UWS OSCEs List

Discussion in 'Exams & OSCE's' started by Havox, Dec 2, 2011.

  1. Havox

    Havox Sword and Martini Guy! Emeritus

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    Below are a list of past UWS OSCE stations. These have been taken from the forums, reformatted and arranged in year order for convenience. The original authors are acknowledged next to the OSCE title and a link to the original thread for full discussion can be found below.

    http://www.medstudentsonline.com.au/f52/uws-osces-7661/

    Year 1

    Formative OSCE, 2007 - Matt

    1. Perform a basic abdominal examination

    2. Take Chest pain history
    · Ask on risk factors
    · Make a differential diagnosis of unstable angina​
    3. Perform a basic respiratory examination

    4. Take a dysphagia history
    · Identify oesophageal dysphagia (as opposed to oropharyngeal)
    · Differentiate between mechanical obstruction and a motility disorder​

    Formative OSCE, 2008 - Matt


    1. Perform a basic examination of the respiratory system
    2. Take a palpitations history
    · Identify 3 factors that indicate a serious cause
    · Identify precipitating factors​
    3. A patient presents with syncope take the patient's vital signs excluding temperature
    · Remember to first take the blood pressure lying down and then standing up​
    4. Take a history from a patient presenting with abnoral bowel movements (constipation) and abdominal pain
    · Identify three differential diagnoses

    Formative OSCE 2009

    1. Take a history from a patient complaining of chest pain (with 4 differentials and leading diagnosis), and branch off into associated symptoms and risk factors.
    2. Take a history from a patient complaining of breathlessness (with 4 differentials and leading diagnosis), and branch off into associated symptoms and risk factors.
    3. Perform an abdominal examination
    4. Perform a cardiovascular examination
    Formative OSCE 2010 Diametric and Havox:

    1. Patient complaining of palpitations. Take a history. Asked about what aspects of the history would indicate to you whether the palpitations were serious or not.
    2. Perform a respiratory examination. Real patient with actual symptoms, some of which have nothing to do with resp. Asked at the end whether the patient had crepitations, which was difficult to ascertain and I said it was 'slight crackles.' Other students didn’t have real patients.
    3. Patient complaining of abdominal pain, also has difficulty opening bowels, however, opening bowels slowly does away with the pain (patient is constipated). Take a history. Most likely cause, being the hypertension medication she was taking, I forgot to ask about. Oh well. Also asked for provisional ddx with reasons and mechanism.
    4. Perform a cardiovascular examination. Expected to report certain findings, such as the rate and rhythm of the radial pulse. Question about what a pansystolic murmur might indicate asked at end. Asked what further examination I would perform.
    Year 2

    Summative OSCE, 2008 - Matt

    1. Explain the rational for performing a routine spirometry and guide the patient through this procedure

    2. Take a Dyspnoea history
    · Identify relevant risk factors
    · Take a brief smoking history
    · Make 3 differential diagnoses​
    3. Perform a basic examination of the knee

    4. Take a palpitations history
    · Identify 3 factors that indicate a serious cause
    · Identify precipitating factors​
    5. Perform a basic abdominal examination

    6. Take a menstrual history (irregular periods)
    · Ask on menopause and possible pregancy (patient was 45yrs old)
    · Take a brief reproductive history​
    7. Perform a basic neurological examination of the upper limbs

    8. Take a pain history (wrist, knucles, phalanges)
    · Differentiate rheumatoid vs osteoarthritis
    · Identify one other possible cause

    Summative OSCE 2009 - zyvx
    1. Procedural skills station: Perform a urinalysis (presumably discussing with the patient what the tests means and what the results mean??)
    2. Perform a neurological examination of the upper limbs
    3. Perform an abdominal examination
    4. Take a history from a patient presenting with weight gain and a lump in the neck (+ 3 differentials)
    5. Take a history from a patient with haemoptysis (+ 3 differentials?)
    6. Take a history from a patient with back pain (who also has lupus) and identify red flag symptoms (+ differentials?)
    OSCE 2010(Summative, 10%) by Woozy:

    1. 58 Year woman presents with back pain.

