GP OSCE

Question 1

Explain Type 2 diabetes & management

Answer 1

Intro 
ICE
Explain diabetes:
- High sugar, hormone called insulin can't removed sugar from blood to cells 
Risk: 
- 40, families, overweight, race
Symptoms:
thirst, urine, tired, weight-loss 

Complications:
Heart: 4 x MI & 2 x Stroke
Eye problems: blurred vision, cataracts, blindness
Kidney problems
Nerve damage: loose sensation in feet & can get ulcers
Reassure: that keeping blood sugar low and attending reg to diabetic clinic we can prevent these from happening

Management:
Diet:
- Maintain healthy weight 
- Starchy foods
- 5 portions of fruit & veg
* can give you example diet sheets or refer you to a dietician 

If diet does not work:

• Medication (tablet called metformin)
• Insulin injections (few ppl need this)

Other:

• feet & eyes checked regulary
• control blood pressure
• stop smoking
• have flu jabs
• How do you feel about these measurements?
• Support at home?

Follow up:
See you in diabetic clinic: review blood sugar, urine, bp & medication
- refer u to dietician
- leaflet

Do u have any Q’s I haven’t addressed?
Summarise
Thank

Question 2

Diabetic foot examination

Answer 2

Intro, explain, consent, 45 angle, expose, say you would let them rest for 25 mins.

Equipments: microfilament, tuning fork, tendon hammer

Inspection:
colour, skin changes, ulcers (check everywhere), swelling.

Palpation:
Temperature (back of hand)
Posterior tibial & dorsalis pedis (doppler)
Cap refil

Sensation: microfilment

• chest
• eyes closed - feet

Vibration:
Long tuning fork (chest then distal phalanx)

Proprioception
up/down

Ankle jerk reflex

Gait

Check footwear

Finish

• full neurovascular examination of lower limbs
• Bedside glucose
• Advice good footwear
• ABPI

Question 3

How to tell the difference between ischaemic & neuropathic ulcer

Answer 3

ischaemic ulcer is painful, pale & pulseless

neuropathic is not painful, red, loss of sensation

Question 4

How to calculate ABPI

Answer 4

Take highest reading from either leg or either arm.

Leg reading divided by arm = ABPI

Question 5

What actions would you take if the ABPI was:
0.5-0.8
<0.5

Answer 5

0.5-0.8: apply no more than light (class 1) compression, as arterial disease is likely and compression may further compromise arterial blood supply.
<0.5: compression stockings should not be worn, as severe arterial disease is likely- REFER to vascular

Question 6

Epilepsy diagnosis

Answer 6

Take Hx:
Ask about seizures:
- prodrome 
- aura
- during seizure 
- witness, what did they say happened, LOC, tongue biting 
- After what did u feel like 
- how long before you felt normal 
- Triggers: sleep, alcohol, new medications, trauma 

HxPc
- Other seizures
in childhood, with fever

Dhx: Tricyclics, cocainr
Fix

Epilepsy: sometimes have seizures (fits). There are different types of seizure and everybody experiences them differently.

Seizure: Electrical activity is happening in your brian all of the time. A seizure happens when there is a sudden burst of intense electrical activity. How this burst of activity effects you depends on which area of the brain it happens in. Some ppl can have strange sensations, parts of the body may twitch or jerk, some ppl fall to the floor and jerk violently.

Seizures last between a few seconds & minutes. After a seizure you usually return to normal. Can happen asleep or awake.

Causes:
6/10 have no known cause. Other is can be due to damage to the brian, difficult birth, injury to head, stroke or infection of the brain

Living with epilepsy

Driving: tell DVLA

Entitlements:

• All medical prescriptions free
• If you can’t drive: discounted bus fair GOV.UK

Saftey

• Tell other ppl so they can help u
• Epilepsy identify card
• Who lives with you- could fit alarm at home.
• Shower not bath

Sport & leisure
- safe to do most sports- just tell supervisor or member

Alcohol

• Doesn’t react with medications
• But alcohol can make the side effect of epilepsy medications worse
• Drinking a lot can cause ‘withdrawal seizures’

What to do during seizure:

• protect head
• do not restrain
• maintain airway
• ring 999 if >5 mins

Support groups, epilepsy nurses, support groups

Prescribing Meds
partial - carbamazepine 100mg BD
all others- Sodium valproate 300mg BD
Warn: pregnancy, do not stop taking without specialist, many interactions
SE:
C: drowsy, blurry vision, confusion, agitation, problems with blood or liver
SV: nausea, tummy upset, weight gain, liver dysfunction

Question 7

OSCE diagnosing chronic kidney disease

Answer 7

Chronic kidney disease is a long term condition where the kidneys don’t work as well as they should. It is associated with getting older. CKD can gradually get worse over time. Many ppl with kidney disease are able to live long, largely normal lives.

Symptoms:
In the early stages there are often no symptoms instead is picked up by blood or urine tests.

