MRCS Part B OSCES Essential Revision Notes - PasTest

MRCS
Part B OSCES
Essential Revision Notes
Second Edition
Catherine Parchment Smith
BSc(Hons) MBChB(Hons) MRCS (Eng)
Julia Massey
MBBS MRCS(Ed)

CONTENTS
About the Authors v
Acknowledgements vi
Permissions vii
1. Introduction 1
A. The Intercollegiate MRCS Examination 3
B. Structure of the OSCE 3
C. Candidate instructions for the OSCE station 6
D. How to prepare for the OSCE 7
E. Survey of past candidates 9
F. Focus of this book 12
SECTION 1: CLINICAL SKILLS IN HISTORY TAKING AND
PHYSICAL EXAMINATION 13
2. Overview of Clinical Skills Stations 15
A. Structure of this content area 17
B. History taking – a ‘general formula’ 17
C. History to assess fitness for surgery 24
D. How to present a history 25
E. Top tips in history taking and clinical examination 29
3. Head and Neck 31
A. The Histories 33
B. The Examinations 43
C. The OSCE Cases 57
D. Survey results 149
4. Trunk and Thorax 151
A. The Histories 153
B. The Examinations 183
C. The OSCE Cases 205
D. Survey results 305
iii

5. Limbs 309
A. The Histories 311
B. The Examinations 325
C. The OSCE Cases 383
D. Survey results 510
6. Neurosciences 513
A. The Histories 515
B. The Examinations 525
C. The OSCE Cases 531
D. Survey results 554
SECTION 2: COMMUNICATION SKILLS 557
7. Communication Skills 559
SECTION 3: SURGICAL SKILLS AND PATIENT SAFETY 597
8. Surgical Skills 599
9. Patient Safety 627
SECTION 4: SURGICAL SCIENCE, CRITICAL CARE,
ANATOMY AND PATHOLOGY 677
10. Applied surgical science and critical care 679
11. Anatomy and surgical pathology 689
12. Mock OSCE examinations 697
Abbreviations List 711
Bibliography 716
Index 717
Summary cards 727
iv

CHAPTER 2
OVERVIEW OF CLINICAL
SKILLS STATIONS
A History taking – a ‘general formula’ 17
B History to assess fitness for surgery 24
C How to present a history 25
D Top tips in history taking and
clinical examination 29
15
CHAPTER 2
CLINICAL SKILLS STATIONS

‘How far can you walk on the flat without stopping?’, ‘Can you climb a flight
of stairs?’ ‘Can you dress yourself without getting SOB/chest pain?’ (Assessing
their exercise tolerance is also vital in determining whether you think they will
get through an operation. For instance, if they are too short of breath due to
cardiac failure to lie flat for 30 minutes, it is unlikely they will manage to get
through a groin hernia repair, even if it is under regional or local anaesthesia,
and a better option might be a supportive truss).
‘Have you had an anaesthetic before?’ (If yes, determine what type, e.g.
general, regional, local, when they had it and did they have any problems with
it?)
‘Do you take any regular medication?’ (especially warfarin or antiplatelet
agents?)
C HOW TO PRESENT A HISTORY
It is important to practice presenting histories, either to your consultant/other
colleagues at work, friends or family. By doing this, your presentation will
become precise and accurate.
Presentation
The presentation to the consultant should follow a logical structure, contain
appropriate clinical language (if the patient is no longer present), pick out
the key points and should cover the information obtained thoroughly but
succinctly.
Questions
You may be asked:
• What differential diagnosis would you suggest at this stage based on the
history you have taken?
• What signs would you specifically look for when examining this patient?
• What investigations would you request for this patient?
When presenting, make sure that you are sitting up straight, looking the
examiner in the eye and speaking in a clear, measured voice.
25
CHAPTER 2
CLINICAL SKILLS STATIONS

