Year 5 OSCE April 2018

Station 1 – ABCDE- BLS
– Pt collapsed
– Two nursing students present
– Check pulse and breathing; nil
– Ask them to flatten bed, start chest compressions, get bag and valve mask
– Nurses limited in skills; had to teach them to do chest compressions and ventilate
– place pads on chest
– Analysis showed PEA
– ADRENALINE returned them to normal pulse but still not breathing
– Insert laryngeal airway and maintain breathing
– Handover using SBAR; say still need to complete A to E exam



– Ask the most junior out of the two helpers to “call 2222, tell them it’s an adult cardiac arrest, and get the crash trolley on the way back”
– Once the nurse was back (in this simulated scenario, she came back in about 10 seconds), ask her to take over chest compressions (teach if necessary).
– Insert Guedel Airway (the orange one tends to be the right size for Keele dummies), add bag and mask, ‘connect’ to high flow oxygen 15L, and ask the second helper to give a breath every 6 seconds. Covert to I-Gel once you have a handle on everything else.
– place pads on chest (tell helper to continue with chest compressions while you do this)
Specifics in this station:
– Analysis showed PEA
– ADRENALINE returned them to normal pulse but still not breathing
– Towards the end of the station, the ‘consultant’ (examiner) approached and asks you what’s going on – handover using SBAR; say still need to complete A to E exam
– Was not penalised for using automated defib


Station 2 – Prescribing-Hypercalcaemia
– Stickers present for identity info
– Did not have to do VTE assessment and the front 2 pages of the chart
– pt hypercalcaemic with aCa>3.5
– Sx like abdo pain
– Pt had a history of multiple myeloma, and was also on allopurinol and a calcium tablet (calceous).
– Bloods done 12 hours later also showed severe hypercalcemia (the idea was that this patient had aCa>3.5 that had not responded to initial, conservative, measures).
– Therefore, had to look at guidelines for Hypercalcemia and manage accordingly;
– Write up IV pamidronate in the infusion section and initiale fluids
– eGFR (?47). Look up allopurinol in BNF; max dose in renal impairment is 100mg so can continue at renoprotective dose (although some people decided to stop it altogether).
– Stop calceous
– Said would consult senior for calcitonin as did not appear life threatening



Station 3 – Safe discharge- Depression (not suicidal)
– Young pt 17yo
– Depressed, dark clothes, looking to floor
– No feelings of high mood or psychosis
– Cut her wrists and wearing bandege under sweater
– No suicide risk; said would not do it again
– Reason for doing bcs “felt good”
– Bad relations with mum’s boyfriend and not happy at school
– No abuse
– Pet snake
– Refer to cams; would not initiate SSRI for child in GP; try councelling, CBT, etc
– Not suicidal so do not admit



Station 4 – Interpretation/SBAR- Ureteric sepsis
– Given sheets of PC, exam results Ix rsults
– Traveller with sudden onset loin and groin pain, features of fever and infection
– Interpret and give results to Reg (the examiner) using SBAR
– Stop nephrotoxic drugs



Station 5 – Councelling- Subclinical hypothyroidism
– Elevated TSH but normal T4
– Had already had tests to rule out associated conditions (negative coeliac screen, negative pernicious anaemia screen, normal HBA1c)
– No personal hx of thyroid
– Sister has hypothyroid
– Explain why not start on thyroxine like sister; she is not deficient in T4
– Completely asymptomatic
– Would do bloods in 1-3 months to check if she had low t4 then, and could start it then



Station 6 – Exam- SOB
– Patient presenting in a GP setting with SOB
– Meant to do full respiratory exam (my patient had fine inspiratory crackles throughout)
– Interpret spirometry and give ddx
-Results given included a flow-volume loop (which I had no idea how to interpret), but also spirometry results which were classic restrictive pattern; so most likely Pulmonary Fibrosis
– Most likely cause is idiopathic, can be coal



Station 7 – Hx- TIA
– Unilateral sudden onset painless vision loss while on holiday
– Patient gave absolute classic textbook history of amaurosis fugax (even including some sparing of peripheral vision)
– Lasted hours then resolved
– No weakness or paraesthesia
– No pain, headache or eye redness
– Ex smoker, poor diet, no excersise
– No PMHx
– Refer for specialist review within 24hr and carotid dopper within 3 wk per ABCD2 score
– DVLA; Tell pt not to drive



Station 8 – ABCDE- Biliary Sepsis
– ? Pancreatitis cause it was after ercp ? Ascending cholangitis
– Amylase
– Sepsis 6
– Stop nephrotoxic drugs
– Erect CXR ?perforation



Station 9 – Councelling- Hyponatreamia
– Pt on Sertraline for anxiety and Ramipril for HTN
– Initially some people jumped to Rampril for being the cause (but she had been on it for 3 years with no problems, and K+ was in normal range)
– SSRIs can cause isolated hyponatremia
– Stop sertraline (patient said it wasn’t helping anyways). I advised to stop gradually and titrate down, but she was on the minimum dose of sertraline (?50mg) anyway, so some people just stopped it.
– Start CBT (the patient was worried she would have to wait a long time for referral, could say you would try calling up and explaining she needed it fast-track because SSRIs were contraindicated in her).



Station 10 – Prescribing & Consent- Blood transfusion
– Annoying SP
– Explained x3 that there is a choice she could opt for IV iron and or epo injections
– Kept on saying “if i had no choice” implying i was forcing her
– Blood transfusion guidelines present
– Managed to prescribe 1 united packed rbc over 3 hrs said would reassess and prescribe more
– Apparently ppl saying 2 sets of stickers put on purpose; some with right pt details some wrong; had to check with pt; EVIL



Station 11 – Teaching- Occular cranial nerve
– Different SP’s with different clinical signs
– Mine had an enlarged scotoma in L eye
– Acquity 6/6
– Retina had black patches ? Retinitis Pigmentosa
– Whole point of station is to show you know how to do it and demonstrate to student
– Those that did offer opthalmoscope to SP (student) found the student declined it



Station 12 – Challenging Hx- (Angry pt )Stress Incontience and Malignancy
– Urinary stress incontince- pelvic floor msk excersise, medications (OXYBUT)
– SP very combative when suggested sinister aetiology to cough
– had weight loss and smoke 15 for 40days
– 2 week + CXR



Station 13 – Exam- Knee
– OA
– Different pts with different signs
– Mine had varus deformity
– Limitied extension and flexion
– Pain on flexion and extension
– Interpret XRAY
– Rx- Conservative, Medical, Surgical



Station 14 – Ethics- Confidentiality
– GP setting
-Case stem said that one of your patients, an 85-year old woman, had a blood test recently showing iron-def anaemia, and you had referred her under the 2-week rule for GI investigations.
– Her daughter has come in today to ask about her condition. She knew that her mother had iron-def anaemia and had been referred.
– Meant to reply firmly but sympathetically you could not discuss pt case with relative without consent
-Was surprisingly tricky! At one point, the daughter showed me the list of causes of iron-def anaemia (printed from the NHS website no less!) and had worked out that because her mother had a good diet, was post-menopausal, did not give blood, no other medical conditions etc, the only remaining possibility in that list was cancer.
– Some people suggested to her that she speak with her mother, and if she was happy, accompany her to her next consultation so we could discuss the results together.