OSCE Stations AB - Part 1

Question 1

OSCE A: ABCDE - Loss of consciousness OR Consciousness assessment
[Process]
[Questions]

Answer 1

|NB: ‘Loss of consciousness’ is different OSCE to ‘Consciousness assessment.’)

[Process]
ABCDE*
state pupil size in mm*
pupils reactive*
CT brain*/head/neck
may need to escalate the airway management* (rw)

[Questions]
*Q*: What are the next steps?
consider cervical spine fracture*
cervical spine blocks*
log roll patient to assess back*
Pabrinex*
CT brain*/head/neck
may need to escalate the airway management* (rw)

*Q: Assess the GCS*
Squeeze trapezius + Supraorbital pressure*
GCS:
…EVM is 125.*
…GCS equals 8.
check pupils:
…state pupil size in mm.*
…pupils are reactive.*

Question 2

OSCE A: ABCDE - Pulmonary embolism

Answer 2

ask: any pain? (yes, on inspiration and on coughing).*
ABCDE*:
…high-flow oxygen via a non-rebreathing mask.
…‘normal bilateral* and symmetrical* air entry with normal auscultation*.’
…no cyanosis present.*
…expose any wound dressing*
…calves*
‘It appears to be a pulmonary embolism, based on SHIT (surgery, hypotension, immobility, tender + swollen calf) and pain on inspiration + coughing.’* (rw)
senior advice*
ITU
thrombolysis
UFH
CT pulmonary angiogram.

Question 3

OSCE A: ABCDE - Burn

Answer 3

prompt analgesia as priority*
hoarse*
burnt nasal hair*

ABCDE + START + PIC + CC + AMPLE:
…ABCDE
…soot
…trauma mask
…area (total body surface area (BSA))
…record:
……Lund + Browder chart
……rule of 9s:
………hand=1%
………arm=9%
………leg=18%
………anterior/posterior trunk=18%
…toxins: determine carbon monoxide level
…Parklands formula*:
……4 x kg x BSA = litres in 24h.
……half of fluid in first 8 hours.
…IV fluid
…catheter
…cool burn
…cling film burn*
…
…(warm patient: e.g. warm fluids)
…AMPLE*:
……A - Allergies
……M - Medications
……P - Past Illnesses
……L - Last Oral Intake (Sometimes also Last Menstrual Cycle.)
……E - Events Leading Up To Present Illness / Injury
damp drapes*
depth of burn*
genital burn*
ABG:
…carboxyhaemoglobin (NB: oximetry no good if this is raised).
PEFR
CXR
O/E abdomen (?)
examine long bones (?):
…fracture for DVT/PE (?)
anterior and posterior burns
admit patient*
refer to burns unit*

*Q: The man weighs 100kg, how much fluid?*
Parklands formula:
…4 x kg x BSA (18%?) = 7.2 litres over 24 hours.
…half (3.6 litres) in first 8 hours.

Question 4

OSCE A: Lymphoreticular system
[Process]
[Instruction]
[Questions]

Answer 4

[Process]
ask:
…any pain?
…(response: painless)
THIS LUMP:
…Tender
…Hot:
……ask: is the lump hot?
……ask: are you hot?
…Irregular, Increasing in size
…Size
…
…Location:
……(response: only in neck)
…Uniform colour
…Mobile
…Pulsatile

B-Sx:
…loss of weight
…fever
…night sweats
TTT:
…travel
…transfusion
…tattoos

TB exposure
recent infection
tiredness
sexually active
bruising
jaundice
palor
joint pain
joint swelling
rash
animal contact
IVDU

PMHx:
…URTI
…gum infections
…STDs
DHx
SHx:
…alcohol
…smoking

[Instruction]
Do an examination of the lymphoreticular system.

[Questions]
*Q: Which investigations?*

CRP/ESR: acute phase response
FBC: anaemia, white cell count
HIV serology
CD4 count: HIV
Monospot: EBV

*Q: How would you manage this patient?*

I would refer this patient to ENT due to unresolved lymphadenopathy.* (rw)

Question 5

OSCE A: Mental state examination (incomplete)
[Process]
[Questions]

Answer 5

[Process]
appearance*
behaviour*
speech:
…rate*
…rhythm*
…volume: reduced*
…tone: monotone*
…quantity: minimal
mood:*
…energy*
…enjoyment*
…appetite*
…increase in food intake
…increase in weight
…sleep*
affect*
thought form*
thought content*:
…self esteem
thought TWIBE*:
…thought withdrawal
…thought insertion
…thought broadcasting
…thought echo
perception
cognition:
…loss of concentration*
…loss of memory*
insight
judgement:
…what would you do if your house is on fire?

[Questions]
*Q: What is your diagnosis?*
depression because the patient appears withdrawn.*
unlikely to be major depressive disorder as it is short-term.

Question 6

OSCE A: Blood transfusion
[Process]

Answer 6

[Process]
Have you had a transfusion before?*
A blood transfusion is the process of transfusing red blood cells.*
A blood sample is taken beforehand so that we check the ABO blood group and irradiation requirements.*
It is generally done when a person has signs of anaemia*, which includes:
…cyanosis
…increased heart rate
…increased respiratory rate
…confusion
The benefits of a blood transfusion include:
…reduced bleeding due to increased platelets.*
…increased oxygenation of tissues.*
…increased chances of survival.*
…small chance of reaction*
The risks of a blood transfusion include:
…viral transfer which can cause hepatitis.*
…bacterial transfer which can cause sepsis.
…fluid overload.*
…lung injury.*
…allergic reaction which can cause haemolysis, although this chance is reduced through cross-matching.*
…non-haemolytic febrile reaction.*
Let me explain cross-matching:
…ABO matched*
…Rhesus matched*
…irradiate for CMV*
…test for antibodies*
There are alternative treatments, which includes saline and erythropoietin.*

*Complete blood transfusion form.*
ask patient for name*
ask patient for spelling of name*
ask patient for DOB*
Mark as urgent.*
Check if irradiation is required.*
Check form against:
…sample tube*.
…wrist band*.
Sign form.*

Question 7

OSCE A: Irregular PV bleed (+Menorrhagia)
[Irregular PV Bleed - Process + Questions]
[Menorrhagia - Questions]
[Painful periods - Questions]

Answer 7

[Irregular PV Bleed - Process + Questions]
*Take a brief history*

Can you describe to me a typical period?
Effect on daily life?
How does it make you feel?
Does it affect you socially?
pain:
…SOCRATES
…medication relief

FUN DICK TAMPON:
…flushing
…UTI / Urinary Sx
…number of: days
……days bleeding
……days in cycle
……tampons used
…discharge
…itch
…constipation
…klots (clots)
…
…thyroid status
…amount: heavy, light
…menopause/menarche
…period:
……LMP
……regular
……pain during sex
……post-sex bleeding
…OCP
…night sweats
contraception:
…previous
…now
…future plans
pregnancies:
…number
…method
…terminations
…miscarriages
weight gain for hypothyroidism.
hair loss for hypothyroidism.
brusing for coagulation disorder.
cyanosis
tiredness
unusual vaginal smell

PMHx:
…coagulation disorder:
……e.g. von Willebrand’s disease.
…STDs
…smears:
……last
……results
DHx:
…anti-coagulants
…anti-platelets
FHx:
…coagulation disorder:
……e.g. von Willebrand’s disease.

