Osce Handbook 1f42j

OSCE Handbook

Table of Contents Table of Contents ..................................................................................................................... 2 3rd year Stations ....................................................................................................................... 6 Basic Life ......................................................................................................................................................7 Cranial Nerve Examination ........................................................................................................................................8 CVS Examination ........................................................................................................................................................9 HAND Examination ................................................................................................................................................. 11 SHOULDER .............................................................................................................................................................. 13 RESP ........................................................................................................................................................................ 14 Upper Limb Examination 2 ..................................................................................................................................... 16 Sensory Examination 2............................................................................................................................................ 18 Lower Limb Examination 2 ..................................................................................................................................... 19 EAR .......................................................................................................................................................................... 21 Peripheral Vascular (Limb) Examination................................................................................................................. 22 Assessing Hydration Status OSCE ........................................................................................................................... 24 Fluid balance ........................................................................................................................................................... 26 FLUID BALANCE ....................................................................................................................................................... 27 NUTRITONAL ASSESSMENT .................................................................................................................................... 28 Heart Murmurs – Harvey ........................................................................................................................................ 29 HARVEY CVS examination Clinical skills GUIDE....................................................................................................... 30 Ulcer Exam .............................................................................................................................................................. 42 Abdominal Examination.......................................................................................................................................... 43 MINI MENTAL STATE EXAM .................................................................................................................................... 45 'Lumps and Bumps' Examination ............................................................................................................................ 46 Sensory Exam .......................................................................................................................................................... 47 HERNIA .................................................................................................................................................................... 48 Cerebellar Function Examination ........................................................................................................................... 50 Myasthenia Gravis Examination ............................................................................................................................. 51 Multiple Sclerosis Exam .......................................................................................................................................... 52 Parkinson's Disease Examination............................................................................................................................ 53 Speech Assessment................................................................................................................................................. 54 GALS ........................................................................................................................................................................ 55 Upper Limb Examination ........................................................................................................................................ 56 Lower Limb Examination ........................................................................................................................................ 58

SPINE ....................................................................................................................................................................... 60 HISTORY in the OSCE............................................................................................................................................... 61 Breaking bad News ................................................................................................................................................. 62 Consenting a patient for an Operation ................................................................................................................... 63 MCA: Ethics and Law............................................................................................................................................... 64 Ethics and Law: General Rules of engagement....................................................................................................... 65 Inhaler Technique ................................................................................................................................................... 66 IV Fluid istration ........................................................................................................................................... 67 OSCE: Glycosuria Differentials and Ix ..................................................................................................................... 68 Heart Burn .............................................................................................................................................................. 69

4th year Stations ..................................................................................................................... 71 Psychiatry and Neurology ....................................................................................................... 71 Alcohol dependence ............................................................................................................................................... 72 ADHD station .......................................................................................................................................................... 74 Agoraphobia history ............................................................................................................................................... 76 Anorexia nervosa written ....................................................................................................................................... 78 OSCE: counselling about autism ............................................................................................................................. 79 Alcohol cessation .................................................................................................................................................... 80 Alcohol dependence ............................................................................................................................................... 82 Alcohol dependence ............................................................................................................................................... 84 Explaining Alzheimer’s disease ............................................................................................................................... 85 OSCE: counselling about autism ............................................................................................................................. 87 Bipolar affective disorder ....................................................................................................................................... 88 Blood test results in psychiatric disease ................................................................................................................. 89 Counselling OSCE: Beta-blockers and sexual dysfunction ...................................................................................... 90 Explaining clozapine treatment .............................................................................................................................. 92 Conduct disorder .................................................................................................................................................... 93 CSF profiles station ................................................................................................................................................. 95 Delirium written...................................................................................................................................................... 97 Depression History and screen of a 7 year old ....................................................................................................... 99 Epilepsy ................................................................................................................................................................. 101 Explain Schizophrenia ........................................................................................................................................... 103 Fundoscopy Reporting Technique ........................................................................................................................ 104 Mental Health Act ................................................................................................................................................. 106 Headache History.................................................................................................................................................. 107 Bi-Polar Affective Disorder ................................................................................................................................... 109 Lithium toxicity written ........................................................................................................................................ 111

Migraine history.................................................................................................................................................... 113 OCD History........................................................................................................................................................... 114 Idiopathic Parkinson’s Disease ............................................................................................................................. 116 PTSD history .......................................................................................................................................................... 119 Radiology Stations ................................................................................................................................................ 120 Explaining Ritalin treatment ................................................................................................................................. 125 Management of school refusal because of bullying ............................................................................................. 126 School Refusal ....................................................................................................................................................... 128 Taking a depression history .................................................................................................................................. 129 Explaining tricyclic antidepressants ...................................................................................................................... 130 Sixth nerve palsy ................................................................................................................................................... 131

4th year Stations ................................................................................................................... 132 Obstetrics and Gynaecology ................................................................................................. 132 Adult UTI ............................................................................................................................................................... 133 OSCE: Down’s syndrome....................................................................................................................................... 134 Down’s Syndrome ................................................................................................................................................. 135 Ethics & Law station: Contraception .................................................................................................................... 136

4th year Stations ................................................................................................................... 137 Paediatrics............................................................................................................................ 137 Pallor and Fatigue in a young female child ........................................................................................................... 138 OSCE scenario: childhood Anaemia ...................................................................................................................... 140 OSCE Scenario – BRONCHIOLITIS .......................................................................................................................... 142 Child UTI ................................................................................................................................................................ 144 Crohn’s disease history ......................................................................................................................................... 145 Ethics & Law station: Stopping Treatment ........................................................................................................... 147 Explain eczema treatment to a father .................................................................................................................. 149 Faecal Soiling ........................................................................................................................................................ 151 Faecal Soiling 2...................................................................................................................................................... 153 Febrile convulsions ............................................................................................................................................... 155 OSCE Scenario: Abdominal Pains and Diarrhoea: Paediatrics .............................................................................. 157 Head Circumference ............................................................................................................................................. 160 Childhood Asthma ................................................................................................................................................ 162 Childhood Vaccination .......................................................................................................................................... 164 MMR Vaccination ................................................................................................................................................. 166 Neonatal Examination .......................................................................................................................................... 169 Nocturnal enuresis................................................................................................................................................ 170 Limp in a child ....................................................................................................................................................... 172

Psoriasis History .................................................................................................................................................... 174 Psoriasis 2 ............................................................................................................................................................. 176 Smoking cessation ................................................................................................................................................ 177 Picture of a ‘bleed’ ................................................................................................................................................ 179 Suicidality risk assessment.................................................................................................................................... 180 Neonatal Vomiting Station ................................................................................................................................... 182

Question Lists from Previous Years ....................................................................................... 184 Psychiatry and Neurology from previous years 1 ................................................................................................. 185 Psychiatry and Neurology from previous years 2 ................................................................................................. 190 Obs and Gynae ...................................................................................................................................................... 192 O&G EMQ Dec 2005 ............................................................................................................................................. 198 Obs & Gynae OSCE April 07 .................................................................................................................................. 200 OSCE STATIONS: O+G APRIL’06. ENJOY!!!! ........................................................................................................... 205 Condom Use.......................................................................................................................................................... 209 Paeds OSCE 3 ........................................................................................................................................................ 220

Paediatrics/GP/Derm 2002 ................................................................................................... 248 Paeds and GP April 2004 OSCE stations ............................................................................................................... 249 Pyschiatry/Neuro 2002 ......................................................................................................................................... 252 Psychiatry OSCE Stations. ..................................................................................................................................... 269

Part 1 3rd year Stations

Basic Life 1. Check for danger to yourself and the child 2. Ascertain whether there is any chance of cervical spine injury 3. Check the child’s responsiveness a. Gently stimulate the child and ask loudly, ‘Are you all right?’ b. Do not shake infants, or children with suspected cervical spine injuries. 4. Shout for help 5. Airway a. Head tilt & chin lift (neutral for infants, sniff the air for children) b. Check for foreign body 6. Breathing a. Look for chest movements. b. Listen at the child’s nose and mouth for breath sounds. c. Feel for air movement on your cheek. d. Give 5 initial rescue breaths 7. Circulation a. Feel for pulse over 10 seconds i. Brachial or femoral for infant ii. Carotid for children iii. Compressions are necessary for an absent pulse or rate <60/min 8. Give breaths and chest compressions at a ratio of 15:2 9. Go and get help after 1 minute of R 10. Return and continue R Questions Main causes of arrest in an adult? Main causes of arrest in a child? Name 4 differences between adult and child BLS? 1. In child BLS 5 rescue breaths before checking circulation 2. In child BLS you try R for 1 minute before leaving (or taking child with you) to call an ambulance 3. Different airway position 4. Breath to compression rate in adults is 30:2 5. Chest compression technique is different 6. in adults can check breathing and circulation at same time 7. Call a different team (i.e. paeds resus team)

Cranial Nerve Examination Wash Hands Introduce yourself to the patient, ask the patient if it is ok to examine the nerves of their face. Have the patient sitting in a chair Firstly inspect for muscle weakness, facial droop, fasciculations, tremors and surgical scars I. Olfactory Nerve Ask the patient to close their eyes and identify coffee by smell II. Optic nerve Visual Acuity Distance vision is tested using a Snellen chart -stand or sit the patient 6m from the card and ask them to read the lowest line they can Near vision can be tested using reading test types Colour Vision Red-green deficiency can be assessed using Ishihara plates. If 13 or more plates are read correctly, colour vision can be regarded as normal. Visual Fields Sit approximately 1m from the patient Test each visual field with one eye and then the other To check for a parietal lesion resulting in visual inattention present your moving fields in both halves of vision simultaneously Fundoscopy Assess optic disc’s shape, colour and clarity Examine the vessels Examine the fundus III/IV/VI: Oculomotor/Trochlear/Abducens nerves Pupillary light response: Ask the patient to focus on a distant object. Shine a light from the side of both eyes. Both pupils should constrict in both circumstances

Check full eye movements while also looking for nystagmus

CVS Examination WIPER Wash hands Introduce Permission and Pain Expose Reposition

Waist up 45o

END OF THE BED Patient Well or unwell? Breathless Scars Can you hear an artificial heart sound? Peripheral oedema Evidence of other disease Marfans, Turners, Thyroid Around the bed

HANDS and ARMS Hands

Oxygen Fluid restriction GTN spray

Signs of Infective Endocarditis Osler’s, Janeway, Splinter Haem’ Clubbing Quincke’s sign Tar Staining Signs of Liver disease Signs of other disease Capillary refill Hands warm and well perfused

Pulses Radial rate and rhythm Radial Radial delay Brachial Pulses character Collapsing Pulse

subclavian stenosis

ASK FOR BP FACE Eye

Face

corneal arcus Xanthelasma Subconjunctival pallor Jaundice  heart valves Malar Flush Other Facies

MENTION FUNDOSCOPY Mouth

NECK

Teeth Central Cyanosis Palate – high arched?

Mitral Stenosis Downs, Marfans HTN retin’p, Roth spots

Carotid pulse

JVP

Slow rising Waterhammer  Corrigan’s sign Height Form/Character

CHEST WALL Inspect the chest wall closer PALPATION Apex beat

SCARS, PULSATIONS, PACEMAKER, VISIBLE APEX

Apex beat  check lateral and then medial (displacement Count down to define If not present feel on right side of chest (dextracardia)

Heaves Thrills

LV or RV heave Metallic Valves

AUSCULTATION TIME AGAINST THE CAROTID describe heart sounds as Normal, Soft, Loud or Metallic 1. 2. 3. 4. 5. 6. 7. 8. 9.

Mitral Tricuspid Pulmonary Aortic Carotid Sit forward Aortic held in expiration Lung Bases Sacral oedema Mitral Valve area – roll over to left side

COMPLETING THE EXAM    

Examine the rest of the vascular tree – peripheral pulses Abdominal aortic aneurism Temp ECG

Thank patient and ask if needs help to get dressed

HAND Examination WIPER Wash hands Introduce Permission and Pain Expose Reposition LOOK Nails DIP PIP M Carpal ts Wrist Thumb Turn over hands Inspect for

bare above elbows sitting comfortably, offer a pillow

EXAMINE SKIN

Assess movement, normal or antalgic Thenar eminences Callosities Carpal tunnel scars

FEEL Palpate thenar and hypothenar eminences Test Sensation of Median, Ulnar and Radial nerves Ulnar Pulses and Radial Pulses Turn hands over Capillary Refill on nails Temperature of hands, wrists and forearm Palpate all ts that appear to have abnormality Squeeze over M ts Test Sensation of Radial nerve Inspect and feel extensor surface of Arm MOVE Assess active then ive – if difficulty Extend Fingers fully and test power Assess ulnar nerve Make a fist Wrist flexion and extension Prayer sign and wrists down ively assess movements Assess the power of Median and radial nerve FUCTION Test power grip Assess fine finger movement Special Tests Ask patient to demonstrate doing up button Tinnell’s or Phalen’s test if suspecting carpal tunnel Finish up Neurovascular exam of Upper limb Examine elbow Relevant exam if relevant systemic disease is identified in hands ELBOW

WIPER Wash hands Introduce Permission and Pain Expose Reposition

bare above elbows sitting comfortably, offer a pillow

LOOK Carrying angle Flexion deformity DWARFS FEEL Temperature of t Palpate Swelling Tennis Elbow (lateral condyle) Golfer’s Elbow (medial Condyle) Olecranon bursitis MOVE Assess elbow extension and flexion Actively and ively Assess pronation and supination Check for crepitus FUCTION Check that patient can raise hand to mouth Finish up Neurovascular exam of Upper limb Examine Hands and shoulder Relevant exam if relevant systemic disease is identified

SHOULDER WIPER Wash hands Introduce Permission and Pain Expose Reposition

Top off Standing

Look Observe patient standing thoroughly inspect

D.W.A.R.F.S., Front, Side and Back Sprengel’s Shoulder? failure of embryonic descent of the scapula from its fetal position in the neck to the normal position in the upper posterior thorax Klippel-Feil Syndrome congenital fusion of any 2 of the 7 cervical vertebrae

Feel Temperature over the Palpate the bony landmarks for tenderness

Palpate t line Palpate muscle bulk Check for sensation over Deltoid

Sternoclavicular t Clavicle Acromioclavicular t Acromion process Around Scapula Supraspinatus, Infraspinatus, Deltoid Axillary nerve damage

Move Ask Pt: Hands behind head Ask Pt: Behind back Elbow flexed at 90o Flexion and extension Adduct Arm Conduct ive movements + feel crepitus Assess abduction from behind patient

External rotation Internal rotation define restriction by level Ask Pt: external and internal rotation Assess Painful arc (between 10o and 120o) Try to go beyond limitations of the patient If possible indicates tendinous injury Observe scapular movement

Special Tests Assess limitation of Function Rotator cuff injuries Ligamentous Tear tests

abduct arm from side of body against resistance Subscapularis – internal rotate arm held behind - tear or tendonitis Supraspinatus - arm at side test abduction - tear or tendonitis @ 60o Infraspinatus and Teres minor – external rotation at 30o Bicipital tendonitis – supinate arm, assess flexion against resistance

Finish off Neurovascular exam of upper limbs X-Ray of Shoulders: 2 views Additional examinations as relevant

RESP WIPER Wash hands Introduce Permission and Pain Expose Reposition END OF THE BED Patient Is the patient Well or unwell? Breathless/distress Use of accessory muscles Chest wall movement Scars Evidence of other disease Around the bed


Pulse Respiration

Abnormal breathing pattern?

Sputum Pots Peak flow meter Inhalers, Oxygen tubing

Clubbing Tar Staining Signs of other disease Hands warm and well perfused Salbutamol and CO2 retention flap Radial rate and rhythm respiratory rate Pattern of breathing

ASK FOR BP FACE Eye

Mouth NECK JVP

Horner’s Syndrome Lupus Pernio Lupus vulgaris Subconjunctival pallor Jaundice  heart valves Central Cyanosis

Height Cricosternal distance

Lymph Nodes

Palpate Supraclavicular and Axillary

Trachea

Central?

The next section should be performed Both Anteriorly and Posteriorly CHEST WALL Inspect Chest Wall deformity Scars Use of Accessory muscles

Sarcoid TB

Asymmetry of chest wall expansion PALPATION Apex beat

Apex beat position

Chest Expansion

Depth and relative movement

PERCUSSION ANTERIOR and POSTERIOR: 4 regions

AUSCULTATION ANTERIOR and POSTERIOR: 4 regions Listen Vesicular? Added Sounds: Wheeze, Crackles, Rubs Vocal Resonance

99 Whispering Pectoriloquy

COMPLETING THE EXAM    

Ankle Oedema Peak flow O2 saturation Sputum examination


Cor pulmonale

Upper Limb Examination 2 Inspect End of the bed: Is the patient well? Examine the arms for… Deformity Wasting Asymmetry Rashes Fasciculations Swellings / Scars Motor Examination Check for pronator drift. Ask the patient to hold their arms out in front of them and close their eyes. Possibilities:  The arm on the side of an upper motor (pyramidal lesion) will pronate.  The fingers will continuously move up and down indicating pseudoathetosis  The arm will rise in cerebellar disease Tone  

Ask the patient if they have any pain in the arms or shoulders As if shaking hands (while holding the elbow) move the patient through movements to assess tone; o Elbow – spasticity (clasp-knife phenomenon) o Wrist – spasticity (supinator catch) o Wrist – cogwheel rigidity

Power Test each muscle group in turn, comparing the same muscle group in the other limb. Test against gravity before applying a force.          

Shoulder abduction. (Deltoids, Axillary nerve, C5) – Hold your arms out like a chicken Elbow Flexion (Biceps, musculocutaneous nerve, C5/C6) Elbow Extension (Triceps, radial nerve, C6/C7/C8) Wrist extension (C7) Wrist flexion (C7) Finger extension (extensor digitorum, posterior interosseous nerve, C7/C8) Finger flexion (flexor digitorum superficialis & profundus, median & ulnar, C8) Finger abduction (Dorsal interossei, ulnar nerve, T1) Finger adduction (2nd palmar interosseous, ulnar nerve, T1) Thumb abduction (Abductor pollicis brevis, median nerve, T1)

Froment’s Sign Ask the patient to hold a piece of paper between the thumb and a flat palm. The object is then pulled away  A normal individual will be able to maintain a hold on the object without difficulty  However, with ulnar nerve palsy, the patient will experience difficulty maintaining a hold and will compensate by flexing the flexor pollicis longus of the thumb (median nerve)

Record as MRC (Medical Research Council) grade 0-5 5 4 3 2 1 0

Normal power for age & sex Movement against resistance but incomplete Movement against gravity Movement with gravity eliminated Flicker of movement No movement

Reflexes Get the patient to bend their elbows 90° and put their hands on their belt area, palms down. Biceps (C5/C6) Place the thumb or index finger of your left hand on the biceps tendon Supinator (C5/C6) Triceps (C7) Finger reflex (C8) If there is a suspicion of hyperreflexia in the fingers then test for Hoffman’s reflex by flicking the middle fingernail downwards. A positive Hoffman’s sign will result in the thumb flexing and adducting. Reflexes graded as: 0  1+ 2+ 3+ 4+

= absent = present only with reinforcement = present but depressed = normal = increased = clonus

Co-ordination Check for dysdiadochokinesis and finger-to-nose test

Sensory Examination 2 Ask the patient if they have any areas of altered sensation such as numbness, pins and needles or pain. Light touch Use a piece of cotton wool. Place it on the patient’s sternum so that they know what it feels like and then ask them to close their eyes and say yes when they feel it on their skin. Pain Same but with a neurotip Temperature Use the back of the tuning fork to test for cold Vibration Use a 128Hz tuning fork. Make the tuning fork vibrate and place it on their sternum so they know what it feels like and then stop it so that they know what they feels like. Close their eyes and place the tuning fork t position sense Demonstrate first

Lower Limb Examination 2 Inspect End of the bed: Is the patient well? Examine the legs for… Deformity Wasting Asymmetry Rashes Fasciculations Swellings / Scars Motor Examination Tone Roll the knee, Lift the knee & watch the heel, Hold the knee and heel and flex the knee. Check for ankle clonus Power        

Hip flexion (Iliospoas, lumbar sacral plexus, L1/L2) Hip extension (Gluteus maximus, inferior gluteal nerve, L5/S1) Knee extension (Quadriceps femoris, femoral nerve, L3/L4) Knee flexion (Hamstrings, sciatic nerve, L5/S1) Foot dorsiflexion (tibialis anterior, deep peroneal nerve, L4/L5) Foot plantarflexion (gastrocnemius, posterior tibial nerve, S1) Big toe extension (extensor hallicus longus, deep peroneal nerve, L5) Extension of all toes (extensor digitorum brevis, deep peroneal nerve, L5/S1)

Reflexes Knee reflex (L3,L4. Femoral nerve) Ankle reflex (S1-S2. Tibial nerve) Can place hand on ball of foot with the ankes at 90° and striking the hand. Plantar response Co-ordination Heel-shin test: “Lift up your leg and place the point of your heel on your knee and then run it down the sharp part of your shin.” Sensory Examination

Ask the patient if they have any areas of altered sensation such as numbness, pins and needles or pain. t position sense Demonstrate first Vibration Use a 128Hz tuning fork. Make the tuning fork vibrate and place it on their sternum so they know what it feels like and then stop it so that they know what they feels like. Close their eyes and place the tuning fork Light touch Use a piece of cotton wool. Place it on the patient’s sternum so that they know what it feels like and then ask them to close their eyes and say yes when they feel it on their skin. Pain Same but with a neurotip

Temperature Use the back of the tuning fork to test for cold

EAR WIPER Inspect EXAMINE BETTER HEARING EAR FIRST Examine Pinna

Look behind ears Pull on pinna and ask if it is sore Examine size of Meatus

Size, Shape and Deformity Preauricular sinuses Endaural scar Postauricular scar Hearing Aids External auditory meatus infection, Temporomandibular t problems Wide = possible previous mastoid surgery

Auroscopy Examine external auditory canal Examine right ear with right hand

Place hand on patient’s face to avoid trauma to canal

Pull pinna back and upwards to straighten canal Inspect Canal Wax Foreign bodies Furunculosis (boils) Active inflammation = Otitis externa Posterior wall defect – Mastoid operation (for cholesteatoma) Examine tympanic membrane Elicit Light reflex with Auroscope Travel clockwise around the membrane toward the Attic Examine Pars Flaccida examine for debris Cholestoma Examine Pars Tensa Perforation EXAMINE OPPOSITE EAR Finish Up Free field hearing tests Examine Function of Facial Nerve

Peripheral Vascular (Limb) Examination

Introduction & General Features 1. Wash your hands, introduce yourself, and ask permission (consent) to examine. Always ask if the patient has any pain. 2. Obtain adequate exposure of the limb (ideally, tros should be removed so the full lower limb can be visualised from groin downwards). 3. Step back and observe (eg. walking aids, amputated limbs, gangrenous extremities, ulcers, other trophic changes). 4. Hands: check the pulse (for Atrial Fibrillation (AF) - this can be a source of emboli, leading to ischaemia) 5. Neck: carotid pulses (character) & auscultate for bruits 6. +/- Heart (confirm the presence of AF if required) Steps 5 & 6 do not always need to be performed. If you are, for example, asked to perform an examination of the vascular system of the patient's lower limbs, then checking the radial pulse will probably be adequate. If you find gangrenous toes, at the end of the examination you can mention to the examiner that you would like to examine the patient further for atrial fibrillation.

Inspection Look carefully: - Gently lift legs up & look at the underside (this can be easily missed) - Look between the toes: scars / ulcers. Note that arterial ulcers have a 'sloughy' base and are punched out) - Trophic (skin) changes: hair loss - 'glaborous', shiny appearance, venous guttering (when you raise the limbs and gravity empties the veins, their paths will appear to 'indent') - Colour: dusky red or black (ischaemic), brownish eczematous/dry/thickened skin (venous disease - note that 'lipodermatosclerosis' needs to be palpated for by feeling for the hard thickened skin) - Muscle bulk (check for symmetry) - Other features: drains, wounds, amputated digits/limbs, etc.

Palpation Feel for: - Temperature (may be cool if compromised vascular supply) - Capillary refill: pinch the area of the nail-bed for 5 seconds and then release. Normal filling is <2 seconds. - Pulses: start at the abdominal aorta, then femoral (mid-inguinal point - midway from anterior superior iliac spine to pubic symphysis), popliteal, posterior tibial (midway between medial malleolus and calcaneum) & dorsalis pedis (cleft between the first and second metatarsals) - Squeeze the calf: there will be tenderness in critical limb ischaemia - Sensation: screen for generalised loss of sensation

Auscultation Listen for: - Bruits (renal / femoral / carotid bruits)

Extras To complete your examination: Whilst you may not actually perform these remaining tests, make sure you know a bit about them, and in particular how they are performed, indications and complications. Mention to the examiner (at the end) that you would like to perform these to complete your examination of the peripheral vascular system. - Buerger's test: Raise the limb as far as possible into the air (flex at the hip t). Once the limb appears pale, get the patient to sit with the leg hanging off the side of the bed. Look for the ?sunset rubor? (dusky red colour) that the leg will take on as it refills. Record how long this takes. The dusky colour is due to reactive hyperaemia. Note that this can be painful for patients, so be gentle. - Ankle-Brachial Pressure Index (ABPI): This is a ratio (normal=1.0) of the systolic BP at the ankle/the 'norma;' systolic BP at the arm. The brachial BP is measured as usual. To measure the ankle BP, place the cuff over the ankle as low as possible, whilst listening to the foot pulses using a Doppler probe. Note that you can obtain falsely high results in patients with diabetes due to the presence of vascular wall calcification. Generally, scores of >1.0 are normal, scores of 0.5-0.7 are compatible with intermittent claudication, and scores <0.4 are suggestive of critical limb ischaemia. A gangrenous limb will most likely have a score of 0.2 or below. In normal individuals, scores should not fall with exercise. - Corridor walking test: Thus can be a useful and simple method of quantifying exactly what the patient can do (ie. the patient's functional ability). - Doppler / duplex assessment: Doppler produces an audible waveform and duplex complements this with multicoloured displays of the vascular flow, allowing a graphic representation of the flow patterns to be observed. These popular non-invasive techniques allow pressures to be recorded at different sites along the route of the vessels. Normal arterial waveforms are 'triphasic'. This becomes biphasic in the presence of arterial stenosis. - Angiography (digital subtraction or CT): There are a number of complications associated with angiography. Spiral CT can provide detailed images of the entire vessel length.

Finish – Thank/redress

Assessing Hydration Status OSCE Wash your hands Introduce yourslef Permission Expose the patient Reposition the patient (45˚) Look:         Feel:   

General body habitus, i.e. decreased sweating and skin blood flow in dehydration, shortness of breath in overhydration Mucous membranes – eyes and mouth (dry/wet) JVP (if overhydrated will be raised, if dehydrated, veins will not fill even when below 45˚) Urine colour Dizziness/fainting on standing (orthostatic pressure is poorly tolerated in dehydration) Oedema (especially hands, feet and ankles in overhydration) Ascites (in fluid overload) Orthopnoea (in overhydration)

Skin turgor (lax and inelastic in dehydration) Pulse (rate increases to maintain CO due to decreased plasma volume and therefore decreased stroke volume, strong and rapid in overhydration) Temperature (increases in dehydration)

Listen:  Lung bases (crackles if overhydrated) Measure: (many measurements require a baseline level and need comparison to be helpful)  BP (decreased in dehydration, increased in overhydration)  Capillary refill (slow in dehydration)  Urine output  Plasma osmolality  Sodium concentration (increases in dehydration)  Urine osmolality  Urine specific gravity  Skinfold thickness  Body weight  Hb and haematocrit concentrations Ask about:  Headache  Constipation  Thirst  Tiredness Facts about hydration:  ~60% of body weight is water  Water deprivation leads to death within a few days  Water can be lost from skin, urine, faeces, and lungs

Causes Causes of dehydration External or stress-related causes  Prolonged physical activity without consuming adequate water, especially in a hot and/or humid environment  Prolonged exposure to dry air, e.g. in high-flying airplanes (5-12% relative humidity)  Survival situations, especially desert conditions  Blood loss or hypotension due to physical trauma  Diarrhoea  Hyperthermia  Shock (hypovolemic)  Vomiting  Burns  Lacrimation  Use of Methamphetamine, Amphetamine and other stimulants.  Drinking of Alcohol. (In place of water)

Infectious diseases 

Cholera



Gastroenteritis



Shigellosis



Yellow fever

Causes of overhydration Blood transfusion reaction

Chronic liver disease Congestive heart failure Cushing's syndrome Glomerulonephritis o Acute o Focal or embolic o Membranoproliferati o Postinfectious o Post-streptococcal Heart problems

Hyperaldosteronism Kidney failure Liver failure

Malnutrition



Electrolyte disturbance

o

Hypernatraemia (also caused by dehydration)

o

Hyponatraemia, especially from restricted salt diets



Fasting



Recent rapid weight loss may reflect progressive depletion of fluid volume (the loss of 1 L of fluid results in a weight loss of 1 kg or 2.2 lb).[1]



Patient refusal of nutrition and hydration

Other causes of obligate water loss



Lung problems

Severe hyperglycaemia, especially in Diabetes mellitus (Glycosuria)



Nephritis (kidney inflammation) o Familial interstitial o Hereditary o Lupus o Secondary Nephropathy Nephrotic syndrome Preeclampsia Pregnancy or Surgery / operation complications

Fluid balance WIPER PS Examine in sequence – do the following 1. Inspect the patient from the end of the bed 2. Note anything around the bed

Is patient well or unwell? Note any drip lines/vomit bowls/

3. Has the patient got a catheter? 4. Look at and feel the hands 5. Cap Refill 6. Hands warm and well perfused? What’s this patient’s temperature 7. Pulse

Heart rate

Character of pulse

8. Ask for Blood pressure – mention that would like to do standing and lying comparison 9. Look at face

distressed/pain?

10. Examine mucous membranes

Are they dry?

11. Assess JVP 12. Check skin turgor 13. Listen to heart for flow murmurs 14. Listen to lung bases 15. Examine abdomen

Swelling

16. Hepatomegaly 17. Look at catheter bag/urine specimen

what colour is the urine?

18. Peripheral oedema

Sacral and Lower Limb

Ask patient about 1. 2. 3. 4.

Headache Constipation Thirst Tiredness

Complete Examination by doing following 1. Examine any system requiring specific attention e.g. CVS or Abdo 2. Review observation charts/complete assessment 3. Examine/investigate urine i. Specific gravity ii. Osmolality 4. Look at fluid balance charts 5. Weight patient Especially if on dialysis or in fluid overload 6. Review notes and biochemistry i. Electrolyte balance ii. Renal function

FLUID BALANCE THIS EXAMINATION CONCERNS 2 SITUATIONS Hypovolaemia – Fluid Depletion Hypervolaemia – Hypoproteinaemia, Fluid overload WIPER Wash hands, Introduce, Permission and Pain Expose Waist up Reposition 45o 1. Inspection Inspect the patient from the end of the bed Are they well or unwell? Look around the bed Cannulae/Central Lines/I.V. Fluids – Check which fluids are running Kidney dishes – vomiting Catheter? NG tube/PEG Drains Evidence of burns or other wounds (e.g. surgical) Nil by mouth signs 2. Hands Capillary refill+ Peripheral Cyanosis Peripheral shut down Radial Pulse rate Taccycardic, (failure and hypovol) Thready Pulse in sev. Hypovol. Quickly observe if tachypnoeic In extremis: Hypovolaemia, Heart failure, Cor Pulmonale DO LYING AND STANDING Blood Pressure 3. Face Mucous Membranes Dry tongue and lips (NB relatively inconstant sign) Tongue offer to do Temperature Sunken features 4. Neck JVP Raised in overload/May be in hypovolaemia 5. Chest Skin turgor Assess skin turgor on anterior chest wall or neck Gently pinch a piece of skin for a few seconds and release Examine heart Listen to Lungs “Cardiac asthma” Wheeze (failure), bibasal insp. crackles 6. Abdomen Any intra-abdominal surgery has risk of bowel ileus – 24-48hours pt. has up to 8L/day 3rd space loss Inspect abdomen for swelling 3rd space losses may be a cause of intravascular hypovolaemia Inspect stoma +++ risk of fluid loss if high output (e.g. Ileostomy) Inspect catheter Functioning properly, draining, check with fluid charts Listen for bowel sounds absent in Ileus Concentration of urine 7. Legs Check for peripheral oedema Sacral and Limb Check peripheral pulses, Dorsalis pedis and Posterior tibial Periph shutdown 8. Special Tests Review fluid charts for patient Complete vital signs assessment Weight Patient Review Renal function and haematocrit Write up fluids/Diuretics Also HR Mucous membranes Bp Urine Turgor JVP

NUTRITONAL ASSESSMENT ANTHROPOMETRIC PARAMETERS AND GROWTH Weight, stature (length or height) and head circumference Growth charts Stature and weight proportionality: weight for stature, Body Mass Index Other parameters: skinfold and arm circumference measurements Estimations of stature: arm span, knee height, crown-rump sitting height Expected weight and stature: height-age, weight-age, expected weight, midparental height Specialty growth charts References DIETARY INTAKE Methods of data collection Questions to ask to assess nutrient intake, behaviors, relationships, attitudes, feeding skills, development Standards to evaluate adequacy of intake References MEDICAL ISSUES Common drug/nutrient interactions References DEVELOPMENT Assessment of feeding skills References BEHAVIOR Why should I assess behaviors related to feeding? Evaluating behavior-related problems Evaluating parent and child interactions Evaluating environmental factors Evaluating physiologic problems What does a nutritional assessment include? Assessment of a child’s nutritional status includes evaluation of several sets of indicators: Anthropometric indicators (e.g., weight, stature, and skinfold measurements) provide information about a child's physical growth. Measurements can be compared to growth charts to help determine nutritional risk, and over time, they provide information about a child’s long term nutritional status. Dietary information in a nutritional assessment can be affected by a variety of factors, including physical, environmental and social influences. Nutrient intake, developmental appropriateness of foods offered, and social and environmental influences are evaluated in this portion of the assessment. Behaviors around food and eating should be examined as well. Biochemical indicators (laboratory values) can provide information about a child’s macro- and micronutrient stores; e.g., a low serum albumin might reveal a risk for protein deficiency. Hemoglobin and hematocrit values can provide information about iron status. Cut-off levels vary for specific institutions. The use of norms for adults is not necessarily appropriate in pediatric populations. Medical conditions, including fluid imbalances, and drugnutrient interactions must be taken into consideration when interpreting lab values. Clinical indicators are physical signs of nutritional status; e.g., fatigue, dry or scaly skin, and lackluster hair. Medical conditions that may alter intake and/or growth should be considered in the assessment. Possible drugnutrient interactions should be evaluated.

Heart Murmurs – Harvey WIPER PS Conduct a CVS exam of Harvey as you would normally focusing on the following areas Inspect from the end of the bed Comment on Apex beat Feel pulse and calculate rate Measure BP Feel carotid pulse Inspect JVP whilst feeling Pulse Feel apex character

Displaced Heaving Tapping

Heaves and thrills Ausculation

Comments on the following features of a murmur Timing Shape Location Radiation Intensity Pitch quality

Harvey Program Normal Innocent Murmur Aortic scelorsis

pt well Normotensive murmur over the pulmonary region low intensity pt HTN Aortic and Mitral systolic crec-dec murm’

HARVEY CVS examination Clinical skills GUIDE Mitral Stenosis Mitral rtegurg

Pt hypotensive, Large V wave,

Getting started with HARVEY

Harvey is located at the: Royal Free Clinical Skills Centre, Royal Free Hospital 020 7472 6192 Whittington Clinical Skills Centre, Holborn Union Building, 020 7288 3673 UCH Clinical Skills Centre, Rockefeller Building 020 7679 6900

© Academic Centre for Medical Education

GETTING STARTED WITH HARVEY

What is Harvey and who can use it?

Harvey is a learning tool used by many medical undergraduates and postgraduates worldwide. He is a cardiac simulator which recreates precordial movements, cardiac murmurs, as well as alterations in blood pressure in a variety of cardiac conditions. By examining Harvey, you can expand your examination skills and learn how different cardiovascular conditions can present. As he has a wide range of programmed conditions, he can be used by learners at all stages of their training.

Guidance for using Harvey

Harvey is programmed with 30 different conditions that can be selected by entering the appropriate number into the control . The heart sounds can be auscultated using the ‘Harvey’ stethoscope. (please note you can not hear these with your own stethoscope). There is also a computer program that accompanies Harvey. The package has further case studies for each of the conditions and integrates a wide range of information including clinical and laboratory data with echocardiograms and cardiac catheter studies. Some of the detail is very advanced and relates to postgraduate education and is therefore beyond the scope of this initial session. Harvey is an expensive machine; to replace him would cost £30, 000; therefore care should be taken when examining him. Avoid leaving the stethoscope on the skin when not examining. Do not attempt Basic Life on Harvey or use pens and markers near him. Most importantly treat Harvey as if he is one of your patients. How does this study guide work? This pack will guide you through your first session with Harvey. It is a self directed learning session completed in groups of eight students.. This pack will help you get started listening to abnormal heart sounds.. Examination of patients and further reading will add to the knowledge that you gain during this session. Please note it is not possible to gain all the cardiovascular knowledge needed to your exams using Harvey alone-you need to examine real patients. Harvey is however a useful tool for students learning about cardiovascular conditions for the first time. This pack is divided into seven sections. The first section relates to the normal heart and then the following four sections relate to four individual murmurs. Each section is centred on a case with questions relating to the objectives of the session. The sixth section summarises the symptoms and signs of all four murmurs. The final section lists additional resources that may be useful in your learning. You can book extra sessions with Harvey to expand your experience further or to refresh your memory before exams. the Clinical Skills Centre at any of the three sites to book another session (telephone numbers for each skill centres are provided on the first page of this study guide)

Aims of session Examine Harvey and familiarise yourself with four key murmurs  mitral regurgitation  mitral stenosis  aortic stenosis  aortic regurgitation Learning objectives By the end of your first session with Harvey you should be able to:

1. 2. 3. 4. 5.

auscultate the chest for the normal heart sounds auscultate the chest for the four murmurs and identify where they are heard loudest identify whether a murmur is systolic or diastolic draw a diagram to represent each murmur identify where the murmurs radiate to

What is a murmur and when is it heard?

TEACHING BOX 1 - SUMMARY OF MURMURS A heart murmur is caused by turbulent flow that may be produced by a number of mechanisms. It may be due to high blood flow across a normal valve or normal blood flow through an abnormal valve. The turbulent flow could also be due to regurgitation of blood through a leaking valve. Pathological murmurs are divided into three groups; the systolic, diastolic and continuous murmurs.

Ejection systolic Systolic murmurs

Pansystolic Late systolic

Heard separately from the first and second heart sound. Intensity is greatest in mid-systole

Extends from the first to second heart sound with equal intensity throughout systole Distinct from first sound but extends up to second sound

Occur at the same time as the carotid pulsation Usually arise from mitral or tricuspid valves Diastolic murmurs Always associated with cardiac disease

Mid-diastolic Early diastolic

Results from aortic regurgitation, but may also occur from pulmonary hypertension secondary to mitral stenosis giving rise to pulmonary regurgitation (Graham Steell murmur)

May occur due to a combination of systolic and diastolic murmurs via a connection between the aorta and pulmonary artery (eg patent ductus arteriosus) or arteriovenous anastamosis.

Continuous

SECTION 1-NORMAL HEART SOUNDS Case 1 Mr A is a 30 year old man who has chest pain on exertion. The pain started 3 days ago when he was playing squash and is located on the left side of his chest. The pain is sharp and does not radiate. It is not present at rest but is worse when he goes to the gym or plays squash. He is otherwise well. His father died last year from a myocardial infarction. Mr A is a non smoker and drinks less than 5 units of alcohol a week. Examine Harvey as if he was Mr A. Tasks 1. Start by selecting setting 46 – The normal heart. 2. Measure and record Mr A’s blood pressure.

mmHg

3. Inspect the chest and palpate the apex beat. Where is it located? ……………………………………………………………………………….. 4. Use the stethoscope to auscultate the chest. The four principal areas of interest are shown in the picture below.

TEACHING BOX 2 – Areas to auscultate Area M - The apex and Mitral valve region

A

Area T - The left lower sternal border region overlying the Tricuspid valve.

P T

Area P - 2nd intercostal space on the left corresponding to the area of the Pulmonary valve.

M

Area A - 2nd intercostal space on the right overlies the Aortic valve.

TEACHING BOX 3 – The Heart sounds

S1

S2

S3 S4

S1

AP In a healthy adult like Mr A there are two heart sounds; the first, S1 and the second, S2. S1 corresponds to Mitral and Tricuspid valve closure. S2 corresponds to Aortic and Pulmonary valve closure. This heart sound is split as the pulmonary valve closes approx. 0.06seconds after the aortic valve. This is best heard in the pulmonary region in inspiration. Two other heart sounds, S3 and S4 can occasionally be ausculated. S3 occurs in rapid Left Ventricular filling, when blood hits the valve apparatus and the ventricle wall. It is only pathological when heard in those over 30 years. S4 occurs with Atrial contraction in conditions such as hypertension, Aortic Stenosis or Acute Myocardial infarction

TEACHING BOX 3 – Changes in the heart sounds Characteristics of first heart sound S1 Loud Soft Mitral Stenosis Severe Mitral regurg. Short PR Long PR

Characteristics of the second heart sound S2 Loud Soft Wide split Hypertension Aortic RBBB Pulmonary stenosis (A2) Inspiration hypertension Pulmonary (P2) stenosis (P2)

Variable Ventricular Tachy. Nodal Tachy. Atrial Fibrillation

Reverse split LBBB Aortic stenosis Patent ductus arteriosus

Wide split RBBB LBBB

Fixed split Atrioseptal defect

Which heart sounds can be heard?

……………………………………………………………………………………… NB Listen carefully in the pulmonary region for the splitting of the second heart sound.

Single Tetralogy of Fallot VSD

SECTION 2 - MITRAL REGURGITATION Case 2 Mr B is a 50 year old man who has had shortness of breath for 2 days. It was sudden in onset and is worse when lying down (orthopnoea). He has no chest pain. He has been tired for 2 months and has had a low-grade fever. He has no cough, haemoptysis, leg pain or ankle oedema. He has no relevant past medical history and is a nonsmoker. Examine Harvey as if he were Mr B. Tasks 1. Select setting 6 on the control – mitral regurgitation (acute). 2. Measure and record Mr B’s blood pressure.

mmHg

3. Palpate for the apex beat. Where is it located? … …………………………………………………………………………….. 4. Listen to the chest in all four regions. Where is the murmur loudest? ………………………………………………………………………………… 5. Palpate the carotid pulse whilst listening to the murmur. Is the murmur systolic or diastolic? ………………………………………………………………………………… 6. Where does the murmur radiate to? ………………………………………………………………………………….. 7. Using diagram below, draw the murmur

S1

S2

S1

For a summary of the symptoms and signs of mitral regurgitation see teaching box 5 on page 11.

SECTION 3 – MITRAL STENOSIS Case 3 Mrs C is a 55 years old woman who has shortness of breath, which has been worsening on exertion for 2 years. Examine Harvey as if he were Mrs C. Tasks 1. Select setting 4 on the control – mitral stenosis

2. Measure and record Mrs C’s blood pressure.

mmHg

3. Palpate for the apex beat, where is it located? ………………………………………………………………………………….. 4. Listen to the chest in all four regions. Where is the murmur loudest? …………………………………………………………………………………. 5. Is the murmur systolic or diastolic? ………………………………………………………………………………….. 6. Where does the murmur radiate to? ………………………………………………………………………………….. 7. What could you ask Mrs C to do to make the murmur louder? ………………………………………………………………………………….. 8. Using the diagram below, draw the murmur

S1

S2

S1

For a summary of the symptoms and signs of mitral stenosis see teaching box 6 on page 11.

SECTION 4 – AORTIC STENOSIS Case 4 Mr D a 46 year old man has had exercise induced syncope and chest pain for 2 months. He also has shortness of breath (dyspnoea) on exertion. Examine Harvey as if he was Mr D Tasks 1. Select setting 13 on the control – aortic stenosis

2. Measure and record Mr D’s blood pressure.

mmHg

3. Palpate for the apex beat, where is it located? ………………………………………………………………………………….. 4. Listen to the chest in all four regions. Where is the murmur loudest? …………………………………………………………………………………. 5. Is the murmur systolic or diastolic? ………………………………………………………………………………….. 6. Where does the murmur radiate to? ………………………………………………………………………………….. 7. Using the diagram below, draw the murmur

S1

S2

S1

For a summary of the symptoms and signs of aortic stenosis see teaching box 7 on page 12.

SECTION 5 – AORTIC REGURGITATION Case 5 Mr E,a 30 year old man has had shortness of breath and paroxysmal nocturnal dyspnoea for 1 year. He also has palpitations with chest pain on exertion. Examine Harvey as if he were Mr E. Tasks 1. Select setting 17 on the control – aortic regurgitation. 2. Measure and record Mr E’s blood pressure.

mmHg

3. Palpate for the apex beat. Where is it located? ………………………………………………………………………………….. 4. Listen to the chest in all four regions. Where is the murmur loudest? ……………………………………………………………………………….. 5. Is the murmur systolic or diastolic? ………………………………………………………………………………….. 6. What could you ask Mr E to do to make the murmur louder? ………………………………………………………………………………….. 7. What other signs would you examine Mr E for? ………………………………………………………………………………….. 8. Using the diagram below, draw the murmur

S1

S2

S1

For a summary of the symptoms and signs of aortic regurgitation see teaching box 8 on page 12.

SECTION 6 – REVIEW OF MURMURS

TEACHING BOX 5 – MITRAL REGURGITATION

S1

S2

S1

Causes    

Rheumatic heart disease (50%) Prolapsing mitral valve Infective Endocarditis – mitral valve leaflet destruction Rupture of chordae tendineae following MI, Infective endocarditis or trauma.

Symptoms:   

Palpitations due to increased stroke volume Dyspnoea and orthopnoea due to pulmonary venous hypertension Fatigue and lethargy because of reduced cardiac output.

On examination    

There is a displaced thrusting apex beat. The first heart sound is soft and may be obscured. S3 may be present. The murmur of Mitral regurgitation is pansystolic or holosystolic and is heard best at the apex. The murmur radiates to the axilla.

TEACHING BOX 6 – MITRAL STENOSIS

S1

S2

S1

OS

Causes  

Almost all cases are due to Rheumatic heart disease Rare congenital mitral stenosis

Symptoms    

Usually no symptoms until the valve is moderately stenosed Doesn’t usually happen until several decades after having Rheumatic fever as a child Progressively severe dyspnoea, frank haemoptysis may occur Pulmonary hypertension leads to right heart failure with fatigue and leg oedema

On examination     

Mitral facies or malar flush There is a tapping apex beat which is undisplaced. There is a loud S1 The murmur is a mid-diastolic rumbling heard best at the apex with an opening snap. Can be auscultated more efficiently by rolling patient onto left lateral side.

SECTION 6 – REVIEW OF MURMURS

TEACHING BOX 7 – AORTIC STENOSIS

S1

S2

S1

Soft Causes

  

Congenital aortic valve stenosis due to a congenitally abnormal (bicuspid) valve Rheumatic heart disease results in thickening and calcification of a normal valve Calcific valvular disease – inflammatory process thickening the leaflets Symptoms:  Late onset of symptoms when opening down to a third of normal size.  Exercise induce syncope, angina and dyspnoea develop On examination  Slow rising pulse with a narrow pulse pressure.  Heaving apex  There is a soft A2 and reverse splitting of S2, with P2 before A2.  An ejection click may be heard.  It is an ejection systolic murmur heard best in the aortic region and may radiate to the carotids.

TEACHING BOX 8 – AORTIC REGURGITATION

S1

S2

S1

Causes  Rheumatic fever and infective endocarditis complicating a previously damaged valve  Numerous other causes incl. Reiter’s syndrome, RA, Hypertension, Connective tissue disorders Symptoms  Palpitations, angina pectoris and varying degrees of dyspnoea. On examination  A collapsing pulse with a wide pulse pressure.  Thrusting apex, S3 may be heard.  It is an early diastolic decrescendo murmur heard best at the left sternal edge in expiration.  Other signs of chronic AR include  Corrigan’s sign – Waterhammer pulse with a wide pulse pressure  De Musset’s sign – Nodding head  Quincke’s sign – Nail bed reddening and blanching  Duroziez’s sign – To and fro flow bruit heard over femorals.  Hill’s sign – Femoral systolic hypertension



Section 7- Additional resources Further Harvey learning resources can be found at: http://www.harveyresourcecentre.org.uk/

You can listen to heart sounds and murmurs at: http://solutions.3m.com/wps/portal/3M/en_US/Littmann/stethoscope/education/heart-lung-sounds/ The UCL guide of how to examine the cardiovascular system is found at: http://moodle.ucl.ac.uk/file.php/1133/PAL_PACK_2008-2009.doc

The mark sheet for cardiovascular examination in UCL OSCE’s can be found at: http://www.ucl.ac.uk/medicalschool/current-students/assessments/p3y5assessments/longstation_osce04/station2_cardioexam_ju06.jpg

Ulcer Exam WIPER PS Wash hands Introduce Permission Expose Reposition Pain Stop Inspection Size and shape Number or multiple ulcers Exact anatomical site

specific site ulcers: Rodent/TB/Trophic(neuropathic)/ Venous/Arterial

Margin

Healing Spreading Chronic non healing

Edge

Sloping Punched edge Undermined Raised Everted

healing ulcer vertical edge – trophic/arterial ulcer TB – subcutaneous destruction of Rodent ulcer Malignant

Floor

Granulation Slough Discharge

Normal/pale/hypertrophic (with serosanginuous discharge) necrotic soft tissue overlying healing

Surrounding area

Palpation

White outer, blue and red lines Red Inflammation and irregularity Fibrosis – thick white skin

Local inflammation Pigmentation Local swelling Scaring Hypopigmentation

non healing ulcer

Don Gloves

Temp of surrounding skin Tenderness around ulcer Palpate edge Palpate /Granulation Attachment to underlying structure

Soft/Firm (fibrosis)/Hard Bleeding? Assess Attachment of slough Consistency of base Firm/Indurations (malignant) Ask patient to contract muscle

Local/Systemic Examination Palpate Local lymph nodes Vascular Examination Test sensation of surrounding skin Examine ts close to ulcer Finish up Relevant Systemic exam

Thank Patient

matted/Tender/Soft tender map anaesthesia Assess muscular/tendinous involvement

CVS RS Abdo

Failure = poor healing for ulcers TB Splenomegaly (Haemolysis)

Abdominal Examination WIPER Wash hands Introduce Permission and Pain Expose Reposition END OF THE BED Patient Well or unwell? Patient Calm and comfortable? Weight Loss Level of hydration Signs of easy Bruising Scars Abdominal distension/Peripheral oedema Evidence of other disease? Ask patient to raise feet and head off bed whilst lying down – Ask them to cough Hernias Around the bed

Fluid restriction Sick Bowls Suppliments etc


Palmar Erythema Clubbing Skin Turgor Dupuytren’s Contracture Koilonychia Leuconychia Liver Flap Signs of other disease Hands warm and well perfused

Pulses Radial rate and rhythm FACE Eye

Alcohol: AF

Red Eye corneal arcus Parotid Swelling Kaiser-Flechier Rings Xanthelasma Bruising Subconjunctival pallor

Mouth

Teeth Ask about Ulcers Jaundice

CHEST WALL AND NECK Inspect

JVP

Hepatic Encephalopathy

quickly assess Spider Naevi

? Iritis/Uveitis Alcohol Abuse Wilson’s disease

Liver

Gynaecomasia Body Hair distrubution ABDOMEN Inspect the Abdomen Closer

Shape/Symmetry Distension Scars Prominent veins Hernia Visible Peristalsis

Position PALPATION

AUSCULTATION

COMPLETING THE EXAM


MINI MENTAL STATE EXAM Wash hands Introduce Explain procedure Permission Sitting comfortably Orientation 5 points for Time

5 points for Location

Year Season Month Day of week Exact Date Country County City Hospital Floor

Short Term Memory Retention and Recall 6 Points for Recall Pen Wallet Flower Attention 5 Point for Calculation subtract 7 from 100 for times (93, 86, 79, 72, 65) Or spell WORLD backwards Language 2 Points for Naming Paper Pen 3 Points for Commands 3 step command 1 point Drawing 1 point Writing 1 point Reading 1 point Repetition

Copy 2 intersecting Pentagons [constructional apraxia] Write a sentence Obey a written command e.g. “close your eyes” “no ifs and no buts” [conductive Dysphasia]

Calculate Score 24 – 30: "normal" range 20 – 23: mild cognitive impairment or possible early-stage/mild Alzheimer's disease 10 – 19: middle-stage/moderate Alzheimer's disease 0 – 9: late-stage/severe Alzheimer's disease Finish Off Thank patient

'Lumps and Bumps' Examination Introduction It is important to be able to accurately describe lumps and bumps as this can be a popular OSCE station. There are always a surprising amount of things you can say about every mass. Your description should be good enough for a doctor to come up with a differential diagnosis without seeing the patient. It should also be recorded in the notes as a record of how the lump was on that particular day. Here are the main headings: Always start by: washing your hands, introducing yourself and obtaining consent.

