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APPENDIX OSCE Scenario Answers
481
1. Describe how you will manage this patient’s warfarin
prior to surgery.
With elective surgery the best option is to stop the warfarin;
aer 3–5 days the INR should be below 2 and therapeutic low-molecular-weight heparin (LMWH) can be given
instead. On the night before surgery a DVT prophylaxis
dose can be given. Following the operation, full anticoagulation can be commenced when clinically safe to do so (i.e.
risk of post-op bleeding). An alternative is using i.v. heparin; the anticoagulant eect will be gone aer stopping the
infusion aer 60–90 min. e patient would need to be in
hospital, however, receiving the infusion.
2. On the evening before the operation the INR has come
back as 1.9; you tell your consultant who says it must
be below 1.5 and asks if you will kindly sort this out.
Describe what you can do to lower the INR and why it
will work given the method of action of warfarin.
e patient could be given vitamin K – a dose of 2 mg i.v.
would likely be satisfactory but could be repeated. Warfarin
acts as a vitamin K antagonist and interferes with the production by the liver of vitamin K dependent clotting factors
II, VII, IX and X. It is important not to give too high a dose
of vitamin K as you may nd it dicult to re-warfarinize
the patient post-op.
3. Imagine the patient has presented with an INR of 6 and
has small bowel obstruction and needs urgent surgery;
describe what options you have to reverse the action of
warfarin.
In an emergency it is not appropriate to wait for the
INR to fall by omitting warfarin; vitamin K takes several hours to take eect and may need several doses. A
patient can be given FFP, which is rich in all clotting factors, or a prothrombin concentrate complex can be used
(e.g. Beriplex), which will reverse the eects of warfarin
in under 30 min.
OSCE SCENARIO ANSWER 21.1
A 37-year-old male attends A&E, complaining bitterly of
pain in his le groin. On examination the skin appears red
and cellulitic. He is in severe pain when it is touched, and
he has a tachycardia of 133 beats/min and a temperature of
38.8°C.
1. Given the above information, what broad dierential
diagnoses are you considering?
• Likely:
• necrotizing fasciitis
• cellulitis
• infected femoral injection site +/− pseudoaneurysm.
• Less likely:
• strangulated inguinal/femoral hernia.
2. What questions would you like to ask this patient to get
a rapid idea of the diagnosis? Important points to elicit
would include:
• history of trauma, particularly intravenous drug
abuse
• course of illness and spread of erythema
• loss of sensation of skin over groin
• systemic illness, e.g. anorexia, rigors
• predisposing factors, e.g. diabetes, immunological
compromise.
3. What investigations and management plan would you
initiate?
Investigations
• Blood tests: FBC/U&Es/LFT/CRP/ESR/blood cultures.
• Arterial blood gas.
• Wound swabs.
• If time permits, X-rays may show gas in tissues.
Management
• Surgical debridement is urgently needed as a lifesaving measure.
• Prepare for theatre immediately.
• Resuscitate using i.v. uids.
• Start high-dose i.v. antibiotics aer discussion with
a senior microbiologist regarding the antibiotic
protocol in your hospital for suspected necrotizing
infections.
• Contact senior anaesthetist and request help with
lines/monitoring, etc.
• Send multiple tissue cultures for microbiology at
time of surgery.
e patient rapidly becomes haemodynamically unstable
and a diagnosis of septic shock due to severe so tissue
infection is assumed. He is taken to theatre where extensive
debridement of infected and necrotic tissue is performed
along the fascial planes of his leg.
4. What are the diagnosis and prognosis, and which
organisms are commonly associated with this
condition?
• Diagnosis: necrotizing fasciitis.
• High mortality rate: 15–40% quoted for treated
cases, and much higher if untreated.
• Common organisms include clostridia, group A
streptococci and anaerobes; but increasingly combinations of aerobes and anaerobes are possible,
including MRSA.
OSCE SCENARIO ANSWER 21.2
A 68-year-old male patient develops acute retention of urine
aer repair of a right inguinal hernia. An indwelling urethral
catheter was inserted and he has now developed a urinary
tract infection. He was started on appropriate broad-spectrum
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SECTION IV Appendix
antibiotics and is now systemically much better. He has asked
to speak to one of the surgical team as he is upset about developing a hospital-acquired infection (HAI).
1. Answer the patient’s questions about HAI.
e tone of this conversation should be considerate to this
man’s feelings and to provide him with information about
the condition in language he can understand. Important
things to mention would include:
• e need for a catheter when a patient develops postoperative retention, to avoid renal failure.
• The risk of developing an infection at the time of
catheter insertion (despite this risk being reduced
by the use of aseptic technique) or from organisms that can travel up the catheter whilst it is
indwelling.
