Documentos de Académico
Documentos de Profesional
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January 1
MRCGPINT
OSCE 2011
DR.ABDELNASIR ABBAS ELSHEIKH DRSAWSAN GAMAL ELDIN 3rd
MRCGP-INT NGHA MRCGP-INT RKH-RIYADH
EDITION
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Erectile Dysfunction
He has a great social circle which has supported him over the last two
years since his wife died of cancer. In the last few months he has
entered a new relationship and has discovered he has erectile
impotence (he can only achieve a partial erection and has lost his
normal early morning erections and is unable to achieve a full erection
during masturbation). This is worrying him and he is keen to sort it out,
although a little embarrassed about having to see a GP about the
problem.
His ideas are (he has an erection problem and attributes it to his age),
concerns are (he is worried his GP will think that old men like him
should not be bothered about sex, also he is worried about Viagra and
his history on MI) and expectations are (a trial of Viagra, as
recommended by a few of the chap in the golf club).
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He has no allergies.
Examination Card
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Chronic fatigue
She is married but her husband is disabled with MS and her two
children have left home.
She feels as though she is tired all the time ‘as though wading through
treacle’ and all her muscles ache ‘as if I had just done a marathon’. Her
concentration is poor and she can fall asleep at any time and has been
sleeping in excess of 10 hours a day.
She wants a diagnosis and her symptoms sorting out. She has privately
wondered if she may have chronic fatigue syndrome, as she has
recently typed a referral letter about a patient with symptoms just like
hers who was being referred to the Chronic Fatigue Service at the
hospital.
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DIABETES
Mr G
An overweight man in his late 50s, young child and young wife.
Stressful job at the moment.
PMH – Gout, AF, TIA, Type 2 diabetes, peptic ulcer disease, amblyopic
in his right eye
FH – IHD
1. Hba1c – 7.5%
2. Cholesterol 4.5 and LDL 2.2
3. U&Es are ‘normal’ but e-GFR 58
4. Urate slightly elevated
5. BP 145/85
6. Urine ACR 4.5
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Mr G
An overweight man in his late 50s, young child and young wife.
Stressful job at the moment.
PMH – Gout, AF, TIA, Type 2 diabetes, peptic ulcer disease, amblyopic
in his right eye
FH – IHD
7. Hba1c – 7.5%
8. Cholesterol 4.5 and LDL 2.2
9. U&Es are ‘normal’ but e-GFR 58
10.Urate slightly elevated
11.BP 145/85
12.Urine ACR 4.5
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Palpitations
Dave is 55 and soon to retire. He has been self employed all his life
and is selling his business to enable him to take early retirement, as
both his children are now in full employment having finished their
university degrees.
Dave runs a plumber’s merchant store and is soon to sell his business.
Although he feels this is the right thing to do he has started to worry
about the life changes which will follow. He has enjoyed developing his
business and being the boss and now that there is a buyer for the
business he wonders how he will fill his time.
In the last few weeks leading up to the signing of the contacts he has
been waking up in the early hours with palpitations and a tight chest
which he has attributed to stress. A few nights ago he had a ‘bad do’
which lasted over an hour when his heart played the ‘devils tattoo’
during which he had chest tightness and sweating. This has worried
him, as his dad had a heart attack in his early sixties. He has decided to
have a check up.
He has no previous medical history of note and has been fit and well.
He drinks 10 pints a week and smokes a few Monte Cristo cigars at
weekends to help him relax.
He is happily married and his two children are doing well in their
chosen careers. He loves his classic Triumph TR4a sports car.
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Examination Card
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Osteoporosis
Jim is 49 and had presented with chronic thoracic back pain over the
last year. A thoracic spine X-ray revealed osteopaenia and a spinal
wedge fracture of T5. As a consequence of which you arranged a
DEXA scan which has just come back revealing a T score of -3.0 for
both hip and spine. He is using paracetamol and ibuprofen for his back
pain.
Jim restores vintage cars which can be quite a heavy job and his back
pain has been causing problems at work. He is married with two
children at university and things are financially difficult at a result.
He is currently using paracetamol and ibuprofen for his back pain. His
main objective is to get better analgesia so he can continue working.
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hypertension
Neil is 44 years old and has recently joined the practice when he and
his family moved into the area to work at the local chemical plant.
