Diagnosis and Management - OSCE 2024

What are the treatment options for eczema and give the order of when to use

1st line - emollients

2nd line - hydrocortisone (mild steroid)

3rd line - clobetasone (moderate steroid)

4th line - sedating antihistamine (if can't sleep)

describe emollient dosing

use regularly and liberally

describe hydrocortisone cream dosing

apply twice daily for a maximum of 7 days

describe clobetasone dosing

apply twice daily for a maximum of 7 days

what are the 1st and second line treatments for acne

1st line - benzoyl peroxide gel

2nd line - free derm gel

describe the dosing of benzoyl peroxide gel

apply once or twice daily to affected areas, avoid eyes

what is the extra information needed to be given with steroids

max 15g sold at a time, do NOT apply to face, genital area, broke or infected skin. Apply sparingly for a max of 7 days. Only use a pea sized amount for skin area the size of your hand.

what ages can you give hydrocortisone to

over 10s only

what ages can you give clobetasone to

over 12s only

what extra information needs to be given when giving benzoyl peroxide

can bleach hair, clothes etc

avoid the eye area

start very sparingly once a day, if irritation occurs be even more sparing, if skin can tolerate increase to twice a day

only pea sized amount needed

describe the dosing of free derm

use twice daily to affected areas

what are the first and second line treatment options for fungal infections

clotrimazole

terbinafine cream (laminal)

what ages can you use either clotrimazole or terbinafine cream on?

over 16s only

describe the dosing of clotrimazole

apply two to three times daily, normally for 2 weeks and then another 1-2 weeks after the lesion heals

describe the dosing or terbinafine

apply once daily fir 7 days only

what are the first and second line treatment options for athletes foot infections and groin (which can be used for what?)

1st line - tolnafate (foot and groin)

2nd line - undecenoates (foot only)

describe the dosing for both tolfanate and undecenoates

apply twice daily and continued for atleast 7 days after the lesion heals

describe the history taking needed for eczema

onset, where is it / how severe

recent travel?

occupational factors?

family/ household contract factors

When to refer eczema?

widespread/severe

secondary infection

pomphyolyx (fluid filed vesicles on hands)

facial lesions unresponsive to emollients

under 10s needing steroids

when to refer fungal infections?

on scalp

athletes foot in diabetics

what advice should you give to people with fungal infections?

wash affected area daily and carefully pat dry

what are the first, second and third line treatments for constipation

1st line - lifestyle advice

2nd line - bulk forming laxatives (Fybogel)

3rd line - Osmotic laxative (lactulose, macrogol sachets)

what additional information should be given for fybogel?

1. increase fluid intake

2. Up to 72 hours for effect

3. Contra in analgesics

4. continue until stools soften without straining 3x a week

what additional info should be given for lactulose/macrogol?

up to 48hrs for effect, lots of water!! continue treatment until stools soften without straining 3 times per week

if a child under 12 presents with constipation, what is the barrier to giving treatment

they need a prescription

what are the 1st and 2nd line options for treating diarrhoea

1st - oral rehydration (dioralyte)

2nd - Anti-motility drugs (loperamide or pesto bismol)

what age is pepto biysmol liscened for

over 16s only

what are the flavour options for dioralyte?

blackcurrant, citrus, plain

describe the dosing for dioralyte

1 or 2 sachets dissolved in 200-400ml water

describe the dosing for loperamide

2 capsules straight away followed by 1 after every loose bowel movement for a maximum of 8 in 24hrs

describe the dosing for peptobismol

30ml in dosing cup, take every 30mins to 1hr if needed - max of 8 in 24hrs

what are the treatment options for haemorrhoids

Germoloids (lidocaine) or Anusol plus HC (hydrocortisone)

who can hydrocortisone be used for

only over18s- can't be used in pregnancy

describe the dosing of germoloids

apply twice a day and after a bowel movement

describe the dosing of anusol plus HC

apply twice a day and after bowel movement, maximum of 4 times a day for 1 week

describe the 1st and 2nd line treatment options for IBS

1st line - hyoscine (buscopan IBS relief)

2nd line - meberverine (colofac IBS relief)

describe the side effects of buscopan (hyoscine)

dry mouth, constipation

what are the treatment options of mild dyspepsia

rennies (calcium and magnesium carbonates - antacids)

what are the side effects of magnesium salts and aluminium salts

magnesium can cause diarrhoea but aluminium can cause consipation

how do alginates work?

by forming a gel-like raft on top of stomach contents, preventing acid reflux

what are the 1st and 2nd line treatment options for heartburn

1.gaviscon (alginates)

2. PPI- omeprazole , esomeprazole etc

what can be taken alongside gaviscon for heartburn

Antacids

how long should treatment with PPI last?

no longer than 2 weeks if symptoms don't improve, max 4 weeks OTC treatment, see GP if symptoms reoccur after treatment

vomiting associated with gastroenteritis (stomach bug)

oral rehydration therapy (dioralyte)

what should be considered when giving dioralyte for vomiting

can the fluids even be tolerated?

what are the treatment options for migraine related nausea and vomiting? and what is the route of administration? and what age?

