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OSCE-Aid Revision Course April 2014

Short Station Scenarios

CONTENTS:

Communication skills and SBAR, Dr Giles Hockridge Page 2

Communication and Explaining, Dr Kevin Clarkson Page 9

Fluid balance assessment, Dr Zahra Haider Page 18

History taking, Dr Adam Monsell Page 23

Cranial nerve examination, Dr Clara Belessiotis Page 29

DR ABC, Dr Kiran Patel Page 38

Edited by: Dr Celine Lakra Please note: these resources are copyright of the authors and OSCE-Aid. Please refer to our website terms and conditions at: http://www.osce-aid.co.uk/terms&conditions.php . All resources can be printed and shared for personal use only. No amendment or alteration to these resources is allowed, unless otherwise agreed by the OSCE-Aid team. For any queries, please contact the team at: contact@osce-aid.co.uk

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OSCE Short Station: Communication Skills and SBAR Overview: This is a role-play exercise based on an OSCE communication station related to SBAR. In a typical scenario, the students will be asked to read the station and then carry out the scenario. Format of the exercise:

5 minutes Discussion o Discuss SBAR with the group first what it is and why it is important (notes provided

in Appendix 1)

10 minutes Carrying out the scenario o Ask for one student volunteer. The examiner will act as the colleague at the end of

the phone. The student should be informed they have 10 minutes to read the information (Appendix 2) and take appropriate action i.e. calling for appropriate help and discussing the patient with the registrar.

o Ask the student to read the headline instructions to the group before beginning. o When the student first uses the phone, ask them who they would like to call. o Prompt the student where appropriate e.g.: ask for results required o The examiner will be provided with a mark scheme and a model answer script

(Appendix 3)

5-10 minutes Feedback o Gather feedback. Start with the student then open it up to the group. Finally, provide

your own feedback to the student. Think of the following: Structure: did they cover all the main areas (see Appendix 1)? Content: did they deliver the most important points and express the urgency

of the situation at hand? Style. Comment on speech (rate and tone) and professionalism Safety: did they call the right person and give the relevant information? Did

they understand the urgency of the scenario?

10 minutes Discussion o If time to spare (likely), discussion of related topics (notes provided in Appendix 4).

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APPENDIX 1: Notes on SBAR

What is it and how can it help me?

SBAR is an easy to remember mechanism that you can use to frame conversations, especially critical ones, requiring a clinician's immediate attention and action. It enables you to clarify what information should be communicated between members of the team, and how.

The tool consists of standardised prompt questions within four sections, to ensure that staff share concise and focused information. It allows staff to communicate assertively and effectively, reducing the need for repetition. The tool helps staff anticipate the information needed by colleagues and encourages assessment skills. Using SBAR prompts staff to formulate information with the right level of detail. A description of the steps involved: S Situation:

Identify yourself the site/unit you are calling from

Identify the patient by name and the reason for your report

Describe your concern

Firstly, describe the specific situation about which you are calling, including the patient's name, consultant, patient location, code status, and vital signs.

B Background:

Give the patient's reason for admission

Explain significant medical history

You then inform the consultant of the patient's background: admitting diagnosis, date of admission, prior procedures, current medications, allergies, pertinent laboratory results and other relevant diagnostic results, in addition to your examination findings. You need to have collected information from the patient's chart, flow sheets and progress notes.

An Assessment:

Clinical impressions, concerns

You need to think critically when informing the doctor of your assessment of the situation. This means that you have considered what might be the underlying reason for your patient's condition. Not only have you reviewed your findings from your assessment, you have also consolidated these with other objective indicators, such as laboratory results.

R Recommendation:

Explain what you need - be specific about request and time frame

Make suggestions

Clarify expectations

Finally, what is your recommendation? That is, what would you like to happen by the end of the conversation with the physician? Any order that is given on the phone needs to be repeated back to ensure accuracy.

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APPENDIX 2: Scenario to be read by the student You are an FY1 doctor covering the medical wards on-call. You have been asked to review a patient on Olive ward complaining of abdominal pain. Imagine that you have assessed the patient, written your patient notes (as below) and now feel that you need senior support. Please read the notes and call an appropriate senior for support on the phone provided. You are being assessed on your communication skills. You have 10 minutes to complete the station. You have been provided with:

1. Patient notes 2. Observation chart 3. Fluid balance chart 4. Drug chart 5. List of numbers to call

Patient notes Patient details: Mrs Cathy Groves, DOB 17/02/1954, Hospital Number 01234567 History of admission: Patient has known Ulcerative Colitis and has been admitted 3 days ago with a flare of her disease. Her normal bowel habit is 4 times a day but for the previous week she had been passing 10+ bloody type 7 stools each day. She is being treated with systemic steroids and Mesalazine. She is also being supported with IV fluids. She is fit for full escalation of treatment. PMH: UC, HTN, High cholesterol DHx: Mesalazine, Prednisolone, NKDA SHx: Retired teacher, Ex-smoker, 20 pack year history, 4 units EtOH / week On examination: General looks unwell, IV fluids running slowly Observations RR 30 breaths min, Sats 92% on room air, PR 120 bpm, BP 90 / 47, Temp 36.5. CVS Capillary refill 4 seconds Pulse -120 bpm regular Normal heart sounds, no pulmonary/peripheral oedema RS RR 30 breaths / min Auscultation normal GIS Abdomen distended On palpation abdomen is rigid and extremely tender throughout, no masses palpable Bowel sounds are absent Neurology - GCS 13/15 (eyes open to voice, disorientated), moving all 4 limbs

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Staff contact numbers: Medical SHO on-call 2700 Medical SpR on-call 2701 Medical Consultant on-call 2702 Surgical SHO on-call 3700 Surgical SpR on-call 3701 Surgical Consultant on-call 3702 Anaesthetist on-call 4701

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APPENDIX 3: Mark Scheme and Model answer script: SITUATION:

Introduces self and role Location Patient info: NAME / DOB / HOSPITAL NUMBER RESUS status of patient Appropriate HEADLINE of situation Vital signs explained clearly BACKGROUND

Patient admitted on PC and admission diagnosis HPC PMH DHx Examination findings ASSESSMENT

I think the problem is: PERFORATION If they do not know what the problem is states patient is UNWELL Identifies patient is in SHOCK Identifies patient needs immediate SpR review RECOMMENDATION

Urgent SpR review 2 x large bore cannula Bloods:

- FBC Hb for blood loss, WCC for sepsis - U&Es electrolytes disturbance, dehydration - CRP sepsis - INR assess bleeding risk - Group and Save prep for surgical intervention / transfusion - ABG / VBG Raised lactate suggestive of bowel ischaemia

IV Fluids Catheter monitor fluid balance CXR erect AXR Call ITU / Surgical SpR Contact NOK RESPONSE

Is there anything you would like me to do?

PROFESSIONALISM COMMUNICATION SKILLS

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Situation

"This is ..The Medical House Officer on-call, calling from Olive Ward. The reason I'm calling is that a patient Mrs Cathy Groves (Give DOB, Hospital number) has become very unwell. She is for full escalation and has no DNAR in place. She is tachypnoeic with a respiratory rate of 30, her blood pressure is 90 / 47, her pulse is 120 bpm and her sats are 92% on room air. She has also passed only 30mls of urine in the past 6 hours. She is currently afebrile.

Background

"Mrs. Groves is a 60-year-old woman who was admitted three days ago with a flare of her Ulcerative Colitis. Her past medical history also includes hypertension and high cholesterol. She was started on steroid and mesalazine treatment and is being supported with intravenous fluids. This morning her observations were stable with her BP 120 / 80, HR 85 bpm and her RR 16. She has steadily got worse with her blood pressure falling and her heart and RR increasing despite receiving 2L of IV fluids. Her urine output has dropped in this time. On examination she looks generally unwell with a GCS of 13/15. Her capillary refill time is prolonged at 4s, her heart sounds are normal and her chest sounds clear. Abdominal examination revealed a distended, rigid abdomen that was extremely tender throughout. Bowel sounds were absent.