*Q: Differential diagnosis?*
ectropion
cervical polyp
cervical carcinoma
PCOS
vaginitis
cervicitis

*Q: What examinations?*
Abdominal examination:
…mass on left hand side
Bimanual examination
Speculum examination
I would consider using:
…acetoacetic acid
…iodine

*Q: What investigations would you do?*
FBC: anaemia
TFT: hypothyroidism
USS uterus: fibroids
LFT: clotting
coagulation profile
urine hCG: pregnancy
hysteroscopy*
Pipelle biopsy*

*How would you manage this patient?*
COCP
mefanamic acid:
…(NSAID)
MDT for cancer*
hysterectomy:
…subtotal
…total
…total with bilateral salping-oophorectomy*
washings*

[Menorrhagia - Questions]

*Q: What is the differential diagnosis for menorrhagia?*
obesity
hypothyroidism
coagulation disorder:
…e.g. von Willebrand’s disease.
fibroids
endometrial polyps
endometriosis
endometrial carcinoma
copper contraceptive intrauterine device.

*Q: What are the treatment options for menorrhagia?*

tranexamic acid:
…(anti-fibrinolytic)
mirena coil:
…(progesterone coil)

[Painful periods - Questions]

*Q: What is the differential diagnosis?*
endometriosis
PID

Question 8

OSCE A: Tiredness
[Process]

Answer 8

[Process]
symptoms*
duration of symptoms*
severity
prevents daily tasks
constant or specific times of day.
energy*
enjoyment
appetite
increase in food intake
increase in weight*
sleep*
coffee/energy drinks*
chocolate*
headaches*
mood*
SOBOE*
skin colour*
periods:
…anaemia
…LMP
…regular
…number of tampons
…post-sex bleeding
…painful sex
flu-like symptoms
pregnancy symptoms
change in bowel habits
rectal bleeding
haematuria
haematemesis
haemoptysis
neurological changes
ICE*

PMHx:
…depression*
…hypothyroidism*
DHx:
…pain killers for headache*
FHx:
…any children
SHx:
…alcohol*
…smoking*
…live alone
…employment

*What is your differential diagnosis?*
TAD SADD:
…thyroid
…alcohol
…drugs
…sleep apnea
…anaemia
…depression
…diabetes

*Q: Investigations?*

TFT:
…hypothyroidism
MSE
FBC:
…anaemia

Question 9

OSCE A: Boy - Growth chart
[Process]

Answer 9

[Process]

plot height*
plot weight*
plot OFC (occipital-frontal circumference)*
identify centiles*

thin because reduced energy intake
birth measurements
previous measurements
present height

chart:
…normal birth weight*
…mid-parental height*

failure to thrive:
…illness*
…diet*
…bowel problem*

diet:
…milk vs solids*
…reduced energy foods*
…reduced frequency feeding*
…dairy free*

exclusions:
…urinalysis for renal failure*
…LFT for albumin*
…anti-tissue transglutamase for celiac disease*
…sweat test for cystic fibrosis*

*Q: possible causes?*
neglect*
social*

*Q: Next steps?*
safety of siblings*
senior review*
social services*
parenting skills*

Question 10

OSCE A: Peripheral vascular disease (claudication)
[Process]

Answer 10

Q: How would you manage this patient?*

[Process]
COWPAT CHANGES SUNA (APUC):
…claudication*
…offer BP
…warning sign (for angina/MI)
…pain: (ro)
……pain relief by medication*
……rest pain* (relieved by rest)
……rest pain at night*
……reducing claudication distance*
…appearance
…tissue changes

…CHANGES SUNA: (unused)

CARD CLAPS

PMHx: (ro)
…diabetes*
…stroke*
…angina*
…MI*
DHx:
…drug allergies
FHx
Social history:
…smoking

*Q: Diagnosis?*
(intermittent) claudication*
critical limb ischaemia*

*Q: Investigations?*
ABPI:
…(ankle-brachial pressure index)
…<0.9 indicates atherosclerosis.
ECG:
…screen for heart disease.
…looking for LVH, LBBB, other markers.
USS Doppler:
…allows evaluation of all vascular beds.
PVD examination
Venous insufficiency examination
CT angiogram in case of critical limb ischaemia* (rw)
coagulation profile
blood glucose
lipid profile
LFT for starting statin.

smoking cessation advice:
…CHANGES
statin
increase exercise
control BP
control glucose
angioplasty +/- stent

Question 11

OSCE A: Back pain (orthopaedics)
[Process]

Answer 11

[Process]
upper or lower back*(rw)
symptom duration*
change in symptoms over time?*(rw)
pain at night?* (no)
effect on sleep
trauma*
heavy lifting
SOCRATES:
…site
…onset
…character
…radiation*
…alleviating factors*
…trigger
…exacerbating factors*

red flags:
…unexplained fever
…unexplained weight loss*
…focal neurological symptoms
…urinary problems*
…bowel problems*

B-Sx:
…night sweats*
…anorexia*
…weight loss* (already asked)

PMHx:
…sciatica*
…osteoporosis*
…carcinoma*
DHx
FHx
SHx:
…employment*
…effect on employment*

*Q: Do an examination*

inspect back
REMS Back examination
Lower neurological examination:
…tone
…power
…reflexes
…coordination
…sensation
…proprioception
…gait
SLRT

*Q: Differential diagnosis?*
osteoarthritis
spinal stenosis*
intravertebral disc prolapse*
anklyosing spondylitis*
mechanical back pain*
primary or secondary tumour*

*Q: What is the diagnosis?*
sciatica*

*Q: immediate investigations?*

neurological examination
FBC* for anaemia and infection
CRP/ESR for an acute phase response
U+E* for electrolye imbalances (causing muscle cramps?)
LFT for metastases*
bone profile*
bone scan*
blood culture
plasmapheresis* for multiple myeloma.
PSA* for prostate carcinoma
urinalysis: pyelonephritis
urgent MRI lumbar spine*
CT abdomen pelvis for other malignancies*

*Q: Later investigations?*
BBBB CANCER:
…(back pain)
…(bone pain)
…bone profile
…bone scan
…calcium
…antigen markers:
……PSA
……CEA
……CA-125
……CA19-9
…neurological exam
…CT CAP: staging
…electrophoresis:
……monoclonal band
…radiology:
……XR spine for bone lesions.
FBC:
…anaemia
U+E:
…osteoporosis secondary to renal failure.
DEXA:
…bone density.

