Obstetrics, gynaecology, and sexual health
Station 74 Speculum examination and liquid based cytology test 201
• Immediately rinse the brush in the preservative solution by pushing it into the bottom of the
pot ten times, forcing the bristles apart. Then swirl the brush vigorously to further release
material.
• Inspect the brush to ensure that it is free of material.
• Discard the brush.
• Carefully remove the speculum. Hold it in the open position and completely unscrew it. Then
slowly withdraw it, rotating it sideways and allowing it to close as it is withdrawn.
After the procedure
• Dispose of the speculum and the gloves.
• Offer the patient a box of tissues and give her the opportunity to dress.
• Meanwhile, tighten the cap on the pot and place it in a specimen bag, along with the request
form.
• Warn the patient about the possibility of spotting/bleeding after the test.
• Tell her when and how she will receive the test results and the possible outcomes:
– normal test – do nothing
– inadequate or unsatisfactory test (e.g. due to inadequate number of cells in sample, infection, inflammation, menstruation) – repeat the test
– borderline or mild dyskaryosis – repeat the test in 6 months
– moderate or severe dyskaryosis – refer for colposcopy
• Tell her when her next screening test should take place (the test is carried out 3-yearly if
between 25 and 49 years old, and 5-yearly if between 50 and 64 years old).
• Ask her if she has any questions or concerns.
• Thank her.
Clinical Skills for OSCEs
202 Station 74 Speculum examination and liquid based cytology test
Examiner’s questions
Staging of Cervical Intraepithelial Neoplasia (CIN)
CIN (cervical dysplasia) is the potentially premalignant transformation and abnormal growth
(dysplasia) of squamous cells of the surface of the cervix.
CIN I Mild dysplasia confined to basal 1/3 of the epithelium.
CIN II Moderate dysplasia confined to basal 2/3 of the epithelium.
CIN III Severe dysplasia that spans more than 2/3 of the epithelium (carcinoma in situ).
Staging of cervical cancer
Stages are described in terms of the International Federation of Gynecology and Obstetrics (FIGO)
system, which is based on clinical rather than surgical findings.
Stage 0 Carcinoma in situ. Tumour is present only in epithelium.
Stage I Invasive cancer with tumour strictly confined to cervix.
Stage II Invasive cancer with tumour extending beyond cervix or upper two-thirds of vagina, but
not onto pelvic wall.
Stage III Invasive cancer with tumour spreading to lower third of vagina or onto pelvic wall.
Stage IV Invasive cancer with tumour spreading to other parts of the body.
NB: Various sub-stages are also described.
203Obstetrics, gynaecology, and sexual health
Station 75
Breast history
Before starting
• Introduce yourself to the patient, and confirm her name and date of birth.
• Explain that you are going to ask her some questions to uncover the nature of her complaint,
and obtain consent.
• Ensure that she is comfortable.
The history
• Is the patient pregnant or lactating?
Presenting complaint and history of presenting complaint
• Use open questions to ask about the presenting complaint. Explore the patient’s ideas, concerns, and expectations (ICE).
• Ask specifically about pain, a lump in the breast, and nipple discharge.
For pain, use the mnemonic ‘SOCRATES’ to determine:
• Site.
• Onset.
• Character.
• Radiation.
• Associated signs and symptoms:
– local, e.g. lump, discharge, bleeding, skin changes (e.g. dimpling, peau d’orange, erythema,
ulceration), nipple retraction/inversion, change in breast size
– systemic e.g. fatigue, fever, night sweats, weight loss, chest or back pain
• Timing/cyclicity.
• Exacerbating and alleviating factors.
• Severity from 1 to 10.
For a lump, determine:
• Onset.
• Duration.
• Site (also ask about any lumps in the other breast, neck, or armpits).
• Size.
• Cyclicity.
• Texture, e.g. hard or soft, smooth or bumpy.
• Mobility.
• Temperature.
• Pain.
• Associated symptoms (local and systemic).
For nipple discharge, determine:
• Unilateral or bilateral.
• One duct or several.
• Amount.
• Colour, e.g. clear, milky, green.
• Blood.
• Consistency.
• Spontaneity.
Clinical Skills for OSCEs
204 Station 75 Breast history
• Timing/cyclicity.
• Exacerbating and alleviating factors.
• Associated symptoms (local and systemic).
• Has the patient been breast-feeding?
Past medical history
• Previous breast problems and their outcomes.
• Breast tattoos/piercings.
• Breast implants.
• Regularity of menses and date and character of LMP.
• Current, past, and childhood illnesses.
• Surgery.
Drug history
• Prescribed medication, especially oral contraceptives and HRT. Note that certain drugs, e.g.
antipsychotics, can cause hyperprolactinaemia and galactorrhoea.
• Over-the-counter medications.
• Recreational drug use.
• Allergies.
Family history
• Parents, siblings, and children. Ask specifically about breast problems and cancers.
Social history
• Lifestyle, e.g. diet, exercise.
• Smoking.
• Alcohol use.
• Employment, past and present.
• Housing.
Systems enquiry
• If metastases are a possibility, be sure to enquire about systemic symptoms such as fatigue,
weight loss, breathlessness, bone pain, and jaundice.
After taking the history
• Ask the patient if there is anything that she might add that you have forgotten to ask about.
• Thank her.
• Summarise your findings and offer a differential diagnosis.
• State that you would like to examine the patient and, if appropriate, refer her to the one-stop
breast clinic for ‘Triple Assessment’:
1. History and examination.
2. Imaging: ultrasound (<35 years), or mammography and ultrasound (>35 years).
3. Histology/cytology: fine needle aspiration (FNAc) or core biopsy.
Obstetrics, gynaecology, and sexual health
Station 75 Breast history 205
Conditions most likely to come up in a breast history station
Fibroadenoma
• Non-cancerous mass of fibrous and glandular breast tissue.
• Most commonly affects young women (<30 years old).
• Presents as a painless, smooth, solitary, firm (‘rubbery hard’), and highly mobile lump.
• Can be multiple and bilateral.
Fibrocystic disease
• Common condition characterised by non-cancerous lumps in the breast.
• Usually affects women aged 20–40 years.
• Can sometimes cause persistent or cyclical discomfort that peaks just before the menses.
• Lumps are smooth with defined edges, usually free-moving, and most often found in the
upper, outer quadrant of the breast.
• Lumps can be associated with a nipple discharge that is clear, white, or green in colour.
• The condition usually subsides after the menopause.
Breast cyst
• Benign, fluid-filled lumps in the breast tissue.
• Common in women aged 35 years or older, especially around the menopause.
• May be painful.
Mastitis
• Bacterial infection (often S. aureus) of the breast tissue, often in connection with pregnancy
and breast-feeding (puerperal mastitis).
• Signs and symptoms include fever, malaise, breast swelling and tenderness, skin redness
(often in a wedge-shaped pattern), and pain or a burning sensation either persistently or
specifically while breast-feeding.
• The most serious complication is breast abscess.
Breast abscess
• The lump and nearby area are red, hot, tender, and painful.
• Other signs and symptoms can include fever, purulent nipple discharge, and axillary
lymphadenopathy.
• Principal complications are gangrene and septicaemia.
Mammary duct ectasia
• Dilatation and inflammation of a milk duct.
• Most common in women in their 40s and 50s.
• Often asymptomatic. However, some women may have nipple discharge and breast
tenderness or inflammation in the area near the nipple.
Carcinoma
• Cancer originating from breast tissue, most commonly from the inner lining of milk ducts
(ductal carcinoma) or the lobules (lobular carcinoma).
• Signs and symptoms include an irregular breast lump or thickening, a change in the size or
shape of the breast, changes to the skin over the breast such as dimpling, inverted nipple,
bloody nipple discharge, and lymphadenopathy.
continued
Clinical Skills for OSCEs
206 Station 75 Breast history
Conditions most likely to come up in a breast history station – continued
Intraductal papilloma
• Benign proliferation of duct epithelial cells that may present as a small painful lump in the
area of the nipple.
• Most common cause of a bloody nipple discharge in young women.
Examiner’s questions: Risk factors for breast cancer
• Female sex.
• Increasing age.
• History of breast cancer.
• Family history of breast or ovarian cancer.
• Smoking.
• Obesity.
• HRT.
• Uninterrupted oestrogen exposure:
– early menarche
– late menopause
– nulliparity
– first child after age 30
[Note] Breast-feeding is protective
207Obstetrics, gynaecology, and sexual health
Station 76
Breast examination
Specifications: In this station you may be asked to examine a patient wearing synthetic breasts. You
may also be asked to take a brief history beforehand.
A full breast examination involves inspection, palpation of the breast tissue, palpation of the nipple,
and palpation of the lymph nodes.
Before starting
• Introduce yourself to the patient, and confirm her name and date of birth.
• Explain the examination, and obtain consent.
• Request a chaperone.
• Ask the patient to undress from the waist up and hand her a drape or blanket to cover herself
up with.
• Ask her to sit on the edge of the couch, and ensure that she is comfortable.
• Ask her whether she has had any pain or nipple discharge.
The examination
General inspection
• From a distance, observe the patient’s general appearance (age, state of health, any obvious
signs).
Inspection of the breasts
• Note the size, symmetry, contour, and colour of the breast; also note the pattern of venous
drainage. In particular, look for the important signs of nipple inversion or retraction and peau
d’orange (breast carcinoma). Is there a visible discharge? Are there any scars? Also remember to
look under the breasts (ask the patient to lift up her breasts for you).
• Now ask the patient to put her hands atop her head and then to press them against her hips.
Look for tethering and asymmetrical changes in the breast contour.
Palpation of the breasts
• Ask the patient to sit back on the couch, reclining at 45 degrees.
• Ask her to put the arm ipsilateral to the breast to be examined behind her head.
• Warm up your hands.
• Before palpating the breasts, ask if there is any breast or chest pain.
• Starting with the normal breast, palpate the breast tissue with the palmar surface of the middle
three fingers, using an even rotary movement to compress the breast tissue gently towards the
chest wall. If the breasts are large, use one hand to steady the breast on its lower border.
• Examine each breast following a circular, concentric trail (Figure 46). Alternatively, use the
vertical strip or wedge palpation techniques.
• Palpate the tail of Spence between thumb and forefinger.
Clinical Skills for OSCEs
208 Station 76 Breast examination
Assess any lump for location, size, shape, colour, consistency, mobility, surface, temperature, tethering,
and tenderness.
Don’t forget that there are two breasts that need examining, a common enough oversight
in the artificial and anxiety-provoking OSCE situation.
Palpation of the nipple
• Hold the nipple between thumb and forefinger and gently compress it in an attempt to express
a discharge (or ask the patient to do this). A discharge could signify normal lactation, galactorrhoea, duct ectasia, a carcinoma, or an intraductal papilloma. Any fluid expressed should be
smeared for cytology and swabbed for microbiology.
Palpation of the lymph nodes
• Expose the right axilla by lifting and abducting the arm and supporting it at the wrist with your
right hand.
• With your left hand, palpate the following lymph node groups (See Figure 4 in Station 9):
– apical
– anterior
– posterior
– infraclavicular and supraclavicular
– nodes of the medial aspect of the humerus
• Now expose the left axilla by lifting and abducting the left arm and supporting it at the wrist
with your left hand.
• With your right hand, palpate the lymph node groups, as listed above.
Assess any nodes for size, shape, consistency, mobility, and tenderness.
Directions of palpation over breast surface
Figure 46. The circular palpation
technique. Other palpation techniques
include the vertical strip and wedge
techniques.
Obstetrics, gynaecology, and sexual health
Station 76 Breast examination 209
After the examination
Indicate that you could also:
– palpate the liver edge for an enlarged liver (liver metastases)
– palpate the spine for tenderness (spinal metastases)
– auscultate the lung bases (pleural effusions)
• Cover up the patient.
• Thank her.
• Ensure that she is comfortable.
• Summarise your findings and offer a differential diagnosis.
• Offer further investigations if appropriate, e.g. mammogram, USS, or FNAc.
Conditions most likely to come up in a breast examination station
• Fibroadenoma.
• Fibrocystic disease.
• Mastitis.
• Breast abscess.
• Mammary duct ectasia.
• Carcinoma.
• Interductal papilloma.
• See Station 75 for a description of these
conditions.
Clinical Skills for OSCEs
210 Station 77
Sexual history
This is a history that students often find difficult because of the highly personal nature of
the questions involved. The trick is to remain formal and professional throughout, yet to
exert tact and, if the patient becomes uncomfortable, a measure of restraint. The OSCE
may ask you to focus on either risk assessment or sexual function. If the latter, do not
forget that sexual dysfunction often results from medical and psychiatric disorders and/or
their treatments, e.g. antihypertensives, antidepressants.
Before starting
• Introduce yourself to the patient, and confirm his name and date of birth.
• Set the scene: “I’d like to ask you a few standard questions about your sex life. I don’t mean to
embarrass you, and it’s alright if you’d rather not answer some of my questions. May I begin?”
• Reassure the patient about confidentiality.
• Explore the patient’s ideas, concerns and expectations.
The history
Would you describe yourself as heterosexual, homosexual, or bisexual?
Who
• “Who did you last have sex with, and when was this?”
• “Who else have you had sex with in the last three months?”
• “Were they male or female?”
• “Were they regular or casual partners?”
How
• “Did you have vaginal/oral/anal sex?”
• “If oral or anal sex, did you give or receive it?”
• “Did you use protection on each occasion?”
• If yes, “did you have any problems with it?”
• “Have you ever been injured or abused by your partner?”
• “Have you ever paid or been paid for sex?”
Where
• “Have you had sex whilst abroad? Whom with?”
• “Where are your partners from?”
• “Is it possible that they have had sex whilst abroad?”
Sexually transmitted diseases
Ask about:
• Any sores, discharge, bleeding, itching, rashes, dysuria, and abdominal pain (in females).
Explore any positive findings.
• History of sexually transmitted diseases (including HIV and hepatitis B) in both the patient and
his partner(s).
• Other risk factors for HIV and hepatitis B, e.g. blood transfusions, intravenous drug use, tattoos.
• In females, date and result of the last cervical smear test.
Obstetrics, gynaecology, and sexual health
Station 77 Sexual history 211
Sexual function
• “‘Do you have any problems with, or concerns about, having sex?” You may ask specifically about
erectile dysfunction and ejaculatory dysfunction in males, and about hypoactive sexual desire,
anorgasmia, vaginismus, and dyspareunia in females.
• Determine the onset, course, and duration of the problem. Is the problem primary or secondary?
• Determine the frequency and timing of the problem. Is the problem partial or situational? In
situational erectile dysfunction, the patient is still able to have morning erections.
• Assess the effect that the problem is having on the patient’s life.
Table 28. Types of sexual dysfunction (common types are in bold)
Type of sexual dysfunction Male Female
Sexual desire disorders Hypoactive sexual desire
Sexual aversion (rare)
Hypoactive sexual desire (F > M)
Sexual aversion (rare)
Sexual arousal disorders Erectile dysfunction* Failure of genital response
Sexual pain disorders Dyspareunia Dyspareunia (F > M)
Vaginismus§
Orgasm disorders Ejaculatory impotence
Premature ejaculation**
Anorgasmia (F > M)
*Erectile dysfunction or impotence is more common in elderly males.
**Premature ejaculation is more common in young males engaging in their first sexual relationships.
§
Vaginismus describes involuntary vaginal contractions in response to attempts at penetration.
Past medical history
• History of sexually transmitted diseases.
• History of sexual problems.
• Menstrual history: regularity of menses and date and character of LMP.
• Medical conditions and previous hospital admissions.
Obstetric and gynaecological history (if appropriate)
• Menstrual history: regularity of menses and date and character of LMP.
• Past pregnancies, deliveries, miscarriages, and terminations.
• “Is it possible that you might be pregnant?”
Drug history
• Contraceptives.
• Recent antibiotic use.
• Smoking and alcohol.
• Drug use (including needle sharing).
Social history
• Occupation.
• Living arrangements.
Clinical Skills for OSCEs
212 Station 77 Sexual history
After taking the history
• Ask if there is anything that the patient would like to add which you may have forgotten to ask
about.
• Thank the patient.
• Summarise your findings and offer a further course of action, e.g. physical examination, microbiological testing, contact tracing.
Conditions most likely to come up in a sexual history station
Candidiasis
• Common fungal infection involving any of the Candida species. Infection of the vagina or
vulva is often asymptomatic but may cause severe itching, burning, soreness, irritation, and a
whitish or whitish-grey ‘cottage cheese’ discharge.
• In men, there may be red and itchy or painful sores on the penile head or foreskin.
• Candidiasis is not classified as an STD.
Bacterial vaginosis (BV)
• Common bacterial infection involving, among others, Gardnerella vaginalis.
• Results from disruption in the balance of bacteria in the vagina.
• Although BV is not classified as an STD, it is more common in women who are sexually active
and increases their susceptibility to STDs.
• It may be asymptomatic or there may be a thin, homogeneous, off-white, and malodorous
vaginal discharge, usually in the absence of redness, itchiness, or pain.
Chlamydia
• One of the most common STDs involving the bacterium Chlamydia trachomatis.
• In women it is symptomatic in around 20–30% of cases, presenting with a yellow and
odourless mucopurulent cervical discharge, dysuria, and frequency.
• In men, it is symptomatic in around 50% of cases, presenting with a white penile discharge
with or without dysuria.
• Major complications are pelvic inflammatory disease in women, epididymitis in men, and
Reiter’s syndrome (triad of arthritis, conjunctivitis, and urethritis) in both.
Gonorrhoea
• A common STD caused by Neisseria gonorrhoeae.
• In women it is symptomatic in around 50% of cases, presenting with a greenish–yellow
malodorous vaginal discharge, dysuria, and frequency.
• In men, it presents with a yellow–white penile discharge and dysuria. Symptoms typically
occur 4–6 days after being infected.
• Major complications are pelvic inflammatory disease in women and epididymitis in men, or
systemic spread to affect the joints and heart valves.
Trichomoniasis
• STD caused by the protozoan parasite Trichomonas vaginalis.
• Typically, only women experience symptoms but even they may be asymptomatic.
• Symptoms typically occur 5–28 days after being infected and include copious amounts of a
frothy, foul-smelling greenish–yellow mucopurulent discharge, itchiness, dysuria, and frequency.
• Discomfort may increase during intercourse and upon micturition.
Obstetrics, gynaecology, and sexual health
Station 77 Sexual history 213
Syphilis
• STD caused by the bacteria Treponema pallidum.
• The disease can also be transmitted from mother to foetus, resulting in congenital syphilis.
• Signs and symptoms depend on which of the four stages it presents in:
– primary stage presents at an average of 21 days after initial exposure, typically with a single
lesion (chancre)
– secondary stage presents with a diffuse rash and other symptoms such as fever, malaise,
headache
– in the latent stage, there is serological proof of infection but few if no symptoms
– tertiary stage supervenes 3–15 years after initial infection with gummas and neurological
and cardiac symptoms
Genital herpes
• Genital infection by Herpes simplex virus (HSV) that may lead to clusters of inflamed papules
and vesicles on the outer surface of the genitals or on surrounding skin.
• These usually appear 4–7 days after sexual exposure to HSV.
• Other common symptoms include pain, itching, discharge, fever, and myalgia. After 2–3
weeks, the lesions progress into ulcers and then crust and heal.
Genital warts
• Highly contagious STD caused by some sub-types of human papillomavirus (HPV), and spread
through direct skin-to-skin contact during oral, genital, or anal sex.
• Approximately 70% of those who have sexual contact with a partner with an active infection
develop genital warts, and while less than 1% of those become symptomatic, those infected
can still transmit the virus.
• Usually painless and benign, but can be unsightly.
Sexual dysfunction
• Sexual dysfunction can occur at any stage of sexual intercourse: initiation, arousal, penetration,
and orgasm (see Table 28).
• It can result from organic causes (such as diabetes, angina, prostate surgery, antihypertensives,
antidepressants, antipsychotics) or from psychological causes (e.g. depression, anxiety,
sexual inexperience, traumatic sexual experience, relationship difficulties, stress), or from a
combination of either.
• In secondary dysfunction there is a history of normal function, but in primary dysfunction such
a history is lacking. The epidemiology of sexual dysfunction is difficult to establish, but erectile
dysfunction and premature ejaculation are common in males, and anorgasmia and hypoactive
sexual desire in females.
Clinical Skills for OSCEs
214 Station 78
HIV risk assessment
Before starting
• Introduce yourself to the patient, and confirm his name and date of birth.
• Explain that you are going to ask him some questions to determine his likelihood of having
contracted HIV, and obtain consent.
• Reassure him about confidentiality.
• Remember to be especially sensitive, tactful, and empathetic.
The risk assessment
• Explore the patient’s reason for attendance, e.g. ideas, concerns, and expectations.
Sexual behaviour
• Does the patient have sex with men, women, or both?
• Does he have unprotected anal, vaginal, or oral sex? If so, when, where, how often, and with
how many different partners? Unprotected receptive anal intercourse is especially high risk.
• Has he had sex outside the UK or with partners from outside the UK?
• Has he ever paid or been paid for sex?
• What are the sexual practices of his partners? Are any of them HIV positive?
• Has he recently contracted any sexually transmitted diseases?
Illicit drug use
• Does the patient inject himself? If so, has he been sharing needles?
• Do any of his partners inject themselves?
Piercing and tattoos
• Has the patient had any piercings or tattoos performed outside of the UK?
• Does he have any concerns about the needles that were used?
Blood products and transfusions
• Is the patient a haemophiliac?
• Has he received blood products or transfusions prior to about 1985 or outside of the UK?
Occupational risk
• Ask about the patient’s occupation to determine whether he poses an occupational risk.
After the risk assessment
• Ask the patient if there is anything that he might add that you have forgotten to ask about.
• Give him feedback on his HIV risk and, if appropriate, indicate a further course of action, e.g.
an HIV test.
• Address his concerns.
• Thank him.
215Obstetrics, gynaecology, and sexual health
Station 79
Condom explanation
Male and female condoms are barrier methods of contraception and prevent sperm from reaching
the ovum. They are very effective at preventing sexually transmitted infections but less effective than
methods such as the pill in preventing pregnancy.
There are many different types of male condoms available on the market. These include plain-end
or teat-end, shaped/ribbed or straight-sided, and lubricated (e.g. with inert silicone or nonoxynol-9
spermicide) condoms. Femidom is the only female condom available in the UK.
Spermicidal condoms are no longer recommended as evidence suggests that nanoxynol-9 may
increase the risk of HIV and other sexually transmitted infections such as chlamydia and gonorrhoea.
Before starting
• Introduce yourself to the patient, and confirm his name and date of birth.
• Establish how much he already knows about using condoms. If correctly used, the male condom
is 98% effective, and the female condom 95% effective. Condoms also protect against STDs.
The equipment
• Two condoms
• A model of a penis
• An information booklet on condom use
Explain the use of a condom
• Condom use should be discussed with the partner(s).
• The condom should be put on before any genital contact takes place.
• Principal side-effects are due to latex allergy and spermicide sensitivity.
• Principal contraindications are oil-based lubricants such as Vaseline, hormonal vaginal creams,
and antifungal preparations (Canesten is safe to use).
• Explain/demonstrate the use of a condom:
– check for the British Kite mark (Figure 47) or equivalent symbol, a guarantee of quality
– check the expiry date
– carefully tear open the pack and remove the condom – do not use teeth or sharp nails
– position the condom on the tip of the erect penis
– squeeze out the air from the tip of the condom and gently roll it out to the base of the penis
– hold the condom at the base of the penis during penetration
– after intercourse, remove the condom ensuring that semen is not spilt
– dispose of the condom in the bin – condoms must never be re-used
• Ask the patient to repeat the procedure.
Figure 47. British kite mark.
Explain that condoms can occasionally tear and that, in this event, the patient and his
6 Station 79 Condom explanation
After the explanation
• Ask if the patient has any questions or concerns. (He may ask you about other methods of
contraception.)
• Tell him to return should he have any further questions.
• Give him an information booklet on condom use.
217Obstetrics, gynaecology, and sexual health
Station 80
Combined oral contraceptive pill (COCP)
explanation
Before starting
• Introduce yourself to the patient, and confirm her name and date of birth.
• Confirm the reason for her attendance and her understanding of the COCP.
• Has she considered other methods of contraception?
Explaining the COCP – items to cover
Efficacy
99.9% if used correctly, 97% in practice.
It is important to emphasise that the pill does not protect against STDs.
Principal benefits
• Easy to take, reversible, and non-invasive.
• More regular periods, less blood loss, fewer period pains.
• Decreased risk of ovarian cancer, endometrial cancer, ovarian cysts, and benign breast disease.
• Acne often improves.
Principal risks
• Increased risk of deep vein thrombosis and pulmonary embolism.
• Increased risk of myocardial infarction.
• Increased risk of breast cancer and cervical adenocarcinoma.
Principal adverse effects
• Headache.
• Nausea.
• Dizziness.
• Hypertension.
• Breast tenderness.
• Weight gain.
• Depression.
Principal contraindications
Absolute
• Age over 50.
• BMI over 35.
• Thrombophlebitis, thromboembolitic disorder, or history of thromboembolism.
• Severe migraine with focal aura/neurology.
• Stroke.
• Ischaemic heart disease.
• Liver disease.
Clinical Skills for OSCEs
218 Station 80 Combined oral contraceptive pill (COCP) explanation
• Kidney disease.
• History of breast cancer or other oestrogen-dependent cancers of the reproductive organs.
• Pregnancy.
Relative
• Uncontrolled hypertension.
• Smoking (> 15 cigarettes a day and over the age of 35).
• Abnormal vaginal bleeding.
• Sickle cell disease.
• Breast-feeding.
• Family history of hyperlipidaemia, heart disease, or kidney disease.
Remember to take a quick drug history, as enzyme-inducing drugs – including antipsychotics, anti-depressants, anti-epileptics, and some antibiotics – can alter the
effectiveness of the pill.
How to take the pills
• Start taking the pill on the first day of your period. If you start on any other day of your cycle,
you need to use barrier contraception for the first 7 days.
• Take one pill a day at the same time every day for either 21 or 28 days, depending on the
number of pills in the pack.
• After finishing the 28-day pack, start another one immediately (the last seven pills in the 28-day
pack are ‘dummy pills’).
• After finishing the 21-day pack, stop taking the pill for 7 days and then start another pack.
• If you develop vomiting or diarrhoea, use barrier contraception until your next period.
• If you take a course of antibiotics, use barrier contraception during the course and for
2–3 days after.
SUN MON TUES WED THU FRI SAT
28 Day
Figure 48. A 28-day pack.
What if pills are missed
• If one pill is missed:
– take a pill as soon as you can remember to do so
– take the next pill at the regular time
• If two or more pills are missed:
– take a pill as soon as you can remember to do so (earlier missed pills should not be taken)
– continue taking one pill a day, as per usual
– use barrier contraception for 7 days
• If there are fewer than seven pills left in the pack (after the missed pill), start on the next pack
without taking a break
Obstetrics, gynaecology, and sexual health
Station 80 Combined oral contraceptive pill (COCP) explanation 219
Before finishing
• Summarise and check understanding.
• Hand out a leaflet on the COCP.
• Tell the patient to report any severe or unexpected symptoms.
Examiner’s questions: Other forms of contraception
Combined hormonal contraceptives are also available as a skin patch, worn for 3 out of every 4 weeks.
Low-dose progestogen-only contraceptives such as the traditional progestogen-only pill (POP,
‘mini-pill’), subdermal implants (e.g. Norplant), and intrauterine systems (e.g. Mirena) inconsistently
inhibit ovulation but thicken the cervical mucus and reduce sperm penetration, and also make the
endometrium unsuitable for implantation. Intermediate-dose progestogen-only contraceptives such
as the Cerazette® pill are much more reliable at inhibiting ovulation, and high-dose progestogen-only
contraceptives such as the injectable Depo-Provera inhibit ovulation completely (in the case of DepoProvera, for up to 3 months).
The POP is taken continuously without any breaks. Whereas the COCP can be taken within a window
of 12 hours, the mini-pill has a much shorter window of 3 hours. Thus, whilst the efficacy of the minipill is similar to that of the COCP, it is more dependent on user compliance. The POP is not affected by
broad-spectrum antibiotics, and can often be used when the COCP is contraindicated, e.g. in smokers
above the age of 35. It is contraindicated in cardiovascular disease, liver disease, breast cancer, ovarian
cysts, and migraine. Side-effects, if any, are generally mild and transient. There is a small increased risk
of ectopic pregnancy and breast cancer. Unlike the COCP, the POP does not regulate menstruation and
can lead to either irregular menstruation or amenorrhoea.
Emergency post-coital contraception comes either in the form of an intrauterine device (IUD) or an
emergency contraceptive pill (ECP, ‘morning-after pill’) that, in contrast to medical abortion methods,
act before implantation, either by postponing ovulation or by preventing implantation. The Levonelle
brand contains levonorgestrel which is a progestogen hormone, and is licensed for use up to 72 hours
after intercourse. There is an approximate 80% reduction in the risk of pregnancy, to about 1–2% (this
compares to virtually 0% for the IUD). Generally speaking, the advantages of using the ECP outweigh
any theoretical or proven risks, and harm to a foetus that has already implanted is thought to be very
unlikely. Side-effects include nausea, vomiting, abdominal pain, fatigue, headache, and dizziness. The
ECP should not be confused with the ‘abortion pill’ (high dose mifepristone, RU 486).