    S: Lumbar back pain
    O: 3 weeks age
    C: Dull and sharp pains
    R: radiating down the posterior of the R leg.
    A: as above
    T: constant
    E: Movements involving the lower back
    S: 10/10

    PMHx: SLE
    Meds: Voltaran, Methotrexate, Prednisone (corticosteriods), etc. Patient also takes calcium supplements.
    Familial history: Father CVD.
    Social history: Supported by husband.
    Red flags asked: post-menopausal?, IV drug user, occupation, infection, trauma.

    DDx: corticosteriods use causing increased bone degeneraiton leading to compression fracture, sciatica, etc.

    2. Lower limb neurological assessment, instructions noted that we were not required to perform a sensory exam: even though we we're told we would have actors, this patient had pathology. I conducted the full lower limb neurological assessment, inc gain and testing of the dermatomes. See T and O'C.

    Asked to distinguish between UMN and LMN, 3 examples of lower limb UMN signs. Hyperreflexia, Hypertonia, Fasciculations.

    3. 4X YO woman out with daughter when she suddenly losses consciousness.

    S: N/a
    O: Sudden and unexpected. No aura or warning signs.
    C: loss of consciousness, you should ask if it was witnessed, it was important to distinguish 'blackout' and 'loss of consciousness', etc which the patient used interchangably, for this interview i asked if anyone witnessed the event, the interviewer said yes and i proceeded to interview the daughter about the LOC. Other students were given bonus marks for getting the patient to define what they meant when using those terms, apparently only 1 student asked out of the 30 of us. I also asked about the context in which this occured: the patient was sitting, which was a key diagnostic indicator.
    R: N/A no other features
    A: None reported by patient or daughter. Patient had no aura, or contractions, loss of continence.
    T: A few minutes
    E: None known
    S: N/A

    H of PC: 2 other recent episodes of syncope, in the last month, including one fall, one other witnessed by husband.
    PHX: Heart attack 10 years ago, patient unable to describe any details about this.
    Meds: Lipitor
    FHX: Diabetes in the family... can't remember

    Students: from the prompts and direct questioning of the students by the markers it seems we were required to ask questions to help distinguish between: vasovagal, cardiogenic syncope, and epilepsy in the interview.

    DDx: Cardiogenic syncope.

    4. Respiratory exam.

    Patient: was wearing pants, bed was completely flat with no pillows.

    Full respiratory exam from T & O'C performed, i forgot to add neurological signs such as wrist tenderness, finger abduction, and adduction. Apparently later in the day there was a patient with pulmonary hypertrophic osteoarthropathy. Also say the examinations you would like to perform but can't since the patient is wearing pants, the bed isn't at the right angle etc, such as JVP, checking for oedema, peripheral pulses. Some students we're asked to proceed straight to chest, or to skip certain parts of the exam due to time constraints or by taking too long. Most students we're still examining the back when told to stop.

    We we're then asked what are some possible DDx: of hyperreasonance. Pleural effusion, pneumonia, etc.

    Also what other exams we would like to perform: Cardio of course, GIT possibly, since the patient possibly had gynaecomastia on inspection.

    5. Patient presents with polyuria.

    Needed to distinguish between pathology and inc frequency from excessive fluid intake. The patient also had nocturia.

    Patient also had: visual disturbances (blurred vision at times) and tingling/numbness of the left foot.

    FHX: Sister and Aunt with type II mature onset diabetes.

    Questions asked:
    Fasting and non-fasting blood glucose: 4-6mmol/ and 4-8mmol i think.

    Also to explain to the patient what BSL's are, there levels and why it is important to maintain BSL in this range. Explain the inc in urination as well.
    DDX: Diabetes mellitus (mature onset, type II) given possible diabetic retinopathy and neuropathy/peripheral signs.

