OSCE Management

Asthma

- Medical condition affecting the airways

- Airway narrowing in response to a trigger, with associated increase in mucous
- Symptoms: SOB, wheeze
- Reliever (salbutamol) and a preventer (normally Flixotide which is an ICS)
o Increase ICS to highest dose, and then add a LABA if needed
o Refer is this is still insufficient
- Management (acute attack)
o Salbutamol
o Oxygen
o Hydrocortisone (IV) or prednisolone (PO)
o Ipratropium
o Magnesium sulphate
 Magnesium can relax smooth muscle and hence may cause bronchodilation
by competing with calcium at calcium-mediated smooth muscle ̶ binding
sites
o Theophylline
 ‘Energy saver’ by acting as a smooth muscle relaxant, anti-inflammatory and
increasing diaphragm contractility
o Intubate
- Longer term management
o Rule of 4’s
o Technique
 Prime inhaler and attach to spacer
 Breath all the way out and seal mouth over mouthpiece
 Push down on puffer and take 4 slow, deep breaths
 Repeat 4 times
 Wait 4 minutes, and if there is no improvement then repeat again
 Call ambulance if there is no improvement after second burst, and continue
4x4x4
o Ensure Asthma Action Plan is filled and current

COPD

- Chronic lung disease ‘umbrella term’ for chronic bronchitis and emphysema
- Often a result of smoking
- Symptoms: SOB, wheeze, mucous, cough, frequent infections, more prone to pneumothorax
o Pink puffers (emphysema) and blue bloaters (chronic bronchitis)
- Management
o As for asthma (salbutamol and ipratropium, may need a short-course of oral
corticosteroids)
o Need controlled oxygen to prevent impairment of respiratory drive
  May need BiPAP
o Antibiotics for infective exacerbations
o Stable COPD
 Salbutamol or ipratropium
 Can escalate to add a LAMA (or LABA)
 Ensure inhaler technique is correct
 Pulmonary rehab
 Immunisations
 Fluvax and pneumococcal
 Lifestyle
 Diet, exercise, smoking cessation, weight loss
 Smoking cessation reduces lung function decline by 50% and
prolongs survival
o Home oxygen for patients with hypoxaemia
o Can undergo surgery for a bullectomy and / or lung volume reduction
o Inhaled corticosteroids can provide some relief as an add-on therapy in severe
disease, but they are also associated with an increased risk of infection
o Should have a written COPD Action Plan for exacerbations

Atrial fibrillation

- An abnormal heart rhythm

- Upper part of the heart quivers instead of beating properly, meaning blood isn’t pumped
effectively around the body
- Some blood can become static in the heart and clot, and when it is eventually pumped out it
can lodge in blood vessels and cause, for example, a stroke
- Types:
o Paroxysmal = terminates spontaneously
o Persistent = fails to self-terminate within 7 days
o Permanent = fails to terminate despite treatment
- Symptoms
o Irregular pulse, weakness, dizziness, palpitations, chest pain
- Risk factors
o Age, heart disease, alcohol caffeine, medications, HTN, DM, hyperthyroidism, lung
diseases, viral infections, stress due to surgery or illness, and sleep apnoea
o Should perform opportunistic screening (pulse and ECG) in patients > 65 years
- Management
o Acute management
 If less than 48 hours, perform a TOE and if there are no thrombi then aim to
cardiovert (electrical / chemical)
 Investigations: ECG, telemetry, echo
 Anti-coagulate
o Rate control
 Beta-blocker, i.e. metoprolol
 Non-dihydropyridine calcium channel blocker, i.e. verapamil (don’t use
diltiazem with beta-blockers)
  (Digoxin)
 (Amiodarone)
o Rhythm control (if rate control not successful)
 Electrical / pharmacological cardioversion
 Maintained with long-term anti-arrhythmic medications, such as flecainide,
sotalol or amiodarone (pill in the pocket)
o Manage precipitating factors
o Assess stroke risk against bleeding risk
 Should anti-coagulate if not contra-indicated
 Warfarin for valvular, NOACs for non-valvular (unless very impaired renal
function, then they get warfarin too)
o Can perform catheter / AV node ablation

