MBBS2 OSCE REVISION 2012

Clinical assessments primarily test skills and attitudes that cannot

be tested easily in other exam formats. Guidance on what to revise
can be inferred from clinical experience alone. However, for your
first ever clinical assessment, such experience is limited.
Therefore, you are being provided with a long list of possible
stations
Each OSCE has a mix of:
History-taking
Communication skills
Practical skills
Anatomy

For all stations, you should be able to demonstrate appropriate

knowledge and skills, including interpretation of data gleaned
within the station and what your next steps would be in clinical
practice.
16 active stations + 4 rest stations
5 mins each
Long station = 11 mins
A total of about 2hrs
Communication Stations

 History Taking (Long and Short)

Psychiatry
Explaining a medical condition or associated monitoring
/treatment to a patient
Exploring a patients ideas, concerns and expectations
Sensory Awareness (Visual and Hearing Impaired)
Access to Healthcare
Practical Stations
Infection Control
BP Measurement
Subcutaneous Injection
Asthma
Resuscitation
BMI Measurement
Growth Chart
Urine Dipstick
Blood Film Examination
Anatomy (Surface, Skeletal, Organ)
Histology
Movement Disorder
History-taking
Focussed (FHT)
Take history of presenting condition
Explore impact of condition on quality of life
Explore context of current condition - PMH, FH, Drugs &
allergy, smoking & alcohol
For Pain: use the SOCRATES framework
Site
Onset
Character

Radiation
Associations (next slide)
Time course
Exacerbating/Relieving factors
Severity

Long history (double station):

As FHT and:
Systematic review of other systems
More detailed exploration of context not restricted to current
condition
May need to work for a diagnosis patient may not tell you
why they have presented until probing questions have been
asked.
Psychiatry
Assessing a patient with cognitive impairment

Cognitive impairment, depression and dementia

o Ensure comfortable and at ease
o Onset and duration
o Previous episodes
o Effect on everyday life

o May need to use digit span memory test

o
o
o
o
o
o
o

Treatments so far, previous outcomes

Screening questions: mood, anxiety, obsessions, abnormal beliefs
History of neglect, self-harm, violence
Typical day, interest, hobbies
Lonely, isolated
Developmental milestones, emotional problems, educational achievement
Suicide risk

History taking with examples of what you might say:

The following is a general schema to follow, and your skill is in

remembering what is relevant in different kinds of histories and

remember what is relevant to the PC.
Chest pain, remember to characterise pain, cardiac risk factors
including other medical problems, ask about nausea / vomiting and
any recent travel or immobility.
Asthma, characterise admissions, how often, peak flow and what is
normal for them, their trigger, what they were doing when an
attack occurred and their current medication.
Hypertension, characterise symptoms if any, cardiac events,
medication and cardiac risk factors.
Pain or any symptom anywhere, follow the schema! Use
SOCRATES!
Introduce yourself with full name, that youre a second year
medical student and explain why you want to speak to the
patient and gain consent at the same time. Say that anything from
this conversation is confidential, and will remain between
yourselves and the healthcare team.
Introduction: Age, Name, Occupation
Presenting complaint (PC): Why did you come in today?
History of PC: When? Sudden? What is it like? Intermittent or
constant? How long ago?
What were you doing? Where? Development / progression /
regression? Anything before? How often & for how long?
Associated with other symptoms? Anything make it better or
worse? Have you taken anything?
Past Medical History: Any previous medical problems,
admissions or surgeries? If time, ask about JAM THREADS
(Jaundice, Anaemia, MI, TB, Hypertension, Rheumatic fever,
Epilepsy, Asthma, Diabetes, Stroke)
Family: Any illnesses in the family? Are your parents still with us?
What did they die of?

At what ages? (A heart attack at age 71 is not relevant, but at 50 it

may be.)
If a bereavement comes up - acknowledge it (Im sorry to hear
that) but move on!
Drugs: Are you taking anything? Have you been taking anything
else? How about the oral contraceptive pill? Over the counter
drugs?
Allergies: What happened when you took it? Allergy is itch / rash /
serious complications. Gut irritation alone is not, although it may
be a part of allergy.
Social: Smoke? How many a day? Drink? How many in an
average week? (what, when, how much etc.) Recreational drugs?
Do you take anything else? Have you travelled recently?
Systemic Review (only in a long history, not a focussed one)
(Yes/No questions!):
Any problems with headaches? Blackouts? Eyesight? Breathing?
Chest pain? Getting out of breath? Nausea? Vomiting? Appetite?
Weight gain / loss? Bowels? Waterworks? Periods/menopause?
Moving about / joints? Swelling?
Ask the patient if there is anything they would like to add,
summarise and thank the patient
Communication skills
Exploring

explore a patients ideas, concerns and expectations,

Example scenario: Patient comes into the surgery enquiring about
travel jabs. He reveals he has been recently unemployed. Says he is
travelling to taken up voluntary work in the Far East. Upon further
questioning you find he has found being made redundant extremely
stressful.
This station requires you to speak to a patient to explore their

ideas, concerns and expectations. It is easy but requires you to put

all your communication skills into action!
1. Begin by introducing yourself to the patient, and asking for
consent to speak to them.
2. Ensure they are aware of the concept of patient confidentiality
and inform the patient of this to build trust.
3. Then proceed with open questions e.g. what brings you to the
doctors surgery today?
4. Listen to what the patient is saying, allowing them to talk and not interrupting unless necessary.

5. As you find out more about the patient, use increasingly closed
questions to clarify facts and details e.g. when did you first
notice the pain in your arm?
6. Explore the patients ideas, concerns and expectations (example
questions below)
7. Summarize to the patient and check for completeness

8. Ask if the patient has any questions

9. Thank the patient
Ideas (beliefs)
Tell me about what you think is causing it.
What do you think might be happening?
Have you any ideas about it yourself?
Do you have any clues; any theories?
Youve obviously given this some thought, it would help me to
know what you were thinking it might be.
Concerns
What are you concerned it might be.
Is there anything particular or specific that you were concerned
about?
What was the worst thing you were thinking it might be?
In your darkest moments ...
Expectations
What were you hoping we might be able to do for this?
What do you think might be the best plan of action?

 How might I best help you with this?

Youve obviously given this some thought, what do you think
would be the best way of tackling this?
Remember, this is a communication skills station so make sure you
do all those things you know so much about!
Establish rapport with the patient by being respectful, smiling
when you see them and greeting them with kindness
Listen to what the patient is saying, allowing them to talk and
not interrupting unless necessary
Demonstrate empathy: Im sure that must have been very
difficult for you
Use body language appropriately. Maintain eye contact.
Explaining - Explain a medical condition or associated monitoring
/treatment to a patient
The best way to learn about speaking to patients is by looking at
patient information leaflets. A good website for these is
www.patient.co.uk.
Most likely to feature are Asthma, Hypertension and Diabetes
1. This station is, again, seriously straightforward if you are
constantly aware of your communication skills. It is about much
more than explaining an illness, procedure or treatment.
2. Begin by introducing yourself to the patient and gaining their
consent to speak to them. It is likely the patient will be someone
who has just been diagnosed with an illness, and you are asked
to explain the condition in a manner the patient will understand.
3. Before jumping in, ask what the patient already knows about the
condition, and if they know anyone who is also affected.
4. Once this is done, use it as a platform to explain the nature of the
condition or treatment to the patient, avoiding medical jargon,

and, where possible, using analogies.

For example, in asthma, the airways in the lungs become
narrow and fill up with thick mucus or in high blood
pressure, the arteries become narrower like water in a
hosepipe. The water pressure is increased if you open the tap
more, but also if you make the hosepipe narrower by partially
blocking the outflow with your thumb.
5. After youve explained your condition or treatment, check for
patient understanding: does all this make sense? and invite
questions: is there anything you would like to ask me?
6. Once this is done, summarise all that youve said to the patient
in 2 or 3 sentences, and mention that there are patient
information sheets available for them to take away with them.
7. Thank the patient before leaving!
Asthma

Asthma is a common condition that affects the smaller airways (of

the lungs). From time to time the airways narrow in people who
have asthma. The typical symptoms are wheeze, cough, chest
tightness, and shortness of breath. Symptoms can range from mild
to severe in an attack. The extent of the narrowing, and how long
each episode lasts, can vary greatly.
Asthma is caused by inflammation in the airways. The
inflammation irritates the muscles around the airways, and causes
them to squeeze (constrict). This causes narrowing of the airways.
It is then more difficult for air to get in and out of the lungs. This
leads to wheezing and breathlessness. The inflammation also
causes the lining of the airways to make extra mucus which causes
cough and further obstruction to airflow.
What can make asthma symptoms worse and bring on an attack?

