Master OSCE exam

Master

Exam
Dr. Mona Yehia M.
MBBS, MSC, SDFM
A concise guide for family medicine clinical
exams and daily general practice
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Master OSCE exam

Book: Master OSCE exam

Author: Dr. Mona Yehia M.
Revised by: Dr. Mohammed A. Alalfi
Dr. Saleh A. Alharbi
Registration number at The Egyptian National
Library and Archives: 2798/2018
L.S.B.N: 978-977-278-681-7
1st edition – January 2018
All rights reserved

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Master OSCE exam

MASTER OSCE EXAM

A CONCISE GUIDE FOR FAMILY MEDICINE
CLINICAL EXAM AND DAILY GENERAL PRACTICE

By: Dr. Mona Yehia M.

MBBS, MSC, SDFM

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Master OSCE exam

Dedication
To everyone who taught me even a single
letter and supported me

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Master OSCE exam
Dear reader,
What you hold now between your hands is the result of several years
of struggling to learn, practice and teach family medicine and general
practice.
I'm an Egyptian family medicine specialist, having Master degree in
Family and community medicine as well as Saudi Diploma of Family
Medicine.
I'm the owner and creator of (Review of Family medicine), a medical
educational web page, currently has tens of thousands of followers,
whom are all physicians of different specialties all over the world.
In this book, I collected the most common presenting problems in our
daily practice, as well as in family medicine clinical exams, discussed
concisely how to approach them in a family medicine biopsychosocial,
patient-centered way.
Each problem presented in one page, making it easier to memorize,
with the help of colored icons, that are consistent throughout the book.
I chose 30 topics of most common consultations in family medicine, 10
counseling and health education topics, and 10 examination and minor
procedures topics as well.

Each topic shows a complete approach to the problem, including:

history, examination, investigation, management options including
health education and pharmacological agents, differential diagnosis as
well as red flags and referral criteria. With a very important
introduction about OSCE station and how to tailor according to age and
sex, and a very important summary of recommended periodic health
examination in different age and sex.

I mentioned the brand names of pharmacological management, as a

guide for prescribing.
Wish you all good luck and to have a great benefit of this book.
Dr. Mona Yehia M.
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Master OSCE exam

Revised by:

1. Dr. Mohammed Aliraqi Alalfi

MBBS, DLO, ABFM

Family Medicine Consultant - Assistant

Professor in Qassim University – Saudi

Board Trainer

2. Dr. Saleh Ali Alharbi

MBBS, SBFM

Family Medicine Consultant – Saudi Board

Trainer

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Master OSCE exam

Recommendation

It was my pleasure to review this book (Master

OSCE exam) written by Dr. Mona Yehia
Mohammed, who was one of my most active trainees
in Saudi Family Medicine training program.

I found her book very useful and concise, thanks to

her skills and talent in teaching and summarizing.

I recommend it to read by all general practitioners,

family physicians, post-graduate residents and
medical students as well.

I wish her all the best and success.

Dr. Mohammed Alalfy

Assistant professor – Consultant Family
medicine – Saudi Board trainer

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Master OSCE exam

Recommendation

I reviewed (Master OSCE exam) book written by Dr.

Mona Yehia, and I must admit I am really impressed
with its professional, highly informative, well-
structured and enjoyable material, despite its
relatively small size.

I know dr. Mona as a trainee and a colleague, and

her dedication and enthusiasm are really inspiring.

I wish you many years of success and great

achievements. Congrats.

Dr. Saleh Alharbi

Consultant family medicine
Saudi Board trainer

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Master OSCE exam

Introduction

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Master OSCE exam

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 Master OSCE exam

Objective Structured Clinical Examination (OSCE)

OSCE exam consists of a series of stations where you are presented typical
scenarios. All candidates rotate through the same series of stations, each
station is 7-10 minutes long with two minutes between stations. At each
station, a brief written statement introduces a clinical problem and outlines
your tasks (e.g., take a history, perform a physical examination, etc.). In
each station, there is at least one standardized patient (or a simulator) and a
physician examiner.
Standardized patients have been trained to present a real patient’s signs
and/or symptoms in a reliable and consistent manner. You should interact
with standardized patients as you would with your own patients. This
includes draping a patient appropriately for different elements of a physical
examination (regardless of their gender). Interacting with standardized
patients also includes questioning them and responding to their problems.
Your interaction with the standardized patient is part of what the physician
examiner is assessing. Your performance is assessed based on your ability
to focus on the task and the patient problem.
While you will generally not interact with the physician examiner, they may
intervene in the following circumstances:
• If they believe you have misunderstood the directions (e.g., you are pursuing
a history during the physical examination station)
• If they believe there is a problem for the standardized patient
• To provide you with information or results further to an examination
maneuver on your part. This will save you time and allow you to move on
to other sections of the physical examination. For instance, an examiner may
be directed to give a blood pressure reading or the results of an
ophthalmoscopic examination. They can only do this in certain stations and
only if you have initiated the examination maneuver.
• To provide results for some tests. This only occurs at those stations where
you are expected to order tests or investigations. Results are not given for
all the tests or investigations that are ordered. Please note that ordering a
certain laboratory investigation may be a correct procedure, even if no
results are forthcoming.
You may be requested to bring your own examination equipment. You
should have your ID and lab coat.
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Master OSCE exam
OSCE Station

1. First, wash your hands.

2. Greet the patient and introduce yourself (name and position).
3. Check the patient identity (name and date of birth).
4. Start with open question about complaint (how can I help you?)
5. If complaint does not need urgent interference start building a rapport with
patient starting by brief personal and social history.
6. Analyze presenting complaint [Onset – course – duration - recurrence –
aggravating/relieving factors – associated symptoms (to limit the differential
diagnosis) – Investigations done – action taken (medication/procedures) and
response]. If pain: add: site – character - radiation – grading 1- 10
7. Start with open questions and progress to closed ones as needed.
8. Use non-verbal communication skills (such as maintaining eye contact,
empathic facial expressions, caring tone of voice, nodding, inclining your
body forward and active listening). Don't be judgmental.
9. Exclude red flags and alarm features.
10.Explore patient's idea about the condition, his/her concern, expectation and
impact of condition on quality of life (ICEE).
11.Enquire about smoking, alcohol or drug abuse.
12.Past history: Chronic or infectious diseases - Hospital admission - Surgical
operations - Blood transfusion - Travel – Allergies
13.Family history: of same condition, or chronic, infectious or inherited
diseases.
14.If patient is female: take menstrual, obstetric and contraceptive history.
15.Summarize the key data in the history and complaint, with clarification of
unclear or missing points. Check for hidden agenda.
16.Ask for consent for examination, explain procedure and wash hands.
Summarize examination findings and reassure the patient.
17.Request rational investigations if needed.
18.Management of presenting complaint, as well as continuous problems (as
chronic diseases) and opportunistic health promotion (including health
education/counseling, immunization, primary prevention and screening)
sharing decisions and responsibilities with patient, or Refer if needed, for
further investigations or management options.
19.Check patient's understanding and arrange for follow up providing
guidance on how and when to seek further medical help (safety netting)
20.Thank patient, wash hands and manage your emotions before next
consultation (housekeeping)
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Master OSCE exam
OSCE Station template

1. Revise patient's data

2. Start

3. How can I help you?

4
.

5. Summarize history

6.

7. Summarize findings

8.

9.

10. Housekeeping
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 Tailor OSCE station to a child (0 – 5 years)
1. Pregnancy, birth and neonatal history: maternal 2. Social history: order in family – father's job – living
infections, smoking, drugs, illnesses during pregnancy – status - working mother? – Who is the care taker? – Family
gestation at birth – mode and duration of delivery – birth function – family member with psychiatric illness or
wt – birth injury – congenital malformation – neonatal alcohol/drug abuse – Family history of chronic or inherited
jaundice, fever, fits, bleeding disorders, feeding problem 3. Feeding history: breastfed or
artificially fed or both – difficulty –
10. Health maintenance: screening formulation – sterilization - how
– immunization – health education - many feeds/day – complementary
anticipatory guidance - Vitamin D feeding (quantity, quality, timing)
400 units since birth + 1 mg 4. Vaccination: routine schedule
elemental iron/kg/d at 4 months for + influenza yearly started 6 mo
exclusively breastfed infants
5. Growth: plot wt, length (up
to 2 years, then height), head
9. Child abuse: bruises, cuts and circumference & BMI on chart
fractures of different healing stage – Red flag: < 3rd percentile or
developmental delay – underweight crossing 2 major percentiles
- aggression – poor hygiene – poor
bond with parents - poor social skills 6. Development: Red flags: not achieve
indicated milestones – strong parent
8. Safety & injury prevention: indoors & concern – significant loss of skills – lack of
outdoors (burn – drowning – fall – poisoning response to auditory/visual stimuli – poor
7. Parental concern:
– chemicals – choking - electric shock - interaction – motor/sensory difference
explore and take it seriously
transportation – sports – bicycle – violence) between both sides of body - floppy or stiff

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Master OSCE exam

Tailor OSCE station to an Adolescent (10 – 19 yr old) (WHO)

1. Risk reduction: inquire about [driving (esp. motor
cycle) - unsafe sexual behaviour which may lead to
unintended pregnancy & sexually transmitted diseases
– exposure to violence or feeling unsafe – weapons]
8. Health maintenance: Screening –
Immunization - Health & sexual
education – identify main concerns of
adolescent and answer his questions -
parental guidance for how to deal with
adolescent & prepare for autonomy -
manage continuous problems
2. Relations to family members and community:
Family function and transitions – power struggle – home
environment – social history - Exclude disruptive behavior
disorders (aggressive - angry outbursts – refuses to comply
with rules - antisocial – destruct property – skipping school)
3. Healthy food vs junk food and
empty calories - Caffeinated
beverages – Obesity - Exclude
eating disorders (anorexia and
bulimia nervosa, binge eating) –
obsession with being thin in girls

7. School performance, relations to 4. Abuse: Physical/emotional/sexual

other students and teachers, skipping Signs: social withdrawal – change in
school, friends known to parents?, behaviour/school performance – fear
change type?, after school activities – avoidance of situations or places -
attempts at suicide or running away
6. Mental health: Screen for depression
Anxiety disorders, Suicidal /homicidal 5. Tobacco, alcohol & illicit drug: Signs: change in peer group, careless
thought/attempts, Body dysmorphic with grooming, decline in academic performance, loss of interest in favourite
disorder, Personality disorder, psychosis activities, change in eating or sleeping habits, conflicts with family, stealing

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Master OSCE exam
Tailor OSCE station to an elderly (≥ 65 yr old) (WHO)
1. Activities of daily living:
Set of activities necessary for
normal self-care and
independency, such as:
toileting, bathing, eating,
dressing, and transferring
10. Health maintenance:
screening/immunization/HE
9. Geriatric depression:
Underdiagnosed - screen last
2 wks for loss of interest and
depressed mode – Can
cause reversible dementia –
should assess suicidal risk
8. Elder abuse: Physical, sexual,
emotional, financial, or neglect.
Sign: Bruises/cuts/fractures
inconsistent with explanation –
unsuitable clothing – bad hygiene –
malnutrition - control - forced
isolation - argument with elder –
changed personality - missing
appointments – inadequate care
(medication, investigation, aids)
2. Mini-cog test: Step 1: Tell patient 3 unconnected words e.g. ball,
tree, book – ask him to repeat them back – Step 2: Ask to draw a
clock with all numbers, and hand set to 10 past 11 (11:10) within 3
min (2 points if normal – 0 if abnormal or refused). Step 3: Recall 3
words stated in step 1 (1 point for each) <3 = dementia
3. Timed up and go test: patient
sitting in a standard arm chair, identify
a line 3 m, ask him to stand up, walk
to the line at his normal pace, turn,
walk back to chair and sit down. ≥12
sec = high risk for fall
H/o falls last year – home adjustment
4. Mini-Nutritional Assessment
score: last 3 months did he have:
↓ food intake, wt loss, immobility,
stress, neuropsychological problem
+ BMI or calf circumference
5. Polypharmacy: ≥ 5 medications
different physicians + herbal & OTC
May cause severe interaction, side
effects, and non-adherence
6. Urinary: underreported –may lead to social
7. Assess visual acuity & isolation and abuse Fecal: chronic constipation,
hearing, inquire about using aids painful anal condition, or neurological
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 Screening and immunization children and adolescents
Age Screening & prevention Immunization
group
Metabolic screening,
Newborn hemoglobinopathies and Hepatitis B within 24 hrs
(0-28 d) thyroid function (A) of birth
Hearing screening (B) + routine immunization
Topical ocular prophylaxis for schedule
gonococcal (A)
Oral fluoride supplementation
if water supply is deficient in Routine immunization
Children fluoride 6 m – 5 yrs (B) schedule
6m–5 Fluoride varnish starting at + Annual inactivated
yrs age of 1ry eruption up to 5 yrs Influenza vaccine starting
(B) from 6 mo
Vision screening 3 -5 yrs (B)
HPV vaccine to all
Tobacco use counseling in
adolescent aged 11 or 12
school-aged & adolescents
yrs, 2 doses, 2nd after 6-12
(B)
mo, or 3 doses (0, 1-2, 6
Obesity screening 6 yrs &
> 5 yrs m) if initiated at age 15 or
older (B)
older
Screen for depression in
Tdap 1 dose to all
adolescent 12 -18 yrs (B)
adolescents aged 11 or 12
Counsel for skin cancer
yrs regardless of interval
prevention for fair skin starting
since last tetanus and
at 10 years – minimizing
diphtheria containing
exposure to ultraviolet (B)
vaccine
Screen for HIV starting at 15
yr if at increased risk (A)
Chlamydia & gonorrhea for
At risk sexually active females up to
(Sexually 24 yr or older if at increased
active risk (B)
- IV drug Screen for hepatitis B (B)
abuse) Folic acid 400 to 800 mcg
daily if planning or capable of
pregnancy (A)
Inactivated influenza
Hepatitis B – HIV – Syphilis in vaccine anytime during
st
Pregnant 1 visit (A) pregnancy
Screen for gestational DM Tdap vaccine (any time
after 24 wks (B) but optimal between 27&
36 wks)

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Master OSCE exam
Adult Screening and immunization Guidelines (USPSTF)
Age Screening Immuniza-
Male Frequency Female Frequency tion
Pap test Td every
starting 3 yrs 10yrs
after 1st +
intercourse or Every 3 yrs Flu
at age 21 in vaccine
Measure
sexually yearly
18 Blood
Every 2 yrs active which +
- pressure
is 1st (A) Pneumoco
(A)
24 Chlamydia & Every year up to ccal
Gonorrhea in age 24/ vaccine
all sexually Or older if at risk one dose
active women (B) <65 yr if at
BP Every 2 yrs high risk
Screen all adults for tobacco use (A) and alcohol misuse (B) with brief behavioral counseling
HIV & Syphilis infection screen for persons ages 15 to 65 years who are at increased risk
Adults ≥ 20 years for lipid disorders if at high risk of CAD (B)
Screen all adults for obesity, refer for multicomponent intervention if ≥30kg/m2
Lipid ≥ Every 5 yrs Every 3 yrs Td every
Pap test
35y (A) 10yrs
Lipid ≥45y(A) Every 5 yrs + Flu
25 Blood Every 2 yrs vaccine
Pressure BP Every 2 yrs
- yearly
- Cancer colon at age 40 if 1st degree (or two 2nd degree) relative have colon cancer or
49 adenomatous polyps (or 10 yrs earlier if relative diagnosed < 60yrs whichever comes first)
- Screen for blood glucose in adults 40 to 70 years who are overweight or obese q 3 yrs (B)
Prostate Insufficient Pap test Every 3 yrs Td every
Cancer evidence Mammogram Every 2 yrs (B) 10yrs
Lipid Every 5 yrs Lipid Every 5 yrs +
BP Every 2 yrs Every 2 yrs Flu
BP
50 vaccine
Occult fecal Occult fecal yearly
- blood /yr blood /yr +
64 Cancer Sigmoidoscop Cancer Sigmoidoscopy/ Zoster
colon y/5 yr colon 5 yr (Shingles)
(A) Colonoscopy/ (A) Colonoscopy/ vaccine
10yr 10yr once a life
Until 75 ys Until age 75 ys >60yrs
Aspirin 45 to 79 yrs Aspirin 55 – 79 yrs
Screen lung cancer by low dose CT in adults 55-80 ys who smoke 30 pack/yr or quit within past 15 yrs
Statin if 40-75 yrs or CVD risk, Aspirin in 50-59 yrs with ≥ 10% 10-year CVD risk & no bleeding risk (B)
Abdominal Screening Td every
aortic once, men 65- Every 2 yrs 10yrs
Mammogram
aneurysm 75 yrs who till 74 yrs + Flu
≥ (B) ever smoked vaccine
65 Lipid Every 5 yrs Lipid Every 5 yrs yearly
BP Every 2 yrs BP Every 2 yrs + Zoster
vaccine
Ca colon Till age 75 yrs once a life
Cancer ≥65 yrs or +pneumoc
Till age 75 yrs Bone
colon younger if high occal one
density (B) dose >65
fracture risk
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Master OSCE exam

Consultation
and
health maintenance

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Master OSCE exam

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Master OSCE exam
1. Abnormal uterine bleeding (AUB)

Age - marital status/sexual activity - detailed menstrual &

bleeding history - associated symptoms (pain/fever/discharge/
ovulation symptoms) - relation to coitus - contraceptive -
bleeding/bruises - drugs (tamoxifen - anticoagulant - drugs
causing hyperprolactinemia) - thyroid dysfunction - surgeries

Frequency every 24-38 days – fairly regular intervals (variation

less than 7-9 days) – blood loss < 80 mL – duration 4.5-8 days

Pregnancy the 1st cause to be excluded in AUB in all women

in reproductive age – Causes in non-pregnant women include:
Heavy menstrual bleeding: leiomyoma - adenomyosis - C.S.
scar defect - bleeding disorder - endometrial hyperplasia - IUD
Intermenstrual bleeding: endometrial polyp – endometritis –
PID – contraception - endometrial hyperplasia/carcinoma
Irregular bleeding (ovulatory dysfunction): characterized by
phases of no bleeding lasting for 2 or more months, and
phases of spotting or heavy bleeding. Can be caused by PCO
– thyroid dysfunction - hyperprolactinemia - uncontrolled DM -
eating disorders - intense exercise - anti-psychotic/epileptic

General: fever, pallor, ecchymoses, enlarged thyroid, evidence

of hyperandrogenism (hirsutism/acne/clitoromegaly/male
pattern baldness), acanthosis nigricans, galactorrhea
Pelvic: Potential sites of bleeding (vulva/vagina/cervix/urethra/
anus/perineum), volume of current bleeding, uterus size/
contour, adnexal mass/tenderness, cervical motion tenderness

Pregnancy test in all reproductive-age women with AUB –

CBC ± (TSH – prolactin – androgen – FSH/LH – coagulation
profile - ultrasound) based upon history & examination
Endometrial sampling in all women ≥ 45n yrs with AUB, and
in <45 yrs if persistent/refractory bleeding, or hormonal therapy

Hormonal: Combined contraceptives - cyclic progestin (for 21

days, starting 5th day of flow) for 3-6 months e.g. Provera®
(medroxyprogesterone 10mg) tab or Primolut-N®
(noresthisterone 5mg) tab - levonorgestrel IUD (Mirena®) -
high-dose estrogen only if extremely heavy flow
Non-hormonal: NSAIDs – tranexamic acid (Cyklokapron®
500mg 2 tab TID) starting on 1st day of flow for 5 days - manage
other endocrinal causes e.g. hyperprolactinemia, thyroid
Surgical: removal of local cause (myomectomy/polypectomy/
..) - hysterectomy if hormonal therapy failed or contraindicated
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Master OSCE exam
2. Acne vulgaris

Age – smoking – drugs (e.g. steroids, androgens, OCPs) –

use of cosmetics – relation to menses - stress - previous
use of topical and/or oral medications for acne & response?

