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90 “Are you bothered about persistent thoughts that you can-not get out of your mind?” “Do you ever repeat certain activities over and over again even though you do not want to?” Psychotic Screen: “Do you see or hear things other people do not?” Screen for Organic Causes: Illnesses, drugs, or alcohol use related Problems with Relationships: Important for this station. Usually some relationship problem with partner or spouse. Safety Check: Self-harm or homicidal ideation or plan Self-care Past Medical History: Any other health issues? Past Psychiatry History: Diagnosis, treatments, admis-sions, follow-ups, previous similar episodes, and previous suicidal attempts Medication History: Medications and any side effects Allergies: “Do you have any allergies?” Family History and Family Psychiatric History Social History: Smoking, alcohol, drugs, sexual history Living Condition and Relationships Work Conditions and Financial Status Support: Family and friends Wrap-Up: Describe the Diagnosis and Management Plan: It should have two important parts: normalizing her problem and vali-dating her feelings. “Mrs.... I know you are worried about your eye problem and you have visited many physicians. I understand the fact that you have been seen by an eye doctor and a neurologist. They have declared that you don't have an eye problem now, but it does not mean that there may be a medical issue that may become apparent later. So, I would like to recommend to you that it is very important to stick to one doctor. If you will do so, then your doctor can follow you and your health problems. If some new symptoms or health issue appears, then he can arrange further work-up or referrals. “Some people who are under stress and are anxious or people facing marital infidelity sometimes automatically activate a defense mechanism that gives them time to adjust. This whole response is not under their control. This reaction will also help them to seek support from people around. This is a normal reaction for them. These people can present with many different symptoms such as visual problems, numb-ness of arms or legs, or an inability to speak or listen. ” Management Plan: Addressing the anxiety and stress. “Do you need a social worker to help?” Talk therapy. If marital infidelity: “I would like to see your husband. We can have another discussion if you like with him alone or you together, whichever your prefer. We can arrange a marital therapist who can help you. ” Medical Treatment: “I can give you some medicine (Benzodiazepam) for anxiety for short-term use if you want. No further investigations are required at this time. ” Follow-Up: “I would like you to have brief frequent visits so we can discuss about your progress or your concerns. I will see you in 2 weeks from now. ” History and Counseling: Somatization Disorder Candidate Information: A 33-year-old female presents in your clinic asking for a computed tomography (CT) scan for her muscle pain. She has a history of recurring pain at various parts of the body. Her pains have been investigated by many physicians. She was found to have normal labs results. Please take a history and talk to her. Differentials: Somatization disorder Conversion disorder Depression Anxiety Hypochondriasis Fibromyalgia Chronic fatigue syndrome Factitious disorder/malingering Spouse abuse Drug seeker Less likely to be a somatic problem. The first few questions should be asked regarding the pain and then should proceed to psychiatric evaluation questions. Starting the Interview: Knock on the door. Enter the station. M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

91 Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attend-ing physician for today. Are you Miss....? And you are 33 years old?” Chief Complaint: “I understand you are here because of a pain problem. Is it alright if I ask you some questions about it? Then we can discuss about the plan. Do you have any concern?” (It is extremely important in this station to take a relevant history linked with somatization disorder such as anxiety, depres-sion, unnecessary medicines, or surgeries. ) History of Present Illness: While going through the history of present illness, you should try to cover most of the somatization disorder screen. Recurring, multiple, clinically significant physical com-plaints resulting in seeking treatment. Four pain symptoms related to four different sites or functions: Two GI symptoms: Other than pain One sexual symptom: Other than pain One pseudo-neurology problem: Other than pain Pain questions: “How did it start?” “Where is the pain? First site or multiple sites?” (typical in somatization disorder) “Since it started, does your pain remain all the time or comes and goes?” “When did it start?” “Is your pain progressing or getting better with time?” “How does it feel like?” (“What kind of pain?”) “What is the intensity of the pain? On a scale of 1-10. ” “What brings it on?” “Does your pain occur at a certain time? At rest, awake you from sleep, or certain activity?” “Any radiation?” “Anything that relieves it or aggravates it?” “Is it affecting your life or daily routine?” Mood Screen Depression: Low mood: “How is your mood nowadays?” Loss of Interest: “What kind of activities you do for pleasure? Do you still enjoy them?” or “Do you enjoy social activities and relationships?” Lack of sleep: “Do you have problems with going to sleep or maintaining sleep? Do you wake up early morn-ing and then find it difficult to go back to sleep?” Guilt: “Do you feel guilty?” Decreased Energy: “Do you feel lack of energy?” Inability to Concentrate: “Do you have difficulty in concentrating?” Weight: “Did you notice any change in your weight lately?” Loss of Appetite: “Has your appetite changed recently?” Psychomotor Retardation: “Do you have hopelessness?” Anxiety Screening: “Are you kind of a person who worries a lot?” (Excessive fear) “Do you ever have sudden onset of intense anxiety?” “Any special fear?” Psychotic Screen: Do you see or hear things other people do not? Screen for Organic Causes: Illnesses, drugs, or alcohol use related Problems with Relationships: Important for this station Safety Check: Self-harm or homicidal ideation or plan Self-care Past Medical History: “Any other health issues?” Ask if previous surgery (patient with somatization disorder usually has multiple surgeries) Past Psychiatry History: Diagnosis, treatments, admis-sions, follow-ups, previous similar episodes, and previous suicidal attempts Medication History: Patient may be on high doses of pain medications. Ask for common side effects. Allergies: “Do you have any known allergies?” Family History and Family Psychiatric History Social History: Smoking, alcohol, drugs, sexual history Living Condition and Relationships Work Conditions and Financial Status 3 Psychiatry

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

92 Support: Family and friends Wrap-Up: Describing the Diagnosis: “I understand that you are here to get CT scan for your muscle pains. Based on our discussion today, first thing, I want to assure you that you don't have a serious underlying problem. I think the best explanation of your symptoms is a medical condition known as somatization disorder. ” Question: “What do you know about it?” Answer: “In somatization disorder, patients have recurring and multiple physical complaints resulting in frequent visits to physicians, seeking treatment. The onset is usually before age 30. The symptoms can be mild to severe. In some patients it can cause significant function impairment. The exact etiol-ogy is often not known, but stress definitely plays a role in most of the patients. I can give you some more information in the forms of literature and Websites to read about it. ” Marital infidelity can lead to somatization disorder. If there is marital infidelity involved, then add: “I would like to see your husband. We can have another discussion if you like with him alone or you together, whichever you prefer. We can arrange a marital therapist who can help you. ” Medical Treatment: I can give you some medicine (benzodiazepam) for anxiety for short-term use if you want. No further investigations (CT scan) are required at this time. ” Counseling: “I would like to refer you to a psychiatrist for counseling. He will also help you deal with the stress. ” “We can arrange a family meeting. ” “Do you need a social worker to help?” Follow-Up: (Close follow-ups) “I would like you to have brief frequent visits, so we can discuss about your progress or your concerns. I will see you in 2 weeks from now. ” History and Counseling: Psychosis/ Schizophrenia Candidate Information: A 37-year-old male comes to the emergency department. He believes that the police are chasing him. Take history and address his concerns. Differentials: Brief psychotic disorder Persecutory delusions Schizophrenia Bipolar disorder Associated with medical disorder Substance abuse or withdrawal Brain tumor, head trauma Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attend-ing physician for today. Are you Mr....? Are you 37 years old? How can I help you today?” Body Language and Clues: In psychosis scenarios, sometimes the first interaction with a patient may surprise the candidate. You must be prepared and should be ready to customize your history accordingly. Look for body language and clues: poor hygiene, restless, irritable, tense, moving around in the room, suspicious looking, pos-ture, and gestures. You must reflect with your questions that you have picked up the clues. May ask you to show your ID then may ask you if you work for police. Show him the ID and then reassure him you are a physician. If he looks very agitated or active during the interview, you must reflect it by saying: “You look very anxious. Is something bothering you or you want to discuss with me?” If the patient is talking to himself, ask him: “Who are you talking to?” If the patient is moving around the room, then you may say: “I understand you're here because you are worried that the police are chasing you. I am here to help you, can you please sit down? So we can have a talk about it. ” Patient may show concerns about his safety. Reassure him that he is safe. During the interview, if the patient stands up again, then reassure him again and request that he sit down. Patient may want to leave during the interview, then tell him that you will call security and will certify him to be admitted in hospital without his will. History of Present Illness: “Why are the local police chasing you?” “Is anyone else other than the police chasing you?” “How did it start?” “How long have they been chasing you?” “Is it affecting you?” “How are you protecting yourself?” M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

93 “Have you discussed it with anyone else?” “Does any certain environment provoke your symptoms?” Mood Screening: “How is your mood these days? Low or high?” Anxiety Screening: “Are you the kind of a person who wor-ries a lot?” (Excessive fear) Psychosis Screening: Hallucinations: “Do you see, hear, or smell things that others cannot?” “Do you sense things that are not actually there?” “How long has it been going on?” “When, how many times did you see/hear/smell them?” “What do you see/hear/smell and how?” “Do you recognize these?” “Do these command you to do anything or convey to you some special messages?” “Do they talk to you or ask you to do something?” “Do you feel as if something is crawling or creeping on your skin? How do you feel about these?” Delusions: “Do you have any fixed, firm, untrue beliefs?” “Do you have certain beliefs about yourself or about oth-ers that others find odd?” Grandiose: “Do you feel that you have special assign-ments/tasks/powers? Do you feel that you are super tal-ented or have a mission?” Erotomanic: “Do you feel that you are being loved by a person who is a celebrity or of a higher status?” Persecutory: “Do you feel someone is following you?” Control: “Do you feel that someone is controlling you?” Reference: “Do you feel things happening around you have some reference with you?” Paranoid: “Do you feel that the TV is sending messages?” “Do you think that people can steal your thoughts?” “Do you think that people are reading your mind?” “Do you feel someone is putting thoughts in your mind?” Jealousy: “Do you feel that your partner is unfaithful?” Religious: “Do you have a special religious mission or mandate?” Somatic: “Do you feel you have a general medical condition?” Mind reading: “Do you feel someone is reading your mind?” Disorganized Behavior: Excitement, negativism, stupor, agitation Disorganized Speech: Frequent derailment or incoherence Negative Symptoms: Affect Flattening: Inappropriate emotions Anhedonia: Loss of interest Alogia: Inability to speak Avolition: Loss of motivation or drive Attention deficit: Lack of concentration Screen for Organic Causes: Illnesses, drugs (important in this station), or alcohol use related. Past Medical History: Any previous health issues? Past Psychiatric History: Depression, previous treatments. Medication History: Medications and any side effects Family History and Family Psychiatric History (Schizophrenia) Social History: Smoking, alcohol, drugs (cocaine), sexual history Self-Care, Living Condition, and Relationships Work Conditions and Financial Status Support: Family and friends Wrap-Up: Question: (From patient) “Am I crazy?” Answer: “There is no medical condition called 'crazy. ' Sometimes people find it difficult to handle their thoughts and behavior and this is called schizophrenia. ” Question: “Do you know about it?” Answer: “Schizophrenia is a long-term mental illness. It is a mental disorder that impairs the way you perceive reality. It could be very disabling. People may have faulty perceptions and emotions so they may present with inappropriate actions and feelings. They may also withdraw themselves from reality. They may live in fantasies and may have delusions. ” Management Plan: “I need to examine you and will send some blood tests. I will request a psychiatrist to come and asses you. We may need to admit you today. I would also do a detailed physical exami-nation and will run some tests. I can call your family or friend if you want. I can also call the social worker if you need any help. ” Medical Treatment: Risperidone to reduce the symptoms. Side effects: drowsiness, weight gain, increased blood glucose. or Haloperidol: Side effects: sedation, extrapyramidal symptoms, tardive dyskinesia, weight gain, diabetes, ele-vated prolactin. 3 Psychiatry

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

94 If the patient wants to leave, tell him, “I need to keep you in the hospital. ” If he refuses, then tell him that you will call security and will admit him against his will (fill the appropri-ate forms). “Any questions or concerns?” Investigations: CBC, toxicology screen, ECG, septic work- up, CT/MRI brain. Further Reading: Psychosis scenarios can present in different ways: A 43-year-old male is brought by his friend to the emer-gency department. The patient was found locked in his house and did not want to come out of his house. He believes that his surroundings are infected with germs and bugs. Talk to him and get a detailed history. In this particular case, the history can be started with some questions about germs and bugs: “What do you mean by germs and bugs infestation?” “When did you first start feeling about these bugs and germs?” “How long has it been going on?” “How do you know that there are germs and bugs everywhere?” “How do you manage to see them?” “How do you avoid them?” “Is there any specific place where you feel it is infected or is it everywhere?” “What do you think is going on?” “How are you coping with these?” “Have you done anything to clean these places?” “Do you think these germs are only in your home or are outside your home too?” “Any triggering condition?” “Is it affecting you?” “How are you protecting yourself?” “Have you discussed it with anyone else?” “Any recent stress in your life?” “Does any certain environment provoke your symptoms?” It should be followed with questions regarding hallucina-tions and delusions as mentioned in the previous case. Then complete the rest of the history. The examiner may ask for the diagnosis, which will be paranoid schizophrenia. Here is another example: A 53-year-old male comes to the clinic; he feels that the local police are chasing him. Take his history and address his concerns. The differential diagnosis will be: Brief psychotic disorder Persecutory delusions Bipolar disorder Associated with medical disorder Substance abuse or withdrawal Brain tumor Head trauma If the patient is moving around the room, then you may say: “I understand you're here because you have worries that the police are chasing you. I am here to help you, please sit down. ” Make sure he sits in front of you. If the patient asks if he is safe here, reassure him that he is safe. During the interview, if the patient stands up again, then reassure him again and request he sit down. If the patient wants to leave during the interview, then tell him that you will call security and will certify him to be in hospital against his will. Once the patient settles down, then start with the chief complaint: “Why are the local police chasing you?” “Is anybody else than the police chasing you?” “How did it start?” “How long have they been chasing you?” “Is it affecting you?” “How are you protecting yourself?” “Have you discussed it with anyone else?” The rest of the history will be the same as the previous cases. One important question not be missed in this station is about use of drugs such as marijuana, cocaine, and amphetamine. In a similar case scenario, a patient may show a picture of something or may show a metal rod and may tell you that someone has planted this to spread radiation in the area. You must address this concern and may reply: “It may be like a radiation for you, but not for me. ” Then explain what the picture or object actually is. The patient may present with a weird sensation in his hand, or a patient asks to arrange for a DNA test for his kid. Checklist: Psychosis/Schizophrenia See Table  3. 4 for a checklist that can be used as a quick review before the exam. History and Counseling: Eating Disorder Candidate Information: A 16-year-old female brought by her mother to your clinic with falling weight for 5 months. Please take history and do relevant physical examination. M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

95 Differentials: Anorexia nervosa Bulimia nervosa Pregnancy Chronic disease Thyroid Diabetes mellitus Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attend-ing physician for today. Are you Miss....? Are you 16 years old? How can I help you today?” The patient may explain that her mom is worried about her weight. “Is it alright if I ask you a few questions about your weight loss and then I would like to do a physical exam-ination? If you have any concern please let me know. ” History of Present Illness: “How did you notice any change in your weight?” “How did it start? Gradually or suddenly?” “Are you feeling low/depressed since it started?” “Can you please tell me is there any particular event that has triggered your symptoms?” “Any recent stress at home or work?” “Do you have concerns about your body image?” “Have you ever weighed less than what you should?” “What is your current weight?” “How tall are you?” “What was your previous highest weight?” “What was your previous lowest weight?” “Since how long have you been losing weight?” “Are you afraid of gaining weight?” “What is your perception about your body image and how you look?” “Do you see the mirror every day?” “Do you think you look fat while others say you are not?” “Did you ever do binge eating? How much did you eat?” “Did you feel that you lost control of yourself?” “Did you ever induce vomiting after an episode of binge eating?” “Have you ever used laxatives, enemas, or water pills to reduce weight?”Table 3. 4 Psychosis/schizophrenia checklist Starting the station Knock on the door Enter the station Hand-wash/alcohol rub Greet the examiner and the patient Give stickers to the examiner if required or show your ID badge Sit on the chair or stand on the right side of the patient and start the interview Opening Introduction, greet, explain, position, and exposure/drape Make good patient rapport Start with an open-ended question Chief complaint Pick up patient body language and clues and reflect in interview Talking to himself, avoiding eye contact, asking for your identity check, looking toward walls or ceiling Be empathetic and supportive History of present illness Analyze the symptoms: onset, course, content, duration, and any action Any current stress or precipitating events Screen about hallucination and its content Grandiosity, somatic, persecutory, reference, thought, control, and religious Screen for delusions Bizarre: thought, reference, control, religious Non-bizarre: persecutory, grandiosity, somatic Screen for depression Screen for anxiety Screen for organic causes Medical illness causing psychosis Safety check Self-care Past medical history Past psychiatric history Medication history Medications and any side effects Family history and family psychiatric history (schizophrenia) Social history Smoking, alcohol, drugs, sexual history Personal history Living condition and relationships Work conditions and financial status Support Family and friends Wrap-up Describe the diagnosis Management plan Admission, laboratory tests, psychiatry consult, and medical treatment You must read about common medicines used in treatment of psychosis such as haloperidol and clozapine Ask if any questions or concerns 3 Psychiatry

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

96 “I would like to ask few questions about your diet”: “What is your dietary history?” “How many meals do you eat per day?” “Do you take sneaks?” “Do you calculate calories of what you eat?” “Do you like to eat alone?” “Do you exercise? How many hours in day/week?” Differentials: “Do you feel dizzy?” “Any pallor?” “Any fever?” “Any night sweats?” “Are you losing your hair?” “Does your heart race? Palpitations?” “Do you have any oral/genital ulcers?” “Any change in bowel routine? Constipation?” “Any problem with cold weather?” Psychiatric Symptoms Screening: Depression Screening: (5/9 and 2-week period): Low Mood: “How is your mood nowadays? Have you been feeling low/sad/down or depressed these days? Is your mood always low or it alternates?” “How were you feeling before this?” Loss of Interest: “What kind of activities do you do for pleasure? Do you still enjoy them?” or “Do you enjoy social activities and relationships you used to enjoy?” If first two questions are negative, then jump to mania questions. Otherwise, complete the depression screening. Lack of Sleep: “How is your sleep?” Guilt: “Do you feel guilty/hopeless/worthless?” Decreased Energy: “Do you feel lack of energy? Do you feel tired?” Inability to Concentrate: “Do you have difficulty in concentrating?” Loss of Appetite: “Has your appetite changed recently?” Psychomotor Retardation: “Do you think that you have slowed down your usual pace?” Suicide Ideas: (very important in this station) “Do you have any plan to hurt yourself or others? Any previous attempt? Recurrent thoughts? Left a note?” Mania Screening: “Any periods of time feeling high?” Anxiety Screening: “Are you kind of a person who worries a lot?” (Excessive fear)Psychosis Screening: “Do you see, hear, or smell things that others cannot?” Screen for Organic Causes: Illnesses, drugs, or alcohol use related Menstrual History: “When was your last menstrual period?” “Are these regular? How many days for one cycle? How many days? How heavy?” Teenager Screening: Home: “How is your living like? Who lives with you? Are your parents married, divorced, or separated? How long you have been living in your current residence? What does your parent do for work?” Education: “Which grade you are in? What school do you go to? How are your grades? Do you like going to school? Have you made any future plans in studies?” Employment Activities: “Do you have friends? Do you have a best friend? What do you do outside of school? Any hobbies?” Alcohol: “People your age sometimes have problems with excessive drinking. Do you ever have such prob-lems? Do your friends bring alcohol to the parties you attend?” Diet: “People your age, sometimes they have concerns about their body weight, shape, and image. Do you ever have such concerns?” Drugs: “People your age sometimes experiment with street drugs. Have you ever tried street drugs? Do your friends experiment with street drugs or your friends bring any drugs to school or parties?” Sexual Activity: “Are you in a relationship? Are you sexu-ally active? Some people in your age group are uncertain about their sexual orientation. Do you have any concern about it? Do you know about sexual or physical abuse? Have you ever experienced or had any event that is concerning?” Past Medical History: Any previous health issues? Past Psychiatric History: Depression, previous treat-ments. Any criminal history? Medication History: Use of laxatives or diuretics and any side effects Family History and Family Psychiatric History: Family history of eating disorders Social History: Smoking, alcohol, drugs Self-Care, Living Condition, and Relationships Work Conditions and Financial Status Support: Family and friends Physical Examination: General: Vitals (Low HR, low BP, orthostatic changes, low temp) M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

97 Height and weight Head: Pallor, sunken eyes, parotid enlargement Mouth: Perioral skin irritation, oral mucosa for ulcers, dental caries, loss of dental enamel Neck exam: Thyroid Skin: Dry skin, yellow skin, lanugo hair, hair thinning, and hair loss Hands: Redness knuckles, scars and calluses on the dor-sum of the hand, pitting of nail beds Legs: Bruising, muscle wasting, pedal edema Gait Systems: Cardiovascular (arrhythmia), chest exam, abdominal exam CNS: Exam for cerebellum and the cranial nerves Wrap-Up: Describe the Diagnosis: “We need to run some tests. ” CBC, Electrolytes, Mg, Ca, PO4, blood glucose, urea and creatinine, liver panel, TSH, lipid profile, 12-lead ECG “Based on this conversation, I have come to the conclusion that you may be suffering from anorexia nervosa. Do you know what anorexia nervosa is? Anorexia nervosa is a serious and potentially life-threatening eating disorder. Some people develop a wrong image about their body weight and intense fear of gain-ing body weight. It guides them to go for a strict diet. It restricts their appetite and sometimes a complete aversion to eating. A person will be unable to maintain a normal and healthy weight; they lose a considerable amount of weight. So no matter how thin and skinny they become, it would not be enough for them. ” Management Plan: “Fortunately it is a treatable disease. We may need to involve a dietitian, gynecologist, and a psychiatrist. A dietitian can help you to figure out a diet plan, appropriate food, and daily caloric requirements. We need to monitor the gradual increase in your weight, which should be around 1-2 lbs per week. A gynecologist can help to treat menses disturbances. A psy-chiatrist for exploring the etiology, talk therapy, family ther-apy, and psychotherapy. Do you think you need extra help? We can arrange a supporting group or a social worker visit. ” “Sometimes we may have to admit the patients with this condition, especially if their weight is lower than 65% of standard body weight, there are electrolyte abnormalities, and to monitor the complications and re-feeding syndrome. ” “Talk therapy will help in improving the thoughts and feelings. ” “The medicines for depression usually work slowly and take 2-3  weeks to start showing signs of improvements. Common side effects are dry mouth, constipation, and seda-tion. These side effects are usually transient and improve with time. You should take the medicine for about 6 months once symptoms have improved. ”Contract: “People with anorexia nervosa sometimes feel very low and may think about hurting themselves or others. If you have such thoughts, I would like you to promise me that you will seek immediate help. You should talk to a family member or a friend. You can also go to a hospital or to a clinic. ” Follow-Up: Follow up once lab results are back. Drug Seeker Candidate Information: A 33-year-old male presented in your clinic asking to renew his Tylenol #3 prescription for his headache. Talk to him. Differentials: Headache (migraine, infection, subdural hematoma, sub-arachnoid hemorrhage, referred pain, and temporal arteri-tis discussed in neurology cases) Depression Hypothyroidism Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attend-ing physician for today. Are you Mr....? Are you 33 years old?” Chief Complaint: “I understand you are here because of headache. ” “Is it alright if I ask you some questions about it?” “Then we will discuss about the plan?” History of Present Illness: Start with headache: -Onset: “How did your headache start?” -“Did it start suddenly or gradually? Unilateral or bilateral?” -Course: “Did it change since it started or stay the same?” -“Was it present all the time? Or it comes and goes?” -Duration: “When did it start?” -Character: “Can you please explain it more? What kind of pain it is? Band around the head? Pressing, around the eyes or nose?” 3 Psychiatry

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

98 -Frequency: “How often does this happen?” Then Pain Question: Progression, quality of pain, radia-tion, severity, and timing? Red eye/lacrimation/photopho-bia/phonophobia? Events Associated: “Can you please tell me is there any particular event that has triggered your symptoms? History of head injury?” Associated Symptoms: Nausea/vomiting, neck pain/ stiffness, weakness/numbness of limbs. Stress: “Any recent stress at home or work?” Relieving Factors: “Does anything relieve your head-ache? Acetaminophen, ibuprofen, rest?” Precipitating Factors or Aggravating Factors: “Does anything aggravate your headache? Alcohol, smoke, smell, light, fatigue? Worst at night?” Functional status or severity or impact on life activities? Questions Regarding Tylenol #3: “How long have you been taking it?” “Who prescribed it to you?” “Who renewed it and when?” “Did you bring a bottle?” “How many tablets do you use every day?” “How many tablets were you using before?” “How long did you increase the dose?” “When you take it, how do you feel?” “Do you have any nausea, vomiting, shaking, heart racing?” “Do you fill it from one pharmacy or different pharmacies?” “Will it be alright if I contact your pharmacy or your fam-ily physician?” Psychiatric Symptoms Screening: “I am going to ask you some screening questions now. ” Depression Screening: Mood: “How is your mood nowadays?” Loss of Interest: “What kind of activities you do for pleasure?” “Do you still enjoy them?” Lack of Sleep: “How is your sleep?” “Do you have problems with going to sleep or maintain-ing sleep?” Guilt: “Do you feel guilty/hopeless/worthless?” Decreased Energy: “Do you feel lack of energy?” “Do you feel tired?” Inability to Concentrate: “Do you have difficulty in concentrating?” Loss of Appetite: “Has your appetite changed recently?” Psychomotor Retardation: “Do you think that you have slowed down in your usual pace?” Suicide Ideas: “Do you have any plan to hurt yourself or oth-ers? Any previous attempt? Recurrent thoughts? Left a note?”Mania Screening: “Any periods of high mood?” Anxiety Screening: “Are you the kind of person who worries a lot?” (Excessive fear) Psychosis Screening: “Do you see, hear, or smell things that others cannot?” “Do you sense things that are not actually there?” Screen for Organic Causes: Illnesses, drugs, or alcohol use related Past Medical History: “Any previous health issues?” Past Psychiatric History: Depression, previous treatments. Medication History: Medications (other than Tylenol #3) and any side effects Family History and Family Psychiatric History (depression) Social History: Smoking, alcohol, drugs (ask about street drugs), sexual history Self-Care, Living Condition, and Relationships Work Conditions and Financial Status Support: Family and friends Wrap-Up: Describe the Diagnosis: “I understand you came to renew your prescription for Tylenol #3. I just want to know what is your understanding of Tylenol #3?” “Tylenol #3 contains two medicines: One is Tylenol, which is used usually for pain and fever. It is quite safe and effective medicine. It can be used for longer periods of time. But in higher doses, it can affect your liver and kidneys. The other one is codeine. It is a narcotic. Narcotics are similar to morphine. It is a good pain killer. It is usually prescribed for short-term use, because long-term usage is associated with tolerance. ” “Do you know what is tolerance? A patient needs to keep increasing the dose of a certain medicine to get the same effect. That's why these medicines are also known as habit- forming drugs. ” “Besides tolerance, people taking codeine for longer period of time, if they try to stop it, suddenly they develop withdrawal symptoms, which may be sweats, shaking, run-ning nose, heart racing, nausea, vomiting, agitation, tearing, muscle aches, drowsiness. ” M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

99 Management Plan: “So, I think instead of renewing it, we should stop it and change it to another medication, which will be a nonnarcotic for your pain. I would like to do a physical examination and would like to run some tests. There are resources available who can help you. If you would like to talk to a social worker, I can arrange that for you. ” Follow-Up: “It will take few days when the new medicine will kick in. I can see you in 2 weeks, if you want to have an early follow-up. ” “Do you have any question?” History and Counseling: Suicide Candidate Information: A 22-year-old comes to your clinic. He recently attempted suicide. Please take a detailed history and make a manage-ment plan for him. Patient with suicidal ideation or after a failed suicidal attempt may voluntarily present in emergency department or may be brought by a close friend or family friend. The same patient may be brought by police and may be under orders to be restrained in the emergency department against patient's will. In these circumstances, if patient wants to go home, you must counsel the patient that you will not let him/her go. You will assess the patient first. Patient needs to be assessed by mental health/psychiatric unit and may need to be admitted for further assessment and treatment. If patient will threaten to leave anyways, then tell that you are calling the security or peace officer to hold patient in. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning /good afternoon. I am Dr.... I am your attending physician for today. Are you Mr....? And you are 22 years old? What brings you to the clinic today?” Body Language and Clues: Then let the patient talk and listen carefully. The patient will talk about the events and his circum-stances leading him to the decision of attempting suicide. In this particular station, it is very important to show empa-thy and support. The patient may look sad or low and may avoid eye contact. If so then one should offer support and help. You must encourage the patient by saying it is a good thing he did come to the clinic to seek help. You are here to help him. Suicide History: “What happened?” “When did it happen?” “Did you have thoughts of hurting yourself?” “How long have you been thinking about suicide?” “When did you plan it? What was the method?” “How long you have been planning on it? How often do you have these thoughts?” “How severe are your thoughts? Do these suicidal thoughts affect your activities of daily life? Have you ever been hospitalized?” “What made you decide to act on today's event? Any recent event or stressor precipitated in these thoughts?” Or may ask, “What made you want to kill yourself?” “Did you leave a note?” “Did you make a will?” “Did you tell someone?” “Did you give away your belongings?” “Did you select a date or specific time? Any particular place?” “Did you buy a weapon? How did you get the gun/ pills?” “Did you try stopping these thoughts? Did you seek help?” “Is there anything that has held you from executing the suicide plan? Family, friends, religion?” “Did it happen before? When?” “Do you still have a plan to kill yourself? What are your plans?” “Any time lag between the suicide attempt and arrival in emergency?” “What do you feel to survive from the attempt you made?” Assessment: Modified “SAD PERSONS” scale score of greater or equal to 6 shows need for emergency psych consult (Table 3. 5). Psychiatric Symptoms Screening Depression Screening: Low mood: “How is your mood nowadays? Have you been feeling low/sad/down or depressed these days? Is your mood always low or does it alternate?” “How were you feeling before this?” “How long have you been feeling like this?” 3 Psychiatry

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

100 Loss of Interest: “What kind of activities do you do for pleasure? Do you still enjoy them? Or do you enjoy social activities and relationships, you used to enjoy?” Lack of Sleep: “How is your sleep? Do you have prob-lems with going to sleep or maintaining sleep? Do you wake up early in the morning and then find difficult to go back to sleep? Do you feel you are sleeping for longer duration than before?” Guilt: “Do you feel guilty/hopeless/worthless?” Decreased Energy: “Do you feel lack of energy? Do you feel tired?” Inability to Concentrate: “Do you have difficulty in concentrating?” Loss of Appetite: “Has your appetite changed recently?” Psychomotor Retardation: “Do you think that you have slowed down in your usual pace?” Suicide Ideas: (Very important in this station) “Do you have any plan to hurt yourself or others? Any previous attempt? Recurrent thoughts? Left a note?” Screen for Anxiety: Just one question Screen for Mania: Just one or two questions Screen for Psychosis: Just one question about delusions and one for hallucinations Screen for Organic Causes: Illnesses, drugs, or alcohol use related Past Medical History: Any previous health issues? Past Psychiatric History: Diagnosis, treatments, admis-sions, follow-ups, previous suicidal attempts Medication History: Antidepressant, anxiolytics, antipsy-chotics or any other medications and any side effects Family History and Family Psychiatric History Social History: Smoking, alcohol, drugs, sexual history Self-Care, Living Condition, and Relationships Work Conditions and Financial Status Support: Family and friends Wrap-Up: Management Plan: The wrap-up for the suicide station varies according to the clues gathered in the history. If the patient is still suicidal, still has an active plan or access to weapons or other lethal means, and has a known or suspected psychiatric disorder, then he needs admission and a psychiatric consultation as soon as possible with or without the patient's will. If the patient does not show any active plan and has no access to weapons or other lethal means and if he is ready to get further help, then offer him support and provide informa-tion about the community resources. Offer a family meeting or a social worker support. Discuss about the survival skills. Contract: Very important for this station. “In life, sometimes the circumstances can make people feel hopeless. In such circumstances people may feel very helpless and may think about hurting themselves or others. I would like you to promise me that you will immediately seek help if you have such thoughts again. You should talk to a family member or a friend or you should come to a hospital or to a clinic. ” Follow-Up: “We will arrange a psychiatric consultation for you and my clinic will call you about the appointment. ” History: Dementia Candidate Information: A 75-year-old female is brought by her son because of increasing forgetfulness for 1 month. Take a history and dis-cuss a management plan. Vital Signs: HR, 78/min, regular; BP, 140/80 mm Hg; temp, 36. 8; RR, 17/min; O 2 saturation, 98% No examination required for this station. Differentials: Long list of differentials. Some common ones are: Alzheimer's, Parkinsonism, and multi-infarct dementia Depression, pseudodementia Table 3. 5 Modified SAD PERSONS scale Points Sex male 1 Age <19 or >45 1 Depression 2 Previous attempt 1 Alcohol 1 Rational thinking loss 2 Separated 1 Organized plan 2 No support 1 Stated future intent 2 Total points: Score of ≥6 shows need for emergency psychiatric consult M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

