3-5th year osce

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Peer-Assisted Learning Initiative / Glasgow University Medical School / peerassisted.org

3rd

– 5th

Year OSCE

Notes and mock mark schemes

April 2011

Peer-Assisted Learning Initiative

Glasgow University Medical School

peerassisted.org

Chan P, Katechia DT, Thant KZ, Adams C, Alanie O, Boyle A, Brookfield S, Connelly

L, Devine K, Dyer K, Hynd I, Kidd A, Little C, Low L, Lumsden A, Lynch L, Peiris D,

Sadler R, Syeda S, Tindell A.


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Contents

Breast examination

Cerebellar examination

Cranial nerves III-VII

Fundoscopy

Intramuscular injection

Intravenous cannulation

Neck examination

Otoscopy and free-field voice test

Peripheral arterial examination

Suturing

Visual acuity testing

Digital rectal examination

History: Assessing suicide risk

History: Chest pain

History: Dysphagia

History: Falls and palpitations

History: Giving information – Colonoscopy

History: Haematuria

History: Headache

History: Hyperthyroidism (thyrotoxicosis)

History: Jaundice

History: Rectal bleeding

History: Shortness of breath

A note on the contents

This work was produced entirely by final year MBChB undergraduates at Glasgow University

Medical School in April 2011. The contents are in no way official documents used by the

medical school for assessment purposes.


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Year Mock OSCE Mark Scheme

Breast examination

Instructions: Perform a full breast examination on this breast model/patient.

Time: 5 minutes.

Task Marks

1. Introduces self and checks identity by asking full name and date of birth. 0 1

2. Explains procedure and gains consent. 0 1

3. Offers chaperone. 0 1

4. Washes hands before and after examination. 0 1

INSPECTION

5. General inspection (e.g. cachexia, distress). 0 1

6. Inspects breasts with patient!s arms by her side. 0 1

7. Inspects breasts and axillae with hands on hips. 0 1

8.Inspects breasts with patient pushing down on bed or hips and comments on any

dimpling (tethering).0 1

0 1

0 19.

Comments on:

1. Symmetry.

2. Skin changes (e.g. peau d!orange).

3. Lumps.

4.

Scars.5.

Nipple changes (e.g. inversion, Paget!s disease).

6. Nipple discharge.

! mark for each. 0 1

PALPATION

10. Positions patient lying flat with hands behind head and asks if tender anywhere. 0 1

11. Palpates four quadrants of breasts. 0 1

12. Palpates axillary tail. 0 1

13. Palpates lymph nodes (axillary, supraclavicular ± head and neck). 0 1

0 1

0 114.

Describes masses appropriately: site, size, shape, consistency, surface, temperature,

tenderness, mobility, overlying skin.

Up to 3 marks available. 0 1

SUMMARY

15. Summarises findings and offers differential diagnosis. 0 1

16. Mark for excellence. 0 1

Circle: Pass / Borderline Pass / Fail Total marks: ______ / 20


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3rd

Year OSCE Revision Course Notes

Breast examination

Written in April 2011 by Andrew Boyle and Alistair Tindell.

How to describe a lump

• Site (e.g. “mass in the upper inner quadrant of the left breast”).

• Overlying Skin (Colour? Punctum? Discharge?)

• Size.

• Shape.

• Consistency.

• Surface (craggy/smooth).

• Temperature.

• Tenderness.

• Fluctuance.

•

Tethering to skin.• Transillumination.

Always check local lymph nodes if lump is found.

Malignant Lump

• Overlying skin changes – tethering, peau d!orange.

• Nipple inversion/discharge.

• Non-tender, firm.

• Non-fluctuant, no transillumination.

• Irregular, craggy.• Attached to deep tissues ± skin.

Triple Assessment

(very likely to be asked this, good to know for OSCE and clinical attachments):

• Under 35y:

1. History and examination.

2. Ultrasound (+ mammography if >35yrs).

3. Fine needle aspiration (faster, only shows cells) or core biopsy (shows structure).

For distant disease, further investigations are needed to detect metastases (e.g. LFTs, CT, skeletal survey).

Staging

Nottingham Prognostic Index (tumour size, tumour grade, lymph node status).

Sentinel node biopsy Identifies draining lymph node during surgery. Injection of blue dye into tissue shows which lymph node drains the

area first by this lymph node turning blue first. This lymph node is then removed for pathological assessment for

cancerous cells during the surgery. If positive, axillary node clearance will be performed. If negative, no further

removal of lymph nodes is required.

Treatment

MDT, including breast care nurses, radiologists, oncologists, pathologists…

Combination of:

• Surgery, including lymph nodes and reconstruction.

• Chemotherapy.

• Endocrine agents e.g. Tamoxifen, Herceptin. Pathology instructs which to use.

• Radiotherapy.

•

And for distant disease, palliation.


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Cranial nerves III-VII examination

Instructions: Examine this patient!s cranial nerves III-VII.

Time: 5 minutes.

Task Marks

1. Introduces self and checks patient!s identity. 0 1

2. Explains procedure, obtains consent and washes hands before and after examination. 0 1

CN III, IV, VI

3. Inspects for ptosis, strabismus and pupillary size, shape & regularity. 0 1

4.

Tests light reflex.

i. Direct and consensual.

ii.

Swinging flashlight test.

0 1

5. Tests pupillary response to accommodation (convergence and pupillary constriction). 0 1

6. Tests eye movements (H pattern of movement). 0 1

7. Checks for nystagmus. 0 1

8. Asks patient if they experience diplopia with eye movements. 0 1

CN V – SENSORY

9.

Tests light touch sensation in 3 areas, comparing left and right.

i.

Ophthalmic branch.

ii.

Maxillary branch.iii.

Mandibular branch.

0 1

CN V – MOTOR

10. Palpates masseter and temporalis bulk with teeth clenched. 0 1

11. Asks patient to open jaw against resistance. 0 1

12. Offers to perform jaw jerk reflex. 0 1

13. Offers to perform corneal reflex. 0 1

CN VII – MOTOR

14. Inspects for facial asymmetry. 0 1

15. Asks patient to wrinkle up forehead. 0 1

16. Asks patient to shut eyes tightly against resistance. 0 1

17. Asks patient to puff out cheeks. 0 1

18. Asks patient to show their teeth. 0 1

19. Summary and differential diagnosis. 0 1

20. Thanks the patient / mark for excellence. 0 1



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Cranial nerves III-VII examination (page 1 of 3)

Written in April 2011 by Sam Brookfield and Liying Low.

Inspection

Inspection of the face can include looking for facial weakness, asymmetry and any involuntary movements.

Inspection of the eyes includes looking at the pupils, eyelids for ptosis and eyes for nystagmus.

Pupillary Responses

Pupil responses are afferent via CN II and efferent via CN III and are often considered part of CN II examination but

included here for completeness. Direct (same eye) and indirect (opposite eye) pupillary responses to light should be

assessed. When focusing from a distant to a close object pupils should converge and constrict.

Eye Movements

Start by asking the patient to look at your finger, asking if they have any double vision (diplopia) and looking for

nystagmus. If they do have diplopia, ask whether it is vertical or horizontal. Then trace out an H pattern, looking for

nystagmus or ophthalmoplegia and asking the patient to report any double vision. In identifying the lesion it helps to

remember which nerves supply which extra-ocular muscle.

Trigeminal Nerve (CN V)

The trigeminal nerve is sensory to the face, which can be assessed by light touch –cotton wool or a fingertip. Start by touching the patient on the sternum as a reference

point, then testing each side of the face and asking, “Can you feel this? Does it feel the

same?” to the three areas of the trigeminal nerve as shown on the diagram. The

trigeminal nerve also supplies touch (not taste) to the anterior tongue, although, this is

not often tested.

It is also motor to the muscles of mastication. Ask the patient to clench their teeth and

palpate masseter and temporalis bulk. Ask the patient to open their jaw against

resistance, and move from side to side.

Jaw Jerk

Not routinely tested. Place one finger in the centre of the jaw and gently strike your

finger with a tendon hammer. It is normally absent or a slight, brisk contraction of the

masseter may suggest an upper motor neurone lesion. The jaw jerk is both afferent and

efferent via the trigeminal nerve.

Corneal Reflex

Not routinely tested. Use a wisp of cotton wool to stimulate the lower outer quadrant of the cornea. This should cause

direct and consensual blinking. The corneal reflex is afferent via CN V and efferent via CN VII.

Facial Movements

Ask the patient to raise eyebrows/wrinkle forehead, and show their teeth. Test power by resisting screwing up eyelids

and puffing out cheeks. You can also test taste to the anterior tongue, lacrimation and hearing.


