Contains information on how to present information in a medical exam, e.g. an OSCE.

1. Presentation Mantras
Christiane Riedinger May 2014

2. General Presentation of Examinations
● Avoid narrating everything you’ve done in the order you’ve done it.
● Introduction: “I have just examined …”
● “My most notable finding was …”
● Important +ves
● Important -ves for the differential diagnosis
● Relevant system specific negatives
● Differential diagnosis / diagnosis
● Management
○ Investigations - which one is the definitive diagnostic Ix?
○ Treatment
■ Immediate/emergency
■ General

3. How to decide what’s relevant
● What is the most notable finding?
● What other findings back up the most notable finding?
● What are the most important negatives

4. Mind Map Technique
http://www.passmed.co.uk/hxnotes.html

5. Treatment
● Conservative
● Medical
● Surgical
● Palliative
● Remember Management includes investigations as well.

6. How to Describe a Lump
● Features of a lump: she cuts the fish 3x + PER
● Size, site, surface
● Contour, colour, consistency
● Temperature, tenderness, transillumination
● Fluid-filled, fixed (tethering vs. fixation), fields (lymphatic drainage)
● Pulsatile
● Expansile
● Reducible

7. How to Describe a Lump: ctnd
● Inspection
○ What, where: Size, site (=> lymphatic drainage)
○ Surface: Surface, colour
○ Content: Transillumination, fluid filled
● Palpation
○ Contour
○ Consistency
○ Tethering vs. fixation
○ Temperature
○ Pulsatile
○ Expansile
○ Reducible
● What the patient tells you tenderness/pain
● What you know lymphatic drainage

8. How to Describe a Skin Lesion: Overview
● Number
● Size
● Distribution
● Type
● Colour
● Pigmentation
● Morphology
○ Shape
○ Pattern
○ Symmetry
○ Surface
○ Edges/Border

9. How to Describe a Skin Lesion: Detail
● Number
● Size If multiple, single or various sizes?
● Site/Distribution Flexures, contact, grouped, isolated, extensor/flexor surfaces
● Type
○ Flat Macule < Patch (10mm)
○ Raised Papule* < Nodule (5mm)
Nodule < Plaque (20mm)
○ Fluid Vesicle < Bulla (5mm)
● Cyst has epithelial lining
● Pustule is filled with pus
○ Rash Large area of abnormal skin or >20 multiple lesions
● Colour Erythematous (red, dil. vessels, blanches), purpuric (bleeding into skin)**
● Pigmentation Regular/irregular

10. How to Describe a Skin Lesion: Detail ctnd.
● Morphology
○ Shape Monomorphic, polymorphic, regular, pedunculated
○ Pattern Ring, oval, linear, targetoid
○ Symmetry Symmetrical, asymmetrical
○ Surface ========================>
○ Edges/Border Regular, irregular
Distinct, indistinct
“Active” edge = different colour
○ Scaly With thickened keratin
○ Desquamated Loss of epithelial cells,
can be in combination with scaly
○ Crusty With accumulated dried
exudate
○ Horn-like Elevated projection of
keratin
○ Lichenification Epidermal thickening
○ Ulcerated Skin loss
○ Eczematous Epidermal breakage
○ Eroded Break in the epidermis
not extending to dermis
○ Excoriated Superficial ulceration
from scratching
○ Macerated Surface softening due
to wetting
○ Purpuric, petechial Subdermal bleeding

11. How to Describe a Murmur
● Timing Systolic, diastolic, early, late, middle
● Shape Constant, crescendo, decrescendo, crescendo-decrescendo
● Location Where best heard
● Radiation Sound radiates in the direction of the blood flow
● Intensity 1 = audible after longer listening
2 = audible with stethoscope
3 = audible without stethoscope
4 = palpable audible without stethoscope
5 = palpable and audible with rim of stethoscope
6 = palpable and audible with lifted stethoscope
● Pitch Low (press gently, bell), medium, high (press hard, diaphragm)
● Quality Harsh, musical, rumbling, blowing

12. How to report and X-ray
● http://radiologymasterclass.co.uk/tests/x-ray_osce_presentation_tips.html
“This is a… (e.g. plain CHEST/ABDOMINAL radiograph),
of… (PATIENT'S NAME, AGE and DOB),
taken on … (DATE at TIME).
It is a… (PA/AP/SUPINE/MOBILE image)
and I note the side marker is in the (IN/CORRECT) position.
The image seems of (ADEQUATE QUALITY).** (describe orientation, penetration, rotation, fields, inspiration,
artifacts)
The most obvious abnormality is (XXX),
analysing the image systematically (how to do that see next page), I note… “
*In the OSCE it probably is, unless it is blatantly obvious that it isn’t

13. CXR Interpretation - Summary
● ID image and date
● ID patient
● Adequacy
○ Orientation
○ Penetration
○ Rotation
○ Field
○ Inspiration
● Artifacts / Foreign bodies
● Most obvious abnormality?
● Systematic Approach HDM HLA CR
○ Heart
○ Diaphragm
○ Mediastinum
○ Hila
○ Lungs
○ Airway
○ Chest wall
● Review areas ============================>
● Summary, link to scenario, suggest management
● Costophrenic angles
● Lung apices
● Retrocardiac
● Subphrenic
● Bones
● Soft tissues
Alternative approach: ABC system BETTER?
● Anatomy/Airway
○ Trachea
● Breathing
○ Lung fields, diaphragms, costophrenic angles, pleura
● Circulation
○ Heart, vessels (hila)
● Soft tissues
○ Mediastinum, chest wall
● Review areas
CXR
Evaluate structures
- Size
- Position
- Density
- Borders
- Symmetry

14. How to report the ECG
● Name/age of patient, date.
● Are they in pain?
● Rate, Rhythm Normal, fast or slow
Regular vs. irregular, describe P-wave
● Cardiac axis What is it, what does it tell us?
● Conduction intervals P-R and Q-T Evidence of conduction failure?
● QRS complex description Width normal or too wide? Height?
● ST segments Elevated?
● T waves Inverted?

15. Psych Case Formulation
● Introduction of patient (demographics…)
● Presenting problem => DD
● Predisposing factors
● Precipitating factors
● Perpetuating factors
● Protective factors
● All of above subcategorised into: biological, psychological, physical, social
(environmental and relationships)
● Treatment plan

16. Viva Answers
● I would take an appropriate history and examination, initiate investigations and
special tests while simultaneously carrying out resuscitation and emergency
assessments and treatments
● Investigations - how to structure them
○ Bedside tests: Urinalysis, BM
○ Simple blood tests: FBC, biochemistry
○ Testing for infection: Urine MCS, blood cultures, CRP/ESR
○ Imaging: Plain film, US, CR/MRI
○ Specialised tests:

17. Viva Answers: Continued
● Management
○ Major structure
○ Conservative Patient education, lifestyle advice, monitoring, genetic counselling
○ Medical
■ Targeted Treat actual conditions
■ Supportive Analgesia, ...
■ Symptomatic Analgesia, ...
■ Palliative Analgesia, ...
○ Interventional E.g. percutaneous coronary intervention
○ Surgical
○ Radiological
○ MULTIDISCIPLINARY TEAM APPROACH!