Prochloperazine buccal tablets (high in the top lip) over 18s only

what are the 1st and 2nd line treatment options for travel sickness

1st line -antihistamines (cinnarzine, promethazine)

2nd line - anticholinergics (hyoscine)

what ages are the antihistamines liscenced for?

adults only

what are the treatment options for mouth ulcers?

Not in any order

1. chlorhexidine mouth wash

2. Choline salicylate (bonjela)

3. lidocaine gel

3. hydrocortisone oromucosal tablet

what needs to be noted about the hydrocortisone tablet

should not be sucked, allow to dissolve close to ulcer

what needs to be noted about the bonjela get

dont use more than once every 3 hours

what is the pneumonic for red flags in constiption?

ALARM

Anaemia

Loss of weight

Anorexia

Recent onset of symptoms

Malaenia (blood in poo)

what are the red flag symptoms for diarrhoea

blood in stool

unable to drink fluids, dehydration associated vomiting

tiredness, weakness, dry mouth, sunken eyes, decreased utine output, thirst

weight loss

recent hospital stay or antibiotics use (CDIFF)

diarrhoea referral symptoms

recent foreign travel + presence of foul smelling, watery discharge

recent or sudden change in bowel habit

failed treatment

symptoms longer than 2-3 days in children or elderly

medicine induced

lifestyle advice for diarrhoea

plenty of clear fluids

avoid very sugary drinks

avoid milk and milky drinks

eat depending on appetite

careful hygiene

haemorrhoids referral symptoms

blood in stools

3rd or 4th degree harmorrhoids

persistent and/or sudden change in bowel habit

severe pain/stabbing / sharp pain with defecation

symptoms taht dont resolve within 7 days

haemorrhoids advice

avoid constipation (lots of fibre and water)

anal hygiene

dont ignore the call

avoid straining

positioning

haemorrhoids red flag referrals

unexplained weight loss

rectal bleeding

recent change in bowel habit

persistent bloating in females over 50

symptoms with family history of bowel cancer

patients with NO HISTORY IBD

haemorrhoids lifestyle advice

-any trigger foods to avoid?

-any stress or physiological changes that could have caused?

- avoid missing meals , have regular meals

-atleast 8 cups of fluid per day

-avoid fizzy drinks

-high fibre foods + greens

-daily oats, limit fruit to 3 x day

what are the risk factors for dyspepsia

pregnancy, medicines such asCCBS, steroids, smoking, overweight, family history

dyspepsia red flags

anaemia, coffee ground vomiting

loss of weight unexplained

anorexia

recent set of progressive and recurrent symptoms - including change in bowel habit

melena

abdominal or bacl pain with weight loss

what timeline should you refer dyspsia when treating

when treatment failed in 7-14 days

referral symptoms nausea and vomiting

-severe abdominal pain

-dehydration

-blood in vomit

-recurrent symptoms - can't keep fluids down -refer the same day if sick one or twice a days for 2 days , refer kids in 24 hrs , in neonates, refer any vomiting

-pregnancy

what are the possible causes of mouth ulcers?

stress

trauma

nutritional deficiencies

food sensitivities

questions to ask about ulcers

-how many do you have, one larger or smaller individual

-where are the ulcers? side, tongue, side of lips or near back of mouth?

-shape - small or big

-painful?

-any recently prescribed drugs or recent dose increases, cytotoxic drugs (imunosuprresors), NSAIDs, beta blockers

-can you think of a cause, trauma?, born from food? biting lip?

referral symptoms mouth ulcers

a single lesion lasting longer than 3 weeks (potential oral cancer)

larger than 1cm

crops of 5-10 or more, duration, painless ulcers

multiple size involvement

advice for mouth ulcers

-avoid cause (if known)

