Yesterdays mock OSCE exam for Core Medical Trainees took place in the PM Room aimed mainly at pathology learning.
As promised I have listed the stations with answers. Due to copyright and legal reason no photographs or specimen photographs included. The Photographs can be viewed in the Ferriman Library for a short period of time. (Ask the reception)
Robert Hooke first coined the term cell in his book Micrographia (1665) as the microscopy of cork resembled a monks cell.
Eos is the Titan goddess of the dawn who with her pink fingers opens the skies for the sun god to traverse the world! Eosin is the pink stain that give cytoplasm eosinophilic (acidophilic) staining properties.
photos and radiology (donut sign) of Intussuception with a macro specimen of ileo caecal intussusception.
Gastric polyp endoscopy. A pot showing similar features
Typical appearance of a GIST (Gastrointestinal Stromal Tumour (usually CK117 and DOG1 positive immuno). Origin from the Interstitial Cell of Cajal.
This is a CT abdo of a patient with 2 week history of abdominal pain getting progressively worse
Macros specimen is a gastric abscess
Diagnosis Fishbone perforation of the stomach (Fish & Chips 2 weeks before)
NB AXR will only pick up 50% CT Scan > 90%
Biopsy of stomach H&E and Toludine blue stains
What is this histology showing. Little toludine blue positive organisms on the surface. High power would be like little seagull shaped or spiral
Diagnosis Helicobacter like organisms (usually H pylori)
Histological picture and macroscopy of Pseudomembranous Colitis (C Diff)
This is the high power histology of a patient with diarrhoea who had spent the previous 3 months in a London psychiatric hospital. You are seeing the surface slough. What is the diagnosis
Diagnosis Amoebic Colitis
Station 4 C
Histology of 4 polyps Tubular adenoma, Hyerplastic Polyp, Villous Adenoma, Peutz Jegher Polyp
This is a patient with malabsorption. A duodenal biopsy was performed
Give the pathological diagnosis. Coeliac Disease
First described by Aretaeus of Cappadocia (2ndC BCE). Named Coeliac Disease by Samuel Gee in 1887
Give the three classical diagnostic features
- Marsh stage 0: normal mucosa
- Marsh stage 1: increased number of IELs, usually exceeding 20 per 100 enterocytes
- Marsh stage 2: proliferation of the crypts of Lieberkühn
- Marsh stage 3: partial or complete villous atrophy and crypt hypertrophy
Another patient has abdominal symptoms and anaemia, The duodenal biopsy is shown
What is the diagnosis ? Giardia on the surface of the duodenum
High power should see sickle shape (on side) or nuclei and flagella,face on
What is the treatment Metronidazole
Compare and contrast macro specimens of Crohns Disease and Ulcerative Colitis
Photograph of cobblestone mucosa of Crohn’s Disease.
This is a Rectal Carcinoma
Histology was of a moderately differentiated adenocarcinoma invading into the muscularis propria and present in 4 out of 20 nodes including the apical node with a confirmed metastasis in the liver
What is the Dukes’ Stage C2
What is TNM Stage PT2 N2 M1
Photos of Alfred the Great and President Eisenhower – both had Crohns Disease
Burrill Crohns (disease named after)
Antoni Lesniowski (described it in 1904 in Poland where it called Lesniowski-Crohns Disease)
Stations 7 – 11 are examples photographs of hands and fingers showing clinical signs related to a variety of pathological conditions and causes
Stations 7a Hands
- Gross irregularity of shape and size
- rheumatoid arthritis, Paget’s disease of bone, neurofibromatosis.
- Unilateral enlargement of a hand
- manual labour , arteriovenous aneurysm ,
- Square dry hands
Station 7b Blunt Fingers
- Large Acromegaly
- Small Renal failure with secondary hyperparathyroidism
Stations 8A Mees Lines
- Any acute illness
- Heavy metal toxicity (eg arsenic, Thallium)
Station 8B Terry’s Half and Half
Proximal portion is white (oedema and anaemia), the distal portion is dark.Implies either liver or (if + brown band) renal disease
Station 9A Beau’s Lines named after Joseph Honoré Simon Beau 1806-1865
- Severe infection
- Myocardial infarction
- Hypotension, shock
- Intermittent doses of immunosuppressive or chemotherapy
- Severe zinc deficiency
Station 9B Longitudinal Brown Lines
- Addison’s disease
- Naevus at the nail base
Clinical erythematous patch on the neck. Histology of full thickness high grade dysplasia of squamous epithelium. Diagnosis Bowen’s Disease = Squamous Cell Carcinoma in Situ
Named after John Templeton Bowen (1857–1940) was an American dermatologist
Dupytren’s Contracture. Named after Guillaume Dupuytren (treated Bonaparte’s piles who made him a Baron) . Histology is Palmar Fibromatosis – Histology shown
Thomas Willis book Cerebri Anatome was published in 1664 with drawings by Christopher Wren. The circle of Willis photograph shows a Berry Aneurysm.
