OSCE Flashcards

Question

**Scenario 2 (AXR 3 – plain film)** * 42 year old man presents with 12 hours of severe left flank pain - colicky in nature and radiating to his groin, with associated nausea and vomiting * Past medical history – appendicectomy age 18 * Medications – nil regular * OE – Pt. is tachycardic and hypertensive

Answer 1

See LAO of GI CS for more examples

Answer 2

See LAO in GI CS for more examples

Answer 3

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

Answer 4

Attached to GI/Liver exam 2 LAO

Answer 5

Attachment can be found LAO of GI Examination 2 **Introduction and consent** **Hand hygiene and wear gloves** **Sample collection:** * Give patient sterile specimen container and saline wipe and carefully instruct: * Take to toilet * Spread the labia/retract the foreskin * Prior to urination cleans urethral meatus with saline-soaked gauze, wipe in a downwards motion FRONT TO BACK, then dry * Instruct patient to collect midstream specimen in sterile container after passing a small amount of urine into the toilet, and then finish passing urine **Procedure:** * Attend hand hygiene, don non-sterile gloves * Retrieve specimen jar (yellow top, clear) from patient * Mix specimen well immediately before using * Confirm that the test strips are within the expiration date on the bottle * Remove one strip from the bottle and replace the cap immediately * Inspect the strip. If reagent areas are discoloured, do not use the strip * Gold standard is to draw up urine into sterile syringe and drop onto reagent squares carefully. Alternatively, dip the test strip into the urine up to the last test pad for no more than 1 second – note this can potentially contaminate the urine for M/C/S * On drawing the strip out of the sample, run its edge over the rim of the container to remove excess liquid or blot on paper towel * After 60 seconds (60–120 seconds for leukocytes) compare the reaction colour in the test area against the colour scale on label * Discard urine in contaminated waste * Remove gloves, wash hands * Record results in patient notes **Important Points:** * Avoid tipping test strip on to its end as the fluid and colour may run affecting interpretation capabilities * If the tests cannot be done within two hours of urine collection, keep the specimen in a refrigerator at +4°C

