OSCE Stations C - Part 1 Flashcards
OSCE C: Abdominal pain
[Q: DDx?]
[Q: Management?]
where is abdominal pain
rapid or gradual pain
migration of pain
duration of pain
pain exacerbated by:
…meals
…coughing
…straining
pain relieved by:
…analgesia
…laying down
bone pain
previous episodes
appetite
vomiting
change in bowel habit
B-Sx:
…fevers
…night sweats
…weight loss
rigors
PMHx
DHx:
…OCP
[Q: DDx?]
acute appendicitis
pancreatitis
gastroenteritis
pyelonephritis
ectopic pregnancy
ovarian torsion
ovarian cyst
ascending cholangitis
biliary colic:
…exacerbated by meals
…transient pain (1 hour)
[Q: Management?]
FBC
CRP
U+E
LFT
serum beta-HCG:
…pregnancy
serum amylase:
…pancreatitis
urinalysis:
…septic pyuria
blood culture
coagulation profile
group and save
abdominal USS:
…gynaecological pathology
transvaginal USS:
…gynaecological pathology
erect CXR:
…subdiaphragmatic air for perforation.
NBM
IV fluid
analgesia
Tx Acute appendicitis:
…laparoscopic/open appendectomy.
Tx cholecystitis:
…cholecystectomy.
OSCE C: Abdominal pain - pregnancy
[DDx?]
patient age
foetal age
foetal movement
EBL
cause of blood loss:
…sex
…trauma
…violence
placenta position
previous pregnancy:
…hyperemesis
…delivery
…post-partum complications
…miscarriages
…terminations
smears:
…recent
…results
urinary Sx
bowel Sx
vomiting Sx
B-Sx:
…weight loss
…fever
…night sweats
PMHx:
…hypertension
…pre-eclampsia
DHx:
…medications prior to pregnancy
…medications during pregnancy
FHx
SHx:
…drugs
[DDx?]
concealed placenta abruption
OSCE C: Alternative treatment
current diagnosis
why refusing
coerced or own decision
discuss with:
…family and friends
…diagnosis
…opinions
…work
how Tx works, e.g. chemotherapy.
side effects
may not suffer side effects.
alternative Tx may work but less evidence.
patient should weigh up options.
discuss a compromise.
alternative methods.
OSCE C: Angry patient
allow patient to vent anger.
accept responsibility.
apologise for mistake.
explain how mistake could have arisen.
offer to alleviate patient’s dissatisfaction.
mistake can be prevented in future:
…e.g. highlight allergy in Kardex.
…e.g. anti-histamines + steroids to relieve rash.
PALS complaint procedure:
…patient and liason service.
doctor will submit a Datex.
course of action.
OSCE C: Anorexia nervosa
[Q: DDx?]
[Q: Next steps?]
|NB: don’t forget there is OSCE A: Eating disorder|
pattern of eating habits
‘what do you think of your body?’
‘what is a normal weight?’
triggers:
…triggers
…stressors
…life events
fear of fatness
binging
exercise
loss of concentration
loss of libido
depression:
…mood
…energy
…enjoyment
…appetite
…sleep
physical signs:
…cold
…dizzy
…weakness
…thin hair
…nausea
…vomiting
…diarrhoea
period:
…amenorrhoea
suicide:
…self harm
…suicidal ideation
insight
PMHx
DHx:
…steroids (depression)
…levothyroxine
…orlistat
…laxatives
FHx:
…psychiatric disorders:
……eating disorders
……depression
……bipolar
SHx:
…impact on social life.
…drugs
[Q: DDx?]
anorexia nervosa
bulimia
[Q: Next steps?]
ask for a consultation with spouse/mother:
…educate about eating disorder.
FBC:
…anaemia
CRP
U+E:
…electrolyte imbalance.
LFT
serum iron:
…IDA
serum ferritin:
…IDA
serum cortisol:
…Cushing’s syndrome
TFT:
…hypothyroidism
FSH and LH:
…ovulation.
ECG:
…electrolyte imbalances causing arrhythmia.
referrals:
…individual psychotherapy
…family psychotherapy
SSRI:
…depression
anti-psychotics:
…low-dose
…anxiety
follow-up:
…regular monitoring
…mood state
…suicidal ideation
OSCE C: Ante-partum haemorrhage
[Process]
[Q: DDx]
[Q: r/f of placenta praevia]
[Q: Tx APH]
[Process]
patient age*
fetal age*
domestic violence*
pain (no, painless)*
trigger* e.g. sex, trauma (none)
estimated blood loss*
estimated due date
fetal movement*
smears*
trigger:
…sex
…penetration by fingers
…surgery
previous APH/PPH
any previous pregnancies*
any previous caesarean sections*
previous ultrasound scans:
…placenta position
blood info:
…ABO group
…Rhesus
pregnancy:
…patient previous pregnancy*
…patient’s partner previous pregnancy*
…termination
…miscarriages
PALT:
…pre-term births
…abortions
…living now
…term births
state sum of PALT
PMHx:
…bleeding disorder
…cervical screening
…UTI screening
…pre-eclampsia
DHx
FHx:
…bleeding disorder
SHx:
…drugs
…domestic abuse
…
[Q: DDx]
placenta praevia
vasa praevia
placenta accreta
placental abruption
ectropion
ectopic pregnancy
cervical carcinoma
cervical polyps
cervicitis
[Q: r/f of placenta praevia]
multiparity
previous c-section
fibroids
smoking
old maternal age
multiple pregnancy
[Q: Tx APH]
admit patient
raise legs
catheterise:
…aim UO>30ml/h
discuss domestic violence
smears
ABCDE
IV access
IV fluid
OTT 15L mask with reservoir
emergency cross match 6 units of packed RBCs
blood transfusion
if Rh -ve mother:
…anti-D prophylaxis
vitamin K
tranexamic acid
expose patient
look for bleeding
if PV bleeding…:
…do not perform digital PV examination
……(may provoke further bleeding, e.g. placental praevia)
if placenta praevia:
…do not do digital vaginal exam.
…do ultrasound first.
coagulation profile:
…thrombophilia
transvaginal USS:
…for diagnosis.
…exclude placenta praevia.
abdominal USS:
…for diagnosis.
speculum exam:
…for diagnosis.
O/E abdomen (obstetrics):
…|ABCDE U DUCK vagina: ABCDE, uterus, DDx, USS, CTG, Koagulation profile, vaginal bleeding|
…firm uterus: placental abruption
CTG
call obstetrician
cal anaethetist
reassess ABCDE
OSCE C: Arthritis
[Q: DDx?]
[Q: Next steps?]
symptoms
symptom duration
trigger
joints:
…pain
…swelling
…stiffness
…distribution:
……single joint
……small joints
……large joints
…diurnal variation
…lumps:
……rheumatoid nodules
……Bouchard’s nodes
……Heberden’s nodes
better or worse:
…heat
…cold
…activity
trauma:
…can cause OA.
red eyes
reduced tear production:
…Sjogren’s syndrome
eye dryness:
…Sjogren’s syndrome
mouth dryness
mouth ulcers
genital ulcers
B-Sx:
…weight loss
…fevers
…night sweats
rigors
recent infection
appetite
nausea
vomiting
diarrhoea
neurological Sx
affect on life:
…ADLs
…employment
…household chores
…depression
[Q: DDx?]
RA
OA:
…OA
…OA secondary to trauma.
septic arthritis
crystal arthropathy
gout
pseudogout
[Q: Next steps?]
FBC
CRP/ESR
U+E:
…phosphate
…magnesium
LFT
anti-CCP antibodies
TFT
rheumatoid factor:
…RA
ANA:
…SLE
anti-Ro:
…SLE
anti-La:
…SLE
HLA-B27:
…ankylosing spondylitis
XR hands:
…RA, OA, PA
XR lumbar spine:
…ankylosing spondylitis
light microscopy of joint aspirate.
parotid gland biopsy:
…focal lymphocytic aggregation:
……Sjogren’s syndrome
slit-lamp examination:
…keratitis of eye:
……Sjogren’s syndrome
exercise
physiotherapy
occupational therapy:
…aids
…splints
manage cardiovascular risk factors as atherosclerosis is accelerated in RA:
…anti-hypertensives
…statin
smoking cessation
reduce weight
referral to rheumatology
NSAID for pain
steroids
DMARD
infliximab
intra-articular steroid injection.
hydroxychloroquine
joint replacement:
…for severe OA.
OSCE C: Asthma
[Q: DDx?]
[Q: Next steps?]
‘Do you feel breathless now?’* (rw)
symptoms:
…symptoms
…onset
…duration
…progression
cough:
…frequency
SHREWDS:
…sputum:
……volume
……colour
……normal sputum amount
……normal sputum colour
…haemoptysis
…relieving factors
…exacerbating factors
…wheeze
…discharge
…sneeze
normal exercise amount:
…stairs
…straight road - e.g. 100metres.
infectious contacts
immunisations
pregnancy:
…preterm
…spontaneous vaginal delivery
…illness of mother
birth:
…birth weight
…birth condition
…delivery complications
…illness of baby
developmental history:
…weight
…height
…milestones
…gross motor
…fine motor
…vision
…hearing
…social
systemic enquiry:
…cardiovascular:
……sweating
……cyanosis
……pallor
……SOB
…respiratory:
……cough
……wheeze
……snoring
…gastrointestinal:
……appetite
……diet
……vomiting
……pain
…neurology:
……headaches
……fits
……weakness
…musculoskeletal:
……limp
……limb pain
……joint swelling
PMHx:
…diet
DHx
FHx:
…atopy
SHx:
…siblings
…parents job
…school
…hobbies
…pets
…second-hand smoke
[Q: DDx?]
asthma:
…asthma
…episodic viral associated asthma.
lower respiratory tract infection.
viral illness
allergic rhinitis.
