Ultimate Finals List - Surgery

Surgery

• Surgery: A game in how to fail an osce. Guy had colostomy with parastomal hernia. So I looked, got told off for running commentary (don’t do it to a surgeon) did the abdo exam, thought I’d finished and spent the next minute with the examiner looking at me and saying come on then.. have you really finished? I was in such a state by then, couldn’t remember if I’d done all the exam and didn’t want to continue it if I had so kept deciding to re-examine then stopping like some demented jack in a box. Questions on the stoma, very brief. Asked about possible reasons for the stoma // Patient had a parastomal hernia. examine and present findings. Asked why patient has had a stoma (Hartmann's Vs AP resection), types of stoma and indications. Asked what i would examine next - i said perineum, hernial orifices and external genitalia. Examiner then asked me to examine hernial orifices - normal except for two tattoo marks from radiotherapy (which the examiner told me everybody else missed!) then asked to put it all together and say why patient has a stoma - colorectal cancer, surgery, stoma which hasn't been reversed and radiotherpy for malignancy! // patient with colostomy and scars. Was asked to examine groin – patient had rash on one side but not on the other and also a radiotherapy tattoo mark but was unable to put it all together.

• Abdominal exam- stoma- colostomy. Asked why the gentleman may have it in place. Then what else I would like to check... when I mentioned that I would like to check the anus as it would differentiate between an abdomino-perineal resection and an anterior resection, the examiner then made me examine the perineum without gloves and made every student after me do it too, so know how to examine it!!! I can't remember much about this station, it was my first one and the perineum examination threw me a bit!! // "Examine this patient's abdomen" ...the patient had a stoma. I don't know why I was still panicking, I saw the stoma and focused too much on it. I completely forgot to check for bowel sounds or shifting dullness!!! The stoma was the main thing, the man had a midline laparotomy scar as well, so I was quizzed on what I thought the stoma was (a colostomy) and why (left sided etc etc) operation the patient had, I said Hartmann's because the examiner had told me the anal canal was patent. That was apparently correct, the examiner then asked me why this patient might have had Hartmann's I said colorectal carcinoma or acute diverticulitis which was also apparently fine. The examiner then asked what ELSE it could be, I then said an A-P but I would have expected the rectum to be over sewn (i.e. anal canal NOT PATENT). The examiner then said "REALLY?" and I said " YES" and then had a million other ways of saying the same thing, and the examiner started shaking his head....I'm still not sure what he wanted me to say!!!

• GI - - abdo exam of patient with stoma, Urostomy bag / ileal conduit due to bladder cancer plus ascites

• Surgical - Abdo examination - small bowel obstruction post op, nephrectomy scar present, asked on causes of SBO, different types of resection

• Surgical exam- Lady with multiple scars including midline laparotomy, left subcostal, plus stoma in right iliac fossa. Couldn't find any other signs or think of explanation for scars. I mentioned I would test for hernias to complete the exam, was told to procced but bell went. Was told she had Crohn's and asked about its surgical treatment. Didn't get round to mentioning about stenosis, fistulae, perianal abscesses etc.

• Breast examination, left upper outer quadrant mass, DDx, genetic counselling

• Surgical exam - mastectomy and examination of other breast, followed by discussion about breast cancer, risk factors, treatment options etc.

• Surgery - peripheral vascular exam of legs, arterial history, varicose veins (needed to be stood up) // Peripheral vascular examination of claudicant asked about Buerger's Test. Values for ABPI and how would do it Surg stations was peripheral vasc- this was difficult and bitty- buergers was positive but the reactive hyperaemia was mild and i think many students said it was negative. Useful to do this test on a real patient before the exam! Ques- what would you expect his ABPI to be? What is normal? Explain how to do it. // SURGERY I had a gentleman with and amputated foot, lots of weird pigmentation around his ankles, I was asked to do a vascular examination of the legs, so got to him to stand up looking for varicose veins, he had none, so went on to arterial, had to Buerger's test to, I made it up completely, I could not see the leg going pale at all, but there was and obvious hyperaemic reaction when he swung his leg round, he had obvious haemosiderin deposits too, I think I would've done better if I knew what type of amputation he had, he asked me why what is a positive Buerger's test, why do u get a hyperaemic reaction, what does it mean if he has haemosiderin deposits, what was an ABPI, what reading would indicate critical ischaemia, this station was never ending!!!

• Vascular - gentleman with an aortofemoral bypass graft (scars) and claudication. Poor pulses. // surgery: peripheral vascular disease....he asked: there is a scar in right groin and on medial aspect of right knee put it together...femoro-popliteal bypass...then he said feel the bypass and it has a hard lump on it..then he said to present the lump and a lumo!!! duo station...sly... // Surgery - peripheral arterial examination on an Asian patient with an amputated foot and scars from a fem-pop bypass on the left hand side, but normal pulses on the right. Very nice examiner, I examined the patient and presented and then it was more an informal discussion rather than proper question and answer, I got a question wrong and the examiner just corrected me. // Surgery: Peripheral vascular examination, did not want me to perform burgers when I tried. No radial, femoral pulses on the left, Sternotomy scar. Turn out to have lots of scars which were very hard to spot, got asked about a scar...which vein and what it was for (CABG), also about another scar which was a fem-pop bygraft // Surgery – assess this patient’s vascular STATUS (means varicose veins AND arterial examination). Man had no varicosities but had absent pulses below femorals bilaterally, also had positive Buerger’s test in right leg, had to scars over upper thighs and midline abdomen, was an aorto-bifemoral bypass operation. I was then asked what other reasons he would have had this operation besides atherosclerosis, no idea.

• Peripheral vascular examination - femoral atherosclerosis

• The next patient I was told to "examine the legs", I did not know if it was a surgical, locomotor or neuro station so the examinrer just said "why don't you ask the patient to stand up." The patient had huge varicose veins. I was asked to examine this and the peripheral vascular system of the leg. Then asked about the pathogenesis and anatomy of varicose veins. // pvd, Qs asked-where do u suspect the prob to besuperficial femoral (needed basic anat knowledge), treatment

• Peripheral Vascular Disease. Patient had cold white legs. Pulses difficult to find. His radial pulse on the left was weaker on the left than on the right. If you found this sign you were asked about the possible causes and in most cases ridiculed by the especially unpleasant examiner. Which was nice.

• vasc- wasn’t sure if this was varicose veins or arterial I did arterial though there were tourniquets I didn’t touch them. bit ulcers and all sorts- not my best station! I said the patient had oedema- examiner asked what type, I said pitting. then I was asked to demonstrate this. it wasn’t pitting! so he said what is it called! I said dependent oedema? the examiner said 'LYPHOEDEMA' 'have you ever heard of lymphoedema?' yes I had thanks for making me feel thick! // Surgical – pls examine this pt’s legs – fat ulcer on lat malleolus. Did arterial exam and went with arterial ulcer but q’s on venous ulceration... // surgery - arterial examination. only question was why arterial on grounds of inspection? obvious discolouration and arterial ulcers etc // 

• Hernias - inguinal and incisional, keloid scars, direct hernia // Surgery : Examine this persons groin. Direct Inguinal hernia. Asked about treatment options. // Surgery: Guy with lump in the inner thigh- lipoma. Had to test for cough impulse, lying and standing, felt scrotum for masses, mentioned that I would like transilluminate th mass. Examiner was happy and asked me for differentials and to say why I thought it was not that: e.g. femoral artery aneurysm - NOT pulsatile, saphena varix - NO cough reflex, sebaceous cyst -NO punctum etc. This sounds a litte bit daunting but it really was a nice station, and the examiner was very encouraging throughout. For these 2 stations, students are given a list of the questions they will be asked well in advance on the revision courses and handouts. The mark sheets are also available online so it's a good idea to use them and make sure you can answer the questions about different scenarios.

• surgical: the patient had two lumps. One on her right forehead and another of right forearm. I went through site, size, shape, colour...etc..and said findings were most consistent with lipomas. The examiner said that was correct but wanted other differentials..we talked about sebaceous cysts, lymph nodes, AV malformations, dermoid cysts and other weird and wonderful lumps and bumps.. at the end he asked if I would refer this lady ..I said 'the lesions appear benign on examination but I would refer to be safe'..examiner said 'good’. examiner then asked what my first line imaging modality would be ' I said ultrasound'..examiner said 'good'.