    6. Venipuncture for FBC.

    Remember to keep looking and talking to the actor and actor and not the venipuncture arm.

    Some students complained that they we're unfamiliar with the equipment, since we we're asked to use rubber torniquets which aren't used at Blacktown MDH. Also vaccutainer syringes we're different from BMDH.

    Most students we're unfamiliar with filling out the pathology request form and asking the patient to sign the form, etc.

    1. Wash hands
    2. Introduce self to patient.
    3. Check patient's details and wrist band, check for allergies
    4. Explain procedure, reasons why
    5. Contraindications/preferred arm be sure to gain consent only 3 students out of 30 or so at BMDH asked last year for spirometry!
    6. Gather equipment - other equipment such as syringes were there a lot of students choose to use the 'open' method which requires the use of a syringe and changing needles, this is not the preferred method. Also the wrong tubes we're also present. Some students choose the grey vaccutainer for HB1AC (blood glucose) and not the purple FBC ones! Clean site, etc...
    7. Wash hands/glove up
    8. Procedure - remember to remove the torniquet as soon as the needle is in. Also cotton-ball + tape for Pt
    9. Safe disposal of sharps!!! Don't forget!!!
    10. Write details on Vaccutainer, and path form, send to pathology.

    Summative OSCE 2011 – Chezza and Havox
    6 Stations, 8 minutes per station. 3 Histories, 2 clinical examinations, 1 procedural skills. 10% weighting.

    Histories (3) -
    As worded by the patient/actors:

    -Woman with small, rubbery lump in neck and underneath the arms (on both sides). Mother had breast cancer. Patient is presenting with unintentional weight loss. Appetite isn't increased. Take history, give 3 differentials + likely diagnosis

    - Woman with chest pain - relieved within 20 minutes without medication. Has had it before, started a month ago. Exercise triggers problem. Task history and ask about risk factors - ex-smoker, moderate drinker, not a diabetic, poor diet/exercise and high stress job. List modifiable risk factors + likely cause.

    - Woman with shortness of breath. Gradually getting worse. Stopped smoking 5 years ago - 20 cigarettes a day. Has a cough - grey sputum, 5mLs. History of bronchitis. No pain anywhere. Take history, 3 differentials and likely cause.

    Examinations (2) -
    - GIT Examination + 4 differentials for hepatomegaly
    -Lower limb neuro exam - patient had absent knee reflex. Nerve roots involved in knee reflex + is absent knee reflex caused by an upper or lower motor lesion?

    Procedural skills (1) -
    - Perform blood cultures (with nurse there to assist you)

    Year 3

    Summative OSCE - 30% of final year's grade - Matt and Kyle


    1. A postoperative patient on the ward develops fever, chills and hypotension. Perform and ABG (on a model hand) and explain the rationale and procedure to a patient (volunteer)
    · Remember to performs Allen's test
    · Remember to check ID
    · Remember to label specimen​
    2. A 57 year old women is concerned her mother is becoming increasingly forgetful. Take a history
    · Develop 3 DDx
    · Clinically it sounded like alzheimers, but had some vasc path history and hypertension so potentially vascular as well. Also mentioned withdrawl, possible decreased affect so depression was on the cards. Had UTI recently, and gets them often, so delirium was in the differential. No disinhibition, hallucination, concrete thinking​
    3. Examine a patient with Diabetes and present your findings as you go
    · The patient has incredibly severe diabetic disease of the foot and probably of other places too but I was too slow to find much of it
    · Sensory loss to sharp touch, vibration and proprioception in feet up to about knee level.
    · Decreased pedal pulses
    · Acanthosis nigracans
    · rubeosis iridis
    · tendon xanthelasmata (not diabetes per se, but relevant)
    · asked for BP, UA and BSL​
    4. Perform an examination of a patient's cranial nerves
    5. Take a history from a lady presenting with recent weight gain, cold intolerance and fatigue
    · Develop 3 DDx
    · hypothyroidism. For the last few years has noted weight gain (10kg), cold intolerance, hair loss, dry skin, fatigue, increased sleep, occasional depressed mood, growing lump on her neck. Mother had underactive thyroid. No past thyroid investigations. Diet she described has lots of iodine. Most likely hashimoto's thyroiditis or incidental goitre + depression or mix of the two.​
    6. A 67 year old man with a significant (>60 years or something) pack history mentions recent haemoptysis, weight loss, loss of appetite, and lethargy on a routine visit for ear syringe. After he says "I think it might be lung cancer, doc". You invite him into your room to talk about the possibility.
    Communicate effectively with this patient.
    · The patient has had a friend die recently (of lung cancer) with the same symptoms who's quality of life suffered with chemotherapy/radiation therapy
    · The patient believes his friend was given false hope and is adamant that he does not want aggressive treatment​
    7. Perform a Cardiovascular examination and present your findings in the final minute
    · The patient has a couple of signs to find. I only found digitial ischaemia and a systolic murmur. The jury's still out on what the murmur actually was but I haven't asked many other people. There was also abdominal distension and expiratory wheeze but I didn't finish the examination in time to properly assess the distended abdomen.​
    8. Take a history from a patient presenting with right flank pain
    · Develop 3 DDx​

