1ffea 1

(Thai National License-3)
2551
(...)
2546

4 5
14

1 2551
National License PIII OSCE SWU

OSCE National Licese PIII
... 3
(Physical examination)
(Procedures skills)
Communication skills
(History taking)
Interpretation skills
Management
Key Clinical Skills (10 )

(History taking)

Consent
...

2546
(...)
3

1 (Basic science - MCQ) 3
2 (Clinical science - MCQ) 5
3 (Clinical competence MEQ ,Long cases OSCE)
1 2
3 (OSCE)
(...) 3
20
- 4
- 4
- 4
- 3
- 5
2.1

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.

18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.

33.
34.
3.5.1

1.4 - 1.7
1. /
2.
3.
4.
5.
6.
7.
8.
9.
1.
2.
3.
4.
5.
6. Counseling
7.
8. autopsy
9.
10. /
3.2 - 3.4
/
History taking
Medicine
I.
1.
2.
3.
4.
5.
6.
7.
8.
9.
II. dyspnea
1.
2.
3.
4.
5.
6.
7.
wheezing
8.
9.
10.
11.
12.
13.
14.
III. syncope ()
1.
2.
3.
4.
5.
6.
7.
8.
IV.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12. orthopnea PND
V.
1.
2.
3.
4.
5.
6.
7.
8. orthopnea PND
VI.
1.
2.
3.
4. colicky pain
5.
6.
VII.
1.
2.
3.
4.
5.
6.
7.
10
VIII.
1.
2.
3.
4.
5.
6.
7.
8.
9.
IX.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
X.
1.
2.
3.
4.
11
5.
6.
7.
shock
XI.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
steroid AIDS
XII.
1.
2.
3.
4.
5.
6.
7.
regurgitation
8.
9.
heart burn epigastrium
12
XIII.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
XIV.
1. colic
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

13
XV.
1.
2.
3.
4.
5.
6.
7.
8.
XVI.
1.
2.
3.
4.
5.
6. NSAID
7. stress
8.
9.
10.
11.
XVII.
1.
2.
3.
4.
5.
14
6.
7.
8.
9.
10.
11.
XVIII. Headace
25 3
1
Age of onset ( , )
2
(//)
3
(//)
4
,
,
5

6
Aura
7
,
, ,
8
(throbbing pain),
(stabbing pain), (thunderclap headache),
9
, ,
, , , ,
10
, , ,
,
11
, ,
12

13
14
, ,
15
multiple partners, homosexual
15
16
17
, ,
,
16
Surgery
I. Abdominal pain
. 40
()
1
1. site / location of pain

2. progression of pain/ shifting of pain
3. characteristic of pain
4. refer pain
5. associated symptoms
6. aggravating/ releasing
7. co-morbidity
2
1. general appearance of abdomen
2. auscultation
3. palpation
- McBurney point
- Psoas sign
- Obturator sign
- rebound tenderness
- Rovsing sign
4. Digital rectal examination
3
1. Acute appendicitis
2. Acute diverticulitis
3. Peritonitis
17
Psychiatry
I. Suicide
30 ./ /
() . Paracetamol 120

1. Demographic data
2.
3. intention to die
4. suicidal act & plan

.
5.

6.
7.
8. psychosis ,mania, anxiety

9.
10.
11.
12. supporting system
13. Major depressive disorder
14. high risk suicide
18
Physical examination
Medicine
1.vital signs
: Temperature, BP, PR , RR
2.Cardiovascular system
1. general appearance (edema, cyanosis, clubbing,etc.)

