MBBS 1 Summative Mock OSCA April 2012

Live Stations
Dear friends in M16, Facing the first summative examination in medical school may have given you a lot of pressure already. The uncertainty of your own ability and the ambiguity of the syllabus may make you lose your way. We sincerely hope that this mock OSCA can give you a better understanding of the OSCA examination. We would like to relieve your fear not only by our notes but by the Love from Jesus. Knowledge will fade, but His love will be with you throughout your examination. God is our refuge and strength, an ever-present help in trouble. (Ps 46:1) You all will be in our prayers. May God bless you.

M15 Fellowship
N.B. The solutions provided here are only suggestions. You are encouraged

to refer to standard textbooks for accurate descriptions if necessary.

MBBS 1 Summative Mock OSCA 2010 Live Stations

Stations 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Respiratory examination Cardiovascular examination Abdominal examination Performing an IV drip Performing an ECG Measuring blood pressure Palpation of peripheral pulses Performing a throat swab Demonstrating the use of a pulse oximeter Demonstrating the use of a peak flow meter Knee jerk reflex Hand washing & using a surgical mask Measuring BMI, skin fold

14. Spirometer to obtain a Forced Expiratory Flow rate (Appear in the Summative 09,10,11) please refer to the Dead OSCA notes and Physiology Practicals. These are just suggestions of what you can practice for the examination. You should also revise the notes of the clinical skills sessions. Summary of Summative 09 1) Peak flow meter (+ effect of salbutamol) and pulse oximeter (+ possible sources of error) 2) Palpation of peripheral pulses (two pulses in the upper limb, four pulses in the lower limb, 3) 4) 5) 6) 7) why pitting edema is most prominent on ankle) BMI and skinfold measurement Spirometer (measure FEV1 and FVC) Blood pressure measurement (correct cuff, effect of wrong cuff, possible errors) Abdominal examination (examination of spleen, ascites) Respiratory examination (assess respiratory system of the patient, percussion both front

and back, count respiratory rate) 8) IV Drip 9) Infection Control (wear and take off a surgical mask, three aspects of transmission-based precautions, Which two can be prevented by surgical mask) 10)ECG (measure lead II, point out area of ventricular depolarization, point out of atrial depolarization, calculate heart rate)

Be still, and know that I am God. (Psalms 46:10)

2

MBBS 1 Summative Mock OSCA 2010 Live Stations

Points to note in the examination - You will be examined in 10 Live Stations in addition to the 10 Dead Stations - There may be 1 rest station in between, just relax and refresh your memory on the live osca running commentary during that lovely 5 minutes. Please make sure that there is no question paper so that you wont miss a station! - Listen CAREFULLY to the instructions provided by the examiner before performing any task. - Dress FORMALLY, with lab coat, name tag and stethoscope - Stationery: Pencil & pen, eraser & correction tape, calculator, ruler; a watch for rate calculation - Do NOT wear watch or finger ring (for the handwashing station). Cut your nails! - Patients RIGHT side is always the RIGHT side! - Introducing yourself and obtaining consent are of paramount importance!!! - Remember to greet the examiner and patient with Good morning / afternoon and a warm smile ! e.g. / XXX XXX ? ***General notes for Respiratory, Cardiovascular and Abdominal Examination***
Standard approach 1. The right side is always the right side. 2. 3C: Consent, Curtain, Chaperone. Introduce yourself to the patient and get an informed consent. Say you will blind the curtain to ensure patients privacy. If opposite sex say you will carry out the examination in the presence of a chaperone. Sequence of examination 1. General 2. Inspection 3. Palpation 4. Percussion 5. Auscultation 6. Extra signs and symptoms *Note the appropriate position and posture for every examination. *Ask for pain every time before you touch the patient.

For I know the plans I have for you," declares the LORD, "plans to prosper you and not to harm you, plans to give you hope and a future. (Jeremiah 29:11)
3

MBBS 1 Summative Mock OSCA 2010 Live Stations

Respiratory Examination () - 3Cs - Patient Position: Lying supine 45o to horizontal - Adequate exposure: Entire thorax (ask patient to exposure or help patient exposure, BUT DO ASK FIRST! ?) - General Examination: Mention some (e.g., pallor, central AND peripheral cyanosis, finger clubbing, peripheral edema) Inspection: (MUST stand at the end of bed) (If examiner was there, ask him/her away politely) Any sign of respiratory distress. E.g. use of accessory muscles (e.g. neck muscles: sternocleidomastoid and scalene), in-sucking of intercostal and subcostal space) Any chest wall deformity, mass or scar. Assess chest wall movement, ask the patient to take a **deep breath** for easier observation. Observe symmetry. Count the respiratory rate. (Normal adult 12-18 breaths/min) Ask the patient to cough and assess. Palpation: Tracheal deviation, if trachea is not deviated, say trachea is central Cardiac apex: whether it is palpable or not; any displacement (count ribs and draw MCL; normal: 5th ICS on MCL) Tell the patient to breathe according to your directions, then use both hands to check for symmetry of chest wall movement for 3 zones including upper, middle and lower zones. Look for equal separation of your 2 thumbs. Tactile Fremitus: ask patient say 1,2,3 as you place the base of you palm to the anterior chest, followed by posterior if indicated. Normally, vibration should be felt symmetrically. (on black region) Percussion: Okay lets listen to your lungs. Percuss in the front and compare both sides 1. Supraclavicular fossa (apex of the lungs) 2. Left and right clavicle (direct tapping) 3. Left and right ANTERIOR chest: 3 times (2nd 3rd 4th ICS),

1 2 32 33 34 4

1 2 32 33 34 4

4. Left and right LATERAL chest: 2 times 5. Posterior chest: Ask if it is needed.

REPORT: The percussion notes are resonant and equal on both sides. Cast your cares on the LORD and he will sustain you. (Psalms 55:22)
4

MBBS 1 Summative Mock OSCA 2010 Live Stations

***4 types of percussion notes and examples of relevant pathology***: i. hyperresonance- pneumothorax, COPD (emphysema) ii. resonance- normal iii. dull- consolidation (pneumonia, tumour, lung collapse) iv. stony dull- directly implies pleural effusion Cardiac and hepatic dullness: Normally present. But area of cardiac dullness might be reduced by emphysema and asthma. Level of hepatic dullness is normally at the 5th rib, a lower level may be a sign of hyperinflation (due to emphysema or asthma) Auscultation: Auscultate the same regions as in percussion. (Figure refer back to percussion) Also compare both sides. Note the nature of breath sounds (vesicular); look for any additional breath sounds (wheezing, crepitations). Ask the patient to say 1,2,3 and listen again at those regions for any change in vocal resonance. Examine the back and ask the patient to embrace his/her arms in order to spread away the scapula for better examination of the lung. Repeat the above examination at the back (some pathology like pleural effusion is more easily detected in the back).