    2011 OSCE's - Woozy

    1. CXR and ABG interpretation of an 85 year old woman, who presents with 3 days of fever and cough.
    CXR - Check details, quality, PA Erect, inspiratory or expiratory, check adequacy of inspiration, check for rotation
    X-ray details: Osteoarthritis of shoulder, pacemaker, blunting of right costophrenic angle, right lower zone pneumonia.

    ABG from same patient
    pH 7.25
    Hypoxic
    Inc PaCO2
    Bicarb normal
    BE 0

    Had to classify: type 2 resp failure with respiratory acidosis.

    2. Lower limb diabetic and vascular exam
    Actually had to feel for femoral pulse, explain anatomy, etc.
    Also asked for 6 things you would do or inspect for to check arterial circulation.

    3. History 22 YO woman (Sales rep) who presents to the ED with Right sided abdominal pain.

    On history, central abdo pain which migrated to RIF pain over the course of 2 days, 7/10 sharp pain. Pain on movement and leg extension. Bowels opened and regular, last ate this morning, vomiting (I should have asked more about this). Able to keep fluid down.
    LMP: 4 weeks ago, periods regular, no previous pregnancy, etc.
    Medical history: tonsiliectomy, no other known conditions
    Allergies: nil
    Smoking: 5 cigarettes/day
    Alcohol: social
    Travel: nil
    Occupation: not stressed

    4. BLS/ALS - You are a JMO on night shift and see a man collapsed on the floor in the hallway, you have a resuscitation cart next to you. You are by yourself.

    DRSABCD

    D- no danger
    R - no response from patient
    S - call out for MET CALL
    A - vomit, clear with suction which is available and insert guadel
    B - check (look, listen, feel)
    C- compressions immediately.

    Defib + nurse arrives
    Nurse takes over compressions immediately.

    You attack defib and electrodes - remember white is right, and smoke over fire.

    Follow ARC guidelines. The patient was in VT, shocked immediately. Ensure oxygen is away and continue compressions until ready to shock, then clear. Pt still in VT after first shock, continue CPR after 2nd shock administer 1 mg adrenaline, after 3rd shock amiodarone.

    Questions asked: The patient is now in sinus rhythm and conscious how would you manage the patient?

    5. 63 or 65 year old woman presents to a general practice with facial droop, which occurred a week ago.

    HPC: Left sided facial droop, slurred speech, bumping into things on the left side, L arm weakness, L leg weakness which resolved the same day.

    Pre-morbid function good, ADLS and IADLS intact.
    B/g: osteoarthritis and hypertension. Postmenopausal, hot flushes.
    Meds:
    Coversyl (ACEI)
    Panadol osteo,
    Glucosamine
    Allergies: nil

    On further questioning also takes Vitamin D

    Diagnosis: TIA caused by embolic plaque.
    Questions: Give other DDX, explain why palpitations may have caused this.