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Cranial Nerve Normal function Features of cranial nerve lesion

CN III (oculomotor) Supplies all extraocular muscles

except lateral rectus and superior

oblique.

Efferent limb of pupillary reflex.

Supplies levator palpebrae

superioris (elevates eyelids).

Eye down and out

(unopposed CN IV and CN VI

action).

Pupil dilation, unreactive to directlight. Intact consensual reaction inopposite normal eye.

Ptosis.

CN IV (trochlear) Supplies superior oblique.

Tip: Think SO 4

Remember SIN: Superior oblique

INtorts the eye.

Weakness of downward andoutward eye movements. Head tilt

away from lesion, i.e. to opposite

shoulder.

CN VI (abducens) Supplies lateral rectus.

Tip: Think LR6

Failure of lateral eye movement,horizontal diplopia (i.e. images are

side by side and parallel to eachother), convergent strabismus.


Motor:Supplies muscles of Mastication

(Masseter, & teMporal).

Tip: Think M!s

Supplies Pterygoid muscles, whichfunctions to oPen the mouth

Tip: Think P!s

Jaw jerk or masseter reflex.

Wasting and weakness of musclesof mastication.

In unilateral lesion, jaw deviates tothe affected side.

Jaw jerk is exaggerated in UMNL

above pons.

CN V (trigeminal)

Sensory:

Afferent limb of corneal reflex.

Facial sensations at ophthalmic,maxillary and mandibular regions.

Loss of corneal reflex.

Loss of facial sensation.


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Motor:

Supplies muscles of facial

expression.

i. Frontalis

(receives bilateral UMN

innervation)

ii. Orbicularis oculi

(receives innervation from

contralateral cortex)

iii.

Orbicularis oris

(receives innervations fromcontralateral cortex)

Stapedius muscle, which normally

contracts in response to loud

noises and dampens ossicular

movements.

Facial asymmetry.

UMNL – Contralateral drooping of

the corner of the mouth, flattening

nasolabial fold, with forehead

sparing.

(i.e. Left UMNL – Drooping of

corner of mouth and flattening of

nasolabial fold on the Right side).

UMNL refers to the lesion above

the level of the brainstem nucleus.

LMNL – Ipsilateral drooping of the

corner of the mouth, flattening

nasolabial fold, smoothening of

wrinkled forehead.

(i.e. Left LMNL – Drooping of

corner of mouth, flattening

nasolabial fold, smoothening ofwrinkled forehead on the Left side).

LMNL refers to the lesion at thelevel of the nucleus or nerve root.

Hyperacusis (intolerance to loud,

high-pitched sounds).

CN VII (facial)

Sensory:

Chorda tympani, which receives

sensation from the anterior two-

thirds of tongue.

Loss of taste sensation in anterior

two-thirds of tongue.

Bibliography and further reading

1. Chan P, Thant KZ, Katechia DT. PALI Clinical Years Companion, 1st Ed.

2.

Douglas G, Nicol F, Robertson C. Macleod!s Clinical Examination, 11th

Ed. Elsevier 2005, p249-259.

3.

Talley NJ, O!Connor S. Clinical Examination: A Systematic Guide to Physical Diagnosis, 6th

Ed. Elsevier2009.


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Fundoscopy

Instructions: Examine this patient!s fundus.

Time: 5 minutes.

Task Marks

1. Introduction, checks identity. 0 1

2. Washes hands before examination. 0 1

3.Explains procedure and gains consent. Warns about bright light, that it might be

uncomfortable and that you will turn off the lights.0 1

4. Explains that ideally, would have instilled dilating drops 10-15 minutes beforehand. 0 1

5. Turns off room light and sets ophthalmoscope to 0. 0 1

6. Correctly holds ophthalmoscope (same eye as patient, and same hand). 0 1

7. Checks for red reflex in correct position (30cm away). 0 1

8. Comments on external appearance of eye: scars, discharge, swelling, redness. 0 1

9.Explains to patient to focus on a spot in the distance and warns about coming in close

to them.0 1

10. Alters power until the fundus is in focus. 0 1

11. Comments on optic disc: cup-disc ratio, colour of disc, margins, neovascularisation. 0 1

12. Follows the four blood vessel arcades, and comments on appearance: tortuosity,microaneurysms, A-V nipping. 0 1

13.Comments on appearance of periphery of fundus (nasal + temporal to disc):

haemorrhages, exudates, new vessels, photocoagulation scars, cotton wool spots.0 1

14. Asks patient to look directly at light to examine macula. 0 1

15. Comments on appearance of macula: exudates, abnormal pigmentation. 0 1

16. Expresses wish to examine other eye. 0 1

17. Summarises findings. 0 1

18. Offers correct diagnosis. 0 1

19. Washes hands after examination. 0 1




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Fundoscopy

Written in April 2011 by Andrew Lumsden and Sarah Syeda.

Tips on using the direct ophthalmoscope

• Use the same eye as the patient!s eye you!re examining and use the same hand, e.g. when examining the

patient!s right eye, use your right eye and hold the ophthalmoscope in your right hand.

• Use the other hand to stabilise your head and lift the patient !s lid if needed.• Adjust the power of the lens to minus (myopic) direction until the fundus is in view.

Red reflex should appear red. Any opacities (they look like shadows) indicate e.g. cataracts.

Optic disc

Common scenarios likely to appear

1. Diabetic retinopathy

• Non-proliferative

o Dot + blot haemorrhages.

o Hard exudates.

o Microaneurysms.

o

Cotton wool spots (pre-proliferative).

• Proliferative – includes the above +…

o

New vessels, classified as:

a. NV at disc.

b. NV elsewhere.• Photocoagulation scars may be visible in the periphery (they look like black/white burns).

2. Hypertensive retinopathy – signs include:

• A-V nipping: arteries nip the veins where they cross. You may see the vein bulge adjacent to site of nipping.

• Flame haemorrhages.

• Cotton wool spots.

• Exudates.

•

Optic disc swelling.• Microaneurysms.

3. Papilloedema

• Optic disc swelling (disc margins indistinct). Most commonly due to ICP. May also be due to papillitis due tooptic neuritis.

4. Optic atrophy

• Pale optic disc. May be due to optic neuritis, glaucoma, ischaemic/toxic optic neuropathy.


1.

B. James, C. Chew, A. Brown. Lecture Notes: Ophthalmology. 10 th Ed. Blackwell Publishing.2.

M. Batterbury, B. Bowling, C. Murphy. Ophthalmology: An Illustrated Colour Text. 3rd

Ed. Elsevier.

1. Cup-disc ratio

• 0.3-0.5 = normal.

• >0.5 = glaucoma.• No cup visible = papilloedema.

2. Colour

• Pink = normal.•

Pale = optic atrophy.

3. Margin

• Indistinct = disc oedema.


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Instructions: Draw up and administer medication via intramuscular injection to the mid-deltoid model.

You must choose an appropriate injection site, appropriate needle and use the Kardex.Time: 5 minutes.

Task Marks

1. Introduces self and checks identity by asking full name and date of birth. 0 1

2. Explains purpose of injection and gains consent. 0 1

3.Washes hands before and after procedure and puts on appropriate protective

clothing.0 1

4. Consults Kardex for drug and dose. 0 1

5. Consults Kardex for date and time of administration. 0 1

6. Consults Kardex for route of administration. 0 1

7. Consults Kardex for correct patient. 0 1

8.Gathers equipment: gloves, alcohol wipe, syringe, 21G needle, 23G needle, drug vial,

sharps box; and puts on gloves.0 1

9. Selects drug in the appropriate volume and dosage, and checks expiry date. 0 1

10. Selects appropriate injection site (mid-deltoid). 0 1

11.Draws up the appropriate volume of drug required (1ml) with a 21G needle and then

disposes of needle safely.

0 1

12.Selects appropriate gauge (23G) and length of needle for the preferred site of

injection.0 1

13. Cleans site with alcohol wipe and allows to dry. 0 1

14.Warns the patient, and then pulls skin to one side (Z-track technique) and introduces

needle at 90° with a firm darting motion, penetrating with 2/3 of the needle.0 1

15. Observes the patient throughout the procedure, providing reassurance if required. 0 1

16.Aspirates (over 5-10 seconds) to ensure needle has not entered a blood vessel, and

injects slowly at a rate of 1ml/10s, if no blood is seen on aspiration.0 1

17.Withdraws needle, immediately releases retracted skin and applies pressure with

cotton wool ball.0 1

18. Disposes of needle safely, and places other material in a clinical waste bin. 0 1

19. Signs Kardex to record administration of drug. 0 1




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Written in April 2011 by Philip Chan and Kyaw Zayar Thant.