Assessment "I think she may have perforated her bowel.'" "This patient is in shock and I am worried." Recommendation "I recommend an urgent surgical SpR review. In the meantime I suggest commencing oxygen therapy, inserting 2 large bore cannulae and sending bloods including FBC, U&Es, CRP, Clotting, Group and Save. I also recommend running an arterial blood gas. I suggest giving a 500ml fluid challenge and inserting a catheter to closely monitor the fluid balance. I would also like to order an urgent AXR and erect CXR. Following these things I would like to contact the next of kin and inform them of the situation. Is there anything else you would like me to do? "When are you going to be able to get here?

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APPENDIX 4: Notes for killing time Differentials for the acute abdomen draw abdomen arrange differentials by site.

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OSCE Short Station: Communication and Explanation

Overview: This is a role-play exercise based on a typical OSCE communication and explanation station. In a typical scenario, the students will be asked to take a brief history then explain a new diagnosis or a procedure. Two example scenarios have been provided rheumatoid arthritis and a total knee replacement although there is likely to be time only for one scenario during the session. Format of the exercise:

Ask one student to be the actor and one to be the OSCE finalist. Provide the actor with their brief and the student with the scenario instructions (both overleaf).

Ask the student to read the instructions to the group. Check for questions.

The student should proceed to manage the actor allow 10 minutes only.

Any questions should be directed towards the actor. The examiner should only volunteer answers to specific questions as detailed below and should provide examination and investigation findings when specifically asked by the student.

Afterwards, gather feedback. Start with the student then open it up to the group.

Finally, provide your own feedback to the student. Try not to focus on the clinical information theyve provided (except to point out whole sections they might have missed out). Instead, think of the following:

Structure: did they cover all the main areas (see model answer)? Did they jump back and forth between topics or was there a coherent flow? Too much information or not enough? Too much of one topic at the expense of another?

Patient focus: did they allow the patient to shape the content by eliciting and responding to concerns? Was there space for the patient to confirm they understood and ask questions?

Style. Comment on speech (rate and tone), empathy and body language.

Extending the session: If theres time available, you may want to initiate some group work after the scenario:

A generic outline suitable for most explaining stations has been provided (below) together with model answers for each scenario. If there is time after the feedback session, you can brainstorm a model answer of another scenario with the group, focusing on the structure they want to use and the information they think is important. Remember the structure should accommodate both conditions (like RA, Crohns etc.) and procedures (TKR, cholecystectomy etc.). You can then re-run the scenario with the format youve brainstormed write it on the board and let them to refer to it as they go along and ask the group to comment on any differences second time around.

Key learning points for the students

Have a format. This ensures you touch on all the main point scoring areas within the topic. Keep it simple. You dont have to provide a comprehensive list of treatments, side-effects etc.

Just a few examples will get you the points.

Respond to the cues youre given. Acknowledge questions and concerns (verbally, if possible) and shape youre information based on the patients agenda.

Chunk and check really works, but dont go overboard. Practice wrapping up each sub topic with a question: Does that sound OK? Do you think thats clear? Is there anything you want to ask me about diagnosis/treatment/management?

Deploy open questions wisely. Their cost you time but are vital for eliciting patient ideas and concerns.

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Scenario 1: Explaining Rheumatoid Arthritis Student instructions To be read out loud by the student to the group A 58 year old clerical assistant has come to the GP to discuss the results of blood tests and x-rays which were ordered after s/he presented with pain and swelling in the wrists and the small joints of the hand. You are an FY2 on a General Practice rotation. Please take a brief history to confirm your diagnosis before discussing the results. Answer any questions they may have on their condition. Results:

Rheumatoid factor Negative

Anti-cyclic citrullinated peptide (anti-CCP) Strongly positive

X ray, both hands Right: Widespread juxta-articular osteopaenia with bony erosions in 2

nd, 3

rd and 4

th DIP.

Evidence of active soft tissue swelling in the 4th

and 5th DIP.

Left: A similar degree of osteopaenia is evident in the left hand with less prominent soft tissue swelling. There is marked loss of joint space in the 2

nd, 3

rd and 4th DIP.

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Scenario 1: Explaining Rheumatoid Arthritis Actors brief You are a 58 year old part time clerical assistant and have come to the GP for the results of a blood test. Youve been experiencing episodes of pain and swelling in both wrists and in the small joints of your hands for two years. More recently, youve begun to notice reduced manual dexterity, most obvious when typing. Youve not noticed any problems in the larger joints, have no nodules and no breathlessness. You use ibuprofen to control pain during a flare. If questioned directly, you have been experiencing dry, itchy eyes for around 6 months but put it down to allergies. You have hypertension, for which you take amlodipine, but no other medical problems. Your mood is generally good. Your mother had rheumatoid arthritis and you are very worried that you will end up like her with severely deformed joints, loss of mobility and chronic pain. You would like to know if this could happen to you too. You also want to know if it will affect your work. Only volunteer specific information about symptoms, concerns and your past medical history when asked the relevant and specific questions by the student. If any questions cannot be answered with the above information, please answer no or dont know.

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Scenario 1: Explaining Rheumatoid Arthritis

Model answer

The prompts below (in bold) can be applied to just about any conditions or procedures youre asked to

explain. The examples in italics describe rheumatoid arthritis.

1. Introduce yourself and gain consent. Its often helpful to paraphrase the task from the brief. Hello. My name is Dr Clarkson. May I ask your name please? I understand youve had some tests recently, and Id like go through the results with you. Are you happy for us to do that today? 2. Give the patient the opportunity to influence the agenda. Is there anything else you were hoping to cover today?... OK Ill make sure we discuss that, but please do ask questions as we go along especially if anythings unclear. 3. Briefly summarise their issue. If youve been asked to take a history, now is the time to expand on what youve already been told. It shouldnt be exhaustive this isnt a history station but you will have to follow up on any positives. Ask a few questions and move on. I understand youve had problems with pain and swelling in your hands. Is that right? Do you every have (i) pain or stiffness in other joints, (ii) dry or painful eyes, or blurred vision (iii) breathlessness or (iv) chest pain. How has this affected you at home/at work? Anyone in the family had the same? 4. Establish their ideas and concerns pre-diagnosis/procedure. This is a chance for the patient to air any preconceived ideas about their condition and its causes. Do you have any ideas about what might be causing these symptoms? Have you thought about what the test results will tell us? 5. Warning shot! Give them time after the shot to collect their thoughts before you carry on. In some OSCE scenarios the patient will already be aware of their diagnosis or the need for a procedure in which case you can skip this. Ive reviewed the results and Im concerned that they include some bad news . 6. Name the condition/procedure and find out what they know Together with the symptoms you describe, your test results show that you have a condition called Rheumatoid Arthritis. Is this something youve heard of before? Can you tell me what you understand about the condition? 7. Describe the condition (WHAT and WHY): Fill in the gaps from what theyve told you already but keep it simple and focussed on the patient. Tell them WHAT the disease will do to them and WHY its happening to them. WHAT: Rheumatoid Arthritis a disease of the joints that presents with many of the symptoms youve described episodes of stiffness and swelling, often of the hands and feet, but sometimes larger joints. If not managed early, these episodes can lead over time to permanent damage. Its a disease that can affect many parts of the body, including the heart, lungs and nervous system. Although theres no cure, many people have very good control over the disease, living normal lives. WHY: Were not sure exactly what causes it, but we know theres a family link and some genes have been identified as increasing your risk. There may be an infectious component, but the evidence is limited and research is still ongoing. 8. Describe the goals of treatment: Is it curative or is long-term management the goal? There is no curative treatment but there are things WE can do, and things YOU can do to control the disease. The goals of treatment are to control the symptoms, prevent the damage caused by flare ups of the disease and monitor you closely to catch any complications early. 9. Management (WE and YOU): For most conditions/procedures youll be expected to cover what the medical profession can do (WE) and what the patient can do (YOU). Chunk and check as you go. WHAT WE DO: Medical/General, Pharmacological and Surgical interventions - MEDICAL: I will arrange early referral to a Rheumatologist - a specialist in conditions like this. They will co-ordinate a team of people looking after your care, including nurse specialists, occupational therapists, podiatrists, psychologists and social services. All with the goal of reducing the impact of the disease on your day-to-day life. - PHARMACOLOGICAL: There are many effective medicines used to treat the condition. We use anti-inflammatory drugs to treat the symptoms of pain and swelling. These include non-steroidal anti-inflammatory drugs as well as short courses of steroid medications. Other drug can be used to modify the course of the disease, not just treat the symptoms, and may be started after discussion with your rheumatologist. These are powerful medications that can be very effective but need careful monitoring as they have side effects that may harm the immune system or affect organs like your liver or kidneys. This is one of the reasons we monitor you closely, particularly at the early stages of treatment.