[Q: Next steps?]
peak flow meter:
…peak expiratory flow rate.
asthma attack:
…ABCDE
…OTT:
……SpO2 > 94%
…SPRIMTh
…theophylline
…hydrocortisone IV
…IV magnesium sulphate
OSCE C: Bipolar affective disorder + Schizophrenia
[Q: DDx?]
[Q: Tx?]
|NB: Same history as depression|
‘anything in particular worrying you?’
previous episode
loss of concentration
loss of emotion
loss of libido
mood:
…energy
…enjoyment
…appetite
…weight gain/loss
…assess affect
sleep:
…trouble falling asleep
…loss of sleep
…coffee before bed
…bed early
…wake up early
…duration
caffeine:
…coffee
…energy drinks
alcohol
nihilism:
……(rejection of religion and beliefs,
…belief that life is meaningless).
delusions
hallucinations
suicidal thoughts:
…self-harm
…suicidal ideation
thoughts of harming other people.
PMHx:
…depression
…BAD
…schizophrenia
DHx
FHx
SHx:
…work:
……stress at work
……absences
……drugs
……educate colleagues about BAD/schizophrenia.
[Q: DDx?]
BAD - manic/depression episode.
cyclothymic disorder
schizophrenia
drug-induced
[Q: Tx?]
on-call psychiatrist:
…needs admission as having an acute manic episode.
admit under the mental health act.
during admission:
…anti-psychotic drugs.
…sedation.
blood tests
urinalysis
drug-screen
Care Programme Approach:
…key worker
…care plan
OSCE C: Blood transfusion reaction
[Q: Next steps?]
patient understands condition
patient understands need for blood transfusion.
symptoms:
…symptoms
…onset
…duration
…pain
…resolving
B-Sx:
…night sweats
…fever
…weight loss
rigors
flank pain
allergies
explain:
…patient had a reaction to a blood transfusion.
…it is called an ‘acute haemolytic transfusion reaction’.
…antibodies attacking RBCs.
…due to poorly matched blood.
reassure:
…patient will be monitored.
…unlikely to be fatal.
…transfusion was terminated immediately.
…alert nurses if further deterioration.
…report Sx:
……jaundice
……haematuria
……syncope.
[Q: Next steps?]
instruct nurse to:
…check patient details for clerical error.
…blood bank labels for clerical error.
…not to throw away any tubing.
…return documentation to blood bank for checking.
look at bag:
…expiry
…clots
…imperfections
IV fluid
repeat blood culture
repeat group and save
FBC
U+E
CRP
LFT
monitor UO:
…hourly
…observe for haematuria
furosemide (consider)
Datex
OSCE C: Breaking bad news
relative would like anybody else present.
warning shot - ‘It’s bad news I’m afraid’.
give bad news.
silence.
feelings
concerns.
how much information do you want now?
diagnosis
prognosis:
…e.g. full recovery with physiotherapy
referral to specialist.
further investigations.
treatment options.
time to recover.
hospital stay.
discuss news with family.
offer counselling.
follow-up
leaflet
doctor offers department contact details for emergency or further questions.
OSCE C: Breaking confidentiality (driving)
occupation, e.g. bus driver.
patient is still driving
continue to drive:
…illegal
…prosecution
…endanger others if seizure
…car insurance may not cover.
must be seizure free for 1 year or only having seizures during the night for 3 years.
bus driver must be seizure free for 10 years.
acknowledge it is difficult for patient.
discuss with family and friends.
opinions of family and friends.
disclose to the DVLA.
medical team will talk to DVLA.
public safety at risk then confidentiality can be broken.
comply with medication to become seizure free.
discuss why medications are not being taken.
patient to discuss health matters at work.
alternative role at work.
OSCE C: Breast lump + nipple discharge
[Q: DDx?]
[Q: Next steps?]
pain
bone pain
previous occurrence
when first noticed
current size
increasing in size
recent trauma
nipple discharge:
…unilateral
…blood
…quantity
NIPPLE:
…noticed
…imaging: MMG (>35yo), CXR, MRI, FNA
…presentation:
……DUDE (dimpling, ulcer, discharge, eczema)
……unilateral/bilateral
……inverted, everted
…partition:
……# children
……age of first
……FHx childrenless
……period
……menarche/menopause
…lump: PC SEALS (pain, consistency, size, edge, attachment, location, shape)
…everything else:
……BOTH:
………(breast fed, OCP, HRT, trauma)
lymphadenopathy (axiliary)
THIS LUMP:
…tender (or painful)
…hot
…increasing in size
…size
…location
…uniform colour
…mobile
…pulsatile: aneurysm
……
period:
…LMP
…regular
…tampons used
…pain after sex
…bleeding after sex
…menarche/menopause
gynaecomastia
sexual dysfunction
urinary dysfunction
change in bowel motions
infertility
B-Sx:
…fever
…night sweats
…weight loss
PMHx:
…surgery
…radiation
…HRT
…oestrogen
DHx
FHx
SHx
[Q: DDx?]
lump:
…breast cancer
…simple cyst
…papilloma
…fat necrosis
…fibroadenoma
…abscess
…lipoma or sebaceous cyst
…phyllodes tumour
nipple discharge:
…intraductal papilloma
…duct ectasia
…breast cancer
[Q: Next steps?]
triple assessment:
…history
…examination
…imaging
O/E breast: (describe PC SEALS) no lump->lump->painful
…no lump: consider DCIS
…hard, non-tender lump: assume breast cancer until proven otherwise
…larger tender lump: breast cyst
…lump in inframammary fold in mid-clavicular line: accessory nipple
abdomen examination:
…metastases
lung examination:
…metastases
nipple discharge:
…cytology
…magnetic resonance galactography
USS breast:
…age<35yo
MMG:
…age>35yo
…(MMG = More than 35yo)
…microcalcification (DCIS)
…Normal: duct ectasia (produces discharge, no breast lump)
sentinel node biopsy
FNA/Core biopsy:
…tumour size
…tumour grade
…completeness of excision
…vascular invasion
…lymph node involvement
…other: HER2 status, steroid receptor status.
biopsy grading:
…tubules
…pleomorphism
…mitoses
biopsy histology:
…myoepithelial layer present
…acini present
…fibrosis present: fibroadenoma
…columnar epithelium: ductal papilloma
…signet ring cells: invasive lobular carcinoma
…dense collagenous stroma: invasive ductal carcinoma
CXR:
…metastases
CT chest abdomen pelvis:
…staging
MRI
bone scan:
…matastases
BRCA1/BRCA2: (BReast CAncer)
…ductal adenocarcinoma
ER/PR status
Bloom-Richardson grade
FISH:
…(florescence in-situ hybridisation)
…HER2 status
Allred score:
…Percentage of cells that have hormone receptors.
if HER2 positive:
…herceptin
if ER positive:
…tamoxifen
if cyclical mastalgia…:
…primrose oil
…tamoxifen
if bacterial mastitis…:
…flucloxacillin
if galactocele…:
…aspiration
if abscess…:
…abscess
if fibrocystic change…:
…NSAID
chemotherapy:
…doxorubicin
radiotherapy
wide local excision with axillary sampling/clearance
mastectomy with axillary sampling/clearance
OSCE C: Breech pregnancy
pregnancy:
…complications
…delivery method
…pain
USS fetus:
…recent USS results.
…do you realise the baby is in breech?
…do you understand what breech means?
external cephalic version:
…ECV is required
…explain procedure
…contra-indications:
……fibroids
……placenta position
……ante-partum haemorrhage
……premature rupture of membranes
…if pregnancy is high-risk:
……ECV is still possible.
…ECV is not always successful.
…50% chance of ECV failing or baby returning to breech position.
…if EVC fails or patient refuses:
……c-section at 38 weeks.
if patient goes into labour:
…must go to hospital immediately.
…risk of cord prolapse.
previous breech fetus.
OSCE C: Capacity to accept treatment
understand current situation
understand implications of treatment
understand risk of refusing treatment
understand alternative options to treatment
retain information for long enough
decision of treatment
justify reason for decision
acknowledge patient’s right to refuse treatment
express a wish to test patient’s mental state.
summarise:
…patient does/doesn’t have capacity.
…justify reason:
……confused.
……unable to balance risks/benefits.
……unable to understand Tx.
OSCE C: Capacity to refuse treatment
patient understands situation
discuss reasons behind situation
why refusing?
social circumstances
home life
support available:
…counselling for depression
…care home to alleviate family stress.
…treatment is safe.
…no safe alternatives.
refusal of medical help will slowly result in death.
risk of xTx vs benefits of continuing Tx.
explore:
…mental health
…emotions
…feelings with spouse.
…feelings with family.
request to test mental state.
not a mental health issue, so cannot detain under the Mental Health Act.
OSCE C: CBT explanation
patient reason for CBT
patient understanding of CBT
previous therapies tried
previous medications tried
CBT:
…talking therapy
…useful for range of disorders:
……eating disorder
……depression
…focuses on:
……current state of affairs
……not the past
……different ways of problem solving
……different ways of thinking about issues.
…may get practical.
…may involve homework.
…length of time is not fixed.
…number of sessions is not fixed.
…tailored to patient needs by therapist.
…duration:
……e.g. mild anxiety, mild OCD, = normally 1-3 months.
what patient can hope to benefit.
anti-depressants can still be continued.
therapist is fully trained…:
…psychiatrist
…psychotherapist
…mental health counsellor.
therapist is bound by confidentiality unless risk of harm to self or public.
…
OSCE C: Cervical smear results
smear:
…recent
…results
understand what dyskaryosis means.
dyskaryosis:
…means abnormal cells.
…potentially pre-cancerous cells
…i.e. ‘CIN’ (cervical intraepithelial neoplasm).
…diagnosed by biopsy.
…need to identify CIN to decide removal.
…require colposcopy to do this.
colposcopy:
…what patient understands.
…book a date not on your period.
…examination of the cervix.
…day case
…doctor or nurse specialist.
…sedation
…general anaesthetic not required.
…speculum
…colposcope (microscope) inserted into vagina.
…look at cervical cells in detail.
