UCL MBBS (Fach) / OSCEs (Lektion)

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• O&G Consultation Infertility Full Hx Previous children, regular intercourse, tried for how long Periods? (Previous) contraception? Hx of gynae problems / STIs Consider both woman and partner Options: refer to fertility clinic for IVF
• O&G Emergency Fetal Distress --
• Onc Emergency SVCO --
• Onc Emergency Brain Mets / Confusion --
• Opthal Exam Fields --
• Psych Consultation Clozapine --
• O&G Data Interpretation Partogram --
• Paed Emergency Intussusception --
• Paed Emergency Acute Diarrhoea --
• Paed Emergency Bronchiolitis DR ABCDE Oxygen, salbutamol; admit if unwell and not feeding +/- NG tube
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• Paed Emergency Febrile Convulsion --
• Pae Emergency Choking --
• Paed Consultation Neonatal Jaundice Causes Physiological 2ds-2wks Pathological: e.g. sepsis, haemolysis (Rh, sphero, G6PD), biliary atreasia Tx: light therapy, transfusion according to curve Risk: kernicterus (bilirubin in basal ganglia) with tetany, deafness, movement disorders; no cognitive impairment
• GP Consultation Asthma Review Questions Frequency of reliever use Night-time symptoms Exercise limitations Also meds review and ICE
• Paeds Skill APGAR Score Max 10, 0-2 for Appearance Pulse cutoff 100 Grimace Activity Respiration
• O&G Skill 3rd Stage of Labour --
• Psych Mental State Exam Appearance & behaviour Speech Mood & Affect Thought form Thought content - delusions Perceptions - Hallucinations Cognition - orientation, memory, concentration Insight Risk Psych Hx ⇒ premorbid personality, illicit drugs Meds / organic / other psych causes, past psych diagnoses & treatment
• Psych Depression Hx --
• Psych Schizophrenia Hx Quick: Appearance, mood / affect, speech, past psych history, development WIPER-QQAPC: Onset, duration, change, timing (constant / intermittent), better / worseScreening: Hallucinations - auditory, 3rd person, running commentary Delusions - paranoid of grandeur & prosecution & reference Thought control - broadcasting, interference Risk assessment: Self: Mood; Ideation → plan → intent Risk to others PMH, PSH, DH, FH, SH, ICE
• O&G Consultation Gillick Competence Understand Tx Why it it proposed Pro's and con's What if not having it
• Paeds Communication Parental Responsibility --
• O&G Consultation Fraser Guidelines --
• O&G Communication FGM --
• O&G Breast Hx WIPER-QQAPC: Onset, duration, any changesScreening: Pain (→Socrates), discharge (blood, mucus, pus), skin changes, lumps (breast, axilla, elsewhere), B symptoms (weight loss, lethargy, night sweats), mets (dyspnoea, bone pain); explode as appropriateRisk factors: Family/personal Hx (Men, 1st degree relatives < 50), smoking, oestrogen (early menarche, late menopause, not breastfeeding, OCP, HRT)PMH, PSH, DH, FH, SH, ICE ⇒ Refer for triple asessment, unless obviously not cancer
• Psych Explain Dementia --
• Exam: Thyroid & neck WIPER-QQ General exam patient: ?flushed, ?tremor, ?restless; ?toad-like face paraphernalia: meds Neck: Lump (size, shape, symmetry, consistency, mobility on tongue protrusion / swallowing) DDx non-midline swellings (cysts, nodes etc) Auscultation for bruit Eyes: Exophthalmos, lid lag (look from behind)Pulse: Tachycardia, AFLegs: MyxodoemaOffer: USS, nuclear medicine uptake
• Haematology exam → Peripheral lymph nodes Head, neck, inguinal, axilla nodes Spleen, liver Anaemia in the eyes Any skin rash
• Exam: Diabetic foot Combination of Peripheral arterial, incl ?↑ABPI Peripheral venous Neurological lower limb Also check: BM, Hb1Ac, UnEs, cholesterol, fundoscopy
