OSCE Stations Flashcards

Question

Communication: breaking bad news

Answer 1

S etting up the interview- choose environment have a plan of what to say and think of what patient might ask P erception - assess patients perception what do they know what do they understand so far what are they expecting I nvitation- how much information do they want K nowledge and information- warn patient of bad news start basic and give patient time and depending on how much they wanted to know chunk further information E motions - give time for emotions and respond accordingly identifying anxieties were appropriate S trategy and summary - explain what comes next ask patient to repeat back to you what was said to ensure they have understood and offer leaflets and future appointments to rediscuss, write down information.

Answer 2

PC: Patient demographics, referred by? presenting complaint in own words HPC: nature of the problem, duration, frequency, timing, associated symptoms, precipitating/aggravating/ relieving factors PPHx: any previous contact with services e.g. GP, outpatient, admission. Any past treatment if so length and outcomes. Medications that worked and those that did not. Depot, ECT, Lithium, Clozapine? DHx: current medication type, dose, frequency, route, blood screening required? Allergies? PMHx: illnesses, operations, treatment FHx: history of medical or psychiatric illness PHx: - Childhood: Birth (NVD or complications), SCBU, Developmental Delay (milestones), early separation, neurotic traits (thumb sucking, school refusal, bed wetting) - School: age started school, peer relationships, academic achievement, relationship to teachers (authority), suspension/expulsion, "special" school, exams and qualifications - Employment: all jobs and durations with reasons for leaving/moving, any notable period of unemployment? - Relationships: menarche, first sexual experience, history of abuse, longest past relationship and others, sexual orientation, current relationship FoHx: forensic history e.g. Criminal Behaviour, Arrests, prison, probation, dates seriousness, forensic psychiatrist SHx: housing situation, finances, debts, friends, social interests, religion, substance misuse (alcohol and illicit drugs, how much, how long, what, blackouts, withdrawal, reasons, hospital admissions) MMSE Collaborative history from family or other carers

Answer 3

- WIPER QQ - ensure you have correct equipment, cotton ball, pen torch, fundoscope (offer), tuning fork, tendon hammer, snellen carts and ishihara plates (offer) - Olfactory nerve (1): ask the patient if they have noticed any change in their sense of smell, formally test with distinct odor e.g. coffee, vinegar, orange. - Optic nerve (2): test Acuity, Colour, Fields, Light reflexes and perform fundoscopy. The first can be down with a snellen chart, and the second with ishihara plates. To test visual fields ask patient to look directly at you whilst covering one eye and wiggle fingers in each of the four quandrants starting at your peripheries working your way to the centre. also test for visual extinction here. Visual reflexes comprise of direct and concentric refleces shine in one eye and check both constrict. offer to perform fundoscopy. - Oculomotor nerve (3), Trochlear nerve (4), and Abducens nerve (6): asking the patient to keep their head perfectly still, ask to follow finger whilst moving it along horizontal plane reporting any dizziness or double vision, looking for nystagmus. also draw a large H. - Trigeminal nerve (5): Test sensory supply to face using cotton wall and blunt pin in each division, maxillary, mandibular, opthalmic, and offer corneal reflex. also test motor supply of muscles of mastication feeling the bulk of the masseter and temporalis and asking the patient to open mouth against resistance - Facial nerve (7): motor branches of muscles of facial expression also supplies anterior 2/3 of tongue so ask about change in taste and then ask patient to crease up forehead or raise eyebrows, keep eyes closed against resistance, puff out cheeks, show their teeth, - Vestibulocochlear nerve (8): innervation to hearing apparatus use Rhinnes, and Weber tests to differentiate between conductive and sensori-neural hearing loss. Rhinnes is air vs bone conduction, webers fork is placed on centre of forehead. - Glossopharyngeal nerve (9): provides sesnory supply to palate, tested by gag reflex. - Vagus nerve (10): provides motor supply to pharynx ask patient to say ahh check for deviation towards side of lesion. - Accessory nerve (11): provides motor supply to sternocleidomastoid and trapezius to test ask patient to shrug shoulders and turn head against resistance. - Hypoglossal nerve (12): motor supply of tongue, ask patient to stick out of tongue and move it side to side, will deviate to side of lesion. - Thank patient - full neurological examination of upper and lower limbs - take a full history

Answer 4

WIPER QQ Look: - Deformity, Wasting, Asymmetry, Rashes, Fasciculations, Scars - Swelling or bruising Feel: - Feel for temperature change suggesting inflammation - Bend the knee to about 70 degrees and sit on the edge of the cough facing the knee, feel the bony contours around the joint and the attachment of the ligaments and tendons e.g. quadriceps tendon, medial collateral ligament, lateral collateral ligament, patella ligament and note any tenderness. - Test for synovial thickening by grasping patella between thumb and middle finger and attempting to lift it off the femoral groove, normally it can be gripped quite firmly but if the synovium is thickened fingers slip off. - feel the medial and lateral aspects of the patellofemoral joint by straightening the leg and pushing the patella either side feeling the undersurface of the bone for tenderness. A feature that is often encountered in patellofemoral osteomalacia or osteoarthritis. Move: - Ask patient to bend and straighten knee fully, note range of movement - Repeat the process while placing a hand over the front of the knee feeling for crepitus and testing passive movements. Tests: - patella tap/bulge test for intra-articular fluid - collateral ligaments (hold leg in extension with foot under arm and both hands around knee test mediolateral movement no movement at extension repeat at 30 degrees - anterior/posterior drawer test +/- lachmans Conclusion: - Thank patients - Wash hands - neurovascular examination of limb - Appropriate imaging e.g. MRI or X-ray

Answer 5

Wash hands, Introduce self, confirm patient details, explain examination, gain consent Inspect: - pinna, auricule, helix, antihelix - any visible wax or discharge, blood - preauricular sinuses - any scars behind the ear - hearing aids - the meatus itself is it wide? Palpate: - tug gently on the pinna - any tenderness? - Press over the mastoid process - any tenderness? - palpate the tragus - any tenderness? - Palpate for any cervical or periauricular lymphadenopathy Otoscopy: - gently hold ear up and back to straighten the ear canal - gently insert the otoscope - look at the canal wall - any wax/discharge/bleeding - look at the tympanic membrane any perforation, light reflex present, bulging drum, retracted drum, grommets, cholestatoma, fluid bubbles. Special Tests: - Whispered voice hearing tests - Rhine test - Weber test Conclusion: - examine facial nerve for signs of damage - formal audiometric testing