Thank the patient and politely (show an effort to) dress him up after you finish.

Be strong and courageous. Do not be terrified; do not be discouraged, for the LORD your God will be with you wherever you go. (Joshua 1:9)
5

MBBS 1 Summative Mock OSCA 2010 Live Stations

Cardiovascular Examination ()
4 Parts: General Examination; Pulse; Inspection and Palpation; Auscultation. Usually test only one part. - 3Cs - Patient Position: Lying supine 45o to horizontal - Adequate exposure: **Entire thorax** (ask patient to exposure or help patient exposure, BUT

DO ASK FIRST! ?)
General Examination Head: Eyes (pale conjunctiva pallor; yellow discoloration of sclera jaundice) Xanthelasma (intracutaneous yellow fatty deposits around the eyes suggests hypercholesterolemia) Tongue (blue central cyanosis) Lips (blue peripheral cyanosis)

Hand: Clubbing of fingernails: suggests infective endocarditis, congenital cyanotic heart disease Blue nail-bed: suggests peripheral cyanosis Signs of infective endocarditis: Osler nodes (tender), Janeway lesion (non-tender), splinter hemorrhage (nails) Xanthoma (intracutaneous yellow fatty deposits in hand joints, elbow, knees, Achilles tendon): suggests hyperlipidemia

Ankle: Look for edema by touch/feel; if any, compare the size of them on both feet. Pitting edema refers to the area which when compressed by the doctor rebounds slowly because of increased extravascular fluid. For CVS, it indicates 1) congestive heart failure [bilateral], 2) Deep vein thrombosis [unilateral pitting edema]; in contrast to lymphedema or myxedema which are edema of other causes and non pitting in nature). Apply digital pressure onto the region close to the medial malleolus (part of body supported with bone) for around 10 sec, a pit pitting edema

Repeat the digital pressure up along the limb to look for the level of the pitting edema (if present) Q: Why more prominent in lower limb? Answer: Because of gravitation effect.

In the same way, the Spirit helps us in our weakness. We do not know what we ought to pray for, but the Spirit himself intercedes for us with groans that words cannot express. (Romans 8:26)
6

MBBS 1 Summative Mock OSCA 2010 Live Stations

Pulse Peripheral Pulse: (details in an independent section) Additionally, pay attention to: Pulse Rate, Pulse Rhythm, Pulse Volume (best appreciated at carotid pulse) Pulse Nature (best appreciated at carotid pulse, details of nature not required in year 1) **Collapsing Pulse**: While feeling for the radial pulse with one hand, use the other hand to raise the patients arm (may indicate aortic regurgitation).

Jugular Venous Pressure: Lie the patient down at 45o. Inspect for any internal jugular pulsation (normally not observable). If jugular venous pulsation is not visible, apply firm pressure over the center of the abdomen for 5 to 10 seconds. This refers to the abdominojugular reflux which transiently increases venous return. Tips: If you are not sure whether the pulsation you are viewing is jugular venous ones, you can palpate the contralateral carotid pulse, if its rhythm is not the same as what you are looking at JVP

Measure the vertical height from the sternal angle to the top of the observed jugular venous pulsation (normal: <4.5 cm).

Ah, Sovereign LORD, you have made the heavens and the earth by your great power and outstretched arm. Nothing is too hard for you. (Jeremiah 32:17)
7

MBBS 1 Summative Mock OSCA 2010 Live Stations

Inspection and Palpation of the Precordium: Lie the patient at 45o Ensure adequate exposure (entire thorax) Look for scars and any abnormal pulsations, e.g. enlarged left ventricle may lead to visible apex beat Lay the whole hand flat on the chest and localize the apex beat (If fail, ask the patient to roll slightly to the left) Count the ribs spaces from the sternal angle (2nd intercostal space) and refer to the MCL. Report the location of the apex (5th ICS on MCL) Use the base of your palm, palpate the left border of the sternum for left parasternal heaves (suggests right heart enlargement) Use the middle of your palm, palpate generally for any thrills (palpable murmur) at sites of auscultation Auscultation: 4 areas: Mitral Triscupid Pulmonary Aortic **********Auscultation made easy: (B: bell, D: diaphragm)*********** Auscultation made easy: (B: bell, D: diaphragm) 1) Apex Beat B (5th ICS on MCL) 1) Apex Beat B 2) Ask patient turn to his left side (still listening with B) 2) Ask patient turn to his left side (still listening with B) 3) Ask patient turn back to supine position 3) Ask patient turn back to supine position 4) Apex Beat D 4) Apex Beat D 5) Axilla D 5) Armbit D 6) Lower left sternal border (Tricuspid) D (Left, 4th ICS) 6) Lower left sternal border (Tricuspid) D 7) Pulmonic D (Left, 2nd ICS) 7) Pulmonic D 8) Aortic D (Right, 2nd ICS) 8) Aortic D 9) Bilateral neck D (for carotid bruit: Radiation from Aortic STENOSIS murmur or Coronary 9) Bilateral neck D (for carotid bruit*) stenosis ) 10) Ask patient to sit up and lean forward, full expiration D (on Left lower sternal border: AR) 10) Ask patient to sit up and lean forward, full expiration D (on Left lower sternal border: Aortic 11) Bilateral basal crepitation D (base of both lung: pulmonary edema) regurgitation) 11) Bilateral basal crepitation D (base of both lung: pulmonary edema) [REPORT: The heart sounds are dual with no murmur or any other added sound] [REPORT: The 1st and 2nd heart sounds are normal with no murmur or any other added sound] *Auscultate for carotid bruit: Use DIAPHRAGM (since arterial bruit is usually high frequency as a result of turbulent and fast blood flow within high-pressure artery e.g. carotid artery) Ask patient to take a breath and then hold it place diaphragm on carotid artery Sound heard carotid bruit (ddx: carotid artery stenosis, aortic stenosis, Graves Disease)

Thank the patient and politely (show an effort to) dress him up after you finish.

