OSCE Flashcards

Question

key steps for peripheral arterial examination

Answer 1

* pain and chaperone * general inspection * inspect hands * cap refill * temperature * upper body pulses * radial * rado-radial delay * ulnar pulse * allens test * brachial pulse * waterhammer pulse * listen first then carotid pulse * inspect eyes lips and tongue * inspect abdomen * inspect feet legs and toes * wiggle toes * check temp between legs * cap refill on toes * lower body pulses * femoral pulse * radio-femoral delay * popliteal * posterior tibeal * dorsalis pedis * Assess light touch sensations starting distally * if intact distally don't keep going * Auscultate * carotids * subclavian * aorta * femoral arteries * Special teste * Buerger's test * stand at bottom of bed and raise legs for 2-3 mins * observe for pallor * buerger's angle is the level at which pallor develops * if buerger's angle less than 20 degrees then you have severe limb ischaema * then put legs over side of bed * observe for reactive hyperaemia * white → normal pink → red * time it takes for limb to become pink is buerger's time * Ankle brachial pressure index * ABPI \<0.8 = significant peripheral arterial disease * to complete * cardiovascular

Answer 2

* tremor temperature * inspect forearm for wasting * eye movements and lid lag * swallow and stick tongue out while palpating AND observing * look for lingual thyroid * palpate for tracheal deviation * percuss for retrosternal thyroid * auscultate thyroid * proximal muscle weakness * pre-tibial myxoedema * reflexes * to complete * tfts * ecg * US thyroid * fundoscopy

Answer 3

* **Median sternotomy scar:** located in the midline of the thorax. This surgical approach is used for cardiac valve replacement and coronary artery bypass grafts (CABG). * **Anterolateral thoracotomy scar:** located between the lateral border of the sternum and the mid-axillary line at the 4^th or 5^th intercostal space. This surgical approach is used for minimally invasive cardiac valve surgery. * **Infraclavicular scar:** located in the infraclavicular region (on either side). This surgical approach is used for pacemaker insertion. * **Left mid-axillary scar:** this surgical approach is used for the insertion of a subcutaneous implantable cardioverter-defibrillator (ICD).

Answer 4

* Apex beat * In healthy individuals, it is typically located in the 5th intercostal space in the midclavicular line. Ask the patient to lift their breast to allow palpation of the appropriate area if relevant. * Heaves * Place the heel of your hand parallel to the left sternal edge (fingers vertical) to palpate for heaves. * If heaves are present you should feel the heel of your hand being lifted with each systole. * Parasternal heaves are typically associated with right ventricular hypertrophy. * Thrills * A thrill is a palpable vibration caused by turbulent blood flow through a heart valve (a thrill is a palpable murmur). * You should assess for a thrill across each of the heart valves in turn (see valve locations below). * To do this place your hand horizontally across the chest wall, with the flats of your fingers and palm over the valve to be assessed.

Answer 5

* Measure [blood pressure](https://geekymedics.com/blood-pressure-measurement/) * [Peripheral vascular examination](https://geekymedics.com/peripheral-vascular-examination/) * [Record a 12-lead ECG](https://geekymedics.com/record-ecg/) * [Dipstick urine](https://geekymedics.com/urinalysis-osce-guide/) * [Bedside capillary blood glucose](https://geekymedics.com/blood-glucose-measurement/) * F[undoscopy](https://geekymedics.com/eye-examination-osce-guide/)

Answer 6

* which eye * trauma * visual disturbance * far or near * colour * flashes/floaters * double vision * red eye * discharge * watering * grittiness * dryness * itching * swelling * photophobia * driving * glasses or contact lenses * conditions associated with opthalmic conditions * diabetes * hypertension * autoimmune disease

Answer 7

* Check [oxygen saturation](https://geekymedics.com/basic-observations-vital-signs-osce/) (SpO₂) and provide supplemental oxygen if indicated. * Check other [vital signs](https://geekymedics.com/basic-observations-vital-signs-osce/) including [temperature](https://geekymedics.com/basic-observations-vital-signs-osce/) and [blood pressure](https://geekymedics.com/blood-pressure-measurement/). * Take a [sputum sample](https://geekymedics.com/sputum-sample-collection-osce-guide/). * Perform [peak flow assessment](https://geekymedics.com/2014/03/01/peak-expiratory-flow-rate-pefr/) if relevant (e.g. asthma) * Request a [chest X-ray](https://geekymedics.com/chest-x-ray-interpretation-a-methodical-approach/) (if abnormalities were noted on examination) * Take an [arterial blood gas](https://geekymedics.com/2014/01/07/arterial-blood-gas-sampling/) if indicated * Perform a full [cardiovascular examination](https://geekymedics.com/2010/09/29/cardiovascular-examination-2/) if indicated (e.g. cor pulmonale)

