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191 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: Question: How will you manage him (if you suspect pep-tic ulcer bleeding)? Answer: Continuous monitoring. Attach a pulse oximeter and cardiac monitor to the patient. Assess for: heart rate, respiratory rate, recumbent blood pressure, postural hypotension, reduced filling time, hydration status (dry tongue, sunken eyes, reduced skin turgor), pallor, and decreased urine output. Look for stig-mata of liver disease (flapping tremors, jaundice, spider naevi). "I will put two large-bore intravenous (IV) lines, will take blood, and send for complete blood count (CBC), electro-lytes, liver panel, kidney function test, urine analysis, and group and save. Commence high-dose oxygen via a face mask. Maintain the oxygen saturation above 94%. Begin fluid replacement with normal saline 10-20  ml/kg, targeting urine output of 0. 5-1 ml/kg per hour. I will start IV PPI (Pantoprazole 80 mg IV followed by an infusion 8 mg/h). Question:What you will do next? Answer: “I will consult the on-call gastroenterologist and discuss. Patient may require an urgent upper GI endos-copy. Arrange a family meeting and social worker visit if required. ” History and Counseling: Epigastric Pain Candidate Information: A 45-year-old male presents to your clinic with a history of epigastric pain for the past 1 month. Vital Signs: HR, 76/min, regular; BP, 120/65 mm Hg; Temp, 36. 8; RR, 14/min; O2 saturation 99% Please take a detailed history. Discuss your probable diag-nosis and management plan with examiner. No physical examination is required for this station. Differentials [8]: Esophagitis Acute/chronic gastritis Peptic ulcer disease (PUD) Gastric erosions Gastroesophageal reflux disease (GERD) Acute coronary syndrome Acute cholangitis Biliary colic Cholecystitis Cholelithiasis Gastroenteritis Inflammatory bowel disease Viral hepatitis Pancreatitis Acute coronary syndrome Epigastric pain/discomfort is a common presentation in a GP setup. The common epigastric pain cases in OSCE are gastroesophageal reflux disease or peptic ulcer disease. An important part of this station is to rule out serious medical problems such as acute coronary syndrome or pancreatitis. The important points in a history of gastroesophageal reflux/peptic ulcer disease are: The pain or discomfort is burning in nature. Burning sensation when lying down. Pain is not severe in intensity. Does not radiate up to the chest or elsewhere. Usually lasts from 30 min to a few hours. It usually has inconsistent relationship to eating. It is temporarily relieved by antacids. It does not wake patient from sleep. It is not associated with exertion. It is worse during stressful days. Sometimes history suggests recent NSAIDs use. 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....? And you are 45 years old? What brings you here today?” 6 The Gastrointestinal System

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

192 History of Present Illness: “How would you describe the discomfort?” “Can you show me exactly where it is?” Onset: “When did it start? Started suddenly or gradually?” Duration: “When was the first time you noticed it?” Progression: “Is it progressing?” “What makes your discomfort worse?” -“What effect does food, milk, and antacids have?” -“What effect does coffee have?” -“What effect does a big meal have?” -“What about drinking alcohol? Wine?” -“What effect does exercise have?” -“Do fried or fatty foods make it worse?” -“Do hot spicy foods affect it?” “What relieves it?” “Does the problem come on at night soon after you go to bed?” “Does it wake you up at night?” “Do you use any pillows when you lie down?” “Does bending over make it worse?” “Do you rush your meals?” “Do you chew your food properly?” Questions to Rule Out Differentials: “Nausea and vomiting?” “Do you feel discomfort between your shoulder blades, shoulders, or throat?” “Do you have difficulty swallowing?” “Lump or constriction in throat?” “Acid regurgitation?” “Water brash?” “Bloating? belching?” Symptoms of anemia: “Dizziness, tiredness, or shortness of breath?” “Night time cough?” “Tiredness?” “Change in bowel habits?” “Have you lost weight recently?” “Do you get constipated or have diarrhea?” “Difficulty on swallowing or pain on swallowing?” “Any abdominal 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)?” 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?” Past Hospitalization and Surgical History: “Have you had any previous hospitalization or previous surgery?” Medication History: “Are you taking any medication, over-the-counter or herbal, and any side effects?” Allergic History: “Do you have any known allergies?” Family History: “Any family history of significant health problems?” Social History: “Do you smoke or does anyone else in your home or close at work smoke? Do you drink alcohol?” If yes then fur-ther questions: “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: Question: What is your most likely diagnosis? Answer: M. H. Sherazi

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

193 Peptic ulcer disease Non-ulcer dyspepsia Gastritis Question: What will you do next? Answer: “I will do physical examination. ” “Investigations: CBC, urea, creatinine, electrolytes, lipase, and ECG. ” “Specific test: Urea breath test. ” Question: What are a few important factors for this patient that you will assess in the history? Answer: Unexplained weight loss >10% Bleeding (hematemesis/melena) Dysphagia and odynophagia Palpable mass Anemia Chronic NSAID use Family history (FHX) or upper GI tract or colorectal cancer Short history of symptoms Question: What are your other differentials? Answer [9]: 1. Gall bladder: Gall bladder related issues such as acute cholecystitis, biliary colic, cholangitis -RUQ pain, fever, and jaundice -radiate to right shoulder or shoulder blade and raised liver function tests (LFTs). 2. Pancreatitis: Constant pain, gradually increases over 30-60  min, pain radiates to the back, vomiting, and increased amylase/lipase more pronounced than with cholecystitis; LFTs may be increased if due to gall stones. Symptoms and examination correlate with severe pain associated with marked tenderness. 3. Intestinal obstruction: Colicky pain with nausea and vomiting, no bowel movement, and obstructive pattern seen on imaging. 4. Dissecting aortic aneurysm: Sudden onset; pain may radiate to lower extremities. 5. Perforated PUD: RUQ or mid-epigastric pain, sudden onset, and free intraperitoneal air. 6. Pneumonia: Fever and respiratory symptoms such as dyspnea, cough, sputum, and chest pain. 7. Acute coronary syndrome: Epigastric/chest pain, short-ness of breath, and abnormal ECG/rise in troponins. 8. Mesenteric ischemia: Abdominal pain severe, out of proportion to tenderness with a fairly benign examina-tion. Look for post-prandial abdominal pain, weight loss, and abdominal bruit. Question: What will be your management plan? Answer: Educate the patient and lifestyle modification: -Weight reduction. -Reduction or cessation of smoking. -Avoid fatty foods, coffee, tea, and chocolate. -Avoid coffee and alcohol at night. -Reduction or cessation of alcohol. -Avoid gaseous drinks. -Leave at least 3  h between the evening meal and retiring. -Increase fiber intake. -Small regular meals and snacks. -Eat slowly and chew food well. -Sleep on left side. -Have main meal midday and light evening meal. -Avoid spicy foods and tomato products. -Avoid drugs: doxycycline, calcium channel blockers, iron sulfate, steroids, and NSAIDs. -Elevation of head of bed or wedge pillows. Antacids: Gaviscon or Mylanta plus. Proton-pump inhibitors (PPIs): Omeprazole or Pantoprazole × 4 weeks. Triple therapy if Helicobacter pylori (+ ve): clarithro-mycin, amoxicillin, and omeprazole. Follow up in 4 weeks. If symptoms persist then continue PPI and review by a gastroenterologist. History and Management: Lower Gastrointestinal Bleeding Candidate Information: You are working in an emergency room. A 64-year-old male presents with complaining of passing bright red blood in his stools. Vital Signs: HR, 89/min, regular; BP, 120/65 mm Hg; Temp, 36. 4; 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 required for this station. Differentials: Rectal/anal: -Anal fissure -Hemorrhoids -Anorectal trauma (elderly abuse) -Proctitis Diverticular disease Angiodysplasia Bowel cancers Ischemic colitis 6 The Gastrointestinal System

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

194 Polyps Invasive diarrhea (enteroinvasive Escherichia coli) Inflammatory bowel disease (ulcerative colitis) Upper GI bleeding: -Esophageal varices -Aortoenteric fistula -Ischemic colitis -Mallory Weiss tear Coagulopathy 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 64 years old? What brings you to the emergency room today?” History of Present Illness: Patient will give details that he has noticed blood coming with his bowel movements. He may show that he is concerned and worried about it. Show empathy and offer support. Inform him that you need to ask him a few questions to find out the cause of this blood in his bowel movements, then you will discuss about the plan. Ask him. “Is this alright?” “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, evi-dence of postural hypotension, and capillary filling time. ” The examiner may give the information and the patient will be stable enough to continue with the history: “Can you please describe your bleeding?” “Where is the blood coming from?” (urethra, vagina for female patients, rectum) “When did it start?” “How long has the bleeding been going on?” “How many times did you notice?” “What is the quantity?” “Has it gotten worse?” “How is the stool?” (loose/watery/formed/solid) “What is the color (black or bright red)?” “Does anything make the bleeding better or worse?”Associated Symptoms to Rule Out Differentials: “Pre-syncope?” “Syncope?” “Signs of anemia?” (tiredness, pallor, pre-syncope) “Any history of bleeding disorder?” “Dyspepsia?” “Nausea?” “Dysphagia?” “Did you notice any changes in your bowel habits?” (cancers) “Is the stool getting narrower? Mucus? Pus?” “Have you noticed any change in caliber of your stool?” (pencil stools) “Does this constipation alternate with diarrhea?” “Do you feel pain while having the bowel movement/ perianal itching?” (fissure) “Do you have any mass coming out of the bowel move-ment?” (hemorrhoids) “Any urgency to pass your bowel?” (colon cancer) “Did you have a colonoscopy done?” (“Have you had any test done with a camera from your back passage?”) “Any history of polyps?” “Do you have chronic diarrhea?” “Did you have abdominal pain/epigastric pain (IBD/isch-emic colitis)?” Ask for extra-intestinal manifestations: -“Do you have any skin rash/nodule?” -“Do you have any joint swelling?” -“Do you have eye redness or eye discharge?” “What is your sexual orientation?” (trauma) “Have you eaten any suspect food?” (undercooked meat) “Have you recently eaten beets or iron pills?” (may change color of stools) Explore about liver problems: -“Jaundice?” -“Any ongoing liver disease?” -“Any previous screening for liver disease?” -“Any bruising in body?” -“Increase in abdominal size lately?” 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 esoph-agus or stomach problem, previous history of esophageal varices/ cancer? Previous liver disease? Ever had a scope? Previous intes-tinal surgery? Previous intestinal bleeding? Coagulopathy? Abdominal aortic aneurysm repair (aortoenteric fistula)?” M. H. Sherazi

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

195 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 fur-ther questions: “How much? Daily? How long?” CAGE questionnaire. “Have you ever tried any recreational drugs?” If yes. “Which one? How long? When?” “Are you experiencing physical or sexual abuse?” 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?” Support: “Do you have good family and friends support?” Functional status or severity or impact on life activities? Wrap-Up: Question: What is your plan of management? Answer: “I will perform a physical examination, and I will take consent and will perform a digital rectal exam (DRE). ” “I will also look for stigmata of liver disease. I will inform the patient about my findings and plan. I will discuss with my seniors to admit him to the emergency room. I will ask the nurse to attach a pulse oximeter and cardiac monitor to the patient. I will assess for heart rate, respiratory rate, recumbent blood pressure, postural hypotension, reduced filling time, hydration status (dry tongue, sunken eyes, and reduced skin turgor), pallor, and decrease urine output. I will put in IV lines; I will take blood and send for CBC, electrolytes, liver panel, kidney function test, and group and save. ” “Collect a stool sample (if infectious cause), and send for culture and sensitivity or ova/parasites and Clostridium dif-ficile toxin. Commence high-dose oxygen via a face mask. Maintain the oxygen saturation above 94%. If patient is unstable, then I will begin fluid replacement with normal saline 10-20 ml/kg, targeting urine output of 0. 5-1 ml/kg per hour. ” Question: What you will do next? Answer: “According to the history, physical examination, and blood results findings, I will consult the on-call gastro-enterologist and discuss. CT scan vs upper and lower endos-copies outpatient or inpatient according to the patient's condition. Arrange a family meeting and social worker visit if required. ” History and Counseling: Constipation Candidate Information: A 67-year-old male presented to your clinic complaining of constipation off and on for 8 weeks. He has difficulty in passing stools and has a sensation of incomplete evacuation. Vital Signs: HR, 89/min, regular; BP, 120/65 mm Hg; Temp, 36. 8; RR, 14/min; O2 saturation 99% Please take a detailed history. Address patient concerns. No physical examination is required for this station. Differentials: Functional constipation Bowel obstruction (adhesions/stricture/tumors/internal or external hernias) Irritable bowel syndrome (IBS) Metabolic: hypothyroidism and hypercalcemia (hyperparathyroidism) Hemorrhoids Anal fissure/stricture Spinal cord injury/stroke/autonomic neuropathy Drugs 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. 6 The Gastrointestinal System

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

196 Opening: “Good morning/good afternoon. I am Dr.... I am your attend-ing physician for today. Are you Mr....? Are you 67 years old? What brings you to the clinic today?” History of Present Illness: Patient will tell about his decreased number of bowel movements. “When did this start?” “Can you please describe to me more about your current bowel movements?” “How frequent do you have bowel movements?” “Please tell me about its color?” “How about consistency of stool?” “How is the stool?” (loose/watery/formed/solid/too hard) “Shape?” “What is the quantity?” “Was there any urgency to pass a stool?” “Did you notice any pain while passing bowel movements?” “Do you have feelings of incomplete evacuation of stool?” “Do you have any urinary problems?” “Have you noticed any bleeding with passing a bowel movement?” -“Has it gotten worse?” -“What is the color?” (black or bright red) -“Does anything make the bleeding better or worse?” “Have you tried any over-the-counter constipation medicines?” “Do you drink enough water?” Associated Symptoms to Rule Out Differentials: “Did you notice any changes in your bowel habits?” (cancers) “Does this constipation alternate with diarrhea?” “Any urgency to pass your bowel?” “Have you noticed any change in caliber of your stool?” (pencil stools) “Is the stool getting narrower? Mucus? Pus?” “Did you have a colonoscopy done?” (“Have you had any test done with a camera from your back passage?”) “Do you feel pain while having the bowel movement/ perianal itching?” (fissure) “Do you have any mass coming out of the bowel move-ment?” (hemorrhoids) “Do you have any nausea or vomiting?” “Did you have abdominal pain?” (bowel obstruction) “Do you feel fatigued?” “Increase in abdominal size lately?” Ask about hypothyroidism: -Cold intolerance -Weight gain Ask about hyperparathyroidism:-Bone pain -Fracture -Renal stone -Abdominal pain -Depression Constitutional Symptoms: “Fever, night sweats, loss of weight, loss of appetite, and any lumps or bumps?” Past Medical History: “Any previous medical problems? Intestinal cancer, perianal disease, IBS, stroke, hypothyroid or hyperparathyroid, or rectal stricture” Past Hospitalization and Surgical History: “Have you had any previous hospitalization or previous sur-gery? Abdominal surgery?” Medication History: “Are you taking any medication, over-the-counter or herbal, and any side effects (antidepressants, tricyclic antidepres-sants, opioids)?” Allergic History: “Do you have any known allergies?” Family History: “Any family history of medical problems?” Social History: “Do you smoke or does anyone else in your home or close at work smoke? Do you drink alcohol?” If yes then fur-ther questions: “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?” Support: “Do you have good family and friends support?” Functional status or severity or impact on life activities? Wrap-Up: Question: What is your plan of management? Answer: “I will perform physical examination and will take consent and will perform a DRE (fecal impaction). ” M. H. Sherazi

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

197 Question: What you will do next? Answer: “According to the history and physical examina-tion, I will order routine blood tests, thyroid screen, and stool examination. ” Question: What is constipation? Answer: “Constipation is hard, often small stools and infrequent bowel movements, or it can be simply defined as a feeling of unsatisfied emptying of the bowel. One can expect to have many other symptoms, such as bloated, uncomfortable abdomen, straining to pass stools, and longer time spent in toilet to pass a bowel movement. Constipation occurs when stool moves through the large intestine too slowly. In the large intestine, the fluid from the stool is absorbed into the body, so the stool becomes hard and dry. This leads to the stool being difficult to pass. ” Question: What causes constipation? Answer: “There are many factors that cause constipa-tion. ” Some causes are listed below: Neglecting the habit of going to the toilet. Not responding when there is a desire to go to toilet. Inadequate fluids intake. Poor nutrition. Poor diet with a lack of fiber. Inadequate sleep. Stress and anxiety. Change in daily routine, such as while traveling. Overuse of laxatives/painkillers. Limited exercise. Some diseases may also cause constipation, such as bowel cancers. Old age. Question: What are the risks? Answer: “Constipation can cause discomfort in the abdo-men and lead to blockage of the bowel. This can present as impaction of hard stool with overflow incontinence of liquid stool. Straining and chronic constipation can cause perianal itching, hemorrhoids, and anal fissures and can even lead to rectal prolapse. ” Question: How does fiber help with constipation? Answer: “Fiber is the part of plant food that is not digested. There are two kinds of fiber: soluble and insoluble. Soluble fiber gives stool bulk. Apples, bananas, oats, and beans are good sources of soluble fiber. Insoluble fiber speeds up the transit of food in the digestive tract and helps prevent constipation. Most vegetables, wheat bran, and legumes are good sources of insoluble fiber. The goal should be to have around 20-30 g dietary fiber. ” Question: What advice will you give to your patient? Answer: I will counsel my patient for the following: Adequate exercise. Plenty of fluids -around 2 l a day. Eat food that provides bulk and provides adequate fiber. Attend the toilet to empty your bowel as soon as possible once the desire comes to defecate. If laxatives are required, then contact your physician first. Usually the physicians may recommend one of the hydro-philic bulk-forming agents such as ispaghula or psyllium. Sometimes an osmotic laxative such as macrogol or lactulose. History and Counseling: Diarrhea Candidate Information: A 36-year-old male presents to the emergency department with a 1-week history of diarrhea and intermittent vomiting. He vomited a few times today. Vital Signs: HR, 89/min, regular; BP, 120/65 mm Hg; Temp, 36. 8; RR, 14/min; O2 saturation 99% Please take a detailed history. Address the patient's con-cerns. No physical examination is required for this station. Differentials: Infectious: Bacterial, viral, parasitic, and pseudomembra-nous colitis Metabolic: Hyperthyroidism Idiopathic/iatrogenic: IBD, IBS, malabsorption Congenital: Cystic fibrosis, lactose intolerance Autoimmune: Celiac disease, Whipple disease Vascular: Ischemic colitis 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 36 years old? What brings you to the clinic today?” History of Present Illness: Start history with two symptoms -vomiting and then loose stools. “When did you start vomiting?” -“How did it start? Suddenly or gradual onset?” -“Forceful and retching?” -“How many times did you vomit?” 6 The Gastrointestinal System

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

198 -“How much?” -“What are the contents of vomit?” -“When was your last vomiting?” -“How did you notice that there was blood in your vomit?” Then start with loose stools. “When did your loose stool start?” “Can you please describe to me more about your current bowel movements?” “How frequently do you have bowel movement?” “Constant or intermittent?” “Do you pass large amount every time or scanty?” “What is the consistency?” (loose, watery, bulky, shape-less, greasy, sticky, floating) “Please tell me about its color. ” (normal, green, pale, black, blood streaks and mixed with blood) “How is the stool?” (loose/watery/formed/solid/too hard) Odor: “Foul smelling?” (malabsorption) Mucus: “Do you pass a lot of mucus?” “Was there any urgency to pass a stool?” “Did you notice any pain while passing bowel movements?” “Do you have feelings of incomplete evacuation of stool?” “Do you have any urinary problems?” “Have you noticed any bleeding with passing a bowel movement?” -“Has it gotten worse?” -“What is the color?” (black or bright red) -“Does anything make the bleeding better or worse?” “Did you notice any undigested food?” “Any particular triggers: Stress, dining out, antibiotics, or laxatives?” “Where were you when these symptoms started?” (Recent travel: “Tropical and subtropical regions? Have you had infectious contact? Did you think you drank contaminated water?”) “Do you drink enough water?” “Have you ever had these symptoms before?” “Do you think anything makes these symptoms better?” If yes, then “What? Fasting/medications?” “Anything that makes the symptoms worse? Dairy?” Associated Symptoms to Rule Out Differentials: “Do you have any nausea or vomiting?” “Did you have abdominal pain?” (bowel obstruction) “Did you notice any changes in your bowel habits?” (cancers) “Have you noticed any change in the caliber of your stool?” (pencil stools) “Does this constipation alternate with diarrhea?” “Do you feel fatigued?” “Bloating with gas?” “Worst in early morning?” (IBS) “Facial flushing?” (carcinoids) “Heat intolerance?” IBD extra-intestinal manifestations: “Joint pain, red eyes, vision problems, bone pain, skin rash, and light-headedness?” Symptoms of Dehydration: Light-headedness Dry mouth Faint when stand Thirsty Decreased amount of urine Heart racing Weight loss Constitutional Symptoms: Fever, night sweats, loss of weight, loss of appetite, and any lumps or bumps? Past Medical History: “Any previous medical problems?” (previous history of diar-rhea, liver disease, pancreas disease, thyroid disease, diabe-tes mellitus, HIV, abdominal surgery) Past Hospitalization and Surgical History: “Have you had any previous hospitalization or previous sur-gery? Abdominal surgery?” Medication History: “Are you taking any medication? Antibiotics, laxatives?” Allergic History: “Do you have any known allergies?” Family History: “Any family history of medical problems? IBD?” Social History: “Do you smoke or does anyone else in your home or close 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 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?” M. H. Sherazi

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

199 Support: “Do you have good family and friends support?” Functional status or severity or impact on life activities? Wrap-Up: Question: What you will do next? Answer: “According to the history and physical examina-tion, I will order routine blood tests and stool examination. ” Question: What is diarrhea? Answer: Diarrhea is the passing of a number of watery, loose, and offensive smelly bowel movements. It is usually associated with abdominal pain and vomiting. It is com-monly caused by a viral, bacterial, or parasitic infection of the intestines. Usual sources are eating contaminated food or drinking contaminated water. Common viruses are rotavirus and norovirus and bacteria are E. coli, Campylobacter, Shigella, Salmonella, and Staphylococcus aureus. Common parasites are Giardia lamblia and Cryptosporidium. Question: What is the treatment? Answer: “Diarrhea often resolves naturally. ” Rest: “Take rest as much as you can until the diarrhea stops. ” Diet: “You should avoid eating solid food in the start. Try to drink enough fluids to prevent dehydration. These may include clear fluids such as water and tea. Take an electro-lyte solution such as hydrolyte or gastrolyte, which you can get over the counter. Take these until the diarrhea settles. Once diarrhea starts resolving, eat low-fat and starchy foods such as boiled rice, soups, mashed bananas, boiled potatoes, and mashed vegetables. ” “Avoid alcohol, coffee, strong tea, fatty foods, fried foods, spicy foods, raw vegetables, and raw fruit. ” “Start eating dairy produce such as yogurt containing live cultures, a small amount of milk in tea or coffee, and a little butter or margarine on toast around the third day. ” Medicines: “Diarrhea often resolves naturally. Medicines are best to avoid. Kaolin-based preparations or intestine- slowing drugs such as loperamide (e. g., Imodium, Gastro- Stop) or Lomotil can be helpful. Question: How will you diagnose pseudomembrane colitis? Answer: Clostridium difficile toxin assay Question: What are the risk factors? Answer: Risk factors for Clostridium difficile include: Recent antibiotic use Long hospital stay Cancer chemotherapy and other immune suppression Other serious underlying illness Question: “What is the management?” Answer: “Metronidazole or oral vancomycin in more severe disease and recurrent infections. Oral or IV hydration” History: Jaundice Candidate Information: This is important and frequently repeated in various different ways: A 29-year-old male presents with jaundice for 4 days. Or A 29-year-old male just returned from Mexico. He com-plains of yellowish discoloration of his eyes and skin and felt tired. Take a focused history. Or A 29-year-old comes to your clinic with a blood test showing an abnormal liver test. (There might be a liver panel report attached or it may be given by the examiner). Take a focused history. Vital Signs: HR, 71/min, regular; BP, 120/65 mm Hg; Temp, 36. 8; RR, 14/min; O2 saturation 99% Please do not perform rectal, genitourinary, or breast examination. Differential Diagnosis: Infectious: Viral hepatitis (hepatitis A, B, or C) Idiopathic/iatrogenic: Biliary tract obstruction (choledo-cholithiasis, biliary stricture) Cancers: Obstructing biliary cancer (cholangiocarcinoma, pancreatic carcinoma) Alcoholic hepatitis Drug-induced (birth control pills, NSAIDs, isoniazid, diuretics, angiotensin-converting-enzyme inhibitor [ACEI]) Metabolic: Hemolysis Autoimmune hepatitis 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 29 years old? Is it 6 The Gastrointestinal System

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

200 alright if I ask you few questions about jaundice? If you have any concern or question, please ask me. ” History of Present Illness: 1. “What do you mean by jaundice?” 2. “Yellowness of eyes/skin/dark urine/stool?” 3. “When did you notice? How long?” 4. “Is it progressing? Stationary?” 5. “Is it the first time you had jaundice?” 6. “Any ongoing liver disease?” 7. “Any previous screening for liver disease?” Explore Risk Factors of Hepatitis: Blood transfusions Ear or body piercing Acupuncture Tattoos Unprotected sex IV drug abuser Occupation (blood handlers, dentist) Patient on dialysis Explore Travel to Mexico: “How long did you stay in Mexico?” (hepatitis A incuba-tion period) “Did you consume unhygienic food or drinks there?” “Have you been exposed to people with hepatitis?” “Did you have unprotected sexual intercourse there?” If yes, then ask: With how many partners?” (hepatitis B) “Any history of a blood transfusion?” (hepatitis B and C) “Any history of drug abuse?” (hepatitis B and C) Explore Associated Symptoms: “Itching?” “Nausea/vomiting?” “Abdominal pain?” “Any cough?” “Shortness of breath?” “Headache?” “Loss of appetite?” “Any change in bowel habits?” “Any change in color of stool? Clay color or white?” “Does your stool float in the commode?” (pancreatic disease) “Any change in passing urine?” “Fatigue?” “Any recent travel?” “Confusion?”Constitutional Symptoms: “Fever, night sweats, loss of weight, loss of appetite, and any lumps or bumps?” Past Medical History: “How is your health otherwise? Past history of gall stones? Hepatitis? Cirrhosis? Malignancy, Pancreatic disease? IBD? Anemia? Blood diseases such as sickle cell anemia?” Past Hospitalization and Surgical History: “Have you had any previous hospitalization or previous surgery?” Medication History: “Are you taking any medication prescribed, over-the-counter, or herbal?” (birth control pills, methotrexate, NSAIDs, methyldopa, anticonvulsants, chemotherapy, chlorproma-zine, antipsychotics, isoniazid, diuretics, ACEI) Allergic History: “Do you have any known allergies?” Family History: “Does anyone in your family have jaundice or any ongoing health problem? History of pancreatic cancers, blood dis-eases, or gall stones?” Social History: “Do you smoke?” (Important) “Do you drink alcohol?” If yes, then: “How much? How long?” CAGE questions. “Have you ever tried any recreational drugs?” Relationships: “Are you sexually active? Do you have sexual preferences? Man, woman, or both?” Self-Care and Living Condition: “How do you support yourself?” Functional status or severity or impact on life activities? Wrap-Up: Thank the patient. Ask the patient if he wants to ask any questions or has any concerns. Wrap up your findings with the examiner or the patient. M. H. Sherazi

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201 Question: What are the symptoms of your main differentials? Answer: Hepatitis symptoms: Nausea, vomiting, anorexia, mild fever, and chills Cholelithiasis: Pain RUQ and indigestion Pancreatic cancer: Painless jaundice and weight loss Question: What you will do next? Answer: “I will do a detailed physical examination. I would also like to order routine blood tests and liver panel. According to the most probable diagnosis, I may add ultrasonography (USG) of the liver and biliary tree. ” Question: What signs you will look for in liver disease? Answer: Jaundice Palmer erythema Dupuytren's contracture Lindsay's nail (white spots in the nails) Bulging flanks Caput medusae Gynecomastia Redistribution of hair pattern Liver bruits Venous hum Liver size (decreases in cirrhosis) Ankle edema Fluid thrill Shifting dullness Question: Which will be initial tests for liver disease? Answer: Liver function test Hepatitis serology USG of abdomen/liver and biliary tree Prothrombin time (PT), activated partial thromboplastin time (APTT), international normalized ratio (INR) Question: Patient has obstructive picture in labs? What are your two top differentials? Answer: Choledocholithiasis and carcinoma head of pancreas Question: What investigation will you write to assess level of obstruction? Answer: Endoscopic retrograde cholangiopancreatography (ERCP) Follow-Up: “I am sending your blood workup. The clinic will call you once the results are back. Do you have any questions?” Checklist: Physical Examination for Cirrhosis/ Chronic Liver Disease Table 6. 4 provides a checklist that can be used for a quick review before the exam. Table 6. 4 Physical examination checklist for cirrhosis or chronic liver disease 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 examination Opening Introduction, greet, explain, position, and exposure/drape Ask for vital signs -interpret the vital signs Position Sitting and then lying General physical examination Mental status: check for alert and orientation (time and place), drowsiness, asterixis Head and neck examination: jaundice, parotid gland enlargement, temporal muscle wasting, Keiser Fleischer ring Hands: clubbing, palmar erythema, Dupuytren contracture, Terry's nails Inform the patient about abdominal examination Inspection Chest: gynecomastia, spider angiomas, armpit hair loss Abdomen: caput medusae, bulging flanks, abdominal mass, or hernias Auscultation: liver bruit and spleen bruit Percussion: liver span, ascites (fluid thrill and shifting dullness) Back: sacral edema Legs: edema Genitourinary: testicular atrophy Wrap-up Thank the patient. Ask to cover up Wrap up your findings and ask patient if any concern 6 The Gastrointestinal System

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202 History: Increased Abdominal Girth Candidate Information: A 52-year-old male presented in your GP clinic with com-plaining of increasing abdominal girth. Vital Signs: HR, 72/min, regular; BP, 120/65 mm Hg; Temp, 36. 8; RR, 14/min; O2 saturation 99% Please take a detailed history. No physical examination required for this station. Differentials: Cirrhosis of liver Abdominal cancers Bowel obstruction Abdominal wall hernia Heart failure Renal failure 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 52 years old? How can I help you today?” History of Present Illness: “When did it start?” Or “When did you notice that your abdominal size was increasing?” “How did it start?” (sudden vs gradual) “Has it gotten worse or the same?” “How did you notice that?” (“Trouble putting pants on or increased the holes in your belt?”) “Any trouble putting shoes on?” “Any increase in overall body weight? How much and since how long?” “Any aggravating or relieving symptoms?” Associated Symptoms to Rule Out Differentials: “Did you have abdominal pain?” Explore liver problems: -“Did your skin turn yellow?” (jaundice?) -“Change in color of your eyes?” (becoming yellow?)-“Any ongoing liver disease?” -“Any previous screening for liver disease?” -“Itching?” -“Nausea or vomiting?” -“Decreased appetite?” -“Change in urine color (tea or cola color) and volume?” -“Change in stool color?” (gray) -“Any bruising in body? Easy bruising?” -“Confusion?” Risk factors for liver disease: -Blood transfusions -Ear or body piercing -Acupuncture -Tattoos -Unprotected sex -IV drug abuser -Occupation (blood handlers, dentist) -Patient on dialysis “Chills?” “Did you notice any changes in your bowel habits?” (cancers) “Have you noticed any change in the caliber of your stool?” (pencil stools) “Does this constipation alternate with diarrhea?” “Did you have a colonoscopy done?” (“Have you had any test done with a camera from your back passage?”) Alcohol: “How long? How much?” “Any long-term disease?” “Shortness of breath with activity?” (heart failure) “Shortness of breath on lying flat or at night time?” “Ankle swelling?” “Face swelling?” “Is there any change in the abdominal swelling with posi-tion or cough?” (abdominal wall hernia) Constitutional Symptoms: “Fever, night sweats, loss of weight, loss of appetite, and any lumps or bumps?” Past Medical History: “Any previous medical problem?” Past Hospitalization and Surgical History: “Do you have any previous hospitalization or previous sur-gery?” Ask specifically, “Abdominal surgery?” Medication History: “Are you taking any medication, over-the-counter, or herbal medication, and any side effects?” M. H. Sherazi

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203 Allergic History: “Do you have any known allergies?” Family History: “Any family history of esophageal or bowel cancers?” 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 questions: “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?” Support: “Do you have good family and friends support?” Functional status or severity or impact on life activities? Wrap-Up: Question: What will you do next?Answer: “I will complete physical examination. I will order blood test according to the history and physical exami-nation findings. If it is secondary to cirrhosis of the liver, then add ultrasound abdomen and referral to gastroenterolo-gist and discuss. ” References 1. Blausen. com staff (2014). Medical gallery of Blausen Medical 2014. Wiki J Med. 1(2). https://doi. org/10. 15347/wjm/2014. 010. ISSN 2002-4436. 2. Mc Burney's point. https://en. wikipedia. org/wiki/Mc Burney%27s_ point. Accessed 11 Sept 2017. 3. Hutson JM, Beasley SW.   Abdominal pain: is it appendicitis? In: The surgical examination of children. Berlin: Springer; 2013. p.  19-39. 4. Rovsing's sign. https://en. wikipedia. org/wiki/Rovsing%27s_sign. Accessed 11 Sept 2017. 5. Courvoisier's law. https://en. wikipedia. org/wiki/Courvoisier%27s_ law. Accessed 11 Sept 2017. 6. Bergman RA, Heidger PM, Scott-Conner CEH.  Ch 1. The anatomy of the spleen. In: Bowdler AJ, editor. The complete spleen. Totowa: Humana Press; 2002. 7. Ganti L.  Ch. 70. Manual reduction of abdominal hernia. In: Ganti L, editor. Atlas of emergency medicine procedures. New  York: Springer Science + Business Media; 2016. p.  399-402. 8. Anand BS.  Peptic ulcer disease differential diagnoses. Medscape. 2017. http://emedicine. medscape. com/article/181753-differential. Accessed 11 Sept 2017. 9. Michigan State University. Differential diagnosis of acute epigastric pain. Just in Time Medicine. https://www. justintimemedicine. com/ Curriculum Content. aspx?Node ID=4227. Accessed 11 Sept 2017. 6 The Gastrointestinal System

