Plab 2 Stations_Dr Sonia

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Golden Tips

Dear collegues a lot of plab2 candidates asked me to explain examination.So I am going to explain few common examinations which people fail a lot.

GOLDEN TIP 1:-One important thing that I would like to mention that you all know how to

do examinations as you all have done in your medical school just need revision.One essential thing to pass the examination is that while you are performing the examination pt should feel respect,dignity and autonomy.This is the most important thingtopass the

examination.GOLDEN TIP 2-:You must stop your examination at 4.30 bell and upto this point 70% examination must be completed.At 4.30 bell thank the pt and ask him to cover up in his/her privacy,turn to the examiner that i would like to complete my examition by

doing(remaining part of examination) -My most probable dx is this(dx)

GOLDEN TIP 3:-While doing examination hold the pt with confidence.

GOLDEN TIP 4:-Explain every step before performing on the pt,also if he/she already has

pain on examination site and ask for permission by non verbal gesture by looking into the eyes of pt with plesant smile on your face and wait for the response.If the step you are going to perform can cause pain or discomfort tell the pt and ask for co.operation.Look at the face of pt for discomfort and say sorry for this.

Golden tip 5:

-If you think that pt is dx with chronic disease causing any disability or complication and sending pt back to home.ALWAYS ASK IS THERE ANYONE AT HOME WHO CAN SUPPORT YOU?

GOLDEN TIP6:- MEMORIZE THESE FOUR WORDS

1-THANK YOU 2-LOVELY

3-THAT'S GREAT 4-EXCELLENT

And use these words very frequently during examination and after easch step of examination. DEAR COLLEGUES:There is no trick to pass the examination station.Practice a lot and be very very gentle to the pt.

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Incontinence, ID, HPI

O – How long have you been incontinent for? (acute vs. chronic) P – Frequency

Q – Intermittent or constant dribble

S – How severe is the problem? (daily functioning, social) T – Day or night.

What kind of urinary incontinence is it?

Urge – larger volumes, frequency, day and night Stress – dripping with laughing,coughing

↑ intra-abdominal pressure, daytime

Overflow – small, hesitancy, incomplete voiding If onset is acute . . .

D delirium/dementia, stroke, Parkinson’s, cord compression – recent onset confusion, disorientation, distractibility – numbness, weakness of lower limbs

– CVA, trauma, metastatic cancer Infection

– history of UTIs, dysuria, changes in frequency Aatrophic vaginitis

– irritation or burning in vagina, use of local estrogen cream, oral estrogen preparation P pharmaceuticals

– diuretics, sedatives, anticholinergics Eendocrine

– DM (polyuria, polydipsia), hyperparathyroidism R restricted mobility

S stool impaction (constipation) stress

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If onset is chronic Causes

– Bladder tumor or stone – BPH

– Neurological deficits (CVA, Alzheimers, neoplasms, cord compression) – Surgery

– Polyuria (DM, hypercalcemia) PMHx

– Surgery (vaginal, pelvic, prostate) – Childbirth

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SIM MAN

DO NOT MISS this station

You will have three sim man stations in which you should do management 1- acute asthma

2- acute limb ischemia

3-CVS simman with preop assessment of Hystrectomy.

I have seen many doctors have struggled in these three stations so I would like to talk about these three stations

SHORTNESS OF BREATH IN SIMMAN:

-To begin with, as you know shortness of breath in sim man has two stations: One of these is acute asthma, which involves taking history, examination and management.

- The other is infective exacerbation of COPD, which involves taking history and

examination, NOT management. This means before starting the station you can be sure if there is management in the task, the station is acute asthma

.

COMMON MISTAKES in acute asthma station;

1-Many doctors forget to fasten the mask properly, maybe they are thinking about choosing a right mask at the beginning of the station. There is usually only one mask, Hudson with reservoir, which is the right one. Therefore, it should not distract you. Please fasten the mask properly when you start your treatment in very early stage of station. Don't expect to pass if you don't fasten it properly. It is a good idea when you are putting the mask tell the examiner '' I'm giving my patient oxygen and let the examiner ask you about percentage (high flow 100%), and rate (15 L/ min). The examiner will ask you, however, if he did not so you can talk about them.

2-Many doctors could not reach to auscultation .To tackle this problem you should aim to auscultate the chest at least 90 sec before the station finishes because in this station the most important finding is on Auscultation. The best way to manage your time is you must keep looking at the monitor and as soon as oxygen saturation drops below 90%, then should start your next treatment step, so you can save time and don't let sim man to waste your time. For example, during taking history, you have to give oxygen when you come to know he has asthma. During the examination, when you see oxygen saturation drop below 90% immediately talk about nebulized salbutamol 5 mg every 15 minute. The simman may deteriorate once more, so you keep tracking the monitor and this time please talk about IV hydrocortisone 5 mg every 4-6 hours .By doing this, you don't let sim man to start showing you his shortness of breath in which you have to ask him

“what is happening?” and he can't talk due to shortness of breath you have to wait and ask it again and ….

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This approach not only save your time but also gives a good impression to the examiner as you keep looking at the monitor.

3-Many doctors at the end of the station when the examiner asks them a question they answer something else!

-When you finishes your auscultation plz talk about your findings,which is wheez and diagnosis is Acute Asthma.

-If the examiner asks you"what are you going to do now?"plz do not talk about the other options because when you finish the station simman is usually stable.The examiner does not look for other steps of treatment.

-Here you should talk about the investigations,which is CXR,ABG and ECG.As you know after steroids(either IV hydrocortisone or oral prednisolon 40-50mg)If pt deteriorates you should inform ITU and your seniors so the stage after steroid should not be the examiner's concern.However if he asks "what are you doing if your pt deteriorates?"Plz tell the examiner "I informing my senior and ITU team and they may consider megnesium sulphate and

intubation."

BRIEF HISTORY POINTS BOTH IN ASTHMA AND COPD:

-When you enterd the room pt will be gasping for air,sometime asking for help.Immidiately tell the pt I can see your oxygen saturation is low that is e,g 88%.Do you smoke?Have you ever smoked?answer would be no ar less number of cigarett not fulfilling the crieteria of copd.

-Give the pt high flow oxygen. -Now introduce youself.

-Take brief history.How long have you been SOB.?How did it start?What were you doing at that time?Do you have asthma?Any chest pain?Any heart problem?Any fever,cough and spotum?Any recent surgery or travel?Any Hx of Clots in lungs and legs.

-In asthma keep eye on monitor while taking history as you have to manage the pt simultaneously.

-On examination part directly start from percussion to save your time for auscultation which is ultimately passing point.

COPD:

-Approach is the same.When you ask for smoking this pt will give you hx of smoking >40 years and >30 cigretts per day.Fever,cough and green spotum +ve.

-Dont give oxygen because in the question it is mentioned that take hx and do relevant examination.

-Same points of Hx as in asthma.

-On examination part verbalise I,ll look for clubbing,peripheral and central cyanosis.check for tracheal deviation and chest expansion,and start from percusstion and auscultation. -Tell the examiner your dx=Acute excerbation of COPD

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NEUROLOGICAL HAND EXAMINATION:

HI FRIENDS this station came recently in the exam and people were worried that what it was hand how to conduct this examination.