Inspection Look for: - Site (describe in relation to fixed anatomical landmarks) - Size (make a visual estimate of the size - you will confirm this upon palpation) - Shape (often compared to real-life objects, eg. fruit, golf balls, etc.) - Colour

Palpation Feel for: - Tenderness (always ask if patient is in any pain first!) - Temperature - Size (use cm or fruit!) - Shape (3 dimensions) - Surface + edge - Composition (consistency, translucency, pulsatile, compressible) - Reducible (eg. hernias - don't forget cough impulse for these) - Relationship to other structures (eg. origin and attachment)

Percussion For: - Fluid thrill - Extent of mass (eg. thyroid lumps - percuss from the neck down the sternum to see if goitre mass extends 'retrosternally')

Auscultation Listen for: - Bruits (especially if you suspect a vascular structure)

Extras Don't forget: - Transillumination (especially for cystic lumps) - ideally look down through a small tube, such as a 'Smarties' tube, pressed down onto the midpoint of the lump, whilst illuminating the mass from the side using your pen-torch - in reality you probably won't be able to do this, so mention that 'ideally I would use a tube', but for the purposes of the examination you can then just illuminate with your pen-torch - Regional lymph nodes - always palpate for these - Say you would like to examine the local tissues for any pathology ? skin, muscle, bone, vessels, nerves - Say that you would ideally also perform a general examination ? always examine the whole patient to look for more of the same! - Common examination lumps: lipomas, thyroid masses, aneurisms, hernias.

Sensory Exam WIPER PS

Examiner will specify area to assess

Inspection D.W.A.R.F.S Have you noticed any alteration in your sense of touch? Have you had any “pins and needles” ? Anatomy Sensation Nerve Type Pathway Proprioception/vibration Large Fast fibers Dorsal Columns Medulla Pain and Temperature Small Slow fibers Spinothalamic Rules Ask patients to avert Gaze RATHER than close eyes Move from Hyposensitive to Hypersensitive e.g. Hypo  Normal  Hyper

Decussation Spinal Level

Light Touch - - Use Cotton Wool Demonstrate normal on sternum Assess Dermotomes (Dabbing action), Compare both sides Superficial Pain - - Use Neurotip Demonstrate normal on sternum Assess Dermatomes (Dabbing action), Compare both sides Deep Pain - - use hands NOT instrument Ask pt to report Discomfort Squeeze muscle bellies Apply pressure to nail beds Temperature - - use Tuning Fork Touch patient with cold metallic object Vibration - - Use 128 Hz Demonstrate normal on sternum Test Bony Landmarks Ask patient to say when vibration Stops t Position Sense Ask patient to close eyes Hold distal phallanx of toe on sides Test up and down 5 times

Hallux, Ankle, Tibial Tuberosity – work superiorly

NB normal in elderly is up to 3/5

Point Localization And Two Point Discrimination - - Ideally for testing hands [finger pulps] Ask Patient to close eyes Test minimum distance that Two point discriminator can be reliably felt Confirm naming convention of fingers ( e.g. first, middle) Assess finger Agnosia Ask patient to close eyes and assess localization of fingers Sereognosis, Graphaesthesia and Neglect - - test with Eyes closed Bicortical stimulation of sensory stimulus Close eyes and Touch backs of hands separate and then together Give pt a common object, ask to name Trace letters on pts palm, ask to name Finish up

Thank pt and Wash hands Full neurovascular Cranial N Further

Mental Assessment

Tests as ness’

HERNIA Facts you should know: - Mid inguinal point = ASIS to pubis symphysis (femoral artery) - Midpoint of inguinal ligament = ASIS to pubic tubercle (deep inguinal ring: 1 to 2cm above femoral pulse) - Superior inguinal ring = above & medial to pubic tubercle - Inguinal hernia = above and medial to pubic tubercle - Femoral hernia = below and lateral to pubic tubercle - Indirect can extend into scrotum - Divarication of the recti = This is not strictly a type of hernia. This occurs when the two rectus abdominus muscles (either side of the midline) deviate from one another. More pronounced superiorly, and is due to the either intrinsic laxity of the linea alba, or weakening secondary to repeated surgery or chronic abdominal distension/raised intra-abdominal pressure. To demonstrate a divarication, ask the patient to lift their head off the pillow whilst lying down - the divarication will become pronounced. It will then almost completely disappear when the patient lies flat again. It is not painful and does not require surgery. - to look for hernias at end of GI examination. Inguinal Hernias General features: - More common in men than women - Congenital: secondary to patent processus vaginalis - Acquired: weakness of wall Indirect: - often found in younger patients - arise lateral to inferior epigastric artery - always acquired Direct: - often older patients (weaker abdominal walls) - arise medial to inferior epigastric artery Examination Key points: 1. Wash your hands, introduce yourself, and ask permission (consent) to examine. Always check if patient is in any pain. Adequately expose the area. 2. Ask patient to stand: see reducible hernias & see hernias on other side, as well as scars. Can examine lying down if the hernia is still obvious lying down. Otherwise examine patient whilst standing. 3. Kneel to side of patient (not directly in front, or will look slightly dodgy). Get patient to cough and feel for a cough impulse (suggestive of herniae). 4. Ask patient if they can reduce the lump or 'make it go away' themselves. This can be a useful way of demonstrating reduction without hurting the patient. 5. If not painful and a reduction is possible, put your fingers over the superficial ring and repeat cough test. If the hernia does not reappear then it is indirect. 6. Check the contralateral side. 7. Say to the examiner that you would also like to examine the abdomen. 8. Cover patient up/allow to redress

Complications Operative complications: - vascular damage - nerve damage (ilio-inguinal) - spermatic cord damage - bowel damage - bruising - recurrence Complications of hernias: - incarceration (become non-reducable) - strangulation (become ischaemic, as vascular supply gets cut off) - Richters hernia = strangulated but not obstructed (lumen partially obstructed) - bowel obstruction Other Types of Hernia Umbilical: - These are common, and are often congenital. - Small ones usually spontaneously close by 2yrs. Larger ones/non-closing ones are usually operated on when the child is around 3-4yrs old. - Can occur later in life (umbilicus is a 'weak spot') - often appear later in the elderly and women who have given birth. Incisional: - These are also very common post-operatively. - A number of factors can predispose to an increased risk of incisional hernia. Learn these factors for good 'wound healing'. They are divided into pre-operative (nutritional status, age, obesity, etc.), operative (good surgical suture technique, good haemostasis, etc.) and post-operative (infections, controlling cough, etc.). - These often frequently recur with repair. Spigelian: - Found along edge of rectus abdominus. Obturator: - Rare. Relatively more common in women. - Hernia sac protrudes through obturator foramen. More likely to be symptomatic rather than cause a visible mass. Epigastric: - Occurs between the umbilicus and the xiphisternum (in the midline). - Often composed of fat/omentum - rarely contain bowel. Can often be painless and easily reduced.

Cerebellar Function Examination Signs of Cerebellar Pathology

Signs of a cerebellar lesion include: Dysdiadochokinesia Ataxia (lower limbs ? impaired heel-shin) Nystagmus (ipsilateral) Intention tremor (on finger-nose test) Staccato speech (slurred) Heel-toe walking impaired Introduction

Wash your hands, introduce yourself and ask permission (consent) to examine. Always ask if the patient has any pain. Gait Observe the patient walking and look for: - an ataxic gait (ask the patient to walk to other side of room and back - gait is broad based & incoordinated) - heal-toe walking impaired (patient cannot walk in a line - ie. putting one foot in front of the other, then repeating) - Romberg's test: Get patient to stand with legs close together and arms by side, then ask patient to close their eyes. A positive test is when they are more unstable upon closing their eyes, and is a sign of peripheral proprioceptive failure - NOT cerebellar pathology, which is a common misconception. With cerebellar pathology, there is 'Rombergism' (ie. patient is unstable with and without eyes closed). - Always stand next to the patient and remain by their side to them if they become unsteady. Face Look for: - eye movements (nystagmus will be seen upon making patient slowly alternate gaze from side to side) - speech (slurred / staccato) - get the patient to say "university" or "British constitution" and then ask them to speak - for example, by describing your clothes etc. Arms Look for: - mildly decreased tone - past pointing / intention tremor (finger-nose test - "touch my finger then your nose, then repeat as fast as you can". Make sure you keep your finger at an arm's length away, and move the position of your hand from time to time.) - dysmetria (arms out with flat palms + eyes closed, then push down on an arm suddenly. If it suddenly springs upwards then this test is +ve) - dysdiadochokinesia (make big movements starting at shoulder - not small movements with hand only as you are testing the big proximal muscle groups that the cerebellum controls.) To complete: Thank the patient, redress.

Myasthenia Gravis Examination Introduction Wash your hands, introduce yourself, and ask permission (consent) to examine. Ask if the patient has any pain before you begin.

Inspection Look for: - Ptosis (drooping eyelids) - Thymectomy scars (thymus malignancies are associated with myasthenia gravis) - ?Snarling? facies Eyes Look for: - Movements (may have opthalmoplegia) & diplopia - Fatiguability ? test sustained upgaze - Fatiguability - test repeated blinking Speech Listen for: - Nasal sounding speech(bulbar-like palsy) - Get the patient to count upwards - may slow down/change character of speech as they fatigue Arms Test: - Make ?chicken wings? type movements (to demonstrate fatiguability) - Always exercise your judgement in of 'over-straining' the patient. If they are starting to get tired then bear this in mind and modify your examination accordingly. Always thank them when you finish. To complete: Thank the patient, redress.

Multiple Sclerosis Exam Introduction Wash your hands, introduce yourself, and ask for permission (consent) to examine. Ask if the patient has any pain before you begin.

Gait Look for: - Spastic gait (a sign of upper motor neurone pathology) - Weakness

Face Look for: - Eye movements +/- nystagmus - Internuclear opthalmoplegia - Make a fist with one hand , and hold a single finger of the another hand up. Ask the patient to 'look at my finger, then look at fist, and then alternate'. If INO is present, then the abducting eye will show nystagmus, and the adducting eye will fail to adduct and will remain fixed centrally. The reason for this is damage to the medial longitudinal fasciculus, which normally links the VI nerve nucleus (abducting eye) to the III nerve nucleus (adducting eye). A lesion here (caused by demyelination in multiple sclerosis) leads to a lack of this coordinated response during rapid lateral gaze movements. - Fundi (atrophic discs - optic nerve demyelination) - Speech - say ?university? etc. (look for patterns of speech seen in cerebellar pathology, or a pseudobulbar palsy) Arms Test for: - Cerebellar function (slightly increased tone and weakness, as well as impaired finger-nose coordination) - To complete: Thank the patient.

Parkinson's Disease Examination Introduction Wash your hands, introduce yourself, and ask permission (consent) to examine. Ask if the patient has any pain before you begin. Gait and Stance Key points: - Festinating gait (slow and shuffling movements when walking) - Decreased arm swing - Difficulty turning and initiating movements (patients may use a walking stick to 'poke' their feet to get them to move). Lines or markings on the floor can sometimes help. - Stooping posture - Postural instability Inspection Look for: - Hypomimia (decreased facial expression) - Blepharoclonus (fine eyelid tremor) - Resting tremor (brought out by distraction - such as conversation) - Tardive dyskinesia (chewing movements of the mouth - drug treatment side effect) Face Look for: - glabellar tap (keep blinking - normally adjust) - normal eye movements but abnormal vertical gaze + VOR (in supranuclear palsy) - speech ? monotonous voice Trunk Test: Axial rigidity (found in the 'supranuclear palsy' form of Parkinson's disease) Arms Look and test: - Tremor ('pill rolling', more pronounced at rest - as opposed to cerebellar tremors that are more pronounced upon initiation of movement) - Normal muscle bulk / reflexes / power - Increased tone - leadpipe rigidity (move whole arm around elbow t) & cog-wheel rigidity ( forearm and flex/extend the flat palm at the wrist - cogwheeling is the jerky 'stepwise' movement that is felt due to tremor superimposed upon rigidity) ? these features are enhanced by asking the patient to move the other arm up and down as a 'distractor' or 'reinforcer' - Bradykinesia (slowness of movement - observed when patient is asked to flap arms up and down) - Finger-nose pointing (tremor decreases) Extras For a few bonus points, you can test/mention the following: - Micrographia (small writing) - Examine the observations chart for a postural BP drop (in the 'multisystem atrophy' form of Parkinson's) - Examine the drug chart (is this perhaps a drug-induced 'Parkinsonism' - caused by anti-dopaminergic drugs such as metoclopromide) - Examine the cerebellar system's function (also affected in 'multisystem atrophy') To complete: Thank the patient.

Speech Assessment WIPER PS Inspection Orientation

Signs of Stoke, CN lesions Basic Assessment a. Time b. Place c. What Handedness are you?

Cranial nerves IX and X

Wasting/Fasiculations Gag Reflex Uveal Movement

Comprehension

3 step Command

Expressive Dysphasia [Brocas]

Tell me your name and address What is this? Pen and Watch Fluency in naming types of fruit/what you had for breakfast Repetition British Constitution/Baby Hippopotamus/West street Say “no ifs ands or buts” [Conductive Dysphasia]

Dysarthria

Say “K” or “G” Say “M” Say “L”

Dysphonia

Assess volume of speech

[Wernicke’s]

Palatal Facial Tongue movement

Reading and Writing Swallowing

Take a sip of water and hold in mouth Perform again Comment on “Wet face” or Coughing or Choking

Finish up Thank Patient Wash hands Offer to perform full neurovascular examination of upper and low`er limbs Offer to perform Cranial Nerve exam

GALS WIPER 3 Questions P Do you have any pain? D Do you have any difficulty dressing S Do you have trouble with stairs Inspection Ask patient to stand in Anatomical position Front Deltoid Wasting Full elbow extension Quads bulk Knee or hip pathology Genu Valgum/Varum Forefoot abnormalities Any other obvious abnormalities DWARFS Side Shoulder Bulk and symmetry Cervical lordosis Thoracic kyphosis Lumbar lordosis Knee flexion/hyperextension Back Shoulder Muscle bulk and symmetry Spinal Alignment Scoliosis Gluteal muscle bulk and symmetry Popliteal swelling or abnormalities Calf muscle bulk and symmetry Hind foot abnormalities Psoriasis Gait Pt: Take a few steps, turn and walk back

Assess

Arms Ask to copy movements and observe patient doing Hands behind head Hands out in front palms down, fingers outstretched Turn hands over Make a fist Squeeze fingers Finger to thumb in turn Squeeze across the metacarpophalangeal ts

assess back of hand Assess movements and assess palm assess range of movements Power grip strength fine precision observe any pain

Spine Inspect spine once again Press on Supraspinatus to test for Fibromyalgia Ask pt: Tilt head to shoulder Ask pt: Touch toes then extend on return Ask pt: Look up and down and open mouth

assess lateral flexion check for diversion of lumbar vertebrae Check Flexion and extension of neck. Checks Temporomandibular

Legs Flexion of knees Internal and external rotation of hip Ask Pt to move feet from side to side Patellar Tap Inspect sole of feet for deformity, swelling and callosities Squeeze metatarsphalangeal ts

Upper Limb Examination Inspection: - Muscle wasting - Fasciculations - Deformities - Skin changes - Ask if the patient has any pain! Tone: Move 2 ts at a time. For the patient's right arm, hold the patients right hand with your right hand (as if shaking hands) and then gently rotate clockwise and anticlockwise. At the same time, their upper arm with your left hand and gently flex and extend their arm at the elbow t. Tone can be: - Increased - Upper Motor Neurone (UMN) lesion - Normal - Decreased - Lower Motor Neurone (LMN) lesion - Cog-wheeling/Lead-pipe rigidity - Parkinsonian signs. If the wrist t feels rigid in a 'step-wise' fashion during flexion and extension, then this is cog-wheel rigidity (tremor superimposed upon rigidity). Lead-piping is a similar rigidity in the entire arm (movement about the elbow t). Power: Always compare the two sides, and try and compare with similar forces (so you try and oppose with similar movements). It may often be best to make the movements yourself to demonstrate first. - Shoulder abduction (C5, deltoid) - Make "chicken-wings" shape and patient pushes up whilst you push down around the upper humerus. Can do both sides at once. Command = 'push up against me as hard as you can'. - Forearm flexion (C5/6, biceps) - Patient makes a fist and flexes arm at elbow t, one arm at a time. Whilst ing yourself on patients opposite shoulder, you pull their arm away whilst they try and flex. Command = 'pull me towards you'. - Forearm extension (C7/8, triceps) - As above, but you push against patient's arm whilst they push you away. Command = 'push me away'. - Wrist extension (C7, wrist extensors, radial nerve) - Patient makes a fist and holds one arm out. the forearm with one of your hands and with the other, get the patient to raise their fist up whilst you push down with your fist. Command = 'hold your arm out straight, make a fist facing downwards and push up against me at your wrist'. - Finger abduction (T1, palmar interosseus, ulnar nerve) - Patient holds arm out with fingers spread. With a finger of each hand of your hands, try and push the patients index and little fingers inwards (so you are opposing their fingers with your fingers). Command = 'spread your fingers and stop me pushing them closed'. - Thumb abduction (T1, median nerve) - abduction of the thumb is it's movement straight up (as opposed to up and laterally, which is extension). Tell patient to raise thumb up and you oppose with your thumb.

Command = 'raise your thumb up straight and stop me pushing your thumb down'. that the radial nerve supplies the extensors of the wrist, whilst the ulnar nerve supplies all of the intrinsic muscles of the hand, except for 'LOAF', which are supplied by the median nerve: L ateral two lumbricals (fingers 2 and 3) Oppons pollicus Abductor pollicus brevis Flexor pollicus brevis Coordination: - Finger-nose (intention tremor / past pointing). Command = 'With your right hand, touch your nose, then my finger, then your nose. Then repeat as fast as you can'. to move the position of your finger and to keep it at exactly arms length from the patient. - Rapid alternating movements (hands) - 'dysdiadochokinesis'. This requires big movements that originates at the shoulder t as the role of the cerebellum is generally in the control of large proximal motor groups and not small fine groups. Command = 'Hold your left palm out still and flat. Now clap onto it with your right palm. Then raise your right arm up fully and then then clap onto your left palm with the back of your right hand. Then repeat as fast as you can'. Reflexes: Ensure limb is full relaxed. It is often best to move and 'flop' the arm around a bit to ensure this. Practice reflexes with the patient lying down. Those on the opposite side of the patient's body require some practice as you cannot move over to the other side of the bed! - Biceps (C5/6) - rest patient's arms on their abdomen. - Supinator (C5/6) - rest patient's arms on their legs - Triceps (C7/8) - examiner lifts the appropriate (flexed) arm by the wrist and s it against the area of the opposite clavicle to ensure full relaxation. to use techniques of reinforcement if required, eg. 'when I count to 3, clench your teeth'. Coincide your tendon hammer strike with the patient's teeth clenching. Sensation: Dorsal columns: - Light touch - use a piece of rolled up cotton wool and compare dermatomes on both limbs. to rub this against the patients forehead or lower neck area to demonstrate what it feels like first. Press down on the skin do not 'stroke' as this activates more than just the light touch response. - Proprioception - demonstrate this to the patient with their eyes open first so that they understand. Hold either side of the finger tip (not on the nail bed), whilst ing their wrist with your other hand. Then move either up or down. Patient should then close their eyes, whilst you move their fingers at the distal interphalangial t . Very small movements should produce a response. If they are unable to do the test, then try more proximal (bigger) ts, such as the wrist. - Vibration - use a tuning fork on bony prominences. Again, show the patient what this feels like first. Make the fork vibrate first, then place on a t. Then dampen the vibration and ask the patient to tell you when it stops vibrating (with their eyes closed). Spinothalamic tracts: - Pain - use a 'neurotip' - a small red specially designed disposable pin, in the dermatomal distribution. - Temperature - you can use the metal of your tendon hammer head as 'cold' and the rubber part of this as 'hot'.

Lower Limb Examination Inspection: As for upper limb: - Muscle wasting - Fasciculations - Deformities - Skin changes - Gait - asking the patient to walk before you start the examination can help prevent you from forgetting later! - Romberg's test - you can perform this now, before the patient lies down. See 'sensation' section, below. - Ask if the patient has any pain. Tone: Move 2 ts at a time. You can, for example, move the foot whilst flexing and extending the knee t. It can be useful to 'pick up' the leg at the knee by flexing it with one palm underneath, and by then (gently) dropping the leg to the bed. If the tone is normal, it should just flop back onto the bed. With increased tone, it will remain flexed for longer. Tone can be: - Increased - Upper Motor Neurone (UMN) lesion - Normal - Decreased - Lower Motor Neurone (LMN) lesion Clonus: Check for this by externally rotating the hip t and slightly flexing the knee. Then, gently dorsiflex/plantarflex the foot a few times. Finally, make a sudden dorsiflexion movement of the foot and hold it there. Observe the calf area, looking for 'beats' or pulsations of the muscle. Greater then 3 beats count as clonus, and is a sign of an upper motor neurone lesion. Power: - Hip flexion (L1/2) - Test one leg at a time. Push down against the quadriceps muscle. In most cases you should not be able to overcome the strength of this movement. Start with the patients leg already in the air (rather than whilst it is still flat on the bed). Command = 'keep your leg straight at the knee and raise it off the bed, pushing against my hand'. - Hip extension (L5/S1) - Keep a flat hand under the patients upper thigh area (hamstrings). Command = 'push your knees into the bed against my hand'. Knee flexion (L5/S1) - Get patient to bend the knees and place feet flat on the bed. Use one hand against the patients hamstring area to steady yourself and the patient whilst pulling the calf towards you. Command = 'with your knees bent, stop me pulling your legs straight'. Knee extension (L3/4) - As above. Command = 'try and straighten your leg/'kick out' towards me'. Ankle dorsiflexion (L4/5 - Upwards movement (plantar extension) of the foot. Start with the foot dorsiflexed then apply resistance. Command = 'push your toes up and stop me pushing them down'. Ankle plantarflexion (S1) - Downwards movement of the foot. Command = 'push your toes down away from you'.

Coordination: Hell-shin test: Involves patient running the heel of one foot down from the knee of the other leg to the foot of the other leg, raising the leg up and repeating as fast as possible. Then repeat with the other leg. Command = 'Keep your left leg flat on the bed. Raise your right leg into the air, and run the sole of your right food down from your right knee to your right foot. Then raise your right leg into the air and move it back to over your right knee. Then place it down again, and repeat as fast as you can'. Reflexes: Knee (L3/4) - Flex the knees, by placing your left arm underneath them to all of the weight. Flop them up and down until the patient is fully relaxed. Then tap at the patellar tendon. Ankle (L5/S1) - As for clonus, externally rotate at the hip and lightly flex at the knee. Then, to relax the patient, use your left hand to lift up-and-down at the upper leg (quadriceps/hamstrings area) a few times. Once relaxed, tap at the Achilles tendon, and observe the calf for a reflex. Practice the 'opposite leg' as this can be tricky (hold your tendon hammer in reverse - almost like you would hold a dart). Plantar (Babinski) (L5) (S1/S2) - Using a not-too-sharp object (opinions vary - some say the end of a tendon hammer is ok, other examiners prefer car keys), gently but firmly stroke the outer (lateral) border of the sole of the foot. Start at the base, and come in medially as you approach the toes. It is the movement of the big toe (hallucis) that you are looking at, not the movement of the other toes. If the test yields no clear result, the plantars are said to be 'equivocal'. For reinforcement, you can use the 'teeth grinding' technique as discussed above. Alternatively, get the patient to interlock their fingers (place left palm flat, place fingers of right palm over left fingers, and interlock by flexing at the M ts). Ask the patient to pull their arms apart (whilst fingers are still interlocked) on the count of 3. Sensation: Test all modalities, as for upper limb. It may be worth performing Romberg's test whilst the patient is standing, at the start of the examination. - Light touch - Vibration - Pain and temperature - Proprioception (inc. Romberg's test) Romberg's test: determinator of cerebellar (unsteady all the time) vs proprioceptive (peripheral) sensory input deficit (in which case the patient will be increasingly unsteady with eyes closed). Ask the patient to stand with legs next to one another and arms by side. Then ask them to close their eyes. Make sure you them if they are unsteady. A positive test is when they are more unsteady when their eyes are closed (indicates a peripheral sensory problem).

SPINE WIPER Wash hands Introduce Permission and Pain Expose Reposition

Top off Standing

Look Observe patient standing thoroughly inspect Assess kyphosis and lordosis Check for Scoliosis Feel Spinous processes Sacroliliac ts Paraspinal muscles Warn the patient lightly percuss the spine Move Lumbar flexion and extension Spine Lateral flexion Cervical spine movements Sit Patient Thoracic rotation Straight Leg raise

D.W.A.R.F.S.

ideally with the patient prone Assess tenderness

finger test Ask patient to run hand down side of leg Lateral flexion, Flexion, Extension, Rotation ask patient to cross arms and turn to side Put hands on shoulders to guide movement Raise leg lying flat Dorsiflex foot to assess pain

Assess limb reflexes Dorsiflex big toe Special Tests Schober’s Test Root compression Tests Straight leg raise and dorsiflexion of foot Tibial Nerve Stretch test Femoral Nerve Stretch test Flip Test Finish up Neurovascular exam of upper and lower limbs Assess Periph pulses x- Ray of spine: 2 views Additional examinations as relevant

Ankylosing spondylosis Sciatica Sciatica - Tibial nerve Femoral nerve Assessment of true sciatica

HISTORY in the OSCE What to Do when taking a history in an OSCE 1. 2. 3. 4. 5. 6. 7. 8.

9.

10. 11. 12. 13. 14.

Ask permission and explain why Start with age and occupation Tell me in your own words what’s been going on SOCRATES the symptom Have you had this before? What do you think it is? Systems Review the system Ask in turn i. PMH ii. Previous Surgery iii. DH iv. Allergies v. FH vi. Smoking vii. Alcohol viii. Mood Do a Brief systems review. Any problems/trouble with : i. Fevers/Feeling poorly ii. Heart? iii. Lungs? iv. Tummy or the bowels? v. Waterworks? vi. ts and bones? vii. Skin? viii. Funny turns/Problems with hearing, sight or smell ix. Pins and needles/weakness? Ideas, Concerns, Expectations Anything you would like to add? Summarise to Patient Summarise to Examiner Present Differential Diagnosis

Breaking bad News WIPER PS Appropriate introduction full name and grade Establishes rapport with patient Listens effectively Explores Patient’s Ideas Concerns and Expectations Aknowledges patient’s feelings/concerns and responds appropriately Appropriate use of empathy and correct body language Checks patient’s understanding of disease Negotiates and discusses Plan of action/management Offers Leaflets Arranges follow up Asks patient if they have any further questions Summarises at end and checks understanding Avoids Jargon and repetition Professional throughout

Consenting a patient for an Operation Introduction 1. Introduce with name and grade 2. Discuss aim of Consultation

“I’ve come to discuss the options we have ahead in your case”

3. Check Understanding

“Tell me about what you understand what’s happened so far”

4. Elicit patient’s concerns

“what are you particularly worried about”

5. Explain indication of Proc’/Op’

“You’ve got …. Which means….” “We’ve discussed your case So we need to do…to investigate/treat/etc”

6. Explain preparation required before

“the procedure involves”

7. Explain the implications of not doing

“If you don’t have… then….”

8. Talk through procedure i. Before

“First we…”

ii. During

“then during…” [Describe Procedure/Op]

iii. After

“After you will… until results/stable/free to

go/etc”

9. Discuss Risks and benefits

“there are some common Risks which you should be aware of”

10. Discuss Alternatives

“Just so that you’re sure we should discuss other options

11. Describe out come

likelihood of success

“In the majority of cases….”

i. Discharge date

“Hospital for ..days/free to go”

ii. Follow up

“come and see us in…”

iii. Restrictions on lifestyle after

“rest/do not eat/stay on the

ward” 12. Asks for questions

“Do you have any questions?”

13. Explore concerns

“Is there anything else you’re worried about”

14. Future management plan

“right now we need to do.../we’re waiting for…/wait till op’”

15. Offer leaflets

“if you’d like some more information… leaflet’s available”

16. Summarise key points

“Quickly recap what we’ve talked about”

17. Formalise consent

“Well if that’s ok then please sign the consent form to show that you understand what’s about to take place”

18. Mention free withdrawal 19. Thank patient

“this is not a contract you are free to withdraw at any stage”

MCA: Ethics and Law Candidate instructions You are a Foundation Year doctor in General Medicine. Mr James Winters, age 65, was itted yesterday having had a massive stroke (he had a previous minor stroke eight months ago). He is unconscious and no recovery of function is expected. The consultant is considering artificial nutrition. The patient’s wife was not present at the recent ward round and has asked to speak to you. Use this opportunity to discuss whether artificial nutrition is appropriate. Examiner instructions Candidates are expected to apply the relevant provisions of the Mental Capacity Act. They should know that they are bound to consult the patient’s family (in this case, wife) about what the patient would have wanted. They should ask about advance decisions/statements and LPAs and know that in the absence of these the doctor will make a decision in the patient’s best interests (even if this is contrary to the wife’s wishes). The wife should be listened to respectfully; her views must, according to the Mental Capacity Act, be “taken into ”, and this means that on no should the doctor appear dismissive or contemptuous of her views. The doctor should also show sensitivity. This woman is likely to be deeply upset, and the doctor should be responsive to this, even if she is a little irrational. Ultimately, however, the law demands that treatment or non-treatment is guided by what the patient would have wanted. Students should not therefore give the wife the impression that they are willing to follow her wishes uncritically. Even life-prolonging/life-saving treatment can be stopped by the doctor if it is not considered to be in the patient’s best interests. Actor instructions Eight months ago, James, your husband, had a minor stroke from which he made a full recovery. You were both very shocked by this, James particularly so. He told you that if he had another stroke, and became unable to care for himself and unable to talk, he wouldn't want any treatment that would keep him alive. Yesterday your husband had a massive stroke. You were told that he was unlikely to recover. You missed the consultant ward round this morning because you were trying to your children, and have asked to speak to the junior doctor on the team to find out what the plan is. After the junior doctor introduces him/herself say: “Thank you for seeing me, doctor. I missed the ward round and wanted to find out what plans are being made for James.” If you are asked your views about what treatment you would want for your husband, say you want them to do everything possible to keep him alive (give him any treatment they feel would be helpful, including artificial feeding), as you are not ready to let him go. If you are asked what your husband would have wanted, say that he was a very proud man and after the minor stroke made it clear that he couldn’t bear the idea of having his life drawn out by tubes and machines when he was unable to look after himself. He insisted that he should be allowed to die if he became helpless and dependent. However, you should then say: “I know my husband said this, but surely he wouldn’t have wanted me to stand by and watch him die. Please, doctor, will you do all you can for him?” Make sure that you ask, at some point: “What happens if you start the treatment? Does that mean it has to go on indefinitely?” If you are asked whether James created an advance decision, advance directive, living will or Lasting Power of Attorney, say no. If you are asked whether your husband had discussed his wishes with other family member or friends, say no.

Ethics and Law: General Rules of engagement Scenario • Knowledge – •

•

Knowledge of legal and professional guidelines

Skills –

Clarifies legal and professional guidelines appropriately and establishes rapport

–

Negotiates and agrees a plan in line with legal and professional guidelines

Attitude –

Treats the person with respect and sensitivity and maintains professional bearing

•

Scenario

•

You are a Foundation Year doctor in General Medicine.

•

Mr James Winters, age 65, was itted yesterday having had a massive stroke (he had a previous minor stroke eight months ago). He is unconscious and no recovery of function is expected. The consultant is considering artificial nutrition. The patient’s wife was not present at the recent ward round and has asked to speak to you.

•

Use this opportunity to discuss whether artificial nutrition is appropriate.

•

ACTOR • “Thank you for seeing me, doctor. I missed the ward round and wanted to find out what plans are being made for James.” •

“I know my husband said this, but surely he wouldn’t have wanted me to stand by and watch him die. Please, doctor, will you do all you can for him?”

“What happens if you start the treatment? Does that mean it has to go on indefinitely?”

Inhaler Technique WIPER PS Introduce and explain purpose of interview Check understanding of Asthma and rationale behind inhaler therapy 1. Stand up sit up straight before using inhaler 2. Remove cap and shake inhaler 3. Hold canister vertical for delivery of drug 4. Hold canister with middle finger and thumb 5. Put mouthpiece in mouth at start of inspiration 6. Inhalation should be slow and deep 7. Press canister down with index finger 8. Hold breath for 10 seconds 9. Wait about 30 seconds before istering the next dose 10. Close cap Offer Spacer if still difficult Rotahaler

Same rules just breath normally through spacer

Capsule istration of drug Twist to release drug – inhale simultaneously Hold breath for 10 s

Other inhalers Easi-breath (teeth bite mouthpiece inhaler), Accuhaler (metered dosing)

IV Fluid istration WIPER PS Introduce and explain that you will be istering IV drug Check for allergies to any substances that are being given 1. Washes hands and collects equipment 2. Opens Bag and giving set 3. Dons gloves 4. Unwinds giving set and closes adjustable valve 5. Removes sterile cover from bag outlet and sharp end of giving set 6. Unites giving set with bag safely and aseptically 7. Hang bag up on stand 8. Squeeze drip chamber 9. Opens valve partially and lets fluid run – gets rid of any bubbles 10. Cleans cannula with alcohol wipes and attaches giving set 11. Sets correct drip rate by opening valve on giving set 12. Checks if patient is ok Finish up Tidy equipment Dispose of any clinical waste RULES Each bag should not hang for more than 24 hours Each giving set should be changed every 48 hours Cannula should be inspected daily Sterile dressings should be changed daily

OSCE: Glycosuria Differentials and Ix Differential Diagnoses  Diabetes Mellitus  Pregnancy (reduced renal glucose threshold)  Impaired glucose threshold in thyrotoxicosis (T4/T3 stimulate sympathetic NS, NA/A increase blood glucose levels as a part of this response), acromegaly (GH increases lipolysis, reduces uptake of glucose by liver, promotes gluconeogenesis in the liver) and after gastrectomy (?due to early dumping)  Raised blood glucose levels, secondary to raised adrenaline levels e.g. in phaeochromocytoma, stress, anxiety (adrenaline acts to increase blood glucose levels)  Gross cerebral injury or haemorrhage  Severe infection e.g. Staphlococcus  Renal tubular problems e.g. anything that can cause Fanconi’s syndrome (proximal tubular function of kidneys is impaired) o Aetiology of Fanconi’s syndrome :  Cystinosis (in children, autosomal dominant lysosomal storage disorder- impaired cystine transport leading to its accumulation in many tissues)  Multiple myeloma (due to the paraprotein, Bence Jones protein)  Nephrotic syndrome  Sjogren’s syndrome  Heavy metal poisoning e.g. lead  Nutritional disorders e.g. Kwashikor’s, rickets  Drugs e.g. outdated tetracycline, salicyclates  Following shock/major surgery  Metabolic disorders e.g. galactosaemia o Symptoms and signs  Polyuria  Polydipsia  Anorexia  Vomiting  Growth failure o Clinical features:  Glycosuria  Aminoaciduria  Phosphaturia  Renal tubular acidosis type 2 (type 2)  Rickets/osteomalacia Ix            

FBC: CRP/ESR, WCC, Hb, plt U + Es Amylase, lipase ABGs (?DKA) Random blood glucose, fasting blood glucose, Hb A1C, 2hr OGTT Urine 24 hour collection: albumin creatinine ratio, protein Urine analysis: glucose, protein, paraproteins, amino acids CXR- some lung tumours can secrete ACTH pregnancy blood culture TFTs IGF 1 (?acromegaly)

Heart Burn You are a 5th year medical student and have been asked to see John Sampson who has come to get the results of an investigation following heart burn. Test results: OGD: ulceration of gastric mucosa CLO test performed after gastric biopsy: POSITIVE FOR H. PYLORI I am Mr Sampson, a 57 year old taxi driver with stomach pain after eating. I came to the GP about 3 weeks ago and was sent for a test last week where they put a camera down my throat and today I’ve come for my results. I wasn’t too worried about the pain but I got worried when I founded out I needed such an invasive test. I smoke and I’m overweight. I have high blood pressure and take nifedipine for this. I want to know what happens next? If I still have the symptoms after treatment will I be checked and treated again? What if I still have symptoms after second treatment Will I need to come to the doctor regularly? Will I be followed to see if I get stomach cancer? Mark scheme: 1. 2. 3. 4.

5. 6.

7.

8.

Appropriate introduction (full name and role) Establishes reason for consultation Elicits and responds to patient’s concerns Explains test result to patient a. He has a stomach ulcer b. 70% of stomach ulcers occur in people with H. pylori (95% of duodenal ulcers) Establishes whether ulceration is associated with NSAID use. (if so then PPI for 2 months before eradication therapy) Explains H. pylori eradication therapy a. PAC500 regimen: PPI, amoxicillin, clarithromycin 500mg (bd 7 days) b. PMC250 regimen: PPI, metronidazole, clarithromycin 250mg (bd 7 days) c. Explain management eradicates 85% of H. pylori infections d. Side-effects: diarrhoea, nausea and vomiting e. Complications? Offers lifestyle advice a. Antacid/alginate therapy b. Avoid alcohol, coffee, chocolate, fatty foods c. Weight reduction d. Smoking cessation e. Raise head of the bed f. Main meal well before going to bed Asks for patient questions and concerns a. He will be re-tested once more after treatment if dyspepsia remains because he has an ulcer, then no more b. Other drugs available… PPI, H2RA or prokinetics for 1 month c. You don’t need to come to the doctor regularly if symptoms resolve

d. If your symptoms don’t resolve then we might send you for specialist care to see again if anything more sinister can be found. Alternative: If the patient has come for results of a positive carbon-13 urea breath test or stool antigen test which is positive, then advise that eradication therapy will only be tried once. Following that PPI, H2RA or prokinetic can be tried for once month and if still no resolution then they can be referred for specialist care.

Urgent referral for endoscopy       

Chronic GI bleeding Progressive weight loss Dysphagia Iron deficiency anaemia Persistent vomiting Epigastric mass Pe

Referral Criteria for urgent (within 2 weeks) endoscopy:        

Significant acute GI bleeding – IMMEDIATE Chronic GI bleeding Progressive, unintentional weight loss Dysphagia Iron deficiency anaemia Persistent vomiting Epigastric mass Persistent disease in those > 55yrs



Part 2A 4th year Stations Psychiatry and Neurology

Alcohol dependence Alan Smith is a 44-year-old man who has been referred because of his drinking. He has yet to be assessed, and you are the SHO for the alcohol team. Take an alcohol history, with particular emphasis on symptoms of dependence syndrome. I am Alan Smith, a 44-year-old man. I first started drinking in my late teens and would drink at weekends with friends in the pub. In my late twenties I started drinking more, and at the end of each working day. I lost my job and my wife in my early 30’s because of my drinking. I started attending Alcoholics Anonymous after this and for many years I managed to control my drinking. My daughter was killed in a car accident 9 years ago and I started drinking after this. I have been drinking pretty much every day for the last few years. I drink a mixture of vodka and cider, up to a bottle of vodka and 2L of cider a day. I start drinking in the morning to take away the shakes and sweats. I spend most of the day drinking or go around to my friend’s house to drink. I have had to drink more and more over the last few years. If I don’t have a drink in the morning I feel shaky & sick. I find it hard to control my drinking. I crave alcohol if I haven’t had a drink for a while. I managed to cut down my drinking a few months ago but started again at the same level after a couple of weeks. I have no real hobbies or interests; drinking dominates my life. I think that my memory and concentration have been affected by my drinking, and it I have lost my marriage and job because of alcohol. My mood is low and I sleep poorly. My appetite is low but I eat one meal a day and my weight is stable. I have poor motivation but can get down to the supermarket to buy alcohol. I have a laugh with my mates and enjoy watching football on TV. I am pessimistic about the future and sometimes feel hopeless. I’m not suicidal. I think I probably have a problem with my drinking but don’t think that much can be done. Mark Scheme: 1. Introduction; empathy, rapport 2. Drinking history a. When started drinking b. Any triggers to start drinking more c. Units per day ( to ask volume of bottles consumed) d. Type of alcohol 3. History of dependence syndrome a. A strong desire or sense of compulsion to drink (do you get cravings?) b. Difficulty in controlling the amount drunk (cut down once but started again) c. Physiological withdrawal state (shakes & nausea) after drinking stops i. Use of alcohol to relieve this d. Tolerance (having to drink more) e. Neglect of alternative pleasures & interests (no real hobbies, just drinking) f. Persistence in spite of evidence of harm. (do you think alcohol harms you any way?) g. Prominence of drink seeking behaviour.

4. Have you ever tried to stop drinking before? 5. Effects on functioning a. Ever been in trouble with the police or arrested? b. Has drinking affected your relationships? c. Has drinking affected your job? 6. Mood symptoms a. Low mood? b. Sleep disturbance? c. Appetite change? d. Poor concentration? e. Lack of energy f. Loss of pleasure in interests. 7. Ever thought of hurting yourself or ending your life? 8. Psychosis:- hallucinations of formication, delusions of infestation (Ekbom’s) Do you use any other substances besides alcohol?

ADHD station – A mother is worried her child might have ADHD. She has asked to have a chat to you about how it might be diagnosed and medical treatment for the condition. 1. What do you know about ADHD? 

3 main signs: inattention, hyperactivity, impulsiveness



Persisted for at least 6 months



6 symptoms of inattention: careless, poor attention to detail, fails to sustain attention to tasks, easily distracted, appears not to listen, disorganised in tasks, forgetful



3 symptoms of hyperactivity: fidgets, leaves seat inappropriately in class, runs/climbs excessively, unduly noisy in playing, excessive motor activity unmodified by social context



1 symptom of impulsivity: blurts out answers before question has been asked, fails to wait turn in queue or games, intrudes into conversations, talks excessively without appropriate response to social restraints

2. Does it have any other complications or associated illnesses: 

CD and ODD



Learning disorders



Anxiety



Depression



Tic disorders

3. What caused it? 

Any FHx? (25% first degree relatives)



Maternal stress during pregnancy



Poor quality early care-giving e.g. institutional or foster care



Foetal exposure to drugs and alcohol

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Perinatal complications e.g. hypoxia, toxins

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Prematurity

4. How would you diagnose it? 

From Hx (6 symptoms of inattention, 3 of hyperactivity, 1 of impulsivity) persistent for at least 6 months



Rule out differentials (through medical and psych Hx, and physical exam) i. Impaired hearing (hearing tests) ii. Seizures/epilepsy (EEG) iii. Head trauma iv. Insufficient sleep v. Poor nutrition

vi. Hyperthyroidism (TFTs) vii. Drugs (alcohol, illegal drugs) viii. Psych disorders (autism, CD/ODD, anxiety, OCD, attachment disorders, Tourette’s, Foetal alcohol syndrome) 

Information from school



Observation- clinic and school/home



Psychological testing



You, the mother and the teacher must each fill out a Connor’s Questionnaire

5. Can it be treated? 

Parent training programmes, to reinforce positive behaviour and decrease punitive strategiesthese can reduce stress and oppositional behaviour in children, but not cure the problem



CBT- aims to enhance self control by teaching self-instructing strategies



Social skills training- group work with peers and adults

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Drugs (stimulants) e.g. Ritalin- but only if it is very severe, because it can cause side effects, the main one being suppression of growth

In school; extra help in classroom and special education needs nurse Teachers should have a meeting with doctors and child 6. Will my child have it as an adult? 

With help, most children’s hyperactive symptoms settle down in mid-teens



<50% will last past 20 years old



Restlessness and inattention may continue into adulthood



But, specialist treatment tailored to your child’s needs will assist them with their learning and forming friendships

There may be self esteem issues later in life because of having a ‘condition’

Agoraphobia history You are Jenny Peters, a 45-year-old married housewife with marked anxiety attacks. It began 3 months ago when I was out in town and found myself becoming sweaty and felt my heart racing fast. I got worried and went home where I calmed down. I am now fearful of leaving the house. I can go out with my husband or family but become anxious in busy, crowded places such as supermarkets. I can’t use public transport but I am ok in the car. I avoid social situations as much as possible. I have little or no anxiety whilst at home. I have a friend’s wedding coming up and am very anxious about making a fool of myself there. Mark Scheme: 1. Introduction 2. Establish nature of consultation 3. Elicitation of anxiety symptoms a. Psychological symptoms i. Worry ii. Apprehension iii. Tense iv. Nervous b. Physical symptoms i. Tremor ii. Palpitations iii. Sweating 4. Situations that cause the anxiety a. Social phobia vs agoraphobia vs generalised anxiety b. Questions i. Do you worry excessively about minor matters on most days of the week? (GAD) ii. Have you ever been so frightened that your heart was pounding and you thought you might die? (panic attack) iii. Do you avoid leaving the house alone because you are afraid of having a panic attack or being in a situation from which escape will be difficult or embarrassing? (agoraphobia) iv. Do you get anxious in social situations, like speaking in front of people or making conversation? (social phobia) v. Do some things or situations make you very scared? Do you avoid them? (specific phobia) 5. History of panic disorder a. Presence of panic b. Frequency c. Calm between attacks? d. Location 6. Other symptoms a. Avoidance b. Anticipatory anxiety i. Fear of having another attack 7. Impact on life 8. Presence of mood symptoms

9. Social History a. Alcohol b. Drugs c. Family Treatment 1. Agoraphobia a. CBT – graded exposure to avoided situations b. SSRIs 2. Generalised Anxiety Disorder a. CBT – Identify morbid anticipatory thoughts and replace them with more realistic cognitions, distraction techniques, breathing and relaxation exercises. b. SSRIs c. Self-help d. 2nd lines: benzos for 2-4 weeks, SNRIs, buspirone, pregabalin 3. Panic Disorder a. CBT SSRIs

Anorexia nervosa written Body Mass Index =

Psychiatric conditions that can mimic Anorexia Nervosa  Bulimia Nervosa  Depression  Psychotic disorders with delusions concerning food  Substance or alcohol abuse  OCD Organic conditions that can mimic Anorexia nervosa  Diabetes Mellitus  Hyperthyroidism  Malabsorption syndromes  Addison’s disease (Physical) Symptoms of Anorexia Nervosa  Amenorrhoea  Hair loss from scalp  Hypothermia / cold intolerance  Ankle swelling  Constipation Signs of Anorexia Nervosa  Lanugo hair  Hypotension  Bradycardia  Syncope  Emaciation Treatments of Anorexia Nervosa  Individual therapy o Cognitive Behavioural Therapy o Psychodynamic Psychotherapy  Family Therapy is first choice for adolescents  In-patient treatment o Observation during and after meals and of “exercise” o Medication – for co-morbid physical / mental health problems o Naso-gastric feeding

OSCE: counselling about autism Please talk to this mother of a 4 year old boy 1. How much do you know about autism?  Autistic Spectrum Disorders- i.e. there is a range of severity, so a child may only present with a few of the associated features, or he might have all of them, in which case he would be on the most severe end of the spectrum.  Triad of abnormalities: impaired social communication, impaired language and understanding, restricted interests and resistance to change 2. Can you tell me more about these impairments please?  Social: poor/odd non-verbal communication, difficulty seeing things from another person’s perspective, gaze avoidance, difficulty forming friendships , lack of give and take in conversations, prefer being alone, difficulty understanding unwritten social rules  Communication: delayed language development, unusual tone of voice, palilalia/echolalia, stock phrases, difficulties understanding abstract concepts or sarcasm  Restricted interests and repetitive behaviours: repetitive/unimaginative play, order/sameness, unusual/intense preoccupations, odd repetitive motions e.g. arm flapping or rocking, hypo or hypersensitive to light or noise  Other common problems: hyperactivity, sleep difficulties, food fads, self-injurious behaviours, epilepsy (30%), visual and hearing difficulties, motor clumsiness  Cognitive: IQ <100 (may or may not have a learning difficulty) 3. Will my child have this forever?  Yes, it is a lifelong condition  There is no cure  But, your child’s social, language skills, etc can be improved using the following interventions: extra educational assistance, speech and language therapy, occupational therapy (APPLIED BEHAVIORAL ANALYSIS)  Family can also be provided, which will be helpful for yourselves, in assisting you with parenting techniques and for your child  National Autism society  Medical treatment for some of the more specific medical associations .g. epilepsy, stimulants for ADHD (hyperactivity), risperidone for aggression and repetitive behaviours 4. My child had the MMR, is that why he got autism?  No link between the two  No real cause known  But an association with Fragile X syndrome and Rett’s syndrome (these are chromosomal/genetic disorders, which autism may be a feature of), and also NF and some metabolic disorders 5. If I have another child, will they have it? 6. 3% Leaflets

Alcohol cessation You have been asked to talk Jonas, a 28 year old man who wants to cut down his drinking I am Jonas, a 28 year old bricky. I mainly drink at home or with regulars at the pub. I drink 4 pints of larger a night but if I don’t go to the pub then I can finish half a bottle of whiskey at home. I can’t be sure if I get symptoms when I don’t drink, I’ve only not had whiskey at home once and I did feel anxious and had the shakes. I sometimes miss 3 days a week of work because I have a hangover or I’m still drinking and I’m worried I’m going to lose my job. My boss gave me an ultimatum and said if I don’t make changes in the next week then he’s going to fire me. CAGE answers: Yes to everything I’ve tried to drink less before. I used to drink a few of pints a night in my early 20s and was trying to cut down but my wife and me split up 6 years ago and since then nobody bothered me about my drinking.

Mark scheme: 1. Appropriate introduction (full name and role) 2. Establishes reason for consultation 3. Asks about current drinking (cage questionnaire) a. How many units do you drink a week b. In what situations do you drink? c. Do you drink alone? d. Do you drink daily or in binges? e. What kind of alcohol do you drink? f. Withdrawal symptoms:- anxiety, fits, hallucinations & tremor? g. Cage questionnaire i. Have you ever felt you should cut down on your drinking? ii. Have people annoyed you by criticising your drinking? iii. Have you ever felt bad or guilty about your drinking? iv. Have you ever had a drink first thing in the morning to steady your nerves or get over a hangover? 4. Reinforce the risks of drinking to the patient. a. Deaths – 40,000 deaths per year in the UK directly caused by alcohol b. Social i. Marriage breakdown ii. Loss of work c. Mental problems i. Anxiety ii. Depression iii. Suicidal thoughts iv. Wernicke’s / Korsikoff’s d. Physical effects i. Liver disease ii. Foetal damage iii. Hypertension

5. 6.

7. 8. 9.

iv. Strokes v. Cancers; mouth, larynx, oesophagus, breast, liver Review previous attempts to stop drinking. a. Any groups or medication used? Advice on reducing intake a. Refer to community alcohol team b. Group therapy, long term counselling, alcoholics anonymous, involve family & friends c. Keep a diary of alcohol consumption d. Agree targets e. Consider detoxification i. Disulfiram - conditioning ii. Chlordiazepoxide qds over 1 week – attenuate withdrawal symptoms Offer a follow up appointment in 2 weeks to check progress Offer information & advice sheet Does all in a fluent and professional manner.