Answer 8

* trigeminal * has sensory (V1, V2 and V3) and motor (V3) components * sensory * check they can feel cotton wool on sternum * check sensation on: * forehead (V1 opthalmic) * cheek (V2 maxillary) * chin (V3 mandibular) * ask if same on both sides * ask if they want you to do pinprick * motor (V3 mandibular) * palpate masseter bilaterally as they clench teeth * ask to open mouth against pressure * offer jaw jerk reflex * would be exaggerated in an UMN lesion * offer corneal reflex * absense of blinking would mean trigeminal or facial lesion

Answer 9

* facial * sensory to anterior two thirds of tongue * “any change to your sense of taste?” * motor to muscles of facial expression * inspect face for symetry * movements * *“Raise your eyebrows as if you’re surprised.”* * *“Scrunch up your eyes and don’t let me open them.”* * *“Blow out your cheeks and don’t let me deflate them.”* * *“Can you do a big smile for me?”* * *“Can you purse your lips like you're trying to whistle?”*

Answer 10

* vestibulocochlear * “any change to your sense of hearing?" * gross hearing assessment * occlude ear from behind * whisper three numbers from an arms length * if can't hear use conversational volume * if can't hear then use loud volume * if still can't hear move 15cm from ear * use whisper and conversational - don't shout * repeat for other ear * Rinne's with 512 tuning fork * Weber's with 512 tuning fork * Ask the patient to **march on the spot** with their **arms outstretched** and their **eyes closed:** * **Vestibular lesion:** the patient will turn towards the side of the lesion * head thrust test - ask if they have neck pain before doing it

Answer 11

Glossopharyngeal it is assessed together with cranial nerve 10

Answer 12

vagus it is assessed together with cranial nerve 9

Answer 13

* ask * any problems swallowing * any changes to voice * any cough * inspect soft palate and uvula * uvula deviates towards the side of the vagus nerve lesion * say aaah * cough * vagus nerve lesions cause a weak bovine cough * ask to take sip of water * ineffective swallow can be caused by either vagus or glossopharyngeal nerve lesion * say you would try to elicit a gag reflex * ineffective gag reflex can be caused by either vagus or glossopharyngeal nerve lesion

Answer 14

The [_glossopharyngeal nerve_](https://geekymedics.com/the-glossopharyngeal-nerve-cn-ix/) transmits **motor** information to the **stylopharyngeus** **muscle** which **elevates the pharynx** during swallowing and speech. The glossopharyngeal nerve also transmits **sensory** information that conveys **taste** from the **posterior third** of the **tongue**. Visceral sensory fibres of CN IX also mediate the **afferent limb of the gag reflex**.

Answer 15

* accessory nerve * inspect and palpate for sternocleidomastoid/trapezius wasting * raise shoulders and resist me pushing them down * turn hear and resist me turning it back * do both sides

Answer 16

* Hypoglossal * open mouth and inspect for wasting/fasciculations * protrude tongue and observe for deviation * occurs towards lesion * push tongue against finger on cheek * weakness on side of lesion

Answer 17

* Full neurological examination including the [_upper_](https://geekymedics.com/upper-limb-neurological-examination/) and [_lower limbs_](https://geekymedics.com/lower-limb-neurological-examination/). * Neuroimaging (e.g. [_MRI head_](https://geekymedics.com/the-basics-of-mri-interpretation/)): if there are concerns about space-occupying lesions or demyelination. * Formal [_hearing assessment_](https://geekymedics.com/hearing-ear-examination-osce-guide/) (including pure tone audiometry): if there are concerns about vestibulocochlear nerve function.

Answer 18

* offered to all women between the ages of 25-64 years * 25-49 years: 3-yearly screening * 50-64 years: 5-yearly screening * in pregnancy is delayed until 3 months post partum * process * speculum inserted to visualise cervix * small brush used to collect cells from around the opening of the cervix * shouldn't be painful * small amount of bleeding afterwards * results * HPV first system * if negative return to normal recall * if positive then the cytology is examined * if cytology abnormal → colposcopy * if cytology normal then test repeated at 12 months * if HPV now negative at 12 months then normal recall * if HPV still positive at 12 months then return in another 12 months * if HPV positive at 24 months then colposcopy * if sample inadequate then repeat in 3 months * if two inadequate samples then colposcopy

Answer 19

* Large loop excision of transformation zone (LLETZ) is the most common treatment for cervical intraepithelial neoplasia. * LLETZ may sometimes be done during the initial colposcopy visit or at a later date depending on the individual clinic. * once treated for CIN1, CIN2, or CIN3 they should have a cervical sample in the community 6 months after treatment for a test of cure