• at you have sent o a sample of his urine to try to
identify the particular bug causing the infection, so
that the antibiotics can be tailored to this.
• Explain that you understand he is feeling upset, and
that you regret he suered a complication of the
treatment.
He is satised with your explanation and feels much happier now; however, he is worried about the possibility of
getting an MRSA infection whilst he is in hospital, as he has
read so much about it in the newspapers.
2. Explain what MRSA is, the dierent sources of infec-
tion and methods of spread.
• MRSA is a type of bacteria that normally lives on
people’s skin, particularly around the nose, armpits
and groin.
• e reason that MRSA is dierent from the normal
type of this bug is that it has developed resistance
to the more common types of antibiotics used to
treat it.
• It can be a very serious infection, and MRSA infec-
tion risk is increased in the elderly, those who have
been in hospital for a long time, or have been in and
out of hospital a lot, and those who have been on lots
of antibiotics and have wounds.
• It is most commonly spread by touch.
3. Explain the methods employed in hospitals for preven-
tion and control of HAI.
e methods employed by hospitals to reduce HAI include:
• Sta and patient/visitor education and awareness,
e.g. handwashing teaching, posters.
• Good sterile techniques before examinations or
procedures.
• Sterilization and disinfection of equipment.
• Protective clothing and barrier nursing when treat-
ing those infected.
• Careful tracking of hospital/ward infection rates.
OSCE SCENARIO ANSWER 21.3
A 31-year-old male patient who admits to regular intravenous drug use is admitted with cellulitis of his right groin,
which began 48 h aer repeated attempts to inject his femoral vessels. He saw his GP and was started on oral antibiotics
but tells you the redness is increasing, though he is systemically well. On examination, the area is warm, pink and swollen but there is no evidence of abscess.
1. Which two bacterial species are the most likely to be the
cause of this patient’s infection?
Staphylococcus and Streptococcus.
Microbiology culture results of a wound swab taken by
the patient’s GP report that a resistant organism has been
isolated.
2. Explain how organisms develop and spread resistance
to antimicrobials.
Resistance can be:
• Intrinsic (innate) – e.g. when the organism lacks
the target site for the agent or is impermeable to the
antibiotic.
• Acquired – resistance develops in organisms that
were previously susceptible to the antibiotic by:
• altering the target site of the antibiotic
• altering antibiotic uptake (by changing cell per-
meability or actively pumping drug out of the cell)
• antibiotic-inactivating enzymes, e.g. β-lactamase.
Resistance is spread by:
• Chromosomal mutations causing altered protein
expression.
• Genes on transmissible plasmids.
• Transposons.
e antibiotics are changed, but as the erythema settles, the
patient develops a uctuant area in the skin, consistent with
an abscess. e patient is prepped for theatre.
3. What considerations and precautions should be taken
when operating on this patient?
Special precautions should be taken when operating on
a patient who is high risk for a blood-borne virus. ese
measures include:
• Informing personnel involved in patient care of the
potential/actual risk.
• Arrangements for disposal of contaminated material.
• Minimizing theatre sta present to essential personnel only.
• Removal of all but essential equipment.
• Disposable drapes and gowns.
• Double-gloving and indicator gloves.
• Visors to prevent splash injuries.
• Blunt suture needles or staples.
• Use of kidney dishes to pass all instruments.
APPENDIX OSCE Scenario Answers
483
• orough post-operative cleansing of theatre.
In addition, an ultrasound scan of this man’s groin would
help to reassure the surgeon that the abscess did not communicate with a false aneurysm.
OSCE SCENARIO ANSWER 21.4
A 67-year-old male patient was admitted with perforated
duodenal ulcer that necessitated laparotomy and repair.
Postoperatively, he recovered on the high-dependency unit
and was stepped down to the ward and deemed medically
t for discharge. He was commenced on H. pylori eradication therapy and was awaiting a social package. However,
he developed severe diarrhoea a few days later along with
abdominal pain and distension. He had T of 39.5°C, PR of
140/min, RR of 25/min and his blood tests showed WBC
count of 35,000 × 106/dL. Abdominal X-ray showed very
dilated colon.
1. What is the most likely diagnosis and responsible
microorganism?
e diagnosis is consistent with colitis due to Clostridium
dicile, which is a gram-positive spore-forming anaer-
obic bacillus. It is present in the gut of 3% of healthy
adults and remains the most common cause of hospitalacquired infectious diarrhoea. It can cause a spectrum of
illnesses ranging from mild diarrhoea to life-threatening
pseudomembranous colitis, paralytic ileus, peritonitis
and death.
2. What are the predisposing risk factors for acquiring
this infection in this context?
Risk factors for C. dicile colonization/ infection include:
• Antibiotic use, especially broad-spectrum antibiotics.
• Acid-suppressing medication (especially proton
pump inhibitors).
