UCL MBBS (Fach) / OSCEs (Lektion)

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• Explain: Upper GI endoscopy WIPER-QQPrevious understandingIndicationProcedure: nasal spray beforehand; diagnostic & therapeuticLogistics: Sedation if wanted (driving etc)Risks: failure to visualise, sore throat, perforation
• Explain: Lower GI endoscopy WIPER-QQ Gather prior knowledge and understanding of indication ("rule out anything nasty") Agree on structure: test itself ⇒ logisitics ⇒ risks Chunk and check, allow questions Test itself Camera test from the bottom end; gas inflation; trained professional; gown and trolley; takes about 20 min ± sedation, cooperation required May take biopsy and remove polyps Surgeon may gve impression straight away if everything is fine Before Bowel prep, nil by mouth from the night before Sign consent form, can change mind After Recovery room, home as soon as feels ready No driving with sedation Biopsy results after a week or so, given in clinic Risks Feeling bloated afterwards Perforation 1:1500, requires surgery to fix Infection Failure to visualize everything, may need another go
• Explain: ERCP WIPER-QQIndication: Symptoms? Diagnosis? (e.g. gallstones); diagnositc + therapeutic (e.g. stent, stone removal) benefitProcedures: Upper GI endoscopy, dye into biliary tree, imaging via fluoroscopyLogistics: SedationRisks: Pancreatitis (5%), small bowel perforation, bleeding; sore throatC/I: Pregnancy, allergy to contrast, acute pancreatitis, bleeding disorder, recent MI/PE
• Explain: Lumbar puncture WIPER-QQPrevious understandingIndication: Obtain fluid for lab analysis to exlcude infection, bleeding etc; measure pressureProcedure: Lateral position, needle in the lower back; results take timeRisks: Infection, bleeding, nerve damage, headache (→lie flat afterwards)
• Explain: Aspiration of breast lump May be US guided FNA vs core biopsy Results in a few weeks time at next appointment Risks: Infection, bleeding; but very safe
• Explain: Aspiration of thyroid lump WIPER-QQIndication: What symptoms? Get a diagnosisProcedure: USS guided, may be uncomfortable, done in clinicLogisitics: No special preparation or considerations; results may take a while; given in clinicRisks: Infection, bleeding, nerve damage
• Explain: Induction of anaesthesia Process Consent: includes hypnosis, analgesia, paralysis Gown & trolley Separate room next to theatre IV access Oxygen loading IV, or gaseous, anaesthetic Will feel tired Risks Death Sore throat Need for additional medication to maintain blood pressure →airway management
• Explain: Airway management Simple Jaw-thrust, head-tilt / chin-lift Oro-/nasopharyngeal airway adjunct iGel Ventilatory suport via bag-valve mask Advanced O2 loading Anaesthetic induction: IV or gas via mask Endotracheal tube under vision via laryngoscope Constant monitoring (expiratory CO2 etc) by anaesthesist Side effects: May have sore throat after, broken incisor, aspitation pneumonia
• Explain: Recovery room procedures WIPER-QQ Indication: What operation / procedure done? Previous information? Worries? Procedure: Cubicle in room, monitored by nursing staff, reviewed by doctor if problems occur, home / back to ward when well Logistics: None
• Explain: Radio- and chemotherapy Tx: Pattern, time course, number of sessions, e.g. prostate 4x5 days, 15min each Side effects: lethargy, hair loss, diarrhoea, urinary retention, scarring, fibrosis, infections Specifics: Tattoo, adminsitration IV / linear acceleerator
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• Explain: Setting up a syringe driver WIPER-QQIndication: Clarify diagnosis, symptoms; aim to give medsProcedure: subcut line in tummy; attached to machine; beware bleepsRisks: Infection, injection site reaction, overdose (depending on drugs)
• Explain: Verifying or confirming death WIPER-QQ Check nameband Check notes for DNAR Pupillary reflexes Carotid pulse 1min Breath sounds 1min Heart sounds 1min Check for pacemaker Document everything, incl. time of death Liaise with bereavement service Inform relatives
• Explain: Metered dose inhalers / spacer devices WIPER-QQ Prior knowledge Expiry date Shake Remove cap Stand-up, exhale Tight seal, inhale, press plunger Hold breath for 10 secs Repeat after 30 secs Spacer: cleaning with water, leave out to dry Get from pharmacy with prescription → OSCE book
