1. 2017/2018
Ace the 2a OSCE – Part 1

2. CVS & Respiratory Phase 2b Revision Session Eleanor Rosario
Laura Horseman
03/10/2017
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3. OSCE revision series 03/10/17 CVS & respiratory 05/10/17 GI & Liver
10/10/17 Neuro & Endocrine
12/10/17 MSK & Rhematology
Covering mainly history taking.
Practice examinations on anyone and everyone.
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4. Revision resources Your green handbook!
OSCE – A teaching manual for undergraduates
Peer teachers
Peer teaching website
Each other! And non-medic friends for examinations, maybe buy them chocolate in return
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5. Taking a history Wash your hands. Practice your intro.
Presenting Complaint
Specific problem e.g. “chest pain”
History of Presenting Complaint
Explore PC (SOCRATES)
Ask about other relevant complaints (lots of marks available here!)
RED FLAGS
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6. Taking a history Past Medical History Drug History
Anything you see your doctor about regularly?
Any surgery/hospital admissions?
MJ-THREADS can help jog memory
Anything especially relevant to PC
Drug History
Any medications?
Any allergies?
Medications can give you a clue if you missed anything in PMH!
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7. Taking a history Family History Social History
Anything run in the family?
Anything relevant (e.g. atopy, autoimmune, MI)
Social History
Alcohol/drugs
Smoking
Occupation
Housing situation
Anything relevant (e.g. pets in asthma)
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8. Taking a history Summarise ICE Systems review if time
Ideas
Concerns
Expectation
Systems review if time
Thank the patient and smile!
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9. Cardiac presenting complaints
Chest pain
SOB (dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea)
Ankle swelling
Cough, sputum and haemoptysis
Dizziness
Presyncope and syncope
Palpitations
Leg pain on exertion
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10. Chest Pain Cardiac: Myocardial infarction Musculoskeletal:
Pericarditis
Angina AF
Acute myocarditis
Aortic dissection
Musculoskeletal:
Costocondritis
Trauma
Muscle sprain
Gastrointestinal:
GORD
Peptic ulcer disease
Oesophageal spasm/stricture
Chest Pain
Respiratory:
- PE
- Infection (pneumonia, TB etc)
Pneumothorax
Malignancy
Other:
Anxiety
Sickle cell crisis (acute chest syndrome)
Shingles

11. CHEST PAIN
Site – where is the pain? Can you point with one finger to the pain?
Onset – when did the pain start? What were you doing when it started?
Character – how does the pain feel? Sharp, crushing, stinging, boring etc
Radiates – does the pain move around your chest or anywhere else?
Associated symptoms
Timing – has it progressed since it started?
Exacerbating/alleviating factors – does anything make it better? Does anything make it worse?
Severity – rate /10
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12. Clues from site, radiation and character:
MI – central, crushing, radiates down left arm and jaw
Pericarditis – central pain, bores through to back, better if sat forward, worse if lying down
Angina – central tightness or heaviness, radiates to arm(s) and jaw. Key is link to exertion and relief by rest!
Acute myocarditis – key in history will be preceding flu symptoms
Aortic dissection – ‘tearing’ pain, central or abdominal
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13. Associated Symptoms:
NB MI can be ‘silent’, esp if diabetics/diabetics – unlikely to be a history station but useful info for a question. Syncope, epigastric pain, vomiting.

14. ANY CV HISTORY
PMH – hospital/A&E visits, seeing GP regularly? Previous stents etc?
Smoking history
Alcohol
Diet and lifestyle
Occupation – sedentary?
Home – carers? Coping with household activities?
FMH – MI < 55years 1st degree relative significant
What’s your main concern/which symptom is most problematic?
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15. ANGINA Stable vs acute angina Stable – exertion key, relieved by rest.
Quantify exertion!
Other precipitants – cold, emotion, heavy meals
How frequent are the attacks?
How is this affecting your life?
What do you do to stop the pain when the attacks happen?
Is this worsening of existing angina or a new diagnosis?
Associated symptoms, lifestyle, PMH
Caused by athema mostly therefore ask re CV disease risk factors (diet, sedantary lifestyle etc) and past cardiac history
Are they taking a statin or using a GTN spray? Have they had a past MI? are they on aspirin?
Can be caused by anaemia, thyroxicosis, hyperlididaemia, aortic stenosis – modify these risk factors in treatment
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16. ACUTE ANGINA With MI = acute coronary syndromes
Chest pain at rest >20 minutes and associated symptoms
Risk factors – non modifiable vs modifiable
PMH – history of hypertension or IHD?
FH – significant = IHD 1st degree relative <55 years old
Non modifiable – male, age, family history IHD
Modifiable – smoking, hypertension, hyperlidiaemia, obesity, sedantary life style
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18. SOB Onset Pattern – constant? Daytime variation?
How is this affecting your daily life?
QUANTIFY
PMH – asthma? Malignancy? CV history? Anaemia?
Drug history
Associated symptoms – wheeze? Weight loss? Swelling?

