OSCE previous stations

Question 1

5 principles of mental capacity act

Answer 1

1. Assume capacity
2. Support individuals to make decision.
3. Unwise decisions
4. Best interests
5. Least restrictive option

Question 2

Heart failure: management

Answer 2

Pharmacological:
1. ACEi (or ARB)
2. bb
3. Diuretic (furosemide?) weight monitoring

Others
–> aldosterone (spironolactone) if uncontrolled
–> IVABRADINE (of sinus rhythm >70 despite mx BB dose)

Non pharmacological:
–> cardiac resynchronisation therapy device (if QRS prolonged)
–> implantable cardioverter defibrillator: consider if ventricular arrhythmia’s

Question 3

Clinical features of heart failure

Answer 3

1. Reduce perfusion
Symptoms
–> fatigue
–> exercise tolerance
Signs
–> cyanosis
–> tachypnoea / tachycardia
–> cool extremities
–> oliguria

2. Pulmonary congestion
Symptoms
–> SOB OE
–> orthopnoea
–> white / pink frothy sputum
–> cardiac wheeze

Signs
–> pulmonary oedema (fine bibasal creps)
–> pleural effusion
–> S3 ventricular gallop

3. Systemic congeston
   Symptoms
   –> peripheral oedema
   –> weight gain
   –> bloating and reduced appetite

Signs
–> raised JVP
–> peripheral oedema (pedal, sacral, scotal)
–> hepatomegaly
–> ascites

Question 4

PSA test counselling

Answer 4

1. PSA (prostate specific antigen)
2. Normal for men to have PSA in blood, sometimes raised PSA can indicate PROSTATE cancer

However can be raised for many reasons:
–> UTI
–> recent vigorous exercise
–> prostate stimulation, recent ejaculation
–> enlarged prostate

Possible advantages
1. may help pick up prostate cancer before symptoms
2. may help pick up fast growing cancer, when treatment could stop it spreading

Possible disadvantage
1. PSA raised for many things!
2. some patients with low PSA may be found to have prostate cancer later on
3. if PSA level rasied may need biopsy: pain, infection, bleeding

Higher risk of prostate cancer
1. over 50
2. close relative affected (brother or father)
3. black origin

Refrain from sex 2 days before.
Can’t have had biopsy 6 weeks before test.

Further test MRI

Question 5

Anorexia nervosa: key questions to ask

Answer 5

SCOFF

1. Do you make yourself sick? or use laxatives
2. Do you worry you’ve lost control over how much you eat?
3. Have you lost or gained more than 1 stone in 3 months?
4. Do you think you are fat when others perceive you to be thin?
5. Do thoughts of food dominant your life

Question 6

ANOREXIA NERVOSA : mx

Answer 6

Assessment
1. BMI <13 or 1kg weight loss weekly

Investigation
1. FBC
2. LFT
3. U&Es
4. CRP
5. glucose
6. phosphate
7. magnesium
8. ECG ? (brady, increased QTC, hypokalaemic changes)

ADULTS
1. Eating disorder focused CBT
2. MANTRA (maudsley anorexia nervosa treatment for adults)
3. SSCM (specialist supportive clinical management)

Children
1. Eating disorder focused family therapy

Question 7

Prescribing in palliative care: managing symptoms

Answer 7

1. Pain / Breathlessness
–> Morphne (1/6 total opioid dose subcut)
2. Nausea
–> cyclizine, leveopromazine, haloperidol
3. Agitation
–> midazolam
4. Respiratory secretions
–> glycopyronium or hyoscince hydrobromide
5. Delerium
–> Haloperidol

Question 8

Male testicular exam

Answer 8

Inspection:
1. skin: erythema, rashes, excoriations, scars, ulcers
2. testes: asymmetry, swelling, oedema , obvious masses
3. foreskin: phimosis, adhesions and glans abnormalities