*Q: How would you manage this patient?*

SPACER:
…sick note*
…paracetamol (stronger painkillers*)/ PT*
…avoid heavy lifting
…come back if worsens
…exercise
…review in 2 weeks*
NSAID
infliximab
local steroid injection

Question 12

OSCE A: Milestones (incomplete)
[Process]
[Questions]

Answer 12

[Process]

stranger awareness*:
…6-12 months
waves*:
…1 year

gross motor:
…sit*
…roll*
…crawl*
…run*
fine motor:
…building blocks*:
……3 blocks:
………18 months
……6 blocks:
………24 months
……bridge:
………36 months
…drawing:
……scribble*
……line
……triangle
……square
……circle
…pincer*
…transfer*
…palmar grasp:*
……4 months
…put in mouth:*
……6 months
hearing:(ro)
…localises sound:*
……3 months
…responds to maternal voice:*
……3 months
…imitates adults:*
……4 months
…understands name:*
……5 months
…enjoys music:*
……9-12 months
vision:
…follow toy:*
……6 month
…follow person:
……12 months

finger food*:
…7-11 months

[Questions]
*Q: What is the distraction test?*
A test you can do for a baby about 6-8 months old.
Make a sound baby recognises. Baby turns to sound.
Move sound out of view.
Keep reducing sound volume to determine lowest volume.

Question 13

OSCE A: Mental state examination

Answer 13

mood*
energy*
sleep*
appetite*
loss of concentration*
loss of memory*
self esteem*
hopelessness*
guilt*
thought content*:
…poor
…self esteem
worry about daughter*
delusions (none)*
suicidal ideation*
suicidal intent*
no evidence of formal thought disorder*
concentration is poor*

*Q: what is the diagnosis?*
moderate depression with somatic features* because … (you focus on XYZ)* (xRw)
(somatic features is extreme focusing on one element, such as pain, fatigue).

Question 14

OSCE A: Infertility
[Process]
[Questions]

Answer 14

[Process]
…‘I am sorry to hear about your struggles.’*
partners: (PINCA)
…prostitution
…IVDU
…N
…C
…Ages:
……patient*
……patient’s partner*
protection (contraception*):
…past
…now
practices
pregnancy:
…patient previous pregnancy*
…patient’s partner previous pregnancy*
…termination
…miscarriages
past sexual history:
…patient*
…patient’s partner*
period:
…age of menarche
…LMP*
…regular
…bleeding duration
…bleeding amount
…bleeding during sex*
…pain during sex*
…any amenorrhoea.
STD*
smear:
…last smear
…any other smears
…results
surgery*
alcohol
previous USS uterus/ovaries.
sex frequency
length of time trying for a baby
reassure that there is no reason patient is ‘infertile’, so no medication just yet, but more tests necessary.

PMHx:
…hirsutism
…diabetes
…weight problems
…acne
…previous treatments
…previous investigations
DHx

[Questions]
*Q: How would you advise to this patient?*
sex 3 times per week*
patient/partner to reduce alcohol intake*
folate*
repeat smear*
test to ensure ovulation positive (P day 21)*

*Q: What investigations?*
MALE
semen analysis*:
…2-3 days after sex.
DRE:
…prostatitis
FSH:
…to determine primary or secondary testicular failure.

FEMALE
test to ensure ovulation positive (P day 21)*
Testosterone:
…increase: PCOS
LH:
…day 2-5: assess ovarian function.
FSH:
…day 2-5: assess ovarian function.
LH/FSH ratio: PCOS
progesterone:
…day 21.
…increase: confirms ovulation.
TFT:
…hypothyroidism
bimanual:
…fibroids
…ovarian cyst
cervical screening:
…Chlamydia trichomonas
cervical cytology:
…Chlamydia trichomonas.
check Rubella status
XR hysterosalpingography:
…tubal patency.
laparoscopy:
…endometriosis.

*Q: semen analysis results*
low sperm count* due to surgery*.

*Q: next steps?*
refer to conception unit due to low sperm count.*
healthy diet
weight loss
medication for PCOS once diagnosed, to help conceive:
…metformin
…clomiphene

*Q: explain PCOS?*
it exists on a spectrum.
She may not have the syndrome, it depends on biochemical tests and clinical symptoms.
It is over-secretion of LH and oestrogen, sometimes making conceiving more difficult, but not always.

Question 15

OSCE A: Patient with chest tightness
[Process]
[Questions]

Answer 15

[Process]
SOCRATES:
…site
…onset
…character
…radiation
…alleviating*
…trigger
…exacerbating
…severity*
CARD CLAPS:
…claudication*
…cold peripheries*
…abdominal (sacral*) oedema
…rest pain
…dizziness
…cyanosis
…LOC
…ankle oedema
…palpitations*
…pillows*
…stairs*
…SOB*
nausea and vomiting*

[Questions]
*Q: present the ECG*
rate
rhythm:
…regularly regular:
……sinus
…regularly irregular:
……sinus arrhythmia
……second degree heart block (2:1,2:2).
…irregularly irregular:
……AF
……atrial ectopics
……ventricular ectopics
……atrial flutter with variable heart block.
sinus*:
…P-waves are present.
PR interval:
…120-200 ms.
QRS complex:
…60-100 ms.
axis
ST changes*
ST-depression*
diagnosis*
artery affected:
…posterior:
……posterior descending artery.
…anterior:
……left anterior descending artery.
…lateral:
……left circumflex artery.
…inferior:
……right coronary artery.

*Q: immediate treatment?*
AGOA:
…aspirin*
…GTN spray*
…oxygen
…analgesia (IV opiate*)
clopidogrel* or ticagrelor*
fondaparinux*
refer to cardiology*
refer for percutaneous coronary intervention (PCI) for repurfusion*.
thrombolysis
CABG

*Q: What investigations to determine heart damage?*

troponin I*
Echo*
CK-MB

*Q: what discharge medications?*
AS ABC:
…aspirin*
…statin*
…ACE inhibitor*
…beta-blocker*
…clopidogrel* or ticagrelor*
Others:
…rivaroxaban
…GTN spray
…warfarin

Question 16

OSCE A: Respiratory examination - SOB
[Process]

Answer 16

[Process]
respiratory examination:
…muscle wasting*
…identify the subject of the test* (??)

*Q: Interpret spirometry results*
FVC*:
…state low (?)
FEV1*
…observed < 80%: obstructive pattern
…COPD severity:
……80-100: mild
……50-80: moderate
……30-50: severe
……0-30: very severe
FEV1/FVC:
…observed < 70%: obstructive pattern:
……COPD
……asthma
…observed >70%: restrictive pattern:
……obese
……interstitial fibrosis
eNO:
…increased expiratory oxide indicates infection.*
Results show an obstructive pattern.*

*Q: diagnosis?*
asthma or COPD.