19. Key for CV…Heart Failure
Differentials – heart failure, PE and other respiratory causes
Left ventricular failure
New York Association Classification of HF symptom severity
What was normal for the patient before diagnosis?
Quantify activity
Pillows at night. Are they sleeping in a chair/can they climb the stairs?
Dyspnoea, PND, orthopnoea, poor exercise tolerance, fatigue, cough, wheeze – ‘cardiac asthma’.
Dyspnoea – shortness of breathe
Orthopnea – SOB on lying flat
PND – SOB at night, waking from sleep
I – no limitations, ordinary physical activity doesn’t cause above symptoms
II – slight limitation of physical activity, comfortable at rest but ordinary physical activity causes sympto s
III – marked liitation of physical activity
IV – CCF symptoms present even at rest, any physical activity = symptomatic

20. PERIPHERAL SWELLING Think RV heart failure!!
Pitting oedema of the legs – check in CV exam
Sacral oedema – don’t forget in respiratory exam
+ ascites, nausea, facial engorgement, anorexia
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21. Cough, Sputum and Haemoptysis
Overlap with resp
LV failure – cough with pink frothy sputum
RV failure – lung disease a cause, therefore may have cough
Nocturnal cough – asthma a Dx, also heart failure
Haemoptysis, think PE and malignancy.
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22. PALPITATIONS Frequency Onset Duration
‘Describe the last episode to me’
Can you tap out the rhythm?
Dizziness or LOC
Anxiety Hx
PMH – diagnosis of AF? Are you on any blood thinners? Have you ever had a stroke or mini stroke? History of valve disease?
Learn CHADS2VASC (risk of a stroke if patient has AF), HASBLED (risk of bleeding on warfarin)
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23. DIZZINESS, PRE/SYNCOPE
Postural hypotension, vasovagal attack, severe aortic stenosis, AF
When do you get dizzy
How many episodes/week
Have you had any blackouts
Associated symptoms – palpitations, sweating, hyperventilation, chest pain, headache etc
Pick up marks by covering all systems in brief
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24. LEG PAIN ON WALKING Intermittent claudication SOCRATES history
Calf (femoral) vs buttock pain (iliac)
QUANTIFY! Claudication distance – how far before pain starts
Ask re risk factors – smoking, alcohol, diabetes, hypertension, hyperlipidaemia
Associated symptoms – gangrene, burning, foot pain (‘I’m hanging my foot off the bed at night’) = critical ischaemia. Impotence.
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25. EXAMINATION TIPS Patients with pacemakers
Difference between a pacemaker and a ICD
Murmurs – likely aortic stenosis/mitral regurg
Aortic stenosis – ejection systolic murmur heard loudest over aortic region, potentially radiates to carotids, loudest sat forward in held expiration. Caused by old age calcification of valve.
Mitral regurg – pansystolic murmur loudest in axilla. Causes – lv hypertrophy, IE, valve calcification.
Mitral regurg