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205 © 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_7Ethics Mubashar Hussain Sherazi Introduction to Ethics Cases The following stations will require good communication skills. You should be attentive and respectful throughout these stations. Your ability to transfer important and relevant information to the patient or a relative in an understandable and a simple way will be assessed. There are no exact right or wrong answers. There are no red flags for these stations, and there are no set of key questions. In almost all the objective structured clinical examination (OSCE) stations, there will always be a rush to chase the time lines. The ethical stations are quite different; many can-didates are able to finish these within the first 5 min. Then it will be the examiner, patient (role-player), and you sitting in a quiet room looking at each other. To avoid getting into this kind of situation, it is suggested not to rush into the problem- solving part of the station. Commence with making good rapport initially and then getting some further information about the situation. As the discussion goes along, try to resolve the issue or give precise and relevant information. Before finishing the conversation, you should have a plan in place and ask if the patient agrees to and understands the plan. In all of these cases, finishing off with offering further support or asking if they want to have another family meet-ing is recommended. Case Discussion: Death Before Arrival Candidate Information A 62-year-old male was rushed to the emergency department in a profound coma; he died while being transported to the hospital. You attended him and pronounced him dead. He had a background history of diabetes mellitus and was on insulin. You were told by the ambulance staff that his wife gave him an extra insulin dose by mistake. His wife and son are in the family room. Please visit them and address their concerns. Inform the family that the coroner must be notified. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient's family. Give stickers to the examiner (if required) and/or show your identification (ID). Sit on the chair and start the interview. Opening: “Good morning/good afternoon, I am Dr.... and you are? I am here to discuss about Mr..... Is it alright if I ask you a few questions about Mr....? Can you please describe what hap-pened?” They may describe that insulin was given before dinner, and Mr.... became unresponsive. They called the ambulance, and he was brought to the emergency department. Ask them: “How much insulin was injected and when?” “Who injected it?” “What was the usual dose?” They may ask you, “How is Mr....?” Inform the family that unfortunately Mr.... passed away during transport in the ambulance. He died before arrival to the hospital. Provide a moment of silence. Show empathy and respond according to their emotions. M. H. Sherazi Mallacoota Medical Centre, Mallacoota, VIC, Australia7

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206 If they ask, “What was the possible cause of death?” Explain that for now it looks like that the possible cause of death was an insulin overdose. If his wife expresses feelings of guilt, respond by saying “Don't blame yourself. Any person in your place may have reacted in the same way. ” Discuss the next steps: Need for an autopsy. Ask about their wishes Tell them about the need to inform the coroner. If they ask “Why is the coroner's involvement neces-sary?”, explain that a notification to the coroner is required in all deaths where: There is involvement of: -Violence -Negligence -Misconduct In cases of sudden or unexpected death Death due to unknown disease Death due to suspicious circumstances The coroner will determine the cause of death and means of death (natural or accidental). Ask if there is a will and who is the power of attorney. Ask them if they want to inform anyone or call anyone. Offer further help and support. Thank the relatives. Case Discussion: Brain Death and Organ Donation Candidate Information: A 37-year-old male was brought in a critical condition after a motor cycle accident by ambulance to the emergency depart-ment. He had a major head injury. He was intubated and resus-citated but did not improve. He has been pronounced to have “brain death” by a neurologist in the emergency department. His wife is in the family room. Please inform her about his condition and discuss about possible organ donation. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient's wife. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair and start the interview. Opening: “Good morning/good afternoon, I am Dr..... Are you Mrs....? I am here to discuss about your husband's condition. Is it alright to go ahead?” Start with Some Information About the Resuscitation Efforts: Tell her that Mr.... came in a critical condition after having a motorcycle accident. You and your team worked hard and started immediate resuscitation. Further state that chest com-pressions were given and he was intubated. “When he came in, he was not breathing. We needed to put a tube down in his wind pipe to support breathing and attached him to a machine called a ventilator. As his heart was not beating, we also did chest compressions. ” Inform His Wife of the Outcome: “Despite all the possible efforts to improve his condition, unfortunately it seems that things did not improve. He is not responding to treatment due to the severe trauma to the head. ” Explain Brain Death: Inform her that he is in a state called “brain death. ” Ask her if she understands what brain death means: Irreversible brain damage. Brain is not functioning at all. When we shine a light into his eyes, his pupils do not respond to the light. No response on pain stimulation. No spontaneous breathing; he is only breathing with a breathing machine. His heart is being supported by drugs. He will never gain consciousness, which means he will not recover. Certainty of Diagnosis: Legal term for death. Confirmed by two specialists. Apnea test: Ventilator ceased followed by no spontaneous breathing. Certainty of prognosis: We can clearly say, “He is dead now. ” Further state that it is a legal definition of death. Give a pause. Show empathy and react according to her response. What Should Be Done Next? He is on a support machine to breathe, which should then be stopped. M. H. Sherazi

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207 Show empathy again. You are sorry for her loss; the patient was very young. Give her time if she wants to express her feelings. Bring Up Organ Donation: He was very healthy and he is thus a good candidate for organ donation. Ask her if he ever mentioned his views about organ donation. Further ask if he had a will or advanced directive. Ask about her views about organ donation. If she agrees, appreciate her decision. Then say that it will be a precious gift and will save many lives. Explain How Organ Donation Is Handled: If she asks about the process of organ donation, explain: A team of doctors will be involved. They will respond very quickly. There is a time limit; the decision should be made within the next 24 h. Many organs can be used. Tell her she will be notified which organs are used and where they go, but she will not get the individual recipi-ents' names. Explain How Organ Donation Affects the Funeral: Reassure her that it will not affect the funeral arrangement. Still can have the open casket, because organ donation will not affect the face. Address Any Questions or Concerns: Offer her the option to visit him now. Case Discussion: Decision to Forgo Treatment Candidate Information: A 72-year-old male was admitted to a medical unit. This morning he was diagnosed with having bowel cancer. The nurse just informed you that he is refusing any treatment and wants to go home. Please visit him and discuss with him. The patient has the right to make a decision about his own health and body, but to make this kind of decision, the patient needs to be competent. Being competent means that the patient: Understands the nature of the disease/issue Knows the different treatment options available Has reasonable information about the advantages and dis-advantages of each treatment Understands the consequence of his decision Should not be diagnosed with any psychiatric illness (depressed), confusion, intoxication, and/or delirium Does not have a burden of suffering so great that it impairs his decision Has no memory loss Will make a reasonable decision that a reasonable person will make This station is to assess the patient's ability to make a decision. If the patient is competent and capable, then respect his wishes and decision. In the end make sure to offer help and all the support even if the patient changes his wishes at any time. Be supportive and empathetic throughout the interview. 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 and start the interview. Opening: “Good morning/good afternoon, I am Dr..... Are you Mr....? How are you today? I was informed by the nurse that you do not want to continue with any treatment. May I discuss this with you?” Ask for Reasons: “Why do you not want to go ahead with any treatment?” “How long have you been thinking that way?” “Have you discussed your decision with anyone?” Ascertain His Understanding of the Disease: “What is your understanding of your illness?” Assess His Views About the Disease: “If you don't have this disease, then what will be your thoughts about your life?” Treatment Options: “Has anyone discussed with you about the diagnosis and various treatment options? What do you think about them?” Discuss further that if he will not get any treatment what the consequences will be. Is he aware about supportive treatments such as pain medication, intravenous (IV) fluids, and use of antibiotics? 7 Ethics

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208 Collateral Information: Would he like to talk to someone who has a similar condition? Consequences: “What do you think would happen if you don't want to go ahead with treatment?” If he persists on not getting any treatment, next ask him whether he wants to die. “I just want to make sure you understand about your con-dition, and I want to make sure that this is what you want. ” Ask about life-sustaining measures such as oxygen, intu-bation, and chest compression. Ask About Depression: “When we discuss about decision-making, we need to also ask about mood. So please tell me how is your mood lately?” Interests? Suicidal ideation? Any major event, death, accident in the family recently? Offer Help: “Do you want someone to talk to you further, what is going on?” “I can ask a psychiatrist to come and visit you. ” “Do you think you would want to see a social worker?” “Are you aware that we also have clergy/chaplain avail-able in the hospital? If you would like, I can ask one to come and talk to you. ” “Do you want to discuss this with your family members or any friend?” Ask about his home situation, job, family, and support system. Ask if he would like to seek help in any regard. “Do you think you need some time to think about it?” Further Treatment Option: Assess if the patient is aware of what he needs for further investigations and you will be referring him to specialists who are experts in this field. Make a Conclusion: If the patient does not agree and is competent, then tell him that you respect his decision. He has the right to refuse treatment. Further inform him that you can come and visit him again if he would like to discuss anything or if he changes his mind at any time. If the patient is noncompetent, then state that you would like to arrange a family meeting, call a social worker, and arrange a mental health review. Tell him “I will come back to talk to you again. ” Case Discussion Phone Call: Confidentiality Candidate Information: A 28-year-old female is your general practice patient. She has been under treatment for depression. Her mother is also your patient. Her mother calls you and tells you that she is very much concerned about her daughter. She wants to know the diagnosis, her medication, and further plan of treatment. This is a phone consultation. Please talk to the mother on the phone. Starting the Station: Knock on the door. Enter the station. There will be no one in the room. Observe carefully the phone and the instruction sheet. Sit down on the chair. Lift up the phone, and press the button mentioned in the instruction sheet or will be clearly marked on the phone. As soon as you press the button, commence talking. Keep in mind you do not need to talk very loud or fast. If the person on the other side is not able to hear you well, then you may need to adjust the volume. And you can also request that the person on the phone speak a bit louder if you think you are not listening properly. Opening: “Good morning/good afternoon, I am Dr..... To whom am I speaking? Are you the mother of Miss....? How can I help you today?” She will introduce herself and will tell you that her daugh-ter is your patient. She wants to discuss about her daughter's medical issues. Refuse to discuss about her daughter's medical history. State that due to confidentiality you can not disclose the information. Tell her that you are happy that she called and is con-cerned about her daughter. Appreciate her role as a caring person. You should inform her that you will document this phone conversation in her chart. Ask her why did she not discuss this with her daughter directly. Offer her a joint meeting with her and her daughter together if both agrees, but she will need to talk to her daughter about it. Tell her that as a doctor you have an obligation to keep your patient's information confidential and protected. Further emphasize that it is against the law to disclose such information. Say that the patient may lose trust in the doctor if there will be a breach of confidentiality. M. H. Sherazi

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209 Show empathy and support and recognize her feelings and emotions. If she says that she will talk to her daughter and they will visit together, then offer to book a follow-up appointment. Case Discussion: Confidentiality Candidate Information: You are a general practitioner (GP) and wrote a prescription for birth control pills to a 19-year-old female a few days back. Her mother found your clinic appointment card in her daughter's coat while doing laundry. Her mother came to visit you, inquiring about her daughter's visit. Please talk to the mother. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient's mother. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair and start the interview. Opening: “Good morning/good afternoon. I am Dr..... Are you the mother of Miss....? How can I help you today?” She will introduce herself and will tell you that she found your clinic's appointment card in her daughter's coat. She wants to know why her daughter visited the clinic. Address the Confidentiality and Reason: Start by refusing to tell her the reason for her daughter's visit. -You can admit that the daughter is your patient (mom has the appointment card), but explain to the mother that you cannot discuss the reason why she came to your office due to patient confidentiality. -Mention that a doctor and patient's relationship is confidential. She may say, “I am her mother and would like to know everything about my daughter. She is only 19 years old and very young to make her own decisions. ” -Address this concern first. Tell her that her daughter is competent and mature. She understands the situation and so you believe she can make her decisions on her own. Tell the mother that you are happy that she is concerned about her daughter. Appreciate her role as a caring person. You should inform her that you will document her visit in her daughter's chart. Tell her the best way to get the information is from her daughter. Ask her why she did not discuss this with her daughter directly. Offer her a joint meeting with her and her daughter together if they both agree, but she will have to talk to her daughter about it. Tell her that as a doctor you have an obligation to keep the patient's information confidential and protected. Further emphasize that it is against the law to disclose such information. Say that the patient may lose trust in the doctor if there is a breach of confidentiality. Show empathy and support and recognize her feelings and emotions. If she says that she will talk to her daughter and they will visit together, then offer to book a follow-up appointment. Case Discussion: Relative as Decision-Maker A 72-year-old male with known chronic obstructive pulmo-nary disease (COPD) comes frequently to the emergency department with severe episodes of shortness of breath. He came today in a critically ill condition and you provided treatment. He is improving with initial management. He is currently in the resuscitation room. His daughter is in the family room. She wants to discuss with you about “do not resuscitate” (DNR) orders for the patient. Please discuss with her. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient's daughter. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair and start the interview. Opening: “Good morning/good afternoon. I am Dr..... Are you the daughter of Mr....? How can I help you today?” She will introduce herself and will tell you that she does not want her father to be resuscitated and would like to sign a DNR document. Start by asking her why she is asking for a DNR order for her father. Ask about her father's usual mental status. Mention that he is now alert and competent. Ask her if she has discussed this matter with her father before. 7 Ethics

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210 Ask if her father has an advance directive. Further inquire if she knows about her father's wishes and preferences in this regard. Mention that it is her father's right to decide. Ask her to put herself in his condition and see how she feels. Tell her that you are going to discuss this with her father directly. Offer her to take her to the resuscitation room and talk to her father first. You can arrange a meeting with her and her father together if both agree. Refuse to write a DNR without her father's consent. Appreciate her concern about her father. Stay firm but not hostile. Case Discussion: Surrogate Decision-Maker Mr.... is the husband of Mrs...., a 59-year-old female who got into a roadside accident few years back. She has been in a vegetative state since then. She is fully dependent on the nurses' care. She has had a feeding tube since the accident. He has come to see you because he wants to discuss the pos-sibility of removal of the feeding tube. Please discuss with him and address any concern. Surrogate Decision-Maker: One who decides on behalf of an incompetent patient Who can be a surrogate decision-maker: -Power of attorney -Spouse -Parents -Children -Sibling Starting the Station: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient's husband. Give stickers to the examiner if required or show your ID badge. Now sit on the chair and start the interview. Opening: “Good morning/good afternoon. I am Dr..... Are you Mr....? How can I help you today?” He will introduce himself and will tell you that his wife has been in the hospital for a long time now, and he wants to get her feeding tube removed. Start by asking him why he wants to have the feeding tube removed. Ask if she has made an advance directive. Ask if she has a written will. Ask about who is the legal power of attorney. Ask about wishes of other close family members. Does she have parents or children? Ask if he has discussed this with them. Offer to have a family meeting before making a final decision. Encourage him that it will be a big step for him and he should involve close family members in this decision. It will be great to have the family members' support with him. Further inquire that if he knows about his wife's wishes and preferences in this regard. Ask him to put himself in her condition and see how he feels. Offer support from a chaplain or a support worker. If everything favors him and he is the right surrogate decision-maker, then agree to remove the tube. Inform him that you will need to let the hospital staff know about it. Tell them that you will document all this in her chart and you and he will need to sign it for record keeping. Empathize and understand his feelings. Case Discussion Telephone Call: Pharmacist Refusal to Fill Prescription You are a GP in a small community. A 16-year-old female came to your practice in the morning concerned that she had unprotected sex last night and asked for a “morning after” pill. You gave a prescription. The local pharmacist refused to fill the medication for her. Your nurse told you that he is on the phone and wants to discuss it with you. This is a phone consultation. Please talk to the pharmacist on the phone. Starting the Station: Knock on the door. Enter the station. There will be no one in the room. Carefully observe the phone and the instruction sheet. Sit down on the chair. Lift up the phone and press the button mentioned in the instructions sheet or that will be clearly marked on the phone. As soon as you press the button, start talking. Keep in mind you do not need to talk very loud or fast. Talk as you usually talk on the phone. If the person on other side is not able to hear you well, then you may need to adjust the volume. And you can also request that the person on the phone speak a bit louder if you think you are not able to listen properly. Opening: “Good morning/good afternoon, I am Dr.... and you are... ? How can I help you today?” He will mention that your patient M. H. Sherazi

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211 is in the pharmacy and she is only 16 years old asking for a “morning after” pill. He may further suggest to talk to her parents and inform them about her visit because he knows them. Ask him why does he think so. Tell him that you also know the parents but in this regard she is competent to make her own decision. She is mature and can decide for herself. State that a 16-year-old can decide independently about herself. Further mention that it will breach confidentiality if we inform her parents. Discuss that by breaking the confidentiality, she will lose trust in him and the pharmacist as well. Tell him that we can only inform her parents if she allows. Offer a meeting with both the patient and the pharmacist. Mention the urgency of the issue in that she needs to have the pills now. Appreciate his paternalistic role. If the pharmacist agrees to fill in the prescription, then thank him and offer to have a later meeting to discuss these kinds of issues that may come up in the future. If the pharmacist resists, then inform him that it is against the rules and regulations set by the College of Pharmacists. Tell him that by not filling the prescription and by inform-ing the parents, he will violate her rights. Inform him that you will discuss the matter with the College of Pharmacists today. Stay firm but not hostile. It is a phone conversation so keep a check on your tone and volume throughout the conversation. Case Discussion: Truth Telling You are looking after Mr...., a 62-year-old male who has been recently diagnosed with metastatic bowel cancer. His son has asked to see you in the family room and is requesting that you not disclose the information to the patient. Please talk to the son and address his concerns. Starting the Interview: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the patient's son. Give stickers to the examiner (if required) and/or show your ID. Sit on the chair and start the interview. Opening: “Good morning/good afternoon. I am Dr..... Are you Mr....? How can I help you today?” He will mention that his father has been diagnosed with metastatic bowel cancer today. He does not want his father to be informed about the diagnosis. Appreciate that he is concerned about his father. Make a Comment: Start with making a comment: “It is not unusual for families to have that request. ” Ask the Son Why He Thinks So: He will say that his father will not able to handle the bad news due to ongoing health issues, depression, and a fragile personality. Ask about advanced directive or a will. Ask about a substitute decision-maker. Ask if he has ever discussed this matter with his father. Then discuss with him that it is reasonable to have such feelings about loved ones. Tell him, “People go through vari-ous stages when faced with bad news. We have specialists here who can help the patient and his family members to adjust with the reality of the situation. ” Reasons to Disclose the Information to the Patient: The patient has the right to know. The patient needs to be involved in his own decision-making. We need to discuss further treatment options. If he agrees, then I will refer him to an oncologist. Explain the Implications Not to Tell: It is difficult to hide information, as the decision-making is a teamwork process. He will eventually know or find out. Mention: Conclude that you will go and talk to the patient and will ask his wishes about how much detail he wants to know. Ask the son to discuss with the family first and then talk to the patient. Plan: Offer a family meeting. Offer social worker support. Encourage the son to discuss with other family members. You can have a family meeting before talking to the patient. Thank him. Case Discussion: Pre-Human Immunodeficiency Virus Test Visit Mr...., a 32-year-old male, is your next patient in your gen-eral practice clinic. He is a new patient to your practice. He has booked an appointment to get his human immunodefi-ciency virus (HIV) test done. 7 Ethics

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212 Please discuss with him about the test and address any concern. 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 and start the interview. Opening: “Good morning/good afternoon. I am Dr..... Are you Mr....? How can I help you today?” The patient will mention that he is here to get his HIV test done. Welcome him to your practice. Be very supportive and show him that you are ready to help him. “Absolutely, I can arrange that for you. ” Discuss with him first before ordering the test. Because it is his first visit to you, you need to ask a few questions. You need to know about the patient's health before order-ing the test. Who is this person? Check his identity. How is his general health? Does he have any ongoing medical problems? Is he on any home medication? Does he smoke, drink, or use any other drugs? Why does he want to have this test? Any particular concerns? Rule Out HIV Risk Factors: Inquire about his sexual behavior: -“Are you sexually active?” -“How many partners do you have?” -“Do you have sex with female or male or both?” -“Do you use condoms all the time?” “Do you or your partners have any of the following physi-cal symptoms?”: -Fatigue -Fever -Weight loss -Frequent infections -Penile or vaginal discharges -Lymph nodes enlargement “Have you had blood transfusions before?” Use of IV drugs? Sharing the needles? Tattoo or piercing? Does the partner know about his visit today?Before giving the information about the test, check with the patient: How much does he know about the test itself? What is his understanding about the test? Explain the Test: Need the patient's signed consent and this will be docu-mented in the chart. Various test options: Nominal/non-nominal/anonymous Further explain if he wants to know: -Non-nominal reporting: meaning that the full name of the individual is not reported to public health. The first name, initials, and date of birth are reported to the Medical Health Officer for surveillance purposes. The full name of the individual is still on the specimen sent to the laboratory. How We Do the Test: “We will sent the bloods and request form to the lab. The lab will do the screening test, which usually takes about 2 weeks for the results to come back. ” Negative Test Results: If the results are negative, they will send a negative test report. And it is suggested to repeat the same test. Explain the window period. When people have picked up the virus, it usually takes quite a few months for the body to develop enough antibodies to be detectable in the blood test. Waiting for about 3 months after exposure is recommended. Newer HIV tests have shortened the window period. The average window period for newer enzyme immunoassays (EIA) tests, which detect p24 antigen and HIV antibodies, is about 16-18 days. Positive Test Results: If the results are positive, then the lab will reconfirm the test before sending the positive report. What does a positive test mean? HIV + is different from acquired immunodeficiency syndrome (AIDS). There are advantages of earlier detection of the virus because treat-ments are available to control the disease process. A posi-tive test needs to be reported to public health. Ask the patient if he has any question. How is his mood now? Did he understand the information? Ask if he has any suicidal or homicidal ideation. Ask if he requires any help or support. Inform him that the results are not given on the phone, so once the results come back, the practitioner will call him to book a follow-up visit. Ensure him that the information will be kept confidential. M. H. Sherazi

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213 Advise him to engage in protected sex regardless of the results of the test from now on. Ask him if he has any concerns. Offer him further information about HIV (Web site or a handout) Case Discussion: Delivering Bad News (HIV Test Positive Results Visit) You are working as a locum general practitioner in a general practice. Mr...., a 32-year-old male, is your next patient. Another GP requested an HIV test for him 2 weeks back. The results have come back positive. Please inform him about the results. Please address any concern. 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 and start the interview. Opening: “Good morning/good afternoon. I am Dr..... Are you Mr....? How can I help you today?” The patient will mention that he is here to get his HIV test results. Introduction: Tell him that his GP is on vacation and you are covering for him as a locum GP. “I have your file with me. Can I please ask you a few questions before I go through the results of your tests?” “Why did you request the test?” “Did you feel sick in any way?” “Was there anything that made you worried about your own health?” Be empathetic and flexible. Give the Test Result (Breaking Bad News): SPIKES (setting, perception, invitation, knowledge, empa-thy/exploration, and summary/strategy): Setting: Familiarize yourself with the patient's back-ground, medical history, test results, and future manage-ment plan. Arrange for a colleague or a nurse to accompany you. Relatives can be in attendance in the patient prefers. Arrange for privacy. Switch off your phone or pager. Perception: Assess the patient's understanding of his condition. -“What do you know about HIV?” -“What do you think is going on?” -“What have you been told about all this so far?” -“Are you worried that this might be something serious?” Invitation: “How much detail do you want me to discuss with you?” -“How much information would you like me to tell you about your diagnosis and treatment?” -“Are you the kind of person who prefers to know all the details?” -“Do you want someone else to be present?” Knowledge: -Gently inform him of the result of the test. -“Unfortunately, I have some bad news to tell you. I am sorry to tell you that your test results are positive. ” -Silence. -Monitor the patient's reaction. Wait until he expresses his emotions. -Be sensitive to his emotions. -“Do you want me to proceed?” Empathy: -Normalize the patient's feelings. Say, “All the feelings you are having now are very normal. ” Offer a glass of water. -“Do you need more time?” -“How do you feel now? I think I understand how you must be feeling now. ” -Please do not say: “I know how you feel. ” -If he argues that there might be an error or mistake, mention that you are pretty sure about the result, because they do two tests before giving a positive result. Strategy and Summary: -Assess the patient's expectations of further treatment and plan. -“What kind of thoughts are going through your mind?” -“Do you have any questions or concerns now?” -Tell him that you have an obligation to inform the pub-lic health department. Partner: Ask about the partner or partners. How to tell the partner? “You should tell your partner. ” Ask about the duration of the relationship; how close they are to each other. Partner has to know: -There is a risk of infection. -Partner needs to be tested as well. -Even if he will not inform the partner, the public health department will. -Prefer for him to tell, but offer him some help to tell his partner. 7 Ethics

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214 If he asks if he has AIDS, say, “You don't have AIDS. ” Ask him if he wants to know more about HIV and AIDS. What Is HIV/AIDS? HIV stands for human immunodeficiency virus, which is the virus that causes HIV infection. The abbreviation “HIV” can refer to the virus or to HIV infection. AIDS stands for acquired immunodeficiency syndrome. AIDS is the most advanced stage of HIV infection. HIV attacks and destroys the infection-fighting CD4 cells of the immune system. The loss of CD4 cells makes it difficult for the body to fight infections and certain cancers. Without treatment, HIV can gradually destroy the immune system and advance to AIDS.  HIV is spread through contact with the blood, semen, pre-seminal fluid, rectal fluids, vaginal fluids, or breast milk of a person with HIV. Antiretroviral therapy (ART) is the use of HIV medicines to treat HIV infection. People on ART take a combination of HIV medicines (called an HIV regimen) every day. ART cannot cure HIV infection, but it can help people with HIV live longer and healthier lives. HIV medi-cines can also reduce the risk of transmission of HIV [1]. Before Discharging the Patient: Ask if he understands the information provided. Summarize important issues (wrap up). Ask the patient if he has any questions. How is his mood now? Make sure the patient is safe to go home, safe to drive back, and no suicidal or homicidal ideation. Make sure to arrange a follow-up visit. Offer any help or support if required. Emphasize the importance of safe sex: Advise the use of barrier contraceptive methods always with all partners to prevent transmission in the future. Ask him if he has any concerns. Offer him further information about HIV (Web site or a handout). Management and Counseling: Medical Error -Wrong Blood Transfused You are working in a busy medical unit. A nurse just informed you that a 65-year-old male was started on the wrong blood transfusion bag. Please go and talk to the nurse and then manage the patient. Starting the Station: Knock on the door. Enter the station. Hand-wash/alcohol rub. Greet the examiner and the nurse. Give stickers to the examiner if required or show your ID badge. Sit on the chair and start the interview. Opening: “Good morning/good afternoon. I am Dr..... Are you the nurse? Are you looking after Mr....? I just got a call to come and attend Mr..... What happened?” She will tell you that Mr.... was supposed to get a blood transfusion today, and by mistake the wrong blood bag was started. But she noticed it soon after the transfusion was started. The first question you must ask the nurse is: “Did you stop the blood?” If she says yes, then appreciate her decision. That is a good thing she did. If she says no, then ask her to immediately stop the blood transfusion. She may request that you should not tell the patient because she is worried that she may lose her job. Address this concern first. Tell her, “It is too early to determine who is responsible. Errors take place in medical practice. We do not know what happened exactly. We need to assess and stabilize the patient. You want to ensure he is fine and deal with this issue later. ” Now address the patient who will be lying on the bed. Mention again to cease and remove the blood unit but keep in the cannula. Now Talk to the Patient: “I am Dr.... and I am the doctor in charge. It looks like an unin-tentional medical error took place. You have been started on the wrong unit of blood. We need to make sure you are stable. ” If he asks who is responsible? Say, “We don't know who is responsible. There are at least 15 steps and within any step there could have been an error. We will fill out an incident report, and as soon as we get the results we will inform you. ” If he states that he will sue the hospital, inform him that “You can sue, it is your right. However, at the moment it is my priority to stabilize you. ” Start a Primary Survey (ABCD): Ask the nurse to get you a set of vital signs. A: Assess Airway -“Can you please open your mouth?” -Check for signs of anaphylaxis: Swelling in mouth or around the lips. Ask if there is any itchiness. Difficulty in breathing. B: Breathing/Oxygen Saturation -Assess for breathing. -Assess for air entry (auscultate lungs). -Listen for heart sounds. C: Circulation -Put the patient on a cardiac monitor. -Request an electrocardiogram (ECG). -Start a new IV line. -Get blood samples for a full blood count (FBC), elec-trolytes, international normalized ratio (INR), partial M. H. Sherazi

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215 thromboplastin time (PTT), liver function test (LFT), creatinine, and urea. -Send urine for analysis and check for hemoglobulinuria. -Blood unit to be sent to blood bank for cross matching. -Ask the nurse to call the blood bank and inform them about the incident. D: Disability -Check the pupils: Round, active, and symmetrical. -“Squeeze my finger, wriggle... wriggle... ” -Ask for blood sugar. -Check the glaucoma coma scale (GCS) Drugs: If febrile ask the nurse to give paracetamol (acetaminophen). Ask the nurse: “Please prepare for me Benadryl (diphen-hydramine) 50 mg, hydrocortisone, and epinephrine, just in case we require these next. ” Secondary Survey: Take some further history: -“Why was the blood transfusion given?” -“Is it the first time you have received a blood transfusion?” -If he received blood before, then ask “Were there any complications?” -Does he have any long-term diseases? How is he feeling now? Check for symptoms of anaphylactic shock: -Swelling around the lips or fingers? -Difficulty in breathing? Chest wheezing? -“Do you feel warm?” -Itchiness? -Chills? -Tingling? -Hives? -“Did you have a fever before the transfusion was started?” Check for hemolytic reaction. “Do you have any back or flank pain?” Check for any bleeding. Counseling: Ask him if he would like to know more about blood transfu-sions. Tell him “It is a life-saving measure, and there are a lot of steps and set protocols that are taken into account to make sure that it is safe. Like any other medication, blood transfu-sions may cause some side effects. Some of these side effects can be serious. Some common side effects are: “Febrile reaction. Usually it is self-limiting. It can poten-tially happen again in subsequent blood transfusions. Next time you receive a blood transfusion, we will give you paracetamol. ” “Anaphylactic reaction. It is a severe allergic reaction, which is very serious and cannot be predicted. Whenever we give a blood transfusion, we make ourselves ready for this, and we have good measures to deal with it. ” “Hemolytic reaction. This usually happens when patients receive blood belonging to another blood group. ” If the patient asks whether he is going to have a hemolytic reaction: “The blood which was started for you was of the same blood group as yours. Your symptoms are not consis-tent with a hemolytic reaction. The blood has been sent to the blood bank, and once results are back, we can discuss it further. ” Offer support. Ask the patient if he wants to talk to a family member or a friend. Tell him that you will keep him under close observation and will visit him again shortly. Ask him if he has any concerns or questions. Thank the patient. Counseling: Marijuana Found in Son's Bag Mrs.... is your patient. She has booked an urgent appoint-ment today because she found a small amount of “green stuff” in her son's belongings. She is in the clinic room. Please talk to her and address her concerns. 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 and start the interview. Opening: “Good morning/good afternoon. How are you, Mrs....?” (She is your regular patient. ) “How can I help you today?” She will mention that among her son's belongings, she has found a small plastic bag of “green stuff,” which she thinks is marijuana. She is here to talk to you about it. Appreciate that she is concerned about her son. Tell her that you need to ask a few questions about him. Introduction: “What is his name? What is his age?” “What makes you believe that it was marijuana?” “Where did you find it?” “How much did you find?” “Did you ask him about it?” 7 Ethics

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216 “Is it the first time you have found it?” “How do you know that he is using it?” Changes in Behavior: “Did you notice any change in his behavior?” “How is his mood lately?” “Is he depressed?” “Is he still interested in his hobbies?” “Does he worry a lot?” “Does he have excessive fears and avoid situations?” “Do you have concerns that he may harm himself or any-one else?” “Is he very excited at times? Laughing out?” “Is he preoccupied?” “Does he spend more time in his room?” “Does he stare at a wall?” “Does he talk to himself?” “Is he aggressive at times?” “Is he more forgetful?” “Does he lose his belongings easily?” “Does he take more time to react?” Social History: “How much time do you spend with him?” “How much time is he out of the home?” “How much time does he spend with his friends?” “Do you know any of his friends?” “What kind of activity are they involved in?” “Does he have a lot of money?” “Does he get into fights?” “Has he had any problems with the law?” “Does he have any criminal records?” “Does he ask for money?” “Do you believe he steals money?” “Do you think he smokes?” “Do you think he drinks?” “Do you think he uses other drugs?” Education: “How is he doing in school?” “Have his grades dropped?” Past Medical History: Any other health issues? Past Psychiatry History: Diagnosis, treatments, admis-sions, follow-ups, previous similar episodes Medication History: “Is he on any medications?” Allergies: “Does he have any allergies?” Family History and Family Psychiatric History Social History: Already asked Living Conditions and Relationships Counseling: “Based on what you have told me (if there are no changes in behavior), it looks like there is no change in his health and behavior. ” “Marijuana is a commonly used drug. It is used by teen-agers and sometimes only once for experimentation. When we talk about substance abuse and drugs, we talk about dif-ferent drugs. Marijuana is a soft drug. It is not like other hard drugs such as cocaine, heroin, and amphetamines. ” Do You Want to Know More About Marijuana? “It is from the Cannabis family, and it affects the brain by creating feelings of happiness, excitation, and enhances expe-rience. Sometimes with prolonged use or in high doses, it can cause side effects including apathy”. There may also be: Psychological effects -Relaxation -Euphoria -Alteration in perception of time, color, and space -Short-term memory loss -Irritability Physical effects -Dry mouth -Dry eyes -Bloodshot eyes -Increased heart rate Effects are prolonged for 2-3 h after smoking, with no clear evidence of hangover or lasting effect. The ability to drive and ability to operate machinery are impaired due to effects on motor skills and depth percep-tion [2]. It can cause lung cancer. If injected, it increases the risk of HIV and hepatitis B and C. In some teens, in high doses it may unmasks schizophre-nia and can cause psychosis. It can interfere with sexual function. It can cause infertility and weight gain. By itself marijuana is not strongly addictive. If he is using it, then we can help him to stop. It can be a crime to use and possess these drugs. Further add if she has concerns about tolerance, with-drawal effects or hard drugs: “One major concerns of mari-juana is it acts as a bridge to hard drugs. These drugs are addictive. These also cause tolerance, which means one needs to increase the dose to have the same effect. If one wants to stop the drug, it causes withdrawal effects. ” M. H. Sherazi