2. pulse
2.1 4 extremities
2.2 pulse
2.3 radial femoral pulse
3. carotid pulse
3.1 carotid pulse carotid bruits ?
3.2 ,
4. JVP
4.1 30 45 JVP sternal angle
4.2 a v waves carotid
pulse heart sound
5. precordium
5.1 impulse
5.2 apical impulse PMI, abnormal impulse
heart sound
5.3 apical impulse
5.4 5.3 apical contour normal thrust, tap, slap, heave
double apical impulse (left lateral decubitus)
5.5 RV heaving sternum

5.6 stethoscope precordium apex base Lt parasternal aea
5.6.1 bell diaphragm
5.6.2
5.6.3
19
3.Respiratory System
Inspection
1. Cyanosis
2. Clubbing
3 Plethora, venous distension
4 Chest contour
5. Breathing movement rate. depth. rhythm, equality presence of paradox. accessory
muscle use
Palpation
1. Lymph node ()
2. Trache supasternl fossa
3. Chest expansion
- Apical
- Base
. Vocal fremitus expansion 1 2 3
4. subcutaneous emphysema
Percussion
1. 2
2. 2
Auscultation
1. Breath sound 2
2. abnormal bronchial breathi sounds
3. adventitious sounds crackles, wheezes. stridor. pleural rub.
mediastinal crunch
4. Voice-generated sounds
- Vocal resonance (1.2.3 2 )
- Whispering pectoriloquy ( 2 )
Egophony ( E A )
20
4.Gastroenterology
1. Observation:
- general appearance including leg edema
- (anemia. jaundice)
- oral cavity
- signs of chronic liver disease (spider nevi. palmar erthrerna. gynecomastia etc.)
- signs of hepatic encephalopathy(flapping fetor hepaticus)
- abdominal contour and superficial dilated veins ()
2.
- bowel sound
- (bruit or venous hum)
3. -
- light palpation (all quadrants)
- deep palpation (all quadrants)
- examination of liver (describe size. span liver dullness, consistency, edge surface,
tender. etc.)
- examination of spleen (supine and right lateral decubitus )
- bimanual palpation of kidney
- examination of hernia
4. ExamInation of ascites
- fluid thrill
- shifting dullness
5. Rectal examination
5. Cranial Nerve
CN I
(, )

CN II
1. Visual acuity (Pocket near vision chart)
- chart 14
- Chart
2. Visual field (Confrontation test)
- 1
- VF
-
- peripheral field quadrant
3. Fundoscopic examination
-
21
- lens *
- ophthalmoscope ophthalmoscope
disk refraction potic fundi *
()
- *
-*
CN III. IV. VI
1. Exophthalmos
- exophthalmos
2. Puplliary
- pupil
- direct reflex consensual reflex
3. Extraocular movement
- : 5
4. Ptosis
- 2
5.Accommodation
- : convergence miosis
CNV
1. Motors
1.1 Temporalis muscle
- temporal fossa 2 muscle atrophy
- 2
1.2 Masseter muscle
- mandible 2 muscle atrophy
- 2
1.3 Latefal pterygoid muscle
- jaw deviation
-
-
2 Facial sensation
2.1 skin sensation
- (V1) (V2) (V3) 2
2.2 corneal reflex
-
- cornea upward, medial
3. Jaw jerk
- reflex
22
6.Motor Function
.
1. Observe : abnormal movement muscle wasting. fasciculation.
fasciculation
2. Pronator drift : forearm
flexion pronation. finger flexion 2 rebound
3. Muscle tone passive movement joint
- Shoulder joint forearm --
-Elbow joint shake hand -
- Radio-ulnar joint -
-Wrist joint forearm shake hand -.
4. power
- deltoid
- biceps
- triceps
- brachioradialis
- pronator
- supinator
- wrist flexion
-wrist extension
- hand grip ( 2 )
-finger extension
- finger abduction ( 2 )
- finger adduction
- opponens
5. Deep tendon reflex
- Biceps biceps tendon
-Triceps triceps tendon (2 )
- Brachioradialis brachioradialis tendon (2 )
- Finger PIP joint
6. Hoffmann Trommer sign
- extend wrist MCP. PIP joint distal phalanx
palmar flexion
23
1.Observatlon wasting. fasciculation etc.