*Q: What is the main cause of COPD?*
smoking

Question 17

OSCE A: Dyspepsia
[Questions]

Answer 17

‘What do you mean by heartburn?’*
symptoms*:
…heartburn pain*
…abdominal pain*
duration of symptoms*
SOCRATES:
…site*
…onset
…character*
…radiation
…alleviating*
…trigger
…exacerbating*
…severity
swallowing problems*
appetite*
reflux*
nausea*, vomiting*

PMHx*
DHx*
FHx*
SHx:
…alcohol*
…smoking*

[Questions]
*Q: Next steps?*
stop NSAID*
PPI trial*
urgent endoscopy*
barium swallow

*Q: Explain endoscopy*
‘Do you understand what an endoscopy is?’*
It is a camera investigation which is fed down the throat to examine the oesophagus, stomach and then duodenum.* (rw)
The camera is attached to a flexible tube* which is the width of my little finger.
You are slightly sedated.*
Therefore, you cannot drive* so make sure somebody escorts you to and from the appointment.
At the appointment, you are given a local anaesthetic* to the mouth.
The camera is then fed down, and a biopsy* may be taken.
It is a day-case*.
Risks are a sore throat, perforation and bleeding.*

Question 18

OSCE A: Loss of consciousness history (epilepsy)
[Questions]

Answer 18

do you remember the event?
duration of Sx

COLLAPSED (WHITE SCHNAPS):
…confusion
…onset*
…loss of consciousness*
…loss of memory/concentration.
…anxiety
…palpitations
…seizure*
…event
…diabetes
PqRST:
…prodrome*:
……(a symptom which indicates the onset of a seizure).
……e.g. change in mood, taste, smell.
…recovery*
…seizure risk factors:
……TORCH birth illnesses
……abnormal development*
……head injury*
…tongue biting*

repetitive mouth movements
fractures
incontinence

PMHx*
DHx*
SHx:
…smoking
…alcohol*
…drugs*
…live alone*
…hobbies*
…employment* and inform employment

must inform DVLA*
cannot drive for 12 months (?)

[Questions]
*Q: What was the event?*
Seizure*
temporal lobe seizure*:
…An aura (unusual feelings) often precedes a temporal lobe seizure.
…An aura can include:
……fear
……d�j� vu
……taste
……abdominal discomfort (in scenario?!).
…Loss of awareness of surroundings.
…Staring, lip-smacking
temporal lobe seizure secondary to generalised seizure*:
…generalised seizures:
……(i.e. as opposed to partial seizures)
……absence seizures
……tonic clonic (in scenario?!)

*Q: Next steps?*

INVESTIGATIONS

FBC: anaemia
blood culture: exclude meningitis
12 lead ECG*: exclude arrhythmia
CT brain*: exclude trauma
brainwave monitor for 24 hours
refer to neurology
U+E:
…electrolyte imbalance.
BM:
…hypoglycaemia
coagulation profile:
…intracranial bleeding
toxicology:
…TCA
…salicylates
…lithium
anti-convulsant drug levels
CXR: PNM
rashes: sepsis
EEG

TREATMENT

if acute:
…benzodiazepine
glucose
pabrinex
(refer to neurology)

Question 19

OSCE A: Hearing problem - ENT

Answer 19

how is it affecting your life?
cotton buds to clean ears?
any other trauma?:
…fall
…ear syringing
sudden
gradual
hearing loss*
noise exposure*
tinnitus*
ear pain*
ear discharge*
vertigo*
nausea
facial weakness
headache
PMHx:
…previous ear problems*
…URTI
…OME
…ear surgery
DHx:
…ototoxic medications*:
……gentamicin
……furosemide
……NSAID
FHx
SHx

*Ear examination*
pulls pinna
describes observations
describes external canal
describes tympanic membrane
whisper at arm’s length
whisper at 6 inches

*Q: Differential diagnosis*
conductive hearing loss:
…sudden + painful:
……otitis externa
…sudden + painless:
……wax impaction
……foreign body
…gradual + painless:
……cholesteatoma
……otosclerosis
sensorineural hearing loss:
…congenital:
……TORCH infections
…unilateral:
……Meniere’s disease
……acoustic neuroma
…bilateral:
……presbycusis (gradual noise exposure)
……ototoxic medications

*Q: Investigations?*

otoscopy
audiometry
tympanometry

Question 20

OSCE A: Headache history

Answer 20

SOCRATES:
…site*
…onset*
…character*
…radiation
…alleviating factors*
…trigger
…exacerbating factors*
…severity
frequency*
PENNY CARAVAN:
…photophobia*, phonophobia*
…exacerbated by posture*
…nausea, vomiting*
…neurological Sx*
…you hot?
…
…consciousness
…aura
…rash
…anorexia (weight loss*)
…vision changes*
…appetite*
…neck stiffness

PMHx*
DHx:
…pain killers for headache*
FHx*
SHx

summarise:
…‘This must be very concerning for you.’*
…(give summary)
…suggests raised intracranial pressure.

*Q: diagnosis?*
intracranial malignancy*

*Q: next steps?*
full neurological examination*
cranial nerve examination
full general examination*
CT brain*
MRI brain*
consider lumbar puncture (?? - raised ICP)
……

Question 21

OSCE A: Drug prescribing

Answer 21

patient name
DOB
admission date
WAR:
…withhold…
…aspirin (and)
…ramipril
allergies:
…fill in section.
…e.g. ‘trimethoprim -> causes rash’
simvastatin:
…fill in section H:*
……(‘Oral and other drugs’)(?).
…dose*
…route*:
……e.g. ‘ORAL’.
…frequency:
……e.g. circle 2200-2400. (?).
……better taken at night to reduce LDLs.
…date:
……i.e. dd/mm/yy
…sign* and print name*
omeprazole:
…fill in section J:*
……(NB: no section I)
……(‘Oral and other drugs’)(?).
…dose:
……e.g. 30mg
…route*:
……e.g. ‘ORAL’
…frequency:
……e.g. circle 0700-0900 and 1600-1800.
……better taken at meal times.
…date:
……i.e. dd/mm/yy
…sign* and print name*
…

Question 22

OSCE A: Growth chart - small boy (paediatrics)
[Process]

Answer 22

[Process]
calculate age of boy:
…15 months old*
growth chart - height:
…25th centile*
growth chart - weight:
…0.4th centile*
occipital-frontal circumference:
…50th centile*
interpretation:
…thin child*
…low calorie intake*

*Q: What other information do you require?*
parental heights* (ro)
previous measurements*
birth measurements*

*Q: Here is another growth chart - describe it.*
normal mid-parental heights* (ro)
failure to thrive over the last 4 months*
normal birth weight*

*Q: Explain trend.*
development problem* (ro)
diet*
social reasons* (??)
systemic illness*

*Q: What are the diet problems?*
low energy foods* (ro,rw)
food not being given frequently enough* (rw)
refusing food*

*Q: What would you want to exclude?*
exclude malnutrition:* (ro)
…LFT* (with albumin*)
exclude celiac disease:*
…anti-tissue transglutamase test*
exclude cystic fibrosis:*
…sweat tests*

*Q: Plot this on the growth chart.*
plot weight*
interprets* (interpretation?)

*Q: What possibilities does this raise?*
neglect*
non-accidental injury* (xRw)
other social reason* (xRw):
…fear?

