OSCEs 302

Question 1

Migraine with aura:
Symptoms
Treatments
RED flags

Answer 1

1. Flickering lights, loss of vision, pins and needles, dysphasia, last 1 hour)
2. Fluids, sleep, avoid bright light, headache diary, paracetamol 1g, aspirin 900mg, ibuprofen 400mg, take sumatriptan 50-100mg at start of headache and not start of aura, zolmitriptan if early vomiting or severe, metoclopramide 10mg for antiemetic
3. Visual changes, speech difficulties or weakness (stroke)

Question 2

Migraine without aura:
Symptoms
Treatments
RED flags

Answer 2

1. Pulsating headache with nausea and vomiting
2. Fluids, sleep, avoid bright light, headache diary, paracetamol 1g, aspirin 900mg, ibuprofen 400mg, take sumatriptan 50-100mg, zolmitriptan if early vomiting or severe, metoclopramide 10mg for antiemetic
3. Sudden thunderclap headaches, fever, neck stiffness (especially over 50) (haemorrhage or seizures)

Question 3

Motion sickness:
Symptoms
Treatments
RED flags

Answer 3

1. Nausea, vomiting and vertigo during travel
2. anti sickness bands, fluids, focus on horizons, sit in front seat, take as prevention antiemetics hyoscine hydrobromide 150-300mcg 30 mins before travel then 75-150mcg every 6 hours
   Antihistamines cinnarizine 30mg 2 hours before travel then 15mg every 8 hours and cyclizine 50mg TDS 1-2 hours before depature
3. Weakness, dry mouth, (dehydration) speech difficulties (neurological)

Question 4

Gastroenteritis:
Symptoms
Treatments
RED flags

Answer 4

1. Stomach infection with diarrhoea, nausea, vomiting, abdominal cramps
2. Usually self-limiting, antibacterial not usually indicated, fluids, soups, advise ORS 200-400ml, not routinely use antidiarrhoeals but can be OTC if needed
3. Excessive thirst with nausea and vomiting (dehydration), fever (sepsis), vomiting blood or green (GI), blue skin (poor oxygenation), stiff neck and pain with bright lights (meningitis)

Question 5

Traveller’s Diarrhoea:
Symptoms
Treatments
RED flags

Answer 5

1. Loose stools with increased frequency and volume, less than 14 days
2. Symptoms improve in 2-4 days, check for reason, fluids, ORS 200-400ml, hospital for those unable to drink or severe dehydration, loperamide 4mg then 3mg up to 5 days take after each loose stool (max. 16mg)
3. Weight loss, rectal bleeding (cancer), persistent diarrhoea, recent hospital or antibiotic treatment

Question 6

Malaria:
Symptoms
Treatments
RED flags

Answer 6

1. Fever, sweats, chills, headache, confusion
2. Refer if suspected and report to Public Health, for prevention: nets, long sleeves, permethrin spray, DEET spray, Riamet 20/120mg for mixed infection (NO smoking), Atovaquone-proguanil 250/100mg if uncomplicated (pregnancy, quinine + doxycycline (not give under 12 years, pregnancy)
3. Impaired consciousness, acidosis, respiratory distress, shock, sepsis (severe malaria), Hospital admission for elderly, young and pregnant or severity

Question 7

Influenza A:
Symptoms
Treatments
RED flags

Answer 7

1. More virulent and frequent, chills, fever, fatigue, headache
2. Self-limiting, rest, OTC paracetamol or ibuprofen, influenza A vaccine yearly injection during flu season for high risk
3. Difficulty breathing, chest pain, seizures

Question 8

Influenza B:
Symptoms
Treatments
RED flags

Answer 8

1. Milder than A, chills, fever, headache, fatigue
2. Self-limiting, Hib vaccine as children
3. Difficulty breathing, chest pain, seizures

Question 9

Crohn’s Disease:
Symptoms
Treatments
RED flags

Answer 9

1. Diarrhoea, abdominal pain, fatigue, weight loss, blood in stool, mouth ulcers, inflammation in GI tract
2. Refer for maintenance, prednisolone 20-40mg OD until remission
3. Severe weight loss, fatigue (cancer), malnutrition