Answer 6

WIPER Inspect: - External appearance of the nose from front, sides, top and bottom - any scars, skin changes, asymmetry - use a thudichum speculum to look into the nose, look at nasal vestibule, septum, inferior tubinate if pale and boggy think allegic rhinitis Examine nasal airfow: -using a silver tongue depressor under nose look for teaming Examine sensation of maxillary division of trigeminal nerve Conclusion: - examine the throat - test patients sense of smell - consider using flexible nasoendoscopy - thank patient

Answer 7

- at all stages do I need help? - Dry the baby (unless less than 28wks place under radiant heat (put in bag). - Set a clock in motion, and assess colour, tone, breathing + pulse, grimace (APGAR) if not breathing after 60 seconds then... - control the airway head in neutral position - Support breathing, 5 inflation breaths, aim for inflation pressure of 20cm H2O (max 40cmH2O) Confirm response: visible chest movements or increased heart rate. - if no response, check head position and try a jaw thrust, then 5 inflation breath, confirm response via visible chest movements or increased heart rate. - If still no response get 2nd person to help control the airway and inflation breaths, any sucking out of the pharynx should be under direct vision. Repeat 5 inflation breaths insert Oropharyngeal airway and repeat inflation breaths, consider intubation, confirm response with increased chest moments or increased heart rates. - when chest is moving continue with ventilation breaths if no spontaneous breathing. - Check heart rate, if absent of less than 60 start chest compression, do 3 chest compression to 1 breath for 30secs. - reassess pulse if improving stop chest compression, if not breathing, go on ventilating, if heart rate still low or absent continue both. - consider IV or umbilical access and drugs e.g. Adrenaline 0.1mL of 1:10000 IV/kg

Answer 8

WIPER QQ Questions: - any eye, hip, or congenital heart disease issues in childhood with any first degree relative? - any problems with antenatal scans? - Breech presentation? - has baby passed stool + urine? Listen: -lungs and chest whilst calm, note any murmurs Look: - red reflex - rashes, colour, position, tone, asymmetry, any lumps or bumps, bruising. - ears normal - check for anus - put on back check spine - umbilicus Feel: - fontanelles - clavicles - check for cleft pallet (couple with sucking reflex) - abdomen - femoral pulses - abdomen, any masses - Palpate testes - Barlow + Ortlani tests for DDH Reflexes: - sucking reflex - Moro reflex - grasping reflex Conclusion: - Thank parents - dress baby - report findings - arrange neccessary follow up

Answer 9

- Wash hands, Introduce self, confirm patient details, explain - Reasons for test: explain indicators or ask why patient wants test now. - Ever been tested before? If so when and what was result? - Exposure? Last UPSI, Any risk factors, country of origin, MSM, IVDU, blood transfusions outside UK, seroconversion symptoms (fatigue, fever, sore throat, rash, headache, lymphadenopathy - Benefits of testing. HIV is treatable with normal life expectancy on treatment and knowing positive enables to reduce the chances of transmission. Reassurance if negative. - Basic information on test? POCT has window period of 6-12 wks but results today, blood test has window period of 4-6 weeks but results take longer. - Agreement. Do you have consent to have test today? - Follow up? If the result is positive arrange an appointment with consultant/ health advisor. How would they like results.

Answer 10

- Introduce self , confirm patient details, explain, consent - Why have they come to you? (What's brought them in) -Any symptoms? Women - vaginal discharge, dysuria/frequency, vulval itching/soreness, genital skin changes, abdominal pain, dyspareunia, post-coital bleeding, systemic symptoms Men - Urethral discharge, testicular pain, dysuria/frequency, itching, genital skin changes, systemic symptoms - Menstrual history -LMP, regularity, length of cycle, dysmenorrhea intermenstrual bleeding. - Obs + Gyn history - smears (dates/results), any surgery?, current contraception, possible pregnancy/ - sign post for sexual history, acknowledge sensitivity - when did they last have a sexual encounter - partner demographics I.e. Sex, regular or casual, age - what types of sex did they have? Oral Anal (received or gave or both) Vaginal Digital - was contraception used for all sexual encounters, any issues? - any other partners in the last 3 months? - any previous STIs or tests/results - any medical or surgical problems - any current medications, recent antibiotics? - Social history, smoking alcohol recreational drug use. - HIV risk history, ever had a partner who was HIV possible, ever had sex with a bisexual or participated in MSM, ever injected drugs, paid or been paid for sex - ICE - Thank patients.

Answer 11

WIPER QQ - offer chaperone - don gloves Inspection: - Inspect the genial region and surrounding areas for any skin changes (rash/brushing/swelling), scars, obvious masses. - inspect the penis and glans (ask patient to retract foreskin) - inspect the scrotum asking the patient to hold their penis out of the way, remember to examine posterior aspect by lifting the scrotum, looking for skin changes (rash/ulcers/erythema), scars, masses, necrosis, swelling, brushing. Palpation: - Examine each testicle, starting with the normal testicle, ask the patient to report any pain or discomfort, use thumb and index finger to gently Palpate the testicle. If a mass is felt assess the size/shape, regularity, consistency, pain, whether you are able to get above the mass. Is it fixed to testicle? Is their a cough impulse? Does the mass transilluminate. - Palpate the epididymis located at the posterior aspect of the testicle, pain suggest epididymitis, Phren's test = if testicular pain is relieved by elevating the testes this is strongly suggestive of epididmitis - Palpate the spermatic cord starting at the superior aspect of the testicle using the thumb and index, roll the cord assessing its length for masses and tenderness. - assess the local lymph nodes in the inguinal region for evidence of lymphadenopathy. Conclusion: - thank patient - allow time to dress - dispose of gloves - wash hands - summarise findings - to complete full abdominal examination and USS of the testicles.