*Q: What are appropriate actions to take?*
safety of siblings* (ro,rw)
senior*
social services*
parenting skills*
prosecution service*

Question 23

OSCE A: Growth chart - GI and growth
[Process]

Answer 23

[Process]
FHx IBD*
travel abroad*
joint pain*
clubbing*

*Q: investigations?*
stool culture*
stool microscopy*
faecal calprotectin*
colonoscopy with biopsy

*Q: Diagnosis?*
IBD*

*Q: Diagnostic investigations?*
colonoscopy* with biopsy*
barium meal*

*Q: interpret this barium meal.*
TUNIC:
…thumb printing*
…ulcers*
…narrowing*
…inflammation*
…cobble stoning*

*Q: Treatment options?*
prednisolone*
hydrocortisone*
DMARDs
azathioprine*
sulfasalazine*
total parenteral nutrition*

*Q: What is the pubertal assessment?*
Taner’s stage G2* (sparse pubic hair, male)

*Q: Complete this growth chart.*
plot height
plot weight
calculate childs age
child is small
child is underweight for height*.

*Q: what information do you want from the parents?*
parental heights* to calculate the mid-parental height*
age of puberty* (rw)

*Q: look at this previous growth chart. Discuss.*
growth failure*
delay in puberty* due to IBD*
malnutrition*

Question 24

OSCE A: Rheumatology
[Process]

Answer 24

[Process]
Hand examination:
…ask: any pain?*
…pillow*
…expose to elbows*
…observe hands:
……wasting*
……swelling*
……skin rashes*
……palmar erythema*
……nails*
……elbows*
…do usual hand examination:
……must include:
………fist*
………pincer*
………flexion/extension*
………function*

*Q: What is the diagnosis?*
? (RA/OA)
RAP - ‘RA has proximal joint synovitis with distal joint sparing.’*
DOA - ‘OA does not usually have synovitis, but involves distal joints.’(?)

Question 25

OSCE A: ABG
[Process]

Answer 25

[Process]
*Q: What do the repeat ABG results show?*
Type 2 respiratory failure shown by a low PaO2 and a high PaCO2.*(rw)
The H+ is increasing.*(rw)

*Q: Why is the PaCO2 increasing?*
It is type 2 respiratory failure which means CO2 is being retained. * (rw)

*Q: What is the definition of the acid-base balance abnormality?*
respiratory acidosis*
patient is too exhausted to breath effectively.* (rw)

*Q: How would you manage this patient?*
nebulised salbutamol* (rw)
non-invasive ventilation* such as CPAP, nasal cannula, high-flow oxygen.

Question 26

OSCE A: Suicide risk assessment - patient taken overdose
[Process]

Answer 26

[Process]

ask: previous mental health problems?* (rw)
ask: what medication used to overdose?* (rw)
WAIT SUICIDE WON DAD:
…why*
…alone*
…intention*
…time planned*
…sight/sound hallucinations
…under influence of alcohol*
…ideations - self harm, suicide*
…controlled telepathically
…inactivity
…defensive weapon carried
…enjoyment (none = anhedonia)
…will…*
…or…*
…note*
…drugs*
…alcohol*
…discovery due*

after overdose:
…events*
…hospital attended?*
…still want to die?*
now:
…feelings*
…suicidal*

*Q: Diagnosis?*
Depression.

*Q: Next steps?*
admit to hospital* for paracetamol levels*
refer to psychiatry*

Question 27

OSCE A: Shortness of breath

Answer 27

‘Do you feel breathless now?’* (rw)
SHREWDS:
…sputum:
……volume*
……colour*
…haemoptysis*
…relieving factors
…exacerbating factors
…wheeze
…discharge
…sneeze
normal exercise amount*:
…stairs
…straight road - e.g. 100metres.
normal sputum amount*
normal sputum colour*

PMHx
DHx*:
…medications normally take?* (rw)
…home oxygen*
…nebulisers*
…allergies*
FHx
SHx:
…smoking*

*Q: interpret blood tests.*
WCC is raised* indicating an infection is present.
CRP is raised* indicating an acute phase response.

*Q: ABG interpretation.*
PaO2 is low.*
PaCO2 is high.*
Bicarbonate is high.*

*Q: Diagnosis?*
COPD exacerbation* due to an infection* (rw).
Patient now has type II respiratory failure*, respiratory acidosis* with compensation*. (rw)

*Q: How would you manage this patient?*
SHOT DOA:
…salbutamol nebulised*
…hydrocortisone*
…oxygen*
…therapeutic level:
……88-92%
……low flow.*
…
…Doxycycline…*
…or…
…amoxicillin.*

Question 28

OSCE A: Visual fields
[Process]

Answer 28

[Process]
speed of onset
collapse
double vision

‘I am going to test your visual fields. Cover one eye, look directly at me, and tell me when you see the white pin.’*
Visual field examination*:
…4 bi-oblique meridians
…‘You have a hemianopia.’
…move pin horizontally, from blind to sighted side, upper and lower fields.
…‘It is a left/right homonymous hemianopia.’
…repeat for the other eye.
‘You may have an intracranial tumour*, a haemorrhagic stroke* or an ischaemic stroke*.’
‘It could be from a number of blood vessels, such as the internal carotid artery, or the middle cerebral artery which is supplied by the internal carotid artery*, the basilar artery or the posterior cerebral artery which is supplied by the basilar artery*. Or an intracranial tumour*. We would need to do a CT scan* of your brain, and possibly an MRI. I will also refer you urgently to the stroke unit*. Depending on the results of the CT scan, you may need to have thrombolysis within 4.5 hours. You may also need to take aspirin and have a swallowing test. Depending on the swallowing test, you may need a nasogastric tube.’

Question 29

OSCE A: Obstetrics
[Process]

Answer 29

[Process]
patient age*
fetal age*
domestic violence*
pain (no, painless)*
trigger* e.g. sex, trauma (none)
estimated blood loss*
estimated due date
fetal movement*
smears*
any previous pregnancies*
any previous caesarean sections*
PALT*:
…pre-term births
…abortions
…living now
…term births
state sum of PALT*

*Do an obstetric examination*

*Q: What is the diagnosis?*
antepartum haemorrhage*
transverse lie*

*Q: Summarise + next steps.*
ABCD U HELLP WHIP:
…anti-D*
…BP
…CTG*
…Doppler USS*
…
…urinalysis: pre-eclampsia

…HELLP bloods:
……anaemia
……abnormal LFT
……low platelets

…weight (patient)
…height (patient)
…in-patient*
…Pinnard stethoscope

Question 30

OSCE A: Ultrasound image - gynaecology

Answer 30

Get consent to explain USS findings.*
Recommend further tests.*
Fibroids cause menorrhagia.*
Large uterus which contributes to bleeding.*
Thick endometrium which needs investigating*, e.g. endometrisosis.
Ovaries are normal.*
TV COIL PPPPP:
…telescopic view (uterus lining)*
…cramp (uterus)*
…out-patient*
…infection*
…local anaesthetic*
…
…painful*
…paracetamol*
…polyp*:
……may be found due to thick endometrium.*
…pipelle biopsy*:
……may be required due to thick endometrium.*
……it is an aspirate of the endometrium.*
…perforation*

Question 31

OSCE A: Contraception and consent
[dizziness]