101 Thyroid, DM Tumors, head trauma B12 or thiamine deficiency Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attend-ing physician for today. Are you Mrs....? You are 75 years old? How can I help you today?” History of Present Illness: “How did you notice that you are forgetting things?” “When did it start?” “Did it gradually or suddenly onset?” (sudden delirium, chronic Alzheimer's, or vascular) “Is it progressing with time or fluctuating or getting better?” “Is this your first time to have it?” “What forgetful problem do you have? Names, things, events, dates, maps?” “Is it recent or remote memory?” “Do you have difficulties in speaking or understanding words?” “Do you find problems doing purposeful movements, such as using objects?” “How is your sleep?” (fragmented) “Can you plan an event?” “How is your ability to make judgments?” Screening for Activities of Daily Living: “Can you dress yourself?” “Can you eat by yourself?” “Can you ambulate?” “Do you have any difficulty in using the toilet?” “Are you able to maintain hygiene yourself?” Screening for Instrumental Activities of Daily Living: “Can you do shopping by yourself?” “Can you do housekeeping by yourself?” “Are you able to run your bank account?” “Can you prepare food independently?” “Can you move around the town or use transportation independently?” “How is this affecting your life?”Differentials: “Any recent increase in thirst, eating, or frequent urination?” “Do you drink alcohol?” “Any problem with cold weather?” “Any change in bowel movements?” “Did you lose or gain weight recently?” “How is your appetite?” “Did you notice any fever?” “Do you have night sweating? Night fever?” “Are you on any special diet?” “Have you recently noticed any change in the color of your skin? Any pallor?” “Have you noticed heart racing?” “Do you have any weakness?” “Fatigue? Tingling numbness?” “Did you have any trauma to your head?” “How is your pee? Any burning while peeing?” “Have you had any problem in your vision, hearing, or your balance?” “I am going to ask you some screening questions about your mood. ” Mood Screening: “How is your mood these days?” Anxiety Screening: Are you the kind of person who worries a lot?” (Excessive fear) Psychosis Screening: “Do you see, hear, or smell things that others cannot?” “Do you sense things that are not actually there?” Screen for Organic Causes: Illnesses, drugs, or alcohol use related. Past Medical History: “Have you ever sought any medical advice before?” “When was the last time you went for a general checkup? How was it?” “Any previous health issues? DM, hypertension, thyroid problems, TIA, stroke?” Past Psychiatric History: Depression Medication History: Medications list and any side effects Family History and Family Psychiatric History: Dementia Social History: Smoking, alcohol, drugs, sexual history Self-Care, Living Condition, and Relationships Work Conditions and Financial Status 3 Psychiatry

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

102 Support: Family and friends Wrap-Up: Management Plan: “I would like to do a thorough clinical, neurological, and mental status examination. ” Blood Work: CBC, electrolytes, blood glucose, urea, creati-nine, liver panel, TSH, 12 leads ECG and CT/MRI of brain Describe the Diagnosis: “Based on this history of progressive forgetfulness, I think you have (name the dementia type). ” Here we will talk about Alzheimer's dementia. “Have you heard about it? Dementia is a chronic and progressive condition of our brain. Our brain is like a com-puter. It consists of cells that keep memory about our life. In some people with age, these cells start to lose their ability to function well. So we wouldn't be able to recollect or recall the memories related to our life. It may also affect language, recognition, abstract thinking, and planning. Unfortunately it is an irreversible disease. But there are some medicines to slow down the process. I need to send you to a neurologist. ” “Do you need any kind of assistance? I can arrange a social worker, home care if you want. You can contact sup-port group, adult day care facilities, and respite programs. ” Medication: “There is a medication called Aricept (start 5 mg then 10 mg/ day) to decrease the progress of the disease. SSRI for depres-sion. The side effects are GI upset, nausea/vomiting, weight changes, and sexual. ” “Your living environment should have things to help in orientation such as clocks and calendars. ” “It is better to write an advance directive (power of attor-ney/living will). No driving for now and I will also recom-mend a medical alert bracelet. ” Checklist: Dementia See Table  3. 6 for a checklist that can be used as a quick review before the exam. History and Counseling: Delirium Candidate Information: You are on a ward call. The nurse just called you to attend a 54-year-old male who had a laparotomy 2 days earlier for perforated appendicitis. He has been found in his room with very aggressive behavior. He is yelling at everyone and has pulled his IV lines and blood pressure cuff. Your colleague is attending the patient now. The patient's son is in the family room. Please take a relevant history and address his concern about his dad. Differentials: Long list of differential, most important ones for this particu-lar station are: Infections: Sepsis, UTI, pneumonia Withdrawal: Medicines, alcohol, or drugs Endocrine: Thyroid, DM Deficiencies: B12 or thiamine deficiency Table 3. 6 Dementia checklist Starting the station Knock on the door Enter the station Hand-wash/alcohol rub Greet the examiner and the patient Give stickers to the examiner if required or show your ID badge Sit on the chair or stand on the right side of the patient and start the interview Opening Introduction, greet, explain, position, and exposure/drape Make good patient rapport Start with an open-ended question Chief complaint Onset, course, content, and duration Questions to rule out common differentials such as Alzheimer's, Parkinsonism, and multi-infarct dementia, thyroid, DM, tumors, head trauma, B12 or thiamine deficiency Psychiatric symptoms screening Screen for depression Screen for anxiety Screen about delusions and hallucination Screen for organic cause Illnesses, medications, alcohol, drugs Safety check Self-harm or homicidal ideation or plan Self-care Past medical history Past psychiatric history Medication history Medications and any side effects Family history and family psychiatric history (dementia) Social history Smoking, alcohol, drugs, sexual history Personal history Living condition and relationships Work conditions and financial status Support Family and friends Wrap-up Describe the diagnosis Management plan: Told about laboratory tests and imaging Ask if any questions or concerns Follow-up appointment M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

103 Trauma: Head injury, pulmonary embolism, postoperative Metabolic: Hyponatremia, dehydration, acidosis, or alkalosis Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am doctor on duty doctor. Are you Mr....? You are the son of Mr....?” Chief Complaint: “My colleague, Dr...., is attending your dad now. To have a better understanding of the situation, is it alright if I ask you few questions about your dad's health?” History of Present Illness: “What happened?” “Was he becoming aggressive or angry?” “How did it start?” “Was it gradually or suddenly onset?” “When did it start?” “Did it progress, fluctuate, or get better with time?” “Is this his first time being like this?” “Did you notice that your dad is seeing things or hearing voices that do not exist?” “Did you notice that he was complaining about insects crawling on him?” “How was he on day 1 and 2 after the surgery?” “Was he talking well and recognizing everyone?” “Did he sleep last night or during the day?” “Does he have any recent or remote memory loss?” “Does he have any difficulties in speaking or understand-ing words?” “How is his ability to make judgments?” “I want to ask some screening questions. ” Differentials: Infections: “Any difficulties in peeing? Any burning while peeing?” “Any abdominal pain? Wound pain?” “Calf pain or swelling?” “Did you notice any fever?” “Any night sweating? Night fever?” “Any headache, nausea, vomiting or diarrhea, skin rash, red eyes?” “Any shortness of breath, cough?” DM: “Any recent increase in thirst, eating, or frequent urination?” Thyroid: “Any problem with cold weather?” “Any change in bowel movements?” “Did he lose or gain weight recently?” “How was his appetite?” Alcohol: “Does he drink alcohol?” Deficiency: “Is he on any special diet?” “Has he had any problem in his vision, hearing, or balance?” Anemia: “Have you recently noticed any change in the color of his skin—any pallor?” Trauma: “Did he have any trauma to his head?” “Recent surgery?” “I am going to ask you some questions about his mood. ” Mood Screening: “How is his mood these days?” Anxiety Screening: “Is he the kind of person who worries a lot?” (Excessive fear) Psychosis Screening: “Does he see, hear, or smell things that others cannot?” “Does he sense things that are not actually there?” Screen for Organic Causes: Illnesses, drugs, or alcohol use related Screening of Activities of Daily Living: “Can he dress himself?” “Can he eat by himself?” “Can he ambulate?” “Does he have any difficulty in using the toilet?” “Was he able to maintain hygiene himself?” Screening for Instrumental Activities of Daily Living: “Can he do shopping by himself?” “Can he do housekeeping by himself?” “Is he able to run his bank account?” “Can he prepare food independently?” “Can he move around the town or use transportation independently?” Past Medical History: “Has he ever sought any medical advice before?” “When was the last time he went for a general checkup? How was it?” “Any previous health issues? DM, hypertension, thyroid problems, TIA, stroke?” 3 Psychiatry

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

104 Past Psychiatric History: Depression Medication History: Medications list and any side effects Family History and Family Psychiatric History Social History: Smoking, alcohol, drugs, sexual history Self-Care, Living Condition, and Relationships Work Conditions and Financial Status Support: Family and friends Wrap-Up: Describe the Diagnosis: “Based on our discussion today, it looks like your dad is suffering from a medical condition called delirium. It is a common medical problem that is characterized by changes in the mental function of a patient. Its onset is often sudden. It is usually reversible and fluctuating with impairment of level of consciousness. Patients are found to be confused and aggressive or agitated. Sometimes, a patient may present to be drowsy, withdrawn, sleepy, or very quiet. They are not oriented with time and place. They may see things that are not there. They may lose control of their bladders or bowels. They usually have changes in their sleeping patterns. Some staying awake at night and some being drowsy during the day. It can be a serious manifestation of an underlying condi-tion. Older patients are seen more commonly. ” Question: Who is at risk of developing delirium? Answer: Patients who: Have depression Are very sick Are taking many medicines Have recent surgery Are known to have dementia Are 70 years old or more Question: What causes delirium? Answer: In older people some common causes of delirium: Withdrawal from medication or alcohol Infection Multiple physical illnesses Dehydration Severe pain Heavy alcohol consumption Question: How long does delirium last? Answer: “It usually only lasts for a few days but may per-sist for longer periods for weeks or even months. If delir-ium will not resolve quickly, it can lead to serious problems such as pressure sores, recurrent falls, and eventually lon-ger periods of stay in hospital or in the worst case even death. ” Management Plan: “Delirium is usually related to an underlying cause that can be medical illness. We can go now and discuss with my col-league who is attending your dad. We need to do a detailed neurological and mental status examination. I would also like to run some tests. ” Blood Work: CBC, electrolytes, blood glucose, urea, cre-atinine, TSH, lipid profile, and 12-lead ECG “We will treat him according to the underlying cause of delirium. It will also reduce the risk of complications. ” Follow-Up: “We can have another meeting, once I finish managing him. ” The Mental Status Examination (MSE) Candidate Information: You have been asked to perform a mental status examination on a 72-year-old female. Vital Signs: HR, 81/min, regular; BP, 150/85 mm Hg; temp, 36. 5; RR, 17/min; O 2 saturation, 98% No history or physical examination is required for this station. The mental status examination describes the physi-cian's impression of the patient's current mental, cogni-tive, perceptional, emotional, and judgmental status. It starts once you enter the room, greet the patient, and start introducing yourself to the patient. Mental status examina-tion consists of mostly observational findings and it may vary with time. Broadly, the examination can be divided into seven parts, which can be memorized with the mne-monic ASEPTIC: 1. Appearance 2. Speech 3. Emotional expression (affect and mood) 4. Perception 5. Thought (process and content) 6. Insight and judgment 7. Cognition M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

105 Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician. Are you... ? Are you 72 years old? I have been asked to complete 'the Mental Status Examination' on you. I shall be asking you few questions. Is it alright if I ask you some questions about it? At the end, I will address if you have any concerns. ” 1. Appearance (observational findings): Appearance: Observe the appearance of the patient, body habitat, hygiene, makeup, jewelry, dressing, physi-cal characteristics, body habitus, posture, grooming, facial expressions. Behavior: Look for patient body language. Observe if the patient is attentive, agitated, or has psychomotor retarda-tion. Observe if the patient responds to some visual or auditory hallucinations. Any abnormal movements such as tremors. Eye Contact: Poor, good, or avoidance Dress: Watch for cleanliness of the dress and whether matching with the weather. Wearing coat and sweater in summer! Cooperative: Cooperative, hostile, apathetic, open Face Expressions: No abnormal movements, tics or twitches, expressionless 2. Speech (observational findings while patient talking): Note how the patient is responding to the questions. Observe while asking the first few questions: Voice: Clear, slurred, mute Volume: Low or soft, normal, loud or high, mumbling, whispering Rate/Speed/Tone: Slow, pressured, rapid Rhythm: Monotonous, dramatic, staccato, accent, spontaneous 3. Emotional expression (affect and mood): Mood: Patient subjective expression (in patient's own words). Sad, depressed, angry, happy, guilty, irritable, calm, fearful, frightened, suspicious. Affect: It is physician's observation of the patient's mood. Look for the following: -Appropriateness to thought content -Quality: Depressed, anxious, elevated -Range: Full, flat, blunted, restricted -Stability: Fixed or labile 4. Perception: Hallucination: Sensory perception in the absence of external stimuli that should be similar to the true percep-tion. It can be visual, gustatory, olfactory, tactile. Illusion: Misperception of real external stimuli. Derealization: Subjective feeling of the outer environ-ment or the world as unreal. 5. Thought: Process: It is also assessed with the content of the patient's speech. Observe if thought process is normal, logical/illogical, appropriate, fragmented. How is the stream: circumstantiality, tangentiality, loosening, flight of ideas, or word salad. Content: It is assessed with the content of his or her speech. Should observe if there are any delusions, obses-sions, phobias, thoughts of homicide, or suicide. Obsession: Recurrent or persistent thoughts, impulses, or images that cannot be stopped that are intrusive or inappropriate. Suicidal or homicidal ideation: -Low: No formulated plan. -Intermediate: Well-formulated plan but no active intent. -High: Persistent ideations and profound hopelessness, well-formulated plan—active intent, believes suicide or homicide is only helpful option available. 6. Insight and judgment: Patient's inability to understand, such as awareness regarding their illness: “What is going on?” Note if the patient has some insight, no insight, or appro-priate insight into the problem. Judgment is assessed by directly asking the patient some questions, such as “How will you respond if you see a car accident?” Listen to the patient's response and then ana-lyze the response as good, fair, or poor judgment. 7. Cognition: Alertness or level of consciousness. Orientation: Time, place, and person. 3 Psychiatry

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

106 Memory: Recent, immediate, and remote. Attention and Concentration: Intact or impaired. Global Evaluation of Intellect: $10 is more than $5. Summarize Findings: At the end, the examiner will ask to summarize your find-ings. Here are few examples of how to summarize the mental status examination: 1. Normal Patient: The patient is well dressed, well groomed, and wearing clean clothes, appropriate for the weather. His appearance matches his chronological age. He has good eye contact and he is cooperative. He has no psychomotor retardation. His speech is of normal volume, tone, fluent, not slurred, and not pres-sured. His mood is “normal” and his thoughts are well orga-nized. He does not have any delusions or hallucinations. He does not have suicidal ideation or homicidal thoughts. He has good judgment and his insight is intact. He is alert and well oriented. 2. Depression Patient: Appearance: The patient looks overweight, female, dressed in a black shirt and black pants. Her hair is nicely groomed. She has good hygiene. Behavior: She has poor eye contact, cooperative and psy-chomotor retardation. Speech: Low rate and low volume. Affect: Tearful but appropriate. Mood: “Depressed. ” Perception: No visual or auditory hallucination. Thought (process): Linear, no flight of ideas. Thought (content): Suicidal but no active plan. Not homicidal. Insight: Poor. Judgment: Fair. Cognition: Grossly intact. 3. Patient with Mania: Appearance: The patient looks restless and hyperactive. He is dressed in a colorful shirt and red pants. His hair is nicely groomed. He has good hygiene. Behavior: He is hostile and uncooperative. Speech: High rate and increased volume. Affect: Euphoric and irritable. Mood: “Excellent. ” Perception: No visual or auditory hallucination. Thought (process): Flight of ideas, pressured. Thought (content): Grandiose delusions, feelings of having special power. No suicidal or homicidal ideas. Insight: Impaired. Judgment: Impaired. Cognition: Grossly intact. The Mini-mental Status Examination (MMSE) (Folstein) You have been asked to perform a mini-mental status exami-nation on a 72-year-old female. Vital Signs: HR, 81/min, regular; BP, 150/85 mm Hg; temp, 36. 5; RR, 17/min; O 2 saturation, 98% No history is required for this station and please do not perform rectal, genitourinary, or breast examinations. For mini-mental status, it is very important to memorize the key questions and to practice it before the real examina-tion. It is very easy to forget one or more of the questions, and then the whole trail of questions will be disturbed in the examination. I used to practice this by writing O10 R3 A5 R3 L9 in my blank paper and then start the questions. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr.... I am your attending physician. Are you... ? Are you 72 years old? I have been asked to complete 'the mini-mental status exam-ination' on you. I shall be asking you a few questions and also will ask you to perform some actions. I will mark you for every step we will complete. Once we finish, I will cal-culate your total score and we will discuss the results of this assessment. ” Orientation (Total Score 10): Time (5 Score): One point for each of: -Year: What year is this? -Season: What season are we in nowadays? M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

107 -Month: What month is this? -Date: What is the date today? -Day: What is the day of the week today? Score:__ /5 Place (5 Score): One point for each of: -Country: What country we are in? -Province/state: What is our province/state name? -City: What city are we in? -Street address or town or hospital name: What is your home street address or town? Which hospital you are in right now? -House number or floor number: What is house/floor number? -Score:__ /5 Write your score on the paper or let the examiner know: Orientation is... /10. Registration (Total Score 3): Immediate recall : 1 point for repeating each. Pick three words such as honesty, apple, and black. Ask the patient to repeat after you: honesty, apple, black. Score:__ /3 Write your score on the paper or let the examiner know: Registration is... /3 Attention and Calculation (Total Score 5): 1 point for backward spelling each of the letters of the word “WORLD” or ask the patient to count backward, subtract-ing 7 each time starting from 100. Stop after five times. 100, 93, 86, 79, 72, 65 Score:__ /5 Write your score on the paper or let the examiner know: Attention and calculation is... /5 Recall (Total Score 3): Ask the patient to recall the names of the three objects that you asked her/him to repeat above and score 1 for each corre ct name. Honesty, apple, black Score:__ /3Write your score on the paper or let the examiner know: Recall is... /3 Language (Total Score 9): Naming: Point to two objects, such as watch and pen/pencil, and ask the patient to name them. Score 1 for each correct name. Score:__ /2 Repetition: Ask the patient to repeat, “No ifs, ands, or buts. ” Allow only one trial. Score:__ /1 Three-stage command: Ask the patient to “Take a paper in your right hand, fold it in half, and put it on the floor. ” Score 1 for each part correctly performed. Score:__ /3 Reading: Write a phrase on a piece of paper such as “close your eyes. ” Ask the patient to read it and do what it says. Score 1 if eyes are closed. Score:__ /1 Writing: Ask the patient to make up a sentence about any-thing, but it should have a noun and a verb. Do not dictate a sentence and it must make sense. Correct spelling and punctuation are not necessary. Score:__ /1 Test of spatial ability (copying): Ask the patient to copy the figure exactly. All 10 angles and intersections must be present to score 1. Score:__ /1 Write your score on the paper or let the examiner know: Language score is... /9 At the end, calculate your score and let the examiner know. The mini-mental status is... /30. A total of score 24 or more is considered to be normal. 3 Psychiatry

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108 Checklist: Management of a Violent Patient See Table  3. 7 for a checklist that can be used as a quick review before the exam. Further Reading 1. Hurley KF.   Chapter 10. Psychiatry. In: OSCE and clinical skills handbook. 2nd ed. Toronto: Elsevier Canada; 2011. p.  283-299. 2. The Psychiatric Exam. Amy Ng and Julia Zhu, editors. Essentials of Clinical Examination, 6th. New York: Thieme; 2010. p. 317-334. 3. Jugovic PJ, Bitar R, Mc Adam LC.  Fundamental clinical situations: a practical OSCE study guide. Canada: Elsevier Saunders; 2003. 4. Gao Z-H, Howell J, Naert K (eds). OSCE & LMCC-II: Review notes, 2nd ed. Canada: Brush Education; 2009. 5. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed: USA: DSM-5. American Psychiatric Publishing; 2013. https://www. psychiatry. org/ psychiatrists/practice/dsm. 6. DSM-5. https://en. wikipedia. org/wiki/DSM-5. Accessed 17 Oct 2017. 7. Folstein MF, Robins LN, Helzer JE.  The mini-mental state exami-nation. Arch Gen Psychiatry. 1983;40(7):812. https://jamanetwork. com/journals/jamapsychiatry/article-abstract/493108 Accessed 17 Oct 2017. 8. Mini-mental state examination. https://en. wikipedia. org/wiki/ Mini%E2%80%93Mental_State_Examination. Accessed 17 Oct 2017. 9. Frankford RTS.   Mental status exam. Can Fam Physician. 1977;23:145. https://www. ncbi. nlm. nih. gov/pmc/articles/ PMC2379253/. Accessed 17 Oct 2017. 10. Martin DC.  Ch 207. The mental status examination. In: Walker HK, Hall WD, Hurst JW, editors. Clinical methods: the history, physical, and laboratory examinations. 3rd ed. Boston: Butterworths; 1990. Table 3. 7 Violent patient checklist Starting the station Knock on the door Enter the station Hand-wash/alcohol rub Greet the examiner and the patient Give stickers to the examiner if required or show your ID badge Opening Make sure of your safety and your staff (make sure you have an easy access to an exit door) Introduction and greet Try to establish a quick rapport Behave calmly. Try not to overreact Look for patient's body language and clues Consider cultural and language barriers Address the patient's anger Allow patient to vent verbally Ask direct questions to investigate the cause of patient's concerns: “Why are you so aggressive or angry? What is bothering you?” “What is going on with you?” “Is there anything you want to share with me?” Show him empathy Try to understand what he wants to communicate Clarify information if required Do not blame anyone to support the patient's ideas Redirect questions that challenge hospital policy or staff qualifications to the issues at hand Say you are there to help. Be supportive Once the patient settles, then he will start giving the answers. Go through the history as mentioned in the previous cases Chief complaint Onset, course, and duration Psychiatric symptoms screening Screen for depression, anxiety, mania, psychosis Screen for organic cause Illnesses, medications, alcohol, drugs Safety check Self-harm or homicidal ideation or plan Self-care Past medical history Past psychiatric history Medication history Medications and any side effects Table 3. 7 (continued) Family history and family psychiatric history Social history Smoking, alcohol, drugs, sexual history Personal history Living condition and relationships Work conditions and financial status Support Family and friends Physical examination Respect patient's personal space (stand off to the side of the patient at least a meter away) Ensure patient's privacy Vital signs Any signs of needles (IV drug abuse) or trauma Signs of trauma Patient may agrees: Perform a quick general physical activity, listen to chest, listen to heart sounds, observe and palpate abdomen. Tell the patient or examiner that you would like to draw a blood sample for routine blood tests, liver and kidney function, toxicology, drug levels, alcohol level If patient becomes violent: tell him that you will call security and will order for physical restraint. Need to admit against will, and will fill required forms M. H. Sherazi

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109 https://www. ncbi. nlm. nih. gov/books/NBK320/ Accessed 17 Oct 2017. 11. The royal children's hospital Melbourne. Clinical practice guide-lines: Mental state examination. https://www. rch. org. au/clinical-guide/guideline_index/Mental_state_examination/. Accessed 17 Oct 2017. 12. Monash University. Mental state examination examples. http://www. monash. edu. au/lls/llonline/writing/medicine/psychology/3. 1. xml Accessed 17 Oct 2017. 13. Simon C, Everitt H, van Dorp F, Burkes M.  Oxford handbook of general practice. 4th ed. Oxford: Oxford University Press; 2014. 3 Psychiatry

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111 © Springer Nature Switzerland AG 2019 M. H. Sherazi, E. Dixon (eds. ), The Objective Structured Clinical Examination Review, https://doi. org/10. 1007/978-3-319-95444-8_4The Cardiovascular System Mubashar Hussain Sherazi Common Cardiovascular Symptoms for the Objective Structured Clinical Examination For the cardiovascular system, common presenting symp-toms are [1]: Chest pain Shortness of breath (on rest, on exertion, when supine) Palpitation Light-headedness Fatigue Exercise intolerance Blue lips/fingers Cough Sputum Coughing up blood (hemoptysis) Wheezing History Overview: The Cardiovascular System In the objective structured clinical examinations (OSCE), you are likely to get at least one station related to the cardio-vascular system. Chest pain is the commonest and most important station. I must say, you should master all the pos-sible chest pain cases and should practice very well cardiac and non-cardiac chest pain cases with or without cardiovas-cular examination and management. This chapter outlines a few important cardiovascular cases. See Table  4. 1 for a quick overview of the cardiovascular system history. Physical Examination: The Cardiovascular System Candidate Information A 35-year-old male presented with chest pain for 3 days. Vital Signs Heart rate (HR), 71/min, regular; blood pres-sure (BP), 130/70 mm Hg; temp, 36. 8 °C; respiratory rate (RR), 16/min; O 2 saturation, 98% Please perform a detailed cardiovascular system examina-tion. Please do not perform rectal, genitourinary, or breast examination. No history is required for this station. Starting the Physical Examination Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your identification (ID). Now stand on the right side of the patient and start the examination. Opening “Good morning/good afternoon. I am Dr.... I am your attend-ing physician. Are you Mr....? And you are 35 years old? Is it alright if I examine your (heart) cardiovascular system and a general examination associated with it? During the exami-nation, if you feel uncomfortable, please let me know. Would you like a chaperone present in the room?” Vitals Start with commenting on the vitals given at the door. (They should include pulse rate, blood pressure, respiratory rate, temperature, and O 2 saturation. ) Comment on the vital signs findings, “vital signs are normal,” or mention any abnormal finding, such as “he has fever/tachycardia/tachypnea. ”M. H. Sherazi Mallacoota Medical Centre, Mallacoota, Victoria, Australia4

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112 Mention that you will measure his blood pressure on both arms while he is lying down, then sitting or standing after 2 min, in order to observe for any orthostatic changes. Mention that you will measure his blood pressure in both legs as well, by using a thigh cuff around the thigh and listen-ing to the popliteal artery. Mention that you are looking for postural hypotension and significant upper/lower extremities difference. Systolic BP decreases >15  mm Hg and diastolic BP decreases >0-10  mm Hg and/or heart rate increases more than 20 indicate orthostatic hypotension. It is seen in volume depletion and autonomic dysfunction [2]. General Physical Examination “I need to ask you a couple of questions as a part of my examination. ” (You may skip these questions if it is a history and physical station to save some time): “What is the date today?” “Do you know where you are now?” Comment: “Patient is oriented and alert,” “patient is in distress!”, or “patient is sitting comfortably and he is well oriented and alert. ” “I need to expose you from the neck down to the waist, is that alright?” If you think the patient is having difficulty taking off his/her shirt and requires help, then offer to help; Table 4. 1 Quick overview of the cardiovascular system history Introduction Name and age Chief complaint In patient's own words History of present illness Analysis of chief complaint: Chest pain is the most common presentation Onset Course Duration If pain: Nature Intensity (1-10) Location Progression Frequency Quality Radiation Severity (1-10) Timing Contributing factors Aggravating/alleviating factors Related symptoms Associated symptoms: nausea, vomiting, diaphoresis, shortness of breath, light-headedness, palpitation, fatigue, cough, exercise intolerance, leg pain Predisposing factors Aggravating and relieving factors Red flags/risk factors Rule out differential diagnosis Review of systems: Gastrointestinal tract Respiratory Neurology Risk factors for atherosclerotic heart disease Smoking Hypertension Hyperlipidemia Family history of heart disease Lifestyle (active vs. sedentary) Constitutional symptoms Anorexia, chills, night sweats, fever, lumps/bumps, and weight loss Past medical history and surgical history Medical illnesses Any previous or recent medical issues History of previous surgery/operation Hospitalization history or emergency admission history Medication history-current medications (prescribed, over the counter, and any herbal) Allergic history/triggers-any known allergies Family history Family history of any long-term or specific medical illness Home situation Occupation history What do you do for a living?Table 4. 1 (continued) Social history Smoking Alcohol Street drugs Sexual history If adult female: Menstrual history (LMP) Gynecology history Obstetric history If teen: Home Education Employment Activities Drugs Sexual activity Wrap-up Describe the diagnosis Management plan Possible medical treatment Duration of treatment and side effects Laboratory tests Further information websites/brochures/support groups or societies/toll-free numbers Follow-up M. H. Sherazi

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113 otherwise, let him do it. Drape the patient appropriately if required. Observe for posture, distress, sweating, skin color, diffi-culty in speaking, attached oxygen mask, any medications in patient's hand or at bed side, or attached intravenous (IV) lines (Fig.  4. 1). Hands “Now I would like to examine your hands. ” Observe for color, palmar erythema, peripheral cyanosis (blue fingers, toes), nicotine stain, clubbing, muscle wasting (thenar), contractures (Dupuytren's), Janeway lesions (if with fever), splinter hemorrhages (look all fingers and nail beds), and Osler nodes (Fig.  4. 2a-c). Capillary Refill “I am going to squeeze your thumb/index finger. ” Press on the nail bed and release while looking on your watch: < 3 s (Fig.   4. 3). Inform the examiner that the capillary refill is nor-mal and less than 3 s. Face Color of face, plethora, central cyanosis, cushingoid/ moon face, mitral face (red cheeks in mitral stenosis). Sinuses: Check for tenderness of maxillary and frontal sinuses. Nose: Flare or perforated septum. Lips: Pursed lips. Mouth: Moist tongue, ulcers, thrush, or central cyanosis (blue lips and buccal mucosa: SO2 < 80%). Have the patient speak a sentence for hoarseness. Eyes: -Ptosis (Horner syndrome). -Pallor. -Jaundice. -Xanthelasma: yellow lipid deposition on upper and lower eyelids.-Senile arcus: yellow lipid deposition in cornea at its margins with conjunctiva. -Conjunctival hemorrhages. -Fundoscopy: Just mention, “I will look for copper wires, soft/hard exudates, Roth spots, erythematous lumps, and emboli in the retinal arteries. ” Neck “I am going to feel your neck now. ” Trachea: Position (central or mid line) and mobility. Fig. 4. 1 Observing the patient a cb Fig. 4. 2 (a, b) Hand observation. (c) Check for clubbing of fingers 4 The Cardiovascular System

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114 Tracheal deviation will be away from the contralateral pneumothorax or effusion. Fixed trachea: Mediastinal tumor and tuberculosis. Jugular Vein Distention (JVD) or Jugular Venous Pressure (JVP) Jugular venous pressure (JVP) is a direct assessment of cen-tral venous pressure (right atrial pressure). Position the patient at 30° and ask the patient to turn his head slightly to the left. Then adjust the elevation up to 45° until pulsations are seen: Look between the two heads of the sternocleidomastoid muscle (at the sternal head of the clavicle) for pulsations. If it will be difficult to observe, then try shining a light tangentially across the right side of the neck and look for shadows of pulsations. Determine JVP by measuring the vertical distance from the sternal angle to a horizontal line from the top of the jugular pulsations. Note the waveform: Normally double waveform. Observe Kussmaul sign: Only if JVP is high. It is checked by asking patient to take a deep breath in and observe for change in JVP. Hepatojugular reflex: check only if the JVP is high. For further assessment of a high JVP and to find out if the high JVP is due to right ventricle dysfunction and not due to superior vena cava obstruction, ask the patient to breathe quietly from his mouth and push moderate pres-sure (25-30  mm Hg) over the liver at the right upper quadrant (RUQ) with your hand and keep it for about 10 s. A sustained elevation of the JVP height for >4 cm for 10 s is abnormal. Fig. 4. 3 Checking capillary refill a cb Fig. 4. 4 (a-c) Chest wall palpation M. H. Sherazi

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115 Chest Inspection: Inspect chest. Comment on: -Contour: symmetrical or not symmetrical (normally AP diameter < lateral diameter) -Shape: normal or barrel/funnel/pigeon chest (kyphosis or scoliosis) -Skin: no surgical scars or dilated veins Observe for abnormal pulsations: -Look at the apex, right and left second intercostal space, right and left lower sternal border. -Observe for intercostal retraction. -Note for precordial pulsation. -Observe for epigastric pulsations. Palpation: -Warm up your hands. -Feel the chest wall. -Note any area of tenderness by compressing the chest from side to side and front to back for tenderness (Fig.  4. 4a-c). Ask the patient to lie down supine. Palpable heart sounds (Figs.  4. 5 and 4. 6): -Aortic valve area: (abnormal findings) systolic impulse noted in systemic hypertension and dilated aortic aneurysm. -Pulmonary valve area: (abnormal findings) systolic impulse noted in pulmonary hypertension -Tricuspid valve area: (abnormal findings) Thrill or heave noted in right ventricle enlargement -Mitral valve area: (abnormal findings) Thrill or heave noted in left ventricle enlargement Heaves: Use your finger pads. -Feel for lifts in left parasternal area: use your finger pads. Seen in right ventricle hypertrophy, severe left ventricular hypertrophy. -Thrills: Palpable murmur of loud intensity >3/6 -use the heel of your hand. -Look for implanted pacemakers/defibrillators - usually inferior to the left clavicle. Palpate the apex beat in supine or better felt in the left lateral position. -In the left 5th intercostal space mid clavicular line. -Displaced inferior or laterally in cardiomyopathy. Percussion: Not done for cardiovascular system examination. -Increased cardiac dullness: Pericardial effusion -Decreased cardiac dullness: chronic obstructive pul-monary disease (COPD) Auscultation: Warm up the stethoscope (by rubbing with your palm). “I am going to listen to your heart now. ” -Please listen over five areas starting from the right 2nd intercostal space, left 2nd intercostal space, right lower sternal border, left lower sternal border, and then the apex (Fig.  4. 7 and Table 4. 2). -Listen in the following positions: Supine: Focus on identifying S1 and S2 first and then listen between systolic and diastole (Fig.   4. 8). Fig. 4. 5 Palpating for heart sounds Thrill Ascending aor tic aneur ysm Thrill RV heave Thrill Palpab le P2 Thrill Ape x beat/PMI Left atr ial enlargement Fig. 4. 6 The aortic, pulmonary, mitral, and tricuspid areas should all be palpated as different pathologies can be felt at each location. MCL midclavicular line, A aortic, P pulmonary, M mitral, T tricuspid. (Reprinted with permission from Kusko and Maselli [11]) 4 The Cardiovascular System

