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

Inspect perianal skin 4. Touch perianal area 5. Insert finger posteriorly 6. Sphincter tone assessment (squeeze finger) 7. Feel all sides of rectum 8. Prostate (felt anteriorly, feel all margins) 9. Remove finger slowly 10. Inspect for blood, mucus, faeces FNA C Fine needle aspiration of breast tissue for cytology (not histology this can only be achieved with excision of whole lump). Fat, fluid and cells aspirated into syringe Performed as part of triple assessment (clinical exam, FNAC and imaging) Scored either: C1 C2 C3 C4 C5 unsatisfactory sample benign probably benign probably malignant definitely malignant

If inconclusive core biopsy necessary to assess histology Urinalysis 1. Explain how to take a mid-stream urine sample (MSU) a. Avoid touching inside of pot to maintain sterility b. Dont want start or end of stream 2. Gloves 3. Inspect + smell a. Dark dehydration, jaundice, faeces b. Cloudy/smelly infection (usually smell of ammonia) c. Pink/red blood d. Frothy protein e. Stones f. Debris g. Crystals h. Stones i. Bubbly/smelly/faecal colo-vesicular fistula 4. Dipstick urine a. Check dipstick label expiry date b. Dip c. Shake off excess

5. Wait given time (usually 60s) 6. Read (making sure to have stick up the right way) a. Leu Leucocytes b. Nit Nitrites c. Pro Protein d. PH e. Bld-Sng-Ery-Hb Blood and Hb a. b. c. d. f. SG g. Glu h. Ket Specific gravity Glucose Ketones

Infection, Cancer Infection Nephrotic syndrome, glom-nephritis, infection, Pre-renal haemolytic anaemias (sickle cell) Renal Stones, infection, nephritis, cancer Ureteric cancer (transitional cell carcinoma) Cystic UTI Urethral - STD Changes with dehydration and ARF Diabetes (glucose above threshold for tub trans) DKA, Starvation

Capillary blood glucose measurement (explain) 1. 2. 3. 4. 5. 6. Why do it? Need to monitor glucose levels Small prick into the side of the thumb (shouldnt be painful) Squeeze thumb to draw a small spot of blood Blot onto the white disc at the end of the strip, not too much Insert the disc into the machine Reading within 30s

Injection technique Reconstituting drugs 1. Check label 2. Peel top off bottle 3. Take up correct vol of sterile water 4. ? I/M (slow) 1. Name of patient 2. Consent 3. Equipment + check drug 4. Site choice for volume of drug 5. Gloves and aseptic technique 6. Alcohol 7. Pull skin taught 8. Insert 9. Aspirate 10. Advance 11. Pause for 10s 12. Remove needle 13. Release tension on skin

- needle size green < blue < pink < orange deltoid (0.5-1.0ml), gluteus (<4ml) 30s wiping, 30s drying - 90deg into into muscle - blood vessel? - 10s per ml - so drug doesnt squirt back out when needle removed - Z-track technique, seals wound

S/C 1. As above 2. Pinch skin 3. Insert at 45deg (unless short needle e.g. insulin)

Blood pressure 1. Prepare (Introduce, explain procedure, consent, position arm) 2. Size cuff a. Width should be ~ half circumference of arm b. Length of bladder should be correct 3. Apply cuff with arterial marker (point of entry of tubes) over brachial artery 4. Palpate radial pulse a. Assess systolic pressure inflate slightly above, then release slowly to assess accurately b. This is required as auscultatory gap may be present resulting in misreading of BP 5. Deflate cuff 6. Re-inflate to 30mmHg above palpable systolic pressure 7. Ausculate whilst deflating slowly a. Systolic = once 2 pulse sounds have been heard (Phase II) b. Diastolic = when sounds disappear (phase V) Venepuncture 1. Introduce, explain procedure, consent, expose and comfort 2. Equipment gloves, touniquet, alcohol wipe, needle, syringe(s), cotton wool, plaster 3. Apply tourniquet and choose vein 4. Release tourniquet until ready 5. Alcohol wipe for 30s, dry for 30s 6. Reapply tournquet 7. Vacuum synringe (pull out plunger until it clicks and then snap) 8. Insert needle bevel up 9. Attach vacuumed syringe(s) (acts like vacutainer) 10. Release tourniquet once blood draining 11. Retract needle with cotton wool in place 12. Plaster Setting up IV infusion Cannula 1. Questions a. Consent b. Medications c. Latex allergy d. Mastectomy, stroke (canulate opposite arm to avoid causing swelling) 2. Gloves 3. Tourniquet 4. Choose vein (bouncy) 5. Release tourniquet 6. Alcohol 30s then allow to dry (sterilisation occurs during drying) 7. Prepare cannula remove from packaging, fold out wings, remove bung (place back in packet) 8. Tourniquet 9. Venepuncture 10. Advance1mm after flashback (whole apparatus) 11. Further advance tubing whilst stabilising needle