-Greet the pt, introduce yourself, explain your purpose of examination, take permission and look for general risk factors (e,g pregnancy, hypothyroidism, obesity, trauma, acromegally) ...

EXPOSURE: Role up your sleeves above the elbow and please place your hands on pillow(placed in the lap of pt)

-INSPECTION:

-Muscle wasting (thenar and hypothenar muscles) -Wrist drop

-Tremor and fasciculation -Radial and ulnar deviation

MOTOR POWER: Median Nerve:

1-Thumb abduction (thumbs up while both palms facing upward and thumbs up. tell the pt I am going to push it down, don't let me push it down)

2-Pincer grip: Make a perfect sign and don't let me break it.

ULnar Nerve:

1-Finger abduction(spread finger against resistance)(dorsal interossei)

2-Grip card between thumb and index fingers while hands are verticals and examiner try to pull away pt will adduct his thumb to grip the card(this is to check adductor pllices, if it is affected pt will flex the hand to grip the card=Froment's sign)

3-Grip card between little finger and ring finger while hand is vertical and examiner tries to pull away(Adductor of little finger.

4-Can you please hold my index finger by making fist around it and don’t let me to pull it away (palmer interossei)

Radial Nerve:

1-Wrist extension

2-finger extension (all together)

3-Thumb extension(make a fist with thumbs up and tells the pt don't let me push it down)

SENSORY:

Light touch +Pain:

1-Over DIPJ little and index finger while facing palm up(ulner and median) 2-Over Anatomical snuff box while palm facing down (radial nerve)

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Vibration:

1-Touch the tuning fork on the fingertips of index and little finger while palm facing upward. 2-touch at tha DIPJ on thumb palm facing downward.

SPECIAL TESTS:

1-Phalen's test: reverse prayer sign for 1 minut:+ve if tingling and numbness in case of carpel tunnel syndrome.

2-Tinnel sign: Tap along the course of median nerve, tingling become worse in carpel tunnel syndrome. FUNCTIONS: 1-Pincer grip 2-Squeez my fingers 3-Hold a cup 4-Undo button 5-Write a sentence

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SUICIDAL RISK ASSESSMENT AND MSE:

One of the most common question that comes in gmc exam is the suicidal risk assessment and mental state examination.ppl take this station as common psychiatric hx taking station and lat of ppl fail this station bcz you have to ask specific question for risks that can lead to depression and suicide....

Divide it into three parts1- Incident detail:i_ what was the precipetant(reason) for this

Attempt.ii_ Did you plan thisiii_what methoed did you use( it could be PCM tablet..ask how many....when...was this only thing or have you taken anyother drug or anything elseIiv_did you leave any suicidal will or note?V_ were you intoxicated at that time (taken alcohol ar anyother substance of abuse)Vi_did you took any precaution against discovery(lock the door or waited untill no one at house)Vii_after the incident did you seek any help or were you found and brought to the hospital by someone elseViii_how do you feel now? Do you regret or still wish you could be succeeded.2- OTHER RISKS

I- age>28 II-male>female

III- are you single or in relationship? IV-are you working or unemployed? V- have you tried to take your life before? Vi-Have you ever visited mental health clinic? Vii-Do you have any physical disability?

Viii-Do you drink Alcohol or anyother recreational drug?

Ix-Anyone in family who tried to take his life or family hx of deppresion and drug abuse?

3 -MOOD, INSIGHT, PSYCHOSIS MOOD Core symptoms

I- do you feel low and depress

II- Have you lost interst in things that were enjoyable to you? III- Do feel yourself tired all the time?

Mood Biological symptoms.

I- have you noticed change in your sleeping pattern II-Any change in appetite?

III-Any change in sex drive?

Iv- How about concentration? Are you able to follow the tv program or newspaper without being distracted?

INSIGHT

I-Do you think you have problem and need help(if pt comes by his/her own dont ask this question)

II- How do you see your future?

PSYCHOSIS

I-Do you belief anthing which other people dont agree with? II-Do you hear voices when nobody around you?

III-Do you see images which other people cant see?

Iv- Do you think that other people are stealing your thoughts or putting their thoughts into your mind?

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At the end ask pt:

Do you still have any thoughts of harming yourself? Any plans?

Are you going back to the same environment or have you changed your mind? Thank the pt and give suicidal risk to examiner:

Ms(xyz) has high/low sicidal risk because her Mood is low/high.

Has no/yes insight into her problem. Has got no/yes psychosis.

I will admit her/ discharge her with my senior consultation. Important points.

introduction,permission,confidentiality,keep quite for few second and look at the pt for few second.This gives impression to the pt that at least someone is there to talk to her.Don't start the station with bombardment of question,otherwise she will not talk to you.If she doesn't answer you dont insist on the same question,politely and slowly move forward.

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2 to 7 CRANIAL NERVE EXAMINATION:

2nd Cranial nerve;

Dear friends read the question outside carefully.It is mentioned that don't do red reflex and visual acuity.So,plz dont be robotic understand the instruction.In exam you will start from inspection and directly do visual field by confrontation methoed.

Tell the ex that I am going to check the 2nd cranial nerve(loudly by looking towards ex)

INSPECTION: On inspection just mention pupillary size, ptosis,strabismus,Facial muscle

wasting and facial asymmitry.No need to mention discharge exophthalmosis or proptosis as nothing to do with cranial nerve

.

VISUAL FIELD: You and pt should be at the same level and one meter apart.

-Tell the pt this is a white pin(in exam white neuropin is there for this purpose)Can you see it?yes

-I'll bring it from periphery to the centre.please say yes when you see it.Is clear to you? -can you please cover your right eye with your right hand and look straight into my eye with your left open eye and please fix it.Perform this action in all four quadrants in both eyes. -Interpret findings like this.(loudly so that ex can hear)

1-If normal=2nd cranial nerve is intact

2-Mono ocular visual loss=Right/left optic nerve is affected before optic chiasma 3-Bitemporal hemianopia=2nd cranial nerve affected at the level of optic chiasma.

4-Right/left homonymus hemianopia=2nd cranial nerve is affected behind the optic chiasma 5-Tunnel vision=visual field is constricted due to 2nd cranial nerve lesion at the retinal level.

BLIND SPOT: This performed with red neuro pin (bring out the pin from centre to

periphery(TIP: skip this step as it will consume lot of time and you will not be able to cover 70% examination.)

REFLEXES:

-Accomodation reflex:Ask the pt to fix on a distant point and then at your finger which you bring infront of the pt.(if convergence and pupillary constriction occur,accomodation reflex is normal.

-Direct and Indirect light reflex:mention that would like to dim the light and shine light at the angle of 45 not straight from the front.(tell your findings loudly)

3,4,6 CRANIAL NERVES:

-Now vocalize loudly that I am going to check 3,4,6 cranial nerves simultaneously. -Tell the pt that I am going to move my finger infront of you in figure of H,plz follow my

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finger with your eyes and dont move your head.If you see double anywhere plz let me know. -While moving your finger plz be slow in extreme quadrents and give pt time to give you findings of diplopia or strabismus.

-Give your findings loudly(e,g my pt doesn't have diplopia or strabismus.so,3,4,6 cranial nerve is intact.

5th CRANIAL NERVE:Verbalise loudly I am going to check sensory component of 5th

cranial nerve.