Intramuscular injections

IM injections are given into well-perfused muscles. The rate of absorption is faster than subcutaneous injection butslower than intravenous administration. Indications for IM injection include delivering vaccines.

Five “rights” – right patient, right drug, right dose, right route, right time.

Five sites

• Mid-deltoid

• Maximum volume 1ml.

• Administer 2.5cm below acromion process.

•

Avoid brachial artery and radial nerve.• Ventrogluteal

• Maximum volume 2.5ml.

• Administer at hip.

• Dorsogluteal


• Administer in the upper outer aspect of gluteal muscle.

• Avoid sciatic nerve and superior gluteal arteries.

• Vastus lateralis


• Administer in outer middle third of thigh.

• No significant structures to avoid.

• Rectus femoris• Used for self-administration and infants due to ease of access.

The site used is influenced by age, patient health, muscle bulk and type of medication being injected. Care must be

taken to avoid neurovascular structures.

Size of needle

The size (gauge and length) of needle used depends on the injection site, muscle mass, amount of subcutaneous fat

at the site and the weight of the patient. Needles commonly used are 21-23G and 2.5-5.0cm in length. Always consult

hospital local guidelines.

Z-track technique

The skin over the injection site is pulled to the side before the needle is introduced. When the needle is withdrawn,

the skin is released immediately afterwards. This technique ensures that the medication is trapped in the region that it

is required, reducing leakage. The online resource produced by the University of Nottingham gives a good visualexplanation of this (see link below). The Z-track technique is considered best practice.

After the procedure, do not massage the injection site as this causes leakage and local irritation. However, light

exercise or stretching of the muscle may help increase absorption of the medication.


1. Robb AJP. Intramuscular and subcutaneous injection techniques (presentation). Available from: Glasgow

University VALE clinical skills website.2.

Williams J, Harling M, Hardy C. Intramuscular injection by the Z-track technique (online resource). Available

from: http://www.nottingham.ac.uk/nmp/sonet/rlos/placs/nctl176_ztrack/index.html

3. Early D. Intramuscular injection technique. Video podcast. Available from: Glasgow University VALE clinicalskills website. (This is a really good video).


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Instructions: Perform intravenous cannulation on this model arm.

Time: 5 minutes.

Task Marks

1. Washes hands at start and end. 0 1

2. Introduction, checks identity, explains procedure and gains consent. 0 1

3.

Gathers equipment: gloves, cannula (appropriate size depending on indication),

adhesive cannula dressing, alcohol skin wipe or chlorhexidine spray, gauze, 5 mL

syringe, 5 mL normal saline (check expiry date), sharps bin and tray.

0 1

4. Applies tourniquet to arm. 0 1

5. Palpates for suitable vein. 0 1

6. Cleanses skin and maintains sterility. 0 1

7. Puts on gloves. 0 1

8. Holds cannula in appropriate manner. 0 1

9. Gives patient warning prior to insertion. 0 1

10. Inserts cannula at an appropriate angle, obtaining a flashback. 0 1

11. Withdraws needle slightly and guides cannula into vein. 0 1

12. Releases tourniquet. 0 1

13. Discards needle into sharps bin. 0 1

14. Replaces cannula cap. 0 1

15. Flushes cannula. 0 1

16. Cleans area up and disposes of equipment. 0 1

17. Thanks the patient, ensuring their comfort. 0 1

18. Comments on need to document insertion and ensure regular review of cannula sites. 0 1

19. Performs procedure in a professional and comfortable manner. 0 1




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Written in April 2011 by Dilane Peiris and Lucy Lynch.

Introduction

Cannulation or intravenous (IV) access is the !bread and butter" of junior doctors" clinical skills. Indications for apatient to have IV access, includes:

• Requirement for IV fluids or medication.

• Surgical or endoscopic procedures.

• Radiological investigations requiring contrast media.• Cardiac arrest or peri-arrest situations.

However, patients are often left with cannulas in-situ for days, placing them at risk of local infection, thrombophlebitisand sepsis. It is thus essential to have the skill to place a cannula, and review them frequently.

Equipment

Prepare a small tray with:

• Gloves.

• Cannula (appropriate size depending on indication).

• Adhesive cannula dressing.

• Alcohol skin wipe or chlorhexidine spray.

• Gauze.

• 5 mL syringe.

• 5 mL normal saline (check expiry date).• Sharps bin.

Procedure

• Apply tourniquet, preferably to the non-dominant arm.

•

Select a suitable vein through palpation and sight. Ensure that it is reasonably straight and not too tortuous.• Put on gloves and sterilise the area with an alcohol swab. Following this, avoid touching that area again.

This is a sterile procedure.

• Allow chlorhexidine/alcohol to dry.

• Unsheathe the cannula.

• Hold the cannula between your thumb, index and middle fingers, making sure not to touch the shaft of the

cannula.

• Approach the vein at 10-40° in the direction of blood flow (i.e. up the arm). Your thumb should be providing

the force and, as such, should be positioned at the back of the cannula, over its rear port. Your index finger

and middle finger should fall either side of the cannula shaft and hook lightly round the wings. This providesthe !steering".

• Using your other hand, retract the skin over the vein, and anchor it in place.

• Warn the patient just prior to insertion.

• Pass the cannula through the skin and into the vein. A !flashback" of blood in the body of the cannula should

be seen if the cannula is in the vein. You will also feel a!give

" as you pass through the wall of the vein into

the lumen.

• Ease the plastic tubing of the cannula off the introducer and into the vein.

• Release the tourniquet.

• Remove the introducer entirely, and clamp the vein just proximal to the cannula tip to prevent blood leaking

out.

• Place the introducer in a sharps bin.

• Apply the plastic screw cap to the rear port.

• Secure the cannula with a suitable adhesive. Write the date of insertion on the dressing.

• Draw up 5 mL of normal saline and flush the cannula through the top port. If it fails to flush or causes pain, itis in the wrong place and should be removed and re-sited.

After the procedure

•

Clean up and dispose items in the appropriate receptacles (sharps bins and clinical waste bins).• Ensure that the patient is comfortable.• Thank the patient, wash your hands and document the insertion.


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Neck examination

Instructions: Examine this patient!s neck.

Time: 5 minutes.

Task Marks

1. Introduces self and checks identity. 0 1

2. Explains procedure and gains consent. 0 1

3. Inspects for scars, JVP, distended neck veins, skin lesions. 0 1

4. Inspects for lymph nodes, swelling, goitre. 0 1

5. Asks patient to protrude tongue and comments on movement. 0 1

6. Inspects and palpates the mass when patient is sipping water. 0 1

7. Examine ears, mouth, scalp for source of primary infection. 0 1

8. Palpates trachea. (Ask about pain before palpation.) 0 1

0 1

0 19.

Palpates lymph nodes: cervical, submental, submandibular, parotid, preauricular,

anterior chain, supraclavicular, posterior chain, postauricular, occipital.


10. Identifies thyroid on palpation. 0 1

11. Percusses sternum to locate lower limit of thyroid. 0 1

12. Auscultates thyroid for bruits, after asking patient to hold their breath. 0 1

0 113.

Describes lump (site, size, shape, colour, skin changes).


14. Transilluminates lump (or offers to do it). 0 1

15. Reports findings, suggests differential diagnosis and most likely diagnosis. 0 1

16. Washes hands at start and end. 0 1




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Neck examination

Written in April 2011 by Caroline Little and Rebecca Sadler.

Lymph Node Levels

(1)

Neck Lumps (2)

Midline:

1. Thyroglossal cyst – painless cystic lump, transilluminates, moves on tongue protrusion.

2. Midline Dermoid cyst – mobile, cutaneous.

Anterior Triangle:

1.

Thyroid Swellings – Hyperthyroidism (Graves, toxic nodular goitre).

• Hypothyroidism (Hashimotos, Iodine deficiency, drugs).

• Euthyroid (physiological goitre, multi-nodular goitre, thyroid adenoma).

2. Branchial Cyst – smooth rubbery swelling.

3. Pharyngeal Pouch – can compress.4.

Salivary Glands – stones, tumour, inflammation.

5. Cervical Lymph Nodes.

6.

Carotid body tumour – high up in anterior triangle, painless. 7. Cervical Rib – supraclavicular fossa.

Posterior Triangle:

1.

Lymphadenopathy.

2. Cystic Hygroma – collection of dilated lymphatics.

Posterior Triangle:

1. Ultrasound ± Fine Needle Aspiration.2.

CT/MRI .