• Exam: Venous competence & drainage WIPER-QQGeneral Patient: Well? Comfortable? Paraphernalia: Medicines Inspection (Leg): Get patient to stand and inspect very fully (front and back) Watch gait Inspect lying: Skin colour changes, (Ankle) swelling  (DVT; HF) Venous insufficiency Venous eczma and haemosiderin deposits (damaged capillaries leak blood → red-brown patches) Lipodermatosclerosis (inflammation of subcutaneous fat → woody hard skin, pigmentation, swelling, redness, inverted champagne bottle leg) Venous ulcers / atrophie blanche Superficial venous dilatation and tortuosity (varicose veins) Distribution (long saphenous is all the way up the medial part of the leg, short saphenous is up the lateral part of the lower leg) Colour Prominence Palpation Varicosities for tenderness and hardness (phlebitis) Saphenofemoral junction (5cm below and med to femoral pulse) and cough impulse  15deg elevation → rate of venous emptying Trendelenburg / tourniquet test to localize Calf tenderness for DVT, pitting oedema, peripheral pulses Percuss / Auscultate varicositiesTests: ABPI, and venous occlusion testsOffer: Peripheral arterial exam, abdominal / pelvic / neurological exam, fundoscopy if diabetic; JVP if oedema
• Exam: Stoma WIPER-QQ Inspect: Take it off! Site, type (end vs loop, flush vs spouted), working? Hernia? Skin irritation? Contents (urine, loose / formed stool) Palpate: Hernia Offer: Full abdominal exam
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• Exam: Hernia WIPER-QQ: chaperone,glovesInspect: leg-raise, head-raise, cough, standing up; erythema; size; location; scarsPalpate: ?reducible, ?peristalsis, get above it in the scrotum?; ?translucent; direct vs indirect by occlusion of the deep ringPercussion / Auscultation: for bowel sounds in the lumpOffer: Abdominal exam, PR, external genitalia / pelvic; cardio-resp exam to assess fitnessManagement: conservative: do nothing; surgery
• Prescribing Core drugs with doses Aspirin Morphine etc See MoDA cards
• SBAR Situation, e.g. PC Background, e.g. PMH Assessment, e.g. vital signs, examination findings Recommendation, e.g. plan
• Emergencies Oxford handbook Moodle → acutely unwell patient; Dr WHO Include DR ABCDE management Prescribing Investigations Relevant protocols Relevant follow-up care
• ILS algorithm DR ABC Components: →Airway management, →CPR, →AED, →post-resus care Reversible causes: T4, H4 High-flow O2, Fluids, ABG on everyone
• Written / Practical: NEWS recording Normally 4° Components Blood pressure Heart rate Temperature Resp rate Pain score AVPU Interpretation Low: 0-4; Medium: RED or 5-6; High: ≥ 7 Interpret trends
• Data interpretation CXR Method Patient details: Name, DoB, date take Technicalities: AP/PA, standing/lying, rotation, exposure, inspiratory effort Obvious abnormality? Hila, heart, lungs (incl borders), pleura (incl costophrenic angles), bones, soft tissues Review areas: Apices - pneumothorax? Bones - fracture? C - Cardiac shodow Diaphragm - pneumoperitoneum Edge of image - effusion, sot tissue Common findings Pneumonia, collapse, SOL, cavity, heart failure, effusion
• Clinical skills ECG WIPER-QQ Record Expose, shave Place electrodes B, R, L, G;  V1-V6 Breath normally, don't move Read Present → Management
• Medical Statistics Definitions and interpretations Sensitivity, specificity, postiive / negative predictive value Number needed to treat / harm p-value Odd's ratio, hazard ratio Absolute / relative risk (reduction) Study design double-blind RCT Cohort study Case control
• Abdominal exam WIPER-QQ End of the bed Patient: visible distension Paraphernalia: NBM, sick bowl, catheter General Pedal oedema Hands: Temperature, perfusion, pulse; liver disease (Dupuytren's, palmar erythema, leukonychia, clubbing); asterixis; JVP Face:  Anaemia, icterus, Kaiser-Fleischer rings, oral ulcers, stomatitis, glossitis; Virchow's node Abdomen Inspections: scars, striae, bruising, dilated veins, spider naevi; stomas, cough impulses, pulsations, visible masses Palpation: 9 quadrant superficial + deep; hepatosplenomegaly; kidneys Percussion: Hepatosplenomegaly; bladder; shifting dullness Auscultation: Bowel sounds; hepatic border; renal bruit Extras External genitalia / pelvic exam PR Hernial orificies, stoma
