Sore throat Hx OSCE

Sore Throat - OSCE

Table of Contents

History Taking * Presenting Complaint & Analysis (HOPI) * Differentiation (Viral vs. Bacterial - Centor Criteria) * Review of Systems (Specific to Sore Throat) * Past Medical & Surgical History * Medication History & Allergies * Family History * Social History * Sexual History * Patient’s Perspective (ICE) & Functional Impact * Summarization * Differential Diagnosis * Clinical Examination * Investigations * Management Plan (CRAPRIOPS Framework Implied) * Diagnosis Explanation, Education & Reassurance * Specific Management Strategies (Based on Likely Cause) * Addressing Patient’s Specific Concerns & Expectations * Lifestyle Advice & Opportunistic Health Promotion * Follow-up & Safety Netting * Shared Decision Making & Understanding

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Scenario Overview

Information for Student

Patient Brief Record / Brief Scenario:

• Patient Name: Zainab
• Age: 31 years
• Marital Status: Married with 5 children
• Occupation: Teacher
• Medical History: Not known to have any chronic illness
• Vital Signs:
  • Blood Pressure: 120/78 mm Hg
  • BMI: 32
  • Temperature: 37.1 °C

Patient Presentation: Mr. Ahmad [(Note: Name inconsistency in original text, assuming patient is Zainab based on other details)] is a 31-year-old, presented today with the complaint of fever and sore throat.

TASK: Take a focused history from this patient to arrive at the most likely diagnosis.

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Information for the Simulated Patient (SP)

Case-2: Sore Throat

Patient Brief Record / Brief Scenario:

• Patient Name: Zainab
• Age: 31 years
• Occupation: Teacher
• Marital Status: Married, with 5 children between 2-14 years old
• Contraception: Currently taking Combined Oral Contraceptive (COC) pills

Patient Presentation: You have a sore throat since 3 days; this is associated with mild fever, dry cough, headache, and generalized body aches.

Opening Scenario: “Doctor, I have a painful throat.” (You will admit only this initially).

Tell your doctor about the following information only if specifically asked about:

• Symptoms:
  • Sore throat started 3 days ago.
  • Associated with mild fever, dry cough, headache, generalized body ache.
  • Also have sneezing and a running nose.
  • This is the 3rd episode during this year.
  • Tried Panadol tablets (paracetamol) yourself: 2 tablets every 12 hours with mild benefit (obtained over-the-counter from a pharmacy).
• Ideas, Concerns, and Expectations (ICE):
  • Ideas: Believes it is an infectious disease that should be treated with a strong antibiotic.
  • Concerns: Worried about spreading this problem to all family members.
  • Expectations:
    • Wants the doctor to prescribe an antibiotic and more potent painkillers.
    • Wants sick leave to get rest for 2-3 days.
    • Wants to know whether tonsillectomy would be an appropriate option.
• Smoking Habits:
  • Smoker: 20 cigarettes/day (one pack).
  • Smokes as soon as waking up.
  • Smokes even when tired or sick.
• Specific Points to Raise/Insist On:
  • Ask for an antibiotic; insist, mentioning you got one from another doctor on a previous visit.
  • Ask about the suitability of tonsillectomy.
  • Request sick leave for 2-3 days.

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Candidate Expectations & Key Areas to Cover

General OSCE Skills / Doctor-Patient Interaction

• Professional Behavior & Rapport:
  • Introduce self clearly (smiling), confirm patient identity (name, age, file number if applicable).
  • Build rapport effectively (good posture, respectful tone, appropriate body language).
  • Obtain consent and explain the purpose of the consultation.
  • Demonstrate interest, concern, and respect throughout. Show empathy. Maintain good eye contact.
• Communication Techniques:
  • Start with open-ended questions (e.g., “How can I help you today?”, “Tell me more about that?”).
  • Use a mix of open-ended and closed questions appropriately and in sequence.
  • Listen attentively, allow patient time to respond, avoid interruptions.
  • Use facilitation techniques (verbal/non-verbal encouragement, silence, nodding).
  • Use concise, easily understood language; avoid or explain medical jargon.
  • Periodically summarize (“Internal Summary”) to check understanding and invite corrections.
• Patient-Centered Approach:
  • Actively elicit the patient’s Ideas, Concerns, and Expectations (ICE).
  • Encourage the patient to talk and express their views.
  • Promote informed, shared decision-making regarding the management plan.
• Structure & Timing:
  • Maintain a logical flow throughout the consultation.
  • Attend to timing.