CHAPTER 2
CLINICAL SKILLS STATIONS
1. Introductory Sentence
Name, age and occupation.
‘I would like to present Matthew Hardy, a 47-year-old chemistry teacher.’
2. Presenting Complaint
In one or two words state the MAIN COMPLAINT that has caused the patient
to be referred to the hospital and the time that they have been suffering from
it. ‘His presenting complaint is a 3-month history of weight loss and bloody
diarrhoea.’
3. History of the Presenting Complaint
A. The story:
Background to the illness
When last well
What exactly happened, including timescale
Treatment given/GP seen
‘The history of the presenting complaint: Mr Hardy is a gentleman who was
fit and well until 3 months ago. The first thing he noticed was that he started
to open his bowels three to four times per day, having previously only opened
them once a day. He initially thought it might pass, but it continued and
he became worried when he noticed what looked like blood mixed in with
the loose stool. During the last 2 weeks he’s been experiencing some lower
abdominal pain. He’s lost about a stone in weight during this time and when
his symptoms didn’t settle he went to see his GP.’
B. Details of the complaint
If it’s a pain – SIROD CASP
‘The pain was described as a gradual-onset, intermittent, colicky ache specific
to his left iliac fossa. At worst he scored it 8/10 and it is normally aggravated
when opening his bowels and relieved by taking co-codamol. The pain lasted
up to 3 hours and had made him nauseous. He hasn’t experienced a pain
similar to this before.’
C. Relevant medical history
‘Mr Hardy has had no previous problems with his bowels apart from having
occasional trouble from haemorrhoids.’
26

D. Review of the relevant system (GI tract in this case)
‘In addition to his weight loss, Mr Hardy has noticed a decrease in his
appetite. He has no problems with swallowing and doesn’t suffer from
indigestion. Although he has had increased frequency of his motions he
doesn’t complain of tenesmus.’
E. Risk factors for the presenting complaint
‘He is an ex-smoker and has a strong family history of bowel cancer, with his
father dying at the age of 51 from it.’
F. Risk factors for surgery
‘He has no risk factors for surgery, being in good general health and having
had one previous uncomplicated general anaesthetic.’
4. Past Medical and Surgical History
A. Operations
B. Hospital admissions
C. Major illnesses
D. Question directly about: Diabetes
Heart attack
Stroke
Hypertension
Epilepsy
Asthma
Bronchitis
Tuberculosis
Rheumatic fever
Childbirth (women!)
PE/DVT
‘Apart from an appendicectomy performed 5 years ago, Mr Hardy has never
been in hospital.’
27
CHAPTER 2
CLINICAL SKILLS STATIONS

CHAPTER 2
CLINICAL SKILLS STATIONS
5. Medication/Allergies
List all the tablets the patient is currently taking. You may have to remind
women about the pill or HRT, which they often don’t include as medication.
‘Mr Hardy does not take any regular medication and has no known allergies.’
6. Social History
A. Smoking/drinking
‘Mr Hardy used to smoke 30 cigarettes a day, but gave up five years ago. He
only drinks a few pints of beer at the weekend.’
B. Home
‘Mr Hardy lives with his wife and one daughter, aged 5.’
7. Family History
‘Apart from his father’s bowel cancer, there is no other family history of note.’
8. Review of Non-relevant Systems
‘There is nothing of note on review of his cardiovascular, respiratory or other
systems.’
9. Summarise
Summarise the main points of the history in one short sentence.
‘In summary, Mr Hardy is a 47-year-old man, normally fit and well, who
presents with a 3-month history of increased frequency of bowel motions,
rectal bleeding and significant weight loss.’
10. Differential Diagnosis
‘The differentials I would like to exclude are bowel neoplasia (if presenting in
front of the patient)/cancer (if presenting in private) or inflammatory bowel
disease. Other possibilities are infective diarrhoea or diverticular disease.’
28

D TOP TIPS IN HISTORY TAKING
AND CLINICAL EXAMINATION
c
TOP TIPS FOR HISTORIES
• Try and establish a good rapport with the ‘patient’
• Let them do the talking initially
• Ask ‘open’ questions rather than leading the patient with ‘closed’ questions
• Check you have understood the patient by summarising at appropriate intervals
• Try to elucidate a set of differential diagnoses via targeted questions
• Use a list of ‘red flag’ symptoms for any given presenting complaint which are focused and
a useful fallback if things are going badly
• Also try to elicit the patient’s ideas, concerns and expectations or ‘ICE’
• Avoid medical jargon and explain terms as required
c
TOPS TIPS FOR EXAMINATIONS
• Introduce yourself and wash your hands with alcohol gel
• Ask if the patient has any tenderness
• Demonstrate a systematic approach
• Show your handling is gentle and respectful
• Demonstrate satisfactory inspection and palpation
• Identify and interpret key clinical signs
• Present findings logically
You are not required to give a running commentary in the exam and in
certain stations you may be required to take a focused history simultaneously.
However, you must explain to the patient anything that you are doing to them.
29
CHAPTER 2
CLINICAL SKILLS STATIONS

