OSCE Stations Flashcards

Question 1

Q

Examination: Parkinson’s Disease

Answer

A

WIPER QQ:
-patient should be sat on a chair away from edge of the chair with hands apart and face up

Inspect:

look around bed for walking aids, medications
look at patient at rest for any signs of tremor

Gait:

Slow initiation of movement
poor arm swing (often worse on right side)
simian posture
slow turn
festinating gait
pull test - PD patient will fall back

Arms (Tremor, Tone, Brady):

increased tone + tremor = cogwheel rigidity
resting tremor unilateral pill rolling (count backwards from 20-1)
synkinesis (tap other hand whilst testing tone (sudden increase)
finger-nose
duck beak hands
piano hands

Face, Speech, Eyes:

inspect face for hypomimia, slow blink rate, sialorrhoea (drooling), seborrheic dermatitis
open question - slow monotonous speech
H-shape eye movements, vertical gaze palsy (Progressive supranuclear palsy)
offer glabellar tap

Function:
-undo top button

Special Tests:

micrographia copy sentence, copy spiral
(glabellar tap)

Conclusion:

thank patient
full neuro exam + Hx
examine drug chart
lying standing BP (Multiple system atrophy)
MMSE (lewy-body dementia)

Question 2

Q

Examination: Cerebellar

Answer

A

WIPER QQ:

Inspect:

look around bed for walking aids, medications
look at patient for signs of alcholism e.g. ascities, jaundice, spider naevi, look for tremor, look for truncal ataxia

Gait:

wide-based ataxic gait
heel-toe (reduced coordination)
rhombergs test (-ve in cerebellar disorder)

Arms:

pronator drift
rebound
disdiadokokinesis
Finger-nose looking for intention tremor and dysmetria (overshoot or undershoot due to poor coordination)
tone (hypotonia)

Legs:
- knee reflexes (pendular)

Speech, eyes:

open question
42 west register street
baby hippopotamus
british constitution
looking for slurred stoccato speech
Horizontal eye movement looking for nystagmus (fast phase beats towards side of lesion)

Function:
-undo top button

Conclusion:

thank patient
full neuro exam + Hx
examine drug chart (drugs causing cerebellar syndrome = phenytoin, lithium, carbamazapine)

Question 3

Q

Examination: Tremor

Answer

A

WIPER QQ

Inspect:

resting tremor? (parkinson’s)
hypomimia (parkinson’s)
truncal ataxia (cerebellar)

Screening tests:

resting tremor count backwards from 20-1 (Parkinson’s)
finger-nose test intention tremor? (cerebellar)
postural tremor? outstretched arms (benign essential tremor)

Gait:

Is it a slow festinating gait (parkinson’s)
Is it a wide based ataxic gait (cerebellar)

Continue with either parkinsons exam or cerebellar exam depending on findings. or if no signs do a section from each in turn.

Question 4

Q

Examination: Hand

Answer

A

WIPER QQ

Look:

look around the bed for walking aids or medication
look at the nails for psoriatic changes such as pitting or onycholysis.
look at the fingers for a swellings or deformities. Osteoarthritis typically shows herbedens and bouchard nodes. RA spares the DIP joints look for boutonierres and swan neck deformities. Look for signs of scleroderma such as calcified deposits, telangiectasia, sclerodactly and raynauds.
look at the dorsum for MCP subluxation or ulnar deviation (RA) or squaring of the thumb (osteoarthritis)
look at the palm for thenar wasting or scars (Carpal tunnel)
look at the elbows for psoriatic changes and nodules (RA)
look at the ears for gouty tophi (gout) and the face for microstomia (scleroderma)

Feel:

feel temperature of hand
palpate each joint with the two hand technique looking for joint effusions.
MCP squeeze looking for pain
test sensation over median, ulnar and radial distributions.
check pulses

Move:

power grip
opposition
finger and thumb pinch power
prayer and reverse prayer

Special tests:

Phalens aka reverse prayer (Carpal tunnel)
Tinels (carpal tunnel)
Froments (ulnar nerve palsy)
Finklesteins (DeQuervain’s tendonitis)
Allens (asses vascular supply)

Function:

pick up pen
undo top button

Conclusion:

Thank patient
orthopaedic examination of all joints
Full UL neurovascular exam
Full Hx looking for extra articular manifestations of RA, scleroderma

Question 5

Q

Examination: Peripheral Vascular

Answer

A

Wiper QQ:
-Ideally patient in underwear

Inspect:

Look around bed for signs of diabetic monitoring
Look for VAC pumps
Look for Amputations or any ulcers

Upper Limb:

Inspect for cyanosis, ulcers, gangrene, amputations, cigarettes stains, and/or pin-pricked finger tips (diabetic monitoring)
Palpate hand for warmth and test CRT. Feel radial pulse and brachial pulse. Offer BP on each side, lying and standing

Neck and Face:

Look for carotid endarterectomy scars
Test each of the carotid pulses in turn (not together)
Look in eyes for corneal arcus (hyperlipidaemia) and xanthelasma (hypercholesterolaemia).
Auscultate carotids for bruits (ask to hold breath)

AAA:

Palpate should be pulsatile but no expansile.
Auscultate for renal bruits

Lower Limb:

Inspect for ulcers, gangrene, amputations, scars such as Varicose Vein stripping or CABG harvest, look at skin colour, and hair loss.
Palpate all the leg pulses i.e. femoral, popliteal, posterior tibial and dorsalis pedis
Feet, look between toes for damage, test CRT and feel for warmth:
Auscultate for femoral bruits.

Special tests:
-Buergers Tests

Conclusion:

Thank patient
offer to help dress if appropriate
Full CVS examination + venous exam
Doppler assessment of pulses
ABPI
Urine dipstick
Swab any ulcers
ECG (to exclude AF as cause of embolic ischaemia

Question 6

Q

Examination: Hernia

Answer

A

Wiper QQ:
- offer chaperone

Inspect Standing:

look for hernia, size, location
Look for surgical scars
ask patient to cough

Inspect Lying:

Lift patients head and then legs off bed
look for hernia, size, location
ask patient to cough

Palpation:

describe the lump (size, shape, consistency, tenderness, colour, temperature
can you get above the lump?
is there a cough impulse
ask the patient if they are able to reduce the hernia
even if you cant see a hernia palpate inguinal hernias bilaterally and ask patient to cough

Percuss + Auscultate:

bowel sounds
offer to transilluminate hernia (does not transluminate)

Direct vs Indirect:

reduce hernia
find deep inguinal ring (midway between pubic tubercle and anterior iliac spine)
compress the deep inguinal ring
an indirect will be controlled by compression a direct hernia will not.
just an estimate

Conclusion:

Thank patient
offer help to dress
FRAPE
Femoral pulses and inguinal lymph nodes
Resp exam
Abdo exam
PR
External genitalia

Question 7

Q

Examination: Varicose Veins

Answer

A

WIPER QQ

Ideally patient exposed waste down
Patient standing for examination

Inspect:

look around the bed for compression stockings, anticoagulants.
Does the patient have a large abdominal mass? Are they pregnant?
Look at the legs for site, size, and distribution of VVs
Look for any skin changes such as haemosiderosis, lipodermatosclerosis, ulceration, eczema

Palpation:

note the temperature of the leg, and feel for tightness of lipodermatosclerosis
palpate the course of any VVs
feel for a cough impulse (Morrissey’s test) at the saphenofemoral junction (4cm lateral and inferior to the pubic tubercle)
Tap the varicose veins distally whilst palpating SFJ feeling for transmitted impulse suggesting incompetent valves

Auscultate:
-Listen to VVs for bruit which would suggest AV malformation

Special Tests:

Offer Torniquet test (milk veins, torniquet SFJ, assess refilling of VVs, repeat on SPJ)
Offer perthes test (assess deep veins, apply torniquet at SFJ, walk for 5 mins, abnormal will get pain and increased VVs

Conclusion:

Thank patient, offer to help dress if appropriate
Full peripheral arterial examination
Doppler examination of pulses, and valves
ABPI
PV + PR looking for causes of increased abdominal pressure

Question 8

Q

Examination: Speech and Swallow

Answer

A

WIPER QQ

Inspection:

Look for hearing aids, walking aids, dentures, NBM signs
Look for signs of stroke, facial droop/asymmetry, hemiplegic posturing

3 Questions:

Any hearing problems?
Is english your first language?
Are you left or right handed?

