OSCE Skills Rectal examination 1. Introduce, inform, consent, comfort 2. Gloves 3. Lubricate finger with water-based gel 4.

Inspect perianal skin 5. Touch perianal area 6. Insert finger posteriorly 7. Sphincter tone assessment ( s!"ee#e finger$% &. 'eel all sides of rect"m (. rostate (felt anteriorly, feel all margins% 1). Remove finger slowly 11. *nspect for blood! mucus! "aeces #$% C 'ine needle aspiration of breast tiss"e for cytology (not histology + this can only be achie,ed with e-cision of whole l"mp%. 'at, fl"id and cells aspirated into syringe .erformed as part of triple assessment (clinical e-am, '/01 and imaging% 2cored either3 11 14 13 14 15 "nsatisfactory sample benign probably benign probably malignant definitely malignant

*f inconcl"si,e core biopsy necessary to assess histology &rinal'sis 1. Explain how to take a mid-stream "rine sample (526% a. 0,oid to"ching inside of pot to maintain sterility b. 7on8t want start or end of stream 2. Gloves (. Inspect ) smell a. 7ark dehydration, 9a"ndice, faeces b. 1lo"dy:smelly infection ("s"ally smell of ammonia% c. .ink:red blood d. 'rothy protein e. 2tones f. 7ebris g. 1rystals h. 2tones i. ;"bbly:smelly:faecal colo-,esic"lar fist"la 4. *ipstick "rine a. 1heck dipstick label e-piry date b. 7ip c. 2hake off e-cess

5. +ait gi,en time ("s"ally 6)s% 6. Read (making s"re to ha,e stick "p the right way% a. <e" <e"cocytes b. /it /itrites c. .ro .rotein d. .= e. ;ld-2ng->ry-=b ;lood and =b a. b. c. d. f. 2A g. Al" h. Bet 2pecific gra,ity Al"cose Betones

*nfection, 1ancer *nfection /ephrotic syndrome, glom-nephritis, infection, .re-renal + haemolytic anaemias (sickle cell% ?enal + 2tones, infection, nephritis, cancer 6reteric + cancer (transitional cell carcinoma% 1ystic + 6@* 6rethral - 2@7 1hanges with dehydration and 0?' 7iabetes (gl"cose abo,e threshold for t"b trans% 7B0, 2tar,ation

Capillar' blood ,lucose measurement (e-plain% 1. 4. 3. 4. 5. 6. Chy do itD /eed to monitor gl"cose le,els 2mall prick into the side of the th"mb (sho"ldn8t be painf"l% 2!"ee#e th"mb to draw a small spot of blood ;lot onto the white disc at the end of the strip, not too m"ch *nsert the disc into the machine ?eading within 3)s

In-ection techni.ue Reconstitutin, dru,s 1. 1heck label 4. .eel top off bottle 3. @ake "p correct ,ol of sterile water 4. D *:5 (slow% 1. $ame of patient 2. Consent 3. E.uipment E check dr"g 4. Site choice for ,ol"me of dr"g 5. Gloves and aseptic techni!"e 6. %lcohol 7. ull skin ta"ght &. Insert (. %spirate 1). %dvance 11. ause "or 21s 14. Remove needle 13. Release tension on skin

- needle si#e green F bl"e F pink F orange + deltoid ().5-1.)ml%, gl"te"s (F4ml% + 3)s wiping, 3)s drying / 01de, into into m"scle - blood ,esselD - 1)s per ml - so dr"g doesn8t s!"irt back o"t when needle remo,ed - G-track techni!"e, seals wo"nd

2:1 1. 0s abo,e 4. .inch skin 3. *nsert at 34de, ("nless short needle e.g. ins"lin%

