OSCEs for Medical Students, Volume 3 Second Edition, Study notes of History

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OSCEs for Medical

Students, Volume 3

Second Edition

Adam Feather

John S P Lumley

Jonathan Round

Ramanathan Visvanathan

Contents

Contributors iv Acknowledgements vi Preface vii Preface to the Second Edition viii Introduction ix How to Use this Book xiv Glossary xvi Normal Values xxiv Generic Approach to Examinations xxvii

OSCE Stations

Chapter 1: Paediatrics 1 Chapter 2: Obstetrics and Gynaecology 33 Chapter 3: Endocrine and Breast 57 Chapter 4: Ethics and Legal Medicine, including Consent and IV Procedures 101

Answers with explanations and

comments

Chapter 1: Paediatrics Answers 119 Chapter 2: Obstetrics and Gynaecology Answers 163 Chapter 3: Endocrine and Breast Answers 223 Chapter 4: Ethics and Legal Medicine, including Consent and IV Procedures Answers 277

Mock Examinations 301 The OSCE Marking Scheme 302 Revision Checklist 304 Recommended Reading List 306 Index 307

Contents

Paediatric History

1.1 – Examination of a child with a heart murmur 1.2 – Examination of a child with difficulty breathing 1.3 – Examination of a child with abdominal distention 1.4 – Assessment of Growth 1.5 – Assessment of baby's cranium 1.6 – Assessment of a child with a possible genetic condition 1.7 – Neurological assessment 1.8 – Assessment of developmental milestones 1.9 – Assessment of skin conditions 1.10 – Assessment of Gait 1.11 – Neoanatal assessment 1.12 – History of poor growth 1.13 – History of convulsion 1.14 – History of cough 1.15 – History of vomiting 1.16 – Data interpretation – infectious disease 1.17 – Data interpretation – vomiting 1.18 – Neonatal CPR 1.19 – Management of the paediatric airway 1.20 – Explanation of medications 1.21 – Explanation of peak flow readings 1.22 – Prescription of antibiotics 1.23 – Explanation of investigation results 1.24 – Explanation of immunisation 1.25 – Explanation of asthma 1.26 – Radiology interpretation 1.27 – Radiology interpretation 1.28 – Paediatric investigation 1.29 – Interpretation of the Paediatric ECG 1.30 – Radiology interpretation and management

2 OSCEs for Medical Students, Volume 3

Chapter 1

Paediatrics

Paediatric History

When you take a paediatric history, discuss first what is of concern. Use the lists below to find out more about the area of concern, for instance the antenatal, birth and development in a child with fits. Go beyond these questions in an area of interest. There are too many questions here to ask in every situation, but touch on each area. For instance, ‘are there any problems with his heart?’ can be used rather than asking about scans and murmurs. The most important aspect of history taking is to listen.

Pregnancy

Planned/unplanned/IVF/donor/adopted Scans – when and any problems Previous births – gestation and weight Mode of delivery – induction/SVD/LSCS (emergency or elective), and why Resuscitation needed SCBU afterwards Apgars (but parents unlikely to know)

Development

Any concerns Problems at school – academically or in games Developmental screen (only use in < 5 years unless developmental problem): Smiling by 6 weeks (time of concern) Sitting by 9 months

Turns to sound by 6 months First words by 18 months

Walking by 18 months Talking two-word sentences by 3 years

OSCE Stations

Respiratory

Any breathing difficulties

How is he now

Noisy breathing – inspiratory or expiratory

Episodes of cyanosis, apnoea or working hard

What makes it better/worse

Day or night variation

Cough – dry/wet/barking, worse at night

Previous treatments and their effect

Cardiovascular

Antenatal scans

Murmur heard – how investigated?

Episodes of cyanosis or shortness of breath, especially feeding

Operations?

Gut and nutrition

Breastfeeding – any problems. Is baby satisfied by feed, how often?

Milk – which formula, how much, how often?

Concerns about growth – (look at ‘centiles in red book)

Eating solids (after about 4 months)? Any dietary requirements

Diarrhoea/constipation – consistency, how often – any treatment

Vomiting – what/when/how much

Take a 24 h intake/output history

Renal

Previous UTIs – any investigations

Unexplained fevers

Irritability/blood in urine

Swelling around eyes or abdomen.

