UCL MBBS (Subject) / OSCEs (Lesson)

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• Ethics: Towards the end of life Dignity, patient choice, limits on respect for autonomy Futility, sanctity of life, quality of life Doctrine of Double Effect Withholding and withdrawing treatment DNAR Euthanasia and assisted suicide: Distinctions, laws and ethical arguments Death certification, autopsy, coroners, cremation
• Professional: "Good medical practice" Follow GMC guidelines, duties of a doctor; SJT stuff
• Exam: Eye WIPER-QQ Inspection: redness, discharge, cataract etc Visual acuity (Snellen chart, incl reflexes) Colour vision (Ishihara plates) Fields incl neglect Eye movements Fundoscopy Offer: Tonometry, slit-lap, referral to ophtalmology DDx: Acute glaucoma, cataract, inflammation; neuropthalmology
• Exam: Diabetic foot WIPER-QQ:Look Gait, shoes Skin, incl nails, webspaces for ulcers (describe them!), oedema, eczema Deformities, e.g. Charcot joint Feel Neuropathy: Sensation with single filament: dermatomes and length-dependent; motor assessment (weakness, wasting), reflexes Arteriopathy: pulses, temperature Offer: Fundoscopy, ABBI, BM / HbA1c, neurological exam
• ILS: Airway management Recognise problems Talking? Noises: snorring, stridor, wheeze, coughing Secure management Manoeuvres: head-tilt, chin-lift; jaw-thrust Adjuncts: naso-/oropharyngeal iGel airway Call anaesthesist Oxygen Bag-valve non-rebreathe mask Manual NIV
• ILS: External automatic defibrillator Attach correctly Stand clear Follow instructions
• ILS: CPR Check, response, lie flat, call for help Secure airway: maneuvers, adjuncts Support breathing: O2, bag-mask Start CPR if not breathing AED, shock if shockable (VF, pulseless VT) Give adrenaline Get notes Treat reversible causes: cannulas, fluids, do ABG, glucose Post-resus care: ABG, CR, cardiac monitor, ITU
• Hyperkalaemia Causes: CKD /AKI , tumour lysis, drugs, rhabdomyolysis Signs: Patient: confused ECG: Tall tented t-wave, wide QRS complexes, sinusoidal pattern Management: Stop drugs, e.g. spironolactone, ACE-I's, ARBs 50ml 50%Dextrose + 10 units actrapid, given over 15 min ± 10ml 10% calclum gluconate, if ECG changes
• Emergency: Upper GI bleeding Recognise: shocked, haematemesis, melaena DR ABCDE Varices Fluids and/or blood products Urgend OGD with banding Antibiotics Omeprazole 80mg IV STAT Terlipressin (if high risk)
• Emergency Addisonian crisis DR ABCDE Fluid resusc Hydrocortisone 100mg IV STAT
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• Emergency: ACS Unstable angina / NSTEMI: → medical management Morphine 5mg IV + Metoclopramide 10mg IV Oxygen if needed GTN sublingual if needed Dual antiplatelets: Aspirin 300mg + Clopidogrel 600mg LMWH, e.g. fondaparinux, dose ???? STEMI: → PCI, or thrombolysis Morphine 5mg IV + Metoclopramide 10mg IV Oxygen if needed GTN sublingual if needed Single antiplatelet: Aspirin 300mg NO LMWH
• Emergency: Acute heart failure Signs: Bibasal crackles, SoB, orthopnoae, PND; peripheral oedema Management: Sit forward, high-flow O2 Diuresis: Frusomide 40mg IV Nitrate infusion: 1-10mg/hr to maintain systolic BP > 90 mmHg Ventilatory support: non-/invasive Inotropes
• Emergency: DKA Recognise it: BM>12, ketonuria > ++, ph<7.3 Management: DR ABCDE Fluid resuscitation Fluid replacement 1 L NaCl 0.9% 1° 1L NaCl 0.9% 2° x2 1L NaCl 0.9% 4° x2 Add KCl to later bags Insulin Fixed-rate infusion 0.1 units/kg/hour 50 units soluble insulin (∼ 0.5ml) in 50ml NaCl 0.9% Infusion rate 0.1 ml/kg/hr Glucose: If BM < 14, or dropping rapidly, add 10% Glucose 125ml/hr Monitor: pH, CO32-, glucose, ketones After Restart short-acting insulin before meal, stop infusion after meal