Alcohol dependence Alan Smith is a 44-year-old man who has been referred because of his drinking. He has yet to be assessed, and you are the SHO for the alcohol team. Take an alcohol history, with particular emphasis on symptoms of dependence syndrome. I am Alan Smith, a 44-year-old man. I first started drinking in my late teens and would drink at weekends with friends in the pub. In my late twenties I started drinking more, and at the end of each working day. I lost my job and my wife in my early 30’s because of my drinking. I started attending Alcoholics Anonymous after this and for many years I managed to control my drinking. My daughter was killed in a car accident 9 years ago and I started drinking after this. I have been drinking pretty much every day for the last few years. I drink a mixture of vodka and cider, up to a bottle of vodka and 2L of cider a day. I start drinking in the morning to take away the shakes and sweats. I spend most of the day drinking or go around to my friend’s house to drink. I have had to drink more and more over the last few years. If I don’t have a drink in the morning I feel shaky & sick. I find it hard to control my drinking. I crave alcohol if I haven’t had a drink for a while. I managed to cut down my drinking a few months ago but started again at the same level after a couple of weeks. I have no real hobbies or interests; drinking dominates my life. I think that my memory and concentration have been affected by my drinking, and it I have lost my marriage and job because of alcohol. My mood is low and I sleep poorly. My appetite is low but I eat one meal a day and my weight is stable. I have poor motivation but can get down to the supermarket to buy alcohol. I have a laugh with my mates and enjoy watching football on TV. I am pessimistic about the future and sometimes feel hopeless. I’m not suicidal. I think I probably have a problem with my drinking but don’t think that much can be done. Mark Scheme: 9. Introduction; empathy, rapport 10. Drinking history a. When started drinking b. Any triggers to start drinking more c. Units per day ( to ask volume of bottles consumed) d. Type of alcohol 11. History of dependence syndrome a. A strong desire or sense of compulsion to drink (do you get cravings?) b. Difficulty in controlling the amount drunk (cut down once but started again) c. Physiological withdrawal state (shakes & nausea) after drinking stops i. Use of alcohol to relieve this d. Tolerance (having to drink more) e. Neglect of alternative pleasures & interests (no real hobbies, just drinking) f. Persistence in spite of evidence of harm. (do you think alcohol harms you any way?) g. Prominence of drink seeking behaviour.

12. Have you ever tried to stop drinking before? 13. Effects on functioning a. Ever been in trouble with the police or arrested? b. Has drinking affected your relationships? c. Has drinking affected your job? 14. Mood symptoms a. Low mood? b. Sleep disturbance? c. Appetite change? d. Poor concentration? e. Lack of energy f. Loss of pleasure in interests. 15. Ever thought of hurting yourself or ending your life? 16. Psychosis:- hallucinations of formication, delusions of infestation (Ekbom’s) 17. Do you use any other substances besides alcohol?

Alcohol dependence ICD-10 Diagnostic guidelines A definite diagnosis of dependence should usually be made only if 3 or more of the following have been experienced or exhibited at some time during the previous year a) A strong desire or sense of compulsion to take alcohol b) Difficulties in controlling alcohol-taking behaviour in of its onset termination, or levels of use c) A physiological withdrawal state when alcohol use has ceased or been reduced, as evidenced by: the characterstic withdrawal syndrome for alcohol; or use of the alcohol with the intention of relieving or avoiding withdrawal symptoms d) Evidence of tolerance, such that increased doses of alcohol are required in order to achieve effects originally produced by lower doses e) Progressive neglect of alternative pleasures or interests because of alcohol use, increased amount of time necessary to obtain or take alcohol or to recover from its effects f) Persisting with alcohol use despite clear evidence of overtly harmful consequences, such as harm to the liver through excessive drinking; efforts should be made to determine that the was actually, or could be expected to be, aware of the nature and extent of the harm. Symptoms of withdrawal       

Coarse tremor Nausea and vomiting Weakness and malaise Anxiety, irritability and depressed mood Headache and insomnia Autonomic hyperactivity; tachycardia, hypertension Transient hallucinations and delusions

Symptoms of delirium tremens  Delirium  Gross tremor of hands  Sympathetic overactivity  Hallucinations/pseudohallucinations  Dehydration and disturbed blood biochemistry o Leucocytosis o Raised ESR o Poor LFTs

Explaining Alzheimer’s disease I’m Sarah Palmer and my mother has been diagnosed with Alzheimer’s disease. I know that its a disease that affects the old and causes dementia but know nothing else.

I want to know; What is it? What will happen to my mother? Does she need to go into a residential home? What are the treatments? Will it kill her?

Mark Scheme: 1. Appropriate Introduction 2. Explains what Alzheimer’s is a. Alzheimer’s disease is the most common cause of dementia b. Occurs with markedly increased frequency in the elderly c. Dementia describes the loss of mental abilities such as memory and reasoning d. It is unfortunately a progressive and incurable disease although there are treatments that can slow down its development e. Abnormal changes in the brain structure and chemicals worsen over time, eventually interfering with many aspects of brain function f. Memory loss is one of the earliest symptoms, along with a decline in intellectual and thinking abilities and changes in behaviour 3. Risk factors a. Family b. Low educational attainment 4. What will happen to her mother a. No case of Alzheimer’s disease is ever the same as different people react in different ways b. Commonly Alzheimer’s starts in its mild form; your mother may experience memory loss, confusion, mood swings and problems with speech c. When moderate she may experience hallucinations and delusions and disturbed sleep and may have trouble controlling her bowels and water works d. Eventually if severe she may experience difficulty swallowing & moving, loss of appetite and increased vulnerability to infection. 5. Does she need to go into a residential home? a. Nobody is ever forced to send their relatives to a residential care home b. People with Alzheimer’s disease are usually cared for by family in their own home in the early stages c. But there comes a time, as the disease progresses and the behavioural pattern becomes more difficult to cope with, when carers find they can no longer cope with their needs. d. If you were to be in this situation your mother would have a care manager who can give you advice on either helping you to care for your mother at home or if it comes to the point, be able to help you find somewhere that better suits her needs. 6. a. Community nurses b. Home carer c. Social worker

7.

8.

9. 10.

d. Occupational health e. Disability living allowance f. Carer’s allowance g. Respite care Treatments a. Currently no cure b. Medications available that can help delay the development of the condition in early stages c. Donepezil, rivastigmine – act by increasing the amount of the chemical acetylchonine in the brain d. Memantine affects glutamate in the brain and can be used for moderate - severe AD Mortality i. Alzheimer's disease can shorten life-expectancy. This is often due to developing another condition, such as pneumonia, as a result of having Alzheimer's disease. Therefore, Alzheimer's may not be the only cause of death, but it may contribute towards it. Give a leaflet Organisations – Alzheimer’s society, dementia relief trust

OSCE: counselling about autism Please talk to this mother of a 4 year old boy 7. How much do you know about autism?  Autistic Spectrum Disorders- i.e. there is a range of severity, so a child may only present with a few of the associated features, or he might have all of them, in which case he would be on the most severe end of the spectrum.  Triad of abnormalities: impaired social communication, impaired language and understanding, restricted interests and resistance to change 8. Can you tell me more about these impairments please?  Social: poor/odd non-verbal communication, difficulty seeing things from another person’s perspective, gaze avoidance, difficulty forming friendships , lack of give and take in conversations, prefer being alone, difficulty understanding unwritten social rules  Communication: delayed language development, unusual tone of voice, palilalia/echolalia, stock phrases, difficulties understanding abstract concepts or sarcasm  Restricted interests and repetitive behaviours: repetitive/unimaginative play, order/sameness, unusual/intense preoccupations, odd repetitive motions e.g. arm flapping or rocking, hypo or hypersensitive to light or noise  Other common problems: hyperactivity, sleep difficulties, food fads, self-injurious behaviours, epilepsy (30%), visual and hearing difficulties, motor clumsiness  Cognitive: IQ <100 (may or may not have a learning difficulty) 9. Will my child have this forever?  Yes, it is a lifelong condition  There is no cure  But, your child’s social, language skills, etc can be improved using the following interventions: extra educational assistance, speech and language therapy, occupational therapy (APPLIED BEHAVIORAL ANALYSIS)  Family can also be provided, which will be helpful for yourselves, in assisting you with parenting techniques and for your child  National Autism society  Medical treatment for some of the more specific medical associations .g. epilepsy, stimulants for ADHD (hyperactivity), risperidone for aggression and repetitive behaviours 10. My child had the MMR, is that why he got autism?  No link between the two  No real cause known  But an association with Fragile X syndrome and Rett’s syndrome (these are chromosomal/genetic disorders, which autism may be a feature of), and also NF and some metabolic disorders 11. If I have another child, will they have it? 12. 3% 13. Leaflets

Bipolar affective disorder 1. Introduction 2. Finds duration of episode 3. Elicits manic features a. Grandiosity b. Increased pleasurable activity without thought of consequences c. Increased talkativeness d. Decreased need for sleep e. Flight of ideas f. Increased goal-driven activity 4. Enquires about mood previously 5. Enquires about drug history 6. Enquires about recreational drug use 7. Enquires about psychotic features a. Hallucinations b. Special powers / other delusions 8. Enquires about past medical history 9. Enquires about past psychiatric history 10. Asks about family history 11. Asks if the patient has any questions.

Blood test results in psychiatric disease You are given 5 sets of blood results, match them to the following diseases: bulimia, drug induced psychosis, depressive episode, delirium, alcohol intoxication Bulimia Most obvious is hypokalaemia.   

FBC, WCC, PLTs – anaemia due to lack of absorption (iron, B12, folate) Iron, folic acid U&Es o ↑urea  dehydration o Hypokalaemia, hypochloraemic acidosis  vomiting o ↑Serum amylase  vomiting o Hyponatraemia, hypomagnesaemia  vomiting o ↑cortisol o ↑GH o ↓T3 o ↓FSH&LH o Hypercholesterolaemia o Hypercarotenaemia

Drug Induced Psychosis Urine drug screen positive for amphetamines and cannabinoids Alcohol intoxication Increased gamma GT and abnormal LFTs Acute confusion / delirium

Counselling OSCE: Beta-blockers and sexual dysfunction You are a GP and Mr Young has come to discuss his beta-blocker medication with you. Please counsel him and give appropriate advice and management changes. Ernest Young, I am 56 years old and was diagnosed with high blood pressure a few months ago. My GP has prescribed me atenolol tablets and I take one 50mg tablet a day. To be honest with you I don’t feel that different to how I did before so I’m not sure that they’re making any difference. I’ve just had my blood pressure checked and the nurse has assured me that my blood pressure is normal. Can I stop now that my BP is fine? I think I have been having some side effects with this medication; I feel like I have less energy than before (bradycardia), my finger are always cold and they used to be before but it’s got worse since I started taking this medication (peripheral vasoconstriction). I looked these things up on the internet and it says there that atenolol does cause these problems. It also said that I may become impotent! Why did you prescribe a drug with such a long list of side-effects? I don’t want to keep taking this medication, what’s the worst that can happen?

Markscheme  Washes hands or comments  Appropriate introduction  Establishes reason for visit  Shows empathy regarding side effects  Explains side effects occur rarely and that all medications have a list of uncommon potential side effects  Asks about Sx of hypertension (evaluates current regimen) and what may have led to the diagnosis i.e. BP record o BP when diagnose o N + V, headaches, visual disturbances, sweating, fits, tachycardia  Asks about PMHx / comorbidities o Hyperlipidaemia, Smoking, FHx, PMHx thrombotic events, Diabetes  Explains the importance of taking antihypertensive medication and the consequences / risks of not.  Explains management of hypertension: conservative and drug management – appropriate lifestyle changes if they have been made may mean that the dose of beta-blocker etc can be reduced and this would hopefully mean fewer side effects  Enquires how patient would feel about perhaps altering treatment regimen  Gives 2-3 other drugs that could be tried  Asks whether the patient is happy to change  Inquires about any ICE  Summarises: management and consultation  Re-arranges a follow-up appointment to monitor progress.  End consultation appropriately  Washes Hands

1. Hypertension:





Treatment should be started if sustained BP≥160/100mmHg OR 10yr cardiovascular risk > 20% OR Existing vascular disease, OR target organ damage eg. Brain. Kidney, HF, retina with BP>140/90mmHg. Complications of hypertension: i. Vessels: atherosclerosis, aortic dissection, aneurysm rupture ii. Heart: LVH /LVF iii. Brain: Stroke / Cerebral haemorrhage iv. Kidney: benign/ malignant nephrosclerosis – leading to permanent RF v. Others: Visual / eye effects.

2. Side effects of beta-blockers  GI disturbances, heart failure, bradycardia, heart failure, hypotension, conduction disorders, peripheral vasoconstriction (presenting as Raynaud’s or exacerbating it/intermittent claudication). Bronchospasm, dyspnoea, headache, fatigue, sleep disturbances, dizziness, vertigo, sexual dysfunction, purpura, visual disturbances and thrombocytopenia 3. Drug therapy or guidelines  Aims to reduce the risk cardiovascular problems and death.  Optimise life style factors i. Reduce salt intake ii. Limit ETOH iii. Stop smoking iv. Reduce Weight v. Increase Exercise vi. Veg/ Fruit vii. HbA1C < 7%  Beta-blockers are not first-line drugs! Only consider if younger, intolerant to ACEi / A2RB, increased sympathetic drive in children of childbearing potential.  : i. Step 1  < 55yo, Caucasian: ACEi or A2RB (or beta blocker)  >55 yo, Black : Calcium channel blocker, Thiazide diuretics ii. Step 2  ACEi + Ca blocker/Thiazide iii. Step 3  ACEi + Ca + Thiazide iv. Step 4  Consider alpha blocker, spironolactone, other diuretics If cardiovascular disease risk is > 20% then a STATIN is recommended

Explaining clozapine treatment Side Effects:  Neutropenia (just under 1% of patients)  Risk of seizures in high doses  Hypersalivation  Weight gain  Moderate risk of diabetes  Sedation early on  Constipation o Eat fibre and drink lots of water  Hypotension  Arrythmias, myocarditis  Others: anticholinergic, anti-adrenergic Before starting rx:  FBC  ECG How do I take it?  Orally (or as suspension) Regular blood tests  Weekly for the first 18 weeks  Fortnightly up to 52 weeks  Four weekly thereafter 

After your blood is taken it is sent to the laboratory to make sure that the levels of your white blood cells have not dropped. If the blood result is normal, it is called a “green” blood result.



All patients with clozaril clinic, where they have these regular blood tests.



Drug levels only measured if requested: o

0.3-0.5 blood levels are normal

o

> 1: seizure and toxicity risk

If you forget to take one dose of clozapine then take it as soon as possible but not 2 doses in one go. If it has been over 48 hours since your last dose consult your doctor because you cannot start on the same dose again straight away.

Conduct disorder What are the causes of bad behaviour  Conduct disorder / Oppositional Defiant Disorder  Hyperactivity disorder  Antisocial behaviour within deviant peer group  Autistic spectrum disorder  Normal child, unrealistic expectations What is conduct disorder? Persistent failure to control behaviour appropriately within socially defined rules   

Defiant of authority Aggressive Antisocial behaviour; violating property, rights or people

ICD-10; at least 3 behavioural criteria must have been exhibited in the last 12 months, with at least one criterion present in the last 6 months. What is Oppositional Defiant Disorder? ODD is a subsection of conduct disorder (ICD-10) – occurs in children under 12    

Often lose temper Argue with adults Often defies adult requests Deliberately annoys others

Is it caused by genetics or environment?  Conduct disorder clusters in families  Possible association with variant of MAO A gene Are there any risk factors?

  

Often shifts blame Easily annoyed Often angry

Family  Marital discord  Substance misuse  Criminal activity  Abusive parenting  Injurious parenting Environment  Social disadvantage  Homelessness  Low socioeconomic status  Overcrowding  Social isolation Individual  Difficult temperament  Brain damage  Epilepsy  Chronic Illness  Cognitive deficits

Can it be treated? 1. Parenting Programmes 2. Social Skills Groups 3. Problem solving skills training Prognosis: 40% of children become delinquent adults

CSF profiles station Normal CSF properties Pressure White Cells Protein Glucose

80-180 mm of CSF <5/µL 0.1-0.4 g/L ≥50% of serum value (typically 2.8-4.7 mM)

Guillain Barré Syndrome Raised CSF protein concentration (1-10 g/L) with normal cell count Multiple Sclerosis Lymphocytosis with active disease, raised protein (particularly immunoglobulins (IgG)), oligoclonal bands by electrophoresis Sub-Arachnoid Haemorrhage Numerous RBCs, xanthochromia (yellowish appearance of CSF) and increased pressure Meningitis Type of meningitis Acute bacterial Acute viral Tuberculous Fungal Malignant

Glucose Low Normal Low Low Low

Protein High Normal or high High High High

Cells PMNs, often > 300/mm3 Mononuclear, < 300/mm3 Mononuclear > 300/mm3 & PMNs >300/mm3 Usually mononuclear

Management of meningococcal meningitis: I.V. cefotaxime / ceftriaxone 3 complications of meningococcal septicaemia other than death 1. Disseminated intravascular coagulation 2. Focal neurological deficits a. Cranial nerve palsies b. Blindness c. Deafness 3. Conjunctivitis 4. Seizure disorder 5. Ataxia 3 complications of meningitis 1. Seizures 2. Hydrocephalus 3. Permanent localising symptoms; e.g. paralysis, ophthalmaplegias 95

A bloke has a history of weakness and sensory changes in the lower limbs; possible explanations are Guillain Barré, Multiple Sclerosis & acute cord compression. What immediate bedside test would you do? Anal reflex / anal sphincter tone, PEFR/vital capacity? What other tests?  MRI of brain and spinal cord – may reveal plaques or cord compression  Visual evoked potentials – show delayed central conduction in the visual pathways  Forced vital capacity measurements – to establish progression of GBS  Nerve conduction studies – prolonged in GBS What are the treatments for your differential diagnoses... Guillain Barré In the progressive phase vital capacity should be measured frequently and the ECG monitored continuously. If ability to swallow saliva, rapidly ↓ vital capacity warrant ission to intensive care with probable need for artificial ventilation and nasogastric feeding. ive care: 1. Physio for limb weakness. 2. Turning to avoid pressure sores. 3. LMWH for DVT prophylaxis. Medical treatment: 1. Plasma exchange 2. High-dose IVIG; 5 day infusion Multiple Sclerosis Corticosteroids (methylprednisolone) for an acute attack Interferon-β, Glatiramer, Natalizumab Control of symptoms Cord compression Immediate referral for specialist review

96

Delirium written 1. 2. 3. 4.

Give 3 symptoms Give 4 causes Give 2 nursing treatments Give 2 medical treatments

Physical Signs:      



   

Sudden onset Reduced ability to focus, maintain and shift attention Altered consciousness Fluctuation and diurnal variation Disturbed sleep-wake cycle Changes in mood o Anxiety o Depression o Lability o Irritability o Aggression Perceptual distortions o Misidentification o Illusions o Hallucinations Disorganised thinking o Rambling, irrelevant or incoherent speech Memory impairment Disorientation in time and place Physical signs of underlying cause

Aetiology Infection Metabolic Endocrine Medication Drugs/alcohol Cerebrovascular Trauma Raised I Intracranial infection Epilepsy

Respiratory, urinary, cellulitis Hypo/hyper-glycaemia, uraemia, hepatic failure, electrolyte disturbance, hypoxia Addisonian crisis, thyroid/parathyroid Anticholinergics, psychotropic drugs, steroids, anticonvulsants, overdose Intoxication/withdrawal, delirium tremens, Wernicke’s encephalopathy CVA/TIA, subdural haematoma Head injury Tumour, abscess Encephalitis, meningitis Pre-ictal aura, temporal lobe epilepsy, post-ictal states

Differential Diagnoses 97

FBC, CRP, Culture LFT, BM, U&E TFT, calcium Drug level, urine LFT, Drug levels, B1, B12 MRI, CT, Doppler Imaging

EEG

    

Dementia Psychotic disorders Mood disorders Anxiety disorders Drugs and alcohol

Management The nursing treatments of delirium  Treat underlying physical cause  General ive measures o Nutrition o Hydration o Correction of electrolyte and fluid balance o Thiamine if indicated  Careful attention to environment o Consistency of staff o Regular reorientation o Adequate lighting o Make environment safe  Liaison of medical and surgical teams with psychiatrists The medical treatments of delirium Symptomatic treatment of psychosis or acutely disturbed behaviour o Use single medication at low dose o Start with single dose and review after 2-4hrs o Antipsychotics: haloperidol, risperidone o Benzodiazepines in certain cases  Hepatic failure  Withdrawal from alcohol / benzodiazepines o Review dose regularly and taper / stop ASAP Investigations  Bloods, urine MC&S, CXR, ECG, MRI head, LFTs, TFTs, calcium, glucose, CRP, blood cultures, urine drug screen

98

Depression History and screen of a 7 year old Please take a history from a 7 year old girl’s mother who’s worried her daughter is suffering from depression. My name is Sarah and my daughter Molly and is 7.        

She’s been feeling sad for about a month and she seems depressed to me. She snaps at me when I try and ask her what’s wrong; she shouts and cries and runs to her room. She doesn’t enjoy things like she used to like school or playing and painting at home which she used to love. She feels tired a lot, like she don’t have a lot of energy Her teachers at school say she is not paying attention in class and takes a long time to finish her work She doesn’t eat; she occasionally eats crisps. On weekends when I don’t make her get up she sleeps for over 12 hours. She doesn’t like to talk a lot, especially to strangers and I’m not sure she has any friends at school She’s never tried to hurt herself thank God

I’ve been suffering from depression for the last 4 years, I’m on medication though (Amitriptyline) and I’ve been fine for the last year. I got depressed because I lost my job and my husband and I got divorced. Molly still sees her father every other day. I’m struggling with money because I still don’t have a job yet but Molly doesn’t know about these money problems Has she got depression because I had it; is it genetic or has she picked up her behaviour from me? Mark Scheme: 1. Appropriate introduction 2. Establishes reason for consultation 3. Takes a history / screens for depression a. Symptoms i. Duration of symptoms ii. Depressed mood or irritability iii. Anhedonia and/or reduced energy leading to fatiguability iv. Poor concentration and attention v. Sleep and/or eating disturbance vi. Reduced self-esteem vii. Pessimistic view of future / ideas of guilt viii. Ideas or acts of self harm / suicide b. Effect on day to day activities 4. Makes an attempt to establish severity of depressive episode a. Mild: depressed/irritable + anhedonia/tiredness + 2 other symptoms b. Moderate: depressed/irritable + 5/6 further symptoms c. Severe: 7 symptoms. Possibly delusions, hallucinations, stupor 5. Explains the relationship between depression in parents and children a. 40% of children of depressed parents have a psychiatric disorder 99

6.

7.

8. 9.

b. Increased risk of depression in relatives including off-spring c. Poor family function linked to a range of childhood disorders d. Genetics less important in pre-pubertal children (Rice et al 2002) Possible triggers a. Parental conflict + divorce can cause high levels of disturbance b. Bereavement Discusses treatment a. Officially assess her b. Mild: Group CBT / guided self help (2-3 months) c. Moderate – severe: CBT/IPT/ family therapy for 3 months, add in fluoxetine only if unresponsive to therapies Asks parent for questions and concerns Does all in an empathic and organized manner.

100

Epilepsy Take a history from Samantha Jones, an 18 year-old girl, who had a blackout. Also, give her management advice. Her friend witnessed the incident, and reported there to be jerking in all limbs, loss of urinary continence and tongue biting (side of the tongue). After the shaking stopped, she was unconscious for about half an hour. Following the incident, Samantha went to sleep for a few hours; she was feeling drowsy and her muscles and back were aching. She also complained of a headache. Samantha had been out drinking the night before. She is on the O.  Wash hands  Introduce and check patient’s name, age, occupation and dominant hand  Has this ever happened before?  Did you notice anything unusual before you blacked out? o Aura- strange feeling in the gut? Sensation or experience such as déjà vu? Strange smells? Flashing lights? o Dizziness / nausea? o Irritability / anxiety? o Did your friend perhaps notice a distinct ‘cry’?  Did you fit/shake when you fell/blacked out? o How long did this last for? o Which parts of your body were shaking?  During the episode, was there any: o Loss of urinary continence? (and faecal?) o Tongue biting? Which part?  After the shaking stopped did you regain consciousness straight away?  When you did regain consciousness, how did you feel? o Drowsy / confused? o Headache? o Stiffness? o Weakness of your limbs? (Todd’s palsy) o Any injury? o Back pain?  Where were you when the blackout occurred? What had you been doing? o TV, flashing lights involved  PMHx o HTN, cardiac conditions o Psych disorders o History of febrile seizures?  FHx  SHX o Smoking o Alcohol  DHx  Patient asks, is this epilepsy? o Epilepsy cannot be diagnosed unless 2 or more episodes  Patient asks whether she needs medication o Explain that blood tests, EEG have to be done 101

o





But if she were to go on medication, because she is on the O, her dose would have to be increased Other advice o If epilepsy diagnosed, DVLA would have to be informed o She would not be able to drive unless seizure-free for 6 months or more o Avoid triggers: alcohol, flashing lights o Avoid swimming, rock and tree climbing Questions to rule out differentials (most of them have been covered in the above Hx) o Pseudoseizures  Pelvic thrust-type movements  Patient keeps eyes closed even when you try to move them o Vasovagal syncope  What were you doing prior to the attack? Did it involve you standing for long periods of time? o Cough syncope? o Micturition syncope? o Effort syncope  Were you exercising prior to the event? o Carotid sinus syncope?  Were you shaving before the attack (if a man!)? o Hyperventilation/panic attack  Had you been particularly anxious? o TIA  CV risk factors  Smoking?  Alcohol?  HTN?  Weakness of face, 1 side of body, slurred speech, etc? o Hypoglycaemia  DM?  When did you last eat before the fall? o Narcolepsy  Were you feeling particularly sleepy before the attack? o Migraine  Headache?  Aura? o Vestibular disorders  Hearing difficulties?  Balance problems?

Menigitis?

102

Explain Schizophrenia 1. Introduction 2. What is schizophrenia? a. A serious mental disorder affecting 1 in 100 people b. People with schizophrenia can have problems distinguishing what’s real and what’s not and this affects the way they think, feel and behave. As a result, they can come up with strange ideas (delusions), or hear and see things that aren’t really there (hallucinations) c. Negative Symptoms i. Lack of motivation, initiative and movement ii. Social withdrawal iii. Poverty of thought and speech iv. Blunting of affect / mood disorder 3. Causes? a. Exact cause unknown b. Genetic background may partly ; having a parent with schizophrenia increases risk by 10x c. Other factors are birth complications and drug use d. Stressful life events don’t cause schizophrenia but can trigger its appearance 4. Treatments a. Psychological treatments i. Family therapy ii. Cognitive behavioural therapy b. Medications i. Schizophrenia (psychotic episodes) is caused by an excess of dopamine in the brain and antipsychotics are designed to correct the balance ii. Typical antipsychotics 1. Haloperidol, chlorpromazine 2. Side-effects; stiffness, restlessness, sleepiness, blurring of vision, involuntary movements of facial and neck muscles iii. Atypical antipsychotics 1. Clozapine, olanzapine, 2. Side effects; weight gain, sexual dysfunction, hypertension, diabetes, neutropenia c. Social i. Benefits ii. Accommodation iii. Daytime activities iv. Social v. for carers 5. Prognosis a. Roughly 20% of people with schizophrenia recover completely after the first episode but 70% will have breakdowns in the future. Continuing to take medications will decrease the chances of these breakdowns from happening b. Help available from community mental health teams consisting of psychiatrists, psychologists, therapists and nurses. 103

Fundoscopy Reporting Technique How you’re supposed to report a fundoscopy examination 1. Optic disk a. Colour (pale => atrophy) b. Cup (glaucoma) c. Contour (inflammation, infection, papilloedema) 2. Haemorrhages a. Dot haemorrhages (microaneurysm) b. Blot haemorrhages (bleeding capillary) c. Flame haemorrhages => hypertensive retinopathy d. Pre-retinal haemorrhages (due to new vessel formation) 3. White lesions a. Exudates b. Cotton wool spots c. Drusen – pale lesions discretely scattered in macula (ARMD) d. Laser scars e. Atrophy



 

Background o Exudates o Dot haemorrhages o Blot haemorrhages Pre-proliferative o Cotton wool spots Proliferative o Pre-retinal haemorrhage

Eye drops     

Tropicamide – anticholinergic. A weak papillary dilator (action lasts for 4-6 hours) used to facilitate examination of the fundus Phenylephrine – α1-adrenoceptor agonist. A papillary dilator also. Mydriasis occurs within 60-90 minutes Cyclopentolate – anticholinergic also Oxybrupocaine – a topical local anaesthetic Fluorescein + proxymetacaine – detection of lesions / foreign bodies

104

Side 0 – Normal retina Slide 1 – Senile macular degeneration – Disc appears normal but unusual pigmentation at the macula. (The retina is quite pale). This patient also has drusen which are asymptomatic nodules occuring in the choroid. Slide 2 – Central retinal vein occlusion: Typical ‘stormy sunset’ appearance with engorged veins with haemorrhages alongside them. (disc can’t really be seen; it looks like an exploding sun. Can’t see the veins on the disc). Slide 3 – Hypertensive retinopathy: The retinal arteries have become narrow and tortuous. In more advanced cases haemorrhages and ‘star burst’ exudates occur together with papilloedema. (The disc margins are not very obvious. Otherwise not much else wrong) Slide 4 – Papillodeoma: The disc is swollen and the disc margin has disappeared. The veins are congested (disc margins can’t be seen but can still see the vessels over the disc, unlike CRVO. Also the disc is in the middle of the slide on this one) Slide 5 – Disc cupping: Here the degree of cupping is mild but suggestive of glaucoma. As the condition progresses, the optic disc becomes pale and the cup wider and deeper. (the centre of the disc is REALLY PALE/BRIGHT YELLOW) Slide 6 – Optic atrophy: The optic disc is pale and the condition is associated with gradual loss of vision. It may be secondary to a number of conditions including glaucoma, retinal damage, ischaemia and poisoning. (The whole disc is really yellow) Slide 7 – Mild background diabetic retinopathy: Haemorrhages and microaneurysms can be seen. (nasal half of the disc can’t really be seen. A few haemorrhages and dots but not much else) Slide 8 – Background diabetic retinopathy: Areas of hard exudates and some evidence of macula involvement. (Disc is fine. Quite a lot of hard exudates which are on the edge of the macula with a small cluster in the middle) Slide 9 – Preproliferative diabetic retinopathy: with haemorrhages, microaneurysms and hard and soft exudates. (Less hard exudates than slide 8. Soft exudates at the very top and bottom.) Slide 10 – Preproliferative diabetic retinopathy: extensive haemorrhages and exudate formation and a preretinal (subhyloid) haemorrhages. (The preretinal haemorrhage is really obvious) Slide 11 – Proliferative diabetic retinopathy: with new vessel formation. (Paler retina. Hardly any vessels in macula area. Really thin vessels on and around the optic disc.) Slide 12 – Diabetic retinopathy recently treated with laser photocoagulation: (Loads of white dots panretinally)

105

Mental Health Act You are an psychiatry SHO who has received a call from a GP regarding one of his patients being stuck in a tree. He wants to know whether he can use a section of the MHA to detain the patient. Please answers his questions and advise him on the best course of action. “Hi, I’m Dr Ginsberg, I wanted to ask you about one of our patients. He is stuck in a tree and is refusing to get down. His family say that he has been up the tree for 16 hours. He thinks that there are people after him and that they are surrounding the tree. He appears frightened of them and is worried that they will hurt him if he doesn’t get down. He shouts abuse and threatens strangers that walk past. He has not actually hurt anyone and nor has he ever in the past. He has a previous history of paranoid schizophrenia diagnosed 8 years ago. We don’t think he has taken any substances although he is known to have in the past. We cannot seem to get close enough. He has been in with the local AOT team, until 2 weeks ago.” 1.

When is it justified to use the MHA? The patient is suffering from a mental disorder that is of nature and degree to merit treatment in hospital and that such treatment cannot be provided without detention. Refuses to go to hospital Risks to: patients health and safety and protection of others What is a mental disorder? – it is any disorder or disability of the mind

2.

3.

4.

What section can I bring him in under? Would I be able to to get the police to bring him in on a Section 136?

a.

Section 2 – 28 day assessment order where you can treat as long as its part of the assessment process

b.

Section 136 – applies to people that police suspect of having a mental illness which confers immediate risk. Taken to a place of safety where the duty psychiatrist makes an assessment and discharges detainment not merited. Or the MHA assesment deems it suitable for Section 2 or 3.

c.

Section 4 – Emergency treatment order, probably not warranted.

How many people do I need to make an assessment? What else do I need? a.

Assessment order, lasts 28days

b.

Needs one Section 12 approved doctor plus another doctor (usually patient’s GP) and an AMHP – usually psychiatrist and GP t assessment

c.

Can take place anywhere

What happens next? Medical Recommendation Form (MRF) is given to the AMHP to apply for the section. The AMHP applies, the 2 doctors recommend it.

What should I do if I we cannot bring him is in a peaceful way? 106

Headache History Cheryl Cole is a 23 year-old lady, presenting with a 1 month history of headaches, which are unilateral and throbbing in nature. She gets them on average 3 times a week. They usually last several hours, and sometimes they don’t improve unless she goes to sleep, in which case she would wake up headache-free (however, it is quite difficult for her to fall asleep as the headache is so sever). The headaches are preceded by visual distortion about an hour before their onset, lasting about 15 minutes. Cheryl also experiences severe nausea with these headaches and on a few occasions has vomited also. They are worsened by routine activity, and Cheryl is unable to attend work when the headache is present. She feels that chocolate and cheese may be triggers. The only thing that helps is lying in a dark room. She has tried paracetamol and Nurofen, but neither improved her symptoms. Her mother suffers from migraines, and Cheryl is worried that she may be having the same problem. She is particularly concerned, as she is being forced to take a lot of time off work during a very stressful season where many deadlines are due, and would like medicine that can improve her headaches. 1. Was hands and introduce 2. HPC:  Duration, Onset, frequency, severity, location, nature of headaches  Aura? (visual/auditory/sensory/speech, its length and how long prior to the actual headache it occurs)  N + V?  Photophobia/phonophobia?  Aggravating factors: light, routine activity  Triggers: Chocolate, cheese, alcohol, exercise, caffeine, anxiety, travel  Possible causes: stress/tension, medication overuse (ask specifically about analgesics containing codeine, CO) 3. Rule out alarm signs:  Fever  Neck stiffness  Rash  Fits  Reduced consciousness  Travel abroad (?malaria)  Trauma/head inury  Tenderness in scalp (temporal arteritis)  Loss/ change in vision  Loss of power in limbs 4. PMHx (diabetes, clotting disorders)/FHx/SHx (smoking, alcohol) 5. ICE 6. Summary

Discuss diagnosis, differentials, investigations and management with the examiner 1. Diagnosis:  Migraine, because: o Chronic (1 month history) o Unilateral, throbbing 107

o Preceded by aura o Associated N+ V o Laying in a dark room helps o Triggered by chocolate and cheese 2. Differentials:  Tension headache  Cluster headache (pain is usually around the eye, each headache occurs about twice a day and only lasts 15-160 mins)  Chronically raised intracranial pressure (typically worse on waking, focal signs including vomiting, visual disturbances epilepsy, mental change)  Medication misuse (not on CO, and rarely uses analgesics)  Sinusitis/otitis media (no coryza-like symptoms, fever or earache, more acute onset)  Less likely causes: o TIA (too young) o Antiphospholipid syndrome o AV malformation o Meningitis (acute onset, no neck stiffness, fever, rash) o Encephalitis (acute onset, no fever, fits) o Subarachnoid haemorrhage (acute onset) o Head injury (no Hx of trauma, acute onset) o Glaucoma (too young) o Temporal arteritis (too young) 3. Mx o Non-pharmacological: o Ice packs or warm packs o Spinal manipulation o Rebreathing into paper bag o Weight loss (if obese)  Prophlaxis (if frequency more than twice a month- Cheryl meets this criteria): o 1st line: Pizotifen, propranolol, amitryptiline o 2nd line: sodium valpoate, NSAIDs, gabapentin, topiramate  Rx: o Aspirin o Paractamol o Sumatriptan o Ergotamine TYPES Secondary Headache Raised Intra-cranial pressure Low pressure headaches Meningeal irritation Giant cell arteritis Primary headaches Migraine  Abnormal sensory sensitisation o Light, sounds, smell and movement Cluster Headache Tension-type headache AND Chronic daily headache 108

Bi-Polar Affective Disorder Explain Lithium to Mrs. Jones, a 30 year-old lady, who has had 2 past episodes of BPAD Mark scheme  Wash hands 

Introduce and check patient’s name



Check patient’s understanding of BPAD o Mood disorder o Associated with periods of extreme ‘highs’ and/or ‘lows’, which impair daily functioning



Check patient’s understanding of need for lithium o Lithium will help to stabilise your mood o It is used to help prevent further mood disturbances from occurring o Its exact mechanism of action is unknown, but it is very effective, and is therefore the first line choice of drug for preventing further mood disturbances in BPAD o Thought to act by decreasing NA release and increasing 5HT synthesis



Explain side effects o Weight gain o Increased thirst and need to go for a wee o Tremor- ‘ a bit shaky’ o Skin problems o Memory/concentration problems o Hypothyroid- ‘underactive’ o Renal dysfunction- ‘can affect kidneys’ o Cardiac t wave flattening or inversion- ‘can affect heart’ o Leucocytosis- ‘more at risk of infection’ o Teratogenecity- ‘baby at risk if pregnant, strongly advised to avoid pregnancy while on it’



Explain contraindications o Pregnancy, breastfeeding o Renal insufficiency- ‘kidney problems’ o Thyroid disease o Heart conditions o Neurological conditions eg Parkinson’s, Huntington’s



Ask if patient is on any contraindicated drugs o Diuretics o ACE-is o NSAIDs o Antipsychotics



Explain that the likelihood of getting side effects will be reduced by careful, regular monitoring of the drug levels in the blood o Every week until stable for 4 weeks in a row, then every 3 months thereafter 109

o

o

Particularly to prevent ‘toxic syndrome’ at levels of 1.5 or above  1.5-2: N + V, apathy, coarse tremor (shaking), ataxia (walking affected), muscle weakness  >2: nystagmus (abnormal eye movements), dysarthria (slurred speech), decreased BP and urine output, hyperactive reflexes, , impaired consciousness, drowsiness, coma Other blood tests to make sure the ‘at risk’ organs of the body haven’t been affected  Kidney function- every 6 months  TFTs- every 12 months



Also, prior to starting rx, following tests must be done to ensure that the ‘at risk’ systems aren’t already compromised, as starting lithium would then put them at further risk o FBC (lymphocytes) o U + E (kidneys) o TFT o Pregnancy o ECG o Weight



Any alternatives? Or if lithium doesn’t work? o Valproate, Carbamazepine o ECT

110

Lithium toxicity written Indications for lithium (give 2 main uses)  Prophylaxis of bipolar affective disorder  Augmentation of treatment-resistant depression  Acute Mania  Adjunct to antipsychotics in schizoaffective disorder and schizophrenia Lithium side-effects  Polydipsia, polyuria, weight gain, oedema, fine tremor, concentration and memory problems, hypothyroidism, impaired renal function, t-wave flattening or inversion, leucocytosis, teratogencity Toxicity 1.5-2 mmol/L >2 mmol/L

Nausea, vomiting, apathy, coarse tremor, ataxia, muscle weakness Nystagmus, dysarthria, impaired consciousness, hyperactive tendon reflexes, oliguria, hypotension, convulsions, coma

What two things would you advise a patient with a lithium level >2. 1. Stop taking it 2. Go to hospital 3. Drink plenty of water What could be done in the case of lithium toxicity / overdose?  Whole bowel irrigation  If no clinical manifestations, stimulate urine production by drinking fluids (not diuretics)  Haemodialysis may be needed  Benzodiazepines may be required for agitation Drugs that can increase lithium levels  Diuretics (especially thiazides)  NSAIDs  ACE-inhibitors Conditions that will increase lithium levels  Renal insufficiency o Dehydration o In the elderly o Kidney failure  Sodium depletion Time after lithium dose that blood tests should be taken  Lithium blood tests need to be taken at least 12 hours after the last dose of lithium to make sure the test is reliable.

111

Management of psoriasis

1. Lifestyle changes: avoid a. Stress b. Smoking c. Alcohol d. Obesity (suggest weight loss?) e. Sunlight f. Trauma-related sports e.g. rugby g. Drugs- B-blockers, lithium, anti-malarials 2. Emollients a. Act as a barrier to cutaneous fluid loss, relieve itching and help replace water and lipids therefore restoring the barrier function of dry skin. b. Regular general application c. Ointments, creams, tars, lotions 3. Topical agents a. Applied only to the diseased skin i. Coal tar: normalises keratinocyte growth patterns, antipruritic + antimicrobial ii. Vitamin D: calmodulin inhibitors (calcipotriol) iii. Vitamin A: tazarotene iv. Dithranol v. Steroids: reduce the superficial inflammation within plaques. However, relapse usually occurs on cessation and tachyphylaxis is observed. 1. Mild - hydrocortisone 2. Moderate – betnovate 3. Potent – betamethasone 4. Very potent - dermovate 4. Phototherapy a. UVB- Side effects include skin burn, increased risk of skin malignancy (with chronic use), Contraindicaions are SLE, previous skin malignancy, xeroderma pigmentosum) b. PUVA- Side effects include skin burn, skin pigmentation, increased risk of skin malignancy, cataracts (eye protection worn to prevent this) c. Excimer laser- like UVB, but more precise d. Procedure- the lesions are exposed to UV rays (light) in the hospital or in clinic, and in PUVA therapy, a drug called psoralen is taken orally or applied as a ‘paint’ on the skin prior to the light therapy 5. Systemic agents a. Oral Vit A analogue (acitretin) i. SE: liver damage, teratogenecity (women must remain on CO for 2 years after stopping treatment) ii. CI: liver impairment, hyperlipidaemia, DM b. Methotrexate i. Reduces epidermal skin cell turnover ii. SE: myelosuppression (ie risk of infections), heptotoxicity, pulmonary toxicity, teratogenecity; Regular blood tests required to monitor this toxicity c. Ciclosporin 6. Biological agents a. Infliximab, etanercept

112

Migraine history Mark Scheme: 1. Introduction 2. Pain a. SOCRATES b. Aggravated by movement, photophobia, phonophobia, osmophobia 3. Prodrome a. Psychological; depression, irritability, euphoria b. Constitutional; sluggishness, anorexia, hunger c. Neurological; dysphasia, yawning, hyperosmia d. Autonomic; urination, diarrhoea, constipation 4. Aura a. Visual; spots, flashing lights, zigzag lines b. Sensory; tingling, paraesthesia, numbness c. Motor; limb weakness, dysphasia 5. Other symptoms a. Nausea & Vomiting b. Morning headache c. Focal signs d. Fever 6. Previous history of headache 7. Family history 8. Explains migraines are common. 15% of people in their lifetime. 9. Management a. Avoid triggers b. Regular sleep, exercise, meals, work habits & relaxation c. NSAIDS or paracetamol d. Disease-specific treatments i. Triptans ii. Ergotamine derivatives iii. Anti-emetics e. Prophylaxis i. Pizotifen ii. Beta-blockers iii. TCA iv. Sodium valproate v. Topiramate vi. Methysergide

113

OCD History Please talk to Anna Jones. A 35-year-old married woman has been referred by her company’s occupational health department as she does not appear to be coping at work

Mark Scheme: 1. Introduction 2. Assess obsessions and compulsions a. Eliciting obsessions or compulsions if necessary i. Do you worry about contamination with dirt even when you have already washed? ii. Do you have awful thoughts entering your mind despite trying hard to keep them out? iii. Do you repeatedly have to check things that you have already done (lights, taps)? iv. Do you find that you have to arrange, touch or count things any times over? 3. ICD-10 guidelines for OCD a. Obsessions or compulsions present for at least 2 successive weeks i. And a source of distress (do you think think these thoughts are unreasonable?) b. Are they your thoughts or do you feel like they’re being put into your mind? c. Are the thoughts unpleasant and repetitive? d. What happens if you try to stop thinking these thoughts? e. Does ‘washing your hands’ making you feel better or just less anxious? 4. Assess for depression a. Have you ever suffered from depression? b. Have you been feeling low, lost interest in things you normally enjoy or been very low on energy? 5. Assess for other anxiety disorders a. Does anything provoke/stimulate these thoughts? 6. Assess for eating disorders a. Morbid fear of fatness? b. Does not believe thoughts are unreasonable 7. Assess for psychotic disease a. Are these thoughts not your own and being put in your mind? b. Hallucinations? 8. Management a. Mild effect on life: CBT with exposure therapy and response prevention i. Self-help materials ii. On the phone iii. In a group iv. individually b. Moderate: SSRI or CBT c. Severe: Both

Questions to ask and why ICD-10 criteria for the diagnosis of OCD Obsessions/compulsions daily for at least 2 consecutive weeks Must interfere with the patient’s life Known to be their own thoughts 114

Obsessions are horribly repetitive Compulsions give no relief apart from anxiety relief Obsessions recur despite resistance

What seems to be the problem? How long has this been a problem? How many days a week? Are they distressful? Do they interfere with your daily activities? What happens if you don’t wash your hands? How often do you have the obsessions? Does washing your hands make you happy or just relieve anxiety? What happens if you actively try to not think of germs on your hands? Do you ever suffer from low mood? Any thoughts of harming yourself? Alcohol or drug use? Ever hear voices?

Do you worry about contamination with dirt even when you have already washed? Do you have awful thoughts entering your mind despite trying hard to keep them out? Do you repeatedly have to check things that you have already done (stoves, lights, taps, etc.)? Do you find that you have to arrange, touch or count things many times over?

115

Idiopathic Parkinson’s Disease Physical signs  Akinesia o Bradykinesia o Micrographia o Poverty of facial expression (hypomimia) o Difficulty in changing position o Quiet & monotonous speech  Gait o Festinant gait o Flexed or stooped position o Slow turning and initiation of movement o Reduced arm swing  Rigidity o Leadpipe rigidity o Cogwheel rigidity  Resting tremor  Cranial nerves o Mild impairment of upgaze o Tremulous eyelids o Glabellar tap sign o Drooling (sialorrhoea) because of difficulty swallowing o Decreased blink rate Differential Diagnoses  





Drug-induced Parkinsonism; phenothiazines, metoclopramide Progressive Supra-Nuclear Palsy o Failure of downgaze, upgaze then horizontal gaze o Early postural instability o Dementia Multiple System Atrophy o Autonomic failure (Shy-Drager syndrome)  Sexual, bladder dysfunction, postural hypotension o Olivopontocerebellar atrophy  Ataxia, dysarthria, tremor o Parkinson’s features Corticobasal degeneration

Treatments What are 2 first line treatments? 1. Levodopa (+ peripheral dopa decarboxylase inhibitor) 2. Non-ergot-related dopamine agonists – ropinirole, pramipexole, rotigotine

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You have been asked to see Jane Adams, a 33-year-old single mother, who has found it difficult coping after giving birth to a son 2 months ago. Her community nurse has noted that she has been withdrawn and tearful recently. They mention that she struggled throughout her pregnancy, and that her partner left her 7 months ago. She doesn’t have much at home. Interview her and take a history of disturbance of mood. Assess Aspects of risk I am Jane Adams, a 33-year-old single mother. I am depressed but willing to speak to somebody because I have little from friends or family. I have been feeling isolated for some time. My mood has been low since a week after my son was born but has become worse since the baby started crying a lot more a month ago. My mood I have been feeling low all of the time; I get tearful and irritable and my mood doesn’t vary throughout the day. It takes me over an hour to get to sleep and I wake up early in the morning and can’t get back to sleep. My appetite is reduced and I’ve lost some weight. My concentration is poor, I’ve been finding it difficult to read baby books. I am pessimistic about the future. I don’t see things getting better since I have no . I feel like a failure and feel unable to cope; I think I deserve it because I’m a bad mother. No psychotic features. Over the last 2 weeks I have been wishing I were dead because I don’t know how to cope. I have thought about taking an overdose but haven’t really pursued this as an option. Initially I had hoped that my mother would take my baby if I died but recently I’ve been thinking about taking the baby with me because I think he’d be better off that way. These thoughts made me feel very guilty and often make me cry myself to sleep. I live in a council flat on my own. My partner left 7 months ago which left me distraught. I have been too tired during this pregnancy to see any of my friends and I generally sit at home doing very little. I have one or two close friends with children but have not seen them and would feel bad asking them for . I have struggled with basic cleaning and shopping. I haven’t worked since finding out I was pregnant, I previously worked as a travel agent. Mark Scheme: 1. 2. 3. 4.

Introduction; congratulations, how’s the baby? Worried about anything? Name, age, occupation Duration of symptoms Symptoms a. Has your mood been low? (Diurnal variation?) b. Have you felt really low on energy? More than previous pregnancies? c. Have you stopped getting pleasure from things you normally like doing? d. Have you been less able to concentrate on tasks? e. Sleeping more or less than usual? Early morning wakening? f. Lost or gained weight/appetite g. Negative view of yourself, the world, the future? 5. Exclude baby blues a. Onset within the first 10 days? Peaks between 3rd & 5th day. i.e. short duration 6. Exclude puerperal psychosis 117

a. Belief that other people are watching / want to harm you? b. Feeling that the TV/radio is making reference to you? c. Thoughts are being interfered with or read by anyone? d. Hearing sounds or voices when nothing or nobody to make those sounds? 7. Assessment of risk a. Suicide i. Have you ever felt so down that you wished you were dead? ii. Have you thought about how you would do this? iii. Have you made any plans? b. Harming the baby i. Ever felt that you would harm your baby or end its life? ii. Ever seen or heard anyone telling you to harm the baby? iii. Would you act on these? Made plans? 8. Assessment of social circumstances and network a. Live in a house or a flat? b. Live with family, other people or alone? c. Single, divorced, separated, married? d. Been in with friends? Enjoying hobbies? e. Been coping with shopping and cleaning? f. Currently working? g. Do you see your parents? Do they help? h. Financial 9. Risk factors a. How was the birth? i. Complications ii. Instrumental iii. Caesarian b. History of depression or psychiatric disease c. Have you ever taken elicit drugs? d. Do you drink alcohol? Did you drink during your pregnancy?

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PTSD history You are Mary Jones, a 32-year-old woman who was out with her husband 6 months ago when you were both attacked. 6 months ago when walking home at night my husband was beaten unconscious by 3 men and suffered major facial injuries. I was held forcibly and threatened with violence. I witnessed my husband’s attack. Since then I have been signed off work by my GP because of problems with mood, poor sleep, anxiety and panic attacks. Mark Scheme: 10. Introduction 11. Establish nature of consultation 12. History of traumatic event and perception of threat a. Did you fear for your life? 13. Timing of onset of symptoms (within 6 months) 14. Did you the police? 15. Re-experiencing of event a. Images, thoughts, flashbacks b. Acting or feeling as if the event was reoccurring c. Distressing dreams of the event d. Intense physiological distress /reactivity at exposure to internal or external cues 16. Persistent avoidance a. Avoiding thoughts, or conversations associated with the trauma b. Avoiding activities, places or people that arouse recollection c. Feeling of detachment from others d. Restricted range of affect e. Sense of foreshortened future (“doom”) 17. Increased arousal a. Difficulty falling or staying asleep b. Irritability or outbursts of anger c. Hyper-vigilance d. Exaggerated startle response 18. Other associated anxiety symptoms 19. Presence of depressive symptoms 20. Comorbid drug/alcohol misuse 21. Social a. Do they have children?

Acute Stress Reaction Adjustment disorder

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Radiology Stations

Cervical spinal cord MRI in the sagittal plane of a 28-year-old woman with polyphasic neuromyelitis optica. (A) T1-weighted image showing thickening of the cord from C7 to T2 with patchy areas of subtle intraparenchymal hyperintensity. (B) T1-weighted image, post gadolinium contrast istration, showing several enhancing lesions from C7 to T2. (C) T2-weighted image showing a contingous area of increased signal intensity spanning from C6 to T3.

What plane is this image in? – sagittal What abnormalities are shown? – (A) Thickening of the cord, patchy areas of intraparenchymal hyperintensity. (B) Thickening of the cord, several enhancing lesions. (C) Increased signal intensity suggesting inflammation and demyelination i.e. a plaque Diagnosis? – Multiple Sclerosis Where is the lesion? – from C6 to T3 Would the lesion cause weakness in the shoulders? – yes because C6 is affected which with C5 innervates deltoid. Would this patient present with a sensory level? - yes Treatment? No cure available  Management of acute relapse o Corticosteroids (methylprednisolone IV/PO)  Modification of the course of the disease o Interferon-β o Glatiramer acetate o Natalizumab – twice as effective as interferon-β  Control of symptoms o Spasticity – muscle relaxants; dantrolene, baclofen, tizanidine, diazepam o Cerebellar tremor – clonazepam, isoniazid, gabapentin o Fatigue – amantadine, selegiline

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What plane? – Axial Abnormalities? – Biconvex area of increased density; spread limited by adhesion of the dura to the skull = Epidural haematoma. Effacement of the sulci and ventricles. Treatment? -Medical - I.V. Mannitol bolus, possibly artificial ventilation – Surgery – horse shoe craniotomy flap. If patient deterioration is rapid, provide temporary relief by means of a burr hole and craniectomy.