Slice of brain with haemmorhagic infarcted Mammillary Bodies associated with Wernicke Korsakoff Syndrome
Macro photo and histology. Histology is of a Lobular Capillary Haemagioma (a better name) but better known as Pyogenic Granuloma. This can occur in the mouth in pregnancy (rare = Pyogenic Gravidarum)
Keratoacanthoma versus Squamous Cell carcinoma of the skin =. Can look the same histologically. Difference is the length of history (KA short = weeks SCC long = months)
Clinical Picture of the head with a prominent (tender) temporal artery. Histology is of an artery with prominent lymphocytic and giant cell inflammation. Diagnosis Temporal Arteritis.
Low power view of a lymph node with prominent follicle (high power you would see loss of polarity of the germinal centres) = Follicular Lymphoma
Low power view of a diffuse lymphoid process with “star sky” appearance” due to prominent macrophages . Typical of Burkitts Lymphoma (B cell lymphoma associated with EBV)
Professor Epstein was my professor of Pathology who gave me my first pathology job!
Station 16 Station
Photograph of a Liver with multiple nodules of adenocarcinoma. Clinically it is Carcinoma of Unknown Primary. What immunochemistry can the Pathologist do to help in identifying a primary ?
The following immuno chemistry are a useful panel depending on the clinical background
- CD20 CDX2 (Large bowel)
- CK7 (Stomach Breast Pancreas Biliary Ovary)
- ER/PR (Breast Ovary)
- TTF1 (Lung)
- CK5/6 (Squamous)
- Chromogranin CD56 Synaptophysin (Neuroendocrine)
- PSA (Prostate)
- AFP (HCC)
“Anchovy Sauce” Abscess – Amoebic Liver Abscess
Station 17 B
Alcoholic Hepatitis histology. Mallory-Denke Bodies are CAM5.2 (cytokeratin marker) positive
Some examples of Cause of Death statements
Q1. Ia septicaemia b – c –
Incorrect; septicaemia is a mode of dying. It stated alone, the death will be treated as a death due to unknown cause by the Registrar of Births and Deaths and will automatically be reported to the Coroner. The term is acceptable if it is accompanied by an Underlying Cause of Death, for example, septicaemia due to recurrent infected pressure sores due to multiple sclerosis.
Q2. Ia bronchopneumonia b – c – II –
Could be correct, but usually there is an Underlying Cause of Death precipitating the bronchopneumonia, and if this is the case it should be stated.
Q3. Ia bronchopenumonia b carcinoma of bronchus c – II –
Correct; but give further site and histopathological details if known.
Q4. Ia carcinoma of Rt Tonsil b metastases c – II –
Incorrect; sequence should be reversed. Abbreviations should not be used, and further histopathological detail of the carcinoma should be given if known.
Q5. Ia cardiopulmonary failure b bronchopneumonia c –
II lung cancer
Incorrect; seems likely that lung cancer is part of the sequence of events leading to death and should not therefore appear in Part II but in Part I as the Underlying Cause of Death. This is however ultimately a matter for your clinical judgement. More detail on site and Histopathology should be given if known.
Q6. Q6. Ia left-sided heart failure b ischaemic heart failure c – II –
Incorrect. “failure” is a mode of death an not used as an underlying cause
Q7. Ia old age b – c – II –
Correct; however, this term should only be used if a more specific cause of death cannot be given and if the deceased is over 80
CONSENT 1. It is always a legal requirement to obtain a signed consent form prior to any surgical procedure. False
Although completion of a consent form in most cases is not a legal requirement, the use of such forms is good practice where intervention such as minor surgery is to be undertaken. Exceptions include abortion and certain treatments under the Mental Health Act.
Consent must be taken by the doctor doing the procedure. False
If you are the doctor providing treatment or undertaking an investigation, it is your responsibility to discuss it with the patient and obtain consent as you will have a comprehensive understanding of the procedure or treatment, how it is carried out and the risks attached to it. Where this is not practicable, you may delegate these tasks to someone who is suitably trained and qualified, and has sufficient knowledge of the procedure and understands the risks.