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217 Plan: Offer her to have a family meeting with her and her son. Try to be close to him. She should talk and discuss the matter with him. Try to find out about his friends and try to know what his activities are outside the home environment. Offer further information about marijuana (Web sites and handout). Book a follow-up visit if she wants. Thank the patient. References 1. https://aidsinfo. nih. gov/understanding-hiv-aids/fact-sheets/19/45/ hiv-aids%2D%2Dthe-basics. Accessed Oct 13, 2017. 2. https://patient. info/doctor/cannabis-use-and-abuse. Accessed Oct 13, 2017. Further Reading 3. Hebert PC.  Doing right: a practical guide to ethics for medical train-ees and physicians, 3rd. Oxford University Press; 2014. 4. Green CB, Braddy A, Roberts CM.  Pass the situational judgement test: a guide for medical students, 1st. Student Edition. Elsevier; 2016. 5. Varian F, Cartwright L.  The situational judgement test at a glance, 1st. Wiley-Blackwell; 2013. 7 Ethics

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219 © 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_8The Genitourinary System Mubashar Hussain Sherazi Introduction In the objective structured clinical examinations (OSCE), the number of stations is always limited between 10 and 14, with 1-2 pilot stations. One may or may not get a case from the genitourinary system. This is usually a history-taking station with counseling or discussing a management plan with the patient. You would not be asked to perform a pelvic, rectal, or vaginal examination. Please keep in mind that with the increasing use of manikins/plastic models in practice mod-ules and training facilities, one can expect to take a history from a role player, and then the examiner can ask you to perform a rectal/vaginal examination on a manikin/model. So do not be surprised if you get one. Breast examination has already been introduced in some OSCE, in a similar way. This chapter outlines common genitourinary system- related topics important for the OSCE.  An overview of the history taking required for the genitourinary system stations is given in the start of the chapter. The outlines of male and female examinations of the genitourinary system are also given. Common Genitourinary System Symptoms for the Objective Structured Clinical Examination Common presenting symptoms are: Male: Change in frequency, urgency, and quantity of urination -Difficulty in either initiating or stopping/holding uri-nary stream Post-void dribbling and/or feels bladder is incompletely empty Painful or difficulty in urination (dysuria) and its associ-ated timing during voiding (at the start or at the end or throughout voiding) -Pain in the costovertebral angle or suprapubic Urinary retention Excessive urination at night (nocturia) Involuntary leakage of urine (incontinence -including urge and stress) -Change in color or smell of urine -Blood in urine (hematuria) -Presence of stones or sediment in the urine -Testicular pain or swelling/mass -Discharge from the penis, itching -Lesions on external genitalia Fever/rigors (infection/urosepsis) Nausea/vomiting (pyelonephritis) Female: Change in frequency, urgency, and quantity of urination Involuntary leakage of urine (incontinence -including urge and stress) -Painful or difficulty in urination (dysuria) -Urinary retention -Change in color or smell of urine -Blood in urine (hematuria) -Presence of stones or sediment in the urine Pelvic pain Discharge from the vagina/urethra, itching -Lesions on external genitalia Symptoms related with pregnancy, ectopic or pelvic inflammatory disease (PID): -Missed period (last menstrual period (LMP) date?) -Pain during intercourse (dyspareunia) -Postcoital bleeding -Urethral or vaginal discharge -Lesions on external genitalia -Itching M. H. Sherazi Mallacoota Medical Centre, Mallacoota, VIC, Australia8

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

220 History Overview: The Genitourinary System See Table  8. 1 for an overview of the pattern of history taking required for genitourinary system stations. Detailed History: Genitourinary 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 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/Mrs... ? Are you... years old?” Chief Complaint Chief complaint or the reason the patient is visiting the clinic. “What brings you in today?” or “Tell me about your symptoms. ”Table 8. 1 An overview of the pattern of history taking required for genitourinary system stations Introduction Name and age Chief complaint In patient's own words History of present illness Analysis of chief complaint: 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 (see Common Genitourinary Symptoms in detailed history) Associated symptoms: nausea, vomiting, change in bowel habits, appetite, blood in vomiting/feces/urine Predisposing factors Aggravating and relieving factors Red flags/risk factors Rule out differential diagnosis Review of systems: Respiratory Cardiovascular Neurology Musculoskeletal Constitutional symptoms: Anorexia Chills Night sweats Fever Weight loss Past medical history and surgical history Medical illnesses Any previous or recent medical issues History of previous surgery/operation, especially relevant to the area of concern Any related anesthetic/ surgical complication? Hospitalization history or emergency admission history Medications history: Current medications (prescribed, over the counter, and any herbal)Table 8. 1 (continued) 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? 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 Red flags Laboratory tests Further information websites/brochures/support groups or societies/toll-free numbers Follow-up M. H. Sherazi

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221 Allow the patient to answer, trying not to interrupt or direct the conversation. Try to facilitate the patient to expand on their presenting complaint if required. Like “So tell me more about that....” It is important to keep in mind that sometimes the patient coming with genitourinary problems will be quite disturbed and will reflect this during the interview. For example, a patient with a prostate problem may say, “I haven't slept well for many nights. ” A female patient with urinary incontinence may say, “I haven't attended a party for many months. ” Showing empathy and support in the early part of the inter-view will help. Secondly, care should be taken to ensure privacy and comfort while conducting the interview and performing the examination. Establish confidence and rapport. It will help particularly in gaining a sexual and psychosexual history. Specific questions may be appropriate. It is important to make the patient aware before asking further questions: such as questions regarding vaginal discharge/history of inter-course/sexual partners. A single sentence may be helpful such as “I need to ask you more questions about your vaginal discharge; is that alright?” Another example relating to posi-tional pain during intercourse would be to explain first that this will give you an idea of which internal structures or organs are producing the pain. Thirdly, the patient should be assessed in the context of the age, gender, and past history. Urinary symptoms may not be indicative of urological abnormality but may have other causes. For example, a patient coming in with fre-quency of micturition might be related to their anxiety. Urinary symptoms also may be caused by a neurological disease. History of Present Illness If pain is the chief complaint, then quickly go through the pain questions Onset Course Duration Progression Quality of pain (burning, throbbing, dull) Radiation Severity (scale of 1-10) Timing (time of the day) Pain before Aggravating Alleviating Associated symptoms: -If the patient is a female, then discuss the relationship of symptoms to menses (dysmenorrhea, Mittelschmerz), and also discuss the relationship of symptoms to inter-course (dyspareunia).-Pay attention to the location and type of pain. Pain originating from the renal capsule will be located in the ipsilateral costovertebral angle and may radiate to the upper abdomen or umbilicus. Mid-ureteral pain may be referred to the lower quadrant of the abdomen and scrotum. Lower ureter pain may be referred to the suprapubic area and penis. Vesical pain will be located in the suprapubic area. Prostatic pain would present in the perineum and may refer toward the lower back/ inguinal region or even to the testes. Constitutional Symptoms: Fatigue, malaise, night sweats, fever, and weight loss Common genitourinary symptoms: Obstruction. Difficulty in starting or initiating in passing urine? “Do you have to strain/push hard to pass urine?” “Did you notice a change in stream? How full is the uri-nary stream?” “Did you notice any dribbling? Is there any terminal drib-bling of micturition?” “After passing urine, do you still have the feeling/need to pass more urine?” Irritation “How many times are you going to the washroom in a day? How many times during the day and how many times during the night? “Does it affect your sleep?” “Do you need to rush/run to the washroom?” “Are you able to make it on time?” “Have you ever lost control?” “Do you have a burning sensation while passing urine or after finishing?” Urinary changes, ask specific questions about the urine: -Color of the urine -Any particular smell/odor -Amount of urine -Consistency Clear urine Frothy urine Cloudy urine Not clear urine Noticed any blood? Incontinence: Is there any incontinence or urgency of micturition? Stress incontinence/detrusor instability, detrusor underactivity, or urethral obstruction. Urge incontinence: Ask if this leads to partial or total voiding. Stress incontinence: Ask what provokes this and whether it leads to partial or total voiding. Renal: Renal stones, pyelonephritis, chronic renal failure Ask about recurrent urinary tract infections (UTIs). 8 The Genitourinary System

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222 Prostate issues (Male Patients): Benign prostatic hyper-trophy (BPH)/prostate cancer Is there any hesitancy of micturition? “Do you have to stand for a few minutes before voiding?” “Did you notice any change in the urine stream?” Weak stream? “Did you notice any dripping of urine?” “Did you notice any change in frequency of passing urine? Increase in urination with or without increased urine output?” “Are you peeing more frequently during the night?” Nocturia “Did you have any painful urination? In the start, during urination, or at the end?” Dysuria “Do you stand closer to the toilet?” “Do you feel you still want to void after you finish?” Urethral discharge: Color. Amount. Consistency. Odor. Presence of blood. Any itching or burning. Ask about dysuria and possible exposure to sexually trans-mitted diseases. If the answer is yes, then explore further: -When was the last contact? And with whom? -Single or multiple partners? -Has their partner had any symptom? -Are there any other symptoms? Testicular Pain: This can be an intense pain. Ask about: Trauma? When did it start? Sudden onset? Association with other conditions such as mumps? History of trauma, infection, torsion, and epididymitis. Genital Ulcers: Ask similar questions asked for sexually transmitted disease. Impotence: Ask about emotional and psychological factors, associ-ated with drugs and alcohol. Relevant diseases such as diabetes mellitus (DM), neuro-logical disease, and cardiovascular disease. Loss of libido and erectile dysfunction. Infertility: This may be primary (no conception) or secondary (past conception). Conception history Length of infertility Sexual history: -History of sexual development -Timing and frequency of intercourse -Impotence and ejaculation Medication history Medical history: Conditions affecting erectile function Any chemotherapy or cancer treatment Dyspareunia (only female patients): Determine if this is superficial (vaginismus or coming from an episiotomy scar), or if it is deep, then it can be uterine, cervical, or possibly an adnexal origin. Ask if it is intermittent/recurrent or always present. Ask if it occurs on penetration/preventing penetration or full intercourse. Note whether there is radiation of the pain. Discuss positional factors. Any relationship to menses. Ask if libido and foreplay are sufficient. Note whether the patient is postmenopausal. Ask if there is dryness/atrophy. Ask if there is any rash. Establish the degree of distress. Assess for any mood disorder. Vaginal discharge (only female patients): Ask about the vaginal discharge. Color. Amount. Consistency. Odor. Presence of blood. Any itching, burning, or fever. Use of gels, douches, or perfumed bath additives. Any associated localized tenderness (Bartholinitis). Abnormal vaginal bleeding (only female patients): Passing clots or flood of blood. Discuss relationship to menses. Intermenstrual? Relationship to coitus. Postcoital bleeding? Establish periodicity. Ask about possibility of pregnancy. If any of the above symptoms are present, you need to ask and get further details of each: Onset: When did the symptom start? What was the onset - acute or gradual? Course: Is the symptom worsening, improving, and con-tinuing to fluctuate? Intermittent or continuous: Is the symptom always pres-ent, or does it come and go? M. H. Sherazi

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223 Duration: How long has it been going on? Severity: How severe? How many times a day? Previous episodes: Has the patient experienced this symp-tom previously? Precipitating factors: Are there any obvious precipitants/ triggers for the symptoms? Relieving factors: Does anything improve the symptoms? Discuss whether there is restriction on normal activities and plans. Systemic Review: Just ask a few questions from each system. This can pick out any symptoms that patients may have not mentioned before in the presenting complaint. Some symptoms may be rele-vant to the diagnosis; for example, backaches may be associ-ated with kidney stones. Gastrointestinal: Nausea, vomiting, appetite, dysphagia, weight loss, abdominal pain, and bowel routine Cardiovascular system: Chest pain, palpitations, dys-pnea, syncope, orthopnea, and peripheral edema Respiratory system: Cough, wheeze, sputum, hemopty-sis, and chest pain Central nervous system: Problems with vision, headache, motor or sensory loss, loss of consciousness, and confusion Musculoskeletal: Bone point, joint pain, and muscular pain Dermatology: Rashes, ulcers, or lesions Kidney disease: Systemic symptoms of acute kidney injury or chronic kidney disease such as anorexia, vomit-ing, fatigue, pruritus, and peripheral edema Past Medical History: “Do you have any other health issues? Ask about renal disease, renal stones, pyelonephritis, con-genital structural abnormality of the genitourinary tract, recurrent cystitis, pelvic inflammatory disease (PID), human papilloma virus (HPV), sexually transmitted infec-tions (STI), human immunodeficiency virus (HIV), diabe-tes, hypertension (HTN), gout, and history of back injury. Neurological diseases may cause abnormal bladder func-tion such as Parkinson's disease, multiple sclerosis, or cerebrovascular disease. In a male patient, also ask about hydrocele, epididymitis, prostatism, varicocele, hernia, undescended testis, sper-matocele, erectile dysfunction, testicular torsion, and vasectomy. Past Hospitalization and Surgical History: “Have you had any previous hospitalization or surgeries?” Ask about previous catheterization. Abdominal or pelvic surgery can cause denervation injury to the bladder. Ureteric injury may occur following abdominal or gynecological procedures. Medication History: “Are you taking any medications pre-scribed, over the counter, or herbal? If so, have there been any side effects?” Prolonged analgesic use may cause chronic kidney dis-ease. Dosages of some drugs need to be adjusted or stopped in context of chronic kidney disease. Diuretics: May contribute to nocturia/incontinence. Alpha-blockers: Used in prostatic enlargement. Nephrotoxic agents: Angiotensin-converting enzyme (ACE) inhibitors, nonsteroidal anti-inflammatory drugs (NSAIDs), and antibiotics (gentamycin). Allergic History: “Do you have any known allergies?” Social History: “Do you smoke? Or does anyone else in your home or close proximity at work smoke?” “Do you drink alcohol?” If yes, then ask further ques-tions: “How much? Daily? How long?” “Have you ever tried any recreational drugs? If yes, which ones? How long? When?” Specifically ask about intrave-nous (IV) drug use (red flag for back pain). Family History: Marital status, number of children, any significant history in first-degree relatives. Any family his-tory of chronic kidney or polycystic kidney disease Occupational History: Exposure to chemical carcinogens such as 2-naphthylamine or benzidine found in the chemical or rubber industries. These are risk factors for bladder can-cer, after many years of exposure. Foreign Travel: Travel to Egypt or Africa may result in exposure to schistosomiasis. Dehydration during travel time in a hot climate may lead to development of kidney stones. Relationships: “Are you sexually active? Do you have sex with men, women, or both? Do you have single or multiple partners? Do you use protection?” Self-Care and Living Condition: “What do you do for a living? Working status and occupation? Educational status? Who lives with you?” Support: “Do you have good support from your family and friends?” Functional status or severity or impact on life activities. If a teenager, then add questions regarding: Home, edu-cation, employment, activities, drugs, and sexual activity 8 The Genitourinary System

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224 Female Genitourinary History You need to ask further details about the menstrual history, gynecological history, and obstetric history. Menstrual History: Age at menarche? If you notice any abnormality with puberty, then consider precocious puberty or delayed puberty. Ask about the onset of other secondary sexual characteristics and the onset of breast development. Ask about the pattern of the menstrual cycle: -When was the last normal menstrual period? -When was the first day of the last normal menstrual period? -How many days of blood loss? -The duration or length of the cycle? -Whether blood loss was heavy? If yes then ask about number of tampons and/or pads. Ask further about passing clots. -What form of contraception is being used? -Any other vaginal discharge other than the menses? The normal menstrual cycle: -Each cycle usually ranges between 21 and 35  days, with an average of 28. -Most healthy and fertile women have regular cycles with 1 or 2 days of variation. -Blood loss is 50-200 mls with an averages of 70 mls. Passage of large clots suggests excessive bleeding. Different abnormal patterns of bleeding: -Polymenorrhea: Unusually frequent periods. -Oligomenorrhea: Unusually infrequent or scanty periods. -Menorrhagia: Unusually heavy periods. -Menometrorrhagia: Prolonged, excessive, and irregu-lar uterine bleeding. -Intermenstrual bleeding: Bleeding between periods. -Breakthrough bleeding: Patient is on the pill. Diseases of the uterus and cervix: -Mucosal disorders -Postcoital bleeding (usually local cervical or uterine disease) Postmenopausal bleeding: Bleeding occurring more than 12 months after amenorrhea of menopause. Dysfunctional uterine bleeding: Abnormal bleeding that cannot be ascribed to pelvic pathology. Regular pattern will suggest that ovulation is occurring. Irregular pattern suggests no ovulation or anovulatory cycles. Psychosexual History: It should be conducted sensitively. It is important to pick up psychosexual problems and differentiate them from other causes of symptoms. Ask about: Relationship details Intercourse and sexual practices Association of other symptoms Issues of sexuality Libido Orgasm Obstetric History: Ask if the patient has ever been pregnant. How many full-term pregnancies? Ask about the length of labor and whether there was any prolonged pushing? Ask about the size of babies: small or large size baby. Ask whether any methods of assisted delivery were required, such as forceps or cesarean section. Any complications of pregnancy? Such as hypertension, preeclampsia, eclampsia, gestational diabetes, and HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count) syndrome. Ask about any postpartum hemorrhage. How many unsuccessful pregnancies? Any miscarriages or terminations? If the patient is more than 65 years old, add these questions: “Any problem with balance?” “Any difficulty with peeing/urination?” “Any issues sleeping?” “Any change in vision/hearing?” “Any recent change in memory?” “Are you taking any regular medications? Do you have any prescribed medicine? Are you taking any over the counter medicine?” 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: Female Genitourinary System Examination It is highly unlikely to be asked to perform a female pelvic examination. You must be familiar with the main steps and the how to verbalize these. The examiner may ask you to M. H. Sherazi

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

225 verbalize these steps, or you may be asked to perform an examination on a manikin. Candidate Information: You have been asked to do a detailed genitourinary system examination on a 32-year-old female. Vital Signs: heart rate (HR), 76/min, regular; blood pres-sure (BP), 120/75  mm Hg; temperature (Temp), 36. 8  °C; respiratory rate (RR), 16/min; O 2 saturation 100% 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. Preparation for the Examination Equipment should be made ready beforehand (Fig.  8. 1): -Vaginal speculum -Lubricating gel/tape water -Gloves -Culture swab tubes -Light source Ask for a chaperone, preferably another doctor or a nurse. Establish a good rapport. It will help patients to prepare for the pelvic examination. Explain what will you will be doing and why you need to do this examination. Inform the patient that the pelvic examination consists of visual external inspection, inser-tion of the speculum, performance of any tests or cytol-ogy, and then bimanual examination to determine the size and character of the uterus and ovaries. Right-handed individuals generally put their right hand in the vagina and use their left hand abdominally [1]. Make sure you get a clear consent for the examination. Inform the patient that if she does not feel comfortable during the exam, she should let you know, and immedi-ately stop that step of the examination. Encourage patients to empty their bladder before the examination. Opening Introduction (greet, explain, position, and expose/ drape) Ask for vital signs -interpret General Physical Examination (You may skip these questions if it is a history and physical station. ) Check that the patient is alert and oriented. Look for abnormal findings in: -Hands -Face (eyes, nose, lips, mouth) -Neck Mention that you will look for signs related to a possible endocrine disorder: thyroid disease, Cushing syndrome, hirsutism, and acne. Mention that you would like to do a breast examination, a check for lymphadenopathy (especially inguinal nodes), and an assessment of secondary sexual characteristics. Abdominal Examination Posture: Patient lying flat with his arms at the sides. Inspection: Observe for skin, umbilicus, contour, move-ments, peristalsis, pulsation, scars, masses, and cough reflex. Auscultation: Bowel sounds and bruits. Percussion: Shifting dullness and fluid thrill. Large ovar-ian cysts, which can be detected by abdominal percussion revealing central dullness. Liver and spleen span. Palpation: -Superficial/light palpation -Deep palpation -Feel for pregnancy fundal height -Pregnancy (often used to equate the size of other pel-vic tumors): 12 weeks: Palpable above the pubic bone 16  weeks: Palpable midway between the pubic bone and umbilicus 20 weeks: Just below the umbilicus Fig. 8. 1 Speculum and swabs 8 The Genitourinary System

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226 28 weeks: Just midway between the umbilicus and xiphisternum 34 weeks: Just below the xiphisternum -Palpable bladder in urinary retention Liver palpation Spleen palpation Kidney palpation Costovertebral angle (CV A) tenderness: Renal angle tenderness suggesting a renal cause for pain Pelvic Examination Positioning: The patient should be asked to undress from the waist below. Drape her from the waist to knees. The patient should be placed in the dorsal lithotomy position. The dorsal supine lithotomy position is best accomplished with the use of supports, which are adjusted to the patient's leg length and allow the legs to be flexed and abducted (Fig.   8. 2). Most office foot supports require the patient to have ade-quate muscle control to hold her legs upright. For patients with neurologic conditions or who are anesthetized or sedated, the feet can be placed in candy cane stirrups, which support the legs in the lithotomy position [ 2]. In the office or examination setting, the other possible position will be putting the patient supine on the couch with flexed hips and knees with heels together and thighs abducted (Fig.   8. 3) [3]. Cover the patient's abdomen with a sheet. Position lighting to give a clear view of the external genitalia. Put on disposable gloves. Examination of the External Genitalia Systematically examine the labia majora, labia minora, introitus, urethra, and clitoris. Bartholin's glands are not normally tender or palpable. Assess for pubertal development in teenagers. Assess for atrophic changes in those who have reached menopause. Examine the labia majora and labia minora for lesions, ulcerations, masses, induration, and areas of different color and hair distribution. Examine the perineum: lesions, ulcerations, masses, indu-ration, and scars. Examine the clitoris: size, lesions, and ulcerations. Examine the urethra: discharge, lesions, and ulcerations. Examine the urethra: discharge, lesions, and ulcerations. Examination of the Vagina: Both digital and speculum Separate the labia and ask the patient to push down or bear down, then examine the vestibule, and look for cys-tocele, rectocele, and uterine descent or prolapse. Observe the vagina for discharge, inflammation, lesions, ulcerations, masses, induration, nodularity, relaxation of perineum, and atrophy. Examination of the Cervix: Inform the patient that you will be inserting the speculum now (Fig.   8. 4) [4]. It is best to show her the speculum before proceeding. And tell her that this is the instrument you will be using for examination. The patient should breathe deeply and try to relax her vaginal, rectal, and abdominal muscles during insertion. Look for the position of the cervix in relation to uterine position (anteverted, axial, or retroverted). Further examine the cervix for its color, shape, size, con-sistency discharge, erosions, and ulcerations. Cervical os shape relates to whether the patient is parous or not. Fig. 8. 2 Pelvic exam: lithotomy position. (Modified with permission from Simpson [ 3]) Fig. 8. 3 Pelvic exam position: the diamond-shaped position. (Reprinted with permission from Simpson [ 3]) M. H. Sherazi

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227 The cervix may be bluish in early pregnancy (Chadwick's sign). Look for cervical tenderness. The squamocolumnar junction should be visualized. Cytology is important to diagnose and exclude cervical cancer. Take the cervical smears. Swabs should be labeled, pre-pared, and sent according to the local and regional guidelines. The speculum should be removed carefully and without discomfort to the patient. Internal Examination of the Uterus: Explain and perform a bimanual examination (Fig.   8. 5) [5]. Explain that it is required to examine the uterus, fallopian tubes, and ovaries internally. Expose introitus, and hold the labia apart with a gloved left hand. Introduce lubricated right index and middle fingers. Palpate the uterus between abdominal (left) hand and internal (right) hand. Identify the cervix and uterus. The right and left adnexa are not normally palpable. Feel for the uterus position, size, contour, consistency of uterine tissue, and mobility on movement. Palpate for adnexa: ovaries for tenderness, masses, con-sistency, contour, mobility, and pain on movement (Chandelier sign). Assess the size, consistency, and mobility of organs felt. Hegar's sign: in pregnancy, the cervix softens. In uterine or adnexal infection or inflammation, one can observe cervical excitation. Rectal Examination Mention that you will complete your examination with a rec-tal examination if required. Look for pain, occult blood, masses, hemorrhoids, anal fissures, and sphincter tone. Thank the patient. Ask the patient to dress. Describe your findings to the examiner. Checklist: Female Genitourinary System Examination See Table  8. 2 for a checklist that can be used as a quick review before the exam. Physical Examination: Male Genitourinary Examination Just as with the female genitourinary examination, it is highly unlikely to be asked to perform a male pelvic exami-nation. You must be familiar with the main steps. The exam-Fig. 8. 4 Pelvic examination with speculum. (Reprinted with permis-sion from Acevedo [ 4]) Fallopian tube Ovary Uterus Bladder Vagina Rectum Cervix Fig. 8. 5 Bimanual examination of the uterus. (Source: National Cancer Institute, A V Number: A V-0000-4114) 8 The Genitourinary System

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228 iner may ask you to verbalize these steps, or you may be asked to perform an examination on a manikin. Candidate Information: You have been asked to do a detailed genitourinary system examination on a 52-year-old male. Vital Signs: HR, 76/min, regular; BP, 140/75  mm Hg; Temp, 36. 8 °C; RR, 18/min; O 2 saturation 100%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. Preparation for the Examination: Equipment should be made ready beforehand. -Lubricating gel -Gloves -Light source -Cleaning towel/tissue paper Ask for a chaperone. Establish a good rapport. It will help patients to prepare for the pelvic examination. Explain what will you be doing and why you need to do this examination. Inform the patient that the pelvic exami-nation consists of visual external inspection, palpation, and digital rectal examination. Make sure that you get a clear consent for the examination. Opening: Introduction (greet, explain, position, and expose/ drape) Ask for vital signs -interpret General Physical Examination: (You may skip these questions if it is a history and physical station. ) Check that patient is alert and oriented. Look for abnormal findings in: -Hands -Face (eyes, nose, lips, mouth) -Neck -General sexual development and secondary sexual characteristics. -Observe for evidence of anemia. -Mention that you will look for signs related to possible endocrine disorders such as thyroid disease, Cushing syndrome, hirsutism, and acne. -Look for evidence of liver disease or thyroid disease. -Note whether there is evidence of gynecomastia. -Signs of dehydration such as a dry mouth and tongue may indicate kidney failure or polyuria associated with diabetes. Table 8. 2 Checklist for female genitourinary system 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 Introduce/offer chaperone General physical examination Ask for vital signs. Interpret the vital signs Look for any abnormal findings in: Hands Face Neck Chest Abdominal examination Posture: patient lying flat with their arms on the sides Inspection: observe for the skin, umbilicus, contour, movements, peristalsis, pulsation, scars, masses, and cough reflex Auscultation: bowel sounds and bruits Percussion: shifting dullness and fluid thrill Palpation: superficial/light palpation and deep palpation Liver palpation Spleen palpation Kidney palpation CV A tenderness Pelvic examination Positioning Inspection external genitalia: examine the labia majora and labia minora, perineum, clitoris, and urethra Speculum examination: examine the vestibule, vagina, and cervix Palpation: internal examination of the uterus -uterus and adnexa Rectal examination: look for pain, occult blood, masses, hemorrhoids, anal fissures, and sphincter tone Wrap-up Thank the patient Ask patient to get dressed Describe your findings to the examiner M. H. Sherazi

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

229 Feel for lymphadenopathy: Lymph nodes may be enlarged due to metastatic spread from any urological cancer. Abdominal Examination: Posture: Patient lying flat with arms at his sides. Inspection: Observe for the skin, umbilicus, contour, movements, peristalsis, pulsation, scars, masses, and cough reflex. -Abdomen may be distended due to large polycystic kidneys or ascites due to nephritic syndrome or nephrotic syndrome. Auscultation: Bowel sounds and bruits. Auscultation for a renal bruit in renal artery stenosis. Auscultate 2 cm to the left or right of the midline and also in both flanks with the patient sitting up. Percussion: Shifting dullness and fluid thrill. -Liver and spleen span. Palpation: -Superficial/light palpation -Deep palpation -Palpate for an enlarged bladder or an abdominal aortic aneurysm. Liver palpation Spleen palpation Kidney palpation: Examine by bimanual examination with one hand posteriorly lifting up the kidney up toward the other examining abdominally placed hand. Tenderness over the kidney should be tested by gentle pressure over the renal angle. Palpation for renal enlargement or masses. An enlarged kidney usually bulges forward. CV A tenderness: Renal angle tenderness suggesting a renal cause for pain. Hernias and hernial orifices: Check cough reflex. Pelvic Examination: Ask the patient to undress below the waist and cover him over his abdomen. Penis -Inspection and palpation: Prepuce, glans, and foreskin: exclude a phimosis, and watch for signs of hypospadias. -Examine the skin for ulcers and rashes. -The shaft of the penis is examined for plaques of Peyronie's disease. -Urethral discharge. Scrotum -Inspection and palpation: Inspect scrotal skin. Palpate testis for the size, shape, and surface. The testis should be smooth and relatively firm. Small firm testes suggest hypogonadism or testicular atrophy. Absence of a testis: undescended testis, previous excision, or a retractile testis. Feel for a scrotal swelling: -Try getting above the swelling. -Reexamine, while the patient is standing. If it is not possible to locate the upper border of the swelling in the scrotum, then it is likely to be an inguinal hernia. -Feel for the consistency of the swelling: solid or cystic. Identify if it can be a hydrocele, varicocele, or epididy-mal cyst. -Check for translucency with a torch. A solid and non- translucent swelling attached with the testis can possibly be a testicular tumor. A cystic and translucent swelling attached with the testis will likely be a hydrocele. A swelling separate from the testis and that is solid and non-translucent can be a chronic epididymitis; and a cys-tic and translucent swelling will be an epididymal cyst. Examine the groin and lymphatics. Prostate: This is examined by a digital rectal examination. -Feel for its size, consistency, medical sulcus, any ten-derness, and any swelling. -A hard lump in the prostate can represent prostate can-cer, and a biopsy is warranted. Neurological Examination Dermatome sensory loss of the perineum or lower limbs and lower limb motor dysfunction suggest possible spinal cord or root pathology. Trauma or compression of the spinal cord may cause uri-nary retention if acute or urgency of micturition if it is a more chronic process. Acute compression of either the spinal cord or cauda equina may cause bladder and bowel dysfunction and are both neurosurgical emergencies, requiring urgent treat-ment to prevent irreversible neurological damage. On completing the examination, thank the patient. Ask the patient to dress. Describe your findings to the examiner. History and Counseling: Urinary Hesitancy (Benign Prostatic Hyperplasia) Candidate Information: For this station, you may be presented with any of the fol-lowing five cases:. 8 The Genitourinary System

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230 Case 1 A 60-year-old male presents in the emergency department with 6 h of lower abdominal discomfort and inability to uri-nate. An indwelling urinary catheter was passed and 1100 ml urine collected in the bag. Please take a detailed history. What is the most likely cause? Discuss your differentials with the examiner. Case 2 A 60-year-old male presents in your outpatient clinic with difficulty in passing urine. Please take a detailed history. Case 3 A 60-year-old male presents in your outpatient clinic because he is recently feeling very tired. He has to wake up multiple times during the night to go to the toilet for urina-tion. Please take a detailed history and discuss your differen-tials with the examiner. Case 4 A 60-year-old male comes to your outpatient clinic with nocturia, urgency, weak stream, and terminal dribbling. He does not have any weight loss or bone pain. Recently he had to go to the emergency department and was catheterized. Case 5 A 60-year-old male comes to your outpatient clinic with nocturia, urgency, weak stream, and terminal dribbling. He does have a 5 kg weight loss in the last 2 months and has felt fatigued and lower back pain for 2 months. Recently he had to go to the emergency department and was catheterized. Vital Signs: HR, 86/min regular; BP, 155/80  mm Hg; Temp, 36. 8 °C; RR, 18/min; O2 saturation 99% No physical examination is required for this station. Differentials: Benign prostatic hypertrophy Prostate cancer Prostatitis Urinary tract infection Post-traumatic urethral stricture Bladder calculi Renal cell 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 attending physician for today. Are you Mr... ? Are you... years old?” The opening of Case 1 should be handled like this: “I understand you came to the emergency department because of difficulty in passing urine for 6 h and a Foley catheter has been passed. Do you know that 1100 ml of urine was drained. How do you feel now?” If the patient tells that he has pain and asks for medica-tion, then make sure to ask questions about pain in the history of present illness. Show empathy. Now address his concern first about pain. Tell him that you need to ask a few questions and in the meanwhile you will order pain medication and he will get some medication soon. The opening of Case 2 should be: “I understand you are here because you have difficulty in passing urine. Can you please tell me more about this?” The opening of Case 3 should be: Show empathy in the start. “I am sorry to hear that you have not been feeling very well recently. You have to go to toilet multiple times during the night. Should we discuss more about it?” The opening of cases 4 and 5 should be: Because there are multiple presenting complaints, the easiest way to start is with: “How can help you today?” Then let the patient describe the presenting complaints. History of Present Illness: “Can you please tell me more about your difficulty in passing urine?” “When did it first start?” “How did it start? Sudden/gradual?” “Did you notice any change in passing urine?” “Is it the first time you are having this problem?” “Has your problem being progressing?” “How many times did you void during the night and dur-ing the day?” “What were your urinary habits before?” “Is it affecting your sleep?” “Do you have pain anywhere? Do you feel pain while passing urine?” “How much urine are you able to pass each time?” “Do you have difficulty in initiating the stream?” “Did you notice any change in the stream of urine?” “Do you need to push to empty your bladder?” “Did you notice any dribbling of urine?” “Do you have to rush?” “Are you able to make it to the toilet?” M. H. Sherazi

