Anda di halaman 1dari 126

History Taking & Communication Skills Handbook

History-Taking Stations:
Cardiology 1. 2. Respiratory 3. 4. Cough Haemoptysis 10 13 Chest pain Palpitations 4 7

Gastroenterology 5. Abdominal Pain 6. Alcohol Abuse 7. Blood in stool 8. Constipation 9. Diarrhoea 10. Jaundice 11. Weight gain 12. Weight loss Neurology/ Psychiatry 13. Confusion 14. Depressed mood 15. Dizziness 16. Headache 17. Loss of Consciousness 18. Numbness 19. Psychosis Obstetrics and gynaecology 20. Amenorrhoea 21. Dyspareunia 22. Vaginal Bleeding 23. Vaginal discharge

16 19 22 25 28 31 34 37

40 43 46 52 57 60 63

67 70 73 76

Ace Medicine Revision Courses


Ace the 3rd Year OSCE Course Ace the 3rd Year Written Exams Course Ace the 4th Year Specialties Course Ace the Written Finals Course

100% MONEY BACK GUARANTEE you pass your Exams LEARN most topics likely to come up in your exams within HOURS, SAVE yourself WEEKS of revision time! visit www.AceMedicine.com for details and bookings

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

Communication Skills Stations:


Explaining 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 24 Hour urine collection Hip replacement Hernia repair Wafarin therapy Endoscopy Colonoscopy Bronchoscopy MRI TURP STI Diagnosis Treatment DVLA Guidelines Compliance to hypertensive Diabetic wanting to fast Dealing with an angry patient Break news- breast cancer 79 81 84 87 91 94 97 100 103 106 109 112 115 117 120 123

Ace Medicine Revision Courses


Ace the 3rd Year OSCE Course Ace the 3rd Year Written Exams Course Ace the 4th Year Specialties Course Ace the Written Finals Course

100% MONEY BACK GUARANTEE you pass your Exams LEARN most topics likely to come up in your exams within HOURS, SAVE yourself WEEKS of revision time! visit www.AceMedicine.com for details and bookings

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

1) Chest Pain
Instructions given by examiner to candidate: You are a junior doctor working in the A&E. Mr Jones presents with chest pain. Please take an appropriate history from him and summarise your findings at the end with likely differential diagnoses. Information provided to Patient for History Dialogue with Candidate This 55 year-old brick layer presented to A & E with chest pain of 30 minute duration. The pain was sudden in onset, severe (9/10) and centred on the left side of the chest. At times it is felt in the left arm. It is dull in nature. The patient complains of associated symptoms of sweatiness and nausea. He has not had this pain before. At the time it started he was lifting a stack of bricks. He is on a tablet for high blood pressure and has high cholesterol. He smokes 20 cigarettes a week. His late father died of a stroke. Time for Station: 6 Minutes Common differentials Angina Myocardial infarction Pulmonary embolism GORD Pericarditis Pneumonia

Features of the history associated with common differentials Angina: Central chest pain/ discomfort, radiating down arm, up neck and jaw. May be accompanied by nausea, sweating, SOB. The timing of onset is the distinguishing factor: onset is during exertion, emotional upset, heavy meals or cold. Relief occurs at rest or when the trigger is removed. The pain responds to the use of GTN spray. Myocardial infarction: Similar features as stable angina, but more severe. The distinguishing factor is a lack of response to GTN and a persistence of the pain despite removal of stressor. The pain can also come on at anytime i.e. at rest or during exertion. The patient typically refers to the pain as crushing and central. Pulmonary embolism: Typical history will include risk factors for a DVT e.g. recent long haul travel, starting OCP, prolonged immobility or existing cancer. Patient may also have symptoms of SOB and haemoptysis. Pain tends to be pleuritic in nature. GORD: Pain may be described as burning and is often related to meals and lying down. Antacids provide relief. Patient may also suffer from regurgitation, belching and night cough/ wheeze. Pericarditis: Distinguishing factor is that the pain worse on inspiration and lying flat and relieved by sitting forward. Pneumonia: Patient will usually present with cold/ flu symptoms accompanying the chest pain along with production of sputum and fever.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

Introduce Check name, age, occupation and marital status. Permission Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK? Presenting complaint Why have you come here today History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o Site, Onset (speed of onset, what they were doing during onset), Character, Radiation, Alleviating and exacerbating factors, Timing/duration, frequency, speed of recovery, response to analgesia, GTN or antacids. o Additional symptoms e.g. sweating, SOB, nausea, pre-syncope, regurgitation, haemoptysis and cough. o Has this happened before? o Recent illness, trauma, travel abroad or surgery Ideas, Concerns and expectations Do you have any idea what is causing your chest pain, or any concerns about it? Past Medical History Ask about: recent illness, angina, DVT, heart disease, Marfans and other connective tissue disorders, indigestion and stomach ulcers. Drug History Anything medications they have recently started or stopped taking.. Anything remedies, including over the counter taken. Drug allergies Family History Ask about: Marfans, Heart disease and MIs, GI disease. Social History Smoking, diet, alcohol, recreational drugs and exercise i.e. risk factors for heart disease. Travel abroad Systems review General overview of all systems, especially cardiovascular and respiratory. Present case to patient (and examiner) Summarise findings and finish with the most likely cause of the presenting complaint is..... However important differentials to consider would include..... Summary This 55 year-old man presents with a short history of severe left sided chest pain radiating to the left arm, associated with sweating and nausea, which commenced on exertion. He has a strong cardiovascular risk profile. The history is highly suggestive of a myocardial infarct.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

ACE Tips GTN can also relieve pain due to oesophageal spasm, so do not automatically assume that if the pain is relieved by GTN, it is angina. First try to establish if chest pain is cardiac or non-cardiac in origin Chest pain attendees can be frequent and so experienced historians pay close attention to their sentiments. Be especially careful with diabetics presenting with chest pain they may experience minimal pain, despite having a myocardial infarction (silent MI).

Marking Sheet: Chest Pain


Not attempted 1 2 3 4 5 6 7 8 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem Enquires in depth in about the length of the chest pain and severity Asks if pain radiates into the left arm Enquires into other associated symptoms, in particular regarding nausea and sweating Past Medical History (only give 2 if chest pain history specifically enquired about) Asks regarding cardiovascular risk factors (BP, cholesterol etc) Family History Social and Drug History (especially smoking in pack years and diet) 12 13 14 Concerns and Ideas of patient considered Presentation and Summary Differential Diagnoses Provided 0 0 0 1 1 1 2 2 2 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 Attempted adequate 2 2 2 2 2

0 0

1 1

2 2

9 10 11

0 0 0

1 1 1 2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

2) Palpitations
Instructions given by examiner to candidate: You are a junior doctor working in the A&E. Miss Summers presents with palpitations. Please take an appropriate history from her and summarise your findings at the end with likely differential diagnoses.

Information provided to Patient for History Dialogue with Candidate You are a 25 year-old PhD student (Jane Summers) at the local university with a looming deadline for your thesis. You are single and one of lifes go getters. You experienced a very fast heart beat 1 hour ago (9am) whilst at the university working on your thesis. You stayed up until 4am last night at the computer aided with energy drinks from the 24 hr petrol station and came to university via Starbucks coffee house. The palpitations came on suddenly and lasted for 10 minutes, then returned again 20 minutes later. You felt sweaty but did not pass out. This has never happened before. You only past medical history is of an STD as an undergraduate and do not take prescribed or illicit medications. Your family history is unremarkable. You are pretty sure yourself this is due to overwork and lack of sleep. You are not normally anxious but this incident you found scary. Time Allowed: 6 minutes Common differentials Cardiac arrhythmia Anxiety Thyrotoxicosis Drug induced (prescribed or illicit) Systemic fever Anaemia

Features of the history associated with common differentials Arrhythmia: Palpitations alone may be the only symptom if due to ectopics. Otherwise, look out for a history mentioning syncope or pre-syncope or chest pain and SOB. Precipitants may include caffeine, alcohol, smoking and drugs (prescription and recreational) Anxiety: Pay attention to the personality type of the patient. Some patients will clearly look and sound anxious. Typical story will involve worsening of palpitations after consuming caffeine and improvement after drinking alcohol. Their history may also reveal previous signs of anxiety e.g. panic attacks and phobias. Thyrotoxicosis: Look out for typical hyperthyroidism symptoms e.g. heat intolerance, weight loss, increased appetite, irregular periods and hand tremor. Drug related: Pay attention to mention of use of new drug (prescription or recreational) prior to onset of symptoms, or symptoms occurring after taking a dose of the drug. Systemic fever: Fever and sweats, accompanied by localised symptoms of an infections such as sputum production or dysuria. Anaemia: Look for other signs and symptoms which may suggest an underlying anaemia, such as menorrhagia or pallor.

Introduce Check name, age, occupation and marital status.


7

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

Permission Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?

Presenting complaint Why have you come here today? History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o o o o o o o Onset (speed of onset, what they were doing during onset), duration, frequency, speed of recovery and associated LOC. Additional symptoms e.g. SOB, chest pain, weight loss, heat intolerance, hand tremor and panic attacks/ feelings of anxiety. Pattern- ask the patient to tap out the palpitation pattern. Has this happened before? New drug use prior to onset. Change in consumption of caffeine or use of illicit drugs Any change in palpitations after consuming alcohol

Ideas, Concerns and expectations Do you have any idea what is causing these palpitations, or any concerns about it? Past Medical History Ask about: hypertension, heart disease, thyroid disease, psychiatric conditions and previous history of arrhythmias. Drug History Anything they have recently started or stopped taking. Anything including over the counter medications, especially diet pills and caffeine pills. Drug allergies Family History Ask about: Arrhythmias, heart disease, high blood pressure and psychiatric illness. Social History Smoking, diet, alcohol and recreational drug use. Systems review General overview of all systems, especially cardiovascular. Present case to patient (and examiner) Summarise findings and finish with the most likely cause of the presenting complaint is..... However important differentials to consider would include..... Summary Miss Summers is a 25 year old single post-graduate student with sudden onset of palpitations, intermittent in nature, with no pre-syncopal element. This is the first incidence and no associated symptoms. There is no significant past family, drug or medical history, but a recent high intake of caffeinated drinks. My impression is these are drug induced palpitations, although an ECG should be performed to exclude an arrhythmia.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

ACE Tips Pay attention to the times of the day the palpitations occur. Palpitations after eating or when lying down are likely to be due to ectopics. Whilst prolonged pounding palpitations in public, under stress that disappears at rest or relaxation may be due to anxiety. Although anxiety can be worse when a person goes to bed at night because this is the time may ruminate over problems. Pay attention to the demographic of the patient as a clue to the cause of the palpitations. Younger patients are more likely to present with recreational drug use induced palpitations, females with misuse of caffeine containing diet pills, elderly with AF or beta blocker induced palpitations. Remember that these are clues, NOT hard and fast rules. An attentive drug history if a definite must for the palpitation history station

Marking Sheet: Palpitations History


Not attempted 1 2 3 4 5 6 7 8 9 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem Enquires in depth in about nature of the abdominal pain Enquires into other additional symptoms, in altered bowel habit Asks regarding severity of pain in an objective fasion (scale 1 -10) Past Medical History (especially surgery) Family History (For 2 marks must include specific enquiry on GIT pathology) Social and Drug History (alcohol and OTC drugs must be specifically questioned for 2 marks) 11 12 13 Concerns and Ideas of patient considered Presentation and Summary Differential Diagnoses Provided 0 0 0 1 1 1 2 2 2 0 0 0 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 1 1 1 2 2 Attempted adequate 2 2 2 2 2 2

10

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

3) Cough/ SOB station


Instructions given by examiner to candidate: You are a junior doctor working in a GP surgery. You are seeing a patient Joe Philips. Please take an appropriate history from him, and summarise your findings at the end with likely differential diagnoses.

Information provided to Patient for History Dialogue with Candidate You are a 69 year old retired postman. You have been short of breath for the past 4 days, which is getting worse, although even at the best of times you become breathless on exertion. You have cough, with a little sputum, however this is white. You have no blood in the sputum or fever. You have high blood pressure and diverticulosis. You smoke 30 cigarettes a day and have done so since a teenager. Aside from antihypertensives you are not on any other medications. You have no history of heart problems or allergies.

Common differentials Pulmonary oedema Asthma Exacerbation COPD Lung Cancer Pneumonia

Features of the history associated with common differentials Pulmonary oedema: look out for orthopnea, PND (waking up from sleep to catch his/her breath), ankle swelling, coughing up frothy pink sputum. The patient may have pre-existing heart disease or had a recent MI. Asthma: typical history is of early morning coughing, SOB on exertion or after exposure to certain substances like pets, pollen or dust. Look out for a family history or co-existing atopy e.g. eczema or hayfever. COPD: look out for smoking history and gradual onset SOB during great exertion at first but progressing to minimal exertion and at rest. Lung Cancer: Look at for smoking history or occupational exposure to asbestos or other chemicals. Weight loss, haemoptysis and chest discomfort are also features. Pneumonia: Patient will usually present with cold/ flu symptoms +/- chest pain and fever and productive cough.

History Dialogue Introduce Check name, age, occupation and marital status.

Permission Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?
10

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

Presenting complaint Why have you come here today? History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o Onset, time of day it occurs, noted exacerbating and alleviating factors, duration, frequency and any sputum (colour) or blood coughed up. o Additional symptoms e.g. fever, palpitations, swollen ankles, orthopnea, PND, chest pain, wheeze and LOC. o Has this happened before? o Contact with anyone with these symptoms. Ideas, Concerns and expectations Do you have any idea what is causing your SOB/ cough, or any concerns about it? Past Medical History Have you had previous hospital admissions with similar symptoms? Ask about: TB, heart failure, COPD, asthma and pneumonia. Drug History Anything they have recently started or stopped taking. Anything including over the counter. Drug allergies Family History Ask about: Heart disease, asthma, COPD, lung cancer and TB. Social History Smoking history, pets, occupational hazards and recent travel. Systems review General overview of all systems, especially respiratory and cardiovascular. Present case to patient (and examiner) Summarise findings and finish with the most likely cause of the presenting complaint is..... However important differentials to consider would include..... Summary Mr Philips is a retired postman with an acute-on-chronic presentation with shortness of breath. He has a pack year history of more than 70 years, but has not previously required hospital admission for shortness of breath. Although he is producing a little sputum it is clear with no haemoptysis. Given the strong smoking history the impression is of a non infective exacerbation of COPD, but bronchial carcinoma must also be considered and a chest x-ray is recommended to assess for both conditions. ACE Tips Always ask about smoking history and present as pack years For any cough, it is vital to ask about the presence of blood often a concerning feature The amount of previous hospital admissions always provides a good indicator of the chronicity of chest disease Colour of sputum also indicates cause:
11

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

Pink and foamy suggests pulmonary oedema Bloody indicates malignancy, TB or trauma Yellow/green suggests infection like pneumonia. Marking Sheet: Cough/SOB

Not Attempted Attempted attempted inadequate adequate 1 2 3 4 5 6 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem Enquires in depth in about the length of the SOB and severity Enquires into other additional symptoms, in particular regarding fever, cough and haemoptysis Past Medical History Asks regarding sputum and its nature Asks regarding contact with others Family History Social and Drug History (especially smoking in pack years and occupational exposure) Concerns and Ideas of patient considered Presentation and Summary Differential Diagnoses Provided 0 0 0 0 0 0 1 1 1 1 1 1 2 2 2 2 2 2

7 8 9 10 11

0 0 0 0 0

1 1 1 1 1

2 2

12 13 14

0 0 0

1 1 1

2 2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

12

4) Haemoptysis station
Instructions given by examiner to candidate: You are a junior doctor working in the Acute Medical Unit. An elderly gentleman presents after coughing up blood. Please take an appropriate history from him and summarise your findings at the end with likely differential diagnoses.

Information provided to Patient for History Dialogue with Candidate This 71 year-old retired single postman, Mr Tombolo, complains of coughing up blood for the past week on a daily basis. Initially this was just blood stained sputum, but today was frank blood. This was approximately 1 tablespoon in size. Prior to this he has suffered for a cough for the last month and his sister commented that he has lost weight in recent months. He has no previous history of cardio-respiratory disease. He drinks 2 pints of beer a day and smokes 20 cigarettes a day, which has been a habit for the last 50 years. His only medication is over the counter cough syrup. Common differentials Lung cancer TB PE Foreign body/ trauma Bronchiectasis Pneumonia

Features of the history associated with common differentials Lung cancer: Look at for smoking history or occupational exposure to asbestos or other chemicals. Weight loss, haemoptysis and chest discomfort are also features. TB: Pay attention to recent travel to TB prevalent countries or patients who are originally from countries with high TB prevalence. Night sweats, cough, SOB, weight loss, fever and rigors are typical features. PE: Typical history will include risk factors for a DVT e.g. recent long haul travel, starting OCP, prolonged immobility or existing cancer. Patient will also typically have symptoms of SOB and chest pain. Foreign body/ trauma: Accidentally swallowing or inhaling anything or recent chest trauma are signs to look out for. Bronchiectasis: Look out for a persistent productive cough. Sputum is usually thick and green in colour with the haemoptysis occurring intermittently. Have a high suspicion in patients with cystic fibrosis or those that have had previous infection with measles, whooping cough, pneumonia or bronchiolitis. Pneumonia: Patient will usually present with cold/ flu symptoms +/- chest pain and fever.

Introduce Check name, age, occupation and marital status.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

13

Permission Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?

Presenting complaint Why have you come here today? History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o Onset, how much blood and colour of the blood. Also determine frequency, sputum production and colour of sputum. o Additional symptoms e.g. cough, fever, night sweats, weight loss, leg swelling and pain, chest pain. o Has this happened before? o Recent chest trauma. o Recent illness- if so, what? o TB exposure, recent travel abroad and immobility. Ideas, Concerns and expectations Do you have any idea what is causing your symptoms, or any concerns about it? Past Medical History Ask about: previous TB, pneumonia, DVT, cystic fibrosis or any lung disease. Any childhood chest infections? Drug History Anything medication they have recently started or stopped taking. Anything medications, including over the counter. Drug allergies Family History Ask about: Lung disease, cancer and TB. Social History Especially smoking, occupation and travel abroad. Systems review General overview of all systems, especially respiratory. Present case to patient (and examiner) Summarise findings and finish with the most likely cause of the presenting complaint is..... However important differentials to consider would include..... Summary This 71 year old single gentleman presents with a short history of frank haemoptysis, associated with a cough of a months duration and weight loss. He has a non-eventful medication and drug history, but does have a pack history of 50 years of smoking. The presenting symptoms are concerning for a primary lung malignancy. Investigations recommended.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

14

ACE Tips Be sure to ask about what the blood looks like. Is it frank or mixed with saliva or sputum. Always rule out malignancy and TB first as these are the commonest causes of haemoptysis. Caution with the estimate of the amount of blood unless objectively seen, as patients frequently overestimate it. Be sure, especially in the poor historian, to establish whether it is truly haemopytsis and not blood from the gastrointestinal tract or nasopharynx which is then coughed up.

Marking Sheet: Haemoptysis


Not attempted 1 2 3 4 5 6 7 8 8 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem Enquires in the nature of the haemopytsis ( 2 marks only is quantified) Establishes if there are associated symptoms (cough, fever etc) Recent travel Exposure to anyone with chest infection/TB Past Medical History (especially admissions related to the respiratory system) Enquiries if the patient ever had childhood chest infections Family History (asks specifically regarding TB ad lung cancer) Social and Drug History (the smoking history in pack years is needed to get 2 marks) Concerns and Ideas of patient considered Presentation and Summary 0 0 0 0 0 0 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 1 1 1 1 1 1 2 2 Attempted adequate 2 2 2 2 2 2 2 2 2

9 10 11

12 13

0 0

1 1

2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

15

5) Abdominal Pain
Instructions given by examiner to candidate: You are a junior doctor working nights in A&E. Mrs Rapparport, a female presents with RIF abdominal pain. Please take an appropriate history from her and summarise your findings at the end with likely differential diagnoses.

Information provided to Patient for History Dialogue with Candidate You are an 18 year-old first year university student. Over the past 24 hours you have developed abdominal pain, which has become progressively worse. This started all over, but not it is very painful in the lower right side of the abdomen and is associated with nausea and increased bowel motions. You have never been to hospital before, have no medical or drug history. You drink 16 units a week, and are a social smoker. You are currently in a relationship, but dont think you are pregnant. Common differentials Appendicitis Constipation Diverticulitis Renal colic Irritable bowel syndrome Torted ovarian cyst

Features of the history associated with common differentials Appendicitis: Look out for peri-umbilical pain initially that moves to focal tenderness in the RIF. Pain often starts as dull and intermittent and becomes constant and more severe. Exacerbating factors usually include movement e.g. coughing, sneezing. Associated symptoms include fever, constipation, anorexia, nausea and vomiting. Constipation: Look out for change in bowel habit, usually a decrease in frequency and hard smaller quantities passed. The pain of constipation varies, but is often described as dull with occasional pangs of more intense pain. The pain can often be a lower back pain rather than an abdominal pain. Diverticulitis: Look out for colicky pain relieved by defecation. Associated symptoms include fever, bloating, nausea and altered bowel habit. Renal colic: Colicky pain radiating to the groin and into the back. The patient cannot stay still. Associated symptoms include nausea and vomiting. The patient may also present with a co-existing pyelonephritis or cystitis and therefore have a fever and urinary symptoms. Irritable bowel syndrome: Pain is usually colicky in nature and relieved by defecation. Look out for associated symptoms of abdominal bloating, constipation alternating with diarrhoea and mucus. Symptoms need to be present for 6+ months for a diagnosis of IBS to be made.

History Dialogue Introduce Check name, age, occupation and marital status.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

16

Permission Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?

Presenting complaint Why have you come here today? History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o Site, Onset (speed of onset, what they were doing during onset), Character, Radiation, Alleviating and exacerbating factors, Timing/duration, frequency, speed of recovery, response to analgesia. o Additional symptoms e.g. nausea and vomiting, diarrhoea, constipation, abdominal bloating, fever and anorexia. o Has this happened before? o Recent illness, trauma, travel abroad. o Intermittent or constant? o Any suspicious food consumed recently or any contact with anyone with the same symptoms. Ideas, Concerns and expectations Do you have any idea what is causing your symptoms, or any concerns about it? Past Medical History Ask about: previous abdominal surgery, IBD, diverticulosis in the past. Drug History Anything they have recently started or stopped taking. Anything including over the counter. Drug allergies Family History Ask about: GIT disease, cancer, diverticulosis and renal stones. Social History Smoking, alcohol, recreational drugs and diet. Systems review General overview of all systems, especially GI and GU. Present case to patient (and examiner) Summarise findings and finish with the most likely cause of the presenting complaint is..... However important differentials to consider would include..... Summary This 18 year-old university student complains of progressively severe pain, now centred on the right iliac fossa, associated with nausea in the context of no past medical history. The differential diagnosis is between appendicitis and gynaecological pathology, such as pelvic inflammatory disease or ovarian torsion.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

17

ACE Tips Think anatomically when making a differential diagnosis based on the site of abdominal pain With females of child bearing age, always think of pregnancy or complications related to it, whatever the patient says. The differentials given here are for right iliac fossa pain, but note that there are numerous differentials for abdominal pain in general and these should be narrowed down according to the type and location of the pain as well as associated symptoms. Epigastric Pancreatitis Peptic ulcer Cholecyctitis MI RUQ Duodenal ulcer Hepatitis Referred pain from pneumonia Cholecystitis Pyelonephritis LUQ Gastric ulcer Splenic rupture Pyelonephritis Referred pain from pneumonia Abdominal aortic aneurysm RLQ Appendicitis Diverticulitis Constipation Renal colic IBS Ovarian pathology LLQ IBD Sigmoid Diverticulitis Renal colic Ovarian pathology

Remember to enquire about surgical history. If you dont ask, you may never find out that a patient has already has his appendix removed!