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- SURGICAL: If describing a procedure, take a BEFORE, DURING and AFTER approach. Occasionally, specialist surgeons can offer procedures to correct joint defects or minimise pain, however this has become less frequent over time as medical management has improved. WHAT YOU DO: There are things you can do to keep your joints and your heart healthy, for example controlling your weight, taking regular exercise and eating a Mediterranean diet (unsaturated fats, vegetables and oily fish). Its important to take the medication youre given as prescribed and to report any symptoms early so we can help. 10 Take a breather This must be a lot to take in. Is theres anything youd like to ask, or anything I can make more clear? 11. Flush out their worries if theyve not voiced them already. They almost certainly have a secret worry you need to illicit and sometime you have to ask directly. Is there anything in particular your worried or concerned about? 12. Recap Just to recap, Ive explained that you have rheumatoid arthritis, that its treatable with medication and support. Youve told me youre worried about the impact of the disease long-term, but I hope I can reassure you that there are many treatments available and that most people live normal lives with this condition. 13. What happens next Discuss follow up, referral and other sources of information. Were coming to the end of our session, but Im sure youll think of lots more questions later. Why not talk this over with family or friends then make a follow up appointment to discuss it further. Youd be welcome to bring someone with you if youd like. In the meantime, with your permission Id like to make a referral to a rheumatologist at the hospital, who will invite you to an outpatient clinic in a few weeks. If youd like, I can leave some reading material at the reception desk for you to collect before you leave. If youre looking for information online, Id recommend you search for Rheumatoid Arthritis on www.nhs.uk as its always up to date. 14. Wrap up Thank you for taking the time to go through your results today. I hope you feel the information has been useful. Please do arrange another appointment if youd like to talk more. Thanks.

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Scenario 2: Explaining a Total Knee Replacement Student instructions To be read out loud by the student to the group A 67 year old retired social worker with osteoarthritis has been advised to consider a total knee replacement (right knee) by your consultant, and has come back to the outpatient orthopaedic clinic to discuss the matter further before deciding whether to proceed. You are an FY1 doctor on a Trauma and Orthopaedics rotation and have been asked by your consultant to explain the procedure. Please take a brief history to confirm the diagnosis before discussing management. You are not expected to gain signed consent today. Results:

X ray: Both knees, AP and Lateral Right knee: marked loss of joint space with widespread sclerosis. Large left lateral sub-chondral cyst on tibia. Prominent osteophytes. Left knee: moderate sclerosis. Joint space diminished but preserved medially. Lateral osteophyte noted.

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Scenario 2: Explaining a Total Knee Replacement Actors brief You are a 67 year old retired social worker and have been experiencing slowly worsening pain in both knees over the last 10 years. In the last two years the pain in your right knee and right hip have been significant and disabling, and you now walk with a stick. You are otherwise in good health. You take amlodipine for hypertension (which is well controlled) and paracetamol with ibuprofen gel regularly for joint pain. You had a fall recently while playing with your grandchildren and you worry that you are not safe to look after them alone. You are eager for surgery and frustrated that it has taken two months to get an appointment. You want to know about what the procedure entails, the expected recovery time and the common complications. You would like your right hip and right knee replaced in a single procedure as you believe that this will be more efficient. You will pressure the doctor to agree to this and provide you with a consent form to sign today but will back down once the process is adequately explained. Only volunteer specific information about symptoms, concerns and your past medical history when asked the relevant and specific questions by the student. If any questions cannot be answered with the above information, please answer no or dont know.

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Scenario 2: Explaining a Total Knee Replacement

Model answer

The prompts below (in bold) can be applied to just about any conditions or procedures youre asked to

explain. The examples in italics describe a total knee replacement

1. Introduce yourself and gain consent. Its often helpful to paraphrase the task from the brief. Hello. My name is Dr Clarkson. May I ask your name please? I understand youre considering knee replacement surgery on you right knee is that right? Ive been asked to explain the procedure and answer any questions you might have. Are you happy for us to do that today? 2. Give the patient the opportunity to influence the agenda. Is there anything else you were hoping to cover today?... OK Ill make sure we discuss that, but please do ask questions as we go along especially if anythings unclear. 3. Briefly summarise their issue. If youve been asked to take a history, now is the time to expand on what youve already been told. It shouldnt be exhaustive this isnt a history station but you will have to follow up on any positives. Ask a few questions and move on. I understand youve had pain in your right knee for some time. Is that right? Do you every have (i) pain or stiffness in other joints, (ii) problems with mobility or falls. How has this affected you at home/in your daily activities/socially? 4. Establish their ideas and concerns pre-diagnosis/procedure. This is a chance for the patient to air any preconceived ideas about their condition and its causes. How do you feel about surgery? What are your expectations regarding the recovery period? What are you hoping for from the procedure in the longer term? 5. Warning shot! Give them time after the shot to collect their thoughts before you carry on. In some OSCE scenarios the patient will already be aware of their diagnosis or the need for a procedure in which case you can skip this. Not required in this scenario. 6. Name the condition/procedure and find out what they know Together with the symptoms you describe, your test results show that the osteoarthritis in your right knee is advanced. My consultant believes you would benefit from a total knee replacement. 7. Describe the condition (WHAT and WHY): Fill in the gaps from what theyve told you already but keep it simple and focussed on the patient. Tell them WHAT the disease will do to them and WHY its happening to them. WHAT: Osteoarthritis is the process of gradual damage to the joints over time. Loss of cartilage the material that protects the bones that form the joints results in bony erosion and deformity of the joints, causing pain and stiffness. WHY: The disease is very common and affects many people as they age. We know that genetics play a part, but other factors, for example your occupation, your weight, your sex or a previous injury to the joint, can all increase your risk of developing osteoarthritis. 8. Describe the goals of treatment: Is it curative or is long-term management the goal? There is no curative treatment but there are things WE can do, and things YOU can do to control the disease. Initially, the goals of treatment are to manage the symptoms and reduce the rate of damage. In the later stages, we focus on replacing the joint altogether. 9. Management (WE and YOU): For most conditions/procedures youll be expected to cover what the medical profession can do (WE) and what the patient can do (YOU). Chunk and check as you go. WHAT WE DO: Medical/General, Pharmacological and Surgical interventions - SURGICAL: If describing a procedure, take a BEFORE, DURING and AFTER approach. As you know, we can offer a complete joint replacement. Before the procedure we invite you to pre-assessment clinic where we carry out basic tests to be sure youre fit for surgery. This includes giving you advice on any changes to medications pre-op, and suggesting practical things you may need to arrange during the recovery period for example help with the shopping while youre off your feet. Youll come to hospital on the day of your surgery after fasting overnight and will be reviewed by the anaesthetist and consultant before the procedure. At that stage well ask you to sign a consent form. All surgery carries risks. Rarely, patients have experienced damage to the nerves resulting in loss of sensation or muscle weakness, loosening or stiffening of the joint over time, leading to instability or pain. However, for the vast majority of people, the results represent a significant improvement. Do you have any questions before I move on? During the procedure you may be asleep, or we may numb you from the waist down. You can discuss this with your anaesthetist. The surgeon will remove the old worn joint and a new prosthetic joint will be fitted. Youll wake with a neat vertical scar across the knee joint. After the procedure, youll wake up in the recovery room, feeling a bit groggy. We will keep

