The Unofficial Guide to Passing OSCES - Brossura

Brossura

ISBN 10: 0957149905 ISBN 13: 9780957149908

Casa editrice: Zeshan Qureshi, 2012

Riassunto

OSCE examinations are used worldwide as a critical part of medical student assessment, yet there is often little preparation for them provided by medical schools. The Unofficial Guide to Passing OSCEs is intended to fill this gap. It includes over 100 scenarios, covering medical history taking, clinical examination, practical skills, communication skills, plus specialties, meaning that everything is covered in one place. To bring the cases to life, over 300 full color clinical photos are included, including patients with features of important diseases. It also includes clear outlines of how to relay the assessment of a patient to an examiner or to other doctors on a ward round. This book has relevance beyond examinations, for post graduate further education and as a day-to-day reference for professionals.

Su questo libro

Informazioni sull?autore

Zeshan Qureshi is a Paediatrician based at Great Ormond Street and the Institute of Global Health. He graduated with Distinction from the University of Southampton, and has published and presented research work extensively and internationally in the fields of pharmacology and medical education. Whilst working in Edinburgh he was part of the leadership team developing a near peer teaching programme, where by junior doctors, throughout south east scotland, were both trained to teach, and delivered teaching across every hospital in the area. This book is an extension of this philosophy: that junior doctors and fresh graduates know how to express complex ideas in order for it to be easily understood from a students perspective. That junior doctors can teach, and write in a complimentary way to senior doctors: one that is friendly and fun, easy to read and relevant to both exams, and the day to day to life of junior doctors.

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The Unofficial Guide to Passing OSCEs

By Zeshan Qureshi

Zeshan Qureshi

Copyright © 2012 Zeshan Qureshi
All rights reserved.

ISBN: 978-0-9571499-0-8

Contents

1. History Taking (Zeshan Qureshi, Seb Gray, Selina Hennedige-Gray), 
2. Clinical Examination (Zeshan Qureshi), 
3. Orthopaedic Examinations (Mark Rodrigues), 
4. Communication Skills (Zeshan Qureshi, Seb Gray, Selina Hennedige-Gray), 
5. Practical Skills (Zeshan Qureshi, Seb Gray, Selina Hennedige-Gray), 
6. Radiology (Mark Rodrigues), 
7. Obstetrics and Gynaecology (Matthew Wood), 
8. Psychiatry (Sabrina Qureshi and Zeshan Qureshi), 
9. Paediatrics (Seb Gray and Zeshan Qureshi), 
10. Prescribing (Mark Rodrigues and Constantinos Parisinos), 
11. Critical Appraisal (Zeshan Qureshi), 
12. Hospital Letters (Zeshan Qureshi), 

CHAPTER 1

History Taking

Some topics are more likely to surface than others are, and many history taking scenarios have not been mentioned here. After completing a year of attachments, the hope is that you will have accumulated enough neuronal connections to cope with any situation thrown at you! When in doubt or under stress, go back to the basics. The simple history taking format and SOCRATES should never be forgotten, and always remember the importance of communication. Maintain good eye contact, ask a mixture of open and closed questions, and you are already halfway there.

For every OSCE station in the finals, remember the following tips:

• Introduce yourself and wash your hands

• Ensure that patient dignity is preserved in the context of the task

• Explain what you are going to do and offer information leaflets, particularly when counselling a patient

• Gain consent

• If you don't know the answer to any question, then admit this, and say you will speak to a colleague and find out the answer

• Thank the patient at the end of the consult

This chapter contains notes on the following histories:

1.1 Cardiovascular History: Chest Pain

1.2 Respiratory History: Productive Cough

1.3 Gastrointestinal (GI) History: Abdominal Pain

1.4 Gastrointestinal (GI) History: Diarrhoea

1.5 Neurological History: Headache

1.6 Vascular History: Intermittent Claudication

1.7 Orthopaedic History: Back Pain

1.8 Haematology History

1.9 Breast History

1.10 Genitourinary Medicine: Sexual History

1.11 Genitourinary Medicine: Vaginal Discharge

Station 1: CARDIOVASCULAR HISTORY: CHEST PAIN

Mrs Jones is a 60 year-old lady who presented with a two-hour history of shortness of breath, central chest pain and sweating. Please take a history from Mrs Jones and then present your findings.

Pain History ('SOCRATES' mnemonic)

• Site: Central/left/right sided chest pain?

• Onset: Sudden or gradual? What was the patient doing when it came on?

• Character: Gripping? Crushing? Tearing? Burning? Cramping? Heavy? Tight?

• Radiation: Up into the jaw and/or down the left arm? Into the right arm? Through to the back?