• Written: Clinical notes Principes Date, time, sign, name, bleep Problem list / background Today: SOAP
• Written: request forms Imaging Patient details Clinical details ⇒ clincal question Examination requested; incl side Mobility / ambulance Pregnancy / LMP Patient alerts / diabetes / allergies Pathology Patient details Clinical information, onset of symptoms, recent travel Specimen type, date+time of collection Required investigation, e.g. MC+S Antibiotic therapy
• Written: Prescription chart Hospital, GP Controlled drugs; IV meds Fluids Oxygen PRN Anticoagulation - oral, heparin Insulin
• Written: Discharge summary Patient details Diagnosis Operations / procedures Reasons for admisson and PC Clinical narrative: SOAP for admission Investigations Information for patient Advice and future plans (incl GP actions) Outstanding issues, incl investigations Medications stopped / changed; allergies Discharge medications
• Written: Fluid balance chart Indication: Post surgery, heart / liver failure, CKD, AKI Deficit (over 48 hrs) Ongoing losses Maintenance (30ml/kg/24hr, Na+ 1mmol/kg, K+ 1mmol/kg) Special situations: Post-OP Heart failure Kidney failure Stroke
• Written: Centile chart Not tested Weight, length / height, head circumference Beware boys vs girls (pre-/postpubertal), prematurity charts Drop of two centile lines is significant
• Written: Referral letter Use a mixture of SOAP / SBAR Pat will receive clinic appointment in the post
• Written: Death certificate Patient and admin details Post moretem? Coroner? Seen after death? Cause of death a - -c Significant contributions Consultant
• Prescribing: Drug history Multiple sources, e.g. patient, GP, repeat presciption list Drug, dose, frequency, route Day of the week for weekly meds (MTX, alendronate) Anything topical, OTC, eye drops, herbal Brand names of pens and devices, esp insulin Yellow book for warfarin Assess adherence Anything stopped / started recently Any allergies Document reconciliation:  stopped / changed with reasons
• Prescribing: Assess adherence Positive confirmation Check dosing boxes and signed drug charts
• Prescribing: TTAs Drug, dose, frequency, duration, TBC by GP? Controlled drugs: In words, number of tablets to dispense
• Prescribing: Dose calculations Common examples: Phenytoin Insulin IV Amoxicillin
• Prescribing: Common interactions Clarythromycin: ↑Statin, ↑warfarin Beware hidden penicillin (e.g. augmentin) and paracetamol (e.g. codydramol) Methotrexate: trimethoprim (and cotrimoxazole) Digoxin: electrolytes, e.g. loop diuretics
• Prescribing: Adverse events Causes Interactions Allergies Misidentification Wrong dose / route How to deal with them Minimize harm: immediate, short-term, long-term Apologize Implement correct care Reporting Yellow cards Incident reporting Team debreif
• Prescribing: Appraise drug charts Allergies Max doses with combination preparations Renal failure w/o reduced doses Interactions, e.g. statins / warfarin + clarithromycin Units for insulin Sign, date, name, bleep Weekly meds, e.g. methotrexate, alendronic acid
• Prescribing: Antibiotics Common scenarios CAP UTI Cellulitis Surgery H. pylori Meningitis Beware Allergies (x-reactivity cepahlosproins with penicillins 5%) Interactions, e.g. warfarin mit macrolides Pseudomembraneous colitis (c. diff) with cephalosprins, clindamycin, etc → Explain ABx
• Prescribing: Anticoagulants Heparin Unfractionated: easy to reverse, short half-life, usually IV infusion; monitor APTT, beware HIT Low molecular weight (enoxaparin, dalteparin, clexane®): VTE prophylaxis / treatment Warfarin Rapid initiation: 5mg twice, measure INR on day three Monitoring: Daily until stable; then biweekly for 1-2 weeks, then up to 3-monthly; record in yellow book Target INR 2-3: VTE, AF 2.5-3.5: Mechanical aortic valve 3-4: recurrent VTE on anti-coag's; mechanical mitral valve Too high INR Major bleeding → prothrombin concentrate Minor bleeding → IV vit K No bleeding, INR > 8 → oral vit K No bleeding, 5<INR<8 → hold warfarin No bleeding, INR < 5 → reduce warfarin Novel oral anticoagulants: dabigatran, rivaroxaban etc; don't require INR monitoring
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• Prescribing: Analgesics WHO ladder NSAIDs, paracetamol: gastric protection Weak opiods, e.g. tramadol, codeine Morphine Patches: Fentanyl, buprenorphine Doses??