Infections
Pollen

 Exercise
Cigarette smoking
Allergies to dust mites and animal hair
Treatment is usually with inhalers. A typical person with asthma
may take:
a preventer inhaler (brown) every day (to prevent symptoms
developing)
- Taken every day to prevent symptoms from developing.
The drug commonly used in preventer inhalers is a steroid
- Steroids work by reducing the inflammation in the airways.
When the inflammation has gone, the airways are much less
likely to become narrow and cause symptoms
- It takes 7-14 days for the steroid in a preventer inhaler to
build up its effect so effects are not seen immediately.
Therefore it is important to take it every day to prevent
symptoms from coming back.
- a reliever inhaler (blue) as and when required (if symptoms flare
up)
- This makes the airways open wider, and symptoms usually
quickly ease
- Only to be taken when required.
Correct technique for using the inhalers is very important. In some
people, symptoms persist simply because they do not use their
inhaler properly, and the drug from the inhaler does not get into the
airways properly.
Hypertension

High blood pressure is a risk factor that can increase your chance
of developing heart disease, a stroke, and other serious conditions.
As a rule, the higher the blood pressure, the greater the risk.
Treatment includes a change in lifestyle risk factors where these
can be improved - losing weight if you are overweight, regular

physical activity, a healthy diet, cutting back if you drink a lot of

alcohol, stopping smoking, and a low salt and caffeine intake. If
needed, medication can lower blood pressure
Blood pressure is the pressure of blood in your arteries. Blood
pressure is measured in millimetres of mercury (mm Hg). Your
blood pressure is recorded as two figures. High blood pressure is a
blood pressure that is 140/90 mm Hg or above each time it is taken
at the GP surgery.

The top (first) number is the systolic pressure. This is the

pressure in the arteries when the heart contracts.

The bottom (second) number is the diastolic pressure. This

is the pressure in the arteries when the heart rests between
each heartbeat.
I f your blood pressure is always in this range you will normally be offered treatment to bring the pressure
down. A one-off blood pressure reading that is high does not mean that you have 'high blood pressure'. Your
blood pressure varies throughout the day. It may be high for a short time if you are anxious, stressed, or have
just been exercising, or drank any caffeinated drinks.

You have high blood pressure (hypertension) if you have several

blood pressure readings that are high, and which are taken on
different occasions, and when you are relaxed.
Why its important to control your blood pressure

High blood pressure is a risk factor for developing a cardiovascular

disease (such as a heart attack or stroke), and kidney damage. If
you have high blood pressure, over the years it may do some
damage to your arteries and put a strain on your heart. In general,
the higher your blood pressure, the greater the health risk. But,
high blood pressure is just one of several possible risk factors for
developing a cardiovascular disease
There are ways in which blood pressure can be lowered:

Modifications to lifestyle (weight, exercise, diet, salt, caffeine

and alcohol), if any of these can be improved upon (details
below).

Medication (details below)

Lose weight if you are overweight

Regular physical activity
Eat a healthy diet

Briefly, this means:

Five portions, and ideally 7-9 portions, of a variety of fruit

and vegetables per day.
Small intake of saturated fats
EAT LEAN MEAT, or eat poultry such as chicken.
LIMIT SALT in your diet (5-6g/day).
Restrict your number of caffeine drinks

Medication
Contemplate drug treatment
High BP persistent even with adherence to non-drug measures
Systolic sustained > 160 and/or diastolic >100
Systolic sustained > 140 and/or diastolic >90 AND known CVD, diabetes, target organ damage (i.e. renal
impairment) or an estimated CVD risk of .20% over the next 10 years using risk charts

4 main types of medicine that doctors can use to treat high BP

ACE inhibitors
Control hormones affecting BP
-pril
Angiotensin Receptor Blockers (ARBs)
Control hormones affecting BP
- artan
Calcium Channel Blockers (CCB)
Relax artery walls wider/dilated
- pine
Thiazide diuretics
Remove unwanted fluid from the body
- ide

Side effects cough, dizzy, upset stomach

How long is medication needed for?
In most cases, medication is needed for life.

Diabetes Type 1

Type 1 diabetes is the type of diabetes that typically develops in children and young adults. In type 1 diabetes
the body stops making insulin and the blood glucose level goes very high. Treatment to control the blood
glucose level is with insulin injections and a healthy diet. Other treatments aim to reduce the risk of
complications and include reducing blood pressure if it is high, and to lead a healthy lifestyle.
What is diabetes?
Diabetes mellitus (just called diabetes from now on) occurs when the level of glucose (sugar) in the blood
becomes higher than normal. There are two main types of diabetes. These are called type 1 diabetes and type
2 diabetes.

After we eat, various foods are broken down into sugars in the gut.
The main sugar is called glucose. This is absorbed through the gut
wall into the bloodstream. Glucose is like a fuel which is used by
the cells in the body for energy. To remain healthy, your blood
glucose level should not go too high or too low.
So, when your blood glucose begins to rise (after eating), the level
of a hormone called insulin should also rise. Insulin acts on the
cells of your body and makes them take glucose into the cells from
the bloodstream.
Diabetes develops if you do not make enough insulin, or if the
insulin that you do make does not work properly on the body's
cells.
In most cases, type 1 diabetes is thought to be an autoimmune
disease. The immune system normally makes antibodies to attack
bacteria, viruses, and other germs. In autoimmune diseases the
immune system makes antibodies against part or parts of the body.
If you have type 1 diabetes you make antibodies that attach to the
beta cells in the pancreas. These are thought to destroy the cells
that make insulin
The symptoms that usually occur when you first develop type 1
diabetes are:

You are very thirsty a lot of the time.

You pass a lot of urine.

Tiredness, weight loss, and feeling generally unwell.

The above symptoms tend to develop quite quickly, over a few

days or weeks. After treatment is started, the symptoms soon settle
and go.
How is diabetes diagnosed?
A simple dipstick test can detect glucose in a sample of urine. This may suggest the diagnosis of diabetes.
However, the only way to confirm the diagnosis is to have a blood test to look at the level of glucose in your
blood. If this is high then it will confirm that you have diabetes. Some people have to have two samples of
blood taken and you may be asked to fast (have nothing to eat or drink, other than water, from midnight
before your blood test is performed).

Long-term complications
If the blood glucose level is higher than normal, over a long period of time, it can have a damaging effect on
the blood vessels. Even a mildly raised glucose level which does not cause any symptoms in the short-term
can affect the blood vessels in the long-term.

Eye problems which can affect vision. This is due to damage

to the small arteries of the retina at the back of the eye.
Kidney damage which sometimes develops into kidney
failure.
Nerve damage.
Foot problems. These are due to poor circulation and nerve
damage.

What are the aims of treatment?

Although diabetes cannot be cured, it can be treated successfully.
If a high blood glucose level is brought down to a normal or near-normal level, your symptoms will ease and
you are likely to feel well again. Therefore, the main aims of treatment are:

1. To keep your blood glucose level as near to normal as

possible.
2. To reduce any other risk factors which may increase your risk
of developing complications. In particular, to reduce your
blood pressure if it is high, and to lead a healthy lifestyle.
3. To detect any complications as early as possible. Treatment
can prevent or delay some complications from getting worse.
How is the blood glucose level monitored?

It is likely you will need to monitor your glucose levels by using a monitor at home. If you check your blood
glucose level, ideally you should aim to keep the level between 4 and 7 mmol/L before meals, and less than 9
mmol/L two hours after meals.
It may be best to measure your blood glucose level at the following times:

At different times in the day

After a meal
During and after vigorous sport or exercise
If you think you are having an episode of hypoglycaemia (a
hypo)
If you are unwell with another illness (for example, a cold or
infection)

Another blood test is called HbA1c. This test measures a part of the red blood cells. Glucose in the blood
attaches to part of the red blood cells. This part can be measured and gives a good indication of your blood
glucose control over the last 1-3 months. This test is usually done regularly by your doctor or nurse. A level of
HbA1c of 7% or less is usually the target to aim for.

Insulin
To stay well and healthy you will need insulin injections for the rest of your life. Your doctor or diabetes nurse
will give a lot of advice and instruction on how and when to take the insulin. Insulin is not absorbed in the gut
so it needs to be injected rather than taken as tablets. There are various types of insulin. The type or types of
insulin advised will be tailored to your needs.