    6. Cardiovascular exam
    Pt had signs and all had murmurs
    Q - what are the cardiac causes of crepitations
    Q - what other systems would you test and what for: Gastro for AAA, renal bruit, liver bruit, etc. Eyes, Peripheral vascular, Respiratory, etc.

    7. Communication skills: You are on the surgical team treating an elderly Philippino man with malignant lung cancer. His daughter normally translates for him, however you have called a meeting with a medical interpreter for a family conference. The test results show that his lung cancer is terminal and incurable. The daughter asks to speak to you 10 minutes before the conference about the test results.

    Daughter says cultural beliefs mean that they do not want to tell their father the bad news and asks that you tell him it is just an infection, etc.

    The daughter also asks why you need an interpreter this time.

    Question asked by examiner: what are the reasons for a medical interpreter, why shouldn't you get a family member to interpret.


    8. Communication: explain the procedures of an appendectomy surgery to a worried patient.

    Patient asks a number of questions: what is envolved, risks, how the procedure is done, how long the procedure is, admission length, when she can go home, when she can look after the grandchildren, etc.

    Questions: what are the most common post op risk factors of surgery.

    Year 4

    Summative (60% of term) Paediatric OSCE - Matt

    Station 1:
    A parent presents with her 4? week old baby who has a fever and no localising signs. Explain to the parent why you want to do a lumbar puncture on their child, what it will involve (using a model neonate), and what the contraindications. All of this is performed after adequate prompting from the examiner (initiative not required).

    Explain what you would do if a lumbar puncture is not performed, or if it fails, explain what a traumatic tap is and what it means, interpret the CSF results (84 polymorphs, no gram stain, bacterial meningitis) and explain them to the parent, choose an appropriate therapy, explain what you will treat with and why, how long you will treat for and what the possible complications of meningitis are.

    Impression: Communication + knowledge station. Pretty easy station since paediatric medical students are expected to know meningitis pretty well.

    Station 2: Fluid charting station. Presented with a dehydrated child, have an approach to management (including ABCDE), recognise and categorise the child's level of dehydration (in this case severe), chart appropriate fluids (in this case 20mL/kg bolus of NS), take appropriate bloods (FBC, UEC, glucose, not cultures since no fever), interpret blood results and reassessment of patient's fluid status and then chart appropriate replacement fluids (in this case NS + 0.25% glucose working on 5% dehydration).

    The electrolytes show a potassium of 2.5 (very low) and you have to know not to give IV potassium until the patient has passed urine.

    Impression: Very easy and predictable station.

    Station 3: Short answer station, answer about 5 short answer questions based mainly on lectures.

    Impresssion: Students weren't expecting such lecture-oriented questioning, but if they had studied the lectures properly it would be an easy station. I don't think any of us had studied the lectures properly so many of us found it difficult.

    Station 4: Respiratory examination. Basic respiratory exam, bilateral wheeze was the only significant finding for me, know how to interpret growth charts, what initial investigations to ask for, and be able to demonstrate an engaging approach to examining a child (i.e use toys etc). Know to do a blood glucose as a first line investigation if you're worried.

    Impression: Predictable station, not too difficult but requires a well-practised approach to examining children.

    Station 5: History taking from a mum about her 5 week old baby who has projectile vomiting. Mother describes a classical presentation of pyloric stenosis and you're job is to take a basic and thorough vomiting history and identify that all other routine history questions (e.g. surrounding distress, development, pregnancy etc are normal). Then answer the examiner's questions surrrounding differential diagnosis, investigation (examination and ultrasound), management (IV vs oral rehydration fluid), treatment (surgery), and management after treatment.