What plane? – Axial Abnormalities? – Biconcave, concentric shaped, area of increased density spreading around the surface of the cerebral hemisphere. Effacement of the sulci and right ventricle. Dilatation of the left ventricle due to obstruction at the foramen of Munro. Midline shift Treatment? – Nurse in the head down position, evacuate haematoma through 2-3 burr holes. In patients in whom conscious level is not depressed consider conservative treatment with steroids over several weeks.

What plane? – Axial 121

Abnormalities? – Low density lesion with distribution matching the vascular territory of the middle cerebral artery. Midline shift, effacement of the ventricles and sulci. What time after the incident was the CT taken? – 0 hours – no change in density 3 hours – no change in density 4 hours – start to see hypodensity but not representing the entire area of infarction 30 hours – may take up to this time to distinguish clearly the accompanying oedema as a hypodense lesion from unaffected brain tissue 3 days – infarcted area better defined and diminished in density 7 days – infarcted area still hypodense 14-21 days – infarction may appear to disappear due to relatively increased density values 30 days – infarction becomes hypodense again and isodense to CSF Treatment? – Thrombolysis with alteplase if within 3 hours of onset and no contraindications Aspirin within 24 hours of onset for 2 weeks.

What plane? – Axial Imaging modalitiy? – T2 MRI Abnormalities? – Gross enlargement of the lateral ventricles (& effacement) = hydrocephalus. In a communicating hydrocephalus, all ventricles will be enlarged Which ventricles are dilated? Is LP contraindicated? – Yes, LP is contraindicated in non-communicating and communicating hydrocephalus Treatment? – 

Acute obstructive hydrocephalus – urgent surgical management – ventricular drain / ventriculoperitoneal shunting

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These are CT scans of gliomas

Infarct: What time after incident was it taken? Treatment: ission to stroke unit Aspirin 300mg daily, modest benefit when given within 48hrs of onset. Thromboysis; (15%-I.V. tissue plasminogen activator.) Territory;

Middle Cerebral Artery

123

d

c

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Explaining Ritalin treatment I’m Mrs Wright and my 8 year old son has been diagnosed with ADHD. I have been recommended by my child’s psychiatrist to have him take Ritalin. I want to know; What is it? Why is it used? What are the side effects? How will you monitor my son? Mark Scheme: 11. 12. 13. 14. 15.

16.

17. 18.

19. 20.

21.

22.

Appropriate Introduction Establish reason for consultation Explains Ritalin (methylphenidate) is a stimulant It is not a cure, it only modifies the behaviour Mode of action; a. Indirect sympathomimetic b. Increases release of dopamine and noradrenaline Benefits a. Control the difficult behaviours by increasing concentration and attention while decreasing impulsivity b. Effective in 70% Investigations before treatment a. Height, weight, blood pressure, LFTs monitored regularly Side-effects a. Decreased appetite b. Anxiety c. Insomnia d. Tics e. Hypertension f. Seizures g. Growth suppression Drug holidays required a. Long term use can lead to growth suppression. Monitoring a. Regular monitoring by a specialist so that response can be monitored i. Height every 6 months ii. Weight every 6 months apart from initial at 3 months iii. Heart rate and BP every 3 months b. Stop medication if no response after 1 month c. Suspend treatment every 1-2 years to assess condition Stopping the drug a. Not addictive if correct dose taken b. Avoid abrupt withdrawal Other treatments a. Cognitive behavioural therapy b. Parent management training c. Family therapy d. Educational intervention 125

Management of school refusal because of bullying Talk to Sarah Hurley whose 11 year old son is refusing to attend school because of bullying. She has questions to ask and would like to know about management. Qs Could it be the bullying? Could it be related to the stomach pain? Child is threatening to kill himself if sent to school Mark Scheme: 22. Introduction 23. Establish nature of consultation 24. Discuss aetiology a. Separation anxiety b. Specific fears i. Travel to school ii. Bullying iii. School assemblies, specific classes c. Family dynamics i. The child won’t return to school unless sees that both parents want this. d. Depression e. Psychiatric disease 25. Discuss risk factors a. Smaller families or the youngest child or previously ill child b. Anxious personality c. Depressive disorder or OCD d. Vulnerable mother (anxious, depressed, abused, ill, alone) e. Absent father f. Bullying at school g. Learning difficulties h. 5yrs – Separation anxiety i. 11yrs – transfer to secondary school j. 14-15yrs – depression & schizophrenia 26. Discuss presentation a. Onset? b. When does the child express that they do not want to go to school c. Is the child content when at home? d. Do they express somatic complaints (headache, abdominal pain)? 27. Discuss further assessment a. Exclude physical illness b. See whole family c. See child alone d. See parents alone e. school 28. Treatment 126

a. Mild/acute i. Return to school ASAP, agree date with school ii. family to be firm despite distress iii. Brief family therapy may help b. Chronic i. Communication essential ii. Individual psychotherapy – dynamic or CBT iii. Family therapy iv. Behavioural treatment of anxiety, e.g. desensitisation v. Graded return vi. Treat concomitant psychiatry disorder, incl medication c. Prognosis i. Very good for mild/acute/situational cases ii. Severe/chronic 1. 20-30% don’t get back to school (especially older children) 2. 1/3 develop adult neurotic disorder

Discuss with the school Change school (extreme)

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School Refusal 1. Child History  Identify the physical symptoms and take history accordingly  Why do you not want to go to school?  Do your parents know that you don’t go to school? (differentiate from truancy)  Is there anything at school that you find particularly worrying? (bullying?)  Have there been any changes at school recently? (new teachers, new school, tests?)  How do you get on with your classmates?  How do you get on with your teachers?  Exclude physical illness  Exclude mental illness: low mood, anxiety, OCD 2. Parental History  Why do you think he’s not going to school?  Have you ever left the child alone/ What happens when he is left to himself? (separation anxiety)  How would you describe the character of the child? (loner, shy, overly dependent?)  How have you been feeling recently/low mood? (Depressed and dependent mother?)  How do you feel when the child is away from you/at school? (dependent mother)  Are both parents involved in looking after child? (divorce, separated parents?) 3. School/Teacher History  Find out about conduct and nature of relationships of child with teachers and classmates. Treatment  Reassure parents that child may not be physically ill and when they refuse to go to school, they may display physical symptoms as a way of expressing emotional distress  Try and get the child to return to school asap  Agree a date on which to return to school  Tell parents to be firm with their child  Therapies include: family, CBT, psychodynamic, behavioural therapies (graded return)

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Taking a depression history 1. Introduction 2. How long have you been experiencing these symptoms? (at least 2 weeks) 3. [4+ symptoms required including 1 core symptom] a. Core symptoms i. Have you been feeling low? (depressed mood) ii. Have you got little interest and enjoyment out of things you normally enjoy? (Loss of interest and enjoyment) iii. Have you been sleeping more or less than usual? (Reduced energy or increased fatigability) 4. Other symptoms a. Weight or appetite change b. Insomnia or hypersomnia c. Psychomotor agitation or retardation d. Feelings of worthlessness or excessive or inappropriate guilt e. Diminished ability to think or concentrate f. Thoughts of death or suicidal ideation

Diagnostic criteria for depression ICD-10 uses an agreed list of ten depressive symptoms Key symptoms:

 o



persistent sadness or low mood;and/or



loss of interests or pleasure



fatigue or low energy

at least one of these, most days, most of the time for at least 2 weeks

if any of above present, ask about associated symptoms: 

disturbed sleep



poor concentration or indecisiveness



low self-confidence



poor or increased appetite



suicidal thoughts or acts



agitation or slowing of movements



guilt or self-blame

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Explaining tricyclic antidepressants I’m Tom Jones. I have been diagnosed with moderate depression and have been advised to start tricyclic antidepressant treatment.

I want to know; What is it? Why is it used? What are the side effects? Are antidepressants addictive? How long do I have to take them? Can I have any other kind of treatment? If I take them, am I guaranteed to get better? What happens if they don’t work? Mark Scheme: 23. Appropriate Introduction 24. Establish reason for consultation 25. Discusses principles of antidepressants a. Response rates – 50-60% will be improved 26. Explains probably mechanism of action a. Depression seems to be caused by decreased neurotransmitters b. Antidepressants work by increasing the amounts of chemical available 27. Reasons for using TCAs over other antidepressants a. Sedative properties of amitryptyline and doseulepin can help with insomnia 28. Outlines starting antidepressants a. Likelihood of side-effects in first few days i. Some side-effects will relieve over time (more to do with GI disturbance and anxiety in SSRI use) b. It can take 4-6 weeks for antidepressants to work i. Don’t be disillusioned 29. Explains possible side-effects a. Anti-muscarinic – dry mouth, constipation, urinary retention, blurred vision b. Anti-histaminergic – sedation, weight gain c. Anti-adrenergic – postural hypotension d. Cardiotoxic – heart block, arrhythmias, ST-elevation 30. Explains principles of continuation and prophylactic treatment a. Not addictive – no tolerance, no craving if you don’t take them b. Medication continued until 6 months after remission of symptoms 31. Can be withdrawal effects if stopped suddenly i. N+V, flu-like symptoms, agitation, sleep disturbance ii. Taper dose over 6-8 weeks 32. What if they don’t work? a. Antidepressants are tried for 6 weeks before trying another 33. Outlines alternatives to antidepressants a. Cognitive Behavioural Therapy b. Interpersonal therapy c. Psychodynamic psychotherapy 130

Sixth nerve palsy

Sixth nerve palsy. This is the most common isolated muscle palsy Causes of 6th nerve palsy:       

Wernicke’s encephalopathy Tumour in cerebellopontine angle causing compression directly on nerve Raised I compressing nerve against sharp edge of petrous temporal bone Basal skull of fracture Diabetes – mononeuritis complex Mastoid / middle ear infections Suppurative middle ear disease

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Part 2B 4th year Stations Obstetrics and Gynaecology

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Adult UTI You are a GP registrar and have been asked to talk to Lisa Thompson, a 21 year old woman, who has just been told she has a urinary tract infection. Please explain the diagnosis to her and your suggested management taking into any drug interactions. I have been having symptoms of increased need to go to the toilet and pain on urinating for the last week. I have not had a fever, loin pain or vomiting. I have just been told by the nurse that dip-sticking my urine has shown that I have a urinary tract infection. I’m interested in knowing how I got it and if it’s treatable and any long term effects. I also would like to know how to prevent it from happening in the future. I have never had a UTI before. I do not have diabetes, I am not pregnant, and no problems with my waterworks as a child. I am currently taking the combined oral contraceptive pill Mark scheme: 1. 2. 3. 4. 5.

6.

7.

8.

9. 10. 11. 12.

Appropriate introduction (full name and role) Establishes reason for consultation Clarifies symptoms with the patient Explains test results to patient Ask risk factors a. Diabetes b. Pregnant c. Any problems with water works as a child Give advice about how she caught it a. 20-40% of women will have a UTI in their lifetime b. Close proximity of anus and urethra c. Urinary stasis d. Sexual intercourse Gives a management plan a. Trimethoprim 200mg bd for 3 days i. Continue taking the pill as usual and use an extra method of contraception while taking the antibiotics and for seven days afterwards. If you get to the end of the packet while taking the antibiotics start the next pack straight away b. Increase fluid intake c. Alkalinise urine – potassium citrate solution Advises on how to prevent further infections a. Urinate frequently b. Increase fluid intake c. Double void (i.e. go again after 5-10 mins) d. Void after intercourse e. Wipe from front to back Give leaflet regarding UTI Checks correct information with patient Takes history in an empathic manner Does all in a fluent and professional manner.

Nitrofurantoin side effects: N&V, diarrhoea, pulmonary fibrosis, lupus-like syndrome Trimethoprim side effects: GI disturbances including N+V Ciprofloxacin side effects: diarrhoea

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OSCE: Down’s syndrome Mrs. Jones, 30 YO, has just given birth to a girl with Down’s syndrome. She would like to ask you some questions. 1. Introduction 2. 3. Ascertain how much she knows about Down’s, and whether she knew her child would have this condition prior to her birth. 4. Will my child be able to walk and talk?  Down’s syndrome can range from a mild to a severe condition, with variation in the degree of learning difficulty and development of complications between individuals  It is hard to determine the severity at this stage... It should become more evident as the child gets older and has more milestones that she should be achieving eg. Walking, talking, etc  However, most children with Down’s seem to have delayed motor milestones, so your daughter will probably walk and talk later than if she didn’t have this condition  Furthermore, she is at more risk of hearing impairment, due to a higher risk of recurrent ear infections, which could also affect speech development 5. Will she be able to go to normal school?  Again, it depends on the severity  May be able to go to normal school if very mild, might require an assistant in class, or may be better off going to a special needs school 6. If I have any more children, will they have Down’s? 7. How did this happen? Is it genetic? If so, how?  Extra chromosome 21 (should only have 2, but your daughter has 3, chromosomes are made up of genes, so she has more genes than she should)  94% of these cases are due to something called ‘non-dysjunction’, which happens when the eggs are made in the lady, one too many of the 21st chromosome are made and our child ends up with one extra. It is one of those things that can just happen out of the blew. The risk of this increases with increasing age. However, at your age the risk is only 1 in 900, which is less than the average risk for a woman (1 in 650). If this is the cause of your daughter’s Down’s, then the risk of another child having it is about the same, though this rises with increasing age, to 1 in 37 by 44 years of age.  Only 5 % are due to something called an unbalanced Robertsonian’s translocation, which is a mutation that you or your husband may hold. And if this is the cause for your daughter having Down’s, the risk of a further child having Down’s is 10-15 % if it is you who carries this mutation, and 2.5% if your husband carries it.  1% are due to something called mosaicism 8. Will my daughter have other health problems?  Not necessarily  But, problems that your daughter is at an increased risk of having are: o Congenital heart defects (40%)- AVSD/VSD (these vary in severity, but can cause heart failure, breathing difficulties and failure to thrive, and can be corrected) o Duodenal atresia- narrowing or absence of a part of the bowel (duodenum), requires surgery o Hirschprung’s disease- usually presents at birth, with the infant not ing meconium (poo) in the first 24 hours, constipation due to part of the large bowel becoming very narrow due to no nerve supply, so the food contents/faeces cannot get past this point. Surgery can manage this problem. o Increased susceptibility to infections o Visual impairment from cataracts, squint, myopia (short-sightedness), congenital glaucoma o Increased risk of leukaemia and solid tumours o Hypothyroidism- check yearly o Coeliac’s disease- gluten intolerance- check at 2 years o Epilepsy o Alzheimer’s

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Down’s Syndrome Mrs. Jones is 30 year old woman who has just given birth to a girl with Down’s syndrome. She would like to ask you some questions. I am Mrs Jones and I am 30. Last night my daughter Claire was born and the doctors told me that she has Down’s syndrome. She is my first child. I know little about Down’s syndrome except what these children look like. On my antenatal scan they said that the baby was at risk of Down’s syndrome but I did not want any invasive tests and was hoping for the best. My main questions are; What is Down’s syndrome? Will she live for a long time? How did she get it? Is it my fault? If I have another child will they have Down’s syndrome? Mark Scheme: 1. Appropriate introduction 2. Establishes reason for consultation 3. Congratulate mother on new baby and ask how she is 4. Ask daughter’s name 5. Ascertain what she already knows 6. Explain what Down’s syndrome is a. Common genetic condition. 1 in 1000 people will be born with Down’s syndrome. b. It’s caused by the baby having all or part of an extra 21st chromosome in the body’s cells c. Its not a disease and its not a hereditary condition, it occurs by chance at conception 7. Life expectancy a. The overall outlook for individuals with Down’s syndrome has improved dramatically over the years b. Life expectancy of somebody with Down’s syndrome is now 60-65 years old 8. Will she be healthy? a. Some medical problems are more common in people with Down's syndrome. b. However, none of these problems are unique to Down's syndrome, and some children with Down's syndrome are as fit and healthy as any other children. c. 40-50% will be born with heart problems maybe requiring surgery d. A significant number have sight and hearing impairment e. Some have poorer immune systems, respiratory problems and problems with the gastrointestinal tract f. There are screening programs to look for these conditions that are more common in children with Down’s syndrome 9. Cause a. The cause of the extra chromosome is not fully understood in most cases b. There is no way of predicting whether a person is more or less likely to make and egg or sperm with 24 chromosomes c. There is a definite link with advanced maternal age for reasons yet unknown. d. Most children with Down’s syndrome are born to mothers under 35 years old because at his age women have higher fertility rates 10. Is it my fault? a. What we do know is that no one is to blame. Nothing done before or during pregnancy can cause Down's syndrome. It occurs in all races, social classes and in all countries throughout the world. It can happen to anyone. 11. If I have another child will they have Down’s syndrome? a. Its unlikely b. The chance of having a child with Down’s syndrome only increases with maternal age unless she is in a rare 4% of cases where one of the parents carries a mutation that can cause Down’s syndrome. c. We can test either you and partner or her to see if this is the case the Down’s Syndrome Association 135

Ethics & Law station: Contraception Mr Desmond has come to see you today because he wants to know why his 14 year old daughter came to the doctor yesterday. She will not tell him and doesn’t want him to know. You know that she came in for medication to treat menorrhagia. He also wants you to answer another question. I am Rob Desmond, Sarah’s father; she is 14. I found out yesterday that Sarah came to see a doctor hear yesterday and want to know why. I’m her father and in order to protect her I have a right to know why she was here and if she was given any medication or contraception. The other question I have is regarding Sarah’s step father who is married to her mother. I think he’s considering adopting her and I want to know what my rights would be if that were to happen.

Mark Scheme: 1. 2. 3. 4. 5. 6.

7. 8. 9. 10.

Appropriate introduction (name & role) Establishes reason for consultation Empathetically acknowledges father’s anger & calms him down Find out how he knows and whether Sarah has said she doesn’t want him to know Ask if he knows why Sarah does not want him to know Explain the law a. There is no law that imposes a duty on doctors to disclose information that a young person wants to keep confidential b. However in cases where the child is at risk of neglect or abuse, the Children Act of 1989 imposes a duty to disclose to the Child Protection Service and in Sarah’s case this is thought to not be a worry c. The General Medical Council tells doctors in the UK that a young person’s confidentiality should be respected if the child is competent and not at risk of serious harm or putting others at harm d. By default children under 16 are not presumed to be competent e. Children under 16 can prove to be competent if they show understanding of i. What the treatment is ii. Why it is being proposed iii. Its benefits and risks iv. The consequences of not going through with treatment (Gillick vs HA 1985) Talk to Sarah and let her know that you are worried about her and that she can talk to you if she wants. She can also come back to us to discuss anything she wants. If you currently are the legal father of Sarah you have parental responsibility and the legal right to give consent on behalf of her. A step-parent can apply on their own to adopt If this happens it cuts off the child’s legal relationship with the previous parent that had parental responsibility

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Part 2A 4th year Stations Paediatrics

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Pallor and Fatigue in a young female child You are about to see the mother of a 2 year old girl who has just had her blood tested because of symptoms of pallor and fatigue. Her blood results show a full blood count of 7g/dL with a microcytic, hypochromic anaemia and low serum ferritin. Please explain the results to her and your suggested possible management I am a 32 year old, Emma Devereux. Debbie is a two year old girl who has been feeling tired for the last 4 weeks. She just doesn’t seem to have as much energy as she would previously. She is short of breath when she runs. My cousin mentioned the other day that she looked pale. She drinks 3-4 bottles of milk a day (when asked say cow’s milk). She doesn’t always eat her dinner and doesn’t eat red meat of vegetables. She was born at 36 weeks and was in SCBU for a few weeks just to help her nutrition. There is nobody in the family with any types of anaemia such as sickle cell anaemia or thalassaemia If asked about any questions, ask will she need a blood transfusion? Mark Scheme: 1. 2.

3.

4.

Appropriate introduction Takes a history a. Symptoms: pallor, low energy, breathless, jaundiced, cyanosed? b. Other sx: diarrhoea, vomiting, rash, fever, cough, UTI c. Diet: fussy eater, drinks milk, no dark green veg, no meat, no bread? d. PMHx: renal disease? Prematurity? GI symptoms (malabsorption)? Blood loss? e. FHx: inherited anaemias Explains diagnosis to mother a. Low iron and small cells suggest an iron deficiency anaemia b. This is common in children that drink a lot of cow’s milk Explains management to mother a. Dietary advice: eat red meat, dark green vegetables, bread, pulses b. Take these foods with orange juice (vitamin C) c. Avoid cow’s milk, tea and high fibre foods d. Oral iron supplementation for at least 3 months. i. Sytron (sodium iron edentate) ii. Niferex (polysaccharide iron complex) e. Blood transfusion should NEVER be necessary for dietary iron deficiency

Ideal: 1.

Typical history  Demographic: Afro-carribean, Mediterranean, Indian: keep in mind haemoglobinopathies  Fussy eater, pica, likes drinking milk and not much else, someone comments the child in pale, cannot keep up with other children at school; i.e. PE and during classwork. Generally low energy/lethargy  Sx: pallor, low energy, breathlessness (rare because generally only if acute). Symptoms only occur if the Hb < 7-8.

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NORMAL Hb : 6 months to 6 years = 10.5 – 14 7 – 12 years = 11.0 – 16.0 Things to enquire about: o Any chronic disease i.e. renal, prematurity o GI sx – malabsorption o Blood loss

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o 

O/E o

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Dietary history- iron intake  Watch for excessive milk drinking. Child becomes full up and therefore doesn’t want to eat other foods FHx – inherited disorders

o o o o

Pallor; although not entirely reliable. Look at conjunctiva, palmar creases, palms and soles Tachycardic possibly Jaundice Petechia / bruising Splenomegaly- suggesting haemolysis or marrow failure

o o o o o o o

FBC, red cell indices. Reticulocytes, Pancytopenia, peripheral blood film Serum iron, ferritin, TIBC Coombs’ test Vitamin B12 Hb electrophoresis Red cell enzymes: G6PD, pyruvate kinase BMAx

Ix

Blood results o Microcytic, hypochromic anaemia (low MCV and MCH) o Low serum ferritin

2.

Explaining the blood results  Do wiper etc.  The blood results show that ‘blah’s’ cells are slightly smaller and the value for ferritin which gives us an indication of the iron stores is low.  This point to a most likely diagnosis of iron deficiency anaemia in light of the history of drinking too much milk and not eating a balanced diet.

3.

Dietary stuff:  Elemental iron requirement per day: 1mg/kg/day  DO EAT: red meat (beef lamb), Liver, Kidney, oily fish, pulses, beans, dark green vegetables – broccoli, spinach. Nuts and seeds, breast  AVOID; cow’s milk, tea because tannin inhibits iron uptake, high fibre foods because too much also inhibit iron absorption.

4.

Management:  Dietary advice as above. Vit C or orange juice.  Oral iron supplementation: best tolerated and don’t stain teeth  Sytron (sodium iron edentate)  Niferex (polysaccharide iron complex)  Iron supplementation for 3 months. It takes 3 months to replace it. (Hb should rise 1g/dL per week)  Blood transfusion should NEVER be necessary for dietary iron def.  Iron def with normal Hb (i.e. biochemical evidence showed by low serum ferritin)  Controversial whether to treat – b/c toxicity etc.  Provide dietary advice, offer option of additional treatment with iron supplements

139

OSCE scenario: childhood Anaemia You are about to see the mother of a 2 year old girl who has just had her blood tested because of symptoms of pallor and fatigue. Her blood results show a full blood count of 7g/dL with a microcytic, hypochromic anaemia and low serum ferritin. Please explain the results to her and your suggested possible management. I am a 32 year old, Emma Devereux. Debbie is a two year old girl who has been feeling tired for the last 4 weeks. She just doesn’t seem to have as much energy as she would previously. She is short of breath when she runs. My cousin mentioned the other day that she looked pale. She drinks 3-4 bottles of milk a day (when asked say cow’s milk). She doesn’t always eat her dinner and doesn’t eat red meat of vegetables. She was born at 36 weeks and was in SCBU for a few weeks just to help her nutrition. There is nobody in the family with any types of anaemia such as sickle cell anaemia or thalassaemia Mark Scheme: 1. Appropriate introduction 2. Takes a history a. Symptoms: pallor, low energy, breathlessness, jaundiced, cyanosed? b. Other symptoms: diarrhoea, vomiting, rash, fever, cough c. Diet: fussy eater, drinks milk, dark green vegetables, bread d. PMHx: renal disease? Prematurity? GI symptoms (malabsorption)? Blood loss? e. FHx: inherited anaemia? 3. Explains Explain anaemia to a mother explaining that it is likely to be due to iron deficiency 5. Typical history  Demographic: Afro-carribean, Mediterranean, Indian: keep in mind haemoglobinopathies  Fussy eater, pica, likes drinking milk and not much else, someone comments the child in pale, cannot keep up with other children at school; i.e. PE and during classwork. Generally low energy/lethargy  Sx: pallor, low energy, breathlessness (rare because generally only if acute). Symptoms only occur if the Hb < 7-8.

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NORMAL Hb : 6 months to 6 years = 10.5 – 14 7 – 12 years = 11.0 – 16.0 Things to enquire about: o Any chronic disease i.e. renal, prematurity o GI sx – malabsorption o Blood loss o Dietary history- iron intake  Watch for excessive milk drinking. Child becomes full up and therefore doesn’t want to eat other foods o FHx – inherited disorders O/E o o o o

Pallor; although not entirely reliable. Look at conjunctiva, palmar creases, palms and soles Tachycardic possibly Jaundice Petechia / bruising 140

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o

Splenomegaly- suggesting haemolysis or marrow failure

o o o o o o o

FBC, red cell indices. Reticulocytes, Pancytopenia, peripheral blood film Serum iron, ferritin, TIBC Coombs’ test Vitamin B12 Hb electrophoresis Red cell enzymes: G6PD, pyruvate kinase BMAx

Ix

Blood results o Microcytic, hypochromic anaemia (low MCV and MCH) o Low serum ferritin

6. Explaining the blood results  Do wiper etc.  The blood results show that ‘blah’s’ cells are slightly smaller and the value for ferritin which gives us an indication of the iron stores is low.  This point to a most likely diagnosis of iron deficiency anaemia in light of the history of drinking too much milk and not eating a balanced diet. 7. Dietary stuff:  Elemental iron requirement per day: 1mg/kg/day  DO EAT: red meat (beef lamb), Liver, Kidney, oily fish, pulses, beans, dark green vegetables – broccoli, spinach. Nuts and seeds, breast  AVOID; cow’s milk, tea because tannin inhibits iron uptake, high fibre foods because too much also inhibit iron absorption. 8. Management:  Dietary advice as above. Vit C or orange juice.  Oral iron supplementation: best tolerated and don’t stain teeth  Sytron (sodium iron edentate)  Niferex (polysaccharide iron complex)  Iron supplementation for 3 months. It takes 3 months to replace it. (Hb should rise 1g/dL per week)  Blood transfusion should NEVER be necessary for dietary iron def.  Iron def with normal Hb (i.e. biochemical evidence showed by low serum ferritin)  Controversial whether to treat – b/c toxicity etc.  Provide dietary advice, offer option of additional treatment with iron supplements

141

OSCE Scenario – BRONCHIOLITIS You are a Paediatrics SHO working in the A&E department. Emma is a 4 month old girl who has been brought in by her mother. She complains that Emma has had a runny nose and seems breathless. Take a history with a view to making a diagnosis. Be prepared to discuss management options and differentials. Hi, I am Jane Foster. I am a housewife who takes care of my two children. Emma has had this flu for the last few days and has not really been feeling well. She has a cough, which just sounds like a normal cough and she is wheezy; she is not bringing up any phlegm. She looks like she is struggling with breathing and looks like she’s breathing faster than normal. She has not stopped breathing at any time. She is not eating as well as she usually does and has had a slight fever over the last two days (38.5 degrees). She has had all her immunisations and had a wet nappy this morning. She has just started grabbing or reaching for food so I have been letting her eat finger food. She drinks aptamil formula milk, around a 2 bottles a day. She has not had any diarrhoea. Emma was born vaginally at 38+6 weeks and weight 7lbs 4 oz. There are no concerns with her neurodevelopment. She is smiling and making cooing noises. She just started to roll and sit up ed over the last a few days. No previous hospital issions or ITU stays. She has not has this before. My cousin’s son came over 5 days ago and he was also a bit snotty and had a cough. I am worried because of her difficult breathing. Mark Scheme: 1. Appropriate introduction 2. Establishes nature of problem 3. Takes comprehensive history of illness a. Cough: Onset, duration, when in the day, sputum? b. Shortness of breath: wheeze, increased respiratory rate, apnoea? c. Other symptoms: fever, diarrhoea, ear ache, drinking and eating? d. Dehydration: wetting nappies, soiling nappies, change in eyes? 4. Takes comprehensive history of the neonatal period a. Gestation? b. Method of delivery? c. Complications in pregnancy? d. ission to ITU? 5. Takes full background history – developmental and PMH 1. Drug history – asks about immunisations, medications and allergies 6. Asks about family history of childhood respiratory infections or currently infected s 7. Checks correct information with mother 8. Takes history in an empathic manner 9. Does all in a fluent and professional manner.

1. Typical History  Age: aged between 1 – 9 months  Typically causes winter epidemics  Spread: typically epidemic by with respiratory secretions  Sx: too breathless to feed, coryza, breathless, slight fever, characteristic dry/moist cough, apnoeic episodes but otherwise well no signs of sepsis  Signs: tachypnoea > 50, fever (38.5 – 39 degrees), nasal flaring, subcostal and intercostals recession, chest hyperinflation, B/L fine crackles, WHEEZE on auscultation, cyanosis if severe. 142

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Use of accessory muscles and expiratory grunting. Liver palpable because of hyperinflation of lungs with depression of diaphragm. Apnoea: prems, infants < 6 wks, chronic lung or heart disease more likely to be severe Causes: RSV (adenovirus, rhinovirus, parainfluenza, metapneumovirus)

2. Investigations  FBC, U&E, CRP, ESR  Septic screen: NPA (direct fluorescent testing), Urine dipstick (perhaps culture)  CXR: hyperinflation and patchy infiltrates  Apnoea monitor  Pulse oximeter/Sats 3. Management  Hx and Ex  Check ABC  it? i. Mild – Feeding well, RR<40bpm, minimal recession and O2>92% = HOME ii. IT – Difficulty feeding, moderate tachypnoea > 40bpm, marked recession and 02 sats < 92% RA.  Isolate with barrier nursing to prevent spread because RSV is very infectious  ive treatment: hydrate using NG tubes (tube blocks off nasal airways and stomach full of milk may splint the diaphragm and exacerbate dyspnoea) or IV. Treat hypoxia with humified oxygen via nasal cannulae or headbox.  Sometimes may need assisted ventilation  No steroids, antibiotics (only if secondary infection or indicated by rapid deterioration), bronchodilators sometimes used but not thought to have much effect.  Palivizumab (mAb) – for high risk patients to prevent bronchiolitis or reduce the severity of it. 4. Prognosis  Most cases resolve in two weeks - 50% of continue to have cough etc for a few years. A subset of children may go on to develop asthma. 5. Differentials  Pneumonia ; look more unwell, CXR showing consolidation (+ parapnemonic effusion or empyema) , end-inspiratory coarse crackles. Poor feeding, cough, lethargy and cyanosis. Decrease O2 sats  Transient early wheezing; with viral infections, increased risk in preterm and maternal smoking  Atopic asthma – recurrent wheezing, eczema and positive FHx  Non-atopic wheezing – following viral LRTI, increased wheezing during the first 10 years of life  Cardiac failure: respiratory distress, HPM, heat murmur  Inhaled foreign body  Cystic fibrosis  Whooping cough, Croup (typically sealion like barking cough and stridor)

143

Child UTI You are a paediatric SHO and have been asked to talk to Mary Wiseman, a 21 year old woman, whose son is being investigated; your consultant suspects that he has a urinary tract infection. Please explain the diagnosis to her, investigations required and your suggested management. My son Darren is 7 months old and has symptoms of fever of 39C and poor feeding, he’s also been sick twice today and is not wetting his nappies. The doctor says that he thinks Darren might have a UTI and needs to be investigated. Please tell me what you’re going to do next I’m interested in knowing how he got it and if it’s treatable and any long term effects. I also would like to know how to prevent it from happening in the future. He has never had a UTI before. Mark scheme: 13. 14. 15. 16.

17.

18.

19.

20. 21. 22. 23.

Appropriate introduction (full name and role) Establishes reason for consultation Clarifies symptoms with the parent Explains test to parent a. Urine required for dipstick and MC+S b. Clean catch urine preferred c. Urine collection bag as alternative Explains management a. Trimethoprim for 7-10 days (possibly I.V cefalexin for the first 4 days if oral medication not possible) (if UTI is confirmed in a child over 3 months with a fever of <38C then lower UTI treatment is trimethoprim for 3 days) Explains that urinary tract infections in boys are rare and risk factors a. Vesico-ureteric reflux b. Obstructive uropathies (urethral valves) c. Neuropathic bladder d. Dysfunctional elimination syndrome e. Habitual infrequent voiding of urine Explains the need to investigate following resolution of UTI a. 5-15% of children can develop scarring after their first UTI b. After the infection has been treated, if it turns out to be a difficult UTI or because he is a boy he may have an ultrasound scan c. Depending on the results of the ultrasound can we may give him antibiotics for 3 months to prevent further infection until we investigate him with an MCUG in 3 months time Give leaflet regarding UTI Checks correct information with parent Takes history in an empathic manner Does all in a fluent and professional manner.

144

Crohn’s disease history You have been asked to take a history from Mrs Butcher about her son’s recent gastro-intestinal illness. I am the mother of Jacob who is 14 years old. For the last 3 months he has been feeling really tired and terrible with abdominal pain, diarrhoea and weight loss. He has had a constant fever for the last 2 months. The pain is aching in type in the bottom right corner of his belly and he writhes around in pain when he gets it. It is not related to meal times and nothing makes it better. The diarrhoea comes for weeks at a time and contains mucus sometimes. No vomiting. No foreign travel. Immunisations all done. He takes no medications and has no allergies. My mother had Crohn’s disease and her brother had inflammatory bowel disease. He’s short and looks young for his age and has little hair on his body. Jacob lives with me and his two younger sisters who are both healthy. I am a single mother, he does not know his father. Mark scheme: 2. Appropriate introduction (full name and role) 3. Establishes nature of problem 4. Takes comprehensive history of illness a. Length of symptoms b. Lethargy c. Abdominal pain d. Diarrhoea - mucus or blood? e. Weight loss – how much? Over how long? f. Other symptoms? Fever, cough, urinary problems? g. Dehydration? Wetting nappies, soiling nappies, change in eyes? 5. Takes PMH 6. Drug history 7. Identifies family history of inflammatory bowel disease – asks age of dx 8. Identifies developmental history of poor growth and delayed puberty 9. Checks information is correct with mother 10. Identifies patients ideas, concerns, expectations 11. Takes history in an empathic manner 12. Does all in a fluent and professional manner. Discussion; ΔΔ, History, investigations & treatment Hi Please summarise the history you took. What do you think the diagnosis is? Crohn’s disease What in the history made you think that? Family history, chronic weight loss and diarrhoea, abdominal pain and mucus but no blood in stool 145

OK, what are the differentials of this history?  Ulcerative colitis  Irritable bowel syndrome  GI malignancy  Anorexia nervosa  Coeliac Disease  Chronic GI infection (Giardia, campylobacter)  UTI? What investigations would you carry out?  Examination  Blood tests – FBC, CRP, ESR, U+Es (diarrhoea and malabsorption), LFTs (associated hepatitis)  Plain AXR (sacro-ileitis & skip lesions)  Small bowel contrast study  Large bowel enema  CT scanning (for inflammatory masses or abscesses)  USS (abscess detection)  Bone age (may be 2 or more years less than normal)  Endoscopy, colonoscopy with biopsy (full thickness inflammation, non-caseating granulomata, fissuring, ulceration, erosions)  Faecal culture  Urine dipstick? How would you manage this child? 1. Explanation of condition to child and mother 2. Lifestyle advice  There are no specific foods that have to be avoided  In some, low residue diet, e.g. avoid veg & brown bread  Low fat diets 3. Induce remission  Elemental feed  5-ASA  Prednisolone, azathioprine, cyclosporine  Antibiotics (if anal involvement – metronidazole)  Infliximab 4. Reduce growth failure

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Ethics & Law station: Stopping Treatment Antonia, a 14 year old girl with acute myeloid leukaemia, has been receiving chemotherapy for the last year and now wants to stop receiving treatment. Her mother has asked to talk to you about this. I am Joanne, Antonia’s mother. Antonia has been receiving chemotherapy for the last year and a yesterday told the nurses and then me that she intends to stop having her treatment from now on. Antonia is refusing treatment because she says it makes her feel terrible, she is sick and feels nauseous every day and is getting depressed because her hair is falling out. I want her to have the treatment and I want to know if there is anything in the law regarding this and whether I can make her have the treatment. I am a single parent with no input from Antonia’s father Mark Scheme: 11. Appropriate introduction (name & role) 12. Establishes reason for consultation 13. Empathetically acknowledges mother’s grief 14. Find out why Antonia has refused treatment 15. Discuss whether her mother wants her to have the treatment 16. Asks about family 17. Explain the law a. Children under 16 are presumed not to be competent b. Children under 16 can prove to be competent if they show understanding of i. What the treatment is ii. Why it is being proposed iii. Its benefits and risks iv. The consequences of not going through with treatment (Gillick vs HA 1985) c. Young people that are competent can consent to medical treatment (Family Law Reform Act 1969) but they are not able to refuse treatment if consent is given by their parents. d. Courts can give consent when parents refuse e. Doctor may treat in cases of emergency (Defence of necessity) 18. Include Antonia in the decision making process 19. Bottom line – if she still refuses despite discussion, her mother can consent and treatment would go ahead. Ideal: 1. Introduction 2. I’ve been told you want to talk about your daughter’s treatment 3. I understand this is a very difficult situation for you 4. Has your daughter told you why she is refusing treatment? 5. Can I take it that you want her to have the treatment? 6. I just want to explain that being under 16, Antonia is presumed not to be competent to make decisions regarding consenting to treatment. She can show competence if she proves to us that she understands 147

what the treatment is, why it is proposed, its benefits and risks, and the consequences of not proceeding with it. But although competent minors were given the ability to consent to treatment by the Family Law Reform Act (1969), it did not take away the ability of those with parental responsibility to give consent on their behalf. 7. In essence, because Antonia is refusing treatment it’s very important that we discuss this decision with her, help her understand it and try to convince her against it but if she still refuses, you can override her decision and give consent for her.

148

Explain eczema treatment to a father You are a 5th year medical student and have been asked to speak to Mr Foster whose daughter, 2 year old Lisa, is being treated for eczema. I am Mr Foster, a 42 year old father of one. My daughter Lisa has eczema which makes her itch and scratch her inner elbows and torso to the point where she can make her skin bleed. I’m very angry because my daughter was diagnosed a year ago and still her skin is so bad that she hurts herself scratching it and it looks really itchy. We’ve been given so many creams and ointments and none of them are working! We no longer use soap or bubble bath and use aqueous cream as a substitute. We also have an emollient lotion which we use once a day. I was given hydrocortisone cream to put on her skin which I used for about 4 days; it made a tiny difference but hardly and I searched it on the internet and it’s a steroid! I know they have side effects like thinning the skin and causing infections and weight gain so we use it once a week. We can’t think of any irritants in the house making her eczema worse, we don’t have any pets. There is a history of asthma and eczema in my family on my mother’s side but not in my wife’s family. Mark Scheme: 13. 14. 15. 16.

17. 18. 19.

20. 21. 22. 23. 24. 25.

Appropriate introduction (full name and role) Establishes nature of problem Allows the patient to calm down Takes a brief history of the illness a. Duration of symptoms b. Distribution of eczema c. Measures / medications tried Reassure that symptoms are most severe in the first year of life and 50% will resolve by age 12 and 75% by age 16. Stress importance of adequate treatment. Advise on general measures of eczema management a. Avoid irritants & trigger factors b. Avoid soaps & bubble baths c. Loose fitting, pure cotton clothes d. Rinse clothes after washing with detergents e. Avoid extremes of hot and cold f. Cut finger nails short regularly to decrease damage from scratching Reaffirms use of frequent emollients Elicits and listens to patient’s concerns about corticosteroid use Advise regarding strength of steroid, method of application etc. Checks correct information and understanding with father Takes history in an empathic manner Does all in a fluent and professional manner.

General measures:  Stop scratching; histamines at night, mittens in the day

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Loose cotton clothing Avoid perfumed soaps and moisturisers etc.

Importance of skin care  Skin acts as a barrier; keeps infections out and heat in.

150

Faecal Soiling Please take a history from the mother of Richard Ramsey, a 5 year old boy, who is soiling his underwear I am Lynn, the mother of 5 year old Richard. For the last month he has been soiling his underwear. At first it seemed as if he was just not wiping his bottom properly because there was some diarrhoea in his pants but now some days his underwear is just full of poo. He says he doesn’t realise when he needs to go. It happens at home but at school as his nursery as well and his teacher says he gets very embarrassed, I now send him with a spare pair of underwear. It doesn’t happen at any particular time during the day, just randomly. His bowel movements are not painful and he has no other problems. His diet isn’t too bad, he likes pasta and meat and white bread but he doesn’t like drinking that much. He has had no medical problems before this and never had any operations and doesn’t take any medication. It’s getting silly now; my husband tells him off, its obviously not helping but he thinks that Richard is just being lazy. He originally stopped soiling his nappy just before he turned 3 years old. It has been a bit stressful for me as well because I’ve just had another baby and she cries all the time and the problems with Richard make me lose my temper sometimes. If asked – He doesn’t go to the toilet much anyway but I suppose he was going to the toilet even less before this all started happening. Mark Scheme: 26. Appropriate introduction (full name and role) 27. Establishes nature of problem 28. Takes comprehensive history a. Start, frequency, faeces or diarrhoea? b. Constipated recently? c. Situation of occurrence – at home or school? d. In relation to play activities? e. Severity of incontinence f. Painful bowel movements? Abdominal pain? Tightening of buttocks? 29. Diet history 30. Associated – Fever? Rash? Vomiting? 31. Stooling pattern from birth up to present 32. PMHx – anorectal, neurological or spinal abnormalities 33. PSHx 34. Drug history 35. Psychological functioning a. How do you get along with your child? b. Do you punish him when he soils himself? c. Do you find yourself punishing this child more than your others? 151

36. Checks correct information with mother 37. Takes history in an empathic manner 38. Does all in a fluent and professional manner. Discussion; ΔΔ, History, investigations & treatment Please summarise the history you took. What do you think the diagnosis is? Faecal soiling due to retention and overflow incontinence What in the history made you think that? Soiling started as liquid stool and then started filling his underwear, child is unaware of the need to defecate, initial history of bowels not emptying regularly, doesn’t drink a lot, poor diet. OK, what are the differentials of this history?  Retentive encopresis o Environmental problems – lack of toilet facilities, harsh toilet training o Idiopathic – poor coordination with anal sphincter relaxation o Transient constipation – due to dehydration or anal fissure o Organic constipation – Hirschsprung’s disease, drugs or hypothyroidism  Non-retentive encopresis o Neurogenic sphincter disturbance o Psychiatric illness  Gastroenteritis What investigations would you carry out?  Examination o neurological system and abdomen o rectal exam or abdominal palpation to determine whether there is faecal retention o Stool sample How would you manage this child?  Stool softener + laxative or enema to empty the rectum asap  Regular laxatives  Star charts  Sitting on the toilet after meals  Dietary changes: increased fibre  ?picosulphate (stronger) or movicol (weaker)

152

Faecal Soiling 2 Please take a history from the mother of Richard Ramsey, a 5 year old boy, who is soiling his underwear I am Lynn, the mother of 5 year old Richard. For the last month he has been soiling his underwear. At first it seemed as if he was just not wiping his bottom properly because there was some diarrhoea in his pants but now some days his underwear is just full of poo. He says he doesn’t realise when he needs to go. It happens at home but at school as his nursery as well and his teacher says he gets very embarrassed, I now send him with a spare pair of underwear. It doesn’t happen at any particular time during the day, just randomly. His bowel movements are not painful and he has no other problems. His diet isn’t too bad, he likes pasta and meat and white bread but he doesn’t like drinking that much. He has had no medical problems before this and never had any operations and doesn’t take any medication. It’s getting silly now; my husband tells him off, its obviously not helping but he thinks that Richard is just being lazy. He originally stopped soiling his nappy just before he turned 3 years old. It has been a bit stressful for me as well because I’ve just had another baby and she cries all the time and the problems with Richard make me lose my temper sometimes. If asked – He doesn’t go to the toilet much anyway but I suppose he was going to the toilet even less before this all started happening. Mark Scheme: 39. Appropriate introduction (full name and role) 40. Establishes nature of problem 41. Takes comprehensive history a. Start, frequency, faeces or diarrhoea? b. Constipated recently? c. Situation of occurrence – at home or school? d. In relation to play activities? e. Severity of incontinence f. Painful bowel movements? Abdominal pain? Tightening of buttocks? 42. Diet history 43. Associated – Fever? Rash? Vomiting? 44. Stooling pattern from birth up to present 45. PMHx – anorectal, neurological or spinal abnormalities 46. PSHx 47. Drug history 48. Psychological functioning a. How do you get along with your child? b. Do you punish him when he soils himself? c. Do you find yourself punishing this child more than your others? 153

49. Checks correct information with mother 50. Takes history in an empathic manner 51. Does all in a fluent and professional manner. Discussion; ΔΔ, History, investigations & treatment Hi Please summarise the history you took. What do you think the diagnosis is? Faecal soiling due to retention and overflow incontinence What in the history made you think that? Soiling started as liquid stool and then started filling his underwear, child is unaware of the need to defecate, initial history of bowels not emptying regularly, doesn’t drink a lot, poor diet. OK, what are the differentials of this history?  Retentive encopresis o Environmental problems – lack of toilet facilities, harsh toilet training o Idiopathic – poor coordination with anal sphincter relaxation o Transient constipation – due to dehydration or anal fissure o Organic constipation – Hirschsprung’s disease, drugs or hypothyroidism  Non-retentive encopresis o Neurogenic sphincter disturbance o Psychiatric illness  Gastroenteritis What investigations would you carry out?  Examination o neurological system and abdomen o rectal exam or abdominal palpation to determine whether there is faecal retention o Stool sample How would you manage this child?  Stool softener + laxative or enema to empty the rectum asap  Regular laxatives  Star charts  Sitting on the toilet after meals  Dietary changes: increased fibre  ?picosulphate (stronger) or movicol (weaker)

154

Febrile convulsions I’m Mrs Wright and my 3 year old daughter just had a ‘febrile convulsion’. This was her first febrile convulsion. It lasted for 6 minutes. Her whole body shook. She only had one convulsion.

I want to know; Is it epilepsy? And could she get epilepsy? Will it happen again? Can I prevent it from happening again? What should I do if another convulsion occurs

Mark Scheme: 34. 35. 36. 37.

38.

39.

40.

41.

42.

Appropriate Introduction I’m sorry to hear that your daughter had a convulsion, it must have been very scary. Mention that seizures are very common (1 in 30 children) Is it epilepsy? a. Explain febrile convulsions b. Simple febrile seizures do not cause brain damage c. 1-2% chance of developing epilepsy (same as rest of the population) d. If complex; 4-12% chance of developing epilepsy Will it happen again: About 1 in 3 have a recurrence. a. More likely if there’s a family history b. Or if the first convulsion happened at a very young age Preventing further convulsions a. Fever control i. Tepid sponging ii. Cold drinks iii. Calpol/paracetomol OR ibuprofen iv. Not too many clothes What should I do if it happens again a. Child in recovery position b. Can be given rectal diazepam if the seizure lasts > 5 mins. Ask brief history a. First convulsion? b. How old is the child? c. More than one convulsion? d. How long did it last? (if over 20 mins) e. Partial? Did her whole body shake or just one side? Asks family history of febrile convulsions 155

a. If yes; did they go on to develop epilepsy? 43. Family history of epilepsy?

156

OSCE Scenario: Abdominal Pains and Diarrhoea: Paediatrics You are an SHO in Paediatrics. Mr Lissauer has brought in his 7 year old son Mosby who is complaining of abdominal pains and diarrhoea. Please take a full history with a view to making a diagnosis. My son Mosby has been complaining of abdominal pain and diarrhoea since midday yesterday. He says it is quite painful and he has been having cramping sensations in his tummy (lower part and generalised). He also vomited twice altogether. The abdominal cramping comes and goes and grades it at 7/10. He has been to the toilet several times already this morning and it is still very watery. There has been some blood but I don’t think there has been any mucus. There was probably two to three table spoon fulls of blood in the stool and it was fresh i.e. red. The stool is not bulky or pale and does not smell too bad. It has not been difficult to flush. He has not sustained any trauma to the abdomen. The vomit is clearish and does not contain any blood/mucus/bile. This has not ever happened before. He is up to date with his immunisations. He does not have a rash and has not been for a ‘wee’ since yesterday that I . I checked his temperature this morning and it was 38 degrees. He also appears less energetic and slightly drowsy today. I think it may have been triggered by what we ate yesterday. We had gone to have lunch at an Indian restaurant in Bethnal Green. He had the chicken tikka. We have been trying to keep up his oral intake, but he has not managed to eat much, only a slice of toast. He has probably only managed a glass of water since last night. He is not usually picky and eats everything include bread, wheat and cows milk. There is no FHx of any similar problems and no one else in the home has been affected. He does not have any developmental concerns, any significant antenatal/ perinatal history. PMHx, DHx. We are currently living in a home in Mile End. His mother and I are getting on well and we are all happy. We are concerned for him. Will he be okay? Diagnosis: GASTROENTERITIS, probably organisms Salmonella, Campylobacter, Bacillus cereus. Markscheme 1. Washes Hands 2. Appropriate introduction 3. Establishes reason for visit 4. Takes a comprehensive history including: a. History of presenting complaint b. Duration of illness and frequency of diarrhoea c. Asks specific details of diarrhoea and vomiting; i.e. constituents d. Associated symptoms: vomiting, GCS, tenesmus, fever, headache, feeding, excretion and micturition. e. Travel history f. Inquires about antenatal, perinatal, immunisations, DHx, FHx, SHx 5. Tries to exclude any differentials: a. Intussusception: redcurrant jelly stool (empty rectum), pulling up legs b. Acute appendicitis c. Mesenteric adenitis 157

6. 7. 8. 9. 10. 11.

d. IBD e. Malabsorption diarrhoea: loose bulky stools, difficult to flush, very smelly. i. Causes CF or Pancreatitis, Coeliacs disease (gluten in diet previously) f. Food intolerance: Lactose intolerance/ Cow’s, milk protein intolerance g. Others: Addresses parental concerns Asks about ICE Summarises the history Any questions? Thanks the patient Washes hand

Questions for the following station - Summarise the history -

What do you think is the diagnosis? Gastroenteritis: Campylobacter jejuni/ Salmonella enteritidis

-

What are the differentials for abdominal pain and diarrhoea? o Intussusception - abdo pain, not diarrhoea, occurs in 2 months – 2 years (peaks 6-9months). No abdo distension (sausage shaped mass) o Acute appendicitis – would cause abdo pain central to RIF, vomiting perhaps and temp. Not colicky however. No signs of peritonism, pain not worse on movement (more likely to perforate) o Mesenteric adenitis – Probably more a diff for appendicitis, no Hx of previous viral infection. Abdo pain resolves within 24-48hrs. o IBD: causes bloody diarrhoea and abdo pain. No previous GI history or FHx. No systemic signs: clubbing, erythema nodosum, uveitis, arthritis. Pyoderma gangrenosum. Good growth and no FTT. o Malabsorption: would cause diarrhoea and possibly abdominal pain. Though probably not crampy. No Hx; abdominal distension, frequent respiratory infections, gluten sensitivity or lactose intolerance. o UTI o SEPSIS o TRAUMA How would you investigate and manage this patient? o ABC: perhaps establish some IV access because likely to need fluids. o Clinical history and examination: Assess degree of dehydration o O/E: Raised temperature, drowsy, reduced tissue turgor, dry mucous membranes, reduced tears, cap refill > 2s, reduce UO, tachycardia and possibly tachycardic, Normal BP. o Ix:  Bloods: FBC, U&E, CRP, blood cultures?  Urine: dipstick and culture  Stool: MC&S and viral antigen testing  Weight  AXR – if no improvement o Mx

-

158

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 



Rehydrate: 20ml/kg 0.9% saline (repeat if no effect), further rehydration according to whether this is hypernatraemic of hypo/iso natremic dehydration. Likely to be hypo/iso. Correct defecit + maintainence – bolus over 24 hrs. Using 0.45 % saline and 2.5% dextrose. Monitor: Fluid balance, weight, plasma creatinine and electrolytes, cardio status clinically. Check for overload or pulmonary oedema precipated by ARF secondary to hypovolemia. Antibiotics:  Campylobacter – usually self limited, treat severe: macrolide, ciprofloxacin  Salmonella – “ “ : ciprofloxacin, cefotaxime  Normal gastroenteritis does not treatment Advise parents about:  Post-gastroenteritis syndrome: transient lactose intolerance precipitates further diarrhoea after introduction of normal diet. Multiple intolerances.  Post-infective IBS

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5. a.

