Year 4 OSCE Station Notes

Page
CHDA
Explain Alzheimers Disease 3
Explain Breastfeeding 6
Dermatology History and Examination 10
Discharge Plan and Assessment 14
Down's Syndrome 17
Explain Febrile Convulsions 20
Explain Immunisations 23
Neonatal Jaundice 26
Explain MMR 29
Paediatric Abdominal Examination 31
Paediatric History 35
Explain Paediatric UTI 40
Palliative Care History 42
Suicide Assessment 44
Sun and Sunscreen Advice 47

EMTL
Advanced Life Support (ALS) 50
Cannulation 52
Explain Epidural 55
Foot Examination 57
GALS 59
Hand Examination 63
Hip Examination 66
Knee Examination 68
Moulage – AAA 71
Moulage – Breathlessness 73
Moulage - Unconsciousness 77
Explain PCA 78
Explain Post-herpatic Neuralgia 82
Pre-op Assessment 84
Explain Spinal Anaesthesia 87
Spine Examination 89
Suturing 92
Explain Trigeminal Neuralgia 94

RSH
Breast History and Examination 98
Explain Condoms 100
Explain Depo Contraception 102
Explain Ectopic Pregnancy 105
Female Catheterisation 109
GUM History 111
Gynaecological Examination 113
Gynaecological History 116
HIV Risk Assessment 119
Explain Implanon 121
Explain IUCD/MIRENA 123
Obstetrics Examination 128
Obstetrics History 130
Threatened Miscarriage 133
Termination of Pregnancy 136

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Child Health, Development and
Ageing (CHDA)

Page 2
 EXPLAIN ALZHEIMER'S DISEASE GERIATRICS
PSYCH
The aim of this station is to show rapport and good communication skills with the relative of a patient with AD. You
must explain AD in a comprehensible way, including the type of disease it is, it's aetiology, clinical features,
investigations, management and prognosis. Do not necessarily explain all of this, but be guided by what the patient
wants and the time you have available.

-Introduce yourself to the relative: ask their name and age and relationship to the patient
-Rapport: thank the relative for coming
-Start with an open question e.g. 'how can I help you'?

ICE
-Ask the person what ideas they have had about their relative's problems
-Ask them if they have any concerns/worries
-Expectations: what were they hoping for today with this appointment?

Summarise
-your uncle has had memory problems for ........ (time period) and he was seen in a special clinic
-he did have memory problems and we did tests to uncover a cause for these problems
-I have all the results

Break Bad News

-Say you've got the test results
-Say that the results were not as good as you had hoped: leave pause to let patient prepare themselves
-Say that the results show that the relative probably has Alzheimer's disease: let the patient take it all in
-Say that today we should talk today about what that will mean for the future
-Empathy: This must be very difficult for you; anyone in your situation would feel upset etc (if she cries=would you like
a tissue or water etc)

Explanation
-Ask if they know anything about Alzheimer's Disease already (how much do you know about AD already?)
-Explain difference between AD and dementia i.e. AD is the commonest dementia but there are other types of dementia
(vascular=dementia from blood vessel disease, Lewy body=Parkinson's dementia); in total more than 100 types
-Give statistic (almost half a million in UK have AD) and say happens mostly in old age
-Dementias are conditions in which a person's memory (and other brain functions) change; may see changes in their
recalling old information and learning new information
-The patient loses their brain cells faster than in ageing; memory parts of the brain are affected first
-They may remember things from years ago better then new things; they will thus start losing things around the house
and may repeat questions again and again
-Later on as other brain areas are affected there can be effects on speech (problems finding the right words) and
performing tasks like preparing meals/getting washed and dressed
-You may notice changes in their language, planning, attention, recognising objects, carrying out movements, judgement,
decision-making, orientation, (behaviour and personality usually later on); they may become confused and withdrawn
-starts gradually but goes on continually: the patient will keep on decreasing in their function; they won't improve,
there is no cure
-I know this is a lot to take in: offer the patient a followup appointment o discuss things again

Epidemiology
-almost half a million people in the UK have AD

Aetiology
-brain cells die due to 'tangles' in the brain/changes in the structure of the brain
-also there is a shortage of some chemicals in the brain needed for passing around messages inside the brain by which
we understand things
-that is the disease process but we don't know what triggers it; its believed to be more than 1 thing e.g. age, genetics
(very few cases of AD are clearly inherited;in most cases if you have a relative with it the risk is only slightly higher),
unknown environmental factors, head injuries/boxing/whiplash injury, smoking, high BP and high cholesterol

All Due To Age?

-as people get older they do suffer decline in their capability of learning new things
-however this tends to be mild; in your uncle it is more severe and this indicates that he has a medical condition
causing his symptoms, not old age

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Violence
-at some point in AD, patients can display violent outbursts; this tends to be verbal rather than physical and up to 65%
of AD patients will show aggressiveness
-this tends to happen in late disease
-it is more likely if the person had a history of aggression earlier in life or if they do not have a good relationship with
their carer
-they may have mood swings due to being sad or angry; they can be scared or frustrated about memory problems

The Investigations
-your uncle was interviewed and we found out all about how his symptoms developed
-we ruled out mood problems as the cause of his memory problems (depression can cause it)
-we examined him physically; there was no illness that could account for his memory problems
-we did blood tests and with these ruled out causes like vitamin deficiency and thyroid gland problems which can affect
memory
-a psychologist also spoke to him and did tests of memory and brain function
-a CT scan of the head was done; this uses X-rays and it showed that the tissues of the brain have shrunk, which
happens in dementia; but there was nothing else like tumours growing or strokes to account for his memory loss

Why 'Probably' AD
-there is no one definite test
-done by ruling out other things e.g. thyroidism, vitamin deficiency, infection, brain tumours, drug side-effects and
depression

Management: there are many things that can be done to help the patient to live as independently as possible for as
long as possible
-multidisciplinary
-will need a carer: can be a relative
-aim is to treat the patient and support the carer
-will need social services to operate the care plan (I have referred your uncle to SS); they will organise a community
care assessment and then they either provide help directly or through other agencies
-a community nurse can visit home and can be contacted for advice (the GP and SS together arrange this); works with
social services to make sure all benefits are received; has a lot of experience of working with AD patients
-a home carer can visit and help with personal care like washing and dressing
-encourage physical, mental and social activities e.g attend day centre or luncheon club; interventions for coping=lists,
alarms, calendars
-safe environment in patient's home in most cases: use a predictable routine and bring in occupational therapy to do a
home assessment for hazards and safety advice/improvement: falls, wandering, self-neglect, fire risk, driving,
(aggression), (financial issues)
-carer support: support groups, respite care (in care homes/residential homes: for days to 2 weeks), sitting services,
family support visitor
-if ultimately the carer feels that caring at home is no longer possible then social services can arrange for permanent
care in a residential or nursing home
-medical: drugs in early and middle stage illness (can slow worsening of memory for awhile but cannot prevent it; the
main drugs available keep a chemical level in the brain stable for awhile=acetylcholine; Side effects=diarrhoea, nausea,
insomnia, fatigue, loss of appetite; 1 newer drug can be used later in the disease and can prevent damage to the brain
cells; side-effects=confusion, dizziness, headaches, hallucinations and tiredness); modify reversible factors: constipation,
sepsis (infections), anaemia, side-effects of drugs and take off unnecessary meds; depression treatment
-OPD follow-ups e.g. in memory clinic
-Alzheimer's disease society: make books and leaflets and have a good website: www.alzheimers.org.uk
-the carer/relatives can join a relatives support group
Issue of disclosure of diagnosis
-in most cases it is better to let the patient know they have the condition so they can plan their future

Prognosis
-some live with it for 5 years, some for 20 years: it's quite variable
-most studies have shown patients live for 5-6 years after diagnosis
-predictions can't be made in individual cases; your uncle's AD is mild right now and he is in good medical health for a
person his age

-Say to the patient you know that they may not have taken in everything and that's fine; I think it will be a good idea
if you came back again for another appointment and we talk about it again and with the patient present next time

-give a summary and

-assess patient's understanding
-ask the patient if they have any questions and encourage it; answer them

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-offer leaflet and mention Alzheimer's Disease Society as a source of info; the community mental health nurse may also
be able to help in the meantime if you speak to her
-thank patient for coming today

You are a GP. Ms Reynolds has come to your clinic to speak to you about her uncle's reasons for memory loss.
Following assessment in the memory clinic such as blood tests, CT scan and neuropsychology, an investigation results
report was produced. You now have the result of her uncle's Ix. The report is on your seat: read it first.

REPORT: Mr Henry appears to have Alzhemier's disease

ALZHEIMER'S DISEASE
Introduction
Consent
Rapport
Determine what the patient knows
Determine what the patient would like to know
Determine if the patient is worried about anything
Break bad news appropriately: warn beforehand
Explain probable AD
Know difference between dementia and Alzheimer's
>100 dementias; ruled these out with tests
Epidemiology
Aetiology
Clinical features
Progressive
Not inevitably due to age
Offer realistic hope
Prognosis
Arrange follow-up
Says referral to SS's
AD's society
Multidisciplinary management, needs a carer
Sensitivity
Empathy
Eye contact
Rapport
Information in small chunks
Repeat and clarified
Checks patient understands regularly
Patient is given time to respond
Explore emotions and concerns about Alzheimer's Disease
Honesty
Unhurried
Avoids medical jargon

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 BREASTFEEDING
Breast Is Best
-the best nutrition for babies
-provides all nutrients a baby needs
-recommended to exclusively breastfeed for 6 months; the baby needs no other food or drink, not even water (they get
a drink from the breastmilk)
-thus 6 months is the recommended age for weaning onto solids (from 6 months onwards you need more than just
breastmilk); can carry onto 1 year since it is beneficial

Advantages of Breastfeeding
-perfect combination of all nutrients: cannot be duplicated by bottle feeds (may still need some vitamin K separately
though)
-no preparation time
-PPH (post0partum haemorrhage) less as breastfeeding causes womb contraction
-free (thus cheaper) and gives babies attractive smell
-helps mum lose weight and gives some contraception (but not reliable)
-protects against breast cancer
-increases emotional input from mum from mutual gaze, increases bonding
-less likelihood of hypertension, obesity and insulin resistance
-less risk of diabetes, RA, IBD and food allergies
-less risk of atopic eczema
-lower risk of infant death (sudden cot death)
-less ear infections, lung infections, coughs and colds, constipation and diarrhoea
-strengthens immune system by transfer of mum's defences; friendly bacteria grow in gut so less gut infections
-may help intellectual development
-cannot give too much

Disadvantages
-there are none
-any worries have a solution (see below)

Learning Breastfeeding
-it is better to be taught breastfeeding then to rely solely on leaflets and encouragement
-ideally the teaching should happen antenatally

Best Time To Begin Breastfeeding

-just after birth as it decreases risk of PPH and
-promotes bonding
-but it's never too late to start, as long as milk is still being made

The Technique
-it does not necessarily come naturally
-it's like learning to drive: difficult and anxiety provoking at first but if you stick at it, it becomes easy
-sit upright while learning it and make sure you are comfortable; relax as this helps the let-down reflex (milk comes
behind nipple); can keep baby on pillow in lap
-inadequate feeds at the beginning don't matter: you don't need to switch to bottle since babies have a lot of fuel
reserve
-top up bottle feeds can reduce benefits of breastfeeding (by effects on the GI tract) and can reduce confidence in it
-you could try teasing the baby by touching it's lip to the nipple and then away to induce a big gape
-with 1 movement bring to the breast, chin should touch first and the baby should get a mouthful of the nipple AND
breast, not nipple alone
-avoid forcing the nipple into the mouth; do not put your hand over the occiput and press forwards; try to cradle the
head in the crook of the arm
-indications of correct attachment: mouth wide open with chin touching breast (nose should be barely touching), baby
should take in breast and not just nipple, lower lip curled back, sucking and slow deep jaw movements, 1st few sucks
may just induce the 'let-down reflex'=milk comes down; the baby's shoulder and head should face the breast and mum
should hold her breast with her fingers flat on her chest (not in a scissors grip which impedes milk form flowing to the
baby)
-in the beginning the milk will be colostrum, a creamy/yellow substance; this will always remain but proper milk will
start appearing after about 3 days postpartum
-check for plenty of wet nappies

Summary Of Method

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-get comfortable; sit so that your back is straight and your lap is flat; you can use a pillow to support your baby
-turn your baby's body towards your tummy; tuck your baby's bottom under your elbow, or support your baby by
using a pillow; hold your baby behind the neck and shoulders
-start with your baby's nose opposite your nipple
-allow your baby's head to tilt back; move your baby's mouth gently across your nipple until your baby's mouth opens
really wide
-bring your baby towards your breast quickly; your baby's bottom lip and chin should touch your breast first
-your baby's chin is in close contact with your breast; your baby is able to breathe easily; you can feel your baby has
a big mouthful of breast; you may need to support your breast
-babies love to breastfeed, but they usually come off by themselves when they have had enough; you will know when
breastfeeding is right; it will feel comfortable; your baby will be relaxed; you will hear a soft swallowing; if it does not
feel right then start again; slide 1 finger into the baby's mouth, gently break the suction and try again
-its OK to ask for help

Expressing Breastmilk Is Useful For

-relieving breast engorgement between feeds
-if the nipples need a rest due to soreness (a common problem): it can keep production of milk going
-to help nutrition if sucking is reduced for any reason e.g. premature, cleft lip
-if mum will be separated from the baby for a few feeds e.g. at work
Best Way To Learn Expressing Breastmilk
-from a midwife or another mother that does it
It can be done with special pumps bought from a chemist or by hand
-wash hands and dry on clean towel then start flow by
-roll the nipple briefly; this can induce the let-down reflex, more-so if the baby is nearby
-stroke breast towards the nipple gently
-using circular movements massage the breast gently with the 3 middle fingers
-applying warm flannels or expressing in the bath can help flow, for instance when first learning and only a few drops
are coming
-the above is just the method of starting the flow
The Expression Itself
-thumb above nipple area and index finger below
-whole hand pressing breast back on chest wall
-exert gentle pressure on the ampullae (15 knotty things under the areola, palpable as knotty once the milk comes in)
-with rhythmic pressure and release, milk should flow
-the container should be sterile
-don't let your fingers slip down to the nipple as this can damage the narrowing ducts
-practice and concentrate on catching the sometimes oddly angled jets
Storage
-lasts up to 48 hours maximum in the fridge
-lasts up to 3 months if frozen; you need to learn the method of thawing it safely:
-stand in a jug of warm water
-if unfrozen milk is not used it should be thrown away after 24 hours and not refrozen
-putting it in the fridge is better then freezing and thawing it; this is because antioxidant levels of the milk fall if it is
stored but whether or not this matters is unknown

Feed on Demand
-enhances milk production and keeps baby happy
-less problems of the breast e.g. engorgement, abscesses
-the baby should feed a minimum of 6 times a day once feeding is established
-your milk production will change according to the baby's demands e.g. when it has growth spurts
-if you remove the baby before it has itself finished and disengaged, it may cry more often and demand more feeds,
which will tire you
Feeding By Routine
-is also possible but need to make a plan and can promote a diurnal sleep cycle
Sleeping With Baby
-may disturb sleep less but the risk of inadvertent smothering will be there
CIs
-HIV in mum (only so in rich countries: in poorer countries there may be no way of feeding other than breast)
-Amiodarone
-Antimetabolites
-Antithyroid meds
-Opiates
-triplets and higher order children may not be entirely sustainable by breastfeeding alone (twins can be)
-preterm babies can't suck (but should be given expressed milk until they can)
-you can breastfeed with Hep C

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Complications ('Problems That Can Arise')
-breast engorgement (solution is to breastfeed)
-breast abscess (infection)
-treated by using breast more effectively in terms of technique, keeping breasts empty with hourly feeds or expression
-for abscess give antibiotic (flucloxacillin=safe for baby); sometimes surgery needed
-discomfort of engorgement can be reduced with nursing bras (but not too tight)
-breast pads can help with leakage

Worries About Breastfeeding

-urban unfriendly environment, unfriendly work environment: even if you have to return to work breastfeeding for a
short interval can help; you could express milk; if embarrassed you can put the baby under a loose top, T Shirt or half-
unbuttoned blouse
-breasts seen only as sexual object, no non-sexual role models: more and more public places now cater for
breastfeeding
-commitment: 24/7 for months which noone can help her with (but expressed milk allows others to feed)
-family pressures
-hostility of partner (70% breastfeed if he approves vs 10% if he does not): partner can still be involved by cuddling
baby and giving expressed milk in a bottle

Help
-speak to your midwife, health visitor or breastfeeding specialist/support group: don't give up since apparently big
problems may have a very simple solution; also talk to your partner
-The Pregnancy Book and The Birth To Five Book both have very good information on breastfeeding
-There is also a 24 hour helpline of the La Leche League, an organisation set up to help women who are breastfeeding:
0845 120 2918; they also have a website www.laleche.org.uk ; they aim to give mum to mum support, the people who
answer the helpline are breastfeeding mums; there are numbers of other organisations in The Pregnancy Book
-it's your choice but if you decide not to breastfeed, you may not be able to switch from bottle back to breast

You can make as much as 1 litre of milk a day and even more, depending on demand from the baby.
Vitamin K should be given even if babies breastfeed; no other supplementation needed.
Contraception: POP and IUD safe with breastfeeding (IUD put in at 6 weeks)

You are in General Practice. Ms Gladstone is a 22 year old new mum. She is struggling to establish breastfeeding and
wants more information.

BREASTFEEDING
Introduction
Consent
Name and age of parent and child
ICE
Breast is best
Recommended to exclusively breastfeed for 6 months; no supplementation needed
Wean to solids at 6 months for adequate nutrition; can carry breastfeeding onto 1 year
Advantages: all nutrients, no preparation time, less PPH, free, lose weight, contraception, nice smell, less breast
cancer, bonding, less hypertension/obesity/insulin resistance, less diabetes/RA/IBD, fewer allergies/atopic
eczema, less cot death, less ear/lung infections/coughs and colds, constipation and diarrhoea, less gut
infections, strengthens immune system, helps intellectual development
No disadvantages (all concerns have a solution):
Urban environment/work: can express milk; in public put under top/loose blouse/T shirt, more and more public
places now designated for breastfeeding, partner hostility can be dealt with by letting him give feeds via
expressed milk and this can also take the pressure of commitment off mum
Feed on demand: keeps milk flowing and baby happy; baby will detach by itself also
Minimum 6 times a day once established; will change with growth spurts e.g. could be 12 times day
Duration of feeds will also vary: could be minutes, could be an hour; your body will adapt it's milk production
to the baby's needs, both in terms of amount of milk and composition
Feeding by routine is also possible but seek advice from midwife on that
Breast engorgement: solution is to breastfeed more frequently and with better technique
Rarely breast abscess: antibiotics
Nursing bras can help engorgement
Nursing pads for leaks (but avoid plastic)
Very few women can't breastfeed: HIV, amiodarone, opiates, antithyroids, triplets
Learning: best to be taught, not just learn from leaflets/books

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Best to begin just after birth: bonding and less PPH; but never too late as long as milk still made
Method: sit upright, back straight, pillow and baby in lap, relax, nose opposite nipple, head tilts back, tease,
bottom lip and chin first, nose mostly free, mouthful of nipple and breast, may need to support breast, will
hear swallowing, if not right slide in finger and try again
Plenty of wet nappies will encourage you its going well
Expression: work, for engorgement, rest from soreness, premature; by hand or pump
Storage: 48 hrs fridge, 3 months frozen; learn to thaw from midwife
Help: it's OK to ask; speak to midwife/health visitor/breastfeeding specialist, partner also
The Pregnancy Book and The Birth to Five Book
Many organisations e.g. La Leche League (all listed in The Pregnancy Book)

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 DERMATOLOGY HISTORY-TAKING
-Introduction
-Consent: say you will ask questions to find out about the skin problem and ask permission for it
-Age of patient
-Occupation

Presenting Complaint

Open question
-let the patient tell the complaint in their own words without interruption
-if the patient uses a technical term like blister, ask them to describe it (don't assume it is what they say it is)

History of the Presenting Complaint

-Duration of rash/when did it start?

-Where did it start and how did it start?
-Onset: sudden or gradual
-How has it changed since? (What did the lesions look like in the beginning and did they change or are they the same?)
-Spread and distribution?
-Is it always there?
-Trigger factor originally? (e.g. new med started or fever in 2 weeks prior to rash?)
-Exacerbating factors e.g. heat, sunlight, soap, trauma (like scratching)
-Relieving factors
-Is it getting worse or staying the same?
-Past episodes
-Associated symptoms: pain, itch, bleeding, joint pain, weight loss, appetite, fever
-Treatments tried so far=systemic e.g. tablets; topical e.g. creams and ointments; medical vs cosmetic; conventional vs
alternative medicine
-Effect of rash on life: occupation, social life, mood, sleep (good way of judging the severity of itching or pain), self-
confidence, personal relationships (could ask what does it stop you from doing or how is it affecting your life?)
-ICE: must find out worries/concerns of the patient

Sun History

-What is the patient's skin type?

-Do they tan or burn? Does it happen easily? How many times has it happened?
-Sunbed use
-Do they use sun protection?

Past Medical and Surgical History

-previous skin problems and skin cancer

-atopy (hay fever, asthma, eczema)
-medical illness-past and present (TB, diabetes, arthritis, ever had a HIV test)
-surgery and any post-op complications

Drug History and Allergies

-Allergies and drug reactions

-Prescribed and OTC (pills, creams, ointments, moisturisers), oral pill
-Alternative meds
-Recreational

Family History

-Any similar problems in family?

-Atopy: eczema, hayfever, asthma
-Any skin problems in the family? (psoriasis, eczema)
-Any skin cancer in the family?
-Any significant medical illnesses in the family: parents, siblings, children (1 st degree relatives) e.g. hayfever, asthma
-Sexual contacts if relevant
-Do any partners or friends have the same condition?

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Social History

-Job-occupational materials/chemical exposure, other affected colleagues; does your skin get better during holidays?
-Hobbies
-Home situation
-Alcohol: if relevant
-Smoking: if relevant
-Travel: particularly to tropics, or lived overseas?
-Pets: if relevant

Systems Review

-If relevant: are they fit and well otherwise?

End

-Anything patient wants to add

-Any questions
-Thank
-Summarise and give DD
-Say you would do a dermatological examination (with proper light e.g. Wood's light)

DERMATOLOGY EXAMINATION
-Introduction
-Consent: say you will examine his skin to determine what the problem might be and ask permission for it
-Age of patient
-Wash hands
-Position: can get the patient to stand or sit depending on where the lesions are
-Exposure: to the undergarments
-Ask the patient if they are comfortable and to report any pain they might have
-Comment on adequate lighting-make sure there is enough of it
-Have a torch and measuring tape with you

Inspection of lesions
-site of rash and distribution e.g. knees, elbows, scalp, lower back (psoriasis); face and upper trunk (acne); flexures
(eczema in kids); head and neck (BCCs); localised vs generalized, symmetrical vs asymmetrical; comment on areas
spared
-type of lesion: use the technical dermatology terminology here to describe it and also use relevant secondary terms for
the state of the lesion such as excoriation, scaling, crusting, lichenification, erosion, ulceration, scarring etc
-size: best to actually measure
-shape: can be round, oval, annular, linear or irregular; straight edge and angles indicate external factors
-border and outline: smooth outline (benign); rough outline (malignant); blurred border (eczema); well-defined border
(psoriasis)
-colour: red, purple, brown, slate-black etc
-make it obvious that you are looking at every body part and comment on overall spatial relationship between the
lesions if appropriate e.g. symmetrical extensor distribution

Palpation of lesions
-ask patient if it's OK for you to do it and ask about pain
-surface features: palpable vs impalpable (close your eyes to feel if necessary), elevation, try to make blanch with
pressure, smooth vs rough, assess depth or position in or beneath the skin (firmly palpable=dermis), consistency, lift
scale/crust to see underneath

Systematic examination to complete assessment of any missed primary lesions or secondary features
-nails: finger and toe (psoriasis) (if nails look abnormal, say there is nail 'dystrophy'=can't go wrong)
-fingers and wrists (scabies)
-toe-webs (fungal infection)
-mouth (lichen planus) and lips
-hair and scalp (easy to forget to comment on the hair)
-ears and behind ears
-trunk and limbs
-axillae
-(lymphadenopathy if relevant)

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-(pedal pulses if relevant)
-complete mucous membranes if relevant=nasal passages, mouth, urethra, vagina

-Thank the patient and help the patient redress if appropriate

-Summarise and analyse/interpret findings, giving a differential diagnosis

Conditions likely to come up:

-eczema
-psoriasis
-contact dermatitis
-acne vulgaris
-erythema nodosum
-Bowen's disease
-malignant melanoma
-basal cell carcinoma
-squamous cell carcinoma

Useful tip: a good way of doing a systematic exam is to start at the hands (including nails), then do the arms, then the
head and neck (including scalp, ears, face, lips and mouth), then the trunk (including the armpits) and finally the legs
and feet (including nails)

Mr Thomson has a skin rash. Perform a history and examination of his problem.

DERMATOLOGY HISTORY AND EXAMINATION

Introduction
Consent
Brief History
Age
Open question
Duration
Site of origin and current site
Onset
Distribution
Progression (how changed, getting worse etc)
Intermittent/constant
Trigger factors and exacerbating factors
Relieving factors
Pain, itch, bleeding
Fever, weight loss, joints
Previous history
Treatments tried
Effects of rash on life
Past medial and surgical history
Sun history: previous sun exposure, burning/tanning in sun
Medication and allergies
Family history
Occupation
Travel and social
Examination
Wash hands and correct exposure
Courteous/gentle with patient
Describes site and distribution
Describe skin condition type and secondary features
Describes size and shape
Describes border/outline and colour
Describes palpable features (consistency, blanching etc)
Nails, hands and wrists
Arms, legs and feet
Head, neck and lymphadenopathy
Scalp, hair and ears

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Mucous membranes
Trunk and axilla
Analyse/interpret signs and check and summarise

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 DISCHARGE PLAN AND ASSESSMENT
-Introduce yourself-give your name and get the patients
-Consent: say you will ask questions to find out about his admission and ask permission for it
-Age of patient
-Occupation

Starting off
-Ask the patient why they were admitted; if you know already then summarise the state of affairs for them
-Ask about progress-what effect has the disorder and admission had on them?
-Find out about their condition and whether they understand it

Assessment
-Tell the patient you are considering discharging them to go home
-Ask about any worries the patient may have about going home; address these worries: ICE
-If there is a worry about transport, tell the patient that can be organised for them from within hospital
-Find out the patient's situation at home and support they have there:
-Home: type of accommodation, who do they live with, any stairs to climb, which floor is the bathroom on?
-Support: family and friends, how often do they come?
-Barthel's scale (10 things) : transfer, toilet use, bowels, bladder, bathing, grooming, dressing, stairs, feeding, mobility

Post-discharge needs
-Any additional help the patient needs? Like meals on wheels, home help (bathing, shopping, cleaning), social services,
health visitors, specialist nurse, district nurse, occupational therapist, physiotherapist, dietician, SALT, continence advisor,
psychologist, palliative care team, day centre, self-help group
-Any housing needs? Like living on the ground floor, single level, adaptations
-Any risk factors? Like lifestyle aspects e.g. Exercise, healthy balanced diet, smoking cessation, or prevention of falls
measures
-Medication-talk about it with the patient and think about compliance; make sure the patient does not have any worries
about medication, ask them what they will be taking and offer written information to them about it if necessary, offer a
Dossett box from the Pharmacy to reassure them if they are worried about the meds
-Follow-up: suggest they come to outpatients or their GP depending on which is more relevant

Summarise
-Give the patient a summary of what you discussed
-Check that they understood it
-Ask if the patient has any questions or worries
-Thank them

Stroke Discharge Issues

-return to the community is best coordinated by the stroke multidisciplinary team
-early discharge may be useful if the patient can transfer and there is a specialist community stroke team available
-later discharges are planned by the team, usually after careful assessment of needs (home alterations, care packages
etc)
-the GP should be alerted to continue medical monitoring, in particular optimising secondary prevention
-community teams (district nurses, community rehab teams, home carers etc) should be aware of the patient's needs
(continence, diabetic monitoring, ongoing therapy needs etc) and ideally be involved in the discharge planning
-the patient and family should have adequate information and training, as well as a contact point in case of problems
(stroke coordinators often take this role)
-voluntary agencies are often helpful and the patient should be alerted to them e.g. www.stroke.org.uk=The Stroke
Association
-make sure the patient is aware of driving restrictions before they are discharged

Protecting Your Patient From Another Stroke

-make sure you address:
-smoking, diet and exercise
-anti-platelet therapy: aspirin
-antihypertensive: ACE inhibitors and thiazide diuretics
-anti-cholesterol: statins
-anticoagulation for AF: warfarin (safe to start too weeks after infarction; with haemorrhage have to wait several months
for haemorrhagic transformation; with primary haemorrhage it may never be safe to give warfarin)
-carotid endarterectomy: >70% stenosis with symptoms is an indication (since stroke risk is 15% per year); better to do
early for higher benefit; patient must have good recovery and be fit for surgery; is done with just LA

Page 14
If The Patient Has Had A Stroke: Check-list For Follow-up (usually 2-4 months post-discharge)
-secondary prevention: check drugs, BP, diabetic control and cardiac rhythm
-continence: are there continence problems? If a catheter is in situ, has mobility improved to a point at which trial
removal can be done? If the patient was discharged on bladder stabilising drugs, and has remained continent, can these
be tailed off?
-nutrition: is it adequate? If not refer to dietician. If a PEG tube is in place, is it still required? Does the patient warrant
another assessment of swallowing (by SALT) to allow oral nutrition to begin?
-communication and speech: are there still problems? Is there a need for a speech and language therapy review?
-mood: is the patient depressed? Do they need referral to a psychologist or (psychiatrist)? If discharged on an
antidepressant, can it be discontinued?
-physical progress: is there ongoing physical therapy? If not is there continued improvement? If there has been
deterioration then refer back for assessment for further therapy (RCP guidelines)
-contractures: are there any contractures developing? If so refer to physiotherapy
-muscle spasms: have these developed, or lessened since discharge? Review need for anti-spasmodic medication: titrate
down if no longer required
-pain: commonly in shoulder or post-stroke pain; has this developed or lessened? Review need for medications
-daily living: are there any issues in managing day-to-day?Is all the necessary equipment in place? (and is it still needed
e.g. a commode can be returned when the patient is able to mobilise to the toilet alone). Is there anything they would
like to be able to do that they cannot? (e.g. read a book, take a bath). Would a further review by a therapist be
helpful? Do they wish to drive? (see below).
-support: are they contact with a community stroke coordinator (if available)? Are they aware of voluntary
organisations?
-driving and stroke: TIA with full neurological recovery=1 month off driving; recurrent TIAs=3 months off driving
following last TIA; stroke with residual neuro deficit after a month=patient must notify DVLA and it is decided on a case-
by-case basis; stroke with seizure=treated as provoked seizure and may be less than 1 year ban depending on
circumstances

Mr Caplan is a 77 year old widower. He came to hospital 2 moths ago with right hemiplegia. He was managed in a
stroke unit and given rehab. You are the ward SHO and are asked by your SpR to talk to Mr Caplan about discharge.

DISCHARGE ASSESSMENT
Introduction
Consent
Age and occupation
Reason for admission
Summarises the situation for patient
ICE
Explores effect of admission and illness
Explore mood and current feelings
Explains consideration of discharge
Asks how patient feels about that: any concerns about being at home?
Informs that transport available
Home situation and support
Who patient lives with
Type of accommodation
Stairs and lifts
Bathroom accessibility for bathing and relieving oneself : is it upstairs?
Changes in housing/adaptations needed
Visitors and how often they come
ADLs Barthel: transfer, toilet use, bowels, bladder, bathing, grooming, dressing, stairs, feeding, mobility
4 marks
Shopping, meals on wheels (nutrition)
Social services, health visitors, specialist nurse, district nurse, occupational therapist, physiotherapist, dietician,
SALT, continence advisor, psychologist, palliative care team, day centre, self-help group

Medication and patient's concerns

Compliance and Dossett box from Pharmacy
Statins, anti-hypertensives, anti-clotting drugs, diabetic drugs, cholesterol
Risk-factors: need to avoid smoking, eat well, do physical activity
Family contacts
Muscle contractures and spasms
Follow-up: GP will be informed and OPD appointment

Page 15
Community (stroke) team will be informed
Offer contact number of coordinator
Offer leaflet and voluntary organisations e.g. stroke.org.uk
Driving restrictions
Will the patient have any problems at home they want addressed?
Summary
Checks patient's understanding
Any questions from patient addressed

Page 16
 DOWN'S SYNDROME
Definition: Down's syndrome is a common genetic condition in which there are effects on mental function and
appearance. It is incurable.

Alternative Names: trisomy 21, mongolism

Aetiology and Epidemiology: It happens in 1 in 650 live births (without antenatal screening). It is caused by having an
extra chromosome 21. Mostly (in 94%) it is due to non-disjunction=meiosis error: one gamete (the sperm usually) has
two chromosome 21's while the other has one, so the zygote after fertilization has three; in a non-Down's person there
are 2 chromosome 21's but the Down's patient has 3. The parents are normal: it is not inherited but happens during the
baby's development in the reproductive organs. Mosaicism and translocations happen in the other 6% of cases and here
the parents need to have their genes tested (even though 75% of translocations are de novo=not due to parental genes);
translocations happen in 5% of Down's cases; this is when the third Chr 21 is joined onto another chromosome; in the
25% of cases of this where a parent has a translocation there is a recurrence risk (10-15%/1in 10 if the mum is the
carrier, 2.5%/1 in 40 if the father is the carrier), mosaicism is rare (only 1% of cases) and it means that some of the
cells have trisomy 21 and others are normal; in mosaicism the abnormality arises after zygote formation and the
phenotype can be milder: the parents don't have genetic abnormalities and so don't need testing

Risk Factors: family history, age of mum

Clinical Features: floppy limbs (hypotonia: usually the first sign post-delivery), single palmar crease, duodenal atresia
(undeveloped gut), brachycephaly (wide head), flat occiput and 3rd fontanelle (back of the head), round face, oblique
palpebral fissures (eye slits are up-slanted/diagonal instead of horizontal), gap between the big toe and 2 nd toe, loose
skin on nape (back) of neck, hyperflexibility, low set ears, small ears, protruding tongue (due to roof of mouth being
narrow), small mouth, flat nasal bridge (upper bony part of the nose is flat), muscular hypotonia (loose muscles/limbs),
epicanthic folds (a skin fold of the upper eyelid going from the nose to the inner part of eyebrow: common in non-
Downs healthy East Asian races but not in Caucasians), Brushfield spots (a ring of speckles or pigmented spots in the
eye because of having a lot of connective tissue), short little finger, in-curved little finger, short broad hands, high
arched palate, short neck, congenital heart defects (heart problems from birth), transient myelodysplasia of the newborn
(blood abnormalities), learning difficulties (moderate to severe), delayed motor milestones, small stature

Prenatal Screening and Diagnosis: The purpose of screening is to identify women at higher risk then that indicated by
age alone; after this if the women chooses she can have invasive testing for diagnosis by fetal karyotype after
appropriate counselling about risks of chorionic villus sampling and amniocentesis. Screening and diagnostic tests can be
declined. Having a test can reassure that the baby will be healthy, allow the parent to consider termination of an
affected baby, give time to prepare for the arrival of a baby with special needs and give useful info about care during
pregnancy. Discussion should happen between the mother with her partner, midwife, doctor and friends.
All pregnant women are offered screening tests measuring biochemical chemical markers in blood samples and nuchal
thickening on USS to identify an increased risk of Down's syndrome in the fetus. The risk screening involves a
combination of markers +/- USS in the 1st or 2nd trimester. The USS is the Nuchal translucency scan which measures
the thickness of skin at the nuchal fold (fat pad at the back of the neck) at 10-12 weeks gestation (in fact it is done at
11 weeks and 13 weeks).
1st trimester:
-The Integrated Test=safest and most effective method for 1st trimester attenders; it is the nuchal scan together with
PAPP-A (pregnancy-associated plasma protein A) in the 11 th week, then in the early 2nd trimester AFP, UE3
(unconjugated estriol), free beta or total hCG and inhibin-A (so 6 things in total); the detection rate is 85% (in fact 1 st
trimester detection can be higher than 90%); it does not help for twins and other higher pregnancies
-The Combined Test=all in first trimester: Nuchal scan, PAPP-A and hCG
2nd trimester:
-The Double Test (not really clinically relevant) =AFP and hCG
-The Triple Test (not really clinically relevant) = AFP and hCG and UE3
-The Quadruple Test= AFP and hCG and UE3 and inhibin-A
Note that AFP can only be done
-in the 2nd trimester at 15-20 weeks; it is made by the baby and passes into the mum's bloodstream; it is low in
Down's and high with spina bifida
USS gives
-an image of the baby in the womb so you can tell if structures have been affected, like the spine, neck and head
If the screening is
-'positive' this means high-risk (more than 1:250 risk is high risk)
-'negative' this means low-risk

Page 17
When the above screening shows an increased risk the patient is offered
-amniocentesis (not usually chorionic villus sampling): both procedures get a sample of fetal cells
Chorionic Villus Sampling (sampling the placenta)
-can be done early at 10-13 weeks but has a lower accuracy (96-98%) and a slightly higher miscarriage rate
-does not inform about spina bifida
-a 10-20 minute test that can be a little uncomfortable
-a needle is put through the tummy or sometimes a tube through the vagina and cevix
-results can take 2 weeks
Amniocentesis (sampling the amniotic fluid)
-can be done at 14-16 weeks but is 99.5% accurate and has a lower miscarriage rate
-minor discomfort; under imaging guidance a needle is put through the tummy into the fluid around the baby
-tests take around 3 weeks before complete results (in some areas some results come in 48 hours); will also tell you the
baby's sex (you can request not to know this)
There is an operator specific miscarriage risk
-with both procedures
-amniocentesis miscarriage risk is around 1 in a 100 (0.5-1%); so weigh the risk of miscarriage against the value of the
result to you
-CVS miscarriage risk is 1-2 in a 100 (1-2%)
In most cases amniocentesis will give a normal chromosome pattern result but
-the possibility of an abnormal result and the option of TOP should be discussed before
-normal results do not rule out all abnormalities (they will only rule out chromosomal disorders and also, if requested,
sickle cell and thalassaemia)

Post-Natal Diagnosis and Screening: the diagnosis is often suspected because of hypotonia or facial appearance; the
diagnosis is not made on clinical signs alone; instead the senior paediatrician should be informed and they will then
confirm it; the confirmation is by blood test using rapid FISH (fluorescent in-situ hybridisation) techniques and the result
takes 1-2 days to come back; the parents must be told that the blood is being sent for a Down's syndrome test before it
is sent

Investigations: Echo soon after birth for congenital heart problems, hearing tests before 6 months and eye tests for
glaucoma and cataracts

Associated Complications of Down's

-heart: atrioventricular canal defect (commonest), VSD, secundum atrial septal defects, persistent PDA, tetralogy of Fallot;
Down's patients without any congenital heart problems may get mitral valve prolapse or aortic regurgitation when adult:
thus assessing in adulthood is recommended
-ENT: conductive hearing loss, sensorineural hearing loss and mixed hearing loss; otitis media, sinusitis and pharyngitis
are also all more common in Down's; OSA (obstructive sleep apnoea) may develop
-Eyes: cataracts, strabismus, nystagmus, congenital glaucoma, refractive errors, keratoconus
-GI: duodenal atresia, oesophageal or tracheo-oesophageal fistula, pyloric stenosis, Meckel's diverticulum, Hirschsprung's
disease, GORD, imperforate anus, dental problems, coeliac disease
-Orthopaedic: scoliosis, atlanto-axial instability, hyperflexibility, hip dislocation after 2 years, foot deformities, patellar
subluxation/dislocation
-Endocrine: hypothyroidism
-Neurological: learning disabilities, behavioural problems, seizures in 5-10% (epilepsy), AD in 60% >60 years old
-Haematological: infections 12 times higher risk e.g. pneumonia from impaired cell immunity, AML (acute myeloblastic
leukaemia) risk is higher, ALL (acute lymphoblastic leukaemia) risk is higher and acute megakaryoblastic leukaemia risk
is higher, polycythaemia and transient myeloproliferative disorder of the newborn (a self-limiting leukaemia which
regresses by 2 months of age spontaneously)

Recurrence Risk
-if there has been 1 child with trisomy 21 due to non-disjunction then the recurrence risk is 1 in 200 (0.5%) for a mum
<35 years old; for mums > 35 the risk is almost the same as their age-related risk
-with translocation the recurrence risk is <1% if it was a de nova translocation (75% of cases=parents genes are
normal); in the 25% of cases where a parent has a balanced translocation

Age-Related Risk
-1 in 650 overall risk all ages without antenatal screening
-20: 1 in 1530
-30: 1 in 900
-35: 1 in 385
-37: 1 in 240
-40: 1 in 110
-44: 1 in 37

Prognosis

Page 18
-it is hard to predict in a newborn because there is much individual variation in learning difficulties and development of
complications
-85% will live to more than 1 year old (congenital heart problems are an early cause of death)
-at least 50% live >50 years old of age

Written Information
-there is information on Antenatal Testing in The Pregnancy Book under the Section on Antenatal Care and Antenatal
Classes pages 57-59
-you need to give the parents written information e.g. 'Testing For Down's Syndrome in Pregnancy' leaflet on
www.screening.nhs.uk/downs/home.htm; or a Down's Syndrome leaflet
-counselling should be offered to help the family deal with grief, anger or guilt; counselling by a geneticist may be
appropriate, especially in cases of translocation
-they should also know what help is available form professionals e.g. follow-up appointments and
-self-help groups e.g. Down's Syndrome Association: 20,000 members, mostly parents of patients www.downs-
syndrome.org.uk

Ms Low is pregnant with her first child. She is due to have an ultrasound scan and has a sister-in-law with a Down's
syndrome child. As her GP, elicit her concerns and answer her questions.