-Ask the pt if he has pain or tingling anywhere on his face.

-Tell the pt this is wisp of cotton,i am going to touch it on your face while your eyes will be closed.plz say yes when you feel it.It feels like this(on sternum)can you feel it?yes

-Touch on ophthalic,maxillary and medibular division of nerve by comparing both sides. -Same process with neuropin for pain sensation(use the blunt end)

-VERBALISE loudly that sensory component of 5th cranial nerve is intact.

NOW I AM GOING TO CHECK MOTOR COMPONENT OF 5th CRANIAL NERVE. -Can you please clinch your teeth while I'll be placing my hands on your face to feel the muscle.

-can you plz move your jaw side to side.

-Ideally I would like to perform jaw jerk and corneal reflex

VERBALISE loudly motor component of 5th cranial nerve is intact.

7th CRANIAL NERVE(Verbalize loudly)

-Can you plz frown at me?

-Can you plz close your eyes tightly I'll try to open them.Don't let me do it. -Can you plz puff your cheeks I 'll try to break by tapping.Don't let me do it. -Can you plz smile for me.

-Do you have any problem with your taste? 7th CRANIAL NERVE IS INTACT. THANK YOU VERY MUCH

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Insulin dose calculation

I am going to describe insuline dose calculation because a lot of people have confusion about it.

Sometime in Exam question says prepare infusion at the rate of 1 unit insuline/100ml/hr for 5 hrs and sometime it says 2 unit/100ml/hr for 5 hrs.

1-Ask the examiner I would like to do calculations in presence of witness. ...

1 unit insuline given= 1hour

X units of insuline given in5 hours=1×5 X=5units

Or

2 units given=1 hour X units given in 5 hrs =2×5 X= 10 units

100ml N/S in=1hour

X ml N/S in 5 hours=100×5 X= 500ml

2- show your calculations to the examiner

3-Check expiry dates of insuline voil and Normal saline. 4-Clean the voil with alcohol swab.

5-Take the required dose from voil(a slightly more because you have to discard some insuline while removing the bubble)

6-Remove the needle from the syringe and put it into the sharp. 7-Place your sample on the table to show the examiner.

8-If mentioned in the question that inser into the bag than attatch a new needle on the syringe otherwise leave as it is( In exam never ask to put it into the bag.so upto point 7 ur station is complete.)

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PRE-ECCLAMPCIA:

It comes in two scenarios.In first scenario you will be asked to take hx and discuss

anagement with the examiner.2nd scenario take brief hx and talk to the pt and adress her concern(this pt has been refered by GP with baseline investigations done.Your task at this station s to convince the pt to stay at hospital for mx and monitoing.

1St scenario;

-I understand that you have been refered to us as you are having some complaints.Is that right?...

-Can you plz tell me what symptoms you are experiencing?-Ask about headache,blurr vision,epigastric pain or burning,sudden onset of puffiness of face and feet.-Are you feeling the kicks of your baby?RISK factors:

-Is this your first pregnancy?

-have you attended all your antenatal clinics? -What was your booking BP?

-Do you have any medical condition like high BP and sugar,,CKD and antiphospholipid syndrom?

-Anyone in the famly who have high BP during pregnancy?

-If it is not first pregnancy of pt than you can ask hx of pre-ecclampcia in previous pregnancy?

Thank the pt and now tell the examiner management.

MANAGEMENT.

-I would like to check the BP and urinary protein.

-At this point examiner will tel you that BP is 160/110 and urinary protein 3+. -Tell the examiner my most probable dx on the basis of hx and ex is pre-ecclampcia. -I will admit the pt.

-Send blood for CBC,LFT,RFT,Clotting Scren. -24 hour urinary protein and monitor BP. -I will connct the pt with CTG machine.

-i will give my pt antihypertensive as per hospital protocol(Methldopa,labetalol,hydralazine) -i will consider anti convulsant and steroid for lung maturation of baby after discussing with seniors.

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 In preeclampcia you have to convince the pt for admission by telling her that condition is very dangerous for you as well as for your baby. If you throw a fit, it can cause bleeding in your brain which is very serious and life threatning condition.2ndly due to this

condition afterbirth(plancenta) can be detached and can cause severe fetal distress.  In PV bleeding if placenta previa and placental abruption has been ruled out.Ask the

mother if she is feeling the kicks of baby.

Tell the mother as you are telling me that you are feeling the kicks of baby, hopefully your child will be fine however we will connect you to the CTG machine to check the heart beat of baby and tell you finally.

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SEXUALL HISTORY TAKING;

Sometime this station comes as only hx taking.

-Guys explanation and taking consent before hx taking is very crucial at this station

-“I’ve been asked to take a sexual history from you, this is going to involve me asking some personal questions which you may find uncomfortable. Everything you tell me is confidential within the boundaries of the team looking after your care. If you would like to stop at any time, please let me know.”

-So,what brought you to the hospital? -Can you plz tell me more about it? Symptoms;

-For each of the symptoms below ensure you clarify duration/ severity / course (worsening vs improving) exacerbating & relieving factors / etc.

-Vaginal discharge: itchy/offensive – different to normal

“Have you noticed any discharge? Does it smell? What does it look like?” -Dysuria / frequency:

“Do you have any pain when passing urine? Do you feel you are going more often?” -Vulval itching/soreness:

“Do you have any itching/soreness down below?” -Genital skin changes:

“Have you noticed any skin changes around your vagina?”

“Have you noticed any blisters, spots or ulcers around your vagina or anus?” -Abdominal pain – SOCRATES is useful here

“Have you had any pain in your tummy?” “Where in the tummy is the pain?”

“Does it move anywhere else?”

-Pain during or after intercourse – dyspareunia

“Do you ever experience any pain around the time of sex?”

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“When does it occur? How long does it last?” (before/during/after) -Systemic symptoms (which may be related)

“Have you noticed any rashes elsewhere on your body?” “Do you have any pain in your joints?”

“Have you had any pain in your eye?"

Menstrual history::

Last menstrual period (LMP) – “When was your last period?”

Regularity – monthly / unpredictable – “Do you have regular periods?” Length of cycle – “How long is your cycle? / How long do you bleed for?”

Dysmenorrhoea – “Any problems with pain or heavy bleeding during periods?” (new vs longstanding)

Post-coital bleeding – “Do you experience any bleeding after sexual intercourse?” (new vs longstanding)

Intermenstrual bleeding – “Do you have episodes of bleeding between periods?” (new vs longstanding)

-Gynae history

Smears – dates / results

“Have you had a smear? When? What were the results?” “Have you ever had an abnormal smear?”

Treatment – previous gynaecological treatment – e.g. Loop excision “Have you had any previous treatment to your cervix?”

-Obstetric history

Contraception – type of contraception, length of use, any issues, any previous contraception “What do you use for contraception at the moment?”

Pregnancy:Is there any chance that you could be pregnant?

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Sign-posting here is of benefit to ensure the patient (and yourself!) are prepared for the nature of the questions surrounding the specific sexual health aspect.

“Next, I’m going to move on to discuss your sexual history. Some of these questions are sensitive, and can make people feel embarrassed. It’s important for me to find out this information though, so we can assess the risk of you being in contact with a sexually transmitted infection, and any others involved.”