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you comfortable and provide medication for pain and nausea, and fluids if youre dehydrated. Well have you on your feet within the first 2 days, and home usually within 5 days depending on progress. Youll have to avoid driving for 6 weeks, and carry a medical alert card to help you through airport security! Well remove your stitches around day 10 post-surgery, and your GP will look after you until we see you again at your 6-week follow up appointment. Does this sound like what you were expecting? - PHARMACOLOGICAL: Well ensure you have adequate pain control before you leave hospital and on discharge. - MEDICAL: The key to recovery is physiotherapy, both in hospital and after discharge. You will be seen by the physiotherapists as an outpatient, and given exercises to help strengthen your new joint. Also, remember that your GP is there to help if your pain is not well controlled or if you need advice. WHAT YOU DO: There are things you can do to keep your joints healthy, for example controlling your weight and taking regular exercise. Its important to take the medication youre given as prescribed to control pain and help to keep you mobile, and that you follow the exercise plan youll be given by your physiotherapist. 10 Take a breather This must be a lot to take in. Is theres anything youd like to ask, or anything I can make more clear? 11. Flush out their worries if theyve not voiced them already. They almost certainly have a secret worry you need to illicit and sometime you have to ask directly. Is there anything in particular your worried or concerned about? 12. Recap Just to recap, Ive explained that you have osteoarthritis and that a total knee replacement is the best option for managing your pain and mobility problems. Youve told me that youre keen to have the surgery but that youre also worried about your hip. My advice is to focus on the knee surgery as the hip may improve once your knee is realigned. I can also get a second opinion for you regarding this. I wont be able to consent you today but my surgical colleagues will take care of this after pre-op clinic. 13. What happens next Discuss follow up, referral and other sources of information. Were coming to the end of our session, but Im sure youll think of lots more questions later. Why not talk this over with family or friends then make a follow up appointment with your GP to discuss it further. Remember youll be able to ask questions at the pre-op assessment. Youd be welcome to bring someone with you if youd like. In the meantime, with your permission Id like to schedule your surgery and arrange the pre-op assessment. If youd like, I can leave some reading material at the reception desk for you to collect before you leave. If youre looking for information online, Id recommend you search for Total Knee Replacement on www.nhs.uk as its always up to date. 14. Wrap up Thank you for taking the time to go through this today. I hope the information has been useful, but do contact your GP if youd like to talk more, or talk to us at pre-assessment clinic. Thanks.

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OSCE Short Station: Assessment of Fluid Balance

Overview: This is a role-play exercise based on a typical short OSCE examination station. In this scenario, the students will be given ten minutes to examine a patients fluid status.

Format of the exercise:

Ask one student to be the patient and one to be the OSCE finalist. Provide the student with the scenario instructions (both overleaf).

Ask the student to read the instructions to the group. Check for questions.

The student should proceed to manage the actor allow 8 minutes for examination and 2 minutes to summarise/ask questions below

The examiner should only volunteer answers to specific questions as detailed below and should provide examination and investigation findings when specifically asked by the student.

Afterwards, gather feedback. Start with the student then open it up to the group. Then provide your own feedback to the student.

Finally, discuss key learning points. Suggestions for questions to ask the group, a recommended model answer and key discussion points re: fluids are included overleaf.

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Student instructions To be read out loud by the student to the group

Mr Smith is an 82 year old man who had a Hartmanns surgical procedure 5 days ago. Please assess

his fluid balance status, request appropriate further bedside investigations/tests and prescribe

appropriate fluids on the chart provided. You have ten minutes to complete this station.

Please talk through your examination.

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Mark Scheme and Model answer script:

Introduction Appropriate introduction

Washes hands

Consent

Examination Observes from end of the bed around the patient and at

the patient as a whole

Assessment of GCS

Hands: Capillary refill

Skin turgor

Warm, well perfused hands?

Arm: BP lying and standing

Pulse rate, character

Face: Assesses mucous membranes

Assess mouth

Neck: JVP

Carotid pulse

Chest: Skin turgor

Auscultates lungs

Listens to heart sounds

Abdomen: Assesses for ascites

Back Sacral oedema

Legs pedal oedema

General: Catheter in place?

Stoma bag? Output?

Observations: Assesses: Temperature

BP (110/60)

HR (115)

RR

Sats

Urine output

To complete: I would look at the input output chart

I would want to see the drug chart

Ask the nurses to put a catheter in

Prescribes fluids: Fluids at an appropriate rate (e.g.: 4 hours, or a fluid challenge)

With 40 mmol of KCl correctly prescribed if not giving challenge

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Questions/answers for group:

1. What else would you like to see at the patients bed side?

Fluid balance sheet

Daily weights

2. What is the patients fluid status?

Patient is clinically dehydrated

3. What would you instruct the nurses to do?

Request they put up the fluids

Recommend regular observations

To call you if any concerns or changes in patients clinical state

Monitor urine output hourly

4. Any blood tests the candidate would like to see? Show them these results

Blood results: U&Es:

Sodium 132

Potassium 3.0

Creatinine 199

Urea 11.2

FBC normal

CRP 6

Urea and electrolytes in particular with focus on urea and sodium

Full blood count/CRP any reasons for dehydration concurrent infection

5. Blood tests: Ask the candidate to interpret the results above

The patient is dehydrated. He needs urgent fluid resuscitation

He is also hypokalaemic with a mild hyponatraemia

I would also want to prescribe potassium with the fluids

6. Would this change their management plan in any way?

Patient is hypokalemic an ECG needs to be done urgently

ECG changes in hypokalemia:(Show them ECG)

o Small or inverted T wave

o Prominent U waves (after T wave)

o A long PR interval

o Depressed ST segments

Daily U&Es and strict monitoring of fluid input/output

Investigation of the cause of the hypokalaemia (e.g.: drugs, diarrhoea)

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Key learning points on fluids:

5% Dextrose o Isotonic fluid o Contains a small amount of glucose (50g/L) o Liver metabolises all the glucose, so only water is left o This equilibrates through all fluid compartments o Good for maintaining hydration

0.9% Saline o Has the same Na content as plasma therefore isotonic with plasma o 0.9% Saline will equilibrate rapidly through the extracellular compartment only and

take longer to reach the intracellular compartment o Appropriate for resuscitation and maintenance

Colloids e.g.: Gelofusin o Has high osmotic content similar to that of plasma and therefore will remain in the

intravascular space for longer than other fluids o Appropriate for resuscitation but not for general hydration o Small risk of anaphylactoid/anaphylactic reactions

Hartmanns o Meant to be similar to blood constitution of electrolytes o Appropriate for resuscitation and maintenance

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OSCE Short Station: History taking

Overview: This is a role-play exercise based on a typical OSCE history taking station. In this typical scenario, the students will be given 10 minutes to take a short history from the patient, suggest a management plan and be questioned on key points in the scenario. This scenario focuses on a patient who is tired all the time a common presentation seen in exams. Format of the exercise:

10 minutes Carrying out scenario o Ask the student to read the instructions to the group. Check for questions. o Teacher as actor or alternatively you can pick a student as the actor go by brief

overleaf: 8 minutes o After 6 minutes of history taking, prompt the student to discuss the initial

investigations/management with the patient o After 7 minutes of history taking, ask the student to summarise and present his/her

history: 1 minute o Last minute: Teacher to press the student on an aspect of the history that they

elicited i.e.: If thyroid tests were mentioned;

What pattern of results you would expect?

What treatment regimen you might want to try in a hypothyroid patient?

How can hypothyroidism mimic many other illnesses/carry similar signs/symptoms?