1.

http://www.droid.cuhk.edu.hk/web/specials/lymph_nodes/lymph_nodes.htm2.

http://www.firstinmedicine.com/summarysheets_files/ent.html

1. Submental.

2. Submandibular.

3. Parotid.

4.Upper cervical, above the level of hyoid bone, and

along the internal jugular chain.

5.Middle cervical, between the level of hyoid bone and

cricoid cartilage, and along the internal jugular chain.

6.Lower cervical, below the level of cricoid cartilage,

and along the internal jugular chain.

7. Supraclavicular fossa.

8. Posterior triangle (also known as accessory chain).


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Instructions: Examine this patient!s right ear and assess his/her hearing using a free-field voice test.

Time: 5 minutes.

Task Marks

1.Washes hands at start and end, introduction, checks identity, explains procedure and

gains consent.0 1

2.Examines external ear for scars, skin tags, tophi, sinuses, discharge, erythema,

swelling.0 1

3. Selects otoscope and selects appropriate speculum. 0 1

4.Uses appropriate technique: Gently pulls pinna up and back, holds otoscope like a

pen, with right hand for right ear (or left hand for left ear).0 1

5. Uses appropriate technique: Ulnar border of hand resting gently against patient!s

face.0 1

6. Comments on external auditory canal. 0 1

7. Identifies tympanic membrane. 0 1

8. Assesses for “cone of light” reflex. 0 1

9. Comments on tympanic membrane: Colour, Translucency, Position, Integrity. 0 1

10. Identifies any abnormality and reports accurate clinical findings. 0 1

11. Gently withdraws otoscope. 0 1

12. Correctly explains free-field voice test to patient. 0 1

13.Selects ear to test and reaches hand behind patient!s head to block other ear. Rubs

ear to create noise during test.0 1

0 1

14.

Begins with whisper at arms length, then moves to 6 inches beside patient if needed.

Then normal voice at arms length, then moves to 6 inches beside patient if needed.

Up to 2 marks available.0 1

0 115.

Repeats free-field voice test on other ear.


16. Reports findings accurately and offers differential diagnosis. 0 1

17. Safely disposes of speculum. 0 1




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Written in April 2011 by Andrew Kidd and Innes Hynd.

Anatomy of the ear

The pinna (or auricle) is the outer projecting portion of the ear. It is composed of elastic cartilage covered with skin.The external ear canal is about 2-5cm long in adults and extends from the external auditory meatus to the tympanicmembrane.

The tympanic membrane consists of the pars tensa and the pars flaccida. The malleus handle lies in the middle layerof the pars tensa. The most medial structure in the drum is the lateral process of the malleus. The tip of the handle iscalled the umbo, and a cone of light can usually be seen extending anteroinferiorly from the umbo.

Otoscopy equipment and technique

The otoscope consists of a handle and a head. The head contains a light and magnifying lens. The front end of theotoscope has an attachment for disposable plastic ear specula. The speculum size should be appropriate for thepatient's canals. Hold the otoscope in a pencil grip with the hand of the same side as the ear you are about toexamine. The pencil grip allows the side of your hand to rest on the side of the patient's face, reducing the risk oftrauma if the patient’s head suddenly moves.

Free-field voice testing

This is a useful test of hearing where each of the patient’s ears are tested in turn. The examiner should stand to theside of the patient and reach their hand behind the patient’s head to rub the ear that is not being examined. This waythe noise created prevents the patient hearing through this ear.

The examiner should begin at arms length by whispering a combination of 3 numbers (e.g. 5, 8, 1) that the patientshould repeat. If the patient does not hear this then move to 6 inches beside the patient’s ear and use anotherrandom whispered combination. If the patient’s responses have not yet been accurate, then the process is repeated,again starting at arms length but this time with a conversational normal voice, not whisper. If this is still not heard thenuse a conversational normal voice at 6 inches.

N.B. The whisper should be a “loud” whisper.

Please note that the Rinne and Weber tuning fork tests may be relevant in a cranial nerve examination, but they donot test quality of hearing in patients and are not discussed here or recommended in an ENT examination. Pure toneaudiometry is the most accurate way of formally assessing a patient’s hearing.


1. Alberti P. The anatomy and physiology of the ear and hearing. Available from:

http://www.who.int/occupational_health/publications/noise2.pdf2. Hawke M, Keene M, Alberti PW. Clinical otoscopy: an introduction to ear disease. 2nd ed. Edinburgh:

Churchill Livingstone; 1990.3. Swan, Ian R C. Examination of the Ear (video). Available from: Glasgow University VALE clinical skills

website.


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Instructions: Examine this patient!s lower limb pulses, and suggest appropriate subsequent

investigations.Time: 5 minutes.

Task Marks

1. Introduces self. 0 1

2. Checks patient details. 0 1

3. Explains examination. 0 1

4. Gains consent. 0 1

5. Washes hands before and after examination. 0 1

6.Inspects legs, commenting on colour, scars, trophic skin changes and tissue loss

(ulceration/gangrene).0 1

7. Inspects between toes and under heels. 0 1

8. Feels temperature of both feet and legs using back of hand. 0 1

9. Measures capillary refill on both feet. 0 1

10. Palpates dorsalis pedis pulses. 0 1

11. Palpates posterior tibial pulses. 0 1

12. Palpates popliteal pulses. 0 1

13. Palpates femoral pulses. 0 1

14. Feels for abdominal aortic aneurysm. 0 1

15. Auscultates for femoral bruits. 0 1

16. Performs/indicates need to perform Buerger!s test. 0 1

17. Compares both sides. 0 1

18. Presents findings accurately. 0 1

19. Suggests appropriate investigations, e.g. Duplex Doppler USS; MR angiogram, DSA. 0 1




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Written April 2011 by Claire Adams and Kerri Devine.

General inspection

It is good practice in any examination to take a step back and make some general observations about the patient.

Abdominal Aortic Aneurysm

This is detected as a pulsatile and expansile mass found above the level of the umbilicus (the aorta bifurcates here).

To demonstrate this, place one hand on either side of the pulsation – if it is expansile, your hands will be seen to

move apart in time with the pulse. A mass that is pulsatile but not expansile may only be transmitting a pulse

underneath it, and it is normal to palpate a pulse in thin subjects.

Anatomical Landmarks for Lower Limb Pulses

1. Dorsalis pedis – lateral to extensor hallucis longus tendon on dorsum of foot. It is a common mistake to aim

too low on the foot, and be sure to palpate gently or you may occlude a weak pulse.

2.

Posterior tibial – in the groove between the Achilles ! tendon and medial malleolus.

3. Popliteal – in popliteal fossa. Palpate bimanually with patient!s leg relaxed and slightly flexed at knee.

Difficult to feel! Consider a popliteal aneurysm if easily felt. Remember that if you have already managed to

feel the lower pulses, it should be in there!

4. Femoral – the femoral pulse is located at the “mid-inguinal point” – halfway between the anterior superioriliac spine and the pubic symphysis. It is good exam practice to demonstrate locating these landmarks inorder to pinpoint the femoral pulse.

Ulcers

Remember to look between the patient!s toes for ulceration and necrosis, and lift their heels off the bed to perform athorough inspection.

A venous ulcer is typically in the “gaiter area” over the medial malleolus. There may also be other signs of highvenous pressure (usually due to varicose veins or previous DVT). These include haemosiderin deposition (a reddish

brown stain to the legs), oedema, lipodermatosclerosis, and varicose veins.

An arterial ulcer has typically a "punched out! appearance with some areas of necrosis and is more likely to be

painful.

A neuropathic ulcer is a painless ulcer occurring on pressure areas, e.g. the heel – they are often surrounded by

callous. Diabetic patients can present with neuropathic ulcers, although in practice may be a mixed aetiology (arterial

and neuropathic).

Buerger!s Test

With patient lying supine, elevate both legs at the same time to approximately 45°. Observe for onset of pallor in the

soles of the feet. The smaller the angle raised at which this occurs, the more severe the ischaemia (the angle at

which pallor occurs is termed “Buerger!s angle”). Then swing the patient!s legs round so they are hanging off the side

of the bed and observe for reactive hyperaemia (the foot turns purplish). “Pallor on elevation” followed by “rubor on

dependency” is a positive Buerger!s test.


1. Gilmour D. Peripheral Arterial Examination: Abdomen and Lower Limbs (video). Available from: Glasgow

University VALE clinical skills website.

2. ACE the OSCE (a good resource you can purchase online, helpful before finals).

3.

MacLeod!s Clinical Examination.


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Suturing

Instructions: Reappose the wound aseptically using the suturing equipment provided. Treat the model

as you would a real patient.Time: 5 minutes.