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116 Aortic area: second r ight intercostal space Pulmonic area: second left intercostal space Erb's Point: third left intercostal space (left ster nal border) Tricuspid area: fourth left intercostal space (left lo wer sternal border) Mitral area or ape x: fifth left intercostal space (midcla vicular line)Fig. 4. 7 Schematic of the five discrete areas for cardiac auscultation: (1) aortic valve at the second left intercostal space, (2) pulmonic valve at the second right intercostal space, (3) both semilunar valves at the third left intercostal space, (4) tricuspid valve at the fourth left intercostal space, and (5) mitral valve at the heart's apex. (Reprinted with permission from Kusko and Maselli [11]) Table 4. 2 Heart sounds Heart sound Description What the sound represents S1 First sound -sounds like “lub”Mitral M 1 and tricuspid T 1 valves closing S2 Second sound -sounds like “dub”Aortic A 2 and pulmonary P2 valves closing OS Opening snap Stenotic mitral valve opening S3 Third sound -present in some normal individuals, particularly children Diastolic filling gallop or V or protodiastolic gallop S4 Fourth sound -usually abnormal Atrial contraction creating an atrial or presystolic gallop Fig. 4. 8 Heart sound auscultation Upright (using diaphragm of stethoscope): Listen to the above five areas (Fig.  4. 9). Sitting upright, leaning forward, and holding exhalation: Increases aortic stenosis, aortic regur-gitation, and pericardial rub. Left lateral decubitus: Ask patient to turn half-way away from your side. (Now switch to bell side of stethoscope. ) Listen over the apex (Fig.   4. 10). Listen for S3, S4, and mitral stenosis. -Murmurs: If present, describe: Timing: systolic, diastolic, or continuous Shape: crescendo, decrescendo, crescendo- decrescendo, or plateau Location: of maximum intensity Radiation: axilla, back, or to the neck Quality: blowing, harsh, rumbling, musical, machin-ery, scratchy Duration Intensity: out of 6 (not an indication of clinical severity) Pitch: high, medium, or low Relationship to respiration -Peripheral bruit: Listen for carotid bruit (Fig.  4. 11). -Listen for the abdominal aorta. -Auscultate for renal bruit: 5 cm above the umbilicus and 5 cm to either side from the mid line. -Auscultate on iliac arteries. Below the umbilicus on both sides. -Just mention that you would auscultate the femoral arteries. Listen to the lungs: Ask the patient to sit up, listen to the anterior lung then posterior and lastly the bases for crackles. Peripheral edema: -While the patient is sitting and you are listening to the back of the chest, check for sacral edema. -Sacral edema: Press against sacrum (Fig.  4. 12). -Ankle edema: Press against the tibia bilaterally (Fig.  4. 13). M. H. Sherazi

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117 Peripheral pulses: Feel for various pulses and comment on: -Rate -Rhythm-Contour -Amplitude (volume) -Symmetry Radial pulse: Check both at the same time and count for 30 s (Figs.  4. 14 and 4. 15). Carotid pulse: Inform the patient that you will be feeling the pulse in the neck (Fig.  4. 16). Femoral artery pulse: -Just mention that you would feel both at the same time. -Also check for radio-femoral delay: One side only. Popliteal artery pulse: -Just mention. -Check pulse behind the knee; use both your hands' fin-gers under the knee at the same time holding the leg with the thumbs at the sides while lifting the knee 10-20°. Posterior tibial artery: -Just mention. -Palpate behind and slightly below the medial malleo-lus. Both legs at the same time with both your hand fingers. Fig. 4. 9 Heart sound auscultation Fig. 4. 10 Auscultation of left lateral decubitus Fig. 4. 11 Listening for carotid bruit Fig. 4. 12 Check for sacral edema Fig. 4. 13 Check for ankle edema 4 The Cardiovascular System

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118 Dorsalis pedis artery: -Palpate the dorsum of the foot at the lateral to the extensor tendon of the big toe. Both legs at the same time with both your hands' fingers. Wrap-Up Thank the patient and ask the patient to dress. Ask the patient if he has any question or has any concern. Wrap up your findings with the examiner or the patient. History and Management: Acute Chest Pain Candidate Information A 45-year-old male is brought in by ambulance to the emer-gency department, with left-sided chest pain for about 1 h. Manage this case. There is a nurse in the room to assist you. Differentials Cardiovascular system: Acute coronary syndromes Aortic dissection Myocarditis Pericarditis Stable and unstable angina Aortic stenosis Gastrointestinal system: Biliary colic Gastroesophageal reflux Esophageal spasm Peptic ulcer disease Hiatus hernia Acute cholecystitis Boerhaave's syndrome (perforated esophagus) Respiratory system: Pneumonia Pulmonary embolism Pulmonary infarction Pleurisy Pleural effusion Tension pneumothorax Rib fractures Bronchiectasis Tuberculosis Empyema Subphrenic abscess Musculoskeletal pain: Chest wall pain Costochondritis Fig. 4. 14 Check radial pulse Fig. 4. 15 Comparing both radial arteries at the same time Fig. 4. 16 Checking the carotid pulse M. H. Sherazi

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119 Thoracic radiculopathy Texidor's twinge (precordial catch syndrome) Psychiatric: Anxiety Panic attack Somatization Cocaine ingestion (important for OSCE) Sympathomimetic ingestion Trauma: Rib fractures Skin related: Shingles Starting the Station Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner, the nurse, and the patient. Give stickers to the examiner (if required) or show your ID badge. Now stand on the right side of the patient and start. Opening Triage immediately. Call the patient's name and check the response and immediately tell the examiner about your find-ings. If patient is conscious and stable, then introduce your-self to the patient: “Good morning/good afternoon. I am Dr.... I am your attending physician for today. Are you Mr....? And you are 45 years old?” Ask the nurse for vital signs -interpret the vital signs: Temp: 37. 5 °C HR: 78 Blood pressure: 130/75 RR: 17 Mention to Examiner: “I Will Start by Assessing the Airway, Breathing and Circulation (ABCD)” Airway: -Is the airway patent? -Comment on airway. -If patient talking well, then mention that airway is patent. Breathing: -Is the patient breathing? -Check respiratory rate.-Pulse oximetry. -If oxygen saturation is low, then consider delivering high-flow oxygen 15  L/min via reservoir mask and titrate to achieve oxygen saturation (S p O2) 94-98%. -Listen to the chest and heart. Circulation: -Check pulse, BP. -Ask the nurse to please pass a large-bore cannula (G14/G16). -Ask the nurse to get you a 12-lead electrocardiograph (ECG). Usually in an OSCE, patient is stable enough to go ahead with the history. History of Present Illness Start with chest pain questions. Pain questions: -Onset: “When did the pain start?” -Course: “How did it start (suddenly or gradually)?” -Duration: “How long do you have this pain?” -Location: “Where does the pain start?” Then clarify the area. -Character: “What is the nature of the pain?” -“Did the paramedics give you a tablet to be kept under your tongue?” -Progression: “Is the pain progressing?” -Radiation of pain: “Left shoulder, left arm, left side of jaw, or neck?” -Severity: “From 0 to 10, 10 being the worst pain and 0 as no pain, how is your pain now?” -Aggravating: “Anything that increases the pain? Exercise/exertion? Movements? Deep inspiration? Lying down? Eating?” -Alleviating: “Anything that relieves the pain? Rest? Glyceryl trinitrate? Antacid? Sitting forward?” Associated symptoms: Nausea, vomiting, sweating, shortness of breath, dizziness, heart racing -Have you been under stress recently? -Cough with blood stained sputum. Gastroenterology: -Acidic/metallic taste in the mouth -Heart burn -Difficulty in swallowing -Known stomach ulcer problem Musculoskeletal: -“Have you had any trauma to the chest?” 4 The Cardiovascular System

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120 -“Were you recently pulling and pushing heavy weights?” -“Are there any blisters on chest?” Respiratory system: -“Did you have any flu recently?” -“Cough with phlegm?” Risk Factors “I need to ask you more question for additional information that could be related to your pain right now. ” Ask about (explore each only if it is present otherwise move on): High blood pressure. Diabetes mellitus. High cholesterol. Cigarette smoking. Alcohol. Recreational drugs. Ask specifically about taking cocaine. Obesity. Physical inactivity. Family history of premature cardiovascular disease (men < 55 years and for females less than 65). Stress (at work, at home, relationship). Past Medical History Any previous health issues? Previous coronary artery disease (CAD), COPD, and previous hospi-tal admissions? Medication History Blood pressure medication, aspirin, blood thinners, nitroglycerine? Any other medication? OTC medications? Herbal remedies? Allergic History “Do you have any known allergies?” Family History Hypertension, diabetes, heart attacks, stroke? Social History Smoking, alcohol, drugs (ask only if missed in risk factors), sexual history Now Back to Management (Check and Follow Your Regional and Hospital Guidelines) You may need to read an ECG (Fig.   4. 17a, b). (If the ECG will be normal, then mention that you will wait for troponin results. ) Read the ECG carefully and then mention your find-ings to the examiner: Anterolateral myocardial infarction (MI). Initiate and follow the regional non-ST-elevation myocar-dial infarction (NSTEMI) or ST-elevation myocardial infarc-tion (STEMI) pathway: Ask nurse to put continuous cardiac monitoring. Ask nurse to please give sublingual nitroglycerin (check for allergies and contraindications). If the patient is in severe pain, ask the nurse to please bring 5-10 mg of morphine, and inform the patient that you have ordered some pain medication. Ask the nurse to please draw blood samples for full blood count, troponin, electrolytes, urea, creatinine, liver function (you can send blood in C part of initial assess-ment ABCD). Order a portable X-ray of the chest. Chest radiography may help to identify the etiology of symptoms of chest pain syndrome. Inform the patient about the diagnosis that he is having a heart attack and you need to consult a cardiologist imme-diately. (The goal for thrombolytic treatment is a door-to- needle time of 30  min or less. The goal for primary percutaneous coronary intervention [PCI] is a door-to- dilatation time of 90 min or less. ) Order fluids and inotropes if the patient is in hypotensive. Mention that you will complete your examination now: Patients with STEMI or persistent symptoms of a cardiac origin should be evaluated for emergent mechanical reperfusion or fibrinolytic therapy. If there is still time left, then continue with asking about contraindications for the use of thrombolytic agents. Order aspirin and clopidogrel (loading dose -check aller-gies and any particular contraindication and order with cardiology consultation). Order heparin (80 units/kg bolus, 18 units/kg/h infusion) or enoxaparin (1 mg/kg q12 h subcutaneously) with the consultation of cardiology. Ask the patient if he wants to inform someone: friend or family member. Tell him that he will be admitted to the cardiology unit. Thank the examiner, nurse, and patient. History and Physical Examination: Palpitation Candidate Information A 34-year-female presents with heart racing for 5  weeks. Please take a focused history and perform a relevant physical examination. Differentials Cardiac: Sinus tachycardia, supraventricular tachycar-dia, rapid atrial fibrillation, or ventricular tachycardia Congenital: Wolff-Parkinson-White (WPW) syndrome M. H. Sherazi

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121 Metabolic: Fever, anemia, hypo-/hyperthyroidism, acro-megaly, hypokalemia, or hypomagnesemia Hyperthyroidism: Graves' disease, subacute thyroiditis, Hashimoto's thyroiditis, toxic multinodular goiter, or toxic adenoma Psychiatric: Sympathomimetic withdrawals, anxiety dis-order, or panic attack (time duration) Neoplastic: Pheochromocytoma Medication: Antidepressants, antiemetics, antidysrhyth-mics causing long QT a b Fig. 4. 17 (a) Acute anterolateral infarction; inferior infarct age indeterminate. (Reprinted with permission from Khan and Marriott. [12]. (b) Acute anterior MI caused by ostial occlusion of the LAD.  Anterolateral ST-segment elevation. Reprinted with permission from Romanò [13]) 4 The Cardiovascular System

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122 Starting the Interview Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening “Good morning/good afternoon, I am Dr.... I am your attend-ing physician for today. Are you Miss... ? Are you 34 years old?” Chief Complaint “Can you please tell me what is going on?” The patient will tell you about her symptoms. History of Presenting Illness “How long has it been going on?” “How has this problem come about? (suddenly versus gradual)” “Is this the first time or has it happened before?” “When did you first notice these symptoms?” “What was the duration of the attack?” “How long does each episode last?” “Are these progressing?” “How often do you notice these symptoms? (intermittent vs. constant)” Ask the patient to tap with their fingers the heartbeat (reg-ular or irregular). “Do you miss a beat?” “Do you feel your heart is racing?” “Do you feel that your heart is slowing down?” “On a scale of 1-10, how has it affected the quality of your life?” “Does it occur even at night?” “Which symptoms getting worse?” “What makes it worse? (Coffee, recreational drugs, stress, smoke, chocolate, or alcohol)” “Anything that makes it better? (Valsalva maneuver, med-ication, or carotid massage)” “How was your health prior to the palpitations?” Associated Symptoms Cardiovascular and respiratory system: Chest pain, shortness of breath, orthopnea, dizziness, sweating, swell-ing of feet, and cough. Nervous system: Weakness, paralysis, vision loss, diffi-culty in finding words or loss of sensation. Thyroid related: History of thyroid problem? Hypothyroid/hyperthyroid. “Have you noticed any swelling in the neck?” (goiter). Weight loss? How much? Over what duration of time? “Do your clothes still fit you?” “How is your appetite?” (usually good or even increased). Heat intolerance? How severe? Accelerated heart rate or palpitations? “Do you feel irritable?” Muscle weakness and trembling? “Did you notice that your hands shake or do you have tremors in your hands?” “Have you noticed any change in bowel habits? Diarrhea?” Sweating? Nervousness, agitation, and anxiety? Changes in menstruation, including scantier flow and increased cycle length? Last menstrual period? “Do you have any swelling in your legs?” (pretibial myxedema). Itching? “Did you notice any change in your eyes? Bulging?” “Did you notice any change in your vision? Double vision? Staring gaze?” Pheochromocytoma: Repeated headaches, high blood pressure, heavy sweating, rapid heartbeat (tachycardia), tremors, pallor, and shortness of breath [3]. Constitutional Symptoms: Fever, chills, night sweats, anorexia. Past Medical History “Do you have any previous health issues? Heart disease, thyroid disease, rheumatic fever?” Hospitalization History or Emergency Admission History “Do you have any previous hospitalization or pre-vious surgery?” Medication History Current medications? Cold medication, asthma medication, anti-angina, antihy-pertensive, diuretics, anti-arrhythmic? Prescribed, over the counter, and any herbal? Allergic History “Do you have any known allergies?” Family History “Does anyone in your family have similar symptoms or similar health problem?” Social History “Do you smoke? Do you drink alcohol?” If yes, then fur-ther ask, “How much? Daily? How long?” “Have you ever tried any recreational drugs?” Relationships “Are you sexually active? Do you have sex-ual preferences? Men/women or both?” M. H. Sherazi

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123 Self-Care and Living Condition “What do you do for a living? Who lives with you?” Support “Do you have good family and friends support?” Impact on Life/Disability and Adaptation Effects on life. “Any effect on your daily activity?” Physical Examination “Now, I will start the examination. ” Comment on the vital sign findings: check for presence of tachycardia, heart rhythm, and respiratory rate. Atrial fibrillation? Fever? Check level of consciousness, alertness, and orientation. General Physical Examination Now start with observation and evaluating body habitus and nervousness/anxiousness. Further observe for anx-ious facial expressions. Skin: Look for color, texture, and moisture. Hands: Feel the hands for any sweating. Look for tremors. Cardiovascular Examination Palpate peripheral pulses. Note: pulse volume, contour, and rhythm. Auscultate. Respiratory System Inspection: Check chest expansion and percussion. Auscultate: Breath sounds and adventitious sounds. Neurology Examination Note for tremors. Motor power. Muscle tone (proximal myopathy). Sensations. Reflexes (hyperreflexia may be present). Thank the patient and ask the patient to cover up. Wrap up your findings with the examiner or the patient. History and Physical Examination: Heart Failure Candidate Information A 74-year-old male presents to the emergency department with worsening shortness of breath and swelling in the legs. He is known to have heart failure. Please take a detailed his-tory and perform the relevant physical examination. Differentials [4] Cardiovascular -Congestive heart failure (CHF) -Acute coronary syndrome -Acute valve dysfunction -Aortic dissection -Endocarditis -Hypertensive emergency -Pericardial tamponade Pulmonary -Pneumonia -COPD -Pulmonary embolism -Pneumothorax -Emphysema -Massive atelectasis -Large pleural effusion -Interstitial pulmonary fibrosis V olume overload -Renal failure -Cirrhosis -Posttransfusion Sepsis Causes of Congestive Heart Failure Decompensation [5] Acute coronary syndrome Acute valve dysfunction Arrhythmias Uncontrolled hypertension Fluid overload Inappropriate medications (e. g., negative inotropes) Medication noncompliance Anemia Dietary noncompliance Infection Thyrotoxicosis Alcohol withdrawal Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Triage Immediately Call patient name and check patient's response and immediately tell the examiner about your find-ings. If patient is conscious and stable, then introduce your-self to the patient: “Good morning/good afternoon. I am 4 The Cardiovascular System

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124 Dr.... I am your attending physician for today. Are you Mr....? And you are 74 years old?” Ask for a set of vital signs (usually given outside on the doorway information) -interpret the vital signs: Temp: 37. 5 °C HR: 72 Blood pressure: 155/75 RR: 17 Mention to Examiner: “I Will Start Assessing the Airway, Breathing and Circulation (ABCD)” Airway -Is the airway patent? -Comment on the airway. -If the patient is talking well, then mention that airway is patent. Breathing -Is the patient breathing? -Check respiratory rate. -Pulse oximetry. -Deliver high-flow oxygen 15 L/min via reservoir mask and titrate to achieve oxygen saturations (S p O2) 94-98%. -Listen to the chest and heart. Circulation -Check pulse and BP. -Ask the nurse to please pass a large-bore cannula. -Ask the nurse to get you a 12-lead ECG. Mention that “my patient is stable enough to go ahead with the history. ” History of Present Illness Start with shortness of breath. Ask, “I understand you are here for shortness of breath, how are you doing now?” Is the patient able to speak? If the patient is speaking and does not show any signs of restlessness or shortness of breath, then continue with the history. “Are you comfortable sitting? I want to ask you some questions about your shortness of breath? Should we start?” “What do you mean by shortness of breath?” Difficulty in breathing, not enough air, chest pain, chest tightness? “When did it start?” “How did it start? Was it a sudden onset or gradual?” “Does it come and go or is it progressive?” How long has it been going on? If acute onset “Can you please tell me what happened?” “What were you doing at that time?” “Were you doing any physical exertion or lying or sitting?” “How severe is your shortness of breath now on a scale of 1 to 10, with 1 being mild and 10 being the worst?” “Has it got worse recently?” “Have your legs ever been swollen?” “What did you do once you became short of breath?” “Was there any wheezing?” “Did you notice any chest tightness?” “Any sweating? Did you turn blue? Did you notice your heart racing? Does it get better or worse? Were you able to talk? Did you pass out/lose consciousness?” “Did you notice any frothy sputum?” “Did you have to go to the ER?” “Were you intubated or put on a breathing machine? Did they give you any medicine? What medicines? Did they give you any discharge medication?” If gradual onset “In which setting does it come on: minimal activity, walk-ing (how far), running (for how long), taking stairs (how many flights), cold, stress, at rest, lying flat?” “Does it cause you to wake up at night?” “Has it been getting worse recently?” “How many times in a day or in a week does this occur?” “Are you already taking medications such as a puffer or any other medication for your shortness of breath?” (If patient's history suggests asthma or any other differential, then continue with the specific history instead of short-ness of breath. ) Cough If shortness of breath with cough: “When did your cough start?” “Did it start gradually or suddenly?” “Is it continuous or does it come and go?” “Is the cough present all the time or at any specific time (day/night)?” “Does your cough present with any certain position?” (Lying down?). “Is it accompanied by phlegm?” -If phlegm present then (consistency, odor, color, amount, blood) “What increases or decreases this cough?” Associated symptoms “Do you have pain anywhere in the body? Joint pain? Pain in your legs?” “Any recent travel?” “Any fever? Chills? Night sweats?” “Any weight loss?” “Any loss of appetite?” M. H. Sherazi

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125 “Any swelling in your ankles?” “How is this affecting your daily activity?” Precipitating or Aggravating Factors “I will ask you some questions that will guide me to why you have shortness of breath. ” (Choose questions according to the history. ) “Do you suffer from heartburn or gastroesophageal reflux disease (GERD)?” “Have you recently experienced (up to 10 weeks) any flu-like symptoms or chest infection?” “Does the shortness of breath come on with exercise?” “Any recent stress or emotional triggers?” “Any exposure to cold air, odor, dust, smoke, or pollen?” “Do you, or anyone around you, smoke?” “Have there been any recent changes in your home envi-ronment? Paints, carpets, linens, pillows, blankets, cur-tains, pets, plants, or renovations?” “Do you have any mold in your home or workplace?” “Do you have any exposure to chemicals at your work site?” Relieving Factors “Does anything relieve your symptoms?” Constitutional Symptoms Fever, chills, night sweats, anorexia Risk Factors for Cardiovascular Disease “I need to ask you more questions for additional information that could be related to your symptoms. ” Ask about (explore each only if it is present otherwise move on): High blood pressure? Diabetes mellitus? High cholesterol? Cigarette smoking? Alcohol? Obesity? Physical inactivity? Family history of premature cardiovascular disease (men <55 years and for females less than 65). This patient is 74 years old, so this question may be skipped. Past Medical History “Do you have any previous health issues?” “History of ischemic heart disease, valvular disease, peripheral vascular disease, stroke or malignancy?” [6]. Medication History Current medications? Cold medication, asthma medication, anti-angina, antihy-pertensive, diuretics, anti-arrhythmic? Prescribed, over the counter, and any herbal? Hospitalization History “Do you have any previous hospi-talization or previous surgery?” Allergic History “Do you have any known allergies?” Family History “Does anyone in your family have similar symptoms or similar health problems?” Social History “Do you smoke? Do you drink alcohol?” If yes, then ask further questions, on “How much? Daily? How long?” “Have you ever tried any recreational drugs?” Relationships “Are you sexually active? Do you have sex-ual preferences? Men, women, or both?” Self-Care and Living Condition “What do you do for a living? Who lives with you?” Support “Do you have good family and friends support?” Impact on Life/Disability and Adaptation Effects on life? “Any effect on your daily activity?” Physical Examination “Now, I will start the examination. ” Comment on the vital sign findings. Check level of consciousness, alertness, and orientation. General Physical Examination Evaluate body habitus, observe for signs of respiratory distress or apparent cachexia. Skin: Look for color, texture, and moisture. Note any sweating, cyanosis, or pallor. Mouth: Central cyanosis. Trachea: Position. Hands: Feel the hands for any sweating. Check capillary refill. Is there any clubbing? Cardiovascular Examination Palpate peripheral pulses. Note: pulse volume, contour, and rhythm. Pulses may be decreased or pulsus alternans may be present. JVP and hepatojugular reflux (increased venous pressure in CHF). Apex beat may be displaced in left ventricular hypertro-phy. Palpate for thrills and heave. Auscultate (S3 or a murmur). 4 The Cardiovascular System

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126 Respiratory System Inspection: Check chest expansion and percussion. Assess tactile fremitus. Decreased tactile fremitus and flat percussion indicates pleural effusion. Auscultate: Breath sounds and adventitious sounds. Inspiratory crackles heard in pulmonary edema or expira-tory wheezes (cardiac asthma). Abdomen Inspect for ascites. Percuss for shifting dullness and fluid thrill. Assess liver span. Palpate liver and spleen. Palpate pitting edema over tibia and presacral area. Wrap-Up Thank the patient and ask the patient to cover up. Wrap up your findings with the examiner or the patient. Question “What is heart failure?” Answer “Heart failure is a condition in which the heart is unable to generate a cardiac output sufficient to meet the demands of the body without increasing diastolic pressure. It can result from any cardiac disease that compromises ven-tricular systolic or diastolic function or both. The term “con-gestive heart failure” is reserved for patients with breathlessness and abnormal sodium and water retention resulting in edema. Heart failure comprises a wide range of clinical scenarios, from patients with normal left ventricular ejection fraction (LVEF) >50% to those with reduced myocardial contractility (LVEF<40%) [7]. Question “What investigations will you order?” Answer CBC (rule out anemia) Urea, creatinine, and electrolytes B-type natriuretic peptide (BNP) ECG X-ray chest: -Kerley B lines (thick and horizontal engorged lym-phatic vessels) -Interstitial edema -Pulmonary venous congestion -Pleural effusion -Alveolar edema/infiltrates -Cardiomegaly Troponin/CK Ultrasound Formal transthoracic echocardiogram Standard exercise stress testing History and Physical Examination: Hypertension -A Routine Checkup Candidate Information A 55-year-male with known hypertension presented to your GP clinic for a routine checkup. Please take a history and perform the relevant physical examination. Starting the Interview Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening “Good morning/good afternoon. I am Dr.... I am your attend-ing physician for today. Are you Mr....? Are you 55 years old?” Chief Complaint “I understand that you are here for a routine checkup. I will ask you a few questions about your blood pressure and gen-eral health and then I will do a physical examination. If you have any questions or concerns, please do ask me. ” “How are you doing today?” “How long have you been diagnosed with hypertension for?” “How was it diagnosed?” “What treatment you are on?” “Are you taking medication regularly?” “Have you had any recent change in your health?” “Usual level of blood pressure? Any sudden change in the severity of hypertension?” “Who does the follow-ups?” “When was the last time you had a checkup?” “When was the last time you had your blood tests done?” Ask about associated symptoms: Headache Visual changes Chest pain Pallor Sweating M. H. Sherazi

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127 Palpitations Tremor Decreased level of consciousness Fainting Shortness of breath Stroke (weakness/numbness) Vision changes Peripheral vascular disease Leg pain Kidney disease Symptoms of secondary hypertension Pheochromocytoma: “Do you have episodes of palpita-tions, headache, and/or sweating?” Hyper-and hypothyroidism: Feeling hot and/or feel excessive cold? Tremors? Cushing's syndrome: Bruising of skin, moon/cushin-goid face, and weight gain. Renal symptoms or a past history of renal disease. Risk factors Diabetes mellitus High cholesterol Cigarette smoking Alcohol Recreational drugs Obesity Physical inactivity Family history of premature cardiovascular disease (men <55 years and for females less than 65) Stress (at work, at home, relationship) Past Medical History “Do you have any previous health issues?” Eye problems Ischemic heart disease Nephropathy: microalbuminuria, renal failure Hospitalization history or emergency admission history Medication History Current medications? History of antihypertensive drug use, effectiveness, side effects, and intolerance Prescribed, over the counter, and any herbal? NSAIDS, cyclooxygenase inhibitors, steroids, or sympathomimetics? Hospitalization History “Have you had any previous hos-pitalization or previous surgery?” Allergic History “Do you have any known allergies?”Family History Diabetes? Vascular disease? Lipid disor-ders, obesity, hypertension, endocrine disorder? Social History “Do you smoke?” “Do you drink alcohol?” If yes, then ask further questions on: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” Self-Care and Living Condition “What do you do for a living? Who lives with you?” Support “Do you have good family and friend support?” Impact on Life/Disability and Adaptation Effects on life. “Any effect on your daily activity?” General Physical Examination “Now, I will start the examination. ” Comment on the vital signs. Ask for patient height and weight with a body mass index (BMI). Check level of consciousness, alertness, and orientation. General appearance. Head and neck exam: -Oral: Hygiene, thrush, and caries -Nose -Mouth and throat -Thyroid assessment -Cervical lymph nodes -Mention that you will perform a fundoscopic examina-tion of eyes Cardiovascular Examination JVP. Palpate peripheral pulses. Note: pulse volume, contour, and rhythm. Auscultate for bruits. Inspect and palpate the apex beat. Palpate for thrills and heaves. Auscultate for S3 and murmurs. Examine for arterial insufficiency in lower limbs. Pedal edema. Respiratory System Inspection: Check chest expansion and percussion. Auscultate: Breathing sounds and adventitious sounds. Abdominal Examination Inspection and palpation (pulsatile mass). 4 The Cardiovascular System

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128 Neurology Examination Mental status Motor power Sensations (proprioception, vibration, light touch) Reflexes Wrap-Up Thank the patient and ask the patient to dress. Ask the patient if he has any questions or any concerns. Sum up your findings with the examiner or the patient. Question “What tests will you order?” Answer Full blood count Hb A1c Fasting lipid profile Urea and creatinine Electrolyte Estimated glomerular filtration rate (e GFR) Urine dip ECG Fundoscopy Ophthalmologist referral for eye exam (check your regional guidelines) Question “How will you counsel patient about hypertension?” Answer “Blood is the pressure that blood exerts outward on the walls of the arteries as it flows through these arter-ies. This pressure is the measure of how much blood the heart pumps out and the resistance of artery walls to the blood. In routine the amount of blood that enters and flows through the arteries results in normal blood pressure. When there is increased resistance in the blood arteries' vessel walls, the heart has to work harder to pump blood through these arteries. Hypertension is high blood pressure that persists over time. ” Question “Please tell me, what are the blood pressure values?” Answer “If you look at the blood pressure values, it has two numbers: one higher and one lower number. These two num-bers indicate the two phases of the heartbeat. The systolic or the higher number represents the blood pressure when the heart is contracting and the diastolic reading represents the blood pressure when the heart relaxes. Normal blood pres-sure is usually less than 120 mm Hg systolic and less than 80 mm Hg diastolic which is noted as 120/80. A person has hypertension if his or her blood pressure is consistently 130 over 80 mm Hg or higher” (see Table 4. 3) [8]. Question “What are various conditions that hyperten-sion may contribute to?” Answer Hypertension can lead to various conditions, including: Coronary heart disease Angina pectoris Heart attack/myocardial infarction Congestive heart failure Cardiomyopathy Stroke Kidney failure Blurred vision and blindness Question “What are various risk factors that influence the development of hypertension?” Answer Several risk factors influence the development of hypertension, including [9]: Heredity/genetic. Age: The risk of developing hypertension increases after age 35 (65% of people older than 60 have hypertension). Gender: Until age 55, men are more likely to develop hypertension than women. Women become more likely to develop hypertension with age. Race: African Americans are more likely to develop hypertension than Caucasians. Medications. Smoking. Alcohol. Sedentary lifestyle. Obesity. Question “What are the treatment options?” Answer “Primary hypertension can be controlled but can-not be cured. Secondary hypertension can be cured by treat-ing the particular cause. There are many factors, like diet and exercise habits, that can affect your blood pressure. First-line recommendations toward treating high blood pressure will be making lifestyle changes [9]. These include: Eating a low-sodium diet Losing weight Exercising Table 4. 3 Blood pressure ranges from normal to crisis levels (Adapted from the American Heart Association guidelines [8]) Blood pressure Systolic (mm Hg) Diastolic (mm Hg) Normal <120 <80 Elevated 120-129 <80 Hypertension Stage 1 130-139 Or 80-89 Hypertension Stage 2 ≥140 Or ≥90 Hypertension crisis >180 >120 M. H. Sherazi

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129 Quitting smoking Limited use of alcohol” Patient will be followed up and if lifestyle modifications do not control hypertension alone then, doctors can add medica-tions. These medications are called antihypertensives and include [9 ]: Angiotensin drugs Beta-blockers Diuretics Calcium channel blockers Direct-acting vasodilators (relax blood vessel walls) Centrally acting agents (affect brain chemistry) Peripherally acting agents (act on the nerves that regulate blood pressure) Checklist Physical Examination: Volume Status Examination You are working as a resident in the orthopedic department. You have been called to attend a 72-year-old male who had hip replacement about 3 days back. He has not been passing urine for 3 h. Please do a volume status examination (Tables 4. 4 and 4. 5) [10]. Table 4. 4 Checklist for a volume status examination Starting the station Knock on the door Enter the station Hand-wash/alcohol rub Greet the examiner and the patient Give stickers to the examiner if required or show your ID badge Now sit on the chair or stand on the right side of the patient and start the interview Opening Introduction, greet, explain, position, and exposure/ drape Ask for vital signs -interpret the vital signs Blood pressure (BP) examination Ask for BP and mention that BP should be done twice while lying and sitting First check while patient is supine Wait about 2 min and ask patient to sit up with legs dependent or standing position Observe for change in blood pressure Check heart rate while patient sitting and then while sitting up or standing Observe the change Systolic BP decreases >15 mm Hg and diastolic BP decrease >0-10 mm Hg and/or heart rate increases more than 20 indicate orthostatic hypotension. It is seen in volume depletion and autonomic dysfunction [10] General physical examination Check for alertness and orientation Look for any abnormal findings in: Eyes: pallor Mouth: open and look for dehydration. Flip tongue for central cyanosis Palms: pallor in creases, cold, clammy, dry Fingers: capillary refill -should be less than 2 s Jugular venous pressure (JVP)Properly position the patient with the head side of the bed up at a 30° angle and the patient's head turned left Use tangential lighting Read the JVP on the right side of the patient Distinguish between the carotid and JVP (see Table 4. 5) Make determination of JVP height above sternal angle Comment on wave form (a wave, x wave, and Y descent) Explain the normal JVP 3-4 cm above sternal angle Observe for Kussmaul sign: It is a paradoxical increase in the JVP on inspiration. It occurs because the heart is unable to accommodate the increase in the venous return that accompanies the inspiration fall in intrathoracic pressure. It is seen in right-sided heart failure, constrictive pericarditis, restrictive cardiomyopathy Perform abdominojugular reflux: it is considered to be abnormal if there will be rise in JVP >4 cm after applying abdominal pressure for a minimum of 15-30 s Abdomen Feel percussion at suprapubic to see if the bladder is full Ask if the patient has a Foley's catheter. Mention that you want to make sure that there is no problem with the catheter, such as kinking or blockage. If there is any concern, ask for a bedside bladder scan Cardiac examination Auscultate for heart -listen for S3 and S4 sounds Respiratory examination Auscultate lungs for crackles Ask for input and output chart and patient weight charts Edema examination Check for dependent pitting edema (ankle and sacrum) Check for ascites (fluid thrill and shifting dullness) Wrap-up Thank the patient and summarize your findings to the examiner Table 4. 5 Differences between the carotid and jugular venous pres-sure (JVP) wave forms Carotid waveform JVP wave form Palpable Not palpable Single wave Multiple wave Vigorous quality Soft and undulating Not affected by pressure Obliterated by applying pressure Height not affected by inspiration Height changes with inspiration Height not affected by Valsalva Height changes with Valsalva Height not affected by sitting up Height changes with sitting up 4 The Cardiovascular System

