Q1 — Neck Swelling (Right Lower Neck, 32F) — Thyroid Cyst

1. Differentials: Thyroid cyst, thyroid adenoma, multinodular goitre, lymph node, branchial cyst
2. Investigations: TFTs, USS neck, FNAC, CXR (for retrosternal extension)
3. Management: If benign on FNAC → USS surveillance or surgery (hemithyroidectomy); if malignant → total thyroidectomy

Q2 — Bilateral Lymphadenopathy (43M, Fever, Lethargy)

1. Likely cause: Lymphoma (Hodgkin's or Non-Hodgkin's) — bilateral neck + axillary nodes with B-symptoms
2. Confirm diagnosis: Excision biopsy of lymph node for histology ± CT staging
3. Cervical LN classification: Levels I–VI (Memorial Sloan Kettering system)
4. Indications for surgery: Biopsy for diagnosis; bulky disease causing obstruction; rarely for resection — mainly managed with chemo/radiotherapy

Q3 — Neck Swelling + Exophthalmos (40F)

1. Examination findings: Diffuse hyperplastic goitre (anterior neck swelling) + bilateral exophthalmos (proptosis)
2. Diagnosis: Graves' disease (primary hyperthyroidism)
3. Confirmatory tests: TFTs, thyroid antibodies (TSH-receptor antibody/TRAb), thyroid USS, radionuclide scan
4. TFT result: Low/suppressed TSH, elevated free T3 and T4

Q4 — Large Neck Swelling ×10 years (61F)

1. Diagnosis: Large multinodular goitre
2. Complications: Tracheal compression/deviation, dysphagia, superior vena cava obstruction, haemorrhage into nodule, malignant change
3. Features of malignancy: Rapid growth, hard fixed nodule, hoarseness (RLN involvement), cervical lymphadenopathy, dysphagia
4. Treatment: Total thyroidectomy

OSCE 5 — Left Breast Lump (45F)

1. Inspection: A smooth, rounded lump in the left breast with no skin changes, no nipple retraction — appears well-defined
2. Benign features: Smooth, well-defined, mobile, soft/rubbery, no skin tethering, no nipple changes, non-tender
3. Investigations: Triple assessment — clinical exam + mammogram/USS + FNAC or core biopsy

OSCE 6 — Breast Skin Changes (45F)

1. Findings: Peau d'orange (skin oedema causing orange-peel appearance) with nipple retraction
2. Significance: Signifies dermal lymphatic invasion by breast carcinoma — indicates locally advanced malignancy
3. Investigations: Triple assessment — mammogram + USS + core biopsy; CT chest/abdomen/pelvis for staging

OSCE 7 — Painful Breast Swelling, Breastfeeding (27F)

1. Diagnosis: Breast abscess
2. Cause: Staphylococcus aureus (most common in lactational mastitis/abscess)
3. Treatment: Incision and drainage (or USS-guided aspiration) + antibiotics (flucloxacillin) + continue/cease breastfeeding as appropriate

OSCE 8 — Nipple Discharge (57F)

1. Most likely complaint: Multi-duct nipple discharge (bloodstained or serous)
2. Causes: Multi-duct → duct ectasia or infection; single-duct → intraductal papilloma or carcinoma
3. Investigations: Mammogram, USS, ductogram/galactogram, cytology of discharge, FNAC/core biopsy

OSCE 9 — Breast Dimpling (60F, Nulliparous)

1. Sign: Skin dimpling and puckering
2. Significance: Indicates breast carcinoma (tumour tethering overlying skin via Cooper's ligaments)
3. Best way to demonstrate: Ask patient to raise both arms above head or lean forward — accentuates dimpling

Q10 — Right Groin Swelling (45M)

1. Diagnosis: Right inguinal hernia (indirect, given age and lifting precipitant)
2. Risk factors: Male sex, chronic cough, constipation/straining, heavy lifting, obesity, previous abdominal surgery, connective tissue disorders
3. Differentials: Femoral hernia, lymph node, lipoma of cord, hydrocele, undescended testis, saphena varix, femoral artery aneurysm

Q11 — Scrotal Swelling (25M, 3 days, No Fever)

1. Differentials: Epididymo-orchitis, torsion of testis, incarcerated inguino-scrotal hernia, haematocele, testicular tumour
2. Investigations: Scrotal USS with Doppler, urine FEME & C/S, FBC, serum tumour markers (AFP, β-hCG, LDH)
3. Clinical distinction from inguinal hernia: Can you get above the swelling? — If YES → scrotal origin (not hernia); if NO → inguinal hernia descending into scrotum. Hernia is also reducible and has an expansile cough impulse at the inguinal ring.