DOWN'S SYNDROME
Introduction
Consent
Name and occupation
ICE
Explains what Down's syndrome is
1 in 650
Risk factors: age of mum, family history
Not inherited except in less than 5% of cases
Clinical features
Prenatal tests indicate low risk/high risk
Non-diagnostic, offered to all mothers
Blood tests with ultrasound nuchal scan
Followed by diagnostic test if high risk
Choices: keep, adoption, termination
Combined/integrated test: 1st trimester OR
Quadruple test: 2nd trimester
Amniocentesis: risk of miscarriage 0.5-1%, accurate 99.5%, 14-16 wks
Can't rule out all anomalies
CVS: earlier scan, higher miscarriage risk, less accurate
Results 2-3 weeks (for complete results)
Living with Down's child: associated complications, prognosis
Recurrence risk
Follow-up appointment for more discussion/refer to counsellor
Offer leaflet e.g. Testing For Down's Syndrome in Pregnancy
The Pregnancy Book (chapter on Antenatal Tests and Screening)
Self help organisations
Checks understanding
Fluent and non-repetitive
Clear
Asks for any questions
Thanks patient

Page 19
 FEBRILE CONVULSIONS
Definition and epidemiology: Febrile convulsions are non-epileptic fits that happen in 3% of children (so 3 in a 100) from
6 months old up to 5/6 years old. In most it is between the age of 6 months and 3 years. There is a genetic
predisposition with a 10% risk if the child has a 1st-degree relative that had febrile fits. Before 6 months and after 6
years is very rare.

Cause:tends to occur early in a viral infection when there is a rapidly rising temperature. Any infection that causes fever
can cause it. Most are due to common illnesses like ear infections, coughs, colds and flu. Serious infections like
pneumonia, meningitis and kidney infections are less common causes.

Clinical features: the fits tend to be brief and are generalised tonic-clonic fits. The child may look hot and flushed and
their eyes may appear to roll backwards. They may appear dazed and then become unconscious. Parts of the body
may twitch or shake. It does not usually last long. It may only be a few seconds and it is unusual for it to last more
than 5 minutes. The child may be sleepy for some time afterwards. An hour or so later the child often appears a lot
better when their temperature has come down.

Recurrence: 30-40% will get the fits again; this is more likely the younger the child is, the lesser the illness duration
before the fit, the lesser the temperature at the time of fit and with a positive FH.

Types of febrile fits: simple febrile seizures and complex febrile seizures; simple febrile seizures don't cause brain
damage and the child's intellectual development is no different from children without febrile seizures; there is no
increased risk of epilepsy, the risk being the same as in all children (1-2% risk). Complex febrile fits, which are focal,
prolonged or repeated in 1 illness; such complex seizures do increase the chances of epilepsy up to 4-12% (obviously
higher than the 1-2% in the general population)

Management for the Doctor: clinical examination focuses in finding the cause of the fever=viral infection in most cases
but need to rule out bacterial infection including meningitis; may have to do an infection screen (blood cultures, urine
culture and lumbar puncture). Of course if the child is unconscious with GCS <8 LP is contraindicated and antibiotics
should be started.

Management for the Parents: reassure them and give them information. Advice sheets on temperature control with tepid
sponging and antipyretics should be given. The family should be taught the first aid of seizure management. If the
seizures are prolonged (>5 minutes) then give rescue therapy with PR diazepam or buccal midazolam. Oral prophylactic
anti-epileptic drugs do not decrease the risk of epilepsy nor do they reduce recurrence of febrile seizures. An EEG is not
indicated as it does not act as a guide to treatment nor does it predict whether or not seizures will recur. So EEG/CT
not done in first febrile convulsion.

First aid for parents: check the time it starts, lie the child on their side with their head level with or just below their
body (the recovery position). Don;t put anything in the child's mouth but take out anything that can affect breathing like
food or vomit. Don't shake the baby. After the fit ends, bring down the baby's temperature to make them comfortable.
The way to do that is to take off all the baby's clothes. Then after baby recovered enough to be able to swallow, give
them some paracetamol or ibuprofen to bring the temperature down.

Prevention: it's not really possible to prevent a febrile fit from happening again; if it's going to happen, it's going to
happen; but if you find that your baby has a feverish illness, you can try to keep the baby cool, stop it's temperature
going up. So you can keep the child quite lightly dressed or even take all of it's clothes if it's in a warm room to begin
with. Give paracetamol like Calpol or ibuprofen. Give lots of cool drinks. Unfortunately the evidence shows that keeping
the temperature down doesn't prevent the fit from happening if it's going to happen. Why this is is not known, but it
may be because a chemical the body releases during fever causes the fits rather than the fever itself. So even if you
keep the fever low, the chemical may still be released and may cause the fits. OK: but luck is on your side because
most children don't have a fit again and so I'm fully expecting that with your baby: I'm not expecting it to happen
again.

Will it happen again (recurrence)?: in most cases only 1 fit occurs; in 3 in 10 children who have had a FC it will
happen a second time with a feverish illness. 3 or more further FC's will only happen in 1 in 10. Recurrence is more
likely if the child is <15 months old with the first fit or if there is positive FH in parents or siblings. Once the child is
past 3 years old, recurrence is unlikely.
So overall recurrence is not common but it's best to be prepared so practice putting the baby in recovery position, keep
ibuprofen or paracetamol in the house and learn the advice on how to bring fever down.

Danger: FC's are not usually dangerous; the child should be seen by the doctor after having had one to rule out any
serious infections like pneumonia or meningitis (but usually these are present and it's just an ordinary viral infection).
You only need to call an ambulance or a doctor if the baby is having difficulty breathing or if the fit lasts more than 5

Page 20
minutes or if the child does not improve soon after the fit or if a second convulsion happens soon after the first one
ended. In those situations you should call an ambulance but I don't expect any of these to happen, they are all rare,
I'm just mentioning them to make you aware that you almost certainly will not need to call an ambulance.

Treatment: not needed for the fit if it stops in a few minutes; treatment might be needed for the infection causing the
fever, particularly if the doctors think it is a bacterial infection. If the fit lasts longer (rare) (>5 minutes) then the doctor
may give some medication to stop the fit. This may be a liquid called diazepam put through the back passage of the
baby. If a baby gets febrile convulsions repeatedly the parents will be given this and shown how to use this at home.

Prognosis: full recovery with no permanent damage is usual. There are no after-effects. There are no effects from the fits
but sometimes if the infection is serous, like meningitis or pneumonia, the infection can lead to complications. A very
long fit of 30 minutes or more can lead to some injury to the brain.

Epilepsy: febrile convulsions are not a type of epilepsy. They are related to fever and not to any brain abnormality.
Epilepsy causes fits without fever. Though epilepsy and FC's are separate conditions, a tiny minority of children will
develop both. The risk of epilepsy in children with FC's is the same as any other child (except if they are complex FC's).

Immunisations: a child with febrile convulsions should still have all of it's immunisations. Some children get fever after an
immunisation and a very small number will then get a febrile convulsion. However, this is very unlikely to cause any
serious harm and it is also unlikely to occur again after a future immunisation.

Extra info (don't mention in OSCE station):A common cause of febrile convulsions is primary human herpes virus 6
(HHV6) infection. Most children are infected with this by the age of 2, commonly from the oral secretions of a relative.
The infectious syndrome caused by HHV6 is called exanthem subitum (roseola infantum). This causes malaise and high
fever for a few days followed by a macular rash that is generalised. The rash appears as the fever declines. It can also
happen just as fever without rash, or can be subclinical infection. It is a common cause of febrile convulsions. Up to the
age of 1 it is linked to 1/3rd of febrile convulsions.
Differential diagnosis of HHV6 infection: it is often wrongly diagnosed as rubella or measles (thus rubella and measles
should be confirmed serologically as they are more important). It is also often wrongly thought to be an allergic reaction
to drugs because the doctor prescribes antibiotics with the fever and then when the rash appears it is thought to be a
drug reaction.
HHV7 can also cause febrile convulsions because it causes similar clinical manifestations like exanthem subitum. Again
most children get it in the early years of life.

Ms Robertson brings her baby to A+E after it had a seizure. She is very worried and blaming herself for having allowed
her baby to have the MMR vaccination yesterday. You are the SHO asked to speak to her about this problem.

FEBRILE CONVULSIONS
Introduction
Consent
ICE
Baby's name, age and gender
Establish diagnosis
Explain febrile convulsions
6 months to 6 years
Causes: infections, usually viral
Explain fits
Discuss management: strip clothes, EEG/CT not used for 1st FC, NSAIDs, appropriate investigations to confirm
FC
Anticonvulsants are not effective prophylactics
Recurrence risk
Discuss prognosis
FH of FC
No increase in risk of epilepsy compared to general population
Brain damage unlikely after FC
Not dangerous
Keep paracetamol/ibuprofen at home
Show to doctor after fit
No need for ambulance unless prolonged fit
1 in 1000 after MMR get FC
Unlikely to get fit 2nd time with immunisations (less likely 2nd time around)

Page 21
Unlikely to cause harm
Missing immunisations can lead to greater harm
Use non-jargon and non-repetition

Page 22
 EXPLAIN IMMUNISATIONS GENERAL
-Introduce yourself-get parent's name and age
-Find out the name of their child and its age

-ICE
-Inform the parent/child first of what you will explain to them
-Find out what the parent/child already know
-Find out how much the parent/child want to know (is there anything they don't want to know?)
-Bring out the worries/concerns that the parent/child have
-Give the information

What is immunisation and what is its purpose

-it is an injection that protects you against serious illness (safest and most effective way of protecting)
-injected into thigh or upper arm
-it has in it small parts of virus or bacteria or chemicals made by them, enough for the body to recognise it and make
a defence against it but not enough to cause disease (strengthens your body's defence system)
-used in millions of people internationally and the safety has been checked
-infections like polio and whooping cough have almost vanished in UK due to them
-free in childhood

What's the point if the infections have been eliminated?

-the infections are still caught by people going overseas and your unimmunised child could catch it from such people
when they come back into the UK
-infections are contagiousness so you are protecting others too and especially those babies who cannot be immunised for
medical reasons (e.g. immunodeficiency/HIV)

Safety
-checked before licensing and then rare SE's monitored even after licensing
-SEs can happen with all medications but immunisations are amongst the safest of all meds in terms of side effect profile

Side-effects
-crying=common (usually only for a few minutes; they get better after a cuddle)
-rash and fever in 10% Flu-like symptoms and
-site inflammation sore site of injection
-may be irritable for 48 hours; can give paracetamol or ibuprofen by oral syringe (get from pharmacy)
-allergic reaction=very rare; can be just a rash or an itch that the doctor or nurse will know how to treat; this is no
reason to withhold immunisation; even more rarely the child could have a severe reaction that causes breathing
problems (anaphylactic reaction)= in 1 in a million immunisations (some statistics say 1 in 10,000 immunisations); even
these can be treated and the child recovers completely

Give the parent/child the immunisation schedule:

Birth:
-nothing given usually
-BCG at 3 days if TB risk= in a family member in last 6 months or from area of high prevalence; in some parts of UK
given to all at birth e.g. Lewisham; contraindications= immunodeficiency
-Hep B if mum is HbsAg positive; also then at 1 month and 2 months; given IM

2 months:
-2 injections
-5 in one: DTP (diphtheria, tetanus, pertussis), polio and Hib; give at 2 months even when prem; can give before 10
years old if not given
-Pneumococcal conjugate vaccine (PCV): Prevenar® 7-valent pneumococcal (protects against pneumonia and a type of
meningitis)

3 months:
-2 injections
-5 in one: DTP (diphtheria, tetanus, pertussis), polio and Hib; give at 3 months even when prem; can give before 10
years old if not given
-Meningitis C: for a type of meningitis and blood poisoning

4 months:
-3 injections

Page 23
-5 in one: DTP (diphtheria, tetanus, pertussis), polio and Hib; give at 2 months even when prem; can give before 10
years old if not given
-Meningitis C
-Pneumococcal conjugate vaccine (PCV)

12-15 months (usually 13 months):

-3 injections
-MMR (measles, mumps, rubella) given SC 0.5mL at around 13 months (not needed before due to immunity transferred
from mum to baby)
-Meningits C and Hib= 1 injection at around 12 months
-Pneumococcal conjugate vaccine (PCV) at around 13 months

3.5-5 years (preschool):

-2 booster injections
-DTP and polio (no Hib)
-MMR
(-Meningitis C if not already given)

10-14 years:
-1 injection
-BCG: now only given to those who have risk factors/indicated by the heaf test (=tuberculin skin test) being negative
(this has been phased out)

13-18 years (usually 16 years=school-leaver):

-1 booster injection
-DTP
(-Meningitis C if not given before but must be between 15-24 years old)

Adult:
-4 boosters
-Diphtheria
-Tetanus
-Polio
-Travel vaccines (special criteria needed)

Any age:
-BCG if at risk of TB
-Hepatitis B if at risk
-MMR if missed
-Pneumovax II®: a one off 23-valent pneumococcal vaccine; give a 2nd time if risk increases after 5 years
-Flu vaccine every year if there is kidney, heart or chest disease or diabetes or splenic dysfunction (such as sickle cell or
coeliac disease) or immunocompromised (such as HIV or chemotherapy or cirrhosis or splenic dysfunction)
-Give 3 PCVs (pneumococcal conjugate vaccines) if there is HIV

Immunodeficiency:
-see guidelines of Royal College for vaccination of these patients

Chickenpox:
-not done universally in UK
-only in USA

Contraindications
-all vaccinations are contraindicated by acute febrile illness (but not just a cold)
-live vaccines (BCG, MMR) are contraindicated by primary immunodeficiency, steroid treatment of more than
2mg/kg/day and caution with HIV, chemotherapy, transplantation
-HIV: can give all live vaccines except BCG
-acute anaphylactic rections or reactions to certain antibiotics (neomycin streptomycin or polymyxin B)
-speak to your doctor if your child has a bleeding disorder (may need SC injection instead of IM) or has had fits
unrelated to fever

Method of giving >1 live vaccine

-you must give them at the same time at different sites or
-more than 4 weeks apart

Swimming

Page 24
-you can take your baby swimming at anytime prior to or after immunisation

Types of Immunisation
-2 types:
-active: immune system is stimulated=cellular immunity and humoral immunity
-passive: this has preformed antibody in it-the antibody can be antigen-specific or non-specific

Pain Reduction For The Child

-injection pain can be minimised with
-oral glucose
-EMLA®=5% cream topical lidocaine-prilocaine
-both given at the time of injection
-evidence indicates that pain is decreased based on objective pain markers

If missed an immunisation
-never too late: can have them later as well
-but times chosen in schedule are to minimise infection risk and reaction to injection

Mr Patel is a 35 year old father. His 3 day old newborn child is causing him concern with regard to immunisations.
Explore his concerns.

MARK SHEET IMMUNISATIONS

Introduction
Consent
Parent's name and age
Name of child and age
Assesses knowledge (I)
Determine what the patient would like to know (E)
Determine if the patient is worried about anything (C)
Refer to Birth to Five book
Explains what an immunisation is
Explains what mechanism of action is
Safety checked in millions; safest and best way of protection
Explains seriousness of missing immunisation
Contagiousness and spread from overseas
Alludes to immunisation schedule and types of infection
Free in childhood
Contraindications
Side-effects
Anaphylactic reaction : 1 in a million
Discuss other immunisation/vaccine choices
Explain limitations
Explain reasons for postponing
Repeat and clarify
Checks understanding
Avoids medical jargon
Summarise

Page 25
 JAUNDICE
Definition: What is Jaundice?
-it means yellow skin and yellow eyes

Types (no need to tell the patient unless issue of damage from jaundice raised)
-unconjugated: potentially toxic but can be physiological or pathological
-conjugated: not toxic but always pathological

Epidemiology
-many babies get jaundiced: 60% (6 out of 10) term infants and 80% (8 out of 10) premature infants get it
-it can last for up to 2 weeks after birth

Aetiology
-a pigment called bilirubin causes the yellow colour in the skin
-physiological: the liver is immature and the body is breaking down more red blood cells then later in life: this releases
the pigment; starts usually on day 2 or 3, can last up to 10 days and will start to recede by around 7 days; the
pigment level is not high enough to harm the baby unless the baby is premature or has bruising/cephalhaematoma etc
-1st 24 hours (pathological): infection, haemolytic disease, haematoma, autoimmune haemolytic anaemia in mum,
Crigler-Nijjar syndrome, Gilbert's syndrome
-prolonged jaundice (>14 days in term and >21 days in preterm): breastmilk jaundice=resolves by 6 weeks or rarely by
4 months (why it happens is unknown but there are no toxins in breastmilk), infection, hypothyroidism, hypopituitarism,
galactosaemia, biliary atresia, choledochal cyst, neonatal hepatitis; 5-10% of babies get prolonged jaundice but in most
cases it resolves
-conjugated jaundice: infection, parenteral nutrition (TPN), CF, hypothyroidism, hypopituitarism, biliary atresia,
choledochal cyst, neonatal hepatitis, galactosaemia, alpha 1 antitrypsin deficiency, aminoacidurias, organoacidaemias

Risk-Factors
-male
-East Asian
-premature and small for dates babies
-breastfed babies
-maternal diabetes
-high altitude population

When Did It Start?

-first 24 hours: always pathological
-beyond 24 hours: can be physiological or pathological but obviously it's very common to have physiological jaundice
Breastfeeding
-you must not stop breastfeeding the baby when it has jaundice
-the breastfeeding is good for the baby

Clinical Features
-the face and forehead are the first visible sites of pigmentation; it then affects the trunk and extremities; colour can be
revealed by blanching; in most cases yellow colour is the only clinical feature
-drowsiness is a feature of severer jaundice
-neurological symptoms/signs are worrying and need immediate intervention to prevent kernicterus; such signs include
altered crying, irritability, lethargy, poor feeding, change in muscle tone (floppy baby/stiff baby, opisthotonos), seizures
-certain pathological causes of jaundice can cause petechial rash, microcephaly and heptosplenomegaly
-pale stools and dark urine occur with severe jaundice and are always pathological (since conjugated jaundice is always
pathological); it tends to present in the 3rd week and is the result of heaptitis (e.g. CMV, toxoplasmosis, rubella) or
biliary atresia

Investigations
-the doctor, midwife or health visitor may suggest a simple blood test if they think the jaundice is getting worse to
measure pigment levels
-they will also do tests if the jaundice persists beyond 2 weeks or with other symptoms like dark urine/pale stools
-if it is just jaundice that started at day 2 or 3 and baby is well, only test=total bilirubin
-if unwell and jaundiced (even if started day 2 or 3) or jaundice in first 24 hrs or prolonged jaundice:
-do more tests: total, conjugated and unconjugated bilirubin; LFTs; infection screen (swabs of throat and umbilicus, urine
and blood culture, LP, CXR); haemolysis (blood type, rhesus, direct Coombs test, Hb and haematocrit, peripheral blood
film, red cell enzyme assays), urine reducing substance, USS may be needed +/- further imaging, TFTs

Page 26
Treatment
-sometimes it can be needed if the jaundice gets worse in the first few days after birth
-hydration (oral or IV) since dehydration exacerbate jaundice
-phototherapy (but separated from mum, loose stools and need to increase fluid intake): blue-green light breaks down
bilirubin
-treat underlying cause
-exchange transfusion (if very severe i.e. dangerous)

Concerns
-if the parent is worried about their baby's jaundice they should speak to their GP, midwife or health visitor
Reasons to definitely tell someone
-if the baby is still jaundiced after 2 weeks then see your GP
-if the jaundice started in the first 24 hours
-if the baby is ill/not feeding
-if the urine is persistently yellow/dark or if the stools are pale then tell your doctor, midwife or GP regardless of
whether the baby appears jaundiced or not

If the mum is concerned about cerebral palsy then

-explain to her that this does not happen with physiological jaundice
-it can only happen with kernicterus (bilirubin pigment going into the brain)
-kernicterus can only happen occasionally at very high levels of jaundice; these only occur if jaundice starts in the first
day of life or if the baby shows signs of illness or if the jaundice is prolonged >2 weeks; which is why we investigate
further in all of these cases
-we have very good Tx for severe jaundice, which is why kernicterus is rare in the UK now; cases of cerebral palsy in
the UK are very rarely due to kernicterus
-but physiological jaundice that happens in most babies does not cause kernicterus and cerebral palsy and breastmilk
jaundice does not cause kernicterus or cerebral palsy either; lower levels of jaundice don't cause kernicterus because the
albumin in the blood can 'mop up' the bilirubin

If mum is concerned about biliary atresia then

-tell her that this causes dark urine and stools
-causes severe jaundice and tends to present in the 3 rd week of life
-thus Ix of prolonged jaundice will reveal it
-will need surgery by 60 days of life; surgery=join gut (jejunum) to the ducts; 80% of kids get bile drainage then; if not
successful may need liver transplant
-rare: 1 in 14,000 births; tubes in the liver and outside the liver which make bile, a substance we need to digest food,
are damaged or even not present; can lead to liver failure and death
-normal birthweight; jaundiced and from day 2 the stools are pale and urine dark
Choledochal cyst
-a cystic (fluid-filled) swelling of the bile ducts; get 25% presenting in infants with jaundice; do USS or radionuclide scan
to diagnose and then surgery to remove it (

Offer to examine the baby to allay mum's fears if necessary (can also offer to test the bilirubin level)
Offer Birth to Five book and leaflet on neonatal jaundice

Ms Harrison has a newborn baby with jaundice. She is concerned about the baby developing cerebral palsy. You will
be marked on your history taking skills, communication skills and explanation of neonatal jaundice.

NEONATAL JAUNDICE
Introduction
Consent
Names and ages of parent and child
ICE
Explains jaundice, caused by bilirubin
60% term and 80% preterm babies get jaundice
Can last 2 weeks
Physiological jaundice and breastmilk jaundice
No need to stop breastfeeding: healthy
Risk factors
Takes brief history of jaundice from mum e.g. when, where, how long now, getting worse?, is baby ill?, is
baby feeding (and mode of feeding) and giving wet nappies, is it crying/behaving differently?, pale
stools/dark urine, mum's health in pregnancy and general, family history (e.g. biliary atresia), drug history
(diazepam/sulphonamides can cause jaundice), birth history, immunisations, how affecting life?

Page 27
Physiological jaundice
No need to investigate or Tx unless started in first 24 hours, prolonged (>2 weeks) or baby ill
Even prolonged jaundice can be normal breastmilk jaundice (ends around 6 weeks)
If worried about jaundice speak to GP, midwife or health visitor
Signs that indicate you should show doctor: unwell baby, jaundice in first 24 hrs, prolonged jaundice
Allay mum's fears about kernicterus, cerebral palsy and/or biliary atresia (if she raises it)
Birth to Five Book
Leaflet

Page 28
 EXPLAIN MMR
-Introduce yourself-give your name and get the parent's name and age
-Find out the name of their child and its age

-ICE
-Inform the parent/child first of what you will explain to them
-Find out what the parent/child already know
-Find out how much the parent/child want to know (is there anything they don't want to know)
-Bring out the worries/concerns that the parent/child have
-Give the information

What is immunisation and what is its purpose

-it is an injection that protects you against serious illness/diseases
-injected into thigh or upper arm
-it has in it small parts of virus, enough for the body to recognise it and make a defence against it but not enough to
cause disease; it is treated specially to ensure this
-used in millions of people internationally and the safety has been checked

MMR
-protects against measles, mumps and rubella viruses: protects against 3 different illnesses
-all 3 illnesses are very serious
Measles causes
-fever and a rash
-complications: deafness, brain inflammation (encephalitis), pneumonia, fits, death
Mumps causes
-fever and swollen glands
-complications: deafness, meningitis, myelitis, infertility in men, brain inflammation
Rubella causes
-rash and swollen glands
-complications: heart abnormalities, eye abnormalities, deafness (in neonates); 'malformations' i.e. birth defects if
pregnant woman has it
Contagiousness
-all 3 infections are contagious, meaning they will spread to others
-76% uptake in Ireland meant there was an outbreak in which some children (2) died
Given at
-12-15 months (usually 13 months)
-3.5-5 years =pre-school
Contraindications to MMR
-acute febrile illness (as with all vaccines)
-egg allergy
-immunocompromised (weak immune system)
Side-effects
-crying=common
-rash and fever in 10% (Flu-like symptoms and
-site inflammation sore site of injection)
-allergic reaction=very rare
-autism is NOT a side-effect
Disease risk
-the risk of illness from measles, mumps and rubella is higher than the side-effects and small risks of the vaccine
-with declines in MMR use, the infections increase: measles is more common now in older children in the UK due to
neglect of MMR by some parents and it is associated with more complications in this age group
Safety
-given since 1972 more than 500 million times (so more than half a billion doses)
-shown it is very safe and very effective
Autism
-nothing to link MMR with autism; consider stopping here unless patient asks for more
-autism existed before MMR
-autism did not increase when MMR introduced in 1988
-1997-a study showed that 12 children had autism and also intestinal measles virus; this is where the controversy
began; however the study has since been shown to be biased (meaning unreliable) to the extent that the magazine
(journal) that published it has withdrawn it i.e. completely disowned it
-it was biased because the person that wrote it had a conflict of interest in money terms; also the sample base was
skewed

Page 29
-there is no evidence for MMR causing autism whatsoever
-unfortunately autism tends to be diagnosed around the time MMR is given; but you need evidence for any vaccine link
-because the cause of autism is unknown,as with most childhood psychiatric disorders, people want to find a cause-
that's fine but this study was flawed, it was withdrawn and shown to be wrong; the fact that autism existed before
MMR was ever introduced and did not increase after MMR shows there is no link
-larger reliable studies than the one in 1997 have shown MMR to be unlinked to autism and IBD; the WHO endorses
the vaccine and a Finland study showed no link in over 3 million vaccinations; in the USA it has been given for over 30
years with no deaths nor permanent effects
-separate measles/mumps/rubella-no benefit at all over combined; not offered on NHS-just increases from 1 injection to
3 and increases risk of infection in the meantime and the risk of an injection being missed or delayed and decreases
population coverage
-no benefit to separate vaccines
End
-any questions
-offer a leaflet about MMR
-suggest a website like NHS Direct
-refer to Birth to 5 book

Mrs Jackson has a 12 month old baby who is up to-date with vaccinations. She is concerned about the controversy over
MMR and refusing this vaccine for her child. Explore her ideas.

MMR
Introduction 1 mark
Consent 1 mark
Name of child and age 1 mark 2 marks
Assesses knowledge 1 mark 2
marks
Determine what the patient would like to know 1 mark
Determine if the patient is worried about anything 1 mark
Refer to Birth to Five book 1 mark
Explains what an immunisation is 1 mark 2 marks
Explains what mechanism of action is 1 mark 2 marks
Tested in millions and safe 1 mark
Explains seriousness of missing MMR 1 mark 2 marks
Measles 1 mark 2 marks
Mumps 1 mark 2 marks
Rubella 1 mark 2 marks
Contagious 1 mark
Alludes to immunisation schedule and time MMR given 1 mark 2 marks
Contraindications 1 mark 2 marks
Side-effects 1 mark 2 marks
Discuss other immunisation/vaccine choices (single jabs) 1 mark 2 marks
Explain limitations 1 mark
Explain reasons for postponing 1 mark
Not linked to autism 1 mark
Autism before MMR 1 mark
No evidence, original study wrong, larger studies show opposite 1 mark 2 marks
Diagnosed at time of vaccine 1 mark
Offers helpful advice 1 mark
Repeat and clarify 1 mark
Checks understanding 1 mark
Avoids medical jargon 1 mark
Summarise 1 mark
Leaflet/NHS Direct 1 mark 2 marks

Page 30
 PAEDIATRIC ABDOMINAL EXAMINATION
You may have to alter the conventional order of the exam in a very young child e.g. Examine with the child on the
knee of the parent or listen to the chest whenever they stop crying

-Introduction and ask age

-Explain examination
-Consent (from child and also parent if they are present)
-Position child so they are flat and reveal the abdomen as much as possible (usually xiphisternum to symphysis pubis)
(NOT nipples to knees)
-Make sure the patient is comfortable
-Can ask the child to empty their bladder to avoid bladder dullness
-Wash hands and establish rapport e.g. what school do you go to? Are your parents around?

Inspection from the end of the bed

-is the patient well or unwell?
-jaundice
-anaemia (pallor)
-nutritional status-consistent appearance
-attachments:any tubes, drains, oxygen or medications?
-age-consistent appearance

Abdominal inspection from end of bed and diagonally

-distension
-visible peristalsis (intestinal obstruction, pyloric stenosis)
-ascites (fullness in the flanks)
-everted umbilicus (ascites)
-swelling/distension (size: generalised or localised) (-protuberant/distended abdomen in the infant and young children is
normal due to increased lumbar lordosis; abdominal movement with respirations is also normal)
-masses
-dilated veins from liver disease
-striae
-scars ans skin changes

Hands
-clubbing and other nail signs (hands and feet)
-palmar erythema
-liver flap
-pulse: rate and rhythm
-temperature and colour

Arms
-inspect carefully for arteriovenous fistulae

Eyes
-periorbital oedema (nephrotic syndrome)
-jaundice (sclera)
-anaemia (conjunctivae)

Mouth
-angular stomatitis (nutritional deficiency)
-ulcers (Crohn's)
-atrophic glossitis (iron, folate and B12) (check tongue coating and colour)
-tongue furring (appetite loss)
-dentition state
-halitosis (foetor hepaticus, uraemia fishy smell, abdominal sepsis, ketotic breath)

Neck
-lymphadenopathy (can check the occipital lymph nodes for german measles=rubella if you wish)

Palpation
-must be at the level of the tummy
-ask about pain
-relax the abdominal muscles for palpation; you can achieve this by getting the patient to bend their knees up

Page 31
-warm your hands and explain what you will do to the patient i.e. I'm just going to feel your tummy like this: put their
hand on their own tummy and press on the back of their hand to accustom them to abdo palpation (or just use their
hand to palpate); or give them a toy

Superficial/Light palpation
-palpate the 9 areas including the umbilicus for tenderness and guarding (start away from the pain)
-watch the patient's face for grimacing!
-if there is tenderness determine if it is localised (as with appendicitis, hepatitis and pyelonephritis) or generalised (as
with mesenteric adenitis and peritonitis)
-if there is guarding it may be irrelevant in children (in this age group it usually is unreliable)
-peritoneal irritation is suggested by pain with coughing, pain with movement, walking and bumps in the car journey;
back bent while walking can mean appendicitis from psoas inflammation

Deep palpation
-palpate the 9 areas for masses
-with any mass describe: size, shape, position, consistency, mobility, tenderness and whether or not you can get above it
or not

Liver palpation
-start palpation in the right iliac fossa and move up to the costal margin (usually palpable in infants)
-feel for the liver either with the fingertips or the radial border of the index finger
-if you feel the edge describe: the degree of extension below the costal margin in cm in the mid-clavicular line, whether
the edge is soft or firm, whether or not you can get above it, whether or not it is tender (a sign of
hepatitis=inflammatory pain), whether or not it moves with respiration (the liver does)
Liver percussion
-dullness will reveal the upper and lower border; you should record the span

Spleen palpation
-start palpation in the right iliac fossa and move across to the left costal margin
-feel for the spleen either with the fingertips or the radial border of the index finger
-if you feel the edge describe: the degree of extension below the costal margin in cm in the mid-clavicular line, whether
the edge is soft or firm (the spleen is typically soft), whether or not you can get above it (should not be able to),
whether or not it is tender (a sign of hepatitis=inflammatory pain), whether or not it moves with respiration (the spleen
does) and whether the notch is palpable or not
-if not sure you can turn the child on their right side and can also use the bimanual approach
Spleen percussion
-dullness will reveal the lower border alone

Kidney palpation
-get the patient to be at the edge of the bed
-always keep your left hand under the child and the right hand on the abdomen for both sides
-ballot bimanually
-kidneys move on respiration
-you can get above them
-tenderness means inflammation
-unlikely to feel a normal kidney beyond the neonatal period; you may be able to feel the right kidney in a thin person
-normal consistency=firm and surface is smooth

Bladder palpation
-an enlarged one feels like a rounded fullness while an enlarged uterus feels like a more distinct solid structure
Aortic palpation
-halfway between the xiphisternum and umbilicus
-press the fingers posteriorly and medially

Inguinal region palpation

-lymphadenopathy: palpate
-inguinal hernias: cough (inguinal hernias or femoral hernias); examine standing since it becomes visible due to raised
intraabdominal pressure whereas lying down reduces it
-a femoral hernia lies below the pubic tubercle and lateral to it
-an inguinal hernia lies above and medial to the pubic tubercle
-to distinguish between a direct and indirect hernia, first fully reduce the hernia towards the internal inguinal ring by
pushing up; once it is reduced occlude the internal ring with a finger pressed on the internal inguinal ring (mid-inguinal
point); then ask the patient to cough: if it is an indirect hernia it won't reappear with coughing until you release the
pressure; if it is a direct hernia it can appear again even with pressure on the internal inguinal ring

Percussion

Page 32
-liver: comment on it’s size and suggest measurement if there is a palpable liver edge, to rule out chest pathology
pushing the liver down
-spleen
-bladder: suprapubic dullness should be sought by vertical percussion form the umbilicus down; if present it indicates
distension
-shifting dullness for ascites; percuss from resonant towards dull (do especially with distension); when the resonance
becomes dull you have reached a gas-fluid interface; do this in 2cm increments; mark the area of interface with a water
soluble pen; then turn the patient to their opposite side to the one you percussed to, and repeat the percussion from the
midline to the flank-it should now be tympanic (resonant) beyond the mark you made

Auscultation
-listen for 30 seconds at least in the mid-abdomen with the diaphragm for bowel sounds (borborygma=intermittent
gargling at 5-10 sec intervals though longer silence can happen); present vs absent; hyperactive or tinkling vs
hypoactive vs normal ; accentuated (increased) in bowel obstruction and acute diarrhoea; absent in paralytic ileus and
peritonitis
(-abdominal aorta bruits: avoid in paediatric; place the diaphragm over the aorta with moderate pressure; heart sounds
are transmitted to this region but the aortic flow should be silent; if you hear a systolic murmur it is a bruit; it means
turbulent flow and thus either arteriosclerosis or an aneurysm)
-renal artery bruits: place the stethoscope 2.5cm above and lateral to the unbilicus; it indicates renal artery sclerosis
(congenital or arteriosclerotic) or narrowing due to fibromuscular hyperplasia
-(liver auscultation and spleen auscultation: over an enlarged liver you may hear a soft and distant bruit and this is
always abnormal, meaning primary liver cell carcinoma or acute alcoholic hepatitis; a secondary cancer does not
transmit bruits; a 'creaking rub' over the liver or spleen means inflammation of the outer capsule and peritoneum next
to it, possibly due to perisplenitis or perihepatitis or rarely carcinomatous infiltration)
-(succession splash: pyloric obstruction-do only in children of age group likely to get this disorder)

Genitals
-say you would inspect in infants and young kids but not in older children unless there is an indication e.g. vaginal
discharge or unexplained abdominal pain
-penis: normal size? Well developed scrotum? Palpable testes? (feel with other hand on the inguinal region) Record if the
testes are descended, retractile or impalpable. Any scrotal swelling? (hernia or hydrocele)
-females: external genitalia normal? Normal anus? Fissure?

Anus and rectum

-inspect the anus in a very young child i.e. infant; wasted buttocks instead of rounded can be a sign of coeliac disease
or malnutrition leading to malabsorption
-do not suggest a rectal examination in children (it is often substituted with an abdominal x-ray to avoid discomfort and
fear of doctors in the child); it is sometimes done for intussusception and a retrocaecal appendix

-thank patient and parent

-offer help to redress
-ask about any questions
-give DD

Ix
-suggest urinalysis if appropriate: clean catch sample if possible with dipstick for proteinuria, haematuria, glycosuria and
leukocyturia; microscopy for determining origin of red cells (at the very least say you would do urine dipstick)
-suggest looking at the growth chart (if very young child)
-blood tests e.g. FBC, LFTs, Us & Es, clotting screen
-USS

An abdominal exam is done in detail in a child if they have the following symptoms:
-diarrhoea
-constipation
-vomiting
-abdominal swellings
-abdo pain
Generalised abdominal distension is due to
-fat
-foetus
-flatus (intestinal obstruction, malabsorption)
-faeces (constipation)
-fluid (ascites in kids is not common: mostly due to nephrotic syndrome)
-rarely a very large liver
-rarely a very large spleen

Page 33
-muscle hypotonia
Localised abdominal distension is due to
-gastric dilatation if upper abdomen (from hepatomegaly, spelnomegaly, pyloric stenosis)
-masses and distended bladder if lower abdomen

Masses
-Wilms' tumour: a mass that does not cross the midline
-Neuroblastoma: a firm mass that is irregular and can cross the midline; the chíld tends to be unwell
-Faecal masses: identable, mobíle and tender
-Intussusception: will be unwell acutely, there may be palpable mass and is most commonly in the RUQ

PAEDIATRIC ABDOMINAL EXAM

• Introduction and consent
• Exposure: xiphisternum to pubic symphysis
• Wash hands
• Inspection from end of bed
• Inspection of abdomen including scars underneath
• Hands: clubbing, palmar erythema, flap, pulse
• Eyes: jaundice, anaemia
• Mouth: ulcers, angular stomatitis etc
• Neck: lymphadenopathy
• Spider naevi, dilated veins, gynaecomastia if male
• Note any arteriovenous fistulae
Palpation
• Asks about pain and at level of abdomen
• Warm hands and ensure patient is relaxed
• Superficial and deep palpation
• Watches face
• Liver palpation
• Spleen palpation
• Bimanual kidney palpation
• (Aortic impulse)
• Inguinal hernias and lymphadenopathy
Percussion
• Liver percussion
• Spleen percussion
• Bladder percussion
• Ascites shifting dullness
Auscultation
• Bowel sounds
• Renal bruits
• (Aortic bruits)

• Suggest genital examination

• Suggest appropriate investigations
• Gentle and sensitive to patient
• Modify exam relevant to findings
• Examines relevantly for age and clinical situation
• Describes signs and fluent
• Appreciates signs' significance

Page 34
 PAEDIATRIC HISTORY TAKING
-Introduce yourself-first to the parent, then to the child; shake hands if appropriate
-Name of parent and child
-Consent: say you will ask questions to find out about the problem and get permission for it
-Make the child comfortable; if it is a young child give toys for them to play, so have toys at hand
-Establish eye contact with the family and rapport: an infant is best placed on the parent's lap while a young child may
need time to get to know you; try not to have a desk or bed between you and not to tower over children

The History

The child's
-name
-age
-sex
The adult (s) 's
-relationship to the child
-age

Presenting Complaint

Open question e.g. what brought you here? What brought you to see me?
-let the patient tell the complaint in their own words without interruption
-must find out worries/concerns of the parent (consider using ICE)

History of the Presenting Complaint

-Nature
-Duration-time from onset to presentation etc
-Time course
-Past episodes
-Onset-sudden, gradual or after a more minor symptom (like febrile convulsion after malaise)
-Getting worse, better or staying the same?
-Pain-site, onset, character (aching, burning, colicky, stabbing), radiation (where does it go), relieving and aggravating
factors (rubbing, sleeping, changing posture, micturition, defecation, eating/drinking), severity, associated (nausea,
jaundice, diarrhoea, altered consciousness, vomiting, urinary frequency:wet nappies, constipation etc)
-Relieving factors
-Aggravating factors
-Associated symptoms: nausea and vomiting, constipation + diarrhoea, altered consciousness, urinary frequency
-Treatment (s) already taken for the complaint
-What was the reason for referral? Or why did they come to see the GP?
-How has the problem affected the life and daily routine of the child? And how has it affected the parent(s) and
siblings? What have they done about this?
-What are the concerns of the parent? What are the worries of the child? What do they feel or think might be
happening?
-Each symptom must be opened and explored
-Make sure you and the patient mean the same thing when addressing a problem

Systems Review

Cover each system for a brief period, asking about relevant areas
-General: crying, personality and behavioural changes, liveliness, active, being able to recover from a minor illness,
normal growth, pubertal development, appetite, feeding, drinking
-CVS: cyanosis, colour change-pallor or blue baby, tired, heart murmur, exercise tolerance in older child
-RS: breathing problem=feeding problems in infants, SOB, wheeze, cough, stridor, croup ('noisy breathing'), chest
infections
-ENT: earache, infections, nose bleed, deafness, sore throat/throat infection, snoring, stridor,
-GI: feeding, weight gain/loss, diarrhoea and vomiting, constipation, jaundice, abdominal pain (infant colic=drawing legs
up)
-GU: wet nappies, enuresis (wetting), frequency, discharge, dysuria, toilet-trained
-NS: headache, fits, vision, balance and coordination, muscle problem, abnormal movements
-MSS: joint stiffness, joint pain, redness, swelling, limp, gait disturbances, limb pain, functional abnomality
-Skin: eczema, rash
-Sleep: patterns of sleeping

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-Make sure you and the patient mean the same thing when addressing a problem

Past Medical History (PMH)

-Any similar problems like this in the past?

