9 Jan 2011 Sudan referendum-pray for Sudan

January 1

MRCGPINT OSCE
DR.ABDELNASIR ABBAS ELSHEIKH MRCGP-INT NGHA

2011
3rd EDITION

DRSAWSAN GAMAL ELDIN MRCGP-INT RKH-RIYADH

[MRCGP-INT-OSCE scenarios

2011 ]

This book will show how the osce scenarios set, and the simulated patients preparation, which help candidate to be ready for SP challenging . Here are some sample of OSCE case scenarios, i hope you will get the max benefit, you can return back to the 1st and the 2nd editions for more detailed on how you can approach each case.

Gratitude Dear Dr.Sawsan I'm not sure how to best say it so here goes: THANK YOU! You are a true and genuine wife and I appreciate very much the thoughtfulness and support. Best regards,

[ABDELNASIR]

[MRCGP-INT-OSCE scenarios Cases scenarios to facilitate MRCGP OSCE assessment

2011 ]

Erectile Dysfunction Notes for candidate MR X is a 65 year old widower. He is now retired and enjoys life to the full. He has a PMH of MI 10 years ago and occasionally gets classical angina with strenuous exertion. He can however play 18 holes of golf with no problems. DH GTN spray, aspirin, ramipril, atenolol and simvastatin Notes for simulator MR X is a 65 year old widower. He is now retired and enjoys life to the full. He has a PMH of MI 10 years ago and occasionally gets classical angina with strenuous exertion (he has not needed his GTN spray in the last 6 months). He can play 18 holes of golf with no problems. 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. He has decided to see the GP with a vague backache to check them out and if they seem approachable then to discuss his erection problems. 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). MR X in a non smoker since his MI and drinks little alcohol. He has no family history of note.

[MRCGP-INT-OSCE scenarios

2011 ]

He has no symptoms of diabetes (blurred vision, thirst, fatigue, weight loss, frequency etc). He has no urinary symptoms. His current medication includes: GTN spray, aspirin, ramipril, atenolol and simvastatin He has no allergies. Areas the candidate should explore/offer 1. His hidden agenda. 2. His ideas, concerns and expectations. 3. What he means by erection problems (partial, complete, sudden onset, gradual onset, absence of morning erections etc). 4. Important medical red flags e.g. frequency of GTN use, symptoms of stress or depression or guilt, symptoms of diabetes, hypogonadism etc. 5. Alcohol, drug and smoking history. 6. Examination - Pulse, BP, external genitalia. 7. An explanation of possible causes e.g. arterial disease/poor blood flow 8. Investigation e.g. U&Es, fasting BS, cholesterol & LDL, LFTs and testosterone. 9. A good explanation of treatment options focussing on PDE5 inhibitors (Cialis, Viagra etc). 10.An explanation of how PDE5 inhibitors work, how to take them, potential side effects, PDE5s and IHD. The fact he will need to pay for them. 11.Safety netting for assessment of effect, potential side effects or exploration of alternatives.

Examination Card Pulse 80 reg, BP 135/70, external genitalia normal

[MRCGP-INT-OSCE scenarios Chronic fatigue Notes for candidate

2011 ]

MS B is 50 years old and works as a typist in a neighbouring Practice. She had little PMH of note other than an episode of back pain a year ago and irritable bowel syndrome 10 years ago. She was last seen 10 months ago for her low back pain. She is married but her husband is disabled with MS and her two children have left home.

Notes for simulator MS B is married but her husband is disabled with MS and her two children have left home. She has had profound fatigue for the last five months and has soldiered on. She has come today as she has been in trouble with her Practice Manager, as she fell asleep at work and the standard of her work has deteriorated dramatically. Wendy is fearful that she may loose her job (she is the sole wage earner). 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 has a happy marriage and although her husband is disabled he copes very well at home with all the aids and adaptations OT have fitted in the home. She is not depressed but is worried over the possibility of losing her job and is sick of feeling tired all the time! Her weight is steady and she has no symptoms of diabetes (thirst, blurred vision, urinating ++ etc). She has no history of joint swelling or inflammation and no history of rectal or vaginal bleeding. 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.