Open Question:

Ask a general question (can you tell me what your normally do in a day at home?) and interpret response as follows
Receptive/ Wernicke’s Dysphasia: understanding imparied, but fluent speech, often doesn’t make sense
Expressive/ Broca’s Dysphasia: Understanding is intact, unfleunt/broken speech, difficulty finding words
Dysphonia: decreased volume of speech, vocal cords often imparied
Quality of speech: nasal = bulbar palsy, Donald Duck speech -= psuedobulbar palsy

Dysphasias:

Test for receptive dysphasia (temporal lobe) by asking 1 stage command e.g. touch your ear, 2 stage command e.g. touch your right ear, 3 stage command e.g. touch your left ear with your right hand. be sure not to give visual cues.
Test for expressive dysphasia (frontal lobe) by asking to write a sentence
Test for conductive dysphasia (arcuate Fasciculus) by asking to repeat sentence e.g. No ifs and or buts
Test for nominal dysphasia (Parietal lobe, angular gyrus) by asking to name objects, ask them to point to an object out of three, also ask them to choose the object that acheives a function e.g. choose the item you write with

Articulation:

‘mmm’ assesses CN 7
‘kkkk’ assesses CN 9/10
‘ta ta ta ta’ assesses CN 12

Fatigue/ MG:
-look for fatigue ask to count down from 20 - 1

Swallow:

Ask if any pain or difficulty on swallowing, any choking or coughing when swallowing
Saliva first put fingers on hyoid and thyroid cartilage feel for movement and check mouth for residual
if okay progress through teaspoon of water, sip, gulp, yogurt, solid
offer to perform jaw jerk

Conclusion:

Thank patient
Test cognitive function (AMTS, MMSE)
Full cranial nerve and UL, LL exam
Formal SALT assessment
Barium Swallow

Question 9

Q

Examination: Stoma

Answer

A

Site:

Where is the stoma
upper right quadrant tend to be for defunctioning colostomy
Lower right quadrant tend to be for ileostomy
Lower left quadrant tend to be for colostomy

Bag (Contents):

What is in the bag?
Ileostomy produce continuous liquid stool
Colostomy produce intermittent semi-solid normal like faeces

Stoma:

What does the stoma look like?
Ileostomy tend to be raised/spouted
Colostomy tend to be flush
single lumen indicates an end ileostomy/colostomy
Double lumen tends to be for defunctioning for easy reversal
inspect skin around stoma for signs of infection, fistuale, skin excoriations, is the stoma retracted or prolapsed?
vascularity? Dusky or pink and healthy?
palpate around stoma = cough test feeling for parastomal hernias
offer digital examination of stoma

Abdomen:
-Look for scars

Conclusion:

Thank patient
Offer full abdominal examination
Offer to examine perineum (Does the patient have an anus if not think AP resection)

Question 10

Q

Examination: Hydration status

Answer

A

WIPER QQ
-In underwear 45 degrees initially

Inspection:

Look around bed for NBM signs, Fluid restrictions, Fluids running, Water jug
Look at patient, do they appear oedematous, SOB, are they bleeding?

3 Questions:

Are you thirsty?
Any diarrhoea or vomiting?
Any dizziness when standing?

Hands:

Are they warm?
Well perfused?
Capillary refil time
Radial Pulse and Respiratory rate

Arms:

Brachial pulse
offer BP lying and standing

Neck:
-JVP

Face:

Do the eyes appear sunkern?
Do the mucous membranes appear dry?
Does the tongue appear dry?

Chest:

Decreased skin turgor is a sign of dehydration = rubbery skin
Central Refill time
Palpate apex beat
Ascultate heart - 3rd heart sound = heart failure
Lung bases, bibasal fine crepitations = pulmonary oedema
Sacral oedema

Abdo:

Inspect for ascites or high-output stoma
Shifting dullness ?ascites
Ballot kidneys
Palpate and percuss for bladder

Legs:
-Peripheral oedema

Conclusion:

Thank patient offer to help dress
In summary this patient is hypovolaemic/euvolaemic/hypervolaemic
Ask to look at fluid balance chart
Ask to look at weight chart
Ask to look at drug chart and fluids prescribed
Ask to look at bloods, esp U+E

Question 11

Q

Examination: DR ABCDE

Answer

A

Danger:

Identify hazards about patient
Wash hands

Response:

Hello sir/madam can you hear me?
Ask for observations
Aware of any cervical spine injuries
Consider calling for help

Airway:

If patient talking airway is patent
Look inside mouth for obvious obstruction
Listen for upper airway noises e.g. Snoring/ stridor
Feel for breath with cheek
Treat by removing visible obstruction using magill forceps or yankuer sucker, Airway manoeuvres e.g. head tilt, chin lift (if no suspected C-spine injury) jaw thrust
Airway adjuncts such as oropharyngeal and nasopharyngeal airways
if compromised airway call for help e.g. anaesthetist / PERT team (2222)

Breathing:

Look for central and peripheral cyanosis, does breathing look effortful?, is there symmetrical chest movement
Auscultate lungs
Feel, percuss the chest, is the trachea central, Is chest expansion adequate
Measure respiratory rate and SaO2
Treat with high flow O2, ABG, CXR, and treat underlying cause if identified

Circulation:

Look at the patient for palor, sweating, bleeding, peripheral oedema, JVP
Listen to heart sounds
Feel pulses assess HR and character of pulse, Cap refil time, Peripheral oedema
Measure HR, BP, Urine output, Temperature
Treat with 2 large bore (grey) cannulae, one in each antecubital fossa, Take bloods for FBC, U+E, G+S, CRP, Clotting profile, Troponin, Cultures. Get an ECG and treat any identified cause.

Disability:

AVPU/ GCS
Glucose
Pupils

Exposure:
- General examination, any bleeding, Rashes or swelling?

Conclusion:

Do not leave patient
Reassure patient
Look at notes and PMHx
Systemic handover using SBAR format
MAKE SURE TO CALL FOR HELP

Question 12

Q

Examination: Thyroid

Answer

A

WIPER QQ

Patients should be sat down with chair away from wall
Fully expose neck

General Inspection:

Look for medications around the bed, abnormal amount of clothing regarding weather
Look at the patients skin, hair and general appearance

Hands:

Warm? Sweaty?
Thyroid acropatchy (clubbing of fingers with soft tissue swelling)
Dry skin?
Pulse, tachycardic?
Tremor?

Eyes:

Any proptosis/exopthalmus (bulging eye)
Lid retraction
Corneal drying
Ask patient to close eye to see extent to which eyelids cover eyes
Lid-lag? (delay in in eyelid to follow eye when looking down)
Opthalmoplegia (difficulty following fingers with eyes)
Offer to test visual acuity

Thyroid:

Inspect size shape and symmetry, ask patient to swallow should move up, protrude tongue (shows thyroglossal cyst)
Palpate from behind patient (warn them) palpate at rest feeling inferior to the thyroid cartilage for the isthmus and then each of the glands. then palpate whilst swallowing and protruding tongue

Neck:

inspect neck for scars
Palpate trachea centrality
feel lymph nodes
percuss posterior sternum for dullness indicating retrosternal goitre
Ausculate as high activity thyroid may have bruit

Extra Features:

Proximal myopathy - (arms up like a chicken don’t let me push the down, fold your arms across your chest and stand up)
Reflexes - hypothyroidism shows slow relaxing reflexes
Pembertons test - ask patient to lift arms if goitre is obstructing SVC patients face will go red and neck veins will engorge.

Conclusion:

Thank patient
full Hx
Cardiovascular exam
look at drug chart
Bloods (TFTs, FBC, autoantibodies)
Imaging (US)
FNA/biopsy

Question 13

Q

Clinical Skill: Venepuncture

Answer

A

Wash hands, introduce self, check patients wrist band/confirm patient details, ask if patient had the procedure and explain if not, gain consent, check if the patient has an allergies, specifically latex
Gather equipment: alcohol wipes, barrel, needle, blood tubes, tourniquet, gloves, gauze, tape
Return patient, confirm they are still happy to have the procedure
expose area up to 3 inches above antecubital fossa
reposition patients arm with forearm and palm facing upwards
apply tourniquet and palpate suitable vein
Don new pair of gloves and wash area with alcohol wipe
prepare needle and open
anchor skin 3 inches below point of insertion and warn patient of sharp scratch
insert needle bevel up and look for flash back, shallow insertion angle and procede slightly forward
fill blood tubes
remove tourniquet keeping needle in situ
remove needle and dispose in sharps bin
apply gauze and keep pressure on the wound for 2 minutes
tidy area

Conclusion:

Thank patient
invert the tubes 2-3 times and label them
wash hands

Question 14

Q

Clinical Skill: Cannulation

Answer

A

Wash hands, introduce self, check patients wrist band/confirm patient details, ask if patient had the procedure and explain if not, gain consent, check if the patient has an allergies, specifically latex
Gather equipment: alcohol gel, gloves, alcohol wipe, IV cannula, bung, needle, 0.9% saline, syringe, gauze, tourniquet
don gloves
Return to patient confirm they are happy to have the procedure
apply tourniquet and palpate suitable vein
Don a new pair of gloves and wash area with alcohol wipe
remove safety sheath from cannula, anchor skin and warn patient of sharp scratch
Insert needle bevel up at 30 degrees, advanced needle until flashback occurs.
Shallow angle and advance 2mm forward. hold needle and advance cannula.
Put gauze under the cannula, release tourniquet, and remove needle disposing in the sharps bin
attach bung to end of cannula and use strips to secure wings of cannula
clean the cannula site of blood
apply the plaster to the cannula
flush the cannula warn of cold feeling, with 0.9% cannula- look for resistance or pain, if so stop flushing and start again

Conclusion:

Thank patient
signs and date cannula in notes

Question 15

Q

Clinical Skill: ABG

Answer

A

Wash hands, introduce self, check patients wrist band/confirm patient details, ask if patient had the procedure and explain if not, gain consent, does that patient have an allergies particularly local anaesthetic (1% lidocaine)
Check for contraindications, is that patient on any blood thinners? e.g. warfarin of aspirin, does that patient have any issues with clotting of the blood?, Does the patients have any problems with the liver
Perform allens test to test circulation, patient makes a fist, then apply pressure to ulnar and radial artery, patient relaxes hand, release pressure on ulnar artery, colour should return to the hand within 9 seconds
Gather equipment: Arterial blood gas needle, red drawing up needle, orange needle, syringe, 1% lidocaine without adrenaline, gauze and tape, gloves.
Return to patient confirm they are still happy to have the procedure
Wash hands and put on apron, position patients hand with wrist in extension, palpate radial artery
don gloves and clean site with alcohol wipes
warn of sharp scratch and infiltrate 0.1-0.2mls of 1% lidocaine subcutaneously over planned injections site be sure to aspirate before injecting
wait 60s for anaesthetic to work
attach needle to heparin syringe and expel heparin
withdraw plunger slighly.
use one hand to palpate the artery and with the other insert the needle at a 30 degree angle
as the artery is punctured the syringe should begin to fill with bright red blood in a pulsatile manner
once acquired amount of blood is acquired quickly remove the needle and press gauze down firmly on the wound ideally for 5 minutes
insert needle into rubber block and remove and safely dispose of the the needle,place cap on syringe
dress wound with gauze and tape