Marking Sheet: Abdominal Pain History


Not attempted 1 2 3 4 5 6 7 8 9 10 11 12 13 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem Enquires in depth in about nature of the abdominal pain Enquires into other additional symptoms, in altered bowel habit Asks regarding severity of pain in an objective fasion (scale 1 -10) Past Medical History (especially surgery) Family History (For 2 marks must include specific enquiry on GIT pathology) Social and Drug History (alcohol and OTC drugs must be specifically questioned for 2 marks) Concerns and Ideas of patient considered Presentation and Summary Differential Diagnoses Provided 0 0 0 0 0 0 0 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 Attempted adequate 2 2 2 2 2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

18

6) Alcohol Abuse
Instructions given by examiner to candidate: You are a junior doctor working in a GP surgery. You are seeing a patient Laura Riley. You have not met Miss Riley before but note from previous entries in her notes that she is a frequent attendee for sick notes following alcohol related incidents. Please take an alcohol history from her and summarise your findings at the end.

Information provided to Patient for History Dialogue with Candidate You are Laura Riley a call centre worker, who is attending for another sick note from work her 8th this year. Your excuse on this occasion is fatigue. You are a divorced 29 year old, with no dependents. When the GP initially starts asking about your alcohol consumption you deny it, but after careful probing you release the following information. You drink wine and whisky including at lunchtime and throughout the evening. Occasionally you have alcohol in the mornings. This amounts to over a bottle of wine and half a bottle of whisky a day. You have been drinking excessively for more than 5 months, since your divorce. You know its harmful and tried cutting down, but you get withdrawal symptoms,. You know you have to try again, but dont like it when people tell you so. The remainder of your past medical, family and social history is unremarkable. Common differentials In a station of this nature, the aim is not to recognise potential diagnoses, but to adequately obtain an alcohol history. History Dialogue Introduce Check name, age, occupation and marital status.

Permission Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?

Presenting complaint It is likely that the patient will not present for their alcohol use, therefore the topic of taking an alcohol history has to be subtly introduced. We can certainly discuss your ...., but first there is something I wanted to discuss with you. I apologise in advance if you feel offended by anything I say but I do feel it is necessary to address any health related problems you may have is a good way of introducing an alcohol history. History of presenting complaint Establish drinking habit o What do you drink- beer, wine, spirits? o do you drink at a particular time of the day/ talk me through your a typical day o How much do you drink per day/ week? o How long have you been drinking like this for?
19

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

Establish signs of alcohol dependency o Do you feel compelled to drink even when you plan not to? o Has the amount of alcohol you need to drink to get the same effect increased? o Does drinking seem to take priority over other things or people in your life? o If you dont have a drink for a while, do you suffer any symptoms such as tremors, sweating, nausea or hallucinations? o Do you think drinking too much alcohol is harmful to your health?

CAGE o o o o Have you ever tried to Cut down on how much you drink? Do you feel Angry when people comment on your drinking habits? Do you ever feel Guilty about how much you drink? Have you ever needed an Eye opening drink first thing in the morning?

Ideas, Concerns and expectations/ motivation to change Do you think you need to cut down on how much you drink? Do you have any concerns about how much you drink? Have you tried to cut down before? What happened? Would you be willing to try and cut down again? Past Medical History Ask about: chronic conditions, psychiatric conditions especially depression or anxiety, previously diagnosed substance dependency/ misuse. Drug History Do you take any medications? Anything including over the counter. Drug allergies Family History Ask about: Alcohol or substance dependency, addictions of any nature, psychiatric illnesses. Social History Check for stressors which may be driving the drinking habit. Systems review (if time) General overview of all systems, especially all systems affected by alcohol use i.e. neurological, cardiovascular and GI. Present case to patient (and examiner) Summary This is Laura Riley a 29 year-old divorcee. She scores 4/4 in her CAGE questionnaire and has a alcohol consumption and habit well in excess of 100 units a week, consistent with alcohol dependency. ACE Tips: Remember the aim of this station is to assess alcohol dependency, therefore do not allow the patient to draw you down the path of taking a history for their presenting complaint. Bypass this by saying you will address that after you have asked a few questions about drinking their habits.
20

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

Remember to tread carefully. It is easy to offend the patient if they are unaware of their extent of drinking. Patients may respond with aggression. Know the drinking limits advised for men and women, it can easily come up during the consultation. It is up to 14 units for females and up to 21 units for males weekly. Take the history in a non-judgemental fashion. The patient may want to stop drinking as much as you would like him/her too.

Marking Sheet: Alcohol Abuse Station


Not attempted 1 2 3 4 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem at the pain sees it Enquires in the nature of the patients alcohol use Establishes accurately the units consumed per day Assesses for features of alcohol dependency Asks the CAGE questionnaire (1-3 parts = 1 mark, all 4 components for 2 marks) Past Medical History (especially admissions due to alcohol misuse and any suicide attempts) Asks if previously sought help to stop drinking Family History (including dependents and who is caring for these) Social and Drug History (any illicit drug use and stressors must be asked for 2 marks) 12 13 Concerns and Ideas of patient considered Presentation and Summary 0 0 1 1 2 2 0 0 0 0 Attempted inadequate 1 1 1 1 Attempted adequate 2 2 2 2

5 6 7 8

0 0 0 0

1 1 1 1

2 2 2

9 10

0 0

1 1 2

11

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

21

7) Blood in Stool
Instructions given by examiner to candidate: You are a junior doctor working in acute medical unit. Mrs Sheppard, an elderly lady presents with blood in her stools. Please take an appropriate history from her and summarise your findings at the end with likely differential diagnoses.

Information provided to Patient for History Dialogue with Candidate You are an 81 year-old retiree, living alone, but independent for activities of daily living. You asked your daughter to bring you to hospital as you have had 3 episodes of blood coating your motions in the last 2 weeks. Initially you thought it might just be piles or due to straining, but now you are distressed by it. The blood is on or partly mixed with the stool, but is red and this you found frightening. You feel otherwise well and it has never happened before. It is not painful and you are not constipated. You are on a water tablet for blood pressure and have been for 12 years. You have no other medical or family history. Time Allowed: 6 minutes Common differentials Haemorrhoids Anal/ rectal trauma Angiodysplasia Colorectal polyps Colorectal cancer Ulcerative colitis

Features of the history associated with common differentials Haemorrhoids: The hint towards this diagnosis is that the blood is bright red, often either coating the outside of the stool or on the toilet paper. Large haemorrhoids can present as blood dripping into the toilet after a bowel motion. Look out for mention of anal pain, worse on standing and on straining, as well as a palpable lump peri-anally. Do not ignore a history of constipation as this is a risk factor for haemorrhoids. Anal/ rectal trauma: Ask about history of anal trauma sexual or other. Pain will usually be an accompanying symptom. Again the blood will be bright red and worsened by straining. Angiodysplasia: The patient is usually elderly. The blood is fresh and bright red, often large in quantity. This is usually a diagnosis of exclusion and not made by history taking alone. Often recurrent. Colorectal polyps: Blood is often mixed in with the stools and is red in colour although nor bright red. Mucus may also be present. Colorectal cancer: Look out for associated symptoms of weight loss, abdominal pain, altered bowel habits, anaemia symptoms i.e. SOB, fatigue, pallor or dizziness. Ulcerative colitis: Usually accompanied by an increased frequency of motion and accompanied by mucus. When severe accompanied by constitutional symptoms.

Introduce Check name, age, occupation and marital status.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

22

Permission Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?

Presenting complaint What has been causing you concern? History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o Onset- Did anything preceded the onset of the bloody stools? o What does the blood look like- mixed in or on the surface of the stools, any blood on the toilet paper, blood dripping in the toilet afterwards? o Any noted exacerbating or alleviating factors? o Any trauma to the perirectal region? o Recent changes in drugs, especially NSAIDs, aspirin, anticoagulants or steroids. o Additional symptoms e.g. haematemesis, abdominal pain, weight loss, symptoms of anaemia (SOB, syncope, pallor), anorexia, anal pain/ discomfort. o Has this happened before?

Ideas, Concerns and expectations Do you have any idea what is causing your symptoms, or any concerns about it? Past Medical History Ask about: haemorrhoids, previous cancer, bleeding disorder, liver disease, pre-existing varices, peptic ulcers and indigestion. Drug History Anything they have recently started or stopped taking especially aspirin, NSAIDs, warfarin or steroids. Any over the counter preparations? Drug allergies Family History Ask about: GI disease, cancers, inflammatory bowel disease, stomach ulcers and bleeding disorders. Social History Smoking, alcohol, recreational drugs and diet. Systems review General overview of all systems, especially GI tract. Present case to patient (and examiner) Summarise findings and finish with the most likely cause of the presenting complaint is..... However important differentials to consider would include..... Summary This 81 year-old lady presents with a short history of several episodes of rectal bleeding, largely coating the stool. There are no other gastrointestinal tract symptoms and no weight loss. Her past medical, drug, family and social history do not reveal anything of significance to the presenting complaint.
Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com 23

The differential diagnosis lies, between angiodysplasia and colorectal malignancy. The latter needs to be excluded. ACE Tips Anticoagulants alone arent usually a cause of GI bleed, but their use in the presence of GI bleed causing pathology is enough to exacerbate the bleed. So even if a patient is on warfarin, the site of the bleed still needs to be located as the diagnosis. Many may be embarrassed to talk about haemorrhoids or anal trauma therefore you must directly ask about this as they may not volunteer the information on their own. In the paediatric population another important cause of blood in the stools is intusseception, which classically has red current stools Marking Sheet: Rectal Bleeding History
Not attempted 1 2 3 4 5 6 7 8 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem Enquires in depth in about nature of the abdominal pain Enquires into other additional symptoms, in altered bowel habit Asks regarding severity of pain in an objective fasion (scale 1 -10) Past Medical History (especially surgery) Family History (For 2 marks must include specific enquiry on GIT pathology) Social and Drug History (alcohol and OTC drugs must be specifically questioned for 2 marks) Concerns and Ideas of patient considered Presentation and Summary Differential Diagnoses Provided 0 0 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 1 1 2 Attempted adequate 2 2 2 2 2 2

10

11 12 13

0 0 0

1 1 1

2 2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

24

8) Constipation
Instructions given by examiner to candidate: You are a junior doctor working in a GP surgery. You are seeing a middle aged female 3 days after discharge from A&E with a sprained ankle. Please take an appropriate history from her and summarise your findings at the end with likely differential diagnoses.

Information provided to Patient for History Dialogue with Candidate You are Sue Hill, a 37 year-old married teacher and keen sports enthusiast. You recently sprained your ankle whilst playing in a seniors netball match and had to attend A & E. You didnt break it but got some painkillers as it was very uncomfortable. These have been very effective over the past 3 days. Even since the fall you have not been to the toilet, to the point you feel bunged up. You normally go twice a day. You have eaten loads of veggies and drank litres of water to no effect. You are diligent with your diet. You have no regular medications aside from the OCP, and the drug from A & E Codeine something. Time Allowed: 6 minutes Common differentials Drugs Dietary Dehydration IBS Anorectal disease e.g. fissure Depression

Features of the history associated with common differentials Drugs: Look out for recent commencement of drugs such as codeine, lithium, iron and no change to diet or lifestyle. Dietary: Look out for diet lacking in fibre and water. The patient may have had a recent lifestyle change which has affected his/her eating habits or may be trying to lose weight (decreased intake generally leads to constipation). Dehydration: Look out for diet lacking in fluid intake. Patient may also have a lifestyle change which means they are sweating more than normal e.g. increased exercise or working in a hot environment. IBS: Abdominal pain which is usually colicky in nature and relieved by defecation. Look out for associated symptoms of abdominal bloating, constipation alternating with diarrhoea and mucus. Symptoms need to be present for 6+ months for a diagnosis of IBS to be made. Anorectal disease: In the form of piles, fissure etc. If defecation is painful, the patient is less likely to answer the urge to defecate or empty colon fully, leading to constipation. Symptoms will include pain on defecation, bleeding PR and lumps or lesions perianally. Depression: Look out for usual symptoms of depression i.e. low mood, anhedonia, sleep disturbance, change in appetite and weight, loss of libido, social withdrawal. There may be a history of life change prior to onset of symptoms that hints towards cause for a reactive depression.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

25

Introduce Check name, age, occupation and marital status.

Permission Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?

Presenting complaint Why have you come here today? History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o What exactly they mean by constipation- is it decreased frequency, hard consistency or difficulty in opening bowels? o Any noted exacerbating or alleviating factors? o Recent changes in diet and lifestyle- including new drugs? o Additional symptoms e.g. nausea and vomiting, alternating diarrhoea, abdominal bloating or pain, perianal swelling or pain, and anorexia. o Has this happened before? o Changes to mood Ideas, Concerns and expectations Do you have any idea what is causing your symptoms, or any concerns about it? Past Medical History Ask about: previous abdominal surgery, IBD, IBS, peri-anal disease, diverticulosis and mood disorder or psychiatric illness. Drug History Anything they have recently started or stopped taking. Anything including over the counter medications. Drug allergies Family History Ask about: GI disease, cancers, diverticulosis and constipation in general. Social History Smoking, alcohol, recreational drugs Detailed dietary history, including recent changes to it. Systems review General overview of all systems, especially GI and GU. Present case to patient (and examiner) Summarise findings and finish with the most likely cause of the presenting complaint is..... However important differentials to consider would include..... Summary This 37 year old female has a 3 days history of constipation commencing following the consumption of codeine analgesics following an injury to the ankle. He health and diet is impeccable, even to the extent she has increased her fibre and water intake, but with no effect. The history is in keeping with a drug induced constipation.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

26

ACE Tips Remember to ask patient about their usual bowel habits. Definition of constipation is made in comparison to the patients usual bowel habits- a patient who opens their bowels twice daily will feel constipated if this decreases to every other day, whilst for some every other day is the normal frequency of bowel motions. Think simple first diet and medications are the commonest causes Never be afraid to ask the patient straight out what do you think is the cause. People know their own bodies better than doctors!

Marking Sheet: Constipation History


Not attempted 1 2 3 4 5 6 7 8 9 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem Enquires in depth in about nature of the abdominal pain Enquires into other additional symptoms, in altered bowel habit Detailed dietary history Past Medical History (especially surgery) Family History (For 2 marks must include specific enquiry on GIT pathology) Social and Drug History (alcohol and OTC drugs must be specifically questioned for 2 marks) Concerns and Ideas of patient considered 0 0 0 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 1 1 1 Attempted adequate 2 2 2 2 2 2 2 2 2

10

11

Ace the OSCE


BMA Prize Winning OSCE Video Series Learn exam technique quickly & easily Real patients with real signs Money Back Guarantee you PASS! 10% discount with promo code AOSCE2 Subscribe today at AceMedicine.com

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

27

9) Diarrhoea
Instructions given by examiner to candidate: You are a junior doctor working in A&E. Mr Collins, a young male presents with diarrhoea. Please take an appropriate history from him and summarise your findings at the end with likely differential diagnoses.

Information provided to Patient for History Dialogue with Candidate You are 25 year-old single taxi driver, James Collins, who has been suffering from diarrhoea for the past 36 hours. The motions are liquid, occurring 8-10 times a day and are associated with abdominal cramps. You normally go once a day. You notice that the motions are particularly foul smelling, but there is no blood or mucus in the motions. You have no history of recent travel. You have an unchanged diet with no meals at external catering establishments in the last week. The only past medical history is of an appendicectomy, but you did have a rather nasty chest infection for which you have been prescribed cefuroxime 5 days ago. You smoke 10 cigarettes a day and drink 6 pints of beer a week. No family history of note. Common differentials Inflammatory bowel disease Gastroenteritis Colorectal cancer Colonic polyps Pseudomembranous colitis Thyrotoxicosis

Features of the history associated with common differentials Inflammatory bowel disease: Sudden onset diarrhoea +/- blood and mucus, associated with colicky abdominal pain, fever, nausea and anorexia. In Crohns disease the patient may also complain of peri-anal disease e.g. tags, fissures and fistulas. Gastroenteritis: Look out for history of suspicious food consumption, such as take-away food or seafood or exposure to others with the same symptoms. Associated with nausea and vomiting- but not always, and abdominal pain. Colorectal cancer: Look out for older patient- at least middle aged, presenting with altered bowel habit which may just be diarrhoea or may be constipation as well. There may be blood in the stools, abdominal pain, weight loss, abdominal bloating or a mass and symptoms of anaemia. Colonic polyps: Associated with blood or mucus PR. Often a previous history. Pseudomembranous colitis: Look out for recent antibiotic use or contact with person with clostridium difficle. Symptoms include bloody diarrhoea. Thyrotoxicosis: Look out for typical hyperthyroidism symptoms e.g. heat intolerance, palpitations, increase in appetite, irregular periods and hand tremor.

History Dialogue Introduce Check name, age, occupation and marital status.
28

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

Permission Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?

Presenting complaint Why have you come here today History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o What exactly they mean by diarrhoea- is it increased frequency, soft/liquid consistency? o Any noted exacerbating or alleviating factors? o Recent changes in diet and lifestyle- including new drugs especially antibiotics. o Additional symptoms e.g. PR bleeding, nausea and vomiting, alternating constipation, abdominal bloating or pain, perianal swelling or pain, and anorexia. o Has this happened before? o Changes to mood. Ideas, Concerns and expectations Do you have any idea what is causing your symptoms, or any concerns about it? Past Medical History Ask about: previous abdominal surgery, IBD, IBS, peri-anal disease, cancer, thyroid disease, diverticulosis and mood disorder or psychiatric illness. Drug History Anything they have recently started or stopped taking. Anything including over the counter. Drug allergies Family History Ask about: GI disease, cancers, IBD, diverticulosis, thyroid disease and diarrhoea in general. Social History Smoking, alcohol, recreational drugs and diet. Systems review General overview of all systems, especially GI and endocrine. Present case to patient (and examiner) Summarise findings and finish with the most likely cause of the presenting complaint is..... However important differentials to consider would include..... Summary This 25 year-old man has a 36 hour history of diarrhoea, with motions up to 10 times a day. No blood or mucus is present in the stools and there has been no recent suspicious food consumption. Significantly he has recently received a course of antibiotics for a chest infection. No significant medical, family or social history. The most likely cause for the diarrhoea is pseudomembranous colitis secondary to antibiotic therapy.
Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com 29

ACE Tips It is important to ascertain if blood in the stool as this is diagnostic of certain conditions. The presence of mucus further helps to differentiate. Blood and mucus points to IBD. Gastroenteritis does not cause bloody diarrhoea, unless it is due to dysentery causing organisms, which are generally not encountered in day to day food poisoning or viral gastroenteritis. In thyrotoxicosis the consistency of stool is usually still formed, it is the frequency of bowel motions that increases. Be sure to establish the patients normal bowel habit as a reference point for how the motions have changed. Both the colour and smell of pseudomembranous colitis is distinct. Always consider this in those on antibiotics, especially cephalosporins.

Marking Sheet: Diarrhoea History


Not attempted 1 2 3 4 5 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of heache Nature of headache enquired about (eg, site, duration, radiation, severity etc) (0=none, 1 = 2-3 factors, 2 = 4 or more factors) 6 Asks regarding associated symptoms (eg, vomiting, photophobia, weakness) (0=none, 1 = 2-3 factors, 2 = 4 or more factors) Past Medical History Family History Social and Drug History Concerns and Ideas of patient Presentation and Summary Differential Diagnoses Provided Answers questions from examiner 0 1 2 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 Attempted adequate 2 2 2 2 2

7 8 9 10 11 12 13

0 0 0 0 0 0 0

1 1 1 1 1 1 1

2 2 2 2 2 2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

30

10)

Jaundice
Instructions given by examiner to candidate: You are a junior doctor working in A&E. Mr Sugden, a young male presents with jaundice. Please take an appropriate history from him and summarise your findings at the end with likely differential diagnoses.

Information provided to Patient for History Dialogue with Candidate You are a 21 year-old single former university student, who dropped out after 2 years to go travelling the world. Prior to travelling in South East Asia for 9 months you had no medical history. You left in a hurry to go travelling and did not seek any vaccination advice prior to departure. During you travels you have explored life with various heterosexual encounters, as well as illicit drug use. You however do not use alcohol. It was whilst back in the UK to try and earn some money for future travel that you friends commented on yellowing of the skin, which has been progressive. In addition you feel more tired than normal. You have no significant family history and are not on prescribed medications. Time Allowed: 6 minutes Common differentials Hepatitis (A, B or C) Viral infections including CMV, EBV Alcoholic hepatitis Drug induced hepatitis Malaria Hepatopancreatobiliary tumour

Features of the history associated with common differentials Hepatitis A, B or C: For hepatitis A, look out for recent travel abroad, exposure to suspicious water source. For hepatitis B&C, look out for unprotected sex with infected person, IVDU and blood transfusions especially abroad. Health workers, renal failure patients on dialysis and people working in institutions are at risk of hepatitis B. Malaria: Look out for travel in the last 2 months to a malaria prevalent area. Symptoms associated with the jaundice include fever, malaise, anorexia, headache, myalgia and symptoms of anaemia e.g. SOB, pallor and fatigue. Viral infections including CMV, EBV: CMV- look out for recent organ transplant, blood transfusion, immunocompromised status or stress. Symptoms to look out for include fever, pneumonia, colitis and retinitis. For EBV, look out for sore throat, fever, malaise, anorexia, lymphadenopathy and splenomegaly. Alcoholic hepatitis: Look out for history of alcohol abuse. Patient usually presents with ascites, signs of encephalopathy, splenomegaly, GI bleeds and coagulopathy e.g. easy bruising. Drug induced hepatitis: Look out for paracetamol overdose in recent past, isoniazid, halothane, amiodarone, methotrexate or methyldopa use. Knowledge of medications causing hepatitis.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

31

Introduce Check name, age, occupation and marital status.

Permission Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?

Presenting complaint Why have you come here today? History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o Onset- gradual or sudden? o Risk factors i.e. recent travel abroad, recent illness, alcohol consumption, new drugs started. o Associated symptoms e.g. fever, sore throat, abdominal distension, confusion, myalgia and malaise. o Any noted exacerbating or alleviating factors? o Sexual history and past blood transfusions. o Has this happened before? o Contact with anyone with the same symptoms. Ideas, Concerns and expectations Do you have any idea what is causing your symptoms, or any concerns about it? Past Medical History Ask about: alcohol dependency, rheumatological conditions, TB, glandular fever, organ transplants, HIV. Drug History Any medications they have recently started or stopped taking. Any including over the counter remedies. Drug allergies Family History Ask about: Liver disease, jaundice in general. Hereditary blood dyscrasias Social History Smoking, alcohol, recreational drugs and diet. Systems review General overview of all systems, especially GI. Present case to patient (and examiner) Summarise findings and finish with the most likely cause of the presenting complaint is..... However important differentials to consider would include.....

