NEUROLOGY & PSYCHIATRY OSCEs Neurology OSCEs 1.

CT Interpretation

Unobserved station. Head CT showing midline shift and haemorrhage. Essentially the patient has had a haemorrhagic stroke with a large blood clot resulting in midline shift. There are a series of MCQ questions about aetiology, treatment options and risk factors. 2. CSF Interpretation

Unobserved station. Lumbar puncture results with MCQ questions on possible diagnoses. Normal values NOT given. 3. Visual Pathways

Unobserved station. Match lesions in visual pathways to the type of visual defect (e.g. optic chiasm lesion leads to bitemporal hemianopia). True or False MCQs - arrows pointing to different
parts of the optic tract with statements like If there was a lesion in arrow A, the patient would have bitemporal hemianopia.

4.

Neuro Examination

Observed station. You are asked to examine a specific body region and specific modalities (e.g. sensation only) follow instructions carefully and always compare both sides. You may be asked for a differential diagnosis. 5. Visual Field Testing

Test peripheral and central vision on a patient. Neurology Written Examination 1) Head injury - learn criteria for referral to neurosurgeon and criteria for doing a CT scan 2) Parkinson drugs especially variation with age, alternatives and side-effects 3) Meningitis 4) Epilepsy drugs 5) Red eye - conjunctivitis, scleritis, episcleritis, uveitis, Reiter's syndrome 6) Loss of vision 7) Headache 8) Investigations for patients with seizures 9) Sensory neuropathy 10) Coma/Emergency Neurology

Psychiatry OSCEs

All stations have an examiner and a case scenario printed on a sheet of paper kept on the station desk. You are asked for the main points in the history and MSE (Mental State Examination) and then for a diagnosis. There is no actor present. For each psych case, start with the history (i.e. presenting complaint, past psych, personal circumstances etc) and then what aspects you would ask about in respect to the scenario you have been given (e.g. for depression ask about a positive family history whereas in the case of schizophrenia this is less important). Then go through the mental state examination and what you would expect to find in each case. Potential stations include: 1) 2) 3) 4) 5) 6) 1. Overdose Depression Paranoia Alcoholism Dementia viva station (instead of alcoholic patient history) Anxious patient (instead of depression) Overdose

Observed Station. This is essentially a risk assessment of someone with a history of DSH (Deliberate Self Harm) and attempted suicide. Discuss suicidal risk assessment, as well as features of the history that you might want to know to establish an underlying mental illness (e.g. depression). SUICIDE 2. Suicide - plans in existence or ideas of deliberate self-harm Unexplained or unbidden feelings of guilt or worthlessness Inability to function (e.g. psychomotor retardation or agitation) Concentration impaired Impaired appetite Decreased sleep (especially early morning awakening) Energy low (or unaccountable fatigue) Depression

Observed Station. This was quite a confusing history involving a sad and weepy woman presenting to A&E. Dont discuss suicide risk. Instead mention the biological symptoms of depression - signs, symptoms, and risk factors. DEPRESSION Down in mood (especially in the morning) Energy low Poor concentration / Psychomotor retardation Reduced appetite (with resultant reduction in weight may also be increased) Enjoyment reduced - guilt Sex drive reduced / sexual dysfunction Suicidal thoughts or attempts Insomnia Oversleeping (also possible)

Negative view of self, world and future (Becks Triad - feelings of worthlessness, helplessness, and hopelessness)

The OHCS (p.337) describes the 7 markers of severe depression patients with these symptoms are most likely to benefit from antidepressant drugs. 3. Paranoia

Observed Station. The scenario is of a young man who is paranoid that his neighbours were spying on him (i.e. schizophrenia). Ask about first rank symptoms, other symptoms, risk factors (e.g. positive family history) and a mental state examination. You are 16 times more likely to become schizophrenic if one parent was schizophrenic, and 50 times more likely if both were schizophrenics. Monozygotic-twins concordance rates are far higher in schizophrenia than most mental disorders with the exception of bipolar depression. The features of paranoid personality disorder are: PARANOID Persistently bears grudges / Perceives others as the enemy Assume the worst of people Rebuffs - very sensitive to Avoid discussing their business Never trusts people Occasionally can become psychotic Involve themselves in legal wranglings Delicate self esteem

Also remember the 5 Ss:

Suspiciousness Stubbornness Sensitivity to rebuffs Self-importance high Self-esteem low

Try to give a differential diagnosis not just paranoid schizophrenia. Drug-induced paranoid delusions and schizophrenia are important to exclude as Personality Disorders (PDs) are lower down in the ICD-10 hierarchy, but the schizophrenia can develop on a background of paranoid personality. The drugs used in the treatment of schizophrenia (neuroleptics) are also prescribed for paranoid (and for that matter, schizotypal personality disorders). Only discuss this when the history you are provided shows the patient has a chronic (long-term) personality disorder. The prepsychotic element to paranoid disorder is easy to remember when you know a little about the DSM-IV cluster A personality disorders. There are 4 types of schizophrenia:

CHiPS Catatonic Hebephrenic Paranoid Simple Here is a summary of schizophrenia:

SCHIZOPHRENIA

Simple Catatonic Hebephrenic Increased in single people ZM (monozygotic) concordance is 50% compared with 10% in DZ (dizygotic) twins Onset men before women Paranoid High expressed emotion perpetuates Residual/ chronic schizophrenia Equal sex incidence Negative symptoms/ Positive symptoms Increased in social classes IV and V Associated with obstetric complications/ season of birth and maternal influenza

The positive signs of Schneiders first rank symptoms occur in 70% of schizophrenics and 10% maniacs. Positive symptoms are present during acute exacerbations and are usually drug responsive, thus are state dependent: ABCD

A= Auditory hallucinations - 3rd person/echo-de-la-pense B= Broadcasting of thoughts/ insertion/withdrawal (thought disorder) C= Control experiences/ passivity phenomena D= Delusional perception

Negative symptoms are present both in the acute and residual stage of the illness and are generally not drug responsive thus are trait dependent. Bleulers 4 As (extended to 7) sum them up nicely: 7As

Autistic (withdrawal into a fantasy world, with poverty of speech and thought) Affect blunted Associational disturbances (Illogical or fragmented thought processes) Ambivalence(simultaneous, contradictory thinking) Alogia Amotivation Anhedonia
Alcoholic

4.

Patient

Observed Station. The scenario is one of an old alcoholic chef who several days after surgery is upset and showing signs of confusion. Consider the differential - it is likely to be delirium tremens, but other causes of delirium include infection post-surgery and thiamine deficiency leading
to Wernicke-Korsakoffs syndrome (this is usually precipitated by the patients admission to hospital and IV dextrose administration without concomitant thiamine replacement - thiamine is a coenzyme required for normal carbohydrate metabolism).

Wernicke is CAN (Confusion, Ataxia, Nystagmus) Korsakoff is CAR (Confabulation, Anterograde amnesia, Retrograde amnesia)

Do a mini-mental examination (What month, day, country, city, etc.) and an alcohol history using the CAGE questionnaire for the features of alcohol dependency syndrome (Churchill's Pocketbook of Psychiatry): Have you ever felt you should CUT down on your drinking? Have people ANNOYED you by criticising your drinking? Have you ever felt bad or GUILTY about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (EYE OPENER)

Signs of alcoholism: PR COST TO REWIRE

PRimacy COmpulsion STereotype TOlerance RElief WIthdrawal REinstatement

Delirium tremens consists of more than just the obvious delirium and tremor. Remember: SHIT

Seizures/Sweats Hallucinations (usually visual) Insomnia/Irritability Tremor DEMENTIA

5.

Observed Station. The scenario relates to an 83 year old man who is caring for his disabled wife, who is noticing impairment of his short term memory. He has been ambulated to A&E because the gas was left on. Anyways, your task is to find out about this patients loss of memory; discuss what aspects of the history you will be focusing on, and what investigations you will be requesting to find out about the most likely cause. There was no request to discuss what you would find on physical examination. The key thing about these viva stations is to keep the examiner occupied and preferably entertained, keep talking, and hopefully youll do well!

I think the ideal way of tackling this station would be as follows: 1. State that the most important issue here is to discriminate between an acute confusional state & dementia. The key difference is that delirium is acute and associated with a fluctuating level of consciousness. State that it is imperative to manage the patients physical condition first, and make it more stable, before taking any history. Say that you will make sure the patient is not hypoxic, youll measure his FBC, esp.

carboxyhaemoglobin, ABGs, and do your basic investigations. Next proceed onto the history; state that ideally you will confirm the history from a close friend or relative of the patient. State that you will do a mental state examination, concentrating on the cognitive element and the MMSE. 2. Next what I did was state my most likely diagnosis (Alzheimers disease), but explained that it is a diagnosis of exclusion there are no diagnostic tests for it (CT scan may show some global cortical atrophy, but thats about it. A brain biopsy, looking for the classic pathological changes (neurofibrillary tangles etc), is the diagnostic test but is rarely done. It is important to exclude other diagnoses first. 3. The differential diagnosis for dementia, which I briefly discussed one by one (findings in the history, investigations) etc. to the best of my ability, can be remembered best by using the surgical sieve (A VITAMIN C), but also as follows: DEMENTIA Depression/Deficiency of B12 (sub-acute combined degeneration of the spinal cord a misnomer because brain is also affected) Endocrine disorders (e.g. hypothyroidism) Multi-infarct dementia/ Muhammad Ali (i.e. Parkinsons & Lewy Body Dementia) Ethanol abuse Normal pressure hydrocephalus Tumours/ Trauma (history of accidents, falls on the head etc) Infections Alzheimers