• Associated Symptoms:

• Shortness of Breath: Orthopnoea, paroxysmal nocturnal dyspnoea. How many pillows do they sleep on? Exercise tolerance: what is their current exercise tolerance? What stops them exercising at that point? What is normal for them?

• Autonomic Symptoms: Nausea, vomiting, sweating

• Palpitations: Were they regular or irregular? Did they start and stop suddenly? Did they precede any chest pain or come after it?

• Pre Syncope and Syncope: Did the patient feel dizzy or light headed? Was their level of consciousness affected?

• Ankle Swelling: Unilateral or bilateral?

• Calf Swelling: Any swelling or rashes noticed in the legs? If so, any pain/redness/tenderness?

• Haemoptysis: May be suggestive of a pulmonary embolism or pneumonia. It is also associated with mitral stenosis, lung cancer, and tuberculosis. Pink frothy sputum is associated with pulmonary oedema

• Sputum: Amount, colour, and frequency

• Trauma: Any recent chest trauma?

• Timing:

• How long does it last? If they have had multiple episodes, are they getting longer in duration or more frequent?

• Exacerbating and Relieving Factors:

• Exercise: Is the pain associated with exercise? What is the relationship?

• Food: Does the pain come after eating large meals, or certain foods? Is the pain relieved by antacids? Associated water brash (hypersalivation often post reflux)?

• Position: Does the pain vary with lying flat/sitting forward?

• GTN: Is the pain relieved by GTN? (angina or oesophageal spasm may be relieved, though for oesophageal pain typically takes considerably longer; i.e. 10 minutes, so also ask how long it took the pain to subside)

• Analgesia: Is the pain relieved by paracetamol/ morphine?

• Is the pain pleuritic?

• Is there any pain on movement or any tenderness on pressing? (suggestive of a musculoskeletal cause)

• Severity: Score out of 10 (with 10 being the worst possible pain and 0 being pain-free). How bad is their pain now? How bad was it at its worst?

Has the patient had anything like this before? If the patient has had a previous heart attack/angina, is this the same type of pain?

Past Medical History

Enquire about the following conditions:

• Myocardial infarction (and any previous cardiac procedures)

• Diabetes mellitus

• Hypercholesterolaemia

• Peripheral vascular disease

• Stroke

• Rheumatic fever

Medication History

• Allergy history including reactions to previous contrast agents. Particularly consider cardiovascular medications such as ACE inhibitors and beta-blockers

Social History

• Smoking status (past, present or never): How many? What? For how long? Then calculate number of pack years (1 pack year = 20 cigarettes/day for 1 year)

• Passive smoking

• Diet

• Exercise

• Housing and stairs: to assess effect of any symptoms on day-to-day life

• Alcohol intake and substance misuse e.g. cocaine

Family History

Enquire about 1st degree relatives:

• Coronary artery disease

• Stroke

• Sudden death

• Hypercholesterolaemia

• Diabetes mellitus

• Cardiomyopathy

• Congenital heart disease

If diseases with stronger genetic associations are suspected e.g. Marfan's syndrome, Hypertrophic Obstructive Cardiomyopathy, also take an extended family history (uncle, aunt, cousins)

Risk Factors for Pulmonary Embolism

Long haul flights, recent surgery, immobility, previous PE/DVT, family history of PE/DVT, malignancy, obesity, pregnancy, oestrogen therapy, genetic/acquired thrombophilia

Risk assessment by calculating the Well's score can help guide clinical decisions:

Differential Diagnosis

Cardiac Causes

• Acute Coronary Syndrome (ACS):

• Pericarditis: Pleuritic chest pain worse on lying supine. Widespread saddle-shaped ST elevation on ECG (with no reciprocal ST depression), PR depression (which is virtually diagnostic of pericarditis), and it may be possible to hear a pericardial rub on auscultation (sounds like walking on fresh snow)

• Stable Angina: Chest pain with cardiac characteristics, usually lasting less than 20 minutes, relieved by GTN Spray. It typically occurs after walking predictable distances, and is stable

Management of Suspected Acute Coronary Syndrome

• Airway – Ensure that the airway is patent

• Breathing – Give high-flow oxygen via a non-rebreathing mask (if hypoxic only), listen to their chest, especially for basal crackles, measure respiratory rate and oxygen saturations

• Circulation – Assess the capillary refill time, pulse, JVP, and blood pressure. Attach cardiac monitor/ECG, establish intravenous access, draw blood, and consider ABGs

If the history is suggestive of dissection (sudden onset of tearing chest pain, often radiating to the back), then look for a widened mediastinum on chest X-ray, radiofemoral delay, marked hypotension, and aortic regurgitation. A minimal troponin rise may be seen, but there are usually no obvious ECG changes of MI. The definitive diagnosis is made with a CT aorta, but there may not be time for this as patients often rapidly become extremely unwell