Most people take 2-4 injections of insulin each day. The type and
amount of insulin you need may also vary each day, depending on
what you eat and the amount of exercise you do.
Insulin pumps
Insulin pump therapy continually infuses insulin into the subcutaneous tissue (the layer of tissue just beneath
the skin). Insulin pumps work by delivering a varied dose of fast-acting insulin continually throughout the day
and night, at a rate that is pre-set according to your needs.

Healthy diet
You should aim to eat a diet low in fat, salt and sugar and high in fibre and with plenty of fruit and vegetables.
However, you will need to know how to balance the right amount of insulin for the amount of food that you
eat. Therefore, you will normally be referred to a dietician for detailed advice.

Balancing insulin and diet, and monitoring blood glucose levels

Monitoring your blood glucose level will help you to adjust the amount of insulin and food according to the
level and your daily routine.

Keep your blood pressure down

It is very important to have your blood pressure checked regularly. The combination of high blood pressure
and diabetes is a particularly high risk factor for complications

Do some physical activity regularly

Regular physical activity also reduces the risk of some complications such as heart and blood vessel disease.
If you are able, a minimum of 30 minutes' brisk walking at least five times a week is advised. Anything more
vigorous is even better. For example, swimming, cycling, jogging, dancing. Ideally you should do an activity
that gets you at least mildly out of breath and mildly sweaty. You can spread the activity over the day. (For
example, two fifteen-minute spells per day of brisk walking, cycling, dancing, etc.)

Try to lose weight if you are overweight or obese

Excess weight is also a risk factor for heart and blood vessel disease. Getting to a perfect weight is often
unrealistic. However, if you are overweight, losing some weight will help.
Treatment aim 3 - to detect and treat any complications

Eye checks - to detect problems with the retina (a possible

complication of diabetes) which can often be prevented from
getting worse. Glaucoma is also more common in people with
diabetes, and can usually be treated.
Urine tests - these include testing for protein in the urine, which
may indicate early kidney problems.
Foot checks - to help to prevent foot ulcers.
Blood tests - these include checks on kidney function, and other
general tests. They also include checks for some autoimmune
diseases which are more common in people with diabetes. For
example, coeliac disease and thyroid disorders are more
common than average in people with type 1 diabetes

Type 2 Diabetes

Type 2 diabetes occurs mainly in people aged over 40. The 'firstline' treatment is diet, weight control and physical activity. If the
blood glucose level remains high despite these measures, then
tablets to reduce the blood glucose level are usually advised.
Insulin injections are needed in some cases. Other treatments

include reducing blood pressure if it is high, lowering high

cholesterol levels and also other measures to reduce the risk of
complications
Diabetes mellitus (just called diabetes from now on) occurs when
the level of glucose (sugar) in the blood becomes higher than
normal. There are two main types of diabetes - type 1 diabetes and
type 2 diabetes.
After you eat, various foods are broken down in your gut into
sugars. The main sugar is called glucose which passes through
your gut wall into your bloodstream. However, to remain healthy,
your blood glucose level should not go too high or too low.
So, when your blood glucose level begins to rise (after you eat), the
level of a hormone called insulin should also rise. Insulin works on
the cells of your body and makes them take in glucose from the
bloodstream.
What is type 2 diabetes?
With type 2 diabetes, the illness and symptoms tend to develop gradually (over weeks or months). This is
because in type 2 diabetes you still make insulin (unlike type 1 diabetes). However, you develop diabetes
because:

You do not make enough insulin for your body's needs; OR

The cells in your body do not use insulin properly. This is
called 'insulin resistance'. The cells in your body become
resistant to normal levels of insulin. This means that you need
more insulin than you normally make to keep the blood
glucose level down; OR
A combination of the above two reasons.

Type 2 diabetes is much more common than type 1 diabetes.

Who gets type 2 diabetes?
It develops mainly in people older than the age of 40 (but can also occur in younger people). Type 2 diabetes
is now becoming more common in children and in young people.
What are the symptoms of type 2 diabetes?
Symptoms of type 2 diabetes often come on gradually and can be quite vague at first. Many people have
diabetes for a long period of time before their diagnosis is made.

The four common symptoms are:

Being thirsty a lot of the time.

Passing large amounts of urine.
Tiredness.
Weight loss.
Some people also develop blurred vision and frequent
infections.

How is diabetes diagnosed?

A simple 'dipstick' test may detect glucose in a sample of urine. However, this is not sufficient to diagnose
diabetes definitely. Therefore, a blood test is needed to make the diagnosis. The blood test detects the level of
glucose in your blood. If the blood glucose level is high then it will confirm that you have diabetes. Some
people have to have two samples of blood taken and you may be asked to 'fast' (have nothing to eat or drink,
other than water, from midnight before your blood test is performed).
In many cases diabetes is diagnosed during a routine medical or when tests are done for an unrelated medical
condition.
What are the possible complications of diabetes?

Long-term complications
If your blood glucose level is higher than normal over a long period of time, it can gradually damage your
blood vessels. This can occur even if the glucose level is not very high above the normal level. This may lead
to some of the following complications (often years after you first develop diabetes):

Atheroma ('furring or hardening of the arteries'). This can

cause problems such as angina, heart attacks, stroke and poor
circulation.
Kidney damage which sometimes develops into kidney
failure.
Eye problems which can affect vision (due to damage to the
small arteries of the retina at the back of the eye).
Nerve damage.
Foot problems (due to poor circulation and nerve damage).

Complications of treatment
Hypoglycaemia (which is often called a 'hypo') occurs when the level of glucose becomes too low, usually
under 4 mmol/L. People with diabetes who take insulin and/or certain diabetes tablets are at risk of having a
hypo. A hypo may occur if you have too much diabetes medication, have delayed or missed a meal or snack,

or have taken part in unplanned exercise or physical activity.

What are the aims of treatment?
Although diabetes cannot be cured, it can be treated successfully. If a high blood glucose level is brought
down to a normal or near-normal level, your symptoms will ease and you are likely to feel well again.
Therefore, the main aims of treatment are:

1. To keep your blood glucose level as near normal as possible.

2. To reduce any other 'risk factors' that may increase your risk
of developing complications. In particular, to lower your
blood pressure if it is high, and to keep your blood lipids
(cholesterol) low.
3. To detect any complications as early as possible. Treatment
can prevent or delay some complications from getting worse
How is the blood glucose level monitored?
The blood test that is mainly used to keep a check on your blood glucose level is called the HbA1c test. This
test is commonly done every 2-6 months by your doctor or nurse.
The HbA1c test measures a part of the red blood cells. Glucose in the blood attaches to part of the red blood
cells. This part can be measured and gives a good indication of your average blood glucose level over the
preceding 1-3 months.
Treatment aims to lower your HbA1c to below a target level which is usually agreed between you and your
doctor. The target level is usually somewhere between 6.5% and 7.5%.

Lifestyle - diet, weight control and physical activity

Lifestyle changes are an essential part of treatment for all people with type 2 diabetes, regardless of whether
or not you take medication.
You can usually reduce the level of your blood glucose and HbA1c if you:

Eat a healthy and balanced diet.

Lose weight if you are overweight.

Do some physical activity regularly.

Many people with type 2 diabetes can reduce their blood glucose
(and HbA1c) to a target level by the above measures. However, if
the blood glucose (or HbA1c) level remains too high after a trial of

these measures for a few months, then medication is usually

advised.
Medication
There are various medicines that can reduce the blood glucose level. Different ones suit different people. It is
fairly common to need a combination of medicines to control your blood glucose level.
Medication is not used instead of a healthy diet, weight control and physical activity - you should still do
these things as well as take medication.

Insulin injections
Insulin is needed in some cases if the above treatments do not work well enough. You cannot take insulin by
mouth, as it is destroyed by the digestive juices in the gut. Insulin may be given in addition to taking tablets.
You are less likely to develop complications of diabetes if you reduce any other 'risk factors'. These are briefly
mentioned below :

Keep your blood pressure down

Stop smoking
Other medication, for lowering cholesterol levels
Treatment aim - to detect and treat any complications promptly

Checking levels of blood glucose, HbA1c, cholesterol and

blood pressure.

Ongoing advice on diet and lifestyle.

Checking for early signs of complications, for example:

o
Eye checks - to detect problems with the retina (a
possible complication of diabetes) which can often be
prevented from getting worse. Glaucoma is also more
common in people with diabetes and can usually be
treated.
o
Urine tests - which include testing for protein in the
urine, which may indicate early kidney problems.
o
Foot checks - to help to prevent foot ulcers.
o
Other blood tests - these include checks on kidney
function and other general tests.
It is important to have regular checks, as some complications, particularly if detected early, can be treated or
prevented from getting worse.

