150 Station 54 Lump in the neck and thyroid examination
Conditions most likely to come up in a lump in the neck and thyroid examination station
• diffuse (Graves’ disease), multinodular, toxic nodule (see above).
Hashimoto’s thyroiditis (see above)
Physiological goitre of puberty or pregnancy (or both)
• fibrous cyst that forms from a persistent thyroglossal duct.
• midline lump in the region of the hyoid bone that is smooth and cystic and usually painless.
• moves upwards upon swallowing and upon tongue protrusion.
NB. Other, less likely, possibilities include thyroid carcinoma, branchial cyst, cystic hygroma
(lymphangioma), carotid body tumour, and sternocleidomastoid tumour.
151Ophthalmology, ENT, and dermatology
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain that you are going to ask him some questionsto uncover the nature of hisskin problem,
• Ensure that he is comfortable.
• Use an open question to ask the patient to describe his skin problem.
History of presenting complaint
• When, where, and how the problem started.
• What the initial lesions looked like and how they have evolved. Are the hair and nails also
• Symptoms: especially, pain, pruritus (itching), blistering, and bleeding.
• Aggravating factors such as sunlight, heat, soaps, etc.
• Relieving factors, including any treatments so far.
• Details of previous episodes, if any.
• Atopy (asthma, allergic rhinitis, childhood eczema).
• Present and past medical illnesses.
• Prescribed and OTC/complementary medications, including topical applications such as gels
• Cosmetics and moisturising creams.
• Relationship of symptoms to use of medication.
• Has anyone in the family had a similar problem?
• Medical history of parents, siblings, and children, focusing on skin problems.
152 Station 55 Dermatological history
• Occupation (in some detail). Has the patient’s occupation exposed him to any allergens or
irritants? Have colleagues been suffering from similar symptoms? Do the symptoms improve
• Hobbies (in some detail). Have the patient’s hobbies exposed him to any allergens or irritants?
• Recent travel, especially to the tropics.
• Ask the patient if there is anything that he might add that you have forgotten to ask about.
• Summarise your findings and offer a differential diagnosis.
• State that you would like to carry out a dermatological examination.
153Ophthalmology, ENT, and dermatology
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain the examination and obtain his consent.
• Ask him to undress to his undergarments and temporarily cover him up with a sheet or blanket.
• Ensure that he is comfortable.
• Ask him to report any pain or discomfort during the examination.
• Ensure that there is adequate lighting.
• Describe the morphology of the individual lesions, commenting upon their colour, size, shape,
borders, elevation, and spatial relationship. Use precise dermatological terms. The ‘Handbook
for medical students and junior doctors’ by the British Society of Dermatologists (freely available
online) contains a useful glossary of dermatological terms with accompanying images.
• Note any secondary skin lesions such as scaling, lichenification, crusting, excoriation, erosion,
• Examine the finger nails and toe nails.
• Examine the mucous membranes.
• Check for lymphadenopathy, if appropriate (e.g. if considering infection or malignancy).
• Offer to help the patient to put his clothes back on.
• Ensure that he is comfortable.
• Summarise your findings and offer a differential diagnosis.
Examiner’s questions: Differentiating skin cancers
malignant melanoma is more commonly fatal. Pigmented lesions of the skin should be suspected to
154 Station 56 Dermatological examination
wikimedia.org/wiki/Category:Basal-cell_carcinoma#mediaviewer/File:Basaliom_am_Nasenrücken_2.JPG. (B)
Squamous cell carcinoma. Reproduced from http://commons.wikimedia.org/wiki/Category:Squamous-cell_
carcinoma_of_the_skin#mediaviewer/File:Squamous_Cell_Carcinoma.jpg
Conditions most likely to come up in a dermatological examination station
• chronic, autoimmune skin disease.
• plaque psoriasis is most common type (c. 90%).
• red plaques with silvery scales due to inflammation and excessive skin production.
• frequently on the extensor aspects of elbows or knees, but can also affect any area including
• may be accompanied by nail dystrophy.
• may be accompanied by joint inflammation (psoriatic arthritis).
• may be aggravated by stress, alcohol, smoking, and certain drugs, e.g. lithium, beta blockers,
Ophthalmology, ENT, and dermatology
Station 56 Dermatological examination 155
• most common types are atopic or flexural eczema and irritant-induced contact dermatitis.
• recurrent dryness, itching, and skin rashes that may be accompanied by redness,
inflammation, cracking, weeping, blistering, crusting, flaking, and skin discoloration.
• frequently on the flexor aspects of joints (cf. psoriasis).
• changes in the pilosebaceous units as a result of increased androgen stimulation.
• comedones (blackheads), inflammatory papules, pustules, and nodules that affect the face
and neck and also the chest, back, and shoulders, and that can result in scarring.
• usually appears during adolescence and may persist into early adulthood.
• chronic condition that primarily affects fair-skinned people and that is 2–3 times more
• typically begins as flushing and redness centrally on the face.
• may be accompanied by telangiectasia, red domed papules and pustules, red gritty eyes,
burning and stinging sensations, and, in some advanced cases, a red lobulated nose
• may be aggravated by stress, sunlight, cold weather, alcohol.
Skin cancer (see Examiner’s questions above)
Read in conjunction with Station 116: Explaining skills.
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Tell him what you are going to explain, and determine how much he already knows.
• Enquire about and explore any concerns that he may have.
Explain that there are three types of ultraviolet radiation from the sun: UVA, UVB, and UVC.
• UVA and UVB can cause skin cancer (think UV-’Bad’).
• UVC does not reach the surface of the earth and is therefore of no concern.
Explain that there are three principal methods of protecting against the sun’s rays:
1. Avoid the outdoors and seek shade. The sun’s rays are most direct around midday and so one
should avoid being outdoors from around 11 am to 3 pm.
2. Cover up (clothing should include a wide-brimmed hat and sunglasses that conform to British
and European Standard BS EN 1836:2005).
• A sunscreen’s star rating is a measure of its level of protection against UVA.
• A sunscreen’s sun protection factor is a measure of its level of protection against UVB.
• Use a sunscreen that has a star rating of at least three stars *** and an SPF of at least 15.
• The sunscreen should be applied thickly over all sun-exposed areas, and re-applied regularly.
It is important to stress that sunscreens should not simply be used as a means of spending
Finally advise the patient to report any moles that change in size, shape, colour, or texture.
• Summarise the information and ensure that the patient has understood it.
• Ask him if he has any questions or concerns.
• Give him a leaflet on sun protection.
• As a rule of thumb, the older the child the more he should be involved in the history-taking
process. Try to surreptitiously (indirectly) assess the child’s capacity.
• Observe the child’s behaviour and interaction with the parent as you take the history.
• The parent’s concerns and the child’s concerns are likely to differ: try as much as possible to
• Introduce yourself to the parent and child (in that order), and confirm the child’s name and
• Explain that you are going to ask some questions and obtain consent.
• Ensure that the patient is comfortable; younger children may need some toys to keep them
• Verify the sex, and preferred name of the child.
• Confirm the relationship of the accompanying adult or adults.
Presenting complaint and history of presenting complaint
history. Ask about onset, duration, previous episodes, pain, associated symptoms (e.g. nausea,
vomiting, diarrhoea, urinary frequency, constipation, altered consciousness), and treatments.
Do not under any circumstances denigrate, or omit to address, the parent’s concerns.
– general health: liveliness, change in behaviour, feeding, fever
– ENT: sore throat, earache, infections, deafness, nose bleeds
– CVS and RS: breathing problems (feeding problems in young infants), shortness of breath,
exercise tolerance, colour changes (blue attacks, pallor), cough, croup, wheeze, stridor, chest
– GIS: weight gain, feeding, vomiting, diarrhoea, constipation, jaundice, abdominal pain
– GUS: frequency, discharge, enuresis
– NS: headaches, fits, visual disturbances, balance and coordination, muscle problems
– MSS: limps, joint stiffness, pain, swelling, redness
Use the mnemonic ‘BINDS’, trying to be as age-appropriate as possible.
158 Station 58 Paediatric history
• Immunisations: are immunisations up to date? Have there been any problems?
• Nutrition and growth: is the child eating and drinking? For an infant, enquire whether he is
breast- or bottle-fed, how much he consumes (quantify), and how often. Ask for the child health
record or ‘red book’ and survey the growth charts, immunisation history, and any other entries.
• Development: do not ask whether the child is ‘developing normally’. Ask instead, “Do you have
any concerns with his/her development?”
• Medical: asthma, diabetes, epilepsy, previous hospital admissions and surgery.
• Prescribed and over-the-counter medications.
• Health of parents and siblings, especially if an infective aetiology is being considered.
• Congenital/genetic abnormalities (“Are there any illnesses that run in the family?”).
• Consanguinity (“Prior to getting married, were you and your partner related in any way?”).
• Details of home life, siblings.
• Behaviour at home and at school.
• Pets and smokers in the home (if relevant).
• Ask the parent and child if they have any specific questions or concerns.
• Summarise your findings and offer a differential diagnosis.
Conditions most likely to come up in a paediatric history station
• Respiratory conditions, e.g. asthma, upper respiratory tract infection.
• Behavioural problems, e.g. enuresis.
• Fits, e.g. febrile convulsions, epilepsy.
• Childhood infections/rashes and immunisation compliance (see Station 67: Child immunisation
from this pattern requires further investigation or at least close follow-up.
58). However, in an OSCE setting, you may simply be asked to watch a short video and answer some
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