The LORD is my shepherd, I shall not want. (Psalms 23:1)

8

MBBS 1 Summative Mock OSCA 2010 Live Stations

Abdominal Examination ()
- 3Cs; Patient Position: Lying supine, flat, hands by the sides - Adequate exposure: Undress from nipple line to mid thigh (but examiner should stop you) (if you go higher than nipple, examiner may get angry, be aware!) (ask patient to exposure or help

patient exposure, BUT DO ASK FIRST! ?)

- General examination: Usually omitted Inspection Stand at the end of bed and ask the patient to breathe normally Shape of abdomen: 4Ss: Symmetrical, Swelling, Scar, Skin changes (1. dilated veins 2. striae) Distended abdomen - 5Fs: Feces (indentable), Fat, Fetus, Flatus, Fluid (ascites) () Any obvious mass Umbilicus for flattened / everted / slit-like (slit-like can be due to severe ascites, pregnancy) Movement observed on the abdomen (lower eye level to observe) Visible peristalsis in intestinal obstruction AAA (Abdominal Aortic Aneurysm) showing pulsatile movement Dilated veins If any Striae Bluish-purple subcutaneous lines that later become white Caused by weakening of the elastic tissues in abdominal distension, causing subcutaneous bleeding Seen in pregnancy, excessive obesity, rapid growth during puberty and adolescence, Cushing syndrome General Palpation Kneel / squat / sit beside the bed - this increases the sensitivity of palpation. BETTER NOT STAND Ask for any presence of pain before touching the abdomen. If there is any, start palpating in the area opposite to that with pain to relax the patient LOOK at your patient (e.g. look for pain expression) when palpating Palpate the 9 quadrants one by one (recite the names and locations of the regions!), superficial palpation first Detect any gross abnormalities, mild tenderness Detect any guarding and rigidity Then deep palpation (both hands, one on top of the other) for any mass (which can be liver, spleen, kidney, aorta, stomach bowel, pancreas etc) Delineate the features of mass (Site? Shape? Size? Surface? Consistency? Pulsation? Movement/mobile? Tenderness?) Causes: portal HT (e.g. cirrhosis), IVC obstruction

Indeed, in our hearts we felt the sentence of death. But this happened that we might not rely on ourselves but on God, who raises the dead. (2 Corinthians 1:9)
9

MBBS 1 Summative Mock OSCA 2010 Live Stations

Examination of Individual Organs (Liver, Spleen, Kidneys): Liver Palpation: Start from right ASIS, move hand up gradually, ask patient to breathe in and out each time Hand in waiting position during inspiration and move during expiration The lower border of the liver may be felt just below the costal margin Features of the liver: Consistency: firm /hard Surface: smooth/nodular Edge: regular/ irregular Percussion: Percuss starting from the right iliac fossa to the lower border of the liver Measure length from costal margin to liver border (lower border) Find the upper border of the liver by percussion starting from the 2nd intercostal space (Normal: dullness at 5th ICS) Liver span (upper border at MCL lower border at MCL) normal = 10-12 cm in Asians) Auscultation: Liver bruit (this can be done after palpating and percussion all the individual organs) Spleen Palpation: Start from Right Iliac Fossa along Gardners line: a line drawing from Right ASIS to Left axillary fold (Remarks: students have a tendency to go horizontally to nowhere instead of to go to the left axillary fold) The spleen enlarges along this line If the spleen is not palpable with the patient lying supine, roll the patient onto his right side towards you and repeat the palpation Hooking the spleen: Lift and push against patients left flank with the left hand, while palpating at the left costal margin with the right hand. Ask patient to inhale deeply and try to feel for spleen Percussion: Percuss along the Gardners line for any dullness Kidneys Balloting (both kidneys): Slip left hand under patient, right hand on his abdomen. Left hand throw, right hand feel

Cast all your anxiety on him because he cares for you. (1 Peter 5:7)
10

MBBS 1 Summative Mock OSCA 2010 Live Stations

Percussion for Ascites Shifting dullness: Patient lies supine. Percuss from midline laterally until the 1st point of dullness. Keep your finger there. Ask patient to roll over to the opposite side to your finger. Wait briefly for 10 seconds for fluid to settle, then percuss back towards the umbilicus to find a new level of dullness. If levels of dullness differ then ascites may be present. Note: Signs of ascites can only be detected when at least 1L of fluid is present. Finger to be percussed on should be parallel to the fluid level of dullness. Percussing finger should be perpendicular to the level of dullness Auscultation Use the diaphragm of the stethoscope Auscultate for: Liver bruit Bowel sounds auscultate each of the 4 quadrants and at the ileocecal valve. Renal bruits auscultate on either side of (1-2cm lateral to) the midline above the umbilicus (at the level of the renal arteries) Lastly, SAY: To complete the exam, I would like to examine the hernia orifices and external genitalia and also perform the per rectal examination.

Thank the patient and politely (show an effort to) dress him up after you finish.
11

MBBS 1 Summative Mock OSCA 2010 Live Stations

Performing an IV drip ()
Procedure: Inform patient about the procedure, and get a consent Say you will wash your hands Wear gloves and prepare everything you need (needle, alcohol swab, tourniquet, tegaderm) Test if the drip flow is okay (also help in getting rid of gas bubble) Apply a tournequet on the forearm/upper arm, not too near/too far from the puncture site Ask the patient to hold a fist Select a proper vein (usually at site of branch because less likely to slip away, at dorsum of hand) for drip site, palpate the vein Use alcohol swab to clean the overlying skin (wipe only once) With your left hand, hold the patients hand and tighten the surrounding skin so that the vessel will not slip away Warn the patient that may hurt Puncture the vein at 30o to the skin with the sharp edge of the needle. (basically, better to be more horizontal) Observe if any blood comes out from the angiocath indicating that the angiocath is correctly in situ. Release the tourniquet (BEFORE withdrawal of needle, or else will have profuse bleeding!) Withdraw the needle slightly, and advance the whole angiocath into the vein Withdraw out the needle and dispose into sharp box; press the proximal end to prevent bleeding Connect to a drip set Ensure there are no air bubbles trapped inside the drip set and the fluid is running through the drip Properly attach the tegaderm to fix the angiocath