12. Release tourniquet 13. Apply proximal pressure on vein to stem blood flow 14. Remove needle 15. Bung 16. Flush (10ml normal saline) push-pause technique for max cleaning 17. Dressing Fluids 18. Open fluid, break off tag 19. Open giving set 20. Close rate controller 21. Connect giving set to fluid bag insert needle right up to bevel 22. Hang bag up 23. Prime run fluid right through tube 24. Connect to cannula 25. Set flow rate (count drops per min) For rehydration, transfusion, drug admin NGT insertion 1. 2. 3. 4. 5. 6. 7. Inform (tube through nose into stomach), consent Measure tube (nose to ear lobe, ear lobe to xiphisternum) record measurement Lubricate the end 6cm with jelly (for models) or water (humans) and gauze Advance down and back (not up) through nostril Ask patient to swallow when in the pharynx Tape to secure Confirm positioning a. Aspirate stomach contents with syringe check pH with litmus paper b. Ask patient to talk if in trachea it would elicit cough c. CXR

Urinary catheterisation 1. Introduce, explain, consent 2. Equipment a. Sterile gloves b. Inco pad c. Washing fluid (saline) d. Catheterisation pack (sterile washing kit) e. Syringe and Instillagel (lubricant, anaesthetic, antiseptic) f. Catheter g. Sterile water and syringe to inflate balloon h. Catheter bag 3. Expose (umbilicus to knees) 4. Inco pad 5. Foreskin retraction 6. Wash penis with gauze and saline (3x starting at urethra) 7. Open sterile kit 8. Gloves

9. Sterile field fold sheet in 4 and tear corner penis through middle 10. Warn that gel may sting 11. Anaesthetic gel - apply blob of gel on meatus, insert syringe. 20ml gel in male 12. Insert catheter a. Traction, upwards b. Downwards at point of resistance c. Tray to catch urine! 13. Inflate balloon with sterile water 14. Retract catheter until it stops 15. Catheter bag 16. Foreskin back! document residual volume! ECG Name, date, time Obvious abnormalities? Then Rate Rhythm MI rhythm strip rhythm strip All leads P-waves? Regular or Irregular? Q-wave (except those in aVR and C1! (normal)) (days) ST elevation (hours) Inverted T-wave (years) Where is it? Which leads? Ant (chest) Inf (aVF, II, III) Wide? Rabbits? Where? left (C3-C6) or right (C1-C3)

QRS (BBB) Axis

Chest leads

MI -ve Q-wave (days), ST elevation (acute), inverted T (old) Acute ischaemia ST depression Serious arrhythmias ventricular ectopics before normal beat due, no P-wave, broad complex ventricular tachycardia, no P-waves, broad complex (>3sq), regular ventricular fibrillation chaotic ventricular activity, coarse or fine Atrial fibrillation absent P-waves, irregularly irregular, noisy baseline Chest X-ray interpretation Introduction Adequacy rotation, penetration (intervertebral discs), inspiration sufficient?

Obvious abnormalities? Then Airway Breathing Cardiac Diaphragm Everything else central? lung fields Review areas cardiothoracic ratio air underneath? bones Soft tissues

apices, hila, behind heart, angles, pleura (thickening)

Oedema (cardiomegaly, batswings, upper lobe blood diversion, fluid in horizontal fissure, effusion) Pneumothorax (usually apical lung markings dont extend to outside) Pneumonia (unilateral/bilateral, unilobar/multilobar) Bronchiectasis (dilated bronchi) Emphysema (very blackened lung fields +/- bullae) Inhalers 1. 2. 3. 4. 5. 6. 7. 8. What its for Must always carry one on your person and should always have a spare at home Check expiry date Shake before use Big breathe out Breathe in and press button just after you start the breathe Hold breathe for 10s Breathe normally

