing Tar stains Peripheral cyanosis Erythema Cap refill
How long do cap refill for
3-5 seconds
What is normal cap refill
Less than 2 seconds
What looking for in face resp
Conjunctival pallor Miosis Anydrosis Ptosis Oral candidiasis Hydration status Central cyanosis
What is thing called with cricosternal distance
Cricosternal distacne
What is normal cricosternal distance
Over 3 fingers
What causes pathological cricosternal distance
Hyperinflated chest in COPD
What is pathological cricosternal distance
Under 3 fingers
What looking for chest respiration
Chest wall defromities
Scars
Asymmetrical chest expansion
Intercostal muscle use
Chest wall deformities seen in resp
Barrel chest
Pectus excavatum
Pectus carinatum
What causes pectus excavatum
Marfans
Rickets
Scoliosis
What causes pectus carinatum
Margans
Ehlers danlos
Where to percuss on back
Do medially either side of spine- remember not to laterlally!!
What crackles are heard in bronchiectasis
Coarse
What is wheeze heard in
COPD
Asthma
Bronchiecrasis
What is chronic stridor associated with
Subglottic stenosis
What is pleural rub associated with (4)
Pneumonia
Pulmanonary infarct
Mesothelioma
Timing pleural rub is heard
Throughout systole and diastole
What happens to vocal fremitus in pneumothorax
Reduced
What causes pulmonary HTN
Primary
Massive PE
Chronic lung disease
How to present a resp exam
Today i performed a resp exam on x
On general inspection there were no medical paraphenelia seen around the bed and the patient was breathing comfortably on room air
There were no stigmata of respiratory disease noted on the face or hands and his pulse and RR was xxxx
His JVP wasnt raised, trachea central chest expansion was full and symmetrical
his apex beat was palpated in the 5th ICS MCL
The chest was resonant on percussion and on auscultation there was good air entry bilaterally with vesicular breath sounds heard everwhere
There was no evidence of pedal or sacral oedema
In conclusion this was a normal examination
To complete my examination id like to take a full history take his obs and do a cardiovascular examination id also like to take a sputum sample and peak flow
General inspection of abdo exam
In any pain Scars distension Stomas Hernias Jaundice Hyperpigmentation
What looking for in hands abdo
Clubbing Erythema Bruising Leukonychia Koilonycia Duputyrens contracture Xanthomata Hyperpigmentation
What looking for in arms abdo
Track marks Tattoos Bruising AV fistula Acanthosis nigricans
What to do when examining the eyes abdo
Get to look up when pulling eyelids down as better see jaundice
What looking for eyes in abdo
Xanthelasma Jaundice Conjunctival pallor Kayser fleishcer rings Corneal arcus
What looking for in mouth abdo
Glossitis Angular cheilitis Ulcers Odour Oral candidiasis
What causes nails to go blue
Wilsons- blue lunalae
Important chest signs abdo
Gynaecomastia
Hair loss
Spider naevi
What looking for in abdomen inspection abdo
Scars Distension Caput medusa Striae Cullens and grey turner Hernias Stomas
Scars for abdomen
Kochers- gall bladder surgery Lanz and gridiron- appendicectomy Mercedes benz- liver transplant Midline- laparotomy Hockey stick scar (rutherford morrison)- renal transplant Pfannenstiel- gyane procedure
What is rebound tenderness
When letting go after palpation hurts more than palpating that area to begin with
How to listen to aortic bruit
Just superior to umblicus
How to present an abdo examination
Today i carried out an abdominal examination of x he seemed comfortable at rest with no medical paraphenlia around the bed
On examination of the hands and face there were no peripheral stigmata of abdominal disease
His pulse was x, rr x and bp x
His JVP wasnt raised
On palpation of the abdomen it was soft non tender with no organomegaly
the abdominal aorta was pulsatile and non expansive
on auscultation there were no bruits and bowel sounds were present and normal
In conclusion this was a normal abdominal examination
To complete my examination id like to take a full history, examine the hernial orifices and external genitalia, do a DRE and get a urine dip
What looking for general inspection neuro
Medications Walking aids Slings Feeding status Facial droop
What looking for closer inspection of neuro
Wounds Scars Wasting Fasiculations Fibrillations Dyskinesia
What causes hypotonia
LMN lesion
Cerebellar lesion
What causes hypertonia
Lead pipe and cog wheel rigidity
UMN spasticity
What is 1 on power
Fasiculation
What is 2 on power
Move with gravity eliminated- eg move from side to side on bed
What is 3 on power
Able to move against gravity but not with resistance
What is 4 on power
Able to move weakly against gravity
What do if notice sensory loss in a finger for example
Move up the finger and determine point at which senosry loss
What to look for in lower limb examination
Ulcers
Fasicualtions
Wasting
Walking aids
How to assess tone of ankle when assessing tone in hips
Look at ankles and see if foot follows the leg exactly or is slightly delayed
How do babinksis
Go from sole to big toe
Dermatomes for leg
L1- top part of leg anteriorly L2- middle of thigh anteriorly L3- on top of the knee L4- anteromedial leg L5- just above 3rd toe S1- lateral part of foot
Social history qs must ask
Drinking Smoking Drugs Living situation Job Activity level
Risk factors for cardio to ask
DM HTN High cholesterol Fhx Diet and exercise
SOCRATES extra qs for chest pain
Painful to touch? Eased by GTN spray? Eased by antacids? Worse when breathe in? Worse when eat?