CHAPTER 3
HEAD AND NECK
A e Histories 33
• Neck lump 33
• Thyroid status 36
• Dysphagia 38
• Hoarseness 41
B e Examinations 43
• Examination of a lump 43
• Examination of a neck lump 45
• Examination of the thyroid 47
• Examination of a thyroid lump 48
• Examination of thyroid status 50
• Examination of a parotid lump 52
C e OSCE Cases 57
Lumps
• Lipoma 56
• Sebaceous cyst/epidermal cyst 61
• Dermoid cysts 62
• Haemangioma 64
• Benign papilloma (skin tag) 70
• Keratoacanthoma 72
• Rhinophyma 74
Thyroid
• Diffuse goitre 76
• Multinodular goitre 78
• Thyroid nodule 80
• Hypothyroidism/myxoedema 86
• Thyrotoxicosis and Graves’ disease 88
31
CHAPTER 3
HEAD AND NECK

CONTENTS
Neck lumps
• Thyroglossal cyst 94
• Lymph node/s in the neck 98
o Metastatic 98
o Lymphoma 102
o Tuberculous lymphadenopathy 104
• Branchial cyst 106
• Pharyngeal pouch 110
• Carotid body tumour 112
• Cystic hygroma 114
• Superior vena cava obstruction 116
Salivary glands
• Pleomorphic adenoma of parotid/adenolymphoma/Warthin’s tumour 118
• Carcinoma of the parotid gland 122
• Chronic parotitis 124
• Submandibular calculi 126
Skin lesions
• Basal cell carcinoma 130
• Squamous cell carcinoma 134
• Malignant melanoma 138
• Benign naevus 143
Temporal arteritis 147
D Survey Results 148
32

NECK LUMP/S
A THE HISTORIES
If you are asked to take a history from a patient with a neck lump you need to
initially ask questions about the lump to whittle down the potential differential
diagnoses. You should then ask about relevant associated symptoms or risk
factors that fit in with your differential. Obviously, if you can see a lump, the
position of this might help you (see diagram pg 46). If you run into problems in
the OSCE remember the essential points in the ‘Combined Assessment Box’ to
get you back on track.
Introductions
‘Hello, my name is Dr Parchment Smith. Please can I check your details?
Would you mind if I asked you some questions about your neck lump?’
Ask about demographics.
‘May I ask how old you are?’ 1
‘What do/did you do for a living?’ 2
Presenting complaint (open question!)
‘What has caused you to come and see me today?’
History of presenting complaint (the patient may volunteer the following
information but questions you need to cover about the lump/s include)
‘How many lumps have you noticed?’ 3
1 Some neck lumps are commoner in certain age groups. Age can therefore give you a clue as to the
differential diagnosis:
• Child: cystic hygroma, congenital dermoid cyst (see case on pg 62)
• Young adult: branchial cyst (see case on pg 106)
• Adult: carotid body tumour (>30 usually) (see case on pg 112)
• Older adult: malignant neck nodes due to laryngeal/pharyngeal carcinoma (see case on pg 98),
pharyngeal pouch (>50 usually) (see case on pg 110)
2 For instance a publican may have drunk alcohol/smoked and be at a higher risk for head and neck
carcinoma. Someone who has worked abroad may have a greater risk of TB.
3 If one, possibilities include cystic hygroma, carotid body tumour, carotid artery aneurysm, submandibular
gland stone/tumour, parotid gland stone/tumour, pharyngeal pouch (left side), branchial cyst, thyroglossal
cyst, single thyroid nodule, goitre.
If bilateral, possibilities include chronic parotitis due to stones, mumps, Sjögren/Mikulicz syndrome.
If multiple, possibilities include sebaceous cysts, lipomata, lymph nodes (infective, malignant), multinodular
goitre.
33
CHAPTER 3
HEAD AND NECK