• Signicant co-morbidity e.g. chronic renal failure,
pre-existing bowel pathology, malignancy.
• Naso-gastric feeding.
• Alteration in gut motility, e.g. by laxatives.
• Age over 65.
• Recent healthcare intervention/stay in care facility.
e above patient had recent surgery and hospitalization,
was commenced on broad-spectrum antibiotics and PPI
and likely had postoperative NG feeding. Although the biggest risk factor for C. dicile is prior exposure to antibiot-
ics, cases have been associated with no obvious antibiotic
exposure. Almost all antibiotics have been implicated as
they all cause disruption of commensal microbiota including paradoxically metronidazole and vancomycin, which
are antibiotics used for treatment of C. dicile. However,
the highest-risk antibiotics are broad-spectrum antibiotics such as penicillins, cephalosporins and clindamycin.
Quinolones are high risk for the 027 strain of C. dicile,
which is hyper virulent and hyper transmissible.
3. How do you conrm the diagnosis?
is requires sending a stool sample immediately to test for
C. dicile. If C. dicile toxin is detected; this means the
patient has C. dicile and should be treated in the context
of symptoms. e case would be also subject to mandatory
reporting to the Department of Health.
Occasionally C. dicile toxin is not detected, but C. di-
cile toxin gene is detected. is indicates that the patient is
likely colonized with C. dicile. ey should be reviewed
and assessed for treatment, but it does not trigger mandatory reporting to the Department of Health.
4. How do you manage this condition?
Suspected infectious diarrhoea must be managed by applying the SIGHT mnemonic.
S Suspect that a case may be infective where there is
no clear alternative cause for diarrhoea.
I Isolate the patient and consult with the infection
prevention and control team while determining the
cause of diarrhoea.
G Gloves and aprons must be used for all contacts
with the patient and their environment.
H Hand washing with soap and water should be
carried out before and after each contact with the
patient and the patient’s environment.
T Test the stool for C. difficile by sending a specimen
immediately.
5. What are the precautions required to prevent this
infection from occurring and spreading in hospitals?
Ward staff must isolate symptomatic patients on first
suspicion of C. difficile at the onset of symptoms in a
single room, preferably with en suite toilet facilities.
Isolation can be discontinued when the patient has been
symptom-free for at least 72 h and has passed formed
stool or stool is normal for the patient within that time.
There is no requirement to submit further faeces samples for toxin detection, as toxin may be present in the
gut for some time after the patient has become asymptomatic. All staff and visitors on entering an isolation
room should put on disposable gloves and aprons. PPE
must be removed, and hands washed with soap and water
before leaving the isolation room. Alcohol-based hand
sanitizers are not effective against C. difficile. Stool chart
should be commenced and hospital’s antibiotic policy
for treating C. difficile should be consulted. Generally,
this is based on the severity of symptoms and includes
oral or i.v. metronidazole and oral vancomycin.
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SECTION IV Appendix
OSCE SCENARIO ANSWER 21.5
You attend the minor operation room to perform excision of
skin lesions under local anaesthesia. Your consultant reminds
you of using the pink disinfectant for skin preparation and
performing the procedures under strict sterile measures using
sterile instruments, gloves and gowns.
1. What disinfection agents are used on skin?
ere are several available skin disinfectants. e commonest are alcohol, chlorhexidine and povidine–iodine.
• Alcohol: eective against Gram-positive and Gramnegative organisms and has some antiviral activity;
however, it is relatively inactive against spores and
fungi. Avoid pooling as it is inammable. It can also
irritate sensitive areas.
• Chlorhexidine: non-toxic to skin and mucous
membranes in aqueous solution (0.5%), while 4%
solution is used as surgical scrub. It is more eective
against Gram-positive, but has moderate activity
against Gram-negative; hence, 0.5% concentration
is frequently mixed with 70% alcohol for local antisepsis as it is more eective than aqueous preparations, but caution should be taken with diathermy
to avoid re.
• Povidine–iodine: broad spectrum against bacteria,
spores, fungi, viruses (hepatitis B and HIV). In addition to skin disinfection, it is used for wound antisepsis, but can get inactivated by organic material
such as pus, blood and faeces.
2. What is the dierence between cleaning, disinfection,
and sterilization?
• Cleaning is the process of physically removing
contamination, but it does not inactivate microorganisms.
• Disinfection is the process of reducing the number
of viable microorganisms; however, bacterial spores
and viruses may survive.
• Sterilization is the process of complete eradication of
all microorganisms including spores and viruses.
3. What are the four main methods of sterilization?
• Heat:
• moist heat (autoclave): most used in hospitals:
121°C for 15 min or 134°C for 3 min
• dry heat: higher heat; hence, not suitable for plas-
tics and other material that cannot withstand
such heat: 160°C for 2 h
• Irradiation: for heat labile articles, such as lines,
catheters, syringes.