Investigations

• Blood tests: Full blood count, urea and electrolytes, thyroid function, glucose, cardiac enzymes (troponin 12 hours from onset of chest pain, and in some centres an additional baseline troponin), lipid profile

• Chest X-Ray: A widened mediastinum may increase suspicion of aortic dissection; may show signs of acute left ventricular failure

• Serial ECGs: If pain persists, or if new episodes of pain, look for evolving ECG changes

Summary of ECG changes seen in a STEMI (to differentiate from an NSTEMI)

• Anterior or anteroseptal: ST elevation in V1-4

• Inferior: ST elevation in leads II, III, and aVF

• Lateral: ST elevation in V5-6 and/or lead I and aVL (high lateral)

• Posterior: anterior ST depression and positive R wave – if suspected ECG with posterior leads can be performed

An echocardiogram post myocardial infarction should be done to assess left ventricular function, and to look for complications such as mitral regurgitation. A coronary angiogram will assess whether any stenotic vessels are amenable to either stenting or bypass surgery. Secondary prevention should be started: ACE inhibitors, statins, beta-blockers, aspirin and clopidogrel, unless contraindicated. Patients should be screened and treated appropriately for hypercholesterolemia and diabetes.

Station 2: RESPIRATORY HISTORY: PRODUCTIVE COUGH

Mr Gordon is a 60 year-old gentleman who presents with a 3 day history of a productive cough and has been finding it increasingly difficult to sleep and get around his house. He is a lifelong cigarette smoker. Please take a history from Mr Gordon and present your findings.

Chest Pain

Take a pain history; use the mnemonic 'SOCRATES' as previously described.

Chest pain due to pulmonary disease is characteristically:

• Unilateral

• Aggravated by deep inspiration, coughing and sneezing (pleuritic pain)

• Usually localised to the chest wall, although diaphragmatic pain sometimes refers to the shoulder tip or anterior abdominal wall (Nerve root C3-5 supplies diaphragm but also dermatomes as above – 'C3, 4, 5 keep the diaphragm alive!')

Right lower lobe pneumonia is an important differential diagnosis of upper abdominal pain.

Breathlessness

Current Episode of Breathlessness:

• 'When did it start?' – Note what the patient was doing at the time and their location (e.g. important in occupational asthma)

• 'How did it start?' Note the speed of onset:

• 'How long has the breathlessness lasted?' 'Has the breathlessness gotten better or worse since it came on?' 'What makes it better?' (e.g. rest/inhaler). 'What makes it worse?' (e.g exercise/night time)

Previous breathing problems and baseline function

• 'How has your breathing been in the past?'

• 'Do you get breathless on lying flat (orthopnoea)?' 'Do you ever get woken up from breathlessness during sleep (paroxysmal nocturnal dyspnoea)?' 'How many pillows do you sleep on at night?' Check whether these have changed over time

• Establish change in exercise tolerance: 'How far can you walk without getting breathless at the moment on the flat/on an incline?' 'Were you able to walk further before?' 'If so, how long ago?'

Stridor

• High-pitched, musical sound heard on inspiration and aggravated by coughing

• Due to obstruction of upper airways (e.g. foreign body aspiration), or sub-total obstruction of the trachea/main bronchi (that may be due to a tumour)

Wheeze

• Coarse, whistling sound usually more noticeable during expiration

• Almost invariably accompanied by dyspnoea

• Due to obstruction of small airways (e.g. asthma)

• May get 'cardiac wheeze' due to pulmonary oedema

• Establish when the wheeze occurs. During exercise? At night? In cold?

• Monophonic? (single obstruction e.g. tumour) Polyphonic? (multiple obstructions e.g. COPD)

Cough

• Character: Harsh? Dry or productive? Paroxysmal?

• Bovine: Less explosive cough due to vocal cord paralysis (e.g tumour invasion to left recurrent laryngeal nerve)

Sputum

• Loose? Readily productive of sputum? If so, what colour, volume, frequency, consistency, and duration? Blood stained (haemoptysis)?

• Mucoid: grey, white, clear

• Purulent: yellow, green

• Mucopurulent: mixture of mucoid and purulent

• When does it occur? (e.g. night – heart failure, post-nasal drip)

Haemoptysis

• Differentiate between blood-stained sputum (blood in sputum), frothy pink sputum (pulmonary oedema), haematemesis (vomiting blood), nose bleeds

• 'How much blood did you cough up?' It can be helpful to ask the patient to quantify this by something familiar e.g. a teaspoon of blood. 'How often have you coughed up blood?'