Question 10

Ulcerative Colitis:
Symptoms
Treatments
RED flags

Answer 10

1. Diarrhoea with blood or mucus, abdominal pain and cramping
2. Aminosalicylates sulfasalazine C/I with aspirin allergy or blood dyscrasias
3. Persistent bloody diarrhoea >6 weeks, nocturnal defecation and weight loss

Question 11

IBS:
Symptoms
Treatments
RED flags

Answer 11

1. Abdominal pain, bloating, changes in bowel habits, diarrhoea/constipation
2. Physical activity, avoid triggers, diet diary, restrict caffeine, antispasmodics alverine citrate 60mg OD-TDS, mebeverine MR 200mg BD or peppermint oil 1-2 capsules TDS
   Stimulant Dulcolax 5-10mg OD nocte and Senokot 7.5mg OD nocte, (osmotic lactulose can cause bloating)
   Loperamide 4mg OD for anti-motility diarrhoea
3. Weight loss, rectal bleeding, family Hx of bowel/ovarian cancer (cancer)

Question 12

Rabies:
Symptoms
Treatments
RED flags

Answer 12

1. Flu, fever, headache
2. Prevention by vaccine before travel or soon after exposure (2+ doses), get help abroad, ask for urgent GP appointment if in UK
3. Severe anxiety, hallucinations, confusion, behavioural changes (hospital treatment)

Question 13

Coeliac Disease:
Symptoms
Treatments
RED flags

Answer 13

1. Diarrhoea, abdominal pain and bloating, weight loss
2. Avoid gluten trigger, eat regular meals
3. Itchy rash (dermatitis herpetiformis), weight loss and malnutrition (anaemia or brittle bones)

Question 14

VTE (DVT & PE):
Symptoms
Treatments
RED flags

Answer 14

1. Swelling, pain or tenderness in leg, warm feeling and red/discoloured skin, not always symptomatic unless travelled to lungs
2. Prevention using stockings, exercises, refer if suspected PE, offer leg ultrasound within 4 hours of DVT, in confirmed DVT offer apixaban 10mg BD for 7 days
3. SOB, chest pain, coughing blood (PE)

Question 15

Jet lag:
Symptoms
Treatments
RED flags

Answer 15

1. Fatigue, difficulty sleeping, daytime sleepiness
2. Fluids, good sleep schedule, reduce alcohol and caffeine, melatonin 3mg OD for 5 days, take 1st dose at night before 8pm and after 4am
3. Severe sleep disturbance, prolonged fatigue, feeling unwell (consult doctor)

Question 16

N + V induced chemotherapy:
Symptoms
Treatments
RED flags

Answer 16

1. Nausea and vomiting, within 24 hours of treatment or after 24 hours
2. Netupitant/palonosetron 1 capsule 1 hour before each chemotherapy cycle C/I over 75s
   Ondansetron 8mg for 1 dose 1-2 hours before then 8mg BD for 5 days OR IM injection
3. Persistent vomiting, dehydration, abdominal pain or blood in vomit

Question 17

Breast cancer:
Symptoms
Treatments
RED flags

Answer 17

1. Lump/mass in breast, nipple changes, shape or feel of breast, discharge or pain in breast/armpit
2. -
3. New lump (hard, irregular, painless), same as symptoms, refer to GP

Question 18

Colorectal cancer:
Symptoms
Treatments
RED flags

Answer 18

1. Changes in bowel habit, rectal bleeding, blood in stool, weight loss or fatigue
2. -
3. Persistent rectal bleeding, iron-deficiency anaemia, especially over 50s

Question 19

Benign Prostatic Hyperplasia:
Symptoms
Treatments
RED flags

Answer 19

1. Urinary frequency, difficulty urinating, weak stream
2. Pads/collecting devices, bladder training, pelvic floor exercises, alfuzosin 2.5mg TDS or tamsulosin 400mcg OD
3. Worsening symptoms, acute urinary retention and haematuria (bladder damage)