Angina/ MI

Site and Radiation: diffuse, anterior chest, left arm, neck

Character: tight, pressure, weight, constriction, dull
Triggers (angina): exercise, cold, meals, stress
Relief (angina): rest, GTN
<30 mins Angina
>30 mins MI

Parkinsons

Parkinson's disease (PD) is a chronic (persistent) disorder of part of

the brain. It mainly affects the way the brain co-ordinates the
movements of the muscles in various parts of the body. PD mainly
develops in people over the age of 50. It becomes more common
with increasing age. It affects both men and women but is a little
more common in men.
PD is not usually inherited, and it can affect anyone. However,
genetic (hereditary) factors may be important in the small number
of people who develop PD before the age of 50.
What causes Parkinson's disease?

A small part of the brain called the substantia nigra is mainly

affected. This area of the brain sends messages down nerves in the
spinal cord to help control the muscles of the body. Messages are
passed between brain cells, nerves and muscles by chemicals called
neurotransmitters. Dopamine is the main neurotransmitter that is
made by the brain cells in the substantia nigra.
If you have PD, a number of cells in the substantia nigra become
damaged and die. The exact cause of this is not known. Over time,
more and more cells become damaged and die. As cells are
damaged, the amount of dopamine that is produced is reduced. A
combination of the reduction of cells and a low level of dopamine
in the cells in this part of the brain causes nerve messages to the

muscles to become slowed and abnormal.

The brain cells and nerves affected in PD normally help to produce
smooth, co-ordinated movements of muscles. Therefore, three
common Parkinson's symptoms that gradually develop are:
Slowness of movement (bradykinesia). This is also a
'shuffling' walk with some difficulty in starting, stopping, and
turning easily.
Stiffness of muscles (rigidity), and muscles may feel more
tense. Also, your arms do not tend to swing as much when
you walk.
Shaking (tremor) is common, but does not always occur. It
typically affects the fingers, thumbs, hands, and arms, but can
affect other parts of the body. It is most noticeable when you
are resting. It may become worse when you are anxious or
emotional. It tends to become less when you use your hand to
do something such as picking up an object.

Stroke

A stroke means that the blood supply to a part of the brain is

suddenly cut off. The brain cells need a constant supply of oxygen
from the blood. Soon after the blood supply is cut off, the cells in
the affected area of brain become damaged, or die. The blood
supply to the brain comes mainly from four arteries -these branch
into many smaller arteries which supply blood to all areas of the
brain. The area of brain affected, and the extent of the damage,
depends on which blood vessel is affected.

For example, if you lose the blood supply from a main carotid
artery, then a large area of your brain is affected, which can cause
severe symptoms, or death. In contrast, if a small branch artery is
affected, then only a small area of brain is damaged which may
cause relatively minor symptoms. There are two main types of
stroke - ischaemic and haemorrhagic.
Ischaemic stroke - caused by a blood clot
Ischaemic means a reduced blood and oxygen supply to a part of
the body. It is usually caused by blood clot in an artery, which
blocks the flow of blood. This occurs in about 7 in 10 cases.

The blood clot often forms within the artery itself. This
commonly occurs over a patch of fatty material called
atheroma. Atheroma is often called furring or hardening of the
arteries.

In some cases, the blood clot forms in another part of the

body, and then travels in the bloodstream - this is called an
embolus. The blood clot is then carried in the bloodstream
until it gets stuck in an artery in the brain.
Haemorrhagic stroke - caused by bleeding
A damaged or weakened artery may burst and bleed:

An intracerebral haemorrhage is when the blood vessel bursts

inside the brain. The blood then spills into the nearby brain
tissue. This can cause the affected brain cells to lose their
oxygen supply. They become damaged or die. This happens in
about 1 in 10 strokes.

A subarachnoid haemorrhage is when a blood vessel bursts in

the subarachnoid space. This is the narrow space between the
brain and the skull. This space is normally filled with a fluid
called the cerebrospinal fluid.

What are the symptoms of a stroke?

The functions of the different parts of the body are controlled by

different parts of the brain. So, the symptoms vary depending on
which part of the brain is affected and on the size of the damaged
area. Symptoms develop suddenly and usually include one or more
of the following:

Weakness of an arm, leg, or both. This may range from total

paralysis of one side of the body, to mild clumsiness of one
hand.

Weakness and twisting of one side of the face. This may cause
you to drool saliva.

Problems with balance, co-ordination, vision, speech,

communication, or swallowing.

Dizziness or unsteadiness.

Numbness in a part of the body.

Headache.

Confusion.

Loss of consciousness (occurs in severe cases)

A mini-stroke is a set of symptoms similar to a stroke, but which
last for less than 24 hours. It is due to a temporary lack of blood to
a part of the brain. It is more correctly called a transient ischaemic
attack (TIA). In most cases, a TIA is caused by a tiny blood clot
that becomes stuck in a small blood vessel (artery) in the brain.
This blocks the blood flow and a part of the brain is starved of
oxygen. The affected part of the brain is without oxygen for just a
few minutes, and soon recovers. This is because the blood clot
either breaks up quickly, or nearby blood vessels are able to
compensate.

Unlike a stroke, the symptoms of a TIA soon go. However, you

should see a doctor urgently if you have a TIA, as you are at
increased risk of having a full stroke. Both a stroke and a TIA are
medical emergencies and need immediate medical attention. As a
way of helping the general public to become more aware of the
symptoms of a stroke or TIA, a simple symptom checklist to
remember has been devised and publicised. This is to think of the
word FAST. That is:
F - Facial weakness. Can the person smile? Has their mouth or eye
drooped?
A - Arm weakness. Can the person raise both arms?
S - Speech disturbance. Can the person speak clearly? Can they
understand what you say?
T - Time to call 999.
Tuberculosis

Treatment:
Course of 4 drugs for 2 months RIPE
Followed by 2 drugs for 4 months - RI

Sensory Awareness

- Communicating with deaf patients

May be asked to find details from the patient, such as the

medication they are taking.

In this station, you are asked to communicate with a deaf patient

through lip reading. In doing this, it is important not to forget the
general rules:
1. Begin by introducing yourself and gain consent to speak to the
patient.
2. Be empathetic and maintain eye contact.
3. Begin with open questions and gradually move on to closed
ones.
4. Clarify and check understanding.
5. Allow the patient to ask questions.
6. Summarise and thank the patient.
For patients who prefer speech or lip reading:
Make sure that you have the patients attention before speaking
by taping them on the shoulder.
Use your regular voice volume and lip movement. Maintain eye
contact when you speak.
If you turn your head, you could obscure the view of your face.
When speaking to your patient, dont place things such a pencils,
gum, or food in your mouth.
Avoid standing in front of a light or a window. Overhead
lighting limits shadows.
There may be writing tools at hand, so encourage the patient to
use these when there are any difficulties in communication.

Sensory Awareness: Visual Impairment

- Communicating with blind

patients
For this station, you are required to communicate with and guide a
patient with visual impairment. For this, the guidance given in

Communicating with a Person Who Has a Serious Sight Loss

(Scenario 27 on the VC) is recommended, and is recreated here:
This scenario could involve taking a BMI measurement of the
patient.
Making Initial Contact
If you need to meet someone or merely notice someone who you
think might need help; it is useless trying to get his or her attention
from a distance.
If the person is using a guide dog or a long cane, approach from the
opposite side do not make eye contact with the dog and ignore
it. Remember that most guide dogs are trained to stop working
once they believe a sighted person has taken charge.
Engaging
1. Touch the person on the forearm at the same time you speak.
2. Remove your hand quickly and say who you are.
3. Ask the person if they need assistance and what they need.
Guiding
4. If you need to take them somewhere, ask if they want your arm
or follow your voice.
5. If they say they will follow, keep up a conversation so they can
hear your voice.
6. If they opt to take your arm, place their hand on your arm just
above the elbow. This puts you in front and is much safer.
7. Keep the top of your arm in so they have contact with your body
this gives warning of what they are going to do next.
8. Constantly say which direction youre going in, where you are
and describe the surroundings

Introducing the person to something

8. If you are offering them a seat, put your guiding hand on the seat
or the back of the chair so they can find it themselves. NEVER on
the arm of a chair.
9. If you are pointing something out to someone that they need to
touch, put your guiding hand on to the object and let them slide
their hand down your arm to find it.
Providing Information
10. If you need to do something around or to the person, tell them.
11. If you need to provide information, try to ensure that it is
accessible to the person and that they have understood it.
Acceptable Language
12. Do not be afraid to use words like look, see, watch it is
more embarrassing to hear you trying to search for an alternative.
Disengagement
13. When you are leaving them, even just to fetch something,
always tell them. If they are moving away from you, ensure they
know where they are heading. Thank the patient.
General points
Remember always to allow the person to choose.
Do not behave so carefully that you make the person feel
different because of his/her lack of good sight.
Never assume what people want or what they can or cannot do e.g. always offer alternatives where there are any.
Remember, you may feel more embarrassed than the person
does - they are more used to having help more than you are used
to giving it.

