MRCGP-INT OSCE
DR.ABDELNASIR ELSHEIKH
MRCGP-INT-UK
0202
NASSIR1970@GMAIL.COM
MRCGP OSCE
2010
DR.ABDELNASIR
ELSHEIKH
MRCGP-INT-UK
MFFP-UK
DTP-KSU-KSA
OSCE INSTRUCTOR
NGHA-RIYADH-KSA
12
insomnia
13
alcoholism
19
chronic fatigue
23
COPD
25
chest pain
tennis elbow
26
31
TIA
37
postnatal depression
45
asthma
47
syncope
50
dementia
51
55
contraceptive pill
57
headache
59
angery patient
62
TMN
66
POST -mi
70
herpes zoster
76
prediabetic
78
index
HOW TO
OBTAINE
MEDICAL
HISTORY
IN GENERAL
PRACTICE
Obtaining the Medical History
THE CALSSIC STRUCTURE OF A MEDICAL HISTORY
The presenting complaint(s).
The history of the presenting complaint(s)
Past medical history
Drug/allergy history
Family medical history
Personal and social history
Systems review
Rapport
How I can help you?
Check up?
Yes, I'm not performing as well as I used to
Performing?
Yes, well, you know, I think I'm impotent. My wife is very
good about
it and doesn't complain, but I feel so guilty and ashamed
Ashamed?
I feel terrible. I don't feel a man any more, especially as we
used to
have such a good sex life . . . .
PATIENT ICE
Ideas (beliefs)
Tell me about what you think is causing it.
What do you think might be happening?
Have you any ideas about it yourself?
Do you have any clues; any theories?
Youve obviously given this some thought; it would help me
to know what you were thinking it might be.
Concerns
What are you concerned that it might be.
Is there anything particular or specific that you were
concerned about?
What was the worst thing you were thinking it might be?
In your darkest moments ...
Expectations
What were you hoping we might be able to do for this?
What do you think might be the best plan of action?
How might I best help you with this?
Youve obviously given this some thought, what you were
thinking would be the best way of tackling this?
SUMMARISING AND CHECKING
5
ok MR.B
Id like to get this clear.............am I right?
so...... theres.........
Tell me if Ive got this clear......
Let me take a moment to check that Ive got it right.........
Can I put it into my words..........?
Lets just recap............
You said/you mentioned .......
WHEN SHORT OF TIME AND RUNNING LATE
sorry I am running late (neutral tone).. and then
negotiate where you aim to go together in the rest of the
time available, as above.
Well try to deal with as many problems as
possible.depending on time/how we get on.
Well try to do justice to as many as we can.
I want to give enough time to each of these problems..
Lets get on and see how we go..
OK, lets see what we can do today
how a problem affects a persons life:
If appropriate, pick up a cue:
you said that your knee was giving you a lot of trouble, I
was wondering how that was affecting you
I know that you spend a lot of time looking after you
disabled husband..tell me how you are coping
SENSITIVE ISSUES
Introduce sensitive topics with the common concern
approach: As we age, many of us have more trouble with . .
. or Some people taking this medication have trouble with
sex .
Be teenage friendly .
COMPTENCE(pt aware of his medical problem,
time consuming)
o Through explanation discussion about management
options.
o Checking patient understanding frequently
o Otherwise you will doctors centered.
Common pit falls among candidate
Mechanical rapport.
02
jargon
Miss to explore the ICE
In effective listening
Being doctor centered (giving options inform of lecture
with out involving the patient).
Not considering patient believes during expiation.
Mal management of time.
