OSCE Medicine by DR Bilan

OSCE FOR MEDICAL
WARD
Collected and prepared by Dr BILAN AHMED
By: Dr Bilan Ahmed Ismail

HISTORY
GENERAL
 Lethargy and tiredness
 Pyrexia of unknown origin
 Weight loss
 Dizziness
SYSTEMIC
CARDIO-PUL: GIT:
 Cough  Dysphasia
 SOB  Vomiting
 Chest pain  Hemetaemasis
 Hemoptysis  Abdominal pain
 Palpitation  Abdominal distention
CNS:  Jaundice
 Headache  Diarrhea
 Weakness  Constipation
 LOC  Rectal bleeding
 Tremor +urinary
 Dysuria
 Hematuria
Rheumatology
 Joint pain
 Leg pain
 Back pain
 Ankle swelling
 Unilateral leg swelling

Lethargy and tiredness
0 1 2
1. Introduction and consent
Hello my name is ………..Medical student from Gollis University I
would like to know your health states is that ok? can I confirm you
name and age
2. Cc + duration
3. HPI
OPDFARS
Ask Character (what the patient means by tiredness)
4. Exclusion and rule out
5. Depression screening: asks about mood, previous history of
depression and sleeping patterns
6. Thyroid dysfunction (sweating, tremor, dry hair, neck discomfort,
eye symptoms, bowel changes, menstrual irregularities)
7. Anaemia (shortness of breath, chest pain, palpitations,
menorrhagia)
8. Diabetes mellitus (polydipsia, polyuria, recurrent infection)
9. Cancer (weight loss, night sweats, family history of cancers, cough,
diarrhoea, melaena)
10. Hypopituitarism (loss of appetite, nipple discharge, loss of libido)
11. Chronic kidney disease/nephrotic syndrome (ankle swelling,
orthopnoea)
12. Chronic infection (fevers)
13. Chronic fatigue syndrome symptoms (sore throat, headaches,
muscle pains, exacerbated by exertion)
14. Obstructive sleep apnoea (unrefreshing sleep, feeling sleepy in the
day, loud snoring, waking up suddenly in the night, loss of libido,
irritability)
15. Red flags’: (Night sweats Fevers Weight loss Loss of appetite
Palpable lymph nodes)
16. PMH (any recent illnesses Previous episodes of lethargy/tiredness)
17. FH (Cancers thyroid disorders and diabetes Depression)
18. DRUG H
19. Social H ( Smoking Alcohol Stressors in social life)
20. Thank to the patient

Pyrexia of unknown origin
0 1 2
Hello my name is ………..Medical student from Gollis University I would like
to know your health states is that ok? can I confirm you name and age
2. Cc + duration
3. How does the patient know they had pyrexia?
• What was the temperature (if measured)?
4. OPDFAIRS
5. Pattern: Day/night/intermittent/continuous/ progressive
6. Respiratory: Cough, sputum (pneumonia), Haemoptysis (cancer,
tuberculosis), Shortness of breath
7. Gastrointestinal: Diarrhoea (gastroenteritis) Bloody stools (inflammatory
bowel disease), What/when did the patient last eat?
8. Liver/gallbladder: Right upper quadrant pain, Jaundice
9. Neurological: Headache (abscess, meningism), Neck stiffness, rash
(meningism), Focal neurological symptoms (abscess encephalitis)
10. Cardiovascular: chest pain, shortness of breath, haematuria (infective
endocarditis)
11. Urological: Haematuria, Dysuria (urinary tract infection), Loin pain
(pyelonephritis)
12. Rheumatological, musculoskeletal: Severely painful single joint (septic
arthritis) Pain in small joints (rheumatoid arthritis,systemic lupus
erythematosus), Muscle pain (myositis)
13. ENT: throat pain (upper respiratory tract infection, tonsillitis, tooth pain
(tooth abscess)
14. Skin: rash, inflammation, redness (cellulitis)
15. Gynaecological symptoms: Vaginal bleeding/discharge (pelvic
inflammatory disease) Use of tampons
16. Risk factors for HIV: Multiple/new sexual partners, contact with sex
workers, Contraception, Intravenous drug abuse
17. ‘Red flags’: Night sweats, Palpable lymph nodes, Symptoms of cancer
(weight loss, cough/haemoptysis if smoker, diarrhoea/melaena if
suspecting bowel cancer)
18. Past medical history: Asks from any other symptoms, Asks about recent
illnesses, Previous episodes of (PUO), HIV, TB, CA
19. Family history: HIV, TB, CA, similar illness
20. Drug history: Immunosuppressants, Malaria prophylaxis, OCT, Herbal
remedies
21. Social history: Recent travel history, Recent contact with farm animals,
Alcohol, smoking, illicit drug use, Sexual history (if appropriate and only
after signposting clearly), Occupation
22. Thanks patient

Weight loss
0 1 2
Hello my name is ………..Medical student from Gollis University I would
like to know your health states is that ok? can I confirm you name and
age
2. Cc + duration
3. Asks if anybody else around the patient(family, work colleagues, friends)
has noticed the loss of weight
4. OPDFAIRS (S stand severity, how many Kg)
5. Asks if patient intended to lose weight (e.g. exercise regime)
6. Establishes patient’s appetite and eating habits
7. Ask any change in the patient’s activity levels
8. Asks if patient is suffering from any other symptoms
9. Psychiatric disorder screening:
asks about mood, previous history of depression and sleeping patterns
10. Eating disorder screening:
• Sick (has the patient been vomiting?)
• C = lost control over their eating habits?
• One stone weight loss in last 3 months?
• F = does the patient feel fat?
• F= does the patient spend a lot of time thinking about food?
11. Hyperthyroidism (sweating, tremor, neck discomfort, eye symptoms,
bowel changes, menstrual irregularities)
12. Diabetes mellitus (polydipsia, polyuria, recurrent infection)
13. Addison’s disease (tiredness, pigmentation, faintness)
14. Cancer (weight loss, night sweats, family history of cancers,
cough/haemoptysis if smoker, diarrhoea/melaena if suspecting bowel
cancer)
15. ‘Red flags’: Night sweats, Fevers Palpable lymph nodes, Symptoms of
cancer (as above)
16. PMH (any recent illnesses Previous episodes of weightless )
17. FH (Cancers thyroid disorders and diabetes Depression)
18. DRUG H
19. Social H ( Smoking Alcohol Stressors in social life)
20. Thanks patient

Dizziness
0 1 2
Hello my name is ………..Medical student from Gollis University I
name and age
2. Cc + duration
3. Clarifies/defines what the patient means by dizziness:
• Rotational – vertigo
• Side-to-side – horizontal instability
• Faintness – prior to loss of consciousness
4. OPDFAIRS
5. ENT symptoms: Hearing loss, tinnitus, Nausea, When tilt/turn head
(benign paroxysmal positional vertigo) Pain, blood, discharge from
ear
6. Neurological symptoms:( Loss of consciousness Headaches Motor
weakness Sensory symptoms Visual disturbance Speech problems)
7. Recent head/ear trauma
8. Falls or trauma to head
9. Anaemia: Bleeding/bruising Menorrhagia
10. faintness: Vascular/hypotensive: postural
11. Hypoglycaemia: Sweating Anxiety Palpitations
12. Cardiovascular, arrhythmias: Chest pain, palpitations
13. vertigo: Cerebellar symptoms: (Slurred/staccato speec,
Coordination difficulties, Gait/balance problems)
14. ‘Red flags’: Headache with raised intracranial pressure Loss of
consciousness, Weight loss, night sweats
15. Past medical history:(DM, strokes, aortic stenosis, heart failure,
arrhythmias) Recurrent ear infections, grommets
16. Family history: Same as past medical history
17. Drug history: Any recent changes to medication, Antihypertensive
agents, GTN, Antidiabetic medication, insulin, Sedatives (e.g.
benzodiazepines) Over-the-counter medications
18. Social history: Alcohol, Illicit drug use, Smoking, Occupation, Driving
19. Thanks patient

Cough
0 1 2
21. Cc + duration
22. OPDFARSA
23. Character, variability
24. Asks about any recent illnesses
25. Previous episodes of coughing
26. RESP SX: SOB; Wheeze; CP; Ankle edema; Throat symptoms/irritation
27. GERD: burning epigastric pain; heartburn; regurgitation
28. Recent travel or ill contact
29. ‘Red flags’: Haemoptysis; Weight loss; Fever; Night sweats; Hoarseness
30. Arthralgia; malaise; post nasal drip; appetite loss
31. PMHx: Asthma; COPD; TB; Lung cancer
32. Rx Hx: ACE; Beta-blockers; Inhalers; NSAIDs; Allergies
33. FMHx: Similar case in the family;
34. SHx: Smoking; Working in dust environment; over-crowd living; travel
35. Summarizes
36. Thanks patient.
History of presenting complaint:

• Onset (how it started)
• Character (dry or productive)
• Time (duration)
• Alleviating factors: work/home
• Exacerbating factors:
• Exertion/exercise
• Season (worse in winter, e.g. COPD; worse in summer, e.g. allergic)
• Pollen/chemicals (asthma)
• Posture (worse when lying flat)
• Severity
• Variability:
• Diurnal (worse at night/in early morning)
• Continuous/intermittent
• Environment (home, work, indoors, outdoors)
• Season

SOB
0 1 2
38. Cc + duration
39. OPDFARSA
40. Variability(at rest/orthopnea/PND) and exercise tolerance
42. Previous episodes of SOB
43. RESP/CARDIA SX: Cough; Wheeze; CP; Ankle edema; fever
44. ‘Red flags’: Haemoptysis; Weight loss; Fever; Night sweats; Hoarseness
45. Light headedness; tiredness; palpitation -anemia
46. Hx of DVT; immobilization; recent surgery -PE
47. PMHx: Asthma; COPD; TB; cardiac disease; Lung cancer
48. Rx Hx: Use of inhalers; Allergies
49. FMHx: Similar case in the family;
50. SHx: Smoking; Working in dust environment; over-crowd living; recent
travel; exposure to pets and animals
51. Summarizes
52. Thanks patient.
• Onset (how it started, gradual/sudden)

• Time (duration)
• Alleviating factors
• Exertion/exercise
• Pollen/chemicals (asthma)
• Orthopnoea (worse when lies flat)
• Severity:
• Exercise tolerance on a flat surface
• Exercise tolerance when walking upstairs/up an incline
• Shortness of breath (SOB) at rest
• Variability: Is the SOB continuous throughout the day,
Intermittent or progressively worse? If intermittent, when is it worse/better?