Conclusion:

Thank patient ask if they have any questions
take ABG sample to analyser - document in notes procedure, results and any complications

Question 16

Q

Clinical Skill: Catherisation

Answer

A

Wash hands, introduce self, check patients wrist band/confirm patient details, ask if patient had the procedure and explain if not, gain consent, ask if the patient has any allergies specifically to anaesthetic, offer chaperone
wash hands, don apron and prepare and clean trolley
gather equipment: 2 pairs of gloves, catheter kit, male catheter 12/14 french, apron, water filled syringe, 1% lidocaine gel, saline 0.9%, sterile receiver, catheter bag
set up sterile field
return to patient confirm they understand and are still happy to have the procedure
expose the patient
wash hands again and two pairs of gloves
place sterile absorbent pad underneath the patients genitalia
hold the penis with non-dominant hand and gauze, pull back the foreskin and gauze and using cotton balls clean penis from urethral meatus to base of glans
dispose of top layer of gloves and don new pair of gloves
tear a hole in the sterile drape and place over penis
place the sterile receiver underneath penis, attach catheter bag to catheter
hold the penis with gauze in the non-dominant hand pointing towards the ceiling and warn patient of slight stinging but should go numb quickly, inject 10ml lidocaine slowly.
hold penis vertically for 3-5 minutes for gel to take effect
removing top layer of gloves
remove the top of the catheter bag being careful not to touch the tip of the catheter
warn the patient that your are about to insert catheter and then slowly insert into meatus
continue inserting, pulling back the wrapper of the catheter and advancing the catheter, may feel some resistance when passing prostate, do not force catheter if problems stop and withdraw and consider reattempting or speaking to urology
as you enter the bladder urine may start to drain
continue until catheter fully inserted
once fully inserted inflate ballon with 10ml of water from syringe, warn the patient and ask if they have any pain
once fully inflated withdraw catheter until resistance is felt
if not already attach catheter bag
place catheter bag below level of patient
replace patients retracted foreskin
clean up patient, and area disposing of gloves and equipment, cover them up and offer help to dress

Conclusion:

thank patient, ask if the patient is in any discomfort or has any questions
wash hands
Document procedure in the notes including residual volume, appearance and any complications

Question 17

Q

Examination: Visual Acuity

Answer

A

WIPER QQ
ask the patient whether they use glasses or contact lenses for distance vision. if so they should keep these on the the examination
position the patient 6m from a Snellen chart, or 3m from if using a mini-Snellen chart but still record as normal
ask the patient to cover one eye and read the lowest line on the chart, if they cannot do this ask them to read the one above, repeat this until they complete a line fully
repeat with the other eye
if vision isn’t perfect i.e. 6/6 then use pinhole test to see if vision improves if it does then the problem is with a uncorrected refractive error
record data a 6/ with the number of the lowest line read
if the patient reads most of the lines letters it can be recorded as 6/ minus the number misread on that line
if the patient read only a few letters of a line recorded as the higher line as 6/ plus the number read below that line
a letter suffix should be added as appropriate UA for unaided, C Gl for with glasses, S Gl for without glasses but usually wears them, C Cl for with contact lenses, and PH for improved with pinhole
If they cannot read the top line of the snellen chart half the distance from the chart and record this as 3/ and the line they could read
If no letters can be seen by the patient procede to examine each eye in turn for counting fingers CF
if still not able then wave the hand if they can detect hand motion then HM
if still not able then then shine a light into their eye and if can perceive light record as LP
If not able to see light record as NLP

Conclusion:

Thank patient
assess back of the eye with opthalmascope
examine the 3rd,4th and 6th cranial nerves

Question 18

Q

Examination: Lymphadenopathy

Answer

A

WIPER QQ
Look around patient for any medications, does the patient appear comfortable at rest?, do they look cachetic? any obvious swelling of limbs (?lymphoedema)
Examine the lymph nodes of the head and neck, starting with the submental, submandibular, pre-auricular, anterior cervical, supraclavicular, infraclavicular, posterior auricular, occipital
Examine the axilla, apical, anterior, posterior, lateral
Examine the inguinal nodes
Examine the popliteal fossa
If you feel a node describe it using the 3S’s, 3 T’s, and 3 C’s. Size Shape Site, Temperature Tethering Tenderness, Colour, Contour, Consistency

Conclusion:

Thank patient
Present findings
Finish with full history

Question 19

Q

Clinical Skill: Suturing

Answer

A

Wash hands, introduce self, confirm patients details, explain procedure, ask for allergies specifically anaesthetic
Gather equipment: gloves, suture pack, thick and thin curved needles, 0.9% saline, gauze, lidocaine, orange needle, red drawing up needle, syringes
clean a trolley or use patients bed side and set up sterile field
don gloves
inspect the wound, any pus or necrosis, any skin changes e.g. cellulits, are there any foreign objects, if suspecting or can see foreign objects request x-ray to assess depth of penetration, also check patients tetanus booster status
clean the wound using saline irrigations
attach red drawing up needle to draw up 1% lidocaine (max dose is 3mg per kg, 1% lidocaine has 10mg per 1ml), safetly dispose of needle and attach orange needle. penetrate the tissue at various sites of the wound (i.e. corners) pull back on the plunger first and then inject whilst drawing the needle out slowly
Ideally wait 5 minutes for anaesthetic to take effect, check if the patient can feel a sharp sensation
Change gloves, open suture pack, reposition patient so wound is lying horizontal infront of you. put the needle in the needle holder, Use the toothed forceps to open the wound, penetrate the wound about 1/2 cm from the edge and 1/2cm deep. unclamp the needle, and then reclamp and using the non-toothed forceps pull the needle through, swap back to needle holder and repeat on the other side of the wound but from inside out.
To tie the suture pull the needle through leaving ~2-3cm sticking out of the skin, hold the needle holder parallel to the suture and wrap the long suture thread around the needle holder and then rotate the needle holder 90degrees grasp the small suture tail and then pull tight by pulling the suture to opposite polls, repeat 2 times using the long suture thread to wrap only once, make sure the first knot is tight
the next suture should be 1cm away and repeat until the wound is closed

Conclusion:

Thank patient
explain the sutures should be taken out after 5-7days (unless dissolvable sutures used)
advise to keep area covered with dry dressing and to avoid getting dressing wet
Advise to seek medical advice if signs of infection e.g. fevers, redness, swelling or increased pain
give them a leaflet of suture wound care

Question 20

Q

Explain: Endoscopy

Answer

A

WIPER QQ
Be sure to chunk information and check patients understanding
‘Do you know why you have come in today?’
‘What do you understand about the procedure?’
give the reason of the procedure i.e investigate bleeding/anaemia, dyspepsia
Sedation if needed, LA sprayed on the back of the throat if OGD
You lie on your side on a couch
Fibre-optic tube about 1cm in diameter passed into rectum or through mouth down the oesophagus to the stomach
enables the doctor to look at these regions with camera for anything abnormal
doctors may take a sample, called a biopsy, which willbe sent for tests under a microscope. Doctors may also remove any abnormal tissue for example a polyp
the procedure lasts about 15 minutes
complications common are pain in abdomen with inflation with gas which is normal may help to pass wind, or sore throat.
uncommon complications include tearing, bleeding, perforation, infection
Will feel drowsy after but can go home same day, cannot drive so will need somebody to pick them up
check if the patient has any other questions, if not thank them and wash hands.

Question 21

Q

Clinical Skill: ILS

Answer

A

Wash hands
check for danger and response
If no response call out for help
carry out airway manoeuvre such as head tilt and chin lift if no c-spine injury
look, listen and feel for movement of the chest, breath sounds, carotid pulse for 10 seconds
if no breath or pulse and cardiac arrest is confirmed call 2222 for PERT team and ask for defibrillator trolley
Start CPR 30:2 (15:2 in children) chest compression to breaths, breaths given by bag valve mask with two people, at a rate of 100-120 and compressing the chest 1/3 (5-6cm) of its depth over the lower 1/3 of the sternum
Continue until defibrillator arrives
apply pads one on right sternal heave, and one on the apex beat
explain to team to pause for no more than 5 seconds to assess the rhythm
Shockable rhythms are pulseless VT or VF, Non- shockable rhythms are aystole, or Pulseless Electrical Activity (PEA)

Shockable:

If shockable explain to team that you are going to deliver a charge, everyone is to step pack whilst charging except the person delivering chest compression and then on command they are to step away whilst shock is delivered.
set defibrillator to pads and charge whilst continuing CPR, for the first shock a biphasic defibrillator can be set to 150-200J subsequent shocks to 150-360J. Monophasic can be set to 360J
Administer 1st shock and restart CPR for 2 minutes
reassess rhythm and change algorithm where necessary
Administer 2nd shock and then restart CPR for 2 minutes
reassess rhythm and change algorithm where necessary
Administer 3rd shock and then whilst CPR is taking place give IV 1mg of Adrenaline i.e. 10ml of 1/10000 and 300mg IV Amiodarone
continue Shock and CPR cycle giving adrenaline after every other shock.
During 2 minutes cycle, assess and treat reversible causes of cardiac arrest i.e. Hypovolaemia, Hypothermia, Hypo/hyperkalaemia, Hypoxia, Tension pneumothorax, Tamponade, Toxins and Thrombus