Answer 6

Review LAO for procedure

Answer 7

**Presenting Complaint** * What has brought you to the doctor today? * _Pain_ * SOCRATES * Kidney – pain in loin or flank, dull or sharp, continuous or with movement/position * Ureter – colicky from flank to loin to groin * Bladder – generalised lower abdominal, suprapubic, association with micturition * Urethra –dysuria (burning or stinging passing urine) * _Changes in urination patterns_ * Frequency (passing more often but no increase in overall quantity) * Polyuria (increase in the quantity of urine passed +/- polydypsia) * Urgency (strong urge to urinate even with small amounts of urine in bladder) * Nocturia (How often? Pattern changing?) * Oliguria (decrease in quantity produced: \<400ml urine/24hrs) * Anuria (no urine output) eg. acute renal failure * _Changes in urinary stream_ * Incontinence (stress or urge) * Urinary retention +/- overflow o Hesitancy (bladder outlet obstruction) * Leaking or postmicturition dribbling * Double voiding * Strangury (slow flow +/- pain) * _Changes in urine_ * Colour (concentrated urine is darker – ?dehydration) * Vitamins, medications and food colourings often discolour urine * Urine cloudy and or smelly suggesting pyuria * Frothy urine suggesting proteinuria * Port wine colouration (Porphyria cutanea tarda-rare) * _Haematuria_ * Small amount blood – urine is pinkish, brownish or cloudy * Heavy bleeding – frank blood or clots * Bleeding at start or end of stream * Painful (stones, infection, papillary necrosis) * Painless (infection, neoplasia, acute glomerulonephritis, menstruation or vaginal cause) * _Urethral discharge_ * Amount, odour, colour, blood, pus, pain * History of STIs and recent sexual history * _Systemic systems_ * Constitutional: fever, anorexia, weight loss, night sweats, malaise * Infection: chills, rigors, malaise, sore throat, sepsis (post-streptococcal glomerulonephritis) * Neoplasia: symptoms associated with metastasis – bone pain, headache, confusion, shortness of breath * Autoimmune/systemic inflammatory diseases (eg SLE, vasculitis): arthralgia, myalgia, rash, purpura, alopecia, eye and respiratory symptoms * _Chronic Kidney Disease_ * Oliguria * Anorexia, malaise, vomiting, hiccups, fatigue, insomnia * Itching, bruising * Oedema, breathlessness * Restless leg syndrome * Parasthesia, bone pain * Symptoms due to anaemia * _Other symptoms_ at all? **_Dialysis History if relevant_** * Type of dialysis * haemodialysis or peritoneal * Duration on dialysis * Type of dialysis access * AV fistula or Vascath for haemodialysis * peritoneal catheter for peritoneal dialysis * Complications associated with dialysis * Haemodialysis * blocked access (thrombosed fistula, blocked Vascath), * Vascath infection, * cardiovascular instability (intradialysis hypotension, arrhythmia from electrolyte shift), * bleeding from intradialytic heparin use * Peritoneal dialysis * peritonitis, * peritoneal catheter exit site infection, * catheter displacement or blockage, * abdominal hernias, * hydrothorax from pleuroperitoneal fistula/leak * Check if patient has had previous kidney transplant or if patient is on the renal transplant waiting list * Check whether dialysis is affecting patient’s activities * Check whether patient is depressed **Past Medical Hx** * Have you ever had any medical, dental or cosmetic procedures? * Have you ever been diagnosed with any medical conditions? * Have you ever had any stays in the hospital? * _Other_ * In women with bladder symptoms, ask about obstetric history, pelvic surgery, other gynaecological symptoms * In men with symptoms of bladder outlet obstruction, ask about history of prostate disease, family history of prostate cancer, past PSA screening, prostate examination or imaging **Allergies** * Are you allergic to anything? if so find out what and the nature of the allergy **Medication Hx** * Are you currently taking any medications? * Have you recently started or stopped any medications? * Do you take any over the counter or herbal medications? * What about any medication devices, drops, puffers, patches or creams * _Other_ * Medications taken to treat kidney disease or reduce risk factors eg antihypertensives * Nephrotoxic medications eg NSAIDs, aminoglycoside antibiotics * Medications that are renally excreted and may require dose adjustment in renal failure eg some antibiotics, oral hypoglycaemics **Family Hx** * Tell about your parents and siblings medical history * Polycystic kidney disease * Ureteric abnormalities * Hypertension, gout and diabetes * Renal impairment or disease of any kind * Bladder, kidney or prostate cancer * Deafness, iritis (rare genetic causes of renal disease- Alport syndrome) **Social Hx** * SNAP * Have you ever smoked? * 20 cigs a day for 10 years = 10 pack years * 1 bong = 5 cigarettes * On average, how many standard drinks of alcohol do you consume in a week? * Have you ever taken any recreational drugs? * What is your diet like? What are some typical meals you eat during the week? * _Fluid intake_ - amount and type * How active are you? Do you get a chance to do any physical activity? * _Recently travelled anywhere?_ * Travel (schistosomiasis and other infections) * _Work/Occupational Hx_ * What do you do for work? Particularly possible toxin exposure (eg dyes associated with bladder cancer * _Personal Hx_ * Who do you live with? * Do you currently have a partner? * Flesh out sexual history as relevant * Obstetric history for female if relevant

Answer 8

**Introduction and greeting** **Check if the patient has any injuries** **Inspect Body Habitus** **Hands and Arms** * Cap refill * Palmar erythema * Clubbing * Check for tremor with paper on hands * Radial pulse * Pemberton's sign **Eyes** * Front (follow finger with eyes) * Scrunch eyes to see lid lag * Inspect eyes from side and above **Neck and thyroid** * Inspect from front and ask to sip water, ask patient to stick tongue out * Locate cricoid cartilage and check position for trachea * Lymph nodes * Palpate thyroid from behind * Ask patient to swallow water whilst palpating thyroid * Percuss manubrium * Auscultate over the thyroid and listen for bruits **Legs** * Reflexes - bicep, knee * Oedema on tibia + malleoli * Standing test for proximal muscle strength (If I had time I would also examine the chest for gynaecomastia, systolic flow murmurs and CCF)

Answer 9

**Introduction and greeting** **Inspect Body Habitus** **Check if the patient has any injuries** * especially neck, shoulders, back or legs due to small body movements during the examination **Gait** * Walk normal + back figure 8 * Walk heel to toe * Walk up on toes * Walk on heels * Squat * Romberg test: eyes closed + arms out + support if needed **Upper Limb** _Motor:_ inspect, tone, power, coordination + reflexes * Inspect and compare * **Tone** * Wrist: rotation * Elbows: flexion/extension + supination * **Power (resisted)** * Shoulder: abduction/adduction * Elbow: flexion/extension * Wrist: flexion/extension * Fingers: flexion/extension + abduction/adduction * Thumb: abduction/adduction + opposition * **Coordination** * Drift test - Close eyes, palms up and fingers splayed - push up see drift * Finger-nose test * Hand flip test- Rapid alternation one hand on another palm to dorsal * **Reflexes** * Biceps * Triceps * Radial * Fingers **Sensory** * Soft touch * Pain * Proprioception * Temperature * Vibration