-Timing of last sexual contact

“When did you last have a sexual encounter?” Consensual?

Partner demographics

“What sex was the partner in question?”

Types of sex involved – oral (genital & anal) / anal / vaginal /digital For oral/ anal sex, clarify if the patient gave or received it (or both) “What was involved in this encounter?”

“Was there more than one other person involved?” -Contraception used – condoms / dental dams / etc

-Clarify if contraception was used for all sexual encounters, or only a subset

-Ask if there was any problems with contraception at any point – e.g. condom splitting “Was there any point at which contraception was not used during the sex?”

“Was there any issues with the contraception used?” Other partners in the last 3 months

“Have you had any other partners within the last 3 months?” – If so, repeat the above for each.

-Past medical / Surgical history: -Drug and Allergy h

-Social hx:very important to ask about occupation of the pt.

HIV RISK ASSESSMENT:If asked

Identify if positive risk factors are present:

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“Have you ever had sex with a bisexual man/engaged in male homosexual activity?” “Have you ever had sex with someone abroad, or who was born in a different country?” “Have you ever injected drugs?”

“Are you aware of any of your previous partners having ever injected drugs?” “Have you ever paid someone for sex, or been paid for sex?”

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IRREGULAR BLEEDING(POF):

-At this station no presenting complaints in the question.when you will go inside the cabin and ask pt she will tell you I have irragular periods.

-How long have you been having irragular periods? -How often are you bleeding now?

--Is this heavy bleeding?clots?flooding?...

-Were your periods tegular before that?-What was the length of your cycle?-After how many days did they repeat?-Do you bleed outside of your cycle?-Do you bleed after sex?-Do you feel pain during mensturation?start/throughout the mensturation?-At what age did you have your first period?-When was your first sexuall encounter?risk-Are you on any

contraception?-Are you sexually active?Do you feel pain and vaginal dryness?-When was your last cervical smear?result?-Have you ever done any gynaecological procedure or operation?-Do you have childrens?

ASSOCIATED SYMPTOMS:-Are you having any hot flushes,palpitations,night sweats and

mood swings?-Do you feel depress and low?-Are you having difficulty sleeping?-Does the heat and cold bothers you as it does not bothers other people?-Have you gained weight and noticed any skin changes(oily,greasy and facial hair growth)?-Have you lost weight

recently?-Are you doing any excessive exercise?-How much do you eat food on an average day?RISK FACTORS:

-Any family history of early menopause before the age of 45. -Any parental hx of hip fracture?

-Do you have any medical condition?

-Are you taking any regular,Otc or herbal medication?specially steroids?

SOCIAL HISTORY:

-Employment -Alcohol

-Drug of abuse DX in Exam= POF -Smoking-Housing

MISCARRIAGE:

This is a semi breaking bad news station,so you have to follow 3 layers instead of 6 layers before breaking the news.

-AT this station a lady comes with PV bleed and she is almost 10 weeks pregnant.Sometime it is incomplete miscarriage and sometime missed miscariage(baby does not have heart beat+os is closed and mother is unaware of it).In case of missed miscarriage you will not mention that it will abort naturally,you have to do something to abort the product of conception.

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-HOW TO APROACH THE STATION:

-Greet the pt

-I unerstand that you are 10 weeks pregnant and you came to us with some complaints and we have done your USG scan.Is that right?

-Can you please recap the events so far?(let the pt talk)

-I have the results of the scan with me.Would you like me to discuss the result you now? -Before we go ahead,do you have an idea whats going on?

-Is anyone accompnying you?Would you like me to call someone for you? -Pt becomes abxious here and ask you why?

UNFORTUNATELY I have to break some difficult news to you.Your scan did not manage

to detect the baby's heart beat.At this stage we should be able to pick up a heart beat if it is present.I am sorry to have to tell you,but you have had a miscarriage.

-let the pt swallow the news and respond according to her emotions.If crying offer tissue.If shocked offer some water.

-wait for the responce of pt.

WHY DID IT HAPPEN?DID I DO ANYTHING WRONG?

-I'd like you to know that this is not your fault.This is a very common condition and every 7th pregnancy ends up in miscarriage,and in most cases it is due to a random event.There is nothing you could have done to prevent it.

WILL I GET PREGNANT AND HAVE BABY AGAIN?

-Yes my dear,you can get pregnant and can have normal pregnancy and baby as like other women who does not have miscarriage.Some women are worried about future

pregnancies.having a single miscarriage has no impact on your ability to get pregnant again,or your future chance of having a baby.in fact it's so common to have miscarriage that we only begin looking for a reason for the miscarriage if they happen more than 3 times.

WHAT WILL YOU DO FOR ME NOW?

-There are 3 options of managing your miscarriage.There's no right or wrong choice,and you can choose whichever method suits you.

1-the first choice is to do nothing.Your body will naturally remove the miscarriage from your womb,which may take 2-3 weeks.

2-The second option is to have an operation under general anesthesia,in which a nerrow tube is inserted into the womb to remove the miscarriage.it takes about 10 minuts.

3-The 3rd option is to take some medication which will break down the lining of the womb and take the miscarriage with it.so,you avoid an operation and its quicker than letting nature take it's course

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.

YOU CAN EITHER DECIDE NOW,OR THINK ABOUT IT AND LET US KNOW LATER ON.

WHEN I CAN GO BACK TO WORK?

-You are free to get back to normal activities whenever you feel able.if you need a sick note for work I can provide you one for 2 weeks.Your GP can provide you another sick note if you still need one after 2 weeks.

-Do you have anyothe concern? Thank you

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ANTEPARTUM HAEMORRHAGE:

-PV bleeding after 28 weeks of gestation is called antepartum haemorrhage.At this station you have to discuss mx with pt and adress her concerns.On USG placenta is normal.You have to take brief history and then management.

-When did it happen? -How did it happen?

-What were you doing at that time?...-how much blood have you lost?-Are you passing any clots?-How much sanitry pads have you changed?-What is the color of bleeding?-Are you running any temperature?-Any tummy pain?-Are you feeling the kicks of the baby?-Do you have any bleeding disorder?-Any hx of trauma or instrumentation?-Are you taking any medication?

-SYMPTOMS of Anemia:-are you feeling weak and dizzy?-Is you heart racing?-Are

passing normal amount of urine?

MANAGEMENT:-Well my dear we were worried about two serious conditions that can

present like this,1-when afterbirth is abnormally placed and second when afterbirth is detached from the womb wall.However, from what you are telling me and USG scan shows that you have neither of this condition.This is normal bleeding that can be in normal

pregnancy.we wnant to keep you underobservation for further bleeding and to do some blood test to know how much blood have you lost and for this we need to admit you.HOW IS MY BABY:-My dear as you are feeling the kicks of your baby,hopefully your baby will be fine however we will connect you with CTG machine to check the baby heart beat.CAN I HAVE TERM BABY:-If there is no sever bleeding and your baby is growing well you can have term baby and normal delivery.Anyother concern?Thank you very much

AMENORRHEA:

-How long have been having no periods? -When was your last menstural period?

-Is there any chance that you could be pregnant?

-Were your periods regular before that?...-What was the length of your cycle? -After how many days did they repeat?

-Do you bleed outside of your cycle? -Do you bleed after sex?

