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9 Jan 2011 Sudan referendum-pray for Sudan

January 1

MRCGPINT
OSCE 2011
DR.ABDELNASIR ABBAS ELSHEIKH DRSAWSAN GAMAL ELDIN 3rd
MRCGP-INT NGHA MRCGP-INT RKH-RIYADH
EDITION
[MRCGP-INT-OSCE scenarios 2011 ]

Cases scenarios to facilitate MRCGP OSCE assessment

Erectile Dysfunction

Notes for candidate

MR X is a 65 year old widower. He is now retired and enjoys life to the


full. He has a PMH of MI 10 years ago and occasionally gets classical
angina with strenuous exertion. He can however play 18 holes of golf
with no problems.

DH – GTN spray, aspirin, ramipril, atenolol and simvastatin

Notes for simulator

MR X is a 65 year old widower. He is now retired and enjoys life to the


full. He has a PMH of MI 10 years ago and occasionally gets classical
angina with strenuous exertion (he has not needed his GTN spray in
the last 6 months). He can play 18 holes of golf with no problems.

He has a great social circle which has supported him over the last two
years since his wife died of cancer. In the last few months he has
entered a new relationship and has discovered he has erectile
impotence (he can only achieve a partial erection and has lost his
normal early morning erections and is unable to achieve a full erection
during masturbation). This is worrying him and he is keen to sort it out,
although a little embarrassed about having to see a GP about the
problem.

He has decided to see the GP with a vague ‘backache’ to check them


out and if they seem approachable then to discuss his erection
problems.

His ideas are (he has an erection problem and attributes it to his age),
concerns are (he is worried his GP will think that old men like him
should not be bothered about sex, also he is worried about Viagra and
his history on MI) and expectations are (a trial of Viagra, as
recommended by a few of the chap in the golf club).

MR X in a non smoker since his MI and drinks little alcohol.

He has no family history of note.

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[MRCGP-INT-OSCE scenarios 2011 ]

He has no symptoms of diabetes (blurred vision, thirst, fatigue, weight


loss, frequency etc). He has no urinary symptoms.

His current medication includes: GTN spray, aspirin, ramipril, atenolol


and simvastatin

He has no allergies.

Areas the candidate should explore/offer

1. His hidden agenda.


2. His ideas, concerns and expectations.
3. What he means by ‘erection problems’ (partial, complete, sudden
onset, gradual onset, absence of morning erections etc).
4. Important medical red flags – e.g. frequency of GTN use, symptoms
of stress or depression or guilt, symptoms of diabetes,
hypogonadism etc.
5. Alcohol, drug and smoking history.
6. Examination - Pulse, BP, external genitalia.
7. An explanation of possible causes e.g. arterial disease/poor blood
flow
8. Investigation – e.g. U&Es, fasting BS, cholesterol & LDL, LFTs and
testosterone.
9. A good explanation of treatment options focussing on PDE5
inhibitors (Cialis, Viagra etc).
10.An explanation of how PDE5 inhibitors work, how to take them,
potential side effects, PDE5s and IHD. The fact he will need to pay
for them.
11.Safety netting for assessment of effect, potential side effects or
exploration of alternatives.

Examination Card

Pulse 80 reg, BP 135/70, external genitalia normal

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[MRCGP-INT-OSCE scenarios 2011 ]

Chronic fatigue

Notes for candidate

MS B is 50 years old and works as a typist in a neighbouring Practice.


She had little PMH of note other than an episode of back pain a year
ago and irritable bowel syndrome 10 years ago. She was last seen 10
months ago for her low back pain.

She is married but her husband is disabled with MS and her two
children have left home.

Notes for simulator

MS B is married but her husband is disabled with MS and her two


children have left home. She has had profound fatigue for the last five
months and has ‘soldiered on’. She has come today as she has been in
trouble with her Practice Manager, as she fell asleep at work and the
standard of her work has deteriorated dramatically. Wendy is fearful
that she may loose her job (she is the sole wage earner).

She feels as though she is tired all the time ‘as though wading through
treacle’ and all her muscles ache ‘as if I had just done a marathon’. Her
concentration is poor and she can fall asleep at any time and has been
sleeping in excess of 10 hours a day.

She has a happy marriage and although her husband is disabled he


copes very well at home with all the aids and adaptations OT have
fitted in the home. She is not depressed but is worried over the
possibility of losing her job and is sick of feeling tired all the time! Her
weight is steady and she has no symptoms of diabetes (thirst, blurred
vision, urinating ++ etc). She has no history of joint swelling or
inflammation and no history of rectal or vaginal bleeding.

She wants a diagnosis and her symptoms sorting out. She has privately
wondered if she may have chronic fatigue syndrome, as she has
recently typed a referral letter about a patient with symptoms just like
hers who was being referred to the Chronic Fatigue Service at the
hospital.

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[MRCGP-INT-OSCE scenarios 2011 ]

Areas the candidate should explore/offer

12.Her ideas, concerns and expectations


13.Her mental state – depression, stress etc.
14.Important medical red flags – e.g. weight loss, weight gain,
constipation, rectal or vaginal bleeding, joint swelling, thirst,
urinating ++, (re diabetes, hypothyroidism, anaemia, arthritis etc)
15.Alcohol, drug and smoking history
16.An explanation of possible causes – stress, depression, underactive
thyroid, anaemia, diabetes etc.
17.Investigation – e.g. fasting BS, FBC, ESR, TSH
18.An explanation of the possible treatments for the diagnosis they
propose e.g. a patient information leaflet on CFS, advice re graded
exercise and diet, possible referral to the local CFS clinic and or
sign post to other resources e.g. the action for ME website
www.afme.org.uk
19.Safety netting.