• Emergency: Acute asthma Assess severity Do ABG, ECG, CXR Management: High-flow O2 Salbutamol 5mg NEB Ipratropium 0.5mg NEB Steroids: Prednisolone 40mg PO or hydrocortisone 200mg IV Magnesium sulphate, 1.2-2 g IV infusion over 20 min Aminophylline - not used, no evidence Intermittent PAP ventilation if not responding After: Steroids, 30mg PO OM, for 5 days Review long-term medication
• Emergency: Acute exacerbation of COPD Management: low-flow O2 depending on gas (aim 88-92% if CO2 retaining) Salbutamol 5mg NEB Tiotropium 0.5mg NEB Steroids: Prednisolone 40mg PO or hydrocortisone 200mg IV Anitbiotics (if infective); IV tazocin or according to protocol After: Review long-term meds Rescue pack: steroids + ABx
• Emergency: PE Recognise: Symptoms: chest pain, SoB: leg DVT Risk factors:  female, pregnant, immobility, personal history, clotting disorder Investigation: Only if risk is low: Wells score; D-Dimer, ECG (right heart strain, RBBB, S1 Q3 T3), CXR, CTPA Management High flow O2 Treatment dose LMWH, e.g. tinzaparin 175 units/kg Thrombectomy Exclude other causes, e.g. cardiac
• Emergency: Status epilepticus Management: 5 min: lorazepam 4mg IV (alternative midazolm buccal, diazepam PR) 10 min: lorazepam 4mg IV 20 min: phenytoin 20mg/kg IV in NaCl 0.9% (< 10mg/ml AND < 50mg/min) 40 min: general anaesthesia Also check for blood glucose and electrolyes if possible Get help asap. airway management as needed
• Emergency: Stroke WIPER-QQDR ABCDERecognise: Sudden focal neurology, Face, Arms, Speech, TManagement: Urgent CT head; if not haemorrhagic: aspirin 300mg; if < 4.5 hours: thrombolysis by stroke teamFollow-up management: Beware haemorrhagic transformation Investigate for AF and carotid / vertebral artery stenosis Rehabilitation by MDT 2° prevention, incl life style and meds
• Emergency: Burns DR ABCDE Cover to avoid heat loss: cling film in hyperacute setting Transfer to ITU if major burn or child Rule of 9's
• Prescribing: End of life Syringe driver 20ml water for injection or NaCl 0.9% per 24h Anticipatory prescribing: doses from BNF Drugs Pain: Morphine Nausea: cyclizine Agitation: Midazolam Secretions: Hyoscine bromide Rationalise oral meds
• Explain: Antibiotics Basic info: Used to fight bacteria, 500mg 3x/d with meals, 7 days course (or whatever) Side effects: GI upset (→medical attention if severe or bloody); anaphylaxis (→stop drug & medical attention if itchy rash, swollen tongue/face, or SoB) Lifestyle: Barrier method of contraception, need to finish the course even if symptoms subside (resistance) PMH, DH (→allergies; statin, warfarin, OCP), FH, SH
• Exam: Visual fields Confrontation First coarse, 2x four quadrants blind spot: compare to own, red desaturation Interpretation and DDx Offer to refer to eye clinic for formal assessment
• Complaint procedure Be sensible and refer to complaints office
• Rheumatological Hx APC Pattern of involved joints (distal vs axial, proximal vs distal, large vs small, a-/symmetrical) Morning stiffness > 30min Inflammation: Pain, swelling, redness Extra-articular features Skin / nails: Rashes (psoriasis), photosensitivity (SLE); nodules (RA; TB: gout) Raynaud's phenomenon (e.g. CREST) Eyes: sicca (Sjoegren's), iritis / uveitis (AS), epi-/scleritis GI/GU - Diarrhoea / urethritis: Reiter's Oral / genital ulcers: Behcet's Systemic: Weight loss Screeening Free of pain and stiffness? Can get dressed? Can climb stairs? PMH: UC / Crohn's, gonorrhoea, psoriasisDH: NSAIDs, DMARDs; allergiesFH: Arthritis, psoriasis, any auto-immune diseaseSH: Age, occupation, ethnicity, functional status, living situation, carers, smokingICE