5lood pressure 1. repare (*ntrod"ce, e-plain proced"re, consent, position arm% 4. Si6e c"ff a. Cidth sho"ld be H half circ"mference of arm b. <ength of bladder sho"ld be correct 3. %ppl' cu"" with arterial marker (point of entry of t"bes% o,er brachial artery 4. alpate radial p"lse a. 0ssess systolic press"re + inflate slightly abo,e, then release slowly to assess acc"rately b. @his is re!"ired as a"sc"ltatory gap may be present res"lting in misreading of ;. 4. *e"late cu"" 7. Re/in"late to (1mm8, above palpable s'stolic pressure 7. %usculate whilst deflating slowly a. 2ystolic I once 2 pulse sounds have been heard (.hase **% b. 7iastolic I when sounds disappear (phase J% 9enepuncture 1. Introduce, e-plain proced"re, consent, e-pose and comfort 4. E.uipment + glo,es, to"ni!"et, alcohol wipe, needle, syringe(s%, cotton wool, plaster 3. Apply tourniquet and choose vein 4. ?elease to"rni!"et "ntil ready 5. %lcohol :ipe for 3)s, dry for 3)s 6. ?eapply to"rn!"et 7. 9acuum s'nrin,e (p"ll o"t pl"nger "ntil it clicks and then snap% &. Insert needle be,el "p 0. %ttach vacuumed s'rin,e;s< ;acts like vacutainer< 1). Release tourni.uet once blood draining 11. ?etract needle with cotton wool in place 14. .laster Settin, up I9 in"usion Cannula 1. K"estions a. 1onsent b. 5edications c. <ate- allergy d. 5astectomy, stroke (can"late opposite arm to a,oid ca"sing swelling% 4. Alo,es 3. @o"rni!"et 4. 1hoose ,ein (bo"ncy% 5. ?elease to"rni!"et 6. 0lcohol + 3)s then allow to dry (sterilisation occ"rs d"ring drying% 7. .repare cann"la + remo,e from packaging, fold o"t wings, remo,e b"ng (place back in packet% &. @o"rni!"et (. Jenep"nct"re 1). 0d,ance1mm after flashback (whole apparat"s% 11. '"rther ad,ance t"bing whilst stabilising needle

14. ?elease to"rni!"et 13. 0pply pro-imal press"re on ,ein to stem blood flow 14. ?emo,e needle 15. ;"ng 16. 'l"sh (1)ml normal saline% + p"sh-pa"se techni!"e for ma- cleaning 17. 7ressing Fluids 1&. Lpen fl"id, break off tag 1(. Lpen gi,ing set 4). 1lose rate controller 41. 1onnect gi,ing set to fl"id bag + insert needle right "p to be,el 44. =ang bag "p 43. .rime + r"n fl"id right thro"gh t"be 44. 1onnect to cann"la 45. 2et flow rate (co"nt drops per min% For rehydration, transfusion, drug admin $GT insertion 1. 4. 3. 4. 5. 6. 7. *nform (t"be thro"gh nose into stomach%, consent 5eas"re t"be (nose to ear lobe, ear lobe to -iphistern"m% + record meas"rement <"bricate the end 7cm with 9elly (for models% or water (h"mans% and ga"#e 0d,ance down and back (not "p% thro"gh nostril 0sk patient to s:allo: when in the pharyn@ape to sec"re 1onfirm positioning a. 0spirate stomach contents with syringe + check p= with litm"s paper b. 0sk patient to talk + if in trachea it wo"ld elicit co"gh c. 1M?

&rinar' catheterisation 1. *ntrod"ce, e-plain, consent 4. >!"ipment a. 2terile glo,es b. *nco pad c. Cashing fl"id (saline% d. 1atheterisation pack (sterile washing kit% e. 2yringe and *nstillagel (l"bricant, anaesthetic, antiseptic% f. 1atheter g. 2terile water and syringe to inflate balloon h. 1atheter bag 3. >-pose ("mbilic"s to knees% 4. *nco pad 5. 'oreskin retraction 6. +ash penis with ga"#e and saline (3- starting at "rethra% 7. Lpen sterile kit &. Alo,es

