UCL MBBS (Fach) / OSCEs (Lektion)

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• Exam: Gait & Balance (cerebellar) WIPER-QQInspection Patient: dyskinesias, age, habitus Paraphernalia: walking aids Gait: Normal: Getting up, speed, armswing, speed of turning: broad-based? High step? Heel-to-toe Romberg's test (sensory vs cerebellar ataxia) Head Eyes: SW-jerks, nystagmus, correcting saccades Dysarthria: "Baby hippopotamus", "British constitution" Tongue Arm Screen for pronator drift (pronator=weakness, upward=cerebellar); rebound Tone (?↓reduced), power, reflexes (?↓reduced) Coordination: dysdiadochokinesis, finger-nose test Leg: Tone, coordinationOffer: Full neurological exam, incl. fundoscopy, CN V, VII, VII or DysdiadochokineasiaAtaxiaNystagmusIpsilateral signs / Intention tremorSlurred spechHyporeflexia / -tonus
• Exam: Skin rash / lesion Describe it Examine for systemic features, e.g. nails, joints, eyes, lungs DDx: eczema, psoriasis, malignancy, keratosis, mole, infection (viral, fungal, parasites, bacterial)
• Exam: Skin ulcer DDx: Arterial, venous, nervous; mixed Describe size and site characteristics (shape, edge, colour) secondary features
• Exam: Fractures & Dislocations Hx: Mechanism of injury? Functional impact? Exam: Tender, soft-tissue swelling, RoM, neurovascular status Investigations: X-ray in two planes, →description Management: R4 - resusc → retain → restrict → rehabilitate
• Exam: Mouth, throat & pharynx Mainly inspection with tongue depressor and a good light source
• Exam: Parkinson's disease WIPER-QQ Inspection Patient: hypomimia, resting tremor Paraphernalia: walking aid, medicines, drug chart Gait Shuffling? Speed of turning, arm swing, intitiation of movement Romberg's & pronator drift Face: glabellar tap, nystagmus / vertical gaze diplopa, dysarthria Arm Tremor: resting with distraction, postural, intention Tone: velocity-dependent (clasp-knife), cog-wheeling Bradykinesia: "big-and-quick", micrographia Function: un-/do button, pick up a coin Offer: Lying/standing blood pressure, cognitive evaluation, stool chart DDx: idiopathic PD, PD+ syndromes (PSP, MSA, CBD), drug-induced (e.g. antipsychotics, anti-emetics), Lewy boy dementia
• Exam: External ear & tympanic membrane WIPER-QQInspection: erythema, discharge; skin changesPalpation: tenderness, lymph nodesOtoscopy: ear canal, tympanic membrane: reddening, discharge, bulging, perforation?Hearing test: Weber's, Rinne's x2 Offer: Nose, neck exam
• Exam: Multisystem conditions WIPER-QQGeneral exam:  Pulse, temperature, perfusion; pallor, cyanosis, icterus, lymphadenopathy; pedal oedemaSystems: Listen to lungs, heart; palpate abdomenSpecifics: whatever is suggested by findings
• Exam: Acutely unwell DR ABCDE → specific emergency scenarios
• Practical: Consent Requirements: Informed Voluntarily given Capacity Can be withdrawn at any time Issues Explain common and serious side effects Mental capacity act Mental health act DoLS Explain. gain, record; principle of autonomy; right to refuse; best interest in an emergency; doctrine of least restrictive choice if consent cannot be obtained
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• Practical: Hand washing 7 steps: soap or alcogel palms back of hands between fingers clasped fingers thumbs wrists ulnar sides finger tips
• Practical: Scrub & gown for surgery Not tested 7-steps hand washing, nail picking, drying gloves, gown, mask, hat
• Practical: Infection control and aseptic technique Wash hands Don't touch key parts
• Practical: Waste disposal & sharps Not tested in finals, but look up colors gray - household waste orange - infectious yellow - offensive etc Always use sharps bin, fill to line
• Practical: Manual handling Good vision, stable stance, solid grip, straight back
• Practical: Urinalysis WIPER-QQExplain: Part labia / retract foreskin; mid-stream without stoppingPerform: ready pack; wear gloves; discard rest Measurement: ph, white cells,glucose, protein, blood, nitrites, concentration → interpretation (DKA, UTI, ureteric stone, rhabdo, cancer)
• Practical: Urine pregnancy testing Get a urine sample → use the kit
• Practical: Capillary blood glucose testing Not tested, just use the kit
• Practical: Transcutanenous O2 sats monitoring Cable dorsally; beware nail varnish and poor perfusion