• Filtration: used to sterilize drugs for injection.
• Chemicals:
• ethylene oxide: used for electrical equipment,
sutures
• glutaraldehyde: used for endoscopes, needs 3 h to
kill all microbes
• formaldehyde: for heat labile instruments.
OSCE SCENARIO ANSWER 22.1
A 28-year-old right-handed female attends A&E with a
wound on the radial and volar border of her right index nger, just proximal to the PIPJ. She explains that she cut it last
night with a knife whilst washing dishes, and complains of
radial numbness distal to the wound.
1. Outline how you would examine the patient’s nger to
establish what structures have been injured other than
the digital nerve.
• Need to elicit numbness distal to the wound with loss
of light touch sensation.
• Establish that the nger is well vascularized by testing capillary rell.
• Examine the tendons of the nger to ensure that
extensor digitorum communis (EDC), exor digitorum supercialis (FDS), and exor digitorum profundus (FDP) are intact.
2. Explain to the examiners what would happen patho-
logically and clinically if the nerve injury was le
untreated.
Histopathologically
• Wallerian degeneration would occur: degeneration
of the axons and myelin distal to the wound.
• Regeneration would start to occur 3–4 days postinjury and the axons would grow at 1–2 mm/day.
• Schwann cells would perform remyelination.
• However, if the perineurium has been disrupted,
then the regeneration may not be successful.
Clinically
• Permanent loss of sensation is likely if the nerve has
been transected.
• A painful neuroma may form.
3. Explain your management plan to the patient and
answer any questions she may have.
• It is likely that the nerve has been cut, and to ensure
that no neuroma occurs and to have the best chance
of sensation returning, surgical repair is advised.
• If we repair it, there is a chance that the sensation will
return, but this is not always the case and is oen not
exactly the same as before the injury.
• Nerves grow very slowly, so there will be a long wait
to see how much recovery the nerve will get.
• e most important reason for repairing the nerve is to
try to avoid a neuroma, which is uncontrolled re-growth
of the nerve endings that can be painful and irritating.
• e side of the index nger you have injured is one
that you use to grasp objects (e.g. pens) against your
APPENDIX OSCE Scenario Answers
485
thumb, so we consider this even more important to
try to keep your hand functioning well.
OSCE SCENARIO ANSWER 22.2
A 19-year-old male attends your outpatient clinic with a
3-month history of right knee pain and swelling. e pain and
swelling are worsening, waking him at night, and he now walks
with a limp. He denies any traumatic injury, is otherwise t
and well, and on no medications. An X-ray arranged by his
GP whilst waiting for his referral is shown below (Fig. 22.2Q).
1. Describe the pathological signs on the X-ray (Fig.
22.2A).
• Bone destruction.
• So tissue invasion.
• Growth of bone outside of the cortex and elevating
periosteum.
• Deposition of periosteal bone (Codman’s triangle) –
single arrow.
• Spicules of radiating bone (‘sunray’ spicules) –double
ar row.
2. What is the likely diagnosis, given the history and the
X-ray?
Osteosarcoma (osteogenic sarcoma) of the lower femur.
3. What other investigations could you arrange?
• Alkaline phosphatase.
• ESR.
• CT.
• MRI.
• CXR/CT chest.
• Bone biopsy.
4. What are the management options?
Medical
• Neo-adjuvant chemotherapy to shrink the tumour
and/or lung metastases.
• Post-operative chemotherapy.
Surgical
• Wide local excision with chemotherapy.
• Amputation.
• Resection of pulmonary metastases if appropriate.
OSCE SCENARIO ANSWER 22.3
A 45-year-old female has presented in A&E aer falling
down some steps. She is alert and her pulse and blood pressure are normal, though her oxygen saturations are only
80% on high-ow oxygen. She is complaining bitterly of pain
down her right chest wall, though only grazes are present.
1. How will you approach the assessment of this patient?
Using ATLS principles:
• Airway with C-spine control
• Breathing
• Circulation.
2. Her chest X-ray is shown below (Fig. 22.3Q). What is
the condition shown? What is the likely cause?
• A right-sided closed pneumothorax (Fig. 22.3A).
• ough rib fractures cannot be seen, it is possible
that this is the cause, given the history.
3. How would you treat this condition?
• If oxygenation is severely compromised, needle
decompression of the pneumothorax in the 2nd intercostal space in the midclavicular line is appropriate.
• Denitive treatment is with insertion of a chest drain
connected to an underwater seal.
4. Explain to the examiners the classication of causes
and types of this condition, and how you would have
treated the patient if she had presented with tracheal
deviation and haemodynamic instability.
Types of pneumothorax
• Open.
• Closed.