00
GOUT
MYOPATHY
RHEUMATIOD
ETHICAL ISSUES
DOMESTIC
VIOLENCE
UTI
SORE THROAT
PARKINGNOSIM
OBESITY
EPILEPSY
MENOPAUSE
NEONATAL
JAUNDICE
INCONTENENCE
SCHEZOPHERANIA
INSOMNIA
FATIGUE
PMS
A.F
VERTIGO
DEPRESSION
HYPOTHYRIODISM
HRT counseling
HERPES ZOSTER
BED WETTING
00
PSORIASIS
URTICARIA
GENITAL HERPES
MAMOGRAPHY
SUBSTANCE MISUSE
CHILD ABUSE
DRY EYES
ERECTIL DYSFUNCTION
O.A
OCD
SOMATIZATION
POOR SCHOOLING
CHILD NOT EAT WELL
PRG HYPERTHYRIODISM
ACUTE RENAL COLIC
ACUTE PANCREATITIS
T.B
BREAKING BAD NEWS
PTSD
IBS
ALCOHLISM
OSTEOPROSIS
TRIGEMINAL NEURALGIA
SOCIAL PHOBIA
INSOMNIA
Diagnosis and management of chronic insomnia in primary
care
Initial assessment
03
Causes of insomnia
Physical
Environmental
Psychological
Psychological, e.g.:
o bereavement
o relationship problems
o exam stress
o work worries
Psychiatric
Psychiatric, e.g.:
o depression
o dementia
o anxiety
o bipolar disorder
o schizophrenia
o substance/alcohol misuse
Pharmacological
Pharmacological, e.g.:
o some antidepressants, anxiolytics and
antipsychotics
o appetite suppressants
o decongestants
o beta-blockers
o corticosteroids
o caffeine
o drug/substance withdrawal
Follow up
05
o
o
Non-pharmacological management
Pharmacological treatment
Hypnotics
06
Benzodiazepine hypnotics
Z-hypnotics
Prolonged-release melatonin
Other medicines
When to refer
08
ALCOHOLISM
Sp Mr.XB 45 years, talks to him, exam normal
I am drinking heavily am finding difficulty to cut down,
Alcohol dependence:5
o Strong desire to drink
o Difficulty controlling alcohol intake
o Physiological withdrawal when intake is reduced
o Tolerance, such that increasing amounts are
required to produce the same effect
o Harm resulting from alcohol use, e.g. work,
relationships6
09
CAGE Questionnaire
No
Yes
No
Yes
No
Yes
02
00
00
ch occurs in
people who are depressed.
1) Take a history about his symptoms.
How long have you been feeling tired for?
Are you tired all the time, or does it follow some pattern?
Do you have any other symptoms with the tiredness, like
muscle aches?
Are you normally well?
Do you take any medications?
Do you smoke? Do you take alcohol?
Have you had a cold recently?
2) Ask specific questions about causes of tiredness:
Thyroid: Have you been putting weight on recently? Do you
feel cold when others in the room feel warm? How are your
bowels? How are your periods? (if patient is a woman).
Anaemia: Have you been losing any blood from anywhere such as your bowels, vomiting or waterworks?
Renal Problems: Are your waterworks normal? Have you
been feeling sick?
Malignancy: Have you lost any weight or been having any
03
night-sweats?
Depression: How has your mood been recently? Have you
been sleeping and eating properly?
3) Explain the diagnosis to the patient.
Well, chronic fatigue syndrome is a condition in which you
can feel extremely tired and also have aches and pains. It is
quite common nowadays. We dont know exactly what causes
it but it may be related to an infection. Unfortunately, there is
no blood test to diagnose it and there is no cure. But the
good news is that it gets better itself over time in most
people. There are some treatments that can help some. I will
explain them to you.
4) Explain management to patient.
As I have said earlier there is no cure but some treatments
can help. There are mainly a few options:(a) Cognitive
Behavioural Therapy - I can refer you to a specialist
counsellor who will talk to you and try and help you. He will
help you modify your thinking and help you think more
positively about your condition.
(b) Pacing - here we will teach you to adjust your activity
depending on how you feel. For example if you feel very well
one day then you can increase your activity. If on the other
hand you feel tired, then take it easy that day.
(c) Graded Exercises - here you try to increase your activity
slowly over days. That is everyday you try and do slightly
more than the previous day. Once you feel tired just stop and
rest.
(d) Antidepressants - in some people antidepressant tablets
help. I am not saying that you are depressed but these
tablets can sometimes help. They are not addictive but take a
few weeks to start working.
04
COPD
05
Chest pain
Stable angina
Case scenario MR.X a patient with chest pain. Take history
and examine. management
Introduction, then you may say: as far as I know, you
have pain in your chest. I would like to ask you several
questions concerning your complaint.
History taking:
How long has the pain been there? (Duration)
Is it there all the time or does it come and goes?
(Periodicity)
Can you tell me exactly where it is? (Site)
Does it spread? (Radiation)
Can you describe what it feels like? (Nature)
Does anything seem to make it worse? (Aggravating
factors like:walking in cold weather,
Heavy meal, climbing stairs or hill)
How much can you do before you have to stop?
Do you ever feel pain or discomfort at rest?
Does anything seem to make it better? (Relieving
factors)
Any shortness of breath, cough, fever?