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130 References 1. Hall J, Piggott K, V ojvodic M, Zaslavsky K.  Chapter: the cardiovas-cular exam. In: Essentials of clinical examination handbook. 6th ed. New York: Thieme; 2010. p.  60. 2. Jugovic PJ, Bitar R, Mc Adam LC.  Fundamental clinical situations: a practical OSCE study guide. Toronto: Elsevier Saunders; 2003. p.  185-7. 3. Pheochromocytoma. Mayo Clinic. Accessed 30 March 2018. https:// www. mayoclinic. org/diseases-conditions/pheochromocytoma/ symptoms-causes/syc-20355367. 4. Dumitru I.   Heart failure differential diagnoses. Medscape. 28 Feb 2018. https://emedicine. staging. medscape. com/article/ 163062-differential. 5. Peacock W.  Ch 57. Congestive heart failure and acute pulmonary edema. In: Tintinalli J editor. Tintinalli's Emergency Medicine. A comprehensive study guide. 7th ed. USA: Mc Graw-Hill Education; 2011. p.  405-15. 6. Hurley KF.  Ch 1. Cardiovascular system. Heart failure: History and physical examination. In: OSCE and Clinical Skills Handbook. 2nd ed. Toronto: Elsevier Canada; 2011. p.  1-44. 7. Yusuf SW.   Chronic congestive heart failure. BMJ Best Practice. November 2017. http://bestpractice. bmj. com/topics/en-gb/61. Accessed 30 Mar 2018. 8. Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, et  al. 2017 ACC/AHA/AAPA/ABC/ ACPM/AGS/APh A/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2017. http://hyper. ahajour-nals. org/content/early/2017/11/10/HYP. 0000000000000065 9. Hypertension. Atlantic Cardiology, LLC. http://www. atlantic-cardiology. net/handler. cfm?event=practice,template&cpid=15444. Accessed 30 Mar 2018. 10. Jugovic PJ, Bitar R, Mc Adam LC.  Fundamental clinical situations: a practical OSCE study guide. Toronto: Elsevier Saunders; 2003. p.  185-7. 11. Kusko MC, Maselli K.   Introduction to cardiac auscultation. In: Taylor A, editor. Learning cardiac auscultation. London: Springer; 2015. p.  3-14. 12. Khan MG, Marriott HJL.  Acute Myocardial Infarction. In: Heart Disease Diagnosis and Therapy. Contemporary Cardiology. New York, NY: Humana Press; 2005. p.  1-67. 13. Romanò M.   Ch 11. The Electrocardiogram in Ischemic Heart Disease. In: Text Atlas of Practical Electrocardiography. Milano, Italy: Springer; 2015. Further Reading 14. Gao Z-H, Howell J, Naert K. editors. OSCE & LMCC-II: review notes. 2nd ed. Brush Education. 2009. 15. Bajaj R, Jurkiewicz M, Slessarev M. Chapter: the cardiovascular examination. In: Hall J, Piggott K, V ojvodic M, Zaslavsky K, editors. Essentials of clinical examination handbook, 6th ed. New  York: Thieme; 2010. p.  59-78. 16. Murtagh J.  Ch 86: Hypertension. In: John Murtagh's general prac-tice. 6th ed. North Ryde, Australia: Mc Graw-Hill Australia Pty Ltd; 2015. p.  955-71. 17. Bunce NH.  Ch 23. Cardiovascular disease. In: Kumar P, Clark M, editors. Kumar and Clark's clinical medicine, 9th edition. Elsevier: Edinburgh, 2017. Page 931-1056. 18. Longmore M, Wilkinson IB, Davidson EH, Foulkes A, Mafi AR (eds). Chapter 10. Cardiology and vascular disease. In: Oxford handbook of clinical medicine, 8th ed. Oxford University Press: Oxford. 2010. Pages 231-292. M. H. Sherazi

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131 © Springer Nature Switzerland AG 2019 M. H. Sherazi, E. Dixon (eds. ), The Objective Structured Clinical Examination Review, https://doi. org/10. 1007/978-3-319-95444-8_5The Respiratory System Mubashar Hussain Sherazi Common Respiratory Symptoms for the Objective Structured Clinical Examination For the respiratory system, common presenting symptoms are the following: Cough Sputum Coughing up blood (hemoptysis) Wheezing Runny nose Shortness of breath Chest pain History Overview: Respiratory System In the objective structured clinical examination (OSCE), there is usually one respiratory system scenario. It will either be a history-taking station or history taking along with respi-ratory system examination. The key with history and physi-cal examination stations is time management. It is extremely important to master history-taking skills; you should be able to ask and extract only the most relevant questions and infor-mation. If the station time is 10 min, the history should finish in the first 4-5 min. Before appearing in real examination, you should also practice performing the relevant physical examination in 3-4 min. One to 2 min must be kept in the end to address the patient's concerns/questions or for wrap-ping up the scenario. In respiratory system stations, you should also look for any relevant material/equipment on the side of the bed such as inhaler/disk, spacer, O 2 cylinder, neb-ulizers, and peak flow charts for clues. This chapter will outline common respiratory system top-ics important for OSCE. An overview of the pattern of his-tory taking required for respiratory system stations (see Table  5. 1) is followed by important topics. It is recommended to read guidelines for management of asthma and chronic obstructive pulmonary disease (COPD). You must be good at the emergency management of pneumothorax, hemothorax, and pulmonary nodule. Make yourself familiar with how to read and interpret different chest X-rays. Physical Examination: Respiratory System Candidate Information: A 32-year-old male, an ambulance driver, presents with cough for 1 day. Vital Signs: Heart rate (HR), 66/min, regular; blood pres-sure (BP), 120/65 mm Hg; temp, 36. 8 °C; respiratory rate (RR), 14/min; O 2 saturation, 98% Please perform a detailed respiratory system examination. Please do not perform rectal, genitourinary, or breast examination. Starting the Interview: Knock on the door. Enter the station. Hand wash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your identification (ID). Stand on the right side of the patient and start the examination. Opening: “Good morning/good afternoon. I am Dr....... I am your attending physician. Are you Mr.......? Are you 32 years old? Is it alright if I examine your respiratory system and associated parts of the body affected by it? During the examination, if you feel uncomfortable please let me know. ”M. H. Sherazi Mallacoota Medical Centre, Mallacoota, VIC, Australia5

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132 Vitals: Start with commenting on the vitals given at the door. (It should include pulse rate, blood pressure, respiratory rate, temperature, and O 2 saturation. ) Comment on the vital signs findings: “Mr...... vital signs are normal” or mention any abnormal finding. General Physical Examination: “I need to ask you a couple of questions as a part of my examination. ” (May skip these questions if it is a history and physical examination station to save some time): “What is the date today?” “Do you know where you are now?” Comment: “Patient is oriented and alert. ” Or “Patient is in distress!” Or “Patient is sitting comfortably and he is well oriented and alert. ” “I need to expose you from the neck down to the waist; is that alright?” If you think the patient is having difficulty tak-ing off his/her shirt and requires help, then offer to help; otherwise let him do it. Drape the patient appropriately if required. Stand on the right side of the bed or at the foot of the bed and tell the patient (indirectly to the examiner) “Mr......, I will start with inspecting or observing your chest. ” Observe for posture, distress, sweating, difficulty in speaking, use of accessory muscles attached to oxygen, any Table 5. 1 Quick review of history taking of the respiratory system Introduction: Name and age Chief complaint In patient's own words History of present illness Analysis of chief complaint: Onset Location Duration Character Aggravating/alleviating factors Radiation Timing Severity of symptoms Associated factors Symptoms related to the same system Symptoms related to adjacent systems Constitutional symptoms Review of systems Cardiovascular Gastrointestinal Genitourinary Neurology Predisposing factors Red flags/risk factors Impact on patient Rule out differential diagnosis Past medical and surgical history Medical illnesses, any previous or recent surgery Hospitalization history or emergency admission history Medications history Current medications (prescribed, over the counter, and any herbal) Allergic history/triggers Any known allergies? Family history Family history of same symptoms Family history of any long-term or specific medical illness Any long-term diseases Home situation: With whom do you live? Occupation history How do you support yourself? Personal history (Only if relevant) Birth history Early childhood to adolescence Adulthood Onset of illness Any diagnosis Social history Smoking Alcohol Recreational/illicit drugs Sexual history (male, female, both) Educational/vocational If adult female: Menstrual history (LMP)Table 5. 1 (continued) Gynecology history Obstetric history If teen: Home Education Employment Activities Drugs Sexual activity If child: Birth history Immunization Nutrition Development Wrap-up Describe the diagnosis Management plan Possible medical treatment Duration of treatment and side effects Red flags Laboratory tests Further information websites/brochures/support groups or societies/toll-free numbers Follow-up M. H. Sherazi

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133 medications in the patient's hand or at bedside, or attached intravenous (IV) lines, and cachectic appearance. Hands: “Now I would like to see your hands, is that alright?” Observe for: Color, capillary refill, palmar erythema, peripheral cyanosis, nicotine stain, clubbing, muscle wast-ing, contractures (Dupuytren's), and asterixis, press wrist and note for any tenderness (hypertrophic pulmonary osteo-arthropathy resulting from periosteal inflammation second-ary to Pancoast tumor), and look for flapping tremors or CO 2 retention. Engage the patient by saying: “I am going to feel your pulse now. ” Comment on rate, rhythm, and volume of pulse. Face: Color of the face, plethora, central cyanosis, cushingoid/ moon face. Eyes: Ptosis (Horner syndrome), pallor, jaundice. Sinuses: Check for tenderness of maxillary and frontal sinuses. Nose: Flare, perforated septum. Lips: Pursed lips. Mouth: Moist tongue, ulcers, thrush, central cyanosis - check for focus of infection. Intercostal spaces: Retractions. Have the patient speak a sentence for hoarseness. Neck: “I am going to feel your neck now. ” See Fig.  5. 1. Trachea: Position (central or midline) and mobility. Tracheal deviation will be away from the contralateral pneumothorax or effusion. Fixed trachea: Mediastinal tumor and tuberculosis. Jugular vein distention (JVD) (discussed in cardiovascu-lar examination). Lymph nodes. Chest Examination: Inspection: The chest examination will start with inspection and is done while the patient is sitting: Observe for respiratory rate and pattern. Comment: “Breathing rate is.... It is regular/irregular. ” Look from the front, side, and back. Observe for: Contour: Symmetrical or asymmetric Shape: Normal/barrel shaped/funnel/scoliotic/kyphosis (pectus cavernosum/excavatum or kyphoscoliosis) Skin: Scar marks, erythema/signs of inflammation, dilated veins, or intercostal retractions, radiation marks, and tattoos Expansion: Equal on both sides Palpation Warm up your hands. (Rub your hands for a few seconds to let the patient and examiner know you are warming up your hands for the patient's comfort -especially in cold weather. ) I usually start any palpation on a patient with this ques-tion: “Are you sore anywhere on your chest? Or do you have any pain on your chest?” Method: Inform the patient, “I am going to feel your chest. ” Gently palpate all areas of chest for tenderness and deformity. You can skip this step if it is a history and phys-ical examination station and time is running short. Palpation of the chest is important for musculoskeletal pain and, in case of trauma cases, rib fracture. Also com-press the chest from side to side and front to back for tenderness. Chest Expansion “I will check how well your chest expands with each breath. ” See Fig.  5. 2a-c. Method: Tell the patient to hold both arms crossed on their chest. Place your hands flat on the back of the patient's chest during normal expiration, with the thumbs parallel to the midline at the level of the tenth rib and fingers gripping the flanks. Ask the patient if he can take a deep breath in and out. Watch for symmetry in outward movement of the hands. Normally, the thumbs should move 3-5 cm symmetrically away from the midline. The same procedure can be repeated on the front. (May skip if time is running short. ) Fig. 5. 1 Examining the trachea 5 The Respiratory System

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134 Asymmetry will be seen in pleural effusion, pulmonary fibrosis, lobar pneumonia, bronchial obstruction, and pneu-mothorax [1]. Tactile Fremitus: “I am going to put my hand on various points on your chest. ” Place the ulnar side of your hand on the patient's chest. Ask the patient to say “99” at the same time you feel with your hand on the patient's chest (Fig.   5. 3a-d). Keep moving your hand to the next point and compare both sides. You will feel increased vibrations over areas of consolidation. Start anteriorly at the supraclavicular spaces on the right and left -comparing both sides. Move down to the tenth rib and repeat. Then palpate the posterior starting at the suprascapular spaces medially, moving down at least six posterior positions. Comment on the findings: “Tactile fremitus is symmetrical and normal. ” “Tactile fremitus is increased. ” Consolidation (pneumo-nia) and atelectasis [2]. “Tactile fremitus is decreased (voice is too soft). ” Obstructed bronchus, chronic obstructive pulmonary dis-ease (COPD), pleural effusion, pleural thickening, pneu-mothorax, infiltrating tumor, or thickened chest wall [2]. Percussion: “I am going to tap on your chest with my fingers. ” Start per-cussion in the same areas as you palpated during tactile fremitus, anterior and then posterior. Normal chest notes are resonant except over the areas of cardiac dullness left three to five intercostal spaces. Method: Place your left middle finger firmly on the patient's chest, while the other fingers are off, and then tap the left mid-dle phalanx with your right middle finger moving only your wrist. Percuss on the front of the chest comparing both sides, then the axilla, and then on the back, as shown in Fig.  5. 4. Comment on the findings: “Percussion is symmetrical and normal. ” Listen to see if the examiner will give some specific find-ings for the particular station, such as if the percussion note is dull or hyperresonant in some specific area: Resonant note: Normal lung Dull notes: Consolidation (pneumonia) Flat notes: Large pleural effusion Tympanic: Gastric air bubble Hyperresonant: COPD, pneumothorax a cb Fig. 5. 2 (a) Testing expansion of the midthorax. (b) Expansion of posterior thorax. (c) Testing movements of costal margins M. H. Sherazi

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135 Diaphragmatic Excursion: (Only perform if asked by the examiner. ) It is performed to look for hemiparalysis of the diaphragm. Method: Inform the patient that you are going to draw two marks on his back with a pen. Ask the patient for his permission. 1. The first step is to locate the level of the diaphragm dur-ing quiet respiration. Ask the patient to take normal breaths and start percussing on their posterior chest wall top to bottom. Repeat on both sides of the spine. Observe for a change from resonance to dullness. Mark the area (Fig.  5. 5). 2. The second step is to mark the position of the diaphragm upon deep inspiration. The diaphragm will move down-ward. Ask the patient to take a deep breath in and hold his breath. Percuss from your previous mark downward until a change from resonance to dullness is noted. Mark the level. 3. The third step is to mark the diaphragm's position after expiration. Tell the patient to breathe out as much as possi-a b dc Fig. 5. 3 Tactile fremitus points: (a) anterior points. (b) Placing ulnar side of hand on patient's chest. (c) Posterior points. (d) Placing ulnar side of hand on patient's back 5 The Respiratory System

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136 ble and hold his breath. Percuss from your first mark upward until dullness changes to resonance. Mark this level. 4. Repeat on the other side. 5. The diaphragm level should be at T12 level, and excur-sion should be 4-5 cm and symmetrical on both sides. Chest Auscultation: Inform the patient: “I am going to listen to your chest and back with my stethoscope. ” Warm the stethoscope. Method: Listen to the breath sounds on the same areas as for percussion and tactile fremitus with the diaphragm of a stethoscope, comparing both sides and instructing the patient to take deep breaths through an open mouth (Fig.  5. 6a, b). Listen for intensity, pitch, adventitious sounds, and the ratio of inspiration to expiration: Vesicular breath sounds: Normal breath sounds are described as vesicular breath sounds. These are soft, low- pitch, and like gentle rustling sounds. They are heard over the periphery of the lung fields. The inspiration-to- expiration ratio is 3:1. Bronchial breath sounds: These are loud, high-pitch sounds, like air rushing through the tubes, heard over the manubrium. The inspiration-to-expiration ratio is 1:3. Bronchovesicular breath sounds: Heard over main stem bronchi or in bronchospasm. These are moderate-pitch, moderate-intensity sounds like rustling but tubular. The inspiration-to-expiration ratio is 1:1. Tracheal breath sounds: Very loud, high-pitched sounds heard over the trachea in the neck. Inspiration-to- expiration ratio is 1:1. Adventitious breath sounds: These are discontinuous sounds. If these are present, always describe the location and do vocal fremitus. Crackles/rales/crepitations: These are short, discontin-uous sounds heard mostly upon inspiration. Crackles are heard because of excess airway secretions. Coarse crack-les are low pitched. Fine crackles are high pitched. Crackles are heard in pulmonary edema, congestive heart failure (CHF), bronchitis, respiratory infection, and atelectasis. Wheezes: These are continuous high-pitched sounds caused by air passing through partially obstructed or nar-rowed airways on expiration or inspiration. These are heard in pulmonary edema, asthma, and bronchitis. They are also heard in the presence of tumors and foreign bodies. Rhonchi: These are low-pitched and deep sounds caused by transient airway plugging by mucus, which may disap-pear with coughing; suggest bronchitis. Pleural rub: These are grating, brushing, or creaking sounds heard on the end of inspiration and start of expi-ration. They indicate pneumonia or pulmonary infarction. Stridor: This is an inspiratory sound heard over trachea caused by upper airway extra-thoracic obstruction. At the end of the auscultation, comment on your findings. For example, “Breath sounds are normal with no adventitia. ” Fig. 5. 4 Technique of percussion Fig. 5. 5 Mark the patient's back to show where it changes from reso-nance to dullness M. H. Sherazi

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137 Vocal Fremitus: If there is still some time left, continue with vocal fremitus; otherwise it can be skipped. It is also not required if there are no added breath sounds on the lung periphery (area of consolidation). Bronchophony: Ask the patient to say “99. ” Listen over areas of suspected consolidation. It is usually muffled but will be louder and clearer over areas of consolidation. Egophony: Ask the patient to say “ee. ” Listen on areas of consolidation. It will be heard like “aa. ” Whispered pectoriloquy: Ask the patient to whisper a few words such as “Friday, Saturday, and Sunday. ” The whispered words will be heard more clearly over areas on consolidation. Forced Expiratory Time: Explain to the patient, “I am going to note the time of your breathing in and out. Can you please take a deep breath in as much as you can and hold it?” Note the time in seconds. Ask the patient to breathe out as fast as pos-sible. Note the time. Forced expiratory time should normally be <3 s. If there is still time left, continue with listening to the heart and feel for sacral edema. If time is ending, then mention that you will complete your examination with: Cardiovascular system examination: Listening to the heart and feel for sacral edema. Lymph nodes: Axial, femoral, popliteal, head, and neck. Lower legs: Edema; check for calf tenderness (deep vein thrombosis [DVT], Homan's sign) Wrap-Up: Thank the patient and ask the patient to dress. Ask the patient if he wants to ask any questions or has any concerns. Wrap up your findings with the examiner or the patient. Checklist: Respiratory System Examination See Table  5. 2 for a checklist that can be used as a quick review before the exam. ab Fig. 5. 6 Sites for chest auscultation: (a) Anterior. (b) Posterior 5 The Respiratory System

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138 History and Physical Examination Sore Throat (Common Cold) Candidate Information: A 21-year-old female, a university student, presents with sore throat, runny nose, and fatigue for 3 days. Vital Signs: HR, 66/min, regular; BP, 120/70 mm Hg; temp, 37. 8 °C; RR, 17/min; O2 saturation, 99%Take a focused history and perform a focused physical examination. Please do not perform rectal, genitourinary, or breast examination. Please address the patient's concerns. Differentials: Viral and bacterial pharyngitis Viral and bacterial tonsillitis Upper respiratory tract infection (URTI) (common cold) Infectious mononucleosis Human immunodeficiency virus (HIV), acute retroviral syndrome Other Causes: Gastroesophageal reflux Postnasal drip secondary to rhinitis Persistent cough Allergies Foreign body Smoking Starting the Interview: Knock on the door. Enter the station. Hand wash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr... I am your attend-ing physician. Are you Miss... ? Are you 21 years old?” “Is it alright if I ask you a few questions about your sore throat? I would also like to do a relevant physical examina-tion. In the end we will discuss the plan. During the history or examination if you have any questions or if you feel any discomfort please let me know. Is this alright?” History of Present Illness: “What do you mean by sore throat?” “Can you describe it for me?” “When did it start?” Three days ago. “How did it start?” It's gotten progressively worse over the last 3 days. “Is this the first time you've had such symptoms?” “Is it getting better or worse?” Worse. “Do you need to clear your throat often?” “Do you have a hard time swallowing?” Yes. Precipitating or Aggravating Factors: “Is there anything that makes your throat feel worse?” Nothing. Table 5. 2 Respiratory system examination checklist Starting the interview Knock on the door Enter the station Hand wash/alcohol rub Greet the examiner and patient Give stickers to the examiner if required or show your ID badge Sit on the chair or stand the right side of the patient. Start the physical exam Opening Introduction, greet patient, and explain procedure Position and expose/drape the patient appropriately Ask for vital signs and interpret General physical examination Check level of consciousness and alertness Look for any abnormal findings in: Hands Face (eyes, nose, lips, and mouth) Neck and intercostal spaces Chest examination Inspection Exposure: neck down to the waist Look from the front, side, and back Respiratory rate and pattern Observe for contour, shape, skin, and chest expansion Palpation: warm up your hands Chest expansion Tactile fremitus Percussion Chest auscultation Listen for breathing sounds and the presence of any adventitious sounds V ocal fremitus Bronchophony Egophony Whispered pectoriloquy Cardiovascular Listen to heart and measure JVD Lymph nodes Lower legs Edema, calf tenderness Wrap-up Thank the patient and ask them to dress Ask the patient and examiner if they have any questions or concerns Wrap up your findings with the examiner of the patient M. H. Sherazi

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139 Associated Symptoms: “Do you have runny and stuffy nose?” Yes. “Any cough?” It started today. “Shortness of breath?” No. “Any hoarseness?” No “Any chest pain?” No. “Any headache?” No. “Any fever?” Yes, I've had mild fevers for about 3 days. Tylenol helped lower my temperature. I've also had two to three episodes of chills. “Any night sweats?” No. “Any muscle aches?” Mild. “Any yellowness of eyes/skin or dark urine/jaundice?” No. -Maybe say “Yellowing of the skin?” “Any abdominal pain?” No. “Any nausea/vomiting?” No. “Any loss of appetite?” No, it's been normal. “Any change in bowel habits?” No. “Any change in urination?” No. “Have you had any fatigue?” I've been quite tired for 3 days. “Do you suffer from heart burn or the condition called gastroesophageal reflux disease (GERD)?” No. “Have you had contact with any sick individuals recently? I'm not sure. “Any recent travel?” No. Past Medical History: “How is your health otherwise? Do you have any previous health issues?” No I'm very healthy. Past Hospitalization and Surgical History: “Have you had any previous hospitalizations or any previous surger-ies?” I've never had surgery or been admitted to hospital. Medication History: “Are you taking any prescribed medi-cations? Any over-the-counter or herbal remedies?” I've just been taking Tylenol for my fever. Allergic History: “Do you have any known allergies?” No, none that I know of. Family History: “Is anyone in your family having similar symptoms or any ongoing health problems?” No, everyone in my family is healthy. Social History: “Do you smoke? Do you drink any alco-hol? Have you ever tried any recreational drugs?” I drink socially, one to two drinks each weekend. I don't smoke or do any drugs. Relationships: “Are you sexually active? Do you have sex with men, women, or both?” Yes. Only with my boyfriend/ husband, we always use condoms. Self-Care and Living Condition: “Where do you live?” I'm a university student, I live on campus. Functional Status: “How is this impacting you?” I skipped class today due to a fever. General Physical Examination: “Now, I will start the examination. ” Comment on the vital signs findings and if there are any mentionable findings. Otherwise comment that vitals are normal. Check level of consciousness and alertness. General appearance: Tired and irritated. Head and neck exam. -Nose: Blocked and may be red. -Mouth and throat: Check for sinus tenderness. -Cervical lymph nodes: Several enlarged lymph nodes. Skin: Look for any rash (usually no abnormal finding). Chest examination. -Inspection and auscultation (usually no abnormal finding) Cardiovascular examination. -Auscultation for heart sounds (usually no abnormal finding) Abdominal examination. -Inspection and palpation (usually no abnormal finding) Wrap-Up: Comment on your findings. Thank the patient and tell the patient they can now cover up. Ask the patient if she has any questions. Patient Concerns Question 1. “What is going on with me?” (Questions may be asked by the patient or the examiner. ) Answer: “Miss..., with our current discussion and clini-cal findings, you are suffering from a common cold also known as an upper respiratory tract infection (URTI). The common cold is the most frequent infectious disease in humans. It most commonly occurs in winter. These symp-toms are caused by a viral infection. It is caused by either the rhinovirus, picornavirus, influenza virus, or the parainflu-enza virus” [3]. Question: “Do we need to do any tests?” (Questions can be asked by examiner or patient. ) Answer: “We do not need to do any tests today. But if your symptoms do not improve with conservative manage-ment, then we may consider doing complete blood count 5 The Respiratory System

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140 (CBC), throat swab, sputum culture, heterophile antibody test, C-reactive protein (CRP), chest X-ray (CXR), or viral testing” [4]. Question: “Do I need to take antibiotics? My friend got sick a few weeks back. Her doctor wrote her a pre-scription for antibiotics, and it worked for her. ” Answer: “Because it looks like a viral infection, you do not need antibiotics. The symptoms peak in 2-4 days after the onset of symptoms and usually resolve in 7-10  days. Occasionally they may last longer, up to 2-3 weeks. ” Treatment Plan Patient instructions: “Acetaminophen can be taken to relieve fever and body aches. ” “For your blocked nose, steam inhalation may help. ” “Resting at home will help. ” (Off from work and univer-sity -offer work note. ) “Drink plenty of fluids. Avoid drinking alcohol or eating fatty foods. ” “Throat lozenges and salt water gargles can treat your sore throat. ” Quit smoking advice (this patient is not a smoker). Ask about flu vaccination. If she has not received, then offer one. Warning Signs: “If you do not feel well, or if your fever does not settle, you should seek medical attention immedi-ately. Be aware of the possible complications: pneumonia, otitis media, and sinusitis. ” Follow-Up: Provide a brochure about influenza/common colds (Table 5. 3) and a website for more information. History and Physical Examination Sore Throat (Glandular Fever) Candidate Information: A 21-year-old female presents with sore throat, fatigue, loss of appetite, and fever for 1 week. She complains of a rash, neck lymphadenopathy, and some central and left-sided abdominal pain. Her girlfriend also had similar symptoms recently. Vital Signs: HR, 81/min, regular; BP, 123/78 mm Hg; temp, 38 °C; RR, 16/min Take a focused history and perform a focused physical examination. Please do not perform rectal, genitourinary, or breast examination. Please address the patient's concerns. Differentials: Infectious mononucleosis Viral and bacterial pharyngitis Viral and bacterial tonsillitis URTI (common cold) Less common for OSCE -Acute HIV infection -Secondary syphilis Starting the Interview: Knock on the door. Enter the station. Hand wash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr...... I am your attending physician. Are you Miss......? Are you 21 years old? Is it alright if I ask you a few questions about your sore throat? I would also like to do a relevant physical examination. At the end we will discuss the plan. During the history or examination if you have any questions or if you feel any discomfort please let me know. Would that be alright?” History of Present Illness: “What do you mean by sore throat?” “Can you describe it for me?” “When did it start?” One week ago. “How did it start?” “Is this the first time you've had such symptoms?” “Is it getting better or worse?” Worse. Table 5. 3 Symptoms of the common cold versus those of influenza Symptoms Common cold Influenza Fever Rare Frequent (102-104 °F or 38-41 °C) Sudden onset and lasts for several days Headache Rare Common Cough Sometimes, dry cough Common, wet cough Sore throat Common Common Aches, pains Mild Common, sometimes severe Fatigue, weakness Mild Severe, can last 2-3 weeks Runny or stuffy nose Common Sometimes Sneezing Common Sometimes Chest discomfort Mild Moderate to severe M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

141 “Does speaking irritate your throat?” Yes. “Do you need to clear your throat often?” “Do you have a hard time swallowing?” Yes, I've also felt pain and small lumps in my neck. Precipitating Factors or Aggravating Factors: “Is there anything that increases the intensity of your symp-toms?” Nothing. Associated Symptoms: “Do you have a runny nose?” No. “Any cough?” No. “Any shortness of breath?” No. “Any chest pain?” No. “Any headache?” No. “Any fever?” Yes, going on for about a week, it was 38 °C.  Advil helped in lowering the fever. I've also had two to three episodes of chills. “Any night sweats?” No. “Any yellowing of the skin?” No. “Any abdominal pain?” Some mild pain and discomfort in the center and upper left side of my abdomen. “Can you describe your pain for me? How intense is it on a scale of 1-10?” It's a dull, constant pain, a 4-5/10. “Is your pain aggravated by movement or food? Is it a radiating pain? Is there anything you've found that can alleviate your pain?” It seems to get worse with move-ment, but there is no relation with food. The pain isn't radiating and nothing makes it go away. “Any nausea/vomiting?” No. “Any loss of appetite?” Yes. I haven't eaten much for 3 days. “Any weight loss?” No “Any change in bowel habits?” No. “Any change in urination?” No. “Any fatigue?” I've been feeling tired for a week. “Do you suffer from heartburn or a condition known as GERD?” No. “Have you come into contact with any sick individuals recently?” My girlfriend had similar symptoms a few weeks back. “Any recent travel?” No. “Do you have any pain anywhere else in the body?” No. Past Medical History: “How is your health otherwise? Have you had any previous health issues?” I had a sexually transmitted infection (STI) about a year ago. It was treated with antibiotics twice. Past Hospitalization and Surgical History: “Have you had any previous hospitalizations or any surgeries?” I have never had surgery or been admitted to a hospital. Medication History: “Are you taking any prescribed medi-cations? Any over-the-counter or herbal remedies?” I've been taking ibuprofen for my fever. Allergic History: “Do you have any known allergies?” No, none that I know of. Family History: “Does anyone in your family have similar symptoms or have any ongoing health problems?” No, every-one in my family is healthy. Social History: “Do you smoke? Do you drink alcohol? Have you ever tried any recreational drugs?” I drink socially, one to two drinks every weekend. I smoke five to ten ciga-rettes a day and have for about 1 year now. I've never used recreational drugs. Relationships: “Are you sexually active? Do you have sex with men, women, or both?” Yes, I've had two different part-ners. My boyfriend and I dated up until a year ago and I am currently in a relationship with my girlfriend. Self-Care and Living Condition: “Where do you live?” I'm a university student, I live on campus. Functional Status: “How is this impacting you?” I skipped classes today because of my fever and stomach pain. General Physical Examination: “Now I will start the examination. ” Check level of consciousness and alertness. Head and neck exam. -General appearance. -Nose. -Mouth and throat; check for sinus tenderness. Cervical lymph nodes. Skin: Comment that you are looking for the rash men-tioned by the patient. Chest examination: Inspection and auscultation (usually no abnormal finding). Cardiovascular examination: Auscultation for heart sounds (usually no abnormal finding). Abdominal examination: Inspection and palpation (inspection, palpation for tenderness in the left upper quadrant [LUQ], liver, and spleen -splenomegaly). Wrap-Up: Comment on your findings. Thank the patient and tell the patient they can now cover up. Ask the patient if she has any questions. 5 The Respiratory System

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142 Investigations The presence of at least 10% atypical lymphocytes supports the diagnosis (with 92% specificity) of infectious mononu-cleosis. In a patient with typical symptoms, no further testing is needed. “We need to run some tests”: CBC Throat culture Monospot test Liver panel HIV antibody and viral load (only if risk factors present) Anti-Epstein-Barr virus (EBV) antibodies Venereal disease research laboratory (VDRL); rapid plasma reagin (RPR) Describe the Diagnosis Patient Concerns Question 1. What is going on with me? Answer: “Miss... with our current discussion and clinical findings, my clinical judgment is that you are have a condi-tion called glandular fever/infectious mononucleosis. ” Question 2. What are the symptoms? Answer: “It is a viral infection. Some symptoms are similar to influenza. The symptoms include fever; blocked nose; headache; sore throat; swollen, tender glands in the neck, armpits, and groin; a rash; and sometimes jaundice. ” Question 3. Can you tell you more about it? Answer: “It is also known as infectious mononucleosis/ Epstein-Barr mononucleosis. It is sometimes called “the kissing disease” because it may transmit from one person to another through the mouth. It is also transmitted by coughing and sharing food. The disease is usually seen in 15-to 25-year-olds. ” Question 4. How is it diagnosed? Answer: “It is done with a blood test. The blood test will show abnormal specific cells called monocytes under the microscope. That's why it's called infectious mononucleosis. ” Question: “Can I play basketball?” Answer: “Avoid contact sports for at least 4-6  weeks, once you have recovered completely. Abdominal injury may cause the enlarged spleen to rupture, which can be fatal. ” Management Plan: Question: “How long does it last?” Answer: “You should start feeling better in 2-3 weeks as most of the symptoms usually settle during this period. It may take another 2-3 weeks for the fatigue and weakness to resolve. Occasionally, the fatigue lasts longer and suggests a chronic glandular fever. It sometimes causes hepatitis, which can make patients very sick. ”Treatment Plan: Question: “Do I need to take antibiotics or any other medication?” Answer: “No antibiotics are required (viral infection). Acetaminophen can be taken to relieve discomfort, pain, and fever. ” Patient Instructions: “The symptoms will improve over time. ” “Rest at home will help. ” (Off from work and university - offer work note. ) “Drink plenty of fluids. Avoid drinking alcohol or eating fatty foods. ” “Avoid sharing drinking containers. ” “Avoid any oral contact with your partner. ” “Throat lozenges and gargling soluble aspirin will help the sore throat. ” “Wash and store clothes infected with nose and throat secretions. ” Warning Signs: “If you do not feel well, if your fever will not settle, or if you notice jaundice, you should seek medical attention immediately. I will give you a brochure about infectious mononucleosis and a website to read more about it. ” Follow-Up: “I will send your blood work to the lab. The clinic will call you once the results are back. Do you have any questions?” History and Physical Examination: Sore Throat (Influenza) Candidate Information: A 21-year-old female, a university student, presents with sore throat, runny nose, headache, and high fever for 2 days. Vital Signs: HR, 100/min, regular; BP, 120/70  mm Hg; temp, 38. 8; RR, 20/min Take a focused history and perform a focused physical examination. Please do not perform rectal, genitourinary, or breast examination. Please address the patient's concerns. Differentials: Viral and bacterial pharyngitis Viral and bacterial tonsillitis URTI (common cold) Infectious mononucleosis M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