History Taking

HOPI

Presenting Complaint

• Chief Complaint: Sore Throat.
• Listen Carefully: Allow the patient to describe the problem initially.
• Onset & Duration: When did it start? (3 days ago).
• Location: Where is the soreness felt?
• Severity/Intensity: How bad is the pain (e.g., scale 0-10)?
• Character: Describe the pain (e.g., scratchy, sharp).
• Progression: Getting worse/better/staying the same? Constant or intermittent?
• Aggravating Factors: What makes it worse? (e.g., swallowing food/liquids).
• Alleviating Factors: What makes it better? (Panadol provided mild relief).
• Radiation: Does the pain travel anywhere?
• Associated Symptoms:
  • Fever/Chills? (Mild fever present).
  • Cough? (Dry cough present).
  • Headache? (Present).
  • Generalized body aches? (Present).
  • Sneezing? (Present).
  • Running nose (rhinorrhea)? (Present).
  • Hoarse voice?
  • Problems swallowing (dysphagia - food or liquids)?
  • Halitosis (bad breath)?
  • Swollen lymph nodes? (Ask about neck lumps/tenderness).
  • Rash/skin changes?
  • Shortness of breath?
  • Nausea/vomiting?
  • Fatigue?
  • Abdominal pain?
  • Chest pain / Heartburn? (Consider GERD).
• Previous Episodes: History of similar episodes? (Yes, 3rd episode this year).
• Self-Treatment: Tried any medication? (Yes, Panadol OTC).
• COVID-19 Screen: Able to taste & smell?
• Contact History: History of contact with similar cases?

Differentiation (Viral vs. Bacterial - Centor Criteria)

• Explore symptoms relevant to the Centor score to assess the likelihood of Group A Strep:
  • Fever: History of fever? (Yes, mild). Note: High-grade fever points more towards bacterial.
  • Absence of Cough: Is cough present? (Yes, dry cough present). Note: Absence of cough points more towards bacterial.
  • Tender Anterior Cervical Lymphadenopathy: Any tender lumps in the neck? (Needs examination, but ask).
  • Tonsillar Exudates: (Needs examination, but sometimes patients report seeing white spots).
  • (Age is also part of modified Centor, but less relevant here as patient is 31).
• Initial assessment based on SP script (sore throat, mild fever, cough, headache, body aches, sneezing, running nose) suggests a viral etiology is more likely.

Review of Systems (Specific to Sore Throat)

• Many covered in Associated Symptoms above.
• Appetite changes?
• Weight changes?
• Recent infections?

Past HX

Past Medical & Surgical History

• Any chronic diseases? (None known).
• Allergies? (Especially to medications).
• Previous hospitalizations?
• Any past surgeries? (Specifically ask about tonsillectomy).

Medication History & Allergies

• Current medications (prescription, OTC)? (COC pills, recent Panadol use).
• Any allergies?

Family History

• Any relevant family history (e.g., recurrent infections, autoimmune diseases)?

Social History

• Occupation: Teacher (potential exposure).
• Home: Married, 5 children (potential exposure/spread).
• Smoking: Heavy smoker (20/day, specific pattern - important risk factor and point for intervention).
• Alcohol: Ask about intake.
• Recreational Drugs: Ask about use.

Sexual History

• Consider briefly if Infectious Mononucleosis is suspected (HIV can present with mono-like syndrome).

Patient’s Perspective (ICE) & Functional Impact

• Ideas: Thinks it needs antibiotics.
• Concerns: Spreading it to family.
• Expectations: Wants antibiotics, stronger painkillers, sick leave, information on tonsillectomy.
• Impact: How is it affecting work/daily life? (Implied need for sick leave).

