OSCE Handbook

OSCE Handbook
Table of Contents
Table of Contents ..................................................................................................................... 2
3rd year Stations ....................................................................................................................... 6
Basic Life Support ......................................................................................................................................................7
Cranial Nerve Examination ........................................................................................................................................8
CVS Examination ........................................................................................................................................................9
HAND Examination ................................................................................................................................................. 11
SHOULDER .............................................................................................................................................................. 13
RESP ........................................................................................................................................................................ 14
Upper Limb Examination 2 ..................................................................................................................................... 16
Sensory Examination 2............................................................................................................................................ 18
Lower Limb Examination 2 ..................................................................................................................................... 19
EAR .......................................................................................................................................................................... 21
Peripheral Vascular (Limb) Examination................................................................................................................. 22
Assessing Hydration Status OSCE ........................................................................................................................... 24
Fluid balance ........................................................................................................................................................... 26
FLUID BALANCE ....................................................................................................................................................... 27
NUTRITONAL ASSESSMENT .................................................................................................................................... 28
Heart Murmurs Harvey ........................................................................................................................................ 29
HARVEY CVS examination Clinical skills GUIDE....................................................................................................... 30
Ulcer Exam .............................................................................................................................................................. 42
Abdominal Examination.......................................................................................................................................... 43
MINI MENTAL STATE EXAM .................................................................................................................................... 45
'Lumps and Bumps' Examination ............................................................................................................................ 46
Sensory Exam .......................................................................................................................................................... 47
HERNIA .................................................................................................................................................................... 48
Cerebellar Function Examination ........................................................................................................................... 50
Myasthenia Gravis Examination ............................................................................................................................. 51
Multiple Sclerosis Exam .......................................................................................................................................... 52
Parkinson's Disease Examination............................................................................................................................ 53
Speech Assessment................................................................................................................................................. 54
GALS ........................................................................................................................................................................ 55
Upper Limb Examination ........................................................................................................................................ 56
Lower Limb Examination ........................................................................................................................................ 58
SPINE ....................................................................................................................................................................... 60
HISTORY in the OSCE............................................................................................................................................... 61
Breaking bad News ................................................................................................................................................. 62
Consenting a patient for an Operation ................................................................................................................... 63
MCA: Ethics and Law............................................................................................................................................... 64
Ethics and Law: General Rules of engagement....................................................................................................... 65
Inhaler Technique ................................................................................................................................................... 66
IV Fluid Administration ........................................................................................................................................... 67
OSCE: Glycosuria Differentials and Ix ..................................................................................................................... 68
Heart Burn .............................................................................................................................................................. 69
4th year Stations ..................................................................................................................... 71

Psychiatry and Neurology ....................................................................................................... 71
Alcohol dependence ............................................................................................................................................... 72
ADHD station .......................................................................................................................................................... 74
Agoraphobia history ............................................................................................................................................... 76
Anorexia nervosa written ....................................................................................................................................... 78
OSCE: counselling about autism ............................................................................................................................. 79
Alcohol cessation .................................................................................................................................................... 80
Explaining Alzheimers disease ............................................................................................................................... 85
OSCE: counselling about autism ............................................................................................................................. 87
Bipolar affective disorder ....................................................................................................................................... 88
Blood test results in psychiatric disease ................................................................................................................. 89
Counselling OSCE: Beta-blockers and sexual dysfunction ...................................................................................... 90
Explaining clozapine treatment .............................................................................................................................. 92
Conduct disorder .................................................................................................................................................... 93
CSF profiles station ................................................................................................................................................. 95
Delirium written...................................................................................................................................................... 97
Depression History and screen of a 7 year old ....................................................................................................... 99
Epilepsy ................................................................................................................................................................. 101
Explain Schizophrenia ........................................................................................................................................... 103
Fundoscopy Reporting Technique ........................................................................................................................ 104
Mental Health Act ................................................................................................................................................. 106
Headache History.................................................................................................................................................. 107
Bi-Polar Affective Disorder ................................................................................................................................... 109
Lithium toxicity written ........................................................................................................................................ 111
Migraine history.................................................................................................................................................... 113
OCD History........................................................................................................................................................... 114
Idiopathic Parkinsons Disease ............................................................................................................................. 116
PTSD history .......................................................................................................................................................... 119
Radiology Stations ................................................................................................................................................ 120
Explaining Ritalin treatment ................................................................................................................................. 125
Management of school refusal because of bullying ............................................................................................. 126
School Refusal ....................................................................................................................................................... 128
Taking a depression history .................................................................................................................................. 129
Explaining tricyclic antidepressants ...................................................................................................................... 130
Sixth nerve palsy ................................................................................................................................................... 131
4th year Stations ................................................................................................................... 132

Obstetrics and Gynaecology ................................................................................................. 132
Adult UTI ............................................................................................................................................................... 133
OSCE: Downs syndrome....................................................................................................................................... 134
Downs Syndrome ................................................................................................................................................. 135
Ethics & Law station: Contraception .................................................................................................................... 136
4th year Stations ................................................................................................................... 137

Paediatrics............................................................................................................................ 137
Pallor and Fatigue in a young female child ........................................................................................................... 138
OSCE scenario: childhood Anaemia ...................................................................................................................... 140
OSCE Scenario BRONCHIOLITIS .......................................................................................................................... 142
Child UTI ................................................................................................................................................................ 144
Crohns disease history ......................................................................................................................................... 145
Ethics & Law station: Stopping Treatment ........................................................................................................... 147
Explain eczema treatment to a father .................................................................................................................. 149
Faecal Soiling ........................................................................................................................................................ 151
Faecal Soiling 2...................................................................................................................................................... 153
Febrile convulsions ............................................................................................................................................... 155
OSCE Scenario: Abdominal Pains and Diarrhoea: Paediatrics .............................................................................. 157
Head Circumference ............................................................................................................................................. 160
Childhood Asthma ................................................................................................................................................ 162
Childhood Vaccination .......................................................................................................................................... 164
MMR Vaccination ................................................................................................................................................. 166
Neonatal Examination .......................................................................................................................................... 169
Nocturnal enuresis................................................................................................................................................ 170
Limp in a child ....................................................................................................................................................... 172
Psoriasis History .................................................................................................................................................... 174
Psoriasis 2 ............................................................................................................................................................. 176
Smoking cessation ................................................................................................................................................ 177
Picture of a bleed ................................................................................................................................................ 179
Suicidality risk assessment.................................................................................................................................... 180
Neonatal Vomiting Station ................................................................................................................................... 182
Question Lists from Previous Years ....................................................................................... 184

Psychiatry and Neurology from previous years 1 ................................................................................................. 185
Psychiatry and Neurology from previous years 2 ................................................................................................. 190
Obs and Gynae ...................................................................................................................................................... 192
O&G EMQ Dec 2005 ............................................................................................................................................. 198
Obs & Gynae OSCE April 07 .................................................................................................................................. 200
OSCE STATIONS: O+G APRIL06. ENJOY!!!! ........................................................................................................... 205
Condom Use.......................................................................................................................................................... 209
Paeds OSCE 3 ........................................................................................................................................................ 220
Paediatrics/GP/Derm 2002 ................................................................................................... 248

Paeds and GP April 2004 OSCE stations ............................................................................................................... 249
Pyschiatry/Neuro 2002 ......................................................................................................................................... 252
Psychiatry OSCE Stations. ..................................................................................................................................... 269
Part 1
3rd year Stations
Basic Life Support
1. Check for danger to yourself and the child
2. Ascertain whether there is any chance of cervical spine injury
3. Check the childs responsiveness
a. Gently stimulate the child and ask loudly, Are you all right?
b. Do not shake infants, or children with suspected cervical spine injuries.
4. Shout for help
5. Airway
a. Head tilt & chin lift (neutral for infants, sniff the air for children)
b. Check for foreign body
6. Breathing
a. Look for chest movements.
b. Listen at the childs nose and mouth for breath sounds.
c. Feel for air movement on your cheek.
d. Give 5 initial rescue breaths
7. Circulation
a. Feel for pulse over 10 seconds
i. Brachial or femoral for infant
ii. Carotid for children
iii. Compressions are necessary for an absent pulse or rate <60/min
8. Give breaths and chest compressions at a ratio of 15:2
9. Go and get help after 1 minute of CPR
10. Return and continue CPR
Questions
Main causes of arrest in an adult?

Main causes of arrest in a child?
Name 4 differences between adult and child BLS?
1. In child BLS 5 rescue breaths before checking circulation
2. In child BLS you try CPR for 1 minute before leaving (or taking child with you) to call an ambulance
3. Different airway position
4. Breath to compression rate in adults is 30:2
5. Chest compression technique is different
6. in adults can check breathing and circulation at same time
7. Call a different team (i.e. paeds resus team)
Cranial Nerve Examination
Wash Hands
Introduce yourself to the patient, ask the patient if it is ok to examine the nerves of their face.
Have the patient sitting in a chair
Firstly inspect for muscle weakness, facial droop, fasciculations, tremors and surgical scars
I. Olfactory Nerve
Ask the patient to close their eyes and identify coffee by smell
II. Optic nerve
Visual Acuity
Distance vision is tested using a Snellen chart

-stand or sit the patient 6m from the card and ask them to read the lowest line they can
Near vision can be tested using reading test types
Colour Vision
Red-green deficiency can be assessed using Ishihara plates. If 13 or more plates are read correctly, colour vision
can be regarded as normal.
Visual Fields
Sit approximately 1m from the patient
Test each visual field with one eye and then the other
To check for a parietal lesion resulting in visual inattention present your moving fields in both halves of vision
simultaneously
Fundoscopy
Assess optic discs shape, colour and clarity
Examine the vessels
Examine the fundus
III/IV/VI: Oculomotor/Trochlear/Abducens nerves
Pupillary light response:

Ask the patient to focus on a distant object. Shine a light from the side of both eyes. Both pupils should constrict in
both circumstances
Check full eye movements while also looking for nystagmus

CVS Examination
WIPER
Wash hands
Introduce
Permission and Pain
Expose Waist up
Reposition 45o
END OF THE BED

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

Fluid restriction
GTN spray
HANDS and ARMS

Hands Signs of Infective Endocarditis Oslers, Janeway, Splinter Haem
Clubbing
Quinckes sign
Tar Staining
Signs of Liver disease
Signs of other disease
Capillary refill
Hands warm and well perfused
Pulses
Radial rate and rhythm
Radial Radial delay subclavian stenosis
Brachial Pulses character
Collapsing Pulse
ASK FOR BP
FACE
Eye corneal arcus
Xanthelasma
Subconjunctival pallor
Jaundice heart valves
Face Malar Flush Mitral Stenosis
Other Facies Downs, Marfans
MENTION FUNDOSCOPY HTN retinp, Roth spots
Mouth Teeth
Central Cyanosis
Palate high arched?
NECK
Carotid pulse Slow rising
Waterhammer Corrigans sign
JVP Height
Form/Character
CHEST WALL
Inspect the chest wall closer SCARS, PULSATIONS, PACEMAKER, VISIBLE APEX
PALPATION
Apex beat Apex beat check lateral and then medial (displacement
Count down to define
If not present feel on right side of chest (dextracardia)
Heaves LV or RV heave
Thrills Metallic Valves
AUSCULTATION
TIME AGAINST THE CAROTID
describe heart sounds as Normal, Soft, Loud or Metallic
1. Mitral
2. Tricuspid
3. Pulmonary
4. Aortic
5. Carotid
Sit forward
6. Aortic held in expiration
7. Lung Bases
8. Sacral oedema
9. Mitral Valve area roll over to left side
COMPLETING THE EXAM
Examine the rest of the vascular tree peripheral pulses

Abdominal aortic aneurism
Temp
ECG
Thank patient and ask if needs help to get dressed

HAND Examination
WIPER
Wash hands
Introduce
Permission and Pain
Expose bare above elbows
Reposition sitting comfortably, offer a pillow
LOOK
Nails EXAMINE SKIN
DIP
PIP
MCP
Carpal Joints
Wrist
Thumb
Turn over hands Assess movement, normal or antalgic
Inspect for Thenar eminences
Callosities
Carpal tunnel scars
FEEL
Palpate thenar and hypothenar eminences
Test Sensation of Median, Ulnar and Radial nerves
Ulnar Pulses and Radial Pulses
Turn hands over
Capillary Refill on nails
Temperature of hands, wrists and forearm
Palpate all joints that appear to have abnormality
Squeeze over MCP joints
Test Sensation of Radial nerve
Inspect and feel extensor surface of Arm
MOVE
Assess active then passive if difficulty
Extend Fingers fully and test power Assess ulnar nerve
Make a fist
Wrist flexion and extension Prayer sign and wrists down
Passively assess movements
Assess the power of Median and radial nerve
FUCTION
Test power grip
Assess fine finger movement
Special Tests
Ask patient to demonstrate doing up button
Tinnells or Phalens test if suspecting carpal tunnel
Finish up
Neurovascular exam of Upper limb
Examine elbow
Relevant exam if relevant systemic disease is identified in hands
ELBOW
WIPER
Wash hands
Introduce
Permission and Pain
Expose bare above elbows
Reposition sitting comfortably, offer a pillow
LOOK
Carrying angle
Flexion deformity
DWARFS
FEEL
Temperature of joint
Palpate Swelling
Tennis Elbow (lateral condyle)
Golfers Elbow (medial Condyle)
Olecranon bursitis
MOVE
Assess elbow extension and flexion Actively and passively
Assess pronation and supination
Check for crepitus
FUCTION
Check that patient can raise hand to mouth
Finish up
Neurovascular exam of Upper limb
Examine Hands and shoulder
Relevant exam if relevant systemic disease is identified
SHOULDER
WIPER
Wash hands
Introduce
Permission and Pain
Expose Top off
Reposition Standing
Look
Observe patient standing thoroughly inspect D.W.A.R.F.S., Front, Side and Back
Sprengels Shoulder? failure of embryonic descent of the scapula
from its fetal position in the neck to the normal position in the
upper posterior thorax
Klippel-Feil Syndrome congenital fusion of any 2 of the 7 cervical
vertebrae
Feel
Temperature over the join

Palpate the bony landmarks for tenderness Sternoclavicular joint
Clavicle
Acromioclavicular joint
Acromion process
Around Scapula
Palpate joint line
Palpate muscle bulk Supraspinatus, Infraspinatus, Deltoid
Check for sensation over Deltoid Axillary nerve damage
Move
Ask Pt: Hands behind head External rotation

Ask Pt: Behind back Internal rotation define restriction by level
Elbow flexed at 90o Ask Pt: external and internal rotation
Flexion and extension
Adduct Arm Assess Painful arc (between 10o and 120o)
Conduct passive movements + feel crepitus Try to go beyond limitations of the patient
If possible indicates tendinous injury
Assess abduction from behind patient Observe scapular movement
Special Tests
Assess limitation of Function

Rotator cuff injuries abduct arm from side of body against resistance
Ligamentous Tear tests Subscapularis internal rotate arm held behind - tear or tendonitis
Supraspinatus - arm at side test abduction - tear or tendonitis @ 60o
Infraspinatus and Teres minor external rotation at 30o
Bicipital tendonitis supinate arm, assess flexion against resistance
Finish off
Neurovascular exam of upper limbs
X-Ray of Shoulders: 2 views
Additional examinations as relevant
RESP
WIPER
Wash hands
Introduce
Permission and Pain
Expose
Reposition
END OF THE BED

Patient Is the patient Well or unwell?
Breathless/distress Abnormal breathing pattern?
Use of accessory muscles
Chest wall movement
Scars
Evidence of other disease
Around the bed Sputum Pots

Peak flow meter
Inhalers, Oxygen tubing
HANDS and ARMS

Hands Clubbing
Tar Staining
Salbutamol and CO2 retention flap
Pulse Radial rate and rhythm
Respiration respiratory rate
Pattern of breathing
ASK FOR BP
FACE
Eye Horners Syndrome
Lupus Pernio Sarcoid
Lupus vulgaris TB
Jaundice heart valves
Mouth Central Cyanosis
NECK
JVP Height
Cricosternal distance
Lymph Nodes Palpate Supraclavicular and Axillary
Trachea Central?
The next section should be performed Both Anteriorly and Posteriorly

CHEST WALL
Inspect Chest Wall deformity
Scars
Use of Accessory muscles
Asymmetry of chest wall expansion
PALPATION
Apex beat Apex beat position Cor pulmonale
Chest Expansion Depth and relative movement
PERCUSSION
ANTERIOR and POSTERIOR: 4 regions
AUSCULTATION
ANTERIOR and POSTERIOR: 4 regions

Listen Vesicular?
Added Sounds: Wheeze, Crackles, Rubs
Vocal Resonance 99
Whispering Pectoriloquy
COMPLETING THE EXAM
Ankle Oedema
Peak flow
O2 saturation
Sputum examination

Upper Limb Examination 2
Inspect
End of the bed: Is the patient well?
Examine the arms for
Deformity
Wasting
Asymmetry
Rashes
Fasciculations
Swellings / Scars
Motor Examination
Check for pronator drift.
Ask the patient to hold their arms out in front of them and close their eyes.
Possibilities:
The arm on the side of an upper motor (pyramidal lesion) will pronate.
The fingers will continuously move up and down indicating pseudoathetosis
The arm will rise in cerebellar disease
Tone
Ask the patient if they have any pain in the arms or shoulders
As if shaking hands (while holding the elbow) move the patient through movements to assess tone;
o Elbow spasticity (clasp-knife phenomenon)
o Wrist spasticity (supinator catch)
o Wrist cogwheel rigidity
Power
Test each muscle group in turn, comparing the same muscle group in the other limb. Test against gravity
before applying a force.
Shoulder abduction. (Deltoids, Axillary nerve, C5) Hold your arms out like a chicken
Elbow Flexion (Biceps, musculocutaneous nerve, C5/C6)
Elbow Extension (Triceps, radial nerve, C6/C7/C8)
Wrist extension (C7)
Wrist flexion (C7)
Finger extension (extensor digitorum, posterior interosseous nerve, C7/C8)
Finger flexion (flexor digitorum superficialis & profundus, median & ulnar, C8)
Finger abduction (Dorsal interossei, ulnar nerve, T1)
Finger adduction (2nd palmar interosseous, ulnar nerve, T1)
Thumb abduction (Abductor pollicis brevis, median nerve, T1)
Froments Sign
Ask the patient to hold a piece of paper between the thumb and a flat palm. The object is then pulled away
A normal individual will be able to maintain a hold on the object without difficulty
However, with ulnar nerve palsy, the patient will experience difficulty maintaining a hold and will
compensate by flexing the flexor pollicis longus of the thumb (median nerve)
Record as MRC (Medical Research Council) grade 0-5
5 Normal power for age & sex

4 Movement against resistance but incomplete
3 Movement against gravity
2 Movement with gravity eliminated
1 Flicker of movement
0 No movement
Reflexes
Get the patient to bend their elbows 90 and put their hands on their belt area, palms down.
Biceps (C5/C6)
Place the thumb or index finger of your left hand on the biceps tendon
Supinator (C5/C6)
Triceps (C7)
Finger reflex (C8)

If there is a suspicion of hyperreflexia in the fingers then test for Hoffmans reflex by flicking the middle
fingernail downwards. A positive Hoffmans sign will result in the thumb flexing and adducting.
Reflexes graded as:
0 = absent
= present only with reinforcement
1+ = present but depressed
2+ = normal
3+ = increased
4+ = clonus
Co-ordination
Check for dysdiadochokinesis and finger-to-nose test

Sensory Examination 2
Ask the patient if they have any areas of altered sensation such as numbness, pins and needles or pain.
Light touch
Use a piece of cotton wool. Place it on the patients sternum so that they know what it feels like and then ask
them to close their eyes and say yes when they feel it on their skin.
Pain
Same but with a neurotip
Temperature
Use the back of the tuning fork to test for cold
Vibration
Use a 128Hz tuning fork. Make the tuning fork vibrate and place it on their sternum so they know what it feels like
and then stop it so that they know what they feels like.
Close their eyes and place the tuning fork
Joint position sense
Demonstrate first
Lower Limb Examination 2
Inspect
End of the bed: Is the patient well?
Examine the legs for
Deformity
Wasting
Asymmetry
Rashes
Fasciculations
Swellings / Scars
Motor Examination
Tone
Roll the knee, Lift the knee & watch the heel, Hold the knee and heel and flex the knee.
Check for ankle clonus
Power
Hip flexion (Iliospoas, lumbar sacral plexus, L1/L2)

Hip extension (Gluteus maximus, inferior gluteal nerve, L5/S1)
Knee extension (Quadriceps femoris, femoral nerve, L3/L4)
Knee flexion (Hamstrings, sciatic nerve, L5/S1)
Foot dorsiflexion (tibialis anterior, deep peroneal nerve, L4/L5)
Foot plantarflexion (gastrocnemius, posterior tibial nerve, S1)
Big toe extension (extensor hallicus longus, deep peroneal nerve, L5)
Extension of all toes (extensor digitorum brevis, deep peroneal nerve, L5/S1)
Reflexes
Knee reflex (L3,L4. Femoral nerve)
Ankle reflex (S1-S2. Tibial nerve) Can place hand on ball of foot with the ankes at 90 and striking the hand.
Plantar response
Co-ordination
Heel-shin test: Lift up your leg and place the point of your heel on your knee and then run it down the sharp part
of your shin.
Sensory Examination
Ask the patient if they have any areas of altered sensation such as numbness, pins and needles or pain.
Joint position sense
Demonstrate first
Vibration
Use a 128Hz tuning fork. Make the tuning fork vibrate and place it on their sternum so they know what it feels like
and then stop it so that they know what they feels like.
Close their eyes and place the tuning fork
Light touch
Use a piece of cotton wool. Place it on the patients sternum so that they know what it feels like and then ask
them to close their eyes and say yes when they feel it on their skin.
Pain
Same but with a neurotip
Temperature
Use the back of the tuning fork to test for cold

EAR
WIPER
Inspect
EXAMINE BETTER HEARING EAR FIRST
Examine Pinna Size, Shape and Deformity

Preauricular sinuses
Endaural scar
Look behind ears Postauricular scar
Hearing Aids
Pull on pinna and ask if it is sore External auditory meatus infection, Temporomandibular joint problems
Examine size of Meatus Wide = possible previous mastoid surgery
Auroscopy
Examine external auditory canal

Examine right ear with right hand Place hand on patients face to avoid trauma to canal
Pull pinna back and upwards to straighten canal

Inspect Canal Wax
Foreign bodies
Furunculosis (boils)
Active inflammation = Otitis externa
Posterior wall defect Mastoid operation (for cholesteatoma)
Examine tympanic membrane

Elicit Light reflex with Auroscope
Travel clockwise around the membrane toward the Attic
Examine Pars Flaccida examine for debris
Cholestoma
Examine Pars Tensa Perforation
EXAMINE OPPOSITE EAR
Finish Up
Free field hearing tests

Examine Function of Facial Nerve
Peripheral Vascular (Limb) Examination
Introduction & General Features

1. Wash your hands, introduce yourself, and ask permission (consent) to examine. Always ask if the patient has
any pain.
2. Obtain adequate exposure of the limb (ideally, trousers should be removed so the full lower limb can be
visualised from groin downwards).
3. Step back and observe (eg. walking aids, amputated limbs, gangrenous extremities, ulcers, other trophic
changes).
4. Hands: check the pulse (for Atrial Fibrillation (AF) - this can be a source of emboli, leading to ischaemia)
5. Neck: carotid pulses (character) & auscultate for bruits
6. +/- Heart (confirm the presence of AF if required)
Steps 5 & 6 do not always need to be performed. If you are, for example, asked to perform an examination of the
vascular system of the patient's lower limbs, then checking the radial pulse will probably be adequate. If you find
gangrenous toes, at the end of the examination you can mention to the examiner that you would like to examine
the patient further for atrial fibrillation.
Inspection
Look carefully:
- Gently lift legs up & look at the underside (this can be easily missed)
- Look between the toes: scars / ulcers. Note that arterial ulcers have a 'sloughy' base and are punched out)
- Trophic (skin) changes: hair loss - 'glaborous', shiny appearance, venous guttering (when you raise the limbs and
gravity empties the veins, their paths will appear to 'indent')
- Colour: dusky red or black (ischaemic), brownish eczematous/dry/thickened skin (venous disease - note that
'lipodermatosclerosis' needs to be palpated for by feeling for the hard thickened skin)
- Muscle bulk (check for symmetry)
- Other features: drains, wounds, amputated digits/limbs, etc.
Palpation
Feel for:
- Temperature (may be cool if compromised vascular supply)
- Capillary refill: pinch the area of the nail-bed for 5 seconds and then release. Normal filling is <2 seconds.
- Pulses: start at the abdominal aorta, then femoral (mid-inguinal point - midway from anterior superior iliac spine
to pubic symphysis), popliteal, posterior tibial (midway between medial malleolus and calcaneum) & dorsalis pedis
(cleft between the first and second metatarsals)
- Squeeze the calf: there will be tenderness in critical limb ischaemia
- Sensation: screen for generalised loss of sensation
Auscultation
Listen for:
- Bruits (renal / femoral / carotid bruits)
Extras
To complete your examination:
Whilst you may not actually perform these remaining tests, make sure you know a bit about them, and in
particular how they are performed, indications and complications. Mention to the examiner (at the end) that you
would like to perform these to complete your examination of the peripheral vascular system.
- Buerger's test: Raise the limb as far as possible into the air (flex at the hip joint). Once the limb appears pale, get
the patient to sit with the leg hanging off the side of the bed. Look for the ?sunset rubor? (dusky red colour) that
the leg will take on as it refills. Record how long this takes. The dusky colour is due to reactive hyperaemia. Note
that this can be painful for patients, so be gentle.
- Ankle-Brachial Pressure Index (ABPI): This is a ratio (normal=1.0) of the systolic BP at the ankle/the 'norma;'
systolic BP at the arm. The brachial BP is measured as usual. To measure the ankle BP, place the cuff over the
ankle as low as possible, whilst listening to the foot pulses using a Doppler probe. Note that you can obtain falsely
high results in patients with diabetes due to the presence of vascular wall calcification. Generally, scores of >1.0
are normal, scores of 0.5-0.7 are compatible with intermittent claudication, and scores <0.4 are suggestive of
critical limb ischaemia. A gangrenous limb will most likely have a score of 0.2 or below. In normal individuals,
scores should not fall with exercise.
- Corridor walking test: Thus can be a useful and simple method of quantifying exactly what the patient can do (ie.
the patient's functional ability).
- Doppler / duplex assessment: Doppler produces an audible waveform and duplex complements this with multi-
coloured displays of the vascular flow, allowing a graphic representation of the flow patterns to be observed.
These popular non-invasive techniques allow pressures to be recorded at different sites along the route of the
vessels. Normal arterial waveforms are 'triphasic'. This becomes biphasic in the presence of arterial stenosis.
- Angiography (digital subtraction or CT): There are a number of complications associated with angiography. Spiral
CT can provide detailed images of the entire vessel length.
Finish Thank/redress
Assessing Hydration Status OSCE
Wash your hands
Introduce yourslef
Permission
Expose the patient
Reposition the patient (45)
Look:
General body habitus, i.e. decreased sweating and skin blood flow in dehydration, shortness of breath in
overhydration
Mucous membranes eyes and mouth (dry/wet)
JVP (if overhydrated will be raised, if dehydrated, veins will not fill even when below 45)
Urine colour
Dizziness/fainting on standing (orthostatic pressure is poorly tolerated in dehydration)
Oedema (especially hands, feet and ankles in overhydration)
Ascites (in fluid overload)
Orthopnoea (in overhydration)
Feel:
Skin turgor (lax and inelastic in dehydration)
Pulse (rate increases to maintain CO due to decreased plasma volume and therefore decreased stroke
volume, strong and rapid in overhydration)
Temperature (increases in dehydration)
Listen:
Lung bases (crackles if overhydrated)
Measure:
(many measurements require a baseline level and need comparison to be helpful)
BP (decreased in dehydration, increased in overhydration)
Capillary refill (slow in dehydration)
Urine output
Plasma osmolality
Sodium concentration (increases in dehydration)
Urine osmolality
Urine specific gravity
Skinfold thickness
Body weight
Hb and haematocrit concentrations
Ask about:
Headache
Constipation
Thirst
Tiredness
Facts about hydration:

~60% of body weight is water
Water deprivation leads to death within a few days
Water can be lost from skin, urine, faeces, and lungs
Causes
Causes of dehydration Causes of overhydration

External or stress-related causes Blood transfusion reaction
Prolonged physical activity without consuming adequate water,
especially in a hot and/or humid environment
Prolonged exposure to dry air, e.g. in high-flying airplanes (5-12%
relative humidity)
Survival situations, especially desert conditions
Blood loss or hypotension due to physical trauma
Diarrhoea
Hyperthermia
Shock (hypovolemic)
Vomiting
Burns
Lacrimation
Use of Methamphetamine, Amphetamine and other stimulants.
Drinking of Alcohol. (In place of water)
Chronic liver disease
Congestive heart failure
Cushing's syndrome
Glomerulonephritis
o Acute
o Focal or embolic
o Membranoproliferati
o Postinfectious
o Post-streptococcal
Heart problems
Infectious diseases
Cholera
Gastroenteritis
Shigellosis
Yellow fever
Hyperaldosteronism
Kidney failure
Liver failure
Malnutrition
Electrolyte disturbance
o Hypernatraemia (also caused by dehydration)
o Hyponatraemia, especially from restricted salt diets
Fasting
Recent rapid weight loss may reflect progressive depletion of fluid

volume (the loss of 1 L of fluid results in a weight loss of 1 kg or 2.2 lb).[1]
Patient refusal of nutrition and hydration

Lung problems
Other causes of obligate water loss
Severe hyperglycaemia, especially in Diabetes mellitus (Glycosuria)

Nephritis (kidney inflammation)
o Familial interstitial
o Hereditary
o Lupus
o Secondary
Nephropathy
Nephrotic syndrome
Preeclampsia

Pregnancy or Surgery / operation complications
Fluid balance
WIPER PS
Examine in sequence do the following
1. Inspect the patient from the end of the bed Is patient well or unwell?
2. Note anything around the bed Note any drip lines/vomit bowls/
3. Has the patient got a catheter?
4. Look at and feel the hands
5. Cap Refill
6. Hands warm and well perfused? Whats this patients temperature
7. Pulse Heart rate Character of pulse
8. Ask for Blood pressure mention that would like to do standing and lying comparison
9. Look at face distressed/pain?
10. Examine mucous membranes Are they dry?
11. Assess JVP
12. Check skin turgor
13. Listen to heart for flow murmurs
14. Listen to lung bases
15. Examine abdomen Swelling
16. Hepatomegaly
17. Look at catheter bag/urine specimen what colour is the urine?
18. Peripheral oedema Sacral and Lower Limb
Ask patient about
1. Headache
2. Constipation
3. Thirst
4. Tiredness
Complete Examination by doing following

1. Examine any system requiring specific attention e.g. CVS or Abdo
2. Review observation charts/complete assessment
3. Examine/investigate urine
i. Specific gravity
ii. Osmolality
4. Look at fluid balance charts
5. Weight patient Especially if on dialysis or in fluid overload
6. Review notes and biochemistry
i. Electrolyte balance
ii. Renal function
FLUID BALANCE
THIS EXAMINATION CONCERNS 2 SITUATIONS
Hypovolaemia Fluid Depletion
Hypervolaemia Hypoproteinaemia, Fluid overload
WIPER
Wash hands, Introduce, Permission and Pain
Expose Waist up
Reposition 45o
1. Inspection
Inspect the patient from the end of the bed Are they well or unwell?
Look around the bed Cannulae/Central Lines/I.V. Fluids Check which fluids are running
Kidney dishes vomiting
Catheter?
NG tube/PEG
Drains
Evidence of burns or other wounds (e.g. surgical)
Nil by mouth signs
2. Hands
Capillary refill+ Peripheral Cyanosis Peripheral shut down
Radial Pulse rate Taccycardic, (failure and hypovol) Thready Pulse in sev. Hypovol.
Quickly observe if tachypnoeic In extremis: Hypovolaemia, Heart failure, Cor Pulmonale
DO LYING AND STANDING Blood Pressure
3. Face
Mucous Membranes Dry tongue and lips (NB relatively inconstant sign)
Tongue offer to do Temperature
Sunken features
4. Neck
JVP Raised in overload/May be in hypovolaemia
5. Chest
Skin turgor Assess skin turgor on anterior chest wall or neck
Gently pinch a piece of skin for a few seconds and release
Examine heart
Listen to Lungs Cardiac asthma Wheeze (failure), bibasal insp. crackles
6. Abdomen
Any intra-abdominal surgery has risk of bowel ileus 24-48hours pt. has up to 8L/day 3rd space loss
Inspect abdomen for swelling 3rd space losses may be a cause of intravascular hypovolaemia
Inspect stoma +++ risk of fluid loss if high output (e.g. Ileostomy)
Inspect catheter Functioning properly, draining, check with fluid charts
Listen for bowel sounds absent in Ileus
Concentration of urine
7. Legs
Check for peripheral oedema Sacral and Limb
Check peripheral pulses, Dorsalis pedis and Posterior tibial Periph shutdown
8. Special Tests
Review fluid charts for patient
Complete vital signs assessment
Weight Patient
Review Renal function and haematocrit
Write up fluids/Diuretics
Also
HR Mucous membranes
Bp
Urine
Turgor JVP
NUTRITONAL ASSESSMENT
ANTHROPOMETRIC PARAMETERS AND GROWTH
Weight, stature (length or height) and head circumference
Growth charts
Stature and weight proportionality: weight for stature, Body Mass Index
Other parameters: skinfold and arm circumference measurements
Estimations of stature: arm span, knee height, crown-rump sitting height
Expected weight and stature: height-age, weight-age, expected weight, midparental height
Specialty growth charts
References
DIETARY INTAKE
Methods of data collection
Questions to ask to assess nutrient intake, behaviors, relationships, attitudes, feeding skills, development
Standards to evaluate adequacy of intake
References
MEDICAL ISSUES
Common drug/nutrient interactions
References
DEVELOPMENT
Assessment of feeding skills
References
BEHAVIOR
Why should I assess behaviors related to feeding?
Evaluating behavior-related problems
Evaluating parent and child interactions
Evaluating environmental factors
Evaluating physiologic problems
What does a nutritional assessment include? Assessment of a childs nutritional status includes evaluation of
several sets of indicators:
Anthropometric indicators (e.g., weight, stature, and skinfold measurements) provide information about a child's
physical growth. Measurements can be compared to growth charts to help determine nutritional risk, and over
time, they provide information about a childs long term nutritional status.
Dietary information in a nutritional assessment can be affected by a variety of factors, including physical,
environmental and social influences. Nutrient intake, developmental appropriateness of foods offered, and social
and environmental influences are evaluated in this portion of the assessment. Behaviors around food and eating
should be examined as well.
Biochemical indicators (laboratory values) can provide information about a childs macro- and micronutrient
stores; e.g., a low serum albumin might reveal a risk for protein deficiency. Hemoglobin and hematocrit values can
provide information about iron status. Cut-off levels vary for specific institutions. The use of norms for adults is
not necessarily appropriate in pediatric populations. Medical conditions, including fluid imbalances, and drug-
nutrient interactions must be taken into consideration when interpreting lab values.
Clinical indicators are physical signs of nutritional status; e.g., fatigue, dry or scaly skin, and lackluster hair.
Medical conditions that may alter intake and/or growth should be considered in the assessment. Possible drug-
nutrient interactions should be evaluated.
Heart Murmurs Harvey
WIPER PS
Conduct a CVS exam of Harvey as you would normally focusing on the following areas
Inspect from the end of the bed
Comment on Apex beat
Feel pulse and calculate rate
Measure BP
Feel carotid pulse
Inspect JVP whilst feeling Pulse
Feel apex character Displaced

Heaving
Tapping
Heaves and thrills
Ausculation
Comments on the following features of a murmur

Timing
Shape
Location
Radiation
Intensity
Pitch
quality
Harvey Program
Normal
Innocent Murmur pt well Normotensive murmur over the pulmonary region low intensity
Aortic scelorsis pt HTN Aortic and Mitral systolic crec-dec murm
HARVEY CVS examination Clinical skills GUIDE
Mitral Stenosis Pt hypotensive, Large V wave,
Mitral rtegurg
Getting started with

HARVEY
Harvey is located at the:
Royal Free Clinical Skills Centre, Royal Free Hospital 020 7472 6192
Whittington Clinical Skills Centre, Holborn Union Building, 020 7288 3673
UCH Clinical Skills Centre, Rockefeller Building 020 7679 6900
Academic Centre for Medical Education
GETTING STARTED WITH HARVEY
What is Harvey and who can use it?

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

mitral regurgitation
mitral stenosis
aortic stenosis
aortic regurgitation
Learning objectives
By the end of your first session with Harvey you should be able to:
1. auscultate the chest for the normal heart sounds
2. auscultate the chest for the four murmurs and identify where they are heard loudest
3. identify whether a murmur is systolic or diastolic
4. draw a diagram to represent each murmur
5. identify where the murmurs radiate to
What is a murmur and when is it heard?
TEACHING BOX 1 - SUMMARY OF MURMURS
A heart murmur is caused by turbulent flow that may be produced by a number of mechanisms. It may be due to high
blood flow across a normal valve or normal blood flow through an abnormal valve. The turbulent flow could also be
due to regurgitation of blood through a leaking valve.
Pathological murmurs are divided into three groups; the systolic, diastolic and continuous murmurs.
Heard separately from the first and second heart sound.

Ejection Intensity is greatest in mid-systole
systolic
Systolic Pansystolic Extends from the first to second heart sound with equal
murmurs intensity throughout systole
Late systolic Distinct from first sound but extends up to second sound
Occur at the same time
as the carotid pulsation
Usually arise from mitral or tricuspid valves
Diastolic murmurs Mid-diastolic
Early diastolic Results from aortic regurgitation, but may also occur from
Always associated with
pulmonary hypertension secondary to mitral stenosis giving
cardiac disease
rise to pulmonary regurgitation (Graham Steell murmur)
May occur due to a combination of systolic and diastolic murmurs via a connection
between the aorta and pulmonary artery (eg patent ductus arteriosus) or arteriovenous
anastamosis.
Continuous
SECTION 1-NORMAL HEART SOUNDS
Case 1
Mr A is a 30 year old man who has chest pain on exertion. The pain started 3 days ago when he was playing
squash and is located on the left side of his chest. The pain is sharp and does not radiate. It is not present at rest
but is worse when he goes to the gym or plays squash. He is otherwise well. His father died last year from a
myocardial infarction. Mr A is a non smoker and drinks less than 5 units of alcohol a week.
Examine Harvey as if he was Mr A.
Tasks
1. Start by selecting setting 46 The normal heart.
2. Measure and record Mr As blood pressure. mmHg
3. Inspect the chest and palpate the apex beat. Where is it located?
..
4. Use the stethoscope to auscultate the chest. The four principal areas of interest are shown in the picture
below.
TEACHING BOX 2 Areas to auscultate
Area M - The apex and Mitral valve region
Area T - The left lower sternal border region

overlying the Tricuspid valve.
A P
Area P - 2nd intercostal space on the left
corresponding to the area of the Pulmonary
valve.
T M Area A - 2nd intercostal space on the right

overlies the Aortic valve.
TEACHING BOX 3 The Heart sounds
S1 S2 S1
S3 S4
AP
In a healthy adult like Mr A there are two heart sounds; the first, S1 and the second, S2.
S1 corresponds to Mitral and Tricuspid valve closure.
S2 corresponds to Aortic and Pulmonary valve closure. This heart sound is split as the pulmonary valve
closes approx. 0.06seconds after the aortic valve. This is best heard in the pulmonary region in
inspiration.
Two other heart sounds, S3 and S4 can occasionally be ausculated.
S3 occurs in rapid Left Ventricular filling, when blood hits the valve apparatus and the ventricle wall. It is
only pathological when heard in those over 30 years.
S4 occurs with Atrial contraction in conditions such as hypertension, Aortic Stenosis or Acute Myocardial
infarction
TEACHING BOX 3 Changes in the heart sounds
Characteristics of first heart sound S1

Loud Soft Variable Wide split
Mitral Stenosis Severe Mitral regurg. Ventricular Tachy. RBBB
Short PR Long PR Nodal Tachy. LBBB
Atrial Fibrillation
Characteristics of the second heart sound S2

Loud Soft Wide split Reverse split Fixed split Single
Hypertension Aortic RBBB LBBB Atrioseptal Tetralogy of
Pulmonary stenosis (A2) Inspiration Aortic stenosis defect Fallot
hypertension Pulmonary Patent ductus VSD
(P2) stenosis (P2) arteriosus
Which heart sounds can be heard?
NB Listen carefully in the pulmonary region for the splitting of the second heart sound.
SECTION 2 - MITRAL REGURGITATION
Case 2
Mr B is a 50 year old man who has had shortness of breath for 2 days. It was sudden in onset and is worse when
lying down (orthopnoea). He has no chest pain. He has been tired for 2 months and has had a low-grade fever. He
has no cough, haemoptysis, leg pain or ankle oedema. He has no relevant past medical history and is a non-
smoker.
Examine Harvey as if he were Mr B.
Tasks
1. Select setting 6 on the control panel mitral regurgitation (acute).
2. Measure and record Mr Bs blood pressure. mmHg
3. Palpate for the apex beat. Where is it located?

..
4. Listen to the chest in all four regions. Where is the murmur loudest?
5. Palpate the carotid pulse whilst listening to the murmur. Is the murmur systolic or diastolic?
6. Where does the murmur radiate to?
..
7. Using diagram below, draw the murmur
S1 S2 S1
For a summary of the symptoms and signs of mitral regurgitation see teaching box 5 on page 11.
SECTION 3 MITRAL STENOSIS
Case 3
Mrs C is a 55 years old woman who has shortness of breath, which has been worsening on exertion for 2 years.
Examine Harvey as if he were Mrs C.
Tasks
1. Select setting 4 on the control panel mitral stenosis
2. Measure and record Mrs Cs blood pressure. mmHg
3. Palpate for the apex beat, where is it located?
..
5. Is the murmur systolic or diastolic?
..
..
7. What could you ask Mrs C to do to make the murmur louder?
..
8. Using the diagram below, draw the murmur
S1 S2 S1
For a summary of the symptoms and signs of mitral stenosis see teaching box 6 on page 11.
SECTION 4 AORTIC STENOSIS
Case 4
Mr D a 46 year old man has had exercise induced syncope and chest pain for 2 months. He also has shortness of
breath (dyspnoea) on exertion.
Examine Harvey as if he was Mr D
Tasks
1. Select setting 13 on the control panel aortic stenosis
2. Measure and record Mr Ds blood pressure. mmHg
3. Palpate for the apex beat, where is it located?
..
..
..
S1 S2 S1
For a summary of the symptoms and signs of aortic stenosis see teaching box 7 on page 12.
SECTION 5 AORTIC REGURGITATION
Case 5
Mr E,a 30 year old man has had shortness of breath and paroxysmal nocturnal dyspnoea for 1 year. He also has
palpitations with chest pain on exertion.
Examine Harvey as if he were Mr E.
Tasks
1. Select setting 17 on the control panel aortic regurgitation.
2. Measure and record Mr Es blood pressure. mmHg
3. Palpate for the apex beat. Where is it located?
..
..
..
6. What could you ask Mr E to do to make the murmur louder?
..
7. What other signs would you examine Mr E for?
..
S1 S2 S1
For a summary of the symptoms and signs of aortic regurgitation see teaching box 8 on page 12.
SECTION 6 REVIEW OF MURMURS
TEACHING BOX 5 MITRAL REGURGITATION
S1 S2 S1
Causes
Rheumatic heart disease (50%)
Prolapsing mitral valve
Infective Endocarditis mitral valve leaflet destruction
Rupture of chordae tendineae following MI, Infective endocarditis or trauma.
Symptoms:
Palpitations due to increased stroke volume
Dyspnoea and orthopnoea due to pulmonary venous hypertension
Fatigue and lethargy because of reduced cardiac output.
On examination
There is a displaced thrusting apex beat.
The first heart sound is soft and may be obscured. S3 may be present.
The murmur of Mitral regurgitation is pansystolic or holosystolic and is heard best at the apex.
The murmur radiates to the axilla.
TEACHING BOX 6 MITRAL STENOSIS
S1 S2 S1
OS
Causes
Almost all cases are due to Rheumatic heart disease
Rare congenital mitral stenosis
Symptoms
Usually no symptoms until the valve is moderately stenosed
Doesnt usually happen until several decades after having Rheumatic fever as a child
Progressively severe dyspnoea, frank haemoptysis may occur
Pulmonary hypertension leads to right heart failure with fatigue and leg oedema
On examination
Mitral facies or malar flush
There is a tapping apex beat which is undisplaced.
There is a loud S1
The murmur is a mid-diastolic rumbling heard best at the apex with an opening snap.
Can be auscultated more efficiently by rolling patient onto left lateral side.
SECTION 6 REVIEW OF MURMURS
TEACHING BOX 7 AORTIC STENOSIS
S1 S2 S1
Soft
Causes
Congenital aortic valve stenosis due to a congenitally abnormal (bicuspid) valve
Rheumatic heart disease results in thickening and calcification of a normal valve
Calcific valvular disease inflammatory process thickening the leaflets
Symptoms:
Late onset of symptoms when opening down to a third of normal size.
Exercise induce syncope, angina and dyspnoea develop
On examination
Slow rising pulse with a narrow pulse pressure.
Heaving apex
There is a soft A2 and reverse splitting of S2, with P2 before A2.
An ejection click may be heard.
It is an ejection systolic murmur heard best in the aortic region and may radiate to the carotids.
TEACHING BOX 8 AORTIC REGURGITATION
S1 S2 S1
Causes
Rheumatic fever and infective endocarditis complicating a previously damaged valve
Numerous other causes incl. Reiters syndrome, RA, Hypertension, Connective tissue disorders
Symptoms
Palpitations, angina pectoris and varying degrees of dyspnoea.
On examination
A collapsing pulse with a wide pulse pressure.
Thrusting apex, S3 may be heard.
It is an early diastolic decrescendo murmur heard best at the left sternal edge in expiration.
Other signs of chronic AR include
Corrigans sign Waterhammer pulse with a wide pulse pressure
De Mussets sign Nodding head
Quinckes sign Nail bed reddening and blanching
Duroziezs sign To and fro flow bruit heard over femorals.
Hills sign Femoral systolic hypertension

Section 7- Additional resources
Further Harvey learning resources can be found at:

http://www.harveyresourcecentre.org.uk/
You can listen to heart sounds and murmurs at:

http://solutions.3m.com/wps/portal/3M/en_US/Littmann/stethoscope/education/heart-lung-sounds/
The UCL guide of how to examine the cardiovascular system is found at:
http://moodle.ucl.ac.uk/file.php/1133/PAL_PACK_2008-2009.doc
The mark sheet for cardiovascular examination in UCL OSCEs can be found at:
http://www.ucl.ac.uk/medicalschool/current-students/assessments/p3y5-
assessments/longstation_osce04/station2_cardioexam_ju06.jpg
Ulcer Exam
WIPER PS
Wash hands Introduce Permission Expose Reposition Pain Stop
Inspection
Size and shape
Number or multiple ulcers
Exact anatomical site specific site ulcers: Rodent/TB/Trophic(neuropathic)/ Venous/Arterial
Margin Healing White outer, blue and red lines

Spreading Red Inflammation and irregularity
Chronic non healing Fibrosis thick white skin
Edge Sloping healing ulcer

Punched edge vertical edge trophic/arterial ulcer
Undermined TB subcutaneous destruction of
Raised Rodent ulcer
Everted Malignant
Floor Granulation Normal/pale/hypertrophic (with serosanginuous discharge)

Slough necrotic soft tissue overlying healing
Discharge
Surrounding area Local inflammation

Pigmentation
Local swelling
Scaring
Hypopigmentation non healing ulcer
Palpation Don Gloves
Temp of surrounding skin

Tenderness around ulcer
Palpate edge Soft/Firm (fibrosis)/Hard
Palpate /Granulation Bleeding? Assess Attachment of slough
Consistency of base Firm/Indurations (malignant)
Attachment to underlying structure Ask patient to contract muscle
Local/Systemic Examination
Palpate Local lymph nodes matted/Tender/Soft tender

Vascular Examination
Test sensation of surrounding skin map anaesthesia
Examine joints close to ulcer Assess muscular/tendinous involvement
Finish up
Relevant Systemic exam CVS Failure = poor healing for ulcers
RS TB
Abdo Splenomegaly (Haemolysis)
Thank Patient
Abdominal Examination
WIPER
Wash hands
Introduce
Permission and Pain
Expose
Reposition
END OF THE BED

Patient Well or unwell? Patient Calm and comfortable?
Weight Loss
Level of hydration
Signs of easy Bruising
Scars
Abdominal distension/Peripheral oedema
Evidence of other disease?
Ask patient to raise feet and head off bed whilst lying down Ask them to cough Hernias
Around the bed Fluid restriction

Sick Bowls
Suppliments etc
HANDS and ARMS

Hands Palmar Erythema
Clubbing
Skin Turgor
Dupuytrens Contracture
Koilonychia
Leuconychia
Liver Flap Hepatic Encephalopathy
Pulses
Radial rate and rhythm Alcohol: AF
FACE
Eye Red Eye ? Iritis/Uveitis
corneal arcus
Parotid Swelling Alcohol Abuse
Kaiser-Flechier Rings Wilsons disease
Xanthelasma
Bruising
Mouth Teeth
Ask about Ulcers
Jaundice Liver
CHEST WALL AND NECK
Inspect JVP quickly assess

Spider Naevi
Gynaecomasia
Body Hair distrubution
ABDOMEN
Inspect the Abdomen Closer Shape/Symmetry
Distension
Scars
Prominent veins
Hernia
Visible Peristalsis
Position
PALPATION
AUSCULTATION
COMPLETING THE EXAM

MINI MENTAL STATE EXAM
Wash hands
Introduce
Explain procedure
Permission
Sitting comfortably
Orientation
5 points for Time Year
Season
Month
Day of week
Exact Date
5 points for Location Country

County
City
Hospital
Floor
Short Term Memory Retention and Recall

6 Points for Recall Pen
Wallet
Flower
Attention
5 Point for Calculation subtract 7 from 100 for times (93, 86, 79, 72, 65)
Or spell WORLD backwards
Language
2 Points for Naming Paper
Pen
3 Points for Commands 3 step command
1 point Drawing Copy 2 intersecting Pentagons [constructional apraxia]

1 point Writing Write a sentence
1 point Reading Obey a written command e.g. close your eyes
1 point Repetition no ifs and no buts [conductive Dysphasia]
Calculate Score
24 30: "normal" range

20 23: mild cognitive impairment or possible early-stage/mild Alzheimer's disease
10 19: middle-stage/moderate Alzheimer's disease
0 9: late-stage/severe Alzheimer's disease
Finish Off
Thank patient
'Lumps and Bumps' Examination
Introduction
It is important to be able to accurately describe lumps and bumps as this can be a popular OSCE station. There are
always a surprising amount of things you can say about every mass. Your description should be good enough for a
doctor to come up with a differential diagnosis without seeing the patient. It should also be recorded in the notes as a
record of how the lump was on that particular day. Here are the main headings:
Always start by: washing your hands, introducing yourself and obtaining consent.
Inspection
Look for:
- Site (describe in relation to fixed anatomical landmarks)

- Size (make a visual estimate of the size - you will confirm this upon palpation)
- Shape (often compared to real-life objects, eg. fruit, golf balls, etc.)
- Colour
Palpation Feel for:
- Tenderness (always ask if patient is in any pain first!)