Task Marks

1. Introduces self and checks patient identity. 0 1

2. Explains procedure clearly to the patient. 0 1

3. Obtains consent from the patient. 0 1

4. Washes hands before starting procedure. 0 1

5. Puts gloves on. 0 1

6.Uses the no touch technique to open the equipment. Check the expiry date of the

suture.0 1

7. Inspects the wound and cleans skin using antiseptic. 0 1

8. Appropriately covers the operating field. 0 1

9. Injects local anaesthetic to the operating site. 0 1

10. Allows sufficient time for the local anaesthetic to act. 0 1

0 1

11.

Inserts suture symmetrically along wound edge.

2 marks awarded. 0 1

12. Ties the suture together with correct tension. 0 1

13. Cuts the suture to the correct length. 0 1

14. Disposes the sharps into the sharps bin. 0 1

15. Disposes of the clinical waste appropriately. 0 1

16. Disposes of the instruments appropriately. 0 1

17. Washes hands afterwards. 0 1

18. States a desire to document procedure details into the patient!s medical notes. 0 1


Circle: Pass / Borderline Pass / Fail Total marks:______ / 20


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Suturing

Written in April 2011 by Devvrat T. Katechia and Omer Alanie

Suturing

The very first thing to mention about this station is that only 2 marks out of the 20 are actually awarded for thesuturing technique, so it is important not to get too disheartened if in the exam your suture is not exactly symmetrical.

The objective of suturing the skin is to approximate, oppose and evert the wound edges, thereby reducing the risk of

infection, promoting wound healing and providing a better cosmetic outcome.

Communicate with the patient very clearly what you are going to do and the fact that it should not be too painful.

It is important to maintain a sterile environment when suturing a wound and for the purposes of the exam I would

advise stating this out aloud.

Before suturing the wound it is best to prepare the trolley with the equipment that you require, namely: sterile gloves,tooth forceps, sutures, needle holder, suture scissors, antiseptic for cleaning the wound, local anaesthetic and a

syringe. In the exam this may all be laid out for you.

With regard to the local anaesthetic, it is always best to check the details of the anaesthetic prior to injecting. State

the name of what you!re injecting and the expiry date of it to the examiner. Allow sufficient time for the anaesthetic to

act and in the exam once you state this, the examiner may just ask you to proceed.

Suturing technique

Do not pull the suture too hard as this will place tension on the suture and this will impair wound healing due to tissuestrangulation and wound oedema. Leave sufficient thread when cutting the suture to allow easier removal at a laterdate

Finally it is essential to dispose of the sharps accordingly.

Document the site of the wound closure, date, suture material used and the type of knot used in the medical notes.


1. Aseptic skin closure. Clinical and communication skills OSCE assessment unit. Available from: Glasgow

University VALE clinical skills website.

2. Wiggan JM. Suturing techniques. Available from: http://emedicine.medscape.com.

3.

“Cyberwapx”. Surgery simple interrupted suturing wound. Available from:http://www.youtube.com/watch?v=PFQ5-tquFqY

Needle point

Suture thread

Needle body

Mounting the needle: Insert your thumb and ring finger inside the needle holder. Pickup the suture 1/3 along the needle body from the suture thread attachment (known as

swage). If you hold the suture needle at the tip then this will damage the needle and

therefore it will not pierce the skin as effectively. If you need to manoeuvre the needle,

use the forceps and not your fingers!

Suture placement: Hold the skin edge using forceps and insert the needleapproximately 5mm from the wound edge. Penetrate the skin with the needle at a 90°

angle. This will ensure symmetrical wound closure. Pull the needle through usingforceps and allow sufficient suture material to tie a knot.

Knot tying: Use the needle holder to hold the short piece of thread. The short end of

the suture is then grasped with the tip of the needle holder and pulled through the loopsof the long end by crossing the hands, such that the 2 ends of the suture material are

situated on opposite sides of the suture line. Repeat the process by rotating the long

end once and pulling through, then pulling the short end and again crossing your armsThis is a simple interrupted suture.


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Visual acuity testing

Written in April 2011 by Andrew Lumsden and Sarah Syeda.

One of the main functions of the optic nerve is vision. There are three elements: acuity, fields and colour vision.Here, we will focus on testing visual acuity. The method of assessing this is the Snellen chart and near vision chart.

A. Snellen chart

Snellen charts are used to test a patient!s distance vision.

Preparation

The patient should sit 6 metres away from the Snellen chart, however, often they will sit at 3 metres and look at a 3

metre chart through a mirror. The patient should be asked to wear spectacles or contact lenses for the test, if they

require them.

Assessing and recording vision

Each eye is tested individually by covering one eye at a time and getting the patient to read from the largest letter to

the smallest line they can read. This is repeated for the other eye, and the results are recorded as follows:

Distance from chart / Smallest line read (e.g. Left eye 6/18, Right eye 6/9.)

The number system on the Snellen chart (60, 36, 24, 18, 12, 9, 6, etc.) refers to the distance at which someone with

normal vision could read the line.

If a patient gets some of the letters on a line correct, this should be recorded as:

Distance from chart / Smallest line read with some mistakes MINUS the number of incorrect letters

or Distance from chart / Smallest line with all letters correct PLUS the number of correct letters on thesmaller line.

For example, a patient correctly identifies four letters out of five on the 12 line could be recorded as:

6/12 – 1 or 6/18 + 4.

A pinhole should be used and each eye reassessed. If visual acuity improves, this suggests there is a refractive error.

If a patient is unable to read any of the letters, they should be moved closer to the chart (1 metre at a time until theyare 1 metre away from chart). If they are still unable to read any of the letters, the following should be attempted:

• Counting fingers – hold fingers up at less than one metre.

• Hand movements – wave hand in front of patient (wave up and down and also side-to-side).

•

Light perception – shine a light in the eye. If not seen, recorded as “no light perception”.

Normal vision is 6/6. Partially sighted is between 6/60 and 3/60. Blindness is below 3/60.

B. Near vision chart

Preparation

The patient should be asked to hold the test sheet at the distance they would normally hold a book (this should be

around 40cm). The patient should be allowed to wear spectacles or contact lenses for the test.

Assessing and recording vision

The patient should be asked to read the sentences and the results should be recorded as the smallest line that canbe read (according to the scale on the chart).


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Instructions: Perform a digital rectal examination on this patient.

Time: 5 minutes.

Task Marks

1.Washes hands at start and end, introduction, checks identity, explains procedure and

gains consent.0 1

2. Asks for a chaperone. 0 1

3. Positions the patient correctly and drapes the patient appropriately. 0 1

4. Wears gloves. 0 1

5. Inspects the perianal areas. 0 1

6. Inspects the anus as the patient strains down. 0 1

7. Lubricates index finger. 0 1

8.Tells the patient that they are now going to insert their finger and that they may feel

like their bowels are about to move.0 1

9. Inserts index finger as the anal sphincter relaxes. 0 1

10. Comments on the sphincter tone of the anus. 0 1

11. Notes any tenderness, induration, irregularities or nodules. 0 1

12. Inserts index finger farther into the rectum. 0 1

13. Palpates in sequence: the right lateral, posterior, and left lateral surfaces. 0 1

14.Turns the hand so that the finger can examine the anterior surface and prostate

gland.0 1

15.Notifies patient they are going to feel the prostate gland and that it may feel like they

are going to urinate but they will not.0 1

16.Palpates lateral lobes and median sulcus of the prostate. Comments on the size,

shape, and consistency of the prostate.0 1

17. Withdraws finger and examines finger for faeces, blood and mucus. 0 1

18. Provides the patient with tissue to wipe the anus. 0 1

19. Disposes of the gloves and wipes in the clinical waste bin. 0 1




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Written in April 2011 by Devvrat T. Katechia


Prior to performing a digital rectal examination it is essential to communicate very clearly with the patient the

procedure and what it entails.

You must request a chaperone when performing this examination.

For the purpose of the examination it is best to communicate and present what you are doing with the examiner as

you proceed. This prevents you from forgetting examination steps or findings.

Position

The patient should be positioned on the left hand side with his buttocks close to the edge of the examining table. Ask

the patient to draw their knees up to their chest.

Inspection

Comment on the presence of any lumps, ulcers, inflammation, rashes, excoriations and skin tags.

As the patient strains down, observe for the presence of any haemorrhoids.

Palpation

It is always best to warn the patient before you insert a finger up their anus.

As you insert your index finger, look at the patient for any signs of tenderness or pain. If the patient complains of

severe pain this may indicate the presence of an anal fissure.