??

Head Circumference Please measure this baby’s head circumference and plot it on the growth chart. Mark Scheme: 1. Introduction with name & role 2. Explain to parents what you are going to do a. Measure baby’s head to assess growth b. Approach child from the side 3. Using a cotton tape measure measure anteriorly between hairline + glabella and the occipital prominence postteriorly. 4. Measure 3 times and use the largest measurement 5. Plot on age and sex appropriate chart with a dot. a. Correct for gestational age 6. Ask for previous head measurements from examiner to define trend 7. Check weight and height of child and plot 8. Check head circumference of biology parents 9. Enquire about neurodevelopment of child 10. Neurological examination 11. Look for dysmorphic features and neurocutaneous stigmata 12. Head shape 13. Check the fontanelles and sutures 14. Enquire about signs of increased intra-cranial pressure 15. Ask about pregnancy history Normal growth At birth: 2 months: 4 months: 6 months: 8 months: 10 months: 12 months:

35cm 39cm 42cm 44cm 45cm 46cm 47cm

2 years: 48cm 3 years: 49cm 4 years: 50cm 5 years: 51cm From 5 years onwards head growth progresses at 0.5cm per year until final circumference Adult female mean = 55cm Adult male mean = 56cm 160

Causes of abnormal head circumference Macrocephaly:  normal variation or familial trait  Hydrocephalus (I, bulging fontanelles, sun-setting of the eyes) o Communicating  Meningitis  Sub-arachnoid haemorrhage o Non-communicating  Posterior fossa tumour  Arnold-chiari malformation  Aqueduct stenosis  Inter-ventricular haemorrhage  Hypothyroidism  Rickets  AV malformation  Brain tumour  Subdural haematoma  Neurocutaneous conditions  disproportionate growth in chronic conditions, for example achondroplasia, sickle cell anaemia, rickets, failure to thrive Microcephaly:  Normal variant  Congenital infection  Craniosynostosis  Metabolic abnormality e.g. maternal PKU

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Childhood Asthma Hx of asthma of child from mum. Explain Mx to child. Hx 1.            2.   3.   

HPC How well-controlled is it? Symptoms worsening/improving/the same? Wheeze Cough- worse at night? Productive (if so, colour and amount)? Haemoptysis? SOB Chest pain Fever Frequency of symptoms Precipitating factors- cold, exercise, pets, etc How much school has been missed due to the asthma? Are sport and general activities affected by the asthma? How severe are interval symptoms between exacerbations? PMHx Any previous hospital issions? How were they managed in hospital? Ever been ventilated? FHx Atopy? (asthma, hayfever, eczema, allergic conjunctivitis) Smokers in the family Pets at home?

4. DHx  How is the asthma being managed at the moment? a. Medication b. Frequency c. Method of istration (inhaler, spacer?) d. PEFR Explaining Mx to child 1. Check child’s understanding of their condition  Asthma is a very common illness which affects the lungs and airways. When a person with asthma comes into with something that irritates their airways (an asthma trigger), the muscles around the walls of the airways tighten so that the airways become narrower and the lining of the airways becomes inflamed and starts to swell. Sometimes sticky mucus or phlegm builds up which can further narrow the airways. 2. Explain Mx (‘step ladder’)  Avoid precipitants  Step 1. Start with blue inhaler (short acting B agonist-salbutamol)- this is a ‘reliever’, taken whenever symptoms flare up  Step 2. Add brown inhaler (inhaled steroid- beclometasone)- taken regularly to prevent symptoms from occurring  Steps 3-5 (other inhalers and/or medication) 3. Check child knows how to use inhaler  If not, demonstrate inhaler technique, and see if child can copy it correctly

162

 5.   

Or, suggest use of a spacer device (and show how to use this first) We check that medication is working by keeping a peak flow diary Have you ever used this before? If not, demonstrate how to do this, and get the child to repeat Tell child to keep a diary of recordings in the mornings and evenings, to see if new medication regime is effective in controlling asthma

163

Childhood Vaccination How is the DTaP/IPV/Hib vaccine different from the previous primary vaccinations? 

The polio vaccine does not contain a live virus, so it no longer carries the slight risk of causing vaccineassociated paralytic polio. The vaccine uses inactivated polio vaccine (IPV) instead of live oral vaccine. 'Inactivated' means that the viruses contained in the vaccine have been killed, so that they can't harm you.



The vaccine causes fewer minor reactions



There is no thiomersal (mercury) in the vaccine, which would have a small risk of producing allergic skin reactions



The vaccine uses acellular pertussis vaccine instead of whole-cell pertussis vaccine

How and when is the vaccine given? This vaccine is given intramuscularly (by injection into the muscle) in a dose of 0.5ml. It should not be given intravenously (by injection into the vein). Why does my child need three doses of the vaccination? Three doses are given to make sure that your child's body can develop a good immune response to the disease. The gap between these different doses of vaccines is to make sure that each dose has time to work. Every time another dose of the vaccine is given the body's immune response is boosted. What side effects might I see after the immunisation? Your child may get some of the following side effects within 12 to 24 hours of the vaccine being given: 

a fever



a slightly raised temperature



some sickness and/or diarrhoea



a small lump at the site the injection, which may last for a few weeks.



your baby may be miserable within 48 hours of having the injection.

Up to one in ten children may get some swelling and redness at the site of the injection. Very rarely (in less than 1 in 1000 children), a day or two after they have received this vaccine some babies have 

experienced febrile convulsions (fits)



had very high temperatures



been floppy and less responsive than usual



cries an unusual, high-pitched cry.

If your baby has a fit, call your doctor immediately. 164

Babies usually recover from fits quickly and completely. that young babies can have fits at any time, so if they have a fit after their immunisation, it is not necessarily linked to the vaccine. Do not delay the immunisation - this can increase the chances of babies experiencing fits. It's important to make sure your child gets vaccinated at the right age. As with all vaccines there is a rare possibility of DTaP/IPV/Hib causing anaphylaxis. If you think your child has had any reaction to the DTaP/IPV/Hib vaccine that you are concerned about, then talk to your doctor, nurse or health visitor. Are there any of groups of children for whom particular care is needed? If your child has had any of the following conditions after being given a dose of a vaccine containing pertussis (whooping cough), talk to your doctor, nurse or health visitor before giving them further immunisations: 

A serious allergic reaction to a previous dose of the vaccine. Your doctor, nurse or health visitor may want to give the vaccine in a special clinic. This vaccine should not be given to children who have had an anaphylactic reaction to a previous dose.



Febrile convulsions (fits) within 72 hours of a previous dose of vaccine or a history of convulsions. Your doctor, nurse or health visitor may want to give your child some preventative treatment for fever.

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MMR Vaccination Please talk to Serena Campbell who is the mother of Jack who is an 11 month old boy. She has heard bad things about the MMR vaccine and wants information about it. 



   

What does the MMR vaccine protect against? o Measles (causes deafness & brain damage & death) o Mumps (hospitalisation and death) o Rubella (congenital anomalies) o It is the safest way to protect against these diseases Why should he have it? o If children are not protected against measles, mumps and rubella, we run the risk of new epidemics. o This means not just measles outbreaks, but the return of babies born with terrible defects from congenital rubella syndrome (CRS), or children hospitalised or becoming deaf from mumps. Is it not true that getting the diseases naturally is better at giving protection than the vaccine? o No. The vaccine provides very good protection and the diseases can lead to the terrible consequences Is giving 3 separate immunisations better? o No country in the world recommends giving MMR vaccine as 3 separate injections o Giving them separately leaves the child vulnerable There was a study that said it causes autism o There is no link between the MMR and autism. There are numerous studies that this. o The study suggesting a link found no proof of a link and has since been withdrawn anyway I’ve heard the vaccine wasn’t tested properly o The normal procedure for licensing was used for MMR and the vaccine was thoroughly tested before being introduced into the UK in 1988

Anaphylaxis questions 





What is anaphylaxis o Anaphylaxis (also known as anaphylactic shock) is an allergic condition that can be severe and potentially fatal. o Anaphylaxis is your body's immune system reacting badly to a substance (an allergen), such as food, which it wrongly perceives as a threat. o The whole body can be affected, usually within minutes of with an allergen, though sometimes the reaction can happen hours later. What are the symptoms? o The symptoms of anaphylaxis usually start between three and 60 minutes after with the allergen. Less commonly, they can occur a few hours or even days after . o When you have an anaphylactic reaction, you may feel unwell or dizzy or may faint because of a sudden drop in blood pressure. o Narrowing of the airways can also occur at the same time, with or without the drop in blood pressure. This can cause breathing difficulties and wheezing. Anaphylaxis varies in severity. Sometimes it causes only mild itchiness and swelling, but in some people it can cause sudden death. 166

o



Anaphylaxis can lead to death if breathing becomes severely obstructed or if blood pressure becomes extremely low (known as shock). What’s the cause?

Anaphylactic shock occurs because your body's immune system overreacts in response to a particular substance (allergen) that you have been exposed to before (see the box, right). When the allergen gets into your bloodstream, it causes the body to release massive amounts of the protein histamine and other chemicals. Histamine causes: 

blood vessels to widen, leading to a sudden severe lowering of blood pressure and narrowing of the airways in the lungs, and



blood vessels to leak, causing swelling (oedema) in the surrounding tissues and a further drop in blood pressure.



Treatment:

Anaphylaxis should always be treated as a medical emergency. It can be fatal unless immediate treatment is available.

Severe cases If someone becomes severely ill or collapses soon after an insect bite, eating a particular food or taking medication, call for an ambulance and tell the operator that you think the person has anaphylaxis. Remove the trigger (allergen) if possible. Adrenaline An adrenaline injection (epinephrine) must be given as soon as a serious reaction is suspected. If the person is carrying an adrenaline injection kit, they may be able to inject themselves (see the box, right) or you can help them to use it. If there is no improvement within five to 10 minutes, a second injection may be needed until the condition improves. Recovery normally occurs fairly quickly once adrenaline has been received (see the box, left).

First aid advice 1. If the person is having difficulty breathing, help them to sit up. 2. If they have low blood pressure, get them to lie flat and raise their legs. 3. If they are unconscious, check their airways are open and clear and check their breathing. Then put them in the recovery position (see below). Putting someone who is unconscious in the recovery position ensures that they do not choke on their vomit. Place the person on their side, ensuring that they are ed by one leg and one arm. Open the airway by tilting the head and lifting the chin. If the person's breathing or heart stops, cardiopulmonary resuscitation (R) should be performed. See Useful links for a guide on how to perform R. ission to hospital 1. 2. 3. 4. 5.

Even if adrenaline is given, the person will probably need to be itted to hospital for observation for up to 24 hours as occasionally the symptoms can return a few hours later. An antihistamine or corticosteroid injection may be given, sometimes with fluids through an intravenous drip. The person will be advised to avoid any substance to which they are sensitive, especially if they have had a previous anaphylactic reaction. Adrenaline will be prescribed for future emergencies, so the person can inject themselves with adrenaline from a preloaded syringe (see the box, right). The person should also carry an emergency card or bracelet with full details of their allergy and details of their doctor, to alert others.

167

6.

The person will be advised to arrange a follow-up visit with their GP.

Mild cases If the person has had a mild reaction with only skin symptoms (itchiness or a rash), adrenaline may not be necessary and they may just need antihistamines and steroids. The allergen should be removed if possible. All cases of anaphylaxis should be treated as an emergency. Even in mild cases, an ambulance should be called so the person can get immediate medical attention.

o

168

Neonatal Examination Please explain to me how you would conduct a full neonatal examination on a newborn. Mark Scheme: 1. Appropriate introduction 2. Explains what is going to happen 3. Initial questions a. ed urine? b. Opened bowels? c. Started feeding? 4. Birth weight, gestational age, birth weight centile 5. Expose; baby should be wearing nothing but a nappy to start with 6. General observation a. Plethoric, pale, jaundiced? 7. Head circumference (paper tape measure & record centile) 8. Palpate fontanelles and sutures a. Check fontanelles are not tense or flaccid 9. Observe face for dysmorphic features a. Eyes with an ophthalmoscope for red reflex b. Mouth for central cyanosis c. Finger in mouth to check suck reflex and cleft palate 10. Chest a. Observe for respiratory rate and abnormal breathing b. Auscultate the heart. Normal 110-160bpm c. Central capillary refill 11. Abdomen a. Check for liver, spleen and kidneys b. Check the umbilicus 12. Genitalia & anus a. Remove nappy and inspect for urethral and anal patency b. Check for descended testes 13. Palpate the femoral pulses 14. Moro reflex 15. Turn baby over a. Look for muscle tone b. Inspect and palpate back for midline defects 16. Test for Congenital dislocation of the hip a. Barlow’s test = posterior dislocation b. Ortelani = relocation ‘clunk’ 17. To complete the examination a. Hearing test b. Check for social issues 18. Thank the parent/examiner and ask if they have any questions.

169

Nocturnal enuresis Please take a history from this mother of a 7 year old who is suffering from nocturnal enuresis; explaining to her the syndrome and its management I am Jane Smith. James is my son and he is 7 years old and is still wetting the bed. He went through a period of 3 months of staying dry at night when he turned 6 but after that went back to the same as usual. I’m worried that there might be something physically wrong with him because I know that nearly all of his school friends were dry at night by 4 years of age. He wets the bed about every other night. I know that stress can cause kids to wet the bed but I don’t think that James has a very stressful life In the daytime he does not wet himself and does not need to go very often, 4 times a day. His father, who I’m no longer married to, tells me not to worry and that he was late staying dry but he won’t tell me a lot about it plus he’s a fucking idiot and you can’t believe what he says anyway. Mark Scheme: 12. 13. 14. 15.

Appropriate introduction Establishes reason for consultation Puts mother at ease Takes a detailed history a. Frequency b. Bowel habit / constipation c. UTI d. Stress e. Diabetes mellitus f. Access to the toilet during day & night 16. Explains to the child and parent that the problem is common and beyond conscious control a. 6% of 5 year olds and 3% of 10 year olds are not dry at night. b. There is a genetically determined delay in acquiring sphincter competence i.e. some children just take longer than others. c. Punitive procedures are counterproductive 17. Management a. Pre-bed routine – no drinks before bed. Toilet before bed twice b. Star charts; earns praise and a star each morning the bed is dry. Treat wet beds in a matter-offact way and do not blame the child c. Enuresis alarm; supplementation to a star chart. A sensor that sounds an alarm when wet. Child wakes up, goes to toilet and then helps make the bed before sleeping again d. Desmopressin; short-term relief e.g. sleep overs e. Self-help groups; additional advice and assistance 18. Mentions carrying out investigations a. Urine sample for glucose and protein and infection. 170

b. Assessment of urinary concentrating ability by measuring the osmaolality of an early morning urine sample c. USS of the renal tract

171

Limp in a child You are a 5th year medical student. Take a history from this mother of a 4 year old Congolese boy with newonset limp. My name is Tracy Lamumba. I am 32. My son Barry (4 yrs) is complaining of pain in his right hip. It started this morning. When he is still it doesn’t hurt, only when he is walking. He has been lethargic today and has missed school. I took his temperature today and it was 37.8C. The pain came on suddenly. As far as I know his hip is the only t affected. He has no vomiting, diarrhoea, rash, leg ulcers or dysuria. He has a cold which came on yesterday. He is coughing up small amount of green phlegm with no blood. Barry started walking at 10 months, he is normally very active. He is of normal height and weight. Barry has a 12 year old brother who is fit and well. Other than normal minor scrapes, Barry has no leg injuries. There is no family history of arthritis or sickle cell or TB. Mark Scheme: 10. Appropriate introduction 11. Establishes nature of problem 12. Takes comprehensive history of illness a. Onset, length of symptoms, exacerbating factors, any other ts, range of movement? b. Fever, general well-being c. Recent illnesses including bacterial infection (RTI, UTI, meningitis, gastroenteritis) d. Any trauma? 13. Asks about developmental milestones and previous hip problems 14. Asks about height and weight 15. Asks about any FHx of arthritis, TB, sickle cell, infections 16. Drug history – asks about immunisations, medications and allergies 17. Checks correct information with mother 18. Takes history in an empathic manner 19. Does all in a fluent and professional manner. Discussion; ΔΔ, History, investigations & treatment Please summarise the history you took. What do you think the diagnosis is? Transient synovitis What in the history made you think that? Mild fever, Concurrent viral infection, only pain with movement, sudden onset OK, what are the differentials of this history?  Septic arthritis / osteomyelitis – high fever, unwell pt, pain at rest & minimal movement  Perthes disease – gradual onset  Slipped upper femoral epiphysis – tends to affect obese adolescent boys, int. rotation  Sickle cell disease  Knee problem  Juvenile arthritis – requires minimum 3 month history What investigations would you carry out?  Examination – transient synovitis causes decreased abduction, decreased external rotation  Bloods – FBC (incl. WCC), CRP, ESR, blood culture  X-ray / ultrasound  Possible sickle cell  Possible t aspiration if septic arthritis suspected How would you manage this child?

172

   



Alternative conditions must be excluded. it if Dx in doubt Bed rest o Keep the leg flexed with some external rotation Analgesia – paracetamol Aspiration of effusion when present

Mobilise once the pain has settled

173

Psoriasis History You have been asked to take a history from a 21 year old lady with a skin rash I am Julia Thompson, a 21 year old lady who works as a bank clerk. I’ve come today because for the last month I’ve had this rash on my body. The rash is on my knees and elbows and some is on my scalp. They first looked like red/pink patches and then became a bit different with silvery-white scales on the surface. They do not itch and do not bleed or leak any fluid at all. Some things make them worse like stress. It seems to get better when its sunny. I also have some changes in my nails, they have pits in them and look different. It is starting to impact on my life because work colleagues and customers notice it on my elbows. I’m very self conscious about it because I think everyone assumes it’s contagious. Mark Scheme: 1. Appropriate Introduction (Name & role) 2. Establishes presenting complaint 3. Takes a detailed history a. When did it first start b. Where on the body is it & distribution c. What did it look like at first and how did it evolve d. Symptoms – itch, bleeding, exudates e. Aggravating factors – stress, drugs, infection, trauma, sunburn f. Alleviating factors – sunlight g. Nail changes h. Impact on life 4. Any history of atopy or allergy? 5. Social history a. Occupation b. Hobbies c. Travel d. Alcohol 6. Family history a. Atopy b. Current family member affected? 7. Drug History 8. Checks information with the patient 9. Takes history in empathic manner 10. Explains the diagnosis 11. Explains treatment options a. Emollients b. Topical agents; tar, vitamin D, vitamin A, Dithranol, Steroids 174

c. Phototherapy – PUVA, narrow band UVB d. Systemic agents – Retinoids, methotrexate, ciclosporin e. Biological agents – infliximab, etanercept 12. Offers patient information leaflet 13. Does all in a fluent & professional manner.

175

Psoriasis 2 A psoriasis patient is unhappy with topical treatments. She wants something systemic. Describe the associated risks and calm him down. 1.

She’s had a mixture of creams, none of them worked.

2.

Gain his trust. Tell him there are many more options.

3.

Phototherapy (SE. tanning, burning, skin cancer, cataracts)

4.

Oral acetretin (SE. liver damage)

5.

Immunosuppressants (SE infections)

1.

Introduce

2.

Show empathy

3.

Ask him what creams she has used 

Names? (emollients, tar, topical steroids, vit D analogue-calciporiol, dithranol, vi tA analogueTazarotene)



How long for?



Correct number of times a day?

4.

Explain that avoidance of precipitating factors could help:

5.

 Stress  Smoking  Alcohol  Obesity (suggest weight loss?)  Sunlight  Trauma-related sports e.g. rugby  Drugs- B-blockers, lithium, anti-malarials Other options- Phototherapy 

UVB- Side effects include skin burn, increased risk of skin malignancy (with chronic use), Contraindicaions are SLE, previous skin malignancy, xeroderma pigmentosum)



PUVA- Side effects include skin burn, skin pigmentation, increased risk of skin malignancy, cataracts (eye protection worn to prevent this)



Excimer laser- like UVB, but more precise



Procedure- the lesions are exposed to UV rays (light) in the hospital or in clinic, and in PUVA therapy, a drug called psoralen is taken orally or applied as a ‘paint’ on the skin prior to the light therapy

6.

7.

Other options- Oral Vit A analogue (acitretin) 

SE: liver damage, teratogenecity (women must remain on CO for 2 years after stopping treatment)



CI: liver impairment, hyperlipidaemia, DM

Other options- Methotrexate: 

SE: myelosuppression (ie risk of infections), heptotoxicity, pulmonary toxicity, teratogenecity



Regular blood tests required to monitor this toxicity

176

8.

9.

Other options- Cyclosporin: 

SE: nephrotoxicity



Regular BP checks and blood tests ( U + Es)

Other options- biologics: 

Eg. Anti-TNF-A (etanercept, infliximab)

Smoking cessation You have been asked to talk Lisa, a 39 year old lady who wants to stop smoking I am Lisa, a 39 year old factory worker who has been a smoker for 15 years. I smoke a pack of 20 cigarettes a day. I had a very bad cough over the winter and at the time smoking made it a bit better but I know that I’ve probably got this cough in the first place because of smoking; also my new husband says it smells. I want to quit but think I’ll find it very difficult and want some help. My father died of lung cancer aged 60. I’ve tried to give up once before 5 years ago by reducing my smoking to 10 cigarettes a day with the intention of reducing it slowly but I started smoking 20 cigarettes a day again after a few months because I started to feel irritable and all of my work colleagues smoke. I haven’t considered using any medication because I don’t want to take antidepressants. Mark scheme: 10. Appropriate introduction (full name and role) 11. Establishes reason for consultation 12. Asks about current smoking a. How many cigarettes b. For how long c. Where does she smoke 13. Recognises patient’s concerns 14. Reinforce the risks of smoking to the patient. a. Greatest single cause of illness and premature death in the UK b. Lung cancer + mouth, stomach, colon, bladder cancer c. Cardiovascular disease, heart attack, stroke d. Indigestion and stomach ulcers e. ive smoking risks to others 15. Review previous attempts to stop smoking. a. How many times? b. How long? c. Assistance / medication used? d. Problems encountered 16. Set a date to stop completely, not even one puff 17. Plan ahead – identify potential problems and strategies to cope 177

18. Plan how to handle work colleague situations 19. Consider smoking cessation treatment a. Nicotine replacement therapy; gum, patch, lozenges, nasal sprays, inhalers b. Bupropion – an antidepressant (acts on dopamine and noradrenaline neurotransmission) i. Side-effects: dry mouth, insomnia (avoid bedtime dose), GI disturbance, taste disturbance, impaired concentration, headache, dizziness, depression, anxiety 20. Offer to refer to the smoking cessation clinic 21. Offer a follow up appointment in 2 weeks to check progress 22. Offer information & advice sheet 23. Does all in a fluent and professional manner.

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Picture of a ‘bleed’ What are the causes of spontaneous intracerebral haemorrhage. Aneurysm rupture in chronic hypertensives. (Charcot-Bouchard aneurysms are 1mm in diameter. Principal cause of primary intracerebral haemorrhage.) Bleeding into tumours Vascular malformations – AVMs and cavernous angiomas Bleeding diastheses – thrombocytopenia, leukaemia, haemophilia Amyloid angiopathy – infiltration of amyloid into the arterial walls  weakening of small vessels Complications:  Hydrocephalus  Coning 

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Suicidality risk assessment 1. Introduction – rapport, empathy & style 2. History of overdose a. How long have you been having suicidal thoughts? 3. Degree of preparation a. Planning i. Length of planning ii. Chosen method b. Suicide note c. Last acts i. Will 4. Circumstances of overdose a. Alone b. Intervention unlikely c. Precautions against discovery 5. After the act a. Didn’t seek help b. Stated wish to die c. Believed the act would result in death d. Regrets its failure 6. Recent history of depressive symptoms a. Low mood b. Sleep disturbance c. Weight disturbance d. Poor concentration e. Anergia, anhedonia f. Poor self esteem, worthlessness 7. Current mental state a. Current suicidal thoughts b. Active intention? c. Anything stopping you taking your life? 8. Past psychiatric history a. Past history of self-harm b. Past psychiatric history c. Current medication d. Social history (particular attention to risk factors e.g. drug/alcohol misuse)

Have you ever harmed yourself before? Were you trying to kill yourself? What was the cause of you wanting to hurt/kill yourself? Anything distressing happened in your life recently? 180

Was the act impulsive or planned? Did you prepare in advance? Suicide note? Will? Made sure of isolation? How did you try and commit suicide? What tablets? how many? Had you been drinking or taking drugs? How were you saved? How did you get to medical help? Were you actually trying to end your life or do you think it could have been a cry for help? Did you think you had succeeded? How do you feel now about that attempt? Do you intend to harm yourself again? How do you feel about the future? What is your mood like currently? Was the last suicide attempt your only act of self harm? Ever been diagnosed with a mental health issue or been given treatment for a mental condition?

Assessing risk High level risk  Definite plan for suicide (When? Where? How?)  Major depressive disorder = severe depression  High lethality suicide attempt or multiple attempts  Established / advanced medical disease  Social Isolation  History of psychiatric illness Moderate level risk  Low lethality suicide attempt  Frequent thoughts of suicide  Previous suicide attempts  Persistent depressive symptoms  Serious medical illness  Inadequate social  History of psychiatric illness Low level risk  Suicidal ideation but no suicidal intent  ive environment  Once off adverse event that seems relatively minor  Physically healthy  No history of psychiatric illness

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Neonatal Vomiting Station You are a 5th year medical student clerking Sarah’s 4 week old son with vomiting… I am Sarah, the mother of Jamie, who is 4 weeks old. This episode started yesterday morning. He seemed to be hungry as usual and I fed him but within 5 minutes he was sick. The vomit was curdled and unpleasant smelling milk with no bile or blood but travelled a few feet from his mouth. He was still hungry so I fed him and he was sick again so I waited until the next feed and the same thing happened, I waited until today because I thought it may have just been gastroenteritis. He has no fever, no diarrhoea He usually wets his nappy 5-8 times per day but in the last 24 hours he only has once and he isn’t dirtying his nappy much either, just small pellet-like stools. I haven’t noticed that he has stopped gaining weight. He was born at 38 weeks’ gestation, vaginally and was 3.2kg. He has been well since he was born except for a small mouth abscess for which he was given erythromycin. My grandfather says that he had a problem of vomiting when he was a baby and he needed an operation to correct it! I’m very scared about this. I live with my husband as well as Jamie. The rest of us are fine with no recent illnesses. Mark scheme: 52. Appropriate introduction (full name and role) 53. Establishes nature of problem 54. Takes comprehensive history of illness a. Length of symptoms b. Vomiting? Timing, frequency, volume, contents, colour, odour, bile, blood, projectile, remained hungry afterwards? c. Other symptoms? Fever, cough, diarrhoea? d. Dehydration? Wetting nappies, soiling nappies, change in eyes? 55. Takes comprehensive history of the neonatal period a. Gestation? b. Method of delivery? c. Complications in pregnancy? d. ission to ITU? 56. Takes full background history – developmental and PMH 57. Drug history – asks about immunisations, medications and allergies 58. Asks about family history of childhood vomiting 59. Checks correct information with mother 60. Takes history in an empathic manner 61. Does all in a fluent and professional manner. Discussion; ΔΔ, History, investigations & treatment

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Hi Please summarise the history you took. What do you think the diagnosis is? Pyloric Stenosis What in the history made you think that? Age, Projectile vomiting, hungry after vomiting, no bile in the vomit, first born child Tell me, what metabolic abnormality would this child get? Hypokalaemic, hypochloraemic metabolic alkalosis. Why? The obstruction is proximal to the duodenum so vomiting causes loss of gastric fluid; this causes the kidneys to retain hydrogen ions in favour of potassium. The serum bicarbonate is higher because the hypochloraemia impairs the kidney’s ability to excrete bicarbonate and this prevents correction of the alkalosis

OK, what are the differentials of this history?  Gastro-oesophageal reflux –  Gastroenteritis – but no diarrhoea  Intersusception – but rare in those < 6 months  Overfeeding – but vomit wouldn’t be projectile  Milk allergy  UTI What investigations would you carry out?  Examination including inspection of the abdomen  Test feed – palpating for the olive  Ultransonography – pyloric muscle thickness > 4mm, or a pyloric length > 18mm  Biochemistry to assess dehydration  Barium contrast radiography  pH studies – monitor pH in the lower oesophagus  Upper GI endoscopy – evaluate the oesophageal mucosa for oesophagitis, erosions, etc.  Stool sample  AXR How would you manage this child? 1. Ensure their airway, breathing & circulation is adequate and it 2. Correct dehydration & alkalosis with ½normal saline + KCl over 48 hours 3. Rammsted’s pyloro-myotomy, possibly laproscopic 4. Non-surgical Tx; atropine sulphate (if parents are opposed to surgery)

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Question Lists from Previous Years

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Psychiatry and Neurology from previous years 1 History and counselling stations 1. Headache: Dx temporal arteritis 2. Alcohol Hx 3. Suicide assessment 4. Ritalin: parent with Questions 5. Lithium: side effects, need for Diood tests etc 6. Alzheimer's disease: explain it to daughter of patieril Data interpretation: Short answer questions (note, you don't have enough time to write everything down) 7. LP and CSF profiles: know the difference between, normal, menigitis, TB and SAH. Be able to list 3 early and late complications of LP. 8. Anorexia: work at BMI, list clinical symptoms and signs 9. MHA questions. Know it really well, questions are a bit fine print. 10. Ophthalmology: foreign body, glaucoma, diabetes and the eye. You look at pictures and examiner questions you. Must know your eye drops. 11-12. MSE: Video of psych patient. Write MSE from this. 13. Neuro video (we had transcipt 'cos video was busted): ? delirium 14. Be able to examine certain aspects of the PNS in isolation. For example, jus1 examine the SENSORY nervous system in the lower limbs (no need to illicit reflexes then). . State you diagnosis from findings. I had a guy with a sensory neuropathy, stocking distribution. Don't forgot to observe first.

Psych and Neuro Dec 2003 1. Neurological exam of lower limb (patient had glove and stocking sensory lossing secondary to Diabetes) 2. Video - watch an interview of a manic patient and write a mental state 3. Video again - mental state of depressed 4. SP (simulated patient) - Explain alzheimer's disease to a patients daughter and answer questions she asks you. 5. SP - explain diagnosis and treatment of panic attack to a patient 6. SP - explain autism to a mother and its management. 7. SP - explain the diagnosis of schizophrenia to a patients sister 8. Written station - identify spastic gait 9. Written - identfy left radial nerve palsy from a photo 10. Talking station (examiner will ask you questions-explain about eye drops you would use (e.g. dilators,anaesthetics) 11. Talking - answer question on fundo disc abnormalities 12. Explain contraindications to cataract operation 185

13. Identify CT bleed on picture e.g subdural, subarachnoid 14. SP - answer impact of epilepsy on patients life (O, swimming,climbing,driving etc.) 15. Answer questions regarding causes of delirium.

Neuro 2003/04 OSCE STATIONS Neurology 1) Video presentation/ written station : Read up about Scissor Gait & Cerebral Palsy 2) Talk to family member of patient about ALZHEIMER'S DISEASE 3} Lower Limb Examination : Sensory examintation on the patient's LL. Make a Diagnosis and justify diagnosis, causes OT stocKing distribution. 4) Epilepsy counselling: you are a GP and a lady in her 20's has be diagnosed with epilepsy and is on medication, she's come to you and ask for your advice about epilepsy. 5) CT/MRI scan (Written Station) identify Subdural or subarachnoid haemorrhage, and possible clinical outcome. Psychiatry 1) Do a RISK ASSESSMENT on a SUICIDAL patient. 2) Explain to family member of patient about SCHIZOPHRENIA. 3) Explain to mother of child about AUTISM. 4) Take a history from someone who presents with CHEST PAIN, make a diagnosis and counsel the patient about it. 5) Video session : Do a mental state examintation. (I had a delusional patient) 6) Video Session : Do a mental state examintaion (I had a sad patient) 7) Written station on Mental Health Act. Especially the difference between MHA2&3 Ophthalmology 1) Identify pictures of symptomatic eyes. Contraindication for cataract surgery. Anasthetic used for catarct surgery

Neuro EMQ Written paper: A lot on differential diagnosis for both Nuro and Psyc. Neuro path and genetics. I think it has changed, for us there were % of population with alcohol dependency etc which was really random. Know the various roles of the MDT ir KNOW YOUR LECTURE NOTES REALLY WELL!!' A lot of the definitions are lifted directly from them, so read them well before reading thick books.

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Psych/Neuro 2003 1/ Hx Panic attacks 2/ explain to sister of schizophrenic what it is 3/Video x2 (mental state examination) 4)Ophthalmology station-with an examiner asking qus (mcq,slide,eye drops) 5/ picture and qu's 6th nerve palsy and other q's 6/ take hx of social withdrawal from childs carer 7/ advise epileptic woman about medication and future management 8/PNS examination (lower limb)+differential --was MS i think 9/ video of child walking - had cerebral palsy -scissoring gait 10/hx depression and suicide risk 11/ CT head – subdural haematoma

Pyschiatry/Neuro 2002 1)Hx Panic Attacks 2)Explain to sister of Schizophrenic what it is, Tx, aetiology etc 3)Video x2 (mental state examination) 4)Ophthalmology station-with an examiner asking qus (mcq,slide,eye drops) 5)CT head - diagnosis 6)Picture and qus-6th nerve palsy, other eye qus 7)CSF breakdown-bact/viral/TB meningitis? 8)Take Hx of social withdrawal from a disabled child's carer 9)Hx Headache-migraine 10)Side-effects of Lithium 11)Hx depression and suicide risk 12)PNS examination (lower limb)+differential --was MS I think 13)Explain what Autism is to mother and other differentials

1. MHA section 2&3. compare and contrast. u r a psych sho on call. GP calls with a wacko SCZ pt on a tree. consultant not free for 5 hrs. GP ask u wat she can do? social worker not there. PT mom is. discuss. 2. take hx from a depressed down's syndrome PT from carer (PT mom died 2 yrs ago and PT gone a bit mental only recently.). explain to carer wat is the diagnosis and Mx. 3. Headache Hx. (migraine with aura) 187

4. Depression MSE. video. 5. MSE of PT with dysphasia (expressive). video 6. explain ritalin to mom with ADHD kid. 7. CSF results. explain possible diagnosis. (meningitis, i think! also SAH) 8. Lithium Blood results. explain. (toxicity. and comment on S/E and symptoms of Tox) 9. take suicide risk assessment from woman who just took an OD, presenting at A&E 10. opthalmology. various slides. 1)cataracts 2)diabetic retinopathy 3)macular degen ... 11. Explain Alzheimer's Dx to daughter who's mom is newly diagnosed with AD 12. Take an Alcohol Hx. and comment on whether u think PT is EtOH dependent 13. Peripheral Neuro Exam. with diagnosis (peripheral neuropathy. comment on likely causes) 14. an axial CT brain and MRI spine. i have no freaking clue what the pathologies were. good luck!

Neuro Osce 2005 * bilateral , spastic scissoring gait: name differential dx, expected reflex and sensory changes 

EMG/ nerve conduction studies, Calculate speed of nerve conduction using example provided in OSCE, implication of normal nerve conduction velocity but decreased amplitude



Alcohol dependence: number of units/ criteria + substance dependence criteria



Opthalmology: Ethler�s danlos syndrome---lens dislocationDiabetes retinopathy, pterygium s+s, cataract surgery �manual lens removal , laser dissolution of lens

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History taking : man presenting with a transient hx of hemiplegia involving UL, LL, face----TIA, provide a differential dx , tx, Management

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epilepsy: social and general implications

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History taking: panic attacks, provide advise and possible treatments

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explain over the phone to staff nurse how to manage a acutely confiused patient

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Autism: explain disease and management



Alzheimer�s disease



Bi-polar affective disorders and medication



Schizophrenia

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Psychiatry and Neurology from previous years 2 1) written - anorexia signs symptoms, calculate BMI (was 15.32), know units 2) video - parkinsons – describe signs, write down 3) rest 4) logbook 5) written - lithium, treatment, indications etc 6) ophthalmology - diabetic themed - retina pic, describe, explain treatments 7) rest 8) history - left sided weakness (TIA) 9) rest 10) neuro - examine LL 11) video - downs - withdrawn patient, PTSD/depression, Learning disabilities define 12) rest 13) PTSD history – man mugged, not sleeping since, ddx depression 14) rest 15) depression treatment – patient on tricyclics, wants to know side effects, how long on them, how long before they work 16) alcohol – assess whether patient is dependent 17) written - sections – easy 18) alzheimers - explain diagnosis to patient and care available 19) child getting bullied at school, parent concerned - explain cause of stomach ache and management 20) rest 21) headache, causes etc. cluster, migraine, sinusitis

EMQs psych 1) sections (common stuff) 2,3,4) criteria for diagnosis of depression, PND, puerperal psychosismania, bipolar, cyclothymia, dysthymia; women with children finding it difficult to cope - euthymia? psychosis; grade the severity of depression, hypomania 6,7) illicit drugs - which cause what type of effect, major side effects of them 8) 1st line advice to patients with (eg) withdrawal symptoms as inpatients, with chronic alcoholism; which drug to ister 9) psychiatric drugs used to treat psychosis in pt wiht parkinsons, cardiovascular 10) identify personality disorder (straightforward) 11) child abuse v accidents (kid with 2 bleeding knees and broken arm fell off slide = accident; child scared of people = physical abuse 12) which blood tests to order for particular drugs/interactions 13) 1st 2nd 3rd line treatment of schz 190

14) child psychiatry - aspergers, retts, deafness? neuro -sensory levels etc; which type of sensory loss corresponds to motor defecit, sensory level, differing contralateral signs; dermatomal distributions - peripheral nerve lesions -roles of of the team - assessing for wheelchair, filling out DVLA forms, swallowing (options included: consultant/FY1/Oc Ther/SALT/ASW) -identifying site of lesions in the spinal cord/brainstem corresponding to sensory/motor loss -diagnosis of MND, MG, MS

prioritisation healthcare - what do NICE/GMC guidelines etc. do; who issues them ophthalmology - fields etc, inc pituitary tumour sudden loss of vision ddx traumatic injury, myopic patients more likely to get.... Psychiatry OSCE Winter 2005 15 Stations (5 mins each) 1 log book station 6 rest stations 1. Pictures of eyes – Lateral rectus palsy, VI nerve (false localising) or MLF 2. Parkinsonism – video, name 5 features, 2 drugs used in Rx and differential. 3. Match the disorder to the disturbances in these U&E’s (really easy, low sodium/high sodium = acute confusional state) 4. Anorexia – Physical signs x 4, Physical symptoms x 4, BMI calculation (calc provided) 5. Ophthalmology pictures (with examiner), foreign body (ddx of red eye) and phacoemulsification (know the 4 stages) 6. CT Scans (Extradural, Subdural, Glioma (ring enhancing), Meningioma) – match picture to the options 7. Sensory examination of the upper limb – carpal tunnel syndrome 8. GP station – EtOH dependency history from patient presenting with a sore throat (be careful here!!!) 9. GP station – Headache, trigeminal neuralgia 10. A&E station – History of depression 11. Phone conversation with a GP about the mental health act and a patient who is stuck in a tree (attempting to get closer to God). 12. GP Station – Panic attacks/funny turns – rule out fitting, ask about witness stations. 13. GP Station – Schizophrenia – explain diagnosis and medications to a relative (know the prognosis after a single psychotic episode 20% never again, 70% recurrent, 10% worse and worse still) 14. Autism – Explain diagnosis, prognosis, ddx (Rett’s, Hellers, Aspergers) , and rx (none specific, gluten exclusion diet) with mother (worried, so be sensitive) 15. Mental State Examination on a video – Schizophrenia or Mania, pressed for time on this one. Video is about 3.5 mins.

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Obs and Gynae History and counselling stations 1. Post partum haemorrhage 2. Contraception advice, the pill etc 3. HIV test counselling http://www.aidsmap.com/en/docs/F661F15A-FDD7-41FF-80FA-8FF0F61A18D2.asp 4. Smear test result and explanation 5. Prenatal diagnosis counselling: Down's 6. Needle-stick injury protocol ?hiv infected or not? Data interpretation 7. MCQ's: STD microbiology Practical 8. Bimanual/smear on dummy 9. Mechanisms of labour: move doll through pelvis and interpret partogram 10. How to take a blood culture 11. How to perform an MSU OSCE 2003/2004 OBS AND GYNAE OSCE stations dec, 2003, 1) meningitis: asked to speak to a mother concerned about an outbreak at her child's nursery school, she wants advice on prophylaxis, when can the daughter return to school, etc. tell her about rifampicin (need it or not??????). ask if daughter had meningitis c and Hib http://www.communigate.co.uk/wilts/meningitis/page19.phtml 2) throat swab: dummy on examination bed. take a throat ask what sort of pathogens cause sore throats. 3) sexual history: someone 4) palpation of abdomen and blood pressure: ????? 5) partogram and delivery: there's a model pelvis and doll. move the doll through the pelvis, showing your understanding of the delivery process, there's also a partogram they will ask you to 6) communication skills: woman comes in worried about her recent cervical smear results. she has cin1. explain what that means. 7) communication skills: patient asks about the implications of PID on infertility. take a history/ give her advice 8) communication skills: patient asking aoout amniocemesis. wny is sne navir it done, risks to baby's health, etc 9) needle stick injury: patient comes in from recent injury, asks you what to do next. tell him about the protocol. 10) contraception: lady wants to know what contraception to use. t(ask forr isk factors like previous DVT, clotting disorder if prescribing COC. 192

Obstetrics and Gynaecology 2002 1)Counselling forO/HRT 2)Couselling for Needlestick injury-HIV, procedures 3)TB-tell pt about drugs, side-effects and treating s 4)Taking blood cultures-practical 5)lCervical smear and bimanual exam ????????ABDO EX BEFORE SMEAR????? 6)Hx Postpartum Haemorrhage 7)Written station: STDS gonorrhoea/chlamydia 8)Hx Urethral Discharge/sexual discharge 9)Mechanisms of birth (using plastic pelvis and baby)and describing Partogram 10)Explaining to pregnant lady about antenatal testing 11)examination of pregnant adbomen 12(how to put on a condom) 13(Mcq on malaria) O and G - December 2002 1. advise re amniocentesis 2. blood cultures 3. female sexual history 4. explain partogram and explain the process of delivery and birth by guiding a fake baby through the model of the pelvis. 5. written station: gonococcus, acute testicle, STDs 6. smear and bimanual on a model 7. secondary PPH history 8. HIV post exposur prophylaxis 9. counselling- explain smear result (mod/severe dyskaryosis) 10. HIV pretest counselling 11. examination of a pregnant abdomen 12. contaception counselling 13. dysmennorhoea history 14. explain how to do an MSU

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0 and G - Easter 2002: 1. Blood cultures 2. menorrhagia history 3. HRT counselling 4. male sexual history (herpes) 5. bimanual and speculum on model 6. pregnant abdomen examination 7. infectious diseases pictures 8. secondary PPH history 9. Meningitis counselling (exposure prophylaxis etc) 10. HIV pretest counselling 11. throat swab 12. booking visit counselling (which tests will be done etc) 13. fake baby through pelvis and partogram explanation 14. + one other which i have forgotten but it cant have been that bad though These are the O&G stations we had in Dec 2003 1. Amniocentesis explanation and fill in the consent form 2. Counsel woman on starting the oral contraceptive pill 3. Do a bimanual and chlamydia swab on model 4. Counsel a nurse on needlestick injury and post exposure prophylaxis 5. Counsel woman on smear test result of moderate dyskaryosis 6. Explain how to take Blood pressure and examine pregnant abdomen 7. Male sexual history 8. Female history of right sided abdominal pain 9. Counsel a worried mother about her child's exposurie to meningitis at school and appropriate prophylaxis 10. Explain a partogram (latent and active phase of 1st stage of labour) and guide a baby through the pelvis in labour for delivery 11. Take history of antepartum haemorrhage at 34 weeks gestattion and appropriate management 12. Throat examination taking a swab 194

13. Take a history of subfertility and its causes in this particular case - pelvic inflammatory disease so take a quick gynae and genito-urinary history 14. woman diagnosed with genital warts - counsel her on causes and appropriate treatment and risk of cervical cancer 15. give in logbooks and on firms each station 5 mins

1. Preconception advice for a 41yr old woman 2. HIV PEP advice after needlestick injury 3.Booking bloods 4. TB treatment explanation 5.Pre test counselling for Hep C 6.Labour pain relief options 7.Prescribing O 8.Examine pregnant abdomen 9.Do endo cervical swab 10.Do a VE on rubber model + interpret &explain partogram 11.Blood cultures 12.Take gynae Hx of fibroids 13.Answer questions about menstrual cycle, name phases etc 14. 15. and logbook 1. explain chlamydia test results and implication 2. explain a smear 3. abdominal palpation kick chart n ctg 4. blood culture 5. expllain hrt risks n benefits 6. HIV pretest 7. gyn history ( was PID i think) 8. explain infertility ttests (progetseron, HSG & sperm ananylisis 9. Meningits prophylaxis 10. explain condom use 11. VE in labour 12.consent a patient for eua 13. explain TB drugs 14. Explain booking vsit tests

1. TB management - explain treatment of TB, duration, side effects, tracing etc 195

2. Explain treatment for chlamydia - duration, side effects, future prevention 3. explain to patient benefits and risks of taking HRT 4. HIV pretest conselling - ask why he wants to know, risk factors, what it involves etc 5. Taking history of someone with PID 6. Examination of pregnant abdomen - also have to read a kick chart and CTG 7. VE on a model and there was a graph and examiner asks questions but I can't what it was 8. Explain how to put a condom on to 17 year old boy and demonstrate on model 9. There was a image of a dye test of the uterus, fallopian tubes etc. I really can't remeber what the image is called. ( where they inject dye in the uterus and see if it goes up into the ovaries via fallopian tube or if there is a blockage) anyway you have to exlpain results to a patient but there were blood results as well. Not sure if it was blocked or not. 10. Anxious mother seeks advice because 3 year old son goes to creche where a child been diagnosed with meningitis. Have to reassure her and ask questions about how long he been in with infected child. Explain how to look out for meningitis, treatment, prophylaxis, who needs it etc 11. Explain to patient about smear test ( so all stuff about procedue of using speculum) and a bimanual - I think it's all stuff we learnt in GTA teaching. So all the talking part before actually doing it ( to ask about chaperone, locking door, emptying bladder before so less comfortable) � Obs-Gynae April 2006 1. explain condom use to a 16 year old boy ( to avoid oil lubricants) 2.Male pretest HIV counselling (ask about anal sex) 3.Demonstrate path of baby doll through pelvis at birth 4.Partogram explanation and abdominal exam 5.Infectious endocarditis explanation- treatment and pathogenesis and future prevention 6.Infertility test explanation (hysterosalpingogram ?shows kink, sperm sample below minimum volume- WHO parameters provided) 7.Menorrhagia history in 45+ woman (?fibroids- requires urgent investigation to rule out endometrial ca) 8.Amniocentesis counselling re Downs

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9.Puerperal fever and breathlessness history (ask about symptoms of all possible causes eg endometritis, PE, chest infection, UTI, anaemia, breast abscess 10.Booking history 11.log book double station 12.cervical smear- ask permission, mention chaperone etc, examine abdomen first 13.Throat swab 14.female sexual history (Chlamydia ) http://www.rxpgonline.com/postt25157.html- CIN3 counselling how to put on a condom: http://www.durex.com/cm/assets/SexEds/factsheet9.pdf

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O&G EMQ Dec 2005 1. Medication for PCOS, infert, detrusor inst',prolactinoma 2. PID - presentations 3. Menorrhagia 4. Testing in STD clinic - speculum, swabs, serology 5. Amenorrhoea - primary/secondary, causes 6. Hospital infection - isolation requirements etc. 7. Postnatal events - BF, renal, gut motility (days/weeks etc.) 8. Twins =96 IUGR, TTTS 9. Big for dates =96 same as LapT 10. Bacteria causing what? =96 Staph, strep, one funny UTI (Staph. saprophyticus) 11. Prophylaxis of bacterial infections =96 pneumococcus, meningococcus 12. Histology of gynae cancers =96 HARD!!! 13. Hormone levels =96 PCOS, precocious puberty 14. PPH =96 C/S, forceps, etc. 15. Fungal infections inc. tinea 16. Tropical infections =96 =91coca-cola=92 urine, jaundice (Vietnam) 17. Antenatal bleeding =96 plac. prev., abruption 18. Delivery =96 emergency C/S, fetal bloods, ?CTG etc. 19. Vag. Discharge 20. Different presentations of labour inc. =91precipitate=92 198

21. Subfertility Ix 22. Blood results for , molar preg. etc. 23. Pre-eclampsia + preg-induced hypertension + pre-existing hypertension. 24. Pre-natal screening (combined vs. integrated vs. quadruple) 25. Pre-malignant conditions =96 CIN, VIN, warts etc. 26. Dyspareunia =96 PID +/- bleeding etc. 27. Methods of contraception =96 BF 28. Stages of labour. N.B. No CTG question

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Obs & Gynae OSCE April 07 17 stations – 14 actual stations with 2 rest and a 10 min logbook station which are all stupidly together so you’ll have 20 mins off at some point. 1. Pregnant chicken pox woman 14 week pregnant woman comes to antenatal clinic worried because her son is suffering from chicken pox. She doesn’t know if she’s ever had it so you need to tell her you need to check her antibody status. You need to tell her about 8-21 incubation period, when it’s infectious, congenital and neonatal varicella syndrome, vaccine is contraindicated in pregnancy. She asks some weird questions about all her mates who seem to also be pregnant and whether she should be able to see her, how they’d know if they were affected. Last thing was her son was waiting outside, should he even be there – I suggested no and for her friend to take him no but think I was talking bollocks. 2. Throat swab All it says on the sheet is ‘john smith comes in with a recurrent sore throat, perform an examination and take a swab’. Read up on throat swab, do inspection check lymphadenopaty and also to fill the form in properly with what examination you’ve performed and the patient’s symptoms. I stupidly didn’t – easy marks that don’t need to be wasted! 3. CO Counselling Pretty straight forward tell this woman who has previously been on the pill about what pill is, good points, side effects, contraindications, risks, how to take and missed pill. She doesn’t ask questions so you should have your whole talk planned out. A good one is in that pink osce book. Shite, just forgot that I didn’t tell her she’ll need to come back to get her BP checked after 3mths, to do that. 4. Consent woman for bimanual/speculum You’re a medical student and you need to get permission from a woman to do a bimanual whilst under anaesthetic. Piss easy – to say ‘part of medical basic training to learn internal ex (check rep orgs healthy) and spec (thing you have with your smears), would it be ok to do this under supervision of consultant, won’t affect tx/post op side efx’ then get her to sign form. Takes a minute, then sit and have uncomfortable post -osce chit chat with actor and marker. 5. Community acquired pneumonia This was the killer station. A woman who has had a past splenectomy (loads of ppl didn’t read that bit on the sheet) has pneumonia, has been treated with erythromycin but hasn’t got much better. Tell her:  What tests – she’s already had xray, I said sputum culture and stupidly forgot stuff like fbc, blood cultures  What caused it, what bac can cause CAP  What antibiotics usually treat CAP  Now the tough bit – how to prevent infections, I mentioned all that barrier nursing bullshit when in hospital and prophylactic oral antibacterial and antifungals.  She may ask other random questions – different ppl seemed to get diff qs 200

6. Speculum/Smear and Bimanual The key here is be very quick – a lot of ppl didn’t get onto the bimanual let alone commenting on their findings. I think I spent half the station putting gloves on. This is something that will almost definitely come up so make sure you’re really slick because if you fuck it up like I did you’ll feel like an idiot and it will put you off speculums for the rest of your life. Not that it’s not already a disgusting thing. 7. Antenatal abdomen palpation Woman has high blood pressure, urinalysis negative, examine her abdomen. This was really weird, so different from a normal abdomen which are actually a lot easier. liquor volume at the end! She’ll ask what tests at the end I ran out of time but should have obviously said ctg/ultrasound. Again this really shouldn’t be a station where you lose all your marks but for me it was. 8. Preconception chat with 41 yr old 41 yr old bmi 32 (although she was actually skinny so you forget) comes in wanting to get pregnant and she wants any advice you can give her. I wasn’t sure how everyone else did this but I split it into  Trouble getting preg when older  fert drugs/ivf  Risks for baby esp downs hence talk about all the blood tests, nuchal trans and combined test amniocentesis/cvs for def diagnosis (think they’re offered to all over 40s?)  Risks for her eg more chance PET, gestational diabetes, molar preg, labour complications  General prepreg advice, diet/exercise esp cos of her wt, what not to eat, drink/smoke, folic acid, rubella igG 9. GUM clinic sexual history Take a sexual history from a guy, previous gonorrhoea, cheated on his long term partner and now has discharge, dysuria. Give a differential (gon/chlam). Also recommend condoms for future. 10. HIV Pretest discussion Woman who wants to get preg, has shared a needle with her bf who has used needles loads in the past. This one was tricky as the woman wouldn’t shut up, so try and get a move on and cover as much as you can. Pretty standard, there’s pretty much a mark scheme near the back of the logbook as there is for sexual history. 11. Hepatitis results Gay man comes in you have his hepatitis results – he has Hep a abs so obviously has had in past – tell him bout hep a and there are no serious longlasting complications ( I think I used the word acute 6 times and then thought I shouldn’t even be using this word). Then he is neg for all hep b so you have to tell him about the vaccination process, why he should have vacc, how hep b is transmitted , symptoms, complications and poss treatment. 12. Abnormal smear – moderate dyskaryosis Woman comes in having just got her smear results – mod dysk. So tell her its not cancer, will have to do colposcopy blah blah. Again I think its all covered in the pink osce book. 13. Antepartum haemorrhage Woman comes in 34 weeks, painless bleed since last night – sheet says take history of her presenting complaint, obstetric history, give her a differential and any tests you would do. I think other people dived in 201

and said either praevia or abruption but I said it could be either as it was both painless and scans hadn’t shown low lying placenta but more likely praevia as it was fresh blood. Few people didn’t ask if she had previous bleeding in that preg so that. 14. Booking investigations Woman comes in at 12 weeks – what tests would you do and explain to the woman why. So all your normal blood tests – fbc, group and ab status, hb electrophoresis, the 4 infections, random fasting glucose also mention urine for infection/proteinura and dating scan/nuchal translucency. At the end the examiner said ask her a pet related question, now because in the textbooks PET means pre eclampsia I was like ‘er any visual defects’ examiner said no then I said ‘ok swelling of your fingers or face?’ and he was like ‘no, PET!’ Then the station ended and everyone had said they’d asked about the whole cat/toxoplasmosis thing. This station will most probably repeat so def mention the cat!