• Surgery - incisional hernia (only seen when getting the patient to raise his head), bronze skin + ?hepatomegaly (mentioned haemochromatosis but not sure). Lots of people thought this patient was normal. Got asked lots of questions on scars, hernias and causes of hepatomegaly. // Abdo – no idea, lots of scars, 1 in RIF, I mentioned it could be appendicectomy (examiner looked pleased), instructions actually said, ‘examine this patient’s abdomen, who has a lump in the groin’. So you had to do abdo exam, and then examine his scrotum and hernial orifices. He also had a slight splenomegaly I thought, but others thought it was hepatomegaly, he could not lie flat so this made it difficult to palpate the abdomen. He was tender in the lower abdomen. No idea what was going on. Examiner then asked what the lump in the groin was, I said an inguinal hernia.

• Abdominal exam- man had midline laparotomy and ?appendicectomy scar. Examiner walked off when my back was turned and was replaced by another guy. Maybe this meant he had no signs apart from his scars- I couldn't find any. Examiner said the scars were related. I suggested kidney transplant and he asked why would there be a laparotomy. I said it wasn't a kidney then, and he said he didn't say it wasn't a kidney. Confusing. I think he had an incisional hernia which I was meant to test for- getting him to lift head while lying down. // Surgery - Abdominal - laparotomy scar, AP resection scar, colostomy, urinary catheter but no abdo signs. 

• surgery: inguinal hernia AND abdo exam AND scrotum exam AND examine a strange lump on the back......... not sure i could find a connection between the 2.. i think he had massive hepatomegaly which i gave as a cause for the hernia although i dont think i examined the scrotum properly because i then was asked a lot about clinical findings in a hydrocele and what i would find in the scrotum of someone with an indirect hernia and a hydrocele ie patent processus vaginalis - ie would you be able to feel any discrete masses? // Examine hernia, expected to include scrotum, asked about whether I would refer the atient, to give differntials, then asked a bit about anatomy, lymphatic drainage of the groin and surrounding structures etc - and what a mesh is adn how it work, why heneeds op, risks, is the lump malignancy, can he drive and when after, and when he can go back to work,,,it was not consenting them. 

• Surgery - sebaceous cyst of scalp, a really awkward 10 mins, had finished the examination (where's the red desc lamp!) in about two mins, had to give a differential - lipoma, neurofibroma. Examiner asked me to list the structures of the scalp and then explain to the patient what she should have done about it.

• Surgery - man with a ganglion on the back of his hand. Just exmaine a lump/bump and test median/ulnar nerve function (the guy was a dr himself.. maybe the hernia didnt show up)

• Surgery - Lump in the neck. Assess lump to see if its a thyroid lump and then assess throid status. How would you Ix- TFT, FNA, USS, biopsy. Complications of throid surgery eg, bleeding, infection, damage to laryngeal nerve, damage to parathyroid glands- hypocalcaemia.

Ultimate Finals List - Neurology

Neurology

• CNS – During our five minutes rest before my next station (CNS) one of the patients asks to go to the loo. On his walking back I couldn’t help but notice – stooped posture, expressionless face, slow turning and a lovely pill rolling tremor of the right hand. Five minutes rest up – “please examine this man’s gait and then upper limbs” – differential and diagnosis and that’s it... // Neurology - PD with choreoform movements superimposed from drugs - I just homed in on the chorea even though I elicited all the signs of PD doh! // parkinsons disease ( was very well prepared for this after your course!!! ) - Guy with Parkinsons. Asked to examine upper limbs and gait. Obvious rigidity and tremor. Cogwheel rigidity on synkinesis. Demonstrated glabellar tap and asked by examiner to demonstrate bradykinesia. Examiner asked me most likely cause and then other possible causes. Then how I would manage the gentleman- drugs, MDT, palliative care, information, liaison with primary care etc. cranial nerves, bilateral weakness of the upper part of the face, give differentials // Neuro – The patient had an obvious unilateral pill rolling tremor. The examiner asked me to examine the patient's motor function in his upper limbs. I first got the patient to walk and he did have a shuffling gait. I then examined his arms (and used your scheme of examining roots C5-T1, which was very helpful thanks) and found signs consistent with Parkinson's disease in the arm which had the tremor. The examiner asked me my differentials. I said that all my findings would be consistent with a diagnosis of parkinson's and he said "well common things happen commonly" and then asked me questions about the treatment of parkinson's and the impact on a patient's life ("Are there any other questions you would like to ask this patient?")

• Horners syndrome

• Speech assessment - previous MCA and expressive dysphasia Assessing pt’s speech. Glass of water next to pt – I didn’t use it, although probably should have. She’d had a stroke – questions about which area of brain (expressive aphasia). // Speech Exam, woman had expressive dysphasia. Also had arm in flexed extrapyramidal position, which I noticed, but forgot to mention. Not sure if were meant to do writing/reading/ say would do mental state exam. I missed out all those things from my basic speech exam routine I’d learnt! Examiner quizzed me after I’d talked about testing for a conductive aphasia . When I left I heard him telling the actress that he’d never heard of it and needed to go look it up now and that you learn something new every day!! Bit annoying cos if he hadn’t quizzed me about it I would have had extra time to do more speech exam! I expect he passed me on the station though. // Assess speech of patient, expressive dysphasia // There was a actress with a simulated expressive dysphasia, she also had a 'stroke' arm and a deviated tongue,I assessed comprehension, repetition, reading and writing the examiner asked me if I'd like to do anything else, not quite sure what he wanted. // Was then asked where the lesion was in an expressive dysphasia // Speech examination- in actor with right sided arm flexion deformity, Broca's dysphasia (expressive) I forgot the bit about getting them to repeat "British constitution" "baby hippopotamus" "butter" etc. // Assess Speech – Broca’s aphasia // Speech assessment on an elderly lady with a stroke posture (flexed arm, extended leg). She can’t really say anything well (expressive dysphasia) but can understand commands. Begin by asking her a general open question to assess her general speech, i.e. ‘how did you get here today?’ Ask her to say bread, butter, baby hippopotamus, she says Yes, Yes, Yes, then move on to commands which she complies with. Then ask her to say, ‘no ifs ands or buts’ (which tests the connection between brocas and wernickes areas). Can also ask her to say’ka ka ka, la la la, ma ma ma to assess pharynx, tongue and palatial involvement in speech. Finally do not forget to do a mini-mental test, the examiner should stop you half way as the patient cannot answer any questions properly. Examiner then asked what is wrong? Expressive dysphasia due to stroke. Where is pathology? Broca’s area, in frontal left lobe (usually).

• Neuro- Spastic paraparesis. I was asked about possible differentials. // Neuro - lower limb examination of man with "stiff legs" He had spastic paraparesis. Quite good upper motor neurone signs with pyramidal distribution of weakness. //Neuro was spinal cord lesion with bilat UMN signs in legs // Neuro: Pt had scissoring gait, increased tone, bilat brisk reflexes. I presented  findings and said these were consistent with 'spastic paraparesis'. I talked about finding a sensory level but the examiner only wanted me to perform motor exam. I summarised cause of spinal lesion: demyelination, vascular, mitotic change. Examiner said ' well that seems very comprehensive' . // NEURO- my worst station! had a lovely lady with bilateral upper motor neuro signs in her legs, but the power in the legs varied, and sensation was normal I think, I didn’t get to complete my examination so he just asked me what I would do, he then asked me to present my findings and I went blank and could not remember what I had found! he calmed down and asked me what pattern I had found, I said upper motor neuron lesion, he smiled and said hats all he wanted. he then asked where I thought the lesion was considering both legs were effected, I just said a lesion in the spine, he wanted to know where exactly...the bell went, I ran out!

• right sided hemiplegia - upper limb neuro // Neuro: upper limb examination: right sided weakness with UMNL signs...he asked what else wud u like to do.,. I said examine the leg to look for hemiplegia...indicating stroke..he asked where wud the lesion be...in the left lobe....then he said which one vessel wud u like to examine...carotid n listen for bruits....anything else you’d b interested in: ECG for AF or mitral stenosis embolic stroke, since she was bout 40yrs old. // Neuro: stroke, asked about what other systems I would exam...cranial nerves, cvs looking for risk factors, AF, Ix doppler of carotids, got asked about what gait I would expect the patient would have, I answered spastic, scissoring but examiner was after 'hemiplegic'.

• Neuro- man who had car crash, with multiple cranial nerve palsies. Right IIblind(causes relative afferent pupillary defect), right III (part ptosis), left VII. Couldn't finish all 12- included Rinne, Weber, acuity test etc. // CNS: Multiple cranial nerve lesions in a 16 year old girl.(not corellating to any random syndrome i.e. Cavernous Sinus/Jugular Foramen). Decreased visual field on left temporal, left VI nerve palsy, sensorineural hearing loss on left and fasciculation of the tongue. I concluded that it could be due to meningitis. // Neuro cranial nerves exam - loss of smell, blind in one eye, sensorineual deafness, facial nerve palsy - a great learning case!