Answer 10

**Introduction and greeting** **Inspect Body Habitus** **Check if the patient has any injuries** **Gait** * Walk normal + back figure 8 * Walk heel to toe * Walk up on toes * Walk on heels * Squat * Romberg test: eyes closed + arms out + support if needed **Lower Limb** **_Motor_**_:_ inspect, tone, power, coordination + reflexes * Inspect and compare * **Tone** * Knee * Ankle * **Clonus** * Knee * Ankle * **Power (resisted)** * Hip: Flexion/Extension + abduction/adduction * Knee: flexion/extension * Ankle: plantarflexion/dorsiflexion * Foot: inversion/eversion (isolate heel) * Big toe: abduction/adduction + opposition * **Coordination** * Heel-shin test * Foot-tapping test * **Reflexes** * Knee * Achilles heel * Plantar (C shape on sole of heel to toe) **_Sensory_** * Soft touch * Pain * Proprioception * Temperature * Vibration

Answer 11

**Introduction and greeting** **Inspect Body Habitus** **Check if the patient has any injuries** * especially neck, shoulders, back or legs due to small body movements during the examination **CNI - Olfactory** * Any change or loss of smell **CNII - Optic** * Snellen Chart (with glasses on) * Visual fields * Blind spot **CNIII/IV/VI - Oculomotor, Trochlear + Abducens** * Pupils - inspect, light (direct + consensual) * H pattern * Accommodation **CNV - Trigeminal** * Corneal reflex * Soft touch forehead, cheek, chin * Pain prick forehead, cheek, chin * Clench teeth + palpate masseters + open jaw resist * Reflex jaw jerk **CNVII - Facial** * Resisted eyebrow raise * Resisted eye scrunch * Resisted cheek puff out * Show teeth **CNVIII - Vestibulocochlear** * Whisper test with opposite ear closed * Rinne's - tuning fork on mastoid process till no longer heard then placed alongside ear canal * Weber's - tuning fork placed on head and asked if equal **CNIX/CNX - Glossopharyngeal + Vagus** * Inspect mouth and say “Ahh” for palatal arches * Swallow water * Cough test **CNXII - Hypoglossal** * Inspect tongue * Poke out tongue * Assess tongue power by pushing through cheek **CNXI - Accessory** * Resisted shrug * Resisted left + right head rotation - look to both sides