Answer 20

* Current or past breast cancer * Any oestrogen-sensitive cancer * Undiagnosed vaginal bleeding * Untreated endometrial hyperplasia

Answer 21

Women should be advised that the symptoms of menopause typically last for 2-5 years

Answer 22

* Venous thromboembolism: * A slight increase in risk with all forms of oral HRT. * No increased risk with transdermal HRT. * Stroke: * Slightly increased risk with oral oestrogen HRT. * Coronary heart disease: * Combined HRT may be associated with a slight increase in risk. * Breast cancer: * Increased risk with all HRT although the risk of dying from breast cancer is not raised. * Ovarian cancer: * Increased risk with all HRT.

Answer 23

* Hot flushes * regular exercise, weight loss and reduce stress * Sleep disturbance * avoiding late evening exercise and maintaining good sleep hygiene * Mood * sleep, regular exercise and relaxation * Cognitive symptoms * regular exercise and good sleep hygiene

Answer 24

* Vasomotor symptoms * fluoxetine, citalopram or venlafaxine * Vaginal dryness * vaginal lubricant or moisturiser * Psychological symptoms * self-help groups, cognitive behaviour therapy or antidepressants * Urogenital symptoms * if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not * vaginal dryness can be treated with moisturisers and lubricants. These can be offered alongside vaginal oestrogens if required.

Answer 25

* methotrexate is the most widely used DMARD. * Monitoring needs to be done before starting, weekly until treatment has stabilised and then every three months after that * FBCs → risk of myelosuppression * LFTs → risk of liver cirrhosis. * U&E * Other important side-effects include pneumonitis * not safe until 6 months following pregnancy * even men need to use contraception until 6 months after taking it * taken weekly * folic acid once weekly co-prescribed (taken 24hrs after methotrexate) * interactions * high dose aspirin increases risk of methotrexate toxicity * avoid co-prescribing trimethoprim or co-trimoxazole

Answer 26

* sulfasalazine * only DMARD safe to use in pregnancy * adverse effects: * reversible oligospermia * pneumonitis / lung fibrosis * myelosuppression * may colour tears → stained contact lenses * cautions * G6PD deficiency * allergy to aspirin or sulphonamides (cross-sensitivity)

Answer 27

* ASEPTIC * Appearance and behaviour * Speech * Emotions (mood) * Perception * Thought * Thought content * Thought process * Insight * Cognition and Judgement

Answer 28

* explain procedure * offer chaperone * have patient lie on side with knees drawn up to chest * double glove * lubricate finger * insert finger and palpate prostate anteriorly * rotate finger 360 degrees * assess tone by having patient bear down * withdraw finger and inspect for blood or mucus * clean patient * cover them with sheet

Answer 29

* Note the site of the stoma * Note the number of lumens * Note if there is a spout present * Inspect the contents of the stoma bag * Inspect the surrounding skin * Look for evidence of stoma complications (e.g. parastomal hernia)

Answer 30

* General inspection from end of bed * Differentiate hernia from other lumps * Assess the characteristics of the lump * Number of lumps * Cough impulse * Consistency * Ability to get above the lump * Tenderness * Bowel sounds * Bruit * Transillumination

Answer 31

* Pronator drift * Coordination * finger to nose * dysdiadochokinesia *

Answer 32

* normal gait * tandem gait * walk on heels * rombergs * clonus * babinskis * coordination * heel shin

Answer 33

* full neurological examination * cranial nerves * cerebellum * lower limb neuro * neuroimaging

Answer 34

* full neurological examination * cranial nerves * cerebellum * lower limb neuro * neuroimaging

Answer 35

* gait * normal * tandem * rombergs * speech * nystagmus * upper limbs: * tone * finger nose * rebound phenomenon * dysdiadochokinesia * lower limbs * tone * knee jerk reflex * coordination with heel shin

Answer 36

full neuro examination, neuroimaging and formal hearing assessment

Answer 37

* Explain fundoscopy to the patient * Perform general inspection of the eyes * Prepare for fundoscopy: instil mydriatic eye drops and set up the ophthalmoscope * Assess the red reflex * Assess the optic disc * Assess the retina * Assess the macula * Repeat fundoscopy on the other eye

Answer 38

* expose hands wrists and elbows * general inspection * resting tremor * if not obvious ask them to close their eyes and count back from twenty * hypomimia * intention tremor * finger nose * gets worse as approaches target * bradykinesia * finger tapping * tone * in shoulder, elbow and wrist * velocity non-dependent rigidity * assess for spasticity * cogwheel rigidity may be present * if rigidity is not obvious ask them to tap the other hand on their leg while you assess * gait * sitting to standing with arms around chest * observe arm swing * observe turn * other tests * assess for asymetric progressive micrographia * undo and do up top button