-If relevant to presenting complaint:
-Medical problems e.g. asthma, epilepsy, diabetes
-Surgery
-Past admissions
-Injuries and accidents

Pregnancy and Birth History

-Maternal obstetric history: illness (especially those that affect foetus like hypertension, diabetes and thyrotoxicosis),
bleeding, infections (rubella, toxoplasmosis, cytomegalovirus, AIDs), admissions, foetal growth, scans, blood pressure,
drugs in pregnancy i.e. alcohol, smoking, narcotics, anti-convulsants
-Birth: delivery mode and any difficulties (birth asphyxia, need for resus), gestational age, birth weight, admission to
SCBU and other postnatal problems (respiratory distress, seizures, jaundice, infection)
-Feeding: breast vs bottle-for what duration and how much, age weaned to solids
-Sleeping patterns
-Illness in childhood

Tact is needed as parents often feel responsible for their child's illness

Past Developmental History

-Key developmental milestones-smiling, sitting, walking, talking

-More detailed key milestones (if indicated):
-GM: sitting unsupported, walking around furniture, walking unaided (head control, crawling, walking backwards,
hopping)
-FM and V: following a face, reaching for toys, palmar grip grasping, picking up small objects (how many bricks built
up)
-SL and H: startle to loud noise, cooing/babbling, turning head to sound, saying mama/dada etc, understanding
commands, saying words, talking in sentences (mimicking words)
-SE and B: (neonatal eye regard), smiling, feeding oneself solid food, drinking from a cup, helping with acts like
dressing, toilet training (playing in parallel with other kids, playing with other children)
-Does the parent or patient have any concerns with hearing, vision and development?
-Immunisations history: any missed, ask specifically about MMR; check the personal child health record ('red book') for
most accuracy
-You can include developmental history in the past medical history or birth history if you want to

Family History

-Use tact because some of the complex relationships in many families may be unknown to the child
-Parental health, do the parents live together?
-Heights of parents if relevant
-Sibling health
-Any illnesses that run in the family? (A way of asking about genetic and congenital abnormalities)
-Consanguinity

Draw a family tree; if there is a positive family history then extend it over several generations

Drugs/Allergies

-Allergies
-Prescribed drugs-present and past
-OTC drugs-present and past

Social History

-Better to move from neutral subjects like housing to more sensitive issues like relationships
-You must use tact and think ahead for this section since refusal to answer questions about sensitive issues damages
rapport
-It is best to be structured with open ended questions acting as prompts

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-Jobs of parents-financial problems, type of work, unemployed/working away from home/home late/overworks, mother
full-time vs full-time/part-time job mum, nursery/creche/child minder, relative/nanny looking after when parents working,
enjoys/puts up with/hates
-Home life details-is the child adapted to the arrangements above?, behaviour/temperament=frightened easily, shy, cries
easily, sad, angered easily, aggressive, boisterous, overactive
-Siblings' details-only child/last born, jealousy/aggression/rivalry, isolated
-Home behaviour; happy at home? Preferred leisure/play activity
-School behaviour; happy at school/nursery?, school refusal, name of school/nursery, ordinary/special help, educational
progress, relationship with other kids, teachers helping with treatments/symptoms
-Smoking in the house-when relevant
-Pets in the house-when relevant
-Economic status
-Housing-do you have any problems with housing? (moving soon vs settled, damp/damaged/cold, difficult/isolated
neighbourhood, high-rise/garden, house/maisonette/flat, own/council/privately rented
-Relationships, do the parents live together
-Marital status
-Are you a happy family? (marital problems, financial problems, psychiatric problems, drug/alcohol problems)
-How does he/she get on with you and partner?= disobedience/tantrums, independent/overdependent, disagreement on
management of the child e.g. spoude vs grandparent etc
-Problems at school or with the law? Classroom trouble, truanting, trouble with the police
-Professional help for behaviours? Health visitors, social workers, GP, paediatricians, child psychiatrist, ongoing help

This section of the history is important because of the adult issues that affect child health:
-Partnership instability
-Long term poverty/unemployment
-Poor housing, cramped housing, damp housing
-Alcohol and drug abuse
-Parental psychiatric morbidity

After-History

-Clarify if not already done; thus you check and possibly give a brief summary to ensure there is no misunderstanding
-Ask the parent and child if there's anything they want to say which you didn't ask about
-Ask both parent and child about any specific worries or concerns or if they have any questions (do you want to ask
anything?)-good way of closing by moving to neutral ground and avoiding awkardness
-Thank them all
-Consider giving plans to continue on another occasion or to give an info leaflet
-Summarise findings and give the differential diagnosis and investigations

Likely conditions
-headache
-jaundice
-respiratory disorders (asthma, URTI)
-behavioural disorders (like enuresis)
-fit (epilepsy, febrile convulsion)
-child rash or infection
-issues of compliance with immunisations

Say to examiner you will check the red book-to record your findings and to see past check-ups

Further Questions About Particular Symptoms

Vomiting:
-age of onset of vomiting
-projectile?
-bile-stained?
-abdominal distension
-pain
-headache

Convulsions:
-fitting length
-localized or generalized
-fever before onset
-post ictal behaviour

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Itch:
-any more atopic features
-contact? scabies/chickenpox
-local (e.g. pruritis ani) vs generalized (e.g. eczema)

Fever with rash:

-time relationship between onset of fever and rash contact history
-immunisation status
-the mnemonic to memorise is: Really Sick People Must Take No Exercise=1234567=
-1=rubella, 2=scarlet fever, 3=smallpox,4=measles, 5=typhus, 6=none, 7=enteric fevers
-the numbers are the days after fever onset to appearance of the rash

Psychological/behaviour history of a child

-is the child adapted to the arrangements above? Relationships with the above.
-how getting on at school? happy at school/nursery?, school refusal, name of school/nursery, ordinary/special help,
educational progress, relationship with other kids, teachers helping with treatments/symptoms
-How getting on with siblings? Only child/last born, jealousy/aggression/rivalry, isolated
-Behaviour/temperament=frightened easily, shy, cries easily, sad, angered easily, aggressive, boisterous, over-active
-How does he/she get on with you and partner? Disobedience/tantrums, independent/overdependent, disagreement on
management of the child e.g. spouse vs grandparent etc
-Problems at school or with the law? Classroom trouble, truanting, trouble with the police
-Professional help for behaviours? Health visitors, social workers, GP, paediatricians, child psychiatrist, ongoing help
-Are you a happy family? (marital problems, financial problems, psychiatric problems, drug/alcohol problems)

You are a GP. Jerry is a 1 week old born to Ms Smith. She has noticed that Jerry looks very pale and yellow and has
come to your surgery worried. Explore her concern.

PAEDIATRIC JAUNDICE HISTORY

Introduction
Rapport with mother
Consent
Name and age of child
Open question s
Duration, time
Onset and progress
Relieving and aggravating
Associated: N+V, diarrhoea, seizures, drowsiness, altered consciousness/LOC
Sleep
Bruising, bleeds e.g. mouth/nose
Colour of urine and stools: when did it start?e.g. biliary atresia= day 2 dark urine/pale stools
Always there or comes and goes? (the jaundice and urine/stool changes)
Feeding frequency
Passing urine
Waking for feeds
Swelling in tummy
Treatment taken
How affecting life
ICE
Past medical and surgical history
Pregnancy, birth history and gestational age
Development and immunisations
Family history
Drugs and allergies
Social history: smoking, alcohol, marital status, jobs/finances
Deals appropriately with the concerns of the patient

Ms Johnson is worried about her son's headaches. Explore the problem by taking a history

PAEDIATRIC MIGRAINE HISTORY

Introduction

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Rapport with mother
Consent
Name and age of child
Open question s
Has headache at present or not?
Site and nature
Radiation and severity (worst ever?)
Duration, time (when started, how long do they last?, constant or intermittent?)
When do they happen? e.g. night, morning
Frequency
Onset (sudden?) and progress (getting worse?)
Relieving and aggravating (exertion, coughing, chewing, lying down, sleep etc)
Triggers e.g. foodstuffs like cheese, chocolate, caffeine and ice-cream; menses, the pill etc
Stress/tension/fatigue (at home and school; bullying, illness, exams) vs relaxation
Treatment tried and past episodes
N+V, photophobia, phonophobia, allodynia, neck pain and stiffness, dysarthria
Fevers, rash, seizures and weight loss
Aura (duration) and visual disturbances (flashing lights, blurred, double, watering, redness)
Changes in consciousness/drowsiness and neurological deficits (numbness, weakness)
Behavioural and personality changes/performance change e.g. school; night-time waking
Heavy cold recently, loss of interest/skills, change in memory/mental ability
Head injury and spinal procedures; patent foramen ovale
Tooth, facial pain, eye pain, jaw pain, flushing, eye droop and runny nose; refractive errors
Systems: appetite and eating/drinking, fatigue, breathing, abdominal pain, rashes, joints and muscles, gait and
balance/coordination, head tilt, bowels (diarrhoea and constipation), hearing/tinnitus/vertigo
Drugs and allergies e.g. MAO inhibitors, COC pill, vitamin A, tetracycline, nitrofurantoin, NSAIDs, steroids, beta
blockers, theophylline, nitrates, recreational etc
Rebound headache: aspirin, codeine/other opioids, ergotamine, GTN, Ca channel blockers
Alcohol: relieves, makes worse or withdrawal makes worse
Withdrawal of a drug or caffeine (coffee/tea/soft drinks/chocolate)
Associated with menstruation or pregnancy
PMH (admissions, migraine, obesity, cranial lesions, asthma, BP, diabetes) and PSH/complications
Birth History, Past Developmental History and immunisations (has growth been affected?)
Family history: 1st/2nd degree relatives; migraine and cluster headaches, neurofibromatosis
Consanguinity
Social: travel sickness, smoking, mood; ICE/effect on life:sleep, school, effect on parents

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 PAEDIATRIC UTIs EXPLANATION
-Introduction: tell the patient who you are and ask them their name and age
-Ask the parent the name and age of their child
-Consent for explanation

-ICE: assess knowledge of the patient, what they are worried about and what they want explained
-1 in a 100 boys and 3 in a 100 girls get an infection of the urinary tract with symptoms before the age of 11
-About half of them (50%) will get it a second time within one year
-A urinary tract infection is an infection of the bladder which holds urine or the kidneys which make urine: draw
diagram of kidneys, ureters, bladder and urethra
-Aetiology: incomplete emptying of bladder, constipation, VUR
-Childhood UTI is important because 1) as much as 50% of the children with UTI will have a structural anomaly of the
urinary tract 2) pyelonephritis (kidney infection ) can lead to damage in the growing kidney through scar formation
-scarring and VUR have 2 unfortunate consequences: 1) predisposition to high BP 2) chronic renal failure if the scarring
is bilateral (no reflux no scar)
-scarring does not occur if the child is over the age of 1 and gets a UTI
-so reason for Ix= look for scarring and VUR, structural anomalies

-Investigations and management:

-antibiotics and other medical Tx for the UTI=fluid intake, void regularly, double micturition, avoid constipation, perineal
hygiene
-do USS of kidneys and urinary tract: structural anomalies like dilatation, obstruction, cysts, stones, bladder etc: safe,
pleasant, cheap, non-invasive; so just some cold jelly and can see outline of things: kidney, bladder and tubes
-if USS abnormal then
-DMSA scan for renal scars (Di Mercapto Succinic Acid Test) and/or
-MAG 3 scan (Mercaptuacetyltriglycine) for reflux: looks at kidney function
-DMSA and MAG3 scans are done months after the UTI to avoid false positives from the acute changes in illness (scan
will look 'mucky' if done soon after infection so it is done later)
-DMSA: it is a protein bound radioisotope taken up by the proximal tubules; a small injection given 2 hours before the
scan; little cooperation needed; static scan that shows the parenchyma: 'meat' of the kidneys (take BP, height and
weight and a urine sample; just one needle put in with EMLA cream to prevent feeling of sharp prick, and a small
plastic tube left in the arm and the needle removed; the EMLA cream is first left for about an hour to work; some blood
is taken and an injection of dye given through a syringe; then go and have lunch and come back; child is lain on couch
and some pictures taken with a special camera; only a day procedure so if you go in the morning and you'll be home
by teatime)
-MAG3: (take BP, height and weight and a urine sample; just one needle put in with EMLA cream and a small plastic
tube left in the arm and the needle removed; the EMLA cream is first left for about an hour to work; some blood is
taken and an injection of dye given through a syringe (radioactive tracer taken up by the kidneys); it won't make the
child feel different; the child is lain on a couch and some pictures taken with a special camera; this can last up to 40
mins and the child must be still; can eat/drink, parents can be present
-Contraindications to MAG3: none
-SE's: the scan and injection will not affect the child in any way
-Preparation for MAG3: none: child can eat, drink and take meds at all times (including during the scan)
-Results of MAG3: not on same day; radiologist will send them in a few days to your doctor

Radiation in MAG3
-adjusted according to bodyweight
-like background radiation of 1 year
-benefits outweigh risks

-give a summary and

-assess patient's understanding
-ask the patient if they have any questions and encourage it; answer them
-offer leaflet
-thank patient

Note: MAG3 is done with the child lying on a bed. After this is complete, older children (i.e. at least 3 years old) are
then asked to pass urine on command and a further picture is taken. Obviously micturition on demand is not possible
for a child <1 year old so in these cases some doctors may opt for an MCUG (micturating cystourethrogram): the
disadvantage of this is that it requires catheterisation (whereas a MAG3 is non-invasive).

Ms Thomas has a 9 month old baby. He has been diagnosed with a UTI after urinalysis and culture. She is surprised

Page 40
about the number of investigations this will require. Explain the investigation and management of her child's UTI.

PAEDIATRIC UTIs
Introduction
Consent
Ask child's name and age
Good rapport
Assess knowledge of the patient
Assess what they are worried about
Assess what they want explained
Explain UTI
Epidemiology
Aetiology
Importance of Ix: structural anomalies, scars and VUR
No scarring >1 year
Untreated scarring/VUR causes renal failure and hypertension later in life
Diagram
Acute management: Abx, fluid hydration
Other management: double micturition, avoid constipation
USS (structural anomalies)
If USS abnormal then DMSA for scars and MAG-3 for reflux (VUR)
Time delay to the DMSA and MAG-3 and reason for it
DMSA: IV injection and dye: ionising radiation
MAG-3: IV injection and dye: ionising radiation
Radiation used sparingly, worked out using body weight
Radiation level similar to background radiation of 1 year in MAG3, 4 months in DMSA
Benefits outweigh risks
No effect on kidneys and no evidence it can cause cancer
Summarise
Assess understanding
Avoids medical jargon
Explored concerns appropriately

Page 41
 PALLIATIVE CARE
Introduction: say you are one of the doctors with the palliative care team
Consent to speak
Ask patient what they prefer to be called
General Questions
The main problem/biggest problem patient needs help with today
Pain
Describe pain
Site of pain
Radiation
How long for? Onset sudden/gradual
Constant?
Relieving factors/exacerbating
Severity
Effect on everyday life/activities
Associated relevant symptoms e.g. wasting, tingling/weakness if neuropathic pain
Treatments tried to relieve it
Mood
Support from family and friends
What does the patient think may be causing their pain?
What is the underlying diagnosis the doctors have discussed with the patient?
Community care nurse
Nausea and vomiting
Constipation
Anorexia/fatigue
Breathlessness
Say you will investigate further
Say you will give some medication in the meantime to help the symptoms
Ask the patient if they have any questions
Nausea and vomiting
How long
Constantly?
Relation to time of day/meals etc
What does the vomiting bring up? e.g. undigested food, blood etc
Relieving factors/exacerbating
Medication incl. anti-sickness tablets; route taken by e.g. PO, patches etc
Duration of medication
Treatments tried to relieve it
Bowels opening regularly/constipation
Effect on everyday life/activities
Mood
Support from family and friends
Community care nurse
Concerns they want dealt with today
What is the underlying diagnosis the doctors have discussed with the patient?
What does the patient think may be causing their sickness?
What does the patient understand by their diagnosis?
Pain
Constipation
Anorexia/fatigue
Breathlessness
Say you will investigate further
Say you will give some medication in the meantime to help the symptoms
Ask the patient if they have any questions
Bowels
How long
When last opened bowels
Normal bowel habit e.g. everyday
Characteristic of stools e.g. hard
Treatments tried to relieve it
What does the patient may be causing their constipation?
Medications esp. opioids
Pain esp. abdominal pain and relationship of pain to constipation e.g. started at same time

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 Ask about diet, fluid intake, physical activities
Nausea and vomiting
Breathlessness
Anorexia/fatigue
Mood
Effect on everyday life/activities
Support from family and friends
Community care nurse
What is the underlying diagnosis the doctors have discussed with the patient?
What does the patient think may be causing their constipation?
Say you will investigate further
Say you will give some medication in the meantime to help the symptoms (laxatives)
Ask the patient if they have any questions
Breathlessness
How long
When e.g. at rest, when walking
SOB at night
Getting worse or constant?
Cough
Phlegm
Colour and blood
Fever
Previous problems with SOB
Treatments tried: any good?
What is the underlying diagnosis the doctors have discussed with the patient?
What does the patient think may be causing their breathlessness?
Worries/concerns
Pain
Nausea and vomiting
Constipation
Anorexia/fatigue
Mood
Effect on daily life/activities
Support from family and friends
Known to community care team/community care nurse
Macmillan nurse referral
Say you will investigate further
Say you will give some medication in the meantime to help the symptoms
Ask the patient if they have any questions
PMH
Drug history
Family history
Social history
Spiritual history

Anorexia and Fatigue: also a possible PC

Agitation: also a possible PC

Page 43
 SUICIDE RISK ASSESSMENT ADULT
Remember that even though self-harm, attempted suicide and suicide are 3 different entities, but every self-harm and
attempted suicide could be fatal the next time around.

-Introduce yourself to the patient

-Name and age
-Occupation
-Establish rapport (e.g. 'its a pleasure to meet you') and maintain eye contact even if the patient does not

The Assessment

-Current self-harm episode:

-Precipitant e.g. argument with a partner, stress, having available drugs, depression, chronic disease, bankruptcy,
bullying, too much pressure to succeed, falling behind in work etc
-Planned? For how long? (>24 hours plan=higher risk of subsequent suicide)
-Were things normal to begin with? When did the feelings and events leading up to the act start? What relationships
were important over the last few months? Might the attempt have been made at anytime over this period?
-Method of harm?
-Did they expect it to be lethal?
-Did they make a will or modify a will, leave a note behind or modify their insurance? (if yes what did a note or will
say?)
-Were they alone?
-Did they confide in anyone? e.g friend, relative, GP, previous A+E doctor etc
-Were they intoxicated? e.g. alcohol, drugs
-Any precautions taken against discovery?
-Any help sought after suicide attempt?
-How did they feel when help arrived? Was this what they had expected?
-Had they thought it would take their life?

Empathy and dealing with hostility

-consider a statement like 'I can't begin to imagine what you must be going through but I'm very sorry to hear that
things have been so difficult for you'
-if they are hostile to you say 'I can't begin to imagine what you must be going through but I'm very sorry to hear that
things have been so difficult for you and I would like very much to help you'
-if they are angry about yet another doctor speaking to them and you're a psychiatrist say 'I'm a different type of
doctor from the ones that spoke to you before; I'm the doctor that can help you to decide what will happen next'
-Risk-factors:
-previous suicide attempts and self-harm; if so how serious were they? 'Have you ever made an attempt to take your
life?'
-recent life crisis
-male aged 25-44
-single, divorced or widowed (recent bereavement)
-unemployed
-occupations like medicine, dentistry and farming
-poor level of social support, social withdrawal and severe neglect
-in women 3 or more children < 5 years is a risk factor
-physical illness, chronic pain and disability
-psychiatric illness e.g. depression (sleeping, eating and early morning waking)
-substance misuse
-family history of depression, suicide or substance misuse
-mental state: assess current mood and rule out psychosis (do you ever feel you can see or hear things that other people
can't? Do you ever hear voices outside your head when you're alone?) and PTSD ( has anything happened to you in the
past that makes you very anxious? Any bad event? Do you get flashbacks and bad dreams about it?); GAD, phobic
disorders and OCD (do you feel anxious all the time or feel very afraid of something? Are there any things you do or
thoughts that you have that you wish you could stop but don't seem able to?)
-will he be returning to the same situation? What has changed? 'If you were to leave hospital today, how would you
cope'? 'Do you feel you have a future?'
-inquire about current suicidal ideation; has he made plans? If so how will they do it? Have they made a will or given
things away? Have they thought about their funeral arrangements? Do they want to be buried or cremated? With or
without flowers? Who will come? Who will discover your body? 'Do you feel life's not worth living?' 'Do you ever feel
you'd be better off dead and away from it all?' 'What prevents you from doing it?' 'Is anything a source of hope for
you?'/'do you ever feel completely hopeless?' 'How do you feel about yourself; do you feel that your life is
worthwhile?'

Page 44
Post-assessment
-thank the patient for speaking to you
-summarise findings, state suicide risk, suggest plan of action e.g. more investigations, psychiatric assessment,
hospitalisation, send home and follow-up in outpatients or at home (see more detail on this below)

Extra Information For Those Interested (not vitally important for the OSCE)
-Negotiate a contract for help by asking the family as to how to tackle problems
-Discussion with the family as to how problems can be tackled
-Prevention: by open access, walk in clinics or 24 hour phone service
-Follow-up with the patient alone or the family
-Problem solving by facilitating the patient's understanding of their predicament and by pointing out how they have
coped with their problem in the past
-If you decide to admit, ask why? Is it to gain something not possible outside hospital or is it to make yourself happy?
Why will it be safer to discharge on a few weeks rather than now? Remember there is no such thing as constant
surveillance. Also admission does nothing if it removes the patient from the environment they were in and have to cope
with. You also must distinguish between suicide gestures to influence others and a genuine desire to die. It is best to
think of suicide as something that happens after key events which accumulate risk-it is dynamic with risk factors and
protective factors like family support
-Having a negotiated contract with the patient means: the patient speaking to a professional therapist and then listening
and helping and the patient agreeing to be frank and informing of any suicidal thoughts or plans; agreement about
what problems to tackle should be explicit
;the type of change to aim for is made clear and agreed upon; it should be specified who will be involved in the
patient's care e.g. family, friends, GP; agreement about the timing and place of sessions; agreement about the patient's
responsibility to work effectively with the therapist and to carry out any homework
-NICE says 'the decision to discharge a patient without follow-up after an act of deliberate self-harm shouldn't be based
solely on the presence of low risk of repetition of self-harm and the absence of a mental illness, because many such
people may have a range of other social and personal problems that may later increase risk. These problems may be
amenable to interventions
-assessing the severity of an event means that you must assess perceived risk from the patient's perspective at the time
of the attempt: this may be at odds with the medical seriousness; take into account degree of planning vs impulsivity,
likelihood of interruption during the attempt, reaction to interruption during attempt (disappointment vs relief), suicide
note and it's contents, planning for the future (making of will, contents of suicide note) and personal view of suicide as
a reasonable decision/choice
-specialist referral: always in cases of attempted suicide, suicidal ideation or covert suicide; probably not with non-
persistent or poorly formulated views that life is not worth living
-high suicide risk=direct statement of intent, severe mood change, hopelessness, alcohol or drug dependence, abnormal
personality, living alone: admit via A+E or as psychiatric emergency; use the Mental Health Act for compulsory
admission if voluntary admission is declined
-low suicide risk=arrange for someone to stay with the patient until follow-up; remove all potentially harmful drugs,
liaise with psychiatric services about psych follow-up
-learn the sections under the MHA for holding a patient; also learn about common law powers and assessing capacity

Mrs Arnold is a 84 year old who came to A+E at 2am unconscious. She was resuscitated and after a toxicology screen
was found to have taken an overdose. She is now better. You are the SHO psychiatrist that has been asked to see her.

SUICIDE ADULT ASSESSMENT

Introduction
Consent
Age and Occupation
Good rapport
Maintains eye contact
Open question
Precipitant and how feelings before it
Planned and how long for
Method
Motivation/Hoping it would be lethal
Will or note and contents
Alone when taken overdose and why
Confided in anyone

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Intoxicated with drugs and alcohol
Precautions
After attempt: help sought
Feeling and expectations when discovered
Prior suicide or self-harm
Recent life crisis
Single, divorced or widowed
Employment issues/financial
Assesses level of social support
Assesses psychiatric illness
Physical illness and disability
Assesses for substance misuse
Assesses family history of depression, suicide or substance misuse
Assesses mental state: assess current mood
Rule out depression
Rule out psychosis
Rule out other psychiatric problems e.g. anxiety disorders
Will he be returning to the same situation? What has changed?
Inquire about current suicide ideation; has he made plans?
Thank patient
Summarise and state suicide risk (low vs high)
Mx plan (discharge vs admission etc)

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 SUN ADVICE
Nature of UV light
-Tell the patient that there is such a thing as ultraviolet light/radiation. It is in the rays of the sun (the sunlight that
shines on us)
-There are 3 types- A, B and C
-A and B are the ones to worry about. The C type does not reach the surface of earth so it doesn't reach our skin.
-A and B can get to our skin and cause sunburn, ageing of the skin prematurely and even skin cancer. Around 90% of
UV light that reaches us is UVA. UVB is much more dangerous because it's radiation rays have a higher energy

Exacerbating factors
-There are certain factors which make you more likely to suffer the effects of UV light:
-Time of the day: the sun will affect your skin most at midday
-Time of the year: summertime is a time when skin is more liable to be exposed
-Latitude: closer to the equator means more exposure
-Altitude: the higher up you go the more the exposure
-Clouds: more clouds decrease exposure as opposed to sunny days
-Ozone: where there is less there is more exposure to UV
-Type of skin: the lighter your skin the more likely you are to get burnt

Protection from the sun

-There are 4 ways:
-Avoid the sun from 11am to 3pm when the sun has most intensity; stay away from outdoors if possible
-Stay in the shade
-Use clothes to protect yourself e.g. Hats of wide brim or caps, long-sleeved clothes, sunglasses
-Use sunscreen

Sunscreen
-It works by UV light reflection or absorption; most of the ones that absorb do not protect much; those that do only
protect against UVA. The reflectants are much better as they block UVB and UVA; the problem with them is that they
leave a white film visibly and thus are less acceptable cosmetically.
-Types:
-A star rating is given for the sunscreen's protection against UVA; it can be 1-4 stars with 4 being the maximum
protection; make sure you use one with at least 3 stars
-A sun protection factor rating (SPF) is given for protection against UVB; it can be from 2 up to around 60; make sure
you use one with a rating of at least 30. It tells you the amount of time longer than usual it would take for the skin to
turn red (sunburn). So SPF 30 means it would take 30 times longer than usual. Sunscreens with an SPF of 30 or greater
are considered to give helpful protection against harmful rays of the sun.
-Its vital to remember that you should not spend longer in the sun just because of the sunscreen because it doesn't give
full-proof protection

Method of application
-On all the areas exposed to sun put it on thickly; this means the ears, the neck, a head if bald; any other areas like
arms if exposed
-Re-apply the cream regularly, for instance after swimming

Moles
-These are localized collections of melanocytes (cells that make melanin, a substance that gives skin its colour) that tend
to first appear in childhood. Most people have 5-20 of them. They can be inherited or acquired.
-Not a problem but can become cancerous (malignant)
-Signs of concern:
-Change in size
-Change in shape
-Change in colour (be there more colour or less)
-Change in edge or surface to irregularity
-Bleeding
-Inflammation
-Itching
-Nodularity
-Ulceration
-If any of these signs arise the patient should report it i.e. go and see doctor

-Summarise
-Ask patient if they understand

Page 47
-Any questions?
-Give a leaflet on sun protection/suggest website

SUNSCREEN ADVICE

Introduction
Consent
Brief Hx: does your skin tan or burn easily? How many times happened? Do you use a sunbed? Have you
ever had skin cancer?
Explain UV light
3 types: A, B and C
C does not reach earth's surface, A and B are the worry
A and B can reach our skin to cause sunburn, premature skin ageing and skin cancer
90% of UV that reaches us is UVA but UVB is more dangerous as it has a higher energy
Exacerbating factors: time of day, season, type of skin, altitude, latitude, ozone
4 ways of protection: avoid midday, shade, clothes, sunscreen
Mechanism of sunscreen action: absorption and reflection
Good sunscreen= one that protects against UVA and the more harmful UVB
Star rating 1-4=protection against UVA; should get one with at least 3 stars
SPF (Sun protection Factor) rating 2-60=protection against UVB; should get one with a rating of at least 30
(means it would take 30 times longer than usual for skin to turn red=sunburn)
Precaution with sunscreen: do not spend longer in the sun just because of it; it's not full-proof
Application: apply thickly to all sun-exposed areas e.g. face, ears, bald head, neck, exposed arms
It should be reapplied regularly e.g. after swimming
Explain moles: a collection of cells that make skin pigment; tend to appear in childhood
Can be inherited or acquired
Normal: most people have 5-20 of them
Signs of concern: change in size, shape, colour, change to irregular edge or surface, bleeding, itching,
nodularity; if any of these report it to a doctor, could become something more serious (cancer)
Offer patient leaflet and check understanding; summarise (but don't waste time: hurry on to examination)

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Emergency Medicine, Trauma and
Locomotion (EMTL)

Page 49
 ALS
Method To Use in OSCE Station

-Introduce yourself to examiner

-DRS: danger, response, shout: tell the examiner you'll make sure you are safe, shake the dummy by it's shoulders and
call it's name/say 'can you hear me' etc, give sternal rub and finally call out to someone for help if no response from
patient
-A and C-spine: ask the examiner if you can assume no c-spine injury; apply head tilt and chin lift; look in the mouth
for any obstruction
-B: look, listen and feel with hand on chest and ear/cheek to mouth for no more then 10 secs (while doing head
tilt/chin lift)
-C: check carotid and/or femoral no more than 10 seconds
-If it is only respiratory arrest i.e. no breathing but a pulse, then just ventilate and keep re-checking pulse
-If it is cardiorespiratory arrest i.e. no breathing and no pulse then say you will call 2222 arrest team

Start CPR 30:2

-give 30 compressions at a rate of 100 a minute: centre of the chest, fully extended elbows, 4-5cm deep, do not ever
remove hands from the chest (except for defib): leave 1 hand on to feel the chest rise even while the person in charge
of the airway gives a breath; this also allows you to immediately resume compressions; count the compressions out loud
for the examiner
-give 2 breaths: take the bag and and valve mask and put head into head tilt and chin lift (and some jaw thrust if you
wish); then place your thumb and index finger firmly on the mask and put middle finger, ring finger and little finger on
bone e.g. on angle of mandible(not on soft tissue which can cause airway obstruction); compress the bag twice, each
breath being 1 second in duration; the two-handed technique with an assistant is preferable; after a definitive airway is
in, ventilate at around 10-12 breaths a minute
-when arrest team arrives, say you would place some one in charge of the airway and another in charge of
compressions and would have a team coordinator e.g. yourself
-switch on machine and choose lead 2; put on leads (Ride Your Green Bike); put on the two pads, one on the right
chest under the clavicle and the other in the left mid-axillary line
-check the electrodes are connected and the leads are connected
-tell everyone to stop compressions, check pulses and check rhythm: if VF=shock; if VT with pulse don't shock; if VT with
no pulse=shock; if asystole or PEA=don't shock
-for shock set at 150J, check all clear: 'oxygen away, step back, side clear, back clear, I'm clear' Then make sure you
are looking at the rhythm just before shocking: shout 'shock at 150J' and deliver shock
-continue compressions immediately without checking the rhythm nor pulse for another 2 minutes
-you must tell the examiner that: you would check electrode position and contact (always check the position of electrodes
and leads while compressions are going on to minimise the time you stop compressions for when you stop to shock),
get IV access, get a definitive airway e.g. ET tube so that compressions can be uninterrupted and 100% oxygen can be
given
-you must say you would draw up 4 drugs: adrenaline 1mg, amiodarone 300mg (lidocaine 100mg or 1mg/kg is an
alternative; 3mg/kg is the highest you can give in the first hour; never give both amiodarone and lidocaine), atropine
3mg and magnesium sulphate 8mmol (4ml of 50% solution)
-say you would look for reversible causes: hypoxia (blood gases and secure airway), hypovolaemia (visible wounds,
history, BP, give fluids: saline or Hartmann's, NOT dextrose), hypo/hyperkalaemia/metabolic (blood gases), hypothermia
(check temperature), tension pneumothorax (trachea, hyperresonance on 1 side, decreased air entry on 1 side),
tamponade (muffled heart sounds and raised neck veins), toxins (history, do toxicology screen), thrombosis (blood gases,
history, consider thrombolysis during resus)
-second shock is at 150J-360; with biphasic just do at 150J again
-before 3rd shock give adrenaline 1mg; repeat every 3-5 minutes/every alternate cycle
-before 4th shock give 300mg amiodarone by bolus injection; a further 150mg can be given later if there is refractory
VF/VT, then a 900mg/24 hours infusion
-with asystole and VF, do not recheck pulses since they are imcompatible with life; only check the pulse again if you get
an organised rhythm; with organised rhythms=VT and PEA, you should check the pulse
-with asystole keep doing compressions and give 1mg adrenaline and 3mg atropine as soon as IV access is achieved;
then give adrenaline every 3-5 mins and do not give atropine again
-with PEA keep doing compressions and give 1mg adrenaline as soon as IV access is achieved; then give adrenaline
every 3-5 mins; do not give atropine for fast PEA (>60 beats/min) but give it for slow PEA (<60 beats/min)
-when you have an organised rhythm, and find a pulse:
-go into post-resus care: the aim here is to stabilise the patient before transfer to a high-care area like intensive care:
monitor pulse, BP, O2 sats, ABGs; definitive airway, gastric tube to decompress stomach, chest x-ray, intra-arterial line,
fluids, therapeutic hypothermia, sedation, blood glucose monitoring etc
-if you have an organised rhythm but no pulse, you can't go into post-resus care; follow the non-shockable rhythm

Page 50
protocol in this case
-magnesium is for refractory VF if hypomagnesaemia is suspected; also for torsade de pointes, digoxin toxicity
-calcium can be given for PEA if it is due to hyperkalaemia, hypocalcaemia, OD of calcium channel blocking drugs or
overdose of magnesium (as in pre-eclampsia Tx); the dose is 10ml 10% calcium chloride

Read 18 page document on resus website: http://www.resus.org.uk/pages/als.pdf

BLS/ALS: You are the F1 checking the patients on your ward handover list at 11pm. When you walk into Mr Robinson's
room to see how he is, he doesn't seem to respond to your calls.

BLS/ALS
Assesses for danger/hazards
Assesses patient response with shake and shout and noxious stimulus
Shouts for help when there is no response
ABC
Queries C spine injury
Open airway with head tilt/chin lift or jaw thrust and check for obstruction
Listen, look and feel for breathing for 10 seconds
Check pulse (carotid/femoral)
Calls resuscitation team
BLS
Gives 30 compressions
Centre of chest, 5cm deep, extended elbows, rate of 100 a minute
30:2
Correctly gives 2 breathes with bag and valve mask: 1 sec per breath
Checks for chest rise
ALS
Checks equipment
Applies electrodes
Applies chest pads
Machine: lead 2, 150J biphasic
Assess rhythm (VF/pulseless VT) after stopping compressions
Charge and deliver shock safely
Continue compressions without reassessment of rhythm
During CPR check electrode position
Check leads before shock
Establish IV access (2 large bore cannulae), attempt/verify airway and oxygen
Drugs: adrenaline, amiodarone, atropine, Mg
Give adrenaline 1mg 3-5 min
Consider amiodarone (300mg before 4th shock)
Atropine 1mg once only slow PEA (<60 beats per min) or asystole
Magnesium 8mmol (2g or 4ml of 50% solution) for refractory VF with hypomagnesaemia
Give 100% oxygen (via BVM or ET/LMA)
Give uninterrupted compressions once the airway is secure
Reversible causes: 4 H's and 4 T's
When SR (sinus rhythm) on monitor, CPR for further 2 minutes
Check for signs of life
Post-resus= P, BP, SpO2, ABG etc

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 IV CANNULATION
The purpose of this station is to cannulate the peripheral vein of a model arm and to then administer medication or to
put up an IV fluid bag. You must show safe technique and precautions against needlestick injury to yourself and others.
Speak to the examiner, explaining what you would say to the patient.

-Tell the examiner that you would introduce yourself to the patient and confirm their name, DOB and hospital number
on their wristband (the model actually has a wristband so check it)
-Tell the examiner you will get consent from the patient to place a cannula (a small plastic tube) into their vein to give
fluids and medication; this will involve a brief sting from a needle (of course this explanation is unnecessary if the
station instructs that the patient is unconscious e.g. emergency patient or patient under GA)
-Discuss with the patient their preference, including dominant handedness
-Have the patient lying in bed in case they faint, forearm below the level of the heart; keep the forearm exposed and
well supported
-review any problems with cannulation such as lymph node dissection with lymph stasis (increased risk of cellulitis or
phlebitis), an arteriovenous fistula (into which a cannula should never be inserted)

Cannulation Technique

Place the sharps bin near to you (and open it) so that you don't forget and make sure there is a clinical waste bag
around; wash your hands and roll up your sleeves and then prepare your equipment in a tray:
-small cannula (choose pink=20G; if not that then green=18G) (the smallest is blue 22G but don't use this one if
possible); small cannulae are used generally for fluids and drugs while big ones are used for A+E and surgery; the size
used is decided by the fluid viscosity and the rate of infusion needed; (white=17G, grey=16G, orange=14G); the water
flow rises from 33ml/min for blue up to 270 ml/min for orange
-tourniquet
-gloves (non-sterile)
-cotton wool (pad to absorb blood that overflows)
-sterile (alcohol) wipe
-cannulation bandage/adhesive plaster (a dressing to secure the cannula)
-plus sterile syringe of saline wash of around 5ml to wash through cannula afterwards (plus correct choice of needle
colour to take it out)

20 gauge (pink) and 18 gauge (green) are the most frequently used. Grey is used for resuscitation. The cannula most
used is the cannula-over-needle type. The fluid giving set is attached to the Luer-lock horizontal component whereas
saline wash and syringe drugs/medications are given through the injection port which points vertically/perpendicular to
the axis of the cannula.

