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Breaking bad news seems like a daunting prospect however during an OSCE it is quite predictable. 1. Confirm patient identity 2. Then introduce yourself: My name is .... I am one of the doctors in the team that's looking after you. 3. Ask how they are feeling/ are they in pain. 4. Bring up the topic - I've been told to speak to you today about.... (e.g your leg, your blood results) 5. Find out where the patient is currently at/ what they know: Could you tell me what's been going on so far? How do you feel that it's been progressing? Has anything been worrying you? Do you have any idea of the possible treatments? 6. Slowly break the news: The team have had a discussion about ...... The situation is not as we would have hoped PAUSE Unfortunately .... (the current treatment is anadequate... (or words to this effect but more specific)) PAUSE I'm sorry to say this, but this would mean.... SUPER PAUSE (let the patient speak as much as possible) 7...

How to do a knee exam for an OSCE: Wash hands + Introduce and gain consent Check for pain status. LOOK Observe gait Comment on ratio between stance phase and swing phase e.g Antalgic gait - stance phase reduced on painful side. Stepping height Observe from front while standing Scars Swellings/colour Assymmetry Valgus/Varus Observe from side while standing Fixed flexion deformity Observe from back while standing Popliteal swelling Scars/assymetry Observe from side while standing Fixed flexion deformity Get patient to lie on bed Check once more for cheeky arthroscopy scars FEEL With the leg extedned Feel for temperature Feel for effusion Milk and patella tap or sweep test Offer to measure the quadriceps 20cm above tibial tuberosity With the leg flexed Feel around the patella Feel the tibial tuberosity (Osgood Sch...

Remember you should always ask about the General topics and also the RELEVANT system. There may be more than 1 relevant system e.g Cardio and respiratory normally go together. General Fever Fatigue Sleep Weight/appetite Skin bruising/rashes Head Headache Loss of consciousness Dizziness Vision Hearing Weakness Numbness Loss of memory Anxiety or depression CVS Chest pain Claudication quantify Breathlessness Quantify Orthopnoea PND Ankle swelling Palpitations RS Chest pain Cough Sputum Blood? Breathlessness Wheeze GIS Appetite Dysphagia Nausea and Vomiting Indigestion Jaundice Abdominal Pain Bowel movements Blood? Pale? Genito urinary Dysuria (pain) Urine frequency Haematuria Incontinence Prostate Starting, flow, dribbling Menstruation Onset, Timing + Regularity, Length Women - vaginal discharge, pain on intercourse Muscular Pain/swelling/stiffn...

Key point- Abdominal exam is tight for time so really try and race through the early peripheral signs in hands and face. The routine for Abdo Wash hands Introduce Consent + Explanation Explanation of talking to examiner Pain Observe from end of bed Look around Drains Lines Food/drink Look at patient Comfort Well perfused Alert Orientated Hands Leuconychia Koilonychia Clubbing Tendon xanthomata (turn over) Erythema Dupuytren's (pigmentation of creases?) Arms Asterexis Pulse Fistulae Blood pressure Axilla hair Acanthosis nigricans Face Eyes Pallor ictarus KF rings Corneal arcus or xanthalesma Mouth Angular stomatitis Glossitis Ulcers Pigmentation Telangiectasia Neck JVP Lymph nodes When you have patient up look for scars. FLATTEN BED!!! Chest Gynaecomastia Hair distribution Spider naevi Acanthosis nigricans Abdomen Inspect Scars or stoma Visible...

The routine - neurological exam is brief and only if indicated. Wash hands introduce and gain consent Ask for pain Expose arms to above elbows. Examine extensor surfaces Looking for nodules, psoriatic plaques, scars, tophi. Inspection of Dorsum of hand (proximal to distal) Skin Rash Atrophy Nodules Tophi White fingers Sclerodactyly Purpura (use of steroids) Nails Pitting Onycholysis - nail coming off (may suggest psoriatic) Splinter haemorrhages or clubbing. Suggestive of vascular. Soft tissue Wasting in dorsal interossei or diffuse atrophy Swelling in gutters of MCP Bones Wrist - sublaxation of carpus/distal radioulnar joint MCP - swelling and/or sublaxation/ulnar deviation IPJ - swelling, Swan neck, Boutoniere or Z deformity in thumb. Heberden's nodes and/or Bouchard's nodes. Dactylitis and PIPJ and/or DI...

A key point - remember that GALS is a screening exam. THE ROUTINE Would it be okay if I did an examination of the joints in your body This will involve observing your walking, examining at your neck, back, arms and your legs Ask if patient is in pain before starting. Questions Pain or stiffness in any muscles  or joints? Any trouble washing or dressing? Any trouble climbing up & Down the stairs Examination Gait Walk across the room and turn around and walk back Comment on stride length, symmetry, smoothness and ease of turn Spine Look from the side for kyphosis/lordosis Look from the back for scoliosis Any assymmetry Shoulders  and iliac crest Obvious valgus/varus in knees Look at ankles for hindfoot alignment Look at lumbar  spinal extension as they bend over Test cervical spine by getting them to put their ear on their own shoulder Press the middle of supraspinatous to check for Fibromyalgia Arms ...

When doing an exam for the osce, it is important to have a routine. Here is one. In this routine the following will always be commented on. The routine for resp Wash hands Introduce Consent + Explanation Explanation of talking to examiner (explaining this to the patient) Pain Observe from end of bed Look around Look at patient Comfort Well perfused Alert Orientated Hands Peripheral cyanosis Tar staining Clubbing Palmar creases Hypothenar wasting Tender wrists Arms Pulse Resp rate CO2 retention flap BP Face Conjuctival palor Horner's syndrome Central cyanosis Neck JVP Trachea Deviation Cricosternal distance Tracheal tug (Come back and get your lymph nodes) Chest Inspect Type of breathing Paradoxical chest movements Apex beat Chest expansion TVF Percuss Ascultate Vocal resonance Back Check lymph nodes Check for chest expansion TVF Percuss Vocal resonance Ascult...