Why should you prefer setting up a drip in vein to an artery? (Optional) Risk of air embolism Risk of systemic infection

Do you puncture in the direction towards the heart or against it? Towards it, follow the direction of venous flow

He gives strength to the weary and increases the 12 power of the weak. (Isaiah 40:29)

MBBS 1 Summative Mock OSCA 2010 Live Stations

Performing an ECG ()
Procedure: 3Cs: Consent, Curtain, Chaperone Ask the patient to remove any watches, clocks or mobile phones Lie the patient flat Expose the precordium and the limbs properly Press the on button Press the filter button if any (optional) . Switch to the right mode for the Lead required Put some jelly on the site of connection with the leads Connect the 12 leads to the patient (optional, sometimes only Lead I, II, III are required) (Remember also the right-leg earthing lead!) Ask the patient not to move (because muscle contraction/hand tremor may distort the ECG or even mimic atrial fibrillation, e.g. in Parkinsonism patients with hand tremor) Press the start button and wait for the processing and printing Disconnect the leads afterwards and place them properly back to the original place Clean up the jelly for the patient Dress up the patient afterwards Possible Questions: Can you name the normal parts in a normal ECG complex? (P atrial depolarization, QRS complex ventricular depolarization, T wave ventricular repolarization;) Calculate the PULSE RATE of the patient using the ECG results 300/ No. of (big) squares between consecutive R waves

Red Yellow

Black

Green

13 Come to me, all you who are weary and burdened, and I will give you rest. (Matthew 11:28)

MBBS 1 Summative Mock OSCA 2010 Live Stations

Measuring Blood Pressure 2008 OSCA Examiner: Mr. Wong is anxious that he may have hypertension, please clear his worries. Preparation: Check there are the sphygmomanometer and the stethoscope. Check if they are working. Choose the correct cuff and connect it. (Examiner may ask about your choice of cuff). Completely deflate the cuff. Introduce yourself; informed Consent - Ensure the patient has taken adequate rest (e.g. 15 minutes) and that he is not taking any medication that might affect the reading. 15 ?? Expose the arm adequately so that you can see his whole arm - Make sure his arm is horizontal, supported, and on the same level of the heart. Ask the patient to relax Palpate for the brachial pulse. Put the cuff onto the arm with the marker over the brachial artery and the lower border should be 2.5cm above the cubital fossa. Make sure it is not too tight or too loose Palpate for the radial pulse ask the patient to remove any accessories that might be troubling you. Prepare the patient for the possible discomfort. Inflate the cuff (turn the knob clockwise) Observe the level of blood pressure when there is no further radial pulsation felt (estimated systolic pressure). Deflate the cuff (turn the knob anticlockwise) Report the Estimated systolic pressure to the examiner in unit (mmHg: millimeter mercury) Put the stethoscope underneath the cuff on the area of brachial pulse. Ill now repeat the procedure with my stethoscope to measure the systolic and diastolic pressure more accurately. Inflate the cuff again (this time to a level 30 mmHg above the estimated systolic) - Remember to tighten the knob again first (by rotating turning clockwise) Auscultate again and note the systolic and diastolic blood pressure Round them up to units of 2 mmHg e.g. 115 mmHg rounded up to 116 or 114 mmHg. (dont report anything like 113 mmHg! That means you are lying!) Deflate the cuff and place them back properly. Tell the patient about the readings and whether it is normal or elevated. XXX
XXX/ (normally all patients are normal)

Report to your examiner similarly, this time with the unit of pressure (mmHg). Common Questions asked after the procedure: Which cuff would you choose if three cuffs of different size were given? (The three cuffs are for thigh, arm and infants. Choose the middle size cuff.) (Sometimes a larger cuff for obese people, the optimal size of a cuff depends on the patients arm circumference or else there will be errors) Allow no sleep to your eyes, no slumber to your eyelids. (Proverbs 6:4)
14

MBBS 1 Summative Mock OSCA 2010 Live Stations

What would happen if a larger cuff were used instead? The blood pressure would be underestimated. Extra Notes: Factors that may give a true higher-than-normal BP: (hint: consider sympathetic stimulation) Essential hypertension, stress, white-coat hypertension, exercise, caffeine Factors that may give a true lower-than-normal BP: (hint: consider intravascular volume loss) Hypovolaemic shock Factors that might lead to overestimation of BP: Cuff too small, arm below heart, talking, standing (overestimated diastolic pressure)* Factors that might lead to underestimation of BP Cuff too large, arm above heart, air leaks in the tubing, standing (underestimated systolic pressure)* *Since standing will lead to increase in the action of gravitation force, which in turn lead to distention of vessels in the lower limbs. This will decrease venous return and thus lead to decrease in cardiac output and decrease in systolic blood pressure. (underestimated systolic blood pressure results when standing) The body reacts to the decrease in blood pressure by reflex action. This involves the increase in peripherial resistance and thus increase in diastolic blood pressure. (overestimated diastolic blood pressure when standing)*

Guide me in your truth and teach me, for you are God my Savior, and my hope is in you all day long. (Psalms 25:5)
15

MBBS 1 Summative Mock OSCA 2010 Live Stations

Peripheral pulses 2007 OSCA Exam: Tell 2 pulses found on upper limbs Tell 4pulses found on lower limbs Which of the 4 pulses on lower limbs is the most difficult to be palpated and why? pulse and brachial pulse Palpate for dorsalis pedis pulse Pulse Palpation locations Carotid pulse Palpate for radial

Radial pulse Ulnar pulse (usually radial is preferred between the two pulses in forearm) Brachial pulse Dorsalis pedis pulse: dorsiflexion of the big toe (hallux) reveals the extensor hallucis longus Lower Limb tendon for easier location of the pulse Posterior tibial pulse Popliteal pulse (most difficult since deeply located) Femoral pulse (not convenient to check this pulse in this OSCA) Introduce yourself and Informed Consent Say that you will perform hand hygiene, usually the examiner may tell you to skip, if not then you really need to do it. Palpate the pulse indicated by the examiner with running commentary (the location of the pulse) Remember to palpate all pulses bilaterally except the carotid pulse. (because this will occlude the carotid arteries and thus compromise the blood supply to the brain the patient may feel dizzy) After your palpation, describe the rate, rhythm and character of the pulse, for example: The radial pulse is strong and it displays a normal rate and rhythm. It is also Common Questions asked after symmetrical on both sides . the (sayprocedure: both sides are about the same for carotid) What are the characteristics of the favourable site for pulse palpation? Superficial location with a hard underlying surface, e.g. bone (This also explains why popliteal pulse is relatively more difficult to palpate than other pulses, because the popliteal pulse is not directly lying on a bone and it is deeped located in the popliteal fossa) What is ankle-brachial index (ABI)? It is the value of ankle systolic blood pressure divided by (over) that of the arm (brachial). What is the normal range of ABI? 0.9- 1.1 (<0.9: may be due to Peripheral Arterial Occlusive Diseases (PAOD) refer to PBL case related to intermittent claudication)