• Tension.
Causes
• Spontaneous (primary and secondary).
• Traumatic (open and closed).
• Iatrogenic.
Treatment
• If the patient had presented with tracheal deviation and
haemodynamic instability with clinical signs of a pneumothorax, you would suspect a tension pneumothorax.Fig. 22.2A X-ray of the patient’s right knee.
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Fig. 22.3A The patient’s chest X-ray. A pneumotho-
rax is visible on the right side. The lung edge is visible (arrow).
• As this is a life-threatening condition which can
rapidly cause death, a swi needle decompression
WITHOUT waiting for a chest X-ray would be the
appropriate management.
SECTION IV Appendix
OSCE SCENARIO ANSWER 22.4
A 14-year-old boy attends your clinic with his mother, who
is concerned that her son seems to be developing breasts.
e boy is overweight, with a BMI of 29, but both he and his
mother state that he has lost weight recently and his breasts
are still enlarging. His examination reveals enlarged nipples
with small rm breast bud development.
1. What is the likely diagnosis? What questions would
you like to ask to conrm this?
• Pubertal physiological gynaecomastia.
Relevant points to elicit would include:
• A full drug history to exclude drug-induced gynaecomastia; note that the patient’s mother is in the
room and therefore answers regarding cannabis and
anabolic steroid use may have to be asked at a condential time, e.g. during examination.
• Anything to suggest hypogonadism, i.e. undescended testes, lack of body hair, bilateral torsion,
Kleinfelter’s syndrome.
• Any testicular swellings (testicular tumour).
• Any visual disturbance/lactation (pituitary cause).
• Anything to suggest male breast carcinoma (nipple discharge or retraction, hard lump, lymphadenopathy).
• Family history of gynaecomastia or hypogonadism.
2. Explain the diagnosis and its causes in layman’s
terms, and outline the options for investigation and
management.
Important to perform this very sensitively as the patient
is likely to be embarrassed and confused. Points to raise
would include:
• All men have some breast tissue, and in some men
this tissue can grow – we call this gynaecomastia and
it can happen to babies, teenagers or older men and
it’s actually not that rare.
• is is dierent to just being ‘overweight’ as it is
breast tissue and not just fat causing the swelling,
though weight loss may help.
• is can happen at puberty because of hormonal
imbalances, but oen we don’t really know why it
happens.
• Sometimes there are specic causes such as certain
drugs, which can reduce your male hormones or
increase female hormones, or medical conditions.
• If we aren’t sure of the cause then certain blood tests,
X-rays and even taking a tissue sample can help,
though oen we don’t need to do this if we think the
cause is puberty.
• General options for treatment include:
• removing the cause (i.e. stop any medications
causing it)
• nothing – 90% of physiological gynaecomastia
goes away by itself, though it can take a few weeks
or a couple of years
• medication to reduce oestrogen or increase
testosterone
• surgery to remove the breast tissue – but this will
leave scarring.
OSCE SCENARIO ANSWER 22.5
A 62-year-old male attends A&E with acute onset of severe
abdominal pain radiating to the back. He is pale and sweaty
with a tense, distended, tender abdomen. A CT of his abdomen is shown below (Fig. 22.5Q).
1. What pathology is shown?
A leaking abdominal aortic aneurysm (Fig. 22.5A).
e patient is still in the radiology department and his
blood pressure is stable at 90 mmHg systolic.
2. Outline the immediate management of this patient.
• Immediate surgery is needed to try to save this man’s
life.
Fig. 22.5A CT scan of the patient’s abdomen. There is
a large leaking abdominal aortic aneurysm (arrow).
• Explain the diagnosis to the patient and the urgent
need for surgery.
• Arrange for immediate transfer to theatre.
• Alert the senior anaesthetist on call, the on-call theatre team and the senior surgeon.
• Ensure that the patient has had FBC/U&Es/LFT/
clotting screen taken and is cross-matched for 10
units of blood.
3. What risk factors exist for this condition?
• Smoking.
• Hypertension.
• Male sex.
• Family history.
4. What is the operative mortality risk for this condition?
30–50%.
5. Explain to the examiners the dierent types of this con-
dition, their classication and their aetiology.
• Can be classied in the following ways:
• true: where the wall of the aneurysm contains all
three elements of intima, media and adventitia
(can be subdivided by shape into fusiform and
saccular)
• false: pulsating haematoma with a cavity in continuity with the lumen.
• Or as:
• congenital: ‘berry’ aneurysms around the circle of
Willis
APPENDIX OSCE Scenario Answers
• acquired: aneurysms which develop in life for
various reasons (listed below).
• Or by cause:
• atheromatous
• mycotic
• syphilitic
• dissecting
• arteriovenous aneurysms (aneurysmal varices
associated with A/V stulae).