2.Muscle tone
- roll external internal rotate movement
- lift 2 movement
3. power
- hip flexion
- hip extension
- hip abduction
- knee flexion
- knee extension
- ankle dorsiflexion
- ankle plantar flexion
-eversion
- inversion
- toe dorsiflexion
- toe flexion
4. deep tendon reflex
- Knee flex patellar tendon
-Ankle external rotation dorsiflexion
Archiles tendon
5. plantar reflex lateral aspect
6. ankle clonus dorsiflexion
7. gait
7. Deep Tendon Reflex
1.
-
-
2.Bicetp jerk
- pronation
- biceps tendon
3.Brahiosradialis jerk
- pronation
- radius 2
4.Triceps jerk
-
- triceps 2
24
5.Finger jerk
- supinate
-
6.Knee jerk
- flexion
- pateliar tendon
7.Ankle jerk
- externa; rotation
- dorsiflex
- Archilles tendon
8.()
-
-
8. Cerebellar Function
1. Nystagmus
-, -
2. Tone
- shoulder joint
- elbow joint
- radloulnar joint
- wrist joint
3. Co-ordination ( )
3.1 Finge-to-finger 2
3.2Finger-to-nose
3.3 Finger-to-nose-to-finger
4. Co-ordination
Heel-to-knee
5. Alternate movement ( )
5.1 2
5.2 .-
6. Alternate movement
( )()
7. Tandem walking
25
9. Sign of Meningeal Irrigation
1.Stiff neck(nuchal rigidity)

1.1
1.2
1.3 -
1.4 2
1.5
Positive Extensor
2.Kernigs Sign
2.1
2.2 90o
2.3
2.4
Positive 2 ( 135 o)
Hamstring 2
10.Vibration and Position Sensation (Lower Extremities)
Vibration sensation
1.
- 128 Hz
-
- ( sternum
clavicle )
2. Vibratory
-
2
- 2 )
position sensation
1.
-
2. position sensation
- proximal phalanx
distal phalanx extend reflex
- 2
26
11.Hearing
1.
- 256 Hz
-
-
2. Webers test
-
-
-
lateralization to the..(left or right)
3. Rinnes test
- mastoid
-
-
-
12.
-
-
-
- , 2
(lobe) trapezius muscle
-
-
-

-

27

-
-
-
- ,
-
-
-
-
-
-
bruit
13. Trousseau
1.
2.
3. arm cuff
4. Apply pressure 10-20 . 2-3

1. (carpal spasm)
- adduction thumb
- fIexoim metacarpophalangeal joints
-flexion wrist joint
-flexion elbow joint
accoucheurs hand
2. carpal spasm 4
Grade 1
Grade 2
Grade 3 grade 2 1
Grade 4 grade 2 1
28
3. 5
1.
- ()
-
-
-
2. grade 1 2 4 , grade 3 4
14. Chvostek
1.
2. Chvostek I ( facial nerve ) facial nerve
2-3 .. zvgomatic arch
3. Chvostek II ( facial never )

zygomatic arch
1.
2.
Grade 1
Grade 2 alae nasi
Grade 3 alae nasi orbicularis oculi
Grade 4
1.
- ()
-
-
-
2. grade 1 25
29
15. Deep Vein Thrombosis
1.
2.
3.
4. Homans sign active passive dorsiflexion
4.1
4.2 dorsiflexion
4.3
16.Musculoskeletal System
Inspection
1.Posture:
2.Gait:
3.Derfromity Sign on inflammation: ,
()
Palpation
1.
2.swelling):
synovium
3. (tenderness):
4.(range of motion)
:
:
Special tests ()
1. Carpal tunnel syndrome
1.1 Tinesls test: median nerve distribution
1.2 Phalens test: 1 median nerve distribution
2. Sacroiliitis
: Sign of 4:
fix
SI joint
30
3. Spondyloarthropathy
3.1 Schobers testjModified Schobers test: L5
posterior iliac spine 2 10 ..
( modfied Schobers test L5 5 ..)
13 ..Schobers test 20 .. modified Schobers test
3.2Occiput to-wall: Occiput

3.3 Chest expansion: 4th intercostals spale
5.0 ..
31
Surgery
1. Breast nass
60 2

1 Doctor-patient relationship
1.
2.
3.
4.
2
1.
2.
3. axilla
4.
3
1.
2.
3. 4 quadrant
4. nipple discharge
5. axilla
6. supraclavicular lymph node
ENT.
25
1. Rinne test
2. Weber test
3. Bing test
4. Schwabach test
5.
1 Doctor-Patient Relationship
1.
2.
32
3. /
4.
2 /
1. Rinne test 1
mastoid
2. Weber test