Answer 12

Controlled Drugs prescriptions must: - be indelible (in pen) - be dated - be signed by the prescriber - include the prescribers address - include the name and address of the patient - include the date of birth of the patient - include the form of the preparation e.g. Tablets, Capsules - include the strength of the preparation - include the total quantity in both words and figures or number in words and figures of doses to be supplied - include the dose to be taken ``` E.g. Diamorphine 30mg Injection (SC) Supply 6(six) ampoules 60mg daily by subcutaneous infusion over 24 hours No more items on this prescription ```

Answer 13

Introduction: - Wash hands, introduce self, confirm patient details - "Do you know why you have come in today?" - "What do you understand about the procedure?" - Reason for the procedure e.g. Alleviate symptoms of BPH Pre-procedure: - patient to be nil-by-mouth for at least 6 hours - anaesthetic will be used either spinal or general Procedure: -thin device with a camera at the end is inserted into the urethra. The prostate is visualised and the prostate tissue is then removed. Post-Procedure: - stay overnight with catheter which is usually removed within 24hours - patient will be seen in outpatients for follow up in a few weeks time Complications: -Haemturia, injury to urethra/bladder, urinary incontinence, erectile dysfunction, retrograde ejaculation, TURP syndrome, urinary retention, condition can recur Conclusion: - Any other questions or concerns? - Provide a leaflet and opportunity to discuss further. - offer reassurance and close consultation.

Answer 14

Introduction: - wash hands, introduce self, confirm patient details - check patients understanding of their inhaler Explanation: - explain what the inhaler device is, show it to the patient - explain when the inhaler device should be used e.g. Preventer, remind to rinse mouth after the use. Reliever for during attacks - Check understanding Demonstration: - explain the steps as you demonstrate - prepare the inhaler (take of lid, shake if MDI) - load the dose (if applicable), squirt once to check - breath out gently as far as comfortable - tightly seal lips around mouthpiece - breath in, quick and deep for Dry powder, slow and deep for MDI - remove inhaler from mouth and hold breath for as long as possible (10 seconds) Assess Inhaler technique: - ask the patient to carry out the procedure themselves whilst you observe - tweak as necessary (point out positives then introduce improvement) Spacer devices: - explain they allow more medication to get to the lungs if people struggle. - Prepare inhaler - attach inhaler to spacer device - breath out gently as far as possible - seal lips around the spacer moutpiece - release the dose required - breath in and out through the space mouth price several times listening for the click of the one way valve. - device should be washed with detergent once a month and left to air-dry. - rinse mouth after use of steroid inhaler Conclusion: - any questions - provide information leaflet - advise to get in touch if any issues - thank patient and wash hands.

Answer 15

Introduction: - Wash hands, introduce self, confirm patient details - Starts with open question e.g. Can you tell me a bit about what has brought you in today? How might one make efforts to ensure patient has best capacity: - Avoid jargon - Using pictures - Treating concurrent pain - Allowing time for patient to process information - Asking questions at the best time of day for patient - Having a relative/friend present - Ensure a quiet comfortable setting. Assess patients ability to: - understand current situation - understand the risk of refusing treatment - understand the alternative choices for treatment - sustain the information for long enough to weigh up the implications of treatment versus non-treatment or alternative choices. - communicate a decision about treatment - rationalise reason for this decision Conclusion: - Express a wish to test the patients mental state. - May wish to speak to next of kin if possible

Answer 16

Introduction: - Wash hands, introduce self, confirm patient details - "Can you tell me what you understand has happened so far" Explain: - Febrile convulsions are a fit that happens when a child has a fever. - it is not epilepsy - They are relatively common and in most cases are not serious. - Around 1in20 children have at least one at some point. - They most often occur between the ages of 6months and 6 years. - The risk of developing epilepsy is slightly increased from 1in100 to 1in50 (1in20 if complex seizures) - about 1/3 of children will have another febrile seizure during a subsequent infection - if it happens again place child in recovery position and if the seizure last longer than 5 minutes or you notice any other symptoms such as a non-blanching rash then call for an ambulance. Conclusion: - any questions - give information leaflet - offer opportunity for further questions.

Answer 17

- Wash hands, introduce yourself, confirm patient details, confirm reason for presentation "what brought you in to see us today?" - Enquire about mood and general feelings e.g. How have you been feeling recently - Screen for core symptoms e.g. Feelings of depression, Anhedonia, fatigue. E.g. "In the past month have you felt down, depressed, or hopeless, found that you no longer enjoy things you used to or find little pleasure in life, been feeling overly tired?" - Assessing symptoms of depression e.g. Sleep cycle, mood, appetite, libido, concentration, perception of future, perception of self "do you often criticise of blame yourself when things go wrong? - Rule out differential psychiatric diagnoses e.g. Mania "have you ever experienced periods of feeling particularly high/energetic", evidence of psychoses "people who feel the way that you have been describing can sometimes experience some unusual events and feelings...have you every heard voices speaking when there seems to be no-one around?, do you fear that people may be out to get you? Have you ever felt that something or someone is able to put thoughts into your head? Have you ever felt that something or someone can remove thoughts from your brain. Have you every seen or heard any sensations that seem odd or inexplicable? Assess risk e.g. When people feel down and depressed, they can sometimes feel that things are so bad that life is no longer worth living, have you ever felt like this? Have you had any thoughts of taking your life" (if so how often) Have you ever made any plans or actually tried to take your own life. Have you tried to hurt yourself in any way or ever thought about it? What things do you have that stop you from harming yourself? Are you managing to eat a drink as you normally would? Has you alcohol intake change? Or have you been relying on drugs or alcohol to help make you feel better? Have you felt able to see your friends/family? Past psychiatric history, have you ever felt like this before, have you ever had any other periods of feeling particularly low? Have you ever had any problems with your mental health, any experience with counsellors or hospitals because of mental health? Past medical history Drug history Family History Social history: smoking, alcohol, any financial or housing concerns, Relationship issues? Spoken to friends or family? Support? Is mood affecting work? Do you feel like there is something wrong? Conclusion: - summarise and ask if there is anything to add? - any questions? - thank patient

Answer 18

Introduction: - wash hands, introduce self, confirm patient details - "I understand you have been through a tough time recently, do you think you can tell me what happened to bring you here?" The event: - Before e.g. events leading up to suicide attempt, life events, depression, planning? Suicide note/tell anybody?, precautions - During e.g. How, tablets? How many? Where from? What their intention was? When and where, how discovered, efforts to avoid discovery, alcohol/drug intoxication - After e.g. Feelings now, angry/regretful, future feelings? What has changed? Future risk: - depression symptoms screen - PMH, past suicide attempts/ self harm - social history, social, work relationship stresses - rest of psychiatric history Suicide risk factors: -male, old or young, unemployed, depressed, lack of social support, chronic illness, previous attempts, drug/alcohol abuse Conclusion: - thank patient and questions - offer risk low/moderate/high - crisis, informal admission, section?