CHEST PAIN
0 1 2
2. Cc + duration
3. SOCRA(N/V, sweating, cough, dyspnea)TES
5. Previous episodes of CP
6. Elicits cardiac risk factors: Family hx of myocardial infarction in first-
degree relative <55 years of age; Smoking; Hypertension; Diabetes
mellitus; Hyperlipidaemia
7. Elicits risk factors for PE/DVT: Calf pain/swelling; Recent travel; Recent
surgery; Family history of clotting disorders; Malignancy; Oral
contraceptive pill (if female patient); Pregnancy (if female patient)
8. PMHx: MI; Angina; Stroke; Asthma; COPD; DM
9. Rx Hx: Past and current medications
10. FMHx: Cardiac disease; sudden death; Asthma
11. SHx: Smoking; alcohol; life style and diet
12. Summarizes
13. Thanks patient.
• Site
• Onset:
• Character: burning, crushing, stabbing
• Radiation: jaw, left arm and back (myocardial infarction), back (dissection)
• Associated symptoms: asks specifically about nausea, sweating, light-headedness/loss of
consciousness, shortness of breath, palpitations, fever, cough, heartburn, abdominal pain
• Exacerbating factors: inspiration, lying down, coughing, physical activity
• Alleviating factors: stopping physical activity, sitting up, drugs (e.g. GTN)
• Time course: changes in the pain between onset and now

PALPITATION
0 1 2
2. Cc + duration
3. OPDFARS
5. Previous episodes of palpitation
6. Symptoms of hypoglycemia: jitteriness, hunger, sweating, on insulin
7. Symptoms of anxiety: anxiety, tingling, headaches, nausea
8. Symptoms of hyperthyroidism: weight loss, diarrhoea, eye symptoms,
agitation, sweating, tremor, irregular period
9. Symptoms of the menopause: last menstrual period, vaginal dryness,
mood changes
10. Establishes cardiovascular risk factors: Smoking; Diabetes mellitus;
Hyperlipidaemia; Hypertension; Family history of premature cardiac
disease
11. PMHx: Cardiac disease, multiple sclerosis; Thyroid disease/surgery;
Anxiety disorders; Diabetes mellitus
12. Rx Hx: Past and current medications; Salbutamol
13. FMHx: Cardiac disease; Thyroid disease; Sudden death; Arrhythmias
14. SHx: Smoking; alcohol; exercise; impact on life style
15. Summarizes
16. Thanks patient.
• Duration of episode(s)
• Frequency (if more than one episode)
• Precipitants and relieving factors
• Asks about activities before onset
• Asks about intake of caffeine and alcohol
• Asks about learned methods of termination
• Rhythm of palpitations (regular, irregular)
-Associated symptoms:
• Chest pain, shortness of breath
• Loss of consciousness

HEMOPTYSIS
0 1 2
54. Cc + duration
55. OPDFARSA
57. Previous episodes of hemoptysis
58. Associated symptoms: Weight loss; Night sweats (TB); Fevers (TB,
pneumonia, vasculitis); Hoarseness (cancer); Chest pain (cancer);
Shortness of breath (pulmonary embolism); Ankle swelling; Wheeze
(cancer); Bony pains (cancer); Throat pain (throat malignancy);
Nosebleeds
59. Elicits risk factors for PE/DVT: Calf pain/swelling; Recent travel; Recent
surgery; Family history of clotting disorders; Malignancy; Oral
contraceptive pill (if female patient); Pregnancy (if female patient)
1. PMHx: Lung/ Heart/ Blood disease; Cancer
2. Rx Hx: NSAIDs; Anticoagulant
3. FMHx: Bleeding disorders
4. SHx: Smoking; alcohol; Travel history and BCG; contact; current and
previous occupation;
5. Summarizes
6. Thanks patient.
• Onset (how did it start)

• Duration of symptoms
• Approximate quantity of blood
• Appearance of blood (and sputum)
• Streaks
• Fresh red
• Dark clots
• Exacerbating factors: smoke, dust, exertion
• Asks whether patient is suffering from any other symptoms

HA
0 1 2
2. Cc + duration
3. SOCRATES
5. Raised intracranial pressure: Nausea; vomiting; Worse on
straining/bending down/coughing
6. Meningitis: Fever; Photophobia; Neck stiffness; Haemorrhagic rash
7. Subarachnoid haemorrhage: Sudden onset; Occipital; ‘Worst’ pain the
patient has ever had
8. Temporal arteritis: Scalp tenderness; Ipsilateral visual disturbance;
Shoulder/hip muscle aches (polymyalgia rheumatica)
9. Migraine: Nausea; vomiting; Photophobia; Periodic (e.g. every month),
correlation with menstrual periods Visual disturbance (zigzag lines,
flashing lights); Aura
10. Cluster headache: Pain around one eye; Lacrimation/eye watering;
Excruciatingly severe; Attacks lasting 30–60 minutes persist for a few
weeks to 1–2 months and then stop for 6–12 months
11. Tension headache: ‘Tight’ headache; Diffuse, not localized; Related to
stress
12. Trigeminal neuralgia: Like ‘electric shock’; Short duration (seconds to a
few minutes); Face/in front of ear; Chewing makes it worse
13. Chronic analgesic-dependent headaches: Long-term extensive use of
high-dose analgesics; Daily occurrence
14. ‘Red flags’: Recent trauma; Focal neurological symptoms, LOC,
seizures; vomiting; Worst in the morning/on waking up; Sudden onset;
Fevers; Scalp tenderness; Past medical history of cancer
15. PMHx: Hypertension; Malignancy
16. FMHx: Migraines; Berry aneurism; Malignancy
17. Rx Hx: Analgesics; OCP; Allergies
18. SHx: Smoking; alcohol; Caffeine intake; Stressors:
occupational/rltnship/financial
19. Summarizes
20. Thanks patient.

LOC
0 1 2
2. Cc + duration
3. Expresses intent to get a collateral history from a witness
4. Defines the loss of consciousness:
• Does the patient remember what happened when they were
unconscious?
• Could the patient see or hear anything while unconscious?
5. Duration
6. Frequency
7. What was the patient doing prior to loss of consciousness?
8. Was the patient sitting, standing or lying flat?
9. Where was the patient?
10. Symptoms before loss of consciousness e.g. dizziness
11. Symptoms after loss of consciousness particularly whether they have
any problems with speech, vision, or with moving their arms or legs
12. Previous episodes of loss of consciousness
13. Seizure: Tongue bitten; Urinary incontinence; Confusion (>30 minutes)
after regaining consciousness; Aura (‘feeling funny’, smell of burning)
14. Neurological symptoms: Headaches; Motor weakness; Sensory
symptoms; Visual disturbance; Speech problems; Coordination/balance
difficulties
15. Hypoglycaemia: Sweating; Anxiety; Palpitations; Faintness
16. Vasovagal symptoms: Crowded/warm environment; Nausea
immediately prior to loss of consciousness; Short duration (<5 minutes)
17. Cardiovascular symptoms: Chest pain; Palpitations
18. Micturition syncope: during or immediately after urination
19. PMHx: DM; Seizures/epilepsy; heart diseases
20. FMHx: same as past medical history
21. Rx Hx: Diabetes medication/ insulin; sedatives; Allergies
22. SHx: Smoking; alcohol; Caffeine intake; Safety assessment if vulnerable
(e.g. live alone, dangerous occupation, elderly)
23. Summarizes
24. Thanks patient.

Weakness
0 1 2
2. Cc + duration
3. OPDFARS
4. Asks whether the weakness was confined to one side or affected both
and whether facial muscles were affected
5. Asks about history of headaches and whether the onset of this episode
was associated with headache
6. Asks whether they noticed any visual disturbance
7. Asks whether they noticed any speech disturbances
8. Previous episodes
9. Trauma
10. Hx of anemia: B12 deficiency
11. Thyroid hx
12. Dysphagia: Guan-bare syndrome
13. PMHx: DM; Seizures/epilepsy; heart diseases
14. FMHx: same as past medical history
15. Rx Hx: Diabetes medication/ insulin; sedatives; Allergies
16. SHx: Smoking; alcohol; Caffeine intake; Safety assessment if vulnerable
(e.g. live alone, dangerous occupation, elderly)
17. Summarizes
18. Thanks patient.

Tremor
0 1 2
2. Cc + duration
3. Site (hands, arms, head); Bilateral, unilateral, symmetrical
4. Onset: On deliberate movement (e.g. turning on a light switch, reaching
for a cup of tea); At rest; When anxious/worried
5. Constant or intermittent: If intermittent, duration and frequency of
episodes
6. Time of day
7. Alleviating factors: alcohol ..and Exacerbating factors: Stress, fatigue,
Anxiety
8. Caffeine (how many cups of coffee?)
9. Coordination, gait
10. Previous episodes
11. General neurological symptoms: Headaches; Motor weakness, sensory
symptoms; LOC
12. Parkinson’s disease (slowing, rigidity, falls, depression)
13. Hyperthyroidism (palpitations, weight loss, heat intolerance)
14. Cerebellar disease (slurred/staccato speech, incoordination, imbalance)
15. Anxiety (sweating, palpitations)
16. Salbutamol overuse (frequency of inhaler use, poorly controlled
asthma)
17. Alcohol withdrawal (excess intake, sudden recent reduction)
18. ‘Red flags’: Headache with features of raised intracranial pressure
(early morning, vomiting, worse on coughing, bending down); Loss of
consciousness.
19. PMHx: Hyperthyroidism; Alcohol/drug addiction
20. FMHx: Bening essential tremor; Parkinson’s disease
21. Rx Hx: thyroxine; Salbutamol; allergies
22. SHx: Smoking; alcohol; exercise; impact on life style
23. Summarizes
24. Thanks patient.

Dysphagia
0 1 2
2. Cc + duration
3. How was the jaundice discovered? – did the patient notice it,
or was it someone else?
4. OPDFARSA
5. Character: Solids or liquids?
6. Level: where does food/liquid feel like it is getting stuck?
7. Define at which stage the dysphagia occurs:
• When initiating swallowing
• After swallowing has been initiated
8. Easing after the first swallowing
9. Pain
10. Trauma, Foreign body
11. Feeling of a lump in the throat
12. Asks about recent illnesses
13. Previous episodes of dysphagia
14. GIT: CA; Nausea; vomiting; dyspepsia; early satiety
15. ENT: Hoarseness;
16. Neuromuscular: GBS/STROKE: Weakness; muscle wasting;
tingling/numbness; double vision
17. Pharyngeal pouch: Regurgitation; Halitosis
18. Thyroid gland: sx of hyper/hypo-throidism
19. Broncho-carcinoma: Cough; wt loss; SOB; Hemoptysis
20. XEROSTOMIA: Dry mouth
21. MITRAL STENOSIS: Palpitations
22. PMHx: stroke; thyroid problems; mitral stenosis; ENT surgery
23. Drug Hx: NSAIDS; Tetracycline; bisphosphonates: Allergies
24. SHx: Smoking; alcohol; Spicy foods
25. Thanks patient

Vomiting
0 1 2
2. Cc + duration
3. OPDFARSA
4. amount
5. Color (blood/bile in vomit)
6. Nature (effortless/forceful/projectile; several feet
away)
7. Aggravating and relieving factors.
8. Asks abdominal pain
9. Timing ; morning emesis
10. Ask any nausea
11. Asks whether the vomit contains residues of food taken
the day before
12. Ask about abdominal pain & abdominal distention
13. Any diarrhea & constipation
14. Ask Any jaundice
15. Abdominal distension
16. Red flags: Rectal bleeding/malena; early satiety;
17. Weight loss and loss of appetite
18. asks any fever
19. Asks about urinary symptoms NB; oliguria for renal
failure
20. Asks any headache and neck stiffness
21. Asks altered consciousness
22. PMHx: especially DM
23. Drug hx (digoxin, opiates, theophylline)
24. FMhx: similar case in the family
25. Thanks pnt.