- Temperature
- Size (use cm or fruit!)
- Shape (3 dimensions)
- Surface + edge
- Composition (consistency, translucency, pulsatile, compressible)
- Reducible (eg. hernias - don't forget cough impulse for these)
- Relationship to other structures (eg. origin and attachment)
Percussion For:
- Fluid thrill
- Extent of mass (eg. thyroid lumps - percuss from the neck down the sternum to see if goitre mass extends
'retrosternally')
Auscultation Listen for:
- Bruits (especially if you suspect a vascular structure)
Extras Don't forget:
- Transillumination (especially for cystic lumps) - ideally look down through a small tube, such as a 'Smarties' tube,
pressed down onto the midpoint of the lump, whilst illuminating the mass from the side using your pen-torch - in reality
you probably won't be able to do this, so mention that 'ideally I would use a tube', but for the purposes of the
examination you can then just illuminate with your pen-torch
- Regional lymph nodes - always palpate for these
- Say you would like to examine the local tissues for any pathology ? skin, muscle, bone, vessels, nerves
- Say that you would ideally also perform a general examination ? always examine the whole patient to look for more of
the same!
- Common examination lumps: lipomas, thyroid masses, aneurisms, hernias.

Sensory Exam
WIPER PS Examiner will specify area to assess
Inspection
D.W.A.R.F.S
Have you noticed any alteration in your sense of touch?
Have you had any pins and needles ?
Anatomy
Sensation Nerve Type Pathway Decussation
Proprioception/vibration Large Fast fibers Dorsal Columns Medulla
Pain and Temperature Small Slow fibers Spinothalamic Spinal Level
Rules
Ask patients to avert Gaze RATHER than close eyes
Move from Hyposensitive to Hypersensitive e.g. Hypo Normal Hyper
Light Touch - - Use Cotton Wool

Demonstrate normal on sternum
Assess Dermotomes (Dabbing action), Compare both sides
Superficial Pain - - Use Neurotip

Assess Dermatomes (Dabbing action), Compare both sides
Deep Pain - - use hands NOT instrument

Ask pt to report Discomfort
Squeeze muscle bellies
Apply pressure to nail beds
Temperature - - use Tuning Fork

Touch patient with cold metallic object
Vibration - - Use 128 Hz

Test Bony Landmarks Hallux, Ankle, Tibial Tuberosity work superiorly
Ask patient to say when vibration Stops
Joint Position Sense

Ask patient to close eyes
Hold distal phallanx of toe on sides
Test up and down 5 times NB normal in elderly is up to 3/5
Point Localization And Two Point Discrimination - - Ideally for testing hands [finger pulps]
Ask Patient to close eyes
Test minimum distance that Two point discriminator can be reliably felt
Confirm naming convention of fingers ( e.g. first, middle) Assess finger Agnosia
Ask patient to close eyes and assess localization of fingers
Sereognosis, Graphaesthesia and Neglect - - test with Eyes closed

Bicortical stimulation of sensory stimulus Close eyes and Touch backs of hands separate and then together
Give pt a common object, ask to name
Trace letters on pts palm, ask to name
Finish up Thank pt and Wash hands

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

Complications
Operative complications:
- vascular damage
- nerve damage (ilio-inguinal)
- spermatic cord damage
- bowel damage
- bruising
- recurrence
Complications of hernias:
- incarceration (become non-reducable)
- strangulation (become ischaemic, as vascular supply gets cut off)
- Richters hernia = strangulated but not obstructed (lumen partially obstructed)
- bowel obstruction
Other Types of Hernia

Umbilical:
- These are common, and are often congenital.
- Small ones usually spontaneously close by 2yrs. Larger ones/non-closing ones are usually operated on when the
child is around 3-4yrs old.
- Can occur later in life (umbilicus is a 'weak spot') - often appear later in the elderly and women who have given
birth.
Incisional:
- These are also very common post-operatively.
- A number of factors can predispose to an increased risk of incisional hernia. Learn these factors for good 'wound
healing'. They are divided into pre-operative (nutritional status, age, obesity, etc.), operative (good surgical suture
technique, good haemostasis, etc.) and post-operative (infections, controlling cough, etc.).
- These often frequently recur with repair.
Spigelian:
- Found along edge of rectus abdominus.
Obturator:
- Rare. Relatively more common in women.
- Hernia sac protrudes through obturator foramen. More likely to be symptomatic rather than cause a visible mass.
Epigastric:
- Occurs between the umbilicus and the xiphisternum (in the midline).
- Often composed of fat/omentum - rarely contain bowel. Can often be painless and easily reduced.
Cerebellar Function Examination
Signs of Cerebellar Pathology
Signs of a cerebellar lesion include:
Dysdiadochokinesia
Ataxia (lower limbs ? impaired heel-shin)
Nystagmus (ipsilateral)
Intention tremor (on finger-nose test)
Staccato speech (slurred)
Heel-toe walking impaired
Introduction
Wash your hands, introduce yourself and ask permission (consent) to examine. Always ask if the patient
has any pain.
Gait Observe the patient walking and look for:
- an ataxic gait (ask the patient to walk to other side of room and back - gait is broad based & incoordinated)
- heal-toe walking impaired (patient cannot walk in a line - ie. putting one foot in front of the other, then
repeating)
- Romberg's test: Get patient to stand with legs close together and arms by side, then ask patient to close their
eyes. A positive test is when they are more unstable upon closing their eyes, and is a sign of peripheral
proprioceptive failure - NOT cerebellar pathology, which is a common misconception. With cerebellar pathology,
there is 'Rombergism' (ie. patient is unstable with and without eyes closed).
- Always stand next to the patient and remain by their side to support them if they become unsteady.
Face Look for:
- eye movements (nystagmus will be seen upon making patient slowly alternate gaze from side to side)
- speech (slurred / staccato) - get the patient to say "university" or "British constitution" and then ask them to
speak - for example, by describing your clothes etc.
Arms Look for:
- mildly decreased tone

- past pointing / intention tremor (finger-nose test - "touch my finger then your nose, then repeat as fast as you
can". Make sure you keep your finger at an arm's length away, and move the position of your hand from time to
time.)
- dysmetria (arms out with flat palms + eyes closed, then push down on an arm suddenly. If it suddenly springs
upwards then this test is +ve)
- dysdiadochokinesia (make big movements starting at shoulder - not small movements with hand only as you are
testing the big proximal muscle groups that the cerebellum controls.)
To complete: Thank the patient, redress.

Myasthenia Gravis Examination
Introduction
Wash your hands, introduce yourself, and ask permission (consent) to examine. Ask if the patient has any pain
before you begin.
Inspection
Look for:
- Ptosis (drooping eyelids)

- Thymectomy scars (thymus malignancies are associated with myasthenia gravis)
- ?Snarling? facies
Eyes
Look for:
- Movements (may have opthalmoplegia) & diplopia

- Fatiguability ? test sustained upgaze
- Fatiguability - test repeated blinking
Speech
Listen for:
- Nasal sounding speech(bulbar-like palsy)

- Get the patient to count upwards - may slow down/change character of speech as they fatigue
Arms
Test:
- Make ?chicken wings? type movements (to demonstrate fatiguability)
- Always exercise your judgement in terms of 'over-straining' the patient. If they are starting to get tired then bear
this in mind and modify your examination accordingly. Always thank them when you finish.
To complete: Thank the patient, redress.

Multiple Sclerosis Exam
Introduction
Wash your hands, introduce yourself, and ask for permission (consent) to examine. Ask if the patient has any pain
before you begin.
Gait
Look for:
- Spastic gait (a sign of upper motor neurone pathology)

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

Parkinson's Disease Examination
Introduction
Wash your hands, introduce yourself, and ask permission (consent) to examine. Ask if the patient has any pain
before you begin.
Gait and Stance

Key points:
- Festinating gait (slow and shuffling movements when walking)
- Decreased arm swing
- Difficulty turning and initiating movements (patients may use a walking stick to 'poke' their feet to get them to
move). Lines or markings on the floor can sometimes help.
- Stooping posture
- Postural instability
Inspection
Look for:
- Hypomimia (decreased facial expression)
- Blepharoclonus (fine eyelid tremor)
- Resting tremor (brought out by distraction - such as conversation)
- Tardive dyskinesia (chewing movements of the mouth - drug treatment side effect)
Face
Look for:
- glabellar tap (keep blinking - normally adjust)
- normal eye movements but abnormal vertical gaze + VOR
(in supranuclear palsy) - speech ? monotonous voice
Trunk
Test: Axial rigidity (found in the 'supranuclear palsy' form of Parkinson's disease)
Arms
Look and test: - Tremor ('pill rolling', more pronounced at rest - as opposed to cerebellar tremors that are more
pronounced upon initiation of movement)
- Normal muscle bulk / reflexes / power
- Increased tone - leadpipe rigidity (move whole arm around elbow joint) & cog-wheel rigidity (support forearm
and flex/extend the flat palm at the wrist - cogwheeling is the jerky 'stepwise' movement that is felt due to tremor
superimposed upon rigidity) ? these features are enhanced by asking the patient to move the other arm up and
down as a 'distractor' or 'reinforcer'
- Bradykinesia (slowness of movement - observed when patient is asked to flap arms up and down)
- Finger-nose pointing (tremor decreases)
Extras
For a few bonus points, you can test/mention the following:
- Micrographia (small writing)
- Examine the observations chart for a postural BP drop (in the 'multisystem atrophy' form of Parkinson's)
- Examine the drug chart (is this perhaps a drug-induced 'Parkinsonism' - caused by anti-dopaminergic drugs such
as metoclopromide)
- Examine the cerebellar system's function (also affected in 'multisystem atrophy')
To complete: Thank the patient.
Speech Assessment
WIPER PS
Inspection Signs of Stoke, CN lesions
Orientation Basic Assessment
a. Time
b. Place
c. What Handedness are you?
Cranial nerves IX and X Wasting/Fasiculations

Gag Reflex
Uveal Movement
Comprehension 3 step Command [Wernickes]
Expressive Dysphasia Tell me your name and address

[Brocas] What is this? Pen and Watch
Fluency in naming types of fruit/what you had for breakfast
Repetition British Constitution/Baby Hippopotamus/West register
street
Say no ifs ands or buts [Conductive Dysphasia]
Dysarthria Say K or G Palatal

Say M Facial
Say L Tongue movement
Dysphonia Assess volume of speech
Reading and Writing
Swallowing Take a sip of water and hold in mouth

Perform again
Comment on Wet face or Coughing or Choking
Finish up
Thank Patient
Wash hands
Offer to perform full neurovascular examination of upper and low`er limbs
Offer to perform Cranial Nerve exam
GALS
WIPER
3 Questions
P Do you have any pain?
D Do you have any difficulty dressing
S Do you have trouble with stairs
Inspection Ask patient to stand in Anatomical position

Front Deltoid Wasting
Full elbow extension
Quads bulk Knee or hip pathology
Genu Valgum/Varum
Forefoot abnormalities
Any other obvious abnormalities DWARFS
Side Shoulder Bulk and symmetry
Cervical lordosis
Thoracic kyphosis
Lumbar lordosis
Knee flexion/hyperextension
Back Shoulder Muscle bulk and symmetry
Spinal Alignment Scoliosis
Gluteal muscle bulk and symmetry
Popliteal swelling or abnormalities
Calf muscle bulk and symmetry
Hind foot abnormalities Psoriasis
Gait
Pt: Take a few steps, turn and walk back Assess
Arms
Ask to copy movements and observe patient doing
Hands behind head
Hands out in front palms down, fingers outstretched assess back of hand
Turn hands over Assess movements and assess palm
Make a fist assess range of movements
Squeeze fingers Power grip strength
Finger to thumb in turn fine precision
Squeeze across the metacarpophalangeal joints observe any pain
Spine
Inspect spine once again
Press on Supraspinatus to test for Fibromyalgia
Ask pt: Tilt head to shoulder assess lateral flexion
Ask pt: Touch toes then extend on return check for diversion of lumbar vertebrae
Ask pt: Look up and down and open mouth Check Flexion and extension of neck. Checks
Temporomandibular join
Legs
Flexion of knees
Internal and external rotation of hip Ask Pt to move feet from side to side
Patellar Tap
Inspect sole of feet for deformity, swelling and callosities
Squeeze metatarsphalangeal joints
Upper Limb Examination
Inspection:
- Muscle wasting
- Fasciculations
- Deformities
- Skin changes
- Ask if the patient has any pain!
Tone:
Move 2 joints at a time. For the patient's right arm, hold the patients right hand with your right hand (as if shaking
hands) and then gently rotate clockwise and anticlockwise. At the same time, support their upper arm with your
left hand and gently flex and extend their arm at the elbow joint.
Tone can be:
- Increased - Upper Motor Neurone (UMN) lesion

- Normal
- Decreased - Lower Motor Neurone (LMN) lesion
- Cog-wheeling/Lead-pipe rigidity - Parkinsonian signs. If the wrist joint feels rigid in a 'step-wise' fashion during
flexion and extension, then this is cog-wheel rigidity (tremor superimposed upon rigidity). Lead-piping is a similar
rigidity in the entire arm (movement about the elbow joint).
Power:
Always compare the two sides, and try and compare with similar forces (so you try and oppose with similar
movements). It may often be best to make the movements yourself to demonstrate first.
- Shoulder abduction (C5, deltoid) - Make "chicken-wings" shape and patient pushes up whilst you push down
around the upper humerus. Can do both sides at once.
Command = 'push up against me as hard as you can'.
- Forearm flexion (C5/6, biceps) - Patient makes a fist and flexes arm at elbow joint, one arm at a time. Whilst
supporting yourself on patients opposite shoulder, you pull their arm away whilst they try and flex.
Command = 'pull me towards you'.
- Forearm extension (C7/8, triceps) - As above, but you push against patient's arm whilst they push you away.
Command = 'push me away'.
- Wrist extension (C7, wrist extensors, radial nerve) - Patient makes a fist and holds one arm out. Support the
forearm with one of your hands and with the other, get the patient to raise their fist up whilst you push down with
your fist.
Command = 'hold your arm out straight, make a fist facing downwards and push up against me at your wrist'.
- Finger abduction (T1, palmar interosseus, ulnar nerve) - Patient holds arm out with fingers spread. With a finger
of each hand of your hands, try and push the patients index and little fingers inwards (so you are opposing their
fingers with your fingers).
Command = 'spread your fingers and stop me pushing them closed'.
- Thumb abduction (T1, median nerve) - abduction of the thumb is it's movement straight up (as opposed to up
and laterally, which is extension). Tell patient to raise thumb up and you oppose with your thumb.
Command = 'raise your thumb up straight and stop me pushing your thumb down'.
Remember that the radial nerve supplies the extensors of the wrist, whilst the ulnar nerve supplies all of the
intrinsic muscles of the hand, except for 'LOAF', which are supplied by the median nerve:
L ateral two lumbricals (fingers 2 and 3)

Oppons pollicus
Abductor pollicus brevis
Flexor pollicus brevis
Coordination:
- Finger-nose (intention tremor / past pointing).

Command = 'With your right hand, touch your nose, then my finger, then your nose. Then repeat as fast as you
can'. Remember to move the position of your finger and to keep it at exactly arms length from the patient.
- Rapid alternating movements (hands) - 'dysdiadochokinesis'. This requires big movements that originates at the
shoulder joint as the role of the cerebellum is generally in the control of large proximal motor groups and not
small fine groups.
Command = 'Hold your left palm out still and flat. Now clap onto it with your right palm. Then raise your right arm
up fully and then then clap onto your left palm with the back of your right hand. Then repeat as fast as you can'.
Reflexes:
Ensure limb is full relaxed. It is often best to move and 'flop' the arm around a bit to ensure this. Practice reflexes
with the patient lying down. Those on the opposite side of the patient's body require some practice as you cannot
move over to the other side of the bed!
- Biceps (C5/6) - rest patient's arms on their abdomen.
- Supinator (C5/6) - rest patient's arms on their legs
- Triceps (C7/8) - examiner lifts the appropriate (flexed) arm by the wrist and supports it against the area of the
opposite clavicle to ensure full relaxation.
Remember to use techniques of reinforcement if required, eg. 'when I count to 3, clench your teeth'. Coincide
your tendon hammer strike with the patient's teeth clenching.
Sensation:
Dorsal columns:
- Light touch - use a piece of rolled up cotton wool and compare dermatomes on both limbs. Remember to rub this
against the patients forehead or lower neck area to demonstrate what it feels like first. Press down on the skin -
do not 'stroke' as this activates more than just the light touch response.
- Proprioception - demonstrate this to the patient with their eyes open first so that they understand. Hold either
side of the finger tip (not on the nail bed), whilst supporting their wrist with your other hand. Then move either up
or down. Patient should then close their eyes, whilst you move their fingers at the distal interphalangial joint .
Very small movements should produce a response. If they are unable to do the test, then try more proximal
(bigger) joints, such as the wrist.
- Vibration - use a tuning fork on bony prominences. Again, show the patient what this feels like first. Make the
fork vibrate first, then place on a joint. Then dampen the vibration and ask the patient to tell you when it stops
vibrating (with their eyes closed).
Spinothalamic tracts:
- Pain - use a 'neurotip' - a small red specially designed disposable pin, in the dermatomal distribution.
- Temperature - you can use the metal of your tendon hammer head as 'cold' and the rubber part of this as 'hot'.
Lower Limb Examination
Inspection:
As for upper limb:
- Muscle wasting
- Fasciculations
- Deformities
- Skin changes
- Gait - asking the patient to walk before you start the examination can help prevent you from forgetting later!
- Romberg's test - you can perform this now, before the patient lies down. See 'sensation' section, below.
- Ask if the patient has any pain.
Tone:
Move 2 joints at a time. You can, for example, move the foot whilst flexing and extending the knee joint. It can be
useful to 'pick up' the leg at the knee by flexing it with one palm underneath, and by then (gently) dropping the leg
to the bed. If the tone is normal, it should just flop back onto the bed. With increased tone, it will remain flexed
for longer.
Tone can be:
- Increased - Upper Motor Neurone (UMN) lesion
- Normal
- Decreased - Lower Motor Neurone (LMN) lesion
Clonus: Check for this by externally rotating the hip joint and slightly flexing the knee. Then, gently
dorsiflex/plantarflex the foot a few times. Finally, make a sudden dorsiflexion movement of the foot and hold it
there. Observe the calf area, looking for 'beats' or pulsations of the muscle. Greater then 3 beats count as clonus,
and is a sign of an upper motor neurone lesion.
Power:
- Hip flexion (L1/2) - Test one leg at a time. Push down against the quadriceps muscle. In most cases you should
not be able to overcome the strength of this movement. Start with the patients leg already in the air (rather than
whilst it is still flat on the bed).
Command = 'keep your leg straight at the knee and raise it off the bed, pushing against my hand'.
- Hip extension (L5/S1) - Keep a flat hand under the patients upper thigh area (hamstrings).
Command = 'push your knees into the bed against my hand'.
Knee flexion (L5/S1) - Get patient to bend the knees and place feet flat on the bed. Use one hand against the
patients hamstring area to steady yourself and the patient whilst pulling the calf towards you.
Command = 'with your knees bent, stop me pulling your legs straight'.
Knee extension (L3/4) - As above.

Command = 'try and straighten your leg/'kick out' towards me'.
Ankle dorsiflexion (L4/5 - Upwards movement (plantar extension) of the foot. Start with the foot dorsiflexed then
apply resistance.
Command = 'push your toes up and stop me pushing them down'.
Ankle plantarflexion (S1) - Downwards movement of the foot.

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

Assess kyphosis and lordosis
Check for Scoliosis
Feel
Spinous processes
Sacroliliac Joints ideally with the patient prone
Paraspinal muscles
Warn the patient lightly percuss the spine Assess tenderness
Move
Lumbar flexion and extension finger test
Spine Lateral flexion Ask patient to run hand down side of leg
Cervical spine movements Lateral flexion, Flexion, Extension, Rotation
Sit Patient
Thoracic rotation ask patient to cross arms and turn to side
Put hands on shoulders to guide movement
Straight Leg raise Raise leg lying flat
Dorsiflex foot to assess pain
Assess limb reflexes
Dorsiflex big toe
Special Tests
Schobers Test Ankylosing spondylosis
Root compression Tests
Straight leg raise and dorsiflexion of foot Sciatica
Tibial Nerve Stretch test Sciatica - Tibial nerve
Femoral Nerve Stretch test Femoral nerve
Flip Test Assessment of true sciatica
Finish up
Neurovascular exam of upper and lower limbs
Assess Periph pulses
x- Ray of spine: 2 views
Additional examinations as relevant
HISTORY in the OSCE
What to Do when taking a history in an OSCE
1. Ask permission and explain why

2. Start with age and occupation
3. Tell me in your own words whats been going on
4. SOCRATES the symptom
5. Have you had this before?
6. What do you think it is?
7. Systems Review the system
8. Ask in turn
i. PMH
ii. Previous Surgery
iii. DH
iv. Allergies
v. FH
vi. Smoking
vii. Alcohol
viii. Mood
9. Do a Brief systems review. Any problems/trouble with :
i. Fevers/Feeling poorly
ii. Heart?
iii. Lungs?
iv. Tummy or the bowels?
v. Waterworks?
vi. Joints and bones?
vii. Skin?
viii. Funny turns/Problems with hearing, sight or smell
ix. Pins and needles/weakness?
10. Ideas, Concerns, Expectations
11. Anything you would like to add?
12. Summarise to Patient
13. Summarise to Examiner
14. Present Differential Diagnosis
Breaking bad News
WIPER PS
Appropriate introduction full name and grade
Establishes rapport with patient
Listens effectively
Explores Patients Ideas Concerns and Expectations
Aknowledges patients feelings/concerns and responds appropriately
Appropriate use of empathy and correct body language
Checks patients understanding of disease
Negotiates and discusses Plan of action/management
Offers Leaflets
Arranges follow up
Asks patient if they have any further questions
Summarises at end and checks understanding
Avoids Jargon and repetition
Professional throughout
Consenting a patient for an Operation
Introduction
1. Introduce with name and grade
2. Discuss aim of Consultation Ive come to discuss the options we have ahead in your case
3. Check Understanding Tell me about what you understand whats happened so far
4. Elicit patients concerns what are you particularly worried about
5. Explain indication of Proc/Op Youve got . Which means.
Weve discussed your case So we need to doto
investigate/treat/etc
6. Explain preparation required before the procedure involves
7. Explain the implications of not doing If you dont have then.
8. Talk through procedure
i. Before First we
ii. During then during [Describe Procedure/Op]
iii. After After you will until results/stable/free to
go/etc
9. Discuss Risks and benefits there are some common Risks which you should be aware of
10. Discuss Alternatives Just so that youre sure we should discuss other options
11. Describe out come likelihood of success In the majority of cases.

i. Discharge date Hospital for ..days/free to go
ii. Follow up come and see us in
iii. Restrictions on lifestyle after rest/do not eat/stay on the
ward
12. Asks for questions Do you have any questions?
13. Explore concerns Is there anything else youre worried about
14. Future management plan right now we need to do.../were waiting for/wait till op
15. Offer leaflets if youd like some more information leaflets available
16. Summarise key points Quickly recap what weve talked about
17. Formalise consent Well if thats ok then please sign the consent form
to show that you understand whats about to take place
18. Mention free withdrawal this is not a contract you are free to withdraw at any stage
19. Thank patient
MCA: Ethics and Law
Candidate instructions
You are a Foundation Year doctor in General Medicine. Mr James Winters, age 65, was admitted yesterday having
had a massive stroke (he had a previous minor stroke eight months ago). He is unconscious and no recovery of
function is expected. The consultant is considering artificial nutrition. The patients wife was not present at the
recent ward round and has asked to speak to you.
Use this opportunity to discuss whether artificial nutrition is appropriate.
Examiner instructions
Candidates are expected to apply the relevant provisions of the Mental Capacity Act. They should know that they
are bound to consult the patients family (in this case, wife) about what the patient would have wanted. They
should ask about advance decisions/statements and LPAs and know that in the absence of these the doctor will
make a decision in the patients best interests (even if this is contrary to the wifes wishes). The wife should be
listened to respectfully; her views must, according to the Mental Capacity Act, be taken into account, and this
means that on no account should the doctor appear dismissive or contemptuous of her views. The doctor should
also show sensitivity. This woman is likely to be deeply upset, and the doctor should be responsive to this, even if
she is a little irrational. Ultimately, however, the law demands that treatment or non-treatment is guided by what
the patient would have wanted. Students should not therefore give the wife the impression that they are willing to
follow her wishes uncritically. Even life-prolonging/life-saving treatment can be stopped by the doctor if it is not
considered to be in the patients best interests.
Actor instructions
Eight months ago, James, your husband, had a minor stroke from which he made a full recovery. You were both
very shocked by this, James particularly so. He told you that if he had another stroke, and became unable to care
for himself and unable to talk, he wouldn't want any treatment that would keep him alive.
Yesterday your husband had a massive stroke. You were told that he was unlikely to recover. You missed the
consultant ward round this morning because you were trying to contact your children, and have asked to speak to
the junior doctor on the team to find out what the plan is.
After the junior doctor introduces him/herself say:
Thank you for seeing me, doctor. I missed the ward round and wanted to find out what plans are being made for
James.
If you are asked your views about what treatment you would want for your husband, say you want them to do
everything possible to keep him alive (give him any treatment they feel would be helpful, including artificial
feeding), as you are not ready to let him go.
If you are asked what your husband would have wanted, say that he was a very proud man and after the minor
stroke made it clear that he couldnt bear the idea of having his life drawn out by tubes and machines when he
was unable to look after himself. He insisted that he should be allowed to die if he became helpless and
dependent.
However, you should then say:
I know my husband said this, but surely he wouldnt have wanted me to stand by and watch him die. Please,
doctor, will you do all you can for him?
Make sure that you ask, at some point:
What happens if you start the treatment? Does that mean it has to go on indefinitely?
If you are asked whether James created an advance decision, advance directive, living will or Lasting Power of
Attorney, say no.
If you are asked whether your husband had discussed his wishes with other family member or friends, say no.
Ethics and Law: General Rules of engagement
Scenario
Knowledge
Knowledge of legal and professional guidelines
Skills
Clarifies legal and professional guidelines appropriately and establishes rapport
Negotiates and agrees a plan in line with legal and professional guidelines
Attitude
Treats the person with respect and sensitivity and maintains professional bearing
Scenario
You are a Foundation Year doctor in General Medicine.
Mr James Winters, age 65, was admitted yesterday having had a massive stroke (he had a previous minor
stroke eight months ago). He is unconscious and no recovery of function is expected. The consultant is
considering artificial nutrition. The patients wife was not present at the recent ward round and has asked
to speak to you.
Use this opportunity to discuss whether artificial nutrition is appropriate.
ACTOR
Thank you for seeing me, doctor. I missed the ward round and wanted to find out what plans are being
made for James.
I know my husband said this, but surely he wouldnt have wanted me to stand by and watch him die.
Please, doctor, will you do all you can for him?
What happens if you start the treatment? Does that mean it has to go on indefinitely?
Inhaler Technique
WIPER PS
Introduce and explain purpose of interview
Check understanding of Asthma and rationale behind inhaler therapy
1. Stand up sit up straight before using inhaler
2. Remove cap and shake inhaler
3. Hold canister vertical for delivery of drug
4. Hold canister with middle finger and thumb
5. Put mouthpiece in mouth at start of inspiration
6. Inhalation should be slow and deep
7. Press canister down with index finger
8. Hold breath for 10 seconds
9. Wait about 30 seconds before administering the next dose
10. Close cap
Offer Spacer if still difficult Same rules just breath normally through spacer
Rotahaler Capsule administration of drug

Twist to release drug inhale simultaneously
Hold breath for 10 s
Other inhalers Easi-breath (teeth bite mouthpiece inhaler), Accuhaler (metered dosing)
IV Fluid Administration
WIPER PS
Introduce and explain that you will be administering IV drug
Check for allergies to any substances that are being given
1. Washes hands and collects equipment
2. Opens Bag and giving set
3. Dons gloves
4. Unwinds giving set and closes adjustable valve
5. Removes sterile cover from bag outlet and sharp end of giving set
6. Unites giving set with bag safely and aseptically
7. Hang bag up on stand
8. Squeeze drip chamber
9. Opens valve partially and lets fluid run gets rid of any bubbles
10. Cleans cannula with alcohol wipes and attaches giving set
11. Sets correct drip rate by opening valve on giving set
12. Checks if patient is ok
Finish up
Tidy equipment
Dispose of any clinical waste
RULES
Each bag should not hang for more than 24 hours
Each giving set should be changed every 48 hours
Cannula should be inspected daily
Sterile dressings should be changed daily
OSCE: Glycosuria Differentials and Ix
Differential Diagnoses
Diabetes Mellitus
Pregnancy (reduced renal glucose threshold)
Impaired glucose threshold in thyrotoxicosis (T4/T3 stimulate sympathetic NS, NA/A increase blood glucose levels as
a part of this response), acromegaly (GH increases lipolysis, reduces uptake of glucose by liver, promotes
gluconeogenesis in the liver) and after gastrectomy (?due to early dumping)
Raised blood glucose levels, secondary to raised adrenaline levels e.g. in phaeochromocytoma, stress, anxiety
(adrenaline acts to increase blood glucose levels)
Gross cerebral injury or haemorrhage
Severe infection e.g. Staphlococcus
Renal tubular problems e.g. anything that can cause Fanconis syndrome (proximal tubular function of kidneys is
impaired)
o Aetiology of Fanconis syndrome :
Cystinosis (in children, autosomal dominant lysosomal storage disorder- impaired cystine transport
leading to its accumulation in many tissues)
Multiple myeloma (due to the paraprotein, Bence Jones protein)
Nephrotic syndrome
Sjogrens syndrome
Heavy metal poisoning e.g. lead
Nutritional disorders e.g. Kwashikors, rickets
Drugs e.g. outdated tetracycline, salicyclates
Following shock/major surgery
Metabolic disorders e.g. galactosaemia
o Symptoms and signs
Polyuria
Polydipsia
Anorexia
Vomiting
Growth failure
o Clinical features:
Glycosuria
Aminoaciduria
Phosphaturia
Renal tubular acidosis type 2 (type 2)
Rickets/osteomalacia
Ix
FBC: CRP/ESR, WCC, Hb, plt
U + Es
Amylase, lipase
ABGs (?DKA)
Random blood glucose, fasting blood glucose, Hb A1C, 2hr OGTT
Urine 24 hour collection: albumin creatinine ratio, protein
Urine analysis: glucose, protein, paraproteins, amino acids
CXR- some lung tumours can secrete ACTH
pregnancy
blood culture
TFTs
IGF 1 (?acromegaly)
Heart Burn
You are a 5th year medical student and have been asked to see John Sampson who has come to get the results of
an investigation following heart burn.
Test results:
OGD: ulceration of gastric mucosa

CLO test performed after gastric biopsy: POSITIVE FOR H. PYLORI
I am Mr Sampson, a 57 year old taxi driver with stomach pain after eating. I came to the GP about 3 weeks ago and
was sent for a test last week where they put a camera down my throat and today Ive come for my results. I wasnt
too worried about the pain but I got worried when I founded out I needed such an invasive test.
I smoke and Im overweight. I have high blood pressure and take nifedipine for this.
I want to know what happens next?

If I still have the symptoms after treatment will I be checked and treated again?
What if I still have symptoms after second treatment
Will I need to come to the doctor regularly?
Will I be followed to see if I get stomach cancer?
Mark scheme:
1. Appropriate introduction (full name and role)

2. Establishes reason for consultation
3. Elicits and responds to patients concerns
4. Explains test result to patient
a. He has a stomach ulcer
b. 70% of stomach ulcers occur in people with H. pylori (95% of duodenal ulcers)
5. Establishes whether ulceration is associated with NSAID use. (if so then PPI for 2 months before
eradication therapy)
6. Explains H. pylori eradication therapy
a. PAC500 regimen: PPI, amoxicillin, clarithromycin 500mg (bd 7 days)
b. PMC250 regimen: PPI, metronidazole, clarithromycin 250mg (bd 7 days)
c. Explain management eradicates 85% of H. pylori infections
d. Side-effects: diarrhoea, nausea and vomiting
e. Complications?
7. Offers lifestyle advice
a. Antacid/alginate therapy
b. Avoid alcohol, coffee, chocolate, fatty foods
c. Weight reduction
d. Smoking cessation
e. Raise head of the bed
f. Main meal well before going to bed
8. Asks for patient questions and concerns
a. He will be re-tested once more after treatment if dyspepsia remains because he has an ulcer, then
no more
b. Other drugs available PPI, H2RA or prokinetics for 1 month
c. You dont need to come to the doctor regularly if symptoms resolve
d. If your symptoms dont resolve then we might send you for specialist care to see again if anything
more sinister can be found.
Referral Criteria for urgent (within 2 weeks)

Alternative: If the patient has come for results of a positive
endoscopy:
carbon-13 urea breath test or stool antigen test which is
positive, then advise that eradication therapy will only be Significant acute GI bleeding IMMEDIATE
tried once. Following that PPI, H2RA or prokinetic can be tried Chronic GI bleeding
for once month and if still no resolution then they can be Progressive, unintentional weight loss
referred for specialist care. Dysphagia
Iron deficiency anaemia
Persistent vomiting
Epigastric mass
Persistent disease in those > 55yrs
Urgent referral for endoscopy
Chronic GI bleeding
Progressive weight loss
Dysphagia
Iron deficiency anaemia
Persistent vomiting
Epigastric mass
Pe

Part 2A
4th year Stations
Psychiatry and Neurology
Alcohol dependence
Alan Smith is a 44-year-old man who has been referred because of his drinking. He has yet to be assessed, and you
are the SHO for the alcohol team.
Take an alcohol history, with particular emphasis on symptoms of dependence syndrome.
I am Alan Smith, a 44-year-old man. I first started drinking in my late teens and would drink at weekends with
friends in the pub. In my late twenties I started drinking more, and at the end of each working day. I lost my job
and my wife in my early 30s because of my drinking. I started attending Alcoholics Anonymous after this and for
many years I managed to control my drinking. My daughter was killed in a car accident 9 years ago and I started
drinking after this.
I have been drinking pretty much every day for the last few years. I drink a mixture of vodka and cider, up to a
bottle of vodka and 2L of cider a day. I start drinking in the morning to take away the shakes and sweats. I spend
most of the day drinking or go around to my friends house to drink. I have had to drink more and more over the
last few years. If I dont have a drink in the morning I feel shaky & sick. I find it hard to control my drinking.
I crave alcohol if I havent had a drink for a while. I managed to cut down my drinking a few months ago but
started again at the same level after a couple of weeks.
I have no real hobbies or interests; drinking dominates my life. I think that my memory and concentration have
been affected by my drinking, and admit I have lost my marriage and job because of alcohol.
My mood is low and I sleep poorly. My appetite is low but I eat one meal a day and my weight is stable. I have
poor motivation but can get down to the supermarket to buy alcohol. I have a laugh with my mates and enjoy
watching football on TV. I am pessimistic about the future and sometimes feel hopeless. Im not suicidal.
I think I probably have a problem with my drinking but dont think that much can be done.
Mark Scheme:
1. Introduction; empathy, rapport

2. Drinking history
a. When started drinking
b. Any triggers to start drinking more
c. Units per day (remember to ask volume of bottles consumed)
d. Type of alcohol
3. History of dependence syndrome
a. A strong desire or sense of compulsion to drink (do you get cravings?)
b. Difficulty in controlling the amount drunk (cut down once but started again)
c. Physiological withdrawal state (shakes & nausea) after drinking stops
i. Use of alcohol to relieve this
d. Tolerance (having to drink more)
e. Neglect of alternative pleasures & interests (no real hobbies, just drinking)
f. Persistence in spite of evidence of harm. (do you think alcohol harms you any way?)
g. Prominence of drink seeking behaviour.
4. Have you ever tried to stop drinking before?
5. Effects on functioning
a. Ever been in trouble with the police or arrested?
b. Has drinking affected your relationships?
c. Has drinking affected your job?
6. Mood symptoms
a. Low mood?
b. Sleep disturbance?
c. Appetite change?
d. Poor concentration?
e. Lack of energy
f. Loss of pleasure in interests.
7. Ever thought of hurting yourself or ending your life?
8. Psychosis:- hallucinations of formication, delusions of infestation (Ekboms)
Do you use any other substances besides alcohol?
ADHD station
A mother is worried her child might have ADHD. She has asked to have a chat to you about how it might be
diagnosed and medical treatment for the condition.
1. What do you know about ADHD?

3 main signs: inattention, hyperactivity, impulsiveness
Persisted for at least 6 months
6 symptoms of inattention: careless, poor attention to detail, fails to sustain attention to
tasks, easily distracted, appears not to listen, disorganised in tasks, forgetful
3 symptoms of hyperactivity: fidgets, leaves seat inappropriately in class, runs/climbs
excessively, unduly noisy in playing, excessive motor activity unmodified by social context
1 symptom of impulsivity: blurts out answers before question has been asked, fails to wait
turn in queue or games, intrudes into conversations, talks excessively without appropriate
response to social restraints
2. Does it have any other complications or associated illnesses:
CD and ODD
Learning disorders
Anxiety
Depression
Tic disorders
3. What caused it?
Any FHx? (25% first degree relatives)
Maternal stress during pregnancy
Poor quality early care-giving e.g. institutional or foster care
Foetal exposure to drugs and alcohol
Perinatal complications e.g. hypoxia, toxins
Prematurity
4. How would you diagnose it?
From Hx (6 symptoms of inattention, 3 of hyperactivity, 1 of impulsivity) persistent for at least
6 months
Rule out differentials (through medical and psych Hx, and physical exam)
i. Impaired hearing (hearing tests)
ii. Seizures/epilepsy (EEG)
iii. Head trauma
iv. Insufficient sleep
v. Poor nutrition
vi. Hyperthyroidism (TFTs)
vii. Drugs (alcohol, illegal drugs)
viii. Psych disorders (autism, CD/ODD, anxiety, OCD, attachment disorders, Tourettes,
Foetal alcohol syndrome)
Information from school
Observation- clinic and school/home
Psychological testing
You, the mother and the teacher must each fill out a Connors Questionnaire
5. Can it be treated?
Parent training programmes, to reinforce positive behaviour and decrease punitive strategies-
these can reduce stress and oppositional behaviour in children, but not cure the problem
CBT- aims to enhance self control by teaching self-instructing strategies
Social skills training- group work with peers and adults
Drugs (stimulants) e.g. Ritalin- but only if it is very severe, because it can cause side effects,
the main one being suppression of growth
In school; extra help in classroom and special education needs nurse

Teachers should have a meeting with doctors and child
6. Will my child have it as an adult?
With help, most childrens hyperactive symptoms settle down in mid-teens
<50% will last past 20 years old
Restlessness and inattention may continue into adulthood
But, specialist treatment tailored to your childs needs will assist them with their learning and
forming friendships
There may be self esteem issues later in life because of having a condition
Agoraphobia history
You are Jenny Peters, a 45-year-old married housewife with marked anxiety attacks.
It began 3 months ago when I was out in town and found myself becoming sweaty and felt my heart racing fast. I
got worried and went home where I calmed down. I am now fearful of leaving the house. I can go out with my
husband or family but become anxious in busy, crowded places such as supermarkets.
I cant use public transport but I am ok in the car. I avoid social situations as much as possible.
I have little or no anxiety whilst at home. I have a friends wedding coming up and am very anxious about making a
fool of myself there.
Mark Scheme:
1. Introduction
2. Establish nature of consultation
3. Elicitation of anxiety symptoms
a. Psychological symptoms
i. Worry
ii. Apprehension
iii. Tense
iv. Nervous
b. Physical symptoms
i. Tremor
ii. Palpitations
iii. Sweating
4. Situations that cause the anxiety
a. Social phobia vs agoraphobia vs generalised anxiety
b. Questions
i. Do you worry excessively about minor matters on most days of the week? (GAD)
ii. Have you ever been so frightened that your heart was pounding and you thought you
might die? (panic attack)
iii. Do you avoid leaving the house alone because you are afraid of having a panic attack or
being in a situation from which escape will be difficult or embarrassing? (agoraphobia)
iv. Do you get anxious in social situations, like speaking in front of people or making
conversation? (social phobia)
v. Do some things or situations make you very scared? Do you avoid them? (specific phobia)
5. History of panic disorder
a. Presence of panic
b. Frequency
c. Calm between attacks?
d. Location
6. Other symptoms
a. Avoidance
b. Anticipatory anxiety
i. Fear of having another attack
7. Impact on life
8. Presence of mood symptoms
9. Social History
a. Alcohol
b. Drugs
c. Family support
Treatment
1. Agoraphobia
a. CBT graded exposure to avoided situations
b. SSRIs
2. Generalised Anxiety Disorder
a. CBT Identify morbid anticipatory thoughts and replace them with more realistic cognitions,
distraction techniques, breathing and relaxation exercises.
b. SSRIs
c. Self-help
d. 2nd lines: benzos for 2-4 weeks, SNRIs, buspirone, pregabalin
3. Panic Disorder
a. CBT
SSRIs
Anorexia nervosa written
Body Mass Index =
Psychiatric conditions that can mimic Anorexia Nervosa

Bulimia Nervosa
Depression
Psychotic disorders with delusions concerning food
Substance or alcohol abuse
OCD
Organic conditions that can mimic Anorexia nervosa

Diabetes Mellitus
Hyperthyroidism
Malabsorption syndromes
Addisons disease
(Physical) Symptoms of Anorexia Nervosa

Amenorrhoea
Hair loss from scalp
Hypothermia / cold intolerance
Ankle swelling
Constipation
Signs of Anorexia Nervosa

Lanugo hair
Hypotension
Bradycardia
Syncope
Emaciation
Treatments of Anorexia Nervosa

Individual therapy
o Cognitive Behavioural Therapy
o Psychodynamic Psychotherapy
Family Therapy is first choice for adolescents
In-patient treatment
o Observation during and after meals and of exercise
o Medication for co-morbid physical / mental health problems
o Naso-gastric feeding
OSCE: counselling about autism
Please talk to this mother of a 4 year old boy
1. How much do you know about autism?
Autistic Spectrum Disorders- i.e. there is a range of severity, so a child may only present with a few of the
associated features, or he might have all of them, in which case he would be on the most severe end of
the spectrum.
Triad of abnormalities: impaired social communication, impaired language and understanding, restricted
interests and resistance to change
2. Can you tell me more about these impairments please?
Social: poor/odd non-verbal communication, difficulty seeing things from another persons perspective,
gaze avoidance, difficulty forming friendships , lack of give and take in conversations, prefer being alone,
difficulty understanding unwritten social rules
Communication: delayed language development, unusual tone of voice, palilalia/echolalia, stock phrases,
difficulties understanding abstract concepts or sarcasm
Restricted interests and repetitive behaviours: repetitive/unimaginative play, order/sameness,
unusual/intense preoccupations, odd repetitive motions e.g. arm flapping or rocking, hypo or
hypersensitive to light or noise
Other common problems: hyperactivity, sleep difficulties, food fads, self-injurious behaviours, epilepsy
(30%), visual and hearing difficulties, motor clumsiness
Cognitive: IQ <100 (may or may not have a learning difficulty)
3. Will my child have this forever?
Yes, it is a lifelong condition
There is no cure
But, your childs social, language skills, etc can be improved using the following interventions: extra
educational assistance, speech and language therapy, occupational therapy (APPLIED BEHAVIORAL
ANALYSIS)
Family support can also be provided, which will be helpful for yourselves, in assisting you with parenting
techniques and support for your child
National Autism society
Medical treatment for some of the more specific medical associations .g. epilepsy, stimulants for ADHD
(hyperactivity), risperidone for aggression and repetitive behaviours
4. My child had the MMR, is that why he got autism?
No link between the two
No real cause known
But an association with Fragile X syndrome and Retts syndrome (these are chromosomal/genetic
disorders, which autism may be a feature of), and also NF and some metabolic disorders
5. If I have another child, will they have it?
6. 3%
Leaflets
Alcohol cessation
You have been asked to talk Jonas, a 28 year old man who wants to cut down his drinking
I am Jonas, a 28 year old bricky. I mainly drink at home or with regulars at the pub. I drink 4 pints of larger a night
but if I dont go to the pub then I can finish half a bottle of whiskey at home.
I cant be sure if I get symptoms when I dont drink, Ive only not had whiskey at home once and I did feel anxious
and had the shakes.
I sometimes miss 3 days a week of work because I have a hangover or Im still drinking and Im worried Im going
to lose my job. My boss gave me an ultimatum and said if I dont make changes in the next week then hes going
to fire me.
CAGE answers: Yes to everything
Ive tried to drink less before. I used to drink a few of pints a night in my early 20s and was trying to cut down but
my wife and me split up 6 years ago and since then nobody bothered me about my drinking.
Mark scheme:

3. Asks about current drinking (cage questionnaire)
a. How many units do you drink a week
b. In what situations do you drink?
c. Do you drink alone?
d. Do you drink daily or in binges?
e. What kind of alcohol do you drink?
f. Withdrawal symptoms:- anxiety, fits, hallucinations & tremor?
g. Cage questionnaire
i. Have you ever felt you should cut down on your drinking?
ii. Have people annoyed you by criticising your drinking?
iii. Have you ever felt bad or guilty about your drinking?
iv. Have you ever had a drink first thing in the morning to steady your nerves or get over a
hangover?
4. Reinforce the risks of drinking to the patient.
a. Deaths 40,000 deaths per year in the UK directly caused by alcohol
b. Social
i. Marriage breakdown
ii. Loss of work
c. Mental problems
i. Anxiety
ii. Depression
iii. Suicidal thoughts
iv. Wernickes / Korsikoffs
d. Physical effects
i. Liver disease
ii. Foetal damage
iii. Hypertension
iv. Strokes
v. Cancers; mouth, larynx, oesophagus, breast, liver
5. Review previous attempts to stop drinking.
a. Any support groups or medication used?
6. Advice on reducing intake
a. Refer to community alcohol team
b. Group therapy, long term counselling, alcoholics anonymous, involve family & friends
c. Keep a diary of alcohol consumption
d. Agree targets
e. Consider detoxification
i. Disulfiram - conditioning
ii. Chlordiazepoxide qds over 1 week attenuate withdrawal symptoms
7. Offer a follow up appointment in 2 weeks to check progress
8. Offer information & advice sheet
9. Does all in a fluent and professional manner.
Alcohol dependence
Alan Smith is a 44-year-old man who has been referred because of his drinking. He has yet to be assessed, and you
are the SHO for the alcohol team.
Take an alcohol history, with particular emphasis on symptoms of dependence syndrome.
I am Alan Smith, a 44-year-old man. I first started drinking in my late teens and would drink at weekends with
friends in the pub. In my late twenties I started drinking more, and at the end of each working day. I lost my job
and my wife in my early 30s because of my drinking. I started attending Alcoholics Anonymous after this and for
many years I managed to control my drinking. My daughter was killed in a car accident 9 years ago and I started
drinking after this.
I have been drinking pretty much every day for the last few years. I drink a mixture of vodka and cider, up to a
bottle of vodka and 2L of cider a day. I start drinking in the morning to take away the shakes and sweats. I spend
most of the day drinking or go around to my friends house to drink. I have had to drink more and more over the
last few years. If I dont have a drink in the morning I feel shaky & sick. I find it hard to control my drinking.
I crave alcohol if I havent had a drink for a while. I managed to cut down my drinking a few months ago but
started again at the same level after a couple of weeks.
I have no real hobbies or interests; drinking dominates my life. I think that my memory and concentration have
been affected by my drinking, and admit I have lost my marriage and job because of alcohol.
My mood is low and I sleep poorly. My appetite is low but I eat one meal a day and my weight is stable. I have
poor motivation but can get down to the supermarket to buy alcohol. I have a laugh with my mates and enjoy
watching football on TV. I am pessimistic about the future and sometimes feel hopeless. Im not suicidal.
I think I probably have a problem with my drinking but dont think that much can be done.
Mark Scheme:
9. Introduction; empathy, rapport

10. Drinking history
a. When started drinking
b. Any triggers to start drinking more
c. Units per day (remember to ask volume of bottles consumed)
d. Type of alcohol
11. History of dependence syndrome
a. A strong desire or sense of compulsion to drink (do you get cravings?)
b. Difficulty in controlling the amount drunk (cut down once but started again)
c. Physiological withdrawal state (shakes & nausea) after drinking stops
i. Use of alcohol to relieve this
d. Tolerance (having to drink more)
e. Neglect of alternative pleasures & interests (no real hobbies, just drinking)
f. Persistence in spite of evidence of harm. (do you think alcohol harms you any way?)
g. Prominence of drink seeking behaviour.
12. Have you ever tried to stop drinking before?
13. Effects on functioning
a. Ever been in trouble with the police or arrested?
b. Has drinking affected your relationships?
c. Has drinking affected your job?
14. Mood symptoms
a. Low mood?
b. Sleep disturbance?
c. Appetite change?
d. Poor concentration?
e. Lack of energy
f. Loss of pleasure in interests.
15. Ever thought of hurting yourself or ending your life?
16. Psychosis:- hallucinations of formication, delusions of infestation (Ekboms)
17. Do you use any other substances besides alcohol?
Alcohol dependence
ICD-10 Diagnostic guidelines
A definite diagnosis of dependence should usually be made only if 3 or more of the following have been
experienced or exhibited at some time during the previous year
a) A strong desire or sense of compulsion to take alcohol

b) Difficulties in controlling alcohol-taking behaviour in terms of its onset termination, or levels of use
c) A physiological withdrawal state when alcohol use has ceased or been reduced, as evidenced by: the
characterstic withdrawal syndrome for alcohol; or use of the alcohol with the intention of relieving or
avoiding withdrawal symptoms
d) Evidence of tolerance, such that increased doses of alcohol are required in order to achieve effects
originally produced by lower doses
e) Progressive neglect of alternative pleasures or interests because of alcohol use, increased amount of time
necessary to obtain or take alcohol or to recover from its effects
f) Persisting with alcohol use despite clear evidence of overtly harmful consequences, such as harm to the
liver through excessive drinking; efforts should be made to determine that the user was actually, or could
be expected to be, aware of the nature and extent of the harm.
Symptoms of withdrawal
Coarse tremor
Nausea and vomiting
Weakness and malaise
Anxiety, irritability and depressed mood
Headache and insomnia
Autonomic hyperactivity; tachycardia, hypertension
Transient hallucinations and delusions
Symptoms of delirium tremens

