Pwh Osce

Front 1

Initial newborn examination

Back 1

Wash Hands; Consent/explain to parent; General appearance (jaundice/cyanosed, resp distress, movement, obvious abnormalities); Head (fontanelles, sutures, symmetry, red reflex, ears, mouth/palate); Extremities (morphology, creases); Chest (wall deformities, thrill, heart & breath sounds); Abdomen (distension, umbilical cord, bowel sounds); Pelvis (testicular descent, defined genitalia, patent anus, femoral pulses, hip dysplasia), Back (spinal definition; tube defects); Neuro (Moro reflex, tone, suckling reflex, palmar grasp, stepping)

Front 2

Newborn resuscitation

Back 2

Wash hands; Prep equipment (Heat/Light - 100%, Oxygen - 5L/min, Suction, Blanket); Assess neonate (APGAR, resp distress, meconium, HR); Wipe down baby (if no meconium aspirate); Suction; HR < 100 (head in neutral position, apply 30-60 bpm, reassess every 30s); HR < 100 (ensure airway patency, consider increasing pressure); HR <60 (commence compressions 3:1 w/ventilation, reassessing every 30s); HR < 60 (consider intubation, venous access, adrenaline); continue until crying or adequate spontaneous breathing/HR attained

Front 3

APGAR scoring

Back 3

appearance (colour); pulse (<100); grimace (irritability to stimuli); activity (tone of muscles); respiration (strength of cry)

Front 4

Signs of respiratory distress in neonate

Back 4

nasal flaring, grunting, tachypnoea (>60bpm), paradoxical breathing (bellows breathing), chest wall recessions, cyanosis, limp tone

Front 5

Causes of respiratory distress in neonate

Back 5

TTN, RDS, meconium aspiration, sepsis (GBS), acidosis, pneumothorax, cardiac

Front 6

Cord gases: normal and hypoxic pH

Back 6

normal arterial pH: 7.24; hypoxic pH < 7.10

Front 7

CXR: interpretation

Back 7

ID (name, age, gender, date), Orientation (PA/AP, erect/supine, L/R), centred (clavicles/ribs), Diaphragm (costophrenic angles, right dome slightly higher, herniation), Stomach (bubble present), Silhouette-sign, hilar region (markings), Opacity (symmetry, 'ground glass', signs of collapse), cardiac shadow (normal up to 0.6 cardiothoracic ratio, 'triple bulge' on left mediastinal border), Comment on venous access/drains/feeding tubes/etc

Front 8

Neonatal abstinence syndrome: assessment

Back 8

At risk (maternal substance abuse, ethanol, opioids, barbituates, benzos, caffeine, others), Symptoms (loud/high-pitched crying, sweating, yawning, GI disturbances, tremor/jerks, convulsions, frequent sneezing, nasal flaring), PE (temp, tone, birth defects, RSD, resp rate), Finnegan 31-item scale (every 4 hrs, commencing treatment if 3 consecutive scores >8or 12 for 2 scores), Treatment options: morphine- monitor cardiorespiratory function (opiates), phenobarbitone (non-opiates e.g. benzos, barbiturates, alcohol)

Front 9

Jaundice: assessment and causes?

Back 9

Causes (physiological, hypothyroidism, obstructive, infection, blood-group incompatibility), Management (phototherapy, supportive care)

Front 10

Jaundice history, examination and investigations

Back 10

HISTORY: Age, gest, sex (males more likely with G6PD which is X-linked), pregnancy and any complications during delivery (instrumental --> ? cephalohaematoma or subgaleal haemorrhage), meconium, breast feeding, APGARS, growth charts, when/how jaundice noted, any assoc symptoms [difficulty feeding, lethargy], receiving treatment, FHx of jaundice; EXAMINE: General obs, activity, tone, temperature, urinalysis, colour [yellow sclera or skin, pallor of anaemia, plethora of polycythemia], growth [?small for age], abdominal exam [hepatosplenomegaly as a sign of extramedullary erythropoiesis], any sign of encephalopathy?; INVESTIGATE: Transcutaneous bilirubinometer, SBR (total/conj), FBC, blood film (fragmented RBCs & spherocytes seen in haemolysis), blood group & Rh (mum & bub), Coombs test, G6PD screen, TSH

Front 11

Guthrie test card screens for?

Back 11

Cystic Fibrosis, Congenital Hypothyroidism, PKU, galactassaemia

Front 12

When is Guthrie test card performed?

