Summary of Common Conditions Seen in OSCEs
| Condition | Clues from the history | Investigations |
| Renal failure | Risk factors, e.g. diabetes mellitus, hypertension, use of nephrotoxic drugs, Associated symptoms, e.g. tiredness, metallic taste, yellow tinge to the skin, brown discoloration of the nails | Full blood count, Us+Es, bone profile, 1,25-hydroxy vitamin D levels Renal ultrasound scan Albumin:creatinine ratio |
| Nephrotic syndrome | Periorbital swelling Frothy urine Diabetes, hypertension, features of connective disease (e.g. arthralgia, Raynaud’s phenomenon, photosensitive rash) Haematuria | Urine dipstick Us+Es Albumin:creatinine ratio (or 24-hour urine collection) Clotting screen Lipid profile Autoantibody screen ASO titre Oral glucose tolerance test Hepatitis serology Renal biopsy |
| Right-sided/congestive cardiac failure | Shortness of breath on exertion Chronic long-standing lung disease (e.g. COPD, severe asthma, fibrotic lung disease) | Plasma brain natriuretic protein Echocardiogram Chest X-ray Lung function tests High-resolution CT chest |
| Pulmonary hypertension | Shortness of breath Chest pain | Cardiac catheter studies ECG Echocardiogram |
| Chronic liver disease | Presence of associated symptoms, e.g. jaundice, ascites, confusion Past medical history of excess alcohol intake Risk factors for chronic liver disease, e.g. past medical history or family history of haemochromatosis/Wilson’s disease, intravenous drug use | Liver function tests Clotting screen Liver screen (see Chapter 3 on abdominal examination) Ultrasound abdomen |
| Hypothyroidism | Past history of thyroid surgery Past medical history of other autoimmune conditions Symptoms related to hypothyroidism | Thyroid function tests Thyroid ultrasound scan |
| Venous insufficiency | Prolonged standing Previous deep vein thromboses Presence of brown pigmentation, eczema, dilated tortuous veins | Doppler ultrasound scan Ankle–brachial pressure index Abdomen + pelvic examination + ultrasound scan to screen for venous compression from an abdominal/pelvic mass |
| Pelvic mass causing venous compression | Abdominal distension Constipation Vaginal bleeding Menstrual disturbance | Full blood count, Us+Es, liver function tests, ESR Ultrasound abdomen + pelvis CT abdomen + pelvis |
| Cellulitis | Erythema, history of penetrating injury Fever History of immunosuppression Spreading of erythema | Clinical diagnosis Raised inflammatory markers/C-reactive protein |
| Pregnancy | Child-bearing age Sexually active and not using contraception Vomiting | Urinary beta-hCG Pelvic ultrasound scan |
| Pre-eclampsia | Pregnancy >20 weeks’ gestation Features due to hypertension: headache, frothy urine (proteinuria), vomiting | Urine dipstick (proteinuria) Blood pressure (>140/90 mmHg or significant rise from booking blood pressure) |
| Deep vein thrombosis | Presence of risk factors (outlined above) | Lower limb Doppler ultrasound studies |
| Hereditary lymphoedema | Family history No symptoms to suggest a secondary cause | Investigations to screen for secondary causes |
| Secondary lymphoedema | Radiotherapy Symptoms of intra-abdominal/pelvic malignancy | Ultrasound abdomen + pelvis Tumour markers |
| Iatrogenic | Amlodipine | Investigations to rule out other possible causes apart from the drug in question that may be contributing |
Hints and Tips for the Exams
Ask about the Duration of Ankle Swelling
Ankle swelling of rapid onset is more likely to be caused by an acute process (e.g. deep vein thrombosis), whereas swelling that has developed over the course of weeks or months is more likely to be caused by one of the failures (renal, liver, cardiac or thyroid).
Remember to Take a Thorough Drug History
Ankle swelling is, for example, a common side effect of amlodipine.
Work Through the History Systematically
As you can see from the summary table, ankle swelling can be caused by pathology affecting various organ systems. Hence, it is important to ‘throw the net wide’ early on in your history to screen for pathology related to each of these systems.
Do NOT Forget Pregnancy and Pre-Eclampsia
Obstetrics is examined in the fourth year at most UK medical schools, so the majority of students do not revise this topic for finals. However, contrary to popular belief, obstetric emergencies can be examined in finals. It is thus important to remember that worsening or new-onset ankle swelling in a pregnant female beyond 20 weeks’ gestation should be treated as pre-eclampsia until proven otherwise.
Potential Variations at This Station
- History of unilateral ankle swelling + examination of venous system of the lower limbs
- History of ankle swelling + focused examination. The ‘focused examination’ should include the following:
- Hands: signs of chronic liver disease, clubbing (liver cirrhosis, fibrotic lung disease)
- Eyes: conjunctival pallor (NB. anaemia can be related to chronic kidney disease or cardiac failure)
- Chest: observation for deformities (e.g. Harrison’s sulcus, barrel chest), auscultation of lung fields for crepitations associated with fibrosis or wheeze associated with COPD, auscultation of heart sounds (various murmurs can be associated with congestive heart failure)
- Abdomen: hepatomegaly, palpable pelvic masses, distension (e.g. ascites, pregnancy)
- Legs: other signs associated with chronic venous insufficiency (outlined above)
- Bedside tests: urine dipstick, peak expiratory flow rate
- Hands: signs of chronic liver disease, clubbing (liver cirrhosis, fibrotic lung disease)
Questions You Could Be Asked
Q. What else might you find on examination of the ankles in a patient with ankle swelling secondary to hypothyroidism?
A.
- Pretibial myxoedema (see Chapter 9 on thyroid examination for an illustration)
- Erythema ab igne (arising from large periods of time spent near a fire or heater as a result of cold intolerance)
- Slow-relaxing reflexes
Q. What features would support a diagnosis of chronic rather than acute renal failure?
A.
- Anaemia
- Secondary hypoparathyroidism (low calcium, low 1,25-hydroxy-vitamin D, elevated phosphate, elevated parathyroid hormone)
- Renal osteodystrophy (osteomalacia, osteoporosis, osteosclerosis causing a ‘rugger-jersey’ spine on X-ray)
- Small kidneys on ultrasound scan
- Lack of symptoms despite severe uraemia
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