TIA / stroke

- Either a bleed in the brain or blockage of blood flow to part of the brain
- If symptoms last less than 24 hours, it is a TIA (“mini-stoke”)
- Investigations
o CT, ECG, carotid dopplers, bloods (FBC, coags, others as indicated)
o May need to do an MRI and / or telemetry
- Management
o Control BP
o Ischaemic
 Clot retrieval
 Thrombolysis (if within 4.5 hours and large penumbra)
o Haemorrhagic
 May need a craniotomy
o Control and manage the cause, i.e. AF, smoking, HTN, carotid narrowing
o Long-term
 Antiplatelets
 Rehab

FOBT / colonoscopy

- FOBT detects blood in the stool; hence can indicate bowel cancer but can also be positive
due to multiple benign conditions
- A colonoscopy is the recommended follow up test for a positive FOBT
- NARCOB for colonoscopy
o A camera inserted via the rectum to look at the inside of the large bowel
o Could opt to do nothing, or to repeat the FOBT in a few weeks
o Not having the colonoscopy could mean a serious issue is missed / not treated in the
early stage
o Very small risk of bowel perforation and bleeding, especially if a polyp is removed or
a lesion is biopsied
o Will need to do ‘bowel prep’ for the days leading up to your scope; remain NMB on
the day; the anaesthetist will discuss sedation with you
 o Having the colonoscopy will mean that any serious causes are ruled out or
addressed as soon as possible

Heart failure

- Progressive weakening of the heart muscle, caused by things such as ischaemia, valvular
disorders, hypertension and diabetes
- Chambers in the heart become floppy and less muscular and cannot pump blood as
effectively
- Failure of the left heart causes fluid build up in the lungs, and failure of the right heart
causes fluid build-up in the peripheries
- Symptoms: fatigue, SOB, peripheral oedema, pink frothy sputum
- ‘Batwing’ appearance on CXR
- Management
o Acute pulmonary oedema
 Lasix (diuretics)
 Morphine
 Nitrates IV
 Oxygen
 Position (sit them up)
o Lifestyle optimisation
o Anti-hypertensives
 ACE / ARB
 Beta-blocker
o Diuretics
 Spironolactone
o Inotropes
o Digoxin  increases contractile strength and reduces heart rate
o Others
 Nitrates, anti-platelet agents, statins
o Surgery
 CABG
 Valve repair / replacement
 Implantable cardioverter-defibrillators / pacemakers
 Ventricular assist devices
 Transplant

Osteoporosis

- Weakening of the bones cause by increased bone loss and decreased production
- Can result in pathological fractures (due to a minimal impact fall etc)
- Preceded by osteopenia
- Risk factors
o Post-menopausal women, older age, white/Asian, family history, small body frame,
low calcium diet, hyperthyroidism, long-term steroids, sedentary lifestyle, excessive
alcohol consumption, smoking
- Management
o Investigate by doing a dexa scan
 o Normalise calcium and vitamin D levels
o Medication options:
 Bisphosphonates
 Alendronate
 Need a break from these after about 5 years
 Denosumab (Prolia) – 6 monthly injection
 HRT
 Teriparatide (Forteo) – similar to parathyroid hormone; daily subcut
injection
 Risks: osteonecrosis of the jaw
o Prevention / lifestyle
 Sufficient protein and calcium
 Healthy body weight
 Sufficient vitamin D
 Exercise, specifically weight-bearing

Aortic stenosis

- Narrowing of the aortic valve, which blood passes through as it leaves the heart
- Can be congenital or acquired (calcium build-up; rheumatic fever)
- Symptoms:
o Chest pain, dizziness / syncope, SOB, fatigue, palpitations
- Risk factors
o Age, infections, CVD risk factors
- Management
o Surgical valve replacement