This is what the Sovereign LORD, the Holy One of Israel, says: In repentance and rest is your salvation, in quietness and trust is your strength. (Isaiah 30:15)
16

Upper Limb

MBBS 1 Summative Mock OSCA 2010 Live Stations

****Extra Notes on Anatomical Locations of Pulse**** Radial Pulse: Brachial Pulse: Carotid Pulse: Femoral Pulse: Popliteal Pulse: Posterior Tibial: Dorsalis Pedis: distal forearm near the base of the thumb the elbow (i.e. antecubital fossa) immediately medial to the biceps tendon lateral to the laryngeal prominence (thyroid cartilage), medial to the sternocleidomastoid muscle mid-way between the pubic symphysis and the anterior superior iliac spine (ASIS) in the popliteal fossa at the flexor (posterior) compartment of the knees posterior and a bit inferior to the medial malleolus (midway between medial malleolus and the heel) on the dorsum (dorsal surface) of the foot lateral to the extensor hallucis longus (tendon to the big toe)

(Make sure you remember them, because sometimes if you felt the pulse too quickly, the examiner may doubt your finding/ skill and use these questions to confirm you know where to find the pulses. The examiner may as well ask them right before you palpate.) N.B. Pulses in the upper half the body usually reflects the cardiac output, while those in the lower half are usually related to conditions of the vascular tree.

The fear of the LORD is the beginning of wisdom, and knowledge of the Holy One is understanding. (Proverbs 9:10)
17

MBBS 1 Summative Mock OSCA 2010 Live Stations

Throat swab 2008 OSCA: Please perform a throat swab on a patient (dummy) who has severe sore throat for a week. Ulcerative lesions are seen on the wall of the pharynx. The specimen will be taken for culture and microscopic examination. NO NEED TO introduce yourself to the patient and obtain an informed consent for performing a throat swab Hand hygiene**. Put on your gloves** Open swab packet and take out swab and hold it one hand (dont contaminate the tip!) Keep the tip clean throughout the procedure Use a tongue depressor and a mini touch so that the area to be swabbed can be visualized clearly Ask the patient to open his/her mouth and say Ahh The swab is gently stroked over the tonsillar fossa and tonsils and then quickly across the posterior pharynx near the uvula

Areas of inflammation, ulceration, exudation, or membrane formation should be swabbed, if there is any. Avoid the palate, buccal mucosa, teeth, tongue and the cheek to prevent contamination Avoid touching the uvula and back of tongue to prevent gag reflex Do the swabbing quick to prevent excessive discomfort Put the swab back into the medium without contaminating the tube Dispose the tongue depressor immediately Tell the patient that it is finished. Put down the patients particulars on the label of the specimen container and the request form (Look for a sheet nearby that will provide the patients particulars) Send the specimen to the laboratory immediately. If not possible for immediate delivery to laboratory, refrigeration (NOT freezing) should be done.

My grace is sufficient for you, for my power is made perfect in weakness. (2 Corinthians 12:9)
18

MBBS 1 Summative Mock OSCA 2010 Live Stations

Common Questions asked after the procedure: What are palatine tonsils? They are masses of lymphoid tissues. Where are they located? In the tonsillar fossa between the palatoglossal arch (anterior) and palatopharyngeal arch (posterior). Where are the common pathogens that can be detected by throat swab? Only bacteria, e.g. Corynebacterium diphtheriae, Neisseria gonorrheae, Group A streptococcus (N.B. Influenza, TB, picornavirus, pertusis cannot be detected) Nasal swab: Staph. aureus Nasopharyngeal swab (the painful one): rhinovirus, influenza, parainfluenza virus, Bordetella pertusis Extra Notes: [Reviewing the anatomy of the throat may help: The palate forms the roof of the pharynx and the floor of the nasal cavities. It consists of a hard part (hard palate) anteriorly and a soft part (soft palate) posteriorly. The most posterior part of the soft palate hangs down as the uvula. Laterally, the soft palate is continuous with the wall of the pharynx. It is joined to the tongue and pharyngeal walls by the palatoglossal and palatopharyngeal arches respectively. The palatine tonsils are on each side of the pharynx. Each lies within a tonsillar fossa, bounded by the palatoglossal and palatopharyngeal arches and the tongue. (Refer to an anatomy atlas for appropriate illustrations)]

Jesus said, "In this world you will have trouble. But take heart! I have overcome the world." (John 16:33)
19

MBBS 1 Summative Mock OSCA 2010 Live Stations

Pulse oximetry Usually combined with Peak Flow Meter (as in 2008 OSCA), and usually is performed by yourself Examiner may ask the function of it: A pulse oximeter is a medical device that indirectly measures the oxygen saturation of a patient's blood. Make sure that is no nail polish. Press the On button and connect the probe to the finger tip (usually index finger) Read the oxygen saturation (of your arterial blood, in %) and the pulse rate (bpm) on the monitor, whether they are normal and why. N.B. Normal SaO2 is about 97-99%, danger if <90% which corresponds to PaO2 <8.0 kPa (60 mmHg), i.e. the criteria for Type I respiratory failure. If the oximeter reads 100% SaO2, it is probably an error and the test has to be repeated. Normal range of pulse rate in adult is 60-100/min, <60 suggests sinus bradycardia, >100 suggests sinus tachycardia. It is normal in some athletes to have heart rate around 50/min. Situations where pulse oximeter is useful: Respiratory diseases, e.g. Chronic Obstructive Pulmonary Diseases (COPD), asthma Patients with cardiac failure Post-operation patients Sources of error: You are expected to know how the error would affect the result. Also, you need to differentiate between a technical error and a deviation due to patients factors Presence of abnormal hemoglobin (patient) Nail polish (patient) Skin pigmentation (patient) Anemia (may have a normal reading even the patient is hypoxic, the patient may be hyperventilating as well (patient) Shock (patient) Venous congestion (patient) Increased bilirubin (patient) External light sources (technical) Motion artifact (technical) Improper placement of the probe (technical) EM waves (technical) You may be asked: Name of the curve (O2 dissociation curve) X and y-axis labels and units Factors shifting the curve a) CO2 b) 2, 3- DPG (increased production during exercise) c) Temperature d) pH