Presenting examination findings

It is always best to rehearse presenting your findings either with friends or in front of the mirror. This helps you look

as slick as possible and enables you to obtain the mark for excellence.

For the rectal examination you may say the following:

On examination of Mr. X!s perianal region and rectum, there were no abnormalities to note on inspection. On

palpation there was normal anal tone and no irregularities to note in the rectum. The prostate was of normal size,

consistency and surface. On examining the glove there is no mucus, faeces or blood. I would like to complete the

examination by performing a full abdominal examination on this patient.


1.

Oxford Handbook of Clinical Examination and Practical Skills by James Thomas and Tanya Monaghan.


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History: Assessing suicide risk

Written in April 2011 by Philip Chan.

Risk factors for suicide risk

• Male gender.

• Age.

• Previous suicide attempt or self-harm.

• Psychiatric illness.

• Hopelessness.

• Social isolation.

• Low socio-economic status.

• Unemployment.

• Alcoholism and drug abuse.• Major life events, e.g. difficult childhood.

Actor behaviour when assessing suicide risk

• Do not be put off if the actor does not respond to your questions. Allow enough silence for them to

reflect, but don!t forget that you have a long list of questions to get through in five minutes, so just keepasking. The examiner will give you the marks even if they don !t answer.

• The actor will often not make eye contact with you throughout the entire interview.

• A lot of marks will be allocated for actor !s assessment, and so it is important that you use good

communication skills, e.g. showing empathy, using appropriate body language, leaning in to speak to thepatient, allowing silences, speaking at the appropriate volume.

Assessing a real patient

• It is unrealistic to expect you to take a full psychiatric history and perform a full mental state examination in a

five-minute OSCE station. However, this is what would be expected in a real life scenario.

• Full psychiatric history taking and the mental state examination will be taught in more detail during your

psychiatry block in your clinical years.

• Drug overdose is one of the most common A&E presentations and so suicide risk assessment is animportant skill that you must learn.


1. Suicide risk assessment and threats of suicide. Patient UK. Available from:

http://www.patient.co.uk/doctor/Suicide-Risk-Assessment-and-Threats-of-Suicide.htm2. Harrison P, Geddes J, Sharpe M. Psychiatry (Lecture Notes series), 10

th Ed. (The best and only book you

need for psychiatry for finals, in my humble opinion.)


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History: Chest pain

Instructions: Take a focussed history of a 60-year-old patient who presented with chest pain.

Time: 5 minutes.

Task Marks

1. Introduction, checks identity and gains consent. 0 1

2. Site of pain. 0 1

3. Radiation of pain. 0 1

4. Character of pain. 0 1

5. Onset of current chest pain. 0 1

6. Timing and duration of pain. 0 1

7. Exacerbating factors and relieving factors 0 1

8. Severity of pain. 0 1

9.Associated cardiovascular symptoms: breathlessness, nausea/vomiting, sweating,

palpitations, loss of consciousness, ankle swelling.0 1

10. Associated respiratory symptoms: cough, wheeze, haemoptysis, sputum. 0 1

11. Associated GI symptoms: heartburn, waterbrash, pain related to meals. 0 1

12. Establishes previous episodes of chest pain. 0 1

0 1

0 113.

Asks about:

1. Past history of angina, MI, stroke or PVD.

2. Past history of diabetes, hypertension, hyperlipidaemia.3. Past history of CABG/PCTA. 0 1

14. Asks about drug and allergy history. 0 1

15. Asks about family history. 0 1

16. Asks about social history (must include smoking, drinking). 0 1

17. Summarises and welcomes questions. 0 1




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History: Chest pain

Written in April 2011 by Kyaw Zayar Thant.

Main differential diagnoses and typical presentations

When considering the cause of chest pain, visualise the anatomy of the chest. Pain may arise from the

cardiovascular system (heart & aorta), respiratory system (lungs, pulmonary vessels), GI system (oesophagus, upperstomach) or musculoskeletal system (chest muscles, rib cage).

Cardiovascular

1. Acute coronary syndrome (STEMI, NSTEMI, unstable angina)

Middle aged/elderly patient with central, !crushing/tight" chest pain, radiating to either both arms ± neck/jaw.

Pain is sudden onset while patient is at rest, not relieved by GTN, antacids or resting and lasts more than just a few mins. (cf. stable angina, which is pain on exertion, relieved by rest/GTN; lasting a few mins). May

have associated breathlessness, nausea/vomiting, sweating and sense of !impending doom". Typically,

there is history of angina, MI, stroke, intermittent claudication and other cardiovascular risk factors (diabetes,hypertension, hyperlipidaemia, smoking, alcohol excess, family history).

2. Aortic dissection

Severe, !tearing" chest pain, located centrally or to one side, radiating to the back. May have a difference inblood pressure and radio-radial delay between the arms.

3. Pericarditis

Central, sharp chest pain which may radiate to the left shoulder or neck, exacerbated by lying down,

respiration or movement and relieved by leaning forward or use of NSAIDs. Mainly occur in patients post-MI.Respiratory

4.

Pulmonary embolism

Presentation of PE can be varied and difficult to diagnose. Typically, history of sudden onset shortness of

breath, ± pleuritic chest pain ± haemoptysis in someone with a hot, swollen, tender calves (DVT) or other

risk factors for blood clots (surgery, malignancy, pregnancy, period of immobility)

5. Pneumothorax

Sudden onset of pleuritic chest pain with breathlessness.GI

6. Oesophagitis/GORD

Central, !burning" chest pain with no radiation, precipitated by heavy meals or bending down, e.g. to touch

his toes, relieved by antacids. May have associated waterbrash, acid brash.7.

Oesophageal spasm

Oesophageal spasm can mimic angina closely; i.e. central crushing chest pain, which may radiate to the

neck or upper arms, brought on by exercise and relieved by GTN. However, the pain may show relation to

meals and be accompanied by transient dysphagia and symptoms of GORD.

8. Musculoskeletal pain

Pain is variable. Pain which varies with posture and movement of upper body, ± local tenderness overrib/cartilage are clues to musculoskeletal pain.

You must exclude the following diagnoses in all cases as they are potentially fatal and need immediate Rx:

1. Acute coronary syndrome.

2. Aortic dissection.

3. Pneumothorax.4. Pulmonary embolism.

Key investigations

1. 12 lead ECG.

2. Chest X-ray.3. Blood tests: FBC, U&E, LFT, CRP, glucose, lipids, admission and 12 hour troponin.


1.

Colledge NR et al. Davidson"s principles and practice of medicine. 21st

ed. Edinburgh; Elsevier: 2010.2. Farne H, Norris-Cervetto E, Warbrick-Smith J. Oxford Cases in Medicine and Surgery. Oxford; Oxford

University Press: 2010.


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History: Dysphagia

Instructions: Take a focussed history of a 65-year-old patient who presents with difficulty swallowing.

Time: 5 minutes.

Task Marks

1. Washes hands at start and end, introduction, checks identity, gains consent. 0 1

2. Clarifies patient!s symptoms and position where patient feels things are sticking. 0 1

3. Timing and duration of symptoms. 0 1

4. Difficulty in swallowing progressive or intermittent? 0 1

5. Difficulty swallowing solids and liquids or both? 0 1

6. Pain on swallowing. 0 1

7. Associated symptoms: coughing, choking, gurgling. 0 1

0 1

8.

Neurological symptoms: weakness in any limbs, tired after repetitive chewing.

Difficulty or change in their speech, previous strokes, MS.

2 marks available.0 1

9. Rheumatological symptoms: pain, stiffness or swelling in any joints. 0 1

0 1

0 110.

Malignant features: weight loss, anorexia, lethargy, anaemia.

3 marks available. 0 1

11.Past medical history (must ask about GORD, peptic ulcer disease, previous

malignancy).0 1

12. Drug history (must ask about NSAIDs, indigestion tablets) and allergies. 0 1

13. Family history. 0 1

14. Social history (quantify smoking and drinking habits). 0 1

0 115.

Summary and elicits patient!s concerns sensitively.

2 marks available.0 1




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History: Dysphagia

Written in April 2011 by Devvrat T. Katechia.

Dysphagia

Dysphagia is a difficulty in swallowing. It is important to clarify what a patient means when they say they have a“swallowing difficulty”. Painful swallowing is known as odynophagia, which can be due to malignancy but more

commonly due to an infection such as candidiasis. Globus describes the sensation of having a lump in the throat and

this must be distinguished from dysphagia.

Dysphagia is caused by either:

• Neurological pathology, which is commonly described as a functional problem. This can be further

subdivided into higher or lower dysphagia depending on which part of the nervous system is affected.