Hematemesis
0 1 2
2. Cc + duration
3. OPDFARSA
4. Amount
5. Color
6. Abdominal pain,
7. Hepatic: jaundice; ankle swelling
8. GERD: Heartburn, chest pain; regurgitation
9. Symptoms of shock/anemia (faintness; shortness of breath; lethargy)
10. Coagulopathy: Bleeding, bruising elsewhere, epistaxis
11. ‘Red flags’: Weight loss, loss of appetite; Dysphagia
12. Trauma to abdomen
13. Ingestion of (red fluid/food, spanish) in 24-48hrs
14. PMHx: PUD , liver dz; Bleeding problems
15. Drug history: NSAIDs, ASA, warfarin
16. FMHx: esophageal/stomach cancer
17. SHx: smoking; alcohol; diet
18. Thanks the informant/chi
NB;
• Volume: If large volume, patient needs to be assessed and resuscitated immediately

• Number of episodes
• Character/colour:
• Coffee grounds
• Dark clots
• Fresh, bright red
• Mixed with vomitus
• Onset (what brought it on):
• Medications, alcohol
• Vomiting/retching (Mallory–Weiss tear)
• Precipitating factors:
• Alcohol → Mallory-Weiss tear
• NSAIDs

Abdominal pain
Check list 0 1 2
1. Appropriate introduction
2. Confirms patient’s name and age
3. Explains reason for consultation
4. Obtains consent
5. Open question to elicit presenting complaint
6. Signposts: e.g. ‘Mr/Miss…, thank you for telling me about this
problem. I would like to ask a few more detailed questions. Is that
all right?’
7. Description of pain (SOCRATES)
8. Asks if patient is suffering from any other symptoms
10. Previous episodes of abdominal pain
11. Family members/contacts with similar symptoms
12. Gastrointestinal/colorectal symptoms:(Nausea/vomiting; Bowel
habit, diarrhoea/constipation; abdominal distension)
13. IBD Sx: arthralgia, eye symptoms, skin features, oral ulcers.
14. Hepatic/Gallstone Sx: jaundice; pale stools; pruritis
15. Renal Sx: dysuria; flank pain
16. Females: Correlation with menstrual periods; Possibility of patient
being pregnant (LMP)
17. Constitutional Sx: Fever; wt loss; loss of appetite; bleeding
18. Hx of recent trauma
19. PMHx: DM; previous surgeries; similar Hx in the past
20. FMHx: Colon cancer; IBD
21. Drug Hx; NSAIDs regularly; Allergies
22. SHx: Alcohol (peptic ulcer, gastritis); Smoking; Diet: Spicy foods
(peptic ulcer disease), High-fibre foods (low intake may correlate
with diverticulitis); Occupation; Activities of daily living.
23. Summarises
24. Thank the pnt.
• Onset (how it started):

• Sudden
• Gradual
• Character:
• Colicky (renal stones)
• Sharp/sudden (rupture of viscus)
• Burning (peptic ulcer disease)
• Dull
• Radiation:
• To back (abdominal aortic aneurysm, ruptured duodenal ulcer)
• To testicles/groin (hernia)
• To shoulders (gallbladder)
• Loin to groin (renal stone)

• Time:
• Duration
• Intermittent, continuous, progressive
• Alleviating factors:
• Dietary factors
• Opening bowels
• Dietary factors
• Swallowing (oesophagus/stomach)
• Fatty foods (gallstones)
• Acidic/spicy foods, hot drinks (peptic ulcer disease)

1. Abdominal Distension
Check list 1 2
0
4. Obtains consent
5. Open question to elicit presenting complaint
6. Signposts: e.g. ‘Mr/Miss…, thank you for telling me about this problem. I would like to
ask a few more detailed questions. Is that all right?’
7. Abdominal distension analysis (SOCRATES)
9. Previous episodes of abdominal distension
10. Associated symptoms: Gastrointestinal/colorectal symptoms: Abdominal pain;
Flatulence; Nausea/vomiting; Bowel habit/diarrhoea/constipation: any correlation of
distension with opening bowels? Dysphagia/dyspepsia?
11. Ascites:
• Facial swelling
• Ankle swelling
• Shortness of breath/orthopnoea
Liver/hepatobiliary symptoms: right upper quadrant pain, jaundice, dark stools, pale
urine.
Renal symptoms: urinary symptoms, frothy urine (nephrotic syndrome), lethargy,
pruritus
Heart failure symptoms: chest pain
Hypothyroidism
12. Females: gynaecological symptoms:
• Correlation with menstrual periods
• Irregular/painful periods
• Intermenstrual/postcoital bleeding
• Pelvic pain
13. Females: obstetric symptoms:
• Possibility of patient being pregnant
• Last menstrual period
• Unprotected sexual intercourse: must signpost before taking sexual history
• Contraception
14. ‘Red flags’:
• Bleeding (rectal, melaena, vaginal)
• Weight loss, loss of appetite, night sweats (malignancy)
15. PMHx:Abdominal surgery; heart failure;
16. FMHx: Cancers; Hernia; fibroids
17. RxHx: Allergies
• Laxative history: any recent changes, stopped taking
• Oral contraceptive pill (OCP, if patient female)
• Over-the-counter medication
18. SHx:
• Alcohol (peptic ulcer disease, gastritis)
• Smoking
• Illicit drug use (especially intravenous drug abuse for hepatitis B/C)
• Diet:
• Intake of fiber

• Recent change in diet
• Occupation
• Activities of daily living
19. Summarises
20. Thank the pnt.
• Site:
• Generalised
• Localised
• How did the patient first notice it?
• Sudden
• Gradual
• Character:
• Soft fluctuant/fluid swelling
• Hard, mass-like swelling
• Radiation:
• To testicles/groin (hernia)
• Time:
• Duration
• Intermittent/continuous/progressive
• Correlation with menstrual periods
• Dietary factors
• Opening bowels
• Dietary factors/meals
• Position (e.g. worse on lying down/standing
– hernia), coughing (hernia)
• Worse at the end of the day (oedema)

JUANDICE
0 1 2
2. Cc + duration
3. How was the jaundice discovered? – did the patient notice it, or was
it someone else?
4. Site
5. OPDFARSA
6. Fevers; wt loss; loss of appetite
8. Previous episodes of jaundice
10. Gallstones, biliary duct obstruction: Abdominal pain; Pale stools;
Itching; Steatorrhoea; Dark urine
11. Liver symptoms: Abdominal swelling; Ankle swelling; Bleeding,
bruising
12. Autoimmune conditions: Arthralgia; Vitiligo; Skin rashes (SLE)
13. Risk factors for viral hepatitis: Hep B&C; Contaminated needles: (
Intravenous drug abuse; Blood transfusions; Ear/body-piercing)
Foreign travel/contacts; Sexual history*1; Hep A; swimming
14. Rules out Heart failure (for congestive liver failure) and Hemolytic
anemia
15. ‘Red flags’: No abdominal pain
16. PMHx: liver disease; heart disease; IBD
17. FMHx: Viral hepatitis; heaptobilliary cancer;
18. Drug history: Hepatitis B and C immunisations; Tuberculosis
medications; Herbal medication
19. SHx: smoking; alcohol; diet (Barbecues)
20. Thanks patient

Diarrhea
0 1 2
Introduction and consent
60. Cc + duration
61. OPDFARSA
62. Color/Appearance (blood, mucous, sticky, floating)
63. Consistency (formed, loose, watery)
64. Amount
66. Previous episodes of diarrhoea
68. Association with diet
69. Gastrointestinal/colorectal Sx: :Nausea/vomiting; Bloating;Abdominal
pain: is it reduced with defecation; Abdominal swelling; Anal pain;
Constipation; Tenesmus; Faecal incontinence; Fevers
70. Symptoms of IBS: alternating Diarrhea/Constipation; Psychosocial
stressors;
71. Symptoms of IBD: Blood; Arthralgia; Back pain (sacroiliitis); Oral ulcers;
Skin problems; Eye pain
72. Hyperthyroidism: Heat intolerance; tremor; goiter
73. Symptoms of anaemia: Lethargy; Shortness of breath; Dizziness →
postural
74. Symptoms of malabsorption: generalized weakness/lethargy
75. Risk factors for Clostridium difficile: Recent hospital admissions; recent
antibiotic courses.
76. ‘Red flags’: Rectal bleeding; Black stools; Weight loss; Loss of appetite;
fever
77. PMHx: DM; previous surgeries
78. Drug Hx: ( laxatives, Mg containing antacid, abx, metformin); Allergies
79. FHx : colon cancer; IBD; coeliac disease
80. SHx: recent travel; smoking; alcohol; occupation
81. thanks pnt.

Constipation
0 1 2
83. Cc + duration
84. OPDFARSA
85. Color/Appearance (blood, mucous, sticky, floating)
86. Consistency (formed, loose, watery)
87. Pain on defecation
88. Straining during defecation.
89. Abdominal, rectal or anal pain. ( abd.pain relieves pain?)
90. Abdominal distension, lumps or masses.
91. Feeling of incomplete empting; fecal incontinence
92. Nausea and vomiting
93. Regurgitation
94. Cold intolerance;
95. Anemia: SOB; lethargy; tiredness
96. Wt loss; loss of apetite, fever
97. PMHx: DM; previous surgeries.
98. Drug Hx: opiates; TCA; iron tablets
99. FHx : similar case in the family; Bowel cancer; IBD
100. SHx: Diet habits; exercise; smoking; alcohol
101. thanks the informant/child

Rectal bleeding
0 1 2
2. Cc + duration
3. How was the jaundice discovered? – did the patient notice it, or was it
someone else?
4. OPDFARSA
5. Site: Mixed with stool; Around stool; Dripping from anus; Spotting on
tissue paper
6. Character: Fresh, bright red; Dark,/ melaena; Clots/ Liquid
7. Amount, volume
8. Frequency
9. Trauma
10. Straining when opens bowels
11. Previous episodes of rectal bleeding
12. Family members/contacts with similar
13. Asks about other colorectal/anal symptoms: Pain/soreness; Itching;
Tenesmus; Lumps, swellings,(something coming down from anus);
Ulcers; Change of bowel habit; Faecal incontinence; Abdominal pain
14. IBD: joint pain; oral ulcers; skin rash; vision problem; bloody diarrhea
15. Anemia: lethargy; SOB; dizziness
16. Red flags: weight loss; loss of appetite; fever
17. Bleeding elsewhere (vomiting, ears, bruising, epistaxis)
18. PMHx: surgery; colon CA
19. Drug Hx: NSAIDs; Warfarin
20. FMHx: Hemorroids; IBD; Colon CA
21. SHx: Smoking; alcohol; Spicy foods; travel
22. Thanks patient