143 Starting the Interview: Knock on the door. Enter the station. Hand wash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr... I am your attend-ing physician. Are you Miss... ? Are you 21 years old? Is it alright if I ask you a few questions about your sore throat? I would also like to do a relevant physical examination. At the end we will discuss the plan. During the history or examina-tion if you have any questions or if you feel any discomfort please let me know. Would that be alright?” History of Present Illness: “What do you mean by sore throat?” “Can you describe it for me?” “When did it start?” Two days ago. “How did it start?” It came on suddenly. “Is this the first time you've had these symptoms?” “Is it getting better or worse?” Worse. “Do you need to clear your throat often?” “Do you have difficulty swallowing?” Yes. Precipitating Factors or Aggravating Factors: “Does anything make your symptoms worse?” Talking. Associated Symptoms: “Do you have runny nose?” Yes. “Are your eyes irritated and watering?” Yes. “Any coughing?” Yes with some white phlegm. “Any shortness of breath?” No. “Any hoarseness?” No. “Any chest pain?” No. “Any headache?” Yes. “Any fever?” Yes, I've had a fever for about 2 days; it was 39 °C last night with chills. Tylenol helped to lower it. ” “Any night sweats?” No. “Any muscle aches?” Yes, my whole body is sore. “Any yellowing if the skin?” No. “Any abdominal pain?” No. “Any nausea/vomiting?” I've had some nausea but no vomiting. “Any loss of appetite?” Yes, I've had a decreased appetite. “Any change in bowel habits?” No. “Any change in urination?” No. “Any fatigue?” I've been feeling extremely tired for 2 days. “Do you suffer from heart burn or GERD?” No. “Have you been in contact with any sick individuals recently?” Not sure. “Any recent travel?” No. Past Medical History: “How is your health otherwise? Do you have any previous health issues?” I am otherwise healthy. Past Hospitalization and Surgical History: “Have you been hospitalized in the past? Any previous surgeries?” I've never been hospitalized nor had any surgeries. Medication History: “Are you taking any prescribed medi-cation? Any over-the-counter or herbal remedies?” I've been taking Tylenol for my fever. Allergic History: “Are you allergic to anything?” No, not that I know of. Family History: “Does anyone in your family have similar symptoms or any ongoing health problems?” No, my family is healthy. Social History: “Do you smoke? Do you drink alcohol? Have you ever tried any recreational drugs?” I drink socially, one or two drinks over the weekends. I don't smoke and I've never used recreational drugs. Relationships: “Are you sexually active? Do you have sex with men, women, or both?” Yes, I've had one male partner and we always used condoms. Self-Care and Living Condition: “Where do you live?” I'm a university student, I live on campus. Functional Status: “How are your symptoms impacting your life?” I skipped classes today because of my fever. General Physical Examination: “Now, I shall start the examination. ” Comment on the vital signs: “Vital signs are normal” or mention if there is any abnormal finding. Check level of consciousness and alertness. General appearance: tired and irritated. Head and neck exam: -Face: flushed. -Eyes: may be red and watering. -Nose: blocked or secreting discharge. -Mouth and throat, check for sinus tenderness: throat may be congested/hyperemic. Cervical lymph nodes: Several enlarged lymph nodes. Skin: Warm/hot and moist. 5 The Respiratory System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

144 Chest examination: Inspection and auscultation (dry cough with clear lungs or rhonchi, with focal wheezing). Cardiovascular examination: Auscultation for heart sounds (usually no abnormal finding). Abdominal Examination: Inspection and palpation (usu-ally no abnormal finding). Wrap-Up: Comment on your findings. Thank the patient and tell the patient they can now cover up. Ask the patient if she has any questions. “We need to run some tests. ” Patient Concerns/Examiner Questions Question 1. What is going on with me? Answer: “Miss... with our current discussion and clinical findings, my clinical judgment is that you are suffering from influenza (the flu). It is a viral infection caused by many kinds of influenza viruses. These viruses keep changing over time, and we need to get vaccinated every year against influ-enza to keep from getting infected. ” Question 2. How did I catch it? Answer: “Usually, it is seen in epidemics as it spreads through coughs and sneezes. The virus enters the nose or throat and then spreads to the lungs. It is extremely infectious. ” Question 3. What are the risks? Answer: “The influenza infection may spread to the lungs and possibly cause bronchitis or even pneumonia. These complications are more likely to be seen in patients with poor nutrition and other health issues, such as chest prob-lems in heavy smokers and the elderly. Other possible com-plications are otitis media, tracheobronchitis, acute sinusitis, Reye's syndrome, pericarditis, myositis, myoglobinuria, encephalitis, transverse myelitis, Guillain-Barré syndrome, and rhabdomyolysis. ” Questions 4. What is the treatment? Answer: “The flu usually lasts 3-4 days, sometimes lon-ger. Symptoms can be eased, and complications can be pre-vented through proper care. ” Medication: The use of antiviral drugs is reserved for severe cases. Anti-influenza drugs used are zanamivir (Relenza) and oseltamivir (Tamiflu). Routine antibiotics are not helpful (viral infection). Acetaminophen is given to relieve discomfort and pain. Pain medicines such as codeine compound and anti- inflammatory compounds such as ibuprofen can also be used. Patient Instructions: “The symptoms improve over time. ” “Rest at home will help. ” (Off from work and university - offer work note. ) “Drink plenty of fluids. Avoid drinking alcohol or eating fatty foods. ” “Avoid sharing drinking containers. ” “Throat lozenges and gargling soluble aspirin will help the sore throat. ” “Wash and store clothes infected with nose and throat secretions. ” “Any special remedy that makes the patient feel comfort-able is good. Some people find freshly squeezed lemon juice mixed with honey helpful. ” “Some people find that taking 1 to 2 grams of vitamin C each day helps recovery. ” Prevention: The influenza vaccine helps some people, but vaccination does not provide immunity to all influenza strains. Vaccination is worthwhile specially for patients at risk, for example, patients with lung diseases and diabetes or who are over 65 years, very young, or pregnant. Warning Signs: “If you do not feel well or you experience that your symp-toms are not improving, then you should seek medical atten-tion immediately. I can give you a brochure about influenza/ common colds and a website to read more about it. ” Follow-Up: “I am sending you for blood work. The clinic will call you once the results are back. Do you have any questions?” Further Discussion: Other Infectious Causes: 1. Group A Beta Hemolytic Strep (GABHS): GABHS is one of the most common bacterial causes of pharyngi-tis. Patients usually do not have rhinorrhea, cough, or conjunctivitis. Patients present with fever, sore throat, throat exudates, respiratory difficulty, and swollen neck lymph nodes. There is usually a history of recent expo-sure to infection and often presence of comorbid condi-tions such as diabetes. While doing the physical examination, one should look for fever, rash, pharyn-geal swelling/erythema, edematous uvula, tonsillar exudates, and cervical adenopathy. It is also important to listen for the presence of a heart murmur and feel for hepatosplenomegaly. M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

145 Centor criteria can be used to identify the likelihood of a bacterial infection (Table 5. 4) [5]. See Fig.   5. 7 for algorithm for evaluating patients with sore throat. Investigations: Laboratory testings should be used as an adjunct to the history and physical examination. Throat culture. Rapid antigen detection test or rapid streptococcal anti-gen test. Monospot test. Complications: Untreated GABHS infection may last up to 7-10  days. Patients with untreated streptococcal pharyngitis are infec-tious during the acute phase and 1 week after. Antibiotic ther-apy reduces the infectious period to 24 h and also decreases the duration of symptoms by 1 day and also prevents most complications. Complications such as rheumatic fever, scar-let fever, peritonsillar abscess, and post-streptococcal glomer-ulonephritis are not commonly seen these days. 2. Gonococcal pharyngitis occurs in sexually active patients. It presents with fever, sore throat, dysuria, and a greenish exudate. Gonococcal pharyngitis is diagnosed by a positive culture (Thayer-Martin medium) for Table 5. 4 Centor criteria to identify likelihood of a bacterial infection [5 ] Symptom Score Fever Add 1 point Absence of cough Add 1 point Tender anterior cervical adenopathy Add 1 point Tonsillar swelling or exudates Add 1 point Modified criteria includes patient's age Age Score Younger than 15 years Add 1 point 15-45 years 0 points Older than 45 Subtract 1 point Score interpretation: 0 or-1 points Streptococcal infection ruled out 1-3 points Order rapid test -treat accordingly 4-5 points Probable streptococcal infection - consider empiric antibiotics Sore thr oat Low probability of strep throat Moderate probability of strep throat High probability of strep throat Consider other causes Rapid strep test Rapid strep test or prescr ibe empir ic antibiotics Positiv e: treat f or strep Negativ e: consider other causes Re-ev alute if patient does not impro ve or worsens Test for mononucleosis (Epstein-Barr vir us) if patient is 10 to 25 ye ars old Treat with antibiotics if throat culture is positive. If the mononuclear spot test is negati ve, order throat culture for a patient y ounger than 10 or older than 25 ye ars old. If there is unresolv ed phar yngitis, consider ENT ref erral. Fig. 5. 7 Sore throat diagnosis algorithm. ENT ear, nose, throat 5 The Respiratory System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

146 Neisseria gonorrhoeae. Vaginal, cervical, penile, and rec-tal cultures should also be obtained when gonococcal pharyngitis is suspected. 3. Diphtheria is another cause of sore throat. Patients pres-ent with sore throat, low-grade fever, an adherent grayish membrane, and inflammation of the tonsils, pharynx, or nasal passages. The throat is moderately sore, with tender cervical adenopathy. The incubation period for diphtheria is 2-4 weeks. A confirmatory diagnosis is made by micro-bacteriologic analysis. 4. HIV (acute retroviral syndrome) is another possible differential. The patient may present with sore throat, fever, rash, and weight loss. Patient may give a history of IV drug use and sharing needles. Will need to get CBC, peripheral smear, HIV antibody and viral load, CD4 count, throat culture, and liver panel. Treatment will depend on the lab results and may include referral to an HIV clinic. 5. Atypical pneumonia: A patient with atypical pneumonia may present with 1-2 weeks of ongoing nonproductive cough, sore throat, and possibly a runny nose. Investigations required are CBC, sputum Gram stain and culture, chest X-ray, immunoglobulin M (Ig M) detection for Mycoplasma pneumoniae, and urine Legionella antigen. History and Physical Examination: Shortness of Breath Candidate Information: A 40-year-old man comes to your clinic with shortness of breath. Vital Signs: HR, 81/min, regular; BP, 130/78 mm Hg; temp, 37 °C; RR, 16/min; O2 saturation, 96% on room air Take a focused history and perform a focused and relevant physical examination. Please do not perform rectal, genito-urinary, or breast examination. Candidates usually find shortness of breath a difficult sta-tion in OSCE scenarios. Patients may have an underlying respiratory or cardiovascular disease. Some life-threatening conditions may also present with shortness of breath. Missing red flags and skipping important questions in the history can result in failure of this station. One of the examples of such cases is pulmonary embolism. In this station, asking about recent travel and other risk factors for pulmonary embolism will be crucial. It is extremely important to practice the history and physi-cal examination stations before the real exam with a time limit. The history should be relevant and focused. Try not to miss any red flags or serious differentials. The second part of the station is examination. You should be able to perform the examination in 3-4 min. Try to save 1-2 min for wrap-up or counseling. Differentials: For the respiratory system, some of the possible differentials include the following: Pneumonia Asthma Asthma exacerbation Exercise-induced asthma COPD Bronchiectasis Bronchogenic carcinoma (less likely in this station, but you must rule it out) Pulmonary embolism Pneumothorax Pulmonary tuberculosis HIV Anemia Starting the Interview: Knock on the door. Enter the station. Hand wash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr... I am your attend-ing physician. Are you Mr... ? Are you 40 years old?” History of Present Illness: “I understand you are here for shortness of breath; how are you doing now?” Start with a quick evaluation of the airway, breathing, and circulation. The patient may require an immediate interven-tion such as supplemental O 2 or airway management. Is the patient able to speak? If the patient is speaking and does not show any signs of restlessness or shortness of breath, then continue with the history. “Are you comfortable sitting? I want to ask you some questions about your shortness of breath? Should we start?” “What do you mean by shortness of breath?” Difficulty in breathing, not enough air, chest pain, chest tightness. “When did it start?” M. H. Sherazi

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147 “How did it start? Was it a sudden onset or gradual?” “Does it come and go or is it progressive?” If acute onset: “Can you please tell me what happened?” “What were you doing at that time?” “What did you do once you became short of breath?” “Was there any wheezing?” “Did you notice any chest tightness?” “Any sweating? Did you turn blue? Did you notice your heart racing? Does it get better or worse? Were you able to talk? Did you pass out?” “Did you have to go to the ER?” “Were you intubated or put on a breathing machine? Did they give you any medicine? What medicines? Did they give you any discharge medication?” If gradual onset: “In which setting does it come on: minimal activity, walk-ing (how far), running (for how long), taking stairs (how many flights), cold, stress, at rest, lying flat?” “Does it cause you to wake up at night?” “Is it recently getting worse?” “How many times a day or in a week does this occur?” “Are you already taking medications such as puffer or any other medication for your shortness of breath?” (If patient history suggests asthma or any other differential then con-tinue with the specific history instead of shortness of breath. ) Cough If shortness of breath with cough: “When did your cough start?” “Did it start gradually or suddenly?” “Is it continuous or does it come and go?” “Is the cough present all the time or at any specific time?” (day/night) “Does your cough present with any certain position?” (Lying down?) “Is it accompanied by phlegm?” -If phlegm then (consistency, odor, color, amount, blood). “What increases or decreases this cough?” Associated Symptoms: “Do you have pain anywhere in the body? Joint pain? Pain in your legs?” “Any recent travel?” “Any fever? Chills? Night sweats?” “Any weight loss?” “Any loss of appetite?” “Any swelling in your ankles?” “Any skin rash?” “How is this affecting your daily activity?” Precipitating or Aggravating Factors: “I will ask you a few more questions that will guide me to why you have shortness of breath. ” (Choose questions according to the history. ) “Do you suffer from heartburn or GERD?” “Have you recently experienced (up to 10 weeks) any flu-like symptoms or chest infection?” “Does the shortness of breath come on with exercise?” “Any recent stress or emotions?” “Any exposure to cold air, odor, dust, smoke, or pollen?” “Do you, or anyone around you, smoke?” “Have there been any recent changes in your home envi-ronment? Paints, carpets, linens, pillows, blankets, cur-tains, pets, plants, or renovations?” “Do you have any mold in your home or workplace?” “Do you have any exposure to chemicals at your work site?” Relieving Factors: “Does anything relieve your symptoms?” Past Medical History: “Do you have any previous health issues?” “Any lung, heart, or kidney disease?” “Any immunocompromised states?” “Have you ever had a tuberculosis test?” Past Hospitalization and Surgical History: “Have you ever been hospitalized or undergone any surgeries? If so, were there any complications?” Medication History: “Are you taking any medication?” If he says no, then continue to the next question. Otherwise, ask for aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), amiodarone, bleomycin, methotrexate, B-blockers, over-the-counter or herbal remedies, and any side effects. Allergic History: “Do you have any known allergies?” Family History: “Has anyone in your family had similar symptoms or health problems? Is there any lung or heart dis-ease in your family?” Social History: “Do you smoke? Does anyone else in your home or close at work smoke?” “Do you drink alcohol?” If the answer is yes, then ask further questions: “How much? Daily? For how long?” 5 The Respiratory System

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148 “Have you ever tried any recreational drugs?” If the answer is yes, “Which ones? For how long? When?” Relationships: “Are you sexually active? Do you have sex with men, women, or both?” Self-Care and Living Condition: “How do you live? Do you live alone or with someone? Do you require any help in daily self-care activities? Work Conditions and Financial Status: “What do you do for living? How do you bear your routine expenses? What is your occupation? Do you have health insurance or have a private health insurance coverage?” Support: “Do you have good support from your family and friends?” Functional Status: “How has this impacted your life?” Physical Examination: “Now, I shall start the respiratory system examination. ” Comment on vital signs. Check level of consciousness and alertness. Look for any abnormal findings in: -Hands -Face (nose, lips and mouth) -Neck and intercostal spaces Chest Examination: Inspection: -Position: sitting -Exposure: neck down to the waist -Observation: performed from front, side, and back -Respiratory rate and pattern -Observe and comment on contour, shape, skin, and chest expansion Palpation: -Warm up your hands -Chest expansion -Tactile fremitus Percussion. Chest auscultation: Listen for breathing sound and pres-ence of any adventitious sounds. Comment: “I will complete my examination by performing the vocal fremitus, listening to the heart, and measuring the JVD.   I would also like to do cervical and axillary lymph nodes. ”Wrap-Up: Thank the patient and tell him that he can now cover up. Ask the patient if he has any questions or concerns. Tell the patient that you need to run some tests (select from the following list). Investigations: O2 saturation ABGs CBC, electrolytes, liver panel, kidney function test, lipid profile, and blood sugar TSH and D-dimer Urine analysis Pulmonary function test (PFT) Chest X-ray (pneumonia, infection, neoplasm) ECG Describe the Diagnosis: According to the station diagnosis. Explain the nature of the disease and goals of treatment “Do you want me to tell you more about......... ?” Management Plan Possible Medical Treatment -Describe the duration of treatment, use of prescribed medication, compliance, and common side effects. Further Information Advice regarding lifestyle modification. Triggers and environmental control. Warning signs. Information through brochures, websites, and support groups. Flu shot every year in the fall and pneumococcal vaccine. Follow-Up: Discuss a follow-up visit according to the diagnosis. “Do you have any questions?” History: Pneumonia Candidate Information A 40-year-old man comes to your clinic with productive cough, fever, and pleuritic chest pain for 3 days. Vital Signs: T, 39. 7 °C; HR, 100; BP, 110/65; RR, 22; O 2 saturation, 92% Please take a detailed history. Discuss a management plan with the examiner. No examination required for this station. M. H. Sherazi

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149 Differentials: Community-acquired pneumonia Acute bronchitis Upper respiratory tract infection-associated cough HIV (Pneumocystis jiroveci) Pulmonary tuberculosis Lung abscess Lung cancer Starting the Interview: Knock on the door. Enter the station. Hand wash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr...... I am your attending physician. Are you Mr......? Are you 40  years old?” History of Present Illness: “I understand you are here for a cough. I am going to ask you few questions. Should we start?” “When did your cough start?” Three days ago. “Did it start gradually or suddenly?” It came on gradually. “Is it continuous or does it come and go?” It has been continuous since it started. “Is the cough present all the time or does it come on at a specific time?” No particular time. “Does your cough come with certain positions? Lying down?” There is no change in my cough in any position. “Is it getting worse with time?” Yes it is. “How long does each bout of coughing last?” A few minutes. Associated Symptoms: “What increases/decreases this cough?” Talking, walking, or taking the stairs. “Is it accompanied by phlegm?” Yes. -Consistency: Thick -Odor: No odor -Color: White -Amount: About half a cup a day -Any blood: No blood “Do you become short of breath?” No. “Have you noticed any difficulty in breathing, not enough air, chest pain, chest tightness, or wheezing?” No. “Do you have any upper respiratory tract symptoms such as nasal discharge, sore throat, dryness of mouth, and dif-ficulty in swallowing?” No. “Do you have any chest pain?” Yes, sharp chest pain, which increases with taking deep breaths. More on right side. “Do you have pain anywhere else in your body? Or any joint pain?” No pain. Risk Factors: “Have you had any recent contact with sick people?” No. “Do you have any pain in your legs?” No. “Have you traveled recently?” No. “Do you smoke?” No. “Have you ever taken any recreational drugs?” No. “Do you have any birds at home?” No. Precipitating or Aggravating Factors: “I will ask you more questions, which will guide me to why you have this cough. ” “Do you suffer from heartburn or GERD?” No. “Have you recently experienced (up to 10 weeks) any flu-like symptoms or chest infection?” No. “Have you had the flu vaccine?” Yes, last year. “Do you exercise?” I do not do any exercise. “Have you experienced any recent stress or emotions?” No. “Have you been exposed to cold air, odor, dust, smoke, or pollen recently?” No. “Do you or does anyone around you smoke?” No. “Has there been any recent change in your home environ-ment such as paints, carpets, linens, pillows, blankets, curtains, pets, plants, and renovations?” None. “Are you exposed to mold in your home?” No. “Are you exposed to chemicals at your work site?” No. Relieving Factors: “Does anything relieve your symp-toms?” Yes, lying down or sitting. Constitutional Symptoms: Fever -Yes, with chills for 3 days Night sweats -None Loss of weight -None Loss of appetite-Good appetite Past Medical History: “Do you have any previous health issues?” No. “Do you have any lung, heart, or kidney problems? Any immunocompromised states?” None. “Have you ever had a tuberculosis test?” No. 5 The Respiratory System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

150 Past Hospitalization and Surgical History: “Have you ever been hospitalized? Have you ever undergone any sur-geries? If so, were there any complications?” I've never been hospitalized nor had any surgeries. Medication History: “Are you taking any medication?” No regular medication s. Allergic History: “Do you have any known allergies?” No, none that I know of. Family History: “Does anyone in your family have similar symptoms or similar health problems? Is there any lung or heart disease in your family?” No. Social History: “Do you smoke? Do you drink any alcohol? Have you ever tried any recreational drugs?” I drink socially. I don't smoke and I've never used any recreational drugs. Relationships: “Are you sexually active?” Yes, I live with my wife and my 4-year-old son. Self-Care and Living Condition: “What do you do for a living?” I'm an office manager. Support: “Do you have good support from your family and friends?” Yes, they are very supportive. Functional Status: “How is this affecting your day-to-day activities?” I didn't go to work today. Wrap-Up Question: “What would you like to do next?” Answer: “I would like to do a general physical and respi-ratory system examination. I would also like to run some tests. ” Question: “Do you want to do any investigations?” Answer: Suggest the following: -O2 saturation -ABGs -CBC, ESR, inflammatory markers, electrolytes, blood cultures, liver panel, kidney function test, D-dimer, urine for legionella, and PCR -Urine analysis -Sputum culture -Will send for a pulmonary function test and a chest X-ray if required Findings: The examiner may provide these findings: History : Pain on inspiration, fever, and chest pain Investigation: -WBC 15500 -ESR 29 The examiner may give an X-ray (Fig.   5. 8): CXR -right middle lobe consolidation Question: “What is your diagnosis?” Answer: “With this history, clinical examination, and investigation findings, in my opinion, you are suffering from a condition called pneumonia. ” Question: “Doc, can you please tell me more about pneumonia?” Answer: “Pneumonia is an inflammation of the lung tis-sue due to either a bacterial or a viral infection. It is called a lobar pneumonia if an area or lobe of the lung is involved. In cases of patchy involvement, it is called bronchopneu-monia. It will be called atypical pneumonia if it is caused by bacteria other than the typical ones that cause infection. Common pneumonia found attended in family practice is also classified as hospital-acquired or community-acquired pneumonia. ” Fig. 5. 8 On day 1 of pneumonia, the chest X-ray shows subpleural flakes of blurry shadow at the right lower lung. (Reprinted with permis-sion from Liang [ 6]) M. H. Sherazi

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151 Causes: Streptococcus pneumonia Haemophilus influenza B Mycoplasma pneumoniae Chlamydia pneumoniae Legionella pneumophila Question: “Can we do something for pneumonia prevention?” Answer: “Immunization for influenza through the annual flu injection given in autumn can help prevent pneumonia. The pneumococcal vaccine is recommended for those over 65 years of age and for those at risk of infection. Avoiding smoking and seeking immediate medical care for respiratory infections, especially when there is a preexisting health issue will also help. ” Further Information for the Patient Treatment at Home -This is acceptable if you are generally healthy and if the pneumonia is not severe: Take analgesics such as acetaminophen or ibuprofen. Rest is important. Drink lots of fluids. Take prescribed antibiotics (if infection is bacterial). “We can review the antibiotics after the sputum culture report is back to identify the bug and its appropriate antibiotic. ” Avoid cough-suppressant medications. Treatment at a Hospital -Hospital admission is required for: Patients with poor health. Moderate to severe pneumonia. For patients who do not respond quickly to antibiotics. Some strains such as influenza may rapidly progress to a life-threatening state, causing the need for immediate hospital admission. Question: “What antibiotics you would like to prescribe?” (Please check your regional guidelines. ) Answer: No comorbidities/previously healthy; no risk fac-tors for drug-resistant S. pneumoniae: Azithromycin/clarithromycin/doxycycline If patient received antibiotics in the last 3 months: Azithromycin/clarithromycin plus amoxicillin/ amoxicillin-clavulanate Respiratory fluoroquinolone (e. g., levofloxacin or moxifloxacin) Comorbidities present (alcoholism, bronchiectasis/cystic fibrosis, COPD, IV drug user, post-influenza, asplenia, dia-betes mellitus, lung/liver/renal diseases) Levofloxacin/moxifloxacin/amoxicillin-clavulanate Ceftriaxone/cefuroxime plus a macrolide (azithromycin or clarithromycin) Duration of Therapy: A minimum of 5 days and patient should be afebrile for 48-72 h. There is longer duration of therapy if initial therapy was not active against the identified pathogen or if it was complicated by extrapulmonary infec-tions [7]. Further Information: Advice regarding lifestyle modification. Triggers and environmental control. Warning signs. Information through brochures, websites, and support groups. Flu shot every year in the fall and pneumococcal vaccine if over 65 or at risk. Follow-Up: “Follow up in 3 days or once the labs will be back. Do you have any questions?” History: Atypical Pneumonia Candidate Information A 24-year-old man comes to your clinic with complaints of fever and cough and feels unwell and tired for 2 weeks. Vital Signs: T, 38. 7 °C; HR, 100; BP, 110/65; RR, 22; O 2 saturation, 92% Please take a detailed history. No examination is required for this station. Differentials: Atypical pneumonia (Legionella pneumophila, Mycoplasma pneumoniae, and Chlamydophila pneumoniae) Post-upper respiratory tract infection Reactive airway disease HIV (Pneumocystis jiroveci) Lung cancer Pulmonary tuberculosis Tropical diseases (Q fever, psittacosis, brucellosis, bovine TB) 5 The Respiratory System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

152 Starting the Interview: Knock on the door. Enter the station. Hand wash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr... I am your attend-ing physician. Are you Mr... ? Are you 24 years old?” History of Present Illness: “I understand you have not been feeling well for a few days. I am going to ask you a few questions; should we start?” “How long you have been feeling unwell?” About 2 weeks. “Can you please tell me more about it?” I started feeling tired and low in energy for the first few days and then had a low temp. I took Tylenol, which partially helped in reducing the fever and tiredness. Two to 3 days after the symptoms started, a dry cough started, which changed to a productive one over the next few days. “How is your fever now?” It comes and goes. It is not constant, but it has been happening almost every day now for the last 5 days. The highest temp I recorded at home was 38. 8  °C.   My fever seems to be reduced by taking Tylenol. “Is it associated with chills or night sweats?” I feel cold and have chills when my fever is coming back. I haven't had any night sweats. “How is your appetite?” It has decreased. I do not feel like eating or drinking. “How is your cough now?” I still have a cough and it is producing phlegm every day. “Is the cough present all the time or at a specific time of day?” No particular time. “Does your cough come on with a certain position such as lying down?” No change with any position. “Is it getting worse?” Yes, it is. “How long does each bout of coughing last?” A few minutes. “You just mentioned phlegm? Can you describe it?” -Consistency: Thick. -Odor: No odor. -Color: White to start and now it is greenish. -Amount: About half a cup a day. -Any blood: No blood. “Any lumps and bumps?” No. “Bone pain?” No. “Any itchiness?” No. “Any headache or sensitivity to light and neck pain?” Yes, I've had a headache since the symptoms started. “Any history of sinusitis, nasal stuffiness, sore throat, or ear pain?” None. “Have you had any recent dental procedures?” No. “Any shortness of breath (SOB) or chest tightness?” No. “Any discomfort in the tummy?” No. “Any discoloration of the skin?” No. “Any bowel or urine problems?” No. “Any joint pain?” No. “Any skin nodules?” No. Associated Symptoms: “What increases/decreases this cough?” Talking, walking, or taking the stairs makes my cough worse. “Do you become short of breath?” No. “Do you notice any difficulty in breathing, chest tight-ness, or wheezing?” No. “Do you have any upper respiratory tract symptoms such as nasal discharge, sore throat, dryness of the mouth, or difficulty in swallowing?” No. “Do you have any chest pain?” Yes, I get sharp chest pain that increases with taking deep breaths in. More on the right side. Risk Factors: “Have you had any recent contact with sick individuals?” No. “Do you have any pain in your legs?” No. “Have you done any recent travel?” No. “Are you a smoker?” Yes. “Have you ever done any recreational drugs?” No. “Do you have any birds at home?” No. Precipitating Factors or Aggravating Factors: “I am going to ask you more questions, which will guide me to why you have this cough. ” (Pick a question according to the history. ): “Do you suffer from heartburn or GERD?” No. “Have you recently experienced (up to 10 weeks) any flu-like symptoms or chest infection?” No. “Have you had the flu vaccine?” Yes, last year. “Do you exercise?” I do not do any exercise. “Have you experienced any recent stress or emotions?” None. “Have you recently been exposed to any cold air, odor, dust, smoke, or pollen?” None. “Does anyone smoke around you?” No. “Has there been any recent change in your home environ-ment such as paints, carpets, linens, pillows, blankets, curtains, new pet, plant, renovations?” None. “Is there any mold present in your house?” No. “Are you exposed to chemicals at your work site?” None. M. H. Sherazi

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153 Relieving Factors: “Does anything relieve the symptoms?” Sitting or lying down. Constitutional Symptoms: (Ask here if you have not already asked) Fever? Yes, with chills for 3 days. Night sweats? None. Weight loss? None. Loss of appetite? Good appetite. Past Medical History: “Have you had any previous health issues?” None. “Have you ever had a tuberculosis test?” No. “Have you ever been in contact with an individual with TB?” No. “Have you ever been in an immunocompromised state?” No. Past Hospitalization and Surgical History: “Have you ever been hospitalized or undergone any surgeries? If so were there any complications?” No. Medication History: “Are you taking any medications?” No regular medication. Allergic History: “Do you have any known allergies? No allergies that I know of. Family History: “Does anyone in your family have similar symptoms or similar health problems? Is there any lung or heart disease in your family?” No. Social History: “Do you smoke or drink? Have you ever taken any recreational drugs?” I drink socially and have smoked five to ten cigarettes a day for 5 years. I've never taken any illicit drugs. Travel History: “Have you done any recent travel?” I went to Thailand with friends last month. I did some scuba diving training. “Where did you stay?” We stayed in a hotel. “Did you get any tattoos or body piercings?” No. “I need to ask you a personal question. Did you have unprotected sex during or after your trip?” No. Relationships: “Are you sexually active?” Yes, I live with my girlfriend. She does not have similar symptoms. Self-Care and Living Condition: “What do you do for liv-ing?” I work in an office as a receptionist. Support: “Do you have good support from your family and friends?” Yes, they are very supportive. Functional Status: “How has this impacted your day-to- day activities?” I didn't go to work today. Wrap-Up: Question: “What would you like to do next?” Answer: “I would like to do a general physical and respi-ratory system examination. I would also like to run some tests. ” Findings: The examiner may provide these findings: History: Pain on inspiration, fever, and chest pain Vital Signs: Temp 38. 7 °C, HR 100, BP 110/65, RR 22, O2 sat 92% Physical examination: -Slight RUQ tenderness -Reduced chest wall movement on the right side -Dullness on percussion of the right lung base -Crackles and bronchial wheezing to the right lung base Question: “Do you want to do any investigations?” Answer: Suggest the following: O2 saturation ABGs CBC, ESR, CRP, electrolytes, and blood cultures D-dimer, urine for legionella antigen, and Ig M detection for Mycoplasma pneumoniae Urine analysis Sputum examination for AFB staining Sputum microscopy and culture Pulmonary function test Chest X-ray (Fig.  5. 9) Question: “What is your diagnosis?” Answer: “With this history, clinical examination, and investigation findings, in my opinion, you are suffering from a condition called atypical pneumonia. ” Question: “Can you tell me more about it?” Answer: “Atypical pneumonia is also called walking pneu-monia. It is an infection of the lung caused by certain bugs that are usually acquired by droplet rather than by one of the more common pathogens. A variety of microorganisms cause it such as Legionella pneumophila, Mycoplasma pneu-moniae, and Chlamydophila pneumoniae. It is mostly seen in late summer and fall, but most cases are seen throughout the year. ” 5 The Respiratory System

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154 “Mycoplasma pneumonia is caused by the bacteria M. pneumoniae and often affects patients younger than 40. Legionella pneumonia is commonly seen in middle-aged and older adults, patients with chronic illnesses, and smokers. It may cause severe symptoms, and the pneumonia is also known as Legionnaires' disease. ” “Chlamydia causes a milder form of pneumonia. It can occur at any time during the year. ” When it develops independently from another disease, it is called primary atypical pneumonia. Most of the patients with atypical pneumonia are treated as outpatients, and some can even go to work and continue with their daily routines. “Atypical pneumonia spreads with droplets from the nose and throat mostly through sneezes and coughing. It spreads slowly. The contagious period is usually less than 10 days. People who live and work in crowded areas such as homeless shelters and prisons are at a higher risk of contracting the disease. ” Question: “Can we prevent atypical pneumonia?” Answer: “There is no vaccine for mycoplasma infections, but there are certain steps we can take to reduce the risk of getting atypical pneumonia. ” Further Information for the Patient: Treatment at home -“This is acceptable if you are gen-erally healthy and if the pneumonia is not severe. ” -“Take analgesics such as acetaminophen or ibuprofen. ” -“Rest is important with adequate sleep. ”-“Drink lots of fluids and maintain a balanced diet. ” -“Take prescribed antibiotics (bacterial pneumonia). ” -“We can review the antibiotics after the sputum culture report is back to identify the bug and its appropriate antibiotic. ” -“Avoid cough-suppressant medication. ” -“Wash your hands frequently. ” -“Please try to stop smoking. Smokers are more suscep-tible to infection. ” -“Cover your mouth with your sleeve when you cough or sneeze. Coughing and sneezing are the most com-mon ways to spread infection. ” Treatment as outpatient -“Macrolides (azithromycin) are considered the treatment of choice. In addition to macrolides, fluoroquinolones are recommended for the treatment of adults and tetracyclines (e. g., doxycycline) can be used for older children and adults” [ 8]. Patient instructions : “You need to take antibiotics for at least 2 weeks. If during that time you develop any symp-toms such as a high spiking fever, vomiting, malaise, or difficulty in breathing, you should immediately seek med-ical attention. ” Possible complications [9]: -Severe lung damage -Meningitis, myelitis, and encephalitis -Hemolytic anemia Follow-Up: “Please understand that the symptoms of atypical pneumonia take a long time to resolve. However, we will follow you up with a repeat X-ray and culture in about 2 weeks. The prog-nosis is good, so don't worry. ” Advice regarding lifestyle modification: Triggers and environmental control Warning signs Information through brochures, websites, and support groups Flu shot every year in the fall and pneumococcal vaccine “I will follow up in 3 days or once the labs will be back. Do you have any questions?” Physical Examination: Human Immunodeficiency Virus and Pneumonia Candidate Information A 31-year-old HIV-positive man comes to your clinic with 5 days of shortness of breath, cough, and fatigue. Vital Signs: HR, 81/min, regular; BP, 130/78 mm Hg; temp, 37 °C; RR, 16/min; O2 sat 93% Fig. 5. 9 Atypical pneumonia. X-ray showing diffuse infiltration. (Reprinted with permission from Liang [ 6]) M. H. Sherazi