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

32

Summary Mr Sugden is a 21 year-old former student wit jaundice who has recently returned from travelling abroad during which time he had numerous sexual partners and engaged in illicit drug use. No vaccinations were performed prior to his departure. He has no significant medical, family or drug history. My first impression is of a hepatitis, although other viral infections must also be considered.

ACE Tips The patient may not know the name of the drugs they take, however always be suspicious of drug induced hepatitis in rheumatology and TB patients as the main drugs used within treatment of these conditions are toxic to the liver. Pay attention to the young gap year traveller who presents with jaundice. It is less likely to be alcohol and more likely to be viral especially Hepatitis A or EBV.

Do not be shy to ask personal questions regarding sexual lifestyle and recreational drug use as a doctor you are there to find the answer and offer medical help, not to judge social habits.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

33

11)

Weight Gain
Instructions given by examiner to candidate: You are a junior doctor working in a GP surgery. Mrs Davidson a young aged female presents with weight gain. Please take an appropriate history from her and summarise your findings at the end with likely differential diagnoses.

Information provided to Examiner for History Dialogue with Candidate You are a 34 year-old single medical typist concerned about weight gain over the past 3 months. You have gained 12kg despite no change in diet, exercise or other aspects of your lifestyle. You do have naughty food like fish and chips once a week, but this is unchanged. You walk to work each day and play badminton once a week. You are not on any prescribed of over the counter medications. You have no medical history. You are not sexually active. You do not freely offer it, but on direct questioning from the doctor you reveal a number of associated symptoms, including fatigue, irregular periods and dry hair/skin. You are sure this is not purely down to diet. Common differentials Dietary/ lack of exercise Cushings syndrome/ disease Drugs e.g. HRT or OCP Hypothyroidism Depression Undiagnosed Pregnancy

Features of the history associated with common differentials

Dietary/ lack of exercise: Look out for recent change in lifestyle, social or work habits that have led to change in diet/ exercise whether the patient is aware of these dietary changes or not. Cushings syndrome/ disease: Specific Cushingoid features include; weight gain distributed mainly on face, neck, abdomen and back to give features such as moon face and buffalo hump. Thick purple striae, mood change (low mood, irritability), muscle weakness, impotence, oligomenorrhoea, acne, hirsutism, easy bruising and thin skin. Drugs: look out for use of drugs such as HRT, OCP, antidepressants, anti-psychotics preceding the weight gain by a few weeks. Hypothyroidism: Look out for weight gain despite decreased appetite, dry hair and skin, complaint of neck swelling (goitre), swollen legs, hands and eyelids), cold intolerance, constipation. Depression: Look out for low mood, anhedonia, sleep disturbance, change in appetite and weight, loss of libido, social withdrawal. There may be a history of life change prior to onset of symptoms that hints towards cause for a reactive depression. Pregnancy: Look out for the young female of childbearing age, sexually active, amenorrhoea with insufficient contraceptive use.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

34

Introduce Check name, age, occupation and marital status.

Permission Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?

Presenting complaint Why have you come here today? History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o When weight gain was first noticed and if any lifestyle, social or family circumstances changed at that time. o Food intake, exercise and dietary supplements. o How much weight gained over how long? o Associated symptoms e.g. low mood, sleep disturbance, abdominal pain, change in bowel habit, abdominal bloating, cold intolerance, irregular menstruation, hair or skin changes, and muscle weakness. o Has this happened before? o Any new drugs started recently. Ideas, Concerns and expectations Do you have any idea what is causing your weight gain, or any concerns about it? Past Medical History Ask about: thyroid disease, psychiatric history including mood disorders and eating disorders, conditions treated with steroids e.g. rheumatoid, sarcoidosis, asthma etc. Drug History Any medications they have recently started or stopped taking. Any including over the counter medications. Drug allergies Family History Ask about: Psychiatric illness, thyroid disease, endocrine disorders especially adrenal or pituitary tumours, and obesity. Social History Social stressors including work, diet, smoking and alcohol. Systems review General overview of all systems, especially GI. Present case to patient (and examiner) Summarise findings and finish with the most likely cause of the presenting complaint is..... However important differentials to consider would include.....

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

35

Summary This 34 year-old single women with no previous medical history admits to a significant weight gain of 12kgs over the past three months which she does not relate to changes in lifestyle. This is accompanied by fatigue, oligomenorrhoea, dry skin and dry hair. The most likely diagnosis is hypothyroidism. ACE Tips Remember some drugs can cause an increase in appetite which leads to weight gain. In these cases both diet and the drug need to be addressed, especially if the drug is one that cannot be substituted for another. Be specific when asking about diet and exercise. Patients have a varying opinion of what a healthy diet is and what constitutes adequate exercise. Ideals are 30 minutes of exercise 5 times a week and a diet high in fresh fruit, vegetables and complex carbohydrates whilst low in salt, saturated fats, simple carbohydrates and alcohol. If you have concerns over whether the patient really is telling the truth with food intake and exercise, provide them with a food diary to bring completed to their next appointment Marking Sheet: Weight Gain Station
Not attempted 1 2 3 4 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial understanding of why you are speaking with them Explains the diagnosis of epilepsy and checks patients understanding of disease (0=none, 1 = 2-3 factors, 2 = 4 or more factors) Enquires regarding patients knowledge of how epilepsy will effect his/her activities (0=none, 1 = 2-3 factors, 2 = 4 or more factors) Explains need and why DVLA must be informed. Deals with the patients distress and concerns with empathy Explains other activities which need to be stop or changed (eg, shower not bath) Allows patient to raise concerns and questions Summary Rapport with patient Thank the patient 0 0 0 0 Attempted inadequate 1 1 1 1 Attempted adequate 2 2 2 2

5 6

0 0

1 1

2 2

7 8 9 10 11 12 13

0 0 0 0 0 0 0

1 1 1 1 1 1 1

2 2 2 2 2 2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

36

12)

Weight Loss
Instructions given by examiner to candidate: You are a junior doctor working in a GP surgery. Miss Rivers, a young female attends with her mother. She presents with weight loss. Please take an appropriate history from her mother and summarise your findings at the end with likely differential diagnoses.

Information provided to Patient for History Dialogue with Candidate You are a 24 year-old woman and attend with your mother as you still live at home and are ot particularly fond of hospitals. You and your family are concerned about how thin you have become over the past 3 months. You are now a size 0 dress. You have lost 13kgs in total.The weight loss is not intentional having been only a size 8 before. You flatly deny any suggestions of an eating disorder and you mum supports you in that you eat the same if not more than normal presently. You are happy, but feel anxious at times with reduced sleep requirements. Your mum adds you keep opening the windows at home, when the others feel its cold. You have not had a period for 4 months. Your family, medical, social and drug history are all unremarkable. Common differentials Type 1 diabetes mellitus Malignancy Intentional weight loss Depression Thyrotoxicosis Malnutrition & malabsorption disorders

Featuresof the history associated with common differentials Type 1 diabetes mellitus: increased thirst, frequent urination and fatigue generally accompany weight loss as presenting symptoms of IDDM. The patient is also likely to be in their teens or younger. Intentional weight loss: Look out for an initially overweight patient or increase in exercise and decreased/ healthier food consumption. Warning signs of eating disorders include preoccupation with weight and appearance, also look out for the patient who is of normal/ underweight but insists they need to lose weight. Depression:Features to look out for include low mood, loss of appetite and libido, insomnia, low self esteem, feelings of guilt and suicidal ideation. Thyrotoxicosis:Look out for typical hyperthyroidism symptoms e.g. heat intolerance, palpitations, increased appetite, irregular periods and hand tremor. Malnutrition/ malabsorption e.g. IBD or coeliacs disease: Look out for (bloody) diarrhoea, mouth ulcers, peri anal disease, abdominal pain, bloating and general discomfort.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

37

History Dialogue Introduce Check name, age, occupation and marital status.

Permission Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?

Presenting complaint Why have you come here today? History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o When weight loss was first noticed and if any lifestyle, social or family circumstances changed at that time. o Food intake, exercise and dietary supplements. o How much weight lost over how long ? o Associated symptoms e.g. low mood, sleep disturbance, abdominal pain, change in bowel habit, abdominal bloating, thirst, polyuria or frequency, heat intolerance, irregular menstruation or palpitations. o Has this happened before? o Patients body image- do they think they need to lose weight and how does this relate to their true size. Ideas, Concerns and expectations Do you have any idea what is causing your weight loss, or any concerns about it? Past Medical History Ask about: thyroid disease, psychiatric history including mood disorders and eating disorders, GI disease. Drug History Any medications they have recently started or stopped taking. Any over the counter remedies or nutritional products. Drug allergies Family History Ask about: Psychiatric illness, thyroid disease, IBD, coeliacs disease and other malabsorption states and weight loss in general. Social History Social stressors including work, diet, smoking and alcohol. Systems review General overview of all systems, especially GI/ GU . Present case to patient (and examiner) Summarise findings and finish with the most likely cause of the presenting complaint is..... However important differentials to consider would include.....

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

38

Summary This 24 year-old female has unintentionally loss 13kg in the past 3 months. There has been no reduction in food intake supported by a collaborative history from her mother. The weight loss have been accompanied with heat intolerance and amenorrhoea. The most likely diagnosis is thyrotoxicosis. ACE Tips Eating disorder is less likely if the patient presents on his/her own, but explore if patient is brought in by a parent against their own wishes, even if they deny intentional weight loss. Tread carefully and take the history from the patient away from the parent in order to get a true picture of their eating habits. A depressed patient may be truly oblivious to the fact that they are depressed and unwilling to accept they have a low mood despite having all the core and biological symptoms of depression. It is common for a depressed patient to not believe in depression or have been depressed for so long they feel it is normal. If the patient is unable to quantify their weight loss ask about change in dress sizes, trouser size or number of belt holes used to do up belt. Remember weight loss may be the presenting complaint of an undiagnosed malignancy

Marking Sheet: Weight Loss History


Not attempted 1 2 3 4 5 6 7 8 9 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem Enquires in depth in about nature of the abdominal pain Enquires into other additional symptoms, in altered bowel habit Asks regarding severity of pain in an objective fasion (scale 1 -10) Past Medical History (especially surgery) Family History (For 2 marks must include specific enquiry on GIT pathology) Social and Drug History (alcohol and OTC drugs must be specifically questioned for 2 marks) Concerns and Ideas of patient considered Presentation and Summary Differential Diagnoses Provided 0 0 0 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 1 1 1 2 2 Attempted adequate 2 2 2 2 2 2

10

11 12 13

0 0 0

1 1 1

2 2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

39

13) Confusion/ memory loss station Instructions given by examiner to candidate: You are a junior doctor working in an acute medical unit. Its around 10pm and an elderly lady was found wandering the street on her own and was brought into hospital by police. Please take an appropriate history from her, and summarise your findings at the end with likely differential diagnoses, with the most likely offered first. Time Allowed: 8 minutes Information provided to Patient for History Dialogue with Candidate This 84 year-old lady lives alone in her bungalow, with minimal input 3 times a week from her family with no outside assistance. She has a history of hypertension and sinusitis for which she is taking limited medication. Her last admission to hospital was 20 years ago with a chest infection. She regularly plays bingo at her local church hall and is involved with matters in the local church. Over the past 48 hours her neighbour noticed he been muddled and she is now out rightly confused, being unaware of the day of the week or her pet dogs name. Her neighbour indicates she did complain of some lower abdominal comfort prior the confusion. She is teetotal and has not recently suffered and injury. Common differentials Dementia - Alzheimers type Dementia Multi-infarct type Delirium Alcohol intoxication/ withdrawal Hypoglycaemic episode Head injury Drug side effect/Poly-pharmacy Infection low grade UTI or LRTI

Features of the history associated with common differentials Dementia: gradual worsening over a long period of time with Alzheimers or a sudden stepwise deterioration in memory with multi-infarct(vascular) dementia. Activities of daily living are compromised, loss of orientation to time, person and place occurs. Patient presents in old age. Risk factors for vascular dementia, such as hypertension, diabetes, previous strokes provide clues. Delirium: look out for fluctuating confusion and behaviour change. Sleep wake pattern reversal, decreased consciousness, visual and tactile hallucinations and inattention are Alcohol intoxication/ withdrawal: tremors, seizures, history of chronic alcohol use and smell of alcohol are features to watch out for. Visual and tactile hallucinations can also feature in alcohol withdrawal. Hypoglycaemic episode: check for mention of diabetes, use of insulin, oral hypoglycaemics, alcohol, quinine and beta blockers as these can cause hypoglycaemia. History typically reveals autonomic symptoms e.g. sweating, anxiety, hunger and tremors before confusion and drowsiness sets in. Head injury: watch out for apparently unimportant incidents where the patient could have injured his/her head.
40

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

Drug side effect: e.g. opiates, BDZs and recreational drugs. Infection: The patient may complain of a cough or dysuria or fever. The exclusion of other causes on history taking may lead to this diagnosis. History Dialogue

Introduce Check name, age, occupation and marital status.

Permission Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?

Presenting complaint You were found wandering in the street and looking a bit lost, do you remember what you were doing? History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o How aware are they of their confusion o How much it is impacting on their daily life o Do an AMT to check level of cognitive impairment. o If anyone they see frequently has commented on a change o If any medications, drugs, alcohol, or acute illnesses recently. Ideas, Concerns and expectations Do you have any idea what is causing your headache, or any concerns about it? Past Medical History Ask about: Diabetes, high blood pressure, CVA, or depression. Drug History Especially BDZs, opiates. Drug allergies Family History Ask about: Alzheimers, high blood pressure and strokes. Social History Ask about risk factors for vascular disease: Smoking and alcohol. Systems review Ask especially about signs of systemic illness like fevers, headaches, coughs, cold and urinary symptoms as these could cause delirium. Present case to patient (and examiner) Summary This 84 year-old female has been confused for the past 48 hours, with an otherwise limited medical history. There is no history of trauma, alcohol ingestion or poly-pharmacy. She is normally
Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com 41

independent of her daily tasks of living, with no recent hospital admissions. The only positive other symptom is of lower abdominal discomfort via a collateral history from her neighbour. Given the patients background history and absence of trauma an infection, such as a UTI is the most likely cause. I would do simple laboratory tests to confirm this. ACE Tips: o Try to obtain collateral history. If the patient attends with a relative, be sure to ask the relative about the history of the presenting complaint. Alternatively neighbours or carers may offer assistance. During working hours the patients GP may be able to assist. For short (5-7 minute stations), do not attempt to do a 30 point MMSE as it will be hard to complete it. Do the AMT as it will provide a rough idea of cognitive state and show your awareness that a formal test needs to be done in addition to the history. Dont forget hypoglycaemia is a common cause of confusion preceding coma. If your patient is young remember to first exclude hypoglycaemia. Ensure that simple causes of confusion in the elderly are excluded first, such as a UTI. Polypharmacy is a significant and easily corrected cause of confusion so be sure to take an accurate drug history.

o o o

Marking Sheet: Confusion/Memory Loss History


Not attempted 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem Enquires in depth in about the length and nature of the confusion Enquires into other additional symptoms, in particular regarding fever, dysuria and cough Past Medical History (especially memory problems*) * Essential to score 2 marks Asks regarding diabetic history Asks regarding recent head trauma Family History Social and Drug History Concerns and Ideas of patient considered Presentation and Summary Differential Diagnoses Provided 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 1 1 1 1 1 1 1 1 Attempted adequate 2 2 2 2 2 2 2 2 2 2 2 2 2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

42

14) Depressed Mood Instructions given by examiner to candidate: You are a junior doctor working in a GP surgery. Miss Tanner presents with low mood. Please take an appropriate history from her, and summarise your findings at the end with likely differential diagnoses. Time Allowed: 8 minutes Information provided to Patient for History Dialogue with Candidate This 27 year old solicitor, Mary Jones, presents complaining of low mood, which has been present for the past 4 weeks, but is progressively worse to the point she is finding difficulties attending to her professional duties. She no longer enjoys sailing or tennis, to the point she remains at home during the weekend. She wakes at 4am every day, despite work commencing at 9am. She also feels at her worst during the mornings and always feels tired. She has no past medical history and doesnt take with prescribed or illicit drugs. Common differentials Clinical depression- mild, moderate, severe Adjustment disorder Bipolar disorder Psychoactive substance induced mood disorder Dysthymic disorder Depression secondary to general medical disorder

Features of the history associated with common differentials Clinical depression- mild, moderate, severe: at least 2 weeks in duration, 2 out of 3 of the following symptoms- low mood, anhedonia and decreased energy/ increased fatigability. Plus 2 of the additional symptoms (see ACE tips box) if mild, 3/4 of the additional symptoms if moderate, 5+ of the additional symptoms if severe. Adjustment disorder: low mood when the patient has had to adapt to a significant life change e.g. bereavement, divorce, and retirement. Bipolar disorder: deviation of mood from normal to depressed or manic. Look out for mention of past episodes of excessive energy, reduced sleep, regretted decisions e.g. excess money spent. Hypomanic and depressed. Psychoactive substance induced mood disorder: look out for history of recreational drug use. Dysthymic disorder: onset usually in early 20s. Low mood constantly present at a mild level i.e. patient may still function well despite the chronic low mood. Depression secondary to general medical disorder: low mood may arise following a chronic medical condition which may be psychiatric e.g. anxiety disorder, personality disorder, eating disorder OR medical e.g. COPD, renal failure.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

43

History Dialogue Introduce Check name, age, occupation and marital status.

Permission Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?

Presenting complaint Why have you come here today? History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o Onset and duration o Presence of core symptoms: low mood, anhedonia and fatigability o Additional symptoms: sleep, appetite, suicidal ideation, guilt, self esteem, attention, futility of future. o If anyone they see frequently has commented on a change o Triggers e.g. change in circumstances, stress Ideas, Concerns and expectations Do you think you are depressed? How would you like me to help you/ how would you like to proceed from here? Past Medical History Ask about: past depressive or manic episodes, past psychotic episodes, past suicide attempts and any chronic illnesses or psych illnesses. Drug History Anything including over the counter. Drug allergies Family History Ask about: Depression and psychiatric conditions in general. Social History Especially alcohol and recreational drugs as these can be a cause of depression. Systems review General overview could reveal a cause esp. Endocrine system as hypothyroidism can present as depression if untreated for a long time. Present case to patient (and examiner) Summarise findings and finish with the most likely cause of the presenting complaint is..... However important differentials to consider would include..... Summary This 27 year old lady has a history consistent with moderate clinical depression as evidenced by anhedonia, to her usual sporting interests, low mood for nearly a month, early morning wakening and decreased energy.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

44

ACE Tips: Remember to ask about variation of mood throughout the day. In clinical depression low mood is worse in morning and improves as the day progresses. Find out more about sleep pattern. In clinical depression the patient typically suffers from early morning waking. Dont forget to compare current sleep pattern to pre-morbid sleep pattern. Be sure to ask about illicit drug consumption, however uncomfortable this may be to broach Depression is frequently recurrent ask if the patient has had similar episodes before.

Marking Sheet: Depressed Mood History


Not attempted 1 2 3 4 5 6 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem Enquires in depth in about the length and nature of the low mood Enquires into other additional symptoms, in particular diurnal mood variation and early morning waking Asks regarding anhedonia Past Medical History (especially past depression*) * must ask for 2 marks Family History (For 2 marks must include specific enquiry on depression) Social and Drug History (alcohol and illicit drugs must be specifically questioned for 2 marks) Concerns and Ideas of patient considered Presentation and Summary Differential Diagnoses Provided 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 Attempted adequate 2 2 2 2 2 2

7 8

0 0

1 1

2 2

10

11 12 13

0 0 0

1 1 1

2 2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

45

15) Dizziness
Instructions given by examiner to candidate: You are a junior doctor working in a GP surgery. Mrs Thorn comes in to see you, complaining of dizziness. Please take an appropriate history from her, and summarise your findings at the end with likely differential diagnoses.

Information provided to Examiner for History Dialogue with Candidate Please use the information below to use in a role play scenario with a colleague (the student) with you as both the patient and examiner. You are a 52 year-old postmistress living alone called Joan Thorn. You have been having increasing problems with dizziness over the past month, which is frequently accompanied by nausea. Each episode lasts for around a minute and typically occurs at work when you keep turning your head to attend to customers. It is now beginning to interfere with your work, which is your main concern. You have been well until now and do not take any medications. You have the occasional sherry, dont smoke and only have a family history of nasal polyps. Time Allowed: 6 minutes Common differentials Benign Positional Vertigo Menieres disease Acoustic neuroma Ototoxicity Viral labyrinthitis Alcohol intoxication Features of the history associated with common differentials Benign Positional Vertigo: Specific movement of the head triggers the dizziness lasting more than 30 seconds. It is accompanied with nausea that can persist beyond the dizziness. Patient is often a middle aged woman. Menieres disease: Longer lasting dizziness of up to 12 hours. Associated with nausea, vomiting, tinnitus and deafness. Attacks occur in clusters. Acoustic neuroma: Hearing loss comes first. Vertigo presents much later, followed by involvement of V, VI, IX and X nerve. Ototoxicity: Look out for history of ototoxic drug use e.g. gentamicin. Viral labyrinthitis: Sudden onset vertigo lasting days, associated with nausea and vomiting. NO tinnitus or deafness occurs. Alcohol intoxication: A recent alcohol history will be present.

History Dialogue Introduce Check name, age, occupation and marital status.

Permission

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

46

Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?

Presenting complaint Why have you come here today History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o Onset, duration, exacerbating and alleviating factors especially head movement. o Additional symptoms and their onset and duration in relation to the dizziness. Ask about nausea, vomiting, tinnitus and deafness. o Recent head injury Ideas, Concerns and expectations Do you have any idea what is causing your dizziness, or any concerns about it? Past Medical History Ask about: recent illness, ENT history, TIAs/CVA or MS. Drug History Anything they have recently started or stopped taking Anything including over the counter. Drug allergies Family History Ask about: ENT conditions, acoustic neuroma or dizziness in general. Social History Alcohol, smoking, recreational drug use and how well the patient is functioning at home and at work since onset of symptoms. This will give you an insight into severity of the dizziness. Systems review General overview of all systems, especially neurological symptoms- focus on cranial nerve signs. Present case to patient (and examiner) Summarise findings and finish with the most likely cause of the presenting complaint is..... However important differentials to consider would include..... Summary This 52 year old middle aged female has a short history of dizziness associated with head movement, which is often accompanied by nausea. Each lasts for a short duration, but is causing difficulties with work. Her medical, family and social history are unrevealing. The most likely cause of the presenting complaint is benign positional vertigo,. ACE Tips Be sure to ask the patient specifically what they mean by dizziness. Do they mean they are spinning, the room is spinning, they feel lightheaded or faint etc?