Systems review for cardio
Chest pain SOB How many pillows sleeping with at night? Ever wake up gasping for air? Fainted? Palpitations? Leg swelling or pain?
Resp system review
SOB? How many pillows at night? Ever wake up gasping for air? Cough? Wheeze? Chest pain?
Abdo system review
Oral ulcer Dysphagia N&V Pain on eating Any tummy pain Discolouration of skin Itching Diarrhoea Constipation Change in colour of stool Change in habit Any blood in stool Problems with the water works Going more often Change in colour
Chest pain system review
Full cardio Full resp Nausea Sweating Pain worse after meals Pain worse lying down
Pleuritic chest pain risk factor questions
Any lung problems in past or currently Recent travel Recent surgery Recent illness Leg swelling
Imperial flaws must ask
Fever Tired Weight loss Appetitie Wake up in morning drenched in sweat Skin changes
Questions to ask about SOB
Sob at rest or on exertion? Currently how far can walk without getting SOB on flat surface Before this started same thing Worse lying down? How many pillows do you sleep with? Exposure to anything make it worse Are you more tired
What to do in SOB history if ask someone about tiredness and say yes
Go straight to flaws
Systems review in SOB
Full cardio Full resp Coughed up any sputum Weakness in limbs Eye problems Blood in stool or urine THEN FLAWS if not tired
What is relevant in PMH resp
Lung illness
TB
Rheumatoid
What is relevant in drug history of resp
Allergies to everything
Vaccinations
What is relevant in fhx resp
Allergies
Lung problems
What is relevant in social history resp
Smoking
Travel
Occupation
Pets
Questions to ask for cough
When start? Is it productive? Is it always there? Any blood? Does anything trigger it youve noticed such as animals What does it sound like?
Questions for productive cough
How much?
What colour?
Ever blood?
After cough waht question do ask?
Do you have a fever?
Systems review for cough
Full resp
Full cardio
Pain on eating
FLAWSS
Risk factor Qs for cough
Pets
Job
Smoking
When have chest pain what is first 2 questions to ask
Pain to touch it
Painful when breathe in or cough
Have had it before
Questions to ask for diarrhoea
How long has it been going on How many times a day do you have it Since it started has there been a change to the consistency Is it painful What colour is the stool Ever black, pale or have blood in it Does it wake you up at night Does it come on urgently Does it flush easily Do you feel like you always empty your bowels Have you started any medications recently What is your diet like
First 2 questions for diarrhoea in systems review
Pain
Nausea and vomiting
Questions to ask for jaundice
When did it start Is it always there Is it getting worse Where have you noticed it Noticed change to colour of stools Noticed change to colour of urine Any itching Are you feeling tired or short of breath
Questions to ask for palpitations
How often does it happen How long do they last Does it feel regular or irregular Do you feel lightheaded when it happens Do you get chest pain or sob Do you feel anxious when happens Are you feeling more anxious than normal recently about something thats coming up Do you drink caffeine or alcohol This is an uncomfortable question but do you take any recreational drugs
Important additional socrates points to add in through headache history
Onset- did it come on suddenly Character- has this changed at all radiation- to jaw Timing- is it always there, worse in am Exacerbating factors- does coughing make it worse, combing hair or eating Severity- does it affect your daily life
Risk factor questions for ALL headache
Anything like it in the past
Have you hit your head or noticed any bruising
Before it starts do you have any warning its going to happen such as seeing things
Anything trigger it like chocolate, cheese
Nausea
Neck stiffness
How are you with bright lights
Runny nose
FLAWSS
Neuro system review
Any fits Fainted LOC Dizziness Problems with vision Facial droop Problems with speech or swallowing Weakness in legs or arms Tingling or numbness Incontinence of any type
Gastro systems review