IF THE DOCTOR OFFERS EXAMINTION THERE ARE NO


ABNORMALITIES TO BE FOUND

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[MRCGP-INT-OSCE scenarios 2011 ]

DIABETES
Mr G

An overweight man in his late 50s, young child and young wife.
Stressful job at the moment.

Last consultation focussed on stress and debt management

Prior to that he was counselled about his new diagnosis of Type 2


diabetes and he is still awaiting his education session.

PMH – Gout, AF, TIA, Type 2 diabetes, peptic ulcer disease, amblyopic
in his right eye

DH – bisoprolol 5mg , warfarin 2mg, ramipril 5mg , simvastatin 20mg,


allopurinol 100mg, sildenafil 100mg prn

FH – IHD

SH – smoker of cigars, overweight, stressful job ++

Allergies – none known

1. Hba1c – 7.5%
2. Cholesterol 4.5 and LDL 2.2
3. U&Es are ‘normal’ but e-GFR 58
4. Urate slightly elevated
5. BP 145/85
6. Urine ACR 4.5

 What aspects of his current medication cause concern?


 How might you manage a flare up of his gout?
 How will you address his results & BP (Points 1 to 6)?
 If he presented later in the year with a history of transient
speech disturbance and focal right sided weakness – what
information would you need to find out and how might that
effect your management?

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[MRCGP-INT-OSCE scenarios 2011 ]

Mr G

An overweight man in his late 50s, young child and young wife.
Stressful job at the moment.

Last consultation focussed on stress and debt management

Prior to that he was counselled about his new diagnosis of Type 2


diabetes and he is still awaiting his education session.

PMH – Gout, AF, TIA, Type 2 diabetes, peptic ulcer disease, amblyopic
in his right eye

DH – bisoprolol 5mg , warfarin 2mg, ramipril 5mg , simvastatin 20mg,


allopurinol 100mg, sildenafil 100mg prn

FH – IHD

SH – smoker of cigars, overweight, stressful job ++

Allergies – none known

7. Hba1c – 7.5%
8. Cholesterol 4.5 and LDL 2.2
9. U&Es are ‘normal’ but e-GFR 58
10.Urate slightly elevated
11.BP 145/85
12.Urine ACR 4.5

 What aspects of his current medication cause concern?


 How might you manage a flare up of his gout?
 How will you address his results & BP (Points 1 to 6)?
 If he presented later in the year with a history of transient
speech disturbance and focal right sided weakness – what
information would you need to find out and how might that
effect your management?

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[MRCGP-INT-OSCE scenarios 2011 ]

Palpitations

Notes for candidate

Dave is 55 and soon to retire. He has been self employed all his life
and is selling his business to enable him to take early retirement, as
both his children are now in full employment having finished their
university degrees.

He rarely sees his GP and has no PMH of note.

Notes for simulator

Dave runs a plumber’s merchant store and is soon to sell his business.
Although he feels this is the right thing to do he has started to worry
about the life changes which will follow. He has enjoyed developing his
business and being the boss and now that there is a buyer for the
business he wonders how he will fill his time.

In the last few weeks leading up to the signing of the contacts he has
been waking up in the early hours with palpitations and a tight chest
which he has attributed to stress. A few nights ago he had a ‘bad do’
which lasted over an hour when his heart played the ‘devils tattoo’
during which he had chest tightness and sweating. This has worried
him, as his dad had a heart attack in his early sixties. He has decided to
have a check up.

He has no previous medical history of note and has been fit and well.
He drinks 10 pints a week and smokes a few Monte Cristo cigars at
weekends to help him relax.

He is happily married and his two children are doing well in their
chosen careers. He loves his classic Triumph TR4a sports car.

Areas the candidate should explore/offer

20.His ideas, concerns and expectations.


21.What he means by palpitations (How long, how fast, regular or
irregular)
22.Important medical red flags – e.g. chest pain/tightness, shortness of
breath, sweating, feeing faint, feeling anxious, finger or peri-oral
tingling, weight loss, diarrhoea etc)
23.Alcohol, drug and smoking history

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[MRCGP-INT-OSCE scenarios 2011 ]

24.An explanation of possible causes – stress, heart disease,


thyrotoxicosis, anaemia etc
25.Examination - Pulse, BP, heart and lungs
26.Investigation – e.g. fasting BS, FBC, TSH, U&Es, Chol:HDL ratio and
ECG.
27.A good explanation of possible angina.
28.An explanation of the 999 rules, smoking cessation, treatment
options and PILeaflet for angina, referral for stress testing, 24 hour
heart monitoring etc.
29.Safety netting.

Examination Card

P80 reg, BP 135/70, HS normal, no oedema, chest clear.

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[MRCGP-INT-OSCE scenarios 2011 ]

Osteoporosis

Notes for candidate

Jim is 49 and had presented with chronic thoracic back pain over the
last year. A thoracic spine X-ray revealed osteopaenia and a spinal
wedge fracture of T5. As a consequence of which you arranged a
DEXA scan which has just come back revealing a T score of -3.0 for
both hip and spine. He is using paracetamol and ibuprofen for his back
pain.

Notes for Simulator

Jim restores vintage cars which can be quite a heavy job and his back
pain has been causing problems at work. He is married with two
children at university and things are financially difficult at a result.

He does little exercise, is a non smoker and drinks 6 pints of beer a


week over the weekend.

PMH – Juvenile arthritis which required high dose steroids as a child.


Otherwise no PMH of note other than his back pain and wedge fracture.
No FH of osteoporosis.

He is currently using paracetamol and ibuprofen for his back pain. His
main objective is to get better analgesia so he can continue working.