Delirium
Gross tremor of hands
Sympathetic overactivity
Hallucinations/pseudohallucinations
Dehydration and disturbed blood biochemistry
o Leucocytosis
o Raised ESR
o Poor LFTs
Explaining Alzheimers disease
Im Sarah Palmer and my mother has been diagnosed with Alzheimers disease. I know that its a disease that
affects the old and causes dementia but know nothing else.
I want to know;
What is it?
What will happen to my mother?
Does she need to go into a residential home?
What are the treatments?
Will it kill her?
Mark Scheme:
1. Appropriate Introduction
2. Explains what Alzheimers is
a. Alzheimers disease is the most common cause of dementia
b. Occurs with markedly increased frequency in the elderly
c. Dementia describes the loss of mental abilities such as memory and reasoning
d. It is unfortunately a progressive and incurable disease although there are treatments that can
slow down its development
e. Abnormal changes in the brain structure and chemicals worsen over time, eventually interfering
with many aspects of brain function
f. Memory loss is one of the earliest symptoms, along with a decline in intellectual and thinking
abilities and changes in behaviour
3. Risk factors
a. Family
b. Low educational attainment
4. What will happen to her mother
a. No case of Alzheimers disease is ever the same as different people react in different ways
b. Commonly Alzheimers starts in its mild form; your mother may experience memory loss,
confusion, mood swings and problems with speech
c. When moderate she may experience hallucinations and delusions and disturbed sleep and may
have trouble controlling her bowels and water works
d. Eventually if severe she may experience difficulty swallowing & moving, loss of appetite and
increased vulnerability to infection.
5. Does she need to go into a residential home?
a. Nobody is ever forced to send their relatives to a residential care home
b. People with Alzheimers disease are usually cared for by family in their own home in the early
stages
c. But there comes a time, as the disease progresses and the behavioural pattern becomes more
difficult to cope with, when carers find they can no longer cope with their needs.
d. If you were to be in this situation your mother would have a care manager who can give you
advice on either helping you to care for your mother at home or if it comes to the point, be able to
help you find somewhere that better suits her needs.
6. Support
a. Community nurses
b. Home carer
c. Social worker
d. Occupational health
e. Disability living allowance
f. Carers allowance
g. Respite care
7. Treatments
a. Currently no cure
b. Medications available that can help delay the development of the condition in early stages
c. Donepezil, rivastigmine act by increasing the amount of the chemical acetylchonine in the brain
d. Memantine affects glutamate in the brain and can be used for moderate - severe AD
8. Mortality
i. Alzheimer's disease can shorten life-expectancy. This is often due to developing another
condition, such as pneumonia, as a result of having Alzheimer's disease. Therefore,
Alzheimer's may not be the only cause of death, but it may contribute towards it.
9. Give a leaflet
10. Organisations Alzheimers society, dementia relief trust
OSCE: counselling about autism
Please talk to this mother of a 4 year old boy
7. How much do you know about autism?
Autistic Spectrum Disorders- i.e. there is a range of severity, so a child may only present with a few of the
associated features, or he might have all of them, in which case he would be on the most severe end of
the spectrum.
Triad of abnormalities: impaired social communication, impaired language and understanding, restricted
interests and resistance to change
8. Can you tell me more about these impairments please?
Social: poor/odd non-verbal communication, difficulty seeing things from another persons perspective,
gaze avoidance, difficulty forming friendships , lack of give and take in conversations, prefer being alone,
difficulty understanding unwritten social rules
Communication: delayed language development, unusual tone of voice, palilalia/echolalia, stock phrases,
difficulties understanding abstract concepts or sarcasm
Restricted interests and repetitive behaviours: repetitive/unimaginative play, order/sameness,
unusual/intense preoccupations, odd repetitive motions e.g. arm flapping or rocking, hypo or
hypersensitive to light or noise
Other common problems: hyperactivity, sleep difficulties, food fads, self-injurious behaviours, epilepsy
(30%), visual and hearing difficulties, motor clumsiness
Cognitive: IQ <100 (may or may not have a learning difficulty)
9. Will my child have this forever?
Yes, it is a lifelong condition
There is no cure
But, your childs social, language skills, etc can be improved using the following interventions: extra
educational assistance, speech and language therapy, occupational therapy (APPLIED BEHAVIORAL
ANALYSIS)
Family support can also be provided, which will be helpful for yourselves, in assisting you with parenting
techniques and support for your child
National Autism society
Medical treatment for some of the more specific medical associations .g. epilepsy, stimulants for ADHD
(hyperactivity), risperidone for aggression and repetitive behaviours
10. My child had the MMR, is that why he got autism?
No link between the two
No real cause known
But an association with Fragile X syndrome and Retts syndrome (these are chromosomal/genetic
disorders, which autism may be a feature of), and also NF and some metabolic disorders
11. If I have another child, will they have it?
12. 3%
13. Leaflets
Bipolar affective disorder
1. Introduction
2. Finds duration of episode
3. Elicits manic features
a. Grandiosity
b. Increased pleasurable activity without thought of consequences
c. Increased talkativeness
d. Decreased need for sleep
e. Flight of ideas
f. Increased goal-driven activity
4. Enquires about mood previously
5. Enquires about drug history
6. Enquires about recreational drug use
7. Enquires about psychotic features
a. Hallucinations
b. Special powers / other delusions
8. Enquires about past medical history
9. Enquires about past psychiatric history
10. Asks about family history
11. Asks if the patient has any questions.
Blood test results in psychiatric disease
You are given 5 sets of blood results, match them to the following diseases: bulimia, drug induced psychosis,
depressive episode, delirium, alcohol intoxication
Bulimia
Most obvious is hypokalaemia.
FBC, WCC, PLTs anaemia due to lack of absorption (iron, B12, folate)
Iron, folic acid
U&Es
o urea dehydration
o Hypokalaemia, hypochloraemic acidosis vomiting
o Serum amylase vomiting
o Hyponatraemia, hypomagnesaemia vomiting
o cortisol
o GH
o T3
o FSH&LH
o Hypercholesterolaemia
o Hypercarotenaemia
Drug Induced Psychosis
Urine drug screen positive for amphetamines and cannabinoids
Alcohol intoxication
Increased gamma GT and abnormal LFTs
Acute confusion / delirium

Counselling OSCE: Beta-blockers and sexual dysfunction
You are a GP and Mr Young has come to discuss his beta-blocker medication with you. Please counsel him and
give appropriate advice and management changes.
Ernest Young, I am 56 years old and was diagnosed with high blood pressure a few months ago. My GP has
prescribed me atenolol tablets and I take one 50mg tablet a day. To be honest with you I dont feel that different
to how I did before so Im not sure that theyre making any difference.
Ive just had my blood pressure checked and the nurse has assured me that my blood pressure is normal. Can I
stop now that my BP is fine?
I think I have been having some side effects with this medication; I feel like I have less energy than before
(bradycardia), my finger are always cold and they used to be before but its got worse since I started taking this
medication (peripheral vasoconstriction). I looked these things up on the internet and it says there that atenolol
does cause these problems. It also said that I may become impotent! Why did you prescribe a drug with such a
long list of side-effects?
I dont want to keep taking this medication, whats the worst that can happen?
Markscheme
Washes hands or comments
Appropriate introduction
Establishes reason for visit
Shows empathy regarding side effects
Explains side effects occur rarely and that all medications have a list of uncommon potential side effects
Asks about Sx of hypertension (evaluates current regimen) and what may have led to the diagnosis i.e. BP
record
o BP when diagnose
o N + V, headaches, visual disturbances, sweating, fits, tachycardia
Asks about PMHx / comorbidities
o Hyperlipidaemia, Smoking, FHx, PMHx thrombotic events, Diabetes
Explains the importance of taking antihypertensive medication and the consequences / risks of not.
Explains management of hypertension: conservative and drug management appropriate lifestyle changes if
they have been made may mean that the dose of beta-blocker etc can be reduced and this would hopefully
mean fewer side effects
Enquires how patient would feel about perhaps altering treatment regimen
Gives 2-3 other drugs that could be tried
Asks whether the patient is happy to change
Inquires about any ICE
Summarises: management and consultation
Re-arranges a follow-up appointment to monitor progress.
End consultation appropriately
Washes Hands
1. Hypertension:
Treatment should be started if sustained BP160/100mmHg OR 10yr cardiovascular risk > 20% OR
Existing vascular disease, OR target organ damage eg. Brain. Kidney, HF, retina with
BP>140/90mmHg.
Complications of hypertension:
i. Vessels: atherosclerosis, aortic dissection, aneurysm rupture
ii. Heart: LVH /LVF
iii. Brain: Stroke / Cerebral haemorrhage
iv. Kidney: benign/ malignant nephrosclerosis leading to permanent RF
v. Others: Visual / eye effects.
2. Side effects of beta-blockers

GI disturbances, heart failure, bradycardia, heart failure, hypotension, conduction disorders,
peripheral vasoconstriction (presenting as Raynauds or exacerbating it/intermittent claudication).
Bronchospasm, dyspnoea, headache, fatigue, sleep disturbances, dizziness, vertigo, sexual
dysfunction, purpura, visual disturbances and thrombocytopenia
3. Drug therapy or guidelines

Aims to reduce the risk cardiovascular problems and death.
Optimise life style factors
i. Reduce salt intake
ii. Limit ETOH
iii. Stop smoking
iv. Reduce Weight
v. Increase Exercise
vi. Veg/ Fruit
vii. HbA1C < 7%
Beta-blockers are not first-line drugs! Only consider if younger, intolerant to ACEi / A2RB, increased
sympathetic drive in children of childbearing potential.
Remember:
i. Step 1
< 55yo, Caucasian: ACEi or A2RB (or beta blocker)
>55 yo, Black : Calcium channel blocker, Thiazide diuretics
ii. Step 2
ACEi + Ca blocker/Thiazide
iii. Step 3
ACEi + Ca + Thiazide
iv. Step 4
Consider alpha blocker, spironolactone, other diuretics
If cardiovascular disease risk is > 20% then a STATIN is recommended

Explaining clozapine treatment
Side Effects:
Neutropenia (just under 1% of patients)
Risk of seizures in high doses
Hypersalivation
Weight gain
Moderate risk of diabetes
Sedation early on
Constipation
o Eat fibre and drink lots of water
Hypotension
Arrythmias, myocarditis
Others: anticholinergic, anti-adrenergic
Before starting rx:

FBC
ECG
How do I take it?

Orally (or as suspension)
Regular blood tests

Weekly for the first 18 weeks
Fortnightly up to 52 weeks
Four weekly thereafter
After your blood is taken it is sent to the laboratory to make sure that the levels of your white blood cells
have not dropped. If the blood result is normal, it is called a green blood result.
All patients register with clozaril clinic, where they have these regular blood tests.
Drug levels only measured if requested:
o 0.3-0.5 blood levels are normal
o > 1: seizure and toxicity risk
If you forget to take one dose of clozapine then take it as soon as possible but not 2 doses in one go. If it has been
over 48 hours since your last dose consult your doctor because you cannot start on the same dose again straight
away.
Conduct disorder
What are the causes of bad behaviour
Conduct disorder / Oppositional Defiant Disorder
Hyperactivity disorder
Antisocial behaviour within deviant peer group
Autistic spectrum disorder
Normal child, unrealistic expectations
What is conduct disorder?

Persistent failure to control behaviour appropriately within socially defined rules
Defiant of authority
Aggressive
Antisocial behaviour; violating property, rights or people
ICD-10; at least 3 behavioural criteria must have been exhibited in the last 12 months, with at least one criterion present in
the last 6 months.
What is Oppositional Defiant Disorder?
ODD is a subsection of conduct disorder (ICD-10) occurs in children under 12
Often lose temper Often shifts blame

Argue with adults Easily annoyed
Often defies adult requests Often angry
Deliberately annoys others
Is it caused by genetics or environment?

Conduct disorder clusters in families
Possible association with variant of MAO A gene
Are there any risk factors?

Family
Marital discord
Substance misuse
Criminal activity
Abusive parenting
Injurious parenting
Environment
Social disadvantage
Homelessness
Low socioeconomic status
Overcrowding
Social isolation
Individual
Difficult temperament
Brain damage
Epilepsy
Chronic Illness
Cognitive deficits
Can it be treated? 1. Parenting Programmes 2. Social Skills Groups 3. Problem solving skills training
Prognosis: 40% of children become delinquent adults

CSF profiles station
Normal CSF properties
Pressure 80-180 mm of CSF
White Cells <5/L
Protein 0.1-0.4 g/L
Glucose 50% of serum value
(typically 2.8-4.7 mM)
Guillain Barr Syndrome
Raised CSF protein concentration (1-10 g/L) with normal cell count
Multiple Sclerosis
Lymphocytosis with active disease, raised protein (particularly immunoglobulins (IgG)), oligoclonal bands
by electrophoresis
Sub-Arachnoid Haemorrhage
Numerous RBCs, xanthochromia (yellowish appearance of CSF) and increased pressure
Meningitis
Type of meningitis Glucose Protein Cells

Acute bacterial Low High PMNs, often > 300/mm3
Acute viral Normal Normal or high Mononuclear, < 300/mm3
Tuberculous Low High Mononuclear > 300/mm3 & PMNs
Fungal Low High >300/mm3
Malignant Low High Usually mononuclear
Management of meningococcal meningitis: I.V. cefotaxime / ceftriaxone

3 complications of meningococcal septicaemia other than death
1. Disseminated intravascular coagulation
2. Focal neurological deficits
a. Cranial nerve palsies
b. Blindness
c. Deafness
3. Conjunctivitis
4. Seizure disorder
5. Ataxia
3 complications of meningitis
1. Seizures
2. Hydrocephalus
3. Permanent localising symptoms; e.g. paralysis, ophthalmaplegias
95
A bloke has a history of weakness and sensory changes in the lower limbs; possible explanations are
Guillain Barr, Multiple Sclerosis & acute cord compression.
What immediate bedside test would you do? Anal reflex / anal sphincter tone, PEFR/vital capacity?
What other tests?

MRI of brain and spinal cord may reveal plaques or cord compression
Visual evoked potentials show delayed central conduction in the visual pathways
Forced vital capacity measurements to establish progression of GBS
Nerve conduction studies prolonged in GBS
What are the treatments for your differential diagnoses...
Guillain Barr
In the progressive phase vital capacity should be measured frequently and the ECG monitored
continuously. If ability to swallow saliva, rapidly vital capacity warrant admission to intensive care with
probable need for artificial ventilation and nasogastric feeding.
Supportive care:
1. Physio for limb weakness.
2. Turning to avoid pressure sores.
3. LMWH for DVT prophylaxis.
Medical treatment:
1. Plasma exchange
2. High-dose IVIG; 5 day infusion
Multiple Sclerosis
Corticosteroids (methylprednisolone) for an acute attack
Interferon-, Glatiramer, Natalizumab
Control of symptoms
Cord compression
Immediate referral for specialist review
96
Delirium written
1. Give 3 symptoms
2. Give 4 causes
3. Give 2 nursing treatments
4. Give 2 medical treatments
Physical Signs:
Sudden onset
Reduced ability to focus, maintain and shift attention
Altered consciousness
Fluctuation and diurnal variation
Disturbed sleep-wake cycle
Changes in mood
o Anxiety
o Depression
o Lability
o Irritability
o Aggression
Perceptual distortions
o Misidentification
o Illusions
o Hallucinations
Disorganised thinking
o Rambling, irrelevant or incoherent speech
Memory impairment
Disorientation in time and place
Physical signs of underlying cause
Aetiology
Infection Respiratory, urinary, cellulitis FBC, CRP, Culture

Metabolic Hypo/hyper-glycaemia, uraemia, hepatic LFT, BM, U&E
failure, electrolyte disturbance, hypoxia
Endocrine Addisonian crisis, thyroid/parathyroid TFT, calcium
Medication Anticholinergics, psychotropic drugs, Drug level, urine
steroids, anticonvulsants, overdose
Drugs/alcohol Intoxication/withdrawal, delirium LFT, Drug levels, B1, B12
tremens, Wernickes encephalopathy
Cerebrovascular CVA/TIA, subdural haematoma MRI, CT, Doppler
Trauma Head injury Imaging
Raised ICP Tumour, abscess
Intracranial infection Encephalitis, meningitis
Epilepsy Pre-ictal aura, temporal lobe epilepsy, EEG
post-ictal states
97
Dementia
Psychotic disorders
Mood disorders
Anxiety disorders
Drugs and alcohol
Management
The nursing treatments of delirium

Treat underlying physical cause
General supportive measures
o Nutrition
o Hydration
o Correction of electrolyte and fluid balance
o Thiamine if indicated
Careful attention to environment
o Consistency of staff
o Regular reorientation
o Adequate lighting
o Make environment safe
Liaison of medical and surgical teams with psychiatrists
The medical treatments of delirium

Symptomatic treatment of psychosis or acutely disturbed behaviour
o Use single medication at low dose
o Start with single dose and review after 2-4hrs
o Antipsychotics: haloperidol, risperidone
o Benzodiazepines in certain cases
Hepatic failure
Withdrawal from alcohol / benzodiazepines
o Review dose regularly and taper / stop ASAP
Investigations
Bloods, urine MC&S, CXR, ECG, MRI head, LFTs, TFTs, calcium, glucose, CRP, blood cultures, urine
drug screen
98
Depression History and screen of a 7 year old
Please take a history from a 7 year old girls mother whos worried her daughter is suffering from
depression.
My name is Sarah and my daughter Molly and is 7.
Shes been feeling sad for about a month

and she seems depressed to me. She snaps at me when I try and ask her whats wrong; she
shouts and cries and runs to her room.
She doesnt enjoy things like she used to like school or playing and painting at home which she
used to love.
She feels tired a lot, like she dont have a lot of energy
Her teachers at school say she is not paying attention in class and takes a long time to finish her
work
She doesnt eat; she occasionally eats crisps. On weekends when I dont make her get up she
sleeps for over 12 hours.
She doesnt like to talk a lot, especially to strangers and Im not sure she has any friends at school
Shes never tried to hurt herself thank God
Ive been suffering from depression for the last 4 years, Im on medication though (Amitriptyline) and Ive
been fine for the last year. I got depressed because I lost my job and my husband and I got divorced.
Molly still sees her father every other day.
Im struggling with money because I still dont have a job yet but Molly doesnt know about these money
problems
Has she got depression because I had it; is it genetic or has she picked up her behaviour from me?
Mark Scheme:
1. Appropriate introduction
3. Takes a history / screens for depression
a. Symptoms
i. Duration of symptoms
ii. Depressed mood or irritability
iii. Anhedonia and/or reduced energy leading to fatiguability
iv. Poor concentration and attention
v. Sleep and/or eating disturbance
vi. Reduced self-esteem
vii. Pessimistic view of future / ideas of guilt
viii. Ideas or acts of self harm / suicide
b. Effect on day to day activities
4. Makes an attempt to establish severity of depressive episode
a. Mild: depressed/irritable + anhedonia/tiredness + 2 other symptoms
b. Moderate: depressed/irritable + 5/6 further symptoms
c. Severe: 7 symptoms. Possibly delusions, hallucinations, stupor
5. Explains the relationship between depression in parents and children
a. 40% of children of depressed parents have a psychiatric disorder
99
b. Increased risk of depression in relatives including off-spring
c. Poor family function linked to a range of childhood disorders
d. Genetics less important in pre-pubertal children (Rice et al 2002)
6. Possible triggers
a. Parental conflict + divorce can cause high levels of disturbance
b. Bereavement
7. Discusses treatment
a. Officially assess her
b. Mild: Group CBT / guided self help (2-3 months)
c. Moderate severe: CBT/IPT/ family therapy for 3 months, add in fluoxetine only if
unresponsive to therapies
8. Asks parent for questions and concerns
9. Does all in an empathic and organized manner.
100
Epilepsy
Take a history from Samantha Jones, an 18 year-old girl, who had a blackout. Also, give her
management advice.
Her friend witnessed the incident, and reported there to be jerking in all limbs, loss of urinary
continence and tongue biting (side of the tongue). After the shaking stopped, she was unconscious for
about half an hour. Following the incident, Samantha went to sleep for a few hours; she was feeling
drowsy and her muscles and back were aching. She also complained of a headache. Samantha had
been out drinking the night before. She is on the OCP.
Wash hands
Introduce and check patients name, age, occupation and dominant hand
Has this ever happened before?
Did you notice anything unusual before you blacked out?
o Aura- strange feeling in the gut? Sensation or experience such as dj vu? Strange
smells? Flashing lights?
o Dizziness / nausea?
o Irritability / anxiety?
o Did your friend perhaps notice a distinct cry?
Did you fit/shake when you fell/blacked out?
o How long did this last for?
o Which parts of your body were shaking?
During the episode, was there any:
o Loss of urinary continence? (and faecal?)
o Tongue biting? Which part?
After the shaking stopped did you regain consciousness straight away?
When you did regain consciousness, how did you feel?
o Drowsy / confused?
o Headache?
o Stiffness?
o Weakness of your limbs? (Todds palsy)
o Any injury?
o Back pain?
Where were you when the blackout occurred? What had you been doing?
o TV, flashing lights involved
PMHx
o HTN, cardiac conditions
o Psych disorders
o History of febrile seizures?
FHx
SHX
o Smoking
o Alcohol
DHx
Patient asks, is this epilepsy?
o Epilepsy cannot be diagnosed unless 2 or more episodes
Patient asks whether she needs medication
o Explain that blood tests, EEG have to be done
101
oBut if she were to go on medication, because she is on the OCP, her dose would have to
be increased
Other advice
o If epilepsy diagnosed, DVLA would have to be informed
o She would not be able to drive unless seizure-free for 6 months or more
o Avoid triggers: alcohol, flashing lights
o Avoid swimming, rock and tree climbing
Questions to rule out differentials (most of them have been covered in the above Hx)
o Pseudoseizures
Pelvic thrust-type movements
Patient keeps eyes closed even when you try to move them
o Vasovagal syncope
What were you doing prior to the attack? Did it involve you standing for long
periods of time?
o Cough syncope?
o Micturition syncope?
o Effort syncope
Were you exercising prior to the event?
o Carotid sinus syncope?
Were you shaving before the attack (if a man!)?
o Hyperventilation/panic attack
Had you been particularly anxious?
o TIA
CV risk factors
Smoking?
Alcohol?
HTN?
Weakness of face, 1 side of body, slurred speech, etc?
o Hypoglycaemia
DM?
When did you last eat before the fall?
o Narcolepsy
Were you feeling particularly sleepy before the attack?
o Migraine
Headache?
Aura?
o Vestibular disorders
Hearing difficulties?
Balance problems?
Menigitis?
102
Explain Schizophrenia
1. Introduction
2. What is schizophrenia?
a. A serious mental disorder affecting 1 in 100 people
b. People with schizophrenia can have problems distinguishing whats real and whats not
and this affects the way they think, feel and behave. As a result, they can come up with
strange ideas (delusions), or hear and see things that arent really there (hallucinations)
c. Negative Symptoms
i. Lack of motivation, initiative and movement
ii. Social withdrawal
iii. Poverty of thought and speech
iv. Blunting of affect / mood disorder
3. Causes?
a. Exact cause unknown
b. Genetic background may partly account; having a parent with schizophrenia increases
risk by 10x
c. Other factors are birth complications and drug use
d. Stressful life events dont cause schizophrenia but can trigger its appearance
4. Treatments
a. Psychological treatments
i. Family therapy
ii. Cognitive behavioural therapy
b. Medications
i. Schizophrenia (psychotic episodes) is caused by an excess of dopamine in the
brain and antipsychotics are designed to correct the balance
ii. Typical antipsychotics
1. Haloperidol, chlorpromazine
2. Side-effects; stiffness, restlessness, sleepiness, blurring of vision,
involuntary movements of facial and neck muscles
iii. Atypical antipsychotics
1. Clozapine, olanzapine,
2. Side effects; weight gain, sexual dysfunction, hypertension, diabetes,
neutropenia
c. Social
i. Benefits
ii. Accommodation
iii. Daytime activities
iv. Social Support
v. Support for carers
5. Prognosis
a. Roughly 20% of people with schizophrenia recover completely after the first episode but
70% will have breakdowns in the future. Continuing to take medications will decrease the
chances of these breakdowns from happening
b. Help available from community mental health teams consisting of psychiatrists,
psychologists, therapists and nurses.
103
Fundoscopy Reporting Technique
How youre supposed to report a fundoscopy examination
1. Optic disk
a. Colour (pale => atrophy)
b. Cup (glaucoma)
c. Contour (inflammation, infection, papilloedema)
2. Haemorrhages
a. Dot haemorrhages (microaneurysm)
b. Blot haemorrhages (bleeding capillary)
c. Flame haemorrhages => hypertensive retinopathy
d. Pre-retinal haemorrhages (due to new vessel formation)
3. White lesions
a. Exudates
b. Cotton wool spots
c. Drusen pale lesions discretely scattered in macula (ARMD)
d. Laser scars
e. Atrophy
Background
o Exudates
o Dot haemorrhages
o Blot haemorrhages
Pre-proliferative
o Cotton wool spots
Proliferative
o Pre-retinal haemorrhage
Eye drops
Tropicamide anticholinergic. A weak papillary dilator (action lasts for 4-6 hours) used to
facilitate examination of the fundus
Phenylephrine 1-adrenoceptor agonist. A papillary dilator also. Mydriasis occurs within 60-90
minutes
Cyclopentolate anticholinergic also
Oxybrupocaine a topical local anaesthetic
Fluorescein + proxymetacaine detection of lesions / foreign bodies
104
Side 0 Normal retina
Slide 1 Senile macular degeneration Disc appears normal but unusual pigmentation at the macula.
(The retina is quite pale). This patient also has drusen which are asymptomatic nodules occuring in the
choroid.
Slide 2 Central retinal vein occlusion: Typical stormy sunset appearance with engorged veins with
haemorrhages alongside them. (disc cant really be seen; it looks like an exploding sun. Cant see the
veins on the disc).
Slide 3 Hypertensive retinopathy: The retinal arteries have become narrow and tortuous. In more
advanced cases haemorrhages and star burst exudates occur together with papilloedema. (The disc
margins are not very obvious. Otherwise not much else wrong)
Slide 4 Papillodeoma: The disc is swollen and the disc margin has disappeared. The veins are congested
(disc margins cant be seen but can still see the vessels over the disc, unlike CRVO. Also the disc is in the
middle of the slide on this one)
Slide 5 Disc cupping: Here the degree of cupping is mild but suggestive of glaucoma. As the condition
progresses, the optic disc becomes pale and the cup wider and deeper. (the centre of the disc is REALLY
PALE/BRIGHT YELLOW)
Slide 6 Optic atrophy: The optic disc is pale and the condition is associated with gradual loss of vision. It
may be secondary to a number of conditions including glaucoma, retinal damage, ischaemia and
poisoning. (The whole disc is really yellow)
Slide 7 Mild background diabetic retinopathy: Haemorrhages and microaneurysms can be seen. (nasal
half of the disc cant really be seen. A few haemorrhages and dots but not much else)
Slide 8 Background diabetic retinopathy: Areas of hard exudates and some evidence of macula
involvement. (Disc is fine. Quite a lot of hard exudates which are on the edge of the macula with a small
cluster in the middle)
Slide 9 Preproliferative diabetic retinopathy: with haemorrhages, microaneurysms and hard and soft
exudates. (Less hard exudates than slide 8. Soft exudates at the very top and bottom.)
Slide 10 Preproliferative diabetic retinopathy: extensive haemorrhages and exudate formation and a
preretinal (subhyloid) haemorrhages. (The preretinal haemorrhage is really obvious)
Slide 11 Proliferative diabetic retinopathy: with new vessel formation. (Paler retina. Hardly any vessels
in macula area. Really thin vessels on and around the optic disc.)
Slide 12 Diabetic retinopathy recently treated with laser photocoagulation: (Loads of white dots pan-
retinally)
105
Mental Health Act
You are an psychiatry SHO who has received a call from a GP regarding one of his patients being stuck in
a tree. He wants to know whether he can use a section of the MHA to detain the patient. Please answers
his questions and advise him on the best course of action.
Hi, Im Dr Ginsberg, I wanted to ask you about one of our patients. He is stuck in a tree and is refusing to
get down. His family say that he has been up the tree for 16 hours. He thinks that there are people after
him and that they are surrounding the tree. He appears frightened of them and is worried that they will
hurt him if he doesnt get down. He shouts abuse and threatens strangers that walk past. He has not
actually hurt anyone and nor has he ever in the past. He has a previous history of paranoid schizophrenia
diagnosed 8 years ago. We dont think he has taken any substances although he is known to have in the
past. We cannot seem to get close enough. He has been in contact with the local AOT team, until 2 weeks
ago.
1. When is it justified to use the MHA?
The patient is suffering from a mental disorder that is of nature and degree to merit treatment in
hospital and that such treatment cannot be provided without detention.
Refuses to go to hospital
Risks to: patients health and safety and protection of others
What is a mental disorder? it is any disorder or disability of the mind
2. What section can I bring him in under? Would I be able to to get the police to bring him in on a Section 136?
a. Section 2 28 day assessment order where you can treat as long as its part of the assessment process
b. Section 136 applies to people that police suspect of having a mental illness which confers immediate
risk. Taken to a place of safety where the duty psychiatrist makes an assessment and discharges
detainment not merited. Or the MHA assesment deems it suitable for Section 2 or 3.
c. Section 4 Emergency treatment order, probably not warranted.
3. How many people do I need to make an assessment? What else do I need?
a. Assessment order, lasts 28days
b. Needs one Section 12 approved doctor plus another doctor (usually patients GP) and an AMHP
usually psychiatrist and GP joint assessment
c. Can take place anywhere
4. What happens next?
Medical Recommendation Form (MRF) is given to the AMHP to apply for the section. The AMHP applies, the 2
doctors recommend it.
What should I do if I we cannot bring him is in a peaceful way?
106
Headache History
Cheryl Cole is a 23 year-old lady, presenting with a 1 month history of headaches, which are unilateral and
throbbing in nature. She gets them on average 3 times a week. They usually last several hours, and
sometimes they dont improve unless she goes to sleep, in which case she would wake up headache-free
(however, it is quite difficult for her to fall asleep as the headache is so sever).
The headaches are preceded by visual distortion about an hour before their onset, lasting about 15
minutes. Cheryl also experiences severe nausea with these headaches and on a few occasions has vomited
also.
They are worsened by routine activity, and Cheryl is unable to attend work when the headache is present.
She feels that chocolate and cheese may be triggers. The only thing that helps is lying in a dark room. She
has tried paracetamol and Nurofen, but neither improved her symptoms.
Her mother suffers from migraines, and Cheryl is worried that she may be having the same problem.
She is particularly concerned, as she is being forced to take a lot of time off work during a very stressful
season where many deadlines are due, and would like medicine that can improve her headaches.
1. Was hands and introduce
2. HPC:
Duration, Onset, frequency, severity, location, nature of headaches
Aura? (visual/auditory/sensory/speech, its length and how long prior to the actual headache it
occurs)
N + V?
Photophobia/phonophobia?
Aggravating factors: light, routine activity
Triggers: Chocolate, cheese, alcohol, exercise, caffeine, anxiety, travel
Possible causes: stress/tension, medication overuse (ask specifically about analgesics containing
codeine, COCP)
3. Rule out alarm signs:
Fever
Neck stiffness
Rash
Fits
Reduced consciousness
Travel abroad (?malaria)
Trauma/head inury
Tenderness in scalp (temporal arteritis)
Loss/ change in vision
Loss of power in limbs
4. PMHx (diabetes, clotting disorders)/FHx/SHx (smoking, alcohol)
5. ICE
6. Summary
Discuss diagnosis, differentials, investigations and management with the examiner

1. Diagnosis:
Migraine, because:
o Chronic (1 month history)
o Unilateral, throbbing
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o Preceded by aura
o Associated N+ V
o Laying in a dark room helps
o Triggered by chocolate and cheese
2. Differentials:
Tension headache
Cluster headache (pain is usually around the eye, each headache occurs about twice a day and
only lasts 15-160 mins)
Chronically raised intracranial pressure (typically worse on waking, focal signs including vomiting,
visual disturbances epilepsy, mental change)
Medication misuse (not on COCP, and rarely uses analgesics)
Sinusitis/otitis media (no coryza-like symptoms, fever or earache, more acute onset)
Less likely causes:
o TIA (too young)
o Antiphospholipid syndrome
o AV malformation
o Meningitis (acute onset, no neck stiffness, fever, rash)
o Encephalitis (acute onset, no fever, fits)
o Subarachnoid haemorrhage (acute onset)
o Head injury (no Hx of trauma, acute onset)
o Glaucoma (too young)
o Temporal arteritis (too young)
3. Mx
o Non-pharmacological:
o Ice packs or warm packs
o Spinal manipulation
o Rebreathing into paper bag
o Weight loss (if obese)
Prophlaxis (if frequency more than twice a month- Cheryl meets this criteria):
o 1st line: Pizotifen, propranolol, amitryptiline
o 2nd line: sodium valpoate, NSAIDs, gabapentin, topiramate
Rx:
o Aspirin
o Paractamol
o Sumatriptan
o Ergotamine
TYPES
Secondary Headache
Raised Intra-cranial pressure
Low pressure headaches
Meningeal irritation
Giant cell arteritis
Primary headaches
Migraine
Abnormal sensory sensitisation
o Light, sounds, smell and movement
Cluster Headache
Tension-type headache AND Chronic daily headache
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Bi-Polar Affective Disorder
Explain Lithium to Mrs. Jones, a 30 year-old lady, who has had 2 past episodes of BPAD
Mark scheme
Wash hands
Introduce and check patients name
Check patients understanding of BPAD

o Mood disorder
o Associated with periods of extreme highs and/or lows, which impair daily functioning
Check patients understanding of need for lithium

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

o Weight gain
o Increased thirst and need to go for a wee
o Tremor- a bit shaky
o Skin problems
o Memory/concentration problems
o Hypothyroid- underactive
o Renal dysfunction- can affect kidneys
o Cardiac t wave flattening or inversion- can affect heart
o Leucocytosis- more at risk of infection
o Teratogenecity- baby at risk if pregnant, strongly advised to avoid pregnancy while on it
Explain contraindications
o Pregnancy, breastfeeding
o Renal insufficiency- kidney problems
o Thyroid disease
o Heart conditions
o Neurological conditions eg Parkinsons, Huntingtons
Ask if patient is on any contraindicated drugs

o Diuretics
o ACE-is
o NSAIDs
o Antipsychotics
Explain that the likelihood of getting side effects will be reduced by careful, regular monitoring of
the drug levels in the blood
o Every week until stable for 4 weeks in a row, then every 3 months thereafter
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o Particularly to prevent toxic syndrome at levels of 1.5 or above
1.5-2: N + V, apathy, coarse tremor (shaking), ataxia (walking affected), muscle
weakness
>2: nystagmus (abnormal eye movements), dysarthria (slurred speech),
decreased BP and urine output, hyperactive reflexes, , impaired consciousness,
drowsiness, coma
o Other blood tests to make sure the at risk organs of the body havent been affected
Kidney function- every 6 months
TFTs- every 12 months
Also, prior to starting rx, following tests must be done to ensure that the at risk systems arent
already compromised, as starting lithium would then put them at further risk
o FBC (lymphocytes)
o U + E (kidneys)
o TFT
o Pregnancy
o ECG
o Weight
Any alternatives? Or if lithium doesnt work?

o Valproate, Carbamazepine
o ECT
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Lithium toxicity written
Indications for lithium (give 2 main uses)
Prophylaxis of bipolar affective disorder
Augmentation of treatment-resistant depression
Acute Mania
Adjunct to antipsychotics in schizoaffective disorder and schizophrenia
Lithium side-effects
Polydipsia, polyuria, weight gain, oedema, fine tremor, concentration and memory problems,
hypothyroidism, impaired renal function, t-wave flattening or inversion, leucocytosis,
teratogencity
Toxicity
1.5-2 mmol/L Nausea, vomiting, apathy, coarse tremor, ataxia, muscle weakness
>2 mmol/L Nystagmus, dysarthria, impaired consciousness, hyperactive tendon reflexes, oliguria,
hypotension, convulsions, coma
What two things would you advise a patient with a lithium level >2.
1. Stop taking it
2. Go to hospital
3. Drink plenty of water
What could be done in the case of lithium toxicity / overdose?

Whole bowel irrigation
If no clinical manifestations, stimulate urine production by drinking fluids (not diuretics)
Haemodialysis may be needed
Benzodiazepines may be required for agitation
Drugs that can increase lithium levels

Diuretics (especially thiazides)
NSAIDs
ACE-inhibitors
Conditions that will increase lithium levels

Renal insufficiency
o Dehydration
o In the elderly
o Kidney failure
Sodium depletion
Time after lithium dose that blood tests should be taken

Lithium blood tests need to be taken at least 12 hours after the last dose of lithium to make sure
the test is reliable.
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Management of psoriasis
1. Lifestyle changes: avoid

a. Stress
b. Smoking
c. Alcohol
d. Obesity (suggest weight loss?)
e. Sunlight
f. Trauma-related sports e.g. rugby
g. Drugs- B-blockers, lithium, anti-malarials
2. Emollients
a. Act as a barrier to cutaneous fluid loss, relieve itching and help replace water and lipids
therefore restoring the barrier function of dry skin.
b. Regular general application
c. Ointments, creams, tars, lotions
3. Topical agents
a. Applied only to the diseased skin
i. Coal tar: normalises keratinocyte growth patterns, antipruritic + antimicrobial
ii. Vitamin D: calmodulin inhibitors (calcipotriol)
iii. Vitamin A: tazarotene
iv. Dithranol
v. Steroids: reduce the superficial inflammation within plaques. However, relapse
usually occurs on cessation and tachyphylaxis is observed.
1. Mild - hydrocortisone
2. Moderate betnovate
3. Potent betamethasone
4. Very potent - dermovate
4. Phototherapy
a. UVB- Side effects include skin burn, increased risk of skin malignancy (with chronic use),
Contraindicaions are SLE, previous skin malignancy, xeroderma pigmentosum)
b. PUVA- Side effects include skin burn, skin pigmentation, increased risk of skin
malignancy, cataracts (eye protection worn to prevent this)
c. Excimer laser- like UVB, but more precise
d. Procedure- the lesions are exposed to UV rays (light) in the hospital or in clinic, and in
PUVA therapy, a drug called psoralen is taken orally or applied as a paint on the skin
prior to the light therapy
5. Systemic agents
a. Oral Vit A analogue (acitretin)
i. SE: liver damage, teratogenecity (women must remain on COCP for 2 years after
stopping treatment)
ii. CI: liver impairment, hyperlipidaemia, DM
b. Methotrexate
i. Reduces epidermal skin cell turnover
ii. SE: myelosuppression (ie risk of infections), heptotoxicity, pulmonary toxicity,
teratogenecity; Regular blood tests required to monitor this toxicity
c. Ciclosporin
6. Biological agents
a. Infliximab, etanercept
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Migraine history
Mark Scheme:
1. Introduction
2. Pain
a. SOCRATES
b. Aggravated by movement, photophobia, phonophobia, osmophobia
3. Prodrome
a. Psychological; depression, irritability, euphoria
b. Constitutional; sluggishness, anorexia, hunger
c. Neurological; dysphasia, yawning, hyperosmia
d. Autonomic; urination, diarrhoea, constipation
4. Aura
a. Visual; spots, flashing lights, zigzag lines
b. Sensory; tingling, paraesthesia, numbness
c. Motor; limb weakness, dysphasia
5. Other symptoms
a. Nausea & Vomiting
b. Morning headache
c. Focal signs
d. Fever
6. Previous history of headache
7. Family history
8. Explains migraines are common. 15% of people in their lifetime.
9. Management
a. Avoid triggers
b. Regular sleep, exercise, meals, work habits & relaxation
c. NSAIDS or paracetamol
d. Disease-specific treatments
i. Triptans
ii. Ergotamine derivatives
iii. Anti-emetics
e. Prophylaxis
i. Pizotifen
ii. Beta-blockers
iii. TCA
iv. Sodium valproate
v. Topiramate
vi. Methysergide
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OCD History
Please talk to Anna Jones. A 35-year-old married woman has been referred by her companys
occupational health department as she does not appear to be coping at work
Mark Scheme:
1. Introduction
2. Assess obsessions and compulsions
a. Eliciting obsessions or compulsions if necessary
i. Do you worry about contamination with dirt even when you have already
washed?
ii. Do you have awful thoughts entering your mind despite trying hard to keep them
out?
iii. Do you repeatedly have to check things that you have already done (lights, taps)?
iv. Do you find that you have to arrange, touch or count things any times over?
3. ICD-10 guidelines for OCD
a. Obsessions or compulsions present for at least 2 successive weeks
i. And a source of distress (do you think think these thoughts are unreasonable?)
b. Are they your thoughts or do you feel like theyre being put into your mind?
c. Are the thoughts unpleasant and repetitive?
d. What happens if you try to stop thinking these thoughts?
e. Does washing your hands making you feel better or just less anxious?
4. Assess for depression
a. Have you ever suffered from depression?
b. Have you been feeling low, lost interest in things you normally enjoy or been very low on
energy?
5. Assess for other anxiety disorders
a. Does anything provoke/stimulate these thoughts?
6. Assess for eating disorders
a. Morbid fear of fatness?
b. Does not believe thoughts are unreasonable
7. Assess for psychotic disease
a. Are these thoughts not your own and being put in your mind?
b. Hallucinations?
8. Management
a. Mild effect on life: CBT with exposure therapy and response prevention
i. Self-help materials
ii. On the phone
iii. In a group
iv. individually
b. Moderate: SSRI or CBT
c. Severe: Both
Questions to ask and why
ICD-10 criteria for the diagnosis of OCD
Obsessions/compulsions daily for at least 2 consecutive weeks

Must interfere with the patients life
Known to be their own thoughts
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Obsessions are horribly repetitive
Compulsions give no relief apart from anxiety relief
Obsessions recur despite resistance
What seems to be the problem?

How long has this been a problem? How many days a week?
Are they distressful?
Do they interfere with your daily activities?
What happens if you dont wash your hands?
How often do you have the obsessions?
Does washing your hands make you happy or just relieve anxiety?
What happens if you actively try to not think of germs on your hands?
Do you ever suffer from low mood?

Any thoughts of harming yourself?
Alcohol or drug use?
Ever hear voices?
Do you worry about contamination with dirt even when you have already washed?
Do you have awful thoughts entering your mind despite trying hard to keep them out?
Do you repeatedly have to check things that you have already done (stoves, lights, taps, etc.)?
Do you find that you have to arrange, touch or count things many times over?
115
Idiopathic Parkinsons Disease
Physical signs
Akinesia
o Bradykinesia
o Micrographia
o Poverty of facial expression (hypomimia)
o Difficulty in changing position
o Quiet & monotonous speech
Gait
o Festinant gait
o Flexed or stooped position
o Slow turning and initiation of movement
o Reduced arm swing
Rigidity
o Leadpipe rigidity
o Cogwheel rigidity
Resting tremor
Cranial nerves
o Mild impairment of upgaze
o Tremulous eyelids
o Glabellar tap sign
o Drooling (sialorrhoea) because of difficulty swallowing
o Decreased blink rate
Drug-induced Parkinsonism; phenothiazines, metoclopramide

Progressive Supra-Nuclear Palsy
o Failure of downgaze, upgaze then horizontal gaze
o Early postural instability
o Dementia
Multiple System Atrophy
o Autonomic failure (Shy-Drager syndrome)
Sexual, bladder dysfunction, postural hypotension
o Olivopontocerebellar atrophy
Ataxia, dysarthria, tremor
o Parkinsons features
Corticobasal degeneration
Treatments
What are 2 first line treatments?

1. Levodopa (+ peripheral dopa decarboxylase inhibitor)
2. Non-ergot-related dopamine agonists ropinirole, pramipexole, rotigotine
116
You have been asked to see Jane Adams, a 33-year-old single mother, who has found it difficult coping
after giving birth to a son 2 months ago. Her community nurse has noted that she has been withdrawn
and tearful recently. They mention that she struggled throughout her pregnancy, and that her partner
left her 7 months ago. She doesnt have much support at home.
Interview her and take a history of disturbance of mood. Assess Aspects of risk
I am Jane Adams, a 33-year-old single mother. I am depressed but willing to speak to somebody because I
have little support from friends or family. I have been feeling isolated for some time.
My mood has been low since a week after my son was born but has become worse since the baby started
crying a lot more a month ago. My mood
I have been feeling low all of the time; I get tearful and irritable and my mood doesnt vary throughout
the day. It takes me over an hour to get to sleep and I wake up early in the morning and cant get back to
sleep. My appetite is reduced and Ive lost some weight. My concentration is poor, Ive been finding it
difficult to read baby books. I am pessimistic about the future. I dont see things getting better since I
have no support. I feel like a failure and feel unable to cope; I think I deserve it because Im a bad mother.
No psychotic features.
Over the last 2 weeks I have been wishing I were dead because I dont know how to cope. I have thought
about taking an overdose but havent really pursued this as an option. Initially I had hoped that my
mother would take my baby if I died but recently Ive been thinking about taking the baby with me
because I think hed be better off that way. These thoughts made me feel very guilty and often make me
cry myself to sleep.
I live in a council flat on my own. My partner left 7 months ago which left me distraught. I have been too
tired during this pregnancy to see any of my friends and I generally sit at home doing very little. I have
one or two close friends with children but have not seen them and would feel bad asking them for
support. I have struggled with basic cleaning and shopping. I havent worked since finding out I was
pregnant, I previously worked as a travel agent.
Mark Scheme:
1. Introduction; congratulations, hows the baby? Worried about anything?

2. Name, age, occupation
3. Duration of symptoms
4. Symptoms
a. Has your mood been low? (Diurnal variation?)
b. Have you felt really low on energy? More than previous pregnancies?
c. Have you stopped getting pleasure from things you normally like doing?
d. Have you been less able to concentrate on tasks?
e. Sleeping more or less than usual? Early morning wakening?
f. Lost or gained weight/appetite
g. Negative view of yourself, the world, the future?
5. Exclude baby blues
a. Onset within the first 10 days? Peaks between 3rd & 5th day. i.e. short duration
6. Exclude puerperal psychosis
117
a. Belief that other people are watching / want to harm you?
b. Feeling that the TV/radio is making reference to you?
c. Thoughts are being interfered with or read by anyone?
d. Hearing sounds or voices when nothing or nobody to make those sounds?
7. Assessment of risk
a. Suicide
i. Have you ever felt so down that you wished you were dead?
ii. Have you thought about how you would do this?
iii. Have you made any plans?
b. Harming the baby
i. Ever felt that you would harm your baby or end its life?
ii. Ever seen or heard anyone telling you to harm the baby?
iii. Would you act on these? Made plans?
8. Assessment of social circumstances and support network
a. Live in a house or a flat?
b. Live with family, other people or alone?
c. Single, divorced, separated, married?
d. Been in contact with friends? Enjoying hobbies?
e. Been coping with shopping and cleaning?
f. Currently working?
g. Do you see your parents? Do they help?
h. Financial support
9. Risk factors
a. How was the birth?
i. Complications
ii. Instrumental
iii. Caesarian
b. History of depression or psychiatric disease
c. Have you ever taken elicit drugs?
d. Do you drink alcohol? Did you drink during your pregnancy?
118
PTSD history
You are Mary Jones, a 32-year-old woman who was out with her husband 6 months ago when you were
both attacked.
6 months ago when walking home at night my husband was beaten unconscious by 3 men and suffered
major facial injuries. I was held forcibly and threatened with violence. I witnessed my husbands attack.
Since then I have been signed off work by my GP because of problems with mood, poor sleep, anxiety
and panic attacks.
Mark Scheme:
10. Introduction
12. History of traumatic event and perception of threat
a. Did you fear for your life?
13. Timing of onset of symptoms (within 6 months)
14. Did you contact the police?
15. Re-experiencing of event
a. Images, thoughts, flashbacks
b. Acting or feeling as if the event was reoccurring
c. Distressing dreams of the event
d. Intense physiological distress /reactivity at exposure to internal or external cues
16. Persistent avoidance
a. Avoiding thoughts, or conversations associated with the trauma
b. Avoiding activities, places or people that arouse recollection
c. Feeling of detachment from others
d. Restricted range of affect
e. Sense of foreshortened future (doom)
17. Increased arousal
a. Difficulty falling or staying asleep
b. Irritability or outbursts of anger
c. Hyper-vigilance
d. Exaggerated startle response
18. Other associated anxiety symptoms
19. Presence of depressive symptoms
20. Comorbid drug/alcohol misuse
21. Social support
a. Do they have children?
Acute Stress Reaction

Adjustment disorder
119
Radiology Stations
Cervical spinal cord MRI in the sagittal plane of a 28-year-old woman with polyphasic neuromyelitis
optica. (A) T1-weighted image showing thickening of the cord from C7 to T2 with patchy areas of subtle
intraparenchymal hyperintensity. (B) T1-weighted image, post gadolinium contrast administration,
showing several enhancing lesions from C7 to T2. (C) T2-weighted image showing a contingous area of
increased signal intensity spanning from C6 to T3.
What plane is this image in? sagittal

What abnormalities are shown? (A) Thickening of the cord, patchy areas of intraparenchymal
hyperintensity. (B) Thickening of the cord, several enhancing lesions. (C) Increased signal intensity
suggesting inflammation and demyelination i.e. a plaque
Diagnosis? Multiple Sclerosis
Where is the lesion? from C6 to T3
Would the lesion cause weakness in the shoulders? yes because C6 is affected which with C5 innervates
deltoid.
Would this patient present with a sensory level? - yes
Treatment? No cure available
Management of acute relapse
o Corticosteroids (methylprednisolone IV/PO)
Modification of the course of the disease
o Interferon-
o Glatiramer acetate
o Natalizumab twice as effective as interferon-
Control of symptoms
o Spasticity muscle relaxants; dantrolene, baclofen, tizanidine, diazepam
o Cerebellar tremor clonazepam, isoniazid, gabapentin
o Fatigue amantadine, selegiline
120
What plane? Axial
Abnormalities? Biconvex area of increased density; spread limited by adhesion of the dura to the skull =
Epidural haematoma. Effacement of the sulci and ventricles.
Treatment?
-Medical - I.V. Mannitol bolus, possibly artificial ventilation
Surgery horse shoe craniotomy flap. If patient deterioration is rapid, provide

temporary relief by means of a burr hole and craniectomy.
What plane? Axial

Abnormalities? Biconcave, concentric shaped, area of increased density spreading around the surface
of the cerebral hemisphere. Effacement of the sulci and right ventricle. Dilatation of the left ventricle due
to obstruction at the foramen of Munro. Midline shift
Treatment? Nurse in the head down position, evacuate haematoma through 2-3 burr holes. In patients
in whom conscious level is not depressed consider conservative treatment with steroids over several
weeks.
What plane? Axial
121
Abnormalities? Low density lesion with distribution matching the vascular territory of the middle
cerebral artery. Midline shift, effacement of the ventricles and sulci.
What time after the incident was the CT taken?
0 hours no change in density

3 hours no change in density
4 hours start to see hypodensity but not representing the entire area of infarction
30 hours may take up to this time to distinguish clearly the accompanying oedema as a
hypodense lesion from unaffected brain tissue
3 days infarcted area better defined and diminished in density
7 days infarcted area still hypodense
14-21 days infarction may appear to disappear due to relatively increased density values
30 days infarction becomes hypodense again and isodense to CSF
Treatment? Thrombolysis with alteplase if within 3 hours of onset and no contraindications

Aspirin within 24 hours of onset for 2 weeks.
What plane? Axial

Imaging modalitiy? T2 MRI
Abnormalities? Gross enlargement of the lateral ventricles (& effacement) = hydrocephalus.
In a communicating hydrocephalus, all ventricles will be enlarged
Which ventricles are dilated?
Is LP contraindicated? Yes, LP is contraindicated in non-communicating and communicating
hydrocephalus
Treatment?
Acute obstructive hydrocephalus urgent surgical management ventricular drain /

ventriculoperitoneal shunting
122
These are CT scans of gliomas
Infarct: What time after incident was it taken?