    Impression: Not a difficult history station but difficult when pyloric stenosis is obvious from the first open-ended question and you spend the rest of the time asking questions and receiving answers all to the tune of very normal. The examiner's questions at the end weren't easy, not many of us knew the ins and outs of pyloric stenosis work up but most of us could give differentials and knew to ultrasound. Not many of knew whether oral rehydration or IV fluids were an appropriate initial treatment (baby sounded like it was mildly dehydrated).

    Obstetrics and Gynaecology Viva Voce Exam
    (teaching session II) - Matt

    Students are presented with a case trigger/summary and are then required to discuss differential diagnoses, important points on history, examination, investigation, management, complications, and communication. Stations were 10 minutes (2 minutes reading time, 8 minutes discussion).

    This sort of exam is comparable to the idea of sitting down with a consultant/specialist while they grill you on a topic they have extensive knowledge on. Stations included:

    1. Menorrhagia and dyspareunia in 34 year old woman, married and in a stable relationship with three children.

    2. Pelivic pain and vaginal discharge in a 24 year old nulliparous (no children) woman who has recently begun a new relationship and who does not use any form of contraception

    3. A pregnant lady presents for the first time with a reported 18 week gestation pregnancy that is measuring large for dates (24 weeks). You are required to discuss causes, investigations, management, screening and complications mostly in the setting of a twin pregnancy

    4. A pregnany lady presents at 34 weeks gestation with an antepartum haemorrhage (plus history of the same in one of two previous pregnancies).

    This sort of exam is benefited by the fact that there are only really 20 different significant obstetric and gynaecological conditions and about as many types of presentations. While there aren't that many conditions to know, however, you are required to know them in depth. Furthermore, you are required to demonstrate your knowledge in front of an expert who may very well belittle and patronise you if you say something silly.... which is very easy to do when you're flustered.

    My impression was that this was a fair exam. I knew the first two stations well and was able to 'motor-mouth' my way through them without too much prompting. The third station was unexpected and I hadn't prepared for it properly (can't think why, I should have), the consultant picked this up pretty early, belittled my answers and destroyed the confidence I'd built. The fourth station I knew well but I felt pretty bad after the third and I don't think I did nearly as well as I could/should have.

    Mental Health OSCE
    , Teaching Session 3 - Matt

    1. Watch a two minute video of a 67 year old retired teaching brought in by her husband after notcing she is becoming increasingly forgetful. Video of a well-dressed and clearly spoken older aged lady with terrible long term memory, no short term memory problems and little insight. Nil confabulation and good attention/concentration
    · Present a mental status examination
    · Discuss clinical features you would seek
    · Give a Diagnosis
    · Give a Differential Diagnoses​

    2. Counsel a 32 year old woman who has recently been discharged from the inpatient unit for the second time following a psychotic illness.

    Respond to:
    · I've been diagnosed with schizophrenia does that mean I have a split personality?
    · What causes schizophrenia?
    · I'm planing to have children, will they have schizophrenia?
    · Possibly other questions I may have forgotten.

    Stations were 10 minutes with 5 minutes reading time. Station 2 seemed to be really short for me and I wonder if there weren't timing issues.
     
  2. Dr Worm

    Dr Worm Regular Member

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    2014: 3rd Year Summative OSCE (30% of grade)
    Dr Worm, posting the group effort of her study group (hence the different colours, and also some possibly hilarious, maybe unwanted insight into our post-osce conversation):

    8. Take a history from 19 year old man with right lower abdominal pain with view to DDx


    • Actor was very nonspecific about site unless asked specifically
    • Yes it might be embarrassing but did it go to groin?
    • Possible appendicitis. Nope had appendix taken out before. Volunteered this information easily when asked about past medical issues.
    • Other symptoms: nausea, nil vomitting/diarrhoea, no bowel disturbance, no fever, no urinary signs, no recent illness, no meds
    • PMHx: literally none I could elicit aside from appendectomy in childhood, nil meds, not sexually active for 12 months.
    • SHx: current light smoker, I think? Worked as a tradie, but denied heavy lifting
    • Question at the end: what is it and what you do?
    • Testicular torsion and physical exam, ultrasound and refer to surgeon on call. I said evaluate the cramasteric reflex, which would have been slick if I had remembered the word “cremasteric” correctly which, alas, I did not.
    • I said also manually fix the torsion but the examiner said no. Snap: I said, if not manually reducible, urgent surgical review.
    • DDx; testicular torsion, incarcerated hernia? couldn’t think of anything else.