• Practical: 12 lead ECG & cardiac monitor WIPER-QQ Prepare skin: shave, clean, dry Attach electrodes: BRLG, V1-6 Instruct patient: sit still, normal breathing, non-invasive test Enter patient details, check all traces, print, interpret & document in the notes
• Practical: ECG interpreation Patient details Rate & Rhythm: Brady- / tachyarrhythmias Axis Intervals QRS complex ST segment: elevation? depression? P waves: inversion? Tall? Blocks? Other salient features: ectopic beats, U waves
• Practical: Venepuncture Procedure Washes hands, Introduces oneself to the patient and checks nameband Explains procedure to the patient and gets verbal consent Washes hands, leaves patient to collect equipment Collects and cleans tray starting with inside first then outside. Gathers the correct equipment in the tray Opens up and assembles equipment Washes hands on return to patient Applies the tourniquet in the correct place Selects a vein in a desirable location Uses alcohol swab to clean skin Dons gloves prior to taking blood Warns patient of 'sharp scratch' Successfully collects some blood Removes bottle and gently inverts 2-3 times Removes tourniquet (before needle) Removes needle from the arm demonstrating safe handling of sharp Applies pressure Safely disposes of sharp Disposes of waste Labels bottles Thanks patient, checks patient's comfort offering him/her a plaster and washes hands Order of draw Clotting - blue - citrate Biochemistry - yellow / green Haematology - purple Transfusion - pink
• Practical: Blood culture All available sites in sepsis; take before ABx are given If using butterfly: aerobic before anaerobic If decanting from syringe: anaerobic first
• Practical: ABG Washes hands Introduction: full name and role Ask for permission to do arterial blood gas (ABG) Explain indication Explain procedure fully Discusses use of local anaesthetic Ask about contra-­indications Ask about allergies, specifically local anaesthetic (confirms with drug chart) States would perform Allen’s Test Gathers equipment: Gloves, Apron, ABG syringe, Alcohol wipes, Gauze, Tape, Sharps bin, 2.5 ml syringe, Lidocaine 1% without adrenaline, red/green and orange needle, incopad Dons gloves Checks Lidocaine with colleague: Drug, strength, expiration date (need all 3 for mark) Draws up 2ml of 1% Lidocaine without adrenaline using green or red needle then disposes sharp Attaches orange needle (25G) ABG syringe: pre-­‐withdraws plunger Repositions: extends wrist-­‐ uses a rolled inco-­‐pad/towel/pillow Locates radial artery: Identify greatest pulsation Cleans area with wipe Local anaesthetic-­‐ Warns patient “sharp scratch” Pull plunger back to check for blood Creates bleb of local anaesthetic using 0.5-­‐1 ml Disposes sharp safely in sharps bin States wait 2 minutes Clean area with wipe again Warns patient about to do procedure Inserts ABG needle at 30-­45deg bevel up Obtains at least 0.5‐1ml of blood Disposes sharp safely in sharps bin Applies pressure with gauze for 5 minutes to prevent bruising Attaches cap and rolls sample in hand Transport sample (with ice if > 15 mins) Document in notes: Use of local anaesthetic, results (with inspire %O2 ), any complications (need all 3)
• Practical: Take swabs WIPER-QQ, gloves Source: throat, ear, nose, skin, genital Equipment: stick, container Process: Label, →request pathology investigation
• Practical: Request forms Types Imaging, e.g. CTPA, x-ray, MRI Pathology, e.g. sputum sample, blood culture Format Patient details Clinical summary & question Test details Formalities
• Practical: Assess nutritional and hydration status Hydration Vital signs: BP (lying and standing), HR cap refill, mucus membrane, thirst bibasal crackles, peripheral oedema, fourth heart sound Nutrition weight and BMI Refer to dietician Refeeding syndrome: low Mg2+ and Po32-
• Practical: Bloods for cross-match and transfusion Two different sites, two different times (≥30min apart), hand-label them after positive wristband ID which bottle? Order of draw ??? → venepuncture
• Practical: Cannulation & IV infusion Cannulation Mentions handwashing, introduces oneself to the patient and checks nameband Explains procedure to the patient and gets verbal consent Collects and cleans tray starting with inside first then outside Gathers the correct equipment in the tray Washes hands, opens up and assembles equipment Applies the tourniquet in the correct place Selects a vein in a desirable location Uses alcohol swab to clean skin Dons gloves Warns patient of a sharp 'scratch' Inserts cannula at approx degree angle (25-35 degrees) to skin Gets a flashback of blood Safely inserts the cannula Removes tourniquet Removes needle from cannula Secures with tape Safely disposes of sharps in sharps bin Flushes cannula with 5mls of normal saline IV infusion → see video