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231 “Have you ever lost control on passing urine?” “Do you have sensation of incomplete emptying of your bladder? Did you have urge to pass more urine even after passing urine?” “Do you have urge to void even after you have once passed urine?” Show empathy. Associated Symptoms to Rule Out Differentials: Ask a few questions about urinary changes. Ask specific questions about urine: -Color of urine -Any particular smell/odor? -Amount of urine -Consistency Clear urine Frothy urine Cloudy urine Not clear urine Noticed any blood? “Have you ever been screened or diagnosed with having prostrate disease?” “Have you ever had the blood test for prostate?” (Prostate- specific antigen [PSA]) Previous recurrent urinary tract infections? “Have you noticed passing any stones in urine?” “Did you notice any burning sensation?” “Did you have any flank pain/back pain?” “Did you notice any fever?” “Did you have nausea or vomiting?” “Did have any previous back injury?” “What setting do you notice this problem? Home or in public places?” (Psychological) Ask about symptoms of liver disease. (Liver metastasis) Ask about cough or blood in sputum. (Lung metastasis) Ask about confusion or any neurological weakness. (Brain metastasis) Ask about symptoms of renal failure: puffy face, decrease or no urine output, and swollen ankles. Constitutional Symptoms: Fever, night sweats, loss of weight, or loss of appetite Past Medical History: “How is your health otherwise? Any medical problems? DM, HTN, history of kidney/pros-tate problem, urinary tract infections?” Past Hospitalization and Surgical History: “Have you had any previous hospitalization or previous surgery?” Medication History: “Are you taking any medication?” If he says no, then continue to the next question. “Anticholinergics? Over-the-counter or herbal medications and any side effects?”Allergic History: “Do you have any known allergies?” Family History: “Any family history of prostate cancer? Who and age at which diagnosed?” 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 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 sex-ual preferences? Man, woman, or both?” Self-Care and Living Condition: “What do you do for liv-ing? 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: Question: What is BPH? (Questions may be asked by the patient or the examiner. ) Answer: “Benign prostatic hyperplasia (BPH) is the name given to enlargement of the prostate gland. This enlargement is believed to be caused by the effects of male sex hormones. Rarely symptoms of BPH occur before the age of 40, but more than 50% of men in their 60s and as many as 90% in their 70s and 80s have some symptoms of BPH.   Some men begin to have difficulty in passing urine because the enlarged prostate gland presses against the urethra, the tube leading from the bladder. This causes the urethra to narrow, obstructing urine flow from the body. Your doctor will check your symptoms, check the size of your prostate, and may carry out a blood test. ” Question: What is a prostate gland? Answer: “The prostate is a small gland found at the base of a man's bladder. It is about the size of a chestnut and sits around the urethra, through which urine passes. The role of the prostate is not understood fully. It is believed to assist in the production of semen. ” Question: Is BPH a type of cancer?s Answer: “BPH is not a type of cancer. Some of the symptoms of BPH and prostate cancer are similar, but having BPH does not mean that you have cancer of the prostate or that you will develop this type of cancer later on. However, if ever you notice blood in your urine or semen, you should tell your doctor” [6 ]. 8 The Genitourinary System

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232 Question: What is your most likely diagnosis? Answer: “Benign prostatic hyperplasia” Question: What are two other likely diagnoses? Answer: “Urinary tract infection or prostate cancer” Question: What investigations? Answer: Rectal examination, urea/creatinine, urinalysis, prostate-specific antigen (PSA), renal/prostate ultrasound Question: What are other investigations, if considering prostatic malignancy? Answer: Ultrasonography (USG) of the prostate (transrec-tal) and computed tomography (CT) pelvis Question: What are the risk factors? Answer: Risk factors for prostate gland enlargement include [7 ]: Aging. Prostate gland enlargement rarely causes signs and symptoms in men younger than age 40. About one- third of men experience moderate to severe symptoms by age 60, and about half do so by age 80. Family history. Having a blood relative, such as a father or brother, with prostate problems means you are more likely to have problems. Ethnic background. Prostate enlargement is less common in Asian men than in white and black men. Black men might experience symptoms at a younger age than white men. Diabetes and heart disease. Studies show that diabetes, as well as heart disease and use of beta blockers, might increase the risk of BPH. Lifestyle. Obesity increases the risk of BPH, while exer-cise can lower your risk. Question: What initial treatment will you recommend for BPH? Answer: Watchful waiting; 50% resolve spontaneously. Medical: -Alpha-adrenergic antagonists: Alfuzosin (Uroxatral) Doxazosin (Cardura) Silodosin (Rapaflo) Tamsulosin (Flomax) Terazosin (Hytrin) -5-Alpha-reductase inhibitors Dutasteride (Avodart) Finasteride (Proscar) Surgery: transurethral resection of prostate (TURP) and others. A urologist will decide. History and Counseling: Hematuria Candidate Information: A 60-year-old male presents with microscopic hematuria on his annual checkup urinalysis. Please take a detailed history and determine what is the most likely cause. Discuss your differentials with the examiner. What investigations would be helpful? Or A 60-year-old male presents with sudden onset of severe flank pain and noticed blood in his urine since the morning. Please take a detailed history and determine what is the most likely cause. Discuss your differentials with the examiner. What investigations would be helpful? Differentials: See Tables 8. 3 and 8. 4 for etiology and key symptoms of hematuria. Painless/Painful Hematuria Painless hematuria: -UTI -Renal or bladder stones -Trauma -Autoimmune: Wegener granulomatosis, Goodpasture syndrome -Sickle cell anemia, coagulopathy -Drugs -Glomerulonephritis -Exercise Flank pain and hematuria: -Urinary tract infection -Trauma -Renal colic -Hemorrhagic cystitis -Incarcerated/strangulated hernia -Diverticulitis -Hematologic or coagulation disorders -Sickle cell anemia -Ruptured/leaking abdominal aortic aneurysm Table 8. 3 Etiology of hematuria by age Age range Etiology 0-20 Glomerulonephritis, UTI, congenital anomalies 20-40 UTI, stones, bladder tumor 40-60 Male: UTI, stones, bladder tumor (transitional cell carcinoma of bladder), renal cell carcinoma Female: UTI, stones, bladder tumor >60 Male: UTI, BPH, bladder tumor, prostate cancer, renal cell carcinoma Female: bladder tumor, UTI UTI urinary tract infection, BPH benign prostate hypertrophy M. H. Sherazi

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

233 Gynecologic sources should be excluded in female patients. Gross hematuria in adult patients represents malignancy until proven otherwise. 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 60 years old? I understand you are here because of pain and passing blood in urine. Is it alright if I ask you a few ques-tions about it? Then we can discuss a management plan. ” If the patient looks tired or worried, show empathy. History of Present Illness Start with pain questions. If pain is the chief complaint, then quickly go through the pain questions: -Onset -Course -Duration -Progression -Quality of pain (burning, throbbing, dull) -Radiation-Severity (scale of 1-10) -Timing (time of the day) -Pain before -Aggravating -Alleviating -Associated symptoms (back pain, groin pain) Continue with urinary symptoms: -Urinary changes, ask specific questions about urine: -Noticed any blood? Yes. -Then continue with more questions about blood in urine: What color is the urine? Bright red or dark? Passing clots? When was the first time he notice blood in urine? Any pain while passing urine? Any other bleeding from any other body site? -Any particular smell/odor? -Amount of urine. -Consistency. -Cloudy urine. -Ask a few questions to rule out obstruction: Difficulty in starting or initiating in passing urine? “Do you have to strain/push hard to pass urine?” “Did you notice change in stream? How full is the urinary stream?” “Did you notice any dribbling? Is there any termi-nal dribbling of micturition?” “After passing urine, do you still have the feel/need to pass more urine?” Irritation. -“How many times do you go to the washroom?” -Any recent change in frequency of urination? Any change before or especially any change during the night? -“Have you ever lost control?” -“Do you have burning sensation while passing urine or after finishing?” -Incontinence: Is there any incontinence or urgency of micturition? -Ask about recurrent urinary tract infections? (UTIs) -Previous history of passing stones or any grit in urine? -Provoking factors (exercise, trauma). -Any urethral discharge? Systemic Review: GI: Nausea, vomiting, appetite, weight loss, abdominal pain, and bowel routine Cardiovascular system: Chest pain, dyspnea Respiratory system: Cough, hemoptysis, and chest pain Central nervous system: Problems with vision, headache, loss of consciousness, and confusion Table 8. 4 Hematuria and key related symptoms Key related symptoms Urolithiasis Hematuria and CV A tenderness, severe colicky flank pain; pain may migrate to the groin Glomerulonephritis Ig A nephropathy is most common. Acute glomerulonephritis -presents with gross hematuria. Presentation is usually concurrent with UTI, GI symptoms, or a flu-like illness BPH Classic urinary symptoms, microscopic hematuria if present Prostate cancer Urinary symptoms, metastatic symptoms, and examination findings may present Renal cell carcinoma Hematuria, flank pain, and a palpable mass Bladder cancer Hematuria, irritative voiding symptoms, occupational exposure CVA costovertebral angle, Ig A immunoglobulin A, UTI urinary tract infection, GI gastrointestinal, BPH benign prostate hypertrophy 8 The Genitourinary System

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234 Musculoskeletal: Bone point, joint pain, and muscular pain Kidney disease: Systemic symptoms of acute kidney injury or chronic kidney disease such as anorexia, vomit-ing, fatigue, pruritus, and peripheral edema. Constitutional Symptoms (Only Ask if Not Asked Before in the History): Fatigue and malaise, night sweats, fever, weight loss Past Medical History: “Do you have any other health issues?” Ask about renal colic/disease, renal stones, pyelonephri-tis, or recurrent cystitis. Past Hospitalization and Surgical History: “Have you had any previous hospitalization or surgeries?” History of recent UTI, sexually transmitted diseases (STDs), tuberculosis (TB) exposure, pelvic irradiation, and bleeding diathesis. Ask about previous catheterization. Abdominal or pelvic surgery. Medication History: “Are you taking any medication prescribed, over the counter, or herbal? If so, have there been any side effects?” Analgesics, anticoagulants, or chemotherapy -hemor-rhagic cystitis. Allergic History: “Do you have any known allergies?” Social History: “Do you smoke? Or does anyone else in your home or close at work smoke?” “Do you drink alcohol?” If yes, then ask further ques-tions: “How much? Daily? How long?” “Have you ever tried any recreational drugs? If yes, which ones? How long? When?” Specially ask about intrave-nous (IV) drug use (red flag for back pain). Family History: “Any family history of chronic kidney dis-ease, sickle cell anemia, renal colic, or polycystic kidney disease?” Occupational History: “Any exposure to chemical carcin-ogens such as 2-naphthylamine or benzidine in the chemical or rubber industries?” These may induce bladder cancer many years later after the exposure. Foreign Travel: Travel to Egypt or Africa may result in exposure to schistosomiasis. Dehydration during the time in a hot climate may lead to development of kidney stones. 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? Working status and occupation? Educational status? Who lives with you?” Support: “Do you have good support from your family and friends?” Functional status or severity or impact on life activities. Wrap-Up: Question: What will you do next? Answer: “I will like to perform a physical examination. ” These are the physical examination findings: Patient is in no acute distress. Vitals signs: Within normal limits. Respiratory: Clear breath sounds bilaterally with good air entry. Cardiovascular: Normal S1/S2; no murmurs. Abdomen: Soft, nondistended, and nontender. No hepatosplenomegaly. No mass or hernia. Mild right CV A tenderness. Extremities: No edema. Question: Describe the diagnosis. Answer: “Most likely renal colic due to renal or ureteric stones” Question: What investigations will you advise to rule out differential diagnosis? Answer: Genital exam: To find out a urology-related source of bleeding in men. Rectal exam: To feel and detect prostatic enlargement or nodules. Complete blood count (CBC): To rule out anemia. Blood urea nitrogen (BUN)/creatinine: To assess kid-ney function. Urinalysis (UA): To assess hematuria, pyuria, and bacteriuria. Dysmorphic red blood cells (RBCs) or casts are signs of glomerular disease. Urine culture: To exclude UTI. Urine cytology: For detecting bladder cancers. PSA: Correlates with the volume of both benign and malignant prostatic tissue. Can be normal in about 20% of patients who have nonmetastatic prostate cancer. USG kidneys: Can detect bladder and renal masses and stones. Cystoscopy: The gold standard for the diagnosis of blad-der cancer. M. H. Sherazi

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

235 CT abdomen/pelvis: To evaluate the urinary tract. It can pick up stones, benign lesions, as well as neoplasms. Question: One of my friends told me that blood in urine is due to my old age. Is that true? Answer: “Blood in urine is rarely normal. We need to investigate it and find a source of bleeding. ” Question: What will be the management plan? Answer: “Initial pain medication and according to the diagnosis. Likely an urgent urology referral” History and Counseling: Erectile Dysfunction Candidate Information: A 41-year-old male presents with impotence that started 3 months ago. He has hypertension and diabetes. He is on atenolol and metformin. Vital Signs: T 36. 6 °C, HR 65, BP 120/70, RR 18, O2 satu-ration 100% Take a detailed history. Discuss your differentials with the examiner. What investigations would be helpful? Differentials: Drug-related erectile dysfunction (ED) -see Table  8. 5 for a list of medications that may cause ED [8]. ED caused by diabetes mellitus (diabetic neuropathy). Psychogenic ED: Anxiety and other psychiatric disorders. Nerve and brain disorders: Stroke, head injury, multiple sclerosis, Alzheimer's disease, and Parkinson's disease. Surgery: Procedures to treat prostate and bladder cancer. Injury: Pelvis, bladder, spinal cord, or penis injuries. Chronic alcoholism. Hormone problems: Pituitary gland tumors, related to kidney or liver disease, or hormone treatment for prostate cancer. Peyronie's disease: Peyronie's disease is the devel-opment of fibrous scar tissue inside the penis that causes curved, painful erections. Penises vary in shape and size, and having a curved erection is not necessarily a cause for concern. But Peyronie's dis-ease causes a significant bend or pain in some men. This can prevent you from having sex or might make it difficult to get or maintain an erection (erectile dys-function) [9 ]. Leriche syndrome: Aortoiliac occlusive disease, also known as Leriche syndrome, is a form of central artery disease involving the blockage of the abdominal aorta as it transitions into the common iliac arteries. In male Table 8. 5 Medications that may cause erectile dysfunction Drug type Name of drug Antiarrhythmics Disopyramide (Norpace) Amitriptyline (Elavil) Amoxapine (Asendin) Buspirone (Buspar) Chlordiazepoxide (Librium) Clomipramine (Anafranil) Clorazepate (Tranxene) Desipramine (Norpramin) Antidepressants Diazepam (Valium) Doxepin (Sinequan) Antianxiety drugs Fluoxetine (Prozac) Imipramine (Tofranil) Antiepileptic drugs Isocarboxazid (Marplan) Lorazepam (Ativan) Nortriptyline (Pamelor) Oxazepam (Serax) Phenelzine (Nardil) Phenytoin (Dilantin) Sertraline (Zoloft) Tranylcypromine (Parnate) Antihistamines Dimenhydrinate (Dramamine) Diphenhydramine (Benadryl) Hydroxyzine (Vistaril) Meclizine (Antivert) Promethazine (Phenergan) Chemotherapy drugs Busulfan (Myleran) Cyclophosphamide (Cytoxan) High blood pressure drugs Diuretics Beta-blockers Alpha-blockers Atenolol (Tenormin) Bumetanide (Bumex) Captopril (Capoten) Chlorthalidone (Hygroton) Clonidine (Catapres) Enalapril (Vasotec) Furosemide (Lasix) Guanfacine (Tenex) Hydralazine (Apresoline) Hydrochlorothiazide (Hydro DIURIL, Hydropres, Inderide, Moduretic) Labetalol (Normodyne) Methyldopa (Aldomet) Metoprolol (Lopressor) Nifedipine (Adalat, Procardia) Phenoxybenzamine (Dibenzyline) Propranolol (Inderal) Spironolactone (Aldactone) Triamterene (Maxide, Dyazide) Verapamil (Calan, Isoptin, Verelan) Histamine H 2-receptor antagonists Cimetidine (Tagamet) Nizatidine (Axid) Ranitidine (Zantac) Muscle relaxants Cyclobenzaprine (Flexeril) Orphenadrine (Norflex) (continued) 8 The Genitourinary System

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236 patients it presents as a triad of claudication of the but-tocks and thighs, absent or decreased femoral pulses, and erectile dysfunction [10]. 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 41 years old? How can I help you today?” The patient will tell about his ongoing problem of erectile dysfunction. “Is it alright if I ask you a few questions about it? Then we can discuss a management plan. ” Show empathy. History of Present Illness: “Can you please describe a bit more about your prob-lem?” Patient: Not able to get erections for 3 months. “When did it start?” 3 months back. “How did it start? Sudden or progressive?” It is gradual in onset. “Is your problem continuous or intermittent?” Continuous. “Is it progressing?” Yes. “How is the severity of your problem?” Getting worse. “Do you have any problems of sexual desire?” Desire for sex is present during the day. “Do you have nighttime erections?” Yes. “Do you have any problem with ejaculation?” No. “Do you think anything is aggravating your problem?” Aggravated by stress. “Anything that relieves your problem?” No relieving factors. No associated problems. No previous episodes of sexual dysfunction. No previous treatment/evaluation. Questions to Rule Out Differentials: “Do you have any pain in the legs (claudication)?” No pain in the legs or thighs. Screen out recent stress, anxiety, or depression: -Mood Screening: “How is your mood these days? Low or high?” -Anxiety Screening: “Are you the kind of a person who worries a lot?” (Excessive fear). Ask about thyroid problems. Ask about any recent trauma. Any new urinary symptoms. Any associated incontinence. Ask if the patient has any questions. Past Medical History: “Do you have any other health issues?” Ask about hypertension, diabetes, high cholesterol, and atherosclerotic vascular disease. He has diabetes and high blood pressure. Had general-ized anxiety disorder for about 4 years and took buspi-rone. Discontinued buspirone a few months back. Past Hospitalization and Surgical History: “Have you had any previous hospitalization or surger-ies?” Prior prostate surgery. History of recent UTI, STDs, pelvic irradiation, or any abdominal or pelvic surgery? No. Medication History: “Are you taking any medication pre-scribed, over the counter, or herbal? If so, have there been any side effects?” Atenolol and Metformin. Allergic History: “Do you have any known allergies?” None. Social History: “Do you smoke? Or does anyone else in your home or close at work smoke?” “Do you drink alcohol?” If yes, then ask further ques-tions: “How much? Daily? Alcohol two to three beers/day for about 10 years. “Have you ever tried any recreational drugs? If yes, which ones? How long? When?” Specially ask about intrave-nous (IV) drug use. None. Family History: Any family history of chronic diseases? None. Occupational History: “What do you do for work?” Works as a plumber. Table 8. 5 (continued) Drug type Name of drug Nonsteroidal anti-inflammatory drugs (NSAIDs)Indomethacin (Indocin) Naproxen (Anaprox, Naprelan, Naprosyn) Parkinson's disease drugs Benztropine (Cogentin) Biperiden (Akineton) Bromocriptine (Parlodel) Levodopa (Sinemet) Procyclidine (Kemadrin) Trihexyphenidyl (Artane) Prostate cancer drugs Flutamide (Eulexin) Leuprolide (Lupron) Modified from [8] M. H. Sherazi

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

237 Relationships: “Are you sexually active? Do you have sex with men, women, or both?” Yes, with wife and one other female sexual partner. Having problems with both of them. Wrap-Up: Question: What do you next? Answer: “I will check his blood sugar level, cholesterol, and fast-ing lipid profile. ” “Blood tests to rule out kidney and liver disease. ” “A urine dip test. ” “I will do a general physical examination and blood pressure. ” “I will examine cardiovascular system, genital and rectal exams. ” “I will examine pulsations in lower limbs. ” “I will also request for an electrocardiogram (ECG). ” Question: Can you please explain to the patient what is erectile dysfunction? Answer: “ED means that one cannot get and/or maintain a proper erection. Most cases are due to narrowing of the arteries that supply blood to the penis. This is due to a build- up of fatty deposits in these arteries. The mechanism is the same in which the heart arteries are affected in patients with heart disease. In some patients, the penis does not become hard enough to have sex properly, and in some patients, there is no swelling or fullness of the penis at all. ” Question: What will you counsel the patient? Answer: “I will explain the physical findings and diagnosis. ” “I will explain further work-up. ” “I will advise regarding home glucose monitoring. ” “I will advise a strict diabetic diet. ” “I will explain the importance of lifestyle modifications” [11]: -“Smoking: It increases your risk of hardening of the arteries. This reduces blood flow to the penis. It's that blood flow that helps you get an erection. ” -“Being overweight: Carrying extra pounds increases your risk of blood vessel disease, a cause of ED. ” -“Inactive lifestyle: If you want to reduce your chance of getting ED, get off the couch. Regular exercise can help to make sure that when the time comes, you're ready. ” -“Poorly managed diabetes: Diabetes can affect blood flow to your penis. Maintain a healthy diet, get regular exercise, and take your medicine as prescribed. ” -“High cholesterol: It can damage the linings of blood vessels, including those in the penis. It can also affect the arteries leading to your genitals. Eat right, exercise regularly, and take your meds. ”-“Alcohol: If you have more than two drinks a day, you could be hurting your ability to get an erection. Alcohol restricts blood flow to the penis and can hinder produc-tion of testosterone. Low testosterone can affect not only your performance but your desire, too. ” -“Illegal drug use: Marijuana, cocaine, and other recre-ational drugs can cause ED by damaging blood ves-sels. They can also restrict blood flow to the penis. ” -“Stress and anxiety: These are leading causes of tem-porary ED.  If your mind's too occupied, it's hard to relax enough to be 'in the mood'” [11]. Question: What are the treatment options? Answer: “A specialist assessment may be required for patients with ED having hormonal problem and circulatory problems or if the symptoms have started after an injury. Most of the patient can be managed in the GP clinic. ” “The most important aspect in treating ED is to find a cause; if there is an obvious cause, then the first step will be to start treating the underlying cause, for example, treating anxiety or depres-sion, hormonal replacements, switching medications, lifestyle modifications, cutting back on drinking alcohol. ” “There are medical treatments available. These medica-tions work by increasing the blood flow to the penis. They do this by affecting c GMP, the chemical involved in dilating the blood vessels when sexually aroused. These are sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra), and avanafil (Spedra). ” “There are creams available, topical alprostadil. The cream comes with a plunger. The cream is applied to the tip of the penis and the surrounding skin. It should be used 5-30 min before you have sex. ” “There are also injections available. Patients are taught how to inject a medicine into the base of the penis. This causes increased blood flow, following which an erection usually develops within 15 min. ” “There are small urethral pellets available. The patient is taught to put a small pellet into the end of the tube that passes urine and opens at the end of the penis. The medicine is quickly absorbed into the penis to cause an erection, usually within 10-15 min. ” “There are different vacuum devices. Basically, you put your penis into a plastic container. A pump then sucks out the air from the container to create a vacuum. This causes blood to be drawn into the penis and cause an erection. When erect, a rubber band is placed at the base of the penis to maintain the erection. The plastic container is then taken off the penis, and the penis remains erect until the rubber band is removed, which must be removed within 30 min. ” “Sometimes a penile prosthesis may be required. A sur-geon can insert a rod permanently into the penis. The most sophisticated ones can be inflated with an inbuilt pump to cause an erection. The more basic type has to be straightened by hand. ” 8 The Genitourinary System

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238 History and Counseling: Burning Micturition/Urinary Tract Infection (UTI) Candidate Information: A 28-year-old male presents with a burning sensation during urination and urethral discharge. Please take a detailed his-tory. Address the patient's concerns. Vital Signs: HR, 86/min, regular; BP, 120/70  mm Hg; Temp, 36. 8 °C; RR, 18/min; O2 saturation 100% No physical examination is required for this station. Differentials: Urinary tract infection Lower urinary tract infection (cystitis, prostatitis, and urethritis) Sexually transmitted disease (chlamydia, genital herpes, and gonorrhea) Honeymoon cystitis Acute urinary retention Urethral obstruction/stricture/injury Bladder stones/tumors Renal stones Medication related Benign prostatic hyperplasia Cystocele Vulvovaginitis (females) Vaginal changes related to menopause (females) 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 28 years old? How can I help you?” History of Present Illness: Start with questions on burning micturition: -Onset -Course -Duration -Progression -Aggravating -Alleviating-Associated symptoms: Fever Foul or stronger-smelling urine Cloudy or bloody urine Increased urinary frequency or urge to urinate Flank pain -Itching -Burning -Blisters or sore for genital herpes -Abnormal discharge Ask questions about urethral discharge -Color -Amount -Pus in urine -Cloudiness -Consistency Any previous history of similar discharge? Did he get any previous treatment? Constitutional Symptoms: Fatigue, malaise, night sweats, fever, and weight loss Genitourinary Symptoms: “Difficulty in starting or initiating in passing urine?” “Do you have to strain/push hard to pass urine?” “Did you notice a change in stream? How full is the uri-nary stream?” “Did you notice any dribbling? Is there any terminal drib-bling of micturition?” “After passing urine, do you still have the feeling/need to pass more urine?” “How many times do you go to the washroom?” “Do you need to rush/run to the washroom?” “Have you ever lost control?” “Do you have a burning sensation while passing urine or after finishing?” “Is there any hesitancy of micturition?” “Did you notice any change in frequency of passing urine? Increase in urination with or without increased urine output?” “Did you have any painful urination? In the start, during urination, or at the end?” “Do you feel you still want to void after you finish?” Ask about dysuria and possible exposure to sexually transmitted diseases. If the answer is yes, then explore further: -When was the last contact? And with whom? -Single or multiple partners? -Has the partner had any symptom? -Are there any other symptoms? Systemic Review: Just ask a few questions from each sys-tem. This can pick any symptoms that patients may have not mentioned before in the presenting complaint. Some symp-M. H. Sherazi

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

239 toms may be relevant to the diagnosis, such as how back-aches may be associated with kidney stones. GI: Nausea, vomiting, appetite, weight loss, abdominal pain, and bowel routine Cardiovascular system: Chest pain Respiratory system: Cough, shortness of breath, and chest pain Musculoskeletal: Bone point, joint pain, and muscular pain Dermatology: Rashes, ulcers, or lesions Kidney disease: Systemic symptoms of acute kidney injury or chronic kidney disease like anorexia, vomiting, fatigue, pruritus, and peripheral edema Past Medical History: “Do you have any other health issues? Ask about renal disease, renal stones, pyelonephritis, congeni-tal structural abnormality of the genitourinary tract, recurrent cystitis, human papilloma virus (HPV), sexually transmitted infections (STI), human immunodeficiency virus (HIV), dia-betes, hypertension, gout, and history of back injury. Past Hospitalization and Surgical History: “Have you had any previous hospitalization or surgeries?” Medication History: “Are you taking any medications pre-scribed, over the counter, or herbal? If so, have there been any side effects?” Allergic History: “Do you have any known allergies?” Social History: “Do you smoke? Or does anyone else in your home or close proximity at work smoke?” “Do you drink alcohol?” If yes, then ask further ques-tions: “How much? Daily? How long?” “Have you ever tried any recreational drugs? If yes, which ones? How long? When?” Specifically ask about intrave-nous (IV) drug use (red flag for back pain). Family History: Marital status, number of children, any significant history in first-degree relatives. Any family his-tory of chronic kidney or polycystic kidney disease? Foreign Travel: Any recent foreign travel? Relationships: “Are you sexually active? Do you have sex with men, women, or both? Do you have single or multiple partners? Do you use protection?” Self-Care and Living Condition: “What do you do for a living? Working status and occupation? Educational status? Who lives with you?”Support: “Do you have good support from your family and friends?” Functional status or severity or impact on life activities. If a teenager, then add these questions regarding: Home, education, employment, activities, drugs, and sexual activity Wrap-Up: Question:What will you do next? Answer: “I would like to perform a physical examination. ” “I will perform a genital examination. ” “I will get a urine dip test. ” “I will also send urine for analysis and culture. ” “Gram stain and culture of urethral discharge -chlamydia and gonorrhea polymerase chain reaction (PCR). ” Questions: What are the various factors that can increase the chance of developing a UTI? Answer: Advancing age Being a woman Pregnancy Diabetes Question: How will you treat UTI? Answer: “UTIs are usually treated effectively with antibiotics. We can start with the broad-spectrum antibi-otics according to the regional guidelines and can be reviewed once the culture and sensitivity reports come back. ” Question: What is vesicoureteric reflux? Answer: “The most common urinary system condition is vesicoureteric reflux. This means the valve between the blad-der and ureter is not working properly and allows urine to flow back to the kidney, increasing the risk of a kidney infection. ” “Since this disorder tends to run in families, it is impor-tant to screen children as early as possible if a close relative is known to have the problem. ” “Vesicoureteric reflux and the associated infections can scar or permanently damage the kidney. It can also lead to: High blood pressure Toxemia in pregnancy (raised blood pressure, swelling, and protein in the urine of the mother) Kidney failure. ” 8 The Genitourinary System

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240 Question: Are there preventive measures one can take? Answer: “Exclusion from childcare, preschool, school, or work is not necessary. ” “Drink lots of fluids to flush the urinary system. Water is best. ” “Urinate as soon as you feel the need rather than holding on. ” “For women and girls, wipe your bottom from front to back to prevent bacteria from around the anus entering the urethra. ” “Urinate shortly after sex to flush away bacteria that might have entered your urethra during sex. ” “Wear cotton underwear and loose-fitting clothes so that air can keep the area dry. Avoid tight-fitting clothes and nylon underwear, which trap moisture and can help bacte-ria grow. ” “Using a diaphragm or spermicide for birth control can lead to UTIs (in women) by increasing bacteria growth. Unlubricated condoms or spermicidal condoms increase irritation, which may help bacteria grow. Consider switch-ing to lubricated condoms without spermicide or using a non-spermicidal lubricant” [12]. Thank the patient and the examiner. History and Physical Examination: Increase Frequency of Urination Candidate Information: A 47-year-old female presents in your clinic with low energy and increased frequency of urination. Vital Signs: T 36. 6 °C, HR 65, BP 120/70, RR 18, O2 satu-ration 100% Please take a detailed history and perform a relevant physical examination. Please do not perform rectal, genito-urinary, or breast examinations. Differential Diagnosis Diabetes mellitus Diabetes insipidus Psychogenic polydipsia Depression Chronic fatigue syndrome Urinary tract infection -cystitis Hyperthyroidism Diuretics and other drug intake 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... ?” History of Present Illness: “I understand you are here because you have increased fre-quency of urination and low energy. Can you please tell me more about it?” The patient will describe that she has not been feeling well for 2-3 months. She was feeling tired. She also noticed increased urination eight to ten times and increasing day by day. She has to pass urine each night two to three times. She also has increased volume of urine. She denies burning uri-nation or urgency. She has had increased thirst for about 1 month. She has been drinking a lot of water and eating a lot these days. She also has lost 12-14 lb weight over these 3 months. Questions to Cover Increased Frequency of Urination: (Customize the list according to the details already provided by the patient as above. ) Onset. Course. Duration. Progression. Aggravating. Alleviating. Associated symptoms: -Fever -Foul or stronger-smelling urine -Cloudy or bloody urine -Increased urinary frequency or urge to urinate -Flank pain Itching. Burning. Blisters or sore for genital herpes. Abnormal discharge. Ask about the thirst. Ask about daily water intake. Ask questions about urethral discharge: -Color -Amount M. H. Sherazi

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241 -Pus in urine -Cloudiness -Consistency Any previous history of similar discharge? Did she get any previous treatment? Constitutional Symptoms: Fatigue, malaise, night sweats, fever, and weight loss Genitourinary Symptoms: “Difficulty in starting or initiating in passing urine?” “Did you notice a change in the stream? How full is the urinary stream?” “Did you notice any dribbling? Is there any terminal drib-bling of micturition?” “After passing urine, do you still have the feeling/need to pass more urine?” “How many times do you go to the washroom?” “Do you need to rush/run to the washroom?” “Have you ever lost control?” “Do you have a burning sensation while passing urine or after finishing?” “Is there any hesitancy of micturition?” “Did you notice any change in frequency of passing urine? Increase in urination with or without increased urine output?” “Did you have any painful urination? In the start, during urination, or at the end?” “Do you feel you still want to void after you finish?” Ask about dysuria and possible exposure to sexually transmitted diseases. If the answer is yes, then explore further: -When was the last contact? And with whom? -Single or multiple partners? -Has their partner had any symptom? -Are there any other symptoms? A Few Questions About Mood: “I am going to ask you some questions about your mood”: Mood screening-How is his mood these days? Anxiety screening-Is he kind of a 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 actu-ally there? Screen for organic causes: Illnesses, drugs, or alcohol use related. Past Medical History: “Do you have any other health issues?” Ask questions to rule out diagnosis: -Ask about the trauma to head. -Ask about the psychiatric problems. -Ask about the thyroid symptoms (heat/cold intoler-ance, hair loss, constipation/diarrhea, tremors, and sweating). -Ask about renal disease, sexually transmitted infec-tions (STI), diabetes, and hypertension. Past Hospitalization and Surgical History: “Do you have any previous hospitalization? Have you ever undergone any surgery in your past?” Medication History: “Are you taking any medication?” Allergic History: “Do you have any known allergies? Allergies to anesthetics or other drugs?” Family History: “Any family history of chronic medical illnesses? Problems with anesthetics?” Social History: “Do you smoke or does anyone else in your home or around you 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?” Self-Care and Living Condition: “What is your living sit-uation like? Who lives with you? Who will look after you after the surgery? Do you have good family and friends sup-port? Do you need any help? (home services, meals on wheels, social worker). ” Physical Examination: “I would like to perform a physical examination. ” These are the physical examination findings: Patient is in no acute distress. Vitals signs: Within normal limits. Respiratory: Clear breath sounds bilaterally with good air entry. Cardiovascular: Normal S1/S2; no murmurs. Inspect and palpate thyroid: Not palpable. Test muscle power in both upper and lower limbs: Intact. Test sensations in both upper and lower limbs: Intact. Test reflexes in both upper and lower limbs: Intact. Abdomen: Soft, nondistended, and nontender. No hepatosplenomegaly. No mass or hernia. No CV A tenderness. Extremities: No edema. 8 The Genitourinary System

