Candidate

Instructions
The patient in the next room is Nick, who is 20 years old. He is concerned because he has noticed a lump on the left side of his neck. You have been given this patients full history. You have eight (8) minutes to discuss with the examiner three differential diagnoses- these should be the most likely diagnoses. You should include at least two (2) positive and two (2) negative features of this history, other than those listed above, which support or refute your diagnoses. You should expect the examiner to ask questions around your reasoning. Tasks Differential diagnoses with reasoning 8 minutes

Year 2 OSCE Practice 2011 Set 3, Clinical Reasoning Station

History of Presenting Complaint Name- Nick Age- 20 Occupation Engineering student and keen football player Social history- Lives in apartment with girlfriend of 6 months Drug/ alcohol Non smoker. 5-6 units alcohol (mid strength beer) following football on Friday nights. Nil recreational drugs Presenting complaint Painless lump on left side of neck, noticed by girlfriend whilst cutting his hair. Presents with concern regarding a 2.5cm lump on the left side of his neck, antero-medial to sternocleidomastoid muscle. It was first noticed by his girlfriend 3 weeks ago whilst she was cutting his hair. Initially patient thought that he had an enlarged gland associated with a viral illness, as he had experienced similar swellings in the neck during a glandular fever infection (age 17). The lump is not painful and has never been warm or erythematous. He reports no dysphagia, dysphonia or discomfort associated with the lesion locally. Patient is concerned that the lump has not reduced in size and he is experiencing some fevers and lethargy. He reports no recent weight loss. Nick is currently studying engineering at UQ and is heavily involved as a player and coach for his local football club. Recently he has been finding it difficult to maintain his usual training and coaching regimen due to easy fatigue. He reports no dyspnea or palpitations at rest, but breathlessness has reduced his exercise tolerance over the past 6 weeks. He has been dating Cassie, a dietician at RBWH, for the past 6 months and they have recently moved into a studio apartment together. She is his first serious girlfriend, although Nick admits to having brief sexual relationships with 5-6 women in the past. Currently Cassie takes the oral contraceptive pill and this is the couples main form of contraception. Nick describes his current relationship as harmonious, and Cassies health is currently good. Oral hygiene is maintained and Nick denies any tooth pain or infection, he has not recently undergone any dental procedure. Nick has not experienced any nasal congestion, sore throat or cough recently although he has felt feverish at night and occasionally wakes from sleep drenched in sweat. He does not report headache, muscle ache, joint or bone pain. He reports no nausea or vomiting. Urinary habits are unchanged, in particular he has no symptoms of burning or frequency of urination. He has no genital lesions or urethral discharge.
Year 2 OSCE Practice 2011 Set 3, Clinical Reasoning Station

Past Medical History: Epstein- Barr virus infection (Glandular fever) age 17 Acne vulgaris- age 16 current Meds Minocycline 100mg mane PO Allergies /ADRs Penicilliin- rash Past Surgical History: Appendicectomy aged 10 Adenotonsillectomy age 8 Immunizations : Up to date Family History: Both parents alive and well. No sibilngs Father -Type 2 Diabetes Mother - Rheumatoid Arthritis. Lifestyle Smoking Alcohol Diet Exercise Non smoker 5-6 units beer at weekends Football/ coaching 4 nights per week Hobbies football Pets none
Year 2 OSCE Practice 2011 Set 3, Clinical Reasoning Station

Instructions to Examiners
The patient is Nick a 20 year old man, who is complaining of a painless lump on the left side of his neck, associated with fevers, night sweats and fatigue. The candidate has been given this patients history. The candidate has eight (8) minutes to discuss three differential diagnoses, including positive and negative features of this history which support or refute their diagnoses. Conduct of this station Ensure the candidate understands the task that he/she has to do. The candidate is expected to discuss 3 possible differential diagnoses citing at least two (2) positive and two (2) negative points in the patients history, other than those listed above, that support or refute their choices. They are expected to have a balanced reasoning, and have prioritised the most likely diagnoses. They should be able to justify their reasoning with questions, if required- they are expecting some questioning from the examiners. If the candidates appear to have chosen an unlikely diagnosis- please ask them to justify their choice. Prompting the candidate for another diagnosis is permitted to allow them opportunity to discuss a more likely diagnosis. TASKS Differential diagnoses with reasoning 8 minutes

Year 2 OSCE Practice 2011 Set 3, Clinical Reasoning Station

 Differential Diagnoses 1. Lymphoma (Hodgkins / Non-Hodgkins) Positive Negative 2. Leukaemia (Acute Lymphoblastic Leukaemia) Positive Negative
Year 2 OSCE Practice 2011 Set 3, Clinical Reasoning Station