• Practical: Parenteral drug Wash hands using 7 stage approach Explain and discuss the procedure with the patient Check the identity of the patient using the nameband, prescription chart and the infusion container. Check for any drug allergies. Inspect the infusion site Clean tray Assemble all necessary equipment for procedure Check the name, dose, administration route and expiry date of drug to be administered against the prescription chart in accordance with Trust Drug Administration Policy Check name, strength, volume and expiry date of any required diluent Don gloves Reconstitute the drug according to prescription and manufacturers guidelines Re- check the identity of the patient using the nameband, prescription chart and the infusion container. Check for any drug allergies. Avoid contamination of connection and additive ports at all times Wash hands using 7 stage approach and change gloves. CLEAN BUNG with alcohol swab and allow to dry Flush injection site with at least 5ml saline Check that no resistance is met, no pain is felt by the patient, no swelling is evident, no leakage occurs around the cannula and there is good back-flow of blood on aspiration Inject the drug as perscribed in drug leaflet using a non-touch technique Ask the patient if any abnormal sensations or reactions are experienced. Observe and monitor the patient for adverse reactions throughout the infusion Flush the cannula AGAIN with sodium chloride. Thank the patient Wash hands using 7 stage approach Complete the patients prescription chart, fluid balance chart
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• Practical: SC and IM injections Trivial, marksheets as PDF, not tested
• Practical: Bladder catheterisation Introduces oneself to the patient Explains procedure and mentions verbal consent Washes hands using 7 stage technique Prepares and cleans trolley Opens catheter pack and arranges sterile field Dons sterile gloves and disposable gloves in appropriate order Creates a hole (if necessary) in sterile towel and places over the penis Wraps a gauze swab around shaft of the penis and holds with non dominant hand Mentions retracting the foreskin Cleans penis with cotton wool and cleansing solution, wiping away from the meatus Inserts lignocaine gel (warns patient beforehand) States would allow 3-5 minutes for lignocaine to act Discard top pair gloves Places receivers dish between the patient's leg (or attaches catheter bag to catheter) Inserts catheter to level of the bifurcation using sterile non touch technique Inflates balloon with appropriate amount of water Withdraws catheter until slight resistance is felt Mentions pulling back foreskin if retracted Finishes procedure by mentioning residual volume, relevant tests and tidying area
• Practical: O2 therapy Devices Nasal canula - 1-4L/min Simple face mask - 6-10L/min Venturi 24%, 28%, 35%, 40%, 60% - volume according to mask Non-rebreathe mask - 15L/min Target 94-98% normally 88-92% if CO2 retention likely, e.g. COPD Prescribe it!
• Practical: Set up nebuliser Not tested; see oscestop notes Drug checking routine 8-10L/min of oxygen or compressed air
• Practical: Clean wound & suture WIPER-QQ Washes hands, wears gloves Inspects wound for foreign bodies: glas ⇒ soft-tissue X-ray Discusses need to clean wound either by irrigation or with betadine; debridement Discusses need to administer local anaesthetic & provides explanation of procedure: check for allergies; 2% solution; max dose 3mg/kg Open suture pack and equipment on trolley, prepare sterile field Correctly mounts needle in needle holder (needle perpendicular & 1⁄4 to 1/3 way along needle length) USES & HOLDS INSTRUMENTS CORRECTLY: Forceps, Ringed Instruments USES CORRECT SUTURING TECHNIQUE: Suture inserted in two bites, suture at least 1 cm long, adequate tension, adequate spacing (at least 0.5 cm), surgeon’s knot used (one double throw followed by two single throws) Safe & appropriate disposal of sharps OVERALL:  aseptic technique, eneral ability throughout procedure Document in the notes, thank patient, get a dressing