Palpation
1. comment on:
–> testes
–> epididymis
–> spermatic cord
–> inguinal lymphadenopathy
–> reflexes (prehn’s, cremasteric)

Differentials:
* hydrocele
* varicoele
* epididymal cyst
* testicular tumour
* inguinal scrotal hernia (cannot get above it)
* epididymitis
* testicular torion
* orchitis

Prehn’s : if testicular pain is relieved by elevating testes: epididymitis, if not then think torsion

Cremasteric: stroke inside of leg and watch scrotal skin tighten (absent in torsion)

Question 9

Shoulder exam: common shoulder pathology

Answer 9

1. Supraspinatuous tendonitis (impingement syndrome)
–> painful arc , tx: physio, analgesia, corticosteroid , arthroscopic acromoplasty
2. Rotator cuff tears
–> supraspinatus wasting
3. Adhesive capsulitis
–> stiffness, loss of active and passive movement. tx: NSAIDs, physio
4. Anterior shoulder dislocation
5. Osteoarthritis

Question 10

Epilepsy: management

Answer 10

Consider other cause of seizures:
–> metabolic (hyponatraemia, hypoglycaemia)
–> CNS infection (encephalitis , meningitis) alcohol withdrawal
–> environmental

https://geekymedics.com/explaining-a-diagnosis-of-epilepsy/

Question 11

Breast exam

Answer 11

1. Firboadenoma : firm, non-tender, highly mobile
2. breast cyst: palpable not fixed
3. intraductal papilloma : benign, warty lesion, blood stained?
4. breast abscess: malaise, fever, red , hot, lymphadenopathy
5. fat necrosis: due to trauma, irregular, craggy mass, skin tethering, nipple retraction

TRIPLE ASSESSMENT
1. Clinical hx and exam by breast surgeon
2. radiological imaging
3. core biopsy and fine needle aspiration

Imaging : USS if under 40 (denser breast tissue)
Mammogram: over 40, two views,

Endocrine therapy
Endocrine medications essentially aim to reduce oestrogen activity to reduce tumour growth:

Tamoxifen: used in premenopausal women with ER+ cancer, works by blocking oestrogen receptors
Aromatase inhibitors (Letrozole, Anastrozole, Exemestane): only used in postmenopausal women with ER+ cancer. They work by blocking the enzyme aromatase which converts androgens into oestrogen.
Biologics
For cancers that express HER2, a drug called trastuzumab (also called Herceptin) is used, which is a monoclonal antibody that targets HER2.

Question 12

opthalmoscopy : review eye differential diagnoses

Question 13

HYPONATRAEMIA

Answer 13

Severe: < 120

Causes:
Hypovolaemic (dehydrated)
–> transdermal, GI loss
Hypervolaemic (‘overloaded’)
–> third spacing
Euvolaemic

Question 14

Causes of Hypervolaemic hyponatraemia

Answer 14

1. Congestive cardiac failure
2. Liver cirrhosis
3. End stage renal failure
4. Nephrotic syndrome

Question 15

Euvolaemic hyponatraemia: causes

Answer 15

SIADH

check urine osmolality

If decreased –> primary polydipsia (water intoxication)

If raised urine osmolality in presence of low serum osmolality –> SIADH

Question 16

Clinical features of hyponatraemia

Answer 16

Mild to moderate symptoms of hyponatraemia include:4

HALCANS

Anorexia
Headache
Nausea/vomiting
Lethargy
Confusion
Ataxia

Severe symptoms of hyponatraemia include:

Seizures
Cerebral obtundation / coma

Question 17

Management of Hyponatraemia

Answer 17

1. Acute hyponatraemia –> hypertonic saline bolus IV

The general goal of treatment is to correct by no more than 6mmol/L in the first 6 hours and no more than 10mmol/L in the first 24 hours.1

Hypovolaemic hyponatraemia
Rehydration with intravenous 0.9% normal saline, with regular monitoring of serum sodium.