If a mood disorder is focussed on (as it will be from the brief), press them on: What they would do next. (i.e.: would you start them on an

antidepressant/refer them for other help?).

What would you do if a patient was frankly suicidal (sectioning/informal admission to a psych unit/crisis team input/community support)? What other things are important to consider here (drug/alcohol abuse, risk to others and safeguarding).

5 minutes Feedback o Provision of feedback to the student via teacher and the group: particularly focus on

feedback of the students history taking/communication skills Pick one student to list 3 things they did well Pick one student to provide 3 things that could have gone better Pick one student to provide a champagne moment for the history

something standout; i.e. eliciting a difficult component to the history, or picking up on a clue dropped by the historian.

o Questions for the student (2-3) you could recommend questions they could ask in a future history

10 minutes Discussion

Discussion of the material covered in key learning points (overleaf) This would benefit from a big flipchart and a pen get the students to brainstorm the

areas you would like to see covered in the history.

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Student instructions To be read out loud by the student to the group

You are a GP on your second foundation year placement. Ms Hardwick has presented to you stating

that she is tired all of the time. Please take a history focussing on relevant details and discuss the

initial investigations you would like to perform with her. You have eight minutes to do this in total. You

will have two minutes to discuss the case with the examiner.

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Actors brief Mr Hardwick a somewhat gruff character, who might like to read a Haynes manual in his spare time. Work-focussed, and alone after his divorce of 6 months ago. Considers himself a coper, and capable of overcoming any task if he sets his mind to it, but willing to entertain idea that he has had a stressful time if approached with proviso that he remains a capable person. I promised my daughter that I would see the doctor she made the appointment for me and the least I could do for her was to come along. Background medical history: High blood pressure (on amlodipine 5mg). BMI of 40 Previous cholecystectomy (laparoscopic). Family history Father died of MI 79 Mother bowel ca. 82 Brother has type 2 diabetes. Recent life stressors Divorce of 6 months ago (she left for unknown reason very little contact since). Re-applying for job at work and recently taken out new mortgage to cover cost of new extension to house. I am a 57 year old man, and I work for an engineering firm. For the past 3 months Ive been having trouble getting going and Ive felt generally rubbish. Ive been struggling to motivate myself to get going at work. This is particularly frustrating, as were going through a re-structure and everyone is having to re-apply for their jobs. Its very stressful. Im falling behind, and I think colleagues are noticing that Im not my old self. My concentration is all off, and thats whats really concerning me I never used to be like that. Ive not been able to get to sleep at night, and when I do, I wake up really early (about 4 oclock, if asked). I tend to get up and try to plan for things at work over a cigarette, but I never get very far. I suppose I dont enjoy things like I used to anymore; but I think this is probably because Im focussed on work. My appetite is pretty unchanged. I havent noticed much weight loss, but I know I should lose quite a bit my daughter keeps on telling me. I havent really been in the mood for sex, if asked, but then Im an old bloke carrying a bit of weight and presume no one would really want to look at me if I did. Im having a bit more to drink than I used to probably three or four scotches (singles) to get to bed at night, but no more than that. Ive noticed my hair thinning recently, and my voice has been a little croaky over the last few days I thought it was just age, and smoking a bit more, respectively. I havent noticed feeling cold, but then my house is sensibly insulated. I have been peeing more recently Im getting up about twice a night and going 6-8 times a day, but I havent been extra thirsty if asked more about this, Ive been experiencing urgency, finding it difficult to work up a stream and get post mictural dribbling. My brother has type II diabetes. Ive not been getting particularly breathless at night or during the day. I do snore (my wife always used to complain), but I wouldnt be able to tell you if Ive ever stopped breathing at night. I dont drop off at work, but do feel a bit sleepy after a meal. I would probably fall asleep if you put me in the passenger seat of a car, but not in the driving seat (at a red light). If approached correctly (i.e. acknowledgement that Ive been through some stresses recently that would impact anyone), I will accept the offer of seeing someone in the community, and will think about starting an antidepressant if offered. Im not suicidal only broad thoughts about it being easier if I wasnt around. Ive got my daughter and my job to live for, and I have plans to retire to the countryside.

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Key learning points: Lethargy is a feature of many disorders, so a tired all the time history will mostly be about showing an examiner that you can structure your history to time in order to fit the main ones in, then tailor it to fit others pertinent to the patient you are presented with. Main ground to cover these should be covered with any patient presenting to you:

1. Thyroid disorder 2. Anaemia 3. Diabetes 4. Mood disorders/life stressors

Then go on to consider the following, depending on the patient you are presented with, and their risk factors:

1. Cardiac dysfunction (AF/failure) 2. Respiratory disorder (OSA/SHS) 3. Renal dysfunction (nephrotic/nephritic syndromes) 4. Infective (glandular fever, post viral fatigue syndrome) 5. Drugs (i.e. those of abuse, especially stimulants, and those prescribed by doctors/OTC)

Questions pertaining to the main risk factors/signs/symptoms for the aspects youve focussed on will show the examiner that you are thinking about the main causes. Then spend the last minute coming up with a series of investigations youd like to perform and agree this with the patient. This will probably run along the lines of Id like to do some blood tests to check your thyroid status, your blood sugars, your kidney function and the levels of haemoglobin in the first instance, then we might want to do some more tests of your heart and lungs if all of these are normal. If the patients presentation seems to be more life-stressor/mood-orientated, you can state that you would still like to do the tests to rule out an organic cause, but then plan to explore their coping strategies and most importantly, risk, with them. As with all GP consultations; remember to safety net if you have any more concerns, or if x gets worse, you can make an appointment to come and see me again Or if you are concerned about their risk levels, a referral to community mental health services (IAPS, or more acutely a crisis team) may be appropriate. NB: Chronic fatigue syndrome is a possible diagnosis in a tired all the time history, but perhaps not one to plump for in a short case. Show the examiner that you can exclude all of the other diagnoses first. If you like you could raise the possibility of chronic fatigue if all tests are negative, but state you would like to carry out tests of the more common causes first. Thyroid disorder: Hypothyroidism Risk factors: Women (6:1 F:M), over 40 years old, other autoimmune diseases such as viteligo, primary biliary cirrhosis (primary atrophic hypothyroidism/Hashimotos thyroiditis high antibody titres). Remember amiodarone therapy (amiodarone is iodine-rich and looks like T4; thus can suppress TSH; actual T4 is not released. Presenting symptoms/signs: Lethargy, low mood, cold intolerance, constipation, hoarse voice, impaired thinking, myalgia, constipation, weakness, eventually dementia, weight gain, thinning of hair, loss of outer third of eyebrows (most sensitive sign), goitre (less common than in hyperthyroid) Investigations: High TSH and low T4, OR low TSH and low T4 (in secondary; very rare). Cholesterol and triglycerides also raised. (NB: Tx: levothyroxine low dose in elderly (25 microgram intervals), start at 100mcg in younger. Recheck TSH 12 weeks, recheck every 6 weeks to normal state and then yearly).