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242 Wrap-Up: Question: What investigations will you order? Answer: “I will order routine blood work-up. Routine tests should include CBC, electrolytes, liver panel, kidney function test, and urine analysis. I will also ask for thyroid profile. ” Wrap up according to the diagnosis and positive findings. Follow-Up: Tell the patient that she will need to come back for a follow- up once all the results will be back. Ask if she has any con-cerns or questions. History and Physical Examination: Uterovaginal Prolapse and Urinary Incontinence Candidate Information: A 48-year-old female who has had four children presents in your clinic complaining of leakage of urine. Vital Signs: T 36. 6 °C, HR 65, BP 120/70, RR 18, O2 satu-ration 100% Please take a detailed history and perform a relevant physical examination. Please do not perform rectal, genito-urinary, or breast examination. Differential Diagnosis: Urinary tract infection Sphincter damage or weakness Delirium Atrophic urethritis/vaginitis Pharmacological Diuretics -Antihypertensives/vasodilators: ACE inhibitors, pra-zosin, labetalol -Bladder relaxants: Anticholinergics, tricyclic antide-pressants (TCAs) -Bladder stimulants: Cholinergics, caffeine -Sedatives: Antidepressants, antihistamines, antipsy-chotics, hypnotics, tranquilizers -Others: alcohol, loop diuretics, lithium Psychological Acute distress Endocrine Hypercalcemia Environmental Unfamiliar surrounding Restricted mobility Stool impaction 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....? Can you confirm your age please?” History of Present Illness: “I understand you are here because you have leakage of urine. Can you please tell me more about it?” She will tell about her symptoms. She is leaking urine while coughing, running, and lifting weights. She needs to wear a diaper at all times. She has been recently avoiding attending any parties or functions. Do not forget to show empathy: “It must be difficult for you to cope. ” Start with questions on incontinence: -Onset: After the birth of her fourth child a few years back -Course: Gradually progressing -Duration -Aggravating: Coughing, lifting weights, running -Alleviating: lying flat Do you see or feel a bulge in your vagina? Ask about the fourth child labor: -Was it a difficult labor? -Was it an assisted labor? -Was it an assisted delivery? -Symptoms of menopause? -Did she have hot flushes? -Did she have painful intercourse? -Does she have recent mood swings? -When was the last Pap smear? -Did she have any previous history of STDs? -“Have you started with mammography?” Associated symptoms: -Fever -Foul or stronger-smelling urine -Cloudy or bloody urine -Increased urinary frequency or urge to urinate -Flank pain -Itching -Burning M. H. Sherazi

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243 -Blisters or sore for genital herpes -Abnormal discharge -Ask questions about urethral discharge: Color Amount Pus in urine Cloudiness Consistency Any previous history of similar discharge? Did she get any previous treatment? -Difficulty in starting or initiating in passing urine? -“Do you have to strain/push hard to pass urine?” -“Did you notice any dribbling? Is there any terminal dribbling of micturition?” -“Do you need to rush/run to the washroom?” -“Have you ever lost control?” -“Do you have a burning sensation while passing urine or after finishing?” -“Is there any hesitancy of micturition?” -“Did you notice any change in frequency of passing urine? Increase in urination with or without increased urine output?” Constitutional symptoms: Fatigue, malaise, night sweats, weight loss Systemic review: Just ask a few questions relevant to patient history. -GI: Nausea, vomiting, appetite, abdominal pain, and bowel routine -Cardiovascular system: Chest pain -Respiratory system: Cough, shortness of breath, and chest pain -Kidney disease: Systemic symptoms of acute kid-ney injury or chronic kidney disease such as anorexia, vomiting, fatigue, pruritus, and peripheral edema Past Medical History: “Do you have any previous health issues?” None. Past Hospitalization and Surgical History: “Have you had any previous hospitalization? Have you ever undergone any surgery in your past?” Medication History: “Are you taking any medication?” Allergic History: “Do you have any known allergies? Allergies to anesthetics or other drugs?” Family History: “Any family history of chronic medical illnesses? Problems with anesthetics?” Social History: “Do you smoke or does anyone else in your home or around you 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?” Self-Care and Living Condition: “What is your living sit-uation like? Who lives with you? Who will look after you after the surgery? Do you have good family and friends sup-port? Do you need any help? (home services, meals on wheels, social worker). ” Physical Examination: “I would like to perform a physical examination. ” These are the physical examination findings: Patient is in no acute distress. Vitals signs: Within normal limits. Respiratory: Clear breath sounds bilaterally with good air entry. Cardiovascular: Normal S1/S2; no murmurs. Abdomen: Soft, nondistended, and nontender. No hepatosplenomegaly. No mass or hernia. No CV A tenderness. Extremities: No edema. Tell the examiner that you need to perform a pelvic examination. The examiner will tell the pelvic examination finding: Grade 4 uterine prolapse with stress incontinence. Wrap-Up: Question: What investigations will you order? Answer: “I will order routine blood work-up, ECG, and chest X-ray. Routine tests should include CBC, electrolytes, liver panel, and kidney function test. Urine analysis and send for cultures. ” Urodynamic Studies: Measure pressure in the bladder and urethra: Urge incontinence: Pressure in bladder increases very fast, reducing bladder capacity. Stress incontinence: Intravesical pressure does not increase when urine fills; bladder capacity is normal. Question: What are the risk factors? UTI Obesity Smoking Caffeine Constipation Chronic cough 8 The Genitourinary System

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244 Multiparity Menopause Question: How will you counsel the patient? Answer: “It looks like you have a condition called stress incontinence. Small amounts of urine involuntarily leaks dur-ing coughing, straining, and laughing. When the urethra (urine tube) is no longer in the pelvis and if there is an increase in intra-abdominal pressure, which affects both bladder and urethra increasing the bladder pressure more than the urethral pressure, it results in involuntary loss of urine. It may occur due to weakening of muscles in the pelvis. ” “There is another condition similar to it called urge incon-tinence in which large amounts of urine leaks through when one wants to go to bathroom but cannot control and hold. It is secondary to a problem with detrusor or nerves. ” “I need to make a management plan for you”: “Stress incontinence is highly associated with UTI, so I would like to order urine microscopy and culture. ” “I would advise you to maintain a bladder diary. ” “Avoid too much physical stress and lifestyle modifica-tion (weight reduction, smoking cessation, decrease caf-feine intake) and avoid constipation and coughing. ” “Start pelvic floor exercises -contract your pelvic mus-cles as if you are lifting your pelvis or holding urine 40-50 times daily for 3 months. ” “I will also refer you to a gynecologist regarding vaginal pessaries. They may consider giving you HRT and uro-dynamic studies but that will be decided upon by the specialist. ” “Surgery will only be indicated if conservative measures fail. Bladder neck suspension, suburethral rings, and local injection of collagen. ” “For urge incontinence, bladder training and anticholiner-gic medications (e. g., oxybutynin) and further referral to a physiotherapist. ” Follow-Up: Tell the patient that she will need to come back once all results will be with you. Ask if she has any concerns or questions. References 1. https://emedicine. medscape. com/article/1947956-technique. Accessed 30 Jan 2018. 2. https://emedicine. medscape. com/article/1947956-periprocedure#b5. Accessed 30 Jan 2018. 3. Simpson KM.  Table manners and beyond: the gynecological exam for women with developmental disabilities and other functional limitations. Oakland: Women's Wellness Project. 2001. http://lurie. brandeis. edu/pdfs/Table Mannersand Beyond. pdf. Accessed 30 Jan 2018. 4. Acevedo R.   Empathic pelvic examination. In: Sulik S, Heath C, editors. Primary care procedures in women's health. New  York: Springer; 2010. p.  27-37. 5. http://www. familydoctor. co. uk/topic/hysterectomy/hysterectomy-examinations-and-test/. Accessed 30 Jan 2018. 6. http://www. empr. com/patient-fact-sheets/benign-prostatic-hyperplasia-bph-patient-information-fact-sheet/article/222387/. Accessed 30 Jan 2018. 7. https://www. mayoclinic. org/diseases-conditions/benign-prostatic-hyperplasia/symptoms-causes/syc-20370087. Accessed 30 Jan 2018. 8. https://www. webmd. com/erectile-dysfunction/guide/drugs-linked-erectile-dysfunction. Accessed 30 Jan 2018. 9. https://www. mayoclinic. org/diseases-conditions/peyronies-dis-ease/symptoms-causes/syc-20353468. Accessed 30 Jan 2018. 10. https://en. wikipedia. org/wiki/Aortoiliac_occlusive_disease. Accessed 30 Jan 2018. 11. https://www. webmd. com/erectile-dysfunction/guide/lifestyle-fac-tors-linked-to-ed. Accessed 30 Jan 2018. 12. http://www. sahealth. sa. gov. au/wps/wcm/connect/public+content/ sa+health+internet/health+topics/health+conditions+preventio n+and+treatment/infectious+diseases/urinary+tract+infection/ urinary+tract+infection+uti+-+including+symptoms+treatment+an d+prevention. Accessed 30 Jan 2018. Further Readings 13. Jugovic PJ, Bitar R, Mc Adam LC.  Fundamental clinical situations: a practical OSCE study guide. Elsevier Saunders, Canada; 2003. 14. Gao Z-H, Ng D.  OSCE & LMCC-II: review notes. Brush Education, Canada; 2009. 15. Essentials of clinical examination handbook. 6th ed. The Medical Society Faculty of Medicine University of Toronto. The Urological Examination, Canada; 2010. p 353-372. 16. Surgery on Call, (LANGE on call) 4th ed. Mc Graw-Hill Education, USA; 2005. 17. Hurley KF.  Chapter 4 genitourinary system. In: OSCE and clinical skill handbook. 2nd ed. Toronto: Elsevier; 2011. p.  120-38. M. H. Sherazi

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245 © 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_9General Surgery and Trauma Mubashar Hussain Sherazi History Overview: General Surgery In most of the Objective Structured Clinical Examination (OSCE), general surgery topics are very important. One can expect at least one scenario related to general surgery. Many times case scenarios are combined with other systems. One common example is an abdominal pain scenario, usually combined with an abdominal examination. General surgery topics such as acute appendicitis, acute cholecystitis, acute diverticulitis, and management of a trauma patient are all very important and frequently repeated in many OSCEs. It is also important to check with your regional and local guidelines about further investigations, management plans, and hospital admission protocols. I also like to recommend to attend Basic Life Support (BLS) and Advance Trauma Life Support (ATLS). These will be required in management of a trauma patient. See Table  9. 1 for an overview of the pattern of history taking required for general surgery. The remainder of the chapter covers common general surgery presentations. Checklist: Physical Examination of the Abdomen See Table  9. 2 for a checklist that can be used as a quick review before the exam. (See also the Gastrointestinal chap-ter for details of the abdominal examination. ) History and Physical Examination: Preoperative Visit Candidate Information: A 65-year-old female is referred to the medical outpatient clinic; she has been booked for a surgical procedure next month. She is here for a complete preoperative checkup in order to assess her readiness for surgery. The purpose of preoperative assessment is to: Identify important health-related problems. Optimize their treatment. Inform the patient about the risks associated with the surgery. Gather further information about hospital stay and post-operative care. Find out the social issues and make a plan for postopera-tive care. 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 attending physician. Are you... ? Can you please confirm your age? How can I help you today?” M. H. Sherazi Mallacoota Medical Centre, Mallacoota, VIC, Australia9

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246 Questions About the Surgery: Patient will mention that she has been booked for (hernia repair/gall bladder removal/breast surgery/bowel resection) next month. The surgical department has referred her for a preoperative assessment. “Is it alright if I ask you a few questions about your surgery?” “Who decided about the indication of surgery?” “How was the decision made?” “Any recent investigation performed? Blood tests, ultra-sound scan (USS), computed tomography (CT) scans, electrocardiogram (ECG), X-rays?” “How are your symptoms now?” “Do you have any immediate concern about it? Requiring pain medication?” “How are you feeling about it?” “Has the consent being taken for surgery?” “Are you aware about the procedure and what to expect on the day of surgery? Where to go and whom to contact?”Table 9. 1 Pattern of history taking for general surgery stations Introduction Name and age Chief complaint In patient's own words History of present illness Analysis of chief complaint Onset Course Duration If pain Nature Intensity (1-10) Location Progression Frequency Quality Radiation Severity (1-10) Timing Contributing factors Aggravating factors Alleviating factors 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, night sweats, fever, and weight loss Review of systems Respiratory Genitourinary Cardiovascular Neurology Impact on body Rule out differential diagnosis Past medical history and surgical history Medical illnesses Any previous or recent medical issues Cancers: breast, thyroid, prostate, kidney History of previous surgery/operation, especially relevant to the area of concern Any related anesthetic/surgical complication? 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 any long-term or specific medical illness Home situation Occupation history What do you do for a living?Table 9. 1 (continued) Social history Smoking Alcohol Street drugs Sexual history If adult female Menstrual history (last menstrual period [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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247 “Do you seek further information regarding your proce-dure?” (risks of procedure/anesthesia) “I am going to ask you a few questions about your general health. ” Past Medical History: “Do you have any previous health issues?” Cardiovascular: -“Angina, coronary artery disease (CAD), arrhythmia, thrombolytic history, angioplasty history, coronary artery bypass grafting, congestive heart failure, periph-eral vascular disease, or valvular heart disease?” -“Have you ever had your blood pressure checked? Hypertension?” -“High cholesterol?” Lungs: -“Do you have any health issues related to your lungs?” (asthma, chronic obstructive pulmonary disease [COPD]) -“Sleep apnea?” -“Recent upper or lower respiratory tract infection?” -“Smoking history?” -“Restrictive lung disease?” (pneumoconiosis) -“Previous blood clots in legs or lungs?” Kidney: -“Renal failure, infections, stones?” Nervous system: -“Upper motor neuron disease, transient ischemic attack (TIA), cerebrovascular accident (CV A), sei-zures, migraine, headache, spinal or head injury, neu-romuscular disorder?” Gastrointestinal: -Reflux -Hepatic disease -Jaundice -Peptic ulcer disease Endocrine: -“Have you ever been screened for diabetes?” -“Thyroid dysfunction?” Hematologic: -“Previous blood transfusion?” -“History of bleeding disorders?” -“Anemia?” Musculoskeletal: -Neck pain -Thoracic pain -Low back pain Dental: -Loose teeth -Use of dentures/permanent or fixed teeth General: -“Recent diagnosis of cancer?” -“Do your wounds heal slower as compared to others?” Past Hospitalization and Surgical History: “Do you have any previous hospitalization?” “Have you ever undergone any surgery in your past?”Table 9. 2 Checklist for the physical examination of the abdomen 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 Check for alert and orientation Look for any abnormal findings in the 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's sign Murphy's sign Courvoisier's sign Liver palpation Spleen palpation Kidney palpation Costovertebral angle (CV A) tenderness Mention “I will next palpate for hernias and groin lymph nodes and perform a digital rectal and vaginal examination” “I will also do a respiratory and cardiovascular examination” (The examiner will provide the findings) Wrap-up Thank the patient and ask the patient to cover up Wrap up your findings with the examiner or the patient 9 General Surgery and Trauma

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248 -“What surgery?” -“How did it go?” -“When was that?” -“Any complication?” (intraoperative or postoperative) -“Any problems related to anesthesia?” -“Requiring prolonged hospital stay?” Medication History: “Are you taking any medication?” If she says no, then con-tinue to the next question. Otherwise ask specifically for aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, medications for hypertension/diabetes, anticoagu-lant, over-the-counter or herbal. Ask about any side effects of these medications. Allergic History: “Do you have any known allergies? Allergies to anesthetics or other drugs?” Family History: “Any family history of chronic medical illnesses? Problems with anesthetics?” Social History: “Do you smoke or does anyone else in your home or around you 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?” Self-Care and Living Condition “What is your living situation like? Who lives with you? Who will look after you after the surgery? Do you have good family and friends support?” “Do you need any help?” (home services, meals on wheels, social worker) Physical Examination: (Go through the examination part. Remember to leave 1-2 min for wrap-up. ) “Now, I will start the examination. ” Comment on the vital sign findings if there are any mentionable findings; otherwise state that vitals are normal. Ask for patient height and weight with body mass index (BMI). Check level of consciousness, alertness, and orientation. General Appearance: Head and neck exam: -Nose-Mouth and throat (limitations to intubation) -Cervical lymph nodes Skin: -Look for any rash Chest examination: -Inspection, auscultation, palpation, and percussion Cardiovascular examination: -Auscultation for heart sounds Abdominal examination: -Inspection. and palpation Wrap-Up: Comment on your findings. Thank the patient and tell the patient to cover up. Ask the patient if she has any questions or concerns. Question: What investigations will you order? (Questions may be asked by the patient or the examiner. ) Answer: “I will order routine blood work-up, ECG, chest X-ray. Routine tests should include complete blood count (CBC), electrolytes, liver panel, kidney function test, and urine analysis. ” Counsel the patient about case-specific risk factors such as: Recent myocardial infarction (MI): Higher chances of heart-related complications during surgery, such as another heart attack, low blood pressure, and death Coagulation problems: Higher risk of bleeding Diabetes and hypertension: Intraoperative and postop-erative complications Smoking: Should be stopped around 8  weeks before surgery Deep vein thrombosis (DVT) prophylaxis: According to nature of surgery Preoperative medication to stop or adjust: Insulin, oral diabetic medications, warfarin, and other anticoagulants Follow-Up: Tell the patient that she will need to come back once all results will be with you. Ask if there are any concerns or questions. History and Physical Examination: Postoperative Fever Candidate Information: You are working in a general surgery unit. The unit nurse called you to attend a 45-year-old female with fever who had a laparoscopic incisional hernia repair 2 days ago. M. H. Sherazi

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249 Please attend the patient. Please do not perform rectal, genitourinary, or breast examinations. Differentials: Postoperative days 0-2: -Atelectasis -Aspiration pneumonia -Wound infection -Intra-abdominal surgical complications; i. e., bowel perforation Postoperative day 3 or more: -Urinary tract infection (UTI) -Wound infection -Intravenous (IV) site infection -Deep venous thrombosis (DVT) -Pulmonary embolism -Abscess 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 Ask for a set of vitals. Comment on temperature. Introduce yourself to the patient. “Good morning/good afternoon. I am Dr.... I am your attending physician. I was told by your nurse that you have a fever. I need to ask you a few questions and then I will do a relevant examination to find out the source of fever. Are you happy for me to begin?” Questions About the Surgery: Ask about the surgery. Abdominal incisional hernia repair “Any operative complication?” (related to anesthesia, intraoperative or postoperative phase -in the recovery room) “How is your pain control? (0-10)” “Were you able to mobilize out of bed or to the toilet?” Review of Systems Pulmonary: -Shortness of breath (Sitting/lying flat) -Chest pain -Cough (sputum/without sputum) -Hemoptysis Wound: -Pain-Redness around wound margins -Bleeding -Discharge -Stitch line hot and tender Urinary: -Catheterization? When was the catheter inserted/ removed? -Change in frequency of urine -Pain while passing urine -Cloudy urine -Blood in urine -Suprapubic discomfort -Previous history of urinary tract infection Deep Venous Thrombosis: -Calf pain and tenderness -History of DVT “I am going to ask a few questions about your general health. ” Past Medical History: “Do you have any previous health issues?” Past Hospitalization and Surgical History: “Do you have any previous hospitalization?” Medication History: “Are you taking any medication?” If she says no, then con-tinue to the next question. Allergic History: “Do you have any known allergies? Allergies to anesthetics?” Family History: “Any family history of chronic medical illnesses?” Social History: “Do you smoke? Do you drink alcohol?” If yes, then ask further questions: “About how much? Daily? How long?” “Have you ever tried any recreational drugs?” If yes, “Which one? How long? When?” Physical Examination: (Go through the examination part. Remember to leave 1-2 min for wrap-up. ) “Now, I will start the examination. ” Comment on the vital sign findings: Mention the high temperature if not done at the start of the interview. Comment on the rest if any other finding such as tachycardia or hypotension. Check level of consciousness, alertness, and orientation. General appearance: a very quick look at head and neck: 9 General Surgery and Trauma

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250 -Nose -Mouth and throat -Cervical lymph nodes Chest examination: -Inspection, auscultation, palpation, and percussion Cardiovascular examination: -Auscultation for heart sounds Abdominal examination: -Inspection, palpation, and auscultation for bowel sounds -Wound and stitch examination Wrap-Up: Comment on your findings. Thank the patient and tell her to cover up. Ask the patient if she has any questions. Question: What will you do first? Answer: If there are no contraindications, I will ask the nurse to give her paracetamol (acetaminophen). Question: What investigations you will order? Answer: “I will check if any recent blood tests have been done. If not done in the postoperative phase, then I will order CBC, electrolytes, liver panel, kidney function test, blood cultures, urine analysis, and a chest X-ray. ” Question: On postoperative day 1, if the patient was found agitated and with decreased concentration, what will be your impression? Answer: Delirium. Question: What if the patient has a persistent spiking fever, diarrhea, and pelvic pain at around days 5-7, what will be your impression? Answer: Pelvic abscess. Question: How will you diagnose an abdominal or pelvic abscess? Answer: CT scan. Question: What is the treatment of pelvic abscess? Answer: “Antibiotics and according to the size and location of the abscess possibly a percutaneous CT/US-guided aspi-ration and placement of drainage catheter. ”Question: What if the patient wants to go home as they were told before the surgery that they will likely go home on day 2? Answer: Tell the patient about your finding and that you would like to keep the patient in the unit while you are trying to find out the cause of her fever. Ask if she has any questions or concerns. History and Physical Examination: Pain Right Lower Quadrant of the Abdomen -Acute Appendicitis Candidate Information: A 22-year-old female presents in your clinic with right-sided lower abdominal pain for 24  h. She is nauseated and has vomited once. Vital Signs: Temp, 37. 9 °C; HR, 100; BP, 120/70; RR, 18; O2 saturation, 98% on RA. Please take a detailed history and perform a relevant physical examination. Please do not perform rectal, genito-urinary, or breast examination. Differential Diagnosis: Adults -Acute appendicitis -Urinary tract infection -Pyelonephritis -Inflammatory bowel disease -Pelvic inflammatory disease -Bowel obstruction -Diverticulitis -Malignancy -Cholecystitis Adult females -Ectopic pregnancy -Ovarian torsion/cyst rupture Children -Intussusceptions -Meckel's diverticulitis -Gastroenteritis -Mesenteric lymphadenitis -Constipation Starting the Interview: Knock on the door. Enter the station. M. H. Sherazi

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251 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 22 years old?” History of Present Illness: “I understand you are here because you have abdominal pain. I am going to ask you a few questions to find out what is going on. Should we start?” “When did this pain start?” It started yesterday afternoon. “Where did the pain start?” Around the belly button. “Has the pain radiated/changed in severity or location?” Worsened and migrated to the right lower quadrant. “What is the pain like?” Dull pain. “How did it come on?” Started suddenly and progres-sively increased. “Does the pain go anywhere?” It started around the belly button and has moved to mostly right lower part of abdomen. “How severe is the pain from 1 to 10? 1 being mild pain and 10 most severe. ” Now it is 7-8. “Does anything aggravate the pain?” Exacerbated by movement and breathing. “Anything that relieves the pain?” Sitting and lying flat. “Have you ever had this pain before?” No. “Have you had any nausea, vomiting, or loss of appetite?” Yes, vomited once. “Are you passing gas?” Yes. “Have you noticed any changes in your bowel habits (blood in stool, diarrhea)?” No. “Any fevers, chills, or night sweats?” Fever. “Recent contact with sick people”: No such contact. “Recent travel?” No. Past Medical History: “Do you have any previous health issues?” None. Past Hospitalization and Surgical History: “Have you ever been hospitalized? Have you ever undergone any surgery? Any complications?” None. Medication History: “Are you taking any medication?” No regular medication. Allergic History: “Do you have any known allergies?” No known allergies. Family History: Noncontributory. Social History: Nonsmoker, does not drink, and no drug use. Gynecology History: Last menstrual period (LMP): 2 weeks back Vaginal discharge/bleeding: None Sexually Active: No. Travel History: None. Physical Examination: Review vital signs with the examiner. Exposure: Stand on the right side of the bed, and tell the patient (indirectly to the examiner), “Miss... I am starting my examination now. During the examination if you feel uncomfortable at any point, please do let me know. ” Position: Supine, arms on the side, legs uncrossed. Observe: Is the patient moving around comfortably? Look for posture, distress, and sweating. Face: Color of the face, pallor, jaundice, plethora, central cyanosis. Mouth: Moist tongue, ulcers, thrush, central cyanosis. Abdominal Examination: Inform the patient: “Now I am going to examine your abdomen. ” Inspection: “Is it alright if I expose your abdomen from the ribs to the waist?” (Please do not expose the breasts or the inguinal area). Drape the patient appropriately for abdominal examination. Observe for contour, umbilicus, abdominal skin, surgical scars, obvious masses, hernias, movements with respira-tion, peristalsis, visible pulsation. Comment if any abnor-mal finding; otherwise move on. Auscultation: Then inform the patient, “I am going to listen to your bowel sounds with my stethoscope. ” Auscultate in at least two quadrants but do not spend too much time on it. Comment on your finding and move on to palpation. 9 General Surgery and Trauma

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252 Palpation: Warm up your hands. Then remember to examine the tender area at the end. (Keep a look at the patient's facial expressions while you are palpating. ) -Superficial/light palpation: Gently palpate each quadrant. Make sure to go through all the areas. -Deep palpation: Again palpate for all four quadrants but this time with deeper palpation. Feel for any tender-ness or a lump/mass. Start from area of least tender-ness. Examine for areas of tenderness or guarding, paying particular attention to Mc Burney's point (located one-third of the distance along a line drawn from the anterior superior iliac spine to the umbilicus). -Rebound tenderness: Check for rebound tenderness in right lower quadrant (RLQ) -present in acute appendicitis -Rovsing's sign: Pain elicited in RLQ with palpation to left lower quadrant (LLQ) -may present in acute appendicitis -Psoas sign: Pain on extension of the right hip (retro- cecal appendix) -may present in acute appendicitis -Obturator sign: Pain on internal rotation of hip (pel-vic appendix) -may present in acute appendicitis -Murphy's sign: Not present -Feel for costovertebral angle tenderness Inform the examiner that, “I will complete my examination by performing an examination for groin hernias, pelvic, digital rectal, cardiovascular, and respiratory system examinations. ” Thank the patient and describe your findings to the examiner. Wrap-Up: Question: What would you like to do now? Answer: “I will order: Some blood tests (CBC, electrolytes, creatinine, liver enzymes, C-reactive protein [CRP]) Urinalysis dip, urine beta-human chorionic gonadotropin (B-h CG) for pregnancy test (very important to rule out pregnancy). CT scan or ultrasound (in children)” Question: What is the diagnosis? Answer: “Acute appendicitis. ” Question: What is the appendix? Answer: “The appendix is a small, worm-shaped pouch 90 mm long that hangs off the first part of the large bowel called the cecum. In our ancestors it was quite large and helped digest cellulose. However, in modern humans it has no particular use; but it can become diseased. ”Question: What is appendicitis? Answer: “Appendicitis is inflammation of the appendix. If it comes on suddenly and is very painful, it is called 'acute appendicitis. ' If it develops slowly and simply hangs around, it is referred to as chronic appendicitis. ” I will draw a picture like this (Fig.  9. 1) for patient ease. Question: What is the cause? Answer: “The inflammation is caused by an infection by bacteria that are normally present in the intestine and the appendix. It is believed to follow a blockage in the appendix such as from a lump of firm feces. The infected appendix gradually swells and becomes filled with pus. ” Question: How common is the problem and who gets it? Answer: “Each year about 1 in 500 people has an attack of appendicitis. It is the most common form of abdominal pain in young people requiring emergency surgery. It affects peo-ple of all ages but is rare in children under 2 years and in older people. It is most common between the ages of 15 and 25; with teenagers being the most commonly affected group” [1 ]. Fig. 9. 1 Location of the appendix relative to other organs of the gastrointestinal system. (William Crochot (US PD picture. ) [Public domain], via Wikimedia Commons) M. H. Sherazi

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253 Question: What is the treatment? Answer: “Once we diagnose someone with acute appendici-tis, we need to arrange early treatment. Because delaying the treatment may lead to a perforated appendix, which can make you very sick. I need to send you to the local hospital and a general surgeon needs to see you. You need to be admitted and your appendix needs to be surgically removed. The operation is called an appendicectomy (or appendec-tomy). It is done as a laparoscopic procedure and is usually a straightforward surgery with little risk of complications. Antibiotics will usually be given for more severe cases with complications. ” History and Physical Examination: Pain Right Upper Abdomen -Acute Cholecystitis Candidate Information: A 42-year-old female presents in your clinic with right-sided upper abdominal pain for 4 h. She is nauseated and has vom-ited once. Vital Signs: Temp, 38. 1 °C; HR, 100; BP, 130/80; RR, 18; O2 saturation, 98% RA. Please take a detailed history and perform a relevant physical examination. Please do not perform rectal, genito-urinary, or breast examination. Differential Diagnosis: Acute cholecystitis Biliary colic Perforation of peptic ulcer Pancreatitis Appendicitis Pneumonia Acute hepatitis Rupture of aortic aneurysm Acute pyelonephritis Bowel obstruction Trauma to chest (rib fracture) 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 42 years old?” History of Present Illness: “I understand you are here because you have abdominal pain. I am going to ask you few questions to find out what is going on. Should we start?” “When did this pain start?” It started about 4 h back. “Where did the pain start?” Right side of upper abdomen, just below the ribs. “What is the pain like?” Sharp, stabbing type of pain and localized. “How did it come on?” Started suddenly and progres-sively increased. I came back from a party where I had a big meal. “Does the pain radiate anywhere?” To the back along the ribs and tip of right shoulder blade. “How severe is the pain from 1 to 10? 1 being mild pain and 10 most severe. ” 7-8. “Does anything aggravate the pain?” Exacerbated by movement and breathing. “Does anything relieve the pain?” Lying flat. “Have you ever had this pain before?” Yes, a few months back. “What did you do at that time?” I took pain medication and the pain settled. “Have you had any nausea, vomiting, or loss of appetite?” Yes, vomited twice -no blood. “Are you passing gas?” Yes. “How are your bowel movements?” Normal as usual. Last one was today in the morning. “Any fevers, chills, or night sweats?” I felt I had a fever but did not check. “Did you notice any change in the color of your skin/ eyes?” No. “Any cough/shortness of breath/urinary problems?” None. “Any other associated symptoms?” None. “Recent contact with sick people?” No such contact. Past Medical History: “Do you have any previous health issues?” Yes, acid peptic disease -treated few years back. Gall stones diagnosed 5 months back. Past Hospitalization and Surgical History: “Have you ever been hospitalized? Have you ever undergone any surgery? Any complications?” No. Medication History: “Are you taking any medication?” No regular medication. 9 General Surgery and Trauma

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254 Allergic History: “Do you have any known allergies?” No known allergies. Family History: Noncontributory. Social History: Nonsmoker, does not drink. No drug use. LMP was 2 weeks ago. Sexual History: Active with husband. No previous history of sexually transmitted disease. Travel History: None. Physical Examination: Review vital signs with the examiner. Vital Signs: T 38. 1, HR 100, BP 130/80, RR 18, O2 saturation 98% RA. Exposure: Stand on the right side of the bed, and tell the patient (indirectly to the examiner) “Miss... I am starting my examination now. During the examination if you feel uncomfortable at any point, please do let me know. ” Position: Supine, arms on the side, legs uncrossed. Observe: Is the patient moving around comfortably? Look for posture, distress, and sweating. Face: Color of the face, pallor, jaundice, plethora, central cyanosis. Mouth: Moist tongue, ulcers, thrush, central cyanosis. Abdominal Examination: Inform the patient: “Now I am going to examine your abdomen. ” Inspection: “Is it alright if I expose your abdomen from the ribs to the waist?” (Please do not expose the breasts or the inguinal area). Drape the patient appropriately for abdominal examination. Observe for contour, umbilicus, abdominal skin, surgical scars, obvious masses, hernias, movements with respira-tion, peristalsis, visible pulsation. Comment if any abnor-mal finding; otherwise move on. Auscultation: Then say, “I am going to listen to your bowel sounds with my stethoscope. ” Auscultate in at least two quadrants but do not spend too much time on it. Comment on your finding and move on to palpation. Palpation: Warm up your hands. Then remember to examine the tender area at the end. (Keep an eye on the patient's facial expressions while palpating. ) -Superficial/light palpation: Gently palpate each quadrant. Make sure to go through all the areas. -Deep palpation: Again palpate for all four quadrants but this time with deeper palpation. Feel for any tender-ness or a lump/mass. Start from area of least tender-ness. Examine for areas of tenderness or guarding, paying particular attention to the right upper quadrant. -Murphy's sign: It is performed by asking the patient to breathe out and then gently palpate the right subcos-tal area and then ask the patient to inspire deeply. If the patient feels pain upon this maneuver and catches her breath, the sign is positive and is a sign of cholecystitis -present. -Boas' sign: Gall bladder pain radiates to the tip of the scapula; there may be an area of skin below the scap-ula, which is hypothetical. This is Boas' sign -may be present [2]. -Rebound tenderness: Check for rebound tenderness in right upper quadrant (RUQ) -none. -Rovsing's sign: Pain elicited in RLQ with palpation to LLQ -none. -Psoas sign: Pain on extension of the right hip (retroce-cal appendix) -none. -Percuss for liver span. Auscultate the lungs. Inform the examiner that “I will complete my examina-tion by performing examination for hernias, pelvic, digital rectal, cardiovascular, and respiratory system examination. ” Thank the patient and describe your findings to the examiner. Wrap-Up: Question: What would you like to do now? Answer: “I will order: Some blood tests (CBC, electrolytes, creatinine, liver enzymes, and lipase) Urinalysis dip, urine B-h CG for pregnancy test (very important to rule out pregnancy) Ultrasound abdomen” Question: What is the diagnosis? Answer: “Acute cholecystitis. ” Question: What is the function of the gallbladder? Answer: “The gallbladder functions to store and concentrate bile made by the liver during periods of fasting. In response to food, the gallbladder contracts and releases bile into the duodenum. ” Question: What is the difference between biliary colic and cholecystitis? Answer: “Biliary colic is the transient obstruction of the cystic duct by gallstones leading to pain lasting for several hours. Cholecystitis is dilation and inflammation of the gall-bladder that results from gallstones being impacted at the neck of the gallbladder, obstructing the cystic duct. ” Question: How common are gallstones? Answer: “Gallstones are present in 10-40% of the general population. The majority of patients with gallstones remain M. H. Sherazi