Treatment: Admission to stroke unit
Aspirin 300mg daily, modest benefit when given within 48hrs
of onset. Thromboysis; (15%-I.V. tissue plasminogen
activator.)
Territory;
Middle Cerebral Artery
123
d c
124
Explaining Ritalin treatment
Im Mrs Wright and my 8 year old son has been diagnosed with ADHD.
I have been recommended by my childs psychiatrist to have him take Ritalin.
I want to know;
What is it?
Why is it used?
What are the side effects?
How will you monitor my son?
Mark Scheme:

12. Establish reason for consultation
13. Explains Ritalin (methylphenidate) is a stimulant
14. It is not a cure, it only modifies the behaviour
15. Mode of action;
a. Indirect sympathomimetic
b. Increases release of dopamine and noradrenaline
16. Benefits
a. Control the difficult behaviours by increasing concentration and attention while
decreasing impulsivity
b. Effective in 70%
17. Investigations before treatment
a. Height, weight, blood pressure, LFTs monitored regularly
18. Side-effects
a. Decreased appetite
b. Anxiety
c. Insomnia
d. Tics
e. Hypertension
f. Seizures
g. Growth suppression
19. Drug holidays required
a. Long term use can lead to growth suppression.
20. Monitoring
a. Regular monitoring by a specialist so that response can be monitored
i. Height every 6 months
ii. Weight every 6 months apart from initial at 3 months
iii. Heart rate and BP every 3 months
b. Stop medication if no response after 1 month
c. Suspend treatment every 1-2 years to assess condition
21. Stopping the drug
a. Not addictive if correct dose taken
b. Avoid abrupt withdrawal
22. Other treatments
a. Cognitive behavioural therapy
b. Parent management training
c. Family therapy
d. Educational intervention
125
Management of school refusal because of bullying
Talk to Sarah Hurley whose 11 year old son is refusing to attend school because of bullying. She has
questions to ask and would like to know about management.
Qs
Could it be the bullying?
Could it be related to the stomach pain?
Child is threatening to kill himself if sent to school
Mark Scheme:
22. Introduction
24. Discuss aetiology
a. Separation anxiety
b. Specific fears
i. Travel to school
ii. Bullying
iii. School assemblies, specific classes
c. Family dynamics
i. The child wont return to school unless sees that both parents want this.
d. Depression
e. Psychiatric disease
25. Discuss risk factors
a. Smaller families or the youngest child or previously ill child
b. Anxious personality
c. Depressive disorder or OCD
d. Vulnerable mother (anxious, depressed, abused, ill, alone)
e. Absent father
f. Bullying at school
g. Learning difficulties
h. 5yrs Separation anxiety
i. 11yrs transfer to secondary school
j. 14-15yrs depression & schizophrenia
26. Discuss presentation
a. Onset?
b. When does the child express that they do not want to go to school
c. Is the child content when at home?
d. Do they express somatic complaints (headache, abdominal pain)?
27. Discuss further assessment
a. Exclude physical illness
b. See whole family
c. See child alone
d. See parents alone
e. Contact school
28. Treatment
126
a. Mild/acute
i. Return to school ASAP, agree date with school
ii. Support family to be firm despite distress
iii. Brief family therapy may help
b. Chronic
i. Communication essential
ii. Individual psychotherapy dynamic or CBT
iii. Family therapy
iv. Behavioural treatment of anxiety, e.g. desensitisation
v. Graded return
vi. Treat concomitant psychiatry disorder, incl medication
c. Prognosis
i. Very good for mild/acute/situational cases
ii. Severe/chronic
1. 20-30% dont get back to school (especially older children)
2. 1/3 develop adult neurotic disorder
Discuss with the school

Change school (extreme)
127
School Refusal
1. Child History
Identify the physical symptoms and take history accordingly
Why do you not want to go to school?
Do your parents know that you dont go to school? (differentiate from truancy)
Is there anything at school that you find particularly worrying? (bullying?)
Have there been any changes at school recently? (new teachers, new school, tests?)
How do you get on with your classmates?
How do you get on with your teachers?
Exclude physical illness
Exclude mental illness: low mood, anxiety, OCD
2. Parental History
Why do you think hes not going to school?
Have you ever left the child alone/ What happens when he is left to himself? (separation
anxiety)
How would you describe the character of the child? (loner, shy, overly dependent?)
How have you been feeling recently/low mood? (Depressed and dependent mother?)
How do you feel when the child is away from you/at school? (dependent mother)
Are both parents involved in looking after child? (divorce, separated parents?)
3. School/Teacher History
Find out about conduct and nature of relationships of child with teachers and classmates.
Treatment
Reassure parents that child may not be physically ill and when they refuse to go to school, they
may display physical symptoms as a way of expressing emotional distress
Try and get the child to return to school asap
Agree a date on which to return to school
Tell parents to be firm with their child
Therapies include: family, CBT, psychodynamic, behavioural therapies (graded return)
128
Taking a depression history
1. Introduction
2. How long have you been experiencing these symptoms? (at least 2 weeks)
3. [4+ symptoms required including 1 core symptom]
a. Core symptoms
i. Have you been feeling low? (depressed mood)
ii. Have you got little interest and enjoyment out of things you normally enjoy?
(Loss of interest and enjoyment)
iii. Have you been sleeping more or less than usual? (Reduced energy or increased
fatigability)
4. Other symptoms
a. Weight or appetite change
b. Insomnia or hypersomnia
c. Psychomotor agitation or retardation
d. Feelings of worthlessness or excessive or inappropriate guilt
e. Diminished ability to think or concentrate
f. Thoughts of death or suicidal ideation
Diagnostic criteria for depression ICD-10 uses an agreed list of ten depressive symptoms
Key symptoms:
persistent sadness or low mood;and/or
loss of interests or pleasure
fatigue or low energy
at least one of these, most days, most of the time for at least 2 weeks
o if any of above present, ask about associated symptoms:
disturbed sleep
poor concentration or indecisiveness
low self-confidence
poor or increased appetite
suicidal thoughts or acts
agitation or slowing of movements
guilt or self-blame
129
Explaining tricyclic antidepressants
Im Tom Jones. I have been diagnosed with moderate depression and have been advised to start tricyclic
antidepressant treatment.
I want to know;
What is it?
Why is it used?
What are the side effects?
Are antidepressants addictive?
How long do I have to take them?
Can I have any other kind of treatment?
If I take them, am I guaranteed to get better?
What happens if they dont work?
Mark Scheme:
24. Establish reason for consultation
25. Discusses principles of antidepressants
a. Response rates 50-60% will be improved
26. Explains probably mechanism of action
a. Depression seems to be caused by decreased neurotransmitters
b. Antidepressants work by increasing the amounts of chemical available
27. Reasons for using TCAs over other antidepressants
a. Sedative properties of amitryptyline and doseulepin can help with insomnia
28. Outlines starting antidepressants
a. Likelihood of side-effects in first few days
i. Some side-effects will relieve over time (more to do with GI disturbance and
anxiety in SSRI use)
b. It can take 4-6 weeks for antidepressants to work
i. Dont be disillusioned
29. Explains possible side-effects
a. Anti-muscarinic dry mouth, constipation, urinary retention, blurred vision
b. Anti-histaminergic sedation, weight gain
c. Anti-adrenergic postural hypotension
d. Cardiotoxic heart block, arrhythmias, ST-elevation
30. Explains principles of continuation and prophylactic treatment
a. Not addictive no tolerance, no craving if you dont take them
b. Medication continued until 6 months after remission of symptoms
31. Can be withdrawal effects if stopped suddenly
i. N+V, flu-like symptoms, agitation, sleep disturbance
ii. Taper dose over 6-8 weeks
32. What if they dont work?
a. Antidepressants are tried for 6 weeks before trying another
33. Outlines alternatives to antidepressants
a. Cognitive Behavioural Therapy
b. Interpersonal therapy
c. Psychodynamic psychotherapy
130
Sixth nerve palsy
Sixth nerve palsy. This is the most common isolated muscle palsy
Causes of 6th nerve palsy:
Wernickes encephalopathy
Tumour in cerebellopontine angle causing compression directly on nerve
Raised ICP compressing nerve against sharp edge of petrous temporal bone
Basal skull of fracture
Diabetes mononeuritis complex
Mastoid / middle ear infections
Suppurative middle ear disease
131
Part 2B
4th year Stations
Obstetrics and Gynaecology
132
Adult UTI
You are a GP registrar and have been asked to talk to Lisa Thompson, a 21 year old woman, who has just
been told she has a urinary tract infection. Please explain the diagnosis to her and your suggested
management taking into account any drug interactions.
I have been having symptoms of increased need to go to the toilet and pain on urinating for the last
week. I have not had a fever, loin pain or vomiting. I have just been told by the nurse that dip-sticking my
urine has shown that I have a urinary tract infection. Im interested in knowing how I got it and if its
treatable and any long term effects. I also would like to know how to prevent it from happening in the
future.
I have never had a UTI before. I do not have diabetes, I am not pregnant, and no problems with my
waterworks as a child.
I am currently taking the combined oral contraceptive pill
Mark scheme:

3. Clarifies symptoms with the patient
4. Explains test results to patient
5. Ask risk factors
a. Diabetes
b. Pregnant
c. Any problems with water works as a child
6. Give advice about how she caught it
a. 20-40% of women will have a UTI in their lifetime
b. Close proximity of anus and urethra
c. Urinary stasis
d. Sexual intercourse
7. Gives a management plan
a. Trimethoprim 200mg bd for 3 days
i. Continue taking the pill as usual and use an extra method of contraception while
taking the antibiotics and for seven days afterwards. If you get to the end of the
packet while taking the antibiotics start the next pack straight away
b. Increase fluid intake
c. Alkalinise urine potassium citrate solution
8. Advises on how to prevent further infections
a. Urinate frequently
b. Increase fluid intake
c. Double void (i.e. go again after 5-10 mins)
d. Void after intercourse
e. Wipe from front to back
9. Give leaflet regarding UTI
10. Checks correct information with patient
11. Takes history in an empathic manner
Nitrofurantoin side effects: N&V, diarrhoea, pulmonary fibrosis, lupus-like syndrome

Trimethoprim side effects: GI disturbances including N+V
Ciprofloxacin side effects: diarrhoea
133
OSCE: Downs syndrome
Mrs. Jones, 30 YO, has just given birth to a girl with Downs syndrome. She would like to ask you some questions.
1. Introduction
2.
3. Ascertain how much she knows about Downs, and whether she knew her child would have this
condition prior to her birth.
4. Will my child be able to walk and talk?
Downs syndrome can range from a mild to a severe condition, with variation in the degree of learning
difficulty and development of complications between individuals
It is hard to determine the severity at this stage... It should become more evident as the child gets older
and has more milestones that she should be achieving eg. Walking, talking, etc
However, most children with Downs seem to have delayed motor milestones, so your daughter will
probably walk and talk later than if she didnt have this condition
Furthermore, she is at more risk of hearing impairment, due to a higher risk of recurrent ear infections,
which could also affect speech development
5. Will she be able to go to normal school?
Again, it depends on the severity
May be able to go to normal school if very mild, might require an assistant in class, or may be better off
going to a special needs school
6. If I have any more children, will they have Downs?
7. How did this happen? Is it genetic? If so, how?
Extra chromosome 21 (should only have 2, but your daughter has 3, chromosomes are made up of genes,
so she has more genes than she should)
94% of these cases are due to something called non-dysjunction, which happens when the eggs are made
in the lady, one too many of the 21st chromosome are made and our child ends up with one extra. It is one
of those things that can just happen out of the blew. The risk of this increases with increasing age.
However, at your age the risk is only 1 in 900, which is less than the average risk for a woman (1 in 650). If
this is the cause of your daughters Downs, then the risk of another child having it is about the same,
though this rises with increasing age, to 1 in 37 by 44 years of age.
Only 5 % are due to something called an unbalanced Robertsonians translocation, which is a mutation that
you or your husband may hold. And if this is the cause for your daughter having Downs, the risk of a
further child having Downs is 10-15 % if it is you who carries this mutation, and 2.5% if your husband
carries it.
1% are due to something called mosaicism
8. Will my daughter have other health problems?
Not necessarily
But, problems that your daughter is at an increased risk of having are:
o Congenital heart defects (40%)- AVSD/VSD (these vary in severity, but can cause heart failure,
breathing difficulties and failure to thrive, and can be corrected)
o Duodenal atresia- narrowing or absence of a part of the bowel (duodenum), requires surgery
o Hirschprungs disease- usually presents at birth, with the infant not passing meconium (poo) in the
first 24 hours, constipation due to part of the large bowel becoming very narrow due to no nerve
supply, so the food contents/faeces cannot get past this point. Surgery can manage this problem.
o Increased susceptibility to infections
o Visual impairment from cataracts, squint, myopia (short-sightedness), congenital glaucoma
o Increased risk of leukaemia and solid tumours
o Hypothyroidism- check yearly
o Coeliacs disease- gluten intolerance- check at 2 years
o Epilepsy
o Alzheimers
134
Downs Syndrome
Mrs. Jones is 30 year old woman who has just given birth to a girl with Downs syndrome. She would like
to ask you some questions.
I am Mrs Jones and I am 30. Last night my daughter Claire was born and the doctors told me that she has
Downs syndrome. She is my first child. I know little about Downs syndrome except what these children
look like. On my antenatal scan they said that the baby was at risk of Downs syndrome but I did not want
any invasive tests and was hoping for the best.
My main questions are; What is Downs syndrome? Will she live for a long time? How did she get it? Is it
my fault? If I have another child will they have Downs syndrome?
Mark Scheme:
3. Congratulate mother on new baby and ask how she is
4. Ask daughters name
5. Ascertain what she already knows
6. Explain what Downs syndrome is
a. Common genetic condition. 1 in 1000 people will be born with Downs syndrome.
b. Its caused by the baby having all or part of an extra 21st chromosome in the bodys cells
c. Its not a disease and its not a hereditary condition, it occurs by chance at conception
7. Life expectancy
a. The overall outlook for individuals with Downs syndrome has improved dramatically
over the years
b. Life expectancy of somebody with Downs syndrome is now 60-65 years old
8. Will she be healthy?
a. Some medical problems are more common in people with Down's syndrome.
b. However, none of these problems are unique to Down's syndrome, and some children
with Down's syndrome are as fit and healthy as any other children.
c. 40-50% will be born with heart problems maybe requiring surgery
d. A significant number have sight and hearing impairment
e. Some have poorer immune systems, respiratory problems and problems with the gastro-
intestinal tract
f. There are screening programs to look for these conditions that are more common in
children with Downs syndrome
9. Cause
a. The cause of the extra chromosome is not fully understood in most cases
b. There is no way of predicting whether a person is more or less likely to make and egg or
sperm with 24 chromosomes
c. There is a definite link with advanced maternal age for reasons yet unknown.
d. Most children with Downs syndrome are born to mothers under 35 years old because at
his age women have higher fertility rates
10. Is it my fault?
a. What we do know is that no one is to blame. Nothing done before or during pregnancy
can cause Down's syndrome. It occurs in all races, social classes and in all countries
throughout the world. It can happen to anyone.
11. If I have another child will they have Downs syndrome?
a. Its unlikely
b. The chance of having a child with Downs syndrome only increases with maternal age
unless she is in a rare 4% of cases where one of the parents carries a mutation that can
cause Downs syndrome.
c. We can test either you and partner or her to see if this is the case
Contact the Downs Syndrome Association
135
Ethics & Law station: Contraception
Mr Desmond has come to see you today because he wants to know why his 14 year old daughter came to
the doctor yesterday. She will not tell him and doesnt want him to know. You know that she came in for
medication to treat menorrhagia.
He also wants you to answer another question.
I am Rob Desmond, Sarahs father; she is 14. I found out yesterday that Sarah came to see a doctor hear
yesterday and want to know why. Im her father and in order to protect her I have a right to know why
she was here and if she was given any medication or contraception.
The other question I have is regarding Sarahs step father who is married to her mother. I think hes
considering adopting her and I want to know what my rights would be if that were to happen.
Mark Scheme:
1. Appropriate introduction (name & role)

3. Empathetically acknowledges fathers anger & calms him down
4. Find out how he knows and whether Sarah has said she doesnt want him to know
5. Ask if he knows why Sarah does not want him to know
6. Explain the law
a. There is no law that imposes a duty on doctors to disclose information that a young
person wants to keep confidential
b. However in cases where the child is at risk of neglect or abuse, the Children Act of 1989
imposes a duty to disclose to the Child Protection Service and in Sarahs case this is
thought to not be a worry
c. The General Medical Council tells doctors in the UK that a young persons confidentiality
should be respected if the child is competent and not at risk of serious harm or putting
others at harm
d. By default children under 16 are not presumed to be competent
e. Children under 16 can prove to be competent if they show understanding of
i. What the treatment is
ii. Why it is being proposed
iii. Its benefits and risks
iv. The consequences of not going through with treatment
(Gillick vs HA 1985)
7. Talk to Sarah and let her know that you are worried about her and that she can talk to you if she
wants. She can also come back to us to discuss anything she wants.
8. If you currently are the legal father of Sarah you have parental responsibility and the legal right to
give consent on behalf of her.
9. A step-parent can apply on their own to adopt
10. If this happens it cuts off the childs legal relationship with the previous parent that had parental
responsibility
136
Part 2A
4th year Stations
Paediatrics
137
Pallor and Fatigue in a young female child
You are about to see the mother of a 2 year old girl who has just had her blood tested because of
symptoms of pallor and fatigue. Her blood results show a full blood count of 7g/dL with a microcytic,
hypochromic anaemia and low serum ferritin. Please explain the results to her and your suggested
possible management
I am a 32 year old, Emma Devereux. Debbie is a two year old girl who has been feeling tired for the last 4
weeks. She just doesnt seem to have as much energy as she would previously. She is short of breath
when she runs. My cousin mentioned the other day that she looked pale.
She drinks 3-4 bottles of milk a day (when asked say cows milk). She doesnt always eat her dinner and
doesnt eat red meat of vegetables.
She was born at 36 weeks and was in SCBU for a few weeks just to help her nutrition.
There is nobody in the family with any types of anaemia such as sickle cell anaemia or thalassaemia
If asked about any questions, ask will she need a blood transfusion?
Mark Scheme:
2. Takes a history
a. Symptoms: pallor, low energy, breathless, jaundiced, cyanosed?
b. Other sx: diarrhoea, vomiting, rash, fever, cough, UTI
c. Diet: fussy eater, drinks milk, no dark green veg, no meat, no bread?
d. PMHx: renal disease? Prematurity? GI symptoms (malabsorption)? Blood loss?
e. FHx: inherited anaemias
3. Explains diagnosis to mother
a. Low iron and small cells suggest an iron deficiency anaemia
b. This is common in children that drink a lot of cows milk
4. Explains management to mother
a. Dietary advice: eat red meat, dark green vegetables, bread, pulses
b. Take these foods with orange juice (vitamin C)
c. Avoid cows milk, tea and high fibre foods
d. Oral iron supplementation for at least 3 months.
i. Sytron (sodium iron edentate)
ii. Niferex (polysaccharide iron complex)
e. Blood transfusion should NEVER be necessary for dietary iron deficiency
Ideal:
1. Typical history
Demographic: Afro-carribean, Mediterranean, Indian: keep in mind haemoglobinopathies
Fussy eater, pica, likes drinking milk and not much else, someone comments the child in pale,
cannot keep up with other children at school; i.e. PE and during classwork. Generally low
energy/lethargy
Sx: pallor, low energy, breathlessness (rare because generally only if acute). Symptoms only occur
if the Hb < 7-8.
NORMAL Hb : 6 months to 6 years = 10.5 14

7 12 years = 11.0 16.0
Things to enquire about:
o Any chronic disease i.e. renal, prematurity
o GI sx malabsorption
o Blood loss
138
o Dietary history- iron intake
Watch for excessive milk drinking. Child becomes full up and therefore doesnt
want to eat other foods
o FHx inherited disorders
O/E
o Pallor; although not entirely reliable. Look at conjunctiva, palmar creases, palms and
soles
o Tachycardic possibly
o Jaundice
o Petechia / bruising
o Splenomegaly- suggesting haemolysis or marrow failure
Ix
o FBC, red cell indices. Reticulocytes, Pancytopenia, peripheral blood film
o Serum iron, ferritin, TIBC
o Coombs test
o Vitamin B12
o Hb electrophoresis
o Red cell enzymes: G6PD, pyruvate kinase
o BMAx
Blood results
o Microcytic, hypochromic anaemia (low MCV and MCH)
o Low serum ferritin
2. Explaining the blood results

Do wiper etc.
The blood results show that blahs cells are slightly smaller and the value for ferritin which gives
us an indication of the iron stores is low.
This point to a most likely diagnosis of iron deficiency anaemia in light of the history of drinking
too much milk and not eating a balanced diet.
3. Dietary stuff:
Elemental iron requirement per day: 1mg/kg/day
DO EAT: red meat (beef lamb), Liver, Kidney, oily fish, pulses, beans, dark green vegetables
broccoli, spinach. Nuts and seeds, breast
AVOID; cows milk, tea because tannin inhibits iron uptake, high fibre foods because too much
also inhibit iron absorption.
4. Management:
Dietary advice as above. Vit C or orange juice.
Oral iron supplementation: best tolerated and dont stain teeth
Sytron (sodium iron edentate)
Niferex (polysaccharide iron complex)
Iron supplementation for 3 months. It takes 3 months to replace it. (Hb should rise 1g/dL per
week)
Blood transfusion should NEVER be necessary for dietary iron def.
Iron def with normal Hb (i.e. biochemical evidence showed by low serum ferritin)
Controversial whether to treat b/c toxicity etc.
Provide dietary advice, offer option of additional treatment with iron supplements
139
OSCE scenario: childhood Anaemia
You are about to see the mother of a 2 year old girl who has just had her blood tested because of
symptoms of pallor and fatigue. Her blood results show a full blood count of 7g/dL with a microcytic,
hypochromic anaemia and low serum ferritin. Please explain the results to her and your suggested
possible management.
I am a 32 year old, Emma Devereux. Debbie is a two year old girl who has been feeling tired for the last 4
weeks. She just doesnt seem to have as much energy as she would previously. She is short of breath
when she runs. My cousin mentioned the other day that she looked pale.
She drinks 3-4 bottles of milk a day (when asked say cows milk). She doesnt always eat her dinner and
doesnt eat red meat of vegetables.
She was born at 36 weeks and was in SCBU for a few weeks just to help her nutrition.
There is nobody in the family with any types of anaemia such as sickle cell anaemia or thalassaemia
Mark Scheme:
2. Takes a history
a. Symptoms: pallor, low energy, breathlessness, jaundiced, cyanosed?
b. Other symptoms: diarrhoea, vomiting, rash, fever, cough
c. Diet: fussy eater, drinks milk, dark green vegetables, bread
d. PMHx: renal disease? Prematurity? GI symptoms (malabsorption)? Blood loss?
e. FHx: inherited anaemia?
3. Explains
Explain anaemia to a mother explaining that it is likely to be due to iron deficiency

5. Typical history
Demographic: Afro-carribean, Mediterranean, Indian: keep in mind haemoglobinopathies
Fussy eater, pica, likes drinking milk and not much else, someone comments the child in
pale, cannot keep up with other children at school; i.e. PE and during classwork.
Generally low energy/lethargy
Sx: pallor, low energy, breathlessness (rare because generally only if acute). Symptoms
only occur if the Hb < 7-8.
NORMAL Hb : 6 months to 6 years = 10.5 14

7 12 years = 11.0 16.0
Things to enquire about:
o Any chronic disease i.e. renal, prematurity
o GI sx malabsorption
o Blood loss
o Dietary history- iron intake
Watch for excessive milk drinking. Child becomes full up and therefore
doesnt want to eat other foods
o FHx inherited disorders
O/E
o Pallor; although not entirely reliable. Look at conjunctiva, palmar creases, palms
and soles
o Tachycardic possibly
o Jaundice
o Petechia / bruising
140
o Splenomegaly- suggesting haemolysis or marrow failure
Ix
o FBC, red cell indices. Reticulocytes, Pancytopenia, peripheral blood film
o Serum iron, ferritin, TIBC
o Coombs test
o Vitamin B12
o Hb electrophoresis
o Red cell enzymes: G6PD, pyruvate kinase
o BMAx
Blood results
o Microcytic, hypochromic anaemia (low MCV and MCH)
o Low serum ferritin
6. Explaining the blood results

Do wiper etc.
The blood results show that blahs cells are slightly smaller and the value for ferritin
which gives us an indication of the iron stores is low.
This point to a most likely diagnosis of iron deficiency anaemia in light of the history of
drinking too much milk and not eating a balanced diet.
7. Dietary stuff:
Elemental iron requirement per day: 1mg/kg/day
DO EAT: red meat (beef lamb), Liver, Kidney, oily fish, pulses, beans, dark green
vegetables broccoli, spinach. Nuts and seeds, breast
AVOID; cows milk, tea because tannin inhibits iron uptake, high fibre foods because too
much also inhibit iron absorption.
8. Management:
Dietary advice as above. Vit C or orange juice.
Oral iron supplementation: best tolerated and dont stain teeth
Sytron (sodium iron edentate)
Niferex (polysaccharide iron complex)
Iron supplementation for 3 months. It takes 3 months to replace it. (Hb should rise 1g/dL
per week)
Blood transfusion should NEVER be necessary for dietary iron def.
Iron def with normal Hb (i.e. biochemical evidence showed by low serum ferritin)
Controversial whether to treat b/c toxicity etc.
Provide dietary advice, offer option of additional treatment with iron
supplements
141
OSCE Scenario BRONCHIOLITIS
You are a Paediatrics SHO working in the A&E department. Emma is a 4 month old girl who has been
brought in by her mother. She complains that Emma has had a runny nose and seems breathless. Take a
history with a view to making a diagnosis. Be prepared to discuss management options and differentials.
Hi, I am Jane Foster. I am a housewife who takes care of my two children. Emma has had this flu for the
last few days and has not really been feeling well. She has a cough, which just sounds like a normal cough
and she is wheezy; she is not bringing up any phlegm. She looks like she is struggling with breathing and
looks like shes breathing faster than normal. She has not stopped breathing at any time. She is not eating
as well as she usually does and has had a slight fever over the last two days (38.5 degrees). She has had
all her immunisations and had a wet nappy this morning. She has just started grabbing or reaching for
food so I have been letting her eat finger food. She drinks aptamil formula milk, around a 2 bottles a day.
She has not had any diarrhoea.
Emma was born vaginally at 38+6 weeks and weight 7lbs 4 oz. There are no concerns with her
neurodevelopment. She is smiling and making cooing noises. She just started to roll and sit up supported
over the last a few days.
No previous hospital admissions or ITU stays. She has not has this before. My cousins son came over 5
days ago and he was also a bit snotty and had a cough. I am worried because of her difficult breathing.
Mark Scheme:
2. Establishes nature of problem
3. Takes comprehensive history of illness
a. Cough: Onset, duration, when in the day, sputum?
b. Shortness of breath: wheeze, increased respiratory rate, apnoea?
c. Other symptoms: fever, diarrhoea, ear ache, drinking and eating?
d. Dehydration: wetting nappies, soiling nappies, change in eyes?
4. Takes comprehensive history of the neonatal period
a. Gestation?
b. Method of delivery?
c. Complications in pregnancy?
d. Admission to ITU?
5. Takes full background history developmental and PMH
1. Drug history asks about immunisations, medications and allergies
6. Asks about family history of childhood respiratory infections or currently infected contacts
7. Checks correct information with mother
1. Typical History
Age: aged between 1 9 months
Typically causes winter epidemics
Spread: typically epidemic by contact with respiratory secretions
Sx: too breathless to feed, coryza, breathless, slight fever, characteristic dry/moist cough,
apnoeic episodes but otherwise well no signs of sepsis
Signs: tachypnoea > 50, fever (38.5 39 degrees), nasal flaring, subcostal and intercostals
recession, chest hyperinflation, B/L fine crackles, WHEEZE on auscultation, cyanosis if severe.
142
Use of accessory muscles and expiratory grunting. Liver palpable because of hyperinflation of
lungs with depression of diaphragm.
Apnoea: prems, infants < 6 wks, chronic lung or heart disease more likely to be severe
Causes: RSV (adenovirus, rhinovirus, parainfluenza, metapneumovirus)
2. Investigations
FBC, U&E, CRP, ESR
Septic screen: NPA (direct fluorescent testing), Urine dipstick (perhaps culture)
CXR: hyperinflation and patchy infiltrates
Apnoea monitor
Pulse oximeter/Sats
3. Management
Hx and Ex
Check ABC
Admit?
i. Mild Feeding well, RR<40bpm, minimal recession and O2>92% = HOME
ii. ADMIT Difficulty feeding, moderate tachypnoea > 40bpm, marked recession and 02
sats < 92% RA.
Isolate with barrier nursing to prevent spread because RSV is very infectious
Supportive treatment: hydrate using NG tubes (tube blocks off nasal airways and stomach full
of milk may splint the diaphragm and exacerbate dyspnoea) or IV. Treat hypoxia with
humified oxygen via nasal cannulae or headbox.
Sometimes may need assisted ventilation
No steroids, antibiotics (only if secondary infection or indicated by rapid deterioration),
bronchodilators sometimes used but not thought to have much effect.
Palivizumab (mAb) for high risk patients to prevent bronchiolitis or reduce the severity of it.
4. Prognosis
Most cases resolve in two weeks - 50% of continue to have cough etc for a few years. A
subset of children may go on to develop asthma.
5. Differentials
Pneumonia ; look more unwell, CXR showing consolidation (+ parapnemonic effusion or
empyema) , end-inspiratory coarse crackles. Poor feeding, cough, lethargy and cyanosis.
Decrease O2 sats
Transient early wheezing; with viral infections, increased risk in preterm and maternal
smoking
Atopic asthma recurrent wheezing, eczema and positive FHx
Non-atopic wheezing following viral LRTI, increased wheezing during the first 10 years of
life
Cardiac failure: respiratory distress, HPM, heat murmur
Inhaled foreign body
Cystic fibrosis
Whooping cough, Croup (typically sealion like barking cough and stridor)
143
Child UTI
You are a paediatric SHO and have been asked to talk to Mary Wiseman, a 21 year old woman, whose son
is being investigated; your consultant suspects that he has a urinary tract infection. Please explain the
diagnosis to her, investigations required and your suggested management.
My son Darren is 7 months old and has symptoms of fever of 39C and poor feeding, hes also been sick
twice today and is not wetting his nappies. The doctor says that he thinks Darren might have a UTI and
needs to be investigated. Please tell me what youre going to do next
Im interested in knowing how he got it and if its treatable and any long term effects. I also would like to
know how to prevent it from happening in the future.
He has never had a UTI before.
Mark scheme:

15. Clarifies symptoms with the parent
16. Explains test to parent
a. Urine required for dipstick and MC+S
b. Clean catch urine preferred
c. Urine collection bag as alternative
17. Explains management
a. Trimethoprim for 7-10 days (possibly I.V cefalexin for the first 4 days if oral medication
not possible) (if UTI is confirmed in a child over 3 months with a fever of <38C then
lower UTI treatment is trimethoprim for 3 days)
18. Explains that urinary tract infections in boys are rare and risk factors
a. Vesico-ureteric reflux
b. Obstructive uropathies (urethral valves)
c. Neuropathic bladder
d. Dysfunctional elimination syndrome
e. Habitual infrequent voiding of urine
19. Explains the need to investigate following resolution of UTI
a. 5-15% of children can develop scarring after their first UTI
b. After the infection has been treated, if it turns out to be a difficult UTI or because he is a
boy he may have an ultrasound scan
c. Depending on the results of the ultrasound can we may give him antibiotics for 3 months
to prevent further infection until we investigate him with an MCUG in 3 months time
20. Give leaflet regarding UTI
21. Checks correct information with parent
144
Crohns disease history
You have been asked to take a history from Mrs Butcher about her sons recent gastro-intestinal illness.
I am the mother of Jacob who is 14 years old. For the last 3 months he has been feeling really tired and
terrible with abdominal pain, diarrhoea and weight loss. He has had a constant fever for the last 2
months. The pain is aching in type in the bottom right corner of his belly and he writhes around in pain
when he gets it. It is not related to meal times and nothing makes it better. The diarrhoea comes for
weeks at a time and contains mucus sometimes. No vomiting. No foreign travel.
Immunisations all done.
He takes no medications and has no allergies. My mother had Crohns disease and her brother had
inflammatory bowel disease.
Hes short and looks young for his age and has little hair on his body.
Jacob lives with me and his two younger sisters who are both healthy. I am a single mother, he does not
know his father.
Mark scheme:

a. Length of symptoms
b. Lethargy
c. Abdominal pain
d. Diarrhoea - mucus or blood?
e. Weight loss how much? Over how long?
f. Other symptoms? Fever, cough, urinary problems?
g. Dehydration? Wetting nappies, soiling nappies, change in eyes?
5. Takes PMH
6. Drug history
7. Identifies family history of inflammatory bowel disease asks age of dx
8. Identifies developmental history of poor growth and delayed puberty
9. Checks information is correct with mother
10. Identifies patients ideas, concerns, expectations
Discussion; , History, investigations & treatment
Hi
Please summarise the history you took.

What do you think the diagnosis is? Crohns disease
What in the history made you think that? Family history, chronic weight loss and diarrhoea, abdominal
pain and mucus but no blood in stool
145
OK, what are the differentials of this history?
Ulcerative colitis
Irritable bowel syndrome
GI malignancy
Anorexia nervosa
Coeliac Disease
Chronic GI infection (Giardia, campylobacter)
UTI?
What investigations would you carry out?

Examination
Blood tests FBC, CRP, ESR, U+Es (diarrhoea and malabsorption), LFTs (associated hepatitis)
Plain AXR (sacro-ileitis & skip lesions)
Small bowel contrast study
Large bowel enema
CT scanning (for inflammatory masses or abscesses)
USS (abscess detection)
Bone age (may be 2 or more years less than normal)
Endoscopy, colonoscopy with biopsy (full thickness inflammation, non-caseating granulomata,
fissuring, ulceration, erosions)
Faecal culture
Urine dipstick?
How would you manage this child?

1. Explanation of condition to child and mother
2. Lifestyle advice
There are no specific foods that have to be avoided
In some, low residue diet, e.g. avoid veg & brown bread
Low fat diets
3. Induce remission
Elemental feed
5-ASA
Prednisolone, azathioprine, cyclosporine
Antibiotics (if anal involvement metronidazole)
Infliximab
4. Reduce growth failure
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Ethics & Law station: Stopping Treatment
Antonia, a 14 year old girl with acute myeloid leukaemia, has been receiving chemotherapy for the last year
and now wants to stop receiving treatment. Her mother has asked to talk to you about this.
I am Joanne, Antonias mother. Antonia has been receiving chemotherapy for the last year and a yesterday told
the nurses and then me that she intends to stop having her treatment from now on.
Antonia is refusing treatment because she says it makes her feel terrible, she is sick and feels nauseous every
day and is getting depressed because her hair is falling out.
I want her to have the treatment and I want to know if there is anything in the law regarding this and whether I
can make her have the treatment.
I am a single parent with no input from Antonias father

Mark Scheme:
11. Appropriate introduction (name & role)
13. Empathetically acknowledges mothers grief
14. Find out why Antonia has refused treatment
15. Discuss whether her mother wants her to have the treatment
16. Asks about family support
17. Explain the law
a. Children under 16 are presumed not to be competent
b. Children under 16 can prove to be competent if they show understanding of
i. What the treatment is
ii. Why it is being proposed
iii. Its benefits and risks
iv. The consequences of not going through with treatment
(Gillick vs HA 1985)
c. Young people that are competent can consent to medical treatment (Family Law Reform Act
1969) but they are not able to refuse treatment if consent is given by their parents.
d. Courts can give consent when parents refuse
e. Doctor may treat in cases of emergency (Defence of necessity)
18. Include Antonia in the decision making process
19. Bottom line if she still refuses despite discussion, her mother can consent and treatment would go
ahead.
Ideal:
1. Introduction
2. Ive been told you want to talk about your daughters treatment
3. I understand this is a very difficult situation for you
4. Has your daughter told you why she is refusing treatment?
5. Can I take it that you want her to have the treatment?
6. I just want to explain that being under 16, Antonia is presumed not to be competent to make decisions
regarding consenting to treatment. She can show competence if she proves to us that she understands
147
what the treatment is, why it is proposed, its benefits and risks, and the consequences of not
proceeding with it. But although competent minors were given the ability to consent to treatment by
the Family Law Reform Act (1969), it did not take away the ability of those with parental responsibility
to give consent on their behalf.
7. In essence, because Antonia is refusing treatment its very important that we discuss this decision with
her, help her understand it and try to convince her against it but if she still refuses, you can override
her decision and give consent for her.
148
Explain eczema treatment to a father
You are a 5th year medical student and have been asked to speak to Mr Foster whose daughter, 2 year old Lisa, is being
treated for eczema.
I am Mr Foster, a 42 year old father of one. My daughter Lisa has eczema which makes her itch and scratch her inner
elbows and torso to the point where she can make her skin bleed.
Im very angry because my daughter was diagnosed a year ago and still her skin is so bad that she hurts herself scratching
it and it looks really itchy. Weve been given so many creams and ointments and none of them are working! We no longer
use soap or bubble bath and use aqueous cream as a substitute. We also have an emollient lotion which we use once a
day.
I was given hydrocortisone cream to put on her skin which I used for about 4 days; it made a tiny difference but hardly and
I searched it on the internet and its a steroid! I know they have side effects like thinning the skin and causing infections
and weight gain so we use it once a week.
We cant think of any irritants in the house making her eczema worse, we dont have any pets.
There is a history of asthma and eczema in my family on my mothers side but not in my wifes family.
Mark Scheme:

15. Allows the patient to calm down
16. Takes a brief history of the illness
a. Duration of symptoms
b. Distribution of eczema
c. Measures / medications tried
17. Reassure that symptoms are most severe in the first year of life and 50% will resolve by age 12 and 75% by age
16.
18. Stress importance of adequate treatment.
19. Advise on general measures of eczema management
a. Avoid irritants & trigger factors
b. Avoid soaps & bubble baths
c. Loose fitting, pure cotton clothes
d. Rinse clothes after washing with detergents
e. Avoid extremes of hot and cold
f. Cut finger nails short regularly to decrease damage from scratching
20. Reaffirms use of frequent emollients
21. Elicits and listens to patients concerns about corticosteroid use
22. Advise regarding strength of steroid, method of application etc.
23. Checks correct information and understanding with father
General measures:
Stop scratching; histamines at night, mittens in the day
149
Loose cotton clothing
Avoid perfumed soaps and moisturisers etc.
Importance of skin care

Skin acts as a barrier; keeps infections out and heat in.
150
Faecal Soiling
Please take a history from the mother of Richard Ramsey, a 5 year old boy, who is soiling his underwear
I am Lynn, the mother of 5 year old Richard. For the last month he has been soiling his underwear. At first it
seemed as if he was just not wiping his bottom properly because there was some diarrhoea in his pants but
now some days his underwear is just full of poo. He says he doesnt realise when he needs to go. It happens at
home but at school as his nursery as well and his teacher says he gets very embarrassed, I now send him with a
spare pair of underwear. It doesnt happen at any particular time during the day, just randomly. His bowel
movements are not painful and he has no other problems.
His diet isnt too bad, he likes pasta and meat and white bread but he doesnt like drinking that much. He has
had no medical problems before this and never had any operations and doesnt take any medication.
Its getting silly now; my husband tells him off, its obviously not helping but he thinks that Richard is just being
lazy.
He originally stopped soiling his nappy just before he turned 3 years old.
It has been a bit stressful for me as well because Ive just had another baby and she cries all the time and the
problems with Richard make me lose my temper sometimes.
If asked He doesnt go to the toilet much anyway but I suppose he was going to the toilet even less before
this all started happening.
Mark Scheme:

28. Takes comprehensive history
a. Start, frequency, faeces or diarrhoea?
b. Constipated recently?
c. Situation of occurrence at home or school?
d. In relation to play activities?
e. Severity of incontinence
f. Painful bowel movements? Abdominal pain? Tightening of buttocks?
29. Diet history
30. Associated Fever? Rash? Vomiting?
31. Stooling pattern from birth up to present
32. PMHx anorectal, neurological or spinal abnormalities
33. PSHx
34. Drug history
35. Psychological functioning
a. How do you get along with your child?
b. Do you punish him when he soils himself?
c. Do you find yourself punishing this child more than your others?
151

What do you think the diagnosis is? Faecal soiling due to retention and overflow incontinence
What in the history made you think that? Soiling started as liquid stool and then started filling his underwear,
child is unaware of the need to defecate, initial history of bowels not emptying regularly, doesnt drink a lot,
poor diet.

Retentive encopresis
o Environmental problems lack of toilet facilities, harsh toilet training
o Idiopathic poor coordination with anal sphincter relaxation
o Transient constipation due to dehydration or anal fissure
o Organic constipation Hirschsprungs disease, drugs or hypothyroidism
Non-retentive encopresis
o Neurogenic sphincter disturbance
o Psychiatric illness
Gastroenteritis

Examination
o neurological system and abdomen
o rectal exam or abdominal palpation to determine whether there is faecal retention
o Stool sample

Stool softener + laxative or enema to empty the rectum asap
Regular laxatives
Star charts
Sitting on the toilet after meals
Dietary changes: increased fibre
?picosulphate (stronger) or movicol (weaker)
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Faecal Soiling 2
Please take a history from the mother of Richard Ramsey, a 5 year old boy, who is soiling his underwear
I am Lynn, the mother of 5 year old Richard. For the last month he has been soiling his underwear. At first it
seemed as if he was just not wiping his bottom properly because there was some diarrhoea in his pants but
now some days his underwear is just full of poo. He says he doesnt realise when he needs to go. It happens at
home but at school as his nursery as well and his teacher says he gets very embarrassed, I now send him with a
spare pair of underwear. It doesnt happen at any particular time during the day, just randomly. His bowel
movements are not painful and he has no other problems.
His diet isnt too bad, he likes pasta and meat and white bread but he doesnt like drinking that much. He has
had no medical problems before this and never had any operations and doesnt take any medication.
Its getting silly now; my husband tells him off, its obviously not helping but he thinks that Richard is just being
lazy.
He originally stopped soiling his nappy just before he turned 3 years old.
It has been a bit stressful for me as well because Ive just had another baby and she cries all the time and the
problems with Richard make me lose my temper sometimes.
If asked He doesnt go to the toilet much anyway but I suppose he was going to the toilet even less before
this all started happening.
Mark Scheme:

41. Takes comprehensive history
a. Start, frequency, faeces or diarrhoea?
b. Constipated recently?
c. Situation of occurrence at home or school?
d. In relation to play activities?
e. Severity of incontinence
f. Painful bowel movements? Abdominal pain? Tightening of buttocks?
42. Diet history
43. Associated Fever? Rash? Vomiting?
44. Stooling pattern from birth up to present
45. PMHx anorectal, neurological or spinal abnormalities
46. PSHx
47. Drug history
48. Psychological functioning
a. How do you get along with your child?
b. Do you punish him when he soils himself?
c. Do you find yourself punishing this child more than your others?
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Hi

What do you think the diagnosis is? Faecal soiling due to retention and overflow incontinence
What in the history made you think that? Soiling started as liquid stool and then started filling his underwear,
child is unaware of the need to defecate, initial history of bowels not emptying regularly, doesnt drink a lot,
poor diet.

Retentive encopresis
o Environmental problems lack of toilet facilities, harsh toilet training
o Idiopathic poor coordination with anal sphincter relaxation
o Transient constipation due to dehydration or anal fissure
o Organic constipation Hirschsprungs disease, drugs or hypothyroidism
Non-retentive encopresis
o Neurogenic sphincter disturbance
o Psychiatric illness
Gastroenteritis

Examination
o neurological system and abdomen
o rectal exam or abdominal palpation to determine whether there is faecal retention
o Stool sample

Stool softener + laxative or enema to empty the rectum asap
Regular laxatives
Star charts
Sitting on the toilet after meals
Dietary changes: increased fibre
?picosulphate (stronger) or movicol (weaker)
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Febrile convulsions
Im Mrs Wright and my 3 year old daughter just had a febrile convulsion.
This was her first febrile convulsion. It lasted for 6 minutes. Her whole body shook. She only had one
convulsion.
I want to know;
Is it epilepsy? And could she get epilepsy?

Will it happen again?
Can I prevent it from happening again?
What should I do if another convulsion occurs
Mark Scheme:

35. Im sorry to hear that your daughter had a convulsion, it must have been very scary.
36. Mention that seizures are very common (1 in 30 children)
37. Is it epilepsy?
a. Explain febrile convulsions
b. Simple febrile seizures do not cause brain damage
c. 1-2% chance of developing epilepsy (same as rest of the population)
d. If complex; 4-12% chance of developing epilepsy
38. Will it happen again: About 1 in 3 have a recurrence.
a. More likely if theres a family history
b. Or if the first convulsion happened at a very young age
39. Preventing further convulsions
a. Fever control
i. Tepid sponging
ii. Cold drinks
iii. Calpol/paracetomol OR ibuprofen
iv. Not too many clothes
40. What should I do if it happens again
a. Child in recovery position
b. Can be given rectal diazepam if the seizure lasts > 5 mins.
41. Ask brief history
a. First convulsion?
b. How old is the child?
c. More than one convulsion?
d. How long did it last? (if over 20 mins)
e. Partial? Did her whole body shake or just one side?
42. Asks family history of febrile convulsions
155
a. If yes; did they go on to develop epilepsy?
43. Family history of epilepsy?
156
OSCE Scenario: Abdominal Pains and Diarrhoea: Paediatrics
You are an SHO in Paediatrics. Mr Lissauer has brought in his 7 year old son Mosby who is complaining of
abdominal pains and diarrhoea. Please take a full history with a view to making a diagnosis.
My son Mosby has been complaining of abdominal pain and diarrhoea since midday yesterday. He says it is
quite painful and he has been having cramping sensations in his tummy (lower part and generalised). He also
vomited twice altogether. The abdominal cramping comes and goes and grades it at 7/10. He has been to the
toilet several times already this morning and it is still very watery. There has been some blood but I dont think
there has been any mucus. There was probably two to three table spoon fulls of blood in the stool and it was
fresh i.e. red. The stool is not bulky or pale and does not smell too bad. It has not been difficult to flush. He has
not sustained any trauma to the abdomen. The vomit is clearish and does not contain any blood/mucus/bile.
This has not ever happened before. He is up to date with his immunisations. He does not have a rash and has
not been for a wee since yesterday that I remember. I checked his temperature this morning and it was 38
degrees. He also appears less energetic and slightly drowsy today.
I think it may have been triggered by what we ate yesterday. We had gone to have lunch at an Indian
restaurant in Bethnal Green. He had the chicken tikka.
We have been trying to keep up his oral intake, but he has not managed to eat much, only a slice of toast. He
has probably only managed a glass of water since last night. He is not usually picky and eats everything include
bread, wheat and cows milk.
There is no FHx of any similar problems and no one else in the home has been affected. He does not have any
developmental concerns, any significant antenatal/ perinatal history. PMHx, DHx. We are currently living in a
home in Mile End. His mother and I are getting on well and we are all happy. We are concerned for him. Will he
be okay?
Diagnosis: GASTROENTERITIS, probably organisms Salmonella, Campylobacter, Bacillus cereus.

Markscheme
1. Washes Hands
3. Establishes reason for visit
4. Takes a comprehensive history including:
a. History of presenting complaint
b. Duration of illness and frequency of diarrhoea
c. Asks specific details of diarrhoea and vomiting; i.e. constituents
d. Associated symptoms: vomiting, GCS, tenesmus, fever, headache, feeding, excretion and
micturition.
e. Travel history
f. Inquires about antenatal, perinatal, immunisations, DHx, FHx, SHx
5. Tries to exclude any differentials:
a. Intussusception: redcurrant jelly stool (empty rectum), pulling up legs
b. Acute appendicitis
c. Mesenteric adenitis
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d. IBD
e. Malabsorption diarrhoea: loose bulky stools, difficult to flush, very smelly.
i. Causes CF or Pancreatitis, Coeliacs disease (gluten in diet previously)
f. Food intolerance: Lactose intolerance/ Cows, milk protein intolerance
g. Others:
6. Addresses parental concerns
7. Asks about ICE
8. Summarises the history
9. Any questions?
10. Thanks the patient
11. Washes hand
Questions for the following station

- Summarise the history
- What do you think is the diagnosis?