In its advanced stages it can cause:

• Anaemia tiredness & SOB
• Oedema: swollen ankles, feet, hands,
• blood in your urine, frequency
• bone problems

Causes:
Kidney disease is usually caused by other conditions that put strain on the kidneys, often a combination
- high BP: strain on blood v
- diabetes: glucose damages tiny filters in kidney
- high cholesterol: build up in blood vessels supplying K
- Kidney infections
- Kidney inflammation
- Polycystic kidney disease
- Blockages in flow of urine
- Long term use of certain medicine

Prevent CKD: healthy lifestyle

Tests for CKD

• blood test: measure waste product (creatinine)- calculation with age, gender & race - eGFR normal healthy is over 90ml/min
• urine test- check levels of albumin & creatinine also check protein
• US/MRI

Treatment
No cure, but Tx can help relieve symptoms and stop it getting worse.

Treatment depends on how severe your CKD is.

1. YOU lifestyle measure
   - stop smoke, balanced diet, ↓ salt, exercise, ↓ alcohol, do not take NSAIDs (ibuprofen)
2. Medications to prevent symptoms:
   - High bP
   - high cholesterol
   - water retention
   - anaemia
   - bone problems

In a small proportion 1/50 there kidneys will stop working. This rarely happens suddenly so we will discuss that if we need too. Tx includes:

3. Dialysis remove waste products & excess fluid from blood
4. transplant: most effective for advanced disease- major surgery and life long pills

Outlook.
Can range from mild with no symptoms to serious.
Most ppl: regular check ups, only 1/50 develop into kidney failure

• Even with mild, increased risk of developing other serious conditions, such as cardiovascular disease: heart attack & stroke

Summarise
ICE
Leaflet.

Question 8

OSCE explain COPD and its management

Answer 8

COPD is the name for a group of lung diseases that can cause difficultly with breathing.

• Damages to air sacs in lungs
• long-term inflammation of airways or tubes leading to lungs

Commonly effect middle aged adults who smoke. Many ppl do not realise they have it.

Breathing tends to get gradually worse with time & can limit daily activities, Tx can keep condition under control.

Symptoms:

• increasing breathlessness, can occur when exercising and may sometimes wake up feeling breathless
• persistant chest cough with phlegm
• frequent chest infections
• persistent wheezing

Will get worse with time, and get have flare-up,a few a year, more common in winter.

Causes:

• Lungs become inflamed, damaged & narrowed
• Mainly smoking although can affect some ppl who have never smoked
• ↑ risk the more u smoke & the longer u smoke

Management
1. Stop smoking- prevent further damage. NHS Smokefree for advice & info

2. Inhalers: relax and widen airways
   a) SAMA: use when u feel breathless for a maximum of four times a day
   b) LAMA or LABA once daily: if symptoms occur throughout the day
   c) Still breathless, or have frequent flare ups (more than 2 in a year)
3. Medications
   - Theophylline Tablets BD: relax & open airway- requires regular blood tests
   - Mucolytic tablets (carbocisteine): if persistent chesty cough with thick phlegm
   - Steroid tablets: flare-up 7-14 days to ↓ inflammation
   - Antibiotics: chest infection: temp, chest pain, yellow/green phlegm
4. Pulmonary rehabilitation
   specialist programme & education to help ppl with lung problems. Excersie, education, diet advice, emotional support - 6 weeks
5. Other Tx
   - Nebulised medications: breath medication through a mouthpiece
   - Long term oxygen therapy: 16 hours a day, oxygen through nasal or mask DO NOT smoke when using oxygen as it is highly flammable

Outlook:
- varies from person to person, it cannot be cured or reversed but Tx can keep it under control so it doesn’t severely limit daily life.

Question 9

Smoking cessation advice

Answer 9

• Establish motivations for change. Have they tried to quit before? What happened?
• Establish their understanding of health problems associated to smoking
• Congratulate on taking 1st step towards quitting

Why smoking is bad for you.

• It causes
  cancer: Lung and many many more. A male that smoke is 23 times more likely to get lung cancer than a non smoker

chronic lung problems: can not be reversed.

heart disease: risk of heart attack

100,000 ppl a year die because of smoking each yr in UK. These deaths are preventable. Even 1 a day can treble the risk of lung cancer.

It can also cause problems with the stomach causing ulcers or make IBS worse.

Smoking is a health hazard to those around u- second hand smoke can increase risk of cancers and heart problems and can severely effect children.

Benefits of stopping:

• ↓ risk of smoking related disease
• Breath more easily, gives you more energy, reduce stress, improve sex, improve fertility, smell & taste, younger-looking skin, whiter teeth, live longer
• protect health of ppl around u
• ↓ chances of ur children suffering from asthma
• Improve your fertility
• Improve breathing and general fitness
• ↓ cost of smoking
• Better for skin, hair
• Stop clothes and house smelling

Why is it difficult to stop?

• Cigarettes are addictive- 70% of smokers want to give up and it can take a few tomes before pl manage to quit for good.
• Nicotine is physically addictive.
• Stopping can lead to withdrawal symptoms such as anxiety, irritability, ↑ appetite, poor concentration. These are TEMPORARY LAST LESS than 1 month.
• Management options to help reduce these negative feeling.