I lift up my eyes to the hills where does my help come from? My help comes from the LORD, the Maker of heaven and earth. (Psalms 121:1-2) 20

MBBS 1 Summative Mock OSCA 2010 Live Stations

Peak flow meter () Usually combined with Pulse Oximetry (as in 2008 OSCA), and usually is performed by yourself The student is asked to demonstrate the use of a peak flow meter (to an asthmatic patient). Introduce yourself to the patient (if there is a patient) Insert a clean mouthpiece into the peak flow meter Stand up** and hold the peak flow meter without restricting movement of the marker (the examiner may trap you by asking you to sit down at first!) Make sure the marker is at the bottom of the scale Hold the meter horizontally (to avoid gravity) Take a deep breath Put the peak flow meter in the mouth Seal the lips around the mouthpiece tightly Make sure your tongue is not obstructing the air passage Breathe out as hard and fast as possible Record the result Return the marker to zero Repeat twice more and choose the highest of the three readings (remember them) Report the reading to the examiner with UNIT : L/min Deform the mouthpiece and dispose it appropriately Check against the reference values in the chart (if the examiner did not indicate you need to do so, try ask him whether you need as it may not be necessary sometimes) Reasons for decreased peak flow rate: Asthma Chronic Obstructive Pulmonary Diseases (COPD) Nervousness Not using his maximum effort (since the test is effort-dependent) Extra Notes: Peak flow meter assesses the flow rate (peak expiratory flow (PEF), unit: L/min), NOT lung volume A handy meter, can be performed at home Highly reliable The taller the better, the older the worse. DO NOT use a nose clip, which is for spirometry. Common Questions asked after the procedure: What would you expect in the result from a patient with Asthma? The peak flow rate should be lower. How will the result be affected if you take bronchodilator e.g. salbutamol before the testing? The peak flow rate should be higher (since salbutamol is a bronchodilator which decrease the resistance to airflow) [refer to Lectures on ANS Pharmacology] You, dear children, are from God and have overcome them, because the one who is in you is greater than the one who is in the world. (1 John 4:4) 21

MBBS 1 Summative Mock OSCA 2010 Live Stations

Knee jerk 2008 OSCA Examiner: Please examine this patients knee jerk reflex. Introduce yourself and obtain an informed consent from the patient Say that you will perform hand hygiene, usually the examiner may tell you to skip, if not then you really need to do it. Properly position the patient (lying, or sitting with crossed-legs or sitting on the bed with legs hanging). Ask the patient to relax. Expose adequately above the knee enough (expose quadriceps) to see the contraction of the quadriceps and knee extension (Remember to STARE at the quadriceps)

or Slide one of your arms under the knees if the patient is lying, so they are slightly bent and supported. This slightly stretches the tendon to enhance the reflex, but not over bending (usually around 30 degrees) which will otherwise obliterate the reflex by over-extension

Palpate for the patellar tendon. Hold the tendon hammer at the end to ensure smooth swinging action of the pendulum onto the tendon. (Use the wrist for the swinging motion, NOT the whole forearm!) Tap the hammer directly onto the tendon with good swinging movement. Observe for the contraction of the quadriceps (primarily), and knee extension **If no obvious reflex seen, ask the patient to do reinforcement maneuver Interlock the fingers and then pull apart hard at the moment just before the hammer strikes the tendon (more commonly used by us) D 3 , 1, 2, 3 (tap
onto the tendon)

Or ask the patient to clench his/her teeth tightly just before the strike (the examiner may ask: what if the patient has no arms?)
D 3 , 1, 2, 3 (tap onto the tendon)

Remember that you must test for both knees and compare both sides before you finish Report the result to the examiner (normal on both sides or diminished, and they are symmetrical)

Do not be anxious about anything, but in everything, by prayer and petition, with thanksgiving, present your requests to God. (Philippians 4:6) 22

MBBS 1 Summative Mock OSCA 2010 Live Stations

Common Questions asked after the procedure: What type of reflex is this? Stretch reflex How many synapses does it involve? One What is the spinal level of this reflex? L2 L4* (Discrepancies between textbooks)) *Please note that L2 only has little contribution, so this knee jerk test only offers you to test L3- L4 clinically, yet actually L2 is still involved in the reflex. What can you do if there is no obvious reflex? Perform the reinforcement maneuver (Be prepared to demonstrate this) N.B. Prepare to do BOTH the reinforcement maneuver because students have been asked What if the patient has no hands? What else do you want to do? (If asked after testing on one knee) Test the other knee. N.B. DO NOT ask the patient to cross his legs if he is sitting on the bed with the legs hanging! Other reflexes: - Lower limb: ankle jerk, plantar jerk Upper limb: biceps jerk, triceps jerk, supinator jerk (brachioradialis reflex)

Extra Notes:

I can do everything through him who gives me strength. (Philippians 4:13)

23

MBBS 1 Summative Mock OSCA 2010 Live Stations

Hand washing & use of a surgical mask Hand washing Keep nails short, its better to take off your watch or finger ring. Pull up your sleeves. In case of washing with water: Open the water tap; make sure the water temperature is okay. Wet your hands and wrists, apply enough antiseptic skin cleanser. The hands are then rubbed together in 6 steps, repeat each step for at least five times: 1. Palm to palm (for palms) 2. Right palm over left dorsum and vice versa (for palm-backs) 3. Palm to palm, fingers interlaced (for finger webs) 4. Backs of fingers to opposing palms, finger interlocked (for fingertips) 5. Rotational rubbing of right thumb clasped in left palm & vice versa (for both thumbs) Rotational rubbing backwards and forwards with clasped finger of right hand in left palm and vice versa (optional) 6. The wrists are rubbed Rinse thoroughly under running water Wipe and dry hands well with paper towel Turn off water tap using paper towel N.B. For alcohol hand-rubbing - Apply enough alcohol on your hands (with alcohol filling the palm), it dries up quite fast.