Ulcers in mouth Dysphagia Pain on eating Any tummy pain Jaundice Itching Swelling of tummy Constipation Diarrhoea Blood in stool Problems with weeing such as blood or going more often Changes to smell
Management to prevent further SVTs
Ablation
B blockers
How are varicose veins managed
Depends on severity, only if very severe do operate
Normally lifestyle
How are varicose veins managed conservatively
Exercise
Leg elevation
Compression stockings
Lose weight
How to do breast exam station
Introduce self
Confirm name and DOB
State going to ask a few questions then examine your breast which will involve me inspecting them and then placing my hands on it to assess the tissue is that alright
For the purpose of the exam you will need to take off your bra, i understand this can be uncomfortable so the examiner will act as a chaperone
Are you in any pain today
Also for the purposes of the examination youll be required to be sat back at 45^
Whats brought you in today
QUESTIONS ELSEWHERE
Ok so now I’m going to move on to examine the breast so ill pop out of the room whilst you get unchanged thank you
Inspect at rest
Ask to put hands on head and lean forward
Ask to push hands into waist
Assess in circular motion starting from nipple and feel the axillary tissue too
Go back to assess lump at end
Squeeze nipple
Do lymph nodes by lifting up arms and you taking all the weight
Thank patient and let them get dressed
Questions to ask about breast lump
When did you first notice it Is it getting bigger Is it there all the time Where exactly is it Have you tried feeling it Is it painful+ to touch Any skin changes Any nipple discharge To the best of your knowledge are you pregnant
Questions to ask for breast pain
SOCRATES * ask about cyclical nature Any lumps Any skin changes Any discharge from the nipple To the best of your knowledge are you pregnant
Questions after HPC to ask everyone with breast pain or lump
Pregnancy When was your last period When was your first period Have you ever had children If so did you breastfeed them FLAWS Back pain, SOB, Headaches Smoking Family history of breast problems ICE!!!!!
HF with unidentifiable cause in history
Valvular disease
What is ABPM cut off for stage 2 HTN
150/95
Target BP for over 80s
145/85
What looking for in PR interval
Short equals WPWS
Long equals HB
Pericarditis if depressed
What is normal PR
120-200
What is normal QRS
80-100
What is normal QT interval
400-440
What to say when presenting CXR
This CXR is not rotated, taken in inspiration, adequate exposure and well penetrated
The trachea isnt deviated, the lung fields appear clear with no pleural thickening, hilar region shows no abnormalities
Looking at the heart it is not enlarged and located centrally with good visualisation of the left and right heart border. The aortic knuckle is visible with no enlargement of the mediastinum
Costophrenic angles are visible and the diaphragm shows no pneumoperitoneum
There is no obvious bony abnormality or soft tissue lesions
To summarise these are my positive findings and my differentials are
When explaining a procedure what are key parts to include
What the procedure is
Reason for it
Before during and after
Risks
Explaining a colonoscopy
Good morning ive been asked to come and have a chat with you to explain your colonsocopy thats coming up
Do you know why you’re in today
What brought you to go to doctor in the first place
What do you understand about a colonoscopy from what you’ve been told so far
ICE
What the procedure is
- it involves passing a small flexible tube through your back side which has a camera in, this camera is the best way for your doctor to see whats going on then also can take a few cells to look at under microscope
Reason for it
- help find the reason for whats been going on- find a source of your…. that’ll best allow the doctor to manage the problem*** match to why presented
What goes on before
- you’ll recieve a leaflet letting you know that 2/3 days before can only eat plain food
- 1 day before only clear fluids and laxatives to completely clear the bowel and make the insides very clear to the doctor
- NBM a few hours before
What goes on on day
- can someone drive you?