Answer 39

perform a cerebellar examination perform an eye movement assessment perform a cognitive assessment

Answer 40

* painful arc assessment * supraspinatus impingement * empty can test * supraspinatus assessment * external rotation against resistance * teres minor and infraspinatus * external rotation in abduction * teres minor * internal rotation against resistance * lift off test * scarf test

Answer 41

* perform a full neurovascular examination of the upper limb * examine the C spine * examine the elbow * review any available imaging

Answer 42

* chest expansion * schobers test * sciatic nerve stretch test * femoral nerve stretch test

Answer 43

perform a neurovascular examination of the upper and lower limbs, examine the hip and shoulder joints and review any imaging

Answer 44

* gait * trendellenburg's * apparent leg length * between the umbilicus and the tip of the medial malleolus * true leg length * between the anterior superior iliac spine to the tip of the medial malleolus * thomas's test for fixed flexion deformity

Answer 45

* Neurovascular examination of both [_lower limbs_](https://geekymedics.com/lower-limb-neurological-examination/). * Examination of the joints above and below ([_lumbar spine_](https://geekymedics.com/spine-examination/)and [_knee joint_](https://geekymedics.com/knee-examination/)). * Further imaging if indicated (e.g. X-ray and MRI).

Answer 46

* gait * patellar tap * posterior sag * anterior draw * collateral ligament assessment * mention meniscal assessment

Answer 47

neurovascular examination of both lower limbs, examination of the joint above and below and further imaging

Answer 48

* screening questions * pain or stiffness in muscles, joints or back? * difficulty getting dressed without any help? * problems going up or down the stairs? * observe gait * assess footwear * inspect from all sides * arms * hands behind head * hands out in front of you with spread out fingers * inspect dorsum of hands * turn hands over * inspect palm of hands * make a fist * squeeze my fingers * MCP squeeze * do up your buttons * legs * passive knee flexion * passive knee extenson * passive hip internal rotation * MTP squeeze * patellar tap * spine * assess cervical lateral flexion * assess lumbar flexion * TMJ function

Answer 49

focused examination of joints suspected of having pathology, review any available imaging

Answer 50

* general inspection * ask patient to point to lump * inspect closely from front to side * if midline mass consider thyroid examination * palpate lump * apply light source to see if it transilluminates * auscultate lump for bruit * palpate lymph nodes

Answer 51

* perform a thyroid status assessment * perform an examination of the lymphoreticular system * perform an examination of the oral cavity * perform routine blood tests * perform an ultrasound scan of the lump * perform a fine needle aspiration of the lump

Answer 52

* intro * check patient's resuscitation status * review patient's notes * clarify circumstances surrounding death * introduce self and offer condolences to the family members present * wash hands * confirm identity of patient by checking wrist band * confirming death * inspect for obvious signs of life * assess response to verbal stimuli * assess pupillary reflexes * palpate carotid artery * assess response to pain * auscultate for heart sounds for 2 minutes * auscultate for breath sounds for 2 minutes

Answer 53

* position them on couch at 45 degrees * Ask if any pain in shoulder * Begin by inspecting each axilla for evidence of scars, masses, or skin changes * for right axilla, hold patient’s right forearm in your right hand and tell them to relax it completely, allowing you to support the weight. * Palpate the axilla including the pectoral (anterior), central (medial), subscapular (posterior), humoral (lateral), and apical groups of lymph nodes. * Repeat assessment on the contralateral axilla (using your left hand to hold the patient’s left forearm)

Answer 54

* general inspection * hands * inspect * assess and compare temperature * CRT * assess skin turgor * pulses and BP * radial rate * resp rate too * brachial * BP * JVP * Face * eyes * mouth * chest * central CRT * heart sounds * auscultate lungs * sacral oedema * abdo * inspect abdomen * assess for shifting dullness * pedal oedema

Answer 55

* contraindications * pregnancy * risk of or active bleeding * once daily tablet usually in evening * start at 5mg * then INR on days 3,4 and 5 * after that INR frequency depends on stabilisation * dose changes take 2-3 days to affect INR * should avoid * alcohol binges * liver * spinach and leafy greens * smoke as much as they do right now * side effects * bleeding * diarrhoea * nausea

Answer 56

* stops one of the proteins that causes clots from working - thereby thinning the blood * once or twice daily tablet * take with full glass of water sitting upright * contraindicated in renal failure * check renal function before and annually * side effects * GI disturbance * bleeding