Clinical Skills for OSCEs
220 Station 81
Pessaries and suppositories explanation
Read in conjunction with Station 116: Explaining skills.
Like tablets, pessaries and suppositories are medication. Suppositories are for rectal use, common
examples being pain-killers and steroids, whereas pessaries are for vaginal use, common examples
being antibiotics and progesterone.
They are used if oral drugs cannot be given, for example, in the post-operative period or if the patient
is vomiting, and if the site of action of the drug is the rectum or vagina, or near enough, for example,
the colon or cervix.
In this station you may be asked to explain the use of a pessary and/or a suppository to a patient. Both
scenarios have been described here.
Before starting
• Introduce yourself to the patient and verify her name and date of birth.
• Confirm the reason for attendance.
• Ask her if she has ever used a pessary or suppository before, and whether she has any questions
or concerns.
The explanation: items to cover
Be sensitive to the psychological and sociocultural issues involved in placing a finger into
the vagina or rectum, and be sympathetic and understanding.
Pessaries
• Pessaries are bullet-shaped medicines designed for easy insertion into the vagina using your
fingers or an applicator. Your body temperature will slowly dissolve the pessary and release the
medicine into your vagina.
• Before using a pessary, check its expiry date.
• Wash and dry your hands.
• Remove the pessary and applicator (if supplied) from its foil or wrapper.
• If an applicator is supplied, push the pessary into the hole at its end.
• Lie down with your knees bent and legs apart.
• Carefully push the pessary high up into your vagina, pointed end first, using either your fingers
or the applicator.
• If using an applicator, push the plunger to release the pessary and then remove the applicator.
• Wash your hands afterwards.
• The pessary may leak from your vagina, so it may be best to insert it before bedtime and to use
a sanitary towel to avoid staining of the clothes.
• If you miss a dose, insert the pessary as soon as you remember, and then carry on as normal.
• Store in a cool, dry place and out of children’s reach.
• Continue using your pessaries until the course is completed, even if this means inserting them
during your monthly period.
Obstetrics, gynaecology, and sexual health
Station 81 Pessaries and suppositories explanation 221
Suppositories
• Suppositories are bullet-shaped medicines designed for easy insertion into the lower bowel
(rectum) using your fingers. Your body temperature will slowly dissolve the suppository and
release the medicine across your rectum and into the bloodstream.
• Before using a suppository, check its expiry date
• Empty your bowels if necessary.
• Wash and dry your hands.
• Remove the suppository from its foil or wrapper.
• Lie down on your side with one leg bent and the other straight.
• Carefully push the suppository 2–3 cm up your bottom, pointed end first, using your finger.
Some people may prefer to wear a glove, but this is not necessary.
• Close your legs and lie still for a few minutes.
• Wash your hands afterwards.
• If you open your bowels within 2 hours of inserting the suppository, you need to insert another.
• The suppository may leak from your rectum, so it may be best to insert it before bedtime and
(if female) to use a sanitary towel to avoid staining of the clothes.
• If you miss a dose, insert the suppository as soon as you remember, and then carry on as normal.
• Store in a cool, dark place and out of children’s reach.
• Continue using your suppositories until the course is completed.
After the explanation
• Summarise and check the patient’s understanding.
• Ask if she has any questions or concerns.
• Offer her a leaflet.
Clinical Skills for OSCEs
222 Station 82
Rheumatological history
Before starting
• Introduce yourself to the patient, and confirm his name and date of birth.
• Explain that you are going to ask him some questions to uncover the nature of his complaint,
and obtain consent.
• Ensure that he is comfortable.
The history
Name, age, and occupation, if this information has not already been supplied.
Presenting complaint
Ask the patient about the nature of his complaint. Use open questions.
Pain
Determine site (joints affected), severity, and timing (e.g. is it worse in the morning or later in the day?).
Stiffness
Determine site, severity and timing.
Swelling
Determine site, severity and timing.
History of presenting complaint
Ask about:
• Onset and any provoking factors such as trauma or infection.
• Progression.
• Any associated features:
– local: swelling or inflammation, deformity, cracking, clicking, locking, loss of movement
– systemic: skin problems, eye problems, GI disturbances, urethral discharge
– general: Raynaud’s phenomenon (peripheral vasospasm), fever, night sweats, weight loss
• Any aggravating or relieving factors such as activity, rest, NSAIDs, steroids.
Social history
Ask about:
• Difficulty in completing everyday tasks and the effect that this is having on his life. If need be,
you can get him to describe a typical day: getting out of bed, toileting, dressing, etc. What did
he used to do that he can no longer do?
• Housing and home-help. Are there stairs to climb?
• Mood. Screen for the core features of depression: low mood, fatigability, and loss of interest.
• Recent travel. If appropriate, ask about vaccines, gastroenteritis, and unprotected sexual intercourse (reactive arthritis/Reiter’s syndrome).
Orthopaedics and rheumatology
Station 82 Rheumatological history 223
Past medical history
• Current, past, and childhood illnesses.
• Surgery.
• Recent visits to the doctor.
Drug history
• Prescribed medication, e.g. NSAIDs, steroids, immunosuppressants.
• Over-the-counter medications.
• Allergies.
• Smoking, alcohol use, and recreational drug use.
Family history
• Parents, siblings, children. Has anyone in the family ever had similar problems?
After taking the history
• Ask the patient if there is anything he might add that you have forgotten to ask about.
• Thank the patient.
Conditions most likely to come up in a rheumatological history station
Rheumatoid arthritis:
• Chronic, systemic inflammatory disorder that may affect many tissues and organs, but
principally the synovial joints, leading to destruction of articular cartilage and ankylosis of the
joints.
• Women are three times more commonly affected than men.
• Onset is often at age 40–50, but can be at any age.
• Affects multiple joints, often in a symmetrical fashion, and most commonly the small joints of
the hands, feet, and cervical spine.
• Affected joints are swollen, warm, painful, and stiff, particularly early in the morning, on
waking, or following prolonged activity.
• In time, there is decreased range of movement and deformity, e.g. ulnar deviation,
boutonnière deformity, swan neck deformity, Z-thumb.
Osteoarthritis:
• ‘Wear and tear’ arthritis.
• Commonly affects the hands, feet, spine, and the large weight-bearing joints.
• Affected joints are painful, tender, and stiff, with symptoms worsening throughout the day
and after exercise.
• There may be hard bony enlargements called Heberden’s nodes on the distal interphalangeal
joints and Bouchard’s nodes on the proximal interphalangeal joints.
• There may be crepitus upon movement, restricted range of movement, joint mal-alignment,
and effusions.
Clinical Skills for OSCEs
224 Station 82 Rheumatological history
Psoriatic arthritis:
• Systemic inflammatory disorder associated with psoriasis.
• Asymmetrical or relatively asymmetrical arthritis most commonly affecting the distal joints in
the hands and feet.
• Symptoms of inflammation, pain, and stiffness typically wax and wane.
• There may be swelling of an entire finger or toe (dactylitis) as well as fingernail and toenail
involvement.
Gout:
• Caused by elevated levels of urate in the blood.
• More common in men.
• Presents as recurrent attacks of acute inflammatory arthritis.
• Commonly (but not exclusively) affects the metatarsal–phalangeal joint at the base of the big
toe.
• The joint is red, tender, hot, and swollen.
• May be associated with hard, painless deposits of uric acid called tophi.
• Pseudogout can be difficult to distinguish from gout; it involves calcium pyrophosphate
dihydrate rather than urate deposition, and it normally affects the knee and larger joints rather
than the foot.
Ankylosing spondylitis:
• Chronic, inflammatory disorder principally affecting the axial skeleton and sacroiliac joints and
potentially leading to fusion of the spine (‘bamboo spine’) and to damage of the spinal cord,
roots, and nerves.
• There is a strong genetic component.
• It is more common and tends to be more severe in males.
• Commonly presents at ages 20–40.
• Morning stiffness is characteristic, and pain improves with physical activity.
• May be associated with systemic features such as fever and weight loss and extra-articular
manifestations such as uveitis.
Septic arthritis:
• Septic arthritis is a medical emergency.
• Results from direct invasion of one or several joint spaces by various microorganisms, with the
knee being the joint that is most commonly affected.
• Acute onset of joint pain with possible systemic symptoms and possible history of underlying
joint disease or trauma, unprotected sexual intercourse or intravenous drug use.
• The joint itself is red, tender, hot, and swollen, and there is often an effusion.
Orthopaedics and rheumatology
Station 82 Rheumatological history 225
Polymyositis and dermatomyositis:
• Polymyositis is an inflammatory myopathy related to dermatomyositis.
• It commonly presents in early adulthood with bilateral and progressive proximal muscle
weakness.
• The muscles may be painful and tender and there may be systemic symptoms such as fatigue
and fever.
• In dermatomyositis there is also a skin rash.
• The cause or causes of polymyositis and dermatomyositis is unknown.
Polymyalgia rheumatica:
• Muscle pain and stiffness in the neck, shoulders, and hips, especially in the morning or after
inactivity.
• The disorder may develop either rapidly or gradually.
• Systemic symptoms may include fatigue, fever, and anorexia.
• There is an association with temporal arteritis.
• Usually affects older adults, more commonly females.
• The cause of polymyalgia rheumatica is unknown.
• Prognosis is good, especially with corticosteroid treatment.
Tendon rupture
Complications of steroid treatment
Clinical Skills for OSCEs
226 Station 83
The GALS screening examination
GALS: ‘Gait, arms, legs, and spine’. Remember that GALS is a screening test and that a detailed
examination is therefore not called upon.
Before starting
• Introduce yourself to the patient, and confirm his name and date of birth.
• Explain the examination and obtain his consent.
• Ask him to undress to his undergarments.
• Ensure that he is comfortable.
The GALS screening examination
Brief history
• Name, age, and occupation, if this information has not already been supplied.
• “Do you have any pain or stiffness in your muscles, back, or joints?”
• “Do you have any difficulty in climbing stairs?”
• “Do you have any difficulty washing or dressing?”
The examination
General inspection
Inspect the patient standing. Note any obvious scars, swellings, deformities, and/or unusual posturing.
Spine
Look
• From the front.
• From behind, looking in particular for list, scoliosis and lumbar lordosis.
• From the side, looking in particular for kyphos, kyphosis and fixed flexion deformity.
Feel
• Press on each vertebral body in turn, trying to elicit tenderness.
Move
• Ask the patient to bend forwards and touch his toes. Look for lumbar lordosis and for scoliosis,
which should become more pronounced.
Ask him to sit down on the couch.
• Lateral flexion of the neck. Ask him to put his ear on his shoulder and then do the same on the
other side.
• Flexion and extension of the neck. Ask him to put his chin on his chest and then look up towards
the ceiling.
• Spinal rotation. Ask him to turn his upper body to either side.
Demonstrate each of these movements to the patient. In particular, look for restricted range of
movement and pain on movement.
Orthopaedics and rheumatology
Station 83 The GALS screening examination 227
Arms
Look
• Skin: rashes, nodules, nail signs
• Muscles: wasting, fasciculation
• Joints: swelling, asymmetry, deformity
Do not forget to inspect both surfaces of the hands.
Feel
• Skin: temperature
• Muscles: general muscle bulk
• Joints: tenderness and warmth; squeeze each hand at the level of the carpal and metacarpal joints, and try to localise any tenderness by squeezing each individual joint
in turn
Move
• Hands: ask the patient to squeeze your finger (grip strength); then ask him to make a
pinch and attempt to ‘break’ his pinch (precision pinch)
• Wrists: ask him to put his hands in the prayer position and then in the reverse prayer position
• Elbows: ask him to bring up hisforearms asif he were lifting weights and then to straighten
out his arms alongside his body
• Shoulders: ask him to raise his arms above his head (abduction) and to then to put his hands
behind his head (internal rotation); coming from below, ask him to touch his back
between the shoulder blades (external rotation).
Demonstrate these movements to the patient. Look for restricted range of movement and pain on
movement.
Legs
Now ask the patient to lie on the couch.
Look
• Skin: rashes, nodules, callosities on the soles of the feet
• Muscles: wasting, fasciculation
• Joints: swelling, asymmetry, deformity
Feel
• Skin: temperature
• Joints: tenderness, warmth, and swelling; palpate each knee along the joint margin;
squeeze each foot, and try to localise any tenderness by squeezing each individual
joint in turn
Move
• Ask the patient to bring his heels to his bottom.
• Hold the knee and hip at 90 degrees of flexion and internally and externally rotate the hip. Keep
an eye on the patient’s face as you do this and ensure that you do not cause him unnecessary
pain.
• Next, place one hand on the knee joint and extend it, feeling for any crepitus as you do so.
• Repeat on the other side.
Clinical Skills for OSCEs
228 Station 83 The GALS screening examination
Gait
Ask the patient to walk, observing:
• General features: rhythm, speed, stride length, limp.
• The phases of gait: heel-strike, stance, push-off, and swing.
• Arm swing.
• Turning.
• Transfer ability: sitting and standing from a chair (note that you should already have had a
chance to observe this).
After the examination
• Thank the patient.
• Offer to help him dress.
• Ensure that he is comfortable.
• Summarise your findings.
• If appropriate, indicate that you would perform a more detailed physical examination.
229Orthopaedics and rheumatology
Station 84
Hand and wrist examination
Before starting
• Introduce yourself to the patient, and confirm his name and date of birth.
• Explain the examination and obtain his consent.
• Ask him to expose his arms.
• Ensure that he is comfortable.
The examination
Look
First inspect the dorsum and then the palmar surfaces of the hands.
• Skin: colour, rheumatoid nodules, scars, nail changes such as pitting or loosening.
• Joints: swelling, Heberden’s nodes (on DIP joints), Bouchard’s nodes (on PIP joints).
• Shape and position: normal resting position of the hand, ulnar deviation, boutonnière and swan
neck deformity of the fingers, mallet finger, finger droop, Z-deformity of the thumb, muscle
wasting in the thenar or hypothenar eminences, Dupuytren’s contracture.
• Elbows: psoriatic plaques, gouty tophi, rheumatoid nodules.
Figure 49. The arthritic hand. Boutonnière and swan neck deformity of the fingers.
Feel
Ask if there is any pain before you start.
• Skin: temperature.
• Finger and wrist joints: swelling, synovial thickening, tenderness.
• Anatomical snuff box (fractured scaphoid).
• Tip of the radial styloid (de Quervain’s disease) and head of the ulna (extensor carpi ulnaris
tendinitis).
Move
Test active and passive movements, looking for limitation in the normal range of movement. Ask the
patient to report any pain.
Wrist
• Flexion and extension.
• Ulnar and radial deviation.
• Pronation and supination.
Boutonnière deformity Swan neck deformity
Clinical Skills for OSCEs
230 Station 84 Hand and wrist examination
Thumb
• Extension. “Stick your thumb out to the side.”
• Abduction. “Point your thumb up to the ceiling.”
• Adduction. “Collect your thumb in your palm.”
• Opposition. “Appose the tip of your thumb to the tip of your little finger.”
Fingers
Each finger should be fully extended and flexed. Look at the movements of the metacarpophalangeal
and interphalangeal joints. Test the grip strength by asking the patient to make a fist and try to squeeze
your fingers. Try to open the fist. Test the pincer strength by trying to break the pinch between his
thumb and first finger.
Special tests
• Carpal tunnel tests:
– try to elicit Tinel’s sign by extending the hand and tapping on the median nerve in the
carpal tunnel
– try to elicit Phalen’s sign by holding the hand in forced flexion for 30–60 seconds
Figure 50. An alternative and quicker method for
eliciting Phalen’s sign.
• Flexor profundus: hold a finger extended at the proximal interphalangeal joint and ask the
patient to flex the distal interphalangeal joint of that same finger.
• Flexorsuperficialis: ask the patient to flex a finger whilst holding all the other fingers on the same
hand extended.
• Assess function by asking the patient to make use of an everyday object such as a pen or cup.
After the examination
• State that you would also like to examine the vascular and neurological systems of the upper
limb.
• If appropriate, indicate that you would order some tests, e.g. X-ray (AP and lateral), FBC, ESR,
rheumatoid factor, etc.
• Thank the patient.
• Ensure that he is comfortable.
• Offer to help the patient put his clothes back on.
• Offer a differential diagnosis.
Orthopaedics and rheumatology
Station 84 Hand and wrist examination 231
Conditions most likely to come up in a hand and wrist examination station
Osteoarthritis (see Station 82)
Rheumatoid arthritis (see Station 82)
Psoriatic arthritis (see Station 82)
Lesions of the median, radial, or ulnar nerves
(see Station 33)
Gout (see Station 82)
Carpal tunnel syndrome:
• Compression of the median nerve in the
carpal tunnel.
• More common in females.
• Burning pain, tingling, and numbness in
the distribution of the median nerve.
• Possible wasting of the thenar eminence
and weakness of the abductor pollicis
brevis.
• Tinel’s sign and Phalen’s sign are
positive.
Dupuytren’s disease:
• Fixed flexion contracture of the hand
with the ring and little fingers most
commonly affected.
• Scar tissue palpable beneath the skin of
the palm with dimpling and puckering
of the skin over that area.
De Quervain’s tenosynovitis:
• Idiopathic inflammation of the tendons of
extensor pollicis brevis and abductor pollicis
longus muscles concerned with radial
abduction of the thumb.
• Accompanied by difficulty gripping and
pain, tenderness, and swelling over the
radial styloid.
• The diagnosis is verified by holding the
thumb inside a clenched fist and ulnar
deviating the wrist; this stretches the
inflamed tendons over the radial styloid,
thereby exacerbating the patient’s pain
(Finkelstein’s test).
Trigger finger:
• Idiopathic catching, snapping, or locking of
the involved finger flexor tendon.
• Associated with pain and loss of function.
• Middle and ring finger most commonly
affected.
• The finger clicks when it is flexed and gets
stuck in the flexed position.
• Overcoming this resistance leads to the
finger snapping straight, hence the name
‘trigger finger’.
Clinical Skills for OSCEs
232 Station 85
Elbow examination
Thisstation is unlikely to come up on its own but may be asked as part of a hand and wrist examination,
and is included here for the sake of completeness.
Before starting
• Introduce yourself to the patient, and confirm his name and date of birth.
• Explain the examination and obtain his consent.
• Ask him to expose his arms.
• Ensure that he is comfortable.
The examination
Look
Ask the patient to hold his arms by his side.
• Overall impression: varus or valgus deformities (look from behind), effusions, inflammation
of the olecranon bursa
• Skin: rheumatoid nodules, gouty tophi, scars
• Muscle wasting: biceps, triceps, forearm
Feel
Ask if there is any pain before you start.
• Skin: temperature, psoriatic plaques, rheumatoid nodules, gouty tophi
• Joints: tenderness, effusions, synovial thickening
• Bones: tenderness of the lateral and medial epicondyles
Move
• Flexion and extension:
– tennis elbow: ask about pain at the lateral epicondyle on elbow extension and forced wrist
extension
– golfer’s elbow: ask about pain at the medial epicondyle on elbow flexion and forced wrist
flexion
• Pronation and supination. Show the patient how to tuck his elbowsinto hissides and to turn his
arms so that the palm of his hands face up and down (a bit like the gesture for ‘I don’t know’).
After the examination
• State that you would also like to examine the wrist and hand.
• State that you would also like to examine the vascular and neurological systems of the upper
limb.
• If appropriate, indicate that you would order some tests, e.g. X-ray (AP and lateral), FBC, ESR,
rheumatoid factor, etc.
• Thank the patient.
• Offer to help him put his clothes back on.
• Ensure that he is comfortable.
• Summarise your findings and offer a differential diagnosis.
Conditions most likely to come up in an elbow examination station
• Osteoarthritis • Rheumatoid arthritis • Olecranon bursitis
233Orthopaedics and rheumatology
Station 86
Shoulder examination
Before starting
• Introduce yourself to the patient, and confirm his name and date of birth.
• Explain the examination and obtain his consent.
• Ask him to undress from the waist upward.
• Ensure that he is comfortable.
The examination
Look
Inspect from front and back.
• Overall impression: alignment, symmetry, position of the arms, axillae, prominence of the
acromioclavicular and sternoclavicular joints
• Skin: colour, sinuses, scars
• Muscle wasting: deltoid, periscapular muscles (supraspinatus and infraspinatus)
Feel
Ask if there is any pain before you start.
• Skin: temperature – compare both sides
• Bones and joints: palpate the bony landmarks of the shoulder, starting at the sternoclavicular joint and moving laterally along the clavicle. Try to localise any
tenderness. Can you feel any effusions?
• Biceps tendon: ask the patient to flex his arms and palpate the biceps tendon in the
bicipital groove. Tenderness suggests biceps tendinitis
Figure 51. Anatomy of the shoulder joint.
Clavicle
Acromioclavicular
joint/ligament
Sternoclavicular
joint/ligament
Sternum Scapula
Glenohumeral
joint
Humerus
Acromion
Coracoid
process
Clinical Skills for OSCEs
234 Station 86 Shoulder examination
Move
Demonstrate these movements to the patient. Ask him to tell you if he feels any pain at any point. Note
where the pain starts and stops, and any restriction in movement.
• Abduction: “Raise your arms above your head, making the palms of your
hands touch.”
• Adduction: “Cross your arms across the front of your body.”
• Flexion: “Raise your arms forwards.”
• Extension: “Pull your arms backwards.”
• External rotation: “With your arms bent and your elbows tucked into your sides
separate your hands.”
• Internal rotation: “With your arms bent and your elbows tucked into your sides
bring your hands together.”
• Internal rotation in adduction: “Reach up your back and touch your shoulder blades.”
• External rotation in abduction: “Hold your hands behind your neck, like you do at the end of the
day.”
If any one movement is limited, also test the passive range of movement.
Serratus anterior function
Ask the patient to put his hands against a wall and to push against it. Observe the scapulae from
behind, looking for asymmetry or winging.
After the examination
• State that you would also like to examine the vascular and neurological systems of the upper
limb.
• If appropriate, indicate that you would order some tests, e.g. X-ray (AP and lateral), FBC, ESR,
rheumatoid factor, etc.
• Thank the patient.
• Offer to help him put his clothes back on.
• Ensure that he is comfortable.
• Summarise your findings and offer a differential diagnosis.
Orthopaedics and rheumatology
Station 86 Shoulder examination 235
Conditions most likely to come up in a shoulder examination station
Frozen shoulder (adhesive capsulitis):
• The shoulder capsule becomes inflamed, resulting in pain and stiffness.
• Range of active movements is almost the same as that of passive movements.
• The movement that is most severely restricted is external rotation.
• Often idiopathic.
• More common in females.
• Rarely presents under the age of 40.
Calcific tendinitis:
• Pain and restricted movement result from deposits of hydroxyapatite in any tendon of the
body, but most commonly in those of the rotator cuff.
• Pain is aggravated by elevation of the arm.
• Calcific deposits are visible on X-ray.
• Calcific tendinitis predisposes to frozen shoulder.
Rotator cuff tear:
• Tears of one or more of the four tendons of the rotator cuff muscles, particularly that of
supraspinatus.
• Often asymptomatic, but may cause tenderness and pain that may radiate along the arm.
• The movement that is most severely restricted is abduction; however, if the arm is passively
abducted beyond 90°, the patient can abduct his arm further using the deltoid muscle.
Impingement syndrome:
• Impingement of the supraspinatus tendon between the acromion and the humeral head.
• There is pain, weakness, and restricted movement with a painful arc of movement from 60 to
120° of abduction.
• Impingement syndrome predisposes to rotator cuff tear.
Shoulder dislocation:
• Separation of the humerus from the scapula at the glenohumeral joint.
• Partial separation is referred to as subluxation.
• 95% of shoulder dislocations are anterior.
• Anterior dislocations are usually caused by the arm being forced into abduction and external
rotation.
• Apart from a visibly displaced shoulder, there is severe pain that may radiate along the arm
and a severely restricted range of movement.
Bicipital tendinitis:
• Inflammation of the long head of the biceps tendon, often associated with trauma or overuse.
• There is shoulder pain that is exacerbated by overhead activity and by lifting.
• There is tenderness over the bicipital groove.
• In cases of rupture of the long head of the biceps tendon, the retracted muscle belly bulges
over the anterior upper arm (Popeye sign).
Osteoarthritis (see Station 82)
Winging of the scapula
Referred pain from the cervical spine or the heart
Clinical Skills for OSCEs
236 Station 87
Spinal examination
Before starting
• Introduce yourself to the patient, and confirm his name and date of birth.
• Explain the examination and obtain his consent.
• Ask him to undress to his undergarments.
• Ensure that he is comfortable.
The examination
Look
Inspect from front and back.
• General inspection: ask the patient to stand and assess posture. Are there any obvious malformations?
• Skin: scars, pigmentation, abnormal hair, unusual skin creases.
• Shape and posture.
• Spine:
– lateral curvature of the spine – scoliosis (observe from the back)
– abnormal increase in the kyphotic curvature of the thoracic spine – kyphosis (observe from
the side)
– sharp, angular bend in the spine – a kyphos (observe from the side)
– loss or exaggeration of lumbar lordosis
• Asymmetry or malformation of the chest.
• Asymmetry of the pelvis.
Feel
Ask if there is any pain before you start.
• Palpate and percuss the spinous processes and interspinous ligaments. Then palpate the paravertebral/paraspinal muscles. Note any pain or tenderness.
Move
Ask the patient to copy your movements, looking for any limitation of range of movement. Ask him to
indicate if any of the movements are painful.
Gait
Cervical spine
• Flexion: “Put your chin on your chest.”
• Extension: “Look at the ceiling.”
• Lateral flexion: “Put your ear onto your shoulder without lifting your shoulder.”
• Rotation (normal range is about 80 degrees to each side): “Look back over each shoulder.”
Thoracic spine
• Rotation. “Please sit down” (to stabilise the pelvis) “and twist from side to side”.
Measure chest expansion. It should be at least 5 cm.
Orthopaedics and rheumatology
Station 87 Spinal examination 237
Lumbar spine
• Flexion: “Touch your toes, keep your knees straight.”
• Extension: “Lean back, keep your knees straight.”
• Lateral flexion: “Slide your hand alongside the outside of your leg.”
Schober’s test: measure lumbar excursion by drawing a line from 10 cm above L5 to 5 cm below it
and asking the patient to bend fully forwards. Extension of the line by <5 cm indicates movement
restriction. (Rather than drawing a line, you can just use two fingers or a measuring tape.)
Special tests
Ask the patient to lie prone.
• Palpate the sacroiliac joints for tenderness.
• Press on the mid-line of the sacrum to test if movement of the sacroiliac joints is painful.
• Femoral stretch test (L2–L4):
– with the patient lying prone, raise the leg so as to flex the knee
– if this does not trigger any pain, raise the leg further so as to extend the hip – pain suggests
irritation of the second, third, or fourth lumbar root of that side
Ask the patient to lie supine.
• Straight leg raise (L5–S2):
– with the patient lying supine, flex the hip while maintaining the knee in extension: pain in
the thigh, buttock, and back suggests sciatica
– the response can be amplified by concomitant dorsiflexion of the foot (Bragard’s test)
– if you’re after a gold medal, perform Lasègue’s test: flex the knee and then flex the hip to 90
degrees; with your left hand on the knee, gradually extend the knee with your right hand
until the pain is reproduced
After the examination
• State that you would also like to carry out neurological and vascular examinations.
• If appropriate, indicate that you would order some tests, e.g. X-ray, MRI, DEXA, FBC, ESR, bone
profile, etc.
• Thank the patient.
• Offer to help the patient put his clothes back on.
• Ensure that he is comfortable.
• Summarise your findings and offer a differential diagnosis.
Figure 52. The femoral stretch test.
Clinical Skills for OSCEs
238 Station 87 Spinal examination
Conditions most likely to come up in a spinal examination station
Osteoarthritis (see Station 82)
Ankylosing spondylitis (see Station 82)
Prolapsed disc:
• Part of the nucleus pulposus herniates through the outer part of the disc with attending
inflammation and nerve root compression.
• Most cases occur in the lumbar spine, most commonly at L4/L5 and L5/S1.
• Symptoms may include back pain that is aggravated by coughing, sneezing, or straining and
relieved by lying flat; nerve root pain (often involving the sciatic nerve, ‘sciatica’); other nerve
root symptoms such as numbness and paraesthesiae; cauda equina syndrome.
• The distribution of the symptoms helps to identify the level of the lesion.
• Straight leg raise, Bragard’s test, and Lasègue’s test are positive.
• Commonest in men and in middle age.
Muscular back pain
Scoliosis
239Orthopaedics and rheumatology
Station 88
Hip examination
Before starting
• Introduce yourself to the patient, and confirm his name and date of birth.
• Explain the examination and obtain his consent.
• Ask him to undress to his undergarments.
• Ensure that he is comfortable.
The examination
Look
Inspect from front and back.
• General inspection: posture, symmetry of legs and pelvis, deformity, muscle wasting (especially
the gluteals), scars.
• Gait (observe from the front and back): note any limp – antalgic, short leg, or Trendelenberg (see
Station 37).
• Trendelenberg’s test: ask the patient to stand on each leg in turn, lifting the other one off the
ground by bending it at the knee. Face the patient and support him by the index fingers of his
outstretched hands. The sign is positive if the pelvis drops on the non-weight bearing side.