- this can be up to you on the day they can give you painkillers, gas or a sedative to help you relax
- during the procedure some air will be passed through camera which may make you feel a bit bloated or like you need to go toilet
- then the procedure should last about 30 mins it can give you some tummy pains but again there are pain killers to help you relax
What about after
- someone will have to drive you home
- avoid alcohol or machinery
- follow up will be arranged
Risks very small risk of perforation- 1 in 1000
Can feel uncomfortable in tummy
How to classify weght loss causes for OSCE
Cancer
Infective
Gastro
Endo
Infective causes of weight loss
Endocarditis
TB
Hepatitis
Gastro causes of weight loss
Coeliac Peptic ulcer IBD Cancer NAFLD Chronic pancreatitis
Endo causes of weight loss
Addisons
DM
Hyperthyroid
How to do weight loss history
Weight loss
- how much and for how long
- any changes to lifestyle which could have contributed
FLAWSS, joint pain, muscle aches, weakness and how has mood been recently
Anything else you’ve noticed, any new pains?
Then questions listed elsewhere
After FLAWSS and has anything else been going on what quesitons should ask in weight loss
Tummy pain Diarrhoea Change to bowel habits Change in colour of stool, blood? Change to waterworks? Going more often Blood in urine Going more often Thirsty? FULL systems review
Weight loss in fat person with loads of rfx
NAFLD
Questions for haemoptysis
Establish if actually haemoptysis When started How many times has it happened Getting worse What did you bring up- streaked on sputum or frank blood? Colour How much do you think it was
How to do haemoptysis history
Haemoptysis questions Blood in urine Cough at same time? Resp and cardio systems review DVT risk factors
DDx for haemoptysis
PE TB Cancer Bronchiectasis Abscess- staph aureus, klebsiella, TB COPD Recent bronchoscopy
PMH asthma and has noticed getting worse
ABPA
How to do back pain history
SOCRATES in particular - worse at any time in day - how does exercise affect it - walking uphill easier Then ask about - stiffness - recent trauma - any other joint pain Neuro systems review FLAWSS and recent ilnesses Risk factors - immuno suppression like steroids - history of cancer
Back pain ddx
Spinal canal stenosis Cancer mets, meyeloma Trauma Seronegative spondyloarthropathies Abdominal aortic aneurysm CES GBS Oesteomyelitis Muscular sprain
How to do syncope history
How are you feeling now, did you hurt yourself when fell Did someone witness it Have you hit your head recently Before - what were you doing at time - was there any warning symptoms palpitations, weird feelings During - how long did it last - can you remember it - did you shake, tongue biting, incontinent After - how long did it take for you to return to normal - confused - arm weakness - face flushing ICE Neuro and cardio systems review FLAWSS and recent illness
Back pain with fever differentials
Transverse myelitis
Osteomyelitis
Abscess
Potts disease
Questions for limb weakness
Where is it
Clarify if actually weakness or pain/sensory
How is it affecting your life/ to what extent (depending on onset)
Anything happen before it
When start
Getting better or worse
Is it always there
Is it worse at any particular point in the day/ noticed anything particular times when its worse/ anything make it worse or better
Ever noticed it before
How to do limb weakness history
Limb weakness questions Any headache, back or neck pain Trauma SOB Diabetic Neuro system review FLAWSS and recent illness
Unilateral weakness
Stroke/TIA SOL MS MND Todds paresis Hypoglycaemia Migraine Radiculopathy
Weakness with headache
Migraine
SOL
Differentials for dysphagia- functional
MS MG MND Stroke Achalasia CREST Oesophageal spasm diffuse and nutcracker
Differentials for dysphagia- obstructive
Pharyngeal and oesophageal cancer Plummer vinson Zenckers diverticulum Benign stricture from GORD Lung cancer GOITRE Oesophagitis
Questions for dysphagia
When start
Is it getting worse
Is it there every meal
Is it painful
What do you mean by difficulty swallowing is it you feel gets stuck or trouble initiating that movement
Is it to both liquids and solids or just to one of them
Anything make it better or worse
Extra dysphagia qs to ask
Bring up food or vomit Change to voice or hiccups Bad taste in mouth Neck swelling Cough Pain on eating SOB/haemoptysis
How to do dysphagia history
Dysphagia questions(291)
Extra dysphagia questions(292)
Neuro and gastro systems review
FLAWSS and recent illnesses
Questions for PR bleeding
When first happen Ever happened before How many times What colour How much Is it mixed in/streaked or on wiping Painful Is it itchy Mass in anus or skin changes Tenesmus Diarrhoea Constipation Change in bowel habits Diet?