Dysuria
0 1 2
Hello my name is MISS bilan Medical student from Gollis University I
name and age
2. Cc + duration
3. SOCRETES + color, consistency, amount, oder
4. Lower UTI: (cystitis )frequency, urgence, lost of bladder control,
suprapubic pain, oder, red urine,)
5. Upper UTI: flank pain, fever, chills, n/vomiting, cloudy urine,
6. Kidney stone: any sever and radiating pain for other site, red urine, N/V,
frequency,
7. Urthral stricture: decrease urine volume, incomplete bladder empting,
straining, urgency, frequency.
8. STI: risk factors: (sexually active, num of partners, contact with similar ill
person )
9. Urethrites: (Chlamydia, gonorrhea) Lower abdominal pain, discharge,
redness, frequency, pain on intercourse, bleeding after intercourse,
testicular pain in male,
any other complain if gonorrhea (throat, eyes, rectum, joint )
10. Vaginites (bacterial vaginosis, candidiasis, trichomniasis): pain, soreness,
itching, foul smelling discharge pain during intercource.
11. Genital Herpes and syphilis: blister/ sores, ulcer, any other site of ulcer,
painful or painless
12. Prostaties: if male ask; perineal pain, urine retention tender ptostate,
fever
13. Menapause if female: dryness, mood change, hotness.
14. Foreign thing: chemical(anti septic), catheterized, using tampon if
female.
15. Red flags: Fevers; wt loss; loss of appetite, lymphoid enlargement.
16. PMHx: Privieus similar illness, recent illness.
UTI, DM, Renal diseases, ca
17. FMHx: similar ilnes, DM, STI.
18. Drug history:
19. SHx: smoking; alcohol;
20. Thanks patient

JOINT PAIN
0 1 2
2. Cc + duration
3. Description of pain (SOCRATES)*1
4. Limitation of movement/activity
5. Morning stiffness: duration of morning stiffness – an easily forgotten
point
6. Redness, swelling (gout, septic arthritis)
7. Locking (cartilage injury), giving way (ligament injury)
8. Fevers
10. Previous history of joint pains
11. Skin and nail changes*2
12. Eye pain( anterior uveitis in AS); Eye dryness ( Sjögren’s syndrome );
Chest pain (pericarditis)
13. Lungs: cough (sarcoid, fibrosis) ; SOB (pulmonary fibrosis)
14. GIT: diarrhoea (Reiter’s syndrome), bloody diarrhoea (inflammatory
bowel disease)
15. Renal: haematuria, ankle swelling (nephritis)
16. GU: urethritis, ulcers, discharge, dysuria (Reiter’s syndrome)
17. Sensitively ask any recent unprotected sexual contact
18. Peripheral nervous system: Pain, tingling, numbness in the first 3.5
fingers (carpal tunnel syndrome)
19. Generalized: fever, weight loss, tiredness, myalgia
20. ‘Red flags’: Weight loss, night sweats
21. PMHx,: Traumatic injury, fractures; Recent joint injection (septic
arthritis); Joint surgery; Cancer; Autoimmune conditions; Osteoarthritis
Diabetes (pseudogout, septic arthritis)
22. FMHx: joint diseases; cancer
23. RxHx: Long-term steroids (osteoporosis); Thiazide diuretics (gout);
NSAIDs (gout); Allergies
24. SHx: occupation; strenuous activity; impact on daily life; smoking;
Alcohol
25. Thanks patient

*1• Site:
• Which joints specifically?
• Small/large joints
• Symmetrical *2. Skin:
• Proximal/distal • Erythematous patches with silver scaly patches (psoriasis)
• Onset: • Erythematous patches with silver scaly patches (psoriasis)
• Trauma • Butterfly rash (SLE)
• Injection • Nodules, calcinosis (CREST)
• Chronic/gradual • Raynaud’s syndrome (CREST)
• Acute, severely painful (septic, gout, fracture) • Skin tightness (CREST)
• Radiation • Dry mouth (Sjögren’s syndrome)
• Time: • Nails: pitting, onycholysis (psoriasis)
• Duration of joint pain
• Intermittent, continuous, progressive (raised intracranial pressure)
• Movement (inflammatory)
• Movement (mechanical/degenerative)
• Worse in morning (inflammatory)
• Severity (excruciating pain with complete immobility: ? septic arthritis)
*1• Site: which part of back (cervical/thoracic/ lumbar/sacral)
• Sudden
• Gradual
• After trauma/sudden movement
• Character: sharp shooting
• Radiation:
• To legs:
• Which side? Bilateral?
• To buttocks
• To feet
• To groin (loin to groin pain – the classical kidney/ureteric stone pain that radiates from the back to the groin)
• Around chest
• Time:
• Duration
• Intermittent, continuous, progressive (raised intracranial pressure)
• Flexion/extension
• Walking
• Coughing
• Morning, with inactivity
• Night
• Heavy lifting
• Severity

BACK PAIN
0 1 2
2. Cc + duration
3. Description of pain (SOCRATES)*1
4. Limitation of movement/activity, problems moving
5. Weakness; numbness; tingling
6. Difficulty controlling bladder or bowel movements
7. Whether the pain keeps the patient awake at night or wakes them up
from sleep
8. Recent history of trauma or strained/injured him/herself in any way
recently
9. Wt loss; fever; night sweats
10. Eye pain/redness; blurred vision; diarrhoea; oral ulcers
11. Asks whether the patient has been feeling low in mood at all recently or
whether they are under any particular stress at the moment
12. Previous episodes of back pain
13. PMHx: DM; TB; Malignancy; joint diseases
14. FMHx: joint diseases; cancer
15. RxHx: Long-term steroids (osteoporosis); Allergies
16. SHx: occupation; impact on daily life; smoking; Alcohol
17. Thanks patient

Ankle swelling
0 1 2
Hello my name is …………..Medical student from Gollis University I would
like to know your health states is that ok? can I confirm you name and
age
2. Cc + duration
3. Site (unilateral, bilateral )
4. OPDFAIRS
5. Change in relation to time of day
6. Signs of inflammation (redness/pain/hot to touch)?
7. heart failure: SOB.PND, orthopnoea,
8. chronic liver disease: abdominal distension, jaundice.
9. kidney disease: swelling of face, haematuria, frothy urine, oliguria
10. venous insufficiency: eczema, ulceration, pigmentation, risk factors, e.g.
prolonged standing, high heels
11. hypothyroidism: decreased tolerance of cold, weight gain, mood
changes
12. pelvic mass: abdominal distension, constipation
13. deep vein thrombosis: severe pain
risk factors for deep vein thrombosis: recent surgery, past deep vein
thrombosis, immobility, thrombophilia, cancer
14. possibility of being pregnant If female
15. ‘Red flags’: Weight loss, loss of appetite, night sweats (malignancy)
16. PMH:( Asks any other ymptoms, Asks about any recent illnesses,
Previous episodes of ankle swelling. Chronic illness (IHD, Liver disease,
Diabetes, Hypertension, Cancer Pelvic surgery
17. Family history:• Ischaemic heart disease
18. Drug history:Current medication, Recent changes to dose, OTD
19. Social history: Smoking, Alcohol, Illicit drug use (especially intravenous
drug abuse – hepatitis B/C), Occupation, Activities of daily living
20. Thanks patient

UNILATERAL LEG SWELLING
Check list 0 1 2
4. Obtains consent
5. Open question to elicit presenting complaint + Duration
6. Signposts: e.g. ‘Mr/Miss…Thank you for telling me about this
problem. I would like to ask a few more detailed questions. Is
that all right?’
7. OPDFA(standing for long time)R(walking/lying down)S(site; size)
8. Associated factors: Signs of inflammation (redness/pain/hot to
touch)?
9. Fever; weight loss; night sweats;
10. SOB; chest pain; hemoptysis
11. Recent surgery; pregnancy;
12. Limb fracture; long plane flights/travels
13. Joint pain; morning stiffness; skin nodules; deformities
14. Visible varicose veins
15. Insect bite
16. Recent trauma
17. PMHx: DM; PVD; CHF; Malignancy;
18. RxHx: contraceptive pills; Steroids; Anti-inflammatory; CCBs
19. SHx: Alcoholism
20. Thank patient
DDx:
DVT; Cellulitis; RA; Allergy; trauma; Varicose veins; filariasis; Ruptured backer;
INVESTIGATIONS:
CBC; Doppler Ultrasound; Angiography; Limb x-ray; CXR; CT scan; LN biopsy

LEG PAIN
Check list 0 1 2
24. Obtains consent
25. Open question to elicit presenting complaint + Duration
26. Signposts: e.g. ‘Mr/Miss…Thank you for telling me about this
problem. I would like to ask a few more detailed questions. Is that all
right?’
27. SOCRATES
28. Fever, weight loss, night sweats, fatigue
29. Unilateral or bilateral.
30. Trauma.
31. Joint swelling, stiffness, limitation, redness, hotness, pain.
32. Any deformity.
33. Puncture wound, discoloration of skin or swelling, hot or cold.
34. History of infection elsewhere.
35. prolonged rest/travel (DVT).
36. Resent surgery, malignancy, pregnancy
37. SOB; chest pain; hemoptysis
38. Lump behind the knee or around the knee (baker's cyst).
39. Backache, muscle spasm
40. Bone pain or swelling.
41. Itching.
42. PMHx: DM, HIV, IHD, hyperlipidemia.
43. RxHx: contraceptive pills; Steroids
44. SHx: Smoking
45. Thanks patient
DDx:
1. Trauma.
2. RA, Gout.
3. Cellulitis, DVT.
4. Baker's cyst.
5. Intermittent claudication.
INVESTIGATIONS:
Fluid aspiration/analysis: Uric acid (gout); Duplex Doppler; CT; Local x-ray; Angiogra

COUNCELLING, BBN and OTHERS
COUNCELLING
Explanation
 HYPERTENTION Inhaler
 DM Spacer
 GONORRHEA PEFR
 EPILEPSY Asthma medication
 PSORIASIS Eye drop
 HBV CT\MRI
 WAFARIN DRUG
BBN
 HIV
 SUDDENT DEATH
 LEUKEMIA
OTHERS
 DEATH CONFORMATION
 DISCHARGE PLANING AND negotiation
 CARDIO VASCULAR RISK ASSESMENT

COUNSELLING DIABETES
Points to cover:
Definition: Diabetes is a long-standing disorder that disrupts the way your body uses sugar.
All the cells in your body need sugar to work normally. Sugar gets into the cells with the help of
a hormone called insulin. If there is not enough insulin, or if the body stops responding to
insulin, sugar builds up in the blood. That is what happens to people with diabetes.There are 2
different types of diabetes. In type 1 diabetes, the problem is that the body makes little or no
insulin. In type 2 diabetes, the problem is that:
●The body’s cells do not respond to insulin
●The body does not make enough insulin
●Or both
Symptoms: Type 2 diabetes usually causes no symptoms. When symptoms do occur, they
include:
●The need to urinate often
●Intense thirst
●Blurry vision
Treatment:
1. Life style changes:
 Diet “mention you’ll a dietician for him/her to look at what is he/she eating and
how may they change it’.
 Exercise & weight loss: the more exercise you do, the more sugar you burn up,
and the lower your blood sugar level will be.
 FOOT CARE: keep your foot as clean as your face.
 Healthy life: stop smoking
2. Medications: tablets that help control of blood sugar
3. Insulin: very unlikely you need injections
Reassurance: But the good news is a small minority of people have to go to insulin treatment.
And a proportion of people can be managed with just changes in their diet, & life style and a
proportion of people just need medication.
Complications: So if we don’t treat diabetes, than what happens is that the high blood sugar
levels might cause serious problems over time. These include it may irritate your eyes, damage
your heart and kidneys and cause pain or loss of feeling in the hands and feet, and the need to
have fingers, toes, or other parts of the body to be removed.