[MRCGP-INT-OSCE scenarios Areas the candidate should explore/offer

2011 ]

12.Her ideas, concerns and expectations 13.Her mental state depression, stress etc. 14.Important medical red flags e.g. weight loss, weight gain, constipation, rectal or vaginal bleeding, joint swelling, thirst, urinating ++, (re diabetes, hypothyroidism, anaemia, arthritis etc) 15.Alcohol, drug and smoking history 16.An explanation of possible causes stress, depression, underactive thyroid, anaemia, diabetes etc. 17.Investigation e.g. fasting BS, FBC, ESR, TSH 18.An explanation of the possible treatments for the diagnosis they propose e.g. a patient information leaflet on CFS, advice re graded exercise and diet, possible referral to the local CFS clinic and or sign post to other resources e.g. the action for ME website www.afme.org.uk 19.Safety netting.

IF THE DOCTOR OFFERS EXAMINTION THERE ARE NO ABNORMALITIES TO BE FOUND

[MRCGP-INT-OSCE scenarios

2011 ]

DIABETES Mr G An overweight man in his late 50s, young child and young wife. Stressful job at the moment. Last consultation focussed on stress and debt management Prior to that he was counselled about his new diagnosis of Type 2 diabetes and he is still awaiting his education session.

PMH Gout, AF, TIA, Type 2 diabetes, peptic ulcer disease, amblyopic in his right eye DH bisoprolol 5mg , warfarin 2mg, ramipril 5mg , simvastatin 20mg, allopurinol 100mg, sildenafil 100mg prn FH IHD SH smoker of cigars, overweight, stressful job ++ Allergies none known

1. 2. 3. 4. 5. 6.

Hba1c 7.5% Cholesterol 4.5 and LDL 2.2 U&Es are normal but e-GFR 58 Urate slightly elevated BP 145/85 Urine ACR 4.5

What aspects of his current medication cause concern? How might you manage a flare up of his gout? How will you address his results & BP (Points 1 to 6)? If he presented later in the year with a history of transient speech disturbance and focal right sided weakness what information would you need to find out and how might that effect your management?

[MRCGP-INT-OSCE scenarios Palpitations Notes for candidate

2011 ]

Mr.B 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. He rarely sees his GP and has no PMH of note. Notes for simulator Mr.B runs a plumbers 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. Areas the candidate should explore/offer 20.His ideas, concerns and expectations. 21.What he means by palpitations (How long, how fast, regular or irregular) 22.Important medical red flags e.g. chest pain/tightness, shortness of breath, sweating, feeing faint, feeling anxious, finger or peri-oral tingling, weight loss, diarrhoea etc) 23.Alcohol, drug and smoking history

[MRCGP-INT-OSCE scenarios

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24.An explanation of possible causes stress, heart disease, thyrotoxicosis, anaemia etc 25.Examination - Pulse, BP, heart and lungs 26.Investigation e.g. fasting BS, FBC, TSH, U&Es, Chol:HDL ratio and ECG. 27.A good explanation of possible angina. 28.An explanation of the 999 rules, smoking cessation, treatment options and PILeaflet for angina, referral for stress testing, 24 hour heart monitoring etc. 29.Safety netting. Examination Card P80 reg, BP 135/70, HS normal, no oedema, chest clear.

[MRCGP-INT-OSCE scenarios Osteoporosis Notes for candidate

2011 ]

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.

Notes for Simulator 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 does little exercise, is a non smoker and drinks 6 pints of beer a week over the weekend. PMH Juvenile arthritis which required high dose steroids as a child. Otherwise no PMH of note other than his back pain and wedge fracture. No FH of osteoporosis. He is currently using paracetamol and ibuprofen for his back pain. His main objective is to get better analgesia so he can continue working. Areas the candidate should explore/offer 1. 2. 3. 4. 5. 6. 7. Smoking, alcohol and exercise. Family history PMH Red flags for hypogonadism/low testosterone, hyperthyroidism, Patients understanding of osteoporosis. An explanation of the DEXA scan and osteoporosis. Arrange investigation FBC, ESR, TFTs, TTG antibodies, adj calcium, alk phos and PTH, testosterone and SHBG 8. Discuss measures Jim can take e.g. weight bearing exercise, healthy diet etc 9. Touch on treatment options calcium and vitamin D, biphosphonates, testosterone replacement, strontium etc 10.Safety net

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[MRCGP-INT-OSCE scenarios Hypertension Notes for candidate

2011 ]

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
Notes for simulator 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. He is on no medication and he is a non smoker. At his new patient medical he was discovered to have a high BP 170/100 and he has had it checked again two months running and it still high despite him cutting down on alcohol from 28 to 14 units a week and cutting down on his salt intake (as suggested by the Practice Nurse). The Practice Nurse had asked him to book an appointment today as he might need some tablets.