Non-shockable:
-give IV Adrenaline 1mg i.e. 10ml of 1/10000 as soon as possible
-give CPR for 2 minutes
-reassess rhythm and change algorithm where necessary
give CPR for 2 minutes
-reassess rhythm and change algorithm where necessary
-Continue cycle with IV Adrenaline 1mg 1/10000 after every other cycle i.e 3rd, 5th
-stop if return of spontaneous circulation (ROSC), shockable rhythm develops, decision to stop by arrest team

ROSC:
-get new sets of obs, waveform capnography, intubation, ITU transfer, ABCDE assessment, consider Thermoregulation

Question 22

Q

Clinical Skills: IV fluids

Answer

A

WIPER QQ
be sure to ask about allergies, especially if giving antibiotics
check if patient has a cannula in situ
reposition arm to expose cannula
Check the date of cannula, ideally less than 3 days but up to 5 if no sign of complications e.g. Swelling, redness, phlebitis

Check Fluid against prescription chart looking at:

name of fluid
strength of fluid
volume of the fluid
route of the fluid
time to be given over
any additional drugs to be given
makes sure the fluid has not already been given
the prescription is signed
Gather equipment: gloves, alcohol swab, giving set, fluid prescribed/drug, saline flush,
don gloves
ensure giving set tube is closed
insert giving set needle into fluid bag
fill the giving set chamber to half full
open the giving set tap and run the fluid to the end of the line and then close the tap ensuring no bubbles
return to patient recheck details
remove gloves, wash hands and don new gloves
clean the cannula site with a alcohol wipe
flush cannula ensuring it was easy to flush, did not leak, and did not cause pain.
insert the giving set tip into the cannula

-Squeeze the giving set chamber until it is half-filled with fluid, then set to whatever rate is prescribed. To do this, you must calculate the ‘drip rate per minute’:
Drip rate per minute = amount of fluid (L) / hours in minutes it should be given over X 20

Count the drops over a minute to make sure that this number is the same as the one you calculated, so you know you are administering the fluid over the correct duration
Thank the patient, tidy up your equipment and wash your hands, document fluids given on drug chart and fill in fluid balance chart where appropriate

Question 23

Q

Explain: Lumber Puncture

Answer

A

WIPER QQ

Be sure to chunk information and check patients understanding
‘Do you know why you have come in today?’
‘What do you understand about the procedure?
Give reason for the procedure e.g. to take CSF which surrounds the spine to look for signs of infection, bleeding or to confirm a neurological diagnosis
patient is placed on their left side with the back on the edge of the bed, knees flexed to the chin
local anaesthetic (check allergies) will be given to the skin and deeper layers on the lower back where the sample will be taken
a needle is inserted in between the spaces of two intervertebral bodies and CSF is collected and the amount is only small of the total amount in the space
Complications may occur such as , bleeding, infection at the site of puncture, meningitis, result could be poor, CSF leak
After the procedure the patient will stay in hospital overnight as results will not be back for a while and patient ill need to lie flat on their back for at least 4 hours post-procedure to help prevent CSF leak and headache
Check if the patient has any other questions or concerns
Thank patient and wash hands

Question 24

Q

Clinical Skills: Manual Handling

Answer

A

WIPER

make sure you have as many people as needed for the movement
be sure to check if patient has any injuries
check how many people the patient usually has to help them

Moving a load:

assess the area
stand close to the load
bend the knees
assess the weight of the load grabbing opposite corners
straighten your legs to lift
hold the box close to you
keep your back straight

Assisted stand:

WIPER
position appropriate walking aids if needed
position behind patient one hand on lower back one on the front of the chest
patient should be positioned in a chair at the edge of the chair with the arms braced on the armrest
instruct patient that they will be rocked back and forth and on ready-steady-stand they will push themselves up with the arm rest
perform the procedure supporting them whilst they stand
stay with patient whilst they move if unstable.

Sliding Patient:

WIPER
reposition bed, remove head board and rails
with two people roll patient, place folded sliding sheet underneath them
roll to the opposite side and pull the bottom of the folded sliding sheet, using the sheet against itself to place the sheet flat
ensure the patient is centred on the sliding sheet
position correctly and rehearse and perform sliding manoeuvre (ready steady slide)
ensure patient is comfortable and reassure
remove sliding sheet
replace head board and side rails
thank patient

Log roll:

Explain patient
leader controls head and coordinates
5 people needed
Roll patient in synchronised fashion maintaining straight spine
PR and check spine for pain
Roll back down

Transfer to bed:

4 people needed
raise trolley to level of bed
two people roll patient towards them
put sheet underneath patient with one side bunched up
roll patient to the other side and pull half sheet through
place sliding mate underneath patient and over gap between beds
all 4 grab scrunched sheet and on ready-steady-slide pull/push patient onto the bed
roll patient and remove sliding board
thank patient

Question 25

Q

Communication: breaking bad news

Answer

A

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

Question 26

Q

History Taking: Psychiatric History

Answer

A

PC: Patient demographics, referred by? presenting complaint in own words

HPC: nature of the problem, duration, frequency, timing, associated symptoms, precipitating/aggravating/ relieving factors

PPHx: any previous contact with services e.g. GP, outpatient, admission. Any past treatment if so length and outcomes. Medications that worked and those that did not. Depot, ECT, Lithium, Clozapine?

DHx: current medication type, dose, frequency, route, blood screening required? Allergies?

PMHx: illnesses, operations, treatment

FHx: history of medical or psychiatric illness

PHx:

Childhood: Birth (NVD or complications), SCBU, Developmental Delay (milestones), early separation, neurotic traits (thumb sucking, school refusal, bed wetting)
School: age started school, peer relationships, academic achievement, relationship to teachers (authority), suspension/expulsion, “special” school, exams and qualifications
Employment: all jobs and durations with reasons for leaving/moving, any notable period of unemployment?
Relationships: menarche, first sexual experience, history of abuse, longest past relationship and others, sexual orientation, current relationship

FoHx: forensic history e.g. Criminal
Behaviour, Arrests, prison, probation, dates seriousness, forensic psychiatrist

SHx: housing situation, finances, debts, friends, social interests, religion, substance misuse (alcohol and illicit drugs, how much, how long, what, blackouts, withdrawal, reasons, hospital admissions)

MMSE

Collaborative history from family or other carers

Question 27

Q

Examination: Cranial Nerves

Answer

A

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

Question 28

Q

Examination: Knee

Answer

A

WIPER QQ

Look:

Deformity, Wasting, Asymmetry, Rashes, Fasciculations, Scars
Swelling or bruising

Feel:

Feel for temperature change suggesting inflammation
Bend the knee to about 70 degrees and sit on the edge of the cough facing the knee, feel the bony contours around the joint and the attachment of the ligaments and tendons e.g. quadriceps tendon, medial collateral ligament, lateral collateral ligament, patella ligament and note any tenderness.
Test for synovial thickening by grasping patella between thumb and middle finger and attempting to lift it off the femoral groove, normally it can be gripped quite firmly but if the synovium is thickened fingers slip off.
feel the medial and lateral aspects of the patellofemoral joint by straightening the leg and pushing the patella either side feeling the undersurface of the bone for tenderness. A feature that is often encountered in patellofemoral osteomalacia or osteoarthritis.

Move:

Ask patient to bend and straighten knee fully, note range of movement
Repeat the process while placing a hand over the front of the knee feeling for crepitus and testing passive movements.

Tests:

patella tap/bulge test for intra-articular fluid
collateral ligaments (hold leg in extension with foot under arm and both hands around knee test mediolateral movement no movement at extension repeat at 30 degrees
anterior/posterior drawer test +/- lachmans

Conclusion:

Thank patients
Wash hands
neurovascular examination of limb
Appropriate imaging e.g. MRI or X-ray

Question 29

Q

Examination: Ear

Answer

A

Wash hands, Introduce self, confirm patient details, explain examination, gain consent

Inspect:

pinna, auricule, helix, antihelix
any visible wax or discharge, blood
preauricular sinuses
any scars behind the ear
hearing aids
the meatus itself is it wide?

Palpate:

tug gently on the pinna - any tenderness?
Press over the mastoid process - any tenderness?
palpate the tragus - any tenderness?
Palpate for any cervical or periauricular lymphadenopathy

Otoscopy:

gently hold ear up and back to straighten the ear canal
gently insert the otoscope
look at the canal wall - any wax/discharge/bleeding
look at the tympanic membrane any perforation, light reflex present, bulging drum, retracted drum, grommets, cholestatoma, fluid bubbles.

Special Tests:

Whispered voice hearing tests
Rhine test
Weber test

Conclusion:

examine facial nerve for signs of damage
formal audiometric testing

Question 30

Q

Examination: Nose

Answer

A

WIPER

Inspect:

External appearance of the nose from front, sides, top and bottom
any scars, skin changes, asymmetry
use a thudichum speculum to look into the nose, look at nasal vestibule, septum, inferior tubinate if pale and boggy think allegic rhinitis

Examine nasal airfow:
-using a silver tongue depressor under nose look for teaming

Examine sensation of maxillary division of trigeminal nerve

Conclusion:

examine the throat
test patients sense of smell
consider using flexible nasoendoscopy
thank patient

Question 31

Q

Clinical Skills: Neonatal life support

Answer

A

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

Question 32

Q

Examination: Newborn Baby Check

Answer

A

WIPER QQ

Questions:

any eye, hip, or congenital heart disease issues in childhood with any first degree relative?
any problems with antenatal scans?
Breech presentation?
has baby passed stool + urine?