…colposcope does not enter vagina (i.e. like binoculars).
…long swab.
…2x stains applied.
…biopsy under LA.
…duration 20 minutes.
…can return to work same day.
…some bleeding is normal.
…some vaginal discharge is normal.
…bring sanitary pad.
…avoid tampons.
…avoid sex
…avoid vaginal creams.
…biopsy results available in a week.
…depending on biopsy results:
……diathermy
……laser therapy
……large excision
…link exists between Tx and pre-term labour. So if become pregnant, inform consultant so can be managed correctly e.g. cervical length scan.
OSCE C: Confidentiality
establish:
…reason for relative’s discussion with doctor.
…circumstances leading to relative’s queries.
…what they know about patient’s diagnosis.
anger underlying reason:
…frustration
…fear
…guilt
acknowledge relative’s feelings and concerns.
patient information is confidential.
right to privacy
respect patient’s wishes.
confidentiality applies to relatives, no matter how close.
disclosure would undermine the doctor-patient relationship.
doctors cannot give out personal information about the patient without consent.
doctors can only give out personal information when public health is at risk, however, this is not the case.
apologise for not giving out any information.
suggest that the relative talks to the patient.
offer to set up a meeting:
…with relative and patient.
…to discuss management.
…check relative is happy with this to go ahead.
…doctor still cannot divulge personal information.
…assistance for help, e.g. counselling.
relative-patient relationship.
approached patient.
negotiate a course of action.
OSCE C: Delirium tremens
[Q: Differential diagnosis?]
[Q: Next steps?]
CAGE
alcohol:
…type
…amount
…duration
…tolerance
…cravings
tremor
insomnia
panic attack
paranoia
hallucinations
nausea
low mood
seizures
abdominal pain
B-Sx:
…fever
…night sweats
…weight loss
rigors
recent infection
PMHx:
…pancreatitis
…alcohol-related admissions to hospital.
FHx:
…Alcohol use.
SHx:
…loss of partner.
…loss of employment.
[Q: Differential diagnosis?]
delirium tremens
[Q: Next steps?]
warn:
…patients with DT have a high mortality rate.
FBC:
…exclude co-existing infection.
U+E:
…deranged
LFT
coagulation profile
amylase:
…pancreatitis
BM:
…likely low.
ECG:
…exclude arrhythmia.
CXR:
…exclude PNM.
BDZ:
…e.g. reducing regime of chlordiazepozide.
pabrinex:
…thiamine to prevent Wenicke-Korsakoff syndrome.
vitamin B (PO).
consider ITU.
OSCE C: Depression
[Q: DDx?]
[Scoring]
[Ix]
[Tx]
‘anything in particular worrying you?’
previous episode
loss of concentration
loss of emotion
loss of libido
mood:
…energy
…enjoyment
…appetite
…weight gain/loss
…assess affect
sleep:
…trouble falling asleep
…loss of sleep
…coffee before bed
…bed early
…wake up early
…duration
caffeine:
…coffee
…energy drinks
alcohol
nihilism:
……(rejection of religion and beliefs,
…belief that life is meaningless).
delusions
hallucinations
suicidal thoughts:
…self-harm
…suicidal ideation
thoughts of harming other people.
PMHx:
…depression
…BAD
…schizophrenia
DHx
FHx
SHx:
…work:
……stress at work
……absences
……drugs
[Q: DDx?]
depression
BAD
seasonal affective disorder
[Scoring]
SAD PERSON:
…calculates suicide risk
Hospital Anxiety and Depression (HAD) scale:
…determine degree of anxiety and depression.
patient health questionnaire (PHQ-9):
…depression severity
DSM-IV criteria:
…(diagnostic and statistical manual)
…grades depression
…questions:
……loss of energy
……depression most of day nearly every day
……loss of weight
[Ix]
mental state examination (MSE)
[Tx]
determine suicide risk
determine risk to others
determine type of medication:
…suicide risk: no TCAs
…co-morbidities
…drug allergies
…previous response to anti-depressant therapy
…existing therapy
…interactions with current medications
fluoxetine (SSRI):
…inform patient that SSRIs take 2-6 weeks to take effect
…once feeling better, take for a further 6-9 months
if condition worsens:
…check compliance
…increase dosage
…lithium (mood stabiliser)
…mirtazapine (5-HT2 receptor blocker, caution with serotonin syndrome)
…venlafaxine (SNRI)
consider wash out time (time gaps) between medications
consider contacting others for long-term follow up:
…community psychiatric nurse
…psychologist
…GP
consider detaining patient:
…nurse can detain a patient for 2 hours .
…(or call police if they go missing so an emergency detention certificate can be issued).
…doctor has 1 further hour to examine patient.
…issue Emergency Detention Certificate to detain for 72 hours.
patient to bring spouse in for next consultation:
…to explain depression.
…explore couples counselling.
therapies:
…CBT
…interpersonal psychotherapy
…counselling
OSCE C: Diabetes
[Process]
|OSCE B:Diabetes + more stuff|
[Process]
*OSCE C*
how is diabetes control going so far?
previous hospitalisations
previous DKA
previous hypoglycaemic attacks
how frequently do you see the diabetic clinic?
how is…?:
…BP
…heart
…eyes
…kidney
…neurology
medication:
…doses
…insulin type
…insulin sites
…compliance
BM:
…results
…frequency
life-style:
…dirnking
…smoking
…diet
patient understands sick day rules:
…don’t stop insulin
…if ill…:
……increase insulin
……try and keep sugary drinks down if can’t eat
……see doctor early
life-events or triggers for poor diabetic control
alcohol intake
how alcohol affects blood sugar
patient understands pros and cons of diabetic control.
patient is confident in using insulin.
ask patient how diabetic control is going on a 1-10 scale.
explore how to achieve a higher scale.
*OSCE B*
weight gain
increase calorie intake
reduced exercise
explain diabetes:
…type I is insulin depletion.
…type II is insulin resistance:
……increased insulin resistance -> increased insulin synthesis -> hyperinsulinaemia -> repeats until B-cells burn out.
Sx:
…polydipsia
…polyuria
Complications:
…heart
…eye
…kidney
…feet
…nerves
strict monitoring
strict glucose control
*Investigations*
*Management*
stop smoking
exercise:
…(NICE guidelines)
…2.5 hours per week of moderate intensity (brisk walking)
…or…
…1.25 hours per week of high intensity (jogging).
weight loss:
…aim to lose 10% per year.
…calculate BMI
…aim for BMI of 18.5 to 24.5.
diet:
…high-fibre
…low sugar
…low fat
dietician
regular screening
capillary blood glucose
fasting blood glucose
oral glucose tolerance test
HbA1c
lipid profile
if hypercholesterolaemia:
…statin required.
if high BP:
…anti-hypertensive medications.
check for retinopathy:
…ophthalmology referral.
…retinopathy screening by accredited optician.
check for neuropathy:
…foot screening for sensation, circulation.
…podiatry input.
check for depression:
…feeling down?
…hopeless?
…little interest in things?
…low energy?
check for nephropathy:
…U+E
…urinary albumin-to-creatinine ratio
…blood pressure control
…blood glucose control
…consider ACE inhibitor.
metformin:
…biguanide
…inhibits gluconeogenesis
…improves sensitivity to insulin
…Indx: obese
gliclazide:
…sulphonylurea
…stimulates pancreas to release insulin
acarbose:
…alpha-glucosidase
…prevents intestinal sugar absorption
pioglitazone:
…thiazolidinedione
…improves sensitivity to insulin
sitagliptin:
…DPP-4 inhibitor (dipeptidyl peptidase-4 inhibitor)
OSCE C: Diet advice in renal failure
history of renal disease
progression
previous dietary advice
current diet
daily fluid intake
important to maintain a careful diet in renal disease:
…prevent renal disease progression
…avoid pulmonary oedema
…avoid increased potassium
…avoid hyperuraemia
advice:
…low protein diet
…low potassium diet
…avoid lots of meat
…avoid lots of fruit (esp. bananas)
…avoid fruit smoothies
…low glucose diet:
……worsens diabetic control
……worsens renal function
…avoid large fluid intake:
……hypertension
……pulmonary oedema
…try to make intake match UO, typically 1L/day.
…Sx of increased fluid, potassium, protein:
……nausea
……vomiting
……itching
……muscle weakness
……paralysis
…spouse to help prepare food
referral to dietician.
offer leaflet
suggest websites
OSCE C: Dizziness
[Q: DDx?]
[Q: Examinations?]
[Q: Treatment for benign paroxysmal positional vertigo?]
how is it affecting your life?
hearing:
…hearing loss
…noise exposure
…tinnitus
ear:
…ear pain
…ear discharge
vertigo:
…vertigo
…vertigo with a rotational component.
…sudden onset
…provoked by head movements
…episodic
…severity
…duration
meningitis Sx:
…photophobia
…neck stiffness
…headache
nausea
vomiting
facial weakness
B-Sx:
…weight loss
…fever
…night sweats
[Q: DDx?]
benign paroxysmal positional vertigo
Meniere’s disease
vestibular neuritis
viral labyrinthitis
acoustic neuroma
stroke
multiple sclerosis
vertebrobasilar insufficiency
brainstem lesions
otosclerosis
[Q: Examinations?]
otoscopy
full neurological examination
cranial nerve examination
Hallpike test:
…looking for vertigo and rotatory nystagmus towards the effected ear for several seconds.
audiometry:
…exclude cochlear dysfunction.
electronystagmography:
…assess vestibular function.
calorimetry
brainstem-evoked responses.
lumbar puncture
CT Head
MRI Head
[Q: Treatment for benign paroxysmal positional vertigo?]
reassurance for BPPV:
…self-limiting
avoid provocation by reducing head movements and moving slowly.
Epley manoeuvres
anti-emetics
vestibular suppressants:
…prochlorperazine
…short-term
Brandt-Daroff exercises at home.