Answer 57

* once daily tablet * dose changes take 4-6 weeks to take effect * TSH every 2-3 months until stable * when TSH stable check it annually * warn about symptoms of hyperthyroidism * vomiting * diarrhoea * head ache * palpitations * heat intolerance * warn about symptoms of hypothyroidism * cold intolerance * constipation * weight gain * menorrhagia

Answer 58

* contraindications * pregnancy * statins stop liver making cholesterol * explain that hypercholesterolaemia is a cardiovascular risk factor * counsel about other risk factors * once daily tablet in evening * LTFs * at baseline * at 3 months (20% transient increase normal) * at 12 months * lipid profile to track progress and adjust dose * at baseline * at 1 month * then every 12 months * side effects * muscle pains * head ache * itching * nausea * rhabdomyolysis * contact doctor if severe muscle pain and dark urine

Answer 59

* check understanding of condition * check for contraindications * explain how drug works * explain how it's taken * explain any monitoring required * explain any side effects uppity cows want to meet elephants

Answer 60

* 1-3 times daily tablet or syrup * works best if taken without food but most take it with food because it can irritate the stomach * takes 3-4 weeks for Hb to normalise * treatment needs to continue for a further 3 months after this to fully replenish stores * Hb will be checked after 3-4 weeks * side effects * GI irritation * black/green stools * metallic taste

Answer 61

* contraindications * suicidal risk * mania * alter imbalance of serotonin that may have been causing depression symptoms * once daily tablet * may be gradually stopped 6 months after feeling better * effects seen in 4-6 weeks * in that time it may get worse before it gets better * side effects * GI - nausea vomiting diarrhoea * Headaches * Drowsiness (but if so can take at night) * Anxiety for two weeks at beginning * withdrawal * may increase risk of suicidality in young people

Answer 62

* contraindications * pregnancy * breast feeding * hepatic impairment * active infection * immunodeficiency * alters immune system to improve symptoms * once weekly tablet * folic acid tablet on another day * takes 3-12 weeks to improve symptoms * Monitoring * FBC, U&E, LFT * before starting * every two weeks until stabilised * then every 2-3 months * give patient a monitoring book * side effects * alopecia * headaches * infections * seek medical advice if infective symptoms * get annual flu jab * bleeding

Answer 63

* contraindications * 1st trimester pregnancy * breast feeding * cardiac insufficiency * significant renal impairment * stabilises mood - exact mechanism unknown * once or twice daily tablet * takes one to two weeks to work * before starting * FBC * U&E * TFT * BHCG * ECG * check lithium level * after 5 days * then every week until stable for 4 weeks * then every 3 months * lithium toxicity symptoms * GI: * anorexia * diarrhoea * vomiting * Neuromuscular * dysarthria * dizziness * ataxia * muscle twitching * other * drowsiness * apathy * restlessness * other side effects * nausea * metallic taste * fine tremor * urinary frequency and urgency

Answer 64

* contraindicated in glaucoma * replaces dopamine which your brain is no longer producing * particularly helps with rigidity and slow movements * given with carbidopa which stops it being broken down * taken 3-4 times a day with food * important not to miss a dose * starts working straight away * after 5 years most have “on-off” symptoms of rigidity when next dose is due * no monitoring * side effects * psychosis * nausea and vomiting * dyskinesias * postural hypotension * impulsive behaviour * dizziness

Answer 65

* contraindications * pregnancy * dysphagia * recent peptic ulcer * significant renal impairment * unable to sit upright for 30 minutes * prevents bone from being broken down and helps to build new bone * counsel on lifestyle factors can help * exercise * not smoking (we can help) * well balanced diet * how to take * once daily or once weekly tablet * swallow with full glass of water * at least 30 minutes before food * upright for 30 minutes after taking it * need regular dental check ups in case of osteonecrosis of jaw * side effects * headache * heartburn bloating indigestion * diarrhoea/constipation * seek urgent medical advice if * vomiting blood/black stools * dysphagia/odynophagia * osteonecrosis of the jaw

Answer 66

* **Benefits** * Only used during intercourse * Reduces STI transmission * Side effects are rare * **Limitations** * Can break, split or tear during use * Can interrupt intercourse to put a male condom on * Technique is important * latex allergy (alternative materials are available) * Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 18%

Answer 67

* **Benefits** * Only used during intercourse * Can be put in place in advance of intercourse * Side effects are rare * **Limitations** * Can break, split or tear during use * May interrupt intercourse to put the diaphragm/cap in * Patients need to know the correct technique for using a diaphragm/cap * Does not protect against STIs * **Unintended pregnancy rate** * 12% of women will experience an unintentional pregnancy in a year of typical use