What does he know about acne? What's his main concern

about it? How it affects his life? What's his expectation?
Screen for anxiety/depression/social withdrawal

BMI – hirsutism – acanthosis nigricans – abdominal stria

Comedonal (black & white heads) – Mild (comedones + few
papules/pustules) – Moderate (comedones + more
papules/pustules) – severe (Nodulocystic ± scars)

Acne is a skin condition characterized by excess sebum

production, hyperkeratinization, and bacterial growth with
inflammation. It maybe precipitated by hormonal changes,
occlusive cosmetics and stress. Vigorous washing or
scrubbing can worsen acne and damage the skin's surface.
No strong evidence about role of diet in acne.

Non-soap cleaner (Cetaphil® - Sebamed®) twice/day - dry

gently - don not pick pimples - moisturize - oil-free or non-
comedogenic cosmetics/skin products - sunblock ≥ 15 SPF

If only Comedonal: topical retinoid [e.g. Acretin® (tretinoin) –

Differin® (adapalene)] once before bed time
If mild: topical retinoids + topical antibiotic (e.g. Dalacin-T®
(Clindamycin 1%) or Derma-T® (erythromycin 2%)
If moderate: Topical retinoids and/or Benzoyl peroxide (e.g.
Acnezoyl®) + oral antibiotics [e.g. Vibramycin® (doxycycline)
100mg or Erythrocin® 250mg (erythromycin)]
If severe: oral isotretinoin, prescribed by dermatologist
Choose vehicle: gel in oily skin – cream or lotion in dry/normal
– solution for large area – foam for hairy area
Wash face & let dry before application – apply thin film – try
1st away from face – can cause erythema, peeling & dryness

Do not rush – don't evaluate response before 4 wks – do not

stop once improved, may need maintenance for > a year

If not responding to treatment - to exclude another differential

- If severe refer to dermatologist to prescribe oral isotretinoin
- If has indented scars refer for Fraxional laser
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Master OSCE exam
3. Anemia
May be presented as easy fatigue, headache, bleeding,
exertional dyspnea, pica - Or maybe noticed as pallor in
examination - or discovered in routine investigation

Nutrition: Is patient vegetarian? On diet? eating

disorders or food allergy? Had bariatric surgery?
full nutritional history or food diary for 3 days

Blood loss: per orifices e.g. Vaginal/rectal/

epistaxis/hematuria... – black stool – NSAIDs use
– prolonged dyspepsia -

FH of hemoglobinopathies, cancer colon or IBD

Vitals - Pallor – jaundice? – angular stomatitis/glossitis –

spooning of nails – CVS – rectal examination
If child  check spleen and LNs + signs of neglect

CBC: anemia is diagnosed when HBG < 13gm/dl in men, <

12 in women, < 11 in pregnant, < 10.5 in children - MCV <
78  microcytic, > 95  macrocytic, otherwise normocytic

1. Microcytic: Iron deficiency (high RDW >15, low S. ferritin,

high TIBC – Mentzer index > 13) – Thalassemia (increased
ferritin – normal TIBC – Mentzer index < 13) – anemia of
chronic disease – sideroblastic anemia – lead toxicity
2. Normocytic: acute blood loss - hemolysis -  production
3. Macrocytic: Vit B12/folic deficiency - alcohol - liver disease

Food rich in iron as meat, beans, lentils, dark green leafy

vegetables, dried fruits and iron-fortified cereals
Adult: 120 mg elemental iron/day - Child: 3mg/kg (up to 60
mg/d) - 3-4 months after correction of HGB to replenish
stores. Reserve parental iron to resistant patients, who do
not tolerate oral, or have malabsorption, renal failure or IBD

Repeat CBC after 1 month  should have at least 1 gm

increase in HGB to confirm iron deficiency anemia, if not:
1. Check adherence
2. Re-evaluate: - Family history of hemoglobinopathies e.g.
thalassemia, sickle cell, elliptocytosis, ...
- Iron studies and blood film
Resistant – HGB<7 gm/dl – suspect hemolysis or malignancy
– man or postmenopausal female with no obvious cause
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Master OSCE exam
4. Antenatal care
Age, occupation, smoking, alcohol, chronic diseases, drug
use, planned pregnancy?, screen for depression & abuse,
consanguinity, family history of congenital/inherited diseases

LMP – EDD [add 7 to days (or 15 in Hijri) and 9 to months]

GTPAL [G=gravida - T=term ≥ 37 wks - P=preterm < 37 wks
- A=abortion (fetal demise < 20 wks, if ≥ 20 wks  IUFD or
stillbirth) – L=living (neonatal death if < 28 days after delivery)
Previous C.S.? –last delivery - h/o GDM, preeclampsia,
bleeding – postpartum complications (e.g. fever, bleeding,
depression) – child with inherited or congenital problem
Pre-existing problem (chronic, infectious, autoimmune,
PCO, infertility) – Obesity – Age (<18 yr, >35 yr) –
alcohol/smoking – Previous pregnancy (recurrent abortion,
preterm, stillbirth, birth defects, Rh incompatibility, C.S.,
thromboembolic) - Current pregnancy (multiple gestation,
GDM, high BP, bleeding, growth & amniotic fluid problems)

Initial: BP - BMI - general – pelvic – breast & nipples - dental

Every visit: BP and Wt every visit – fundal height (starting 20
wks) – foetal heart sound (starting 10 wks) – LL oedema

Initial: BG & Rh – CBC – urine – HBsAg – Rubella – syphilis

– HIV - Each visit: urine dipstick
12-16 wks  urine for asymptomatic bacteriuria
12 wks  Dating U/S
11-13 wks  Combined test (U/S – ßHCG – PAPPA)
18-20 wks  Anomaly scan
24-28 wks  1 hr 50 gm glucose challenge test (+ve >140)
35-37 wks  rectovaginal swab for group B streptococcus

Small frequent meals – ginger/lemon for nausea – light

exercise – avoid [OTC drugs & herbals, hair dye, hot bathing,
scuba diving, long trip] – air travel safe up to 36 wks

Folate 400 mcg daily (1mg if diabetic or epileptic, 5 mg if H/o

neural tube defect) – 30-60 mg elemental iron daily, start 2nd
trimester – anti-D if Rh -ve (at 28 wks, 1st 72 hrs postpartum)

Monthly visits until 28 wks – then every 2 wks until 36 wks –

weekly onwards (at least 4 visits throughout pregnancy)

Severe vomiting - bleeding - BP≥140/90 with [proteinuria, low

platelet, renal/liver impairment, cerebral/visual symptoms] -
BP>160/110 - epigastric pain - severe headache – jaundice
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Master OSCE exam
5. Breaking bad news
Setting up the interview: a comfortable, quiet and private
room – minimize interruption and turn off phone – have tissue
available – close chairs with no physical barriers (as desk) –
greet the patient (and relative if present) and have him/them
seated – establish rapport – ask patient if he prefer to be with
a family member or a friend, or if someone is already in the
room check if he would prefer to be told alone

Explore patient's perception: discuss symptoms leading to

investigations done – check what he already knows or
expecting – what his main concern is?

Wait for patient's invitation: check if the patient wants to

receive their results today “I have the result here today; would
you like me to explain it to you now?”. Some patients who may
recognize the news is not what they hoped for, may want to
postpone it until family are present, or after an important event

Give Knowledge and information: Give a warning shot to get

the patient ready "As you know we did …. (investigation) and
unfortunately the results were not as we hoped" – allow a large
pause if needed to let patient digest that shot – then (in a
respectful gentle tone) provide the diagnosis in simple clear
words "I'm sorry to tell you this, but your investigations show
you have …." – give facts in small doses with pausing in-
between – give time for patient's emotional reaction, wait for
him to re-initiate the conversation, or seem to be ready to talk

Empathic response to patient's emotions: acknowledge his

emotions and just listen with acceptance and empathy -
Patient's reaction varies (crying, denial, angry, aggression,
asking questions in disbelief, or just go quiet) - let the patient
lead the conversation, and you only answer his questions, if
silence prolonged you can ask about how he feels - if he turned
violent ensure your safety first - Never give false hope – if he
asked about information you don't know; tell him you don't have
enough information now, and by the next visit you'll have the
answers, or refer to a specialty team under your follow up

Have a clear strategy and summarize: agree on a plan about

next step - don't rush the patient to make decisions if possible
– summarize and check patient's understanding – offer
assistance to call a family member to fetch him – give yourself
time to resolve negative feelings before the next consultation
22
Master OSCE exam
6. Bronchial asthma
Frequency & diurnal variation of cough / wheeze / SOB
Other atopic diseases? Family History of BA?
Related factors: drugs/smoking/pets/occupation/residence?
Brief personal, social, past and family history
Control = [symptoms or need for reliever ≤ twice/wk – no
night symptoms or activity limitation - ≤ 1 exacerbation/year]

Vital signs - Wt - Ht - cyanosis - distress - perfusion – JVP –

chest – CVS - ENT/skin for allergy – LL edema

Peak flow meter: Check predicted PEFR according to sex, Ht

& age: > 80% green  Continue same plan - 50- 80% yellow
 step up - < 50% Red  get help/start oral steroid

What is BA? - How & when to use different types of inhaler &
peak flowmeter – action plan – avoid triggers – red flags

Chronic inflammatory airway disease with Hyper-

responsiveness leading to paroxysmal & reversible
bronchospasm related to triggers

Reliever (e.g. Ventolin®): bronchodilator, use as needed to

relieve symptoms, or 10-15 min before exercise
Preventer (e.g. Flixotide®): steroid, anti-inflammatory, use
regularly if indicated
Mixed (e.g. Seretide®, Symbicort®): bronchodilator + steroid
Only 10% of powder reaches airways with proper technique:
Breath out  seal mouth  press and inhale  hold breath
for 10 sec  exhale normally  can repeat after 1 min

Step 1: Start SABA as needed - Step 2: add low dose ICS

Step 3: medium dosed ICS – Step 4: LABA + medium dosed
ICS – Step 5: LABA + high dosed ICS – Step 6: add oral
corticosteroid (Consider Omalizumab if having allergies)
In exacerbation: 4-10 puffs of reliever/nebulization q 20 min
± controlled O2 – re-evaluate after 1 hr  ER if not improved

Check adherence – environmental & trigger control (exercise –

emotions – cold air - dust mites – pets – mold - cockroaches –
smoke - perfumes – air pollution – chemicals) – comorbid
conditions (URTI, GERD...) - Step-up - Reconsider diagnosis

PEFR < 50% - distress (RR >30 + use of accessory muscles)

not improved by BD - severe limitation of activity - difficult to
complete sentence – can't lie flat - O2 saturation < 90%
23
Master OSCE exam
7. Chest pain
Typical anginal pain: substernal – discomfort – provoked by
exercise or stress – relieved by rest or nitrates
if severe give IV morphine & 0.5mg sublingual nitroglycerine
1. Acute myocardial infarction: pain radiate to arms, S3, BP
2. Chest wall: localized pain, reproducible by palpation
3. GERD: burning, sour/bitter taste, improve by PPIs/antacid
4. Other: panic, pericarditis, pneumonia, PE, aortic dissection
Site: retrosternal vs lateral
Radiation: cardiac  Lt arm, shoulder, neck, jaw - aortic
dissection  back
Character: constricting/heaviness  cardiac – stinging 
chest wall – burning  GERD
Duration: if cardiac pain last for > 15 minutes & not relieved
by nitrates  Acute coronary syndrome (unstable angina/MI)
Severity on 1-10 scale
Provoking: exercise/stress  cardiac – inspiration /reclining
 pericarditis – palpation  MSK – hunger/eating  GERD
Relieving: rest/sublingual nitrates  cardiac – leaning
forward  pericarditis – food/antacid/PPIs  GERD
Associated symptoms: cough – acid regurge - skin rash …

Symptoms of DVT (3) - No alternative diagnosis better

explains illness (3) - tachycardia (1.5) - immobilization (1.5) -
prior H/o DVT or PE (1.5) - hemoptysis (1) - malignancy (1)
Score > 6 high probability of PE - <2 low probability

Sweating, in pain, S3 gallop, hypotension, tachycardia  MI

Unequal BP/radio-radial delay  aortic dissection
Friction rub, tachycardia, ↑ JVP  pericarditis
Fever/egophonypneumonia–Tachypnea/tachycardiaPE

ECG  ST elevation ≥ 1mm in ≥ 1 lead (MI) - saddle shaped

in most leads (pericarditis) - ST depression (ischemia)
CXR  wide mediastinum (aortic dissection) – pericardial/
pleural effusion – CHF – consolidation – pneumothorax
Cardiac enzymes – D-dimer (Well's<2), angiography (≥6)
Sublingual nitroglycerine (GTN) 0.5 mg, if improved 
reassure + long term management: control CVD risk factors
(healthy diet – wt loss – control DM/HTN/dyslipidemia - stop
smoking - physical activity – stress management), if not
improved give another after 5 min, if not improved after 3 tabs
give 4-tab Aspirin 81-100mg + O2 + IV morphine, refer ER
Refer other causes as PE, aortic dissection, pneumothorax...
24
Master OSCE exam
8. Cough
Age - occupation - onset - course - duration (chronic>8 wks) -
recurrence – aggravating/relieving factors – associated
symptoms (fever – sputum – sore throat - runny nose - wheeze
- SOB - heartburn - chest pain - nausea/vomiting/diarrhea –
frequent throat clearing - muscle ache – night sweating – wt
loss – extreme fatigue) – smoking – drugs – atopy - malignancy

1. Infection: acute/chronic bronchitis -pertussis -TB- pneumonia

2. Asthma: cough, SOB and wheezing in response to triggers
3. Upper airway cough syndrome: rhinosinus conditions related
to cough: postnasal drip, allergic/non-allergic rhinitis, sinusitis
4. Gastroesophageal and laryngopharyngeal reflux
5. Drugs (angiotensin converting enzyme inhibitors ACEI)
6. Chronic obstructive airway disease and chronic bronchitis
7. Congestive heart failure and pulmonary edema
8. Foreign body and fluid aspiration
9. Tumor: bronchogenic carcinoma – thyroid mass
10. Others: sarcoidosis - psychogenic - anatomical (as Zenker
diverticulum, tracheoesopageal fistula, arteriovenous
malformation) - neuromuscular disorder - chronical tonsillar
enlargement – ear foreign body or impacted cerumen – PVCs
Dyspnea/distress – hemoptysis – wt loss – persistent fever –
chest pain – orthopnea – LL edema - risk factors for TB or HIV
Vital signs (temp – RR – pulse) - cyanosis – clubbing - signs of
distress – ENT examination – cervical and supraclavicular
lymph nodes – full chest examination – LL edema

CBC with differential - sputum cytology – serum procalcitonin

(high in bacterial infection) - CXR/CT – spirometry with BD
Reassure that coughing is important for clearing secretions
from airways and assist in recovery from respiratory infections
– most cases of acute bronchitis are viral – cough of acute
bronchitis generally persists 2-3 wks – maintain good fluid
intake, proper hygiene, use of humidifier & smoking cessation

Acute cough: There is a little evidence to support use of cough

suppressants, mucolytic or expectorant agents – no need for
antibiotics unless bacterial, or at-risk patient with comorbidities
Chronic cough: Manage the cause/stop ACEI  empiric
treatment for postnasal discharge (oral 1st generation
antihistaminic + decongestant ± intranasal steroid)  empiric
management of asthma by inhaled bronchodilators/steroids 
empiric treatment for GERD by PPIs  refer to pulmonologist
25
Master OSCE exam
9. Depression
Screen by Patient health questionnaire PHQ-9 in patient with:
- Chronic (esp. uncontrolled), disabling, or disfiguring disease
- Multiple vague somatic complaints e.g. headache, fatigue, ..
- Looks depressed, teary, looking down, avoiding eye contact
At least one of [Depressed Mode – Markedly Diminished
Interest in All or Almost All Activities] + ≥ 4 of [significant wt
loss/gain or decreased/increased appetite - insomnia or
hypersomnia – psychomotor retardation/agitation - fatigue or
loss of energy - feeling worthless or excessive guilt sensation
– decrease ability to think or concentrate – recurrent thoughts
Z
of death or suicidal ideation] nearly every day for > 2 wks
Suicide risk (thoughts – plan - previous attempts)
↑ in male, lack support, major physical/mental illness

Psychotic features: delusion and/or hallucination

Manic episode: inflated self-esteem – decreased

need for sleep – pressure to keep talking – flight of
ideas – distractibility – increase in goal-directed
activities – excessive involvement in activities that
have high potential for painful consequences

Drug abuse or alcohol

Nature of disease – long course and delayed action of SSRI

'Adverse effects, patient preference and cost' dictate choice:

1. Fluoxetine (Prozac® 10, 20mg cap): stimulant - lower
discontinuation reaction (long half-life) - delayed onset of
action, avoid in severe depression with agitation/anxiety
2. Sertraline (Zoloft® 25,50,100mg): can be used in breast-
feeding & post MI. Has benefit in premature ejaculation
3. Citalopram: cause dose-dependent QT prolongation
4. Escitalopram (Cipralex®10,20mg): lowest drug interaction
5. Paroxetine (Seroxat® 10,20,30mg or Seroxat® CR 12.5,25
mg): sedative - wt gain - high incidence of discontinuation
reaction - avoid in pregnancy & sexual dysfunction.
6. Fluvoxamine (Faverin® 50, 100mg): less sexual
dysfunction, high GIT problems, more drug interaction
7. TCAs: sedative - anticholinergic side effects

Start low dose 1st wk, f/u weekly 1st 4 wks, wait 2-12 wks for
improvement, continue 4-9 mo after satisfactory response,
withdraw gradually to avoid discontinuation syndrome

Refer to ER if high suicidal risk - Refer psychiatry if psychotic

features, suspect bipolar, resistant to treatment, or recurrence
26
Master OSCE exam
10. Diabetes
Age – occupation/education – marital status – had DM for how
long? – frequent hypoglycemia? – symptoms of complication
(altered vision - chest pain – tingling/burning of hands/feet –
foot lesion - calf pain on walking - sexual dysfunction) - ER
admission for DM emergency? - ICEE – screen for depression

Age (M>45, F>55), obesity, smoking, DM, HTN, dyslipidemia,

sedentary life, unhealthy food & Family history of premature
coronary heart disease (<55 yr in male or 65 yr in female)

Wt, Ht, BMI – BP – Thyroid – CVS – abdomen – FOOT –

signs of 2ry DM (hemochromatosis – Cushing – Acromegaly
– PCO - …) – fundus examination at time of diagnosis in type
2, 5 yrs after diagnosis in type 1, then annually - skin - thyroid

Glucose monitoring each visit (goal FBS 80 -130 mg/dl –

PPBS <180mg/dl) – HbA1c q 3 months if meeting goals, 6 mo
if not (goal <7%, or ,8% if complications or comorbidities) -
Annual [RFT including eGFR and urine albumin: creatinine
ratio – fasting lipid profile – LFT] – initial ECG - TSH in DM 1

Chronic disease due to ↓ insulin production, insulin

resistance or autoimmune ß cell destruction. Insulin
facilitate glucose entry to cells, needed for their function
Adherence to management plan (both pharmacological and non-
pharmacological) lower risk for micro (retinopathy, nephropathy,
neuropathy) & macrovascular (CAD, PAD, stroke) complications

Whole grains, fish, skinless chicken, lean beef, more vegetables

and low glycemic index fruits, limit sweets and added sugar, limit
sodium to < 2500 mg/day, reduce saturated and trans-fat, moderate
intensity exercise 150 min/wk – reduce wt to BMI (18.5 – 24.9)
Glucose<70 mg/dl - Symptoms: tachycardia, sweating, shakiness,
intense hunger, or confusion – Management: 15 gm sugar (3
spoons or 3/4 cup of juice), recheck after 15 min, repeat till 90mg/dl

Self-monitoring of blood glucose is recommended if patient is on

insulin; recurrent hypoglycemia; using oral medication increase risk
of hypoglycemia while driving or operating machinery; or is pregnant

Wash with lukewarm water & soap, dry gently especially toe webs,
moisturize but not in toe webs, trim nails straight, inspect daily with
mirror for lesions/signs of inflammation, cotton socks, inspect shoes
Brush at least twice daily – floss once daily – checkup every 6 months
27
Master OSCE exam
Diabetes (cont.)
1. Metformin: 1st line of management of DM type 2 unless
contraindicated [severe renal impairment (eGFR <30 mL/
min/1.73 m2), not recommended if <45 - hepatic impairment] - It
decreases hepatic glucose production & improves insulin
sensitivity – with meal – most oral agents  HbA1c by 0.5-1.25%
Glucophage® 500, 850, 1000mg q 8-12 hr, maximum 2550mg/d
Glucophage XR® 500,750,1000mg qDay, maximum 2000mg/d
2. Sulfonylurea: stimulate ß cells' insulin secretion, can cause hypoglycemia
and wt gain – taken prior to meal – pregnancy category C even glyburide
Diamicron® (Gliclazide) 80mg q12hr, maximum 320mg/d, Diamicron MR® 30
mg qDay, maximum 120mg/d - Daonil® (Glibenclamide) 5mg q12hr,
maximum 20mg/d - Amaryl® (Glimepiride) 2mg qDay, maximum 8mg
3. Dipeptidyl peptidase4 (DPP4) inhibitors: inhibits DPP4  ↑ incretin
levels (GLP-1 and GIP)  inhibit glucagon release  stimulate glucose-
dependent insulin release (so do not cause hypoglycemia) + slow gastric
emptying – can be used with other oral antidiabetic drugs or insulin – once
daily - can be taken with or without food – Januvia® (Sitagliptin)
25,50,100mg, maximum 100mg/d - Galvus® (Vildagliptin) 50mg, maximum
100mg/d - Onglyza® (Saxagliptin) 2.5,5mg, maximum 5 mg/d – Tradjenta®
(linagliptin) 5mg (safe in renal & hepatic impairment)
4. Glucagon-like peptide 1 (GLP-1) agonist: same action as DPP4
inhibitors – injectable only – Bydureon® (Exenatide) once/wk, Byetta®
(Exenatide) BID, Trulicity® (Dulaglutide) once/wk, Victoza® (Liraglutide) OD
5. Sodium-glucose co-transporter 2 (SGLT2) inhibitors: block renal
reabsorption of glucose  increase glucose excretion - Avoid in severe renal
impairment – once daily - can be taken with or without food - most common
side effects are UTI and vaginal candidiasis. Invokana® (Canagliflozin) 100,
300mg, Forxiga (dapagliflozin) 5,10mg, Jardiance (empagliflozin) 10,25mg
6. Insulin: 1st line of management of DM type 1 & gestational diabetes. Start
0.1-0.2 units/kg, maintain on 0.5-1 unit/kg. Basal: [Humulin N® (NPH) once or
twice daily, Lantus® (glargine), Levemir® (detemir) or Tresiba® (degludec)
once at bedtime – F/U by morning FBS] – Prandial [Actrapid® (regular),
Humalog® (Lispro), Novorapid® (Aspart), Apidra® (glulisine) – prior to meal –
F/U by 2hr PPBS] – Mixed [Mixtard® (NPH/R 70/30), Humalog mix® (Lispro
protamine /lispro 50/50 or 75/25) - Novomix® (Aspart protamine/aspart 70/30)]

7. Others: Thiazolidinediones (insulin sensitizers) as Avandia®

(rosiglitazone) or Actos® (pioglitazone) taken once daily with or without food
– Glinides (insulin secretagogues) as Prandin® (repaglinide) or Starlix®
(nateglinide) taken once or twice daily prior to meal - α-glucosidase
inhibitors (↓CHO digestion & absorption) as Glucobay® (acarbose) or
Glyset® (miglitol) taken with first bite of meal
Follow up annually by dilated eye examination & comprehensive foot exam
28
Master OSCE exam
11. Difficult patient
• Take a deep breath – remain calm (remember: it's not personal)
– active listening, maintain eye contact – acknowledge his
feelings "I understand how upsetting this must be for you" –
identify the cause - avoid arguing or criticizing - deal with
compassion, firmness and professionalism - use short simple
statements – ask for solution "Do you have some suggestions
on ways to solve this?" - keep your personal safety in mind

Identify the cause of talkativeness – listen patiently and figure

out when you have reached the point where you've heard
enough then use art of interruption (e.g. So sorry to interrupt
you, I need to get back onto …. Or How lovely to chat with you,
I'd love to hear the rest of story next visit as I have a patient
waiting) – be more directive – use closed ended questions –
summarize - give limited time with follow up appointment

Ascertain patient's needs – ask for details – set limits and

explain rational – avoid arguments and ask for collaboration -
pay attention to the way you say (No) – acknowledge feelings

Explore perception according to (health belief model) - discuss

possible barriers (economic – psychologic – social – multiple
doses or drugs – poor communication) – Don't be judgmental
or criticizing – clear health education about benefits of
adherence to management plan and hazards of nonadherence
– defy common myths – identify his cues to action - document
problem for follow up – consider senior consultation or referral

Acknowledge the patient's suffering – never jump to false

reassurance - provide an acceptable explanation to symptoms
– schedule regular follow-up visits – CBT ± antidepressants

Set clear and firm boundaries – recognize underlying mental

issues – schedule follow up visits and give written instructions
– give home tasks – shared decision and management plan

Set clear and firm boundaries – speak in a clear, direct and

professional way, maintaining eye contact – discuss realistic
expectation – endorse to other health team members - work
with the family and develop a trusting relationship

Patient should understand that his knowledge about the

subject is just the tip of the iceberg – professionalism in
sharing rationale – refer to authoritative websites if possible
29
Master OSCE exam
12. Dizziness
Describe dizziness with another word [Spinning – going to faint
- imbalanced - lightheaded] - time course – provoking or
aggravating factor - recurrence - associated symptoms:[nausea
/vomiting - hearing loss - tinnitus - unbalanced gait - headache
- double vision - visual or speech disturbance – paresthesia –
weakness - loss of consciousness – fit] - recent URTI - drug
history - H/o trauma or CVA/IHD - screen for depression/anxiety

1. Vertigo: spinning - worse with head movement or valsalva -

can be associated with tinnitus, hearing loss, ear pressure and
nystagmus – causes: peripheral [benign positional (episodic,
last for seconds, associated with position change, no hearing
loss) vestibular neuritis (last for days, no hearing loss), Ménière
(last for hours + tinnitus and hearing loss)] - central (e.g. CNS
tumors, CVA, MS, vertebrobasilar insufficiency)
2. Disequilibrium: sense of imbalance – causes: peripheral
neuropathy or musculoskeletal/ vestibular/ cerebellar disorder
3. Presyncope: near faint – causes: cardiac (e.g. arrhythmia) -
drugs causing orthostatic hypotension – vasovagal attack
4. Nonspecific dizziness: often continuous – if aggravated by
hyperventilation it's mostly psychogenic - can be caused by
(hypoglycemia, anemia, medication induced, ..)

Vital signs (BP supine & standing) - ear examination – hearing

test (whisper, Rinne & Weber) - neck range of motion - CVS -
neurologic examination (gait, cranial nerves, motor, sensory,
balance, coordination) - Dix-Hallpike test [turn head 45° to one
side and rapidly guide patient from sitting to supine position,
keep for 30 seconds, looking for latent nystagmus (use +20
lenses to inhibit fixation) - symptoms precipitate by movement,
resolve by maintaining position] – hyperventilation for 2minutes
CBC – RBS – electrolytes - routine imaging is not indicated
unless abnormal neurological findings - electronystagmography

Review medications, summarize findings & explain symptoms

BPPV: symptomatic + Epley maneuver (to reposition the
canalith) and/or vestibular rehabilitation (a physical therapy
designed to habituate symptoms, and promote adaptation)
Vestibular neuritis: vestibular suppressants: antiemetic as
prochlorperazine (Stemetil®) – antihistaminic as promethazine
(Phenergan®) or Betahistine (Betaserc® 16 mg tab TID) - BDZ
Ménière: salt restriction – reduce caffeine & alcohol - diuretics
- vestibular suppressant - transtympanic gentamycin (chemical
labyrinthectomy) - endolymphatic sac decompression
30
Master OSCE exam
13. Dyspepsia
Dyspepsia according to Rome IV criteria: one or more
symptoms: Postprandial fullness, early satiation, epigastric
pain or burning for the last 3 months, at least 3 days/wk, with
symptom onset at least 6 months before diagnosis

Onset of symptoms – course – duration - recurrence

Site of pain – character – radiation – grade on 1-10
Aggravating and relieving factors?
Stress – smoking – alcohol - Frequent use of NSAIDs or Cox2
Other medications can cause dyspepsia (CCBs – nitrates –
theophylline – bisphosphonate – corticosteroid – doxycycline)
H/o antacid, H2 blocker and PPI drugs – improved?
H/o H. pylori test and treatment? H/o previous endoscopy?
Associated symptoms: Acid regurge – cough – painful or
difficult swallowing - change in Wt, appetite, stool color
Past history of DM, cardiac problems, biliary, malignancy?
Family history of GIT cancer
BMI – pallor – epigastric tenderness - abdominal mass - LNs
Non-invasive H. pylori testing (urea breath test or stool Ag) if <
55yrs, high prevalence of H. pylori >10%, & no alarm features
New onset of dyspepsia in age ≥ 55 yr
Unexplained anorexia and/or wt loss
Resistant iron deficiency anemia/ pallor
Persistent vomiting
GI bleeding
Progressive dysphagia or odynophagia
Abdominal mass
FH of GI cancer

Healthy eating – Wt reduction – smoking cessation – stop

offending drug - avoid alcohol, coffee, chocolate & fatty foods.
Raise head of the bed - Last meal well before going to bed -
CBT may reduce dyspeptic symptoms

If < 55yrs, no alarm features, low prevalence of H. pylori (<5%),

or test -ve for H. pylori  give full dose PPI [as Nexium®
(esomeprazole) 40 mg, or Controloc® (pantoprazole) 40 mg tab
OD] for 4-8 wks  then on lowest effective dose
If +ve H. pylori test  Nexium Hp7® (esomeprazole 20 mg +
Amoxicillin 1 gm + clarithromycin 500mg) BID for 7-10 days

Refer patients [≥ 55 yr, with alarm features, or resistant to

treatment] for early upper endoscopy (within 2 wks)
31
Master OSCE exam
14. Failure to thrive
Weight/BMI for age persistently < 3rd- 5th percentile, or fall over
2 major percentiles - or < 80% of median wt for length
Social (finances, educational level & occupation of caregiver,
family structure, residency, day care, health insurance)
Prenatal (maternal age – smoking/abuse – infection), natal
(labor complications), neonatal (gestational age, birth wt,
Apgar score, jaundice, sepsis, feeding difficulty)
Detailed feeding history (quantity, quality, frequency, feeding
difficulty, caregiver beliefs, barriers, food intolerance)
Growth and developmental history (delayed or regressed)
Immunization, allergies, medications
Recurrent [vomiting, diarrhea, fever, OM, respiratory infection]
Chronic disease: DM, cardiac, malabsorption, thyroid
Family history: growth failure, inherited or chronic diseases
When to suspect child abuse or neglect: multiple Bruises/
fractures/cuts – delay in seeking medical care – bad hygiene
– not properly dressed – child aggression/ withdrawal - recent
family crisis – stressful living condition – lack of support –
psychiatric illness, alcohol or drug abuse of a family member
Vitals – BP in one arm & one leg - Plot Wt (unclothed), length,
head circumference, Wt for Ht, BMI on the appropriate growth
chart – dehydration - dysmorphic/special features – chest –
abdomen – genitalia – neurologic – muscle – signs of vitamin
deficiency – signs of abuse/neglect - behavior – development
Observe food preparation, feeding technique, and attachment

CBC – urine & stool – TSH – RFT – LFT – wrist x-ray for bone
age (if short stature) & rickets ± additional tests as indicated

Avoid blaming caregiver - provide support - multidisciplinary

team (nutritionist, pediatrician, endocrinologist, physical
therapist, mental health professionals, & health educator) -
Obtain 72-hr diet diary - Aggressive feeding plan (>120
Kcal/kg/d) to catch-up wt and prevent cognitive loss, schedule
3 regular meals + 2 snacks, ↑ protein and solids, eliminate
empty calories as high sugar drinks, avoid distractions at meal
time, consider vitamins/minerals, no routine medications

Check wt weekly using same scale until sustained growth is

documented for months – home visits – monitor development
Admit child if [dehydrated, significantly ill, severe malnutrition,
poor response, suspect abuse/neglect/unsafe environment]
Refer child with developmental disability, dysmorphic features,
short stature, failure of management for evaluation
32
Master OSCE exam
15. Fatigue
Age – sex – occupation (heavy, stressful or shift work) –
describe fatigue - Onset – related to event or illness? – course
- duration, daily pattern - aggravating/relieving factors - impact
on QOL – associated symptoms (sore throat, joint pain,
headache, memory problems, wt loss) - detailed sleep history/
is it refreshing? - drugs, alcohol - h/o malignancy – FH of thyroid

1. Physiological: sleep deprivation, heavy work, stress, ….

2. Secondary to medical, psychiatric condition or drug use e.g.
anemia, hypothyroid, DM, infection (as URTI, UTI), obstructive
sleep apnea, depression, antiepileptics, steroid, diuretic
3. Chronic fatigue syndrome: severe fatigue > 6 months, no
clear cause + ≥ 4 of (impairment in memory or concentration,
sore throat, tender LNs, muscle pain, multiple joint pain without
signs of inflammation, headache of new type/pattern/severity,
unrefreshing sleep, post-exertional malaise >24 hrs)
Unintentional weight loss - recent onset of fatigue in a
previously well older patient - abnormal bleeding - shortness of
breath - unexplained lymphadenopathy – fever - recent onset
or progression of cardiovascular, gastroenterological,
neurological or rheumatological symptoms

General (level of alertness, psychomotor agitation/retardation,

grooming, pallor, jaundice) – lymphadenopathy – thyroid,
Cardiopulmonary, neurologic, musculoskeletal examination

