OSCE in Ca… tips

Introduction:
Stay at the facts, do not get emotional…
Each patient is treated as individuals…
Be empathetic
Do not hammer the patient

How can I help you today?

What is happening?
Would you mind if I examine you?
Could you let me do ...
I will do this or that…
Understand patients concerns
May I ask your permission to examine you?
Carry out an examination?
I understand that you have this, would you mind if I…
I should take the history, do you mind if I do so?
Do you mind if I check this or that?
Lie down and relax
Everything looks fine, let me listen.
Do you feel any tenderness?

Visualization:
I am looking for
Pallor, jaundice, diaphoresis, cyanosis,
Distress, pain

Abuse:
What are you going to do now?
What do you want?
What he does with you? Are you forced to do something that you do not like?
Do you have marks in your body? Would you mind showing them to me?
Do you fear for your life?
Do you have relatives that can protect you?
Will you fear for your life?
Sex: What she does with you?

Depression:
How are you sleeping?
Are you eating?
Will you take your life?
 Ask for level of function
Drugs: when, what, last time (IV ones)

Screen: During the past two weeks, have you ever been bothered by:

Little interest or pleasure in doing things?

Feeling down, depressed or hopeless?

http://www.aetna.com/aetnadepressionmanagement/tools/diagnosticTools.html

Ask re OH, and addictions

Have you thought to harm your self or others?
Do you have a family or friends that you can call or chat with?
Ask re function and triggers (What happened recently)
Would you like to report this to the police?
What are you going to do now?
Where are your kids? Are they also abused?

Do you ever see things or hear voices or that other people do not see?
Is there any reason why he is agitated?
Do you think I can help you?
If not chance to talk to the patient, talk to the examiner and explain that you will
likely contact family or see if there are any previous records ( MH comm. Or
police)

Breast Ca
Estrogen receptors
Likelihood to have a genetic type

http://www.radiologyinfo.org/en/info.cfm?pg=breastcancer
http://www.cancer.med.umich.edu/prevention/breast_ovarian_cancer_genetic_ri
sks.shtml

Delivering bad news:

http://www.aafp.org/afp/20011215/1975.html (copy and paste or the link does
not work…)
http://asheducationbook.hematologylibrary.org/cgi/content/full/2002/1/464
(quite good one...)

Contraception:
Oral forgetfulness increases failure
Implants norplan for long term may have weight gain and acne
Injections (CIC and PIC) may have weight gain and acne
IUD no
Condom only one fro STD’s
Diaphragm some on STD not easy
Emergency contraception ok
No recommended for:

• A history of heart attack or stroke

• Blood clots in the legs (thrombophlebitis), lungs (pulmonary embolism), or
eyes
• A history of blood clots in the deep veins of your legs
• Chest pain (angina pectoris)
• Known or suspected breast cancer or cancer of the lining of the uterus,
cervix, or vagina
• Unexplained vaginal bleeding (until a diagnosis is reached by your doctor)
• Yellowing of the whites of the eyes or of the skin (jaundice) during
pregnancy or during previous use of the pill
• Liver tumour (benign or cancerous)
• Known or suspected pregnancy

Relative risks

• Breast nodules, fibrocystic disease of the breast, an abnormal breast x-ray

or mammogram
• Diabetes
• Elevated cholesterol or triglycerides
• High blood pressure
• Migraine or other headaches or epilepsy
• Mental depression
• Gallbladder, heart or kidney disease
• History of abnormal or irregular menstrual periods

http://www.oralcontraceptives.com/about_faq.asp

Cardio vascular:
JVP 30 degrees head elevation, Hints lefts or thrills
Hearth, extra sounds and murmurs
Bell for S3 (diastolic)
Aortic insufficiency left para sternal
Scars, stria, dilated veins or rushes Shape and contours, masses or pulsations,

Auscultation: Abd and femoral bruises,

Percussion: timpani and dullness

Walk on heels and toes

Bruit suggest narrowing arteries

Abdomen:
Scars, distension…
Tenderness? Rebound tenderness?
I am looking for hyper resonances or dullness
Assessing guarding, tenderness or pain
Air filled loop of bowel
Please cough
Does it hurt if I press down?
Press down and let go to see if you have rebound tenderness.
I will palpate the liver so, please bear with me…
Take a deep breath please
Please turn or lie on your R side
You have active bowel sounds and your abdomen is soft and non tender
Breathe normally
Bowell sounds, are they diminish or normal
Bruise at aorta
Ask for area of pain and start away from it.
Liver or gallbladder inflammation

Abdominal aorta is 3 cm diameter.

Respiratory
Contour, symmetry, deformities
Accessory muscles
Normal sounds are Vesicular and Bronchial.
Adventitious sounds are crackles (intermittent non musical), Rhonchi and
wheezes (musical) rales,
Palpation, inhale and exhale deeply and fully
Repeat after me 99 or blue moon Fremitus
Repeat after me i i = if e e: there is a consolidation
Percusion

Counseling:
Male breast cancer
Quitting
Self exam (last day of your period)
Breast lumps
Pain in breast
Mammogram (X ray of your breast)
Prevention bilateral mastectomy
Genetic testing
Weight lost
Fever
Chills

Sports injuries: RICE:

Rest
Ice
Compression
Elevation

Palpate vertebra, does not appear to be tender or swell.

SI joints for tenderness
Range of motion
Is this bringing you any pain?
Does any of this irritate your back?
Do you have any sensation that goes down your leg?
Sensation, tingling, snap pain…

(neck) Tip your chin to your chest

Tilt your head back
Turn your chin to your sides
(Shoulder) Bend your head towards your left or right shoulder
Tenderness at joints on shoulder
Raise both arms (Flexion and extension) internal and external rotation (you can
have a hand on shoulder so you can feel crepitus
(Hand) Make a fist with your hands
(Spine) Bend forward to touch your feet with your fingers
Bend to the L or R
Twist your shoulders to the L or R
(Hip) Have the patient lie over no painful side and knee flexed on the affected
side, palpate the hip, trocanter,
Check flexion with your hand in lumbar
Extension asking to move the lag along the table
Internal and external rotation with knee at 90 degrees
(knee) Inspect alignment or deformity atrophy of quadriceps patellar pouch for
thickening, swelling or tenderness.
Palpate for Meniscal tenderness and along collaterals
Ask the patient to squat and stand up, and provide support as needed
Rotate foot
MCL 30 degree flexion (palanca)
LCL id
ACL Anterior Draw sign - Draw the tibia forward compare sides
PCL Posterior draw sign
(Ankle) Note deformities, nodules, calluses, and corns
Palpate joints
Evert and invert at mid tarsal joint

Recommendations for Tetanus Prophylaxis

Clean minor wounds All other wounds*

History of tetanus prophylaxis Td TIG Td TIG

Uncertain or less than 3 doses Yes No Yes Yes

3 doses or more
Last dose within 5 years No No No No
Last dose within 5 to 10 years No No Yes No
Last dose more than 10 years ago Yes No Yes No

Td = tetanus-diphtheria toxoid; TIG = tetanus immune globulin.

*--For example, contaminated wounds, puncture wounds, avulsions, burns and crush injuries.
Reprinted with permission from Hollander JE, Singer AJ. Laceration management. Ann Emerg Med
1999;34:356-67.

Cases
MI or Atrial fibrillation
COPD, Asthma
Depression, psychotic Minimental
Ankle strain, outreach hand, snuff box, repit X ray at 14 days
Allergy or shock ER: ABC