-Put on gloves
-Find a good vein: avoid joints so not the antecubital fossa if possible; try to find a vein at a 'V intersection' in the
dorsum of the hand; the forearm and dorsum of hand are the most commonly used sites and so review these first;
choose away from bruised, infected, oedematous, scarred or thrombosed veins to avoid infection or necrosis; best to
choose a vein that can be seen and palpated, is healthy, not close to a valve and patent; veins you can feel are
generally better then the ones you can see; a distended vein feels firm and bouncy; you will feel a pulse over arteries
e.g. the brachial artery close to the median cubital vein
-If you can't find a good vein, strategies for vein distension include asking the patient to close their hand into a fist and
then unclench it (though this raises potasssium levels and gives false hyperkalaemia and so is best avoided), keeping the
arm below heart level, gently tapping the veins; applying the tourniquet for 1 minute, undoing it and then reapplying it;
running arm under warm water for about 1 minute
-Put on the tourniquet just above the wrist or site of insertion; the pressure should be enough to impede venous
distension and flow, but not arterial distension and flow; and assess the vein again
-Wipe the vein with alcohol and leave it to dry (drying kills the bacteria); wipe only once unidirectionally
-While it is drying, open the venflon pack and take the guard off the cannula, take off the cap at the back and put it to
one side
-Anchor the vein with your left hand because veins can move prior to puncture; tether the surrounding skin with your
thumb and index finger to stretch the skin and anchor the vein down ; tell the examiner you would tell the patient to
expect a needle sting/sharp scratch and to not move their arm (in situations where movement is a worry get assistance
from auxiliary staff like a nurse)
-Hold the cannula in such a way that your fingers do not go below the wings at all; in other words there should be
nothing between the undersurface of the cannula and the skin
-enter at a shallow angle of 30º; either enter the vein directly or go into the skin first, then the vein; do all this in one
assertive move
-tell the examiner you are looking for flashback in the back of the cannula; once you see flashback, reduce the angle of

Page 52
30º, advance the cannula further by a couple of millimetres
-pull out the needle and simultaneously advance the cannula in a smooth motion (if the cannula turns out to not be in
the vein then do not ever reintroduce the needle and stylet back into the vein)
-undo the tourniquet one the cannula is fully in before taking out the needle
-apply pressure proximally to the cannula and elevate the arm above heart level to prevent blood spillage; place tissue
paper distally to the cannula to catch any spillage
-check that the cannula is fully in and then remove the needle and bin it immediately
-put the cap on the end of the cannula
-put the dressing on the cannula to secure it; the 2 wings of the dressing should point to the proximal end/cap end of
the cannula
-open the injection port of the cannula and inject saline wash; this checks patency of the cannula and washes away
blood to stop it coagulating in the proximal cannula and causing blockage; also look at the vein to look for any saline
entering the subcut space causing swelling (indicates misplaced cannula)
-throw away waste in the clinical waste bag
-record the time and date of cannulation on the dressing
-good to remove a cannula when it is no longer needed
-thank the patient

Fluid Technique

-Check the drug chart and check it is the patient's chart and check any allergies (on the drug chart and on their
wristband)
-Check the type of prescription fluid they need e.g. saline
-Get the right fluid bag and open the packaging; check the name on the bag and the expiry date
-Get the giving set and have the pole for hanging the bag nearby; hang the bag on the pole
-Open the giving set's packaging and take off the protective piece at the bottom of the fluid bag's exit port
-take off the protection from the pointed end of the giving set and penetrate this into the fluid bag's exit port
-close the giving set roller's position (down=closed)
-remove the protective covering from the other end of the giving set (this must be kept sterile)
-squeeze and release the collecting chamber of the giving set until it is around half full
-run it through at the tap to remove air bubbles, holding the end at the same level as the chamber; then close the
giving set again
-attach it to the fluid port of the cannula and turn it on, hanging the fluid bag
-adjust the drip rate (1 drip a second is around 1 litre/6 hours; 80/min may be more appropriate)
-thank the patient
-dispose of any waste in the clinical waste bag
-sign the fluid chart with the time of administration and date

Medication Technique

-Check the drug chart and check it is the patient's chart on the chart and check any allergies (on the drug chart and on
their wristband)
-Check the type of drug they need and the dose e.g. 250mg amoxicillin
-Get the right drug vial and check the name, dosage and expiry date
-Get a sterile syringe and appropriate sized needle to put on it to extract the medication; take out a few mls of the
medication and then detach safely and dispose of the needle in the sharps bin
-open the injection port of the cannula and inject the drug
-sign and date and give the time of administration on the prescription chart

Drip rates with a standard giving set= 20 drips/ml (don't need to know this for year 4 OSCE)
-40 drips/min= 1 litre every 8 hours (infusion rate 2 ml/min or 125 ml/hour)
-60 drips/min= 1 litre every 6 hours (infusion rate 3 ml/min or 166 ml/hour)
-80 drips/ min= 1 litre every 4 hours (infusion rate 4 ml/min or 250 ml/hour)
-160 drips/min= 1 litre every 2 hours (infusion rate 8 ml/min or 500 ml/hour)
-320 drips/min= 1 litre every 1 hour (infusion rate 16 ml/min or 1000ml/hour)

Station 1): Insert an IV cannula into this arm and give fluids.
Station2): Insert a cannula into this arm and give the required medication.

IV CANNULATION
Introduction: name
Checks DOB and wristband of patient for hospital number
Consent

Page 53
 Preferred hand
Wash hands
Wears gloves
Sharps bin
Chooses correct sized cannula e.g. 20 gauge pink
Applies tourniquet
Select suitable vein
Prep skin and leave to dry
Tether the skin and hold cannula correctly
Enter at shallow angle
Inform patient they will feel a sharp scratch
Flashback
Advance cannula and withdraw needle and stylet
Undo tourniquet and apply pressure proximally
Dispose of needle in sharps bin immediately
Cap cannula
Applies dressing correctly and dates dressing
Saline wash injected through injection port to wash through cannula
Throw away waste and thank patient
Fluids
Check drug chart and wrist band
Checks allergies
Wears gloves
Checks type of fluid and expiry date
Giving set attached to fluid bag
Squeeze and release collecting chamber until half full
Run through to remove air
Attach to fluid port of cannula and run
Aseptic technique
Adjust fluid drip rate
Sign and date chart
Throw away waste and thank patient
Medication
Check drug chart and wrist band
Checks allergies
Wears gloves
Checks type of medication and dose and expiry date
Ensures no allergies to this drug
Use right sized needle (e.g. green needle) and syringe to extract drug from vial
Dispose of needle in sharps bin immediately
Administer drug through injection port and sign and date the chart
Throw away waste and thank patient

Page 54
 EXPLAIN EPIDURAL
-Introduce yourself to the patient
-Name, age, occupation
-Consent for discussing epidural

-Give a summary of what the presenting symptoms of the patient are e.g. 'you're going to have abdominal surgery and
are a candidate for an epidural as pain relief'
-Inform the patient first of what you will explain to them e.g. 'I'll tell you what an epidural is and what it's benefits and
risks are'

-Find out what the patient already knows (I) e.g. 'have you had an epidural before?'
-Find out how much the patient wants to know (is there anything they don't want to know) (E) e.g. 'what would you
like me to tell you about an epidural?'
-Bring out the worries/concerns that the patient has (C) e.g. 'are you worried about having an epidural? What worries
you?'

-Give the information:

-Definition: an epidural is a local anaesthetic +/- opiates (into space between L3 and L4) which blocks the feeling of
pain in your lower body; this means you can't feel pain in the lower body after it: it will feel numb; (complete sensory
(except pressure) and partial motor block from upper tummy down is usual)
-Method (1): a needle is put into your back to be near the nerves for pain that go into the spine; an anaesthetic is
released to block the nerves; a tube is left in the back so that the anaesthetic can carry on being given to top it up
when it runs out or it can be given continuously
-Method (Continued): you lie on side or sitting; slight stinging when LA in; discomfort when tube put in; warm and numb
feeling-no more pain but may feel pressure, touch and movements; heavy legs
-Benefits: will give pain relief during and after surgery and is good pain relief=makes you painfree; you can remain
awake in surgery; allows you to go back to movements, eating and drinking more quickly (faster recovery); decreases
surgical complications like nausea, infection, sickness, vomiting and blood clots; epidurals are better for smokers also;
-Stopping it: stopped when you don't need it anymore; tube taken out a few hours after stopping;the feeling comes
back to your legs a few hours after no more drugs being given; nurses and pain relief team will monitor you to make
sure all is working well with the epidural
-Contraindications: sepsis, blood thinners, clotting problem, severe spine arthritis or deformity, LA allergy, back infection,
active neuro disease, hypovolaemia
-Side-effects: can't pass urine (catheter needed), lowers BP, itching, backache, headache; rare= nerve damage, fits; more
supervision needed to check BP and pulse, bed bound and so lose mobility (except with low-dose regimes mixed with
spinal), urinary retention from decreased bladder sensation, maternal fever more common, instrumental delivery more
likely though not C sections; hypotension can be dealt with by giving fluids first (+/- ephedrine later); transient fetal
bradycardia (does not usually lead to fetal distress), no evidence for link between epidural and back pain post-delivery
of baby; risks: 0.5% spinal tap=puncture dura and CSF leak causes severe headache, can be treated with blood patch to
seal the leak; very rarely=IV injection causes convulsions and cardiac arrest; LA into the CSF accidently can progress up
spinal cord and cause total spinal analgesia (TSA) and respiratory paralysis; very safe in expert hands but needs more
midwifery care and modification of second stage of labour to avoid increased instrumental deliveries (summary: spinal
tap, TSA, hypotension, LA toxicity, more instrumental deliveries, poor mobility, urinary retention, catheterisation often
needed, maternal fever, cardiac outflow obstruction)
-Choice: if you don't want it you can have a spinal injection, GA, regional anaesthetic drugs by mouth (if possible) or
PCA (be prepared to explain the basics of these also)

-give a summary and

-assess patient's understanding
-ask the patient if they have any questions and encourage it; answer them
-thank the patient

Obstetrics: an epidural does decrease the urge to push which is automatic in women without epidural; but all this means
is that pushing with an epidural has to be directed in the second stage of labour (told to push with contractions 3 times
for 15 sec per contraction), whereas it happens without direction without epidural since the mum is not encouraged to
push until she has the urge to ; it means delivery may be a little longer with epidural and means there is a higher
chance of instrumental delivery(but not C section) since the second stage may not be completed in 1 hour as it's meant
to be; but the point is you can still push with epidural

Mr Gerard is about to undergo an operation and has requested an epidural. You are the SpR in Anaesthetics. Discuss
his request.

Page 55
 EXPLAIN EPIDURAL
Introduction
Consent
Rapport
ICE
Suitability for epidural
Explains epidural
Advantages and disadvantages of epidural
Thromboembolism
Pain relief
Mobility
Chest/physio compliance
Contraindications
Risks
Alternatives: GA, PCA,paracetamol, NSAIDs, IM
Checks understanding
Summarises
Clear
Addresses concerns appropriately

Page 56
 Foot Examination
Note: this almost never comes up in the Year 4 OSCE: the common stations are shoulder, hip, back, knee, hand and
GALS

Introduce yourself
Explain the exam and get consent-may I assess your ankle and foot with some questions and a clinical examination?
Exposure: from waist down keeping on underwear; shoes and socks off

The History

-Name
-Age
-Occupation

-Pain: SOCRATES. Where? What type? For how long? Gradual or sudden onset? Continual or comes and goes? Getting
better or worse? Radiation? Alleviating/exacerbating factors? Severity-how affecting life= sleep/pills?
-Swelling: Where? For how long? Gradual or sudden onset? Continual or comes and goes? Triggers? How long after
after triggering factor did it appear? (immediate vs delayed)
-Stiffness: morning (RA); after inactivity; after movement
-Neurological: weakness, tingling/numbness
-Trauma
-Function: walking, running, going up and down stairs

The Examination

Look standing
-from front: toe disorders like hallux valgus, redness and swelling (1 st MTP in gout) , sausage toe (dactylitis= psoriatic
arthritis); oedema, splay-foot (widening at the MTPs=synovitis);
-from side: midfoot: the medial longitudinal arch for pas cavus (high arched foot) or pes planus (flat foot); if they have
pes planus ask the patient to stand on their tiptoes-it will correct if it is a mobile deformity but not if it is structural;
-from behind: alignment of the heel= normally valgus?

Gait
-antalgic, Trendelenburg, shortened limb
-high stepping=foot drop
-is the foot supinated or pronated when it hits the ground?
-hallux rigidus (limited movement of the big toe)

Look lying
-callosities on the soles of the feet: thickened areas caused by repeated pressure and rubbing from shoes or socks (these
are different from corns in that they occur on areas that experience wear and tear e.g. heel, and also they don't have a
hard centre as corns do)
-inspect the shoes for abnormal pattern of wear on the soles and any insoles/other fittings in the shoe
-corns: circular thickened lesions found on areas less susceptible to pressures of wear and tear e.g. the tips of toes, and
have a hard centre
-claw-toes: MTPs are dorsiflexed while PIPs and DIPs are plantar flexed
-hammer toes: MTPs and DIPs are dorsiflexed but the PIPs are plantar flexed
-mallet toe: just the DIP is plantar flexed
-desquamation of skin (gout)
-nails
-sinuses
-joint swelling
-scars
-colour
-bruises
-ulcers
-foot drop
-fixed plantar flexion

Feel
-ask if there is any pain and watch patient's face
-temperature above ankles (for comparison), ankle and foot joints
-press the forefoot (MTPs): pain could be Morton's neuroma or RA

Page 57
-palpate the joints, watching the patient's face as you do so:
-DIPs
-PIPs
-MTPs
-the ankle joint: the malleoli, the ankle bones, around the joint line
Move-do actively and passively
-plantar flexion:ankle (45º)
-dorsiflexion:ankle (15º); if restricted, try with the knee extended and flexed; if more is possible with knee flexion then it
could be a gastrocnemius contracture
-inversion: subtalar (20º): dorsiflex the foot to isolate the subtalar joint and then do inversion/eversion
-eversion: subtalar (10º); you can then test the combined joint movements by holding the heel in left hand and forefoot
in right and then testing dorsiflexion, plantar flexion, adduction, abduction, pronation and supination
-toe flexion and extension; if there is pain, try to work out which joint it is due to (i.e. MTPs, PIPs, DIPs)

Special tests
-put the patient on a chair kneeling with both knees
-palpate the Achilles tendon: feel the Achilles tendon and the gastrocnemius to judge any swelling and elicit any
tenderness; if the tendon is ruptured you will feel a gap roughly 5cm above the calcaneal insertion
-Thomson's test/Simmond's test: find the place of maximum circumference in the leg (the calf area); squeeze just distal to
this area with your thumb on one side and index finger/other fingers on other side; if the Achilles tendon is intact the
foot will plantarflex; if not intact it won't

Suggest:
-complete neurovascular examination of the lower limbs
-examine the knee and hip; the back also if foot symptoms are in a myotomal and/or dermatomal distribution

End
-thank the patient
-help the patient to redress make sure they are comfortable
-summarise and give differential diagnosis and management plan (Ix and Tx)

Possible OSCE conditions

-RA
-OA
-plantar fasciitis
-ankle injury
-foot deformity

For foot problems see www.footphysicians.com

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 GALS
GALS is gait, arms, legs and spine
It is a screening test only, not a detailed assessment; it screens for musculoskeletal deficits, neurological deficits and
functional ability in routine clerking

Introduce yourself
Explain the exam and get consent-may I examine/assess your joints with some questions and a clinical examination?
Exposure: to the undergarments (underwear) and get them to stand in front of you (after asking the questions below
ideally); socks off

History

What is your
-age
-occupation
Is there
-pain or stiffness in your joints, muscles or back? (do you have pain or stiffness in your joints, muscles or back?)
Is there
-difficulty in climbing stairs up and down? (can you climb up and down stairs without any difficulty?)
Is there difficulty in
-washing or dressing? (can you dress and wash yourself completely without any difficulty?)
If they say no to all three
-it is improbable that any musculoskeletal problem is present; move on to examination
If the patient says yes then
-go into more detail in your assessment i.e. a more detailed history e.g. site, severity, are you fit and well, what
happened, how did it start?, when did it start?
These 3 questions can be incorporated into
-the routine systemic enquiry of all history-taking

Examination

Wash hands
Inspection standing in the anatomical position with straight elbows
-generally look for:
-abnormal posture
-scars
-swellings
-deformities
From the front look for
-shoulder bulk
-elbow extension
-quadriceps bulk and asymmetry
-knee swelling and deformity
-foot arches: high or flat or normal?
-forefoot or midfoot deformities
From the side look for
-cervical lordosis
-thoracic kyphosis
-lumbar lordosis
-knee flexion or hyperextension
From the back look for
-shoulder muscle bulk and asymmetry
-straight spine and symmetrical paraspinal muscles
-level iliac crests
-gluteal bulk and symmetry
-popliteal swelling
-calf muscle bulk
-hindfoot abnormalities

Gait (instruction: walk some paces in a straight line and back); look for
-symmetry of the gait and its smoothness
-ability to turn quickly
-gait phases: stance, push-off, swing and heel strike

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-general: rhythm, speed, turning, limp, arm swing, stride length
-transfer ability: sitting and standing from a chair (you should actually have seen this already as part of the
consultation)

Spine
-look:
-from front
-from behind for scoliosis and lumbar lordosis and muscle wasting, trunk and leg symmetry; at the level of the iliac
crests look for asymmetry (suggestive of leg shortening on 1 side); anomalies and swelling of calf muscles, popliteal
muscles, gluteal muscles and hamstring muscles; observe the hindfoot area and the Achilles tendon for swelling or
(dwelling?!)
-from side for kyphosis and fixed flexion deformity

-feel:
-palpate the vertebral bodies one by one in an attempt to elicit tenderness; and the paraspinal muscles

-move:
-get the patient to bend forward and touch their toes (you look for anomalous spinal curvature and limitation of hip
extension could be revealed); while doing this do Schober's test by putting your fingers on back: even better measuring
tape 10cm above and 5cm below the ASIS level
-look for loss of the lumbar lordosis when they bend and scoliosis (it becomes more prominent on bending) and the
range of movement-is it normal?
-extension of lumbar spine
-lateral lumbar flexion: slide hand down the leg

-on the couch:

-just getting the patient to lie on the couch-this is a test of the ability of the patient to do it
-open jaw and move from side to side: this is for the TMJs
-neck: cervical lateral flexion-'put your ear on your shoulder keeping your shoulder still' (first thing to be abnormal with
cervical spondylosis)
-neck flexion and extension-'put your chin on your chest'
-spinal rotation-'turn your upper body to either side' (you must stabilise the hip and the patient can't use their feet: this
is thoracolumbar rotation)
-show each of the above movements to the patient; you are looking for a restricted movement range and pain on
movement

Arms
-look with elbows tucked in to side:
-skin for nail signs, rashes and nodules
-muscles for wasting and fasciculation e.g. backs of hands
-joints for deformity, swelling and asymmetry
-look at both dorsal and palmar surfaces both

-feel
-skin for temperature
-muscles for the general bulk
-joints for warmth, tenderness and effusion; at the carpal and metacarpal joint level squeeze each hand; find local
tenderness by feeling each joint in turn (pain can mean joint or tendon synovitis)
-palpate the midpoint of each supraspinatus muscle above the spine of the scapula gently with your index finger to pick
up hyperalgesia typical of fibromyalgia (other typical sites are the trapezius muscle, lateral epicondyle of elbow and
medial knee)

-move: get the patient to put their elbows against the side of their body bent 90º
-shoulders: full external rotation and abduction (via putting the hands behind their head with the elbows fully back); this
tests function also since getting to the head is needed for dressing, washing and feeding
-hands: power grip by the patient squeezing your finger (your index and middle fingers) and pincer grip by the patient
stopping you from breaking their pinch; before doing this get the patient to show you they can make a fist without
squeezing your fingers and get them to touch their thumb to each finger before testing pincer grip power
-wrists: flexion and extension: get patient to make the prayer sign asking the patient to bend the wrist as far back as
possible; then do the same with the backs of the hands against each other
-elbows: flexion and extension: bend the elbow such that the hands reach the shoulders (flexion); then ask the patient to
hold the arms straight (extension)

-supination and pronation at the elbow and wrist: get the patient to turn their palms up and down
-clench the fists and then open the hands flat (with elbows tucked into sides): this is a test for the hands and wrists
-check that the fingers can be extended fully at the MCPs, the PIPs and the DIPs

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-touch each finger with your thumb: this assesses precision grip quality and coordination and concentration
-squeeze the metacarpal heads (MCPs area): tenderness can mean there is an inflammatory disorder such as RA
affecting MCPs and PIPJs
-show each movement to the patient; look for restricted movement range and pain on movement

Legs
-patient is now told to lie down on the couch supine
-look:
-skin for rashes, nodules and callosities and ulcers on the soles of the feet (suggestive of anomalous load bearing)
-muscles for wasting and fasciculation (especially quadriceps)
-joints for deformity, asymmetry and swelling; look for leg length discrepancy

-feel
-skin for temperature
-joints for warmth, tenderness, swelling (at the knee and MTP joints especially)
-squeeze each foot and try to localise the tenderness by squeezing each joint in turn (squeeze the metatarsal heads;
tenderness can mean there is an inflammatory disorder such as RA)
-patellar tap (for effusions and inflammation: if there is fluid consider aspirating it and testing for infection or crystals)
-move
-bend each of the knees passively by pushing of the heel into the buttocks and then extend with your hand on the knee
to feel for crepitus in the patellofemoral joint
-flex the hip also and then internally and externally rotate the hip with the knee and hip in 90º flexion passively: watch
the patient's face to make sure they don't have pain and also look for limitation of movement
-after that put your hand on the knee joint and do extension of the knee, palpating with the other hand for crepitus

End
-thank the patient
-offer to help the patient to redress; make sure they are comfortable
-summarise and give differential diagnosis and management plan (Ix and Tx); summarisation is with 'appearance and
movement' :

Perform a musculoskeletal screening assessment (GALS) on this patient.

GALS
Introduction
Consent
Name and occupation
History
Pain or stiffness in joints, muscles or back
Difficulty in climbing stairs
Difficulty in washing or dressing
Examination
Wash hands
Correct exposure
Full inspection: from front, side and behind
Assesses gait and comments appropriately on it
Asks about pain before palpation
Spine
Inspects spine for deformities
Palpate spinous processes
Palpate soft tissues
Lumbar flexion and measurement
Lumbar extension
Lateral lumbar flexion
TMJs and neck movements: flexion, extension, lateral flexion and rotation
Thoracolumbar rotation
Arms
Inspection with elbows tucked to side: swelling, wasting and deformities of palm and dorsum
Palpate for temperature
Squeeze MCPs
Shoulder external rotation and abduction (hands behind head)
Elbow flexion and extension
Supination and pronation
Wrist flexion and extension

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 Precision: touch each fingertip with thumb
Power grip
Pincer grip
Clench fist and open fully
Legs
Inspect for deformity and swelling in feet and knee, wasting, fasciculations, callosities and ulcers
Inspect for asymmetry
Palpate temperature (knees and feet)
Squeeze MTPs
Patellar tap
Knee flexion and extension with hand over patella
Hip flexion and internal rotation
Thanks patient and offers to help redress

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 Hands
Introduce yourself: do not shake hands with the patient
Explain the exam and get consent-may I assess your hands and arms with some questions and a clinical examination?
Exposure: to the elbows

The History

-Name
-Age
-Occupation

-Pain: SOCRATES. Where? What type? For how long? Gradual or sudden onset? Continual or comes and goes? Getting
better or worse? Radiation? Alleviating/exacerbating factors? Severity-how affecting life= sleep/pills?
-Swelling: Where? For how long? Gradual or sudden onset? Continual or comes and goes? Triggers? How long after
after triggering factor did it appear? (immediate vs delayed)
-Stiffness: morning (RA); after inactivity; after movement
-Neurological: weakness, tingling
-Function: dressing (zips/buttons), washing, bathing, feeding, cooking, cutting food and help at home

The Examination

Comfort
-put hands on a white pillow and ensure comfort

Look at dorsum of hand:

-nails: pitting (psoriasis and alopecia areata), onycholysis, hyperkerotosis (psoriasis), koilonychia (Raynaud's, iron
deficiency), nail-fold infarcts (vasculitis), dilated end-capillary loops at nailfold (dermatomyositis), Beau's lines (transverse
furrows: Raynaud's syndrome), clubbing (exaggerated longitudinal curvature, loss of the dip=the angle between the nail
and nailfold, the nail feels 'boggy'
, splinter haemorrhages (trauma or infection)
-swelling of finger joints (indicates synovitis), Heberden's nodes, Bouchard's nodes (OA), Gottren's papules on MCPs
(dermatomyositis)
-muscle wasting of dorsal interossei (ulnar neuropathy or T1 nerve root lesion)
-deformity: look at alignments: ulnar deviation at MCPs (RA), Boutonniere deformity (PIP fixed flexion: RA), swan neck
deformity (PIP hyperextension:RA), mallet finger (DIP flexion deformity that can be corrected passively; usually because of
trauma affecting the extensor expansion), finger droop, Z-deformity of the thumb (RA?), overall symmetry between left
and right hands
-wrist swelling and deformity; volar displacement can can be the result of RA (it is due to partial dislocation); squaring
-position and shape: hand's normal resting position, mallet finger, finger droop, Dupuytren's contracture
-scars, colour (erythema happens with inflammation from soft tissue infection, septic arthritis, tendon sheath infection and
crystal induced disease= gout and pseudogout)
-long fingers=arachnodactyly (Marfans); thickening= sclerodactyly (scleroderma)

Look at palm of hand:

-calcinosis (scleroderma and dermatomyositis), Raynaud's
-rashes
-palmar erythema (polycythaemia, cirrhosis, pregnancy)
-wasting of thenar eminence (median nerve lesion=CTS)
-wasting of hypothenar eminence (ulnar nerve lesion)
-scars of carpal tunnel release
-pallor of palmar creases=anaemia
-Dupuytren's contracture=palmar fascia contracture and fibrosis (ageing, liver, epilepsy, trauma)
-thinning of skin/bruises= on steroids
Look at the elbows
-get the patient to flex their elbows and show you
-rheumatoid nodules
-gouty tophi
-psoriatic plaques

Feel the palm of the hand

-Ask about pain before touching!
-wasting in thenar/hypothenar eminence: feel for it
-capillary refill time (i.e. is the patient warm and well perfused?)

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-ulnar nerve sensation (little finger or hypothenar eminence)
-median nerve sensation (index finger or thenar eminence)
-the ulna side of the arm: feel for rheumatoid nodules

Fell the dorsum of the hand

-Ask about pain before touching!
-temperature
-pressing on joints: the maximum pressure is that which can change the colour of a nail; use less then this for patients
with joint disease/tenderness
-watch face while you palpate
-DIPs: use a 4 finger technique: thumb and index finger at sides of joint and above and below it (swollen DIPs=OA,
gout or psoriasis)
-PIPs: use a 4 finger technique: thumb and index finger at sides of joint and above and below it (swollen PIPs=RA if
DIPs not affected)
-MCPs: place fingers on palmar side and use your 2 thumbs to press it
-you are looking for tenderness, effusions (fluctuance), consistency of any nodules/swellings, synovial thickening
-CMC joint and anatomical snuff box
-wrists: feel with 2 thumbs on the wrist and index fingers below on palmar surface; feel the carpal bones, the radial
styloid tip and the head of the ulna
-radial nerve sensation (index finger and thumb webspace)
Move
-look for restriction of range of movement and pain on movement
Wrist
-flexion (reverse prayer sign) and extension (prayer sign) (feel for radial nerve power here also: extend the wrist and
fingers against resistance; test wrist extension with your palm as the fist hurts); 90º is normal range for wrist flexion
and extension
-supination and pronation: passively
-ulnar deviation and radial deviation: passively
Thumb
-flexion-into your palm
-extension-away from your palm
-abduction-point your thumb to the ceiling (test median nerve power here also)
-adduction-put your thumb next to your palm
-opposition-touch thumb to fingertips
Fingers
-flexion (make a fist) (all the fingers should point to the scaphoid tubercle and should not cross each other, otherwise
suspect rotational deformity of the phalanges=a complication of fractures)
-extension (open the fist fully)
-do flexion and extension of each finger fully
-abduction (spread your fingers apart) (test ulnar nerve power here by testing index finger and little finger)
-adduction (put your fingers together)
Swellings
-any swellings you notice should be palpated
-if hard=likely to be an osteophyte (OA), a mucous cyst or a tumour (rare)

Special tests
-power grip strength by getting patient to squeeze your fingers
-pincer strength by trying to get patient to hold while you attempt to break (this is median nerve power)
-carpal tunnel: Tinnel's sign= extend wrist and tap at the crease of the wrist in the middle (this is over the carpal
tunnel); Phalen's sign= put hand in forced flexion for 30-60 seconds or get patient to make the reverse prayer sign for
30-60 seconds
-flexor digitorum profundus (the only DIP joint flexor): hold finger extended at PIP by having the hand palmar side up
and placing your index finger over the DIP; then ask patient to flex at DIP (do it on the middle finger)
-flexor digitorum superficialis: flex finger at PIP with other fingers held extended
-function: put hands to mouth, get to pick up an object like a pen or a cup or a coin, do up/undo buttons

Suggest:
-complete neurovascular examination of the upper limbs
-examine the elbow and shoulder; the neck also if hand symptoms are in a myotomal and/or dermatomal distribution

End
-thank the patient
-help the patient to redress make sure they are comfortable
-summarise and give differential diagnosis and management plan (Ix and Tx)

Page 64
-finger extension: spread fingers and extend fully; if they can't be extended then it could be ext. tendon rupture, joint
disease or neuro damage

HAND EXAMINATION
Introduction: don't shake hands
Consent
History
Age and occupation
Pain
Swelling
Stiffness
Neurological
Function
PMH and drugs
Examination
Wash hands
Correct exposure: up to elbows
Hands on pillow with sitting comfortable patient
Inspects dorsum: nails, joints, muscles, deformities and nodes, swelling, symmetry
Inspects palm: rashes, calcinosis, muscles, scars, colour, symmetry
Inspects elbows: plaques, tophi, nodules
Ask about pain
Palpate palm: wasting, CRT, median nerve sensation, ulnar nerve sensation
Palpate ulnar side of forearm and elbow: rheumatoid nodules
Palpate dorsum: temperature, DIPs, PIPs, MCPs, CMCs, wrists, watches face of patient, radial nerve sensation
Movements and power: wrist flexion, wrist extension, radial nerve power, thumb flexion, thumb extension,
thumb abduction, thumb adduction, opposition, median nerve power, finger flexion, finger extension, finger
abduction, finger adduction, ulnar nerve power
Special tests: power grip, pincer grip, Tinnel's sign, Phalen's sign, flexor digitorum profundus, flexor digitorum
superficialis
Function: hand-to-mouth, pick up coin/coin/cup, do/undo button
Suggest examination of joint above and below: elbow and shoulder/neck
Suggest complete neurovascular examination of upper limbs

Page 65
 Hip
Introduce yourself
Explain the exam and get consent-may I examine/assess your hip joint with some questions and a clinical examination?
Exposure: undress to the undergarments (underwear) and get them to stand in front of you (after asking the questions
below ideally); you need to see the iliac crests so pull underpants down enough to see if necessary; socks off

History

What is your
-age
-occupation
-What happened? (Tell me what the problem is)
-How did it start?
-When did it start?
-Pain: site (groin, anterior knee and buttock i.e. can be local or referred), SOCRATES (relieving;alleviating, radiation)
-Stiffness:worse in morning, worse after sitting
-Mobility: Are you on crutches/other walking aid or do you walk unsupported? Limp? Walking distance? Stairs (up and
down)? Standing up from sitting? How does it restrict your life? (walking, shopping, time managed out of home)
-Were you carried on a stretcher?
-Site, other joints
-Severity:pills, at night, crutches
-Are you fit and well?

Examination

Wash hands

Standing inspection
-front: straight spine, shoulders parallel to ground and placed over the pelvis symmetrically, pelvic tilt (can mask a hip
deformity or true leg shortening), anomalies of hip/knee/ankle/foot, muscle wasting 2º to arthritis or polio
-side: stoop, increased lumbar lordosis (both cause hip flexion contracture)
-behind: straight spine or scoliosis (lateral curvature)-if scoliosis check shoulder/pelvis positions; gluteal atrophy, measure
leg length (leg shortening may be compensated for by scoliotic posture or longer leg flexion; adduction and abduction
abnormalities are compensated for by knee flexion; a flexion deformity is compensated for by exaggerated lumbar
lordosis)
Shoulders parallel to ground and positioned symmetrically to the pelvis
Pelvic tilt
Hip, knee, ankle ,foot anomalies
Colours, scars, dressings, sinuses, skin changes
Deformity: will get a mark for mentioning
Gluteal muscle wasting
Muscle wasting=polio, disuse
Posture
Asymmetry
Psoas abscess
Spine: scoliosis, increased lumbar lordosis or stooping patient

Gait
-antalgic-short stance phase (limp)
-short leg gait-shoulder up on one side
-Trendelenburg's gait-will swing from side-to-side (waddling gait=sign of hip pain or proximal muscle weakness)

Trendelenburg's test
-put hands on patient's ASIS on both sides
-ask them to put their arms on your shoulders
-ask them to stand on 1 leg with their leg pointing backwards (the sole facing posteriorly) for 30 seconds
-the iliac crest should go up or stay the same on the side the leg is lifted on-this is normal and is a negative test; if it
falls/sags the test is positive-it indicates that there is an abnormality of ABduction on the opposite side e.g. gluteus
medius and gluteus minimus muscle weakness or pain (e.g. OA or hip joint stuctural anomaly like developmental hip
dysplasia or coxa vara)

Lying supine

Page 66
Look
-from end of bed:
-attitude: position the iliac crests in the same horizontal plane at 90º to the spine (not possible with abduction and
adduction deformities); put the feet together by holding at the ankles and then look for shortening, neutral position vs
internally/externally rotated, adducted/abducted, flexion deformity (stretch feet out as much as possible in equivalent
positions to take away effects of anomalous posture or soft tissue contracture)
-measurements: apparent leg length is from umbilicus or xiphisternum to the medial malleolus (if there is shortening it is
due to pelvic tilting-most commonly from adduction deformity if the true length is the same on both sides) while true leg
length is from the ASIS to the medial malleolus (shortening can mean hip pathology on the side of the shorter leg);
make sure iliac crests are horizontally level with each other before measuring; if there is shortening do blood tests
-skin colour
-psoas abscess in groin
-scars, dressings, sinuses
-wasting (but not quadriceps since that is more for the knee but can mention it)

Feel
-GT: palpate for trochanteric bursitis; find it by following the inguinal region to the ASIS; then go directly down from it
and the next bony prominence is the GT; if you have a patient in whom it is hard to find the GT internally and
externally the hip to make it easier to find

Move and Special Tests

-make sure pelvic brim is at 90º/perpendicular to the spine
-Thomas' test: before this you must ask about hip replacement as it can dislocate the hip on the non-test side being fully
flexed; get the patient to flex both their knees to around 90º; then put your hand under the lumbar spine and passively
flex one knee until the lumbar lordosis is eliminated; ask the patient to hold the flexed knee to their chest; then tell them
to straighten out the other knee-put hand under it to check if fit goes onto the bed-may not completely with fit people
with good gluteal muscles that keep it up a little; tight trousers can do the same; otherwise it is a fixed flexion
deformity (extension is incomplete); 2 problems: if you can't flex enough you can't eliminate lumbar lordosis; and a
flexion deformity of the ipsilateral side can confuse the test-do it with patient on side in the latter case; the test is for
incomplete extension (fixed flexion deformity)-this can be masked by pelvic and lumbar spine movement and by
increased lumbar lordosis
-flexion: ask patient about hip replacement; put your left hand in patient's back to pick up hip movements masked by
lumbar spine and pelvic movements; normal flexion =120º
-abduction: put your left hand on the ASIS of the opposite side e.g. left ASIS-then abduct the right hip; when you feel
the pelvis tilt that is the limit of degrees of movement; test adduction also with hand on opposite ASIS; then put your
hand on the right ASIS and test the left hip; normal=45º for abduction
-adduction; put your hand on the ASIS of the same side; cross leg over and then keep moving it medially; normal=25º
-internal rotation and external rotation: flex the hip and knee 90º; then with hand supporting knee and other holding
ankle rotate the hip both ways; normal=45º for both; can also do with legs extended by holding at the ankles and
looking at the knees to judge the rotation

Prone Position
-inspect for scars
-do hip extension (suggest to examiner): lift the hip passively by flexing the knee and putting one hand on the pelvis on
SI joint to detect tilting and another on the ankle;normal is 20º

End
-say you would do a neurovascular assessment of the lower limb (pulses, tone, power, reflexes, sensation)
-say you would examine the joint above and below: the spine and knees
-thank patient and offer to help them to redress
-summarise positive findings and give differential diagnosis and management plan (Ix and Tx)
-Ix: order tests like x-ray of hip, knee and spine, FBC, ESR, bone profile, DEXA etc

Page 67
 KNEE EXAMINATION
Introduce yourself
Explain the exam and get consent-may I assess your knee with some questions and a clinical examination?
Exposure: to the waist (from waist downwards) and get them to stand in front of you (after asking the questions below
ideally); socks off

History

What is your
-age
-occupation
-What happened? (Tell me what the problem is)
-How did it start? 3 main questions
-When did it start?
-Pain: site (groin, anterior knee and buttock), SOCRATES (relieving, alleviating, radiation); mechanism and direction of
impact are important (can predict which structure is injured); knee pain can be referred from the hip
-Swelling: effusion tells you there is an intra-articular pathology e.g. synovial fluid, pus, blood or a mixture (normal
synovial fluid: 1-2mL, increased if the synovial membrane is inflamed from RA, trauma, synovitis or septic arthritis;
<30mins severe swelling= haemarthrosis; lesser swelling over 24 hours=traumatic effusion e.g. tear of meniscus, septic
arthritis; septic=pain, swelling, tenderness, redness, not wanting to move joint passively or actively=aspirate for Gram
stain and microscopy; crystal arthropathy=aspirate and polarised light microscopy
-Redness
-Stiffness:worse in morning, worse after sitting
-Locking: block to full extension; is it intermittent or long-standing? (OA and osteochondritis dissecans cause loose body
and another cause can be a meniscal tear)
-Giving way (instability): the 4 main ligaments can rupture 2º to trauma or degenerative disease leads to loose
ligaments
-Mobility: Are you on crutches/other walking aid or do you walk unsupported? Limp? Walking distance? Stairs?
Standing up from sitting?
-Were you carried on a stretcher?
-Site-where is the problem?, other joints
-Severity:pills, at night, crutches
-Are you fit and well? (haemophilia, other bleeding diathesis, gout/pseudogout)

Examination

Exposure:
Wash hands
Look standing for
-front: genu valgum (knock knees) and genu varum (bow legs) postural deformities, swelling
-side: flexion deformity (can be knee or hip problem or both), hyperextension (genu recurvatum)
-back: popliteal swelling like Baker's cyst

Gait
-antalgic
-shortened leg
-Trendelenburg

Lying
-inspect again: from end of bed for deformities, colour, rashes, sinuses, surgical and arthroscopic scars
-measurements: wasting of quadriceps: offer to measure 5cm above the tibial tuberosity (the quadriceps takes only days
up to 2 weeks to waste with pathology) (quadriceps wasting is a sensitive indication of knee pathology)

Feel
-ask patient 'do you have any pain?'
-feel temperature
-patellar tap (for moderate to large effusions)
-bulge test/ripple test (for smaller effusions)
-joint lines: femoral and tibial; try to localise any tenderness; joint line tenderness=meniscal tear or OA; if it is over the
tibial tuberosity it is usually Osgood-Schlatter disease
-look for symmetrical height of the legs and length of the thighs to make sure that the femur and tibia are the same
length in both legs

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Movements
-flexion and extension:
-flex actively: bend your knee until your heel goes into your bottom: keep your hand between the femoral condyles and
patella to feel for crepitus (OA or chondromalacia patellae); at the end of movement see if you can press it in any
further passively; the normal movement range is 140º; if flexion is fixed at 15º and flexion goes up to 110º only, say
the movement range is 15º-100º
-extension: get the patient to straighten out their leg on the bed after flexion; full extension is recorded as 0º; up to
-10º is normal; hyperextension (genu recurvatum) is tested for passively by lifting with the right hand holding the heel
and the left hand over the knee

Special tests

-Anterior draw and posterior draw tests: 1) Flex the knee to 90º and trap the foot with your thigh; inspect for posterior
sag (sign of posterior subluxation of the tibia on the femur which can cause a false positive anterior draw sign); put
thumbs on the tibial tuberosity and rest of hand around the back holding the upper tibia-feel that the hamstrings are
relaxed; pull the tibia forward-more movement on 1 side than the other indicates a lax ACL; more than 1.5cm indicates
ACL rupture
2) Push the tibia backwards to test PCL

-Lachman's test: slightly flex the knee around 10-20 degrees (you can support it by putting your own knee under it if
you wish); then plce your dominant hand around the tibia and your non-dominant hand over the femur-hold the femur
in place while you pull the tibia upwards to assess if it moves excessively over the femur in an AP orientation); this is a
test for ACL rupture and is more sensitive than the anterior draw test