Listen:
-lungs and chest whilst calm, note any murmurs

Look:

red reflex
rashes, colour, position, tone, asymmetry, any lumps or bumps, bruising.
ears normal
check for anus
put on back check spine
umbilicus

Feel:

fontanelles
clavicles
check for cleft pallet (couple with sucking reflex)
abdomen
femoral pulses
abdomen, any masses
Palpate testes
Barlow + Ortlani tests for DDH

Reflexes:

sucking reflex
Moro reflex
grasping reflex

Conclusion:

Thank parents
dress baby
report findings
arrange neccessary follow up

Question 33

Q

Communication: HIV Pre-test consenting

Answer

A

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

Question 34

Q

History Taking: Sexual History

Answer

A

Introduce self , confirm patient details, explain, consent
Why have they come to you? (What’s brought them in)

-Any symptoms?
Women - vaginal discharge, dysuria/frequency, vulval itching/soreness, genital skin changes, abdominal pain, dyspareunia, post-coital bleeding, systemic symptoms

Men - Urethral discharge, testicular pain, dysuria/frequency, itching, genital skin changes, systemic symptoms

Menstrual history -LMP, regularity, length of cycle, dysmenorrhea intermenstrual bleeding.
Obs + Gyn history - smears (dates/results), any surgery?, current contraception, possible pregnancy/
sign post for sexual history, acknowledge sensitivity
when did they last have a sexual encounter
partner demographics I.e. Sex, regular or casual, age
what types of sex did they have? Oral Anal (received or gave or both) Vaginal Digital
was contraception used for all sexual encounters, any issues?
any other partners in the last 3 months?
any previous STIs or tests/results
any medical or surgical problems
any current medications, recent antibiotics?
Social history, smoking alcohol recreational drug use.
HIV risk history, ever had a partner who was HIV possible, ever had sex with a bisexual or participated in MSM, ever injected drugs, paid or been paid for sex
ICE
Thank patients.

Question 35

Q

Examination: Testicular

Answer

A

WIPER QQ

offer chaperone
don gloves

Inspection:

Inspect the genial region and surrounding areas for any skin changes (rash/brushing/swelling), scars, obvious masses.
inspect the penis and glans (ask patient to retract foreskin)
inspect the scrotum asking the patient to hold their penis out of the way, remember to examine posterior aspect by lifting the scrotum, looking for skin changes (rash/ulcers/erythema), scars, masses, necrosis, swelling, brushing.

Palpation:

Examine each testicle, starting with the normal testicle, ask the patient to report any pain or discomfort, use thumb and index finger to gently Palpate the testicle. If a mass is felt assess the size/shape, regularity, consistency, pain, whether you are able to get above the mass. Is it fixed to testicle? Is their a cough impulse? Does the mass transilluminate.
Palpate the epididymis located at the posterior aspect of the testicle, pain suggest epididymitis, Phren’s test = if testicular pain is relieved by elevating the testes this is strongly suggestive of epididmitis
Palpate the spermatic cord starting at the superior aspect of the testicle using the thumb and index, roll the cord assessing its length for masses and tenderness.
assess the local lymph nodes in the inguinal region for evidence of lymphadenopathy.

Conclusion:

thank patient
allow time to dress
dispose of gloves
wash hands
summarise findings
to complete full abdominal examination and USS of the testicles.

Question 36

Q

Clinical Skills: Controlled Drugs

Answer

A

Controlled Drugs prescriptions must:

be indelible (in pen)
be dated
be signed by the prescriber
include the prescribers address
include the name and address of the patient
include the date of birth of the patient
include the form of the preparation e.g. Tablets, Capsules
include the strength of the preparation
include the total quantity in both words and figures or number in words and figures of doses to be supplied
include the dose to be taken

E.g.
Diamorphine 30mg Injection (SC)
Supply 6(six) ampoules
60mg daily by subcutaneous infusion over 24 hours
No more items on this prescription

Question 37

Q

Communication: Explain TURP

Answer

A

Introduction:

Wash hands, introduce self, confirm patient details
“Do you know why you have come in today?”
“What do you understand about the procedure?”
Reason for the procedure e.g. Alleviate symptoms of BPH

Pre-procedure:

patient to be nil-by-mouth for at least 6 hours
anaesthetic will be used either spinal or general

Procedure:
-thin device with a camera at the end is inserted into the urethra. The prostate is visualised and the prostate tissue is then removed.

Post-Procedure:

stay overnight with catheter which is usually removed within 24hours
patient will be seen in outpatients for follow up in a few weeks time

Complications:
-Haemturia, injury to urethra/bladder, urinary incontinence, erectile dysfunction, retrograde ejaculation, TURP syndrome, urinary retention, condition can recur

Conclusion:

Any other questions or concerns?
Provide a leaflet and opportunity to discuss further.
offer reassurance and close consultation.

Question 38

Q

Clinical Skill: Inhaler Technique

Answer

A

Introduction:

wash hands, introduce self, confirm patient details
check patients understanding of their inhaler

Explanation:

explain what the inhaler device is, show it to the patient
explain when the inhaler device should be used e.g. Preventer, remind to rinse mouth after the use. Reliever for during attacks
Check understanding

Demonstration:

explain the steps as you demonstrate
prepare the inhaler (take of lid, shake if MDI)
load the dose (if applicable), squirt once to check
breath out gently as far as comfortable
tightly seal lips around mouthpiece
breath in, quick and deep for Dry powder, slow and deep for MDI
remove inhaler from mouth and hold breath for as long as possible (10 seconds)

Assess Inhaler technique:

ask the patient to carry out the procedure themselves whilst you observe
tweak as necessary (point out positives then introduce improvement)

Spacer devices:

explain they allow more medication to get to the lungs if people struggle.
Prepare inhaler
attach inhaler to spacer device
breath out gently as far as possible
seal lips around the spacer moutpiece
release the dose required
breath in and out through the space mouth price several times listening for the click of the one way valve.
device should be washed with detergent once a month and left to air-dry.
rinse mouth after use of steroid inhaler

Conclusion:

any questions
provide information leaflet
advise to get in touch if any issues
thank patient and wash hands.

Question 39

Q

Communication: Assessing Capacity

Answer

A

Introduction:

Wash hands, introduce self, confirm patient details
Starts with open question e.g. Can you tell me a bit about what has brought you in today?

How might one make efforts to ensure patient has best capacity:

Avoid jargon
Using pictures
Treating concurrent pain
Allowing time for patient to process information
Asking questions at the best time of day for patient
Having a relative/friend present
Ensure a quiet comfortable setting.

Assess patients ability to:

understand current situation
understand the risk of refusing treatment
understand the alternative choices for treatment
sustain the information for long enough to weigh up the implications of treatment versus non-treatment or alternative choices.
communicate a decision about treatment
rationalise reason for this decision

Conclusion:

Express a wish to test the patients mental state.
May wish to speak to next of kin if possible

Question 40

Q

Communication: Explain Febrile Convulsions

Answer

A

Introduction:

Wash hands, introduce self, confirm patient details
“Can you tell me what you understand has happened so far”

Explain:

Febrile convulsions are a fit that happens when a child has a fever.
it is not epilepsy
They are relatively common and in most cases are not serious.
Around 1in20 children have at least one at some point.
They most often occur between the ages of 6months and 6 years.
The risk of developing epilepsy is slightly increased from 1in100 to 1in50 (1in20 if complex seizures)
about 1/3 of children will have another febrile seizure during a subsequent infection
if it happens again place child in recovery position and if the seizure last longer than 5 minutes or you notice any other symptoms such as a non-blanching rash then call for an ambulance.

Conclusion:

any questions
give information leaflet
offer opportunity for further questions.

Question 41

Q

History: Depression

Answer

A

Wash hands, introduce yourself, confirm patient details, confirm reason for presentation “what brought you in to see us today?”
Enquire about mood and general feelings e.g. How have you been feeling recently
Screen for core symptoms e.g. Feelings of depression, Anhedonia, fatigue. E.g. “In the past month have you felt down, depressed, or hopeless, found that you no longer enjoy things you used to or find little pleasure in life, been feeling overly tired?”
Assessing symptoms of depression e.g. Sleep cycle, mood, appetite, libido, concentration, perception of future, perception of self “do you often criticise of blame yourself when things go wrong?
Rule out differential psychiatric diagnoses e.g. Mania “have you ever experienced periods of feeling particularly high/energetic”, evidence of psychoses “people who feel the way that you have been describing can sometimes experience some unusual events and feelings…have you every heard voices speaking when there seems to be no-one around?, do you fear that people may be out to get you? Have you ever felt that something or someone is able to put thoughts into your head? Have you ever felt that something or someone can remove thoughts from your brain. Have you every seen or heard any sensations that seem odd or inexplicable?

Assess risk e.g. When people feel down and depressed, they can sometimes feel that things are so bad that life is no longer worth living, have you ever felt like this? Have you had any thoughts of taking your life” (if so how often) Have you ever made any plans or actually tried to take your own life. Have you tried to hurt yourself in any way or ever thought about it? What things do you have that stop you from harming yourself? Are you managing to eat a drink as you normally would? Has you alcohol intake change? Or have you been relying on drugs or alcohol to help make you feel better? Have you felt able to see your friends/family?