• Ethics - Advanced Directive Definition: set of instructions about future medical treatment; put into action when no longer able to make decisions (accident, chronic illness) Form: Living will, lasting power of attorney Content: things you would prefer or prefer to refuse, e.g. CRP, IV fluids, parenteral nutrition; excludes demand for illegals (e.g. assisted suicide) or specific drugs, refusal of treatment for mental health conditions or basic care Practice: Solicitor - not necessary, but useful; friends & family; make available to doctorsFuture: Can be altered (→annual review) and overriden, as long as capacity is presentValidity: need to be signed and witnessedNotes: plan in place in case something happens best medical treatment up to defined ceiling of care →DNAR, Mental Capacity Act, withholding/-drawing treatment, Mental Health Act
• Ethics - End of Life - DNAR Medical decision, no appeal possible, but relay concerns to consultant Issued if CRP is futile, not of clinical benefit, or not in patient's interests / not consented Stressful procedures, often unsuccessful, QoL afterwards often poor Best medical treatment otherwise, e.g. fluids, antibiotics, pain meds, etc.
• Ethics - Mental Health Act Sections 2 - Assessment up to 28 days; AMHP + 2 doctors, one of whom experienced 3 - Treatment up to 6 months; AMHP + 2 doctors, one of whom experienced 4 - emergency up to 72 hours; AMHP + 1 doctor Holding powers 5(1) - doctor's holding power; up to 72 hrs 5(2) - nurse's holding power; up to 6 hrs Magistrates' powers 135 - place of safety from home 136 - place of safety from public "suffering from a mental disorder of a nature or to a degree that he ought to be detained in hospital in the interest of his own health, his safety, or for the protection of others" Application by relative or AMHP, support by doctors Appeal to Mental Health Tribunal, free legal representation, list of solicitors from PALS
• Explain: Drugs - Structure Introduction: WIPER, knowledge & concerns Basic info: dose, schedule, monitoring Side effects: severe & mild; safety netting; counter measures Life style changes: diet, exercise, drug interactions, pregnancy Starting the drug: loading dose, initial blood tests PMH, DH, FH, SH: allergies Examples: Statin, warfarin, steroids, digoxin, antibiotics, insulin
• Explain: Digoxin WIPER-QQ Basic info: AF or heart failure; slows the heart, stronger beats, life long Monitoring: UnE's S/E: nausea, vomiting, green vision C/I Lifestyle → Athletes from OSCEstop
• Explain: Opiates Basic info: Regular tablets (e.g. MST) plus breakthrough pain (e.g. Oramorph), dose adjusted to pain; until recovered or indefinite; SC in palliative care via syringe driverS/E: Nause & vomiting (→metoclopramide 10mg), constipation (→senna); respiratory depression and addiction not usually a problem; tolerance can be overcome with higher doses.Lifestyle: patient controlled analgesia, no other tranquilizers (e.g. benzos) PMH, DH (→allergies, previous problems with opiates), FH, SH
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• Legal: Autopsy aka post mortem Patient consent or coroner / court ruling Remove pacemake for cremation
• Exam: Dermatomes Upper limb: C5 - T1 Lower limb:  L1 - S1 → myotomes
• Exam: Myotomes Upper limb: Not clinically relevant Lower limb L2 - Hip flexion & adduction - Nil L3 - Hip adduction, knee extension - knee jerk L4 - Knee extension, foot inversion & dorsiflexion - knee jerk L5 - Hip extension and abduction; knee flexion; foot & great toe dorsiflexion - great toe jerk S1 - Knee flexion; Foot and toe plantar flexion; foot eversion - ankle jerk Foot drop, L5, common perineal nerve → dermatomes