-Do you feel pain during mensturation?start/throughout the mensturation? -At what age did you have your first period?

-When was your first sexuall encounter?risk -Are you on any contraception?

-Are you sexually active?Do you feel pain and vaginal dryness? -When was your last cervical smear?result?

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-Have you ever done any gynaecological procedure or operation? -Do you have childrens?

ASSOCIATED SYMPTOMS:

-Are you having any hot flushes,palpitations,night sweats and mood swings? -Do you feel depress and low?

-Are you having difficulty sleeping?

-Does the heat and cold bothers you as it does not bothers other people?

-Have you gained weight and noticed any skin changes(oily,greasy and facial hair growth)? -Have you lost weight recently?

-Are you doing any excessive exercise?

-How much do you eat food on an average day?

-Have you noticed any headache,visual change or milky discharge from your nipple?

-Have you ever been pregnent before?what was the outcome/Any history of miscarriage,any procedure down below and excessive bleeding?

RISK FACTORS:

-Any family history of early menopause before the age of 45. -Any parental hx of hip fracture?

-Do you have any medical condition?

-Are you taking any regular,Otc or herbal medication?specially steroids?

SOCIAL HISTORY:

-Employment:Ask about workplace stress -Housing

-Smoking -Alcohol -Drug of abuse

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JAUNDICE:

IN EXAM JAUNDICE+LFTs are given in the exam so try figure out the major causes according to the LFTs.

ALT is raised=viral hepatitist...

GGT is raised=Alcohlic hepatitisALP is raised=billiary obstructionSometime ALT and GGT are raised so you are not sure what it is.So at the end of hx you have to explain and council the pt for viral serology to make a

clear dx.

-Common differentials Hepatitis (A, B or C)

Viral infections including CMV, EBV Alcoholic hepatitis

Drug induced hepatitis Malaria

Hepatopancreatobiliary tumour

PRESENTING COMPLAINTS:

Did your skin or the eyes’ white areas turn yellow or red?.. o When did you notice that your skin becoming yellow? o How did it start?all of a sudden or gradually?

o Is it becoming worse or improving since started? o Any excerbating and releiving factors?

o Is it contineous or intermittent? o Are you running any temperature? o Wt loss?

o Do you feel sick? o Any sore throat?

o Any joint and muscle pain? o Any abdominal pain? o Any flank fullness?

o Change in color of urine and stool?

o Have you been recently in contact with a person with jaundice?

RISK FACTOR

TRAVEL HISTORY:(Hep A) o Hx of eating out?

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o Have you ever had blood transfusion specially abroad? o Malarial prophylaxis in case of endemic areas?

SEXUAL HX

o Are you sexually active? o Is your partner male or female? o Is your partner stable or unstable? o Do you practce safe sex?use condoms?

o How many sex partner do you have in previous 3 months? o Any sex partner known iv drug abuser?

o Do you use any recreational drud by injection?

Drug HX:

o Are you using any regular medication specially drus for TB and epilepsy? o Any recent hx of paracetamol overdose?

o Allergy to any medication?

Social Hx:

o Drink alcohol?Type?How much? o Occupation

o Housing and employment o smoking

PAST MEDICAL HX:

o Has this happened before?

o Have you ever been dx with TB and Chronic liver disease. o Any recent surgery under general anesthesia?

FAMILY HX:

o Any family hx of CLD and liver disease and hepatitis.

DX=Viral Hepatitis

If ALT and GGT both are raised and question says that council the pt tell pt at that as we are not clear at the moment that what is the actual cause.you are consuming moderate amount of alcohol.so to know about exact cause we need to do another blood test to check either this is viral hepatitis or not?

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CONTRACEPTION:

I know about two scenario about contraception.one i got in the exam and other my friend got in the exam.

1-suitable contraception advice in 28 year old lady with history of DVT.(it is not mentioned in the question she will tell you only if you ask her the medical condition and she is on warfarin).

2-forty year old lady,smoker and has two children looking for contraception.

Guys no need to diliver a lecture on all types of contraception methoeds,discuss only those options that are suitable for her because topic of contraception is so lengthy that you cant talk about all option.If you will try to do this, you will run out of time only at 2nd or 3rd type or you will have to make a speech like a robot which is not good at all.

HOW TO APPROACH THE STATION;

-First ask few question to assess that about which option you have to talk. 1-What do you already know about contraception?

2-Do you have any specific concern or question??

NOW ask question about sexual,menstural and medical hx before discussing about contraception.

1-Sexual Hx:

-Are you currently sexually active? -Are you in a longterm relationship?

-Are you using any form of contraception?reson for discontinuation? -Have you or your partner ever been diagnosed with STI?Successfully treated or not?

2-Menstural Hx: -When was your LMP? -Do you have regular periods?

-Any pain or bleeding outside of your bleeding? -Any chance you could be pregnent?

-Have you given birth to any child recently? 3-Medical and medication Hx:

-Do you have any medical condition e,g high BP,Migrins,blood clots,liver disease, epilepsy?Any family Hx of Clots,cancer

-Are you on any medication? -Do you smoke?

-What is your weight and height? -And you are 28 year old?right?

SUITABLE CONTRACEPTION IN A PT WITH DVT;

1-POP 2-Mirena coil 3-Sterilization.

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POP:

-My dear,first option that suits you is called PROGESTRON ONLY PILLS,some people call it mini pills and it contains synthetic hormone,similar to progestron which is produced by your bady.

-It works by two methods 1-it thickens the mucus at the neck of the womb and make it difficult for sperm to reach the egg, 2ndly,it makes the lining of the womb thinner,so make it less likely for a fertilised egg,from implanting in the womb.

-You start taking pills from 1-5 day of your cycle and continue taking 1 tablet everyday.It is very important that you need to take medication everyday on the same time otherwise its efficacy is reduced and won’t protect you properly.

-If taken regularly,it is very effective almost 99%

-However,it does not protect you from STI.you need to use condom to prevent STI. -Advantage of this contraception is that it makes your period lighter and painless. It also decreases the risk of ovarian and endometrial carcinoma. It carries less risk of having clots as compared to other contraception that contains estrogen hormone.

-Disadvantage of these pills is that it can cause bloating, headache and wt gain. It also slightly increase the risk of breast and cervical cancer.

-Do you have any question?

MIRENA:

-2nd option is a mirena coil, is a small T shaped plastic device that is inserted into your womb through your front passage. It also contains the synthetic progesterone hormone and acts by the same method as pop. it is also very effective almost 99%.

-The advantage of mirena coil is that you need not to worry about taking any pills or injection. it'll last for 5 years. If you have heavy periods and looking for long term

contraception, this best option for you as it also makes period lighter .It is very easy to insert almost in 5 minutes.

-The disadvantage is that it may cause short term cramping pain after we put it also at the beginning some women experience heavy periods. It can also cause headache and breast tenderness.

-Do you have any question?

Sterilisation:

-If you have completed your family and want permanent protection from pregnancy you can have sterilisation. Its a surgical procedure in which the tube that brings egg to the womb will be blocked by ligation.

-However the disadvantage of procedure is that it is almost irreversible and NHS does not fund for reversal of procedure.