Past psychiatric history, have you ever felt like this before, have you ever had any other periods of feeling particularly low? Have you ever had any problems with your mental health, any experience with counsellors or hospitals because of mental health?

Past medical history

Drug history

Family History

Social history: smoking, alcohol, any financial or housing concerns, Relationship issues? Spoken to friends or family? Support? Is mood affecting work?

Do you feel like there is something wrong?

Conclusion:

summarise and ask if there is anything to add?
any questions?
thank patient

Question 42

Q

History: Suicide Risk Assessment

Answer

A

Introduction:

wash hands, introduce self, confirm patient details
“I understand you have been through a tough time recently, do you think you can tell me what happened to bring you here?”

The event:

Before e.g. events leading up to suicide attempt, life events, depression, planning? Suicide note/tell anybody?, precautions
During e.g. How, tablets? How many? Where from? What their intention was? When and where, how discovered, efforts to avoid discovery, alcohol/drug intoxication
After e.g. Feelings now, angry/regretful, future feelings? What has changed?

Future risk:

depression symptoms screen
PMH, past suicide attempts/ self harm
social history, social, work relationship stresses
rest of psychiatric history

Suicide risk factors:
-male, old or young, unemployed, depressed, lack of social support, chronic illness, previous attempts, drug/alcohol abuse

Conclusion:

thank patient and questions
offer risk low/moderate/high
crisis, informal admission, section?

Question 43

Q

Examination: Ankle and foot

Answer

A

WIPER

Look:

is the patient demonstrating a normal heel strike/ toe off gait?
is each step of normal height (high stepping gait sign in foot drop)
Symmetry of feet/ankle
toe alignment
bunions
scars
swelling or erythema of the foot or ankle
examine shoes for asymmetrical wearing
foot arches
achilles tendon, any obvious deformity or erythema

Feel:

ask patient to lay
assess temperature of both legs
assess pulses
palpate the achilles tendon
palpate MTP joints, tarsal joint, ankle joint, subtalar joint, medial/lateral malleoli, proximal fibula

Move:

foot plantarflexion
foot dorsiflexion
foot inversion
foot eversion
toe of the above

Special Tests:
-simmonds to assess for rupture of the achille, kneel on chair and squeeze calf normally foot plantar flexes

Conclusion:

thank patient
wash hands
examine knee and hip joint
Full NVS of lower limb
imaging of joint

Question 44

Q

Examination: Hip

Answer

A

WIPER
-ask if patient has had a hip replacement if so internal rotation, addiction and flexion greater than 90 should be avoided due to risk of dislocation

Look:

ask patient to stand
look at front to assess pelvic tilt, quadriceps wasting, scars
look at the side to assess lumbar lordosis
look from behind to assess for scoliosis, gluteal wasting, pelvic tilt
observe gait and evidence of trendelenburg or antalgic gait?

Feel:

ask patient to lie down
palpate the tissues overlying the hip joint for tenderness/warmth
palpate the greater trochanter
assess leg length (apparent = umbilical to tip of medial malleolus, true = ASIS to medial malleolus)

Move:

flexion assess individually normal ROM is 120
internal rotation normal ROM is 40
external rotation normal ROM is 45
Abduction whilst stabilising the contralateral iliac crest normal ROM is 45
Adduction whilst stabilising the contralateral iliac crest normal ROM is 30
hip extension lie prone, normal ROM is 10-20

Special Tests:

Thomas test (fully flex the hip until lumbar lordosis flat, then extend inability to extend = fixed flexion deformity)
trendelenburg tests (hands on both iliac crests ask patient to stand on one leg, normally the iliac crest on the side with the foot up should rise if it falls it is positive (abnormal) suggesting weak hip abductors on the contralateral side)

Conclusion:

Thank patient
wash hands
summarise
to complete full NVS examine joint above and below and consider further imaging if indicated

Question 45

Q

Examination: Elbow

Answer

A

WIPER

Look:

in anatomical position for any scars, swelling/erythema, carrying angle (usually 5-15)
look at the side for fixed flexion deformity, olecranon bursitis, scars etc
look at back of elbow for rheumatoid nodules and psoriatic plaques

Feel:

temperature
palpate the jointlines e.g. Epicondyles and olecranon

Move:

Assess elbow flexion (NROM 145)
elbow extension (NROM 0)
pronation/supination
feel for crepitus

Special Tests:

Medial epicondylitis aka golfers elbow (ask patient to actively flex the wrist whilst elbow is flexed localised pain over the medial epicondyle is +ve finding)
lateral epicondylitis aka tennis elbow (as the patient to actively extend the wrist while elbow is flexed localised pain over the lateral epicondyle is +ve finding)

Conclusion:

Thank patient
wash hands
summarise
examine joint above and below, full NV of upper limbs
further imaging if neccesary

Question 46

Q

Examination: Shoulder

Answer

A

WIPER

Look: (anterior, lateral, posterior) scars, asymmetry, swelling, muscle wasting.

Feel:

assess temperature of shoulder joints
palpate sterno-clavicular joint, clavicle, acromioclavicular joint, coracoid process, head of humerus, greater tuberosity of humerus, spine of scapula.

Move:

compound movements
hands behind your head (external rotation and abduction)
hands as far u your back as you can (internal rotation + adduction)
flexion FROM = 150-170
extension FROM 40
Abduction FROM 160-180
Adduction FROM 30-40
External rotation FROM 70
Internal rotation (average T5)
assess scapular movement during abduction

Special Tests:

supraspinatus ask patient to abduct from neutral against resistance earl abduction suggests tendonitis
painful arc, panicle abduct arm to maximum point ask mpatient to lower, impingement causes pain between 60-120
external rotation against resistance, pain or loss of power suggests infraspinatus/teres minor tendonitis/tear
internal rotation against resistance tests subscapularis

Conclusion:

Thank patient
wash hands
summarise
to complete full NV and examine spine and elbow
further imaging as necessary

Question 47

Q

Communication: Warfarin Counselling

Answer

A

WIPER

Checks patient understanding about warfarin therapy

Explains to patient the need for warfarin (e.g. Its indications)

Explain that the medication is taken once a day and that the dose required may vary on different days depending on control of INR

Explain that treatment will be monitored in an anticoagulation clinic by blood tests to check the INR (A measure of clotting) as warfarin increases INR.

Explain that the patient will receive a yellow book and this is used to record their INR level and warfarin dosage

Explain that on the first few days a high dose called a loading dose is given

Explain the possible side-effect e.g. Bleeding, skin necrosis, alopecia, DNV, jaundice.

Warn patient about possibility of over anticoagulation and need to seek medical help, e.g. Epistaxis, haematuria, bleeding gums, excessive bruising.

Explain alcohol intake to decrease as causes increased anticoagulation, diet must decreased in food with vitamin K e.g. Green vegetables. Avoid contact sports

Warn patient about getting pregnant whilst on warfarin as teratogenic

Tells patient to alert any health professionals and read all drug instruction leaflets carefully before taking warfarin with other medicines.

Gives advice regarding missing doses of warfarin (do not take double) and also do not suddenly stop taking warfarin

Suggest that a medical alert bracelet be worn

Invites questions and checks understanding throughout.

Question 48

Q

Clinical Skills: Lumbar Puncture

Answer

A

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

Question 49

Q

Clinical Skills: Ascitic Drain

Answer

A

Indications: Refractory ascitis secondary to portal hypertension, palliation in malignant ascites, respiratory distress due to diaphragmatic splinting.

Contraindications: local infection, thrombocytopenia, coagulopathy (INR over 2), pregnancy, organomegally, bowel obstruction

Complications: bleeding, infection (SBP), perforation, intravascular depletion and renal impairment, recurrence.

Wash hands, introduce, explain procedure, consent patient (risks include infection, bleeding, pain, failure, perforation, leakage, can use ultrasound to confirm fluid and insertion site.

Set up sterile trolley with sterile field, gloves, chlorhexadine swabs, 10mls lidocaine, orange needle, green needle, 10ml syringe, 20ml syringe, scalpel, cannula dressing x2, urinary Cather bag, blood culture bottles, paracentesis catheter (bonnano catheter)

Position patient spine in bed with head on pillow, select an appropriate point on abdominal wall in the right or left lower quadrant, lateral to rectus sheath. Clean site and apply sterile drape.

Anaesthetise skin with lidocaine using orange needle and deeper tissues using green needle aspirating as you insert needle to ensure not in a vessel.

Take the bonnano catheter and advanced needle to tip of catheter thus straightening it out. Insert the catheter using a z track i.e. Perforate skin perpendicularly and then a dvance obliquely in the sub cutaneous tissue for 1-2cm before returning to a perpendicular position to puncture peritoneal cavity.

Gradually advance the Catheter into the peritoneal space. Pull the needle back whilst advanced catheter to hilt and completely remove needle.

Fix with two sterile cannula dressings and affix the drainage bag after obtaining samples with 20ml syringe for the blood culture bottles.

Post procedure monitor pulse BP and respiration 15 minute for 1 hour 30 mins for 1 hr then hourly for 4 hours, ensure and record drain and urine output

Question 50

Q

Examination: Acromegaly

Answer

A

Introduction: Wash hands, introduce self, ask patients name and DOB, explain examination and get consent

General inspection: Increased foot, hand and head size. Mildly Hirsute, OA signs such as Kyphosis.