Exercises
However well you may have carried out exercises in training
situations, it is important to practice as frequently as possible. Try
to role play with friends and colleagues when situations permit.
This will make you easier when doing it for real.

Access to healthcare

These stations usually involve a complaint of some sort and require

you to (again) put your communication skills into full effect.
Stations in previous years have involved things like:
A partially-sighted patient complaining that the stairs in the
doctors surgery do not have the fluorescent white lines on the
edges they need to see them clearly
A complaint about a staff-member speaking to them in a rude
manner
Begin such stations by introducing yourself and gaining consent to
speak to the patient. Confidentiality
Establish good rapport by being polite, professional and friendly.
Then ask the patient about their particular query, for example, if it
is a complaint: I heard you were displeased about something Mr
Jones. Please tell me what has upset you.
Give the patient time to explain the situation and vent their anger.
Be empathetic: Im sorry you had to go through that. Be
empathetic and do not be afraid to apologise it helps the patient
feel that you truly care about their concern.
If the complaint concerns a colleague, it is important to support
them whilst remaining empathetic: Dr Smith is usually very polite.
Im sure he did not mean to sound rude. I will speak to him to

inform him that you are upset. I am sure he will be saddened to

hear that.
The skill is to diffuse the situation through effective listening,
showing that you value the patients input and aim to resolve it
in an effective and non-confrontational manner.

Hand Hygiene and Infection Control

Demonstrate appropriate infection control by hand washing

and answering questions
Check the infection control CAL exercise for full details on
how to wash your hands.
1. Roll up sleeves and remove any watches/jewellery
2. Prepare the station: paper towels, warm water, and bin
3. Discard first paper towel
4. Wet hands and apply soap
5. Perform 6 step hand washing technique
6. Rinse hands, pointing fingers upwards
7. Close tap with elbows, dry hands thoroughly and dispose of
towel in bin
8. Do not touch anything!

Soap and water

Socially clean, non-invasive procedures (if hands

visibly soiled, before and after assisting with
hygiene needs, before preparing or handling food)

Soap and water or alcohol rub

Before and after direct patient contact

Aqueous chlorhexadine (hibbiscrub) In ward after possible hand contamination

Hibbiscrub (or povidone iodine)
Before clinical procedure e.g. insertion of IV line
Hibbiscrub (3 minutes)

Before surgery

Hibbisol (alcoholic chlorhexadine) High dependency unit

Hibbiscrub then hibbisol

Outbreaks

Example Questions after hand washing:

What other precautionary measures do the medical team take to
prevent the spread of infection?
Ties, watches, tie hair back, gloves, apron, bare below elbows,
alcohol gel.
What are the main bacteria and viruses found in hospital?
C.difficile, Norovirus, Klebsiella, MRSA, E.coli, HIV, Hep B.
What are the medical and surgical interventions that lead to
hospital-acquired infection?
Invasive procedures (intubation, catheterization, chest drain).
Patient contact, in between procedures, arriving/leaving ward.
When do you not use alcohol rub?
C. Difficile, Norovirus
What is the difference between the soap and alcohol procedure?
Leave alcohol to dry
No need to use water to wash hands
When do you practice hand hygiene?
Before patient contact and after patient contact
Between a clean and dirty procedure
Arriving on a ward especially ITU
Leaving a ward
Before food
Before administering medication
Before examining a new born child
Before gowning in theatre
Difference between cleaning, disinfecting and sterilisation
Cleaning
Removal of organic material from a surface or medical

instrument typically using detergent, hot water and physical

action. The detergent surrounds the organic material and
solubilises it. Need to clean before disinfecting or sterilisation
because pathogens are protected by organic material.
Disinfecting

Necessary when HCPs hands have been contaminated with blood or bodily fluids, before and after
immunocompromised patient visits and before and after surgical procedures

Removal of most pathogens

Usually chemical
Must disinfect all equipment that enters normally sterile tissue
or the vascular system or through which blood flows or that
touches a mucous membrane
Sterilisation

Sterilisation is necessary at the start of the day, before and after a patient procedure

Removal of all pathogens

Physical and chemical means eg steam autoclave, ethylene
oxide gas, dry heat, chemicals
Autoclave operates at 134 degrees, 2.25bar, 3 minutes
Hospital acquired infections An infection that arises more than
48 hours after admission
Healthcare-associated infection due to an intervention. Not
necessarily in hospital
MRSA (sensitive to vancomysin)
(methycillin-resistant staphylococcus aureus)
Spread by hands, environment
Causes bacteraemia
Management:
Isolation
Handwashing
Careful management of cannulas etc
C. Difficile (sensitive to vancomysin and metronidazole)
Spread by hands, environment

Cause diarrhoea, colitis

Management:
Isolation
Hand washing
Environmental cleaning
Reduce inappropriate use of antibiotics
Multiple-resistance coliforms
Klebsiella, proteus, enterobacter, serratia
Spread by hands, environment
Cause UTI, bacteraemia
Management:
Handwashing
Isolation
Gloves and apron
Good line/catheter care
VRE (Vancomysin-resitant enterococci)
Spread by hands, environment
Causes UTI, bacteraemia
Management:
Isolation
Handwashing
Good line/catheter care
What precautions does a medical team take to avoid spreading
infections?
1. Universal precautions: Washing hands, aprons, gloves, hair back,
no watch, arms bare, cover cuts, eye protection, clean spillages
2. Aseptic techniques
3. Prevent cross infection: hand washing, gloves/apron, isolation

4. Dispose waste properly

5. Disinfect equipment correctly
What are the medical/surgical procedures that lead to hospitalacquired infections?
Major surgery
Intensive care
Chemotherapy
Placement of intravenous lines
Catheters
When is a patient at increased risk of infection?
Immuno-compromised
Open wound
Major surgery
Cannulation
Bin bags
Yellow clinical waste and body parts
Orange clinical waste
Black/transparent household
White used linen
Red soiled linen
Green theatre linen
Why wash hands?
To prevent spread of infection to others
To prevent spread to self

Blood Pressure Measurement

Introduction
Introduce self and gain consent
Wash hands
Check patients name, D.O.B. and occupation
Explain
Explain procedure
Check patient understanding of hypertension
Inform them that procedure may cause some discomfort
Ask them to stop you at any time if uncomfortable
Confirm
Ensure patient has:
o rested for >15 mins
o not smoked or had any caffeine prior to the procedure
o pregnant hypertension can occur (usually mild)
Procedure
1. Select appropriate cuff size for patient
2. Check that the cuff is fully deflated and attached correctly
with the marker over the brachial artery
3. Clean stethoscope
4. Position patient with arm supported and extended at the level
of the heart
5. Ensure legs are uncrossed and the patient is sitting up, watch
removed
6. Palpate brachial pulse and place cuff around arm with the
arterial marker over the brachial artery
7. No talking and relax

8. Measure approximate systolic level by palpating

brachial/radial artery, then deflate cuff
9. Place stethoscope over brachial artery (2 cm above antecubital
fossa)

10.Inflate cuff to ~20mmHg above estimated SBP

11.Deflate cuff at rate of ~2mmHg/sec
12.When first Korotkoff sound is heard: SBP
13.When sound is no longer heard: DBP
14.Deflate cuff completely
Finishing off
Report BP to examiner and patient
Ask patient if they have symptoms of postural hypotension
(eg falls, postural dizziness)
Say you would carry out a standing BP if appropriate
Ask patient if they have any questions
Thank patient and wash hands
You may be asked to interpret results:
Hypertensive if systolic or diastolic pressure (or both) are
above 140/90 mmHg on 2 separate occasions

BP varies with sleep, exercise, stress, age

Systolic P reflects cardiac function and artery stiffness
Diastolic P reflects TPR

Classification
SBP DBP
Pre HT
Mild
Moderate
Severe

Blood Pressure (mmHg)

130 - 139
140 - 159
160 - 179
> 180

80 - 89
90 - 99
100 - 110
>110

If hypertensive, action to take:

1. Repeat reading in few weeks. Requires elevated blood
pressure over a period of time to diagnose hypertension. Also
eliminate white coat hypertension
2. Recommend dietary changes,
5 a day
Balanced diet, correct proportions of each food group
Lower saturated fat intake
Lower salt in diet
3. More exercise
4. Maybe worth considering a urine dipstick to check for
diabetes, nephropathy and assess general kidney function due
to the high blood pressure reading.
If these factors fail to improve high BP, patient may be started on
anti- hypertensive drugs.
These include:
Calcium channel blockers
Beta blockers
Diuretics Thiazide and loop
ACE inhibitors

Subcutaneous Injection

One man station so talk the examiner through the process.