CBC with differential – ESR - ferritin – glucose – RFT – LFT –

electrolytes – TSH – HIV - creatine kinase if pain or weakness

Stop offending drug - return to work - graded exercise therapy

- cognitive behavioral therapy – sleep hygiene [Keep a
consistent sleep schedule - Get up at the same time every day,
even on weekends or during vacations - Set a bedtime that is
early enough for you to get at least 7 hours of sleep - Don’t go
to bed unless you are sleepy - If you don’t fall asleep after 20
minutes, get out of bed - Establish a relaxing bedtime routine
- Use your bed only for sleep and sex - Make your bedroom
quiet and relaxing - Keep the room at a comfortable, cool
temperature - Limit exposure to bright light in the evenings -
Turn off electronic devices at least 30 minutes before bedtime
- Don’t eat a large meal before bedtime - If hungry at night, eat
a light, healthy snack - Exercise regularly and maintain a
healthy diet - Avoid consuming caffeine/alcohol in the late
afternoon or evening - Reduce fluid intake before bedtime.
Get some exercise. Being physically active during the day can
Treat underlying cause – antidepressant – iron if low ferritin
help you fall asleep more easily at night.
33
Master OSCE exam
16. Febrile child (under 5)
How temperature is measured – onset, course, duration and
degree of fever – recurrence - associated symptoms [change in
mental status, or eating/crying/behavioral pattern - rash - sore
throat - runny nose - cough - breathing difficulty - ear discomfort
- vomiting - change in stool pattern - change in urine color/smell/
frequency/painful micturition - abdominal pain - joint pain/
swelling - seizure] - home management - sick contact/day care
– parental concern - Past: immunization history– recent travel
– contact with animals - chronic illness - impaired immunity -
drug history - recent hospitalization/surgery/trauma
Family: autoimmune/ hereditary conditions
Traffic light system for risk stratification (NICE guidelines)
Low risk Intermediate risk High risk
(green) (Amber) (Red)
Normal color of
Pallor reported by Pale/mottled/
color skin, lips,
parent/carer ashen/blue
tongue
- Responds
- No response to social
normally to
- Not responding cues
social cues
normally to social cues - Looks ill
- Smiles
- No smile - Does not wake or if
Activity - Stays awake
- Wakes with roused does not stay
or awaken
prolonged stimulation awake
quickly
- Decreased activity - Weak/high-pitched or
- Strong normal
continuous cry
cry/not crying
- Nasal flaring
None of amber - Grunting
-Tachypnea(RR> 50 6-
or red - RR > 60/min
Respiratory 12mo - RR>40 >12mo)
symptoms or - Moderate or severe
- O2 sat 95%
signs chest indrawing
- Crackles
- Tachycardia (>160
<12 mo, >150 12-24
- Normal skin & mo, >140 2-5 yrs)
Hydration
eye - Capillary refill ≥3sec
And Reduced skin turgor
circulation - Moist mucus - Dry mucus
membranes membranes
- Poor feeding
-  urinary output
- Age<3months with a
- Age 3-6mo with a
temperature≥38°
temperature≥39°
None of amber - Non-blanching rash
- Fever for ≥5 days
or red - Bulging fontanelle
other - Swelling of a limb or
symptoms or - Neck stiffness
joint
signs - Status epilepticus
- Non-weight bearing
- focal neurological signs
limb
- Focal seizures
34
Master OSCE exam
Febrile child (cont.)
Pallor/jaundice/cyanosis - level of consciousness - temperature
– pulse – respiratory rate – signs of dehydration (prolonged
capillary refill time (CRT) - abnormal skin turgor - abnormal
respiratory pattern - weak pulse - cool extremities) - examine
ear, throat, chest, abdomen, & skin for rash/infection - signs of
meningococcemia (ill looking – purpura >2mm - CRT≥3 sec –
neck stiffness) – signs of meningitis (neck stiffness – bulging
fontanelle -  level of consciousness – status epilepticus) –
signs of herpes simplex encephalitis (focal neurological
signs/seizures -  level of consciousness) – signs of
pneumonia (tachypnea – chest crackles – nasal flaring – chest
indrawing – cyanosis – O2 sat ≤ 95%) – signs of UTI (vomiting/
poor feeding – lethargy/irritability – abdominal pain/tenderness
– urinary frequency/dysuria) – signs of septic arthritis
(swelling of a limb or joint – not using an extremity – non-weight
bearing) – signs of Kawasaki disease (fever > 5 d + ≥ 4 of:
bilateral conjunctival injection, change in mucous membranes
or extremities, polymorphous rash, cervical lymphadenopathy)

CBC – blood culture - CRP - urine ± [CXR, stool culture,

lumbar puncture] if indicated, in all children <3 mo, or children
>3mo with fever without apparent source who have any of 'red'
or 'amber' features - If > 3mo with 'Green' do urine analysis

Rest - fluids – continue breastfeeding – sponging is not as

effective as antipyretics, and not recommended as a treatment
of fever – never use cold water or alcohol sponging - do not
underdress or over-wrap – consider using paracetamol (10-15
mg/kg/dose q4-6 hr) or ibuprofen (5-10 mg/kg/dose q 6-8 hr) if
child appears distressed, alternate only if distress persists or
recur before the next dose is due - do not give aspirin -
antipyretics do not prevent febrile convulsions - check for sign
of dehydration (sunken fontanelle, dry mouth, sunken eyes, no
tears, looks ill) – seek immediate help if child develops fit, non-
blanching rash, poor feeding, looking unwell, breathing
difficulty, inconsolable, or unarousable – keep away from
nursery/school while feverish – check the child during night

Refer immediately all children < 3 mo, with life-threatening

condition (as shock or sepsis), or shows any of 'red' or 'amber'
features – treat those with 'green' features accordingly – do not
give empiric antibiotics - safety netting for alarm features
35
Master OSCE exam
17. Hand pain
Personal: Job of frequent flexion/extension of wrist
Analysis of pain: Onset – course – duration – site - character
grade on 1-10 – frequency – diurnal variation - aggravating &
relieving factors – radiation - other joints affected
Morning stiffness: if > 1 hr  inflammatory
Systemic symptoms: Fever – rash – Wt loss – night sweat –
eye dryness & ↓ visual acuity – GIT symptoms – mouth ulcers
Past history: trauma - DM – thyroid – autoimmune or
rheumatological diseases – use of medications

Carpal tunnel syndrome: pain/numbness/paresthesia of

palmar aspect of thumb/index/middle fingers - can radiate
distally - more at night relieved by shaking hand - weak hand
grip - difficult fine movements - dropping objects

Scars – Swelling – deformity – rash – pallor – nicotine staining

- muscle wasting – nail changes – elbow (plaques/nodules)

Temperature – radial pulse – capillary refill – muscle bulk

(thenar & hypothenar) – palmar thickening
Palpate joints bimanually: PIP – DIP – CMC – MCP – wrist
and elbow, squeeze MCP joints together, palpate snuffbox.
Check sensation of median (index finger), ulnar (little finger),
radial (First dorsal web space)
Fingers: Full finger extension and fanning - Making fist
Wrist: Flexion & extension (both 90°), Pronation (70°) &
supination (80°), radial deviation (20°), ulnar deviation (40°)
Finger/wrist extension against resistance (Radial nerve)
Finger abduction against resistance (Ulnar nerve)
Thumb abduction against resistance (Median nerve)
Power grip (around examiner's middle & index fingers) –
Pincer grip (try to break patient's ok sign) – pick a small object

Tinel's test: Tap over carpal tunnel  tingling in lateral fingers

Phalen's test: hold wrist in complete forced flexion for 1-2 min
Finkelstien's test: Hold adducted thumb in fist then tilt wrist to
ulnar deviation  if pain  De Quervain's tenosynovitis

Brace especially at night for minimum 3 wks (hold wrist in

neutral or slight extension) – local steroid injection - NSAIDs
– Physiotherapy – Surgical release under local anesthesia.

For investigations as nerve conduction or EMG, and/or

management
36
Master OSCE exam
18. Headache
Onset – course - duration – recurrence – severity on 1-10 scale
Site: unilateral – bilateral - temporal – occipital – frontal
Character: throbbing – pressing – dull – stabbing - sharp
Aggravating factors: exercise, stress, cough, postural change
Relieving factors: lying flat – sleep – analgesics
Aura: flickering light, scotomata, face tingling, disturbed speech
Associated symptom: nausea/vomiting – photo/phonophobia
- weakness – wt loss - fever – meningism – tender temple - jaw
claudication - eye pain - ipsilateral lacrimation/nasal congestion
Brief personal/ social history – medications e.g. antihypertensive,
analgesics or OCPs - past history of chronic diseases, stroke or
malignancy – family history of migraine or cancer – patient's ICEE

1. Tension headache: mild to moderate - pressing/tightening -

bilateral - frontal/occipital - episodic or chronic - not aggravated
by physical activity - often upon rising - no nausea/vomiting
2. Migraine: moderate to severe – pulsating – unilateral –
frontotemporal/ocular – aggravated by routine physical activity –
nausea and/or vomiting – photophobia & phonophobia – 4:72hr
3. Cluster headache: recurrent - severe to very severe – sharp
- strictly unilateral (orbital/supraorbital/temporal) + ipsilateral ≥1
of (conjunctival injection, lacrimation, nasal congestion,
rhinorrhea, sweating, miosis, ptosis, eyelid edema - 5 min: 3 hr
New headache above 50 yrs, or in patient with HIV, cancer or
history of thromboembolism - sudden very severe (thunderclap
headache) – triggered by cough, sneeze, straining or change
in position – significant change in frequency/severity/character
– constant pain in same site – systemic/neurological symptoms
CBC – FBS – ESR (≥ 50/hr in temporal arteritis) – PNS skull x-
ray if suspecting sinusitis – MRI brain if any red flag

Sit in cool dark quiet room – stress management – relaxation

techniques – headache dairy document triggers (e.g. stress -
skipping meal - certain foods – alcohol - strong light/noise/smell
- change environment/altitude – ↑/↓caffeine - sleep deprivation)

1. Tension: simple analgesics - non-pharmacological treatment

2. Migraine: simple analgesics if mild to moderate – add triptan
+ IV metoclopramide if severe – prophylaxis: B – TCA - CCBs
3. Cluster: 100%O2 by mask± sumatriptan – prophylaxis: CCBs
Severe refractory pain - suspect 2ry cause - red flag – temporal
arteritis (treat by high dose corticosteroid to prevent blindness)
37
Master OSCE exam
19. Hypertension
Age – occupation – smoking – nutritional history - stress
Symptoms of 2ry HTN: attacks of flushing/headache/sweating
/palpitation (Pheochromocytoma) – apneic sleep events
(obstructive sleep apnea) - fatigue+constipation+renal stones
(hyperparathyroidism) – symptoms of thyroid dysfunction
Symptoms of target organ damage: chest pain, LL edema,
shortness of breath, altered vision, unilateral weakness, ….

e.g. renal artery stenosis, renal parenchymal disease, 1ry

aldosteronism, OSA, pheochromocytoma, Cushing's, …
Suspect 2ry HTN if: early age of onset - severe or resistant
HTN - acute onset or change in control - abnormal findings

How to measure BP: ensure device is validated & calibrated.

Patient is seated comfortably for few minutes, arm flexed,
elbow at the level of the heart, bladder size should be ≥80% of
circumference of upper arm, wrap cuff around upper arm, with
lower edge 2.5 cm above antecubital fossa, put stethoscope
bell/diaphragm just below cuff's edge, rapidly inflate cuff to
180mmHg, release at a moderate rate (3mm/sec), 1st sound is
the systolic BP, and when sound disappears it's the diastolic,
record reading, repeat in other arm, if > 20 difference repeat.

SBP ≥140 (or ≥150 if ≥60 yr) or DBP ≥ 90, on 2 occasions or

at least 4 hours apart - or SBP ≥160 or DBP ≥110 even once
Normal BP: Systolic <120 mm Hg, diastolic < 80 mm Hg
Prehypertension: Systolic 120-139, diastolic 80-89 mm Hg
Stage 1: Systolic 140-159 mm Hg, diastolic 90-99 mm Hg
Stage 2: Systolic ≥160 mm Hg, diastolic ≥100 mm Hg

Target < 140/90 if < 60 yr or with DM or CKD, or < 150/90 if

≥ 60 yr - if uncontrolled  check adherence to medications &
lifestyle - wt reduction – titrate to maximum dose and/or add
another antihypertensive up to 3 - check for 2ry cause

Measure BP in both arms (difference should <15mmHg), in LL

(should be 10-40 mmHg higher), and in standing position (if
decreased > 20 systolic/10 diastolic = orthostatic hypotension.
Check for signs of 2ry causes as abdominal bruit (renal artery
stenosis), buffalo hump, central obesity & stria (Cushing),
radio-femoral delay & low BP in LL (coarctation of aorta), neck
circumference > 37 cm in women or > 43 in men (OSA).
Check for signs of target organ damage as ↑JVP, basal rales,
tachycardia, S3 gallop, LL edema (heart failure), unilateral
weakness facial paresis (stroke), retinopathy
38
Master OSCE exam
Hypertension (cont.)
FBS, S. electrolyte, RFT, S. lipids, urine, ECG + if suspecting
2ry: Doppler U/S/MRI with contrast (renal artery stenosis),
echo in child/MRI in adult (coarctation of aorta), 24 hr urine
cortisol (Cushing), metanephrines (pheochromocytoma), TSH

calculate risk of cardiovascular event or stroke in next 10

years according to age, sex, race, smoker or not, diabetic or
not, systolic BP, total and HDL cholesterol (≥ 5% start statin)
- Dietary approach to stop hypertension (DASH): rich in fruits/
vegetables/dairy food, low in saturated/total fat (↓ SBP 8 -14)
- Reduce daily sodium intake to < 2.4 g (↓ SBP 2-8 mmHg)
- Weight loss (↓ SBP 5-20 mmHg per 10 kg
- Stop smoking, limit alcohol intake (↓ SBP 2-4 mmHg)
- Discourage excessive consumption of caffeine-rich products
- Exercise 30 min daily for most days (↓ SBP 4-9 mmHg)
- Relaxation techniques such as breath focus and prayer
Initiate with thiazide diuretic, calcium channel blocker
(CCBs), angiotensin-converting enzyme inhibitor (ACEI), or
angiotensin receptor blocker (ARB): alone or combination
If black treat with thiazide or CCBs only
If diabetic or CKD treat with ACEI or ARBs (not together)
Avoid B in asthma (may cause bronchospasm) in diabetic
(may mask hypoglycemia awareness), and in peripheral
vascular disease (can use cardioselective B as metoprolol,
bisoprolol). Reserve B for CHF and post-MI
Diagnosis: SBP≥140 or DBP≥90 (before 20wks =chronic HTN
– >20 wks = gestational HTN) - Goal: SBP<150 – DBP <100
Use: methyldopa, labetalol, hydralazine or nifedipine
Avoid ACEI/ARBs: can lead to major congenital malformation
Avoid diuretics as they can cause electrolyte disturbance
2ry causes difficult to be assessed in pregnancy due to high
progesterone level & normal increase in endogenous cortisol
Preeclampsia: HTN + either [proteinuria - thrombocytopenia -
renal or liver impairment - cerebral or visual symptoms –
pulmonary edema] developed after 20 wks gestation

ACEI can cause cough & angioedema, check S. creatinine

after 2 wks, if > 0.5 mg/dL increase = renal artery stenosis) -
CCBs can cause edema - B can cause fatigue & bradycardia

BP> 220/120 mmHg (if with target organ damage =

emergency, should be referred to ER immediately) if not 
give captopril 25 mg PO, recheck after 30 min, F/U 1-7 days
39
Master OSCE exam
20. Joint pain
Age – gender - race – occupation – recent trauma - onset –
course – duration – radiation – recurrence – aggravating/
relieving factor – associated symptoms (swelling, erythema,
warmth, morning stiffness, skin/eye/nail changes, oral ulcers,
nodules, ) – drugs - sexual history – travel – tick bites –
alcohol/IV drug – past H/o joint disease – FH of arthritic disease
1. Monoarthritic: pain or swelling in a single joint
a. Septic arthritis: pain, effusion, fever, erythema, warmth
b. Trauma - recent surgery - hemarthrosis
c. Avascular necrosis: common in patients taking steroids
c. Osteoarthritis: insidious onset, asymmetric, pain worsen with
activity, brief morning stiffness, crepitus,
d. Gouty arthritis: swelling/erythema common in 1st MTP joint
e. Osteomyelitis: hematogenous or direct inoculation
2. Polyarthritic:
a. Infectious: viral, bacterial either direct or indirect (reactive)
b. Systemic rheumatic diseases: RA, SLE, scleroderma, …
c. Crystal-induced synovitis: gout – pseudogout
d. Spondyloarthropathies: ankylosing spondylitis - Psoriatic
arthritis – IBD – reactive arthritis (Reiter's syndrome)
e. Systemic vasculitis disease: polyarteritis nodosa, Wegner's
granulomatosis, giant cell arteritis, Henoch-Schonlein purpura
f. Endocrine: hypo/hyperthyroidism - hyperparathyroidism
g. Malignancy: metastatic cancer – multiple myeloma
h. Other: osteoarthritis, fibromyalgia, osteomalacia, sarcoidosis

Vital signs (temp, pulse) – gait - Joint exam (tenderness -

crepitus - effusion - warmth - limited range of motion/pain) -
extraarticular manifestation (skin, eye, nail, oral mucosa) –
lymphadenopathy - CVS – GIT – genitourinary – neurological

CBC - urine - ESR & CRP - X-ray - arthrocentesis + others

(e.g. RF, anti-CCP, ANA, anti-Sm, anti double-stranded DNA)

Osteoarthritis: reduce joint load, appropriate exercise, oral &

topical analgesic, intraarticular hyaluronan, orthotic devices
Septic arthritis & osteomyelitis: IV antibiotics ± drainage
Acute crystalline synovitis: NSAIDs at maximum daily dose
Chronic gout: allopurinol/probenecid- daily colchicine/NSAIDs
Systemic vasculitis disease: hospitalization
Chronic inflammatory arthritis: Disease modifying
antirheumatic drugs (DMARDs) such as methotrexate,
leflunomide and TNF antagonist + low dose steroid
Surgery: total arthroplasty or arthroscopic surgeries
40
Master OSCE exam
21. Low back pain
Age – occupation (physically strenuous, lifting heavy object,
prolonged sitting, operating vibrating machine, frequent bending
& twisting, psychologically strenuous, contact with animals) –
smoking – IV drug use - Analysis of pain: Site – onset/course
/duration (chronic ≥3m) – recurrence – severity (1-10) - character
- radiation - aggravating & relieving factors - diurnal variation -
Associated symptoms: fever, urine/fecal incontinence, limb
weakness, calf pain on exercise, wt loss, pelvic/abdominal pain
Past: trauma or fall - HIV, TB, malignancy, brucellosis - drugs

Non-specific: > 85% - no specific underlying condition identified

Mechanical: strain, OA, disc herniation, spinal stenosis,
malalignment, Fracture: traumatic, compression fracture
Inflammatory: ankylosing spondylitis – Reiter's syndrome
Infection: diskitis – osteomyelitis – epidural abscess
Tumor: multiple myeloma, metastatic, benign/malignant tumor
Referred: e.g. PUD, pancreatitis, aortic aneurysm, PID, UTI
Age>50 yrs – thoracic pain – fever – unexplained wt loss –
bladder/bowel dysfunction – H/O malignancy – progressive
neurological deficit – saddle anesthesia – H/O significant
trauma - H/O osteoporosis – chronic steroid or IV drug use

Psychosocial factors, indicative of long term chronicity and

disability: perception of LBP as severely disabling, social/
financial problem, depression/anxiety, job dissatisfaction