Hands: Inspection and palpation with hands on pillow, large spade-shaped, feel joints for OA evidence, Palms sweaty, glucose stick marks on finger pulps (Diabetes), signs of carpal tunnel syndrome

Face: Coarse facial features, acne, enlarged nose and ears, macrognathia, hypophysectomy scar under upper lip

Eyes: visual fields (bitemporal hemianopia in pituitary adenoma) prominent supra-orbital ridges.

Mouth, prognathism, wide spaces between teeth, macroglossia and ridges from teeth on sides of tongue.

Neck: Thyroid goitre, JVP (cardiomyopathy), acanthosis nigricans.

Chest: thick, skin tags, acanthosis nigricans in axilla, listen to heart look for signs of cardiac failure listen to bases.

Limbs: proximal myopathy, (patient stand up with arms crossed, shrug shoulder against resistance. Gait (tolling gait with bowed legs.

Conclusion: thank patient, i would complete my examination by measuring blood pressure doing a thyroid exam, a cardiovascular exam and formally testing visual fields.

I would also want a plasma IGF-1, and an Oral glucose tolerance tests, and MRI pituitary.

Question 51

Q

Examination: Marfans

Answer

A

Wash hands, introduce, explain, permission, confirm patient name DOB

General inspection: tall and thin, scoliosis

Hands: arachnodactly (ask them to wrap fingers around their wrist), measure arm span (wide), flexible joints.

Face: long thin face, myopia, high arched palate, test visual acuity.

Chest: pectus carinartum/excavatum, aortic regurgitation (early diastolic murmur), mitral prolapse (late-systolic with mid-diastolic click)

Conclusion:
-(autosomal dominant mutations on Fibrillin-1 gene on chromosome 15) genetic testing, eye exam, echocardiogram.

Question 52

Q

Examination: Breast

Answer

A

WIPER, get chaperone.

Inspect sitting on edge of bed breasts for any asymmetry, scars, lumps or swellings, nipple abnormalities or skin changes whilst patient has hands down. Ask patient to lift hands and repeat inspection, then ask patient to place her hands on hips and push inwards to tense pectoral is muscles.
then lay patient down with arms above head and examine each breast individually starting with the normal side. Examine all areas of the breast from periphery to nipple. Palpate around and underneath the nipple to check for discharge and lumps. Take hold of patients arm and examine the axilla. Repeat on other side.
Palpate the supracalvicular fossa on both sides.

Conclusion:

thank and cover patient.
wash hands
describe any lumps SSS, TTT, CCC
to complete triple assessment with imaging +/- biopsy, and cytology

Question 53

Q

Clinical Skills: Death certification

Answer

A

What to do when a patient has died:

Assess patient and confirm death, clearly documenting in the notes
Discuss the death with the consultant in charge of the patient
Liaise with the bereavement office to organise an appropriate tie to attend with the patients medical notes to complete death certificate.
Complete medical certificate of cause of death form
perform a full external examination of the patient body in the mortuary (ensure no implantable devices, check for bruising/pressure sores, any suspicious findings)

Completing The Death Certificate:

Personal details of the diseased Age in years and place of death
Last seen alive by me (record date), information from post mortem, seen after death (who saw deceased after death)

Cause of death:

Consider main causal sequence of condition that lead to death
the disease that led directly to death should be documented in 1a line.
CANNOT write, FAILURES (CCF is ok), asphyxia, asthenia, cachexia, cardiac arrest, coma, exhaustion, frailty of old age (only used in those over 75)
Part 2 are conditions that contributed to death e.g. Parkinson’s, IHD
Sign certificate include GMC number, residence is the hospital working in, and consultants name included at bottom if died in hospital

Counterfoil:
-There is a counter foil on the left hand side which gets left in the death certificate book you need to document the patients name and cause of death and conditions contributing to deaths and document personal details again.

Reasons to refer to the coroner:
-Unknown cause of death
-Sudden or unexpected death
-Deceased person not seen by a doctor within 14 days of death
-Death is considered suspicious/unnatural/violent
-Death may be due to an accident, self neglect or neglect from others
-death may be due to an abortion
-death occurred during an operation or before recovery from anaesthetic
-the death occurred during or shortly after a period of police custody
-the death may be suicide
THESE ARE WRITTEN ON THE BAC OF THE MCCD FORM

Question 54

Q

Examination: GALS

Answer

A

Wash hands, introduce self, confirm patient details, explain and gain consent, expose patient to their underwear.

Screening Questions:

Do you have a pain in your muscles, joints, or back:
Are you able to dress yourself independently without any difficulty?
Are you able to walk up and down the stairs independently without any difficulty?

Gait: ask patient to walk to the end of the room and back whilst you observe:

Symmetry
Smoothness, heel strike + toe off, step height
Speed of turn
Arm swing
Antalagic? Wide-based? Festinating? Circumducting? High-stepping?

Inspection:

Front e.g. Shoulder bulk, carrying angle, quadriceps bulk, knee deformity, foot deformity
Side e.g. Kyphosis, hyperlordoisis, knee joints, foot arches
Behind e.g. Shoulder muscles, spinal alignment, iliac crest alignment (pelvic tilt may suggest hip abductor weakness), gluteal bulk, popliteal swellings, hind foot abnormalities.

Arms:

Ask the patient to place their hands behind their head (shoulder abduction and eternal rotation
ask the patient to hold their hands in front of them with palms down and joint swelling or assymetry, then turn over (pronation) inspect thenar muscle bulk
as the patient to make a fist, test power grip, precision grip, MCP squeeze

Spine:

ask the patient to tilt their head to each side, moving their ear towards the shoulder (lateral flexion of cervical spine)
place 2 fingers on the lumbar vertebrae, ask the patient to bend and touch their toes, observe young fingers as they flex (should move apart)

Legs:

lay the patient on the examination couch
assess passive full knee flexion and extension, and passive flip flexion and internal rotation.
patellar tap for effusions
MTP squeeze

Conclusion:

Thank patient, wash hands, summarise findings
To complete my examination I would like to perform a full orthopaedic examination on joints with suspected pathology, and request further imaging of joints e.g. X-ray/CT/MRI with suspected pathology.

Question 55

Q

Communication: SBAR Handover

Answer

A

Introduce self, name role, location. Confirm whom you are speaking to.

Explain purpose of the call e.g. To handover a patient/ discuss a request/patient.

Situation:

Patient details, DOB, HN
Patient Location
The main issue

Background:

Admission details, date, admission reason, treatments
Past medical history
any other relevant aspects of history

Assessment:

Vital signs
Examination findings
Investigations received/pending
Management so far

Recommendation:

Diagnosis/differentials
Management plan + outstanding jobs
What would you recommend?

Conclusion:
-thanks

Question 56

Q

Communication: Mental Health Act.

Answer

A

Was hands, introduce self, open question, what does the patient want to know/ already understand?

Explain what the mental health act is:
-The mental health act 1983 is the law under which a person can be admitted, detained and treated for a mental health condition in hospital against their wishes. It comprises of different sections which involve admittance for treatment and for assessment of mental health disorder.

Section 2 allows a patient to be detained for up to 28 days for assessment +/- initial treatment. The application for the section is made by a relative or approved mental health professional along with recommendations from two doctors one of which has special experience in managing mental health disorders.

Appeal can b made to the Mental Health Tribunal within the first 14 days of section 2. The patient may ask for a list of mental health solicitors who may represent them and are entitled to free representation at tribunals under the legal aid scheme

Section 2 of the mental health act cannot be renewed but a section 3 act may be enforced where the patient may be detained for treatment which the doctors deem to be either necessary for the patients health or the safety of others.

Section 3 duration is of 6 months. This section may be renewed after a further 6 months, then annually thereafter if required.

Explain that the patient has no right to refuse treatment for their mental health condition however there are some treatments that cannot be given e.g. ECT without the patients direct consent.

The act only deals with mental health disorders and the patient will not be treated against their will for medical problems unless their medical disorder is life-threatening and they are deemed not to have capacity.

ICE + Summary, Chunk and Check

Thank patient.

Question 57

Q

Communication: DNACPR

Answer

A

Wash hands, introduce self, open question, what does the patient want to know/already know?

DNAR order:

What does patient understand?
Explain that it only applies to CPR not medical treatment
Patient will still receive current medical management and therapy.
Explain that CPR is very distressing to put a patient through and not usually successful in frail patients.
Explain that it is in the patients best interests to be kept comfortable and with dignity and self-esteem
DNAR is a medical decision made by the consultant or most senior doctor in charge
It is not possible to appeal against it or refuse it however family opinions will be taken strongly in consideration and relayed to consultant.

-Reassure patients that medical team are still very much involved and have not given up.

Close, summary, chunk and check, ICE, Invite questions/ leaflet/future discussions.

Question 58

Q

Communication: Advanced Directives

Answer

A

Wash hands, introduce self, elicit what the patient understands/wants to know.

State that an advanced directive is a legally binding set of instructions that a patient wishes to be carried out regarding their future medical treatment and it is put into action only when the patient can no longer provide these instructions themselves (aka lack capacity)

Another type of advanced directive is known as power of attorney where the patient appoints a person they trust to make decisions on their behalf.

Advanced directives are useful for stating wishes regarding decision such a s the use of life-saving treatment, CPR, administration off fluids or parenteral nutrition at the end of life.

Advanced decisions cannot be used to ask for a specific treatment or something that is illegal e.g. Assisted suicide or refusal of treatment for a mental health condition.

It is not necessary to seek legal advice to draw up an advanced directive, however it is recommend to prevent a failure for wishes to be carried out.

You can change an advanced directive at a later date if you have capacity or change mind as long as patient still has capacity.