If you have attack and dont have nebuliser to hand, take 10 puffs of inhaler If patient unable to use standard inhaler, the following alternatives exist: 1. Spacer device plastic reservoir, spray inhaler into tube and then breathe out of it 10 times 2. Inhalers activated by inhalation 3. Nebuliser Examination of the ear 1. Hearing (voice) test sensitive to 30dB deficiency a. Mask one ear by rubbing tragus against bone b. Say number from arms length and get patient to repeat (loud, intermediate & v quiet whisper) 2. Tuning fork tests a. Rinnes tuning fork on mastoid, then parallel to EAM which is louder? i. Normal: air > bone, Conductive: bone > air, Sensorineural: bone > air (other cochlea) b. Webers forehead louder on one side or the same? i. Normal: =, Conducte.: louder on affected side, Sensorl: louder on unaffected side 3. Inspection around and behind ear (scars, swellings) 4. Otoscopy a. Hold like pen b. Little finger always touches patient first!! c. Comment on ear canal (waxy, red, swollen) d. Ear drum (grey, handle of malleus visible) describe any abnormaliy in terms of quadrants Tympanometry For measuring pressure in middle ear Low frequency sound into ear Pressure of reflection measured Measures compliance of ear drum Flat trace effusion (fluid in middle ear) Increased compliance (floppy ear drum) Reduced compliance (thickened, scarred)

Pure tone audiometry (interpret) In sound-proofed booth, headphones, press button when sounds of different frequencies heard Trace is normalised so 0 = normal hearing 3 traces shown air, masked bone conduction, unmasked bone conduction (other cochlea) Conductive reduced air, normal masked / unmasked bone conduction Sensorineural reduced air, reduced masked bone conduction, less reduced unmasked bone conduction Presbycusis / noise trauma high frequency drop-off *ABPI using Doppler (measure of leg ischaemia) 1. Prepare 2. Palpate radial pulse 3. Apply cuff 4. Jelly and probe establish strong signal (angle probe up artery) 5. Inflate cuff until signal stopped 6. Repeat with posterior tibial Express ABPI as ankle pressure / radial pressure Normal = 1 Ischaemia is anything < 0.9 (int claud 0.5-0.95, gangrene <0.2) >1 due to artefact such as calcification of vessels Aortic and lower limb angiography 1. Anatomy a. Aorta (bifurcates at L4) b. Common iliacs c. Internal and external iliacs d. External iliac e. Femoral (upon passing under inguinal ligament) f. Popliteal (upon passing through adductor hiatus) g. Anterior and posterior tibials i. Anterior tibial (1st branch) becomes dorsalis pedis anteriorly ii. Posterior tibial gives off peroneal branch 2. Recognise occlusion, stenosis, collaterals (mesh of tiny wiggly vessels around site of occlusion) Peak flow 1. 2. 3. 4. 5. 6. 7. Sit up straight Set to zero Keep fingers clear of dial Deep breath in Seal lips Hard and fast breath out as though you are blowing out a giant candle - demonstrate Repeat 3 times (take best result)

Express as % of patients best (if known) or predicted according to height and sex >75% - mild/moderate <50% - severe <33% - life threatening Factors affecting result: Height, Age, Sex, Disease Angiography interpretation Catheter inserted into femoral artery after local anaesthetic and passed up to desired location (e.g. coronaries) Contrast medium injected Time series of radiographs taken Stenosis or sights of rupture (leakage) can be visible Angioplasty may be carried out at the same time if indicated History Endocrine Examinations Thyroid Breast Cranial nerves Neck Ear Blood pressure Peripheral vascular Renal Neurological (UMN and LMN lesion) Abdominal CVS Respiratory

Insulin Injection Technique Technique is important in order to get a proper dosage of insulin. A good technique will make your insulin therapy as effective and successful as possible. Injecting at the proper depth is an important part of good injection technique. Most healthcare professionals recommend that insulin be injected in the subcutaneous fat, which is the layer of fat just below the skin. If you inject too deep, the insulin could go into muscle, where it's absorbed faster but might not last so long Most people inject into their thigh Squeeze a couple of inches of skin between your thumb and two fingers, pulling the skin and fat away from the underlying muscle. (If you use a 5 millimeter mini-pen needle to inject, you don't have to pinch up the skin when injecting at a 90 angle; with this shorter needle, you don't have to worry about injecting into muscle.) Insert the needle. Hold the pinch so the needle doesn't go into the muscle. Push the plunger (or button if you're using a pen) to inject the insulin. Release the grip on the skin fold. Remove the needle from the skin.