Back 12

At least 48 hours post-breast milk, so usually day 4-5

Front 13

Breast feeding education

Back 13

Benefits to baby (provided on demand; nutritiously balanced; antibodies; reduced ear infections, less NEC, less risk of allergies/atopy, diabetes, SIDS), Benefits to mother (bonding with baby; cheap; involution of uterus; weight loss; delays menstruation/ovulation; reduced breast discomfort/infection; reduced risk of PPH; reduced risk of breast/ovarian cancer, UTI, osteoporosis), Changes in milk (start of production, letdown, colostrum, maturation), Timing (within 30 min of birth, every 1 to 3 hours, exclusivity until 6/12, maintain 6/12-24/12), Technique (skin-to-skin, grip, alignment, shape nipple, stimulate lower lip, bring baby forward as mouth opens), Sufficiency (1+ poo/day, 7 wet nappies), Common problems (sore nipples, engorged breasts, blocked ducts, mastitis, insufficient milk)

Front 14

Breast feeding: signs of correct attachment

Back 14

Mouth open wide, aerola emersed in mouth, lower lip curled back, slow rhythmic sucking movements

Front 15

Mastitis: education

Back 15

Symptoms (hardening, plugged, painful, fever, chills), Cause (S aureus, E coli, streptococcus), Tx (continue nursing frequently, apply heat before feeds, massage during, NSAIDs, discard pustulent milk, moisturize nipples), Antibiotics (>24hrs of symptoms, flucloxacillin/dicloxacillin/cephalexin 500mg QID until resolved)

Front 16

Discuss contraception options

Back 16

OCP (usage, missed doses), OCP benefits (endometrial and ovarian cancer, reduced menstrual bleeding, controls endometriosis, reduced risk of PID), OCP risks (DVT/PE, stroke, mood changes, weight gain/fluid retention, nausea, breakthrough bleeds, acne, migraine, no barrier from STIs, inhibits lactation, breast/endometrial cancer), PoP (less effective, same time each day), Implanon (progestin implant for 3 years, no compliance issues, no E2, 80% amenorrhea), IUD - Copper/Mirena (10 year protection, bleeding with Copper, low dose P4 w Mirena, compliance), Barrier - condom (STIs but HSV, human error), Barrier - diaphragm (fitted)

Front 17

Gynaecological history

Back 17

Presenting complaint (site, onset, characters, etc), Periods (menarche, cycle length, duration of menstruation, heaviness, LMP, intermenstrual bleeding, spotting, post-coital bleeding, pains, gushing, clotting), Pap smears (sexually active, last PS, any abnormal, vaccinated), Parity (contraception, new partners, pain, STIs, discharge, pregnancies/miscarriages/ToP/planned, IOL/SRM, mode of delivery, complications), Other conditions/hospital admission, Surgeries, Medications, Social, Family ...

Front 18

Menorrhagia: assessment & management options

Back 18

History (Menstrual, Dysmenorrhoea, Thyroid symptoms, Pap smears, HxObs, surgeries, meds, social), PE (Gen appear, Thyroid, Abdo, Pelvic), Ix (FBC, beta-hCG, pap smear, TVUS, hysteroscopy), Management (hormonal, endometrial ablation, hysterectomy)

Front 19

Pap smear - explanation and consent

Back 19

Assess patient's experience, explain cervical anatomy, cervical cancer development from HPV, progression and screening (frequency), treatment options, explain procedure: (remove clothing/coverage, palpate abdomen, insert speculum & open, inspect cervix, sample with cytobrush, smear on slide & adfix, release and remove speculum, insertion of two gloved fingers, palpate uterus with free hand, feel for adnexal masses, finished and change), give opportunity to ask questions

Front 20

Pelvic exam and pap smear

Back 20

consent and ask to remove clothing/cover, prepare slide/gloves/speculum, reassure about pain/vocalize if any pain, explain findings throughtout, warm hands, palpate abdomen, turn on light, wash hands, put on gloves, lubricate (if desired) & insert speculum/lock open, inspect cervix, sample with cytobrush, smear on slide & adfix, release and remove speculum, insert two gloved fingers to posterior fornix, palpate uterus with free hand, feel for adnexal masses, ask patient to change, discuss follow-up of results