Summarization

• Summarize key points back to the patient to ensure accuracy.

Differential Diagnosis

• Viral Pharyngitis: (Most likely based on symptoms: cough, running nose, mild fever). Common cold viruses, influenza, adenovirus, etc.
• Streptococcal Tonsillopharyngitis (Strep Throat): Bacterial infection (Group A Streptococcus). Less likely given cough/rhinorrhea, but needs exclusion (Centor).
• Infectious Mononucleosis (EBV): Consider especially with fatigue, lymphadenopathy, possible splenomegaly (would need exam). Can present with significant sore throat/exudate.
• Gastroesophageal Reflux Disease (GERD): Can cause chronic sore throat, especially if worse in the morning or associated with heartburn.
• (Other less common causes: Other bacterial pharyngitis, fungal pharyngitis (candida), peritonsillar abscess (quinsy), epiglottitis (rare in adults, emergency), diphtheria, HIV primary infection).

Clinical ExaminationY

(State intention clearly, ask permission, wash hands, ensure privacy)

• General Look: Assess for distress, respiratory effort, hydration status.
• Vital Signs: Temperature (37.1°C), BP (120/78 mmHg), Heart Rate, Respiratory Rate. Note BMI (32 - Obesity Class I).
• Head and ENT:
  • Oropharynx: Inspect throat carefully using a light source and tongue depressor. Look for:
    • Redness (erythema) of pharynx and tonsils.
    • Tonsillar enlargement.
    • Tonsillar exudates (white patches/pus).
    • Palatal petechiae (small red spots - can suggest Strep or Mono).
    • Uvula position (deviation suggests peritonsillar abscess).
  • Nose: Check for nasal congestion/discharge.
  • Ears: Briefly check tympanic membranes if ear pain suggested.
• Neck Examination:
  • Palpate for cervical lymph nodes (anterior and posterior chains). Note size, tenderness, mobility. (Tender anterior nodes suggest bacterial infection/Strep).
• Chest Examination:
  • Auscultate lungs (especially given cough).
• Abdominal Examination:
  • Palpate for splenomegaly or hepatomegaly (if Infectious Mononucleosis suspected).
• Skin Examination:
  • Check for any rashes (some viral infections, scarlet fever associated with Strep).

Investigations

(Guided by history and examination findings. Often not needed for likely viral pharyngitis unless severe)

• If Bacterial Pharyngitis (Strep) Suspected (e.g., based on Centor score ≥2-3 or clinical gestalt):
  • Rapid Strep Antigen Detection Test (RADT): Provides quick results. Sensitivity varies.
  • Throat Culture: Gold standard but takes 24-48 hours. Consider if RADT is negative but suspicion remains high.
• If Infectious Mononucleosis Suspected:
  • CBC: Look for lymphocytosis, atypical lymphocytes. (May also show anemia, thrombocytopenia).
  • Peripheral Blood Smear: To identify atypical T lymphocytes.
  • Monospot Test (Heterophile Antibody Test): Can be negative early in illness.
  • Anti-EBV Antibodies: More specific, used if Monospot is negative but suspicion is high (IgM for acute infection).
• (CBC might be considered more broadly if systemic symptoms are significant or diagnosis unclear).

Management Plan (CRAPRIOPS Framework)

Diagnosis Explanation, Education & Reassurance

• Explain the likely diagnosis based on history and exam (e.g., “Based on your symptoms like the cough and runny nose along with the sore throat, this is most likely a viral infection, similar to a common cold”).
• Explain the expected natural course (usually resolves in 5-7 days).
• Address Antibiotic Expectation Directly:
  • Explain that antibiotics are not effective against viruses.
  • Explain the disadvantages of unnecessary antibiotic use: side effects (diarrhea, allergy, thrush), promoting antibiotic resistance (making future infections harder to treat for her and the community).
  • Reassure that symptomatic treatment will help her feel better while her body fights the virus.
  • Consider offering a delayed/backup antibiotic prescription strategy if appropriate (e.g., “If you are not starting to feel better in 3-5 days, or if you get significantly worse, then use this prescription”).

