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Primary OSCE 12
35-year-old Mrs Rehman presents for elective hysterectomy with haemoglobin of 8.1 g/dl. She has a past medical history of six babies, but had no problems with any. She has a history of cough/sore throat and night sweats for 6 weeks. Her GP has done blood tests for the same but she does not know the results. She has also had menorrhagia for 6 months. Take a full history.
A healthy African presents for day case arthroscopy. He has a previous history of road traffic accident, with fractured ribs, splenectomy, ITU admission and ventilation. He has no other significant medical history. He has been tested for thalassaemia, but does not know the results. Take a full history.
A Jehovah’s witness presents for elective hysterectomy, and you are asked to obtain consent.
The patient will not accept anything containing animal products, and has refused preoperative blood donation. Ask the patient about erythropoietin etc. She is happy to defer surgery until her Hb level improves, and happy for a cell saver (her attitude being ‘the blood must remain in circulation’ ). She is a very cooperative patient.
A thoracolumbar 3-D reconstruction of the image, easily showing a wedge compression fracture of L1 vertebra with obvious displacement of the same. Patient had fracture of both tibia and femur.
Answer questions on the following:
- Is the L2 nerve root intact?
- What might the hypotension (96/66 mmHg) and heart rate of 130 bpm be due to?
- Are steroids are indicated?
- Does the patient need urgent decompression?
- Can only the lumbar vertebrae be seen?
- is T12 with the rib easily seen?
5) Nerve blocks and anatomy
You are asked to demonstrate how to perform a 3-in-1 block, and are questioned about:
- the distribution of the nerves and dermatomes
- the level of analgesia
- the nerve root of the femoral nerve and obturator nerve
- the nerve supply of adductors
- how to block the ilioinguinal and iliohypogastric nerve (their nerve root value)
You are presented with an 80-year-old patient who needs four pillows to sleep; if the pillows slip, she begins to cough. Her ECG shows AF.
Answer 10 true/false questions, including the following:
- axis N/abnormal
- left bundle branch block is present
- QRS duration is normal
- peribulbar block is satisfactory for this patient
- the ECG shows signs of digoxin toxicity
7) Capnograph trace
A patient is in the prone position. You are shown the capnograph trace and asked a series of true/false questions, including:
- surgery should be stopped immediately
- there is a risk of cerebral hypoxia present
- the slope of the inspiratory phase is dependent on tidal volume
- D is the end tidal point
8. Examination of the airway
A patient has a grade III Mallampati and a rather short neck. You are shown a head and neck lateral X-ray and asked to comment on whether the intubation will be difficult . The X-ray is of poor quality, but shows temporomandibular ankylosis.
9. Examination of the cranial nerves
Carry out a full clinical examination of the cranial nerves.
10. Resuscitation station
A young adult is seen near a pond, collapsed. The information card says to assume drowning with no trauma. Shout for help etc, and perform resuscitation for 1 minute. At the end of administering artificial breathing, demonstrate how to put the patient into the recovery position. Fill in an algorithm for the rhythm on the monitor (VF).
- how many layers does it have and what are their names?
- what is the function of the sinus of Valsalva?
- from which aortic sinus do the coronary arteries arise?
- explain venous drainage
- how many cusps are there in the aortic/mitral/tricuspid valves?
- what are the cordae tendinae and what is their function?
- what happens if the cordae rupture?
- what is the dominant artery?
- which nerves supply the SA and AV nodes?
You are shown a coronary angiogram:
- identify the coronary artery?
- what is the pathology here?
- can you identify anything other than atherosclerosis?
- which vessels are narrowed?
- which part of the myocardium is now at risk?
12. Machine check
You are asked to check a Bain circuit. There is a big hole in the outer tubing, in the undersurface, where it will attach with the adjustable pressure-limiting (APL) valve (not easily visible)
- answer questions on fresh gas flow, minute volume etc.
- what will happen if the bag of the circuit fell off suddenly when the patient is breathing spontaneously?
Answer 10 true/false questions (no negative marking):
(Regarding different categories of data).
You are shown a photograph of entonox
- what is the pseudocritical temperature?
- what happens at this temperature?
- what is the critical temperature?
- does the gauge press reflect the amount left?
- who else is authorised to use entonox other than doctors?
- describe the 2-stage regulator
15. Anaesthesia hazards
You are shown various filters, then asked questions, including:
- identify an epidural filter; what is its use?
- identify a blood filter; how often it should be changed?
- identify a bacterial filter in an anaesthetic breathing circuit; answer questions on dead space
- identify a white blood cell (WBC) filter)
- what virus is transmitted by WBC?
- arrange the following in order of size, starting with the smallest: platelets, red blood cells and coccus
16. Check the arterial line set-up, which might contain the following faults:
- venflon cannula with side port, kinked 18G
- ordinary iv tubing instead of non-compliant
- glucose instead of Hepsal
- non-pressurised bag
- lots of air in the tubing
- how would you zero?
- what is high pressure zero?
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