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[MRCGP-INT-OSCE scenarios

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Ideas No real understanding of high blood pressure Concerns Mortgage medical coming up, as the family have found a place they want to buy. Expectations Another lecture on weight loss! Areas the candidate should explore/offer 30.Why he is here today. 31.His ideas, concerns and expectations around high blood pressure. 32.Alcohol, drug and smoking history. 33.An explanation of hypertension. 34.Appropriate examination P, BP, HS, Pulses, Retinas etc 35.An explanation of how he can help himself (diet, exercise, weight loss). 36.An explanation of why he needs life long medication. 37.An explanation of the need for further investigations ECG, MSU and fasting bloods (fasting glucose, cholesterol:hdl ratio, triglycerides and u&es). 38.Provide a PIleaflet e.g. from www.patient.co.uk 39.An overview of his schedule of care (once BP controlled 6 monthly BP check and annual fasting bloods). 40.Safety netting arrange review to answer further questions and review the results of his investigations and start treatment e.g. Ramipril or Bendrofluazide.

Examination Card P80 reg, BP 160/95, BMI 28, HS normal, no radio-femoral delay, no retinopathy

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[MRCGP-INT-OSCE scenarios Notes for candidate

2011 ]

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. Notes for simulator 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 smokes 20 cigarettes a day. He no longer goes out with the lads but does like a few bottles of beer every night, as a way or relaxing. 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. He thinks its just indigestion but is concerned he may have an ulcer, as his dad had the same symptoms a few years ago and almost died from a bleeding ulcer. John has been on the internet and has read about H Pylori infection as a potential cause of ulcers.

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[MRCGP-INT-OSCE scenarios Areas the candidate should explore/offer Areas the candidate should explore/offer

2011 ]

41.His ideas, concerns and expectations 42.His mental state depression, stress etc. 43.Current medications OTC Gaviscon and Ibuprofen 44.Family Hx re dyspepsia, ulcers or GIT malignancy 45.Important medical red flags e.g. dysphagia, weight loss, vomiting, bleeding pr, anaemia symptoms (SOB on exertion, fatigue etc). 46.Alcohol and smoking history 47.An explanation of possible causes ibuprofen, lifestyle (smoking and alcohol) etc, H Pylori, stress etc. 48.Discuss potential investigations e.g. H Pylori faecal antigen testing or breath testing if symptoms relapse after treatment 49.An explanation of the possible treatments smoking cessation advice, reducing alcohol, avoiding late eating, avoiding large evening meals, bed head elevation, stopping ibuprofen, a trail of a PPI such as lansoprazole 30mg a day for a month. A change of footwear or shoe inserts for his foot pain. 50.Safety netting e.g. 2c GP if symptoms relapse after treatment cessation in one months time. 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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[MRCGP-INT-OSCE scenarios

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Low Back Pain Notes for candidate 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. Notes for simulator 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 has no sinister symptoms (i.e. no weight loss, no power loss, no pins and needles, no loss of continence and no numbness over his buttocks, no cough, no shortness of breath, no haemoptysis, no chest pain). 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 cant help wondering if he might have something serious. He drinks 16 units a week.

Ideas Sciatica but also possible lung cancer Concerns lung cancer Expectations a chest X-ray

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[MRCGP-INT-OSCE scenarios Areas the candidate should explore/offer

2011 ]

51.His ideas, concerns and expectations. 52.The psycho-social & physical implications of her back pain. 53.A detailed history of the nature of the pain. 54.Red flags (nocturnal pain, weight loss, sphincter disturbance, saddle parathaesia, shortness of breath, haemoptysis, chest pain etc) 55.An appropriate examination chest and back http://www.pennine-gp-training.co.uk/physical-examinationvideos-for-the-csa.htm 56.Reassurance that there is nothing to suggest he has cancer. 57.An explanation of possible causes e.g. low back sprain rather than sciatica. 58.An explanation that there is no need for investigations at this stage. 59.A good explanation of treatment options e.g. continued mobilisation, safe lifting, physio, analgesia, nsaids etc. 60.A PIleaflet e.g. www.patient.co.uk 61.Shared decision making. 62.Safety netting for assessment of effect? May need physio referral.