Areas the candidate should explore/offer

1. Smoking, alcohol and exercise.


2. Family history
3. PMH
4. Red flags for hypogonadism/low testosterone, hyperthyroidism,
5. Patient’s understanding of osteoporosis.
6. An explanation of the DEXA scan and osteoporosis.
7. Arrange investigation – FBC, ESR, TFTs, TTG antibodies, adj
calcium, alk phos and PTH, testosterone and SHBG
8. Discuss measures Jim can take e.g. weight bearing exercise,
healthy diet etc
9. Touch on treatment options – calcium and vitamin D,
biphosphonates, testosterone replacement, strontium etc
10.Safety net

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[MRCGP-INT-OSCE scenarios 2011 ]

hypertension

Notes for candidate

Neil is 44 years old and has recently joined the practice when he and
his family moved into the area to work at the local chemical plant.

He has had his new patient medical and the notes read

12th of Jan
New patient medical
No PMH of note
No FH of note
Married, non smoker, 28 units per week
BMI 28
BP 170/100 re-check monthly for 2 months

22nd of Feb
BP 165/98

4th of March
BP 160/95 – to see GP

Notes for simulator

Neil is 44 years old, married and has two teenage children. They have
recently moved into the Practice area to take up a new job in the
nearby chemical plant. He is enjoying the new job and the children
seem to be settling into their new school.

He has no medical history of note. He is an only child; mum and dad are
both alive and well.

He is on no medication and he is a non smoker.

At his new patient medical he was discovered to have a high BP


170/100 and he has had it checked again two months running and it still
high despite him cutting down on alcohol from 28 to 14 units a week
and cutting down on his salt intake (as suggested by the Practice
Nurse).

The Practice Nurse had asked him to book an appointment today as he


‘might need some tablets’.

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[MRCGP-INT-OSCE scenarios 2011 ]

Ideas – No real understanding of high blood pressure


Concerns – Mortgage medical coming up, as the family have found a
place they want to buy.
Expectations – Another lecture on weight loss!

Areas the candidate should explore/offer

30.Why he is here today.


31.His ideas, concerns and expectations around high blood pressure.
32.Alcohol, drug and smoking history.
33.An explanation of hypertension.
34.Appropriate examination – P, BP, HS, Pulses, Retinas etc
35.An explanation of how he can help himself (diet, exercise, weight
loss).
36.An explanation of why he needs life long medication.
37.An explanation of the need for further investigations – ECG, MSU
and fasting bloods (fasting glucose, cholesterol:hdl ratio,
triglycerides and u&es).
38.Provide a PIleaflet e.g. from www.patient.co.uk
39.An overview of his schedule of care (once BP controlled 6 monthly
BP check and annual fasting bloods).
40.Safety netting – arrange review to answer further questions and
review the results of his investigations and start treatment e.g.
Ramipril or Bendrofluazide.

Examination Card

P80 reg, BP 160/95, BMI 28, HS normal, no radio-femoral delay, no


retinopathy

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[MRCGP-INT-OSCE scenarios 2011 ]

Notes for candidate

John is a 30 year old policeman who last saw his GP 10 years ago for a
sore throat. He has no previous medical history of note and is on no
medication.

Notes for simulator

John is a 30 year old policeman who is happily married with two young
children. His job is stressful, as he covers a tough part of town. Over
the last six months he has been getting indigestion at night with reflux
symptoms. He has been buying OTC Gaviscon which initially provided
some relief but now is failing to control his symptoms.

He smokes 20 cigarettes a day. He no longer goes out ‘with the lads’


but does like a few bottles of beer every night, as a way or relaxing.

He has been using Tescos Ibuprofen for a pain in his left foot (pain in
his heel pad) which he attributes to ‘walking the beat’ eight hours a
day.

He does not have any difficulties swallowing or any weight loss. He has
not been vomiting, his bowels are fine and has never passed blood pr.

He thinks it’s ‘just indigestion’ but is concerned he may have an ulcer,


as his dad had the same symptoms a few years ago and almost died
from a bleeding ulcer.

John has been on the internet and has read about H Pylori infection as a
potential cause of ulcers.

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[MRCGP-INT-OSCE scenarios 2011 ]

Areas the candidate should explore/offer

Areas the candidate should explore/offer

41.His ideas, concerns and expectations


42.His mental state – depression, stress etc.
43.Current medications – OTC Gaviscon and Ibuprofen
44.Family Hx re dyspepsia, ulcers or GIT malignancy
45.Important medical red flags – e.g. dysphagia, weight loss, vomiting,
bleeding pr, anaemia symptoms (SOB on exertion, fatigue etc).
46.Alcohol and smoking history
47.An explanation of possible causes – ibuprofen, lifestyle (smoking
and alcohol) etc, H Pylori, stress etc.
48.Discuss potential investigations e.g. H Pylori faecal antigen testing
or breath testing if symptoms relapse after treatment
49.An explanation of the possible treatments – smoking cessation
advice, reducing alcohol, avoiding late eating, avoiding large evening
meals, bed head elevation, stopping ibuprofen, a trail of a PPI such
as lansoprazole 30mg a day for a month. A change of footwear or
shoe inserts for his foot pain.
50.Safety netting e.g. 2c GP if symptoms relapse after treatment
cessation in one months time.

Examination Card

BMI 24. No anaemia, no clubbing, no jaundice, abdo soft and non tender
with no masses. No abnormalities found on foot examination.

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[MRCGP-INT-OSCE scenarios 2011 ]

Low Back Pain

Notes for candidate

Len is 60 and runs the local garage which specialises in vintage car
restoration. He is has no previous medical history of note and is on no
regular medication.

Notes for simulator

Len is 60 and runs the local garage which specialises in vintage car
restoration. Although he is the boss with a couple of employees he still
has to help out test driving cars, dealing with customers and lending a
hand with the ‘heavy stuff’.

Three weeks ago while helping lift a gearbox into a Riley his ‘back
went’ and he has had low back pain radiating to his right knee ever
since. It does not wake him from sleep but it is interfering with work
and preventing him playing his weekly 18 holes of golf.