Answer 19

WIPER Look: - is the patient demonstrating a normal heel strike/ toe off gait? - is each step of normal height (high stepping gait sign in foot drop) - Symmetry of feet/ankle - toe alignment - bunions - scars - swelling or erythema of the foot or ankle - examine shoes for asymmetrical wearing - foot arches - achilles tendon, any obvious deformity or erythema Feel: - ask patient to lay - assess temperature of both legs - assess pulses - palpate the achilles tendon - palpate MTP joints, tarsal joint, ankle joint, subtalar joint, medial/lateral malleoli, proximal fibula Move: - foot plantarflexion - foot dorsiflexion - foot inversion - foot eversion - toe of the above Special Tests: -simmonds to assess for rupture of the achille, kneel on chair and squeeze calf normally foot plantar flexes Conclusion: - thank patient - wash hands - examine knee and hip joint - Full NVS of lower limb - imaging of joint

Answer 20

WIPER -ask if patient has had a hip replacement if so internal rotation, addiction and flexion greater than 90 should be avoided due to risk of dislocation Look: - ask patient to stand - look at front to assess pelvic tilt, quadriceps wasting, scars - look at the side to assess lumbar lordosis - look from behind to assess for scoliosis, gluteal wasting, pelvic tilt - observe gait and evidence of trendelenburg or antalgic gait? Feel: - ask patient to lie down - palpate the tissues overlying the hip joint for tenderness/warmth - palpate the greater trochanter - assess leg length (apparent = umbilical to tip of medial malleolus, true = ASIS to medial malleolus) Move: - flexion assess individually normal ROM is 120 - internal rotation normal ROM is 40 - external rotation normal ROM is 45 - Abduction whilst stabilising the contralateral iliac crest normal ROM is 45 - Adduction whilst stabilising the contralateral iliac crest normal ROM is 30 - hip extension lie prone, normal ROM is 10-20 Special Tests: - Thomas test (fully flex the hip until lumbar lordosis flat, then extend inability to extend = fixed flexion deformity) - trendelenburg tests (hands on both iliac crests ask patient to stand on one leg, normally the iliac crest on the side with the foot up should rise if it falls it is positive (abnormal) suggesting weak hip abductors on the contralateral side) Conclusion: - Thank patient - wash hands - summarise - to complete full NVS examine joint above and below and consider further imaging if indicated

Answer 21

WIPER Look: - in anatomical position for any scars, swelling/erythema, carrying angle (usually 5-15) - look at the side for fixed flexion deformity, olecranon bursitis, scars etc - look at back of elbow for rheumatoid nodules and psoriatic plaques Feel: - temperature - palpate the jointlines e.g. Epicondyles and olecranon Move: - Assess elbow flexion (NROM 145) - elbow extension (NROM 0) - pronation/supination - feel for crepitus Special Tests: - Medial epicondylitis aka golfers elbow (ask patient to actively flex the wrist whilst elbow is flexed localised pain over the medial epicondyle is +ve finding) - lateral epicondylitis aka tennis elbow (as the patient to actively extend the wrist while elbow is flexed localised pain over the lateral epicondyle is +ve finding) Conclusion: - Thank patient - wash hands - summarise - examine joint above and below, full NV of upper limbs - further imaging if neccesary

Answer 22

WIPER Look: (anterior, lateral, posterior) scars, asymmetry, swelling, muscle wasting. Feel: - assess temperature of shoulder joints - palpate sterno-clavicular joint, clavicle, acromioclavicular joint, coracoid process, head of humerus, greater tuberosity of humerus, spine of scapula. Move: - compound movements - hands behind your head (external rotation and abduction) - hands as far u your back as you can (internal rotation + adduction) - flexion FROM = 150-170 - extension FROM 40 - Abduction FROM 160-180 - Adduction FROM 30-40 - External rotation FROM 70 - Internal rotation (average T5) - assess scapular movement during abduction Special Tests: - supraspinatus ask patient to abduct from neutral against resistance earl abduction suggests tendonitis - painful arc, panicle abduct arm to maximum point ask mpatient to lower, impingement causes pain between 60-120 - external rotation against resistance, pain or loss of power suggests infraspinatus/teres minor tendonitis/tear - internal rotation against resistance tests subscapularis Conclusion: - Thank patient - wash hands - summarise - to complete full NV and examine spine and elbow - further imaging as necessary

Answer 23

WIPER Checks patient understanding about warfarin therapy Explains to patient the need for warfarin (e.g. Its indications) Explain that the medication is taken once a day and that the dose required may vary on different days depending on control of INR Explain that treatment will be monitored in an anticoagulation clinic by blood tests to check the INR (A measure of clotting) as warfarin increases INR. Explain that the patient will receive a yellow book and this is used to record their INR level and warfarin dosage Explain that on the first few days a high dose called a loading dose is given Explain the possible side-effect e.g. Bleeding, skin necrosis, alopecia, DNV, jaundice. Warn patient about possibility of over anticoagulation and need to seek medical help, e.g. Epistaxis, haematuria, bleeding gums, excessive bruising. Explain alcohol intake to decrease as causes increased anticoagulation, diet must decreased in food with vitamin K e.g. Green vegetables. Avoid contact sports Warn patient about getting pregnant whilst on warfarin as teratogenic Tells patient to alert any health professionals and read all drug instruction leaflets carefully before taking warfarin with other medicines. Gives advice regarding missing doses of warfarin (do not take double) and also do not suddenly stop taking warfarin Suggest that a medical alert bracelet be worn Invites questions and checks understanding throughout.