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155 Perform relevant physical examination. Please do not per-form rectal, genitourinary, or breast examination. In this station, we need to do a relevant general physical examination and detailed respiratory system examination. HIV and AIDS are not the same diseases. Signs of infection or malignancy in an HIV patient indicate the progression of AIDS. Important in this station is to look for specific physical findings related to HIV. Differentials: Pneumonia (Streptococcus, Mycoplasma, Haemophilus) Pneumocystis carinii pneumonia (PCP) Tuberculosis Mycobacterium avium Starting the Physical Examination: Knock on the door. Enter the station. Hand wash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Stand on the right side of the patient and start the examination. Opening: “Good morning/good afternoon. I am Dr... I am your attend-ing physician. Are you Mr... ? Are you 31 years old?” “I understand you are here because of shortness of breath, cough, and fatigue. I have been asked to perform your exami-nation. During the examination, if you feel uncomfortable at any point, please let me know. ” Comment on the vital signs given by the candidate information. Interpret the findings: “Vitals are normal. ” HIV-positive patient may have fever and tachypnea. General appearance: looks malnourished and dehydrated. General Physical Examination: “I need to ask you a couple of questions as a part of my examination. ” “What is the date today?” “Do you know where you are right now?” Comment: “Patient is oriented and alert. ” Observe the patient for: -Distress -Sweating -Difficulty speaking Hands: “Can I see your hands?” Observe for color, capillary refill, palmar erythema, peripheral cyanosis, nicotine stain, clubbing, muscle wasting, contractures (Dupuytren's), and asterixis. “I am going to feel your pulse now. ” Comment: rate, rhythm, and volume of pulse. Face: Observe for the following: -General: Face: color, plethora, central cyanosis, cushingoid/ moon face, ptosis (Horner syndrome) Nose: flare, perforated septum Lips: pursed -Eyes: CMV retinitis, pallor, jaundice. -Oral cavity: angular cheilitis, stomatitis, hairy leuko-plakia, thrush, mucosal petechiae, and gingivitis -Sinuses: tenderness -Skin and mucous membranes: bacteria/fungal infec-tion; Kaposi's sarcoma; morbilliform eruption; sebor-rheic dermatitis; eosinophilic pustular folliculitis; herpes simplex/herpes zoster, nasolabial and genital areas/chest wall; warts, molluscum contagiosum; and HPV, hairy leukemia and clubbing and cyanosis (cen-tral, peripheral) Neck: “I am going to feel your neck now. ” -Trachea: Position (central or mid line) and mobility. Look for use of accessory muscles. -Lymph nodes: Palpate for cervical lymph nodes. Look for generalized lymphadenopathy. Cardiovascular: Listen for murmurs and rubs (underly-ing pericarditis, myocarditis, or endocarditis). Joint: Look for sensory/motor dysfunction, arthritis, or vasculitis. Neural: Look for meningitis/encephalitis-meningeal irri-tation and focal defects. Mental status: Check for dementia/delirium. Abdomen: Palpate for tenderness, any mass, in the liver and spleen. GU: Just mention. If there will be any positive finding, the examiner will tell or will ask what investigations you will do further in this regard. DRE, Pap smear, and any cervical lesions. Respiratory Inspection: Observe from the front, side, and back. -Look for contour, shape, skin, intercostal retractions, respiratory distress, and expansion. Respiratory rate and pattern. Palpation: Check for tenderness. -Chest expansion Findings: Chest movements may be asymmetrical. -Tactile fremitus Findings: May be increased on the areas of consolidation Percussion: Comment on the findings -percussion note will be asymmetrical and dull at the pneumonia site. 5 The Respiratory System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

156 Chest auscultation: “I am going to listen to your chest. ” -Expected auscultation findings: Breath sounds may be decreased over the consolidated area. Bronchial or bronchovesicular breath sounds and late inspiratory crackles may also be heard in this area. -At the end of the auscultation: Comment on your findings. Wrap-Up: Thank the patient and tell him he can now cover up. Ask the patient if he has any questions. Describe your findings to the patient or to the examiner. Question: “What would you like to do next? Answer: “I would like to do some tests”: O2 saturation ABGs CBC, CRP, electrolytes, and blood cultures HIV antibody and viral loads CD4 count Urine analysis Sputum examination for AFB staining Sputum microscopy and culture Pulmonary function test Chest X-ray The examiner may show an X-ray or will ask about the X-ray findings (Fig.  5. 10 showing pneumonia). Question: “What is your diagnosis?” Answer: “With the clinical examination and X-ray find-ings, in my opinion, you are suffering from a condition known as Pneumocystis carinii pneumonia. ” Question: “Can you tell me more about it?” Answer: “Pneumocystis carinii pneumonia is a serious infection spread through air, caused by a fungus called Pneumocystis jiroveci, which leads to inflammation and fluid collection in the lungs. Most of the population are exposed to this fungus at a young age. But the immune system of a healthy individual will overcome it. In indi-viduals with HIV, due to the weak immune system, the patients become prone to this opportunistic infection, and it may cause pneumonia. Sometimes, PCP can affect other parts of the body such as the liver, lymph nodes, and bone marrow. ” “Patients may present with cough, sputum, tachypnea, cyanosis, and abrupt onset of high fever. Findings may vary in presentation. In most cases, the chest X-ray will show an interstitial pattern. However, the X-ray finding may vary as irregular pattern distribution of infiltrate, nodules, cavities, diffuse or focal consolidation, or cystic changes. ” “Two HIV tests are recommended. The HIV viral load test helps to diagnose a new HIV infection. An HIV antibody test is done for a preexisting infection. With the use of HIV medication, PCP rates have decreased significantly. PCP is still the most common opportunistic infection in people with HIV/AIDS.  Those with a CD4 cell count less than 200 units ab Fig. 5. 10 Pneumocystis carinii pneumonia (PCP). (a ) X-ray demon-strates grid-like and cord-like shadows at both lungs and accompany-ing diffusely increased density. (b ) In a different patient with PCP, X-ray demonstrates large flakes of shadows with increased density in both lungs and left pneumothorax. (Reprinted with permission from Liang [6 ]) M. H. Sherazi

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157 are at highest risk. PCP is a highly treatable and preventable infection” [10]. Treatment: Oxygen: Keep Sa O 2 >90% Trimethoprim-sulfamethoxazole is recommended as the treatment of choice for pneumocystis pneumonia (PCP) of any severity in HIV-infected patients [11]. This is fre-quently combined with a course of oral steroids. Other drugs that may be used are Dapsone, inhaled pent-amidine, and Mepron (atovaquone) can be taken as an oral suspension. Preventing Pneumocystis Pneumonia: There is no vaccine available to prevent this type of pneumonia. Highly active antiretroviral therapy (HAART) is consid-ered to be the best option to prevent PCP. Quitting smoking also reduces the risk for PCP. Another recommendation is to start PCP drugs before CD4 cell counts drop too low. Further Information for the Patient: “I would strongly recommend using condoms during intercourse to avoid unwanted pregnancy and to prevent STIs. ” “If during that time you develop any symptoms such as high fever, vomiting, malaise, or difficulty in breathing, you should immediate seek medical attention. ” Advice regarding lifestyle modification. Information through brochures, websites, and support groups. Flu shot every year in the fall and pneumococcal vaccine. Follow-Up: Follow-up in 1 week or once labs are back. Please ask before finishing the conversation: “Do you have any questions?” History: Cough for 4 Weeks Candidate Information A 40-year-old man comes to your clinic with an ongoing cough for 4 weeks. Please take a detailed history. Differentials: Asthma GERD Postnasal drip Post infectious cough (Post viral URTI) Chronic bronchitis Bronchiectasis Interstitial lung disease Cardiac causes: congestive heart failure Drugs: ACE inhibitors Occupational Starting the Interview: Knock on the door. Enter the station. Hand wash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr... I am your attend-ing physician. Are you Mr... ? And you are 40 years old?” “I understand you are here for a cough. I am going to ask you a few questions. Should we start?” History of Present Illness: “How would you describe your cough?” “When did your cough start? Is it a chronic cough lasting more than 3 weeks?” “How did it start? Gradually or suddenly?” “Is this the first time you've had this cough?” “Is it continuous or does it come and go?” “Is the cough present all the time or more so at a particu-lar time of day/night?” “Does your cough come on with a specific position such as lying down?” “Is it worsening with time?” “How long does each bout of coughing last?” “What increases/decreases this cough?” Associated Symptoms: “Does the cough come with spu-tum/phlegm?” If yes, ask about consistency, odor, color, amount, and blood. Shortness of breath and asthma: -“Have you had any shortness of breath?” -“Do you get shortness of breath with a change in position?” -“Has there been any wheezing?” -“Did you notice any chest tightness?” -“Any sweating? Did you turn blue?” -“Did you notice any heart racing?” -“Does it get better or worse?” -“Were you able to talk?” -“Did you use your puffer or any other medication?” -“How many times did you use the puffer?” Upper respiratory tract symptoms -“Do you have any nasal discharge?” 5 The Respiratory System

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158 -“Do you have a sore throat?” -“Do you have any dryness of the mouth?” -“Do you have difficulty swallowing?” -“Do you feel any dripping in your throat that you have to clear (postnasal drip)?” -“Do you recall any recent contact with sick people?” -“Did you recently travel anywhere out of town?” Chest pain: If the patient has chest pain, then ask about pain and the associated symptoms such as a racing heart, nausea, vomiting, and syncope. GERD: “Do you suffer from heartburn or GERD/reflux?” (Cough is worse on lying down, after meals or after bend-ing on waist. Ask for any previous PPI treatment. ) Allergic history (it can be asked here or after the past medical history). “How is this affecting your daily activity?” Constitutional Symptoms: Fever, night sweats, loss of weight, loss of appetite Precipitating Factors or Aggravating Factors: “I am going to ask you a few more questions that will guide me to why you have this cough. ” “Is your cough aggravated by exercise?” “Do you think your cough is related to emotions or stress?” “Does cold air, odor, dust, smoke, or pollen worsen your cough?” “Do you, or does anyone around you, smoke?” “Is there any recent change in home environment such as new paints, carpets, linens, pillows, blankets, curtains, new pet, plant, or renovations?” “Are you exposed to chemicals at your work site?” Relieving Factors: “Does anything relieve your symptoms?” Past Medical History: “Have you had any previous health issues?” “Do you have any health issues related to your lungs, heart, or kidneys?” “Have you ever had a tuberculosis test?” Past Hospitalization and Surgical History: “Have you ever been hospitalized or had any surgeries? If so, were there any complications?” Medication History: “Are you taking any medications?” If he says no, then con-tinue to next question. Otherwise ask for aspirin, NSAIDs, amiodarone, bleomycin, methotrexate, beta-blockers, over- the-counter or herbals, and any side effects. Allergic History: “Do you have any known allergies?” Family History: “Does anyone in your family have similar symptoms or simi-lar health problems? Is there any lung or heart disease in your family?” Social History: “Do you or does anyone else in close proximity to you smoke? Do you drink alcohol?” If yes, then further ques-tions: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” If yes, “Which one? How long? When?” Relationships: “Are you sexually active? Do you have sex with men, women, or both?” Self-Care and Living Condition: “What do you do for living? Who lives with you?” Work Conditions and Financial Status: “Are there any current renovations at your work or home?” Support: “Do you have good support from your friends and family?” Functional Status: “How is this impacting your day-to-day life?” Wrap-Up: Further steps: “I would like to do a general physical and respiratory system examination. I would also like to run some tests (only if asked). ” Investigations: Suggest the following: O2 saturation ABGs CBC, electrolytes, liver panel, kidney function test, and D-dimer Urine analysis Pulmonary function test Chest X-ray (pneumonia, infection, neoplasm) ECG Describe the Diagnosis: According to the station diagnosis, nature of the disease, and goals of treatment. Ask, “Do you want me to tell you more about it?” M. H. Sherazi

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159 Management Plan: Possible medical treatment: Duration of treatment, use of prescribed medication, compliance, and common side effects Further Information: Advice regarding lifestyle modification. Triggers and environmental control. Warning signs. Information through brochures, websites, and support groups Flu shot every year in the fall and pneumococcal vaccine (if patient is over 65 or at risk). Follow-Up: Discuss about a follow-up visit according to the diagnosis. Ask, “Do you have any questions?” Checklist: Cough See Table  5. 5 for a checklist that can be used as a quick review before the exam. History: Hemoptysis Candidate Information A 65-year-old man who coughed up some blood at home presents to the emergency department. Please take a detailed history. No physical examination is required Differentials: Acute infection (URTI or acute bronchitis) Chronic bronchitis Community-acquired pneumonia Pulmonary tuberculosis Bronchogenic carcinoma/metastatic carcinoma Table 5. 5 Checklist for cough Starting the interview Knock on the door Enter the station Hand wash/alcohol rub Greet the examiner and patient Give stickers to the examiner if required or show your ID badge Sit on the chair or stand the right side of the patient. Start the physical exam Opening Introduction OCD of cough What increases/decreases cough How cough is affecting daily activity Triggers Associated symptoms Sputum Consistency, odor, color, amount, blood If shortness of breath is present: Ask a few questions about it (with change in position, etc. ) Upper respiratory tract symptoms: Runny nose, sore throat, dry mouth, difficulty swallowing, postnasal discharge Chest pain: Ask questions regarding the pain and about racing heart, nausea, vomiting, syncope Constitutional symptoms: Fever, night sweats, weight loss, loss of appetite GERD: Does anything relieve the symptoms?Table 5. 5 (continued) Risk factors Recent contact with sick people Leg pain Recent travel Allergies Smoking Drugs HIV Past medical history Past hospitalization and surgical history Medication history Allergic history Family history Social history Smoking/alcohol/drug/sexual Self-care/living conditions and relationships (what they do for a living) Work conditions and financial status Renovations at work or home Support From family and friends Functional status Impact on daily activities Wrap-up Commit to do a general physical and respiratory system examination Investigations Describe the diagnosis Nature of the disease and goals of treatment Management plan Explain possible medical treatment Further information Advice regarding lifestyle modifications Triggers and environmental control Warning signs Information through brochures, websites, and support groups Flu shot every year in the fall and pneumococcal vaccine if over 65 or at risk Discuss follow-up visit according to diagnosis Ask patients if they have any questions 5 The Respiratory System

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160 Pulmonary embolism/infarction Trauma Left heart failure Autoimmune diseases (Goodpasture and Wegener granulomatosis) Lung abscess Bronchiectasis Aspiration of foreign body Anticoagulation therapy Starting the Interview: Knock on the door. Enter the station. Hand wash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr... I am your attend-ing physician. Are you Mr... ? Are you 65 years old?” History of Present Illness: “How can I help you today?” Doc, I am very worried about myself. I coughed up some blood!! Show empathy: “I am sorry to hear that, that must have been scary!” Quickly evaluate the patient to see if the patient needs any immediate intervention. Show support: “I am here to help you. I am going to ask you a few questions. ” “How are you now? Will you be able to answer some questions?” “Are you comfortable sitting or do you want to lie down?” “Are you feeling dizzy/tired or have you lost consciousness?” Ask for a set of vitals from the examiner and comment: “I just want to make sure my patient is stable enough to pro-ceed with a history. ” “When did you cough up blood?” Early this morning. “Did you cough up blood or vomit blood?” Coughed up. “How much blood?” About a cup. “What was the color? (bright red/pink/brown/rusty or like coffee ground appearance?)” Bright red. “Was is pure blood or was there mucus mixed with the blood?” It was mixed with phlegm. “Was this the first time, or how long has this been going on?” It is the first time. “What were you doing when it happened?” I had just woken up and was getting ready to go to work. “Did you have an ongoing cough?” No. If There Is an Ongoing Cough, Then Ask a Few Questions About the Cough: “Is the cough continuous or does it come and go?” “Is the cough present all the time or does it worsen at a particular time of day?” “Does your cough worsen with a specific position such as lying down?” “Is your cough worsening?” “How long does each bout of coughing last for?” Associated Symptoms: “Was it accompanied by sputum?” Yes. -Consistency: Thick. -Odor: No odor. -Color: It was white to start with; now it is yellow. -Amount: Almost a cup a day. “What increases/decreases this cough?” Nothing in particular. “Any hoarseness in your voice?” No. If Shortness of Breath Is Present, Then Ask a Few Questions About It: Do you get shortness of breath with change in position? Upon lying flat? If Chest Pain Is Present, Then: Ask about the pain and the presence of a racing heart, nau-sea, vomiting, syncope. Constitutional Symptoms: Fever, night sweats, loss of weight, and loss of appetite Risk Factors: “Have you recently had any flulike symptoms or a chest infection?” “Have you had any recent contact with sick people such as people with tuberculosis?” “Have you ever been screened for tuberculosis?” “Do you have any pain in your legs?” “Have you done any recent travel?” “Are you bleeding elsewhere? Bleeding gums?” “Are you exposed to asbestos?” “Do you smoke or do drugs?” “Are you exposed to birds?” Past Medical History: “Have you had any previous health issues?” “Any lung, heart or kidney disease problems? Any immu-nocompromised states?” “Have you ever had a tuberculosis test?” Past Hospitalization and Surgical History: “Have you previously been hospitalized or undergone surgery?” M. H. Sherazi

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161 Medication History: “Are you taking any medication?” If he says no, then con-tinue to the next question. Otherwise ask about use of blood thinners, anticoagulants such as warfarin, any over-the- counter or herbals, and any side effects. Allergic History: “Do you have any known allergies?” Family History: “Has anyone in your family had similar symptoms or similar health problems? Is there any lung or heart disease in your family?” Social History: “Do you or does anyone else in your home or close to you at work smoke? Do you drink alcohol?” If yes, then ask further questions: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” If yes, “Which ones? How long? When?” Relationships: “Are you sexually active? Do you have sex with men, women, or both?” Self-Care and Living Condition: “What do you do for living? Who lives with you?” Support: “Do you have good support from your family and friends?” Functional Status: “How is this affecting your daily activities?” Wrap-Up: “I would like to do a general physical and respiratory system examination. I would also like to run some tests (only if required based on history). ” Investigations: CBC, ABGs, electrolytes, liver panel, kidney function test, and D-dimer INR/PTT Urinalysis Sputum for cytology, AFB, C&S, and fungal Pulmonary function test Bronchoscopy Serology (ANA, ANCA, C3, C4, anti-GBM) Management Plan: “I want to keep you in the emergency room until we will get the lab results and chest X-ray back. We may need to admit you for further evaluation and specialist evaluation. ” “Do you have any questions?”If the similar patient presents in a walk-in clinic and patient seems to be stable enough to do outpatient blood work up and a chest X-ray, then the patient may be sent home and a follow-up should be booked. If the patient is unstable and requires immediate attention, then refer him to the emer-gency room or call an ambulance for transfer. History: Asthma Candidate Information Scenario 1: A 22-year-old male came into the office for a follow-up. He has had asthma for 4 years. He recently had an asth-matic attack and was treated in the emergency department. Please take a detailed history and address the patient's concerns. Scenario 2: A 22-year-old male comes to your office with a cough and shortness of breath that he has been experiencing for 1 day. Scenario 3: A 22-year-old male has shortness of breath, which increases with exercise. He also has a cough at night. He has had a history of asthma since the age of 9. He uses a Ventolin inhaler as required. Please take a detailed history. No examination is required for this station. Differentials: Asthma Asthma exacerbation Exercise-induced asthma COPD Pneumonia Bronchiectasis Bronchogenic carcinoma Starting the Interview: Knock on the door. Enter the station. Hand wash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr... I am your attend-ing physician. Are you Mr... ? Are you 22 years old?” Introduction (for Scenario 1): “I understand you had to go to the emergency department 3 days ago with an asthma attack. How do you feel now?” 5 The Respiratory System

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162 History of Present Illness: “I would like to ask you some questions about your recent asthma attack. ” History of Recent Event: “Can you tell me what happened at the time of your attack?” “Have you visited the ER before for your asthma?” “When did it happen?” “Was it a sudden or a gradual onset?” “Did you have any shortness of breath?” “Was there wheezing?” “Did you notice any chest tightness?” “Any sweating? Did you turn blue?” “Did you notice your heart racing?” “Is it getting better or do you think it is getting worse?” “Were you able to talk?” “Did you pass out?” “Did you use the puffer or any other medications to ease your symptoms?” If so, ask: “How many times did you use the puffer?” “How did you get to the ER?” “Did they give you any medicine?” If so, ask: “Which medicines?” “Were you intubated?” “Did they give you any discharge medicines?” History of Asthma: “As I am seeing you for the first time, I want to ask you about your asthma. ” “When were you diagnosed?” “How were you diagnosed?” “Are you on any puffers? Which ones?” “Do you use a spacer?” “Do you use a peak flow meter/spirometer?” “Has your asthma been under control since?” “How many times do you use your puffer?” “Do you use it before exercise?” “Have you noticed a need to increase the doses recently?” “Have you noticed any increase in the number of attacks recently?” “Do you have regular follow-ups?” “When was the last time you were seen by your GP?” “When was the last time you had a pulmonary function test?” “Have you had any attacks during the night?” “Have you had any attacks at rest?” “Does your doctor have to adjust your medication often?” “How often do you have to use your medicine?” History of Cough: “When did your cough start?” “Did it come on gradually or start suddenly?” “Was it continuous or does it come and go?” “Is the cough present all the time or does it worsen at a particular time of day?” “Does your cough worsen with a specific position such as lying down?” “Does your cough produce any sputum?” If there is sputum, ask about consistency, odor, color, amount, or with blood. “What increases and decreases this cough?” Relieving Factors: “Does anything relieves your symptoms?” Precipitating Factors or Aggravating Factors: “I'm going to ask you a few more questions that will guide me as to why you had this recent asthma attack. ” An easy way is to go through the following list [12]: -A: Allergen -B: Bronchial infection -C: Cold air -D: Drugs -aspirin, NSAIDS, and beta-blockers -E: Emotions, exercise -F: Food -sodium metabisulfite, seafood, nuts, and monosodium glutamate -G: GERD -H: Hormones -pregnancy and menstruation -I: Irritants -smoke, perfumes, and smells -J: job -wood dust, flour dust, isocyanates, and animals “How do you use your puffer?” “Do you carry it with you so that it's readily available in case of emergency?” “Have you checked its expiry date?” “Do you store it properly?” “Have there been any recent changes in your home envi-ronment such as new paints, carpets, linens, pillows, blan-kets, curtains, new pets, plants, or renovations?” “Is there any mold present in your home?” Associated Symptoms: “Do you have pain anywhere in your body?” “Have you recently traveled anywhere?” “Have you noticed any fever?” “Have you recently lost weight?” “Do you have night sweats? Do you ever wake up with your clothes or body wet with a lot of sweat?” “How is this affecting your daily activities?” “Are you currently under any stress?” Past Medical History: “Do you have any health issues?” “Do you have a history of eczema, fever, runny nose, or allergies?” M. H. Sherazi

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163 “Any lung, heart, or kidney diseases? Any immuno- compromised states?” “Have you ever had a tuberculosis test?” Past Hospitalization and Surgical History: “Have you previously been hospitalized or undergone surgery?” Medication History: “Are you taking any medication?” If he says no, then con-tinue to next question. Otherwise ask about use of blood thinners, anticoagulants such as warfarin, any over-the- counter or herbals, and any side effects. Allergic History: “Do you have any known allergies?” Family History: “Does anyone in your family have asthma? Are there any other lung or heart diseases in your family?” Social History: “Do you or does anyone else in your home or close to you at work smoke? Do you drink alcohol?” If yes, then ask further questions: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” If yes, “Which ones? How long? When?” Relationships: “Are you sexually active? Do you have sex with men, women, or both?” Self-Care and Living Condition: “What do you do for living? Who lives with you?” Support: “Do you have good support from your family and friends?” Functional Status: “How is this affecting your daily activities?” Wrap-Up: “I would like to do a general physical and respiratory system examination. I would also like to run some tests. ” Investigations: PEF, CBC, ABGs, electrolytes, liver panel, kidney func-tion test, lipid profile, blood sugar, blood cultures, and CRP ABG analysis and D-dimer Chest X-ray (to rule out pneumonia, infection, or neoplasm) Sputum for cytology, AFB, C&S, and fungal testing ABGs: Acute attack -patients usually show a normal or slightly reduced Pa O2 and low Pa CO2 secondary to hyperventilation. -If Pa O2 is normal and the patient is hyperventilating, then the ABGs should be repeated later. -If Pa CO2 is raised, the patient needs to be transferred to high dependency unit or ICU as this signifies failing respiratory effort [13]. Spirometry is the key investigation: FEV1 < 80% of the predicted value. -FEV1/FVC ratio < 80% predicted indicates obstruc-tion. In case of asthma, there will be a characteristic rise in FEV1 > 12% after bronchodilator (SABA) use. Allergy tests. Describe the Diagnosis: “From our discussion today, it looks like your asthma is not very well controlled with your current use of a Ventolin (blue) puffer. ” Question: “Can you tell me more about asthma?” Answer: “Asthma is a common chest condition (7-10% in adults) in which there is reversible and temporary narrow-ing of the breathing tubes in the lungs. It occurs because these breathing tubes become hyper-responsive to various stimuli. There will also be tightening of the muscles present in the breathing tube walls. These tubes also become inflamed, and there will be swelling of their linings and increased mucus secretion in their lumens. All of these effects will lead to a deceased air flow through breathing tubes. ” “The main symptoms are shortness of breath, tightness in the chest, wheezing, sputum, and coughing (especially at night). ” Management Plan: Triggers and environmental control-“It is extremely important to learn about your trigger factors and make a plan to control the environment to minimize your expo-sure to these. ” Education and action plan -“Read about asthma and be informed. ” Self-management education including the following: -Education regarding nature of the disease, avoidance of triggers, and goal of treatment. -Understanding the use of prescribed medications. -Importance of compliance of medications. -Proper use of inhalation devices. -Use of peak flow monitor. -Knowing and understanding severe symptoms/red flags. -Regular follow-up with your family physician. -Learn breathing exercises. 5 The Respiratory System

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164 Action Plan: Action plans are a key component of care for all ages (Fig.  5. 11). An action plan should outline the following: Daily preventive management to maintain control. When and how to adjust reliever and controller therapy for loss of control. Clear instructions regarding when to seek urgent medical attention. Some national asthma action plans can be viewed at: -https://www. lung. ca/sites/default/files/media/asthma_ action_plan. pdf -https://www. nhlbi. nih. gov/files/docs/public/lung/ asthma_actplan. pdf -https://www. asthmaaustralia. org. au/Article Documents/ 1073/AAP_Do HA. pdf. aspx -https://www. ucalgary. ca/icancontrolasthma/files/ican-controlasthma/2012 asthma guidelines. pdf [15]. Persistent asthma: daily medication Step 1Step 2Step 3Step 4Step 5Step 6 Preferred:Pref erred: Alter nativ e:Alter nativ e:Alter nativ e: Alter nativ e: Assess control Pref erred:Pref erred:Pref erred:Pref erred: SABA PRN Each step: Patient education, environmental contr ol, and management of comorbidities. Steps 2-4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma (see notes). SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of oral systemic corticosteroids may be needed. Key: Alphabetical or der is used when more than one treatment option is listed within either preferred or alternative therap y. ICS, inhaled corticosteroid; LABA, inhaled long-acting beta2-agonist, LTRA, leukotriene receptor antagonist; SABA, inhaled short-acting beta2-agonist The stepwise approach is meant to assist, not replace, the clinical decisionmaking required to meet individual patient needs. If alternative treatment is used and response is inadequate, discontinue it and use the preferred treatment before stepping up. Theophylline is a less desirable alternative due to the need to monitor serum concentration levels. Step 1 and step 2 medications are based on Evidence A. Step 3 ICS + adjunctive therapy and ICS are based on Evidence B for efficacy of each treatment and extrapolation from comparator trials in older children and adults-comparator trials are not available for this age group; steps 4-6 are based on expert opinion and extrapolation from studies in older children and adults. Immunotherapy for steps 2-4 is based on Evidence B for house-dust mites, animal danders, and pollens; evidenc e is weak or lacking for molds and cockroaches. Evidence is strongest for immunotherapy with single allergens. The role of allergy in asthma is greater in children than in adults. Clinicians who administer immunotherapy should be prepared and equipped to identify and treat anaphylaxis that may occur. Notes:Caution: Increasing use of SABA or use >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step up treatment. Quic k-Relief Medication f or All P atients Low-dose ICSEITHER: Low-dose ICS + either LABA, LTRA, or Theophylline OR Medium-dose ICSCromolyn, LTRA, Nedocromil, or Theophylline Medium-dose ICS + LABA Medium-dose ICS + either LTRA or Theophylline High-dose ICS + either LTRA or Theophylline High-dose ICS + either LTRA or Theophylline + oral systemic corticosteroid Step up if needed (first, check adherence inhaler technique, environmental control, and comorbid conditions) Step down if possible (and asthma is well controlled at least 3 months)High-dose ICS + LABAHigh-dose ICS + LABA +oral systemic corticosteroid Intermittent asthma Consult with asthma specialist if step 4 care or higher is required. Consider consultation at step 3. Fig. 5. 11 Stepwise approach for managing asthma. (Reprinted from National Asthma Education and Prevention Program Expert Panel Report 3 [14]. Used under terms of Creative Commons Attribution 2. 5 Generic license. https://creativecommons. org/licenses/by/2. 5/deed. en) M. H. Sherazi

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165 Medical Treatment Medication Delivery Modes: The most effective mode of delivery of medication into the lungs is by inhalation: Puffer with a spacer device Dry powder inhaler Nebulizer There are three types of puffers that are usually used: Relievers-(Ventolin, Bricanyl, or Atrovent) Also called bronchodilators, they are quick acting and open the air-ways during an attack. Preventers -(Pulmicort, Flixotide, Alvesco) These are slow acting. They prevent an attack or treat inflammation. Combined-Preventer + reliever (Seretide or Symbicort). Question: “Do you know how to use the puffer (MDI)/ inhalers?” Answer: “In order for the medication to reach deep into the lungs, it is important to use the puffer correctly. It is a common error to not use the puffer correctly. The most important thing to understand about the puffer is your coordinated inhalation with the simultaneous pushing of the puffer chamber. It is not the pressure of the aerosol pushing the medication into the lungs. ” “I can explain how to use it. You can also seek help from your asthma educator or pharmacist if you have any further questions. ” The Closed-Mouth Technique of Using Puffers 1. Remove the cap. 2. Shake the puffer vigorously. 3. Hold it upright (canister on top and mouthpiece on the lower end). 4. Place the mouthpiece between your teeth and close your lips around it. 5. Breathe out gently and hold your breath. 6. Tilt your head back slightly. 7. Then slowly start breathing in from your mouth not from nose. At the same time, press the puffer canister firmly, breathing in as much as you can for 3-5 s. 8. Remove the puffer from your mouth and hold your breath for approximately 10 s. 9. Breathe out gently. 10. Breathe normally for about 1 min. 11. Repeat the process if you need to. Question: “Do you know how to use the inhalers with a spacer?” Answer: “Some people who have difficulty using the metered dose inhalers (MDIs) can use a spacer devices. The spacer device is attached onto the mouthpiece of the inhaler. The patient puts the mouthpiece of the spacer in his mouth. One puff of the inhaler is put into the spacer. The patient breathes in and out from the spacer mouth-piece, taking a deep breath, which should be followed by one to two very deep breaths (four to six normal breaths)” (see Fig.  5. 12). Signs and Symptoms of Severe Asthma/Red Flags: Inform and advise the patient: “If you notice any of the fol-lowing symptoms, you should seek urgent medical attention or call the ambulance” [16]: Marked breathlessness Sleep being greatly disturbed by asthma Feeling frightened Difficulty in speaking; unable to say more than a few words Pulses paradoxes Exhaustion and sleep deprivation Drowsiness and confusion Silent chest Cyanosis Chest retraction Respiratory rate greater than 25 (adults) or 50 (children) Pulse rate >100 beats/min Peak flow <100 L/min or <40% predicted FEV1 Oximetry on presentation (Sa O2) <90% Fig. 5. 12 An asthma inhaler spacer. (Source: Oxiq, own work. Reprinted under terms of Creative Commons CC0 1. 0 Universal Public Domain Dedication. https://creativecommons. org/publicdomain/zero/1. 0/deed. en) 5 The Respiratory System