Past Medical History

• Childhood asthma/wheeze/bronchiolitis

• Malignancy

• Infections (TB, pneumonia)

• Chest trauma or operations (including problems with intubation)

• Asthma/COPD

• Thromboembolic disease (DVT/PE)

It is helpful to check whether the patient has had any previous respiratory investigations (e.g. lung function tests, CT scans, or allergen testing).

Social History

• Recent travel: (could indicate atypical infections and long-haul travel is associated with DVT/PE)

• Occupational history: all jobs, NOT just the most recent one (e.g. asbestos exposure, coal mining, paint spraying, farming, baking)

• Pets

• Hobbies (e.g. pigeon racing)

• Alcohol consumption

• Illicit drugs: whether inhaled or smoked?

• Sexual history: HIV/AIDS and respiratory implications

Smoking History

• Calculate the pack year history (see section 1.1)

Family History

• Atopic illness, cancer, DVT/PE or infectious diseases such as TB

• Current health of close contacts (infections)

Drug History

• Use of inhalers (assess compliance and inhaler technique)

• Use of steroids (dose, route, number of courses in last year)

• Other drugs relevant in respiratory disease in terms of side effects (e.g. ACE inhibitors and cough; aspirin and NSAIDs inducing wheeze in some patients with asthma)

Allergies

• Not only to drugs but also food, inhaled allergens and pets

Systematic Enquiry

• Loss of appetite

• Malaise

• Weight loss

• Night sweats

• Fever/rigors

• Upper respiratory tract symptoms (e.g. nasal obstruction, bleeding or discharge?)

• Urinary symptoms: stress incontinence secondary to cough

• Cardiovascular symptoms: angina or ankle swelling (cardiac disease often causes respiratory symptoms, and chest pain can be cardiac in origin)

• Rheumatoid arthritis/other connective tissue diseases

• Neuromuscular diseases

Station 3: GI HISTORY: ABDOMINAL PAIN

Mrs Smith is a 25 year-old patient complaining of abdominal pain and vomiting. Please take a history from Mrs Smith and present your findings.

Pain History

• Site:'Where is the pain?' Ask the patient if they can point to a specific site. Localising the pain to a quadrant (e.g. right upper quadrant) helps narrow the differential diagnosis

• Onset: What was the patient doing when the pain came on? Large fatty meal (e.g. gall stones)? Exercise? Alcohol binge? 'Did the pain come on gradually (e.g. endometriosis) or suddenly (e.g. renal colic)?'

• Character:'What does the pain feel like?' Sharp (e.g. ectopic pregnancy)? Tight band? Dull? Electric shock? 'Is the pain at a constant level (e.g. bowel perforation), or does it increase and decrease (in a colicky pattern e.g. small bowel obstruction, biliary colic)?'

• Radiation:'Does the pain spread anywhere?' (e.g. from the epigastrium through to the back (pancreatitis)). 'Has the pain shifted from one site to another?' (e.g. periumbilical pain localising to the right iliac fossa (appendicitis))

• Associated Symptoms (as outlined in table on page 19)

• Timing:'How long does the pain last?' 'How frequently does it occur?' 'Is it constant?'

• Exacerbating and relieving factors:'What worsens the pain?' 'What eases the pain?' (e.g. paracetamol, movement, position, food). Peritonitic pain is worsened by movement

• Severity:'How severe is the pain on a scale of 1 to 10 (with 10 being the worst)? 'Is it getting better or worse?'

Has the patient ever had this pain before? Was the cause identified at that time?

Past Medical and Surgical History

• 'Any previous bowel problems?' Has the patient ever been investigated for bowel problems? (E.g. endoscopy, CT scan, colonoscopy)

• 'Any previous surgery?' (adhesions from previous surgery are an important cause of bowel obstruction)

• Previous radiotherapy treatment

Drug History

• Document all drugs currently being taken, and allergies. Ask about recent use of NSAIDs (including aspirin) and blood thinning agents (warfarin, clopidogrel) if concerned about GI bleeding. Steroids are also associated with gastric upset

(Continues...)

Excerpted from The Unofficial Guide to Passing OSCEs by Zeshan Qureshi. Copyright © 2012 Zeshan Qureshi. Excerpted by permission of Zeshan Qureshi.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

Dettagli dell?edizione

• Editore: Zeshan Qureshi
• Data di pubblicazione: 2012
• ISBN 10: 0957149905
• ISBN 13: 9780957149908
• Rilegatura: Copertina flessibile
• Lingua: Inglese
• Numero edizione: 3
• Numero di pagine: 288
• Redattore: Qureshi Zeshan