• Neurological assessment of eyes, meningism, photophobia & headache, SAH & meningitis, obs chart (high BP & low pulse) - visual fields, eye movements, accommodation, Ex & signs - acuity & opthalmoscopy, Kernig's, DDx, Ix - CT/LP //  Hx and Ex of headache and eye pain???? no one knew what that was about!! Examination of eyes - presenting complaint: acute onset severe headache, problem with eyes, high blood pressure. (on the table nxt to pt was a 'sensory neuro' set ie. cotton wool, tuning fork etc..?! also hatpin, pen torch) - asked by examiner to proceed - pt was covering eyes with hands (photophobia) - basically went through eye examination ie. acuity (told not to worry about that as there was another station that tested this), fields, light responses, extraocular eye movements... - then asked for what else I might expect to find on examination with his presenting complaints eg meningism sign - asked to perform tests to elicit this (i did kernigs) - asked about my differential diagnosis: SAH and Meningitis - asked investigations i'd do, CT, LP, bloods - then asked to look at the Blood pressure again and whether this is what i expected if DDx was SAH, it was a high bp so i said yes! (is that right!?!) Overall comment: the examiner really helped me along on this one, she definitely wanted to see what I could do, not what i couldnt. This station had come up either last year or the year before. // Examination station. Patient presents with sudden onset of severe headache. Told not to take a Hx or do a full neuro exam, so i exmained the eye movements. accomodation, pupil reflexes, acuity and fundoscopy. I also tested for neck stiffness, and signs of meningism. asked to present findings and give a differential diagosis. Asked what condition i wanted to exclude and what investigations i would order and what i would find if it was SAH. examiner was happy with that // Actor covering his eyes and shouting out that his head was in a lot of pain!!! Supposed to do all the eye exams but basically you picked up say, an ophthalmoscope, and examiner said 'very good, move on' I also did Kernigs and made him move his neck around. Diagnosis subarachnoid haem and questions on it. // A women with symptoms of a sub arachnoid - 'examine her eyes'

• Neuro - glove and stocking sensory loss - DDx, hemiplegia, myotonic dystrophy // Peripheral neuropathy, very nice case!!! I was asked the differentials after I said peripheral neuropathy secondary to diabetes, I said I didn't know, then the examiner said B12...and then I realised he meant the differentials for the causes, I had a complete panic attack and said "I know these!!!!!!" and then literally machine gunned about 10 causes at the examiner who again smiled to himself. The examiner then asked me what I would prescribe if the patient had neuropathic pain. I said gabapentin and the examiner asked what would be my first line. I then said tricyclics which was apparently fine because the examiner didn't bother asking anymore

• Neuro - post-ear op, VII nerve palsy

• PNS – MS, MND, mixed UMN and LMN signs // Neuro – lower limbs motor. Middle aged gentleman with two walking sticks, wasting of calves, upgoing plantar on right, hyperreflexic on right. Reduced power bilaterally, more on right. Asked differentials and a diagnosis, I said motor neurone disease, to which the examiner asked, ‘what feature is NOT present which you would expect to be present in a patient with MND? I had no idea, examiner said ‘· fasciculation’. // Neuro- asked to perform an neuro exam of the lower limb. Still not sure what it was- mixed UMN and LMN on legs. Spasticity, Increased knee reflexes, decreased ankle reflexes and down going plantars! Normal sensation. She asked for my findings, then differential. She then asked if I thought it was UMN or LMN, I mentioned it was mixed signs. She asked me to pick one. I said UMN and then she asked no more questions!

• Upper limbs neuro and advice for sensory loss over axilliary area - The scenario for the short case was a young man who had been in a car accident with a whiplash injury, all X-rays had come back normal, but several days later he represents with some concerns. On questioning he says he has pins and needles in a patch over the outer upper aspect of his right arm. However on examination he has no pain, no stiffness of his neck and a neurological examination was entirely normal. He then asked for advise about whether he could return to work as a secretary. My flatmate took the osce at another site, the same scenario but a different actor who had mildly reduced power and sensory loss in a C6-8 distribution. She was asked what investigations she might do. 

• There were several stations where I found your advice to be flexible particularly useful- e.g. you are a doc in A&E and a patient presents 3 days post whiplash injury. instructions were not clear as to whether we should examine neuro of arms, locomotor of neck, history or explanation re return to job and physio etc. Obviously time allowing we would have liked to do all of these and most of us squeezed in as much as we could. // Management of whiplash - tingling in neck - examine neck and UL neuro, and reassure pt - examine c-spine, neck movements (and does it cause any tingling) - Tx, Mx, exercise, can i go back to work?

• Neuro - power loss in one leg and sensory loss below knees - struggled with putting the signs together. // The next patient again I was asked to "examine the legs". He had wasting, normal tone, 3/5 power, brisk reflexes and no co-ordination (due to decrease power) in the left leg and a normal right leg. he also had a glove and stocking peripheral neuropathy in both legs. I said he had a peripheral neuropathy and a LMN lesion, but didn't really know. I got asked about my differential for peripheral neuropathy.

• Neuro - common peroneal nerve and median nerve palsy 

• Neuro - patient with neurofibromatosis type 1, asked to examine her skin and then the ulnar nerve and her reflexes, other features? - neuro- neurofibromatosis- patient had many neurofibromas and cafe au lait spots.. asked about differential .. then a bit about the condition, when we would chose to operate.. wheere the neurofibromas can grow and what other problems it may cause....she also had a scar on her forearm which was over the ulnar nerve....then i had to show the examiner how to test for ulnar nerve palsy (thanks to your course i was able to do this well) also asked about hypertension and why these patients get it-

• Visual fields testing-homonymous hemianopia and questions about causes (Stroke, Cerebral tumour, trauma asked which most common) // Visual fields (given red and white pin - I only used the red but not sure) - bitemporal hemianopia but actor was unsure... // Neurology: Examine this patients visual fields. Patient had a bilateral left sided lower quadrantanopia. Asked about where lesion may be and causes. Right sided parietal lobe.

• neuro - i gave him 0/0 power in the limbs because he wouldnt move them when i asked him to... but forgot i had just assessed his gait which was relatively normal....!!

• Cranial nerves: unilateral LMN lesion

• Neuro - obvious diagnoses of myasthenia (bilat ptosis) examiner asked me what I wanted to do next, all the stuff was there for cranial nerves so I did them and discovered a field defect on the Right. A lot of other people said they wanted to examine her for fatiguability and the examiner just let them carry on making her wave her arms around, he gave no indication of which examination you were expected to perform. I found it very useful to ask the examiner at the beginning of each station whether they wanted me to talk through, most said that it was up to me. One consultant told me to remain quiet so that I couldn't prompt myself(?) another said "thank you for asking me what I'd prefer, all of your colleagues rabbit on dreadfully, it's tiresome". Mind you he was about a hundred and ten.

• neuro- cerebellar examination // Cerebellar syndrome secondary to phenytoin toxicity. In addition i performed sensory examination for peripheral neuropathy and examined for diplopia as these are also side effects. Note: scenario only tells you that patient has long standing epilepsy and now presents with a drunken gait please examine as appropriate. Examiner asked me to present findings, give him a Dx ( cerebellar syndrome secondary to phenytoin) // causes of a cerebellar syndrome.

• Oh god - neuro! Said 'do lower limb exam'. Young man had obvious upper motor neurone signs in both legs as even I could get all the reflexes (never normally happens!)But I completely panicked and forgot to make him stand and walk-aargh!! So had lots of time left and started doing sensory exam – loss of sensation in both legs. Diagnosis was obviously MS

• Neuro - this station was the worst station I have ever done in my life. We all felt it was incredibly unfair. We had to perform a cranial nerves examination on a really non-compliant patient. In the end she was so bad at following my instructions that I only managed to get to cranial nerve 5 in 7 minutes, although I think the examiner was aware of why this was because for students after me, he stopped them in their examination much earlier on and just grilled them instead because the patient was really not helpful. In the end she had a VP shunt running down her neck and frontal bossing, which although strictly speaking not part of a neuro exam, were how you were supposed to figure out that this patient has hydrocephalus. And then you had to answer questions on that. If the medschool have got half a brain, they will not use his patient again cos she is not compliant enough for exams.

• NEURO-bilateral weakness one side worse than the other, I thought it was · unilateral with a semi-circular gait, Qs- could it be and what is Brown Sequard?