Examination
06
07
Associated symptoms
o
Breathlessness, cough,
Excessive sweating
Palpitations, dizziness,
and
haemoptysis
syncope
08
09
32
TENNIS Elbow
History taking
Pain [when,where,how,radiation,helps,worst,other
joint-shoulder ]
What about the other ARM
Sleep
trauma recent
numbness, Loss of sensation
weakness
fever
Patient ICE
WORK
HOME ACTIVITY
COPING
PMS-ARTHIRITIS,DM
What is "tennis elbow"?
"Tennis elbow" is a general term that is usually is not
related to playing tennis. However, this term came into
use because it can be a significant problem for some
tennis players. Tennis elbow is a condition usually
caused by overuse of the arm muscles that result in
pain at the elbow.
Tennis elbow most commonly involves the area where
the muscles and tendons of the forearm attach to the
outside bony area
30
33
34
35
TIA
Take history
The main signs and symptoms of a TIA can be remembered
by the word FAST:
dizziness,
communication problems, difficulty talking and difficulty
understanding what others are saying,
problems with balance and coordination,
difficulty swallowing,
severe headaches,
numbness/weakness resulting in complete paralysis of
one side of the body, and
loss of consciousness (in severe cases).
explanation
36
37
Men have a greater risk of having a TIA compared with premenopausal women. However, the risk of TIA and stroke
increases in postmenopausal women.
Ethnicity
African and south Asian people have an increased risk of
developing high blood pressure and diabetes, and therefore
also have a greater risk of having a TIA.
Family history
If you have a history of stroke, or TIA, in your family, your
risk of having a TIA is increased. However, the risk is
relatively small, and having family members who have had a
TIA will not necessarily mean that you will have one.
Lifestyle risk factors
High blood pressure
High blood pressure, or hypertension, is one of the biggest
risk factors that is associated with TIA. Having high blood
pressure puts extra strain on your blood vessels in your
body, causing them to become narrowed or clogged.
Weight and diet
Eating a poor diet that is high in saturated fat increases your
risk of developing atherosclerosis. If there is too much salt in
your diet, it is likely that your blood pressure will be
elevated which, like atherosclerosis, is a major risk factor for
TIA. Being overweight also puts your heart under strain, and
weakens your blood vessels.
Smoking
Smoking can double your risk of having a TIA, or stroke.
This is because the harmful chemicals in cigarette smoke
38
39
Blood tests
If you have had a TIA, you might require a series of blood
tests which may include:
Healthy eating
Eating a healthy, balanced diet will help you to lose any
excess weight, and will also help keep your arteries healthy.
Alcohol
Drinking an excessive amount of alcohol may increase you
risk of having TIA and a stroke. Therefore, you should make
sure that you stay within the recommended limits of alcohol.
These limits are:
Stop smoking
40
People who have had a TIA but who present late (more
than 1 week after their last symptom has resolved)
should be treated as though they are at lower risk of
stroke using the low risk pathway.1
43
Postnataldepression
Clinical features:
- Similar to those of depression, but
o Suicidal thoughts less common but must still ask about
them in OSCE
o Tend to have feelings of guilt or inadequacy towards the
baby
Management:
- Get senior help consider getting psychiatrist involved
- Make assessment of severity:
o Use Edinburgh PND Scale is important to recognise
early on that there might be severe depression
o Make social assessment, including possible risk to the
baby
- Options:
o Psychological need to explore feelings w mother, and
reassure her. Can go further, and refer for counselling or
consultation w a psychiatrist
o Medical eg fluoxitine should observe baby if breast
feeding, and may need to stop breast feeding if need large
doses
o If severe, might need ECT or lithium, or transdermal
oestrogens
History;
1)Introduce yourself
2)Explain that you would like to talk about how things have
been going, and ask permission
3)Start w open questions
- General depression questions
- Edinburgh PND scale:
o Mood
o Tearfulness
o Unable to laugh and see the funny side of things
o No longer look forward w enjoyment to things
o Feelings of being unable to cope/feeling inadequate/things
getting on top of you
44
45
Asthma
TAKE HISTORY FOR ASTHMA PATIENT
Cardinal symptoms
Cough
Breathlessness or chest tightness
Wheezes
Triggers
Dust
Exercise
Colds
Infections
Stress
Risk factors
Smoking
Family history
Occupational factor
Home environment
High probability symptoms
Early morning and night worsen
Increase with exercise and allergen
Atopic
Relation to medicine ASP,B-blocker
46
47
Smoking cessations
Avoid allergens
Home use of PFM
PHARMACOLOGICAL
Reliever and preventers inhalers
USE OF INHAERS
1.Remove the cap from the end of the inhaler device.