How to stop

Best way is to stop altogether. Some ppl cut down the amount they smoke.

Cutting down, usually replacing some cigarettes with nicotine containing product.

Nicotine replacement therapies, provides low levels of the additice element without the other poisnoess chemicals in cigarette smoke: help withdrawal effects, bad mood…
choices: skin patch, gum, inhalators, tablets spray.

2 different prescription tablets that can help ppl quit

• varenicline
• bupropion

E-cigarretes: electronic device that delivers nicotine in a vapour. Not available on prescription and should be used alongside NHS stop smoking service.

Help:

• Stop smoking services: free and provide encouragement & advice. Refer from GP
• One to one. GP smoking cessation nurse
• Telephone support
• Try and keep positive. Written a list of reasons why its good to stop
• Identify when you crave cigarettes
• Keep positive

Check understanding

Question 10

Describe AF and its management

Answer 10

AF is heart condition that causes an irregular and often an abnormally fast heart rate. (> normal 60-100)

This can cause problems: dizzy, SOB, tired, aware of heart, many have no symptoms.

What causes it?
Normally: heart wall contract to force blood around body, then relax to fill up again. In AF the heart contract to randomly and so fast the heart can’t fill up properly causing ↓ in the hearts performance. It occurs as the abnormal electrical impulses in the heart override the heart’s natural pacemaker which controls it rhythm.

Causes are not fully understood but occur in certain groups and can be triggered by certain situations:

AF more common in ppl with heart conditions: ↑BP, athersclorsis
Medical conditions: overreactive thyroid. asthma, COPD, diabetes
Triggers: excessive drinking, overweight, drinking lots of caffeine, illegal drugs, smoking
more common with ↑ age

AF is classified deepening on the degree to which it effect u.
Paroxysmal AF: episode come & go, stop within 48 hrs w/o Tx
Persistent: > 7 days
long-standing persistent AF: > 1 yr
Permanant AF: present all the time

diagnosis: ECG

Complications:
stroke: blood blots
heart failure

Treatment:
Not usually life-threatening but can be uncomfortable.

Step 1: find a cause and treat.

Step 2:

• medications to ↓ risk of stroke
• medications to control AF
• Cardioversion (electrical shock Tx)
• Catheter ablation
• pacemaker

Controling AF
- restore normal rhythm
flecainide, beta-blocker (sotalol), amiodarone

• restore rate
  beta-blocker (bisoprolol), calcium channel blocker (verapamil, diltiazem)

Stroke prevention: depending on risk: anticoagulants (warfarin..)

Cardioversion: in hospital, controlled electric shock.

Catheter ablation: destroy diseased area of heart and interrupts abnormal electrical circuits. Under GA

Pacemaker: battery-operated implanted device in chest below collarbone.

See a GP if you notice a sudden change in your heartbeat. Symptoms of dizzy, SOP, chest pain.

Question 11

How do you decide if an AF patient needs to be anti coagulated?

Answer 11

CHA2DS2-Vasc

Congestive heart failure 1
Hypertension 1
Age:
65-75 1
>75 2
Diabetes 1
Stroke or TIA 2 
Sex (f) 1 
Vascular disease 1

1: consider
2+: give

Question 12

Following high CHADsVAsc describe warfarin

Answer 12

• ‘Blood thinner’
• Why they need it: ‘stop clots, stroke’
• Check allergy and current meds
• How to take it: oral tablet OD, rest of life.
• Regular blood checks: INR, once daily, once week, 3 monthly
• Side effects: risk of bleeding, GI upset
• Warning about contact sport
• Drugs interactions: antibiotics, anti-epileptics
• Tell dentist/health professionals before any procedure
• Address concerns & questions & book follow up

Question 13

Heart Failure: symptoms, management

Answer 13

HF: blood is unable to pump blood around body. To hard or weak. It’s a long term condition that tends to get gradually worse. It can not be cured but symptoms can often be controlled over many years.

Symptoms vary person, can start suddenly or develop gradually

• breathlessness: rest or activity, may be worse when you lie down or may wake u up at night.
• fatigue
• swallon ankles and legs: tends to be better in morning and get worse during day

Other: persistent cough, palpitations (fluttering heart), weight changes.

If you experience sudden worsening of symptoms see your GP. If it’s very severe & sudden ring 999.

The severity of heart failure is scored depending on symptoms from 1-4, 1 being least severe and 4 being the worst. Guides Tx.

Treatment.

YOU: healthy lifestyle:

• smoking, eating, alcohol, salt, exercise, vaccination
• Take your medication
• Attend regular reviews

Medications
2-3 medications: may have to try a few medicines before we find a way that best suits symptoms that don’t cause side effects.
Do you want Examples? ACEi (control BP) Beta-blockers (slow HR)

Devices:
Some ppl may require a small implanted device in their chest to help control their hearts rhythm,
- pacemakers: monitors HR and sned impulses to keep heart beating reg
- careful hospital equipment & air security

Surgery:
Some ppl require surgery
- valve surgery 
- bypass
- transplant