Professional Documents
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Master
Exam
Dr. Mona Yehia M.
MBBS, MSC, SDFM
A concise guide for family medicine clinical
exams and daily general practice
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Dedication
To everyone who taught me even a single
letter and supported me
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Master OSCE exam
Dear reader,
What you hold now between your hands is the result of several years
of struggling to learn, practice and teach family medicine and general
practice.
I'm an Egyptian family medicine specialist, having Master degree in
Family and community medicine as well as Saudi Diploma of Family
Medicine.
I'm the owner and creator of (Review of Family medicine), a medical
educational web page, currently has tens of thousands of followers,
whom are all physicians of different specialties all over the world.
In this book, I collected the most common presenting problems in our
daily practice, as well as in family medicine clinical exams, discussed
concisely how to approach them in a family medicine biopsychosocial,
patient-centered way.
Each problem presented in one page, making it easier to memorize,
with the help of colored icons, that are consistent throughout the book.
I chose 30 topics of most common consultations in family medicine, 10
counseling and health education topics, and 10 examination and minor
procedures topics as well.
Revised by:
Board Trainer
MBBS, SBFM
Trainer
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Master OSCE exam
Recommendation
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Recommendation
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Master OSCE exam
Introduction
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2. Start
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.
5. Summarize history
6.
7. Summarize findings
8.
9.
10. Housekeeping
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Tailor OSCE station to a child (0 – 5 years)
1. Pregnancy, birth and neonatal history: maternal 2. Social history: order in family – father's job – living
infections, smoking, drugs, illnesses during pregnancy – status - working mother? – Who is the care taker? – Family
gestation at birth – mode and duration of delivery – birth function – family member with psychiatric illness or
wt – birth injury – congenital malformation – neonatal alcohol/drug abuse – Family history of chronic or inherited
jaundice, fever, fits, bleeding disorders, feeding problem 3. Feeding history: breastfed or
artificially fed or both – difficulty –
10. Health maintenance: screening formulation – sterilization - how
– immunization – health education - many feeds/day – complementary
anticipatory guidance - Vitamin D feeding (quantity, quality, timing)
400 units since birth + 1 mg 4. Vaccination: routine schedule
elemental iron/kg/d at 4 months for + influenza yearly started 6 mo
exclusively breastfed infants
5. Growth: plot wt, length (up
to 2 years, then height), head
9. Child abuse: bruises, cuts and circumference & BMI on chart
fractures of different healing stage – Red flag: < 3rd percentile or
developmental delay – underweight crossing 2 major percentiles
- aggression – poor hygiene – poor
bond with parents - poor social skills 6. Development: Red flags: not achieve
indicated milestones – strong parent
8. Safety & injury prevention: indoors & concern – significant loss of skills – lack of
outdoors (burn – drowning – fall – poisoning response to auditory/visual stimuli – poor
7. Parental concern:
– chemicals – choking - electric shock - interaction – motor/sensory difference
explore and take it seriously
transportation – sports – bicycle – violence) between both sides of body - floppy or stiff
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1. Risk reduction: inquire about [driving (esp. motor 2. Relations to family members and community:
cycle) - unsafe sexual behaviour which may lead to Family function and transitions – power struggle – home
unintended pregnancy & sexually transmitted diseases environment – social history - Exclude disruptive behavior
– exposure to violence or feeling unsafe – weapons] disorders (aggressive - angry outbursts – refuses to comply
with rules - antisocial – destruct property – skipping school)
8. Health maintenance: Screening –
Immunization - Health & sexual 3. Healthy food vs junk food and
education – identify main concerns of empty calories - Caffeinated
adolescent and answer his questions - beverages – Obesity - Exclude
parental guidance for how to deal with eating disorders (anorexia and
adolescent & prepare for autonomy - bulimia nervosa, binge eating) –
manage continuous problems obsession with being thin in girls
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Screening and immunization children and adolescents
Age Screening & prevention Immunization
group
Metabolic screening,
Newborn hemoglobinopathies and Hepatitis B within 24 hrs
(0-28 d) thyroid function (A) of birth
Hearing screening (B) + routine immunization
Topical ocular prophylaxis for schedule
gonococcal (A)
Oral fluoride supplementation
if water supply is deficient in Routine immunization
Children fluoride 6 m – 5 yrs (B) schedule
6m–5 Fluoride varnish starting at + Annual inactivated
yrs age of 1ry eruption up to 5 yrs Influenza vaccine starting
(B) from 6 mo
Vision screening 3 -5 yrs (B)
HPV vaccine to all
Tobacco use counseling in
adolescent aged 11 or 12
school-aged & adolescents
yrs, 2 doses, 2nd after 6-12
(B)
mo, or 3 doses (0, 1-2, 6
Obesity screening 6 yrs &
> 5 yrs m) if initiated at age 15 or
older (B)
older
Screen for depression in
Tdap 1 dose to all
adolescent 12 -18 yrs (B)
adolescents aged 11 or 12
Counsel for skin cancer
yrs regardless of interval
prevention for fair skin starting
since last tetanus and
at 10 years – minimizing
diphtheria containing
exposure to ultraviolet (B)
vaccine
Screen for HIV starting at 15
yr if at increased risk (A)
Chlamydia & gonorrhea for
At risk sexually active females up to
(Sexually 24 yr or older if at increased
active risk (B)
- IV drug Screen for hepatitis B (B)
abuse) Folic acid 400 to 800 mcg
daily if planning or capable of
pregnancy (A)
Inactivated influenza
Hepatitis B – HIV – Syphilis in vaccine anytime during
st
Pregnant 1 visit (A) pregnancy
Screen for gestational DM Tdap vaccine (any time
after 24 wks (B) but optimal between 27&
36 wks)
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Adult Screening and immunization Guidelines (USPSTF)
Age Screening Immuniza-
Male Frequency Female Frequency tion
Pap test Td every
starting 3 yrs 10yrs
after 1st +
intercourse or Every 3 yrs Flu
at age 21 in vaccine
Measure
sexually yearly
18 Blood
Every 2 yrs active which +
- pressure
is 1st (A) Pneumoco
(A)
24 Chlamydia & Every year up to ccal
Gonorrhea in age 24/ vaccine
all sexually Or older if at risk one dose
active women (B) <65 yr if at
BP Every 2 yrs high risk
Screen all adults for tobacco use (A) and alcohol misuse (B) with brief behavioral counseling
HIV & Syphilis infection screen for persons ages 15 to 65 years who are at increased risk
Adults ≥ 20 years for lipid disorders if at high risk of CAD (B)
Screen all adults for obesity, refer for multicomponent intervention if ≥30kg/m2
Lipid ≥ Every 5 yrs Every 3 yrs Td every
Pap test
35y (A) 10yrs
Lipid ≥45y(A) Every 5 yrs + Flu
25 Blood Every 2 yrs vaccine
Pressure BP Every 2 yrs
- yearly
- Cancer colon at age 40 if 1st degree (or two 2nd degree) relative have colon cancer or
49 adenomatous polyps (or 10 yrs earlier if relative diagnosed < 60yrs whichever comes first)
- Screen for blood glucose in adults 40 to 70 years who are overweight or obese q 3 yrs (B)
Prostate Insufficient Pap test Every 3 yrs Td every
Cancer evidence Mammogram Every 2 yrs (B) 10yrs
Lipid Every 5 yrs Lipid Every 5 yrs +
BP Every 2 yrs Every 2 yrs Flu
BP
50 vaccine
Occult fecal Occult fecal yearly
- blood /yr blood /yr +
64 Cancer Sigmoidoscop Cancer Sigmoidoscopy/ Zoster
colon y/5 yr colon 5 yr (Shingles)
(A) Colonoscopy/ (A) Colonoscopy/ vaccine
10yr 10yr once a life
Until 75 ys Until age 75 ys >60yrs
Aspirin 45 to 79 yrs Aspirin 55 – 79 yrs
Screen lung cancer by low dose CT in adults 55-80 ys who smoke 30 pack/yr or quit within past 15 yrs
Statin if 40-75 yrs or CVD risk, Aspirin in 50-59 yrs with ≥ 10% 10-year CVD risk & no bleeding risk (B)
Abdominal Screening Td every
aortic once, men 65- Every 2 yrs 10yrs
Mammogram
aneurysm 75 yrs who till 74 yrs + Flu
≥ (B) ever smoked vaccine
65 Lipid Every 5 yrs Lipid Every 5 yrs yearly
BP Every 2 yrs BP Every 2 yrs + Zoster
vaccine
Ca colon Till age 75 yrs once a life
Cancer ≥65 yrs or +pneumoc
Till age 75 yrs Bone
colon younger if high occal one
density (B) dose >65
fracture risk
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Consultation
and
health maintenance
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1. Abnormal uterine bleeding (AUB)
What is BA? - How & when to use different types of inhaler &
peak flowmeter – action plan – avoid triggers – red flags
Start low dose 1st wk, f/u weekly 1st 4 wks, wait 2-12 wks for
improvement, continue 4-9 mo after satisfactory response,
withdraw gradually to avoid discontinuation syndrome
Wash with lukewarm water & soap, dry gently especially toe webs,
moisturize but not in toe webs, trim nails straight, inspect daily with
mirror for lesions/signs of inflammation, cotton socks, inspect shoes
Brush at least twice daily – floss once daily – checkup every 6 months
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Diabetes (cont.)
1. Metformin: 1st line of management of DM type 2 unless
contraindicated [severe renal impairment (eGFR <30 mL/
min/1.73 m2), not recommended if <45 - hepatic impairment] - It
decreases hepatic glucose production & improves insulin
sensitivity – with meal – most oral agents HbA1c by 0.5-1.25%
Glucophage® 500, 850, 1000mg q 8-12 hr, maximum 2550mg/d
Glucophage XR® 500,750,1000mg qDay, maximum 2000mg/d
2. Sulfonylurea: stimulate ß cells' insulin secretion, can cause hypoglycemia
and wt gain – taken prior to meal – pregnancy category C even glyburide
Diamicron® (Gliclazide) 80mg q12hr, maximum 320mg/d, Diamicron MR® 30
mg qDay, maximum 120mg/d - Daonil® (Glibenclamide) 5mg q12hr,
maximum 20mg/d - Amaryl® (Glimepiride) 2mg qDay, maximum 8mg
3. Dipeptidyl peptidase4 (DPP4) inhibitors: inhibits DPP4 ↑ incretin
levels (GLP-1 and GIP) inhibit glucagon release stimulate glucose-
dependent insulin release (so do not cause hypoglycemia) + slow gastric
emptying – can be used with other oral antidiabetic drugs or insulin – once
daily - can be taken with or without food – Januvia® (Sitagliptin)
25,50,100mg, maximum 100mg/d - Galvus® (Vildagliptin) 50mg, maximum
100mg/d - Onglyza® (Saxagliptin) 2.5,5mg, maximum 5 mg/d – Tradjenta®
(linagliptin) 5mg (safe in renal & hepatic impairment)
4. Glucagon-like peptide 1 (GLP-1) agonist: same action as DPP4
inhibitors – injectable only – Bydureon® (Exenatide) once/wk, Byetta®
(Exenatide) BID, Trulicity® (Dulaglutide) once/wk, Victoza® (Liraglutide) OD
5. Sodium-glucose co-transporter 2 (SGLT2) inhibitors: block renal
reabsorption of glucose increase glucose excretion - Avoid in severe renal
impairment – once daily - can be taken with or without food - most common
side effects are UTI and vaginal candidiasis. Invokana® (Canagliflozin) 100,
300mg, Forxiga (dapagliflozin) 5,10mg, Jardiance (empagliflozin) 10,25mg
6. Insulin: 1st line of management of DM type 1 & gestational diabetes. Start
0.1-0.2 units/kg, maintain on 0.5-1 unit/kg. Basal: [Humulin N® (NPH) once or
twice daily, Lantus® (glargine), Levemir® (detemir) or Tresiba® (degludec)
once at bedtime – F/U by morning FBS] – Prandial [Actrapid® (regular),
Humalog® (Lispro), Novorapid® (Aspart), Apidra® (glulisine) – prior to meal –
F/U by 2hr PPBS] – Mixed [Mixtard® (NPH/R 70/30), Humalog mix® (Lispro
protamine /lispro 50/50 or 75/25) - Novomix® (Aspart protamine/aspart 70/30)]
CBC – urine & stool – TSH – RFT – LFT – wrist x-ray for bone
age (if short stature) & rickets ± additional tests as indicated
Counseling
and
health education
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Introduction to counseling
- Ask patient's permission to speak about the problem
- Does he/she know hazards of the problem?
- Identify patient's stage in the cycle of change:
Precontemplation (Uninterested, unaware or unwilling to
make a change) maintain positive relationship, show
empathy, avoid argument, ask questions rather than advices
Contemplation (considering a change) move to (Assess)
Preparation (prepare to make a change) move to (Assist)
Action (active change) move to (Arrange)
Maintenance (sustained change) – Relapse (fall back)
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5. HIV counseling
CD4 & viral load /3-6 months [the lower the load the less the
transmission risk, the higher CD4 the better the prognosis]
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6. Obesity
Brief personal & social history – Progressive wt gain –
physical activity – sleep apnea – joint pain/LBP – dyspnea –
symptom of hypothyroidism – smoking/alcohol/drug abuse –
steroid – OCPs – infertility - chronic diseases – screen for
depression – you know about obesity complication? – impact
of obesity on your quality of life? - Are you willing to change?
– Did you try before to lose wt? – What was the roadblocks?
–
BMI [Wt in kg/Ht in m2]– BP - waist circumference - waist: hip
ratio – thyroid – chest /CVS – abdomen – LL – neck
circumference if sleep apnea (>37cm women, >43cm men)
BMI 25: 29.9 kg/m2 overweight – 30 :34.9 Class I obesity
35: 39.9 Class II obesity - ≥ 40 kg/m2 Class III obesity
After about 4 weeks, you'll be able to drive your car, air travel
and back to your regular sexual activity. PDE5 inhibitors (for
treatment of erectile dysfunction) must be avoided in patients
treated with nitrates as this can lead to dangerously low blood
pressure, it may be considered after at least 6 months post MI
Advise smokers to stop smoking, offer support and /or
medication - Reduce alcohol consumption to no more than 21
unit for men, or 14 units for women weekly
Advice all overweight/obese patients to achieve healthy weight
Mediterranean-style diet: ↑ bread, fruit, vegetables & fish; less
meat; replace butter & cheese with products based on plant oils
- BP control is the single most important factor in prevention
- Patient will be discharged on [ACEI at maximum tolerated
dose - B – high intensity statin – dual antiplatelet therapy]
for at least 1 year, continue ACEI, aspirin and statin life-long
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Examination
And
Minor procedures
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Examination/procedures template
Examination
/ procedure
Start
Examination/
Summarize investigation
findings to complete
examination
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1. Breast examination
1. Expose from waist up ① 2. Sitting upright on the side of the bed
3. Neutral position (arms by side, hands relaxed 4. Then arms above head, and lean forward as so
on thighs) then hands on hip and pushing inwards
Scars, asymmetry, skin changes (erythema,
4.Nipple (retraction, discharge, fissuring or scaling) puckering, peau d'orange), obvious masses
Use distal
A. Breast: Examine with ipsilateral arm B. Axilla: Examine in sitting position while
pads of middle
raised, while sitting as well as lying 45° ② ipsilateral arm resting on my other arm
3 fingers
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2. Cardiovascular examination
Position: lying 45° - exposed from waist up
Is the patient in pain? or distressed? Check vital signs
Check surroundings (IV fluids – O2 – drugs – walking aid -..)
Face: Pallor – jaundice – central cyanosis – malar flush (MS)
– angular cheilitis – glossitis – xanthelasma
Neck: visible IJV pulse – masses – scars
Chest: asymmetry – scars – visible bulge – visible pulsation
– deformity – barrel-shape - gynecomastia
Hand: cyanosis – clubbing – palmar erythema – janeway
lesions – Osler's nodes – splinter hemorrhage - xanthomata
Leg: edema – scars – hyperpigmentation - ulcers - varicosity
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6. Knee examination
①
Front: skin – scars – asymmetry – Back: swelling, scar, muscle wasting
sinus – swelling – color – deformity – Sides: hyperextension (genu
malalignment – muscle wasting recurvatum) – flexion contracture
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7. Rectal examination
Left lateral decubitus, with hip and knees flexed (knee to chest)
Rectal prolapse
Slotted anoscope
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8. Shoulder examination
①
From front, back and sides: Pushing into the wall: For winging
Scars – asymmetry – misalignment – swelling – or asymmetry of scapula
redness - muscle wasting – drooping shoulder
Anterior Posterior
Joint parts: sternoclavicular joint –
Temperature ② clavicle – acromioclavicular joint –
coracoid process – greater tuberosity
– scapular spine and borders
Abduction moving
laterally up to 180◦
Flexion ③
Extension
moving moving
forward backward Adduction moving Internal and
up to 180◦ up to 40◦ medially up to 40◦ external rotation
Compound movements for rapid screening for shoulder joint: Hands behind head = abduction + external rotation - Hands
behind back as far up as he can = adduction + internal rotation
* Ask patient to do all movements actively first, if no pain no need to proceed to passive movement. If painful active movement,
then move the joint passively, if pain disappears in passive movement so the problem is in muscle or tendon, if pain persists
so the problem is in other joint's structures. Adhesive capsulitis (Frozen shoulder) = Inflammation & thickening of joint capsule.
Patient supine to lock scapula limitation of both active and passive range of motion in different directions regardless of pain
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9. Suturing
Absorbable: internal structures, mucosa, deep layers - Natural
(chromic gut) – Synthetic (Vicryl, Monocryl) - Non-absorbable:
Natural (silk) - synthetic (Nylon, Prolene) Use 3–0/4–0 suture
on trunk, 4–0/5–0 on extremities & scalp, and 5–0/6–0 on face.
1. Clean the wound: Place a pad under the injured body part,
wear apron, irrigate with normal saline, clip local hair
2. Examine: wound size & depth – surrounding skin and vital
organs – distal neurovascular status – tendon function
3. Give anesthesia: 1ml of lidocaine 1% per each cm of
laceration (draw by green needle & inject by orange one), given
SC, around edges, aspirate first then inject while slowly
drawing the needle out, check by sharp object for effectiveness
4. Suturing (Simple interrupted sutures): hold the needle-
holder between ring & thumb, clamp needle perpendicularly at
its 2/3, 1st suture in the middle of the wound, penetrate skin at
a 90° angle, 0.5 cm from the wound edge, take the whole
thickness of skin, pronate to rotate needle, unclamp, pull
needle with forceps, (use toothed or untoothed forceps to
visualize the wound, but never use toothed to grasp needle),
repenetrate the other edge at same depth, re-pronate and exit
skin perpendicular, unclamp, tie 2-3 knots by rotating tip of
needle holder twice around the long end of suture then short
end is pulled through the loop tightly, cut, leave 1 cm between
sutures, dispose needle in sharps pin
5. Dressing: apply Steri-Strips to suture lines+ sterile dressing
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Table of contents
Introduction of the author………………………………………..........6
Introduction to OSCE station……………………………………….7
OSCE station template…………………………………………….….9
Tailoring history according to age…………………………………...10
Children………………………………………………………………....10
Adolescent……………………………………………………………....11
Elderly……………………………………………………………...…...12
Health maintenance………………………………………………….13
Screening and immunization of children and adolescents………............14
Screening and immunization of adults…………………………….….…15
Chapter 1: Consultation and health maintenance
1. Abnormal uterine bleeding…………………………………….…18
2. Acne vulgaris………………………………………………….….19
3. Anemia…………………………………………………………...20
4. Antenatal care…..………………………………………………...21
5. Breaking bad news…………………………………………….….22
6. Bronchial asthma…………………………………………………23
7. Chest pain………………………………………………………...24
8. Cough…………………………………………………………….25
9. Depression…………………………………………………….….26
10. Diabetes……………………………………………………….27
11. Difficult patient………………………………………….…….29
12. Dizziness………………………………………………………30
13. Dyspepsia……………………………………………………...31
14. Failure to thrive……………………………………….….……32
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15. Fatigue………………………………………………………...33
16. Febrile child…………………………………………...………34
17. Hand pain……………………………….….………………….36
18. Headache……………………………………...……………….37
19. Hypertension……………………………….….………………38
20. Joint pain………………………………………………………40
21. Low back pain…………………………………………...…….41
22. Muscle ache…………………………………………...………42
23. Nocturnal enuresis…………………………………………….43
24. Painful anal condition…………………………………………44
25. Recurrent abdominal discomfort...………………….…………45
26. Sore throat……………………………………….….…………46
27. Urinary incontinence…………………………….….…………47
28. Urinary tract infection……………………………...………….48
29. Vaginal discharge……………………………….….………….49
30. Vitamin D deficiency………………………………………….50
Chapter 2: Counseling and health education
Introduction to counseling…………………………………………54
1. Complementary feeding………………………………………….55
2. Contraceptive counseling………………………………………...56
3. Epilepsy health education………………………………………...57
4. Febrile convulsions………………………………………………58
5. HIV counseling……………………………………………….….59
6. Obesity…………………………………………………………...60
7. Post MI care……………………………………………………...61
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8. Pre-travel advise………………………………………………….62
9. Smoking cessation…………………………………………….….63
10. Vaccination defaulter……………………………….…………64
Chapter 3: Examination and minor procedures
Introduction to examination………………………………………68
1. Breast examination……………………………………………….69
2. Cardiovascular examination……………………………………...70
3. Chest examination…………………………………………….….71
4. Cranial nerve examination…………………………………….….72
5. Diabetic foot examination………………………………………...73
6. Knee examination……………………………………….…….….74
7. Rectal examination……………………………………….………75
8. Shoulder examination…………………………………………….76
9. Suturing…………………………………………………….….…78
10. Thyroid examination……………………………………….….79
Next book:
Master Data
interpretation
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