OSCE C: DNAR
relative understands current situation.
relative understands what DNAR means.
explain DNAR:
…only applies to CPR.
…does not apply to treatment.
…patient will still receive management and treatment.
…CPR is very distressing.
…not usually successful in the elderly.
…it is a medical decision made by a consultant or senior doctor in charge.
…it cannot be appealed or refused.
…strong objections can be passed to the consultant.
patient quality of life beforehand.
acknowledge patient has good quality of life.
reassure:
…patient’s best interests is to be comfortable with dignity and self-esteem.
…medical team very involved in patient care.
…DNAR does not stem from a lack of interest in wellbeing.
doctor is unable to write DNAR without team meeting.
OSCE C: Domestic violence
home circumstances
patient at home
children at home
occupation
support network:
…family
…friends
triggers:
…alcohol
…drugs
…violence
…intimidation
nature of violence:
…duration
…frequency
…explanation for husbands behaviour.
form of abuse:
…sexual abuse
…emotional abuse
…financial abuse
reassure:
…patient is not to blame.
…what she wants to happen now.
…high prevalence of abuse during pregnancy.
…have a bag pre-packed.
…keep mobile phone close by.
support:
…GP helpline.
…charity phone numbers.
…leaflets.
OSCE C: Down syndrome screening
patient understanding of Down syndrome
explain:
…trisomy 21
…sporadic not inherited
…maternal age
…learning disabled
…low set ears
…large tongue
…short life expectancy
…duodenal atresia
…not fully independent
previous pregnancy:
…if Down’s child then more likely to happen again.
national screening programme:
…offered to all women.
…do not diagnose Down’s syndrome.
…detects women with increased risk.
…non-invasive
…blood test:
……beta-hCG
……PAPPA-A
……AFP
……inhibin A
……unconjugated estriol
…USS:
……size of nuchal pad
…results calculated.
…high risk:
……diagnostic screening offered:
………amniocentesis
………chorionic villus sampling
……chance of miscarriage (1% and 2% respectively)
……invasive
if Down’s syndrome:
…offered termination.
further counselling
further support.
…
OSCE C: Dysphagia
[Q: Differential diagnosis?]
[Q: Management?]
dysphagia onset
food
liquids
food difficulty progressed to liquid difficulty
food stuck
aspiration
coughing
vomiting
appetite
total oral intake
total nutritional intake
symptoms when eating:
…neck swelling
…abdominal pain
…vomiting
…haematemesis
…change in bowel habit
B-Sx:
…fevers
…night sweats
…weight loss
rigors
[Q: Differential diagnosis?]
oesophageal cancer
oesophageal spasm
foreign body
achalasia:
…(smooth muscle unable to relax,
…sphincter remains closed).
goitre
myasthenia gravis
stroke
[Q: Management?]
FBC:
…IDA
serum iron:
…IDA
serum ferritin:
…IDA
CRP
U+E
LFT
urgent referral for OGD.
barium swallow:
…SLURP
CT chest abdomen pelvis:
…primary tumour
…staging
referral to gastrology and MDT.
OSCE C: Early pregnancy complications
[Q: DDx?]
[Q: name one blood test and imaging test you would request?]
symptoms:
…onset
…duration
…pain
PV bleeding:
…volume
…colour
…frequency
…clots
period:
…LMP
…length of cycle
pregnancy:
…complications
ectopic pregnancy risk factors:
…previous ectopic pregnancy
…previous ectopic pregnancy management
…PID
…assisted conception
…previous pelvic surgery
…
previous pregnancies:
…miscarriage
…terminations
smears:
…recent
…results
urinary Sx
bowel Sx
vomiting Sx
B-Sx:
…night sweats
…fever
…weight loss
rigors
[Q: DDx?]
ectopic pregnancy
threatened miscarriage
[Q: name one blood test and imaging test you would request?]
beta-hCG
trans-vaginal USS.
OSCE C: Endoscopy results
drowsy during OGD so information wasn’t given.
previous Ix for peptic ulcer:
…h. pylori breath test
…CLO test
…gastric biopsy
…OGD report
…histology report
h. pylori can result in malignancy.
histology reports can take a week.
treatment is available for h. pylori.
triple therapy:
…omeprazole
…amoxicillin
…clarithromycin
reassure surgery isn’t needed for peptic ulcer.
OSCE C: Epistaxis
[Q: DDx?]
[Q: Ix?]
[Q: Emergency treatment?]
frequency
one or both nostrils
trauma to nose:
…nose-picking
…nose-blowing
…blocked nose
anaemia:
…pale
…faint
…tachypnoea
…tachycardia
risk factors:
…drugs:
……warfarin
……aspirin
……anti-coagulants
…bleeding disorders:
……idiopathic thrombocytopaenia purpura
……hereditary haemorrhagic telangiectasia
…nasal sprays:
……especially steroid nasal sprays.
PMHx:
…previous surgery to nose
…previous interventions to nose
…hereditary haemorrhagic telangiectasia
…malignancy of the nose.
DHx:
…aspirin
…warfarm
…anti-coagulants
…nasal sprays:
……especially steroid sprays
…cocaine use.
FHx
SHx
[Q: DDx?]
trauma:
…nose-picking
…facial trauma
mucosal irritation:
…sprays
…hot dry weather
…cocaine use
septal abnormalities
rhinosinusitis
tumours
blood disorders
[Q: Ix?]
head and neck examination
nasal speculum
rigid or flexible nasendoscopy
FBC:
…anaemia.
…platelets.
coagulation profile
haematological screen
[Q: Emergency treatment?]
first aid:
…sit up
…lean forward
…pinch fleshy tip of nose for 5-10 minutes.
ABCDE
suction
gauze with vasoconstrictor
nasal packing
IV access
IV fluid
blood transfusion
NBM
CT head
silver nitrate cauterisation
surgery
ligation of maxillary artery
if haemophilia with life-threatening bleed:
…clotting factors
if anterior nose bleed:
…1. direct pressure
…2. anterior nasal packing
if recurring nose bleed:
…cautery of the bleeding area
if long-term:
…refer to otolaryngologist
OSCE C: Failure to thrive (paediatrics)
small for age
vomiting
irritability
poor feeding
frequency of dirty nappies
nature of stools
diet
appetite
during pregnancy:
…smoking
…alcohol
…illness
…medications
…preterm
…method of delivery
birth:
…weight
…height
…condition
…complication
…neonatal illnesses
…gross motor function
…fine motor function
…social function
…vision
…hearing
…immunisations
cardiovascular:
…sweating
…cyanosis
…pallor
…SOB
respiratory:
…cough
…wheeze
…snoring
GIT:
…appetite
…diet
…vomiting
…pain
…abdominal distension
neurology:
…headaches
…fits
…weakness
musculoskeletal:
…limp
…limb pain
…joint swelling
…pain
PMHx:
…surgery
…previous hospitalisations
DHx
FHx:
…other children
…children dietry requirements
SHx:
…smoking
…second-hand smoke exposure
OSCE C: Fatigue
[Q: DDx?]
[Q: Next steps?]
symptoms
symptom duration
trigger
previous episodes
pain
bone pain
fatigue acknowledged
fatigue severity
fatigue prevents ADLs
fatigue features:
…constant
…during tasks
…times of day
change in bowel habit
rectal bleeding
neurological Sx
flu-like Sx
pregnancy Sx
B-Sx:
…weight loss
…night sweats
…fever
rigors
recent infection
period:
…regular
…LMP
…number of tampons
…bleeding after sex
…painful sex
blood loss:
…haematuria
…haematemesis
…haemoptysis
anaemia Sx:
…confusion
…SOB
…palpitations
…pale
…
mood:
…depression
…life events
[Q: DDx?]
anaemia secondary to colorectal carcinoma.
diverticulitis
diverticular abscess
Cushing’s syndrome
hypothyroidism
chronic alcohol consumption
poorly controlled diabetes
[Q: Next steps?]
FBC
CRP
U+E
LFT
fasting glucose:
…diabetes
HbA1c:
…diabetes
ferritin:
…IDA
tumour markers:
…CEA
…AFP
pituitary profile:
…TFT
…prolactin
…FSH
…LH
…24 hour urinary cortisol level
…low-dose DXM suppression test
…midnight cortisol levels:
……diurnal cortisol variation.
…MRI pituitary gland
colonoscopy with biopsy
CT chest abdomen pelvis:
…staging.
referral to colorectal MDT.
referral to general surgery team.
referral to endocrinologist.``
OSCE C: Febrile convulsion (i.e. collateral epilepsy)
[DDx]
[Q: Next steps?]
symptoms
symptom duration
previous episode
trigger
during seizure:
…jerking of all 4 limbs
…LOC
…drowsiness
medication given
baby Sx:
…vomiting
…crying
…irritable
…fever
…poor feeding
…sleep
…change in bowel habit
…rash
infectious contacts
immunisations
pregnancy:
…preterm
…spontaneous vaginal delivery
…illness of mother
birth:
…birth weight
…birth condition
…delivery complications
…illness of baby
developmental history:
…weight
…height
…milestones
…gross motor
…fine motor
…vision
…hearing
…social
systemic enquiry:
…cardiovascular:
……sweating
……cyanosis
……pallor
……SOB
…respiratory:
……cough
……wheeze
……snoring
…gastrointestinal:
……appetite
……diet
……vomiting
……pain
…neurology:
……headaches
……fits
……weakness
…musculoskeletal:
……limp
……limb pain
……joint swelling
PMHx:
…previous hospitalisations
…previous surgery
DHx
FHx:
…seizures
…epilepsy
[DDx]
febrile convulsion
childhood epilepsy
[Q: Next steps?]
advice:
…50% will have another febrile convulsion next time they have a fever.
…Chances lessen with age.
…don’t restrain child.
…support child’s head.
…turn head to one side to prevent injury and choking.
…after seizure, put in recovery position.
…paracetamol/ibuprofen to lower temperature.
…diazepam to shorten episodes if repetitive.
…family pre-disposition.