Ask the patient to lie supine.
• Skin: colour, sinuses, scars.
• Position: limb shortening, limb rotation, abduction or adduction deformity, flexion deformity.
• Limb length.
– to measure true leg length, position the pelvis so that the iliac crests lie in the same horizontal plane, at right angles to the trunk (this is not possible if there is a fixed abduction or
adduction deformity) and then measure the distance from the anterior superior iliac spine
(ASIS) to the medial malleolus. True leg shortening suggests pathology of the hip joint
Figure 53. Negative (left) and positive Trendelenberg’s test.
A positive Trendelenberg’s test suggests weakness of the
abduction of the weight-bearing hip, and hence a problem in
that hip.
Clinical Skills for OSCEs
240 Station 88 Hip examination
– to measure apparent leg length, measure the distance from the xiphisternum to the medial
malleolus. Apparent leg shortening suggests pelvic tilt, most often due to an adduction
deformity of the hip
• Circumference of the quadriceps muscles at a fixed point.
Feel
Ask if there is any pain.
• Skin: temperature, effusions (difficult to feel).
• Bones and joints: bony landmarks of the hip joint, inguinal ligament.
Move
Look for limitation of the normal range of movement, and ask the patient to report any pain.
• Flexion and Thomas’ test:
– flex both hips and place your hand in the small of the back to ensure that the lumbar lordosis
has been eliminated
– hold one hip flexed and straighten the other leg, maintaining your hand in the small of the
back – if the leg cannot be straightened and the knee is unable to rest on the couch, a fixed
flexion deformity is present
– repeat for the other leg
• Abduction and adduction:
– drop one leg over the edge of the couch to fix the pelvis
– place one hand on the anterior superior iliac spine of the other leg and carry it through
abduction and adduction
– repeat for the other leg
• Rotation:
– flex the hip and knee to 90 degrees
– hold the knee in the left hand and the ankle in the right hand
– using your right hand, rotate the hip internally and externally (approximately 45 degrees in
each direction)
– repeat for the other leg
Ask the patient to lie prone.
• Look for scars, etc.
• Feel for tenderness.
• Extend each hip in turn. Keep a hand under a bent knee and extend the hip by pulling the leg
up at the ankle.
After the examination
• State that you would also like to examine the vascular and neurological systems of the lower
limbs.
• If appropriate, indicate that you would order some tests, e.g. hip and knee X-ray, DEXA, FBC,
ESR, bone profile, etc.
• Thank the patient.
• Offer to help the patient put his clothes back on.
• Ensure that he is comfortable.
• Summarise your findings and offer a differential diagnosis.
Orthopaedics and rheumatology
Station 88 Hip examination 241
Conditions most likely to come up in a hip examination station
Osteoarthritis:
• The hip is held in flexion, external rotation, and adduction.
• This is accompanied by pain and restricted movement.
• There is apparent limb shortening.
• There are other signs of osteoarthritis, e.g. Heberden’s nodes on the distal interphalangeal
joints.
Slipped upper femoral epiphysis:
• Fracture through the physis resulting in slippage of the overlying epiphysis, producing a
‘melting ice-cream cone’ on X-ray.
• Limited movement of the hip, particularly internal rotation and abduction, and pain in the hip,
groin, or knee.
• External rotation and shortening of the affected leg.
• Often presents in obese prepubescent males.
Trendelenburg gait (see Station 37)
Antalgic gait (see Station 37)
Hip replacement
Hip arthrodesis
Trochanteric bursitis
Clinical Skills for OSCEs
242 Station 89
Knee examination
Before starting
• Introduce yourself to the patient, and confirm his name and date of birth.
• Explain the examination and obtain his consent.
• Ask him to undress from the waist downwards.
• Ensure that he is comfortable.
The examination
Ask the patient to stand.
Look
• Gait: observe from in front and behind, looking for instability, limp, and limited range of movement.
• Position: neutral, varus, valgus, fixed flexion, hyperextension (recurvatum).
• Squat test (avoid in elderly patients).
Ask the patient to lie supine.
• Skin: colour, sinuses, scars (including arthroscopic scars).
• Shape: alignment, effusion, patellar alignment.
• Position: hyperextension, varus, valgus (distal portion is displaced laterally).
Measure quadriceps circumference a hand breadth above the patella.
Feel
Ask if there is any pain.
• Skin: temperature (compare both sides).
• Effusions: cross fluctuation, patellar tap test, and bulge test.
– cross fluctuation: place the thumb and index finger of one hand on the joint line just below
the patella and with the other hand empty the suprapatellar pouch. If an impulse is transmitted across the joint line, this indicates a large effusion
– patellar tap test: empty the suprapatellar pouch with one hand and dip the patella with
the thumb, index finger, and middle finger of the other hand. If the patella is felt to tap the
underlying bone and to bounce back up, this indicates a medium sized effusion
– bulge test: empty the medial parapatellar fossa by stroking the medial aspect of the joint;
then empty either the suprapatellar pouch or the lateral parapatellar fossa. If the medial
parapatellar fossa is seen to bulge out, this indicates a small effusion
• Joint line at 90 degrees of flexion. Feel for any synovial thickening.
• Surrounding structures: ligaments, tibial tuberosity, femoral condyles.
• Patella: note size and height of patella and carry out patellar apprehension tests. Displace the
patella laterally while flexing the knee. If the patella is unstable, the patient will either contract
the quadriceps muscle or discontinue the test.
Move
• Active:
– flexion
– extension
Orthopaedics and rheumatology
Station 89 Knee examination 243
• Passive:
– flexion (to 140 degrees), feeling for crepitus and clicks
– extension (to 0 to -10 degrees)
Special tests
• Collateral ligament tears.
– apply varus and valgus stresses at 0 degrees and 20 degrees of flexion. Hold the leg under
one arm and apply pressure on the medial/lateral side of the knee joint
• Cruciate ligament tears.
– posterior sag test: flex the knee to 90 degrees and look for a sag across the knee. The presence of a sag indicates a posterior cruciate ligament tear
– anterior and posterior drawer tests: flex the knee to 90 degrees, sit on the foot (ask the
patient first!), and pull the tibia back and forth. Exaggerated anterior displacement indicates
that the anterior cruciate ligament is probably torn, whereas exaggerated posterior displacement indicates that the posterior cruciate ligament is probably torn
– Lachman’s test (Figure 54): flex the knee to 30 degrees and, holding the thigh in one hand
and the proximal tibia in the other, attempt to make the joint surfaces slide upon one
another. Exaggerated anterior displacement of the tibia indicates that the anterior cruciate
ligament is probably torn
• Meniscal tears.
– McMurray’s test (Figure 55): place one hand on the knee and the other on the ankle. Flex the
hip and knee. To test the medial meniscus, palpate the posteromedial margin of the joint.
Then hold the leg in external rotation and extend the knee. To test the lateral meniscus, palpate the posterolateral margin of the joint. Then hold the leg in internal rotation and extend
the knee. A positive test is one that elicits pain, resistance, or a reproducible click
– Apley’s grinding test (not usually performed)
Figure 54. Lachman’s test.
Clinical Skills for OSCEs
244 Station 89 Knee examination
Lie the patient prone.
• Popliteal fossa:
– inspect the popliteal fossa
– palpate the popliteal fossa for a Baker’s (popliteal) cyst
After the examination
• State that you would also like to examine the vascular and neurological systems of the lower
limbs.
• If appropriate, indicate that you would order some tests, e.g. X-ray (AP and lateral), FBC, ESR,
bone profile, rheumatoid factor, etc.
• Thank the patient.
• Offer to help the patient put his clothes back on.
• Ensure that he is comfortable.
• Summarise your findings and offer a differential diagnosis.
The age and sex of the patient have a strong bearing on the differential diagnosis.
Conditions most likely to come up in a knee examination station
• Recurrent subluxation of the patella.
• Chrondromalacia patellae.
• Collateral ligament tears.
• Cruciate ligament tears.
• Meniscal tears.
• Osteoarthritis.
• Rheumatoid arthritis.
• Prepatellar and infrapatellar bursitis.
• Baker’s (popliteal) cyst.
• Tibial apophysitis (Osgood–Schlätter’s disease).
Figure 55. McMurray’s test.
245Orthopaedics and rheumatology
Station 90
Ankle and foot examination
Before starting
• Introduce yourself to the patient, and confirm his name and date of birth.
• Explain the examination and obtain his consent.
• Ask him to undress from the waist downwards.
• Ensure that he is comfortable.
The examination
The patient is standing.
Look
• General inspection: posture, symmetry, and any obvious deformities. Look for clues such as
walking aids and abnormal wear on shoes. Ask the patient to turn around.
• Gait: observe from front and back. Pay particular attention to height of step, ankle movement,
and foot strike. Ask the patient to stand on his tiptoes and then on his heels.
Ask the patient to lie on the couch.
• Skin: colour, sinuses, scars, corns, calluses, ulcers, bunions (big toe), Tailor’s bunion/bunionette
(little toe).
• Shape: alignment, pes planus (flat foot), pes cavus (arched foot), deformities of the toes (hallux
valgus, claw, hammer, and mallet toes).
• Position: varus or valgus hindfoot deformity.
Feel
Ask about any pain.
• Skin: temperature (compare both sides), abnormal thickening on the soles of the feet.
• Pulses: dorsalis pedis, posterior tibial.
• Bone and joints: palpate the joint margin, forefoot (metatarsals and metatarsophalangeal
joints) and hindfoot, and localise any tenderness. Remember to keep looking at the patient’s
face.
Move (active and passive)
Look for restriction of the normal range of movement. Ask the patient to report any pain.
Figure 56. Claw, mallet (DIP
joints), and hammer toes
(PIP joints).
Clinical Skills for OSCEs
246 Station 90 Ankle and foot examination
Ankle joint
• Hold the heel in the left hand and the forefoot in the right hand.
• Plantarflex the foot (normal range 40 degrees).
• Dorsiflex the foot (normal range 25 degrees).
• Compare range of movement to that in the other foot.
Subtalar joint
• Hold the heel in the left hand and the forefoot in the right hand, as above, with the ankle fixed
at 90 degrees.
• Invert the foot (normal range 30 degrees).
• Evert the foot (normal range 15 degrees).
• Compare the range of movement to that in the other foot.
Midtarsal joint
• Hold the heel in the left hand and the forefoot in the right hand.
• Flex, extend, invert, and evert the forefoot.
Toes
• Flex and extend each toe in turn. If there is any tenderness, try to localise it to a particular joint.
Ask the patient to lie prone.
• Look for any scars and for wasting of the calves.
• Palpate the calf muscle and the Achilles tendon.
• Simmond’s test: squeeze the calf – if the foot plantarflexes, the Achilles tendon is intact.
After the examination
• State that you would also like to examine the vascular and neurological systems of the lower
limbs.
• If appropriate, indicate that you would order some tests, e.g. foot and ankle X-ray (AP and lateral), FBC, ESR, bone profile, rheumatoid factor, etc.
• Thank the patient.
• Offer to help him put his socks and shoes back on.
• Ensure that he is comfortable.
• Summarise your findings and offer a differential diagnosis.
Conditions most likely to come up in an ankle and foot examination station
• Osteoarthritis.
• Rheumatoid arthritis.
• Ankle injuries.
• Deformities of the foot.
• Plantar fasciitis.
247Emergency medicine and anaesthesiology
Station 91
Adult Basic Life Support
• Make sure you, the victim, and any bystanders are safe.
• Check the victim for a response. Gently shake his shoulders and ask loudly, “Are you all right?”
If he responds:
• Leave him in the position in which you find him provided there is no further danger.
• Try to find out what is wrong with him and get help if needed.
• Reassess him regularly.
If he does not respond:
• Shout for help.
• Turn him onto his back and open the airway using the head-tilt, chin-lift technique:
– place your hand on his forehead and gently tilt his head back
– with your fingertips under the point of his chin, lift the chin to open the airway
– holding his airway open, put your ear to his mouth. Listen, feel, and look for breathing for no
more than 10 seconds. If you have any doubt about whether breathing is normal, assume
that it is not
Agonal breathing (occasional gasps, slow, laboured, or noisy breathing) is common in the
early stages of cardiac arrest and should not be mistaken for a sign of life.
2 rescue breaths
30 compressions
30 chest
compressions
UNRESPONSIVE ?
Adult Basic Life Support
Shout for help
Open airway
NOT BREATHING NORMALLY ?
Call 999
Figure 57. Basic Life Support algorithm.
Clinical Skills for OSCEs
248 Station 91 Adult Basic Life Support
If he is breathing normally:
• Turn him into the recovery position.
• Call for an ambulance by mobile phone or, if this is not possible, send a bystander to call. Leave
the victim only if there is no other way of obtaining help.
• Check for continued breathing.
If he is not breathing normally:
• Ask someone to call for an ambulance and bring an automated external defibrillator (AED) if
available. If you are on your own, use your mobile phone to call for an ambulance. Leave the
victim only if there is no other way of obtaining help.
• Deliver 30 chest compressions followed by 2 rescue breaths. To deliver chest compressions:
– kneel by the side of the victim
– place the heel of one hand in the centre of the victim’s chest
– place the heel of the other hand on top of the first hand
– interlock the fingers of your hands and ensure that pressure is not applied on the victim’s
ribs, bottom end of his chest bone, or upper abdomen
– position yourself vertically above the victim’s chest and, with your arms straight, press down
on the sternum 5–6 cm
– after each compression, release all the pressure on the chest without losing contact between
your hands and the sternum – repeat at a rate of about 100–120 per minute
– compression and release should take an equal amount of time
To deliver rescue breaths:
– after 30 compressions, again open the airway using head-tilt and chin-lift
– pinch the soft part of the victim’s nose closed using the index finger and thumb of the hand
on his forehead
– allow his mouth to open, but maintain chin lift
– take a normal breath and place your lips around his mouth, making sure that you have a
good seal
– blow steadily into his mouth whilst watching for his chest to rise – take about 1 second to
make his chest rise
– maintaining head-tilt and chin-lift, take your mouth away from him and watch for his chest
to fall
– deliver a second rescue breath and return to chest compressions without delay
• Continue with chest compressions and rescue breaths at a ratio of 30:2.
• Stop to re-check the victim only if he starts to show signs of regaining consciousness, such as
coughing, opening his eyes, speaking or moving purposefully AND starts to breathe normally;
otherwise do not interrupt resuscitation.
Figure 58. The head-tilt, chin-lift technique.
Emergency medicine and anaesthesiology
Station 91 Adult Basic Life Support 249
• If your rescue breaths do not make the chest rise as in normal breathing, check the victim’s
mouth and remove any obstruction and re-check that there is adequate head-tilt and chin-lift.
Do not attempt more than 2 rescue breaths each time before returning to chest compressions.
• If there is more than one person present, the person providing chest compressions should
change every 1–2 minutes with no interruption to the chest compressions.
If the rescuer is unable or unwilling to give rescue breaths, he can give chest compressions
at a rate of 100–120 compressions per minute, stopping only to recheck the victim if he
shows signs of regaining consciousness AND starts to breathe normally.
Continue resuscitation until qualified help arrives or until the victim shows signs of regaining
consciousness AND starts to breathe normally or until exhaustion.
The recovery position
• Remove the victim’s spectacles, if any.
• Kneel beside her and make sure that both her legs are straight.
• Place the arm nearest to you out at right angles to her body, elbow bent, with the hand palm
uppermost.
• Bring the far arm across the chest, and hold the back of the hand against the cheek nearest to
you.
• With your other hand, grasp the far leg just above the knee and pull it up, keeping the foot on
the ground.
• Keeping her hand pressed against her cheek, pull on the far leg to roll her towards you and
onto her side.
• Adjust the upper leg so that both the hip and knee are bent at right angles.
• Tilt the head back to ensure that the airway remains open.
• Adjust the hand under the cheek, if necessary, to keep the head tilted.
Figure 59. The recovery position.
Clinical Skills for OSCEs
250 Station 92
Choking
Choking is a physiological response to obstruction of the airways by a foreign object, and can lead
to asphyxia (oxygen starvation) and brain hypoxia, and, ultimately, loss of consciousness and death.
Victims of choking are likely to grab or point at their neck. Young children are prone to choking on
food and small objects, so eating or playing prior to the episode is strongly suggestive of choking.
Differentials of choking include fainting, heart attack, seizure, and other conditions that may cause
sudden respiratory distress, cyanosis, or loss of consciousness.
The first step is to ask the victim, “Are you choking?”
Mild airway obstruction
The victim is able to breathe, speak, or cough forcefully.
• Encourage the victim to cough, and intervene only if the situation begins to deteriorate.
Severe airway obstruction
The victim is unable to breathe or speak, or his breathing sounds wheezy, or his attempts at coughing
are silent or ineffective. He may simply respond by nodding.
• Apply the ‘five-and-five’ protocol.
• Deliver up to five back blows:
– stand to the side and slightly behind the victim
– support the chest with one hand and lean him well forwards so that, if it is dislodged, the
object falls out of the mouth rather than further down the airway
– with the heel of your other hand, deliver up to five back blows between the shoulder blades,
checking between each blow whether the obstruction has been relieved
• If obstruction persists, deliver up to five abdominal thrusts (Heimlich manoeuvre):
– stand behind the victim
– wrap your arms around his waist and lean him forward
– clench your fist and place it between the umbilicus and xiphisternum
– grasp this fist firmly with your other hand and pull sharply inwards and upwards
– repeat up to five times
• If, after five abdominal thrusts, the obstruction still has not been cleared, repeat the ‘five-andfive’ protocol.
Unconscious victim
• Support the victim carefully to the ground. Call an ambulance immediately. Begin CPR (see
Station 91). Initiate chest compressions even if a pulse is present.
Pregnant or obese victim
• Adapt the Heimlich manoeuvre by placing your clenched fist just above where the lowest
ribs meet.
Infants below the age of one
• Place the child in a head-down, prone position over your forearm or on your lap.
• Hold the jaw with one hand to support the head.
• Deliver up to five back blows between the shoulder blades.
Emergency medicine and anaesthesiology
Station 92 Choking 251
• If the obstruction has not cleared, place the child in a head-down, supine position and deliver
chest compressions using the two-finger technique (see Station 66).
• If the obstruction still has not been cleared, repeat the ‘five-and-five’ protocol.
• If the child is unconscious, open the airway, deliver 5 rescue breaths, and start CPR (see
Station 66).
[Note] Following successful treatment for choking, victims with a persistent cough, difficulty swallowing, or with a sense
of something still stuck in the throat should seek immediate medical attention.
Clinical Skills for OSCEs
252 Station 93
In-hospital resuscitation
This sequence should be followed for a collapsed patient in hospital.
• Ensure personal safety.
• Shout for help.
• Check the patient for a response – gently shake his shoulders and loudly ask “Are you all right?”
• If the patient responds:
– urgent medical assessment is required – depending on local protocols, this may be by the
resuscitation team
– while awaiting the arrival of this team, assess the patient using the ABCDE approach
– give the patient oxygen
– attach basic monitoring
– obtain venous access
Handover to
resuscitation team
Advanced Life Support
when resuscitation team
arrives
Apply pads/monitor
Attempt de brillation
if appropriate
CPR 30:2
with oxygen and airway
adjuncts
Shout for help and assess patient
Collapsed/sick patient
Call Resuscitation Team
e.g. dial ‘2222’
Assess ABCDE
Recognise and treat
Oxygen, monitoring,
IV access
Call resuscitation team
if appropriate
Signs
of life? NO YES
Figure 60 In-hospital resuscitation
algorithm.
Emergency medicine and anaesthesiology
Station 93 In-hospital resuscitation 253
• If the patient does not respond:
– turn the patient onto his back
– open the airway using the head-tilt, chin-lift technique
[Note] if there is a risk of C-spine injury, use the jaw-thrust or chin-lift technique with manual in-line stabilisation (MILS)
of the head and neck by an assistant (if sufficient staff are available). If airway obstruction persists despite jaw
thrust or chin lift, add head tilt a small amount at a time. Establishing an airway should take priority over concerns
about a potential C-spine injury.
• Holding the patient’s airway open, put your ear to his mouth. Listen, feel, and look for breathing
for no more than 10 seconds. Inspect the oropharynx for a foreign body or vomitus.
• Assess the carotid pulse at the same time or after the breathing check.
Agonal breathing (occasional gasps, slow, laboured, or noisy breathing) is common in the
early stages of cardiac arrest and should not be mistaken for a sign of life.
• If the patient has a pulse or other signs of life:
– urgent medical assessment is required. Depending on local protocols, this may be by the
resuscitation team
– while awaiting the arrival of this team, assess the patient using the ABCDE approach
– give the patient oxygen
– attach monitoring
– obtain venous access
• If there is no pulse or other signs of life:
– one person should start CPR as others call the resuscitation team and collect the resuscitation equipment. If only one member of staff is present, this will mean leaving the patient
– give 30 chest compressions followed by 2 ventilations. Place your interlocked hands in the
middle of the lower half of the sternum and depress the chest by 5–6 cm, aiming for a rate
of 100–120 compressions per minute. The person providing the chest compressions should
change every 2 minutes or earlier, with only minimal interruption to the chest compressions
– maintain the airway and ventilate the lungs with the most appropriate equipment immediately at hand. A pocket mask, which may be supplemented by an oral airway, is usually
readily available. If no equipment is immediately at hand, give mouth-to-mouth ventilation
unless there are clinical reasons to avoid mouth-to-mouth contact (e.g. TB or SARS)
– use an inspiratory time of 1 second and give enough volume to produce a chest rise as in
normal breathing. Add supplemental oxygen as soon as possible
– once the airway has been secured, continue chest compressions uninterrupted at a rate of
100–120 compressions per minute and ventilate the lungs at approximately 10 breaths per
minute. Only stop compressions for defibrillation or pulse checks
Figure 61. The head-tilt jaw-thrust technique.
Clinical Skills for OSCEs
254 Station 93 In-hospital resuscitation
– upon arrival of the defibrillator, apply self-adhesive defibrillation pads to the patient without
interrupting chest compressions
– if using an automated external defibrillator (AED), switch on the machine and follow the
visual prompts
– for manual defibrillation, minimise the interruption to CPR to deliver a shock
– pause briefly to assess the heart rhythm. With a manual defibrillator, if the rhythm is VF or
pulseless VT (VF/VT), charge the defibrillator and restart chest compressions
– once the defibrillator is charged, oxygen sources have been removed, and all the rescuers
apart from the one doing the chest compressions are clear, pause the chest compressions,
rapidly check that everyone is clear (tell the remaining rescuer to “stand clear”), and deliver
the shock. Restart the chest compressions immediately. This sequence should be planned
before stopping the chest compressions
– continue resuscitation until the resuscitation team arrives or until the patient shows signs
of life. If using an AED, follow the voice prompts. If using a manual defibrillator, follow the
algorithm for ALS (see Station 94)
– prepare intravenous cannulae and drugs likely to be used by the resuscitation team (e.g.
adrenaline)
– identify one person to be responsible for handover to the resuscitation team leader and
locate the patient’s notes
• If the patient is not breathing but has a pulse (respiratory arrest):
– ventilate the patient’s lungs as described above, checking for a pulse after every 10 breaths
(about every minute)
– if there are any doubts about the presence of a pulse, start chest compressions until more
experienced help arrives
• If a patient has a monitored and witnessed cardiac arrest:
– confirm cardiac arrest and shout for help
– if the initial rhythm is VF/VT, give up to three quick successive (stacked) shocks. Start chest
compressions immediately after the third shock and continue CPR for 2 minutes
– a pre-cordial thump in these settings works rarely and may succeed only if given within
seconds of the onset of a shockable rhythm. It should not delay calling for help or accessing
a defibrillator
Adapted from Resuscitation Council (UK) 2010 Guidelines.
255Emergency medicine and anaesthesiology
Station 94
Advanced Life Support
Specifications: A mannequin in lieu of a patient.
Figure 62. Advanced Life Support algorithm.
Unresponsive?
Not breathing or
only occasional gasps
Return of
spontaneous
circulation
Immediate post cardiac
arrest treatment
Call
resuscitation team
CPR 30:2
Attach de brillator/monitor
Minimise interruptions
Assess
rhythm
Shockable
(VF/pulseless VT)
1 Shock
Immediately resume
CPR for 2 min
Minimise interruptions
Non Shockable
(PEA/Asystole)
During CPR
Ensure high-quality CPR: rate, depth, recoil
Plan actions before interrupting CPR
Give oxygen
Consider advanced airway and capnography
Continuous chest compressions when
advanced airway in place
Vascular access (intravenous, intraosseous)
Give adrenaline every 3–5 min
Correct reversible causes
Use ABCDE approach
Controlled oxygenation
and ventilation
12-lead ECG
Treat precipitating cause
Temperature control/
therapeutic hypothermia
Reversible Causes
Hypoxia
Hypovolaemia
Hypo-/hyperkalaemia/metabolic
Hypothermia
Thrombosis (coronary or pulmonary)
Tamponade, cardiac
Toxins
Tension pneumothorax
Immediately resume
CPR for 2 min
Minimise interruptions
Clinical Skills for OSCEs
256 Station 94 Advanced Life Support
The patient has arrested and CPR is under way. The defibrillator/monitor has just been attached.
• Assess the rhythm.
• Pause briefly to check the monitor, confirm VF or pulseless VT from the ECG, and resume the
chest compressions immediately.
• Select the appropriate energy on the defibrillator (150–200 J biphasic for the first shock and
150–360 J biphasic for subsequent shocks) and press the charge button.
• Once the defibrillator is charged, oxygen sources have been removed, and all the rescuers apart
from the one doing the chest compressions are clear, pause the chest compressions, rapidly
check that everyone is clear (tell the remaining rescuer to “stand clear”), and deliver the shock.
Restart the chest compressionsimmediately. Thissequence should be planned before stopping
the chest compressions.
• Continue CPR for 2 minutes at a ratio of 30:2.
• Pause briefly to check the monitor and take the carotid pulse. If VF or pulseless VT persists,
repeat the relevant steps above to deliver a second shock.
• If VF or pulseless VT still persists repeat the relevant steps above to deliver a third shock.
Ventricular tachycardia
Ventricular brillation
Figure 63. Positioning of the defibrillator paddles or pads.
One paddle goes under the right clavicle and the other in the V6
position in the mid-axillary line.
Figure 64. ECG traces of ventricular fibrillation
and ventricular tachycardia.
Emergency medicine and anaesthesiology
Station 94 Advanced Life Support 257
• Resume chest compressions immediately and perform CPR for a further 2 minutes, during
which time give adrenaline 1 mg IV and amiodarone 300 mg IV.
• Keep on repeating this 2 minute CRP – rhythm/pulse check – defibrillation sequence for as long
as VF/VT persists.
• Give further adrenaline 1 mg IV after alternate shocks, i.e. after every 3–5 minutes.
• If organised electrical activity compatible with a cardiac output is seen during a rhythm check
(and not otherwise), check for central pulse. If a pulse is present, start post-resuscitation care. If
a pulse is absent, continue CPR and switch to the non-shockable algorithm.
Precordial thump
A single precordial thump has a very low success rate for cardioversion of a shockable rhythm and
is only likely to succeed if given within the first few seconds of the onset of a shockable rhythm.
Delivery of a precordial thump must not delay calling for help or accessing a defibrillator. It is therefore
appropriate therapy only when several clinicians are present at a witnessed, monitored arrest, and
when a defibrillator is not immediately to hand. Using the ulnar edge of a tightly clenched fist, deliver
a sharp impact to the lower half of the sternum from a height of about 20 cm, then retract the fist
immediately to create an impulse-like stimulus. A precordial thump is most likely to be successful in
converting VT to sinus rhythm.
Non-shockable rhythms (PEA and asystole)
Survival after cardiac arrest with PEA or asystole is unlikely unless a reversible cause can be found and
treated successfully.
Sequence of actions for PEA (cardiac electrical activity in the absence of any palpable pulse).
• Start CPR 30:2.
• Give adrenaline 1 mg IV as soon as IV access is achieved.
• Continue CPR 30:2 until the airway is secured, then continue chest compressions without pausing during ventilation.
• Consider possible reversible causes of PEA and correct any that are identified.
• Recheck the patient after 2 minutes.
• If there is still no pulse and no change in the ECG appearance:
– continue CPR
– recheck the patient after 2 minutes and proceed accordingly
– give further adrenaline 1 mg IV after every 3–5 minutes (alternate loops)
• If VF/VT, change to the shockable rhythm algorithm
• If a pulse is present, start post-resuscitation care.
Sequence of actions for asystole and slow PEA (rate < 60 per minute).
• Start CPR 30:2.
• Without stopping CPR, check that the leads are attached correctly.
• Give adrenaline 1 mg IV as soon as IV access is achieved.
• Give atropine 3 mg IV (once only).
• Continue CPR 30:2 until the airway is secured, then continue chest compressions without pausing during ventilation.
• Consider possible reversible causes of PEA and correct any that are identified.
• Recheck the patient after 2 minutes and proceed accordingly.
• If VF/VT, change to the shockable rhythm algorithm.
• Give further adrenaline 1 mg IV after every 3–5 minutes (alternate loops).
Adapted from Resuscitation Council (UK) 2010 Guidelines, which can be found at www.resus.org.uk/
pages/als.pdf and which you are encouraged to read.
