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Primary OSCE 27

Created: 22/7/2005
1. History taking
A 35-year-old woman presents for elective hysterectomy. She has a haemoglobin level of 8.1 g/dl. Her history shows that she has had six babies, with no problems arising in any of the pregnancies. For the past 6 weeks she has been complaining of cough/sore throat and night sweats, for which her GP has carried out blood tests, the results of which are, as yet, unknown. She has also had menorrhagia for 6 months. All questions into all other possible organ systems elicited no positive response.

2. History taking
A healthy African patient presents for day-case arthroscopy. He has been in a road traffic accident, as a result of which he sustained fractured ribs, had to undergo a splenectomy, was admitted to intensive care and received ventilation. There was no other significant medical history. The patient had been tested for thalassaemia, but did not know the results.

3. Communication
A Jehovah’s witness presents for elective hysterectomy, and you have to obtain consent. The patient refuses to receive anything containing animal products and refuses a preoperative blood donation. Rather than receiving erythropoietin etc, she is willing to defer surgery until her haemoglobin level has improved, and opts for a cell saver device to be used, as it is her philosophy that ‘the blood must remain in circulation’. Overall, this was a very cooperative patient.

4. X-ray
You are shown a thoracolumbar three-dimensional reconstruction from an X-ray image, showing a wedge compression fracture of the L1 vertebra with obvious displacement of the latter. The patient had a fracture of both the tibia and fractured femur. You are asked the following true/false questions:
- The L2 nerve root is intact. (T/F?)
-There is a fracture at L1. (T/F?)
- The patient is suffering from hypotension (96/66 mmHg) and a heart rate of 130 bpm. This is because of spinal shock. (T/F?)
- Steroids are indicated. (T/F?)
- The patient needs urgent decompression. (T/F?)
- Only the lumbar vertebrae can be seen. (T/F?)

5. Nerve blocks and anatomy
You are asked to demonstrate how to perform a 3-1 block. Answer the following questions:
- Discuss the distribution of spinal nerves and dermatomes.
- Where is the nerve root of the femoral nerve and the obturator nerve?
- Describe the nerve supply of the adductor muscles.
- How would you block the ilioinguinal and iliohypogastric nerve?

6. ECG
You are shown the ECG of an 80-year-old patient. She needs to sleep with her head raised (using four pillows), or else she coughs. Her ECG shows atrial fibrillation. Answer the following true/false questions:
- The axis is normal. (T/F?)
- Left anterior hemiblock is present. (T/F?)
- The QRS duration is normal. (T/F?)
- Peribulbar block is satisfactory for this patient. (T/F?)
- The ECG shows signs of digoxin toxicity. (T/F?)

7. Data interpretation
You are presented with a patient in the prone position, whose capnograph trace is shown below. Answer the true/false questions that follow:

- Surgery should be stopped immediately. (T/F?)
- There is a risk of cerebral hypoxia present. (T/F?)
- The slope of the inspiration phase is dependent on the tidal volume. (T/F?)
- D is the end-tidal point. (T/F?)

8. Examination
You are shown the head and neck lateral X-ray of a patient with a grade III Mallampati laryngoscopy with a rather short neck.
- Will this patient be difficult to intubate?
- Describe the features you can see on the X-ray.

9. Examination
You are asked to carry out this examination of the cranial nerves on a patient, using tuning forks.

10. Resuscitation
A young adult is seen near a pond; he has collapsed, and you are to assume he has drowned, but there is no evidence of trauma.
- What would you do?
- Complete an algorithm for the rhythm on the monitor (VF).

11. Anatomy
Answer the following questions on the anatomy of the heart:
- How many layers are there in the heart?
- Name the layers.
- What is the function of the sinus of Valsalva?
- From which aortic sinus does the coronary artery arise?
- Describe the venous drainage of the heart.
- How many cusps are there in the aortic/mitral/tricuspid valves?
- What are the chordae tendinae, and what is their function?
- What happens if the chordae rupture?
- Which is the dominant artery?
- Which artery supplies the sinoatrial and atrioventricular nodes?
- You are shown a coronary angiogram:
Which coronary artery is shown?
What pathology is shown here?
Which vessels are narrowed?
Which part of the myocardium is now at risk?

12. Equipment check
You are asked to check a Bain circuit.
- What will happen if the bag of the circuit falls off suddenly, while the patient is breathing spontaneously?

13. Statistics
Answer the following true/false questions (no negative marking):

- Can the following be classified as nominal data: 13 patients admitted under the surgeon, Mr X. (Y/N?)
- Can the following be classified as ordinal data: a Na+ concentration of 139 mmol. (Y/N?)
- An alpha error describes the probability of accepting a false-positive statement. (T/F?)
- A beta error describes the probability of accepting a false-negative statement. (T/F?)
- A beta error is minimised by reducing the sample size. (T/F?)
- The probability of throwing a 6 on a dice is 0.167. (T/F?)
- Sensitivity is the probability of obtaining a false-negative result. (T/F?)
- Specificity is the probability of obtaining a false-positive result. (T/F?)
- The following can be classified as ordinal data: 1st patient, 2nd patient, 3rd patient etc. (Y/N?)
- The following can be classified as interval data: Mary 1st rank, Tom 2nd rank, Harry 3rd rank etc. (Y/N?)

14. Equipment
You are shown a photograph of an entonox inhalation unit. Answer the following questions:
- What is the pseudocritical temperature?
- What happens at this temperature?
- What is the critical temperature?
- Does the gauge pressure reflect the amount of entonox remaining?
- Besides the doctors, who else is authorised to use entonox?
- Describe the two-stage regulator

15. Hazards
You are shown various filters and asked the following questions on them:
- Identify an epidural filter and describe its use.
- Identify a blood filter; how often should it be changed?
- Identify a breathing circuit bacterial filter (answer a question on dead space).
- You are shown a big flat white filter attached to an i.v. set and asked to identify it.
- What virus is transmitted by white blood cells?
- Arrange the following in increasing order of size: platelet, red blood cell, coccus.

16. Equipment check
– You are shown an arterial line and asked to point out errors. The errors are:
Venflon catheter with side port, kinked 18G.
Contains ordinary i.v. tubing instead of non-compliant tubing.
Contains glucose instead of heparinised saline.
Contains a non-pressurised bag.
There is too much air in the tubing.
- How would you zero the equipment?
- What is high pressure zero?

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