-Collateral ligaments stability: flex to 30º so that the ligaments are not taut and then apply varus stress (lateral collateral
ligament) and valgus stress (medial collateral ligament); can do by resting the ankle inbetween your elbow and axilla or
just by holding the foot at the ankle with your right hand while you use the left to support the knee (you flex to 30º so
that the ligaments are not taut-in full extension abduction and adduction is not possible except if there is a ruptured or
lax ligament; if there is a partial tear then there will be pain but no movement since the joint won't open)

-McMurray's test: 1) Flex the knee fully and externally rotate the foot; then abduct the leg at the hip keeping the foot in
the midline so the knee is put into varus; then smoothly extend the knee; any clicks/clunks felt or heard and severe
discomfort can mean a medial meniscal tear-sometimes there may even be locking
2) Flex the knee fully and internally rotate the foot; then adduct the leg at the hip keeping the foot in the midline so the
knee is put into valgus; then smoothly extend the knee; any clicks/clunks felt or heard and discomfort can mean a
lateral meniscal tear-sometimes there may even be locking

-Appley's grinding test: (not needed in OSCE-can verbally suggest and be ready to do if examiner insists)

-Squat test (don't do in OSCE)

At end
-say you would do a neurovascular assessment of the lower limb
-say you would check the joint above and below=hip and ankle/foot
-thank patient and offer to help redress
-summarise positive findings and offer differential diagnosis
-management: suggest Ix and Tx

KNEE EXAMINATION
Introduction
Consent for history and examination
Age and occupation
History
Open questions 'What happened?' 'When did it happen?' 'How did it happen?'
Pain: SOCRATES
Swelling: when?
Stiffness
Locking
Giving way
Carried on stretcher or walked away?
Effect on life: sleep, pills, mobility: using crutches?, walking, mood/psychological
Are you fit and well?
Examination

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Wash hands
Correct exposure
Inspection standing: uses phrase 'deformity'
Assesses gait
Inspection lying
Quadriceps wasting (suggest measurement)
Temperature
Patellar tap
Bulge test
Joint line palpation
Look for symmetrical height of the legs and length of the thighs
Knee flexion
Knee extension
Feel for crepitus
Check for hyperextension
Anterior draw
Posterior draw
Lachman's test
Collateral ligaments
Menisci (McMurray's or Apley's grinding test)
Suggest a neurovascular assessment of the lower limb
Suggest you would check the joint above and below=hip and ankle/foot
Thank patient and offer to help redress
Positive findings and offer differential diagnosis

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 MOULAGE ABDOMINAL AORTIC ANEURYSM
An aneurysm is a increase in 50% or more of the normal diameter of the vessel. Abdominal aneurysms are typically
abdominal and are the result of atheroma.
Leaks of aortic aneurysms are rare <55 years of age. The patient tends to have generalised vascular disease.
Clinical features
-back pain (occasionally they may have had an episode a few days before also); epigastric pain may radiate to the
back
-generalised abdo pain with vague tenderness and fullness (pain may radiate to the groin)
-hypotension
-pallor and sweating
-sudden collapse
-expansile pulsatile mass
-weak/absent femoral pulses and radial-femoral delay
-hypovolaemic shock
Classical features can be entirely absent: pain can be mild, femoral pulses can be present without radio-femoral delay
and there may be no palpable pulsatile mass

Investigations
-clotting studies (60% of patients have coagulopathy on admission)
-FBC (40% have low platelets)
-urea and electrolytes (30% have impaired renal function)
-ECG (ischaemic changes occur in the majority due to coexisting coronary heart disease and hypotension worsens
ischaemia)
-do not order an abdominal x-ray since it is not indicated
-an USS can show free fluid around an aortic mass, thus confirming the diagnosis of leaking aneurysm, but surgical
referral must not be delayed by Ix

Management
-high-flow oxygen 15L by bag and valve mask with non-rebreathing bag
-pulse oximeter for SaO2 monitoring
-BP monitoring
-pulse monitoring
-ECG monitoring
-put in 2 infusions via large-bore cannuli; the volume replacement has to be carefully controlled; the aim is to maintain
adequate cerebral and coronary perfusion without increasing blood loss; give fluids until large pulses are palpable, the
target being to keep SBP from 70-90mHg but not greater
-call for surgical and anaesthetic help
-crossmatch 8-10 units of packed RBCs and order also a similar number of units of FFP (fresh frozen plasma) and
platelets; too much fluid can rupture a leaking aneurysm but anaemia will also be detrimental in a low output state;
thus transfusion with packed RBCs should begin as soon as possible (haemoglobin should be kept at around 10g per dL
but always above 8g per dL)
-send off blood for FBC, clotting studies, urea, electrolytes and glucose
-get an ECG and chest X ray
-give small increments of IV analgesia as needed but being careful since opiates can decrease vital sympathetic tone
-pass a urinary catheter and measure the urine output

Prognosis
-Only around 50% of patients with a ruptured aortic aneurysm get to hospital alive
-another 10% lack surgical fitness (so 60% are dead offhand)
-for the remaining 40% surgical mortality is between 30-60%

MOULAGE ABDOMINAL AORTIC ANEURYSM

Introduction: name and age
Explain aim of assessment
PC, HPC, PMH
Wash hands
Airway
Checks airway and comments on airway patency
Breathing
Pulse oximeter

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 Oxygen 15L high-flow via bag and mask with non-rebreathing bag
RR
Cyanosis
JVP
Tracheal deviation
Expansion and percussion
Auscultation
Circulation
CRT, pallor/sweating
Pulse
BP
2 large IV cannulae
Heart sounds
Pulses: carotid, femoral, aortic
Bloods: FBC, coagulation screen, Us & Es, LFTs, blood group and save crossmatch, glucose, amylase
Give 2 warmed large fluid infusions until large pulses felt and to maintain SBP between 70-90mmHg
Order 10 units of packed red blood cells, 10 of FFP and platelets
Put in urinary catheter to monitor urine output
Intra-arterial access and blood gases
Summon senior anaesthetist (for airway management during transfer)
Summon vascular surgeon and inform emergency theatre staff
Disability
Pupillary reflexes and size
AVPU
Limb posture
Exposure
Check temperature
Position: keep flat
Expose whole body for examination
Monitoring
Keep reassessing ABC
Monitor BP, pulse, RR, SpO2 and ECG
IV antibiotics e.g. 500mg metronidaloze and 1.5g cefuroxime
IV analgesia in small increments with anti-emetics but careful since opiates can decrease sympathetic tone
Secondary Survey
Head to toe exam and log-roll
GCS
AMPLE history

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 MOULAGE: BREATHLESSNESS/SOB
Respiratory emergencies you need to know as a 4 th year medical student:
-asthma
-spontaneous pneumothorax
-COPD

The moulage station is likely to be an asthma scenario. The patient could be an adult or child.

You should not get patients with respiratory distress to lie down: leave them in the position they are comfortable in
(examine their abdomen later lying down). Remember airway compromise will kill.
Asthma is an inflammatory condition of the airways characterised by reversible airways narrowing.
It is classified as mild, moderate, severe and life-threatening by the peak-flow reading.
Mild:>75% normal peakflow
Moderate: 50-75% normal peakflow
Severe: 33-50% normal peakflow
Life-threatening: <33% normal peakflow
Of course this is not a useful classification because when a patient has respiratory distress you don't ask for a peakflow
since it will give unreliable results as they may not blow properly. So clinical signs are more important.
Looking at the patient: RR, pallor (hypoxia triggers this response), cyanosis (close to death if present), speaks in full
sentences, use of accessory muscles
Sensorium: agitation (sign of hypoxia), unduly cooperative/drowsy (hypoxia AND hypercapnia) , do AVPU and allude to
GCS score, sweaty, exhausted
Pulse: tachycardia (hypoxia triggers sympathetic response) (salbutamol can also drive up HR as a beta agonist),
bradycardia (disaster), pulsus paradoxus (really it is the BP that is worrying)
So say all this in the exam: 'I'll be worried about hypotension and bradycardia' etc.
(note that HR and RR rise but later fall)

Palpation:
-trachea: tension pneumothorax, pneumothorax, PE (main differentials of asthma)

Percussion
-asthma=hyperresonance all over and wheezes (old name=rhonchi)

Management:
-Start the clock!
-Give O2
-Give 5mg salbutamol
-Give 500 micrograms ipratropium bromide
-Give 40mg prednisolone in adults, 20mg in children (except if they can't swallow)
-Give IV hydrocortisone if vomiting or unconscious (will have to thus put in a line early if you're going to do this) (but
the IV method has no advantage over the oral method)
-while you give all the above get a baseline of RR, sats, pulse and peak flow

-after 15 minutes have passed:

-review when the nebs run out
-if the patient is getting better then repeat salbutamol nebulisers

-after 30 minutes:
-if better examine chest again and prepare for discharge
-but if at 30 minutes not better:
-repeat salbutamol nebs, stick in cannulae and review diagnosis:
-how?:
-AGB's: PE
-CXR: pneumothorax
-ECG: hypokalaemia of salbutamol (u waves)
-FBC, D-dimers, blood cultures : preparing for the unknown

-after 45 minutes:
-if not better after the 3rd neb, repeat neb and CALL FOR HELP
-then consider 2nd line treatment (which you must not start without calling for help)
-2nd line Tx:
-aminophylline: a problem because it has a narrow therapeutic window and is cardiotoxic; on top of that the heart is

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already 'twitchy' from the effects of salbutamol and the patient will not be in a fit state to tell you if they are on
theophylline; so aminophylline is DANGEROUS; can give a loading dose or maintenance dose
-IV magnesium: primes the bronchial muscles to respond better to nebs
-do not give aminophylline nor magnesium without the presence of senior staff such as anaesthetic staff

3 possibilities at the end:

-send home (say urgent GP review in 24 hours)
-ward admission
-ITU to possible death: this should not happen
How will you know which of these should occur? By the parameters: RR, sats, pulse and peakflow

You need to know the Tx they are discharged home on:

-nebs
-GP review in 24 hrs
-prednisolone 40mg daily for 5 days
Ward
-not getting better but not quite ITU
-nebs, PRN abxs, prednisolone
-if they don't get better you need an early warning system

COPD:
-early ABGs are vital: if acidosis=get worried
-oxygen debate: never mind whether they are a carbon dioxide retainer or not; just give enough to keep o2 sats >92%
-in trauma always use high-flow oxygen but in COPD you start at a low concentration and then increase it in increments
until Sats are >92%

Method of OSCE Station

-Introduce yourself to the patient

-Name and age
-Explain purpose of the interview/assessment

A:
-Ask a few quick questions: tell me what's wrong? Do you have any illnesses? Do you know where you are and how
you were brought here?
-You will now know whether or not they can finish a full sentence: comment on this to the examiner e.g. 'they can
finish a whole sentence, which indicates they have a patent airway and sufficient ventilation; they are conscious and
alert and responsive and therefore have adequate cerebral perfusion' or 'they can't complete a sentence, which indicates
that the asthma is ....... (and I'm concerned about their airway and ventilation').
-I'll keep time and start the clock so that I know how the patient is progressing every 15 minutes

-B:
-give 100% oxygen (and say you would give 5mg salbutamol nebulised while you are assessing if it is definitely an
asthma patient, or just say you would ask for the nebs to be prepared)
-Look, listen and feel
-end of the bed:
-do they look well or unwell?
-observe the chest moving from the end of the bed: symmetry of expansion, degree of expansion, signs of distress: use
of accessory muscles (subcostals, sternocleidomastoids)
-RR
-depth of breathing
-cyanosis
-pallor
-check hands for peripheral cyanosis, mouth for central
-tracheal deviation
-palpate expansion
-percussion
-auscultation: equal entry, wheezes
-say you would put on pulse oximeter (because you need a baseline O2): if possible before nebs
-get patient to do peakflow if they can: before nebs

C:
-CRT
-skin colour
-feel palm for sweatiness/cold/clamminess
-pulse

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-BP
-(ECG: say you would put it on at 30 minutes if no improvement?)
-say 'I'll be worried about hypotension and bradycardia'

Treatment
-sit up
-high-flow O2 100% via non-rebreathing bag
-PO prednisolone 20mg/40mg if they can swallow
-if they can't swallow give IV hydrocortisone 100mg
-ipratropium bromide 0.5mg/500micrograms

-ask any questions: theophylline and steroid use, past admissions, ICU admissions
-review after 15 minutes and give salbutamol and ipratropium nebs again
-know signs of getting worse: hypotension, bradycardia, increased respiratory rate followed by decreased, silent chest,
cyanosis, exhaustion, confusion, agitation, drowsiness, SaO2 <92%, low pH, normal or high PCO2, feeble respiratory
effort, low PO2 <8kPa (60mmHg) even with O2 Tx

-after 30 minutes review and give 3 rd time nebs

-if better prepare for discharge on prednisolone 40mg daily for 5 days, GP urgent review in 24 hours, inhaled
bronchodilators and knows how to use properly, telephone number of A+E, good home support, letter for GP, own
peakflow meter, respiratory clinic appointment in a month
-if not better: review diagnosis:
-put in cannulae
-send off ABGs and put and leave in intra-arterial line
-CXR: for pneumothorax
-ECG monitoring
-Bloods: FBC, D-Dimers,

-after 45 minutes give nebs again and call for help if not better, including anaesthetist to intubate if necessary
-call ITU
-consider aminophylline loading dose 5mg/kg IVI over 20 min, then 500micrograms/kg/hour maintenance dose
-consider IV magnesium sulphate 1.2-2g over 20 minutes
-if life-threatening features earlier on, call ITU and senior help and consider these drugs then

Remember
-RR, sats, pulse and peakflow parameters
-3 outcomes: discharge, ward admission and ITU

Differential of asthma
-pneumothorax: tension and simple spontaneous
-COPD (adults)
-heart failure (more often adults; rare in child but possible)
-PE (adults)
-CF and bronchiectasis (usually wet cough/sputum production, clubbing, poor growth)
-pneumonia
-immunodeficiency disease
-URTI
-foreign body obstruction
-tracheo-oesophageal fistula
-bronchopulmonary dysplasia

MOULAGE: BREATHLESSNESS/SOB
Introduce yourself to the patient
Name and age
Explains reason for assessment
PMH
Symptoms: breathlessness, wheeze, dry cough, tight chest etc
Airway
Airway: comment on patency
Ability to complete a sentence (if SOB interferes with talking then attack is severe)
Breathing
Pulse oximeter (at least 92%) (<92% on air means severe or life-threatening)
15L oxygen/high flow by facemask (or nasal prongs) to get SpO2 >92% (so given if any evidence of arterial
oxygen desaturation)

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 Peakflow (>75%, 50-75%, 33-50% severe, <33%)
Breathing: RR (>30/min >5 years or >50/min 2-5 years=severe asthma) and depth, inspection, depth, accessory
muscles (e.g. neck), cyanosis, tracheal deviation
Expansion, percussion and auscultation of chest
Circulation
Circulation: pulse (>120/min >5 years or >130/min 2-5 years=severe asthma), BP, skin colour, CRT
Comment on pulsus paradoxus: the SBP falls more than usual on inspiration (>10mmHg); indicates moderate to
severe asthma
JVP, heart sounds
ECG monitoring: usually put in at 30 minutes (needed for IV Tx)
Disability
AVPU, agitation, altered consciousness, exhausted, too cooperative
Mentions life-threatening features (silent chest, cyanosis, poor resp. effort, exhaustion/fatigue, agitation and
reduced level of consciousness/drowsiness)
Treatment
(If moderate to severe asthma can just give 10 puffs of MDI via large volume spacer and assess improvement)
Time management to 15 minute intervals
Sit up, 5mg salbutamol nebulised (2.5mg in 2-5 year old, 5mg if >5 years old) with oxygen as driving gas (as
soon as diagnosis made)
PO prednisolone 20mg child (40mg adult) (10mg in <2 years old, 20mg in 2-5 years old, 30-40mg in >5
years old) or 2mg/kg up to a max of 60mg IF already on systemic steroids
Mentions IV hydrocortisone 100mg or 4mg/kg for more accuracy (50mg in 2-5 years old, 100mg in >5 years
old)
0.5mg (0.25mg in 2-5 year old) ipratropium bromide if life threatening features or poor response to Tx
Past admissions, ITU, asks if on theophylline and steroids
15 minutes repeat nebs
IV access, ABGs, CXR (to rule out pneumothorax, pneumomediastinum, consolidation=pneumonia as a cause),
bloods (FBC, D Dimers, blood cultures)
Consider aminophylline loading dose 5mg/kg IVI over 20 min (only given in ITU/HDU) and then continuous
infusion; risks=severe vomiting, seizures and arrhythmias; omit loading dose if on theophylline; monitor ECG
and electrolytes
Consider IV magnesium sulphate 1.2-2g over 20 minutes (only given in ITU/HDU)
(IV salbutamol 15 mg/kg)
If everything fails: artificial ventilation
Discharge plan: inhalers, check technique of use, review regular Tx, GP follow-up in 24-48 hrs, written plan,
PO prednisolone for 5 days, phone no. of A+E, OPD appointment in 4 weeks, good home support, own
peakflow meter and diary
Not responding to Tx: admit: add antibiotics, continue nebs and prednisolone
Poor response to Tx: immediate transfer to PICU/HDU (persistent hypoxia or hypercapnia, feeble respirations,
exhaustion, confusion, drowsiness, respiratory arrest, coma)
Senior help, anaesthetist, ITU, definitive airway (call ITU/senior help earlier if the attack is life-threatening to
begin with)
Monitor RR, sats, pulse and peakflow parameters to assess progress
Differential diagnosis

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 MOULAGE UNCONSCIOUSNESS
Introduction
Wash hands, apron and gloves
Explain aim of assessment/shout at patient to assess alertness after inspecting; shake/shout/sternal rub
Airway and C Spine
Protect C spine if trauma: collar, sandbags (either side of head) and tape (over forehead)
Checks airway for obstruction e.g. foreign body/teeth; if gargling ask for suction
Comments on airway patency and need for accessory airway (i.e. if jaw thrust not sufficient) (e.g.
Guedel/nasopharyngeal; if all else fails then LMA)
Uses just jaw thrust, not head tilt/chin lift
Breathing
Pulse oximeter
Oxygen 15L high-flow via bag and mask with non-rebreathing bag
RR
Cyanosis
JVP
Tracheal deviation
Expansion and percussion
Auscultation
Circulation
CRT, pallor/sweating
Pulse: if increased say you would look for the source of bleed (external or chest, lungs, abdomen, pelvis)
BP
2 large IV cannulae
Heart sounds
Pulses: carotid, femoral, aortic
Bloods/tests: FBC, coagulation screen, Us & Es, LFTs, CRP, ESR, blood group and save crossmatch if trauma,
glucose, amylase, blood cultures, TFTs, cortisol, toxicology screen (paracetamol and salicylates), pregnancy test
in female (with in and out catheter)
Give warmed fluid infusions (Hartmann's, ringer's lactate)
Put in urinary catheter to monitor urine output
Intra-arterial access and blood gases
After ABC
-call for help e.g. summon senior anaesthetist for definitive airway
Disability
Pupillary reflexes and size
AVPU
Limb posture
Exposure
Check temperature
Position: keep flat
Expose whole body for examination incl. Battle's sign, eardrums for perforation, nose for rhinorrhoea
Monitoring
Keep reassessing ABC
Monitor BP, pulse, RR, SpO2, ECG, core temperature
Secondary Survey
Head to toe exam and log-roll
GCS, Plantar response, PR exam, Kernig's sign and Brudzinski's sign
AMPLE history
CT head
X-rays of C-spine, chest and pelvis
LP
Consider thiamine for alcoholics
Protect eyes with tape

Page 77
 PCA EXPLANATION
-Introduce yourself-give your name and get the patient's name and age
-Give a summary of what the presenting symptoms of the patient are e.g.
-Inform the patient first of what you will explain to them e.g. I would like to discuss with you a method of pain relief
called PCA. Is that alright?

The Explanation
-meaning: tell the patient what PCA means: patient controlled analgesia; analgesia is just a word for pain-relief; so it's
patient controlled pain relief
ICE
--Find out what the patient already knows (I) e.g. have you ever had PCA before? Has anyone talked to you about it?
-Find out how much the patient wants to know (E) e.g. would you like me to go through with you how it works and
why it's useful? Is there anything else in particular you would like me to explain about it?
-Bring out the worries/concerns that the patient has (C) e.g is there anything about PCA you find worrying?

Purpose of PCA
-PCA allows you to take pain relief safely as and when you feel that you need it and to give yourself the amount of
pain relief you think you need.
-because pain is a personal matter; the amount of pain relief you need is better known to you then to anyone else; so
you can take it when you feel you need it rather than relying on others to decide when you need it and to then bring
the painkillers to you.
-you need pain relief after surgery to help you to get better quickly and to prevent chest infections and DVTs (blood
clots in the leg)
-PCA is used for moderate to severe pain and when pain is ongoing for days e.g. post-op

Action mechanism
-PCA is actually a machine which sits next to your bed on a stand
-it looks a little like a computer keyboard: it's rectangle shaped and it's about this long (show the patient it's
approximate length)
-this machine has a syringe at the top of it which has your pain relief drug inside it; a tube comes out of this syringe
and goes into a vein in your arm; we'll have to put a little plastic tube in your vein called a cannula
-so this will allow you to decide when the pain-killer in that syringe will go into the tube, down the tube and then
through the cannula tube in your hand into your blood.
-button: you will have a hand-held button, which you can press to give yourself the pain-killer; so it's basically a drip
into your arm but it doesn't give you anything until you press the button
-the amount you get with each press of the button is small; you can then then see if it helps by waiting a few minutes;
if it hasn't helped you can press the button again to give you a little more
-only you are allowed to press the button because: you are the only person that can tell if you need it; so you shouldn't
allow anyone that visits you in hospital to press the button (the doctors look at the number of times you press it to
decide how much pain you are in)
-Do you have any questions about that so far? Anything worrying you about it?

Drugs used
-strong painkillers like morphine

Safety-is it safe?
-yes it is very safe
-it is locked with a key so that the syringe can't be pressed on to give too much pain killer
-it has a password for changing settings; the password is only known by the pain experts
-the button can only give you a safe level of painkiller; it has an upper limit so that regardless of whether you press the
button 5 times an hour or 700 times an hour it will only give you a safe level of pain killer
-mobile phones: some of the older mobile phones interact with the PCA machine so you cannot keep a mobile within 1
metre of the machine
-PCA machine has an alarm to alert nurses
-nurses are told to monitor you when you are on PCA: your pulse, breathing, BP, your level of drowsiness

Side-effects
-drowsiness
-nausea and vomiting
-itching
-sometimes the skin stings as the painkiller goes in
-the side-effects don;t occur in all cases

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-all strong painkillers can make you feel sick and sleepy
-there are medications for the side-effects also e.g. sickness drug
-it is not addictive when used for pain relief

Alternatives
-injection into muscle: hurts
-tablets: can only take if stomach working after surgery and not feeling very sick or vomiting
-suppository: a pellet into the back passage
-epidural: makes your legs heavy and numb; used for leg and abdo and stomach surgery

Contraindications:
-can't have PCA if:
-arthritis in hands great enough to stop you pressing button
-allergic to painkillers in the machine

Patient Controlled Analgesia

If you have a private operation planned, it may involve an anaesthetic procedure, in this instance patient controlled
analgesia. You may wish to know what this involves.
 
The information here is a guide to common medical practice. Each
hospital and doctor will have slightly different ways of doing things, so you should follow their guidance where it is
different from the information given here. Because all patients, conditions and treatments vary it cannot cover everything.
Use this information when making your treatment choices with your doctors. You should mention any worries you have.
Remember that you can ask for more information at any time.

What is the problem?

You have moderate to severe pain that needs to be controlled. You may have had an accident and been injured. You
may be about to have an operation and the surgery is likely to cause pain afterwards. Patient controlled analgesia is a
safe and effective way to control your pain.

What is patient controlled analgesia?

Patient controlled analgesia (PCA) is a way to control moderate to severe pain. The device is a pump, filled with strong
painkillers, such as morphine. The pump is connected by a thin tube to a drip in your vein, usually in your arm or
hand.

You will be given a small button to press. This button may be like a watch around your wrist, or a toggle on a cable.
Both are easy to push. When you press the button a small dose of painkiller is given into the drip. This reduces your
pain. The pump will only give you so much painkillers; it does not matter how often you press the button.

The aims
The aim of the PCA is to allow you to control your pain safely and effectively.

The benefits
The greatest benefit is that you do not need to wait for anyone to bring painkillers to you. As soon as you press the
button, you are given a small dose of strong painkiller.

The PCA pump is safe, as it cannot give you too much painkiller. A special timer stops the pump from working for a
few minutes after it is pressed. The anaesthetic doctor (anaesthetist) will decide how long this should be and tell you. It
is usually 5 minutes. During this time pressing the button does not work. This is called a ‘lockout’. This stops you
from getting too much of the drug in the pump. After the lockout, the pump will work again when pressed.

It is better to get small but frequent doses of painkiller than an injection into a muscle. The amount of painkiller in your
bloodstream is better controlled. This means that you are less likely to feel nausea and vomit. You should also be less
sleepy.

The PCA pump means that you do not have repeated injections to give pain relief.

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The nurses benefit as they have more time to do other things around the ward.

Are there any alternatives?

There are several alternatives to a PCA. These are:

Intramuscular injection - The most common way to give strong painkillers before PCA was by injection. A dose of drugs
such as morphine can be injected into your muscle. This is usually into your backside (buttock). The injection is released
over a period of time. It reduces pain for about 4 to 6 hours. It will be a little uncomfortable to have the injection. The
injection can be repeated if your pain comes back and is still severe.

Epidural - It may be suitable to perform an epidural, which means placing a needle into an area close to the spinal
canal. This method involves threading a plastic tube through the needle, which allows medications to be given down the
tube over time. This allows pain relief to be given for several days. The tube lies just outside the covering of the spinal
cord, which is called the dura, hence the name epidural. This method is only good for injuries or operations on the
lower part of the body. Generally the parts of the body below the breastbone can use an epidural for pain relief. There
is another leaflet that describes this in detail.

Suppositories - A suppository is a soft pellet of painkiller. It is inserted into your back passage (rectum). The pellet is
gently pushed in through your anus. It gradually dissolves over a period of hours and is absorbed into your
bloodstream. This is safe and effective. The suppositories may be put in while you are asleep during a general
anaesthetic. You will then know nothing about it. However, the anaesthetist will warn you of this and get your
permission before the operation. Suppositories are never essential.

Tablets - It is possible to have tablets to control your pain. To use these your stomach must be working. After minor
surgery you may be able to take tablets within a few hours. This may be the easiest way to control your pain.

After some major operations the stomach and intestines stop working, often for several days. If you are feeling
nauseous and vomiting, then the tablets will come back out and be useless. Once your stomach is working then tablets
can be used. Even strong painkillers such as morphine can be given as a tablet or a liquid to be taken by the mouth
(orally).

Who should have it done?

General reasons for having a PCA, are listed below:

If you are having moderate or severe pain.

If you are having an operation that may be painful for several days.

Who should not have it done?

If you are unwilling to have a PCA, then other methods of controlling your pain can be used.

Additionally there are specific medical situations when a PCA should not be used and these are as follows:

Allergy to the strong painkillers used in the PCA pump.

If you are not able to press the button well. People with bad arthritis may have a problem squeezing the
button, so the PCA may not work for them.

Author: Dr Sean White FRCA. Consultant in pain

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Mr Fellini is a 65 year old man undergoing abdominal surgery for IBD. He is told he will be given pain relief with PCA
post-surgery on the ward but is confused about what it is and says he won't use PCA until it is explained to him. You
are the SpR on the pain team and are bleeped.

PCA EXPLANATION
Introduction
Consent
Rapport
ICE
Suitability for PCA
Explains PCA
Advantages and disadvantages of PCA
Safety
Only patient can press button
Pain relief
Mobility
Mobile phones
Contraindications
Alternatives: epidural, paracetamol, NSAIDs, IM
Checks understanding
Summarises
Clear
Addresses concerns appropriately

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 EXPLAIN POST-HERPETIC NEURALGIA
Post-herpetic neuralgia (meaning 'pain after shingles') is a pain that persists in some people who have had shingles. It
often eases and goes in time. Medication can often ease the pain.
It is is a nerve pain (neuralgia) that persists after a shingles rash has cleared. If the pain goes, but then returns at a
later date, this too is called PHN.

Shingles is an infection of a nerve, and causes a typical rash. It is caused by the varicella-zoster virus. About 1 in 5
people have shingles at some time in their life. Shingles can occur at any age, but it is most common in people aged
over 50. Most people with shingles have pain, but the pain usually eases soon after the rash clears. PHN is pain that
persists.

Epidemiology of PHN:
-PHN is unusual in people aged under 50, and if it does occur it tends to be mild. PHN is more likely to develop, and
is more likely to be severe, in people aged over 60. About 1 in 4 people aged over 60 who have shingles develop PHN
that lasts more than 30 days.

Clinical features of PHN:

-PHN causes pain on and around the area of skin that was affected by the shingles rash. The pain is mild or moderate
in most cases. However, the pain is severe in some cases.
-The pain is usually a constant, burning, or gnawing pain. In addition, or instead of this, you may have sharp or
stabbing pains that come and go. The affected area of skin is often very sensitive. Even slight touch may cause pain
such as the rubbing of clothes or a draught of air on the affected area. You may also have reduced sensation to touch,
and be itchy over the affected area.

Why does the pain remain?

-Shingles causes inflammation of the nerve. Pain can be expected whilst the rash and inflammation occur. However, it is
not clear why some people continue to have pain when the inflammation has gone. It is thought that some scar tissue
next to the nerve, or in the nearby part of the spinal cord, may be a factor. This may cause pain messages to be sent
to the brain.

Will the pain go away?

-Without treatment, PHN typically eases gradually and goes. In about 5 in 10 people with PHN, symptoms are gone by
three months. However, without treatment, about 3 in 10 people with PHN still have pain after a year.

What are the treatments for post-herpetc neuralgia?

-general measures: it is best to use loose fitting clothes made of cotton to decrease irritation of the area of skin affected;
the pain can be eased by using ice-cubes wrapped in a plastic bag to cool the area; taking a cool bath may also help;
putting clingfilm over the area can help too: the clothes will slide over the skin without irritation
-painkillers: paracetamol or paracetamol with codeine may give some relief; it is better to take them regularly to keep
on top of the pain rather than PRN/occasionally; if these don't work see a doctor for anticonvulants or antidepressants
-antidepressants: tricyclics are used but not to help depression; they ease nerve pain separately to their effects on
depression; amitriptyline is the most commonly used (though imipramine and nortriptyline are also possibilities for PHN);
in 8 out of 10 PHN patients put on amitriptyline the pain is greatly eased or stopped; it may work in a few days but it
could take 2-3 weeks to work in easing the pain; max benefit may only be after several weeks; so its best to persist for
4-6 weeks and not discontinue treatment to wait and see how well it is working; if it does work you can keep taking it
for a month after the pain is eased or has gone and then the dose is reduced before it is finally stopped; if the pain
comes back it should quickly be restarted; SEs: drowsiness sometimes that tends to ease with time; to avoid it a low
dose is given at first and then this is increased gradually ; another SE is dry mouth and this can be helped with
frequent sips of water
-anticonvulsants: gabapentin, pregabalin; these relieve nerve pain separately to their effect on epilepsy; they can stop
nerve impulses causing pain; they are an alternative to antidepressants but can be used with them together if one on it's
own does not work
-capsaicin: this can occasionally be used if antidepressants and anticonvulsants don't work, or if they cannot be used
due to SE's/problems; it blocks nerves from sending pain messages; it is applied 3-4 times a day; wash your hands
straight after applying it; when applied it can cause an intense burning feeling-this is more so when it is put on less
than 3-4 times a day or just after a hot bath or shower; this SE does tend to wear off with regular use; you should not
apply it to broken or inflamed skin, thus it is not suitable for use in a shingles episode; it can only be used on healthy
skin that is painful from PHN
-itch: some people with PHN have a severe itch; this is hard to treat; an antihistamine taken at bedtime can help you
sleep better and decrease scratching you do at night (and this may then make it less severe in the daytime also)
-others: TENS, anaesthetic or soothing creams, injections, bio-feedback, ultrasound etc; these are usually only advised
under specialist supervision in the pain clinic

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-TENS machine: used for chronic pain; small pads are put on the skin either side of where you have pain with some
gel; switch on the machine; it gives a tingling feeling; can be used anywhere from 45 minutes-12 hours; works in 2
ways: on a low setting it assists the body's own pain relief mechanisms (it helps the body release pain relief
chemicals); on a high setting it blocks pain signals to the brain; the machine can be clipped onto a belt or put on pocket
and you can use it on the move; CI's=epilepsy, pacemaker, heart disease, pregnancy, pain of unknown cause; caution:
not for damaged skin, nor neck, nor near eyes/mouth, nor areas of reduced sensation, nor near water (water/shower),
when driving, operating machinery; done in specialist clinic

Mr Hicks is in the pain clinic today after having had shingles. The consultant leaves for a while and you are asked to
speak to Mr Hicks about his pain.

POST-HERPETIC NEURALGIA
Introduction
Consent: may I ask you some questions about your pain?
Name, age, occupation
ICE
What ideas does the patient have about their condition?
What concerns do they have about it?
What are they expecting/hoping for?
Pain
Establish pain level
SOCRATES
Itching
Empathy
Explanation
'Post-herpetic neuralgia'=pain after shingles; it is a nerve pain after shingles rash
If the pain goes and returns it is also PHN
Shingles is nerve infection causing rash; 1in 5 people get it; commoner >50
Most with shingles get pain but it eases after rash; with PHN it persists after rash
So not something mysterious: it is a recognised clinical entity after shingles
PHN: rare <50; likely to be severe >60; 1 in 4 >60 get PHN >30 days after shingles
Explain what chronic pain is
Pain often eases and goes with time; in 5 in 10 pain gone in 3 months without Tx; 3 in 10 have pain after a
year without Tx; (may not go away)
Explain neuropathic pain: burning, shooting, electric shock
Triggers: light touch (allodynia), clothes, air
Aetiology: not fully understood, could be scar tissue near the nerve
Tricyclics: amitriptylline: assists patient's own pain mechanisms; 8 out of 10 better; 4-6 wks
Dose: 10mg
Contraindications: IHD, prostatism
Side-effects of tricyclics: dry mouth (sip water) and sleepiness (tends to diminish; helps sleep if sleep
disturbance)
Anticonvulsants: gabapentin/pregabalin: calms down irritated nerves
Side-effects: sedation, loss of balance, weight gain
Capsaicin: blocks pain messages, 3-4 times, wash hands, SEs, cautions
TENS: pads, gives a signal that tingles to skin; low/high signal, CIs, cautions
Itching: antihistamines at bedtime
Normal pain-killers ineffective and why e.g. paracetamol, nurofen, codeine
General: loose fitting cotton clothes, plastic bag with icecubes in it, cool bath, clingfilm
Summarise
Reassuring and deals appropriately with patient's concerns

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 THE PREOPERATIVE ASSESSMENT
Note the procedure of TURP is only explained below because some students last year claimed they had to briefly
explain it together with doing a Pre-op Assessment. It is unlikely that the station wil focus on TURP (as it is a year 5
station). It is more important to learn the pre-op assessment.

Transurethral Resection of the Prostate (TURP)

What is TURP?
-Part of the prostate gland is cut away. This stops it pinching the tube that carries urine out from the bladder and
through the penis. This is tube is called the urethra.
-The prostate is normally the size of a chestnut and sits under the bladder. It is partly wrapped around the urethra. It
makes the milky fluid called semen that comes out of the penis during an orgasm.
-The operation is called TURP because the Doctor will pass a tube through the urethra (transurethral) and then cut away
the prostate (resection of the prostate).

Why TURP is Needed

-it is common for a man's prostate to get bigger with age; this is called BPH (benign prostatic hyperplasia)
-it is extra growth of normal cells and is not cancer
-why it happens is not known but it is thought to be due to changes in hormones in the body
-BPH is not serious but if the prostate is big it can press on the urethra and bladder causing urinary symptoms
-not everyone with BPH needs TURP unless they get recurrent infections, acute retention, large bladder stones or severe
effects on life

Epidemiology
-40,000 a year in the UK have TURP
-it is the commonest enlarged prostate operation

The Operation
-lasts 30 minutes to 1 hour
-pain relief choice: GA or epidural are fine
-a tube is put into the urethra and the end part of it cuts the prostate; the pieces of prostate are flushed down the tube
with water
-a thin flexible tube called a catheter is put into your urethra to drain your urine and any bits of prostate left, because
your urethra is sore after surgery and you can't pee normally; the doctor can flush fluid up the catheter to drain any
blood clots; the flushing feels like your bladder is constantly full
-no stitchings or dressings are needed after the operation

Benefits
-stronger strain of urine, less need to strain or push
-go less often, less urgently, more control over when you go
-less interference with normal activities
-9 out of 10 men said their symptoms were better 3 years after the surgery in 1 study

Risks
-all operations have risks
-anaesthetic risk: allergic reactions, breathing or heart problems (all rare but can happen); 1 in 200,000 mortality
-bleeding during and after surgery: 1 in 50 men need extra blood or have to be taken back to theatres to stop bleeding
-infection: UTIs can happen; small chance of this only
-bloodclots: may wear tight stockings during surgery
-TURP syndrome: 1 in 50 men: unsteady, confused, queasy, vomiting, possibly increased blood pressure and sight
problems; it is easily treated and resolved but is harmful in people with heart or kidney problems; caused by absorption
of the fluid used to wash in the operation leading to salt imbalance
-dry climax: 7 in 10 men get this (retrograde ejaculation); no or less semen will come out of the penis in orgasm; can
still feel it and enjoy sex with erections but may nit be able to father children through intercourse
-erection problems: the nerves controlling erections are next to the prostate and can be damaged; there is some
evidence that TURP may not cause such damage
-incontinence (loss of control over urine flow): 1 in 50 will get this after TURP; this is due to the ring of muscle around
the bladder (sphincter) being damaged during surgery; again the evidence about whether this occurs with TURP is
conflicting: it may not
-problems passing urine again: 1 in 25 men get scarring at the bladder opening or in the urethra and need a repeat
operation
-recurrence: 1in a 100 need another TURP due to further prostate enlargement
-death: possible but very rare

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-men above 80 are at higher risk of complications

What You Can Expect After Surgery

-you may feel a bit sore and tired
-it's important to tell the nurse/doctor if your pain relief is not working
-a thin tube draining your urine called a catheter will be removed from your bladder after 2-3 days and you'll stay in
hospital until then
-your urine may flow faster straight away but you may not be able to urinate normally for awhile; some have to come
back to hospital and have a catheter put in again for a day or two
-in the 6 weeks after surgery the problem of needing to urinate often will probably ease off as the urethra heals
-for a few weeks after surgery you may get stinging when you pee and you may see blood in your urine
-you may be fit enough to be out and about in a week; it may be 2-3 weeks before return to work; several weeks to
return to sex; better to avoid strenuous activity like sport and heavy lifting for 6 weeks
-drink plenty of water to flush out infections and to prevent constipation
-complete healing: a couple of months
-most men are better then previously after healing

GA Anaesthetic mortality=1 in 200,000 (compare to 1 in a 1000 for an endoscopy)

Mr Grace is due for a TURP procedure. You are the F1 Doctor. Assess his fitness for surgery.