Gastroenteritis: Campylobacter jejuni/ Salmonella enteritidis
- What are the differentials for abdominal pain and diarrhoea?

o Intussusception - abdo pain, not diarrhoea, occurs in 2 months 2 years (peaks 6-9months). No abdo
distension (sausage shaped mass)
o Acute appendicitis would cause abdo pain central to RIF, vomiting perhaps and temp. Not colicky
however. No signs of peritonism, pain not worse on movement (more likely to perforate)
o Mesenteric adenitis Probably more a diff for appendicitis, no Hx of previous viral infection. Abdo pain
resolves within 24-48hrs.
o IBD: causes bloody diarrhoea and abdo pain. No previous GI history or FHx. No systemic signs: clubbing,
erythema nodosum, uveitis, arthritis. Pyoderma gangrenosum. Good growth and no FTT.
o Malabsorption: would cause diarrhoea and possibly abdominal pain. Though probably not crampy. No
Hx; abdominal distension, frequent respiratory infections, gluten sensitivity or lactose intolerance.
o UTI
o SEPSIS
o TRAUMA
- How would you investigate and manage this patient?
o ABC: perhaps establish some IV access because likely to need fluids.
o Clinical history and examination: Assess degree of dehydration
o O/E: Raised temperature, drowsy, reduced tissue turgor, dry mucous membranes, reduced tears, cap
refill > 2s, reduce UO, tachycardia and possibly tachycardic, Normal BP.
o Ix:
Bloods: FBC, U&E, CRP, blood cultures?
Urine: dipstick and culture
Stool: MC&S and viral antigen testing
Weight
AXR if no improvement
o Mx
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Rehydrate: 20ml/kg 0.9% saline (repeat if no effect), further rehydration according to whether
this is hypernatraemic of hypo/iso natremic dehydration. Likely to be hypo/iso. Correct defecit
+ maintainence bolus over 24 hrs. Using 0.45 % saline and 2.5% dextrose.
Monitor: Fluid balance, weight, plasma creatinine and electrolytes, cardio status clinically.
Check for overload or pulmonary oedema precipated by ARF secondary to hypovolemia.
Antibiotics:
Campylobacter usually self limited, treat severe: macrolide, ciprofloxacin
Salmonella : ciprofloxacin, cefotaxime
Normal gastroenteritis does not treatment
Advise parents about:
Post-gastroenteritis syndrome: transient lactose intolerance precipitates further
diarrhoea after introduction of normal diet. Multiple intolerances.
Post-infective IBS
159
5.
a. ??
Head Circumference
Please measure this babys head circumference and plot it on the growth chart.
Mark Scheme:
1. Introduction with name & role

2. Explain to parents what you are going to do
a. Measure babys head to assess growth
b. Approach child from the side
3. Using a cotton tape measure measure anteriorly between hairline + glabella and the occipital
prominence postteriorly.
4. Measure 3 times and use the largest measurement
5. Plot on age and sex appropriate chart with a dot.
a. Correct for gestational age
6. Ask for previous head measurements from examiner to define trend
7. Check weight and height of child and plot
8. Check head circumference of biology parents
9. Enquire about neurodevelopment of child
10. Neurological examination
11. Look for dysmorphic features and neurocutaneous stigmata
12. Head shape
13. Check the fontanelles and sutures
14. Enquire about signs of increased intra-cranial pressure
15. Ask about pregnancy history
Normal growth
At birth: 35cm
2 months: 39cm
4 months: 42cm
6 months: 44cm
8 months: 45cm
10 months: 46cm
12 months: 47cm
2 years: 48cm
3 years: 49cm
4 years: 50cm
5 years: 51cm
From 5 years onwards head growth progresses at 0.5cm per year until final circumference
Adult female mean = 55cm

Adult male mean = 56cm
160
Causes of abnormal head circumference
Macrocephaly:
normal variation or familial trait
Hydrocephalus (ICP, bulging fontanelles, sun-setting of the eyes)
o Communicating
Meningitis
Sub-arachnoid haemorrhage
o Non-communicating
Posterior fossa tumour
Arnold-chiari malformation
Aqueduct stenosis
Inter-ventricular haemorrhage
Hypothyroidism
Rickets
AV malformation
Brain tumour
Subdural haematoma
Neurocutaneous conditions
disproportionate growth in chronic conditions, for example achondroplasia, sickle cell anaemia, rickets,
failure to thrive
Microcephaly:
Normal variant
Congenital infection
Craniosynostosis
Metabolic abnormality e.g. maternal PKU
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Childhood Asthma
Hx of asthma of child from mum. Explain Mx to child.
Hx
1. HPC
How well-controlled is it? Symptoms worsening/improving/the same?
Wheeze
Cough- worse at night? Productive (if so, colour and amount)? Haemoptysis?
SOB
Chest pain
Fever
Frequency of symptoms
Precipitating factors- cold, exercise, pets, etc
How much school has been missed due to the asthma?
Are sport and general activities affected by the asthma?
How severe are interval symptoms between exacerbations?
2. PMHx
Any previous hospital admissions? How were they managed in hospital?
Ever been ventilated?
3. FHx
Atopy? (asthma, hayfever, eczema, allergic conjunctivitis)
Smokers in the family
Pets at home?
4. DHx
How is the asthma being managed at the moment?
a. Medication
b. Frequency
c. Method of administration (inhaler, spacer?)
d. PEFR
Explaining Mx to child
1. Check childs understanding of their condition
Asthma is a very common illness which affects the lungs and airways. When a person with asthma comes into contact
with something that irritates their airways (an asthma trigger), the muscles around the walls of the airways tighten so
that the airways become narrower and the lining of the airways becomes inflamed and starts to swell. Sometimes
sticky mucus or phlegm builds up which can further narrow the airways.
2. Explain Mx (step ladder)
Avoid precipitants
Step 1. Start with blue inhaler (short acting B agonist-salbutamol)- this is a reliever, taken whenever symptoms flare
up
Step 2. Add brown inhaler (inhaled steroid- beclometasone)- taken regularly to prevent symptoms from occurring
Steps 3-5 (other inhalers and/or medication)
3. Check child knows how to use inhaler
If not, demonstrate inhaler technique, and see if child can copy it correctly
162
Or, suggest use of a spacer device (and show how to use this first)
5. We check that medication is working by keeping a peak flow diary
Have you ever used this before?
If not, demonstrate how to do this, and get the child to repeat
Tell child to keep a diary of recordings in the mornings and evenings, to see if new medication regime is effective in
controlling asthma
163
Childhood Vaccination
How is the DTaP/IPV/Hib vaccine different from the previous primary vaccinations?
The polio vaccine does not contain a live virus, so it no longer carries the slight risk of causing vaccine-
associated paralytic polio. The vaccine uses inactivated polio vaccine (IPV) instead of live oral vaccine.
'Inactivated' means that the viruses contained in the vaccine have been killed, so that they can't harm
you.
The vaccine causes fewer minor reactions
There is no thiomersal (mercury) in the vaccine, which would have a small risk of producing allergic skin
reactions
The vaccine uses acellular pertussis vaccine instead of whole-cell pertussis vaccine
How and when is the vaccine given?
This vaccine is given intramuscularly (by injection into the muscle) in a dose of 0.5ml. It should not be given
intravenously (by injection into the vein).
Why does my child need three doses of the vaccination?
Three doses are given to make sure that your child's body can develop a good immune response to the disease.
The gap between these different doses of vaccines is to make sure that each dose has time to work.
Every time another dose of the vaccine is given the body's immune response is boosted.
What side effects might I see after the immunisation?
Your child may get some of the following side effects within 12 to 24 hours of the vaccine being given:
a fever
a slightly raised temperature
some sickness and/or diarrhoea
a small lump at the site the injection, which may last for a few weeks.
your baby may be miserable within 48 hours of having the injection.
Up to one in ten children may get some swelling and redness at the site of the injection.
Very rarely (in less than 1 in 1000 children), a day or two after they have received this vaccine some babies
have
experienced febrile convulsions (fits)
had very high temperatures
been floppy and less responsive than usual
cries an unusual, high-pitched cry.
If your baby has a fit, call your doctor immediately.
164
Babies usually recover from fits quickly and completely.
Remember that young babies can have fits at any time, so if they have a fit after their immunisation, it is not
necessarily linked to the vaccine.
Do not delay the immunisation - this can increase the chances of babies experiencing fits. It's important to
make sure your child gets vaccinated at the right age.
As with all vaccines there is a rare possibility of DTaP/IPV/Hib causing anaphylaxis.
If you think your child has had any reaction to the DTaP/IPV/Hib vaccine that you are concerned about, then
talk to your doctor, nurse or health visitor.
Are there any of groups of children for whom particular care is needed?
If your child has had any of the following conditions after being given a dose of a vaccine containing pertussis
(whooping cough), talk to your doctor, nurse or health visitor before giving them further immunisations:
A serious allergic reaction to a previous dose of the vaccine. Your doctor, nurse or health visitor may
want to give the vaccine in a special clinic. This vaccine should not be given to children who have had
an anaphylactic reaction to a previous dose.
Febrile convulsions (fits) within 72 hours of a previous dose of vaccine or a history of convulsions. Your
doctor, nurse or health visitor may want to give your child some preventative treatment for fever.
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MMR Vaccination
Please talk to Serena Campbell who is the mother of Jack who is an 11 month old boy. She has heard bad things
about the MMR vaccine and wants information about it.
What does the MMR vaccine protect against?

o Measles (causes deafness & brain damage & death)
o Mumps (hospitalisation and death)
o Rubella (congenital anomalies)
o It is the safest way to protect against these diseases
Why should he have it?
o If children are not protected against measles, mumps and rubella, we run the risk of new
epidemics.
o This means not just measles outbreaks, but the return of babies born with terrible defects from
congenital rubella syndrome (CRS), or children hospitalised or becoming deaf from mumps.
Is it not true that getting the diseases naturally is better at giving protection than the vaccine?
o No. The vaccine provides very good protection and the diseases can lead to the terrible
consequences
Is giving 3 separate immunisations better?
o No country in the world recommends giving MMR vaccine as 3 separate injections
o Giving them separately leaves the child vulnerable
There was a study that said it causes autism
o There is no link between the MMR and autism. There are numerous studies that support this.
o The study suggesting a link found no proof of a link and has since been withdrawn anyway
Ive heard the vaccine wasnt tested properly
o The normal procedure for licensing was used for MMR and the vaccine was thoroughly tested
before being introduced into the UK in 1988
Anaphylaxis questions
What is anaphylaxis
o Anaphylaxis (also known as anaphylactic shock) is an allergic condition that can be severe and
potentially fatal.
o Anaphylaxis is your body's immune system reacting badly to a substance (an allergen), such as
food, which it wrongly perceives as a threat.
o The whole body can be affected, usually within minutes of contact with an allergen, though
sometimes the reaction can happen hours later.
What are the symptoms?
o The symptoms of anaphylaxis usually start between three and 60 minutes after contact with
the allergen. Less commonly, they can occur a few hours or even days after contact.
o When you have an anaphylactic reaction, you may feel unwell or dizzy or may faint because of
a sudden drop in blood pressure.
o Narrowing of the airways can also occur at the same time, with or without the drop in blood
pressure. This can cause breathing difficulties and wheezing.
Anaphylaxis varies in severity. Sometimes it causes only mild itchiness and swelling, but in some people
it can cause sudden death.
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o Anaphylaxis can lead to death if breathing becomes severely obstructed or if blood pressure
becomes extremely low (known as shock).
Whats the cause?
Anaphylactic shock occurs because your body's immune system overreacts in response to a particular
substance (allergen) that you have been exposed to before (see the box, right).
When the allergen gets into your bloodstream, it causes the body to release massive amounts of the protein
histamine and other chemicals.
Histamine causes:
blood vessels to widen, leading to a sudden severe lowering of blood pressure and narrowing of the airways in
the lungs, and
blood vessels to leak, causing swelling (oedema) in the surrounding tissues and a further drop in blood pressure.
Treatment:
Anaphylaxis should always be treated as a medical emergency. It can be fatal unless immediate treatment is available.
Severe cases
If someone becomes severely ill or collapses soon after an insect bite, eating a particular food or taking
medication, call for an ambulance and tell the operator that you think the person has anaphylaxis. Remove the
trigger (allergen) if possible.
Adrenaline
An adrenaline injection (epinephrine) must be given as soon as a serious reaction is suspected. If the person is carrying an
adrenaline injection kit, they may be able to inject themselves (see the box, right) or you can help them to use it.
If there is no improvement within five to 10 minutes, a second injection may be needed until the condition
improves. Recovery normally occurs fairly quickly once adrenaline has been received (see the box, left).
First aid advice
1. If the person is having difficulty breathing, help them to sit up.
2. If they have low blood pressure, get them to lie flat and raise their legs.
3. If they are unconscious, check their airways are open and clear and check their breathing. Then put them in
the recovery position (see below).
Putting someone who is unconscious in the recovery position ensures that they do not choke on their vomit.
Place the person on their side, ensuring that they are supported by one leg and one arm. Open the airway by tilting the
head and lifting the chin.
If the person's breathing or heart stops, cardiopulmonary resuscitation (CPR) should be performed. See Useful links for a
guide on how to perform CPR.
Admission to hospital
1. Even if adrenaline is given, the person will probably need to be admitted to hospital for observation for up to 24
hours as occasionally the symptoms can return a few hours later.
2. An antihistamine or corticosteroid injection may be given, sometimes with fluids through an intravenous drip.
3. The person will be advised to avoid any substance to which they are sensitive, especially if they have had a
previous anaphylactic reaction.
4. Adrenaline will be prescribed for future emergencies, so the person can inject themselves with adrenaline from a
preloaded syringe (see the box, right).
5. The person should also carry an emergency card or bracelet with full details of their allergy and contact details of
their doctor, to alert others.
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6. The person will be advised to arrange a follow-up visit with their GP.
Mild cases
If the person has had a mild reaction with only skin symptoms (itchiness or a rash), adrenaline may not be necessary and
they may just need antihistamines and steroids. The allergen should be removed if possible.
All cases of anaphylaxis should be treated as an emergency. Even in mild cases, an ambulance should be called so the
person can get immediate medical attention.
o
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Neonatal Examination
Please explain to me how you would conduct a full neonatal examination on a newborn.
Mark Scheme:
2. Explains what is going to happen
3. Initial questions
a. Passed urine?
b. Opened bowels?
c. Started feeding?
4. Birth weight, gestational age, birth weight centile
5. Expose; baby should be wearing nothing but a nappy to start with
6. General observation
a. Plethoric, pale, jaundiced?
7. Head circumference (paper tape measure & record centile)
8. Palpate fontanelles and sutures
a. Check fontanelles are not tense or flaccid
9. Observe face for dysmorphic features
a. Eyes with an ophthalmoscope for red reflex
b. Mouth for central cyanosis
c. Finger in mouth to check suck reflex and cleft palate
10. Chest
a. Observe for respiratory rate and abnormal breathing
b. Auscultate the heart. Normal 110-160bpm
c. Central capillary refill
11. Abdomen
a. Check for liver, spleen and kidneys
b. Check the umbilicus
12. Genitalia & anus
a. Remove nappy and inspect for urethral and anal patency
b. Check for descended testes
13. Palpate the femoral pulses
14. Moro reflex
15. Turn baby over
a. Look for muscle tone
b. Inspect and palpate back for midline defects
16. Test for Congenital dislocation of the hip
a. Barlows test = posterior dislocation
b. Ortelani = relocation clunk
17. To complete the examination
a. Hearing test
b. Check for social issues
18. Thank the parent/examiner and ask if they have any questions.
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Nocturnal enuresis
Please take a history from this mother of a 7 year old who is suffering from nocturnal enuresis; explaining to
her the syndrome and its management
I am Jane Smith. James is my son and he is 7 years old and is still wetting the bed. He went through a period of
3 months of staying dry at night when he turned 6 but after that went back to the same as usual. Im worried
that there might be something physically wrong with him because I know that nearly all of his school friends
were dry at night by 4 years of age.
He wets the bed about every other night. I know that stress can cause kids to wet the bed but I dont think that
James has a very stressful life
In the daytime he does not wet himself and does not need to go very often, 4 times a day.
His father, who Im no longer married to, tells me not to worry and that he was late staying dry but he wont
tell me a lot about it plus hes a fucking idiot and you cant believe what he says anyway.
Mark Scheme:

14. Puts mother at ease
15. Takes a detailed history
a. Frequency
b. Bowel habit / constipation
c. UTI
d. Stress
e. Diabetes mellitus
f. Access to the toilet during day & night
16. Explains to the child and parent that the problem is common and beyond conscious control
a. 6% of 5 year olds and 3% of 10 year olds are not dry at night.
b. There is a genetically determined delay in acquiring sphincter competence i.e. some children
just take longer than others.
c. Punitive procedures are counterproductive
17. Management
a. Pre-bed routine no drinks before bed. Toilet before bed twice
b. Star charts; earns praise and a star each morning the bed is dry. Treat wet beds in a matter-of-
fact way and do not blame the child
c. Enuresis alarm; supplementation to a star chart. A sensor that sounds an alarm when wet.
Child wakes up, goes to toilet and then helps make the bed before sleeping again
d. Desmopressin; short-term relief e.g. sleep overs
e. Self-help groups; additional advice and assistance
18. Mentions carrying out investigations
a. Urine sample for glucose and protein and infection.
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b. Assessment of urinary concentrating ability by measuring the osmaolality of an early morning
urine sample
c. USS of the renal tract
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Limp in a child
You are a 5th year medical student. Take a history from this mother of a 4 year old Congolese boy with new-
onset limp.
My name is Tracy Lamumba. I am 32. My son Barry (4 yrs) is complaining of pain in his right hip. It started this
morning. When he is still it doesnt hurt, only when he is walking. He has been lethargic today and has missed
school. I took his temperature today and it was 37.8C. The pain came on suddenly. As far as I know his hip is
the only joint affected. He has no vomiting, diarrhoea, rash, leg ulcers or dysuria. He has a cold which came on
yesterday. He is coughing up small amount of green phlegm with no blood.
Barry started walking at 10 months, he is normally very active. He is of normal height and weight. Barry has a
12 year old brother who is fit and well. Other than normal minor scrapes, Barry has no leg injuries. There is no
family history of arthritis or sickle cell or TB.
Mark Scheme:

a. Onset, length of symptoms, exacerbating factors, any other joints, range of movement?
b. Fever, general well-being
c. Recent illnesses including bacterial infection (RTI, UTI, meningitis, gastroenteritis)
d. Any trauma?
13. Asks about developmental milestones and previous hip problems
14. Asks about height and weight
15. Asks about any FHx of arthritis, TB, sickle cell, infections

What do you think the diagnosis is? Transient synovitis
What in the history made you think that? Mild fever, Concurrent viral infection, only pain with movement, sudden onset

Septic arthritis / osteomyelitis high fever, unwell pt, pain at rest & minimal movement
Perthes disease gradual onset
Slipped upper femoral epiphysis tends to affect obese adolescent boys, int. rotation
Sickle cell disease
Knee problem
Juvenile arthritis requires minimum 3 month history

Examination transient synovitis causes decreased abduction, decreased external rotation
Bloods FBC (incl. WCC), CRP, ESR, blood culture
X-ray / ultrasound
Possible sickle cell
Possible joint aspiration if septic arthritis suspected
172
Alternative conditions must be excluded. Admit if Dx in doubt
Bed rest
o Keep the leg flexed with some external rotation
Analgesia paracetamol
Aspiration of effusion when present
Mobilise once the pain has settled
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Psoriasis History
You have been asked to take a history from a 21 year old lady with a skin rash
I am Julia Thompson, a 21 year old lady who works as a bank clerk. Ive come today because for the last month
Ive had this rash on my body. The rash is on my knees and elbows and some is on my scalp. They first looked
like red/pink patches and then became a bit different with silvery-white scales on the surface. They do not itch
and do not bleed or leak any fluid at all.
Some things make them worse like stress. It seems to get better when its sunny.
I also have some changes in my nails, they have pits in them and look different.
It is starting to impact on my life because work colleagues and customers notice it on my elbows. Im very self
conscious about it because I think everyone assumes its contagious.
Mark Scheme:
1. Appropriate Introduction (Name & role)

2. Establishes presenting complaint
3. Takes a detailed history
a. When did it first start
b. Where on the body is it & distribution
c. What did it look like at first and how did it evolve
d. Symptoms itch, bleeding, exudates
e. Aggravating factors stress, drugs, infection, trauma, sunburn
f. Alleviating factors sunlight
g. Nail changes
h. Impact on life
4. Any history of atopy or allergy?
5. Social history
a. Occupation
b. Hobbies
c. Travel
d. Alcohol
6. Family history
a. Atopy
b. Current family member affected?
7. Drug History
8. Checks information with the patient
9. Takes history in empathic manner
10. Explains the diagnosis
11. Explains treatment options
a. Emollients
b. Topical agents; tar, vitamin D, vitamin A, Dithranol, Steroids
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c. Phototherapy PUVA, narrow band UVB
d. Systemic agents Retinoids, methotrexate, ciclosporin
e. Biological agents infliximab, etanercept
12. Offers patient information leaflet
13. Does all in a fluent & professional manner.
175
Psoriasis 2
A psoriasis patient is unhappy with topical treatments. She wants something systemic. Describe the associated risks
and calm him down.
1. Shes had a mixture of creams, none of them worked.
2. Gain his trust. Tell him there are many more options.
3. Phototherapy (SE. tanning, burning, skin cancer, cataracts)
4. Oral acetretin (SE. liver damage)
5. Immunosuppressants (SE infections)
1. Introduce
2. Show empathy
3. Ask him what creams she has used
Names? (emollients, tar, topical steroids, vit D analogue-calciporiol, dithranol, vi tA analogue-
Tazarotene)
How long for?
Correct number of times a day?
4. Explain that avoidance of precipitating factors could help:
Stress
Smoking
Alcohol
Obesity (suggest weight loss?)
Sunlight
Trauma-related sports e.g. rugby
Drugs- B-blockers, lithium, anti-malarials
5. Other options- Phototherapy
UVB- Side effects include skin burn, increased risk of skin malignancy (with chronic use),
Contraindicaions are SLE, previous skin malignancy, xeroderma pigmentosum)
PUVA- Side effects include skin burn, skin pigmentation, increased risk of skin malignancy, cataracts (eye
protection worn to prevent this)
Excimer laser- like UVB, but more precise
Procedure- the lesions are exposed to UV rays (light) in the hospital or in clinic, and in PUVA therapy, a
drug called psoralen is taken orally or applied as a paint on the skin prior to the light therapy
6. Other options- Oral Vit A analogue (acitretin)
SE: liver damage, teratogenecity (women must remain on COCP for 2 years after stopping treatment)
CI: liver impairment, hyperlipidaemia, DM
7. Other options- Methotrexate:
SE: myelosuppression (ie risk of infections), heptotoxicity, pulmonary toxicity, teratogenecity
Regular blood tests required to monitor this toxicity
176
8. Other options- Cyclosporin:
SE: nephrotoxicity
Regular BP checks and blood tests ( U + Es)
9. Other options- biologics:
Eg. Anti-TNF-A (etanercept, infliximab)
Smoking cessation
You have been asked to talk Lisa, a 39 year old lady who wants to stop smoking
I am Lisa, a 39 year old factory worker who has been a smoker for 15 years. I smoke a pack of 20 cigarettes a
day. I had a very bad cough over the winter and at the time smoking made it a bit better but I know that Ive
probably got this cough in the first place because of smoking; also my new husband says it smells. I want to quit
but think Ill find it very difficult and want some help.
My father died of lung cancer aged 60.
Ive tried to give up once before 5 years ago by reducing my smoking to 10 cigarettes a day with the intention
of reducing it slowly but I started smoking 20 cigarettes a day again after a few months because I started to feel
irritable and all of my work colleagues smoke. I havent considered using any medication because I dont want
to take antidepressants.
Mark scheme:

12. Asks about current smoking
a. How many cigarettes
b. For how long
c. Where does she smoke
13. Recognises patients concerns
14. Reinforce the risks of smoking to the patient.
a. Greatest single cause of illness and premature death in the UK
b. Lung cancer + mouth, stomach, colon, bladder cancer
c. Cardiovascular disease, heart attack, stroke
d. Indigestion and stomach ulcers
e. Passive smoking risks to others
15. Review previous attempts to stop smoking.
a. How many times?
b. How long?
c. Assistance / medication used?
d. Problems encountered
16. Set a date to stop completely, not even one puff
17. Plan ahead identify potential problems and strategies to cope
177
18. Plan how to handle work colleague situations
19. Consider smoking cessation treatment
a. Nicotine replacement therapy; gum, patch, lozenges, nasal sprays, inhalers
b. Bupropion an antidepressant (acts on dopamine and noradrenaline neurotransmission)
i. Side-effects: dry mouth, insomnia (avoid bedtime dose), GI disturbance, taste
disturbance, impaired concentration, headache, dizziness, depression, anxiety
20. Offer to refer to the smoking cessation clinic
21. Offer a follow up appointment in 2 weeks to check progress
22. Offer information & advice sheet
178
Picture of a bleed
What are the causes of spontaneous intracerebral haemorrhage.
Aneurysm rupture in chronic hypertensives. (Charcot-Bouchard aneurysms are 1mm in diameter.

Principal cause of primary intracerebral haemorrhage.)
Bleeding into tumours
Vascular malformations AVMs and cavernous angiomas
Bleeding diastheses thrombocytopenia, leukaemia, haemophilia
Amyloid angiopathy infiltration of amyloid into the arterial walls weakening of small vessels
Complications:
Hydrocephalus
Coning

179
Suicidality risk assessment
1. Introduction rapport, empathy & style
2. History of overdose
a. How long have you been having suicidal thoughts?
3. Degree of preparation
a. Planning
i. Length of planning
ii. Chosen method
b. Suicide note
c. Last acts
i. Will
4. Circumstances of overdose
a. Alone
b. Intervention unlikely
c. Precautions against discovery
5. After the act
a. Didnt seek help
b. Stated wish to die
c. Believed the act would result in death
d. Regrets its failure
6. Recent history of depressive symptoms
a. Low mood
b. Sleep disturbance
c. Weight disturbance
d. Poor concentration
e. Anergia, anhedonia
f. Poor self esteem, worthlessness
7. Current mental state
a. Current suicidal thoughts
b. Active intention?
c. Anything stopping you taking your life?
8. Past psychiatric history
a. Past history of self-harm
b. Past psychiatric history
c. Current medication
d. Social history (particular attention to risk factors e.g. drug/alcohol misuse)
Have you ever harmed yourself before?

Were you trying to kill yourself?
What was the cause of you wanting to hurt/kill yourself?
Anything distressing happened in your life recently?
180
Was the act impulsive or planned?
Did you prepare in advance?
Suicide note?
Will?
Made sure of isolation?
How did you try and commit suicide?
What tablets? how many?
Had you been drinking or taking drugs?
How were you saved? How did you get to medical help?
Were you actually trying to end your life or do you think it could have been a cry for help?
Did you think you had succeeded?
How do you feel now about that attempt?
Do you intend to harm yourself again?
How do you feel about the future?
What is your mood like currently?
Was the last suicide attempt your only act of self harm?
Ever been diagnosed with a mental health issue or been given treatment for a mental condition?
Assessing risk
High level risk

Definite plan for suicide (When? Where? How?)
Major depressive disorder = severe depression
High lethality suicide attempt or multiple attempts
Established / advanced medical disease
Social Isolation
History of psychiatric illness
Moderate level risk
Low lethality suicide attempt
Frequent thoughts of suicide
Previous suicide attempts
Persistent depressive symptoms
Serious medical illness
Inadequate social support
History of psychiatric illness
Low level risk
Suicidal ideation but no suicidal intent
Supportive environment
Once off adverse event that seems relatively minor
Physically healthy
No history of psychiatric illness
181
Neonatal Vomiting Station
You are a 5th year medical student clerking Sarahs 4 week old son with vomiting
I am Sarah, the mother of Jamie, who is 4 weeks old. This episode started yesterday morning. He seemed to be
hungry as usual and I fed him but within 5 minutes he was sick. The vomit was curdled and unpleasant smelling
milk with no bile or blood but travelled a few feet from his mouth. He was still hungry so I fed him and he was
sick again so I waited until the next feed and the same thing happened, I waited until today because I thought it
may have just been gastroenteritis. He has no fever, no diarrhoea
He usually wets his nappy 5-8 times per day but in the last 24 hours he only has once and he isnt dirtying his
nappy much either, just small pellet-like stools. I havent noticed that he has stopped gaining weight.
He was born at 38 weeks gestation, vaginally and was 3.2kg.
He has been well since he was born except for a small mouth abscess for which he was given erythromycin. My
grandfather says that he had a problem of vomiting when he was a baby and he needed an operation to
correct it! Im very scared about this.
I live with my husband as well as Jamie. The rest of us are fine with no recent illnesses.
Mark scheme:

a. Length of symptoms
b. Vomiting? Timing, frequency, volume, contents, colour, odour, bile, blood, projectile, remained
hungry afterwards?
c. Other symptoms? Fever, cough, diarrhoea?
d. Dehydration? Wetting nappies, soiling nappies, change in eyes?
55. Takes comprehensive history of the neonatal period
a. Gestation?
b. Method of delivery?
c. Complications in pregnancy?
d. Admission to ITU?
56. Takes full background history developmental and PMH
58. Asks about family history of childhood vomiting
182
Hi

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

Gastro-oesophageal reflux
Gastroenteritis but no diarrhoea
Intersusception but rare in those < 6 months
Overfeeding but vomit wouldnt be projectile
Milk allergy
UTI

Examination including inspection of the abdomen
Test feed palpating for the olive
Ultransonography pyloric muscle thickness > 4mm, or a pyloric length > 18mm
Biochemistry to assess dehydration
Barium contrast radiography
pH studies monitor pH in the lower oesophagus
Upper GI endoscopy evaluate the oesophageal mucosa for oesophagitis, erosions, etc.
Stool sample
AXR

1. Ensure their airway, breathing & circulation is adequate and admit
2. Correct dehydration & alkalosis with normal saline + KCl over 48 hours
3. Rammsteds pyloro-myotomy, possibly laproscopic
4. Non-surgical Tx; atropine sulphate (if parents are opposed to surgery)
183
Question Lists from Previous
Years
184
Psychiatry and Neurology from previous years 1
History and counselling stations
1. Headache: Dx temporal arteritis
2. Alcohol Hx
3. Suicide assessment
4. Ritalin: parent with Questions
5. Lithium: side effects, need for Diood tests etc
6. Alzheimer's disease: explain it to daughter of patieril
Data interpretation: Short answer questions (note, you don't have enough time to
write everything down)
7. LP and CSF profiles: know the difference between, normal, menigitis, TB and SAH. Be able to list 3 early and
late complications of LP.
8. Anorexia: work at BMI, list clinical symptoms and signs
9. MHA questions. Know it really well, questions are a bit fine print.
10. Ophthalmology: foreign body, glaucoma, diabetes and the eye. You look at
pictures and examiner questions you. Must know your eye drops.
11-12. MSE: Video of psych patient. Write MSE from this.
13. Neuro video (we had transcipt 'cos video was busted): ? delirium
14. Be able to examine certain aspects of the PNS in isolation. For
example, jus1 examine the SENSORY nervous system in the lower limbs (no need to
illicit reflexes then). . State you diagnosis from findings. I had a guy with a
sensory neuropathy, stocking distribution. Don't forgot to observe first.
Psych and Neuro

Dec 2003
1. Neurological exam of lower limb (patient had glove and stocking sensory lossing secondary to Diabetes)
2. Video - watch an interview of a manic patient and write a mental state
3. Video again - mental state of depressed
4. SP (simulated patient) - Explain alzheimer's disease to a patients daughter and answer questions she asks
you.
5. SP - explain diagnosis and treatment of panic attack to a patient
6. SP - explain autism to a mother and its management.
7. SP - explain the diagnosis of schizophrenia to a patients sister
8. Written station - identify spastic gait
9. Written - identfy left radial nerve palsy from a photo
10. Talking station (examiner will ask you questions-explain about eye drops
you would use (e.g. dilators,anaesthetics)
11. Talking - answer question on fundo disc abnormalities
12. Explain contraindications to cataract operation
185
13. Identify CT bleed on picture e.g subdural, subarachnoid
14. SP - answer impact of epilepsy on patients life (OCP, swimming,climbing,driving etc.)
15. Answer questions regarding causes of delirium.
Neuro 2003/04
OSCE STATIONS
Neurology
1) Video presentation/ written station : Read up about Scissor Gait & Cerebral Palsy
2) Talk to family member of patient about ALZHEIMER'S DISEASE
3} Lower Limb Examination : Sensory examintation on the patient's LL. Make a
Diagnosis and justify diagnosis, causes OT stocKing distribution.
4) Epilepsy counselling: you are a GP and a lady in her 20's has be
diagnosed with epilepsy and is on medication, she's come to you and ask for your
advice about epilepsy.
5) CT/MRI scan (Written Station) identify Subdural or subarachnoid haemorrhage, and possible clinical
outcome.
Psychiatry
1) Do a RISK ASSESSMENT on a SUICIDAL patient.
2) Explain to family member of patient about SCHIZOPHRENIA.
3) Explain to mother of child about AUTISM.
4) Take a history from someone who presents with CHEST PAIN, make a diagnosis and counsel the patient
about it.
5) Video session : Do a mental state examintation. (I had a delusional patient)
6) Video Session : Do a mental state examintaion (I had a sad patient)
7) Written station on Mental Health Act. Especially the difference between
MHA2&3
Ophthalmology
1) Identify pictures of symptomatic eyes. Contraindication for cataract surgery. Anasthetic used for catarct
surgery
Neuro EMQ
Written paper:
A lot on differential diagnosis for both Nuro and Psyc. Neuro path and genetics. I think it has changed, for us
there were % of population with alcohol dependency etc which was really random. Know the various roles of
the MDT ir KNOW YOUR LECTURE NOTES REALLY WELL!!' A lot of the definitions are lifted directly from them,
so read them well before reading thick books.
186
Psych/Neuro 2003
1/ Hx Panic attacks
2/ explain to sister of schizophrenic what it is
3/Video x2 (mental state examination)
4)Ophthalmology station-with an examiner asking qus (mcq,slide,eye
drops)
5/ picture and qu's 6th nerve palsy and other q's
6/ take hx of social withdrawal from childs carer
7/ advise epileptic woman about medication and future management
8/PNS examination (lower limb)+differential --was MS i think
9/ video of child walking - had cerebral palsy -scissoring gait
10/hx depression and suicide risk
11/ CT head subdural haematoma
Pyschiatry/Neuro 2002
1)Hx Panic Attacks
2)Explain to sister of Schizophrenic what it is, Tx, aetiology etc
3)Video x2 (mental state examination)
4)Ophthalmology station-with an examiner asking qus (mcq,slide,eye drops) 5)CT head - diagnosis
6)Picture and qus-6th nerve palsy, other eye qus
7)CSF breakdown-bact/viral/TB meningitis?
8)Take Hx of social withdrawal from a disabled child's carer
9)Hx Headache-migraine
10)Side-effects of Lithium
11)Hx depression and suicide risk
12)PNS examination (lower limb)+differential --was MS I think
13)Explain what Autism is to mother and other differentials
1. MHA section 2&3. compare and contrast. u r a psych sho on call.

GP calls with a wacko SCZ pt on a tree. consultant not free for 5
hrs. GP ask u wat she can do? social worker not there. PT mom is.
discuss.
2. take hx from a depressed down's syndrome PT from carer (PT mom

died 2 yrs ago and PT gone a bit mental only recently.). explain to
carer wat is the diagnosis and Mx.
3. Headache Hx. (migraine with aura)
187
4. Depression MSE. video.
5. MSE of PT with dysphasia (expressive). video
6. explain ritalin to mom with ADHD kid.
7. CSF results. explain possible diagnosis. (meningitis, i think! also SAH)
8. Lithium Blood results. explain. (toxicity. and comment on S/E and symptoms of Tox)
9. take suicide risk assessment from woman who just took an OD, presenting at A&E
10. opthalmology. various slides. 1)cataracts 2)diabetic retinopathy 3)macular degen ...
11. Explain Alzheimer's Dx to daughter who's mom is newly diagnosed with AD
12. Take an Alcohol Hx. and comment on whether u think PT is EtOH dependent
13. Peripheral Neuro Exam. with diagnosis (peripheral neuropathy. comment on likely causes)
14. an axial CT brain and MRI spine. i have no freaking clue what the pathologies were. good luck!
Neuro Osce 2005
* bilateral , spastic scissoring gait: name differential dx, expected reflex and sensory changes
EMG/ nerve conduction studies, Calculate speed of nerve conduction using example provided in OSCE,
implication of normal nerve conduction velocity but decreased amplitude
Alcohol dependence: number of units/ criteria + substance dependence criteria
Opthalmology: Ethlers danlos syndrome---lens dislocationDiabetes retinopathy, pterygium s+s, cataract

surgery manual lens removal , laser dissolution of lens
History taking : man presenting with a transient hx of hemiplegia involving UL, LL, face----TIA, provide a
differential dx , tx, Management
epilepsy: social and general implications
History taking: panic attacks, provide advise and possible treatments
explain over the phone to staff nurse how to manage a acutely confiused patient
188
Autism: explain disease and management
Alzheimers disease
Bi-polar affective disorders and medication
Schizophrenia
189
Psychiatry and Neurology from previous years 2
1) written - anorexia signs symptoms, calculate BMI (was 15.32), know units
2) video - parkinsons describe signs, write down
3) rest
4) logbook
5) written - lithium, treatment, indications etc
6) ophthalmology - diabetic themed - retina pic, describe, explain treatments
7) rest
8) history - left sided weakness (TIA)
9) rest
10) neuro - examine LL
11) video - downs - withdrawn patient, PTSD/depression, Learning disabilities define
12) rest
13) PTSD history man mugged, not sleeping since, ddx depression
14) rest
15) depression treatment patient on tricyclics, wants to know side effects, how long on them, how long
before they work
16) alcohol assess whether patient is dependent
17) written - sections easy
18) alzheimers - explain diagnosis to patient and care available
19) child getting bullied at school, parent concerned - explain cause of stomach ache and management
20) rest
21) headache, causes etc. cluster, migraine, sinusitis
EMQs
psych
1) sections (common stuff)
2,3,4) criteria for diagnosis of depression, PND, puerperal psychosismania, bipolar, cyclothymia, dysthymia;
women with children finding it difficult to cope - euthymia?
psychosis; grade the severity of depression, hypomania
6,7) illicit drugs - which cause what type of effect, major side effects of them
8) 1st line advice to patients with (eg) withdrawal symptoms as inpatients, with chronic alcoholism; which drug
to administer
9) psychiatric drugs used to treat psychosis in pt wiht parkinsons, cardiovascular
10) identify personality disorder (straightforward)
11) child abuse v accidents (kid with 2 bleeding knees and broken arm fell off slide = accident; child scared of
people = physical abuse

12) which blood tests to order for particular drugs/interactions
13) 1st 2nd 3rd line treatment of schz
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14) child psychiatry - aspergers, retts, deafness?
neuro
-sensory levels etc; which type of sensory loss corresponds to motor defecit, sensory level, differing
contralateral signs; dermatomal distributions
- peripheral nerve lesions
-roles of members of the team - assessing for wheelchair, filling out DVLA forms, swallowing (options included:
consultant/FY1/Oc Ther/SALT/ASW)
-identifying site of lesions in the spinal cord/brainstem corresponding to sensory/motor loss
-diagnosis of MND, MG, MS
prioritisation healthcare - what do NICE/GMC guidelines etc. do; who issues them
ophthalmology - fields etc, inc pituitary tumour

sudden loss of vision ddx
traumatic injury, myopic patients more likely to get....
Psychiatry OSCE Winter 2005
15 Stations (5 mins each)

1 log book station
6 rest stations
1. Pictures of eyes Lateral rectus palsy, VI nerve (false localising) or MLF

2. Parkinsonism video, name 5 features, 2 drugs used in Rx and differential.
3. Match the disorder to the disturbances in these U&Es (really easy, low sodium/high sodium = acute
confusional state)
4. Anorexia Physical signs x 4, Physical symptoms x 4, BMI calculation (calc provided)
5. Ophthalmology pictures (with examiner), foreign body (ddx of red eye) and phacoemulsification (know
the 4 stages)
6. CT Scans (Extradural, Subdural, Glioma (ring enhancing), Meningioma) match picture to the options
7. Sensory examination of the upper limb carpal tunnel syndrome
8. GP station EtOH dependency history from patient presenting with a sore throat (be careful here!!!)
9. GP station Headache, trigeminal neuralgia
10. A&E station History of depression
11. Phone conversation with a GP about the mental health act and a patient who is stuck in a tree
(attempting to get closer to God).
12. GP Station Panic attacks/funny turns rule out fitting, ask about witness stations.
13. GP Station Schizophrenia explain diagnosis and medications to a relative (know the prognosis after
a single psychotic episode 20% never again, 70% recurrent, 10% worse and worse still)
14. Autism Explain diagnosis, prognosis, ddx (Retts, Hellers, Aspergers) , and rx (none specific, gluten
exclusion diet) with mother (worried, so be sensitive)
15. Mental State Examination on a video Schizophrenia or Mania, pressed for time on this one. Video is
about 3.5 mins.
191
Obs and Gynae
1. Post partum haemorrhage
2. Contraception advice, the pill etc
3. HIV test counselling http://www.aidsmap.com/en/docs/F661F15A-FDD7-41FF-80FA-8FF0F61A18D2.asp
4. Smear test result and explanation
5. Prenatal diagnosis counselling: Down's
6. Needle-stick injury protocol ?hiv infected or not?
Data interpretation
7. MCQ's: STD microbiology
Practical
8. Bimanual/smear on dummy
9. Mechanisms of labour: move doll through pelvis and interpret
partogram
10. How to take a blood culture
11. How to perform an MSU
OSCE 2003/2004
OBS AND GYNAE
OSCE stations dec, 2003,

1) meningitis: asked to speak to a mother concerned about an outbreak at her child's nursery school, she wants
advice on prophylaxis, when can the daughter return to school, etc. tell her about rifampicin (need it or
not??????). ask if daughter had meningitis c and Hib
http://www.communigate.co.uk/wilts/meningitissupport/page19.phtml
2) throat swab: dummy on examination bed. take a throat ask what sort of pathogens cause sore throats.
3) sexual history: someone
4) palpation of abdomen and blood pressure: ?????
5) partogram and delivery: there's a model pelvis and doll. move the doll through the pelvis, showing your
understanding of the delivery process, there's also a partogram they will ask you to
6) communication skills: woman comes in worried about her recent

cervical smear results. she has cin1. explain what that means.
7) communication skills: patient asks about the implications of PID on infertility. take a history/ give her advice
8) communication skills: patient asking aoout amniocemesis. wny is sne navir
it done, risks to baby's health, etc
9) needle stick injury: patient comes in from recent injury, asks you what to do next. tell him about the
protocol.
10) contraception: lady wants to know what contraception to use. remember t(ask forr isk factors like previous
DVT, clotting disorder if prescribing COC.
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Obstetrics and Gynaecology 2002
1)Counselling forOCP/HRT
2)Couselling for Needlestick injury-HIV, procedures
3)TB-tell pt about drugs, side-effects and treating contacts
4)Taking blood cultures-practical
5)lCervical smear and bimanual exam ????????ABDO EX BEFORE SMEAR?????
6)Hx Postpartum Haemorrhage
7)Written station: STDS gonorrhoea/chlamydia
8)Hx Urethral Discharge/sexual discharge
9)Mechanisms of birth (using plastic pelvis and baby)and
describing Partogram
10)Explaining to pregnant lady about antenatal testing
11)examination of pregnant adbomen
12(how to put on a condom)
13(Mcq on malaria)
O and G - December 2002
1. advise re amniocentesis
2. blood cultures
3. female sexual history
4. explain partogram and explain the process of
delivery and birth by
guiding a fake baby through the model of the
pelvis.
5. written station: gonococcus, acute testicle,
STDs
6. smear and bimanual on a model
7. secondary PPH history
8. HIV post exposur prophylaxis
9. counselling- explain smear result (mod/severe dyskaryosis)
10. HIV pretest counselling
11. examination of a pregnant abdomen
12. contaception counselling
13. dysmennorhoea history
14. explain how to do an MSU
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0 and G - Easter 2002:
1. Blood cultures
2. menorrhagia history
3. HRT counselling
4. male sexual history (herpes)
5. bimanual and speculum on model
6. pregnant abdomen examination
7. infectious diseases pictures
9. Meningitis counselling (exposure prophylaxis etc)
11. throat swab
12. booking visit counselling (which tests will be done etc)
13. fake baby through pelvis and partogram explanation
14. + one other which i have forgotten but it cant have been that bad though
These are the O&G stations we had in Dec 2003
1. Amniocentesis explanation and fill in the consent form
2. Counsel woman on starting the oral contraceptive pill
3. Do a bimanual and chlamydia swab on model
4. Counsel a nurse on needlestick injury and post

exposure prophylaxis
5. Counsel woman on smear test result of moderate dyskaryosis
6. Explain how to take Blood pressure and examine pregnant abdomen
7. Male sexual history
8. Female history of right sided abdominal pain
9. Counsel a worried mother about her child's exposurie to meningitis at school and appropriate prophylaxis
10. Explain a partogram (latent and active phase of 1st stage of labour) and guide a baby through the pelvis
in labour for delivery
11. Take history of antepartum haemorrhage at 34 weeks gestattion and appropriate management
12. Throat examination taking a swab
194
13. Take a history of subfertility and its causes in this particular case - pelvic inflammatory disease so take a
quick gynae and genito-urinary history
14. woman diagnosed with genital warts - counsel her on causes and appropriate treatment and risk of
cervical cancer
15. give in logbooks and feedback on firms
each station 5 mins
1. Preconception advice for a 41yr old woman

2. HIV PEP advice after needlestick injury
3.Booking bloods
4. TB treatment explanation
5.Pre test counselling for Hep C
6.Labour pain relief options
7.Prescribing OCP
8.Examine pregnant abdomen
9.Do endo cervical swab
10.Do a VE on rubber model + interpret &explain partogram
11.Blood cultures
12.Take gynae Hx of fibroids
13.Answer questions about menstrual cycle, name phases etc
14.
15.Feedback and logbook
1. explain chlamydia test results and implication

2. explain a smear
3. abdominal palpation kick chart n ctg
4. blood culture
5. expllain hrt risks n benefits
6. HIV pretest
7. gyn history ( was PID i think)
8. explain infertility ttests (progetseron, HSG & sperm ananylisis
9. Meningits prophylaxis
10. explain condom use
11. VE in labour
12.consent a patient for eua
13. explain TB drugs
14. Explain booking vsit tests
1. TB management - explain treatment of TB, duration, side effects, contact tracing etc
195
2. Explain treatment for chlamydia - duration, side effects, future prevention
3. explain to patient benefits and risks of taking HRT
4. HIV pretest conselling - ask why he wants to know, risk factors, what it involves etc
5. Taking history of someone with PID
6. Examination of pregnant abdomen - also have to read a kick chart and CTG
7. VE on a model and there was a graph and examiner asks questions but I can't remember what it was
8. Explain how to put a condom on to 17 year old boy and demonstrate on model
9. There was a image of a dye test of the uterus, fallopian tubes etc. I really can't remeber what the image is
called. ( where they inject dye in the uterus and see if it goes up into the ovaries via fallopian tube or if there is
a blockage) anyway you have to
exlpain results to a patient but there were blood results as well. Not sure if it was blocked or not.
10. Anxious mother seeks advice because 3 year old son goes to
creche where a child been diagnosed with meningitis. Have to
reassure her and ask questions about how long he been in contact
with infected child. Explain how to look out for meningitis,
treatment, prophylaxis, who needs it etc
11. Explain to patient about smear test ( so all stuff about

procedue of using speculum) and a bimanual - I think it's all stuff
we learnt in GTA teaching. So all the talking part before actually
doing it ( remember to ask about chaperone, locking door, emptying
bladder before so less comfortable)
Obs-Gynae April 2006

1. explain condom use to a 16 year old boy (remember to avoid oil lubricants)
2.Male pretest HIV counselling (ask about anal sex)
3.Demonstrate path of baby doll through pelvis at birth
4.Partogram explanation and abdominal exam
5.Infectious endocarditis explanation- treatment and pathogenesis and future prevention
6.Infertility test explanation (hysterosalpingogram ?shows kink, sperm sample below minimum volume- WHO
parameters provided)
7.Menorrhagia history in 45+ woman (?fibroids- requires urgent investigation to rule out endometrial ca)
8.Amniocentesis counselling re Downs
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9.Puerperal fever and breathlessness history (ask about symptoms of all possible causes eg endometritis, PE,
chest infection, UTI, anaemia, breast abscess
10.Booking history
11.log book double station
12.cervical smear- ask permission, mention chaperone etc, examine abdomen first
13.Throat swab
14.female sexual history (Chlamydia contact)
http://www.rxpgonline.com/postt25157.html- CIN3 counselling

how to put on a condom: http://www.durex.com/cm/assets/SexEdDownloads/factsheet9.pdf
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O&G EMQ Dec 2005
1. Medication for PCOS, infert, detrusor inst',prolactinoma
2. PID - presentations
3. Menorrhagia
4. Testing in STD clinic - speculum, swabs, serology
5. Amenorrhoea - primary/secondary, causes
6. Hospital infection - isolation requirements etc.
7. Postnatal events - BF, renal, gut motility (days/weeks etc.)
8. Twins =96 IUGR, TTTS
9. Big for dates =96 same as LapT
10. Bacteria causing what? =96 Staph, strep, one funny UTI (Staph.
saprophyticus)
11. Prophylaxis of bacterial infections =96 pneumococcus, meningococcus
12. Histology of gynae cancers =96 HARD!!!
13. Hormone levels =96 PCOS, precocious puberty
14. PPH =96 C/S, forceps, etc.
15. Fungal infections inc. tinea
16. Tropical infections =96 =91coca-cola=92 urine, jaundice (Vietnam)
17. Antenatal bleeding =96 plac. prev., abruption
18. Delivery =96 emergency C/S, fetal bloods, ?CTG etc.
19. Vag. Discharge
20. Different presentations of labour inc. =91precipitate=92
198
21. Subfertility Ix
22. Blood results for , molar preg. etc.
23. Pre-eclampsia + preg-induced hypertension + pre-existing hypertension.
24. Pre-natal screening (combined vs. integrated vs. quadruple)
25. Pre-malignant conditions =96 CIN, VIN, warts etc.
26. Dyspareunia =96 PID +/- bleeding etc.
27. Methods of contraception =96 BF
28. Stages of labour.
N.B. No CTG question
199
Obs & Gynae OSCE April 07
17 stations 14 actual stations with 2 rest and a 10 min logbook station which are all stupidly together so youll
have 20 mins off at some point.
1. Pregnant chicken pox woman

14 week pregnant woman comes to antenatal clinic worried because her son is suffering from chicken pox. She
doesnt know if shes ever had it so you need to tell her you need to check her antibody status. You need to tell
her about 8-21 incubation period, when its infectious, congenital and neonatal varicella syndrome, vaccine is
contraindicated in pregnancy. She asks some weird questions about all her mates who seem to also be
pregnant and whether she should be able to see her, how theyd know if they were affected. Last thing was her
son was waiting outside, should he even be there I suggested no and for her friend to take him no but think I
was talking bollocks.
2. Throat swab
All it says on the sheet is john smith comes in with a recurrent sore throat, perform an examination and take a
swab. Read up on throat swab, do inspection check lymphadenopaty and also remember to fill the form in
properly with what examination youve performed and the patients symptoms. I stupidly didnt easy marks
that dont need to be wasted!
3. COCP Counselling
Pretty straight forward tell this woman who has previously been on the pill about what pill is, good points, side
effects, contraindications, risks, how to take and missed pill. She doesnt ask questions so you should have your
whole talk planned out. A good one is in that pink osce book. Shite, just forgot that I didnt tell her shell need
to come back to get her BP checked after 3mths, remember to do that.
4. Consent woman for bimanual/speculum

Youre a medical student and you need to get permission from a woman to do a bimanual whilst under
anaesthetic. Piss easy remember to say part of medical basic training to learn internal ex (check rep orgs
healthy) and spec (thing you have with your smears), would it be ok to do this under supervision of consultant,
wont affect tx/post op side efx then get her to sign form. Takes a minute, then sit and have uncomfortable
post -osce chit chat with actor and marker.
5. Community acquired pneumonia

This was the killer station. A woman who has had a past splenectomy (loads of ppl didnt read that bit on the
sheet) has pneumonia, has been treated with erythromycin but hasnt got much better. Tell her:
What tests shes already had xray, I said sputum culture and stupidly forgot stuff like fbc, blood cultures
What caused it, what bac can cause CAP
What antibiotics usually treat CAP
Now the tough bit how to prevent infections, I mentioned all that barrier nursing bullshit when in hospital
and prophylactic oral antibacterial and antifungals.
She may ask other random questions different ppl seemed to get diff qs
200
6. Speculum/Smear and Bimanual
The key here is be very quick a lot of ppl didnt get onto the bimanual let alone commenting on their findings.
I think I spent half the station putting gloves on. This is something that will almost definitely come up so make
sure youre really slick because if you fuck it up like I did youll feel like an idiot and it will put you off speculums
for the rest of your life. Not that its not already a disgusting thing.
7. Antenatal abdomen palpation

Woman has high blood pressure, urinalysis negative, examine her abdomen. This was really weird, so different
from a normal abdomen which are actually a lot easier. Remember liquor volume at the end! Shell ask what
tests at the end I ran out of time but should have obviously said ctg/ultrasound. Again this really shouldnt be a
station where you lose all your marks but for me it was.
8. Preconception chat with 41 yr old

41 yr old bmi 32 (although she was actually skinny so you forget) comes in wanting to get pregnant and she
wants any advice you can give her. I wasnt sure how everyone else did this but I split it into
Trouble getting preg when older fert drugs/ivf
Risks for baby esp downs hence talk about all the blood tests, nuchal trans and combined test
amniocentesis/cvs for def diagnosis (think theyre offered to all over 40s?)
Risks for her eg more chance PET, gestational diabetes, molar preg, labour complications
General prepreg advice, diet/exercise esp cos of her wt, what not to eat, drink/smoke, folic acid, rubella igG
9. GUM clinic sexual history

Take a sexual history from a guy, previous gonorrhoea, cheated on his long term partner and now has
discharge, dysuria. Give a differential (gon/chlam). Also recommend condoms for future.
10. HIV Pretest discussion

Woman who wants to get preg, has shared a needle with her bf who has used needles loads in the past. This
one was tricky as the woman wouldnt shut up, so try and get a move on and cover as much as you can. Pretty
standard, theres pretty much a mark scheme near the back of the logbook as there is for sexual history.
11. Hepatitis results