• Prescribing: Cardiovascular drugs Prevention 1°: Aspirin 75 mg PO OD, statin PO ON 2°: Aspirin 75mg PO OD, Statin (e.g. simvastatin 20mg PO ON), ACE-I (e.g. lisinopril 5 mg PO OD), β-blocker (e.g. tindolol, propranolol) Single vs dual platelet: 2 weeks after Acute: TIA: Aspirin 300mg PO OD until further evaluation, then 75mg ACS: Morphine 5mg IV, metoclopramide 10mg IV, Aspirin 300mg PO, Clopidogrel 600mg PO, ± LWMH Heart Failure: O2, Frusomide 40mg IV, Nitrate 1-10 mg/hr to maintain sBP > 90mmHg, non-/invasive ventilation, inotropes Arrythmias: SVT → adenosine (6/6/12 mg); AF → rate / rhythm control (flecainide, amiodarone) Chronic: Stable angina: 1° prevention + β-blocker, nicorandil Hypertension: C+A, +D, +B Heart failure: frusomide, ACE-I (or ARB), β-blocker (e.g. carvedilol, bisoprolol); ⇒ spironolactone, digoxin, mechanical support Digoxin Monitoring: electrolytes, renal function, levels (6 hours after dose) Toxicity: low K+, digibind
• Prescribing: Inhaled / Nebulised meds Nebs driven by O2 or air: Salbutamol 5 mg Tio-/Ipratropium 0.5 mg Adrenaline Steroids, e.g. budesonide Inhaled doses much smaller Asthma / COPD treatment ladders
• Prescribing: Steroids Common doses Oral prednisolone: 30-40mg; higher for GCA Hydrocortisone: 100-200mg IV: asthma, COPD, Addison's etc Reducing doses, long-term use (gastric protection, osteoporosis etc)
• Prescribing: Insulin Variable rate infusion, e.g. after surgery Choose plan A, B, C 50 units in 50ml Sodium Chloride 0.9% under infusion; special instructions: as per variable-rate infusion sheet 5% Dextrose 50ml / hr to avoid hypos, conditional on BM<14, or according to protocol Maintenance / replacement fluids as per normal Fixed-rate regimen, e.g. in DKA: may keep long-acting insulin 0.1units / kg / hr 50 units in 50ml NaCl 0.9% at 0.1ml/kg/hr under infusions Rehydration fluids with 20mmol KCl from 2nd bag 10 Dextrose at 125ml/hr if BM<14 or falling too quickly Hyperkalaemia: 10units in 50ml 50% Dextrose over 15min; ± 10ml calcium gluconate 10% over 10-20min ± loop diuretic ± dialysis Switch back to SC Give normal short-acting dose before meal Stop infusion after meal Maintenance doses Prescribe every day based on BM's; adjust by ~10% Order BMs, and dipsticks in advance Same brands → anticoagulation
• Prescribing: IV fluids & infusions Choices NaCl 0.9% 5% Dextrose Hartmann's Volume requirement 30 ml / kg / day Electrolyte requirements beyond "1 salt, 2 sweet" Input / Output Insensible losses 500ml / da Urine output: at least 0.5 ml / kg / hr = 30ml / hr = 750ml / day Make up for deficit and projected losses Monitored on fluid-balance chart
• Prescribing: Drugs of abuse Alcohol Pabrinex (parenteral vitamins B and C) Chlordiazepoxide fixed dose regimen Opiate withdrawal / overdose Chronic: Methadone Acute withdrawal: Titrate codeine to effect Naloxone Paracetamol Treatment curve N-acetylcysteine King's college transplantation (pH<7.2, APTT > 100ms, encephelopathic, Creatinine high) Poisoning Heavy metals ⇒ desferrioxamine, mercapto-sth Insecticides ⇒ pralidoxime Tricyclic antidepressants ⇒ bicarb Aspirin / salicylate
• Prescribing: Polypharmacy Stop interacting drugs Stop drugs causing side effects, e.g. ankle swelling and amlodipine Beware maxium dose Stop preventive drugs in palliative settings Switch from oral to e.g. SC infusion Reduce doses in elderly / renal patients