He has had his new patient medical and the notes read
12th of Jan
New patient medical
No PMH of note
No FH of note
Married, non smoker, 28 units per week
BMI 28
BP 170/100 re-check monthly for 2 months
22nd of Feb
BP 165/98
4th of March
BP 160/95 – to see GP
Neil is 44 years old, married and has two teenage children. They have
recently moved into the Practice area to take up a new job in the
nearby chemical plant. He is enjoying the new job and the children
seem to be settling into their new school.
He has no medical history of note. He is an only child; mum and dad are
both alive and well.
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Examination Card
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John is a 30 year old policeman who last saw his GP 10 years ago for a
sore throat. He has no previous medical history of note and is on no
medication.
John is a 30 year old policeman who is happily married with two young
children. His job is stressful, as he covers a tough part of town. Over
the last six months he has been getting indigestion at night with reflux
symptoms. He has been buying OTC Gaviscon which initially provided
some relief but now is failing to control his symptoms.
He has been using Tescos Ibuprofen for a pain in his left foot (pain in
his heel pad) which he attributes to ‘walking the beat’ eight hours a
day.
He does not have any difficulties swallowing or any weight loss. He has
not been vomiting, his bowels are fine and has never passed blood pr.
John has been on the internet and has read about H Pylori infection as a
potential cause of ulcers.
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Examination Card
BMI 24. No anaemia, no clubbing, no jaundice, abdo soft and non tender
with no masses. No abnormalities found on foot examination.
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Len is 60 and runs the local garage which specialises in vintage car
restoration. He is has no previous medical history of note and is on no
regular medication.
Len is 60 and runs the local garage which specialises in vintage car
restoration. Although he is the boss with a couple of employees he still
has to help out test driving cars, dealing with customers and lending a
hand with the ‘heavy stuff’.
Three weeks ago while helping lift a gearbox into a Riley his ‘back
went’ and he has had low back pain radiating to his right knee ever
since. It does not wake him from sleep but it is interfering with work
and preventing him playing his weekly 18 holes of golf.
He is worried as his dad presented the same way and it turned out he
had lung cancer with spinal secondaries. Len had been a light smoker
(10 a day for 30 years) until he stopped on his 50th birthday. As his
pain has gone on so long he can’t help wondering if he might ‘have
something serious’.
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Examination Card
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Depression
Samantha has recently been made redundant (from a travel agency) due
to the current economic situation. Her husband who works full time has
had to take on overtime to help make up some of the financial shortfall.
In the last month or so she has become tearful, low in mood and short
tempered with her husband and children. She no longer enjoys reading
which had been one of her ways of relaxing after the boys have gone to
bed. Even if she did want to read she feels her concentration is so poor
that it would be pointless.
She has been drinking more than she should (half a bottle of wine night)
to help her get to sleep. She is not suicidal but very low and feels
worthless since the loss of her job and now despairs over her son’s
‘teenager behaviour’.
After another argument with her son she has decided she needs help
and has come to see her GP. Is there a tablet that might help?
Areas the candidate should explore/offer
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He has had Type 2 diabetes for 10 years and has been on maximum
tablet treatment for the last 3 months. His diabetes is still poorly
controlled, such that he suffered from fatigue and having to pass urine
3x per night.
Other than his diabetes he has hypertension for which he takes ramipril
10mg one table a day and an elevated cholesterol for which he takes
simvastatin 40mg a day. He also takes aspirin 75mg a day but is not
sure why he is on it.
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[MRCGP-INT-OSCE scenarios 2011 ]
Examination findings
72.His ideas, concerns and expectations around diabetes & insulin AND
address some of the negative views he may have.
73.The presence or absence of osmotic symptoms (thirst, fatigue,
blurred vision, frequency of micturition etc).
74.An explanation of how he can help himself (diet, exercise, etc) with
respect to reducing the risk of weight gain and insulin conversion.
75.Explore possible options 1 Refer to diabetes specialist nurse. 2
Refer to specialist service. 3 Manage in-house. (E.g. once daily
insulin with metformin and sulphonylurea & possible pio cessation,
twice daily bi-phasic insulin with metformin & SU cessation and
possible pio cessation).
76.Safety netting – arrange review to answer further questions and
address his ICE.
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[MRCGP-INT-OSCE scenarios 2011 ]
Shoulder Pain
Jane is a 45 year old divorcee. She looks after her elderly demented
mum who has become very dependent in the last couple of years. She
manages to hold down her job as a secretary by using home care, a day
centre and sitter services.