• Exam: Volume status Hx: Thirst, SoB, ankle swelling; drugs, e.g. diuretics Examination Vital signs: L/S BP, HR, urine output; fluid input /  output chart if available Dry: ‌↓ cap refill, BP, ↑HR, ↓ skin turgor, dry mucus membranes, ↓ urine output Overloaded: ↑JVP, bibasal crackles, dependent oedema, 4th heart sound Mx: Fluid restriction ± diuretics / resuscitation
• Counselling: MRSA Screening swabs: nasal Home treatment: Chlorhexidine - for how long? Hair? Surgery Colonistion not a contraindication Last on OP list with special protocol to prevent transmission
• Exam: Shoulder WIPER-QQScreen for cervical spine symptomsLook: front/back/lateral/axilla: Asymmetry, wasting, scars, winging; redness, swellingFeel: SCJ → clavicle → ACJ → biceps groove → scapular spine → tip; tenderness?Move Passive: Flexion, extension, abduction, internal / external rotation RoM, painful arc? Throacoscapular disassociation? Dynamic winging? Muscle strrength: Resisted ext rot, Jobe's test, lift-off / belly-press test Joints: Scarf test, Hawking for impingement, anterior apprehension Other: pectoralis, lat dorsi, rhomboids, trapezium Offer: Exam of elbow and spine, neurovascular assessment, two-plane x-rays
• Exam: Elbow WIPER-QQScreen for cervical spine symptomsLook: Carrying angle, swelling, redness, wasting, symmetryMove: Feel: Joint lines, lateral / medial epicondyle, biceps tendon, ulnar nerve Provocation tests for epicondylitis Stability of collateral ligaments Offer: Hx, shoulder / hand exam, neurovascular assessment, x-rays in two planes
• Exam: Hand WIPER-QQScreen for cervical spine symptomsLook: Deformities, swellings, scars; whole arm + plus earsFeel: Bimanual palpation for tenderness and swelling; include palmar fasciaMoveSpecial tests Tinel's / Phalen's- Carpal tunnel De Quervain's - tenosynovitis Function Finger-to-palm distance in scleroderma Button, pen, coin Thumb to fingers Offer: Elbow exam, neurovascular assessment, x-rays; systemic manifestiation (lung, eyes, GI tract)
• Exam: Spine WIPER-QQLook: Curvatures, scars, wastingFeel: Tenderness, abdomenMove: Spinal, incl Schober's Squat, heel, trendelenburg, toes ⇒ walk Neuro Incl tone, dermatomes, myotomes, reflexes (don't forget abdomninal, Hoffman's) Provocation: SLR / lesuesge, femoral stretch; l'hermitte Vascular: Pulses
• Exam: Hip WIPER-QQLook: scars, leg length discrepancy, hyperlordosis(Feel): greaer trochanter, AISMove: walk, trendelenburg Lie flat, square the pelvis, Thomas' test active / passive flexion, extension, ab-/adduction, int/ext rotation Measure true / apparent leg length Offer: Special tests (e.g. Patrick's), neurovascular assessment, X-ray
• Exam: Knee WIPER-QQStand & Look: Q-angle; scars, wasting, deformity; walking aidsWalk & Look: behind the leg; varus / valgus thrust, fott / patellar progression anglesSit down: patellar height, tracking & crepitusLie down Look: quadriceps wasting Feel: effusion x3, joint line tenderness Move: Active and passive flexion and extension Ligaments Cruciates: Posterios sag, drawer x2, Lachmann's for ACL Collateral: Varus / Valgus strain: RoM, soft/hard end-point Further tests: Menisci, ligaments, patellofemoralOffer: Knee / ankle exam; neurovascular assessment, X-rayManagement: Analgesia, physio, surgery
• Exam: Ankle ---
• Exam: GALS WIPER-QQ 3 Questions:  pain/stiffness, get dressed, climb stairs Spine: look, walk, cervical (incl TMJ), Schober's Arms: behind head, hold out, turn, grip and pinch, squeeze Legs: Knee effusion, passive hip movement, squeeze feet, soles
• Emergency: Hypertension ---

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