If information about the procedure will make the patient anxious, you should not mention it.
Doctors may withhold details of treatment and attendant risks if disclosure would be likely to cause serious harm to the mental or physical health of a patient. However, this is not licence for paternalistic medicine. The emphasis is on the likelihood of disclosure causing serious harm.
If information leaflets set out all that the patient needs to know about the procedure, there is no need for the doctor to explain the procedure as well. False
Information leaflets are a valuable adjunct to counselling prior to treatment. Numerous studies have demonstrated how little information may be retained by patients following a consultation, particularly when they are anxious, or have just received bad news. Using illustrations during the counselling process and providing written information to patients is therefore valuable, but must never be seen as a replacement for adequate discussion between doctor and patient.
When discussing treatments you should describe any serious or frequently occurring risks.
The information which patients want or ought to know before deciding whether to consent to treatment or an investigation may include:
- Explanations of the likely benefits
- The probabilities of success
- Discussion of any serious or frequently occurring risks, and of any lifestyle changes which may be caused by, or necessitated by the treatment
Competent patients have a right to refuse treatment even if they may die as a result.
If the process of seeking consent is to be a meaningful one, refusal must be one of the patient’s options. A competent adult is entitled to refuse any treatment except in circumstances governed by the Mental Health Act 1983. However, the situation for children is more complex. If, after discussion of all treatment options, a patient refuses all treatment, this fact should be clearly documented in the notes.
- A competent patient has the option of nominating a person to make certain decisions for them. True
A competent person can nominate a person to make decisions for them, for example, when setting up an Lasting Power of Attorney in accordance with the Mental Capacity Act (2005). It would be rare for a competent person to nominate another person to make decisions at a time when they had capacity.
- In an emergency, when you cannot obtain consent, you can provide urgent, necessary treatment.
In an emergency, where consent cannot be obtained, you may provide medical treatment to anyone who needs it, provided the treatment is limited to what is immediately necessary to save life or avoid significant deterioration in the patient’s health.
- Intimate examinations require express consent. True
It is important to remember that consent is a process and that consent is required for absolutely every physical examination, referral etc.
- Explain what needs to be done and why
- Explain what the examination will entail
- Obtain the patient’s permission
- Offer a chaperone, or the patient’s companion of choice, and document this.
Children under 16 years cannot consent to medical treatment. False
“Provided that the patient, whether a boy or girl, is capable of understanding what is proposed, and of expressing his or her own wishes, I see no good reason for holding that he or she lacks the capacity to express them validly and effectively and to authorise the medical man [sic] to make the examination or give the treatment which he advises.” Extract from Gillick v Wisbech Area Health Authority 1986.
Advance directives or living wills – statements made by patients when competent about treatment they would not wish to receive if subsequently incompetent – are binding on treating doctors. True
You must respect any refusal of treatment given when the patient was competent, provided the decision in the advance statement is clearly applicable to the present circumstances, and there is no reason to believe that the patient has changed his/her mind.
A patient can refuse to be tested for HIV. True
You must respect a patient’s decision to refuse an investigation, or treatment, even if you think their decision is wrong. Explore your concerns and the positive consequences to the patient, but do not pressurise them
1) The photo shows a vegetation on one of the mitral valve leaflets. The signs of sub-acute bacterial endocarditis include:
- in the hands: clubbing and splinter haemorrhages
- in the abdomen: splenomegaly and microscopic haematuria
- in the heart- variable murmurs
- Osler’s nodes
- Roth spots
- Janeway lesions
2) X-ray shows mottled shadows in both mid and lower zones, loss of costo-phrenic angles and prominence of vessels to upper lobes. Suggest Pulmonary Oedema
The physical signs include:
- Acutely unwell- looks ill, cold, clammy peripheries, frothy sputum, sometimes blood stained
- Short of breath at rest with use of accessory muscles
- Tachycardia or atrial fibrillation
- Signs of valvular heart disease eg mitral regurgitation
- Additional heart sounds eg HS3 or HS4
- Fine basal crackles
3) Left ventricular aneurysm. Persistent ST elevation- concave upwards (“saddle appearance”).
- cardiomegaly (displaced apex, sometimes with a double pulsation- “paradoxical apex”),
- third heart sound,
- signs of mitral regurgitation.