A THE HISTORIES
‘Where do you notice the lump/s?’ 4 (This may be obvious from observation
and therefore it may be more appropriate to check you are both talking
about the same lump: ‘Is it the lump I can see on the left there that you are
concerned about?’)
‘How long have you noticed the lump?’ 5
‘Has it been getting bigger, smaller or remaining the same?’
‘Is the swelling present all the time or does it come and go?’ (Intermittent
swelling can be caused by salivary gland stones; these tend to be related to
food. Therefore if the answer is yes, ask about precipitating factors: ‘Have you
noticed anything that brings the lump on?’
‘Has the lump/s ever been painful?’ (If the answer is yes, investigate further
with questions about onset, duration, precipitating 6 and relieving factors.)
You need to ask about associated symptoms that may either help you reach a
diagnosis or be distressing to the patient and need treatment. The relevance of
these questions depends on what you think is going on.
‘Have you been getting difficulty with swallowing?’ (If yes, questions
which may help you work out what kind of neck lump they have include)
‘Is it painful when you swallow?’ 7 , ‘Does your neck bulge or gurgle on
swallowing?’ 8 )
‘Have you had any difficulty with your breathing?’ 9
‘Have you had a cough lately?’ If yes, ‘Have you been coughing anything up?
‘Have you seen any blood? ’10
‘Have you noticed any change in your voice?’ 11
‘Have you lost any weight?’
‘Have you had any problems with temperatures/sweating at night?’
4 Side of the neck: possibilities include sebaceous cyst, lipoma, lymph nodes (infective, malignant), cystic
hygroma, carotid body tumour, carotid artery aneurysm, submandibular gland stone/tumour, parotid gland
stone/tumour, pharyngeal pouch (left side), branchial cyst, thyroid nodule.
Midline: thyroglossal cyst, dermoid cyst, thyoid mass.
Bilateral: see above.
5 Lump/s which have been present for

Other questions to ask if you are concerned about head and neck cancer
include ‘Have you had any ear pain?’ 12 , ‘Have you had a sore throat?’ 13
If you think the patient may have a thyroid lump you need to ask about
symptoms caused by hyper/hypothyroidism (see Thyroid history on pg 36)
Past medical and surgical history
In particular, what investigations have they had of the neck lump. Have they
had any operations/radiotherapy/chemotherapy. ‘Have you had any tests to
investigate the lump?’, ‘Have you had any treatment for the lump?’
Medication and allergies
‘Do you take any regular medication?’, ‘Do you have any allergies?’
Social history (smoking and drinking) It is important to ask about smoking
and alcohol as these are common risk factors for head and neck carcinoma. 14
‘Are you a current or ex-smoker?’ If yes, ask about smoking habits, ‘What do
you smoke?’, ‘How many do you smoke a day’, ‘How long have you smoked
for?’ 15
‘Do you, or have you ever, drunk alcohol?’ If yes, ‘What type of alcohol do
you drink?’ (e.g. spirits, wine, beer) ‘How much do you drink per week?’
(convert this to units per week). ‘How long have you drunk for?’
Combined Assessment Box – NECK LUMPS
Ask:
• Where is the lump? How long has it been there for?
• Are there any associated symptoms, e.g. hoarseness, difficulty swallowing, cough, pain
• Do you smoke?
• Have you lost any weight?
Examine:
• Inspect the neck
• Ask patient to swallow
• Ask patient to stick their tongue out
• Palpate the lump
• Palpate the regional lymph nodes
12 Otalgia: referred ear pain can occur with pharyngeal and laryngeal carcinoma. Remember the old saying
‘Beware the hoarse patient with the painful ear’.
13 Sore throat can occur with oropharyngeal carcinoma.
14 Less common risk factors include:
• Nasopharyngeal carcinoma: patients from China/Hong Kong, EBV infection
• Oropharyngeal carcinoma: dental sepsis, ionising radiation
• Laryngo/hypopharyngeal carcinoma: Plummer-Vinson syndrome, pharyngeal web, radiotherapy, asbestos/
nickel exposure
15 You can use this information to calculate the number of ‘pack years’ a patient has smoked. A ‘pack year’ is
20 cigarettes per day for 1 year, so if a patient has smoked 10 cigarettes a day for 20 years this equates to 10
‘pack years’.
35
CHAPTER 3
HEAD AND NECK