Examination Card Good ROM L-S spine SLR 80 degrees on the right, sciatic stretch negative. Reflexes rt=lft Able to walk on heels and toes Chest examination normal

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[MRCGP-INT-OSCE scenarios Depression Notes for candidate

2011 ]

Samantha is 44 years old, she has a PMH of hypertension and takes bendroflumethazide daily. Her only contact with the surgery in the last few years has been for BP checks and annual medication reviews. Notes for simulator Samantha is 44 years old, she has a PMH of hypertension and takes bendroflumethazide daily. She is married and has two children one of whom, John aged 15, can be quite demanding. 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 sons 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 63.An exploration of the symptoms of depression low mood, weepiness, low self worth, hopelessness, insomnia, loss of appetite, weight change, lack of enjoyment, thoughts of self harm etc. 64.An exploration of the psychosocial impact drink, finances, relationships etc 65.A Mental State Examination including suicide risk assessment. 66.Alcohol, drug and smoking history 67.Her ideas, concerns and expectations 68.An explanation of depression & checking of her understanding. 69.An exploration of options support form family & friends, benefits advisor, counsellor, exercise, drink reduction, self help resources

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[MRCGP-INT-OSCE scenarios

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(PILeaflet or internet), antidepressants, sleep hygiene, PHQ9 etc. Perhaps when she feels up to it to consider a self help book on teenager taming. 70.An explanation of the options selected and how quickly they are likely to take effect. 71.Safety netting follow up within 1 to 2 weeks.

Mental State examination reveals Tearful, poor eye contact, slow initially to talk, speech is then of normal speed and content, no formal thought disorder, not suicidal and good insight.

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[MRCGP-INT-OSCE scenarios Insulin conversion scenario Notes for candidate

2011 ]

Jake Foster aged 38 runs a small carpet business in a converted church in town and has been there over ten years. He is married with two teenage sons. He has had Type 2 diabetes for 10 years and is currently using metformin 850mg tds, gliclazide 80mg 2 bd, pioglitazone 45mg and sitaglitpin 100mg. On looking at the notes the Practice Nurse in diabetic clinic has commented BP is excellent (130/70), non smoker, alcohol = 12 units per week, BMI 25 (keen not to put on any more weight), to see GP in light of persistently elevated Hba1c (10.5%) re ? referral for conversion to insulin.

Notes for simulator Jake Foster aged 38 runs a small carpet business in a converted church in town and has been there over ten years. He is married with two teenage sons. 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. He runs a small successful carpet warehouse with is brother and he usually looks after the sales side of the business but occasionally has to drive the truck to deliver the larger carpets. He worries about being overweight and fears the prospect of insulin as his dad went blind shortly after he was put on insulin in the 1980s. 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. He is keen to avoid weight gain, more tablets or conversion to insulin.

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[MRCGP-INT-OSCE scenarios He is not currently checking his blood sugars.

2011 ]

Examination findings P80 reg, BP 130/70, BMI 25

Areas the candidate should explore/offer 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 Shoulder Pain Notes for candidate

2011 ]

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. Notes for simulator 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. She is a non smoker and drinks little alcohol and is on no medication. 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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[MRCGP-INT-OSCE scenarios

2011 ]

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 77.Her ideas, concerns and expectations. 78.The psycho-social & physical implications of her shoulder pain. 79.A detailed history of the nature of the pain. 80.An appropriate examination http://www.pennine-gp-training.co.uk/physical-examinationvideos-for-the-csa.htm Simulators to feign pain when lifting their arm above shoulder height but otherwise to have a full range of movement in their shoulder. 81.An explanation of possible causes e.g. rotator cuff tear, impingement. 82.An explanation of possible investigations e.g. USS rather than X-ray or MRI 83.A good explanation of treatment options e.g. physio, analgesia, steroid injection or surgery. 84.Shared decision making Steroid injection would be her favourite choice as this could be achieved within the 3 week window +/USS. 85.Safety netting for assessment of effect ? May need orthopaedic referral.