•

Structural pathology where there is pathology involving either the lumen, the oesophageal wall (mural) ordue to external compression of the oesophagus (extrinsic). Dysphagia due to luminal pathology is commonlydue to a foreign body. (See table below for specific conditions).

Functional causes Structural causes

Higher dysphagia

Stroke

Parkinson!s disease

Myasthenia gravis

Multiple Sclerosis

Mural

Oespophageal cancer

Pharyngeal pouch

Stricture: caustic or inflammatory

(hence we ask about previous GORD

and ulcers)

Lower dysphagia

Achalasia

Diffuse oesophageal spasm

Extrinsic

Bronchial carcinoma

Retrosternal goitreMediastinal mass

Radiological investigations

1.

Barium swallow: used in those with pathology high up in the oesophagus.

2. Endoscopy: useful in those with luminal or mural pathology. Tissue samples can also be obtained through

this method for biopsy.

3. Videofluoroscopy: useful in patients with suspected higher functional dysphagia.

4. Oesophageal manometry: used to measure the pressures in the lower oesophageal sphincter andperistalsis. Manometry is used for diagnosing motility disorders.

Treatment of dysphagia will depend on the cause. It is important to obtain a very clear and thorough history from

patients presenting with swallowing difficulties to aid the process of making a diagnosis.


1.

Oxford Cases in Medicine and Surgery by Hugo Farne, Edward Norris-Cervetto, James Warbrick-Smith.

2.

History Taking in Medicine and Surgery by Jonathan Fishman, Laura Fishman.


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Instructions: Take a history from this 65-year-old patient who has presented to A&E after a fall. The

patient has also been complaining of palpitations. Offer a differential diagnosis at the end.Time: 5 minutes.

Task Marks


2.Establishes that the patient lost consciousness prior to falling and regained

consciousness minutes after.0 1

3.

Establishes the circumstances of the patient!s fall, i.e. location, time, what they were

doing (e.g. exercising, getting out of bed, coughing or straining, extending their neck,

experiencing an intense emotion). In this case the patient was walking from their living

room to the kitchen in the afternoon.

0 1

4.Excludes mechanical cause of fall, i.e. tripping over something, and establishes that

the patient is mobile without walking aids and has normal vision.0 1

5. Establishes that a witness was present during the fall. 0 1

6. Excludes seizure. 0 1

7. Excludes headache or confusion after recovery. 0 1

8.Excludes focal neurological symptoms after fall (e.g. loss of power, loss of sensation,

loss of vision, facial drooping, dysphagia, dysphasia).0 1

9. Excludes major injuries from the fall. 0 1

10. Establishes a history of recurrent falls of a similar nature. 0 1

11.Establishes that by "palpitations" the patient means that they are aware of their heart

beating.0 1

12. Excludes chest pain and shortness of breath. 0 1

13.Excludes anxiety disorder (symptoms include sweating, hyperventilation, dizziness,

nausea, fear, and can be caused by a trigger).0 1

14.Past medical history (must specifically ask about epilepsy, stroke/TIA, heart

conditions, diabetes).0 1

15. Drug history and allergies. 0 1


17. Social history. 0 1


19.Diagnosis: Atrial fibrillation/Stokes-Adams attack/supra-ventricular tachycardia/multi-

factorial fall.0 1




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Common causes of falls in the elderly

Falls are one of the most common presentations in elderly medicine and can be caused by a wide range ofpathologies. It is a serious matter that has a major impact on quality of life and has medical and social implications.

• Dysrhythmias including atrial fibrillation, supraventricular tachycardia and Stokes-Adams attacks.

• Mechanical falls can occur if the patient has difficulty mobilising due to weakness or disability. Visual

defects can also play a part in this. Often lack of mobility or poor vision will contribute to other potential

causes of falls.

• Peripheral neuropathy can cause loss of proprioception, contributing to falls. It can be a complication of

long-standing diabetes.

• Postural hypotension can cause syncope. It is diagnosed if there is fall of 20mmHg on lying to standing

blood pressure measurement. Causes include hypovolaemia, autonomic insensitivity with increasing age

and over-medication with hypotensive drugs.

•

Vasovagal syncope can occur after emotional stress, coughing, straining or standing up quickly. Prodromicsymptoms are often experienced, such as tinnitus, sweating, feeling hot, nausea and visual disturbances.

• Epilepsy should be ruled out.

• Multi-factorial falls occur when a combination of the above factors are present. This is often the case inelderly patients.

Key investigations, etc.

• Routine blood tests, including blood glucose.

• ECG.

• 24hr ambulatory ECG (Holter tape).

• Echocardiogram.

• Lying (or sitting) to standing blood pressure.

• Formal assessment of vision.

•

Physiotherapist assessment of mobility.• Formal neurological assessment including neuroimaging, if indicated.

Causes of palpitations

Palpitations describe an intermittent awareness of your own heartbeat. The heartbeat can be normal, slow or fast in

rate, and regular or irregular in rhythm. It is useful to ask the patient to tap out the rate and rhythm of their palpitationsto help determine the underlying problem.

• Anxiety disorder is a term used to describe a range of psychiatric problems. It is a non-cardiac cause of

palpitations that should be ruled out from the history.

• Tachycardia includes supraventricular tachycardia and ventricular tachycardia. Paroxysmal tachycardia

can occur due to junctional re-entry phenomena.

• Bradycardia requires an increased stroke volume to maintain cardiac output. This can cause palpitations.

•

Atrial fibrillation is experienced as an irregularly irregular rhythm that can be slow or fast. The three maincauses of AF are: 1. Ischaemic heart disease, 2. Rheumatic heart disease and 3. Thyrotoxicosis.

• Extrasystoles (premature beats) are often benign. They are felt by patients as “missed beats”.

• Cardiomyopathy can cause dysrhythmias.

Key investigations, etc.

• Routine blood tests, including thyroid function tests.

• ECG.

• 24hr ambulatory ECG (Holter tape).

• Exercise ECG. • Echocardiogram.


1.

Recurrent falls. Patient UK. http://www.patient.co.uk/doctor/Recurrent-Falls.htm2. Palpitations. Patient UK. http://www.patient.co.uk/doctor/Palpitations.htm


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3rd


History: Giving information – Colonoscopy

Instructions: Please explain to this patient what a colonoscopy entails and give enough accurate

information so that they will be capable of giving informed consent to the procedure.Time: 5 minutes.

Task Marks


PATIENT PERSPECTIVE (Ideas/Concerns/Expectations)

2. Concerned about procedure what will happen? 0 1

3. Is it painful or uncomfortable? 0 1

4. What about work afterwards? 0 1LIFESTYLE/RISK FACTORS IDENTIFICATION

5. Enquires about both smoking and alcohol intake. 0 1

6. Enquires about significant family history. 0 1

INFORMATION GIVING

7. The test looks at large bowel using flexible tube. 0 1

8. Safe test, discomfort should be minimal, can use IV sedation but not GA. 0 1

9. Bowel needs to be empty – laxatives will be provided, biopsy maybe taken. 0 1

10. Complications rare, patient should not drive home afterwards. 0 1

ASSESSMENT OF UNDERSTANDING

11. Checks understanding of information. 0 1

12.Encourages patient questioning and identifies additional information needs

throughout.0 1

SUMMARY

13. Summarises all key points in the interview including patient!s concerns. 0 1

14. Encourage the patient to ask questions and respond appropriately. 0 1

PATIENT/ACTOR ASSESSMENT

15. Listen to concerns. 0 1

16. Respond to concerns. 0 1

17. Student respect and understanding of situation. 0 1

18. Confidence in student!s knowledge. 0 1

19. Behaviour/manner appropriate. 0 1

20. Mark for excellence from actor. 0 1



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3rd


History: Haematuria

Instructions: Take a focussed history of a 55-year-old patient who has presented with haematuria.

Time: 5 minutes.

Task Marks


2. Establishes whether microscopic or macroscopic. 0 1

3. Establishes timing of the bleeding: beginning, end or throughout the stream. 0 1

4. Establishes duration of symptoms. 0 1

5. Presence of clots in the urine. 0 1

6. Associated pain. 0 1

7. Loin mass. 0 1

8. Symptoms of UTI: urinary frequency, dysuria, suprapubic pain, foul-smelling urine. 0 1

9. Symptoms of LUTS: urgency, frequency, hesitancy, strangury, poor stream, dribbling. 0 1

10. Trauma to loin. 0 1

11. Symptoms of malignancy: weight loss, anorexia, lethargy. 0 1

12. Establishes past episodes of haematuria. 0 1

13. Asks about past medical history (must include: renal stones, UTIs). 0 1

14. Asks about drug and allergy history (must include: anticoagulants). 0 1

15. Asks about family history. 0 1

16. Asks about smoking. 0 1

17. Asks about drinking. 0 1

18. Asks about occupation and past exposure to carcinogens. 0 1





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3rd


History: Haematuria

Written in April 2011 by Kyaw Zayar Thant.