He has no sinister symptoms (i.e. no weight loss, no power loss, no


pins and needles, no loss of continence and no numbness over his
buttocks, no cough, no shortness of breath, no haemoptysis, no chest
pain).

He is worried as his dad presented the same way and it turned out he
had lung cancer with spinal secondaries. Len had been a light smoker
(10 a day for 30 years) until he stopped on his 50th birthday. As his
pain has gone on so long he can’t help wondering if he might ‘have
something serious’.

He drinks 16 units a week.

Ideas – Sciatica but also possible lung cancer


Concerns – lung cancer
Expectations – a chest X-ray

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[MRCGP-INT-OSCE scenarios 2011 ]

Areas the candidate should explore/offer

51.His ideas, concerns and expectations.


52.The psycho-social & physical implications of her back pain.
53.A detailed history of the nature of the pain.
54.Red flags (nocturnal pain, weight loss, sphincter disturbance, saddle
parathaesia, shortness of breath, haemoptysis, chest pain etc)
55.An appropriate examination – chest and back
http://www.pennine-gp-training.co.uk/physical-examination-
videos-for-the-csa.htm
56.Reassurance that there is nothing to suggest he has cancer.
57.An explanation of possible causes e.g. low back sprain rather than
sciatica.
58.An explanation that there is no need for investigations at this stage.
59.A good explanation of treatment options e.g. continued mobilisation,
safe lifting, physio, analgesia, nsaids etc.
60.A PIleaflet e.g. www.patient.co.uk
61.Shared decision making.
62.Safety netting for assessment of effect? May need physio referral.

Examination Card

Good ROM L-S spine


SLR 80 degrees on the right, sciatic stretch negative.
Reflexes rt=lft
Able to walk on heels and toes

Chest examination normal

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[MRCGP-INT-OSCE scenarios 2011 ]

Depression

Notes for candidate

Samantha is 44 years old, she has a PMH of hypertension and takes


bendroflumethazide daily. Her only contact with the surgery in the last
few years has been for BP checks and annual medication reviews.

Notes for simulator

Samantha is 44 years old, she has a PMH of hypertension and takes


bendroflumethazide daily. She is married and has two children one of
whom, John aged 15, can be quite demanding.

Samantha has recently been made redundant (from a travel agency) due
to the current economic situation. Her husband who works full time has
had to take on overtime to help make up some of the financial shortfall.

In the last month or so she has become tearful, low in mood and short
tempered with her husband and children. She no longer enjoys reading
which had been one of her ways of relaxing after the boys have gone to
bed. Even if she did want to read she feels her concentration is so poor
that it would be pointless.

She has been drinking more than she should (half a bottle of wine night)
to help her get to sleep. She is not suicidal but very low and feels
worthless since the loss of her job and now despairs over her son’s
‘teenager behaviour’.

After another argument with her son she has decided she needs help
and has come to see her GP. Is there a tablet that might help?
Areas the candidate should explore/offer

63.An exploration of the symptoms of depression – low mood,


weepiness, low self worth, hopelessness, insomnia, loss of appetite,
weight change, lack of enjoyment, thoughts of self harm etc.
64.An exploration of the psychosocial impact – drink, finances,
relationships etc
65.A Mental State Examination including suicide risk assessment.
66.Alcohol, drug and smoking history
67.Her ideas, concerns and expectations
68.An explanation of depression & checking of her understanding.
69.An exploration of options – support form family & friends, benefits
advisor, counsellor, exercise, drink reduction, self help resources

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[MRCGP-INT-OSCE scenarios 2011 ]

(PILeaflet or internet), antidepressants, sleep hygiene, PHQ9 etc.


Perhaps when she feels up to it to consider a self help book on
‘teenager taming’.
70.An explanation of the options selected and how quickly they are
likely to take effect.
71.Safety netting – follow up within 1 to 2 weeks.

Mental State examination reveals

Tearful, poor eye contact, slow initially to talk, speech is then of


normal speed and content, no formal thought disorder, not suicidal and
good insight.

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[MRCGP-INT-OSCE scenarios 2011 ]

Insulin conversion scenario

Notes for candidate

Jake Foster aged 38 runs a small carpet business in a converted church


in town and has been there over ten years. He is married with two
teenage sons.

He has had Type 2 diabetes for 10 years and is currently using


metformin 850mg tds, gliclazide 80mg 2 bd, pioglitazone 45mg and
sitaglitpin 100mg.

On looking at the notes the Practice Nurse in diabetic clinic has


commented BP is excellent (130/70), non smoker, alcohol = 12 units
per week, BMI 25 (keen not to put on any more weight), to see GP in
light of persistently elevated Hba1c (10.5%) re ? referral for
conversion to insulin.

Notes for simulator

Jake Foster aged 38 runs a small carpet business in a converted church


in town and has been there over ten years. He is married with two
teenage sons.

He has had Type 2 diabetes for 10 years and has been on maximum
tablet treatment for the last 3 months. His diabetes is still poorly
controlled, such that he suffered from fatigue and having to pass urine
3x per night.

He runs a small successful carpet warehouse with is brother and he


usually looks after the sales side of the business but occasionally has
to drive the truck to deliver the larger carpets.

He worries about being overweight and fears the prospect of insulin as


his dad went blind shortly after he was put on insulin in the 1980s.

Other than his diabetes he has hypertension for which he takes ramipril
10mg one table a day and an elevated cholesterol for which he takes
simvastatin 40mg a day. He also takes aspirin 75mg a day but is not
sure why he is on it.

He is keen to avoid weight gain, more tablets or conversion to insulin.

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[MRCGP-INT-OSCE scenarios 2011 ]

He is not currently checking his blood sugars.