• neuro, still don’t know what that was I was asked just to do sensory of lower limb patient said he felt everything so I didn’t find anything wrong. though I was asked to Romberg’s and patient was wobbly even though jps was normal so I don’t know! it wasn’t cerebellar either

• Neuro - man with diplopia which miraculously disappeared as I was examining him - he said I was a magical Dr and that I had healed him - a good thing to happen in an OSCE. Had to work out which eye muscle was faulty etc. 

• Neuro - evil station, 'this man has problems with his vision, please examine his cranial nerves'. I was made to perform fundoscopy, test his visual acuity (which was all normal) I got to CN 7 and the bell went, so had to present my findings of my half finished exam! I found his left eye was unable to abduct and he had nystagmus on all aspects of eye movements - so presented my findings. Gave some differentials as cavernous sinus thrombosis, false localising sign of raised intracranial pressure, mononeuritis multiplex from Diabetes and MS and was pressed for more and more diagnoses, which I was then blank! Asked about management - I suggested tests for DM and for MS, but the examiner wanted something else and kept pressing me...and asked 'if you could give his man one thing what would it be...' at which point the bell went and I went tot he next station - turns out the answer was an eye patch as we saw the patient coming out of the room at the end! // Neuro – HORRIBLE!! Missed the lateral rectus palsy and got thoroughly humiliated // Neuro - cranial nerves - 6th CN palsy. Causes, treatment, what to expect on fundoscopy // Neuro – cranial nerves – asked about course of 6th nerve. At that point she said I was doing well and not to worry as my mind went blank. Don’t think I ever knew that!

• Neuro- The worst station. Everything about it was dreadful. Were told the lady had problems swallowing and chewing and asked to examine her cranial nerves. I clarified with the examiner who told me to examine whichever ones I wanted, and so I started with 9-12 thinking I had an idea of what was wrong, only to not pick up any signs. I then for some reason decided to examine the rest of them but in a sporadic, unstructured manner, rather than starting at 1 and working through them. In my defence I think I did this as I was aware of the time constraints but it meant my examination looked unpractised and unstructured and I forgot things. On top of that, the lady had very obscure signs and no-one had a clue what was going on with her.

... and just for fun...

• Neuro lower limb (motor and sensory) (my patient fell asleep after 3 mins and kept snoring then)

Ultimate Finals List - Locomotor

Locomotor

• Gals and knee - nice, patient looked like he wanted to sleep. Pain in all his joints, lots of OA. Also had Pagets. I thought his legs looked Bowed, but didn’t mention it, had to have the examiner point it out later! Note, if you think something say it! He had big lumpy thing below his knee.. not sure if that’s an osteosarcoma. Questions on tests for Pagets, eg bloods what would be high and low and who and how and why to treat. Straightforward. // GALS on a patient who was actually half asleep. I forgot all my gals questions and half the examination but this doesn't seem to matter too much (!). I examined the knee after doing GALS because the man had a scar on his knee. The examiner then asked why the man had a scar on his knee. It was a knee replacement scar so I said so. He then asked why this patient might have had a knee replacement. I said osteoarthritis or rheumatoid. He then asked me if this patient had rheumatoid, I said no. He then asked what investigations I would do. After all the bloods etc etc, I got to bone scan and he asked apart from rheumatoid and osteoarthritis ...what else could show on a bone scan. I finally saw the light and said Paget’s. He also asked me look at the patient's legs again and pointed out (I quote) "there is subtle bowing of the tibia." He then asked me about blood tests for Pagets, I said alk phos, he asked what I would see. I said it was raised, and he asked me about calcium and phosphate which I said would both be normal. He then asked about the treatment of Pagets, I said bisphosphonates, although most patients are usually symptomatic. He nodded and said "yeess" so I think I made up for missing the diagnosis! He then made me answer questions about osteoarthritis and rheumatoid arthritis, about the investigations, and the treatment and the WHO analgesic ladder.

• Knee exam on med student pretending to have a gait disorder. Just examined and told to explain actions. I even had to do the Mcmurray test // Knee exam – football injury. Was medial collateral ligament. // examination - anterior cruciate ligament tear

• Please perform the GALS and the examine this lady’s hands. UNIlateral MCP subluxation, Z thumb, flexion deformity of the MCPs, Boutonniere’s – the works except the unilateral bit. Examiner didn’t know why either but rheumatoid was the answer. // GALS screen - rheumatoid hands and feet, DDx and Ix // details of DMARD side effects // asked about how long I thought the patient had had the condition, asked differentials and which other joint would be improtant to examine, then had to examine it, I picked the neck // Musculoskeletal- Do GALS and then examine hip of a young man with RA. He had one leg shorter than the other. // locomotor- I performed GALS. The patient said he had pain in his arms and could not dress himself. On inspection there was obvious subluxation at wrists and ulnar deviation at MCPs. I went on to perform Rheum hand exam. I gave the differentials of RA, Psoriatic arthropathy, SLE (had pt been young and female). Once I had presented the examiner asked me about the reasons for patient having leg and foot bandages. I didn’t have a clue but I said 'pt may have had operation to fix deformity caused by rheumatoid arthritis', or patient may have ulcers due to systemic effect of connective tissue disease. Not sure what examiner was getting at. // GALS + hands - RA - asked what else I would examine and I said "feet" and he made me do a foot exam!! // rheumatoid hands. good station but they hid a medic alert bracelet under the patients watch so only saw it if looking very closely

• Locomotor exam- "GALS of just the arm" plus hand exam. She had osteoarthritic changes- Heberden's nodes (forgot to call them this), Bouchard's nodes (forgot to call them this), no rheumatoid nodules, no vasculitic lesions, marked DIP involvement.

• GALS in a lady who could not lie on the bed due to pain, so slightly pointless. she had had a knee replacement, and the examiner just asked questions on that. // Mention would complete examination by examining neurovascular status of legs and examine joint above and below (hip and feet).

• GALS – Patient with scleroderma. She had a waddling gait and sclerodactyly. Scleroderma seems to be a common thing in exams. Might want to imprint that to students, so they dun get caught out (which i am sure a lot did) // MSK - scleroderma - only signs were painful joints and raynauds phenomenon - had to do GALS then examine the hands // GALS and MSS - did a GALS screen on a lady who had very limited signs! I thought she had limited internal rotation of her hips, so presented my GALS screen and said 'I would further like to formally examine this lady's hips'...to which the examiner suggested I examined her hands...oops! On examination her hands were near normal, with some slight redness and thickening of her skin from her PIPJ's distally. I was almost ready to present her a normal case (and was slightly panicking now!) but with 1 min to spare the examiner said 'if you want to ask her a few questions go ahead' - so I asked the lady if she had any pain or stiffness at any time of day, she replied 'not time of day, but time of year...Finally! I then asked the questions you suggested on your course 'do you notice they change colour at all? (yes..they did!) and she had some difficulty in swallowing too!) She had scleroderma (although really didn't have the typical facial features I've seen before! - then presented her case, discussed a little re scleroderma what investigations I would like etc etc.

• Locomotor - hip examination. right sided restricted movement due to pain, DDx, ?OA secondary to trauma, RA vs OA

• GALS screen, ank spond and psoriatic arthritis I think. // MSK - ank spond - did GALS then stood there looking at the woman for ages That station was run by a fairly.. shall i say..notorious rheum consultant. She wouldn’t let me talk to her till 7 mins was up (which is fair enough). The instructions were that this young man had a problem with his neck and I was to do a GALS screen and anything else necessary to make an assessment. So I did the GALS screen - he basically had severely limited ROM in the cervical, lumbar and thoracic spine and stiffness on internal and external rotation of the hips, otherwise all normal. Having done full inspection, palpation and movement of the spine i couldnt think of anything else to do. There was a box of neuro 'toys' - vibration, orange sticks, etc so i tested his sensation in broad terms and the power, but i was done within about 4 and half minutes. so i just waited. The questions were 'so tell me what you found' and she shook her head all the way through it, which was a little off putting. Then she said what was my main differential - so i said ank spond. and she asked for any other possibilities.. and I couldn’t think of anything else. so I said lupus (hahah) which is the answer to everything along with HIV, TB and idiopathic. then the bell went. // Asked me to present, asked differential, then extra articular manifestations of ank spond and lastly, the available treatment

• Orthopaedics - examine back and hip in 6 mins. Ank Spond, Hip Replacement (scar), OA of other hip.