Question 20

Erectile dysfunction:
Symptoms
Treatments
RED flags

Answer 20

1. Difficulty maintaining erection sufficiently for sexual intercourse, reduced firmness, premature ejaculation, decreased libido
2. Smoking cessation, BMI, reduced alcohol, sildenafil 50mg 1 hour before initially for short-acting
   Tadalafil 10mg initially 30 mins before, 5mg OD for activity 2+ weekly for long-acting for spontaneous activity
3. sudden onset with saddle anaethesia, hx of trauma to genital area, pelvis or spine

Question 21

Prostatitis:
Symptoms
Treatments
RED flags

Answer 21

1. Pain/burning urination, pain in back pelvis or genitals, difficulty urinating
2. Immediate antibacterial prescription of ciprofloxacin 500mg BD for 14 days and midstream sample before treatment for culture, refer to hospital if patients symptoms do not improve after 48 hours of treatment
3. Sudden fever, chills, feeling unwell, inability to urinate

Question 22

Diarrhoea:
Symptoms
Treatments
RED flags

Answer 22

1. Loose stools for less than 14 days, cramps, stomach pain, bloating, nausea
2. Eat regular meals, fluids!, ORT like Dioralyte 200-400ml (1-2 sachets) after each loose stool
3. Diarrhoea over 7 days, bloody/black stool (bleed), weight loss, dehydration

Question 23

Constipation:
Symptoms
Treatments
RED flags

Answer 23

1. <3 bowel movements a week, straining to pass, hard lumpy stools, incomplete bowel movement
2. Fluids, fibre intake increased, wholegrains, fruit and veg
   Small hard stools: bulk-forming isphagula husk 1 sachet BD in water after food morning & evening
   Increase motility but cause cramps: bisacodyl 5-10mg OD nocte
   Faecal softener: docusate sodium 100mg TDS or 120mg 1 dose rectum
   Osmotic laxative: lactulose 15mL BD can cause bloating
3. Sudden bowel change, bloody stools, rectal bleeding, iron deficiency anaemia

Question 24

Dyspepsia/GERD:
Symptoms
Treatments
RED flags

Answer 24

1. Heartburn, feeling full and bloated, nausea and belching for 4+ weeks
2. Healthy eating, weight loss, trigger foods, smoking cessation, eating 3-4 hours before bed
   Remove NSAIDs, TCAs, nitrates, steroids, CCBs, beta blockers, BZDs, aspirin
   Uninvestigated: PPI lansoprazole 30mg BD for 4 weeks, test for H.pylori if positive treat lansoprazole 30mg BD, amoxicillin 1g BD for 7 days and clarithromycin 500mg BD for 7 days or metronidazole 400mg BD for 7 days (depend on previous treatment)
3. Urgent endoscopy in dysphagia, weight loss over 55, upper abdominal pain, GI bleeding

Question 25

Diverticulitis: Symptoms Treatments RED flags

Answer 25

1. Abdominal pain, constipation or diarrhoea, N + V, fever, pain localised to left abdomen (large intestine) 2. Simple analgesia like paracetamol >51kg 1g 4-6 hours or <51kg 15mg/kg, refer patients with persistent or worsening symptoms to hospital for further assessment, refer for suspected complicated for same day Urgently refer for rectal bleeding 3. Severe abdominal pain or rectal bleeding

Question 26

Peptic ulcers: Symptoms Treatments RED flags

Answer 26

1. Abdominal pain, burning or gnawing in upper abdomen, indigestion, heartburn, acid reflux 2. Remove NSAIDs if on H.pylori eradication, same as dyspepsia, remove drug triggers, refer for H.pylori testing, if positive and NSAID use PPI lansoprazole 30mg BD for 8 weeks followed by H.pylori treatment, negative for both use lansoprazole 30mg BD for 4-8 weeks 3. Radiating pain in abdomen to back, bleeding like black tarry stools or bloody vomit REFER