Paediatrics 5

OSCE Stations

Bones and joints Any problems running?

Swollen joints

Neurological How are they doing at school? – development

Any fits – if so, age, type, investigations, medication used

Interventions Medications and inhalers, special diets

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OSCE Stations

STATION 1.

Growth

Michael has been attending the growth clinic. Please can you measure his growth and plot them on a centile chart fig 1.4a. The examiner may then ask you some questions based on this. Please use any of the equipment provided in fig 1.4b. (10 minute station)

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OSCE Stations

fig 1.4a

STATION 1.

Examination of the Head

Please demonstrate to the examiner how you might examine this baby’s cranium.

(5 minute station)

Paediatrics 9

OSCE Stations

fig 1.4bi

fig 1.4bii fig 1.4biii

STATION 1.

Skin examination

Look at the five images (figs 1.9a, 1.9b, 1.9c, 1.9d, 1.9e) of various skin appearances. Please complete the following table by selecting one of the available diagnoses and management plans. Each diagnosis and plan can be used once, more than once, or not at all.

(5 minute station)

Paediatrics 11

OSCE Stations

fig 1.9a fig 1.9b

fig 1.9c fig 1.9d

fig 1.9e

Meningococcal sepsis Reassure – it will resolve spontaneously

Herpes simplex Reassure – it is a birthmark Chickenpox Systemic aciclovir

Rubella Topical aciclovir Molluscum contagiosum Surgery

Milaria Dietary advice Capillary haemangioma Topical antifungal

Cavernous haemangioma Systemic steroids Eczema Topical steroids

Café au lait patch Observe Pityriasis versicolor Intravenous antibiotics

(Mongolian) blue spot

Picture Diagnosis Management plan fig 1.9a

fig 1.9b

fig 1.9c

fig 1.9d

fig 1.9e

12 OSCEs for Medical Students, Volume 3

OSCE Stations

Answers

Chapter 1:

Paediatrics Answers

• 118 OSCES for Medical Students, Volume

Comment

Paediatric cardiovascular examination should be straightforward. The keys are to see if the child is either cyanosed or in heart failure and if the child has a scar. If the child is blue, there is a problem getting blood into the lungs. Most likely, the child has Fallot’s tetralogy. If the child is tachypnoeic and pink (and does not have respiratory disease), the child will be in heart failure and is likely to have a VSD or AVSD. Scars may be midline (implying a curative operation such as VSD closure or Fallot’s repair) or subclavicular, suggesting a palliative systemic-pulmonary shunt or a coarctation resection.

An alternative presentation will be a child with a murmur who is neither blue nor tachypnoeic. This will either be an innocent or pathological murmur. Innocent ones do not radiate, are quiet and precordial and the child is otherwise well. Some alter with position. If it is not innocent, the position where it is loudest gives a clue as to the cause and also its character. Those loudest below the nipples are pansystolic (VSD, Fallot’s, AVSD) and those above ejection systolic (PDA, AS, coarctation). In an examination, never forget the femorals, the blood pressure or the weight.

120 OSCEs for Medical Students, Volume 3

Answers

STATION 1.

Respiratory examination

This station can use a patient with no respiratory signs, or one with longstanding illness, such as CF or asthma.

Assessment Good Adequate Poor/not done

1 Appropriate introduction (full name and role)

2 Candidate washes their hands using the alcohol handwash provided (no marks if candidate only expresses the need to wash if handwash is provided) 3 Inspects for cyanosis, clubbing, scars

4 Inspects for tachypnoea, recession, expansion 5 Listens for crackles, wheeze, breath sounds

6 Correctly identifies ausculation findings 7 Feels for expansion, tracheal position

8 Percussion (but must justify why) 9 Feels pulse (but must say for paradoxus or bounding as with CO 2 retention)

10 Measures peak flow and offers to measure weight 11 Keeps patient comfortable and at ease

12 Does examination in professional manner

Paediatrics Answers 121

Answers