- Fluid balance – standard every year station. Mention looking around bed for drugs, drips, lines, catheters in situ, cannulae, central lines. Then feel peripheries (?warm), cap refill (examiner asked for normal time <2s), check pulse. There is a blood pressure cuff, he asks you to measure the BP, so do it fast, other students spent ages fiddling with the cuff and wasted time, the examiner will not let you proceed until you get the BP. Then check JVP, examiner asks for normal height (=2cm). Then assess skin turgor, auscultate heart and lungs especially lung bases for crackles (?pulmonary oedema), check for sacral and ankle oedema // I asked if patient had had a fever, recent surgry, diarrhoea or vomitting // How to do a lying and standing BP and the time interval between measuring both. // Examiner then wants to know what else, so mention all of your charts:
- obs chart (temperature, BP, O2 sats, pulse, RR).
- Urine output chart.
- Drug chart – is patient on any diuretics?
- Further Ix i.e. U&Es, FBC, central line monitoring
- Spacer - Explain spacer and demonstrate its use with a MDT. Woman was on bd inhaler of salbutamol, I don’t know why it wasn’t prn. I started discussing this before the bell went. Asked about why should use a spacer, had to assemble and demonstrate technique. Should have been a very straightforward station. Actress was very pleasant and trying to help. // Inhaler with spacer – advise newly diagnosed asthmatic woman on how to use it. Assemble it in front of her and tell her to rinse it with warm water and leave to dry without drying manually. Replace spacers every 6 months or so for optimum delivery of drugs. I offered to explain other things like side effects of salbutamol, but she stated that she already knew these things and only wanted to know about the spacer device and its advantages over using only an inhaler.// make sure you check his actual technique with the spacer and inhaler provided!
- Certifying death. Nurse bleeps you, says thinks pt has died, you come on over and do your thing. Look at the notes, signs of death (look, listen, pupils etc). // Told patient died expectantly. Had to demonstrate what would do on a very dead plastic dummy! eg. Test pain, check pupils, listen to heart sounds and lung sounds. Then had to document appropriate things in the notes. the examiner asked if there was anything else I’d like to write that I missed things out. Hmm, maybe I forgot to write down about pacemakers? // do the basics: check for pain, shine light in eyes to check pupils r dilated...no response to pain..no breath sounds...no heart sounds...apnoeic....CHECK for PACEMAKER!!! then write ur finding in notes... // Write the date and time etc and who is doing the ward round, then mention findings and I also wrote a management plan, which included: a) fill out death certificate, b) contact family, c) arrange for patient to be moved to morgue etc
- Bladder catheterisation - No one expected this to come up as we all thought UCL would be too stingy to provide catheters for everyone! We were right about them being stingy - the catheters were reused. This was to test our comm skills and catheterisation, there was a guy sitting on a bed with a plastic penis between his legs - hilarious
- Insert cannula
- Suturing - double station. Was my last station, by which time I was a blithering idiot and managed to take 3 minutes to discuss a sterile field! The examiner kept asking me what I needed to do to clean the wound, and I just said sterile water and lignocaine 5 times till he pointed at the green sheet and I got the message! The girl pretending to be drunk saw I was a wreck and didn’t even chat to me, which I think they were meant to do to put you off. I did my stitches competently enough. Chuck sharps! Questions on advice to patient re wound care and max dose of lignocaine. // suturing...10 min station!!! u had to suture wound of an alcoholic n I had this annoying patient who was acting drunk and completely overacting and trying to disturb me...which was the whole point of the station since it was a mixed communication skills station // she kept asking things like do u love ur job??? r u happy being a doc???? and she wouldn’t be quiet...so after about 6 minutes I thought lets put her out of her misery and I replied " yes I love myself, and I love my job and my university is the best university in the world. being a doctor is the best job in the world and I wouldn’t trade it for anything" and hooray I made the examiner smile! // apparently on the second day they asked people what kind of dressing they would use // Remember your lignocaine dose, 3mg/kg maximum, I was asked this. Also remember to arrange a safety et, tell the patient to attend GP if any worries (red, oozing wound, stitches come out etc) and to attend GP in about 7-10 days time for stitches removal. // Consent, check wound, tetanus, allergy, LA etc then x3 // I think marks may have been given for attempting to make small talk. Also patient had fear of needles so had to give counselling prior. // Examiner was nice enough but a bit annoying as kept saying ‘pretend I’m not here’ and then proceeded to talk to me or to keep telling me to ‘pretend’ he wasn’t there.