• Practical: Apply dressings Change gloves
• Practical: Remove sutures / staples Equipment: scalpel, special scissors Dressing Not tested
• Practical: remove operative drain WIPER-QQ just do it, change glove, "deep breath in"
• Practical: CPR / life support Responsive? Call for help Breathing? (Carotid pulse?) ⇒ Lie flat, chest compression 120 min-1, 30:2 → ILS / ALS, AED
• Practical: Insulin Emergencies DKA: Fixed rate 0.1 units/kg/hr; given as 50units in 50 ml NaCl 0.9% Hyperkalaemia: 10 units in 50 ml 50% dextrose over 15 min Types: soluble (for IV); short-acting, long-acting, mixturesRoute: subcut or IVDose: initally ~ 0.5units/kg/day; may go up to 100-200 in obese patientsDevices: pens (dial correct dose, SC), insulin syringes (graded in units)Sliding scale: 50 units in 50ml NaCl 0.9 %; dose adjusted to BG; + 10% dextrose + 20mmol KCL @ 50ml/hrMonitoring: hourly BG; if >20, bloods for bicarb; daily UnE and lab glucose
• Practical: Teach patient to collect MSU mid-stream without stopping; part labia / retract foreskin to avoid contamination
• Explain: Monitoring central venous pressure WIPER-QQ Indication: Symptoms? Diagnosis? Specific worries? Procedure: Central venous line in the neck, e.g. internal jugular; done by professional (surgeon / anaesthesist) under USS guidance; small incision in the skin → wire → cathether; advanced into right atrium (picture); stays there for as long as necessary; can be done on the ward Risks: Infection, pneumothorax, puncture of the artery (→stroke) Logistics: None
• Explain: Exercise testing for cardiac ischaemia WIPER-QQ Indication: symptoms, previous information Procedure: Treadmill and/or spinbike, with monitoring of BP, HR, ECG; stop when symptoms occur Practicalities: Outpatient, maybe bring sports clothes
• Explain: Doppler studies for arterial occlusion WIPER-QQ Indication: symptoms (claudication? Syncopes?), previous information Procedure: Done by radiographer/-logist; non-invasive with cold jelly; turn blod flow into sound; assess structure of vessel and dynamics of flow Practiccalities: Outpatient, no preparation necessary
• Explain: CT/MRI abdomen WIPER-QQIndication: symptoms? what happened so farProcedure: Outpatient / collected from the wards; painless; loud machine; IV contrastRisks: radiation, contrast (anaphylaxis, kidney - AKI)Results: By radiologist
• Explain: CT/MRI brain WIPER-QQPrevious understanding, incl symptoms, diagnosisIndication: Visualize the brain, exclude pathologyProcedure: Radiology department (gown, trolley etc), +/- iv contrast; noisy and crammed; may take a long time (up to an hour)Risks: AnaphylaxisCI: pacemakers, surgical clips, some joint prostheses; claustrophobia; pregnancy; overweight; renal failure Results reported by radiologists
• Explain: Cardiac ultrasound Non-invasive vs transoesophageal Cold jelly Diagnostic Looks at structure and function of the heart (contraction, valves, flow, gradients) Results straight away if all seems fine or later Risks: none vs oesophageal rupture, infection, sore throat
• Explain: Coronary angiography Indication: Ischaemic heart diseae, angina: to diagnose and plan treatment Procedure: LA, awake, cathether through femoral / radial / brachial arteries, cntrast agent, X-ray images Risks: bleeding, haematoma, infection; stroke, heart attack C/I: renal failure
• Explain: Complex lung function tests PEF, FVC, FEV1 COPD: obstructive pattern: FEV1/FVC < 75%, severity based on FEV1 %predicted Fibrosis: restrictive pattern: FEV1/FVC >= 100%, FVC reduced / normal Asthma: sequential PEF to monitor response and assess severity Loop spirometry Indication: diagnose breathing difficulty, done as outpatients Conditions: Flow ± vs lung expansionNormal, emphysema, extrathoracic airway narrowing Gas transfer coefficient (KCO): CO diffusion cap (DLCO) corrected for alveolar volume measured using CO uptake and lung volume via helium dilution low in emphysema high in pulmonary haemorrhage TLC, RV: obstructive vs restrictive / MSK Risks: none, but requires some cooperation
• Explain: Tapping a pleural effusion WIPER-QQ Indication: Symptoms (chest infection, SOB), diagnosis (e.g. pneumonia); diagnostic + therapeutc intent Procedure: Local anaesthetic, US guided aspiration with a needle. Risk: Bleeding, infection, haemothorax, nerve damage (save triangle) → pleural drain

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