THE PREOPERATIVE ASSESSMENT

Introduction
Consent: may I ask you some questions to assess your fitness for surgery?
Name, age, occupation

The Assessment

Anaesthetic History
Previous anaesthesia: have you had anaesthesia before? Any problems with intubation? Any problems with
adverse reactions? Post-op: N+V? Do you get motion sickness? (increased PONV risk), suxamethonium apnoea
(have you ever stayed asleep for hours after anaesthesia was stopped?), malignant hyperpyrexia (ever get hot
and rigid after anaesthetic and end up in ICU?)
Previous surgery
Previous hospital admissions

Medical History
Any medical problems?
CVS: hypertension, palpitations, angina, MI in the last 6 months (can cancel operation), heart failure, chest pain,
orthopnoea, PND, cardiac surgery, TIAs, stroke, aortic stenosis (can cancel operation), any problems with heart
valves, DVT/PE, phaechromocytoma, carcinoid syndrome (the latter two need beta blockers before surgery)
Exercise tolerance
RS: breathlessness, SOB, asthma (how bad, how often, what is their peakflow, been in ITU?, steroids, Tx, bring
inhalers to op if severe asthma)), cough, TB, URTI (can cancel operation), COPD, bronchitis, hay fever, CF (need
lots of physio pre-op)
GI: renal failure, liver problems, jaundice, heartburn (will need PPIs), dysphagia, hiatus hernia, stomach ulcer
(better to avoid general anaesthesia in these patients; RSI is a way of avoiding aspiration)
Haem: sickle cell, clotting disorder, bleeding, bruising, anaemia
Rheum: RA, neck, arthritis (needs pre-op physio)
Neuro: epilepsy, fainting, muscle disease, Guillain-Barre, polio, myasthenia gravis
Psych: depressed, any psychiatric medication
Gynae: LMP date, could you be pregnant?
Diabetes: insulin, diet or tablets?
Thyroidism (for thyrotoxicosis they may need beta-blockers before surgery)

Family History
Adverse reactions to anaesthesia, particularly breathing problems and death
Malignant hyperpyrexia

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 Suxamethonium apnoea

Drugs/Allergies
Allergic to drugs, plasters, latex, foods
Tablets, patches, inhalers, OC pill (stop COC pill 4 weeks before surgery to prevent DVT)
Aspirin, ibuprofen
Warfarin (switch to heparin)
Steroids
Diabetes pills: stop for surgery night before; insulin: don't stop (since it will kill them)
Tell patient to keep taking any cardiac or hypertension pills up to the operation if they ask
Recreational drugs: cannabis, heroin, cocaine, amphetamines
Smoking
Alcohol

Starvation
Last food and drink

Metal
Any body piercings?
Any capped/crowned loose teeth or dentures?
Metal in or attached to body?
Pacemakers, hearing aids and contact lens

Post-surgery
Responsible adult >18 to take home in a car or taxi?
Someone to look after you for 24 hours?

May be asked at the end to do a brief Anaesthetics Exam if time allows

-fully extend and flex neck (look at ceiling and touch chin on chest)
-open mouth fully and assess (Mallampati criteria)
-clench teeth
etc

Page 86
 EXPLAIN SPINAL
-Introduce yourself to the patient
-Name, age, occupation
-Consent for discussing spinal

-Give a summary of what the presenting symptoms of the patient are e.g. 'you're going to have surgery and will need
pain relief for it'
-Inform the patient first of what you will explain to them e.g. 'I'll tell you what a spinal is and what it's benefits and
risks are'

-Find out what the patient already knows (I) e.g. 'have you had a spinal before?'
-Find out how much the patient wants to know (is there anything they don't want to know) (E) e.g. 'what would you
like me to tell you about it?'
-Bring out the worries/concerns that the patient has (C) e.g. 'are you worried about having a spinal? What worries
you?'

-Give the information:

-Definition: a spinal is an anaesthetic which blocks the feeling of pain in your lower body; this means you can't feel
pain in the lower body after it: it will feel numb
-Method (1): an injection is put into your back to be near the nerves for pain that go into the spine; an anaesthetic is
released into the fluid around the spine to block the nerves; the needle is then taken out
-Method (2): you lie on side or sitting; slight stinging when LA in; discomfort when tube put in; warm and numb feeling-
no more pain but may feel pressure, touch and movements; heavy legs and may not be able to move them at all
-Benefits: will give pain relief during surgery for about an hour and it is good pain relief; you can remain awake in
surgery; after an hour it will wear off; allows you to go back to movements, eating and drinking more quickly (faster
recovery); decreases surgical complications like nausea, infection, sickness, vomiting and blood clots; spinals are better
for smokers also;
-Stopping it: stops by itself an hour after injection; the feeling comes back to your legs then also; nurses and pain relief
team will monitor you to make sure all is working well with the epidural
-Contraindications: blood thinners, clotting problem, severe spine arthritis or deformity, LA allergy, back infection, blood
infections resistant to antibiotics e.g. MRSA
-Side-effects: can't pass urine (catheter needed), low BP, itching, backache, headache; rare= nerve damage, fits; all SEs
of spinals can happen even without a spinal ; 'total spinal analgesia'=rare
-Choice: if you don't want it you can have an epidural injection, combined spinal and epidural, GA, regional aneasthetic
drugs by mouth (if possible) or PCA

-give a summary and

-assess patient's understanding
-ask the patient if they have any questions and encourage it; answer them
-thank the patient

Patrick is a 61 year old Carpenter. He is having leg surgery for varicose veins. He is very worried about having spinal
analgesia and wants you to explain to him what it will entail.

EXPLAIN SPINAL
• Introduction
• Consent
• Rapport
• ICE
• Suitability for spinal
• Explains spinal
• Advantages and disadvantages of spinal
• Thromboembolism
• Pain relief
• Mobility
• Chest/physio compliance
• Contraindications
• Alternatives: PCA,paracetamol, NSAIDs, combined epidural/spinal
• Checks understanding
• Summarises

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• Clear
• Addresses concerns appropriately

Page 88
 SPINE EXAMINATION
-Introduce yourself
-Explain the exam and get consent-may I assess your back with some questions and a clinical examination?
-Exposure: to the waist and get them to stand in front of you (after asking the questions below ideally)

History

-Asks about presenting symptoms and their chronology

-For pain (especially back or leg pain): duration, onset (e.g. suddenly after lifting something, or gradually), site, radiation,
exacerbating factors , cyclicity (constant symptoms or periods of remission), relation of symptoms to any particular
posture
-For symptoms: early morning stiffness, joint swelling, deformity
-Distinguish inflammatory from mechanical pain
-Stiffness can be sudden and close to complete (after disc prolapse) or it can be continuous and worse in the mornings
(inflammatory arthritis or AS)
-Deformity: scoliosis, shoulder asymmetry, clothes not fitting
-Impact/consequences of symptoms on patient's function and psychology
-Other symptoms of musculoskeletal disorders: joint swelling, deformity, cracking, clicking, locking and loss of movement
-Involvement of other systems
-Constitutional symptoms: fever and weight loss
-Psychological aspects: sleep, fatigue, anxiety, depression

-Bowels and bladder

-Neuro symptoms and signs: paraesthesia, numbness and weakness in the legs (numbness aggravated by
standing/walking and relieved by bending forward and sitting=spinal stenosis)
-Diarrhoea, urethral discharge and sore eyes (Reiter's disease)

Examination

Wash hands
Exposure: down to the underclothes

Look standing
-front: posture of the head and neck: deformities and anomalies e.g. loss of cervical lordosis (usually due to muscle
spasm)
-side: cervical lordosis, thoracic kyphosis, lumbar lordosis
-back: posture, muscle wasting, obvious scoliosis, level iliac crests, soft tissue anomalies (lipoma, hairy patch etc over a
congenital anomaly like spina bifida)

Gait

Feel
-midline spinous processes: occiput to T1 (the most prominent one) and then down from there to the SI joints: you can
feel the L4/L5 interspinous space at the iliac crest level (note any prominence or 'step')
-paraspinal soft tissues: paraspinal muscles, interscapular, trapezius (palpate paraspinal muscles for fibromyalgia)
-if it is a neck exam check the supraclavicular fossa (cervical rib) and for enlarged cervical lymph nodes and the
anterior neck structures i.e. the thyroid gland

Movements
-neck: lateral flexion 45º (first movement to be affected in OA=cervical spondylosis degenerative changes), lateral
rotation 80º, extension 50º, flexion 80º (chin-chest distance...); watch the flexion and extension from the side; if active
neck movements are reduced, the next step is to do them passively to work out whether it's pain or stiffness that
prevents full movement; also ask the patient about pain or parasthesiae in their arm when you do the
movements=involvement of cervical nerve roots
-lumbar flexion: keep your legs/knees straight and touch your toes with your fingers-put 2 fingers on the spine while
they do this to get a rough idea of the amount of movement; suggest Schober's test as a more objective
measurement(make a mark in the midline in line with the iliac crests/ASIS, then a mark 10cm above and 5cm below
this point; hold a tape measure between these 2 points as the patient flexes: if it increases from 15cm to more than
20cm i.e. >5cm, it is normal; otherwise it is restricted lumbar flexion); make sure that you look for the smoothness of
movement and that the upper parts flex before the bottom parts
-lumbar extension: get the patient to stand straight and lean back as much as they are able to with straight knees; 10-
20º is normal from the erect position
-lumbar lateral flexion: run your hands down your leg keeping your knees straight

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Sitting movements
-thoracic rotation: turn from side to side with arms folded (or your hands on your hips): best seen from above
-if it is ankylosing spondylitis, suggest chest expansion measurement (has to be at least 5cm): this tells you
costovertebral junction mobility

Special tests
-SLR=straight leg raise: lie the patient supine and raise their leg with an absolutely straight knee; when they get pain
stop and ask them where the pain is; if the pain is in their leg it is suggestive of nerve root irritation of the lumbosacral
roots(thigh pain only is common and not significant but if it is in the buttock and back it is significant); then dorsiflex the
foot (Bragard's test)-this should exacerbate it if it is nerve irritation; flexing the knee should relieve it; then you can flex
the hip some more and then extend the knee again-should increase the pain (Lasegue's test); most normal patients
should reach around 60º before getting any pain (in total 80-90º flexion is possible)-just some tightness around the
back of the knee is normal; SLR on the unaffected side can cause pain on the other affected side, which indicates severe
root tension usually due to a prolapsed disc (crossed sciatic tension)
-Sacroiliac joints: flex the knee of the right leg to 90º and then externally rotate the hip; place the lateral side of the
right leg over the knee of the left leg; press on the ankle of the right leg in a downwards direction to the floor to stress
the SI joints
-Femoral nerve stretch test (L2, L3, L4): disc herniation rarely happens at this high a level; therefore ask the examiner if
he wants you to demonstrate it; turn the patient prone and flex their knee: this alone may cause pain; then raise their
leg (hip extension) by placing one hand of yours at the knee and another at the ankle; ask the patient if they feel any
pain; pain in the back extending into the anterior thigh is a positive test, meaning there is irritation of L2, L3 or L4 of
that side

At end
-say you would do a neurovascular assessment of the lower limb and upper limb: learn all the myotomes and
dermatomes
-say you would check the joint above and below=neck/shoulder and hip
-summarise positive findings and offer differential diagnosis
-management: suggest Ix and Tx

Full neurological examination of lower limbs:

-inspection from the end of the bed: wasting (quadriceps and shin), fasiculations (quadriceps), asymmetry, hair pattern
-tone: shake knees to look for lag, clonus
-power: hip flexion (L1, L2 and L3), hip extension (L5, S1 and S2), knee extension (L2, L3 and L4), knee flexion (L5, S1
and S2), ankle dorsiflexion (L4 and L5), ankle plantar flexion (S1 and S2), toe extension (L5)
-reflexes: knee (L3 and L4), ankle (S1 and S2), plantar (up in UMN lesion) (scratch from lateral part of sole under the
little toe up to the little toe 5 th metatarsal and then across to the big toe 1st metatarsal)
-sensory: L2 (pockets), L3 (knee), L4 (medial side of leg), L5 (dorsum of foot in line with big toe), S1 (sole of foot in line
with small toe) If you suspect cauda equina, also check further up around the back with the patient prone: S2 (back of
thigh and buttocks), S3 (buttocks), S4 (buttocks), S5 (buttocks) Do light touch, vibration sense and pinprick
-coordination and proprioception: check toe movements with eyes closed and do heel-shin test

Mr Donaldson experienced back pain while gardening. Assess his spine.

SPINE EXAMINATION MARKSHEET

Introduction
Consent for history and examination
Age and occupation
History
Open questions 'What happened?' 'When did it happen?' 'How did it happen?'
Pain: SOCRATES; specifically asks if in leg AND back
Stiffness
Deformity
Effect on life: sleep, pills, mobility: using crutches?, walking, mood/psychological
Bowels and bladder
Neurological: numbness, weakness
Systemic: weight loss and fever
Examination
Wash hands

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 Correct exposure
Inspection standing: uses phrase 'deformity'
Assesses gait
Palpates spinous processes
Palpates soft tissues
Lumbar flexion and measurement
Lumbar extension
Lumbar lateral flexion
Neck movement: lateral flexion, extension, flexion, rotation
Thoracic rotation sitting
Straight leg raise test
Sacroiliac joints
Femoral nerve stretch test
Suggest neurovascular assessment
Suggest examination of joint above and below
Neurological
Inspection: wasting, fasciculations, hair changes
Tone
Hip flexion
Hip extension
Knee flexion
Knee extension
Foot and big toe dorsiflexion, plantar flexion
Reflexes: knee, ankle and plantar
Sensory inc. proprioception
Thank patient and offer to help redress

Page 91
 SUTURING
Method of Doing It In The OSCE

There will be a pad of skin instead of a patient. The station will expect you to talk throught he procedure and then to
show your suturing technique. For the demonstration, just practice.

Introduce yourself to the patient

Explain the procedure and get consent
Examine wound looking for debris, dirt and tendon damage
Say that you would request an x-ray to rule out a foreign body
Assess distal motor, sensory, and vascular function
Position the patient appropriately and ensure that he is comfortable

The Equipment
-gather in a tray or trolley:
-sharps bin
-suture pack
-suture of right size and type (natural/synthetic, absorbable/non-absorbable)
-5ml syringe, 21G and 25G needles and a vial of local anaesthetic e.g. 1% lidocaine
-antiseptic solution
-non-sterile gloves

The Suturing
-wash hands
-open suture pack thus making a sterile field
-pour antiseptic solution into the receptacle
-open the suture, the syringe and both needles onto the sterile field
-wash your hands using sterile technique
-don the non-sterile gloves
-attach a 21G needle to the syringe
-ask an assistant (the examiner) to open the vial of LA and then you should draw up 5ml of LA
-discard the needle into the sharps bin and attach the 25G needle to the syringe
-clean the wound (use forceps) with antiseptic soaked cotton wool and drape the field (normal saline is for cleansing
and irrigation of 'clean' wounds while dirty wounds can be cleansed with povidone iodine
-inject LA into the apices and edges of the wound; make sure to pull back on the plunger before injecting
-discard the needle into the sharps bin
-indicate that you would give the anaesthetic 3-5 minutes to operate (or as long as it takes)
-apply the sutures approximately 0.5cm from the wound edge and 1 cm apart; use toothed forceps to hold the needle
and forceps to pick up the skin margins; knot the sutures around the toothed forceps (by toothed forceps they mean the
needle holder, as shown in the diagram)

Post-procedure
-clean the wound and indicate that you would apply a dressing
-assess the need for a tetanus injection
-give appropriate instructions for wound care and indicate the date sutures should be removed (face 3-4 days, scalp 5
days, trunk 7 days, arm or leg 7-10 days, foot 10-14 days)
-ask the patient if they have any questions or concerns
-thank patient

Suture this patient's forearm wound using safe technique.

SUTURING
Introduction
Age and occupation
Consent for Hx, Ex and suturing and complications e.g. infection, hitting a nerve/tendon etc
Take history: mechanism, timing, foreign bodies, contamination (glass, dirt)
Pain, neurological symptoms (sensory/motor), pallor
Allergies (latex and LA) and tetanus protection
Examination: type of wound (incision, laceration, abrasion, contusion, penetrating injury)
Depth of wound, need for subcut sutures, contamination, damage to underlying structures (nerves, tendons
vessels)

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Distally assesses motor, sensory and vascular
Removes rings
Sharps bin
Washes hands
Sterile field for equipment (e.g. suture pack on trolley)
Gloves, aprons and visor if big wound
Arranges and checks equipment before starting
Cleans with antiseptic from middle to edge
Drape wound creating sterile field
Type of LA used (say)
Correct dosage, toxicity symptoms, draw out with correct sized needle and throw away needle
Inject LA correctly with different sized needle and throw away
Checks for safety of LA injection (pulls back plunger before injection)
Check LA taken effect
Chooses correct sized suture (e.g. 4-0 for forearm)
Places needle correctly in needle holder (1/3: 2/3)
Holds skin correctly with toothed forceps
Ties surgical knot effectively using needle holders
Pass needle through each side individually
0.5 cm from wound edge
Change forceps
Spaces stitches appropriately
Cut to 1 cm
Check for inversion
Dress wound
Aseptic technique
Dispose of sharps into bin at end
Tell patient to return for removal
Document suturing
Thank patient

Page 93
 TRIGEMINAL NEURALGIA
Trigeminal neuralgia (TN) is a condition that causes recurring severe pains in parts of your face. It usually affects people
aged over 50. Treatment with a medicine called carbamazepine usually works well to stop the pains. Surgery is an
option if medication does not work, or if side-effects are a problem

The Trigeminal Nerve

The trigeminal nerve (also called the fifth cranial nerve) is one of the main nerves of the face. There is one on each side.
It comes through the skull from the brain, in front of the ear. It is called trigeminal as it splits into three main branches.
Each branch divides into many smaller nerves.
The nerves from the first branch go to your scalp, forehead and the area around your eye. The nerves from second
branch go to the area around your cheek. The nerves from the third branch go to the area around your jaw.
The branches of the trigeminal nerve take sensations of touch and pain to the brain from all areas of your face, teeth
and mouth. The trigeminal nerve also controls the muscles used in chewing, and the production of saliva and tears.
Clinical features
Neuralgia means pain coming from a nerve. In TN you have sudden, and usually severe, pains coming from one or
more branches of the trigeminal nerve. The second and third branches are the most commonly affected. Therefore, the
pain is usually around your cheek, jaw or both. The first branch is less commonly affected so pain over your forehead
and around your eye is less common. It usually affects one side of your face. Rarely, both sides are affected.
The pain is stabbing ("like electric shocks"), piercing, sharp, or knife like. It usually lasts a few seconds but can last up
to two minutes. The pain can be so sudden and severe that you may jerk or grimace with pain. The time between each
pain may be minutes, hours, or days. Sometimes several pains repeat in quick succession. After an attack of pain you
may have a dull ache and tenderness over the affected area which soon eases. However, constant pain in the face is
not a feature of TN.
You may have 'trigger points' on your face where touch or even a draught of air can trigger a pain. These are often
around the nose and mouth. Because of these, some people do not wash or shave for fear of triggering a pain. Eating,
talking, smoking, brushing teeth, or swallowing may also trigger a pain.
Between attacks of pain, there are no other symptoms, the nerve works normally, and a doctors examination would find
no abnormality.
Aetiology
In many cases it is thought that blood vessels press on the root of the nerve where the nerves comes out from the brain.
However, it is not known why blood vessels should start to press on the trigeminal nerve in later life. Rarely, TN is a
symptom of multiple sclerosis. (But note: most people with TN do not have multiple sclerosis.) In some people the cause
is not known.
Epidemiology
TN is uncommon. About 5 people in 100,000 develop it each year. It mainly affects older people, and it usually starts
in your 60s or 70s. It is rare in younger adults. Women are more commonly affected than men.
Investigations
There is no test that can confirm TN. However, no test is needed as the diagnosis is made from the typical symptoms.
Natural history
A first attack of pain usually occurs 'out of the blue' for no apparent reason. Further pains then come and go. The
frequency of pains varies from up to a hundred times a day, to just an occasional pain every now and then. This first
'bout' or 'episode' of pains may last days, weeks, or months, and then typically the pains stop for a while.
Further bouts of pain usually develop sometime in the future. However, several months or even years may pass between
bouts of pains. It is impossible to predict when the next bout of pains will occur, or how often the bouts will recur.
Bouts of pains tend to become more frequent as you become older.
Complications
The pain itself can be severe and distressing. If left untreated, this may make you depressed or anxious. You may
neglect to clean your teeth, or not eat for fear of triggering the pain. This can lead to weight loss and poor mouth
hygiene. However, there are no complications of the trigeminal nerve itself or of the brain.
Treatment: Carbamazepine is the usual treatment
Carbamazepine is classed as an anticonvulsant medicine. It is
normally used to treat epilepsy. TN is not epilepsy. However, the effect of carbamazepine is to quieten nerve impulses
and works well for TN. Carbamazepine eases symptoms of TN within 24 hours in about 7 in 10 cases, and within two
days in over 9 in 10 cases. A low dose is started and built up gradually until a dose is reached that stops the pains.
You should then take it regularly to prevent pains from returning. The dose of carbamazepine needed to control the
pains varies from person to person.

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It is common to take carbamazepine until about a month after the pains have stopped. The dose may then be reduced
gradually, and stopped if possible. After this there is often a period when pains do not occur for some time (remission).
However, the pains are likely to return sometime in the future. Treatment can then be restarted. Some people find that
carbamazepine works well at first but less well over the years.
Side-effects occur in about 1 in 10 people who take carbamazepine. Side-effects are more likely if higher doses are
needed, but even low doses cause side-effects in some people. Read the medicine packet leaflet for a full list of possible
side-effects. The most common include: drowsiness, feeling sick, tiredness, and dizziness. Quite often these are only
temporary, so it is worth persisting with the medicine if the pains ease and side-effects are not too bad.
Rarely, carbamazepine can cause serious blood or liver problems. Therefore, tell your doctor if you develop any of the
following whilst taking this medicine: fever, sore throat, ulcers in your mouth, easy bruising, or a rash - particularly if
the rash is of small purple spots. (These symptoms may be due to blood problems caused by medication.)
Other medicines
Other medicines may be tried if carbamazepine does not work well or causes bad side-effects. These
include other anticonvulsants such as gabapentin, and amitriptyline. A combination of two medicines is occasionally tried
if one alone does not help.
Normal painkillers such as paracetamol or codeine do not work for TN.
Surgery
An operation is an option if medication does not work or causes bad side-effects. Basically, the aim of surgery is
to ease any pressure at the root of the trigeminal nerve (which is often caused by pressure from nearby blood vessels).
There are various techniques, each with their pros and cons. The advice from a specialist is essential. The chance of a
cure from surgery is very good, but there is a small risk that surgery can affect normal sensation to parts of your face
or eye.
Further help and advice:
Trigeminal Neuralgia Association UK
PO Box 413, Bromley, BR2 9XS
Web: www.tna.org.uk

Mr Roberts has facial pain and has been referred to the pain clinic. Explain the diagnosis of trigeminal neuralgia to him
and the treatment options.
Mr Barry has had burning facial pains for the last 3 months. He has been referred to the chronic pain clinic with a
diagnosis of trigeminal neuralgia. The pain consultant asks you to speak to him in the clinic.

TRIGEMINAL NEURALGIA
Introduction
Consent: may I ask you some questions about your pain?
Name, age, occupation
ICE
Does the patient understand their condition and do they have any ideas about it?
What concerns do they have about it?
What are they expecting/hoping for?
Pain
Establish pain level
SOCRATES
Allodynia, hyperaesthesiae, hyperalgesia
Empathy: 'that sounds awful; I'm very sorry that you're in so much pain' 'How is it affecting your life'? 'Are
you still working?' etc
Mood
Explanation
Explain what chronic pain is
Pain will not go away in some cases; most do find some relief
Explain neuropathic pain: burning, shooting, electric shock
Trigeminal neuralgia: intense burning, shooting pain from the main nerve that gives feeling in the face; there is
1 nerve on each side; usually unilateral, more often the right side; affects cheek or chin region usually' a
shock-like pain; lasts a few seconds (rarely 2 mins); no constant pain but can have an ache after an episode;
can happen only occasionally to 100 times a day
Triggers: washing the area, talking, eating, shaving, light touch, breeze; time between pains unpredictable=mins,
hrs or days
Age: females>males; >50 is commonest but can happen even in younger people; children=rare; 5 in 100,000
get it each year
Causes: in most cases unknown; protective sheath of the nerve comes off; can be due to a blood vessel
pressing on your nerve in later life; can be MS, aneurysm, tumour, zoster, malformation; not inherited (but
don't tell patient all these causes unless they ask you)
Tests: no test for it but diagnosed from the symptoms (exam usually normal)

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No damage to brain or nerves
Anticonvulsants (quietens down nerve signals that cause pain): Carbamazepine 100mg every 12 hours; 9 in 10
pain eased within 2 days of use; take for 1 month after pain stops; SE's 1 in 10: drowsiness, dizziness, sick,
tired, blurred vision; SEs tend to go away but see doctor if ulcers, rash, sore throat, fever
Lamotrigine
Phenytoin 200-400mg every 24 hours
Gabapentin
Can combine two
Baclofen
Antidepressants: amitriptyline
Have to take regularly to keep at a certain level in your blood; need blood tests to check
MRI scan
Surgery: Microvascular decompression (opening made behind your ear and the doctor removes blood vessels
away from your nerve; 95% get relief; 75% still have relief 5 years later; needs GA and about a week in
hospital; it is very unlikely that there would be nerve damage; recommended in younger patients); nerve
damage procedures to block the nerve (put a needle through the cheek: freeze it or heat it or inject it with
glycerol or squash it with a balloon; damage the nerve and give relief for a few months to a few years; can
be repeated; leave a feeling of numbness in the face; Gamma knife (fire radiation onto the base of the nerve;
only a few hospitals doing it in UK: pain-free and non-invasive but still having trials); chance of cure from
surgery is good
Start with meds and then if ineffective or side effects try surgery
Normal pain-killers ineffective and why e.g. paracetamol, nurofen, codeine
Leaflet
Trigeminal Neuralgia Association UK www.tna.org.uk

Page 96
Reproductive and Sexual Health
(RSH)

Page 97
 BREAST HISTORY
Remember there is no breast history station. Its history AND examination in 6 1/2 mins. So the history should be done
within around 2-3 minutes max.

-Introduction
-Explain that you will ask questions to uncover the nature of her complaint
-Ask consent to do this
-Age
-Occupation
-Pregnant?
-Lactating?

Presenting Complaint
-open question
-must ask about 3 things: pain, lump and nipple discharge
-pain: SOCRATES, cyclicity, has the patient had it before, related to menstrual cycle, any other breast changes,
associated (local: lump, discharge, bleeding, skin change, nipple inversion/retraction; systemic: fever, night sweats, tired,
weight loss, chest pain and back pain)
-lump: size, site, onset, duration, cyclicity, has the patient had it before, associated (local: pain, bleeding, discharge, skin
changes, nipple inversion/retraction; systemic: fever, night sweats, tired, weight loss, chest and back pain)
-nipple discharge: amount, colour, unilateral or bilateral, if it is from a single duct or several, if it is spontaneous, are
they breast-feeding, have they had it before?, have they had surgery or trauma?, associated (local: pain, lump, bleeding,
skin changes, nipple inversion/retraction; systemic: fever, night sweats, tired, weight loss, chest and back pain)

Past gynaecological history

-LMP date; was it normal?
-regular or irregular?
-menarche
-menopause
-last cervical smear result; ever abnormal?
-ever have cervical, endometrial or ovarian cancer?
-any kids and how old? Did she breastfeed them?

Past medical history

-breast investigations and breast cancer
-illnesses, past and present
-recent visits to the doctor
-surgery/day surgery; any complications?

Drug history
-allergies
-prescribed: warfarin, HRT, oral contraceptives; drugs that cause galactorrhoea and hyperprolactinaemia e.g.
antipsychotics
-OTC
-recreational drug use

Family history
-parents
-siblings
-children
-any breast problems
-any cancers

Social history
-smoking
-alcohol
-employment=past and present
-housing
-hobbies

Systems
-only if indicated

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End
-ICE: very important to ask them what they think it might be
-ask them if they want to ask anything that you forgot to ask about
-thank the patient
-summarise and give differential
-state you would want to examine and to do a triple assessment i.e. clinical Hx and Exam, imaging (mammogram) and
biopsy

Say to the patient: Based on what you've said, I need to do an examination of the breasts to find the cause of your
pain/discharge/lump(s). I'm going to get a female colleague of mine to be present during the examination: will that be
OK with you? OK, while I do that can I ask you to undress down to the waist and to also remove your bra, I'll close
the curtain for you and we'll begin the examination with you sitting on the edge of the bed.

Likely conditions:
-fibroadenoma (if <35 years old)
-fibrocystic disease (if >35 years old)
-carcinoma

Remember you only have 6 mins 30 secs to take a breast Hx and do the exam also. Do not take longer than 3 minutes
for the history at most.

This patient is concerned about an abnormality of her breasts. Take an appropriate history and carry out a full
examination of her breasts. The examiner will ask you for your findings and interpretation of them.

BREAST HISTORY
Elicits nature of problem and any concerns
Asks about pain/tenderness in the breasts
Asks about discharge from the nipples
Takes a menstrual history
Asks about drugs: OC pill/HRT
Ask about FH of breast disease
Asks about past history of breast disease
Asks about previous Ix

Introduction
Consent
Open questioning
Pain
Nipple discharge
Lumps
Bleeding
Skin changes
Nipple inversion/retraction
Fever, chest/back pain, weight loss, night sweats, tiredness
Takes menstrual history
Pregnant/lactating
PMH and PSH
Drugs and allergies
Pill/HRT
FH of breast disease
Social history
Smoking
ICE (e.g. worried about breast cancer) and reassure

Page 99
 CONDOMS
Condoms are a barrier method of contraception, be they male or female condoms. They work by preventing sperm from
reaching the egg.
They are less effective then the pill in preventing pregnancy but very effective at preventing sexually transmitted
infections.
There are a number of types of condoms available. These include lubricated and non-lubricated condoms, straight-sided
and shaped/ribbed and teat-ended vs plain ended.
Spermicidal condoms are not recommended since evidence indicates that nanoxynol-9 increases the risk of HIV and
other STIs like chlamydia and gonorrhoea being transmitted.

-In this station you may have 2 condoms, a model of a penis and an info booklet on use of condoms

-Introduce yourself and get consent; may I discuss with you your method of contraception?
-Name, age , occupation

ICE
-I: what do they already know about condoms?
-C: do you have any concerns/any other concerns about using condoms?
-E: is there anything you're expecting me to explain?

Effectiveness if used correctly

-male condom 98%
-female condom 95%

Condom Use On A Model

-put on before genital contact
-discuss it's use with your partner

Check
-the British kite mark, a guarantee of quality (or its equivalent e.g. CE mark)
-check expiry date
-tear the pack open and take out the condom; don't use your teeth or sharp nails
-the condom should be put on an erect penis only, on it's tip
-the air from the tip of the condom should be squeezed out and then it should be rolled onto the penis base
-in penetration the condom should be held at the base of the penis
-post-intercourse take off the condom without spilling semen
-the condom should be thrown in the bin and shouldn't be reused ever

After demonstrating it on the model

-get the patient to repeat it to ensure they understood
-make sure they show you how to put it on

Tearing
-tell the patient that condoms can tear sometimes and that the GP or family planning clinic should be consulted by them
and partner if this occurs

Side-effects of Condoms
-latex allergy
-spermicide sensibility

Contraindications
-oil-based lubricants:
-Vaseline
-hormonal vaginal creams
-antifungal preparations except for Canesten (which is safe)

End
-ask about any questions or concerns e.g. may ask about other types of contraception
-tell them to return if he has any more questions
-give him an info booklet on condom use

Page 100
You are a medical student on attachment in a family planning clinic. You are asked to see a patient that wants advice
on putting on a condom correctly. Elicit any concerns and give the appropriate instruction using the plastic training
model provided. You will be marked on your communication skills, practical skills and the information provided.

CONDOMS
Introduction
Consent
Clinical Hx: Elicits reason for attending
ICE
Suitability of condoms
Statistics for effectiveness
Kite mark and expiry date
Method of putting on inc. no genital contact before on
Danger of tearing with ring/nails during removal from package
Different types: size, shape and material
Expel air from the teat
Non-latex condoms
STI protection
Causes for split
Avoid various products that weaken condom:oil-based lubricants
Female condoms
Open product supplied
Disadvantages
Demonstrates rolling the condom onto the condom demonstrator
Holding the condom onto the base of the penis in withdrawal
Failure rate 2-16 per 100 woman years
Mentions emergency contraception can be used if condom fails
Mentions checking whether condom has been damaged
General fluency including use of non-jargon and repetition
Summarises
Acknowledgement of and appropriate response to feelings
Checks understanding
Conclude effectively

Page 101
 DEPO TB
Definition
-Depo-Provera is an injection that prevents pregnancy (acts as contraception)
-used since 1960s

Types Of Progestogen Only Injections

-2 types: Depo-Provera is the commonest brand
-Noristerat is not used much (so don't mention it in the OSCE) and is given every 8 weeks at 200mg; it is licensed for
more short-term use then Depo-Provera; amenorrhoea is not as common with it and its side-effects are less pronounced
than Depo-Provera; efficacy rate=0.4-2 per 100 women years; fertility can be delayed in returning with it; unlike Depo,
Noristerat is affected by enzyme inducers but not by antibiotics; maximum 2 injections are allowed so may be used
after partner's vasectomy until the surgery is effective

Epidemiology
-3% women of reproductive age use it

How? (Mechanism of Action)

-it is a hormone: progestogen
-it prevents the egg being released (ovulation)
-it also has an effect on the womb (thins it to make attachment of egg unlikely) and mucus of the neck of womb
(thickens it until it forms a mucus plug in the cervix to stop sperm getting in to join egg)
-the hormone is released gradually into the circulation after injection; there is a high level at the beginning which then
falls rapidly

Effectiveness
-it is very effective, more than 99% effective
-less than 1 woman in a 100 will get pregnant if they used it for 1 year (compared to >80/100 women using no
contraception)
-it is long-acting and thus more effective then oral contraceptives in practice

Frequency
-given every 12 weeks (licensed for 12 weeks + 5 days) (in reality, it is effective up to 14 weeks)
-150mg DMPA (medroxyprogesterone acetate)
-almost always given in the bum, sometimes the arm (IM)

When
-if given in the first 5 days of the cycle, won't need extra precautions: this is the normal time to give it; if cycle is
shorter then 28 days then use barrier methods for 7 days
-if after delivery of baby then start at 6 weeks as long as not pregnant; starting earlier is possible but it may affect the
bleeding pattern in an adverse way
-if it is post-abortion you can start depo the same day
-always ask about sex: if the patient has had no sex in the current cycle, you can give depo (or implanon) that very
day
-in any case if you give the injection anytime other than in days 1-5 of the cycle you will need extra precautions for 7
days

Advantages
-very effective and safe
-long-lasting
-no interference with sex
-won't forget a daily dose
-reversible (mean return of fertility is 9 months after last injection)
-OK for use with EIs (epilepsy, HIV, TB)
-heavy menstrual bleeding decreases with it after initial time period of few months
-can decrease other menstrual problems like PMT, heavy bleeding and pain
-can be good for mood, epilepsy and migraine
-can be good for sickle cell disease: stabilises the red cell membrane
-can be good for endometriosis and fibroids
-can use depo while breastfeeding
-can protect against womb cancer and does not increase the risk of breast cancer
-can protect against PID (but not STIs) (may partly prevent bacterial ascent into the womb cavity with the mucus plug)
-no oestrogen and no oestrogen SEs (weight gain, fluid retention, blood clots, brown spots on skin etc); can be taken by
women who cannot take the COCP

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-protects against ectopic pregnancy and safe for previous ectopics
-use in people with prior VTE or prothrombotic abnormality

Disadvantages
-periods change: irregular bleeding can happen for some months and you can't predict what will happen: there can be
any pattern of bleeding; in the long term amenorrhoea in many, in some light irregular bleeds
-any SEs will have to be tolerated for 3 months or more: you cannot remove the hormones after injection
-your appetite may increase; many stay the same weight but if they eat more=will gain weight 2kg minimum average
-depression, headache, breast tenderness, acne, mood swings
-return of fertility can take 9 months average (so even as early as 6months it can return); may not start having
ovulation until 12-18 months after; 91% had conceived by 2 years in 1 study (time of return of fertility is not connected
to how long depo used)
-enuresis can return in women that had it when adolescents (perhaps due to an effect on smooth muscle)
-bone density decreases in first two years of use and then levels off (due to fall in oestrogens from ovarian suppression);
not associated with osteoporosis nor fractures; will be restored to normal when you stop taking it (but don't give to
people with osteoporosis or <18 years old since they have not achieved peak bone mass); if 45 years old or older,
advise on other contraceptive options; with younger women you can put them on depo for 2 years, then take off it and
use an alternative means of contraception, then put them back on depo again
-slight reduction in glucose tolerance in diabetics

Absolute Contraindications
-cancers
-pregnancy
-osteoporosis
-undiagnosed genital tract bleeding
-recent trophoblastic disease
-porphyrias
Other CIs
-wanting pregnancy soon after a short-term contraceptive method
-multiple risk factors for arterial CV disease=diabetes, smoking, hypertension, older age (can get lipid changes)
-active thromboembolism
-IHD
-stroke
-active hepatitis/severe cirrhosis
-osteoporosis

Antibiotics and Enzyme inducers

-OK to use depo with EIs and antibiotics
-advice used to be to decrease the injection interval for patients on EIs such as rifampicin; no longer the case but is still
common practice

What if injection overdue?

-it can be given up to 14 weeks after the previous injection without effects on contraception
-after 14 weeks you can give it if the woman is not pregnant according to reasonable certainty but must advise to use
barrier methods for 7 days ; if there is a chance of it don't give the injection and do pregnancy test after 3 weeks
-if there was UPSI after 14 weeks, give emergency contraception
-it is not teratogenic to a pregnancy but it can have virilising effects on the the female foetus if repeated doses are
given in pregnancy
-if a woman is on depo and has no periods, then do a pregnancy test after 2 weeks

-Offer leaflet at the end and let patient know they can think about it
-In practice always take a full medial history, including FH, menstrual, contraceptive and sexual

Ms Ginsbury wants a method of contraception. She is taking TB medications including rifampicin. She does not want an
IUCD. Discuss her options with her.

TB MEDICATION AND LONG-ACTING CONTRACEPTON

Introduction and consent
ICE
Establishes Depo and Implanon as long acting choices
Progestogen only methods
Establishes last LMP and cycle length and last UPSI

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Implanon cannot be used with EIs
Depo can be given with EIs: every 12 weeks in the bum
Aware no need to reduce Depo interval with EIs
Aware still common practice to redo interval with EIs
Mentions effectiveness e.g. more than 99% or 'very'
Describes method of action: ovulation suppression, endometrial/mucus discharge
No periods, irregular bleeding
Side-effects
Benefits: LA (long-acting), not intercourse related
Safe strategy given i.e. 1-5 day cycle so no extra precautions needed
Disadvantages
CIs
STIs: not protected
Missed injection
Establishes patient understands
Offers opportunity to ask questions
Offer leaflet

Page 104
 ECTOPIC PREGNANCY
-Introduce yourself to the patient and get consent 'may I speak to you about the investigations we have been doing for
the bleeding you've had'?
-Summarise what has happened: e.g. 'so you've been in hospital for a day for bleeding during pregnancy and we
examined you and did a scan to see why that was'
-ICE: may I ask what ideas did you have about the bleeding? Do you have any worries or concerns about the bleeding?
What are you expecting from the medical staff/your hospital admission? (remember the patient may not have even
known they were pregnant as many ectopic pregnancies happen in women who were unaware a pregnancy was
present; ICE is the way to find out if they knew they were pregnant if you don't already know)

Hostility
-the patient will behave belligerently
-Acknowledge her feelings
-she may demand to see a consultant: tell her she will be able to see one (but convince her to speak to you first e.g. I'll
speak to you about the investigations we've done and then after that I'll call my consultant and you can speak to them)
-apologise and tell her you can't imagine how difficult things must be for her and I'm sure that others in your situation
would feel the same way

Give Scan Result: Break Bad News

-We did the scan of your tummy and I have your results now.PAUSE
-I'm afraid the results were not as good as we'd expected. LONGER PAUSE (let patient prepare)
-We found 2 things in your scan.
-The first thing was a cyst-a sac which is filled with fluid-in your right ovary-the organ which makes your eggs; this is
not something which we are worried about: it's alright to have a cyst in your ovary, many women have it and it's no
problem
-The second thing we found is that:
-The scan shows that you are pregnant and your pregnancy is not in the womb. PAUSE
-It's outside the womb in one of your tubes. The tubes that carry your egg from the ovary to the womb. That means
that the pregnancy can't grow in the normal way it's meant to and it can't be delivered at the end. LONG PAUSE
-I can't imagine how difficult it must be for you to take all this in. LONG PAUSE.
-Let the patient cry or express her sad feelings without interruption; offer water/tissues if you wish to

Reassure and Give Hope

-even though this has happened there is a good chance that you will have a healthy pregnancy after this; I expect that
you will and I think you should be hopeful of that and we'll give all the help that we can; we'll monitor your next
pregnancy closely
-this type of pregnancy happens from time to time and we see many of the women to whom it happens going on to
have successful pregnancies
-if you want to talk to someone I can put you in touch with a counsellor who is experienced in helping women who
have had these kinds of pregnancies; because we don't want you to get depressed since you have a good chance of
getting pregnant again; would you like to talk to someone?