…only 1% develop epilepsy.
OSCE C: Gestational diabetes
do you realise the results suggest that you have gestational diabetes?
what do you understand about gestational diabetes?
OGTT:
…impaired:
……blood glucose >7.9 but <11.1 mmol/l.
explanation:
…lack of resistance to the body of insulin.
…results in rise of blood sugar.
…the condition can be managed.
advice:
…diet control.
…cut down sugar intake.
…if blood sugars are poorly controlled:
……may need tablets.
……may need injection.
…check own blood sugar levels regularly.
…monitor own progress x3 per day, before meals.
…more frequent ante-natal visits.
…diabetic specialists:
……doctors
……nurses
warn of implications for baby:
…typically an induction of labour at 38-39 weeks.
…macrosomia
…shoulder dystocia
…baby may have problems with blood sugar initially.
…doctors will check baby’s blood sugar regularly.
…possibly jaundice
…possible breathing problems
pregnancy so far:
…problems
…polyuria
…polydipsia
…miscarriages
…terminations
PMHx:
…diabetes
…gestational diabetes
DHx
FHx:
…diabetes
…gestational diabetes
SHx
OSCE C: Groin lump
[Process]
[Q: DDx?]
[Q: Next steps?]
[Process]
Hx trauma
Hx hernias
Hx previous surgery
pain:
…pain
…bone pain
occurrence:
…previous occurrence
…when first noticed
…current size
…increasing in size
…recent trauma
risk factors:
…coughing
…obesity
…heavy lifting
…constipation
obstructive Sx:
…colicky abdominal pain
…nausea
…vomiting
…constipation
does the lump come and go?
does it change with exertion?
lymphadenopathy (axiliary)
THIS LUMP:
…tender (or painful)
…hot
…increasing in size
…size
…location
…uniform colour, unilateral
…mobile
…pulsatile: aneurysm
B-Sx:
…fever
…weight loss
…night sweats
rigors
PMHx:
…surgery in the area of the lump
DHx
FHx
SHx
[Q: DDx?]
inguinal hernia:
…protrude above and medial to pubic tubercle.
fermoral hernia
groin abscess
psoas abscess
lipoma
sebaceous cyst
lymphadenopathy
haematoma
femoral artery aneurysm
cancer
[Q: Next steps?]
abdomen examination
PR examination
if lump is erythematous, irreducible, tender…:
…urgent referral to surgical team for evaluation.
if no obstruction, no strangulation:
…referral to surgical team.
USS lump:
…Determine contents, i.e. bowel, fat, omentum
AXR (*important Ix*):
…Determine contents, i.e. bowel, fat, omentum
surgical repair (open, laparotomy)
OSCE C: Haematuria
[Process]
[Q: DDx]
[Q: Next steps?]
[Process]
onset
progression
extent of blood loss
urine smell
abdominal pain
back pain
frequency
pain during urination
hesitancy
URINATION:
…urgency
…rate:
……fast
……dribble
……retention
……volume
…incontinence
…night (get up, bed wetting)
…ankle/abdomen oedema
…tried passing stones?
…impotence
…other: pain, colour, smell, LMP, SOCRATES
…number of children/pregnancies/miscarriages/abortions
B-Sx:
…weight loss
…fever
…night sweats
[Q: DDx]
transitional cell carcinoma
urethritis
cystitis
urethral cancer
bladder carcinoma
renal carcinoma
glomerulonephritis
Goodpasture’s syndrome
coagulation disorder
prostate cancer
trauma
TB
dyes:
…beetroot
[Q: Next steps?]
genitourinary examination
PR examination
urinalysis:
…haematuria
…proteinuria
…leukocytes
…nitrites
FBC:
…anaemia
coagulation profile:
…clotting disorder
U+E:
…renal dysfunction
USS bladder
KUB
flexible cystoscopy with biopsy:
…diagnose bladder and urethral abnormalities.
CT pelvis:
…staging
consider blood transfusion:
…if Hb is low.
TURBT:
…trans-urethral resection of bladder tumour.
external beam radiotherapy.
stop smoking:
…reduce recurrence rate.
cystoprostatectomy
OSCE C: Hyperemesis gravidarum
[DDx]
[Next steps?]
vomiting:
…duration
…tolerating food
…tolerating water
previous pregnancy:
…hyperemesis
…delivery
…post-partum complications
…miscarriages
…terminations
smears:
…recent
…results
abdominal pain
headache
urinary Sx:
…volume
…colour
previous USS:
…exclude molar pregnancy
…exclude twins.
bleeding in pregnancy
travel
food poisoning
infective contacts
B-Sx:
…weight loss
…fevers
…night sweats
rigors
PMHx
DHx:
…medications taken during pregnancy
…medications taken before pregnancy
FHx:
…twins
…hyperemesis
[DDx]
hyperemesis gravidarum
twin pregnancy
food poisoning
dehydration
[Next steps?]
admit for tests
FBC
CRP
U+E
LFT
glucose
urinalysis:
…ketones
…proteinuria
…infection
USS fetus:
…exclude twins
…exclude molar pregnancy
close monitoring:
…BP
…pulse
…renal function
anti-emetics:
…(safe during pregnancy)
…metoclopramide
…prochlorperazine
…cyclizine
…promethazine
…ondansetron
IV fluid:
…resuscitation
OSCE C: Intra-uterine growth retardation
pregnancy:
…complications
…delivery method
…pain
USS scans to date:
…ask results
…ask about charted growth from scans
previous pregnancy:
…hyperemesis
…hypertension
…pre-eclampsia
…IUGR
…delivery:
……if c-section:
………why was this necessary?
…post-partum complications
…miscarriages
…terminations
smear:
…recent
…results
PMHx:
…kidney problems
…clotting disorders
…poor nutritional intake
OSCE C: Jehovah’s witness
patient is aware of risks of operation.
consent form signed.
doctor cannot go against patient’s wishes.
doctor will protect doctor-patient relationship.
discuss:
…spouse’s feelings
…further talks with spouse.
…other family members involved?
…family views
options to minimise blood loss:
…autologous blood transfusion.
…IV fluid
…Epo
…laparascopic procedure to minimise blood loss.
…immediate ligation of blood vessels.
meet with consultant.
reassure but no false hope.
action plan.
…
OSCE C: Loss of memory
[Q: DDx?]
[Q: Next steps?]
symptom
symptom duration
trigger:
…stress
…anxiety
…life event
mental health issues:
…depression
…delusions
…personality changes
…hallucinations
previous head trauma
previous episodes
difficulty recognising familiar places/faces.
antegrade amnesia
retrograde amnesia
memory loss causing danger to patient:
…e.g. not looking before crossing road.
memory loss causing danger to public:
…e.g. leaving gas on.
paraesthesia
weakness
altered speech
visual disturbance
headache
hearing loss
tinnitus
B-Sx:
…fever
…night sweats
…weight loss
rigors
recent infection
appetite
PMHx:
…diabetes:
……(vascular disease risk factor)
…heart disease
……(vascular disease risk factor)
…high cholesterol
……(vascular disease risk factor)
…[Q: DDx?]
dementia (Alzheimer’s)
vascular dementia
Lewy body dementia
stroke
TIA
small vessel ischaemia
UTI
gastroenteritis
respiratory tract infection
[Q: Next steps?]
vitals
FBC
CRP
U+E
LFT
confusion screen:
…MSU: CAMPINGS
…BM
…vitamin B12
…folate
…syphilis screen
…CT head:
……confusion
…renal USS:
……renal damage
mini MSE
if dementia:
…memantine:
……NMDA blocker.
…donepezil:
……acetylcholineresterase inhibitor.
…old age psychiatry referral under DSM-IV criteria.
if UTI:
…trimethoprim
…nitrofurantoin
…co-amoxiclav
…maintain hydration
…nurse in well-lit area.
…familiar surroundings to avoid agitation.
OSCE C: Lower urinary tract symptoms (LUTS)
[Process]
[Q: DDx?]
[Q: Next steps?]
[Process]
onset
progression
haematuria:
…extent of blood loss
urine smell
abdominal pain
back pain
frequency
pain during urination
straining
hesitancy
URINATION:
…urgency
…rate:
……fast
……dribble
……incomplete voiding
……retention
……volume
…incontinence
…night (get up, bed wetting)
…ankle/abdomen oedema
…tried passing stones?
…impotence
…other: pain, colour, smell, LMP, SOCRATES
…number of children/pregnancies/miscarriages/abortions
B-Sx:
…weight loss
…fever
…night sweats
constipation
PMHx:
…surgery
DHx
FHx
SHx
[Q: DDx?]
benign prostatic hyperplasia (BPH)
prostate cancer
bladder/urethral cancer
chronic UTI
urinary tract stones
detrusor muscle weakness
chronic prostatitis
diabetes:
…due to polyuria.
multiple sclerosis:
…due to neurological Sx.
[Q: Next steps?]
abdomen examination
genital examination
prostate examination
urinalysis
urine cytology
urine CAMPING
urinary frequency charting
flow-rate and post-void residual volume measurement.
FBC:
…anaemia from haematuria.
U+E:
…renal dysfunction
LFT
tumour markers:
…CEA
…AFP
…PSA
…beta-hCG
serum/urine hCG:
…pregnancy test
catheterisation
transrectal ultrasound of the prostate.
alfuzosin:
…alpha-blocker
finasteride:
…5-alpha reductase inhibitor
furosemide:
…late afternoon loop diuretic.
advice:
…fluids
…caffeine
OSCE C: Methadone prescription stolen
acknowledge methadone prescription stolen.
reported to police.
does chemist use photo ID?
acknowledge patient’s feelings.
acknowledge need for repeat prescription.
doctor supervising methadone treatment.
not allowed to prescribe controlled drugs.
alternatives:
…psychiatrist who can prescribe.
doctor to refuse to prescribe methadone.
offer to discuss situation with senior doctor.
offer to inform patient’s regular GP.