3. Bing test mastoid

4. Schwabach test
4.1 mastoid mastoid
4.2 mastoid
mastoid
5.
1. Rinne test

2. Weber test
3. Bing test

4. Schwabach test

. Conductive hearing Lt, Normal hearing Rt
33

Eye- ENT.
1. / 1
foreign body upper palpebral conjunctiva

remove foreign body
1 Doctor-Patient Relationship
1.
2.
3. /
4.
2 /
1. /
2. Alcohol
3. /
4.
5.
6. /
fulcrum
Fix
7. foreign body upper palpebral
conjunctival
8. foreign body foreign body
9.
Antibiotic eye drop remove F.B.
10.
11.
12. Antibiotic /
34
2. Anterior packing Vaseline gauze
1.
,
2.
10% Xylocaine ( 5% cocaine) + Ephedine pack
5 10 ()
3.
Nasal speculum
4.
Chloramph oint Vaseline guaze
5.
bayonet forcep Vaseline gauze 10 - 15 cm.
speculum gauze
6.
speculum forcep
7.
guaze
8.
guaze
9.
Posterior packing Foleys cath.
10. bleed admit 2
Pediatric
35
1. 1 12
BCG, HBV3 , DPT3 , OPV3 , MMR1
,
Medicine
1. Fist aid management of injury pateint
1 . 25

1.
2.

36
(Pre-hospital treatment First Aid)

1 ( 15-20 1
)

2 (fang mask)
ABC : A (Airway), B (Breathing),

(Circulation)

povidine iodine

: vital sign,
(fang mark)
echymosis, petechiae
37
()
Venous clotting time (VCT)

CBC + platelet
(urinalysis) BUN, creatinine, electrolyte
Admit 24 6
VCT

VCT VCT

NSAIDs
2.basic life support

1;
1.
2.
3. head tilt chin lift
4. ( )
5. 2
6. 3
7.
7.1 30 100 /
7.2 1.5-2.0
7.3 50% cycle
7.4
8. ratio 30:2 5
9.
10.
38
2. airway management
15

( )
1.
2. head-tilt chin-lift techniques
finger sweep
( finger sweep )
3. 10 look-listen-feel
4. mouth-to-mouth 2 ( )
5.
6. xyphoid process
7. abdominal thrust x 5
9. mouth-to-mouth 2 ( )
10. carotid ( )
11. recovery position
3. airway mangement
22 10
diazepam 20
(
)

2. 10 look-listen-feel
3. carotid ( pulse)
4. Laryngoscope
(suction) ( 7.5-8)
cuff cuff
39
stylet
Lidocaine gel
(face mask) ambu bag
5.
( )

(ambu bag & mask) oxygen
ambu bag ambu bag 1/3-1/2 bag
6.

laryngoscope () blade
epiglottis
glottis ()
stethoscope
ambu. bag

syringe cuff
6. (chest X-ray)
3. ACLS
1. 42 type 1 DM 10 NPDR DN 2 severe
rheumatoid arthritis 3 2
2 15

1. ABCD
Airway (RA risk atlantoaxial subluxation) Breathing ()
Circulatio ( pulse / apex)
EKG VT
40
Defibrillation
( biphasic defibrillator/cardiovertor)
2. CPR 5 cycle
( CPR median nipples)
3. Pulseless electrical activity; PEA ( normal EKG pulse)
4. Adrenaline 1 mg IV CPR 5 cycle
5. check EKG pulse 5 (EKG asystole)
6. Adrenaline atropine 1 mg CPR 5 cycles
7. Check EKG pulse
(EKG-normal sinus, pulse + check 5H, 5T asystole)
2. 68
Management ( endotracheal tube , monitor BP
pulse oximetry)
check airway, breathing, conscious, circulation
Key : , SpO =70%
2
CPR (chest compression + ambu) 2
Key : 180 /mm BP = 90/40
management
Key : Paddle EKG lead EKG
EKG
Key : regular, wide complex tachycardia
P BP management
Key : synchronized cardioversion
defibrillation/cardioversion unit
synchronized
100 J (monophasic)
jelly paddle paddle 2 jelly paddle
paddles right upper sternum clavicle apex
paddle 2-3 cm.
charge apex paddle
fully charged clear
paddle 25 lb/paddle discharge/shock paddle 2
cardiac rhythm, P, BP

