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Clinical Skills for OSCEs

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

Toxic goitre:

• diffuse (Graves’ disease), multinodular, toxic nodule (see above).

Hashimoto’s thyroiditis (see above)

Physiological goitre of puberty or pregnancy (or both)

Thyroglossal cyst:

• 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.

Enlarged lymph nodes

NB. Other, less likely, possibilities include thyroid carcinoma, branchial cyst, cystic hygroma

(lymphangioma), carotid body tumour, and sternocleidomastoid tumour.

151Ophthalmology, ENT, and dermatology

Station 55

Dermatological history

Before starting

• 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,

and obtain consent.

• Ensure that he is comfortable.

The history

• Name and age.

Presenting complaint

• Use an open question to ask the patient to describe his skin problem.

History of presenting complaint

Ask about:

• When, where, and how the problem started.

• What the initial lesions looked like and how they have evolved. Are the hair and nails also

involved?

• Symptoms: especially, pain, pruritus (itching), blistering, and bleeding.

• Aggravating factors such as sunlight, heat, soaps, etc.

• Relieving factors, including any treatments so far.

• Effect on everyday life.

• Details of previous episodes, if any.

Past medical history

• Previous skin disease.

• Atopy (asthma, allergic rhinitis, childhood eczema).

• Present and past medical illnesses.

• Surgery.

Drug history

• Prescribed and OTC/complementary medications, including topical applications such as gels

and creams.

• Cosmetics and moisturising creams.

• Relationship of symptoms to use of medication.

• Allergies.

Family history

• Has anyone in the family had a similar problem?

• Medical history of parents, siblings, and children, focusing on skin problems.

• Sexual contacts.

Clinical Skills for OSCEs

152 Station 55 Dermatological history

Social 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

during holiday periods?

• Hobbies (in some detail). Have the patient’s hobbies exposed him to any allergens or irritants?

Has he been using sunbeds?

• Home circumstances.

• Alcohol use.

• Smoking.

• Recent travel, especially to the tropics.

Systems review

(If appropriate.)

After taking the history

• Ask the patient if there is anything that he might add that you have forgotten to ask about.

• Thank him.

• Summarise your findings and offer a differential diagnosis.

• State that you would like to carry out a dermatological examination.

153Ophthalmology, ENT, and dermatology

Station 56

Dermatological examination

Before starting

• 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.

The examination

• Describe the distribution of the lesions: are they generalised or localised, symmetrical or asymmetrical, affecting only certain areas, e.g. flexor or extensor surfaces. Make a point of looking at

all parts of the body.

• 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,

ulceration, and scarring.

• Palpate the lesions (ask the patient if this is OK first). Assess their consistency. Do they blanch?

• Examine the finger nails and toe nails.

• Examine the hair and scalp.

• Examine the mucous membranes.

• Check for lymphadenopathy, if appropriate (e.g. if considering infection or malignancy).

• Check the pedal pulses, if appropriate (e.g. if considering vascular insufficiency or diabetic foot).

After the examination

• Offer to help the patient to put his clothes back on.

• Thank him.

• Ensure that he is comfortable.

• Wash your hands.

• Summarise your findings and offer a differential diagnosis.

Examiner’s questions: Differentiating skin cancers

BCC (75% of skin cancers) most often looks like a pearly bump or nodule on sun-exposed areas of skin.

Bleeding or crusting may develop in the centre of the tumour, as in the photograph below. In contrast,

squamous cell carcinoma (SCC, 20% of all skin cancers) most often looks like a red, scaling, thickened

patch, sometimes with bleeding, crusting, or ulceration. Although less common than either BCC or SCC,

malignant melanoma is more commonly fatal. Pigmented lesions of the skin should be suspected to

be malignant melanomas if they are asymmetrical, if they have irregular borders, if their colour varies

from one area to another, or if their diameter is larger than that of a pencil eraser (6 mm). This is easily

remembered as A, B, C, D.

Clinical Skills for OSCEs

154 Station 56 Dermatological examination

Figure 38. (A) Basal cell carcinoma (BCC). Reproduced under a Creative Commons License from: http://commons.

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

Psoriasis:

• 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

the scalp, palms, and soles.

• 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,

chloroquinine.

(A)

(B)

Ophthalmology, ENT, and dermatology

Station 56 Dermatological examination 155

Eczema:

• 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).

Acne vulgaris:

• 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.

Rosacea:

• chronic condition that primarily affects fair-skinned people and that is 2–3 times more

common in women.

• peak age of onset is 30–50.

• 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

(rhinophyma).

• may be aggravated by stress, sunlight, cold weather, alcohol.

Skin cancer (see Examiner’s questions above)

Clinical Skills for OSCEs

156 Station 57

Advice on sun protection

Read in conjunction with Station 116: Explaining skills.

Before starting

• 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.

The advice

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, other than causing skin cancer, UV radiation can also cause the skin to burn and (horror!)

to age prematurely.

UV levels depend on a number of factors such as the time of day, time of year, latitude, altitude, cloud

cover, and ozone cover.

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).

3. Use sunscreen.

• 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

more time in the sun.

Finally advise the patient to report any moles that change in size, shape, colour, or texture.

After giving the advice

• Summarise the information and ensure that the patient has understood it.

• Tell him that, if anything, he can remember ‘Slip, slap, slop’ – slip on some clothes, slap on a hat,

and slop on sunscreen.

• Ask him if he has any questions or concerns.

• Give him a leaflet on sun protection.

157Paediatrics and geriatrics

Station 58

Paediatric history

General points:

• 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

address both.

Before starting

• Introduce yourself to the parent and child (in that order), and confirm the child’s name and

date of birth.

• 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

distracted.

The history

• 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

• Ask about the nature of the presenting complaint and how it has affected the child’s daily routine. Start by using open questions and then explore the symptoms as you might in any other

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.

Systems review

• The major systems should be covered briefly, placing the emphasis on areas of particular relevance.

– 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

infections, heart murmurs

– 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

– skin: rash, eczema

Past medical history

Use the mnemonic ‘BINDS’, trying to be as age-appropriate as possible.

• Birth history:

– Maternal obstetric history: gestation at delivery, mode of delivery, place of delivery, complications before, during, and after delivery, drug history and smoking and drinking during

pregnancy

Clinical Skills for OSCEs

158 Station 58 Paediatric history

– Early paediatric history: birth weight, neonatal problems, admission to special care or neonatal unit

• 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?”

• Social: is the child sleeping through the night? Is he playing as he usually does? Is he thriving at

nursery or school?

• Medical: asthma, diabetes, epilepsy, previous hospital admissions and surgery.

Drug history

• Prescribed and over-the-counter medications.

• Allergies.

Family history

• 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?”).

Social history

• Parental occupation.

• Details of home life, siblings.

• Behaviour at home and at school.

• Pets and smokers in the home (if relevant).

After taking the history

• Ask the parent and child if there is anything that they might add that you have forgotten to ask about.

• Ask the parent and child if they have any specific questions or concerns.

• Thank the parent and child.

• 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.

• Headache.

• Behavioural problems, e.g. enuresis.

• Fits, e.g. febrile convulsions, epilepsy.

• Childhood infections/rashes and immunisation compliance (see Station 67: Child immunisation

programme).

159Paediatrics and geriatrics

Station 59

Developmental assessment

Development in the early years of life is fairly consistent from child to child. Any significant deviation

from this pattern requires further investigation or at least close follow-up.

The developmental assessment is usually performed alongside a general paediatric history (see Station

58). However, in an OSCE setting, you may simply be asked to watch a short video and answer some

questions about it. If you are asked to carry out a developmental assessment, remember to tailor your

assessment to the age of the child, and that much of the assessment can be carried out by observation

alone.