Question 27

Nocturnal enuresis: Symptoms Treatments RED flags

Answer 27

1. Bedwetting after age 5, wets the bed after a few months of being dry at night, pain passing urine, often thirsty 2. Fluid intake, diet, toileting behaviour, alarms under 7 review after 4 weeks, desmopressin 200mcg OD nocte used if partial alarm response, refer to specialist for further combination therapy, same for adults if necessary 3. Daytime frequency, pain passing urine, thirsty (diabetic), UTIs, leaking

Question 28

Urinary incontinence: Symptoms Treatments RED flags

Answer 28

1. Leaking urine when cough or sneeze, urge to urinate strongly, loss of bladder control 2. Monitor fluid intake, pelvic floor exercises, reduce caffeine, pads, urgency incontinence bladder training for 6 weeks or stress pelvic floor for 3 months, offer dipstick for infection Urgency: oxybutynin hydrochloride 5mg BD-TDS, review after 4 weeks Stress: duloxetine 40mg BD AFTER pelvic floor, review 2-4 weeks Mixed: treat with predominant type 3. Refer if pain urinating, pelvic mass, hx of incontinence surgery, recurrent UTI, visible haematuria, older adults

Question 29

UTIs: Symptoms Treatments RED flags

Answer 29

1. Pain/burning urinating, frequency, urgency, cloudy/foul smelling urine, lower abdominal pain 2. Fluids, wipe front to back, loose underwear, paracetamol 1g or ibuprofen 400mg for pain relief, non-pregnant nitrofurantoin 50mg QDS for 3 days (7 days in males and pregnant women) OR MR 100mg BD for 3 days (7 in other groups) 3. Severe worsening pain, back pain (kidneys), haematuria, confusion, fever (sepsis)

Question 30

Pyelonephritis: Symptoms Treatments RED flags

Answer 30

1. Fever, chills, flank pain and nausea, kidney infection 2. Obtain midstream urine sample, immediate antibacterial cefalexin 500mg BD-TDS 7-10 days for male and non-pregnant, refer if significantly dehydrated, pregnant or higher risk of complications 3. Thirst and dehydration, sudden fever, unable to urinate, confusion/mental changes

Question 31

Osteoarthritis: Symptoms Treatments RED flags

Answer 31

1. Cartilage in joints wears away, pain, stiffness, reduced range of motion in joints, swelling, bone spurs (hard lumps) 2. Topical diclofenac 1% TDS-QDS, review after 28 days then topical ibuprofen 5% TDS or oral ibuprofen 400mg TDS NOT paracetamol or weak opioids LONG term 3. Persistent pain especially in morning or after inactivity, grating or popping of joints, bone spurs, fever or warmth

Question 32

Spondylosis: Symptoms Treatments RED flags

Answer 32

1. Neck stiffness and pain with headaches, pain radiating in arms or legs sometimes 2. Refer to specialist therapist, start on NSAID at lowest effective dose, consider PPI 3. Severe pain, weakness, numbness in limbs, gait disturbances, bowel/bladder dysfunction (spinal cord compression)

Question 33

Septic arthritis: Symptoms Treatments RED flags

Answer 33

1. Hot, swollen, acutely painful joint with restricted movement 2. Flucloxacillin or clindamycin 4-6 weeks (longer if complicated), seek specialist advice if prostheses present, REFER 3. REFER

Question 34

Severe active ankylosing spondylitis: Symptoms Treatments RED flags

Answer 34

1. Inflammation of spine, pain, stiffness, fusion of vertebrae 2. Methotrexate 7.5mg once weekly or adalimumab 40mg every 2 weeks if not responded to DMARDs 3. Chronic back pain and stiffness worsening morning and night, improves with movement and worsens with rest

Question 35

Psoriatic arthritis: Symptoms Treatments RED flags

Answer 35

1. Joint pain, swelling and stiffness accompanied by skin and nail changes of psoriasis 2. Methotraxate 7.5mg once weekly 3. Worsening joint pain, swelling, worsening psoriasis lesions, change in nail colour, refer to GP

Question 36

Systemic lupus erythematosus: Symptoms Treatments RED flags

Answer 36

1. 2. For mild, chloroquine 155mg daily particularly for skin and joints or prednisolone 60mg daily to be reduced 3.

Question 37

Rheumatoid arthritis: Symptoms Treatments RED flags

Answer 37

1. Stiffness worse at rest, swelling, tenderness and heat in joints 2. Exercise, stress management, refer for cause, methotrexate 7.5mg weekly 3. Worsening joint pain, swelling, stiffness, fatigue, fever, digestive issues

Question 38

Ascites: Symptoms Treatments RED flags

Answer 38

1. 2. Chlortalidone up to 50mg daily, spironolactone 100-400mg daily 3.

Question 39

Varices: Symptoms Treatments RED flags

Answer 39

1. 2. Carvedilol 6.25mg OD or propanolol 40mg BD 3.

Question 40

Hepatic encephalopathy: Symptoms Treatments RED flags

Answer 40

1. 2. Lactulose 30-50mL TDS adjust to produce 2-3 soft stool per day 3.

Question 41

Obesity: Symptoms Treatments RED flags

Answer 41

1. 2. Exercise, weight management programme, diet, orlistat 120mg TDS before during or after main meal >30 or >28 BMI with co-morbidities with failed lifestyle changes, semaglutide (Wegovy) 0.25mg once weekly for 4 weeks then increase if tolerated, all under specialist care 3.

Question 42

Acute alcohol withdrawal: Symptoms Treatments RED flags

Answer 42

1. 2. Chlordiazepoxide 10-30mg QDS moderate or 10-50mg QDS severe or clomethiazole initially 2-4 capsules then 9-12 capsules in 3-4 divided dose day 1 then 6-8 day 2 then 4-6 day 3 etc. 3.

Question 43

Non-alcoholic fatty liver disease: Symptoms Treatments RED flags

Answer 43

1. 2. Weight loss, healthy diet and exercise to improve liver health 3.

Question 44

Non-alcoholic steatohepatitis: Symptoms Treatments RED flags

Answer 44

1. 2. Weight loss, healthy diet and exercise to treat 3.

Question 45

Korsakoff syndrome (unresolved Wernicke): Symptoms Treatments RED flags

Answer 45

1. 2. Pabrinex followed by oral thiamine long term 3.

Question 46

Wernicke encephalopathy (acute): Symptoms Treatments RED flags

Answer 46

1. 2. Pabrinex followed by oral thiamine long term 3.

Question 47

Hyperlipidaemia: Symptoms Treatments RED flags

Answer 47

1. Leg cramps, pain in feet and toes but usually asymptomatic 2. Exercise, diet, smoking and alcohol then 10%+ QRISK3 score or co-morbidities give atorvastatin 20mg OD also CKD 3.

Question 48

Hypertension: Symptoms Treatments RED flags

Answer 48

1. Headaches, blurred vision, chest pain but usually asymptomatic 2. Lifestyle changes, offer ABPM/HBPM at 140/90-179/119 if then 135/85-149/94 with T2DM or <55 offer ramipril 1.25mg-2.5mg OD or >55 or Black African or African-Caribbean offer amlodipine 5mg OD 3. 180/120 same-day specialist review if symptoms with it

Question 49

Stable angina: Symptoms Treatments RED flags

Answer 49

1. Chest pain or pressure from physical exertion or stress, radiates to neck, shoulders, jaw or arms, pain relieved at risk 2. Sublingual glyceryl trinitrate to prevent attack 1 tablet or 1 tablet to treat then repeat at 5 min intervals max. 3 tabs, for long-term prevention beta blocker like atenolol 100mg 1-2 divided doses 3. Chest pain unrelieved by GTN, lasts longer than 15 mins, new symptoms