• Explain: Steroids Basic info: Indication; one tablet taken in the morning, for the indefinite future; no routine monitoring Side effects: Severe: Osteoporosis (→calcium + vitamin D supplements), AVN, hypertension (→regular check-ups), gastritis/ulcers (→PPI's), diabetes (→beware polyuria-/dipsia), cataracts, infections, bruising Mild: Weight gain, acne, myopathy, mood swings, thin skin Lifestyle: Healthy diet, moderate exercise; no NSAID's; need to tell doctors / dentists; must not stop suddenly (→steroids card, Addisonian crisis) PMH, DH (→NSAIDs, allergies), FH, SH
• Explain: Insulin Basic info: Replaces physiological hormone, necessary to control sugar levels to prevent long-term effects Side effects: Hypoglycaemia (→adrenergic, →cerebral symptoms), injection site reactions (rotate around) Lifestyle: carb counting; emergency sugar source; DVLA; refer to DNS (teach SC injections)
• Explain: warfarin Basic info: tablet form, variable dose, regular INR monitoring in anticoagulation clinic (up to every 12 weeks), yellow book (INR and doses); taken for 6 weeks / 3 months / 6 months / lifelong Side effects: Bruising, liver damage, skin necrosis (rare) Life style: Diet: Minimize alcohol, onsistent, balanced diet (no vit K binges) no contact sports ask doctor before taking NSAIDs or antibiotics, let doctors / dentists know, medical alert bracelet; use contraception (teratogenic) Starting the drug: loading dose, initial blood tests (on day 3, then biweekly for 2 weeks), initially frequent monitoring for about 5 days PMH, DH (→allergies), FH, SH
• Explain: Discharge arrangements Transport Clinic appointments Home visits by nurse specialist, e.g. with stoma Social care package Ongoing PT input
• Explain: illness / management plan Aetiology Management options Prognosis Answer questions Negotiate agreement To patient / carer / family
• Professional: Teach a student a basic skill Method Assess prior knowledge Examples X-ray interpretation Blood pressure Examination
• Professional: Give feedback Constructive, timely Sandwich technique No more than 2-3 points
• Communication GP / hospital doctor on the phone distressed patient / family deaf person learning difficulties laguage barrier with / without interpreter sensitive issues, incl prognosis, risk & uncertainty Break bad news complaints/ conflicts
• Ethics: Consent Requirements for valid: voluntary informed Capacity In advance: Advance statement Advance directive Lasting Power of Attorney Court in difficult situations Can refuse, but not demand treatment
• Ethics: Confidentiality When to breach Patient consents, anonymise, within the medical team Duty: Court order, police; harm to the general public Optional: Harm to others, e.g. HIV How to share, store, transmit data Electronic systems Secure notes Good practice Check identiy of relatives / carers Check for patient's consent before disclosing information
• Ethics: Duty of care Principles To whom - GP list / region; hospital; not general public Negligence (duty of care, below standard, harm) Bolam test (+ what would a reasonable patient expect)
• Ethics: Capacity Mental capacity act DoLS Assessment of capacity Legal context of Advance Decision, Advance Statement, LPoA, Deputy of Court, IMCAs

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