1. Clean hands using alcohol gel and use gloves
2. Introduction with FULL NAME, second year medic
3. Check patients name, D.O.B. and hospital number cross
reference with drug chart

4. Explain procedure and obtain consent

5. Check notes for any allergies/drug reactions and confirm with
patient
6. Consult prescription for time, drug, dose, route of
administration and signature of doctor
7. Select and prepare appropriate equipment
i. Syringe (choose size, usually 1/2ml), Needles (green and
orange or insulin), Alcohol swab, Dressing/Gauze,
sharps and clinical waste bin
8. Check medication correct drug, concentration, expiry date
9. Mention disinfecting vial with alcohol wipe

10.Possible sites of injection:

Antero-lateral aspect of
thigh
Abdominal area
Gluteus medius
Posterior of upper arm
11.Clean site of injection using swab in one direction, pinch skin,
warn of sharp scratch and inject at appropriate angle and
speed (1ml /10sec)
Insulin: 90

 Others : 45
12.Dispose of sharps in sharps bin, and non-sharp waste in
orange clinical waste bin
13.Ensure patient is comfortable questions/concerns
Tell patient to notify healthcare team if experiencing any
side effects, such as dizziness and fever)
14.Clean hands with alcohol gel
15.Record drug administration on drug chart
16.Any questions?
17.Thank the patient
Resuscitation (HOLOS)
Provide basic life support

Remember for all situations: DR ABC

1. Ensure your own safety assess environment for safety. Check
for hazards. Wear gloves if they are present. Shout for help
Hazard/Help/Hygiene
2. Check patients responsiveness shake and shout, then check
pain reflex by pinching patients ear lobe, or nail bed.
3. Open mouth; check for remove any obvious obstruction.
4. Open airway head back chin lift/jaw thrust if c spine injury
5. Check for breathing look at chest, listen to breath sounds, and
feel for breathing for 10 seconds.
If patient is not breathing:
1. Dial 999/2222 ask for ambulance/crash team depending on
setting. (Unconsious patient, not breathing, location)
2. Perform 30 chest compressions rate of 120/min. In an adult its
approximately 1/3 of the depth of their chest (5cm). Should have
shoulders over the patient, elbows straight, dominant palm
placed halfway between sternal notch and xiphisternum.
3. Give 2 rescue breaths check for breathing after each breath.
Use a pocket mask if it is available.

4. Continue CPR (30:2)

Reasons to stop:
Help arrives
Patient regains consciousness
You become too tired to continue
If it is a CHILD/DROWNING VICTIM:
Commence with 5 rescue breaths, followed by 30 chest
compressions, then 2 rescue breaths
Do this before calling 999
Continue CPR
If the patient is breathing
1. Perform a head to toe exam (checking for bleeding and broken
bones)
Head, neck, eyes/ears/nose, clavicle, chest, abdomen, pelvis,
legs, lower back and arms
2.
Place patient in recovery position,
perform examination of their back
3. Dial 999

Manage a choking patient

Signs of Asphyxia:
Pale skin, blue cyanosed lips
Rapid, difficult, gasping breaths
Losing consciousness
Trying but unable to talk
Procedure:
1. Ask the patient if they are okay. Get them to try to cough
2. 5 backslaps between the scapulas

3. 5 abdominal thrusts (stand behind patient, clasp fists under

xiphisternum and pull upwards and backwards)
If patient collapses:
1. Call 999
2. Start CPR
Manage a fitting patient
Seizures can be caused by many reasons including Epilepsy, head
injury, alcohol/drug induced and diabetic hypos.
Procedure:
1.
Protect the patient by removing any surrounding dangers
2.
Increase their air by loosening any tight clothing
3.
Once the seizure is over, check the patients breathing
4.
Place the patient in the recovery position
5.
Remain with the patient until fully recovered
6.
If they do not recover, call 999 and commence CPR
Do NOT:
- Move the patient unless they are in danger
- Try to restrain them
- Place anything in their mouths or try to remove an
obstruction
General advice:
- Check for tags that indicate that they are epileptic
Manage an asthmatic

Procedure:
1.
Keep the patient calm.
2.
Position the patient in an upright position
3.
Assist the patient with their medication, usually their reliever
(blue inhaler)
4.
Advise them to take deep breaths
5.
Call 999, stay with the patient until help arrives

Manage a shocked patient

Shock is a failure of the bodys circulation. It can be caused by:
- Failure of blood bleeding
- Failure of pumping heart attack
Signs of shock:
- Skin pale, cold and clammy
- Pulse rapid and weak
- Breathing Rapid and shallow
- Weakness, nausea, thirst and vomiting
- Decreasing consciousness
Procedure:
1.
Assess the patient, checking DR ABC
and signs of blood loss
2.
Treat the cause (bleeding etc)
3.
Lay down the patient on their back
and raise their legs
4.
Give the patient: Warmth, Air, Rest
and Reassurance (WARM)
5.
Call 999
6.
Monitor the patients vital signs (ABC)
Manage bleeding
1.
Assess the patient with DR ABC
2.
Position the patient ideally on their back so that you can perform
a secondary survey (head to toe exam)
3.
Using gloves if available perform a secondary survey, hopefully
finding the source of bleeding, be aware it could be internal
bleeding, so patient would have signs of shock
4.
Apply direct pressure to the site and elevate.
5.
If severe bleeding or cannot be contained, dial 999

Indirect pressure
- Use when unable to contain bleeding by direct pressure.
- Apply pressure to a pulse point (axillary artery in arm, femoral
artery in leg for 10 mins MAX)
- Then relax. Do NOT use a tourniquet
- For foreign bodies, wrap around without adding direct pressure
- Call 999 if bleeding persists
6.

Mock Mark Scheme

BASIC LIFE SUPPORT (BLS)

Total Mark:

1. Danger area safe/hazards/blood?

2. Response hello, can you hear me, open your eyes
3. No response = shout for help
Airway
4. Inspect mouth obvious obstructions? Never do blind
finger sweep
5. Open with head tilt and chin lift
6. Suspected C-spine injury? = use jaw thrust instead
Breathing
7. Look chest rising?
8. Listen breath sounds?
9. Feel warm air on cheek?
10. For 10 seconds
11. YES: recovery position, 999, re-assess 2222 in hospital
12. NO: 999, CPR 2222 in hospital
Compressions
13. Position lower half of sternum, heel of hand
14. Technique straight arms, shoulders directly above, press
down 5cm
15. Rate 30 compressions @ 100 bpm
Breaths
16. Position open airway, good seal over mouth and nose,
face mask
17. Technique look for chest rise, dont overinflate
18. Rate 2 breaths, both take no more than 5s
Repeat

Marks
(1)
(1)
(1)
(1)
(2)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)
(1)

/21

19. Repeat 30 compressions to 2 breaths

20. Stopping help arrives/patient recovers/exhausted

(1)
(1)

Asthma - Peak Flow Meter

1. Introduce yourself to the patient

2. Check patients identity (Name/D.O.B/Occupation)
3. Explain why you have been asked to see patient: I have been
asked by your GP/Dr. to show you how to use a peak flow meter,
is that OK? (NB. CONSENT)
4. Explain that it measures the highest rate at which gas can be
expelled from the lungs via an open mouth
5. Check patients understanding of asthma
6. Give the patient a non technical explanation of asthma
7. Explain importance of using a PEFR (Peak Expiratory Flow
Rate) meter and importance of using it correctly
Measures lung capacity by seeing the maximum speed that
air can be breathed out of a patients lungs.
An indicator to see how obstruction of the airways
(mucus/inflammation) is affecting the patients ability to
breath
Using it incorrectly means inaccurate reading
8. Explain that PEFR meter is to be used first thing in the morning
and at any time has a symptom of asthma.
Procedure:
1. Attach clean mouth piece to peak flow meter
2. Slide the marker to bottom of the numbered scale
3. Get patient to stand up straight to blow into the meter as hard
as they can
4. Hold the peak flow meter horizontal, keeping fingers away
from the marker
5. Take a deep breath
6. Insert mouthpiece and firmly seal lips around