Examination findings

P80 reg, BP 130/70, BMI 25

Areas the candidate should explore/offer

72.His ideas, concerns and expectations around diabetes & insulin AND
address some of the negative views he may have.
73.The presence or absence of osmotic symptoms (thirst, fatigue,
blurred vision, frequency of micturition etc).
74.An explanation of how he can help himself (diet, exercise, etc) with
respect to reducing the risk of weight gain and insulin conversion.
75.Explore possible options 1 Refer to diabetes specialist nurse. 2
Refer to specialist service. 3 Manage in-house. (E.g. once daily
insulin with metformin and sulphonylurea & possible pio cessation,
twice daily bi-phasic insulin with metformin & SU cessation and
possible pio cessation).
76.Safety netting – arrange review to answer further questions and
address his ICE.

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[MRCGP-INT-OSCE scenarios 2011 ]

Shoulder Pain

Notes for candidate

Jane is a 45 year old divorcee. She looks after her elderly demented
mum who has become very dependent in the last couple of years. She
manages to hold down her job as a secretary by using home care, a day
centre and sitter services.

Notes for simulator

Jane is a 45 year old divorcee. She looks after her elderly demented
mum who has become very dependent in the last couple of years. She
manages to hold down her job as a secretary by using home care, a day
centre and sitter services. The one thing that enables her to keep going
is her passion for judo. She trains twice a week and this helps her burn
off her stress and has greatly helped her self esteem. She has recently
passed her grading so that not only is she a black belt but she is taking
a course on teaching judo.

Over the last four months she has suffered from shoulder pain which
she attributes to a bad throw during a judo tournament. She has tried
ibuprofen to no avail, so she went to an osteopath who was expensive
and unable to help. The pain in her shoulder is getting more intrusive
such that it hurts at every training session and even on the days when
she is not training. It is starting to causes problems with handling and
lifting her mum and to make matters worse she has an important
tournament coming up soon.

She feels the pain over the outside of her shoulder and upper arm. The
pain now occurs while performing overhead activities (with the arm
above head height) and pain at night has become quite common. After a
training session she can even have difficulty performing simple
activities such as combing her hair.

Other than one episode of depression around the time of her divorce 5
years she has no medical history of note.

She is a non smoker and drinks little alcohol and is on no medication.

One of the judo team have suggested going to a sports physio while
another recommended a steroid injection and her friend suggested she
should get an MRI! She has no idea which avenue might produce the

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[MRCGP-INT-OSCE scenarios 2011 ]

outcome she desires (sport with no pain – preferably by the time of the
next tournament three weeks away).

The pain caused her to almost drop her mum while she was helping her
transfer and it is this and the imminent tournament which has triggered
her attendance today.
Areas the candidate should explore/offer

77.Her ideas, concerns and expectations.


78.The psycho-social & physical implications of her shoulder pain.
79.A detailed history of the nature of the pain.
80.An appropriate examination
http://www.pennine-gp-training.co.uk/physical-examination-
videos-for-the-csa.htm

Simulators to feign pain when lifting their arm above shoulder height
but otherwise to have a full range of movement in their shoulder.

81.An explanation of possible causes e.g. rotator cuff tear,


impingement.
82.An explanation of possible investigations e.g. USS rather than X-ray
or MRI
83.A good explanation of treatment options e.g. physio, analgesia,
steroid injection or surgery.
84.Shared decision making – Steroid injection would be her favourite
choice as this could be achieved within the 3 week window +/-
USS.
85.Safety netting for assessment of effect ? May need orthopaedic
referral.

Examination Card

Normal contour, no localised tenderness, pain on abduction over 90


degrees.

Neer’s sign positive


Hawkin’s test positive

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[MRCGP-INT-OSCE scenarios 2011 ]

Hirsutism

Notes for candidate

Samina is 20 years old and works in the marketing department of a


local company. She had little PMH of note other than acne in her
teenage years and a recent attendance because of concerns over her
irregular periods.

She is unmarried and lives with her parents.

Notes for simulator

Samina is 20 years old and works in the marketing department of a


local company. She is unmarried and lives with her parents. Over the
last couple of year she has had problems with prominent facial hair and
hair on her arms which cause her embarrassment. She wears long
sleeve blouses and has been bleaching and plucking her facial hair to
minimise its visual impact. She does not shave, as she has heard this
makes the hairs grow quicker.

She has been surfing the net and has seen an article on Polycystic
Ovary Syndrome which seems to be an exact description of her (excess
hair growth, acne, irregular periods etc) and she is interested in the
article that recommends metformin as a treatment.

She is a non smoker, non drinker, enjoys her job and is worried about
her excessive body hair as she feels it’s unsightly and may cause
problems with potential future relationships.

She has no family history of note other than Type 2 diabetes (dad) and
none of her siblings or her mum has excess body hair.

She has no symptoms or signs of virilism e.g. male pattern balding,


deep voice etc.

She had little PMH of note other than acne in her teenage years and a
recent attendance because of concerns over her irregular periods.

She is on no regular medication.

Ideas – She believes she has PCO, medication will sort it out, shaving is
bad because it makes hair grow quicker.

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[MRCGP-INT-OSCE scenarios 2011 ]

Concerns – Problems with potential future relationships.

Expectation – A prescription for metformin which will resolve her


symptoms promptly.

Areas the candidate should explore/offer

86.Her ideas, concerns and expectations


87.Important medical red flags – e.g. sudden onset of hair growth,
deepening voice, male pattern balding, acne etc.
88.An explanation of possible causes – familial hirsutism, PCO and
androgen excess.
89.Investigation – e.g. LH:FSH ratio, Testosterone, fasting blood
glucose, pelvic ultrasound. Also ? 17-HO progesterone, ?? GTT.
90.An explanation of PCO and a PILeaflet or signposting to
www.patient.co.uk
91.Discussion around weight loss and its advantages in managing PCO.
92.An exploration of other therapeutic options & the fact that most take
3 to 6 months to take effect.