• Knee examination - osteoarthritis // Knee examination (he then asked me to examine the neurovasculature of the foot) // GALS I had to a gals screen and then I focussed examination depending on what I found, this lady had a very bad knee, every time I touched her she would yelp. I did the best I could, the examiner was quite sympathetic, even when the time to examine was up, she gave me an extra minute to complete my examination, I presented, and said I thought she had osteoarthritis, she asked what else could she have, I wasn’t too sure what she was getting at, I said an atypical presentation of rheumatoid or septic arthritis although I would expected more redness, I think that’s what she wanted me to say, she then said considering what u found in her back what is the most likely diagnosis, I then realised I hadn’t tested flexion of the back in my gals screen but obviously thought I had, just goes to show, if you act confident they wont even realise that you've missed anything out! it was OA of back and knee

• A hip examination. The patient had undergone arthrodesis of the right hip and the left hip had severe osteoarthritis and almost no range of movement. He had scars EVERYWHERE from previous orthopeadic surgery. I don't know about the history of this patient but he had deep sinuses in his lower spine which looked like some kind of neural tube defect. V confusing. I’d never seen anything like it and it really distracted me. I’m sure they just wanted us to mention it and then focus on the hip but it was difficult not getting distracted. // He couldn't flex hip past 20 degrees so i was unable to test int and ext rotation in flexion so instead did it in extension. Quest- management of OA (worth having a spiel for that one i think- my friends and I prepared OA pretty well as it seems to come up most of the time).

• Musculoskeletal – I think I was just asked to examine the patient's joints so I did the GALS screen. The only abnormalities I found were bony swellings over the PIPs and DIPs and that the patient had had some knee pain in the past when I asked the 3 questions. When I reported this to the examiner and said that this would be consistent with a diagnosis of OA he said "What about his spine?" I had found forward flexion of the patient's spine to be normal during the GALS screen but the one movement I had forgotten to test in the GALS screen was lateral flexion of the spine! I remembered when the examiner prompted me, tested this and sure enough it was markedly reduced. The examiner then asked me to look at the patient's hands which were erythematous. He asked me what this could be and led me towards saying Raynaud's. I had trouble putting this all together but then the time was up.

• Patient had congenital kyphoscoliosis // Klingon syndrome or something similar?!!

• GALS - this was ridiculous. You were asked only to perform a gals screen. We all offered to examine another joint to help with the diagnosis, but the examiner wouldn't let us, so instead we all finished the station in 2 minutes and twiddled our thumbs for 5 minutes not knowing what to do until the examiner starting asking questions. None of us have any idea what was wrong with this patient. I am pretty sure she had scelrodactyly because when I offered this to the examiner, she seemed to think I was on the right tracks, but then she kept asking me what sclerodactlyly was called, even though I'd already told her. I said I thought it was scleroderma and she asked me for another diagnosis seeing as that was so rare.

• MSK: knee exam....again which was nice...massive swollen left knee on an elderly lady in pain! wasn’t sure but he told me its a tense effusion....then he waned to make sure that we know what to do when we see a swollen single joint!!! so septic arthritis 1st differential and aspirate with broad spectrum antibiotic n he was happy with that answer... then he said how to investigate: FBC, ESR., CRP (inflammatory markers) // Musc skeletal: Examination of a hot red swollen knee, too painful to do special tests asked about differentials, what is important to rule out, what I think it could be...I said pre patella bursa, Then asked about Ix

• do gals then examine the spine. patient had scoliosis had to give a differential and why I didn’t think this was ank spond.

... and for fun...

• GALS screen - my examiner knocked over the cubicle walls and spent about 5 mins rebuilding them! I just carried on blissfully, afterwards the examiner apologised and said that I had passed, which was nice!

Blood Transfusion

Order Blood

Patient ID
Name
DOB
Gender
HN

Background Info
Why?
What type?
How much?
Special requirements eg CMV -ve
Needed when?
Needed where?

Legal
Requesting doctor
Bleep
Signature

Sample
Confirm ID
Name
DOB
Gender
HN

Checks
Verbally confirm with patient
Confirms matches wristband 
Matches requesting form
Label tube
NO PRE-PRINTED LABELS on TUBE

Send sample to blood bank

Pre-transfusion Checks
Match ID on blood pack to any form of patient ID
Sign out blood

Check pack
Record patient obs before transfusion
Verbal check with patient
Check with wristband
Check with compatibility form
Check form with blood pack

Record
Why transfusion
Date and time
Sign pre-transfusion checks

Transfusing...
Blood
- within 4hrs from ridge
- within 30mins from out of fridge
- over 3-4hrs
- after platelets

Platelets
- ASAP
- over 30-40mins

Reactions
Symptoms?
Stop and get help
Obs
- Temp <1.5 degrees, slow transfusion and give paracetamol
- Mild urticaria - chlorphenamine 10mg IV and slow transfusion
- ABO incompatibility - stop, return to blood bank, IV fluids, urine output, furosemide if necess
- Severe allergy - stop, return, IV chlorphenamine 10mg, O2, salb nebs, adrenaline
- ?bact - blood cultures, BSp antibiotics

LA Vs GA, Closed Vs Open

The advantages of local anaesthetic are:
1. Quicker recovery time allowing for earlier discharge.
2. The local injection will act as pain relief over the hernia area for a period of time after the operation has finished
3. Less risks associated if you have any other concurrent illnesses eg:lungs or heart

The disadvantages of local:
1. The patient will be awake
2. The patiemt may flee pressure over that over during the operation
3. there is increased liklihood of local structure damage

Laparoscopic:
advantages are:
*less painful
*earlier discharge
*smaller incisional site

disadvantages are:
*more expensive
*risk of conversion to open
*always need a general anast
*unsuitable for some hernias

Open surgery
advantages are:
*can be done under local or general
*has been performed by more surgeons for a longer period of time
*suitable for alll types of hernias

disadvantages:
*longer hospital stay
*more painful post op

IV Drug Administration

WIPERNA

Wash hands

Hello____
My name is______
I'm a _____

Explain
I was wondering if I could give you some medication - would that be alright? I believe you have a cannula already in site, so we don't need to use an injection and we can use that.

Check name/nameband/prescription chart/allergies

Check infusion site
?redness
?swelling
?pain

Ex/Nm/Nb/Pc/All/Cann

Equipment
Clean tray
2 sterile needles
2 alco swabs
2 syringes

Saline
Drug
Dilutent - sterile water

Sharps bin

& Assemble

Reconstitute
Check prescription chart with drug name, dose, strength, volume, route, time, date, signature - if not signed, not legal to give - therefore find doctor who prescribed it

Check with leaflet or trust drug administration policy

Check name, strength, volume of drug

Check expiry dates x3 - saline/dilutent/drug

Double check with another person

Pc/Lt/Dg/ExpD/x2P

Reconstitute according to guidelines

What you want / Got x What's it in

Wash hands

Glove

Needle + syringe

Flip cap off ampoule

Wipe wth alc swab

Aspirate sterile water

Inject into ampoule

Agitate

Draw up drug

Draw up flush

Distinguish CAREFULLY

WH/Gl/N&S/FpCp/Wp/SW/Amp/Agit/Flh/Dist

Patient

Recheck name, nameband, prescription chart, allergies

Wash hands

Change gloves

Remove port cap

CLEAN BUNG with alco swab and allow to dry

Flush with 5ml saline

?resistence, pain, swelling, leakage around cannula, back flow of blood on aspiration

Inject drug - over recommended time

1ml

Feeling ok? Watch for adverse effects - flushing, resp difficulties, tachycardia

... if occurs...

Stop injection

W/D back into syringe

Get help

Stay with patient

... if added to IV infusion

Fill in additive label and stick onto bag

Date/Time/Drug/Signature

Finish flush

Replace bung/cap

Rc-N/Nb/Pc/All
WH/Gl/Bg/CB/Fs/Dg/AE/Fs/Bg

Thank you

Tidy away

Wash hands
Complete prescription chart and fluid chart - sign

Inform nurse if delayed reaction

Venepuncture

WIPERNA

Hello ______
My name is_______
How are you?

Explain
I was wondering if I could take some blood from you, just so we can do some tests on it, and hopefully help with your care. Have you had this done before? It's not painful, but you will feel a sharp scratch - but I'll warn you, and let you know when it's all over. You don't have to look. Are you okay with needles? Any questions?

Check nameband
I'm just going to get the equipment

Prepare Equipment
Clean tray inside and outside

Tourniquet
Alco swab
Needle
Vacutainer
Blood Bottles
Gauze/cotton wool
Plaster

Wash hands
Assemble equipment
 - attach needle to vacutainer

Prepare Patient
Pt comfortable
Arm exposed from elbow
Lying next to them

Wrap tourniquet
Select vein
Alco swab skin

Cm/Ex/Re/Tq/V/Alc

Gloves
Stabilise vein
Sharp scratch!
Angle - 45 degrees
Reduce angle

Swap hands if necess
Grab bottles

Collect blood
Fill bottle
Remove bottle

Removes tourniquet
Remove needle
Flip back top if attached vacutainer
Sharps bin

Gl/SV/SS!/45/Bt/xTq/xN/Shp

Pressure
Plaster
Invert bottles

Pr/Pl/IB

Thank you
Are you okay?