A THE HISTORIES
THYROID STATUS
You may be asked to take a history of a patient’s thyroid status, in which case
follow this guide, or you may be asked to take a history of a patient with a
neck lump, in which case follow the neck lump history on pg 33. Then, when
it becomes obvious it is a thyroid lump, ask the following questions. If you run
into problems in the OSCE remember the essential points in the ‘Combined
Assessment Box’ to get you back on track.
Introductions
‘Hello, my name is Dr Parchment Smith. Please can I check your details?
Would you mind if I asked you some questions?’
Ask about demographics.
‘May I ask how old you are?’
‘What do/did you do for a living?’
Presenting complaint (open question!)
‘What has caused you to come and see me today?’
History of presenting complaint (the patient may volunteer the following
information but questions you need to cover include)
‘Do you prefer a warm or cold room?’ 16
‘Have you gained or lost any weight recently?’ If yes, ‘How much and over
how long?’ 17
‘Has your appetite increased recently?’ 18
‘Has your bowel habit changed?’ 19
‘Have you noticed a change in your mood?’ 20
‘Have you noticed any palpitations or chest pain?’ 21
‘Have you noticed a change in your periods?’ 22 (female patients only!)
‘Have you noticed a change in your appearance?’ 23
‘Have you had a change in your vision?’ 24
16 Cold = hyperthyroid, warm = hypothyroid.
17 Weight loss = hyperthyroid/carcinoma, weight gain = hypothyroid.
18 Yes suggests hyperthyroidism
19 Diarrhoea = hyperthyroidism, constipation = hypothyroidism.
20 Increased anxiety = hyperthyroidism, depression = hypothyroidism.
21 Palpitations/angina = hyperthryroidism.
22 Altered menstruation can occur with hyperthyroidism or hypothyroidism.
23 Hypothyroidism can cause weight gain, thinning hair, loss outer third eyebrow, neck lump (see case on
pg 86). Hyperthyroidism can cause weight loss, sweatiness, neck lump (see case on pg 88).
24 Eye disease (exophthalmos, lid lag) in Graves’ disease can cause visual symptoms, including double vision
and discomfort.
36

‘Have you noticed a lump in your neck?’ If yes, ‘Does it cause you any
problems?’ Local complications of a goitre may include stridor, SVC
obstruction, dysphagia, sudden painful enlargement (haemorrhage into cyst).
Past medical and surgical history
‘Do you have any other medical conditions?’ 25
‘Have you had any operations on your thyroid or radiotherapy to your neck in
the past?’
Medication and allergies
‘Are you on any medication for your thyroid? Do you have any allergies?’
Combined Assessment Box – THYROID STATUS
Ask:
• Have you noticed any change in your weight?
• Do you prefer a hot or cold room?
• Has there been a change in your bowel habit?
• Have you noticed any change in your appearance?
Examine:
• Inspect neck
• Ask patient to swallow
• Ask patient to stick out tongue
• Palpate lump
• Palpate regional lymph nodes
• Assess thyroid status (hands/pulse/face/eyes)
25 Associated diseases include: hypothyroidism – depression, carpal tunnel syndrome. Associated
autoimmune diseases: pernicious anaemia, haemolytic anaemia, diabetes, Addison’s disease,
rheumatoid arthritis, Sjogren syndrome, ulcerative colitis, lupoid hepatitis, systemic lupus erythematosus,
hypoparathyroidism.
37
CHAPTER 3
HEAD AND NECK