 Weight loss strategies


 Bleaching, shaving, waxing, hair removal creams, electrolysis,
laser depilation etc.
 Dianette, Yasmin, spironolactone, metformin and pioglitazone
 Eflornithine cream

93.Safety netting.

Examination Card

BMI 29, prominent facial hair, mild acne and hair on her arms.
No male pattern balding, voice normal, no hair on chest or back

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[MRCGP-INT-OSCE scenarios 2011 ]

Prostatism

Notes for candidate

Kevin is 48 years old, he has hypertension which was identified at his


new patient medical two years ago. He has no other PMH of note.

Drug history = Amlodipine 10mg a day

His last BP performed two months ago was 120/70 mmHg

Notes for simulator

Kevin is 48 years old, married and has two teenage children. He is an


Engineer who works for the local steel fabrication company. He has a
happy family life and other than his hypertension he has no medical
history of note.

His mother died in her 50s from chronic renal failure as a complication
of her diabetes. His father is still fit and well.

He enjoys fell walking with his wife. He drinks 20 units a week and is
an ex smoker.

He feels fit and well (with no symptoms of diabetes such as thirst,


fatigue, blurred vision, frequency of micturition) but over the last year
or so has had problems with passing urine frequently, getting up about
three times every night to pass urine, having to “wait around” while
things get going, a poor stream but no terminal dribbling. He has no
pain on passing urine and has had no blood in his urine.

He has seen a program on TV about prostate cancer and the symptoms


seem to be just like the ones he has and this shapes his ideas, concerns
and expectations.

Ideas – he might have a prostate problem


Concerns – it might be prostate cancer
Expectations – a PSA blood test and prostate exam and possible
prostate operation.

25
[MRCGP-INT-OSCE scenarios 2011 ]

Areas the candidate should explore/offer

94.An exploration of his symptoms.


95.His ideas, concerns and expectations.
96.The presence or absence of symptoms of diabetes (thirst, fatigue,
blurred vision, frequency of micturition etc), other GU problems
(dysuria, haematuria etc).
97.Alcohol, drug and smoking history.
98.BP & Prostate examination
99.An explanation of prostate problems & PSA testing.
100. Provide a PILeaflet on PSA & prostate problems.
101. Arrange further investigation (U&Es, fasting BS, MSU and ?
PSA). Ask him to complete the I-PSS scoring sheet.
102. Discuss potential treatment options.
103. Safety netting – arrange review to answer further questions,
discuss results and plan treatment.

Examination Card

P80 reg, BP 130/70, genitalia normal, enlarged and benign feeling


prostate (smooth and symmetrical)

26
[MRCGP-INT-OSCE scenarios 2011 ]

TIA

Notes for candidate

Phillip is 61 years old and his daughter has made him book into the on
call surgery. He is an ‘infrequent attender’ and his last consultation was
in 1995 when he had hurt his back.

PMH – Nil of note

DH - None

Notes for simulator

Phillip is 61 years old, married and both his children have left home. He
is use to robust good health and has only seen a GP four times in his
life! His last consultation was in 1995 when he had hurt his back.

He is man who ‘does not like to make a fuss’.

Early this morning at the breakfast table he developed slurred speech,


although no facial or limb weakness which lasted 30 minutes and has
now fully resolved. His daughter, who popped round at lunchtime, was
alarmed by these symptoms and has cajoled him into seeing the on-call
GP, just in case he has had a small stroke.

He has no medical history of note. His mother is still alive and well in
her 80s but his father who had diabetes died of metastatic lung cancer.

He drinks very little and he is an ex-smoker.

He is on no medication

Ideas – He does not think there is anything serious; he is keen not to


make a fuss and has only come to keep his daughter happy.

Concerns – None

Expectations – Return home with no need for investigation or treatment.

27
[MRCGP-INT-OSCE scenarios 2011 ]

Areas the candidate should explore/offer

104. Why he is here today.


105. His ideas, concerns and expectations
106. An exploration of his symptoms
107. Alcohol, drug and smoking history.
108. Appropriate examination – P, BP, HS, Carotid bruits, brief
neurological examination etc
109. ABCD2 assessment.
110. An explanation of TIA.
111. An explanation of why he needs to be seen in hospital within a
week.
112. An explanation of why he needs a stat dose of aspirin 300mg
now, which is to be continued until he is seen in clinic whereupon it
will be reduced to 75mg a day 2 weeks post TIA.
113. An explanation of the need for further investigations – Carotid
duplex scanning, cranial CT?, FBC, fasting glucose, cholesterol &
LDL, LFTs and U&Es.
114. Provide a PIleaflet e.g. from www.patient.co.uk
115. Safety netting – arrange review to answer further questions and
review the results of his investigations and address secondary
prevention issues.

Examination Card

P80 reg, BP 145/85, BMI 28, HS normal, carotid bruit, no focal


neurology

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[MRCGP-INT-OSCE scenarios 2011 ]

Headache

Notes for Candidate

Mrs Thomas is a 68 yr old lady who is usually fit and well. She usually
avoids coming to the doctors as she treats common ailments with
homeopathy. Her sister suffers from mental health problems and
learning difficulties. Mrs Thomas has recently come back from America
after a 2-month stay with her daughter and family.

Notes for Simulator:

Mrs Elizabeth Thomas is a 68-year-old retired schoolteacher.


She has come to the doctor today about her headache, which she has
had for 3 weeks ‘off and on’. It’s an achy pain, which is felt more when
she is doing her crosswords or watching the telly intently. It’s relieved
when she is relaxed, such as. talking to her grandson on the phone or
socialising.