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

47

Watch out for mentioning loss of consciousness. This points towards a diagnosis of epilepsy or syncope, NOT vertigo. If hearing loss or tinnitus is associated with the dizziness, think of 8th nerve or labyrinth pathology. Marking Sheet: Dizziness Station
Not attempted Attempted inadequate 1 1 1 1 Attempted adequate 2 2 2 2

1 2 3 4

Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial understanding of why you are speaking with them

0 0 0 0

5 6 7 8 9 10 11 12 13 Explains need and why DVLA must be informed. Deals with the patients distress and concerns with empathy Explains other activities which need to be stop or changed (eg, shower not bath) Allows patient to raise concerns and questions Summary Rapport with patient Thank the patient

0 0 0 0 0 0 0 0 0

1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2

Ace the OSCE


BMA Prize Winning OSCE Video Series Learn exam technique quickly & easily Real patients with real signs Money Back Guarantee you PASS! 10% discount with promo code AOSCE2 Subscribe today at AceMedicine.com

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

48

Dizziness station
Instructions given by examiner to candidate: You are a junior doctor working in a GP surgery. Mrs Thorn comes in to see you, complaining of dizziness. Please take an appropriate history from her, and summarise your findings at the end with likely differential diagnoses.

Information provided to Examiner for History Dialogue with Candidate Please use the information below to use in a role play scenario with a colleague (the student) with you as both the patient and examiner. You are a 52 year-old postmistress living alone called Joan Thorn. You have been having increasing problems with dizziness over the past month, which is frequently accompanied by nausea. Each episode lasts for around a minute and typically occurs at work when you keep turning your head to attend to customers. It is now beginning to interfere with your work, which is your main concern. You have been well until now and do not take any medications. You have the occasional sherry, dont smoke and only have a family history of nasal polyps. Time Allowed: 6 minutes Common differentials Benign Positional Vertigo Menieres disease Acoustic neuroma Ototoxicity Viral labyrinthitis Alcohol intoxication Features of the history associated with common differentials Benign Positional Vertigo: Specific movement of the head triggers the dizziness lasting more than 30 seconds. It is accompanied with nausea that can persist beyond the dizziness. Patient is often a middle aged woman. Menieres disease: Longer lasting dizziness of up to 12 hours. Associated with nausea, vomiting, tinnitus and deafness. Attacks occur in clusters. Acoustic neuroma: Hearing loss comes first. Vertigo presents much later, followed by involvement of V, VI, IX and X nerve. Ototoxicity: Look out for history of ototoxic drug use e.g. gentamicin. Viral labyrinthitis: Sudden onset vertigo lasting days, associated with nausea and vomiting. NO tinnitus or deafness occurs. Alcohol intoxication: A recent alcohol history will be present.

History Dialogue Introduce Check name, age, occupation and marital status.

Permission

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

49

Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?

Presenting complaint Why have you come here today History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o Onset, duration, exacerbating and alleviating factors especially head movement. o Additional symptoms and their onset and duration in relation to the dizziness. Ask about nausea, vomiting, tinnitus and deafness. o Recent head injury Ideas, Concerns and expectations Do you have any idea what is causing your dizziness, or any concerns about it? Past Medical History Ask about: recent illness, ENT history, TIAs/CVA or MS. Drug History Anything they have recently started or stopped taking Anything including over the counter. Drug allergies Family History Ask about: ENT conditions, acoustic neuroma or dizziness in general. Social History Alcohol, smoking, recreational drug use and how well the patient is functioning at home and at work since onset of symptoms. This will give you an insight into severity of the dizziness. Systems review General overview of all systems, especially neurological symptoms- focus on cranial nerve signs. Present case to patient (and examiner) Summarise findings and finish with the most likely cause of the presenting complaint is..... However important differentials to consider would include..... Summary This 52 year old middle aged female has a short history of dizziness associated with head movement, which is often accompanied by nausea. Each lasts for a short duration, but is causing difficulties with work. Her medical, family and social history are unrevealing. The most likely cause of the presenting complaint is benign positional vertigo,. ACE Tips Be sure to ask the patient specifically what they mean by dizziness. Do they mean they are spinning, the room is spinning, they feel lightheaded or faint etc? Watch out for mentioning loss of consciousness. This points towards a diagnosis of epilepsy or syncope, NOT vertigo. If hearing loss or tinnitus is associated with the dizziness, think of 8th nerve or labyrinth pathology.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

50

Marking Sheet: Dizziness Station

Not Attempted Attempted attempted inadequate adequate 1 2 3 4 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial understanding of why you are speaking with them 0 0 0 0 1 1 1 1 2 2 2 2

5 6 7 8 9 10 11 12 13 Explains need and why DVLA must be informed. Deals with the patients distress and concerns with empathy Explains other activities which need to be stop or changed (eg, shower not bath) Allows patient to raise concerns and questions Summary Rapport with patient Thank the patient

0 0 0 0 0 0 0 0 0

1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2

Ace Medicine Revision Courses


Ace the 3rd Year OSCE Course Ace the 3rd Year Written Exams Course Ace the 4th Year Specialties Course Ace the Written Finals Course

100% MONEY BACK GUARANTEE you pass your Exams LEARN most topics likely to come up in your exams within HOURS, SAVE yourself WEEKS of revision time! visit www.AceMedicine.com for details and bookings

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

51

Headache history OSCE station

Instructions given by examiner to candidate You are a junior doctor working in A&E. This 44 year old man presents complaining of headache. Please take an appropriate history and summarise your findings succinctly. Please give a short list of differential diagnoses, stating which you think is the most likely diagnosis. Time Allowed: 8 minutes

Information provided to Examiner for History Dialogue with Candidate

Please use the information below to use in a role play scenario with a colleague (the student) with you as both the patient and examiner.

This 44 year-old single male teacher, called Mark Chopra. He complains of a left sided headache of 14 hours in duration. Unremitting and non radiating in nature. It has become progressively worse over this period, with associated photophobia and nausea. It has been unresponsive to over the counter analgesics (paracetamol and NSAIDS) Worse than previous headaches only ever had tension type headaches like most people now and again, but this feels different. He has no medical, drug or family history and is a tea-total non-smoker. No drug allergies. The headache has followed a rather busy period with his work, due to recent school examinations, with late nights drinking coffee whilst marking assessments. The patient has a migrainous headache, as evidence by the unilateral nature, unremitting nature in response to standard analgesics, recent high caffeine intake, associated symptoms, in particular photophobia.

Common and Important Differentials Tension Headache Migraine Cluster Headache Temporal Arteritis Raised intracranial pressure Head injury

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

52

Key Features of the history associated with common differentials The information in bold italics is the key question to rule this pathology in as being most likely. Cluster headache: Unilateral pain once or twice daily, each episode lasts up to 2 hours, occurring in clusters of 4-12 weeks followed by a pain free period. Headache is associated with bloodshot eyes, lacrimation, rhinorrhoea and Horners. Migraine: Aura of 15-30 minutes followed by unilateral throbbing headache. Aura includes visual disturbance, weakness, and dysphasia. Triggers include; cheese, OCP, Caffeine, Alcohol, and anxiety. Tension headache: tight band around my head typically bilateral around the temporal regions. Often stressors at home or work. Temporal arteritis: Usually patients are 50 years or older. Tender temple, usually unilateral, with pain on combing hair and chewing food. May have associated visual problems. Tender to palpation over the temporalis muscle. Raised intracranial pressure: Headache on waking up, which is worsens on lying down, accompanied by vomiting, papilloedema or seizures. Head injury: The headache is usually at the site of the trauma or a generalised headache. Resistant to analgesia and can persist up to 2 weeks. Beware of variable conscious level as it may indicate a subdural haematoma.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

53

History Taking Dialogue What to ask Introduction Check the patients; name, age, occupation and marital status.

Consent and Courtesy Explain who you are and why you are there. E.g. I am a final year medical student currently attached to the admissions ward. I would like to ask you about how you are feeling at the moment, is that OK? Presenting complaint What problem has brought you here today?

History of presenting complaint o o Open question: Tell me a bit more about it .... and then allow the patient to talk. Specifically ask about (direct questioning):

o o o o Ideas, Concerns and Expectations

Site, Onset, Character, Radiation, Alleviating (including painkiller use) and Exacerbating factors, Timing and Duration, Severity. Associated symptoms (vomiting, nausea, visual disturbance, photophobia, weakness, jaw claudication or scalp tenderness) Previous head injury Past history of headache Stress levels

Do you have any idea what is causing your headache, or any concerns about it?

Past Medical History Ask about: Epilepsy, Hypertension, stroke, migraines, tension headaches or neurosurgery.

Drug History Especially analgesia or nitrates. Include over the counter of alternative remedies. Drug allergies

Family History Ask about: Migraines, high blood pressure, headaches, and inherited conditions.

Social History
Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com 54

Ask about: Smoking, alcohol, recreational drug use, high in caffeine usage, chocolate or cheese.

Systems review Ask especially about neurological changes and signs of systemic illness like fevers.

Present case to patient (and examiner) Ensure this is succinct, measured and ordered. Summarise findings and finish with the most likely cause of the presenting complaint is..... However, important differentials to consider would include.....\

Summary of History

This 44 year-old single teacher complains of a left sided headache of 14 hours in duration. It has become progressively worse over this period, with associated photophobia and nausea. It has been unresponsive to over the counter analgesics and worse than previous headaches. The headache has followed a rather busy period with his work, due to recent school examinations, with late nights drinking coffee whilst marking assessments. He has no medical, drug or family history and is a tea-total non-smoker. The most likely cause of the patients headache is a migraine. A tension headache would be less likely given the unilateral nature and associated symptoms, but may be considered.

ACE Tips: o The patients individual account is most central to diagnosis. Accurate history taking will often give you the diagnosis, without the need for expensive investigations. Be aware of any clues the patient is giving you e.g. throwaway comments about stress at home or work or mention of minor accidents recently during which (s)he may have injured his/her head. Always tailor your differential to age. For example a 15 year old is very very unlikely to have temporal arteritis. Reserve the use of imaging investigations for those you are most concerned about and only after commentating on the necessity of a through history and examination. Beware of the all over the place patient. One whose ability to express their concerns is chaotic. It is your job to keep them directed and on track, especially with limited time.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

55

Marking Sheet: Headache History

Not Attempted Attempted attempted inadequate adequate 1 2 3 4 5 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of heache Nature of headache enquired about (eg, site, duration, radiation, severity etc) (0=none, 1 = 2-3 factors, 2 = 4 or more factors) 6 Asks regarding associated symptoms 0 (eg, vomiting, photophobia, weakness) (0=none, 1 = 2-3 factors, 2 = 4 or more factors) Past Medical History Family History Social and Drug History Concerns and Ideas of patient Presentation and Summary Differential Diagnoses Provided Answers questions from examiner 0 0 0 0 0 0 0 1 2 0 0 0 0 0 1 1 1 1 1 2 2 2 2 2

7 8 9 10 11 12 13

1 1 1 1 1 1 1

2 2 2 2 2 2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

56

17) Loss of Consciousness


Instructions given by examiner to candidate: Its early evening and you are a junior doctor working in A&E. Miss Lewis has just been brought in by a fellow passenger who saw her lose consciousness on a train. Please take an appropriate history from her and summarise your findings at the end with likely differential diagnoses. Time Allowed: 6 minutes Information provided to Patient for History Dialogue with Candidate You are Jo Lewis, a 21 year old university student returning on a long journey home after a busy week of examinations and strife with your boyfriend. It is warm in the carriage and it was difficult to find a seat, requiring you to stand in between carriages. You dont recall must of the events apart from feeling sweaty prior to the episode then waking up with a wet tissue on your forehead. After a short period you felt back to normal. You have no medical history or take either prescribed or recreational drugs. You had a small bottle of lager prior to getting on the train, but dont drink regularly. No family history of cardiac disease or diabetes. Common differentials Vasovagal syncope Situational syncope Epilepsy Cardiac causes e.g. transient arrhythmia Hypoglycaemia Intoxication

Features of the history associated with common differentials Vasovagal syncope: Provoked by emotion, standing too long, pain and fear. Patient may experience nausea, sweating, pallor and altered vision prior to the LOC. It never occurs when lying down. Situational syncope: the commonest is micturition syncope typically occurs in men at night, effort syncope Epilepsy: Aura can precede the attack, and patient can be lying or standing Cardiac causes e.g. transient arrhythmia: Stokes Adams attacks. The patient can be lying or standing. The LOC happens within seconds without warning and the patient goes very pale. Recovery is also rapid, within seconds and the patient flushes bright red. Hypoglycaemia: Preceded by autonomic symptoms of sweating, tremor and hunger. Confusion then occurs before LOC. Look out for a diabetic history (on oral hypoglycaemics or insulin) or use of drugs like beta blockers and quinine which can cause hypoglycaemia. Intoxication: The consumption of significant volumes or alcohol and illicit drugs may precipitate as loss of consciousness, especially if the patient is found with no witnessed history.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

57

History Dialogue Introduce Check name, age, occupation and marital status.

Permission Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?

Presenting complaint Why have you come here today History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o Onset (speed of onset, what they were doing during onset), duration, frequency, speed of recovery. o Any aura e.g. vision, hearing or tactile disturbance prior to LOC. o Any movement during the attack e.g. twitching or fits? o Incontinence or tongue biting. o Post attack behaviour- any headache, amnesia, sore tongue or confusion? o Additional symptoms e.g. palpitations, tremors, o Recent head injury o Ideas, Concerns and expectations Do you have any idea what is causing your loss of consciousness, or any concerns about it? Past Medical History Ask about: recent illness, diabetes, heart disease, epilepsy. Drug History Anything they have recently started or stopped taking. If on insulin or hypoglycaemic, establish adherence to correct dosing schedule. Anything including over the counter. Drug allergies Family History Ask about: Epilepsy, diabetes, heart disease and arrhythmias, loss of consciousness in general. Social History Especially alcohol as this can trigger hypoglycaemic episodes. Recreational drug history is also important as recreational drug use can trigger arrhythmias and lead to LOC Systems review General overview of all systems, especially neurological Present case to patient (and examiner) Summarise findings and finish with the most likely cause of the presenting complaint is..... However important differentials to consider would include.....

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

58

ACE Tips: What the patient is doing before losing consciousness is crucial to the diagnosis. Vasovagal syncope does NOT occur whilst lying down; epileptics will have an aura whilst cardiac syncope can occur lying down. A collateral history is a great way to obtain clues about the cause of loss of consciousness. A patient may be unaware if they went pale or flushed, if they twitched or jerked etc, which is vital for distinguishing between the different causes of LOC. Be cautious not to jump to the diagnosis of epilepsy given the practical implications of this diagnosis. Jerking can briefly occur in other conditions. One should be especially cautious of the history if a lay person made the observation.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

59

18) Numbness / Weakness (in arm and leg)


Instructions given by examiner to candidate: You are a junior doctor working in the Acute Medical Unit. An elderly gentleman (Mr Kuilap) has been brought in by his daughter after noticing he had been off his legs all day. Please take an appropriate history from him and summarise your findings at the end with likely differential diagnoses. Information provided to Patient for History Dialogue with Candidate You are a 76 year-old man, who until the last 2 days have been independent and active. Yesterday your legs felt heavy, but you thought nothing of it at your age, but today you had real problems from the minute you woke up. You needed help to get out of bed, and also notice you had wet yourself without even realising. The area around your genitals feels numb and you cannot lift your legs. You dont have a headache. You have no recent history of trauma. You have been attending the urology clinic for several years with prostate problems and have hypertension. You had your gallbladder removed 43 years ago. You have never smoked and have the odd brandy. Time Allowed: 6 minutes Common differentials TIA Stroke Brain tumour Demyelinating disease Spinal cord compression malignant or other Muscular disorder

Features of the history associated with common differentials TIA: Onset is fairly sudden and recovery is swift and within 24 hours. The patient may have a history of episodes of weakness which resolve within the day. Stroke: Onset is rapid- within minutes or progresses in a stepwise fashion over hours and recovery is slow, by definition, greater than 24 hours. Affected limbs are flaccid initially then become spastic later. Brain tumour: Presentation can vary from sudden to slow and progressive. Other symptoms may be present, esp. of space occupying lesion so look out for history including headache, nausea and vomiting in addition to other focal neurological deficits. Demyelinating disease: Spinal cord compression: loss of sensation, loss of sphincter control- both bowels and bladder. If cauda equina look out for urinary retention and legs are flaccid rather than stiff. Muscular disorder:

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

60

Introduce Check name, age, occupation and marital status.

Permission Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?

Presenting complaint Why have you come here today? History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o Onset (speed of onset, what they were doing during onset), duration, frequency, speed of recovery and associated LOC. o Additional symptoms e.g. headache, loss of sensation, pins and needles, speech or swallowing disturbance and incontinence or urinary retention. o Has this happened before? o Recent head injury Ideas, Concerns and expectations Do you have any idea what is causing your weakness, or any concerns about it? Past Medical History Ask about: recent illness, hypertension, diabetes, heart disease and previous strokes. Drug History Anything they have recently started or stopped taking, especially warfarin. Anything including over the counter medications. Drug allergies Family History Ask about: Strokes, diabetes, heart disease and high blood pressure. Social History Risk factors for CVA e.g. smoking, diet and alcohol. Systems review General overview of all systems, especially neurological. Present case to patient (and examiner) Summarise findings and finish with the most likely cause of the presenting complaint is..... However important differentials to consider would include..... Summary Mr Kiulap is a 76 year-old man with a limited medical history of prostate problems, who has a 36 hour history of progressive weakness in his legs, accompanied by perineal numbness and lost of bladder control.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

61

In conclusion the patient has a history concerning for spinal cord compression and needs urgent referral to the spinal surgeons for an MRI. My concern, given the history of prostate problems, is of a metastatic cord compression. ACE Tips: Pay attention to demographic of patient. A stroke is a less likely diagnosis in a young and fit patient. Be sure to compare how the symptoms were at onset to how they are at presentation. If resolving rapidly, think TIA. If progressing over hours think stroke. A brain tumour is unlikely to suddenly start progressing rapidly over 1 day! Filter out those needing urgent clinical imaging, such as red flag signs of spinal cord compression.

Marking Sheet: Numbness/Weakness History


Not attempted 1 2 3 4 5 6 7 8 9 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem Enquires in depth in about nature of the abdominal pain Enquires into other additional symptoms, in altered bowel habit Asks regarding severity of pain in an objective fasion (scale 1 -10) Past Medical History(especially surgery) Family History (For 2 marks must include specific enquiry on GIT pathology) Social and Drug History (alcohol and OTC drugs must be specifically questioned for 2 marks) Concerns and Ideas of patient considered Presentation and Summary Differential Diagnoses Provided 0 0 0 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 1 1 1 2 2 Attempted adequate 2 2 2 2 2 2

10

11 12 13

0 0 0

1 1 1

2 2 2 62

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

19) Psychosis
Instructions given by examiner to candidate: You are a junior doctor working in A&E. Mr Logan was brought in by the police as he was found shouting at cars in the middles of a busy main road. Please take an appropriate history from him, and summarise your findings at the end with likely differential diagnoses. Information provided to Patient for History Dialogue with Candidate You are a 20 year-old man is 7 months into his first year studying astrophysics at the local university. He is in shared accommodation with other students. His behaviour has become increasing odd of late up(4 weeks) until this incident of being found in the road. You believe the cars are all being driven by members of the secret service who are trying to get at you after you failed to secure an A grade in your recent examination. They also talk to you via the plants on the university campus. You mention seeing a dog walking in front of you wearing a party hat during the interview with the doctor. You deny anything is wrong with you. You admit to enjoying cannabis increasingly so since commencing university. No past medical history. Your alcohol intake is limited and have a normal family background. Time Allowed: 8 Minutes Common differentials Schizophrenia Schizoaffective disorder Drug induced psychosis Delusional disorder Mania with psychosis. Depressive episode with psychosis

Features of the history associated with common differentials Schizophrenia: at least one month exhibiting thought disorder, delusions, auditory hallucinations, negative symptoms or delusional perceptions. First presentation is usually in late teens or early 20s. Schizoaffective disorder: Simultaneous schizophrenic symptoms and mood disorder (mania or depression) symptoms. Drug induced psychosis: Look out for history of recreational drug use, esp. chronic cannabis use, cocaine and amphetamines. Also look out for medications such as steroids, antiParkinson and anticholinergics as these can cause psychotic symptoms. Delusional disorder: the patient exhibits one single or a set of delusions for at least 3 months. In delusional disorder, the only symptom is the delusion, unlike true schizophrenia, there are no hallucinations, thought disorder or delusions of thought control. The patient typically has a high level of functioning. Mania with psychosis: Patient exhibits symptoms of mania e.g. lack of sleep, increased energy, poor concentration, accelerated thinking and grandiosity. In addition, psychotic symptoms also feature, typically disorders of thought form e.g. flight of ideas and perceptual disturbance. Depressive episode with psychosis: Occurs in patients with severe depression. Hallucinations, delusions or a stupor are the psychotic symptoms to look out for.
63

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

History Dialogue Introduce Check name, age, occupation and marital status.

Permission Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?

Presenting complaint Why have you come here today? if they patient has attended of their own willing. If they have been brought in by a worried relative or police, try Your mother has mentioned you have not been acting like yourself lately and is quite worried about this. Why do you think she feels this way? History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o Onset and duration o Presence of ICD 10 symptoms: delusions of control, auditory hallucinations, thought insertion/ withdrawal/ broadcasting, thought disorder, negative symptoms and catatonic behaviour. o Additional symptoms: symptoms of depression and mania. o If anyone they see frequently has commented on a change o Triggers e.g. drugs, medications, recent illness, change in circumstances, stress Ideas, Concerns and expectations Assess level of insight Do you think you think you have been acting out of the ordinary? Do you think you need help to try and get things back to normal? Remember that typically (97%) there is a lack of insight in schizophrenia, especially with first presentations. Past Medical History Ask about: past psychiatric history or contact with a psychiatrist. Drug History Anything they have recently started or stopped taking Anything including over the counter. Drug allergies Family History Ask about: Schizophrenia and psychiatric conditions in general. Social History Especially recreational drugs as these can be a cause of psychosis. Systems review General overview of all systems is essential as many medical conditions can lead to psychotic symptoms e.g. B vitamin deficiency, SLE, Endocrine disorders, cerebral infection, trauma or infarct.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

64

Present case to patient (and examiner) Summarise findings and finish with the most likely cause of the presenting complaint is..... However important differentials to consider would include..... Summary This 20 year-old male university student has experienced increasingly odd behaviour over the past month in particular he is exhibiting delusions and hallucinations. The symptoms strongly correlate with the use of recreational cannabis. Although the differential lies between schizophrenia and drug induced psychosis the later is more likely given the known recreational drug use.

ACE Tips Remember the history taking process is unlikely to go smoothly with an acutely psychotic patient therefore be prepared to recap everything at the end to ensure you have covered all vital topics. Schizophrenia is diagnosed using ICD-10 guidelines OR Schneiders first rank symptoms. Remember that you do not want to offend your patient especially if they are psychotic- you do not want to anger them, therefore it is important to carefully word your questions. E.g. I apologise if the questions I ask seem a little strange, they are just routine questions which wont necessarily apply to you. A collaborative history may be required to ascertain all the information required. Indicate this is something you would consider undertaking.

Marking Sheet: Schizophenia History

Not Attempted Attempted attempted inadequate adequate 1 2 3 4 5 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem Enquires in depth in a professional manner about the delusions the patient exhibits Enquires into other additional symptoms, in particular hallucinations 0 0 0 0 0 1 1 1 1 1 2 2 2 2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

65

and negative symptoms 7 8 9 Past Medical History (especially psychiatric history) Family History Social and Drug History (especially illicit drug use) 10 11 12 Concerns and Ideas of patient considered Presentation and Summary Differential Diagnoses Provided 0 0 0 1 1 1 2 2 2 0 0 0 1 1 1 2 2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

66

20) Amenorrhea station Instructions given by examiner to candidate: You are a junior doctor working in a GP surgery. Miss Fuller, a young female presents with amenorrhea. Please take an appropriate history from her and summarise your findings at the end with likely differential diagnoses.