• Exam: Upper / lower limb neurology Inspection: Scars: including back for spinal surgery Wasting / muscle bulk: deltoid, supra-/infraspinatus, hypo-/thenar eminence; vastus medialis, tibia Fasciculations Asymmetry Tone: velocity-in/dependent (clasp knife, cog-wheeling), clonusPower: MRC grading x/5; distal → proximal or by myotomes or peripheral nervesCoordination:Reflexes:Sensation: Dermatomes, level, 4 mods (soft touch, pin-prick, vibration, proprioception)Function: Walking / buttons / writing ⇒ vascular assessment, cranial nerves, spine; relevant investigations DDx for upper / lower motor neuron lesions
• Cranial nerves exam I: change in sense of smell / taste; offer testingII glasses? offer visual acuity and colour vision Reflexes: direct & consensual, RAPD, accommodation Visual fields DDx: Horner's III, IV, VI 9 positions of gaze: double vision, pain DDx: 3rd (medical vs surgical), 6th, INO V Sensation: 3 divisions, corneal reflex Muscles of mastication: Masseter, temporalis, lateral pterygoids VII: Muscles: Frontalis, orbicularis oculi, cheeks, smile DDx: Asymmetry → stroke, Bell's palsy, facial nerve injury VIII: bedside hearing; Rinne's & Weber's test IX, X: Cough, uvula XI: Sternomastoid, trapezius XII: fasciculations, symmetry, speed of movement Offer cognition, speech, cerebellar, mmse, upper/lower limb neurology
• Exam: Peripheral arterial circulation WIPER-QQInspection Patient: amputations, ulcers, necrosis Paraphernalia: walking aids, whell chair Legs Look: ulcers (incl. heel, between toes, sole of the foot), necrosis, blisters; scars Feel: Temperature, pulses (femoral, popliteal, post tibial, dorsalis pedis), sensation Move: Wiggle toes Arms: dittoCentral: Look for sternotomy scars; Feel carotid pulses and AAAOffer: ABPI, venous and neurological exam
• Exam: Male genitalia & inguinal region WIPER-QQ Inspection: Scars, swellings, dilated veins, phimosis Palpation: Foreskin retraction; bimanual testes (pole, epidydimis, vas deferens), neurovascular bundle; cremasteric reflex; inguinal & para-aortic lymph nodes; bladder and kidney Offer: PR exam
• Rectal examination WIP(left-lateral, knees to chest)ER-QQ Equipment: double-glove, lubricant Inspection: Skin tags, fissures, fistulae, blood (also on glove at the end) Palpation: Sphincter tone, masses, impacted faeces, prostate (size, consistency, symmetry, tenderness, smoothness) →proctoscopy, rigid sigmoidoscopy
• Exam: Subcutaneous lumps Not tested (unless surgical) Describe them S3C3T3 DDx: lymph nodes, EN, mets, fibroadenoma in breast, rheumatoid / gout nodules
• Exam: Peripheral lymph nodes Sites: Head / neck: mental, submandibular, pre-/postauricular, occipital, an/post cervical chain; Clavicle: supra-/infraclavicular; axillae Legs: femoral Description: Size, shape, surface (smooth/ragged) Consistency (soft/firm/hard/rubbery), compressible Mobile, tender, pulsatile etc Considers spleen and liver
• Exam: Glasgow Coma Scale E-V-M max 4-5-6, total 15; min 3 Eye 4 - open spontaneously 3 - open to voice 2 - open to pain 1 - closed Voice 5 - coherent, alert speech 4 - confused speech 3 - understandable words 2 - incomprehesible sounds 1 - silent Motor 6 - follows commands 5 - localizes to pain 4 - withdraws from pain 3 - abnormal flexion 2 - abnormal extension 1 - no movement Alternatives: AVPU, FOUR score; part of APACHE-II
• Exam: Assessing Mental Capacity Not being tested Components Understand Retain Weigh Communicate
• Exam: Speech & Swallowing WIPER-QQ Dysarthria Talk: rhythm, speed, volume,  Pronounciation: Labial (m-m-m), velar (k-k-k), alveolar (l-l-l) Fatigue: Count back from 30 Palate: Cough & say "Aaaaah" Dyspraxia: Baby hippopotamus, British constitution Dysphasia - fluency & appropriate content Nominal: name objects (e.g. coat, pen, apple, watch) Conductive: repeat "no ifs, ands or buts" Receptive: Follow written command "close your eyes"; verbal 3-stage command Expressive: Write sentence containing subject+verb Dyslexia & dysgraphia Dysphonia: Hoarseness / huskinessDysphagia Cough Swallow: dry, sip of water, full; inspect for drooling & coughing Offer: Neurological assessment, SALT referral

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