Label bottles

Suturing

WIPERNA

Hello, I'm________
I'm a_________
How are you?

Explain
Okay, I understand you had an accident. It seems that you'll need a few stitches for your wound, just to help it heal properly, and reduce scar formation, hopefully. This involves using a small needle and special thread, and we'll use LA to help ensure that you're not in pain. Does that sound okay? You're happy for us to go ahead? Are you alright with needles?


I'll just get my equipment.

... Wash hands...
Equipment
Sterile gloves

Lignocaine 1% LA (max 3mg/kg)
Syringe
Green needle

Orange needle

Sterile water/Saline
Gauze
Syringe
Suture pack
-tray
-needle holder
-scissors
-curved scissors
-toothed forceps (skin only)
-non-toothed forceps (needle only)
Suture Needle

Sharps box

Prepare Equipment
Wash hands

Open suture pack with sterile technique

Drop pair of gloves, syringes, sutures and needles into field

Put antiseptic solution into bowl

Sterile gloves on

WH/SF/SW/Gl

Prepare Patient
Questions - tetanus, allergy, LA ?
Inspect wound for debris/dirt - clean and debride if present
X-ray - potential of foreign body
Cleanse/irrigate wound and surrounding skin

0.9% saline soaked gauze/in syringe or with chlorhexidine/betadine (high risk contamination)

Swab held with forceps/hand

Centre outwards

Postion pt so they're comfortable

Cover wound with drape with hole in it - sterile field

Q/Insp/Clean/SF

Anaesthetic
Select syringe and attach the 21G green needle
Draw up 10ml of 1% lignocaine
Dispose of green needle
Attach orange needle

Inject LA into skin encompassing wound approx 0.5-1cm from its edge
Aspirate needle on inserting to ensure a vessel has not been entered
Fan shape around wound

Wait 5-10mins for anaesthetic to work - test area
Ask pts after signs of LA toxicity eg tingling in mouth, metallic taste, dizziness or light headaches, ringing in ears or difficulty in focusing eyes

Max lignocaine = 3mg/kg
Lasts approx 30 mins

Lg/Fan/Wt

Suturing
Mount needle
Grasp curved needle with needle holder (short. blunt forceps with straight jaw)
Hold needle 2/3 along shaft from tip
Perpendicular to needle holder
Hold needle holder with thumb and ring finger, with index to stabilise

Pass through skin about 0.5cm wound edge at middle of wound
Use forceps to pick up skin (toothed) - above hand
Pass N perpendicularly
Full thickness through skin to the base of the wound - xbacteria
Pull suture threat through hole, leaving 2-3cm tail behind
Pass N through opposite skin edge using forceps to hold the skin
Not too tight or loose
Make sure exit hole opposute insertion hole, and 0.5cm from edge
Put needle in sterile tray

Tie knot
- double throw
- needle holder parallel to wound
- wind two loops of long end of suture in a clockwise motion around the needle holder
- needle holder to 12 o'clock
- pull short end of stitch through the loops using the mouth of the needle holder
down to 6 o'clock
- pull knot gently down to the skin, opposing the two sides of wound at the same time

- tighten so skin edges are apposed but without tension

2nd throw - single

3rd throw - single
- single throws in opposite direction
Suture material can then be cut to complete the stitch
- 1cm
- ensure the knots created are everted and spaced 5-10mm apart
- knots on same size
- good opposition - no pie crust or puckering

Halves
- offer to place the next suture (rule of halves) half-way between the present suture and the distal, medial end of the wound. Repeat until the wound closed

Mount/SgKn/Hvs

Tidy Up
Dressing
- dry dressing
- Tetanus immunity if wound contaminated / pt has not had booster in last 10years

Document
- detail of sutures
- polypropelene

Dispose of waste
inform pt that sutures can be removed in 10days

Tell the patient to attend GP
- if any worries (red, oozing wound, stitches come out etc)
- and to in about 7-10 days time for stitches removal./or come back to A&E

Dr/Tt/Doc/Disp/GP

Thank you
Any questions?

Sutures
- scalp
3/0, non absorbable
7 days

- trunk
3/0, non absorbable
10 days

- limbs
4/0, non absorbable
10 days

- hands
5/0, non absorbable
10days

- face
6/0 non absobable
3-5days

Deep wounds
Absorbable eg monocryl, vicryl, dexon
Superficial wounds
Monofilament non-absprbable
eg Nylon (Ethilon) or Prolene

Male Catheterisation

WIPERNA

Hello________
My name is_______________
I'm a doctor
How are you feeling?

I was wondering whether I could catheterise you? Do you know what a catheter is?
We insert a small plastic tube to reach your bladder through your penis, so we can collect the urine into a bag. It helps us monitor how you are doing, and means you won't have to get up to go to the loo. We'll use local anaesthetic so it won't be painful, but it might be uncomfortable at first. Any concerns? Okay - so you're happy with us to go ahead?


I'll just go get my equipment ready

Equipment
Catheter pack
Foley catheter 16/18 - smallest cath poss

Catheter bag

Trolley
Sterile gloves x2
Lignocaine gel 2%
Sterile water/saline
Syringe x2
Bin

Prepare Trolley
Wash hands - 7 stage
Put on apron
Clean trolley - top & bottom
Open cath pack and slide onto trolley, preparing sterile field

Place equipment into sterile field

Attach yellow disposable bag onto side of trolley/move bin nearby

Pour sterile water into small bowl with swabs

Fill syringe with 10mls and place outside sterile field if not already within pack

Put on sterile gloves

Put on disposable gloves

WH/Ap/CT/CP/SF/SW/GL/GL

Prepare Patient
Expose + reposition
Make hole in drape and place onto pt - 2nd sterile field
Wrap gauze around shaft and keep in sling, with left hand raised
Retract foreskin
Clean penis - holding swabs in right hand/with forceps and wipe out from meatus x2
Dispose
Warn anaesthetic
Insert LA (lignocaine 2%) - squeeze 5ml into urethra
Hold for 3-5mins to give time for the anesthetic to work
Discard top gloves

E+R/SF/SL/FSK/x2Cl/LA/Wait/xGl

Catheter
Place receiver dish inbetween legs/attach catheter to bag
Open catheter
Insert catheter into urethra - ANTT
 - touch plastic only
 - massage out and into urethra
 - if necess when negotiating prostate, lower penis
 - if resistance ask pt to breathe deeply
 - move till bifurcation
 - by now urine should start emptying into plastic/kidney dish
Inflate balloon - 1ml of sterile water
Any pain?
Continue to fill with remaining 9ml
Withdraw catheter to make sure balloon becomes lodged into neck of bladder
Attach catheter bag if not yet attached

Dish/Cath/Ball/WD/Bag

Finishing Off
Restore foreskin/ask pt to (avoid paraphimosis)
Thank pt

Cover them up

Throw away remaining waste

Document:
A) date & time
B) size and type of catheter
C) amount of water in balloon
D) ?problems

E) residual volume of urine intially collected

Tests - dipstick & MSU
10ml from sampling port

Fsk!!/TY/Cov/Cl/DocRV/Ix

Making Errors

Digoxin Side Effect 
Excessive/ppt by hypokalaemia: anorexia, nausea, vomiting, diarrhoea, abdominal pain, visual disturbances, headache, fatigue, drowsiness, confusion, dizziness, delirium, hallucinations, depression, arrhythmias, heart block
Tx: Potassium-sparing diuretics, potassium supplements, digoxin-specific antibody fragments

Mx: blood levels, cardiac monitoring

Methotrexate 

Toxicity: anorexia, diarrhoea, toxic megacolon, hepatotoxicity, pulmonary oedema, dizziness, blood disorders (sore throat, bruising, mouth ulcers), liver toxicity (nausea, vomiting, abdominal discomfort, dark urine), respiratory effects (shortness of breath)

Mx: FBCs, LFTs, Obs

Insulin 
OD: hypoglycaemia

Tx: 50% dextrose, IM glucagon, sugary drink

Mx: Blood glucose

Warfarin 
OD: haemorrhage

Mx: INR, withhold warfarin, Vitamin K

Penicillin Allergy 
Anaphylactic Reaction: urticaria, angiooedemam, fever, inflammation

Mx: Stop antibiotic, adrenaline, chlorphenamine, steroids, fluid

Communications:
- Apologise 

- ?Admit responsibility- Explain carefully what has happened
- Short-term effects
- Long-term effects
- "This shouldn't have happened and we will do everything we can to make sure it does not happen again
- There are many checks and balances"- Notify senior
- Will make an inquiry/Fill in incident form
- Direct to PALS (Patient Advice and Liaison Services)

- Independent Complaints Advocacy Service (ICAS)
- Complaints can be made to Trust Complaints Manager 

- Can talk to consultant

- Write to ward manager
- Give name and bleep number

Alzheimer's Counselling

Alzheimer’s

Normal

-          lose memory, brain cells, difficult to retain information

Alzheimer’s

-          more pronounced

-          changes in brain structure (plaques, tangles, loss of mass) and reduced chemicals involved in transmission of signals

How?