Information provided to Patient for History Dialogue with Candidate You are a 24 year-old masters student, and are both single and sexually inactive. You did have a boyfriend until 6 months ago, but since have been off men, in part due to feeling low in self confidence, due to your appearance. Your weight has gone up and you have been rather spotty in addition to your prime concern of having had no period for 4 months. Before you had a very regular 28 day cycle. Your course is hectic but you are no more stressed than normal. You have no medical history, other than an appendicectomy, no family history of diabetes and merely use multivitamins from the supermarket as you are vegetarian. Common differentials Pregnancy Stress induced Polycystic ovarian syndrome Excessive weight loss/ exercise Hyper/hypothyroidism Premature ovarian failure Features of the history associated with common differentials Pregnancy: Look out for the young female of childbearing age, sexually active, amenorrhoea, nausea and vomiting and ineffective contraceptive use. The nausea and vomiting may be triggered by specific foods and odours which previously did not cause nausea in the patient. Stress induced: Look out for patient with lifestyle change leading to increased stress, e.g. new job, increased working hours, divorce, moving house etc. Polycystic ovarian syndrome: Look out for classic symptoms including weight gain, acne, hirsuitism. There may also be a strong family history of PCOS and difficulty conceiving. The patient may also be diabetic, hypertensive or have high cholesterol. Excessive weight loss/ exercise: Look for patient with low BMI, increased exercise +/- low calorie intake. The patient may have an eating disorder or be rigorously training for marathon etc. Hyper/hypothyroidism: Periods tend to be irregular rather than completely absent. If hyperthyroidism, look for hand tremor, weight loss, heat intolerance, eye swelling/ protrusion, increased appetite and irritability. For hypothyroidism, look out for weight gain, decreased appetite, cold intolerance, depression and dry skin and hair. Premature ovarian failure: Look out for symptoms of menopause e.g. hot flashes, night sweats, irritability, loss of libido, vaginal dryness, painful sex and infertility. A family history may also be prominent or there may be a previous chemotherapy or radiotherapy. The patient should be under the age of 40 for this to be considered as a diagnosis.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

67

Introduce Check name, age, occupation and marital status. Permission Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK? Presenting complaint Why have you come here today? History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o Onset- gradual or sudden, duration, o Lifestyle changes coinciding with onset of symptoms. o Associated symptoms e.g. low mood, hand tremor, heat intolerance, weight loss or gain, cold intolerance, night sweats, vaginal dryness, nausea and vomiting, acne or increased skin hair. o Has this happened before? o Sexual history. o Menstrual history o Diet and exercise habits. Ideas, Concerns and expectations Do you have any idea what is causing your symptoms, or any concerns about it? Past Medical History Ask about: psychiatric conditions, thyroid disease, cancers treated with radiotherapy or chemotherapy, diabetes and hypertension. Drug History Anything they have recently started or stopped taking. Anything including over the counter. Drug allergies Family History Ask about: diabetes, amenorhoea, PCOS, psychiatric conditions or thyroid disease. Social History Smoking, alcohol, recreational drugs and diet. Systems review General overview of all systems especially GI/GU and endocrine. Present case to patient (and examiner) Summarise findings and finish with the most likely cause of the presenting complaint is..... However important differentials to consider would include..... Summary This 24 year-old postgraduate student complains of a 4 month history of amenorrhoea, on the background of very unremarkable medical history. This has been associated with weight gain and skin problems.
Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com 68

The differential diagnosis lies between hypothyroidism and polycystic ovarian syndrome. Laboratory and radiological investigations should be performed to aid diagnosis.

ACE Tips The patient may be unaware of the level of stress they are under, or unwilling to admit it because it means admitting they cannot cope. Do not discount the impact of stress just because a patient does not accept that their current situation is stressful. Tread carefully when enquiring about eating habits. A patient with an eating disorder who comes to see a doctor about amenorrhoea is likely to be at a different stage of acceptance of their condition to one who comes seeking treatment for their eating disorder. Therefore even if the patient has a glaringly obvious exercise/ eating problem they may deny it. Dont necessarily take the patients word for it if she says she cant be pregnant everyone looks silly if the cause is pregnancy and is found out months later.

Marking Sheet: Amenorrhoea History


Not attempted 1 2 3 4 5 6 7 8 9 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem Enquires in depth in about nature of the abdominal pain Enquires into other additional symptoms, in altered bowel habit Asks regarding severity of pain in an objective fasion (scale 1 -10) Past Medical History (especially surgery) Family History (For 2 marks must include specific enquiry on GIT pathology) Social and Drug History (alcohol and OTC drugs must be specifically questioned for 2 marks) Concerns and Ideas of patient considered Presentation and Summary Differential Diagnoses Provided 0 0 0 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 1 1 1 Attempted adequate 2 2 2 2 2 2 2 2 2

10

11 12 13

0 0 0

1 1 1

2 2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

69

21) Dyspareunia station


Instructions given by examiner to candidate: You are a junior doctor working in a GP surgery. Miss Anderson, a middle aged female presents with dyspareunia. Please take an appropriate history from her and summarise your findings at the end with likely differential diagnoses.

Information provided to Patient for History Dialogue with Candidate You are Jane Anderson a 54 year-old barrister, who although not married are in a long term relationship and are sexually active. In recent months you have been having increasing discomfort during sexual intercourse, which you have on average twice a week. This is to the point of not wanting to have sex most recently. The pain is quite superficial and you have no pain at other times. You have been having irregular periods over the last 8 to 12 months, and have hot flushes on and off. You have a single sexual partner and you sexual habits have not changed for years. You have no discharge. Your medical and social history is unremarkable, in particular no history of sexually transmitted diseases. You last smear a year ago was normal. You have no children. You own opinion is that the pain is due to you going through the menopause. Time Allowed: 6 minutes Common differentials PID Vaginitis Vaginal dryness/ atrophy Endometriosis Pelvic adhesions

Features of the history associated with common differentials PID: if chronic, deep dyspareunia is reported rather than superficial. It is often associated with pelvic or lower abdominal pain, profuse discharge which may be blood stained. Periods may be particularly heavy and painful. Vaginitis: Symptoms include a superficial dyspareunia, vaginal soreness and inflammation, increased and offensive smelling discharge and dysuria. Vaginitis often arises due to a vaginal infection (STI or not) or postmenopause. Vaginal dryness/ atrophy: Usually occurs as part of hormone changes in menopause. Look out for older woman with other symptoms of menopause e.g. night sweats, irritability, amenorrhoea etc. Endometriosis Pelvis Adhesions Psychological Introduce Check name, age, occupation and marital status.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

70

Permission Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about the problem you are having at the moment, is that OK?

Presenting complaint Why have you come here today? History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o When did it first start? Does it happen every time you have intercourse? o Associated symptoms e.g. abdominal/ pelvic pain, discharge, fever, mucus, ameorrhoea and bleeding intermenstrually. o Alleviating and exacerbating factors e.g. if due to dryness, use of lubricant may reduce the pain. o Is the pain superficial e.g. during initial penetration or deep? o Has this happened before? o Sexual history & gynaecological/ obstetric history o Menstrual history o Vaginal or abdominal trauma Ideas, Concerns and expectations Do you have any idea what is causing your symptoms, or any concerns about it? Past Medical History Ask about: menopause, previous STIs, thrush, abnormal smears, cervical/vaginal cancer, diabetes and immunodeficiency. Drug History Anything they have recently started or stopped taking. Anything you use from over the counter. Drug allergies Family History Ask about: cancers, menstrual abnormalities, abnormal smears, diabetes. Social History Smoking, alcohol, recreational drugs and diet. Systems review General overview of all systems especially GU and endocrine. Present case to patient (and examiner) Summarise findings and finish with the most likely cause of the presenting complaint is..... However important differentials to consider would include.....

Summary Miss Anderson is a 54 year with a long term sexual partner who up until recently has been sexually active without difficulty. She has recently been having pain during intercourse largely superficial, but persistent and it is now affecting her relationship. Her sexual and
Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com 71

gynaecological history is unremarkable. Her personal inference is that it is related to the menopause, which she feels is in progress. I concur with the patients feelings and I think her dyspareunia is related to dryness and atrophy secondary to oestrogen deficiency as part of her imminent menopause. ACE Tips The differentials given here are for physical causes, but do not forget that it may also be psychological. It is important to determine if the dyspareunia is superficial i.e. felt around the vaginal entrance or deep i.e. felt further inside within the pelvis. The type of dyspareunia gives clues about the likely diagnosis as vaginitis from infection usually presents as superficial pain. Remember to tread carefully, this is a topic many patients will not be very comfortable taking about or may use vague descriptive terms. Be sure to ascertain exactly what and where the pain is, do not allow this to be left for you to assume. Make sure early in the consultation that you highlight to the patient that everything you talk about will be in the strictest of confidence and no need to be embarrassed as we need to address the problem for her.

Marking Sheet: Dyspareunia History


Not attempted 1 2 3 4 5 6 7 8 9 10 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem Enquires in depth in about nature of the abdominal pain Enquires into other additional symptoms, in altered bowel habit Asks regarding severity of pain in an objective fasion (scale 1 -10) Past Medical History(especially surgery) Family History (For 2 marks must include specific enquiry on GIT pathology) Social and Drug History (alcohol and OTC drugs must be specifically questioned for 2 marks) Concerns and Ideas of patient considered Presentation and Summary Differential Diagnoses Provided 0 0 0 0 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 1 1 1 1 2 2 2 Attempted adequate 2 2 2 2 2 2

11 12 13

0 0 0

1 1 1

2 2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

72

22) Vaginal Bleeding station


Instructions given by examiner to candidate: You are a junior doctor working in a GP surgery. Miss Roy, a young female presents with vaginal bleeding. Please take an appropriate history from her and summarise your findings at the end with likely differential diagnoses. Information provided to Patient for History Dialogue with Candidate You are a 23 year-old single shop assistant and have become very worried in the last week after noticing some bleeding into your pantyliner. You last period finished 2 weeks ago. You have noticed that the blood is mixed with an unpleasant smelling discharge something which is unfamiliar to you. You are known amongst you friends as a party animal and when the doctor asks about you sexual history admit you have had multiple sexual partners in the last 18 months. You have never had a cervical smear.You use the oral contraceptive pill so once in a while you have engaged in sexual intercourse without the use of a condom. You smoke 10 cigarettes a day and drink alcohol at weekends. You have no past medical or family history and aside from the OCP you are not on medications. Time Allowed: 6 minutes Common differentials Cervical polyps Cervical ectropian Dysfunctional uterine bleeding Cervical cancer Pelvic Inflammatory Disease Endometrial carcinoma

Features of the history associated with common differentials Cervical polyps: Vaginal bleeding, especially post coital. There may also be vaginal mucus. Cervical ectropian: Like a polyp symptoms i.e. bleeding and mucus. The patient may have recently started the OCP, be pregnant or in puberty as these are times when the ectropian extend. Dysfunctional uterine bleeding: Look out for heavy or irregular periods. The patient is likely to be close to menopause or recently started her periods. Cervical cancer: There may be no symptoms aside from the vaginal bleeding. Check for previous abnormal smears or a lack of previous smears. Pelvic Inflammatory Disease: Look out for lower abdominal/ pelvic pain, dyspareunia, fever and offensive smelling discharge. Endometrial carcinoma: post menopausal bleeding, is the typical presentation Introduce Check name, age, occupation and marital status.

Permission Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

73

Presenting complaint Why have you come here today? History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o Onset, duration, quantity and colour of blood. o Associated symptoms e.g. abdominal/ pelvic pain, discharge, fever, mucus, dyspareunia. o Has this happened before? o Sexual history o Gynaecological/ obstetric history o Menstrual history o Vaginal or abdominal trauma Ideas, Concerns and expectations Do you have any idea what is causing your symptoms, or any concerns about it? Past Medical History Ask about: previous STIs, abnormal smears, cervical/vaginal cancer, Drug History Any medications they have recently started or stopped taking. Any over the counter preparations. Drug allergies Family History Ask about: cancers, menstrual abnormalities, abnormal smears and cervical polyps/ ectropians. Social History Smoking, alcohol, recreational drugs and diet. Systems review General overview of all systems especially GU and endocrine. Present case to patient (and examiner) Summarise findings and finish with the most likely cause of the presenting complaint is..... However important differentials to consider would include..... Summary This 23 year-old single, but sexually active, women complains of a short history of vaginal bleeding mixed with a general discharge which is offensive to smell. She has engaged in unprotective sex of late. There are no other positive findings from the history. The differential diagnosis is between, cervical cancer, cervical polyps and PID, the latter of which I think is by far the most likely. ACE Tips Cervical cancer is more common in smokers, those with a history of STIs, early first coitus and multi-parous state. Use this as a clue when taking the history from a patient, but be
74

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

careful when asking about sexual history to obtain information in a non judgemental manner. Forgetting to ask about the last smear and its results are unforgivable in a station of this nature. Do not forget!! Remember to enquire about sexual activity. If a patient has never been sexually active, certain diagnoses e.g. PID can be discounted from differentials.

Marking Sheet: Vaginal Bleeding


Not attempted 1 2 3 4 5 6 7 8 8 9 10 11 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem at the pain sees it Enquires in the nature of the patients alcohol use Establishes accurately the units consumed per day Assesses for features of alcohol dependency Asks the CAGE questionnaire (1-3 parts = 1 mark, all 4 components for 2 marks) Past Medical History (especially admissions due to alcohol misuse and any suicide attempts) Asks if previously sought help to stop drinking Family History (including dependents and who is caring for these) Social and Drug History (any illicit drug use and stressors must be asked for 2 marks) Concerns and Ideas of patient considered Presentation and Summary 0 0 0 0 0 0 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 1 1 1 1 1 1 Attempted adequate 2 2 2 2 2 2 2 2 2 2 2 2

12 13

0 0

1 1

2 2

Ace the OSCE


BMA Prize Winning OSCE Video Series Learn exam technique quickly & easily Real patients with real signs Money Back Guarantee you PASS! 10% discount with promo code AOSCE2 Subscribe today at AceMedicine.com

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

75

23) Vaginal Discharge Instructions given by examiner to candidate: You are a junior doctor working in a GP surgery. Mrs Patterson, a young female presents with vaginal discharge. Please take an appropriate history from her and summarise your findings at the end with likely differential diagnoses. Information provided to Patient for History Dialogue with Candidate You are a Molly, a 27 year old estate agent. You are single and have only had one boyfriend a few years back, and this was never a sexual relationship. You are in fact a virgin, albeit rather embarrassed to confess this. This is one reason you are very concerned and surprised to have been suffering from a white vaginal discharge for the past 3 weeks. It is really itchy, which is why you have come to the doctor as it is unbearable. You only wish to speak with a female doctor. You deny all questions regarding it being sexual as you have never been sexually active. You know this is not the usual discharge as this is new. It is fairly un-offensive to smell. You have a regular 28 day cycle. You have no medical history aside from migraine, which you dont take regular medications for. Only when the doctor asks have you noticed anything else unusual? do you mention you have lost 8kg unintentionally in the last month and feel thirsty all the time. Time Allowed: 6 minutes Common differentials Vaginal thrush (candida) Bacterial vaginosis Physiological discharge STI especially gonorrhoea, Chlamydia, trichomonas Endometrial malignancy Cervical polyps

Features of the history associated with common differentials Vaginal thrush: Associated symptoms include vulval/ vaginal redness, itching and soreness. The discharge itself is often white in colour. Look out for risk factors e.g. antibiotic use, diabetes, OCP, pregnancy or immunodeficiency. Bacterial vaginosis: The discharge is described as fishy smelling. Unlike thrush there is no itching or vulval soreness. Physiological discharge: This diagnosis is more likely if the discharge is not offensive smelling and no associated itching or soreness. Physiological discharge is clear most of the time and closer to menstruation it becomes thicker and may increase in quantity. STI especially gonorrhoea, Chlamydia, trichomonas: Sexual history should allude to opportunity to have acquired an STI (if the patient has never been sexually active then an STI is impossible!). Other symptoms include dysuria, pelvic pain (if PID) and fever. In many cases there are no symptoms. Endometrial malignancy: Cervical Polyps:

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

76

Introduce Check name, age, occupation and relationship status.

Permission Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK? If a male doctor, you may wish to specifically ask if the patient is happy to speak with you or would prefer a consultation with a female doctor.

Presenting complaint Why have you come here today?

History of presenting complaint Open question: tell me a bit more about it and then allow the patient to talk. Specifically ask about: o Onset, duration, quantity, odour, colour and variation with menstrual cycle. o Associated symptoms e.g. abdominal/ pelvic pain, discharge, fever, mucus, dyspareunia and bleeding intermenstrually. o Is there any blood with the discharge? o Has this happened before? o Do you normally have a discharge and if so is this different from normal? o Sexual history (especially the number of recent sexual partners and any unprotected sex) o Gynaecological/ obstetric history o Menstrual history o Vaginal or abdominal trauma

Ideas, Concerns and expectations Do you have any idea what is causing your symptoms, or any concerns about it? Past Medical History Ask about: previous STIs, thrush, Abnormal smears, cervical/vaginal cancer Diabetes and immunodeficiency Drug History Anything they have recently started or stopped taking, especially the pill, antibiotics and steroids. Anything including over the counter remedies. Drug allergies Family History Ask about: cancers, menstrual abnormalities, abnormal smears, diabetes. Social History Smoking, alcohol, recreational drugs and diet. Systems review General overview of all systems especially GU and endocrine.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

77

Present case to patient (and examiner) Summarise findings and finish with the most likely cause of the presenting complaint is..... However important differentials to consider would include..... Summary Molly is a 27 year old single female with no past sexual history. She has a short history of a white, relatively odourless persistent vaginal discharge accompanied by itch. Her menstrual, sexual and medication history are normal. She does however on probing have a short history of weight loss and thirst. I am very suspicious that the discharge is related to thrush and have concerns over the possibility of this being due to undiagnosed diabetes mellitus for which I would like to test. ACE Tips The commonest cause of vaginal discharge is thrush. Remember that thrush is often not sexually transmitted as it is likely the patient will ask this question during the station. Always check the blood glucose of those presenting with thrush as it may be the presenting complaint for a newly diagnosed diabetic Gonorrhoea can affect any surface lined with columnar epithelium e.g. rectum, pharynx, conjunctiva, cervix and urethra. Remember some STIs are asymptomatic in one sex, but not so in the opposite sex, so a patient may be surprised if his/her sexual partner has no complaints.

Marking Sheet: Vaginal Discharge History


Not attempted 1 2 3 4 5 6 7 8 9 10 11 12 13 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and relationship status of patient Open question to commence history establishing initial details of problem Enquires in depth in about nature of the discharge (1 mark if 1-3 details and 2 marks for 4 or more) Enquires into other additional symptoms, Sexual History (1 mark for 1-3 details and 2 marks for 4 or more) Past Medical History Family History Social and Drug History Concerns and Ideas of patient considered Presentation and Summary Differential Diagnoses Provided 0 0 0 0 0 0 0 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 1 1 1 1 1 1 1 Attempted adequate 2 2 2 2 2 2 2 2 2 2 2 2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

78

24) 24 Hour Urine collection Instructions given by examiner to candidate: You are a junior doctor working in renal outpatients. Mr Collier, a middle aged male presents to you after coming in to pick up his container for a 24 hour urine collection arranged by his endocrinologist who is not in clinic today. Mr Collier has told nursing staff he has no idea what he is meant to do with the bottle and nursing staff have asked you to kindly see him. Please explain the nature of the test and answer any questions he may have.

Information provided to Patient for History Dialogue with Candidate You are a 49 year-old man and have come to collect a container, which is something to do with urine. You were told about it by the doctor at the clinic but had other things on your mind and do not remember a thing about what you were instructed. You ask to speak with the doctor to tell you about it. You listen carefully and by the end understand you have to pee in a pot for a day and bring it back. You ask what are you trying to find out and when will you know the result. You are also specific about where you are meant to return it to as it will be heavy. Introduction and rapport building Check name, age, occupation and marital status. Explain purpose and gain permission Explain who you are and why you are there e.g. I am a junior doctor at this clinic and I believe you want to know more about the 24 hour urine collection requested by us. Inform them you will slowly outline the information about a test they will be having done over the next 24 hours.

Ideas, concerns and expectations Explain why the procedure needs to be done e.g. Your symptoms suggest you may have a condition called Cushings disease, where the level of steroid hormones in your body are higher than normal. As these hormones are found in the urine we like to collect the urine and measure the amount of hormone in it. Explaining the procedure The test is called a 24 hour urine collection and as you said, its aim is to measure the levels of a hormone called cortisol in your urine. If it is over a certain figure then it suggests you may have a condition called Cushings disease. You will be given a large specimen container that holds 2 litres. This container has been pre-treated with a chemical so please dont empty or wash it out. It is more convenient to start the collection when you get up in the morning. The best thing to do is to pass urine into the toilet bowl normally the first time you empty your bladder that morning. From then onwards pass everything straight into the bottle. Also make sure you write down the time when you first emptied your bladder as the start time. Continue doing this until the same time the next day, then the test is over and you no longer need to collect anymore urine.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

79

What to do once the 24 hours are over: Bring it to our specimens department as soon as you can. Make sure you write your name and date of birth on the bottle and put the container along with the paper you have recorded the times on, into a large bag you will be given by the nurse before you leave today. Follow up: We will see you in outpatients within a week to discuss the results with you and decide how to proceed with your management from there. Side effects: There are no side effects or anything like that to worry about. The only thing I should tell you is that because the bottle has been chemically pre-treated make sure if at any point you spill the contents of the container that you wipe or wash the area it has spilled onto very thoroughly with water only. Also take care to ensure the lid is tightly screwed on when the container has been filled.

Any questions? Checking understanding/ summary Can I ask you to tell me what youve understood about how to do the urine collection? Leaflet Thank you and goodbye. ACE Tips 24 hour urine collection may be performed to calculate the creatinine clearance, estimate protein excretion, or to measure the excretion of free cortisol or steroid metabolites in patients with suspected adrenal disease. Explaining the procedure is a lengthy process. In most cases the patient will lead the explanation by asking questions. Allow the patient to do this rather than giving a long uninterrupted explanation. If you allow the patient to lead the explanation you are more likely to cover all the points on the examiners mark sheet as the patients questions will be structured around this. Emphasise the need to bring the container promptly back to the hospital once the 24 hours is complete

Ace Medicine Revision Courses


Ace the 3rd Year OSCE Course Ace the 3rd Year Written Exams Course Ace the 4th Year Specialties Course Ace the Written Finals Course

100% MONEY BACK GUARANTEE you pass your Exams LEARN most topics likely to come up in your exams within HOURS, SAVE yourself WEEKS of revision time! visit www.AceMedicine.com for details and bookings

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

80

25) Hip Replacement Surgery Instructions given by examiner to candidate: You are a junior doctor working on a surgical ward. Mrs Timpson has been admitted for a hip replacement tomorrow morning. Please explain the procedure to her and answer any questions she may have.

