OSCE SPOTTER STATIONS

Final Year Revision

By Dr Mehreen Jameel (FY1 General Medicine)

Past Spotters
      

Parkinsons Disease Pagets Disease Stomas AV Fistulas Neurofibromatosis Atrial Fibrillation Duputyrens Contracture

   

Myeloma Ankle Oedema Hypercholesterolemia Dermatology Spotters

Parkinsons Disease


History


Gait


ADLs, handwriting, buttons & shoes, turning over in bed

Tremor, masked face, posture, blink rate, drooling, walking aids

Inspection


Festinant gait, reduced arm swinging, flexed posture, difficulty starting and stopping, turning, retropulsion Micrographia

Examine
    

Other tests


Rigidity- cog wheeling Tremor Bradykinesia Loss of postural reflexes Glabellar Tap

reinforced by synkinesis

Parkinsons Continued
 

TriadTriad- tremor, rigidity, bradykinesia Differential  Vascular events-strokes events Orthostatic hypotension+ atonic bladder= MSA  Dementia + vertical gaze= SRO Syndrome  Kayser Fleisher rings = Wilsons disease  Apraxic gait= communication hydrocephalus  Antipsychotics, antiemetics

Management
 

 

MDT Approach Assess disability/cognition eg time to walk 10m, dress alone Medication when QoL affected eg L-Dopa + Dopa LDecarboxylase Inhibitor, MR forms, newer drugs eg D agonist- Ropinirole, agonistcarbergoline Anticholinergics (help motor symptoms) ModafinilModafinil- daytime sleepiness (all in OHCM)

Pagets Disease


Briefly Examine legs  Inspection: Sabre Tibia, lateral bowing of femur  Feel: Warmth Complete examination by:  Examine skull appearance (>55cm abnormal)  Hearing defect (conductive(conductiveossicles or VIII nerve compression  OA involvement  Raised JVP (HF, Hyperdy Circ)  Kyphosis (Auscultate vertebral bodies for bruits)

Diagnosis  Normal Ca & Phosphate  ALP  Urinary hydroxyproline secretion Complications  Bone- #s, sarcomatous change Bone1% in 10 yrs  Neurology- CN palsies, cord Neurologycompression, headache, fits  Cardiac- high output HF CardiacManagement  Symptomatic- analgesia, Symptomaticbisphosphonates, calcitonins  Surgical- for OA Surgical-

Pagets Continued


Radiological Features:


Local bony enlargement, patchy cortical thickening, scelrosis, osteolysis, deformity SkullSkull- Honeycomb, Cotton wool VertebraVertebra- Picture frames sclerotic changes PelvisPelvis- Brim Sign, thickening iliopectineal line, enlargement of pubic and ischial bones

Stomas
Stoma Type Location Features
Perm/Temp, mucosa sutures to skin (flush)

Output
SemiSemi-solid, intermittent passage

Indication
Colorectal Ca, Diverticular Dis, Bowel Isch, Trauma

Colostomy

LIF/ R Hypochondrium

Ileostomy

RIF

Liquid stool, bile Usually stained, permanent, spout, (non flush) continuous

Bowel Ca, IBD (UC), Trauma, Bowel Isch, Obstruction, Renal Tract Ca, Obstruction, Hydronephrosis

Urostomy

L/R Flank Lower abdo wall

Ureteric catheter protruding

(nephrostomy if origin renal pelvis)

Clear urine, continuous

Stomas Continued


Complications


Prepare for surgery



Early
    

Haemorrhage Stoma Ischaemia High Output Obstruction (adhesions) Stoma retraction Dermatitis, Stoma Prolapsed Parastomal hernia Fistulae Obstruction

  

Delayed
    

Psychosocial, physical prep and support Clinical stoma nurse specialist Counselling How to manage stomas Stoma site avoided:


Bony areas, umbilicus, scars, waistline skin fold & creases

RRT
 

Dual Lumen Tunnelled Cuffed Catheters AV Fistulas

 

Types of dialysis


Haemodialysis, haemofiltration, CAPD Acidosis Electrolyte imbalance Ingestion Overload Uraemia

BrachioBrachio-cephalic, RadioRadiocephalic, ulna-basilic ulna2-3 months arterialised matured Scar, dilated veins, thrill, bruit Venous stenosis, Thrombosis, Distal Ischaemia, infection, aneurysm.