Clinical Skills for OSCEs
258 Station 95
The primary and secondary surveys
In this station, you are going to be asked to assess a patient with a medical emergency or who has
suffered severe trauma (e.g. from a road traffic accident). What follows is a general outline of the areas
that you are going to need to cover.
Primary survey
The quick look
• Inspect the patient.
• Introduce yourself to him. Is he responsive? Try to elicit a response by shouting out his name.
Airway and cervical spine
• Assess the airway for obstruction.
• If necessary, clear and secure the airway. If there is suspicion of a cervical spine injury, use the
jaw-thrust technique.
• If there is suspicion of cervical spine injury, immobilise the cervical spine in a stiff collar. Place
sandbags on either side of the head and tape them across the forehead.
Breathing
• Assess breathing: look, listen, feel.
• Expose the chest.
• Note the rate and depth of respiration.
• Look for asymmetries of chest expansion.
• Look for chest injuries.
• Palpate for tracheal deviation. Palpate, percuss, and auscultate the chest. Try to exclude flail
segments, pneumothorax, or haemothorax.
• Attach a pulse oximeter.
• If appropriate, ventilate using a bag, mask, and oropharyngeal airway or endotracheal tube.
Circulation and haemorrhage control
• Control any visible haemorrhage by direct pressure.
• Look for clinical signs of shock: assess the pulse, skin colour, capillary refill time, JVP, heart
sounds, and blood pressure. Try to exclude cardiac tamponade.
• Attach an ECG monitor.
• Place two large-bore (grey) cannulas into large peripheral veins.
• Take a sample of blood for group and cross-match.
• Start fluid replacement.
Disability (neurological assessment)
• Assess neurological function on the AVPU scale:
– A Alert
– V Voice elicits a response
– P Pain elicits a response
– U Unresponsive
• Assess the pupils for size and reactivity.
• Check that all limb extremities can be moved.
Emergency medicine and anaesthesiology
Station 95 The primary and secondary surveys 259
Exposure and environmental control
• Remove the patient’sremaining clothing and inspect both hisfront and back. Log-roll him (with
the help of others) so that his spine remains immobilised.
• Cover him with a blanket.
Secondary survey
Once the patient is stable:
• Take a short, AMPLE history:
– Allergies
– Medications and tetanus immunity
– Previous medical history
– Last meal
– Events leading to the injury
• Carry out a head-to-toe physical examination.
• Monitor ECG, BP, oxygen saturation, and core temperature.
• Insert a urinary catheter and, if necessary, a naso-gastric tube (to aspirate stomach contents).
• Order investigations: full blood count, urea and electrolytes, liver function tests, amylase,
glucose, coagulation profile, arterial blood gases, toxicology screen, and X-rays of the lateral
cervical spine, chest, and pelvis.
• Encourage questions from the patient and address his concerns.
Clinical Skills for OSCEs
260 Station 96
Management of medical emergencies
Acute asthma
You are called to see a 28 year old man in A&E. The patient is in obvious respiratory distress, and
is struggling to speak. The nurse tells you that the patient has a history of asthma. PEFR is 40% of
predicted, and oxygen saturation is 91%. What is your immediate course of action?
• Assess the severity of the attack by carrying out a brief physical examination, including ABCs.
A severe attack is indicated by:
– PEFR <50% of predicted or best
– respiratory rate >25/min
– pulse rate of >110 beats/min
– inability to complete sentences
A life-threatening attack is suggested by:
– oxygen saturation <92%
– silent chest, cyanosis, poor respiratory effort
– bradycardia, arrhythmia, or hypotension
– exhaustion, confusion, or coma
• If this is a severe attack, call for senior or specialist help and inform an anaesthetist and the ITU.
Begin treatment immediately.
• Sit the patient up and give 100% oxygen through a non-rebreather mask with a reservoir bag.
• Give 5 mg salbutamol and 0.5 mg ipratropium bromide nebulised with oxygen.
• Give a corticosteroid such as hydrocortisone 100 mg IV, or prednisolone 30–60 mg PO (if the
patient is not too distressed to take tablets).
• Once the patient is stable, carry out investigations including arterial blood gases (ABGs) and
a chest X-ray. A life-threatening attack can be confirmed on ABGs by a PaO2 < 8 kPa, a PaCO2
> 5 kPa (due to poor respiratory effort), and a pH < 7.35 (due to CO2 retention or lactic acidosis
from tissue ischaemia). ABGs can also be used to monitor serum electrolytes, particularly K+
which may be decreased. Chest X-ray is helpful in excluding differentials such as inhalation of a
foreign body, pneumothorax, pulmonary oedema, and acute exacerbation of COPD.
• If initial measures fail, add magnesium sulphate 1.2–2 g IV over 20 minutes and give salbutamol
nebulisers every 15 minutes.
• Continue monitoring the patient at regular intervals. If he is still not improving, consider aminophylline IV. Discuss with your seniors and with the ITU registrar.
Acute pulmonary oedema
You are called to the ward to see a 55 year old lady with acute shortness of breath. She was admitted
with severe diarrhoea and vomiting, and was therefore being aggressively rehydrated. An old ECG
suggests left ventricular damage. On physical examination you find a raised JVP, gallop rhythm, and
bilateral crackles. What is your immediate course of action?
• Sit the patient up.
• Give 100% oxygen through a non-rebreather mask with a reservoir bag. Care must be taken if
the patient has COPD.
• Obtain IV access and attach an ECG monitor. Treat any arrhythmias as appropriate.
• Give GTN spray 2 puffs SL, unless the patient is hypotensive.
• Give diamorphine 2.5–5 mg IV slowly. Care must be taken if the patient has COPD.
• Give frusemide 40–80 mg IV slowly. Note that both diamorphine and frusemide are primarily
acting as vasodilators in this context.
Emergency medicine and anaesthesiology
Station 96 Management of medical emergencies 261
• Once the patient has stabilised, further investigations can be carried out such as arterial blood
gases, chest X-ray, cardiac enzymes, and U&Es. Continue monitoring the patient at regular
intervals.
• Start a nitrate infusion, e.g. isosorbide dinitrate 2–10 mg/h (titrated to BP) unless the patient is
hypotensive. (If systolic BP is < 100 mmHg, treat as cardiogenic shock.)
• If the patient deteriorates, discuss with your seniors and with ITU. Consider increasing the
nitrate infusion or giving more frusemide. Re-consider alternative diagnoses such as asthma,
COPD, pneumonia, and pulmonary embolism.
• Asthis patient hasleft ventricular failure, an ACE-I isindicated once her condition hasstabilised.
Acute myocardial infarction
You are tending to a 65 year old gentleman with known cardiovascular disease when he suddenly
clutches his chest in severe pain. You look up at the cardiac monitor and see prominent ST elevation.
What is your immediate course of action?
• Assess ABCs.
• Give 100% oxygen through a non-rebreather mask with a reservoir bag.
• If not already in place, set up continuous cardiac monitoring and obtain a 12-lead ECG.
• Gain IV access and take blood for baseline troponins, FBC, U&Es, glucose, and lipids.
• If possible, carry out a brief assessment of the patient, including brief history and focused physical examination.
• Give morphine 5–10 mg IV with an antiemetic. Two puffs of sublingual GTN can be given to
provide further relief if the patient is not hypotensive.
• Give aspirin 300 mg PO.
• If the patient is diabetic or the blood glucose is >11 mmol/l, an insulin sliding scale may be
indicated.
• Call the cardiology registrar. For a STEMI, thrombolysis should ideally be given within 90
minutes, e.g. streptokinase 1.5 million units in 100 ml saline IVI over 1 hour. Alteplase may be
indicated if the patient has previously received streptokinase. In equipped centres, primary percutaneous coronary angioplasty/intervention (PCI) is carried out in preference to thrombolysis.
The indications for thrombolysis are:
– ST elevation of >2 mm in 2 or more chest leads
– ST elevation of >1 mm in 2 or more limb leads
– New onset LBBB
– Posterior MI, as evidenced by dominant R waves and ST depression in leads V1–3
Ensure that there are no contraindications to thrombolysis such as internal bleeding or severe liver
disease. If so, consider urgent angioplasty instead of thrombolysis.
• Following thrombolysis, give a beta blocker such as atenolol 5 mg IV and an ACE inhibitor such
as lisinopril 2.5 mg (unless contraindicated).
• For a NSTEMI, give LMWH, a beta blocker such as atenolol 5 mg IV, and IV nitrates (unless contraindicated). Medium and high risk patients should be given an infusion of GPIIb/IIIa inhibitor,
e.g. abciximab and urgent angiography. Low risk patients may be discharged following a stress
test (exercise ECG/stress echo).
• Following an MI, unless there are any contraindications, the patient should receive:
– long term low-dose aspirin (75mg OD)
– clopidogrel (4 weeks for STEMI, 3 months for NSTEMI)
– long term statin
– long term beta blocker
– long term ACE inhibitor
Clinical Skills for OSCEs
262 Station 96 Management of medical emergencies
Massive pulmonary embolism
You are fast-bleeped to the ward, where a 48 year old lady who had surgery for ovarian carcinoma 12
days ago has collapsed on the toilet. She has developed acute dyspnoea with pleuritic chest pain. You
assess ABCs and carry out a brief physical examination and find tachycardia, hypotension, and signs of
right ventricular strain. What is your immediate course of action?
• Give 100% oxygen through a non-rebreather mask with a reservoir bag.
• Obtain IV access. Take blood for FBC, clotting screen, D-dimers, cardiac enzymes, U&Es, and creatinine. ABGs should also be taken and may reveal reduced PaO2
, reduced PaCO2
, and acidosis.
• Give morphine 10 mg IV with an anti-emetic.
• Start unfractionated heparin 10000 U IV bolus, then 18 U/kg/h IVI as guided by APTT. Low
molecular weight heparin can be given as an alternative.
• If systolic BP is >90 mmHg, confirm the diagnosis by carrying out ECG, chest X-ray, and computed tomographic pulmonary angiogram (CTPA) which is the gold standard for diagnosing
PE. Chest X-ray is most often normal, but is useful in excluding other chest disease such as
pneumothorax and pneumonia. ECG may revealsinustachycardia or AF, right ventricularstrain,
RBBB, and, uncommonly, the SI
, QIII, TIII pattern: deep S waves in lead I, Q waves in lead III, and
inverted T waves in lead III.
• Start warfarin 10 mg OD PO. Stop heparin once INR is in the range 2–3.
• If systolic BP is <90 mmHg, give a rapid colloid infusion and call for senior help. The patient
may require inotropic support and thrombolysis. Surgical embolectomy is an alternative if
immediately available.
Status epilepticus
You are the duty A&E doctor when a fitting patient is brought in by ambulance. You establish that the
fitting started more than 20 minutes ago. What is your immediate course of action?
• Assess ABCs.
• Secure the airway.
• Place the patient in the recovery position.
• Give 100% oxygen through a non-rebreather mask with a reservoir bag to prevent cerebral
hypoxia from seizure activity. Regular suctioning may also be required.
• Record and monitor blood pressure.
• Obtain IV access.
• Take bloods for ABGs, glucose, U&Es, calcium, magnesium, LFTs, FBC, toxicology screen, and
anticonvulsant levels to try to determine the cause of the seizures, e.g. hypoglycaemia, metabolic
disturbance, alcohol, drugs, inadequate anticonvulsant dose, cerebral lesion or infection, and, if
the patient is pregnant, eclampsia. Pseudo-seizures are a possibility to bear in mind. Obtain some
information about the patient, e.g. from an accompanying relative, if at all possible.
• If hypoglycaemia is suspected to be the cause, give 50 ml of 50% dextrose IV. If alcohol is suspected to be the cause, give thiamine 250 mg IV over 10 minutes.
• To stop the seizures, give a benzodiazepine such as lorazepam 4 mg IV slowly or diazepam
10 mg IV/PR. IV benzodiazepines should only be given if resuscitation facilities are available.
• If this measure is unsuccessful, the next step is a phenytoin IV infusion. With a blood pressure
and ECG monitor attached, give 15–18 mg/kg, at less than 50 mg/min.
• If this is unsuccessful, call for senior help and for an anaesthetist. General anaesthesia in ITU
may be required.
Diabetic ketoacidosis
A 17 year old boy with no previous medical history presents to A&E complaining of vomiting and
abdominal pain. When you see him, he appears severely dehydrated and is breathing heavily. You can
smell ketones on his breath. What is your immediate course of action?
Emergency medicine and anaesthesiology
Station 96 Management of medical emergencies 263
• Assess ABCs.
• Obtain a rapid blood glucose and urine dipstick for urinary ketones.
• Establish IV access and take blood for laboratory glucose, osmolality, U&Es, HCO3
–
, amylase, FBC,
and blood cultures. Obtain an arterial sample for blood gases.
• Give IV fluids. Be careful, as one of the commonest causes of death in DKA (diabetic ketoacidosis) is from cerebral oedema from over-rapid rehydration. One regimen is to give 1 l of normal
saline over 30 min followed by 1 l over 1 hour, 1 l over 2 hour, 1 l over 4 hour, and 1 l over 6
hours. Change to 5% dextrose once blood glucose is 10–15 mmol/l.
• Start a sliding scale of insulin via an IVI pump. Add 50 U of Actrapid to 50 ml of saline in a
syringe, and give insulin at an initial rate of 4–8 U/h (4–8 ml/h).
• Monitor vital signs, ECG, glucose, U&Es, and HCO3
–
. Aim for a fall in glucose of 5 mmol/h. Plasma
K+ falls as K+ enters cells, so KCl should be added to IV fluids as appropriate.
• Investigate the cause of the episode and treat any precipitating factors such as infection.
• Other measures:
– give unfractionated heparin 5000 units TDS SC for venous thromboembolism prophylaxis
– consider a naso-gastric tube if the patient is nauseated, vomiting, or unconscious
– consider a urinary catheter if there is persistent hypotension, cardiac failure, renal failure, or
no urine output for 2 hours
– consider a CVP line in the frail and elderly or if there is cardiac failure or renal failure
Acute poisoning
• Carry out ABCs and take action as appropriate. Nurse in semi-prone position if unconscious.
• If possible, take a focussed history from the patient or friends/relatives concentrating in
particular on:
– the drugs ingested and their quantities
– associated alcohol or drug use
– symptoms, including vomiting
– other aspects of the history, particularly past medical history, past psychiatric history, and
drug history
Carry out a full physical examination. If no history is available, try to identify the ingested drug from
your findings.
Table 29. Acute poisoning – identifying the ingested drug
Drug Signs and symptoms
Paracetamol Initially: none or nausea, vomiting, and RUQ pain
Later: jaundice, hypoglycaemia, encephalopathy, renal failure
Salicylates Vomiting, dehydration, increased respiratory rate, hyperventilation, sweating, warm
extremities, bounding pulse, tinnitus, vertigo, deafness, metabolic disturbances,
pulmonary oedema, renal failure, seizures, coma
Opiates Pin-point pupils (sometimes absent if other drugs are involved), nausea, vomiting,
drowsiness, respiratory depression, coma
• Obtain IV access and take blood for FBC, U&Es, creatinine, LFTs, INR/PT/clotting screen, blood
glucose, paracetamol and salicylate levels, other specific drug levels (as appropriate, contact
senior colleagues or the National Poisons Information Service if unsure). Other investigations
that need to be carried out include urine/serum toxicology screen, ABGs, and an ECG.
• Monitor vital signs such as respiratory rate, oxygen saturation, pulse rate, blood pressure, and
temperature. Consider attaching a cardiac monitor to monitor ECG and inserting a urinary catheter to monitor urinary output.
Clinical Skills for OSCEs
264 Station 96 Management of medical emergencies
• If appropriate, consider
– gastric emptying and lavage (NB. gastric lavage alone is rarely used)
– activated charcoal (50 g in 200 ml water) to reduce the absorption of, for example, paracetamol or salicylates from the gut
Paracetamol
• Specialist help from the gastroenterology team should be sought early if severe liver damage is
likely. In adults, 150 mg/kg or more may be fatal.
• Transfer to a specialist unit if systolic BP < 80 mmHg, blood pH < 7.3, INR > 2, creatinine > 200,
or there are signs of encephalopathy or increased intracranial pressure.
• Repeat paracetamol level, ideally at 4 hours post-ingestion.
• If < 8 hours post-ingestion and paracetamol level is above the normal treatment line, give
N-acetylcysteine (NAC, Parvolex) IVI as per protocol. If the patient is malnourished (e.g. in anorexia or alcoholism), or on an enzyme-inducing drug, prefer the high-risk treatment line instead
(Figure 65).
• If>8hourspost-ingestionandthepatienthastakena significant overdose,startN-acetylcysteine
and stop if paracetamol level returns below the treatment line and INR/ALT is normal. Note that
paracetamol level is unreliable after 15 hours or in the event of a staggered overdose; simply
treat according to the initial amount ingested.
200
190
180
170
160
150
140
130
120
110
100
90
80
70
60
50
40
30
20
10
0
1.3
1.2
1.1
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
0 2 4 6 8 10 12
Time (h)
Plasma paracetamol concentration (mg/l)
Plasma paracetamol concentration (mmol/l)
14 16 18 20 22 24
High-risk treatment line
Normal treatment line
Figure 65. Paracetamol poisoning: normal and high-risk treatment lines.
Emergency medicine and anaesthesiology
Station 96 Management of medical emergencies 265
• Continue monitoring vital signs at regular intervals and repeat U&Es, creatinine, LFTs, and INR/
PT on the next day.
Salicylates
• IV fluids to correct any dehydration, with particular attention to K+ supplements.
• Give 1.26% sodium bicarbonate IVI to correct any metabolic acidosis.
• Repeat salicylate levels at 2 hours post-ingestion. Levels above 700 mg/l are potentially fatal:
call for senior or specialist help.
• If plasma level > 700 mg/l or severe acidosis, renal failure, heart failure, or seizures, consider
haemodialysis.
• Monitor salicylate levels, ABGs, blood glucose, U&Es, and urinary output.
Opiates
• Naloxone, e.g. 0.4–2 mg IV, titrated to response.
• As naloxone has a shorter half-life than opiates, it may need to be given often or as an intravenous infusion to prevent re-occurrence of signs and symptoms. If the patient is threatening to
self-discharge, it can be given IM.
• Naloxone may precipitate severe withdrawal in high-dose opiate misusers, who may be very
angry at you for ruining their ‘trip’.
Once the patient is medically stable, he should be referred for a psychiatric assessment.
Clinical Skills for OSCEs
266 Station 97
Bag-valve mask (BVM/’Ambu bag’) ventilation
Specifications: A mannequin in lieu of a patient.
• Open the airway using the head-tilt, chin-lift method. Remove any visible obstruction from the
mouth.
• Identify the need for a Guedel airway (e.g. if the airway is obstructed or the patient is unconscious).
• Size the Guedel airway by measuring the distance from the incisors to the angle of the jaw. The
most commonly used sizes are 2 for a small adult, 3 for a medium adult, and 4 for a large adult.
• Insert the Guedel airway so that its concave side faces away from the tongue. After inserting it
almost to the back of the pharynx, rotate it 180 degrees and slide it in to its full extent.
• Choose an appropriately sized bag-valve mask.
• Attach the bag-valve mask to an oxygen supply. Adjust the flow rate to 15 l per minute.
• Hold the mask over the face with your dominant hand. Place your thumb over the nose and
support the jaw with the middle and ring fingers (Figure 66). Ensuring a tight seal is difficult, so
make sure you get sufficient practice.
• Maintain the head-tilt, chin-lift position.
• Use your free hand to compress the bag.
• Look for a rise in the chest.
If a second person is available (e.g. the examiner), use both hands to hold the mask and
get him to squeeze the bag.
• Ventilate at a rate of 10 compressions per minute until the patient starts breathing or until the
patient can be intubated and put on a ventilator.
Figure 66. Bag-valve mask ventilation
technique.
267Emergency medicine and anaesthesiology
Station 98
Laryngeal mask airway (LMA) insertion
Specifications: A mannequin in lieu of a patient.
Table 30. Laryngeal mask sizes
Size 1 Infant
Size 2 Child
Size 3 Small adult
Size 4 Normal adult
Size 5 Large adult
The equipment
Gather in a tray:
• A pair of non-sterile gloves • An air-filled syringe
• Laryngeal mask of appropriate size (see Table 30) • A bandage
• Lubricant
Before inserting the laryngeal mask
• Don the gloves.
• Assemble the equipment.
• Check inflation and deflation of the laryngeal mask airway (LMA).
• Lubricate the laryngeal mask.
• Ensure that the patient has received adequate anaesthesia (the cough reflex should be suppressed).
• Ensure that the patient has been pre-oxygenated, or pre-oxygenate him by bag ventilation for
1 minute.
• Use the head-tilt, chin-lift technique to ensure that the mouth is fully open.
• Check the state of the dentition.
Inserting the laryngeal mask
• Insert the tip of the LMA into the mouth, ensuring that the aperture is facing the tongue.
• Press the tip of the LMA against the hard palate as you introduce it into the pharynx.
• Use your index finger to guide the tube into the pharynx until resistance can be felt.
• Check that the black line on the tube is facing the upper lip.
If you do not succeed in inserting the laryngeal mask within 30 seconds, you must preoxygenate the patient a second time before you try again.
Clinical Skills for OSCEs
268 Station 98 Laryngeal mask airway (LMA) insertion
After inserting the laryngeal mask
• Inflate the cuff, ensuring that you do not over-inflate it. A size 3 LMA needs <20 ml of air, a size
4 <30 ml, and a size 5 <40 ml.
• Attach the breathing system and check that the patient is being satisfactorily ventilated.
• Secure the cuff in place by means of a length of bandage.
Larynx
Trachea
Epiglottis
Cu
Oesophagus
Figure 67. Laryngeal mask insertion.
269Emergency medicine and anaesthesiology
Station 99
Pre-operative assessment
The surgical pre-assessment is about half the job of a surgical house officer, so is not unlikely to be
examined in a final year OSCE. The aims of the pre-operative assessment are primarily to:
• Ascertain that the patient is fit for surgery and anaesthesia.
• Take appropriate action if he is not.
• Ensure that he fully understands the proposed procedure.
• Ensure that he fully understandsthe peri-operative process and any special requirements of the
proposed procedure.
• Minimise any remaining fears or anxieties.
[Note] The responsibility for gaining informed consent from the patient is no longer that of the junior house officer, but
that of the operating surgeon.
Specifications: In this station you may be asked to talk through or carry out a part or parts of the
pre-operative assessment.
Before starting
• Introduce yourself to the patient, and confirm his name and date of birth.
• Explain that you are going to ask him some questions and carry out a physical examination to
assess his fitness for surgery.
• Ensure that he is comfortable.
The assessment
History
• Medical history, in particular:
– previous surgery and anaesthesia – ask specifically about history of anaesthetic complications, e.g. suxamethonium apnoea, malignant hyperpyrexia
– previous hospital admissions
– cardiovascular: hypertension, palpitations, angina, myocardial infarction, cardiac failure,
orthopnoea, other ‘heart problems’, stroke or TIA
– respiratory: dyspnoea, asthma, cough, tuberculosis
– GI and renal: dysphagia, heartburn, liver disease, renal failure
– other: diabetes, sickle cell anaemia, epilepsy, neuromuscular problems
• Drug history:
– prescribed medication – ask specifically about recent changes in medication, insulin, and
anticoagulants
– over-the-counter and alternative medication
– recreational drugs (especially cocaine, ecstasy, and narcotics)
• Allergies including to antiseptic, plaster, and latex.
• Smoking.
• Alcohol.
[Note] Most drugs should be taken as normal on the day of the surgery, although special advice is needed for insulin and
anticoagulants.
• Family history of allergic reactions, anaesthetic complications, and medical and surgical conditions.
• Social history, e.g. level of support in post-operative period.
Clinical Skills for OSCEs
270 Station 99 Pre-operative assessment
Physical examination
• Record height and weight and calculate the patient’s body mass index as given by weight in
kilograms/(height in metres)2
, e.g. 70 kg/(1.8 m)2 = 21.6 (normal 18.5–25).
• Examine the cardiovascular, respiratory, gastrointestinal, and neurological systems.
• Assess neck mobility by asking the patient to flex and extend his neck.
• Assess jaw mobility by asking him to open and close his mouth.
• Inspect the state of the dentition.
• Carry out a Mallampati pharyngeal assessment. To do this you need to ask the patient to open
his mouth as wide as possible and to extend his tongue (Figure 68).
Figure 68. Mallampati pharyngeal assessment:
III – Pharyngeal pillars, soft palate, and uvula visible;
III – Soft palate and uvula visible;
III – Soft palate and the base of the uvula visible;
IV – Soft palate not visible
NB: Mallampati scores of III or IV are relative contraindications to surgery
• Determine the ASA physical status rating, a health index at the time of surgery (Table 31).
Table 31. The ASA physical status rating
1* Healthy, no systemic disturbance
2* Mild/moderate systemic disease. No activity limitation.
3* Severe systemic disturbance. Some activity limitation.
4* Life-threatening systemic disturbance. Severe activity limitation.
5* Moribund with limited chance of survival.
* Add suffix E for emergency.
I II III IV
Emergency medicine and anaesthesiology
Station 99 Pre-operative assessment 271
Pre-operative investigations
Table 32. Indications for pre-operative investigations
Group and save/crossmatch
Group and save for e.g. cholecystectomy, ERCP, mastectomy, amputation
Cross-match for e.g. laparotomy (2 units), TURP (3 units), hip replacement (4
units), liver surgery (6 units), aneurysm repair (4 units if elective, 10 units if
emergency)
FBC Cardiorespiratory disease, anaemia, blood loss, chronic disease, blood
disorders, on an oral anticoagulant, alcohol misuse, female patients, male
patients > 40 years
Clotting screen Liver disease, alcohol misuse, on an anticoagulant
Sickle cell screening Patients from Africa, the Caribbean, and the Mediterranean
U&Es Hypertension, heart failure, renal failure, liver disease, diabetes, dehydration,
starvation, on diuretics, digoxin, steroids, or lithium, age > 60 and having
major surgery
Glucose Diabetes, obesity, on steroids
LFTs (including
clotting screen)
Liver disease, alcohol misuse, malignancy, malnutrition
ECG Arrhythmias, angina, myocardial infarction, heart murmurs, heart failure,
cardiovascular risk factors, age > 50
CXR Hypertension, cardiorespiratory disease or symptoms, malignancy, age > 60
and having major surgery, recent immigrant
Cervical spine X-ray Severe chronic rheumatoid arthritis, cervical spondylosis
Other TFTs in thyroid disease
Amylase in abdominal pain or hepatobiliary surgery
Lung function tests in severe respiratory disease
Drug levels, e.g. if on digoxin or lithium
HIV
Peri-operative management
Explain about:
• Fasting, in most cases:
– stop solids from 6 hours before the operation
– stop clear fluids (and chewing gum) from 2 hours
• Pre-medication:
– benzodiazepines can be given before the operation to help the patient feel sleepy or less
anxious
• The anaesthetic procedure:
– patient information about different anaesthetic procedures can be found on the website of
the Royal College of Anaesthetists: http://www.rcoa.ac.uk/patientinfo
• Post-operative pain relief:
– oral analgesia, e.g. paracetamol, cocodamol, NSAIDs such as diclofenac and ibuprofen,
tramadol, opiates
– parenteral analgesia
Clinical Skills for OSCEs
272 Station 99 Pre-operative assessment
– suppositories
– local anaesthetics and regional blocks
– patient-controlled analgesia
– patches
• Post-operative nausea and vomiting:
– explain to the patient that he may feel sick after the operation and reassure him that this is
quite normal and that he can be given an anti-sickness tablet or injection
• Going home and driving.
After the procedure
• Ask the patient if he has any remaining questions or concerns.
• Thank him.
• Order the appropriate investigations (Table 32) and remember to check up on the results!
• Talk to the anaesthetist if you have any concerns.
273Emergency medicine and anaesthesiology
Station 100
Syringe driver operation
There are two different sorts of syringe driver: the 50 ml syringe pump, frequently used for heparin,
glyceryl trinitrate, and insulin infusions, and for epidural and patient-controlled analgesia; and the
Graseby syringe driver, which installs a 10 ml or 20 ml syringe and is frequently used in palliative care.
There are two varieties of the Graseby syringe driver: the blue Graseby MS 16A, which is designed to be
programmed at an hourly rate, and the green Graseby MS 26, which is designed to be programmed at
a 12, 24, or 48 hourly rate. In this station, you may be required to set up and operate a Graseby syringe
driver for two drugs, e.g. diamorphine and cyclizine.
Figure 69. The blue Graseby MS 16A, designed to be programmed at an hourly rate.
Before starting
• Introduce yourself to the patient.
• Explain the need for a syringe driver and the procedure involved, and gain consent.
• Gather the appropriate equipment.
The equipment
• Non-sterile gloves
• Graseby syringe driver (check the battery is in place and the device is functioning)
• Luer-lock syringe (10 ml or 20 ml)
• Subcutaneous giving set
• Drug
• Diluent (sterile water or normal saline)
Clinical Skills for OSCEs
274 Station 100 Syringe driver operation
The procedure
• Consult the prescription chart and check:
– the identity of the patient
– the prescription: drug(s), dose(s), diluent, route of administration, duration of the infusion,
date and time of starting
– drug allergies
• Check the name, dose, and expiry date of the drug(s) on the vial(s).
• Ask a colleague (registered nurse or doctor) to confirm the name, dose, and expiry date of the
drug(s) on the vial(s).