Information provided to Patient for History Dialogue with Candidate You are a 66 year-old former playground attendant who has been having hip problems for years and are now having it replaced tomorrow. Three of your friends have already had it done and the outcome has been superb so you are looking forward to the operation, albeit a little anxious about being put to sleep. You only concern is how quickly you will be mobile again as your husband can be needy at times. You are keen to learn what the hip replacement looks like and how long the surgery takes to perform. Introduction and rapport building Check name, age, occupation and marital status. Explain purpose and gain permission Explain who you are and why you are there e.g. I am a junior doctor on this ward and I would like to talk to you about your operation tomorrow, is that OK? Establish understanding about why the consultation is taking place Do you understand what we plan to do for you tomorrow at surgery? If they do not know why they are there, inform them that it is to get information about an operation they will be having on their hip.

Ideas concerns and expectation Do you have any concerns about your symptoms, the procedure or the post operative period?.

Check understanding of what the procedure is. Do you understand why you need this procedure? And how much do you know about how a hip replacement is done? Explaining the procedure The hip joint is a ball and socket joint and we will be replacing the ball part with a metal ball with a stem coming out of it, and the socket part with a piece of metal shaped like a shallow cup. Most patients who receive a hip replacement say it benefits them because it relieves their hip pain and improves the function of the hip and the ease with which they can move around. Pre-procedure You will not be allowed to eat anything 6 hours before the surgery and should only drink small sips of water up to 2 hours before the surgery. This ensures your stomach is empty and reduces the risk of you accidentally bringing up any food when you are having the surgery, as it will be done under a general anaesthetic.
Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com 81

Peri-procedure The surgery takes about 2 hours. The surgeon will remove the existing hip joint then fit in the artificial joint. After the operation is finished, you will be moved to a recovery room where you will be monitored until the anaesthetic wears off. You will then return to the ward. Post procedure Overall hospital stay is usually 3 to 4 days to ensure adequate recovery to manage at home. The physiotherapists will teach you some hip strengthening exercises which you should practice at home. These will help you get moving around quicker. You will be given a stick to walk with so you feel supported as you start to walk around. We encourage mobilization within a few days of the surgery, but take things slowly and avoid driving and strenuous exercise, heavy lifting and kneeling down for 6 weeks. Lifetime avoidance of extreme sports like skiing or horse riding is advised. Pain will be present for up to 2 weeks and it can take up to 4 months to get back to normal functioning. You will be provided with pain killers on discharge. Side effects Hip replacement is major surgery, but it is also done routinely worldwide and our surgeons are very skilled in this area so complications are unlikely. However, complications that can arise include o infection o blood clots in the leg For most patients over 70 years of age, only one hip surgery is needed in their lifetime. In 10% of cases a revision surgery is needed 10-15 years later. Any questions ? Check understanding and summary Can I ask you to tell me what youve understood about the hip replacement? Offer leaflet Thank you and goodbye

ACE Tips Familiarize yourself with common operations such as hip replacements. If you have a brief overview of what the operation involves you will be able to apply the guidelines given here to any operation that may come up during the OSCE. Pay attention to the patients age as this will determine their likelihood of needing a further hip replacement later in life. The general rule is that if the patient is over 75, it is likely that this hip replacement will be the only one they have in their lifetime.

It can be helpful to make a little sketch or if models are available demonstrate using this to show the patient how the hip is replaced
82

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

Marking Sheet: Hip Replacement Surgery


Not attempted 1 2 3 4 5 6 7 8 9 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem Enquires in depth in about nature of the abdominal pain Enquires into other additional symptoms, in altered bowel habit Asks regarding severity of pain in an objective fasion (scale 1 -10) Past Medical History (especially surgery) Family History (For 2 marks must include specific enquiry on GIT pathology) Social and Drug History (alcohol and OTC drugs must be specifically questioned for 2 marks) Concerns and Ideas of patient considered Presentation and Summary Differential Diagnoses Provided 0 0 0 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 1 1 1 2 2 Attempted adequate 2 2 2 2 2 2

10

11 12 13

0 0 0

1 1 1

2 2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

83

26) Hernia Repair Instructions given by examiner to candidate: You are a junior doctor working on a surgical ward. Mr Gander has been admitted for a hernia repair tomorrow morning. Please explain the procedure to him and answer any questions he may have.

Information provided to Patient for History Dialogue with Candidate You are a 27 year-old single IT analyst, your life of which revolves around sport and socialising. Two months back after a triathlon, you noticed a small lump in your groin with nagging pain. This continued, in fact the lump became larger, to the point sport became impossible. This has caused you much distress and inconvenience and you simply cant wait to get it fixed so you can resume your normal life activities. You have read about the surgery extensively and spoken with you old school friend, who is a surgeon, about what it entails. You impress upon the doctor your chief question is when you can safely return to running, swimming and cycling. You realise it will be keyhole and you have to stay overnight in hospital. Introduction and rapport building Check name, age, occupation and marital status. Explain purpose and gain permission Explain who you are and why you are there e.g. I am a junior doctor on this ward and I would like to talk to you about your operation, is that OK? Establish understanding about why the consultation is taking place Do you know why you were asked to come in today? If they do not know why they are there, inform them that it is to get information about an operation they will be having tomorrow to repair the hernia they have in the groin.

Ideas concerns and expectation Do you have any concernsabout the hernia or the procedure?

Check understanding of what the procedure is. What do you understand by a hernia? And how much do you know about how a hernia repair is done? Explaining the procedure The hernia repair will be done under general anaesthetic which means you cannot eat from midnight onwards to ensure your stomach is empty during the operation and you cannot drink anything 2 hours before the operation. You will be unconscious for the operation which will last up to 45 minutes. It will be performed laproscopically which means that instead of having a big cut in your groin, a camera will be put in via a tube in your belly button and the operation will be done via the belly button which means you wont have a scar where the hernia was.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

84

The bit of bowel that is protruding through your abdominal muscles and into the groin, will be pulled back to where it is meant to be, and a small square of mesh will be placed between the bowel and muscle wall to prevent the hernia from recurring. You dont have to worry about the mesh, it is completely sterile, inert and you wont be able to feel it at all.

Aftercare Because you have had a general anaesthetic, we like our patients to stay overnight for monitoring then you can go home the next morning. Straight after the surgery, you will go to the recovery room for the anaesthetic to wear off before coming back up to the ward. Once you do go home, we advise you take it easy for 14 days. That means no driving and no going to work. Avoid strenuous exercise, including heavy lifting, for up to 6 weeks. Because the operation will be done laproscopically there are no stitches as such to remove. We will see you at a surgical outpatients review clinic 4 weeks later. If you have any problems in the interim please ring the ward. Side effects and risks It is a very common procedure done routinely all over the UK and is very safe. With all operations there is a risk of infection or bleeding, but this is very rare. Hernia recurrence. Any questions? Check understanding and summary Can I ask you to tell me what youve understood about the hernia repair? Offer leaflet Thank you and goodbye

ACE Tips Take care when reading the instructions for the station. Although most hernia repairs are done laproscopically, they can also be performed via the traditional open technique. Do not make the mistake of giving instructions for the wrong type of hernia repair. It is helpful to make use of any paper available at the station when explaining what a hernia is and how the repair is performed. Drawing a sketch is likely to provide a clearer picture in the patients mind and save time compared to a convoluted verbal explanation.

This kind of station is all about you non-verbal communication and bedside manner so be measured, open and approachable to the patient.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

85

Marking Sheet: Hernia Surgery Station


Not attempted 1 2 3 4 5 6 7 8 9 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem Enquires in depth in about nature of the abdominal pain Enquires into other additional symptoms, in altered bowel habit Asks regarding severity of pain in an objective fasion (scale 1 -10) Past Medical History (especially surgery) Family History (For 2 marks must include specific enquiry on GIT pathology) Social and Drug History (alcohol and OTC drugs must be specifically questioned for 2 marks) Concerns and Ideas of patient considered Presentation and Summary Differential Diagnoses Provided 0 0 0 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 1 1 1 2 2 Attempted adequate 2 2 2 2 2 2

10

11 12 13

0 0 0

1 1 1

2 2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

86

27)

Warfarin therapy

Instructions given by examiner to candidate You are a junior doctor working on a general medical ward. This 54 year old lady was

admitted with a DVT last week and is now ready for discharge after being adequately treated with low molecular weight heparin. She is going home with a warfarin prescription which she will take for the next 6 months. Please explain the new treatment she is starting and answer questions she may have.
Time Allowed: 8 minutes Information provided to Examiner for History Dialogue with Candidate Please use the information below to use in a role play scenario with a colleague (the student) with you as both the patient and examiner. You are a 54 year-old female Jane Wilson, with no past medical history until this admission with a DVT. You are married and work as a clerk at a local solicitors. You quiety absorb the information outlined to you by the doctor regarding the commencement of warfarin therapy, but during the course of the examination enquiry about the following: I heard it is rat poison will it be safe for me to take? I hope it will make by clot disappear. Can I still drink wine? How often do I need to get my blood checked? Common Things to Consider in The Consultation The patient may be any educational level adapt to individuals In the elderly you may wish to speak to the patient with a relative to ensure the information is successfully delivered and understood. Always summarise at the end with an open offer to ask any further questions Offer a contact point (number of person) if the patient has queries once they go home Compliance warfarin is required for several months so this is important to secure History Dialogue Introduction and rapport building Check name, age, occupation and marital status. Explain purpose and gain permission Explain who you are and why you are there e.g. I am a junior doctor on the team looking after you and I would like to talk to you about your health, is that OK?

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

87

Establish understanding about why the consultation is taking place Do you know why you I have come to see you today? If they do not know why they are there, inform them that it is to discuss management of their DVT at home. Briefly establish what their management has been so far and how symptoms have responded/ how they are feeling now.

Ideas concerns and expectation The drug we are sending you home on is one youve already taken 3 days doses of so far. Its called warfarin. Do you have any knowledge of warfarin or any concerns or expectations from using it?

Check understanding of proposed treatment How much do you know about how warfarin is used in managing DVT? If they have minimal understanding, explain that the tablet thins the blood and that by doing this it helps to stop the clot from re-forming and ensure the clot that was there is fully dissolved so to speak It is likely the patient will mention the use of warfarin in rat poison. If they do, be sure to emphasise that it is effective as a rat poison as it thins the rats blood to fatal levels. However in humans, small doses of warfarin are used to ensure he blood in NOT thinned to a fatal level. In addition, INR is measured to ensure the blood doesnt get too thin.

Check suitability for treatment history of strokes, stomach ulcers, high blood pressure or bleeding from any site such as coughing up blood or passing blood in urine or stools, pregnancy or future plans of getting pregnant. Inform of teratogenicity of warfarin and need to see GP if wanting to get pregnant or suspect they have become pregnant whilst on warfarin. Alcohol, smoking and drug history. Be sure to advise to minimise alcohol intake to about one drink daily maximum because alcohol can increase the effectiveness of warfarin as well as increase the chance of bleeding from stomach ulcers. Explaining treatment- how and when to take it Taken as a tablet once daily. Take it at the same time every day, if a dose is missed take as soon as you remember. If its been more than one day, just take the next days dose, dont double up doses. There are many drugs which can interact with warfarin so it is best to ask GP or pharmacist about interactions between warfarin and any new drugs started in the future whilst on warfarin. This also goes for over the counter medicines. Side effects The main side effects that may or may not happen are: Hair thinning, skin rashes and stomach complaints like nausea, vomiting or diarrhoea. Inform patient to go to GP or getting in with the hospital ASAP if you prolonged bleeding from any cuts or blood in your urine, stools or vomit is noticed as this is a likely sign the warfarin dose is too high.
Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com 88

Follow up Treatment for DVTs for 6 months. As the dose needed to achieve the right thinness of blood varies with each person, we need to ask you to have several blood tests to keep an eye on this. Since your INR is at the right level at the moment, we will check it again every other day for the first week, then weekly for the next 3 weeks, then monthly after that until treatment is finished. You can have the blood tests done at your GP but we will also invite you to our outpatient clinic every couple of weeks initially to make sure everything is going fine. Importance of yellow card and bracelet Here is a little yellow book in which we will record your INRs in every time your blood is tested, so please take it with you to the GP and to your outpatient appointments. We can also give you a medic alert bracelet which state you are taking warfarin. This is important if you need emergency treatment for any reason, as it will let the medical professionals know you are taking warfarin so they can adjust their treatment accordingly. Any questions? Check understanding and summary Can I ask you to tell me what youve understood about what we have discussed today? Offer leaflet Thank you and goodbye Summary Just to summarise Jane. You are aware of the need to commence treatment with warfarin for a period of 6 months to treat your DVT. It is safe in medicinal doses, despite people being aware of its use as rat poison and part of this includes frequent INR blood tests, usually every 3 weeks. Alcohol is not usually recommended with warfarin, but the occasional single small glass of wine should be tolerable. The yellow card system will enable you to monitor your INR. ACE Tips Try to remember to mention the yellow card and the medic alert bracelet. Points like this set the ordinary students aside from the excellent students as it shows you have specific knowledge of management strategies for patients on warfarin. Be prepared for the inevitable but if it kills rats, wont it be dangerous for me to take comment. Remember to emphasise that the mechanism by which it kills rats is the same mechanism by which it treats a DVT, but in a lower dose so the response is less dramatic. Have a few side effects memorised for warfarin (and any commonly used drug in a hospital setting). There is no need to remember all of them, but do mention the very

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

89

important side effects like bleeding (and the need to come straight to A&E if it happens). Try to get the patient to fix the time that take it with part of their routine, like when they have their bedtime drink or the like.

Marking Sheet: Explaining Warfarin Therapy


Not attempted 1 2 3 4 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial understanding of what warfarin is Explains treatment (0=none, 1 = 2-3 factors, 2 = 4 or more factors) Explains side effects (eg, nausea, bleeding, rash) (0=none, 1 = 2-3 factors, 2 = 4 or more factors) Checks suitability for use of warfarin Explains the need and nature of follow up blood tests Explains yellow card and bracelet system Allows patient to raise concerns and questions Summary Rapport with patient Thank the patient 0 0 0 0 Attempted inadequate 1 1 1 1 Attempted adequate 2 2 2 2

5 6 7 8 9 10 11 12 13

0 0 0 0 0 0 0 0 0

1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

90

28) Endoscopy Instructions given by examiner to candidate: You are a junior doctor working in upper GI clinic. Mrs Townsend is a middle aged female who will be coming in for an OGD next week to investigate a 6 month history of dyspepsia. Please explain the procedure to her and answer any questions she may have.

Information provided to Patient for History Dialogue with Candidate You are a 46 year-old housewife, mother of 3, and are attending for an OGD next week, after having acid problems for the last 6 months, which are not responding to medications from you GP. You understand it involves swallowing a hosepipe, which you are a little anxious about, but know you need to have the test done. Your husband has told you to chill out it will be nothing, but it not him having the test done. You really who like to have sedation before the OGD. You enquire about how long it will take and if you will need a lift home later as your husband does shift work. When asked to explain to the doctor what you have understood, you ask for clarification about the throat spray as you have forgotten the details. Time Allowed: 6 minutes Introduction and rapport building Check name, age, occupation and marital status. Explain purpose and gain permission Explain who you are and why you are there e.g. I am a junior doctor at this clinic and I would like to talk to you about your health, is that OK? Establish understanding about why the consultation is taking place Do you know why you were asked to come in today and what it entails? If they do not know why they are there, inform them that it is to get information about a test they will be having done next week to investigate the cause of the indigestion symptoms that they have been experiencing. Let the patient tell you what they understand before giving your own information.

Ideas, concerns and expectations Do you have any ideas or concerns about the cause of your symptoms? Check understanding of what the procedure is. And how much do you know about how the test is done? Explaining the procedure The test is called an OGD which stands for oesophogastroduodenoscopy- a bit of a mouthful hence the shortened version OGD! It involves looking into the gullet and stomach using a small plastic tube about the same width as a pencil. It has a camera and light built into the end of the tube and this allows us to see inside as the tube is passed down. The whole thing usually takes less than 10 minutes

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

91

Pre-procedure You will be awake but youll be given a numbing throat spray before the tube is passed, and this minimises the discomfort. In addition, you will also be given a mild sedative (if you choose) before the procedure so that although you are awake, you will feel very relaxed during the procedure. After the procedure you will remember very little about what happened.You need to remember to avoid eating or drinking 6 hours before the endoscopy. This is to ensure your stomach is empty as when someone is sedated they are less able to protect their airway and this increases the chance of food from the stomach being brought up and accidentally inhaled during the procedure. We also need the stomach to be empty to have an accurate look. Peri-procedure During the procedure you will be lay on a bed and a mouth guard will be placed in your mouth to keep it open. The tube called an endoscope will be passed through this mouth guard and gently eased down the throat and into your airways. When you feel the tube at the back of your mouth try to swallow it and avoid gagging if at all possible. We may need to take a small sample of tissue called a biopsy and this will be done via small forceps down the endoscope. When we are finished, you will be taken to the recovery area to rest and allow the sedation to wear off. Post procedure Once the sedation wears off, usually within 2 or so hours, you will be able to go home. Now although the sedation will have worn off, you will still be unsteady on your feet so we ask that you have someone else drive you home and avoid operating heavy machinery, driving or drinking alcohol for 24 hours following the end of the OGD. We also suggest you take the rest of the day off work. You should be fine to go to work the next day. Results Inform the patient how and when they will get their results. Usually the doctor will tell them the results after the endoscopy and they may need a follow up out-patient appointment if a biopsy was taken or if something was discovered during the endoscopy that needs treatment.

Side effects and risks Bleeding, infection or perforation of the gullet or stomach (very very uncommon). Inform patient to keep an eye out for fever, vomiting blood or coffee ground particles, or severe abdominal pain. If so they must come back to A&E to be seen by a doctor and check that no problems have arisen. Keep in mind that you may cough up a little bit of blood or have a sore throat, but that will be normal and due to the tube scratching your throat as it was passed down. Any questions ? Check understanding and summary Can I ask you to tell me what youve understood about the procedure you will be having next week? Offer leaflet Thank you and goodbye

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

92

ACE Tips Some patient will be unaware of the actions of a sedative and be anxious that they are going to be awake during the procedure. Be sure to pick up on any facial expressions given by the patient when you mention that the procedure will not be under general anaesthetic. If the patient looks anxious and perhaps unwilling to have the endoscopy, try another tact like explaining lots of people are surprised afterwards it not as bad as they expected Try to show the patient with something you have to hand like a pen, what the width of the endoscope is like to give them a practical idea.

Marking Sheet: Endoscopy


Not attempted 1 2 3 4 5 6 7 8 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem Enquires in depth in about nature of the abdominal pain Enquires into other additional symptoms, in altered bowel habit Asks regarding severity of pain in an objective fasion (scale 1 -10) Past Medical History (especially surgery) Family History (For 2 marks must include specific enquiry on GIT pathology) Social and Drug History (alcohol and OTC drugs must be specifically questioned for 2 marks) 11 Concerns and Ideas of patient considered 0 1 2 0 0 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 1 1 2 Attempted adequate 2 2 2 2 2 2

10

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

93

29) Colonoscopy Instructions given by examiner to candidate: You are a junior doctor working in colorectal clinic. Mrs Bleeker is an elderly female who will be coming in for a colonoscopy in 3 days time to investigate a 4 week history of bloody diarrhoea. Please explain the procedure to her and answer any questions she may have. Information provided to Patient for History Dialogue with Candidate You are Eileen Bleeker, a 79 year-old widower. You live alone, but are independent of daily needs. You are anxious about the forthcoming camera test and feel a little upset about it all when talking with the doctor. You ask how long it will take, will I be put asleep, when will I get the result and can I go home afterwards as you have a cat at home. You understand why you need to have it done and query how long before you have to fast and take the bowel cleaning liquid you heard from your friend it is not nice. Introduction and rapport building Check name, age, occupation and marital status. Explain purpose and gain permission Explain who you are and why you are there e.g. I am a junior doctor at this clinic and I would like to talk to you about your health, is that OK? Establish understanding about why the consultation is taking place So why have you come here today? /Do you know why you were asked to come in today? If they do not know why they are there, inform them that it is to get information about a test they will be having done next week to investigate the cause of the symptoms that they have been experiencing, e.g.

The aim of the test is to visualise the bowels to see if there is anything within them that could explain the change in bowel habits and the bleeding. Many things can cause bloody diarrhoea so doing a test like this helps narrow down the possible causes.

Ideas, concerns and expectations Do you have any ideas or concerns about the cause of your symptoms? Check understanding of what the procedure is. And how much do you know about how the test is done? Explaining the procedure The test is called a colonoscopy. It involves using a small plastic tube slightly wider than the width of a pencil. It has a camera and light built into the end of the tube and this allows us to see inside your bowels. The whole procedure takes about 30 minutes. Pre-procedure You will be awake but youll be given a mild sedative before the procedure so that although you are awake, you will feel very relaxed during the procedure and after the procedure you will remember very little about what happened.
Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com 94

The colon needs to be empty before the test so we can get a good view of the walls of the bowels. To do this you will be put on a special diet. Since your colonscopy is in 3 days, you should start eating light foods only, avoiding meats. 1 day before the test you should eat no solid foods and drink clear fluids only. You will be given some sachets of laxatives to have on that day and these can be quite powerful so stay close to a toilet. Can I give you this leaflet which details exactly how and when to take the laxatives. In brief you will take one sachet at around 2pm the day before the colonoscopy, then half of another sachet at around 7pm. On the day of the colonoscopy, you will take the other half sachet at around 6am. Make sure to mix the sachet contents with a large glass of water.

Peri-procedure During the procedure you will be laid down on your side on a bed. The tube called an colonoscope will be passed via your anus and into your back passage. We may need to take a small sample of tissue called a biopsy and this will be done via small forceps down the colonoscope. We may need to blow some air into the bowels to get a better look at the area so you may feel this as a sensation of needing to pass wind but this is quite normal. When we are finished, you will be taken to recovery to rest and allow the sedation to wear off. It will take about 20 minutes. Post procedure Once the sedation wears off, usually within 2 or so hours, you will be able to go home. Now although the sedation will have worn off, you will still be unsteady on your feet so we ask that you have someone else drive you home and avoid operating heavy machinery, driving or drinking alcohol for 24 hours following the end of the colonoscopy. We also suggest you take the rest of the day off work. You should be fine to go to work the next day. Results Inform the patient how and when they will get their results. Usually the doctor will tell them the results after the colonoscopy and they may need a follow up out-patient appointment if a biopsy was taken or if something was discovered during the colonoscopy that needs treatment. This usually takes about a week.

Side effects and risks Bleeding, infection or perforation of the bowels. Inform patient to keep an eye out for a fever, bleeding more than normal from the back passage or severe abdominal pain. If so please come back to A&E to be seen by a doctor and check that no problems have arisen. Keep in mind that you may have some mild abdominal pain for a day or so, but that is fairly normal and usually due to the air that was blown into the bowels during the procedure. Any questions? Check understanding and summary Can I ask you to tell me what youve understood about the procedure you will be having next week? Offer leaflet Thank you and goodbye

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

95

Summary Just to summarise to you Mrs Bleeker. You understand that you will be coming in 3 days time for a camera study of the colon. You will need to take the bowel cleaning preparation and fast before the procedure and that it will take roughly 20 minutes and you will be given some sleepy medicine beforehand. You can go home a couple of hours later and you will receive the result in about a week when you return to clinic. ACE Tips Be sure to emphasise that mild abdominal pain post colonoscopy is normal but severe or persistent abdominal pain is not normal and requires immediate medical attention (in case of perforation). The explanation of bowel preparation given here is not the only type available. Some hospitals like to use enemas, some laxatives and others liquid only diets prior to a colonoscopy. It is not important to give a precise explanation of the bowel preparation, just be aware of the need to have some sort of bowel emptying before the procedure. Remember the most trivial aspect to you may be of great important to the patient, such as getting home to care for a pet or missing an important daily activity. It is often helpful with the elderly for them to be accompanied by a relative or friend when explaining a procedure and instructions.