Main differential diagnoses of frank haematuria and typical presenting histories

1.

Bladder cancer

Middle aged/elderly male, presenting with painless frank haematuria ± clots ± associated symptoms of

malignancy (weight loss, anorexia, fever etc). Risk factors of smoking, occupational exposure to chemical

carcinogens, e.g. rubber, textile, leather, paint industry.2.

Renal cell carcinoma

Middle aged/elderly male, presenting with triad of haematuria, loin pain and loin mass ± associatedsymptoms of malignancy (weight loss, anorexia, fever, etc).

3.

Renal stones

Male or female presenting with colicky loin pain radiating to groin ± haematuria (usually microscopic).4.

UTI

Female presenting with urinary frequency, dysuria, suprapubic pain and foul-smelling urine. 5.

Bleeding from prostate

Elderly male with symptoms of LUTS and haematuria at end of stream with raised PSA.

Key investigations

1. Urinalysis.2.

MSSU

a. Microscopy: confirms haematuria and help to distinguish medical and surgical causes.

b. Culture and sensitivity: confirms UTI.

3. CT urography: identifies lesions in the kidneys and ureters.

4. Cystoscopy: identifies lesions in the bladder.5. Routine bloods: FBC, U&E, LFT, CRP, Coag.


1.

Kumar P, Clark M. Kumar & Clark!s Clinical medicine. 7th

ed. Edinburgh: Saunders Elsevier, c2009.

2.

Feather A, Lumley JSP, Visvanathan R. OSCEs for medical students. Volume 2. 2nd

ed. Knutsford; Pastest;2004.


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3rd


History: Headache

Instructions: Take a focussed history of a 40-year-old patient who has presented with a headache and

suggest a diagnosis at the end.Time: 5 minutes.

Task Marks


0 1

0 12.

Asks specific questions about pain – site, onset, character, radiation, associated

symptoms, timing, exacerbating/relieving factors, severity.

1/3 mark for each. 0 1

3. Visual disturbances. 0 1

4. Photophobia. 0 1

5. Altered level of consciousness. 0 1

6. Neck stiffness. 0 1

7. Rash. 0 1

8. Fever. 0 1

9. Nausea and vomiting. 0 1

10. Focal neurological signs (weakness, loss of sensation or paraesthesia). 0 1

11. Aura (in migraines). 0 1

12. Asks questions to exclude cancer – weight loss, anorexia, fatigue. 0 1

13. Past medical history. 0 1

14. Drug history and allergies. 0 1




18. Diagnosis and mark for excellence. 0 1



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3rd


History: Headache


Classical presentations of headache

Tension-type headache

• A gradual onset of global, tightening pain, of mild-moderate severity. The pain is non-pulsatile, not made

worse by physical activity.

• This is the most common cause of headache.• Most occur episodically but 3% of population have chronic TTH.

Migraine

• A gradual onset of unilateral, pulsating, moderate-severe pain that is aggravated by exercise, typically

lasting hours or days.• Associated symptoms may include nausea, vomiting, photophobia and phonophobia.

• May or may not occur following an “aura”. An aura is a prodromic sensory phenomenon that ranges fromvisual disturbance (e.g. flickering lights or blind spots) to paraesthesia. Auras can occur hours or days beforea migraine and typically last 5-60 minutes.

Cluster headache

• A rapid onset of unilateral, sharp, non-pulsatile pain, typically felt behind the eye, at the temple, or at the

forehead.

• Pain is severe and can be described as the worst ever felt.• Each episode lasts 45-90 minutes and characteristically occurs at the same time every day.

Subarachnoid haemorrhage

• Classically described as a “thunderclap” headache that comes on suddenly and lasting only a few seconds.The pain is often the worst ever experienced.

• After the initial event, a less severe headache lingers for 1-2 weeks.• Associated symptoms may include seizures, vomiting, stiff neck and photophobia.

Meningitis

• A severe, throbbing, global headache with classical associated symptoms, such as fever, neck stiffness,altered consciousness, shock, Kernig!s sign (pain and resistance on passive extension of the knee, when

the hip is in a flexed position) Brudzinski !s sign (hips flex when flexing the neck forward), focal neurological

deficits and seizures.• Meningococcal meningitis is associated with a non-blanching purpuric rash found anywhere on the body.

Temporal arteritis

• Classically an elderly lady complaining of a severe, dull headache with scalp tenderness when she combs

her hair and jaw ache when she eats.• Associated with polymyalgia rheumatica.

Idiopathic intracranial hypertension

• Classically a young, obese woman complaining of a two-week history of headaches that are worse in themorning and on lying down.


1.

Headache. Patient UK. Available from: http://www.patient.co.uk/doctor/Headache.htm


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3rd


History: Hyperthyroidism (thyrotoxicosis)

Instructions: Take a history from this 35-year-old woman who presents with weight loss and heat

intolerance.Time: 5 minutes.

Task Marks


2. Confirms weight loss, establishes amount of weight lost and over what period of time. 0 1

3.Excludes other symptoms suggestive of malignancy (fatigue and loss of appetite).

Appetite is increased in hyperthyroidism, however, fatigue may be present.0 1

0 1

0 1

0 1

0 1

0 1

0 1

0 1

4.

Symptoms of hyperthyroidism:

Tremor, irritability, sweating, heat intolerance, palpitations, oligomenorrhoea or

amenorrhoea (in females), loss of libido, altered mental state, anxiety, hair loss,

weakness, fatigue, diarrhoea.

See notes below.

1 mark each, up to a maximum of 8.0 1

5. Asks about neck swelling (goitre). 0 1

6. Asks about visual loss/blurring (in Graves! disease). 0 1

7. Past medical history. 0 1

8. Drug history. 0 1




12. Diagnosis: Hyperthyroidism (most likely Graves! disease). 0 1




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3rd


History: Thyroid


Hyperthyroidism

Causes

• Graves! disease is the most common cause of hyperthyroidism (thyrotoxicosis). It is an autoimmune

disease.

• Toxic multinodular goitre is common in the elderly.• Toxic thyroid adenoma is a solitary benign tumour of the thyroid.

SYMPTOMS SIGNS

• Weight loss.

• Increased appetite.

• Heat intolerance.

•

Irritability.• Tremor.

• Diarrhoea, palpitations, sweating,

breathlessness, oligomenorrhoea or

amenorrhoea, poor libido.

• Visual disturbance (in Graves! eye disease).

• Tremor.

• Hyperkinesis.

• Tachycardia or atrial fibrillation.

•

Full pulse.• Warm peripheries.

• Goitre.

• Thyroid acropachy, pretibial myxoedema.

• Exophthalmos, lid retraction (in Graves! eye

disease).

• Lid lag can be present in any cause of

hyperthyroidism and not just Graves! disease.

Hypothyroidism

Causes

Primary hypothyroidism

• Iodine deficiency is the most common cause of hypothyroidism worldwide, but is uncommon in the UK.

• Autoimmune disease such as Hashimoto!s thyroiditis.

• Iatrogenic due to treatment of hyperthyroidism with thyroidectomy or radioiodine therapy.

Secondary hypothyroidism

• Impaired pituitary function causes reduced production of TSH (thyroid-stimulating hormone). This canresult from, e.g. tumour, surgical or radiological damage.

Tertiary hypothyroidism

• Impaired hypothalamic function causes reduced production of TRH (thyrotropin-releasing hormone).

SYMPTOMS SIGNS

• Lethargy.

• Weight gain.

• Cold intolerance.

• Goitre.

• Depression, constipation, menorrhagia or

oligomennorhoea, loss of appetite, arthralgia,

myalgia, poor libido.

• Mental slowness.

• Dry hair and hair thinning.

• Dry skin.

• Slow-relaxing reflexes.

• Bradycardia.

• Cold peripheries, hypothermia, hypertension,

oedema, carpal tunnel syndrome, ataxia.


1. Hyperthyroidism. Patient UK. http://www.patient.co.uk/doctor/Hyperthyroidism-(Thyrotoxicosis).htm

2.

Hypothyroidism. Patient UK. http://www.patient.co.uk/doctor/Hypothyroidism.htm3. Kumar and Clark, 6

th Ed. The Thyroid Axis. p. 1071-1074.


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