2. Shake the inhaler device and ensure it is "primed"
(sprays freely).
3. Hold the inhaler in front of your mouth but not inside of
your mouth. See image for correct spacing.
4. Exhale comfortably.
5. While depressing the silver canister within the inhaler
device, take as deep of a breath as possible through your
mouth.
Hold your breath for 5 to 10 seconds
48
SYNCOPE
49
DEMENTIA
Michael Foster came to your office to talk about his father,
Frank Foster, who is 78 year old. He think he has got
forgetfulness. Please talk to him in the next 5/10/15 minutes
concerning his father and your possible plan.------------------------------------------------------------------Frank Foster, a 78 year old man came to your office because
his son, Michael, asked you to see him because he think his
father has got forgetfulness. Please talk to him in the next
5/10/15 minutes.
-------------------------------------------------------------------Ask whether there is a family history of dementia or other
illnesses. The person being treated and often a close relative
or partner will be asked about:
52
50
50
53
54
AGE
39 YEARS
PATIENT NAME XX
AGE 35 YEARS
MRN 12345
DATE 30/6/2
55
56
57
HEADACHE
Screening/diagnosis
Almost all headaches are benign and should be managed in general practice.*
Use questions / a questionnaire assessing impact on daily living for diagnostic
screening and to aid management decisions. (Any episodic, high impact
control of their management and the doctor providing education and guidance.)
Provide individualised care for migraine and encourage patients to treat
themselves. (Migraine attacks are highly variable in frequency, duration,
medications for migraine. Avoid the use of drugs that may cause analgesicdependent headache, e.g. regular analgesics, codeine and ergotamine.)
Prescribe prophylactic medications to patients who have four or more migraine
attacks per month or who are resistant to acute medications. (First-line
Positional component
Nausea, vomiting, photophobia, sonophobia
58
Neurological phenomena
Previous headaches (is this similar)
Migraine:
Triggers
o
o
o
o
o
o
o
o
Stress
Food (nitrates, chocolate, caffeine)
EtOH
Smoking
Menses
Weather
Allergies
Lack of sleep
Tension:
59
Cluster:
Acute onset
Male, young
Retro-ocular
Multiple/day
May have red, watery eye
Treatment: CCB (but difficult)
Meningitis:
Subarachnoid hemorrhage:
Sudden onset
Worst headache of life
Risk factor: HTN!
Nausea (blood is an irritant to brain, meninges)
Vomiting
Isolated neurological symptoms (i.e. anterior inferior surface 3rd CN palsy)
Positional (better sitting b/c of increased ICP from blood)
Treatment: admit and do serial CT scans; control BP <180/110
62
ANGERY PATIENT
No matter what field you work in, these tips will help you
keep your cool when patients take their frustrations out on
you.
Even patients who are normally calm may quickly reach the
boiling point when illness threatens their health, mobility, and
independence. Pain and fear can lead to increased stress,
anxiety, and frustration, which can result in anger and even
loss of control. But do you know how to spot your patient's
anger early and defuse it?
For guidance, read on. These tips will help you get control of
the situation and hopefully reduce the likelihood of legal
action down the road.
Look for the signs
There are signs that indicate a patient's emotional state is
deteriorating. Look for changes in body language, including a
tightened jaw, tense posture, clenched fists, fidgeting, and
any other significant change from earlier behavior. A
talkative person, for example, may suddenly become quiet.
Observe the patient for additional signs that his temper is
rising. Is his voice raised? Is he demanding excessive
attention?
If you detect any of these warning signs, you'll need to act
fast to help the patient vent his feelings in a productive
manner. Start by spending extra time with the patient.
Although you might be tempted to spend less time with him,
doing so only increases your risk of liability. Ignoring his
60
explode, maintain eye contact with the patient and just listen.
Try to understand the event that triggered the angry
outburst.
When the person has quieted down, acknowledge his
feelings, matching your words to his level of anger. Express
regret about the situation, and let the person know you
understand. Try to find some point of agreement, perhaps
acknowledging that his complaint is a valid one.
Ask for the patient's solution to the problem. Use phrases
like, "Can you tell me what you need?" or "Do you have some
suggestions on ways to solve this problem?" End the
conversation by trying to reach an acceptable arrangement.