Common Skin disinfectants (refer to Dr SSY Wongs lecture) Iodine compound (e.g. povidone-iodine) Chlorhexidine gluconate (4%, commonly seen in wards, red one, called Hibiscrub) RESIDUAL EFFECT Cetrimide (together with chlorhexidine, called Savlon) Alcohol (70% ethanol or 60% isopropanol) Putting on a mask Putting it on 1. Wash your hands with disinfectant first. 2. 3. 4. 5. 6. Take a mask from the box; bend the metal bar a little to fit the nose. Put the mask onto the face; make sure it is not inside out or upside down. Tie both sets of strings; make sure it is not too tight or too loose. Shape the metal bar to fit your nose and face. Pull down the lower part of the mask to make sure it covers your jaw.

Taking it off 1. First, wash your hands. 2. Carefully take off the mask and fold in half with the outside (contaminated) inwards. 3. 4. Dispose it properly into the waste bin. Wash your hands again with disinfectants. My God will meet all your needs according to his glorious riches in Christ Jesus. (Philippians 4:19)
24

MBBS 1 Summative Mock OSCA 2010 Live Stations

Types of mask (N.B. Be prepared to identify the types of masks) 1. Paper mask 2. 3. Q: Surgical mask Respirator (N95) Under which circumstance is each of the masks most often used? Paper mask is used for blocking large particles, e.g. dust., never useful in infection control Surgical mask can block transmission through droplets, e.g. influenza. Respirator can also block transmission through aerosols, in addition to droplets, preventing spread of air-borne disease, e.g. TB. Q: All masks can block transmission through direct contact. Briefly explain the design of a surgical mask. The outside surface is water-repelling, while the inner surface is water-absorbing. This is to prevent droplets carrying bacteria or viral particles from entering through the mask.

And the peace of God, which transcends all understanding, will guard your hearts and your minds in Christ Jesus. (Philippians 4:7) 25

MBBS 1 Summative Mock OSCA 2010 Live Stations

BMI & Skin fold Both part essential, never forget to perform the skin fold after BMI, vice versa. BMI Introduce yourself to the patient and get an informed consent. Calibrate the meter. Ask the patient to take off his shoes Ask the patient to stand straightly on the stadiometer platform with feet together, head up and eyes looking forward Measure and report height (in metres) and weight (in kilograms) Ask the patient to go down from the platform. Remember the readings by heart when you are checking the height and weight respectively. For using the calculator provided, remember that you need to do the division by 2 times BMI = Weight (kg) / Height2 (m2) First report to patient, then examiner. Tell whether it is within the normal range. Remember to report also the unit to the examiner (kg/m2). WHO classification of BMI****** (better use this as the updated news report that it is more significant) Body mass index (BMI) 18.49 Underweight 18.50 to 24.90 Normal 25.00 to 29.90 Overweight (pre-obese) 30.00 Obese Skin fold measurement Obtain an informed consent again Ask the patient to put up his sleeves

Ask him to flex his left arm (measure the non-dominant arm) at a right angle, support it with another arm and keep it relaxed
,

Find the midpoint between the olecranon process (at the elbow) and the acromial process (shoulder) Prepare the patient of discomfort Pinch up a fold of skin at 1cm above the mark Apply caliper jaws on the mark Read the scale after 1-2 seconds, not more than that Ask the patient to pull down his sleeves.

Report to the patient, then the examiner. (unit in mm) Remember to check the chart! The chart maybe placed on the chair or desk, look for it! Normal if it is within the 3rd 97th percentiles. A cheerful heart is good medicine, but a crushed spirit dries up the bones. (Proverbs 17:22)
26

MBBS 1 Summative Mock OSCA 2010 Live Stations

Use of Spirometer
VC - Vital capacity; the largest volume measured on complete exhalation after full inspiration

IRV - Inspiratory reserve volume; the maximal volume of air inhaled from end-inspiration

ERV - Expiratory reserve volume; the maximal volume of air exhaled from end-expiration RV - Residual volume; the volume of air remaining in the lungs after a maximal exhalation VT - Tidal volume; the volume of air inhaled or exhaled during each respiratory cycle IC - Inspiratory capacity; the maximal volume of air that can be inhaled from the resting expiratory level FRC - Functional residual capacity; the volume of air in the lungs at resting end-expiration TLC - Total lung capacity; the volume of air in the lungs at maximal inflation

FVC - Forced Vital Capacity - after the patient has taken in the deepest possible breath, this is the volume of air which can be forcibly and maximally exhaled out of the lungs until no more can be expired. FVC is usually expressed in liters. Normal Value: 80% - 120 %

FEV1 - Forced Expiratory Volume in One Second - this is the volume of air which can be forcibly exhaled from the lungs in the first second of a forced expiratory maneuver. It is expressed in liters. Normal Value: 80% - 120%

FEV1/FVC - this is the ratio of FEV1 to FVC - it indicates what percentage of the total FVC was expelled from the lungs during the first second of forced exhalation - this number is also called FEV1%, %FEV1 or FEV1/FVC ratio.

Some trust in chariots and some in horses, but we trust in the name of the LORD our God. (Psalms 20:7)
27

MBBS 1 Summative Mock OSCA 2010 Live Stations

Spirograms and flow volume curves. (A) Restrictive ventilatory defect. (B) Normal spirogram. (C) Obstructive ventilatory defect

Forced expiration (expired volume against time) 1. Clip the nose. 2. Maximum inhalation maximal exhalation for at least 3s

3. Try to produce a smooth curve 4. Read FVC and FEV1 from the from the curve 5. Calculate FEV1/FVC ratio 6. Evaluation on the measurement a) Good: Normal value of FEV1/FVC = 75-75% b) Bad: Abnormal value OR not maximal expiration OR expiration < 3s

For God did not give us a spirit of timidity, but a spirit of power, of love and of self-discipline. (2 Timothy 1:7)
28

MBBS 1 Summative Mock OSCA 2010 Live Stations

For Your Reference ONLY Patient counseling: a patient with asthma

Case scenario: Ah Ming, 7 years old boy, newly diagnosed extrinsic asthma was brought to see you by his mother. They are worried about so called asthma and would like to know more about the disease and their management. Mrs Kam is very angry for waiting you for almost 2 hours. Address the patient and introduce yourself Give apology to the patient and explain why you are so late Back to the subject First ask the patient and the patients family if they have any questions. Answer them correspondingly. Explain to patient about asthma: disease etiology, risk factors and disease outcomes Assess the home environment Assess the exercise tolerance of patient Assess the severity of attacks of patient Explain the treatment and give modification to his home environment. Ask if there are any other questions. Mention that the patient is welcomed to come back whenever the patient has any questions about the disease