Answer 24

- Wash hands, introduce, patients name DOB, wrist band, Explain procedure, get written consent. - Risks: headache, bleeding, paraesthesia, pain, infection, failure, CSF leak, trauma - Do not perform if risk of increased ICP e.g. Decreased GCS, focal neurology, pupil abnormalities, papilloedema, seizures. - Check patients clotting/platelet, and any anticoagulation medications, get an assistant - Prepare equipment, sterile pack, cleansing snap-sponge, 10ml syringe and 3 needles (1 orange 2 green), spinal needle (black 22G needle) LP manometer, cotton gauze swabs, sterile gloves, 10ml 1% lidocaine, 4 white topped collection bottles labelled 1-4, 1 glucose biochem bottle, 3 way tap - Confirm patient still happy, open sterile pack to form sterile field - expose patients back, lying on their left hand side with neck and hips and knees flexed as much as possible (foetal position) - locate insertion point by identity iliac casts the disk space in the horizontal plane between the iliac crests is L3-L4 the insertion point is mid way between the L3/L4 or L4/L5 mark insertion point with pen indentation - wash hands and apply sterile gloves using sterile technique, sterilise area with snap-sponge in circle motion from middle outwards, apply sterile drape - draw up 10ml lidocaine with assistant, change to orange needle and infiltrate a small bleb of anaesthetic over insertion site, change to 2nd green needle and insert perpendicular to skin to anaesthetise tract aspirate when advanced needle and before injection and anaethsie area leave needle in and disconnect syringe and wait for anaesthetic to take effect. Assemble manometer while waiting - remove green needle, insert spinal needle perpendicular to skin aiming towards umbilical using two hands, slowly advance the needle regularly withdrawing the stiletto at small increments of increasing depth observing for drops of CSF, should feel a give once inside the subarachnoid space. - remove the stiletto and connect the manometer to the needle via the 3 way tap when off switch pointing posteriorly to close posterior tap. Take opening pressure - Ask assistant to place collection bottles under the posterior tap in labelled order when ready turn the 3 way tap switch anteriorly to close the tap connected to the spinal needle allowing CSF to drop from manometer into the collection tubes, when all the cSF is used up turn superior to bypass manometer. Collect 10-15 drops per tube. And 5-10 for biochem. - remove the manometer and 3 way tap replace the stilletter and then remove the needle (reduces headache incidence) - apply sterile dressing - to complete thank patient advise them to stay lying for at least an 1 hour, ask nurses to perform neurological observations twice during the hour. Bin equipment and label samples tubes urgently and send tubes 1 and 3 for MC&S, tube 2 for protein and glucose, tube 4 for xanthochrmia (keep this sample dark in an envelope) and perform venepuncture for blood glucose and protein level. Fully document LP procedure and consent in notes

Answer 25

Indications: Refractory ascitis secondary to portal hypertension, palliation in malignant ascites, respiratory distress due to diaphragmatic splinting. Contraindications: local infection, thrombocytopenia, coagulopathy (INR over 2), pregnancy, organomegally, bowel obstruction Complications: bleeding, infection (SBP), perforation, intravascular depletion and renal impairment, recurrence. Wash hands, introduce, explain procedure, consent patient (risks include infection, bleeding, pain, failure, perforation, leakage, can use ultrasound to confirm fluid and insertion site. Set up sterile trolley with sterile field, gloves, chlorhexadine swabs, 10mls lidocaine, orange needle, green needle, 10ml syringe, 20ml syringe, scalpel, cannula dressing x2, urinary Cather bag, blood culture bottles, paracentesis catheter (bonnano catheter) Position patient spine in bed with head on pillow, select an appropriate point on abdominal wall in the right or left lower quadrant, lateral to rectus sheath. Clean site and apply sterile drape. Anaesthetise skin with lidocaine using orange needle and deeper tissues using green needle aspirating as you insert needle to ensure not in a vessel. Take the bonnano catheter and advanced needle to tip of catheter thus straightening it out. Insert the catheter using a z track i.e. Perforate skin perpendicularly and then a dvance obliquely in the sub cutaneous tissue for 1-2cm before returning to a perpendicular position to puncture peritoneal cavity. Gradually advance the Catheter into the peritoneal space. Pull the needle back whilst advanced catheter to hilt and completely remove needle. Fix with two sterile cannula dressings and affix the drainage bag after obtaining samples with 20ml syringe for the blood culture bottles. Post procedure monitor pulse BP and respiration 15 minute for 1 hour 30 mins for 1 hr then hourly for 4 hours, ensure and record drain and urine output

Answer 26

Introduction: Wash hands, introduce self, ask patients name and DOB, explain examination and get consent General inspection: Increased foot, hand and head size. Mildly Hirsute, OA signs such as Kyphosis. Hands: Inspection and palpation with hands on pillow, large spade-shaped, feel joints for OA evidence, Palms sweaty, glucose stick marks on finger pulps (Diabetes), signs of carpal tunnel syndrome Face: Coarse facial features, acne, enlarged nose and ears, macrognathia, hypophysectomy scar under upper lip Eyes: visual fields (bitemporal hemianopia in pituitary adenoma) prominent supra-orbital ridges. Mouth, prognathism, wide spaces between teeth, macroglossia and ridges from teeth on sides of tongue. Neck: Thyroid goitre, JVP (cardiomyopathy), acanthosis nigricans. Chest: thick, skin tags, acanthosis nigricans in axilla, listen to heart look for signs of cardiac failure listen to bases. Limbs: proximal myopathy, (patient stand up with arms crossed, shrug shoulder against resistance. Gait (tolling gait with bowed legs. Conclusion: thank patient, i would complete my examination by measuring blood pressure doing a thyroid exam, a cardiovascular exam and formally testing visual fields. I would also want a plasma IGF-1, and an Oral glucose tolerance tests, and MRI pituitary.

Answer 27

Wash hands, introduce, explain, permission, confirm patient name DOB General inspection: tall and thin, scoliosis Hands: arachnodactly (ask them to wrap fingers around their wrist), measure arm span (wide), flexible joints. Face: long thin face, myopia, high arched palate, test visual acuity. Chest: pectus carinartum/excavatum, aortic regurgitation (early diastolic murmur), mitral prolapse (late-systolic with mid-diastolic click) Conclusion: -(autosomal dominant mutations on Fibrillin-1 gene on chromosome 15) genetic testing, eye exam, echocardiogram.