Hypervolaemic hyponatraemia
Fluid restriction (<1.5L/24h), with regular monitoring of serum sodium.

Euvolaemic hyponatraemia
Fluid restriction (1.5L/24h), with regular monitoring of serum sodium. Oral salt tablets may be required if fluid restriction alone is ineffective.

Question 18

Complications of hyponatramia

Answer 18

1. Gait disturbane
2. Cerebral oedema (brainstem herniation and death)
3. Osmotic demyelination syndrome (Rapid correction of hyponatramia, occurs 2-4 days post treatment)

Question 19

Ventricular fibrillation management

Answer 19

SHOCKABLE

CPR 2 mins

Adrenaline every 3-5 mins

Amiodarone after 3 shocks

Identify and treat reversible causes

Question 20

Neutropenic sepsis

Answer 20

Assessment

• History:
  
  • Type and timing of chemo regimen and any other immunosuppressive medication being taken.
  • Localizing symptoms e.g right lower-quadrant pain associated with neutropenic enterocolitis
  • Recent infections and antibiotics used
  • Latent infections are known to reactivate (e.g. TB), sick contacts, blood transfusions
  • Co-morbidities
  • Any intravascular devices
• Examination:
  
  • DRABCDE
  • Systems-based examinations
  • ENT
  • Fundoscopy
  • DO NOT perform DRE until antibiotics given)
• Investigations:
  
  • 2 sets of blood cultures
  • Swabs from any indwelling lines
  • Blood tests from complete blood cell count, WCC, inflammatory markers, renal and liver function.
  • CXR
  • Serology and PCR for viruses e.g. CMV
  • Sputum, urine, stool samples, CT scans etc. where clinically indicated.

Management

• DRABCDE approach
• If low risk can give oral antibiotics (quinolone + co-amoxiclav)
  
  • Features suggesting low risk:
    
    • Hemodynamically stable
    • Doesn’t have acute leukaemia
    • No organ failure
    • No soft tissue infection
    • No indwelling lines
• For most patients, they need empirical IV treatment with piperacillin and tazobactam (tazocin), with added coverage for MRSA or gram-negatives if thought at risk. A macrolide should also be added if diagnosed with pneumonia (to cover atypical organisms)
• Daily measures of fever and baseline bloods until the patient is apyrexial and neutrophil count above 0.5x10^9^
• When the neutrophil count is normal, has been afebrile for 48 hours and blood tests have normalized, antibiotics can be stopped.
• Prophylaxis with a fluoroquinolone can be offered

Question 21

Head CT interpreation powerpoint

Question 22

Emergency contraception counselling

Answer 22

Question 23

STEMI treatment

Answer 23

Question 24

Airway management

Answer 24

https://geekymedics.com/airway-equipment-explained/

Question 25

death certificate

Answer 25

https://geekymedics.com/certification-death-uk-osce-guide/

Part 1 - main casual sequence of conditions leading to death 1

Part 2 - conditions that may have contributed to death: e.g. IHD

Reasons to refer to the Coroner
There are several situations in which a patient’s death should be referred to the Coroner including:

The death was due to poisoning including by an otherwise benign substance
The death was due to exposure to, or contact with a toxic substance
The death was due to the use of a medicinal product, the use of a controlled drug or psychoactive substance
The death was due to violence, trauma or injury
The death was due to self-harm
The death was due to neglect, including self-neglect
The death was due to a person undergoing any treatment or procedure of a medical or similar nature
The death was due to an injury or disease attributable to any employment held by the person during the person’s lifetime
The person’s death was unnatural but does not fall within any of the above circumstances
The cause of death is unknown
The registered medical practitioner suspects that the person died while in custody or otherwise in state detention
There was no attending registered medical practitioner, and there is no other registered medical practitioner to sign a medical certificate cause of death in relation to the deceased person
The attending medical practitioner is not available within a reasonable time of the person’s death to sign the certificate of cause of death
The identity of the deceased person is unknown