General look - gait – vital signs – BMI – inspection (asymmetry,

scar,..) - palpate spines & paravertebral muscles - lumbar range
of motion (flexion, extension, lateral flexion, rotation) - Schober
test - Neurologic examination of LL (strength, sensation, reflex)

ESR and/or CRP if suspecting inflammation, infection or

malignancy. No routine imaging in patient with acute LBP (<4
wks) as symptoms improve in vast majority within 4 wks, and
incidental findings unrelated to symptoms are common.
Imaging indicated if serious underlying conditions suspected by
history/physical examination, or no improvement after 4-6 wks.
The best initial exam is MRI with contrast
Stay as active as pain allows - heat wraps & message for acute
- exercise, acupuncture, relaxation therapy & CBT for chronic

Acute: often resolve spontaneously – NSAID or muscle relaxant

Chronic LBP: 1st choice: NSAIDs– 2nd choice: tramadol (50 -
100mg) – SSRI: Duloxetine (Cymbalta® 30-60 mg cap OD)
41
Master OSCE exam
22. Muscle ache
Pain analysis - Associated symptoms: weakness, sleep
disturbance, cognitive problem, joint pain/inflammation,
headache, fatigue, sleep apnea, abdominal pain, dark urine

Social - family function – stress – job dissatisfaction - screen

for depression, anxiety and somatoform disorders

Hypothyroid – RA – SLE – cardiac – autoimmune – IBD –

IBS – malignancy – medications e.g. statins
Fibromyalgia: widespread body pain,
fatigue, waking unrefreshed with cognitive
symptoms ≥ 3 months, not explained by
other disorder
Diagnostic criteria: [Widespread pain
index WPI ≥ 7 + Symptom severity SS ≥ 5
or WPI 3-6 + SS scale score ≥ 9]
WPI (number of areas of pain over past wk
– Score 0-19  Rt & Lt jaw - Rt & Lt
shoulder girdle - Rt & Lt upper arm - Rt & Lt
lower arm - Rt & Lt hip - Rt & Lt upper leg -
Rt & Lt lower leg – neck – chest – abdomen
SS scale score: Score 0-12 – Severity of the 4 symptoms (0
no problem – 1 mild – 2 moderate – 3 severe)

Gait – joints for signs of inflammation, deformities and range

of motion – neurological examination – skin/hair/nail

Muscle weakness – fever – dark urine – joint swelling – bone

tenderness to palpation - weight loss – h/o malignancy

CBC – TSH – Vitamin D – ESR (high in inflammatory condition

– very low in chronic fatigue syndrome) – RFT – LFT – iron
study – urine – Ca/P/Mg level – creatinine phosphokinase

Good nutrition – vitamins – wt loss – exercise – sleep

hygiene – stress management – Cognitive behavior therapy
– hypnotherapy – massage – meditation - acupuncture

Analgesics (week opioid) – Anxiolytic (short course) – Muscle

relaxant as Dantrium® (dantrolene) 25mg cap OD, titrate
gradually, maximum 300mg/d – Antidepressant as Cymbalta®
(Duloxetine) 60mg cap OD or TCA – Anticonvulsant as
Lyrica® (pregabalin) 75 mg cap Bid – Lidocaine patches –
vitamin & mineral supplement + treat underlying condition
42
Master OSCE exam
23. Nocturnal enuresis

1ry= never achieved satisfactory period of nighttime dryness

2ry= Relapse after completely dry (either spontaneous or with
treatment) for ≥6m
Voiding history: diurnal/nocturnal? How many times/wk? How
many times/night? amount? Frequency/urgency/dysuria? -
fluid intake - recurrent UTI – Parent/sibling with h/o enuresis?
Defecation history: Encopresis? (at least once/month, for ≥ 3
months, > 4 yr old) - Constipation? - Overflow incontinence?

Developmental/ behavioral/ Mental /health problem?

Family function? new event/baby? loss of loved one/divorce?
Fear/ phobia? Sleep alone? Enough light? Bathroom is near?
Family reaction to the event? Impact on quality of life?

Encopresis – incontinent day & night - Neurological

manifestations (limb weakness - abnormal gait – saddle
anesthesia) - signs of abuse - suspect developmental or
intellectual disability
Growth & development milestones - BP - abdominal & pelvic
examination: (ext. genitalia – anal wink - saddle anesthesia) –
palpate spine - neurologic examination of LL – signs of abuse

Screening urine test (± RBS – U/S – scotch tape test – VCUG)

If < 5 yr reassure & non- pharmacological only - never punish

or reinforce - ample fluids at daytime, restrict at night - Void
regularly during day & just before bed - avoid caffeine/cola/juice
- bed protection - star chart, reward system - share child in plan

Alarm 1st choice – a sensor in water proof sheet - f/u 4 wks –

patient register when & how many times it rings - Stop after 2
wks dry or 3 mo failure – May cause anxiety & disturbed sleep

Desmopressin Minirin® (tab – injection - nasal spray) 120-

200mcg at bed time – fluid restriction at least 1 hr before & 8
hrs after administration – f/u after 2 wk, double dose if limited
response, continue for 3 mo – stop gradual – high relapse rate
Others: anticholinergic e.g. Oxybutynin (Ditropan®) – bedtime
imipramine (Tofranil®) 25mg for 5-8 yr old, 50mg for older

Red flags – recurrent UTI - physical problem or comorbidity -

Failure/ resistance of treatment – for CBT to child & family
43
Master OSCE exam
24. Painful anal condition
Pain: with defecation, contact or continuous? Bleeding:
quantity/color/timing - Mass: only with defecation or fixed?
Painful? - constipation (details) – diarrhea - fecal incontinence
– urinary symptoms - medication (constipating as iron, TCA,
antipsychotics, antiepileptics, opioids, antihistaminic, antacids)
– sexual abuse - Family history of cancer colon, polyps or IBD
1. Anal fissure: a painful linear tear in distal canal ranges from
only epithelium to full thickness of anal mucosa, causing severe
tearing pain with defecation ± drops of bright red blood
2. Hemorrhoids: swollen blood vessels in lower rectum, most
commonly present by bright red rectal bleeding after defecation.
Thrombosed external piles present as acutely painful mass.
3. Anorectal abscess: present by dull pain and pruritus,
aggravated by sitting or defecation ± swelling ± discharge
4. Pruritus ani: mechanical, dermatologic, infectious, systemic
5. Proctalgia fugax: severe episodes of spasm-like pain,
lasting for minutes, often occur at night, no specific etiology

Rome IV criteria for functional constipation: at least 2 of the

following symptoms over the preceding 3 months: [Fewer than
3 spontaneous bowel movements per week – Straining - Lumpy
or hard stools (Bristol 1-2) - Sensation of anorectal obstruction
- Sensation of incomplete defecation - Manual maneuvering to
facilitate defecation]+ loose stool rarely present without laxative

General (pallor – fever – in pain – not sitting comfortably) –

abdomen (masses – tenderness – fecal impaction) - Rectal

CBC ± investigations to exclude possible D.D. (coagulation

profile – stool for occult blood & calprotectin/lactoferrin for IBD)
Increase fluid intake – high-fiber diet – exercise - avoid caffeine
& spicy, acidic food – avoid straining & prolonged sitting – avoid
topical scented products - proper hygiene using non-irritant
soap - Sitz bath after bowel movement – avoid trauma (as
motorcycle or horse) and tight clothing – stop constipating drug

Stool softener ± laxative (e.g. Colace® tab/liquid (Na docusate),

Minalax® tab Na docusate + Bisacodyl) – topical nitroglycerin
(Rectiv® or GTN formula) – local anesthetic with defecation

- Urgent referral of thrombosed hemorrhoids (elliptical

incision), anorectal abscess (drainage) or severe bleeding
- Failure of medical therapy  surgical (sphincterotomy in
fissure - hemorrhoidectomy in piles) or non-surgical (as laser
hemorrhoidoplasty, infrared coagulation or band ligation)
44
Master OSCE exam
25. Recurrent abdominal discomfort
Acute abdomen: rapid onset of severe abdominal pain ER
Rt upper quadrant: biliary, colitis, pneumonia, PE, renal, …
Epigastric: biliary, MI, PUD, pancreatitis, aortic dissection, ...
Suprapubic or Rt lower quadrant: appendicitis, ectopic preg,
ovarian torsion, PID, colitis, diverticulitis, IBD, IBS, renal, ...
Lt lower quadrant:colonic,gynecologic,renal (infection, stone)

Site – onset – course - duration (chronic ≥3m) – recurrence –

severity - character - radiation – aggravating & relieving
factors - diurnal variation - Associated symptoms (fever,
nausea/vomiting, diarrhea/ constipation, hematemesis, black
stool, dysuria, vaginal bleeding/missed period, jaundice, dark
urine, tachypnea) - Family history of IBD, colon cancer/polyps
Onset after 50 yr age – rectal bleeding - wt loss – nocturnal
symptoms – iron deficiency anemia - FH of certain organic GI
dis (IBD/celiac sprue/colorectal CA)  urgent endoscopy
Rome IV criteria for diagnosis of irritable bowel syndrome:
recurrent abdominal pain, at least 1 day/wk, during the
previous 3 months, associated with 2 or more of the following:
- Related to defecation (increased or unchanged)
- Associated with a change in stool frequency
- Associated with a change in stool form or appearance
Vital signs – pallor/jaundice/cyanosis – patient's position –
abdominal examination (inspection – auscultation –
percussion – palpation – Special tests  abdominal exam)
Together with cardiovascular and pelvic examination

CBC, electrolytes, plasma glucose, RFT, LFT, S. lipase/

amylase, ßHCG, urinalysis, U/S abdomen, CT with contrast
Dietary and lifestyle management: eliminate foods that may
aggravate symptoms (such as dairy products, legumes,
cruciferous vegetables as cabbage & cauliflower – regular
meals - avoid fried food (boiled or grilled) – increase water
intake - avoid soft drinks and caffeine – regular exercise –
daily diary to monitor symptoms – CBT/stress management

- Anticholinergic: help reduce colon contractions, as

Levsin® (hyoscyamine) 0.125mg, or Bentyl® (Dicyclomine)
10,20,40 mg - Antidepressant: low dose TCA or SSRI -
Antidiarrheal: Imodium® (loperamide) 2 mg cap, before meal
- Laxative: bulk forming (as Polyethylene glycol 3350, OD),
better avoid osmotic laxative as lactulose, may worsen
bloating - Other: Rifaximin - probiotic - alosetron - Linaclotide
45
Master OSCE exam
26. Sore throat
Onset – course – duration – recurrence - aggravating &
relieving factors – medications used – H/o sick contact – H/
Associated symptoms: fever – painful/difficult swallowing –
cough – coryza - SOB – chest pain – skin rash – neck mass –
joint pain/swelling - acid regurge – ear pain – toothache

Infectious: Viral (80%) – Bacterial - candida

Non-infectious: GERD – postnasal drip – acute thyroiditis –
persistent cough – trauma – referred dental pain - smoking –
allergies – familial Mediterranean fever - neoplasm

GC - dehydration - Temp – RR – throat examination – cervical

LNs (anterior – posterior) – chest – spleen – ear – skin for rash

Age [3-14yr (1) – 15-44yr (0) - ≥ 45yr (-1)] - Temperature ≥

38◦C (1) – Absence of cough (1) – swollen tender anterior
cervical LNs (1) – Tonsillar swelling or exudate (1)
[0 – 1]  no further testing or antibiotic
[2-3]  test (rapid Ag test or throat culture) treat if +ve
[≥ 4]  consider empiric treatment with antibiotics

Toxic look – Distress – hemoptysis – odynophagia – drooling

of saliva – [unilateral tonsillar swelling – hot potato voice –
altered mental status  Peri tonsillar abscess] –
splenomegaly – polyarthritis - wt loss – generalized LNs

Rapid strep Ag test (if Centor criteria 2-3)

CBC – Monospot test if suspecting infectious mononucleosis
Throat culture if recurrent pharyngitis
Neck x-ray if suspecting foreign body, epiglottitis or croup

Rest – fluids – saltwater gargles – warm beverages (chicken

soup – honey or lemon tea) – sucking on hard candy –
analgesics – air humidifier – stop smoking – good hygiene
Viral is self-limited, only symptomatic: Analgesic
acetaminophen or NSAIDs + non-pharmacological
1st choice of antibiotics: Penicillin V/ Amoxicillin 25-50 mg/kg/d
q8hrs × 10d - If penicillin allergy: severe allergy  macrolide
- minor or delayed rash  can use Cephalosporin
Do not give antibiotics if suspecting IMN

Recurrent (≥ five/yr) or severe disabling episodes – wt loss,

generalized lymphadenopathy – other non-infectious causes
Refer ER if: epiglottitis – tonsillar abscess – distress – croup
– foreign body – inability to maintain adequate oral intake
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Master OSCE exam
27. Urinary incontinence
Age – occupation (repetitive increase in intraabdominal
pressure) - duration of complaint – frequency – quantity of urine
lost – constant or intermittent? – triggering events? - is it
worsening - associated frequency/urgency/dysuria –
constipation/fecal incontinence – pelvic organ prolapse –
comorbid medical problem (as DM, COPD, CHF, BPH) –
medications (as diuretic, muscle relaxant, antidepressant) –
obesity - smoking – alcohol – excessive caffeine - Past history
[recurrent UTI – pelvic or spinal surgery – urologic procedures]

1. Stress: urine leakage (typically few drops) associated with

increased abdominal pressure from laughing, sneezing,
coughing or making effort, due to weak pelvic floor muscles
2. Urge: involuntary leakage (of the entire bladder content)
accompanied by urgency (strong desire to void), due to
overactive bladder, precipitated by washing dishes, hearing
running water or turning a key in the door.
3. Mixed: a combination of stress and urge incontinence
4. Overflow: urine loss (small amount) associated with bladder
overdistension due to retention (as by drugs as anticholinergic)
or bladder neck obstruction (BPH, stool impaction)
5. Functional: inability to hold urine due to reasons other than
neuro-urologic dysfunction (e.g. delirium, psychiatric illness,
UTI, impaired mobility, atrophic vaginitis, medications, …)

BP – BMI – chest – CVS – Abdomen: for scars, hernias,

masses, organomegaly, palpable bladder after voiding – Back:
deformity, dimpling, hair tuft – Neurologic: mental status, gait,
reflexes, sensation of perineum, anal wink– Pelvic: atrophy,
masses, organ prolapse, fistula - Rectal: anal tone, prostatic
enlargement, stool impaction – Stress test: with bladder at
least half full, have the patient in lithotomy position, instruct to
bear down while directly visualizing urethra for leakage

Urine analysis – bladder scan for post-void residual volume

Wt reduction – stop smoking – reduce alcohol, caffeine - pelvic

floor muscle exercise – manage the cause (cough, constipation)

Stress: alpha agonist (e.g. pseudoephedrine)

Urge: Anticholinergic (e.g. tolterodine, oxybutynin)
Overflow: alpha blocker (prazosin, Tamsulosin) or alpha
reductase 5 (finasteride) for prostatic hyperplasia
Resistant – neurological symptoms – marked prostatic
enlargement – pelvic organ prolapse – hematuria/proteinuria –
pelvic pain – postvoid residual volume > 200 ml – H/o pelvic
surgery or radiation – patient is candidate for bariatric surgery
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Master OSCE exam
28. Urinary tract infection
Age - sex - occupation – analysis of complaint: onset, course,
duration, aggravating/relieving factors, recurrence - associated
symptoms: [change color/clarity of urine, dysuria, frequency,
urgency, suprapubic/flank pain, fever, nausea/ vomiting,
dribbling, hesitancy, penile ulceration/discharge, vaginal
discharge, dyspareunia] - drugs – recent surgery/procedure

Cystitis: infection of urinary bladder - presents as dysuria,

frequency, urgency, suprapubic pain ± hematuria
Pyelonephritis: infection of kidney and upper urinary tract -
presents as fever, chills, nausea/vomiting, flank pain,
costovertebral angle tenderness, ± symptoms of cystitis
Complicated UTI: All UTI in men – underlying condition as
(DM, pregnancy, immunosuppression, renal failure or
transplantation, functional/anatomic urinary tract abnormality
or obstruction,) - symptoms ≥ 7 d before seeking care -
hospital acquired - recent instrumentation of urinary tract or
presence of catheter/stent/tube - resistant organism - H/o
acute pyelonephritis past year or UTI in childhood
Acute prostatitis: symptoms of cystitis + fever/malaise/
perineal pain + obstructive symptoms (dribbling - hesitancy)
Urethritis: must be considered in sexually active men – C/P:
penile ulceration – urethral discharge - no hematuria - PID:
vaginal discharge – cervical motion tenderness on P/V -
Asymptomatic bacteriuria: +ve culture with no symptoms

Urine analysis clean catch midstream urine (local disinfection

with a non-foaming antiseptic soap – dry with a sterile swab –
minimize contact of urinary stream with mucosa by spreading
labia in females and pulling foreskin in uncircumscribed males
– discard 1st voided urine – take the 2nd midstream sample)
It is sufficient (either by microscopy or dipstick) if there is UTI
symptoms, unless complicated - WBC casts diagnostic for
upper UTI - Hematuria is not a predictor for complication
Culture: done if symptoms are not consistent with UTI, if
symptoms persist after 48-72 hrs of appropriate antimicrobial
therapy or recur within 3 months after prior antimicrobial
therapy, if a complicated infection is suspected, all women with
acute pyelonephritis, and all men with symptoms of UTI - Most
common organism E. coli – no need to repeat culture if
improved, unless pregnant (a wk after completion of therapy)
Imaging: by CT or U/S is indicated if symptoms persist after
48-72 hrs of appropriate antimicrobial therapy for acute
uncomplicated UTI, complicated or recurrent
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Master OSCE exam
Urinary tract infection (cont.)
Screening for asymptomatic bacteriuria: In pregnant
women (at 12 - 16 wks gestation or the 1st ANC visit if later),
and in patients undergoing urological procedures