Key :
41
1. electrolytes imbalance
2. ischemic heart disease
3. pneumothorax
lab : K = 7.0 meq/l
Key :
1. 10 % Ca gluconate
2. Insulin + 50% glucose 50 cc / 7.5% NaHCO3 50 cc
3. Kayexalate
4.
; BYRD
16 (tidal volume) 400 cc.
- = 1:2 air-mixed
1.
2.
(sensitivity, effort)
3.
4.
5.
400 cc.
6. 16 /

expiratory time
7. I:E = 1:2
I : E 1 : 3
expiratory flow rate
8. air-mixed
FiO2 1.0

FiO2 1.0
42
5. arterial blood gas

arterial blood gas radial artery

1. ,
2.
3.Hyperextend
4.
5. Modified Allens test ( radial ulnae artery
ulnae artery )
22 24 syringe 5 .
6. heparin 0.5 . syringe heparin
syringe radial artery
7. 1-3 . syringe
5
8. syringe
6. subcutaneous
; 50
NPH 14 U sc ac insulin
1.
2.
3.
4.
insulin ()
insulin
insulin insulin
*
5. insulin 70% alcohol
6.
*
7. syringe insulin
8. insulin syringe
syringe insulin
43
9. insulin syringe
insulin syringe
10.
11. syringe
12. 70% alcohol
13.
14. syringe
45-90
15. syringe
16.
7.
1. 45
2. ascites shifting dullness
3. sterile
5. 70% alcohol povidine 2-3
5.
6. peritoneum
7. 18-20 G syringe 10 cc.
8. peritoneum (Z track
technique)
9. ascites
10. ascites
11. specimen
(albumin, cell count, cell differential, culture hemoculture)
44
7. lumbar puncture CSF
1
2
3
4
5
6
7
8
9
10

L3-L4 (
Iliac crest )
spinal needle No.18-21
set povidine 70% alcohol
18 1%xylocaine 5 ml 22
interspinous ligament
styletbevel stylet
spinal manometer three way stopcock
spinous process
guard
,subcutaneous, interspinous ligament ligamentum flavum()
subarachnoid space stylet
opened pressure spinal manometer
CSF sterile 3-4
1 culture
2 protein&sugar
3 cell
closed pressure stylet

2-4
45
9. MDI
1.
2.
3.
4.
5.
6.
7.
8.

2
1
10
2 puff 1
2
- 1
inhaled steroid bronchodilator
inhaled steroid
10. Oxygen therapy

oxygen therapy with T-piece
1.
2. T-piece
1 T-piece 22 .
6 12 T-piece 22 .
3. Nebulizer ( bubble Jet)
4. oxygen flow > 6 Lpm ( 6 ) >10 Lpm ( 1
5. T-piece 15 . ETT
6. Nebulizer
46
Surgery
Excission

excision subcutaneous mass
1
1. Betadine solution
2.
2
1.
2. push air
3.
4. negative pressure
5. ( field block )
3
1.
2. forceps
3. ( elliptical incision )
4.
2. Dressing wound
. Dressing post operative thyroidectomy proper sterile technique
disposable
1. forcep sterile technique

2. forcep
3. alcohol
4. forcep alcohol
5. forcep gauze 4x4
6.
7.
47
3.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
cutting
1 /3
silk
holder
forcept
vertical mattress
half bury
non tooth forcep
4. BK amputation stump
- Anterior bandage 2
-
- distal stump stamp
eg. Distal medial
distal ulnar
5. Digital block
1.
2. Sterilized alcohol, plaint
3. landmark
4. superficial landmark neurovascular digit
5.
- Syringe 10 ml.
- 25
6. periosteal point dorsum & point volar
48