(. Sterile "ield + fold sheet in 4 and tear corner + penis thro"gh middle 1). Carn that gel may sting 11. %naesthetic ,el - apply blob of gel on meat"s, insert syringe. 4)ml gel in male 14. Insert catheter a. Traction, upwards b. ownwards at point of resistance c. @ray to catch "rineN 13. In"late balloon with sterile water 14. ?etract catheter "ntil it stops 24. Catheter ba, 16. #oreskin backN doc"ment residual volumeN ECG /ame, date, time Lb,io"s abnormalitiesD @henO Rate Rh'thm =I rhythm strip rhythm strip 0ll leads .-wa,esD ?eg"lar or *rreg"larD K-wa,e (e!cept those in a"# and C$% &normal'% (days% 2@ ele,ation (ho"rs% *n,erted @-wa,e (years% Chere is itD Chich leadsD 0nt (chest% *nf (aJ', **, ***% CideD ?abbitsD ChereD left (13-16% or right (11-13%

>RS ;555< %xis

1hest leads

5* -,e K-wa,e (days%, 2@ ele,ation (ac"te%, in,erted @ (old% 0c"te ischaemia 2@ depression 2erio"s arrhythmias ventricular ectopics before normal beat d"e, no .-wa,e, broad compleventricular tach'cardia! no .-wa,es, broad comple- (P3s!%, reg"lar ventricular "ibrillation chaotic ,entric"lar acti,ity, coarse or fine 0trial fibrillation absent .-wa,es, irreg"larly irreg"lar, noisy baseline Chest ?/ra' interpretation *ntrod"ction 0de!"acy rotation, penetration (inter,ertebral discs%, inspiration s"fficientD

Lb,io"s abnormalitiesD @henO 0irway ;reathing 1ardiac 7iaphragm >,erything else centralD l"ng fields ?e,iew areas cardiothoracic ratio air "nderneathD bones 2oft tiss"es

apices, hila, behind heart, angles, ple"ra (thickening%

Ledema (cardiomegaly, batswings, "pper lobe blood di,ersion, fl"id in hori#ontal fiss"re, eff"sion% .ne"mothora- ("s"ally apical + l"ng markings don8t e-tend to o"tside% .ne"monia ("nilateral:bilateral, "nilobar:m"ltilobar% ;ronchiectasis (dilated bronchi% >mphysema (,ery blackened l"ng fields E:- b"llae% Inhalers 1. 4. 3. 4. 5. 6. 7. &. Chat it8s for =ust al:a's carr' one on 'our person and sho"ld always have a spare at home 1heck e-piry date Shake before "se ;ig breathe o"t ;reathe in and press b"tton 9"st after yo" start the breathe =old breathe for 1)s ;reathe normally

*f yo" ha,e attack and don8t ha,e neb"liser to hand, take 1) p"ffs of inhaler *f patient "nable to "se standard inhaler, the following alternati,es e-ist3 1. 2pacer de,ice + plastic reser,oir, spray inhaler into t"be and then breathe o"t of it 1) times 4. *nhalers acti,ated by inhalation 3. /eb"liser Examination o" the ear 1. =earing (,oice% test + sensiti,e to 3)d; deficiency a. 5ask one ear by r"bbing trag"s against bone b. 2ay n"mber from arms length and get patient to repeat (lo"d, intermediate Q , !"iet whisper% 4. @"ning fork tests a. ?inne8s + t"ning fork on mastoid, then parallel to >05 + which is lo"derD i. /ormal3 air P bone, 1ond"cti,e3 bone P air, 2ensorine"ral3 bone P air (other cochlea% b. Ceber8s + forehead + lo"der on one side or the sameD i. /ormal3 I, 1ond"ct8e.3 lo"der on affected side, 2ensor8l3 lo"der on "naffected side 3. *nspection + aro"nd and behind ear (scars, swellings% 4. Ltoscopy a. =old like pen b. <ittle finger always to"ches patient firstNN c. 1omment on ear canal (wa-y, red, swollen% d. >ar dr"m (grey, handle of malle"s ,isible% + describe any abnormaliy in terms of !"adrants T'mpanometr' 'or meas"ring press"re in middle ear <ow fre!"ency so"nd into ear .ress"re of reflection meas"red 5eas"res compliance of ear dr"m 'lat trace + eff"sion (fl"id in middle ear% *ncreased compliance (floppy ear dr"m% ?ed"ced compliance (thickened, scarred%