- Written station (true/false mcqs), fluid balance chart, massive haematemesis
- Venepuncture
- IV drugs administration (2 stations)- one to prepare the drugs and the second one to adminster it. Have to talk through what one would look for in the drug information leaflet and drug chart // Look at drugs chart for pt with severe asthma – need to give IV Hydrocortisone 100mg Look at drug chart- cherk allergies, correct drug, dose, route, time,date, not yet given and that it has been signed for (IT WASN’T SIGNED) // explain how u calculate drug dose- look @ sheet to see how slow to give as IV - glove up and go to next station to give the drug Give the drug having checked pt name, dob etc ad that no signs inflammation- flush, give according to sheet, flush and discuss re what would do if anaphylaxis
- Filling in crossmatch form, checks before administering blood - asked what ANTT stood for and no one could work it out!! Aseptic Non-Touch Technique!! What you would do if you dropped a syringe before taking blood // most of the marks for this section seemed to be concerned with triplechecking the identity of the patient and filling in forms and blood bottle labels to send correct bloods off for the right tests. // The examiner gives the candidate a set of labels with the patients details on to use on the blood form but this is a trick!!! You have to hand write the patient's details on the blood form!!
- Prescribing - Given drug chart. Mr X is on paracetamol post-op, has kidney failure, and is in pain, about 4/10. Prescribe him something – you’re given a BNF if you need it. Some people went with morphine, and the things that go with it: laxative and anti-emetic. I just went one step up the ladder and gave co-codamol. // Think I should have put in something in the stat section too, but I forgot and just did the regular section. I had to ask the examiner the date, he told me but looked at me like I was a muppet! Stress does curious things, I tell you //You do not write up morphine as it is too strong for pain of 4/10. Other people I spoke to wrote up NSAIDs, he was already on paracetamol so DO NOT OVERDOSE HIM by giving paracetamol as well. I wrote up co-codamol and mentioned that I would stop the existing paracetamol. Remember to fill in the patient details, ward, consultant, date etc first as these are the main marks. // Had renal failure too so went with co-codamol // in the end I wrote up paracetamol, NSAIDS regularly and some opiates and metoclopramide in the PRN section.
- Prescribing - Given ABGs for acute exacerbation of COPD. Asked to write up meds on a prescription chart.
- then...TTA Letter - I found this station very confusing we had to fill out a TTA form for a lady who had had an exacerbation of COPD. There was a BNF there as well. I hardly filled anything in - it was unclear whether we had to list the drugs for the acute episode or prescribe her regular meds as written out in the scenario.
- Discharge form - Write a discharge letter for a post-MI patient // Writing up TTOs // Explaining to a patient about drugs post MI, side effects and implications (statin, aspirin, atenolol etc.. with questions from patient about DVLA regulations on driving after an MI) - taxi driver, Heparin – explain will stop, Aspirin - lifelong, Atenolol - lifelong, Atorvastatin - lifelong nocte, Temazepam – didn’t sleep ion hosp 2 nights – not chronic used so can stop, Last Q had to explain cannot drive for a month (although examiner kept saying do I want to change my answer- though was that long but would check with colleagues, DVLA etc
- Discharge summary - a LONG instructions page followed by a LONG history - patient had been diagnosed with temporal arteritis, needed to be placed on steroids and bisphosphanates. - needed to fill out the discharge summary form. Everything on it!
- then... Talking to the patient whose discharge summary you filled in. She is on Prednisolone and bisphosphonate after first presentation of temporal arteritis. Explain side effects of both, steroid card. // Advise lady who needs to be on steroids because of temporal arteritis. Tell her the side effects of steroids - i couldn't remember any initially and finally blurted out 'you might go psychotic' (don't do this!)Also show her steroid card and advise her to keep it on her at all times. She asks when she can come off them - I said when her ESR was back to normal and all her symptoms had gone.
- Read notes-style information about the admission of a man for asthma attack after exposure to a neighbour's dog. Fill in discharge summary with patient details, take home medications, instructions to the GP to review spacer technique and then sign and date form (there wasn't enough time to do all of this properly).
- then... Meet the man (actor) whose discharge summary you've just filled out. He is worried that he was only on PRN salbutamol before admission and that now he is on 2 inhalers and oral steroids. He has heard about bad side effects for oral steroids so isn't happy about this. You needed to find out what his worries are – he thinks he has to stay on the oral pred indefinitely but is only on a 7 day course, talk to him about this, about his inhalers and demonstrate use of a spacer. // Write TTA for patient after being admitted with exacerbation of asthma - everyone found it difficult to do in 5 mins but it was easy enough, just copying info off discharge summary
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