-Do you have any question? Thank you very much Guys this station ends here

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2ND SCENARIO: -Suitable contraception 1-pop 2-Depot injection/Implants 3-Mirena 4-Sterilization

whole station will be same but you need to talk about briefly about injections and implants -Progestron injections repeated every 3 to 4 months and have the same mode of action as pop and the same side effects.

-One important thing that I need to mention is that if you wish to get pregnent and stop taking injection,It takes almost 6 months to reverse your firtility.

-Implants also contains progestron in a small plastic tube that is inserted under the skin.easy to insert and easy to remove and can protect you upto 3 years.

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OCCUPATIONAL Needle Stick Injury:

-In this scenario a nurse pricked herself while taking blood from an unconcious pt.

HOW TO APPROACH THE STATION:

-Take the incident detail as I described earlier but skip few questions which in this case obviously this incident has happened in the hospital....-The important question to ask why pt was admitted(what was the complaint).-dx is not confirmed but suspician of meningitis.-Also ask about previous plus recent invstigations of pt and also any significant hx that increases the risk of blood born viral infections.-Hospital based NSI are not tetnus pron so no need to talk about it.-Ask the pt when was your hep B vaccine booster?-Ask pt concerns?-She is worried about meningitis infection?-Tell her that we will consult the microbilogist consultant if it is meningitis l,He will prescribe you PEP antibiotics-Also take permission to take blood to check anti-Hbs antibody titer.-Tell her if anti-Hbs titer is less than 10micro liter give the her ig,if between 10 to 100 give her booster dose.-Take informed consent to check for anti-Hcv and HIV.(as you cant check the pt anti-Hcv ,HIV without informed consent).-Tell her that we will fill the incident report form and refer you to occupational health department.-Tell her though the chances of pt having HIV are less and you have done a great job by squeezing and washing the wound,there are still risk of having HIV is there.There is medication for post exposure prophylaxis in this case.The best time to start this medication is within 1 hour of injury but can be taken within 72 hrs and for 28 days.This medication can cause quite serious side effeccts e,g liver and kidney damage.-Its your choice if you want to start it.-any other concer?-thank you very much

Note: anti Hbs is less than 10ug/ml she needs immunoglobulin and if more the vac booster:)

if below 10 than Ig and booster if between 10 - 100.if more than 100 than no need to give anything.

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INFERTILITY:

At this station you have to take hx of female as well as her partner.

While you are taking history plz take detail hx of menstural cycle and gynaecological history.

History Taking:

...

-How long have you been try to get pregnant?

Sexual Hx:

-Are you in a stable relationship?

-Are you practicing regular unprotected intercourse? -How often?

-Do you know about your fertile days? -Are you satisfied with your relationship? -Do you feel pain while having sex? -Do you bleed after having sex? -Any discharge hx down below? -Are you on any contraception?

MENSTURAL HX:

-Do you have regular periods? -What is your cycle length? -Do you pass any clots?flooding?

-Do you feel pain during mensturation?at start or throughout the mensturation? -Do you bleed outside of your normal cycle?

-When was your last cervical smear test.

-Have you get pregnant ever before?What was the outcome?Any history of excessive bleeding or instrumentation down below?

-Have you noticed any change of hair growth pattern specially on the face and weight gain? -Any milky discharge from the nipples.

-Do you feel hotflushes,palpitation and night sweats.

-Does the heat and cold bothers you as it does not bother other people. -Any FH of Infirtility,early menopause before age of 45.

-Do you have any medical condition or on any medication?

Now lets talk about your partner:

-What is the age of your partner? -What is his occupation?

-Does he smok?drink alcohol/ -any stress in his life?

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children from his previous relationship? -Has he suffered from STI or mumps recently? -What type of cloths he likes to wear?

-Any family history of infertility on your partner side? Dds in exam:PCO/asherman syndrom/sheehan syndrom Thank you vey much.

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GMC Do not

 Say ‘Everything you tell me will be kept confidential’

patients can assume that doctors will keep details of the consultation confidential. You therefore do not need to say this, and indeed it could sound odd to a patient.

 Say ‘May I ask you a personal question?’

Signposting when you are changing the line of questioning can sometimes be helpful; for example when moving from asking about symptoms to lifestyle habits. ‘I’d like to ask you about lifestyle habits’.

 Say ‘May I ask you some questions?’; ‘Is that OK?’.

As in real life, you can assume that patients (unless detained under the Mental Health Act) have sought the consultation with you. They will expect a doctor to ask questions and they will generally wish to be cooperative. In routine

consultations expressions such as ‘May I ask you some questions?’ or adding ‘Is that OK?’ to statements can sound odd coming from a doctor.

It is however appropriate when examining a patient to say ‘I would like to examine you, is that OK?’ to check implied consent before proceeding.

 Refer the patient to the internet.

The stations are designed to within the capability of a doctor at the level of the beginning of Foundation Year 2 in the UK, and the examiners want to hear what your advice is. There will not be any circumstances under which this is an

appropriate response. Similarly, be wary of telling patients that you will discuss with a senior colleague. You will not gain any marks if this is not an appropriate response.

 "How may I address you?"

This is likely to sound strange and it would be more natural to say something like "What would you like me to call you?"

Prefix the given, or forename with a title. For example, if your patient's name is 'John Smith' and he has agreed that you should call him John, it would not be considered normal to address him as Mr John

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 Over-simplify names for parts of the body.

Most patients will know the commonly-used names for parts of the body, so there is no need to over-simplify, unless you think the patient has not

understood. For example, it would be reasonable to expect most people to know the terms 'bladder', 'ovary' and 'vein'. Expressions such as 'water bag', 'egg-producing gland' and 'blood channel' are likely to sound odd. If you doubt that the patient has understood what you are saying, check.

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UNCONCIOUS PATIENT EXAMINATION:

-IN This station it is crucial to calculate GCS accurately.

-The difference in real life and examination is that you have to give instruction to the dear simulator which means that you are requesting him to give you findings smile emoticon -Pt will not show any response on insufficient painfull stimuli.PLEASE apply painful

stimulus on the nailbed of pt untill he shows response by moving his arm(might be withdrawl or localization of pain)

-While applying painful stimulus look at the eyes of pt(sometime pt opens eye and close it immidiately.If you miss that thing your GCS calculation will be wrong.

-GCS chatrt is available in the exam.Dont worry about it.the most important thing is that you interpret it accurately.

-Eye opening response is easy to calculta(that would be 2 or 3 on verbal command or on painful stimuli) ppl make mistakes in calculation of verbal and motor respnse.So,I am going to explain these two component.

VERBAL RESPONSE:

-If answers you accurately regarding time place and person then score is 5

-If you ask the pt time,place and person(time morning instead of evening,home instead of hospital,some other name other than than his own).It is confused conversation....score is 4 -If pt is randomly speaking any words that does not make any sense e,g car,sky,school etc then it is counted as inappropriate words and score is 3.

-If pt is just mumbling,it is counted as incomprehensible sounds and score is 2.

MOTOR RESPONSE:

-If obey command...score is 6

-If try to push your hand away from painful stimulus with his other hand,it is localization of pain and scor is 5

-If flex his that arm where you applied the pain,it is withdrawl and score is 4 -If flex his both arms, it is abnormal flexion and score is 3

-If extend his both arms(moving backward),it is abnormal extension and score is 2.