Answer 31

You are concerned your daughter has been given contraception when she is under 16yo.*
It is legal to give COCP to a girl under 16yo.*
CuntRA(ception):
…confidential*:
……duty to maintain confidentiality.*
……don’t want to lose trust.*
……only daughter can discuss her consultations.*
…use correctly
…no good for STDs
…thromboembolism (SFx)
…relationship*
…approached daughter*:
……approached yet*
……plans to approach*
……how will approach*
…CIndx
…emboli (CIndx)
…pregnancy (CIndx)
…tenderness of breast (SFx)
…increased BP (SFx)
…obese (SFx)
…nausea (SFx [dizziness])
Gillick test: PUSC PUT PUTC*
…Patient Under Sixteen can Consent.
…Patient Understands Treatement.
…Patient Understands Treatment Consequences.
Fraser competence: PUBSS
…Persuade parents
…Understands advice
…Best interests
…Sex anyway
…Suffer

Question 32

OSCE A: Haematuria
[Questions]

Answer 32

previous haematuria*
BLOOD BLOB CLOT In URINation:
…B-Sx*:
……weight loss*
……fever*
……night sweats*
…loin pain*
…onset
…other:
……dyes
……beetroot
……rifampicin*
…duration*
…
…blood…*
…little…*
…or…*
…big*
…
…clots
…
…urgency*
…rate*
…incontinence*
…nocturia*
…ankle oedema
…tried passing stones?
…impotence
…other:
……pain
……smell
……LMP
……colour
…number of children

PMHx
DHx:
…rifampicin*
FHx*
SHx:
…employment involving dyes.*
…alcohol*
…smoking*

[Questions]
*Q: How would you manage this patient?*
DRE*:
…prostate cancer.
…boggy high riding prostate.
Abdominal examination:
…ballot the kidneys*.
KUB*:
…renal tract
USS kidneys*:
…size
…cysts
…tumours
MSU*:
…infection.
cystoscopy* with biopsy:
…bladder cancer.
urgent referral to urology.*

Question 33

OSCE A: Jaundice
[Process]
[Questions]

Answer 33

[Process]
SOCRATES:
…site*
…onset*
…character
…radiation*
…alleviating Sx*
…trigger
…exacerbating Sx*
…severity
duration of pain*
sudden or gradual pain*

duration of jaundice*
sudden or gradual jaundice*
JAUNDICE DUPeS Bitch TTT:
…jaundice Hx*
…ABx
…unprotected sex*
…nausea*, vomiting*, diarrhoea*
…dyspepsia*
…IVDU*
…change in bowel habit*
…ethanol
…dark…
…urine*:
……obstructive jaundice
…pale…
…stools*:
……obstructive jaundice
…B-Sx:
……weight loss*
……fever
……night sweats
…itch*
…travel*
…tattoo
…transfusion*

rectal bleeding*

PMHx*
DHx*:
…allergies*
FHx
SHx:
…alcohol*

[Questions]
*Q: What is your differential diagnosis?*
gallstones*
pancreatic cancer*
hepatitis virus A/B/C/D/E*

*Q: What further investigations would you request?*
urinalysis*:
…bilirubin
LFT*:
…abnormal transaminases
hepatitis A/B/C/D/E serology
coagulation profile:
…liver problems can affect clotting.
abdominal USS*:
…hepatomegaly
…irregular border
ERCP
MRCP*

*Q: name annotations on this ERCP image.*
A. Left hepatic duct*
B. Common bile duct, stone visible.*(rw)
C. Common bile duct*.

*Q: What key haematological investigation is required before this test is performed?*
coagulation profile* for risk of bleeding (rw)
LFT* to compare liver function tests pre-ERCP and post-ERCP.
*Q: Which radiological tests are important?*(?)
MRCP*
ultrasound of the biliary tree.*

*Q: Describe 2 potential complications of this procedure?*
perforation*
bleeding*
infection
pancreatitis*
sore throat

Question 34

OSCE A: Atrial fibrillation
[Questions]

Answer 34

[Questions]
*Q: Investigations for aetiology of atrial fibrillation?*
TFT to exclude thyrotoxicosis.*
Echo to evaluate any structural heart disease.*
Transoesophageal and transthroacic echocardiaogram.
MRI chest for structural heart problems.

*Q: What drugs for rate-control in atrial fibrillation?*
digoxin*
rate-limiting calcium channel blocker, e.g. verapamil*
beta-blocker, e.g. bisoprolol.*

*Q: How would you restore normal sinus rhythm?*
amiodarone for rhythm control.*(rw)
DC Cardioversion*

*Q: How would you reduce the risk of stroke?*
warfarin*
apixaban*
rivaroxaban
dabigatran
(NB: don’t say aspirin!)

*Q: How would you assess the risk of stroke?*
CHAD-VASC score.*
ATRIA score:
…(risk factors: age, previous stroke.)

*Q: Risk of treatment?*
HAS-BLED score for risk of bleeding.*

Question 35

OSCE A: X-ray of wrist
[Process]

Answer 35

[Process]
SSS POPE D:
…swelling (soft tissue)*
…sparing (of distal interphalangeal joints)*
…space (joint space narrowing)*
…
…peri-articular osteoporosis*
…peri-articular erosions*
…joint deformity*

*Q: What investigations?*
rheumatoid factor to determine whether seronegative or seropositive.* (ro)
CRP and ESR for acute phase response.*
FBC for anaemia*.
U+E:
…phosphate
…magnesium
anti-CCP antibodies to help determine prognosis*:
…(positive: more likely severe Sx).
urate to exclude gout.
USS joint for synovitis.*
light microscopy of aspirate.

Question 36

OSCE A: Child with OCD handwashing

Answer 36

how was pregnancy, labour and delivery? *(xRw)
HOPELESS SO FAR:
…health*
…odd behaviour*
…play*
…emotional attachment*
…language*
…eye contact*
…sharing*
…school*
…smiles*
…ordinary behaviour*
…friendships*
…aggression*
…relationships (family, peers)
present on most days for 2+ weeks
distress
interferes with activities

*Q: Differential diagnosis?*

obsessive compulsive disorder*
child is on the autistic spectrum disorder*(rw)
depression*

Question 37

OSCE A: CXR showing consolidation

Answer 37

patient name
patient DOB
patient CHI*
previous imaging for comparison
RIPE:
…rotation:
……checking that spinous processes are equidistant to the medial clavicle.
……rotated? (looks like it could be yes!)
…inspiration*:
……5-6 anterior ribs
……(FRONT=5)
…projection*:
……AP or PA (assume AP unless stated)
…exposure*:
……vertebrae visible behind heart
tracheal deviation
hilar structures:
…for unilateral or bilateral enlargement.
heart borders
cardiothoracic ratio*
costaphrenic angles for blunting
diaphragm for sub-diaphragmatic air
gastric bubble
lung zones:
…lower:
……clear
…middle:
……clear
…upper:
……there is right upper zone opacity.*(rw)
……it appears to be right upper lobe consolidation because it is limited inferiorly by the horizontal fissure*.(rw)
……air bronchogram present.
……likely right upper lobe pneumonia.
bones for fractures

*Q: What clinical signs would you expect from this patient?*
PARCH:
…percussion is dull
…auscultation for coarse breath sounds
…respiratory rate increased
…chest expansion decreased
…heart rate increased.