Epidemiology
-most ectopics grow in the tubes but sometimes in the ovary or abdomen
-in the tube it cannot ever survive
-1 in 100 pregnancies in the UK=common

Aetiology
-not mum's fault
-it can happen to anyone
-at higher risk groups (don't tell to mum!!!!!): previous ectopic (if she mentions having had one before say ' O I see,
that must be very difficult; if you have had this type of pregnancy before, it can happen a second time, but the chance
of having a successful pregnancy is about 7 times greater so you are likely to have a non-ectopic pregnancy next time);
if the tube is damaged from previous pelvic infection (chlamydia and gonorrhoea are commonest); pregnancy after
sterilisation: 1 in 20 will be ectopic; surgery to the tube or surrounding structures; endometriosis (a condition of the
womb and surrounding areas); progestogen releasing IUCD; infertility treatments ('assisted conception'); older when
pregnant
-if the women is in a high-risk group she should see the doctor as soon as she thinks she is pregnant; can test for
pregnancy within 7-8 days of fertilisation; will get early scan

Investigations
-a pregnancy test (urine)
-USS can show the ectopic; may not be clear if it is very early pregnancy; patient may need observation for a few days

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if symptoms are not severe; a repeat scan days later may then show it
-blood tests for pregnancy hormones
-look in the tummy with a special telescope=laparoscopy: can confirm it

Outcomes: it's important for us to talk about what to do next: do you have any thoughts about that?
-could just miscarry: it will die, often within days of the pregnancy; around half of ectopics end like this; you might not
have any symptoms, you may not even realise you were pregnant; or you may have tummy pain or bleeding from the
vagina; if this happens the body sorts out the consequences and you don't need treatment
-it could just grow, stretching the tube; eventually this will cause symptoms and is the usual time of diagnosis
-the tube splits; causes heavy bleeding inside the body

Symptoms
-pain in the lower part of the tummy; can be on one side; can start all of a sudden or gradually grow over days (often
after a missed period)
-shoulder tip pain: because of blood from tummy affecting a muscle for breathing
-bleeding from vagina:heavier or lighter than period; could be dark; could look like period blood though
-feeling faint, diarrhoea or pain with passing stools
-collapse and severe pain from tube splitting and heavy bleeding inside the tummy
-can be asymptomatic until the tube splits
-symptoms can start anytime between 4-10 weeks of pregnancy, usually around week 6
-you may not know you are pregnant, for e.g. if you have irregular periods or if you were using contraception
(condoms or the pill) you may not have realised that it failed to prevent pregnancy
-symptoms may coincide with the start of a period so it may seem to you to be a late period if you didn't know you
were pregnant

Dangerous
-it is a good thing that we've found what we've found on the scan early because this type of pregnancy outside the
womb can become a problem
-it grows in your tube, which is a small space; as it grows it could cause a sudden bleed to occur, which can be life-
threatening to you: you could become ill, unconscious and then not recover ('ectopic' means outside the womb, so not in
the correct place: literally it means 'misplaced' but don't say that to the mum)
-if you were brought into hospital in time you would need emergency surgery to remove the pregnancy from your tube
and to remove part of your tube

Treatment
-ruptured ectopic: emergency surgery to take out the split tube and the pregnancy to stop bleeding; this is potentially
life-saving
-non-ruptured ectopic: a planned operation or medical: a drug called methotrexate; only if a very early pregnancy and
it kills the cells (stops the pregnancy growing) in the tube; will need repeated blood tests to make sure it worked and
may cause side effects); (wait and see: if left with no or minor symptoms the body may end the growth by itself but
there is no guarantee that would happen; will need blood tests and repeat scans; could have a split in the tube
tomorrow and then not recover); advantage of the latter two options is avoidance of surgery

Laparoscopy
-we want to treat you before the tube splits and you get life-threatening bleeding
-this is why we are going to need to do a procedure called a laparoscopy, where we put a little telescope into your
tummy after making a small cut; it's keyhole surgery so we only make small cuts in your tummy and look in with a
telescope; done under GA (you'll be sleeping)
- find the place of bleeding and we can then have a look at where the pregnancy is growing and we can remove it
before it makes you much worse then you already are
-sometimes we can leave the tube in but often we have to take it out also so you won't be able to get pregnant from
an egg on that side in the future-that is one of the risks of the operation; having it treated early minimises damage to
the tube, making it more likely that you will have a pregnancy on that side again if the tube is left in
-have you ever had surgery on your tubes? OK, then you'll still be able to become pregnant from the tube on the other
side
-we'll need to do this procedure today
-recovery: can take up to 6 weeks' you may feel bloated and may feel some pain and discomfort

Transplantation
-the tube is not able to nurture the pregnancy and there is no way for a doctor to simply transplant
it into the womb
-the tube does not have the nutrients for it to grow

Lutein Cyst
-the scan also shows that you have a cyst on your ovary, the reproductive organ that makes eggs: a cyst is a fluid-filled
sac

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-these cysts are not significant: they won't affect your pregnancy
-they are actually a normal finding in pregnancy because your ovaries support your pregnancy so it's not at all a
surprise to find a cyst on the ovary: it shows the ovaries were supporting the pregnancy
-you may not need any treatment for it
-if it gets bigger than 5cm we may offer you the option of having it drained or removed
-they usually go away by themselves in 4-6 weeks; they are common and usually painless; it will probably go away
after your pregnancy and are not at all dangerous or worrying
-treatment: observation, have another scan in a month's time to check it has disappeared

Recurrence
-1 in 10 risk of having an ectopic pregnancy in the future but the chance of a successful pregnancy is 7 out of 10; so
you are far more likely to have a successful pregnancy' most have a healthy pregnancy as soon as they try again and
it is better to probably wait a few cycles before trying again to allow you to recover from the surgery; if in the
meantime you or your partner need to talk to someone, please tell us and we can arrange that
-even if you lose a tube you can still have a normal pregnancy
-if unable to conceive you will be candidate for IVF (in vitro fertilisation) fertility treatment

Follow-up
-we'll give you an appointment to come to our outpatients department to discuss your future pregnancies. We'll do
everything we can to support you in future pregnancies so they have a good outcome.
-the anaesthetist and the operating surgeon will speak to you before the procedure and explain to you all of it's details.
You'll have to remain nil by mouth until the procedure, so no food, you can keep on drinking water until 2 hours
before the procedure.
-Do you have any questions for me?
-Is anything worrying you?
-is there anyone you want to contact to come to hospital to be with you? Let us know if there is
-I'll be around on the ward today so you can ask for me and if I'm not on the ward someone will bleep me and I'll
come if you want to speak to me again. I'll let all the staff on the ward know about your situation so that they take
good care of you. We see cases like yours regularly so the staff are very good and you'll be in capable hands. I'll see
you later.

Ms Santiago came into A+E at 2am with lower abdominal pain and heavy vaginal bleeding. She had collapsed out of
hospital. An USS was ordered urgently and gives the following result:
There is a fetal sac in the right fallopian tube. There is a 3cm luteal cyst on the right ovary.
Discuss the result with Ms Santiago as the night on-call F2.

ECTOPIC PREGNANCY
Introduction
Consent
Give a summary of what the presenting symptoms of the patient are
Inform the patient first of what you will explain to them
ICE: Find out what the patient's ideas about what is happening to her
Find out what her concerns are
Find out what she is expecting
Breaks bad news
1 in a 100
Can be without pain and signs of pregnancy
Symptoms 4-10 weeks; peak 6 weeks
Never successful delivery
Can progress to miscarriage or rupture
Bleeding duration
Bed rest won't prevent miscarriage
Not mother's fault
Says cyst not significant
Next scan for cyst
Explain laparoscopy needed and what it is
Tube may be removed
Ectopic pregnancy in future
Can't be transplanted
Dangerous (would need planned or emergency operation)
Needs operation on same day
Sympathetic

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Reassures
Gives sensitive advice
Copes with aggressive manner
Explains whether or not mum can go home
Explains when next scan will be
Tell doctor early next time pregnancy suspected
Follow-up
Closes effectively checking any leftover concerns

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 FEMALE CATHETERISATION
Note that for this station there may be an actor lying in the lithotomy position with a catheterisation model inbetween
their legs to prompt you to show your communication skills in addition to the skill of catheterisation.

Female Catheterisation:
-Introduction: patient's name and hospital number (wristband)
-Consent (use the word consent) and ask patient if they would like anaesthetic: problems passing urine, make this
easier for them by inserting a thin tube called a ‘catheter’ into the bladder.
-ICE: have they had it before? Concerns.
-Allergies, particularly to latex
-Chaperone
-Close door and curtains
-Undress below waist and lie on back; keep self covered with cloth
-Wash hands
-Open catheterisation pack on trolley touching only the outside of pack; chose size 12-16F; choose 12 if available
(expiry date also)
-Open catheter bag partially (does not come in catheter pack; also contains in it the syringe with water)
-Open Instillogel pack partially (also does not come with catheterisation pack; 10ml syringe with 5ml in it) (if not
prepared use 2% lidocaine 5ml)
-Pour saline wash on top of your cotton wool balls in the pot of the catheterisation pack
-Choose 2 gloves: size 7 and size 8: open and drop your 2 glove packs onto sterile area (in reality can drop them onto
non-sterile area too)
-Wash your hands again, this time in scrub fashion (not just social wash) for around 5 mins; dry with the cloth provided
in the pack; then place this cloth after drying between patient's legs under vulva
-Put on both gloves: first the smaller one (size 7) and then the bigger one (size 8); throw away the packets
-Drape the patient: rip hole in the paper (fold in half and tear off a piece, then open)
-With one cotton wool wipe the outer left labia, then with another the outer right labia; then do the same with the inner
labia with 2 further wipes and throw in bin afterwards (wipe downwards once for each part); make sure you clean the
urethra
-Inject Instillogel (a few ml e.g. 2 ml); put some onto your sterile field to dip the catheter tip into
-Leave to work for 5 mins
-Discard your outer pair of gloves
-Place kidney dish between patient's legs and under the vulva
-Insert catheter parting labia with left hand; you can dip the tip of it in Instillogel beforehand if you like but this is
purely for lubrication-it has no anaesthetic effect; push in catheter until you get urine; do not touch the catheter, just
push in holding the plastic; the first bit of urine will come out in the plastic pack; take out the end and put in the kidney
dish; one you have urine, keep pushing the catheter in further as the balloon can still be outside the bladder-it is
recommended to push in the catheter all the way to it's hilt
-Inject 5-15ml of the water syringe into the smaller port of the catheter (saline is not used: it forms crystals); the amount
to inject is written on the catheter; this will inflate the balloon in the bladder; you should inject the whole amount
written on it otherwise the catheter can slip out; ask the patient if they feel pain when you inject
-afterwards pull back to feel resistance gently
-attach the catheter bag to the catheter's larger port after removing the plastic guard from the end of the catheter bag
-can attach catheter to thigh by tape
-help patient to redress, ask her if she has any questions or concerns and address and thank her
-discard rubbish, remove gloves and wash hands
-place in file the date, the time, the size and type of catheter, how much water volume injected (you get a sticker to
put in the file for the catheter in the catheter pack) and urine volume drained

FEMALE CATHETERISATION
Introduction: patient's name and hospital number (wristband)
Consent
ICE
Chaperone
Close door and curtains
Correct exposure and position
Washes hands
Create sterile field and collect equipment
Open catheter of correct size and instillogel packaging partially
Pour saline onto cotton balls

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Wash hands again and use cloth in pack to dry
Put on 2 sets of gloves
Ask patient to raise heels to buttocks and drape
Clean labia including urethra
Inject Instillogel and leave for 5 minutes to work
Discard outer gloves
Position kidney dish
Insert catheter without touching it until urine comes out, then push in further (to hilt if possible)
Inject sterile water in amount mentioned on catheter pack, asking patient to report any pain
Pull back gently until resistance felt
Attach catheter bag
Redress and address any questions
Treats patient sensitively
Discards waste and washes hands
Records catheter information in notes

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 GUM HISTORY
The Sexual History

You may be asked to focus on: sexual history OR risk assessment for HIV

-Introduction and consent (this will involve asking you some very personal questions about your sex life)
-Name, age and occupation

Sexual preference (not vitally important: can omit as it could be perceived as discrimination or stereotyping)
-heterosexual (straight)
-homosexual (gay)
-bisexual

Partners
-when was the last time you had sex? (a good question to start with)
-who was this with?
-are they a regular partner?
-have had sex with anyone else in the last 3 months?
-have you had any casual partners?
-have you had any partners of the same gender/opposite gender/both?

Place of sex
-have you always lived in this country or have you lived overseas?
-where are your partners from?
-have you ever had sex overseas?

Type of sex
-with your partner, what type of sex did you engage in?: was it vaginal or rectal or fallatio or all of these? Did you
give or receive?
-did you always use protection? (condoms)
-ask about each partner and the type of sex with them, and whether it was always protected sex
-(have you ever been hurt or abused by your partner: don't ask in OSCE)

STIs
-sores
-discharge
-itching
-dysuria
-abdominal pain (females)
-testicular pain (males)
-ask any relevant further questions about the above symptoms
-have you ever been tested for STIs/HIV before? What was the result? Why did you have that test and when?
-ever had an STI before?
-has your partner had an STI/HIV or been tested?

Cervical smear test

-last smear date and result
-if abnormal=what was done?
-LMP?

Contraception
Menstrual history
Obstetric history

Sexual function: not releveant for Year 4 OSCE

-do you any difficulties or worries about sex?
-females: dyspareunia, hypoactive sexual desire, anorgasmia or vaginismus
-males: ejaculatory dysfunction, erectile dysfunction
-any problem: onset, frequency, course, duration, timing
-is it 1º or 2º?
-is it partial/situational? e.g. in situational erectile dysfunction the patient can still have morning erections
-the effect it is having on their life?

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Past medical history

Drugs and allergies

Family history

Social history
-smoking
-alcohol
-recreational drugs

End
-ICE
-do they want to ask anything?
-thank and summarise
-present findings and suggest course of action

Ms Seth has come to the GUM clinic complaining of vaginal discharge. Take a history.

GUM HISTORY
Introduction
Consent
Open questioning
Discharge
Dysuria
Itching
Pain
Symptoms/duration/associated
Last sex
Recent partner and condom
Last 3 months partners and condoms
Place of sex
Type of sex
Previous tests incl. HIV
Last cervical smear
Contraception
Menstrual history
Obstetric history
PMH and general health
Drugs and allergies
Family history
Social history
Responds to feelings
Why do they want a check-up?
Summarise and end effectively

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 GYNAECOLOGY EXAMINATION
Method of Gynaecology Examination OSCE Station

-Introduce yourself to the patient and ask their name, age and occupation
-Summarise for them why they are here: you've come today to have a smear test; have you had one before? ICE
-Explain the procedure to them: I'll take a sample from the neck of your womb, the cervix (from where babies are
delivered); this is to take a sample of cells; the cells of the cervix undergo changes; these changes usually return back to
normal by themselves; but if they don't then after 10-20 years they can turn into a more serious state; so the smear is
a screen to find those changes early on and keep an eye on them, making sure they return to normal; OK?
-I'll be performing the smear test with this instrument, a speculum; it will gently open up and make a tunnel through the
vagina with which I'll be able to see the neck of the womb; it's only this part that goes in, not this part (the opening
mechanism); it shouldn't hurt but you may just feel some pressure from it; I'll also use this brush to take the cell sample
from the cervix which will then be sent to a lab for analysis; do I have your consent to do that?
-after that I'll also do an internal examination where I place 2 fingers in the vagina and check that your reproductive
organs are all healthy; do I have your consent for that also?
-may I ask if you've emptied your bladder?
-I'm going to call in a female chaperone to be present during the examination; is that alright?
-during the examination you'll be behind curtains; however I can also lock the door if you prefer for extra privacy;
would you like me to do that?
-(can ask LMP, last USI and if the patient thinks she could be pregnant since smears should not be done in pregnancy;
the rise in cervical mucus (and resultant decrease in the no. of cells obtained) usually renders the sample inadequate and
the results unreliable; also ask about use of hormonal treatment like HRT and contraception, last smear details and
previous abnormal results, irregular bleeding e.g. PCB or PMB; where appropriate offer chlamydia screening i.e. <25
years and symptomatic): however this is mostly irrelevent in year 4 OSCE station
-I'm going to prepare for the examination; you can go behind the curtain and please undress below the waist and you
can keep the large paper towel which I've placed there as a covering until the examination begins; you'll be lying on
your back for the examination
-I'll wash my hands and prepare my equipment on a trolley; I'll check the liquid based cytology vial's expiry date and
will date the sample vial; also write the patient's name and DOB on it; I'll collect a pair of non-sterile gloves; I'll have
my cervix brush ready (a green one on which the head does not detach or a blue one which does have a detachable
head); I'll have a small amount of KY jelly (not aqua gel) prepared; I'll choose an appropriate sized Cusco speculum by
asking the patient if they have any children (no vaginal deliveries=small speculum; 1-3 vaginal deliveries=medium sized
speculum; 4 or more vaginal deliveries or obese=large speculum)
-I'll then ask the patient to uncover their tummy and I would perform an abdominal examination after getting consent to
assess for masses and tenderness and also to establish a physical rapport with the patient before moving on to more
intimate areas; inspection first: scars (periumbilical region for laparoscopy, suprapubic for C section), distension, masses;
'do you have any pain'? Then I would palpate the 9 areas by light and deep palpation watching their face for any
grimacing indicating tenderness
-I'm now going to palpate for lymph nodes (inguinal region)
-After that's done I'll tell the patient that everything is fine and I'm now ready to do the smear test; can she please
bend her knees until her heels are touching her buttocks and then let her knees fall apart sideways with her heels
together
-put on gloves and open the vial top
-put gel on either side of the speculum after warming it (run under water or just rub it); the closed blades should project
between the index and middle fingers with the main body in the palm; inspect the labia/vulva, telling the patient you
are inspecting: look for scars, colour changes, warts, skin changes, hair changes, discharge, masses
-part the lips of the labia majora with your non-dominant hand using your index finger and thumb: inspect the vulva,
clitoris, urethral meatus (opening) and vaginal introitus (opening) for any abnormalities: redness, discharges, ulcers,
atrophy and old scars; ask the patient to cough or strain down and look at the vaginal walls for any prolapse
-tell the patient you are now starting the examination and will pass the speculum: insert the speculum with the opening
mechanism pointing to the right; angle it downwards and backwards; once near the cervix turn it 90 degrees so that
the mechanism points to the ceiling; protect the clitoris and hair from catching by using the non-dominant hand held
behind the opening mechanism as the speculum goes in
-ask the patient if they are alright once all the way in and open the speculum with the non-dominant hand that was
protecting the clitoris; maintain a downward pressure as you do this and press on the thumb piece to hinge the blades
open; visualise the cervix; if you can see it, lock the speculum in place by rolling the thumb screw onto the opening
mechanism to secure it; check with the patient that they are comfortable
-say that you would ask the chaperone to position a light so you could see the cervix clearly; inspect the cervix: colour
(pink is normal), ectropian/ectopy (erosions look like strawberry red areas spreading circumferentially around the os and
represent extension of the cervical epithelium onto the surface of the cervix),cysts, masses, ulceration, polyps, discharge,
spontaneous bleeding, the external os cervical opening (is it open and shape: round=nulliparous, slit-shaped=after
childbirth); ('the cervix looks pink, smooth and regular, which is normal)'
-take the cervix brush and place the central bristles in the endocervical canal through the os while the outer bristles

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contact the ectocervix; rotate clockwise 5 times using pencil pressure (the bristles are bevelled to scrape cells only in a
clockwise rotation); check for contact bleeding (red inflamed cervix that bleeds on contact and gives off a mucopurulent
discharge is suggestive of cervivitis and will need swabs for culture)
-part the bristles at the bottom of the vial repeatedly (10 times) and vigorously to remove/transfer the sample into the
vial by rinsing in the Thinprep® preservative (if it is a green brush); inspect the bristles afterwards for any remaining
material and repeat if necessary; seal the vial; alternatively break the head and drop it in the vial without touching the
bristles if it is a blue brush
-throw away the brush and send off the liquid based cytology vial in transport packaging with a filled in request form
-tell the patient you're going to remove the speculum and first undo the screw entirely, but keep the mechanism fully
open manually with the non-dominant hand protecting the clitoris and avoiding hair trapping; with the dominant hand
use the thumb and index finger to pull out the speculum around 1cm so it is distal to and away from the cervix; then
let go of the opening mechanism with the non-dominant hand to allow the speculum to close
-withdraw the speculum slowly making sure to inspect the walls of the vagina up to the introitus; you can rotate the
blades in an anticlockwise direction to see the anterior and posterior walls also; the walls of the vagina will naturally
close the blades of the speculum (except with the metal speculum, as the vaginal walls are not strong enough to close it;
thus the lack of proper closure makes extraction of this speculum more difficult than the plastic speculum); near the
introitus close the blades making sure not to pinch the hairs nor the labia
-throw away the speculum

-tell the patient you took the sample and everything looks fine; you're now going to perform the internal examination
-gel your index and middle finger both sides and part the labia; tell the patient you're now going to examine
-enter the vagina with the palmar surface of the fingers pointing to the patient's right; once you reach the cervix turn
your palm so that it faces upwards
-ask the patient if she is alright and that everything is fine; palpate the cervix; normally it points downwards in the
upper vagina if unable to locate it easily consider the possibility that the uterus is retroverted (20% of women) and feel
in the anterior and posterior fornices (above and below the centre) to try to locate it; if you find the os easily this makes
it likely that the uterus is anteverted
-palpate the os and comment on it's shape, diameter and whether it is open or closed; comment on any palpable
masses or irregular consistency as opposed to smoothness (the normal cervix has a similar consistency to the cartilage
in the tip of the nose) ; assess for cervical excitation by moving the cervix gently from side to side by pushing first on
one side of the cervix then the other; watch the patient's face for a painful reaction (positive test suggests infection)
-feel for the uterus; tell mum you're going to check her organs and with your non-dominant hand find the fundus of
the uterus starting around 4cm above the symphysis pubis on the lower anterior abdominal wall; you will feel the uterus
hit your internal fingers once you find it; keep palpating and comment on it's size (is it the normal size of a non-
pregnant uterus?=lemon sized; uniformly enlarged=pregnancy, fibroid or endometrial tumour), position (anteverted vs
retroverted; the former is easily palpable abdominally but the latter may not be; try putting your fingers in the posterior
fornice if it is retroverted), mobility (mobile=normal), tenderness (can occur in conditions like adenomyosis and
endometritis) and masses (e.g. fibroids: if multiple these can give the womb a lobulated feel); with masses comment on
consistency, size, mobility, shape, tenderness etc
-feel in the adnexae by moving the internal fingers into the right and left lateral fornices upwards and laterally (finger
pulps facing the ant.abdo wall and fingers pointing upwards) and palpating abdominally in the iliac fossa inwards and
downwards for any masses or tenderness; this is mainly for the ovaries and tubes; if there is a mass, decide whether
you can get below it and whether or not it is separate from the uterus (one way of doing this is to move the cervix and
uterus and see if the mass moves also;if it does=probably a uterine mass palpable in the adnexae rather than an
ovarian mass; an adnexal mass may have a line of separation between it and the uterus and the mass should be felt
distinctly from the uterus) (e.g. 'on the right side I can feel a fullness ; it's a mass of about 4cm diameter; it's round and
mobile; it is soft and possibly cystic; I can get below it and I don't think it's arising from the uterus; my impression is
that it is ovarian in origin' or 'on the right side there are no palpable masses'); ovaries are firm, ovoid and often
palpable; if there is unilateral or bilateral ovarian enlargement, consider benign cysts (smooth and compressible) and
malignant ovarian tumours; normal fallopian tubes are impalpable; there may be marked tenderness of the lateral
fornices and cervix in acute infection of the fallopian tubes (salpingitis); while the consistency of a mass can help to
distinguish it's origin in certain cases, an USS may be necessary
-remove the examining fingers and examine your gloves for blood/discharge; tell the patient that everything went fine
and the examination is complete; redrape her genital area and offer her a tissue box to wipe herself and tell her you're
just going to wash her hands and then she can redress (does she need any help?) behind the curtains and you can then
talk outside the curtains
-tell her the smear results will take 2 weeks to process; will be sent in the post to her and the GP; if there are cell
changes that's fine and we'll see you again; very occasionally the sample is considered to be insufficient by the lab and
we'll need to do another one; but I fully expect your sample to come back normal and healthy and your reproductive
organs seemed healthy. Do you have any questions?
-Offer a Patient Information Leaflet on cervical smear testing
-you will need another smear test in 3 years time, even with normal results (women aged 25-65 get screening)

Take a cervical smear and perform a bimanual examination on the mannequin. You will be marked on your technique
and communication skills.

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 GYNAECOLOGY EXAMINATION
Introduction: Name, Age and Occupation
Summarise why they are there
Explain cervical smear
Explain internal examination
Consent
Bladder
Chaperone
Lock door
Wash hands
Advise on correct exposure and prepare equipment
Date and write name and DOB of patient on vial and open vial
Correct speculum size based on number of deliveries
Abdominal inspection and palpation (light and deep) for masses and tenderness
Lymph node palpation
Wear gloves
Apply gel to speculum and hold correctly
Correct positioning of patient (supine with heels to buttocks, knees apart, ankles together)
Inspect genitals with closed and then parted labia
Insert speculum correctly and gently and turn 90º while protecting clitoris
Open speculum until cervix visualised and then lock
Inspect cervix under direct light
Take smear clockwise 5 times
Remove sample into vial correctly (10 rinses or throw in head), seal vial and throw away brush
Send off vial with request form
Unscrew speculum and hold open and place hand to protect against hair being caught
Withdraw enough to avoid cervix being caught and then release opening mechanism
Withdraw speculum at it's lower tunnel inspecting the vaginal walls to the introitus
Discard speculum
Internal Examination
Part labia and insert 2 fingers
Turn fingers 90º and feel the cervix: comment
Uterine palpation: size, position (anteverted/retroverted), mobility, masses, tenderness
Right and left adnexae palpation: masses and tenderness
Inspect gloves
Redrape patient and offer tissues
Discard gloves and wash hands
Ask patient to redress and offer help
Outside the curtains: results take 2 weeks, sent to patient and GP, expect to be normal
If changed cells, will see again and will probably return to normal
If deemed to be inadequate sample: come back for repeat smear
Next smear: usually after 3 years
Offer a leaflet

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 GYNAECOLOGY HISTORY
-Introduction
-Consent
-Name, age, occupation, social status (single vs partner vs married)

The History

The Presenting Complaint (PC)

-ask an open question to find out the complaint(s)
-do not interrupt and listen carefully to let the patient reveal their sometimes multiple problems

History of the Presenting Complaint

-with any complaint ask about:
-duration
-onset and triggers
-getting worse?
-severity: get the patient to rate their problems in order of severity
-how is it affecting your life? (distressed and how so vs not concerned)
-seen doctor about it? What was done?
-pain: SOCRATES (esp. pelvic pain: in gynae it is usually low abdo or suprapubic); is it related to menstrual cycle? Or
mid-cycle=day 14 every month?
-associated e.g. fever

Past Gynaecological History

-menarche age
-menopause age (=no periods for 6 months; normal age 51 in UK)
-LMP date; was the LMP normal?
-cycle: regular or irregular?
-no. of days from day 1 of cycle to day 1 of the next (cycle length)
-number of days bleeding
-intermenstrual bleeding (IMB): regular in every period?
-postcoital bleeding (PCB)
-post-menopausal bleeding (PMB) (if any=endometrial carcinoma until proven otherwise)
-pre-menstrual tension (PMT): does she get it?
-menorrhagia (heavy bleeding); if yes how many pads used a day? How often does she have to change them? (every
hour, 3 hrs etc) Does flooding occur (whole pad/tampon soaked)? Does she have to use tampons in addition to pads?
Any clots?
-dysmenorrhoea (pain with bleeding)

Past Vaginal and Urinary History

-any discharge from vagina? If yes: amount, colour, itch, smell, timing (is it purulent?)
-any mass or dragging sensation in vagina? (prolapse) If yes: timing, severity, exacerbated by standing?
-FUN: frequency, urgency, nocturia
-HELD: haematuria, enuresis, leaks, dysuria; if yes to leaks find out about severity and if linked to urgency or cough
-incontinence: severity, timing, exacerbations e.g. when standing, coughing; is there faecal incontinence also etc

Past Sexual History and Past Contraceptive History

-sexually active? If not, in the past? How many partners in last 3 months?
-dyspareunia? Is the pain around the outside with penetration or deep inside?
-contraceptive method used now and in the past?
-STIs before: if yes, ask about partner (remember chlamydia can cause bleeding)
-sex problems: physical vs emotional
-infertility and problems with conceiving

Past Cervical Smear History

-date of last smear test
-result of last smear
-ever been abnormal? If yes, then what actions were taken?

Past Obstetric History

-have you ever been pregnant? (Gravida) If no, skip and move to the next section (but remember to ask about fertility
problems)
-if yes, ask how many times?

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-did you ever miscarry?
-did you have any TOPs (abortions)?
-did you have any stillbirths?
-how many children do you have? (Parity if you add stillbirths to it)
-if no children, any adopted?
-go through the pregnancies chronologically; for each ask:
year
gestation
birthweight
mode of delivery
outcome: how is child now?
-For each miscarriage and TOP find out
why?
how in case of TOP?
how far into pregnancy did it happen?
-Mum's health in pregnancy, in labour and in the puerpurium (6 weeks post-delivery)

Past Medical and Surgical History

-any disorders: gynaecological, anaemia, hypertension, diabetes, DVT/PE, heart, lung
-admissions and outpatients
-surgery, especially abdominal, hysterectomy, breast, any surgical TOPs

Family History
-any illnesses that run in the family e.g. diabetes, BP, blood clots, heart
-anyone in the family been seen by gynaecologist?
-any similar problems in family?
-cancers: breast, ovarian, endometrial, cervical (at what age if yes)
-colon cancer (at what age if yes)
-any hysterectomies, at what age and why (for fibroids or cancer?)
-if suspecting menopause ask what age was mum's menopause
-partner's health (if STI is a differential); siblings, children and parents

Drugs/Allergies
-allergic to anything? e.g. meds, penicillin, latex
-prescribed drugs and why on them?
-OTC
-pill/depo/implanon/ever taken emergency contraception
-HRT
-smoking: how much?
-alcohol: how much?
-illicit drugs

Social History
-family at home and stable relationship
-accommodation: what kind? And where?
-income/financial situation
-job
-social support
-housing
-travel

Systems Review (don't do it in OSCE: no marks for it and no time)

-GI (waterworks)=more important to ask
-GU (bowels)=more important to ask
-breast
-skin
-neuro/eyes
-cardiac
-pulmonary
-endocrine
-musculoskeletal
-ENT/infections
-psychiatric

-Give patient chance to add anything you left out

-Questions

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-Summarise and give DD
-Ix and Mx

Scenarios in the OSCE tebd to be menopause history or menorrhagia history

Sarah Basheer is a 44 year old woman who comes to your Gynaecology clinic as a new referral from her GP. As the
Gynae SHO in clinic that afternoon, your consultant asks you to speak to her.

GYNAECOLOGY HISTORY
Introduction
Consent
Establishes rapport with the patient
Age and occupation
Social status e.g. stable relationship
Open questioning
Appropriate questions about PC: duration, onset, triggers, progression, severity
ICE
How is the PC affecting the patient's life
Treatments used for problem and any doctors seen
Menarche
Menopause
LMP date and nature
Cycle length and regularity
Day of bleeds
IMB and PCB
PMB and PMT
Menorrhagia and quantify i.e. pads/tampons, floods/clots
Dysmenorrhoea and other pain: SOCRATES (is it related to the cycle?)
Discharges
Prolapses
Urinary symptoms
Sexually active
Dyspareunia
Contraception
STDs
Problems with sex or conception/fertility
Last smear date and result
Ever have an abnormal smear
How many pregnancies
Number of TOPs, miscarriages and stillbirths; why?
Adopted kids
Birth history in chronological order
Mum's obstetric health
PMH and PSH
Family history
Drugs and allergies inc. HRT, pill
Social history inc. home support and who lives with
Systems
Summarise

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 GUM HIV RISK ASSESSMENT
-Why are they having the test? e.g. sexual risk of them or partner, injecting drug risk of them or partner, symptoms,
med exam/pre-op assessment, HIV positive previous partner, STI screen, antenatal screen, new relationship/stopping
condoms, sexual/physical assault, blood donation, occupational exposure, new drug therapy, insurance, mortgage, pre-
employment, coroner's exam
-It must be a non-judgemental process enabling the patient to make an informed decision on whether or not to have the
test; it is actually a pre-test discussion rather than counselling
-If doing a HIV test you have to make arrangements for dealing with a positive diagnosis and an onward referral
-assess risks, prepare for positive diagnosis, health promotion/risk reduction, partner notification, establish supportive
relationship, obtain informed consent (competent to consent, should understand risks and benefits of testing vs non-
testing, voluntary consent)
-give enough time for discussion, privacy, non-judgemental approach, watch body language, simple language, let patient
make the decision, not the doctor who should only tell the pros and cons

Method
-aware of what is being tested=HIV antibody test, difference between HIV and AIDs
-why test today?
-risk assessment: what is the patient's perceived risk and appropriately challenge their view of the risk, have they tested
before and if so when, where and what was the result?, last risk activity including the 3 month window period, last
sexual risks and that of their partners=UPVI, UPAI, UPOI; UPSI with contacts from countries of high prevalence of HIV or
their partners, men who have sex with men or their partners (i.e. is their partner bisexual), history of IVDU and that of
their partners, rape/sexual/physical assault/torture, occupational exposure e.g. NSI, invasive procedures in unsterile
conditions e.g. tattoing/circumcision (male and female)/ritual scarification, history of blood/blood products exposure or
organ recipient prior to 1985 in UK
-advantages/pros of HIV testing: if positive can access health and support services and look at future treatment options,
if negative can look at future risk reduction, will know HIV status, is protecting sexual partners against infection, can
have interventions to reduce vertical transmission (and in the case of men and women to have kids with chosen partner
by special 'washing' of sperm/ova of HIV)
-disadvantages/cons of HIV testing: there are psychological implications of having a positive or negative result, stigma
and issues of confidentiality, possible adverse effects on relationships, possible restrictions for those who are positive e.g.
health service roles, possible insurance implications
-prepare for positive result: what do you think the result may be?, if positive how would you cope?, if positive would
you want to know the result?, identify the patient's support networks, inform opf what happens next if diagnosed HIV
positive e.g. medical intervention and emotional support (multidisciplinary team)
-partner notification: does your partner/family/friend know you are testing?, who do you think has been at risk? e.g.
current/previous partners and children, who would you tell the result?, who needs to know?, do they have to tell? e.g.
GP, workplace, colleagues, schools, dentist
-health promotion: safer sex, safer injecting drug use, condom use and benefit, screening for other STIs, contraception
-closure: are you going ahead with the test today?, document whether verbal consent given or not, when will the
results be available?, how will the results be obtained?, is referral appropriate?

Giving HIV result

-check result in the notes/available
-check patient's name/number
-give HIV result clearly-give it first if there are a number of tests
-if negative: re-test if necessary (if they are still in the window period), STI screen or Hep B vaccination if necessary,
discuss safer sex/injecting drug use, refer on as necessary
-if positive: get to the point straight away; once the result has been given stay silent letting the patient reflect and don't
say 'I'm sorry'; be aware of shock factor: keep the info you give to a minimum, avoid impulse to refer to many people
or to do something straight away, take cues from patient and just let the process be, focus on how they will cope in the
next few days, check who they will want to know the result, respect patient's views, check who knows the patient is
receiving the result on that day, arrange a confirmatory HIV test, link into HIV medical department for further medical,
emotional support/ counselling, advice and follow-up, liase with the HIV team if on the ward, discuss safer sex and
partners, refer on as appropriate

Summary
-remember if the patient is in hospital and quite unwell they may be having numerous Ix and may already have
heightened anxiety and worry about their health
-patient confidentiality with regards to family and friends
-if Dx HIV positive on the ward, with discharge planning link into the HIV department
-if you or your department do the HIV test it is your responsibility to arrange and give the result; if the HIV medical
team or Health Advisers are involved they can give the result
-avoid medical jargon and tailor the session to the patient

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-don't make assumptions; your beliefs are yours and not the patient's
-be non-judgemental
-have adequate time and privacy for discussion

Samantha Beran is a patient attending the genito-urinary medicine clinic. Elicit the reasons for her attendance. Perform a
risk assessment and explain what a HIV test involves. You will be marked on your ability to communicate with the
patient and the advice you give.

HIV Risk Assessment

-Elicit patient's reasons for wanting the test
-Asks about risk factors appropriately
-Explains window period
-Explains confidential nature of test
-Explains what test involves and what it detects
-Offers appropriate referral for further counselling

Interviewing Skills
-Establishes and maintains rapport throughout
-Appropriate listening skills
-General fluency including non-use of jargon and repetition
-Acknowledgement of and positive response to patient's feelings
-Summarises and concludes interview effectively

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 IMPLANON
Definition
-implanon is a small and flexible tube put under the skin of the upper arm; it is 40mm long and 2mm wide like a hair
grip
-it contains progestogen hormone (30-40mcg of etonorgestrel)

Site
-implanon is inserted into the medial aspect of the non-dominant upper arm
-done by a person with special training
-in community sexual health clinic (or GP practice)
-use LA to numb skin and put in under skin; keep area clean and dry for a few days
-SE's: bruising can happen as with any break in the skin, infection rare, allergic reaction=rare
-can feel the tube under the skin (for removal)
-no incision made for insertion (only for removal)

Time of Insertion
-first 5 days of cycle (to make sure you are not pregnant) will give immediate protection
-be careful with cycles <28 days
-can be put in on any day of the cycle if pregnancy ruled out but then have to use barrier methods for 7 days and do
pregnancy test after 3 weeks
-postpartum can put it in from day 21 and will give immediate protection (with breastfeeding there are no proper
periods so don't talk about day 1-5 of the cycle with breastfeeders; just tell them to take the implant and use barrier
methods for 7 days)
-if post-1st trimester abortion put in straight away for protection

Time of Removal
-can be removed at any time
-done by a person with special training
-takes a little longer then insertion
-use LA
-small incision and take out with small forceps
-apply steristrips and use wound procedures afterwards
-USS may be needed if the implanon has shifted to a difficult position
-if impalpable then refer to specialist for assessment and scanning; while this is done use other contraception
-use barrier methods for 7 days before it's removal and after its removal as return of fertility is fast

Duration
-it lasts for 3 years

Efficacy
-almost 100% effective
-very effective, >99%
-if 100 women used it for a year, <1 would get pregnant (compared to >80 out of the 100 if no contraception)
-if it fails this is just about always the result of conception before insertion or interaction of implanon with other drugs
the patient is on (see below)

Mechanism
-it prevents the egg from being released: main effect
-thins womb lining (preventing implantation)
-thickens cervical mucus (preventing sperm from reaching the egg)

Advantages
-high success rate
-no interference with sex
-3 years long acting so only have to consider contraception every 3 years
-some protection against PID
-steady low blood levels
-can be used with breastfeeding
-no oestrogen in it
-good for past ectopic patients
-good if patient wants cycle abolished, helps period pains usually
-reverses very quickly: within 1 week of removal
-no effects on bone density unlike Depo

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Disadvantages
-change in periods in the first year (can settle to a regular pattern after 1 year but may stay irregular): 20% frequent
bleeds, 35% regular periods, 45% get infrequent bleeds or amenorrhoea
-headaches, acne, tender breasts, bloating, mood swings (short-term uncommon SEs that last 3-6 months) (no longer any
evidence for weight gain)
-allergic reactions and infection (from a slight break in the skin)=rare
-drug interaction with enzyme inducers=epilepsy drugs, TB drugs, HIV drugs, antifungals, St John's Wort; if these drugs
are used then condoms are advised and should continue to be used until 4 weeks after the drugs are stopped

Norplant is not used in the UK

-it was stopped in 1999
-but some women still have it and women from overseas may have it
-duration of 5 years and is 6 tubes rather than 1

Always ask about sex: if the patient has had no sex in the current cycle, you can give depo (or implanon) that very day

Alison is 19 and about to go on holiday. She is currently on the COC pill but thinks she might try the implant as she
will be working long hours and can be forgetful. She has been on sodium valproate for years, is fit and healthy and
had regular periods both before and during the COC pill method. She confides she is terrified of the actual procedure
for the implant.