OSCE C: Needlestick injury
[Process]
[management]
[Process]
explain what happened
time since incident
type of exposure:
…percutaneous
…mucocutaenous
patient details
what happened to equipment afterwards (risk to other staff)
immunisations:
…hepatitis B
first aid:
…squeeze blood out
…wash under running water
…don’t scrub wound
contact occupational health
if high-risk, i.e. HIV:
…post-exposure prophylaxis (PEP):
……28 day course of anti-retroviral drugs.
……test after 3 months.
……SFx:
………nausea, vomiting, diarrhoea.
………headaches
………dizziness
……must complete course.
…triple therapy started within 1 hour.
test for:
…HIV
…hepatitis B and C
safe sex
don’t donate blood during this process.
PEP can reduce HIV transmission by 80%.
% risk of contracting diseases:
…HBV + unimmunised: 30%
…HBC: 3%
…HIV: 0.3%
do not go back to take blood.
ask somebody else to take blood.
document exposure in patients notes.
ask both patients for blood sample if either are high risk.
Datex.
TTTT
PMHx:
…immunisations
DHx
FHx
SHx:
…IVDU
…safe sex practiced
[management]
blood sample:
…label ‘serum storage only - do not test’
…for retrospective analysis if complications arise.
if exposure to hepatitis:
…anti-tetanus prophylaxis
…hepatitis vaccination
…send completed vaccination form to blood transfusion:
……to obtain immunoglobulin
……(they do not require blood sample)
if HIV risk:
…Combivir prophylaxis PO
…Nelfinavir
if bitten (Tx for needlestick is similar to Tx for bite):
…augmentin
…+/- metronidazole
follow-up with infectious diseases
Datex
OSCE C: Osteoporosis
DEXA scan:
…recent
…results
patient understands osteoporosis.
patient understands osteoporosis Tx.
explain osteoporosis:
…condition affecting bone.
…weak and brittle.
…more likely to fracture.
explore osteoporosis aetiology:
…steroids
…post-menopausal
…lack of calcium
…lack of vitamin D
…eating disorder
…FHx osteoporosis
life-style:
…calcium intake
…exercise
…weight-bearing exercises
…brisk walking
…stop smoking
…reduce alcohol
…alter home for risk of falls
explain bisphosphonates:
…slow the rate cells break down bone.
…swallow tablets whole.
…take with glass of water.
…then stand up for 30 minutes.
…SFx:
……oesophagitis.
……jaw necrosis.
……hence why take them standing up.
OSCE C: Pain relief after surgery
previous experience of surgery and pain relief.
pain relief used in the past:
…was it effective
…methods prefer to have
…methods prefer to avoid
patient controlled analgesia:
…good pain relief
…explain:
……device hooked up to cannula.
……delivers opioid
……press button
…benefits:
……patient controls how often
……when analgesia given
……device has a lock out time (5-10 mins)
……unable to become addicted.
…SFx:
……nausea
……vomiting
……constipation
……dizziness
……sedation
…if unhappy with PCA:
……epidural:
………device in epidural space.
………pre-operative
………SFx:
…………headache
…………numbness
…………weakness
…………intense nursing
…………fluid leaks out of compartment:
……………BP reduced
……………IV fluid required
……
types:
…NSAID
…opioids
…local anaesthetic
…TENs
…hypnotherapy
OSCE C: Post-menopausal bleeding (+ pelvic pain)
[Q: DDx?]
[Q: Next steps?]
post-menopausal age
number of episodes of post-menopausal bleeding:
…volume
abdominal pain
pelvic pain
urinary Sx
change in bowel habit
painful sex
bleeding after sex
vaginal dryness during sex
FUN DICK TAMPONS WHITE: |menorrhagia = FUN DICK TAMPONS|
…flushes
…UTI
…number of days: bleeding, cycle, intermenstrual
…discharge
…itch
…constipation
…klots (clots)
…thyroid status
…amount: heavy, light
…menopause
…period: LMP
…OCP
…night sweats
…smear
…weight loss
…HRT
…infection (STI)
…tamoxifen
…excisions (e.g. hysterectomy)
past sexual history:
…smears:
……last smear
……results
…STDs
contraception:
…type
…duration
pregnancies:
…number
…delivery methods
…complications
…terminations
…miscarriages
other blood loss:
…haemoptysis
…haematemesis
…haematuria
…rectal bleeding
anaemia Sx:
…pallor
…fatigue
mets Sx:
…bone pain
B-Sx:
…weight loss
…fever
…night sweats
PMHx:
…fibroids
…prolapsed
…polyps
…ovarian cysts
…gynaecological cancers
DHx:
…HRT use:
……type
……duration
FHx:
…ovarian cancer
…breast cancer
…type of relative:
……i.e. 1st/2nd degree on mothers side.
[Q: DDx?]
bleeding:
…endometrial cancer
…endometrial polyp
…cervical cancer
…atrophic vaginitis
discharge:
…sepsis
…endometritis secondary to PID
…fibroid degeneration
jaundice + vaginal discharge:
…Gilbert’s syndrome
…viral hepatitis
[Q: Next steps?]
trans-vaginal USS or pelvic USS:
…endometrial thickness
hysteroscopy with Pipelle biopsy
dilation and curettage:
…endometrial polyp
OSCE C: Pre-eclampsia
[DDx]
[Ix]
[Tx]
[Px]
Hx pre-eclampsia
Hx primigravida: may unknowingly succumb to pre-eclampsia.
Hx HTN
headache
visual disturbance
facial oedema
peripheral oedema
upper abdominal pain
vomiting
seizures
pregnancy:
…patient previous pregnancy*
…patient’s partner previous pregnancy*
…termination
…miscarriages
smears:
…recent
…results
B-Sx:
…fever
…night sweats
…weight loss
rigors
PMHx:
…HTN
…diabetes
DHx:
…medication taken during pregnancy
…medication taken before pregnancy
…NSAID:
……not safe during pregnancy
…paracetamol:
……OK to use during pregnancy
FHx:
…pre-eclampsia
SHx:
…housing circumstances
…dependants
[DDx]
pre-eclampsia
migraine
tension headache
gastritis
[Ix]
BP: increase
SpO2:
…reducing: pulmonary oedema
FBC:
…platelets: decrease => HELLP
Haematinics:
…Hct: disease activity
LFT:
…transaminases: increase => HELLP
U+E:
…creatinine: increase => underlying renal disease
serum urate
USS foetus
…bi-parietal diameter
…head circumference: to estimate foetal weight
…abdominal circumference: to estimate foetal weight
…femur length: to estimate foetal weight
…foetal movement
…liquor volume
…Doppler umbilical arterial to middle cerebral artery
…Doppler ductus venosus
CTG:
…variability: <5bpm for 40+ minutes => problem.
…baseline tachycardia: problem
…late decelerations: problem
urinalysis:
…proteinuria: pre-eclampsia (*important Ix*)
[Tx]
admit to obstetrics:
…close monitoring
manage patient in left lateral position
seek consultant obstetrician
regular BP monitoring
FBC:
…platelets:
……HELLP syndrome
U+E:
…renal failure
LFT:
…HELLP syndrome
coagulation profile
urinalysis:
…proteinuria for pre-eclampsia
24 hour urine collection
CTG:
…assess foetus
labetalol:
…PO -> IV -> more IV -> nifedipine
…CIndx:
……bradycardia
……asthma
anti-hypertensive
magnesium sulphate:
…anti-convulsant
H2 blockers at labour
deliver placenta and baby
[Px]
HELLP
fetal asphyxia
placental abruption
small baby
DIC
OSCE C: Puerperal pyrexia
[DDx]
explain:
…fever within last 6 weeks of pregnancy.
symptoms:
…onset
…duration
…progression
pregnancy:
…complications:
……retained placenta
……prolonged rupture of membranes
……pyrexia
…delivery method
…pain
specific:
…number of pads being soaked.
…clots
…perineal wound
…offensive vaginal discharge
…cough
…sputum
…skin wounds e.g. recent cannula
urinary Sx
bowel Sx
B-Sx:
…night sweats
…fever
…weight loss
smears:
…recent
…results
[DDx]
endometritis
pyelonephritis
OSCE C: Rash - baby
[Q: DDx?]
[Q: Next steps?]
symptoms
symptom duration
previous episode
trigger
nature of rash:
…distribution
…description
…itch
…red
…blotchy
…discharge
…bleeding
medication given
baby Sx:
…vomiting
…crying
…irritable
…fever
…poor feeding
…sleep
…change in bowel habit
infectious contacts
PMHx:
…previous hospitalisations
…previous surgery
immunisations
pregnancy:
…preterm
…spontaneous vaginal delivery
…illness of mother
birth:
…birth weight
…birth condition
…delivery complications
…illness of baby
developmental history:
…weight
…height
…milestones
…gross motor
…fine motor
…vision
…hearing
…social
systemic enquiry:
…cardiovascular:
……sweating
……cyanosis
……pallor
……SOB
…respiratory:
……cough
……wheeze
……snoring
…gastrointestinal:
……appetite
……diet
……vomiting
……pain
…neurology:
……headaches
……fits
……weakness
…musculoskeletal:
……limp
……limb pain
……joint swelling
[Q: DDx?]
measles
chicken pox
rubella
scarlet fever
[Q: Next steps?]
measles:
…supportive.
paracetamol/ibuprofen:
…reduce fever.
…pain relief.
advice:
…take baby to GP if not recovering well.
…complications:
……bronchitis
……pneumonia
……encephalitis
…
OSCE C: Rectal bleeding / Diarrhoea
[Q: Differential diagnoses?]