*Q: immediate management?*
paracetamol for any pleuritic pain and to reduce any fever.*(rw)
anti-biotics based on hospital guidelines.*(rw)
repeat chest x-ray to observe any changes.*(rw)
blood culture for possible sepsis.

Question 38

OSCE A: Post-operative infection

Answer 38

SOCRATES:
…site*
…onset
…character*
…radiation
…alleviating factors
…trigger
…exacerbating factors
…severity
nausea*
vomiting
change in bowel movements*
fever*
SOB*
spike temperature*
describe scar*
stained dressing*
swelling*
calf swelling* (no)
quadriceps muscle wasting*:
…due to antalgic gait(?)
urinary symptoms

*Q: perform an examination?*

examination of the abdomen??:
…distension (none)*
…palpation - state where tender*
…auscultation - state findings*
percussion state tender*
tachycardia*

*Q: Describe this photo?*
calf swelling* (no)
quadriceps muscle wasting*

*Q: What is the diagnosis?*
post-operative infection*

*Q: Investigations?*
FBC* for infection markers (WBC)
CRP* for acute phase response
blood culture* for infection
wound swab* for infection
gram stain the swab*
aspirate the knee* using an aseptic procedure*.
gram stain the aspirate*
CT abdomen

*Q: What further radiological investigation?*

CT abdomen*

*Q: next steps?*
sepsis evident*
senior help*
antibiotics after gram stain* (?)

Question 39

OSCE A: Paediatric diabetes

Answer 39

how is diabetes going in general?
hospitalisations e.g. DKA
onset* (ro)
DKA episodes*
hypoglycaemia episodes*
blood sugar monitor (BM monitor)*
BM recordings
diet*
carbohydrates*
who gives the insulin*
where is it injected*
insulin types*
insulin times*
insulin pump*
compliance
HbA1c results
school attendance
hobbies
blood pressure
heart problems
kidney
sight
neurology
frequency of visits to diabetes clinic
understand sick day rules:
…don’t stop insulin
…increase dose if ill
…drink sugary drinks if can’t eat
…doctor early
triggers for poor diabetic control
life events
alcohol affects glucose levels

*Q: What is DKA?*
you need insulin to live* (rw)
DKA occurs when there is not enough insulin* (rw)
it is a medical emergency.* (rw)
you get abdominal pain*
breath heavily* (Kussmaul breathing)
lose energy*
vomit*

*Q: advice?*
test ketones in urine*
if increased ketones then regular monitoring* (rw)
call a hospital doctor* or your diabetic team*

Question 40

OSCE A: Eating disorder

Answer 40

typical daily diet* (rw)
food groups avoided*
diet pills*
make self vomit* (rw)
over exercising*
constipation*
thin soft hair* (lanugo hair)
bruising*
cold intolerance*
losing weight because avoiding fatty foods.*
body image distortion with ‘dread of fatness’* (xRw)
anhedonia
trigger

*Q: diagnosis?*
restrictive type of anorexia nervosa because will only eat specific foods.*

*Q: look up the BMI?*
…BMI is less than 17.5.

*Q: what would you want to exclude?*
endocrine disorder* involving the hypothalamus-pituitary-gonadal axis with amenorrhoea* (xRw).
hyperthyroidism

Question 41

OSCE A: Patient discovered daughter had appointment (confidentiality)

Answer 41

I’m sorry you are upset.* (rw)
clearly you are angry so please tell me why so I can help you.* (rw)
I understand why you are upset.*
confidential consultations*:
…mother
…daughter
need permission
cannot disclose no matter how close to family.
undermines doctor-patient relationship.
I’m sorry I cannot disclose information.
Doctors can only disclose information if it’s in the public interest.
relationship with daughter*
approached daughter*
why do you think your daughter behaved that way?*
any issues with your other children?*
are you coping with your other daughter moving away?*
depression*
manage anxiety*
live with family*
partner working away*
smoking*
let us put a plan together*

Question 42

OSCE A: Multiple sclerosis (neurology)

Answer 42

gradual symptoms*
symptoms resolved*
neurological symptoms:
…muscle weakness
…paraesthesia
bladder symptoms*
bowel symptoms*
visual symptoms*:
…change in vision
…blurring
…painful vision (optic neuritis)
Bell’s palsy*
previous neurology*
brain tumour*
headache
problems swallowing
tremor
slurred speech
muscle wasting

PMHx
DHx*
FHx
SHx

*Q: What is the diagnosis?*
multiple sclerosis.*
Relapsing-remitting MS (RRMS):
…Sx occur then mostly resolve.
Primary progressive MS (PPMS)
Secondary progressive MS (SPMS)

*Q: What risk factors?*
Ex female
Hx first/second degree relatives with MS
HLA-A3
female
smoking
vitamin D deficiency
EBV

*Q: What investigations?*
O/E neurology:
…fasciculations
Ix Cerebellar function
Cranial and spinal cord MRI with gadolinium labelling:
…old lesions and new lesions
…demyelination
…(historical lesions not associated with symptoms at the moment of the evaluation.)
Lumbar Puncture:
…oligoclonal bands of IgG on electrophoresis.
…increased myelin protein.
visual evoked potentials:
…brain response electrical study.
HLA-A3
MacDonald Diagnostic Criteria:
…dissemination in space.
…dissemination in time.
…dissemination in both.

*Q: Management*

methylprednisolone for acute relapses.
natalizumab (disease modifying agent)
TCA for neuropathic pain.
gabapentin for neuropathic pain.
baclofen for spasticity.
physiotherapy
exercise and diet for fatigue.

Question 43

OSCE B: Post-dates pregnancy
[Process]

Answer 43

[Process]
complications with current pregnancy
previous pregnancies
complications with previous pregnancies.
miscarriages
abortions
smears:
…last smear
…results
post-dates is after 42 weeks pregnancy.
cause for post-date pregnancy is not well established.
risks to mother and baby.
risks to baby:
…malnutrition.
…chest-related complications.
cervical sweep or induction needed.
cervical sweep:
…can induce labour within 48 hours.
…vaginal examination to assess favourability.
…two fingers are used to sweep between cervix and membranes.
…risks:
……bleeding
……rupture of membranes.
……painful.
…no infection risk to baby.
induction of labour:
…internal examination to assess favourability of cervix.
…if cervix is favourable:
……membranes will be ruptured.
……hormone drip started to induce contractions.
…if cervix is unfavourable:
……vaginal tablet ‘Prostin’ to ripen cervix.
……may need to be repeated.
……prostin can cause the uterus to stimulate too much, so another medication may be given to relax the uterus.
…if a hormone drip is used then the baby needs CTG monitoring.
pregnancy should not go beyond 42 weeks without action.