Obstetrics and infection Impey

Aids pre test Learn microbiology.

Anaemia in pregnancy Chlamydia Throat swab Post partum pyrexia Stem cell transplant infections Breech abdomen Hiv pre test Fever in returning traveller Speculum with a swab Bacterial vaginosis Thallasaemia Explain speculum and smear Delivery of placenta Threatened miscarriage

Possible stations Chlamydia smear Explain smear Abdominal palpation chart Blood culture Explain hrt Hiv pre test Pid history Infertility tests Condom use Ve in labour and partogram Consent for eua Tb drugs Booking bloods and tests Pre conception advice 41 year old Hiv pep advice Pre test counselling hep c Labour pain relief options Examine pregnant abdomen Cervical swab Blood cultures Fibroids Menstrual cycle, phases Pcos Stages of labour and ctg Meningitis - involvement Co

Throat swab Mrsa on op list subfertility Booking bloods Post partum depression. Endocarditis history and treatment. Delivery of a model baby. Delivery of a placenta. Putting condom on - ask if boy or girl. Postpartum pyrexia Menorrhagia Chlamydia Pregnant abdomen Amniocentesis consent 202

Advantages and disadvantages of epidural 1.

explain chlamydia test results and implications

2.

explain a smear

3.

abdominal palpation kick chart n ctg

4.

blood culture

5.

explain hrt risks n benefits

6.

HIV pretest

7.

gyn history ( was PID i think)

8.

explain infertility tests (progetseron, HSG & sperm ananylisis)

9.

explain condom use

10.

VE in labour

11.

consent a patient for eua

12.

explain TB drugs

13.

Explain booking visit tests

14.

Preconception advice for a 41yr old woman

15.

HIV PEP advice after needlestick injury

16.

Booking bloods

17.

TB treatment explanation

18.

Pre test counselling for Hep C

19.

Labour pain relief options

20.

Examine pregnant abdomen

21.

Do endo cervical swab

22.

Do a VE on rubber model + interpret & explain partogram

23.

Blood cultures

24.

Take gynae Hx of fibroids

25.

Answer questions about menstrual cycle, name phases etc

26.

Hx of Polycystic ovaries and explain treatment

27.

Stages of labour + CTG with a doll/pelvis

28.

Infertility test results

29.

Meningitis – woman comes for advice on hearing a kid at her sons school has it, explain protocol, ask about men c vaccine + Prophylaxis 203

30.

Conset pt for EUA

31.

CO counselling know the CI

204

OSCE STATIONS: O+G APRIL’06. ENJOY!!!! 1. Infective endocarditis: Explain to the patient what endocarditis is, she has just been diagnosed and had a ECHO done and hasn’t started treatment, she had rheumatic fever in her childhood, and went for a root canal repair 2 months ago. She asks you: what increases your chances of getting infective endocarditis? She wants to know what the investigations show? What exactly is it? How does bacteria cause it? How would you treat her, how long for? She asks: how do you know what antibiotics to use? How do you know that they are going to work? What are the side effects? How will she know whether she has a side effect? 2. Interpreting subfertility tests: Explain to a patient the results of her partners sperm count, her day 21 progesterone level and a hysterosalpingogram photo. Know what normal sperm count is, and in her case the partner had >70% abnormal forms (the rest of the count was normal I think). Explain what mid-cycle progesterone tells you about her fertility? Interpret the hystosalpingram, know what normal looks like! She asks how what can you do for her husbands problem? 3. How to put a condom on? A 14 year old boy has come to the clinic and wants to know how to put a condom on. Explain and show him on a condom trainer. Mention emergency contraception available for partner in case of accident. Get him to demonstrate. 4. Antenatal clinic. Lady is 12 weeks pregnant has come for her 1st antenatal appointment; explain the tests you would do. Tip: I think what they are really getting at here are just the routine bloods (make sure you know at least 5 tests…the examiner kept asking me for more but I went blank), urine tests etc. Not ultrasound scans (since I talked about this for most of the station and I peaked at the mark sheet and didn’t get good mark). 5. Post-partum pyrexia and bleeding for 5 days after delivery initially flooding then period like, clots and smells really bad. Take history and explain management. 6. Menorrhagia History and management. I got confused here since the patient who is 43 years old, had heavy bleeding for the past 6 months, (flooding and clots), and has had 3 children. She has tried tranexamic acid but didn’t help. In the past was told she had a small fibroid. She was going for a scan (didn’t get round to asking why?). I suggested endometrial ablation she was not too keen, I suggested CO and she was not too keen (I guess not a good idea because of her age) Tip: you get some marks for basically taking a gynae history even if you don’t know management. But I guess hysterectomy was probably a reasonable suggestion but I ran out of time. 7. Log book station and (10 minutes). A consultant asks you how you found the attachment and what marks you got from your consultants etc. 8. Chlamydia history. A young women whose partner was diagnosed with Chlamydia 3 weeks ago currently on treatment, last had sexual intercourse 1 and a half weeks ago. She wants to have a Chlamydia test. She asks is he being unfaithful? Know treatment. 9. MRSA and due for prosthetic surgery tomorrow. What is MRSA? Why does she have it? Can she spread it? Will people at home get it? What is the treatment? Can she have her surgery tomorrow if so what antibiotics will she need? What is the MRSA decolonisation protocol? 10.Examine pregnant abdo and interpret partogram. 205

11. CTG and baby and pelvis explain stages of birth. Straight forward: CTG had a big deceleration, reduced variability and no accelerations……….hence fetal distress, so probably hypoxic, I suggested fetal scalp electrode and immediate delivery. The baby and the pelvis are really straight forward just go practice in clinical skills. 12. Smear. The sheet told me to do a smear. But the examiner also told me to do a bimanual. She asked me what does the cervix look like? (it was a cervical ectropion). She also asked me if the uterus was retroverted or anteverted? (I laughed cause I thought it was a joke, I mean how can you tell on a plastic model?...but maybe she was being serious?). 13. Throat swab. I found this one tricky since the guy taking the station was really weird. There was a dummy and then the examiner. The instructions said to take a clinical history from Mr John Smith, then do a throat swab. So I naturally faced the examiner to ask him the history of the sore throat and he kept pointing to the dummy (so I got confused). 14. Amniocentesis and consent for it using the form they give you. Explain the process, and inform her about the risks. 15. AIDS pre-test discussion. Discuss about HIV pre-test. Explain that you cannot catch AIDS. Explain HIV and AIDS? Explain window period. Some extra tips for the module: The EMQ was tough you really need to know details. Esp. communicable diseases …a lot of stuff on fungi came up. Know HIV and complications well. Communicable diseases: For microbiology go to all of Dr Shettys teaching at UCL, she is amazing!!!!!!!! (I was based at RFH but went to all her teaching). And she gives you all the details you need to know and extra tips on the OSCES. Dr BalaKrishnas lectures at RFH are also very good. Also make sure you go to all the case discussion lectures since these are really useful for OSCES. We didn’t have anything on Gastroenteritis in the EMQ or OSCE so will probably come up next time.

1. Dr Shetty- MRSA this came up last block. Patient is going in for hip surgery. Before operation, they have MRSA screen. They have a few questions for you. How will they do this MRSA screen? Swabs taken from nose and also possibly from groin, axillae- Microscopy, culture, sensitivities. Why is this done? MRSA colonises many people externally without causing symptoms. However, with implant surgery, there is a large wound and a large foreign body. Patient is vulnerable to infection, MRSA is difficult to treat and may necessitate removing implant. By screening beforehand, can eliminate MRSA before operation and improve success rate. How would I know if I became infected after the operation? You would feel ill, with fever, wound discharge, breakdown, pain on weight bearing. This may need investigation. How is MRSA eradicated? 206

5-day protocol, involves antibacterial shampoo and bath, mupiricin nasal ointment. This can be done at home (MRSA commensals are not a risk to healthy people in the community). If in-patient is found to be MRSA-positive, they are isolated and healthcare workers should all use infection control procedures. Before operation, patient is given vancomycin/teicoplanin + gentamicin prophylaxis (synergistic killing of gram positive bacteria). If MRSA positive and surgery is emergency, proceed with pre and post-op anti-MRSA prophylaxis. If not emergency, send home for 5-day MRSA suppression. 2. Dr Shetty- Infectious endocarditis – history of rheumatic fever, recent dental operation. Gram positive cocci found on culture, echo shows vegetation. Explain to patient what infectious endocarditis is and how they developed it- rheumatic fever roughened their valves and disrupted bloodflow in region. This encouraged clots, platelets to stick. Dental surgery introduced bacteria to blood from mouth. These were attracted to the platelets and formed colony there, shielded from immune cells. This causes further heart valve damage, fever, risk of damage to other organs… Strep viridans is cultured. How is this treated? IV benzylpenicillin + IV gentamicin (synergistic kill of gram positive- pen breaks down cell wall, gentamicin attacks ribosomes) 2 weeks. Ensuing 4 weeks antibiotic is either amoxicillin PO (can be discharged home) or benzylpenicillin IV (needs to stay in hospital)- decision depends on state of patient, Dr preference. Side effects of gentamicin= ototoxicity, nephrotoxicity. Need to ask about penicillin allergy (would give clindamycin instead). To avoid future episodes, they should have amoxicillin + probenicid prophylaxis for surgery and all invasive procedures. 3. Dr ShettyA 10year old child gave a 3 day history of flu-like illness with no other localising symptoms. Over the course of a few days he presented with characteristic vesicular lesions on his face. Several children in his class at school have been unwell with a similar illness. He continued to be systemically unwell with a temperature of 38. His mother is 10/40 pregnant, is completely well but is concerned about the baby. The veisular lesion was aspirated and clear fluid obtained; this was sent to the lab. Chickenpox is diagnosed. What is causative organism? varicella zoster (human herpesvirus 3) What is incubation? 8-21 days What is the common name given to reactivation?- shingles. What are maternal chickenpox risks to fetus? Risks to fetus: congential varicella syndrome. 0.4% risk if ma infected in 1st trimester, 2% in weeks 13-20, much less after this. In 1st trimester causes congenital defects (~7.8% prev compared to ~3.4% in non-infected), low birthweight, intrauterine death, skin-brain-eye-GI-GU effects: including skin lesions, brain damage, spinal cord atrophy, limb paresis, seizures, chorioretinitis, duodenal stenosis, jejunal dilatation, neurogenic bladder. Diagnosis requires maternal varicella in pregnancy, dermatomal skin lesions at birth, IgM antibodies to VZV after birth/ gG after 6 months. Early detectionantibodies on cordocentesis, characteristic defects on ultrasound/ CVS sample for VZV DNA. Neonatal varicella can cause pneumonitis-hepatitis-meningoencephalitis which has mortality up to 30%. Maternal varicella 5-21 days pre-delivery is less harmful because antibodies are likely to have developed, which cross the placenta. What lab test will you perform on the ma? VZV antibody. What is treatment for active varicella chickenpox in pregnancy?Counsel on risks of chickenpox in pregnancy. Live vaccine is available but contraindicated in pregnancy. Symptomatic relief. Prophylactic VZIg for pregnant, asymptomatic seronegative s of chickenpox (ie woman in this case). Aciclovir if they develop chickenpox (IV if complicated eg pneumonitis). 207

VZIg at birth for baby if ma develops chickenpox 7 days before - 28 days after delivery/ siblings have chickenpox at home, can perform C-s if lumbar area is clear for epidural. Babies should receive IV acyclovir if they develop chickenpox, even if they have had VZIg already, they can still be breastfed, should not be isolated from mother or siblings. The mother asks if she can take son to antenatal appointment. – No. The mother asks if she can go- she is unsure if she had chickenpox as a child and her antibody status is unknown.- no. Child may have infected her, she would be infectious for 3 days before getting lesions on skin. District nurse should visit her at home and test for antibodies. If she is antibody negative and remains symptoms free, she is not clear to visit antenatal until 21 days after all her son’s blisters scab over and are dry. Son’s teacher is also 10/40 pregnant. She asks if she can go to antenatal class- she is asymptomatic, never had chickenpox before and school holidays started 10 days ago.- she is clear because boy was not infectious when she saw him (symptoms started 7 days later). Father of child is heavy smoker with no history of chickenpox, but he has no symptoms does he need treatment? If he is antibody negative (immunity can be acquired without developing chickenpox), he should be treated with prophylactic VZIg as his smoking puts him at increased risk of varicella pneumonitis death (as would immunocompromise). Add acyclovir if he develops lesions. What if mother developed herpes zoster shingles? This is not a problem- she would have varicella antibodies and not on infection to child. Only problem is if it was as result of immunosuppression eg HIV/ paraneoplastic lung cancer Throat swab 1. Introduction and establish rapport 2. Explain the task and ask for consent 3. Ensure that the patient is comfortable 4. Wash hands and wear gloves 5. inspect patient’s face and neck, noting any swelling 6. look at lips for ulcers or fissures 7. assess the gums and teeth for dental hygeiene-remove dentures 8. inspect the buccal mucosa 9. look at the hard palate and the floor of the mouth- ask the patient to protrude their tonge to view the hard palate and to raise it to view the floor 10. look at the tongue for cyanosis and excessive furring. A smooth togue could indicate B12 deficiency 11. Use a tongue depressor anda torch to look at the throat 12. ask the patient to say aaah and inspect both tonsils (either side of the uvula), the posterior pharyngeal walland the movement of the soft palate. 13. For examination of neck, the patient should be upright and examined from behind 14. palpate gently for lympadenopathy beneath the mandible, over the anterior and posterior triangles of the neck and above the clavicles 15. wash hands again 16. loosen swab container 17. ask patient to say ahhh 18. use tongue depressor to keep the tongue on the floor of the mouth 19. point the swab at the back of the patient’s throat and gently roll it around the fauces over the tonsils. 20. Remove the swab and replace it intothe culture medium (label specimen). Ensure its delivery to the lab (with the request form) 21. Conclude by explaining how to get the results of the test and say thank you.

208

Condom Use A: Demonstrate how you would explain condom use to a group of fifteen year-olds. [5 minutes] Provided: condom, prosthetic penis ANSWERS 2- done well, 1- done okay 1. Polite introduction, establish rapport, explains topic to be discussed 2. Explains that most 15 year-olds have not had sex, despite what they may say. Girls do not have to give in/ it is wrong to pressure others into sex. 3. Asks about condom knowledge- why to wear a condom, how to put one on 4. Explains reasons for using condom- prevention of STI’s including HIV, herpes, chlamydia, gonorrhoea. ~1/3 of UK HIV positive don’t know they have it, can appear v.healthy, there is no cure. Asymptomatic STI’s can cause infertility. 5. prevention of pregnancy 6. HIV, herpes, gonorrhoea can be transmitted orally, so use condom 7. Explains condoms are available for free at family planning clinic 8. Demonstrates usecheck date on packet, stronger varieties available for anal sex 9. open carefully and pinch end of condom- if air gets in, sheath can tear, space required for semen 10. put on before penetration as pre-cum contains sperm. Retract foreskin, place on prosthesis, roll to base of shaft 11. during sex, check it doesn’t come off, remove carefully as soon as ejaculation happens, even if premature 12. Important don’ts: don’t use oil-based lubricants (eg Vaseline, massage oils)- they make condom tear, can use water-based 13. don’t use spermicides- they cause inflammation and may increase STI spread, 14. don’t flush down toilet- blocks pipes 15. What to do if goes wrong- post-coital contraception from GP/ family planning within 72 hours/ coil within 5 days 16. post-coital HIV prophylaxis available in certain circumstances 17. chlamydia screening available at GP/family planning 18. Asks for questions 19. Asks 15 year-old to demonstrate on prosthetic and corrects mistakes 20. Does all in a fluent, approachable manner COMMENT Important to communicate appropriately with young people, give serious information, encourage mature discussion without being preachy or manipulative. B: You are a medical student at a GUM clinic. The next patient is a 32 year old woman who wants to be tested for HIV. Perform a pre-test risk assessment, including sexual history. (5 minutes) ANSWERS Patient history “I have been very concerned about my sexual health because I recently had unprotected vaginal sex. It has taken me some time to make myself come here and I am very concerned about confidentiality. I will call myself Jules Gray. I am experiencing an unusual discharge from my vagina that does not go away with washing. I went drinking with my mates and met a man. He took me home and we ended up having sex without a condom, this was one week ago. He was British born. My current partner, from Canada, is unaware, we have been together 4 months and have vaginal and occasional oral sex, the last time being two nights ago. I am on the pill, we only use condoms when I am bleeding. Prior to these two characters, my previous sexual encounter was 6 months ago. We had oral sex only, using a condom. My last smear was 2 years ago, it was normal and I have never had a recall. My last period was 3 weeks ago, my cycle varies from 25-30 days. I had one miscarriage 6 years ago but no other pregnancies. I have never worked in the sex 209

industry, never had sex with a bisexual man, never had a blood transfusion, never had sex with an HIV positive person, though one of my boyfriends was a white South African. I used speed intravenously 3-4 times in my early twenties, did not share needles and have not used other drugs other than alcohol and cigarettes. I go drinking every other weekend, and may take up to 10 units. Other than the oral contraceptive, I am not on any medication and have no allergies. Three years ago I was treated for chlamydia and have had no problems since. I would like to have an HIV test. If positive, I will tell my friends and my mother. I expect the result to be negative. 2- done well, 1- done okay 1. Polite introduction, establishes rapport 2. Explains that information is confidential by law and that no 3rd parties have access- including GP and insurance companies. She does not have to give her real name, contraception and treatment is available free 3. Asks why she has come to the clinic on this particular day- presenting complaint 4. Explains that personal questions have to be asked for risk assessment 5. Establishes obstetric history: pregnancies/ abortions/ terminations 6. Establishes when last menstrual period occurred 7. Establishes current contraception use, if she uses condoms, does she use them all the time 8. Establishes date of last smear, history of abnormal smears 9. Enquires about current health. 10. Establishes current medication/ allergies 11. Asks about any prior/ ongoing drug use including IV and alcohol 12. Asks about history of work in the sex industry 13. Sexual history -establishes when she last had sex, if partner was casual/ regular, if regular how long was relationship 14. -establishes type of sex: oral/ vaginal/ anal 15. -asks if condoms were used- if so all the time? 16. -asks previous person she had sex with before, and find type of sex and condom usage for all partners over the last 6 months 17. -asks if they have ever had sex with: person born in high risk area like Sub-saharan Africa/south America/ SE Asia 18. intravenous drug 19. bisexual man 20. HIV positive person 21. Asks if they have had a blood transfusion in a high HIV prevalence area. 22. Asks about history of STI’s 23. Asks if they want an HIV test, if not why not 24. Explains three-month window of HIV test (antibodies may take 3 months to form, therefore test reflects events occurring up to 3 months before) 25. Establishes when they last had an HIV test and the result 26. Asks what they expect the result to be 27. Establishes who they can tell if the HIV test is positive 28. Does all in a fluent, sensitive, professional manner A. Blood cultures Take a blood culture from this patient. Provided: hand gel, gloves, alcohol swabs, blood culture bottles, vacutainer/ needle and syringe, tourniquet, prosthetic arm. 1. Polite introduction, establishes rapport 2. Explains procedure and gets consent 3. Check identity and if matches name tag 4. Collects all equipment required 5. Cleans skin well with 2-3 alcohol swabs 6. carefully removes flip tops on bottle sbefore use 7. Wipes tops of bottles with an alcohol swab and lets them dry. 8. Takes blood from patient using needle and syringe 210

9. uses fresh needle to inoculate each bottle if using a syringe. 10. labels bottles correctly. 11. Does all in a fluent, professional manner B. A 23 year-old woman wants to start the oral contraceptive. How would you, a family planning Dr enquire after her concerns and counsel her? (5 minutes) “I am at college and do not intend to have children for at least 3 years. I am currently in a long-term relationship, my last period was 7 days ago. We use condoms for contraception. I have never been pregnant, or had an STD. My cycle is regular with 4-5 days of bleeding, cycle lasts 30 days. I have heard that the oral contraceptive is reliable, but has side effects. What are the side effects? How does it work? I do not smoke or drink, have never had DVT-PE, have no breast disease, focal migraines or liver disease. I am on no medication. What do I do if I miss a pill? Or miss three pills? What other contraceptives are there? Do I still need to use condoms?” 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.

21. 22. 23. 24. 25. 26. 27. 28. 29.

Polite introduction, establishes rapport Asks about previous pregnancy, Asks what contraception she is currently using Establishes last menstrual period Asks smoking history Asks about history of STD’s Asks what she knows already about contraceptive Explains mechanism of oral contraceptive- combined pill contains oestrogen and progesterone, causes anovulation, monthly withdrawal bleed, can control heavy periods. Explains 21 days pills followed by 7 day break/ dummy pills Best to take at same time each day. Asks about contraindications:- history / family history of DVT liver disease breast disease migraines with aura- visual disturbance hypertension other: medication eg phenytoin, diabetes Explains side effects: possible weight gain, nausea, high blood pressure, breast pain, protection vs osteoporosis, ovarian cancer, endometrial cancer slight increased risk DVT, breast cancer, stroke-MI Explains what to do if misses- if miss one, take it as soon as possible, continue next day’s dose if miss up to 2, take last missed pill soon as possible, rest of pack as usual if miss 3 or more, take last missed pill as soon as possible, leave rest, use condoms for 7 days, emergency contraception may be needed. If 7 or more pills remain, take one per day and start 7 day break/ dummy pills If <7 left, finish pack and start next cycle without break, Worst to miss at start or end of cycle- first 7 days “blocks ovaries” Caution if diarrhoea/ vomiting: may not work explains that CO is over 99% effective if taken properly Explains importance of condoms vs STI’s and for double safety. Other options: progesterone only pill (including derazette- anovulatory), implanon, depo-provera, mirena Tells to take leaflet and decide for herself Explains need to take blood pressure, examine breasts Does all in a professional manner

14.History: You are a medical student attached to a gynaecology outpatient clinci. The next patient is a 19 year old student who has been referred by her GP for amenorrhoea. Please take a history of the presenting complaint and any other relevant history with a view to making a diagnosis. (5 min) ANSWERS 211

“I was a previously fit and well 19 year old engineering student. I started having periods when I was 11-12 and these have been regular until 8 months ago. My norm cycle was 3-5/24-6. My periods have been irregular for the past 4 months. I was involved in a long term relationship until 6 months ago when I split up with my boyfriend because he was playing away. I was devastated, but have slept with him once since, 2 months ago. We used to use condoms and I have never been on the O. My last period was 2 weeks ago. I have never been pregnant and have not had any other gynaecological problems. I have been relatively well, but lost 4-5 kg after the break-up (I have put some weight back recently). I have been struggling at uni and feel quite depressed. I have been sleeping poorly but have been eating a lot better lately. I have started smoking 10-20 per day. I drink 20-30 units per week. I am not on any regular medication and have never suffered from anorexia or hormone imbalance.” 2- done well, 1 done ok ASSESSMENT 1. polite introduction; establishes rapport 2. Establishes asge of menarche 3. Establishes normal menstrual cycle and last normal cycle 4. Asks about sexual activity: last intercourse/ excludes other symptoms of pregnancy 5. Establishes present contraception, if any 6. Establishes absence of obstetric history 7. Establishes/ excludes other gynae problems- dyspareunia/ pelvic pain, galactorrhoea, post coital bleeds, prementstrual symptoms 8. Establishes/ excludes symptoms of differential causes- endocrine disorders 9. Anorexia/ gross weight loss 10. general disorder: thyroid disease, anaemia, diabetes 11. Enquires social history, personal and family relationships leading to amenorrhoea 12. Establishes smoking and alcohol history 13. establishes not on any medications 14. Summarises findings; gives appropriate diff diagnosis 15. Does allin a fluent, sensitive, professional manner Diagnosis: Secondary amenorrhoea due to stressors of uni course and personal relationship break-up A.History: A married couple in their thirties have come to see you, their GP, with difficulty in starting a family. Please take a history from the wife wit a view to assessing their infertiloity problems. (5min) You may assume she is alone on this visit; you should be prepared to discuss management options. ANSWERS “ We have been married for three years. We both work, he is a solicitor and I am an estate agent. We own the house we live in and we have no finance worries. My husband has a 5 year old child from a previous marriage, whom he s. I have bever been pregnant and wa are bothhealthy and fit. I had an operation for an ovarian cyst 5 years ago, when my right ovary was removed. My periods were regular when I was on the pill buit since 2 years ago when I came off it, they have come every 6 weeks or so and are occasionally heavy. I have no other gynae problems. I am a non-smoker and drink 3-4 glasses of wine each week.” 2- done well, 1 done ok ASSESSMENT 1.polite introduction; establishes rapport 2. Establishes duration of relationship 3. Establishes history of previous pregnancies 4. Establihses if there are any children from previous relationships. 5. Asks about occupations of couple. 6. Asks about home circumstances 7. Establishes past/present health of husband. 8. Establishes past/present health of wife 9. Establihses history of gynae symptoms 212

10. Discussion of ovary problem, hormonal therapy and IVF 11. Does all in a fluent, sensitive and professional manner. COMMENT Infertility should be considered as a couple’s problems rather than individual’s. Infertility should only be diagnosied agter the couple have been trying for a child for one whole year. After the initial interview with the couple together, it maybe approoriate to interiew them separately, but all management decisions should be made in open discussion and with the agtreement of both parties. The loss of an ovary reduces the chances of normal conception by half, as the remaining (healthy) ovary ovulates once in every 2 cycles. Menstrual irregularites may results for sub-optimal endogenou estrogen/ progesterone production. Endocrine therapy may stimulate normal ovulation and conception, provided there are no tubal or uterine abnormalityes. IVF may be considered, with impantationg durig an artificially-induced progestational phase. B. HISTORY: A 33 year old woman is referred to the gynaecology clinic by her GP for sterilisation. Please take a history in order to assess her request. (5 min) ANSWERS “I am single and work as an actress in theatre and TV productions. I want to have my tubes tied because I don’t want a family. I am in a stable relationship and my partner, who works in the theatre, is not keen on kids. We do not plan to marry. My job involves travelling all over the world. I have had 2 early terminations in the past 10 years. I was on the pill until I develioped thrombosis of my leg veins, following surgery for a serious kidney infection a year ago. My GP has not advised me agasint having children, as my kidneys are now working normally. However, I would not wish to stress them by becoming pregnant. I do not think I would miss having hcildren of my own, as my partner and I have nphews and nieves, and we wish to put allour efforts into our careers.” 2- done well, 1 done ok ASSESSMENT 1.polite introduction; establishes rapport 2. Establishes social and family history 3. Establishes reasons for wanting sterilisation 4. Establishes past medical and OG history 5. Presence of chrnoic/long-standing illness that may contraindicate pregnancy 6. Enquires into partner/ husband’s wishes and the possibility of wanting children in the futurre 7. Does all in a fluent, professional manner. C HISTORY: A 27 year old, single woman consults you, her GP, with severe period pains. Please take a history of the presenting complain with a view to making a diagnosis (5min) ANSWERS “ I am having severe lower abdominal cramps just before my periods, and they subside only when myperiod ends. The pain is severe and radiates tomyback and down my thighs. I have to spend the worst dayor two in bed. I am single and work as a flight attendant and am having to later my flight schedule virtuallyeverymonth as a result. My erids tend not o be regular, and I get spotting before they start. They are occasionally heavy, and I had put it down to experimenting with different birth control pills in the past. I have beenoff the O for more than a year and my symptoms have simply got worse. I began my periods when I was 14 years old but they became very painful about 9 months ago. I have never been pregnant and never had a pelvic infection. I ama very health and active person and am not on any medication except for the standard painkillres I take sduring menstruation. “ 213

2- done well, 1 done ok ASSESSMENT 1. polite introduction; establishes rapport 2. Establishes characteristsics of the pain- severity site and duration 3. Duration in relation to cycle 4. Effect on dailylife 5. Establishes menstrual history 6. establishes history of gynaecological ailments and genral health 7. establishes any past pregnancies and outcome 8. asks about the birth control pill or hrmone therapy 9. does allin a fluent, professional manner COMMENT The patient probablyhas secondary dysmenorrhoea: this is usually associated with demonstrable pelvic patholgoy,ie uterine hyperplasia, pelvic inflammatory disaese,pelvic tumour, endometriosis,adenomyosis and cervical or vaginal stnosis. The dysmenorrhoea maybe relived symptomaticallyor bytreatment of the underlying lesion. E. Please read the following information before attempting the next station. You are a medical student attached to a GP’s surgery. The next patient is a 34 year old woman who has returned tosee the GP for the results of a cervical smear which she has had recently and was reported: “Dyskaryotic squamous cells with enlarged nuclei consistent with a diagnosis of CINIII. A colposcopy and biopsy is advised.” Please explain the cervicalsmear report to the patient, address the concerns she expresses and the management involved. (5Min) “I am a school teacher and am returnign for the results of a cervical smear test I had several weeks ago. My previous smear, five years ago, was normal,and I have no anxieties about the results of this test.” When told about the results: Oh my God. Does this mean I have cancer? Will I need a hysterectomy. 2- done well, 1 done ok ASSESSMENT 1. polite introduction; establishes rapport 2. Establishes patient identity and reason for attendance 3. explains in non-jargonsitic manner the results of the smear, communicating appropriately the seriousness of the condition. 4. Explains the need for colposcopy and biopsy 5. Explains the procedure for colposcopy 6. Mentions possible need for local treatment of the cervi 7. Checks patient’s understand of explanation 8. Invites patient’s questions and answers 9. Does all in a fluent, professional manner COMMENT Management of CIN II- women with CIN III require colposcopy and biopsy. Local treatmen incldues cryotherapy, laser treatment and electrodiathermy and the patient requires annual review with cervical smera. If microinvactionoccurs or the squamocolumnar junction is breached, cone biopsy is required, which offers a total cure. When giving the results of an abnormal cervicalsmear, counsellginis essential to avoid emotional problems and possible delay in diagnosis and managemnt. 4.1 A 27 year old woman sees you, her GP on her 1st antenatal visit. Take her history. 214

(5min) Patient history I have been married for 3 years and I work full-time as an istrative officer for a pharmaceuticals compny. My husband is a civil engineer with a road construction firm. My father has diabetes which recently affected his eyesight and kidneys. I had a miscarriage 2 years go and was itted as an emergency and received a blood transfusion. I was on the birth control pill until a few months ago when we decided to start a family. My last period was 10 weeks ago, and thy have always been regular and of normal duration. I have been feeling sick and dizzy most mornings but am getting over it now. I don’t smoke but took sleeping pills at night until recently, when I found out that I was pregnant. 2- done well, 1- done ok 1. Polite introduction 2. Establishes:- LMP or dating scan 3. Use of O 4. Pregnancy test 5. Symptoms of early pregnancy- eg vomiting, breast pain 6. recent febrile illness eg german measles 7. any medications 8. alcohol/smoking 9. recreational drugs 10. History of previous pregnancies (number) 11. Full term deliveries and or prem labour 12. abortions or miscarriages 13. antepartum haemorrhage/ hypertension/ heart disease/ diabetes/ UTI/ eclampsia during pregnancy 14. PMH:- major illnesses and treatment 15. surgical operations and outcome 16. gynae problems and outcome 17. establishes if she works and what she does 18. establishes if in long term relationship 19. asks about fertility treatment 20. family history 21. does all in a fluent, professional manner Comment: The history must include home circumstances and lifestyle, any fertility treatment, multiple pregnancies and/or birth defects, pelvic inflammatory disease and treatment, smoking history, past medical history and family history of heart disease, hypertension and diabetes. Past obstetric complications indicate the need for close monitoring of current pregnancy, to prevent recurrence. 4.2 A 29 year-old woman seeks an urgent consultation with you, her GP. She is worried that she may be pregnant. Please take a history (5min) I have not had my period for 10 weeks and am worried that I am pregnancy, as I did not plan to be. I work full-time as a producer for a local TV and cable company. I am single and have no plans to marry. I have been on the contraceptive pill for the past 8 years or so, but came off it when I swa one of the partners at the practice because of painful breasts. I was diagnosed as having a benign breast condition and was advised to stop taking it. My breasts feel full and sore at present and I feel sick in the mornings. I am getting up at night to water and going more frequently durng the day. My periods have always been regular, and I have never been pregnant. I have always been healthy except for a bad attack of malaria when I was in Africa recently working on a wildlife documentary. 1. polite introduction; establishes rapport 2. establishes symptoms of early pregnancy 3. establishes menstrual history 4. establishes contraceptive practice 215

5. family and social history 6. establishes attitude to pregnancy 7. establishes gynae history and asks about infections and smear history 8. establishes current and past general health- asks about malaria treatment 9. social history 10. family history 11. does all in a fluent manner comment- the patient is anxious and worried and the pregnancy needs confirmation. She must therefore be questions sympathetically and she should develop confidence that she should be supprted and cared for in her present situation. A positive pregnancy test may requitre counselling on the care provided at home and in hospital. 4.3 The same patient as in 4.2 is found to have a positive pregnancy test. Counsel her on her pregnancy, and elicit her underlying concerns (5min) “I have never been pregnant and this is v. unexpected and terrifying. I have not told my boyfriend, who is responsible for the pregnancy and I do not know how he would react to the news. My parents would like me to marry and settle down, but I am not sure if I am ready for this, and my partner and I have never discussed marriage. My work involves a good deal of foreign travel and I have a full work schedule for the next year or so. Taking time off or this would mean professional sacrifices but with the of my patrtner and my family, I may give it a try. If I decide on termination, how much time do I have? Where can it be donee? Would it affect my health in any way? I am confused and unable to decide right now but need your advice and help at arriving at a decision.” 2- done well, 1- done ok 1. Establishes empathy and shows sympathy and understanding 2. Explains antenatal during pregnancy and social service following birth even if boyfriend doesn’t stay 3. Explains procedures for termination of pregnancy- dilatation and suction before week 13 or mini-labour with misoprostol and mifepristone 4. explains that termination in 1st trimester is done as a day procedure and carries negligible risks to health and fertility 5. Mentions /advice from partner/ friend/ family may be worth seeking (though not legally required)- suggests she makes decision and come back, possibly with friend. 6. Offers STD screen 7. Does all in a fluent profession and sympathetic manner Comment- the Dr must guide the patient trhgough a tough decision with underlying socio-religious implications. Counselling of the patient and her partner should be directed towards the available to take her safely through her pregnancy, confinement and antenatal care and, on the patients request, the safety of pregnancy termination in a hospital setting (conscientious objectors are legally bound to refer them on to non-objector if they do not wish to discuss abortion). The Dr should refrain from expressing his/her personal, moral or ethical views. 4.4 Read through the following before talking to the patient: You are the HO attached to an OG firm. The next patient is a 24 yearold primigravida who is returning to the antenatal clinic one week after an oral glucose tolerance test, the results of which are shown below: Glucose tolerance test. Mrs R. Givens DOB 12/3/68 0mins- 6.8mM 30mins- 10.9mM

Unit no 048288 120 mins- 15.5mM

Please explain the results, implications and management to the primip patient Ms Givens. (5 min) “I have always been fit and well, though big boned and am 12 weeks pregnancy with my first child. I am 154cm and 69kg. I have come for the results of a glucose tolerance test I had five days ago. This was because of sugar diabtetes. My great 216

aunt has diabetes, which is controlled with diet and tablets, and I am hoping, if needs be, I can go on these. I have stopped smoking and drinking alcohol since finding out that I am pregnanct but H have a very sweet tooth and tend to eat boxes and boxes of chocolates. Nobody has explained the results or the implications of diabetes, and I am have no concept of what this will mean to me or the baby. Apart from a bit of morning sickness, I have been well in the last few weeks. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

Polite introduction; establishes rapport Establishes ID and reason for attendance Establishes Pt understanding of the investigation Explains th results and diagnosis in a clear fahion Explains the implications on pregnancy:- maternal –eclampsia risk increased operative delivery, labour trauma Fetal complics: increased malformations Macrosomia Hypoglycaemia at birth more respiratory distress … Explains treatment is by diet or insulin, not tablets. stresses importance of v. tight control- far fewer complications finds pt present diet, height and weight Excludes smoking and alcohol. Explans regular blood monitoring invites questions and answers Does all in a fluent manner

Diagnosis- gestation diabetes mellitus (WHO criteria 7.8-11.1mM at 2hrs in tol test) Comment Pre-existing diabetics should optimise their glycaemic control prior to pregnancy and should be cared for by an obstetrician and a diabetologist. Gestational diabetes is though to be a marker of susceptablity to diabetes type 2 in later life, with the stress of pregnancy causng alterations in glycaemic control ( a small percent of women diagnosed as having new onset diabetes during pregnancy will have IDDM) Patients may be managed with a strict diabetic diet, but if this fails, the only option is insulin. Patients are usually started on small doses of mixtard, on a BD regimen, eg 8 units mane, 4 units nocte. If this fails to maintain normoglycaemia a QDS regimen may be adopted, using pre-meal actrapid and an evening dose of an intermediate acting insulin. Doses are tirtated upwards according to the patient’s glycaemic control, which they must e taught to monitor using BM stix. Complications of hyperglycaemia in pregnancy Maternal: infections eg candida, UTIs, polyhydraminos, pre-eclapsia and eclampsia Fetal: Intrauterine death and neonatal mortality greatly increased Macrosomia, increased rate of anomalies (including neural tube and heart defects), polycythaemia leading to jaundice. 4.5 Please read through the following information before attempting the next station You are a medical student attached to a GP. The next patient is 34 weeks pregnancy and is under shared care between the hospital and the GP. She has been under weekly review because her blood pressure has been raised, as shown below. The practice nurse has measured her blood pressure and performed a urinalysis, the results of which are shown. Explain the results to the patient, the implications to the mother and child, and the course of management you would advise. (5min) CWD= consistent with dates; NAD= no abnormality detected 217

Date 12/4 17/4 22/4 (today)

Week 32+4 33+2 34+2

Fundal Height CWD CWD CWD

BP 155/87 162/78 187/98

Urinalysis NAD NAD Protein/ ++

“I am 42 years old and have always been fit and well, and am 34 weeks pregnancy with my 3rd child. My previous 2 pregs were without any probs and both babies were born at full term by normal vaginal delivery. I had slightly raised blood pressure during my last pregnancy but it settled with rest at home. I was told by both the dr in the hospital and the GP that my blood pressure has again been slightly high but I have been taking it easy and when the community midwives checked it, it has been okay. I ralise I may have to be itted to the ospital but am not very keen because of caring for my other children. My partner is very ive but works 6 days a week and at present cannot afford to take time off. My mother in law has offered to come and stay to look after the children but I am not very keen on this as her health is rather fragile. 2 marks good 1 mark done ok 1. Polite introduction 2. excludes danger signs- epigastric/rightupper quad pain, headache with visual disturbance, motor disturbance, aura, shaking, chest pain. 3. Establishes patients understanding of her BP problem and its implications 4. Estbalishes prev obsteric history and history or preg-induced hypertens 5. explains the risk of eclampsia to mother and fetus in a clear non-jargonistic manner 6. explains that patient requires ission- bed rest, treatment of blood pressure, possible C-S 7. Establishes and discusses reasons why patient is reluctant to be itted. 8. Invites patients questions and answers appropriately 9. does all in a fluent and professional manner Diagnosis- pregnancy induced hypertnesion; patient is now pre-eclamptic requiring ission Comment- pre eclamptic toxaemia is one of the leading causes of obstertric mortality in the UK. Possible crises include eclampsia, HELLP syndrome (haemolysis +elevated liver enzymes + proteinuria), placental abruption, renal failure, cerebral haemorrhage. The spectrum of the condition includes uteroplacental insufficiency and intrauterine growth retardation is commonly associated. The patient requires ission for close monitoring of the blood pressure, biochemistry and foetal well being. Indications for delivery include fetal compromise, inability to control maternal bnlood pressure and the development of maternal symptoms suggesting impending crisis eg right upper quadrant pain. 4.6 You are the medical student attached to an antental clinic. The next patient is a 24 year old primigravida who had a routine ultrasound at 20 weeks gestation which showed a low lying placenta grade 4. She had a repeat scan at 34 weeks gestation, yesterday, which shows the placenta lying anteriorly in the lower segment and covering the os. Explain the US findings to her and the future management. (5min) 1. Polite introduction and rapport 2. establishes ID and reason for attendance 3. Estbaishes ptient’s understanding of situation 4. explains the US results in a clear fashion 5. explains the need for a C-S 6. Invites patient’s questions and answers appropriately 7. Does all in a fluent, professional manner Placenta praevia describes the condition where the placenta lies in the lower uterine segment. It is associated with multiple fetuses, an abnormally large placenta, uterine structural abnormalities, benign and malignant tumours, previous uterine surgery, placenta accreta-increta-percreta. 218

Classification Grade I: The lower margins of the placenta do not reach the os Grade II: The lower margins reach but do not cover the os Grade III: The lower margins cover the os when closed but not when dilate Grade IV: The os is totally covered by the overlying placenta.

219

Paeds OSCE 3 1. Perform developmental assessment. Key ages: Newborn; Supine infant (1.5-2 months); Sitting infant (6-9 months); Toddler (18-24 months); Communicating child (3-4). 1. Important to introduce self to parent and child, 8. talking explain what you are going to do, ensure the 9. Current abilities- gross motor skills patient is comfortable. 10. vision and fine movement 2. Get age, name, sex of child. 11. language and hearing 3. Take history from parent- birth history: labour 12. social behaviour probs?, delivery, birthweight, gestation, 13. Immunisation history 4. SCBU ission? High14. Education risk pregnancy (eg diabetes/ hypertension) 15. Nutrition 5. Ask about age of milestones- smiling, 16. Thank the patient and parent- asks if there is 6. sitting anything they want to add/ ask 7. walking Newborn Gross motor Symmetrical without Movements, Limbs flexed Fine motor grasp. Points. And visual

1.5-2 months

6-9 months

Raises head when prone

Rolls, sits up, some weight-bearing

Symmetrical neonatal reflexes (Moro, rooting, suck etc)

Crawls.

Looks at light/ Scans 90 degrees faces

12 months Stands

Walks/ cruises.

Palmar grasp (7 months) smacks 2 toys Pincer

Stares

together. Transfers toy from hand to hand (7months) Follows fallen toys or red ball Picks up 100’s and 1000’s

Hearing and Responds to noises/ Uses 1+ words meaningfully Language voices Understands several words.

Turns to sound

Babbles. Distraction hearing test

Normal cry. Startle response

Responds to own name. Laughs Distraction hearing test

Social

Responds to parents Drinks from a cup. Indicates

Smiles responsively

Eats a cracker. Oral stage.

Skills.

Plays peak-a-boo

wants. Waves bye.

Stranger awareness Warning signs Abn corneal reflex babbling. Asymmetric reflexes sitting/ weight-bearing

Asymmetric reflexes. No scanning.

Persistent neonatal reflexes

No

No eye , no smile

Hand preference, fisting, squint.

No

220

Poor tone, Poor Responsiveness…

Gross motor

Excess head lag, fails to respond to sound. Squint, nystagmus.

No vocalisation

18-24 months 3-4 years Walks upstairs/backwards/ while carrying toys. Climbs chair. Pedals tricycle. Jumps (3), 24 months: kicks ball Stands on 1 foot >4 seconds (4).

Fine motor Scribbles, turns pages in a book, delicate pincer grip (10-18/12) Mature pencil grip. Copies circle (3yrs), draws a man of three parts (4), copies And visual 3 cube tower (1.5 yrs) 6 cube tower (2yrs). cross (4), builds a bridge of 3 cubes (3yrs), 8 cube tower (3)

Hearing and Knows & uses 2+ words. Can use phrases (24 months) gives 1st and Last names. Recognises colours. Talks in sentences. Language Can point to eyes, nose, mouth etc. Obeys simple instructions. Jabbers continually. Social Feeds self with spoon. Indicates toilet needs Washes hands and brushes teeth. Skills. Removes shoe. Symbolic play. Eats with knife and fork.

Plays with other children, names a friend. Likes hearing and telling stories. Imaginative play. Shows empathy, eg with injured friend.

Warning signs Persistent drooling, persistent casting, not walking/ weightDelayed language, lack of imaginative play, lack of social play, poor eye Bearing, no pincer grip, inability to understand simple commands Loss of milestones- regression eg disintegrative disorder, regressive autism, rett’s, . No words known. Subacute sclerosing panencephalitis, …acquired brain damage. Abnormal gait.

5. Paediatric abdomen exam 1. Introduce self to child and patent 2. Explain to child what you will do, remove top, place supine, check they are comfortable, ask about pain. 3. inspection: jaundice, ascites, peripheral oedema, growth, nutritional status, scars, localised masses, distension (may be normal is younger infants). 4. Hands: clubbing, nail signs- koilonychia, onycholysis etc 5. head/neck/upper body: sclera for anaemia, jaundice, mouth ulcers (Crohn’s), angular stomatitis, atrophic glossitis (b12/folate/iron deficiency), furring of tongue (loss appetite as in appendicitis), dentition.

6. cervical, supraclavicular, infraclavicular, axillary lymph nodes. 7. abdo –ask about pain first. may need to distract them with toy to make them relax. Light and deep palpationstarting away from site of pain. 8. Palpate boundaries of liver, spleen kidneys, bladder. 9. confirm palpation with percussion. Test for shifting dullness of ascites 10. ascultate for bowel sounds 30 seconds before concluding they are hyperactive/hypoactive/ absent. 221

11. groin and genitals- norm not required in osce. Inspect and feel for hernia, feel for testes in boy 12 PR- avoid unless specifically indicated.

13. cover the child, thank child and parent 14. mention testing the urine

2.Neonatal examination 1. wash hands 2. Introduce self to mother and explain what you will do. 3. Ask about complications of delivery/ type of delivery, gestation, birthweight, feeding-urinedefecation, her concerns 4. General- colour, tone, respiratory rate, pulse, dysmorphic features, signs of distress, posture. 5. Head- palpate anterior and posterior fontanelles, 6. measure head circumference 7. Face- check ear patency, accessory auricles, nostril patency 8. red reflex, papillary reflex, eye movements 9. mouth- checks for cleft palate with finger 10. inspects palate with torch and spatula 11. Chest- checks radial and femoral pulses (radiofemoral delay in coarctation), 12. Listens to heart using bell 13. Listens to lung using diaphragm 14. Back- examines spine, checking for neural tube defects especially at sacral pit 15. Checks anal patency with finger 16. Abdomen- inspect abdomen and umbilical cord.

17. palpates abdomen- for spleen, kidney and liver, bladder. 18. Examines genitalia (testes should descend by week 32-34), check for hypo/epispadias. Asks about urinary stream 19. Hips- Barlow (adduct hips +flex knees of supine baby and push backwards and down on medial thigh, attempting to dislocate) and Ortolani tests (abduct hips+ flex knees, attempt to relocate hip by pushing up and forward on lateral thigh). Feel for give/ clunk. 20. arms and hands- check for extra digit, single palmar crease (Down’s) 21. Inspect feet and test range of movement 22. Reflexes/ posture- drag baby up by arms and test for head lag. 23. Moro reflex- lift head and shoulders then suddenly drop them back- arms should abduct and extend symmetrically. 24. grasp- finger in palm set it off 25. knee jerk and babinski (should be extensor in new born) 26. Thank patient and mother.