Marking Sheet: Abdominal Pain History


Not attempted 1 2 3 4 5 6 7 8 9 10 11 12 13 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem Enquires in depth in about nature of the abdominal pain Enquires into other additional symptoms, in altered bowel habit Asks regarding severity of pain in an objective fasion (scale 1 -10) Past Medical History (especially surgery) Family History (For 2 marks must include specific enquiry on GIT pathology) Social and Drug History (alcohol and OTC drugs must be specifically questioned for 2 marks) Concerns and Ideas of patient considered Presentation and Summary Differential Diagnoses Provided 0 0 0 0 0 0 0 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 1 1 1 1 1 1 1 Attempted adequate 2 2 2 2 2 2

2 2 2 2 2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

96

30) Bronchoscopy Instructions given by examiner to candidate: You are a junior doctor working in chest clinic. Mr Newton is a middle aged male who will be coming in for a bronchoscopy next week to investigate a 2 week history of haemoptysis. Please explain the procedure to him and answer any questions he may have. Information provided to Patient for History Dialogue with Candidate You are a 55 year-old postman and know you are going to have a camera down your windpipe next week. You are not so much worried about the procedure itself, but more what they might find. You were scared with coughing up blood, and know it can be due to lung cancer. You have been smoking since you were 15 years of age. When asked about the test you accept the doctor is trying to tell you what it all entails, but would rather not know and keep replying, That is enough information and I will leave it in your capable hands. You politely listen to what is told to you and understand what it all means. At the end you ask how long it will be until I know the result, especially if you taken a biopsy sample. Time Allowed: 6 minutes Introduction and rapport building Check name, age, occupation and marital status. Explain purpose and gain permission Explain who you are and why you are there e.g. I am a junior doctor at this clinic and I would like to talk to you about your forthcoming procedure, is that OK? Establish understanding about why the consultation is taking place Do you know why you were asked to come in today? If they do not know why they are there, inform them that it is to get information about a test called a bronchoscopy that they will be having done next week to investigate the cause of the coughing up of blood that they have been experiencing.

Ideas, concerns and expectations Do you have any ideas or concerns about the cause of your symptoms? Check understanding of what the procedure is. And how much do you know about how the test is done? Explaining the procedure The test is called a bronchoscopy and it involves using a small plastic tube about the same width as a pencil to look into the airways in your lungs. It has a camera and light built into the end of the tube and this allows us to see inside your airways as the tube is passed down. The whole thing takes about 30 minutes. Pre-procedure You will be awake, but youll be given a numbing throat spray before the tube is passed, and this minimises the discomfort. In addition, you will also be given a mild sedative before the procedure so that although you are awake, you will feel very relaxed during the procedure. After the procedure you will remember very little about what happened. You
Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com 97

need to remember to avoid eating or drinking 6 hours before the bronchoscopy. This is to ensure your stomach is empty as when someone is sedated they are less able to protect their airway. We dont want food from the stomach being brought up and accidentally inhaled into the lungs during the procedure. Peri-procedure During the procedure you will be lay on a bed and a mouth guard (bit like a rugby player or boxers gum shield) will be placed in your mouth to keep it open. The tube, called a bronchoscope, will be passed through this mouth guard and gently eased down the throat and into your airways. We may need to take a small sample of tissue called a biopsy and this will be done via small forceps down the bronchoscope. When we are finished, you will be taken to the recovery room to rest, be monitored by our nurses and to allow the sedation to wear off. Post procedure Once the sedation wears off, usually within 2 or so hours, you will be able to go home. Although the sedation will have worn off, you will still be unsteady on your feet so we ask that you have someone else drive you home and avoid operating heavy machinery, driving or drinking alcohol for 24 hours following the end of the bronchoscopy. We also suggest you take the rest of the day off work. You should be fine to go to work the next day. Results Inform the patient how and when they will get their results. Usually the doctor will tell them the results after the bronchoscopy. You may need a follow up out-patient appointment if a biopsy was taken or if something was discovered during the bronchoscopy that needs treatment.

Side effects and risks Bleeding or infection of the airways. Inform patient to keep an eye out for a fever, coughing up lots of blood, or severe abdominal pain. If so they must come back to A&E to be seen by a doctor and check that no problems have arisen. Keep in mind that you may cough up a little bit of blood or have a sore throat, but that will be normal, due to the tube scratching your throat as it was passed down. Any questions? Check understanding and summary Can I ask you to tell me what youve understood about the procedure you will be having next week? Offer leaflet Thank you and goodbye ACE Tips The patient is likely to have anxieties about having a bronchoscopy and his/her symptoms in general. Be aware however that the aim of this station is not to explain the possible diagnosis associated with haemoptysis, even if the patient tries to lead you down this road.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

98

Be brief in explaining that there are many causes of haemoptysis and the aim of the bronchoscopy is to provide more information about the likely diagnosis. Be sure to ask if the patient has any questions several times during the consultation as well as allowing some time for the patient to interrupt you and ask questions. If you do so, it is likely that the patient will ask questions about aspects of the procedure you have forgotten to mention, but are on the examiners mark sheet. Pitch the language to the individual. You will be able to judge this after a short time engaging with the patient.

Marking Sheet: Bronchoscopy


Not attempted 1 2 3 4 5 6 7 8 9 10 11 12 13 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem Enquires in depth in about nature of the abdominal pain Enquires into other additional symptoms, in altered bowel habit Asks regarding severity of pain in an objective fasion (scale 1 -10) Past Medical History (especially surgery) Family History (For 2 marks must include specific enquiry on GIT pathology) Social and Drug History (alcohol and OTC drugs must be specifically questioned for 2 marks) Concerns and Ideas of patient considered Presentation and Summary Differential Diagnoses Provided 0 0 0 0 0 0 0 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 Attempted adequate 2 2 2 2 2 2

Ace the OSCE


BMA Prize Winning OSCE Video Series Learn exam technique quickly & easily Real patients with real signs Money Back Guarantee you PASS! 10% discount with promo code AOSCE2 Subscribe today at AceMedicine.com

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

99

31) MRI/ CT scan Instructions given by examiner to candidate: You are a junior doctor working on a general medicine ward. Mr Darson has been admitted with sudden onset back pain. Your consultant suspects a disc prolapse and has arranged an MRI for Mr Darson. Please explain the procedure to him and answer any questions he may have. Information provided to Patient for History Dialogue with Candidate Mr Darson is a 55 year-old investment banker, married with 5 children. He is a keen sportsman, so his admission with back pain has caused him much concern, and is anxious about being away from his work. You are also by your own admission not the best patient and have heard stories from colleagues about how noisy and claustrophobic it is in the MRI scanner. You are also aware that if the diagnosis is a disc prolapse this is likely to require surgery. You are happy with the explanation given by the doctor, but would like the report as soon as possible and ask if the scan can be stopped half way if you are unable to tolerate it. Introduction and rapport building Check name, age, occupation and marital status. Explain purpose and gain permission Explain who you are and why you are there e.g. I am a junior doctor on this ward and I would like to talk to you about your health, is that OK? Establish understanding about why the consultation is taking place So why have you come here today? /Do you know why you were asked to come in today? If they do not know why they are there, inform them that it is to get information about a test they will be having done to investigate the cause of the back pain they have been experiencing. Ideas concerns and expectation Do you have any concerns over the cause of your back pain?

Check understanding of what the procedure is. And how much do you know about how an MRI is done? Explaining the procedure An MRI is a type of test in which we can get pictures of inside the human body in detail. It stands for magnetic resonance imaging. It uses a magnetic field to create a picture but is in no way invasive. Pre-procedure Remove any ferromagnetic items you have on since the machine works with magnetic fields Put on a hospital gown. You can eat or drink whatever you like beforehand. It is also a very noisy machine so you will need to wear ear plugs before you enter the machine.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

100

Peri-procedure The machine is a large tube placed in a room. You will be placed into the tube by a technician and then the technician will leave you alone in the room and go into a room next door separated by a see through large window. You will be left in the tube for up to 30 minutes but if you want the test to stop at any time, just speak out and the technician will hear you through an intercom in the room. Post procedure/ results Once the MRI is finished, you will be brought back to the ward. Your results may then take several hours to come back as one of the radiology doctors will have to look at it and report back on the findings if any. Side effects/ risks Claustrophobia. If it gets unbearable just speak out and the technician will hear you and stop the test. Safety concerns are for people who have metal implants in their body such as pacemakers, metal fragments in the eyes, surgical clips or metal heart valves. Does this apply to you? May need contrast dye- check for diabetes and renal disease or previous allergy to the dye.

Any questions ? Check understanding and summary Can I ask you to tell me what youve understood about the MRI?

Summary So Mr Darson, I hope this has given you some insight into what having an MRI scan entails and will make the process easier for you. I think you have understood all aspects concerned and feel free to ask again before the scan if you have further concerns. Here is an information leaflet for you to read in your own time and to share with your family. Offer leaflet Thank you and goodbye ACE Tips Consider offering the patient a chance to visit the scanner in advance so familiarise themselves, especially if it will aid compliance Introduce the patient to another patient who had already had a scan who may be able to ally their concerns Offer to provide a patient information leaflet on the scan (usually available in radiology departments) so they can reflect in their own time. Explaining a CT scan takes the same format as that of the MRI explanation above. The main differences to mention are that with a CT scan: X-rays are used instead of a magnetic field The patient cannot eat or drink for 2-6 hours before the scan CTs are contraindicated in pregnancy

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

101

Marking Sheet: Having an MRI scan


Not attempted 1 2 3 4 5 6 7 8 9 10 11 12 13 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem Enquires in depth in about nature of the abdominal pain Enquires into other additional symptoms, in altered bowel habit Asks regarding severity of pain in an objective fasion (scale 1 -10) Past Medical History (especially surgery) Family History (For 2 marks must include specific enquiry on GIT pathology) Social and Drug History (alcohol and OTC drugs must be specifically questioned for 2 marks) Concerns and Ideas of patient considered Presentation and Summary Differential Diagnoses Provided 0 0 0 0 0 0 0 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 Attempted adequate 2 2 2 2 2 2

Ace Medicine Revision Courses


Ace the Ace the Ace the Ace the 3rd Year OSCE Course 3rd Year Written Exams Course 4th Year Specialties Course Written Finals Course

100% MONEY BACK GUARANTEE you pass your Exams LEARN most topics likely to come up in your exams within HOURS, SAVE yourself WEEKS of revision time! visit www.AceMedicine.com for details and bookings

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

102

32)

Discussing a TURP procedure with a patient

Instructions given by examiner to candidate: You are a junior doctor working on a surgical ward. Mr Davidson has been admitted for a transurethral resection of the prostate under spinal anaesthesia. Please explain the procedure to him and answer any questions he may have.

Information provided to Patient for History Dialogue with Candidate You are a 56 year-old small businessman and are attending for an operation on your prostate gland. You have done some reading about this on the internet and understand what roughly entails and the potential complications The two things you are unsure about are whether you will be put to sleep for the operation or just have your back numbed and the potential complication of impotence and infertility. The latter is a major concern as you have a much younger thai wife and you would like to have a family with her. You read the impotence rate can be as high as 40%. Is this true? At the end of the consultation you are happen you have understood everything but ask for a contact number for after hospital discharge for if you have concerns to discuss. Time Allocated: 6 Minutes Introduction and rapport building Check name, age, occupation and marital status. Explain purpose and gain permission Explain who you are and why you are there e.g. I am a junior doctor on this ward and I would like to talk to you about your operation, is that OK? Establish understanding about why the consultation is taking place Do you know why you were asked to come in today and do you have any idea what the operation entails? If they do not know why they are there, inform them that it is to get information about an operation they will be having on their prostate gland.

Ideas concerns and expectation Do you have any concerns about your symptoms or the procedure?

Check understanding of what the procedure is. Do you understand why you need this procedure? And how much do you know about how a TURP is done? Explaining the procedure Its called a TURP which stands for transurethral resection of the prostate. It involves the removal of some of the enlarged prostate gland so that urine can flow more freely. The prostate lies at the neck of the bladder and the tube bringing urine to the outside runs through it. It will be done under what we call a spinal anaesthetic which means that you will be awake during the surgery, but feel nothing in your bottom half of the body as an anaesthetic will be injected into a space around your spinal cord via a small plastic tube. The
103

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

good news is that this means you get to go home sooner as you dont have the after effects of having a general anaesthetic to get over before you leave. You wont be able to eat anything for six hours before the operation or drink for 2 hours before. This is done in case for some reason we have to use a general anaesthetic and need to make sure your stomach is empty so you dont accidentally bring any food back up and accidentally inhale it whilst you are asleep. During the operation a thin, tube-like telescope is inserted through your penis and into your urethra. An electric current is used to remove some of the prostate gland and relieve the obstruction. Your bladder will also get flushed with a sterile solution to remove the fragments of removed prostate tissue. A catheter is then inserted through your urethra and into your bladder so urine can empty automatically from the bladder, giving you time to recover before you start urinating as normal. The whole operation can last up to an hour. You will then go into a recovery room where the anaesthetic will wear off, then you will return back to the ward. After the procedure Because we need to make sure you are passing urine satisfactorily after the operation and that there are no complications, you will have to stay in hospital for about 3 days before being discharged. You will have a catheter in your bladder for the first few days after surgery. This will be removed once we feel you are recovering well after the surgery and able to pass urine on your own. Side effects/ risks Haematuria: The most common side effect is passing blood when you urinate. This is fairly normal and should clear up after 2 weeks. Impotence: about 10% of men report problems sustaining an erection after the operation. Pain: It is likely that you will experience pain for a few weeks after the operation. We will give you painkillers to keep the pain to a minimum. Frequency: Some men also notice that they have to pass urine more frequently, but again this settles within up to 6 weeks. Infertility: You may notice cloudy looking urine as well. This is due to some semen entering the bladder on ejaculation. Post operative care Make sure you drink plenty of water to flush the remaining blood from the operation out of your bladder. You will feel sore with mild pain at the site and when you pass urine. If this pain becomes severe or you get a fever, please collect a sample of urine in one of the pots you will be given on discharge, and bring the sample to the laboratory here or to your GP to test for a urine infection. Please refrain from attempting to have sexual intercourse for 2-3 weeks, just to allow everything at the operation site to heal properly. Any questions ? Check understanding and summary Can I ask you to tell me what youve understood about the TURP? Offer leaflet
Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com 104

Thank you and goodbye ACE Tips It may be difficult to discuss all the possible risks and side effects in the allocated time. Be sure to mention haematuria, impotence and infertility as these are side effects which the patient may be unaware of and unwilling to risk happening (especially infertility). In conveying the potential post-operative problems, always make it clear to the patient that you/the team are available at any time to re-discuss any concerns. Pay attention to the instructions given at the start of the station. Many TURPs are done under spinal anaesthetic, but some are still done under general anaesthetic. Take care not to give the patient information about spinal anaesthetic if he is having a general.

Marking Sheet: Discussing a TURP procedure with a patient


Not attempted 1 2 3 4 5 6 7 8 8 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem at the pain sees it Enquires in the nature of the patients alcohol use Establishes accurately the units consumed per day Assesses for features of alcohol dependency Asks the CAGE questionnaire (1-3 parts = 1 mark, all 4 components for 2 marks) Past Medical History (especially admissions due to alcohol misuse and any suicide attempts) Asks if previously sought help to stop drinking Family History (including dependents and who is caring for these) Social and Drug History (any illicit drug use and stressors must be asked for 2 marks) Concerns and Ideas of patient considered Presentation and Summary 0 1 2 0 0 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 1 1 Attempted adequate 2 2 2 2 2 2 2 2

9 10 11

0 0 0

1 1 1

2 2 2

12 13

0 0

1 1

2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

105

33) Sexually Transmitted Disease


Tell somebody they have Chlamydia Instructions given by examiner to candidate: You are a junior doctor working in a GUM clinic. Miss Stone, a young female presents to you, following a test for Chlamydia 1 week ago. The test results are positive, please inform Miss Stone of her test results and provide counselling. Information provided to Patient for History Dialogue with Candidate You are a 25 year old medical secretary and have been with your current boyfriend for 6 months. Prior to this you had been single for 2 years. You have no children. You do not have multiple sexual partners. You had a chalmydia test one week ago after developing a persistent unpleasant smelling vaginal discharge. Your boyfriend is asymptomatic. When told the information by the doctor you initially cry at the thought of having an STI this is something you associate with other people who are promiscuous. This quickly turns to anger, at the thought your boyfriend is playing the field and you become even more incensed when told it can affect future fertility. You understand the treatment involved, but do not wish to do the contact tracing yourself, as right now you want to scream at your boyfriend. You take the information leaflet gracefully and thank the doctor. Time Allowed: 6 minutes Introduction and rapport building Check name, age, occupation and marital status. Explain purpose and gain permission Explain who you are and why you are there e.g. I am a junior doctor at this clinic and I would like to talk to you about your health, is that OK? Establish understanding about why the consultation is taking place Do you know why you were asked to come in today? If they do not know why they are there, inform them that it is to obtain results for a test they had during their last consultation. Be sure to check they know what the test is for.

Ideas, concerns and expectations Do you have any idea or concerns about what the results will be? Breaking the news/ giving the result Explain results clearly and slowly, giving the patient time to absorb the information. Well we do have your test results here and Im afraid they show that you do have Chlamydia, but were negative for any other sexually transmitted infections.

Explanation of diagnosis and treatment Has anyone explain to you what Chlamydia is and how it is treated?
106

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

Chlamydia is a type of bacteria that gets passed on from person to person by sex, not just vaginal, but also anal and oral, so can infect the throat and anus as well as the vagina. It can take several weeks before any symptoms are seen, and in women these symptoms can include vaginal discharge, tummy pain, bleeding after sex or between periods and pain on urinating. Have you experienced anything like this? Well the good news is that Chlamydia is easily treated using antibiotics, either a single dose of one antibiotic called azithromycin or you can take a different antibiotic called doxycycline for 1 week.We will call you back for another swab test after you finish the antibiotics, just to make sure the infection has been fully treated Outline to female patients that Chalmydia is an infection that can be associated with future fertility problems.

Contact tracing Inform the patient of the need to contact all sexual partners from at least the last 6 months so they can be tested. If patient does not want to do so, inform them that you are obliged to contact them and therefore will send letters to them all informing them that they need an STI screen, but not mentioning the name of the patient. Answer any questions Do you have any questions at all? Summary and checking understanding Ive given you a lot of information today which will have been a lot to take in. Is it ok if you recap what you understood from our discussion today, so I can check you have understood everything? Offer leaflet Give leaflet on Chlamydia, STIs and safe contraceptive practice in general. Inform patient that the only way to prevent STIs in the future is by using barrier contraception i.e. condoms. Thank you and goodbye Im very sorry I had this news for you today. Feel free to get in touch if you have any questions, otherwise Ill see you in just over a week for your repeat swab. ACE Tips Remember the importance of mentioning contact tracing as a means of controlling the spread of the infection in general society. You must remember to ask patient about contact tracing to show the examiner you are aware of the importance of it. Be aware of the Chlamydia screening programme as this may be asked about by the patient or the examiner. It involves free home based urine test kits distributed at GP surgeries, sexual health and family planning clinics as well as pharmacies. It targets 16-24 year olds as the highest rates of Chlamydia are in under 24 year olds. Be prepared to deal with patients who may be anything from upset to angry when given news of this nature. Aim to empathise and pacify, without being condescending.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

107

Marking Sheet: Explaining Diagnosis station Sexually Transmitted Disease


Not attempted 1 2 3 4 5 6 7 8 9 10 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial details of problem Enquires in depth in about nature of the abdominal pain Enquires into other additional symptoms, in altered bowel habit Asks regarding severity of pain in an objective fasion (scale 1 -10) Past Medical History (especially surgery) Family History (For 2 marks must include specific enquiry on GIT pathology) Social and Drug History (alcohol and OTC drugs must be specifically questioned for 2 marks) Concerns and Ideas of patient considered Presentation and Summary Differential Diagnoses Provided 0 0 0 0 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 1 1 1 1 2 2 2 Attempted adequate 2 2 2 2 2 2

11 12 13

0 0 0

1 1 1

2 2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

108

34) Treatment
Explain Steroid therapy Instructions given by examiner to candidate: You are a junior doctor working in a chest clinic. Miss Adams is a young woman with asthma uncontrolled by beclomethasone inhalers, therefore you have decided to start therapy with oral steroids. Please explain the new treatment she is starting and answer questions she may have. Information provided to Patient for History Dialogue with Candidate You are Ellisa, a 26 year-old single radiographer. When asked by the doctor you fully understand the necessity for a period on steroids and would like to have improved breathing as it is effecting your life. You have read about the complications like hypertension and acknowledge this when the doctor informs you. You are most concerned about gaining weight, the effects on your skin as you have a new boyfriend. You have also heard steroids make you grow facial hair like the athletes in the 1980s is this true? History Dialogue Introduction and rapport building Check name, age, occupation and marital status. Explain purpose and gain permission Explain who you are and why you are there e.g. I am a junior doctor at this clinic and I would like to talk to you about your health, is that OK? Establish understanding about why the consultation is taking place Do you know why you I have come to see you today? If they do not know why they are there, inform them that it is to discuss management of their asthma. Briefly establish what their management has been so far and how symptoms have responded.

Ideas concerns and expectation In situations such as yours the next step of treatment we would try is a steroid tablet. Do you have any knowledge of steroid tablets or any concerns or expectations from using them?