Offer options by saying, "Here's how we could handle this."
If the patient threatens you physically or you fear for your
safety, don't hesitate to contact security or the police. For
more immediate assistance, consider establishing a code
phrase that indicates when a staffer needs help.
Regardless of the extent of the patient's anger, documenting
complaints--as well as attempts to resolve them and the
results of each intervention--can ward off frivolous claims
or help in your defense if a lawsuit proceeds to trial. If
applicable to your line of work, note administrative
complaints in an incident report. Document clinical
complaints in the patient's chart.
Dealing with difficult patients will always be a challenge. But
your finesse in defusing and managing anger will keep the
focus on getting the patient healthy and protect you from
unwarranted legal action.
64
Location of pain
Distributed trigeminally (usually second or third divisions),
)either alone or in combination (trigeminal neuralgia
First division pain around the eye or forehead occurs in
10%-20% of patients, often with pain in other parts of the
face, usually mid-cheek and upper lip or teeth (trigeminal
)neuralgia
)Usually unilateral (trigeminal neuralgia
In 5%-10% of patients with trigeminal neuralgia only
(3598670), and in 11%-20% of patients with trigeminal
neuralgia and MS, pain sometimes is on the other side of the
face but it is almost never simultaneously bilateral
)(trigeminal neuralgia
)Simultaneous bilateral face pain (atypical facial pain
Distribution of the first division of the trigeminal nerve
)(postherpetic neuralgia
Back of throat, front of neck, or deep in the ear
)(vagoglossopharyngeal neuralgia
Frequency of pain
Often episodic; weeks or months of remission may be
)followed by similar periods of pain (trigeminal neuralgia
Severity of pain
)Varies from mild to severe (trigeminal neuralgia
Refractory period of pain after stimulation of the trigger area
(cannot elicit pain again by touching or pushing immediately
)after a painful attack
Likelihood ratio: positive, 9.5%; negative, 0.05%
66
Carbamazepine
GABAPINTIN
AMITRIPTALINE
SURGERY .
68
POST-MI
MR. b 50 YEARS BP 130/75
TALK TO HIM
I am glad that you have recovered quite well after the heart
attack
How do you feel now.
What do you know about heart attack?
. Your heart is made of muscle. Its most important job is to
pump blood to all parts of your body to provide adequate
supplies of oxygen. It also supplies blood to its own muscle.
It does this through a network of very small pipes called
coronary arteries. If one of these arteries becomes partly or
completely blocked, the heart muscle is deprived of oxygen
and this causes a heart attack (you will sometimes hear this
called a myocardial infarction or an MI).
Follow-up every visit
Patients should be followed regularly following MI,
Approximately every two to three months for the first year
and then twice yearly.
History and physical exam
Ask about recurrent chest pain, dyspnea, palpitations,
and syncope. Focus on early recognition of anginal
symptoms.
Screen for depression.
Measure blood pressure at each follow-up visit and
maintain at 135/85 mm Hg .
69
Cardiac rehabilitation.
Include the following components in comprehensive
cardiac rehabilitation:
72
70
HERPES ZOSTER
Confusion
Fatigue
Fever
Headache
Memory loss
Upset stomach
or abdominal pains
75
Treatment
PHN
Anticonvulsant
antidepressant
76
Prediabetic
History
Present symptoms.
Risk factors.
Symptoms of complications.
Life style and habits
77
78
Challenging
Metformine
Diabetes complications risk
Driving
Case 2 age 34 HA1c 5.9% F/U BP120/80 BMI 29
LIPID T.C 5.9 LDL 3.2
ASP / STATIN
NON-SMOKER, NO BP, NO HEART DISEASE,-VE FH
Physical Examination [R]
Weight, height, body mass index (BMI), blood pressure
Cardiovascular system: heart, blood pressure, peripheral
vascular including pulses and bruits (abdominal, carotid,
femoral)
Feet: nails, web spaces, ulcers, pulses, calluses, structural
deformities, protective sensation and shoes
Other examinations as guided by the patient's symptoms
and/or concerns:
Skin: infections or diseases such as acanthosis nigricans,
xanthoma
Neurological system: sensory state of hands and feet, muscle
wasting, deep tendon reflexes
Mental health: screen for depression and/or anxiety
Referral to an eye specialist to assess optic health
Diagnosis of Prediabetes
Fasting plasma glucose of 100 mg/dL to 125 mg/dL
79
82
References
NICE
SIGN
Patient .uk
MIPCA
80