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255 asymptomatic over their lifetime. Risk factors for gallstones include female sex, obesity, pregnancy, terminal ileal resec-tion, gastric surgery, and Crohn's disease. ” Question: What are signs of cholecystitis on ultrasound? Answer: “Pericholecystic fluid, gallbladder wall thickening, stone impaction, gallbladder distension, sonographic Murphy's sign. ” Question: What is the treatment? Answer: “Once we diagnose someone with cholecystitis, IV antibiotics covering gram-negative aerobes and anaerobic bacteria should be started. Patient needs to be referred to general surgery for a laparoscopic cholecystectomy. It should be performed within 2-3 days of diagnosis. ” History and Counseling: Pain Left Lower Quadrant -Acute Diverticulitis Candidate Information: A 65-year-old female presents to the emergency department with a history of left lower quadrant pain for 2 days. The pain is now getting worse. She feels nauseous but is not vomiting. She has had a fever and abdominal distension. Vital Signs: Temp, 38. 9 °C; HR, 105; BP, 150/85; RR, 18; O2 saturation, 99%. Please take a detailed history and perform a relevant physical examination. Please do not perform rectal, genito-urinary, or breast examination. Differential Diagnosis Diverticulitis Diverticular abscess Constipation with obstruction Perforated bowel Bowel obstruction (adhesion/volvulus/incarcerated hernia) Bowel cancer with obstruction/perforation Inflammatory bowel disease (Crohn's disease or ulcer-ative colitis) Mesenteric ischemia Aortic dissection Musculoskeletal injury Pelvic inflammatory disease Ovarian torsion/mass Uterine mass Renal colic 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 65 years old?” History of Present Illness: “I understand you are here because you have abdominal pain. I am going to ask you a few questions to find out what is going on. Should we start?” “When did this pain start?” It started about 2 days back. “Where did the pain start?” Left side of lower abdomen. “Has the pain changed in severity or location?” Worsened and progressively increasing in intensity. “What is the pain like?” Sharp pain. “How did it come on?” Started suddenly and progres-sively increasing. “Does the pain go anywhere?” The pain is mostly in the left lower abdomen but it is going to all of the lower abdomen. “How severe is the pain from 1 to 10? 1 being mild pain and 10 most severe. ” Now it is 9. “Does anything aggravate the pain?” Exacerbated by movements. “Any relationship with food?” None. “Does anything relieve the pain?” Lying flat. “Have you ever had this pain before?” No. “Have you had any nausea, vomiting, or loss of appetite?” I have nausea but no vomiting. “Are you passing gas?” Yes. “Have you noticed any changes in your bowel habits (blood in stool, diarrhea)?” None but the abdomen felt distended. “Appetite?” Poor. “Any fevers, chills, or night sweats?” Fever, 39. 2 yester-day. Today felt hot, feverish and sweaty. “Recent contact with sick people?” No such contact. “Recent travel?” No. “Any recent trauma?” None. Past Medical History: “Do you have any previous health issues?” None Past Hospitalization and Surgical History: “Have you ever been hospitalized? Have you ever undergone any surgery? Any complication?” None. Medication History: “Are you taking any medication?” No regular medication. 9 General Surgery and Trauma

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

256 Allergic History “Do you have any known allergies?” No known allergies. Family History: Noncontributory. Social History: Nonsmoker, nondrinker, and no drug use. Gynecology History: Menopausal for 15  years. All Pap smears normal. Two children born via normal vaginal deliveries. Vaginal discharge/bleeding: None. Sexually Active: Yes, with husband. Married for 35 years. Travel History: None. Physical Examination: Review vital signs with the examiner. Mention patient has a fever of 38. 9 °C and tachycardia 105. Exposure: Stand on the right side of the bed, and tell the patient (indirectly to the examiner), “Miss... I am starting my examination now. During the examination if you feel uncomfortable at any point, please do let me know. ” Position: Supine, arms on the side, legs uncrossed. Observe: Is the patient moving around comfortably? Look for posture, distress, and sweating. Face: Color of the face, pallor, jaundice, plethora, central cyanosis. Mouth: Moist tongue, ulcers, thrush, central cyanosis. Abdominal Examination: Inform the patient: “Now I am going to examine your abdomen. ” Inspection: “Is it alright if I expose your abdomen from the ribs to the waist?” (Please do not expose the breasts or the inguinal area). Drape the patient appropriately for abdominal examination. Observe for contour, umbilicus, abdominal skin, surgical scars, obvious masses, hernias, movements with respira-tion, peristalsis, visible pulsation. Comment if any abnor-mal finding; otherwise move on. Auscultation: Then say, “I am going to listen to your bowel sounds with my stethoscope. ” Auscultate in at least two quadrants but do not spend too much time on it. Comment on your finding and move on to palpation. Palpation: Warm up your hands. Then remember to examine the tender area at the end. Keep an eye on the patient's facial expressions as you palpate the abdomen. -Superficial/light palpation: Gently palpate each quadrant. Make sure to go through all the areas.-Deep palpation: Again palpate for all four quadrants but this time with deeper palpation. Feel for any ten-derness or lump/mass. Start from area of least tender-ness (right side in this station). Examine for areas of tenderness or guarding, paying particular attention to the left lower abdomen. -Tenderness, guarding, and rigidity -present in LLQ. -Rebound tenderness: Check for rebound tenderness in LLQ -present in acute diverticulitis -In some patients, on a careful palpation, a palpable ten-der sausage-shaped mass in the left iliac fossa may be felt. -Murphy's sign: Not present Inform the examiner that “I will complete my examina-tion by performing examination for hernias, pelvic, digital rectal, cardiovascular, and respiratory system examination. ” Thank the patient and describe your findings to the examiner. Wrap-Up: Question: What would you like to do now? Answer: “I will order some blood tests (CBC, electrolytes, creatinine, liver enzymes, blood cultures, CRP) and urinaly-sis. CT scan abdomen and pelvis. ” Question: CT reported as acute diverticulitis, what is your next step of management? Answer: “I will explain to the patient about the findings. I will place IV lines and will start IV antibiotics. I will call general surgery to come and review the patient for further management. ” Question: What is the difference between diverticulosis and diverticulitis? Answer: “Diverticuli are fingerlike outpouching from the wall of the bowel—usually multiple. The etiology is unknown but most likely due to chronic constipation and low-fiber diet. Because of constipation, hard stools put pres-sure on the wall weakening it and leading to outpouching known as diverticuli. Mostly, they are asymptomatic, but sometimes the stools can get blocked in the pouches and become a good media for the bacteria leading to inflamma-tion called diverticulitis. The symptoms are fever, abdominal pain, and rectal bleeding. ” Question: What are the complications of diverticulitis? Answer: “There can be some complications like abscess, perforation, peritonitis, and fistula formation. ” M. H. Sherazi

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

257 Question: Can it cause cancer? Answer: “Let me reassure you that it is not a pre-malignant condition. ” Question: What is the management plan for diverticulosis? Answer: Pain medication and sometimes antispasmodics are used. Stool softeners for constipation. High-fiber diet is recommended: fruits, vegetables, fluids, cereals, and bran. “You may experience bloating and discomfort, but your body will get used to it. ” Screening colonoscopy after acute episode. Question: Does the patient require surgery for diverticulosis? Answer: “No. Surgery is only recommended when a patient presents with complications of diverticulitis such as bleed-ing, abscess (if not responding well to drainage and antibiot-ics), perforation, or severe bleeding. ” Management: Epigastric Pain (Perforated Peptic Ulcer/Pancreatitis) Candidate Information: You are working in a busy emergency department. Your next patient is a middle-aged man who came in with sudden-onset severe epigastric pain for 3 h. He has been in good health apart from the history of taking ibuprofen 400 mg BD for back pain. Please manage this patient. There will be a nurse at bed-side to help you with any orders. The examiner will give you any findings if required during the management. Differentials: Esophagitis Acute/chronic gastritis Peptic ulcer disease *Perforated peptic ulcer Gastroesophageal reflux disease *Acute pancreatitis Acute cholangitis Biliary colic *Acute cholecystitis Cholelithiasis Inflammatory bowel disease Viral hepatitis Acute coronary syndrome*Important for this station. 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... ? How old are you? What brings you here today?” History of Present Illness: The patient will briefly tell you about his sudden onset of severe epigastric pain and will be moaning with pain. It is extremely important to address the patient's pain at this point. “I can see that you are in pain. I need to ask you a few questions to find out why you have this severe pain. It will also help me to give you appropriate pain medication. We have a nurse here; she will help me with your management. Is it alright if we start?” “When did this pain start?” It started about 3 h back. “Where did the pain start?” Midline in the stomach area. “Has the pain changed in severity or location?” Worsened and progressively increasing in intensity. “What is the pain like?” Sharp pain. “How did it come on?” Started suddenly and it is progres-sively increasing. “Does the pain go anywhere?” It was going to my spine and now it has spread all over the abdomen. “How severe is the pain from 1 to 10? 1 being mild pain and 10 most severe. ” Now it is 9. “Does anything aggravate the pain?” Exacerbated by movements. “Any relationship with food?” None. “Does anything relieve the pain?” Lying flat. “Have you ever had this pain before?” No. “Have you had any nausea, vomiting, or loss of appetite?” I have nausea, but no vomiting. “Are you passing gas?” Yes. “Have you noticed any changes in your bowel habits (blood in stool, diarrhea)?” None. “Appetite?” Poor. “Any fevers, chills, or night sweats?” None. Feel sweaty now. “Any recent trauma?” None. Questions to Rule Out Differentials: “Nausea and vomiting?” 9 General Surgery and Trauma

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258 “Change in bowel habits?” “Have you lost weight recently?” “Melena (sticky, black, dark, tarry stools)? When was your last bowel movement? Color?” Explore about liver problems. Use of NSAIDs (ibuprofen): “How much? How long? Why? Who prescribed?” “Any blood thinners?” “Any long-term disease?” Past Medical History: “Peptic ulcer disease? Ever had a scope? Pancreatitis?” Past Hospitalization and Surgical History: “Have you had any previous hospitalization or previous surgery?” Medication History: “Are you taking any medication, over-the-counter or herbal, and are there any side effects?” Allergic History: “Do you have any known allergies?” Family History: “Any family history of significant health problems?” Social History: “Do you smoke or does anyone else in your home or close proximity 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 one? How long? When?” Physical Examination: Ask the nurse to give you a set of vitals. Blood pressure lying and standing to check for orthostatic changes. Review vital signs with the examiner. Vital Signs: T 38. 1, HR 107, BP 100/70, RR 18, O2 saturation 98%. Exposure: Stand on the right side of the bed, and tell the patient (indirectly to the examiner), “Mr... I am starting your examination now. During the examination if you feel uncomfortable at any point, please do let me know. ” Position: Supine, arms on the side, legs uncrossed. Observe: Is the patient moving around comfortably? Look for posture, distress, and sweating. Face: Color of the face, pallor, jaundice, plethora, central cyanosis. Mouth: Tongue, ulcers, thrush, central cyanosis. Abdominal Examination: Inspection: “Is it alright if I expose your abdomen from the ribs to the waist?” (Please do not expose the breasts or the inguinal area). Drape the patient appropriately for abdominal examination. Observe for contour, umbilicus, abdominal skin, surgical scars, obvious masses, hernias, movements with respira-tion, peristalsis, visible pulsation. Comment if any abnor-mal finding; otherwise move on. Auscultation: Then say. “I am going to listen to your bowel sounds with my stethoscope. ” Auscultate in at least two quadrants but do not spend too much time on it. Comment on your finding and move on to palpation. Bowel sounds absent or decreased. Palpation: Warm up your hands. Then remember to examine the tender area at the end. Keep an eye on the patient's facial expressions while you palpate. -Superficial/light palpation: Gently palpate each quadrant. Make sure to go through all the areas. -Deep palpation: Again palpate for all four quadrants but this time with deeper palpation. Feel for any ten-derness or lump/mass. Start from area of LLQ, exam-ine for areas of tenderness or guarding. Patient will be tender all over abdomen. There will be muscle guard-ing. Patient may not let you elicit any abdominal exam-ination signs due to generalized pain. Examiner may give the findings: Abdomen is distended, tender all over, and resonant note on percussion. “Mr... I am suspecting that you might have perforated an ulcer from your stomach. I am going to start the management now. ” Ask the nurse to put 2 × IV line and draw blood for: -CBC -Urea and creatinine -Lipase -Electrolytes -Blood sugar -Cardiac enzymes -Venous blood gas -Blood for group and hold Attach monitors Nothing to eat and drink Start IV fluids (normal saline 0. 9%) IV morphine or fentanyl for pain ?IV Pantoprazole infusion Order: X-ray erect abdomen/X-ray left lateral decubitus abdominal or CT abdomen if readily available. Question: What will you be looking for in the X-ray? Answer: “I shall be looking for air under the diaphragm. ” Question: Examiner may show an X-ray showing air under the diaphragm or verbally tell the findings. What will be your next step in management? Answer: “I will inform the patient about my findings”: M. H. Sherazi

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259 “In my opinion, you have a condition called acute abdo-men, which is most likely due to a perforated peptic ulcer due to a history of taking ibuprofen. The perforation occurs when the ulcer erodes through the wall of the stomach or duodenum. Gastric or duodenal contents spill out into the peritoneum and that can cause complications such as infec-tion and peritonitis. I am going to consult general surgery. They will come and assess you. It looks like you are requir-ing an urgent surgery. The surgeon will decide whether to perform an open or keyhole (laparoscopic) surgery. Usually they use an omental patch to fix the perforation; they will give you more information. Do you want me to inform any-one on your behalf?” Question: What if there is no air under the diaphragm and the serum lipase levels are high? Answer: “Then my diagnosis will likely be acute pancreatitis. ” Question: What is the pancreas? Answer: “The pancreas is an important organ that lies just behind the stomach and intestines in the abdomen. It produces digestive juices that digest carbohydrates, fats, and proteins in food. This process helps in absorption of food through the intestine. It also produces hormones such as insulin and glucagon, which regulate blood sugar in our bod-ies. A deficiency of insulin leads to diabetes. ” Question: What is acute pancreatitis? Answer: “Pancreatitis is inflammation of the pancreas. Acute pancreatitis develops rapidly, and the patient presents with sudden onset of severe upper abdominal pain, radiating to the back, that is eased by sitting forward; it may be associ-ated with repeated vomiting or retching. The patient may have a low-grade fever and tachycardia with hypotension. On examination the patient will have epigastric tenderness, guarding, and decreased or absent bowel sounds. ” Question: You just diagnosed your patient with acute pancreatitis, what will be your next steps in management? Answer: I will ask about the risk factors including alcohol, gallstones, viruses (mumps), trauma, or recent ERCP (endo-scopic retrograde cholangiopancreatography). Initial management will be: IV lines, routine blood tests, blood gas analysis Fluid resuscitation Pain medication Nothing to eat and drink/NG tube in severe cases CT scan of the abdomen General surgery consultation and admission to hospital “If secondary to gallstones, then removal of gallbladder once pancreatitis has settled down. Usually settles with no permanent pancreatic tissue damage. ” “At times it can make the patient very sick. If the inflam-mation persists, it may develop into chronic pancreatitis in which the patient will likely have recurrent episodes of pan-creatitis and the pancreas will be scarred and damaged. ” “The patient may present with abdominal or back pain, often associated with meals. The pain is aching or dull. Some patients may not even have any pain. Other symptoms will be nausea and vomiting, mild jaundice, weight loss, and typi-cal greasy bulky stools, which is called steatorrhea. Once the pancreas is unable to make insulin, diabetes develops. Treatment will be insulin by injection and oral pancreatic enzymes replacements. ” Management: Severe Abdominal Pain (Mesenteric Infarction) Candidate Information: You are working in an emergency department and are attend-ing a 68-year-old man who came in with a sudden onset of severe generalized abdominal pain for 3 h. He has been hav-ing bloody diarrhea, nausea, and vomited a few times. He has a history of atrial fibrillation. Please manage this patient. There will be a nurse at the bedside to help you with any orders. The examiner will give you any findings if required during the management. Differentials: Mesenteric infarction/ischemia Small bowel obstruction (adhesions) V olvulus Acute diverticulitis Perforated peptic ulcer Acute pancreatitis Acute cholecystitis Inflammatory bowel disease Acute coronary syndrome 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. 9 General Surgery and Trauma

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

260 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... ? Can you please confirm your age? What brings you here today?” History of Present Illness: The patient will briefly tell you about his sudden onset of severe generalized abdominal pain and will ask for pain medication. It is extremely important to address the patient's pain here. “I can see that you are in pain, I need to ask you a few questions to find out why you have this severe pain. It will also help me to give you the appropriate pain medica-tion. We have a nurse here; she will help me with your man-agement. Is that alright?” “When did this pain start?” It started about 3 h back. “Where did the pain start?” Midline around the belly but-ton, but now all over the abdomen. “Has the pain changed in severity or location?” Worsened and progressively increasing in intensity. “What is the pain like?” Sharp cutting pain like a knife cutting through. “How did it come on?” Started suddenly and is progres-sively increasing. “Does the pain go anywhere?” It was going to my spine and now it has spread all over the abdomen. “How severe is the pain from 1 to 10? 1 being mild pain and 10 most severe. ” Now it is 9. “Does anything aggravate the pain?” Exacerbated by movements. “Any relationship with food?” None. “Does anything relieve the pain?” Nothing, it is the same. “Have you ever had this pain before?” No. “Have you had any nausea, vomiting, or loss of appetite?” I had nausea and vomited three times, (just food contents, no blood). “Please tell me about your diarrhea. ” Three to four times, loose and with crampy abdominal pain. Fresh blood -about 50 ml in quantity. No black tarry, sticky stool. “Are you passing gas?” Yes. “Have you noticed any changes in your bowel habits (blood in stool, diarrhea)?” Fresh blood in stool. “Appetite?” Poor. “Any fevers, chills, or night sweats?” None. Feel sweaty now. “Any recent trauma?” None. Questions to Rule Out Differentials: “Change in bowel habits?” “Have you lost weight recently?” Explore about liver problems. “Use of NSAIDs?” “Any long-term disease?” Past Medical History: “I understand that you have atrial fibrillation? How long have you been having AF? What medications are you taking for the AF? Have you been followed up by your family physi-cian or the community coagulation clinic? Do you have any other condition apart from the AF?” AF for 6-7 years. Past Hospitalization and Surgical History: “Do you have any previous hospitalization or previous surgery?” Medication History: “Are you taking any medication, over-the-counter or herbal, and any side effects?” Aspirin and digoxin. Allergic History: “Do you have any known allergies?” Family History: “Any family history of significant health problems?” Social History: “Do you smoke or does anyone else in your home or close proximity at work smoke? Do you drink alcohol?” If yes then ask further questions: “How much? Daily? How long?” Smoker: ten cigarettes per day for 10 years. “Have you ever tried any recreational drugs?” If yes, “Which one? How long? When?” Physical Examination: Ask the nurse to give you a set of vitals. Blood pressure lying and standing to check for orthostatic changes. Review vital signs with the examiner. Vital Signs: Temp 37. 3, HR 107, BP 120/70, RR 18, O2 saturation 98%. Exposure: Stand on the right side of the bed, and tell the patient (indirectly to the examiner) “Mr..., I am starting your examination now. During the examination if you feel uncomfortable at any point, please do let me know. ” Position: Supine, arms on the side, legs uncrossed. Observe: Is the patient moving around comfortably? Look for posture, distress, and sweating. Face: Color of the face, pallor, jaundice, plethora, central cyanosis. Mouth: Tongue, ulcers, thrush, central cyanosis. Abdominal Examination: Inspection: “Is it alright if I expose your abdomen from the ribs to the waist?” (Please do not expose the breasts or the inguinal area). Drape the patient appropriately for abdominal examination. M. H. Sherazi

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

261 Observe for contour, umbilicus, abdominal skin, surgical scars, obvious masses, hernias, movements with respira-tion, peristalsis, visible pulsation. Comment if any abnor-mal finding; otherwise move on. Auscultation: Then say, “I am going to listen to your bowel sounds with my stethoscope. ” Auscultate in at least two quadrants but do not spend too much time on it. Comment on your finding and move on to palpation. (Absent or decreased) Palpation: Warm up your hands. Keep an eye on your patient's facial expressions as you palpate the abdomen. -Superficial/light palpation: Gently palpate each quadrant. Make sure to go through all the areas. -Deep palpation: Again palpate for all four quad-rants but this time with deeper palpation. Feel for any tenderness or lump/mass. Start from area of LLQ, examine for areas of tenderness or guarding. Abdomen will be distended. There will be tender-ness all over the abdomen more in the central abdo-men. There will be muscle guarding. Patient may not let you elicit any abdominal test due to generalized tenderness. Examiner may give the findings: Abdomen is distended, tender all over. Absent bowel sounds. Fresh blood on digi-tal rectal examination. “Mr..., I am suspecting that you might have a condition called mesenteric infarction. I am going to start the manage-ment now. ” Ask the nurse to put 2 × IV line and draw bloods for CBC Urea and creatinine S. lipase Electrolytes Blood sugar Cardiac enzymes Venous blood gas (check for lactate level) Blood for group and hold Attach monitors. Nothing to eat and drink Start IV fluids (normal saline 0. 9%) IV morphine or fentanyl for pain X-ray erect abdomen (look for thumbprint sign) Question: How will you counsel your patient about mes-enteric infarction? What will be your next step in management? Answer: “Mesenteric ischemia occurs when the blood sup-ply of your bowel has been cut off due to the blockage of one of its arteries. This might have resulted from a clot that has traveled from the heart because of your atrial fibrillation. This is a medical emergency. We need to admit you. ” “I will call general surgery to come and assess you. They may decide to do CT angiography of the mesenteric artery if they think they have enough time, but if they believe it is urgent, they might do surgery to open up the blockage as soon as possible to avoid infarction of the affected tissue. During the surgery, if they find that the part of the gut has been affected and no longer viable, they might remove that part. ” “Do you want me to inform anyone on your behalf?” Management: Bowel Obstruction Candidate Information: You are working in a busy emergency department. The nurse has asked you to see a new patient who is a 68-year-old man. He has had generalized abdominal pain for 2 days. He has been having nausea and vomiting. He has not passed any bowel movement for 3 days. Please manage this patient. The examiner may give you required information such as blood results. Differentials: Small bowel obstruction -Adhesions -Hernias -Stricture -Small or large bowel tumors -Gallstone ileus -V olvulus Mesenteric infarction/ischemia Acute diverticulitis Perforated peptic ulcer Ogilvie's syndrome Intussusception Acute pancreatitis Acute cholecystitis In female patients only: Endometriosis, ovarian or uterine tumors 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... ? Can you con-firm your age please? What brings you here today?” 9 General Surgery and Trauma

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

262 History of Present Illness: The patient will briefly tell you about his gradual onset gen-eralized abdominal pain, nausea, and vomiting. Please try to cover all three presenting symptoms (abdom-inal pain/vomiting/no bowel movement) with a minimum set of questions: “When did this pain start?” It started about 2 days back. “Where did the pain start?” Midline around the belly but-ton but now all over the abdomen. “Has the pain changed in severity or location?” Worsened and progressively increasing in intensity. “What is the pain like?” Dull and diffuse pain. Comes and goes and is burning in nature. “How did it come on?” Started gradually and is progres-sively increasing. “Does the pain go anywhere?” It was mostly in umbilical area. No particular radiation. “How severe is the pain from 1 to 10? 1 being mild pain and 10 most severe. ” Now it is 7. “Does anything aggravate the pain?” Exacerbated by movements. “Any relationship with food?” None. “Does anything relieve the pain?” Nothing, it is the same. “Have you ever had this pain before?” No. “Have you had any nausea, vomiting, or loss of appetite?” I had nausea and vomited six times (last two vomit con-tain just bile -no blood). “When was your last bowel movement?” About 3  days back. Bowel moments were regular before that. No black tarry, sticky stool “Are you passing gas?” None (and felt that he was bloated). “Appetite?” Poor. “Any fevers, chills, or night sweats?” None. (May have low-grade fever) “Any recent trauma?” None. Questions to Rule Out Differentials: “Change in bowel habits?” -Constipation/obstipation -Change in frequency -Tenesmus -Caliber of stool -Flatulence -Melena “Have you lost weight recently?” “Any long-term disease?” Past Medical History: “Do you have any previous health issues?” None. Past Hospitalization and Surgical History: “Have you ever been hospitalized? Have you ever undergone any surgery?” Yes, laparotomy and resection of bowel due to a tumor in the small intestine 2 years back. He was doing quite well since his surgery. Medication History: “Are you taking any medication?” No regular medication. Allergic History: “Do you have any known allergies?” No known allergies. Family History: Noncontributory. Social History: Nonsmoker, nondrinker, and no drug use. Physical Examination: Ask the examiner for a set of vitals. Blood pressure lying and standing to check for orthostatic changes. Review vital signs with the examiner. Vital Signs: T 37. 3, HR 107, BP 120/70, RR 18, O2 saturation 98%. Exposure: Stand on the right side of the bed, and tell the patient (indirectly to the examiner), “I am starting your examination now. During the examination if you feel uncomfortable at any point, please do let me know. ” Position: Supine, arms on the side, legs uncrossed. Observe: Is the patient moving around comfortably? Look for posture, distress, and sweating. Face: Color of the face, pallor, jaundice, plethora, central cyanosis. Mouth: Tongue, ulcers, thrush, central cyanosis. Abdominal Examination: Inspection: “Is it alright if I expose your abdomen from the ribs to the waist?” (Please do not expose the breasts or the inguinal area). Drape the patient appropriately for abdominal examination. Observe for contour, umbilicus, abdominal skin, surgical scars, obvious masses, hernias, movements with respira-tion, peristalsis, visible pulsation. Comment if any abnor-mal finding; otherwise move on. Auscultation: Then say “I am going to listen to your bowel sounds with my stethoscope. ” Auscultate in at least two quadrants but do not spend too much time on it. Comment on your finding and move on to palpation. (Absent or decreased) Palpation: Warm up your hands. Keep an eye on the patient's facial expressions while palpating. -Superficial/light palpation: Gently palpate each quadrant. Make sure to go through all the areas. M. H. Sherazi

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

263 -Deep palpation: Again palpate for all four quadrants but this time with deeper palpation. Feel for any ten-derness or lump/mass. Start from area of LLQ, exam-ine for areas of tenderness or guarding. Abdomen will be distended. There will be mild tenderness all over the abdomen more in the central abdomen. There will be muscle guarding. Patient may not let you elicit any abdominal test due to generalized tenderness. -Tell the examiner what you will look for. Examiner may give the findings: Abdomen is distended, tender all over. Absent bowel sounds. “Mr..., I am suspecting that you might have a condition called a bowel obstruction. I am going to start the manage-ment now. ” Ask the nurse to put 2 × IV line and draw blood for: -CBC -CRP -Urea and creatinine -S. lipase -Electrolytes -Blood sugar -Cardiac enzymes -Venous blood gas (check for lactate level) -Blood for group and hold Attach monitors. Nothing to eat and drink. Nasogastric tube Start IV fluids (normal saline 0. 9%) and correct fluids/ electrolyte balances. IV morphine or fentanyl for pain X-ray erect abdomen (dilated loops of small and or large bowel with air fluid levels sign) Question: How will you counsel your patient about bowel obstruction? What will be your next step in management? Answer: “This is a surgical emergency. We need to admit you. I will call general surgery to come and assess you. They may decide to do a CT scan of your abdomen and pelvis, and they might do surgery to open up the blockage as soon as possible to avoid infarction of the affected tissue. During the surgery, if they find that the part of the gut has been affected and no longer viable, they might remove that part. ” “Do you want me to inform anyone on your behalf?” History and Examination: Breast Lump Candidate Information: A 45-year-old female comes in to your clinic. She noticed a small lump in her right breast a few days back while taking a shower. Please take a focused history and perform a relevant physical examination. Differentials: Fibroadenoma of the breast Intraductal papilloma Mammary dysplasia Fat necrosis Fibrocystic disease Breast abscess Breast 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 attend-ing physician for today. Are you... ? Can you please confirm your age? What brings you here today? History of Present Illness: “When did you notice the lump?” “How did you notice it the first time?” “How many lumps?” “Was it present before that?” “Which part of breast is it?” (Quadrant, distance from nipple) Physical features: “What is the shape of lump?” (Round, oval) Consistency: “What does it feel like?” (Soft, rubbery, or hard) Border: “Does it have well-defined edges or ill defined?” Mobility: “Can you move it under the skin or is it fixed?” Delineation: “Discrete or fixed?” Relation to menstrual cycle: “Did you notice any change in size or shape of the lump during menstrual cycle? Any pain during menstrual cycle?” 9 General Surgery and Trauma

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264 Pain and tenderness: “Was there any pain in the lump or breast? One breast or both breasts?” “Any history of breast trauma?” Nipple discharge: “Did you notice any nipple discharge?” (amount, color, smell) Nipple retraction: “Did you notice any nipple retraction?” Breast skin changes: -“Did you notice any change in skin over the swelling or in the breast?” (discoloration, induration, erythema, or dimpling) -Change in texture (peau d'orange) -Signs of inflammation on skin of breast (redness, pain, hot) “Any recent change in size of breast?” “Did you notice any lump or swelling in the axilla?” “Any swelling in the arms?” Constitutional symptoms: fatigue and malaise, night sweat, fever, and weight loss Risk Factors: “Past history of breast cancer?” “Family history of breast cancer/ovarian cyst?” “Previous breast biopsy?” “Age of menarche?” “Last menstrual cycle?” “Nulliparity?” “Children?” “Age of firstborn?” “Radiation exposure?” Signs of Metastasis: Brain: headache, vision changes, nausea, or vomiting Liver: jaundice Bone: pain Lungs: shortness of breath, cough, blood in sputum “Did you ever have a mammogram? When was the last mam-mogram performed?” Past Medical History: “Do you have any previous health issues?” Past Hospitalization and Surgical History: “Have you ever been hospitalized? Have you ever undergone any surgery?” Medication History: “Are you taking any medication?” Allergic History: “Do you have any known allergies?”Family History: “Cancer (breast, colon, ovary)?” Social History: Smoking, alcohol intake, and illicit drug history Menstrual, Gynecology, and Obstetric History: “When did you start your sexual activity?” “Are you sexually active now?” “Any Pap smears at all? Was it a normal smear last time?” “Any bleeding, itching, pain, discharge, previous sexually transmitted disease (STD), warts, ulcers, lumps, bumps?” “Have you ever been pregnant? How many times?” “Did you breast feed your children?” “When was your LMP?” “Was it regular? Period, cycle?” “Do you think that you are pregnant right now?” Physical Examination: Review vital signs with the examiner. Vital Signs: T 36. 3, HR 75, BP 130/70, RR 16, O2 saturation 98%. Stand on the right side of the bed, and tell the patient (indirectly to the examiner), “I am starting your examination now. During the examination if you feel uncomfortable at any point, please do let me know. ” General: -Pallor, jaundice, cyanosis -Hair, skin, and tongue changes -Neck examination, lymph nodes, swellings, thyroid exam -Hand and lower limb edema Exposure: Lower the shirt from the neck to the waist. Position: Examine in four positions: (1) patient sitting with her arms at her sides, (2) in lap, (3) hands pressing over the waist/hips, and (4) leaning forward and hand over the head. Inspection: Inspect the entire breast including the periph-ery, nipple, areola, tail, and axilla: -Size -Symmetry -Color -Visible masses -Shape change -Skin retraction, dimpling, flattening, inversion -Skin ulceration -Erythema -Peau d'orange -Increased vascularity -Nipple discharge (serous, bloody, milky, clear) -Supernumerary nipple M. H. Sherazi

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265 Palpation: -Light palpation and deep palpation. -Palpate entire breast including periphery, nipple, are-ola, and tail. -Use vertical or radial strip method (Fig.  9. 2). -Keep fingers on the breast all the time. -Feel for tenderness -Feel for lump and look for its: Location Size Shape Consistency Mobility -Feel axilla for axillary lymph nodes (anterior, poste-rior, medical, lateral and apical groups) and then supra-clavicular lymph nodes. Wrap-Up: Mention that you will complete your examination by doing a respiratory, cardiovascular, and abdominal examination. Comment on your findings. Thank the patient and tell the patient to cover up. Ask the patient if she has any questions. Question: What are the signs and symptoms of breast cancer? Answer: Palpable mass Breast pain and swelling Skin dimpling, retraction, or ulceration Edema (arm or breast) Erythema Nipple retraction Prominent veins Palpable axillary or supraclavicular lymph nodes Question: What are the risk factors for breast cancer? Answer: Increasing age (over 40 years) Heredity -a strong family history Caucasian race Previous history of breast cancer Hormone replacement therapy, especially longer than 5 years Using the oral contraceptive pill Increased alcohol intake Obesity including heavy postmenopausal weight gain Early age of first period Later age of menopause (55 years or older) Childlessness or having children after 30 Ionizing radiation exposure [3] Question: What if it turns out to be a breast cancer, what will be the treatment? Answer: “The treatment depends on various factors, which include the size, type, and nature of the cancer. The patient's age, health, and her personal preference are also an important consideration. The usual treatment includes surgery, chemotherapy, radiotherapy, and hormone treat-ment. Most of the time, it will be a combination of two or more of these. ” “The first step in the treatment is surgery in order to remove the cancer and surrounding breast tissue as well as adjacent lymph glands. If the lump is small, the preferred method of surgery is a breast-conserving surgery in which either only the lump is removed or part of the breast with the lump is removed. For larger lumps the whole breast with lymph nodes in the axilla needs to be removed. Later, radio-therapy is given to this area. In most of the breast cancers, surgery and radiotherapy are combined with chemotherapy or antihormone therapy such as tamoxifen. ” Fig. 9. 2 Breast examination patterns. (Source: Blausen Medical Communications, Inc. licensed under the Creative Commons Attribution 3. 0 Unported license. https:// creativecommons. org/ licenses/by/3. 0/deed. en) 9 General Surgery and Trauma