COUNSELLING HYPERTENSION
Points to cover:
Definition: Hypertension is a long-standing condition in which you have persistent high blood
pressure.
When your doctor or nurse tells you your blood pressure, he or she will say 2 numbers. For
instance, your doctor or nurse might say that your blood pressure is “140 over 90.” The top
number is the pressure inside your arteries when your heart is contracting. The bottom number
is the pressure inside your arteries when your heart is relaxed.
Epidemiology: common problem
Symptoms: It does not usually cause symptoms. But it can be serious.
Treatment:
4. Life style changes:
 Diet: choose a diet low in fat and rich in fruits, and vegetables. Reduce the
amount of salt you eat
 Reduce weight if you are over-weight
 Exercise: Do something active like walking for at least 30 minutes a day on most
days of the week.
 Healthy life: stop smoking and cut down alcohol
5. Medications: tablets that help lower the blood pressure. The most important thing you
can do is to take it as prescribed for you and don’t miss doses.
Complications: So if we don’t treat diabetes, than what happens is that the high blood pressure
puts you at risk for heart attack, eye problems, stroke, and kidney disease.
Reassurance: But the good news is, its treatment is very effective.

COUNSELLING GONORRHEA
Points to cover:
Definition: Gonorrhea is an infection that you can catch during sex. It’s caused by a bacterium.
It can affect the, Sex organs, Urethra (the tube that carries urine out of the body), Throat,
Rectum or anus (especially in men who have sex with men).
Infections that you can catch during sex are called “sexually transmitted infections.”
Symptoms:
 In women, the symptoms of this infection include:
•Vaginal discharge
•Abnormal vaginal bleeding or spotting
•Belly pain
•Pain during sex
•Burning or pain during urination
 In men, the symptoms of this infections include:
•Burning or pain during urination
•Discharge from the penis
•Pain, swelling, or tenderness of the testicles
Treatment:
 The main treatment for gonorrhea is antibiotics. The antibiotics for gonorrhea come in a
single shot and a pill. Treatment might involve taking a single pill, or it might involve
taking medicine for a whole week. No matter what, make sure you take all the pills your
doctor prescribes. Otherwise the infection might come back.
 If you learn that you have gonorrhea, you should tell all the people you have had sex
with recently. They might also be infected (even if they have no symptoms) and need
treatment.
Complications: Leaving gonorrhea untreated can cause long term problems for both men and
women. In women it can lead to a problem called “pelvic inflammatory disease,” or “PID.” PID
can cause pain and make it hard to get pregnant. In men and women, leaving gonorrhea
untreated can lead to joint infections. It can also increase the risk of becoming infected with
HIV.
Prevention: you can reduce your chances of getting gonorrhea by:
●Using a latex condom every time you have sex
●Avoiding sex when you or your partner has any symptoms that could be caused by an
infection (such as itching, discharge, or pain with urination)
●Not having sex

PSORIASIS
Psoriasis is a relatively common chronic skin condition that can cause widespread skin lesions
and associated psychological comorbidity. Along with eczema and acne, it is one of the core
dermatological conditions that come up regularly in OSCE stations in 'explaining stations'.
What is psoriasis?
underlying redness which comes up in flares

es scaling
and inflammation of the skin
What causes it?
is often a family history of the condition
o Sunlight exposure which has lead to burning of the skin

o Trauma
o Infection (streptococcal)
o Stress
o Drugs (steroids)
What are the symptoms?
are:
o Raised up from the skin
o Have a red 'base'
o With a pale scale covering them
o They are usually very itchy
knees/backs of elbows), as well as the bottom of the back and the scalp
onycholysis - the detachment of the nail from the nail bed, usually starting distally and
progressing proximally) and arthritis in some people (there are several different forms
of psoriatic arthritis)
What are the treatments?
o Reduce causative factors, for example stress and sunburn
o Topical

minutes then wash off
a reduced effect over time
o Systemic (these should usually only be initiated by dermatologists)
then others can be tried
To conclude the consultation:
n or links to online information and support groups

EPILEPSY
Example OSCE station: You are a house officer in the outpatient neurology clinic. You are asked
to see a 23 year old fashion model, who was diagnosed with having epilepsy 6 months ago.
Since this time, she has been having an increasing number of fits. Please discuss the possible
changes she may need to make to her lifestyle, and the pro's and con's of medication.
What is epilepsy?
- occurs in 10 per 1,000 people It is associated
with an increased tendency to have seizures, or fits. This is caused by abnormal electrical
activity in the brain, leading to sensory or motor (movement) signs
Precipitants of seizures in epileptic patients:

Flashing lights, strong emotion, lack of sleep,
Menstruation, hyperventilation recent febrile illness
What causes epilepsy?
Idiopathic tumors, certain drugs (e.g.: diazepam),
Alcohol intoxication or withdrawal, hypoglycaemia, brain abscesses or infection, and trauma to
the head
What treatments are available for epilepsy?
Social:
Lifestyle:
ducing alcohol intake
Medical:
o The drugs available are called 'anticonvulsants', and common drug names: include; valproate,
Epilepsy responds
to treatment about 70% of the time
Surgical: when epilepsy is not well treated with medication and where there is a clear
structural cause found in the brain, sometimes it is appropriate to undergo neurosurgery to try
to remove the cause. This can have longlasting effects on memory and patients are usually very
carefully investigated before considered for surgery
Will I have to stop driving?
Will this diagnosis affect my job?

This depends on what you do for a living.
 Working with heavy machinery will no longer be able to work.
 Jobs requiring driving heavy goods vehicles
What is the prognosis?
cured, for some people it does eventually go away

BREAKING BAD NEWS
0 1 2
1. Introduction
2. Check name and reason for attending
3. Assures the patient for confidentiality
4. Appropriate eye contact
5. Determine what the patient already knows
6. Determine what the patient would like to know
7. Warn the patient that bad news is coming
8. Check the patient would like to disclose the information lonely or with
support
9. Break the bad news
10. Give the patient time to respond “moment of silence”
11. Counsel the patient about the condition
12. Check understanding
13. Ask patient if they have further questions
14. Try to ensure there is someone with the patient when he leaves
15. Fellow up
DO FOLLOWING STEPS FOR ALL BBN

HIV
1
0 2
21. Introduction
Good morning, My name is Muhammad Omar; I’m final year medical student at Amoud University.
22. Check name and reason for attending
Can I confirm your name and age?
You came with the symptoms of diarrhea, weight loss, swelling of glands. We run some blood work
up. So before we talk about the results of your tests, I want to ask you some questions, is that
alright?
A. Do you have wife/wives? Children?
B. What is your sexual preference (multiple partners)?
C. Past medical history?
23. Determine what the patient already knows
What you been told about your condition so far?
24. Determine what the patient would like to know
What about your concerns? What do you expect the results will be?
25. Warn the patient that bad news is coming
The result of your blood test came today morning. Are you anxious to know the result? I’m afraid
that I have a bad news for you.
26. Check the patient would like to disclose the information lonely or with support
Would you like to have the results alone or with someone you can trust?
27. Break the bad news
I’m afraid to say that the blood test confirmed that you are having the HIV virus which causes
AIDS…….. I can understand that this is very shocking news for you.
28. Give the patient time to respond “moment of silence”
29. Counsel the patient about the condition
Would you like me to explain it little further?
having the virus doesn’t mean that you are having the AIDS. HIV is virus infection that damages the
protective cells, weakening the defense system. AIDS is the result of untreated long standing HIV
infection. When the defense system is very weak, the body cannot defend itself against other
infections. People can get infected with HIV if blood or body fluid (such as semen) from a person
with HIV enters their body. For example, a person can get HIV if he or she:
●Has sex without using a condom with someone who has HIV – This includes vaginal, anal, and oral
sex.
●Shares needles or syringes with someone who has HIV
The symptoms you might experience could be body aches, lethargy, swelling of your glands,
headache, weight loss, skin infections, diarrhoea etc.We really don’t know how the disease
progresses. Some people can be free of symptoms for a long time. However it’s important that you
use medications to prevent further deterioration in your conditions. You will also require regular
fellow up with us.You should practice safe sex; you shouldn’t donate blood or share needles and
razors.And you shouldn’t breastfeed (if female patient).
This is an entirely confidential matter but you should tell your GP and any one you have sex with. All
your family members need to be tested for the HIV infection.
Vaccinations contraindicated in HIV: BCG; oral polio; yellow fever
30. Check understanding
31. Ask patient if they have further questions
32. Try to ensure there is someone with the patient when he leaves
33. Thanks

Cardiovascular risk assessment
1. Introduction and consent + Age and name:

 Hello may name …… From Gollis University I would like to ask you some questions to
assess your risk of having cardiovascular disease or heart attack is that ok with you?
 Plz confirm your name and Age?
2. ICE:
Ask:
 Do have any idea about risk factors of heart problem?
 Is the any particular thing you worried about?
 What do you expecting to gain from this consultation?
3. SO here are the questions
Fixed risk factors
1. Ask Age and sex.
2. Ask Ethnic background.
People from a South Asian background are at a notably higher risk of cardiovascular
disease.
3. Ask Past cardiovascular events
e.g. MI or stroke. If the patient has a history of past cardiovascular events, you are
assessing him for secondary rather than primary prevention.
4. Ask Family history.
Ask about a family history of cardiovascular disease and risk factors for Cardiovascular
disease such as hypertension, hyperlipidaemia and diabetes mellitus.
Modifiable risk factors
5. Ask Hypertension
If hypertensive, ask about latest blood pressure measurement, time since first
Diagnosis, and any medication being taken.
6. Ask Hyperlipidaemia.
If hyperlipidaemic, ask about latest serum cholesterol level, time since first diagnosis,
and any medication being taken.
7. Ask Diabetes mellitus.
If diabetic, ask about medication being taken, level of diabetes control being achieved,
time since first diagnosis, and presence of complications.
8. Ask Cigarette smoking.
If a smoker or ex-smoker, ask about number of years spent smoking and average
number of cigarettes smoked per day. Does the patient also smoke roll-ups and
cannabis? Does he use illicit drugs such as cocaine?
9 Ask. Alcohol.
Ask about the number of units of alcohol consumed in a day and typical week.
10. Ask Diet.
In particular, ask about fried food and takeaways.
11. Ask Lack of exercise.