Bipolar

- Psychiatric disorder where mood fluctuates between extremes lows and extreme highs
- Type 1 = manic, type 2 = hypomanic
- Manic / depressive symptoms
o Elevated mood (euphoria), increased productivity, high libido, risk taking,
grandiosity, pressure speech, impulsivity, reduced need for sleep
o Depression, anxiety, irritability, hostility, violence/suicide
o Changes in behaviour
- Hypomanic symptoms
o Infectious elevated mood, increased self-esteem and confidence, grandiosity,
irritability, flight of ideas, elevated energy
- Important to assess premorbid health
- Increased suicidality
- May have comorbid substance abuse
- Management
o Acute manic episode
 Mood stabiliser (lithium) +/- anti-psychotic (olanzapine)
 Acute hospitalisation
 o Preventative treatment
 Long-term lithium / olanzapine
o Depressive episode
 Mood stabiliser
 Only use an anti-depressant if the depression is refractory
 Anti-depressants can trigger a manic episode

Schizophrenia

- A psychiatric illness in which patients lose the ability to determine what is real
- Issue with dopamine activity in the brain
- They can become paranoid, delusional and may hallucinate (often auditory)
- Psychotic episodes may have a prodrome
- Symptoms:
o Positive  delusions, pressured speech, hallucinations,
o Negative  low mood, slowed movement, reduced motivation, poverty of speech,
blunted affect
- Aetiology
o Genetic, trauma history, family history, issues with adolescent brain development,
substance abuse
- Must rule out mood / organic disorders
- Common comorbid depression / anxiety
- Management
o Acute psychosis
 Hospital admission
 Anti-psychotics (clozapine for refractory schizophrenia)
 Must warn of side effects
o Psychotherapy
 Psychoeducation, CBT, family therapy
o Anxiolytics, mood stabiliser, sleeping tablets

Anaemia – Fe deficiency

- Iron is needed to produce haemoglobin which is what carries oxygen on red blood cells
- If someone doesn’t have enough iron then they can’t produce enough RBCs
- Symptoms
o Paleness, fatigue, SOB
- Causes of Fe deficiency
o Bleeding
o Insufficient dietary intake
o Pregnancy
o Impaired absorption (i.e. coeliac)
- Iron studies
o Ferritin (the body’s iron stores) is the most useful indicator
- Management
o Address cause (diet, bleeding, heavy periods etc)
 o Iron supplementation  oral ferrous sulphate tablets, IV iron
o May need transfusion if Hb is <70

Renal calculi

- A stone that forms in the kidneys (can be composed of different substances, i.e. calcium
phosphate)
- It may travel through the urinary system without incident, but some get lodged along the
way and cause significant pain/bleeding and can sometimes cause serious infection
- Investigation:
o Non-contrast CT KUB
- Management
o Depends on the size and location of the stone
o Conservative management with analgesia and good hydration may be sufficient
 Alpha-blockers can help relax muscles and make it easier for the stone to be
passed
o May need to undergo a cystoscopy so the stone can be retrieved / broken up with
lasers via the urethra/bladder
o Occasionally, a PCNL is done and this involves the stone being removed from the
urinary system via a small cut in the back
o A stent may need to be temporarily left in the ureters to stop other stones from
lodging there
- Prevention
o Hydration
o Low oxalate diet
o Reduce salt and animal protein intake
o Caution with calcium supplementation
o Certain medications can be given to prevent the formation of the different types of
stones

Depression

- A mental health issue characterised by low mood

- Low mood affects things such as sleep, appetite, motivation, concentration and self-esteem
- Increases risk of suicide
- Can be severely debilitating
- Management
o CBT
o Medication
 SSRIs are first line
 Will not work immediately, so the patient must persist
 Must be wary of side effects
 Should remain on them for at least 6 months following a depressive episode,
but often longer is required
o Treat comorbid anxiety
o Treat any other mental health / medical conditions
 o Social work support
o Close GP follow up is useful
o Provide patients with helpline info

Pre-eclampsia

- A condition that may occur in pregnancy, usually after 20 weeks

- Risk factors
o Chronic HTN, previous pre-eclampsia, first pregnancy, multiple pregnancy, age >40,
family history, obesity, IVF
- Symptoms
o HTN, proteinuria, peripheral oedema
o Blurred vision, headache, RUQ pain (impending liver capsule rupture)
o Seizures
o Asymptomatic
- HELLP syndrome produces the more severe symptoms
o Haemolysis, elevated liver function tests, low platelets
- Management
o Monitoring
 Bloods and urine
 CTG
o Anti-hypertensives
 Methyldopa
o Magnesium sulphate (neuro-protection)
o Delivery