Increase fluid intake (esp. cranberry juice) – urinate soon after

intercourse – use topical estrogen in postmenopausal

Acute uncomplicated cystitis: empiric nitrofurantoin Uvamin

retard® 100mg BID for 5 days, trimethoprim sulfamethoxazole
(Bactrim® 160/800 mg tab BID for 3 days), or fosfomycin 3 gm
single dose. If symptoms persisted after 48-72 hrs or recurred
within few wks, do culture and change empiric antibiotic -
Avoid nitrofurantoin if suspecting pyelonephritis,  creatinine
clearance < 60mL/min, in 1st trimester of pregnancy & in men
Complicated cystitis: oral fluoroquinolones, or if cannot
tolerate oral treat as complicated pyelonephritis - for 5-14 days
Acute uncomplicated pyelonephritis: oral fluoroquinolones
(Cipro® Ciprofloxacin 500 mg tab BID for 7 days, or Levaquin®
levofloxacin 750 mg tab OD for 5-7 days)
Complicated pyelonephritis: admission – parenteral
cephalosporins (e.g. Rocephin® ceftriaxone 1gm q24 hrs),
quinolones (ciprofloxacin 400mg q12 hrs), or carbapenem if
severe or resistant (e.g. Meronem® meropenem 500mg IV
q8hr) for 10-14 d, shift to oral of same group or according to
culture after improving clinically and tolerate oral fluids
Treatment of asymptomatic bacteriuria is appropriate for
pregnant women and for patients undergoing urologic
procedures in which mucosal bleeding is anticipated
UTI in pregnancy: if asymptomatic bacteriuria or acute
cystitis: oral nitrofurantoin 100mg BID for 5d,
amoxicillin/clavulanate 500 mg BID for 3-7 d, or fosfomycin 3
gm single dose - if pyelonephritis: hospitalization - IV beta
lactams (penicillin and cephalosporins), shift to oral after
improving clinically and tolerate oral fluids - for 10-14 days -
Fluoroquinolones should be avoided in pregnancy
Children: 3rd generation cephalosporins are the 1st line
empiric treatment of UTI in children, either oral or parenteral.
Prophylactic antibiotics for 3-6 months in (Children with
grade III vesico-ureteric reflux or more - Women with > 3
UTI/year – immunocompromised catheterized patients), by
low dose trimethoprim/sulfamethoxazole or nitrofurantoin 3
times/wk at bed time, or after intercourse if postcoital UTI
persistent hematuria – recurrent UTI – neurological disease –
obstructive symptoms – suspect stone – feces or air in urine
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Master OSCE exam
29. Vaginal discharge
Age – marital status – obstetric/menstrual/contraceptive history
– smoking/alcohol – DM - douching - drugs - recent use of
antibiotics or new soap – H/o abdominal/gynecological surgery
Onset, course, duration – recurrence – color/consistency/odor
of discharge – relation to cycle – aggravating/relieving factors
Associated symptoms: bleeding – fever – itching – painful
intercourse – pelvic pain – nausea/vomiting – joint pain – vision
change – painful micturition – partner symptoms/risk factors
Bacterial vaginosis: thin, milky, greyish white discharge, with
fishy odor, becoming worse with menses or after intercourse
Candidiasis: cheesy white discharge, associated with Itching,
vulvar edema and soreness, dysuria, dyspareunia, increase
with pregnancy, DM, OCPs and antibiotics
Trichomoniasis: profuse frothy yellowish green discharge,
malodorous, associated with itching, vulvar edema &
erythema, dysuria, dyspareunia, and strawberry cervix
STI (Chlamydia/gonorrhea): May be asymptomatic, or ↑
vaginal discharge, mucopurulent urethral discharge, dysuria,
dyspareunia, intermenstrual bleeding & lower abdominal pain
Atrophic vaginitis: postmenopausal, pale/dry/smooth vagina
Contact dermatitis: spray/soap/lubricant/spermicide/latex/pad
Temp - vulva/vagina/cervix for lesions/erythema – bimanual
examination for pelvic mass or cervical motion tenderness
Bacterial vaginosis: pH > 4.5 - +ve whiff test (fishy amine odor
when adding 10% KOH) – at least 20% clue cells on wet mount
Candida: pH < 4.5 – budding yeast with pseudo hyphae (KOH)
Trichomonas: pH > 5.4 – flagellated trichomonads + ↑ WBCs
Avoid douches – use plain warm water or unscented non-soap
cleanser to wash genitalia by hand (not a washcloth) from front
to back – pat dry - wear cotton underwear – avoid tight clothes
– avoid scented products or baby wipes – control DM
Bacterial vaginosis: Treat only if symptomatic, unless
pregnant – Flagyl® (metronidazole) 500 mg Bid (250mg TID if
pregnant) for 1 wk or Metronidazole gel 0.75% 5g intravaginal
at bedtime for 5 d – if recurrent  add gel twice/week 4-6 mo
Candidiasis: Diflucan® (fluconazole) 150mg PO single dose -
Gyno-daktarin® (Miconazole) cream/suppository daily for 3 d –
if recurrent  oral Fluconazole 150mg weekly for 6 months
Trichomoniasis: Metronidazole 2 gm PO single dose - treat
partner even asymptomatic, pregnant if symptomatic or >37wk
STI: Ceftriaxone 250mg IM+Azithromycin 1gm PO single dose
Atrophic vaginitis: topical estrogen cream, tablet, or ring
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Master OSCE exam
30. Vitamin D deficiency

Prematurity – nutritional history – sun exposure - delayed

walking – h/o fractures – chronic medical condition – previous
surgery e.g. bariatric- family history of orthopedic abnormalities

- Inadequate exposure to sunlight - Nutritional deficiency

- Exclusive breastfeeding without vitamin D supplementation
- Malabsorption e.g. coeliac sprue, small bowel resection, IBD
- Chronic kidney/liver disease affect vit D synthesis/activation
- Drugs causing vit D catabolism: e.g. rifampicin, phenobarbital

In children: bowing of legs – costochondral beading –

Harrison's groove (flaring of ribs at diaphragm level) –
craniotabes – wide anterior fontanelle – frontal bossing - flaring
of wrists – bone deformities - dental abnormalities – In adults:
periosteal pain on applying firm pressure on sternum/tibia

Vitamin D sufficiency is estimated by measuring 25-

hydroxyvitamin D (25[OH]D or calcidiol) concentrations, if <20
ng/mL (<50 nmol/L) deficiency, if 21-29 ng/mL Insufficiency

Screening for vitamin D deficiency is recommended only in

people at high risk for vitamin D deficiency, as: [Patients with
osteoporosis, malabsorption, black/Hispanic, Obese, disorders
affecting metabolism of vitamin D & phosphate (as CKD)]

Vitamin D deficiency/insufficiency contribute to increase risk of:

Osteoporosis - diabetes – cancer – stroke – cardiovascular
diseases – multiple sclerosis – rheumatoid arthritis

- Unprotected sun exposure between 10 am - 3 pm (↑ skin

pigmentation, aging, & sunscreen use reduce vitD3 production)
- Dietary intake (fortified milk, juice & cereals – canned salmon
& sardines – mackerel – eggs – cod liver oil)
- Vitamin D supplementation: 400 IU daily < 1yr – 600 IU 1-18
yrs – 1500-2000 IU in all adults >18yrs, including pregnants
Benefits: improve bone mineral density and improve muscle
strength, leading to prevention of fractures and reduction in
falls in elderly – improve insulin sensitivity -  mortality

Vitamin D3 (Cholecalciferol) drops or capsules 50.000 IU once

weekly for all ages, or 2000 IU daily for patients <18 yr, and
6000 IU daily for adults, for 6-8 weeks. When serum level > 30
ng/mL, go back to maintenance dose according to age.
Vidrop®/Vi-De3® drops (100 IU/drop – 45.000 IU/bottle) -
Biodal® tab (1000 – 5000 – 10000 – 50000 IU)
51
Master OSCE exam

Counseling
and
health education
52
Master OSCE exam

53
Master OSCE exam
Introduction to counseling
- Ask patient's permission to speak about the problem
- Does he/she know hazards of the problem?
- Identify patient's stage in the cycle of change:
Precontemplation (Uninterested, unaware or unwilling to
make a change)  maintain positive relationship, show
empathy, avoid argument, ask questions rather than advices
Contemplation (considering a change)  move to (Assess)
Preparation (prepare to make a change)  move to (Assist)
Action (active change)  move to (Arrange)
Maintenance (sustained change) – Relapse (fall back)

1. Ask questions to assess patients (health belief):

- Perceived threat (perceived susceptibility to develop
complications + perceived severity of risk)
- Perceived benefit of change
- Perceived barrier: the individual's own evaluation of
obstacles in the way of change (cultural, financial,
emotional...)
- Cues to action (events, people, or things that move
people to change. Should be personalized: e.g. bothersome
symptom, illness of family member, religious, financial, …)
- Self-efficacy: belief in own ability to change
2. General assessment: chronic diseases, medications, …
3. Specific assessment: e.g. nicotine/alcohol dependence
test, BMI and waist circumference, …

- Based on explored patient's knowledge/values/education

- Value his right information, correct others in brief, focused,
simple & evidence-based advice about hazards of problem
& benefits of change in a non-judgmental respectful way
- Discuss available treatment options (e.g. lifestyle
modification, CBT, medications, surgery, ….)
- Give written or audiovisual health education materials
- Set a date of action (when patient is prepared)
- Tailor treatment plan to patient's preference & risk
- Anticipate roadblocks and plan how to overcome them
- Meet family members and significant others for support
- Join community support groups

- Schedule regular follow up visits and phone calls

- Encourage self-monitoring: e.g. food diary, triggers to
smoke
- Refer to specialized health provider e.g. dietician, lactation
counselor, stop smoking center, disease control center, …
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Master OSCE exam
1. Complementary feeding
Age – feeding (breastfed, formula-fed or mixed) – started
complementary food already? – any feeding problems? –
health status – developmental milestones (head support – sit
with or without support – put hands or toys in mouth - feed
himself – rejection) – FH of food allergy or atopic diseases

Exclusive breastfeeding is recommended by WHO (no even

water) as digestive and immune system not well developed (with
exception of ORS, drops/solution of vitamins/minerals/medicines
Offering other liquids/solids ↑ risk of allergies, infections & DM

Soft but thick food – use soft-tipped spoon – start by mixing a

teaspoon of [pureed soft fruit as banana or cooked apple/pear
– pureed cooked vegetable as carrot/potato/sweet potato -
non-wheat cereal] with breast milk or formula - start gradually
with small amount – one new item at a time – do not add sugar
or salt - offer food before or in the middle of his usual milk feed

Mashed or chopped food – full fat dairy products – wheat cereal

- finger food (sticks of cooked vegetables as carrot – pieces of
soft peeled fruit as banana, melon, mango – French fries –
bread – cheese) – beans & lentil soup – boiled egg - meat

Ready to share family food, in mealtime – helps child to

develop social skills – but be careful of small pieces, bones (as
fish bone) and skin (as sausage or fish skin)
Food safety: Hand hygiene – clean utensils – Never refreeze
defrost food – Do not reheat food more than once – throw away
any leftover food – avoid food may cause choking (as nuts,
grapes, raw carrots or candies) – don't feed baby jarred food
directly, serve in a bowl, discard jar after 2-3 days
General advices: Always stay with your baby while eating –
Keep him sitting upright during meal – Never offer food by
bottle – Don't rush the baby or try to force-feed him – let baby
feed himself – if he refused a new food try it later – withholding
solid food beyond 6 mo may ↑ resistance & delay growth.
Signs of food allergy include skin rash, vomiting,
cough/wheeze/SOB, facial & tongue swelling and fainting

Cow/goat milk (poor in iron and highly allergenic), honey (may

lead to botulism) and added salt before 1 yr of age
Skimmed milk and whole nuts under age of 5.
Avoid raw or undercooked food, raw shellfish, fish with high
mercury level (as shark or smoked fish)
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Master OSCE exam
2. Contraception
Age – breastfeeding – smoking – obstetric & menstrual
history (regularity, quantity, duration, pain) – Past history:
DM, HTN, thromboembolic, CAD, PID, migraine with aura,
breast/cervical cancer – Family history of cancer

- When does she want to get pregnant? Sex pattern?

- Did she try a contraceptive before? Had any problem?
- Does she prefer one method? Or refuses another?
- Can keep on daily pills? accept injection/IUD/implant?

BMI – pelvic examination if going to insert IUD, to exclude

distorted uterine anatomy or cervical motion tenderness

COC may decrease acne, menorrhagia, dysmenorrhea,

PMS, and protective against ovarian & endometrial cancer
Progestin only preferred with overweight, DM, epilepsy,
sickle cell anemia, dyslipidemia, or h/o thromboembolic

Permanent sterilization (vasectomy, tubal ligation) > 99.5% -

Implant 99.95%, hormonal IUD 99.8%, copper IUD 99.2%,
injection 94%, pills/patch/ring 91%, condom 82%
Combined: e.g. Marvelon® – Yasmin® – Gynera® – Micro-
gynon 30® - Ortho evra® patch - Nuvaring® vaginal ring
Progestin only: e.g. Microlut® - Cerazette® - Depoprovera®
150mg IM inj q3mo - Implanon® intradermal capsule for 3 yrs
IUD: Paragard 380A®(copper)10 yrs - Mirena®(hormonal)5 yrs

COC: smoker > 35 yr – thromboembolism – CVA/CAD/CHF

DM with vascular complications - uncontrolled HTN - H/o
breast cancer – active liver disease – migraine with aura -
undiagnosed vaginal bleeding – suspected pregnancy
IUD: PID – undiagnosed vaginal bleeding – distorted uterine
cavity – trophoblastic disease with persistent ↑ in ß-HCG

If one: take it as soon as remembered, continue as prescribed

If ≥2, not in last wk: continue, with a backup method for 1 wk
If ≥2 in last wk: continue & start a new one with no pill-free wk

0.75 mg levonorgestrel (1 tab of Contraplan II®, 10 pills of

Microlut®, 7 pills of Yasmin®) repeat after 12 hrs or can be
taken all together - may be effective for up to 5 days (120
hrs) after unprotected sex, but the sooner the more effective

Heavy vaginal bleeding – chest pain – swelling/tenderness/

weakness of one limb – SOB – severe headache
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Master OSCE exam
3. Epilepsy health education
Brief personal, social, past and family history – how & when
diagnosed with epilepsy? – type of seizure – medication - last
attack? – has aura? - postictal symptoms? – does family &
colleagues know about condition & how to deal with attack?

What do you know about epilepsy?

What's your main concern about the condition?
How epilepsy affects your quality of life?
What do you expect us to do today?

Epilepsy is abnormal and excessive electrical activity of the

brain leading to change in awareness, behavior and/or
abnormal movements lasting only a few seconds to minutes
– it is not curable, but controllable – antiepileptic drugs (AED)
usually started after 2nd unprovoked seizure – AED regimen
should be followed as prescribed – never stop on your own
decision – during attack you should be put gently on your
side, clearing area of anything hard or sharp, putting soft
thing under head, loosen tie, remove eyeglasses, time
seizure and call emergency service if lasts longer than 5 min
or have another fit soon after the first one - you should have
a seizure calendar recording fits, triggers and medication
doses, to be revised by neurologist each visit – it is possible
to consider stopping AED gradually if you are fit-free for 2
years or more - you will be asked to do blood test for drug
level, CBC, RFT and LFT regularly - some AED are enzyme
inducers (such as phenytoin and carbamazepine) causing
multiple drug interaction - you should first contact me or your
neurologist before taking any OTC, herbal or even prescribed
medication – you will be prescribed folic acid 400 mcg daily

No swimming or driving until 1-year seizure free – Driving

bus or heavy goods vehicles after being 10 years fit-free -
never operate heavy machines – Seizure-proof home

Avoid flashing lights – loud music – intense exercise – strong

emotions - hunger – sleep deprivation – alcohol - fever

Postpone pregnancy until well-controlled, using alternative

contraceptives other than hormonal such as IUD or barrier -
Inform doctor if planning to get pregnant – Start folic acid
0.4-4 mg 1-3 mo prior to conception – avoid valproic acid in
child bearing age - shift to lamotrigine – breastfeed safely,
shifting to carbamazepine during lactation – inheritance <
5% (compared to 2% general population incidence)
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Master OSCE exam
4. Febrile convulsion

For how long and description of seizure – h/o previous attack

Precipitating factor: fever (grade?) - head trauma – vaccine...
Change in consciousness, motor, sensory, behavior or gait
Prenatal, natal, postnatal, growth and developmental history
Family history of febrile convulsions or epilepsy

Reassure parents it does not affect intelligence or brain

development - having febrile convulsions doesn't mean child
will have epilepsy (yet he has 1-2% higher risk than general
population) – 1/3 of children having febrile seizures will recur

If you witness a child's seizure place him on his side – do not

try to stop his movement – do not put anything in his mouth
– keep an eye on watch, if last> 5 min call emergency or use
one dose of rectal diazepam (Diastat®) if diagnosed before

- Complex seizure: 1 or more of criteria (focal - > 15 min -

recur within same illness - incomplete recovery within 1 hr
- Signs of meningeal irritation
- Status epilepticus (> 30 min)
- Altered level of consciousness after attack
- Abnormal neurological examination

Risk of recurrence higher if:

- Child < 15 months in first attack
- Frequent febrile illnesses
- Short time between onset of fever and seizure
- Seizure with low grade fever
- Parent or sibling with febrile seizure or epilepsy

In most cases supportive care for 5 - 10 min is appropriate.

Ensure adequate airway and breathing while waiting for
convulsion to stop spontaneously.
If seizure persists or onset has not been witnessed, give 0.2-
0.5 mg/kg rectal diazepam, repeat after 5 min if persisted.

In most cases, antiepileptic drugs are not recommended, as

their potential side effects outweigh their benefits - No
evidence that any therapy administered after a first simple
seizure will reduce risk of having afebrile seizure (epilepsy)
- Prophylactic antipyretic is not recommended in afebrile
child, and does not appear to reduce risk.

If any alarm feature – for parent reassurance

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Master OSCE exam
5. HIV counseling

Brief personal, social, past history - High risk sexual

experience? - Male/female partner? - Type of sex? Receiving
/inserting? - High risk area? IV drugs? Blood Transfusion?