[Q: Management?]
normal bowel habits
‘how many time a day are you opening your bowels?’
change in bowel habit:
…pain
…colour
…consistency
…constipation
…diarrhoea
…smell
SILLy:
…straining
…incontinence
…lethargy
…LOC
rectal bleeding:
…previous rectal bleeding
…colour
…amount
…clots
noticed blood on:
…pan
…toilet paper
…streaked on stool
…streaked
B-Sx:
…night sweats
…weight loss
…fevers
rigors
nausea
vomiting
diarrhoea or dizziness
urinary symptoms
travel
new foods
PMHx:
…IBD
…bowel surgery
…haemorrhoids
…CRC
…rectal polyps
FHx:
…FAP
…HNPCC
…polyps
…bowel cancer
[Q: Differential diagnoses?]
haemorrhoids
colorectal cancer
colorectal polyps
constipation
IBD
infectious colitis
[Q: Management?]
full clinical examination
PR examination
vitals
FBC:
…anaemia
CRP
U+E
LFT:
…albumin for malnutrition.
urinalysis:
…infection
blood culture:
…infective colitis
stool culture:
…infective colitis
faecal occult blood
faecal calprotectin:
…IBD
pregnancy test
coagulation profile
CEA:
…colorectal cancer
AFP:
…colorectal cancer
AXR:
…obstruction
Barium enema:
…polyps
…carcinoma
…diverticular disease
…IBD
…ischaemic colitis
USS liver:
…metastases
CT Chest abdomen pelvis:
…cancer staging
proctoscopy:
…in outpatient clinic.
rigid sigmoidoscopy:
…in outpatient clinic.
colonscopy with biopsy:
…diverticular disease
…polyps
…exclude proximal lesion.
IV fluid:
…rehydration
refer to gastroenterology out-patient clinic.
OSCE C: Red eye
[Q: DDx?]
[Q: Next steps?]
previous occurrence
previous trauma to eye
glasses
contact lenses
symptom:
…onset
…duration
…progression
…redness
…grittiness
…discharge
…reduced tear formation
…nasal irritation
…sneezing
…watery rhinorrhoea
eye:
…which side of eye
…unilateral or bilateral or both.
…one eye affected before the other.
…pain
triggers:
…trigger
…weather
…time of day
vision:
…visual problems
contacts:
…anyone else with similar problem?
joint pain
urinary Sx
mouth ulcers
groin ulcers
STIs
food poisoning
PMHx:
…eye surgery
…retinal detachment
…cataracts
…autoimmune disease
…eczema or other atopy
DHx:
…allergies
FHx:
…glaucoma
…allergic rhinitis
…eczema
…autoimmune diseases
SHx:
…pets
…recent sexual contacts
[Q: DDx?]
acute glaucoma
acute iritis
corneal ulcer/abrasion
allergic conjunctivitis
infective conjunctivitis
scleritis
[Q: Next steps?]
skin and nail examination:
…atopy
visual acuity examination
pupillary response
fundoscopy
eye discharge swab:
…purulent fluid
…send to microbiology
chloramphenicol
fusidic acid eye drops
avoid contact lenses
washing hands
using separate towels
clean eye:
…cotton wool soaked in warm water.
OSCE C: Rhesus status explanation
what patient understands
patient understand implications for baby
mother Rh positive/negative (probably negative in this scenario)
father Rh positive/negative
Rhesus status:
…type of blood similar to ABO blood group system.
…different antibodies in blood.
…it is not a disease.
…15% are Rhesus positive.
…if fetus is Rh+ then fetus blood enters mother.
…Mother creates antibodies.
…Mother’s antibodies attacks fetus blood.
…occurs during:
……childbirth
……terminations
……miscarriages
……amniocentesis.
…won’t harm the first pregnancy.
…may harm subsequent pregnancies.
…this is due to cells with ‘memory’.
…these cells cross the placenta.
…disease can occur known as ‘haemolytic disease of the new born’.
…baby can be born jaundice, ill, still born.
…Anti-D required.
…Anti-D suppresses mother’s antibody response.
…Routinely offered at 28-34 weeks if Rh+.
…Kleihauer test:
………(blood sampled from mother and baby)
……will determine if more anti-D is required.
…only dangerous to Rh+ fetus.
…won’t happen to a Rh- fetus.
…if baby is Rh+ then father is Rh+.
Anti-D:
…safe
…no complications for baby
…mother may have allergic reaction
…mother monitored for 20 minutes after injection.
…does not cause congenital abnormalities.
…as long as anti-D given in 1st Rh+ pregnancy, no problems with further pregnancies, but anti-D will still need to be given.
no special need for a c-section.
previous pregnancies:
…ectopics
…miscarriages
…terminations
…bleeding
…
OSCE C: Sick note - under false pretences
acknowledges want sick note
not actually physically ill
explores:
…mental health
…emotions
…offer examination
…why patient not wanting examination
unethical for a doctor to give an untrue sick note.
refuse to write a sick note.
discuss:
…e.g. may fail an exam.
…circumstances with a supervisor.
…patient can resit an exam.
offer:
…to speak to the supervisor.
…help patient with future medical problems.
OSCE C: Smoking cessation
smoking:
…onset
…quantity
…frequency
previous cessation:
…tried to quit
…how
…why restarted
quitting:
…feelings
…motivation
benefits for quitting:
…money
…health
…less stigmatisim
dangers of continuing smoking:
…cancer: lung, throat, stomach
…heart attacks
…strokes
never too late to give up
can quit gradually or cold turkey.
temptation to smoke
how to avoid temptation
friends and family
CHANGES:
…SFx headache, nausea, palpitation.
bupropion:
…SFx increases seizure threshold.
warnings of quitting:
…cravings
…increased appetite
…irritable
…frustration
acknowledges difficulty in quitting.
goal date.
goal date to avoid stressors.
follow-up appointment.
nurse to monitor progress.
…
OSCE C: SOB
[Q: Differential diagnosis?]
[Q: Management?]
symptoms
symptom duration
how does it affect you daily routine
pain:
…chest pain
…pain on coughing
SOB:
…SOBOE or at rest
…onset
…duration
…triggers
…relief:
……rest
……inhalers
…positional
…sleep
…severity:
……‘what can you not do anymore?’
…heart Sx:
……chest pain
……palpitations
……orthopnoea
worse or better
cough
SHREWDS:
…sputum:
……volume
……colour
…haemoptysis:
……number of episodes
……volume of blood
……fresh or clots
…hoarse
…relieving factors
…exacerbating factors
…wheeze
…discharge
…sneeze
B-Sx:
…weight loss
…night sweats
…fever
rigors
vomiting
anaemia:
…energy
…appetite
…pale
…skin rashes
TTTT
confusion
stay in bed more
SOB sleeping
SOB laying flat
surgery
recent infective contacts
previous episodes
PMHx:
…diabetes
…high cholesterol
…high blood pressure
…heart disease
…clotting disorders
DHx:
…inhalers
FHx:
…diabetes
…high cholesterol
…high blood pressure
…heart disease
…clotting disorders
SHx:
…exercise
…life-style
…diet
[Q: Differential diagnosis?]*
CAP
exacerbation of asthma
COPD
pleural effusion
lung cancer
[Q: Management?]
routine:
…FBC
…U+E
…LFT
…CRP
sputum:
…CAMPINGS
blood culture
urine culture
ABG:
…check for acidosis
ECG:
…exclude cardiac cause.
coagulation profile:
…due to haemoptysis.
oxygen
IV fluid:
…check for dehydration.
monitor urine output
CURB65 score
antibiotics:
…amoxicillin 500mg TDS
admit to hospital
refer to respiratory team:
…maybe due to frailty.
…MDT
bronchoscopy with biopsy:
…check for lung cancer
CT chest abdomen pelvis:
…cancer staging.
OSCE C: Swollen legs
[Q: Differential diagnosis?]
[Q: Management?]
symptoms
symptom duration
trigger
Hx Trauma:
…e.g. sporting injury
Hx Flight
Hx VTE
leg Sx:
…leg pain
…one or both legs affected
…swelling extends up to sacrum
…pitting oedema
…position
SOB:
…SOBOE or at rest
…sputum
heart Sx:
…chest pain
…palpitations
…orthopnoea
B-Sx:
…night sweats
…fevers
…weight loss
better or worse
previous episodes
PMHx:
…heart disease
…paroxysmal nocturnal dyspnoea:
……SOB/cough at night
……not relieved by sitting up.
…kidney problems
[Q: Differential diagnosis?]
congestive heart failure
pulmonary oedema
exacerbation of COPD
silent myocardial infarction triggering worsening of heart failure.
[Q: Management?]
FBC
U+E
LFT
CRP
glucose
lipid profile:
…heart disease
ECG:
…arrhythmia
NT-pro-BNP
serial troponins:
…cardiac muscle cell death
CXR:
…cardiomegaly
…pulmonary oedema
Echo:
…structural heart defect
monitor urine output
daily fluid intake
daily weights
high-flow oxygen:
…for acute pulmonary oedema
diuretic:
…for acute pulmonary oedema
increase diuretic dose.
morphine IV
nitrate infusion
OSCE C: Testicular lump
[Q: DDx?]
[Q: most likely testicular tumour?]
[Q: Next steps?]
pain
scrotum ‘dragging’ sensation
when first noticed
current size
increasing in size
recent trauma
THIS LUMP:
…tender (or painful): strangulated
…hot: strangulated
…increasing in size
…size
…location
…uniform colour
…mobile
…pulsatile: aneurysm
gynaecomastia
sexual dysfunction
urinary dysfunction
change in bowel motions
infertility
skin changes:
…eczema
…discolouration
B-Sx:
…fever
…night sweats
…weight loss
PMHx:
…scrotal surgery
DHx
FHx
SHx
[Q: DDx?]
testicular tumour (seminoma)
lymphoma
non-germ cell testicular tumours
hydrocele
epididymal cyst
epididymo-orchiitis
TB
syphilis
mumps
torsion
[Q: most likely testicular tumour?]
seminoma
[Q: Next steps?]
USS scotum
CT chest abdomen pelvis:
…staging
serum/urine hCG:
…tumour marker
AFP:
…tumour marker
orchidectomy via inguinal approach:
…(to avoid tumour seeding)
radiotherapy
chemotherapy
OSCE C: Tuberculosis
[Q: Differentials?]