Q12 — Zieman's Test (Physical Exam)

1. Examination: Zieman's test (finger occlusion test for hernia type)
2. Purpose: To differentiate between indirect inguinal, direct inguinal, and femoral hernia
3. How done & interpretation: Three fingers placed over deep inguinal ring, superficial inguinal ring, and femoral ring respectively; hernia reduced, patient coughs — impulse felt at the corresponding finger identifies the hernia type

Q13 — Transillumination Test (6-month Infant)

1. Test: Transillumination test
2. How done: Torch/light applied to the scrotum in a dark room — light transmitted through fluid-filled swelling
3. Diagnostic of: Hydrocele (fluid-filled, light transilluminates) — differentiates from solid testicular swelling (does not transilluminate)
4. Treatment: Congenital hydrocele — observe (most resolve by age 2); persistent → herniotomy/surgical ligation of patent processus vaginalis

Q14 — Colonoscopy (42M, Family History of Colon Cancer)

1. Diagnosis: Familial adenomatous polyposis (FAP) / multiple colonic polyps
2. (Q2 missing from slide)
3. Significance of family history: FAP is autosomal dominant (APC gene mutation); strong FH indicates high malignant potential — polyps undergo malignant transformation if untreated
4. Treatment: Prophylactic colectomy (total/subtotal) with surveillance; endoscopic polypectomy for limited polyps
5. Complications: Malignant transformation to colorectal carcinoma, obstruction, intussusception, bleeding

Q15 — DRE with Meleana (60M)

1. Picture shows: Melaena (black, tarry stool on glove) — dark altered blood per rectum
2. Possible causes: Peptic ulcer bleeding, gastric/oesophageal malignancy, oesophageal varices, Mallory-Weiss tear, duodenal ulcer
3. Investigations: FBC, blood group & crossmatch, coagulation, LFTs, UGIE (upper GI endoscopy), urea/creatinine ratio
4. Management (Hb 5.6 g/dL): Resuscitate (IV access, fluid/blood transfusion), monitor vitals, urgent UGIE for diagnosis and haemostasis (adrenaline injection/clipping), PPI infusion

Q16 — RIF Mass (51M)

1. Differentials: Carcinoma of caecum/ascending colon, appendicular mass/abscess, Crohn's disease, iliac lymph nodes, ovarian mass (if female), psoas abscess, TB ileocaecal
2. Features to determine: Site, size, shape, surface (smooth/irregular), consistency (hard = Ca), mobility, tenderness, pulsatility, transillumination — to characterise malignant vs inflammatory vs other
3. Investigations: FBC, LFTs, CEA, colonoscopy + biopsy, CT abdomen/pelvis
4. Complications: Obstruction, perforation, fistula, bleeding, metastasis

Q17a — Small Bowel Obstruction X-ray (40M, Post-Appendicectomy)

1. X-ray shows: Dilated small bowel loops with air-fluid levels (supine); no gas in rectum (upright shows multiple fluid levels)
2. Diagnosis: Acute small bowel obstruction (mechanical)
3. "Drip & Suck" regime: IV fluids (drip) + nasogastric tube decompression (suck) — conservative management for SBO
4. Possible cause: Post-operative adhesions (from previous appendicectomy)

Q17b — Haematemesis (62F, on NSAIDs/Aspirin)

1. Additional history: NSAID/aspirin use, alcohol, anticoagulants, previous peptic ulcer, amount/frequency of vomiting, prior episodes, symptoms of liver disease
2. Nature of vomitus: Bright red blood — indicates active upper GI bleeding (haematemesis)
3. Possible diagnoses: Peptic ulcer (NSAID-induced), oesophageal varices, Mallory-Weiss tear, gastric erosions, gastric carcinoma
4. Investigations: FBC, coagulation, LFTs, blood group & crossmatch, UGIE urgently
5. Assess status: Pulse, BP, postural hypotension, urine output, Glasgow-Blatchford or Rockall score to stratify severity

Q18 — Endoscopic Image (Chronic Epigastric Pain)

1. Diagnosis: Peptic ulcer (duodenal ulcer — relieved by milk, aggravated by spicy food)
2. Etiological factors: H. pylori infection, NSAIDs/aspirin, smoking, alcohol, stress, acid hypersecretion (Zollinger-Ellison), steroids
3. Principles of treatment: Eradicate H. pylori (triple therapy), PPI for acid suppression, avoid NSAIDs/smoking; surgery (rarely) for complications (perforation, bleeding, obstruction)