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266 Question: Can you please tell me more about fibrocystic disease of the breast? Answer: “It is a very common breast condition. It is also known as mammary dysplasia, fibroadenosis, and cystic hyperplasia. It is hormone related. It can occur anytime between the first period to the last period. It is most commonly seen between 30 and 50 years of age. The patient's main com-plaint will be breast pain and swelling. The breast may have a nodular feeling and sometimes an obvious lump is palpable. Breasts will be tender to touch. The symptoms tend to increase just before menstruation and resolve or improve after the period. The patients also notice some change in size of mass during each menstrual cycle. Treatment is usually according to the symptoms and clinical findings. For diffuse lumps a mam-mography is advised. For a small lump, a needle biopsy, and for cysts a needle aspiration is recommended. Pain medica-tions are given. Surgery is not required and reserved for removal of undiagnosed lumps only. ” Question: The patient is diagnosed to have a fibroade-noma. How will you counsel your patient? Answer: “A fibroadenoma is a smooth, discrete lump within breast tissue. The name implies that it has a fibrous component and an adenomatous part that consists of glandu-lar tissue. The cause is unknown. These are seen in younger females -usually in their 20s. It is common from 15 to 35 years of age. It is a firm, mobile, smooth, and round lump. It is usually not painful. It appears to change its position; sometimes it is also called a 'breast mouse. ' It will rarely change to cancer. The treatment includes an ultrasound and fine needle aspiration. Surgery is reserved if the lump enlarges or the woman wants to get rid of it. ” Question: How will you counsel your patient about a mammogram? Answer: “A mammogram is a screening test for the early detection of breast cancer. Breast cancer is one of the leading causes of cancer mortality in women. There is significant reduction in deaths from breast cancer among women who are regularly screened. Mammograms can usually find lumps 2 or 3 years before a woman or her healthcare provider can feel them. ” “A mammogram is a special X-ray of the breast with low dose of radiation to see the breast from inside. There are two types of mammogram: screening and diagnostic. Diagnostic mammogram is done in cases of breast mass or suspicion of breast cancer. Before the mammogram, you will be asked to undress from the waist up and change to a hospital gown. Each breast is X-rayed separately. The breast is flattened between two mammogram panels. This might be a bit uncomfortable, but it will only take a few seconds. If possible, try to avoid scheduling your mammogram just before or during your menstrual period, when the breasts are more sensitive. Also, do not use underarm deodorant on the day of your test. ” “A radiologist will interpret the mammogram. Some women will need to have more images taken. Needing more images is common and does not usually mean that you have cancer. These extra images help the radiologist to have the most accurate and clear view of your breast tissue. ” “In general, screening mammograms are less effective in younger women because they tend to have denser breast tis-sue. Mammograms may lead to additional testing. I will pro-vide you with brochures about mammograms. ” Question: What mammographic findings are suggestive of malignancy? Answer: Microcalcification Irregular satellite or speculated mass Architectural distortion Increased vascularity Interval mammographic changes Question: If the patient asks: Can you teach me how to self-examine the breast? Answer: “Self-examination is not recommended and will increase the number of visits to the doctor's office and may increase the number of unwanted biopsies. A physician will do your breast examination periodically. ” Checklist Assessment: Trauma Patient Please read the regional protocols and guidelines for emer-gency management; there are often changes made to these guidelines. It is highly recommended to attend and keep your Basic Life Support, Advance Cardiac Life Support, Pediatric Advance Life Support, and Advance Trauma Life Support certificates updated. Candidate Information: While working in a peripheral hospital emergency depart-ment, a 28-year-old male was brought in by ambulance. He was hit by a truck while crossing the road. Please perform a primary and secondary survey (Table  9. 3a, 9. 3b) [4]. Please do not perform rectal, genito-urinary, or breast examination. M. H. Sherazi

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

267 Table 9. 3a Primary survey for trauma Goals of primary assessment Examine and identify life-threatening conditions Initiate supportive treatment and stabilize the patient Plan/provide definitive treatments and/or organize transfer for definitive treatments Starting the station Knock on the door Enter the station Hand-wash/alcohol rub Greet the examiner, nurse, and the patient Give stickers to the examiner if required or show your ID badge Take a seat or stand on the right side of the patient and start the interview Opening Introduction, greet, drape Ask for vital signs. Interpret the vital signs Primary survey (mnemonic ABCDE) A: Airway maintenance with cervical spine protection Mention “First of all I want to make sure my patient's airway is patent” Check response: Ask the patient: “Hi, what is your name? What happened?” or “How are you?” Assess ability to speak Assess ability to breath Are there any signs or symptoms of airway obstruction? Look for Apnea Noisy breathing Respiratory distress Failure to speak Foreign bodies (Facial or neck trauma) facial, mandibular, or laryngeal fractures Agitation Confusion Choking signs Assume C spine injury (immobilize with collar and sand bags) If you find airway compromise, mention that you need to secure the airway first: Simple suction and secretion control Chin lift or jaw thrust Nasopharyngeal airway Oropharyngeal airway Bag valve mask ventilation Intubation Surgical airway If patient presents with Glaucoma Coma Score (GCS) of less than 8, consider endotracheal intubation as the next step Appropriate response will confirm Patent airway Sufficient airway reserves to permit speech Adequate perfusion Clear sensorium Mention here that the airway is clear but you will reassess it again B: Breathing and ventilation Assess respiratory rate Put pulse oximetry probe and check O 2 saturation Examine chest with adequate exposure and evaluate breathing: Look for chest movements, use of accessory muscles and color (cyanosis/pale) Auscultate for breath sounds, airway obstruction (stridor), and air entry symmetry Feel the chest. Palpate the trachea for its position or shift, chest wall crepitus, subcutaneous emphysema, flail segment, and sucking chest wall wounds Percuss: Both sides from the front and compare. Mention the findings Try to detect: tension pneumothorax, hemothorax, pneumothorax, and flail chest For further information on tension pneumothorax and hemothorax, see details in respiration system chapter If there is any breathing compromise or findings that the examiner provides, then manage accordingly. Assess for the need of immediate needle chest decompression or chest drain insertion. Also mention you may use nasal prongs, venturi mask, and bag-valve mask or can provide high-flow oxygen through a rebreather mask if not intubated and ventilated (continued) 9 General Surgery and Trauma

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268 Table 9. 3a (continued) C: Circulation with hemorrhage control Assess pulse rate Assess pulse quality (strength) Put cardiac monitors and blood pressure cuff Ask for BP and pulse pressure Assess capillary refill Assess skin color Look for any external obvious bleeding and take measures to stop it (pressure bandage): Direct manual pressure should be applied in trying to stop visible bleeding. Tourniquets are not used because of the risk of distal ischemia except for traumatic amputation. Transparent pneumatic splinting devices may control the bleeding and allow visual monitoring Surgery may be necessary if these measures fail to control hemorrhage Occult bleeding into the abdominal cavity, chest, retroperitoneum, or pelvis/long-bone fractures are all problematic. These should be suspected in a patient not responding to initial fluid resuscitation Insert two large-bore peripheral IV lines, or consider central venous catheterization if there is difficulty in getting peripheral lines Get blood samples for baseline tests and for cross match with a group and hold IV fluids need to be given rapidly, usually as 250-500 ml warmed boluses (10-20 ml/kg in children). Often a total of 2-3 L of IV fluids is necessary (40 ml/kg in children), which will then need to be followed by a blood transfusion (O negative to begin with, if typed blood is not available). Ringer's lactate is the preferred initial crystalloid solution D: Disability and neurological status Rapid neurological assessment should be done next. During the primary survey a basic neurological assessment is made, known by the mnemonic A VPU: Alert Verbal stimuli response Painful stimuli response Unresponsive Or by using GCS Pupils: Size, symmetry, and reaction Any lateralizing signs Level of any spinal cord injury (limb movements, spontaneous respiratory effort) Ask for a blood glucose level (finger prick) Observe for causes that may affect level of consciousness; oxygenation, ventilation, drugs, alcohol, and hypoglycemia may all also affect the level of consciousness. If these are excluded, changes in the level of consciousness should be considered to be due to traumatic brain injury until proven otherwise Patients should be reassessed frequently as patients may deteriorate rapidly. Sometimes patients may be lucid after suffering from a head trauma, and these patients deteriorate very quickly. Observe for signs such as pupil asymmetry or dilation, absent light reflexes, and weakness/paralysis in limbs that may suggest an expanding intracranial hematoma or diffuse edema. These may require IV mannitol, ventilation, and an urgent neurosurgical referral E: Exposure/ environmental control Clothes may need to be cut off for proper exposure, but one needs to keep in mind the prevention of hypothermia After a quick examination, cover up the patient and prevent heat loss with warming devices, such as warmed blankets Additional measures need to be done simultaneously while initial assessment and resuscitation are being performed Continuous vital signs monitoring: Pulse oximetry should be attached on finger or ear lobe. Blood pressure cuff should be attached on arm. Pulse rate, blood pressure, respiratory rate, and body temperature should be continuously monitored Electrocardiograph (ECG) monitoring: This can guide resuscitation by diagnosing cardiac arrhythmia and ischemia Blood tests: Full blood count, Chem20, troponin, arterial blood gases/venous blood gases, group and hold, and coagulation screening (if required) X-rays: Portable if required on the bedside in the resuscitation room. If the patient is initially stable, they may be transferred to the radiology department for X-rays and or computed tomography (CT) X-ray chest Pelvic X-ray. It has been suggested that CT scans may be used in some stable patients Lateral cervical spine X-ray FAST scan (focused assessment with sonography for trauma): Very quick and useful tool to look for abdominal injuries; and/or CT scanning to detect occult bleeding Urinary output: May require insertion of a urinary catheter to measure urine output. Adequate output is 0. 5-1 ml/ kg/h. Urine output will determine fluid replacement. It is essential to rule out urethral injury before attempting catheterization. One must suspect urethral injury if there is blood at the meatus, pelvic fracture, scrotal blood, or perineal bruising. A digital rectal and genital examination are mandatory prior to catheter insertion Gastric catheter is inserted to reduce aspiration risk. Suction should be applied M. H. Sherazi

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269 Vital Signs: Temp, 36. 8 °C; HR, 100; BP, 130/80; RR, 18; O2 saturation, 98% on RA. References 1. Murtagh J.  Acute appendicitis. In: John Murtagh's patient educa-tion. 6th ed: Mc Graw-Hill Australia, Australia; 2012. Page 233. 2. Boas' sign. https://en. wikipedia. org/wiki/Boas%27_sign. 3. Murtagh J.  Breast cancer. In: John Murtagh's patient education. 6th ed: Mc Graw-Hill Australia, Australia; 2012. Page 76. 4. St. John Ambulance. The secondary survey. https://www. sja. org. uk/sja/first-aid-advice/what-to-do-as-a-first-aider/how-to-assess-a-casualty/the-secondary-survey. aspx. Further Readings 5. Douglas G, Nicol F, Robertson C.  Macleod's clinical examination: with STUDENT CONSULT online access. 13th ed. Edinburgh: Churchill Livingstone; 2013. 6. Browse NL, Black J, Burnand KG, Thomas WEG.  Browse's intro-duction to the symptoms & signs of surgical disease. 4th ed. Boca Raton: CRC Press, Taylor & Frrancis Group; 2005. 7. Hurley KF.   Chapter 3. Gastrointestinal system. In: OSCE and clinical skill handbook. 2nd ed. Toronto: Elsevier Saunders Canada; 2011. p.  82-119. 8. The Essentials of General Surgery. In: Hall J, Piggott K, V ojvodic M, Zaslavsky K, editors. Essentials of clinical examination hand-book. 6th ed. New York: Thieme; 2010. p.  441-6. 9. Jugovic PJ, Bitar R, Mc Adam LC.  Fundamental clinical situations: a practical OSCE study guide. Collingwood: Elsevier Saunders; 2003. 10. Gao Z-H, Howell J, Naert K, editors. OSCE & LMCC-II: review notes. 2nd ed. Edmonton: Brush Education; 2009. 11. American College of Surgeons. ATLS® student manual. 9th ed. Chicago: American College of Surgeons; 2012. 12. Lefor AT, Gomella LG, Wiebke EA, Fraker DL.  Surgery on call, LANGE On Call. 4th ed. New  York: Mc Graw-Hill Education; 2005. Table 9. 3b Secondary survey for trauma [4] Secondary survey Once life-threatening conditions have been dealt with and ABCDE completed, then a secondary survey should be started. It includes a brief history, a head-to-toe examination, and a reassessment of progress History Allergy: “Do you have any known allergies?” Medication: “Do you take any regular or prescribed medications?” Previous medical history: “Do you have any known medical conditions?” Last meal: “When was the last time you ate or drank something?” Event history: “What happened?” Try to get as much details as possible about how they feel Ask questions about pain. Can they feel any pain? If yes, then explore pain Head-to-toe examination Check for vital signs again Bleeding: Check the body from head-to-toe for any signs of bleeding Head and neck: Is there any bleeding, swelling, or dent in the scalp or on the face? Eyes: What size are their pupils? Response to light? Equal? Nose: Is there any blood or clear fluid coming from the nostrils? Mouth: Look for mouth injuries or burns in their mouth, loose dentures, and any foreign bodies Ears: Observe for an appropriate response when talking to patient. Do an ear examination. Is there any blood or clear fluid coming from either ear? Skin: Note the color and temperature of their skin Neck: Feel for trachea, neck, and cervical spine tenderness Chest: Observe the chest for rise and fall. Feel the rib cage to check for any deformity or sensitivity Collar bone, arms, and fingers: Feel all the way along the collar bones to the fingers for any swelling, sensitivity, or deformity. Check that they can move their elbows, wrists, and fingers. Look for any needle marks on the forearms Spine: Log roll: Need minimum of four people to complete it. One stabilizing the neck, two log rolling, and one palpating the spine. Palpate the entirety of the spine. Look at the back of the chest and back for any injuries. Also do a rectal exam Abdomen: Gently feel their abdomen to check for any signs of internal bleeding Hips and pelvis: Feel both hips and the pelvis for signs of a fracture. Check their clothing for any signs of incontinence, which may suggest a spinal injury or bladder injury Legs: Check the legs for any bleeding, swelling, deformity, or soreness. Ask them to raise one leg and then the other and to move their ankles and knees Toes: Check their movement and feeling in their toes. Compare both feet and note the color of the skin Additional investigations with secondary survey CT scans Ultrasound Contrast X-rays Angiography Wrap-up Thank the patient and ask the patient to cover up Wrap up your findings with the examiner or the patient 9 General Surgery and Trauma

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271 © 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_10The Musculoskeletal System Majid Sajjadi Saravi and Mubashar Hussain Sherazi Musculoskeletal History Overview In most of the objective structured clinical examinations (OSCE), there must be at least one and usually two stations from the musculoskeletal system. It can be either a brief history taking with focused physical examination station or a detailed physical examination station. It can be related to any joint. Practicing all the joints is equally important. It is very important to first memorize the sequence of various tests that need to be performed and, second, practice each test well. The examiner will be watching and it is very important to perform each test properly. Also take care of the patients. Inform them about what to expect and avoid using excessive force while assessing joints. Time management is also key to success in these stations. Customizing the history part and picking up only the most important and relevant tests will be essential. Sufficient time (about a minute) should be allocated for a wrap-up in the end. This chapter outlines musculoskeletal system topics that are important for OSCE.  An overview of the pattern of his-tory taking is given in Table  10. 1. Physical examination checklists are given for a quick review. Most of the tests are shown in pictures as well. Some important topics, such as ankylosing spondylitis, carpal tunnel syndrome, and ankle sprain, are also included. Musculoskeletal History Details 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 attending physician for today. Are you Mr/Mrs... ? Are you... years old?” Chief Complaint: Chief complaint or the reason the patient is visiting the clinic. “What brings you in today?” History of Present Illness: Chief Complaint: Onset -If sudden onset, then ask what the patient was doing when it started. -Chronology (frequency, onset, duration, course) -Acute (<6 weeks) versus chronic (>6 weeks) -History of trauma -Mechanism of injury Course Duration Progression Severity of symptoms Pain Questions: Onset Course Duration Progression Quality of pain M. S. Saravi ( *) Department of Family and Community Medicine, University of Toronto, Family Health Team, Southlake Regional Health Centre, Newmarket, ON, Canada M. H. Sherazi Mallacoota Medical Centre, Resident of Family Medicine, Mallacoota, VIC, Australia10

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272 Table 10. 1 Overview of musculoskeletal system history Introduction: Name and age Chief complaint In patient's own words History of present illness Analysis of chief complaint: Onset Course Duration Progression Severity of symptoms History of trauma Mechanism of injury Pain questions: Onset Course Duration Progression Quality of pain Radiation Severity 1-10 Timing Pain before Mechanical: Clicking Locking Unstable Giveaway Inflammatory: Warm Redness Swelling Tenderness Morning stiffness Joint instability Weakness Numbness Gait/limp Other joints involvement Aggravating and relieving factors Review of systems: Common system review: Gastrointestinal Respiratory Genitourinary Cardiovascular Neurology Systemic diseases: Skin (rheumatoid and psoriasis) Eyes and difficulty urinating (Reiter's) Mouth ulcers (Bechet's) Diarrhea (inflammatory bowel disease [IBD]) Cardiovascular disease IBD, gout, hemophilia, cancers: breast, thyroid, prostate, and kidney Table 10. 1 (continued) Constitutional symptoms Predisposing factors Red flags/risk factors Rule out differential diagnosis Past medical and surgical history Illnesses, any previous or recent surgeries Hospitalization history or emergency admission history Physiotherapy/acupuncture Medication history Current medications (prescribed, over the counter, and any herbals) Allergic history/triggers Any known allergies? Family history Family history of any long-term or specific medical illness Occupation history How do you support yourself? Impact on life Disability and adaptation Effect on life Daily activity Getting up Driving walking running Shower Brushing teeth or hair Hand grip Stairs Squat Effects on ability to work Social history Smoking Alcohol Recreational/illicit drug use Sexual history (M/F/both) If an adult female: Menstrual history (last menstrual period) Gyne history Obstetrics history If a teen: Home Education Employment Activities Drugs Sexual activity Wrap-up Describe the diagnosis Laboratory tests Duration of treatment and side effects Management plan Possible medical treatment Red flags Further information (websites/brochures/support groups or societies) Follow-up M. S. Saravi and M. H. Sherazi

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273 Radiation Severity (scale of 1-10) Timing (time of the day) Pain before Most painful spot Aggravating/alleviating Associated symptoms Mechanical: Clicking Locking Unstable Giveaway Inflammatory: Morning stiffness (>30  min), better with use, constitu-tional symptoms Warmth Redness Swelling Tenderness Limitation of movement Joint instability Weakness Numbness Gait/limp Other joints involvement Noninflammatory: Worse with use. Worse at the end of the day. Can have some stiffness/gelling but usually not prolonged. Seropositive: Rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), Sjögren's syndrome, scleroderma, inflammatory myositis Seronegative: Ankylosing spondylitis (AS), psoriatic arthritis, enteropathic arthropathy, reactive arthritis Pattern of Joint Involvement: Number of joints involved: monoarthritis, oligoarthritis (four or less), polyarthritis (five or more joints) Symmetric vs. asymmetric Small joints (hands/feet) versus large joints (hips, shoul-ders); peripheral joints versus axial involvement (spine, sacroiliac [SI] joints) Tendon involvement Symmetrical small joints polyarthritis (wrist, metacar-pophalangeal [MCP], ankle, metatarsophalangeal [MTP]) Seropositive, psoriatic, tophaceous gout Symmetrical large joint polyarthritis (shoulder, hip) RA, AS, polyarthritis rheumatic Asymmetrical oligoarthritis (knee, ankle, MTP) Seronegative, crystal-induced, infectious Monoarthritis (elbow, wrist, knee, ankle, MTP) Infectious, crystal-induced, traumatic, hemarthrosis, reactive arthritis, bacterial endocarditis Constitutional Symptoms: Fatigue and malaise, night sweats, fever, weight loss Review of Systems and Extra-articular Features: Skin: Malar rash, nodules, panniculitis, telangiectasias, sclerodactyly, calcinosis, heliotrope rash, Gottron's pap-ules, shawl sign, alopecia, periungual erythema psoriasis, nail pitting, onycholysis, oil spots, erythema nodosum, pyoderma gangrenosum Eyes: Ocular iritis, scleritis, conjunctivitis, dry eyes, iritis Mouth: Ulceration/erosion Cardiovascular: Pericarditis, pericardial effusion, con-duction defects Respiratory System: Effusion, pleuritis, pulmonary fibrosis, pulmonary nodules, restrictive Gastroenterology: Gastroesophageal reflux disease (GERD), small bowel obstruction (SBO), malabsorption, bloody diarrhea Neurology: Mononeuritis multiplex, polyneuropathy, central nervous system (CNS) Crystal Arthropathies: Monoarthritis (red, hot) chroni-cally can be polyarthritis: gout (tophi, ETOH history, renal failure, drugs) Calcium Pyrophosphate Deposition (CPPD): Hyperparathyroidism, hypomagnesemia, hypophosphata-sia, ochronosis, hemochromatosis, Wilson's disease, hypothyroidism Septic Arthritis: Mostly monoarthritis, joint red/hot/ten-der, and associated with fever Gonococcal Arthritis: Migratory, with tenosynovitis and skin pustules Impact on Life, Disability, and Adaptation: “How is this impacting your life?” “Has there been any effect on your daily activities?” “Do you have trouble getting up, driving, walking, running, showering, brushing your teeth or hair, stairs, or squatting?” 10 The Musculoskeletal System

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274 Past Medical History: “Have you heard any previous health issues?” “Have you had any health issues related to your lungs, heart, or kidneys?” “Have you ever been tested for tuberculosis?” Past Hospitalization and Surgical History: “Have you ever been hospitalized or undergone surgery?” Medication History: “Are you taking any prescribed, over-the-counter, or herbal medications? If so have there been any side effects?” Allergic History: “Do you have any known allergies?” Family History: “Has anyone in your family had similar symptoms or health problems?” Social History: “Do you or does anyone close to you smoke? Do you drink alcohol?” If yes: How Much? Daily? How Long? “Have you ever tried any recreational drugs?” If yes: Which Ones? How Long? When? Specially ask about intravenous (IV) drug use (red flag for back pain). Relationships: “Are you sexually active? Do you have sex with 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 support from your family and friends?” Functional Status: “How is this impacting your day-to-day activities?” If patient is a teenager, then add these questions Home, education, employment, activities, drugs, and sexual activity If patient is an adult female, then add these ques-tions Menstrual history (last menstrual period [LMP]), gynecology, and obstetrics history If patients are more than 65 years old, then add these questions: “Do you have any problem with balance?” “Do you have any difficulty peeing/urinating?” “Do you have any trouble sleeping?” “Has there been any change in your vision or hearing?” “Have you had any recent change in your memory?” “Do you take any regular medication? Is it 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. Musculoskeletal Physical Examination The musculoskeletal system scenarios usually come as both a history and physical examination station. It is very impor-tant to practice taking a focused history and completing a relevant physical examination [1]. Equipment requirements: A measuring tape A goniometer A tendon hammer A disposable sharp point 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 physical examination. Opening: “Good morning/good afternoon. I am Dr... I am your attend-ing physician. Are you Mr... ? Are you... years old? Is it alright, if I examine your... ? I will also do some tests during which I will ask you to perform some maneuvers. Please ask M. S. Saravi and M. H. Sherazi

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275 me if you do not understand how to do these during the examination. During the examination, if you feel uncomfort-able at any point, please let me know. ” Before starting, mention “I shall be performing the tests on your right side only (if right side is the troubling side) assuming that the left side is normal. ” 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/Miss... your vital signs are normal” (or mention any abnormal findings). 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?” *(You may skip these questions if it is a history and physi-cal station) Comment: “Patient is oriented and alert. ” or “Patient is in distress!” or “Patient is sitting comfortably and he/she is well oriented and alert. ” Look for any abnormal findings in the hands, face (eyes, nose, lips, mouth), and neck. Ensure proper positioning and exposure of the joint you are examining. Drape the rest of the body properly. Joint Inspection General: Joint posture, any dressing/cast and any abnormal movement. Inspect the joint from all possible views. Compare to the other side and comment on symmetry of the joint and then verbalize: “I don't see any swelling, erythema, atrophy, deformity, and skin changes/rash or scar marks (SEADS). ” Joint Palpation Inform the patient again, “I am going to feel your... If you feel pain, please let me know. ” Note and feel for tenderness, effusion, swelling, temper-ature, crepitus, and atrophy. Range of Motion: Active range of movements: Check first for active range of motion (let the patient move a joint through its range of motion in a specific direction and assess the range). Passive range of movements: This is when you move a patient's joint and observe the range of motion. Compare the active and passive range of movements to the normal joint. Test power: Check for power in the same movements as performed while testing for active range of movements. Neurovascular Assessment: Sensory See Fig.  10. 1 for dermatome map [2]. Motor “Shrug your shoulders. ” -C4 “Bend your elbow. ” -C5 “Pull your wrist back. ” -C6 “Straighten your arm. ” -C7 “Open and close your fingers. ” -C8 “Spread your fingers. ” -T1 “Flex your leg at the hip. ” -L1, L2 “Straighten your knee. ” -L3 “Pull your foot up. ” -L4 “Push your foot down. ” -L5, S1 Grading Power 5: Normal power 4: Able to move the joint against a combination of gravity and some resistance 3: Active movement against gravity 2: Able to move with gravity eliminated 1: Trace contraction 0: No contraction Reflexes See Fig.   10. 2 for clinical shorthand to summarize reflex findings. Deep Tendon Reflexes Biceps -C5/C6 Brachioradialis -C6 Triceps -C7 Patellar -L4 Achilles -S1 Plantar Response 10 The Musculoskeletal System

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276 Reflexes Tested in Special Situations Spinal cord injury Frontal release signs Posturing Pulse See Fig.   10. 3 for arterial pulse points. Capillary Refill Pressure is applied to the nail bed until it turns white (blanch-ing) and the pressure is then removed. The time that it takes for the nail bed to turn pink again is the capillary refill. Blanch time of more than 2  s is a delayed response seen in  dehydration, shock, peripheral vascular disease, and hypothermia. Fig. 10. 1 Dermal segmentation (dermatomes). (Reprinted with permission from Keegan and Garrett [ 2]) Scale 0 Absent 1+ Hypoactiv e 2+ Normal 3+ Hyperactiv e 4+ Hyperactiv e with clonus 5+ Sustained clonus2+ 2+2+ 2+ 2+ 2+3+ 3+ Fig. 10. 2 Example of how clinical shorthand is used to summarize the findings of reflex tests M. S. Saravi and M. H. Sherazi

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277 Special Tests These are specific for each joint and details are given in each joint examination. Mention that you will examine the joint above and below and will also compare it with the other side. Thank the patient. Tell them they can now cover up. Wrap up your findings and ask if the patient has any concerns. Question: “What you will do next?” Answer: “I will need to read the radiographs and will then arrange for further investigations. ” Checklist: Musculoskeletal Physical Examination See Table  10. 2 for a checklist that can be used as a quick review before the exam. Fig. 10. 3 Pulse sites. By Jmarchn. https://en. wikipedia. org/wiki/ Pulse#/media/File:Pulse_sites-en. svg. (Reprinted under terms of Creative Commons Attribution-Share Alike 3. 0. https://creativecom-mons. org/licenses/by-sa/3. 0/)Table 10. 2 Checklist for musculoskeletal physical 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 General physical examination (may skip these questions if it is a history and physical station)Check that patient is alert and oriented Look for abnormal findings in: Hands Face (eyes, nose, lips, mouth) Neck Inspection General: Joint posture Dressings/casts Abnormal movement Comment on symmetry of joint by comparing to other side. Verbalize findings, commenting on SEADS: Swelling Erythema Atrophy Deformity Skin changes/rash or scar marks Inspect from all possible views Joint palpation Inform the patient that you are going to feel the joint and to make you aware of any pain they may feel Feel for: Tenderness Effusion Swelling Temperature Crepitus Atrophy Range of motion Active range of movements Passive range of movements Comparison to normal joint Neurovascular assessment Sensory Motor Reflexes Pulse Capillary refill (continued) 10 The Musculoskeletal System

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278 History and Physical Examination: Cervical Spine Candidate Information: A 39-year-old female constructor worker presents with a 3-month history of neck pain. She has some hand weakness. Vital Signs: Hear rate (HR), 76 beats/min, regular; blood pressure (BP), 120/65 mm Hg; temp, 36. 8 °C; respiratory rate (RR), 14/min; O2 saturation, 97% Please take a focused history and perform a relevant phys-ical examination. Please do not perform rectal, genitouri-nary, or breast examinations. Differentials: Cervical spondylosis (C5/6 or C6/7) Whiplash and extension injuries of the neck Ankylosing spondylitis Prolapsed intervertebral disc Spondylolisthesis Degenerative disc disease Vertical compression Hyperextension Shearing injury Quick Review of the Neck Pain: Cervical spine issues can be presented in three distinct ways: cervical radiculopathy, cervical myelopathy, and cervical spondylosis. Cervical radiculopathy is a condition characterized by radiating pain to one upper extremity associated with hypo-esthesia or paresthesia in dermatomal distribution. Cervical myelopathy is due to central pressure on the spinal cord causing lower extremity spastic weakness and a positive Lhermitte test. Cervical spondylosis may cause central neck pain or pain that is felt mainly on the trapezius muscles. The presentation of cervical radiculopathy seems more appropriate for making an OSCE scenario for history-tak-ing scenarios or performing physical examination. The other two do not have enough room for maneuvering of the test designers, but you need to add some simple related examination to show that you are aware of them. Therefore, whenever you see a case with the chief complaint being neck pain, ask about extremities regarding weakness, numbness, and tingling. And whenever you are asked about a case with upper extremity pain or numbness, you should check the cervical spine. 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 39 years old? I know that you are suffering from neck pain; can you tell me more about this?” History of Present Illness: Wait until the patient answers before you start your closed- ended questioning. Onset: “How did your pain start?” A typical case will have a gradual onset. Course and Duration: “How long have you had the pain? Is it getting worse or better? Do you have the pain all the time or does it fluctuate?” Typical pain from cervi-cal radiculopathy fluctuates widely and depends on activ-ity and position. The patient may consider its general trend as worsening, improving, or staying the same. “Can you show me with your hand where you feel the pain?” A patient with cervical spondylosis will put his palm on his trapezius on the back of the neck. Those with cervical radiculopathy will try to demonstrate the radicu-lar nature of their pain by dragging their other hand downward on the involved arm or in more subtle cases touching the cervical spine or trapezius. If a patient puts their palm on their deltoid, it could be a sign that you are dealing with a shoulder case not cervical spine case. Table 10. 2 (continued) Special tests Tell the patient that you will examine the joint above and below and will compare with the other side Wrap-up Thank the patient and tell them that they can cover up Ask the patient and examiner if they have any questions or concerns Wrap up your findings with the examiner or the patient M. S. Saravi and M. H. Sherazi

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279 Quality: “How would you describe the pain?” The pain can be described differently, and it is not practical to put much emphasis on it, but generally speaking at least for the sake of your exam, a burning pain is more typical for radiculopathy, and electrical shock-like pain down the spine for cervical myelopathy will be described, and it is worth asking the patient now. Radiation: “Does the pain shoot anywhere else? Down your arms or back?” Severity: “How would you rate your pain on scale of 1 to 10?” Timing: “At what time of the day is the pain worse?” Cervical pain will intensify with a prolonged upward position, especially sitting in a constant position like in front of a computer, so day time is worse compared to shoulder pain, which is worse at night with sleeping. Alleviating and Aggravating Factors: “Have you noticed anything that makes your pain worse? Anything that makes it better?” Typically rest, painkillers, or mas-sage may be mentioned as the relievers. Work, writing, or typing usually aggregate the pain. Associated Symptoms: Constitutional symptoms are fever, weight loss, night sweats, weakness, and numbness. Functional Status: “How is this impacting your day-to- day activities?” Complete the rest of the history as mentioned under history taking. Cervical Spine and Related Examination Mention here: “I am going to do an examination of your neck. Should we start?” You are expected to do a focused physical exam if you have some elements of history. For example, you will put more emphasis on all the elements of neurological examina-tion of upper extremities if the history is compatible with cervical radiculopathy, not wasting any time on a detailed lower extremity neurological exam. Vitals: Start by commenting on the vitals given at the door. (It should include pulse rate, blood pressure, respiratory rate, temperature, and O2 saturation. ) “Vital signs are normal. ” Or mention if there are any abnormal findings. Inspection: General: Neck posture, any dressings, or abnormal movement. Position: Sitting. Expose from the head down to both shoulders and properly drape the rest of the body inspect the neck from the anterior, lateral, and possibly poste-rior. Patient's nose should be in line with manubrium and xiphoid process of the sternum. From the side, the patient's ear lobe should be in line with acromion pro-cess [3 ]. Verbalize if you do not see any SEADS -swelling, erythema, atrophy (arms and forearm), deformity (torticollis), skin changes/ rash/scar marks, loss of normal anterior/lateral curvature. Joint Palpation: Inform the patient again, “I am going to feel your neck; if you feel pain, please let me know. ” Palpate the spinous processes and facet joints of the cervi-cal vertebra, external occipital protuberance, mastoid pro-cess, paracervical muscles, lymph nodes, supraclavicular fossa, and carotid arteries. Feel for tenderness, effusion, swelling, temperature, crep-itus, fluctuance, and atrophy. Active Range of Movements: Stand in front of the patient and ask them to copy your movements. Show them these movements: flexion, exten-sion, lateral bending, and rotations. Expect some limitation and grimacing to comment on. Then, ask them to put both of their hands on the back of their neck and then on the upper back from behind as a rapid check for shoulder motion. In cervical spine cases, this should be normal and painless. If there is any limitation of active movement, check the passive movement too; otherwise you may skip that. Passive Range of Movements: Check passive movements while you move patient's neck in flexion, extension, lateral bending, and rotation. Power Assessment: Determine muscle power in the movements mentioned previously. Neurological Examination: Motor Exam We need to check further for neurological weakness originating from the nerve roots in the cervical spine by testing the myotomes with the respective movements. There are many ways to perform a nerve root examination; however, for the sake of OSCE, this is a very timesaving approach: Neck flexion -C1-2 Neck side flexion -C3 10 The Musculoskeletal System