Advanced directive may be deemed invalid if it is felt the patient created the document under duress or the document it not signed or witnessed. The advanced directive should also be scenario specific as much as possible.

ICE, chunk and check, summary, further questions/discussion

Question 59

Q

Communication: Angry patient

Answer

A

Wash hands, introduce self, open question.

Acknowledge patients anger, validate their feelings, allow patient to vent, accept responsibility for error/mistakes and apologise. Explain how mistake may have arisen.

Offer to do something to help the patient alleviate their dissatisfaction, e.g. Highlighting allergy in red, discussion of incident with colleagues, measures to prevent happening again.

Advise patient on hospital complaints prosecute with PALS should they wish to submit a letter of complaint

Summaries, invite questions.
L

Question 60

Q

Communication: SSRI Therapy

Answer

A

Wash hands, introduce self, check what patients understands so far?

SSRIs are antidepressants which alter the balance of some of the chemicals in the brain (Neurotransmitters). SSRI antidepressant affect a neurotransmitter called serotonin. An altered balance of serotonin and other neurotransmitters is thought to play a part in causing depression and other conditions.

The tablets are taken once a day and treatment is for a minimum of 3-6months after feeling better. It takes 4-6 weeks for the effects to being and initially (first 2 weeks) may feel worse.

Important side-effects include, D+V, weight change, headaches, drowsiness (take in evening) and withdrawal like symptoms on abrupt cessation, increased risk of suicide so seek support if feeling worse.

Any questions, give leaflet, summarise check understanding.

Question 61

Q

Communication: Methotrexate therapy

Answer

A

Wash hands, introduce self, check patients understanding so far.

Methotrexate is a disease-modifying agent which both reduces inflammation and suppresses the immune system. Early use improves outcomes and symptoms.

It is taken once a week with folic acid at another time, the dose is built up slowly. Usually given as a tablet. It is a long-term treatment and takes 4-6months for its effects to be apparent.

Will require blood monitoring specifically FBC, LFTs, U+Es before starting then every 2 weeks until dose stabilised and then every 2-3months

Side-effects include alopecia, headaches, GI upset, myelosupression, go to A+E if you have fever/infective signs, unexpected bleeding/brushing, anaemia. Can also cause damage to liver so be careful with alcohol and lungs so go to doctor if breathless.

Question 62

Q

Communication: Levodopa

Answer

A

Wash hands, introduce self, check patients understanding of events so far/ purpose of interview.

Levodopa works to replace some of the dopamine your brain is no loner able to make. This will help to reduce your symptoms in particular your rigidity and slow movement. Given with carbidopa which inhibits peripheral levodopa degeneration.

Taken daily or given as depot every 2-4wks. Start at a small dose and then build up over a week or 2 adjusting on patients response. Treatment is for long term, tell doctors if wanting to get pregnant. Several days to weeks to being taking effect.

May need bloods test occasionally to check Liver function.

Side-effects include psychosis, n+v, dyskinesias, postural hypotension, But other drugs such as domperiodone (peripheral dopamine antagonist) and Selegilline (MAO ihibtor that inhibits dopamine degeneration in CNS so lower levodopa dose can be used).

Invites questions, summarise, leaflet.

Question 63

Q

Communication: Bisphosphonates

Answer

A

Wash hands, introduce self, check patients understanding of events so far/ purpose of interview.

Bisphosphonates are drugs that prevent the bone from being broken down and helping to rebuild new bone. Lifestyle factors can also help with this such as exercise, no - smoking and eating a well balanced diet.

Tablets are taken once weekly, witha full glass of water 30 minutes before food. Should remain upright for 30 minutes after swallowing. The tablets are taken long term.

Side-effects include headache, heartburn, bloating, indigestion, GI upset, osteonecrosis of jaw.

Check patients understanding, chunk and check, leaflets, ICE.

Question 64

Q

Communication: Statin Therapy

Answer

A

Wash hands, introduce self, check patients understanding so far/ explain purpose of interview.

Statins stops the liver making cholesterol. Cholesterol is one of the factors that predisposes to artery problems causing heart disease, stroke and kidney disease. It is also important to address the other factors e.g. Non-smoking, weight loss, salt restriction

Tablet is taken once daily at night and is a long term treatment. It’s decreases the risk over many years.

Will need a blood test for the liver before starting and again at 3 months and 1 year.

Side effects include muscle pains, hair loss, itching and nausea, abdo pain, diarrhoea.

Any questions, ICE, leaflet, follow up

Answer 65

A

Wash hands introduce self, explain purpose of interview, consent, and check patients understanding so far.

Explain why the steroids are being prescribed, and the course of treatment

Main side-effects include Peptic ulcers, gastritis, hypertension, diabetes,, osteoporosis, increased risk of infection, mood change, weight gain, proximal myopathy, acne, skin thinning.

In order to prevent some of the more serious side-effects from occurring Vitamin D and calcium supplements may be given to prevent osteoporosis, and an anti-acid tablet (PPI) is also given to prevent peptic ulcer disease.

Informs patients if they start to feel thirsty or a passing increasing amounts of urine to see GP for testing for diabetes.

Informs patients that during their time on the medication they will need to have their blood pressure more closely monitored.

Warns patients not to suddenly stop the steroids at any point without speaking to a doctor as this can cause a severe reaction which may require hospitalisation (addisonian crises)

Do not take any additional NSAIDs whilst on steroids and alert doctors if you start to develop severe stomach pains or vomit any blood.

They will be started on high dose at first and then titrated to lowest possible does to balance effects of disease and side-effects.

Invite questions, ICE, summarise, Chunk and check, leaflet

Answer 66

A

Wash hands, introduce self, check patients understanding of events so far and initial questions?

Central venous pressure allows monitoring of the pressure of the right side of the heart. It is useful in for diagnosis e.g. Right ventricular function, tamponade, heart block, and ensuring central lines are placed correctly, and aiding the management of hypotension.

A venous catheter is inserted with ultrasound guidance into a vein in the neck.

Risks include arrhythmias, brachial plexus injury, cardiac perforation, embolism, Haemorrhage, infection, pneumothorax

These risks are reduced by using ultrasound guidance and it is a procedure performed in well monitored areas e.g. ITU.

Thanks patients, chunk and check, summarise, ICE

Answer 67

A

Wash hands, Introduce self, check patients understanding of event so far/ purpose of interview

An exercise tolerance test is an investigation used to assess the severity of coronary heart disease.

The test uses an ECG to record the electrical activity of the heart whilst you exercise on a treadmill or exercise bike. The exercise starts off at an easy pace and is gradually made more strenuous. The test lasts 15-20 minutes. Blood pressure will also be measured at intervals throughout.

At any stage you can tell the person doing the test if you feel it is too difficult and the test will stop, it will also stop if you develop unpleasant pains or become very tired or short of breath.

There is a small rare risk of developing a heart attack of heart irregularity during the test but medical help is near to deal with any possible problems.

Any questions/ summarise, ICE. Leaflet.

Answer 68

A

Wash hands, introduce self, checks patients understanding so far/ purpose of the interview.

Echocardiogram is an ultrasound scan of the heart. It uses a devices that produces sounds waves to give accurate pictures of the heart muscle, and valves, and it is also possible to measure the pressures and velocities of blood movement in these areas.

During the test you will need to undress your top half and lie on a couch cold jelly will be applied to the chest wall and a sonographer will move a probe around on top of the chest wall to create the images. It is painless, does not use radiation, and takes about 15-30minutes.

The test can also be done using a probe that goes down the gullet (oesophagus), to give clearer views of the heart. For this procedure a sedative usually midazolam is given and a local anaesthetic and so you will need someone to drive you home. But it is more invasive.

Any questions? ICE? Leaflet, chunk and check, summarise

Answer 69

A

Indicate you would check resuscitation status of the patient before anything else, if DNACPR not present or unsure begin CPR.

Wash hands, Confirm patient identity (wrist band)

General inspection, skin colour obvious signs of life

Look for signs of respiratory effort

Does the patient respond to verbal stimuli?

Does the patient respond to pain (Trapezius squeeze, supraorbital pressure)

Assess pupils using pen torch (after death they become fixed and dilated)

Feel for a central pulse- carotid artery

Auscultations listen to heart sounds for at least 2 minutes, listen to respiratory sounds for at least 3 minutes (Varies on local guidelines)

Assess for pacemaker

Wash hands and exit room

Document death complete death certificate

(Brainstem death testing involves, corneal reflexes, ocular-vestibular reflexes, apnoeic testing)

Answer 70

A

Assess severity

Mild airway obstruction able to cough, encourage coughing continue to check for deterioration to ineffective cough or until obstruction relived

Severe obstruction if conscious give five back blows and then 5 abdominal thrusts rotating until obstruction relieved

If unconscious start CPR.

Answer 71

A

WIPER

A PICC is a long hollow tube inserted into one of the large veins in your arm. One end of the tube sits in a vein just above the heart and the other send comes out underneath the skin in your arm.

We use these type of catheters to give certain types of treatment that may irritate or damage smaller veins, or if you need medications over a long period of time.

It is a sterile procedure performed under local anaesthetic. CXR is done to check position.

Risks include infection, bruising, pain at site, stenosis of vein, malpositioning of PICC, Failure to insert, phlebitis

Answer 72

A

Ensure patient has venous access and is breathing O2 fully monitored.

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

Answer 73

A

Patient should be seated leaning forwards with support on table or lying back on a bed with the arm on the affected side raised above the head.

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

Brainscape's Knowledge GenomeTM

OSCE Stations Flashcards

Brainscape's Knowledge Genome^TM