Homosexual men (highest risk - more in receptive) - IV drug

user - H/o STDs - Partner with HIV – unprotected sex with
multiple partners - Patient with TB, hepatitis B / C, lymphoma
* All population 13-64year-olds should be tested at least once
* In high risk individuals
* Routine testing in pregnancy
Antibody detectable in blood or body fluids 3 wk to 3 months
after exposure (window period) - Test result after 48-72 hrs,
(or 15-40 min if rapid test) – repeat +ve test for confirmation
- If still +ve  refer to an HIV center to assess CD4 count &
viral load, & start highly active antiretroviral therapy HAART

- HIV infection start by flu-like symptoms  asymptomatic ±

generalized lymphadenopathy  opportunistic infections
- It's not AIDS until CD4 ˂200 cell/mm3 or illness with an
AIDS-defining condition (infections & cancers that are life-
threatening in people with HIV such as Kaposi sarcoma,
pneumocystis jiroverci pneumonia, Burkitt's lymphoma, …)

Post-exposure prophylaxis: 3 antiretroviral drugs for 28

days within 72 h of high-risk event - The earlier the more
effective – HIV test after 3 months

- Not curable, but treatable, treatment helps living longer

- Early diagnosis and treatment improve outcome
- Ensure confidentiality (breach to sex partner)
- Start HAART once diagnosis confirmed if symptomatic, or
if CD4 count < 350 cell/mm3 if asymptomatic
- Refer to HIV center and notify to disease control center
-- Pregnancy increase the urgency to Start HAART.
- Can deliver vaginally if viral load undetectable, or else
deliver by C/S, with Zidovudine IV during delivery and
neonatal prophylaxis for 6 wks
- Breastfeeding not recommended
- if C/S & no breastfeeding  only 2% transmission risk

CD4 & viral load /3-6 months [the lower the load the less the
transmission risk, the higher CD4 the better the prognosis]
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Master OSCE exam
6. Obesity
Brief personal & social history – Progressive wt gain –
physical activity – sleep apnea – joint pain/LBP – dyspnea –
symptom of hypothyroidism – smoking/alcohol/drug abuse –
steroid – OCPs – infertility - chronic diseases – screen for
depression – you know about obesity complication? – impact
of obesity on your quality of life? - Are you willing to change?
– Did you try before to lose wt? – What was the roadblocks?
–
BMI [Wt in kg/Ht in m2]– BP - waist circumference - waist: hip
ratio – thyroid – chest /CVS – abdomen – LL – neck
circumference if sleep apnea (>37cm women, >43cm men)
BMI 25: 29.9 kg/m2  overweight – 30 :34.9  Class I obesity
35: 39.9  Class II obesity - ≥ 40 kg/m2  Class III obesity

Fasting lipid profile – LFT – TSH – FBS – HbA1c

Metabolic syndrome ↑ risk for coronary heart disease, DM,
fatty liver and several cancers. It is diagnosed when patient
has at least 3 of the following 5 conditions:
- FBS≥100mg/dL (or receiving drug therapy for DM)
- BP ≥130/85 mmHg (or receive drug therapy for HTN)
- TGs ≥150 mg/dL (or receive drugs for hypertriglyceridemia)
- HDL-C <40 mg/dL in men or <50 mg/dL in women
- Waist circumference ≥ 102 cm in men, ≥ 88 cm in women
Obtain 72-hr diet diary - calculate total caloric need
(according to sex, age, Wt, Ht, and activity), should reduce
daily intake 500 – 1000 calories than needs in order to lose
wt – increase vegetables, fruit, low fat dairy products – lean
meat – grill not fry - reduce saturated fat and sugar – increase
water intake – check food labels – Don't skip meals - exercise
redistribute central fat, the main factor for insulin resistance
For BMI ≥30, or ≥27 with at least 1 comorbidity:
Xenical® (Orlistat) 120mg PO TID with meal (impair dietary fat
absorption), Saxenda® (Liraglutide) 3mg daily SC injection
(GLP-1 analogue), Belviq® (Lorcaserin) 10mg PO BID
(centrally acting to promote satiety - not with renal impairment)
Bariatric surgery indicated if BMI > 40 or > 35 with
comorbidities. Gastric bypass (Roux-en-Y): attach small
gastric pouch directly to small intestine, high success rate,
rapid wt loss. Sleeve gastrectomy: ↓ stomach surface area,
less invasive and less risk of malnutrition. Gastric band:
laparoscopic, easy to perform, can be removed or adjusted
Multiple comorbidities – failed trials – candidate of surgery
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Master OSCE exam
7. Post MI care
Brief history about age, marital status, occupation, date of
attack, procedure done, hospital discharge, current medication,
follow up system with hospital – explore his ICEE

Join in a program of multidisciplinary team: cardiologist,

internist, psychiatrist, psychologist, nutritionist, endocrinologist,
physiotherapist, health educator and family physician

Screen for depression - reassure he can go back to his normal

life – offer stress management – involve partner/carer in plan

Start regular physical activity from first days to a comfortable

level, increase duration & intensity gradually.

After about 4 weeks, you'll be able to drive your car, air travel
and back to your regular sexual activity. PDE5 inhibitors (for
treatment of erectile dysfunction) must be avoided in patients
treated with nitrates as this can lead to dangerously low blood
pressure, it may be considered after at least 6 months post MI
Advise smokers to stop smoking, offer support and /or
medication - Reduce alcohol consumption to no more than 21
unit for men, or 14 units for women weekly
Advice all overweight/obese patients to achieve healthy weight
Mediterranean-style diet: ↑ bread, fruit, vegetables & fish; less
meat; replace butter & cheese with products based on plant oils
- BP control is the single most important factor in prevention
- Patient will be discharged on [ACEI at maximum tolerated
dose - B – high intensity statin – dual antiplatelet therapy]
for at least 1 year, continue ACEI, aspirin and statin life-long

Regular immunization more important to people with

cardiovascular disease such as yearly influenza vaccine, Tdap
every 10 years, pneumococcal & zoster vaccines as indicated

- Every visit: BP, wt, review of symptoms, activity limitation,

psychosocial status and adherence to medication/lifestyle
- Renal function and electrolytes after 1- 2 wks of starting ACEI
- Liver function & lipid profile after 3 months of starting statin
- Exercise stress test before returning to exercise
- Echocardiography 3 months after acute MI, then periodically

Patients and family should be taught to recognize cardiac

symptoms, use prescribed nitroglycerin, when to initiate
emergency response system and how to do CPR
61
Master OSCE exam
8. Pre-travel counseling
- Trip: Where? When? How long? Transportation? Trip
program? Activities? Presence of children, old or pregnant?
- Medical: chronic disease, drugs, allergies, CVD, seizure,
psychiatric, thromboembolic + check vaccination status + ICE
Check CDC for common diseases in destination & prophylaxis:
Hepatitis A (2 doses IM, 6:36 mo apart, protection 2-4 wks
after 1st dose, up to 25 yrs) – Meningococcal (IM, 2 doses, ≥
8 wks apart) – Typhoid (4 capsules, one every other day,
protection after 2 wks, up to 5 yrs) – Yellow fever (single dose,
IM/SC, protection after 10d, lifelong) - Japanese encephalitis
(SC, 2 doses, 4 wks apart, protection 1 wk after last dose) -
Malaria prophylaxis: Chloroquine 500mg tab weekly, 1-2 wks
before, up to 4 wks after leaving – or Doxycycline 100 mg OD
(if chloroquine-resistant area) 1-2 days before, up to 4 wks after
DEET Insect repellant on skin (Off® spray/lotion) & permethrin
on clothes and bed nets (Ectomethrin® solution) – conditioned
room – avoid outdoor activities in dark/dusk – wear long
sleeves & tight pants - inspect skin & clothes for ticks daily
Traveler diarrhea is 80-90% bacterial – highest in 1st 2 wks - ↑
if using PPI or antacids – prophylactic antibiotics not routine –
(but if high risk give bismuth 2 tab QID throughout) - usually
self-limited - rehydration and loperamide ± ciprofloxacin 500 mg
repeat after 12 hrs unless (fever – blood in stool – age <18 yrs)
- Solar injury (sunblock SPF≥ 15 - shade- umbrella/wide hat)
- Food safety (well cooked food from trusted restaurant – don't
reheat – only bottled water – avoid ice – hand hygiene)
- Accidental injuries (RTAs, drowning, animal bite) - Safe sex
- Transportation related (DVT  exercise & compression
stockings - motion sickness  control breathing - avoid heavy
/spicy/acidic meal, alcohol, nicotine & caffeine, dehydration -
choose center or front of the vehicle – support head - Avoid
noxious stimuli – look forward at a fixed point - scopolamine
patch 4 hrs before travel, then every 72 hrs as needed)
- Altitude sickness: Slow ascent/rapid descent – slowly
acclimatize ± Acetazolamide 125mg BID, for 3d start 1d before

Medical kit: alcohol swabs – tweezer – cure aid – scissors -

gauze/crepe bandage – analgesic – antihistaminic – Mebo
cream – enough stock of prescribed drugs – medical bracelet

Air travel allowed up to 36 wks - avoid scuba diving, bicycling

& skiing - avoid countries with Zika virus – avoid live vaccines
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Master OSCE exam
9. Smoking cessation
Identify and document tobacco use status for every patient at
every visit (Current – Former – Never) – Brief history
Is he willing to make a quit attempt at this time? Previous attempt?
 Identify patient's stage in the "Cycle of change"
Fagerstrom nicotine dependence test:
1. How soon after wake up do you smoke your 1st cigarette?
Within 5 min (3) – 6:30 min (2) – 31:60 min (1) – > 60 min (0)
2. Is it difficult to refrain from smoking in places where it is
forbidden? (or during fasting) Yes (1) – No (0)
3. Which cigarette you hate most to quit? 1st in the morning (1) - any other(0)
4. How many cigarettes / day do you smoke? 10 or less (0) – 11:21 (1) –
21:30 (2) – 31 or more (3)
5. Smoke more frequently in the morning? Yes (1) – No (0)
6. Smoking even if very ill? Yes (1) – No (0)
1-2 = low dependence, 3-4 = low to moderate dependence, 5-7 =
moderate dependence, 8+ = high dependence
In a clear, strong, and personalized manner, urge every tobacco
user to quit, affirm choice not to smoke (in non-smoker) or
decision to quit (in former smoker)
Hazards of smoking: increase risk for death from all causes -
cigarette smoke has 69 carcinogenic substances, can cause cancer almost
anywhere in the body – increase risk for CAD & stroke 2-4 times, lung cancer
25 times, COPD 12-13 times, DM 30-40% higher – decrease fertility –
increase risk for preterm delivery, stillbirth, low birth weight, sudden infant
death, ectopic pregnancy, birth defects as orofacial clefts
Benefits of quitting: improve taste & smell sensation in few days, improve
cough & breathing within few months, decrease risk for CAD by half after 1
yr, reduce risk for stroke to non-smokers after 2-5 yrs, decrease risk for
cancers other than lung by half within 5 yrs, and for lung cancer after 10 yrs
No safe tobacco smoking, even if smokeless or electronic – hookah is not
less harmful than cigarettes and even more dangerous (charcoal, more puffs
and inhaled smoke per session, water doesn't decrease toxicity)
Non-pharmacological: Set a quit date (after 2 wks) – seek
family/friend support – anticipate barriers & triggers, provide
coping strategy - by that day get rid of all smoking-related items,
launder clothing, vacuum car & home - Pharmacological:
1. Nicotine replacement therapy NRT (patch, gum, lozenge, inhaler, nasal
spray): must stop smoking first, start with high dose with gradual tapering
for 12 weeks - 2. Non-nicotine pharmacotherapy: usually start 1 wk before
quit date, can be used with NRT, start low dose then increase, for 12 weeks
a. Bupropion (Wellbutrin®): antidepressant, start 150mg OD for 3 days,
then increase to BID or XR 300mg OD for 12 wks, avoid in seizure disorders
b. Varenicline (Champix®): Days 1-3: 0.5 mg OD, days 4-7: 0.5 mg BID,
day 8 to 12 wks: 1 mg BID, continue for 12 wks more if successful – avoid
in people with known cardiovascular problems and below 18 years
63
Master OSCE exam
10. Vaccination defaulter
Brief prenatal, natal, neonatal, feeding, growth and
developmental history - H/o chronic or recurrent health
problem – use of medications - H/o food/drug allergy - social
history – mother work - family problems - sick sibling/parent?

Social/marital problems – child illness – a reaction followed

previous vaccination – difficult access to health center –
misconceptions – multiple children – busy/ill mother

When to suspect child abuse or neglect: multiple Bruises/

fractures/cuts – delay in seeking medical care – bad hygiene
– not properly dressed – poor growth - child aggression/
withdrawal - recent family crisis – stressful living condition –
lack of support system – psychiatric illness, alcohol or drug
abuse of a family member  Contact child protection agency

Help protect child & whole community from serious illnesses

What is not considered a contraindication of

vaccination: [Diarrhea – mild illness with or without fever –
current use of antibiotics – being in convalescent stage of
acute illness – mild to moderate local reaction to previous
vaccine – prematurity – chronic non-immunosuppressive dis]
Relation of MMR vaccine to autism has been rejected by
many researches
1. Check received vaccines - Do not repeat given doses
[Not recorded = Not done]
2. Give scheduled vaccines according to current age, plus
what can be added from the missed vaccines (at different
injection site – never 2 doses of same vaccine at a time)
3. Minimum interval between doses is 4 wks, except for
[MCV4 minimum interval is 8 wks – PCV [if 1st dose after
1yr age minimum interval is 8 wks, no further doses
needed if 1st dose ≥2yrs - varicella <13 yr age minimum
interval is 3 months - hepatitis A 6 months – booster
doses of DTaP (after 3 doses) minimum interval is 6 mo]
4. Minimum age for hepatitis A, varicella and MMR is 1 year
5. Maximum age for Rota [1st dose is 15 wks, for last dose
of Rotarix 6 mo, and Rotateq 8 mo]. Maximum age for
pneumococcal PCV & haemophilus influenza Hib is 5 yrs
6. If > 7yr, DTaP will be TdaP, if booster will be DT only

Tag the file for follow up

Notify the local disease control center
64
Master OSCE exam

65
Master OSCE exam

Examination
And
Minor procedures

66
Master OSCE exam

67
Master OSCE exam
Examination/procedures template

Examination
/ procedure

Start

Examination/
Summarize investigation
findings to complete
examination

68
 1. Breast examination
1. Expose from waist up
3. Neutral position (arms by side, hands relaxed
on thighs) then hands on hip and pushing inwards
4.Nipple (retraction, discharge, fissuring or scaling)
Use distal
A. Breast: Examine with ipsilateral arm
pads of middle
raised, while sitting as well as lying 45°
3 fingers
Landmark: a rectangle from clavicle
down to lower rib line, and from mid-
sternum to midaxillary line laterally
3 levels of palpation: Light, medium and deep
A. Vertical strip method: start in midaxillary line,
up and down, move medially
B.
C.
D. B. Spiral method: start from nipple, in a circular
E. clockwise direction, cover the whole landmark
① 2. Sitting upright on the side of the bed
4. Then arms above head, and lean forward as so
Scars, asymmetry, skin changes (erythema,
puckering, peau d'orange), obvious masses
B. Axilla: Examine in sitting position while
② ipsilateral arm resting on my other arm
4 groups of lymph nodes:
Supraclavicular: above clavicle
Infraclavicular: below clavicle
Internal mammary
Axillary: they are subdivided to 5 groups: Apical
(deep in the roof of axilla by tips of fingers),
medial (against chest wall), lateral (against
③ humerus), anterior (in anterior axillary fold) and
posterior (in posterior axillary fold)
Any mass: comment about (Site by quadrant or
clock face – Size – Shape – regularity – margin
– consistency – tenderness – overlying skin)
69
 2. Cardiovascular examination
Position: lying 45° - exposed from waist up
Is the patient in pain? or distressed? Check vital signs
Check surroundings (IV fluids – O2 – drugs – walking aid -..)
Face: Pallor – jaundice – central cyanosis – malar flush (MS)
– angular cheilitis – glossitis – xanthelasma
Neck: visible IJV pulse – masses – scars
Chest: asymmetry – scars – visible bulge – visible pulsation
– deformity – barrel-shape - gynecomastia
Hand: cyanosis – clubbing – palmar erythema – janeway
lesions – Osler's nodes – splinter hemorrhage - xanthomata
Leg: edema – scars – hyperpigmentation - ulcers - varicosity

Hand: temperature – capillary refill

Arm: Radial pulse (comment on vessel wall,
rate/rhythm/volume/character – radio-radial & radio-femoral
delay – Collapsing (or water hammer) pulse (in AR or
hyperdynamic circulation): ask patient if he has shoulder
problem? and then raise arm straight up while feeling
pounding pulse with your palm – brachial pulse – BP
Neck: carotid pulse – IJV (turn head left – check by torch - ↑
by Valsalva maneuver or hepatojugular reflux and disappear
if he holds breath without straining) - measure the vertical
distance between highest wave and sternal angle)
Chest: point of maximum impulse – heave or thrill

Liver: start 3rd intercostal space at mid-clavicular line (usually

starts in 5th space), then from below umbilicus up, then
measure span in midclavicular line (normal 6- 12 cm)
Heart: start right 2nd, 3rd & 4th spaces (should be resonant),
then Left 2nd, 3rd, 4th, 5th spaces (should be dull in 4th & 5th),
then from lateral to apex medially (if dull beyond apex = LVH)

Aortic area: Right upper sternal border, 2nd intercostal space

Pulmonary area: left sternal border, 2nd intercostal space
Tricuspid area: left lower sternal border, 4th intercostal space
Mitral area (Apex): 5th intercostal space at mid-clavicular line
Carotid artery by bell (for bruit) – lung base (for crepitation)
Aortic stenosis (AS): ejection pansystolic murmur, on aortic
area, radiate to carotid (after holding breath)
Aortic regurge (AR): blowing early diastolic murmur, on
tricuspid area, increase by leaning forward
Mitral stenosis (MS): rumbling mid-diastolic murmur, on
apex by bell, increase on left lateral decubitus
Mitral regurge (MR): soft pansystolic murmur, on apex and
radiate to axilla
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Master OSCE exam
3. Chest examination
Position: lying 45° - exposed from waist up
Is patient able to speak in full sentence? Is he distressed?
Or in pain? Coughing? Audible wheeze? Stridor?
Check surroundings (inhaler - O2 – cigarette
Face: Pallor – jaundice – central cyanosis
Chest: asymmetry – scars – visible bulge – deformity
Hand: cyanosis – clubbing – nicotine staining – tremors
Neck: visible IJV pulse
Legs: edema – signs of DVT – erythema nodosum

Hand: temperature – capillary refill – radial pulse

Neck: tracheal position (by index finger with neck muscles
relaxed, comparing distance at both sides)
Chest: Point of maximum impulse
Check chest expansion by fanning fingers around chest
above then below nipple line with thumbs together in
midline, ask patient to take a deep breath, check for
expansion & symmetry manifested by thumb movement
Lymph nodes: supra/infra clavicular – submental –
submandibular – anterior/posterior cervical - pre/post
auricular – occipital - axillary)
Vocal fremitus: ask patient to say (99) repeatedly and
assess tactile vibration by your palm on both sides