Specific Management Strategies (Based on Likely Cause)

• Likely Viral Pharyngitis (or Strep if confirmed): Symptomatic Treatment:
  • Analgesia: Recommend regular paracetamol (like she tried, but ensure correct dosing e.g., 1g qds prn) or Ibuprofen (NSAID - may be more effective for inflammation, check contraindications). Advise on maximum doses.
  • Local Measures: Throat lozenges, throat sprays, gargling with warm salt water.
  • Fluids: Encourage adequate fluid intake.
  • Rest: Advise rest as needed.
  • Other: Honey for cough (if >1 year old), nasal saline spray/decongestants for nasal symptoms (use decongestants short-term only).
• If Streptococcal Tonsillopharyngitis Confirmed:
  • Symptomatic treatment as above.
  • Antibiotics: Explain the role (reduce symptom duration slightly, prevent rheumatic fever - rare in adults but possible, reduce transmission). Prescribe appropriate antibiotic (e.g., Penicillin V or Amoxicillin; Macrolide if penicillin allergic). Emphasize the importance of compliance (completing the full course).
• If Infectious Mononucleosis Confirmed:
  • Supportive care: Hydration, rest, analgesia.
  • Activity Restriction: Advise avoidance of strenuous physical activity and contact sports for at least 4 weeks due to risk of splenic rupture.
  • (Systemic corticosteroids/IVIG reserved for severe complications).
• If GERD Suspected:
  • Trial of PPI or H2 Blockers.
  • Lifestyle modification advice (avoid trigger foods, weight loss, elevate head of bed).

Addressing Patient’s Specific Concerns & Expectations

• Antibiotics: Addressed above (explain why not indicated, risks).
• Painkillers: Recommend appropriate OTC options (Paracetamol, Ibuprofen) with correct dosing advice. Explain stronger painkillers (e.g., opioids) are generally not needed and have risks.
• Sick Leave: Acknowledge her request. Provide a medical certificate for 2-3 days of rest based on symptoms and occupation (teacher - risk of spread).
• Tonsillectomy: Explain indications are typically for recurrent, severe, documented episodes of bacterial tonsillitis (e.g., 5-7 episodes/year for 1 year, or 5/year for 2 years, or 3/year for 3 years - criteria vary slightly). Note her 3 episodes this year. Suggest monitoring frequency and severity, and discussing referral to ENT if criteria are met in the future. Unlikely indicated based on current presentation alone, especially if viral.
• Concern about Spreading: Provide advice on hygiene measures (hand washing, covering coughs/sneezes, avoiding close contact while acutely unwell) to reduce transmission to family.

Lifestyle Advice & Opportunistic Health Promotion

• Smoking Cessation: Strongly advise quitting smoking. Explain it irritates the throat, worsens respiratory symptoms, increases infection risk, and has many long-term health risks. Offer support/resources (nicotine replacement, cessation programs). Link her smoking pattern (first thing in morning, when sick) to high dependence.
• Weight Management: Note BMI is 32 (Obese Class I). Gently raise the topic and offer advice/resources for healthy eating and exercise if appropriate and time permits.
• (Mention relevant vaccinations - e.g., Flu vaccine annually).

Follow-up & Safety Netting

• Advise patient to return or seek urgent care if:
  • Symptoms worsen significantly.
  • No improvement after 5-7 days (or timeframe agreed for delayed prescription).
  • Develops difficulty breathing or swallowing.
  • Develops severe headache, neck stiffness, or rash.
  • Unable to manage fluids/hydration.
  • Develops unilateral throat pain/swelling (suggests quinsy).
• Explain the possibility of developing a secondary bacterial infection.

Shared Decision Making & Understanding

• Check patient’s understanding of the diagnosis, management plan, and reasons for not prescribing antibiotics immediately.
• Involve her in decisions where appropriate (e.g., choice of analgesic).
• Ensure her concerns (ICE) have been addressed.