487
OSCE SCENARIO ANSWER 22.6
A 37-year-old female attends your clinic having been
referred by her GP with excessive sweating, diarrhoea and
neck swelling.
1. Ask this patient about her symptoms and give the
examiners your dierential diagnosis.
• Elicit goitre features:
• How long present for? Is it enlarging?
• Painful?
• Problems swallowing?
• Problems breathing in?
• Change in voice?
• Enlarging?
• Elicit features of hyperthyroidism:
• excessive sweating/heat intolerance
• weight loss; check not intentional, i.e. not dieting
• anxiety/irritability
• palpitations/tremor
• insomnia
• diarrhoea
• menorrhagia.
• Dierential diagnosis is thyrotoxicosis, secondary to:
• a toxic goitre (single/multinodular)
• Graves’ disease
• functioning adenoma.
2. What physical signs may you expect to see on
examination?
• Clubbing.
• Wet palms/excessive sweating.
• Tachycardia/irregular heart rate/AF.
• Eye signs (exophthalmos/lid lag).
• Tremor.
• Pretibial myxoedema/hyper-reexia.
• Proximal myopathy.
3. What investigations might you arrange?
• FBC/ESR/TFTs.
• USS (ultrasound scan) of goitre.
• Radioisotope scan of goitre.
• FNA of goitre.
e results of your investigations suggest a benign toxic
goitre with a dominant nodule.
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SECTION IV Appendix
4. What treatment options are available?
• Medical treatment for symptoms (e.g. beta-blockers).
• Medical treatment to block thyroid hormone production (e.g. carbimazole).
• Radioactive iodine treatment.
• Surgical removal (e.g. total/subtotal thyroidectomy –
will need thyroxine treatment aerwards).
5. If the patient opts for surgery, which nerves are at risk
of intra-operative damage?
• Recurrent laryngeal nerve (related to the inferior
thyroid artery).
• External branch of the superior laryngeal nerve
(related to the superior thyroid artery).
OSCE SCENARIO ANSWER 22.7
e blood results displayed below are those taken from a
49-year-old male ex-alcoholic, feeling generally unwell with
vague abdominal pain, whose GP has referred him to your clinic.
Bilirubin 57 µmol/L
Albumin 22 g/L
Total protein 64 g/L
Alkaline phosphatase (ALP) 152 IU/L
Alanine aminotransferase (ALT) 188 IU/L
Aspartate aminotransferase (AST) 220 IU/L
Gamma glutamyltransferase (GGT) 129 IU/L
1. What biochemical abnormalities are shown?
• Raised levels of bilirubin, AST/ALT/GGT, and to a
lesser extent ALP.
• Reduced levels of albumin.
2. Explain to the examiners the dierent types of jaundice
and give examples of the causes of each type.
Pre-hepatic jaundice
is is due to intravascular haemolysis and some causes
include:
• Congenital defects, e.g. Gilbert’s disease.
• Congenital red cell defects, e.g. sickle cell, hereditary
spherocytosis.
• Acquired red cell defects, e.g. malaria, autoimmune
disease, hypersplenism.
Hepatic jaundice
is is due to intrinsic liver pathology and some causes
include:
• Acute hepatocellular disease due to:
• infections, e.g. hepatitis, CMV, leptospirosis
• drugs, e.g. paracetamol, anaesthetics
• autoimmune disease.
• Chronic hepatocellular disease due to:
• infections, e.g. chronic viral hepatitis
• chronic autoimmune disease
• end-stage liver disease, e.g. alcohol, cirrhosis,
Wilson’s disease.
Post-hepatic/cholestatic jaundice
is is due to either intrahepatic cholestasis or post-hepatic
biliary obstruction and some causes include:
• Intrahepatic causes due to:
• pregnancy
• drugs/nutrition, e.g. chlorpromazine; TPN
• primary biliary cirrhosis.
• Extrahepatic causes due to obstruction in:
• lumen, e.g. gallstones or parasite infestation
(schistosomiasis)
• wall, e.g. strictures, cholangitis, cholangiocarcinoma
• outside of wall, e.g. tumour in head of pancreas,
nodes in porta hepatis, chronic pancreatitis.
3. Which type is this patient’s likely to be from the blood
results?
Blood results suggest a chronic hepatocellular form of
jaundice, possibly due to alcoholic cirrhosis. Chronic element is suggested due to low levels of albumin.
4. Closer questioning reveals that the patient has devel-
oped abnormal stools which are pale, oat, and are difcult to ush away. What other condition is the patient
likely to have developed?
Chronic pancreatitis due to chronic alcoholism.
OSCE SCENARIO ANSWER 22.8
An 82-year-old male is brought into the emergency department with an acutely painful right leg. e symptoms include
the leg feeling cold, looking very pale and pins and needles.
e patient’s ECG is shown below (Fig. 22.8Q).