Examination Card Normal contour, no localised tenderness, pain on abduction over 90 degrees. Neers sign positive Hawkins test positive

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[MRCGP-INT-OSCE scenarios Hirsutism Notes for candidate

2011 ]

Samina is 20 years old and works in the marketing department of a local company. She had little PMH of note other than acne in her teenage years and a recent attendance because of concerns over her irregular periods. She is unmarried and lives with her parents.

Notes for simulator Samina is 20 years old and works in the marketing department of a local company. She is unmarried and lives with her parents. Over the last couple of year she has had problems with prominent facial hair and hair on her arms which cause her embarrassment. She wears long sleeve blouses and has been bleaching and plucking her facial hair to minimise its visual impact. She does not shave, as she has heard this makes the hairs grow quicker. 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 its 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 has no symptoms or signs of virilism e.g. male pattern balding, deep voice etc. She had little PMH of note other than acne in her teenage years and a recent attendance because of concerns over her irregular periods. She is on no regular medication. Ideas She believes she has PCO, medication will sort it out, shaving is bad because it makes hair grow quicker.

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[MRCGP-INT-OSCE scenarios

2011 ]

Concerns Problems with potential future relationships. Expectation A prescription for metformin which will resolve her symptoms promptly. Areas the candidate should explore/offer 86.Her ideas, concerns and expectations 87.Important medical red flags e.g. sudden onset of hair growth, deepening voice, male pattern balding, acne etc. 88.An explanation of possible causes familial hirsutism, PCO and androgen excess. 89.Investigation e.g. LH:FSH ratio, Testosterone, fasting blood glucose, pelvic ultrasound. Also ? 17-HO progesterone, ?? GTT. 90.An explanation of PCO and a PILeaflet or signposting to www.patient.co.uk 91.Discussion around weight loss and its advantages in managing PCO. 92.An exploration of other therapeutic options & the fact that most take 3 to 6 months to take effect. Weight loss strategies Bleaching, shaving, waxing, hair removal creams, electrolysis, laser depilation etc. Dianette, Yasmin, spironolactone, metformin and pioglitazone Eflornithine cream

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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[MRCGP-INT-OSCE scenarios

2011 ]

Prostatism Notes for candidate Kevin is 48 years old, he has hypertension which was identified at his new patient medical two years ago. He has no other PMH of note. Drug history = Amlodipine 10mg a day His last BP performed two months ago was 120/70 mmHg Notes for simulator Kevin is 48 years old, married and has two teenage children. He is an Engineer who works for the local steel fabrication company. He has a happy family life and other than his hypertension he has no medical history of note. 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. He feels fit and well (with no symptoms of diabetes such as thirst, fatigue, blurred vision, frequency of micturition) but over the last year or so has had problems with passing urine frequently, getting up about three times every night to pass urine, having to wait around while things get going, a poor stream but no terminal dribbling. He has no pain on passing urine and has had no blood in his urine. He has seen a program on TV about prostate cancer and the symptoms seem to be just like the ones he has and this shapes his ideas, concerns and expectations. Ideas he might have a prostate problem Concerns it might be prostate cancer Expectations a PSA blood test and prostate exam and possible prostate operation.

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[MRCGP-INT-OSCE scenarios Areas the candidate should explore/offer

2011 ]

94.An exploration of his symptoms. 95.His ideas, concerns and expectations. 96.The presence or absence of symptoms of diabetes (thirst, fatigue, blurred vision, frequency of micturition etc), other GU problems (dysuria, haematuria etc). 97.Alcohol, drug and smoking history. 98.BP & Prostate examination 99.An explanation of prostate problems & PSA testing. 100. Provide a PILeaflet on PSA & prostate problems. 101. Arrange further investigation (U&Es, fasting BS, MSU and ? PSA). Ask him to complete the I-PSS scoring sheet. 102. Discuss potential treatment options. 103. Safety netting arrange review to answer further questions, discuss results and plan treatment.

Examination Card P80 reg, BP 130/70, genitalia normal, enlarged and benign feeling prostate (smooth and symmetrical)

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[MRCGP-INT-OSCE scenarios

2011 ]

TIA Notes for candidate 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. PMH Nil of note DH - None Notes for simulator 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 is man who does not like to make a fuss. Early this morning at the breakfast table he developed slurred speech, although no facial or limb weakness which lasted 30 minutes and has now fully resolved. His daughter, who popped round at lunchtime, was alarmed by these symptoms and has cajoled him into seeing the on-call GP, just in case he has had a small stroke. 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 drinks very little and he is an ex-smoker. He is on no medication

Ideas He does not think there is anything serious; he is keen not to make a fuss and has only come to keep his daughter happy. Concerns None Expectations Return home with no need for investigation or treatment.