1. 55 5

PE Left knee : mild swelling and inflammation, crepitation, varus deformity
Film= OA knee
1 /
1.
2. /
2.1
2.2 x-rays
2.3 50
2.4
2.5 crepitus
3.
3.1 Isometric exercise
3.2 Isotonic exercise
3.3 , , ,
4.
4.1
4.2
4.3

4.4
4.5 lateral wedge
4.6 knee brace
4.7 gait aid
cane
49
2. 42
hypertension, DM

(BMI) = 24.5 kg/m2 Blood pressure 150/95 mm. Hg

FBS
Chest X-ray EKG

Cholesterol 270 mg/dl

HDL
60 mg/dl
Triglyceride 150 mg/dl
A.
B.
C. LDL

hypertension
( 45 55 / // /
/ HDL )

1. 1 2

cholesterol
2. 1 6
50

3. 1 2

4. 3 30
1 LDL 160 mg/dl
51
3.
1.
2.
3. 5 ( 1 = 3 )
4. / /
5.
5.1
5.2
5.3 ( hind milk )
6. 2 3
7. ( 4C ) 24 48
8.
9. ( 14 C ) 3
10. /
11.
4.
Advice
.
1.
(2), (2)
(2 ) COPD (3 )
2.
3.
- 2
-
-
-

5.
STAR
Set a quit date
2
52
Tell family and request support
Anticipate challenges 4D
Deep breath
Drink water
Do something
Delay

Remove tobacco product

Arrange
Relevance

Risks

Rewards

Reloadblocks
Repetition
53
6. 55 5 1-2
Chronic tophacous gout

Creatinine 1.2 / Uric acid 9.8 / gouty attack
colchicines allopurinol
Check list
1.

2.
allopurinol
4-5 (5.5) /
3. allopurinol
100 / 300 / 1

-
-
,
4.colchicine
1-2 1
5. colchicine

6.
1.

, , , ,
2.

54
3.
4.
5.
6.
6. 25
Chick list
1.

Alcohol 70%
Rabies
Immunoglobulin
2. vaccine
Human diploid
cell vaccine Purified vero vaccine Purified
chicken embryo cell vaccine
(deltoid muscle) 1 dose 0,3,
7,14,28 0
3. Rabies immunoglobulin (RIG)

4. 0, 1, 6
( 2 )
55
5.
ampicillin
amoxycillin metronidazole
Clindamycin
6.
7.
,

7. 45 alcoholic cirrhosis Gastroscopy esohpageal

Varice cherry red spot sign diffuse gastritis
.
.
.
Chick list
.
1.
2.
3. , ,
4.
5.
.
1. spironolacione 100 /
2. , folic acid
3. propranolol 40 /
.
1. SBP
2. Hepatic encephalopathy
3. Hepatorenal syndrome
4. Hepatoma
5. Bleeding tendency
56
8. 65 1 5
Paracetamol
Check list
.
1. NSAID
1.1 60
1.2
1.3 (Antacids), H2 antagonist
Omeprazole
1.4
1.5
2.
3. drug interaction
ASA coumadin
.
1. NSAID
2.
3.
4. NSAID Indomethacin
5. NSAID
.
(CBC, urinalysis,lives
enzymes, electrolyts, BUN, creatinine, stool ocult blood
9. 28 1 ,
AFB + 3
Chick list
1.
1.1
1.2
1.3
1.4
2.
2.1
57
( 6 )
2.2
2.3
breast feeding
rifampicin
3.
3.1
3.2
3.3
3.4
4.
. /
, Chest X-ray
.
Chest X-ray, tuberculin test
58

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(Thai National License-3)

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heart burn epigastrium

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1. site / location of pain

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4. suicidal act & plan

8. psychosis ,mania, anxiety

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1. general appearance (edema, cyanosis, clubbing,etc.)

5.5 RV heaving sternum

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1.Observatlon wasting. fasciculation etc.

7. Deep Tendon Reflex

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9. Sign of Meningeal Irrigation

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10.Vibration and Position Sensation (Lower Extremities)

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15. Deep Vein Thrombosis

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foreign body upper palpebral conjunctiva

2. Anterior packing Vaseline gauze

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ABC : A (Airway), B (Breathing),

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Venous clotting time (VCT)

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non tooth forcep

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