Percuss above clavicle, medial 1/3 of clavicle, below clavicle

and intercostal spaces (at the midclavicular line down to 6th
space, then midaxillary down to 8th space). They are all
resonant normally except for bare area of the heart on 4th
and 5th left intercostal spaces (if resonant = emphysema), if
other areas dull = consolidation – fluid – collapse - mass
Auscultate above clavicle, 2nd, 4th, 5th space midclavicular,
6th, 7th at anterior axillary line – 1st to 6th space paravertebral
1. Ask patient to take deep breaths in & out through mouth
Quality: Vesicular (soft, short expiration, no gap) – Bronchial
(harsh, prolonged expiration with pause between inspiration
and expiration – occur with consolidation)
Volume: reduced in obese, fluids, consolidation, collapse
Added sounds: wheeze (musical, in BA & COPD) – rhonchi
(snore-like, =secretions in airway) - coarse crackles (rubbing
hair between fingers, pneumonia – bronchiectasis –
pulmonary edema) – Fine crackles (pulmonary fibrosis)
2. Ask patient to say (99) repeatedly and auscultate again

Repeat all previous steps on the posterior aspect of chest

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Master OSCE exam
4. Cranial nerve examination
Olfactory (I): Function: sensory only, smell
Injury: hyposmia – anosmia - cacosmia
Examination: by strong non-irritant smell in
each nostril apart, while pinching the other
Optic (II): Function: sensory only, vision
Injury: blindness or visual field defect
Examination: pupil, visual acuity, color vision,
visual field, light & accommodation reflex
Oculomotor (III): Function: motor only, innervate all ocular muscles
except superior oblique and lateral rectus (SO4 – LR6)
Injury: outward & inward eye deviation – ptosis – pupil dilatation
Trochlear (IV): Function: motor only, innervate superior oblique
Injury: vertical diplopia on looking downward
Abducens (VI): Function: motor only, lateral rectus
Injury: esotropia (medial deviation) of affected eye
Examination: H-test for restriction of movement or diplopia
Corneal light reflex for alignment – cover/uncover test for latent strabismus
Trigeminal (V): Function: motor (muscle of mastication & tensor
tympani) + sensory (branches: ophthalmic, maxillary& mandibular)
Injury:  sensation – weak jaw clenching & side to side movement
Examination: sensation in its distribution – corneal reflex – jaw clench
– move mandible side to side against resistance – jaw reflex
Facial (VII): Function: motor (muscles of facial expression + stapedius
muscle in inner ear) – sensory (taste sensation in anterior 2/3 of
tongue) – parasympathetic (lacrimal & salivary gland)
Injury: ipsilateral facial muscle paralysis (forehead spared in UMNL due to
double innervation) – hyperacusis – impaired taste in anterior 2/3 – dry eye
Examination: inspect nasolabial fold, forehead wrinkles & wide palpebral
fissure – Ask him to raise brows, blow mouth, show teeth, close eyes tightly
Auditory/vestibulocochlear (VIII): Function: sensory only - hearing
Injury: vertigo ± hearing loss Examination: Rinne & Weber tests
Glossopharyngeal (IX): Function: Motor (styropharyngeus muscle) –
Sensory (posterior 1/3 of tongue, pharynx, middle ear, carotid sinus)
Injury: dysphagia - impaired taste in posterior 2/3
Vagus (X): Function: motor (soft palate, larynx, pharynx, upper esophagus) –
sensory (pharynx, larynx, esophagus, external ear, aortic arch, thoracic &
abdominal viscera)– parasympathetic (cardiovascular, respiratory, GI system)
Injury: dysphonia – dysarthria - aspiration
Examination: ask patient to take a sip of water, say "Ah" to check palatal
movement and symmetry, touch palate by a tongue depressor for gag reflex
Spinal accessory (XI): Function: motor only (Sternomastoid – trapezius)
Injury: shoulder droop - Examination: face turn, raise shoulder against resistance
Hypoglossal (XII): Function: motor only, muscles of tongue
Injury: weakness & atrophy of tongue – tongue deviation on protrusion
Examination: ask to protrude tongue for fasciculation, atrophy or deviation
72
 5. Diabetic Foot examination
Expose up to knee
Skin: color – hair – lesions –
ulcers – callus - dryness
Nail: dystrophy – ingrown nail
Cool  Peripheral vascular disease
Hot  Cellulitis
Hot, red, swollen midfoot 
Charcot arthropathy
- Eyes closed
- Apply enough pressure to bend, &
hold 1- 2 sec
- On 1st & 5th toes, 1st, 2nd & 5th
heads of metatarsals, & heel
Eyes closed - use 128-Hz tuning fork –
start on dorsum of interphalangeal joint
of big toe bilaterally – feel vibration and
its stop – If not felt  try proximal bony
prominence till felt, document the level
① Muscle wasting
Deformities: claw toes –
Charcot foot – pes cavus/planus
Swelling: painless or tender (DVT)
Capillary refill (normal ≤ 2sec)
②
Pulses: by index & middle fingers,
Dorsalis pedis artery (on dorsum of
foot lateral to tendon of extensor
hallucis longus) - Posterior tibial
artery (behind medial malleolus)
Patient sitting, foot resting,
passively positioned and slightly
③
dorsiflexed – Percuss Achilles
tendon directly  positive if calf
muscle contraction and foot
planter flexion
Eyes closed - Fix interphalangeal joint
– Move distal phalanx up, then down
– if not felt  try more proximal
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Master OSCE exam

6. Knee examination
①
Front: skin – scars – asymmetry – Back: swelling, scar, muscle wasting
sinus – swelling – color – deformity – Sides: hyperextension (genu
malalignment – muscle wasting recurvatum) – flexion contracture

Joint line – tibial tuberosity – head of

fibula – patella tendon – medial/lateral Temperature ② Patellar reflex
collateral ligaments – popliteal fossa
Pulse Milking
Patellar
test
Palpate joint parts tap
For small
For large effusion
Active ③ effusion
Flexion 140° - extension 0° Passive
- If there's pain or limitation in active movement
- Assess hyperextension by elevating both legs by heels
- Crepitus (palpable crackles on passive flexion in arthritis)

2. Medial & lateral collateral ligaments 3. Meniscal tear

④ Valgus & varus stress test McMurray test
1. Anterior and posterior cruciate ligaments
Flex knee 30°, hold ankle, adduct Passive flexion of knee,
Anterior and posterior drawer test while other hand on medial side of external rotation of leg
Flex knee 90°, wrap hands around knee. Do the opposite. then slow extension.
proximal tibia, pull anteriorly then Repeat with internal
push posteriorly for significant rotation for pain or
movement popping

74
 7. Rectal examination

Explain procedure – get consent – ask about pain - get

chaperone – maintain privacy - expose from waist down
Prepare: examination gloves, lubricant gel and tissue/gauze

Left lateral decubitus, with hip and knees flexed (knee to chest)

Put gloves on - spread buttocks apart: inspect anus, posterior

perineum, and gluteal folds for (bleeding, abrasions, fissure,
mass/hemorrhoid, abscess, ulcer, sinus, skin tag, skin changes)

- Lubricate dominant hand's index finger generously, warn

patient, ask to relax, slowly advance through anal sphincter
- Ask patient to squeeze on your finger (assess Anal tone)
- Do 360° finger sweep starting from 6 o'clock position
clockwise to 12 o'clock position, return to 6'oclock position and
palpate the other half for: feces, masses, ulcers, fissure,
induration, tenderness – Comment on number, site, size, and
consistency – use anoscope if no clear cause identified by PR
- Examine prostate: anterior - normal size 3.5 cm, firm rubbery
in consistency with smooth surface and a palpable sulcus
between 2 lobes – examine for (tenderness, change in size
and/or consistency, masses, and absence of sulcus)

Anal fissure: acute: is a painful tear, chronic: has fibrosed

edges, proximal hypertrophied papillae and distal skin tag
Hemorrhoids: External hemorrhoids: below dentate line,
covered by skin. Thrombosed hemorrhoid: acute bluish
swelling with severe pain. Internal hemorrhoids better seen by
slotted anoscope, Grade I not prolapsed, Grade II prolapse with
straining, reduce spontaneously, Grade III require manual
reduction, Grade IV thrombosed, cannot be reduced
Anorectal abscess: fluctuant, indurated subcutaneous mass
Inspect for blood, feces, discharge - clean-off lubricant around
anus – take off gloves – thank patient, give tissue, cover and
allow to dress - wash your hands - summarize findings

Rectal prolapse

Slotted anoscope
75
 8. Shoulder examination
①
From front, back and sides: Pushing into the wall: For winging
Scars – asymmetry – misalignment – swelling – or asymmetry of scapula
redness - muscle wasting – drooping shoulder
Anterior Posterior
Joint parts: sternoclavicular joint –
Temperature ② clavicle – acromioclavicular joint –
coracoid process – greater tuberosity
– scapular spine and borders

Abduction moving
laterally up to 180◦
Flexion ③
Extension
moving moving
forward backward Adduction moving Internal and
up to 180◦ up to 40◦ medially up to 40◦ external rotation

Compound movements for rapid screening for shoulder joint: Hands behind head = abduction + external rotation - Hands
behind back as far up as he can = adduction + internal rotation
* Ask patient to do all movements actively first, if no pain no need to proceed to passive movement. If painful active movement,
then move the joint passively, if pain disappears in passive movement so the problem is in muscle or tendon, if pain persists
so the problem is in other joint's structures. Adhesive capsulitis (Frozen shoulder) = Inflammation & thickening of joint capsule.
Patient supine to lock scapula  limitation of both active and passive range of motion in different directions regardless of pain

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Master OSCE exam

Shoulder examination (cont.)

a. Assess c. Assess Rotator
1. Sulcus sign: Patient sitting –
④
joint cuff: 4 muscles:
examiner lateral to him, grip stability
subscapularis –
forearm distal to elbow and apply a
downward traction  if a sulcus
supraspinatus
seen just below acromion = – infraspinatus
inferior instability – teres major
b. Assess
1. Lag sign: Patient
2. Anterior and posterior drawer impingement: sitting/standing – arm beside
test: Patient supine/sitting – Due to rotator cuff body – elbow flexed 90◦ -
shoulder on the edge of table – tendinitis or bursitis externally rotate arm
examiner hold upper arm with one passively, ask him to hold
hand and stabilize scapula and i. Neer's test: in positionlag = posterior rotator cuff tear
coracoid process with the other – Patient standing 2. Resisted empty can:
firmly pull – arm flexed 90◦ Shoulder flexed, slightly
the arm up assess anterior instability, then and fully abducted and internally rotated
push down  assess posterior instability pronated – with thumb directed down,
passively move apply downward pressure on
arm up to maximum flexion patient's forearm 
ii. Hawkins test: Patient with scapula stabilized – pain weakness/pain assess
standing – shoulder and elbow & apprehension = Supraspinatus
flexed 90◦ and fully pronated – subacromial impingement. 3. Lift-off test: Patient
support elbow and push forearm Improvement after U/S guided standing – hand behind back –
Subacromial injection of 10ml push his hand & ask him to
downwards  pain =
lidocaine ± steroid relive pain move hand off his back
supraspinatus tendinitis
(Neer's sign) Assess subscapularis

77
 9. Suturing
Absorbable: internal structures, mucosa, deep layers - Natural
(chromic gut) – Synthetic (Vicryl, Monocryl) - Non-absorbable:
Natural (silk) - synthetic (Nylon, Prolene) Use 3–0/4–0 suture
on trunk, 4–0/5–0 on extremities & scalp, and 5–0/6–0 on face.

Equipment: clean trolley – sharps pin – sterile gloves - sterile

tray (can use cover of suture set) – Suture set (scissors, needle
holder, toothed & non-toothed forceps) – sutures & needle –
anesthetic/syringe – Dressing set (saline, gauze, plaster, strips)

1. Clean the wound: Place a pad under the injured body part,
wear apron, irrigate with normal saline, clip local hair
2. Examine: wound size & depth – surrounding skin and vital
organs – distal neurovascular status – tendon function
3. Give anesthesia: 1ml of lidocaine 1% per each cm of
laceration (draw by green needle & inject by orange one), given
SC, around edges, aspirate first then inject while slowly
drawing the needle out, check by sharp object for effectiveness
4. Suturing (Simple interrupted sutures): hold the needle-
holder between ring & thumb, clamp needle perpendicularly at
its 2/3, 1st suture in the middle of the wound, penetrate skin at
a 90° angle, 0.5 cm from the wound edge, take the whole
thickness of skin, pronate to rotate needle, unclamp, pull
needle with forceps, (use toothed or untoothed forceps to
visualize the wound, but never use toothed to grasp needle),
repenetrate the other edge at same depth, re-pronate and exit
skin perpendicular, unclamp, tie 2-3 knots by rotating tip of
needle holder twice around the long end of suture then short
end is pulled through the loop tightly, cut, leave 1 cm between
sutures, dispose needle in sharps pin
5. Dressing: apply Steri-Strips to suture lines+ sterile dressing

Appropriate tetanus prophylaxis should be administered as

soon as possible following a wound but should be given even
to patients who present late, as incubation period varies.
1. If clean & minor wound: no need for immunoglobulin - give
tetanus toxoid- containing vaccine only if patient received less
than 3 doses before, or unknown vaccination status - or if ≥3
but last dose given 10 years ago or more
2. All other wounds: give vaccine and immunoglobulin to
patients with < 3 doses or unknown – give vaccine only if
patient received ≥3, but last dose given 5 years ago or more

Keep sutures clean & dry – seek medical help if signs of

inflammation/infection – sutures will be removed after (3-5 d if
face – 7-10 d if scalp or arm – 10-14 d if trunk, legs, hands or
feet, 14-21 d if palms or soles) – give a wound care leaflet
78
 10. Thyroid examination
Sitting on a chair – neck exposed – first few
buttons undone – neck slightly extended
General: check surroundings – look: thin,
anxious, fidgety, sweaty vs overweight, lethargic,
apathic, wearing too much clothes, hoarse voice
Hand: dry/sweaty skin - thyroid acropachy
(clubbing, phalangeal periosteal proliferation,
swelling of overlying soft tissue) – fine tremors
Face: myxedematous face – dry/sweaty skin
– loss of outer 1/3 of eyebrow – lid retraction,
exophthalmos, proptosis, lid lag, H-test
Neck: goiter/nodule – asymmetry – scar –
swallow sip of water – stick out his tongue
paper sheet – glass of water – tendon hammer - stethoscope
Hand: Temperature – pulse - sweating
Thyroid: Stand behind patient - use pads of
3 middle fingers of both hands - locate upper
edge of thyroid cartilage in the midline -
move down to cricoid cartilage – locate
thyroid isthmus between cricoid cartilage
and suprasternal notch - palpate each lobe
of thyroid laterally, while fixing other lobe by
other hand – ask patient to swallow while
feeling both lobes for asymmetrical
elevation – ask to protrude tongue while
feeling midline for swelling
Lymph nodes: Supraclavicular – anterior
cervical – posterior cervical – submental LNs
Leg: Pretibial myxedema (nonpitting plaques
on lateral/anterior aspect of leg) – patellar reflex
Percuss down to retrosternal notch, dullness = large goiter
Auscultate both lobes of thyroid for a bruit (turbulent blood
flow suggest increase vascularity, which occurs in Graves'
79
‫مت حبمد اهلل‬

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Master OSCE exam
Table of contents
Introduction of the author………………………………………..........6
Introduction to OSCE station……………………………………….7
OSCE station template…………………………………………….….9
Tailoring history according to age…………………………………...10
Children………………………………………………………………....10
Adolescent……………………………………………………………....11
Elderly……………………………………………………………...…...12
Health maintenance………………………………………………….13
Screening and immunization of children and adolescents………............14
Screening and immunization of adults…………………………….….…15
Chapter 1: Consultation and health maintenance
1. Abnormal uterine bleeding…………………………………….…18
2. Acne vulgaris………………………………………………….….19
3. Anemia…………………………………………………………...20
4. Antenatal care…..………………………………………………...21
5. Breaking bad news…………………………………………….….22
6. Bronchial asthma…………………………………………………23
7. Chest pain………………………………………………………...24
8. Cough…………………………………………………………….25
9. Depression…………………………………………………….….26
10. Diabetes……………………………………………………….27
11. Difficult patient………………………………………….…….29
12. Dizziness………………………………………………………30
13. Dyspepsia……………………………………………………...31
14. Failure to thrive……………………………………….….……32

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Master OSCE exam

15. Fatigue………………………………………………………...33
16. Febrile child…………………………………………...………34
17. Hand pain……………………………….….………………….36
18. Headache……………………………………...……………….37
19. Hypertension……………………………….….………………38
20. Joint pain………………………………………………………40
21. Low back pain…………………………………………...…….41
22. Muscle ache…………………………………………...………42
23. Nocturnal enuresis…………………………………………….43
24. Painful anal condition…………………………………………44
25. Recurrent abdominal discomfort...………………….…………45
26. Sore throat……………………………………….….…………46
27. Urinary incontinence…………………………….….…………47
28. Urinary tract infection……………………………...………….48
29. Vaginal discharge……………………………….….………….49
30. Vitamin D deficiency………………………………………….50
Chapter 2: Counseling and health education
Introduction to counseling…………………………………………54
1. Complementary feeding………………………………………….55
2. Contraceptive counseling………………………………………...56
3. Epilepsy health education………………………………………...57
4. Febrile convulsions………………………………………………58
5. HIV counseling……………………………………………….….59
6. Obesity…………………………………………………………...60
7. Post MI care……………………………………………………...61

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Master OSCE exam

8. Pre-travel advise………………………………………………….62
9. Smoking cessation…………………………………………….….63
10. Vaccination defaulter……………………………….…………64
Chapter 3: Examination and minor procedures
Introduction to examination………………………………………68
1. Breast examination……………………………………………….69
2. Cardiovascular examination……………………………………...70
3. Chest examination…………………………………………….….71
4. Cranial nerve examination…………………………………….….72
5. Diabetic foot examination………………………………………...73
6. Knee examination……………………………………….…….….74
7. Rectal examination……………………………………….………75
8. Shoulder examination…………………………………………….76
9. Suturing…………………………………………………….….…78
10. Thyroid examination……………………………………….….79

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interpretation

83