Answer 12

* **Introduction and greeting** * **Check if patient has any injuries** * especially neck, shoulders, back or legs due to small body movements during the examination ***-NB. for entire session, watch the Patient's expression-*** **_Gait + Stance_ (for pathologies involving thoracolumbar spine)** * Inspect + compare sides * Walk * Squat * Trendelenburg sign - stand on one leg **_CERVICAL SPINE_** * Inspect * Palpate: spinous processes + facet joints + paraspinal muscles + temp **Cervical Spine Active Movements** Observe from side: * Flexion: chin to chest * Extension: look up Observe from front: * Rotation: Look to side * Lateral flexion: Tilt ear to shoulder **_THORACOLUMBAR SPINE_** * Inspect * Palpate: Temp + spinous processes + facet joints + paravertebral & ilio-lumbar muscles * Gentle thumping down and up spine **Thoracolumbar Spine Active Movements** Observe from side: * Extension: Bend forward & touch toes * Flexion: Bend backward (supporting pt.'s back) Observe from behind: * Lateral flexion: Bend sideways - reach hand to knee w/out moving pelvis * Rotation: sit pt. on bed w/ arms crossed → rotate trunk and look to side w/out moving pelvis **_SHOULDER_** * Inspect * Ask pt. to show painful areas & demonstrate limited/painful ROM * Palpate: Temp + sternum + clavicle + acromion + coracoid process + + bicipital groove + scapula **Shoulder Active Movements** Observe from behind w/ pt. standing: * Flexion/extension: raise straight arms forward & up + down & back * Abduction/adduction: Hands from side to top (like a jumping jack) & back down * Do a 2nd time & palpate scapula during movement * Internal/External rotation: rotate flexed elbow (90 deg) in & out, NB. for internal rotation, hand must go behind back **Shoulder Special Tests** Rotator cuff: * Empty can test: hold arms straight out, 30 degrees lateral + thumbs down (pouring out cans) → Push downwards on their arms & ask patient to resist * Take off test: Hand behind back (palm facing outwards) and Dr pushes inwards against it as pt. pushes out * Driving test: elbow @ 90 deg with palms facing each other → Push in against and out Shoulder impingement: * Jumping Jack test: abduct the arm and watch for painful arc between 60 & 120 deg * Hawkins test: Dr places palm on pt. shoulder + pt. arm rests over inner elbow of Dr → Push forearm down (twisting hinge) **_ELBOW_** Pt. standing: * Inspect + assess carrying angle * Ask pt. to locate painful areas & demonstrate limited/painful ROM * Palpate: Temp + inner elbow + olecranon + ulnar nerve + medial & lateral ligaments **Elbow Active Movements** * Flexion/extension: robot arms up & down (palms facing in) * Internal/external rotation: robot arms cross at front and out * Supination/pronation: elbow @ 90 deg → rotate palms up & down **Elbow Special Tests** * Tennis elbow test: hold under pt's distal forearm (elbow bent @ 90 deg with palm down) → push down on hand as pt extends wrist up * Golfers elbow test- as above → Flex wrist down against pressure **_WRIST + HANDS + FINGERS + THUMB_** * Inspect * Palpate: Temp + radial pulse + cap refill + wrist + hand + fingers **Active Movements** Wrist: flexion, extension, abduction and adduction Fingers: bend at MCP flexion/extension (flat fingers) + fingers splayed + claw hand fist (bend at PIP & DIP) Thumbs: flexion/extension + abduction/adduction + opposition **Hand Special Tests** * Carpal tunnel test: namaste praying & reverse * De Quervain's test - wrap thumbs under fist and bend wrist down

Answer 13

* **Introduction and greeting** * **Check if patient has any injuries** * especially neck, shoulders, back or legs due to small body movements during the examination ***-NB. for entire session, watch the Patient's expression-*** **_Gait + Stance_ (for pathologies involving thoracolumbar spine + lower limb)** * Inspect + compare sides * Walk * Squat * Trendelenburg sign - stand on one leg * Heel raise on one leg * Optional: Thessaly Test for knee menisci (one leg standing rotation) **_HIP_** * Lay pt. flat * Inspect * Ask pt. to locate painful areas & demonstrate limited/painful ROM * Measure leg lengths (umbilicus/ASIS/greater trochanter to medial malleoli) * Palpate: greater trochanter + inguinal area **Hip Active Movements** * Flexion: bring knee to chest * Internal & external rotation: rotate bent leg in and out * Abduction + adduction: straight leg medial cross and lateral * Extension: Roll pt. over + fix hips + straight leg extension * Optional: Apley's test (knee grind) **_KNEE_** * Inspect * Ask pt. to locate painful areas & demonstrate limited/painful ROM * Measure circumference of thighs 20cm above tibial tuberosity * Palpate: patella, patellar tracking, ligaments, muscles **Knee Active Movements** * Extension: heel to buttock * Flexion: flip pt. to front and bend knee + grinding test (if not already done) **Knee Special Tests** * Oedema ‘milk fluid down’ test: Patellar tap + Bulge push both sides * Collateral knee ligaments test: bend knee & abduct and adduct lower leg * ACL + PCL test: Sit on pt. foot w/ knee bent & jerk lower leg forward & backwards **_ANKLE + TOES_** * Inspect * Ask pt. to locate painful areas & demonstrate limited/painful ROM * Palpate ankle, foot and toes **Ankle Active movements** * Dorsiflexion + Plantarflexion: point foot forward/backward * Inversion + Eversion: fix heels + point sole of foot in/out **Toe Active movements** * Flexion + Extension: curl + splay toes