Answer 28

WIPER, get chaperone. - Inspect sitting on edge of bed breasts for any asymmetry, scars, lumps or swellings, nipple abnormalities or skin changes whilst patient has hands down. Ask patient to lift hands and repeat inspection, then ask patient to place her hands on hips and push inwards to tense pectoral is muscles. - then lay patient down with arms above head and examine each breast individually starting with the normal side. Examine all areas of the breast from periphery to nipple. Palpate around and underneath the nipple to check for discharge and lumps. Take hold of patients arm and examine the axilla. Repeat on other side. - Palpate the supracalvicular fossa on both sides. Conclusion: - thank and cover patient. - wash hands - describe any lumps SSS, TTT, CCC - to complete triple assessment with imaging +/- biopsy, and cytology

Answer 29

What to do when a patient has died: - Assess patient and confirm death, clearly documenting in the notes - Discuss the death with the consultant in charge of the patient - Liaise with the bereavement office to organise an appropriate tie to attend with the patients medical notes to complete death certificate. - Complete medical certificate of cause of death form - perform a full external examination of the patient body in the mortuary (ensure no implantable devices, check for bruising/pressure sores, any suspicious findings) Completing The Death Certificate: - Personal details of the diseased Age in years and place of death - Last seen alive by me (record date), information from post mortem, seen after death (who saw deceased after death) Cause of death: - Consider main causal sequence of condition that lead to death - the disease that led directly to death should be documented in 1a line. - CANNOT write, FAILURES (CCF is ok), asphyxia, asthenia, cachexia, cardiac arrest, coma, exhaustion, frailty of old age (only used in those over 75) - Part 2 are conditions that contributed to death e.g. Parkinson's, IHD - Sign certificate include GMC number, residence is the hospital working in, and consultants name included at bottom if died in hospital Counterfoil: -There is a counter foil on the left hand side which gets left in the death certificate book you need to document the patients name and cause of death and conditions contributing to deaths and document personal details again. Reasons to refer to the coroner: -Unknown cause of death -Sudden or unexpected death -Deceased person not seen by a doctor within 14 days of death -Death is considered suspicious/unnatural/violent -Death may be due to an accident, self neglect or neglect from others -death may be due to an abortion -death occurred during an operation or before recovery from anaesthetic -the death occurred during or shortly after a period of police custody -the death may be suicide THESE ARE WRITTEN ON THE BAC OF THE MCCD FORM

Answer 30

Wash hands, introduce self, confirm patient details, explain and gain consent, expose patient to their underwear. Screening Questions: - Do you have a pain in your muscles, joints, or back: - Are you able to dress yourself independently without any difficulty? - Are you able to walk up and down the stairs independently without any difficulty? Gait: ask patient to walk to the end of the room and back whilst you observe: - Symmetry - Smoothness, heel strike + toe off, step height - Speed of turn - Arm swing - Antalagic? Wide-based? Festinating? Circumducting? High-stepping? Inspection: - Front e.g. Shoulder bulk, carrying angle, quadriceps bulk, knee deformity, foot deformity - Side e.g. Kyphosis, hyperlordoisis, knee joints, foot arches - Behind e.g. Shoulder muscles, spinal alignment, iliac crest alignment (pelvic tilt may suggest hip abductor weakness), gluteal bulk, popliteal swellings, hind foot abnormalities. Arms: - Ask the patient to place their hands behind their head (shoulder abduction and eternal rotation - ask the patient to hold their hands in front of them with palms down and joint swelling or assymetry, then turn over (pronation) inspect thenar muscle bulk - as the patient to make a fist, test power grip, precision grip, MCP squeeze Spine: - ask the patient to tilt their head to each side, moving their ear towards the shoulder (lateral flexion of cervical spine) - place 2 fingers on the lumbar vertebrae, ask the patient to bend and touch their toes, observe young fingers as they flex (should move apart) Legs: - lay the patient on the examination couch - assess passive full knee flexion and extension, and passive flip flexion and internal rotation. - patellar tap for effusions - MTP squeeze Conclusion: - Thank patient, wash hands, summarise findings - To complete my examination I would like to perform a full orthopaedic examination on joints with suspected pathology, and request further imaging of joints e.g. X-ray/CT/MRI with suspected pathology.

Answer 31

Introduce self, name role, location. Confirm whom you are speaking to. Explain purpose of the call e.g. To handover a patient/ discuss a request/patient. Situation: - Patient details, DOB, HN - Patient Location - The main issue Background: - Admission details, date, admission reason, treatments - Past medical history - any other relevant aspects of history Assessment: - Vital signs - Examination findings - Investigations received/pending - Management so far Recommendation: - Diagnosis/differentials - Management plan + outstanding jobs - What would you recommend? Conclusion: -thanks

Answer 32

Was hands, introduce self, open question, what does the patient want to know/ already understand? Explain what the mental health act is: -The mental health act 1983 is the law under which a person can be admitted, detained and treated for a mental health condition in hospital against their wishes. It comprises of different sections which involve admittance for treatment and for assessment of mental health disorder. Section 2 allows a patient to be detained for up to 28 days for assessment +/- initial treatment. The application for the section is made by a relative or approved mental health professional along with recommendations from two doctors one of which has special experience in managing mental health disorders. Appeal can b made to the Mental Health Tribunal within the first 14 days of section 2. The patient may ask for a list of mental health solicitors who may represent them and are entitled to free representation at tribunals under the legal aid scheme Section 2 of the mental health act cannot be renewed but a section 3 act may be enforced where the patient may be detained for treatment which the doctors deem to be either necessary for the patients health or the safety of others. Section 3 duration is of 6 months. This section may be renewed after a further 6 months, then annually thereafter if required. Explain that the patient has no right to refuse treatment for their mental health condition however there are some treatments that cannot be given e.g. ECT without the patients direct consent. The act only deals with mental health disorders and the patient will not be treated against their will for medical problems unless their medical disorder is life-threatening and they are deemed not to have capacity. ICE + Summary, Chunk and Check Thank patient.

Answer 33

Wash hands, introduce self, open question, what does the patient want to know/already know? DNAR order: - What does patient understand? - Explain that it only applies to CPR not medical treatment - Patient will still receive current medical management and therapy. - Explain that CPR is very distressing to put a patient through and not usually successful in frail patients. - Explain that it is in the patients best interests to be kept comfortable and with dignity and self-esteem - DNAR is a medical decision made by the consultant or most senior doctor in charge - It is not possible to appeal against it or refuse it however family opinions will be taken strongly in consideration and relayed to consultant. -Reassure patients that medical team are still very much involved and have not given up. Close, summary, chunk and check, ICE, Invite questions/ leaflet/future discussions.