The pain is more in the right frontal and parietal scalp area, she has no
jaw tiredness or pain, no ear, hearing problems, nausea or vomiting etc
and her vision is ok. Her scalp doesn’t hurt when she combs her hair
and she reports no injuries. She feels worried but not depressed,
appetite is normal, though she has been feeling a bit tired for a few
days because she has been lying awake thinking about things.

She hasn’t spoken to her husband about this.

Although she doesn’t like taking tablets she has had to resort to taking
ibuprofen that her husband takes for his arthritis. This is a big step
because she usually finds ‘cures’ for her ailments in homeopathy. She
is worried about it being a brain tumour, as her 34-year-old daughter
who lives in the USA was found to have a benign brain tumour on a
routine company medical exam CT scan.

Apart from this she is constantly worried about her sister who has
learning difficulties as well as mental health problems. Amy is currently
admitted to a hospital where she was recently assaulted by another
patient. She feels guilty about her being in a mental institution, whereas
she herself enjoys a good life.

29
[MRCGP-INT-OSCE scenarios 2011 ]

She lives with her 72-year-old husband, who is a retired banker and
there are no other worries. She doesn’t smoke, drink excessively or
take any regular meds. There are no known allergies.

She wants to be examined thoroughly and wants to be reassured that it


isn’t a cancer, she wouldn’t really like to have a scan but would
reluctantly agree to it if the doctor thinks its necessary.

Areas the candidate should explore


 Her ideas, concerns and expectations
 Her mental state – depression, stress etc.
 Important red flags- vision, scalp tenderness, jaw claudication,
vomiting, postural change of headache, hearing problems,
seizures, weakness, paraesthesias, memory or personality
changes.
 Other history points smoking, drugs, alcohol.
 Candidate must attempt to examine her – provide findings
(below)
 Offer investigations- FBC, ESR U&E, TFTs, LFTs, fasting blood
sugar if hx suggests.
 An explanation that this might be related to the stress.
 Offer options- investigations vs relaxation techniques/ tapes,
gentle exercise, counselling, speaking to husband. Medication-
antihistamine for sleep vs amitriptyline if wants.
 PIL for tension headaches.
 Safety netting.

Examination findings

BP 120/80, No neurological deficit or papilloedma

30
[MRCGP-INT-OSCE scenarios 2011 ]

COCP request by a teenager

Notes for candidate

Katie is 15 years old and has no PMH of note and last saw her GP 3
years ago regarding acne.

Notes for simulator

Katie is 15 years old and lives with mum, step dad and two younger
brothers. She goes to Wyke Manor school and is managing ok. She has
a 16 year old boyfriend Dan who is in the class above hers.

She has just started a sexual relationship with Dan and has been using
condoms and both are keen for her to go on the cocp. Katie has a
friend on the pill who says it’s great. Katie has no idea of other
contraception methods although she had overheard someone talking
about an injection.

She does not want her mum and stepdad knowing as they ‘have found
religion’ and she will not accept their involvement at any price! As a
consequence she is quite shy when she first meets the GP and skirts
round the issue of the pill request with a ‘sore throat presentation’,
although she soon discloses her hidden agenda

Katie drinks and smokes at parties but not much else as her parents
would ‘smell it a mile off’.

Other from acne a few years ago you have had no other medical
problems and you don’t know of any family history of illness.

Areas the candidate should explore/offer

116. Her hidden agenda – cocp request.


117. Her ideas, concerns and expectations relating to cocp.
118. Her knowledge of other forms of contraception and safe sex.
119. Who her partner is (age & nature of relationship).
120. Encourages parental involvement but is able to assess Fraser
competence and proceed without it.
121. Shares some information & PILeaflet regarding different forms of
contraception & emergency contraception.
122. Screens for smoking hx, FH of VTE etc.

31
[MRCGP-INT-OSCE scenarios 2011 ]

123. Checks BP & BMI.


124. Briefly discusses the relative merits and risks of the different
forms of contraception.
125. Comes to shared management plan.
126. Discusses cocp starting, missed pill and antbx warnings if
proceeding to prescription.
127. Safety netting/planned F/U around the time of the start of her
next period or signposting to local CASH clinic.

IF THE DOCTOR OFFERS EXAMINTION THERE

BP 12/70 and BMI 24

32
[MRCGP-INT-OSCE scenarios 2011 ]

Notes for candidate

Marilyn is a 15 years old patient who last came to the surgery two
years ago with sore throat which was treated with Penicillin.

PMH: Nil Significant

DH: NKDA
Nil Regular

Examination Card:

O/E Temp: 36.8, There is a small early cold sore on her lip..

Note for simulator:

You are Marilyn 15 years old doing GCSEs at school. You have
developed a small ulcer on the sides of your lip for last 2-3 days.
There is no itching or discharge from the ulcer.

You are under some stress these days as you are preparing for GCSE
exams which are coming up in 4-6 weeks.

You do not have any genital ulcers and do not have any vaginal
discharge. LMP 3 weeks ago. No urinary symptoms.

A friend says that you have ‘herpes’ and a google search mentions the
possibility of genital ulcers and STIs!

Disclose this information only if doctor reassures you that the


consultation is confidential. You are worried if it is some serious
infection that you may have contacted from your boy friend who is your
class fellow. You have not noticed any penile or oral ulcers on your
boyfriend. You are not on any contraceptive pill and occasionally use
condoms. You feel that it’s unlikely you would get pregnant as your
partner is ‘always careful’.

You think your doctor will give might offer you some investigations and
treatment to find out what the ulcers are and treat them.

33
[MRCGP-INT-OSCE scenarios 2011 ]

You are fit and well and never smoked and do not take any medication.
You only drink on weekends when you go out with friends.

You live with your parents and do not have good relations with your
mum. Your elder brother is studying law at a university in London and
come home after 2-3 months. You do not have any not other close
relatives in this city.