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166 Wrap-Up: Offer further information through brochures, websites, and support groups. Encourage flu shot every year in the the fall and the pneu-mococcal vaccine for patients over 65 and at risk. Follow-Up: Follow up in 2-3 weeks. In follow-up visits, you should monitor: Asthma symptom control Asthma triggers Pulmonary function tests Adherence to asthma treatment Inhaler techniques Comorbidities History: Chronic Obstructive Pulmonary Disease Candidate Information A 55-year-old man comes to your clinic presenting a cough with sputum and shortness of breath. He has had COPD for 5 years. He is on two puffers and is a chronic smoker. Please take a detailed history. No physical examination is required. Differentials: Exacerbation of COPD (try to find out triggers, which can be infection, heart failure, non-compliance of inhalers) Pneumonia Chronic bronchitis/emphysema Community acquired pneumonia Bronchiectasis Bronchogenic carcinoma (less likely in this station but must rule out) Pulmonary tuberculosis Starting the Interview: Knock on the door. Enter the station. Hand wash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr...... I am your attending physician. Are you Mr......? Are you 55  years old?”History of Present Illness: “What brings you to the clinic today?” Cough Questions: “When did your cough start?” “Did it come on gradually or start suddenly?” “Is this your first time having this cough?” “Was it continuous or does it come and go?” “Is the cough present all the time or does it worsen at a particular time of day?” “Does your cough worsen with a specific position such as lying down?” “Is your cough getting worse with time?” “How long does each bout of coughing last?” “When was the last PFT done?” “What was the severity of your previous episodes, and how are you coping now?” Associated Symptoms: “Does your cough produce sputum?” If yes to sputum, then ask about consistency, odor, color, amount, and blood. “What increases and decreases your cough?” “Do you become short of breath?” If shortness of breath is present, then ask a few questions about it: Wheezing? Does it come on with any change in position? Signs of infection: Fever, increases quantity or production of purulent sputum. Upper respiratory tract symptoms: Nasal discharge, sore throat, dry mouth, difficulty swallowing. Congestive heart failure: Chest pain, racing heart, swell-ing in legs, shortness of breath upon walking or going up stairs, syncope. Constitutional Symptoms: Fever, night sweats, weight loss, and loss of appetite Risk Factors: “Have you had any recent contact with sick people?” “Do you have any pain in your legs?” “Have you traveled recently?” “Have you had any recent stressor such as anxiety or depression?” “Do you smoke?” If so, “How long have you been smoking? How many cigarettes per day? Have you ever tried to quit?” “Do you do any drugs?” Relieving Factors: “Does anything relieve the symptoms?” Past Medical History: “Do you have any health issues?” “Do you have a history of eczema, fever, runny nose, or allergies?” M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

167 “Any lung, heart or kidney diseases? Any immunocom-promised states?” “Have you ever had a tuberculosis test?” Past Hospitalization and Surgical History: “Have you previously been hospitalized or undergone surgery?” Medication History: “Are you taking any medication?” If he says no, then con-tinue to next question. Otherwise ask about use of blood thinners, anticoagulants such as warfarin, any over-the- counter or herbals, and any side effects. Allergic History: “Do you have any known allergies?” Family History: “Does anyone in your family have asthma? Are there any other lung or heart diseases in your family?” Social History: “Do you or does anyone else in your home or close to you at work smoke? Do you drink alcohol?” If yes, then ask further questions: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” If yes, “Which ones? How long? When?” Relationships: “Are you sexually active? Do you have sex with men, women, or both?” Self-Care and Living Condition: “What do you do for living? Who lives with you?” Support: “Do you have good support from your family and friends?” Functional Status: “How is this affecting your daily activities?” Wrap-Up: The management plan should be made according to severity of the symptoms. Mild Symptoms: Investigation: -Labs: CBC, electrolytes, cardiac enzymes, blood sugar, kidney function and liver panel, and lipid profile -ABGs -ECG -Chest X-ray -Pulmonary function test Treatment plan: -Prolong survival Smoking cessation Respiratory rehabilitation Medications: “COPD medications cannot cure COPD, but they can improve your symptoms. Your doctor will prescribe the COPD medications that are right for you. To help you man-age your COPD medications, your doctor may also give you a COPD action plan that explains what you should do when you are not feeling well. The different types of COPD medi-cines include the following”: Bronchodilators-“With COPD, the main symptom is shortness of breath. You might get short of breath when you exercise, when you do chores, when you feel upset, or for no reason at all. ” “Bronchodilator medications open up the airways (breath-ing tubes). When your airways are more open, it is easier to breathe. Doctors may prescribe more than one kind of bronchodilator to treat your COPD. ” “There are 2 main types of bronchodilators that come in inhalers: -Beta-2 agonists. For example, salbutamol (Ventolin), ter-butaline (Bricanyl), formoterol, and salmeterol (Serevent) -Anticholinergics. For example, ipratropium bromide (Atrovent), tiotropium (Spiriva), and glycopyrronium” Corticosteroid Pills-“Corticosteroid pills are often used for short periods of time, usually when you have a COPD flare-up. However, in some cases they may need to be taken on a regular basis. If you need to take corticosteroid pills on a regular basis, your health care provider will work to keep you on the lowest dose necessary. ” “If you have any questions on medication side effects, you should talk to your health-care provider or pharmacist. ” -“Some side effects of combination inhaled broncho-dilator and corticosteroids include shaky hands (tremor), fast heartbeat, thrush (a whitish film covering your throat and tongue), sore throat, or hoarse voice. ” -“You can have fewer side effects if you take the medi-cine as directed by your health-care provider, rinse your mouth with water after each dose, and use a spac-ing chamber with your inhaler. ” Antibiotics-“COPD flare-ups can be caused by viral infections or bacterial infections. If you have a bacterial infection, you can treat the infection with antibiotics. “As part of a COPD action plan, we will give you an anti-biotic prescription to have on hand and tell you to fill the prescription if you feel a COPD flare-up starting. It is very important for you to recognize the signs of worsen-ing COPD.  Be sure to ask questions of your health-care professional so you understand your action plan. ” 5 The Respiratory System

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168 Flu and pneumonia shots-“Shots (vaccines) can help protect you against some strains of flu and pneumonia. Flu and pneumonia shots can lower your chances of get-ting a flare-up and needing hospital care. You need to take a flu shot every year, usually in the fall. ” Supplemental oxygen-“If you have more severe COPD, it may be hard for you to get enough oxygen from the natural air. Low oxygen levels can make you more short of breath and tired. If your blood oxygen level is very low, your doctor may prescribe supplemental oxygen. People who take supplemental oxygen must continue taking their other medications. “Oxygen therapy can help people with: -Very low blood-oxygen levels (hypoxemia) -Temporary lung damage from infections (e. g., pneumonia)” “Oxygen only helps people who have very low blood-oxygen levels. Ask your doctor to test to see if oxygen might help you” [17]. COPD Exacerbation: This presents with episodes of increased dyspnea, coughing, increase in sputum volume, or purulence. It is usually trig-gered by a URTI, air pollution, congestive heart failure, or pulmonary embolism. If symptoms are severe, then the patient needs to be trans-ferred to the nearest emergency room. Inform the Patient: “Based on our discussion today, I understand that you have been diagnosed with COPD.  Your cough, shortness of breath, and sputum quantity has significantly increased, indicating that you have a chest infection on top of your COPD. ” If the patient is a smoker, please do not forget to mention that one probable cause of COPD flare ups is smoking. “I would like to refer you to the nearest hospital now. I can call the emergency physician and arrange an ambulance for you if you would like. I want to make sure that you will receive proper ventilation on your way to the emergency room. ” Follow-Up: “I will follow up with you after you are discharged from the hospital. Do you mind if we discuss next time the possibility of quitting smoking? Do you have any questions”? Physical Examination: Pneumothorax Candidate Information: A 25-year-old man presents in the emergency room with sud-den onset of right-sided chest pain and shortness of breath. Vital Signs: HR, 101/min, regular; BP, 70/50 mm Hg; temp, 37 °C; RR, 21/min; O 2 saturation, 89% Perform a relevant physical examination. Please do not perform rectal, genitourinary, or breast examination. Differentials: Pneumonia Tension pneumothorax Acute pulmonary embolism Acute myocardial infarction Starting the Physical Examination: Knock on the door. Enter the station. Hand wash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Stand on the right side of the patient and start the physical examination. Opening: “Good morning/good afternoon. I am Dr....... I am your attending physician. Are you Mr.......?” “I have been asked to perform your detailed respiratory system examination. During the examination, if you feel uncomfortable please let me know. Is it alright to start?” Start by commenting on the given vital signs: “Patient has tachycardia, tachypnea, hypotension, and low O2 saturation. ” Further comment: “I will evaluate the patient's airway, breathing, and circulation during my examination. This is to ensure that the patient is stable enough to continue with the examination and he does not require any immediate intervention. ” (During the examination, the examiner will either tell the findings with each part of the examination or at the end. ) General Physical Examination: Observe the patient: Are they alert and conscious? Are they able to speak or do they have difficulty speaking? Observe for any obvious distress, sweating, pallor or cyanosis. Hands: -Check for pulse. -Comment on rate, rhythm, and volume of the pulse: “Tachycardia, regular rhythm, and possible low volume. ” -Check the hands and fingers for any abnormal findings. M. H. Sherazi

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169 Face: Observe for cyanosis. -Nose: Flared Trachea: -Check for position: Deviated to the opposite site of pneumothorax. -Look for use of accessory muscles; patient may be using them. -Look for distension of neck veins. Chest Examination: “I need to expose you from the neck down to the waist; is it alright?” Help the patient take off his shirt if he asks; other-wise let him do it and wait. Then, drape the patient if required by the station. Patient position: Sitting. Observe for respiratory rate and pattern. Comment: “Tachypnea may be present. ” Inspection: -Look from the front, side, and back. -Observe the chest for contour, shape, and skin. Palpation: -Warm up your hands. -Check for any tenderness: usually no tenderness unless a trauma case. -Chest expansion: chest movements may be decreased on the side of the pneumothorax. -Tactile fremitus: decreased or absent on the side of the pneumothorax. Percussion: Findings -Percussion note hyperresonant or tympanic over pneumothorax. Chest auscultation: -Inform the patient: “I am going to listen to your chest. ” -Expected auscultation findings: Breath sounds may be decreased to absent over the pneumothorax. -No added sound is usually heard. -Cardiovascular system: Quickly listen to the heart and measure the JVD. At the end of the auscultation, comment on your findings. Thank the patient and tell him he can now cover up. Wrap-Up: The examiner may either show an X-ray (Fig.   5. 13) or, on the basis of your clinical findings, will ask the possible diag-nosis [ 19]. Question: “What you will do next?” Answer: Immediate next step: Insertion of a large-bore needle into the second intercostal space at the midclavicular line to release the pressure (Fig.   5. 14) and then a portable chest X-ray followed by the insertion of a chest tube Further Management: Admit to hospital. Investigations: CBC, X-ray chest (portable), ABG analysis. Monitor vital signs and ABG. Thoracic surgery consult. Tetanus prophylaxis (penetrating injury). If hypotension persists: Look for other causes of the patient's condition. Question: “What are the causes for tension pneumothorax?” Answer: “It is usually caused by a rupture of the pleura and can be spontaneous. The causes include asthma, COPD, Fig. 5. 13 Right-sided tension pneumothorax (please do not forget to mention the side). (Reprinted with permission from Mc Roberts et al. [ 18]) Neurovascular bundle14 gauge angiocatheter10cc syringe 2nd ICS@ MCL (Note Perpendicular Angle to Chest Wall) Fig. 5. 14 Needle decompression at the second intercostal space (ICS). MCL midclavicular line. (Reprinted with permission from Greene and Callaway [ 20]) 5 The Respiratory System

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170 pneumonia, lung cancer, lung abscess, pulmonary tuberculo-sis, and trauma. ” Question: “What are other immediate life-threatening conditions caused by this?” Answer: “Airway obstruction, open pneumothorax, mas-sive hemothorax, pericardial tamponade, and flail chest” Physical Examination: Hemothorax Candidate Information: A 25-year-old man was brought into the emergency room after a roadside accident. He is conscious and complaining of left-side chest pain and shortness of breath. Vital Signs: HR, 101/min, regular; BP, 70/50 mm Hg; temp, 37 °C; RR, 21/min; O2 saturation, 89% Perform a relevant physical examination. Please do not perform rectal, genitourinary, or breast examination. Differentials: Pneumothorax Hemothorax Atelectasis Pericardial tamponade Flail chest Starting the Interview: Knock on the door. Enter the station. Hand wash/alcohol rub. Greet the examiner and the patient. Give stickers to the examiner if required or show your ID badge. Now sit on the chair or stand on the right side of the patient and start the interview. This is a trauma case; proceed with Advanced Trauma Life Support (ATLS) steps. Start by commenting on the given vital signs: “Patient has tachycardia, tachypnea, hypotension, and low O2 saturation. ” Further comment: “I will evaluate the patient's airway, breathing, and circulation during my examination to make sure that the patient is stable enough to continue with the examination and that he does not require any immediate intervention. ” “I have been asked to perform a detailed respiratory sys-tem examination. During the examination, if you feel uncom-fortable, please let me know. Is it alright to start?” (During the examination, the examiner will either tell you the findings with each part of the examination or at the end. )General Physical Examination: Observe the patient: Is he alert and conscious? Is he able to speak or does he have difficulty speaking? Observe for any obvious distress, sweating, pallor, or cyanosis. Hands: -Check for pulse. -Comment on rate, rhythm, and volume of the pulse: “Tachycardia, regular rhythm, and possible low volume. ” -Check the hands and fingers for any abnormal findings. Face: Observe for cyanosis. -Nose: Flared Trachea: -Check for position: Deviated to the opposite site of hemothorax. -Look for use of accessory muscles; patient may be using them. -Look for distension of neck veins. Chest Examination: “I need to expose you from the neck down to the waist; is it alright?” Help the patient take off his shirt if he asks; other-wise let him do it and wait. Then, drape the patient if required by the station. Patient position: Sitting. Observe for respiratory rate and pattern. Comment: “Tachypnea may be present. ” Inspection: -Look from the front, side, and back. -Observe the chest for: contour, shape, and skin. Palpation: -Warm up your hands. -Check for any tenderness: There may be localized ten-derness on the left side of the chest (as this is a trauma case). -Chest expansion: Chest movements may be decreased on the side of the hemothorax. -Tactile fremitus: Decreased or absent on the side of the hemothorax. Percussion: -Findings: Percussion note will be dull over the hemothorax. Chest auscultation: -Inform the patient: “I am going to listen to your chest. ” -Expected auscultation findings: Breath sounds may be decreased to absent over the hemothorax. -No added sound is usually heard. -Cardiovascular system: Quickly listen to the heart and measure the JVD. M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

171 At the end of the auscultation, comment on your findings. Thank the patient and tell the patient they can now cover up. Wrap-Up: The examiner may either show an X-ray (Fig.   5. 15) or, on the basis of your clinical findings, may ask for a possible diagnosis. Question: “What you will do next?” Answer: Immediate next step: Portable chest X-ray and then insertion of chest tube. Hemothorax can be confirmed by a CT scan. Further Management: Admit to the hospital. Investigations: CBC, routine blood work up, ABG analysis. Monitor vital signs. Thoracic surgery consult. Tetanus prophylaxis, if penetrating injury. If hypotension persists: look for other causes of the patient's conditions. Question: “What are the causes?” Answer: “The most common cause of hemothorax is chest (thoracic) trauma. Thoracic injury directly accounts for 20-25% of deaths from trauma. Hemothorax can also occur in persons who have: A blood clotting defect Chest (thoracic) or heart surgery Death of lung tissue (pulmonary infarction) Lung or pleural cancer, primary or secondary (metastatic, or from another site) A tear in a blood vessel caused by placing a central venous catheter or associated with severe high blood pressure Tuberculosis [ 21]” Question: “What are the complications of chest tube insertion?” Answer: “Common complications associated with chest tube insertion include bleeding and hemothorax due to inter-costal artery perforation, perforation of visceral organs (lung, heart, or intra-abdominal organs), and perforation of major vascular structures such as the aorta or subclavian vessels, intercostal pain due to trauma of neurovascular bundles, sub-cutaneous emphysema, infection of the drainage site, pneu-monia, and empyema. There may be other technical problems such as intermittent tube blockage from clotted blood, pus, or debris or incorrect positioning of the tube causing ineffec-tive drainage. ” History: Lung Nodule Candidate Information A 52-year-old man, asymptomatic, has chest X-ray done during a routine insurance checkup. The X-ray report shows an incidental solitary lung nodule. The patient comes to your outpatient clinic for a follow-up. Please take a detailed history. Discuss various differen-tials with the patient. No physical examination is required. There will be an X-ray on the table, or the examiner will give you the X-ray before starting the interview (Fig.   5. 16). Differentials: Benign -Artifact -Benign lesion (bronchial adenoma, hamartoma) -Fluid-filled cyst -Pulmonary tuberculosis -Hematoma -Infarct/vascular lesion -Fungal (histoplasmosis, aspergilloma) -Lung abscess Malignant -Bronchogenic carcinoma (squamous cell carcinoma, adenocarcinoma, small cell carcinoma, large cell carcinoma) -Metastatic lesion from the breast, head and neck, mel-anoma, colon, kidney, or sarcoma Fig. 5. 15 A chest X-ray showing a large left-sided pleural effusion (please do not forget to mention the side). X-ray by James Heilman, MD, own work. (Reprinted under terms of CC BY-SA 3. 0 license. https://creativecommons. org/licenses/by-sa/3. 0/ ) 5 The Respiratory System

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172 Starting the Interview: Knock on the door. Enter the station. Hand wash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr...... I am your attending physician. Are you Mr......? Are you 52 years old?” History of Present Illness: “What brings you in the clinic today?” The clinic called me and asked me to come in and discuss my X-ray results. Question: “What is going on, Doctor?” Answer: Address the patient's concern: “Mr...... we called you because we found a small spot in your X-ray. I need to ask you some questions to take a detailed history from you and at the end, we will discuss the plan. Is that alright?” “Why was the X-ray taken?” For an insurance checkup. “When was the X-ray ordered? A few weeks back. “Who ordered it?” The insurance company physician. Associated Symptoms: “Do you have any cough?” “Do you have any shortness of breath?” “Have you noticed any wheezing?” “Are you spitting up any phlegm?” If yes, then ask: “Is there any blood with it?” Go through your differentials: Upper respiratory tract symptoms -Nasal discharge, sore throat, dryness of mouth, difficulty swallowing, or hoarseness. Chest pain -Ask questions regarding pain and the pres-ence of racing heart, nausea, vomiting, or syncope. Constitutional Symptoms: Fever, chills, night sweats, weight loss, loss of appetite Pain anywhere else in body (i. e., bone pain) Any seizures or neurological deficit, dizziness Lumps in the neck or anywhere else in the body Change in eye size Risk Factors: “Have you had any recent contact with sick people, such as individuals with tuberculosis?” “Have you ever been screened for tuberculosis?” “Do you have any pain in your legs?” “Have you travelled recently?” “Are you exposed to any hazardous substances such as asbestos?” “Do you have any pets at home?” “Do you smoke?” If so : “How long have you been smok-ing? How many cigarettes per day and have you ever tried to quit?” “Do you do any drugs?” Past Medical History: “Do you have any previous health issues?” “Any lung, heart, or kidney diseases? Any immunocom-promised states?” “Have you ever had cancer?” If so, “Was it treated?” Past Hospitalization and Surgical History: “Have you ever been hospitalized or undergone surgery?” Medication History: “Are you taking any medication?” If not, then continue to next question. Otherwise ask about over-the-counter medica-tions or herbals and any side effects, as well as the use of any puffers such as salbutamol or Spiriva. Allergic History: “Do you have any known allergies?” Fig. 5. 16 Solitary pulmonary nodule (inside black box) in the left upper lobe. (Reprinted from: Lange123 at the German language Wikipedia (GFDL) http://www. gnu. org/copyleft/fdl. html under terms of Creative Commons license CC-BY-SA-3. 0 https://creativecommons. org/licenses/by-sa/3. 0/ ) M. H. Sherazi

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173 Family History: “Is there a history of any lung diseases or chronic health issues in your family?” Social History: “Do you or does anyone else in your home or close to you at work smoke? Do you drink alcohol?” If yes, then ask further questions: “How much? Daily? How long? “Have you ever tried any recreational drugs?” If yes, “Which ones? How long? When?” Relationships: “Are you sexually active? Do you have sex with men, women, or both?” Self-Care and Living Conditions: “What do you do for living? Who lives with you?” Work Conditions and Financial Status: “Are there any renovations underway at your home or work?” Support: “Do you have good support from your family and friends?” Wrap-Up: “I would like to do a detailed physical examination. ” Investigations: “I will look at any available previous chest X-rays for comparison and look for the same nodule. ” Describe the Diagnosis: “I have reviewed your current and previous (if available) chest X-rays. I have also read the radi-ologist report. You have a lesion in your lung called a solitary pulmonary nodule or a lung nodule. ” Question: “What is a lung nodule?” Answer: “By definition, it is a small, round or oval, well- defined margins/borders, ball-shaped spot seen on the X-ray. It can range in size from smaller than a pea to the size of a golf ball or larger. It may or may not be calcified and is usu-ally surrounded by normal lung tissue. ” “Your doctor can see it on a chest X-ray or CT scan. Most of the time, there are no symptoms. ” Question: “Does a lung nodule mean cancer?” Answer: “About 70% of nodules are benign, or not cancer-ous. Infectious granulomas are the most common cause of benign nodules. The other common causes of benign lesions are abscesses, cysts, and benign tumors named as hamartoma or fibroma. Granulomas are formed when a group of immune cells in your body tries to fight an infection. ” Question: “What are the features of benign lesions on X-ray?” Answer: “Less than 3 cm in size, smooth margins, calcified pattern either central or popcorn (hamartoma), usually no cavity. Size doubling time can be less than a month or more than 2 years. ” Question: “Could it be cancer?” Answer: “A lung nodule can also be malignant or cancer-ous, or it may turn into a cancer. Patients who smoke or have smoked in the past, who are older than 40 years, and who have other types of cancers are at higher risk of getting lung cancer. There is a 30% chance that it is malignant (broncho-genic carcinoma such as squamous cell carcinoma, adeno-carcinoma, or small cell carcinoma). It could also be a metastatic lesion from the breast, head, and neck or a melanoma. ” Investigations: O2 saturation ABGs Labs: CBC, electrolytes, liver panel, kidney function test, lipid profile, and blood sugar Sputum cytology Pulmonary function test Chest CT PET scan Biopsy or excision of the nodule Question: “How it should be followed up?” Answer: “We will usually look at X-rays and CT scans of your chest to check a lung nodule. We may also review old X-rays or CT scans to see if the nodule is old or new or has changed over time. ” “We may need to watch the nodule over time with several CT scans. The scans may be done 3, 6, or 12 months apart to make sure the nodule is not growing. ” Question: “What if the nodule is malignant or growing?” Answer: “We may need to send you to a lung or cancer specialist if your nodule is growing or if we suspect that it may be malignant. The specialist might do a biopsy, which is when a doctor takes out a small piece of lung tissue and examines it under a microscope to see if it is cancerous. ” 5 The Respiratory System

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174 Further Information Warning signs Information through websites, such as http://www. aafp. org/afp/2015/1215/p1084. html [22] Flu shot every year in the fall and pneumococcal vaccine if over 65 or at risk Follow-Up: Discuss a follow-up visit according to the diagnosis. “Do you have any questions?” History: Lung Cancer Candidate Information: A 52-year-old man comes in the clinic with cough, blood in sputum, and weight loss for 6 months. Please take a detailed history. Give a management plan. Differentials: Pulmonary tuberculosis Bronchiectasis Emphysema Malignant: -Bronchogenic carcinoma (squamous cell carcinoma, adenocarcinoma, small cell carcinoma, large cell carcinoma) -Metastatic lesions from breast, head and neck, mela-noma, colon, kidney, or sarcoma Starting the Interview: Knock on the door. Enter the station. Hand wash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview, Opening: “Good morning/good afternoon. I am Dr... I am your attend-ing physician. Are you Mr... ? Are you 52 years old?” History of Present Illness: “How can I help you today?” Doc, I am very worried about myself, I coughed out some blood!! Show empathy: “I am sorry to hear about that; that must be really scary. ” Quickly evaluate the patient to determine if the patient needs any immediate intervention. Show support: “I am here to help you. I am going to ask you few questions. ” “How are you now? Are you able to answer some questions?” “Are you comfortable sitting or do you want to lie down?” “Are you feeling dizzy/tired or losing consciousness?” Ask for a set of vitals from the examiner and com-ment: “I just want to make sure my patient is stable enough to proceed with the history. ” “When did you cough up blood?” I have been noticing it for the last few days. Since last night it has increased in quantity. “Did you cough up blood or vomit blood?” Coughed up. “How much blood?” About a cup during the night, other-wise it was just a small amount mixed with phlegm. “What was the color?” (bright red/pink/brown/rusty or like coffee ground appearance) Bright red. “Was it pure blood or was mucus mixed with the blood?” It was mixed with phlegm. “How long has this been going on for?” For about a month. “Have you had an ongoing cough?” Yes. Cough questions: -“Is the cough continuous or does it come and go?” -“Is the cough present all the time or does it worsen at any particular time of the day?” -“Does your cough come with a certain position such as lying down?” -“Is your cough worsening with time?” -“How long does each bout of coughing last for?” -“Does anything increase or decrease this cough?” Nothing particular. -“Any hoarseness of your voice?” No. Associated Symptoms: If shortness of breath is present, then ask a few questions about it: “Wheezing? Does it come on with any change in position?” Upper respiratory tract symptoms -Nasal discharge, sore throat, dryness of mouth, difficulty swallowing, or hoarseness. Chest pain -Ask questions regarding pain and the pres-ence of racing heart, nausea, vomiting, or syncope. Constitutional symptoms: -“Have you noticed any fever?” Yes, I've had a fever off and on and feel very tired. -“Have you noticed any chills/rigors or night sweats?” Yes, I have chills and have had night sweats two to three times. -“Do you have pain anywhere else in your body? Any bone pain?” -“Have you lost any weight?” Yes, I have noticed that I lost about 12 lb in the last 3 months. -“How is your appetite?” I do not feel like eating. M. H. Sherazi

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175 Risk Factors: “Have you had any recent contact with sick people, such as individuals with tuberculosis?” “Have you ever been screened for tuberculosis?” “Do you have any pain in your legs?” “Have you travelled recently?” “Are you exposed to any hazardous substances such as asbestos?” “Do you have any pets at home?” “Do you smoke?” If so, “How long have you been smok-ing? How many cigarettes per day and have you ever tried to quit?” “Do you do any drugs?” “Have you had bleeding anywhere else? In the gums?” Symptom and Presentation by Location of the Tumor Spread: Pain: Patient will have increased pain as the tumor grows in size and spreads along the chest wall and ribs. Lung, hilum, mediastinum or pleura: Pleural effusion, atelectasis, and wheezing Hoarseness: Involvement of the recurrent laryngeal nerve. Lung apex (Pancoast tumor): Pain, muscle wasting, and change in temperature sensation secondary to involve-ment of the sympathetic chain and Horner's syndrome (ptosis, miosis, and anhydrosis). Pleuritic chest pain: Due to involvement of the pleura. Superior vena cava (SVC) obstruction: Neck and facial swelling with cough and shortness of breath. Brain: Any seizures or neurological deficit, dizziness. Lumps in the neck or anywhere in the body. Phrenic N: Paralysis of diaphragm. Distant metastasis: In the brain, liver, or bones. Paraneoplastic syndrome: Most commonly seen in small cell lung cancer (SCLC). Look for hypercalcemia, SIADH, Cushing syndrome, hypoglycemia, gynecomastia, Lambert-Eaton syndrome, peripheral neuropathy, cerebellar degeneration, clubbing, hypertrophic osteoarthropathy, and glomerulonephritis. Past Medical History: “Do you have any previous health issues?” “Any lung, heart, or kidney disease problems? Any immu-nocompromised states?” “Do you have a previous history of cancer?” If so, “Was it treated?” Past Hospitalization and Surgical History: “Have you ever been hospitalized or undergone surgery?” Medication History: “Are you taking any medication?” If not then continue on to the next question. Otherwise ask about over-the-counter medications or herbals and any side effects. Ask about the use of puffers such as salbutamol or Spiriva. Allergic History: “Do you have any known allergies?” Family History: “Is there a history of lung disease or any chronic health issues in your family?” Social History: “Do you, or does anyone else in your home or close to you at work, smoke? Do you drink alcohol?” If yes, then ask further questions: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” If yes: “Which ones? How long? When?” Relationships: “Are you sexually active? Do you have sex with men, women, or both?” Self-Care and Living Condition: “What do you do for living? Who lives with you?” Support: “Do you have good support from your friends and family?” Wrap-Up Question: “What would you do next?” Answer: “I would like to do a detailed physical examina-tion and to run some tests. ” Investigations: Suggest the following: O2 saturation ABGs CBC, electrolytes, liver panel, calcium Pulmonary function test Chest X-ray/CT Sputum for cytology Further Staging Workup: Bronchoscopy and biopsy CT abdomen PET scan Bone scan Mediastinoscopy Describe the Diagnosis: “After our discussion today, unfortunately, I think there is a slight chance that you might be suffering from lung cancer. I cannot say that with certainty, but your history is suggesting 5 The Respiratory System

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176 this. I need to examine you now, after which we will do some lab tests, send a phlegm sample for examination, and take a chest X-ray. I will follow up on your results, at which point I can arrange a visit to a lung specialist if that is required. ” Further Information Quit smoking programs Warning signs Information through websites Flu shot every year in the fall and pneumococcal vaccine for individuals over 65 and at risk Follow-Up: Discuss a follow-up visit. Finish the conversation by asking “Do you have any questions?” References 1. Hurley KF.   Respiratory system. Tactile fremitus: examination. In: OSCE and clinical skills handbook. 2nd ed. Toronto: Elsevier Canada; 2011. p.  52. 2. Chapter: the respiratory exam. In: Hall J, Piggott K, V ojvodic M, Zaslavsky K, editors. Essentials of clinical examination handbook, 6th ed. New York: Thieme; 2010. p.  340. 3. https://en. wikipedia. org/wiki/Common_cold. Accessed 11 June 2017. 4. http://bestpractice. bmj. com/best-practice/monograph/252/diagno-sis/tests. html. Accessed 11 June 2017. 5. https://en. wikipedia. org/wiki/Centor_criteria. Accessed 11 June 2017. 6. Liang L.  Infections atypical pneumonia. In: Li H, editor. Radiology of infectious diseases, vol. 1. Dordrecht: Springer; 2015. 7. Donovan FM.   Community-acquired pneumonia empiric therapy. http://emedicine. medscape. com/article/2011819-overview. Accessed 11 June 2017. 8. Centers for Disease Control and Prevention. Mycoplasma pneumoniae infection. http://www. cdc. gov/pneumonia/atypical/mycoplasma/hcp/ antibiotic-treatment-resistance. html. Accessed 11 June 2017. 9. Atypical pneumonia. Medline plus. https://medlineplus. gov/ency/ article/000079. htm. Accessed 11 June 2017. 10. Thomas CF Jr, Limper AH.   Treatment and prevention of Pneumocystis pneumonia in HIV-uninfected patients. Up To Date. http://www. uptodate. com/contents/treatment-and-prevention-of-pneumocystis-pneumonia-in-hiv-uninfected-patients. Accessed June 11 2017. 11. What is Pneumocystis Pneumonia (PCP)? http://www. webmd. com/ hiv-aids/guide/aids-hiv-opportunistic-infections-pneumocystis-pcp-pneumonia. Accessed 11 June 2017. 12. Murtagh J.   Chapter 82: asthma: causes of asthma. In: John Murtagh's general practice. 6th ed. North Ryde: Mc Graw-Hill ustralia Pty Ltd; 2015. p.  923. 13. Longmore M, Wilkinson IB, Davidson EH, Foulkes A, Mafi AR, editors. Chapter 4. Chest medicine; asthma. In: Oxford handbook of clinical medicine. 8th ed. UK: Oxford University Press; 2010. p.  172. 14. National Asthma Education and Prevention Program Expert Panel Report 3. Guidelines for the diagnosis and management of asthma. US Department of Health and Human Services National Institutes of Health. National Heart, Blood, and Lung Institute. USA: NIH Publication no. 08-4051, 2007. 15. Lougheed MD, Lemiere C, Ducharme FM, Licskai C, Dell SD, Rowe BH, Canadian Thoracic Society Asthma Clinical Assembly, et al. Canadian Thoracic Society 2012 guideline update: diagnosis and management of asthma in preschoolers, children and adults. Can Respir J. 2012;19(2):127-64. https://cts. lung. ca/sites/default/ files/documents/cts/FINAL%20ASTHMA%20GUIDELINE%20 APRIL%202012. pdf. Accessed 11 June 2017 16. Murtagh J.   Chapter 82: Asthma: dangerous signs. In: John Murtagh's general practice. 6th ed. North Ryde: Mc Graw-Hill Australia Pty Ltd; 2015. p.  931-2. 17. Canadian Lung Association. Chronic obstructive pulmonary dis-ease (COPD). Medication. https://www. lung. ca/lung-health/lung-disease/copd/medication. Accessed 11 June 2017. 18. Mc Roberts R, Mc Kechnie M, Leigh-Smith S.  Tension pneumotho-rax and the “forbidden CXR”. Emerg Med J. 2005;22:597-8. 19. FPR-Med. Tension pneumothorax. http://www. fprmed. com/Pages/ Trauma/Tension_Pneumothorax. html. Accessed 11 June 2017. 20. Greene C, Callaway DW.   Chapter 19. Needle thoracostomy for decompression of tension pneumothorax. In: Taylor D, Sherry S, Sing R, editors. Interventional critical care. Cham: Springer International Publishing; 2016. p.  171-8. 21. Medline Plus. Hemothorax. https://medlineplus. gov/ency/arti-cle/000126. htm. Accessed 11 June 2017. 22. Kikano GE, Fabien A, Schilz R.  Evaluation of the solitary pulmo-nary nodule. Am Fam Physician. 2015;92(12):1084-1091A. http:// www. aafp. org/afp/2015/1215/p1084. html. Accessed 11 June 2017 M. H. Sherazi