Front 21

Pap smear - discussion of abnormal findings

Back 21

Discuss HPV (transmission, prevalence); CIN I (if <30 redo PS in 6/12; if >30 colposcopy); CIN II (colposcopy & biopsy; repeat in 4-6/12 for resolution/progression); CIN III (colposcopy & biopsy, discussing LEEP/laser/cone bx options, reviewing yearly for 2 years after cure)

Front 22

Prenatal planning: education and screening

Back 22

Folate (1/12), Bloods - assessment (ABO, Rh, FBC, platelets, iron studies), Bloods - infections (Varicella, Rubella, Syphilis, HBV), MSU (dipstick), consider others (pap smear, haemoglobinopathy, thalassaemia, vitD if dark skinned, HCV, HIV w/counselling)

Front 23

Subfertility: assessment (woman)

Back 23

History (duration, freq of intercourse, menstrual history, past contraception, pap smears, other gyn cond'ns such as PCOS/endometriosis/thyroid/STIs, surgeries, medications, drugs/EtOH), PE (BMI, signs of PCOS, thyroid, galactorrhoea, abdomen, VE), Ix (PRL, TFTs, pap smear, FSH/LH/E2/P4, pelvic U/S, PCOS: T/DHEA(S)/andro/17-hydroxyprogesterone, beta-hCG, tubal patency, complete antenatal screen)

Front 24

Subfertility: assessment (man)

Back 24

History (previous children, STIs, erectile dysfxn, regular intercourse, drugs/EtOH, FHx of infertility, occupation), PE (secondary sex char, abdo exam, genital exam), Ix (semen analysis, Ab-sperm, FSH/LH/T, chromosomal analysis)

Front 25

Antepartum Exam

Back 25

General inspection (demeanour, pallor, scars, tattoos, rashes); Obs (BP, RR, HR); Thyroid Ex; CVS Ex; Resp Ex; **Abdo Obst Ex: expose patient's abdomen; pt rest arms at side; inspect (masses, scars, pigment, fetal movements); fundal height (symphysis pubis, should be 1cm/wk +/- 3cm; fetal lie (long/obl/trans; engagement?); fetal HR (over fetal back -- HR: 110-160bpm)

Front 26

Explain Antenatal Screening

Back 26

INFECTIONS: MSU (asympt bacteriuria), HBV, HCV, HIV, Rubella, Syphilis. RBCs: Anemia (booking & 28/40 when other scr tests performed); Bld grp + Rh (early); atypical red cell alloantibodies (early + 28/40, regardless of Rh status); identify hi risk grps by 10/40 (sickle cell, thal). ANOMALIES: DS: 11-13/40 -> (triple test), morph U/S 18-20/40 allows prep for special Tx/palliative care/disability/TOP. Scan limits: anomaly type, woman's BMI, fetal position. GDM: RF's: BMI >30; prev macrosomia; prior GDM; FHx of DM; family origin (S Asian, Carib, Mid East - offer testing) PRE-ECLAMPSIA: each visit BP + urine; (RF's: 40yrs+; nullip; last preg >10yrs; FHx of pre-eclamp; BMI 30+; CVD (HTN); renal dis; multi-preg. PLACENTA PRAEVIA: if low lying picked up at 18/40, monitor rest of preg. If extends over int os, offer scan at 32/40, & counsel.

Front 27

Ultrasound: indications

Back 27

0-10/40: threatened/recurrent abortion; ectopic; hyperemesis. 11-20/40: routine scan at 18-20 weeks; est fetal maturity; detect multiple pregnancy & fetal malformation; CVS/amnio in conjunction with U/S. 21-30 weeks: detection of multiple pregnancy; diagnosis of fetal death; APH, polyhydramnios. 31-40 weeks: placental location; APH; pre-eclampsia; diabetes; severe renal disease; malpresentation; multiple pregnancy.

Front 28

Antepartum haemorrhage: history & exam

Back 28

HISTORY: 1) Presenting Feat.s (timing, qty (#pads & satur.); assoc feat.s (abdo pain, contractions, fevers/chills); provoking factors (trauma, intercourse); fetal movements Hx, 2) Current Preg: prev episodes of bleeding; r/v U/S exams, note placental site on 20/40 scan, 3) Past obstetric, genetic, med & surg history including any previous STIs (one of the DDx is septic abortion). APH EXAM: A) Pt's general cond'n - pulse, BP, temp. If non major APH, vitals should be normal, B) abdo: uterine tenderness, fundal height, lie & presentation, C) speculum-only exam

Front 29

Gestational Diabetes: education

Back 29

Testing (26-28 weeks, 50g GCT, results: GTT), complications if poorly controlled (pre-eclampsia, PPH, miscarriage, C/S, IUGR, congenital malformations, 50% risk of developing T2DM in next decade, foetal hypoglycaemia, RDS), treatment (mother: weight loss, diet, insulin, reevaluate in periperium), Delivery (IOL between 39-40/40, C/S if over 4.25kg, betamethasone if <36/40, nifedipine for tocolysis if <37/40, test urine for ketones)

Front 30

Antepartum History

Back 30

INTRO (name, age, parity, reason for visit); Hx of CURR PREG (est GA/DOC, LMP: cycle regularity, recent OCP use, U/S & CGA; care model: GP/shared/midwives/specialist; BP, Serology-blood group, Abs, Immunity/infections); CARE to DATE: reg visits, BP, clinical assessment of fetal growth; screen for DS, 18/40 morph scan, 28/40 GCT; PREV OBS Hx (Dates, FPML, gestation(s), wt & sex, wellbeing now, probs in labour/preg, delivery mode); GYN PROBS (STIs, endometriosis, infertility, surgery, PCOS); PAP SMEAR Hx (dates, results of recent, any abnormals); PREV MED/SURG/PSYCH Hx; MEDS (Allergies); SOCIAL (marital status, supports, employment); Smoking; Alcohol; Other drugs; Family Hx

Front 31

Antenatal History (a different approach)

Back 31

CURRENT PREG: Spontaneous/assisted, planned/wanted, EDC/GA by LMP or U/S (?singleton, multiple, any uterine/ovarian problems detected), any other screening/Ix to date, on multivitamins/folate preconception, rubella/varicella immunity status, current preg symptoms (1st tri: hyperemesis, breast tenderness, urinary symp; 3rd tri: GORD, back pain); PAST OBST Hx: pregnancies (for those >20/40: gestation at delivery, mode of delivery, complications for mum [PPH, infections, depression] or bub [shoulder dystocia, feeding, growth, development]), miscarriages (gestation, treatment, any complications), terminations (gestation, mode of TOP, complications), ectopics (where, gestation, Tx, complications); BRIEF GYN Hx: Last pap smear and/or mammogram, sexual activity, partners & any problems, bleeding, vaginal discharge, STIs, pelvic pain; SOCIAL: living situation, financial, smoking, drinking, drugs, supports; MEDS: current meds, allergies; BRIEF MED/SURG/PSYCH Hx & EDINBURGH DEPRESSION TEST

Front 32

Intrapartum history

Back 32

Patient name and age, parity, single or multiple pregnancy, mode of previous deliveries and any complications, brief medical and surgical history, meds (including syntocinon) and any allergies, progress of labour (contractions, VE), status of membranes, colour of liquor, use of analgesia (pethidine, epidural and times of these), assessment of foetal wellbeing (FHR, CTG)- MAKE SURE YOU CHECK FOR SCARS (female genital mutilation still happens and may need to trial the scar), PLACENTA PRAEVIA, MULTIPLE PREGNANCY OR BREECH, GDM, HTN, ANAEMIA, IUGR CONCERNS, MATERNAL ILLNESS (including T1DM, asthma, epilepsy, stroke or cardiac disease)

Front 33

Hypertension: assessment in pregnancy

Back 33

defn: BP >140/90. Occurs prior to 20 weeks, most likely due to chronic HT. After 20 weeks, HT is indicative of pre-eclampsia. Sx of Preeclampsia: visual disturbances, headache, epigastric pain, rapid onset oedema. Maternal SBP >160 or DBP >110 --> severe pre-eclampsia. Mgmt: 1) Confirm Dx: a) HT (take serial BPs every 4hrly) with proteinuria (>300mg in 24h), b) 24h urine collection + UECs (uric acid clearance falls--> rise in serum levels to >0.35mM; hypokalaemia suggests a different cause for the HTN; creatinine > 0.09mM inducates impaired GFR), c) FBC (?volume contracture, thrombocytopenia (DIC))+ film, d) LFTs (elevated, especially AST suggests liver damage) e) Neuro signs (clonus, hyperreflexia, visual changes, headache), f) IUGR (reduced fundal height) 2) admit patient for assessment/surveillance and possible need to deliver [MgSO4, steroid cover, hydralazine/clonidine/methyldopa, fluids to avoid hypovolemia]