Patient interview on passive smoking

Case Scenario: You are a general practitioner. The patient is a 35-year-old woman who married to a non-smoking husband. She is works in catering service. She came to see you because of chronic cough. Carry out a 5-minute counseling with her. Points to cover: Onset, nature (briefly) Identify and focus on reason, most probably exposure to passive smoking at working place (occupational cause) Occupational history and relationship with her cough (in detail) E.g. what exactly does she do? Where does she work? Any smoke in her working area (perhaps household too)? Does her cough aggravate when shes at work / does her cough alleviate when shes off from work? Does her colleagues smoke or have similar problems? Passive smoking and its harmful effects to body systems Multi-system involvement: Carcinogenic (many sites); Respiratory (eg. lung cancer, COPD, asthma); Cardiovascular (eg. atherosclerosis, ischemic heart disease); Central nervous system (eg. addiction); Reproductive (eg. effects on fetus) etc. Suggest some ways to minimize exposure to passive smoking in working area (* the patient is very quiet and passive)

Trust in the LORD with all your heart and lean not on your own understanding; in all your ways acknowledge him, and he will make your paths straight. (Proverbs 3:5-6)
29

MBBS 1 Summative Mock OSCA 2010 Live Stations

Patient counseling: a preterm infant with patent ductus arteriosus

to you. Please counsel on the parents.

()

Case Scenario: Heart murmur is heard during a consultation for flu in private practice and now referred

Greeting Questions to assess the severity of the problem Symptoms of heart failure Breathlessness? Sweating?(especially during feeding or crying) Poor feeding (many times, small volume, regurgitation of milk, turns blue) Recurrent chest infections Explaining what is PDA Failure to close a connection between aorta and pulmonary artery shortly after birth Since the pressure of aorta is higher, blood flow from aorta to pulmonary art Pulmonary artery congested Heart enlarged due to more hardworking to pump more blood out to compensate the entering to pulmonary circulation, therefore to maintain flow to the rest of body Management Common in preterm infant Most of them will ultimately close Conservative Tx (if symptomatic): fluid restriction, diuretics, drugs which help to close (PG synthetase inhibitor) If fail, surgical ligation may be required Ask if there are any other questions. Mention that the patient is welcomed to come back whenever the patient has any questions about the disease

Seek first his kingdom and his righteousness, and all these things will be given to you as well. (Matthew 6:33)
30

MBBS 1 Summative Mock OSCA 2010 Live Stations

Patient counseling: a hypertensive patient

Case scenario: Mr Chan, aged 75, has been diagnosed to have essential hypertension for a year. He is on an ACE inhibitor. He now comes to see you (the chief medical officer for him in QMH) for regular follow-up. You have to assess his management of the disease. Introduce yourself and greet the patient Ask about the present blood pressure and that over a recent period The patient believes that his blood pressure has returned to normal despite an average reading of 170/100! WHO Definition of hypertension: 140/90 (age dependent) (for references (WHO) high normal: 130/85, optimum<120/80) Individual variation: age, weight etc Ask about drug compliance The patient has to take an ACE inhibitor twice daily, but he complains of absent-mindedness! Ways of increasing patient compliance: family assistance, switch to another drug taken once daily etc good doctor-patient relationship! Reiterate that the drug is necessary for the control of his BP and reduce possible complications Ask about lifestyle The patient loves salted fish and Chinese rice wine! He has tried to quit smoking but in vain as he has had this habit for over 50 years! Reduce salt intake Reduce alcohol intake Avoid smoking Regular exercise Encourage patient involvement in setting realistic and clear objectives; the change in lifestyle should be progressive Make sure the patient understands by asking him to repeat Ask for signs of complications Stroke Coronary heart disease Disease presentation in the elderly might be different from classical symptoms; the elderly might also not be able to describe symptoms accurately... e.g. abdominal pain or weakness in CHD Ask if theres anything else he would want to discuss The patients son is turning 50 this month and has frequent episodes of headache. The patient wishes to know if those could be due to hypertension! We have to first clarify the characteristics of headache. Tension headache? Really related to HT? We can explain that there is increased risk for HT in first-degree relatives, but we should also suggest the patients brother to seek medical advice and BP measurement (if you think it may be serious after history.) N.B. Genetic factors play an important role in essential hypertension Therefore do not worry about tomorrow, for tomorrow will worry about itself. Each day has enough trouble of its own.
31

(Matthew 6:34)

MBBS 1 Summative Mock OSCA 2010 Live Stations

Advice on exercise for a patient with hypertension

Case Scenario: Mr. Wong, a 45 year-old business man, has a blood pressure of 150/90. He has come to you and you are going to take his sports history, and give some advice for him to start having some regular exercise. Marking scheme: 1 mark per point unless otherwise specified Greet the patient, introduce yourself and explain what you are going to do Ask him whether he does any exercise Advice him to start doing some regular exercise and give advantages with reference to his own health status (hypertension) Address his concern that he doesnt have enough time to exercise Advice on the kind of exercise, e.g., walking, swimming, etc. mainly mild aerobic exercise Advice on the frequency of exercising Advice on way of progressing: step by step increasing the exercise Address his worry that he has got hypertension and may be dangerous if he does exercise. Advice on precaution: prevent vigorous kinds of exercise, stop when he feels uncomfortable, etc. Ask him whether he has any questions Suggest ways to get more information about exercising and place to seek help in case of problem Thank the patient and say goodbye MR WONG: Does not do any exercise, Busy life style, Worried that exercise may be dangerous for a

hypertension patient, Accept the advice

Answers for our souvenir: Femoral Triangle Superior: Inguinal Ligament Medial: Adductor Longus Lateral: Sartorius Ms. Right Heart Failure Fatigue Increased peripheral venous pressure Ascites Edema Cyanosis Distended jugular vein

All the Best In Your Summative Examination!

The LORD himself goes before you and will be with you; he will never leave you nor forsake you. Do not be afraid; do not be discouraged. (Deuteronomy 31:8)
32