ure tone audiometr' ;interpret< *n so"nd-proofed booth, headphones, press b"tton when so"nds of different fre!"encies heard Trace is normalised so ( ) normal hearing 3 traces shown + air, masked bone cond"ction, "nmasked bone cond"ction (other cochlea% 1ond"cti,e + red"ced air, normal masked : "nmasked bone cond"ction 2ensorine"ral + red"ced air, red"ced masked bone cond"ction, less red"ced "nmasked bone cond"ction *resbycusis + noise trauma +high fre!"ency drop-off @%5 I "sing 7oppler (meas"re of leg ischaemia% 1. .repare 4. .alpate radial p"lse 3. 0pply c"ff 4. Relly and probe + establish strong signal (angle probe "p artery% 5. *nflate c"ff "ntil signal stopped 6. ?epeat with posterior tibial >-press 0;.* as ankle press"re : radial press"re /ormal I 1 *schaemia is anything F ).( (int cla"d ).5-).(5, gangrene F).4% P1 d"e to artefact s"ch as calcification of ,essels %ortic and lo:er limb an,io,raph' 1. 0natomy a. %orta &bifurcates at ,-' b. Common iliacs c. Internal and external iliacs d. External iliac e. #emoral &upon passing under inguinal ligament' f. opliteal &upon passing through adductor hiatus' g. 0nterior and posterior tibials i. 0nterior tibial (1st branch% becomes dorsalis pedis anteriorly ii. .osterior tibial gi,es off peroneal branch 4. ?ecognise occl"sion, stenosis, collaterals (mesh of tiny wiggly ,essels aro"nd site of occl"sion% eak "lo: 1. 4. 3. 4. 5. 6. 7. 2it "p straight 2et to #ero Beep fingers clear of dial 7eep breath in 2eal lips =ard and fast breath o"t as tho"gh yo" are blowing o"t a giant candle$ - demonstrate ?epeat 3 times (take best res"lt%

>-press as S of patient8s best (if known% or predicted according to height and seP75S - mild:moderate F5)S - se,ere F33S - life threatening Factors affecting result. /eight, Age, 0e!, isease %n,io,raph' interpretation 1atheter inserted into femoral artery after local anaesthetic and passed "p to desired location (e.g. coronaries% 1ontrast medi"m in9ected @ime series of radiographs taken 2tenosis or sights of r"pt"re (leakage% can be ,isible 0ngioplasty may be carried o"t at the same time if indicated 8istor' >ndocrine Examinations @hyroid ;reast 1ranial ner,es /eck >ar ;lood press"re .eripheral ,asc"lar ?enal /e"rological (65/ and <5/ lesion% 0bdominal 1J2 ?espiratory

Insulin In-ection Techni.ue @echni!"e is important in order to get a proper dosage of ins"lin. 0 good techni!"e will make yo"r ins"lin therapy as effecti,e and s"ccessf"l as possible. *n9ecting at the proper depth is an important part of good in9ection techni!"e. 5ost healthcare professionals recommend that ins"lin be in9ected in the s"bc"taneo"s fat, which is the layer of fat 9"st below the skin. *f yo" in9ect too deep, the ins"lin co"ld go into m"scle, where itTs absorbed faster b"t might not last so long 5ost people in9ect into their thigh 2!"ee#e a co"ple of inches of skin between yo"r th"mb and two fingers, p"lling the skin and fat away from the "nderlying m"scle. (*f yo" "se a 5 millimeter mini-pen needle to in9ect, yo" donTt ha,e to pinch "p the skin when in9ecting at a ()U angleV with this shorter needle, yo" donTt ha,e to worry abo"t in9ecting into m"scle.% *nsert the needle. =old the pinch so the needle doesnTt go into the m"scle. ."sh the pl"nger (or b"tton if yo"Tre "sing a pen% to in9ect the ins"lin. ?elease the grip on the skin fold. ?emo,e the needle from the skin.