Check understanding of proposed treatment How much do you know about how steroid are good for managing asthma? If they have minimal understanding, explain that Steroids act as anti inflammatories and therefore reduce the inflammation in the airways that make the airways narrow and make it hard for you to get enough air into your lungs, which then leads to the breathlessness you experience with asthma. Check suitability for treatment Diabetes, hypertension, stomach ulcers, TB, osteoporosis, pregnancy, immunosuppression.
Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com 109

Alcohol, smoking and drug history

Explaining treatment- how and when to take it Prednisolone, taken as a tablet once daily. Dose is much lower dose than those given following an acute asthma attack. Not the same steroid as used by athletes. Take it at the same time every day, if a dose is missed take as soon as you remember. If its been more than one day, just take the next days dose, dont double up doses. Side effects The main side effects that may or may not happen are: Increased risk of infection, so take care to avoid people with chickenpox and contagious infections. Blood pressure is also at risk of increasing. Weight gain, especially around the tummy or face as well as make you want to eat more than normal. The skin which can become thinner and easier to bruise than usual. Inform of need to avoid NSAIDs and reduce/ avoid alcohol and smoking Follow up If breathing does not improve within a week of taking the steroids, go and see your GP. During treatment the patient is initially seen in outpatient clinic just to make sure the steroids are effective and to monitor symptom response. The length of time you will be on the steroids for depends on how well you respond to them. It could be months or years and if it is long term, we would look to doing a trial of bringing down the treatment to inhaled therapy in the future to see if they are now effective, rather than keeping you on steroids forever. Importance of steroid card and bracelet A steroid card and a medic alert bracelet must always be carried to inform others that you are on steroids. If emergency treatment is ever needed these 2 items inform medical staff of your steroid use and can treat you appropriately. Any questions ? Check understanding and summary Can I ask you to tell me what youve understood about what we have discussed today? Offer leaflet Thank you and goodbye Summary Just to check with you Ellisa, you understand that you will be starting oral steroids, hopefully for a short period, which do have significant complications such as hypertension and weight gain. With the small dose prescribed I expect the effect on your skin to be minimal. These steroids are different from anabolic steroids (previously used by atheletes) so hair grown is unlikely. If you have any concerns at any point you may contact me again.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

110

ACE Tips Do not forget to check the suitability of the patient for steroids. It is an unforgivable mistake to prescribe steroids for a patient without checking for hypertension, diabetes, pregnancy and immunosuppression. The important side effects to mention are weight gain, blood pressure and infections. Dont forget to give advice on avoiding NSAIDs and alcohol. Inform the patient of an increased susceptibility to infection when on steroids Patients often refer to their steroid inhaler as the preventer or brown inhaler.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

111

35) DVLA guidelines on Post-seizure driving (breaking bad news) Instructions given by examiner to candidate: You are a junior doctor working on a medical ward. Mr Thomas a young man was admitted following a third seizure. He has been diagnosed with epilepsy and has had this explained to him along with this his future management. His was about to be discharged and mentioned to a nurse that he was going to drive home. Please explain the driving guidelines for epilepsy patients and answer any questions he may have.

Please explain the new treatment she is starting and answer questions she may have.
Time Allowed: 6 minutes

Information provided to Examiner for History Dialogue with Candidate Please use the information below to use in a role play scenario with a colleague (the student) with you as both the patient and examiner.

You are a 27 year-old self employed electrician. You have now experienced your third seizure and following investigation epilepsy has been confirmed. You have just learnt your driving license will be removed for a minimum period of a year, and are very upset. You need to drive for your work and to take care of your young family. You are devastated and angry. Deep down inside you know it iss dangerous but you cannot imagine life without the freedom to drive. Eventually after some distress you comply with the doctors position and also understand the other activities you have to do differently for your own safety.
Common Things to Consider in The Consultation

Driving can be an individuals livelihood no license. No job. Removal of the driving license may impair an individuals independence Explain you are doing your job and it is for their and other drivers safety that license removed Do not respond to anger with anger. Stay calm and let the patient express his/her feelings
History Dialogue Introduction and rapport building Check name, age, occupation and marital status. Explain purpose and gain permission Explain who you are and why you are there e.g. I am a junior doctor on the team looking after you and I would like to talk to you about your health, is that OK? Establish understanding about why the consultation is taking place
Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com 112

Do you know why you I have come to see you today? If they do not know why they are there, inform them that it is to discuss their discharge.

Checking understanding of condition Remember there is no need to go over management with him.

Check understanding of impact of condition on everyday activities. Did anyone explain which activities would be affected by your epilepsy? Reiterate which activities he can and cannot do: NO DRIVING: The rules of the DVLA state that after a person has had an epileptic seizure whilst awake like yourself, they are banned from driving for 1 year from the day of the attack. If they remain seizure free for a whole year then their license is re-instated. Showers rather than baths Keep bathroom door unlocked No swimming unaccompanied and preferably in shallow water Avoid dangerous activities with risk of falling e.g. rock climbing

Be sure to emphasise that the driving ban is a total ban- no short trips anywhere. Be sure to emphasise that it is the patients responsibility to inform the DVLA and if he does not comply with this then you or his GP will have to tell the DVLA on his behalf. Follow up Well write to your GP and inform him of your recent admission and we will see you in our out-patient clinic in 2 weeks. Any questions? Leaflet Check understanding and summary Summary This 27 year old man has been diagnosed with epilepsy requiring a period of 1 year suspended from driving, which he understands but is upset about, particularly in view of his job and family being dependent on his ability to drive. You appreciate his concerns, empathise with the position, but confirm his necessity to inform the DVLA. He is also away of the other measures he needs to take to ensure the safety of himself and others in his daily life. Thank you and goodbye ACE Tips Be careful not to be charmed by the patient. No driving means no driving under any circumstances. If he alludes to the fact that he may use the car to pop to the shops be sure to emphasise that it is your responsibility to tell the DVLA if he is
113

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

posing a risk to others and you will do so if he fails to comply. Explaining the potential for an unexpected seizure to lead to his personal injury and others may help convey the message. Marking Sheet: Explain DVLA guidelines on Post-seizure driving
Not attempted 1 2 3 4 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial understanding of why you are speaking with them Explains the diagnosis of epilepsy and checks patients understanding of disease (0=none, 1 = 2-3 factors, 2 = 4 or more factors) Enquires regarding patients knowledge of how epilepsy will effect his/her activities (0=none, 1 = 2-3 factors, 2 = 4 or more factors) Explains need and why DVLA must be informed. Deals with the patients distress and concerns with empathy Explains other activities which need to be stop or changed (eg, shower not bath) Allows patient to raise concerns and questions Summary Rapport with patient Thank the patient 0 0 0 0 Attempted inadequate 1 1 1 1 Attempted adequate 2 2 2 2

5 6

0 0

1 1

2 2

7 8 9 10 11 12 13

0 0 0 0 0 0 0

1 1 1 1 1 1 1

2 2 2 2 2 2 2

Ace the OSCE


BMA Prize Winning OSCE Video Series Learn exam technique quickly & easily Real patients with real signs Money Back Guarantee you PASS! 10% discount with promo code AOSCE2 Subscribe today at AceMedicine.com

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

114

36) Compliance to Hypertensive (Negotiate Management) Instructions given by examiner to candidate: You are a junior doctor working in a GP surgery. Mr Jones a middle aged man was newly prescribed nifidepine for his high blood pressure. He has come to see you today. Please address his concerns and answer any questions he may have.

Information provided to Patient for History Dialogue with Candidate Jonny Jones is a 55 year-old married bricklayer who has recently commenced nifidepine for high blood pressure. He has been taking them for 4 weeks and does not see the benefit. He feels no different and infact has stopped taking them for the past 4 days. He actually feels worse in a nonspecific fashion. He knows that blood pressure problems can cause stroke and heart attacks, but he just doesnt like talking tablets. You are willing to try an alternative tablet and you heard a mate has one called atenolol. Can I try this doctor? You agree to try a new one, starting at a low dose and to return to the doctor in 2 weeks time. History Dialogue Introduction and rapport building Check name, age, occupation and marital status. Explain purpose and gain permission Explain who you are and why you are there e.g. I am a junior doctor at the surgery and I would like to talk to you about your health, is that OK? Establish agenda Why have you come here today? Briefly establish what their management has been so far and how symptoms have responded/ how they are feeling now. Clarify how long they have taken the tablets for and why they stopped taking them.

Checking understanding of management plan When you were given the tablets was the importance of taking them emphasised to you? Illustrate empathy when responding to the answer given and reasons for stopping the tablets. Compromising& checking level of motivation Explain that the patient does need some sort of management to prevent conditions such as stroke, heart failure or kidney failure from happening. Check if there are any other reasons for not complying with treatment- ask about different possible side effects. Ask about willingness to try an alternative tablet that doesnt cause the offending side effect. Checking contraindications Do you have diabetes, asthma, irregular heartbeat, kidney disease or gout? Check past medical history in general Check drug history
Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com 115

Explaining the new compromise Options include diuretics, beta blockers or ACEIs. Remember AB &CD rule! It is also an option to reduce the dose of the tablet they are on and see if the side effect reduces. Side effects Emphasise need to come back if new side effects but do not just stop the new tablets. Follow up Give patient appointment for 2 weeks time, to see how he is responding to the new tablets. Any questions? Check understanding and summary Can I ask you to tell me what youve understood about what we have discussed today? Offer leaflet Summary Mr Jones I understand you concerns over your new medicine, especially when you cannot feel the benefit. I must reassure you it is right to control your blood pressure for your long term health. I believe you understand the benefits and are willing to try a new medicine, atenolol, at a low dose and come back to me in 2 weeks for review. Thank you and goodbye

ACE Tips Erectile dysfunction is a side effect of anti-hypertensives, specifically beta blockers. Be aware that the patient may stop taking his medication for more embarrassing reasons but present to you with a different reason. Be sure to ask about the more embarrassing side effects even if the patient does not mention them. One of the commonest complaints from beta blockers is fatigue a real problem, especially if it has the knock on effect of discouraging exercise. Most patients are willing to compromise with gentle persuasion. Let the patient register their concerns first and treat each patient on individual merits and act accordingly

Ace Medicine Revision Courses


Ace the Ace the Ace the Ace the 3rd Year OSCE Course 3rd Year Written Exams Course 4th Year Specialties Course Written Finals Course

100% MONEY BACK GUARANTEE you pass your Exams LEARN most topics likely to come up in your exams within HOURS, SAVE yourself WEEKS of revision time! visit www.AceMedicine.com for details and bookings

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

116

37)

Diabetic wanting to fast during Ramadan.

Instructions given by examiner to candidate:

You are a junior doctor working in a diabetes outpatients clinic. Mrs Khan is a type 2 diabetic who has poor glycaemic control and has recently started gliclazide and metformin after poor control on metformin alone. She would like to observe the fasting season for the month of Ramadan, but given her poor diabetic control you are to advise her against this and answer any questions she may have. Please explain the new treatment she is starting and answer questions she may have.
Time Allowed: 8 minutes

Information provided to Examiner for History Dialogue with Candidate Please use the information below to use in a role play scenario with a colleague (the student) with you as both the patient and examiner. You are a 61 year-old Muslim housewife with a 4 year history of diabetes, and by your own admission have experienced poor control since diagnosis. Your medications have just changed which you realise if because your blood sugar levels are high and you realise this can cause problems in the future such as eye and kidney disease. Despite this you would like to adhere to your religious beliefs and partake in the fasting season of Ramadan. However, you dont want to cause any problems for your family. Will I pass out if I fast? Will I cause irreversible damage? You would like to consult your family and re-attend with your eldest son.

Common Things to Consider in The Consultation Religious beliefs should be respected It is paramount that you educate your patient in an unbiased fashion Offer time for consideration and consultation with family and friends Provide details of support groups or relevant literature on the topic if available Even if busy find the time to ensure the patient has had the chance to ask any questions. History Dialogue Introduction and rapport building Check name, age, occupation and marital status. Explain purpose and gain permission Explain who you are and why you are there e.g. I am a junior doctor at this clinic and I would like to talk to you about your health, is that OK?
Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com 117

Establish agenda Why have you come here today? Checking understanding of condition How much do you understand about your diabetes in general? If they have no understanding, briefly explain what diabetes is. (The patient should have an understanding so it is unlikely you will have to explain this as this is not the point of the station.) Explain to the patient that her diabetes had been hard to control so far. It has been quite tricky when it comes to keeping your blood sugars stable, but were hopeful that this new tablet, gliclazide, will be helpful. Ideas concerns and expectations Do you have any concerns about fasting during Ramadan? Do you have any concerns over how the fast may affect your health? Explain how the fast may interfere with her diabetes management. She will be unable to take her medication at the right time of the day/ at all. If you were fasting for a short time period, it would be less of a concern, but as Ramadan is for a month, this is a worryingly long time to not adhere to your diabetic medication especially as your control isnt very good at the moment. Do you understand this concern? Suggest compromise and check how amenable she is to the compromise. Do you have any ideas about how we can meet a solution that best suits you? There are special rules for the sick during Ramadan that allow you to be excluded from the fast if you are actively ill or likely to suffer ill or worsened health from doing the fast. Clarify why it is best she forego the fast this year. I dont want to put undue pressure on you, but as your doctor I feel it is important that I provide you with the best medical advice to make this decision. I think that this fast is likely to be detrimental to your health because your diabetic control will be affected by the lack of food during the fast as well as not taking your medications. Your case is particularly worrying as your diabetic control is already quite poor and it is affecting your eyes now as well which I am afraid is a sign that we need to tighten your diabetic control even more if we are to prevent other organs within the body from being damaged. You mentioned that there is an option of opting out of the fast on medical grounds and I think this is the best option for you at this moment in time. How do you feel about everything Ive told you? Offer support and advice her to seek advice from her family members and religious ministers before making a final decision.

Make a definite plan E.g. she will return to you in the afternoon/tomorrow after discussing her options with family and religious officials. Do you have any questions? Check understanding and summary

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

118

Summary You would like to adhere to the fasting month of Ramadan Mrs Khan, but you realise this may be detrimental to your health, not least given the poor control in recent years and the recent introduction of new medicines. You do have your own concerns and would like to return tomorrow after the opportunity to speak with your family. In the meantime you will read some of the independent literature in the leaflet provided. Leaflet Thank you and goodbye ACE Tips: Do not let the consultation end without formulating definite plan. If Mrs Khan does fast you must make arrangements to alter her diabetic medication doses to suit fasting times, arrange rigorous blood sugar checks and see her frequently at the clinic or by her GP during the month to check for hypoglycaemia etc.) Be careful not to coerce the patient. Offer you advice clearly, but ensure she has the final decision. If the patient is coerced into opting out of the fast, it is likely she will undo go the fast anyway. The aim of the consultation is to ensure she doesnt do anything dangerous to her health, not to win an argument. Marking Sheet: Diabetic during Ramadan
Not attempted 1 2 3 4 5 6 7 8 9 10 Introduces self and position Obtains consent via an open question Establishes the name, age, occupation Open question to commence history establishing initial understanding of why the patient has attended today Explains what diabetes is the how fasting affects control (0=none, 1 = 2-3 factors, 2 = 4 or more factors) Identifies patients concerns and wishes Outlines issues with medication during fasting Discusses affect on health of fasting Raises whether a compromise solution is possible Explain your position as a doctor to make her welfare paramount, and then perhaps discussion with family/friends would be helpful Summary Rapport with patient Thank the patient 0 0 0 0 0 0 0 0 0 0 Attempted inadequate 1 1 1 1 1 1 1 1 1 1 Attempted adequate 2 2 2 2 2 2 2 2 2 2

11 12 13

0 0 0

1 1 1

2 2

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

119

38) Dealing with an angry patient- after a mistake has occurred. Instructions given by examiner to candidate: You are a junior doctor working in an acute medical unit. Mr Edwards a middle aged man was admitted yesterday with epigastric pain. Unaware of his history of gastritis, a nurse administered aspirin under the assumption he was an acute cardiac case, however investigations have revealed the chest pain was not cardiac in nature and actually due to an acute on chronic gastritis for which aspirin is contra-indicated. Please inform the patient of the error and answer any questions he may have.

Information provided to Patient for History Dialogue with Candidate You are Tim Edwards a 43 year-old city analyst admitted yesterday with gastritis. The doctor informs you of the receipt of aspirin in error, which should not be prescribed in gastritis. You are angry initially about the error and are critical of the ward staff. You demand to know who made the error and why it happened. You request for a review of practice to be made and wish for a personal apology from the nurse involved. The medical doctor is calm and tells you it is unlikely to cause any real problem and he is giving you an antacid drug to improve the situation. You then calm down, apologise for your initial reaction and do not wish for any further action to take place. History Dialogue Introduction and rapport building Check name, age, occupation and marital status. Explain purpose and gain permission Explain who you are and why you are there e.g. I am a junior doctor on the team looking after you and I would like to talk to you about your health, is that OK? Establish understanding about why the consultation is taking place Do you know why you I have come to see you today? If they do not know why they are there, inform them that it is to discuss management of condition.

Checking understanding of condition Briefly establish what their management has been so far and how symptoms have responded/ how they are feeling now. Specifically ask about if they have been informed of their test results. If they have not, explain it to them. The endoscopy we did showed that your gastritis has flared up and a new ulcer has formed and this is most likely the cause of the chest pain you had when you were admitted yesterday.

Explain treatment they will be receiving. E.g. H. pylori triple therapy for gastritis (amoxicillin, clarithromycin and PPI for 1 week) Explain the error that occurred
Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com 120

It appears that as you presented with chest pain which someone unaware of you medical history could easily mistake for chest pain due to a heart attack, during your initial treatment, you were given some aspirin. Apologise I am so sorry that something like this happened. Allow patient time to think and ask if any questions? It is likely that at this point the patient may be angry and demand to know how it happened. Accept team responsibility and explain exactly how the error happened and how it will be avoided in the future. The initial description of your chest pain sounded a lot like that of someone having a heart attack. In cases such as that, the first thing we do is give aspirin as this helps to reduce the potential severity of damage caused from the heart attack. It is very unfortunate that this same drug that can save the life of someone having a heart attack can also may cause trouble for someone with your condition. Ask how he/ she feels. Explain how error will be counteracted and future management I think the best thing to do from here is to start your acid suppressing omeprazole and antibiotics as soon as possible, so we can start reducing the inflammation. In the meantime, if the pain does feel worse or you vomit any blood or coffee ground like particles, come straight back to hospital again. Is that OK? We will give you an appointment to see us in our outpatient clinic in 1 week to check that everything is OK. I hope that is OK with you? Inform of right to complain and PALS service if the patient is very aggravated and wants to take the matter further. If you do feel that you would like to make a formal complaint, you would be well within your rights as a patient and our PALS service exists for you to do just that if you need to. Any questions? Check understanding and summary Leaflet Thank you and goodbye Summary In summary, Mr Edwards was angry after informing him of an error in the prescription of aspirin. Although initially reacting in an understandably angry manner, he is now content with the explanation and action take to prevent any flare of his gastritis. He does not wish to make a formal complaint. ACE Tips It may be tempting to put the blame of the error on the specific member of staff however remember that professionalism is something the examiner is looking for. It is best to accept team responsibility if the patient specifically asks who caused the error.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

121

Remember to allow the patient time to express their anger- it may be tempting to hurry them up due to lack of time but this will most likely make the patient angrier and lead to a complete breakdown of the consultation.

Communication errors are the commonest complain made by patients against medical staff. Take the time to communicate well after the error and it will often resolve the situation without further action.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

122

39) Breast cancer Instructions given by examiner to candidate: You are a junior doctor working in a breast clinic. Mrs Longmead, a middle aged female presents to you, following triple assessment of a breast lump. All investigations have confirmed that she has breast cancer grade 1, stage T2N0M0. Please inform her of her diagnosis and provide appropriate counselling.

Information provided to Patient for History Dialogue with Candidate You are a 52 year-old married teacher and attended the One Stop Breast Clinic at your local hospital last week after feeling a lump in your right breast whilst showering. You were concerned and with the support of your husband attended clinic today. You are very concerned it might be breast cancer, but are braced for this diagnosis as you have heard so many women being diagnosed. Despite being prepared for it you are visibly upset when told and clench your husbands hand hard. You ask how bad the cancer is and what treatment you will receive and when will it start. You last question is whether you will need reconstructive surgery. Time Allowed: 6 minutes Introduction and rapport building Check name, age, occupation and marital status. Explain purpose and gain permission Explain who you are and why you are there e.g. I am a junior doctor at this clinic and I would like to talk to you about your recent clinic visit, is that OK? Establish understanding about why the consultation is taking place Do you know why you were asked to come in today? If they do not know why they are there, inform them that it is to obtain results for a test they had during their last consultation. Be sure to check they know what the test is for.

Ideas, concerns and expectations Do you have any idea or concerns about what the results will be? Breaking the news/ giving the result Ask if patient would like a friend or family member present. Explain results clearly and slowly, giving the patient time to absorb the information. Well I do have the results here, and Im afraid they show that the lump in your breast is cancerous in nature. After giving the patient time to absorb the information, ask How do you feel about hearing that?

Explanation of diagnosis
Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com 123

Explain what cancer is- abnormal growth of cells where normal cells should be. Explain where the cancer is i.e. the stage. Give a rough idea of the severity of the cancer, as it is likely the patient will want to know how bad is it. Simple terminology like it is in the early stages will suffice.

Explaining treatment Usually treatment options are lumpectomy or mastectomy +/- lymph node clearance, followed by local radiotherapy and chemotherapy. Inform the patient how soon treatment will start and where this will be done/ how often. Inform patient that treatment is not a guaranteed cure but improves prognosis. Some patients will want exact figures. Any questions? Summary and checking understanding Ive given you a lot of information today which will have been a lot to take in. Would it be alright if you recap what you understood from our discussion today, so I can check you have understood everything? Offer leaflet Give leaflet on breast cancer and its treatment. Thank you and goodbye Check if she has any questions for you once again Ok, well thank you for coming in today. I am so sorry about the news, but hopefully now we have some answers, we can start working towards treating you. ACE Tips Breaking bad news is a station that marks weigh heavily on rapport and communication skills rather than content. It is important to place strategic silences throughout the consultation to give the patient time to absorb the information and formulate any thoughts they may be having. If a patient starts crying, allowing then some time to cry is a good idea. Offer a tissue and take your lead from them. Most will apologise for crying and explain why they are crying. When they do so, make an attempt to offer some sort of information about how to overcome their anxiety, e.g. if the patient starts crying and says Ive got a 3 year old at home, I want to be around to see her grow up, a good reply would be to inform the patient that a diagnosis of breast cancer is not equivalent to fatality. Give figures of survival if you know them and inform patient of treatment advances which aid curing breast cancer.

Always leave the patient an open option to contact yourself/specialist nurse at a later date. Often after the shock has subsided and the patient has spoken with family and friends they will have other questions and concerns.

The above scenario is very similar with minor adaptations for breaking a variety of bad news, for example a man with prostate cancer.

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

124

Marking Sheet: Telling a Women She has Breast Cancer


Not attempted Attempted inadequate 1 1 1 1 Attempted adequate 2 2 2 2

1 2 3 4

Introduces self and position Obtains consent via an open question Establishes the name, age, occupation and marital status of patient Open question to commence history establishing initial understanding of why you are speaking with them Explains the diagnosis of epilepsy and checks patients understanding of disease (0=none, 1 = 2-3 factors, 2 = 4 or more factors) Enquires regarding patients knowledge of how epilepsy will effect his/her activities (0=none, 1 = 2-3 factors, 2 = 4 or more factors) Explains need and why DVLA must be informed. Deals with the patients distress and concerns with empathy Explains other activities which need to be stop or changed (eg, shower not bath) Allows patient to raise concerns and questions Summary Rapport with patient Thank the patient

0 0 0 0

5 6

0 0

1 1

2 2

7 8 9 10 11 12 13

0 0 0 0 0 0 0

1 1 1 1 1 1 1

2 2 2 2 2 2 2

Ace the OSCE


BMA Prize Winning OSCE Video Series Learn exam technique quickly & easily Real patients with real signs Money Back Guarantee you PASS! 10% discount with promo code AOSCE2 Subscribe today at AceMedicine.com

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

125

Ace Medicine Revision Courses


Ace the Ace the Ace the Ace the 3rd Year OSCE Course 3rd Year Written Exams Course 4th Year Specialties Course Written Finals Course

100% MONEY BACK GUARANTEE you pass your Exams LEARN most topics likely to come up in your exams within HOURS, SAVE yourself WEEKS of revision time! visit www.AceMedicine.com for details and bookings

Dont miss Ace the OSCE: Video Training Series at www.AceMedicine.com

126