How to do PR bleeding history
PR bleeding (294) Tenesmus Diarrhoea Constipation Change to habits ABDO REVIEW FLAWSS and recent illness
DDx for epigastric pain
Vascular - inferior MI - AAA Pancreas - pancreatitis - cancer Stomach - GORD/Hiatus hernia/Barretts oesophagus - ulcer/gastritis - cancer - functional dyspepsia - boerhaves Biliary - cholecystitis/cholangitis
Questions to make sure ask in SOCRATES epigastric pain
Pain related to eating
Radiate to back?
Relieved by ant acids?
How to do epigastric pain
SOCRATES Nausea and vomiting Sweating Lightheaded Bad taste in mouth SOB Cough Abdo systems review FLAWSS- recent illness
How to do any IF pain
SOCRATES- mainly has pain always been there Diarrhoea Constipation Blood in stool Going to wee more often than not Nausea and vomiting If woman could be pregnant Abdo review and diet FLAWSS and recent illness
Ddx for LIF gastro
Colorectal cancer Diverticular disease UC Gastroenteritis Pseudomembranous colitis Sigmoid volvulus
DDx for RIF gastro
Mesenteric adenitis Appendicitis Crohns Caecal volvulus Caecal cancer
DDx for any IF
Ectopic pregnancy AAA Ovarian cyst/fibroids UTI Stone
Questions for constipation
What mean by constipation(less often or hard to go) How long been going on for Getting worse Always there Consistency of stool Colour Ever any blood Passed wind Painful?
How to do constipation history
SOCRATES questions Tummy pain Diarrhoea Nausea and vomiting Going to toilet more often (wee) Back pain Feeling cold Weakness TIngling Balance Abdo review Diet- fibre and water? FLAWSS and recent illness
DDx for constipation categories 3
Obstruction
Functional
Dont want to push
Obstruction causes of constipation
Cancer
Obstruction
Diverticular disease
Dont want to push causes of constipation
Haemorrhoids
Fissure
Abscess
Fistula
Functional causes of constipation
Post op Metabolic- K, Ca, Mg Hypothyroid IBS Opiods
Drugs causing diarrhoea
Metformin
Colchicine
Thiazides
Abx
How to do diffuse abdo pain
SOCRATES - have you had pain in tummy before - does it hurt to move Constipation Diarrhoea Wee more often Abdo review FLAWSS and recent illness
DDx for vertigo
Meniers BPPV Vestibular neuronitis Stroke/TIA Migraine Cerebellar MS or cancer Acoustic neuroma
Questions for vertigo
Tell me what you mean by vertigo When start Is it always there Is it getting better Does it come on when stand up or turn head Do you feel light headed
How to do vertigo history
FOOTH Fullness in ear Nausea and vomiting Neuro systems review FLAWSS and recent illness
FOOT HD
Facial weakness Otorrhoea Otalgia Tinnitus Hearing loss Dizziness
DDx for acute vision loss
TIA Uveitis Papilloedema Optic neuritis GCA Migraine Acute glaucoma
Questions for acute vision loss
Both eyes? How quickly did it come on Happened before Painful Vision loss Change in appearance or discharge
How to do vision loss history
Modified socrates
Headache
Systems review
FLAWSS and recent illness
Questions for abdo distenstion
Whole abdomen or one particular point? When start, getting worse? Anything like it before? What does it feel like? Painful? To touch? Skin changes? Swelling anywhere else?
How to do abdomen distension history
Whole abdomen or one particular point? When start, getting worse? Anything like it before? What does it feel like? Painful? To touch? Skin changes? Swelling anywhere else? Bruising? History of liver, kidney or heart disease Pain on eating Chest pain SOB Abdo systems review FLAWSS and recent illness
DDx for haematemesis
Variceal bleed Mallory weiss tear Cancer of oesophagus Stomach cancer Ulcer thats bleeding Gastritis Oesophagitis
Haematemesis with history of pain on eating
Ulcer
Oesophagitis
Haematemesis with history of dysphagia
Oesophagitis
Oesophageal cancer
How to do haematemesis history
When first happen Ever happen Before How many times happen What colour Quantify What doing at the time Change to colour of stool
Haematemesis history
Liver disease history Pain on eating in past Bad taste in mouth Dysphagia Do you drink Other nausea and vomiting Abdo systems review FLAWSS and bad taste in mouth
Questions for nausea and vomiting
When start How many times Happened before Getting worse? What bringing up- digested or undigested food, green or any blood Colour How much How long after eating Worse at any point in day Headache Dizziness SOB Headache Tummy or chest pain Abdo review FLAWSS and recent illness