IMPLANON
Introduction
Consent
ICE
Explain implanon suitable choice: long-acting 3 years
Immediate return of fertility
Establishes last LMP and sex in current cycle
Length of cycles
Assesses taking of COC pills correctly
Mentions effectiveness e.g. more than 99% or 'very'
Describes method of action: ovulation suppression, endometrial/mucus discharge
Site of insertion (1/3rd up from elbow), not painful, LA, feel only skin being touched
Won't be able to see, only feel
Side-effects
Bleeding irregularities 1 year; 45% infrequent or amenorrhoea, 20% frequent, 35% regular
Benefits: LA (long-acting), not intercourse related
Safe strategy given i.e. 1-5 day cycle
Inform doctor if any prescribed drugs esp. epilepsy, HIV, TB, antifungals, St John's Wort
Offer pregnancy test if relevant e.g. was not using COC pill correctly
Does not protect against STIs
Establishes patient understands
Offers opportunity to ask questions
Offer leaflet

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 IUCD
Definition: the IUD (intrauterine device) is a small device placed in the womb (uterine cavity). It is made from plastic and
copper. It is for preventing pregnancy (contraception). It was previously known as the coil. It can be placed into the
womb easily by a trained doctor or nurse.

Types: framed (copper and hormone releasing IUS=Mirena) and frameless

Epidemiology: the modern IUD has been used since the early 60s; 156 million people worldwide; in the UK 4% women
reproductive age use it

Mechanism of action:
1) Primarily stops the sperm and egg from meeting (fertilisation); this by being toxic to the egg and sperm, preventing
sperm from passing through the neck of womb and decreasing the ability of the sperm to move about
2) Secondarily it works by preventing any fertilised egg from implanting in the womb (by causing inflammation in the
womb)

Effectiveness:
-99% or more with some of the copper coils; so at most 1 woman in a 100 will become pregnant each year using it at
most; (without any contraception it is >80 in a 100 a year)
-older IUDs are less effective being ~98%; so if 100 women used it then 2 would get pregnant per year of use

Benefits:
-once in you can forget about it; don't have to think about contraception everyday as with the pill -it does not interfere
with sex
-not hormonal method so no effects on rest of body
-most women can have it if they wish
-effective and safe
-cheap
-reversible and long lifespan, as much as 10 years (LARC=long-acting reversible contraception)
-no effect on breastmilk production
-no effect on fertility in the future

Disadvantages: most women with an IUD have no problems but the following can occur:
-periods can become heavier, longer or more painful (menorrhagia and dysmenorrhoea); this tends to be in the initial
months after insertion and then settles down; if you already have heavy or painful periods you may not find the IUD
suitable; heavy and painful periods can be treated with IUCD women in the same way as women without it with
NSAIDs, painkillers etc; an alternative is that you could have a special IUD called the Mirena coil which actually
decreases bleeding and is a contraceptive too
-a second disadvantage is infection; there is a small risk of womb infection (=pelvic infection) in the first 20 days post-
insertion only; for this reason we may ask you to let us do a swab sample of the vagina and cervix beforehand to do
an infection screen e.g. chlamydia before we insert the IUCD; also if you get an STI the IUCD could increase your risk of
it spreading up into the womb; so the IUD may not be advisable if you have a high risk of STIs e.g. more than one
sexual partner; or have had a pelvic infection before; but after the first 20 days the risk is the same as before the IUD
was inserted
-a third disadvantage is ectopic pregnancy=of course the chance of pregnancy is small but if it does happen there is a
higher chance it will be an ectopic i.e. outside the womb in one of the tubes (1 in 20 vs 1 in 100 with no IUD); this is
serious so tell the doctor if you miss a period or get lower abdominal pain; thus IUD not advised if you have had a
previous ectopic pregnancy; overall the chance of having an ectopic pregnancy with IUD is 1 in 5000 per year; so if
5000 women used the IUD for 1 year only 1 would get an ectopic pregnancy
-expulsion: rarely the IUD may come out without you noticing (most likely in first 3 months or in heavy menses; so
check for the threads; it is the likeliest cause of IUD failure=happens in 1 in 20
-damage to the womb (perforation)=in 1 in a 1000 there can be a tear in the womb caused by the IUD (more likely
while breastfeeding so we avoid putting in the IUD 4 weeks after delivery of a pregnancy)
-lost threads
-pain: from malposition, intolerance, infection or ectopic

Absolute CI's:
-any undiagnosed vaginal bleeding
-pregnancy
-current STI or PID
-immediate post-septic abortion
-malignant trophoblastic disease
-distorted womb=congenital or acquired,

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-allergy to constituent
-Wilson's disease
-current STI or PID
-cervical or womb cancer awaiting treatment
Relative CI's:
-48-4 weeks post-partum
-heavy painful periods (Mirena indicated)
-prior ectopic
-prior pelvic infection
-nulliparity is not a CI unless the lifestyle raises STI risk

Fitting method:
-done by an experienced nurse or doctor in a sexual health clinic or GP surgery (GP not common now) or after TOP
procedure
-people that do it keep their skills up to date by doing it regularly and keep special equipment at hand to deal with
post-IUD insertion emergencies
-can put in at anytime in the cycle as long as the risk of pregnancy is excluded; but usually inserted in the first half of
the cycle; so if cycle is 28 days long, will be put in usually in the first 14 days. If delivered baby recently (including by
lower segment C Section), can put in 4 weeks later; if had surgical TOP in 1 st trimester then can put it in straight away;
if inserted post medical TOP then wait 4 weeks before putting in; the cu coil can be out in even 5 days after ovulation
even after ovulation has happened (it is in this way it is used as emergency contraception to prevent pregnancy) but
usually it is put in only in the first half of the cycle electively if a woman wants it for regular contraception
-before fitting doctor will do a bimanual (vaginal exam) and then use a speculum to inspect the cervix, particularly the
os; the cervix will be held steady and then the coil put through the cervix into the womb with an insertion device (after
checking the womb size and position); LA and dilatation of the cervix may be necessary
-sometimes the women may faint (vasovagal reaction) to insertion but this tends to be self-limiting (don't tell the patient
this); so resus equipment, drugs and 2 trained personnel at least should be present
-could be uncomfortable for a few hours afterwards with period pains and light bleeding but paracetamol can help with
this

Follow-up:
-2-6 weeks post-insertion you need to be seen once just to make sure you are alright; but won't need any routine check
for it again until it is removed or you have any specific complaints about it; most women have no problems and the IUD
can remain for years

Removal:
-anytime but if you had sex in the 7 days before removal you can fall pregnant because sperm can survive inside for
up to a week after sex; so if you are having sex you should use other methods of contraception like condoms for a
week before removal
-contact doctor if: abdo pain that won't go away, delayed period or bleeding between periods, delayed period and pain
in lower tummy (ectopic), vaginal discharge +/- pain (infection) or if you think the IUD came out or is coming out (best
to check the threads once a month after a period: if no threads use other contraception until you see doctor)

Pregnancy:
-if you find out you are pregnant after having had an IUD put in, you'll need to have it removed immediately because it
can lead to abortion of the baby from infection

Bleeding:
-can keep using sanitary towels and tampons for periods with IUD in place

Special:
-insertion and removal needs antibiotics if prior endocarditis or prosthetic heart valves; HIV positive patients can have
IUD: it's a good choice in those on enzyme inducer HAART therapy

History of patient that needs coil:

-you must ask why they want the coil
-LMP
-you must ask if they've used other methods of contraception and any problems they've had with them
-for nullips the coil fitting is very uncomfortable unlike multips; it causes some discomfort with all initially, but nullips
may need counselling for it
-can use LA=instillogel; or can do a cervical block (inject LA into the cervix)
-if she has PID currently the IUD is contraindicated

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-if past PID you counsel the patient and screen for chlamydia and gonorrhoea; so you may need 7 days for the results
of this to come back before you put in the IUD
-the copper IUD works by 2 mechanisms: stops fertilisation and a secondary effect on preventing implantation
-need to know what the patient's periods are like before any contraception was used e.g. if it is a lady with just 2 days
of bleeding she may not mind the Cu coil but if she has 7 days of bleeding the Cu coil may be too much (as it may
increase her bleeding too much for her)
-must tell the patient effectiveness, SE's and contraindications
-will have to show her the coil: both may be present in the OSCE station= copper coil (which literally has copper visibly
wound around it) and Mirena (which is usually coloured with red and green stem)
-there are many different types of copper coil but you don't need to know those for the OSCE
-if a woman cannot come back for her follow-up appointment then IUD can be contraindicated
-you can have the Cu coil for many years with no symptoms and then get heavy bleeding from it
-can you change Cu coil to Mirena straight away? Yes but you will need barrier methods for 7 days ;or can wait to the
start of the next cycle to have the Mirena

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 MIRENA COIL
Definition: a small framed T shaped plastic device coated with the hormone progestogen (levonorgestrel) in it's stem; it is
released at a certain rate everyday (20 micrograms per day). It is an effective means of preventing pregnancy
(contraception) as well as being a treatment for heavy bleeding (menorrhagia). Note there is no unframed Mirena

Alternative names: LNG (levonorgestrel), IUS (intrauterine system)

Types: framed only; Mirena is the only IUS available in the UK

Mechanism of action:
1) Primarily hormonal prevention of implantation (by 'thinning' the endometrial lining of the womb) and cervical mucus
more impenetrable to sperm (makes a 'mucus plug' at the cervix to stop sperm getting in); ovulation is not prevented in
>75% of women since the systemic levels of hormone are not enough usually to affect it
2) Secondarily a foreign body effect in the womb

Effectiveness:
-very effective; more than 99% effective
-if 100 women used it for a year none of them should get pregnant; after 5 years 1 of them may get pregnant
(0.18/100 women failure rate) (>80/100 per year will get pregnant if no contraception used)
-thus it is as good as the best Cu IUD

Benefits:
-safe
-convenient
-reversible 'sterilisation' and long lifespan; can last up to 5 years for contraception but can stay in for 20 years for
treating bleeding; LARC
-reduction in period blood loss and dysmenorrhoea (pain) unlike Cu IUD; commonly used as Tx for dysfunctional uterine
bleeding (DUB) and even fibroids bleeding
-may decrease PID
-fine to use while breastfeeding
-once in you can forget about it for 5 years
-does not interfere with sex
-licensed with HRT for womb protection
-does not affect future fertility: returns immediately on removal

Disadvantages:
-bleeding problems to begin with:initial 3-6 months; but at 12 months have amenorrhoea (1 in 5) or hypomenorrhoea in
as many as 65%
-expulsion: same as Cu IUD
-perforation: same as Cu IUD
-malposition: pain
-infection: same as Cu IUD
-minor systemic hormonal effects: worst in first 3 months: breast tenderness, bloating, acne, depression, headache (but
since it is mostly local action it doesn't cause major effects like POP, implanon or depo)
-ovarian cysts: mainly asymptomatic resolving spontaneously (go away by themselves); consider if any abdo pain (if
patient had cysts in the past or has currently you need to scan before putting in coil); but not clinically significant

Absolute CI's: as for Cu IUCD

Relative CI's: as for Cu IUCD but heavy painful periods are an indication for Mirena, not a CI

Fitting method:
-must be in the first 5-7 days of cycle, otherwise may need barrier methods for 7 days (need to beware of short cycles
as with other contraceptive methods)
-if it were put in later than day 7 of the cycle you would definitely need barrier methods (since it will take 7 days to be
effective)
-if put in during days 1-7 it is effective immediately
-everything else is the same as Cu IUCD
-the Mirena cannot be used as emergency contraception

Follow-up: same as Cu IUD

Removal: same as Cu IUD but has to be replaced after 5 years

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Pregnancy:
-if you find out you are pregnant after having had an IUD put in, you'll need to have it removed immediately because it
can lead to abortion of the baby from infection

Offer leaflet to patient

Ms Carson has an IUCD. She comes to you, her GP, complaining about heavy bleeding after IUCD insertion. Advise her
on her contraceptive options.

IUCD/MIRENA
Introduction
Consent
Elicits reasons for attendance
ICE
Explains IUCD and mechanisms
Effectiveness
Benefits
Disadvantages
Duration she has used it
LMP
Has she been using barrier methods, last USI
STI risk
Bleeding onset and duration
Periods before contraception
Floods, clots
Number of tampons and pads and how often changed each day
Effect on life
Other symptoms
Asks about past PID
Removal and replacement by Mirena
Needs barrier methods to prevent pregnancy 7 days after Mirena in; can also wait until next cycle for Mirena
to be put in
Mirena looks like the copper coil but is lined with hormone
Mechanism of Mirena action
Ovulation continues in most cases
Very effective like the copper coil
Advantages
Disadvantages
3-6 months irregular bleeding; by 12 months 65% get less bleeding or amenorrhoea
Cysts
Minor hormonal effects in first 3 months
Fitting method and insertion first 7 days of cycle otherwise use barrier methods
Contraindications
Follow-up: will patient be able to attend
Removal
Show Cu IUD and Mirena IUD to patient
Reason to return to Doctor: prolonged abdo pain, vaginal discharge, expulsion
Checks understanding and offer leaflet on Mirena
Closes effectively

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Method of Obstetrics Examination OSCE Station
-Introduce yourself to the patient: name, age, occupation, congratulations on your pregnancy, how many weeks
pregnant are you? When is baby expected? Have you felt baby kick? Have you decided on a name yet? etc
-I'd like to do a check just to make sure that everything's going OK; this will involve taking your blood pressure/a urine
sample and afterwards examining your tummy to see how the baby is lying in the womb; is it OK for me to do that?
-Consent
-Can I ask you to empty your bladder?
-I'm going to have my senior female colleague in the room to act as a chaperone during the examination; is that OK?
(chaperone is not obligatory for obstetrics exam so can omit if you wish)

-then take the BP or urine dipstick (see separate instructions)

-Have the patient lying on their back or turned on the left side if breathless
-Abdominal inspection from end of bed and tangentially:
-Distension (look for symmetrical distension consistent with pregnancy)
-Flattening of the umbilicus (in pregnancy); eversion (ascites and polyhydramnios)
-Scars (including asking patient to lower their undergarments for C section suprapubic scar)
-Foetal movements
-Any specific masses/areas of fullness
-Palpation
-Feel for fundus using left hand (comment on it e.g. the fundus is close to the xiphisternum consistent with a 3 rd
trimester pregnancy)
-Measure the SFH (symphysis-fundal height) from the fundus to the midpoint of the symphysis pubis; ensure that you do
this blinded to avoid bias i.e. with the cm side turned downwards and only overturned after correct positioning of the
tape
-face the patient and feel around the outside of the womb for the foetal back and lie; push with the right hand on the
womb's left side while holding the left hand on the other side stationary; repeat going in a line downwards; then repeat
with pushing of the left hand on the right side of the womb while keeping the right hand stationary; a line of resistance
on 1 side will indicate where the back is and that it is a longitudinal lie; if it is a transverse lie there will not be any
continuous line of resistance
-then feel the foetal parts more generally in the central part of the uterus to assess whether it could be a multiple
pregnancy and whether the liquor volume is normal or not (oligo/polyhydramnios)
-turn and face the patient's feet; feel the pelvic area for the presenting part and engagement; feel with both hands
gently; if you are still not sure you could use the one-handed Paulik's grip with the thumb on one side of head and
fingers on the other side with your palm facing the mum's face (even though it is painful so better to avoid it): if you
get 2 fingers around head with it=2/5ths palpable, if 3 fingers around it=3/5ths palpable etc; the head is engaged if
less than 3/5ths are palpable (tell the examiner you would ask the patient to report any discomfort with Paulik's grip)
-Auscultation
-use the Pinard stethoscope between head of baby and umbilicus=anterior shoulder and face away from the patient;
press into it with your ear and cheek but without hands; provide sufficient tension
-normal fetal rate=110-160
-ensure you use a watch to count
-Per 10 seconds:
-16=96 beats per minute, 17=102, 18=108, 19=114 (normal), 20=120, 21=126, 22=132, 23=138, 24=144, 25=150,
26=156 (upper boundary of normal), 27=162, 28=168, 29=174, 30=180
-say the fetus is viable because of the heartbeat
-cover the patient's abdomen and offer to help them to get up

Please take this patient's blood pressure (or do urine dipstick). Then carry out an obstetric examination on the model
provided of a woman, Mrs Wright, who is 36 weeks pregnant. Address the modal as if it is the patient and carry out
an obstetric examination. Present your findings and interpretation to the examiner.

OBSTETRIC EXAMINATION
Blood pressure measurement
Chooses appropriate cuff size (2 available)
Places cuff on correctly: artery point on cuff should be over brachial pulse
Positions arm correctly: extended and horizontal
Palpates pulse

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 Positions stethoscope appropriately
Deflates cuff slowly
Measures BP correctly to the nearest 5mmHg

Obstetric palpation
Request permission to examine the patient
Positions patient comfortably
Exposes abdomen above fundus and to pubic hairline
State findings on inspection
Locates fundus of uterus
Measures SFH with tape measure to within 2cm of examiner's finding
Comments correctly on significance
Examine for and comments correctly on lie
Examines for and comments correctly on presentation
Estimates engagement correctly
Comments on viability of fetus (asking re fetal movements or Pinards or sonicaid)
Covers patient

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 OBSTETRICS HISTORY
-Introduction
-Consent
-Name, age, occupation, social status (single vs partner vs married)

The History

The Presenting Complaint (PC)

-ask an open question to find out the complaint(s) (if any)
-do not interrupt and listen carefully to let the patient reveal their sometimes multiple problems

History of the Current Pregnancy and Presenting Complaint (HCPPC)

-elaborate on the complaint e.g. onset, duration, getting worse?, triggers, alleviating factors, severity, how affecting life
e.g. sleep etc
-gestational age (keep in mind what trimester she is)
-EDD
-LMP date
-Cycle regularity before the LMP: were they regular or irregular?
-Cycle length (day 1 of 1 cycle to day 1 of the next)
-Was she using the COC pill? If yes when did she stop using it?
-How many periods were there between stopping the COC pill and the pregnancy? (this is because the LMP is not so
useful if the pill was recently stopped since there can be anovulatory cycles)
-To work out EDD add 9 months and 7 days to the LMP; or add 1 year, take away 3 months and add 7 days
-Foetal movements
-Headache, epigastric pain, oedema, visual symptoms (flashing lights in eyes)=pre-eclampsia
-Abdo pain and tightening
-PV bleed, discharge, water
-Pregnancy Complications: UTIs, diabetes, anaemia, bleeding, hypertension/proteinuria, infections, admissions, fetal
growth concerns
-Tests: booking appointment bloods, USS, prenatal diagnostic tests and scans
-1st trimester: date pregnancy was confirmed; by what means?, planned/unplanned? If unplanned is it desired?,
symptoms of pregnancy (amenorrhoea, tenderness of breasts, urinary frequency, N +V, indigestion, dizziness, headache),
bleeding, USS at 10-12 weeks, chorionic villus sampling 10-13 weeks, nature of antenatal management: midwife led or
consultant led or shared i.e. is it a high-risk pregnancy?
-2nd trimester: amniocentesis at 16-18 weeks, anomaly scan at 18-20 weeks, quickening at 16-18 weeks
-3rd trimester: admissions, pre-eclampsia (BP and proteinuria), any other clinical antenatal findings, Braxton Hicks
contractions

Past Obstetric History

-how many times have you been pregnant?
-for each pregnancy find out:
year (of the birth)
gestation
mode of delivery (with reason why: C sections, home delivery etc.)
birthweight and gender
outcome i.e. any complications to baby and mum
-mother's health: pregnancy, labour, puerperium
-children: postnatal health, health now
-TOPs, miscarriages and stillbirths: why?, how in case of TOPs, how far into pregnancy?

Past Gynaecological History

-last cervical smear date and result: what done about it if abnormal? Ever abnormal?
-PCB, IMB
-vaginal burning
-urinary symptoms: frequency, pain and urgency
-FUN HELD
-contraception; problems conceiving

Past Medical and Surgical History

-illness: now and in past
-surgery (any Caesarians)
-admissions

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-diabetes, heart, epilepsy, jaundice, anaemia
-STIs
-DVTs, PEs
-SLE, antiphospholipid syndrome, HIV, SCD

Family History
-twins or triplets in family or partner's family
-any similar problem in family, especially 1 st degree relatives?
-diabetes
-hypertension
-heart disease
-pre-eclampsia
-inherited conditions
-autoimmune diseases
-thrombophilia

Drugs/Allergies
-allergies like penicillin and latex
-OTC
-prescribed: when taken and when stopped?
-smoking: how much?
-alcohol: how much?
-illicit drugs: which?

Social History
-family at home
-accommodation
-diet: adhering to healthy eating? Avoiding foods harmful to pregnancy? Took folic acid?
-income/financial situation: more problems in pregnancy if poor
-job
-social support: who will look after other kids at home if admitted?

Systems Review (Not needed in OSCE: no marks for it and also no time)
-GU
-GI: when did they last open their bowels?
-breast
-skin
-neuro/eyes
-cardiac
-pulmonary
-endocrine
-musculoskeletal
-ENT/infections
-psychiatric

-Give patient chance to add anything you left out

-Questions
-Ask mum if you can see her maternity record book (if she doesn't have it she is a probably a careless patient as all
mums are meant to have it)
-Summarise and give DD
-Ix and Mx

Ms Anderson is pregnant. You are her GP and she has come to your surgery today to ask about a problem she has
been having with her ankles.

OBSTETRIC HISTORY
Introduction
Consent: can we have a chat about your pregnancy and past pregnancies?
Age and occupation
Stable relationship/married
Gravida and parity: make clear at beginning
Open question
Appropriate questions about presenting compliant e.g. duration, onset, severity

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 ICE
Asks how it is affecting the mum's life
Current pregnancy: gestational age and how has it been progressing?
EDD (by LMP and USS) and LMP date
Was the pregnancy unplanned?
Is it a desired pregnancy?
Previous cycles: regular or not?
Cycle length
Previous contraception
Foetal movement
Pregnancy symptoms: breast tenderness, nausea and vomiting, backache, headache, amenorrhoea, urinary
frequency
Pregnancy complications: UTIs, infections, bleeding, anaemia
GTT: diabetes and high blood pressure
Admissions
Booking appointment attendance
Scans (what type), fetal growth concerns, blood tests, prenatal diagnostic tests
Past obstetric history: mother's health and children's health
TOPs, stillbirths and miscarriages
Babies adopted
Past gynae history: IMB, PCB, last smear date and ever abnormal, prior contraception
Fertility/conception problems
PMH and PSH e.g. heart, hypertension, diabetes, anaemia, jaundice and epilepsy, ever been in hospital
Drugs/allergies e.g. latex/penicillin
Family history: diabetes, BP, clotting, pre-eclampsia, inherited, twins, autoimmune/thrombophilia
Diet incl. folic acid
Smoking and alcohol and how much
Illicit drugs
Accommodation
Home support and social support
Systems review e.g. CV, respiratory, abdo, neuro
Summarises

Calculating expected delivery date:

-it is worked out from the LMP allowing for cycle length
-Nagle's rule= LMP subtract 3 months, then add 7 days and 1 year (this is what the obstetric wheel does for you); if the
cycle is >28 days the EDD will be later than this so you add the number of days longer than 28 days that it is to the
result; if the cycle is <28 days you subtract
-USS: measure crown-rump length and use scan date if >1 week difference between LMP date and scan from 7-14
weeks; if not done measure femur length or biparietal diameter from 14-20weeks if no early scan and LMP unknown;
measuring beyond 20 weeks to work out gestational age is of no use

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 THREATENED MISCARRIAGE
General Information About Miscarriages

Definition
-Miscarriage or abortion is the involuntary loss or termination of a pregnancy at any stage up to the 24th week; most
occur before 13 weeks of pregnancy, but some occur later (80% of spontaneous miscarriages are in the first trimester)
-Loss after 24 weeks is called a stillbirth.
Epidemiology
-bleeding form the vagina happens in the 1st trimester of almost 1/3rd (30%) of pregnancies; of these 50% will have a
miscarriage by 12 weeks (thus 15% of pregnancies=miscarry)
Aetiology
-bleeding causes: physiological bleeding of normal pregnancy, spontaneous abortion (spontaneous miscarriage), ectopic
pregnancy, trophoblastic disease and non-pregnancy related=cervical polyps/ectropian/cancer
Classification
-There are 5 types of miscarriage:
-Threatened miscarriage=uterine bleeding with no cervical dilatation (closed cervix) nor passage of products of conception
(POC). The foetus is still viable and the womb is the expected size for dates; only 25% will subsequently miscarry
-Inevitable miscarriage=heavy bleeding with cervical dilatation (open cervix) but no passage of POC; the foetus may or
may not be alive, but even if it is still alive, miscarriage will definitely occur
-Incomplete miscarriage=bleeding with open cervix and passage of some but not all POC
-Complete miscarriage=bleeding which decreases with complete passage of POC; pain and bleeding decrease, the womb
goes back to normal non-pregnant size and the cervix is closed
-Missed miscarriage=foetal death, pain or bleeding without passage of POC/tissue even thought he foetus died a while
previously; it may not be picked up until bleeding happens or the patient complains of not feeling as pregnant as
before; USS confirms the foetal death; the uterus is small for dates and the cervix is closed
-septic abortion is a 6th type where infection complicates, leading to endometritis and possibly parametritis and
peritonitis; the miscarraige can be any of the above 5 types, the only difference being the additional problem of
infection
Pathology
-1/2 of spontaneous miscarriages may be due to genetic anomalies like trisomy
-

Threatened Miscarriage Station

-Introduce yourself to the patient and get consent 'may I speak to you about the investigations we have been doing for
the bleeding you've had'?
-Deal with hostility: the patient will act angrily from the outset for having to wait so long: Acknowledge her feelings
-Summarise what has happened: e.g. 'so you've been in hospital for a day for bleeding during pregnancy and we
examined you and did a scan to see why that was'
-ICE: may I ask what ideas did you have about the bleeding? Do you have any worries or concerns about the bleeding?
What are you expecting from the medical staff/your hospital admission?

Give Scan Result

-We did the scan of your pregnancy and I have your results now
-The scan shows that your baby is in the womb and has a heartbeat so you haven't had a miscarriage
-Now when you have bleeding and the neck of your womb is closed, it's difficult to tell what will happen next; PAUSE;
it is possible that you could still have a miscarriage; PAUSE: let patient take it in
-(Statistic: ¼ of women with threatened miscarriage go on to miscarry; ¾ have a healthy pregnancy)
-However, there is a very good chance that the pregnancy will go on in a healthy way
-There may be higher chance that your waters will break early and you could have an early delivery so we would
watch you very closely and carefully and think about monitoring your pregnancy in a hospital with really good facilities
for new born babies

Sympathy and Reassurance

-This is going to be a difficult time for you and I'm very sorry about that (uncertainty) but I fully expect that you will
have a healthy pregnancy and I think you have good reason to be hopeful; we'll do everything we can to support you;
(you should tell us if anything changes)
-Not mother's fault:You may be tempted to think that maybe you could have done something to prevent this but it's not
your fault; it can happen to any pregnant mother and it's not because of anything that you did.

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-Not only is this pregnancy likely to be successful but there shouldn't be any effects on future pregnancies either; you
should be able to have future healthy pregnancies if you wanted to have more children

Lutein Cyst
-the scan also shows that you have a cyst on your ovary, the reproductive organ that makes eggs: a cyst is a fluid
filled sac
-these cysts are not significant: they won't affect your pregnancy (cysts are benign=not cancer)
(-you may not need any treatment for it)
-if it gets bigger than 5cm and last more than 2 months we may offer you the option of having it drained or removed
and then recurrence can be prevented by using the OC pill
-they usually go away by themselves in 4-6 weeks; they are common and usually painless; it will probably go away
after your pregnancy or even during the pregnancy
-treatment: observation, have another scan in a month's time to check it has disappeared

Stitch Won't Help (Cervical Cerclage)

-put in in early pregnancy for women with a weak neck of womb
-is to prevent premature delivery in these women; it only is useful in women with a weak/short cervix
-doesn't work in this situation (threatened miscarriage); it won't stop a miscarriage from happening; if it's going to
happen it's going to happen
-the stitch will just expose them to risk of infection and anaesthesia unnecessarily; it can cause bleeding and can
damage the cervix

Bedrest
-bedrest does not prevent miscarriage
-avoiding sexual intercourse does not prevent miscarriage
-(rest is advised together with abstinence from intercourse but probably does not help (no evidence that it will prevent
miscarriage))

Discharge and Next Scan and Duration of Bleeding

-if no severe bleeding, nor pain nor fever, no treatment is needed for threatened miscarriage and the patient can go
home (i.e. no swabs and IV antibiotics nor resus for shock needed)
-anti-D is not needed in rhesus negative mums with threatened miscarriage as long as the pregnancy is before 12 weeks

Need to come back if

-any symptoms recur, especially bleeding or pain (e.g. abdo pain) or fever: will need to see doctor e.g. GP

-Summarise and give reassurance and positive statement at the end e.g. we'll do everything we can; if you have any
further questions or worries, please don't hesitate to ask, I'll be around on the ward. If they are going home leave a
telephone number for them to contact
-Arrange a booking or follow-up antenatal appointment within 2 weeks if it is a viable intrauterine pregnancy (if
viability not clear then book a rescan in 1-2 weeks time)
-Offer leaflet

Mrs Jeremy is a 27 and is 11 weeks pregnant. She had vaginal bleeding and examination showed that the os is closed.
An ultrasound scan has been done.
USS report: there is a 4cm lutein cyst in the right ovary. The fetus is intrauterine and has a heartbeat.

Jean is a 31 year old nullip and is 11 weeks pregnant . She She had vaginal bleeding and was admitted to the gynae
ward for PV bleeding. Examination showed that the os is closed. The ultrasound report has just come to you, the on-call
SHO: there is a fetal heart beat in utero. There is a 3cm luteal cyst on the right ovary.

THREATENED MISCARRIAGE
Introduction
Consent
Give a summary of what the presenting symptoms of the patient are
Inform the patient first of what you will explain to them
ICE: Find out what the patient's ideas about what is happening to her
Find out what her concerns are
Find out what she is expecting
Explains threatened miscarriage
Common
Can be without pain

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Could be a healthy baby
Baby not affected if pregnancy continues (75% of cases)
Can progress to miscarriage (25% of cases)
Bleeding duration
Bed rest won't prevent miscarriage
Not mother's fault
Says that stitch wont help
Says cyst not significant
Sympathetic
Reassures
Gives sensitive advice
Copes with aggressive manner
Explains whether or not mum can go home
Explains when next scan will be
Explains that if bleeding occurs again should see a doctor
Leaflet /contact number

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 TERMINATION OF PREGNANCY
A TOP Consultation
-I'd like a pregnancy test
-OK give a urine sample (Patient returns back)
-Are your periods regular?
-Yes, I'm on the pill but they are regular
-OK so you missed a regular period
-What was your LMP date?
-Do you have any health trouble at all?
-Any previous pregnancies?
-Age?
-Take any tablets?
-Do you know your height or weight?
-I'll take you through it:have you done any research?
-How does your partner feel? Does he know you might be pregnant?
-Partner's age (if a less than 16 year old with a 21 year old contact social services to see if she is known, is she in
education etc; prosecution is a grey area for <16 but prosecution would happen if <13; for less than 16 they would
look at if it is an equal relationship i.e. is the man forcing the girl?)
-Does anyone know? (if <16 you should encourage them to tell someone i.e. parental consent; but it is their right to
choose TOP without telling anyone)
-Do you know all your options? e.g. keep pregnancy, adoptions
-If they mention a problem e.g. housing, then you can ask that if that would be sorted, would you have the baby?
SureStart and other social support networks can be referred to for <18 years (who will help them)
-Is TOP your decision or is someone influencing you?
-You'll come early in the morning until the evening; will take 2 days surgical (!)
-The other option is medical=2-3 days; do you have any preference in terms of time?
-You are in early pregnancy and can choose medical or surgical; medical=more like miscarriage whereas
surgical=taken to theatre and asleep or lightly sedated if not desiring to be asleep
-You can take away this central booking appointment; 1st come first served
-You can bring your partner if you want
-Post-TOP contraception: have you thought about it? (the Mirena coil can be put in after the TOP procedure; a little bit
more uncomfortable in the nulliparous but can still be put in)
-We can do a chlamydia screen today; we'll have you do a swab in the lady's room
-If the woman is unsure of an abortion you can tell her to see a counsellor; you can also tell her about voluntary
agencies; some will go and see friends/relatives/religious heads; say 'there are a number of organisations you can talk
to; they are private so we are not involved with them but it's someone you can talk to'
-If they ask you about the fetus say 'it's early in the pregnancy and the fetus won't feel anything' (this is what some
doctors say: of course it is unknown if the fetus feels pain in reality)
-If the woman comes with another person you should always talk to her alone for a while

http://www.bpas.org/bpaswoman.php?page=74:
Frequently asked questions
Abortion:
What happens at the consultation appointment?
You will see a counsellor and then one of our health care professionals (either a doctor or a nurse). The
consultation normally takes up to two hours.
You will have a urine pregnancy test and then an ultrasound scan to asses your stage of pregnancy this will
help us decide which type of treatment you will have. Please note you will not see any pictures during the scan.
You may also have a simple blood test.

What happens during the abortion procedure?

Abortion procedures vary according to the stage of the pregnancy. Usually, women can choose the procedure
that they feel is most suitable for them and their circumstances.
Details of the different procedures can be found below.

4 5 6 7 8 9 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2
0 1 2 3 4 5 6 7 8 9 0 1 2 3 4

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Medical Abortion

Ma
nua
l
Vac
uu Dilatation & Evacuation
m
Asp
irat
ion

Vac
uu
m
Asp
irat
ion


Medical Abortion
Up to 9 weeks
Two medicines are given, either 6-8 hours apart or 1-3 days apart. An overnight stay is not required.
At the first visit, the client swallows one tablet of a medicine called mifepristone. Mifepristone blocks the action
of the hormone progesterone on the uterus. This stops the growth of the pregnancy and causes the lining of the
uterus to shed. Some side effects such as light bleeding, nausea or vomiting may be experienced before the
next appointment.
At the second visit, tablets of misoprostol, a prostaglandin, are placed in the vagina near the cervix. This
medicine causes the uterus to contract and also causes bleeding and cramping. This medication is normally
administered using a tampon and if you are comfortable using tampons you can insert this medication yourself.
Most women go home straight away with advice on what to do after the misoprostol is placed in the vagina.
Most abortions will happen within 4-6 hours.
Vaginal bleeding alone does not necessarily mean the abortion is complete and follow-up either with a visit or
by phone is important to confirm that the medicines have been effective.

9-23 weeks 5 days

Two medicines are given 24-28 hours apart. An overnight stay may be required.
At the first visit, the client swallows one tablet of mifepristone.
Women who have a pregnancy of 22 weeks or more may have an additional procedure at this visit. The
doctor will put a needle into the uterus and inject medicine to stop the fetal heart. This may be carried out
under local anaesthetic or a light general anaesthetic.
At the second visit, the client is admitted to the treatment unit. Tablets of misoprostol are placed in the vagina
near the cervix. Misoprostol causes the uterus to contract and also causes bleeding and cramping. The client
may also experience nausea, vomiting or diarrhoea. She will be given medication for pain and other symptoms
as needed to keep her comfortable throughout the abortion.
Repeated doses of 2 tablets of misoprostol will be given by vagina or by mouth every 3 hours until abortion
occurs. Most women will have the abortion within 6-8 hours of using the misoprostol but for some women stay
of at least one night will be required.

Surgical Abortion
Manual Vacuum Aspiration
This procedure may be carried out in an operating theatre or a procedure room.

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 An oral analgesic (typically ibuprofen) is given and local anaesthetic is injected into the cervix before the
procedure begins. The client will also have Entonox (“gas and air”) available to use if needed.
The cervix is then gently stretched open using thin metal rods called dilators and the uterus is emptied using a
gentle manual or electric vacuum.
The procedure typically takes 10-15 minutes and recovery time is 30-45 minutes.
An overnight stay is not required.

Vacuum Aspiration
This procedure is carried out in an operating theatre.
A short-acting general anaesthetic is injected into a vein in the hand or arm.
The cervix is then gently stretched open using thin metal rods called dilators and the evacuation is carried out
with either a gentle manual or electric vacuum.
The procedure typically takes about 10-15 minutes and recovery time 1-2 hours.
Clients do not need to stay overnight.

Dilatation & Evacuation (D&E)

Prior to a D&E, the cervix is prepared. Misoprostol softens the cervix and dilators are placed inside the cervix
to slowly stretch the cervix open.
Clients who have a pregnancy of 22 weeks or more will have an additional procedure carried out the day
before the surgery. The doctor will put a needle into the uterus and inject medicine to stop the fetal heart. This
may be carried out under local anaesthetic or a light general anaesthetic. The client may be able to go home
and return to the clinic the following day for removal of the pregnancy.
The D&E is performed in an operating theatre under a light general anaesthetic.
Forceps are used to remove the pregnancy and any remaining tissue is removed using vacuum aspiration.
An overnight stay is not required. Most women are fit to leave the clinic within 6 hours of arriving.

Is there any risk?

Abortion procedures, especially in the early weeks of pregnancy are very safe but no clinical procedure is
entirely without its risk. There is no long term proven association between abortion and any ectopic pregnancy
or infertility.

What about infection?

One of the highest risks after an abortion is infection. All our clients are given a course of antibiotics to
minimise this risk. We also advise women to avoid having sex for two weeks after treatment and to use
sanitary towels instead of tampons. It is normal for some women to experience some bleeding for several days
after the abortion.

How will I feel after the abortion?

Different women experience different feelings after an abortion and will cope in different ways. Many women
find it useful to have someone with them after their abortion. Some women take time off work, while others
feel able to go straight back the next day – both responses are quite normal.
After treatment, some women find that their hormones levels swing quite dramatically whilst their bodies adjust.
This may result in mood changes and it is common for women to feel a bit sensitive and irritable.
After an abortion, some women feel a sense of loss, even if they believe their decision was right. Others may
feel relief.

Will I need counselling?

All women are different and there is no standard amount of time that it takes for a women to put her abortion
experience behind her. Bpas can provide post-abortion counselling at any time after an abortion.

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Ms Lawson has come to see you, her GP, because she believes she is pregnant. She appears anxious. Explore her
concerns about her pregnancy.

TOP
Introduction, age and consent
ICE
Give a urine pregnancy test if indicated
Questions
Establish date of LMP
Regular periods
Establish probable duration of the pregnancy (fully understand how to calculate duration, attempts to explain)
Usual contraception
Planned vs unplanned
Consensual sex
Do you know all of your options?
Does partner know about pregnant? How does he feel?
Age of partner
Does anyone know? (advise to tell parents if <16)
Her choice or someone influencing her?
PMH
Previous pregnancies and previous TOP
Drugs/allergies
Height and weight
Any research on TOP/had before?
Why does she want an abortion?
Contraception post-abortion: what will she use?
Explanation
Explain 3 options: adopt, abort, have
Medical vs surgical
Medical: up to 9th week 2 pills 1-3 days apart; no overnight stay needed; 1 tablet taken (mifepristone) =stops
pregnancy growing, can get light bleeding and N+V; 2nd time a misoprostol tablet placed in vagina as a
tampon= womb contracts and get bleeding/cramping; go home straight away; abortion in 4-6 hours in most
cases; followup needed as bleeding alone does not prove abortion happened
Medical 9-23 weeks 5 days: 2 pills 1 day apart but may need overnight say since the misoprostol may have
to be given every 3 hours until it occurs and may need pain meds; also if 22 weeks may have to give injection
in tummy to stop baby's heart; tends to happen 6-8 hrs after misoprostol
Surgical: up to week 14 vacuum method; general anaesthetic and takes 10-15 mins; recovery 1-2 hrs then
home; if done with LA (only up to 12 weeks) recovery time=30-45 mins (+Ibuprofen and gas and air); thin
metal rods stretch neck of womb and womb is emptied with suction;usually done in theatre
Surgical: from 15 weeks onwards dilatation and evacuation; misoprostol used to soften cervix then dilators
passed; forceps used to remove contents (with vacuum if needed); GA in theatre but can leave same day (6
hours in total); if 22 weeks or more need to sto fetal heart with injection in tummy (done day before surgery)
Infection: a risk; given antibiotics after to prevent; avoid sex for 2 weeks and use sanitary towels instead of
condoms
Normal to have bleeding for several days after abortion
No link between abortion and long-term fertility problems nor ectopic pregnancies; safe (esp. early abortion)
but all clinical procedures have risks
Explains will have chlamydia screening pre-op
Outline appropriate follow-up of problem
Future contraception
Central booking appointment leaflet: can self-book or doctor can book if confidentiality needed will see
counsellor and doctor/nurse; can be 2 hours long; will have urine test, blood test and possibly USS (but won't
be shown pictures); you will be seen within 2 weeks
Right to change mind right up to operating theatre
Counsellor or voluntary agency if not sure of abortion
Post-abortion: may feel sense of loss or relief; some will need someone with them , or time off work; others
return back straight away; each woman is different; hormone changes are common and can lead to mood
changes e..g irritability;
Counselling will always be available after abortion, even 20 years after it; but every woman is different and
can decide when, if at all, she wants post-abortion counselling
Patient can come back and see you if they like; make repeat appointment

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