Answer 14

**Presenting Complaint** * _Confirm if it is both sides_ * _Bones_ * pain (SOCRATES and inc or dec with weight bearing) * Swelling * **Joints –** * joint pain (arthralgia) * stiffness – where? worse in the morning? * swelling or deformity - soft/hard (Fluctuant -\> effusion Spongy/boggy -\> synovitis, haemorrhage Hard/immobile -\> osteophyte/ subchondral bone thickening) * locking - suggests loose bodies or torn cartilages * instability – ‘giving away’ (suggests dislocation, subluxation, torn tendons or ligaments) * noises and redness – clicks, clunks, grating sensations * loss of function – ASK ABOUT IMPACT ON LIFE! * **Systemic manifestations** (connective tissue disease and seronegative arthropathies) * Vasculitis (any fever? Fatigue? Weight loss?) * Skin * Rash (photosensitive, burning? does it blanch? Itchy, distribution) * Skin thickening * Ulcers * Raynaud’s phenomenon (triphasic colour change in feet or fingers in cold – white, blue, red) * Head and face * Alopecia * Headaches * Visual disturbances * Sicca symptoms (dry eyes and/or mouth) OR red, painful eyes * Jaw claudication * Neck and chest * Dysphagia or odynophagia (painful swallowing) * Pleuritis (sharp chest or abdominal pain) * Dyspnoea, haemoptysis, wheezing, chest tightness, hoarse voice, sinusitis * Abdomen * Abdominal discomfort or dragging sensation in abdomen (heapto/splenomegaly) * Postprandial abdominal pain * Testicular pain * Muscle pain/weakness * Neuropathy – motor and/or sensory * **Ask about how it is impacting their life (sleep, work, recreational activities, future, etc)** **_Past medical history_** * Previous joint injury, surgery, or treatment of any kind? * Nerve, muscle, tendon injury/surgery * Diabetes (peripheral neuropathy) * Gout * Peptic/duodenal ulcer * OA (increase steroid use = RF for OA) * Menopause? * Obesity (past or present) * Stress/depression (psychosomatic problems) **_Medications_** * Pain relief * NSAIDs * **Statins (rhabdomyalgia – muscle pain)** * Immunosuppressives including azathioprine, cyclosporine, methotextrate, cyclophosphamide * Corticosteroids * Hydroxychloroquine (plaquenil) * Hydralazine * Procainamide * Anti-thyroid meds **_Allergies_** NSAIDs, immunosuppressive meds, analgesia **_Family history_** RA, arthritis, lupus, scleroderma, sjoren’s syndrome, OA, OP, gout **_Social history_** Occupational – overuse of joint Sporting – Have you had any injuries? Diet (RF for gout - high purine diet) Exercise (What is your exercise regimen like?) Smoking and alcohol