Gay man comes in you have his hepatitis results he has Hep a abs so obviously has had in past tell him bout
hep a and there are no serious longlasting complications ( I think I used the word acute 6 times and then
thought I shouldnt even be using this word). Then he is neg for all hep b so you have to tell him about the
vaccination process, why he should have vacc, how hep b is transmitted , symptoms, complications and poss
treatment.
12. Abnormal smear moderate dyskaryosis

Woman comes in having just got her smear results mod dysk. So tell her its not cancer, will have to do
colposcopy blah blah. Again I think its all covered in the pink osce book.
13. Antepartum haemorrhage

Woman comes in 34 weeks, painless bleed since last night sheet says take history of her presenting
complaint, obstetric history, give her a differential and any tests you would do. I think other people dived in
201
and said either praevia or abruption but I said it could be either as it was both painless and scans hadnt shown
low lying placenta but more likely praevia as it was fresh blood. Few people didnt ask if she had previous
bleeding in that preg so remember that.
14. Booking investigations

Woman comes in at 12 weeks what tests would you do and explain to the woman why. So all your normal
blood tests fbc, group and ab status, hb electrophoresis, the 4 infections, random fasting glucose also
mention urine for infection/proteinura and dating scan/nuchal translucency. At the end the examiner said ask
her a pet related question, now because in the textbooks PET means pre eclampsia I was like er any visual
defects examiner said no then I said ok swelling of your fingers or face? and he was like no, PET! Then the
station ended and everyone had said theyd asked about the whole cat/toxoplasmosis thing. This station will
most probably repeat so def mention the cat!
Obstetrics and infection Aids pre test

Impey
Learn microbiology.
Anaemia in pregnancy
Chlamydia Possible stations
Throat swab Chlamydia smear
Post partum pyrexia Explain smear
Stem cell transplant infections Abdominal palpation chart
Breech abdomen Blood culture
Hiv pre test Explain hrt
Fever in returning traveller Hiv pre test
Speculum with a swab Pid history
Bacterial vaginosis Infertility tests
Thallasaemia Condom use
Explain speculum and smear Ve in labour and partogram
Delivery of placenta Consent for eua
Threatened miscarriage Tb drugs
Booking bloods and tests
Throat swab Pre conception advice 41 year old
Mrsa on op list Hiv pep advice
subfertility Pre test counselling hep c
Booking bloods Labour pain relief options
Post partum depression. Examine pregnant abdomen
Endocarditis history and treatment. Cervical swab
Delivery of a model baby. Blood cultures
Delivery of a placenta. Fibroids
Putting condom on - ask if boy or girl. Menstrual cycle, phases
Postpartum pyrexia Pcos
Menorrhagia Stages of labour and ctg
Chlamydia Meningitis - contact involvement
Pregnant abdomen Cocp
Amniocentesis consent
202
Advantages and disadvantages of epidural
1. explain chlamydia test results and implications

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

27. Stages of labour + CTG with a doll/pelvis
28. Infertility test results feedback
29. Meningitis woman comes for advice on hearing a kid at her sons school has it, explain protocol, ask about
men c vaccine + Prophylaxis
203
30. Conset pt for EUA
31. COCP counselling know the CI
204
OSCE STATIONS: O+G APRIL06. ENJOY!!!!
1. Infective endocarditis: Explain to the patient what endocarditis is, she has just been diagnosed and had a ECHO done
and hasnt started treatment, she had rheumatic fever in her childhood, and went for a root canal repair 2 months ago.
She asks you: what increases your chances of getting infective endocarditis? She wants to know what the investigations
show? What exactly is it? How does bacteria cause it? How would you treat her, how long for? She asks: how do you
know what antibiotics to use? How do you know that they are going to work? What are the side effects? How will she
know whether she has a side effect?
2. Interpreting subfertility tests: Explain to a patient the results of her partners sperm count, her day 21 progesterone
level and a hysterosalpingogram photo. Know what normal sperm count is, and in her case the partner had >70%
abnormal forms (the rest of the count was normal I think). Explain what mid-cycle progesterone tells you about her
fertility? Interpret the hystosalpingram, know what normal looks like! She asks how what can you do for her husbands
problem?
3. How to put a condom on? A 14 year old boy has come to the clinic and wants to know how to put a condom on.
Explain and show him on a condom trainer. Mention emergency contraception available for partner in case of accident.
Get him to demonstrate.
4. Antenatal clinic. Lady is 12 weeks pregnant has come for her 1st antenatal appointment; explain the tests you would
do. Tip: I think what they are really getting at here are just the routine bloods (make sure you know at least 5 teststhe
examiner kept asking me for more but I went blank), urine tests etc. Not ultrasound scans (since I talked about this for
most of the station and I peaked at the mark sheet and didnt get good mark).
5. Post-partum pyrexia and bleeding for 5 days after delivery initially flooding then period like, clots and smells really
bad. Take history and explain management.
6. Menorrhagia History and management. I got confused here since the patient who is 43 years old, had heavy bleeding
for the past 6 months, (flooding and clots), and has had 3 children. She has tried tranexamic acid but didnt help. In the
past was told she had a small fibroid. She was going for a scan (didnt get round to asking why?). I suggested endometrial
ablation she was not too keen, I suggested COCP and she was not too keen (I guess not a good idea because of her age)
Tip: you get some marks for basically taking a gynae history even if you dont know management. But I guess
hysterectomy was probably a reasonable suggestion but I ran out of time.
7. Log book station and feedback (10 minutes). A consultant asks you how you found the attachment and what marks
you got from your consultants etc.
8. Chlamydia history. A young women whose partner was diagnosed with Chlamydia 3 weeks ago currently on
treatment, last had sexual intercourse 1 and a half weeks ago. She wants to have a Chlamydia test. She asks is he being
unfaithful? Know treatment.
9. MRSA and due for prosthetic surgery tomorrow. What is MRSA? Why does she have it? Can she spread it? Will people
at home get it? What is the treatment? Can she have her surgery tomorrow if so what antibiotics will she need? What is
the MRSA decolonisation protocol?
10.Examine pregnant abdo and interpret partogram.
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11. CTG and baby and pelvis explain stages of birth. Straight forward: CTG had a big deceleration, reduced variability
and no accelerations.hence fetal distress, so probably hypoxic, I suggested fetal scalp electrode and immediate
delivery. The baby and the pelvis are really straight forward just go practice in clinical skills.
12. Smear. The sheet told me to do a smear. But the examiner also told me to do a bimanual. She asked me what does
the cervix look like? (it was a cervical ectropion). She also asked me if the uterus was retroverted or anteverted? (I
laughed cause I thought it was a joke, I mean how can you tell on a plastic model?...but maybe she was being serious?).
13. Throat swab. I found this one tricky since the guy taking the station was really weird. There was a dummy and then
the examiner. The instructions said to take a clinical history from Mr John Smith, then do a throat swab. So I naturally
faced the examiner to ask him the history of the sore throat and he kept pointing to the dummy (so I got confused).
14. Amniocentesis and consent for it using the form they give you. Explain the process, and inform her about the risks.
15. AIDS pre-test discussion. Discuss about HIV pre-test. Explain that you cannot catch AIDS. Explain HIV and AIDS?
Explain window period.
Some extra tips for the module:
The EMQ was tough you really need to know details. Esp. communicable diseases a lot of stuff on fungi came up.
Know HIV and complications well.
Communicable diseases:
For microbiology go to all of Dr Shettys teaching at UCL, she is amazing!!!!!!!! (I was based at RFH but went to all her
teaching). And she gives you all the details you need to know and extra tips on the OSCES. Dr BalaKrishnas lectures at
RFH are also very good. Also make sure you go to all the case discussion lectures since these are really useful for
OSCES.
We didnt have anything on Gastroenteritis in the EMQ or OSCE so will probably come up next time.
1. Dr Shetty- MRSA this came up last block.

Patient is going in for hip surgery. Before operation, they have MRSA screen. They have a few questions for you.
How will they do this MRSA screen?

Swabs taken from nose and also possibly from groin, axillae- Microscopy, culture, sensitivities.
Why is this done?

MRSA colonises many people externally without causing symptoms. However, with implant surgery, there is a large
wound and a large foreign body. Patient is vulnerable to infection, MRSA is difficult to treat and may necessitate
removing implant. By screening beforehand, can eliminate MRSA before operation and improve success rate.
How would I know if I became infected after the operation?

You would feel ill, with fever, wound discharge, breakdown, pain on weight bearing. This may need investigation.
How is MRSA eradicated?
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5-day protocol, involves antibacterial shampoo and bath, mupiricin nasal ointment. This can be done at home (MRSA
commensals are not a risk to healthy people in the community). If in-patient is found to be MRSA-positive, they are
isolated and healthcare workers should all use infection control procedures.
Before operation, patient is given vancomycin/teicoplanin + gentamicin prophylaxis (synergistic killing of gram positive
bacteria). If MRSA positive and surgery is emergency, proceed with pre and post-op anti-MRSA prophylaxis. If not
emergency, send home for 5-day MRSA suppression.
2. Dr Shetty- Infectious endocarditis history of rheumatic fever, recent dental operation. Gram positive cocci
found on culture, echo shows vegetation.
Explain to patient what infectious endocarditis is and how they developed it- rheumatic fever roughened their valves and
disrupted bloodflow in region. This encouraged clots, platelets to stick. Dental surgery introduced bacteria to blood from
mouth. These were attracted to the platelets and formed colony there, shielded from immune cells. This causes further
heart valve damage, fever, risk of damage to other organs
Strep viridans is cultured. How is this treated?
IV benzylpenicillin + IV gentamicin (synergistic kill of gram positive- pen breaks down cell wall, gentamicin attacks
ribosomes) 2 weeks.
Ensuing 4 weeks antibiotic is either amoxicillin PO (can be discharged home) or benzylpenicillin IV (needs to stay in
hospital)- decision depends on state of patient, Dr preference. Side effects of gentamicin= ototoxicity, nephrotoxicity.
Need to ask about penicillin allergy (would give clindamycin instead). To avoid future episodes, they should have
amoxicillin + probenicid prophylaxis for surgery and all invasive procedures.
3. Dr Shetty-
A 10year old child gave a 3 day history of flu-like illness with no other localising symptoms. Over the course of a few days
he presented with characteristic vesicular lesions on his face. Several children in his class at school have been unwell with
a similar illness. He continued to be systemically unwell with a temperature of 38. His mother is 10/40 pregnant, is
completely well but is concerned about the baby. The veisular lesion was aspirated and clear fluid obtained; this was sent
to the lab. Chickenpox is diagnosed.
What is causative organism? varicella zoster (human herpesvirus 3)
What is incubation? 8-21 days
What is the common name given to reactivation?- shingles.

What are maternal chickenpox risks to fetus?
Risks to fetus: congential varicella syndrome. 0.4% risk if ma infected in 1st trimester, 2% in weeks 13-20, much less after
this.
In 1st trimester causes congenital defects (~7.8% prev compared to ~3.4% in non-infected), low birthweight, intrauterine
death, skin-brain-eye-GI-GU effects: including skin lesions, brain damage, spinal cord atrophy, limb paresis, seizures,
chorioretinitis, duodenal stenosis, jejunal dilatation, neurogenic bladder. Diagnosis requires maternal varicella in
pregnancy, dermatomal skin lesions at birth, IgM antibodies to VZV after birth/ gG after 6 months. Early detection-
antibodies on cordocentesis, characteristic defects on ultrasound/ CVS sample for VZV DNA.
Neonatal varicella can cause pneumonitis-hepatitis-meningoencephalitis which has mortality up to 30%. Maternal
varicella 5-21 days pre-delivery is less harmful because antibodies are likely to have developed, which cross the placenta.
What lab test will you perform on the ma? VZV antibody.
What is treatment for active varicella chickenpox in pregnancy?-

Counsel on risks of chickenpox in pregnancy. Live vaccine is available but contraindicated in pregnancy.
Symptomatic relief. Prophylactic VZIg for pregnant, asymptomatic seronegative contacts of chickenpox (ie woman in this
case). Aciclovir if they develop chickenpox (IV if complicated eg pneumonitis).
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VZIg at birth for baby if ma develops chickenpox 7 days before - 28 days after delivery/ siblings have chickenpox at home,
can perform C-s if lumbar area is clear for epidural. Babies should receive IV acyclovir if they develop chickenpox, even if
they have had VZIg already, they can still be breastfed, should not be isolated from mother or siblings.
The mother asks if she can take son to antenatal appointment. No.
The mother asks if she can go- she is unsure if she had chickenpox as a child and her antibody status is unknown.- no.
Child may have infected her, she would be infectious for 3 days before getting lesions on skin. District nurse should visit
her at home and test for antibodies. If she is antibody negative and remains symptoms free, she is not clear to visit
antenatal until 21 days after all her sons blisters scab over and are dry.
Sons teacher is also 10/40 pregnant. She asks if she can go to antenatal class- she is asymptomatic, never had chickenpox
before and school holidays started 10 days ago.- she is clear because boy was not infectious when she saw him
(symptoms started 7 days later).
Father of child is heavy smoker with no history of chickenpox, but he has no symptoms does he need treatment? If he is
antibody negative (immunity can be acquired without developing chickenpox), he should be treated with prophylactic
VZIg as his smoking puts him at increased risk of varicella pneumonitis death (as would immunocompromise). Add
acyclovir if he develops lesions.
What if mother developed herpes zoster shingles? This is not a problem- she would have varicella antibodies and not pass
on infection to child. Only problem is if it was as result of immunosuppression eg HIV/ paraneoplastic lung cancer
Throat swab
1. Introduction and establish rapport
2. Explain the task and ask for consent
3. Ensure that the patient is comfortable
4. Wash hands and wear gloves
5. inspect patients face and neck, noting any swelling
6. look at lips for ulcers or fissures
7. assess the gums and teeth for dental hygeiene-remove dentures
8. inspect the buccal mucosa
9. look at the hard palate and the floor of the mouth- ask the patient to protrude their tonge to view the hard
palate and to raise it to view the floor
10. look at the tongue for cyanosis and excessive furring. A smooth togue could indicate B12 deficiency
11. Use a tongue depressor anda torch to look at the throat
12. ask the patient to say aaah and inspect both tonsils (either side of the uvula), the posterior pharyngeal walland
the movement of the soft palate.
13. For examination of neck, the patient should be upright and examined from behind
14. palpate gently for lympadenopathy beneath the mandible, over the anterior and posterior triangles of the neck
and above the clavicles
15. wash hands again
16. loosen swab container
17. ask patient to say ahhh
18. use tongue depressor to keep the tongue on the floor of the mouth
19. point the swab at the back of the patients throat and gently roll it around the fauces over the tonsils.
20. Remove the swab and replace it intothe culture medium (label specimen). Ensure its delivery to the lab (with the
request form)
21. Conclude by explaining how to get the results of the test and say thank you.
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Condom Use
A: Demonstrate how you would explain condom use to a group of fifteen year-olds. [5 minutes]
Provided: condom, prosthetic penis
ANSWERS
2- done well, 1- done okay
1. Polite introduction, establish rapport, explains topic to be discussed
2. Explains that most 15 year-olds have not had sex, despite what they may say. Girls do not have to give in/ it is
wrong to pressure others into sex.
3. Asks about condom knowledge- why to wear a condom, how to put one on
4. Explains reasons for using condom- prevention of STIs including HIV, herpes, chlamydia, gonorrhoea. ~1/3 of UK
HIV positive dont know they have it, can appear v.healthy, there is no cure. Asymptomatic STIs can
cause infertility.
5. prevention of pregnancy
6. HIV, herpes, gonorrhoea can be transmitted orally, so use condom
7. Explains condoms are available for free at family planning clinic
8. Demonstrates use- check date on packet, stronger varieties available for anal sex
9. open carefully and pinch end of condom- if air gets in, sheath can tear, space required for semen
10. put on before penetration as pre-cum contains sperm. Retract foreskin, place on prosthesis, roll to base
of shaft
11. during sex, check it doesnt come off, remove carefully as soon as ejaculation happens, even if premature
12. Important donts: dont use oil-based lubricants (eg Vaseline, massage oils)- they make condom tear, can use
water-based
13. dont use spermicides- they cause inflammation and may increase STI spread,
14. dont flush down toilet- blocks pipes
15. What to do if goes wrong- post-coital contraception from GP/ family planning within 72 hours/ coil within 5 days
16. post-coital HIV prophylaxis available in certain circumstances
17. chlamydia screening available at GP/family planning
18. Asks for questions
19. Asks 15 year-old to demonstrate on prosthetic and corrects mistakes
20. Does all in a fluent, approachable manner
COMMENT
Important to communicate appropriately with young people, give serious information, encourage mature discussion
without being preachy or manipulative.
B: You are a medical student at a GUM clinic. The next patient is a 32 year old woman who wants to be tested for HIV.
Perform a pre-test risk assessment, including sexual history. (5 minutes)
ANSWERS
Patient history
I have been very concerned about my sexual health because I recently had unprotected vaginal sex. It has taken
me some time to make myself come here and I am very concerned about confidentiality. I will call myself Jules Gray. I am
experiencing an unusual discharge from my vagina that does not go away with washing. I went drinking with my mates
and met a man. He took me home and we ended up having sex without a condom, this was one week ago. He was British
born. My current partner, from Canada, is unaware, we have been together 4 months and have vaginal and occasional
oral sex, the last time being two nights ago. I am on the pill, we only use condoms when I am bleeding. Prior to these two
characters, my previous sexual encounter was 6 months ago. We had oral sex only, using a condom.
My last smear was 2 years ago, it was normal and I have never had a recall. My last period was 3 weeks ago, my
cycle varies from 25-30 days. I had one miscarriage 6 years ago but no other pregnancies. I have never worked in the sex
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industry, never had sex with a bisexual man, never had a blood transfusion, never had sex with an HIV positive person,
though one of my boyfriends was a white South African. I used speed intravenously 3-4 times in my early twenties, did
not share needles and have not used other drugs other than alcohol and cigarettes. I go drinking every other weekend,
and may take up to 10 units. Other than the oral contraceptive, I am not on any medication and have no allergies. Three
years ago I was treated for chlamydia and have had no problems since.
I would like to have an HIV test. If positive, I will tell my friends and my mother. I expect the result to be negative.

1. Polite introduction, establishes rapport
2. Explains that information is confidential by law and that no 3rd parties have access- including GP and insurance
companies. She does not have to give her real name, contraception and treatment is available free
3. Asks why she has come to the clinic on this particular day- presenting complaint
4. Explains that personal questions have to be asked for risk assessment
5. Establishes obstetric history: pregnancies/ abortions/ terminations
6. Establishes when last menstrual period occurred
7. Establishes current contraception use, if she uses condoms, does she use them all the time
8. Establishes date of last smear, history of abnormal smears
9. Enquires about current health.
10. Establishes current medication/ allergies
11. Asks about any prior/ ongoing drug use including IV and alcohol
12. Asks about history of work in the sex industry
13. Sexual history -establishes when she last had sex, if partner was casual/ regular, if regular how long was
relationship
14. -establishes type of sex: oral/ vaginal/ anal
15. -asks if condoms were used- if so all the time?
16. -asks previous person she had sex with before, and find type of sex and condom usage for all
partners over the last 6 months
17. -asks if they have ever had sex with: person born in high risk area like Sub-saharan Africa/south
America/ SE Asia
18. intravenous drug user
19. bisexual man
20. HIV positive person
21. Asks if they have had a blood transfusion in a high HIV prevalence area.
22. Asks about history of STIs
23. Asks if they want an HIV test, if not why not
24. Explains three-month window of HIV test (antibodies may take 3 months to form, therefore test reflects events
occurring up to 3 months before)
25. Establishes when they last had an HIV test and the result
26. Asks what they expect the result to be
27. Establishes who they can tell if the HIV test is positive
28. Does all in a fluent, sensitive, professional manner
A. Blood cultures
Take a blood culture from this patient. Provided: hand gel, gloves, alcohol swabs, blood culture bottles, vacutainer/
needle and syringe, tourniquet, prosthetic arm.
2. Explains procedure and gets consent
3. Check identity and if matches name tag
4. Collects all equipment required
5. Cleans skin well with 2-3 alcohol swabs
6. carefully removes flip tops on bottle sbefore use
7. Wipes tops of bottles with an alcohol swab and lets them dry.
8. Takes blood from patient using needle and syringe
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9. uses fresh needle to inoculate each bottle if using a syringe.
10. labels bottles correctly.
11. Does all in a fluent, professional manner
B. A 23 year-old woman wants to start the oral contraceptive. How would you, a family planning Dr enquire after her
concerns and counsel her? (5 minutes)
I am at college and do not intend to have children for at least 3 years. I am currently in a long-term relationship, my last
period was 7 days ago. We use condoms for contraception. I have never been pregnant, or had an STD. My cycle is
regular with 4-5 days of bleeding, cycle lasts 30 days. I have heard that the oral contraceptive is reliable, but has side
effects. What are the side effects? How does it work? I do not smoke or drink, have never had DVT-PE, have no breast
disease, focal migraines or liver disease. I am on no medication. What do I do if I miss a pill? Or miss three pills?
What other contraceptives are there? Do I still need to use condoms?

2. Asks about previous pregnancy,
3. Asks what contraception she is currently using
4. Establishes last menstrual period
5. Asks smoking history
6. Asks about history of STDs
7. Asks what she knows already about contraceptive
8. Explains mechanism of oral contraceptive- combined pill contains oestrogen and progesterone, causes
anovulation, monthly withdrawal bleed, can control heavy periods.
9. Explains 21 days pills followed by 7 day break/ dummy pills
10. Best to take at same time each day.
11. Asks about contraindications:- history / family history of DVT
12. liver disease
13. breast disease
14. migraines with aura- visual disturbance
15. hypertension
16. other: medication eg phenytoin, diabetes
17. Explains side effects: possible weight gain, nausea, high blood pressure, breast pain, protection vs osteoporosis,
ovarian cancer, endometrial cancer slight increased risk DVT, breast cancer, stroke-MI
18. Explains what to do if misses- if miss one, take it as soon as possible, continue next days dose
19. if miss up to 2, take last missed pill soon as possible, rest of pack as usual
20. if miss 3 or more, take last missed pill as soon as possible, leave rest, use condoms for 7
days, emergency contraception may be needed. If 7 or more pills remain, take one per day and start 7 day break/
dummy pills
21. If <7 left, finish pack and start next cycle without break,
22. Worst to miss at start or end of cycle- first 7 days blocks ovaries
23. Caution if diarrhoea/ vomiting: may not work
24. explains that COCP is over 99% effective if taken properly
25. Explains importance of condoms vs STIs and for double safety.
26. Other options: progesterone only pill (including derazette- anovulatory), implanon, depo-provera, mirena
27. Tells to take leaflet and decide for herself
28. Explains need to take blood pressure, examine breasts
29. Does all in a professional manner
14.History: You are a medical student attached to a gynaecology outpatient clinci. The next patient is a 19 year old
student who has been referred by her GP for amenorrhoea. Please take a history of the presenting complaint and any
other relevant history with a view to making a diagnosis. (5 min)
ANSWERS
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I was a previously fit and well 19 year old engineering student. I started having periods when I was 11-12 and these have
been regular until 8 months ago. My norm cycle was 3-5/24-6. My periods have been irregular for the past 4 months. I
was involved in a long term relationship until 6 months ago when I split up with my boyfriend because he was playing
away. I was devastated, but have slept with him once since, 2 months ago. We used to use condoms and I have never
been on the OCP. My last period was 2 weeks ago.
I have never been pregnant and have not had any other gynaecological problems. I have been relatively well, but lost 4-5
kg after the break-up (I have put some weight back recently). I have been struggling at uni and feel quite depressed. I
have been sleeping poorly but have been eating a lot better lately. I have started smoking 10-20 per day. I drink 20-30
units per week. I am not on any regular medication and have never suffered from anorexia or hormone imbalance.
2- done well, 1 done ok
ASSESSMENT
1. polite introduction; establishes rapport
2. Establishes asge of menarche
3. Establishes normal menstrual cycle and last normal cycle
4. Asks about sexual activity: last intercourse/ excludes other symptoms of pregnancy
5. Establishes present contraception, if any
6. Establishes absence of obstetric history
7. Establishes/ excludes other gynae problems- dyspareunia/ pelvic pain, galactorrhoea, post coital bleeds,
prementstrual symptoms
8. Establishes/ excludes symptoms of differential causes- endocrine disorders
9. Anorexia/ gross weight loss
10. general disorder: thyroid disease, anaemia, diabetes
11. Enquires social history, personal and family relationships leading to amenorrhoea
12. Establishes smoking and alcohol history
13. establishes not on any medications
14. Summarises findings; gives appropriate diff diagnosis
15. Does allin a fluent, sensitive, professional manner
Diagnosis: Secondary amenorrhoea due to stressors of uni course and personal relationship break-up
A.History: A married couple in their thirties have come to see you, their GP, with difficulty in starting a family. Please
take a history from the wife wit a view to assessing their infertiloity problems. (5min)
You may assume she is alone on this visit; you should be prepared to discuss management options.
ANSWERS
We have been married for three years. We both work, he is a solicitor and I am an estate agent. We own the house we
live in and we have no finance worries. My husband has a 5 year old child from a previous marriage, whom he supports. I
have bever been pregnant and wa are bothhealthy and fit. I had an operation for an ovarian cyst 5 years ago, when my
right ovary was removed. My periods were regular when I was on the pill buit since 2 years ago when I came off it, they
have come every 6 weeks or so and are occasionally heavy. I have no other gynae problems. I am a non-smoker and drink
3-4 glasses of wine each week.
ASSESSMENT
1.polite introduction; establishes rapport
2. Establishes duration of relationship
3. Establishes history of previous pregnancies
4. Establihses if there are any children from previous relationships.
5. Asks about occupations of couple.
6. Asks about home circumstances
7. Establishes past/present health of husband.
8. Establishes past/present health of wife
9. Establihses history of gynae symptoms
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10. Discussion of ovary problem, hormonal therapy and IVF
11. Does all in a fluent, sensitive and professional manner.
COMMENT
Infertility should be considered as a couples problems rather than individuals. Infertility should only be diagnosied agter
the couple have been trying for a child for one whole year. After the initial interview with the couple together, it maybe
approoriate to interiew them separately, but all management decisions should be made in open discussion and with the
agtreement of both parties. The loss of an ovary reduces the chances of normal conception by half, as the remaining
(healthy) ovary ovulates once in every 2 cycles. Menstrual irregularites may results for sub-optimal endogenou estrogen/
progesterone production. Endocrine therapy may stimulate normal ovulation and conception, provided there are no
tubal or uterine abnormalityes. IVF may be considered, with impantationg durig an artificially-induced progestational
phase.
B. HISTORY: A 33 year old woman is referred to the gynaecology clinic by her GP for sterilisation. Please take a history
in order to assess her request. (5 min)
ANSWERS
I am single and work as an actress in theatre and TV productions. I want to have my tubes tied because I dont want a
family. I am in a stable relationship and my partner, who works in the theatre, is not keen on kids. We do not plan to
marry. My job involves travelling all over the world. I have had 2 early terminations in the past 10 years. I was on the pill
until I develioped thrombosis of my leg veins, following surgery for a serious kidney infection a year ago. My GP has not
advised me agasint having children, as my kidneys are now working normally. However, I would not wish to stress them
by becoming pregnant. I do not think I would miss having hcildren of my own, as my partner and I have nphews and
nieves, and we wish to put allour efforts into our careers.

ASSESSMENT
1.polite introduction; establishes rapport
2. Establishes social and family history
3. Establishes reasons for wanting sterilisation
4. Establishes past medical and OG history
5. Presence of chrnoic/long-standing illness that may contraindicate pregnancy
6. Enquires into partner/ husbands wishes and the possibility of wanting children in the futurre
7. Does all in a fluent, professional manner.
C HISTORY: A 27 year old, single woman consults you, her GP, with severe period pains. Please take a history of the
presenting complain with a view to making a diagnosis (5min)
ANSWERS
I am having severe lower abdominal cramps just before my periods, and they subside only when myperiod ends. The
pain is severe and radiates tomyback and down my thighs. I have to spend the worst dayor two in bed. I am single and
work as a flight attendant and am having to later my flight schedule virtuallyeverymonth as a result. My erids tend not o
be regular, and I get spotting before they start. They are occasionally heavy, and I had put it down to experimenting with
different birth control pills in the past. I have beenoff the Ocp for more than a year and my symptoms have simply got
worse. I began my periods when I was 14 years old but they became very painful about 9 months ago. I have never been
pregnant and never had a pelvic infection. I ama very health and active person and am not on any medication except for
the standard painkillres I take sduring menstruation.
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ASSESSMENT
2. Establishes characteristsics of the pain- severity site and duration
3. Duration in relation to cycle
4. Effect on dailylife
5. Establishes menstrual history
6. establishes history of gynaecological ailments and genral health
7. establishes any past pregnancies and outcome
8. asks about the birth control pill or hrmone therapy
9. does allin a fluent, professional manner
COMMENT
The patient probablyhas secondary dysmenorrhoea: this is usually associated with demonstrable pelvic patholgoy,ie
uterine hyperplasia, pelvic inflammatory disaese,pelvic tumour, endometriosis,adenomyosis and cervical or vaginal
stnosis. The dysmenorrhoea maybe relived symptomaticallyor bytreatment of the underlying lesion.
E. Please read the following information before attempting the next station.
You are a medical student attached to a GPs surgery. The next patient is a 34 year old woman who has returned tosee
the GP for the results of a cervical smear which she has had recently and was reported: Dyskaryotic squamous cells
with enlarged nuclei consistent with a diagnosis of CINIII. A colposcopy and biopsy is advised. Please explain the
cervicalsmear report to the patient, address the concerns she expresses and the management involved. (5Min)
I am a school teacher and am returnign for the results of a cervical smear test I had several weeks ago. My previous
smear, five years ago, was normal,and I have no anxieties about the results of this test.
When told about the results: Oh my God.
Does this mean I have cancer?
Will I need a hysterectomy.

ASSESSMENT
2. Establishes patient identity and reason for attendance
3. explains in non-jargonsitic manner the results of the smear, communicating appropriately the seriousness of the
condition.
4. Explains the need for colposcopy and biopsy
5. Explains the procedure for colposcopy
6. Mentions possible need for local treatment of the cervi
7. Checks patients understand of explanation
8. Invites patients questions and answers
COMMENT
Management of CIN II- women with CIN III require colposcopy and biopsy. Local treatmen incldues cryotherapy, laser
treatment and electrodiathermy and the patient requires annual review with cervical smera. If microinvactionoccurs or
the squamocolumnar junction is breached, cone biopsy is required, which offers a total cure. When giving the results of
an abnormal cervicalsmear, counsellginis essential to avoid emotional problems and possible delay in diagnosis and
managemnt.
4.1 A 27 year old woman sees you, her GP on her 1st antenatal visit. Take her history.
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(5min)
Patient history
I have been married for 3 years and I work full-time as an administrative officer for a pharmaceuticals compny. My
husband is a civil engineer with a road construction firm. My father has diabetes which recently affected his eyesight and
kidneys. I had a miscarriage 2 years go and was admitted as an emergency and received a blood transfusion.
I was on the birth control pill until a few months ago when we decided to start a family. My last period was 10 weeks ago,
and thy have always been regular and of normal duration. I have been feeling sick and dizzy most mornings but am
getting over it now. I dont smoke but took sleeping pills at night until recently, when I found out that I was pregnant.
2- done well, 1- done ok
1. Polite introduction
2. Establishes:- LMP or dating scan
3. Use of OCP
4. Pregnancy test
5. Symptoms of early pregnancy- eg vomiting, breast pain
6. recent febrile illness eg german measles
7. any medications
8. alcohol/smoking
9. recreational drugs
10. History of previous pregnancies (number)
11. Full term deliveries and or prem labour
12. abortions or miscarriages
13. antepartum haemorrhage/ hypertension/ heart disease/ diabetes/ UTI/ eclampsia during pregnancy
14. PMH:- major illnesses and treatment
15. surgical operations and outcome
16. gynae problems and outcome
17. establishes if she works and what she does
18. establishes if in long term relationship
19. asks about fertility treatment
20. family history
21. does all in a fluent, professional manner
Comment: The history must include home circumstances and lifestyle, any fertility treatment, multiple pregnancies
and/or birth defects, pelvic inflammatory disease and treatment, smoking history, past medical history and family history
of heart disease, hypertension and diabetes. Past obstetric complications indicate the need for close monitoring of
current pregnancy, to prevent recurrence.
4.2 A 29 year-old woman seeks an urgent consultation with you, her GP. She is worried that she may be pregnant. Please
take a history (5min)
I have not had my period for 10 weeks and am worried that I am pregnancy, as I did not plan to be. I work full-time as a
producer for a local TV and cable company. I am single and have no plans to marry. I have been on the contraceptive pill
for the past 8 years or so, but came off it when I swa one of the partners at the practice because of painful breasts. I was
diagnosed as having a benign breast condition and was advised to stop taking it. My breasts feel full and sore at present
and I feel sick in the mornings. I am getting up at night to pass water and going more frequently durng the day. My
periods have always been regular, and I have never been pregnant. I have always been healthy except for a bad attack of
malaria when I was in Africa recently working on a wildlife documentary.
2. establishes symptoms of early pregnancy
3. establishes menstrual history
4. establishes contraceptive practice
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5. family and social history
6. establishes attitude to pregnancy
7. establishes gynae history and asks about infections and smear history
8. establishes current and past general health- asks about malaria treatment
9. social history
10. family history
11. does all in a fluent manner
comment- the patient is anxious and worried and the pregnancy needs confirmation. She must therefore be questions
sympathetically and she should develop confidence that she should be supprted and cared for in her present situation. A
positive pregnancy test may requitre counselling on the care provided at home and in hospital.
4.3 The same patient as in 4.2 is found to have a positive pregnancy test. Counsel her on her pregnancy, and elicit her
underlying concerns (5min)
I have never been pregnant and this is v. unexpected and terrifying. I have not told my boyfriend, who is responsible for
the pregnancy and I do not know how he would react to the news. My parents would like me to marry and settle down,
but I am not sure if I am ready for this, and my partner and I have never discussed marriage. My work involves a good
deal of foreign travel and I have a full work schedule for the next year or so. Taking time off or this would mean
professional sacrifices but with the support of my patrtner and my family, I may give it a try. If I decide on termination,
how much time do I have? Where can it be donee? Would it affect my health in any way? I am confused and unable to
decide right now but need your advice and help at arriving at a decision.
2- done well, 1- done ok
1. Establishes empathy and shows sympathy and understanding
2. Explains antenatal support during pregnancy and social service following birth even if boyfriend doesnt stay
3. Explains procedures for termination of pregnancy- dilatation and suction before week 13 or mini-labour with
misoprostol and mifepristone
4. explains that termination in 1st trimester is done as a day procedure and carries negligible risks to health and fertility
5. Mentions support/advice from partner/ friend/ family may be worth seeking (though not legally required)- suggests
she makes decision and come back, possibly with friend.
6. Offers STD screen
7. Does all in a fluent profession and sympathetic manner
Comment- the Dr must guide the patient trhgough a tough decision with underlying socio-religious implications.
Counselling of the patient and her partner should be directed towards the support available to take her safely through
her pregnancy, confinement and antenatal care and, on the patients request, the safety of pregnancy termination in a
hospital setting (conscientious objectors are legally bound to refer them on to non-objector if they do not wish to discuss
abortion). The Dr should refrain from expressing his/her personal, moral or ethical views.
4.4 Read through the following before talking to the patient:

You are the HO attached to an OG firm. The next patient is a 24 yearold primigravida who is returning to the antenatal
clinic one week after an oral glucose tolerance test, the results of which are shown below:
Glucose tolerance test. Mrs R. Givens DOB 12/3/68 Unit no 048288

0mins- 6.8mM 30mins- 10.9mM 120 mins- 15.5mM
Please explain the results, implications and management to the primip patient Ms Givens. (5 min)
I have always been fit and well, though big boned and am 12 weeks pregnancy with my first child. I am 154cm and 69kg.
I have come for the results of a glucose tolerance test I had five days ago. This was because of sugar diabtetes. My great
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aunt has diabetes, which is controlled with diet and tablets, and I am hoping, if needs be, I can go on these. I have
stopped smoking and drinking alcohol since finding out that I am pregnanct but H have a very sweet tooth and tend to
eat boxes and boxes of chocolates. Nobody has explained the results or the implications of diabetes, and I am have no
concept of what this will mean to me or the baby. Apart from a bit of morning sickness, I have been well in the last few
weeks.
1. Polite introduction; establishes rapport

2. Establishes ID and reason for attendance
3. Establishes Pt understanding of the investigation
4. Explains th results and diagnosis in a clear fahion
5. Explains the implications on pregnancy:- maternal eclampsia risk
6. increased operative delivery, labour trauma
7. Fetal complics: increased malformations
8. Macrosomia
9. Hypoglycaemia at birth
10. more respiratory distress
11. Explains treatment is by diet or insulin, not tablets.
12. stresses importance of v. tight control- far fewer complications
13. finds pt present diet, height and weight
14. Excludes smoking and alcohol.
15. Explans regular blood monitoring
16. invites questions and answers
17. Does all in a fluent manner
Diagnosis- gestation diabetes mellitus (WHO criteria 7.8-11.1mM at 2hrs in tol test)
Comment
Pre-existing diabetics should optimise their glycaemic control prior to pregnancy and should be cared for by an
obstetrician and a diabetologist. Gestational diabetes is though to be a marker of susceptablity to diabetes type 2 in later
life, with the stress of pregnancy causng alterations in glycaemic control ( a small percent of women diagnosed as having
new onset diabetes during pregnancy will have IDDM)
Patients may be managed with a strict diabetic diet, but if this fails, the only option is insulin. Patients are usually started
on small doses of mixtard, on a BD regimen, eg 8 units mane, 4 units nocte. If this fails to maintain normoglycaemia a
QDS regimen may be adopted, using pre-meal actrapid and an evening dose of an intermediate acting insulin. Doses are
tirtated upwards according to the patients glycaemic control, which they must e taught to monitor using BM stix.
Complications of hyperglycaemia in pregnancy

Maternal: infections eg candida, UTIs, polyhydraminos, pre-eclapsia and eclampsia
Fetal: Intrauterine death and neonatal mortality greatly increased
Macrosomia, increased rate of anomalies (including neural tube and heart defects), polycythaemia leading to jaundice.
4.5 Please read through the following information before attempting the next station
You are a medical student attached to a GP. The next patient is 34 weeks pregnancy and is under shared care between
the hospital and the GP. She has been under weekly review because her blood pressure has been raised, as shown below.
The practice nurse has measured her blood pressure and performed a urinalysis, the results of which are shown. Explain
the results to the patient, the implications to the mother and child, and the course of management you would advise.
(5min)
CWD= consistent with dates; NAD= no abnormality detected
217
Date Week Fundal Height BP Urinalysis
12/4 32+4 CWD 155/87 NAD
17/4 33+2 CWD 162/78 NAD
22/4 (today) 34+2 CWD 187/98 Protein/ ++
I am 42 years old and have always been fit and well, and am 34 weeks pregnancy with my 3rd child. My previous 2 pregs
were without any probs and both babies were born at full term by normal vaginal delivery. I had slightly raised blood
pressure during my last pregnancy but it settled with rest at home. I was told by both the dr in the hospital and the GP
that my blood pressure has again been slightly high but I have been taking it easy and when the community midwives
checked it, it has been okay. I ralise I may have to be admitted to the ospital but am not very keen because of caring for
my other children. My partner is very supportive but works 6 days a week and at present cannot afford to take time off.
My mother in law has offered to come and stay to look after the children but I am not very keen on this as her health is
rather fragile.
2 marks good 1 mark done ok
1. Polite introduction
2. excludes danger signs- epigastric/rightupper quad pain, headache with visual disturbance, motor disturbance,
aura, shaking, chest pain.
3. Establishes patients understanding of her BP problem and its implications
4. Estbalishes prev obsteric history and history or preg-induced hypertens
5. explains the risk of eclampsia to mother and fetus in a clear non-jargonistic manner
6. explains that patient requires admission- bed rest, treatment of blood pressure, possible C-S
7. Establishes and discusses reasons why patient is reluctant to be admitted.
8. Invites patients questions and answers appropriately
9. does all in a fluent and professional manner
Diagnosis- pregnancy induced hypertnesion; patient is now pre-eclamptic requiring admission
Comment- pre eclamptic toxaemia is one of the leading causes of obstertric mortality in the UK. Possible crises include
eclampsia, HELLP syndrome (haemolysis +elevated liver enzymes + proteinuria), placental abruption, renal failure,
cerebral haemorrhage. The spectrum of the condition includes uteroplacental insufficiency and intrauterine growth
retardation is commonly associated. The patient requires admission for close monitoring of the blood pressure,
biochemistry and foetal well being. Indications for delivery include fetal compromise, inability to control maternal bnlood
pressure and the development of maternal symptoms suggesting impending crisis eg right upper quadrant pain.
4.6
You are the medical student attached to an antental clinic. The next patient is a 24 year old primigravida who had a
routine ultrasound at 20 weeks gestation which showed a low lying placenta grade 4. She had a repeat scan at 34 weeks
gestation, yesterday, which shows the placenta lying anteriorly in the lower segment and covering the os.
Explain the US findings to her and the future management. (5min)
1. Polite introduction and rapport
2. establishes ID and reason for attendance
3. Estbaishes ptients understanding of situation
4. explains the US results in a clear fashion
5. explains the need for a C-S
6. Invites patients questions and answers appropriately
Placenta praevia describes the condition where the placenta lies in the lower uterine segment. It is associated with
multiple fetuses, an abnormally large placenta, uterine structural abnormalities, benign and malignant tumours, previous
uterine surgery, placenta accreta-increta-percreta.
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Classification
Grade I: The lower margins of the placenta do not reach the os
Grade II: The lower margins reach but do not cover the os
Grade III: The lower margins cover the os when closed but not when dilate
Grade IV: The os is totally covered by the overlying placenta.
219
Paeds OSCE 3
1. Perform developmental assessment.
Key ages: Newborn; Supine infant (1.5-2 months); Sitting infant (6-9 months); Toddler (18-24 months); Communicating child
(3-4).
1. Important to introduce self to parent and child, 8. talking
explain what you are going to do, ensure the 9. Current abilities- gross motor skills
patient is comfortable. 10. vision and fine movement
2. Get age, name, sex of child. 11. language and hearing
3. Take history from parent- birth history: labour 12. social behaviour
probs?, delivery, birthweight, gestation, 13. Immunisation history
4. SCBU admission? High- 14. Education
risk pregnancy (eg diabetes/ hypertension) 15. Nutrition
5. Ask about age of milestones- smiling, 16. Thank the patient and parent- asks if there is
6. sitting anything they want to add/ ask
7. walking
Newborn 1.5-2 months 6-9 months 12 months
Gross motor Symmetrical Raises head when prone Rolls, sits up, some weight-bearing Stands
without support
Movements, Symmetrical neonatal reflexes (Moro, Crawls. Walks/ cruises.
Limbs flexed rooting, suck etc)
Fine motor Looks at light/ Scans 90 degrees Palmar grasp (7 months) smacks 2 toys Pincer
grasp. Points.
And visual faces Stares together. Transfers toy from hand to hand
(7months) Follows fallen toys or red ball
Picks up 100s and 1000s
Hearing and Responds to noises/ Turns to sound Babbles. Distraction hearing test
Uses 1+ words meaningfully
Language voices Normal cry. Startle response Responds to own name. Laughs
Understands several words.
Distraction hearing test
Social Responds to parents Smiles responsively Eats a cracker. Oral stage.

Drinks from a cup. Indicates
Skills. Plays peak-a-boo wants. Waves bye.
Stranger
awareness
Warning signs Abn corneal reflex Asymmetric reflexes. No scanning. Persistent neonatal reflexes No
babbling.
Asymmetric reflexes No eye contact, no smile Hand preference, fisting, squint. No
sitting/ weight-bearing
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Poor tone, Poor Excess head lag, fails to respond to No vocalisation
Responsiveness sound. Squint, nystagmus.
18-24 months 3-4 years

Gross motor Walks upstairs/backwards/ while carrying toys. Climbs chair. Pedals tricycle. Jumps (3),
24 months: kicks ball Stands on 1 foot >4 seconds (4).
Fine motor Scribbles, turns pages in a book, delicate pincer grip (10-18/12) Mature pencil grip. Copies circle (3yrs),
draws a man of three parts (4), copies
And visual 3 cube tower (1.5 yrs) 6 cube tower (2yrs). cross (4), builds a bridge of 3 cubes (3yrs), 8
cube tower (3)
Hearing and Knows & uses 2+ words. Can use phrases (24 months) gives 1st and Last names. Recognises
colours. Talks in sentences.
Language Can point to eyes, nose, mouth etc. Obeys simple instructions.
Jabbers continually.
Social Feeds self with spoon. Indicates toilet needs Plays with other children, names a friend.
Washes hands and brushes teeth.
Skills. Removes shoe. Symbolic play. Likes hearing and telling stories. Imaginative play.
Eats with knife and fork.
Shows empathy, eg with injured friend.
Warning signs Persistent drooling, persistent casting, not walking/ weight- Delayed language, lack of imaginative play,
lack of social play, poor eye contact
Bearing, no pincer grip, inability to understand simple commands Loss of milestones- regression eg
disintegrative disorder, regressive autism, retts, .
No words known. Subacute sclerosing panencephalitis, acquired
brain damage. Abnormal gait.
5. Paediatric abdomen exam

1.
Introduce self to child and patent 6. cervical, supraclavicular, infraclavicular, axillary lymph
2. Explain to child what you will do, remove top, place nodes.
supine, check they are comfortable, ask about pain. 7. abdo ask about pain first. may need to distract them
3. inspection: jaundice, ascites, peripheral oedema, with toy to make them relax. Light and deep palpation-
growth, nutritional status, scars, localised masses, starting away from site of pain.
distension (may be normal is younger infants). 8. Palpate boundaries of liver, spleen kidneys, bladder.
4. Hands: clubbing, nail signs- koilonychia, onycholysis etc 9. confirm palpation with percussion. Test for shifting
5. head/neck/upper body: sclera for anaemia, jaundice, dullness of ascites
mouth ulcers (Crohns), angular stomatitis, atrophic 10. ascultate for bowel sounds 30 seconds before
glossitis (b12/folate/iron deficiency), furring of tongue concluding they are hyperactive/hypoactive/ absent.
(loss appetite as in appendicitis), dentition.
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11. groin and genitals- norm not required in osce. Inspect 13. cover the child, thank child and parent
and feel for hernia, feel for testes in boy 14. mention testing the urine
12 PR- avoid unless specifically indicated.
2.Neonatal examination
1. wash hands 17. palpates abdomen- for spleen, kidney and liver,
2. Introduce self to mother and explain what you bladder.
will do. 18. Examines genitalia (testes should descend by
3. Ask about complications of delivery/ type of week 32-34), check for hypo/epispadias. Asks
delivery, gestation, birthweight, feeding-urine- about urinary stream
defecation, her concerns 19. Hips- Barlow (adduct hips +flex knees of supine
4. General- colour, tone, respiratory rate, pulse, baby and push backwards and down on medial
dysmorphic features, signs of distress, posture. thigh, attempting to dislocate) and Ortolani tests
5. Head- palpate anterior and posterior fontanelles, (abduct hips+ flex knees, attempt to relocate hip
6. measure head circumference by pushing up and forward on lateral thigh). Feel
7. Face- check ear patency, accessory auricles, for give/ clunk.
nostril patency 20. arms and hands- check for extra digit, single
8. red reflex, papillary reflex, eye palmar crease (Downs)
movements 21. Inspect feet and test range of movement
9. mouth- checks for cleft palate with finger 22. Reflexes/ posture- drag baby up by arms and test
10. inspects palate with torch and spatula for head lag.
11. Chest- checks radial and femoral pulses 23. Moro reflex- lift head and shoulders then
(radiofemoral delay in coarctation), suddenly drop them back- arms should abduct
12. Listens to heart using bell and extend symmetrically.
13. Listens to lung using diaphragm 24. grasp- finger in palm set it off
14. Back- examines spine, checking for neural tube 25. knee jerk and babinski (should be
defects especially at sacral pit extensor in new born)
15. Checks anal patency with finger 26. Thank patient and mother.
16. Abdomen- inspect abdomen and umbilical cord.
3.Cardiovascular exam, paeds: norm pulse age <1: 100-160bpm, 2-4: 90-140bpm, 4-10: 80-140; 10+: 65-100
1. Introduce to parent and child. 7. heart palpation incl thrills- character + location of
2. explain to child you will examin him. Position at apex ( 4th intercostals midclavicular line in <8s)
45 degrees and get to remove top. Ensure they 8. ausc- aortic area, pulmonary area, tricuspid area,
are comfortable. mitral area. Classify murmur by timing, grade, site
3. Observation- dysmorphoea, resp distress, and radiation.
cyanosis, jaundice, scars of chest etc 9. Murmur may be innocent due to increased blood
4. hands- perfusion, colour, clubbing, splinter flow.
haemorrhages, nail signs 10. Chest- auscultate lungs esp at bases
5. Say you would like to record blood pressure 11. abdo examns- eg ascites, polycystic kidneys,
(using child size cuff) + pulse enlarged liver.
6. Head and neck inspection- sclera for anaemia/ 12. Peripheral pulses- + feel temperatire
jaundice, mouth and tongue for c. cyanosis, JVP 13. Cover, thank child.
assessment, locate carotid and assess pulse.
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Innocent murmurs are common in childhood: systolic, low grade, heard over a small area, asymptomatic. S3 may be heard
in children also (rapid emptying of atria).
Common cases: Ventricular Septal Defect- thrill, possible hyperkinetic displaced apex and pansystolic murmur at left sternal
edge plus s3/s4 (large defect may be silent), louder on expiration (lEft sided). Possible mid-diastolic flow murmur at mitral
valve.
Patent ductus arteriosus- constant machinery murmur at first left intercostals space radiating to back . Wide pulse pressure
with sharp upstroke. Reversed S2 splitting/ single S2 (aortic valve closes later due to increased flow of blood- supplying
pulmonary artery and aorta). Mid-diastolic flow murmur at mitral area and midsystolic at aortic area (increased flow)
possible. Apex deviation and heave possible.
Atrial Septal Defect: mid-diastolic low-pitched tricuspid flow murmur plus pulmonary mid-systolic murmur (increased flow
on right side, louder on inspiration- rIght sided), thrill possible, wide fixed (not affected by breathing in/out) splitting of s2,
possible right ventricular heave. May cause AF, paradoxical emboli, infectious endocarditis. 90% are ostium secundum
defects. Ostium primum defects may be associatied with tricuspid regurgitation, VSD, mitral regurgitation.
Pulmonary stenosis: mid-systolic murmur over pulmonary region (increased on inspiration), weak pulse possible. Giant a
waves on JVP. Right ventricular heave, thrill over pulmonary area. Right sided s4 possible due to right atrial hypertrophy
(high pressure atrial wave reflected off poorly compliant ventricle). Increased splitting S2/ quiet P2. Peripheral cyanosis in
severe cases.
Aortic stenosis/ Hypertrophic obstructive cardiomyopathy: exertional chest pain, exertional syncope, mid-systolic murmur
over aortic region radiating up carotid (louder on expiration, leaning forward- lEft sided), left ventricular heave, apex
deviation possible, S2 splitting decreased/reversed/A2 quiet (aortic valve closes later due to lower flow rate), slow rising
carotid pulse, narrow pulse pressure, possible thrill. Aortic regurgitation common. Possible S4 (atrial pressure reflected off
non-compliant ventricle. Risk of MI/TIAs/stroke/ infectious endocarditis.
Coarctation aorta: continuous murmur loudest at midsystole radiating to back, loud A2, mid-diastolic mitral flow murmur,
midsystolic aortic flow murmur (increased flow, louder on expiration- lEft sided) radiofemoral delay, hypertension in right
arm compared to left arm + legs, impalpable peripheral pulses, blue peripheries, lack of leg development compared to
arms.
4. Paediatric respiratory exam.

1. Introduce self to child and patent
2. explain to child what you will do, place at 45 degrees and get to remove top, ensure they are comfortable, ask about
pain.
3. Inspection- look for growth, clues around the bed (eg inhalers) respiratory rate, cyanosis, nasal flare,
sub/supra/intercostals recession, hyperexpansion, cough, listen for wheeze/stridor/expiratory grunt
4. Inspection2- look for chest deformity, asymmetric chest expansion, use of accessory muscles, Harrisons sulci, operative
scars
5. Hands- clubbing, peripheral cyanosis, peripheral perfusion, pulse, cigarette stains, hypertrophic pulmonary arthropathy
(CF, lung cancer).
6. Head and neck- lymph nodes- cervical, supraclavicular, infraclavicular, axillary lymph nodes, jaundice/anaemia at sclera,
central cyanosis at tongue, JVP.
7. Palpation- ask if they have chest pain before touching. Check fore tracheal deviation,
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8. Check for cardiac apex position
9. palpate for equal chest expansion on front and back.
10. Percuss front and back- including over clavicles and on sides of chest
11. auscultate including 99. Vesicular/ bronchial? Listen for wheeze, crepitations.
12. look in sputum pot.
13. say you would like to do Peak flow, CXR if necessary
14. Cover child, thank child and parent.
Age premature infant term infant 6 years 12 years

Respiratory rate /min 40-60 30-50 19-24 16-21
6. Paediatric neuro exam

1. Introduce self to child and patent
2. Explain to child what you will do, check they are comfortable, ask about pain.
3. Ask parent childs age, ask about developmental milestones- walking, talking, smiling etc. Asks about hearing/ vision
problems
4. Inspect- look for dysmorphic features, movement in all 4 limbs, muscle wasting, pseudohypertrophy of calves (Duchenne
muscular dystrophy), port wine stain- associated Sturge Weber syndrome, adenoma sebaceum + roughened lumbar
Shagreen patches + - associated tuberous sclerosis, 6+ caf au lait spots + axillary freckles, neurofibromas (seen more after
puberty)- neurofibromatosis.
5. gait and movement- if cant walk, watch crawling/bottom sliding- is he using all limbs symmetrically?
6. look specifically for scissoring/ tiptoeing gait (UMN lesion, Duchenne MD, tiptoe also seen in autism), broad based gait
(cerebellar probs), limp (eg hip disloc, trauma, sepsis, arthritis).
7. Watch them getting up from floor. (Gowers sign in Duchenne- use arms to climb up legs to standing position).
8. Tone- asks about pain before touching them. assess tone and range of movement in all four limbs
9. assess truncal tone in younger children (can they sit unsupported), test head lag in young infants.
10. power: mainly by observation, looking for antigravity movement
11. reflexes- biceps (c5-6), triceps (c7-8), supinator (c7-8), knee (L3-4), ankle (S1-2), plantar (S1-2). Infants tend to have
extensor plantar reflex anyway, so not much use. Test for neonatal/ persisting neonatal reflexes: rooting (pouts when
upper lip rubbed), suck, grasp, Moro
12. co-ordination- finger to nose test, jumping (age 3), stands on one foot >4 sec (age 4), stacking cubes (3 by age 1.5, 6
cube tower by age 2, 3 cube bridge by age 3, 8 cube tower by age 3 ).
13. Sensation- indicate that you would test this.
14. indicate that you would test this.
15. Thank patient and parent.
7. UK vaccination schedule 2006

Birth- BCG if deemed at increased risk (dependent on neighbourhood, race, family history)
2months- diphtheria, tetanus, pertussis, intramuscular polio, haemophilus influenza B, neisseria meningitides C,
3months- same as 2 months
4months- same as 2 months
12-15months- Measles mumps rubella first dose (90% protection).
3-4years- diphtheria, tetanus, intramuscular polio preschool boosters, 2nd measles, mumps rubella (99% protection)
10-14 years- BCG dependent on Mantoux test
16 years- diphtheria, tetanua, intramuscular polio school-leavers boost.
MMR scare- measles can cause fits, encephalitis, pneumonia, subacute sclerosing panencephalitis, death.
224
Mumps can cause meningitis, encephalitis, deafness, sterility.
Rubella in pregnancy can cause severe damage to the fetus, including blindness, brain damage, heart defects, abortion.
MMR vaccine is safe and effective, 500 million doses have been given since 1972. One dose gives 90% protection, 2 doses
99%, providing that child is well nourished and has enough vitamin A. Common side-effects include a sore injection site and
flu-like symptoms. Very rarely, an allergic reaction can occur. The 1998 Wakefield et al paper did not prove MMR caused
autism or IBD. Separate administration of MMR provides no added benefit and would result in reduced coverage. When it
was introduced to Japan, autism diagnosis rates continued to increase. At least 80% vaccine coverage is required to prevent
epidemics. 95% coverage is required for eradication.
The possibility of such a link [between MMR vaccine and autism] was raised and consequent events have had major
implications for public health. In view of this, we consider now is the appropriate time that we should together formally
retract the interpretation placed upon these findings in the paper no causal link was established between MMR vaccine
and autism as the data were insufficient.
Simon H Murch, Andrew Anthony, David H Casson, Mohsin Malik, Mark Berkewitz, Amar P Dhillon, Michael A Thomson,
Alan Valentine, Susan E Davies, John A Walker-Smith. 6th March 2004, official statement to Lancet, volume 363, number
9411.
8. SAQ
A 16 year-old schoolboy with a known chronic chest condition presents to his GP with a threee month history of worsening
malaise, lethargy and loose, offensive porridgey stools. On examination he is pale and cachectic, with marked nail clubbing.
Respiraotry examination reveals an expiratory wheeze assocated with coarse bibasal crackles and copious green sputum.
His BM is 17-28.
a) what is the underlying disorder? (1)
b) which 3 complications has he developed? (3)
c) Loist the long-term treatment strategies you would employ (6)
a. cystic fibrosis
b. Pancreatic endocrine involvement leading to diabetes mellitus. Pancreatic exocrine involvement leading to steatorrhoea
and malabsorption. Bronchiectasis.
c. Nutritional support with pancreatic enzyme supplements and regular dietetic review. Diabetic education and insulin
therapy. Daily chest physiotherapy which may be performed by relatives. Rapid and appropriate treatment of infective
exacerbations. Sputum viscosity reduction (eg DNases), genetic counselling of parents and siblings. Consider for heart lung
transplant. Consider entering therapeutic trial.
Comment- CF is an autosomal recessive disorder, whose gene mutation has now been localized to the long arm of
chromosome 7. The protein encoded in this region is called the cystic fibrosis transmembrane regulator. With
improvements in physiotherapy, antimicrobials and nutritional support, life expectancy is now 30-40 years. Patients usually
present in childhood with recurrent pulmonary problems, CF being the main cause of suppurative lung disease in this age
group. They may also present with constipation or even acute obstruction due to meconium ileus equivalent, meconium
ileus being a presenting featurein the neonate.
Males are invariably infertile due to the absence of the vas deferens and epididymis, but females are able to give birth. The
diagnosis is confirmed from the family history, a sodium sweat test and chromosomal analysis. Treatment should be
instituted and followed up in a regional centre of excellence, so that complications are rapidly identified and minimised.
Pseudomonal chest infection is the main cause of exacerbation of chest symptoms and often the cause of death. Newer
anti-pseudomonal regimes include ticarcillin, azlocillin, imipenem, tobramycin. Heart lung transplant is tried in severe cases.
Gene therapy may one day offer a cure.
225
9. Asthma You are the house officer on a gen med firm. Take a history from a 23 year old asthmatic with acute shortness of
breath. He can speak in stilted sentences, pefr= 220l/min. (5min)
I am 23 years old and asthmatic, poorly controlled. I was diagnosed age 14, and have at least 1-2 admission per year since.
The last one was 3 months ago and I was ventilated in ITU. I have been ventilated 3 times. I smoke 5-10 per day and have to
use my inhalers 5-10 times a day. I am on salbutamol, atrovent and beclforte inhalers and have been on prednisolone 30mg
for the past 4 days. My normal PEFR when well is 550l/min. The present illness started 5 days ago with a slight head cold,
but I am now coughing up thick green sputum and am short of breath and wheezy, particularly at night. I am sleeping very
badly and feel exhausted, like before I was ventilated the first time. I had a fever but no blood in sputum or chest pain. I
have no pets, do not know about exacerbants of asthma. I did not have hayfever or eczema as a child and there is no such
stuff in my family. Will I need to be admitted or will I be able to go home?
1. Polite introduction; establishes rapport 9. haemoptysis
2. Establishes duration of asthma 10. worsening wheeze
3. Establishes normal asthma control- meds and 11. fever
frequency, normal PEFR 12. chest pain
4. Establishes previous admissions 13. disturbed sleep
5. Establishes patient has been ventilated 14. Gets smoking history
6. Establishes duration and nature of present illness 15. Asks about precip factors
7. Establishs/ excludes:- cough nocturnal or 16. When askes, appreciates patient needs admission
daytime? 17. fluency
8. sputum colour and vol
Diagnosis= poorly controlled asthmatic now needing admission due to acute infective exacerbation.
10. Dermatological history

1
. introduce self to patient. 9. Previous skin disease
2. Explain you are going to ask some questions to uncover 10. Atopic symptoms (allergic rhinitis, asthma, childhood
the nature of his/ her skin problem and ask for consent. eczema)
3. Ensure that (s)he is comfortable 11. Past or present medical illnesses
4. Asks patient to describe problem 12. surgery
5. HPC- When where and how problem started 13. drugs- prescribed and self administered treatment
6. What initial lesion looked like and how it has changed including creams
7. Symptoms- espec pain, pruritus and bleeding 14. cosmetics and moisturising crea,s
8. Aggravating factors such as sunlight, heat, soaps 15. Allergies
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16 family history- medical history of parents sliblings 20. home background
childrens skin 21. alcohol consumption, travel especially to tropics
17 sexual contacts 22. systems review if req.
18. occupation in detail- does skin improve on holiday 23. thank patient. Asks if they have anything to add.
19. hobbies- detail
11.. Examination the skin

1. introduce self to patient 10. palpate lesions, assess consistency, do they
2. Explain you are going examine, gain consent blanch?
3. Ask to undress to underwear 11. Examine nails
4. Ensure pt is comfortable 12. examine hair
5. Ask pt to report any pain in examination 13. examine mucous membranes
6. ensure adequate lighting 14. check for lymphadenopathy
7. Describe distribution and colour of the lesion (s). 15. check the pedal pulses, if appropriate
Look at whole body 16. offer to help the patient put his clothes back on.
8. Describe morphology of individual lesions, 17. thank the patient
commenting on their size, shape, borders, 18. wash your hands
elevation and spatial relationship. Use derm 19. summarise your findings and offer a differential
terms. diagnosis.
9. Note 2dary skin lesions such as scaling,
lichenification, crusting, excoriation, erosion,
ulceration, scarring
12. Give advice on sun protection

1. Introduce yourself 10. seeking shade
2. Tell what you will explain, determine what is 11. covering up- hat and sunglasses conforming to
already known British standard 2724
3. Explain there are 3 types of radiation from the 12. applying sunscreen/ sunblock
sun- UVA, UVB, UVC 13. Sunscreens star rating is an indicator of its
4. UVA and UVB cause skin cancer protection level vs UVA
5. UVC does not reach the surface of the earth and 14. a sunscreens sun protection factor is a measure
is therefore of no concern of its UVB protection
6. Other than cancer, UV causes burns and rapid 15. It is advisable to use at least 3 star block, SPF 15
ageing or more
7. white people, especially if have freckles/fair skin/ 16. Sunscreen should be applied thickly over all sun-
redhead most vulnerable; dark skinned can get exposed areas and re-applied regularly.
skin cancer too. 17. Sunscreens should not be used as a means to
8. UV levels depend on time of day, time of year, spend more time in the sin
latitude, altitude, cloud cover and ozone cover 18. advise patient to report any moles that change in
9. explain 4 ways of avoiding UV damage- avoiding colour, shape, texture or size.
outdoors 11am-2pm 19. thank the patient, ask for questions.
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Paeds Osce 4
1.Plab OSCE. 15 year old girl presents to A&E requesting emergency contraception because she had unprotected sex 48
hours ago. Take a relevant history and suggest appropriate management. (5min)
ANSWER
1. communication- smile and introduce self.
2. Reassure that even though she is under 16, she is entitled to emergency contraception without the knowledge or
consent of her parents and that everything that is said between you remains confidential.
3. Ensure she is Gillick competent- understands what treatment is, why it is proposed, understands risk of treatment,
understands risk of not going ahead with treatment.
4. PC: Elicit history of unprotected sex and risk of pregnancy. Why do you think you could be pregnant?
5. Did vaginal penetration occur?
6. What contraception have you been using? Why did you think it failed?
7. Confirm barrier failure/ pill failure
8. Where in your menstrual cycle re you? The most fertile period is days 10-19
9. What are your views on regular contraception?
10. Other- When did you start menstruating?
11. Are you periods regular? How long do they last? Are they heavy?
12. Have you ever been treated for a sexually transmitted disease?
13. Have you been pregnant before?
14. Drug history- Are you taking any antibiotics or any other medication? The combines OCP is less effective in the
presence of oral antibiotics or anti-epileptic drugs.
15. Management- I would inform her that she has 2 options. She can take Levonelle which in her particular case gives
her an 85% rate of successful contraception, or be fitted with an IUD coil, which would be 99% effective. [Each tablet
contains 750 mcg levonorgestrel (progestogen only). According to the April 2000 Guidance sheet for emergency
contraception and the recommendation for clinical practive, Levonelle-2 is 95% effective within 24 hours, 85% effective at
48 hours and 58% at 72 hours. If she would like a method that is 99% effective, and IUD can be fitted- works up to 5 days
following unprotected sex. ]
16. Explain next period may be early or late, a barrier method of contraception must be used til the next period
17. needs to wait at least 3 weeks after intercourse for pregnancy test to be valid.
18. she needs to go to GP/ family planning clinic within week of expected next period. Go to GP/A+E promptly if any
lower abdominal pain occurs, due to risk of ectopic- also in 3-4 weeks if menses are abnormally heart/light/ brief or if she
has any concern.
19. Mifepristone anti-progesterone agent can induce miscarriage up to 9 weeks into pregnancy. Combined with
prostaglandins, can induce medical termination later.
20. Discuss STI screen
2. This boy has sudden diminished hearing in his right ear. Examine the ear. (5min)
1. Politely introduce yourself to the patient
2. Ask if you may examine his ears
3. Asks him which is the better hearing ear
4. Ask him if the ear is tender before you touch it
5. Sit down alongside the patient and use a light source as you examin the pinna and behind for scars, redness or
discharge.
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6. Assemble an otoscope or auroscope- whichever is provided- and examine the better hearing ear first unless told
only to examine the right ear. Possibly ask parent to hold childs head. Anchor hand holding otoscope to boys head,
to prevent damage if head moves, use pencil grip for otoscope. Remember to retract the pinna to straighten the
tortuous external auditory canal.
7. Examine the canal for oedema, discharge and vesicles.
8. Examine the tympanic membrane for perforations. Is the perforation dry or wet, central or marginal? What
structures do you see through the perforation? Malleus, incudostapedial joint, promontory etc.
9. Examine the pars flaccida (attic of the tympanic membrane for crusts) and the pars tensa for a bulging membrane
or a retracted membrane.
10. At this point, examiner may ask you what you have foind. The diagnosis may be a perforation, mastoid cavity, otitis
media, otitis externa etc
11. In reality, a complete ear exam continues with steps 12-14. However, owing to the time permitted, you will only be
judged on your ability to use the auroscope or otoscope confidently and professionally.
12. Conduct free-field speech tests. Rub the tragus of the non-examining ear to occlude the canal. Whisper words to
the exposed test ear at distances of 60cm and then repeat different words at conversational level at 60 cm and then
15cm from the exposed ear. Repeat diffeent words at a raised voice level at 60cm and 15cm. This will give you an
idea of the decibel hearing loss.
13. Conduct the Rinne and Weber tuning fork tests using a 512 HZ fork.
14. For the weber test, place the vibrating fork on the middle of the patients forehead and ask him which ear he can
hear the fork the loudest or if it sounds the same in both ears? If he cannot hear the fork, place it on the bridge of
the nose. The patient should hear the tuning fork better in the left ear if hehas a sensorineural loss in the righ or he
should hear it better in the right if he has a conductive loss in the right.
15. Rinne: ask patient to tell you which is louder? First place the tuning fork on the mastoid process and then hold the
vibrating fork 4cm away from the external auditory meatus and ask him to tell you which is louder. Alternatively,
the original test was to wait until the fork could be heard no longer on the mastoid process and asking the patient
whesther he could hear when placing the fork in front of the ear. In either case, if sound is better heard when the
fork is on the mastoid process, a conductive hearing loss is suggested, ie bone conduction is better than air
conduction. If the tuning fork is heard louder or continues to be heard after decay of the fork on the mastoid
process, then the patient either has normally hearing in that ear or a sensorineural hearing loss.
16. Test the facial nerve. Ask the patient to raise his eyebrows (temporal branch), shut his eyes (zygomatic branch),
blow his cheeks (buccal branch), and show you his teeth (mandibular branch).
3. A 13 year old boy is struck on the head by a cricket ball. Assess his level of consciousness using the Glasgow Coma
scale. (5min)
Function Response Score
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Eye opening Spontaneous 4
To speech 3 (respond to shouting or speech)
To pain 2 (can be tested by sternal rub or supra-orbital pressure)
None 1
Best verbal response Orientated 5 (to person, place and time)

Confused orientation 4 (responds, but at times disoriented)
Inappropriate words 3 (random speech)
Incomprehensible sounds 2 (moaning)
None 1
Best motor response Obeys commands 6

Localizes (response to pain) 5 (can be tested by pressing down on the fingernail bed or by applying
supra-orbital or sternal pressure)
Flexes- normal 4 (patient withdraws to pain)
Abnormal 3 (patient responds by decorticate posturing to painful stimuli. The position of the
upper limbs is likened to a rabbit with its raised paws)
Extends (to pain) 2 patient responds by limb extension ie adduction, internal rotation of the shoulder
and pronation of the forearm)
None 1
4.Thomas is a 12 year old boy complaining of fever, cough and shortness of breath. Interpret his CHEST X RAY. (5min)
1. Remark on the view in which the film was taken. this is a PA and lateral view of the chest.
2. The obvious abnormality is the presence of patchy consolidation suggestive of staphylococcal pneumonia.
3. Remark on the heart, mediastinum, hila, diaphragm, root of the neck and trachea, lung fields, soft tissues, bones.
5. This 18 year old presents with weight loss amenorrhoea and depression. Take a relevant history and suggest a
likely diagnosis. (5min)
1. Introduce yourself tro the patient and establish a rapport
2. Note the appearance of the patient and how she interacts with you. What is her affect like? Does she avoid eye
contact?
3. Start with an open-ended question and ask her about her childhood and adolescence. This will help her relax and
express herself in her own words.
4. Gear the converstaon towards the present complaint. How long has the weight loss and depression been bothering
her Did any life event trigger this problem?
5. What was her premorbid condition? Was she always depressed or is this a recent change?
6. What is the patients insight into her own problem? How would she like you to help?
7. Ask specific questions about her weight loss. How much weight has she lost and over what period? Does she binge
or induce vomiting?
8. Ask specific questions about he amenorrhoea. When did her periods stop? Had her menstrual cycles been regular?
Does she exercise excessively?
9. - sleep disturbance?- am waking, insomnia
10. How does she feel about the future?
11. Has she ever considered harming herself or thought about suicide?
12. Ask about personal or family history of psychiatric illness
13. Ask her about her social habits- drinking alcohol, smoke, or indulge in recreational drugs
14. Suggest she may be suffering from anorexia nervosa and depression. Suggest that you would like to perform a
physical examination for evidence of anorexia such as ketone breath, lanugo hair, acid burns on the oral cavity,
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chipped nails from acid damage etc and would arrange for blood tests to exclude metabolic disorders. Suggest
psychotherapy and SSRI (antidepressants) if the diagnosis is confirmed.
6. Obtain informed consent for appendicectomy from 16 year old patient. (5min)
1. Introduce yourself to the patient and establish a rapport
2. Explain that it is necessary for her to undergo an operation to remove her inflamed or diseased appendix called an
appendicectomy. At age 16, she is of legal age to give consent
3. Ask her what understanding is of the procedure and what her concerns are.
4. Explain the procedure- general anaesthesia, small incision lower right hand side abdomen, opened to identify
appendix. The appendiceal artery, appendiceal mesentery and base of the appendix will be clamped, divided and
ligated. The appendix will be removed and the appendix stump ligated and buried in a purse-string suture. The
peritoneum and muscle layers are closed with absorbable sutures and the skin is closed with interrupted nylon
sutures or subcuticular prolene. The skin sutures will need to be removed in a weeks time.
5. Explain the risk is small but needs to be addressed- infection, pelvic or abdominal abscess, paralytic ileus. If she
develops infection, she should be treated with IV antibiotics. If she developed a pelvic abscess that did not respond
to antibiotics, she may need a second operation. If she developed a paralytic ileus, she would be managed with IV
fluids and NG tube until the ileus settled and her bowels returned to normal.
6. Explain that the benefits far outweight the risks. Explain that the appendix could rupture and lead to peritonitis and
gangrene, which can kill.
7. Explain that she would likely remain in hospital for 3-5 days.
8. Ask her if she has understood or whether she needs you to clarify any points.
9. ask her if she would like to contact any family members and involve them in her decision-making process if she feels
unsure.
10. Complete the consent form with the name of the operation and a short list of the complications. Print, sign and
date the consent form.
11. Have her read the consent form, print sign and date at the bottom.
7. Instruct on how to use a peak flow meter and interpret results. (5min)
1. Introduce yourself to patient and establish rapport
2. Hand her peak flow meter with fitted attachment
3. Ask her to take deep breaths in and out. Ask her then to hold a deep breath and blow as hard and as fast as she can
into the peak flow meter. Make sure she has maintained a proper seal with her mouth.
4. Read a peak flow meter
5. Give her another attempt and record the best reading.
6. Ask her for her height. She states she is 5 foot 3. Know how to convert feet to metres: 1 inch= 2.54 cm. She stands
1.6m tall. As she is only 22, she should achieve a peak expiratory flow rate (PEFR). Of just over 400l/min. At age 40,
she should achieve a PEFR of 400l/min and by age 6o this falls to 350l/min.
7. An average young man standing 1.85 m (6 foot 1) should achieve a PEFR of 650l/min and a young man standing 5
7 should achieve 600l/min. These fall by 50l/min by age 40 and by 100l/min by age 60.
8. If her present PEFR falls below her normal PEFR she will need to increase her dose of inhalers during her bout of
chest infection.
9. Thank the patient for her cooperation.
8. Miss P is an 18 year old woman who has recently been diagnosed with epilepsy. She is discharged home on
valproate. Offer her discharge instructions for epilepsy. (5min)
1. Introduce yourself to the patient and establish a rapport.
2. Explain that she has been diagnosed with epilepsy but is well enough to be discharged home. Explain that epilepsy
means seizures or its and that often the cause is unknown.
3. Explain that she has been started on an anticonvulsant medication called valproate to prevent further seizures.
Explain that she must not stop unless advised by her GP. State that possible side effects include drug interactions,
folate deficiency, nausea, ataxia, weight gain but most are associated with chronic use.
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4. Ask her if she is taking a combined oral contraceptive pill. Advise her that valproate interacts with combined OCP
(p450 inhibitor, therefore increases drug levels) and she should see her GP to change the dose.
5. Explain the social consequences include a ban on driving if she has had more than 1 seizure. To obtain a UK license
she has to have been seizure free while awake for 1 year, if her attacks occur in her sleep, she must have been
seizure free for 3 years before the issue of a license.
6. Explain that the laws are stricted for public service vehicle or heavy goods vehicle licenses and that she will not be
issued one.
7. Advise her to wear an ID bracelet to alert people she has epilepsy in case she collapses.
8. Advise the patient to avoid swimming alone or engaging in risky sports alone.
9. Advise the patient to take showers rather than baths.
10. Inform she will be sent a follow up appointment for 4-6 weeks.
11. Inform the patient that the GP will receive a copy of her hospital discharge paper and that he will be capapble of
managing her care
12. ask the patient if she has any questions. Ask if she has understood everything that has been explained to her or
whether she needs clarification.
9. Mrs T is a 35-year-old mother who is telephoning for advice on how to manage her 2-year-old daughter who is febrile
with an ear infection. She is reluctant to bring her daughter into hospital for examination. Give her telephone advice as
to why she should bring her daughter to hospital and explain the daughters risk of meningitis . (5min)
1.dentify yourself to Mrs James on the telephone
2. ask her how you can help. She explain daughter has high temp,not sleeping, complains of right earache. She thinks her
daughter has an ear infection. She has tried calpol to settle the temperature and pain, but to no avail. She exaplins that her
GP cannot see her until next week. Should she bring her daughter to casualty today? She has hear da lot in the news about
meningitis, should she be concerned?
3. Asks her if she has taken daughters temp and if so, how high it is. She tells you it is 40 degrees. Inform that the CF of
meningitis include fever, vomiting, headache, neck stiffness, photophobia, anorexia, irritability, confusion and lethargy. Has
the child had any of these? Has the child had a recent chest infection? Does the child have a rash that does not blanch to
pressure? Mother denies all except fever and right ear pain
4. Reassure the mother that the child probably doesnt have meningitis but that as the temperature is so high, she
should bring her in to paediatric casualty for
assessment. The child may have an ear infection that will need to be treated with antibiotics. The child can also be assessed
to exclude other causes for her
pyrexia and be treated accordingly, as calpol has had little effect.
5.Ask the mother if she has other questions.
10. Miss G is a 17-year-old who complains of malaise and easy bruising. She is always covered in bruises. Her gums bleed
when she brushes her teeth, and her periods are heavy and painful. She also complains of recurrent painful mouth ulcers.
She has no family history of bleeding dyscrasias. She does not smoke or drink. She is not taking any medication. On
examination, you note gum hypertrophy, oral candidiasis and painful lymphadenopathy. You decide to take full
blood count, clotting and U+E. Interpret the results below and suggest a likely diagnosis. How would you confirm this
diagnosis? (5min)
WCC: 11.8 x 10 ^9/litre Hb: 6.5g/dl Platelets: 10^9/litre INR: 0.9 Blood film: few immature blast cells MCV: 84fl
ESR: 20mm/hr
APTT: 1.1 Sodium: 139mM Potassium: 4.6mM Urea: 6.7mM Creatinine: 116uM
Glucose: 5mM
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1. The obvious abnorms are anaemia, thrombocytopenia, and the presence of a few immature blast cells on blood film
2. the most likely diagnosis is acute leukaemia. In this patient, AML, rather than ALL is suggested by the presence of
gum hypertrophy
3. The diagnosis is confirmed by bone marrow examination for a proliferation of blast cells derived from the myeloid
elements.
4. Treatment is threefold and involves supportive care with blood and platelet transfusions, chemotherapy with
daunorubicin, cytosine arabinoside and thioguanine and allogenic bone marrow transplant infused intravenously.
11. Miss F is a 14 tear old girl with widespread acne covering her face, back and arms. She has tried trimethoprim and
benzamycin gel andno success. You are the dermatology SHO. Suggest to the patients mother that her daughter tries
triple therapy with minocin MR tabliets, dianette pills and differin gel. The mother is anxious to know about any side-
effects with these drugs. Counsel her. . (5min)
1. Introduce yourself to patient and her mother and establish a rapport
2. explain that as trimethoprim and benzamycin gel has not been tolerated, that you would like to suggest alternate
treatment with minocin MR (minocycline), dianette and differin gel for 3 months
3. Explain that minocin MR is a once a day antibiotic in the tetracycline class. Explain that the advantage of this antiobiotic is
that it offers less likelihood of bacterial resistance. Bacterial resistance is associated with other antibiotics used for acne
treatment such as erythromycin. Exaplin that as the patient has all her adult teeth present, she is not at risk for tooth
staining. Explain that the reported side effects of minocin MR occur with > 6months use and include liver damage and
systemic lupus erythematosis. She will only be taking the antibiotic for 3 months and so should not be at risk. Other
reported side-effects include dizziness, rash or pigmentation. If this should occur, the drug should be discontinued.
4. Explain that the second pill is called dianette. Explain that it is both a form of hormonal therapy for acne and a combined
oral contraceptice. Explain that the advantage is that it is licensed to be used for the treatment of acne in cases that have
shown resistance to antibiotics.
5. Contraindications to the use of this drug include a history of migraines with a focal aura, hypertension, smoking, a family
history or arterial disease or venous thromboembolism in a first degree relative aged <45. The reported side effects include
nausea, comiting, headaches, breast tenderness, fluid retention and reduced menstrual flow. This does not imply that she
will necessarily experience all or any. If she does, report to her GP. The patient is to take 1 tab a day from day1 of her cycle
for 21 days and then have a 7 day pill free period before starting a new pack.
6. Explain that the differin (adapalene) gel is a topical retinoid used to treat mild to moderate acne. It is to be applied in a
thin layer to the areas of acne at bedtime. Reported side-effects include local reactions such as stinging, burning, erythema
or peeling. If this occurs the drug should be stopped. The patients skin will be sensitive to UVB light and sunlight.
7. Ask the patient and mother if they have any questions or whether they need anything clarified.
8. Hand them prescription.
9. Ask them to make a follow up for 3 months or more.
Paeds OSCE 5 CXR checklist A-H - Talley O connor

A. airway (midline, no obvious deformities, no paratracheal D Diaphragms (rt above left by 1-3cm, costophrenic angles
masses) sharp, diaphragmatic contrast with lung sharp)
B. bones and soft tissue ( no fractures, subcut emphysema) E. Equal volume (count rubs, look for mediastinal shift)
C. Cardiac size, silhouette, retrocardiac diameter normal F. fine detail (pleura and lung parenchyma)
233
G. gastric bubble (above the air bubble one shouldnt see H. hilum (left normally above right by up to 3cm, no larger
an opacity of any more than 0.5cm width) than a thumb), hardware: endotracheal tube, Hickman line
1. A 43 year old bricklayer is admitted through the Accident and Emergency department with a 3 day history of vomiting
coffee ground material and 18 months of progressive dyspeptic symptoms, which are partially relieved by antacids.
a. State the probable clinical diagnosis (2)
b. State 2 investigations to confirm your diagnosis and the expected findings (3)
c. List the drugs and their therapeutic regimes used to cure this disease (5)
a. Peptic ulcer disease

b. Patient is <45, therefore if H.Pylori is present, OGD unnecessary unless danger signs- lymph nodes (eg Virkow), weight
loss, haematemesis/melaena, anorexia, family history of gastric cancer, previous cancer.
non-invasive H-pylori tests: radiolabelled urea breath test, H. pylori serology (remains positive months after eradication),
stool immunoassay
invasive: OesophoGastroDuodenoscopy to visualise ulcer with biopsy and culture/ stain (Giemsa)/ urease test. Also use
OGD + biopsy to exclude biopsy.
c. Aim to eradicate helicobacter pylori. Combine proton pump inhibitors with antibiotics.
Eg ranitidine omeprazole 20mg OD, Metronidazole 400mg BD + amoxicillin 1g BD 1 week. May continue H2 blocker or PPi
for 2 months after to promote healing. Bismuth promotes ulcer healing by its anti-helicobacter activity and stimulates
prostaglandin synthesis at ulcer crater. It is used in some regimens alongside 2 antibiotics and is cheap. It has bad taste,
blackens the tongue and stools and is not heavily marketed. Eradication has ~80% success but requires good compliance.
If no evidence of H.Pylori (minority of cases), try H2 blocker eg cimetidine 400mg BD for 2-3 months or PPI like omeprazole
20mg OD for 4 weeks.
Subsequent urea breath test / endoscopic biopsy with Giemsa stain to check ulcer has healed + H.pylori eradicated.
Lifestyle- recommend to avoid smoking, alcohol excess, take regular meals, avoid NSAIDs use, corticosteroids if possible.
May use low dose H2 blockers/ PPIs at night time or for subsequent attacks.
2. pastest osce: You are a GP. Take history from 18 year old lady with 5 th UTI in past year, with view to referring her to
renal outpatients.
ANSWER I am 18 years old and for the last 5 years I have been getting recurrent urinary infections, blood in my urine.
Most recently I have had dull pain in my lower back. In the last 18 months I have also had recurrent headaches and visual
disturbance. My mother and grandmother both had kidney disease and my mother died of a bleed inside the brain. Each
episode of infection is relieved for a week or two by antibiotics but I have had to self-medicate from time to time to stop
them coming back so frequently. Each infection lasts for 5 to 6 days with frequency, as well as pain and blood when I pass
urine. I have been admitted on three occasions with severe infections with associated fever and shakes.
I have never been further investigates because I am terrified of the possible diagnoses and have always discharged myself
from hostpital before secondary investigations. I have also moved about a lot because of my fathers job in the navy. (5min)
1. polite intro 8. features of

2. Establishes duration of urinary problems hypertension
3. establishes symptoms of UTI 9. establishes family
4. Establishes associated fever and rigors history of renal disease
5. establishes symptoms of PCOS: UTIs 10. Establishes mother died of subarachnoid
6. loin pain haemorrhage
7. haematuria 11. Makes reasonable attempt at a diagnosis
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Diagnosis: recurrent UTI secondary to adult polycystic kidney disease.
3. The following urine sample results have been reported in the microbiology lab. Please match the specimens with the
histories. (5min)
1. 29 year old Asian woman with night sweats and rigors 4. 33 year old with deranged U+E and ankle oedema
2. 74 year old man with indwelling catheter 5. 25 year old pregnant woman
3. 25 year old man with a history of renal stone and acute
severe loin pain.
A. MSU: E Coli >10^5 colony forming units per ml, WCC 750/mm. resistant- amoxicillin, trimethoprim. Sensitive-
gentamicin, nalidixic acid
B. EMU: acid fast bacilli grown after 6 weeks
C. urgent microscopy- no organisms, WCC 100/mm, red cell casts identified
D. MSU- no organisms seen, WCC > 1000/mm
E. CSU pseudomonas > 10^5 CFU per ml, WCC <1/mm. Sensitive- gentamicin, ciprofloxacin.
1B: This urine culture has grown acid fast bacilli, priving this woman has renal tract TB. This requires at least 6/12
treatment.
2E: Although there is significant pseudomonas growth, the white cell count indicates this is likely to be a contaminant.
Unless the patient is unwell, this should not be treated with antibiotics
3D: This patient has renal colic secondary to recurrent stones. The specimen shows a sterile pyuria. Other causes include
interstitial nephritis, papillary necrosis and tuberculosis of the renal tract.
4C: Renal red cell casts are indicative of renal disease. The history is suggestive of renal failure with a possible nephritic
syndrome.
5A: E.coli is a common organism causing urinary tract infections. Other common causes of UTI include proteus,
staphylococcus saprophyticus or epidermis and klebsiella
4. Take a history from a patient with epigastric pain and proven microcytic anaemia. Take HPC and any other relevant
past medical history with a view to making a diagnosis. (5min)
ANSWER
I am a 32 year old scrivener and I am normally fit and well. I drink and smoke too much and live on takeaways. [when
pressed admit to 30 cigarettes/day, 30-40 units of alcohol per week in the form of lager]. In the past 6 months I have had
increasing upper abdominal pain, which is particularly bad when I am under stress or have been on a binge. The pain is
burning in nature and radiates though to my back and occasionally behind my breast bone. It is relieved with rennies and
alka-seltzers. It is usually worse when I am hungry and better after meals. I have been otherwise well, with no other GI
symptoms. My weight is stable and my appetite is fine. I have never vommed blood but I did have some black stools one
morning after a particularly bad episode a few weeks ago. I have bever had any peptic ulcers, hiatus hernias or gastritis in
the past. I have had no symptoms suggestive of anaemia, eg shortness of rbeath, chest pain or faints, but Have been feeling
tired of late.
1. polite intro 4. exacerbating factors

2. establishes onset of symptoms 5. relieving factors
3. Establishes characteristics of abdo pain- site and 6. Establishes/ excludes haematemesis, melaena,
radiation fresh blood PR
235
7. Establishes/ excludes dyspepsia, retrosternal 11. smoking
burning and water brash 12. previous ulcer
8. establishes associated GI symptoms- weight loss, 13. known hiatus hernia
anorexia, nausea and vomiting, dysphagia 14. Establishes/ excludes symptoms of anaemia
9. establishes risk factors for PUD- use of alkaseltzer 15. makes reasonable attempt at diagnosis
(aspirin) 16. fluency
10. alcohol excess
Diagnosis: peptic ulcer disease
5. Please answer the following T/F questions associated with the preceding history (5min)
1. this patient should have an 6. This patient may require triple therapy
oesophogastroduodenoscopy 7. Triple therapy is given for 3-4 weeks
2. This patient will have a high plasma ferritin 8. Clarithromycin is commonly used in triple therapy
3. this patient may have koilonychias 9. Cimetidine is a proton pump inhibitor used in triple
4. This patient will have a raised MCV therapy
5. This patient should have a CLO test 10. this patient requires life-long omeprazole
ANSWER: T F T F T T F T F F
6.Pastest All of the following have haemolytic anaemia. Match patient histories with diagnoses and markers (5min)
History
1. 29 year old Italian man with haemolytic anaemia Disease marker
after eating fava beans. a. Warm antibodies (igG), Coombs positive
2. 34 year old man with cough, fever, bullous autoimmune haemolytic anaemia
myringitis, erythema multiforme b. Hb beta chains that have glutamine not valine at
3. 7 year old Greek girl with transfusion siderosis position 6
and frontal bossing c. Hb electrophoresis shows increased Hb F
4. 24 year old man with butterfly malar rash; renal d. Heinz bodies in the blood
failure secondary to glomerulonephritis and anti- e. Cold antibodies (IgM), Coombs positive
double stranded DNA Ig antibodies. autoimmune haemolytic anaemia
5. 21 year old Afro-Caribbean man with abdominal
and bone pain.
Diagnosis
A: sickle cell disease. B: B-thalassaemia. C: G6PD deficiency. D: Mycoplasma pneumonia. E: SLE
ANSWERS
1dC: G6PD deficiency is an X-linked disorder which has several recognised variants. The variant suffered by black Africans
and Afro-Americans (G6PD GdA-) has a self-limiting haemolytic anaemia as the bone marrow is able to compensate by
increasing red cell production. In the Mediterranean variant (G6PD Gd Med) following an oxidant insult (eg sepsis, MI,
diabetic coma) gross haemolysis occurs and will be fatal unless the cause is treated and the patient transfused. Classically
this reaction may be seen after eating fava beans. Heinz bodies are seen on the film, hence beans means Heinz.
2eD: This patient presents with the classical symptoms of a mycoplasma pneumonia. This is associated with a cold antibody
(IgM) Coombs positive autoimmune haemolytic anaemia. A Coombs test is performed using a combination of the patients
serum and Coombs serum. Coombs serum is an antihuman serum and causes agglutination of the patients red cells if
certain antibodies are present on their surface. The temperature at which these antibodies attach themselves to the red
cells characterize the haemolysis into cold (37 degrees) and warm (40 degrees C) types.
236
3cB: B thalassaemia is a haemolytic disorder found especially in the middle east, Mediterranean and Indian subcontinent.
The patients with severe disease, thalassaemia major, present in the first few years of life with recurrent infection, severe
anaemia and extramedullary haemopoiesis. These patients require regular transfusion and often develop transfusion
siderosis. This is countered by using the chelating agent desferrioxamine.
4aE: SLE is associated with a warm (IgG) Coombs positive autoimmune haemolytic anaemia. Other causes include
carcinoma, haematological malignancy (eg CLL and lymphoma) and drugs, the common being methyl dopa.
5bA: Sickle cell disease is a common haemolytic disorder in Africans. It also occurs in the Indian sub-continent and the
Middle East. The haemolysis is often mild in heterozygotes and may remain undiscovered until a severe insult, such as
sepsis or general anaesthesia. Homozygotes present in childhood and suffer a debilitating multisystem disorder.
Complications include bone pain, bone necrosis, including avascular necrosis of the femoral head, rarely salmonella
osteomyelitis; cerebrovascular events, epilepsy, acute papillary necrosis and tubulointerstitial nephritis causing renal
failure, chest crises causing respiratory failure. Treatment requires addressing the cause of the crisis, hydration with IV
fluids, oxygen via face mask and opiate analgesia.
1. You are a GP. Your patient Burt Reynolds, 65, has ischaemic heart disease and is on low dose aspirin, GTN spray, atenolol
50mg BD, simvastatin 20mg nocte plus bendroflumethazide 2.5mg mane. Ascertain how well this regimen is going, explain
why he should be taking his antihypertensives and what side-effects are to be expected. [5 minutes]
Hello I am Burt Reynolds. Two weeks ago I was put on this medication for heart disease. I occasionally get chest pain when
I am doing the gardening, or walking up one flight of stairs. It lasts ten seconds, does not radiate anywhere, is burning
sensation under left nipple. It gets better when I rest. 4/10 intensity. I have never had a heart attack or any heart surgery. I
do not have diabetes. My father died of a heart attack aged 82 [not a risk factor] but no one else in my family has IHD, I
smoke 5-10 cigarettes a day and drink 10 units a week maximum. I do not get much exercise except golf, sex and gardening.
I took these pills for 5 days but then stopped. I was getting tired, nauseous and depressed. [Only mention if asked
specifically]- I recently got married and felt they were causing bedroom problems. They were also giving me a cough and
double vision. My main problem with them is bedroom problems and this caused me much distress. Now I just take the
aspirin daily, and atenolol when the chest pain comes on, approximately once per week. What do you think is causing my
chest pain? Should I have a bypass?

1. Introduction
2. IHD history- chest pain brief history
3. asks about other risk factors Fhx, smoking, diabetes, alcohol
4. Asks about adherence to antihypertensives
5. Asks about side effects
6. ascertains how much side effects bother patient
7. summarises back to patient
8. Explains why he is on meds and importance of regular usage for drugs to work- aspirin, statins prolong survival with
IHD, others reduce blood pressure.
9. explains GTN is a reliever of chest pain, others are for daily use
10. Explains which reported side effects are associated with the medicines- eg GI bleeds from aspirin, postural
hypotension from antihypertensives plus possible fatigue, erectile dysfunction, GTN causes headache. Fatigue and
ED may be reduced with continuing use.
11. Explains there are other combinations for same problem
12. gives basic lifestyle advice including to stop smoking, take more exercise.
237
13. Puts plan in place. Eg prescribes alternative regimen or suggests persevering for 3 weeks and then reporting back,
change meds if nec.
14. asks if he has questions. Gives good explanation
15. Suggests visiting british heart foundation website.
16. fluency, sensitivity
2. Take history from mother of 4 year old Congolese boy with new-onset limp. Make a differential diagnosis, suggest
investigations
Hello my name is Tracy Lamumba. I am 32. My son Barry is complaining of pain in his right hip. It started this morning.
When he is still it doesnt hurt, only when he is walking. He has been lethargic today and has missed school. I took his
temperature today and it was 37.4 [ slight fever]. The pain came on suddenly. As far as I know, his hip is the only joint
affected. He has no vomiting/ diarrhoea/rash/ leg ulcers/ dysuria/ drowsiness, he has a cold which came on yesterday. He is
coughing up small amounts of green phlegm with no blood [ie could be bacterial or viral, but pneumonia unlikely]. Barry
started walking at 10 months, he is normally very active. He is of normal height and weight. Barry has a 12 year old brother
who is fit and well. Other than normal minor scrapes, Barry has no leg injuries. There is no family history of arthritis, sickle
cell or tuberculosis.
Examiner asks for differential and investigations. Then asks management of irritable hip.
1. introduction
2. Onset, duration, exacerbating factors
3. Asks about fever, general well-being
4. Asks about recent illnesses including bacterial infection, eg pneumonia, UTI, meningitis, E.Coli.
5. asks about leg trauma.
6. Asks about developmental milestones and previous hip problems, height and weight.
7. Asks family history of arthritis, TB, infections, sickle cell.
8. Main differential is irritable hip, septic arthritis, knee problem are other possibilities.
9. mentions Perthes (avascular necrosis femoral head), TB as other less likely possibilities.
10. Explains would examine before investigations- transient synovitis/irrit hip causes decreased abduction, decreased
int-ext rotation with no pain at rest, pt q. well. Septic arthritis causes high fever, unwell patient, pain at rest and on
minimal movement. Perthes has gradual onset, 5x more likely in boys, abduction problems. Slipped epiphysis tends
to affect obese adolescent boys 10-15 especially, causing restricted abduction, extension and internal rotation.
Juvenile chronic arthritis requires minimum 3 month history.
11. Investigate: FBC-neutrophil count, CRP, ESR, blood culture, x ray/ ultrasound, possible sickle test (all normal in
transient synovitis/ irritable hip apart from possible effusion on ultrasound). Possible joint aspiration with U-S guide
if suspect septic arthritis on examination.
12. Explains management of irritable hip/transient synovitis: irritable hip is retrospective diagnosis on recovery with
paracetamol, bedrest +/- skin traction and normal x ray.
13. fluency
Chest x ray
Boundary blurred Lobe affected
Blurred right mediastinum right upper
Blurred right heart border right medial
Blurred right hemidiaphragm right lower lobe
Blurred left mediastinum left upper lobe
Blurred left hemidiaphragm left lower lobe
Paediatric CXR diagnoses
Distribution Feature Appearance Cause
238
Symmetrical effusion at bases, fluid level Heart failure, low albumin,
pneumonia
Symmetrical pulmonary oedema opacity from hilum, Kerley B lines, horizontal fissure fluid Heart failure, low
albumin
Symmetrical Bronchopneumonia patchy opacity especially along bronchi Cystic fibrosis,
mycoplasma
Symmetrical Poor inspiratory effort diffuse hazy, <4.5 anterior ribs seen
Asymmetrical Effusion At base, right fluid level Subphrenic abscess, abdominal
disease
Asymmetrical Tumour solid mass, round neuroblastoma
Lobar consolidation no volume loss, air bronchograms s. pneumoniae
Collapse volume loss, no air bronchograms, fissures pulled down/up mucus plug,
foreign body http://www.virtualpediatrichospital.org/providers/TAP/Cases/Case06/Case06.shtml
Michael P. D'Alessandro, M.D.

Peer Review Status: Internally Peer Reviewed
Chief Complaint:
Five year old male with cough and fever.
Clinical History:
The patient was a 5 year old male with fever, cough, and respiratory distress. The patient was
felt to have a viral pneumonia. His respiratory distress eventually required intubation for 5 days.
Before intubation he had a bronchoscopy which demonstrated subglottic edema.
Clinical Physical Exam:

The patient had a barky cough.
PRESENT THE 2 X RAYs
ANSWERS:
Differential Diagnosis: Viral pneumonia
Imaging Findings:A chest film was obtained on the day of admission and it
demonstrated an anterior mediastinal mass, which was imaged further on a chest CT
exam performed 2 days later.
Imaging Differential Diagnosis:Thymus, prominent
Final Diagnosis:Thymus, Prominent- sail sign
Follow-up and Prognosis: The patient was discharged and did well
2. Michael P. D'Alessandro, M.D. Peer Review Status: Internally Peer

Reviewed
239
. http://www.virtualpediatrichospital.org/providers/TAP/08UnknownsAge.shtml
An 8 year old female with substernal distress. The patient was an 8 year old female who was treated with antibiotics several
times in her first year of life for respiratory infection. She had been followed every two years with ultrasound. Recently she
began complaining of vague substernal distress that was sometimes associated with exercise.
LOOK at the X-ray and comment
ANSWER: Diaphragmatic hernia. Imaging Findings:

The diaphragmatic hernia was demonstrated on chest films, ultrasound, and chest CT exam.
Imaging Differential Diagnosis:
Morgagni HerniaOperative Findings:
Two months after the chest CT exam, the patient underwent an elective repair of a diaphragmatic hernia at the foramen of
Morgagni. The liver was found to be prolapsed into the space behind the sternum, and there was a good deal of scarring
along its anterior surface, suggesting it had been sliding back and forth for a long period of time. The diaphragm defect was
6 cm wide, from the xiphoid in front to the vena cava in back.Final Diagnosis:
Diaphragmatic Hernia, Morgagni
Follow-up and Prognosis:

The patient had an uncomplicated post-operative course
3. Michael P. D'Alessandro, M.D.

QUESTION: look at these x rays, present and diagnose
ANSWER: PA and lateral chest films show a large anterior mediastinal mass causing narrowing and rightward deviation of
the trachea.
Imaging Findings:
A chest film showed an anterior mediastinal mass. An echocardiogram showed the mass to be
cystic (not provided). A chest CT exam showed the mass to be well circumscribed and containing
calcifications. Imaging Differential Diagnosis:
Cystic teratomaOperative Findings:
The patient was taken electively to the operating room and the mass was totally excised.
240
Pathological Findings:
Pathological examination of the surgical specimen revealed findings characteristic for a cystic teratoma.
Final Diagnosis:
Teratoma, Anterior Mediastinal
Follow-up and Prognosis:

The patient had an uncomplicated post-operative course.

LOOK at X-RAY and make diagnostic presentation
Chief Complaint:
Six year old female hit by a truck. Clinical History:The patient was a six year old female who
was riding her bike and was hit on her right side by a truck. She suffered a crush injury with
a right tibia / fibula fracture and compartment syndrome requiring open reduction and
internal fixation.
ANSWER: Clinical Differential Diagnosis:
Possible solid organ injury in the abdomen.
Imaging Findings:
A chest film showed right sided rib fractures and a right lower lobe lung opacity. An abdomen CT exam was obtained to
evaluate for blunt abdominal trauma. It showed a right sided airspace disease and a small pneumothorax. Imaging
Differential Diagnosis:
Pulmonary contusion, pneumothorax Operative Findings:
A right chest tube was placed prophylactically because the patient would need positive pressure ventilation during general
anesthesia for the open reduction internal fixation of the tibia / fibula fracture.Final Diagnosis: Pulmonary Contusion /
Pneumothorax Follow-up and Prognosis: The patient had an uncomplicated post-operative course.

Patient: 11 year old boy with chronic lung disease.