Ask about amount of exercise taken in a day or week. Does the patient walk to work or
walk to the shops?
12. Ask any Stress.
Ask about occupational history and home life.
4. Conclusion
 Ask the patient if there is anything he would like to add that you may have forgotten to ask
about.
 State to the examiner that you request appropriate investigations to give a score, like
 BMI (should be between 18.5 kg/m2 and 24.9 kg/m2)
 waist circumference (should be less than 102 cm for men and 89 cm for women)
 blood pressure (should be under 140/90 mmHg)
 fasting blood glucose levels (should be under 6.0 mmol/L)
 fasting lipid levels
 Give pt feedback on his cardiovascular risk assessment
 (e.g. low, medium, high),
5. finally
Any question or consent
Give leaflet
Thanks the pt

Death confirmation
Step 1: preparation
1. Request details of death:
a. Short history from nersus { like time of death and who witnessed it}
2. Request hospital note/ pt’s file
a. Look for diagnose, drugs and PMH of pt
3. Confirm the pt
a. Check name and bed num
Step two: The procedure:
1. Resuscitation:
a. (Indicates need to consider it)
2. Inspection:
a. General: Checks for pacemaker, color, physical movement and respiratory
movement
b. Pupils: check light (fixed dilated) and corneal reflex
c. verbal stimulus: call the pt
3. Palpation
a. Sternum : tactile stimulus/ painful stimulus
b. Pulses : carotid, radial and femoral arteries
4. Auscultation
a. Heart sounds (offer to listen 1minits)
b. Breathing sounds (offer to listen 3minits)
Step tree: conclusion
1. Consider as postmortem
2. Offer to Tell the relatives
3. Offer to Document it to his file
4. Offer to complete death certificate

Discharge planning and negotiation
 Hello may name …… From Gollis University I would like to give you some information is
that ok with you?
7. ICE
Check:
Idea or understanding of discharge “how do you see to go home”
Concerns “do you have and particular concerns with you illness and going home”
expectations
a. Explanation and check concerns:
Explain that you are considering for the patient to go home and how to see it.
b. Check
 impact of hospitalization on patient
 current mood and disposition
 Home situation “where do you live, what kind of house do you live ”
 Social support “do you live alone or with any one? Do you get support from family”
c. Advice
Medications
Tell their side effects and if become sever tell to come back.
Tell to take regularly and complete them
Life style change:
Stopping smoking, reducing alcohol intake,
eating a balanced diet, taking regular exercise, etc
d. follow-up
Appointment either: At his GP or other Out-Patient Department.
8. Finally
Summarization
Check Understanding
Ask Any question or consent
Give leaflet
Thanks the pt

Inhaler explanation
 Hello may name …… From Gollis university I would like to give you some
information about inhaler device is that ok with you?
10. ICE:
Ask:
 Do have any idea about this device or asthma.
 Is the any particular thing you worried about
 What do you expecting to gain from this consultation
11. Explanation and demonstrate.
I understand that you were admitted to hospital for asthma also I aware that you
have been given a inhaler medication to treat attack so I will explain what about
inhaler device, how to use when and its side effect, are you ready for that
 What is inhaler:
Is a device which delivers medication into your air way or lung for inhalation. If
used correctly, it provides fast and efficient relief from bronchospasm (airway
narrowing).
 When to use inhaler:
Depends on type of medication that you have being prescribed
 How to use inhaler: 8steps
step 1. Vigorously shake the inhaler to mix the drug.
step 2. Remove the cap from the mouthpiece.
step 3. Hold the inhaler between index finger and thumb.
step 4. Breathe out completely.
step 5. Place the inhaler in the mouth such as to make an airtight seal with lips.
step 6. Breathe in steadily and deeply, and simultaneously activate the inhaler once
only.
step 7. Remove the inhaler, hold breath for 10 seconds, and then breathe out slowly.
step 8. Repeat the procedure after 1 minute if relief is insufficient.
 Possible side-effects
Fast heart rate, shakiness, and headaches
12. Ask
Understanding
To carry out steps
Give leaflet
Thanks the pt
NOTE: your can explain inhaler alone or it includes:
Asthma counseling
Asthma medication explanation
Depend on the scenario you have.

Spacer explanation
 Hello may name …… am final year medical std From Gollis university I would like to
give you some information about spacer device is that ok with you?
2. ICE:
Ask:
I understand that you were being diagnosed with asthma and you have been given
a inhaler to treat attack also I aware you have some difficulty in using the inhaler
correctly then recommended to use spacer so I will explain what is spacer, its
important and how to use device are you ready for that?
What is spacer:
Spacer is hollow shaped object which have 2 mouth piece opening one is placed to
your mouth and other is placed to mouth of the metered dose inhaler(which is
device which bring medication )
Advantage:
Spacers increase the amount of medication delivered to the lungs if the patient is
limited by poor Technique or respiratory effort.
How to use:
Assemble the spacer.
Vigorously shake the inhaler to mix the drug.
Remove the cap from the mouthpiece.
Fit the inhaler into the spacer.
Sit up straight and breathe out completely.
Place the spacer in the mouth such as to make an airtight seal with lips.
Activate the inhaler as normal.
Breathe in steadily and deeply, hold breath for 10 seconds, and then breathe out
slowly.
Advise
It should be washed every month with soap and warm water and left to air dry.
It should also be replaced every six months.
13. Ask
Understanding
To carry out steps
Give leaflet
Thank the pt

GTN spray Explanation
 Hello may name …… am final year medical std From Gollis University
Today I would like to give you some information about GTN spray , is that ok with
you?
2. ICE:
Ask:
 Do have any idea about angina and GNT spray?
 Is the any particular thing you worried about it?
3. Explanation
I understand that you were admitted to hospital for angina also I aware that you
have been given a spray to treat so I will explain what about angina, how to use
spray when and its side effect, are you ready for that?
Angina:
is chest pain of discomfort that happen when your heart is not getting enough blood
supply this is mainly caused by buildup of small plague in to your arteries supply
heart.
GNT spray
is medication which works to relaxing the arteries of your body as well as those give
heart for blood
Procedure:
Stop activities and sit down
Shake the spray well and remove the cap
Open mouth and raise your tongue
Deliver two puffs under tongue
Repeat procedure in 10 minutes if pain persists
When to use:
When you feel chest pain
As prophylactic when you carry our strenuous exercise
Side effect
Light headedness
Flushing or dizziness
Advice:
Tell to seek urgent medical help if pain not resolving 15 minutes from onset
4. Ask
Understanding
To carry out steps
Give leaflet
Thank the pt

PEFR meter explanation
(Peak Expiratory Flow Rate)

information about inhaler divice is that ok with you?
2. ICE:
Ask:
I understand that you have several symptoms then recommended to cary out PEFR
merer to rule out asthma So today I would tell you several points like what is PEFR
meter, when to uses and how to use.
What is PEFR meter
Is a small, hand-held device used to monitor or measure a person’s ability to breath
out air at maximum speed.
When to use:
At morning (regularly)
At any time you have symptoms of asthma.
Importance / advantage:
It measure how well air moves out of your lung
It indicate whether asthma under controlled or not
How to use:
Attach a clean mouthpiece to the meter.
Slide the marker to the bottom of the numbered scale.
Stand or sit up straight.
Hold the peak flow meter horizontal, keeping his fingers away from the marker.
Take as deep a breath as possible and hold it.
Insert the mouthpiece into his mouth, sealing his lips around the mouthpiece.
Exhale as hard as possible into the meter.
Read and record the meter reading.
Repeat the procedure three to six times, recording only the highest score.
Check this score against the peak flow chart or his previous readings.
4. Ask
Understanding
To carry out steps
Give leaflet
Thank the pt

Asthma medications
information about inhaler device, is that ok with you?
2. ICE:
Ask:
 Do have any idea about asthma and its medication?
3. Explanation
So today I would tell you several points about asthma medications how to use and
their main side effects
Two types of medication
o Inhale bronchodilators (salbutamol) : reliever – taken as required, both when
symptoms start coming on (the earlier the better), and prophylactically - e.g. 5 minutes
before starting to exercise
Side effects: (usually dose related)
Tremor
Headache
High heart rate
Agitation
o Inhaled steroids(beclometasone): preventer – every day regularly (e.g. twice a day) to
minimize symptoms
Side effects:
Sore throat and hoarse voice if used regularly
Candida infection (oral thrush) is possible,
Prevent this by regular cleaning teeth or rinsing mouth every time after use
4. Ask
Understanding
To carry out steps
Give leaflet
Thank the pt

Instilling eye drops Explanation
Today I would like to give you some information about how to use eye drops, is that
ok with you?
2. ICE:
Ask:
 Do have any idea about conjunctivitis?
3. Explanation
I understand that you were admitted to hospital for having eye symptoms and
diagnosed bacterial conjunctivitis also I aware that you have been given a antibiotic
eye drops to treat so I will explain about what is conjunctivitis and how to use eye
drops, are you ready for that?
Conjunctivitis
It is infection or inflammation of conjunctive (a layer which cover the eyes)
It is mainly caused by viruses but bacterial can cause as well
The procedure:
 Wash your hands
 Stand and look upward with headh tilted back wards.
 Pull down the eyelid and drom one or two drops in to lower lid.
 Close eye tightly
5. Ask
Understanding
To carry out steps
Give leaflet
Thank the pt

CT Scan Explanation
Today I would like to give you some information about CT scan , is that ok with you?
2. ICE:
Ask:
 Do have any idea about CT scan ?
3. Explanation
I understand that you were admitted to hospital for having weakness and so on.
Then requested to perfume CT scan to get diagnose for your condition so today I
would give you some information before you perform imaging , are you ready for
that?
CT scan:
it stands for computerized tomography which is machine uses X-ray to produce
images of the body which are cross-sectional images.
Procedure:
Stop eating and drinking around 2hr
Tell structure of machine: is like washing machine
Tell it is painless
Tell Duration: around 10 minutes
Tell that pt will be alone in the room but assistant are in next adjacent room and can
able to speak them
Tell that its is save procedure
Tell that may by there is iv contrast injection for making clear image
Contraindication
Pregnancy if female ‘ask is there a possibility that you are pregnant?’
4. Ask
Understanding
Give leaflet
Thank the pt

MRI Scan Explanation
Today I would like to give you some information about MRI scan, is that ok with
you?
2. ICE:
Ask:
 Do have any idea about MRI scan?
3. Explanation
I understand that you were admitted to hospital for having back pain and so on.
Then requested to perfume MRI scan to get diagnose for your condition so today I
would give you some information before you perform imaging , are you ready for
that?
CT scan:
it stands for Magnetic resonance imaging which is machine uses magnetic field to
produce images of the body which are cross-sectional images.
Procedure:
Tell that the pt can eating and drinking freely
Tell structure of machine: is like large tube machine
Tell it is painless but can feel little claustrophobic
Tell Duration: around 30 minutes
Tell that pt will be alone in the room but assistant are in next adjacent room and can
able to speak them
Tell that its 100% save procedure
Tell that may by there is iv contrast injection for making clear image
Contraindication
People with pacemaker, surgical lips in their body, metallic heart valves ’
Ask “does any of what I said apply to you”
4. Ask
Understanding
Give leaflet
Thank the pt

EXAMINATION
Cardiovascular Cerebella function

GIT GALS exm
Respiratory Hand exm
Neurology Speech assessment
NOTE FROM:
OSCE FOR MEDICAL FINAL BOOK+
Bedside techniques book
+
Mecloid videos

1. Cardiovascular Examination
1. WIPE:
 Wash your hand
 Introducation and concent
 Position 45degre angle
 Exposure
2. ASK:
 Is there any pain any were
 Are you comfortable to this position
3. GENERAL
 On Surrounding: ECG O2 machine IV- fuids

GTN spray chest X-ray
 On patent:
Position any distress
Alertness cyanosis
4. HANDS:
1. Capillary refill 5. Spinter hemorrhage 9. Pulse
2. Clapping 6. Jeneway lesion 10. Collapsing pulse
3. Cyanosis 7. Osler nodules 11. Radio-radial delay
4. Temperature 8. Requests Blood presure 12.branchial pulse
5. FACE:
 EYE: ⋆ anemia ⋆ xanthelsmi ⋆ corneal aches
 Cheeks: ⋆ malar flash
 Mouth: ⋆ central cyanosis ⋆ dental hygiene ⋆ dehydration
6. NECK:
Carotid pulse JVP
7. CHEST
Inspection:
1. Deformity 2.scars 3.pulsations 4. Pacemaker
Palpation
1. Apex beat (site and char) 3. para-venticular heaviness
2. Thrill 4. hepato-jugular reflex

Auscultation
1. Auscultat 4 sites and Palpate carotid or brachial pulse (if murmur come)
•Mitral area/apex beat (5th intercostal space [ICS], midclavicular line)
• Tricuspid area (4th ICS, right sternal edge)
• Pulmonary area (2nd ICS, right sternal edge)
• Aortic area (2nd ICS, left sternal edge)
2. Auscultat Carotid area {both b/c some murmurs radiate}
 Ask to Breath in and hold
3. Auscultat left axial (b/c MR radiate)
4. Cardiac manoeuvres:
 Auscultat mitral area
(ask patient lying on left side and in expiration for murmur of MR)
 Auscultates aortic area
(ask patient sitting forward and in expiration for murmur of AR)
5. Auscultat lung bases at back
8. ABDOMIN
Auscultate aortic bruits and renal bruit
Secral edema
9. PERIPHERAL
 Pulses bilaterally:
femoral (mid inguinal point) mainly check radio-femoral delay
popliteal (difficult but just demonstrate)
dorsalis pedis (between 1st and 2nd metatarsals)
posterior tibial (half way between tip of heeland medial malleolus)
 Edema
10. FINALLY
 Thank the pt
 Help patient get dressed
 Wash your hands
 Summarize your findings and appropriate DDX
 Offer to sent investigations
Note: you can flow this 10 steps or some times you can offer only to do step 8(abdominal
exam) and step 9 (peripheral vascular examination ) by only checking sacral edema and
peripheral edema.