Dont state this differential diagnosis like that, but instead bear it in mind, and go thorough each, very briefly, one by one, stating the most important features of each, e.g. numbness or fatigue, check the patients FBC (megaloblastic, macrocytic anaemia) and vitamin B12 for SCDSC; cold intolerance, heart problems, CTS features, lethargy, goitre, constipation & check FBC, TFT's etc for thyroid problems. 6. ANXIOUS PATIENT

Observed Station. This is a lady who is suffering an anxiety disorder; your task here is to take a history from her you will find out that she gets panic attacks whenever she goes to the supermarket or is in crowded places. Ask the patient what her main symptoms are (open question), and ask her specifically about the physical and psychological symptoms of anxiety. There are many of these, but I remember the main ones by:

Psychological WISCAR Worry

Physical SAD PUNCH Sweating/Swallowing problems (globus pallidus)

Irritability Sense of doom or panic Checking Avoidance behaviour/Apprehension Restlessness/ Reassurance seeking

Appetite down Diarrhoea/ Dizziness Palpitations/Paraesthesia Urinary frequency Nausea and vomiting Chest pain Hyperventilation

My patient had most of these features. Next you need to find out what type of anxiety disorder she is suffering from; its clear that she is agoraphobic but it is important to exclude other neurotic disorders (e.g. panic disorder, GAD Generalised Anxiety Disorder) before giving that diagnosis. 1. a. b. All the phobias are characterised by a triad so ask specifically about these: Specific phobic stimulus Anticipatory anxiety Avoidance behaviour In GAD, anxiety is pervasive (there all the time), and lasts > 6 months Panic disorder overlaps considerably with agoraphobia; many psychiatrists regard agoraphobia as a severe form of panic disorder with panic attacks indicating severity. They are both recurrent, associated with a need to escape and a fear of dying, going mad or losing control. The key difference is that PANIC DISORDER attacks are UNPREDICTABLE; in AGORAPHOBIA they are PREDICTABLE, and thus associated with this avoidance behaviour.

It is also important to ask every neurotic patient about depression (as soon as I asked about it the examiner ticked a box, so there you go!); 20% of neurotic patients are depressed. In a real life situation it is vital to ask specific questions about organic disorders that may be responsible (e.g. thyrotoxicosis, hypoglycaemia) and any substance abuse. 7. SUICIDE

If you do nothing else when assessing mental state - assess suicide risk Observed Station. The scenario was a depressed patient who attempted to commit suicide with TCA's (tricyclic anti-depressants). The station was organised such that you had to initially explain to the examiner your goals and priorities are (stabilise the patient [any patient who takes an overdose of TCA's need an urgent ECG in view of their cardiotoxicity], gain some understanding of the events leading up to the suicide attempt, explore personal and social circumstances, obtain an alcohol history and perform an MSE, in order to assess future risk of self harm and consideration of admission).

Now turn to the patient. Begin by introducing yourself, notifying your role, and ask the patient if you can talk to them. Ask them about the problem; what has been the trouble lately. Ask them how exactly did they attempt to commit suicide; how many tablets (or whatever) they took, whether they had anything else with it (always ask about alcohol in any depressed patient you get an instant tick!)? Why did they attempt to commit suicide, what was the real intention (explanation of reason and goal)? Ask them whether they regret their action, whether they would

rather not live another day, what problems confront him? Ask the patient about the risk factors for suicide. SAD PERSONS Sex: Male Age: Elderly (most cases >45 yrs) Depression (ask specifically about Becks triad) Previous suicide attempts (details if yes) Ethanol or drug abuse/ Employment (none, doctors, farmers etc) Recurrent psychiatric illness / Rage history Social support lacking (and isolation) (ask the pt who they go to for help)/Social class high or low Organised plan (e.g. alone, leaving a note, precautions taken to avoid discovery, timed so that intervention is unlikely) No spouse Sickness/ Stated future intent

Finally ask the patient what kind of help they might want. You have thereby incorporated Hamilton and Catalans questions in your history (they are the questions on page 10 of your suicide and parasuicide lecture handout). Psychiatry Written Examination There were 40 psychiatry MCQ's:. Make sure you know the little details of incidence, risk of suicide etc. 11) Head injury: learn criteria for referral to neurosurgeon and criteria for doing a CT scan! 12) Parkinsons drugs especially variation with age, alternatives if side effects 13) Meningitis 14) Epilepsy drugs; 15) Red eye - i.e. conjunctivitis, scleritis, episcleritis, uveitis, Reiter's syndrome 16) Loss of vision 17) Headache 18) Investigations for patients with seizures 19) Sensory neuropathy 20) Coma