Jane is a 45 year old divorcee. She looks after her elderly demented
mum who has become very dependent in the last couple of years. She
manages to hold down her job as a secretary by using home care, a day
centre and sitter services. The one thing that enables her to keep going
is her passion for judo. She trains twice a week and this helps her burn
off her stress and has greatly helped her self esteem. She has recently
passed her grading so that not only is she a black belt but she is taking
a course on teaching judo.
Over the last four months she has suffered from shoulder pain which
she attributes to a bad throw during a judo tournament. She has tried
ibuprofen to no avail, so she went to an osteopath who was expensive
and unable to help. The pain in her shoulder is getting more intrusive
such that it hurts at every training session and even on the days when
she is not training. It is starting to causes problems with handling and
lifting her mum and to make matters worse she has an important
tournament coming up soon.
She feels the pain over the outside of her shoulder and upper arm. The
pain now occurs while performing overhead activities (with the arm
above head height) and pain at night has become quite common. After a
training session she can even have difficulty performing simple
activities such as combing her hair.
Other than one episode of depression around the time of her divorce 5
years she has no medical history of note.
One of the judo team have suggested going to a sports physio while
another recommended a steroid injection and her friend suggested she
should get an MRI! She has no idea which avenue might produce the
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outcome she desires (sport with no pain – preferably by the time of the
next tournament three weeks away).
The pain caused her to almost drop her mum while she was helping her
transfer and it is this and the imminent tournament which has triggered
her attendance today.
Areas the candidate should explore/offer
Simulators to feign pain when lifting their arm above shoulder height
but otherwise to have a full range of movement in their shoulder.
Examination Card
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Hirsutism
She has been surfing the net and has seen an article on Polycystic
Ovary Syndrome which seems to be an exact description of her (excess
hair growth, acne, irregular periods etc) and she is interested in the
article that recommends metformin as a treatment.
She is a non smoker, non drinker, enjoys her job and is worried about
her excessive body hair as she feels it’s unsightly and may cause
problems with potential future relationships.
She has no family history of note other than Type 2 diabetes (dad) and
none of her siblings or her mum has excess body hair.
She had little PMH of note other than acne in her teenage years and a
recent attendance because of concerns over her irregular periods.
Ideas – She believes she has PCO, medication will sort it out, shaving is
bad because it makes hair grow quicker.
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93.Safety netting.
Examination Card
BMI 29, prominent facial hair, mild acne and hair on her arms.
No male pattern balding, voice normal, no hair on chest or back
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Prostatism
His mother died in her 50s from chronic renal failure as a complication
of her diabetes. His father is still fit and well.
He enjoys fell walking with his wife. He drinks 20 units a week and is
an ex smoker.
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Examination Card
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TIA
Phillip is 61 years old and his daughter has made him book into the on
call surgery. He is an ‘infrequent attender’ and his last consultation was
in 1995 when he had hurt his back.
DH - None
Phillip is 61 years old, married and both his children have left home. He
is use to robust good health and has only seen a GP four times in his
life! His last consultation was in 1995 when he had hurt his back.
He has no medical history of note. His mother is still alive and well in
her 80s but his father who had diabetes died of metastatic lung cancer.
He is on no medication
Concerns – None
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Examination Card
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Headache
Mrs Thomas is a 68 yr old lady who is usually fit and well. She usually
avoids coming to the doctors as she treats common ailments with
homeopathy. Her sister suffers from mental health problems and
learning difficulties. Mrs Thomas has recently come back from America
after a 2-month stay with her daughter and family.
The pain is more in the right frontal and parietal scalp area, she has no
jaw tiredness or pain, no ear, hearing problems, nausea or vomiting etc
and her vision is ok. Her scalp doesn’t hurt when she combs her hair
and she reports no injuries. She feels worried but not depressed,
appetite is normal, though she has been feeling a bit tired for a few
days because she has been lying awake thinking about things.
Although she doesn’t like taking tablets she has had to resort to taking
ibuprofen that her husband takes for his arthritis. This is a big step
because she usually finds ‘cures’ for her ailments in homeopathy. She
is worried about it being a brain tumour, as her 34-year-old daughter
who lives in the USA was found to have a benign brain tumour on a
routine company medical exam CT scan.
Apart from this she is constantly worried about her sister who has
learning difficulties as well as mental health problems. Amy is currently
admitted to a hospital where she was recently assaulted by another
patient. She feels guilty about her being in a mental institution, whereas
she herself enjoys a good life.
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She lives with her 72-year-old husband, who is a retired banker and
there are no other worries. She doesn’t smoke, drink excessively or
take any regular meds. There are no known allergies.