Front 34

Risk factors for Pre-eclampsia

Back 34

pre-eclampsia in prev preg; FHx of pre-eclampsia; primigravida; new partner; multiple pregnancy; primary hypertension; diabetes; renal disease; connective tissue disease

Front 35

Seizure in pregnancy: management

Back 35

1) Call for help, 2) remove anything harmful from pt's vicinity & roll pt on her side, 3) O2, if able, 4) check for pre-eclampsia (swollen facies, generalized oedema, HT), 5) treat for eclampsia if pt doesn't stop seizure -- a) cannula for FBC, coats, BSL, UEC, CMP, b) IV MgSO4, 6) if seizure stops, stabilize mother -- a) ABCD, b) treat HT aggressively (hyrdalazine 5mg IV), c) maintenance dose of MgSO4

Front 36

PE in pregnancy: management

Back 36

1) admit to hospital, 2) IV therapy with heparin for 5-10 days, 3) chemoprophylaxis throughout pregnancy, 4) thrombophilia screen: Factor V leiden, Factor S+C deficiency, AT III deficiency, Lupus anticoagulant, Anticardiolipin antibody

Front 37

Caesarian: consent

Back 37

1) Describe nature & EXPLAIN procedure, 2) BENEFITS: secure safest/quickest route of delivery when vaginal delivery risks outweigh those of C/S, 3) RISKS: SERIOUS - emerg hysterectomy, further subseq. surgery (ie. curettage, damage to bowel, bladder or blood vessels), admit to ICU, bladder/ureteric injury, DVT/PE, uterine rupture, stillbirth, pl previa/accreta in future preg, 4) RISKS: FREQ: wound discomfort for few months, repeat C/S, infection, hemorrhage, lacerations to fetus, transfusions

Front 38

Bishop's score: factors assessed

Back 38

dilation, cervical consistency, cervical length, cervical position, station of fetus

Front 39

Induction of labour: assessment

Back 39

Examine (fetal presentation, lie, engagement, Bishop's score > 6), ????????? (station 8 of ALL Osce stations)

Front 40

CTG interpretation

Back 40

DR C BRaVADO: Detect Risk (any abnormalities); Contractions (4-6/10min); Base Rate (HR: 110-160); Variability (5-25bpm); Acceleration (reassuring); Deceleration (presence; benign/path); Overall assessment + plan (normal, foetal distress)

Front 41

Placenta: signs of detachment

Back 41

a) cord lengthening, b) gush of blood, c) firming/rising of the uterus

Front 42

PPH: assessment and management

Back 42

Caused by 4 Ts (Tissue, Trauma, Tone, Thrombin); Primary if >500ml in first 24hr; contact consultant/theatre/anaesthetist/blood bank, Resus (review ABCs, 2x16G, fluids), ensure 3rd stage labour completed, admin oxytocic agent, massage uterus and inspect birth canal, admin misoprostol PR (tone), progress to PGF2 into myometrium, proceed to theatre if not resolved (99% will cease before this)

Front 43

Peurperial history

Back 43

Baby (concerns; sleep; activity; crying; weeing; pooping), Mother (coping; recovery from labour; breast feeding; energy levels; mood)

Front 44

Menopause: evaluation & education

Back 44

Menstrual history (LMP, cycle length, bleeding, pain, pap smears, MMGs, contraception, parity), Explanation (onset ~51, 12 months amenorrhea), Symptoms (mood, flushing, night sweats, vaginal dryness, sleep disturbance), Treat symptoms (testosterone for libido, estrogen gels for dryness, temp HRT if not c/i, benefits/risks of HRT)

Front 45

Analgesia in labour

Back 45

Entonox (nitrous oxide/oxygen), narcotics, epidural, spinal block

Front 46

Epidural: Consent

Back 46

Explain procedure (position patient at edge of bed, hug pillow fwd to expose lumbar spine, insert needle & local anaesthetic, give anaesthetic with opioid, leave catheter in place, monitor BP/HR for 30min); Complications: failure, high block, dural tap leading to headache, subarachnoid injection; backache, infection (abscess is worse case scenario), haematoma, neurological deficits and paralysis; If patient becomes hypotensive (due to sympathetic block): tilt bed down, give oxygen, CTG, call anaesthetist!