3.Cardiovascular exam, paeds: norm pulse age <1: 100-160bpm, 2-4: 90-140bpm, 4-10: 80-140; 10+: 65-100 1. Introduce to parent and child. 7. heart palpation incl thrills- character + location of 2. explain to child you will examin him. Position at apex ( 4th intercostals midclavicular line in <8’s) 45 degrees and get to remove top. Ensure they 8. ausc- aortic area, pulmonary area, tricuspid area, are comfortable. mitral area. Classify murmur by timing, grade, site 3. Observation- dysmorphoea, resp distress, and radiation. cyanosis, jaundice, scars of chest etc 9. Murmur may be innocent due to increased blood 4. hands- perfusion, colour, clubbing, splinter flow. haemorrhages, nail signs 10. Chest- auscultate lungs esp at bases 5. Say you would like to record blood pressure 11. abdo examns- eg ascites, polycystic kidneys, (using child size cuff) + pulse enlarged liver. 6. Head and neck inspection- sclera for anaemia/ 12. Peripheral pulses- + feel temperatire jaundice, mouth and tongue for c. cyanosis, JVP 13. Cover, thank child. assessment, locate carotid and assess pulse. 222

Innocent murmurs are common in childhood: systolic, low grade, heard over a small area, asymptomatic. S3 may be heard in children also (rapid emptying of atria). Common cases: Ventricular Septal Defect- thrill, possible hyperkinetic displaced apex and pansystolic murmur at left sternal edge plus s3/s4 (large defect may be silent), louder on expiration (lEft sided). Possible mid-diastolic flow murmur at mitral valve. Patent ductus arteriosus- constant machinery murmur at first left intercostals space radiating to back . Wide pulse pressure with sharp upstroke. Reversed S2 splitting/ single S2 (aortic valve closes later due to increased flow of blood- supplying pulmonary artery and aorta). Mid-diastolic flow murmur at mitral area and midsystolic at aortic area (increased flow) possible. Apex deviation and heave possible. Atrial Septal Defect: mid-diastolic low-pitched tricuspid flow murmur plus pulmonary mid-systolic murmur (increased flow on right side, louder on inspiration- rIght sided), thrill possible, wide fixed (not affected by breathing in/out) splitting of s2, possible right ventricular heave. May cause AF, paradoxical emboli, infectious endocarditis. 90% are ostium secundum defects. Ostium primum defects may be associatied with tricuspid regurgitation, VSD, mitral regurgitation. Pulmonary stenosis: mid-systolic murmur over pulmonary region (increased on inspiration), weak pulse possible. Giant a waves on JVP. Right ventricular heave, thrill over pulmonary area. Right sided s4 possible due to right atrial hypertrophy (high pressure atrial wave reflected off poorly compliant ventricle). Increased splitting S2/ quiet P2. Peripheral cyanosis in severe cases. Aortic stenosis/ Hypertrophic obstructive cardiomyopathy: exertional chest pain, exertional syncope, mid-systolic murmur over aortic region radiating up carotid (louder on expiration, leaning forward- lEft sided), left ventricular heave, apex deviation possible, S2 splitting decreased/reversed/A2 quiet (aortic valve closes later due to lower flow rate), slow rising carotid pulse, narrow pulse pressure, possible thrill. Aortic regurgitation common. Possible S4 (atrial pressure reflected off non-compliant ventricle. Risk of MI/TIA’s/stroke/ infectious endocarditis. Coarctation aorta: continuous murmur loudest at midsystole radiating to back, loud A2, mid-diastolic mitral flow murmur, midsystolic aortic flow murmur (increased flow, louder on expiration- lEft sided) radiofemoral delay, hypertension in right arm compared to left arm + legs, impalpable peripheral pulses, blue peripheries, lack of leg development compared to arms. 4. Paediatric respiratory exam. 1. Introduce self to child and patent 2. explain to child what you will do, place at 45 degrees and get to remove top, ensure they are comfortable, ask about pain. 3. Inspection- look for growth, clues around the bed (eg inhalers) respiratory rate, cyanosis, nasal flare, sub/supra/intercostals recession, hyperexpansion, cough, listen for wheeze/stridor/expiratory grunt 4. Inspection2- look for chest deformity, asymmetric chest expansion, use of accessory muscles, Harrison’s sulci, operative scars 5. Hands- clubbing, peripheral cyanosis, peripheral perfusion, pulse, cigarette stains, hypertrophic pulmonary arthropathy (CF, lung cancer). 6. Head and neck- lymph nodes- cervical, supraclavicular, infraclavicular, axillary lymph nodes, jaundice/anaemia at sclera, central cyanosis at tongue, JVP. 7. Palpation- ask if they have chest pain before touching. Check fore tracheal deviation, 223

8. Check for cardiac apex position 9. palpate for equal chest expansion on front and back. 10. Percuss front and back- including over clavicles and on sides of chest 11. auscultate including “99”. Vesicular/ bronchial? Listen for wheeze, crepitations. 12. look in sputum pot. 13. say you would like to do Peak flow, CXR if necessary 14. Cover child, thank child and parent. Age Respiratory rate /min

premature infant 40-60

term infant 30-50

6 years 19-24

12 years 16-21

6. Paediatric neuro exam 1. Introduce self to child and patent 2. Explain to child what you will do, check they are comfortable, ask about pain. 3. Ask parent child’s age, ask about developmental milestones- walking, talking, smiling etc. Asks about hearing/ vision problems 4. Inspect- look for dysmorphic features, movement in all 4 limbs, muscle wasting, pseudohypertrophy of calves (Duchenne muscular dystrophy), port wine stain- associated Sturge Weber syndrome, adenoma sebaceum + roughened lumbar Shagreen patches + - associated tuberous sclerosis, 6+ café au lait spots + axillary freckles, neurofibromas (seen more after puberty)- neurofibromatosis. 5. gait and movement- if can’t walk, watch crawling/bottom sliding- is he using all limbs symmetrically? 6. look specifically for scissoring/ tiptoeing gait (UMN lesion, Duchenne MD, tiptoe also seen in autism), broad based gait (cerebellar probs), limp (eg hip disloc, trauma, sepsis, arthritis). 7. Watch them getting up from floor. (Gower’s sign in Duchenne- use arms to climb up legs to standing position). 8. Tone- asks about pain before touching them. assess tone and range of movement in all four limbs 9. assess truncal tone in younger children (can they sit uned), test head lag in young infants. 10. power: mainly by observation, looking for antigravity movement 11. reflexes- biceps (c5-6), triceps (c7-8), supinator (c7-8), knee (L3-4), ankle (S1-2), plantar (S1-2). Infants tend to have extensor plantar reflex anyway, so not much use. Test for neonatal/ persisting neonatal reflexes: rooting (pouts when upper lip rubbed), suck, grasp, Moro 12. co-ordination- finger to nose test, jumping (age 3), stands on one foot >4 sec (age 4), stacking cubes (3 by age 1.5, 6 cube tower by age 2, 3 cube bridge by age 3, 8 cube tower by age 3 ). 13. Sensation- indicate that you would test this. 14. indicate that you would test this. 15. Thank patient and parent. 7. UK vaccination schedule 2006 Birth- BCG if deemed at increased risk (dependent on neighbourhood, race, family history) 2months- diphtheria, tetanus, pertussis, intramuscular polio, haemophilus influenza B, neisseria meningitides C, 3monthssame as 2 months 4months- same as 2 months 12-15months- Measles mumps rubella first dose (90% protection). 3-4years- diphtheria, tetanus, intramuscular polio preschool boosters, 2nd measles, mumps rubella (99% protection) 10-14 years- BCG dependent on Mantoux test 16 years- diphtheria, tetanua, intramuscular polio school-leavers’ boost. MMR scare- measles can cause fits, encephalitis, pneumonia, subacute sclerosing panencephalitis, death. 224

Mumps can cause meningitis, encephalitis, deafness, sterility. Rubella in pregnancy can cause severe damage to the fetus, including blindness, brain damage, heart defects, abortion. MMR vaccine is safe and effective, 500 million doses have been given since 1972. One dose gives 90% protection, 2 doses 99%, providing that child is well nourished and has enough vitamin A. Common side-effects include a sore injection site and flu-like symptoms. Very rarely, an allergic reaction can occur. The 1998 Wakefield et al paper did not prove MMR caused autism or IBD. Separate istration of MMR provides no added benefit and would result in reduced coverage. When it was introduced to Japan, autism diagnosis rates continued to increase. At least 80% vaccine coverage is required to prevent epidemics. 95% coverage is required for eradication. “ The possibility of such a link [between MMR vaccine and autism] was raised and consequent events have had major implications for public health. In view of this, we consider now is the appropriate time that we should together formally retract the interpretation placed upon these findings in the paper… no causal link was established between MMR vaccine and autism as the data were insufficient.” Simon H Murch, Andrew Anthony, David H Casson, Mohsin Malik, Mark Berkewitz, Amar P Dhillon, Michael A Thomson, Alan Valentine, Susan E Davies, John A Walker-Smith. 6th March 2004, official statement to Lancet, volume 363, number 9411. 8. SAQ A 16 year-old schoolboy with a known chronic chest condition presents to his GP with a threee month history of worsening malaise, lethargy and loose, offensive porridgey stools. On examination he is pale and cachectic, with marked nail clubbing. Respiraotry examination reveals an expiratory wheeze assocated with coarse bibasal crackles and copious green sputum. His BM is 17-28. a) what is the underlying disorder? (1) b) which 3 complications has he developed? (3) c) Loist the long-term treatment strategies you would employ (6) a. cystic fibrosis b. Pancreatic endocrine involvement leading to diabetes mellitus. Pancreatic exocrine involvement leading to steatorrhoea and malabsorption. Bronchiectasis. c. Nutritional with pancreatic enzyme supplements and regular dietetic review. Diabetic education and insulin therapy. Daily chest physiotherapy which may be performed by relatives. Rapid and appropriate treatment of infective exacerbations. Sputum viscosity reduction (eg DNases), genetic counselling of parents and siblings. Consider for heart lung transplant. Consider entering therapeutic trial. Comment- CF is an autosomal recessive disorder, whose gene mutation has now been localized to the long arm of chromosome 7. The protein encoded in this region is called the cystic fibrosis transmembrane regulator. With improvements in physiotherapy, antimicrobials and nutritional , life expectancy is now 30-40 years. Patients usually present in childhood with recurrent pulmonary problems, CF being the main cause of suppurative lung disease in this age group. They may also present with constipation or even acute obstruction due to meconium ileus equivalent, meconium ileus being a presenting featurein the neonate. Males are invariably infertile due to the absence of the vas deferens and epididymis, but females are able to give birth. The diagnosis is confirmed from the family history, a sodium sweat test and chromosomal analysis. Treatment should be instituted and followed up in a regional centre of excellence, so that complications are rapidly identified and minimised. Pseudomonal chest infection is the main cause of exacerbation of chest symptoms and often the cause of death. Newer anti-pseudomonal regimes include ticarcillin, azlocillin, imipenem, tobramycin. Heart lung transplant is tried in severe cases. Gene therapy may one day offer a cure. 225

9. Asthma You are the house officer on a gen med firm. Take a history from a 23 year old asthmatic with acute shortness of breath. He can speak in stilted sentences, pefr= 220l/min. (5min) “I am 23 years old and asthmatic, poorly controlled. I was diagnosed age 14, and have at least 1-2 ission per year since. The last one was 3 months ago and I was ventilated in ITU. I have been ventilated 3 times. I smoke 5-10 per day and have to use my inhalers 5-10 times a day. I am on salbutamol, atrovent and beclforte inhalers and have been on prednisolone 30mg for the past 4 days. My normal PEFR when well is 550l/min. The present illness started 5 days ago with a slight head cold, but I am now coughing up thick green sputum and am short of breath and wheezy, particularly at night. I am sleeping very badly and feel exhausted, like before I was ventilated the first time. I had a fever but no blood in sputum or chest pain. I have no pets, do not know about exacerbants of asthma. I did not have hayfever or eczema as a child and there is no such stuff in my family. Will I need to be itted or will I be able to go home? 2- done well, 1- done okay 1. Polite introduction; establishes rapport 9. haemoptysis 2. Establishes duration of asthma 10. worsening wheeze 3. Establishes normal asthma control- meds and 11. fever frequency, normal PEFR 12. chest pain 4. Establishes previous issions 13. disturbed sleep 5. Establishes patient has been ventilated 14. Gets smoking history 6. Establishes duration and nature of present illness 15. Asks about precip factors 7. Establishs/ excludes:- cough nocturnal or 16. When askes, appreciates patient needs ission daytime? 17. fluency 8. sputum colour and vol Diagnosis= poorly controlled asthmatic now needing ission due to acute infective exacerbation. 10. Dermatological history 1 . introduce self to patient. 2. Explain you are going to ask some questions to uncover the nature of his/ her skin problem and ask for consent. 3. Ensure that (s)he is comfortable 4. Asks patient to describe problem 5. HPC- When where and how problem started 6. What initial lesion looked like and how it has changed 7. Symptoms- espec pain, pruritus and bleeding 8. Aggravating factors such as sunlight, heat, soaps…

9. Previous skin disease 10. Atopic symptoms (allergic rhinitis, asthma, childhood eczema) 11. Past or present medical illnesses 12. surgery 13. drugs- prescribed and self istered treatment including creams 14. cosmetics and moisturising crea,s 15. Allergies 226

16 family history- medical history of parents sliblings children’s skin 17 sexual s 18. occupation in detail- does skin improve on holiday 19. hobbies- detail

20. home background 21. alcohol consumption, travel especially to tropics 22. systems review if req. 23. thank patient. Asks if they have anything to add.

11.. Examination the skin 1. introduce self to patient 2. Explain you are going examine, gain consent 3. Ask to undress to underwear 4. Ensure pt is comfortable 5. Ask pt to report any pain in examination 6. ensure adequate lighting 7. Describe distribution and colour of the lesion (s). Look at whole body 8. Describe morphology of individual lesions, commenting on their size, shape, borders, elevation and spatial relationship. Use derm . 9. Note 2dary skin lesions such as scaling, lichenification, crusting, excoriation, erosion, ulceration, scarring

10. palpate lesions, assess consistency, do they blanch? 11. Examine nails 12. examine hair 13. examine mucous membranes 14. check for lymphadenopathy 15. check the pedal pulses, if appropriate 16. offer to help the patient put his clothes back on. 17. thank the patient 18. wash your hands 19. summarise your findings and offer a differential diagnosis.

12. Give advice on sun protection 1. Introduce yourself 2. Tell what you will explain, determine what is already known 3. Explain there are 3 types of radiation from the sun- UVA, UVB, UVC 4. UVA and UVB cause skin cancer 5. UVC does not reach the surface of the earth and is therefore of no concern 6. Other than cancer, UV causes burns and rapid ageing 7. white people, especially if have freckles/fair skin/ redhead most vulnerable; dark skinned can get skin cancer too. 8. UV levels depend on time of day, time of year, latitude, altitude, cloud cover and ozone cover 9. explain 4 ways of avoiding UV damage- avoiding outdoors 11am-2pm

10. seeking shade 11. covering up- hat and sunglasses conforming to British standard 2724 12. applying sunscreen/ sunblock 13. Sunscreen’s star rating is an indicator of its protection level vs UVA 14. a sunscreen’s sun protection factor is a measure of its UVB protection 15. It is advisable to use at least 3 star block, SPF 15 or more 16. Sunscreen should be applied thickly over all sunexposed areas and re-applied regularly. 17. Sunscreens should not be used as a means to spend more time in the sin 18. advise patient to report any moles that change in colour, shape, texture or size. 19. thank the patient, ask for questions.

227

Paeds Osce 4 1.Plab OSCE. 15 year old girl presents to A&E requesting emergency contraception because she had unprotected sex 48 hours ago. Take a relevant history and suggest appropriate management. (5min) ANSWER 1. communication- smile and introduce self. 2. Reassure that even though she is under 16, she is entitled to emergency contraception without the knowledge or consent of her parents and that everything that is said between you remains confidential. 3. Ensure she is Gillick competent- understands what treatment is, why it is proposed, understands risk of treatment, understands risk of not going ahead with treatment. 4. PC: Elicit history of unprotected sex and risk of pregnancy. “Why do you think you could be pregnant?” 5. “Did vaginal penetration occur?” 6. “What contraception have you been using? Why did you think it failed?” 7. Confirm barrier failure/ pill failure 8. “Where in your menstrual cycle re you?” The most fertile period is days 10-19 9. “What are your views on regular contraception?” 10. Other- “When did you start menstruating?” 11. “Are you periods regular? How long do they last? Are they heavy?” 12. “Have you ever been treated for a sexually transmitted disease?” 13. “Have you been pregnant before?” 14. Drug history- “Are you taking any antibiotics or any other medication?” The combines O is less effective in the presence of oral antibiotics or anti-epileptic drugs. 15. Management- “I would inform her that she has 2 options. She can take Levonelle which in her particular case gives her an 85% rate of successful contraception, or be fitted with an IUD coil, which would be 99% effective. [Each tablet contains 750 mcg levonorgestrel (progestogen only). According to the April 2000 Guidance sheet for emergency contraception and the recommendation for clinical practive, Levonelle-2 is 95% effective within 24 hours, 85% effective at 48 hours and 58% at 72 hours. If she would like a method that is 99% effective, and IUD can be fitted- works up to 5 days following unprotected sex. ] 16. Explain next period may be early or late, a barrier method of contraception must be used til the next period 17. needs to wait at least 3 weeks after intercourse for pregnancy test to be valid. 18. she needs to go to GP/ family planning clinic within week of expected next period. Go to GP/A+E promptly if any lower abdominal pain occurs, due to risk of ectopic- also in 3-4 weeks if menses are abnormally heart/light/ brief or if she has any concern. 19. Mifepristone anti-progesterone agent can induce miscarriage up to 9 weeks into pregnancy. Combined with prostaglandins, can induce medical termination later. 20. Discuss STI screen 2. 1. 2. 3. 4. 5.

This boy has sudden diminished hearing in his right ear. Examine the ear. (5min) Politely introduce yourself to the patient Ask if you may examine his ears Asks him which is the better hearing ear Ask him if the ear is tender before you touch it Sit down alongside the patient and use a light source as you examin the pinna and behind for scars, redness or discharge. 228

6. Assemble an otoscope or auroscope- whichever is provided- and examine the better hearing ear first unless told only to examine the right ear. Possibly ask parent to hold child’s head. Anchor hand holding otoscope to boy’s head, to prevent damage if head moves, use pencil grip for otoscope. to retract the pinna to straighten the tortuous external auditory canal. 7. Examine the canal for oedema, discharge and vesicles. 8. Examine the tympanic membrane for perforations. Is the perforation dry or wet, central or marginal? What structures do you see through the perforation? Malleus, incudostapedial t, promontory etc. 9. Examine the pars flaccida (attic of the tympanic membrane for crusts) and the pars tensa for a bulging membrane or a retracted membrane. 10. At this point, examiner may ask you what you have foind. The diagnosis may be a perforation, mastoid cavity, otitis media, otitis externa etc 11. In reality, a complete ear exam continues with steps 12-14. However, owing to the time permitted, you will only be judged on your ability to use the auroscope or otoscope confidently and professionally. 12. Conduct free-field speech tests. Rub the tragus of the non-examining ear to occlude the canal. Whisper words to the exposed test ear at distances of 60cm and then repeat different words at conversational level at 60 cm and then 15cm from the exposed ear. Repeat diffeent words at a raised voice level at 60cm and 15cm. This will give you an idea of the decibel hearing loss. 13. Conduct the Rinne and Weber tuning fork tests using a 512 HZ fork. 14. For the weber test, place the vibrating fork on the middle of the patient’s forehead and ask him which ear he can hear the fork the loudest or if it sounds the same in both ears? If he cannot hear the fork, place it on the bridge of the nose. The patient should hear the tuning fork better in the left ear if hehas a sensorineural loss in the righ or he should hear it better in the right if he has a conductive loss in the right. 15. Rinne: ask patient to tell you which is louder? First place the tuning fork on the mastoid process and then hold the vibrating fork 4cm away from the external auditory meatus and ask him to tell you which is louder. Alternatively, the original test was to wait until the fork could be heard no longer on the mastoid process and asking the patient whesther he could hear when placing the fork in front of the ear. In either case, if sound is better heard when the fork is on the mastoid process, a conductive hearing loss is suggested, ie bone conduction is better than air conduction. If the tuning fork is heard louder or continues to be heard after decay of the fork on the mastoid process, then the patient either has normally hearing in that ear or a sensorineural hearing loss. 16. Test the facial nerve. Ask the patient to raise his eyebrows (temporal branch), shut his eyes (zygomatic branch), blow his cheeks (buccal branch), and show you his teeth (mandibular branch).

3. A 13 year old boy is struck on the head by a cricket ball. Assess his level of consciousness using the Glasgow Coma scale. (5min) Function

Response

Score 229

Eye opening

Spontaneous To speech To pain None

4 3 (respond to shouting or speech) 2 (can be tested by sternal rub or supra-orbital pressure) 1

Best verbal response Orientated 5 (to person, place and time) Confused orientation 4 (responds, but at times disoriented) Inappropriate words 3 (random speech) Incomprehensible sounds 2 (moaning) None 1 Best motor response Obeys commands 6 Localizes (response to pain) 5 (can be tested by pressing down on the fingernail bed or by applying supra-orbital or sternal pressure) Flexes- normal 4 (patient withdraws to pain) Abnormal 3 (patient responds by decorticate posturing to painful stimuli. The position of the upper limbs is likened to a rabbit with its raised paws) Extends (to pain) 2 patient responds by limb extension ie adduction, internal rotation of the shoulder and pronation of the forearm) None 1 4.Thomas is a 12 year old boy complaining of fever, cough and shortness of breath. Interpret his CHEST X RAY. (5min) 1. Remark on the view in which the film was taken. “this is a PA and lateral view of the chest. 2. The obvious abnormality is the presence of patchy consolidation suggestive of staphylococcal pneumonia. 3. Remark on the heart, mediastinum, hila, diaphragm, root of the neck and trachea, lung fields, soft tissues, bones. 5. This 18 year old presents with weight loss amenorrhoea and depression. Take a relevant history and suggest a likely diagnosis. (5min) 1. Introduce yourself tro the patient and establish a rapport 2. Note the appearance of the patient and how she interacts with you. What is her affect like? Does she avoid eye ? 3. Start with an open-ended question and ask her about her childhood and adolescence. This will help her relax and express herself in her own words. 4. Gear the converstaon towards the present complaint. How long has the weight loss and depression been bothering her Did any life event trigger this problem? 5. What was her premorbid condition? Was she always depressed or is this a recent change? 6. What is the patient’s insight into her own problem? How would she like you to help? 7. Ask specific questions about her weight loss. How much weight has she lost and over what period? Does she binge or induce vomiting? 8. Ask specific questions about he amenorrhoea. When did her periods stop? Had her menstrual cycles been regular? Does she exercise excessively? 9. - sleep disturbance?- am waking, insomnia 10. How does she feel about the future? 11. Has she ever considered harming herself or thought about suicide? 12. Ask about personal or family history of psychiatric illness 13. Ask her about her social habits- drinking alcohol, smoke, or indulge in recreational drugs 14. Suggest she may be suffering from anorexia nervosa and depression. Suggest that you would like to perform a physical examination for evidence of anorexia such as ketone breath, lanugo hair, acid burns on the oral cavity, 230

chipped nails from acid damage etc and would arrange for blood tests to exclude metabolic disorders. Suggest psychotherapy and SSRI (antidepressants) if the diagnosis is confirmed. 6. Obtain informed consent for appendicectomy from 16 year old patient. (5min) 1. Introduce yourself to the patient and establish a rapport 2. Explain that it is necessary for her to undergo an operation to remove her inflamed or diseased appendix called an appendicectomy. At age 16, she is of legal age to give consent 3. Ask her what understanding is of the procedure and what her concerns are. 4. Explain the procedure- general anaesthesia, small incision lower right hand side abdomen, opened to identify appendix. The appendiceal artery, appendiceal mesentery and base of the appendix will be clamped, divided and ligated. The appendix will be removed and the appendix stump ligated and buried in a purse-string suture. The peritoneum and muscle layers are closed with absorbable sutures and the skin is closed with interrupted nylon sutures or subcuticular prolene. The skin sutures will need to be removed in a week’s time. 5. Explain the risk is small but needs to be addressed- infection, pelvic or abdominal abscess, paralytic ileus. If she develops infection, she should be treated with IV antibiotics. If she developed a pelvic abscess that did not respond to antibiotics, she may need a second operation. If she developed a paralytic ileus, she would be managed with IV fluids and NG tube until the ileus settled and her bowels returned to normal. 6. Explain that the benefits far outweight the risks. Explain that the appendix could rupture and lead to peritonitis and gangrene, which can kill. 7. Explain that she would likely remain in hospital for 3-5 days. 8. Ask her if she has understood or whether she needs you to clarify any points. 9. ask her if she would like to any family and involve them in her decision-making process if she feels unsure. 10. Complete the consent form with the name of the operation and a short list of the complications. Print, sign and date the consent form. 11. Have her read the consent form, print sign and date at the bottom. 7. 1. 2. 3. 4. 5. 6.

7. 8. 9.

Instruct on how to use a peak flow meter and interpret results. (5min) Introduce yourself to patient and establish rapport Hand her peak flow meter with fitted attachment Ask her to take deep breaths in and out. Ask her then to hold a deep breath and blow as hard and as fast as she can into the peak flow meter. Make sure she has maintained a proper seal with her mouth. Read a peak flow meter Give her another attempt and record the best reading. Ask her for her height. She states she is 5 foot 3. Know how to convert feet to metres: 1 inch= 2.54 cm. She stands 1.6m tall. As she is only 22, she should achieve a peak expiratory flow rate (PEFR). Of just over 400l/min. At age 40, she should achieve a PEFR of 400l/min and by age 6o this falls to 350l/min. An average young man standing 1.85 m (6 foot 1) should achieve a PEFR of 650l/min and a young man standing 5’ 7’’ should achieve 600l/min. These fall by 50l/min by age 40 and by 100l/min by age 60. If her present PEFR falls below her normal PEFR she will need to increase her dose of inhalers during her bout of chest infection. Thank the patient for her cooperation.

8. Miss P is an 18 year old woman who has recently been diagnosed with epilepsy. She is discharged home on valproate. Offer her discharge instructions for epilepsy. (5min) 1. Introduce yourself to the patient and establish a rapport. 2. Explain that she has been diagnosed with epilepsy but is well enough to be discharged home. Explain that epilepsy means seizures or its and that often the cause is unknown. 3. Explain that she has been started on an anticonvulsant medication called valproate to prevent further seizures. Explain that she must not stop unless advised by her GP. State that possible side effects include drug interactions, folate deficiency, nausea, ataxia, weight gain… but most are associated with chronic use. 231

4. Ask her if she is taking a combined oral contraceptive pill. Advise her that valproate interacts with combined O (p450 inhibitor, therefore increases drug levels) and she should see her GP to change the dose. 5. Explain the social consequences include a ban on driving if she has had more than 1 seizure. To obtain a UK license she has to have been seizure free while awake for 1 year, if her attacks occur in her sleep, she must have been seizure free for 3 years before the issue of a license. 6. Explain that the laws are stricted for public service vehicle or heavy goods vehicle licenses and that she will not be issued one. 7. Advise her to wear an ID bracelet to alert people she has epilepsy in case she collapses. 8. Advise the patient to avoid swimming alone or engaging in risky sports alone. 9. Advise the patient to take showers rather than baths. 10. Inform she will be sent a follow up appointment for 4-6 weeks. 11. Inform the patient that the GP will receive a copy of her hospital discharge paper and that he will be capapble of managing her care 12. ask the patient if she has any questions. Ask if she has understood everything that has been explained to her or whether she needs clarification.

9. Mrs T is a 35-year-old mother who is telephoning for advice on how to manage her 2-year-old daughter who is febrile with an ear infection. She is reluctant to bring her daughter into hospital for examination. Give her telephone advice as to why she should bring her daughter to hospital and explain the daughter’s risk of meningitis . (5min) 1.dentify yourself to Mrs James on the telephone 2. ask her how you can help. She explain daughter has high temp,not sleeping, complains of right earache. She thinks her daughter has an ear infection. She has tried calpol to settle the temperature and pain, but to no avail. She exaplins that her GP cannot see her until next week. Should she bring her daughter to casualty today? She has hear da lot in the news about meningitis, should she be concerned? 3. Asks her if she has taken daughter’s temp and if so, how high it is. She tells you it is 40 degrees. Inform that the CF of meningitis include fever, vomiting, headache, neck stiffness, photophobia, anorexia, irritability, confusion and lethargy. Has the child had any of these? Has the child had a recent chest infection? Does the child have a rash that does not blanch to pressure? Mother denies all except fever and right ear pain 4. Reassure the mother that the child probably doesn’t have meningitis but that as the temperature is so high, she should bring her in to paediatric casualty for assessment. The child may have an ear infection that will need to be treated with antibiotics. The child can also be assessed to exclude other causes for her pyrexia and be treated accordingly, as calpol has had little effect. 5.Ask the mother if she has other questions. 10. Miss G is a 17-year-old who complains of malaise and easy bruising. She is always covered in bruises. Her gums bleed when she brushes her teeth, and her periods are heavy and painful. She also complains of recurrent painful mouth ulcers. She has no family history of bleeding dyscrasias. She does not smoke or drink. She is not taking any medication. On examination, you note gum hypertrophy, oral candidiasis and painful lymphadenopathy. You decide to take full blood count, clotting and U+E. Interpret the results below and suggest a likely diagnosis. How would you confirm this diagnosis? (5min) WCC: 11.8 x 10 ^9/litre Hb: 6.5g/dl Platelets: 10^9/litre INR: 0.9 Blood film: few immature blast cells MCV: 84fl ESR: 20mm/hr APTT: 1.1 Sodium: 139mM Potassium: 4.6mM Urea: 6.7mM Creatinine: 116uM Glucose: 5mM 232

1. The obvious abnorms are anaemia, thrombocytopenia, and the presence of a few immature blast cells on blood film 2. the most likely diagnosis is acute leukaemia. In this patient, AML, rather than ALL is suggested by the presence of gum hypertrophy 3. The diagnosis is confirmed by bone marrow examination for a proliferation of blast cells derived from the myeloid elements. 4. Treatment is threefold and involves ive care with blood and platelet transfusions, chemotherapy with daunorubicin, cytosine arabinoside and thioguanine and allogenic bone marrow transplant infused intravenously. 11. Miss F is a 14 tear old girl with widespread acne covering her face, back and arms. She has tried trimethoprim and benzamycin gel andno success. You are the dermatology SHO. Suggest to the patient’s mother that her daughter tries triple therapy with minocin MR tabliets, dianette pills and differin gel. The mother is anxious to know about any sideeffects with these drugs. Counsel her. . (5min) 1. Introduce yourself to patient and her mother and establish a rapport 2. explain that as trimethoprim and benzamycin gel has not been tolerated, that you would like to suggest alternate treatment with minocin MR (minocycline), dianette and differin gel for 3 months 3. Explain that minocin MR is a once a day antibiotic in the tetracycline class. Explain that the advantage of this antiobiotic is that it offers less likelihood of bacterial resistance. Bacterial resistance is associated with other antibiotics used for acne treatment such as erythromycin. Exaplin that as the patient has all her adult teeth present, she is not at risk for tooth staining. Explain that the reported side effects of minocin MR occur with > 6months use and include liver damage and systemic lupus erythematosis. She will only be taking the antibiotic for 3 months and so should not be at risk. Other reported side-effects include dizziness, rash or pigmentation. If this should occur, the drug should be discontinued. 4. Explain that the second pill is called dianette. Explain that it is both a form of hormonal therapy for acne and a combined oral contraceptice. Explain that the advantage is that it is licensed to be used for the treatment of acne in cases that have shown resistance to antibiotics. 5. Contraindications to the use of this drug include a history of migraines with a focal aura, hypertension, smoking, a family history or arterial disease or venous thromboembolism in a first degree relative aged <45. The reported side effects include nausea, comiting, headaches, breast tenderness, fluid retention and reduced menstrual flow. This does not imply that she will necessarily experience all or any. If she does, report to her GP. The patient is to take 1 tab a day from day1 of her cycle for 21 days and then have a 7 day pill free period before starting a new pack. 6. Explain that the differin (adapalene) gel is a topical retinoid used to treat mild to moderate acne. It is to be applied in a thin layer to the areas of acne at bedtime. Reported side-effects include local reactions such as stinging, burning, erythema or peeling. If this occurs the drug should be stopped. The patient’s skin will be sensitive to UVB light and sunlight. 7. Ask the patient and mother if they have any questions or whether they need anything clarified. 8. Hand them prescription. 9. Ask them to make a follow up for 3 months or more.

Paeds OSCE 5 CXR checklist A-H - Talley O connor A. airway (midline, no obvious deformities, no paratracheal D Diaphragms (rt above left by 1-3cm, costophrenic angles masses) sharp, diaphragmatic contrast with lung sharp) B. bones and soft tissue ( no fractures, subcut emphysema) E. Equal volume (count rubs, look for mediastinal shift) C. Cardiac size, silhouette, retrocardiac diameter normal F. fine detail (pleura and lung parenchyma) 233

G. gastric bubble (above the air bubble one shouldn’t see an opacity of any more than 0.5cm width)

H. hilum (left normally above right by up to 3cm, no larger than a thumb), hardware: endotracheal tube, Hickman line

1. A 43 year old bricklayer is itted through the Accident and Emergency department with a 3 day history of vomiting “coffee ground” material and 18 months of progressive dyspeptic symptoms, which are partially relieved by antacids. a. State the probable clinical diagnosis (2) b. State 2 investigations to confirm your diagnosis and the expected findings (3) c. List the drugs and their therapeutic regimes used to cure this disease (5) a. Peptic ulcer disease b. Patient is <45, therefore if H.Pylori is present, OGD unnecessary unless danger signs- lymph nodes (eg Virkow), weight loss, haematemesis/melaena, anorexia, family history of gastric cancer, previous cancer. non-invasive H-pylori tests: radiolabelled urea breath test, H. pylori serology (remains positive months after eradication), stool immunoassay invasive: OesophoGastroDuodenoscopy to visualise ulcer with biopsy and culture/ stain (Giemsa)/ urease test. Also use OGD + biopsy to exclude biopsy. c. Aim to eradicate helicobacter pylori. Combine proton pump inhibitors with antibiotics. Eg ranitidine omeprazole 20mg OD, Metronidazole 400mg BD + amoxicillin 1g BD 1 week. May continue H2 blocker or PPi for 2 months after to promote healing. Bismuth promotes ulcer healing by its anti-helicobacter activity and stimulates prostaglandin synthesis at ulcer crater. It is used in some regimens alongside 2 antibiotics and is cheap. It has bad taste, blackens the tongue and stools and is not heavily marketed. Eradication has ~80% success but requires good compliance. If no evidence of H.Pylori (minority of cases), try H2 blocker eg cimetidine 400mg BD for 2-3 months or PPI like omeprazole 20mg OD for 4 weeks. Subsequent urea breath test / endoscopic biopsy with Giemsa stain to check ulcer has healed + H.pylori eradicated. Lifestyle- recommend to avoid smoking, alcohol excess, take regular meals, avoid NSAID’s use, corticosteroids if possible. May use low dose H2 blockers/ PPI’s at night time or for subsequent attacks. 2. pastest osce: You are a GP. Take history from 18 year old lady with 5 th UTI in past year, with view to referring her to renal outpatients. ANSWER “ I am 18 years old and for the last 5 years I have been getting recurrent urinary infections, blood in my urine. Most recently I have had dull pain in my lower back. In the last 18 months I have also had recurrent headaches and visual disturbance. My mother and grandmother both had kidney disease and my mother died of a bleed inside the brain. Each episode of infection is relieved for a week or two by antibiotics but I have had to self-medicate from time to time to stop them coming back so frequently. Each infection lasts for 5 to 6 days with frequency, as well as pain and blood when I urine. I have been itted on three occasions with severe infections with associated fever and shakes. I have never been further investigates because I am terrified of the possible diagnoses and have always discharged myself from hostpital before secondary investigations. I have also moved about a lot because of my father’s job in the navy. (5min) 1. 2. 3. 4. 5. 6. 7.

polite intro Establishes duration of urinary problems establishes symptoms of UTI Establishes associated fever and rigors establishes symptoms of PCOS: UTI’s loin pain haematuria

8.

features of hypertension

9.

establishes family

history of renal disease 10. Establishes mother died of subarachnoid haemorrhage 11. Makes reasonable attempt at a diagnosis 234

12. Does all in a fluent, professional manner Diagnosis: recurrent UTI secondary to adult polycystic kidney disease. 3. The following urine sample results have been reported in the microbiology lab. Please match the specimens with the histories. (5min) 1. 29 year old Asian woman with night sweats and rigors 4. 33 year old with deranged U+E and ankle oedema 2. 74 year old man with indwelling catheter 5. 25 year old pregnant woman 3. 25 year old man with a history of renal stone and acute severe loin pain. A. MSU: E Coli >10^5 colony forming units per ml, WCC 750/mm³. resistant- amoxicillin, trimethoprim. Sensitivegentamicin, nalidixic acid B. EMU: acid fast bacilli grown after 6 weeks C. urgent microscopy- no organisms, WCC 100/mm³, red cell casts identified D. MSU- no organisms seen, WCC > 1000/mm E. CSU pseudomonas > 10^5 CFU per ml, WCC <1/mm. Sensitive- gentamicin, ciprofloxacin. 1B: This urine culture has grown acid fast bacilli, priving this woman has renal tract TB. This requires at least 6/12 treatment. 2E: Although there is significant pseudomonas growth, the white cell count indicates this is likely to be a contaminant. Unless the patient is unwell, this should not be treated with antibiotics 3D: This patient has renal colic secondary to recurrent stones. The specimen shows a sterile pyuria. Other causes include interstitial nephritis, papillary necrosis and tuberculosis of the renal tract. 4C: Renal red cell casts are indicative of renal disease. The history is suggestive of renal failure with a possible nephritic syndrome. 5A: E.coli is a common organism causing urinary tract infections. Other common causes of UTI include proteus, staphylococcus saprophyticus or epidermis and klebsiella

4. Take a history from a patient with epigastric pain and proven microcytic anaemia. Take HPC and any other relevant past medical history with a view to making a diagnosis. (5min) ANSWER “I am a 32 year old scrivener and I am normally fit and well. I drink and smoke too much and live on takeaways. [when pressed it to 30 cigarettes/day, 30-40 units of alcohol per week in the form of lager]. In the past 6 months I have had increaper abdominal pain, which is particularly bad when I am under stress or have been on a binge. The pain is burning in nature and radiates though to my back and occasionally behind my breast bone. It is relieved with rennies and alka-seltzers. It is usually worse when I am hungry and better after meals. I have been otherwise well, with no other GI symptoms. My weight is stable and my appetite is fine. I have never vommed blood but I did have some black stools one morning after a particularly bad episode a few weeks ago. I have bever had any peptic ulcers, hiatus hernias or gastritis in the past. I have had no symptoms suggestive of anaemia, eg shortness of rbeath, chest pain or faints, but Have been feeling tired of late. 1. polite intro 2. establishes onset of symptoms 3. Establishes characteristics of abdo pain- site and radiation

4. – exacerbating factors 5. – relieving factors 6. Establishes/ excludes haematemesis, melaena, fresh blood PR 235

7. Establishes/ excludes dyspepsia, retrosternal burning and water brash 8. establishes associated GI symptoms- weight loss, anorexia, nausea and vomiting, dysphagia 9. establishes risk factors for PUD- use of alkaseltzer (aspirin) 10. – alcohol excess Diagnosis: peptic ulcer disease

11. 12. 13. 14. 15. 16.

– smoking – previous ulcer – known hiatus hernia Establishes/ excludes symptoms of anaemia makes reasonable attempt at diagnosis fluency

5. Please answer the following T/F questions associated with the preceding history (5min) 1. this patient should have an 6. This patient may require ‘ triple therapy’ oesophogastroduodenoscopy 7. Triple therapy is given for 3-4 weeks 2. This patient will have a high plasma ferritin 8. Clarithromycin is commonly used in triple therapy 3. this patient may have koilonychias 9. Cimetidine is a proton pump inhibitor used in triple 4. This patient will have a raised MCV therapy 5. This patient should have a CLO test 10. this patient requires life-long omeprazole ANSWER: T F T F T T F T F F 6.Pastest All of the following have haemolytic anaemia. Match patient histories with diagnoses and markers (5min) History 1. 29 year old Italian man with haemolytic anaemia Disease marker after eating fava beans. a. Warm antibodies (igG), Coombs’ positive 2. 34 year old man with cough, fever, bullous autoimmune haemolytic anaemia myringitis, erythema multiforme b. Hb beta chains that have glutamine not valine at 3. 7 year old Greek girl with transfusion siderosis position 6 and frontal bossing c. Hb electrophoresis shows increased Hb F 4. 24 year old man with butterfly malar rash; renal d. Heinz bodies in the blood failure secondary to glomerulonephritis and antie. Cold antibodies (IgM), Coombs’ positive double stranded DNA Ig antibodies. autoimmune haemolytic anaemia 5. 21 year old Afro-Caribbean man with abdominal and bone pain. Diagnosis A: sickle cell disease. B: B-thalassaemia. C: G6PD deficiency. D: Mycoplasma pneumonia. E: SLE ANSWERS 1dC: G6PD deficiency is an X-linked disorder which has several recognised variants. The variant suffered by black Africans and Afro-Americans (G6PD GdA-) has a self-limiting haemolytic anaemia as the bone marrow is able to compensate by increasing red cell production. In the Mediterranean variant (G6PD Gd Med) following an oxidant insult (eg sepsis, MI, diabetic coma) gross haemolysis occurs and will be fatal unless the cause is treated and the patient transfused. Classically this reaction may be seen after eating fava beans. Heinz bodies are seen on the film, hence “beans means Heinz”. 2eD: This patient presents with the classical symptoms of a mycoplasma pneumonia. This is associated with a cold antibody (IgM) Coomb’s positive autoimmune haemolytic anaemia. A Coomb’s test is performed using a combination of the patient’s serum and Coomb’s serum. Coomb’s serum is an antihuman serum and causes agglutination of the patient’s red cells if certain antibodies are present on their surface. The temperature at which these antibodies attach themselves to the red cells characterize the haemolysis into cold (37 degrees) and warm (40 degrees C) types.

236

3cB: B thalassaemia is a haemolytic disorder found especially in the middle east, Mediterranean and Indian subcontinent. The patients with severe disease, thalassaemia major, present in the first few years of life with recurrent infection, severe anaemia and extramedullary haemopoiesis. These patients require regular transfusion and often develop transfusion siderosis. This is countered by using the chelating agent desferrioxamine. 4aE: SLE is associated with a warm (IgG) Coomb’s positive autoimmune haemolytic anaemia. Other causes include carcinoma, haematological malignancy (eg CLL and lymphoma) and drugs, the common being methyl dopa. 5bA: Sickle cell disease is a common haemolytic disorder in Africans. It also occurs in the Indian sub-continent and the Middle East. The haemolysis is often mild in heterozygotes and may remain undiscovered until a severe insult, such as sepsis or general anaesthesia. Homozygotes present in childhood and suffer a debilitating multisystem disorder. Complications include bone pain, bone necrosis, including avascular necrosis of the femoral head, rarely salmonella osteomyelitis; cerebrovascular events, epilepsy, acute papillary necrosis and tubulointerstitial nephritis causing renal failure, chest crises causing respiratory failure. Treatment requires addressing the cause of the crisis, hydration with IV fluids, oxygen via face mask and opiate analgesia.

1. You are a GP. Your patient Burt Reynolds, 65, has ischaemic heart disease and is on low dose aspirin, GTN spray, atenolol 50mg BD, simvastatin 20mg nocte plus bendroflumethazide 2.5mg mane. Ascertain how well this regimen is going, explain why he should be taking his antihypertensives and what side-effects are to be expected. [5 minutes] “Hello I am Burt Reynolds. Two weeks ago I was put on this medication for heart disease. I occasionally get chest pain when I am doing the gardening, or walking up one flight of stairs. It lasts ten seconds, does not radiate anywhere, is burning sensation under left nipple. It gets better when I rest. 4/10 intensity. I have never had a heart attack or any heart surgery. I do not have diabetes. My father died of a heart attack aged 82 [not a risk factor] but no one else in my family has IHD, I smoke 5-10 cigarettes a day and drink 10 units a week maximum. I do not get much exercise except golf, sex and gardening. I took these pills for 5 days but then stopped. I was getting tired, nauseous and depressed. [Only mention if asked specifically]- I recently got married and felt they were causing bedroom problems. They were also giving me a cough and double vision. My main problem with them is bedroom problems and this caused me much distress. Now I just take the aspirin daily, and atenolol when the chest pain comes on, approximately once per week. What do you think is causing my chest pain? Should I have a by? 2- done well, 1- done okay 1. Introduction 2. IHD history- chest pain brief history 3. asks about other risk factors – Fhx, smoking, diabetes, alcohol 4. Asks about adherence to antihypertensives 5. Asks about side effects 6. ascertains how much side effects bother patient 7. summarises back to patient 8. Explains why he is on meds and importance of regular usage for drugs to work- aspirin, statins prolong survival with IHD, others reduce blood pressure. 9. explains GTN is a reliever of chest pain, others are for daily use 10. Explains which reported side effects are associated with the medicines- eg GI bleeds from aspirin, postural hypotension from antihypertensives plus possible fatigue, erectile dysfunction, GTN causes headache. Fatigue and ED may be reduced with continuing use. 11. Explains there are other combinations for same problem 12. gives basic lifestyle advice including to stop smoking, take more exercise. 237

13. Puts plan in place. Eg prescribes alternative regimen or suggests persevering for 3 weeks and then reporting back, change meds if nec. 14. asks if he has questions. Gives good explanation 15. Suggests visiting british heart foundation website. 16. fluency, sensitivity 2. Take history from mother of 4 year old Congolese boy with new-onset limp. Make a differential diagnosis, suggest investigations “Hello my name is Tracy Lamumba. I am 32. My son Barry is complaining of pain in his right hip. It started this morning. When he is still it doesn’t hurt, only when he is walking. He has been lethargic today and has missed school. I took his temperature today and it was 37.4 [ slight fever]. The pain came on suddenly. As far as I know, his hip is the only t affected. He has no vomiting/ diarrhoea/rash/ leg ulcers/ dysuria/ drowsiness, he has a cold which came on yesterday. He is coughing up small amounts of green phlegm with no blood [ie could be bacterial or viral, but pneumonia unlikely]. Barry started walking at 10 months, he is normally very active. He is of normal height and weight. Barry has a 12 year old brother who is fit and well. Other than normal minor scrapes, Barry has no leg injuries. There is no family history of arthritis, sickle cell or tuberculosis.” Examiner asks for differential and investigations. Then asks management of irritable hip. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

introduction Onset, duration, exacerbating factors Asks about fever, general well-being Asks about recent illnesses including bacterial infection, eg pneumonia, UTI, meningitis, E.Coli. asks about leg trauma. Asks about developmental milestones and previous hip problems, height and weight. Asks family history of arthritis, TB, infections, sickle cell. Main differential is irritable hip, septic arthritis, knee problem are other possibilities. mentions Perthes (avascular necrosis femoral head), TB as other less likely possibilities. Explains would examine before investigations- transient synovitis/irrit hip causes decreased abduction, decreased int-ext rotation with no pain at rest, pt q. well. Septic arthritis causes high fever, unwell patient, pain at rest and on minimal movement. Perthes has gradual onset, 5x more likely in boys, abduction problems. Slipped epiphysis tends to affect obese adolescent boys 10-15 especially, causing restricted abduction, extension and internal rotation. Juvenile chronic arthritis requires minimum 3 month history. 11. Investigate: FBC-neutrophil count, CRP, ESR, blood culture, x ray/ ultrasound, possible sickle test (all normal in transient synovitis/ irritable hip apart from possible effusion on ultrasound). Possible t aspiration with U-S guide if suspect septic arthritis on examination. 12. Explains management of irritable hip/transient synovitis: irritable hip is retrospective diagnosis on recovery with paracetamol, bedrest +/- skin traction and normal x ray. 13. fluency Chest x ray Boundary blurred Lobe affected Blurred right mediastinum right upper Blurred right heart border right medial Blurred right hemidiaphragm right lower lobe Blurred left mediastinum left upper lobe Blurred left hemidiaphragm left lower lobe Paediatric CXR diagnoses Distribution Feature Appearance Cause 238

Symmetrical pneumonia Symmetrical albumin Symmetrical mycoplasma… Symmetrical Asymmetrical disease Asymmetrical Lobar foreign body

effusion

at bases, fluid level

Heart failure, low albumin,

pulmonary oedema

opacity from hilum, Kerley B lines, horizontal fissure fluid

Bronchopneumonia

patchy opacity especially along bronchi

Poor inspiratory effort diffuse hazy, <4.5 anterior ribs seen Effusion At base, right fluid level

Heart failure, low

Cystic fibrosis,

Subphrenic abscess, abdominal

Tumour solid mass, round neuroblastoma consolidation no volume loss, air bronchograms s. pneumoniae Collapse volume loss, no air bronchograms, fissures pulled down/up mucus plug, http://www.virtualpediatrichospital.org/providers/TAP/Cases/Case06/Case06.shtml Michael P. D'Alessandro, M.D. Peer Review Status: Internally Peer Reviewed Chief Complaint: Five year old male with cough and fever. Clinical History: The patient was a 5 year old male with fever, cough, and respiratory distress. The patient was felt to have a viral pneumonia. His respiratory distress eventually required intubation for 5 days. Before intubation he had a bronchoscopy which demonstrated subglottic edema. Clinical Physical Exam: The patient had a barky cough. PRESENT THE 2 X RAYs ANSWERS: Differential Diagnosis: Viral pneumonia Imaging Findings:A chest film was obtained on the day of ission and it demonstrated an anterior mediastinal mass, which was imaged further on a chest CT exam performed 2 days later. Imaging Differential Diagnosis:Thymus, prominent Final Diagnosis:Thymus, Prominent- sail sign Follow-up and Prognosis: The patient was discharged and did well 2. Michael P. D'Alessandro, M.D. Peer Review Status: Internally Peer Reviewed

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. http://www.virtualpediatrichospital.org/providers/TAP/08UnknownsAge.shtml An 8 year old female with substernal distress. The patient was an 8 year old female who was treated with antibiotics several times in her first year of life for respiratory infection. She had been followed every two years with ultrasound. Recently she began complaining of vague substernal distress that was sometimes associated with exercise. LOOK at the X-ray and comment ANSWER: Diaphragmatic hernia. Imaging Findings: The diaphragmatic hernia was demonstrated on chest films, ultrasound, and chest CT exam. Imaging Differential Diagnosis: Morgagni HerniaOperative Findings: Two months after the chest CT exam, the patient underwent an elective repair of a diaphragmatic hernia at the foramen of Morgagni. The liver was found to be prolapsed into the space behind the sternum, and there was a good deal of scarring along its anterior surface, suggesting it had been sliding back and forth for a long period of time. The diaphragm defect was 6 cm wide, from the xiphoid in front to the vena cava in back.Final Diagnosis: Diaphragmatic Hernia, Morgagni Follow-up and Prognosis: The patient had an uncomplicated post-operative course

3. Michael P. D'Alessandro, M.D. Peer Review Status: Internally Peer Reviewed QUESTION: look at these x rays, present and diagnose

ANSWER: PA and lateral chest films show a large anterior mediastinal mass causing narrowing and rightward deviation of the trachea. Imaging Findings: A chest film showed an anterior mediastinal mass. An echocardiogram showed the mass to be cystic (not provided). A chest CT exam showed the mass to be well circumscribed and containing calcifications. Imaging Differential Diagnosis: Cystic teratomaOperative Findings: The patient was taken electively to the operating room and the mass was totally excised.

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Pathological Findings: Pathological examination of the surgical specimen revealed findings characteristic for a cystic teratoma. Final Diagnosis: Teratoma, Anterior Mediastinal Follow-up and Prognosis: The patient had an uncomplicated post-operative course. 4. Michael P. D'Alessandro, M.D. Peer Review Status: Internally Peer Reviewed LOOK at X-RAY and make diagnostic presentation Chief Complaint: Six year old female hit by a truck. Clinical History:The patient was a six year old female who was riding her bike and was hit on her right side by a truck. She suffered a crush injury with a right tibia / fibula fracture and compartment syndrome requiring open reduction and internal fixation. ANSWER: Clinical Differential Diagnosis: Possible solid organ injury in the abdomen. Imaging Findings: A chest film showed right sided rib fractures and a right lower lobe lung opacity. An abdomen CT exam was obtained to evaluate for blunt abdominal trauma. It showed a right sided airspace disease and a small pneumothorax. Imaging Differential Diagnosis: Pulmonary contusion, pneumothorax Operative Findings: A right chest tube was placed prophylactically because the patient would need positive pressure ventilation during general anesthesia for the open reduction internal fixation of the tibia / fibula fracture.Final Diagnosis: Pulmonary Contusion / Pneumothorax Follow-up and Prognosis: The patient had an uncomplicated post-operative course. 5. Michael P. D'Alessandro, M.D. Peer Review Status: Internally Peer Reviewed Patient: 11 year old boy with chronic lung disease. Present 2 x rays ANSWER: PA and lateral chest films show a coarse interstitial pattern, with bronchial wall thickening and bronchiectasis. Look for pneumothorax, cysts, hilar scarring, abscesses. Chest films showed a coarse interstitial pattern, bronchial wall thickening, and bronchiectasis. Chest CT exam confirmed and better displayed the findings. Diagnosis: Cystic fibrosis Using a spacer with your child A spacer is a large plastic or metal container, that helps to deliver medicine to the lungs. Spacers make the inhaler easier to use and reduce the risk of side effects. Why spacers are important 241

A spacer has a mouthpiece at one end and a hole for the aerosol inhaler at the other. Spacers only work with an aerosol inhaler. If your child is under the age of three, or unable to use the mouthpiece, you will probably need to use a face mask as well. There are several different brands of spacer that fit different inhalers and are available on prescription (including Volumatic (pictured), Nebuhaler, AeroChamber and Able Spacer) Spacers are very important because: they make aerosol inhalers easier to use and more effective you get more medicine into your lungs than when just using the inhaler on its own they are convenient and compact and work at least as well as nebulisers at treating most asthma attacks in children and adults they help to reduce the possibility of side effects from the higher doses of preventer medicines by reducing the amount of medicine that is swallowed and absorbed into the body.