• Don a pair of non-sterile gloves.
• Draw up the correct doses of the drugs into the Luer-lock syringe.
• Draw up the correct diluent to make up the requested volume (stated on the prescription chart)
and shake the syringe with the needle capped.
• Connect the giving set to the syringe and run the infusion through it.
• Calculate the rate of infusion by measuring the length of liquid in the syringe in millimetres
and dividing it by the number of hours (Graseby 16A) or days (Graseby MS 26) over which the
infusion should be given.
• Label the syringe with:
– the patient’s name, date of birth, and hospital number
– the date and time of preparation
– drugs used and their doses
– diluent used and its volume
– rate of infusion
– your name
• Place the syringe into the syringe driver and secure the device.
• Set the syringe driver to the rate required.
• Place the giving set subcutaneously and start the infusion.
After the procedure
• Sign the drug chart, and have your checking colleague countersign it.
• Ask the patient if he has any questions or concerns.
• Ensure that he is comfortable.
275Emergency medicine and anaesthesiology
Station 101
Patient-Controlled Analgesia (PCA) explanation
In PCA, the patient presses a button to activate an infusion pump and receive a pre-prescribed
intravenous bolus of analgesic, most commonly morphine or another opioid such as diamorphine,
pethidine, or fentanyl.
Advantages
• Prevents delays in analgesic administration and thereby minimises pain. In the post-operative
period this may forestall a number of adverse events such as disability, pressure sores, DVT, PE,
atelectasis, and constipation.
• Minimises the amount of analgesic used, as the patient only activates the pump if he is actually
in pain. Other people, such as relatives, should be told not to activate the pump.
• Provides a reliable indication of the patient’s pain, and its evolution over time.
• Reduces the chance of dangerous medication errors, as the pump is programmed according to
a set prescription and ‘locks out’ if the patient tries to activate it too often. A typical dose regimen is a 0.5–2.0 mg bolus of morphine with a lock-out of 10–15 minutes.
Disadvantages
• Patients may not receive enough analgesia (see later). In particular, patients may wake up in
pain, as they cannot press the button when they are asleep.
• Patients may be physically or mentally unable to press a button.
• The pumps are expensive and may malfunction, especially if the battery is not adequately
charged.
Side-effects
Side-effects of morphine include:
• Respiratory depression.
• Sedation.
• Nausea and vomiting.
• Constipation.
• Urinary retention.
• Pruritus.
Some of these side-effects can be controlled by additional prescriptions of, for example, anti-emetics,
laxatives, or antihistamines. If the patient is suffering from significant respiratory depression or
sedation, the dose should be decreased and alternative analgesia considered. (Remember that
respiratory depression or sedation can also be caused by important post-operative complications, so
do not omit to exclude these.)
Monitoring
Patientsshould be reviewed at regular intervalsfor pain, analgesic usage, and side-effects; observations
should be made of the patient’s pain score, analgesic usage, pulse, blood pressure, respiratory rate, and
oxygen saturation. If pain relief is inadequate, the dose regime should be altered. In some cases, a
continuous ‘background’ infusion might be considered.
Clinical Skills for OSCEs
276 Station 102
Epidural analgesia explanation
Epidural analgesia, or ‘epidural’, is a form of regional anaesthesia involving the injection of local
anaesthetics and/or opioids through a catheter inserted into the epidural space. Epidurals can be
indicated for analgesia in labour (often simply as a matter of patient choice), for surgical anaesthesia
in certain operations, e.g. Caesarean section, and as an adjunct to general anaesthesia in others, e.g.
laparatomy, hysterectomy, hip replacement. They can also be indicated for post-operative analgesia,
back pain, and palliative care.
Advantages
• Permits analgesia to be delivered as a continuous infusion and/or to be patient-controlled.
• Effective and safe, with a mortality of only about 1 in 100000.
• In post-operative analgesia, reduces the risk of certain post-operative complications such as
nausea and vomiting, chest infections, and constipation.
Disadvantages
• 5% failure rate.
• In labour, increases the risk of an assisted delivery.
Contraindications
Absolute
• Raised intracranial pressure.
• Coagulopathy/anticoagulation.
• Hypovolaemia.
• Skin infection at epidural site.
• Septicaemia.
Relative
• Un-cooperative patient.
• Anatomical abnormalities or previous spinal surgery.
• Certain neurological disorders.
• Certain heart-valve problems.
Procedure
Epidurals are normally performed by a trained anaesthetist with the patient either in the preferred
sitting position or in the left lateral position. The planned entry site is identified and marked. After the
skin is cleaned and local anaesthetic administered, a Tuohy needle is advanced until a loss of resistance
isfelt anterior to the ligamentum flavum. The cathether, a fine plastic tube, isthen threaded through the
needle and the needle is removed, leaving the catheter in place. As epidurals are usually carried out in
the mid-lumbar region, there is very little risk of injuring the spinal cord.
Emergency medicine and anaesthesiology
Station 102 Epidural analgesia explanation 277
Side-effects and complications
• Side-effects of opioids.
• In higher doses can result in loss of other modalities of sensation (such as touch and proprioception) and motor function.
• Hypotension, most often resulting from loss of sympathetic function.
• Urinary retention.
• Accidental dural puncture resulting in a leak and a severe headache that is exacerbated by raising the head above horizontal.
• Accidental infusion into the CSF resulting in a high block or, more rarely, a total spinal involving
profound hypotension, respiratory paralysis, and unconsciousness.
• Epidural haematoma that can cause spinal compression.
• Abscess formation.
Monitoring
Patients receiving epidural analgesia should be monitored for pain intensity, drug-related side-effects,
and signs of complications due to the epidural procedure.
Dura
Epidural space
Skin
Interspinous ligament
Spinous process
Ligamentum avum
Epidural needle
Catheter
Figure 70. Anatomy of the
epidural space.
Clinical Skills for OSCEs
278 Station 103
Wound suturing
Specifications: A pad of ‘skin’ in lieu of a patient. This station most likely requires you to talk through
the parts of the procedure and then to demonstrate your suturing technique. For this second part,
there can be no substitute for practice, practice, and more practice!
Before starting
• Introduce yourself to the patient, and confirm his name and date of birth.
• Explain the procedure and obtain consent.
• Examine the wound, looking for debris, dirt, and tendon damage.
• Indicate that you would request an X-ray to exclude a foreign body.
• Assess distal motor, sensory, and vascular function.
• Position the patient appropriately and ensure that he is comfortable.
The equipment
• A pair of sterile gloves
• A suture pack
• A suture of appropriate type (monofilament non-absorbable for superficial wounds, absorbable for deep wounds) and size (3/0 for scalp and trunk, 4/0 for limbs, 5/0 for hands, 6/0 for
face)
• A 5 ml syringe, 21G and 25G needles, and a vial of local anaesthetic (e.g. 1% lignocaine)
• Antiseptic solution
• A sharps bin
The procedure
• Wash your hands.
• Open the suture pack, thus creating a sterile field.
• Pour antiseptic solution into the receptacle.
• Open the suture, the syringe, and both needles onto the sterile field.
• Wash your hands using sterile technique.
• Don the non-sterile gloves.
• Attach a 21G needle to the syringe.
• Ask an assistant (the examiner) to open the vial of local anaesthetic and draw up 5 ml of local
anaesthetic. For an average 70 kg adult, up to 20 ml of 1% lignocaine can be safely used,
although 5–10 ml is usually sufficient. Epinephrine may be used with lignocaine to minimise
bleeding. The maximum safe dose of lignocaine with or without epinephrine is 7 mg/kg and
3 mg/kg respectively. However, avoid injecting epinephrine when anaesthetising the extremities due to the risk of ischaemic tissue necrosis.
• Discard the needle into the sharps bin and attach the 25G needle to the syringe.
• Clean the wound (use forceps) with antiseptic-soaked cotton wool and drape the field. Dirty
wounds may benefit from cleansing with povidone iodine, whereas normal saline can be used
to cleanse and irrigate ‘clean’ wounds.
• Inject the local anaesthetic into the apices and edges of the wound. Make sure to pull back on
the plunger before injecting to make sure that you are not injecting into a vessel.
• Discard the needle into the sharps bin.
• Indicate that you would give the anaesthetic 5–10 minutes to operate (or as long as it takes for
sensation to a needle prick to be lost).
Emergency medicine and anaesthesiology
Station 103 Wound suturing 279
• Apply the sutures approximately 3 mm from the wound edge and 5–10 mm apart. Use needleholding forceps to hold the needle and toothed forceps to pick up the skin margins. Knot the
sutures around the needle-holding forceps.
Figure 72. Suggested approach for suturing. Knot the sutures around the needle-holding forceps: loop the suture
twice around the nose of the needle-holding forceps using your hand. Then take hold of the short end of the
suture with the needle-holding forceps and carry it through the loops, gently pulling the knot tight. Two further
single loops are then added in a similar fashion to secure the knot. Each loop is pulled in the opposite direction
across the wound edge.
After the procedure
• Clean the wound and indicate that you would apply a dressing.
• Assess the need for a tetanus injection.
• Give appropriate instructions for wound care (in particular, if the wound becomes painful or inflamed,
it should be brought back to medical attention), and indicate the date on which the sutures should be
removed (e.g. face 3–4 days, scalp 5 days, trunk 7 days, limbs 7–10 days, feet 10–14 days).
• Ask if the patient has any questions or concerns.
• Thank him.
Figure 71. Use needle-holding forceps to
hold the needle approximately two-thirds
from the needle tip.
Clinical Skills for OSCEs
280 Station 104
Blood glucose measurement
Specifications: In this station you are far more likely to be asked to talk through a blood glucose
measurement or ‘BM’ (Boehringer Mannheim) than carry it out on a patient or actor.
Before starting
• Introduce yourself to the patient, and confirm his name and date of birth.
• Explain the procedure and obtain his consent.
• Establish when he last ate (fasting blood glucose is usually carried out in the morning before
the patient has had anything to eat or drink).
The equipment
In a tray, gather:
• A pair of non-sterile gloves • A spring-loaded pricker
• An alcohol wipe • A lancet
• A glucose monitor • Cotton wool
• Test strips • A sharps bin
The procedure
• Ask the patient to wash and dry his hands, or use an alcohol wipe to clean the finger that you
are going to prick.
• Wash your hands and don the gloves.
• Massage the finger from its base to its tip to increase its perfusion.
• Turn on the glucose monitor and ensure that it is calibrated.
• Check that the test strips have not expired.
• Insert a test strip into the glucose monitor.
• Load the lancet into the pricker and prick the side of the finger.
It is less painful to prick the side rather than the tip of a finger because there are
comparatively fewer nerve endings there.
• Dispose of the lancet/pricker in the sharps bin.
• Squeeze the finger to obtain a droplet of blood. If no or insufficient blood is obtained, prick the
finger again and be sympathetic to the patient’s plight!
• Place the droplet of blood on the test strip, so as to cover the sensor entirely.
• Give the patient some cotton wool to stop any bleeding.
• Record the reading on the monitor. Units are in millimoles per litre.
• Dispose of the test strip and gloves in a clinical waste bin.
After the procedure
• Tell that patient their blood glucose and explain its significance and any further action that
needs to be taken, e.g. fasting blood glucose, oral glucose tolerance test (OGTT), laboratory
measurement. Note that the diagnosis of diabetes in a symptomatic patient should never be
made on the basis of a single abnormal blood glucose measurement.
• Ask the patient if he has any questions or concerns.
• Thank him.
Data interpretation
Station 104 Blood glucose measurement 281
Table 33. Blood glucose measurement: interpretation of result (normal results vary from lab to
lab)
Units are in millimoles per litre
Normal
fasting glucose
non-fasting glucose*
< 6.0
< 7.8
Impaired glucose tolerance
fasting glucose
non-fasting glucose
6–7
7.8–11.1
Diabetes mellitus
fasting glucose
non-fasting glucose
≥ 7.0
≥ 11.1
* 2-h post 75 g glucose.
Examiner’s questions: Complications of type II diabetes
Acute:
• Hyperosmolar non-ketotic coma (HONK).
• Hypoglycaemia.
• Respiratory infections.
Microvascular:
• Retinopathy and cataracts.
• Nephropathy progressing to renal failure.
• Neuropathy, most frequently distal symmetric sensorimotor polyneuropathy in a glove-andstocking distribution and oculomotor mononeuropathy.
Macrovascular:
• Cardiovascular disease and MI.
• Cerebrovascular disease and CVA/stroke.
• Peripheral vascular disease: foot ulcers progressing to diabetic foot disease, impotence.
Clinical Skills for OSCEs
282 Station 105
Urine sample testing/urinalysis
Before starting
• Introduce yourself to the patient, and confirm his name and date of birth.
• Take a very brief history from him.
• Explain the procedure and obtain consent.
• Ensure that the urine specimen is fresh and that it has been appropriately collected (genitalia
have been cleaned, bottle has not come into contact with body, only mid-stream urine has
been collected).
The equipment
• Urine dipstick and urine dipstick bottle
• A pair of non-sterile gloves
• A pen and paper (or the patient’s case notes)
The procedure
• Wash your hands and don the gloves.
• Inspect the colour and appearance of the urine. In particular, is it cloudy or bloody?
• Stir the urine bottle to ensure that the urine is mixed.
• Check the expiry date on the urine dipstick jar.
• Briefly immerse the urine dipstick into the urine specimen.
• Tap off any excess urine from the dipstick.
• Hold the strip horizontally.
• After 2 minutes, read each colour pad using the colour chart on the dipstick bottle.
• Report and record the results.
• Discard the used urine dipstick and the gloves.
• Wash your hands.
Specific gravity 60 sec
pH 60 sec
Leukocytes 60–120 sec
Blood 60 sec
Nitrite 60 sec
Ketones 60 sec
Bilirubin 60 sec
Urobilinogen 60 sec
Protein 60 sec
Glucose 60 sec Figure 73. The colour chart on
the urine dipstick bottle.
Data interpretation
Station 105 Urine sample testing/urinalysis 283
After testing the urine
• Explain the results to the patient.
• Document the results in the patient’s notes.
• If abnormal, suggest obtaining a second sample of urine or sending the urine for laboratory
analysis, i.e. microscopy, cytology, and sensitivity (MC&S).
• Thank the patient.
Table 34. Urine dipstick: interpretation of results
Leukocytes Urinary tract infection
Nitrites Bacteriuria, contaminated sample
Protein Kidney damage or disease, standing upright for prolonged periods, exercise, fever,
pregnancy, rarer causes, e.g. leukaemia, multiple myeloma, pre-eclampsia
Blood Kidney damage or disease, urinary calculi, urinary tract infection, contaminated sample,
exercise, dehydration, myoglobinuria
Ketones Diabetic ketoacidosis, starvation, alcohol intoxication
Glucose Diabetes mellitus, pregnancy
Clinical Skills for OSCEs
284 Station 106
Blood test interpretation
1. Reference ranges are based on a Gaussian or normal distribution, and usually include about
95% of the population. This means that a result only slightly outside the reference range is
not necessarily ‘abnormal’.
2. Reference ranges do vary from one laboratory to another – don’t let this confuse you!
Full blood count (FBC/CBC)
Normal range
Hb 13–18 g/dl (males); 11.5–16 g/dl (females)
RCC 4.5–6.5 ¥ 1012/l (males); 3.9–5.6 ¥ 1012/l (females)
PCV 0.4–0.54 (males); 0.37–0.47 (females)
MCV 76–96 fl
MCHC 30–36 g/dl
WCC 4.0–11.0 ¥ 109
/l
neutrophils 2.0–7.5 ¥ 109
/l (40–75% WCC)
lymphocytes 1.3–3.5 ¥ 109
/l (20–45%)
eosinophils 0.04–0.44 ¥ 109
/l (1–6%)
basophils 0–0.10 ¥ 109
/l (0–1%)
monocytes 0.2–0.8 ¥ 109
/l (2–10%)
Platelets 150–400 ¥ 109
/l
• Haemoglobin (Hb) and red cell count (RCC) are increased in dehydration, chronic hypoxia,
and polycythaemia. The term ‘anaemia’ describes a Hb of < 13 g/dl in males and < 11.5 g/dl in
females. Anaemia has many causes, including iron deficiency, folate or vitamin B12 deficiency,
chronic illness, blood loss, and blood cell destruction.
• Packed cell volume (PCV) or ‘haematocrit’ is the fraction of total blood volume occupied by red
cells; it decreases in anaemia and increases in dehydration, chronic hypoxia, and polycythaemia.
• Mean corpuscular volume (MCV) is the average volume of a red blood cell, and is thus equivalent to PCV/RCC; it decreases in iron deficiency, chronic disease, thalassaemia, and sideroblastic
anaemia and increases in folate or vitamin B12 deficiency, alcoholism, liver disease, hypothyroidism, pregnancy, reticulocytosis (e.g. in haemolysis), and other haematological diseases.
• Mean corpuscular haemoglobin concentration (MCHC) is the average concentration of haemoglobin in red cells, and decreases in iron deficiency, chronic disease, and chronic blood loss.
• A raised white cell count (WCC) or leukocytosis may indicate infection, inflammation, major
tissue damage, or certain lymphoproliferative disorders. The differential white cell count is
useful in determining the probable cause of a leukocytosis. For example, a raised neutrophil
count or neutrophilia may indicate acute bacterial infection, acute inflammation, or major
tissue damage; a raised eosinophil count or eosinophilia may indicate an allergic reaction or
parasitic infection; and a raised lymphocyte count may indicate an acute viral infection, lymphoma, or an infection such as TB or pertussis. A depressed WCC may indicate overwhelming
sepsis, bone marrow failure/damage, or myelodysplastic disorder.
• A raised platelet count or thrombocytosis may result from haemorrhage, chronic inflammatory
conditions, hyposplenism, and certain myeloproliferative disorders, e.g. chronic myelogenous
leukaemia. A low platelet count or thrombocytopaenia may result from decreased platelet production (e.g. folate or vitamin B12 deficiency, infection, cancer treatment), increased platelet
destruction (e.g. immune thrombocytopaenic purpura, disseminated intravascular coagulation,
systemic lupus erythematosus), or certain drugs.
Data interpretation
Station 106 Blood test interpretation 285
Iron studies (haematinics)
Normal range
Serum iron 14–31 μmol/l (males); 11–30 μmol/l (females)
Ferritin 12–200 μg/l
TIBC 54–75 μg/l
Folate 2.1 μg/l
Vitamin B12 0.13–0.68 nmol/l
• Ferritin is the main protein that stores iron, and so serum ferritin reflects the body’s iron stores.
• Total iron binding capacity (TIBC) reflects the amount of transferrin, a protein that transfers
iron from the gut, in the serum.
• Iron deficiency and chronic disease may both lead to a decrease in serum iron, and therefore
to a microcytic anaemia. In investigating the cause of a microcytic anaemia, serum iron must be
looked at in conjuction with serum ferritin and TIBC. In iron deficiency anaemia, serum ferritin
is decreased and TIBC is increased. In contrast, in anaemia of chronic disease, serum ferritin is
often increased and TIBC often decreased. Note that, in some cases, anaemic of chronic disease
can also present with a normal MCV. Other causes of a normocytic anaemia include acute blood
loss and renal failure.
• By contrast, folate and vitamin B12 deficiency result in a macrocytic anaemia. Folate levels
decrease if dietary intake of folate is inadequate or if demand for folate is increased (e.g.
pregnancy, increased cell turnover) and in alcoholism, malabsorption, pernicious anaemia,
and treatment with certain drugs such as phenytoin and sodium valproate. Vitamin B12 levels
decrease if dietary intake of vitamin B12 is inadequate, and in malabsorption and pernicious
anaemia.
Coagulation/clotting tests
Normal range
PT 10–14 s
APTT 35–45 s
TT 10–15 s
INR 0.9–1.2
D-dimers <0.5 mg/l
• A lack of factors I, II, V, VII, and X or fibrinogen leads to an increase in prothrombin time (PT).
PT thus tests the extrinsic system and is prolonged by warfarin treatment, vitamin K deficiency,
liver disease, and DIC.
• A lack of factors I, II, V, VIII, IX, XI, or XII leads to an increase in activated partial thromboplastin time (APTT). APTT thus tests the intrinsic system and is prolonged by heparin treatment,
haemophilia, liver disease, and DIC.
• Thrombin time (TT) is prolonged by a deficiency of factor I (fibrinogen), heparin treatment, and
DIC.
• INR is the ratio of PT to mean PT in a normal population, and should thus be around 1. Target
INR for DVT and PE prophylaxis is 2–3 (3.5 if recurrent), but 3–4 for prosthetic metallic heart
valves.
• D-dimers are a fibrin degradation product, and are raised in DVT, PE, and DIC, but also in inflammatory states.
Clinical Skills for OSCEs
286 Station 106 Blood test interpretation
ESR
Normal range
ESR < 20 mm/h
Or, for males, (age in years)/2, and for females (age in years + 10)/2
• A raised erythrocyte sedimentation rate (ESR) is a non-specific finding that often results from
inflammation, but sometimes also from injury or malignancy. Serial ESR measurements can be
used to monitor disease severity and treatment response in inflammatory disorders such as
rheumatoid arthritis and temporal arteritis.
Thyroid function tests
Normal range
TSH 0.5–5.7 mU/l
Thyroxine (T4) 70–140 nmol/l
Free T4 9–22 pmol/l
Tri-iodothyronine (T3) 1.2–3 nmol/l
TBG 7–17 mg/l
• Typical findings in hyperthyroidism are decreased TSH (thyroid-stimulating hormone) and
increased (or normal) T4, free T4, and T3.
• Typical findings in hypothyroidism are increased TSH and decreased (or normal) T4 and free T4.
• Increased TSH and increased T4 suggest a TSH-secreting tumour.
• Decreased TSH, T4, and T3 suggest pituitary disease or ‘sick euthyroidism’, which can be seen
in any systemic illness.
• T4 and T3 are increased if TBG (thyroxine-binding globulin) is increased (e.g. in pregnancy or
oestrogen therapy) and vice versa.
Liver function tests
Normal range
Bilirubin 3–17 μmol/l
ALT 5–35 U/l
AST 5–35 U/l
ALP 30–150 U/l
GGT 11–51 U/l (males); 7–33 U/l (females)
Albumin 35–50 g/l
• The amount of bilirubin in the blood reflects the balance between that produced by red
cell destruction and that removed by the liver. A raised bilirubin level results either from
diseases causing increased red blood cell destruction, diseases causing hepatocellular damage,
or diseases causing biliary obstruction and thereby restricting the excretion of bilirubin. The
latter is suggested by a high ratio of conjugated bilirubin to unconjugated bilirubin.
• Raised ALT and AST suggest hepatocellular damage. ALT (alanine aminotransferase) is a relatively specific marker of hepatocellular damage, and is most raised in the acute phase. Although
ALT is also present in cardiac muscle, the rises seen in myocardial infarction are comparatively
small. AST is a less specific marker of hepatocellular damage than ALT and may also be raised
in myocardial infarction, skeletal muscle damage, haemolysis, shock, pregnancy, and exercise.
Data interpretation
Station 106 Blood test interpretation 287
• Raised ALP and GGT suggest biliary obstruction. ALP (alkaline phosphatise) is raised in biliary
obstruction, hepatocellular damage, some bone diseases, and pregnancy. GGT (gammaglutamyl transferase) is raised in alcohol consumption, and also in biliary obstruction and
hepatocellular damage.
• Albumin is a genuine test of liver function and falls in chronic liver disease. Other causes for a fall
in albumin include malnutrition, malabsorption, nephrotic syndrome, burns, pregnancy, and
overhydration, e.g. with IV fluids. A rise in albumin is usually the consequence of dehydration.
Urea and electrolytes
Normal range
Sodium 135–145 mmol/l
Potassium 3.5–5.0 mmol/l
Calcium (total) 2.12–2.65 mmol/l
Bicarbonate 24–28 mmol/l
Urea 2.5–6.7 mmol/l
Creatinine 70–150 μmol/l
Hyponatraemia
• Hyponatraemia is commonly caused by the syndrome of inappropriate secretion of antidiuretic
hormone (SIADH), which itself has a large number of causes including malignancy, pulmonary
disorders, central nervous system disorders, and drugs. Other common causes of hyponatraemia are inappropriate fluid therapy, diuretic treatment, diarrhoea and vomiting, and cardiac
and renal failure. For the causes of hyponatraemia, see Figure 74. Note that high serum glucose,
urea, proteins, or lipids can increase serum volume and result in a pseudohyponatraemia.
Yes
Yes No No Yes
Yes No
No
Is the patient dehydrated?
Hyponatraemia
Renal Na+ loss
• Addison’s
• Renal failure
• Diuretic excess
• Osmolar diuresis
Loss elsewhere
• Diarrhoea
• Vomiting
• Fistulae
• Burns
• Small-bowel obstruction
• Trauma
• CF
• Heat exposure
• Nephrotic syndrome
• Renal failure
• Cardiac failure
• Cirrhosis
• Water overload
• Glucocorticoid insufficiency
• Severe hypothyroidism
• SIADH
Urine osmolality
>500 mmol/kg?
Is urinary Na > 20 mmol/l? Is the patient oedematous?
Figure 74. Causes of hyponatraemia.
Clinical Skills for OSCEs
288 Station 106 Blood test interpretation
• Hyponatraemia may be asymptomatic or may produce nausea, vomiting, headache, confusion,
convulsions, and coma.
• Treat the cause. It is important to determine the volume status of the patient. If the patient is
hypovolaemic, a normal saline infusion may be indicated. Particularly in chronic hyponatraemia, correction should be cautious and gradual (a maximum of 15 mmol/day) so as to avoid
the complication of central pontine myelinosis. If the patient is hypervolaemic, fluid restriction
(with or without frusemide) may be indicated. Hypertonic saline should only be used in emergency situations.
Hypernatraemia
• Causes include:
– insufficient water intake
– inappropriate fluid therapy
– fluid loss, e.g. through diarrhoea, vomiting, and burns
– diuretic treatment
– osmotic diuresis, e.g. in hyperglycaemia
– diabetes insipidus
– mineralocorticoid excess as in Conn’s syndrome or Cushing’s syndrome
• Symptoms include thirst, confusion, convulsions, and coma.
• Treat through oral rehydration or a 5% dextrose infusion, e.g. 4 litres over 24 hours. Note that
over-rapid correction of hypernatraemia can lead to cerebral oedema and convulsions, brain
damage, and death.
Hypokalaemia
• Causes include:
– gastrointestinal losses as in vomiting, diarrhoea, laxative use, villous adenoma
– renal losses as in thiazide or loop diuretic treatment (most common cause), mineralocorticoid excess (e.g. Conn’s syndrome, Cushing’s syndrome), and renal tubular acidosis
– shift into cells as in insulin treatment, metabolic alkalosis, high catecholamines (e.g. due to
pain)
– poor intake as in prolonged fasting, eating disorders
– re-feeding syndrome
– hypomagnesaemia
• In mild cases, hypokalaemia is often asymptomic. In severe cases, the clinical picture is dominated by muscle weakness which can progress to flaccid paralysis and, rarely, respiratory failure.
ECG changes may include T wave flattening, ST segment depression, appearance of U waves,
and tachyarrhythmias.
• Treatment involves addressing the cause and supplementing potassium, either orally or as an
intravenous infusion, depending on severity. Note that too concentrated an infusion is painful
and damages peripheral veins, and too fast an infusion predisposes to ventricular tachyarrhythmias.
Hyperkalaemia
• Causes include:
– artefact due to haemolysis of the blood sample (repeat the measurement)
– excessive intake, most likely in the form of potassium supplements
– impaired excretion as in renal insufficiency, Addison’s disease (reduced mineralocorticoids),
treatment with potassium-sparing diuretics and NSAIDs
– shift out of cells as in diabetic ketoacidosis and other metabolic acidoses
– excessive release from cells, as in burns, rhabdomyolysis, tumour lysis, massive blood transfusion
Data interpretation
Station 106 Blood test interpretation 289
• Although hyperkalaemia is usually asymptomatic, it can lead to cardiac arrhythmia and sudden
death. For thisreason, an ECG should be carried out assoon as hyperkalaemia issuggested. ECG
findings include tall, tented T waves, broadened QRS complex, prolonged PR interval, P wave
flattening, and a sine wave appearance.
• In mild hyperkalaemia, potassium intake should be restricted. In severe hyperkalaemia, or if
there are ECG changes, IV calcium gluconate should be administered to stabilise the myocardium. IV insulin with glucose, the potassium-binding resin calcium resonium, and dialysis
can then be used to reduce potassium.
Calcium
• Calcium (total) needsto be adjusted for albumin by adding 0.1 mmol/l for every 4 g/l that albumin
is below 40 g/l, and subtracting 0.1 mmol/l for every 4 g/l that albumin is above 40 g/l.
• Hypocalcaemia may be caused by hypomagnesaemia, hyperphosphataemia, hypoparathyroidism, pseudohypoparathyroidism (failure of cells to respond to parathyroid hormone),
vitamin D deficiency, and chronic renal failure. Symptoms include depression, perioral paraesthesiae, carpo-pedal spasm (hence Trousseau’s sign), neuromuscular excitability (hence
Chvostek’s sign), tetany, laryngospasm, and cardiac arrhythmias. Treatment involves treating
the cause and, depending on severity, oral or IV calcium replacement.