2. Respiratory examination
1. WIPE:
 Wash your hand
 Introducation and concent
 Position 45degre angle
 Exposure
2. ASK:
3. GENERAL
 On Surrounding: sputum cup

IV- fuids Inhalers Peak flow charts
chest X-ray Oxygen cylinders Nebulisers
 On patent:
Position any distress
Alertness cyanosis
4. HANDS:
a. Tar staining d. Astrexia
b. Clapping e. Pulse
c. Cyanosis / paler f. blood pressure
5. FACE:
 Plethora (polycythaemia)
 EYE: anemia/ pallor conjunctive
 Mouth: central cyanosis
6. NECK:
JVP lymph anodes
7. CHEST
{DO this for steps anterior and posterior chest}
Inspection:
1. RR / respiratory type 4. pulsations
2. Deformity 5. Prominent veins
3. scars
Palpation:
A. Trachea E. Chest movement
B. Cricoid–suprasternal notch distance (<threefinger breadths in hyperinflation)
C. Apex beat (site and char) F .Tectile/ vocal fremitus
D. Chest expansion G. Tenderness and crepitus

Percussion:
Sites
Anterior Posterior
1. Supra clavicular fossae 1. Apices
2. Clavicles 2. Above the spine of scapula
3. 2 and 6th IC space anterior 3. Upto 11th rib
4. 4th and 7th IC space on lateral sides
Auscultation:
 Same sites of percussion
 Again check vocal resonant
8. LEGS :
 Palpates shins or ankles for peripheral oedema
9. FINALLY
 Thank the pt
 Wash your hands
 Offer to do:
 cardio vascular examination
 sent investigations (chest x-ray, lung function test, CBC, peak expiratory
flow rate )

3. Gastrointestinal (GIT) examination
1. WIPE:
 Wash your hand
 Introduction and consent
 Position (supine and flat)
 Exposure
2. ASK:
3. GENERAL
 On Surrounding:
IV- fuids NG-tube Nutritional supplements
Abdominal X-ray Vomiting cup
 On patent:
Position Body mass(thin or obese )
Alertness age (young or old)
4. HANDS:
Clapping Dupuytren contracture Liver flap
Leukonychia (iron deficiency) Palmar erythema Pulse
Koilonychia Astrexia blood pressure
5. FACE:
EYE: • Jaundice • Anaemia • Xanthelasmata
Face:
• Parotid enlargement (alcohol excess)
Mouth:
• Angular stomatitis • Glossitis
• Peri-oral pigmentation telangiectasia
• Ulcers (IBD) • Dehydration
• Smell of breath (hepatic fetor, uraemia) • Dental hygiene
6. NECK:
lymph anodes Virchow’s node( stomach CA )

7. CHEST
Inspection:
Chest:
• Gynaecomastia • Spider naevi (more than five is significant)
abdomen:
• Scars • Stretch marks/striae
• Peristalsis • Drain insertion sites/ stoma
• prominent pulsations • Caput medusae
• Distension • Masses/swellings
•hernia orifice
Palpation:
Light palpation:
(supervical tenderness, rigidity, guarding )
Deep palpation:
( masses, organomegly, Aorta )
Organ palpation :
1. liver 3. Ballots kidneys+ at back check renal punch
2. Spleen 4. gallbladder (murphy’s sign)
Percussion:
1. Liver 4. fluid thril
2.Spleen 5.shift dullnes
3.bladder
Auscultation:
 Bowel sounds
 Renal bruits
 Aortic bruits
8. LEGS :
 Palpates shins or ankles for peripheral oedema
9. FINALLY
 Thank the pt
 Wash your hands
 Offer to do:
 Per-rectal examination
 Genital and groin examination
 sent investigations (abdominal x-ray, Ab- ultrasound, LFT, CBC,UA)

4. Cranial nerve examination
A. WIPE:
 Wash your hand
 Introduction and consent + confirm name and age
 Position (sitting )
 Exposure
B. ASK:
C. Inspection: HEAD
• Facial asymmetry
• Ptosis
• squint
• Medical aids – glasses, eye patch, hearing aids, pen and paper for communication
• Fasciculations
• Wasting
• Abnormal movements
1. Cranial nerve I: olfactory nerve (sensory):

• Inspect or check patency of nostrils
•Ask Any change/loss of smell recently?
• Test smelling (with 2 different known objects while close the eyes)
2. Cranial nerve II: optic nerve (sensory):
• Ask Any change in vision?
• Acuity:
 Far vision- Snellen chart (check both eye differently by close ones each time )
 Near vision –ask to read text book
• Fields:
 Confrontation
 (ask the patient to see the Your faceAnd cover their right eye with their right
hand while you cover opposite one) Then check fields
• Colour vision: Ishihara plates
• Pupillary Reflexes:
• Fundioscopy examination – recommend
3. 4. 6. Cranial nerves III, IV and VI: oculomotor, trochlear, abducens (all

motor):
• Do ‘H’ pattern test (ask pt to flow your finger and not move his head)
• Ask any Double vision
• Check light reflex
• Check Accommodation reflex

5. Cranial nerve V: trigeminal nerve (motor and sensory):
sensory motor
• Tests sensation inV1, V2 and V3 by • ask pt to Opens mouth against resistance
 light touch • ask pt clenches their teeth and Feels/
 pin-prick palpate the temporalis and masseter muscles
• States intent to elicit a corneal reflex • Ask pt to move jaw lateral against resistance
• States intent to elicit a conjunctiva reflex • Jaw jerk
7. Cranial nerve VII: facial nerve (motor and sensory):

motor sensory
• Asks the patient to raise their eyebrows ? • Recommend to Taste in anterior
• ask pt to close their eyes tight against resistance? two-thirds of the tongue.
• Asks them to puff out their cheeks?
• Asks them to show their teeth?
8. Cranial nerve VIII: vestibulocochlear (sensory):
• Simple test of hearing

 (by whispers a number and check both ear separately by close one each time )
• Rinne and Weber tests (256 Hz tuning fork)
• States intent/ offer to perform caloric testing
9. Cranial nerves IX and X: glossopharyngeal and vagus (both motor

and sensory):
motor sensory
• ask pt to cough? • Offers to Taste: posterior third of tongue
•ask pt to say one sentence ( Listens and
identifies hoarseness of voice)
• Asks patient to say ‘Ah’ (uvula)
• Offers to test gag reflex
11. Cranial nerve XI: accessory (motor):

• inspect back (Asymmetry of muscles)
• Asks patient to shrug shoulders against resistance – trapezius
• Asks patient to turn head to left and right against resistance – sternocleidomastoid
12. Cranial nerve XII: hypoglossal (motor):

• ask pt to open a mouth & check (fasciculation)
• Asks patient to protrude tongue & check (deviation)
• Asks patient to moves tongue to left and right
• Ask pt to press tongue under cheeks against resistant of your fingers

D. FINALLY
 Thank the pt
 Wash your hands
 Offer to do:
 Upper and lower neurological examination
 sent investigations ( head CT or MRI)

5. Upper Neurological Examination
WIPE
 Wash your hand
 Position (sitting )
 Exposure
ASK
General examination
 On Surrounding:
walking stick crutches foot supports
wheelchair special glasses hearing aid
 On patient’s arms:
• Asymmetry • Scars • Skin changes • Deformities
• Claw hand • Wrist drop • Fasciculations • Wasting
• Scars • Contractures • Injuries • Neuropathic ulcers
 Inspects patient’s back:
• Spinal scars • Kyphosis •Abnormal movements:
Motor examination
1.Tone:
Checks at each joint in flexion, extension, pronation and supination
2.Power:
• Shoulder abduction: C5 • adduction: C6, C7, C8
• Elbow flexion: C5, C6 • Elbow extension: C7
• Wrist flexion: C8 • Wrist extension: C7
• Fingers: T1
flexion, extension, abduction, adduction, opposition, grip strength
• Thumb: abduction, adduction, extension
3.Reflexes:
• Biceps: C5/C6
• Triceps: C6/C7
• Supinator: C5/C6
• Reinforces if absent (clench teeth or apply Jendrassik* manoeuvre)
5.Coordination:
• Finger–nose testing bilaterally
• Dysdiadochokinesis bilaterally

Sensory examination
Examine all dermatomes in step 1 and 2.
1. Light touch
(dorsal column): uses a wisp of cotton wool
2. Pin-prick
(spinothalamic tract): uses a Neurotip
3. Vibration
(dorsal column): uses a 128 Hz tuning On bone prominence
4. Temperature
(spinothalamic tract): offers to use syringes of hot and cold water
5. Joint proprioception(dorsal column):
{Holds terminal phalanx of thumb. Shows patient ‘up’ ‘down movement’. Asks them to
close their eyes and to say if it is ‘up’ or ‘down’}
6. Two-point discrimination using calipers
Use instrument like a pair of blunt-tipped over their fingers or thumb then
Ask the patient to look close the eyes and ask whether one or two stimuli were felt.
7. Point localization
 With the patient's eyes closed, lightly touch various body parts, e.g. hand, finger,
shoulder, and ask which part has been touched and whether on the right or left
side.
8. Stereognosis
 Ask the patient to close the eyes and Place familiar small objects in the patient's
hand and ask the patient to identify what they are after feeling them
9. Graphaesthesia
 Use the blunt end of a pencil and trace letters or digits on the patient's palm. Ask
the pt to identify the figure
10. Sensory inattention
 Ask the patient to close the eyes.
 Touch the back of each of the pt's hands in turn and ask which has been touched.
 Again touch both hands simultaneously and ask whether the left, right or both
sides were touched.
FINALLY
 Thank the pt
 Wash your hands
 Offer to do:
 Full neurological examination
sent investigations ( head CT or MRI)