Present 2 x rays
ANSWER: PA and lateral chest films show a coarse

interstitial pattern, with bronchial wall thickening and
bronchiectasis. Look for pneumothorax, cysts, hilar
scarring, abscesses. Chest films showed a coarse
interstitial pattern, bronchial wall thickening, and
bronchiectasis. Chest CT exam confirmed and better
displayed the findings.
Diagnosis: Cystic fibrosis

Using a spacer with your child
A spacer is a large plastic or metal container, that helps to deliver medicine to the lungs. Spacers make the inhaler easier to
use and reduce the risk of side effects.
Why spacers are important
241
A spacer has a mouthpiece at one end and a hole for the aerosol inhaler at the other. Spacers only work with an aerosol
inhaler. If your child is under the age of three, or unable to use the mouthpiece, you will probably need to use a face mask
as well.
There are several different brands of spacer that fit different inhalers and are available on prescription (including Volumatic
(pictured), Nebuhaler, AeroChamber and Able Spacer)
Spacers are very important because:
they make aerosol inhalers easier to use and more effective

you get more medicine into your lungs than when just using the inhaler on its own
they are convenient and compact and work at least as well as nebulisers at treating most asthma attacks in children and
adults
they help to reduce the possibility of side effects from the higher doses of preventer medicines by reducing the amount of
medicine that is swallowed and absorbed into the body.
How do I use a spacer with my child?

When you first get the spacer, wash it in warm soapy water and leave to drip-dry.
Fit the mask on to the spacer if necessary.

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

If you are finding it difficult to use a spacer and mask when giving medicine to your baby, try the following.
Cuddle your baby on your knee or cradle the baby in your arms. Gently tuck your baby's arms out of the way with one hand
if she/he tries to knock the mask away.
Be positive and smile. Your baby will know if you are anxious.
Gently stroke your baby's cheek with the mask so that she/he gets used to the feel of it.
Use it when your baby is asleep.
Wipe your baby's face after using a preventer.
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Using a spacer and inhaler with children over two
Sometime between the ages of two and three, your child will learn to use a spacer without a mask.
Show your child how to use their inhaler and spacer first without puffing medicine into it.
Turn the spacer into a toy - decorate it with coloured stickers
Turn it into a counting game. Count aloud as your child takes a deep breaths.
Have a routine - set a time of day to give preventer medicine. It is best to do this before brushing teeth.
Praise your child when she/he uses their spacer correctly.
Many parents find it difficult to use a spacer with very young children. Don't worry - you are not alone, but do keep trying.
Getting a child to take inhaled medicine properly is the most important way to control their asthma.
Children's Health
Asthma: How to Use an Inhaler (for Children)
Whether your child is an infant or a teenager, an inhaler can be a vital part of the program for keeping his asthma under
control. There are two main types of asthma medications: the first type is used regularly to prevent attacks by delivering
anti-inflammatory drugs (it's known as a controller ); the other, called a bronchodilator, is used to open airways when an
attack is under way (it's known as a reliever ). Both of these types of medication can be delivered using an MDI, often called
a puffer, which has an advantage in that medication is delivered directly into the lungs.
The style of inhaler your child uses depends on his age. Your child's doctor will explain how to operate it, but here are a few
basic tips for different age groups:
Infants and Toddlers
Up to age 3, children generally use what's known as a nebulizer. This requires a machine that breaks liquid medication into
very small particles so that they can be inhaled. The nebulizer can be used with a mouthpiece or with a mask (for small
children a mask is preferable). The nebulizer gives continuous medication (more than one type of medication can be mixed
together), and works best in children less than 3 years old and for older children who are having an acute asthmatic attack
and cannot use a Metered Dose Inhaler, or MDI.
Medication for use in a nebulizer comes in two forms. In one method, the exact dose of medication to be added to the
"cup" of the nebulizer is available in unit dose vials. In the other, large bottles of medication generally come with a
calibrated dropper so that you can place the correct amount of liquid in the nebulizer. Your doctor will tell you the correct
amount of medication to use and the number of times a day your child should use each medication. Start by adding the
correct medication(s) to the nebulizer cup. Connect the tubing to the machine and then turn it on. Place the mask over your
child's nose and mouth and make sure that it is comfortable (this may take some time to get used to). Your child need only
breath normally until all of the medication is removed from the nebulizer cup. (He or she will also give you information
about how to use the nebulizer if your child has an asthma attack.)
Some children under the age of 4 may be trained to use a Metered Dose Inhaler, although this is uncommon. The best
method is to use a spacer with a mask (Aerochamber with a mask is one type). Start by placing the canister bottom up in
the plastic holder, then removing the cap from the inhaler. Shake the canister before each dose (this is important). Reassure
your child so he doesn't feel scared, then place the mask over his mouth and nose, making sure it's sealed tight. (If your
child seems anxious, you might demonstrate on yourself first.) Release a puff of medicine by pressing down on the canister.
Hold the mask in place until your child has taken at least six breaths.
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Ages 4 to 8
Your youngster may no longer need a mask, although some 4-year-olds will still need it. However, all children should use an
MDI with a spacer for best results. (Your doctor or health care professional can show you the different types and suggest
one best suited for your child.) Start by placing the canister bottom up in the plastic holder, then remove the cap from the
inhaler. Shake the canister before each dose (this is important). Insert the end of the mouthpiece into the spacer. Have your
child put his lips snugly around the mouthpiece of the spacer, with his teeth apart and his tongue out of the way. Activate
the MDI, then ask him to breathe in slowly and deeply, and then hold this breath in his lungs for five to ten seconds. Exhale,
and then, with the mouthpiece still in place, have him breathe in deeply and hold his breath again to get the full benefit of
the medicine.
Over Age 8
Your child can use either a standard metered-dose inhaler or a dry powder inhaler. To prepare the metered-dose inhaler,
place the canister bottom up in the plastic holder, then remove the cap from the inhaler. Shake the canister before each
dose (this is important). Doctors recommend using a spacer as described above, but your child can also try simply holding
the inhaler one to two inches from his open mouth. (If he has trouble using it this way, he can also try putting the inhaler
directly in his mouth with the lips open.) As he presses down on the canister to release the medicine, he should start
breathing slowly, taking several seconds to inhale, then hold his breath for 10 seconds.
To use a dry powder inhaler, your child should simply put his mouth around the mouthpiece and inhale quickly and deeply.
Many children and their parents prefer this type of inhaler, and a recent study published in the Journal of Allergy and
Clinical Immunology found that almost all children over age 8 quickly learn how to use it.
244
Examinations:
1. Examination of child (or neonate)
2. Examine the eye and ear NB: Febrile convulsions
3. Paeds BLS
4. Congenital Dislocation of Hip and Fundoscopy examination.
5. resuscitation on three year old
6. measure head circumference from a baby doll. Baby presents with a rapidly increasing head circumference within
the first few days of lifeplot your findings on a growth chart.90+ percentile = infantile hydrocephalus
7. BLS: BABY OR 3 YEAR OLD CHILD
8. Neonatal of small child life support.
9. Examination of a child.
History stations:
1. 2)Hx poor feeding...
2. 10)Hx psoriasis..Tx available
3. Diabetes
4. Psoriasis History
5. Peptic ulcer Hx and explanation about eradication therapy.
6. Bronchiolitis Hx
7. take a hx from an adult: poorly controlled asthma, give advice on management in future
8. take a hx from mother: son has painful hip for the past few days. Take hx and talk about investigations
9. give a differential for the last station: transient synovitis,osteomyelitis, septic arthritis, etc.
10. take a hx from male adult: poorly controlled hypertension, quit taking atenolol because of impotence, counsel him
on other options, conservative andmedically
11. take a hx from mother of 7 year old son: still bed wetting at night, is there anything wrong with son? probably not:
talk about psychological problems behind it. ways to treat it conservatively, ie. night alarmr
12. child presenting with nocturnal cough/ wheeze..asthma ( take history from mum)
13. headache history from female on the combined oral contraceptive. advise her to stop and offer alternative.
14. history from mother with child presenting with weight loss and polyuria i.e. diabetes.
15. history of cystic fibrosis (the year before)
16. Hx from mum of her child who has asthma. Explain Mx of the child.
17. Hx of hild with ADHD and/ or deafness.
18. Hx bronchiolytis.
Explaining stations:
1. turns out to be eg.pyloric stenosis (discussion, Tx etc)
2. Explain results to man with peptic ulcer..and Tx
3. Explaining to mother what Down's syndrome is
4. Explain asthma drugs and how to use an inhaler/spacer
5. Discussion of the mng't of diabetes
6. UTI: explain investigations to parent
7. Bronchiolitis Management
8. patient presenting with psoriasis, on all possible meds: emoillents, etc ( discuss PUVA usefulness and side-effects)
9. patient comes to see you for her H. pylori test results, CLO test positive, explain CLO test and management plan
245
10. asthma: 30 male with good inhaler techniquee, deterioration in asthma control, advise to step up with
corticosteroid.
11. explain to mother the ways to investigate uti in 2 year old.
12. Explain febrile seizures, what they are, relation to epilepsy, Rx and future prognosis to parents whose child has jus
had a seizure.
13. GP station Give patient their results of Clo Test, explain H.pylori and gastric ulcers. Lifestlye advice and changes.
14. GP convince a patient to take their blood pressure tablets.
15. You are an A+E doctor acute DM, never had it before. Explain.
16. Smoking cessation and IHD.
Counselling stations:
1. Couselling pt to keep taking BP tablets
2. Hypertension diagnosis and counselling i.e. lifestyle advice etc
3. Convincing a patient to stay on Anti-hypertensives.
4. Counselling a father about how you will manage his son's UTI.
5.
Others:
1. Explaining differentials of badly behaved child-ie.ADHD,Autism etc
2. Side-effects of Ritalin
3. differential dx of short ness of breath
4. ASKED QUESTIONS ABOUT DIABETES AND MANAGEMENT OF DKA.
Data Interpretation
1. Video of child--muscular dystrophies...mcq: Becker's, Duchenne's etc.
2. Picture of rash and graph of lymphocytes etc.. mcq Parvovirus,meningitis,chicken pox
3. Xray abdomen - can't remember what of
4. Video 1: boy showing "Gower's sign' therefore diagnosis is DMD
5. Video 2: Child development: guess the age of the child from 'classic' developmental milestones
6. CT scan with vignette: White lesion on CT. ?Tuberous sclerosis, epilepsy etc
7. Computer screen with 3 pictures: 1. fundus 2. blood film 3. CXR. Case desciption, what's the
diagnosis
8. Data station on blood results with Hx e.g.Bilirubin levels and Hx of constipation and coarse facies.
9. Data station with 1-chest and 2-abdo and 1-limb x-rays.
10. Data station on Development and an abnormal gait (2 videos)
11. computer Xray:diaphragmatic hernia
12. developmental video - guess age
13. picture of blood film blood cells and white cells, dx: infectious mononucleosis
14. Xray: osteomyelitis there were three rest stations as well.
15. video of a teenage girl with pneumonia being examined, decreased air-entry, bronchial breath sounds, dull to
percussion, decreased vocal resonance, whispering pectoriloquy
16. imaging ( aniridia-----wilms, craniopharyngioma----I think)
17. asthma station: shown pefr before and after attack. asked to calculate the percentage reduction and hence the
severity of the attack.also demonstrate inhaler technique and name different devices.
18. resp station: watch a video and listen with headphones, give diagnosis, causes and treatments.
19. picture station eg. chickenpox, resp. distress syndrome, cxr, measles. - mcq station.
20. Menningitis and Jaundice (written station)
21. Video child with muscular dystrophy and gowers sign.
246
22. Guessing the age of a child shown a vidoe where child does some activities.
23. Images Xrays of tuberous sclerosis, osteomyelitis, cystic fibrosis etc.
Dermatology
1 dermatology: name 3 use of a handheld cryotherapy spray. Psoriasis arthropathy, sebhorraeic dermatosis
2 dermatology: 3 pictures with questions on laptop screen. discuss treatments with examiner.
3 occupatoinal health: dermatology history; contact dermatitis, hairdressor with patch of eczema on hands.
4 Psoriasis take Hx and explain Rx, phototherapy and steroid use and side effects.
247
Paediatrics/GP/Derm 2002
1)Examination of child (or neonate)

2)Hx poor feeding...
3)...turns out to be eg.pyloric stenosis (discussion, Tx etc)
4)Explaining differentials of badly behaved child-ie.ADHD,Autism etc
5)Explaining to mother what Down's syndrome is
6)Side-effects of Ritalin
7)Explain asthma drugs and how to use an inhaler/spacer
8)Explain results to man with peptic ulcer..and Tx
9)Couselling pt to keep taking BP tablets
10)Hx psoriasis..Tx available
11)Video of child--muscular dystrophies...mcq: Becker's, Duchenne's etc
12)Picture of rash and graph of lymphocytes etc.. mcq Parvovirus,meningitis,chicken pox
13)Xray abdomen - can't remember what of
OSCE list 2002/2003 Paeds and GP
Histories and counselling stations

1. Diabetes
Data interpretation: Choose the correct answer
5. Video 1: boy showing "Gower's sign' therefore diagnosis is DMD
6. Video 2: Child development: guess the age of the child from 'classic' developmental milestones
8. Computer screen with 3 pictures: 1. fundus 2. blood film 3. CXR. Case desciption, what's the diagnosis
Practical
9. Examine the eye and ear
NB: Febrile convulsions
Paeds/Derm/GP - Dec 2003
1) Psoriasis History
2) Paeds BLS
3) Data station on blood results with Hx e.g.Bilirubin levels and Hx of constipation and coarse facies.
4) Convincing a patient to stay on Anti-hypertensives.
5) Counselling a father about how you will manage his son's UTI.
6) Data station with 1-chest and 2-abdo and 1-limb x-rays.
7) Peptic ulcer Hx and explanation about eradication therapy.
8) Data station on Development and an abnormal gait (2 videos)
9) Congenital Dislocation of Hip and Fundoscopy examination.
10) Bronchiolitis Hx
248
11) Bronchiolitis Management
Paeds and GP April 2004 OSCE stations

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

249
7. HISTORY FROM MOTHER WITH CHILD PRESENTING WITH WEIGHT LOSS AND POLYURIA I.E. DIABETES.
8. ASKED QUESTIONS ABOUT DIABETES AND MANAGEMENT OF DKA.
9. OCCUPATOINAL HEALTH: DERMATOLOGY HISTORY; CONTACT DERMATITIS, HAIRDRESSOR WITH PATCH OF ECZEMA ON
HANDS.
10. PICTURE STATION EG. CHICKENPOX, RESP. DISTRESS SYNDROME, CXR, MEASLES. - MCQ STATION.
11. PREPARATORY STATION FOR NEXT STATION - PREPARE TO GIVE INFO ABOUT INVESTIGATION OF UTI TO MOTHER OF
CHILD.
12. EXPLAIN TO MOTHER THE WAYS TO INVESTIGATE UTI IN 2 YEAR OLD.
13. ASTHMA: 30 MALE WITH GOOD INHALER TECHNIQUEE, DETERIORATION IN ASTHMA CONTROL, ADVISE TO STEP UP
WITH CORTICOSTEROID.
14. REST
15.REST
16. LOG BOOK STATION
17. HISTORY OF CYSTIC FIBROSIS (THE YEAR BEFORE)
PAEDS OSCES STAY PRETTY SIMILAR EACH YEAR APPARENTLY.

PAEDIATRIC STATIONS:
1. Neonatal of small child life support.

2. Explai febrile seizures, what they are, relation to epilepsy, Rx and future prognosis to parents whose child has jus
had a seizure.
3. GP station Give patient their results of Clo Test, explain H.pylori and gastric ulcers. Lifestlye advice and changes.
4. Menningitis and Jaundice (written station)
5. Video child with muscular dystrophy and gowers sign.
6. Guessing the age of a child shown a vidoe where child does some activities.
7. Images Xrays of tuberous sclerosis, osteomyelitis, cystic fibrosis etc.
8. Examination of a child.
9. Hx from mum of her child who has asthma. Explain Mx of the child.
10. GP convince a patient to take their blood pressure tablets.
11. You are an A+E doctor acute DM, never had it before. Explain.
12. Psoriasis take Hx and explain Rx, phototherapy and steroid use and side effects.
13. Smoking cessation and IHD.
14. Hx of hild with ADHD and/ or deafness.
15. Hx bronchiolytis.
MCQ AND EMQ
MCQs/EMQs
-respiratory distress in newborn
-dermatology in paeds: eczema, molluscum, scabies, eczema herpeticum
-SVTs in children
-diarrhoea in kids
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-measles
-side effects of MMR
-public health: primary, secondary, tertiary prevention
-causes of failure to thrive
-constipation: dif. causes in paediatrics
-intussusception
-who gets a hearing test?
-global developmental dela
cerebal palsy
GP (read the GP handbook inside out)
-number of visits/year from each patieni
-number of patients to gp
length of consultation does a longer consultation result in better patient care? Decrease antibiotic prescription commonest
presenting complaint: URTIs, more common in children'
-number of years working in hospital before can become a GP
-stroke: treatment, prevention
-asthma: treatment in adult and child
-public health (read lecture notes given mostly in there) TB, malaria, AIDS
know the world's top killers which disease will be eradicated soon? occupational health: seroconversion illness, hearing loss
in factory worker
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Pyschiatry/Neuro 2002
1)Hx Panic Attacks
2)Explain to sister of Schizophrenic what it is, Tx, aetiology etc
3)Video x2 (mental state examination)
4)Ophthalmology station-with an examiner asking qus (mcq,slide,eye drops)
5)CT head - diagnosis
6)Picture and qus-6th nerve palsy, other eye qus
7)CSF breakdown-bact/viral/TB meningitis?
8)Take Hx of social withdrawal from a disabled child's carer
9)Hx Headache-migraine
10)Side-effects of Lithium
11)Hx depression and suicide risk
12)PNS examination (lower limb)+differential --was MS i think
13)Explain what Autism is to mother and other differentials
Christmas 2003 Psyche Neuro (Add any other remembered ideas Tigers.)
1. Video of guy with insane gait. Was narrow based I think. Was not something common. I had no friggin idea.
2. Opthalmology: Guy talks to you, shows you a slit lamp picture and asks you what it was. Everyone (well, fools like me and
Mathers) said conjunctivitis, for lack of better ideas. Actually it was trauma or something. Then maybe some other pictures,
and then asked us which of a bunch of a box of syringes and stuff would be best used to anaesthetise, etc. the eye. Eye
drops basically. And I had no idea. And still don't.
3. Written station. To do with sections. I think it involved those two similar sounding ones: 136 and 135? It's been a while.
The police one.
4. Epileptic young woman. I remember giving her advice about swimming and contraceptives. All the epileptic bull shit. All
that stuff about driving etc. came up. I remember the unhappy looking examiner said "Dont' spend too long diagnosing the
patient." So it was mostly advice that they were looking for.
5. Probably a rest station because I remember hearing the examiner from the station behind me get really impatient with
the student after me for persisting with the diagnosis aspect for too long. And I foolishly overheard the guy in the next
booth say things about the next station and then made it well obvious I'd eaves dropped to the
examiner by assuming the guy had diabetes when he didn't.
6. Peripheral nerves examination - legs, sensory only. Then talk about diagnoses etc and probably other stuff.
7. Video of manic guy? In the video, there is mental state sheet to fill in.
8. Another video of a depressed guy?
9. DSH risk. Bloke tried to kill himself. Assess his risk. Our guy was high risk because of suicide note, attempts not to be
found etc.I randomly accidently suggested he'd 'chickened' out of it. Do not do this.
10. I think there was a CT scan somewhere, but I am not sure.
11. Rest station. So you get to over hear what your colleague says to the person in station 12.
12. Woman wants to talk about her brother who has schizophrenia. So tell her about it.
13. Breaking bad news/communication skills: Woman's mum has alzheimers.
14. Woman has a son diagnosed with autism. Talk to her about it. But also, more adept medical students than myself were
able to pick up that actually the son had absence epilepsy.
15. Seppukku station.
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That's all I can remember right now.
Psych and Neuro

1. Headache: Dx temporal arteritis
2. Alcohol Hx
3. Suicide assessment
4. Ritalin: parent with questions
5. Lithium: side effects, need for blood tests etc
6. Alzheimer's disease: explain it to daughter of patient
Data interpretation: Short answer questions (note, you don't have enough time to write everything down)
7. LP and CSF profiles: know the difference between, normal, menigitis, TB and SAH. Be able to list 3 early and late
complications of LP.
8. Anorexia: work at BMI, list clinical symptoms and signs
9. MHA questions. Know it really well, questions are a bit fine print.
10. Ophthalmology: foreign body, glaucoma, diabetes and the eye. You look at pictures and examiner questions
you. Must know your eye drops.
11-12. MSE: Video of psych patient. Write MSE from this.
13. Neuro video (we had transcipt 'cos video was busted): ? delirium
Practical
14. Be able to examine certain aspects of the PNS in isolation. For example, just examine the SENSORY nervous system in
the lower limbs (no need to illicit reflexes then). . State your diagnosis from findings. I had a guy with a sensory
neuropathy, stocking distribution. Don't forget to observe first.
Psych and Neuro
Dec 2003
1. Neurological exam of lower limb (patient had glove and stocking
sensory lossing secondary to Diabetes)
2. Video - watch an interview of a manic patient and write a mental
state - hurry up time is limited!
3. Video again - mental state of depressed patient.
4. SP (simulated patient) - Explain alzheimer's disease to a patients
daughter and answer questions she asks you.
5. SP - explain diagnosis and treatment of panic attack to a patient
6. SP - explain autism to a mother and its management.
7. SP - explain the diagnosis of schizophrenia to a patients sister
8. Written station - identify spastic gait
9. Written - identfy left radial nerve palsy from a photo
10. Talking station (examiner will ask you questions) - explain about
eye drops you would use (e.g. dilators, anaesthetics)
11. Talking - answer question on fundo disc abnormalities
12. Explain contraindications to cataract operation
13. Identify CT bleed on picture e.g subdural, subarachnoid
14. SP - answer impact of epilepsy on patients life (OCP, swimming,
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climbing, driving etc.)
15. Answer question regarding causes of delirium.
Neuro 2003/04
OSCE STATIONS
Neurology
1) Video presentation/ written station : Read up about Scissor Gait &
Cerebral Palsy (I think I score 0 on this station so good luck !!)
2) Talk to family member of patient about ALZHEIMER'S DISEASE
3) Lower Limb Examination : Sensory examintation on the patient's LL.
Make a diagnosis and justify diagnosis, causes of stocking distribution.
4) Epilepsy counselling : you are a GP and a lady in her 20's has be
diagnosed with epilepsy and is on medication, she's come to you and ask for your
advice about epilepsy.
5) CT/MRI scan (Written Station) identify Subdural or subarachnoid
haemorrhage, and possible clinical outcome.
Psychiatry
1) Do a RISK ASSESSMENT on a SUICIDAL patient.
2) Explain to family member of patient about SCHIZOPHRENIA.
3) Explain to mother of child about AUTISM.
4) Take a history from someone who presents with CHEST PAIN, make a diagnosis and counsel the patient about it.
5) Video session : Do a mental state examintation. ( I had a delusional patient)
6) Video Session : Do a mental state examintaion ( I had a sad patient)
7) Written station on Mental Health Act. Especially the difference between MHA 2 and 3
Ophthalmology
1) Identify pictures of symptomatic eyes. Contraindication for cataract surgery. Anaesthetic used for cataract surgery.
Neuro EMQ
Written paper:
A lot on differential diagnosis for both Nuro and Psyc. Neuro path and genetics.
I think it has changed, for us there were % of population with alcohol dependency etc which was really random. Know the
various roles of the MDT in Psyc for eg CPNs, OTs consultants etc!
KNOW YOUR LECTURE NOTES REALLY WELL!!! A lot of the definitions are
lifted directly from them, so read them well before reading thick books.
OSCE Neuropsych December 2005

21 stations. 6 rests including 1 logbook station
1. Autism- explain to mother of child what the

disorder is and its treatment(eg special schools,
makaton communication)
2. Schizophrenia- explain disease and prognosis to
sister of patient, being sensitive about suicide risk
3. Suicide history- take history from patient who
attempted suicide and class their current risk (high)
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method, feelings about it now etc
4. Alcohol history- assess if they are dependent(eg
3out of compulsion, lack of control, tolerance,
withdrawal, social effects, health effects, plus
stereotyping, time of first drink, drinking debut, who
they drink with, suicide etc)pthadhistory of violence
towards girlfriend when drunk
5. Biochem data station- urine drug screen, U&E etc
6. Anorexia writeen station- BMI calculation etc,
anorexia criteria
7. Phone Gp and discuss sectioning his patient under
section 2 of MHA-explain what means.
8. Video- do MSE of patient. Video lastsapprox 3 min,
use proper terminology? Young man with long hair and
cap. No actual hallucinations, but odd beliefs-eg
meeting Bill Clinton in his sleep, being a world
leader ? delusions of grandeur? Schizotypal
personality?
9. Video of Parkinsons. Describe gait, hand
movements, face, diff diagnoses, clin fts, treatment
10. Picture- VI palsy and its causes
11. Ophthalmology- describe slides to Dr- retinal
photos plus pictures from cataract surgery- need to
know what is happening,what tools are being used
12. Examine- carpal tunnel syndrome, median nerve
sensory distribution, muscles. Explain treatment- eg
?splint, flexor retinaculum decompression
13. History- trigeminal neuralgia.treat-
carbamazepine. Causes-idiopathic,compression by
aneurysm
14. History of panic attacks- takeHx and explain
aetiol and treatment
15. CT scans written station-
subdural-concave/extradural- convex
haemorrhage,glioma, infarct. (multiple choice)
Mr KY, 23, says that in 2004, the following came up:

history taking of somatization, anorexia epilepsy,
autism, panic attacks gait videos, MSE of psychotic
video, side effects of TCAs and lithium,explanation
and consent for lumbar puncture, contraindiactions of
cataract surgery
neuro /pysch early 2005 what Miss MP can remeber
1. PNS examnation
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2. Exaplain atypical antipyschotics
3. Explain sections
4. Explain alzimers to a daughter
5. Wierd elctryphysiology results....EMG?
6. Meningitis table results...viral bactarial fungal
7 opthamology station will show u pics u have say what
8. CT scans
9. Suicide risk
10 headache hx
Obstetrics and Gynaecology 2002

1)Counselling for OCP/HRT
2)Couselling for Needlestick injury-HIV, procedures
3)TB-tell pt about drugs, side-effects and treating contacts
4)Taking blood cultures-practical
5)lCervical smear and bimanual exam
6)Hx Postpartum Haemorrhage
7)Written station: STDS gonorrhoea/chlamydia
8)Hx Urethral Discharge/sexual discharge
9)Mechanisms of birth (using plastic pelvis and baby)and describing Partogram
10)Explaining to pregnant lady about antenatal testing
11)examination of pregnant adbomen
12(how to put on a condom)
13(Mcq on malaria)
O and G - December 2002

1. advise re amniocentesis
2. blood cultures
3. female sexual history
4. explain partogram and explain the process of delivery and birth
by guiding a fake baby through the model of the pelvis.
5. written station: gonococcus, acute testicle, STDs
6. smear and bimanual on a model
8. HIV post exposur prophylaxis
9. counselling- explain smear result (mod/severe dyskaryosis)
11. examination of a pregnant abdomen
12. contraception counselling
13. dysmenorrhoea history
14. explain how to do an MSU
0 and G - Easter 2002:

1. Blood cultures
2. menorrhagia history
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3. HRT counselling
4. male sexual history (herpes)
5. bimanual and speculum on model
6. pregnant abdomen examination
7. infectious diseases pictures
9. Meningitis counselling (exposure prophylaxis etc)
11. throat swab
12. booking visit counselling (which tests will be done etc)
13. fake baby through pelvis and partogram explanation
14. + one other which i have forgotten but it cant have been that bad though
These are the O&G stations we had in Dec 2003
1. Amniocentesis explanation and fill in the consent form

2. Counsel woman on starting the oral contraceptive pill
3. Do a bimanual and chlamydia swab on model
4. Counsel a nurse on needlestick injury and post exposure prophylaxis
5. Counsel woman on smear test result of moderate dyskaryosis
6. Explain how to take Blood pressure and examine pregnant abdomen
7. Male sexual history
8. Female history of right sided abdominal pain
9. Counsel a worried mother about her child's exposurie to meningitis at school and appropriate prophylaxis
10. Explain a partogram (latent and active phase of 1st stage of labour) and guide a baby through the pelvis in labour for
delivery
11. Take history of antepartum haemorrhage at 34 weeks gestation and appropriate management
12. Throat examination taking a swab
13. Take a history of subfertility and its causes in this
particular case - pelvic inflammatory disease so take a quick gynae and genito-urinary history
14. woman diagnosed with genital warts - counsel her on causes and appropriate treatment and risk of cervical cancer
15. give in logbooks and feedback on firms
each station 5 mins

1. Description of Labour?Partogram/Baby in pelvis
2. Herpes Explanation
3. APH history Placenta Praevia
4. Sexual Hx from gay bloke
5. Pregnant Abdomen exam
6. HIV needlestick
7. Cervical swab/bimanual
8. Amnioscentesis + consent
9. Pill consent
10. Colposcopy does not have cancer
11. Blue Book rest
12. Infertility test explain
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13. Throat swabs
14. Meningococcal contact explain
15. Rest
Obs and Gynae

1. Post partum haemorrhage
2. Contraception advice, the pill etc
3. HIV test counselling
4. Smear test result and explanation
5. Prenatal diagnosis counselling: Down's
6. Needle-stick injury protocol
Data interpretation
7. MCQ's: STD microbiology
Practical
8. Bimanual/smear on dummy
9. Mechanisms of labour: move doll through pelvis and interpret partogram
10. How to take a blood culture
11. How to perform an MSU
OSCE 2003/2004
OBS AND GYNAE
OSCE stations dec, 2003
1) meningitis: asked to speak to a mother concerned about an outbreak at her child's nursery school. she wants advice on
prophylaxis, when can the daughter return to school, etc. tell her about rifampicin. ask if daughter had meningitis vaccine
2) throat swab: dummy on examination bed. take a throat swab.
examiner may ask what sort of pathogens cause sore throats.
3) sexual history: someone wants a HIV test. ask him the routine sexual history
5) partogram and delivery: there's a model pelvis and doll. move the doll through the pelvis, showing your understanding
of the delivery process.
there's also a partogram they will ask you to interpret
6) communication skills: woman comes in worried about her recent cervical smear results. she has CIN I. explain what
that means.
8) communication skills: patient asking about amniocentesis. why is she having it done, risks to baby's health, etc
9) needle stick injury: patient comes in from recent injury. asks you what to do next. tell him about the protocol.
10) contraception: lady wants to know what contraception to use. remember to ask for risk factors like previous DVT,
clotting disorder if prescribing COC.
Paediatrics/GP/Derm 2002
1)Examination of child (or neonate)
2)Hx poor feeding...
3)...turns out to be eg.pyloric stenosis (discussion, Tx etc)
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4)Explaining differentials of badly behaved child-ie.ADHD,Autism etc
5)Explaining to mother what Down's syndrome is
6)Side-effects of Ritalin
7)Explain asthma drugs and how to use an inhaler/spacer
8)Explain results to man with peptic ulcer..and Tx
9)Couselling pt to keep taking BP tablets
10)Hx psoriasis..Tx available
11)Video of child--muscular dystrophies...mcq: Becker's,
Duchenne's etc
12)Picture of rash and graph of lymphocytes etc.. -- mcq:
Parvovirus,meningitis,chicken pox
13)Xray abdomen - can't remember what of
Paeds/Derm/GP - Dec 2003

1) Psoriasis History
2) Paeds BLS
3) Data station on blood results with Hx e.g. Bilirubin levels and Hx of constipation and coarse facies.
4) Convincing a patient to stay on Anti-hypertensives.
5) Counselling a father about how you will manage his son's UTI.
6) Data station with 1-chest and 2-abdo and 1-limb x-rays.
7) Peptic ulcer Hx and explanation about eradication therapy.
8) Data station on Development and an abnormal gait (2 videos)
9) Congenital Dislocation of Hip and Fundoscopy examination.
10) Bronchiolitis Hx
11) Bronchiolitis Managment
OSCE stations dec, 2003

1) meningitis: asked to speak to a mother concerned about an outbreak
at her child's nursery school. she wants advice on prophylaxis, when can the daughter return to school, etc. tell her about
rifampicin. ask if daughter had meningitis vaccine
2) throat swab: dummy on examination bed. take a throat swab. examiner may ask what sort of pathogens cause sore
throats.
3) sexual history: someone wants a HIV test. ask him the routine sexual history
5) partogram and delivery: there's a model pelvis and doll. move the doll through the pelvis, showing your understanding
of the delivery process. there's also a partogram they will ask you to interpret
6) communication skills: woman comes in worried about her recent cervical smear results. she has CIN I. explain what that
means.
8) communication skills: patient asking about amniocentesis. why is she having it done, risks to baby's health, etc
9) needle stick injury: patient comes in from recent injury. asks you what to do next. tell him about the protocol.
10) contraception: lady wants to know what contraception to use. remember to ask for risk factors like previous DVT,
clotting disorder if prescribing COC.
OSCE stations April 2004

1) computer data: X ray: diaphragmatic hernia
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2) take a hx from an adult: poorly controlled asthma. give advice on management in future
3) computer data: developmental video, girl combing hair and turning pages, guess age. picture of blood film: scenario- 11
year old girl with sore throat, fever. film shows blood cells and white cells. dx: infectious mononucleosis
4) take a hx from mother: son has had a painful hip for the past few days. take a hx and talk about investigations
5) give a differential for the last station: transient synovitis, osteomyelitis, septic arthritis, etc.
6) take a hx from male adult: poorly controlled hypertension. quit taking atenolol because of impotence. counsel him on
other options. conservative and medically
7) take a hx from mother of 7 year old son: still bed wetting at night. is there anything wrong with son? probably not: talk
about psychological problems behind it. ways to treat it conservatively. ie. night alarms
9) Xray: osteomyelitis
OSCE 2003
Written stations (MCQs)
child development station; young child sitting up, pointing etc and asked to select best answer re: age of child
2 CXRs on laptop screen-select best possible diagnosis- TB/inhaled foreign body
test results on laptop screen-bloods, stool culture, LFTs etc and picture
of stool sample (jaundiced child) pick most likely diagnosis
another OSCE had abdo X ray of necrotising enterocolitis
another OSCE had MCQs with pictures of Kawasaki disease and
parvovirus
induced
spherocytosis
Practical stations
CVS examination of child-VSD
BLS-young child
Simulated patient
explaining psoriasis treatment-phototherapy to a man who has tried
other treatments and failed
explaining results of endoscopy and further management of pt with gastric ulcer in GP-gven printout of results
history from mum regarding sumptoms of childhood asthma in her child (UTI was used in a later OSCE)
next station then using this hostory to explain to the parent what treatments are available and how their child will be
managed. (This was again carried on for the UTI station in another OSCE)
adult asthma-poorly controlled/exacerbation-take history from patient and explain management
explaining febrile convulsions to a parent (had rest station before this where told what the next station would be so that
you had time to prepare)
ADHD; read a GP referral letter re: troublesome child-go through possible differential diagnoses and explain further
management
non adherence with antihypertensives in GP-exploration of issues (ie impotence s/effs of some of the meds) and further
management
What are you taking or doing for your BP?
What is putting you off from tablets?
Eg. Side effects, bad prescription (worked out some things were contraindicated), another doctor has taken him off, too
many tablets, doesnt like taking cos thinks cant be good for him.
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Are you aware of the dangers of high BP?
Explain dangers of having high BP stroke, MI, PVD, kidney damage, eye problems
Death and disability how do u feel about that?
What are side effects of anti hypertensives:
Thiazides: Wee more, gout and hypokalaemia. (Contra in diabetes mellitus).
Impotence and loss of libido not common now using low doses (flat response curve)
Beta blockers: Contra indicated in asthma. Side effects: Cold hands, fatigue, heart failure, triglycerides up, HDL down,
impotence and loss of libido.
ACE inhibitors: Irritative cough, angio oedema, proteinuria and neutropenia.
Renal failure.
Calcium antagonists: Dizziness, hypotension, flushing and ankle oedema Hydralazine: Reflex tachycardia may provoke
angina. Headaches and fluid retention. Lupus syndrome (arthralgia, fever etc)
What side effects he got?
Try to work out a drug regime avoiding side effects.
Advise life style changes.
(Consider that if not tried life style yet and if hypertension not
severe, could try life style first before trying medication. If severe hypertension
or attempts at life style change have failed (like an incompetent fool
deserving to be fed to the vultures of the desert) then medication is necessary
regardless of whether or not life style changes are introduced)
Arrange to see again to review how blood pressure affected.
How does he feel now? Any questions?
Could reach compromise if being difficult: Reduce dose, remove medication,
OSCE December 2004

GP stations;
woman with psoriasis-was on corticostaeroid cream for 20 years-previous GP
told her to stop it but now her psoriasis is really bad and she wants another
treatment. told to discuss the options and take a focussed dermatological history
man with high bp and FHx of stroke-had meds last year which decreased his bp but he stopped taking them. Discuss why
he needs to take them again as his bp is up again. Explore why he didn't take them and discuss overall management of
hypertension including lifstyle management
man with gastric ulcer-have copy of test restults. have to give him the diagnosis and discuss treatment with him
Practical stations;
hip examination on dummy (have to explain to the examiner what you
are doing and what the tests are called) and opthalmoscopy
resuscitation of a young child
Counselling;
have rest station to prepare where told that mother of a 7/12 old
baby boy
wants to talk to you about her child who has been admitted with
UTI-discuss the further tests that going to have and respond to her questions on the
next station
History
history from mum of 3/12 ex-SCBU baby with bronchiolitis-she has not had primary vaccinations!
next station discuss the diagnosis and management with a Dr.
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Data stations
X rays-limb, CXR, abdo XR and have to choose most likely diagnosis for each
picture of eye and CT scan and blood film and something else and again have to choose most likely diagnosis for each
2 video clops-1st of baby looking at a book and using a brush to mime brushing hair-choose correct age, other of teenager
walking and have to diagnose her condition from her gait
PAEDS OSCEs December 2003

1) Abdominal exam of a 4 yr old with Cystic Fibrosis, PEG
Wash hands, consent
Inspection: Jaundice, Pallor, Bruises

Scars, stomas
Peristalsis sign of Pyloric stenosis
Distension intestinal obstruction and ascites
Inguinal region and genitalia (hernias, hydrocele, testicular
torsion)
Masses Wilms tumour, neuroblastoma, intussuception, faecal
mass,appendix mass
Palpate: Tenderness or guarding

Masses
Organomegaly liver, spllen, kidneys
Perscuss: Liver or spleen enlargement

Shifting dullness
Auscultate: Increased obstruction and acute diarrhoea

Decreased peritonitis
Rectal examination: If intussusception or appendicitis
Cystic Fibrosis Features:
Meconium ileus results in distension, absent bowel sounds. Pale,

greasy and
offensive stools.
2) Hx taking from a mother of a 3 wk old child - Bronchiolistis?
Most common in Winter

Epidemic in 1-9 months
Coryzal symptoms cough, increasing breathlessness
Small infants develop apnoeic episodes
Does your kid have CHD or chronic lung disease
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O/E
Tachypnoea
Subcostal and I.C rcn
Chest hyperinflation
Bilateral fine crackles
High pitched rhonchi on auscultation
3) Discussion of diff. diag + management of the above

i. Pneumonia
ii. Asthma
iii. Whooping cough
iv. Cystic Fibrosis
a. Mild bronchiolitis
Feeding well
RR < 40
Minimal rcn
Rx. Send home and review
b. Moderate bronchioloitis
Feeding difficult
RR > 40
Sat >85%
Marked rcn
Rx: Admit, O2 and fluids
c. Severe bronchiolitis
Not feeding
Tachypnoea RR > 60
Sat < 85%
Recurrent apnoea
Severe recession
Rx: Admit to ICU, high inspired O2, intubate and assisted ventilation
CONTROVERSIES: Salbutamol not used. Adrenaline maybe useful.
4) Explain management options to a Psoriais pt
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Counselling:
Non infectious, common 2% population, you will need lifelong treatment.
Relapsing-remitting course, refer to Psoriasis association
Stable plaque VD analogues with topical steroid

Tazarotene, dithranol (short contact), coal tar
UVB
Extensive plaque - PUVA
Methotrexate, ciclosporin
Guttate Topical steroids
Coal tar
UVB
Facial/flexural Topical steroids
Acitretin
PUVA
Palmoplantar Topical steroids
Acitretin
PUVA
Generalized pustular/Erythrodermic Acitrein
Methotrexate, ciclosporin
VD analogues Calcipotriol and tacalcitol
5) Basic life support 8yr old kid
D Look for danger

R Response (gently stimulate child and ask are you ok)
If child responds leave child in how you found him providing he is in
no further damage, check his condition and get help if necessary. Reassess
regular.
If no response, shout for help and open childs airway. By tilt head
and lift chin.
Avoid head tilt if trauma to head is suspected, then use jaw thrust.
Keep airway open and look, listen and feel for breathing.
If child breathing normally then turn child on side and go for help.
Then recheck for continuous breathing.
If child is not breathing, if airway obstruction remove it. Give 2

rescue breaths (give up to 5 to achieve 2 effective ones) then:-
For a child (1-8 yrs) pinch soft part of nose with index and thumb,
open his mouth a little maintaining chin lift, place your lips around his mouth.
Blow steadily for 1-1.5 seconds. Give 2 effective breaths.
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For an infant (0-1yr) cover mouth and nose with your mouth (if big
infant do mouth to nose breath, cover mouth with your hand). Give 2 effective
breaths.
If effective breath not achievable check mouth for obstruction.
C assess circulation by checking carotid pulse in neck in child, for

infants feel brachial pulse. Shouldnt take more than 10 seconds.
If +ve signs of circulation continue with rescue breathing until child

starts breathing effectively on its own. Recheck circulation regularly.
If ve signs of circulation or unsure or if P < 60 start chest

compressions.
Combine breathing and chest compressions. For child below the nipple
line on the sternum above xiphisternum (1 hand only) for 5 compressions at
100/min rate. Then tilt head and give one effective breath. Carry on 5:1
If older than 8 then use adult method. (15:2)
For infants:
Locate sternum, use 2 fingers about 1 finger breadth below nipple line.
Then do typical 1/3 deep compression at 100/min for 5:1. Or wrap hands around
infant.
6) Computer stations, x-ray, clinical scenarios - ?Thyrotoxicosis &
7) Counsel/ Explain to a father of a 3 yr old boy with UTI, having to

go through all the investigations
8) More computer stations - more x-rays Fallots tetralogy, Septic

arthritis/ osteomyelitis
Fallots Boot shaped (secondary to pulmonary tract obstruction)

Oligaemia
Small heart
Uptilted apex
Septic arthritis XR shows initially normal. Non specific widened

joint space.
Osteomyelitis Normal in first 10 days. Periosteal elevation with
radiolucent necrotic areas (detected between 2-3 weeks)
Osteogenic sarcoma around knee joint in metaphysis of distal femur or
proximal tibia. Destruction and sunburst appearance as tumour breaks through
cortex and spicules of new bone are formed.
265
Ewings Periosteal elevation with onion skinning (from soft tissue
mass) sometimes mets can be seened. Commonly affect mid to proximal femur.
9) GP explain to a patient for whom u have just received H-pylori test
as +ve
Introduce
Why are you here?
What do you know already?
Strong association between peptic ulcers and H.Pylori
H.Pylori is a bacteria. Large percentage of population have H.Pylori
but dont have ulcers.
Eradicate H.Pylori will reduce chances of ulcers
Easily treatable disease dont worry mate

Conservative management lifestyle (avoid worsening foods e.g. spicy,
stop smoking)
Eradicate with antibiotics triple therapy (lanzoprazole,

clarithomycin and amoxycillin or metronidazole) for 1 week.
Suppress acid secretion H2 receptor antagonist (ranitidine,

cimetidine) taken at night for 8 weeks or PPI (lanzoprazole, omeprazole for 4
(duodenal)-8 (gastric) weeks)
If drug caused e.g. NSAID stop it or use H2 receptor antagonist, PPI or

misoprostol (prostaglandin mediator) with NSAID
If symptoms persist then do re-endoscope and re-check for H.Pylori
How do you feel about taking all these drugs?

10) Video stations, guessing correct age, and diagnosis for a 10-15 yrs
old girl with abnormal gait I put Duschenne MD without thinking it
predominantly affect boys
OSCE list 2002/2003

Paeds and GP
Histories and counselling stations
1. Diabetes
Data interpretation: Choose the correct answer

5.Video 1: boy showing 'Gower's sign' therefore diagnosis is DMD
6. Video 2: Child development: guess the age of the child from
266
'classic' developmental milestones
8. Computer screen with 3 pictures: 1. fundus 2. blood film 3. CXR.
Case desciption, what's the diagnosis
Practical
9. Examine the eye and ear
NB: Febrile convulsions
Paeds and GP: April 2004

OSCE stations
1) computer data: X ray: diaphragmatic hernia

2) take a hx from an adult: poorly controlled asthma. give advice on management in future
3) computer data: developmental video, girl combing hair and turning pages, guess age. picture of blood film: scenario- 11
year old girl with sore throat, fever. film shows blood cells and white cells. dx: infectious mononucleosis
4) take a hx from mother: son has had a painful hip for the past few days. take a hx and talk about investigations
5) give a differential for the last station: transient synovitis, osteomyelitis, septic arthritis, etc.
6) take a hx from male adult: poorly controlled hypertension. quit taking atenolol because of impotence. counsel him on
other options. conservative and medically
7) take a hx from mother of 7 year old son: still bed wetting at night. is there anything wrong with son? probably not: talk
about psychological problems behind it. ways to treat it conservatively. ie. night alarms
9) Xray: osteomyelitis
there were three rest stations as well.

-respiratory distress in newborn
-dermatology in paeds: eczema, molluscum, scabies, eczema herpeticum
-SVTs in children
-diarrhoea in kids
-measles
-side effects of MMR
-public health: primary, secondary, tertiary prevention
-causes of failure to thrive
-constipation: dif. causes in paediatrics
-intussusception
-who gets a hearing test?
-global developmental delay
-cerebal palsy
GP (read the GP handbook inside out)

-number of visits/year from each patient
number of patients to gp
length of consultation
does a longer consultation result in better patient care?
267
decrease antibiotic prescription
-commonest presenting complaint: URTIs, more common in children?
-number of years working in hospital before can become a GP
-stroke: treatment, prevention
-asthma: treatment in adult and child
public health (read lecture notes given during lecture week. it's
mostly in there)
- TB, malaria, AIDS
- know the world's top killers
- which disease will be eradicated soon?
- occupational health: seroconversion illness, hearing loss in factory workers, anxiety
268
Psychiatry OSCE Stations.
10th April 2002:
Written Stations:
1) Mania - What would you see under each heading of the Mental State Examination (MSE)?
2) Anorexia - BMI & Psychiatric causes of loss of weight.
3) Forensic - Differences between a medium secure unit and a hospital ward. How to get a patient from prison to hospital.
4) Psychotic man - possible causes.
5) Delirium - Man just out of hospital & wandering in the street. Management and possible causes.
6) Attempted suicide - What factors mean they're likely to do it again? Management.
7) Post partum depression - Incidence and management.
8) Lithium - Side effects and blood tests necessary.
Video Stations:
9) MSE on a patient with psychotic symptoms.
10) MSE on a depressed patient.
SP Stations:
11) Man with panic attacks - Take a history and explain management.
12) Woman with depression - Tell her about different types of psychotherapy.
13) Man with an alcohol problem - Take a history and decide if he's alcohol dependent.
14) Woman with depression - Tell her about the side effects of TCA's, when they'll start working and how long to take them
for. Can she drink? Can she drive?
12th June 2002:
Written Stations:
1) Deliberate Self Harm - common methods, criteria for Borderline Personality Disorder
2) Institutions Vs. Care in the Community - What is institutionalisation?
3) Learning difficulties - prevalence, what will & won't the patient be able to do in life?
4) Sectioning - differences between S2 & S3
5) Alcohol - criteria for dependence
6) Bus driver with depression - treatment with SSRI - duration, SE's and reasons why he's affected.
7) PTSD - symptoms, time scales and treatment
8) Patient with Mania - what would you see under each heading of the Mental State Examination?
Video Stations:
9) MSE on a patient with psychotic symptoms.
10) Cognitive state assessment (Need to know the formal 30 point score cognition examination)
SP Stations:
11) Explain Schizophrenia to the sister of a newly diagnosed patient.
12) Woman with Bulaemia Nervosa - ask appropriate questions and suggest a differential diagnosis.
13) Woman with depression and previous suicide attempt - ask appropriate questions and assess suicide risk.
14) Lithium therapy for bipolar affective disorder - Side effects, blood tests, alternatives etc.
Feb 2005
1) Explain Schizophrenia to the sister of a newly diagnosed patient.
269
2) Woman with depression - Tell her about the side effects of TCA's, when they'll start working and how long to take them
for. Can she drink? Can she drive?
3) Phone call from ward you are HO, pt is being odd :- delirium, take Hx, give advise on Mx
4) Video of abnormal gait, answer questions about gait, differentials etc, where is lesion?
5) Drug/EtOH dependence, treatments
6) Video of MSE
7) Drugs used in ophthalmology, Pictures of operation (Insertion of lens), what is op, what stages are shown
8) Mother of autistic child/ child with ADHD, what is it treatment prognosis etc.
9) Mental Health Act, sections, who how long why.
10) Epileptic, wants to know about med, driving, getting pregnant, interaction with other meds.
11) Learning difficulties video (Downs)
12) Mother of pt with dementia, answer her questions about Rx prognosis etc.
270

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OSCE Handbook

4th year Stations ..................................................................................................................... 71

4th year Stations ................................................................................................................... 132

4th year Stations ................................................................................................................... 137

Question Lists from Previous Years ....................................................................................... 184

Paediatrics/GP/Derm 2002 ................................................................................................... 248

Main causes of arrest in an adult?

Have the patient sitting in a chair

II. Optic nerve

Distance vision is tested using a Snellen chart

Near vision can be tested using reading test types

III/IV/VI: Oculomotor/Trochlear/Abducens nerves

Pupillary light response:

Check full eye movements while also looking for nystagmus

END OF THE BED

Around the bed Oxygen

HANDS and ARMS

MENTION FUNDOSCOPY HTN retinp, Roth spots

COMPLETING THE EXAM

Examine the rest of the vascular tree peripheral pulses

Thank patient and ask if needs help to get dressed

Temperature over the join

Ask Pt: Hands behind head External rotation

Assess limitation of Function

END OF THE BED

Around the bed Sputum Pots

HANDS and ARMS

Lymph Nodes Palpate Supraclavicular and Axillary

The next section should be performed Both Anteriorly and Posteriorly

Chest Expansion Depth and relative movement

ANTERIOR and POSTERIOR: 4 regions

ANTERIOR and POSTERIOR: 4 regions

COMPLETING THE EXAM

Thank patient and ask if needs help to get dressed

End of the bed: Is the patient well?

Examine the arms for

Check for pronator drift.

Record as MRC (Medical Research Council) grade 0-5

5 Normal power for age & sex

Finger reflex (C8)

Reflexes graded as:

Check for dysdiadochokinesis and finger-to-nose test

Same but with a neurotip

Use the back of the tuning fork to test for cold

Close their eyes and place the tuning fork

Joint position sense

End of the bed: Is the patient well?

Examine the legs for

Hip flexion (Iliospoas, lumbar sacral plexus, L1/L2)

Knee reflex (L3,L4. Femoral nerve)

Joint position sense

Close their eyes and place the tuning fork

Same but with a neurotip

Use the back of the tuning fork to test for cold

EXAMINE BETTER HEARING EAR FIRST

Examine Pinna Size, Shape and Deformity

Examine external auditory canal

Pull pinna back and upwards to straighten canal

Examine tympanic membrane

EXAMINE OPPOSITE EAR

Free field hearing tests

Introduction & General Features

Facts about hydration:

Causes of dehydration Causes of overhydration