You will be open to discuss any issues that the doctor may identify.

Areas candidates should explore:

1. Explores her ideas, concerns and expectations.


2. Reassures patient about confidentiality.
3. Rule out other causes and risks of STI.
4. Explore patients health beliefs and address them e.g. risk of
pregnancy and STIs,
5. Makes an attempt to check for Fraser competence.
6. Discuss contraception options and safe sex issues.
7. Explains the nature of oral Herpes on lips.
7. Offers chlamydia screening / a visit to STI clinic.
8. Safety Netting

34
[MRCGP-INT-OSCE scenarios 2011 ]

Information for the candidate

30 year old male/female comes to the surgery and the receptionist


have noted that they are complaining about knee pain.

PMH nil significant

DH nkda

Information for the simulator

30 year old male/female – Jamie Anderson

You were playing rugby on the beach when you were on holiday in
Spain last week. You were tackled when you foot was caught in the
sand, and noticed immediate pain in your right knee. You can’t recall
how what direction the person came at you from.

You think you heard a snap from your knee.

You noticed severe pain in your knee immediately, and you had to sit
out the rest of the game. You put some ice on it but it really hasn’t
helped.

You have taken the odd ibuprofen but it doesn’t seem to be helping
either.

Unable to weight bear. You had our friends help you get about
especially when you were on nights out in Spain celebrating on your
friends stag/ hen night.

You are really worried that you may have damaged one of the
ligaments in your knee as you play first team hockey for your local
team and you have some important matches coming up.

You work in a local bar as that gives you the flexibility to train and
compete in matches.

You know that this would be a very serious injury and it really worries
you as sport is very important to you ,

You are happy to listen to what the doctor has to say, and will accept
pretty much any management. You have insurance, and would be happy

35
[MRCGP-INT-OSCE scenarios 2011 ]

to go privately, to get things sorted as quickly as possible. If you were


given some written information about your knee problem, you would be
happy as well.

Non smoker. Drinks 30 units per week on average

Examination Findings

Obviously finding it painful to walk on his right knee.


Obviously swollen knee with generalised decreased range of movement
No tenderness to palpation of joint line
Anterior draw test positive
Marking Schedule- Positive Indicators

Data Gathering

Elicits information about knee pain.


Finds out about swelling/ tenderness/ locking/ giving way/
trauma/deformity/ functional impairment/
Finds out patients concerns.
Undertakes Knee exam slickly

Interpersonal Skills

Develops rapport
Good use of open and appropriate close questions
Active listening
Encourages patients contribution
Elicits patients ideas
Elicits patients concerns
Elicits patients expectations
Encourages patients involvement in management
Incorporates patients healths beliefs into management plan
Ensures patients understanding

Clinical Management
Comes to diagnosis of likely ACL rupture
Discussed likely needs orthopaedic review, may need immobilisation
and possible operation
Discussed NHS versus private referral
Discusses likely time to recovery
Alcohol consumption counselling
Safe and appropriate follow up and safety netting

36
[MRCGP-INT-OSCE scenarios 2011 ]

Dealing with bad news

It’s a busy post bank holiday Tuesday and you’re on call. A receptionist
rings through at the end of your morning surgery to say that they have
received a fax that needs actioning. She brings it through.

Dear Doctor,

I saw Mr Johnson in surgery outpatients this morning to discuss his


diagnosis of inoperable colonic cancer. During our consultation his wife
became very distressed and I feel that they will need a home visit
today. I think it was because her first husband died of colonic cancer
20 years ago.

Jane Phillips Nurse Practitioner to Mr Addison

Looking at his records you can see he had a ‘fast track’ referral four
weeks ago after presenting with a history of altered bowel habit. The
only clinic letter in the records relates to his normal sigmoidoscopy and
planned colonoscopy.

You decide to ‘bite the bullet’ and do the home visit.

 What additional information might you want?

 Where may you find it?

 How do you intend to use it?

 What are your objectives for this home visit and how do you
intend to achieve them?

 What are the likely pitfalls?

 What consultation model could you use in this situation?

 What is your management plan (patient, doctor, and practice


aspects)?

 Who might be able to help?

 What home services/outside agencies might you use?

 What do they offer?

37
[MRCGP-INT-OSCE scenarios 2011 ]

 What forms might need to be completed? Where do you find them


and what information do they require?

 How do you manage your emotional housekeeping?

A worried relative

Another busy on call day and to make matters worse you notice an
extra being adding to the end of your morning surgery. It’s a telephone
consultation flagged as ‘Please speak with daughter Janice – Living in
Spain so she will be ringing you at 12:00 – daughter requesting a home
visit’.

Quickly looking at the record you see that it is elderly Mr Greenwood.


Mr Greenwood has recently been diagnosed as having inoperable bowel
cancer and his wife Susan has dementia. There is a note from the
district nurses in his record ‘Deteriorating rapidly, refer Marie Curie
day centre and ask McMillan nurse to visit – wife wandering and
behaviour becoming more challenging’.

 What issues does the telephone consultation and home visit


request raise?
 What do you think might be the problem?
 What information might you like to obtain before the telephone
consultation?
 How will you manage the telephone consultation – what skills
may be required?

At 12:00 there is an emergency, a patient has collapsed, and you miss


the telephone call. To make matters worse the reception team don’t
have a contact number for the daughter! So you decide to go and visit
and assess the situation for yourself.

 What are your objectives for this home visit and how do you
intend to achieve them?

 What are the likely pitfalls?

38
[MRCGP-INT-OSCE scenarios 2011 ]

 What is your management plan (patient, doctor, and practice


aspects)?

 Who might be able to help?

 What home services/outside agencies might you use?

 What do they offer?

 How do you access them?

 What are you going to do about Janice the worried daughter?

 What changes need to be instituted at the practice?

39