Answer 15

**Presenting Complaint** * What has brought you to the doctor today? * **_Menstruation_** * _Menstrual History_ * Menarche- age at first period * Age of menopause (if relevant) * Frequency/regularity and duration of cycles including cycle length expressed as days of menstruation/cycle length eg 3/27 * Heaviness of flow - number of tampons/pads used on Day 1, clots * Date of last menstrual period (LMP) -always expressed as 1st day of cycle * Dysmenorrhoea (painful menstruation) -onset (at menarche or later), duration, intensity, location and radiation, relieving factors (eg do NSAIDs relieve pain?) * Pre-menstrual tension/dysphoria -mood changes, breast tenderness, bloating * _Non menstrual bleeding_ * Intermenstrual bleeding (IMB)/breakthrough bleeding (BTB) if on hormonal contraception * Post-coital bleeding (PCB) -after sexual intercourse * Post-menopausal bleeding (PMB) * **_Obstetric (details important if currently pregnant or planning a pregnancy)_** * _Gravida -total number of pregnancies_ (including miscarriages and terminations with gestation reached), include current pregnancy if relevant * _Parity -number of births_ (live or stillbirths) * Gravida and parity are expressed as GxPx eg G3P2 is three pregnancies, two births * _Birth details_ * Gestational ages at birth in weeks (ie 32, 36, 42 etc) * Induction of labour/spontaneous * Duration of labour * Type of delivery- vaginal vs. Caesarean (planned or emergency), forceps, tears/episiotomies * Birth weight, sex of babies, Apgar scores * _Pregnancy complications:_ GDM, hypertension, pre-eclampsia, other medical problems * _Neonatal complications or abnormalities_, multiple births (twins, triplets) * _Blood group and Rh factor_, history of anti-D immunisations * _HIV, Hepatitis B or Hepatitis C infection_ * **_Gynaecological_** * _Past and current contraception_ and any problems with these * _Cervical screening_ history * Date of last pap smear/cervical screen - result * Any abnormal tests in the past * _Genital symptoms_ * Vaginal discharge- all women have physiological vaginal discharge- need to determine if abnormal for her- colour, quantity, odour, irritation, onset, time course, any past diagnoses eg recurrent thrush * Dyspareunia (painful intercourse)- superficial (at the vaginal entrance) or deep * Other genital symptoms eg ulcers, lesions, lumps, rashes, itching * _Micturition/urinary tract symptoms_ * Frequency, dysuria, stress or urge incontinence particularly if past pregnancies * Past urinary tract infections * _Bowel symptoms_- constipation/diarrhoea, pain with defecation, difficulty defecating * _Menopausal history_ (if relevant) * Peri-menopausal -current pattern of bleeding (as in menstrual history) * Post-menopausal -date of final period * Hot flushes and night sweats -frequency and severity * Other symptoms associated with menopause and their effect on life such as: vaginal dryness, mood changes, joint aches and pains, insomnia, loss of libido * _Any past gynaecological diagnoses_ or surgery eg treatment of endometriosis * _Other -_ May need to sensitively ask about past genital mutilation/surgery in women from high risk countries or if suspected on examination * **_Sexual History_** * Current relationship, length of relationship, monogamous or not * Most recent unprotected sex and number of casual partners in last 12 months if relevant * Male or female partners or both * Use of condoms * Any past sexually transmitted infections, especially past genital herpes, syphilis or chlamydia and treatment details * Previous STI testing * Sexual difficulties may be disclosed and may be relevant to the presenting illness eg vaginismus (difficulty with vaginal penetration), painful sex after previous childbirth. * **_Changes in weight?_** * **_Any fevers, nausea or vomiting?_** * **_Other symptoms_** at all? **Past Medical Hx** * Have you ever had any medical, dental or cosmetic procedures? * Have you ever been diagnosed with any medical conditions? * Have you ever had any stays in the hospital? * _Other_ * Mental health history: depression especially postnatal depression, anxiety, any other psychiatric illness, treatment **Allergies** * Are you allergic to anything? if so find out what and the nature of the allergy **Medication Hx** * Are you currently taking any medications? * Have you recently started or stopped any medications? * Do you take any over the counter or herbal medications? * What about any medication devices, drops, puffers, patches or creams * _Other_ * Contraception -current and past use (will be covered in detail in next session) * HRT (if relevant) -current or past use and duration of use * Alternative remedies/herbal medicines * Vitamin supplements, especially iron, iodine & folic acid if pregnant * Immunisations * Gardasil in younger women (was the full course of 3 injections completed?) * Varicella (chicken pox- at least one month prior to pregnancy, cannot be given in pregnancy) * Rubella (at least 1 month prior to pregnancy or postnatally, cannot be given in pregnancy) * Hepatitis B (especially if not Australian born) * Fluvax (can have when pregnant- protects mother and newborn) * Pertussis (can have when pregnant- protects newborn) **Family Hx** * Tell about your parents and siblings medical history * Gynaecological cancers -ovarian, endometrial * Breast cancer- number of first degree relatives affected at what age * Genetic conditions * Pre-eclampsia * Postnatal depression * Twins **Social Hx** * SNAP * Have you ever smoked? * 20 cigs a day for 10 years = 10 pack years * 1 bong = 5 cigarettes * On average, how many standard drinks of alcohol do you consume in a week? * Have you ever taken any recreational drugs? * What is your diet like? What are some typical meals you eat during the week? * How active are you? Do you get a chance to do any physical activity? * _Work/Occupational Hx_ * What do you do for work? * Who do you live with? * Do you currently have a partner? * _If pregnant:_ * _Smoking_- high risk for premature and small babies, document amount smoked, attempts to quit and motivation to quit, refer to Quit Clinic * _Nutrition_- varied, balanced diet high in iron important, avoid foods with risk of Listeria monocytogenes (eg soft cheeses, unpasteurised milk products, salad bars), avoid high levels of caffeine (more than one strong espresso coffee per day) * _Alcohol_- current recommendations are no alcohol in pregnancy, refer for support if problematic * _Physical activity_- moderate exercise is beneficial, supportive back exercises, avoid intense new exercise * _Any drug use_ particularly intravenous drugs (potential risk of hepatitis C) * _Social supports_- partner, extended family, friendships, preschool and school contacts, cultural group etc

Answer 16

Higher Cortical Functions (intelligence, complex problems etc) Levels of Consciousness Fits, epilepsy, funny turns Headache, neck pain, facial pain Cranial nerves (sight, smell, balance, face sensations. pain etc) PNS - gait, back pian etc

OSCE Flashcards

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