Answer 34

Wash hands, introduce self, elicit what the patient understands/wants to know. State that an advanced directive is a legally binding set of instructions that a patient wishes to be carried out regarding their future medical treatment and it is put into action only when the patient can no longer provide these instructions themselves (aka lack capacity) Another type of advanced directive is known as power of attorney where the patient appoints a person they trust to make decisions on their behalf. Advanced directives are useful for stating wishes regarding decision such a s the use of life-saving treatment, CPR, administration off fluids or parenteral nutrition at the end of life. Advanced decisions cannot be used to ask for a specific treatment or something that is illegal e.g. Assisted suicide or refusal of treatment for a mental health condition. It is not necessary to seek legal advice to draw up an advanced directive, however it is recommend to prevent a failure for wishes to be carried out. You can change an advanced directive at a later date if you have capacity or change mind as long as patient still has capacity. Advanced directive may be deemed invalid if it is felt the patient created the document under duress or the document it not signed or witnessed. The advanced directive should also be scenario specific as much as possible. ICE, chunk and check, summary, further questions/discussion

Answer 35

Wash hands, introduce self, open question. Acknowledge patients anger, validate their feelings, allow patient to vent, accept responsibility for error/mistakes and apologise. Explain how mistake may have arisen. Offer to do something to help the patient alleviate their dissatisfaction, e.g. Highlighting allergy in red, discussion of incident with colleagues, measures to prevent happening again. Advise patient on hospital complaints prosecute with PALS should they wish to submit a letter of complaint Summaries, invite questions. L

Answer 36

Wash hands, introduce self, check what patients understands so far? SSRIs are antidepressants which alter the balance of some of the chemicals in the brain (Neurotransmitters). SSRI antidepressant affect a neurotransmitter called serotonin. An altered balance of serotonin and other neurotransmitters is thought to play a part in causing depression and other conditions. The tablets are taken once a day and treatment is for a minimum of 3-6months after feeling better. It takes 4-6 weeks for the effects to being and initially (first 2 weeks) may feel worse. Important side-effects include, D+V, weight change, headaches, drowsiness (take in evening) and withdrawal like symptoms on abrupt cessation, increased risk of suicide so seek support if feeling worse. Any questions, give leaflet, summarise check understanding.

Answer 37

Wash hands, introduce self, check patients understanding so far. Methotrexate is a disease-modifying agent which both reduces inflammation and suppresses the immune system. Early use improves outcomes and symptoms. It is taken once a week with folic acid at another time, the dose is built up slowly. Usually given as a tablet. It is a long-term treatment and takes 4-6months for its effects to be apparent. Will require blood monitoring specifically FBC, LFTs, U+Es before starting then every 2 weeks until dose stabilised and then every 2-3months Side-effects include alopecia, headaches, GI upset, myelosupression, go to A+E if you have fever/infective signs, unexpected bleeding/brushing, anaemia. Can also cause damage to liver so be careful with alcohol and lungs so go to doctor if breathless.

Answer 38

Wash hands, introduce self, check patients understanding of events so far/ purpose of interview. Levodopa works to replace some of the dopamine your brain is no loner able to make. This will help to reduce your symptoms in particular your rigidity and slow movement. Given with carbidopa which inhibits peripheral levodopa degeneration. Taken daily or given as depot every 2-4wks. Start at a small dose and then build up over a week or 2 adjusting on patients response. Treatment is for long term, tell doctors if wanting to get pregnant. Several days to weeks to being taking effect. May need bloods test occasionally to check Liver function. Side-effects include psychosis, n+v, dyskinesias, postural hypotension, But other drugs such as domperiodone (peripheral dopamine antagonist) and Selegilline (MAO ihibtor that inhibits dopamine degeneration in CNS so lower levodopa dose can be used). Invites questions, summarise, leaflet.

Answer 39

Wash hands, introduce self, check patients understanding of events so far/ purpose of interview. Bisphosphonates are drugs that prevent the bone from being broken down and helping to rebuild new bone. Lifestyle factors can also help with this such as exercise, no - smoking and eating a well balanced diet. Tablets are taken once weekly, witha full glass of water 30 minutes before food. Should remain upright for 30 minutes after swallowing. The tablets are taken long term. Side-effects include headache, heartburn, bloating, indigestion, GI upset, osteonecrosis of jaw. Check patients understanding, chunk and check, leaflets, ICE.

Answer 40

Wash hands, introduce self, check patients understanding so far/ explain purpose of interview. Statins stops the liver making cholesterol. Cholesterol is one of the factors that predisposes to artery problems causing heart disease, stroke and kidney disease. It is also important to address the other factors e.g. Non-smoking, weight loss, salt restriction Tablet is taken once daily at night and is a long term treatment. It's decreases the risk over many years. Will need a blood test for the liver before starting and again at 3 months and 1 year. Side effects include muscle pains, hair loss, itching and nausea, abdo pain, diarrhoea. Any questions, ICE, leaflet, follow up

Answer 41

Wash hands introduce self, explain purpose of interview, consent, and check patients understanding so far. Explain why the steroids are being prescribed, and the course of treatment Main side-effects include Peptic ulcers, gastritis, hypertension, diabetes,, osteoporosis, increased risk of infection, mood change, weight gain, proximal myopathy, acne, skin thinning. In order to prevent some of the more serious side-effects from occurring Vitamin D and calcium supplements may be given to prevent osteoporosis, and an anti-acid tablet (PPI) is also given to prevent peptic ulcer disease. Informs patients if they start to feel thirsty or a passing increasing amounts of urine to see GP for testing for diabetes. Informs patients that during their time on the medication they will need to have their blood pressure more closely monitored. Warns patients not to suddenly stop the steroids at any point without speaking to a doctor as this can cause a severe reaction which may require hospitalisation (addisonian crises) Do not take any additional NSAIDs whilst on steroids and alert doctors if you start to develop severe stomach pains or vomit any blood. They will be started on high dose at first and then titrated to lowest possible does to balance effects of disease and side-effects. Invite questions, ICE, summarise, Chunk and check, leaflet

Answer 42

Wash hands, introduce self, check patients understanding of events so far and initial questions? Central venous pressure allows monitoring of the pressure of the right side of the heart. It is useful in for diagnosis e.g. Right ventricular function, tamponade, heart block, and ensuring central lines are placed correctly, and aiding the management of hypotension. A venous catheter is inserted with ultrasound guidance into a vein in the neck. Risks include arrhythmias, brachial plexus injury, cardiac perforation, embolism, Haemorrhage, infection, pneumothorax These risks are reduced by using ultrasound guidance and it is a procedure performed in well monitored areas e.g. ITU. Thanks patients, chunk and check, summarise, ICE

Answer 43

Wash hands, Introduce self, check patients understanding of event so far/ purpose of interview An exercise tolerance test is an investigation used to assess the severity of coronary heart disease. The test uses an ECG to record the electrical activity of the heart whilst you exercise on a treadmill or exercise bike. The exercise starts off at an easy pace and is gradually made more strenuous. The test lasts 15-20 minutes. Blood pressure will also be measured at intervals throughout. At any stage you can tell the person doing the test if you feel it is too difficult and the test will stop, it will also stop if you develop unpleasant pains or become very tired or short of breath. There is a small rare risk of developing a heart attack of heart irregularity during the test but medical help is near to deal with any possible problems. Any questions/ summarise, ICE. Leaflet.