7. Blow as fast and hard as possible

8. Reading repeated 3 times and highest reading is recorded
9. Plot & check results against graph and against previous
readings
10.Check patients understanding by asking them to demonstrate
technique
11. Compare against average on chart and the patients own normal range
12. Importantance of recording readings because it indicates if theyre responding to treatment and
measure their recovery from an asthma attacks

13.Ask if patient has any questions or concerns

14.Thank the patient

Chart uses age (years)

and height (cm)
80-100% of normal asthma under good control
50-100% of normal indicates caution, may mean respiratory airways are narrowing
<50% - medical emergency, severe narrowing

Asthma Inhaler

Introduction:
Introduce
yourself to the
patient
Check the
patients
identity
Explain why
you have been
asked to see the
patient

I understand
your doctor has
discussed
asthma and
medication
with you. Have
you used an inhaler beforeshall we go through the
procedure from the beginning? (CONSENT)
Check patients understanding of asthma
Give patient an explanation of asthma if required
Highlight the importance of correct technique

Procedure
1. Check the medication type and the expiry date
2. Shake the inhaler and take the cap off the mouthpiece
3. Sit up straight or stand with chin slightly lifted
4. Hold inhaler between index finger and thumb, place inhaler
upright in front of your mouth

5. Blow out and take a few deep breaths in

6. Place the mouthpiece in your mouth and seal lips around the
mouthpiece
7. Press down the inhaler canister to release one dose of
medication AND breathe in at the same time.
8. Continue breathing in to allow medicine to reach the lungs
9. Hold your breath for 10 seconds and then breathe out
10.Ask the patient to demonstrate the procedure and ask if they
have any questions or concerns.
Advice
They can repeat the procedure after 30 seconds for a second
dose or if relief is insufficient
Patient needs to stand up for increased lung filling
Use whenever theyre breathless or feel an attack coming on
Provide written information in the form of leaflets to reinforce
technique.

Diabetes - Urine testing

This station is easy to do but easy to fail

Interpreting is key
Advantages: Non-invasive, easy and cheap, performed at the
surgery
N.B. it is a no-person station but the examiner will ask you
questions
Procedure:
1. Use alcohol gel/wash hands

2. Check (ask examiner):

Patients name, D.O.B, Hospital No.
If sample is: fresh (within 2 hours), MSU (mid-stream
urine)
3. If sample is correct, use gloves and apron (if available)
4. Check and comment on sample colour, cloudiness, look for
sediment
Colour: Straw yellow Normal, Colourless Dilute
(due to DM, lots of water, diuretics), Pink/Red blood
stained, Green/Blue Pseudonomal UTI
Cloudy: Infection, mucus, blood, bilirubin
Frothy: suggests proteinurea
5. Check dipstick container check expiry date and if been
stored in cool, dry place; take one stick from tip and close
bottle
6. Shake urine sample lightly
7. Open urine sample - check smell (if foul infection,
peardrops/acetone DKA, sweet DM, the renal threshold)
and dip stick for one second
8. Completely immerse entire stick.
9. Remove excess urine against rim of container
10.Close sample and hold stick horizontally
11.Read results - Check colour of stick at appropriate times
(make sure examiner is aware of this!) and dispose in clinical
waste
12.Wash hands/use alcohol gel.
13.Record results in patient notes (report directly to examiner!)
14.Answer questions!

Read at 30 seconds

Glucose is excreted when the retention capacity of the kidney

is exceeded. Renal injury on infection may occasionally cause
this and diabetes must NOT be diagnosed on a single dipstick.
Likewise many patients with mild hyperglycaemia will not
have glycosuria

Read at 40 seconds

Specific gravity is a measure of urine concentration and

develops quickly
Ketones are formed when fat is metabolised without sufficient
glucose. Occurs in DKA but more commonly in starvation
Bilirubin is excreted only in obstructive jaundice

Read at 60 seconds

Nitrites strongly indicate gram negative urinary tract infection

Urobilinogen indicates biliary obstruction
Protein indicates infection or renal injury
pH can be raised by certain bacteria or lowered in acidosis

(Normal 4.5-8)
o
Acidic= metabolic activity by diet or DKA
Alkaline
= metabolic alkalosis
Blood can be from renal injury, infection, renal colic or
trauma. Always ask about menstruation if raised in women.

Read at 120 seconds

Leukocyte (esterase) indicate UTI

*M&C Microscopy and culture. Further investigation for

bacterial infection

BMI assessment

1. Ask patient to remove heavy clothing, shoes and to empty

their pockets
2. Explain the procedure and obtain consent
You are measuring their height and weight and using the
BMI (body mass index) formula to categorise the patient
into a weight category.

3. Measure their weight (in kg) and height (in metres)

Learn the normal ranges check chart!
4. Plot the patients weight/height on the BMI graph
General advice
- When measuring height, ensure eyes are level with patients
external acoustic meatus. Check that their feet are right up
against the back of the meter and that they are standing
straight.
- When weighing the patient, ensure the scale has been set to
zero.
- Reasons for being overweight: well built and muscular,
hypothyroidism, overeating/lack of exercise, Cushings,
pregnancy
Complications: CV risks, joint problems,
hernias/prolapses, increased risk of diabetes and stroke
Reasons
for being underweight: anorexia, malnourishment,
chronic disease, cancer, hyperthyroidism
Complications: amenorrhea (absence of a menstrual
period in a woman of reproductive age), malnutrition,
anaemia, increased risk of infections

BMI
< 18.5
18.5 24.9
25 29.9
30 34.9
35 39.9
40.0

Interpretation
Underweight
Normal
Overweight
Obesity I
Obesity II
Morbidly Obese

Reasons for taking BMI:

Long term monitoring of weight in
obesity
Recovery from illness when under
nutrition may be a problem
Assessment of growth in young adults
Obesity is a RF for life-threatening medical conditions

Examining blood films

See scenario 34 lecture 4 on information regarding blood films.

See separate notes
Normal Ranges:
Hb
RBC
MCV
MCH
WBC

Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils

Male Female
13.3 16.8
11.5 14.8
4.32 5.66
3.88 4.99
82 98
27 32.6
3.3 - 9.5
3.9 11.1
1.7 - 6.1
1.7 7.5
1.0 3.2
0.2 - 0.6
0.03 0.4
0.02 0.09

Affected by: Use of tourniquet, sex, age, ethnicity, altitude,

pregnancy, exercise, smoking, alcohol, disease
Information retrieval

- Use a simulated internet to extract data &

information

Search for journals/specific publications

PubMed, MedLine , Clinical evidence, best practice, TRIP

PICO approach
Problem: condition, patient, population, setting
Intervention: dose, delivery, frequency
Comparison (may not be one)
Outcome: what happens to P? cost effective? Patients
experience?
Find some evidence: Medline clinical enquiries and The
Cochrane Library
To use the clinical queries limit in Medline, click on limits
(underneath the search box) and then Additional limits. Scroll
down until you see the clinical queries limit option, and then select
Therapy (best balance of sensitivity and specificity)
- Observe a short video & answer questions
Students should be able to identify and answer questions on
Ethics

Basic Principles:
- Autonomy
- Beneficence
- Non-maleficence
- Justice
Using a growth chart

Using the data given you will be asked to plot on a growth chart a

childs growth different charts for males and females and also
different charts for weight, height and head circumference. Ensure
you use the correct chart for the data provided
Interpret the results by assessing the childs growth in comparison
with the general population as well as against previous results. If
the growth curve crosses the centiles, growth is slow, which may
indicate failure to thrive (illness, poor nutrition, abuse, but may be
normal if parents are small). If the childs weight/height/etc is
below the 3rd centile or above 97th centile, it warrants
investigation it may be normal (small/big parents) but may also
be due to illness/poor nutrition/abuse.
Procedure:
1. Identify patients name, D.O.B, sex, age, height and weight
2. Calculate predicted height
3. Parental average + 7 cm (for boys) OR Parental average 7
cm (for girls)
4. Plot predicted height on appropriate chart
5. Identify mid-parental centile
6. Plot predicted and actual heights at current age
7. Compare and report patients current centile
8. Plot patients weight and identify centile
Use the correct chart according to gender
Plot height on corresponding stature line, and weight on
corresponding line
If patient is >97 or <3 percentile, further tests are needed
th

rd

Reasons for short stature:

Physiological (Parents height)
Congenital: Turners (XO), Cystic Fibrosis
Endocrine: hypopituitarism
Drugs: steroid abuse
Environmental: poor diet, abuse
Chronic disease
Reasons for tall stature:

 Endocrine: Acromegaly, Pituitary Gigantism

Genetic: Marfans Syndrome, Kleinfelters (XXY)
Precocious Puberty
The tempo of growth:
Children vary in the speed of growth and can be fast or slow developers
Growth rates before puberty may relate to the timing of puberty
It can also relate to weight
o Overweight children are often early maturers
o Underweight children may be delayed maturers e.g. gymnasts, ballet dancers
The tempo of growth is strongly genetically determined
The best measure of tempo is the bone age Xray on the left hand and wrist to show skeletal
maturity
Growth Charts
A method of describing the growth of a normal population the reference population
A way of comparing the growth of an individual with the reference population
A tool helping to define abnormal growth of an individual
Most countries have their own growth charts
Used for screening and for growth velocity

N.B. Some degree of weight loss is common after birth

(contracting ECF)
Height: Normally distributed
Weight: Positively skewed as fat children are fatter than
thin children are thin

Movement disorders

- Observe a video & answer questions

Check YOUTUBE for movement disorder videos

Epilepsy
Absence seizure
Tonic-clonic seizure
o A primarily generalized seizure lasting 2 - 5 minutes that is characterized by sudden stiffening
('tonic') of muscles, a fall, followed by jerking ('clonic')
Simple partial seizure (old name = Jacksonian)
o A focal cortical seizure characterized by jerking movements that begin in the extremities and
spread throughout the body (Jacksonian march). May be sensory symptoms rather than motor
Temporal lobe epilepsy (also known as psychomotor epilepsy).
o A focal seizure of the temporal lobe that may be a simple focal seizure characterized by
emotional, sensory or memory-related phenomena or a complex focal seizure where the

seizure spreads throughout the temporal lobe impairing consciousness and may be
secondarily generalized to provoke a tonic-clonic seizure. This is the commonest form of
epilepsy
Status epilepticus
o When a seizure does not spontaneously stop but continues or repeats for a period of 30 min or
more the condition is termed status epilepticus and is life threatening.

Parkinsons Disease:
Resting tremors in hands
Bradykinesia/Akinesia difficulty in starting movement, expressionless face, followed by an action tremor
on movement.
Stooped posture, shuffling gait, difficulty in turning,
Ballistic, uncontrolled movements are disease progresses.
Chorea
In Huntingtons Disease
o Rapid, jerky,
o Dance-like-movement in face
o Limbs and trunk
Other causes:
o Drug induced phenytoin, L-Dopa
o Alcohol
Hemiballismus
Violent swinging movement of one side of the body
o usually caused by infarction or haemorrhage
o In the contralateral subthalamic nucleus
Myoclonus Rapid, brief, shock-like muscle jerks
Dystonias
Prolonged spasms of muscle contraction
e.g. spasmodic torticollis (head turned and held to one side or drawn backwards or forwards)

Anatomy

All station types are unmanned except the surface anatomy

stations
Identify and answer questions on muscle attachments bony
structures, joints, nerves and blood vessels

Skeletal

Muscle attachments, bony structures, joints, nerves, blood vessels

Female/Male pelvis, Limb anatomy, skull
Brachial, lumbar, sacral plexus
Skull: Know the components of the anterior, middle and posterior fossa and the foramens and what they
transmit e.g. Foramem spinosum transmits the middle meningeal artery.
Anterior, lateral, posterior and superior aspects of the skull.

Cartilage
Chondroblasts: secrete ground substance and collagen to form a rigid cell. In situ and formed
chondrocytes
No neurovascular elements
Nutrients by diffusion
Preformed in hyaline cartilage articular surfaces (joints) where rigidity and elasticity required
Bone
Support framework
Movement lever for muscles
Protection skull, thorax
Haemopoiesis (blood cell formation in bone marrow)
Storage of calcium and phosphate (blood calcium must be constant, intake isnt)
Constantly being remodelled
Axial and Appendicular skeleton
Axial: skull, sternum, ribs, vertebral column
Appendicular: scapula, clavicle, limbs, hip bones
Shape
o Sesamoid patella
o Long humerus
o Short wrist, trapezoid
o Flat sternum
o Irregular vertebra
Origin
o Endochondral ossification cartilage
o Intramembranous ossification bones of skull achondral, no cartilage
Terminology
o Head expanded end of epiphysis
o Neck between epiphysis and diaphysis
o Condyle smooth articular rounded process
o Trochlea smooth grooved articular process
o Facet small flat articular surface
o Process - projection/bump
o Ramus - extension at an angle
Attachments to ligaments/tendons

o Trochanter large rough projection

o Tuberosity smaller roughened projection
o Tubercle small rounded projection
o Crest prominent ridge
o Line low ridge
o Spine pointed process
Depressions
o Fossa shallow depression
o Sulcus narrow groove
Openings
o Foramen hole
o Fissure narrow cleft
o Meatus/canal passageway through bone
o Sinus/Antrum chamber within bone
Inspiratory muscles
o Diaphragm: phrenic nerve C3-5, moves 1.5-7cm down when contracted, expanding chest
dimensions, decreasing pressure, air drawn in
o Intercostals: mainly external, raise ribs
o Scalene muscles: raise upper ribs
o Accessory muscles of inspiration: sternomastoids, pectoral

Surface
Examine the Head, Neck, Chest, Back & Limbs to identify &
palpate anatomical structures.
If patient present: introduce yourself, gain consent, explain purpose, wash hands , ask to remove shirt, sorry if
hands are cold.Thank the patient

Head
Chest and neck
o Jugular notch
o Sternocleidomastoid
o Mastoid process
o Thyroid
o Limbs
Tendo calcaneus (Achilles tendon)
Popliteal fossa
Acromioclavicular joint
Malleoli
Femoral condyles/epicondyles
Biceps femoris

Back
o Deltoid
o Latissumus dorsi
o Scapula and its muscles
o Erector spinae
Heart
o Heart sounds
o Apex beat
Lungs
o Fissures
o Pleura
Landmarks
o C7
o T12 (angle of Louis)
o L5 (iliac crest)
o ASIS
o Inguinal ligament
o Mid-Axillary line

Organ
Identify & answer questions on structures within and relating to
organs

Structures within and relating to organs

Lung, heart, renal tract, female pelvis

Plastic model of the anatomical part which may be labelled with letters and you will be expected to identify
that part. Expected to know a little about the relation of that labelled part to other parts of the anatomy.

Example: label X (which you have to know is the chordae

tendineae) arise from the papillary muscle.
Where to listen for heart sounds

Histology

Histological sections presented as photographs.

Identify & answer questions on histological sections
Likely to be: female oocyte, skin, respiratory epithelium, CNS,
pancreatic tissue
Histological sections
Common cells incl. respiratory epithelium, bone slides, cervical cells,
Identify major structures and cell types
Wheaters!
Epithelial Tissue
Sheets covering the body surface (epidermis)
Depend on diffusion
Line internal cavities
BVs never pass through BM rest on BM, extracellular matrix (collagen type 4)
Protective barrier, secrete/absorb, detect signals, export waste
Classified by
Shape: cuboidal, columnar, squamous
Layer structure: simple, pseudostratifies, stratified
Surface specialisation: ciliated, brush border, keratinised
Location and function: respiratory, transitional
Skin
Epithelial layer (epidermis), connective tissue (dermis)
o Thick skin: keratinised/cornified layer, lacks hair follicles
o Thin skin: hair follicles
1. Epidermis: stratified, squamous, keratinising
2. Basal layer (striatum basale): cuboidal, columnar, site of cell division
3. Prickle cell layer (striatum spinosum): numerous spot desmosomes, cells enlarge and accumulate keratin
4. Keratin and proteins: filaments (IF), bundles that converge on desmosomes
5. Granular layer: cells begin to flatten, keratinocytes disappear, embedded in cornified layer
6. Cornified layer (striatum corneum): squamous extremely flat, keratins cross-linked, cells die, lose nuclei,
reduced organelles, dehydrated