Unilateral swelling Cervical lymph nodes common location for tumour Painless nodule (as opposed to painful, reactive lymphadenopathy) Localized swelling as opposed to generalized Common malignancy of this age group (4 in 100,000) Most common in 15-30 y.o. with second peak in 50+ More common in Caucasians and males Associated constitutional B symptoms- fevers, night sweats History of EBV infection Fatigue (anaemia, infection) Exertional dyspnea (anaemia)

Relatively uncommon No Hx of weight loss No bleeding or bruising No immunosuppression, Hx radiation, Hx HIV

Neck swelling (lymphadenopathy) Painless nodule Associated constitutional B symptoms- fevers, night sweats Exertional dyspnea (anaemia) Fatigue (anaemia, infection?) Common malignancy of children and young adults

No evidence of infection No bruising or bleeding Localised neck swelling as opposed to generalized lymphadenopathy Relatively less common (1.5 in 100,000)

3. Reactive Lymphadenopathy (Local infections of face and oropharynx, systemic infections including HIV, Syphillis, influenza, EBV, CMV) Positive Negative 2. Pyogenic Lesion (Acne, furuncle, abscess) Positive Negative Painless nodule Long time course without change Associated fatigue and night sweats suggest systemic response to illness 4. Thyroid Nodule (benign or malignant) Positive
Year 2 OSCE Practice 2011 Set 3, Clinical Reasoning Station

Common cause of cervical lymphadenopathy Fatigue and fevers History of unprotected sexual intercourse Recent commencement of new sexual relationship History of acne vulgaris Long-term broad spectrum antibiotic therapy

Non-tender lymphadenopathy No generalized lymphadenopathy No URT symptoms No periodontal infection No genitourinary symptoms or lesions

Common in age and gender demographic History of acne vulgaris Fever Long-term broad spectrum antibiotic therapy (minocycline) Exercise schedule leading to warm, moist skin

Solitary thyroid nodules common (4-7 in 100) Thyroid malignancy common cancer of young people Associated fatigue may indicate hypothyroidism Associated sweating and fever may indicate hyperthyroidism

Negative 5. Branchial Cleft Cyst, Thyroglossal Duct Cyst, Pharyngeal Pouch Positive Common cause of neck swelling May be painless Negative Relatively late presentation for congenital anomaly (thyroglossal duct cyst, branchial cleft cyst) Not midline (thyroglossal duct cyst) No dysphagia or regurgitation (pharyngeal pouch) Does not explain fever, fatigue and night sweats Does not explain combination of fatigue, fever and night sweats No radiation history Low risk of iodine deficiency More common in women

Year 2 OSCE Practice 2011 Set 3, Clinical Reasoning Station

MARKING
Examiners are asked to grade students performance on a scale of 0 - 4 in the areas on the mark sheet in capitals. The standards for awarding these grades are; 0 = Unequivocal fail: Student was unable to demonstrate history or examination skills without significant prompting, OR displayed unethical or unprofessional behaviour. Student lacked a comprehensive approach, and/or needed considerable prompting to complete the task.

1 = Marginal fail: 2 = Borderline pass:

Student performed a systematic examination or history but did not complete some components in a number of areas of the marking guide. Student had a systematic approach, required little or no prompting, was confident and completed most components of the marking guide.

3 = Clear pass:

4 = High pass: Examiners are required to make an overall judgement about the students performance in each area on the marking sheet. The specific items listed are there to remind examiners about issues which might be considered. It is not intended that these items should rigidly translate into a score. It would be helpful, particularly when feedback is being given to poorly performing students, if there is some notation in the comments column. Also examiners may find it helpful, when considering what grade to award, to have indicated in the comments column when items were omitted or when prompting was required. Global Score. This mark does not form part of the students overall mark. The score should reflect the students empathy and overall performance, and is from the examiners perspective only. Student had a high level of proficiency, well above what would be expected of a student in Year 2.

Year 2 OSCE Practice 2011 Set 3, Clinical Reasoning Station

Feature General Organised summaries of diagnoses Appropriate diagnoses chosen Prioritises diagnoses Clear communication for presentation Differential diagnosis ONE Most likely and reasonable diagnosis Appropriate supportive points Appropriate negative points Differential diagnosis TWO Reasonable diagnosis Appropriate supportive points Appropriate negative points Differential diagnosis THREE Reasonable diagnosis Appropriate supportive points Appropriate negative points Adequate Reasoning Balanced reasoning Shows understanding of diagnostic signs with questioning

Comment

Score(please circle) 0 1 2 3 4

Pass Mark = 15/20 Pass/ Fail (Circle as appropriate) Comments (essential if the candidate has failed the station) Global Impression- from examiners only- score 0-4

Year 2 OSCE Practice 2011 Set 3, Clinical Reasoning Station