Answer 44

Wash hands, introduce self, checks patients understanding so far/ purpose of the interview. Echocardiogram is an ultrasound scan of the heart. It uses a devices that produces sounds waves to give accurate pictures of the heart muscle, and valves, and it is also possible to measure the pressures and velocities of blood movement in these areas. During the test you will need to undress your top half and lie on a couch cold jelly will be applied to the chest wall and a sonographer will move a probe around on top of the chest wall to create the images. It is painless, does not use radiation, and takes about 15-30minutes. The test can also be done using a probe that goes down the gullet (oesophagus), to give clearer views of the heart. For this procedure a sedative usually midazolam is given and a local anaesthetic and so you will need someone to drive you home. But it is more invasive. Any questions? ICE? Leaflet, chunk and check, summarise

Answer 45

Indicate you would check resuscitation status of the patient before anything else, if DNACPR not present or unsure begin CPR. Wash hands, Confirm patient identity (wrist band) General inspection, skin colour obvious signs of life Look for signs of respiratory effort Does the patient respond to verbal stimuli? Does the patient respond to pain (Trapezius squeeze, supraorbital pressure) Assess pupils using pen torch (after death they become fixed and dilated) Feel for a central pulse- carotid artery Auscultations listen to heart sounds for at least 2 minutes, listen to respiratory sounds for at least 3 minutes (Varies on local guidelines) Assess for pacemaker Wash hands and exit room Document death complete death certificate (Brainstem death testing involves, corneal reflexes, ocular-vestibular reflexes, apnoeic testing)

Answer 46

Assess severity Mild airway obstruction able to cough, encourage coughing continue to check for deterioration to ineffective cough or until obstruction relived Severe obstruction if conscious give five back blows and then 5 abdominal thrusts rotating until obstruction relieved If unconscious start CPR.

Answer 47

WIPER A PICC is a long hollow tube inserted into one of the large veins in your arm. One end of the tube sits in a vein just above the heart and the other send comes out underneath the skin in your arm. We use these type of catheters to give certain types of treatment that may irritate or damage smaller veins, or if you need medications over a long period of time. It is a sterile procedure performed under local anaesthetic. CXR is done to check position. Risks include infection, bruising, pain at site, stenosis of vein, malpositioning of PICC, Failure to insert, phlebitis

Answer 48

Ensure patient has venous access and is breathing O2 fully monitored. - Abduct the ipsilateral arm fully - don sterile gown an gloves, clean skin with antiseptic and cover with sterile drapes. - identify 5th intercostal space just anterior to the mid-axillary line - infiltrate area with LA e.g. 1% lidocaine - prepare the chest drain, remove and discard the trocar (use 28-32FG in adults) - make a 2-3cmm skin incision in the line of the ribs - use blunt dissection with artery forceps to open the tissues down to the pleural space - puncture the pleural space with the artery forceps - insert a gloved index finger into the pleural cavity to ensure there are no adhesions and that you are within the thoracic cavity - insert the chest drain ensuring all drainage holes are inside the chest (usually 15-20cm) - connect drain to underwater sea look for swinging with respiration - suture drain in place and cover with adhesive dressing - confirm placement with CXR, look for bubbling

Answer 49

Patient should be seated leaning forwards with support on table or lying back on a bed with the arm on the affected side raised above the head. 1. Perform surgical style hand washing and don sterile gloves and gown. 2. Clean the sin and then cover with sterile drape 3. Infiltrate local anaesthetic via a bleb using a 25G orange needle, and then deeper using a 21G green needle. 4. Insert the introduce needle with the bevel facing up in the mid-axillary line 5th intercostal space overlying the 6th rib. Advance the needle aspirating until fluid or air is easily aspirated and seen in the syringe. Advance the needle by 1mm to 2mm to ensure the whole bevel of the needle is within the pleural cavity. Do not advance the needle any further, as you risk damaging soft tissues if you insert it blindly. Note the depth at which you could aspirate fluid or air. 5. If you are draining a pleural effusion, rotate the needle through 180 degrees so the bevel of the needle is pointing down. If you are draining a pneumothorax, keep the needle with the bevel facing up. This well help direct the guide wire, and subsequently the drain into the best position. 6. Remove the syringe and quickly insert the guide wire into the cavity through the seldinger needle. Once in position remove the introduce needle, leaving the guidewire in situ. Do not let go of the guidewire at any point. 7. Make a small incision with a scalpel around the guidewire. 8. Insert the dilator over the guidewire to a depth 1cm more than the recorded depth of fluid /air aspiration, then remove the dilator, leaving the guidewire in situ again. You should keep the guidewire still throughout, as this is the point where kinking the wire often occurs, making the produce far more difficult. 9. Thread the chest drain over the guidewire, keeping the guidewire still. Ensure the drain is inserted enough so that all the fenestration are within the pleural cavity (Usually to a depth of at least 10cm) 10. Ask your assistant to prepare the underwater seal by placing sterile water up to the marking on the bottle. 11. The chest drain usually comes with a stiffener though the lumen of the drain to help with insertion. When removing the guidewire, the stiffener should also be removed at the same time in one movement. 12. The drain should be quickly connected to an underwater seal or clamped to prevent air entering the pleural cavity through the drain. This can be minimised by asking the patient to perform a valsalva manoeuvre while removing the guidewire and stiffener. 13. Suture the chest drain in position, and place a piece of rolled up gauze underneath the tube to support it, apply a transparent dressing over the top to keep clean while still allowing the site to be checked. 14. Document the procedure in the notes, along its the depth of the drain and any complications. Ensure the drain is swinging and bubbling.

OSCE Stations Flashcards

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