[Q: Management?]
pain:
…chest pain
…pain on coughing
SOB:
…SOBOE
…onset
…duration
…triggers
worse or better
cough
SHREWDS:
…sputum:
……volume
……colour
…haemoptysis:
……number of episodes
……volume of blood
……fresh or clots
…hoarse
…relieving factors
…exacerbating factors
…wheeze
…discharge
…sneeze
B-Sx:
…weight loss
…night sweats
…fever
rigors
vomiting
energy
appetite
weight
pale
TTTT
BCG vaccination:
…had vaccination
…scar on arm
any infectious contacts
who lives in close contact (contagious).
work absence
previous episodes
TB leaflet for information.
TB team contact details.
PMHx
DHx
FHx
SHX
[Q: Differentials?]
atypical pneumonia
emphysema
lung cancer
[Q: Management?]
‘TB is serious but treatable.’
FBC
U+E
LFT:
…check liver function before RIPE.
CRP
sputum samples:
…x3
…one as an early morning sample.
…acid fast bacilli.
BC
urine sample:
…CAMPING
ABG
ECG
CXR
referral to respiratory team.
colour vision test before RIPE.
RIPE:
…rifampicin
…isoniazid
…pyrazinamide
…ethambutol
…(daily for 6 months)
…(all 4 drugs for 2 months)
…(RI for further 4 months).
RIPE SFx:
…R: orange discolouration of sweat, tears, urine.
…I: peripheral neuropathy.
…P: gout, arthralgia.
…E: colour blindness. Test before starting.
…(hepatitis, rash, fevers).
2 weeks of RIPE until not infectious.
must be RIPE compliant:
…important
…don’t stop when feeling better
infection control:
…single room
…respiratory mask if leave room.
…stay during first 2 weeks of RIPE.
…stay away from children.
…infectious in first 2 weeks.
after discharge:
…self isolate
…minimal contact with others.
possible TB resistance.
OSCE C: Twin pregnancy
twin-pregnancies are consultant led.
babies are increased risk of:
…pre-term labour
…miscarriage
…congenital abnormalities
…intra-uterine growth restriction
mother is increased risk of:
…gestational diabetes
…hyperemesis
…pre-eclampsia
…anaemia
…c-section
…post-partum haemorrhage:
……hormone drip will be started immediately after delivery to reduce the risk.
explain twin pregnancy:
…dichorionic dizygomatic twin pregnancy:
……dichorionic:
………each fetus has own placenta.
……dizygomatic:
………different oocytes
……twins will not be identical.
home birth is not appropriate
if first twin is in cephalic presentation:
…vaginal delivery is possible:
if first twin is in breech or transverse position:
…c-section
the foetuses change position during labour so unable to determine which mode of delivery yet.
induced at 38-39 weeks.
…
OSCE C: Vaginal prolapse
[Q: DDx?]
[Q: Next steps?]
symptoms:
…symptoms
…onset
…duration
…progression
previous episodes
medications given
prolapse:
…dragging sensation
…description
…exacerbating factors:
……end of day
…interferes with sex
gynaecology:
…menopause age
…LMP
past sexual history:
…smears:
……last smear
……results
…STDs
contraception:
…type
…duration
pregnancies:
…number
…delivery methods
…complications
…terminations
…miscarriages
urinary Sx:
…trigger
…nocturia
…urge incontinence
…stress incontinence
…painful micturition
…increased frequency
change in bowel habit:
…constipation
…diarrhoea
…incontinence
[Q: DDx?]
vaginal prolapse
stress incontinence
[Q: Next steps?]
urodynamic studies for stress incontinence
urinalysis:
…exclude UTI
blood glucose:
…exclude diabetes
prolapse:
…physiotherapy
…weight reduction
…pessary
…anterior/posterior wall repair
…hysterectomy
stress incontinence:
…treat underlying infection
…treat diabetes
…pelvic floor exercise
…physiotherapy
…Burch colposuspension
…tension-free vaginal tape
OSCE C: Vision problem
[Q: DDx?]
[Q: Next steps?]
Hx AF:
…NB:
……retinal artery occlusion
Hx diabetes:
…NB:
……vitreous haemorrhage
……diabetic retinopathy
……diabetic maculopathy
sudden vision loss:
…NB:
……Retinal Artery Occlusion
……Retinal Vein Occlusion
……Retinal Detachment
……Vitreous Haemorrhage (e.g. from diabetic retinopathy)
gradual vision loss:
…NB:
……Neo-vascular or Atrophic AMD
……Chronic Open-Angle Glaucoma
……Diabetic Retinopathy: except vitreous haemorrhage
eye Sx:
…redness
…grittiness
…dryness
…reduced tear formation
…nasal irritation
…sneezing
…watery nose discharge
vision change:
…unilateral/bilateral
…one eye effected before the other.
…blurring
…tunnel vision
…total loss of sight
…haloes
…triggers
…relieving factors
…trauma
…pain
…adapt to darkness:
……problem=> open angle glaucoma.
…black spots:
……NB: vitreous haemorrhage
…clouding:
……NB: cataract
visual acuity reduced:
…NB diabetic maculopathy
visual field loss:
…NB:
……stroke (e.g. hemianopia)
……photocoagulation (e.g. due to proliferative diabetic retinopathy)
diplopia:
…NB: mononeuropathy
painful:
…NB:
……MS: retrobulbar neuritis
headache:
…NB: temporal arteritis
stroke Sx:
…headaches
…paraesthesia
…weakness
…swallowing problems
…altered consciousness
temporal arteritis Sx:
…muscle pain
…scalp tenderness
…jaw claudication
retinal detachment Sx:
…flashes of light
…floaters
…straight lines appearing curved
pituitary Sx:
…excessive growth
…weight loss/gain
…change in period/fertility.
…skin changes
…palpitations
…gynaecomastia
consider contacting DVLA:
…Indx: loss of visual fields
PMHx:
…AF
…heart problems
…high cholesterol
…eye surgery
…eye problems
…cataracts
…retinal detachment
…diabetes
…glaucoma
…cataracts
…stroke
…TIA
DHx:
…eye drops
…allergies
FHx:
…glaucoma
…cataracts
…diabetes
…peripheral vascular disease
…stroke
…heart problems
SHx:
…eye protection worn at work
…work outdoors
…irritants
[Q: DDx?]
refractive error:
…myopia
chronic open angle glaucoma
optic nerve compression
hereditary retinal dystrophies
papilloedema
[Q: Next steps?]
visual fields examination
full neurological examination:
…exclude neurological causes.
swinging light test:
…relative afferent pupillary defect:
……optic nerve lesions.
diabetes check:
…BM
…fasting blood glucose
Snellen chart:
…check if improves with pinhole device.
…severity
…monitor rate of deterioration.
fundoscopy:
…cherry-red spot at macula:
……retinal artery occlusion
…pale fundus:
……retinal artery occlusion
…cattle-trucking in retinal arterioles:
……retinal artery occlusion
…papilloedema
if refractive error:
…improves with pin-hole.
…check diabetes:
……high blood sugar can cause change in shape of lens.
……BM check.
…tonometry:
……glaucoma
…gonioscopy:
……glaucoma
…refer to ophthalmologist.
…refer to optician.
…wear glasses
OSCE C: Vomiting
[Q: Differentia diagnoses?]
[Q: Management?]
vomit:
…volume
…colour
…taste
…content
…bile
…blood
…medication taken to relief vomiting.
…retching
…trigger:
……recent food
……recent travel
GIT:
…BUM LEAK
…constipation
…diarrhoea
…passing gas
…bloated
…rectal bleeding
B-Sx:
…night sweats
…fever
…weight loss
fainting
pregnant
urinary symptoms
[Q: Differentia diagnoses?]
small bowel obstruction:
…early Sx:
……vomiting
……bloating
…late Sx:
……constipation
large bowel obstruction:
…(opposite early/late Sx to small bowel obstruction).
adhesions
hernia
bowel obstruction secondary to intestinal tumour:
…adenocarcinoma
…lymphoma
…gastro-intestinal stromal tumour.
[Q: Management?]
abdominal examination
PR examination
FBC: anaemia
CRP
U+E
LFT:
…for malnutrition.
coagulation profile:
…for rectal bleeding.
group and save:
…for rectal bleeding.
CEA:
…(carcino-embryonic antigen)
…tumour marker.
ABG:
…lactate
…base excess: bowel ischaemia
AXR:
…obstructed bowel loops
CXR:
…sub-diaphragmatic air for intestinal perforation.
nil-by-mouth
NGT:
…4 hourly aspiration
catheter:
…fluid monitoring
IV fluid
anti-emetics:
…cyclizine
…metoclopramide
NSAID:
…ibuprofen
…diclofenac
paracetamol
CT scan:
…exclude obstruction secondary to tumour.
OSCE C: Weakness
[Q: DDx?]
[Q: Next steps?]
symptoms
symptoms duration
trigger
previous episodes
weakness
weakness distribution
numbness
paraesthesia
altered speech
visual changes
headaches
hearing loss
tinnitus
B-Sx:
…fever
…weight loss
…night sweats
rigors
recent infection
appetite
PMHx:
…diabetes (r/f for stroke)
…high BP (r/f for stroke)
…raised cholesterol (r/f for stroke)
[Q: DDx?]
stroke
TIA
space-occupying lesion:
…brain tumour
…brain abscess
[Q: Next steps?]
full neurological examination
vitals
FBC
CRP
U+E
LFT
fasting glucose
cholesterol
homocysteine levels
ECG
Echo
USS Dopper carotid
CXR
CT head
MRI head
referral to stroke unit for treatment and rehabilitation.
referral to neurosurgeons and discussion at neurology MDT.
thrombolysis
if xThrombolysis:
…aspirin 300mg initially
…low-dose aspirin long-term
…PPI
risk factor modification:
…Tx high BP.
Tx atrial fibrillation:
…rate-control or rhythm control.
carotid endartectomy