Answer 68

* they contain a synthetic form of oestrogen and progesterone * they work by: * inhibiting ovulation * thickening the cervical mucus → prevents sperm passage * thinning endometrium → inhibiting implantation

Answer 69

* Migraine with aura * Current breast cancer * High VTE risk factors, such as: * Atrial fibrillation * SLE (positive for antiphospholipid antibodies) * Age over 35 years old and smoking at least 15 cigarettes daily * History of stroke * History of VTE * Known thrombogenic mutations * Complicated valvular or congenital heart disease * Other cardiovascular risk factors such as: * Hypertension: \>160mmHg systolic BP or \>100mmHg diastolic BP * History of ischaemic heart disease * Severe liver disease

Answer 70

There is some evidence to suggest that the risk of breast cancer is increased in individuals using combined contraceptives. However, this risk reduces to normal levels 10 years after stopping the contraceptive. Patients with a history of breast cancer may be allowed to use combined contraceptives but this should only be prescribed with the guidance of their oncology team.

Answer 71

Microgynon 30® and Rigevidon®.

Answer 72

Traditionally, patients take the pill on a 21/7 cycle i.e. 21 days of taking the pill at the same time each day, then a 7-day break where they will have a period-like withdrawal bleed. Depending on patient preference and suitability, other regimens can be used such as 21/4, 63/7, or continuous use with no hormone-free interval

Answer 73

* **Benefits** * No interruption to intercourse * Can be stopped at short notice if not tolerated * Less strict “missed pill rules” than the progestogen-only pill * May make periods more regular, lighter and less painful * May have therapeutic benefits in gynaecological disorders including endometriosis and menorrhagia * **Limitations** * Effectiveness reduced if a pill is forgotten * Side effects may include headaches, nausea, breast tenderness and mood swings * Vomiting and diarrhoea may affect the effectiveness * Certain drugs including anti-epileptic drugs may affect the effectiveness * Increases the risk of VTE and stroke * Potentially increases the risk of breast cancer while using the COCP * Does not protect from STIs * **Unintended pregnancy rate** * Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 9%

Answer 74

One patch is applied for 7 days and then immediately changed for a new patch. Traditionally, 3 patches are worn for 21 days in total and then a 7-day patch-free interval is taken, where a patient may have a period-like withdrawal bleed. As with the COCP tailored regimens can be used. This type of contraceptive might be well suited to someone who does not mind wearing the patch but tends to forget pills.

Answer 75

* **Benefits** * Do not need to remember daily like the pill * No interruption to intercourse * Can be stopped at short notice if not tolerated * May make periods more regular, lighter and less painful * Vomiting and diarrhoea do not affect effectiveness unlike the pill * **Limitations** * Protection from pregnancy may be affected if they forget to change the patch or if it falls off * Side effects may include headaches, nausea, breast tenderness and mood swings * Certain drugs may affect effectiveness including some anti-epileptic drugs * Increases the risk of VTE and stroke * Potentially increases the risk of breast cancer while using the patch * Does not protect from STIs * **Unintended pregnancy rate** * Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 9%

Answer 76

* **Benefits** * Do not need to remember daily like the pill * No interruption to intercourse * Can be stopped at short notice if not tolerated * May make periods more regular, lighter and less painful * Don't need to wear a patch * Vomiting and diarrhoea do not affect effectiveness unlike the pill * **Limitations** * Side effects may include headaches, nausea, breast tenderness and mood swings * Certain drugs may affect protection including some anti-epileptic drugs * Increases the risk of VTE and stroke * Potentially increases the risk of breast cancer while using the ring * Does not protect from STIs * **Unintended pregnancy rate** * Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 9%

Answer 77

The contraceptive vaginal ring (also known as the NuvaRing®) is a small plastic ring that is placed high in the vagina and secretes oestrogen and progestogen to prevent ovulation. The ring is inserted into the vagina for 21 days and then removed for 7 days before the next ring is put in. Again as with the COCP, tailored regimens can be used e.g. wearing 3 rings in a row for 63 days, then taking a 7-day break.

Answer 78

The progestogen-only pill is taken every day without any breaks. These pills do not contain any oestrogen. There are a couple of types of POP used currently: * Desogestrel POP works mainly by inhibiting ovulation. It also works by thickening cervical mucus and thinning the endometrium. * should be taken within the same 12 hours every day to be effective. * example: Cerazette®. * Norethisterone and levonorgestrel POPs work mainly by thickening cervical mucus and thinning the endometrium. * These POPs are taken much less commonly as they should be taken within the same 3 hours every day to be effective.

