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Primary OSCE 52

Created: 9/4/2010

1. History taking
Take a preoperative history from a 40-year-old woman presenting for hysterectomy.

2. Data interpretation
Discuss the case of the woman from Station 1.
- She has anaemia and is on iron tablets
- She has a history of dyspnoea on exertion
- She has had heavy menstrual bleeding
- She gets migraines and takes aspirin for them
- She smokes 10-15 cigarettes/day
- Her alcohol intake is moderate
- She has had a previous Caesarean section and dental procedure:

3. History taking
Take a history from a young man presenting for nasal surgery.

4. Chest X-ray
You are shown a lateral chest X-ray showing lower lobe collapse, and are presented with the following scenario: A young woman has been admitted by the surgeons with a diagnosis of empyema gallbladder, high fever and high white blood cell count.
- Would you be happy for surgery to go ahead?
- Does she need antibiotics?
- Is this a left lateral X-ray?
- Is the breast shadow obscuring the lung fields?
- Will she need a bronchoscopy?
- Will her pO2 be low?
- Is there any osteoporosis of her vertebrae?

5. Chest X-ray
You are shown a lateral chest X-ray showing diaphragmatic hernia.
- Is there any fluid in the thorax?
- Is the patient in danger of aspiration during induction? Or rapid sequence induction?
- Will the patient have reflux symptoms?
- Are there abdominal viscera in the chest cavity?
- Will you hear gut peristaltic sounds in the chest?
- Will the trachea be deviated?

6. Equipment
You are shown a phrenic nerve stimulator and asked to identify it.
- You are then shown a manikin arm with neuromuscular monitoring leads. Demonstrate the method for monitoring the ulnar nerve.
- Which muscle is stimulated?
- Why is a supramaximal current used?
- You are given a laminated sheet with all the four neuromuscular TOF patterns. Name them.
- What is the difference between depolarising and non-depolarising patterns?
- Discuss the frequency and duration of each.
- When can tetanus / train-of-four be repeated?
- When should you use post-titanic count?
- Discuss double-burst stimulation frequency, duration and purpose.

7. Equipment
(a) You are shown three endotracheal tubes: a low pressure high volume disposable tube, an uncuffed tube and a Ring-Adair-Elwyn (RAE).
- Describe each of them

(b) You are shown a laser tube.
- Describe it.
- Why does it have a double cuff?
- Why is saline used?
- What does LASER stand for?
- How is a laser beam produced?
- Describe the different types of laser.
- What are the properties of lasers?
- What precautions should be taken during their use?

8. Equipment
You are shown three diagrams:

(a) A paramagnetic O2 analyser
- Describe the differences between paramagnetic and diamagnetic analysers. Give examples of each.
- Why is O2 paramagnetic?
- What is the dumbbell filled with, and why?
- Describe the principle of action of the instrument.

(b) A Clark electrode
- Label the components
- Describe the uses.

(c) A fuel cell
- Label the components.
- Why is a battery needed?
- What is its lifespan?

9. History taking
Take a history from a woman who is hypotensive after laparoscopic cholecystectomy, who subsequently goes into cardiac arrest.
- What would you do?
- Describe the advanced life support (ALS) algorithm in detail (both the shockable and non-shockable limbs).
- What should happen next?

10. Simulator manikin
Describe how you would treat low oxygen saturation after intubation in a simulator manikin.
- What might the problem be?
- What investigations would you perform?

11. Simulator manikin
An automated external defibrillator is attached to a manikin showing fast atrial fibrillation (AF), with a systolic blood pressure of 70 mmHg.
- What would you do?
- You are asked questions about the tachycardia algorithm.
- What dose of amiodarone would you administer?
- How would you manage fast AF medically?

12. Anatomy
Label three diagrams of the basal skull foramen.
- What structures pass through the cribriform plate, optic canal and supraorbital fissure?
- What is the length of the intraorbital section of the optic nerve?
- Describe the nerve supply to the extraocular muscles.
- Describe the sensory supply to the conjunctiva.
- Describe the technique of peribulbar block.
- Demonstrate this technique, showing the direction of the needle.
- Name two complications of the technique.

13. Anatomy
You are shown a diagram of the spinal cord.
- Label the ascending and descending tracts.
- Describe the sensory modalities conducted by these different pathways.
- What s the volume of the cerebrospinal fluid (CSF)?
- What is the pressure of the CSF?
- Describe the blood supply to the spinal cord?
- What is anterior spinal artery syndrome? Which tracts/modalities are affected?

14. Simulator manikin
Describe how you would perform cannula cricothyroidotomy using a manikin.
- How would you apply local anaesthetic?
- What is the correct site of puncture?
- Describe the step-by-step use of the kit.

15. ECG
You are shown a picture of the human torso and given ECG electrodes.
- Apply the CM-5 configuration.
- Is CM-5 unipolar or bipolar?
- What is its purpose?
- You are then shown an ECG and asked to comment on its calibration, speed and axis.
- You are then shown a set of two ECG waves, one without a filter (i.e. showing interference) and are asked to explain the difference between the two.
- You are asked some questions on interference and filters.

16. Equipment
You are given a face mask, angle connector, laryngoscope, Magills forceps, suction tube, Guedel’s airway etc and asked to examine them to see if they are safe to use.
- You are asked questions on the requirements of rapid sequence induction (indications, technique).

17. Communication
Talk to the daughter of an 80-year-old man undergoing emergency abdominal aortic aneurysm repair after collapse.

18. Examination
You are asked to examine the venous pulse of an actor.
- Describe in detail the wave form and its abnormalities.

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