-          familial (early position)

-          basically unknown

Does it get better?

-          progressive

-          starts with forgetfulness/wandering

-          problems with cooking, cleaning, dressing

-          speech

-          difficulty recognising people

Tx

-          no cure

-          just slow progression of disease, reduce anxiety and memory loss

-          Donepezil, rivastigmine, galantamine (Ach-esterase inhibitors)

Side Effects (resolve within few weeks)

-          sleep disturbance

-          nausea

-          loss of appetite

-          diarrhoea

-          muscle cramps

ECG before & regular review

Support

-          community nurses

-          home carer

-          social worker

-          occupational therapist

-          respite care

-          Day Hospital – group Tx

-          Alzheimer’s society

-          Dementia Relief Trust

Steroid Counselling

Hello_____
My name is ________
I'm a __________

Find The Problem
I understand that you've been recently been put on steroids. How do you feel about that? What do you know about steroids? You understand what it is for? Do you have any understanding of the side effects?

Information

Steroids are naturally produced in the body and help reduce inflammation and swelling. Steroids are often used synthetically to help with health problems characterised by inflammation. They are very different from the kind that you hear about in the news that athletes take - those are known as anabolic steroids and act differently on the body.

However, steroids aren't used unless they have to as they have these side effects, but these usually only occur after prolonged use and with higher doses, and we monitor carefully to see if any of these occur.

These include:
Infection - immunosuppression
Higher blood pressure - monitored regularly
DM - can happen go to GP if feeling tired/going to the toilet more
Osteoporosis - thinning of bones - supplements of Ca and Vit D/bisphosphonates/HRT
WG - fullness of face
Increase in appetite
Skin thinning - bruising
Mood change - irritable/depressed
Dyspepsia - indigestion/stomach upsets

General Advice
Blue steroid card - keep with and inform doctors so they can prescribe safely for you. You can also wear a bracelet to let paramedics know.

You musn't stop suddenly as while you take this medication the body produces less of its own steroids, adn stopping suddenly can cause your body to react badly - for example causing confusion, abdomoinal pain, and can require you to go to hospital.

Avoid smoking/drinking
Avoid ibuprofen
as they can increase the likelihood of indigestion

PMHx
Do you suffer from epilepsy/osteoporosis/diabetes/hypotension/excessive bleeding/tuberculous/chicken pox/stomach ulcers?

DHx
Do you take NSAIDs/any other medication?
Allergies?

SHx
Smoke/Drink

Is that all clear? How do you feel about that? We can arrange a follow-upappontment with GP if you have any further questions you want to ask. What have you taken away from this?

I can give you some leaflets. Steroid cards also carry a lot of info, so don't worry if you forget.

Peak Flow

WIPER

Hi, my name is _______, I'm a doctor here. It's very nice to meet you.

Find the Problem
I understand you have symptoms that might suggest asthma. In order to rule help us to rule in or rule out the diagnosis we do a test called the Peak Flow test. Have you had this test before? Are you happy with your understanding of asthma? Are you happy with doing this test?

This is a peak flow meter. It's just a simple tube that measures how well the air flows out of your lungs, and whether you have any difficulty pushing it out. If you have asthma this shows as being less than normal for a person of your height, sex and age.

Demonstrate
I'll show you how to use it, to help you understand how to do it.
First we reset the pointer to make sure that it's one zero.
We stand up for the test. We put a fresh mouthpiece into the meter.
Breathe in fully deeply, as much as you can. Hold the meter level in front of you making sure your fingers don't cover over the pointer. Make a tight seal with your mouth on the mouthpiece. Blow as hard as you can and as fast as you can, like blowing out the candles on a cake. We're not concerned about how long or how much you blow out. Okay? Like so.

We'll do the test 3 times, and take the highest reading as your score.

General Advice

We record like thus and if we record it in a diary we can keep of track of how your breathing is throughout the day. Asthma tends to vary quite characteristically through the day, and can help us make a diagnosis and see how you are doing on medication.

The best time to take a peak flow are first thing in the morning, and before you go to bed. Also take it when you are experiencing symptoms such as coughing or wheezing.

Repeat Relevant Parts

Would you like to have a go?

ICE
Do you have any questions, concerns or expectations?

We'll need to follow-up to see how you've coped with the medication and if your symptoms have improved.


What factors affect PEFR?
- height
- age
- sex
- acute and chronic resp disease
- smoking

Using Inhalers

Hi, my name is______
I'm a final year student.
How are you today?

Find the Problem
Okay, from your symptoms and peak flow recording we believe you might have asthma. What do you know about asthma? How do you feel about it?

Asthma is a condition of the lung where you can get difficulty breathing. We find sensitive airways, that react by narrowing when they become irritated, making it difficult for air to move in or out. It's this narrowing that causes the chest tightness and wheezing that you've been experienced.

We can do something to help with these symptoms. To help with this condition we can prescribe you salbutamol, which is given in a blue inhaler. It works by opening up the airways so air can move more freely. By being given in an inhaler we can deliver the medicine exactly where it needs to be. Is that okay?

What do you know about inhalers? Have you ever used one before?

Demonstrate
Okay, I'm going to show you how to use the inhaler, because technique is very important in ensuring you get the most out of it and to help your lungs as much as possible. Use it when you art feeling wheezy or tightness of the chest.
First we shake the inhaler with the cap on to mix the medicine properly. We remove the cap from the mouthpiece and hold the inhaler like so, between your thumb and index finger, with your index finger on the canister.
Take a big breath in and fully breathe out. Put the mouthpiece in your mouth. At the same time as you breath in push down on the top of the inhaler. Hold your breath for ten seconds afterwards.

Repeat if necessary after 1 minutes.
Gargle/rinse out your mouth if you are using a steroid inhaler.

Mild side-effects of salbutamol include fast heart rate, shakiness and headaches. If they are worrying you should again come back to us.
Salbutamol can be taken 2 puffs as needed, up to 4 times a day, as the maximum. If you need more than that you should return to us, as we might need to try something else, perhaps combining it with another inhaler.

Does that sound okay to you?

Repeat Relevant Parts
Can you show me know how you would use it?
Can you tell me when should you use it?

General Advice
There may be some leaflets I can give you to help your understanding, and to take home with you.

ICE
Do you have any questions, ideas, concerns, expectations?

We'll review you in a while to see how you are doing with it, and if your symptoms have improved.
Does that sound okay?

Thank you!

Using A Spacer

Hello, my name is....
I'm one of the doctors here.
How are you feeling today?

Find the problem
I understand that you've been having some problems in using an inhaler - tell me a bit about that.
How are your symptoms? You understand that it's important to use - for your asthma? Can you show me you trying to use it?

It's really important that you're able to take your inhaler if you need it but I can see that you're having problems with it. This isn't an uncommon issue for people, it can be fiddly, so there is a device we can use to help you called a spacer. The spacer makes it easier to deliver the medicine to your lungs.

Demonstrate
I'll demonstrate what to do...

The spacer is made up of two parts which slot together easily.

On one end you can attach the inhaler, and on the other side you have the mouthpiece
Shake your inhaler well and attach it to the far end
Release 1 puff into the spacer
Don't worry the medicine stays inside
Make tight with your mouth on the mouthpiece
Breathe deeply in and hold for 10s
Breathe out slowly all the while keeping your mouth attached

Wait 30s before next dose
Do this for three or four times
This should be enough to get the medicine into your lungs

Repeat Relevant Parts
Can you show me how you would use this?

General Advice
In caring for the spacer wash it once a week warm water, and leave it to drip dry
Don't use any detergents as this can cause static inside the spacer, which makes it less effective
Store the device in its box in a cool area to prevent scratches
We should relace the device every 6-12months of use to make sure you have optimum delivery of the drugs

ICE
How does that sound?
Do you have any ideas? concerns? expectations?

We'll follow you up to see how you're doing

Thank you!

Cannulation

WIPERNA

Hello my name is _______
I'm a __________
How are you doing?