• 90% of cases of hypercalcaemia are accounted for by either malignancy or hyperparathyroidism. Symptoms include fatigue, confusion, depression, anorexia, nausea and vomiting,
constipation, abdominal pain, polyuria, renal calculi, and cardiac arrest. Management involves
treating the hypercalcaemia and its underlying cause. Treating the hypercalcaemia involves
fluids (normal saline), frusemide, and bisphonates, e.g. pamidronate.
For acid–base disturbances, see Station 107.
Urea and creatinine
• Urea is increased in renal disease, renal hypoperfusion (e.g. in severe dehydration), and urinary
tract obstruction. It is also increased by a high-protein diet, bleeding into the GI tract, tissue
damage, and certain drugs. It is decreased in overhydration, advanced liver disease, malnutrition, and eating disorders.
• Serum creatinine provides a crude estimate of glomerular filtration. It is increased in renal
disease, renal hypoperfusion, urinary tract obstruction, and rhabdomyolysis. It is decreased in
advanced liver disease, malnutrition, eating disorders, and muscle loss. A better estimate of
glomerular filtration is creatinine clearance.
Clinical Skills for OSCEs
290 Station 107
Arterial blood gas (ABG) sampling
Specifications: An anatomical arm in lieu of a patient.
Before starting
• Introduce yourself to the patient and confirm his name and date of birth.
• Explain the procedure and obtain consent.
• Check the case notes for anticoagulant treatment or platelet or clotting abnormalities.
• Note the patient’s oxygen requirements and body temperature.
• Gather the required equipment in a tray.
The equipment
• Non-sterile gloves • Heparinised 2 ml ABG syringe pack with cap
• Alcohol wipes • 23G (blue) needle (¥4)
• Lignocaine 1% • Gauze
• Syringe for lignocaine • Sharps bin
The procedure
• Wash and dry your hands or cleanse them with alcohol gel.
• Position the patient’s arm so that the wrist is extended.
• Palpate the radial artery over the head of the radius and locate the site of maximum pulsation.
This is important, so take as much time as you need.
• Don the gloves.
• Cleanse the site with an alcohol wipe.
• Inject lignocaine intradermally to form a bleb around the chosen area, taking care not to puncture the vessel or mask its pulsation. (This step can be omitted depending on patient preference.)
• If you do not have a heparinised syringe, attach a 23G needle to the 2 ml syringe and draw up a
little heparin into the syringe (ensure that there is no air in the syringe prior to ABG sampling).
• Discard the needle into the sharps bin.
• Attach a second 23G needle to the syringe.
• Fix the chosen area between the index and middle fingers of your non-dominant hand.
• Warn the patient to expect a ‘sharp scratch’ or some other gross euphemism.
• Directing it proximally up the arm, insert the needle at 45 degrees to the skin.
• Advance the needle a few millimetres in line with the direction of the artery until you obtain a
flashback of bright red arterial blood into the syringe. The syringe should fill from the patient’s
pulse, but gentle aspiration may in some cases be required.
• Allow the syringe to fill with 2 ml of arterial blood.
• Pick up a gauze with your non-dominant hand.
• Withdraw the needle and press firmly over the puncture site with the gauze. State that the
pressure ought to be maintained for 5 minutes, with regular checking for the formation of a
haematoma.
• Discard the needle into a sharps bin.
• Expel any air bubbles from the syringe and cap it.
• State that you would immediately take the blood to a blood gas machine for analysis. At this
point the examiner may hand you a print out from the machine.
Data interpretation
Station 107 Arterial blood gas (ABG) sampling 291
Allen’s test
The radial artery (lateral wrist) is at risk of damage from ABG sampling, leaving only the ulnar artery
(medial wrist) to supply the hand. Allen’s test aims to ensure that the ulnar artery is patent, so as to
minimise the risk of critical hand ischaemia.
• Ask the patient to make a fist and elevate his hand for 15–30 seconds.
• Occlude both the ulnar and radial arteries with your fingers.
• Ask the patient to open his hand: it should appear pale or blanched.
• Release the pressure on the ulnar artery (but not the radial artery). If the ulnar artery is
patent, the hand should return to its normal colour within 6 seconds.
After the procedure
• Ensure that the patient is comfortable.
• Interpret the print-out, if any (see Table 35). If the patient is on oxygen, write this on the print-out.
• Feedback to the patient/examiner.
• Ask the patient if he has any questions or concerns.
• Clear up.
Arterial blood gas interpretation (suggested approach for an OSCE station)
1. Assess PaO2
(>10 kPa, higher readings may indicate that the patient is receiving oxygen).
2. Assess pH
• ≤ 7.35 is acidosis.
• ≥ 7.45 is alkalosis.
3. Assess PaCO2
• If > 6.0 kPa there is either respiratory acidosis or respiratory compensation for metabolic
alkalosis.
• If < 4.7 kPa there is either respiratory alkalosis or respiratory compensation for metabolic
acidosis.
4. Assess standardised HCO3
*
• If < 22 there is metabolic acidosis or renal compensation for respiratory alkalosis.
• If > 28 there is a metabolic alkalosis or renal compensation for respiratory acidosis.
5. Combine information from 2, 3, and 4 above to determine the primary disturbance and
whether there is any renal or respiratory compensation occurring (see Table 35).
Example
pH = 7.30
PaO2
= 6.8
PaCO2
= 7.45
HCO3
= 26.0 mmol/l
This is uncompensated respiratory acidosis due to abruptly impaired ventilation, e.g. asthma
attack.
* You can also assess the base excess (BE, either an excess or a deficit), which represents a more accurate
assessment of the metabolic component of acid–base balance than HCO3
. The normal range is -2 to 2mmol/l.
< -2 indicates metabolic acidosis or compensated respiratory alkalosis; >2 indicates metabolic alkalosis or
compensated respiratory acidosis.
Clinical Skills for OSCEs
292 Station 107 Arterial blood gas (ABG) sampling
Table 35. Arterial blood gas interpretation
pH PaCO2 HCO3
Respiratory acidosis Ø ≠ Æ, ≠*
Respiratory alkalosis ≠ Ø Æ, Ø*
Metabolic acidosis Ø Æ, Ø** Ø
Metabolic alkalosis ≠ Æ, ≠** ≠
Mixed acidosis Ø ≠ Ø
Mixed alkalosis ≠ Ø ≠
* Renal compensation occurring.
** Respiratory compensation occurring.
Examiner’s questions: Disorders of acid–base balance
Respiratory
acidosis
• Results from alveolar hypoventilation.
• Common causes include airway obstruction, respiratory disease, impaired lung
motion, neuromuscular disease, central nervous system depression, and obesity
(Pickwickian syndrome).
• Symptoms are often those of the underlying cause. Respiratory acidosis does not
have a marked effect on serum electrolytes.
• Management involves oxygen therapy, but particular care must be taken in patients
with COPD as oxygen can reduce hypoxic drive. Where possible, treat the cause.
Respiratory
alkalosis
• Results from alveolar hyperventilation.
• Common causes include anxiety, pyrexia, CNS causes such as stroke and
subarachnoid haemorrhage, liver failure, drugs such as salicylic acid and nicotine,
high altitude, and mechanical ventilation.
• There may be signs and symptoms of hypocalcaemia (including positive Trousseau
and Chvostek signs) without a fall in total serum calcium levels (due to increased
binding of calcium).
• Management involves treating the cause.
Metabolic
acidosis
• Results from increased hydrogen ion concentration or decreased bicarbonate
concentration.
• Causes are various: some increase the anion gap (see box) and others do not.
• Causes that increase the anion gap include renal failure, massive rhabdomyolysis,
diabetic ketoacidosis, lactic acidosis, and intoxication with ethanol, methanol,
ethylene glycol, or salicylic acid.
• Causes that do not increase the anion gap include chronic diarrhoea and renal
tubular acidosis.
• Symptoms are various and non-specific. Extreme cases may lead to cardiac
arrhythmias, and coma and seizures.
• Depending on severity, management may involve IV bicarbonate or dialysis.
Data interpretation
Station 107 Arterial blood gas (ABG) sampling 293
Metabolic
alkalosis
• Results from decreased hydrogen ion concentration or increased bicarbonate
concentration.
• Principal causes include vomiting, diuretic treatment, hypokalaemia (due to
intracellular shift of hydrogen ions), hyperaldosteronism, base ingestion, and overcompensation of respiratory acidosis.
• Symptoms include symptoms of hypocalcaemia (due to increased binding of
calcium), symptoms of hypokalaemia (due to intracellular shift of potassium),
hypoventilation, arrhythmias, and seizures.
• Metabolic alkalosis involving the loss of chloride ions is termed chloride responsive,
because it typically corrects with IV administration of normal saline, whereas
chloride-unresponsive metabolic alkalosis does not and typically involves severe
hypokalaemia or mineralocorticoid excess.
• Treat the cause. Correct hypovolaemia and hypokalaemia. In severe cases, consider
dialysis.
Examiner’s questions: The anion gap
• Blood ought to have a neutral charge, with the concentration of cations (+) equal to that of
anions (-).
• Blood tests do not measure the concentrations of all ions in the blood: usually, only [Na+], [K+],
[Cl-
], and [HCO3
-
] are provided.
• These measurements include the majority of the cations in the blood, but leave out a larger
proportion of the anions, including negatively charged proteins and organic acids.
• This gap, the anion gap, is given by:
([Na+] + [K+]) – ([Cl–
] + [HCO3
–
])
• In clinical practice, [K+] is typically omitted from the equation.
• The normal range is 10–18mmol/l.
• The anion gap, which may be normal or increased, can help to identify the cause of metabolic
acidosis.
• Metabolic acidosis involves a decrease in [HCO3
-
], which, to maintain electroneutrality, ought
to be compensated for by an increase in the concentration of other anions.
• If the anion gap is normal, decreased [HCO3
-
] isthe primary pathology and [Cl-
], the only other
major buffering anion, has increased in compensation (hyperchloraemic acidosis).
• If the anion gap is increased, electroneutrality has been maintained by an increase in the concentration of unmeasured anions. This occurs when the acidosis is caused by the introduction of excess acid (but not HCl) into the blood. A good example is lactic acidosis: increased
lactic acid decreases pH and thereby decreases the concentration of HCO3
-
ions, which are
replaced by lactate ions. As lactate ions are unmeasured, the anion gap is increased.
Clinical Skills for OSCEs
294 Station 108
ECG recording and interpretation
Before starting
• Introduce yourself to the patient, and confirm his name and date of birth.
• Explain the indication and procedure, specifying that it is not painful, and obtain his consent.
• Position him so that he is lying on a couch.
• Ask him to expose his upper body and ankles.
The equipment
• A 12-lead ECG machine • Electrode sticky pads (check expiry date)
The procedure
• Indicate that you may need to shave the patient’s chest to abrade and clean the skin prior to
applying the electrode pads.
• Having verified that the skin is dry, attach the electrode pads as per the leads.
• Attach the limb leads, one on each limb. The longest leads attach to the legs, above the ankles,
and the mid-length leads attach to the upper arms.
Table 36. Colour codes for ECG limb and chest leads
Limb leads Chest leads
Red Right arm
Yellow Left arm
Green Left leg
Black Right leg
Red V1
Yellow V2
Green V3
Brown V4
Black V5
Violet V6
Figure 75. Lead placement.
Data interpretation
Station 108 ECG recording and interpretation 295
• Place the chest leads (the shortest leads) such that (see Figure 75):
– V1 is in the fourth intercostal space at the right sternal margin
– V2 is in the fourth intercostal space at the left sternal margin
– V3 is midway between V2 and V4
– V4 is in the fifth intercostal space in the left mid-clavicular line
– V5 is at the same horizontal level as V4, but in the anterior axillary line
– V6 is at the same horizontal level as V4 and V5, but in the mid-axillary line
• Turn the ECG machine on and check calibration (1 mV = 1 cm in height) and paper speed
(25 mm/s).
• Ensure that the patient is relaxed and comfortable, and ask him to remain as still and silent as
possible.
• Press on ‘Analyse ECG’ or a similar button.
See Figure 76 for an example of a normal ECG trace.
After recording the ECG
• Analyse the ECG for any life-threatening abnormalities.
• Remove the leads.
• Discard the electrode pads.
• Ensure that the patient is comfortable.
• Thank him.
Figure 76. Normal ECG.
I aVR V1 V4
aVL V2 V5
aVF V3 V6
II
III
II
150 Hz 25.0 mm/s 10.0 mm/mV 4 by 2.5s 1 rhythm ld MAC5K 005A 12SLTMv231
o
Technician
Vent. rate 66 bpm
PR intervel 134 ms
QRS duration 88 ms
QT/QTc 388/406 ms
Referred by:
Normal sinus rhythm
Normal ECG
Unconfirmed
Clinical Skills for OSCEs
296 Station 108 ECG recording and interpretation
ECG interpretation in 10 steps (suggested approach for an OSCE station)
R
ST T
P
Q
S
QRS
Q-T
PR
0.20 sec.
0.5 mV
Figure 77. The basic ECG complex.
1. Check labelling (name, date, calibration, paper speed, etc.) and eyeball the ECG.
2. Rate: divide 300 by the number of large squares between consecutive R waves.
3. Rhythm: ensure that each P wave is followed by a QRS complex (i.e. sinus rhythm). Use a
pen and card to determine whether the rhythm is regular or irregular. If it is irregular, is it
regularly irregular or irregularly irregular?
4. Axis:
• Normal axis: the QRS complexes are predominantly positive in both leads I and II.
• Left axis deviation: the QRS complex is predominantly positive in lead I but is
predominantly negative in lead II.
• Right axis deviation: the QRS complexes are predominantly negative in both leads I and II.
5. P waves: normal is less than 2.5 mm in height and 0.12 s in width in lead II.
6. PR interval: normal is 0.12–0.20 s or 3–5 small squares in duration.
7. QRS complex:
• Normal is < 0.12 s or 3 small squares in duration.
• The sum of the S wave in V2 and an R wave in V5 or V6 should not be greater than 35 mm.
• Q waves should not be deeper than two small squares or 25% of the following R wave, or
broader than one small square.
8. ST segment: the ST segment should not be elevated or depressed.
9. T waves: T waves should not be tall, flattened, or inverted. T wave inversion in leads I, II, and
V4–6 is always abnormal.
10. QT interval: normal is less than 400 ms or 2 large squares or half the R–R interval.
Data interpretation
Station 108 ECG recording and interpretation 297
ECG interpretation in 10 easy steps – in more detail
1. Check labelling (name, date, indication, calibration 1 cm/mV, paper speed 25 mm/s).
2. Rate: either divide 300 by the number of large squares between consecutive R waves (1 large
square = 0.2 s, 1 small square = 0.04 s) or count the number of R waves in the rhythm strip and
multiply by 6 (as the rhythm strip/lead II is 10 s long).
Sinus bradycardia (<60 bpm and regular): athletes, hypothermia, hypothyroidism, raised ICP,
obstructive jaundice, SA node disease or ischaemia, beta blockade.
Sinus tachycardia (>100 bpm and regular): exercise, pain, fever, hypovolaemia, anaemia, pregnancy, thyrotoxicosis, vasodilators, vagolytics such as atropine.
3. Rhythm: ensure that each P wave is followed by a QRS complex. Use a pen and card to
determine whether rhythm is regular or irregular. If it is irregular, is it regularly irregular or
irregularly irregular? Sinus arrhythmia describes an increase in heart rate upon inspiration and
fall upon expiration.
4. Axis
a. Normal axis: the QRS complexes are predominantly positive in both leads I and II.
b. Left axis deviation: the QRS complex is predominantly positive in lead I but is predominantly
negative in leads II and III. Left axis deviation may indicate left anterior fascicular block and
a number of other conditions, but not usually left ventricular hypertrophy.
c. Right axis deviation: the QRS complexes are predominantly negative in both leads I and
II. Right axis deviation may indicate right ventricular hypertrophy due to pulmonary
conditions or congenital heart disease.
120
120 60
150
150
III
aVR
aVL
aVF Right
axis
Normal
axis
Left
axis
II
30
±180
30
0
60
90
90
I
Explanation: normally the depolarising wave spreads towards leads I, II, and III and is therefore
associated with a predominantly upward QRS deflection in all these leads, but greatest in lead II.
– in right axis deviation, the axis swings to the right so that the QRS deflection in lead I
becomes negative and the deflection in lead III becomes most positive
– in left axis deviation, the axis swings to the left, so that the deflection in lead III becomes negative. Left axis deviation is not significant until the deflection is also negative in lead II
5. P waves: normal is less than 2.5 mm in height and 0.12 s in width in lead II. An inverted P
wave in V1 is likely to indicate an incorrect recording. A tall P wave (P pulmonale) is due to
right atrial enlargement and is seen most commonly in lung disease but also in tricuspid valve
stenosis. A broad, bifid P wave (P mitrale) is due to left atrial enlargement and is seen most
commonly in mitral stenosis. The most common cause of absent P waves is atrial fibrillation.
Clinical Skills for OSCEs
298 Station 108 ECG recording and interpretation
6. PR interval: normal is 0.12–0.20 s (3–5 small squares) in duration. Prolonged in heart block,
shortened in conditions involving an abnormality on the fibrous insulating ring such that signals get past the AV node more quickly, e.g. Wolff–Parkinson–White syndrome.
AV node blocks
• First degree block: atrial conduction to the ventricles is delayed such that the PR interval
is consistently prolonged. This may be a sign of coronary artery disease, acute rheumatic
carditis, digitalis toxicity, or electrolyte disturbances.
• Second degree block: excitation completely fails to pass through the AV node. The causes
of second degree heart block are the same as for first degree heartblock.
– Mobitz type I (Wenckebach phenomenon): there is progressive lengthening of the PR interval and then regular failure of conduction of an atrial beat, followed by a conducted beat
with a short PR interval and then a repetition of this cycle
– Mobitz type II: most beats are conducted with a constant PR interval but occasionally
there is an atrial contraction without a subsequent ventricular contraction. May herald
complete heart block
– 2:1 (or 3:1) conduction: there are alternate conducted and non-conducted atrial beats,
giving twice (or three times) as many P waves as QRS complexes. May herald complete
heart block in patients with MI
• Third degree (complete) block: atrial contraction is normal but no beats are conducted
to the ventricles. A ventricular escape rhythm takes hold, such that there is no relation
between P and QRS. May occur after an MI (usually transient) or due to fibrosis around the
bundle of His.
Data interpretation
Station 108 ECG recording and interpretation 299
[Note] Heart block that is Mobitz type II or above is much more likely to involve haemodynamic compromise, and requires
pacing. The choice between a temporary or permanent pacemaker depends on whether the underlying cause is
transient or permanent.
SA node blocks can also occur but they are uncommon and usually asymptomatic (due to the
establishment of a ventricular escape rhythm). SA node block is not to be confused with SA node
suppression, which occurs when an arrhythmia prevents the SA node from generating an impulse.
7. QRS complex:
a. Normal is <0.12 s or 3 small squares in duration. A broad QRS results either from
depolarisation by a focus in the ventricular muscle or from a bundle branch block (BBB).
i. Right BBB: can be normal, or may be caused by IHD, PE, or ASD.
ii. Left BBB: LBBB invariably reflects underlying heart disease, but its presence precludes
further interpretation of the ECG.
RBBB
characteristics
LBBB
characteristics
V1
rSR’ qRs
V6 V1
rS
R
V6
b. The sum of the S wave in V2 and an R wave in V5 or V6 should not be greater than 35 mm.
If it is, this indicates ventricular hypertrophy.
c. Q waves should not be deeper than two small squares or 25% of the following R wave. If
they are, this indicates an old MI.
Clinical Skills for OSCEs
300 Station 108 ECG recording and interpretation
8. ST segment: the ST segment should not be elevated or depressed. Elevation of >1 mm in two
adjacent limb leads, or >2mm in two adjacent chest leads, indicates full thickness infarction
of the myocardium (ST-elevation MI/STEMI).
Depression of >0.5 mm in two adjacent leads indicates ischaemia, e.g. angina. In the presence
of raised cardiac enzymes (e.g. troponin I) ST depression is indicative of MI (non-ST elevation
MI). Saddle elevation in most leads indicates pericarditis.
9. T waves: T waves should not be tall, flattened, or inverted. Tall, tented T waves indicate hyperkalaemia, flattened T waves indicate hypokalaemia. T wave inversion in leads I, II, and V4–6 is
always abnormal, and indicates subendocardial (partial thickness) infarction, i.e. non-ST elevation MI, angina, or digoxin administration.
10. QT interval: normal is less than 400 ms (2 large squares) or half the R–R interval (ideally, corrected QT (QTc) should be calculated to account for the change with heart rate). Prolongation
is usually secondary to drugs, e.g. antipsychotics, toxins, and electrolyte disturbances, and
predisposes to potentially dangerous ventricular arrhythmias.
Abnormal rhythms
Supraventricular tachyarrhythmias (SVTs)
In SVTs the depolarisation spreads to the ventricles in the normal way via the His bundle so the QRS
complex is normal and the same whether depolarisation was triggered by the SA node, the atrial
muscle, or the junctional region.
Atrial extrasystoles
This example of atrial extrasystoles can be described as non-compensated atrial quadrigeminy:
‘quadrigeminy’ because there is one extrasystole after every three normal beats; ‘non-compensated’
because there is no compensatory pause after the extrasystole. Atrial extrasystoles are common in
healthy people with normal hearts, and also occur in certain conditions such as cardiac failure and
mitral valve disease.
Data interpretation
Station 108 ECG recording and interpretation 301
Atrial tachycardia
In atrial tachycardia, there is a heart rate of about 150 with P waves superimposed on preceding
T waves. Atrial tachycardia typically arises from an ectopic source in the atrial muscle and is often
paroxysmal in nature. Although it is sometimes seen in patients with diseased hearts, it is nearly always
benign.
Atrial flutter
In atrial flutter, the atrial rate is commonly 300 bpm and there is usually a 2:1 block, resulting in a
ventricular rate of 150 bpm. Can occur spontaneously in people with normal hearts, but most often
occurs in people with cardiovascular disease. Frequently degenerates into AF.
Atrial flutter with variable (2:1 and 3:1) block. Fast P waves produce a ‘saw-tooth’ appearance.
Atrial fibrillation (AF)
AF is associated with any disease affecting the heart. There is an ‘irregularly irregular’ ventricular rate
with no true P waves but baseline irregularities representing atrial activation.
AV nodal re-entrant tachycardia (AV ‘junctional’ tachycardia)
A re-entrant circuit is set up in the atria, causing the ventricles to depolarise at fast rates of up to
200 bpm. P waves are often absent, hidden in the QRS.
Clinical Skills for OSCEs
302 Station 108 ECG recording and interpretation
AV re-entrant tachycardia, via an accessory pathway e.g. Wolff–Parkinson–White syndrome
In WPW syndrome, some of the atrial depolarisation passes quickly to the ventricle via an accessory
pathway before it can get through the AV node. The early depolarisation of the ventricle leads to a
shortened PR interval and a slurred start to the QRS wave (delta wave).
Ventricular tachyarrhythmias
Ventricular extrasystole (VE)
Ventricular extrasystoles arise from an ectopic focus leading to a broad and atypical QRS complex that
is unrelated to a preceding P wave. If a VE occurs early in the T wave of a preceding beat it can induce
ventricular fibrillation.
Ventricular trigeminy.
Parasystole refers to a lack of coupling between VEs and the sinus rhythm. This may result in a number
of fusion beats, in which a VE merges into the sinus beat.
Ventricular tachycardia (VT)
Two ventricular extrasystoles are termed a couplet but three or more are termed VT. Sustained VT can
degenerate into ventricular fibrillation and death. Note the obvious dissociation between atria and
ventricles.
Data interpretation
Station 108 ECG recording and interpretation 303
* Accelerated idioventricular rhythm can look like VT, but the rate is <120 and the condition is benign.
For this reason, VT should not be diagnosed unless the heart rate is >120.
** VT can be very difficult to differentiate from SVT with a BBB (as the BBB produces a broad QRS
complex).
Ventricular fibrillation (VF)
Ventricular fibrillation is a chaotic ventricular rhythm which rapidly results in death.
Ventricular flutter
Ventricular flutter is a relatively uncommon and short-lived sine-wave like rhythm that usually
degenerates into VF.
Bradycardias
Most abnormal rhythms are tachycardias, but they can also be bradycardias. The heart rate is normally
controlled by the SA node. However, if the SA node fails to depolarise, the heart rate is taken over by
a focus in the atrial muscle or in the region around the AV node (the junctional region) both of which
have spontaneous depolarisation frequencies of about 50 beats per min. If these also fail, or if the His
bundle is blocked, the heart rate is taken over by a ventricular rhythm of about 30 beats per min. These
slow, protective rhythms are collectively referred to as ‘escape rhythms’. It is important to recognise
them as such, because trying to suppress them can have dire consequences. The trace below shows a
junctional escape rhythm.
Clinical Skills for OSCEs
304 Station 108 ECG recording and interpretation
ECG patterns
Myocardial infarction (MI) and unstable angina
STEMI: ST elevation of >1mm in two adjacent limb leads, or >2mm in two adjacent chest leads, is
the main criterion. In the ‘hyperacute’ phase, there are tall R waves and ST elevation which is sloped
upwards and which often merges into tall, broad T waves. In established MI, there are prominent Q
waves, elevated ST segments, and inverted ‘arrowhead’ T waves.
NSTEMI and unstable angina: ST depression of >0.5mm in two adjacent leads and T wave inversion,
without Q wave changes. NB. NSTEMI and unstable angina cannot be distinguished by ECG findings
alone; a cardiac enzyme test is required.
In posterior MI, posterior wall changes are mirrored in the leads opposite the lesion, i.e. V1
and V2, leading to a tall R, ST depression, and upright ‘arrowhead’ T waves. Note that there
may be no ECG changes in MI, so don’t rely solely on the ECG!
Stable angina
The ECG typically looks normal, although stable angina might, like unstable angina and NSTEMI, be
reflected by ST segment depression and T wave inversion.
Prinzmetal’s angina
ST elevation during an attack.
Myocarditis
Tachycardia, atrial and ventricular extrasystoles, first degree and LAHB (left anterior hemi-block) heart
blocks, ST changes.
Pericarditis
Sinus tachycardia, widespread ‘saddle’ (concave) elevation of the ST segment, T wave abnormalities.
Pericardial effusion
Diminished amplitude of ECG deflections and possibly also T wave inversion and electrical alternans
(alternating QRS amplitude = tall one beat, short the next, and so on).
Data interpretation
Station 108 ECG recording and interpretation 305
Pulmonary embolism
Sinus tachycardia. Other ECG abnormalities are uncommon and the classical SI
QIIITIII syndrome only
occurs in under 10% (prominent S in lead I, Q and inverted T in lead III). There may also be right atrial
enlargement, atrial tachyarrhythmias, right ventricular hypertrophy or ischaemia, and RBBB.
Hyperkalaemia
Initially, tall tented T waves, then disappearance of P waves and, finally, broadened and distorted QRS
complexes leading to ventricular arrhythmia or cardiac standstill.
Hypokalaemia
Flattened T waves and more prominent U waves which may be falsely interpreted as QT prolongation.
There may also be first or second degree AV heart block.
Hypothermia
Sinus bradycardia, prominent ‘J’ wave (upward deflection just after the QRS complex), and QRS and QT
prolongation, leading to blocks, ventricular extrasystoles and, finally, VF.
Try to familiarise yourself with different patterns of ECG, e.g. left ventricular
hypertrophy, ischaemic heart disease, acute myocardial infarct, atrial fibrillation, heart
block, pulmonary embolus. Study ECG libraries such as the one that can be found at
www.ecglibrary.com/ecghome.html.
Clinical Skills for OSCEs
306 Station 109
Chest X-ray interpretation
A systematic approach to interpreting X-rays not only fills out the time and impressesthe examiner, but
also minimises your chances of missing any abnormalities. Before saying anything, it is an excellent idea
to spend one minute looking at the X-ray, rubbing your chin and organising your thoughts.
Figure 78. Normal chest X-ray.
1. The X-ray
• Name and age of the patient.
• Date of the X-ray.
• Projection: PA, AP, or lateral? AP films are normally labelled, but PA films (the most common
type of projection) are often left unmarked. If in doubt, examine the scapulae. With PA films, the
patient lifts his arms, thereby withdrawing the scapulae from the lung fields.
• Erect or supine? (see box)
• Rotation – if there is no rotation, the distances from the vertebral spines to the medial ends of
the clavicles should be equal.
• Penetration – if penetration is normal, the lower thoracic vertebral bodiesshould be just discernible through the heart shadow. If they cannot be discerned, the film is under-penetrated and the
lungs will appear more opaque than they ought. If, on the other hand, they are very clear, the
film is over-penetrated and the lungs will appear more translucent (blacker) than they ought.
• Inspiration – if the chest is appropriately inflated, five or six ribs should be visible above the diaphragm anteriorly, and ten posteriorly. A greater number of ribs above the diaphragm suggests
hyperinflation, as in COPD.
Data interpretation
Station 109 Chest X-ray interpretation 307
Erect or supine?
An X-ray can be confirmed as having been taken in the erect position if the gastric air bubble is found
lying under the left hemidiaphragm.
AP films are almost invariably taken supine, and this has major implications for interpretation. A
supine film differs from an erect film in that:
• there is an enlarged heart size.
• the diaphragm is higher, resulting in an apparent decrease in lung volume.