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280 Shoulder elevation -C4 Shoulder abduction -C5 Elbow flexion -C5, C6 Elbow extension -C7 Wrist extension -C6, C7 Fingers flexion -C8 Fingers abduction -T1 Sensory Exam Take a piece of cotton, and tell the patient that you are going to touch their arm and hands with it. Show them how it feels by first touching it to their neck. Now ask the patient to close their eyes and tell you when they feel the cotton and whether the feeling is the same on both sides. You should touch these areas on both sides: Jaw angle -C2 Shirt collar area -C4 Lateral side of elbow -C5 Dorsum of first web space (thumb) -C6 (radial) Palmar or dorsal aspect of the index finger -C7 (median) Dorsal aspect of distal phalanx of the middle finger -C7 Palmar or dorsal aspect of the little finger -C8 (ulnar) Medial side of the elbow -T1 Deep Tendon Reflexes: Biceps -C5 Triceps -C7 Brachioradialis -C5, C6 Special Tests Occipital Wall Distance: Ask the patient to stand with their back against a wall and measure the occiput-to-wall distance. The occiput-to-wall distance should be zero. The inability to touch the occiput against the wall is abnormal. This measurement may be used to follow the progression of ankylosing spondylitis and can also be used as a part of the assessment for osteoporosis and associated chronic spinal fractures. Spurling Test Guide the patient to simultaneously rotate and laterally flex the neck toward the affected side (Fig.   10. 4). Reproduction of the radicular symptoms (Spurling's sign) is suggestive of cervical root impingement [4]. Compression Test While the patient is sitting, apply down-ward pressure on their head to exert an axial load (Fig.   10. 5). Reproduction of radicular pain is suggestive of cervical nerve root impingement. Lhermitte Sign Ask the patient to flex their neck and ask if they feel any electrical sensation on their back. This is a sign of cervical myelopathy. The sign may also be positive in B12 deficiency, multiple sclerosis, and cervical disc disease. Finding In-Cord Injury in Spinal Trauma: Tenderness over spinous processes Paraspinous swelling Gap between spinous processes Neurological paradoxical breathing: seen in paralysis Flaccid limbs with no response to painful stimuli and no reflexes Painless urinary retention/priapism Thank the patient and tell the patient that they can now cover up. Ask patient and examiner if they have any questions or concerns. Wrap up your findings with the examiner or the patient. Fig. 10. 4 Spurling test. The patient flexes the neck toward the affected side (red arrow) M. S. Saravi and M. H. Sherazi

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281 Wrap-Up: Describe the diagnosis. Question: “How will you investigate this patient?” Answer: X-ray cervical spine, electromyography/nerve conduction velocity (EMG/NCV), magnetic resonance imaging (MRI) cervical spine Question: “What is your management plan?” Answer: “I will start patient pain medication such as NSAIDs (check for allergies and risk factors) and physiotherapy. ” Further information: Websites/brochures/support groups or societies. Follow-up. Checklist Cervical Spine Examination: See Table  10. 3 for a checklist that can be used as a quick review before the exam. History and Physical Examination: Lumbar Spine Candidate Information: A 54-year-old comes up to you complaining of low back pain having lasted 3 days. Fig. 10. 5 Compression test (red arrow shows radicular pain)Table 10. 3 Checklist for cervical spine 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 expose/drape Ask for vital signs -interpret General physical examination (may skip these questions if it is a history and physical station)Check for level of alertness and orientation Look for abnormal findings in: Hands Face (eyes, nose, lips, mouth) Neck Inspection Position Inspect the neck from anterior, lateral, and possibly the posterior angles Verbalize if you do not see any SEADS Joint palpation Tell the patient what to expect in the examination Palpate the spinous processes and facet joints of cervical vertebrae, external occipital protuberance, mastoid process, paracervical muscles, lymph nodes, supraclavicular fossa, and carotid arteries Feel for tenderness, effusion, swelling, temperature, crepitus, fluctuance, and atrophy Active range of movement (ROM)Show the patient how to perform flexion, extension, lateral bending, and rotation Passive ROM Check for passive movements in flexion, extension, lateral bending, and rotations Neurovascular examination Sensory Motor Reflexes Special tests Occipital-to-wall distance Spurling's sign Compression test Lhermitte sign Wrap-up Thank the patient and tell them that they can now cover up Wrap up your findings and ask if the patient has any questions/concerns 10 The Musculoskeletal System

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282 Vital Signs: HR, 76/min, regular; BP, 120/65 mm Hg; temp, 36. 8; RR, 14/min; O2 saturation, 97% Please take a focused history and perform a relevant phys-ical examination. Please do not perform rectal, genitouri-nary, or breast examination. Quick Review of the Low Back Pain: Differential Diagnoses: Simple lumbago: A mechanical type back pain without nerve root irritation Sciatica: A mechanical back pain with nerve root irritation Inflammatory spondyloarthropathies Spinal canal stenosis Others: Infection, tumors, fractures 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. Most of all the lower back pain cases are what we can refer to as mechanical low back pain. No matter what the exact origin of the pain, whether from muscles, ligaments, discs, or nerve roots, a range of similar symptoms can be presented in this common illness. Classic mechanical back pain gets worse with physical activity and improves with rest; however, sitting is not com-fortable. Its severity varies considerably throughout the day or day-to-day and usually responds at least partially to common pain killers. The pain is usually worse in the lumbar area at the midline or on the right or left side of the midline. It commonly radiates to one buttock and thigh but no lower than the knee. There are some particular signs and symptoms that are indicative of nerve root irritation (sciatica) and a number of symptoms and clues in the history that are considered red flags as they should raise suspicion of alternative diagnoses. It is a good strategy to consider lumbago as your primary diagnosis and check all related symptoms and red flags. Here is a list of clues that should be mentioned in the history: 1. Age: Most of the time, the age will be given at the doorway with patient information; however, it is worth considering its importance in our approach to low back pain. If the patient is very young (10-20) especially younger than 15  years of age, consider spondylolysis and primary bone tumors as the cause. On the contrary, if the patient is over 50, that is a red flag for you to con-sider a compression fracture or metastasis. 2. Onset of Pain: “Can you please tell me how your pain started? Did it come on gradually or suddenly?” Typical mechanical low back pain usually starts suddenly at its peak level of pain and then goes down gradually and fluc-tuates. In contrast, inflammatory low back pain as well as canal stenosis pain builds up gradually. With a typical case of mechanical low back pain, the patient may clearly remember a physical activity, like pushing a car, as the causative factor for the pain. A trauma without a signifi-cant severity mechanism, such as falling from a ground level, should prompt thinking of pathologic fractures. 3. Duration: “How long have you had the pain?” Mechanical low back pain can present acutely or chroni-cally, but you should expect an acute presentation for the OSCE.   Compression fractures are acute, while spinal stenosis and inflammatory arthropathies are more insidi-ous and chronic. 4. Location: “Can you show me where you feel the pain?” The patient will put his or her hand on their back. Bend forward or stand up to check the exact location. If the point is at the CV angle, think about various kidney pathologies such as pyelonephritis. Or nephrolithisis. 5. Radiation: “Does the pain shoot anywhere else? Down one or both legs? How far down does it go?” If the pain shoots down the legs, then you must ask which one is more bothering for them: the leg pain or the back pain. In a case of lumbago, the pain can radiate to one or both buttocks and may go down to the knee but not lower than the knee, and the back pain is worse than thigh pain in severity. Sciatica pain goes down on one side as low as the ankle or toes, and the patient will complain more of leg pain rather than the back pain itself. The spondyloarthropathy and spinal steno-sis pain are mainly in the lower back; however, it might also be felt first in the upper back and later in the buttocks and thighs. Bilateral radicular pain should make you think of cauda equina syndrome as an emergency situation. 6. Severity: “How bad is your pain on a scale of 1-10?” Mechanical low back pain can range from mild to excru-ciating, and, as mentioned before, it usually changes in severity widely. Spondyloarthropathies generally pres-ent with mild to moderate pain. Compression fracture pain might start at the upper part of the range and will gradually decrease in severity. Spinal stenosis is unique in its particular association with the type of activities that will be mentioned later. 7. Nature of the Pain: “How would you describe your pain? Sharp, dull, burning, shooting?” Sciatica is usually described as a sharp, shooting, or burning pain with associated elements of tingling that should be asked M. S. Saravi and M. H. Sherazi

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283 about specifically. Pain of a fracture is sharp, while inflammatory arthropathies and spinal stenosis pain are more of a dull pain. 8. Timings: “At what time of day or night is your pain worse?” Mechanical low back pain is worse after physi-cal activity or prolonged sitting and is usually at its peak in the afternoon or evening. Spondyloarthropathies, like ankylosing spondylitis, are worse in the early morning before getting out of bed. Remember also that tumors and infections are notoriously associated with night pain. 9. Aggravating Factors: “Can you tell me what makes the pain worse and what makes it better?” If the patient men-tions bending forward or backward, sitting/driving, or standing still as the worsening factors, consider mechani-cal low back pain, i. e., lumbago, or sciatica as the cause. If walking is mentioned as a causative factor and sit-ting and bending forward as a relieving factor, then go with spinal stenosis. Clarify more to reveal its character-istics and its prominent differential diagnosis, which is intermittent claudication. “How far can you walk before the pain starts and how far can you keep going before the pain makes you stop?” While an exact distance of walking brings up the pain of vascular claudication every time, this distance widely varies for neurologic claudication-spinal stenosis. “Is the pain worse on an upslope or downslope?” Climbing an upward slope is much easier for stenotic patients. The reverse is true for vascular cases. 10. Relieving Factors: “Can you get rid of pain by standing still or do you need to sit down?” Just standing for 10 min is enough to make a patient with vascular claudi-cation ready to walk again, but the neurologic pain needs sitting for a relief. “How long do you need to sit down for before being able to walk again without severe pain?” Twenty to 30 min is the usual required sitting time before waking again for the spinal stenotic cases. “Does riding a bicycle bring on the pain?” No, so many of these patients substitute it for walking as the spinal flexion adapted for riding a bicycle is ideal for reducing pressure over the neural elements. 11. Associated Symptoms: “Besides this back pain, do you have any other symptoms like: “Fever and night sweats?” -Red flags for infection -osteomyelitis, tuberculo-sis, brucellosis “Weight loss?” -Red flag for infection and cancer “Incontinence or difficulty peeing?” -Red flags for cauda equina syndrome “Any numbness when you wipe yourself in the washroom?” -Saddle anesthesia: red flag for cauda equina syndrome “Any weakness or numbness in your legs? Which side?” -Unilateral: sciatica -Bilateral: red flag for cauda equina syndrome “Heel pain?” -Enthesopathy of spondyloarthropathies “Eye pain or red eye?” -Anterior uveitis associated with spondyloarthropathies “Joint pain in the knees or hips?” -Peripheral arthritis may present in various types of spondyloarthropathies, especially ankylosing spondylitis “Abdominal pain or diarrhea?” -Consider reactive arthritis as a type of spondyloarthropathy. “Skin rash?” -Consider psoriatic arthritis and reactive arthritis. Red Flags: Common and important red flags of low back pain with asso-ciation of possible causes of pain are shown in Table  10. 4 [ 5]. Table 10. 4 Common red flags for low back pain Red flags Possible causes of pain Long-term duration (>6 weeks) Infection, tumor, or rheumatologic disorder Younger age <18 years Infection, congenital defect, tumor, spondylolysis, or spondylolisthesis Older age >50 years Infection, tumor, or intra- abdominal processes (e. g., abdominal aortic aneurysm) Major trauma or minor trauma in the elderly Fracture Cancer Tumor Fever, chills, night sweats Infection, tumor Unexplained weight loss Infection, tumor Intravenous drug use Infection Immunocompromised Infection Gastrointestinal or genitourinary surgical procedure Infection Night-time pain Infection, tumor Constant pain, even when lying down Infection, tumor, abdominal aortic aneurysm, or nephrolithiasis Pain becomes worse when coughing, sitting, or Valsalva maneuver Herniated disc Pain that radiates below the knee Herniated disc or nerve root compression below the L3 nerve root Incontinence Cauda equina syndrome, spinal cord compression Saddle anesthesia Severe or rapidly progressive neurologic deficit Modified from Della-Giustina [5] 10 The Musculoskeletal System

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284 Past Medical History: Important to ask about skin dis-eases, abdominal diseases, and eye diseases. Also ask about cancer. A positive history of cancer, like breast cancer or lung cancer, will change your approach. You will request an X-ray and a bone scan. Medicine History: “Have you ever been prescribed any steroids?” A positive history makes osteoporosis and com-pression fracture of the vertebrae more likely. Social History: “How do you support yourself financially? Is it a job associated with heavy weight lifting? Do you smoke?” Smoking is associated with increased rate of mechanical low back pain and lung cancer that can metastasize to the spine. “Have you ever used illicit drugs? If yes, any injections?” Associated with risk of vertebral osteomyelitis. Complete the rest as mentioned in the history-taking details. Lumbar Spine Examination: “Now I am going to start examining your back. Is it alright to go ahead?” Vitals: Start by commenting on the vitals given at the door. (It should include pulse rate, blood pressure, respiratory rate, temperature, and O2 saturation. ) Comment on the vital signs findings, “Mr/Miss... vital signs are normal,” or mention if there are any abnormal findings. Inspection and Palpation: Position: Inspect the back in standing, sitting, and then the supine position. Preferably the patient will be wearing a gown open in the back. In case of acute injuries to the lumbar spine, examine only in the supine position. You should mention that you will need two or more assistants to log roll the patient and then will be able to palpate the thoracolumbar spine and soft tissues. This will also minimize further spinal injury. Walking: Ask the patient to walk for a few steps. Look for any kind of limping or antalgic gait. Now ask your patient to walk on their heels. You are checking the power of ankle dorsiflexion or L4 and L5. Ask them to then walk on their toes to test the power of ankle plantar flexion or S1. Standing: First watch the back, and then verbalize if you do not see any SEADS (swelling, erythema, atrophy, deformity, and skin changes/rash/scar marks) on the back. Then palpate the spinous processes of the thoracic and lumbar vertebrae and paraspinal muscles. Note any step deformity that may indicate spondylolisthesis. Palpate for sacrum, coccyx, iliac crests, ischial tuberosities, and para-vertebral muscles. Note for normal lumbar lordotic curve. Note any asymmetry of the iliac crests. Note any tender-ness on posterior superior iliac spine and sacroiliac joints. While the patient is standing, also check if both iliac crests are level or not to reveal any limb length discrep-ancy (LLD). Inform the patient that you are going to touch their hips, and check areas over and behind the greater trochanter for any tenderness as a sign for trochanteric bursitis. Schober's Test: This is done in the standing position. Stand behind the patient and tell them that you will be putting two small marks on their back. Identify the dimples of Venus (sacroiliac joints) and make a mark on the skin at the mid-line. Take your measuring tape out or find one in the station. Put a mark 10 cm above the previous line and the second mark at 5 cm distal to that. Now command the patient to bend forward. Measure the distance between the two lines again. It should be at least 20 cm (Fig.   10. 6) [6 ]. It will be reduced in ankylosing spondylitis. 10 cm above the iliac crest Dimples of Venus, iliac crest line 5 cm below the iliac crest 5 cm0 cm10 cm Side vie w Back view Fig. 10. 6 Schober's test. (Adapted from [6]) M. S. Saravi and M. H. Sherazi

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285 Percussion: Percuss each vertebra with the hypothenar aspect of your closed fist. Deep pain in response to per-cussion is nonspecific but may be an indication of degen-erative disease, malignancy, or infection. Active Range of Movements: Ask the patient to stand and mimic your movements. Using your hands to fix the pelvis, ask the patient to bend forward (flexion), backward (extension), bend laterally (lateral flexion), and rotate side to side. Forward bending may cause pain in patients with radicu-lopathy. Watch for any scoliosis. Check backward bending. It may be restricted or painful in cases of facet joint involvement, especially if backward bending is mixed with lateral deviation. Check for costovertebral angle (CV A) tenderness on both sides (Fig.  10. 7). Flip Test: Ask the patient to sit at the edge of the bed. Ask the patient to extend their knees one by one. Complete exten-sion is impossible for a patient with radiculopathy as this position equals straight leg raising to 90-degree of hip flex-ion. In a positive flip test, as the passive or active knee exten-sion reaches 45° or more, the patient flips backward and will put their hands on the table behind their body for support (Fig.   10. 8a, b). This test is especially helpful in malingering cases. Neurovascular Assessment Power assessment: Check resisted great toe extension -L5 Check resisted knee extension -L3 and L4 Check resisted hip flexion -L2 Sensory test with a piece of cotton on these spots: Medial side of the thigh -L2 Medial femoral condyle -L3 Medial malleolus -L4 Dorsal surface of the third toe -L5 Lateral surface of the heel -S1 Reflexes: Knee jerk and ankle jerk Pulse: Dorsalis pedis, posterior tibial, and popliteal A Special Tests: Ask the patient to lie down on the bed. Straight Leg Raising (SLR): With the patient lying supine with legs extended, the symptomatic leg is pas-sively raised off the bed (keep knee extended) (Fig.   10. 9). Worsening pain in the affected leg at hip flexion of <60-70° will indicate a positive test. Crossed Straight Leg Raising Test: Repeat the previous movements with the unaffected leg (Fig.   10. 10). Reproduced symptoms at the affected leg is a positive result which is very specific for radioculopathy but lim-ited sensitiviy. Femoral Stretch Test: Used to illicit higher lumbar ( L2- L4) radiculopathicbpain. Ask the patient to lie in prone posi-tion and then passively flex the knee on the affected side. Faber Test: Put the patient's leg in the figure-4 position (Fig.   10. 11). Pain in the sacroiliac joint indicates a posi-tive test. Spinal Stenosis: Patient back pain relieved by bending forward is a positive test. Cauda Equina Syndrome: This dreadful clinical condition should be suspected in any cases of low back pain with one of these features: 1. Saddle anesthesia 2. Decreased anal tone and reflex 3. Fecal incontinence (soil themselves) 4. Urinary retention with overflow incontinence or sudden onset of urge incontinence 5. Bilateral leg weakness or bilateral positive “Straight Leg Raise” Thank the patient. Tell the patient that they can now cover up. Wrap up your findings and ask the patient if they have any concerns. Wrap-Up: Question: How would you explain your possible diagnosis and plan to the patient? Answer: “Based on our conversation and the results of the physical exam, it is highly possible that you have a herniated disc. Discs are structures that connect our vertebral bones, and they consist of an outer firm layer and an inner soft core. Fig. 10. 7 Checking for costovertebral angle tenderness 10 The Musculoskeletal System

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286 ab Fig. 10. 8 (a, b) Flip test When the outer layer tears due to age-related changes or excessive pressure, the core moves out of place and puts pressure on the nearby spinal nerve. This causes sciatica or shooting pain down the legs. Fortunately, most patients with sciatica will recover with some simple treatments such as rest, avoiding harmful move-ment, and some painkillers. However, there is a minority who needs surgery because of progressive weakness or intractable pain. ” “I will give you some medication to control your pain, and I would like you to come back again in 2 weeks to be sure about the course for your condition. If we cannot control your pain in about 6 weeks or if we see any worrisome signs in your exam, such as progressive weakness or loss of reflexes, I will refer you to a neurosurgeon or orthopedics spine surgeon for possible surgery. Meanwhile, if you notice any loss of sensation around your buttock or difficulty uri-nating or controlling your bowel movements, you need to go to the hospital immediately. ” Checklist: Lumbar Spine Examination See Table  10. 5 for a checklist that can be used as a quick review before the exam. M. S. Saravi and M. H. Sherazi

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287 Fig. 10. 9 Straight leg raising Fig. 10. 10 Crossed straight leg raising test 10 The Musculoskeletal System

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288 History: Low Back Pain Candidate Information: A 64-year-old male presents with a 3-week history of low back pain. The pain started suddenly and is progressing in severity: now at 6/10. The pain radiates to the leg. The pain started after lifting heavy boxes at home. He has had an increase in the fre-quency of urination and constipation for 4 days. Vital Signs: HR, 76/min, regular; BP, 120/65 mm Hg; temp, 36. 8 °C; RR, 14/min; O2 saturation, 97% Please take a detailed history; give your three differentials and a management plan. Please do not perform rectal, geni-tourinary, or breast examination. Differentials: Cauda equina syndrome Disc herniation Back sprain Bone metastasis (prostate cancer) Please complete the history as mentioned in the lumbar spine. In this particular case, you need to further add ques-tions for prostate signs and symptoms and some questions about constipation. Red flags for back pain are also impor-tant and not to be missed. Question: What you want to do next? Answer: “I will do a digital rectal examination. I would also like to do cardiovascular and respiratory system examina-tion. ” DRE findings: prostate irregular with hard nodule. Question: What you will do next? Answer: “I will refer the patient to the hospital for investigation. ” Investigation Blood work: CBC differential, ESR, lytes, BUN, creati-nine, Ca+, phosphate, alkaline phosphate, liver panel, PSA Imaging Assessments: X-ray of lumbar spine and pel-vis, MRI of the lumbar spine. History and Physical Examination Checklist: Ankylosing Spondylitis See Table  10. 6 for a checklist that can be used as a quick review before the exam. Question: What investigations would you like to advise? Answer: Blood tests: Complete blood examination, ESR, C-reactive protein (CRP), plasma viscosity (PV) RF (negative) HLA-B27: Most people with ankylosing spondylitis test positive for HLA-B27 X-ray: Bamboo spine -widening of SI joint, square lum-bar spine MRI: May show changes in the spine or sacroiliac joints at an earlier stage of the disease. Fig. 10. 11 Faber test M. S. Saravi and M. H. Sherazi

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289 Table 10. 5 Checklist for lumbar spine 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 expose/ drape Ask for vital signs -interpret General physical examination (may skip these questions if it is a history and physical station)Check for level of alertness and orientation Look for abnormal findings in: Hands Face (eyes, nose, lips, mouth) Neck Inspection Inspect the back Verbalize if you do not see any SEADS Note normal lumbar lordotic curve Note symmetry of the iliac crests Joint palpation Palpate the spinous processes of the thoracic and lumbar vertebrae, paraspinal muscles, sacrum, coccyx, iliac crests, ischial tuberosities, paravertebral muscles, and posterior superior iliac spine and sacroiliac joints Feel for: Tenderness Effusion Swelling Temperature Crepitus Fluctuance Atrophy Percussion Percuss each vertebra with the hypothenar aspect of your closed fist and observe pain level Active range of movement (ROM)Check forward flexion, lateral flexion, rotation, and extension Passive ROM Check forward flexion and extension Neurovascular examination Sensory Motor Reflexes Special tests Flip test Straight leg raising Crossed straight leg raising test Femoral Stretch test Schober's test Faber test Wrap-up Thank the patient and tell them that they can now cover up Mention that you would do a hip and thoracic spine examination Table 10. 6 Checklist for ankylosing spondylitis 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 expose/drape Ask for vital signs -interpret History Focus on issues specific to ankylosing spondylitis (AS) Pain questions: “Is it worse in the morning or later in the day?” “Stiffness in the morning?” “Nocturnal pain?” Some questions about progression of the disease: “How do you sleep?” posture Systemic review: “Any anorexia, fever, chills, night sweats, weight loss?” Cutaneous: skin rashes, mouth ulcers Eyes: symptoms of photophobia/increased lacrimation, conjunctivitis, iritis, uveitis? Cardiovascular: chest pain, palpation, aortitis, aortic regurgitation Gastrointestinal (GI): diarrhea, abdominal pain Genitourinary (G): dysuria, urethritis, immunoglobulin G (Ig G) nephropathy, amyloidosis Musculoskeletal: joint pain, asymmetric large joint involvement, lower limb involvement, dactylitis, Achilles' tendonitis Lymphatics: adenopathy Past medical history: History of infectious disease (tuberculosis), malignancy, intravenous (IV) drug abuse, recent GU procedures, metabolic bone disease (menopause, anorexia nervosa, steroids) Family history: HLA-B27 association General physical examination Look for abnormal findings in: Hands Face (eyes for anterior uveitis and iridocyclitis, nose, lips, and mouth) Neck Inspection Inspect the neck and back. Note any spinal deformities (loss of lumbar lordosis and thoracic kyphosis) Verbalize if you do not observe any SEADS Swelling Erythema Atrophy (arms and forearm) Deformity (torticollis) Skin changes/rash/scars (continued) 10 The Musculoskeletal System

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290 History and Physical Examination: Shoulder Candidate Information: A 25-year-old male comes in with right-sided shoulder pain that has lasted for 2 weeks. Vital Signs: HR, 71/min, regular; BP, 120/65 mm Hg; temp, 36. 8 °C; RR, 14/min; O2 saturation, 98% Please take a brief history and perform a focused shoul-der examination and address patient concerns at the end. Please do not perform rectal, genitourinary, or breast examinations. Shoulder Movements: See Fig.  10. 12 for shoulder movements: Flexion -Raise the arm forward in sagital plane. Extension -Move the arm backwards in sagital plane. Abduction -From side position, raise the arm sideways (keep the elbow straight) so it is parallel with shoulders with palm away from the head. Adduction -From the previous abduction position, lower arm sideways and across the body as far as possible. Internal Rotation -From side position, flex elbow and move arm across the front of the body so that the palm of the hand rests flat against the opposite arm. External Rotation -With the elbow still flexed from the internal rotation position, swing arm outward from the body with the thumb pointing upward, and the arm is lat-eral to the head. Circumduction -Move the arm in a full circle. Shoulder Anatomy: Articulator Surfaces: Sternoclavicular, acromioclavicu-lar, glenohumeral, and scapulothoracic. Four Rotator Cuff Muscles: Supraspinatus, infraspina-tus, teres minor, and subscapularis. Supraspinatus: Performs abduction of shoulder. Infraspinatus and Teres Minor: These two muscles lie below the scapular spine and are the external rota-tors of the shoulder. The infraspinatus primarily acts while the arm is in a neutral position, and the teres minor muscle is more active when the shoulder is in 90° of abduction. Subscapularis: Internal rotator of the shoulder. Deltoid: Abducts the shoulder along with the supraspinatus. Biceps: Flex the elbow and supinate the forearm. The Rotator Cuff Tendons keep the humeral head opposed to the glenoid. Without their function, the humeral head would ride high (due to influence of del-toid) and hit the acromion. Differential Diagnosis of Shoulder Pain: The most important clues are the golden clues, which need to be asked in the history: Age History of the trauma Duration The silver clues: Associated symptoms: loss of motion, paresthesia, fever, and chills Timing: at night, with daytime usual activities, during sports such as swimming Differential Diagnosis: Impingement Syndrome including subacromial bursitis, rotator cuff tendinitis, or a partial tear: -Silver clues: Pain is worse with overhead activities or at night while lying on the involved shoulder. Table 10. 6 (continued) Joint palpation Explain to the patient what they should expect in the examination Palpate spinous processes and facet joints of vertebra Feel for tenderness, swelling, temperature, crepitus, and atrophy Sacroiliac joint for tenderness (Faber maneuver) Enthesitis: tenderness over tendinous insertions (over chest wall, iliac crests, patella, tibial tuberosity, patella, Achilles tendon, fascia near heel) Active range of movement (ROM)Show the patient how to perform each movement: Flexion (most affected) Extension Lateral bending Rotations Special tests Occipital-to-wall distance Spurling's sign Schober's test Faber test Straight leg raising Crossed straight leg raising Lasègue's sign Further comment that you would perform a complete cardiovascular system examination. (Aortic regurgitation is the most common cardiac manifestation with AS.  Conduction abnormalities, ascending aortitis, and pericarditis may also occur) Wrap-up Thank the patient and tell them that they can now cover up Wrap up your findings and ask if the patient has any concerns M. S. Saravi and M. H. Sherazi

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291 Frozen Shoulder (adhesive capsulitis): -Silver clues: Previous trauma and immobilization, his-tory of heart attack, history of chronic neck pain, and diabetes. -Note: The golden clue in the physical exam is the restriction of passive motion. Shoulder Instability: -Silver clues: Previous shoulder dislocation needing closed reduction, pain which is worse with some activi-ties such as breast stroke swimming or putting on a jacket.-Note: Positive apprehension test, sulcus test, and signs of generalized joint laxity like hyperextension of elbows are important clues at the physical exam. They must all be present along with some positive gold or silver clues from the history. Complete Tear of Rotator Cuff: -Sudden loss of shoulder active motions after an injury - such as falling from standing height and sudden shoulder pain while pushing a heavy object -is indicative of this injury. Inability to move the shoulder after successful Shoulder e xtension Shoulder fle xion Exter nal Internal Internal rotation Exter nal rotation Horizontal rotation Adduction Abduction Fig. 10. 12 Shoulder movements. (Reprinted with permission from Malik S, Pirotte A.  Ch 16. Shoulder. In: Sherman SC (ed). Simon's Emergency Orthopedics, 7e. Mc Graw-Hill Medical. 2015) 10 The Musculoskeletal System

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292 closed reduction of a dislocated shoulder in a middle-aged to elderly patient will also lead to this diagnosis. -There would be no limitation of passive motion unless complicated with secondary frozen shoulder. The spe-cific tests for rotator cuff will have positive results. The chronic forms can be presented quite like impingement syndrome or osteoarthritis among the elderly. Metastatic Lesions: -The proximal humerus is one of the most common sites for metastatic tumors. -Silver clues: History of cancer or weight loss. Biceps Tendinitis -Silver clues: pain in front of shoulder, if it is the sole reason for the pain. Acromioclavicular Joint Osteoarthritis -Silver clues: pain mainly on top of shoulder, if it is the sole reason for the pain. Glenohumeral Osteoarthritis: -Among the elderly, associated with crepitation on pas-sive movements. There is a chance of limited passive movements. Uncommon (but Serious) Causes of Shoulder Pain: -Bone tumors: Primary or metastatic -Septic arthritis Specific age related causes of shoulder pain: Very young (first or second decade) with no trauma or insignificant trauma (hitting into another kid while run-ning at the school yard) presents acutely: -Pathologic fracture: Note: Proximal humerus is a common site for a uni-cameral bone cyst (UBC) or primary bone lesions such as an aneurysmal bone cyst (ABC). -Septic arthritis (silver clues of fever, malaise): Not very common, but grave in prognosis if not treated early. The shoulder is a deep joint like the hip, so you cannot expect the local signs of infection to be present all the time. The elderly without significant trauma: -Glenohumeral osteoarthritis -Acromioclavicular osteoarthritis -Metastasis -Septic arthritis History: 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 25  years old?” “Is it alright if I ask you a few questions about your shoul-der pain? I would also like to do a relevant physical examina-tion. It will involve watching and manipulating your shoulder and arm and performing some movements or tests that might be uncomfortable. Is that OK? At any point during the exam-ination if you have severe pain, please let me know, and I will stop immediately. At the end of the examination, we will dis-cuss the plan. ” Shoulder Pain: First establish the location of the pain. It should be in the question stem; otherwise ask the patient: “Can you show me where you feel pain?” Then go through the pain questions history as previously mentioned in the history details of this chapter. Important clues in history: Although pain of impingement syndrome can start sud-denly when there is a partial rotator cuff tear caused by trauma, but a gradual establishment of pain over days or weeks is more common. Pain caused by frozen shoulder starts insidiously after trauma and then decreases spontaneously when the stiff-ness becomes prominent over weeks to months. Pain of osteoarthritis of shoulder or acromioclavicular joint is gradually established. Timing: Pain caused by impingement syndrome, frozen shoulder, and bone tumors is worse at night. Location of the Pain: If the patient puts her palm over her deltoid muscle when asked about the location of her pain, that points toward impingement. If she puts her hand over her trapezius, think of the cervical spine. Putting her hand over the acromion might be a clue for acromioclavicular pathology. Indicating the anterior aspect of shoulder and humerus is indicative of biceps tendinitis. Radiation: The pain caused by impingement goes down to the deltoid insertion. Aggravating Factors: Pain caused by impingement gets worse with lying on the involved shoulder and by over-head activities. In severe cases, every attempt at active movement will increase the pain. Constitutional symptoms: Like fever, weight loss, fatigue. M. S. Saravi and M. H. Sherazi

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

293 Associated Symptoms: Weakness: Almost all shoulder disorders can be accom-panied with some degree of subjective weakness with or without objective weakness on examination. Prominent weakness warrants careful neurological testing to rule out neuropathy. Numbness: If present, think of cervical spine pathology. Stiffness: “Have you noticed any limitation in your shoul-der motion?” -The answer could be “yes” in cases of impingement and frozen shoulder. -Always consider “Polymyalgia Rheumatica” in patients over 50 years of age with bilateral shoulder pain and stiffness, especially if associated with morn-ing stiffness. If you are suspicious, ask about hip pain and stiffness and symptoms that might be related to the associated temporal arthritis like jaw claudication, scalp tenderness, visual changes, and headache. Past Medical History: Adhesive Capsulitis: Common for patients to have a his-tory of cervical discopathy, diabetes, myocardial infarc-tion, and shoulder trauma. Impingement Syndrome: Common for patients to have a history of mild to severe shoulder trauma. Never forget to ask about history of cancer especially from middle-aged or older patients, as the shoulder is a common location for metastasis. Shoulder Examination: “I am going to examine your shoulder now. Should we start?” Vitals: Start by commenting on the vitals given at the door. (It should include pulse rate, blood pressure, respiratory rate, temperature, and O2 saturation. ) Vital signs are normal or mention any abnormal findings. Inspection: Comment on: Position: Patient should be sitting with both shoulders exposed from their neck to their fingers. Properly drape the rest of the body. Inspect the joint from the anterior, lateral, and possibly from posterior angles. Compare to the other side and then comment on the presence of any SEADS: -“I don't see any swelling, erythema, atrophy, defor-mity, skin changes/rash/scar marks, loss of normal anterior/lateral curvature (dislocation), and winging of scapula. ”Sample Findings Description: “Both shoulders are at the same level and symmetric. There is no atrophy of the deltoid (axillary nerve injury), supraspinatus, and infraspinatus (long-lasting rotator cuff tears, impingement syndrome, or suprascapular nerve syndrome). ” Never forget to watch the hands and comment on any finding, as atrophy is a sign of a brachial plexus injury. Point your finger at those muscles or show the examiner with your head position that you are watching the correct spots and comparing with the normal side. “There are no deformities, swelling, or scars. ” Joint Palpation: Inform the patient again: “I am going to feel your shoulder, if you feel pain let me know. ” Feel for tenderness, effusion, swelling, temperature, crep-itus, fluctuance, and atrophy: Sternoclavicular joint Clavicle Acromioclavicular joint (acromioclavicular osteoarthritis) Acromion Subacromial space (impingement) Spine and body of the scapula Coracoclavicular joint Greater tubercle of the humerus Humeral head glenohumeral joint Supraspinatus, infraspinatus, deltoid, and biceps Bicipital grove (biceps tendinitis) Posterior shoulder (quadrilateral space syndrome) Range of Motion: Normal Range of Motion: Abduction: 150° Forward flexion: 180° Extension: 45-60° Rotation: test with the elbow flexed to 90° External Rotation: 90° Internal rotation: 70-90° Active Range of Movements: Ask the patient to stand and mimic your movement. Check active movements in abduction, forward flexion, extension, external rotation, and internal rotation (test with the elbow flexed at 90°). If there is any limitation of active movement, check the passive movement too; otherwise you may skip that. 10 The Musculoskeletal System

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