-decrease levels of house dust mites

-avoid drying soaps

-avoid perfumed toiletries

-avoid abrasive clothing

-sunshine

describe the questions to ask when history taking for acne

-duration, type and distribution of lesions

-previous treatment and response

-factors that may contribute to exacerbations

-physiological impact of acne- anxiety, low mood

-family history

when to refer for acne

moderate or severe with risk of scarring

occupational/ drug induced acne

OTC treatment failure after 2 months

Rosacea

advice for acne

-can take 8-12 weeks for improvement

-wash area carefully before application of treatment

-stress can make acne worse

-sunlight helps

-avoid greasy heavy moisturisers/ makeup

-avoid squeezing spots

what are 1st and 2nd line treatment options for bacterial conjunctivitis

1st line - self help (keeping it clean + hot compress)

2nd line - chloramphenicol

what are the dosing instructions for chloramphenicol eye drops and ointment

eye drops - STORE IN FRIDGE

-1 drop every 2 hours for 48 hours then 1 drop every 4 hours (max of 5 days treatment0

-chloramphenicol ointment (can make vision a bit blurry as oil) apply 3-4 times daily or once at night (at night recommended)

DONT USE CONTACT LENSES

when should you avoid chloramphenicol

under 2 years

avoid in pregnancy or breastfeeding

avoid If history of breast-feeding or bone marrow problems

what are the 1st and 2nd line treatment options for allergic conjunctivitis

1.self help (cold compress - cold wet towel) + sodium cromoglycate eye drops (opticrom allergy)

2.Otrivine antistin (combo)

DONT USE CONTACT LENSES

when should you use sodium cromoglycate

use continuously when exposed to allergen

when shouldn't u use otrivine antistine

avoid in patients with glaucoma and only use short term as rebound effects

what is the 1st line treatment option for dry eyes

hypromellose

what are eye red flags?

-pupils, irregular shape, non responsive to light (A&E) cloudy pupil

-iris (coloured part of eye) if red

-pain

-foreign body

-clouded cornea

-distortion of vision

-photophobia

-vomiting

describe the symptoms of conjunctivitis

-junk in corner of eye

-eye is crusted when you wake up

-both eyes infected but one eye before the other

-no other symptoms

self help for bacterial conjunctivitis

-bathe eyelids with lukewarm water / saline to remove any discharge

-use tissues to wipe eye and then discard

-avoid contact lenses

-wash hands, avoid sharing towels, good hygiene

symptoms of viral conjunctivitis

more likely just one affected eye

generalised redness

maybe associated symptoms of cough or cold

self help for allergic conjunctivitis

cold compress

avoid allergen

avoid rubbing eye

consider artificial tears

describe a sub conjunctival haemorrhage

red eye, from falling over or damage to eye, heals by itself

describe management of a subconjunctival haemorrhage

refer if there is any pain or photophobia or any vision problems, otherwise it is fine to leave, reassure patient

describe what episcleritis looks like

describe the management of episclerirtis

in general is it self limitng

refer to optician if experimenting any pain or discomfort, photophobia etc

suggest paracetamol / ibuprofen for discomfort

often linked to autoimmune disorder

describe keratitis

redness around the eye, can be very painful

watery discharge

photophobia

open leison to eye

describe the management of keratitis

refer

describe uveitis

redness

watery discharge

photophobia

changes in vision

what does a stye look like

how do you manage styes?

-reassure patient that they are self limiting and symptoms will resolve once stye has ruptured

-advise to not pick or squeeze

-warm compress for 5-10mins, 2-4 times a day, will bring it to a head quicker

-refferal only needed if it doesn't resolve

what does blepharitis look like

describe the management of blepharitis

advise good eyeliud hygiene , clean twice a day

apply warm compress to closed eyes for 5-10mins 1 or 2 times a day

baby shampoo diluted 1-10 with water and wipes on eyelids with cotton bud or cloth twice daily, reducing to once when symptoms improve

refer if no improvement in 7-14 days

what are the symptoms of dry eyes

burning, tired eyes

itching, irritated, gritty

lack of ocular redness

long standing history of symptoms

what are the 1st and 2nd line treatments for cystitis

1st line, paracetamol or ibuprofen plus fluids

2nd line, cymalon, canesOasis (not recommended by NICE)

I would recommend d mannose

what are the 1st and 2nd line treatments for vaginal candiasis

1st line fluconazole 150mg oral capsule

2nd line clotrimazole pessaries (internal cream or internal and external, or plus tablet)

ALL not liscenced in pregnancy

what should be noted about internal preparations

only use at night

what is a common side effect of fluconazole

GI disturbances

risk factors

pregnancy, undiagnosed diabetic, increasing age, sexual activity

possible causes in men

underlying bladder or prostate infection

obstruction/ tumour

enlarged prostate