Answer 79

* **Benefits** * Suitable for patients where oestrogen is contraindicated or those who are intolerant to oestrogen * Taken without breaks so don’t have to remember to start and stop pills * No interruption to intercourse * Can be stopped at short notice if not tolerated * **Limitations** * Protection from pregnancy affected if a pill is forgotten * More strict “missed pill rules” than COCP * May cause irregular bleeding, amenorrhoea or more frequent bleeding * Vomiting and diarrhoea may affect protection * Certain drugs including some enzyme-inducers may affect the effectiveness * Does not protect from STIs * **Unintended pregnancy rate** * Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 9%

Answer 80

The injection contains progestogen only and is carried out every 12 weeks. It is typically administered intramuscularly into the buttocks. The systemic progestogen inhibits ovulation, thickens the cervical mucus and thins the endometrium. The Depo-Provera® is one of the most commonly administered contraceptive injections.

Answer 81

* **Benefits** * Suitable for patients where oestrogen is contraindicated or those who are intolerant to oestrogen * Do not need to remember to take a pill daily * No interruption to intercourse * **Limitations** * May cause irregular bleeding, amenorrhoea or more frequent bleeding * The patient needs to tolerate injections * Can affect bone mineral density if used long-term * Does not protect from STIs * Irreversible for the duration of the drug’s effect * Fertility can take months to return after ceasing use * **Unintended pregnancy rate** * Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 6%

Answer 82

The contraceptive implant is a small plastic rod approximately 4cm in length inserted under the skin in the upper arm. It slowly releases progestogen to prevent pregnancy by inhibiting ovulation as well as thickening the cervical mucus and thinning the endometrium. A commonly used type is Nexplanon®.

Answer 83

* **Benefits** * Once inserted, it lasts for 3 years * Suitable for those who cannot use oestrogen * The **most effective form of contraception available**, including sterilization * No interruption to intercourse * reversible as can be removed * **Limitations** * May cause irregular bleeding, amenorrhoea or more frequent bleeding * Qualified practitioner required to insert implant * Can cause or worsen acne * Procedure to fit and remove it which has a risk of bruising and infection * Does not protect from STIs * **Unintended pregnancy rate** * Percentage of unintended pregnancies within 1 year with typical use of contraception method = 0.05% (i.e. 1 in 2000

Answer 84

Hormonal coils, also known as intrauterine systems (IUS), are T-shaped plastic rods inserted into the uterus that release progestogen locally. They prevent pregnancy by thinning the endometrium to prevent implantation and by thickening cervical mucus to prevent sperm passage. The Mirena® or is a hormonal coil licensed for use for 5 years for contraception and for treating menorrhagia. The Jaydess® is a similar size to the Kyleena® and is licensed for 3 years.

Answer 85

* **Benefits** * Lasts for 3 or 5 years * Suitable for those who cannot take oestrogen * Very effective in preventing pregnancy * No interruption to intercourse * More likely than the implant to reduce heavy menstruation (particularly the Mirena®) * **Limitations** * Can make menstruation irregular especially in the first 6 months from fitting and can cause amenorrhoea * Can cause acne, headaches and breast tenderness * Qualified practitioner required to insert coil * Involves a procedure with speculum exam to fit and remove the coil; some women prefer other options due to this * _Small risk of uterine perforation and infection with insertion_ * _If pregnancy occurs, more likely to be an ectopic pregnancy_ * Does not protect from STIs * **Unintended pregnancy rate** * Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 0.2% (i.e. 1 in 500)

Answer 86

Copper coils, also known as intrauterine devices (IUD), are T-shaped plastic and copper rods inserted into the uterus. They prevent pregnancy by creating an inhospitable environment for the sperm and ovum to survive in the uterus. Copper coils generally last for either 5 years or 10 years.

Answer 87

* **Benefits** * Lasts 5-10 years * Suitable for women who cannot use hormonal contraceptives * Very effective in preventing pregnancy * No interruption to intercourse * Effectiveness unaffected by other medications * Can be used as emergency contraception * **Limitations** * Can cause heavier, longer and more painful menstruation * Qualified practitioner required to insert coil * Involves a procedure with speculum exam to fit and remove the coil; some women prefer other options due to this * _Small risk of uterine perforation and infection with insertion_ * _If pregnancy occurs, more likely to be an ectopic pregnancy_ * Does not protect from STIs * **Unintended pregnancy rate** * Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 0.8% (i.e. 1 in 125)

Answer 88

Female sterilisation is a procedure usually done under general anaesthetic or sometimes at the time of Caesarian section. It is considered irreversible when counselling patients, though it is possible in a small number of cases to surgically reverse. Hence, it is only suitable for women who are certain they do not want to become pregnant in the future.