How do I use a spacer with my child? When you first get the spacer, wash it in warm soapy water and leave to drip-dry. Fit the mask on to the spacer if necessary. Shake the inhaler well. Fit the inhaler into the opening at the end of the spacer. Place the mask over your chld's face so it seals around the nose and mouth. Press the inhaler once and allow your child to take five slow breaths in and out of the spacer. This is called tidal breathing. Remove the inhaler and shake again. Repeat steps two to six for each dose of medicine. Your doctor or asthma nurse will tell you how many puffs are needed. Always check with them if you are not sure and ask them to write this down on a personal asthma action plan for your child. : Only put one puff of medicine into the spacer at a time. If you put in more than one puff, the droplets of spray stick together and coat the sides of the spacer so your child actually gets less medicine. Wash your spacer once a month - leave it to drip-dry as this helps to prevent the medication sticking to the sides. Spacers should be replaced at least every year, especially if you use them daily.

Using a spacer and mask with babies If you are finding it difficult to use a spacer and mask when giving medicine to your baby, try the following. Cuddle your baby on your knee or cradle the baby in your arms. Gently tuck your baby's arms out of the way with one hand if she/he tries to knock the mask away. Be positive and smile. Your baby will know if you are anxious. Gently stroke your baby's cheek with the mask so that she/he gets used to the feel of it. Use it when your baby is asleep. Wipe your baby's face after using a preventer. 242

Using a spacer and inhaler with children over two Sometime between the ages of two and three, your child will learn to use a spacer without a mask. Show your child how to use their inhaler and spacer first without puffing medicine into it. Turn the spacer into a toy - decorate it with coloured stickers Turn it into a counting game. Count aloud as your child takes a deep breaths. Have a routine - set a time of day to give preventer medicine. It is best to do this before brushing teeth. Praise your child when she/he uses their spacer correctly. Many parents find it difficult to use a spacer with very young children. Don't worry - you are not alone, but do keep trying. Getting a child to take inhaled medicine properly is the most important way to control their asthma. Children's Health Asthma: How to Use an Inhaler (for Children) Whether your child is an infant or a teenager, an inhaler can be a vital part of the program for keeping his asthma under control. There are two main types of asthma medications: the first type is used regularly to prevent attacks by delivering anti-inflammatory drugs (it's known as a controller ); the other, called a bronchodilator, is used to open airways when an attack is under way (it's known as a reliever ). Both of these types of medication can be delivered using an MDI, often called a puffer, which has an advantage in that medication is delivered directly into the lungs. The style of inhaler your child uses depends on his age. Your child's doctor will explain how to operate it, but here are a few basic tips for different age groups: Infants and Toddlers Up to age 3, children generally use what's known as a nebulizer. This requires a machine that breaks liquid medication into very small particles so that they can be inhaled. The nebulizer can be used with a mouthpiece or with a mask (for small children a mask is preferable). The nebulizer gives continuous medication (more than one type of medication can be mixed together), and works best in children less than 3 years old and for older children who are having an acute asthmatic attack and cannot use a Metered Dose Inhaler, or MDI. Medication for use in a nebulizer comes in two forms. In one method, the exact dose of medication to be added to the "cup" of the nebulizer is available in unit dose vials. In the other, large bottles of medication generally come with a calibrated dropper so that you can place the correct amount of liquid in the nebulizer. Your doctor will tell you the correct amount of medication to use and the number of times a day your child should use each medication. Start by adding the correct medication(s) to the nebulizer cup. Connect the tubing to the machine and then turn it on. Place the mask over your child's nose and mouth and make sure that it is comfortable (this may take some time to get used to). Your child need only breath normally until all of the medication is removed from the nebulizer cup. (He or she will also give you information about how to use the nebulizer if your child has an asthma attack.) Some children under the age of 4 may be trained to use a Metered Dose Inhaler, although this is uncommon. The best method is to use a spacer with a mask (Aerochamber with a mask is one type). Start by placing the canister bottom up in the plastic holder, then removing the cap from the inhaler. Shake the canister before each dose (this is important). Reassure your child so he doesn't feel scared, then place the mask over his mouth and nose, making sure it's sealed tight. (If your child seems anxious, you might demonstrate on yourself first.) Release a puff of medicine by pressing down on the canister. Hold the mask in place until your child has taken at least six breaths. 243

Ages 4 to 8 Your youngster may no longer need a mask, although some 4-year-olds will still need it. However, all children should use an MDI with a spacer for best results. (Your doctor or health care professional can show you the different types and suggest one best suited for your child.) Start by placing the canister bottom up in the plastic holder, then remove the cap from the inhaler. Shake the canister before each dose (this is important). Insert the end of the mouthpiece into the spacer. Have your child put his lips snugly around the mouthpiece of the spacer, with his teeth apart and his tongue out of the way. Activate the MDI, then ask him to breathe in slowly and deeply, and then hold this breath in his lungs for five to ten seconds. Exhale, and then, with the mouthpiece still in place, have him breathe in deeply and hold his breath again to get the full benefit of the medicine. Over Age 8 Your child can use either a standard metered-dose inhaler or a dry powder inhaler. To prepare the metered-dose inhaler, place the canister bottom up in the plastic holder, then remove the cap from the inhaler. Shake the canister before each dose (this is important). Doctors recommend using a spacer as described above, but your child can also try simply holding the inhaler one to two inches from his open mouth. (If he has trouble using it this way, he can also try putting the inhaler directly in his mouth with the lips open.) As he presses down on the canister to release the medicine, he should start breathing slowly, taking several seconds to inhale, then hold his breath for 10 seconds. To use a dry powder inhaler, your child should simply put his mouth around the mouthpiece and inhale quickly and deeply. Many children and their parents prefer this type of inhaler, and a recent study published in the Journal of Allergy and Clinical Immunology found that almost all children over age 8 quickly learn how to use it.

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Examinations: 1. 2. 3. 4.

Examination of child (or neonate) Examine the eye and ear NB: Febrile convulsions Paeds BLS Congenital Dislocation of Hip and Fundoscopy examination.

5. resuscitation on three year old 6. measure head circumference from a baby doll. Baby presents with a rapidly increasing head circumference within the first few days of life……plot your findings on a growth chart…….90+ percentile = infantile hydrocephalus 7. BLS: BABY OR 3 YEAR OLD CHILD 8. Neonatal of small child life . 9. Examination of a child.

History stations: 1. 2. 3. 4. 5. 6. 7. 8. 9.

2)Hx poor feeding... 10)Hx psoriasis..Tx available Diabetes Psoriasis History Peptic ulcer Hx and explanation about eradication therapy. Bronchiolitis Hx take a hx from an adult: poorly controlled asthma, give advice on management in future take a hx from mother: son has painful hip for the past few days. Take hx and talk about investigations give a differential for the last station: transient synovitis,osteomyelitis, septic arthritis, etc.

10. take a hx from male adult: poorly controlled hypertension, quit taking atenolol because of impotence, counsel him on other options, conservative andmedically 11. take a hx from mother of 7 year old son: still bed wetting at night, is there anything wrong with son? probably not: talk about psychological problems behind it. ways to treat it conservatively, ie. night alarmr 12. child presenting with nocturnal cough/ wheeze…..asthma ( take history from mum) 13. headache history from female on the combined oral contraceptive. advise her to stop and offer alternative. 14. history from mother with child presenting with weight loss and polyuria i.e. diabetes. 15. 16. 17. 18.

history of cystic fibrosis (the year before) Hx from mum of her child who has asthma. Explain Mx of the child. Hx of hild with ADHD and/ or deafness. Hx bronchiolytis.

Explaining stations: 1. 2. 3. 4. 5. 6. 7. 8. 9.

turns out to be eg.pyloric stenosis (discussion, Tx etc) Explain results to man with peptic ulcer..and Tx Explaining to mother what Down's syndrome is Explain asthma drugs and how to use an inhaler/spacer Discussion of the mng't of diabetes UTI: explain investigations to parent Bronchiolitis Management patient presenting with psoriasis, on all possible meds: emoillents, etc ( discuss PUVA usefulness and side-effects) patient comes to see you for her H. pylori test results, CLO test positive, explain CLO test and management plan

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10. asthma: 30 male with good inhaler techniquee, deterioration in asthma control, advise to step up with corticosteroid. 11. explain to mother the ways to investigate uti in 2 year old. 12. Explain febrile seizures, what they are, relation to epilepsy, Rx and future prognosis to parents whose child has jus had a seizure. 13. GP station – Give patient their results of Clo Test, explain H.pylori and gastric ulcers. Lifestlye advice and changes. 14. GP – convince a patient to take their blood pressure tablets. 15. You are an A+E doctor – acute DM, never had it before. Explain. 16. Smoking cessation and IHD.

Counselling stations: 1. 2. 3. 4.

Couselling pt to keep taking BP tablets Hypertension diagnosis and counselling i.e. lifestyle advice etc Convincing a patient to stay on Anti-hypertensives. Counselling a father about how you will manage his son's UTI.

5. Others: 1. Explaining differentials of badly behaved child-ie.ADHD,Autism etc 2. Side-effects of Ritalin 3. differential dx of short ness of breath 4. ASKED QUESTIONS ABOUT DIABETES AND MANAGEMENT OF DKA. Data Interpretation 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

Video of child--muscular dystrophies...mcq: Becker's, Duchenne's etc. Picture of rash and graph of lymphocytes etc.. – mcq Parvovirus,meningitis,chicken pox Xray abdomen - can't what of Video 1: boy showing "Gower's sign' therefore diagnosis is DMD Video 2: Child development: guess the age of the child from 'classic' developmental milestones CT scan with vignette: White lesion on CT. ?Tuberous sclerosis, epilepsy etc Computer screen with 3 pictures: 1. fundus 2. blood film 3. CXR. Case desciption, what's the diagnosis Data station on blood results with Hx e.g.Bilirubin levels and Hx of constipation and coarse facies. Data station with 1-chest and 2-abdo and 1-limb x-rays. Data station on Development and an abnormal gait (2 videos) computer Xray:diaphragmatic hernia developmental video - guess age picture of blood film blood cells and white cells, dx: infectious mononucleosis Xray: osteomyelitis there were three rest stations as well. video of a teenage girl with pneumonia being examined, decreased air-entry, bronchial breath sounds, dull to percussion, decreased vocal resonance, whispering pectoriloquy imaging ( aniridia-----wilms, craniopharyngioma----I think)

17. asthma station: shown pefr before and after attack. asked to calculate the percentage reduction and hence the severity of the attack.also demonstrate inhaler technique and name different devices. 18. resp station: watch a video and listen with headphones, give diagnosis, causes and treatments. 19. picture station eg. chickenpox, resp. distress syndrome, cxr, measles. - mcq station. 20. Menningitis and Jaundice (written station) 21. Video – child with muscular dystrophy and gower’s sign. 246

22. Guessing the age of a child – shown a vidoe where child does some activities. 23. Images – Xrays of tuberous sclerosis, osteomyelitis, cystic fibrosis etc.

Dermatology 1 2 3 4

dermatology: name 3 use of a handheld cryotherapy spray. Psoriasis arthropathy, sebhorraeic dermatosis dermatology: 3 pictures with questions on laptop screen. discuss treatments with examiner. occupatoinal health: dermatology history; dermatitis, hairdressor with patch of eczema on hands. Psoriasis – take Hx and explain Rx, phototherapy and steroid use and side effects.

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Paediatrics/GP/Derm 2002 1)Examination of child (or neonate) 2)Hx poor feeding... 3)...turns out to be eg.pyloric stenosis (discussion, Tx etc) 4)Explaining differentials of badly behaved child-ie.ADHD,Autism etc 5)Explaining to mother what Down's syndrome is 6)Side-effects of Ritalin 7)Explain asthma drugs and how to use an inhaler/spacer 8)Explain results to man with peptic ulcer..and Tx 9)Couselling pt to keep taking BP tablets 10)Hx psoriasis..Tx available 11)Video of child--muscular dystrophies...mcq: Becker's, Duchenne's etc 12)Picture of rash and graph of lymphocytes etc.. – mcq Parvovirus,meningitis,chicken pox 13)Xray abdomen - can't what of OSCE list 2002/2003 Paeds and GP Histories and counselling stations 1. Diabetes 2. Discussion of the mng't of diabetes 3. Hypertension diagnosis and counselling i.e. lifestyle advice etc 4. UTI: explain investigations to parent Data interpretation: Choose the correct answer 5. Video 1: boy showing "Gower's sign' therefore diagnosis is DMD 6. Video 2: Child development: guess the age of the child from 'classic' developmental milestones 7. CT scan with vignette: White lesion on CT. ?Tuberous sclerosis, epilepsy etc 8. Computer screen with 3 pictures: 1. fundus 2. blood film 3. CXR. Case desciption, what's the diagnosis Practical 9. Examine the eye and ear NB: Febrile convulsions Paeds/Derm/GP - Dec 2003 1) Psoriasis History 2) Paeds BLS 3) Data station on blood results with Hx e.g.Bilirubin levels and Hx of constipation and coarse facies. 4) Convincing a patient to stay on Anti-hypertensives. 5) Counselling a father about how you will manage his son's UTI. 6) Data station with 1-chest and 2-abdo and 1-limb x-rays. 7) Peptic ulcer Hx and explanation about eradication therapy. 8) Data station on Development and an abnormal gait (2 videos) 9) Congenital Dislocation of Hip and Fundoscopy examination. 10) Bronchiolitis Hx 248

11) Bronchiolitis Management

Paeds and GP April 2004 OSCE stations 1) computer Xray:diaphragmatic hernia 2) take a hx from an adult: poorly controlled asthma, give advice on management in future developmental video - guess age 3)picture of blood film blood cells and white cells, dx: infectious mononucleosis 4) take a hx from mother: son has painful hip for the past few days. Take hx and talk about investigations 5) give a differential for the last station: transient synovitis,osteomyelitis, septic arthritis, etc. 6) take a hx from male adult: poorly controlled hypertension, quit taking atenolol because of impotence, counsel him on other options, conservative andmedically 7) take a hx from mother of 7 year old son: still bed wetting at night, is there anything wrong with son? probably not: talk about psychological problems behind it. ways to treat it conservatively, ie. night alarmr 8) resuscitation on three year old 9) Xray: osteomyelitis there were three rest stations as well. Ocse station 2005 * child presenting with nocturnal cough/ wheeze…..asthma ( take history from mum) * differential dx of short ness of breath * patient presenting with psoriasis, on all possible meds: emoillents, etc ( discuss PUVA usefulness and side-effects) * imaging ( aniridia-----wilms, craniopharyngioma----I think) * imaging -----can’t * measure head circumference from a baby doll. Baby presents with a rapidly increasing head circumference within the first few days of life……plot your findings on a growth chart…….90+ percentile = infantile hydrocephalus * dermatology: name 3 use of a handheld cryotherapy spray. Psoriasis arthropathy, sebhorraeic dermatosis * video of a teenage girl with pneumonia being examined, decreased air-entry, bronchial breath sounds, dull to percussion, decreased vocal resonance, whispering pectoriloquy * patient comes to see you for her H. pylori test results, CLO test positive, explain CLO test and management plan OSCE PAEDS 2004-2005: 1: BLS: BABY OR 3 YEAR OLD CHILD 2. ASTHMA STATION: SHOWN PEFR BEFORE AND AFTER ATTACK. ASKED TO CALCULATE THE PERCENTAGE REDUCTION AND HENCE THE SEVERITY OF THE ATTACK.ALSO DEMONSTRATE INHALER TECHNIQUE AND NAME DIFFERENT DEVICES. 3. HEADACHE HISTORY FROM FEMALE ON THE COMBINED ORAL CONTRACEPTIVE. ADVISE HER TO STOP AND OFFER ALTERNATIVE. 4. DERMATOLOGY: 3 PICTURES WITH QUESTIONS ON LAPTOP SCREEN. DISCUSS TREATMENTS WITH EXAMINER. 5. RESP STATION: WATCH A VIDEO AND LISTEN WITH HEADPHONES, GIVE DIAGNOSIS, CAUSES AND TREATMENTS. 6. LOG BOOK STATION 249

7. HISTORY FROM MOTHER WITH CHILD PRESENTING WITH WEIGHT LOSS AND POLYURIA I.E. DIABETES. 8. ASKED QUESTIONS ABOUT DIABETES AND MANAGEMENT OF DKA. 9. OCCUPATOINAL HEALTH: DERMATOLOGY HISTORY; DERMATITIS, HAIRDRESSOR WITH PATCH OF ECZEMA ON HANDS. 10. PICTURE STATION EG. CHICKENPOX, RESP. DISTRESS SYNDROME, CXR, MEASLES. - MCQ STATION. 11. PREPARATORY STATION FOR NEXT STATION - PREPARE TO GIVE INFO ABOUT INVESTIGATION OF UTI TO MOTHER OF CHILD. 12. EXPLAIN TO MOTHER THE WAYS TO INVESTIGATE UTI IN 2 YEAR OLD. 13. ASTHMA: 30 MALE WITH GOOD INHALER TECHNIQUEE, DETERIORATION IN ASTHMA CONTROL, ADVISE TO STEP UP WITH CORTICOSTEROID. 14. REST 15.REST 16. LOG BOOK STATION 17. HISTORY OF CYSTIC FIBROSIS (THE YEAR BEFORE) PAEDS OSCES STAY PRETTY SIMILAR EACH YEAR APPARENTLY. PAEDIATRIC STATIONS: 1. Neonatal of small child life . 2. Explai febrile seizures, what they are, relation to epilepsy, Rx and future prognosis to parents whose child has jus had a seizure. 3. GP station – Give patient their results of Clo Test, explain H.pylori and gastric ulcers. Lifestlye advice and changes. 4. Menningitis and Jaundice (written station) 5. Video – child with muscular dystrophy and gower’s sign. 6. Guessing the age of a child – shown a vidoe where child does some activities. 7. Images – Xrays of tuberous sclerosis, osteomyelitis, cystic fibrosis etc. 8. Examination of a child. 9. Hx from mum of her child who has asthma. Explain Mx of the child. 10. GP – convince a patient to take their blood pressure tablets. 11. You are an A+E doctor – acute DM, never had it before. Explain. 12. Psoriasis – take Hx and explain Rx, phototherapy and steroid use and side effects. 13. Smoking cessation and IHD. 14. Hx of hild with ADHD and/ or deafness. 15. Hx bronchiolytis.

MCQ AND EMQ MCQs/EMQs -respiratory distress in newborn -dermatology in paeds: eczema, molluscum, scabies, eczema herpeticum -SVTs in children -diarrhoea in kids 250

-measles -side effects of MMR -public health: primary, secondary, tertiary prevention -causes of failure to thrive -constipation: dif. causes in paediatrics -intussusception -who gets a hearing test? -global developmental dela cerebal palsy GP (read the GP handbook inside out) -number of visits/year from each patieni -number of patients to gp length of consultation does a longer consultation result in better patient care? Decrease antibiotic prescription commonest presenting complaint: URTIs, more common in children' -number of years working in hospital before can become a GP -stroke: treatment, prevention -asthma: treatment in adult and child -public health (read lecture notes given mostly in there) TB, malaria, AIDS know the world's top killers which disease will be eradicated soon? occupational health: seroconversion illness, hearing loss in factory worker

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Pyschiatry/Neuro 2002 1)Hx Panic Attacks 2)Explain to sister of Schizophrenic what it is, Tx, aetiology etc 3)Video x2 (mental state examination) 4)Ophthalmology station-with an examiner asking qus (mcq,slide,eye drops) 5)CT head - diagnosis 6)Picture and qus-6th nerve palsy, other eye qus 7)CSF breakdown-bact/viral/TB meningitis? 8)Take Hx of social withdrawal from a disabled child's carer 9)Hx Headache-migraine 10)Side-effects of Lithium 11)Hx depression and suicide risk 12)PNS examination (lower limb)+differential --was MS i think 13)Explain what Autism is to mother and other differentials

Christmas 2003 Psyche Neuro (Add any other ed ideas Tigers.) 1. Video of guy with insane gait. Was narrow based I think. Was not something common. I had no friggin idea. 2. Opthalmology: Guy talks to you, shows you a slit lamp picture and asks you what it was. Everyone (well, fools like me and Mathers) said conjunctivitis, for lack of better ideas. Actually it was trauma or something. Then maybe some other pictures, and then asked us which of a bunch of a box of syringes and stuff would be best used to anaesthetise, etc. the eye. Eye drops basically. And I had no idea. And still don't. 3. Written station. To do with sections. I think it involved those two similar sounding ones: 136 and 135? It's been a while. The police one. 4. Epileptic young woman. I giving her advice about swimming and contraceptives. All the epileptic bull shit. All that stuff about driving etc. came up. I the unhappy looking examiner said "Dont' spend too long diagnosing the patient." So it was mostly advice that they were looking for. 5. Probably a rest station because I hearing the examiner from the station behind me get really impatient with the student after me for persisting with the diagnosis aspect for too long. And I foolishly overheard the guy in the next booth say things about the next station and then made it well obvious I'd eaves dropped to the examiner by assuming the guy had diabetes when he didn't. 6. Peripheral nerves examination - legs, sensory only. Then talk about diagnoses etc and probably other stuff. 7. Video of manic guy? In the video, there is mental state sheet to fill in. 8. Another video of a depressed guy? 9. DSH risk. Bloke tried to kill himself. Assess his risk. Our guy was high risk because of suicide note, attempts not to be found etc.I randomly accidently suggested he'd 'chickened' out of it. Do not do this. 10. I think there was a CT scan somewhere, but I am not sure. 11. Rest station. So you get to over hear what your colleague says to the person in station 12. 12. Woman wants to talk about her brother who has schizophrenia. So tell her about it. 13. Breaking bad news/communication skills: Woman's mum has alzheimers. 14. Woman has a son diagnosed with autism. Talk to her about it. But also, more adept medical students than myself were able to pick up that actually the son had absence epilepsy. 15. Seppukku station. 252

That's all I can right now. Psych and Neuro History and counselling stations 1. Headache: Dx temporal arteritis 2. Alcohol Hx 3. Suicide assessment 4. Ritalin: parent with questions 5. Lithium: side effects, need for blood tests etc 6. Alzheimer's disease: explain it to daughter of patient Data interpretation: Short answer questions (note, you don't have enough time to write everything down) 7. LP and CSF profiles: know the difference between, normal, menigitis, TB and SAH. Be able to list 3 early and late complications of LP. 8. Anorexia: work at BMI, list clinical symptoms and signs 9. MHA questions. Know it really well, questions are a bit fine print. 10. Ophthalmology: foreign body, glaucoma, diabetes and the eye. You look at pictures and examiner questions you. Must know your eye drops. 11-12. MSE: Video of psych patient. Write MSE from this. 13. Neuro video (we had transcipt 'cos video was busted): ? delirium Practical 14. Be able to examine certain aspects of the PNS in isolation. For example, just examine the SENSORY nervous system in the lower limbs (no need to illicit reflexes then). . State your diagnosis from findings. I had a guy with a sensory neuropathy, stocking distribution. Don't forget to observe first. Psych and Neuro Dec 2003 1. Neurological exam of lower limb (patient had glove and stocking sensory lossing secondary to Diabetes) 2. Video - watch an interview of a manic patient and write a mental state - hurry up time is limited! 3. Video again - mental state of depressed patient. 4. SP (simulated patient) - Explain alzheimer's disease to a patients daughter and answer questions she asks you. 5. SP - explain diagnosis and treatment of panic attack to a patient 6. SP - explain autism to a mother and its management. 7. SP - explain the diagnosis of schizophrenia to a patients sister 8. Written station - identify spastic gait 9. Written - identfy left radial nerve palsy from a photo 10. Talking station (examiner will ask you questions) - explain about eye drops you would use (e.g. dilators, anaesthetics) 11. Talking - answer question on fundo disc abnormalities 12. Explain contraindications to cataract operation 13. Identify CT bleed on picture e.g subdural, subarachnoid 14. SP - answer impact of epilepsy on patients life (O, swimming, 253

climbing, driving etc.) 15. Answer question regarding causes of delirium. Neuro 2003/04 OSCE STATIONS Neurology 1) Video presentation/ written station : Read up about Scissor Gait & Cerebral Palsy (I think I score 0 on this station so good luck !!) 2) Talk to family member of patient about ALZHEIMER'S DISEASE 3) Lower Limb Examination : Sensory examintation on the patient's LL. Make a diagnosis and justify diagnosis, causes of stocking distribution. 4) Epilepsy counselling : you are a GP and a lady in her 20's has be diagnosed with epilepsy and is on medication, she's come to you and ask for your advice about epilepsy. 5) CT/MRI scan (Written Station) identify Subdural or subarachnoid haemorrhage, and possible clinical outcome. Psychiatry 1) Do a RISK ASSESSMENT on a SUICIDAL patient. 2) Explain to family member of patient about SCHIZOPHRENIA. 3) Explain to mother of child about AUTISM. 4) Take a history from someone who presents with CHEST PAIN, make a diagnosis and counsel the patient about it. 5) Video session : Do a mental state examintation. ( I had a delusional patient) 6) Video Session : Do a mental state examintaion ( I had a sad patient) 7) Written station on Mental Health Act. Especially the difference between MHA 2 and 3 Ophthalmology 1) Identify pictures of symptomatic eyes. Contraindication for cataract surgery. Anaesthetic used for cataract surgery. Neuro EMQ Written paper: A lot on differential diagnosis for both Nuro and Psyc. Neuro path and genetics. I think it has changed, for us there were % of population with alcohol dependency etc which was really random. Know the various roles of the MDT in Psyc for eg Ns, OTs consultants etc! KNOW YOUR LECTURE NOTES REALLY WELL!!! A lot of the definitions are lifted directly from them, so read them well before reading thick books. OSCE Neuropsych December 2005 21 stations. 6 rests including 1 logbook station 1. Autism- explain to mother of child what the disorder is and its treatment(eg special schools, makaton communication) 2. Schizophrenia- explain disease and prognosis to sister of patient, being sensitive about suicide risk 3. Suicide history- take history from patient who attempted suicide and class their current risk (high) 254

method, feelings about it now etc 4. Alcohol history- assess if they are dependent(eg 3out of compulsion, lack of control, tolerance, withdrawal, social effects, health effects, plus stereotyping, time of first drink, drinking debut, who they drink with, suicide etc)pthadhistory of violence towards girlfriend when drunk 5. Biochem data station- urine drug screen, U&E etc 6. Anorexia writeen station- BMI calculation etc, anorexia criteria 7. Phone Gp and discuss sectioning his patient under section 2 of MHA-explain what means. 8. Video- do MSE of patient. Video lastsapprox 3 min, use proper terminology? Young man with long hair and cap. No actual hallucinations, but odd beliefs-eg meeting Bill Clinton in his sleep, being a world leader ? delusions of grandeur? Schizotypal personality? 9. Video of Parkinsons. Describe gait, hand movements, face, diff diagnoses, clin fts, treatment 10. Picture- VI palsy and its causes 11. Ophthalmology- describe slides to Dr- retinal photos plus pictures from cataract surgery- need to know what is happening,what tools are being used 12. Examine- carpal tunnel syndrome, median nerve sensory distribution, muscles. Explain treatment- eg ?splint, flexor retinaculum decompression 13. History- trigeminal neuralgia.treatcarbamazepine. Causes-idiopathic,compression by aneurysm 14. History of panic attacks- takeHx and explain aetiol and treatment 15. CT scans written stationsubdural-concave/extradural- convex haemorrhage,glioma, infarct. (multiple choice) Mr KY, 23, says that in 2004, the following came up: history taking of somatization, anorexia epilepsy, autism, panic attacks gait videos, MSE of psychotic video, side effects of TCAs and lithium,explanation and consent for lumbar puncture, contraindiactions of cataract surgery neuro /pysch early 2005 what Miss MP can remeber 1. PNS examnation 255

2. Exaplain atypical antipyschotics 3. Explain sections 4. Explain alzimers to a daughter 5. Wierd elctryphysiology results....EMG? 6. Meningitis table results...viral bactarial fungal 7 opthamology station will show u pics u have say what 8. CT scans 9. Suicide risk 10 headache hx

Obstetrics and Gynaecology 2002 1)Counselling for O/HRT 2)Couselling for Needlestick injury-HIV, procedures 3)TB-tell pt about drugs, side-effects and treating s 4)Taking blood cultures-practical 5)lCervical smear and bimanual exam 6)Hx Postpartum Haemorrhage 7)Written station: STDS gonorrhoea/chlamydia 8)Hx Urethral Discharge/sexual discharge 9)Mechanisms of birth (using plastic pelvis and baby)and describing Partogram 10)Explaining to pregnant lady about antenatal testing 11)examination of pregnant adbomen 12(how to put on a condom) 13(Mcq on malaria) O and G - December 2002 1. advise re amniocentesis 2. blood cultures 3. female sexual history 4. explain partogram and explain the process of delivery and birth by guiding a fake baby through the model of the pelvis. 5. written station: gonococcus, acute testicle, STDs 6. smear and bimanual on a model 7. secondary PPH history 8. HIV post exposur prophylaxis 9. counselling- explain smear result (mod/severe dyskaryosis) 10. HIV pretest counselling 11. examination of a pregnant abdomen 12. contraception counselling 13. dysmenorrhoea history 14. explain how to do an MSU 0 and G - Easter 2002: 1. Blood cultures 2. menorrhagia history 256

3. HRT counselling 4. male sexual history (herpes) 5. bimanual and speculum on model 6. pregnant abdomen examination 7. infectious diseases pictures 8. secondary PPH history 9. Meningitis counselling (exposure prophylaxis etc) 10. HIV pretest counselling 11. throat swab 12. booking visit counselling (which tests will be done etc) 13. fake baby through pelvis and partogram explanation 14. + one other which i have forgotten but it cant have been that bad though These are the O&G stations we had in Dec 2003 1. Amniocentesis explanation and fill in the consent form 2. Counsel woman on starting the oral contraceptive pill 3. Do a bimanual and chlamydia swab on model 4. Counsel a nurse on needlestick injury and post exposure prophylaxis 5. Counsel woman on smear test result of moderate dyskaryosis 6. Explain how to take Blood pressure and examine pregnant abdomen 7. Male sexual history 8. Female history of right sided abdominal pain 9. Counsel a worried mother about her child's exposurie to meningitis at school and appropriate prophylaxis 10. Explain a partogram (latent and active phase of 1st stage of labour) and guide a baby through the pelvis in labour for delivery 11. Take history of antepartum haemorrhage at 34 weeks gestation and appropriate management 12. Throat examination taking a swab 13. Take a history of subfertility and its causes in this particular case - pelvic inflammatory disease so take a quick gynae and genito-urinary history 14. woman diagnosed with genital warts - counsel her on causes and appropriate treatment and risk of cervical cancer 15. give in logbooks and on firms each station 5 mins 1. Description of Labour?Partogram/Baby in pelvis 2. Herpes Explanation 3. APH history – Placenta Praevia 4. Sexual Hx from gay bloke 5. Pregnant Abdomen exam 6. HIV needlestick 7. Cervical swab/bimanual 8. Amnioscentesis + consent 9. Pill consent 10. Colposcopy – does not have cancer 11. Blue Book – rest 12. Infertility test explain 257

13. Throat swabs 14. Meningococcal explain 15. Rest Obs and Gynae History and counselling stations 1. Post partum haemorrhage 2. Contraception advice, the pill etc 3. HIV test counselling 4. Smear test result and explanation 5. Prenatal diagnosis counselling: Down's 6. Needle-stick injury protocol Data interpretation 7. MCQ's: STD microbiology Practical 8. Bimanual/smear on dummy 9. Mechanisms of labour: move doll through pelvis and interpret partogram 10. How to take a blood culture 11. How to perform an MSU OSCE 2003/2004 OBS AND GYNAE OSCE stations dec, 2003 1) meningitis: asked to speak to a mother concerned about an outbreak at her child's nursery school. she wants advice on prophylaxis, when can the daughter return to school, etc. tell her about rifampicin. ask if daughter had meningitis vaccine 2) throat swab: dummy on examination bed. take a throat swab. examiner may ask what sort of pathogens cause sore throats. 3) sexual history: someone wants a HIV test. ask him the routine sexual history 4) palpation of abdomen and blood pressure: ????? 5) partogram and delivery: there's a model pelvis and doll. move the doll through the pelvis, showing your understanding of the delivery process. there's also a partogram they will ask you to interpret 6) communication skills: woman comes in worried about her recent cervical smear results. she has CIN I. explain what that means. 7) communication skills: patient asks about the implications of PID on infertility. take a history/ give her advice 8) communication skills: patient asking about amniocentesis. why is she having it done, risks to baby's health, etc 9) needle stick injury: patient comes in from recent injury. asks you what to do next. tell him about the protocol. 10) contraception: lady wants to know what contraception to use. to ask for risk factors like previous DVT, clotting disorder if prescribing COC.

Paediatrics/GP/Derm 2002 1)Examination of child (or neonate) 2)Hx poor feeding... 3)...turns out to be eg.pyloric stenosis (discussion, Tx etc) 258

4)Explaining differentials of badly behaved child-ie.ADHD,Autism etc 5)Explaining to mother what Down's syndrome is 6)Side-effects of Ritalin 7)Explain asthma drugs and how to use an inhaler/spacer 8)Explain results to man with peptic ulcer..and Tx 9)Couselling pt to keep taking BP tablets 10)Hx psoriasis..Tx available 11)Video of child--muscular dystrophies...mcq: Becker's, Duchenne's etc 12)Picture of rash and graph of lymphocytes etc.. -- mcq: Parvovirus,meningitis,chicken pox 13)Xray abdomen - can't what of Paeds/Derm/GP - Dec 2003 1) Psoriasis History 2) Paeds BLS 3) Data station on blood results with Hx e.g. Bilirubin levels and Hx of constipation and coarse facies. 4) Convincing a patient to stay on Anti-hypertensives. 5) Counselling a father about how you will manage his son's UTI. 6) Data station with 1-chest and 2-abdo and 1-limb x-rays. 7) Peptic ulcer Hx and explanation about eradication therapy. 8) Data station on Development and an abnormal gait (2 videos) 9) Congenital Dislocation of Hip and Fundoscopy examination. 10) Bronchiolitis Hx 11) Bronchiolitis Managment OSCE stations dec, 2003 1) meningitis: asked to speak to a mother concerned about an outbreak at her child's nursery school. she wants advice on prophylaxis, when can the daughter return to school, etc. tell her about rifampicin. ask if daughter had meningitis vaccine 2) throat swab: dummy on examination bed. take a throat swab. examiner may ask what sort of pathogens cause sore throats. 3) sexual history: someone wants a HIV test. ask him the routine sexual history 4) palpation of abdomen and blood pressure: ????? 5) partogram and delivery: there's a model pelvis and doll. move the doll through the pelvis, showing your understanding of the delivery process. there's also a partogram they will ask you to interpret 6) communication skills: woman comes in worried about her recent cervical smear results. she has CIN I. explain what that means. 7) communication skills: patient asks about the implications of PID on infertility. take a history/ give her advice 8) communication skills: patient asking about amniocentesis. why is she having it done, risks to baby's health, etc 9) needle stick injury: patient comes in from recent injury. asks you what to do next. tell him about the protocol. 10) contraception: lady wants to know what contraception to use. to ask for risk factors like previous DVT, clotting disorder if prescribing COC. OSCE stations – April 2004 1) computer data: X ray: diaphragmatic hernia 259

2) take a hx from an adult: poorly controlled asthma. give advice on management in future 3) computer data: developmental video, girl combing hair and turning pages, guess age. picture of blood film: scenario- 11 year old girl with sore throat, fever. film shows blood cells and white cells. dx: infectious mononucleosis 4) take a hx from mother: son has had a painful hip for the past few days. take a hx and talk about investigations 5) give a differential for the last station: transient synovitis, osteomyelitis, septic arthritis, etc. 6) take a hx from male adult: poorly controlled hypertension. quit taking atenolol because of impotence. counsel him on other options. conservative and medically 7) take a hx from mother of 7 year old son: still bed wetting at night. is there anything wrong with son? probably not: talk about psychological problems behind it. ways to treat it conservatively. ie. night alarms 8) resuscitation on three year old 9) Xray: osteomyelitis OSCE 2003 Written stations (MCQs) •child development station; young child sitting up, pointing etc and asked to select best answer re: age of child •2 CXRs on laptop screen-select best possible diagnosis- TB/inhaled foreign body •test results on laptop screen-bloods, stool culture, LFTs etc and picture of stool sample (jaundiced child) pick most likely diagnosis •another OSCE had abdo X ray of necrotising enterocolitis •another OSCE had MCQs with pictures of Kawasaki disease and parvovirus induced spherocytosis Practical stations •CVS examination of child-VSD •BLS-young child Simulated patient •explaining psoriasis treatment-phototherapy to a man who has tried other treatments and failed •explaining results of endoscopy and further management of pt with gastric ulcer in GP-gven printout of results •history from mum regarding sumptoms of childhood asthma in her child (UTI was used in a later OSCE) •next station then using this hostory to explain to the parent what treatments are available and how their child will be managed. (This was again carried on for the UTI station in another OSCE) •adult asthma-poorly controlled/exacerbation-take history from patient and explain management •explaining febrile convulsions to a parent (had rest station before this where told what the next station would be so that you had time to prepare) •ADHD; read a GP referral letter re: troublesome child-go through possible differential diagnoses and explain further management •non adherence with antihypertensives in GP-exploration of issues (ie impotence s/effs of some of the meds) and further management What are you taking or doing for your BP? What is putting you off from tablets? Eg. Side effects, bad prescription (worked out some things were contraindicated), another doctor has taken him off, too many tablets, doesn’t like taking cos thinks can’t be good for him. 260

Are you aware of the dangers of high BP? Explain dangers of having high BP – stroke, MI, PVD, kidney damage, eye problems Death and disability – how do u feel about that? What are side effects of anti hypertensives: Thiazides: Wee more, gout and hypokalaemia. (Contra in diabetes mellitus). Impotence and loss of libido – not common now using low doses (flat response curve) Beta blockers: Contra indicated in asthma. Side effects: Cold hands, fatigue, heart failure, triglycerides up, HDL down, impotence and loss of libido. ACE inhibitors: Irritative cough, angio oedema, proteinuria and neutropenia. Renal failure. Calcium antagonists: Dizziness, hypotension, flushing and ankle oedema Hydralazine: Reflex tachycardia – may provoke angina. Headaches and fluid retention. Lupus syndrome (arthralgia, fever etc) What side effects he got? Try to work out a drug regime avoiding side effects. Advise life style changes. (Consider that if not tried life style yet and if hypertension not severe, could try life style first before trying medication. If severe hypertension or attempts at life style change have failed (like an incompetent fool deserving to be fed to the vultures of the desert) then medication is necessary regardless of whether or not life style changes are introduced) Arrange to see again to review how blood pressure affected. How does he feel now? Any questions? Could reach compromise if being difficult: Reduce dose, remove medication, OSCE December 2004 GP stations; •woman with psoriasis-was on corticostaeroid cream for 20 years-previous GP told her to stop it but now her psoriasis is really bad and she wants another treatment. told to discuss the options and take a focussed dermatological history •man with high bp and FHx of stroke-had meds last year which decreased his bp but he stopped taking them. Discuss why he needs to take them again as his bp is up again. Explore why he didn't take them and discuss overall management of hypertension including lifstyle management •man with gastric ulcer-have copy of test restults. have to give him the diagnosis and discuss treatment with him Practical stations; •hip examination on dummy (have to explain to the examiner what you are doing and what the tests are called) and opthalmoscopy •resuscitation of a young child Counselling; •have rest station to prepare where told that mother of a 7/12 old baby boy wants to talk to you about her child who has been itted with UTI-discuss the further tests that going to have and respond to her questions on the next station History •history from mum of 3/12 ex-SCBU baby with bronchiolitis-she has not had primary vaccinations! •next station discuss the diagnosis and management with a Dr. 261

Data stations •X rays-limb, CXR, abdo XR and have to choose most likely diagnosis for each •picture of eye and CT scan and blood film and something else and again have to choose most likely diagnosis for each •2 video clops-1st of baby looking at a book and using a brush to mime brushing hair-choose correct age, other of teenager walking and have to diagnose her condition from her gait PAEDS OSCEs December 2003 1) Abdominal exam of a 4 yr old with Cystic Fibrosis, PEG Wash hands, consent Inspection: Jaundice, Pallor, Bruises Scars, stomas Peristalsis – sign of Pyloric stenosis Distension – intestinal obstruction and ascites Inguinal region and genitalia (hernias, hydrocele, testicular torsion) Masses – Wilms tumour, neuroblastoma, intussuception, faecal mass,appendix mass Palpate: Tenderness or guarding Masses Organomegaly – liver, spllen, kidneys Perscuss: Liver or spleen enlargement Shifting dullness Auscultate: Increased – obstruction and acute diarrhoea Decreased – peritonitis Rectal examination: If intussusception or appendicitis Cystic Fibrosis Features: Meconium ileus results in distension, absent bowel sounds. Pale, greasy and offensive stools. 2) Hx taking from a mother of a 3 wk old child - Bronchiolistis? Most common in Winter Epidemic in 1-9 months Coryzal symptoms – cough, increasing breathlessness Small infants develop apnoeic episodes Does your kid have CHD or chronic lung disease 262

O/E Tachypnoea Subcostal and I.C rcn Chest hyperinflation Bilateral fine crackles High pitched rhonchi on auscultation 3) Discussion of diff. diag + management of the above i. Pneumonia ii. Asthma iii. Whooping cough iv. Cystic Fibrosis a. Mild bronchiolitis Feeding well RR < 40 Minimal rcn Rx. Send home and review b. Moderate bronchioloitis Feeding difficult RR > 40 Sat >85% Marked rcn Rx: it, O2 and fluids c. Severe bronchiolitis Not feeding Tachypnoea RR > 60 Sat < 85% Recurrent apnoea Severe recession Rx: it to ICU, high inspired O2, intubate and assisted ventilation CONTROVERSIES: Salbutamol not used. Adrenaline maybe useful. 4) Explain management options to a Psoriais pt 263

Counselling: Non infectious, common 2% population, you will need lifelong treatment. Relapsing-remitting course, refer to Psoriasis association Stable plaque – VD analogues with topical steroid Tazarotene, dithranol (short ), coal tar UVB Extensive plaque - PUVA Methotrexate, ciclosporin Guttate – Topical steroids Coal tar UVB Facial/flexural – Topical steroids Acitretin PUVA Palmoplantar – Topical steroids Acitretin PUVA Generalized pustular/Erythrodermic – Acitrein Methotrexate, ciclosporin VD analogues – Calcipotriol and tacalcitol 5) Basic life – 8yr old kid D – Look for danger R – Response (gently stimulate child and ask “are you ok”) If child responds leave child in how you found him providing he is in no further damage, check his condition and get help if necessary. Reassess regular. If no response, shout for help and open child’s airway. By tilt head and lift chin. Avoid head tilt if trauma to head is suspected, then use jaw thrust. Keep airway open and look, listen and feel for breathing. If child breathing normally then turn child on side and go for help. Then recheck for continuous breathing. If child is not breathing, if airway obstruction – remove it. Give 2 rescue breaths (give up to 5 to achieve 2 effective ones) then:For a child (1-8 yrs) – pinch soft part of nose with index and thumb, open his mouth a little maintaining chin lift, place your lips around his mouth. Blow steadily for 1-1.5 seconds. Give 2 effective breaths. 264

For an infant (0-1yr) – cover mouth and nose with your mouth (if big infant do mouth to nose breath, cover mouth with your hand). Give 2 effective breaths. If effective breath not achievable check mouth for obstruction. C – assess circulation by checking carotid pulse in neck in child, for infants feel brachial pulse. Shouldn’t take more than 10 seconds. If +ve signs of circulation continue with rescue breathing until child starts breathing effectively on its own. Recheck circulation regularly. If –ve signs of circulation or unsure or if P < 60 start chest compressions. Combine breathing and chest compressions. For child – below the nipple line on the sternum above xiphisternum (1 hand only) for 5 compressions at 100/min rate. Then tilt head and give one effective breath. Carry on 5:1 If older than 8 then use adult method. (15:2) For infants: Locate sternum, use 2 fingers about 1 finger breadth below nipple line. Then do typical 1/3 deep compression at 100/min for 5:1. Or wrap hands around infant. 6) Computer stations, x-ray, clinical scenarios - ?Thyrotoxicosis & 7) Counsel/ Explain to a father of a 3 yr old boy with UTI, having to go through all the investigations 8) More computer stations - more x-rays Fallots tetralogy, Septic arthritis/ osteomyelitis Fallots – Boot shaped (secondary to pulmonary tract obstruction) Oligaemia Small heart Uptilted apex Septic arthritis – XR shows initially normal. Non specific widened t space. Osteomyelitis – Normal in first 10 days. Periosteal elevation with radiolucent necrotic areas (detected between 2-3 weeks) Osteogenic sarcoma – around knee t in metaphysis of distal femur or proximal tibia. Destruction and sunburst appearance as tumour breaks through cortex and spicules of new bone are formed. 265

Ewings – Periosteal elevation with onion skinning (from soft tissue mass) sometimes mets can be seened. Commonly affect mid to proximal femur. 9) GP explain to a patient for whom u have just received H-pylori test as +ve Introduce Why are you here? What do you know already? Strong association between peptic ulcers and H.Pylori H.Pylori is a bacteria. Large percentage of population have H.Pylori but don’t have ulcers. Eradicate H.Pylori will reduce chances of ulcers Easily treatable disease – don’t worry mate Conservative management – lifestyle (avoid worsening foods e.g. spicy, stop smoking) Eradicate with antibiotics – triple therapy (lanzoprazole, clarithomycin and amoxycillin or metronidazole) for 1 week. Suppress acid secretion – H2 receptor antagonist (ranitidine, cimetidine) taken at night for 8 weeks or PPI (lanzoprazole, omeprazole for 4 (duodenal)-8 (gastric) weeks) If drug caused e.g. NSAID stop it or use H2 receptor antagonist, PPI or misoprostol (prostaglandin mediator) with NSAID If symptoms persist then do re-endoscope and re-check for H.Pylori How do you feel about taking all these drugs? 10) Video stations, guessing correct age, and diagnosis for a 10-15 yrs old girl with abnormal gait… I put Duschenne MD without thinking it predominantly affect boys

OSCE list 2002/2003 Paeds and GP Histories and counselling stations 1. Diabetes 2. Discussion of the mng't of diabetes 3. Hypertension diagnosis and counselling i.e. lifestyle advice etc 4. UTI: explain investigations to parent Data interpretation: Choose the correct answer 5.Video 1: boy showing 'Gower's sign' therefore diagnosis is DMD 6. Video 2: Child development: guess the age of the child from 266

'classic' developmental milestones 7. CT scan with vignette: White lesion on CT. ?Tuberous sclerosis, epilepsy etc 8. Computer screen with 3 pictures: 1. fundus 2. blood film 3. CXR. Case desciption, what's the diagnosis Practical 9. Examine the eye and ear NB: Febrile convulsions Paeds and GP: April 2004 OSCE stations 1) computer data: X ray: diaphragmatic hernia 2) take a hx from an adult: poorly controlled asthma. give advice on management in future 3) computer data: developmental video, girl combing hair and turning pages, guess age. picture of blood film: scenario- 11 year old girl with sore throat, fever. film shows blood cells and white cells. dx: infectious mononucleosis 4) take a hx from mother: son has had a painful hip for the past few days. take a hx and talk about investigations 5) give a differential for the last station: transient synovitis, osteomyelitis, septic arthritis, etc. 6) take a hx from male adult: poorly controlled hypertension. quit taking atenolol because of impotence. counsel him on other options. conservative and medically 7) take a hx from mother of 7 year old son: still bed wetting at night. is there anything wrong with son? probably not: talk about psychological problems behind it. ways to treat it conservatively. ie. night alarms 8) resuscitation on three year old 9) Xray: osteomyelitis there were three rest stations as well. -respiratory distress in newborn -dermatology in paeds: eczema, molluscum, scabies, eczema herpeticum -SVTs in children -diarrhoea in kids -measles -side effects of MMR -public health: primary, secondary, tertiary prevention -causes of failure to thrive -constipation: dif. causes in paediatrics -intussusception -who gets a hearing test? -global developmental delay -cerebal palsy GP (read the GP handbook inside out) -number of visits/year from each patient number of patients to gp length of consultation does a longer consultation result in better patient care? 267

decrease antibiotic prescription -commonest presenting complaint: URTIs, more common in children? -number of years working in hospital before can become a GP -stroke: treatment, prevention -asthma: treatment in adult and child public health (read lecture notes given during lecture week. it's mostly in there) - TB, malaria, AIDS - know the world's top killers - which disease will be eradicated soon? - occupational health: seroconversion illness, hearing loss in factory workers, anxiety

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Psychiatry OSCE Stations. 10th April 2002: Written Stations: 1) Mania - What would you see under each heading of the Mental State Examination (MSE)? 2) Anorexia - BMI & Psychiatric causes of loss of weight. 3) Forensic - Differences between a medium secure unit and a hospital ward. How to get a patient from prison to hospital. 4) Psychotic man - possible causes. 5) Delirium - Man just out of hospital & wandering in the street. Management and possible causes. 6) Attempted suicide - What factors mean they're likely to do it again? Management. 7) Post partum depression - Incidence and management. 8) Lithium - Side effects and blood tests necessary. Video Stations: 9) MSE on a patient with psychotic symptoms. 10) MSE on a depressed patient. SP Stations: 11) Man with panic attacks - Take a history and explain management. 12) Woman with depression - Tell her about different types of psychotherapy. 13) Man with an alcohol problem - Take a history and decide if he's alcohol dependent. 14) Woman with depression - Tell her about the side effects of TCA's, when they'll start working and how long to take them for. Can she drink? Can she drive?

12th June 2002: Written Stations: 1) Deliberate Self Harm - common methods, criteria for Borderline Personality Disorder 2) Institutions Vs. Care in the Community - What is institutionalisation? 3) Learning difficulties - prevalence, what will & won't the patient be able to do in life? 4) Sectioning - differences between S2 & S3 5) Alcohol - criteria for dependence 6) Bus driver with depression - treatment with SSRI - duration, SE's and reasons why he's affected. 7) PTSD - symptoms, time scales and treatment 8) Patient with Mania - what would you see under each heading of the Mental State Examination? Video Stations: 9) MSE on a patient with psychotic symptoms. 10) Cognitive state assessment (Need to know the formal 30 point score cognition examination) SP Stations: 11) Explain Schizophrenia to the sister of a newly diagnosed patient. 12) Woman with Bulaemia Nervosa - ask appropriate questions and suggest a differential diagnosis. 13) Woman with depression and previous suicide attempt - ask appropriate questions and assess suicide risk. 14) Lithium therapy for bipolar affective disorder - Side effects, blood tests, alternatives etc. Feb 2005 1) Explain Schizophrenia to the sister of a newly diagnosed patient.

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2) Woman with depression - Tell her about the side effects of TCA's, when they'll start working and how long to take them for. Can she drink? Can she drive? 3) “Phone call” from ward you are HO, pt is being “odd” :- delirium, take Hx, give advise on Mx 4) Video of abnormal gait, answer questions about gait, differentials etc, where is lesion? 5) Drug/EtOH dependence, treatments 6) Video of MSE 7) Drugs used in ophthalmology, Pictures of operation (Insertion of lens), what is op, what stages are shown 8) Mother of autistic child/ child with ADHD, what is it treatment prognosis etc. 9) Mental Health Act, sections, who how long why. 10) Epileptic, wants to know about med, driving, getting pregnant, interaction with other meds. 11) Learning difficulties video (Downs) 12) Mother of pt with dementia, answer her questions about Rx prognosis etc.

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