Grave’s disease

Hashimoto’s disease

Perforated ear drum

Chlamydia

- Full STI screen

- Azithromycin

Placental abruption

DKA / T1DM
T2DM / obesity

- Progressive insulin resistance, meaning the body cannot take up sugar from the blood
- This can damage both small and large blood vessels over time
- Management
o Lifestyle modifications (3 months)
o Medications
 Metformin
 Decreases hepatic GNG, reduces glucose absorption and increases
peripheral glucose uptake
 Sulfonylurea (i.e. gliclazide)
 If SEs of hypoglycaemia and weight gain are not contraindications
 SGLT2 inhibitor or exenatide 5 microg subcut
 Insulin
o Monitor for complications
 Podiatry
 Ophthalmology
 Cardiology
 GP / diabetes educators
- Target HbA1c is <7%
- Educate regarding signs of hypoglycaemia and hyperglycaemia

Delirium

- Transient change in behaviour, cognition and personality

- Often due to infection and may be seen in post-operative patients
- Symptoms
o Visual hallucinations are common symptoms in delirium
- Prevention
o Day and date for orienting
- Management
o Determine the cause and treat
 Sources of infection
 Manage pain
 Medication review
o If aggressive may give low-dose haloperidol or a second-generation anti-psychotic
 These can only be given once all non-pharmacological methods have been
instituted
o Psychological, physical and sensory support
 Dim lights and ensure silence at night
 Calendar and clock
 Routine mobilisation
 Relaxation strategies
 Family and carer involvement
 Minimise changes between rooms / wards
 Visual and hearing aids
  Ensure adequate intake
o Prevent complications

Epilepsy

- A neurological disorder that causes recurrent seizures (abnormal electrical activity in the
brain)
- Can be treated with anti-convulsants (as directed by a neurologist)
- Can impact a person’s ability to drive
- Seizures do not normally cause long-term neurological deficits unless status develops (a
prolonged seizure), as this can starve the brain of oxygen and disrupt normal brain pathways

Retinal detachment

- The retina is found at the back of the eye and it contains all the photoreceptors
- If a defect forms in the retina, fluid from within the eye can make its way into the defect and
cause the retina to detach and peel away from the back of the eye
- This causes a loss of vision, described “like a curtain coming down across the eye”
- It is an ophthalmological emergency

GDM

- Diabetes that develops during pregnancy

- The placenta produces hormones to help the baby grow, but these can also block the action
of the mother’s insulin
- Increases risk of developing T2DM later in life
- Risk factors
o Age >40, family history of T2DM/GDM, overweight, ATSI, Asian, previous GDM,
PCOS, previous macrosomic baby
- Diagnosed with the OGTT which is normally performed at 26/40
- Management
o Lifestyle optimisation
o Monitoring BGLs
o Insulin
- Effects on baby
o Macrosomia, neonatal hypoglycaemia; can sometimes cause miscarriage and
stillbirth
o Macrosomic baby can increase need for c-section / can cause birth trauma

Mental Health Act

- Provides a substitute decision making framework for people with mental health illnesses
- Must demonstrate that the patient doesn’t have capacity
o Cannot process information and weigh up pros/cons and communicate their
decision
CST program / HPV and results

Coeliac

Contraception

DRE

Termination of pregnancy

Post-AMI

- MONAC
o Morphine
o Oxygen (if desaturating or very symptomatic)
o Nitrates – GTN (sublingual or infusion)
o Aspirin (300mg loading dose)
o Clopidogrel (or other antiplatelet
- Definitive
o PCI
o Thrombolysis (if PCI not possible in the 90 mins from first medical contact)
o Will likely also give LMWH along with these interventions
- Long-term
o Lifestyle
o Statin
o ACE, beta-blocker, statin, aspirin

HIV

Anaphylaxis

- 0.01mg/kg of 1/1000
o 0.5ml of 1/1000

PSA

Febrile convulsions