GET AN AF ECG
1. What is the likely diagnosis?
e likely diagnosis given the symptoms and ECG ndings
are an acute arterial embolism leading to acute ischaemia
of the right leg. e ECG shows the classic signs of Atrial
Fibrillation (AF) - irregularly irregular pulse and lack of
P waves.
2. What are the causes?
Causes of acute ischaemia can be divided broadly into
luminal and extra-luminal causes.
• Luminal causes include embolism, thrombosis
(including clotting disorders), arterial dissection.
• Extra-luminal causes include trauma, external compression, popliteal entrapment, and cystic adventitial
disease (the last two rarely present acutely).
3. What other symptoms can occur and which are the
most clinically important?
e classic symptoms of an acutely ischaemic limb are the 6
P’s: Pain, Pulseless, Perishingly cold, Paralysis, Paraesthesia,
and Pallor. e most clinically important of these are the
APPENDIX OSCE Scenario Answers
489
degree of paraesthesia and paralysis; nerves are very sensitive to ischaemia. It is very common to have mild pins and
needles or a mild dierence in sensation; paralysis is oen
absent in the early stages. However, as ischaemia persists, a
limb which is paralysed and insensate may not be salvageable. e 6 P’s does not draw attention to the importance
of pain on muscle squeezing; a patient with pain on compression of the gastrocnemius or anterior compartment has
severe limb ischaemia and is at high risk of compartment
syndrome.
4. What investigations would you perform?
Bit of a trick question this one – it may be none. In a patient
in AF with no previous vascular surgery/interventions and
normal pulses on the opposite side and severe symptoms, the
patient may be taken to theatre for an urgent embolectomy. If,
however, the diagnosis is not so clear cut then a CT angiogram
or duplex ultrasound will give the required information.
5. Are you aware of any classication systems for this
condition?
e most widely used classication system is by Rutherford;
it divides the severity into viable, threatened and irreversible on the grounds of capillary return, degree of paralysis
and sensory loss and whether there are audible arterial and
venous Doppler signals.
6. If the patient had a paralysed and insensate leg with
a purple discolouration which did not blanch under
pressure, what would be the likely management plan?
is sadly sounds like a Rutherford stage 3 ischaemia; the
leg is irreversibly ischaemic; the classic sign is the deep purple discolouration of the leg does not blanch aer digital
pressure. e only treatment is primary amputation or in
patients where this would be inappropriate then palliation.
OSCE SCENARIO ANSWER 22.9
A 56-year-old male is admitted with severe dehydration and
vomiting, his urea and creatinine are raised at 15 mmol/L
and 215 μmol/L. A blood gas shows the following abnormali-
ties: pH 7.55, PO2 10.9 kPa, CO2 6.9 kPa and HCO3 is 21.
1. What type of metabolic abnormality is this patient
displaying?
e patient has a metabolic alkalosis – this is indicated by the
pH showing alkalosis. e fact that is it metabolic in nature is
indicated by the raised CO2 (compensatory hypoventilation)
and the low HCO3 (compensatory loss by the kidneys). e
fact that the HCO3 is low would suggest the cause of the alkalosis is loss of H ions rather than excess HCO3.
2. How has it occurred?
Vomiting results in a loss of H ions and thus a metabolic
alkalosis.
3. e patient has a ‘succussion splash’ on examination –
what is the diagnosis?
A ‘succussion splash’ is a characteristic nding in gastric
outlet obstruction which leads to severe vomiting. It is an
examination nding where you literally shake the patient’s
abdomen from side to side and can hear the uid in the
stomach moving.
4. How would you manage this condition?
e management of this condition would fall into –
• Resuscitation and correction of electrolyte abnormalities.
• Investigation as to the cause – OGD and or CT scan.
• Management of the cause – the commonest causes
are peptic ulcer disease or malignancy. If due to
malignancy then surgical resection of the tumour
or palliative gastro-jejunostomy would be appropriate. If due to peptic ulcer disease then initial medical
management with i.v. PPI is appropriate for 48–72 h.
If there is no improvement then surgical resection
may be deemed appropriate.
OSCE SCENARIO ANSWER 22.11
A 62-year-old male is in the A&E department and is complaining of epigastric pain. is feels like his normal heartburn but has not been relieved by antacids. In addition he is
sweating and has a bradycardia. An ECG is performed and
shows raised ST segments.
1. From the history, what type of myocardial infarction is
the patient having and in what leads would you expect
to see the ST segment rises?
e symptoms are suggestive of an inferior MI – this is an
oen overlooked dierential diagnosis for acute epigastric
pain and explains why an ECG is essential in patients presenting with upper abdominal pain. Classically the leads showing
raised ST segment changes are leads II, III and aVF.
