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.
