OSCE Spring 2003
Tuesday, December 23, 2003
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OSCE Spring 2003/ London
1. Capacity to consent for treatment:
A 47- year old Ms Jackson was admitted to the surgical unit, with a diagnosis of stomach cancer. The Surgeons have offered her an operation to treat that. However, she refused to have the operation & would like to go home. She is known to the psychiatric services with recurrent depression. The surgical team has asked you to assess her capacity to give consent for her operation.
2. Explaining lithium treatment:
A 21-year old lady was admitted after her second manic episode. While In hospital she was started on lithium therapy. You are now seeing her in the out- patient's department, after she was discharged from hospital. Explain to her the implications of lithium treatment. The patient was particularly concerned about the side effects & wondered whether there was any other alternative to lithium.
3. Explaining ECT
Mr. Johnson is a 57-year old man, who was admitted to hospital few weeks back, with depression. He is known to suffer from hypertension & is currently on Atenolol 50 mg/day. He was tried on 2 different anti-depressants (Venlafaxine & Fluoxetine) for a sufficient length of time, with out much improvement. Your Consultant did the ward round this morning & decided to treat him with ECT. He asked you to explain that to him. You are not required to assess his capacity to give consent. Fellow patients on the ward has, advised him not to have ECT, & warned him about memory loss, following ECT.
4. Neurotic_ history:
A GP has asked you to see a 31-year-old business manager, who has been having difficulties coping with his job. He was involved in a car crash 6 months back. His friend was driving at the time. They went to A&E, but discharged the same day, without follow up. He was off sick for 2 weeks. After that he started to have anxiety symptoms, associated with flash backs about the crash, when traveling by car. His anxiety was not confined to any other situations. His job involved traveling between two sites, several times a day. He was worried about losing his job. His concentration was poor, but sleep, appetite & capacity of enjoyment were normal. There was no evidence of depression. He had no thoughts of suicide & DSH. He wasn't abusing alcohol or illicit drugs.
5. Explaining schizophrenia to relatives:
They repeated the same scenario on www.rcpsych.ac.uk
6. Eating disorder history:
A GP has asked you to see a 21-year-old diabetic lady, who has been losing weight. The GP was concerned about her dieting behavior. She has stopped taking her insulin on 2 occasions, in order to lose weight. The patient split up with her boy friend 6 months ago. Since then she has been binge eating 4 times a week. These episodes of binge eating were followed by self--induced vomiting & excessive guilt about eating.
She was swimming on daily bases, up to twice a day. She denied using laxatives & appetite suppressants. She was ambivalent about having dread of becoming fat & about self- perception of fatness. There were no depressive or anxiety symptoms.
7. History of psychosis:
A 36-year old man was brought to A&E by police. He gave himself up to the police earlier in the day, saying that he could no longer hide from them. He worked in the postal service in a local company. The casualty officer asked you to see him; your task is to assess his thinking. He felt that police were after him, because he put letters in the wrong boxes on several occasions. He also thought that they were monitoring him everywhere. He reported hearing noises out side his flat & he thought that police were waiting for him. He had delusions of reference & told me that newspapers have written about him, but didn't mention his name. He denied delusions of thought control & passivity phenomena. Denied having depressive symptoms. He also denied illicit drug use. He has been having symptoms for 3 months.
8. Risk assessment
You were asked to see a 25- year old unemployed lady in A&E. She was admitted following an OD. Talk to her & assess her risk. She took 4 tablets of cocodamol, after she had an argument with her boyfriend, she described the OD as a stupid thing which she regretted. She denied having thoughts of DSH & said she would never do it again. She denied using illicit drugs & was not drinking alcohol in excess. She lived in a 1-bed room flat with her boy friend having no financial problems. She took an impulsive OD a year ago, again after having an argument with her ex-boyfriend.
9. Fundoscopy:
I think it was proliferative diabetic retinopathy, with maculopathy.
Right eye: I saw micro-aneurysms, blot hemorrhages & hard exudates.
Left eye: the above + new vessel formation at 9 O'clock/ vitreous bleeding
at 6, hard exudates at 3 & a macular star.
10. Cranial nerves examination II-XII:
You are not required to do Fundoscopy, pin prick sensation on the face & gag reflex.
11. Alcohol history
A local GP has asked you to see Mr. Jones, who is a 55-year old financial adviser. His wife has threatened to leave him because of his alcohol problem. He had been drinking a bottle of Scottish whisky on daily bases for the last 10 years. He starts drinking 8 am to overcome withdrawal symptoms (palpitation, tremor, anxiety & agitation) He tried to stop drinking for a day or two, but started drinking again, because he experienced similar symptoms. He told me that he never had fits & never been psychotic. He first started drinking when he was 16 year old. He was drinking 2-4 pints over weekends, but gradually increased his intake over the years. He said drinking would help him to relax & concentrate better on his job, He had no financial problems &
Forensic history was unremarkable. He had a good insight to his problems & agreed to accept help to kick the habit.
12. Explain de-sensitization to a patient with agoraphobia
This station was probably the most challenging one. I felt that it wasn't just about explaining de-sensitization. The patient was very anxious from the start & talking about de-sensitization made her even more anxious. She kept saying, “I will have a heart attack”. Reassurance & putting her at ease was an important task in this station. I spent half of the time doing that, before she let me to proceed with explaining treatment. She asked me about who would see her for that "is It a psychiatrist or somebody else", Then she asked about how many sessions a week & for how long she would have the therapy. I explained to her about the waiting lists, one for assessment & the other for placement.