2. Which coronary artery is involved?
e right coronary artery supplies the territory involved
in an inferior MI. Occlusion of the le anterior descending artery (LAD) leads to an anterior and or septal MI.
Occlusion of the circumex branch of the le coronary
artery leads to a lateral MI. Occlusion of the right coronary
artery leads to an inferior MI (as mentioned) and also may
lead to a right ventricle and atrial infarction. Occlusion
of the circumex branch of the right coronary artery can
occasionally cause an inferior MI but more usually a posterior MI.
3. Why is it common to see a bradycardia?
In approximately 60% of the population the SA node is
supplied by the right coronary artery and thus infarctions
involving this territory may present with bradycardia and
conduction problems.
ACKNOWLEDGE
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
INDEX
Page numbers followed by “f” indicate gures, “t”indicate tables, and “b” indicate boxes.
A
Abdomen, 20–23
development, 20–23
mass, 325
Abdominal aorta, 30–32, 30f
Abdominal aortic aneurysms, 32, 213,
406
repair, 213
Abdominal breathing, 13
Abdominal incisions, anatomy of, 25–26
Abdominal muscles
nerve supply of, 24
reex, 167t
Abdominal pain, acute. See Acute
abdominal pain
Abdominal reexes, 164, 167t
Abdominal viscera, 38–60, 38f
anal canal, 45–46
anal sphincters, 46–47, 46f
appendix, 44
bladder, 56–57
blood supply, 39
broad ligament, 59
duodenum, 42
extrahepatic biliary system, 49–51, 50f
fallopian tubes, 59
gall bladder, 51
gastric mucosa, structure of, 41–42, 42f
kidneys, 54–55, 54f
large intestine, 43–44
liver, 47–49
microscopic structure, 39
nerve supply, 39, 41–42
oesophagus, 38–39
ovary, 60
pancreas, 53–54
portal venous system, 51–53, 52f
prostate, 57
rectal examination, 47
rectum, 44–45
seminal vesicles, 57
spleen, 54
suprarenal glands, 56
sympathetic nervous system, 168
Abdominal viscera (Continued)
ureter, 55–56
uterus, 57–59, 58f
vagina, 59–60
vaginal examination, 60
Abdominal wall
anterior, 23–25
muscles, 24, 25f
posterior, 29–30
rectus sheath, 24, 25f
supercial fascia of, 23
Abducens nerve, 159–160, 163f
VI, 155
Abduction movements, 99
Abductor pollicis brevis, thumb, 69
Abductor pollicis longus, thumb, 69
abl oncogene, 323t
Abnormal temperature regulation,
172–173
ABO blood group system, 355, 355t
Abscesses, 307, 370–371, 371t
antibiotic therapy, 368
chronic, 309, 370
metastatic, 370
Absorption, 220, 221t
Acanthosis nigricans, 326
Accessory nerve, 138, 162, 163f
spinal, 135
surface marking of, 135
Acetabulum, 80
Acetylcholine (ACh), 271
neuromuscular transmission, 271–272
Achilles tendon reex, 274
Achondroplasia, 298
Acid-base balance, 177–180
disturbances of, 178–180, 179t
interpretation of changes, 179–180
mixed disorders of, 179
Acoustic neuroma, 389–390
Acromegaly, 252, 253f
Acromioclavicular joint, 66
ACTH. See Adrenocorticotrophic
hormone (ACTH)
Actin laments, 204, 271
Actinomycosis, breast, 402
Action potential
cardiac, 204–205, 204f
nerve, 265, 266f
neuromuscular transmission, 271–272
Activated partial thromboplastin time
(APTT), 348
Acute abdominal pain, 185, 409–410
Acute coronary syndrome, 405
Acute inammation, 305
causes, 305
chemical mediators, 306
eects, 308
macroscopic signs and symptoms, 305
progression from, 309
recurrent episodes, 309
resolution, 308
stages, 305–306
Acute insuciency, 409
Acute osteomyelitis, 392
Acute pelvic inammatory disease, 410
Acute phase response, 255–256, 367
Acute pyogenic cellulitis, 368
Acute pyogenic mastitis, 402
Adaptive immunity, 330
Addison’s disease, 249, 250f, 409
Adduction movements, 99
Adductor canal, 90
Adductor pollicis, thumb, 69
Adenocarcinoma, 318
Adenoma, 318, 423–424
Adenoma-carcinoma sequence, 321,
322f
Aδ bres, 269, 273f
ADH. See Antidiuretic hormone (ADH)
Adherence, 346
Adjuvant radiotherapy, 291
Adrenal cortex
actions, 247–249
disorders, 249–251
hormones, 247–249, 248f
hyperfunction, 408–409
hypofunction, 409
tumours, 409
490
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