26. Respiratory presenting complaints
2 minutes to chat to the person next to you
What questions would you like to ask about the PC
Why?
We will discuss
Please don’t be shy!
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27. Cough What do you want to know? And what will get you marks…
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28. Cough HPC Duration Dry or productive?
Sputum (consistency, colour, odour)
Any blood (how much, fresh or old, bleeding elsewhere, DVT symptoms)
Worse at any time of day?
Exacerbations (pets, pollen, dust, weather, occupation)
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29. Cough Other important symptoms Wheeze
Chest pain (varying with breathing suggests respiratory cause)
Shortness of breath
FEVER, WEIGHT LOSS, NIGHT SWEATS
Do they feel unwell?
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30. Cough PMH DH Acid reflux Asthma COPD (prone to infections) TB
ACE inhibitors
Allergies
Inhalers
TB jab
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31. Cough FH SH Asthma, hayfever, exzema Pneumonia contacts TB contacts
Occupation – specifically industry
Pets
SMOKING
Pollution
Foreign travel
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32. Relevant questions for respiratory
History of TB, asthma, PE, pneumonia, GORD, allergies, rheumatoid
Family Hx of CF, TB, asthma, eczema, hayfever, emphysema
ACE inhibitors, inhalers, immunisations, NSAIDs, methotrexate
Crowded accommodation, damp, occupation, foreign travel, pets
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33. Shortness of breath
What do you want to know? And what will get you marks…
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34. Shortness of breath HPC Describe the sensation Duration
Constant or intermittent
Activity limitation (how far can you walk?)
Is it getting worse
Any exacerbations (e.g. weather)
Any relieving factors (e.g. inhaler)
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35. Shortness of breath Other important symptoms
CHEST PAIN (is it cardiac?)
Can they lie flat at night? (heart failure??)
How many pillows?
Waking from sleep
Ankle swelling
Wheeze
Cough
Systemic illness (fever, weight loss, night sweats)
Anxiety and panic attacks (tingling feeling associated with hyperventilation)
Fatigue (anaemia)
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36. Shortness of breath PMH DH Asthma COPD TB Cardiac disease
Severe lung infections
Blood clot DH
Inhalers
Allergies
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37. Shortness of breath FH SH Asthma Cardiac disease
SMOKING and ex-smoking!
Occupation
Stress and anxiety
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38. Asthma assessment Ask about symptoms Walking at night
Wheeze
Cough
Shortness of breath
Infections
Diurnal variation
Walking at night
Symptoms in morning
Reliever use
Activity limitation
School, work, exercise
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39. Asthma assessment Allergies Social Coping with medications Smoking
Occupation
Pets
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40. Any questions about resp examination?
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41. History 1
Barry is a 67 year old man who comes to the GP with “chest pain”. What do you want to know?
SOCRATES
It’s central and comes on when he walks more than 200m. It goes away when he rests. Sometimes he feels a bit sick with it and it goes to his jaw. It’s a 6/10 in severity.
Which system is this?
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42. History 1 What other cardiac symptoms will you ask about?
What PMH is important?
What FH is important?
What drugs might he be on?
What SH is important?
SOB, palpitations, nausea, sweating, leg swelling, PND, orthopnoea
SH smoking, alcohol, diet, sedentary occupation
Hx MI, angina, HTN, cholesterol, diabetes, stroke
FH of MI and stroke esp at young age, CV disease
Antihypertensives, statin, diabetes medication
GTN spray
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43. History 1 Sometimes feels faint No previous heart problems
He takes amlodipine for hypertension
He smokes 20/day
He’s a lorry driver
What condition is this?
What lifestyle advice do you give him?
What medication do you offer?
What are the side effects?
SOB, palpitations, nausea, sweating, leg swelling, PND, orthopnoea
SH smoking, alcohol, diet, sedentary occupation
Hx MI, angina, HTN, cholesterol, diabetes, stroke
FH of MI and stroke esp at young age, CV disease
GTN spray (low BP, dizziness), beta-blocker reduces symptoms, may also need long acting nitrate, give aspirin, give statin if high cholesterol
Antihypertensives, statin, diabetes medication
GTN spray
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44. History 2
Sylvia is a 75 year old lady. She comes to you as she’s been getting more out of breath. What do you want to know?
Nature of the SOB
It’s been getting worse for the past few months and now she has difficulty getting to the shops which she was always able to do before. There’s no diurnal variation. She has no chest pain or HF symptoms.
Which system is this?
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45. History 2 What other symptoms will you ask about?
She often coughs up white sputum, but no blood, and she feels she wheezes. She’s always been thin and hasn’t noticed any drastic weight loss. She often feels very tired but has no fevers or night sweats.
What PMH is important?
She’s had 3 chest infections in the last year
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46. History 2 What medications might give her a cough?
What family history are you interested in?
Her dad and sister both has a similar thing.
What social history do you ask about?
She lives on her own in a bungalow. She used to smoke 30/day but stopped when her sister got this condition. She used to work as a teacher. She hasn’t been away.
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47. History 2 What condition are you thinking?
What does this show on spirometry?
What reliever might you offer her?
What genetic condition is associated?
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49. PTS 10th Anniversary Competition!!
Peer Teaching Society is proud to present:
Do you make great revision notes and feel that future medical
students would benefit from them?
See full details on the Peer Teaching Website. Alternatively follow this link to the google drive folder:
Revision Resource Competition
Prizes:
1st: £100
2nd: £50
3rd: £25
+ 1yr Pastes+ membership
Sponsored by
TUTORS: please leave this slide on screen at the end of your teachings sessions!!!! Thank you  If you would like more info on the competition please go to the Peer Teaching Website.
Submit revision documents that YOU have made for the chance to win some great cash prizes.. whilst also boosting your CV!!