• pleural fluid levels lie vertically, resulting in an opacification of the lung field.
• any prominence of upper zone vessels does not suggest left heart failure.
2. Obvious abnormalities and interventions
Scan the film and comment on any obvious abnormality or abnormalities. Make a note of any visible
chest drains, ECG pads, etc.
3. The skeleton
Inspect the ribs, shoulder girdles, and spine. Bones may be more translucent in older people. Check for
irregular edges suggestive of fracture, especially in the ribs. Check for areas of relative translucency or
opacity in the bones, suggestive of, respectively, lytic and sclerotic bony metastases. Note any extra or
missing ribs, e.g. a cervical rib.
4. The soft tissues
Inspect the breasts, the chest wall, and the soft tissues of the neck. Look for any distortion, and for any
opacities and translucencies. In a female, check for both breast shadows. With unilateral mastectomy,
one lung field may appear more translucent than the other.
5. The lungs and hila
The lungs: check the lung volumes, then carefully inspect the lung fields for any opacity (e.g. masses,
collapse, consolidation, and pleural effusion) or radiolucency (e.g. pneumothorax and bullae).
The hila: inspect the hila, the densities created by the pulmonary arteries and the superior pulmonary
veins of each lung for any abnormal opacities. The hila ought to be of similar size, shape, and density.
Causes of increased size and density (either unilaterally or bilaterally) include lymphadenopathy (e.g.
from infection, neoplasia,sarcoidosis) and pulmonary hypertension. Check the positions of the hila: the
left hilum should be 2–3 cm higher than its right counterpart. If not, this may suggest lung collapse or
dextrocardia.
6. The pleura
Systematically check all lung margins, looking for pleural opacity, pleural displacement, and loss of
clarity of the pleural edge (the so-called silhouette sign).
7. The diaphragm
Inspect the diaphragm and the area underneath it (the pneumoperitoneum). The right hemidiaphragm
should be higher than the left. Blunting of the costophrenic angles suggests pleural effusion and/or
consolidation.
Clinical Skills for OSCEs
308 Station 109 Chest X-ray interpretation
8. The mediastinum and heart
Mediastinal shift: inspect the trachea for deviation to one side along with the rest of the mediastinum.
An area of collapse draws in the mediastinum; tension pneumothorax pushes it away.
Cardiothoracic ratio (CTR): divide the maximal diameter of the heart by the maximal diameter of the
chest. In a PA film the CTR should be 0.5 or less.
Mediastinum: inspect the trachea and right and left main bronchi. Then inspect the aortic arch, the pulmonary
artery, and the heart. Are there any abnormal opacities (masses) or translucencies (pneumomediastinum)?
Widening of the aorta and pulmonary arteries suggests, respectively, aortic aneurysm and pulmonary
hypertension. Blurred or indistinguishable heart borders suggest collapse or consolidation. Remember to
look behind the heart shadow for lung masses, a hiatus hernia, and left lower lobe collapse.
9. Summarise your findings
Conditions most likely to come up in a chest X-ray interpretation station
Pneumonia (see Figure 79)
• Consolidation (opacification of variable density), possibly interspersed with air bronchograms
(pockets of translucency corresponding to airways that are still filled with air). Unlike with an
effusion or collapse, the outline of an area of consolidation is often poorly defined. Air space
filling with pus is the hallmark of bacterial pneumonias; viral pneumonias tend to cause a
more interstitial pattern and predominantly hazy ground glass opacification. Pneumonia may
be accompanied by a pleural effusion.
Pleural effusion (see Figure 80)
• Depending on the size of the effusion: blunting of the costophrenic angle; obscuring of the
outline of the hemidiaphragm; opacification of the inferior hemithorax associated with a
meniscus shape of the fluid at its upper, lateral margin; opacification of the entire hemithorax;
displacement of the mediastinum to the contralateral side.
Pulmonary oedema
• In cardiogenic pulmonary oedema, the pattern may include cephalization of the pulmonary
vessels, Kerley B lines or septal lines, peribronchial cuffing, perihilar haziness and blurring of
the normally sharp hilar vessels, ‘bat’s wing’ haziness, cardiomegaly, pleural effusion.
COPD (see Figure 81)
• Hyperinflated lungs with flattened hemi-diaphragms, hyperlucent lungs, bullae.
Interstitial pulmonary fibrosis
• Bilateral reticular or reticulo-nodular pattern, loss of lung volume, honeycomb lung in late
stages.
Collapse
• May be limited to a single lobe. Like pleural effusion, associated with an area of opacity. Loss
of lung volume distorts appearance of other structures (including trachea, mediastinum, and
diaphragm), which are drawn towards the area of collapse.
Pneumothorax (see Figure 82)
• Radiolucent area beyond collapsed lung with absence of pulmonary vessel markings beyond
the white line of the pleura; in tension pneumothorax, displacement of the mediastinum to
the contralateral side, flattening of the hemi-diaphragm, soft tissue emphysema.
continued
Data interpretation
Station 109 Chest X-ray interpretation 309
Conditions most likely to come up in a chest X-ray interpretation station – continued
Tuberculosis
• Can manifest as multifocal consolidation or nodules, round relatively opaque areas that are
less than 3 cm in diameter, with spread to regional lymph nodes. This leads to subsequent
scarring with calcification of the lung parenchyma and lymph nodes. Cavitation of the
lesions tends to occur late, with the lesions marked by dense walls and dark air-filled centres,
sometimes with a fluid level. Miliary TB is associated with small (1–5mm in diameter) miliary
nodules throughout the lungs.
Lung cancer
• May present as a single lesion (primary malignancy or single metastasis) or as multiple lesions
(multiple metastases) which can vary greatly in size. Compared to other differentials such as
pneumonia, TB, abscess, and benign tumours, malignant lesions are likely to be irregular in
shape. They may be associated with collapse, mediastinal shift, and lymphadenopathy. Note
that, like TB lesions, malignancies, abscesses, and (occasiona
Station 109 Chest X-ray interpretation
Figure 80. Frontal chest X-ray of adult with a rightsided pleural effusion (marked with arrow).
Figure 82. Anterior–posterior chest X-ray of adult with
a left pneumothorax which has completely collapsed
the left lung.
Figure 81. Frontal chest X-ray of a long term smoker
with COPD.
Figures 79–82 all reproduced from Interpreting Chest X-Rays by
Stephen Ellis.
Figure 79. Frontal chest X-ray of adult male with
pneumonia (marked with arrow).
311Data interpretation
Station 110
Abdominal X-ray interpretation
A systematic approach to interpreting X-rays not only fills out time and impresses the examiner, but
also minimises your chances of missing any abnormalities. Before saying anything, it is an excellent idea
to spend one minute looking at the X-ray and organising your thoughts.
Figure 83. Normal adult supine AP abdominal X-ray.
1. The X-ray
• Name, age, and sex of the patient.
• Date of the X-ray.
• Confirm size of area covered.
• PA or AP? (They are usually AP.)
• Supine (usual), erect, or lateral decubitus? (Look at gastric air bubble and fluid levels.)
• Area covered: the entire length (from diaphragm to pubic symphysis) and breadth of the abdomen should be visible.
• Penetration (lumbar vertebrae should be visible).
• Rotation (not normally an issue as most films are taken supine).
Clinical Skills for OSCEs
312 Station 110 Abdominal X-ray interpretation
2. Obvious abnormalities, interventions, and artefacts
• Scan the film and comment on any obvious abnormality or abnormalities.
• Make a note of any clearly visible interventions or artefacts (Table 37).
Table 37. Abdominal X-ray: interventions and artefacts
Interventions Surgical clips, retained surgical instruments or swabs, nasogastric tube, CVP line,
intrauterine contraceptive device, renal or biliary stents, endoluminal aortic stent,
inferior vena caval filter
Artefacts/other Pyjama bottoms, coins in pockets, body piercings, bullets, drugs (‘bodypackers’),
even, unfortunately, small animals
3. Skeleton
Inspect the:
• Lower rib cage.
• Lumbar vertebrae (scoliosis).
• Sacrum and sacroiliac joints (sacroiliitis, indicated by blurring, sclerosis, and ankylosis of the
sacroiliac joint).
• Pelvis.
• Hip joints and femora (fractured neck of femur).
4. Organs
Inspect the:
• Liver (hepatomegaly).
• Spleen: usually not visualised.
• Kidneys and urinary tract: about three vertebrae in size, the left kidney is higher than the right.
• Bladder: not visualised if empty.
• Prostate: only visualised if calcified.
• Uterus: often not visualised unless it is calcified or an IUD is present.
• Psoas muscles: should be visible either side of the vertebral column
• Stomach.
• Small bowel.
• Large bowel.
The small and large bowels can be distinguished by their respective sizes, positions, and
mucosal markings. The large bowel has a larger diameter and usually sits peripherally,
framing a central area containing small bowel loops, not all of which are likely to be
visible. Large bowel haustra do not completely traverse the diameter of the large bowel; in
contrast, small bowel valvulae conniventes traverse the full diameter of the small bowel. If
in any doubt, the large bowel can easily be traced through the hepatic and splenic flexures.
5. Gas, fluid levels, and faecal matter
• Gas: depending on its amount and distribution, intraluminal gas may be normal, but intramural
or extraluminal gas should be considered abnormal. Intramural gas in an adult usually indicates
ischaemic bowel. Free intraperitoneal gas usually indicates bowel perforation. The small bowel
should not be greater than 3 cm in diameter, the colon 5 cm in diameter, and the caecum 9 cm
in diameter. Look for gas under the diaphragm (pneumoperitoneum), even though this is best
visualised on an erect chest X‑ray.
Data interpretation
Station 110 Abdominal X-ray interpretation 313
• Fluid levels: a fluid level in the stomach and caecum is a normal finding, but multiple fluid levels
in the colon should be considered abnormal.
• Faecal matter: the amount and distribution of faecal matter, which is of a mottled grey appearance, can be revealing of underlying pathology.
6. Abnormal calcification
• Calculi in the kidneys, ureters, bladder, gall bladder, and biliary tree.
• Pancreas (chronic pancreatitis).
• Kidneys.
• Abdominal aorta and arteries. Look for aneurysms.
• Costal cartilages, although note that calcification of the costal cartilages is a benign finding in
the elderly.
• Lymph nodes.
7. Summarise your findings
Conditions most likely to come up in an abdominal X-ray interpretation station
Faecal impaction or overload
• Faecal matter, which is solid, liquid, and gas, has a grey and mottled appearance.
Obstruction (mass, stricture, volvulus, intussusception)
• Large bowel: proximal dilatation (>5 cm, and >9 cm for the caecum) owing to the
accumulation of gas or faeces. An erect or decubitus X-ray may reveal a small number of long
fluid levels proximal to the obstruction. Unless the ileocaecal valve is defective, the small
bowel is not involved.
• Small bowel: proximal dilatation (>3 cm) owing to the accumulation of gas or fluid. An erect
or decubitus X-ray may reveal a large number of short fluid levels at different heights (‘stepladder’ appearance) proximal to the obstruction.
• Volvulus: may yield a grossly distended inverted U-shaped colonic loop, loss of haustra, and
the ‘coffee bean’ sign from a doubled-up loop of distended, oedematous sigmoid colon.
Introduction of contrast medium may produce the ‘bird’s beak’ sign, which corresponds to
tapering of the section of bowel leading to the point of torsion. Volvulus can occur anywhere
in the abdominal GI tract but most commonly affects the sigmoid colon.
• Intussusception: usually associated with signs of small bowel obstruction. It is commoner in
children.
• Apple-core sign: not seen without contrast. Produced by a stenosing carcinoma of the colon
which causes narrowing at a specific point, reducing the flow of faeces at that point.
Paralytic ileus
• Shares a similar appearance to mechanical obstruction. However, in many cases, both the
small and large bowels are distended.
• Can also appear very similar to pseudo-obstruction.
Perforation
• On an erect abdominal X-ray, there may be sub-diaphragmatic gas especially visible on the
right side. This is best visualised on an erect chest X-ray.
• On an abdominal X-ray, there may be a circular gas lucency in the central abdomen (football sign).
• Normally, only the inner surface of the bowel wall is visible. However, when there is air on
both sides of the wall, the outer surface also becomes visible, producing a 3D appearance
(Rigler’s sign).
Clinical Skills for OSCEs
314 Station 110 Abdominal X-ray interpretation
Biliary, renal, or bladder calculi
• Gallstones may be seen as laminated, faceted, and often multiple radio-opacities in the right
upper quadrant, although only in 10–20% of cases.
• Renal calculi may be seen in 80–90% of cases as small, round radio-opacities along the urinary
tract; they often obstruct at the level of the pelviureteric junction, pelvic brim or vesicoureteric
junction. The urinary tract is visualised by looking along the transverse processes of the
vertebrae, across the sacroiliac joint to the level of the ischial spine.
• Bladder calculi may be seen as often large and multiple radio-opacities in the pelvic region.
• Note that calcified costal cartilages, pelvic phleboliths (areas of calcification in veins in the
pelvis), and calcified lymph nodes can all be mistaken for calculi.
Appendicolith
• Small, round, calcified radio-opacity in the region of the right Iliac fossa.
Inflammatory bowel disease
• Both Crohn’s disease and ulcerative colitis result in inflammation and oedema of the bowel
wall and thus, in general, thickening. In the large bowel, this increases the size of the haustral
folds, leading to ‘thumbprinting’.
• Note that infection and ischaemic colitis can also lead to thumbprinting.
Abdominal aortic aneurysm
• The aorta is not normally visible, but with age can become calcified. Bulging on one or both
sides may indicate an aneurysm.
Artefacts (see Table 37)
Learn their signs, especially the barn-door ones such as apple-core and bird’s beak.
315Prescribing and administrative skills
Station 111
Requesting investigations
Request forms for laboratory investigations (biochemistry, haematology, blood grouping and
transfusion, microbiology, cellular pathology, immunology) and radiological investigations differ
considerably from one hospital trust to another, so try to familiarise yourself with your local ones.
Once you have seen the forms, they are actually pretty self-explanatory. Note that in most hospitals,
investigations are ordered on a computer screen and paper forms are only used as a back-up.
On most forms you typically need to provide details about the:
Patient
• Last and first names.
• Sex (usually ‘M’ or ‘F’, but sometimes ‘U’ for ‘unknown’).
• Date of birth.
• Hospital number and NHS number.
Use the patient’s full name, e.g. ‘Dorothy’, not ‘Dot or ‘Dottie’. It is usually possible to omit the patient’s
hospital number and NHS number, but this is not best practice.
Request
• The ward or department that the report needs to go to (‘Location for report’). Sometimes you
are also able to specify a ward or department for a second copy of the report to go to (‘Copy
report’).
• The speciality on behalf of which you are ordering the investigation, e.g. A&E, surgery.
• The name of the patient’s consultant. If this is unclear, you can normally write the name of the
consultant on take or on call.
• The patient’s category (e.g. NHS, private, trial).
• The requesting doctor’s name and signature.
• The requesting doctor’s bleep or telephone number.
Specimen
• The type of specimen, e.g. blood, urine, sputum, other.
• Date and time of collection.
• The (anatomical) site of collection.
Clinical details
• The patient’s clinical details, e.g.
– chest pain, SOB, ECG changes, ? MI
– pyrexia of unknown origin, ? cause
– acute psychosis, due to start antipsychotic medication
• If the investigations are urgent, you can write ‘Urgent please’. If the investigations are really
urgent, take the sample and request form to the laboratory and speak to the technician in
person.
Clinical Skills for OSCEs
316 Station 111 Requesting investigations
On radiology request forms, you generally need to provide more precise clinical details,
and write down what questions the examination should answer. You also need to specify
the patient’s transport (e.g. walking, chair, stretcher, bed) and other (e.g. oxygen, drip,
escort) needs, and fill in a short risk assessment that is often in the form of a tick box list of
questions (e.g. pregnancy, breast-feeding, allergies – yes/no).
Investigations requested
This obviously depends on the clinical situation. Commonly ordered laboratory and radiological
investigations include FBC, haematinics, group and save, U&Es, LFTs, TFTs, glucose, lipids, CRP, ESR,
amylase, D-dimers, blood cultures, MC&S, CXR, and AXR.
Figure 84. A typical request form for laboratory investigations. Note that, in this hospital, biochemistry and
haematology investigations are requested on the same form.
After completing the request form
Before you take the specimen, confirm the patient’s name and date of birth. For blood specimens,
most hospitals use a purple specimen tube for haematology, a pink tube for group and save and crossmatching, a yellow tube for biochemistry (e.g. U&Es, LFTs, TFTs, CRP, lipids), a grey tube for glucose,
and a light blue tube for coagulation screen. Label the specimen tubes using a black ball-point pen,
ensuring that the information on the label matches that on the request form. Place the labelled
specimen tube into the bag on the reverse of the request form, remove the protective strip, and fold
the flap onto the bag so as to seal it. Note that blood cultures require two ‘blood bottles’ with specific
media for aerobic and anaerobic organisms (see Station 5).
PATIENT
REQUEST
SPECIMEN
BLOOD URINE CSF
NHS
M F U
CAT 2 PRIVATE TRIAL OTHER...
OTHER...
CLINICAL DETAILS RISK
LABORATORY USE HAEMATOLOGY INVESTIGATIONS
BIOCHEMISTRY INVESTIGATIONS
TYPE
FOR COPY REPORT
REQUESTING DR.
PATIENT CATEGORY
CONSULTANT/G.P.
SPECIALITY/PRACTICE
LOCATION FOR REPORT
LAST NAME
FBC Other:
Warfarin Control
Heparin Control
Phoned:
Time:
FIRST NAME
DATE OF BIRTH SEX
NHS NUMBER
BLEEP/PHONE
DATE TIME
Prescribing and administrative skills
Station 111 Requesting investigations 317
VACUTAINER TUBE GUIDE – Draw tubes in the order given
Haemoguard Stopper Tube Content Determinations
SODIUM
CITRATE 1:9
Coagulation Screen, Prothrombin Time (INR), APTT,
Thrombophilia Screen, Lupus Anticoagulant Screen
PLAIN
(No Additive) Anti-Cardiolipin antibodies
SST All Biochemistry Tests not mentioned elsewhere (1
Tube), Microbiology (1 Tube)
HEPARIN Chromosome Studies, Lead, Amino Acids, Troponin
EDTA
FBC, Reticulocytes, Sickle Screen, Haemoglobinopathy
Screen, G6PD, GF Test, Viscosity, Malarial Parasites,
RBC Folate, ZPP, Marker Studies, Lead, Mercury
Complement, Glycosylated Haemoglobin
EDTA
(cross match)
Blood Group, Save Serum, Crossmatch, Antibody
Screening, Cord Blood Samples
FLUORIDE/
OXALATE Glucose, Ethanol (Alcohol), Lactate
SODIUM
HEPARIN Copper, Selenium, Zinc
Figure 85. Specimen tube guide. Note that the colours used may differ from one hospital trust to another.
Clinical Skills for OSCEs
318 Station 112
Drug and controlled drug prescription
Before prescribing a drug
• Look at the patient’s medical notes. In particular, is there any hepatic or renal impairment/
failure?
• Find out if he is on any other drugs, and consider possible interactions.
• Ask him if he has any allergies and document these in the medical notes.
• Explain to him the reason for recommending the drug, its likely beneficial effects, and its
common or dangerous side-effects.
Prescribing a drug
• Write legibly and in black ink.
• Avoid all abbreviations other than those that are in common usage (see Table 38).
• Use generic names (unless a particular drug preparation is required).
Table 38. Latin abbreviations commonly used in prescribing drugs
Abbreviation Latin English
OD omni die once a day
BD bis in die twice a day
TDS ter die sumendus three times a day
QDS quarter die sumendus four times a day
QQH quarta quaque horae every four hours
AC ante cibum before food
PC post cibum after food
OM omni mane every morning
ON omni nocte every night
PRN pro re nata as required
Stat. statim at once
Include:
• The date.
• The full name, address, and date of birth of the patient.
• The age of the patient if he is a child under the age of 12.
• The generic name and formulation of the drug – prefer generic names unless a particular preparation is required.
• The dose and frequency – avoid decimal points, e.g. 500 mg and not 0.5 g, and superfluous
zeros, e.g. 4 mg and not 4.0 mg; if prescribing in micrograms, spell out ‘micrograms’ in full.
• For PRN or ‘as required’ drugs, the minimum dose interval, e.g. cyclizine 5 mg 8 hourly.
• The quantity to be supplied.
• The signature of a registered medical practitioner. Any alterations or mistakes should also be
signed (or at least initialled).
Prescribing and administrative skills
Station 112 Drug and controlled drug prescription 319
Prescribing a controlled drug
In your own handwriting, include:
• The date.
• The full name, address, and date of birth of the patient.
• The generic name of the drug.
• The formulation and strength of the preparation.
• The required dose of the drug, frequency, and number of days it is to be taken.
• The total amount of the preparation, or the total number of dose units in both words and figures.
• Your signature and address.
December 12, 2015.
Mr John Adam Smith
42 West Register Street
London XXXX XXX
Date of birth: 01/09/1972
Methadone 10mg tablets
10mg TDS for 7 days
210mg, two hundred and ten milligrams in total.
Signed: Dr Peter Brown
The Best Hospital
London XXXX XXX
Prescribing on a hospital drug chart
• Hospital drug charts vary slightly from one hospital to another, so be familiar with your local
ones. Most drug charts have four main sections, for regular drugs, PRN drugs, ‘once-only’ drugs,
and fluids.
• Always write in black ink and in block capitals.
• Write at least the patient’s name, date of birth, and any allergies/adverse reactions on every
page of the drug chart.
• If prescribing a set course of medication, e.g. a 7-day course of antibiotics, cross off subsequent
days so as to ‘gate’ the prescription.
• Sign and date every prescription. If re-writing a drug chart, the date is not the date today, but the
date on which the drug was first prescribed.
• Record any changes you have made in the patient’s case notes.
• Fluids and drugs such as oxygen, insulin and anticoagulants are sometimes prescribed on separate documents, and it is important to ensure that these documents do not become separated
from the drug chart.
Avoid prescribing drugs you are unfamiliar with, high risk drugs such as anticoagulants and
sedatives, and parenteral drugs without first consulting the British National Formulary
and senior colleagues.
SPECIMEN
Clinical Skills for OSCEs
320 Station 112 Drug and controlled drug prescription
Example for a regular drug
PRESCRIPTION Patient’s
Own
Medicine
For use
Date
Time
6
8
12
14
18
22
Medicine (Approved Name)
Dose Route Quantity
Notes Start Date Date
Prescriber – sign + print Pharmacy
LANZOPRAZOLE
30 mg ORAL
AB AB AB AB AB AB
1
/
7
/
08
2
/
7
/
08
3
/
7
/
08
4
/
7
/
08
5
/
7
/
08
6/
7
/
08
7
/
7
/
08
8/
7
/
08
1/7/15
A Doctor A DOCTOR
Example for a PRN drug
PRESCRIPTION
AS REQUIRED THERAPY
Patient’s
Own
Medicine
For use Date
Time
Dose/Route
Initials
Date
Time
Dose/Route
Initials
Medicine (Approved Name)
Dose + Frequency Route Quantity
Notes Start Date Date
Prescriber – sign + print Pharmacy
PARACETAMOL
1 g 4–6 hourly
Max 4 g/24 hrs
FOR PAIN
PO/BR
1/7/15
A Doctor A DOCTOR
Example for a once-only drug
Date Time Medicine (Approved Name) Dose Route Prescriber – Sign + Print Time
Given
Given
By
ONCE ONLY
1/7/15
1/7/15
0800
0800
1.5 g
500 mg
IV
IV
A Doctor A DOCTOR
A Doctor A DOCTOR
CEFUROXIME
METRONIDAZOLE
0800
0800
AB
AB
Prescribing and administrative skills
Station 112 Drug and controlled drug prescription 321
Example for fluids
INFUSION THERAPY
Date Infusion solution Additives and dose Volume Rate Route Sign Time
Given
Given
By
1/07/15
1/07/15
1/07/15
1 l
1 l
1 l
8º
8º
8º
IV
IV
IV
A Doctor
A Doctor
A Doctor
Normal saline 0800 AB
Normal saline
5% Dextrose
None
None
20 mmol KCI
After prescribing a drug
• If you haven’t done so already, give the patient instructions for taking the drug.
• Ask the patient is he has any questions or concerns.
Table 39. Some commonly prescribed drugs and their adult dosages
Name Dose Frequency Route(s)
Analgesics
Paracetamol 1 g 4–6 h, max 4 g/ 24 h PO/PR
Diclofenac 50 mg TDS PO/PR
Ibuprofen 400 mg QDS PO
Cocodamol 8/500 or 30/500 2 tabs QDS PO
Codeine phosphate 30–60 mg 4 h, max 240 mg/ 24 h PO/IM
Tramadol 50–100 mg 4 h PO/IM/IV
Morphine 5–10 mg 4 h PO/IM/SC
Antibiotics
Trimethoprim 200 mg BD PO
Penicillin V 250–500 mg QDS PO
Penicillin G 300–600 mg QDS IV
Amoxycillin 250–500 mg TDS PO
Co-amoxiclav 250/125 or 500/125 1 tab TDS PO
Flucloxacillin 25–500 mg QDS PO
Cefuroxime 250–500 mg BD PO
Cefuroxime 750 mg–1.5 g TDS IV/IM
Ciprofloxacin 250–750 mg BD PO
Clarithromycin 250–500 mg BD PO
Erythromycin 250–500 mg QDS PO
Metronidazole 400 mg TDS PO
continued
Clinical Skills for OSCEs
322 Station 112 Drug and controlled drug prescription
Table 39. Some commonly prescribed drugs and their adult dosages – continued
Name Dose Frequency Route(s)
Anticoagulants
Tinzaparin DVT prophylaxis 3500 U OD SC
Tinzaparin DVT/PE treatment 175 U/kg OD SC
Dalteparin DVT prophylaxis 2500–5000 U OD SC
Dalteparin DVT/PE treatment 200 U/kg OD SC
Warfarin As per hospital protocol and INR monitoring
Antiemetics
Cyclizine 50 mg TDS PO/IM/IV
Metoclopramide 10 mg TDS PO/IM/IV
Antihistamines
Desloratadine 5 mg OD PO
Cetirizine 5–10 mg OD PO
Hypnotics
Temazepam 10–20 mg ON PO
Zopiclone 3.75–7.5 mg ON PO
Proton pump inhibitors and antacids
Lansoprazole 15–30 mg OD PO
Omeprazole 20–40 mg OD PO
Gaviscon® 10–20 ml TDS PO
Triple therapy (7 days)
Lanzoprazole 30 mg BD PO
Amoxicillin 1 g BD PO
Clarithromycin 500 mg BD PO
Laxatives
Lactulose 15 mls BD PO
Senna 2 tabs ON PO
Glycerin suppository 1–2 PRN PR
Phosphate enema 1 PRN PR
Movicol 1–3 sachets/day Divided doses PO
Other drugs
Aspirin prophylaxis 75 mg OD PO
Simvastatin 10–40 mg ON PO
Bendrofluazide 2.5 mg OD PO
Lisinopril 2.5–20 mg OD PO
¸
˝
˛
323Prescribing and administrative skills
Station 113
Oxygen prescription
Table 40. Guide to oxygen masks
Type of mask Oxygen concentration Indications
Low flow masks
Deliver a variable
concentration of oxygen
Nasal cannula
Simple face mask
Partial rebreather mask
Non-rebreather mask
24–44% depending on the
flow rate*
Up to 60% at 6–10 l/min
60–80% at 10 l/min
Up to 95% at 15 l/min
Patients with mild hypoxia
who are otherwise stable;
long-term domiciliary
treatment
Acutely breathless patients
As above
As above
High flow (Venturi) masks
Deliver a fixed concentration
of oxygen
24–60% in steps depending on
the valve used (see Table 41)
‘Carbon dioxide retainers’ in
whom oxygen control is a
requirement**
* For every litre of flow delivered up to 6 litres, the oxygen concentration increases by about 4%, e.g. at 4 l/min,
oxygen concentration is 36%.
**Note that the commonest cause of a high PaCO2
is not carbon dioxide retention but ventilatory failure, in which
the patient requires a high concentration of oxygen.
Table 41. Venturi mask valves
Valve colour Flow rate (l/min) Oxygen delivered (%)
Blue
White
Yellow
Red
Green
2
4
6
8
12
24
28
35
40
60
Before starting
• Introduce yourself to the patient, and confirm his name and date of birth.
• Explain the need for oxygen and obtain consent.
• Quickly eyeball the equipment around you. There should be a selection of oxygen masks and
Venturi valves.
The procedure
• Determine the patient’s oxygen saturation using a pulse oximeter, and comment upon it.
• Tell the examiner that you would like to take an arterial blood gas sample. At this point, the
examiner is likely to provide you with an arterial blood gas reading.
Clinical Skills for OSCEs
324 Station 113 Oxygen prescription
• Interpret the arterial blood gas reading (see Station 107).
• Select the appropriate piece of equipment and assemble it by connecting one end of the
tubing to the piece of equipment and the other end to the oxygen source.
• Adjust the oxygen flow rate as appropriate.
• Apply the equipment to the patient, ensuring a tight yet comfortable fit.
• Tell the examiner that you would like to take a second arterial blood gas sample after a certain
period of time. If the examiner provides you with a second arterial blood gas reading, interpret
it and make the appropriate changes (if any).