PMHx
DHx:
…medications taken before pregnancy
…medications taken during pregnancy
…allergies

Question 44

OSCE B: Diabetes type II
[Process]

Answer 44

[Process]
weight gain
increase calorie intake
reduced exercise
explain diabetes:
…type I is insulin depletion.
…type II is insulin resistance:
……increased insulin resistance -> increased insulin synthesis -> hyperinsulinaemia -> repeats until B-cells burn out.

Sx:
…polydipsia
…polyuria

Complications:
…heart
…eye
…kidney
…feet
…nerves
strict monitoring
strict glucose control

*Investigations*

*Management*

stop smoking
exercise:
…(NICE guidelines)
…2.5 hours per week of moderate intensity (brisk walking)
…or…
…1.25 hours per week of high intensity (jogging).
weight loss:
…aim to lose 10% per year.
…calculate BMI
…aim for BMI of 18.5 to 24.5.
diet:
…high-fibre
…low sugar
…low fat
dietician

regular screening
capillary blood glucose
fasting blood glucose
oral glucose tolerance test
HbA1c
lipid profile
if hypercholesterolaemia:
…statin required.
if high BP:
…anti-hypertensive medications.

check for retinopathy:
…ophthalmology referral.
…retinopathy screening by accredited optician.
check for neuropathy:
…foot screening for sensation, circulation.
…podiatry input.
check for depression:
…feeling down?
…hopeless?
…little interest in things?
…low energy?
check for nephropathy:
…U+E
…urinary albumin-to-creatinine ratio
…blood pressure control
…blood glucose control
…consider ACE inhibitor.

metformin:
…biguanide
…inhibits gluconeogenesis
…improves sensitivity to insulin
…Indx: obese
gliclazide:
…sulphonylurea
…stimulates pancreas to release insulin
acarbose:
…alpha-glucosidase
…prevents intestinal sugar absorption
pioglitazone:
…thiazolidinedione
…improves sensitivity to insulin
sitagliptin:
…DPP-4 inhibitor (dipeptidyl peptidase-4 inhibitor)

Question 45

OSCE B: Newborn baby station

Answer 45

*Q: Picture of strawberry naevus by the eye. What is it?*
Haemangioma - strawberry naevus type.

*Q: What is the problem with it?*
It forces the eye shut, causing the eye muscles to get weaker, causing a lazy eye (strabismus) and amblyopia.

*Q: Can you demonstrate Ortolani and Barlow’s on a baby doll?*
OK.

*Q: What are the symptoms of DDH?*
SABER + painful limp:
…shortening
…abduction
…external rotation
…painful limp.

*Q: How is it treated?*
Pavlik harness.

*Q: What % of weight does a baby lose after it is born and how long does it take to regain it?*
A baby loses 7-10% after it is born, regained in 2 weeks.

Question 46

OSCE B: Assess gait and lower function - clubfoot? (paediatrics)

Answer 46

ask: WASPS
…walking
…ADLs (dressed)
…stairs
…pain
…stiffness
diet
when clubfoot acquired?

*Q: What is the diagnosis?*
?Rickets

*Q: What causes rickets?*
Lack of vitamin D or calcium, resulting in soft bones.
The adult form is osteomalacia.

Question 47

OSCE B: Dyspepsia

Answer 47

what do you mean by ‘heartburn’?
explain dyspepsia:
…reduced tone of lower oesophageal sphincter (alcohol, surgery)
…increased intragastric pressure (large meal)

SOCRATES:
…Site:
……central burning chest pain (retrosternal)
…Onset
…Character
…Radiation:
……no pain radiation
…Alleviating factors:
……Hx pain relief by antacids
…Trigger
…Exacerbating factors:
……pain worse at night
……pain made worse by heavy meals
……pain made worse by bending down
…Severity

regurgitation
waterbrash
acid brash

*Q: What investigations?*
OGD:
…crypt hyperplasia
…villous atrophy
…loss of rugae
Scoring:
…Los Angeles classification (number of mucosal breaks)
barium meal:
…SLURP
…TUNIC
helicobacter pylori breath test
24 hour continuous pH monitoring

*Q: How would you manage this patient?*

small frequent meals
reduce alcohol intake
lose weight
stop smoking
reduce alcohol
omeprazole
milk of magnesia
Peptobismol
Buscopan
Gaviscon
Ranitidine (H2 antagonist)
Nissen fundoplication:
…wrap fundus around oesophagus to increase pressure.

Question 48

OSCE B: Seizure

Answer 48

PENNY CARAVAN:
…(used for Epilepsy + headache)
…photophobia*, phonophobia*
…exacerbated by posture*
…nausea, vomiting*
…neurological Sx*
…you hot?
…
…consciousness
…aura
…rash
…anorexia (weight loss*)
…vision changes*
…appetite*
…neck stiffness

trigger:
…alcohol
…sleep deprivation
duration of seizure
change in mood hours before
change in taste/smell
loss of concentration
remember the event
confused
drowsy
repetitive mouth movements
tongue biting
fractures
incontinence
what happened after the seizure?
driving
contact with infectious people
pregnant
inform DVLA:
…if isolated seizure then cannot drive for 6 months (?).
…if 2+ seizures then must be seizure free for 12 months.
…empathise with inconvenience.

PMHx
DHx
FHx
SHx:
…alcohol

*Q: Investigations?*

U+E:
…electrolyte imbalance
…calcium
…magnesium
BM:
…hypoglycaemia
coagulation profile:
…intracranial bleeding
toxicology:
…TCA
…salicylates
…lithium
anti-convulsant drug levels
blood cultures:
…infection
ABG:
…consider.
…only if acute.
CXR:
…PNM.
rashes:
…sepsis.
ECG:
…exclude cardiac involvement.
electro-encephalogram:
…brainwave activity.

*Q: Treatment options?*
if acute:
…benzodiazepine
glucose
pabrinex
refer to neurology

Question 49

OSCE B: Miscarriage

Answer 49

amenorrhoea
vaginal bleeding
syncope
cramping abdominal pain
passage of fetal tissue
fever:
…septic miscarriage.
period:
…LMP
…regular
…tampons
…post-sex bleeding
…painful sex
…clots
…flooding
previous:
…pregnancies
…pregnancy complications
…miscarriages
…ectopics
contraception
smears:
…last
…results
…LETZ surgery

PMHx:
…cervical surgery
…uterine surgery
…STI
…DVT/PE
…thyroid

*Q: Differential diagnosis?*
miscarriage
ectopic pregnancy
ectropion
polyp
malignancy

*Q: Next steps?*
if haemodynamically unstable:
…ABCDE
…refer to obstetrics + gynaecology
…bimanual examination
…speculum examination
…urgent transvaginal USS

serum hCG:
…pregnant
thrombophilia screen
anti-phospholipid antibody screen
lupus anti-coagulant screen
TFT
group and save
cross match
if rhesus negative:
…anti-D.
transvaginal USS:
…multiple pregnancy
…retained products
…location (ectopic, uterine)
pelvic USS
dilation and curettage
education:
…if 1 miscarriage: 0 risk of another.
…if 2 miscarriages: 25%
…if 3 miscarriages:
……40%
……specialist review