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177 © Springer Nature Switzerland AG 2019 M. H. Sherazi, E. Dixon (eds. ), The Objective Structured Clinical Examination Review, https://doi. org/10. 1007/978-3-319-95444-8_6The Gastrointestinal System Mubashar Hussain Sherazi History Overview: The Gastrointestinal System In the Objective Structured Clinical Examination (OSCE), you may or may not get one station related to the gastrointes-tinal (GI) system. Usually the scenario includes a detailed history with relevant physical examination. Abdominal examination is very important for OSCE.  You may also be asked to perform an abdominal examination as part of a gen-eral surgery scenario. Abdominal pain is a very common and important station for OSCE, so it is important to practice various abdominal pain cases. (Some cases are explained in detail in the General Surgery chapter. ) Sometimes you may be asked to manage a case of upper or lower gastrointestinal bleeding. This chapter outlines a few important gastrointestinal cases. The chapter begins with an overview of the history taking (Table  6. 1), followed by abdominal examination, and some common gastrointestinal presentations. Common Signs and Symptoms for the Objective Structured Clinical Examination For the gastrointestinal (GI) system, common presenting symptoms are: Difficulty in swallowing Nausea and vomiting Hematemesis Bloating/gas Reflux Mass Diarrhea Melena Loss of appetite Constipation Abdominal pain Jaundice Weight loss Detailed History: The Gastrointestinal System Starting the Interview: Knock on the door. Enter the station. Hand wash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your identification (ID). Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr... I am your attend-ing physician for today. Are you Mr/Mrs/Miss... ? Are you ... years old?” Chief Complaint: Chief complaint or the reason patient is visiting the clinic. “What brings you in today?” History of Present Illness: Chief Complaint: Onset Course Duration Progression Severity of symptoms M. H. Sherazi Mallacoota Medical Centre, Mallacoota, VIC, Australia6

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178 Pain Questions: Onset: “When did the pain start?” Course: “How did it start (suddenly or gradually)?” Duration: “How long have you had this pain?” Location: “Where does the pain start?” Then clarify the area: right upper quadrant (RUQ), right lower quadrant (RLQ), left upper quadrant (LUQ), left lower quadrant (LLQ), suprapubic, epigastrium, or flanks. Character: “What is the pain like?” Progression: “Is the pain progressing?” Severity: “From 0-10 with 10 being the worst pain and 0 as no pain, how is your pain now? What was the maxi-mum pain? When?” Radiation: “Does the pain move anywhere?” Timing (Time of the day): “Is there any specific time when the pain appears?” Same pain before: “Have you ever had similar pain before?” Aggravating: “Anything that increases the pain?” Alleviating: “Anything that relieves the pain?”Table 6. 1 Quick overview of the gastrointestinal system history Introduction Name and age Chief complaint In patient's own words History of present illness Analysis of chief complaint: Onset Course Duration If pain Location: right upper quadrant (RUQ), right lower quadrant (RLQ), left upper quadrant (LUQ), left lower quadrant (LLQ), epigastrium, suprapubic, or flanks Progression Quality Radiation Severity (1-10) Timing Associated symptoms: nausea, vomiting, diarrhea, constipation, change in bowel habits, reflux, appetite, blood in vomiting/feces/ urine, jaundice Predisposing factors Aggravating and relieving factors Red flags/risk factors Constitutional symptoms: anorexia, chills, sweating, fever, weight loss Review of systems: Respiratory Genitourinary Cardiovascular Neurology Impact on body Rule out differential diagnosis Past medical and surgical history Medical illnesses Any previous or recent surgery Hospitalization history or emergency admission history History of hepatitis, previous blood transfusion, inflammatory bowel disease HIV testing? (consent first) hepatitis profile and vaccination history for hepatitis B Medications history: Current medications (prescribed, over-the-counter, and any herbal) Laxatives, antacids Allergic history/triggers: Any known allergies? Family history Family history of same symptoms Family history of any long-term or specific medical illness (inflammatory bowel disease/bowel cancers) Any long-term disease Home situation With whom do you live? Occupation history How do you support yourself? (continued)Table 6. 1 (continued) Social history Smoking Alcohol Street drugs Sexual history Tattoos If adult female: Menstrual history (LMP) Gynecology history Obstetric history If teen: Home Education Employment Activities Drugs Sexual activity If child: Birth history Immunization Nutrition Development Wrap-up Describe the diagnosis Management plan Possible medical treatment Duration of treatment and side effects Red flags Laboratory tests Further information websites/brochures/support groups or societies/toll-free numbers Follow-up M. H. Sherazi

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179 Associated Symptoms: Nausea V omiting. If yes, ask about: -Times, last vomit, contents, odor, amount, blood? -If the patient has vomited multiple times and intake was low, then add questions about dehydration. Diarrhea. If yes, ask about: -Times, last episode, contents, odor, amount, blood? -If the patient has multiple episodes of loose stools and intake was low, then add questions about dehydration. Constipation Change in bowel habits Acid reflux Appetite Blood in vomiting or bowel movements or urine Jaundice Malignancy Symptoms: abdominal distension, pain abdo-men, constipation, weight loss, fever, fatigue, anemia, and bleeding per rectum Constitutional Symptoms: Fatigue and malaise, night sweat, fever, and weight loss Review of Systems and Extra-articular Features: Urine: Hematuria, change in color of urine, dysuria, polyuria, change in frequency of urine, nocturia, and anuria Skin: Malar rash, nodules, alopecia, nail pitting/clubbing, erythema nodosum, and pyoderma gangrenosum Eyes: Iritis, scleritis, and conjunctivitis Mouth: Ulceration/erosion Respiratory system: History of tuberculosis, pulmonary fibrosis, and pulmonary nodules Gastroenterology: Gastroesophageal reflux disease (GERD), small bowel obstruction, and malabsorption Liver disease: Nausea, vomiting, anorexia, abdominal distension, blood in vomiting or blood with bowel move-ments, easy bruising, impotence, change in normal sleep pattern, confusion, bad taste, and jaundice (yellowness of the eyes or skin) Past Medical History: “Do you have any previous health issues?” “Do you have any health issues related to your lung, heart, or kidney?” “Did you ever have a tuberculosis test?” “Previous blood transfusion?” “Inflammatory bowel disease or irritable bowel syndrome?” “Do you have any previous hospitalization or previous surgery?” “History of hepatitis, hepatitis profile, and vaccination history for hepatitis B?” “Human immunodeficiency virus (HIV) testing (need consent first)?” “Previous blood transfusion?” “Tattoos?” “Inflammatory bowel disease?” “Hospitalization history or emergency admission history?” Medications History: Current medications (prescribed, over-the-counter, and any herbal). Laxatives and antacids. If diarrhea then ask about use of recent antibiotics. Allergic History: Do you have any known allergies? Family History: “Has anyone in your family had similar symptoms or similar health problem?” “Family history of any long-term or specific medical ill-ness (inflammatory bowel disease)?” Social History: “Do you smoke? Do you drink alcohol?” If yes, then ask further questions: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” If yes, “Which one? How long? When?” “Ear and body piercing and tattoos?” “Intravenous (IV) drug use?” “Recent travel?” Relationships: “Are you sexually active? Do you have sex-ual preferences? Man, woman, or both?” Self-Care and Living Condition: “What do you do for liv-ing? Who lives with you?” Support: “Do you have good family and friends support?” Impact on Life/Disability and Adaptation: “Effects on life? Any effect on your daily activity?” If Patient Is a Teenager, Then Add These Questions: Home, education, employment, activities, drugs, and sexual activity If Patient Is an Adult Female, Then Ask These Questions: Menstrual history (last menstrual period [LMP]) Gynecology history Obstetrics history 6 The Gastrointestinal System

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180 If Patient Is More Than 65 Years Old, Add These Questions Here: Any problem with balance? Any difficulty in peeing/urination? Any issues with sleeping? Any change in vision/hearing? Any recent change in memory? Any regular medication? Prescribed or over-the- counter? Wrap-Up: Describe the diagnosis. Laboratory tests. Management plan. Duration of treatment and side effects. Red flags. Further information: Websites/brochures/support groups or societies. Follow-up. Physical Examination: The Gastrointestinal System A 32-year-old male, with abdominal pain for 1 week, comes into your clinic. Vital Signs: Heart rate (HR), 76/min, regular; blood pres-sure (BP), 120/75 mm Hg; Temp, 36. 8 °C; respiratory rate (RR), 16/min; O 2 saturation 100%. Please perform a detailed gastrointestinal system exami-nation. Please do not perform rectal, genitourinary, or breast examination. Starting the Interview: Knock on the door. Enter the station. Hand wash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Stand on the right side of the patient and start the examination. Opening: “Good morning/good afternoon. I am Dr.... I am your attend-ing physician. Are you Mr....? Are you 32 years old? Is it alright, if I examine your abdomen? I will also do some par-ticular tests to find out the cause of your symptoms. During the examination, if you feel uncomfortable, please let me know. ” Vitals: Start with commenting on the vitals given at the door. (It should include pulse rate, blood pressure, respiratory rate, temperature, and O2 saturation. ) “Mr..., vital signs are normal” or mention if there is any abnormal finding. Or com-ment like, “He has tachycardia or fever. ” General Appearance: “I need to ask you a couple of questions as a part of my examination: What is the date today? Do you know where you are now?” (You may skip these questions if it is a his-tory and physical station. ) Comment: “Patient is oriented and alert. ” “Patient is not in any distress. ” Or “patient is sitting comfortably and he is well oriented and alert. ” General Physical Examination: It should start with height, weight, waist circumference (body mass index [BMI]) and general nutritional status (just mention). Hands: “I want to start with examining your hands. Can you please let me see your hands?” Look for capillary refill, clubbing, koilonychia (spoon-shaped nails -iron deficiency anemia), leukonychia (white nails -liver dis-ease), palmar erythema, nicotine stains, peripheral cyano-sis, (bluish cool fingers/toes), muscle wasting (thenar and hypothenar muscles) and contractures (Dupuytren's). Asterixis (flapping tremors): “I want you to extend both your arms and back flex your hands. I will show you how to do it. Please follow me. Now you can close your eyes. ” Watch for the patient's wrist and fingers for a flap because of a brief rapid relaxation of wrist dorsiflexion (Fig.  6. 1a-c). Pulse: Engage the patient by saying, “I am going to feel your pulse now. ” Comment on rate, rhythm and volume of pulse. Face: Look for pallor, jaundice, plethora (pink), central cyanosis (blue lips and buccal mucosa SO 2 <80%), cushingoid (moon face round and puffy), myosis, and ptosis (Horner's syndrome). -Nose: Nasal flaring and perforated septum. -Lips: Pursed lips, cheilosis, and dryness. -Mouth: please open your mouth and any bad smell (fetor). -Look at the tongue for: Moist/dry, ulcers, thrush, cen-tral cyanosis, and glossitis. -Check gums for any bleeding. Neck: “I am going to feel your neck now. ” -Trachea: Position (central or mid line) and mobility -Jugular vein distention (JVD) -Cervical lymph nodes Chest: Inform the patient, “I am going to examine your chest first. ” Examine chest only if it is a detailed physical examination station. If it is a history and physical exami-nation station, it can be skipped. -“Can you please uncover your chest?” Look anteriorly and posteriorly. -Comment on your findings: “Chest is symmetrical, normal shape (no barrel, funnel, or pigeon chest), no M. H. Sherazi

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181 surgical scars or dilated veins, no gynecomastia, no axillary hair loss. ” -Do a quick auscultation of the heart and move on to abdomen inspection. Abdominal Examination: Posture: Patient lying flat with his arms on the sides (Fig.   6. 2). Knees can be flexed to relax the abdomen. “I will start with inspecting or observing your abdomen. Is it alright if I expose you abdomen from the ribs to the waist below?” (Please do not expose the breasts or the inguinal area. ) Drape the patient. Observe for: -Skin: Scars, striae, dilated veins, jaundice, and ulceration -Umbilicus: Position, contour, location, color (bluish: Cullen sign), and any herniation. Contour: Symmetrical or asymmetric, flat/bulging/protu-berant, scaphoid, visible mass, and visible organs (Fig.  6. 3). Skin: Scar marks, dilated veins, spider naevi, intercostal retractions, jaundice, or ulceration. Movements: Abdominal thoracic in case of male. Peristalsis: Visible/no visible peristalsis. Pulsation: Check for aortic pulsation (abdominal aortic aneurysm). Ask patient to cough: Check for any visible hernias - umbilical area, epigastric area, inguinal/femoral (just mention -usually not to be exposed). Observe patient posture: -Completely still -peritonitis -Moving in distress -colic -Curled up in fetal position -visceral pain -Lying with one hip flexed -splinting Distended abdomen: -Common causes: Fat, feces, flatus, fluid, fetus, or fatal growth Comment: Abdomen is scaphoid; umbilicus is central and inverted. No visible abnormal finding seen. Auscultation: Bowel sounds: Then say, “I am going to listen to your bowel sounds with my stethoscope. ” Rub the diaphragm to show you are warming it up. Auscultate in at least two quadrants for 30 s each, but do not spend too much time on it. Listen for: clicks, gurgles, or borborygmi (loud and prolonged gurgles) (Table 6. 2). Bowel sounds findings: -Decreased or absent: Ileus or peritonitis -Increased: Diarrhea or early obstruction -Intermittent crescendo with pain onset: Small bowel obstruction a cb Fig. 6. 1 Checking hands for asterixis. (a) Patient extends arms. (b) Patient flexes hand up and (c) down 6 The Gastrointestinal System

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182 Bruits: Vascular bruits: Aortic, iliac, and renal arteries Hepatic bruit: Hepatic cancer or alcoholic hepatitis Venous hum: Portal hypertension Comment: No aortic, renal, iliac, or hepatic bruits Palpation: Warm up your hands (rub your hands for few seconds to let patient and examiner know you are warming up your hands for patient comfort especially in cold weather). I usually start palpation of the abdomen with this ques-tion: “Do you have pain anywhere in your abdomen?” Or ask the patient to cough and ask if patient is tender anywhere. Then remember to examine the tender area at the end. Inform the patient while putting hand on the abdomen, “I am starting now to feel your abdomen. ” Superficial/light palpation: Gently palpate each quadrant (Fig.   6. 4). Make sure to go through all the areas. Feel for any tenderness, mass, or muscular resistance. A simple and easy-to-remember way will be to start from LLQ to LUQ; then epigastrium, umbilical to suprapubic; and then RLQ to RUQ. Deep palpation: (Fig.   6. 5) Again palpate for all four quadrants but this time with deeper palpation. Feel for any tenderness or lump/mass. Specific signs: -Rebound tenderness: If there is any area of tender-ness then inform the patient that you want to do a little test, which consists of pressing firmly with your fin-gers on the area of tenderness and abruptly releasing the pressure from hand. Ask the patient whether the pain was more on pressing or releasing the pressure. Increase of pain on removing the pressure is rebound tenderness. It is a sign of local or diffuse peritoneal irritation by inflammation. -Mc Burney' point: This particular site is one-third the distance between the anterior superior iliac supine and the umbilicus (Fig.   6. 6). Tenderness at this site is the sign of appendicitis [2]. -Rovsing's sign: Tell the patient, “I am going to press on the left side of your abdomen and please let me know if you feel increasing pain on your right lower abdomen. ” If the sign is positive, it is also a classical sign of appendicitis (Fig.  6. 7) [4]. Fig. 6. 2 Abdominopelvic quadrants. (Reprinted under terms of Creative Commons license from Blausen. com staff [1]. Own work https://creativecommons. org/licenses/by/3. 0/) Fig. 6. 3 Note the shape of the abdomen: flat, scaphoid, or distended Table 6. 2 Auscultation for bowel sounds Bowel sounds Absent No bowel sounds for 5 min Hypoactive Bowel sounds are fewer than 5 per minute Active Bowel sounds occur 5-30 per minute Hyperactive Bowel sounds are more than 30 per minute M. H. Sherazi

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183 -Psoas sign : Place the patient in left decubitus and extend right leg at the hip (Fig.   6. 8). If there is pain with this movement, then the sign is positive. The sign is positive in psoas muscle irritation. Occasionally the appendix lies on the psoas muscle, and the patient will lie with the right hip flexed for pain relief. -Obturator's sign: Tell the patient, “I am going to flex your right thigh at the hip with the knee bent. ” Rotate the leg internally at the hip (Fig.   6. 9). Increasing pain suggests obturator muscle irritation and is also seen in cases of acute appendicitis. -Murphy's sign : It is performed by asking the patient to breathe out, and then gently palpate the right sub-costal area and ask the patient to inspire deeply. If the patient feels pain upon this maneuver and holds breath, the sign is positive and is a sign of cholecystitis. -Courvoisier's sign : Comment while palpating the RUQ.   Palpable distended painless gallbladder. This sign is positive in gall bladder cancer [ 5]. Liver palpation : The patient should be positioned supine. Both arms at the sides. Place your right hand paralleled to Fig. 6. 4 Lightly palpate each quadrant of the abdomen Fig. 6. 6 Mc Burney's point Fig. 6. 7 Rovsing's sign. Deep palpation of the left iliac fossa causes pain in the right iliac fossa. (Reprinted with permission from Hutson and Beasley [ 3]) Fig. 6. 8 Psoas sign Fig. 6. 5 Murphy's sign 6 The Gastrointestinal System

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184 the abdomen wall starting from the RLQ.  Ask the patient to take deep breaths in and out. While the patient is in inspira-tion, push inward and upward, and repeat until the edge of the liver is felt on the finger tips. Measure the liver length below the costal margin in midclavicular line. Mention. “The liver is... cm below the costal margin. ” Also mention about the edge of the liver that the edge of the liver is soft, firm, smooth nodular, tender, or not tender. Liver percussion: Let the patient know that you will be tapping on the abdomen. Start in the RLQ below the umbilicus in the midclavicular line, and percuss upward toward the costal margin. Identify and mark the area where the tympanic note becomes dull. The second step is to start percussing in the midclavicular line in the second or third intercostal spaces going downward toward the RUQ.   Note the area where the resonant note becomes dull. Measure the distance between the two marks. It will be the liver span and it should be 6-12 cm at the midcla-vicular line (Fig.  6. 10). Spleen palpation: Start with the patient supine and arms at the sides. Inform the patient, “I am going to lift your left side. ” With the left hand, lift the patient's left rib cage upward. Place your right hand obliquely on the abdomen pointed toward the anterior axillary line starting from the RLQ moving toward the LUQ.  During inspiration, push inward and upward, and repeat until the edge of the spleen is felt on your fingertips (Fig.   6. 11a). Comment that the spleen is not enlarged. Spleen percussion: -Castell's sign: Percuss the tenth intercostal space at the left mid-axillary line (Fig.   6. 11b). The note should be tympanic. Ask the patient to take a deep breath and percuss again. The percussion note should remain tympanic if the spleen is normal in size. If the spleen is enlarged, then the note will change to dull, and Castell's sign will be positive.-Traube's space: Percuss along the left lower anterior chest wall between the area of lung resonance above and the costal margin below. There will be dullness in this space if the spleen is enlarged. -Nixon's sign: Turn the patient to the left lateral decu-bitus position, and start percussing at the midpoint of the left costal margin. Then continue percussing in a perpendicular line toward the axillary region. In case of splenic enlargement, the dullness will be more than 8 cm. Kidney palpation: Kidneys are not palpable in adults. Inform the patient, “Now I am lifting your right side upward. ” With your left hand, lift the patient's right flank upward (below the rib cage). With the right hand, palpate deeply (Fig.   6. 12). Then repeat it on other side. Comment that the kidneys are not palpable. Costovertebral angle (CVA) tenderness: Ask the patient to sit up. Inform the patient, “I will tap on your back. ” Make a fist, and tap gently and repeatedly on the right CV A and then on the left side (Fig.  6. 13). -Ask the patient: Does it hurt? -Comment: There is CVA tenderness. Fig. 6. 9 Obturator's sign Fig. 6. 10 Liver percussion M. H. Sherazi

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185 Percussion: Percussion should be done in four quadrants. The notes should be tympanic. There may be areas of dullness because of fluid or feces. Fluid thrill and shifting dullness: Both tests are per-formed to check for ascites. It becomes detectable once there is ~500 ml of fluid. The patient will tell about an increase in waist size and increase in weight. It is always started with inspecting for protuberant abdomen, bulging umbilicus, and flanks. Fluid thrill or fluid wave is done by asking the patient to put hypothenar aspect of one or both hands in the midline of the abdomen. This helps in stop-ping the transmission of wave through the abdominal wall fat. Then let the patient know that you will be tapping on one side of the abdomen. Tap on the right or left side of the flank with your finger tip and feel on the opposite side for a transmitted wave. A palpable fluid wave/thrill is indicative of ascites. Shifting dullness: You should let the patient know that you will be tapping on the abdomen, then start percussion from the midline going outward. The usual percussion note in the midline will be tympanic, and it will become a dull note in the flanks. Guide the patient to turn onto the other side, then wait for 20-30 s; this area percussion note will change from dull to tympanic. It is because the ascetic fluid will sink with gravity and the bowel loops with gas float on the top (Fig.  6. 14). Hernia Examination: “I would like to check for groin hernias. ” (The examiner will give the findings but will not expose. ) Umbilical, paraumbili-cal, inguinal, femoral, spigelian, and incisional hernias a b Mid-axillary line Direction of e xtension of splenic dullness with enlargement XI XII Fig. 6. 11 (a) Spleen palpation. (b) The common direction of splenic enlargement. An early sign of splenic enlargement is the extension of splenic dullness to percussion anterior to the mid-axillary line along the line of the tenth rib. (Figure  6. 11b reprinted with permission from Bergman and Heidger [6]) Fig. 6. 12 Kidney palpation Fig. 6. 13 Checking for costovertebral angle tenderness 6 The Gastrointestinal System

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186 should be looked for (Fig.   6. 15). In OSCE scenarios it is often written or told that please do not expose the inguinal area. In such a case, if the presentation is with abdominal symptoms, it is very important to mention that you will check for groin hernias. The patient may need to be exam-ined in supine and then in standing position. Tympan y Dull (fluid)Tympan y Dull (fluid)Fig. 6. 14 Shifting dullness in ascites lncisional Umbilical Hiatal Spigelian Obturator Femora l Groin hernias Ventral hernias Inguinal Fig. 6. 15 Types of abdominal wall hernias. (Reprinted with permission from Ganti [7]) M. H. Sherazi

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187 For Hernia Examination: Inspection: Bulge, lump, scars, asymmetry, skin changes, cough reflex, or ask the patient to bear down. Palpation: Palpation of the visible lump or masses. Check for tenderness, size, margins, and reducibility. Auscultation: Not done in the exam. If it needs to be done, it should be done over the lump and done with diaphragm of the stethoscope. Presence of bowel sounds in the hernial sac indicates bowel within the hernia sac. Say, “I will next do palpation for the groin lymph nodes, a digital rectal and vaginal examination. ” (The examiner will give the findings. You will never have to do the rectal or vagi-nal examination in the OSCE. ) Wrap-Up: Thank the patient and ask the patient to cover up. Wrap up your findings with the examiner or the patient. Checklist: Physical Examination of the Gastrointestinal System Table 6. 3 provides a checklist that can be used for a quick review before the exam. History: Dysphagia Candidate Information: A 59-year-old male presents with difficulty in swallowing for 2  months. He has lost some weight and is concerned about it. Vital Signs: HR: 76/min, regular; BP, 120/65  mm Hg; Temp, 36. 8 °C; RR, 14/min; O2 saturation, 99%. Please take a detailed history and discuss your differen-tials with the examiner. No physical examination is required for this station. Differentials: Esophageal stricture (ingestion of caustic substance) Achalasia Obstructive lesions: Tumors (esophageal, pharyngeal, or mediastinal), Zenker's diverticulum, esophageal webs, extrinsic structural lesions, anterior mediastinal masses, and cervical spondylosis Neurogenic disorders: Cerebrovascular accident (CV A) and bulbar palsy Spastic motor disorders: Diffuse esophageal spasm, hypertensive lower esophageal sphincter, and nutcracker esophagus Scleroderma Muscular dystrophy: Myotonic dystrophy and oculopha-ryngeal dystrophy Degenerative diseases: Amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), and Huntington disease Table 6. 3 Checklist for physical examination of the gastrointestinal system Starting the station Knock on the door Enter the station Hand wash/alcohol rub Greet the examiner and the patient Give stickers to the examiner if required, or show your ID badge Now sit on the chair or stand on the right side of the patient, and start the interview Opening Introduction, greet, explain, position, and exposure/drape Ask for vital signs -interpret the vital signs General physical examination (may skip these questions if it is a history and physical station)Check for alertness and orientation Look for any abnormal finding in: hands, face, neck, and chest Abdominal examination Inspection: Observe for skin, umbilicus, contour, movements, peristalsis, pulsation, scars, masses, and cough reflex Auscultation: bowel sounds and bruits Percussion: Shifting dullness and fluid thrill Liver and spleen span Palpation: Superficial/light palpation Deep palpation Specific signs: Rebound tenderness Mc Burney's point Rovsing's sign Psoas sign Obturator sign Murphy's sign Courvoisier's sign Liver palpation Spleen palpation Kidney palpation CV A tenderness Mention “I will next do palpation for the hernias, groin lymph nodes, and a digital rectal and vaginal examination” “I will also do respiratory and cardiovascular examination. ” (The examiner will give the findings) Wrap-up Thank the patient and ask the patient to cover up Wrap up your findings with the examiner or the patient 6 The Gastrointestinal System

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188 Starting the Interview: Knock on the door. Enter the station. Hand wash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: “Good morning/good afternoon. I am Dr... I am your attending physician for today. Are you Mr... ? Are you 59 years old? You are here because you have difficulty in swallowing. Can you please tell me more about this?” History of Present Illness: Start with clarifying about “Feeling of a lump in throat or food getting stuck in the chest?” Onset: “When did it start? Started suddenly or gradually?” Character: “Can you please describe to me regarding your difficulty in swallowing?” -Solid, liquid, or both -Liquids only: Achalasia -Solids: Mechanical obstruction -Both solids and liquids: Motility disorder or diffuse spasm Duration: “When was the first time you noticed it?” Progression: “How did it progress? Initially with solids and then liquids? Is it getting worse? Any aspiration? What kind of diet are you taking?” Level: “Do you have difficulty in initiating the process, or is it difficult to move the things through esophagus? Or where exactly does the food stop?” Frequency: -Intermittent? (ring, web, spasm) -Constant? (stricture, cancers) “Any pain when you swallow?” Associated Symptoms to Rule Out Differentials: “Do you suffer from heart burn or the condition called as GERD?” “Do you have peptic ulcer disease?” If yes then, “Did you ever get any treatment for it?” “Mouth thrush?” “Any cough? “ “Does the food ever come from the nose?” “Any chest pain?” “Choking?” (CV A) “Do you have weakness? Do you have loss of sensation?” (CV A) “Any change in voice? Slurred speech?” (CV A) “Swelling in the neck?” (thyroid) “Does heat or cold bother you more than usual?” “Any swelling of joints?” “Any skin tightness?” (Scleroderma) “Blue fingers in cold weather?” “Do you have abnormal movement of hand?” “History of corrosive material swallowing?” (stricture) “Did you lose any weight? How much weight did you lose?” “Any lumps or bumps?” Relieving Factors: “Does anything relieve the symptoms? Fluids? Any medication makes it better (antacid, spasmolyt-ics)? V omiting or regurgitation?” Constitutional Symptoms: Fever, night sweats, loss of weight, or loss of appetite Weight Loss: Assess the weight loss in the previous 6 months: Less than 5% is insignificant, 5-10% is potentially signifi-cant, and more than 10% will be definitely significant. -“Over what time of span has the weight been lost?” -“Do you still enjoy eating?” -“Describe your usual meals. ” -“Any associated nausea, vomiting, or diarrhea with meals?” -“Do you pass an excessive amount of urine?” -“Have you noticed any recent weather tolerance?” Assess current dietary intake as compared to patient pre-vious intake. “Have you not been eating well?” “Is your appetite normal, decreased, or increased?” Assess for malnutrition: Muscle wasting, loss of subcu-taneous fat, ankle/sacral edema, and ascites Past Medical History: “Gastroesophageal reflux disease?” “Peptic ulcer disease?” “Have you ever been investigated for esophagus or stom-ach problem?” “Ever had a scope? Nasogastric tube?” “Previous history of esophageal cancer? Neuromuscular disease? Iron deficiency anemia? Ingestion of caustic agent? HIV testing?” Past Hospitalization and Surgical History: “Do you have any previous hospitalization or previous surgery?” M. H. Sherazi

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189 Medication History: “Are you taking any medication?” If he says no, then con-tinue to next question. Otherwise ask for aspirin, nonsteroi-dal anti-inflammatory drugs (NSAIDs), over-the-counter or herbal, and any side effects. Allergic History: “Do you have any known allergies?” Family History: “Any family history of esophageal or bowel cancers?” Social History: “Do you smoke or anyone else in your home or close at work smoke? Do you drink alcohol?” If yes, then further ask: “How much? Daily? How long?” “Have you ever tried any recreational drugs?” If yes, “Which one? How long? When?” Relationships: “Are you sexually active? Do you have sexual preferences? Man, woman, or both?” Self-Care and Living Condition: “What do you do for living? Who lives with you?” Work Conditions and Financial Status? Support:“Do you have good family and friends support?” Functional status or severity or impact on life activities? Wrap-Up: Describe the Diagnosis: According to the station diagnosis. Nature of the disease and goals of treatment Question: (If history is suggestive of esophageal can-cer) What you will do next? (Questions may be asked by the patient or the examiner. ) Answer: “I will perform a detailed gastrointestinal sys-tem examination. I will order routine blood workup and will order barium swallow study to see the nature of the lesion. ” “Investigations: CBC, electrolytes, liver panel, kidney function test, urine analysis, and chest X-ray. ” Question: How will you confirm your diagnosis? Answer: “I will refer the patient to a gastroenterologist for upper GI scope and possible biopsy. ” Question: How will you stage it? Answer: “Liver panel, computed tomography (CT) chest/ abdomen, and bronchoscopy” Follow-Up: Discuss about a follow-up visit according to the diagnosis. Ask, “Do you have any questions?” History and Management: Upper Gastrointestinal Bleeding Candidate Information: You are working in an emergency room. A 44-year-old male presents with complaining of vomiting for 1 day. He noticed some blood in his last vomit. Vital Signs: HR, 76/min, regular; BP, 120/65 mm Hg; Temp, 36. 8 °C; RR, 14/min; O2 saturation, 99% Please take a detailed history. Give your differential diag-nosis to the examiner at the end. No physical examination is required for this station. Differentials: Esophagus: -Varices -Esophagitis -Ulcers -Cancer -Mallory Weiss tear Gastric or duodenal: -Peptic ulcer disease (gastric or duodenal ulcer) -Gastric erosions -Gastritis -Duodenal ulcers -Cancers -Dieulafoy's lesion Starting the Interview: Knock on the door. Enter the station. Hand wash/alcohol rub Greet the examiner and the patient. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair or stand on the right side of the patient and start the interview. Opening: Good morning/good afternoon. I am Dr.... I am your attend-ing physician for today. Are you Mr....? Are you 44 years old? What brings you to the emergency room today? History of Present Illness: The patient will give details about the vomiting and how he noticed some blood, which made him come to seek medical help. He may act as he is terrified and worried about it. Show empathy and offer support. Inform the patient, “I am going to ask a few questions to find out the cause of this blood in your vomiting. Then we will discuss about the plan. Is that alright?” 6 The Gastrointestinal System

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf

190 “How do you feel now? I just want to make sure you are stable and therefore I'll give some orders to the nurse. ” Mention, “I will go through ABC (airway, breathing, circulation). I will also need to get a set of vitals. Recumbent blood pressure, evidence of postural hypotension, and capillary fill-ing time. ” The examiner may give the information, and the patient will be stable enough to continue with the history: “When did you start vomiting?” “How did it start? Suddenly or gradual onset?” “Forceful and retching? Or did you start vomiting before the bleeding?” (protracted retching and vomiting - Mallory Weiss tear) “How many times did you vomit?” “How much?” “What are the contents of vomit?” “When was your last vomiting?” “How did you notice that there was blood in your vomit?” “Describe the bleeding. ” “Where is the blood coming from?” “Differentiate between coughing up blood, vomiting blood, or swallowed blood from a nose bleed?” “How much blood?” “How severe was the bleeding?” “Just blood or mixed with food?” “Color of the blood? Dark/bright red/coffee ground?” “Any clots?” “Any smell?” “Did you ever have blood in your vomit or feces before?” “Acute vs. chronic?” “Any bleeding from any other location?” Associated symptoms to rule out differentials: “Pre-syncope?” “Syncope?” “Any abdominal pain?” “Epigastric pain?” “Diffuse abdominal pain?” “Melena (sticky, black, dark, tarry stools)?” “When was your last bowel movement?” “Color?” “Any history of bleeding disorder?” “Hematochezia (passage of bloody stool)?” “Dyspepsia?” “Any nausea?” “Heartburn?” “Dysphagia?” “Weight loss?”Liver: If there will be no pain, then the cause may be likely related to liver disease. Explore about liver problems: “Jaundice?” “Any ongoing liver disease?” “Any previous screening for liver disease?” “Any bruising in body?” “Increase in abdominal size lately?” “Alcohol: How long? How much?” “Use of NSAIDs (aspirin) -How much? How long? Why? Who prescribed?” “Any blood thinner?” “Any long-term disease?” Constitutional Symptoms: “Fever, night sweats, loss of weight, loss of appetite, and any lumps or bumps?” Past Medical History: “Peptic ulcer disease? Have you ever been investigated for esophagus or stomach problem, previous history of esopha-geal varices/cancer? Previous liver disease, ever had a scope? Previous intestinal surgery? Previous intestinal bleeding? Coagulopathy? Abdominal aortic aneurysm repair (aortoen-teric fistula)?” Past Hospitalization and Surgical History: “Have you had any previous hospitalization or previous surgery?” Medication History: (Important for this station) “Are you taking any medication?” Ask for aspirin, NSAIDs, anticoagulants, steroids, over-the- counter or herbal, and any side effects. Allergic History: “Do you have any known allergies?” Family History: “Any family history of esophageal or bowel cancers? Coagulopathy?” Social History: “Do you smoke or does anyone else in your home or close at work smoke? Do you drink alcohol?” If yes, then further question: “How much? Daily? How long?” “Have you ever tried any recreational drugs? If yes, “Which one? How long? When?” M. H. Sherazi

Mubashar Hussain Sherazi Elijah Dixon - The Objective Structured Clinical Examination Review-Springer 2018.pdf