Examination findings
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Katie is 15 years old and has no PMH of note and last saw her GP 3
years ago regarding acne.
Katie is 15 years old and lives with mum, step dad and two younger
brothers. She goes to Wyke Manor school and is managing ok. She has
a 16 year old boyfriend Dan who is in the class above hers.
She has just started a sexual relationship with Dan and has been using
condoms and both are keen for her to go on the cocp. Katie has a
friend on the pill who says it’s great. Katie has no idea of other
contraception methods although she had overheard someone talking
about an injection.
She does not want her mum and stepdad knowing as they ‘have found
religion’ and she will not accept their involvement at any price! As a
consequence she is quite shy when she first meets the GP and skirts
round the issue of the pill request with a ‘sore throat presentation’,
although she soon discloses her hidden agenda
Katie drinks and smokes at parties but not much else as her parents
would ‘smell it a mile off’.
Other from acne a few years ago you have had no other medical
problems and you don’t know of any family history of illness.
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Marilyn is a 15 years old patient who last came to the surgery two
years ago with sore throat which was treated with Penicillin.
DH: NKDA
Nil Regular
Examination Card:
O/E Temp: 36.8, There is a small early cold sore on her lip..
You are Marilyn 15 years old doing GCSEs at school. You have
developed a small ulcer on the sides of your lip for last 2-3 days.
There is no itching or discharge from the ulcer.
You are under some stress these days as you are preparing for GCSE
exams which are coming up in 4-6 weeks.
You do not have any genital ulcers and do not have any vaginal
discharge. LMP 3 weeks ago. No urinary symptoms.
A friend says that you have ‘herpes’ and a google search mentions the
possibility of genital ulcers and STIs!
You think your doctor will give might offer you some investigations and
treatment to find out what the ulcers are and treat them.
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You are fit and well and never smoked and do not take any medication.
You only drink on weekends when you go out with friends.
You live with your parents and do not have good relations with your
mum. Your elder brother is studying law at a university in London and
come home after 2-3 months. You do not have any not other close
relatives in this city.
You will be open to discuss any issues that the doctor may identify.
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DH nkda
You were playing rugby on the beach when you were on holiday in
Spain last week. You were tackled when you foot was caught in the
sand, and noticed immediate pain in your right knee. You can’t recall
how what direction the person came at you from.
You noticed severe pain in your knee immediately, and you had to sit
out the rest of the game. You put some ice on it but it really hasn’t
helped.
You have taken the odd ibuprofen but it doesn’t seem to be helping
either.
Unable to weight bear. You had our friends help you get about
especially when you were on nights out in Spain celebrating on your
friends stag/ hen night.
You are really worried that you may have damaged one of the
ligaments in your knee as you play first team hockey for your local
team and you have some important matches coming up.
You work in a local bar as that gives you the flexibility to train and
compete in matches.
You know that this would be a very serious injury and it really worries
you as sport is very important to you ,
You are happy to listen to what the doctor has to say, and will accept
pretty much any management. You have insurance, and would be happy
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[MRCGP-INT-OSCE scenarios 2011 ]
Examination Findings
Data Gathering
Interpersonal Skills
Develops rapport
Good use of open and appropriate close questions
Active listening
Encourages patients contribution
Elicits patients ideas
Elicits patients concerns
Elicits patients expectations
Encourages patients involvement in management
Incorporates patients healths beliefs into management plan
Ensures patients understanding
Clinical Management
Comes to diagnosis of likely ACL rupture
Discussed likely needs orthopaedic review, may need immobilisation
and possible operation
Discussed NHS versus private referral
Discusses likely time to recovery
Alcohol consumption counselling
Safe and appropriate follow up and safety netting
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It’s a busy post bank holiday Tuesday and you’re on call. A receptionist
rings through at the end of your morning surgery to say that they have
received a fax that needs actioning. She brings it through.
Dear Doctor,
Looking at his records you can see he had a ‘fast track’ referral four
weeks ago after presenting with a history of altered bowel habit. The
only clinic letter in the records relates to his normal sigmoidoscopy and
planned colonoscopy.
What are your objectives for this home visit and how do you
intend to achieve them?
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A worried relative
Another busy on call day and to make matters worse you notice an
extra being adding to the end of your morning surgery. It’s a telephone
consultation flagged as ‘Please speak with daughter Janice – Living in
Spain so she will be ringing you at 12:00 – daughter requesting a home
visit’.
What are your objectives for this home visit and how do you
intend to achieve them?
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