Question 50

STEMI (complete blockage): Symptoms Treatments RED flags

Answer 50

1. Chest pain, pain radiating to arm, neck or jaw, sweating, dizziness, impending sense of doom 2. PCI or fibrinolysis with antiplatelet aspirin 300mg 1 dose and anticoagulant prasugrel 18-74 >60kg 60mg 1 dose then 10mg OD for 12 months 3. Same as symptoms

Question 51

NSTEMI: Symptoms Treatments RED flags

Answer 51

1. Chest pain, SOB, nausea, sweating, pain radiating to arm, neck and jaw 2. Aspirin 300mg 1 dose with prasugrel 60mg loading dose at time of PCI to minimise bleed and fondaparinux sodium 2.5mg OD for up to 8 days or discharge also offered 3. Same as symptoms

Question 52

Type 2 diabetes: Symptoms Treatments RED flags

Answer 52

1. Urinary frequency, thirsty, tiredness, wounds take longer to heal 2. Weight loss, exercise, diet, start on metformin 500mg OD for 1 week take at breakgast then up as necessary if HbA1c above 6.5% with lifestyle alone 3. Same as symptoms

Question 53

Peripheral artery disease: Symptoms Treatments RED flags

Answer 53

1. Shiny skin on legs, skin colour changes, slow-growing toenails, sores on toes that do not heal 2. Rivaroxaban 2.5mg BD or if streptokinase 250,000 UI over 30 mins IV then 100,000 UI every hour for 5 days 3. Severe pain that won't rest, wounds that will not heal, absence of pulses

Question 54

Heart failure: Symptoms Treatments RED flags

Answer 54

1. SOB, persistent coughing and wheezing, ankle swelling, reduced exercise tolerance, jugular venous pressure, pulmonary crackles 2. Smoking cessation, reduce alcohol, exercise, diet and weight loss then rate-limiting CCB verapamil or diltiazem with ACEi ramipril with diuretic furosemide for SOB and oedema 3. Swelling, rapid weight gain, same as symptoms

Question 55

Chronic kidney disease: Symptoms Treatments RED flags

Answer 55

1. Fatigue, swelling in feet and ankles, SOB, change in urine output and colour 2. 3. Frequency, foaming and bubbling urine, swelling, itchy dry skin

Question 56

Acute kidney injury: Symptoms Treatments RED flags

Answer 56

1. N+V, diarrhoea, dehydration, less urination, confusion, drowsiness 2. Manage fluids for dehydration, drain bladder if blockage is cause, stop or adjust medication 3. Sudden increase creatinine, decreased urine

Question 57

Cardiac dysrythmias: Symptoms Treatments RED flags

Answer 57

1. Heart palpitations, fluttering, SOB, lightheadedness, fatigue 2. Check notes 3. Same as symptoms, sudden collapse, fhx of cardiac death, young individuals

Question 58

Atrial fibrillation: Symptoms Treatments RED flags

Answer 58

1. Heart palpitations, SOB, dizziness 2. Check notes 3. Same as symptoms, loss of consciousness, HR >150, drooping

Question 59

Menopause: Symptoms Treatments RED flags

Answer 59

1. Hot flushes, night sweats, vaginal dryness, low mood, reduced libido 2. Sleep, diet, calcium-rich foods, HRT if early menopause <45 or post-menopausal symptoms that affect QoL 1 patch twice week within 5 days of menstruation or 1-2mg daily on first day of menstruation, counsel on breast cancer risk 3. Irregular heavy bleeding, bleeding during sex breast changes (cancer)

Question 60

Stroke: Symptoms Treatments RED flags

Answer 60

1. Vision loss, blurred vision, vomiting, drooping but causing permanent disability 2. Alteplase IV 900mg/kg within 4.5 hours of symptom onset, if disabling then aspirin 300mg OD for 14 days within 24 hours 3. Same as symptoms

Question 61

Transient Ischaemic Attack: Symptoms Treatments RED flags

Answer 61

1. Face drooping on one side, not able to lift arms and speech problems 2. Aspirin 300mg OD until diagnosis established and clopidogrel 300mg 1 dose 3. Sudden onset, neurological deficits and symptoms for 24 hours