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< OSCE
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  • Pic 1: goitre - iodine deficiency, expands in size
  • Psychosocial history was done very poorly in the OSCE
  • Reasons for family history:
    • Genetic disorders (diagnosis)
    • Predisposed to diseases (diagnosis)
    • Person may know all about management already (psychol)
    • Increased anxiety about contracting disease (psychol)

Family history

  • Need full history (not just presenting illness)
  • Ask about parents, children, siblings
  • Parents alive/dead? What did they die from?
  • "Any illnesses in the family?"
  • Older people: "Tell me about your parents?"
  • "Tell me about your children. Are they well?"
  • Want to know any significant illness (not just the presenting ones) eg:
    • Hypertension
    • Diabetes etc
  • Good for confirming past history (might have left out some diseases)
  • Don't need doses or how often yet

Medication and allergies

  • People often leave out:
    • Contraception
    • Puffers
    • Eye drops
    • Pain killers
    • Over the counter drugs
    • Vitamins, herbal remedies
  • Mostly interested in allergies to medications, but also
    • Food or bee stings
    • Hayfever
    • Remember: a lot of people think they have allergies when they don't e.g. diarrhoea with antibiotics. This is normal. We're mostly interested in immune-mediated responses.
    • Ask them what they mean by an allergy.

Lumps and bumps

Features to note

  1. Site
  2. Size
  3. Shape
  4. Consistency
    • Hard/soft/bony/rubbery/firm/nodular (solitary or multiple). Note that lymph nodes in Hodkin's disease are rubbery. Also texture if applicable
  5. Tenderness
  6. Temperature
  7. Mobility or attachments
    • To skin? To bone? To muscle (tense muscle, moves less)?
  8. Fluctuation
    • Press liquid then it fluctuates - spreads all over the lump)
  9. Transillumination
    • Torch on a clear liquid lump (cyst, lymph, NOT blood)
    • Turn off light
    • Fluoresces
    • Fluorescence doesn't occur with solids or blood, but does a LITTLE with bone

Examples

  • Keloid
    • Scar tissue that went crazy
    • Firm, nontender, of normal temperature, nonfluctuant, does not transilluminate, and is attached to the skin
  • Hydrocele
    • Transilluminates
  • Oral carcinoma
    • Hard and craggy
    • Doesn't transilluminate
  • Oral fibroma
    • Benign tumour
    • Smooth, firm, non-tender
  • Abdominal lump
    • Under rib to suprapubic area
    • Spherical
    • Normal overlying skin
    • Incisional hernia
      • Operation damaged underlying tissue
      • Bowel etc herniates through fascia
      • Size of lump changes with movement/muscle contraction etc

Palpation of radial pulse

  • 2nd and 3rd finger
  • Need a watch with a second hand
  • Time for 15 seconds
  • Multiply by 4
  • Irregular pulse
    • Time for 30 seconds and multiply by 2
    • Amplitude

Lymph nodes

Neck anatomy relevant to the examination of lymph nodes. Orange = anterior triangle. Blue = posterior triangle
  • Generally go up in infections
  • Some people have raise LNs normally
  • Cancer
    • Can have LN involvement
    • Craggier, harder LNs
    • Check if it hurts - press tenderly

Sequence of examination

  1. Examine from standing at the back, both sides at once. Start under the chin, checking the submental and submandibular nodes, and the tonsillar nodes.
  2. Go to the angle of the mandible to check the submandibular nodes
  3. Preauricular nodes in front of ear
  4. Behind the ear - palpate the hard bony bit (may have LNs on top/superficially
  5. Go to occipital area - bony bits lateral to the midline at the back
  6. Check posterior triangle near trapezies
  7. Check the sternocleidomastoid area - over the muscle and the anterior area (both superficial and deep)
  8. Check supraclavicular nodes by getting the patient to shrug their shoulders, then palpating vertically with fingers behind the clavicle.

Psychosocial history

  • Don't ask everything of everybody (eg old man unlikely to be IVDU)
  • Focus of psychosocial history is based on the fact that 2 people with the same illness can have different outcomes due to a different psychosocial experience
  • Factors:
    • Lifestyle
    • Activities
    • Home
    • Personal

Lifestyle

  • smoking
  • drinking
  • exercise
  • diet
  • not everybody:
    • recreational drugs
    • sexual history

Activities

  • job - stress, environment (chemicals/hazards/sedentary)
  • hobbies
  • pets - respiratory/allergies etc
  • travel

Home

  • relationships
    • married
    • divorced
    • living alone
    • kids
  • support networks
    • family
    • church, etc
    • big effect on outcomes
  • location, living conditions
  • stairs
  • ADLs (activities of daily living)
    • cooking
    • cleaning
    • shopping
    • shower
  • ADLs especially important for old people/disabled

Personal

  • emotional/psychological state
  • capacity to cope with stress (particularly with chronic illness) e.g. are they a resilient old digger etc
  • financial stress, working long hours, not on top of things etc
  • socioeconomic, community, transport
  • stress of loss, feelings (not just death, but all sorts of things) - e.g. old man dies and his wife dies straight after
  • beliefs
    • religion
    • health beliefs
    • cultural
    • they may ignore you
    • Jehovah's Witnesses against blood transfusion

Additional resources