After the procedure
• Record the instructions and sign the prescription chart.
• Ask the patient if he has any questions or concerns.
• Thank the patient.
325Prescribing and administrative skills
Station 114
Death confirmation
Specifications: A mannequin in lieu of a cadaver (!)
• Take a history from a nurse (or indicate that you would do so) and consider the need for resuscitation.
• Ask for the patient’s notes.
• Confirm the patient’s identity: check his name tag.
• Observe the patient’s general appearance and note the absence of respiratory movements.
• Ascertain that the patient does not rouse to verbal or tactile stimuli, such as pressure on a nailbed.
• Confirm that the pupils are fixed and dilated.
• Use an ophthalmoscope to examine the fundi for segmentation of the retinal columns (‘railroading’ or ‘palisading’).
• Feel for the carotid pulses on both sides.
• Feel for the radial pulses.
• Feel for the femoral pulses.
• Auscultate over the precordium. Indicate that you would listen for one minute. Note whether
the patient has a pacemaker or not (you can always look at a recent chest X-ray if you are
unsure).
• Auscultate over the lungs. Indicate that you would listen for 3 minutes.
• Wash your hands.
If any of your findings are non-corroboratory, you must consider the need for resuscitation.
• Make an entry in the patient’s notes. Remember to include the time and date of death, and your
examination findings.
• Indicate that you would:
– consider the need for a post-mortem (see Station 115: Death certificate completion)
– complete a death certificate (see Station 115)
– inform the patient’s GP and next of kin of the patient’s death
Clinical Skills for OSCEs
326 Station 115
Death certificate completion
Legally, you can only fill in the death certificate if you have seen the patient in his last 14
days. Once the certificate is completed, it should be taken to the Registrar of Births and
Deaths, usually by the patient’s next of kin.
Before starting
You should understand the patient’s history and the circumstances surrounding his death. You should
have seen the patient’s cadaver to confirm his death (or had the cadaver seen by a medically qualified
colleague), noted if he had a pacemaker or radioactive implant, phoned his GP, and considered the
need for a post-mortem examination (see Table 42).
Filling in the death certificate
In black ink, and as clearly and precisely as possible:
• Fill in the patient’s:
– name
– date of death
– age
– place of death
• Fill in the date on which you last saw the patient alive.
• Circle one of the following statements:
1. the certified cause of death takes account of information obtained from post-mortem
2. information from post-mortem may be available later
3. post-mortem not being held
4. I have reported this death to the Coroner for further action
• Circle one of the following statements:
a) seen after death by me
b) seen after death by another medical practitioner but not by me
c) not seen after death by a medical practitioner
• Fill in the cause of death: the disease that led directly to the patient’s death is entered in Section
I (a). The diseases that led to the disease entered in Section I (a) are entered in Sections I (b) and
I (c).
• Fill in other significant diseases contributing to the death but not related to the disease having
caused it in Section II.
• Tick the box if the death is related to employment.
• Sign the death certificate, fill in the date of issue, and print your name and medical
qualification(s).
• Fill in the name of the consultant responsible for the overall care of the patient.
• Fill in the Counterfoil: record the patient’s details and circumstances of death.
• Fill in the Note to Informant, and give it to the next of kin.
Prescribing and administrative skills
Station 115 Death certificate completion 327
Table 42. Some reasons for referral to the coroner
• The cause of death is uncertain.
• The cause of death is due to industrial disease.
• The cause of death is suspicious.
• The cause of death is accidental.
• The cause of death is violent.
• The death is related to surgery or anaesthesia.
• A doctor has not attended in the 14 days prior to the patient’s death.
Clinical Skills for OSCEs
328 Station 115 Death certificate completion
Prescribing and administrative skills
Station 115 Death certificate completion 329 Figure 86. Copy of death certificate.
Clinical Skills for OSCEs
330 Station 116
Explaining skills
These skills can be used to explain a common condition, to explain an investigation, or to explain a
procedure or treatment. They can also be used in your private life, although it may then be unwise to
draw a diagram or hand out a leaflet.
What to do
• Introduce yourself.
• Summarise the patient’s presenting symptoms.
• Tell the patient what you are going to explain.
• Determine how much the patient already knows.
• Determine how much the patient would like to know.
• Elicit the patient’s main concerns (ICE).
• Deliver the information.
– for a medical disorder: aetiology, epidemiology, clinical features, investigations/treatment,
prognosis
– for a pharmacological treatment: name, mechanism of action, procedure involved (dose,
route of administration, frequency, precautions), principal benefits, principal side-effects,
principal contraindications, alternatives including no treatment
– for an investigative procedure: purpose, description of the procedure, principal risks, alternatives including no investigation, preparation required, results
– for a surgical procedure: purpose, description of the procedure, principal risks, alternatives
including no surgery, preparation required, anaesthetic procedure, post-operative care (e.g.
recovery room, oxygen, blood pressure monitoring, etc.), analgesia
• Summarise and check understanding.
• Encourage and address questions.
How to do it
• Be empathetic.
• Explore the patient’s feelings.
• Give the most important information first.
• Be specific.
• Regularly check understanding.
• Pitch the explanation at the patient’s level. Use simple language and short sentences. If using a
medical or technical term, explain it in layman’s terms.
• Use diagrams, if appropriate.
• Use props or anatomical models, if appropriate.
• Hand out a leaflet.
• Be honest. If you are unsure about something, say you will find out later and get back to the
patient.
What not to do
• Hurry.
• Reassure too soon.
• Be patronising.
• Give too much information.
• Use medical jargon.
• Confabulate (make things up).
Communication skills
Station 116 Explaining skills 331
“Really, now you ask me,” said Alice, very much confused, “I don’t think –”
“Then you shouldn’t talk,” said the Hatter.
Alice’s Adventures in Wonderland: A Mad Tea-Party
Lewis Carroll
Some of the medical disorders, pharmacological treatments, investigative procedures, and
surgical procedures that you may be asked to explain in an OSCE
Information can be obtained from websites such as:
www.patient.co.uk
http://besthealth.bmj.com/
Medical disorders
• Asthma.
• Diabetes.
• Hypertension.
• Angina.
• Dementia.
• Miscarriage.
• Osteoarthritis/rheumatoid arthritis.
Pharmacological treatments
• Statins.
• Antibiotics.
• Asthma inhalers.
• Corticosteroids.
• Insulin.
• Antihypertensives.
• Antidepressants.
• Analgesics.
• Glyceryl trinitrate.
• Contraceptive pill (emergency pill, combined pill, progestogen-only preparations).
• Pessaries and suppositories.
• Skin preparations, e.g. emollient, steroid cream, sunscreen.
Investigative procedures
• Chest or abdominal X-ray.
• CT scan.
• MRI scan.
• Ultrasound scan.
• Echocardiography.
• Flexible bronchoscopy.
• Ventilation/perfusion scan.
• Spirometry.
• Oesophagogastroduodenoscopy (OGD).
Clinical Skills for OSCEs
332 Station 116 Explaining skills
• Barium swallow/meal/follow-through.
• Barium enema.
• Flexible sigmoidoscopy.
• Colonoscopy.
• Cystoscopy.
Surgical procedures
• Angioplasty.
• Laparoscopic cholecystectomy.
• Endoscopic retrograde cholangiopancreatography (ERCP).
• Inguinal hernia repair.
• Transurethral resection of the prostate (TURP).
• Hip/knee replacement.
• Varicose vein stripping.
333Communication skills
Station 117
Imaging tests explanation
Read in conjunction with Station 116: Explaining skills.
• Introduce yourself to the patient, and confirm his name and date of birth.
• State the imaging test required and its indication, e.g. “We ought to take an X-ray of your leg to
see if it’s broken.”
• Check the patient’s current understanding, e.g. “Have you ever had an X-ray before?”
• Explain what the test involves (see below).
• Highlight any special preparation involved, e.g. fasting for a certain period prior to the test.
• Check the patient’s understanding.
• Ask whether he has any questions or concerns.
• If possible, tell him where and when the test will take place.
• If possible, give him a leaflet.
• Thank him.
• Document your conversation.
X-ray
What the patient should know
• An X-ray is a picture of the bones and surrounding tissues that is produced by exposure to a
small amount of radiation.
• We are all exposed to sources of natural radiation throughout our lives. A chest X-ray or an X-ray
of your arm or leg is the equivalent of a few days’ worth of background radiation, and has a less
than 1 in 1000000 chance of causing cancer.
• The radiographer will ask you to stand against a flat surface or lie on a table.
• He or she will then stand behind another screen and take a picture of e.g. your leg with the
X-ray machine.
• The procedure takes 5–10 minutes, but your leg will only be exposed to X-rays for a fraction of
a second. It is completely painless.
• You must tell the radiographer if there is any chance that you are pregnant. X-rays are not
thought to pose a risk to an unborn baby, but, out of precaution, X-rays that target the womb
are not recommended unless there’s a clear need for them.
• A radiologist will study your X-ray and discuss it with you or send a report to your GP.
What you should also know
• X-rays have a higher frequency than light and pass through the human body.
• Radiographs are produced by directing X-rays through the relevant part of the body, which is
placed in front of a photographic plate.
• In the past, the photographic plate used the same type of film as a traditional camera, but
nowadays the plate is more often connected to a computer so that a digital image can be taken.
• Radiographs are commonly used to detect bone fractures, and to investigate cardiac, respiratory, and abdominal conditions, among others.
• As X-rays pass through the body, energy particles (photons) are absorbed at different rates.
Metalwork absorbs most radiation so appears bright white. Bone appears white, soft tissues
(e.g. organs) appear grey, fat appears dark grey, and air appears black.
• Contrast material can be used to improve visibility of internal organs, e.g. iodine to look at vessels in the heart (angiogram) or barium to look at the GI tract (barium swallow for the oesophagus, barium meal for the stomach, barium follow-through for the stomach and small bowel, and
barium enema for the large bowel).
Clinical Skills for OSCEs
334 Station 117 Imaging tests explanation
• A radiograph that uses contrast material involves the equivalent of a few years’ worth of background radiation (considerably more than a chest radiograph), and has a 1 in 1000–10000
chance of causing cancer.
Ultrasound scan (USS)
What the patient should know
• A USS uses high-frequency sound waves to create an image of part of the inside of the body.
Radiation is not used.
• The test will take place in the X-ray department (usually) and be performed either by a doctor
or a sonographer.
• The operator will ask you to lie on a bed and move a handheld transducer over the area of the
body to be examined.
• Prior to that, he or she will apply some lubricating gel over the skin. The gel improves contact
between the transducer and the skin and also enables the transducer to move more smoothly.
• The transducer is connected to a computer and monitor. Pulses of sound are sent from the
transducer into your body. They then bounce back from the structures inside your body to be
displayed as a moving image on the monitor.
• The procedure takes 15–45 minutes.
• It is completely painless and harmless (both to you and your baby).
• A report will be sent to your GP.
What you should also know
• Commonly used for antenatal scans; to image the heart (echocardiogram) and other organs,
e.g. liver, breast, thyroid; and to guide biopsies.
• Depending on the scan, it may be necessary for the patient to be fasted or to have a full bladder.
• Some parts of the body are not suitable for ultrasound scanning since ultrasound waves cannot
pass through bone, air, or gas.
• There are different types of scan:
– external ultrasound (US)
– internal US: to look more closely at certain organs, e.g. prostate, ovaries
– endoscopic US: to look more closely at certain areas, e.g. oesophagus, stomach
– Doppler US: to assess flow of blood through vessels
– duplex US: combines grey scale and colour Doppler ultrasound to look at both the structure
of the vessels and the flow of blood through them
Computerised tomography (CT) scan
What the patient should know
• A CT scan involves taking a series of X-rays and using a computer to build up detailed images
of the inside of the body.
• This does involve exposure to radiation, but the potential benefits of the scan outweigh the
potential risks.
• You may be asked to change into a gown and to remove metallic objects such as jewellery,
dentures, hairpins, and so on.
• The radiographer will ask you to lie on your back on a bed that will be moved in and out of the
scanner. The scanner resembles a large ring or doughnut and contains an X-ray unit that will
rotate around you.
• You must keep as still as possible during the scan. At certain times, you might be asked to
breathe in, breathe out, or hold your breath.
• The radiographer will be operating the scanner from an adjacent room. However, he or she
Communication skills
Station 117 Imaging tests explanation 335
will be able to see you and communicate with you through an intercom. You can also ask for a
friend or relative to be with you in the same room.
• The procedure takes 5–10 minutes.
• It is completely painless.
• You must tell the radiographer if there is any chance that you are pregnant.
• Your scan will be examined by a radiologist and may be discussed by other specialists. A report
will be sent to the doctor who ordered the scan and to your GP.
What you should also know
• With CT scanning, digital geometry processing is used to generate a three-dimensional image
of the inside of the body from a large series of two-dimensional radiographic images (‘slices’)
taken around a single axis of rotation.
• CT scans are often used after serious accidents to look for internal injuries, and to prepare for
further tests and treatment.
• Common types of CT scan include head (e.g. for investigating brain tumours, haemorrhages, or
stroke), abdominal, vascular, and bone scans.
• Contrast material can be given through various routes, and might be used to highlight certain
structures.
• CT scans can expose the patient to significant radiation: a whole body scan is equivalent to 4.5
years’ background radiation.
Magnetic resonance imaging (MRI)
What the patient should know
• An MRI uses strong magnets and radio waves to create detailed images of inside the body.
Radiation is not used.
• You will most likely be asked to change into a gown. Because of the strong magnets, it’s important to remove any metal objects from your body, including piercings, dentures, and hearing
aids.
• The scanner looks like a tube or tunnel.
• The radiographer will ask you to lie on a bed which slides into the scanner. You may find this
uncomfortable if you suffer from claustrophobia, particularly if you have to go head first into
the scanner.
• The scanner may be quite noisy so you will be given earplugs or headphones to wear.
• In some cases, a frame containing receivers may be placed over the part of the body being
scanned. The purpose of the frame is to improve image quality.
• You must keep as still as possible during the scan. At certain points, you might also be asked
to hold your breath.
• The radiographer will be operating the scanner from an adjacent room. However, he or she
will be able to see you and communicate with you through an intercom. You can also ask for a
friend or relative to be with you in the same room.
• The procedure takes 15–90 minutes.
• It is completely painless and harmless.
• Your scan will be examined by a radiologist and may be discussed by other specialists. A report
will be sent to the doctor who ordered the scan and to your GP.
What you should also know
• Often used as a second-line when other imaging tests have been unable to provide sufficient
information.
• The magnetic field causes protons in hydrogen atoms in the body to align. Short bursts of
radio waves then knock the protons out of alignment. When the radio waves are turned off, the
Clinical Skills for OSCEs
336 Station 117 Imaging tests explanation
protons realign, and, in doing so, emit radio signals which are picked up by receivers. Protons
in different tissue types realign at different speeds, producing distinct signals.
• MRI can be used to examine almost any part of the body, but, because of the strong magnets,
may be contraindicated in people with an IUD, pacemaker, artificial heart valve, prosthetic joint,
or other metal-containing implants and fragments. As a precaution, MRI scans are not usually
recommended during pregnancy, although there is no evidence to suggest that they are harmful to the embryo or foetus.
• Sedatives can be provided for people with claustrophobia and general anaesthetic for young
children and babies.
• Depending on the scan, the patient may be asked not to eat and drink for up to four hours
beforehand, or to drink a large amount of water.
• In some cases, a contrast material, typically gadolinium, may be injected intravenously to
enhance the appearance of certain details.
• Functional MRI (fMRI) measures the haemodynamic response to transient neural activity resulting from a change in the ratio of oxyhaemoglobin and deoxyhaemoglobin, and is used to map
neural activity in the brain or spinal cord.
337Communication skills
Station 118
Endoscopies explanation
Read in conjunction with Station 116: Explaining skills.
• Introduce yourself to the patient, and confirm his name and date of birth.
• State the test required and its indication, e.g. “To help ascertain the cause of your bleeding, we
would like to look at the inside of your stomach with a small telescopic camera.”
• Check the patient’s current understanding, e.g. “Have you ever had this done before?”
• Explain what the test involves (see below).
• Highlight any special preparation involved, e.g. fasting for a certain period prior to the test.
• Check the patient’s understanding.
• Ask whether he has any questions or concerns.
• If possible, tell him where and when the test will take place.
• If possible, give him a leaflet.
• Thank him.
• Document your conversation.
[Note] The most common endoscopies to come up in OSCEs are oesophagogastroduodenoscopy and colonoscopy.
Oesophagogastroduodenoscopy (OGD, gastroscopy, upper
endoscopy)
What the patient should know
• The procedure involves passing a thin, flexible tube or scope down into the stomach.
• This is often carried out under sedation, meaning that you may be very drowsy. In addition or
alternatively, your throat may be numbed with a local anaesthetic spray.
• You will be asked to lie down on your left-hand side.
• The endoscopist will place the scope in the back of your mouth and require your co-operation
as he or she gently guides it down your gullet and into your stomach.
• The scope carries a light and camera and relays images back to a monitor. If need be, it can also
be used to take tissue samples and even to stretch the gullet or stop bleeding.
• The procedure itself usually takes about 15 minutes and is very safe. (For a diagnostic OGD, serious complications such as bleeding occur in fewer than 1 in 1000 cases; for a therapeutic OGD,
in fewer than 1 in 100 cases.)
• After the procedure, you will be taken to a recovery room where you can remain until the effects
of the sedation have worn off.
• If you are discharged, as is likely, you should arrange for someone to take you home and stay
with you for a day or so. If any complications arise, he or she should take you to A&E. Owing
to the sedative, do not drive, operate heavy machinery, or drink alcohol for 24 hours after the
procedure.
• The results of the procedure will be discussed with you by your referring doctor or your GP, who
will be sent a copy of the results.
• Prior to the procedure, you should not eat or drink anything for at least four hours. If you are on
any prescribed medicines for indigestion, you should stop taking them for at least two weeks
(this does not also apply to antacids). Also, do let the endoscopy unit know if you are on any
diabetes or blood-thinning medication.
Clinical Skills for OSCEs
338 Station 118 Endoscopies explanation
What you should also know
• OGD is used to look for lesions in the oesophagus, stomach, or duodenum. It can also be used
to take biopsies and perform therapeutic and palliative interventions e.g. repair bleeding ulcers
or veins, dilate the oesophagus, remove polyps and early-stage tumours, or provide nutrients.
• Common indications include dysphagia, dyspepsia, haematemesis, melaena, malabsorption,
persistent abdominal pain, and unexplained weight loss.
• Complications include pain, bleeding, perforation, infection, and sore throat.
Colonoscopy
What the patient should know
• Colonoscopy involves passing a thin, flexible tube or scope through the back passage and into
the colon or large bowel.
• This is often carried out under sedation, meaning that you may be very drowsy.
• You will be asked to lie down on your left-hand side.
• After performing a digital rectal examination, the operator will gently push the scope through
the back passage and into the colon.
• Air will be passed up a channel in the scope to make the colon easier to visualise. This may make
you feel cramped or bloated, which is normal.
• The scope carries a light and camera and relays images back to a monitor. If need be, it can
also be used to take tissue samples and even to remove small lumps of tissue or stop bleeding.
• The procedure itself usually takes about 20–30 minutes and is very safe.
• After the procedure, you will be taken to a recovery room where you can remain until the effects
of the sedation have worn off.
• If you are discharged, as is likely, you should arrange for someone to take you home and stay
with you for a day or so. If any complications arise (for example, pain, passing blood, or fever),
he or she should take you to A&E. Owing to the sedative, do not drive, operate heavy machinery, or drink alcohol for 24 hours after the procedure.
• The results of the procedure will be discussed with you by your referring doctor or your GP, who
will be sent a copy of the results.
• The colon needs to be empty for the procedure, and you will have to go on a special diet for the
few days leading up to the test. You will also be given some laxatives to take.
What you should also know
• Colonoscopy is used to look for pathology in the colon as far as the terminal ileum. It enables
the operator to take biopsies and perform therapeutic and palliative interventions, e.g. remove
polyps, stop bleeding, insert a stent.
• Colonoscopy is also used for surveillance in those at risk of colorectal cancer or patients with
IBD.
• Common indications for colonoscopy include PR bleeding, positive faecal occult blood test,
persistent lower abdominal pain, persistent diarrhoea, and change in bowel habit.
• Complications include pain, bleeding, perforation, and infection.
• Flexible sigmoidoscopy is used to look at the rectum and lower colon (up to about 60cm),
sometimes as precursor to a full colonoscopy. The procedures are similar.
339Communication skills
Station 119
Obtaining consent
Common questions
The purpose of gaining consent
Consent is needed on every occasion a doctor wishes to initiate an investigation or treatment or
any other intervention, except in emergencies or where the law dictates otherwise (such as where
compulsory treatment is authorised under the Mental Health Act).
How long is consent valid for?
Consent should be seen as a continuing process rather than a one-off decision. When there has been
a significant period of time between the patient agreeing to a procedure and its start, consent should
be reaffirmed.
Refusal of treatment
Competent adult patients are entitled to refuse treatment even when doing so may result in permanent
physical injury or death. For example, a competent Jehovah’s Witness can refuse a blood transfusion
even if he will surely die as a result. An adult patient is competent if he can:
• Understand what the intervention is.
• Understand why the intervention is being proposed.
• Understand the alternatives to the intervention, including no intervention.
• Understand the principal benefits and risks of the intervention and of its alternatives.
• Understand the consequences of the intervention and of its alternatives.
• Retain the information for long enough to weigh it in the balance and reach a reasoned decision, whatever that decision might be. In some cases, the patient may not have the cognitive
ability or emotional maturity to reach a reasoned decision, or may be unduly affected by mental
illness.
Obtaining consent
When seeking to obtain consent, it is important not to be seen to be rattling through a list
of ‘must dos’. Try instead to elicit the patient’s ideas, concerns, and expectations, and tailor
your explanations accordingly.
• The type of information that should be provided to obtain consent includes:
– what the intervention is (use diagrams if this is helpful)
– why the intervention is being proposed
– alternatives to the intervention, including no intervention
– the principal benefits and risks of the intervention and of its alternatives
– the consequences of the intervention and of its alternatives
• Ask the patient to summarise the above information, and be certain that he is competent to
give consent.
• Remind the patient that he does not have to make an immediate decision and that he can
change his mind at any time.
Clinical Skills for OSCEs
340 Station 120
Breaking bad news
What to do
• Introduce yourself.
• Look to comfort and privacy.
• Determine what the patient already knows.
• Determine what the patient would like to know.
• Warn the patient that bad news is coming.
• Break the bad news.
• Identify the patient’s main concerns.
• Summarise and check understanding.
• Offer realistic hope or appropriate reassurance.
• Arrange follow-up.
• Try to ensure there is someone with the patient when he leaves.
How to do it
• Be sensitive.
• Be empathetic.
• Maintain eye contact.
• Give information in small chunks.
• Repeat and clarify.
• Regularly check understanding.
• Give the patient time to respond. Do not be afraid of silence or of tears.
• Explore the patient’s emotions.
• Use physical contact if this feels natural to you.
• Be honest. If you are unsure about something, say you will find out later and get back to the
patient.
What not to do
• Hurry.
• Give all the information in one go, or give too much information.
• Use euphemisms or medical jargon.
• Lie or be economical with the truth.
• Be blunt. Words are like loaded pistols, as Jean-Paul Sartre once said.
• Prognosticate (“She’s got six months, maybe seven”).
341Communication skills
Station 121
The angry patient or relative
I was angry with my friend:
I told my wrath, my wrath did end.
I was angry with my foe:
I told it not, my wrath did grow.
William Blake
The ‘angry person’ station can be rather unnerving, if only because medical students – and especially
medical students in the earlier years of their training – are relatively sheltered from such persons.
The aim of the game is to diffuse the person’s anger, not to ignore, placate or rationalise it. You should
therefore try to be as empathetic and non-confrontational as possible.
What to do
• Introduce yourself.
• Acknowledge the person’s anger e.g. “I can see that you’re angry”.
• Try to find out the reason for his anger, e.g. frustration, fear, guilt.
• Validate his feelings e.g. “I understand that you’re angry”.
• Let him vent his anger, or any feelings that led to his anger, e.g. frustration, fear, guilt. Be careful
not to interrupt him.
• Offer to do something or for him to do something.
People usually get angry because they feel that they are not being heard – so be sure to
hear them out.
How to do it
• Sit at the same level as the person, not too close but not too far either.
• Make eye contact.
• Speak calmly and do not raise your voice.
• Avoid dismissive or threatening body language.
• Encourage the person to speak. Ask open rather than closed questions, and use verbal and nonverbal cues to show that you are listening.
• Empathise as far as you can.
What not to do
• Glare at the person.
• Confront him.
• Interrupt him.
• Patronise him.
• Get too close to or touch him.
• Block his exit route.
• Put the blame on others/seek to exonerate yourself.
• Make unreasonable promises.
If the angry person is a patient’s relative, be mindful of potential confidentiality issues.
Clinical Skills for OSCEs
342 Station 122
The anxious or upset patient or relative
What to do
• Look to comfort and privacy.
• Introduce yourself and try to establish rapport.
• Acknowledge the person’s emotional state, e.g. “You seem to be very upset.”
• Explore his feelings, e.g. “What’s making you so upset?”
• Validate his feelings, e.g. “I think that most people would feel that way in your situation.”
• Provide honest and accurate information about the situation.
• Offer to do something or for him to do something.
• Summarise, reassure as far as you can, and conclude.
How to do it
• Encourage him to speak, e.g. by asking open rather than closed questions and by prompting
him on, e.g. “Can you tell me more about that?”
• Show that you are listening, e.g. by making appropriate eye contact, adjusting your body posture, and using appropriate verbal and non-verbal cues.
• Be empathetic.
• Use silence at appropriate times. If the person sheds tears, give him the time and space to do
so and hand him a tissue.
• Use physical contact if this feels natural to you.
• Remain poised: speak calmly, use simple sentences, and pace the information that you give.
• Repeat and clarify the information that you give, and check understanding.
• Encourage questions.
What not to do
• Ask only closed questions.
• Interrupt or rush him.
• Do all the talking.
• Dismiss or trivialise his feelings.
• Reassure too soon.
• Offer inappropriate reassurance or false hope, e.g.
– “There’s absolutely nothing to be afraid of, everything will be just fine.”
– “Sure she’s dead, but you’ll get over her much sooner than you think.”
– “I’m sure your father’s in a better place now.”
If the anxious or upset person is a patient’s relative, be mindful of potential confidentiality
issues.
343Communication skills
Station 123
Cross-cultural communication
You do not need to have a Masters in anthropology from the School of Oriental and African Studies to
score highly in this station. All you need to do is use some basic communication strategies, as detailed
here. It is also important that you are seen to respect the patient’s beliefs and/or values.
• Introduce yourself to the patient, and ensure that he is comfortable.
• Confirm his name, age, and occupation.
• Determine his reason for attending.
• Elicit his:
– Ideas
– Concerns
– Expectations
(ICE)
• Establish:
– his cultural or religious group
– the implications that this has on his reason for attending
– his individual beliefs and values
• Check that you have understood his problems.
• Explore possible solutions, and agree a mutually satisfactory course of action.
• Summarise the consultation.
• Check the patient’s understanding.
• Thank him.
Clinical Skills for OSCEs
344 Station 124
Discharge planning and negotiation
Discharging a patient involves discussing and agreeing the various aspects of discharge with both the
patient and the team, providing the patient with appropriate advice and instructions, ensuring that the
relevant services and prescriptions have been put into place, and writing a discharge summary for the
benefit of the patient’s GP and others. The form that has come to emblematise this process goes by a
number of Stalinist names, including discharge summary (DSUM), electronic discharge communication
(EDC), To Take Away (TTA), and To Take Out (TTO).
Setting the scene
• Introduce yourself to the patient, and confirm his name and date of birth.
• Summarise the situation to him.
• Explore the impact that the illness/hospitalisation has had on him.
• Explore his current mood and disposition.
Going home and after
• Explain that you are considering for the patient to go home.
• Elicit and address any concerns that he may have about going home. Reassure him that transport can be organised, if need be.
• Explore his home situation and support system.
• In people who are elderly or disabled, assess Activities of Daily Living (ADL): grooming, bathing,
dressing, feeding, bladder, bowels, toilet use, transfer, mobility, stairs.
• Consider any extra help that can be offered to the patient, for example, social services, home
help, meals on wheels, health visitor, district nurse, specialist nurses, palliative care team, dietician, occupational therapist, speech (language) therapist, physiotherapist, psychologist, continence advisor, self-help group, day centre.
• Discuss medication and compliance. Check that the patient doesn’t have any concerns about
taking his discharge medication and reassure him that the pharmacy can supply a Dosette box/
pill organiser, if need be.
• Address risk factors. Suggest lifestyle changes that the patient may benefit from, such as stopping smoking, reducing alcohol intake, eating a balanced diet, taking regular exercise, etc.
• Offer the patient a follow-up appointment either at his GP surgery or in the Out-Patient
Department.
• Instruct the patient to go to his GP or A&E if, after being discharged, he experiences any unexpected or severe symptoms.
Before finishing
• Summarise what has been said and offer to provide a written summary or written information.
• Check the patient’s understanding of what has been said.
• Ask the patient if he has any further questions or concerns.
• Thank the pat
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