HOW TO APPROACH THE STATION.

-After greeting the examiner look silently to the pt and check either eyes are open or not.If not than say

-Hello are you ok?If noresponse...Tap on both the shoulder gently and ask again are you ok?No response

-Now introduce yourself and tell the pt I am here to examine you. -can you plz open your eyes?

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-Can you plz tell me where you are? -Can you plz tell me what time is now?

-Can you plz raise your arm,leg,take your tongue out?

Now i am going to apply some pain on your finger plz bear with me(Apply pain on index finger only and look at the face of pt for eye response if pt has not opened on verbal command.No need to give pain above the eye.Learn to calculate GCS with sigle painful stimuli.

-CALCULATE YOUR GCS AND TELL THE EXAMINER LIKE THIS:

-Best eye opening response is on painful stimuli that is 2 -Best verbal response is incomprehensible sounds that is 2 -Best motor response is withdrawl from the pain that is 4 -So,the GCS of my pt is 8.

NOW DO THE NEUROLOGICAL EXAMINATION OF BOTH UPPER AND LOWER LIMBS.

I need full exposure for the purpose of examination. I will maintain the privacy of my pt and request for chapron.(assume)

1-Bulk..pt is actually not exposed so say I'll look for muscle bulk and check it with measuring tape.

2-Tone...instruction to the pt...I am going to check some tone in your joints plz let them floppy...move the joint actively in normal direction of joints.(usually in exam there is hypotonia in upper limb and hyper tonia in lower limbs.

3-Reflexes..usually in exam hyporeflexia in upper limbs and hyer reflexia in lower limbs. 4-Ask for orange stick to check the planter and torch to check the pupillary reflex.

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PRIMARY SURVEY:

-Tell the examner i am gowned and gloved and trauma team is with me. -Proceed the pt silently with both hands in ATLS manner.

-In exam collar is already applied,tell the examiner that collar has been placed,I would like to do triple immobilization.

-Now introduce yourself and ask for the pt identity.Are you OK?

-Guys pt is concious and talking and not in any distress plz use your common sense, no need to give oxygen.

-Ask my assisstant to connect pt with all the monitor(BP,Pulse and cardiac monitor)I will also ask him to do primary series of Xrays(neck,ches,pelvis)

AIRWAY:

-Ask the pt to open his mouth and look for any FB or loose denture. “Mr./Ms.., Where are you now?…What day of the week is today?” To the examiner “Patient is alert, oriented, speaking, no noisy breathing, airway is patent.

-If collar is applied no need to open it and check for tracheal deviation,as pt is not in any distress and breathing normally.Just mention as my pt is not in any distress so I assume his trachea is central.

BREATHING:

-Tell the pt that for the purpose of examination you need full exposure,I'll maintain your privacy.examiner says at this point assume you have full exposure.

-Now whatever you are going to do verbalise loudly.

-On inspection of chest I'll look for any chest asymmetry,swelling,bruise,open wound and flail chest.

-Ask the pt if he has pain anywhere in chest as I am going to feel your chest. -On palpation I cannot appreciate any crepitus, flail segments,

sucking wounds or subcutaneous emphysema.

-I am going to tap on your chest plz bear with me(by comparison on both sides) -I canot appreciate any hyper resonance or dull not on percussion.

-tell the pt that I am going to listen your chest plz breath in and out when i say. -Air entry is bilateral equal,I cannot appreciate any wheez,stridor or crepts.

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CIRCULATION:

-i cannot appreciate any blood on the cloths and bed of the pt.

-I would like to check the vitals of pt(at this point examiner will show you vitals) -Tell the pt that Iam going to feel your hands and feet(to check signs of shock...cold periphres.

-If hypotesion and tachcardia resussitate the pt.

-1) “I want 2 wide pore gauge 14-16 IV lines established, please. 2) Start Normal Saline/ Ringer Lactate, one liter on each at 125-1000 ml/h each (choose according to the patient’s BP).

3) Take a blood sample and send for: - Blood group, Rh and cross-match,

- CBC, Lytes, (ABGs, CK-MB, Tropinin) if respiratory/cardiac case - Liver function test (ALT, AST, ALP, and amylase),

- Renal function tests (BUN, Cr), - Coagulation profile (INR/PTT), - Rapid bedside Blood sugar, - Toxicology screen

ABDOMEN:

-On inspection I'll look for bruising,swelling and distension.

-Tell the pt that I am going to feel your tummy.Do you have pain anywhre in your tummy? -Do superficial palpation and look at the face of pt.

-I can't appreciate any rigidity,tenderness and gaurdning

-Tell pt I am going to listen your tummy.(bowel sounds)which are positive.

PELVIS:

-In exam findings are in pelvis.

-On inspection of pelvis i'll look for perineal bruising,meatal bleeding and scrotal hematoma. -Tell the pt I am going to feel your hip,Do you have pain in your Hip.Pt replies i have taken painkiller.so,touch the pelvis with great care and look at the face of pt.

-Pelvic tenderness is positive,my most probable dx is Pelvic fracture

"I'll apply the pelvic strap and refer the pt to the orthopedic team(no need to say i'll resussitae or pelvic xray as you have resussitated pt earlier and sent pelvic xray with primary series of xray)

LEGS:

-I can't appreciate any bleeding,bruising,swelling or deformity in legs. -Palpate the legs and pulse in feet(dorsalis pedis and post tibial) Are you ok?

-Cover the pt to prevent hypothermia.

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DRUG ABUSE HISTORY TAKING AND RISK ASSESSMENT:

This station comes only as History taking and this pt reffered to psychiatric department as he has intention to quite the drug.

Greet the patient and appreciate his intension.Take permission(I Understand that you are taking a recreational drug.Is that right? I am here to ask some question regarding this.Is it ok with you?and just to reassure you whatever you tell me is confidential within the boundries of team taking care of you....

Which drug are you taking?

Is this the only drug or you using anyother drug also? How long are you using this drug?

How do you use this drug?(route e,g by injection or sniffing) Where do you take this drug mostly?(home,street,pub) With home do you take this drug?(friends)

Do you share the needle with your friend? How often do you use this drug?

ASSESS THE DRUG DEPENDENCE:

What happens if you do not take the drug for a day or two?

Do you think that you need to take more amout of drug to get the same effect than you used to?

Do you get anxious or irritable if you do not take drug? Do you feel compulsion to take the drug?

Have your ever thought to cut down on the amount of drug you are taking? Do you get annoyed when other people comment on regarding drug intake? Do you feel guilty the way you are using drug?

RISKS FOR DRUG ABUSE:

Is there anything in life that you think has forced you to take this drug? Are you single or in relationship?

Are you working or unemployed?

Have you ever visited any mental health clinic? Do you have any physical problem?

Do you drink alcohol?

Are you taking any medication?

Any family hx of drug abuse,depression,divorce and alcohol abuse?

MOOD,INSIGHT,SUICIDE,PSYCHOSIS QUESTIONS:

Do you feel depress and low?

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Any change in your appetite,sleep and concentration level? How do you see your future?

Have you ever tried to take your life?Any plans?

Have you ever tried to harm anyother person?any plans?