6.Lower Neurological Examination
WIPE
 Wash your hand
 Position (lying flat)
 Exposure
ASK
 Is there any pain any were •Are you comfortable to this position
General examination
 On Surrounding:
walking stick crutches foot supports
wheelchair walking aids
 On patient’s arms:
• Asymmetry • Scars • Skin changes • Deformities
• Pes cavus • foot drop • Fasciculations • Wasting
• Scars • Contractures • Injuries • Neuropathic ulcers
 Inspects patient’s back:
• Spinal scars • Kyphosis •Abnormal movements:
Motor examination
1. Gait:
 Asks patient to walk and turn then observes gait
 Ask to walk heel
 Ask to walk tip of fingers
+Romberg’s test:
• Asks patient to stand with both feet together and close their eyes
2. Tone:
 Lifting
 Leg Rolling ’ both hips gently
 Checks for clonus (using ankle dorsiflexion)
3. Power:
 Hip flexion: L1, L2 Hip extension: L5, S1
 Knee flexion: L5, S1 Knee extension: L3, L4
 Ankle dorsiflexion: L4, L5 Ankle plantarflexion: S1, S2
 Foot inversion: L4, L5 Foot eversion: L5, S1
 Toe movements: L5, S1
4. Reflexes: Reinforces if absent (clench teeth or Jendrassik* manoeuvre)
 Knee: L3/4
 Ankle: L5/S1
 Plantar: Up (UMNL) or down (LMNL/normal)
5. Coordination:
 Heel–shin testing bilaterally, gait

Sensory examination
Examine all dermatomes in step 1 and 2.
11. Light touch

(dorsal column): uses a wisp of cotton wool
12. Pin-prick
(spinothalamic tract): uses a Neurotip
13. Vibration
(dorsal column): uses a 128 Hz tuning fork on most distal phalanx,
14. Temperature
(spinothalamic tract): offers to use syringes of hot and cold water
15. Joint proprioception
(dorsal column): Holds great toe and shows patient ‘up’ ‘down’ movement Then asks
them to close their eyes, and moves the toe, asking patient to say if it is moving ‘up’ or
‘down’
FINALLY
 Thank the pt
 Wash your hands
 Offer to do:

7. Gait, co-ordination, and cerebella
Function Examination
WIPE
 Wash your hand
 Position (sitting then lying flat)
 Exposure
ASK
Examination of gait
A. Inspection.
a. Ask him to stand up (Inspect posture).
B. Gait and arm swing.
a. Ask him to walk to the end of the room and to turn around and walk back.
b. Note the gait and also the arm swing and any difficulty in standing or turning.
C. Heel-to-toe test/tandem gait.
a. Ask him to walk heel-to-toe, ‘as if on a tightrope’.
D. Romberg’s test.
Ask him to stand unaided with his feet together and his arms by his sides. Assess with
his eyes open and then with his eyes closed.
Examination of co-ordination
Check Upper limbs for:

1. Resting tremor.
2. Intention tremor. .
3. Muscle tone in the arms.
4. Dysdiadochokinesis.
5. Finger-to-nose test.
6. Fine finger movements.
Check Lower limbs for:

1. Muscle tone in the legs
2. Heel-to-shin test.

Assessment of cerebellar function
Carry out the above +
 Test eye movements (nystagmus)
 Ask the patient to say ‘baby hippopotamus’ (slurred/ staccato speech).
FINALLY
 Thank the pt
 Wash your hands
 Offer to do:
Note: If you are then asked to list:

1. cerebellar signs, remember the mnemonic DANISH:
–– Dysdiadochokinesis and dysmetria (finger overshoot)
–– Ataxia
–– Nystagmus – test eye movements
–– Intention tremor
–– Slurred/staccato speech –
ask the patient to say ‘baby hippopotamus’ or ‘British constitution’
–– Hypotonia/hyporeflexia
2. Causes of cerebellar symptoms

 Multiple sclerosis
 Stroke
 Posterior fossa tumour
 Degenerative: alcohol, Friedreich’s ataxia
 Iatrogenic (anticonvulsants: carbamazepine, phenytoin)
 Hypothyroidism
 Paraneoplastic syndrome (lung cancer)

8. The GALS screening examination
WIPE
 Wash your hand
 Position (different positions)
 Exposure
ASK
Brief history
• “Do you have any pain or stiffness in your muscles, back, or joints?”
• “Do you have any difficulty in climbing stairs?”
• “Do you have any difficulty washing or dressing?”
The examination
General
inspection
scars, swellings,
deformities, unusual posturing.
Spine
Look
• From the front: (shoulder symmetry, muscle bulk)
• From behind: (scoliosis and lumbar lordosis)
• From the side: (for kyphos, kyphosis and deformity)
Feel/palpitation
• Press on each vertebral body in turn, trying to elicit tenderness.
Move
• Ask the pt to bend forwards and touch his toes. Look lordosis and scoliosis,
• Ask him to sit down on the couch.
• Ask him to flex Laterally of his neck.
• Ask him to Flex and extend of his neck.
• Spinal rotation. Ask him to turn his upper body to either side.
Arms
Look
rashes, nodules, nail signs
wasting, fasciculation
swelling, asymmetry, deformity
Feel
Temperature muscle bulk
tenderness ( By squeeze the C and MCJ)

Move
• Hands:
power grip
precision pinch grip.
• Wrists:
flexion extension
• Elbows:
flexion extension
• Shoulders:
External/ internal rotation, abduction
Legs
Now ask the patient to lie on the couch.
Look
rashes, nodules, callosities on the soles of the feet
wasting, fasciculation
swelling, asymmetry, deformity
Feel
Temperature swelling
tenderness, warmth,
Move
• Ask the patient to bring his heels to his bottom.
• Hold the knee and hip at 90 degrees of flexion and internally and externally
rotate the hip.
•check patellar tap.
FINALLY
 Thank the pt
 Wash your hands
 Offer to do:
 More detailed physical examination.
sent investigations ( )

Hand examination
1. HEAD
WIPE:
 Wash your hand
 Position {sitting}
 Exposure
ASK:
2. BODY
Look
Dorsum
 Scars
 Deformity (Swan neck deformity, Z-thumb, Boutonnières deformity)
 Nodes ( Bouchard’s nodes (PIP) , Heberden’s nodes (DIP))
 Skin changes – psoriatic plaques
 wasting
 Nails change – pitting & onycholysis – psoriasis
Palm
 Scars – e.g. carpal tunnel release surgery
 Swelling
 Skin color – erythema / necrosis
 Deformity – dupuytren’s contracture
 wasting – Thenar/ hypothenar e.g. carpal tunnel syndrome
Elbows
psoriatic plaques or rheumatoid nodules
Feel
Elbows
Palpate elbow & arm for nodules / tenderness
Palm
 Thenar/ hypothenar bulk – wasting is noted in ulnar/median nerve lesions
 Temperature – wrist & MCP joint lines
 Tenderness
 Thickening of Palmer – dupuytren’s contracture
 Radial pulse –ensure adequate arterial supply to the hand
Dorsum
 Joints of the hand (MCP, DIP, PIP) & wrist
 MCP squeeze
 Anatomical snuffbox –suggest scaphoid fracture
By Bilan Ahmed Ismail.

Sensation:
 Median nerve – thenar eminence
 Ulnar nerve – hypothenar eminence
 Radial nerve – first dorsal web space
Move
Active movement then passive movement
 Wrist
 Flexion and extension: actively (prayer position and opposite ) and do
passive movement
 Ulnar and radial deviation.
 Pronation and supination.
 Finger
 Finger extension flexion
 Power grip – “squeeze my fingers with your hands”
 Pincer grip – “place your thumb & index finger together & don’t let me
separate them”
 Pick up small object – small coin
 Thumb
 Extension. “Stick your thumb out to the side.”
 Abduction. “Point your thumb up to the ceiling.”
 Adduction. “Collect your thumb in your palm.”
 Opposition. “Appose the tip of your thumb to the tip of your little finger.”
 Special tests:
–– try to elicit Tinel’s sign: taping wrist to check any tingling or pain
–– try to elicit Phalen’s sign: opposite of preyar sign and hold 60second
––Flexor profundus test
––Flexor superficiali test.
Motor assessment
 Wrist / finger extension (against resistance) – radial nerve
 Finger abduction (against resistance) – index finger –ulnar nerve
 Thumb abduction (against resistance) – median nerve
3. TAIL
Thank patient
Wash hands
Summaries findings
Offer to Perform a full neurovascular examination of upper limbs Examine with the
elbow joint

Speech Assessment
10. HEAD
A. WIPE:
 Wash your hand
(Hello my name is Mrs Bilan ahmed am Medical student from Gollis University I would like to
assess your speech is that ok? can I confirm you name and age)
 Check that the pt speaks English and that he can hear you.
 Position {sitting}
 Exposure
B. ASK:
11. BODY
Orientation in time and place
Time : Name (year) (season) (month) (date) (day)
Place: Name (country) (county/region) (town) (hospital) (floor)
Dysphasia
Expressive Broca’s area (difficulty in finding the right words whilst in conversation)
Ask directly, “It seems like you know what you want to say but you’re struggling to get the
words out. Am I right?”
Nominal parietal lobe (difficulty naming objects)
Ask the patient to name some common objects such as a watch, pen, or badge.
If he is unable to name the object, ask him what it does:
Receptive Wernicke’s area (difficult of understanding)
asking him to carry out some simple instructions such as
‘Shut your eyes’, ‘touch your nose’, and ‘point to the door’.
Conductive arcuate fasciculus: (difficult to repeat words with intact understanding)
Ask the patient to repeat, “today is Thursday .”
Dysarthria
Ask the patient to repeat some of the following:
‘British constitution’, ‘Baby hippopotamus’,
Assess the structures involved articulation by asking
• ‘Me, me, me’ Lips.
• ‘La, la, la’ Tongue.
• ‘Ah’ Palate, larynx, and expiratory muscles.
Dysphonia
• Make a note of the patient’s volume of speech,
Ask him to cough, and look out for ‘bovine’ cough,

Dyslexia Dominant parietal lobe.
• ask him to read a short paragraph from a newspaper
Dyscalculia Dominant parietal lobe.
• Ask the patient to carry out simple sums and subtractions.
Dysgraphia Dominant parietal lobe.
• Ask the patient to write a sentence.
12. Tail
• Ask the patient if he has any questions or concerns.
• Thank him.
• Summaries your findings, offer a differential diagnosis, and state the probable area of the
lesion.
• Suggest further investigations (mental state examination, full neurological examination,
and speech and language therapy assessment (including an assessment of swallowing).


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OSCE FOR MEDICAL

Collected and prepared by Dr BILAN AHMED

By: Dr Bilan Ahmed Ismail

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History of presenting complaint:

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• Onset (how it started, gradual/sudden)

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• Onset (how did it start)

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• Volume: If large volume, patient needs to be assessed and resuscitated immediately

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• Onset (how it started):

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CBC; Doppler Ultrasound; Angiography; Limb x-ray; CXR; CT scan; LN biopsy

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underlying redness which comes up in flares

What causes it?

is often a family history of the condition

o Sunlight exposure which has lead to burning of the skin

What are the treatments?

o Reduce causative factors, for example stress and sunburn

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a reduced effect over time

o Systemic (these should usually only be initiated by dermatologists)

then others can be tried

To conclude the consultation:

n or links to online information and support groups

By: Dr Bilan Ahmed Ismail

Precipitants of seizures in epileptic patients: