Hassan's OSCE-2nd Edition-Trailer Version - 240126 - 204920

Hassan’s OSCE 2nd Edition
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Hassan’s
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OSCE
For Final Year MBBS, NLE-2
2nd Edition
Note:
 2nd Edition is the Updated Edition in
Best Quality Page and Completely
Coloured Book
 Covers OSCE Stations of All Final
Year Subjects
 The Most Authentic, Best Selling
Book According to Pattern of KMU
Exam
 History Taking and D/Ds
 All Systems Examinations
 Fluids Analysis
 ABGs, Drugs and Poisoning
 Instruments
 X-Rays and ECGS
 Procedures
 Counselling
 EPI Schedule
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 Total Number of Pages=353
PREFACE
When I was a student of final year MBBS at KMC, I found it
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very difficult to study for TOACs examination. Because one
has to study different books for different OSCE stations. So
I felt the need to combine all the relevant OSCE stuff in one
book form, i.e. examination, instruments, and other
stations.
Great effort was made in writing and compiling of
this book. Most of the stuff is taken from standard
books along with ward lectures and examination
books.
This book almost covers all stations in medicine and
Paediatrics TOACs. However, it should be kept in
mind that without proper practice of these stations
and without performing these examinations on
patients, this book will give you theoretical clue.
Please let us know your feedback and suggestions for
improvement of stuff in the next edition at
E-mail: [email protected]
FACEBOOK PAGE: HASSAN OSCE GUIDE
Whatsapp#: 0345-3435070
DR. FAISAL HASSAN

KMC PESHAWAR
THIS BOOK INCLUDES:
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Ward lectures of
• DR. HUMAYUN (HOD MEDICAL WARDS)
• DR. HASHIM (PROF.MDW KTH)
• DR. AWAIS (AP. MDW KTH)
• DR. GHULAM SHABBIR (PROF. MCW KTH)
• DR. SALEEM IQBAL (PROF MBW KTH)
• DR. ZAHID FIDA (PROF. MEW KTH)
• DR. IRSHAD (HOD PEADS KTH)
• DR. QAMAR (PROF.PEADS KTH)
• DR. ZIA (PROF.PEADS KTH)
• DR. SABIR (PROF. PEADS KTH)
• DR.SABAHAT (AP PEADS KTH)
POINTS FROM:
• NICHOLAS TALLEY
• MACLOED’S
• BEDSIDE TECHNIQUES Etc.
ACKNOWLEDMENT
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First of all I am extremely grateful to My Family for
trusting and believing in me. Without whom I can’t even
think of myself.
Special thanks to Doctor SANA (TMO MAW KTH) who
thoroughly checked every word one by one and pointed
out the short comings. Once again thank you so much
ma’am for your precious time, you really helped me a lot.
(1st edition)
SPECIAL THANKS to DR. ABDUL BASIT, my most exacting
critic, my closest friend without whom this book would
not have been this book.
Special thanks to Dr. BUSHRA YOUSAF who helped me a
lot in writing the Procedures and reviewing the Book.
Thanks to NIDA ALAM pharmacist for helping me a lot in
compiling the book.
Gratitude to Dr. HALEEMA WAZIR, my junior who
compiled the newly added stations in the TOACs.
Thanks to the Dr. AZHAR HAYAT, Dr. ZOHAIB, Dr.
AMMAR ZAHID, Dr. NASEEB, and Dr. SABIR who always
treated me as younger brother and encouraged me at
every step.
Thanks to all the Contributors.
CONTRIBUTORS
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I would like to give credit to these people for helping
me in writing and collecting stuff.
1. Dr Abdul Basit
2. Dr. Bushra Yousaf
3. Dr Haleema Wazir
4. Dr Ambareen Khan
5. Dr Marhaba iqbal
6. Dr Syeda Kainat
7. Dr Saima Rahman
8. Dr Azhar Hayat
9. Dr Sabir
10. Dr Rehan Haseen
11. Dr Naqeeb Ansari
12. Dr Fawad Nasir
13. Dr. Raza ul Haq
14. Dr Naseeb
INDEX
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SECTION : 1 EXAMINATIONS
PAGE
History taking & Differentials 11

Diagnosis
General Physical Examination 34
Respiratory System Examination 58

(Chest)
Abdominal Examination (GIT) 71
Diabetic Foot Examination & 84

Thyroid
CVS Examination (precordium) 101
CNS Examination 122

SECTION : 2 FLUID ANALYSIS
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CSF Analysis 160
Ascitic Fluid 167
Pleuritic Fluid 173
Urinalysis 175
SECTION : 3 ABGs , DRUGS &

POISONING
ABGs 180
Drugs 185
Poisoning 203
SECTION : 4 INSTRUMENTS, X-RAYS & ECG
1.Instruments 209
2.X-rays 247
3.ECG 272
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SECTION: 5 PROCEDURES, COUNSELLING, EPI ,
INSTRUMENTS
4.
Nebulization , Resuscitation, I/V 302
cannula, NG tube, catheter, CPR
5.
Counselling Steps 330
6.
EPI schedule + Indications for Nursery 335
admission
7.Gynae & Surgery Instruments 338-

353
HISTORY Taking
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“Always listen to the patient that might be telling
you the diagnosis” (Sir William Osler)
First of all follow the basic steps
 Approach to the patient in friendly, sympathetic

and gentle way
 Greeting + introduce yourself to the patient.
 Take consent + pay full attention to the patient.
 If the patient is eating or doing something
(leaving for washroom etc.) wait for the patient or
visit later.
 Use the patient own words and don’t use difficult
medical terminologies.
 First listen to the patient and don’t interrupt the
patient by asking leading questions.
 At the end you can ask the necessary questions if
any to complete the History.
Record the history in the following pattern.
1. Personal profile
2. Chief/presenting complaints (C/C)
3. History of presenting illness (HOPI)
4. Review of systems (ROS)
5. Current medications and Drug history
6. Past medical/surgical History
7. Personal History
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8. Family History
9. Allergy history
10. Travel history
11. Occupational History
12. Menstrual History (Female)
13. Socioeconomic history
1. PERSONAL PROFILE:
a) Name: (for identification of the patient say
for example XYZ Son/daughter/wife of
ABC.it is also possible that in the same
ward/chamber two different patients with
same name are there. So also ask for the
father/husband name for differentiation)
b) Age: (age is much more important
because some diseases are more common
in certain age group. For example stroke,
malignancy, MI, etc. are more common in
older group and measles, chicken pox etc.
are more common in children)
c) Sex: (some diseases are common in males
(myocardial infarction) and some are
present in females mostly i.e. SLE, primary
biliary cirrhosis)
d) Address : (for further communication and
some diseases are more common in one
place than the other)
e) Religion:
f) Marital status/Habitus: (unmarried
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people are mostly in depression,
married/habitual may have some sexually
transmitted disease.)
g) Occupation: (many diseases are
commonly related to occupation, and to
know about the socioeconomic history of
the patient)
h) Mode of Admission: admitted through
emergency or Pod. Also indicate about the
nature of the disease.
i) Date and Time
2. CHIEF/PRESENTING COMPLAINTs:
The complaints which bring the patient to the
doctor.
Recorded in chronological order i.e. the
symptom started first will be written first and
so on.
And along the symptom duration is also
mentioned.
For Example
1. Abdominal pain……………… 12 days
2. Fever……………………………… 10 days
3. Nausea / vomiting ………… 6 days
Note: use patient own words, no leading questions,
recurrent symptoms can be noted
HISTORY OF PRESENTING ILLNESS (HOPI)
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That part of the history in which the chief complaints
are elaborated in detail.
It is actually the chronological description of present

illness from initial sign to the present.
Elements of HOPI are:
1. Location/site
2. Quality
3. Severity
4. Duration
5. Timing
6. Modifying factors
7. Associated sign and symptoms
For Example:
PAIN (SOCRATES) FEVER (ODIPARA)
S = SITE O = onset
O =ONSET D = Duration
C = CHARACTER I = intensity
(Sharp/dull, (Low Grade or High Grade/

Heaviness, Aching, Rigors and chills)
throbbing, colicky,
Gripping,
Burning/tingling,
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boring/ stabbing,
Crushing,
R = RADIATION P = pattern
Continuous/intermittent/
remittent/ hectic/ relapsing
A = ASSOCIATED A = Aggravating factors

SYMPTOMS
T =TIMING R = Relieving factors

(DURATION,
COURSE, PATTERN)
E = EXACERBATING A = Associated factors

& RELIEVING
FACTORS
S = SEVERITY
DIFFERENTIAL DIAGNOSIS:
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COUGH:
ACUTE COUGH CHRONIC COUGH
Inhaled foreign Nonproductive:

Body
1. Asthma
2. Allergy
3. Vocal Cord dysfunction
4. COVID
5. GERD
6. Drug related like ACE
inhibitors
7. Post nasal drip
Respiratory tract Productive:
infection
1. Pneumonia , Sinusitis ,
Bronchitis
2. TB, lung cancer,
pulmonary
embolism(all are blood
stained)
3. COPD
(purulent/mucoid)
4. Bronchiectasis
(purulent)
5. Pulmonary edema
(pink/frothy)
ABDOMINAL PAIN
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GASTROINTESTINAL GENITOURINARY + VASCULAR
GYNAECOLOGICAL
+ PERITONEUM
1. PUD 1. UTI 1) Mesenteric

2. Gastritis 2. Urinary Angina
3. Malignancy Retention
4. Volvulus 3. Ureteric Colic 2) Aortic
5. Appendicitis 4. Polycystic Aneurysm
6. Obstruction Kidney
7. IBD Disease 3) Mesenteric
8. Strangulated Hernia 5. Pyonephrosis Venous
9. Intussusception 6. Ruptured
Thrombosis
10. Cholecystitis Ectopic
11. Pancreatitis Pregnancy 4) Aortic
12. Cholangitis/Hepatitis 7. Ovarian Cyst
Dissection
13. Diverticulitis Torsion/Ruptu
14. Splenic Rupture re
5) Embolus
15. Peritonitis 8. Severe
Dysmenorrhea (Mesenteric)
9. Salinities
6) Colitis
10. Endometritis
11. Fibroid Red
Degeneration
etc
EXAMINATIONS
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• GENERAL PHYSICAL EXAMINATION
• RESPIRATORY SYSTEM EXAMINATION
• ABDOMINAL EXAMINATION
• DIABETIC FOOT EXAMINATION
• THYROID EXAMINATION
• CVS EXAMINATION
• CNS EXAMINATION
GENERAL PHYSICAL EXAMINATION:
First of all, follow the basic steps “RIPE”

R=Right side approach
I =Introduction and consent
P =Position (supine + arm abduction)
E=Exposure and Explain the procedure to the patient
FIRST IMPRESSION OR GENERAL APPEARANCE:
First impression of the patient’s condition must be

deliberately sought, whether patient feels well, mildly ill
or severely ill.
POSTURE AND ATTITUDE:
It gives information about patient illness e.g.
• A pt. with severe heart failure prefers to sit

propped up because his dyspnea worsens on lying
flat
• A pt. with peritonitis lie down on the back, with

two legs bending. (pain and cannot move)
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• Squatting position in case of congenital heart
disease.
• Severe colicky pain =restless
• In meningitis= neck retraction etc.
CONSCIOUNESS:
Note that pt. is well oriented in time, place and person or

alert, confused and drowsy or unconsciousness by
assessing level of unconscious by using Glasgow Coma
Scale (GCS).
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• For Example: Brain injury is classified as on GCS
• Severe= GCS < 8-9
• Moderate = GCS , 9-12
• Mild = GCS > 13 or equal to 13
PHYSIQUE:
Visual impression is made about a pt. height and weight.

Both should be measured and compared with ideal body
weight and height. Compare the sitting height with arm
span and total height.
• TALL STATURE: Genetic, Marfan’s syndrome,

klinefelter syndrome etc.
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• SHORT STATURE: constitutional, genetic,
achondroplasia, cretinism, hypopituitarism
• In achondroplasia arms and legs are short while
trunk is normal, so sitting height is more than legs.
• In Marfan’s syndrome and hypogonadism arm
span is more than double the sitting height.
HANDS:
Many pathologies can be detected from the hands of pt.
Shaking hands with pt. is important to know about the

disease like dystrophic myotonia in which patient is
unable to let go.
SHAPE:
• Hands adopt special shape in tetany due to carpel

spasm
• Short 4th metacarpal in females is seen in Turner’s
syndrome.
SIZE:
• Hands are large and broad in acromegaly

NAILS:
 Blue nails: cyanosis, Wilson’s disease,

onchronosis
 Red nails: polycythemia, CO poisoning, sometimes

normal finding
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 Yellow nails: yellow nail syndrome, fungal
infection, diabetes etc.
 Brown nails: Chronic kidney disease
 White nails with darker rim: Hepatitis
 Pale nails: Anemia, CHF, liver disease
 Cracked or split nails: Thyroid disease
 Brittle nails: (which can break easily) iron
deficiency anemia, PVD, hypocalcaemia etc.
CLUBBING: (Hippocratic nails/fingers)
It is a physical sign characterized by bulbous

enlargement of soft parts of terminal phalanges with both
transverse and longitudinal curving of the nail.
Also called watch glass nails, drumstick fingers,

Hippocratic nails
TYPES:
Acute: erythematous
Chronic: non erythematous
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Figure: Normal Schamroth sign
Figure: Clubbing
RESPIRATORY SYSTEM EXAMINATION
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OR
CHEST EXAMINATION
COMMAND: EXAMINE FROM THE FRONT FOR CHEST
OR RESPIRATORY SYSTEM
First of all, follow the basic steps “RIPE”
R=Right side approach
I =Introduction and consent
P =Position (supine + arm abducted)
E=Exposure & explain the procedure.
Exposure:
Take off the shirt in male and maintain privacy in
females or do it in presence of female colleague or nurse
Position:
While examining from the front patient should lie supine
with arms abducted or patient lying at an angle of 45.
INSPECTION
Inspect the front and sides from the foot end. Note for
the following
• Shape and symmetry of chest
• Look at the face for SOB, cough and cyanosis
• Respiratory rate counting (missed by most of the
students)
• Type of respiration
• Prominent veins
• Any scars
• Deformity
• Pectus carinatum (pigeon chest)
• Pectus excavatum (funnel chest)

• Harrison’s sulcus
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• Any striae
• Note any wheezing
• Flail rib
• Any mass
• Chest recession or retractions
• Observe the surrounding i.e. any nebulizer,
medicine etc. (accessory equipment)
RESPIRATORY RATE:
Count the respiratory rate for one complete minute (IMP)
Age Normal RR Tachypneic
(breaths/min) (breaths/min)
0-2 months Up to 59 60 or >60
2 months - 1 Up to 49 50 or > 50
year
1-5 years Up to 39 40 or > 40
> 5 years 15-20 >20
NOTE: count the RR in inspection as it is noted by

examiner especially in peads.
MOVEMENT OF CHEST:
• Reduce movements in:
1) Pleural effusion
2) Collapse, fibrosis
3) Consolidation
• Abnormal Movements: airway obstruction i.e.
Emphysema, asthma etc.
TYPES OF BREATHING:
• Thoracoabdominal: normal in females
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• Abdominothoracic: normal in males and children
• Periodic breathing: in babies (breath fast several
times and then have a brief rest for less than 10
sec.)
• Acidotic breathing: renal failure and ketoacidosis
• Cheyne-stokes breathing: over ventilation
alternates with complete apnea i.e. LVF, Inc ICP,
narcotic overdose
PALPATION
While starting palpation
1) Warm your hands.
2) Ask about pain and tenderness (missed by most
of the students).
1. PALPATION OF TRACHEA:
The patient should lie straight. Trachea can be
palpated in the following two position.
1) Either remove the pillow from the pt. head
2) Ask the pt. to extend the neck and look
backwards or toward the roof.
Trachea can be palpated by one, two or three finger

method.
Ideally, we use three finger method to note any
deviation of trachea.
Stabilize middle finger in midline and put other fingers
around the midline in space and note any deviation as
shown in the fig.
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Normally trachea is somewhat towards the right side
but not so much palpable….we consider it in the center
as normal.
Conditions which:
• Pull the trachea: collapse, fibrosis, agenesis of
lungs etc.
• Push the trachea: pneumothorax, pleural effusion
(Air+ water), Kyphoscoliosis.
2. CHEST EXPANSION:
Grasp the sides of the chest with the fingers in such a
way that the thumbs of both hands approximate in the
midline as shown below. Now ask for deep breath and
note any abnormality or symmetry.
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Causes of Reduced chest movements:
UNILATERAL BILATERAL
Pleural effusion and Emphysema

pneumothorax
Chest trauma Hydrothorax
Fibrosis of lung Bronchial asthma
Consolidation Myasthenia gravis
Chest trauma Obesity
After palpation with hands you can also check and

measure the chest expansion with measuring tape.
3. VOCAL FREMITUS:
Place the edge of hand on the chest horizontally and

ask the patient to say 1, 2, and 3 and compare both
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sides.
NOTE: examine the whole chest i.e. interiorly, laterally
and posteriorly.
CAUSES:
DECREASED:
 Pneumothorax
 Pleural effusion
 COPD
INCREASED:
 Pneumonia
 Pulmonary fibrosis
 Tumor
4. APEX BEAT:
Localize the apex beat and note any shift i.e. towards
right or left or in normal place.
PERCUSSION
Percuss all the lobes of lung and compare both sides.
Follow the pattern as shown in the fig below.
Right lung has three lobes i.e. upper middle and lower lobe
and left lung has two lobes upper and lower. Left middle
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lobe is called lingula.
Note: while percussing it is ideal to percuss and auscultate

in the intercostal spaces in lean person and in any region
in obese patient.
Start from the apex i.e. percuss the apices of the lung in
supraclavicular fossa and then from 2nd to 6th intercostal
spaces in front, and from 4th to 7th on lateral sides.
Resonant sounds= normal (loud and low pitched)
Hyper resonant =pneumothorax, asthma or emphysema
(very loud, low pitch and longer in duration)
Tympanic= empty stomach (over gas filled spaces. loud
and high pitch)
Impaired note= fibrosis
Dull note= collapse + consolidation + Obesity (pneumonia,

hemothorax)
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Stony dull= pleural effusion and empyema
IMPORTANT:
Always use the one or two fingers and movement should
entirely at wrist and not at the elbow. And always
compare both sides at every step.
AUSCULTATION
Steps are the same as percussion. Auscultate the apices of
the lung and then from 2nd to 6th intercostal space
anteriorly. From axilla to 8th rib laterally and ask to breath.
Asses the type of breathing.

Normal= vesicular breathing
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Harsh = bronchial breathing
Added sounds (wheezes, crackles etc.)
 VOCAL RESONANCE: similar to vocal fremitus but is
heard with stethoscope and ask the patient to say 3, 3,
3(teen teen teen) and note resonance.
Causes: same as vocal fremitus
Vesicular Breathing Bronchial Breathing

(tracheal)
Inspiration > expiration Expiration > inspiration
No pause b/w Inspiration & Pause in between

expiration
Rustling sound (soft light Blowing character/ high

sound) pitched
Normal sound Seen in pneumonia, heart

failure, COPD
CRACKLES (Clicking, rattling or cracking sound…i.e.

like the take tak of clock)
FINE CRACKLES COARSE CRACKLES
Inspiration > Expiration > inspiration

expiration
No pause b/w Pause in between
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inspiration and
expiration
Rustling sound (soft Blowing character

light sound) (sound)
Low pitched High pitched
e.g. pulmonary fibrosis, e.g. Bronchiectasis

CCF
Note: Crackles that do not clear after cough usually

indicate pulmonary edema or fluid in alveoli due to ARDS
or heart failure.
 Crackles that partially clear or change after cough
may show bronchiectasis ….
WHEEZES: “High pitched, coarse whistling sound

heard during breathing”.
i. Wheezes during expiratory phase shows bronchiolar
disease.
ii. Wheezes during inspiratory phase shows stenosis
caused by tumor, foreign bodies or scarring. Also
occurs in hypersensitivity pneumonitis.
STRIDOR: (MUSICAL BREATHING)

Special type of wheeze, harsh, high pitched and
vibrating sound
 Inspiratory, which occurs when breathing in, and

indicates a blockage above the vocal cords. E.g.
croup, epiglottitis, laryngomalacia, vocal cord

paralysis,
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 Expiratory, which occurs when breathing out, and
indicates a blockage in the windpipe. E.g. tracheal
stenosis, anaphylaxis, bacterial tracheitis etc
 Biphasic, which occurs when a person breathes in
and out, and indicates narrow cartilage directly
below the vocal cords. e.g. Foreign body,
hemangioma, mass or tumor.
• Properly cover the patient

• Thank the patient
IF THE COMMAND IS:

EXAMINE THE PATIENT FROM THE BACK FOR CHEST
EXAMINATION
Same steps i.e. RIPE
Position: while examining back of the patient take off the

shirt and make the position which is most suitable to you.
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Ask the patient to sit with arms crossed anteriorly.
INSPECTION:
Same as that from front, also look for kyphosis, scoliosis or
Kyphoscoliosis etc.
PALPATION:
Always ask for tenderness and pain.
While palpating apices of the lungs place the four fingers
from behind in the supraclavicular fossa and thumb
stretched behind the neck.
Rest of the palpation is same as that of palpation from
front but no apex beat.
PERCUSSION & AUSCULTATION:

Same as from the front side.
• Cover AND thank the patient.
• NOTE: IF THE COMMAND IS:

EXAMINE THE PATIENT FOR THE CHEST
EXAMINATION THEN PERFORM ALL THE STEPS i.e.
BOTH FROM THE FRONT AND BACK ALONG WITH
RELEVANT
SECTION 2: FLUID ANALYSIS
Page-37
1. CEREBROSPINAL FLUID
2. ASCITIC FLUID
3. PLEURITIC FLUID
4. URINALYSIS
CEREBROSPINAL FLUID (CSF) ANALYSIS:
Page-38
CSF is a clear, colorless body fluid found in brain and
spinal cord produced by specialized ependymal cells in
choroid plexus of the ventricles of the brain.
CSF analysis is a group of tests that evaluate substances in
CSF in order to diagnose conditions affecting the brain and
spinal cord (CNS).
TOTAL VOLUME = 100-150 ml
DAILY SECRETION = 400-450 ml
Diseases are widely divided into four categories;
• Infectious disease : meningitis , encephalitis
• Bleeding with in the skull or brain
• Autoimmune disorders; GBS , MS , sarcoidosis
• Tumors of CNS
PHYSICAL PROPERTIES OF CSF:

AMOUNT: Normally suitable amount for CSF analysis =
2-5ml
PRESSURE:
Measurement of pressure during collection i.e. during
starting and closing the collection.
Normal pressure = 50-250 mm of water
Increased = tumors, infection, hydrocephalous or
bleeding (SAH)
Decreased = dehydration, shock or leakage of CSF (sinus
fracture)
COLOUR: Normally CSF is clear and colorless.
Color Cloudy Clear Straw/cloudy Blood Clear
Page-39
/yellow stained(red)
Bacterial meningitis
Multiple sclerosis
Viral meningitis
hemorrhage or
trauma during
Subarachnoid
Tuberculosis
procedure.
meningitis
Present in
CHEMICAL TESTS:
CSF GLUCOSE:
• Normally = 2/3rd of blood glucose
• Decreased (bacteria usually eat sugar so
glucose decreases in) = bacterial meningitis
(even up to 0 in severe cases) and somewhat in
tuberculous meningitis below 40mg/dl
• Normal = SAH , viral, MS
CSF PROTEIN:
• Normal = < 0.45g/L (20-45mg/dl) adults
• In newborn = 120-160 mg/dl are normal
• Increased = increase in all conditions
except in viral and MS which may be
normal/increased
• CSF LACTIC ACID :
Increased = bacterial and fungal meningitis
Normal in viral meningitis
• CSF LDH :
Normal In = viral meningitis
Increased in = bacterial meningitis, leukemia, stroke
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MICROSCOPIC TESTS:
• RBCs : normally not present or 0-2 are
normal
• If present more than 2 then it shows SAH or
trauma during procedure. Also increase in
herpes virus due to vascular involvement
• WBCs : normal = 0-5 cells with 60 to 70 %
lymphocytes (adults)
Neonates = up to 30 cells are normal
Increased in infections etc.
• Bacterial meningitis = from 100-60000+
with neutrophils predominant
• Viral meningitis = 10-100 with
lymphocytes predominant
• Tuberculous meningitis = 10-500 first
neutrophils predominate then
lymphocytes
• Fungal meningitis = monocytes
predominate
TESTS FOR INFECTIONS:

 CSF Gram Staining and C/S
 PCR For Virus Detection
Proteins Glucose Colour Pressure CONDITIONS
mg/dl mg/dl
20-45mg/dl in adults 2/3rd of Clear 50-250 NORMAL

SUMMARY
in newborn 120-160 Glucose mmH2O

mg/dl
Hassan’s OSCE
100-500 Decreased Cloudy(depends Normal BACTERIAL

even up to on /increase MENINGITIS
zero microorganism d
numbers)
100-3000 Decreased Straw/yellow Normal/ TUBERCULOUS

up to increased MENINGITIS
35mg/dl
20-100 normal clear normal VIRAL

MENINGITIS
20-100 Normal Reddish pink Normal SAH

2nd Edition
High Dec -- Increased FUNGAL
Page-41
LACTIC ACID LDH Leukocytes Races
-- -- 0-5=adults 0-2 cells

Up to 30 =neonates
Hassan’s OSCE
Increased Increased 100-1 lac mostly --

neutrophils
Increased Increased 10-500 mostly --

lymphocytes
normal normal 10-150 mostly --

lymphocytes
-- -- -- Increased
2nd Edition
Increased -- Lymphocytes --
predominate
Page-42
Page-43
SECTION 3
 ABGs
 DRUGS
 POISONS
Arterial Blood Gases (ABGs):
Page-44
INDICATIONS:
 Respiratory failure
 Cardiac failure
 Renal failure
 Liver failure
 Hyperglycemic state associated with DM
 Sepsis
 Burns
 Poison/toxins
 Ventilated patient
CONTRAINDICATIONS:
ABSOLUTE:
• Abnormal Allen test (no collateral
blood flow to the hand)
• Local infection
• Distorted anatomy at puncture site
• AV fistulas
• Severe peripheral vascular disease of
limb involved
RELATIVE:
• Severe coagulopathy
• Anticoagulant therapy i.e. warfarin
• Use of thrombolytic agents i.e.
streptokinase etc.
In ABGs we see the
 PH
 PaCO2
 Bicarbonate
 Anion gap
 Alveolar-arterial oxygen gradient (A-a)
Page-45
 PaO2
Normal Acidotic Alkalotic
PH 7.35-7.45 < 7.35 >7.45
Paco2 35-45 mmHg >45 <35
(4.7-6.0 kPa)
Hco3 22-26mEq/L <22 >26
Pa02 80-100 mmHg - -
Base excess -2 to +2 -2mmol/L shows +2mmol/L
(surrogate mmol/L that there is (either due
marker of lower than to primary
metabolic normal amount metabolic
acidosis or of HcO3 in blood alkalosis or
alkalosis) due to primary compensated
metabolic respiratory
acidosis or acidosis )
compensated
respiratory
alkalosis
SECTION 4
Page-46
• INSTRUMENTS
• X-RAYS
• ECG
INSTRUMENTS
Page-47
• NG TUBE
• FOLEY’S CATHETER
• IV CANNULA
• INSULIN SYRINGE
• LP NEEDLE
• ETT
• PEAK FLOW METER
• INHALERS ( MDI + DISKUS)
• SPACER
• VENTURI MASK
• OROPHYRANGEAL AIRWAY
• NASOPHARYNGEAL AIRWAY
• INTEROSSEUS CANNULA
• TRUCUT BIOPSY NEEDLE
• BLOOD SAMPLE TUBES
• BONE MARROW BIOPSY NEEDLE (jamshidi
needle)
• PLEURAL BIOPSY NEEDLE (Abram’s needle)
• CENTRAL VENOUS LINE
• MONOPTY GUN
• AMBO BAG
• NEONATAL BP CUFF
Page-48
NG TUBE (NASO-GASTRIC TUBE)
TYPES: 1.Ryle’s tube 2. Levine’s tube
INDICATIONS:
• Feeding
• Gastric lavage as in poisoning etc.
• Administration of medications
• Aspiration of gastric content for diagnostic purpose
• Stomach decompression as in obstruction etc.
Page-49
• Enteral nutrition
• Prolonged ileus
• UGI bleeding confirmation
CONTRAINDICATIONS:
• Midface injury and basilar skull fracture (b) Hx of
gastric bypass
• Hx of acid/alkali ingestion (d) Esophageal strictures
• Coagulopathy
COMPLICATIONS:
a) Bleeding (b) Perforation (c) Wrong placement
d) Pneumothorax (e) aspiration
(f) vomiting/retching
SIZES : 12 – 18 French (fr) in adults , In neonates
8-10 fr , in infants and children less than 5 years =
8-12 fr
Page-50
URINARY CATHETHER (FOLEY’S catheter)
i. TYPES : Materials: silicon and rubber
Procedure: double lumen and triple
and others shown in fig.
INDICATIONS:
THERAPEUTIC DIAGNOSTIC
1. Comatose Renal
patient function
tests
2. Urinary Residual
incontinence volume
3. Urinary
retention Radiographic
contrast
Page-51
studies
4. Intravesical
chemotherapy
5. In all perineal
operations
6. In
Cerebrovascular
accident
CONTRAINDICATIONS:
1. Acute 2. Blood at
urethritis meatus
3. Urethral 4. Scrotal
trauma hematoma
5. High
riding
prostrate
COMPLICATIONS:
Trauma & hemorrhage UTI
False passage , tube Fistula formation

blockage
CHEST X-RAYS (CXR)
Page-52
IDENTIFICATION: First of all look for
1) Name (2) Date
Type of film:
• Position: PA view, AP view, lateral view,
• lateral decubitus (for sub pleural effusion and
when pleural effusion is less or doubtful)
• Direction: upright etc
PA VIEW AP VIEW
• Apex of lung above Apex of the lung below the
the clavicle due to clavicle
abduction of arm
• Body of scapula Not visible
visible (scapula move
out)
• Heart size is normal Comparatively appears
bigger
• Chin not visible Chin visible
• Posterior ribs Not so
appears more
superficial as
compared to anterior
ribs
• Not marked as PA Usually marked as AP
Technical quality: “RIP”
Page-53
R= Rotation (the clavicular ends must be at equal
distance from the spinous process (vertebral spine
shadow) (tear drop)
 I= Inspiration (the CXR must be taken in full

inspiration and 6th anterior rib must pass through
the mid of Right .hemi diaphragm)
 P= Penetration/exposure (draw a horizontal
line through the most concave part of cardiac
shadow.
NORMAL EXPOSURE:
Vertebrae should be visible above and
disappear as we move down the film i.e. not all
vertebrae are visible means Visible in cervical region
only, slightly visible in chest region and disappears
below the diaphragm.
OVER-EXPOSURE:
If whole of vertebral column is visible.
Look at the big picture
MEDIASTINUM:
Divisions:
Superior and inferior (divided by horizontal line
passing through the angle of Louis)
Anterior, middle, posterior
SUPERIOR MEDIASTINUM:
Trachea, Esophagus, Thymus (up to 8 to 18 months of
age)
INFERIOR MEDIASTINUM:
Page-54
Heart, Lungs, Wide mediastinal shadow = HOTS
H= Histiocytosis
O= Onco i.e. carcinoma lymphoma etc.
T = TB, thymus
S= Silicosis
HEART:
LOCATION:
 1/3rd to the right
 2/3rd to the left (normal)
BORDERS:
 Right border: by right atrium and IVC
 Left border: left ventricle and some of left
atrium
 Inferior border: left and right ventricle
 Superior border: right and left atrium and
the great vessels.
 SIZE: Normal cardiothoracic ratio (CTR) =
< 55%
Cardiomegaly = >55% of CTR
Transthoracic diameter (TTD) or CTR:
• Draw a horizontal line passing just above the
dome of the right diaphragm. (label it as A)
• Draw a perpendicular line in the midline
• Draw a horizontal line from the most concave part
Page-55
of the heart on the right side toward the midline.
(label it as B)
• Draw the same line but from the left side of the
heart. (label it as C)
FORMULA
TTD = (B+C/A) x 100
SECTION 5
Page-56
PROCEDURES
 Nebulization
 Neonatal resuscitation
 IV Cannula
 NG tube insertion
 Female Catheterization
 Male Catheterization
 CPR
 COUNSELLING
 EPI SCHEDULE
 ADMISSION CRITERIA FOR NURSERY
 GYNAE & SURGERY INSTRUMENTS
PROCEDURES
Page-57
NEBULIZATION:
Apparatus:
1) Mask
2) Chamber
3) Tubing
4) Nebulization machine
Dose:
Page-58
• 0.5 ml Ventolin + 0.5 ml normal saline (If child is < 1
yr)
• 1 ml Ventolin + 1 ml normal saline (If child is > 1 yr)
• Standard dose: 1:1 but, in clinical practice 2.5ml
normal saline is used for 0.5 ml Ventolin (0.5ml
Ventolin= 16 drops)
• Normal saline is hypertonic for airway=> oozes out
fluids
• In bronchiolitis=> only normal saline is used for
nebulization
• Ventolin nebulization include 3 to 4 nebulization’s at
one time with a break of 10- 15 minutes
• Anticholinergics are used in a child with congenital
heart disease in place of Ventolin.
• Betamethasone is used for nebulization when there is
severe inflammation
COUNSELLING
Page-59
MEDICAL COUNSELLING STEPS
 Introduce yourself and confirm the disease and patient
(ask his name)
 Take permission for counselling (in front of the
attendant or in separate room)
 Ask the pt. about his/her education, and knowledge
about his/her disease?
 Ask the pt. whether he/she is counselled before or
not?
 Ask the pt. complaints very briefly?
 Describe the disease.
 Pathology -> signs and symptoms
 Investigations
 Diagnosis
 Treatment modalities available
 Describe/explain drugs, duration, adverse effects.
 Compliance to drugs and follow up.
 You can ask any question if you have
 Say thanks to patient.
‫‪Hassan’s OSCE‬‬ ‫‪2nd Edition‬‬
‫‪ ‬السالم ومکیلع !!!‬
‫‪Page-60‬‬
‫‪ .1‬ریما نام ڈارٹک ‪ XYZ‬ےہ۔ اور ںیم ڈارٹکوں ےک اس میٹ اکہصح وہں وج‬
‫ا ےکپ ےچب اک عالج رکواریہ ےہ۔‬
‫‪ .2‬ا پ اس رمضی ےک وادل اصحب ےہ؟ سج وک ہی امیبری ےہ۔‬
‫‪ .3‬ںیم ا پ ےک اٹیب ‪ /‬یٹیب ےک امیبری ےک نارے ںیم ھچک ناںیت ا پ ےس رکنا‬
‫اچاتہ وہں وت سب ےک ساےنم ا پ سننا دنسپ رکںی ےگ نا اےلیک ںیم ۔‬
‫‪ .4‬ا پ یک میلعت ینتک ےہ۔ اور ا پ اےنپ رمضی ےک امیبری ےک نارے ںیم ای‬
‫اجےتن ںیہ۔‬
‫‪ .5‬اپ ںیم ا پ وک ا پ ےک رمضی ےک نارے ںیم اتبوں اگ۔ا پ ےک رمضی‬
‫وک وج امیبری ےہااکسبلطم ےہ۔"اخبر ےک ساھت ےکٹھج انگلریغب ڈامیغ‬
‫نفنک‬
‫ا شن ےک" اشلگن ںیم اےس ‪ Febrile fits‬ےتہکںیہ۔‬
‫‪ ‬اس ںیم وچبں وک اخبر ےک سا ھتےکٹھجاک حطرہ وہنا ےہ۔ ہر ‪ 111‬ںیم‬
‫رقتابیَ ‪ 2-5‬وچبں ںیم ہی وہنا ےہ۔ ڈامیغ وطر رپ ومعامَ نالکل کیھٹ‬
‫وہےت ںیہ۔‬
‫‪ ‬ومعامَ اخبر ےک ساھتےکٹھج ‪ 11‬ےس ‪ 24‬امہ یک رمع ںیم ڑپ سکتےںیہ۔ نکیل‬
‫رضوری ںیہن ہک ہی ‪11-24‬ےک ڈرایمں ںیم وہہکلب ‪ 6‬امہ ےس ‪5‬‬
‫سال ےک ڈرایمں ا سکتے ںیہ۔‬
‫‪ ‬اخبر ںیم ےکٹھج ڈو رطج ےک وہےت ںیہ۔ ‪2.Complex 1.Simple‬‬
‫‪Page-61‬‬
‫‪ .1‬ہی وج ‪ Simple‬وہےت ںیہ سبےس رناڈہ نایئ اجےن وایل مسق ےہ۔اور‬
‫رصف انک‪ 11-15‬ٹنم اک اکٹھج وہنا ےہ۔اور وپرے مسج رپ وہنا ےہ۔‬
‫)‪(Generalized‬‬
‫‪Complex .2‬وج ےہوہ مسج ےک انک اخص ےصح (‪)Focal‬ںیم لسلسم ‪24‬‬
‫ےٹنھگ وہنا ےہ۔نا نارنار ا یت ےہ۔ہچب وک اعریض وطر رپ نارو نا‪ leg‬ںیم ےکٹھج‬
‫ےک دعب زمکوری وسحمس وہےت ںیہ۔‬
‫‪ Febrile Fits ‬ےک فلتخم اابسپ (‪ )Causes‬ںیہ۔‪1‬۔ ‪Infection‬‬
‫‪4 Family Hx -3 (MMR )Immunization-2‬۔‬
‫‪5 Malaria‬۔ ٹیپ یک رخایب‬
‫‪ Febrile Fits ‬ےکعالامپ ھچک اےسی وہےت ںیہ۔اخبر ےک ےلہپ ڈں یہ‬
‫اکٹھج ا نا ےہوج اس ناپ وک ظاہر رکنا ےہہک ہچب امیبر ےہ۔ رناڈہ رت اکٹھج اس‬
‫وقت ا نا ےہج‪(39. oC)102.2 oF‬ےس رناڈہ وہ اجےئ۔‬
‫‪ ‬دنمرہج ڈلی وچبں ںیم ہی نار نار وہاتکس ےہ۔‬
‫‪ ‬رقتابیَ ‪ 31-35‬دصیف ںیم ااسی وہ اتکس ےہ۔‬
‫‪ 15 .1‬امہ ےس مک رمع ںیم الہپ اکٹھج ا نا وہ۔‬
‫‪ .2‬نار نار اخبر وہنا۔‬
‫‪Family Hx .3‬‬
‫‪Page-62‬‬
‫‪ .4‬ےکٹھج ےسےلہپ ‪ Low grade fever‬وہنا۔‬
‫‪ .5‬ارگ اخبر رشوع وہےت یہےکٹھج ےگل وہ۔‬
‫‪ ‬ارگ یسک ےچب ںیم دنمرہج ڈلی ووجاہپ ںیم ےس ڈو نا ڈو ےس رناڈہ وموجڈ وہوت‬
‫رمیگ (‪ )Epilepsy‬ےک‪ 11‬دصیف اچسن ا ےن واےل ںیم وہ سکتے ںیہ۔‬
‫‪ .1‬ارگ وکٹھجں اک ڈوراہین‪ 15‬ٹنم نا اس ےس رناڈہوہ )‪)Complex‬‬
‫‪ .2‬ارگ ےکٹھج انک ےس رناڈہ رمہبت ےگلوہ۔‬
‫‪ .3‬ارگ ےکٹھج مسج ےک رصف انک ےصح ںیم وہےئ وہ۔‬
‫‪ .4‬ارگ ہچب ڈہنی وطر رپ کیھٹ ہن وہ۔‬
‫پ‬
‫‪ ‬ہلیرمہبت ےکٹھج ےنگل یک وصرپ ڈارٹک رمضی ےک ھچک ٹسٹ رکںی ےگسج‬
‫نشخ‬
‫ےس رمص تص ںیم دمڈ ےلم یگ۔‬
‫‪ ‬عالج‪-:‬‬
‫‪ ‬رھگ رپ عالج‪:‬۔ ‪1‬۔زیت اخبر یک وصرپ ںیم ےچب ےک ڑپکے مک رک ڈے۔‬
‫‪2‬۔ رگویمں ےک وممس ںیم اےسڈنھٹی ہگج رپ رںیھک۔‬
‫‪3‬۔ اخبر واال رشبت ہر ‪ 4-6‬ےٹنھگ دعب نالںیئ۔‬

‫‪4‬۔ ارگ اکےکٹھج اک ڈوراہین‪ 5‬ٹنم ےس رناڈہ وہ۔ وت نااخےن ےک راےتسےس‬
‫‪Page-63‬‬
‫‪ (Suppository) Valium‬یک یتب اےس ڈںی نا وفراَاتپسہلےل اجںیئ ۔‬
‫‪5‬۔ ارگ وکٹھجں اک ڈوراہین ‪ 11‬ٹنم ےس رناڈہ وہوت وفراَاتپسہل ےل اجںیئ۔‬
‫‪6‬۔ ومعامَ ےبمل رعےص ےک ےئل ڈوایئ اےسی وکٹھجں ںیم رناڈہ ڈری نک افدئہ ںیہن‬
‫ڈیتی۔ نا مہ اخبر رشوع وہےت یہ‪ Valium‬یک یتب نااخےن ےک راےتس حبص و سام‬
‫‪3‬ےس ‪ 4‬ڈں نک ڈی اجیتکس ےہ۔‬
‫‪ ‬مرند ھچک ولعمامپ ڈراکر وہ وت ھجم ےس وپھچ سکتے‬

‫ںیہ۔‬
INSTRUMENTS GYNAE AND SURGERY
Page-64
Page-65
Page-66
BOOKS AVAILABLE AT:
Page-67
 Swat Book House and Publications
Opposite Saidu Medical College, Saidu Sharif Swat, KPK
Cell# 0346-9049087, Ph# 0946-726817
 London Book Bank, Near Ayub Medical College

Abbottabad, KPK
Ph# 0992-381157, Cell# 0321-9802166
 Prince Bookshop
KTH Underpass, Phase 3 Chowk Hayatabad and Sadar
Peshawar, KPK
Contact# 0333-5556447, 091-5701086, 0333-9111926
 Khyber Bookshop, Khyber Medical College Peshawar

Safeer Cell# 0315-9739220, 0344-6403138
 Noble Book Bank, Near STH Swat

Cell# 0300-5746553
 Noble Book Bank, Near Ayub Medical College

Abbottabad, KPK
Cell# 0300-9110858, 0992-383116
 New Prince Bookshop, Dera Ismail Khan, KPK

Cell# 0345-9889346
 Prince Book Depot, Near Rawalpindi Medical College,

Rawalpindi, Punjab
Phone# 051-5502300, Cell# 0300-5121041
 Global Book Bank, KDA Kohat, KPK

Cell# 0333-9498473
 Student Book Agency, Coffee Shop Peshawar, KPK
Page-68
Cell# 0312-9191998, 0334-9008093
 Marwat Book Bank, Bannu, KPK

Rooh-ul-Amin Cell# 0333-9847238
 Rasheed Medical Books, Malakand Chowk, New Adda

Mardan, KPK
Cell# 0313-7810310, 0333-9890490

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Hassan’s OSCE 2nd Edition

AVAILABLE IN ALL MEDICAL

DR. FAISAL HASSAN

THIS BOOK INCLUDES:

History taking & Differentials 11

General Physical Examination 34

Respiratory System Examination 58

Abdominal Examination (GIT) 71

Diabetic Foot Examination & 84

CVS Examination (precordium) 101

CNS Examination 122

SECTION : 2 FLUID ANALYSIS

Ascitic Fluid 167

Pleuritic Fluid 173

SECTION : 3 ABGs , DRUGS &

SECTION : 4 INSTRUMENTS, X-RAYS & ECG

7.Gynae & Surgery Instruments 338-

First of all follow the basic steps

 Approach to the patient in friendly, sympathetic

Record the history in the following pattern.

f) Marital status/Habitus: (unmarried

HISTORY OF PRESENTING ILLNESS (HOPI)

It is actually the chronological description of present

Elements of HOPI are:

PAIN (SOCRATES) FEVER (ODIPARA)

(Sharp/dull, (Low Grade or High Grade/

A = ASSOCIATED A = Aggravating factors

T =TIMING R = Relieving factors

E = EXACERBATING A = Associated factors

ACUTE COUGH CHRONIC COUGH

Inhaled foreign Nonproductive:

1. PUD 1. UTI 1) Mesenteric

GENERAL PHYSICAL EXAMINATION:

First of all, follow the basic steps “RIPE”

FIRST IMPRESSION OR GENERAL APPEARANCE:

First impression of the patient’s condition must be

POSTURE AND ATTITUDE:

It gives information about patient illness e.g.

• A pt. with severe heart failure prefers to sit

• A pt. with peritonitis lie down on the back, with

Note that pt. is well oriented in time, place and person or

Visual impression is made about a pt. height and weight.

• TALL STATURE: Genetic, Marfan’s syndrome,

Many pathologies can be detected from the hands of pt.

Shaking hands with pt. is important to know about the

• Hands adopt special shape in tetany due to carpel

• Hands are large and broad in acromegaly

 Blue nails: cyanosis, Wilson’s disease,

 Red nails: polycythemia, CO poisoning, sometimes

It is a physical sign characterized by bulbous

Also called watch glass nails, drumstick fingers,

RESPIRATORY SYSTEM EXAMINATION

• Pectus excavatum (funnel chest)

0-2 months Up to 59 60 or >60

1-5 years Up to 39 40 or > 40

> 5 years 15-20 >20

NOTE: count the RR in inspection as it is noted by

Trachea can be palpated by one, two or three finger

Pleural effusion and Emphysema