Is it alright if I put a cannula in your arm? Have you ever had one before?
It's a small plastic sterile tube that we insert into a vein, that acts like a port, that we leave there.
We use it to transport the fluids through.it's not painful, but you probably feel a small scratch. Do you have a problem with needles? Are you fine with me to go ahead?

Checks:
Nameband/dob/name/hospital number

I'm just going to get my equipment.

Equipment
Tray

Gloves

Tourniquet

Alco swab

Cannula (16G grey - 18G green - 20G pink)

10ml syringe

Saline 0.9%
Green needle

Bung
Tegiderm
Sharps bin

Prepare Equipment
Clean tray inside & out
Wash hands
Open cannula
Open bung
Draw up saline

CT/WH/Eq/Flu

Prepare Patient
Roll up sleeve
Pt comfortable?
Tourniquet (clench fist - promote venous filling)
Select vein and direction (distal to proximal)
Clean area with swab

Put on gloves/alcohol gel gloves/change gloves

Tq/V/Alc/W+G

Cannula Bit
Stabilise vein
'sharp scratch'!!!
Cannula - shallow angle 25-35
Flashback?
Lower cannula
Advance by 2mm
Withdraw needle slightly watch blood track along cannula
Advance plastic sheathing
Take off tourniquet
Press over vein above cannula
Remove needle
Bung over cannula

SS!/25-35/FBl/AdvPl/xTq/OutN/Bung/Flush

Secure
Needle into sharps bin
Apply tegiderm over cannula
Flush!

Sec/Sharps/Saline

Finishing Off
Thank pt, make sure they're comfortable

Document:
Cannula gauge
Location
Operator
Site

Dispose waste

Resite immed if signs of inf/phlebitis
Otherwise ev. 72hrs

T/Doc/Disp/Resite

MSK Cases

X-ray

Normal

OA
- narrow joint space
- subchondral sclerosis
- subchondral cysts
- osteophytes

RA
- soft-tissue swelling
- ill-defined marginal erosions
- loss of joint space
- periarticular osteoporosis

Gout
- assymetrical soft tissue swelling
- well-defined periarticular erosions
- bony 'hooks'

MSK Investigations

Ix

Bloods
ESR
CRP
Serum uric
Autoantibodies
Blood cultures

Synovial Fluid Aspirate

Imaging
XR
MRI
CT
Bone Scans
DEXA

Spine Examination - Revision Card

WIPER

... Standing...
Look
Sides, behind - asymmetry, wasting, scoliosis, lordosis, kyphosis

Feel
Spinal processes
Paraspinal muscles

Move
Lumbar
- Flexion - fingers in spinous processes
- Extension
- Lateral flexion - arm down sides
Cervical
- Flexion, extension, lateral flexion, rotation

... Sit on couch, arms crossed...
Thoracic
- rotation

... Lying on couch...
Straight leg raise
Dorsiflexion of foot, and big toe
Limb reflexes

Knee Examination - Revision Card

WIPER

... Standing...
Gait

Look
Valgus/varus deformity
Popliteal swellings

... Couch...
Look
Varus/valgus deformity
Muscle wasting
Scars/Swellings/Erythema/Rash
Side - fixed flexion deformity

Feel
Skin temperature
Patellar tap and crossfluctuation (bulge sign)
Knee slightly flexed - joint line and borders of patella, femoral condyles, tibial tuberosity
Popliteal fossa

Move
Flexion and extension - active & passive
With crepitus
Posterior sag (PCL)
Medial and lateral collateral - 15 degrees
Anterior draw test (ACL)

Hip Examination - Revision Card

WIPER

....Standing....

Move

Assess gait - antalgic/Trendelburg

Trendelenberg test

Look
Gluteal muscle bulk

...Couch...
Look
Fixed Flexion deformity
Leg length
- ALL - xiphisternum - MM
- TLL - ASIS - MM
Scars

Feel
Greater trochanter for tenderness

Move
Flexion - knee flexed
Internal rotation
External rotation
Thomas' test - FFD - loss of pelvic tilt

Shoulder Examination - Revision Card

WIPER

Look
Shoulders - front, side, behind
- symmetry, posture, wasting scars

Feel
Temperature
Palpate bony landmarks - SCJ, ACJ, Acromion process, scapula
Joint lines
Surrounding muscles - supraspinatus, infraspinatus, deltoid muscles

Move
Hands behind head (ext rotation)
Hands behind back (int rotation)
Elbow flexed at 90 degrees
- external rotation
Raise arm
- flexion
Hand behind
- extension
Abduct
- 10 to 120 degrees
- passive
Push against wall
- scapular movement

Function
Hands behind head and back

REMS - General Principle

WIPER

Look
Scars
Swellings
Rashes
Muscle wasting

Feel
Temprature
Swellings
Tenderness

Move
Full range of movement - active and passive
Restriction - mild/moderate/severe

Function

Elbow Examination - Revision Card

WIPER

Look
Scars
Swellings
Rashes

Feel (at 90 degrees)
Skin Temperature
Head of radius
Joint line
Medial & lateral epicondyles

Move
Full flexion & extension - compare
Pronation & supination
Crepitus
Function - hand to mouth or nose

Hand Examination - Revision Card

WIPER

Look
Inspect dorsum of hands for muscle wasting, skin and nail changes/swelling
Can you turn your hands over for me?
Check wrist for carpal tunnel release
Put hands on shoulders? - check elbows

Okay - you can put them back on the pillow

Feel
Skin
- Temperature
- Presence of nodules/plaques at elbows
- Tendon thickening

Joints/Bone
Pain in your hands?
- Squeeze MCPs
- Bimanually palpate swollen/painful joints, incluiding wrist

Nerves
- Radial Nerve - pulse, first web-space
Turn your hands over?
- Median Nerve - thenar eminence bulk, lateral index finger sensation
- Ulnar Nerve - hypothenar eminence bulk, medial aspect of medial fingers
*tendon thickening

Move
Wrist flexion and extension (prayer and inverse prayer sign)
Thumb opposition/abduction
Full finger extension and full finger tuck (extensor tendon ramage, joint damae, neuro damage
Finger adduction/abduction

Function
- grip power 
- pincer grip
- pick up small object

Carpel Tunnel Syndrome?
Tinel's Test
Phalen's Test (60s)
Old Synovitis
Thick, rubbery, non-tender
Active synovitis
Thick, rubbery, effusion, warm, swollen, tender

Confirming a Death

Before approaching the patient...
I would ask the nurse for a brief history of the background to the death - find out who discovered him/witnessed it
I am checking that full attempts at reversal of any contributing factors have been made
I would also confirm that the patient was not for resuscitation
I would also like to read the patient's medical notes and drug chart and recent diagnosis and past medical history

At the patient's side...
Draw the curtain around the model to ensure privacy
I am confirming the patient's identity by checking the wristband with the name and hospital number
I am exposing the patient adequately, and inspecting
I am looking to see if there is any increased muscle tone (rigor mortis)
I am commenting on the absence of respiratory movements
I am looking at the colour and lack of physical movement

Response...
I am seeing whether the patient is responsive to pain eg trapezius squeeze, sternal rub, pressure on orbits

Eyes...
I am inspecting the eyes with a pen torch to see if the pupils are fixed and dilated
Checking for a light response, direct and consensual reflex and noting their absence
I am inspecting the fundi with an ophthalmoscope to see if there is segmentation of the retinal blood columns (only present in 30%),  also looking for tracking/rail roading of the retinal veins

Pulses...
I am  palpaing the major pulses - confirm that no pulses can be palpated - check on both sides for a minute
I am palpating the carotid pulse on either side
I am palpating both femoral pulses on either side

Precordium...
Look for pacemaker scar
I am auscultating the praecordium for heart sounds for 1 minute, and commenting on their absence.
I am auscultating the chest for any breath sounds for 3 minutes,  and commenting on their absence.

Finishing Off...
I am washing my hands
I am documenting in the notes my findings, and the date and time of death
e.g.
Pupils fixed and dilated
No spont resp effort
No response to deep stimuli
Absent heart and breath sounds for 3mins
Time of death: 0000
Date of death 12/12/12

NOTE pt has pacemaker - therefore cannot cremate

Plan

a) fill out death certificate/contact coroner

b) contact family

c) arrange for patient to be moved to morgue

d) contact GP

Signature and date
Printing it with designation and bleep number
I am asking the nurses to contact the deceased's next of kin

NB!!

Conditions that can mimic death
- hypothermia
- hypoglycaemia
- alcohol/drug overdose
- adrenaline use at cardiac arrest can cause dilated pupils
- rigor mortis does not appear until 3hrs after death