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[MRCGP-INT-OSCE scenarios Areas the candidate should explore/offer

2011 ]

104. Why he is here today. 105. His ideas, concerns and expectations 106. An exploration of his symptoms 107. Alcohol, drug and smoking history. 108. Appropriate examination P, BP, HS, Carotid bruits, brief neurological examination etc 109. ABCD2 assessment. 110. An explanation of TIA. 111. An explanation of why he needs to be seen in hospital within a week. 112. An explanation of why he needs a stat dose of aspirin 300mg now, which is to be continued until he is seen in clinic whereupon it will be reduced to 75mg a day 2 weeks post TIA. 113. An explanation of the need for further investigations Carotid duplex scanning, cranial CT?, FBC, fasting glucose, cholesterol & LDL, LFTs and U&Es. 114. Provide a PIleaflet e.g. from www.patient.co.uk 115. Safety netting arrange review to answer further questions and review the results of his investigations and address secondary prevention issues.

Examination Card P80 reg, BP 145/85, BMI 28, HS normal, carotid bruit, no focal neurology

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[MRCGP-INT-OSCE scenarios Headache Notes for Candidate

2011 ]

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.

Notes for Simulator: Mrs Elizabeth Thomas is a 68-year-old retired schoolteacher. She has come to the doctor today about her headache, which she has had for 3 weeks off and on. Its an achy pain, which is felt more when she is doing her crosswords or watching the telly intently. Its relieved when she is relaxed, such as. talking to her grandson on the phone or socialising. 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 doesnt 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. She hasnt spoken to her husband about this. Although she doesnt 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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[MRCGP-INT-OSCE scenarios

2011 ]

She lives with her 72-year-old husband, who is a retired banker and there are no other worries. She doesnt smoke, drink excessively or take any regular meds. There are no known allergies. She wants to be examined thoroughly and wants to be reassured that it isnt a cancer, she wouldnt really like to have a scan but would reluctantly agree to it if the doctor thinks its necessary. Areas the candidate should explore Her ideas, concerns and expectations Her mental state depression, stress etc. Important red flags- vision, scalp tenderness, jaw claudication, vomiting, postural change of headache, hearing problems, seizures, weakness, paraesthesias, memory or personality changes. Other history points smoking, drugs, alcohol. Candidate must attempt to examine her provide findings (below) Offer investigations- FBC, ESR U&E, TFTs, LFTs, fasting blood sugar if hx suggests. An explanation that this might be related to the stress. Offer options- investigations vs relaxation techniques/ tapes, gentle exercise, counselling, speaking to husband. Medicationantihistamine for sleep vs amitriptyline if wants. PIL for tension headaches. Safety netting.

Examination findings BP 120/80, No neurological deficit or papilloedma

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[MRCGP-INT-OSCE scenarios COCP request by a teenager Notes for candidate

2011 ]

Katie is 15 years old and has no PMH of note and last saw her GP 3 years ago regarding acne. Notes for simulator 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 its 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 dont know of any family history of illness.

Areas the candidate should explore/offer 116. Her hidden agenda cocp request. 117. Her ideas, concerns and expectations relating to cocp. 118. Her knowledge of other forms of contraception and safe sex. 119. Who her partner is (age & nature of relationship). 120. Encourages parental involvement but is able to assess Fraser competence and proceed without it. 121. Shares some information & PILeaflet regarding different forms of contraception & emergency contraception. 122. Screens for smoking hx, FH of VTE etc.

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[MRCGP-INT-OSCE scenarios

2011 ]

123. Checks BP & BMI. 124. Briefly discusses the relative merits and risks of the different forms of contraception. 125. Comes to shared management plan. 126. Discusses cocp starting, missed pill and antbx warnings if proceeding to prescription. 127. Safety netting/planned F/U around the time of the start of her next period or signposting to local CASH clinic.