A THE HISTORIES
DYSPHAGIA
Dysphagia refers to difficulty (not pain) when swallowing; pain on swallowing
is called odynophagia. Dysphagia can be caused by diseases you will
encounter in both the ‘head and neck’ section and in ‘trunk and thorax’. 26
If you run into problems in the OSCE remember the essential points in the
‘Combined Assessment Box’ to get you back on track.
Introductions
‘Hello, my name is Dr Parchment Smith. Can I check your details please.
Would you mind if I asked you some questions?’
Ask about demographics.
‘May I ask how old you are?’
‘What do/did you do for a living?’
Presenting complaint (open question!)
‘What has caused you to come and see me today?’
History of presenting complaint (the patient may volunteer the following
information but questions you need to cover include)
‘Have you been getting difficulty with swallowing?’ (Given the subject,
hopefully the answer will be yes!)
‘How long has this been going on for?’
‘Is it constant/intermittent?’
‘Is it painful to swallow?’ (i.e. odynophagia rather than dysphagia)
‘Is the pain constant or intermittent?’ 27
‘Does any particular type of food or drink cause the pain?’ 28
‘Has it been getting progressively worse?’ 29
‘Can you swallow solids, liquids, your saliva?’
‘Can you drink fluid as fast as you used to?’ 30
26 Causes of dysphagia can be divided into anatomical and functional causes. Anatomical causes include:
oesophageal/pharyngeal malignancy, cricoid web, peptic stricture, GORD, extrinsic pressure from
lymphadenopathy or bronchial carcinoma. Functional causes include: motor neurone disease, post-CVA,
globus, diffuse oesophageal spasm, scleroderma.
Causes of odynophagia include: reflux oesophagitis, peptic oesophageal ulceration, thrush, pharyngitis,
diffuse oesophageal spasm, oesophageal/pharyngeal malignancy.
27 Constant odynophagia suggests laryngeal/pharyngeal carcinoma.
28 Odynophagia caused by hot liquids is associated with GORD.
29 Progressive dysphagia from solids to liquids suggests oesophageal carcinoma. This can assist your
management decision regarding need for nutritional/fluid supplementation.
30 If yes suspect a stricture, if no consider a motility disorder.
38

‘Is it difficult to make a swallowing movement?’ 31
‘Does food seem to get stuck anywhere in particular?’
‘Do you ever bring food back up?’ (reflux of food is effortless, it is not
vomiting) 32
‘Do you get a sensation of a lump in your throat?’ 33
Associated symptoms to enquire about include:
‘Have you ever noticed a lump on your neck?’ If yes, possibilities include
metastatic lymphadenopathy from oesophageal or laryngeal/pharyngeal
carcinoma or a pharyngeal pouch (see case on pg 110); if this is a possibility
enquire ‘Does your neck bulge or gurgle on swallowing?’
‘Have you noticed a change in your voice?’ 34
‘Have you noticed any problems with your breathing?’ (As mentioned earlier
you are very unlikely to see a patient with stridor in the exam but you need to
be seen to be asking about their airway.)
‘Have you noticed any weight loss?’ (If yes, try to quantify how much and over
what time period. This could obviously be caused by the dysphagia itself as
well as by the underlying cause for the dysphagia.)
‘Have you developed a cough?’
‘Have you got any pain elsewhere?’ (epigastric pain/heart burn – GORD;
otalgia – referred pain from pharyngeal carcinoma)
Past medical and surgical history
In particular, what investigations have they had for the dysphagia? 35 Have they
had any operations/radiotherapy/chemotherapy? Are they requiring nutritional
supplementation; if yes, what kind?
‘Have you had any investigations for your difficulty in swallowing?’
‘Have you had any treatment for your difficulty in swallowing?’
Medication and allergies
Do they take any medication for reflux/GORD? ‘Are you on any medication?
Do you have any allergies?’
31 If it is difficult for them to swallow suspect neurological causes, e.g. post-CVA, especially if they cough
after swallowing.
32 Reflux of food is found in patients with a pharyngeal pouch.
33 A sensation of a lump in the throat when not swallowing suggests globus.
34 Hoarseness together with dysphagia can be caused by pharyngeal carcinoma.
35 Investigating dysphagia: upper GI endoscopy is usually the first investigation. If this is normal they may
proceed to a barium swallow. An abnormal Upper GI endoscopy may lead to biopsy of lesion/CT if external
compression. If barium swallow is normal consider manometry and pH studies.
39
CHAPTER 3
HEAD AND NECK