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Anaemia: Risk factors: This depends on the cause of anaemia common ones to think about: occult blood loss in older patients (leading to 2 week suspected cancer referral), menorrhagia in younger women, true nutritional causes (iron deficiency/B12 or folate def. in vegans or alcoholics), myelodisplastic disorders, thalassemia/sickle cell, and renal dysfunction. Presenting symptoms/signs: Lethargy, dizziness Pallor (conjunctival, or skin). If more severe tachycardia/palpitations, chest pains, breathlessness. IDA: koilonychia, angular stomatitis, glossitis, think about pica and especially craving ice (pagophagia) Investigations: FBC (microcytic, macrocytic, normocytic?), Iron studies (serum iron, TIBC, Ferritin)

Iron TIBC Ferritin

Iron def - + - Anaemia of CD - - + Haemolysis + - + Haemochromatosis + -/N +

Other investigations if patient is anaemic: LDH, reticulocytes, blood film, B 12, folate TFTs Diabetes Risk factors: Type 1: family history, younger age, other autoimmune conditions Type 2: obesity, age, ethnicity, male gender, poor diet and lack of exercise (though correlates more with simple obesity), FH (MODY) Presenting symptoms/signs: Lethargy, polyuria/nocturia, polydipsia. Increased risk of infections especially skin infections/thrush. Consider the more long-term risks present from diabetes: i.e. eye signs (cataracts, diabetic retinopathy), peripheral neuropathy (ulcers, skin infections), and kidney dysfunction. Can also present as DKA (type 1) or HONK (type 2) Investigations: Urine dip glucose +++ (can be protein too) Random blood glucose of over 11.1 (one with symptoms, two without) HbA1C of over 6.5% (or 48mmol/mol in new money). IGT: fasting plasma glucose of less than 7, but between 7.8-11.1 on OGTT Also IFG fasting plasma glucose between 6.1-7. Mood disorders Risk factors: Life-stressors (The Holmes and Rahe stress scale this lists potential life stressors in order; you could check for the major ones), concurrent or past mental disorder (most likely depression), chronic physical health conditions, social isolation, age. Presenting symptoms/signs: Core symptomatic features: anhedonia, anergia, low mood most of the day, every day for 2 weeks or more. Core biological features: lack of sleep (plus early morning waking; though can be hypersomlenence in c.10%), lack of appetite/weight loss (though appetite can also be increased in c.10%), low libido most of the day, every day for 2 weeks or more. Remember that low mood may have been preceded, or can be followed by manic episodes: check for a history of bipolar.

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Investigations: As with all psychiatric disorders, you must first state that you would like to rule out an organic cause (i.e. by ordering the tests discussed above). Assessing for risk is the most important thing to do when youve established depression as most likely cause. Ask about suicidal intent. Others Cardiac: Likely to be older patients with a background of hypertension/MI/hypercholesterolemia/other cardiac risk factors AF/flutter ECG to diagnose. Failures R vs. left vs. congestive: breathlessness, swelling, exercise tolerance (MRC is a useful scale), chest pain. (then take a brief SOCRATES history to determine if cardiac in nature). Will always want to do an echo with potential for further tests thereafter e.g. MPS, angiography etc. if indicated. Respiratory: Main one to exclude is OSA/SHS. Obese people, unless central apnoea (rare). Do they snore (ask a partner or ask if a partner often sleeps in another room) Often witnessed episodes of apnoea (by family etc.). Tend to fall asleep during the day, and will awake feeling tired/unrested. Epworth Sleepiness Scale. ABG/VBG may show high bicarbonate/type 2 respiratory failure. Infective: Glandular fever: young people starting school/university for first time: ESR, C-reactive protein and monospot test. Atypical mononuclear cells on blood film. Post viral syndrome: recent infection; can take weeks to recover. Drugs: Started any new medication? Have a look at side effects of most prescription/OTC medication lethargy will be one of the main SE listed. Think about alcohol misuse: sleep pattern interruption. Amphetamines: cocaine and ecstasy/MDMA overuse Renal dysfunction Do a urine dip looking for protein. U+Es will tell you creatinine levels (important to know baseline). This may suggest chronic kidney disease.

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OSCE Short Station: Cranial Nerve Examination

Overview: This is a role-play exercise based on a typical short OSCE examination station. In this scenario, the student will be given ten minutes to examine a patients cranial nerves. In any OSCE, a student may be asked to examine all or part of the cranial nerves I XII in this time. Format of the exercise:

Ask one student to be the actor and one to be the OSCE finalist. Provide the actor with their brief and the student with the scenario instructions (both overleaf).

Ask the student to read the instructions to the group. Check for questions.

The student should proceed to manage the actor allow 8 minutes for examination and 2 minutes to summarise/ask questions below

The examiner should only volunteer answers to specific questions as detailed below and should provide examination and investigation findings when specifically asked by the student.

Afterwards, gather feedback. Start with the student then open it up to the group. Then provide your own feedback to the student.

Finally, discuss key learning points. Suggestions for questions to ask the group, a recommended model answer and key discussion points are included overleaf.

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Student instructions To be read out loud by the student to the group

Please examine this patients cranial nerves. Do not take a history. Offer to do all aspects of the

examination; the examiner will tell you to move on if not needed and answer your questions with

findings.

You have 9 minutes to examine the patient and 1 minute to discuss with the examiner at the end.

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Actors brief

On examination: there are no abnormalities.

Only volunteer specific information about symptoms and your past medical history when asked the

relevant and specific questions by the student. If any questions cannot be answered with the above

information, please answer no or dont know.

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Model examination/instructions for examiner

Wash your hands Introduce yourself Tell the patient that you would like to examine the nerves in their head and neck Ask if they are happy to do this Reposition the patient sitting down

I Olfactory offer to do this, move student on

II Optic

Visual acuity offer to do this, move student on Colour recognition offer to do this, move student on Fundoscopy offer to do this, move student on Pupillary reflexes

A) LIGHT - check for pupil symmetry - check for ipsilateral (same side) and contralateral (opposite side) pupil constriction - Test for relative afferent pupillary defect (RAPD) B) ACCOMODATION - ask the patient to focus on a distant spot, then change focus to your finger (15cm in

front of their face). Their pupil should constrict to focus. Convergence - "look at a distant object, now look at my finger" Visual fields:

A) Visual neglect: ask the patient to keep both eyes open. Hold your hands at the periphery of their vision and wave each hand in turn each time asking the patient to state which

hand is waving. Then wave both hands. B) Cover one of your own eyes and ask the patient to cover the mirror eye and fix their gaze

on your nose, keeping their head still. Hold one of your fingers in the upper outer quadrant of their visual field and move it towards the centre asking the patient to identify the point at which they first see the finger/pin. Repeat this for the other 3 quadrants and

then repeat with the other eye. C) Offer to assess blind spot move on

III Oculomotor/ IV Trochlear/ VI - Abducens

Test all three nerves together: move finger in a large 'H' shape across the patient's field of vision and ask patient to follow finger whilst keeping their head still. Ask if patient can see double or if vision is blurred at any point during the test

Test for nystagmus: ask the patient to focus on the tip of your finger. Hold your finger at the left lateral edge of their visual field, and move it rapidly to the right lateral edge of their visual field and hold it there. 2-3 beats is acceptable; more than this indicates pathology. Carry out the reverse (right to left) movement.

V Trigeminal

Sensation: - Test sensation on the sternum with cotton wool first - Press (don't rub) the cotton wool in the distribution of the ophthalmic (forehead), maxillary

(cheek) and mandibular (jaw) divisions - Test like for like bilaterally and ask them if it feels the same on both sides Motor:

- Corneal reflex - offer to do this, move student on - Jaw jerk reflex - offer to do this, move student on - Ask patient to clench their jaw - feel temporalis and masseter muscles for contraction - Open jaw to resistance (try to push their jaw up).

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VII Facial

- Inspect: comment on facial symmetry/appearance - Assess taste - move student on - Raise their eyebrows - Close their eyes tightly - Hold their lips together and blow out their cheeks

VIII Vestibulocochlear

- Rub fingers together by one ear, and whisper a two-digit number (e.g. 72) by the other - Offer to carry out specific tests Weber's Test and Rinne's Test - move student on

IX Glossopharyngeal/ X - Vagus

- Ask the patient to open their mouth and say 'ahh' - look at uvula - Examine the gag reflex (with an orange stick) offer to do this, move student on - Assess the patient's swallow - offer to do this, move student on

XI Accessory

- Ask the patient to shrug their shoulders + resist your attempts to push their shoulders down - Put your flat palm on one side of the patient's face and ask them to turn their head against

your hand. Feel for sternocleidomastoid strength

XII Hypoglossal

- Inspect the tongue for fasciculations at rest - Ask the patient to stick out their tongue straight and check for deviation - Ask the patient to move their tongue from side to side

Questions to ask student

1. Please summarise your findings - normal findings 2. How would you complete your examination? assess speech, swallow, take a full history, full

neurological examination, fundoscopy 3. What investigations/tests you would you like to order consider CT head or MRI brain, bloods

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Key learning points for students on cranial nerve palsies: Group discussion around common cranial nerve pathologies (this should be useful for osces but also for writtens) images on pages below

Questions for group:

CRN 3 PALSY show students PICTURE A

1. What abnormality on the left of the page? 2. Where is the site of the lesion? Partial or total? Consider using clip board for this 3. Causes for 3rd nerve palsy? 4. This is a partial nerve palsy - would you expect this finding in all causes of 3

rd nerve palsy?

5. What questions would you want to ask patient? Tell student that patient is a type 1 diabetic what other neurological findings would you expect?

VISUAL FIELD DEFECTS show students PICTURE C

1. Where are the sites of lesions? 2. Revision of optic pathway 3. Causes of lesions along pathway (see below) encourage students to write in causes as go

through handout and sites of lesions

BELLS PALSY show students PICTURE B

1. What is this? 2. How do you distinguish between this and an UMN lesion?

BULBAR PALSY

1. What is this? 2. How do you distinguish between this and an UMN (pseudobulbar) lesion?

Answers for group/general points:

Questions to consider in cranial nerves examination:

1. Single cranial nerve or groups of cranial nerves? 2. Where is the site of the lesion? In brainstem or outside brainstem?

Common pathologies: Please review with above questions

1. Crn 3 palsy: Findings:

1. Partial or full ptosis 2. Eye down and out 3. Pupils may be equal and reactive to light or fixed and dilated one affected side 4. Convergence will be impaired

Causes: 1. Medical causes: diabetes, atherosclerosis, inflammation, infection,

demyelinating disease egg multiple sclerosis usually partial 3rd nerve palsy 2. Surgical causes: aneurysms egg posterior communicating artery, SOLs/tumours,

trauma, cavernous sinus thrombosis usually total 3rd nerve palsy Other neurological findings if patient was a type 1 diabetic:

1. Diabetic feet e.g.: peripheral neuropathy, charcot joint, ulcers 2. Diabetic gastroparesis/other autonomic neuropathy 3. Fundoscopy proliferative or non-proliferative diabetic retinopathy

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Causes of ptosis: Bilateral: myasthenia gravis, myotonic dystrophy Unilateral: 3rd nerve palsy, horners syndrome

2. Visual field defects:

a. Bitemporal hemianopia loss of temporal fields bilaterally, all other fields intact. Causes: compression at optic chiasm e.g.: pituitary adenoma, craniopharyngioma, internal carotid artery aneurysm

b. Monocular blindness lesion at eye or optic nerve. Causes: eye pathology, MS, GCA c. Homonymous hemianopia or quadrantanopia loss of L or R-sided fields or

quadrants contralateral to lesion in each eye. Lesion beyond optic chiasm, at level of tracts, radiation, or occipital cortex. Causes: stroke, SOL, abscess, inflammatory process e.g.: abscess

3. Facial nerve palsy: a. LMN: unilateral flaccid facial weakness, unable to raise eyebrows. Causes: Bells

palsy, skull fracture, CPA tumours, Lyme disease, Ramsay Hunt syndrome, sarcoidosis, diabetes

b. UMN: spares forehead, able to raise eyebrows. Causes: stroke, tumour

4. Lower cranial nerve findings: a. Bulbar palsy: diseases of nuclei of cranial nerves IX-XII in medulla - LMN.

i. Signs: flaccid, fasciculating tongue, jaw jerk absent, speech is quiet/hoarse/nasal.

ii. Causes: MND, GBS, polio, myasthenia gravis, syringobulbia, brainstem tumours, central pontine myelinolysis

b. Pseudobulbar palsy: UMN lesion due to lesions of corticobulbar tracts i. Signs: slow tongue movements, slow speech, hyperreflexic jaw jerk,

emotional lability ii. Causes: MS, MND, stroke, central pontine myelinolysis

5. Groupings of cranial nerves:

a. V, VI, VIII, IX, X: CPA lesions/tumours egg acoustic neuroma b. V, VI: lesion at apex of petrous temporal bone egg complication of otitis media c. III, IV, VI: stroke, tumours, Wernickes encephalopathy, aneurysms, MS d. III, IV, Va, VI: cavernous sinus thrombosis, superior orbital fissure lesions e. IX, X, XI: jugular foramen lesion

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PICTURE A

PICTURE B

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PICTURE C

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OSCE Short Station: DR ABCDE Overview: This is a role-play exercise based on the DR ABCDE OSCE station. In a typical scenario, a student will be asked manage an acutely unwell patient using this format and will then be asked questions regarding the case. The scenario should take 10 minutes. Format of the exercise:

Ask one student to be the actor and one to be the OSCE finalist. Provide the actor with their brief and the student with the scenario instructions (both overleaf).

Ask the student to read the instructions to the group. Check for questions.

The student should proceed to manage the actor allow 10 minutes only. The examiner should only volunteer answers to specific questions as detailed below and

should provide examination and investigation findings when specifically prompted by the student. An ECG has been provided and can be shown to the student on request.

Afterward the scenario is finished, gather feedback. Start with the student then open it up to the group. Please ensure feedback is constructive. Then provide your own feedback to the student.

Finally, discuss key learning points. Suggestions for questions to ask the group, a recommended model answer and key discussion points are included overleaf.

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Student brief To be read out loud by the student to the group A 66 year old retired lorry driver has been brought in by ambulance to the Accident and Emergency with acute chest pain. You are the FY1 doctor on call and have been bleeped by the nurses to see the patient urgently as they are concerned that he is unwell. Please assess the patient and instigate appropriate management.

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Actor brief You are a 66 year old man retired lorry driver who has been admitted to Accident and Emergency with chest pain. You have had sudden onset chest pain, in the middle of your chest and some numbness in the left arm and jaw. You feel sweaty, nauseous, breathless, and are worried about what is happening to you. You look uncomfortable. In terms of your background, you have high blood pressure, high cholesterol, type 2 diabetes, take little exercise and smoke 30 cigarettes/day. You take amlodipine for your high blood pressure, simvastatin for high cholesterol and metformin for diabetes. You have a family history of your dads dad dying from a heart attack in his 80s. Only volunteer specific information about symptoms and your past medical history when asked the relevant and specific questions by the student. If any questions cannot be answered with the above information, please answer no or dont know.

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Model answer and scenario results Danger Safe to approach, no need for gloves or apron, no danger Response Initial assessment of patient response Inspection: Patient looks pale, sweaty, clammy, in distress, breathless A Look, listen, feel: airway patent, talking full sentences but looks uncomfortable and

short of breath, no oral obstruction, no central cyanosis, no medications etc around the bedside Act: apply high flow oxygen 15 L via a non-rebreather mask, aiming saturations of 94-98%

B Look, listen, feel: RR 25, breathless, talking full sentences No wheeze/stridor/gargling/cyanosis/gasping/pursed lips/tracheal tug or deviation/asymmetrical chest movements

On auscultation: clear lung fields, no creps or wheeze Pulse oximetry: sats 91% Act: request chest x ray and ABG (results not available yet), continue high flow oxygen

C Look, listen, feel: HR 110bpm, BP 98/63, pale, sweaty No blood loss or oedema, not cyanotic, JVP normal, sweaty but warm peripheries, CRT 2 s, auscultation: HS I +II + 0, T: 36.7, UO pending Act: Request ECG, insert 2 wide bore cannulae into both ante-cubital fossae, suggest fluid challenge (250mL gelofusin stat or equivalent) and request blood tests (FBC, U+E, LFT, glc, Trop, blood cultures, VBG) Results of investigations return as:

1. Bloods: Trop 512 (high), all other results normal. 2. ECG: see below. Ask student to present the ECG (T wave inversion V5-V6

with ST depression V4-6 (main +ve findings)) 3. Chest x ray (requested in B) reported as normal

D AVPU alert, talking, responding to voice, GCS15/15 Pupils equal and reactive Glucose: 5.6

E Student should offer to fully expose the patient. There are no signs of haemorrhage, bruising, injury, no gross neurological deficit

The focus of assessment and teaching should be on adequate and safe assessment using ABCDE approach. The student should regularly reassess the patient during this scenario. Results should improve when compared to their original if you feel the student has initiated the correct management. During the assessment the student should be able to identify ACS/NSTEMI as the diagnosis. The ACS protocol should be instigated at appropriate stages as student progresses through initial ABCDE assessment with regular review to the beginning and seeking help from senior, as outlined below.

1. Oxygen: aim sats >94%, avoid sats >98% airway/breathing 2. Analgesia: morphine 5-10mg iv circulation 3. Antiemetic: metoclopramide 10mg iv circulation 4. Nitrates: sublingual GTN spray 2 puffs circulation 5. Antiplatelet: aspirin 300mg PO stat circulation 6. Antiplatelet: clopidogrel 300mg PO stat circulation 7. Antithrombin: fondaparinux 2.5mg s/c stat circulation 8. Call for help/consider early referral to the cardiologists

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Questions to ask student for viva if time in the scenario/group for discussion:

1. What tests would you request for a patient with ACS (acute and non-acute)? Bloods: FBC, U+E, glucose, lipids, troponin; ECG; CXR; Echocardiogram may reveal regional wall motion abnormalities Consider exercise tolerance tests in those with stable angina and 24 hour tapes for arrhythmia.

2. What is the medical management for ACS? As above and see explanations below.

3. What is the definitive treatment for STEMI ACS? Primary percutaneous coronary intervention.

4. How do you determine the offending coronary artery/branch from the ECG? Right coronary artery inferior MI II, III, aVF; arrhythmia common (supplies SAN) Left coronary artery circumflex posterior infarct (R waves, ST dep in V1-2) Left coronary artery LADA anteroseptal V1-V2-V3-V4 Left coronary artery lateral V4-V5-V6 Combinations of the above also likely

5. What is the long term medical management post-ACS? Please see explanations below.

6. What are the common side effects of these drugs? ACE-I: hyperkalaemia, dry cough due to build up of bradykinin (kininogen system) Aspirin/clopidogrel: gastritis, peptic ulcer disease, GI bleeding; use with PPI Beta-blockers: bradycardia, avoid with CCBs (bradycardia) and thiazides (increased risk of diabetes), associated with depression, caution in Raynauds syndrome/peripheral vascular disease Statins: muscles aches/pains, rhabdomyolysis, beware interactions e.g. clarithromycin

7. What other (lifestyle) advice or referrals would you suggest to the patient? See explanations below; secondary prevention.

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Additional key ACS learning points for students: Assessment of risk Assess risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality (Global Registry of Acute Cardiac Events GRACE) Use GRACE score to risk stratify for 6 month risk of adverse cardiovascular events

o 1.5% risk or lower: treat conservatively

o 1.5%-3% risk: 300mg clopidogrel, 75mg clopidogrel od for 12 months Coronary angiography if recurrent ischaemia, whether at rest or provoked Stress test if no recurrent ischaemia. If ischaemia is induced, arrange coronary angiography

o Intermediate (>3.0-6.0%), high (>6-9%) or highest (>9%) risk

300mg clopidogrel, 75mg clopidogrel od for 12 months Consider tirofiban or eptifibatide (GPIIb/IIIa inhibitors) need to balance risk of bleedings vs reduction in ischaemic risk Coronary angiography+PCI within 96 hours of first admission Consider abciximab as adjunct to PCI for these groups who are not already receiving GPIIb/IIIa inhibitors Coronary angiogram: ASAP if clinically unstable/high risk Discuss with senior and cardiologist PCI: single vessel disease (not LCA mainstem) CABG: multivessel disease Discuss with surgeon whether to stop clopidogrel 5 days prior to CABG depending on risk of adverse cardiovascular events

Advanced management Consider intravenous eptifibatide or tirofiban (GPIb/IIIa inhibitors in early management for patient with intermediate or higher risk of adverse cardiovascular events in the next 6 months ie GRACE score of 3.0% or more) Also consider GP IIb/IIIA inhibitors for those who are scheduled to undergo angiography within 96 hours of hospital admission. Offer coronary angiography, with PCI if indicated, within 96 hours of admission if there is intermediate or higher risk (predicted 6-month mortality above 3.0%) if they have no contraindications to angiography (ie active bleeding or co morbidity) Angiography should be performed as soon as possible for those who are clinically unstable or high ischaemic risk Discuss the case with seniors and interventional cardiologist as soon as possible involving the patient at every step. If angiography is not performed consider objectively quantifying ischaemia before discharge e.g. stress test and echocardiogram. If there is evidence of ischaemia, coronary angiogram + PCI should be arranged. Patients should be offered advice on diagnosis, secondary prevention, cardiac rehabilitation, management of lifestyle factors (see below). Secondary prevention following ACS

Lifestyle advice

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1. Do not take supplements containing beta-carotene or antioxidant supplements (vitamin E and/or C) or folic acid to reduce cardiovascular risk

2. Consume at least 7 g of omega 3 fatty acids per week from two to four portions of oily fish If not possible e.g. vegetarians, consider at least 1 g daily of omega-3-acid ethyl esters treatment licensed for secondary prevention post MI for up to 4 years for patients who have had a MI within 3 months. Do not routinely initiate omega-3-acid ethyl esters supplements for patients who have had an MI more than 3 months ago.

3. Encourage patients to eat a Mediterranean-style diet.

4. Offer individual consultation to discuss diet, including their current eating habits, and advice

on improving their diet

5. Advise no more than 21 units of consumption alcohol per week for men or 14 units per week for women and to avoid binge drinking

6. Encourage regular physical activity to increase exercise capacity, aiming to be physically active for 2030 minutes a day to the point of slight breathlessness

If this is not possible, advise to increase activity step-by-step way, gradually increasing exercise capacity, starting at a comfortable level and increasing duration and intensity as they gain fitness.

7. Advise to stop smoking, and offer assistance from a smoking cessation service

8. Offer weight loss advice to those who are overweight and obese

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Pharmacotherapy: ACE-I

Start low, go slow

Start with ACE-I, switching to ARB if ACE-I is not tolerated

Continue indefinitely

Do not use combination of ACE-I and ARB without specialist instruction

Assess LV function in all patients who have had a MI

Measure renal function, U+E and blood pressure before starting ACE-I/ARB and again 1-2 weeks after initiating therapy

Monitor whenever dose is adjusted Antiplatelets

Offer aspirin and continue indefinitely (75 mg od)

Aspirin and clopidogrel should only be continued together for 12 months after NSTEMI unless instructed by expert other indication for dual antiplatelet

Aspirin and clopidogrel should only be continued together for 4 weeks after STEMI unless instructed by expert or other indication for dual antiplatelet

Aspirin 75mg should continue indefinitely for all STEMI and NSTEMI patients

Consider PPI if there is a history of dyspepsia

Risk of MI or death in NSTEMI is determined by signs and symptoms, ongoing ischaemia and raised biomarkers e.g. troponin I

Beta blockers

Start as soon as stable, start low go slow

Continue treatment indefinitely

If there is known heart failure or LVSD, the beta blocker already prescribed may continue to be used

CCBs are not routinely used for secondary prevention, but verapamil or diltiazem may be considered in those who do not tolerate beta blockers

Statin

Start as soon as stable

For patients intolerant of statins, other lipid lowering agents should be considered

Reduce or stop the dose of statins if there are drug or food interactions or metabolic disturbances

Discontinue the statin and seek specialist advice if patients develop peripheral neuropathy due to statins

Measure baseline LFTs before initiating therapy

Do not routinely exclude patients who have raised LFTs from statin treatment

Routine measurement of CK in asymptomatic patients is not recommended unless the patient develop muscle symptoms

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