IF THE DOCTOR OFFERS EXAMINTION THERE BP 12/70 and BMI 24

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[MRCGP-INT-OSCE scenarios Notes for candidate

2011 ]

Marilyn is a 15 years old patient who last came to the surgery two years ago with sore throat which was treated with Penicillin. PMH: Nil Significant DH: NKDA Nil Regular

Examination Card: O/E Temp: 36.8, There is a small early cold sore on her lip..

Note for simulator: 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!

Disclose this information only if doctor reassures you that the consultation is confidential. You are worried if it is some serious infection that you may have contacted from your boy friend who is your class fellow. You have not noticed any penile or oral ulcers on your boyfriend. You are not on any contraceptive pill and occasionally use condoms. You feel that its unlikely you would get pregnant as your partner is always careful.
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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[MRCGP-INT-OSCE scenarios

2011 ]

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. Areas candidates should explore: 1. Explores her ideas, concerns and expectations. 2. Reassures patient about confidentiality. 3. Rule out other causes and risks of STI. 4. Explore patients health beliefs and address them e.g. risk of pregnancy and STIs, 5. Makes an attempt to check for Fraser competence. 6. Discuss contraception options and safe sex issues. 7. Explains the nature of oral Herpes on lips. 7. Offers chlamydia screening / a visit to STI clinic. 8. Safety Netting

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[MRCGP-INT-OSCE scenarios Information for the candidate

2011 ]

30 year old male/female comes to the surgery and the receptionist have noted that they are complaining about knee pain. PMH nil significant DH nkda

Information for the simulator 30 year old male/female Jamie Anderson 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 cant recall how what direction the person came at you from. You think you heard a snap from your knee. 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 hasnt helped. You have taken the odd ibuprofen but it doesnt 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 ]

to go privately, to get things sorted as quickly as possible. If you were given some written information about your knee problem, you would be happy as well. Non smoker. Drinks 30 units per week on average Examination Findings Obviously finding it painful to walk on his right knee. Obviously swollen knee with generalised decreased range of movement No tenderness to palpation of joint line Anterior draw test positive Marking Schedule- Positive Indicators Data Gathering Elicits information about knee pain. Finds out about swelling/ tenderness/ locking/ giving way/ trauma/deformity/ functional impairment/ Finds out patients concerns. Undertakes Knee exam slickly 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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[MRCGP-INT-OSCE scenarios Dealing with bad news

2011 ]

Its a busy post bank holiday Tuesday and youre 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, I saw Mr Johnson in surgery outpatients this morning to discuss his diagnosis of inoperable colonic cancer. During our consultation his wife became very distressed and I feel that they will need a home visit today. I think it was because her first husband died of colonic cancer 20 years ago. Jane Phillips Nurse Practitioner to Mr Addison
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. You decide to bite the bullet and do the home visit. What additional information might you want? Where may you find it? How do you intend to use it? What are your objectives for this home visit and how do you intend to achieve them? What are the likely pitfalls? What consultation model could you use in this situation? What is your management plan (patient, doctor, and practice aspects)? Who might be able to help? What home services/outside agencies might you use? What do they offer?

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[MRCGP-INT-OSCE scenarios

2011 ]

What forms might need to be completed? Where do you find them and what information do they require? How do you manage your emotional housekeeping?

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. Its 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.
Quickly looking at the record you see that it is elderly Mr Greenwood. Mr Greenwood has recently been diagnosed as having inoperable bowel cancer and his wife Susan has dementia. There is a note from the district nurses in his record Deteriorating rapidly, refer Marie Curie

day centre and ask McMillan nurse to visit wife wandering and behaviour becoming more challenging.

What issues does the telephone consultation and home visit request raise? What do you think might be the problem? What information might you like to obtain before the telephone consultation? How will you manage the telephone consultation what skills may be required?

At 12:00 there is an emergency, a patient has collapsed, and you miss the telephone call. To make matters worse the reception team dont have a contact number for the daughter! So you decide to go and visit and assess the situation for yourself.

What are your objectives for this home visit and how do you intend to achieve them? What are the likely pitfalls?

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[MRCGP-INT-OSCE scenarios

2011 ]

What is your management plan (patient, doctor, and practice aspects)? Who might be able to help? What home services/outside agencies might you use? What do they offer? How do you access them? What are you going to do about Janice the worried daughter? What changes need to be instituted at the practice?

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