Answer 89

* Tubal occlusion with surgical clips * Hysteroscopic sterilisation using fallopian implants * Salpingectomy

Answer 90

* **Benefits** * Permanent contraception * No interruption to intercourse * Does not affect their hormonal levels * Effectiveness unaffected by other medications * **Limitations** * Carries risks of surgery including bleeding and infection * Many women experience pain after their surgery * Very difficult to reverse * Women need to be informed that in rare cases they can still become pregnant * If pregnancy occurs, more likely to be an ectopic pregnancy * Does not protect from STIs * **Unintended pregnancy rate** * Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 0.5% (i.e. 1 in 200)

Answer 91

Natural family planning, or fertility awareness, is where intercourse is timed to coincide with the times during the menstrual cycle when ovulation is least likely. Fertility signs such as body temperature and cervical secretions may be monitored by the individual. This aims to prevent pregnancy by reducing the risk of the ovum being available for fertilisation by the sperm. This method is unsuitable for women with irregular menstrual cycles

Answer 92

* **Benefits** * There are no side effects from this type of contraception * It is acceptable to most faiths and cultures * **Limitations** * Much less effective form of contraception * Must avoid sex or use other contraception around the time of ovulation * Requires significant patient commitment to record daily fertility signs * Fertility signs are unreliable when breastfeeding * Fertility signs can be affected by illness and stress * Does not protect from STIs * **Unintended pregnancy rate** * Percentage of women experiencing an unintended pregnancy within 1 year with typical use of contraception method = 24%

Answer 93

ellaone levonelle copper coil

Answer 94

* This contains a high dose of the synthetic progestogen levonorgestrel. * Prevents pregnancy by delaying ovulation, by which time any sperm in the reproductive tract would be non-viable. * Must be taken within 72 hours of UPSI. * If taken after the start of the LH surge that causes ovulation, there is no evidence of this method working

Answer 95

* **Benefits** * Can be taken if the patient has recently taken a progestogen-containing contraceptive * Can start ongoing hormonal contraception on the same day * Can be taken more than once in a menstrual cycle * Unlike the copper coil, no insertion procedure is required * Easily accessible for patients * Fewer contra-indications than ellaOne® * **Limitations** * No evidence of any benefit if taken after LH surge has occurred * More effective at the start of the 72-hour window than at the end * Efficacy affected by enzyme-inducing medications and by patient weight * The _least effective form of emergency contraception_ * Does not provide any ongoing contraception * **Unintended pregnancy rate** * Effectiveness is difficult to quantify but around 1.7-2.2% of women who took this pill within 72 hours of UPSI became pregnant in the same cycle

Answer 96

EllaOne®, which contains ulipristal acetate, prevents pregnancy by delaying or stopping ovulation. It must be taken within 120 hours to be effective, and unlike Levonelle® evidence suggests that some effectiveness remains even after the start of the LH surge (although not after ovulation itself).

Answer 97

* **Benefits** * More effective than Levonelle®, particularly if close to ovulation date * Unlike the copper coil, no insertion procedure is required * Easily accessible for patients * Effective up to 120 hours after UPSI, as compared to 72 hours for Levonelle® * Effectiveness remains the same throughout the 120-hour window * Can be used more than once in the same cycle * **Limitations** * No evidence of any benefit if taken after ovulation has occurred * Efficacy affected by enzyme-inducing medications and by patient weight * Must wait 5 days after taking ellaOne® before starting other hormonal contraceptives * Not recommended in patients with s_evere asthma, hepatic dysfunction, or taking PPIs/antacids_ * Does not provide any ongoing contraception * **Unintended pregnancy rate** * Effectiveness is difficult to quantify but around 1.3-1.6% of women who took this pill within 120 hours of UPSI became pregnant in the same cycle

Answer 98

* Most effective form of emergency contraception and should be offered to all patients for consideration. * Must be inserted either within 5 days of UPSI or within 5 days after ovulation (whichever date falls latest in the menstrual cycle). * As such the coil is effective even if there have been multiple episodes of UPSI earlier on in a cycle, so long as it is inserted within the 5 day window after ovulation. * It can then be left in place to give long-term contraception if desired.

Answer 99

* **Benefits** * The most effective form of emergency contraception * Provides ongoing contraception for up to 10 years * The only form of emergency contraception which is effective if fitted after ovulation * Is not affected by patient weight or other medications * **Limitations** * As explored above, a qualified practitioner is required to insert the coil, which some women may find uncomfortable. The procedure itself carries small risks of perforation and infection. * Less convenient than oral emergency contraception * Absolutely contra-indicated to insert \>5 days after ovulation * **Unintended pregnancy rate** * Effectiveness is difficult to quantify but \<0.1% of women who had the coil inserted during the appropriate window became pregnant in the same cycle

OSCE Flashcards

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