Are you sensing the things which other people think that they are not real?(it covers all type of hallucinations e,g tactile auditory and visual)

How has this been affecting you,your job and relationship and how are you coping? Have you ever tried to to stop drinking?if yes then ask

why it was unsuccesful?

DONT FORGET TO ASK ABOUT SOCIAL HX:

Whom do you live with?

Do you have any dependent children?(they are at risk) Take sexual hx to assess the risk of having HIV. Thank the pt

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NON OCCUPATIONAL NEEDLE STICK INJURY:

-Community acquired NSI specially in children are a cause of significant parental anxiety. -At this station pt has concern about needle acquired infection(Hep B,C,HIV) and generalised infection.

-First take the detail of incident

-INCIDENT DETAIL;

1-When did it happen? 2-Where did it happen?

3-What were you doing when it happened? 4-What is the site of injury on your body?

5-Do you have any idea what could be the source of needle(The person who used the needle) 6-What kind of needle was it?sewing or injection needle?

7-Was it superfecial or deep wound?

8-Have you noticed any blood on the needle? 9-What,if any,first aid has been provided?

10-Immunisation history(specifically tetnus and hepatits B)

(IN THIS CASE THERE COULD BE A MOM WHOSE CHILD GOT NSI WHILE PLAYING IN THE PARK OR IT COULD BE AN ADULT)

-Now ask the pt do you have any specific concern? -Pt shows concern about Hep B,C,HIV,tetnus

-If pt is child and immunised against Hep B and tetnus reassure the mother that for the bug that causes Hepatitis and HIV cant survive outside the body and secondly your child immunisation staus is up to date.It is highly unlikely that your child can contract these infection.

-If pt insists than offer blood test to check HBV and HIV(tell the pt that we will take blood and check it now and after 3 months(serum gel to store) and then we can tell you the result of blood test as this bug can take almost 6 to 8 weeks to appear in blood.

-No need to offer PEP to community acquired NSI untill unless it is high risk(1.source known to be infected with a blood born virus.2.NSI from deliberate assault.3,deep large volume injection with hollow bore needle.4.personal hx of injecting drug use) or pt is non immunised.

-Other concern that pt shows that will you give me antibiotics?

-Needle might be contaminated so there could be chance of infection,thats why pt ask for antibiotics.

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-Ask the pt generally we give antibiotics to the pt who have signs of infection.Let me check if you have redness,swelling or any discharge from injury site/no

-Tell the pt you dont need any antibiotic as we want prescribe antibiotic un necssarily as it can cause resistence which means that antibiotic wont work if you need them in future. -This is the all story if pt immunisation is up to date.

WHEN YOU GIVE PEP IF PT SAYS TETNUS

-My tetnus booster was given >5 years than give booster dose.If < than 5 year no need to give booster.

-If not immunised at all give immunoglobulin as well as vaccine and refer pt for full course of tetnus vaccination.

HEP B:

-If vaccinated against hep B is up to date.no need to give any tx pt will recive vaccine booster on time.

-If not vaccinated;give immunoglobulin and 1st dose of vaccine and than reffer to the GP for further routine vaccination course.

Note: booster is repeated normally after 10 years.but if there occurs tetnus pron injury you

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ALCOHOLIC FOOT EXAMINATION(SENSORY AND REFLEXES)

-Guys at this station dont do any inspection as the task clearly ask you to do only sensory and reflexes not the routine examination.

-Be very gentle with pt and dont rush him/her

-Give the clear instructions to the pt before performing each step.

-In alcoholic neuropathy neurological deficit occur in gloves and stocking pattern.So,start

your examination from distal to proximal(do not follow the dermatoms)

-1. Light touch: S Posterior column and spinothalamic tract function.

Use cotton or a tip of a tissue to touch skin. -Instructions to pt:

“Mr/Ms ..,I’m going to feel your skin with this cotton on several

points of your feet and legs. I want you to say ‘yes’ when you feel it just like this(touch on sternum of pt), okay.. Let us start, close your eyes. ” To the examiner “Light touch lost below the knee.

TIP:Never ask the patient if he/she is feeling the touch every time you touch the skin so he wont know if you are touching or not Start with toes.If intact, stop.If not, move proximal.

2. Pain: S Spinothalamic tract function

. Ask the patient to identify

sensation of pain by touching his sternum.(in exam it is clearly mentioned use only blunt side,so plz dont use sharp side.

“Mr/Ms .., now, I’m going to feel your skin with this paper pin. Again, say ‘yes’ when you feel it and tell me if it is dull or sharp sensation, close your eyes. ”

To the examiner “Pain sensation is lost below the knee.”

-Very important to check sole of the foot with monofilamens at least at 5 points shown in the fig below.

3. Vibration: Posterior column function / Peripheral neuropathy.

Struck the 128 Hz tuning fork and place it on the DIP joint. Ask the patient to tell you when the vibration stops. Check the other side and both lower limbs. If it is impaired move up on bony prominences.

“Mr/Ms ..,now, I’m going to place this tuning fork on your feet and then on legs. Tell me when you feel buzzing and also when it stops, close your eyes…(Also validate the sensation by touching it on the sternum)

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4. Proprioception: S (Joint Position Sense) Posterior column function.

Hold the patient’s big toe from the sides. Begin with the joint at neutral then move it up or down and ask the patient to tell you the direction. Return to neutral position before starting again. S big toes only. “Mr/Ms ..,now, I’m going to move your right big toe up or

down. Tell me if I’m moving it up or down, close your eyes… now the other foot… .”

To the examiner “Proprioception sensation is normal/lost below knee etc

REFLEXES:

Achilles tendon reflex (Ankle jerk) S1 - 2: - Dorsiflex the foot then strike the tendon.

- Look for calf muscles contraction followed by planter flexion of the foot at the ankle.

“Mr/Ms .., now your ankle. …. (Set the foot, strike, and watch twice). Now the other one….”

To the examiner “Achilles tendon reflex is normal & symmetrical/ diminished/ increased.

(58)

PEAK FLOW METER:

This is another common and easy station that ppl fail a lot.

EXPLANATION:

o Hello I am here to explain this device called peak flow meter to check how well do you breath out called peak expiratory flow rate or PEFR,to get an idea how well controlled your asthma is at this time.

o You need to check your PEFR regularly, particularly if YOUR asthma is worse than usual. o Explain that the PEFR meier is to be used first thing in the morning and at any time you have symptoms of asthma

o Attach a clean mouthpiece to the meier.

o Slide the marker 10 the bottom of the numbered scale. o Stand or sit up straight.

o Hold the peak flow meter horizontal, keeping his fingers away from the marker. o Take as deep a breath as possible and hold it.

o Insert the mouthpiece into his mouth, sealing his lips around the mouthpiece. o Exhale as hard as possible inlo the meter.

o Read and record the meter reading.

o Repeat the procedure three to six times, keeping only the highest score. o Check this score against the peak flow chart or his previous readings. o Check the patient's understanding by asking him to carry out the procedure. o Ask him if he has any questions or concerns

TIP: people fail this station because when they ask the simulator to demonstrate the

procedure, pt breath out shallow and marker moves slightly. Candidate becomes happy that at least this station is pass but actually fail because Candidate could not convey the correct method to check the PEFR. Ask the pt to repeat and breathe out as hard as he can and as fast as he can untill he performs it correctly and marker moves swiftly