Indications
    

Examination


Complications


ARF/CRF

RRT Continued


Peritoneal dialysis


Renal Transplantation
   

Tenkoff catheter Peritonitis Infection around catheter site Constipation Pleural effusions CI- Peritoneal adhesions, stoma, hernia, intra-abdo

Complications
    

ESRF Cadaver/ live donor Lifelong immunosuppression CI- HIV, Cancer, Severe heart disease

Complications
 

Acute Rejection 3-6 mths Chronic Rejection > 6 mths

Neurofibromatosis


NF1 (AD Ch 17) 1:2500



NF2 (AD Ch 22) 1:35000

 

     

caf au lait macules >5mm (prepubertal) >15mm (postpubertal 2 neurofibromas or 1 plexiform Freckling Optic glioma 2 lisch nodules Osseous lesions First degree relative affected MDT Annual BP & cutaneous survey Genetic counselling Removal of dermal neurofibromas

Bilateral vestibular schwannomas First degree relative affected or  Unilateral vestibular schwanoma  Neurofibroma, meningioma, glioma, jeuvenille cataract

Management
  

Management
   

Annual hearing test and MRI from puberty Clear scan 30 yr- unlikely inherited Neurosurgery  Complication, hearing loss, facial palsy

Atrial Fibrillation


 

Examine pulse & comment:  Radial-rate/rhythm Radial Carotid- character/volume Carotid Discrepancy in radial and apical rate  Examine CVS DifferentialDifferential- AF/ Multiple Ventricular Ectopics Causes:  CARDIAC- Hypertension, HF, CARDIACcardiomyopathy, mitral valve disease  RESP- pneumonia, lung ca, RESPsarcoidosis  Other- hyperthyroidism, post-op, Otherpostalcohol, PE

Diagnosis + tests:  ECG, U&Es, TFTs, Cardiac enzymes, echo Complications:  Embolic Stroke, Intestinal Ischaemia, Acute Limb Ischaemia Management:  Treat cause eg MI, PE, Pneumonia  Are they Haemodynamically Stable? DC cardioversion or Drug Cardioversion.  Acute AF/ Chronic AF (OHCM)  ANTICOAGULATION, Warfarin (INR 2-3 / Aspirin 300mg + PPI), 2Warfarin CI.  Ablative therapy

Hypercholesterolemia


Screen
   

Management


CHD/ risk f/h CHD or 65yr <CHD Xanthomata, xanthelasmata 50yr <Corneal arcus Pls be aware of 5 types (OHCM)

Primary Hyperlipidaemia


Secondary Lipidaemia


DM, Alcohol, renal failure, nephrosis, cholestasis, hypothyroidism

Exclude familial/2 hyperlipidaemias Lifestyle advice, BMI, Omega3, exercise 1st Statins CI porphyria, myositis, LFTs (decrease synthesis) 2nd Fibrates (decreases absorption) Hypertriglyceridaemia, fibrates, nicotinic acid, fish oils Residual plaques- excision, cryotherapy

Ankle Oedema


Inspection


Differential swollen legs



Swollen, bi/unilateral, hyperkeratosis, discoloured nails Pitting/ non-pitting Inguinal lymphadenopathy Signs of right HF, JVP Hepatomegaly, fluid overload


Palpate
 

CENTRAL- RHF, hypoalbuminaemia, nephrotic syn, hypothyroidism PERIPHERAL- DVT, venous insufficiency 1-congenital disease eg Milroys 2- malignancy, infection, post surgery/radiotherapy Non Surgical- Stockings, elevation, Rx cellulitis Surgical- rare, done when occlusion of lymphatics

1/2 lymphoedema
 

Completion
 

Management
 

Duputyrens Contracture


   

Progressive painless thickening of palmar fascia, skin puckering & teathering Ring + little finger Bilateral Huestons Table Tops Test +ve Causes


Management
   

Physio, splinatege Fasciectomy Fasciotomy Dermofasciectomy

Complications


Bleeding, scarring, recurrence, infection, neurovascular complications

Genetic (AD), Alcoholism, antiepileptics, DM, Peyronies

GOOD LUCK!!

Any Question ?