    1. Lady with vomiting blood (100mls bright red blood BIBA). Large alcoholic history (3 bottle wine/day many years).
    Do exam (my pt was very difficult to examine. Also, several students forgot to put the bed flat) ask question at end about management. Report important positive and negative findings. No need for history

    • Question: what investigations you'd do
    • Vital signs were printed and attached to wall, easy to miss (I did but examiner pointed it out with 2 minutes left) Mine were on table UNDER my clipboard, and I didn’t see them but examiner pointed out when I said I’d do vital signs: vitals were normal, pt stable.
    • Question: DDX (I was asked): mallory weiss tear, ruptured varices, gastric ulcer.


    2. Take history from woman with chronic progressive shortness of breath. At end have to explain to her something.

    • 60 or so pack year smoker, had quit 12 months ago?
    • Persistent cough 5 years: productive; small amts grey mucous.
    • Recent chest infection, productive yellow mucous, resolved with Abx
    • 5 years expertional dyspnoea (2 flights of stairs, from memory? but OK with regular walking)
    • No fever or infective symptoms, no weight loss, no loss of appetite, no chest pain
    • No meds, Had fluvax and pneumovax this year.
    Occupational Hx unremarkable, can’t recall if I asked social.

    • Given results of spirometer patient wants you to explain results to them. Pre and post bronchodilator

    3. Angry patient wants to go home without test. Pt was sent in to hospital by GP with INR of 12, had been given vitamin K, was refusing repeat INR and wanted to go home.Communicate well

    • Remember to introduce yourself as what it says on the instruction (junior doctor not medical student)
    • Patient said I want to talk to a senior
    • Patient was not aggressive or overly offensive, just annoyed and not listening well
    • My pt initially stated they had no idea why they were there or what INR was or what warfarin was for, but once I started to explain, cut me off to demonstrate that he did know what warfarin was for, and did have some recollection of having blood tests for his INR previously.
    • Pts main concerns were: 1) not understanding why he was in hospital and/or what needed to be done and why (seemed genuinely shocked to learn he needed to be there) 2) expressed frustration at waiting around for hours and no on telling him anything. 3) he had plans to look after his young grandkids that weekend so his son and daughter-in-law could take a long planned short holiday, and was supposed to pick them up that night: worried that if he stayed in hospital, their holiday would be ruined.
    • Question 1: what should you do or consider when communicating with an angry pt (you could have said stuff about eliciting pts views, expectations, beliefs and priorities, showing empathy, taking time to sit down and listen so pt felt they’d been heard, non verbal communication, reflective listening, remaining calm yourself etc. I sort of rambled all this stuff out in a non orderly way, and the examiner said “yeah, I agree” but not sure what bit he agreed with :).
    • Question 2: What if the patient does not calm down and escalates their aggression? (basically: ensure they are not in danger, and remember to keep yourself and others safe (ie, call security if needed) but otherwise excuse yourself and leave, try again later or ask someone else to try)

    4. Group and hold for an anaemic pt.

    • Consent
    • Witness
    • Sharps safety
    • Fill out the right form. Pick up the right patient stickers (stickers for the wrong pts were present, and I very nearly stuffed this, realising just in time)
    • Proper identification. Check against MRN and patient
    • Question: how many points of reference to you need for identification?
    • Witness for the collection (patient can witness)
    • Question: What are risks of wrong blood transfusion? Transfusion reaction (ie they could die)

    5. Cardiovascular exam

    • Standard. Was this the one that also said “you are also being assessed on your ability to communicate with the patient?)
    • Has a murmur. Quite audible but confused me (the attractive examiner distracted me…). My patient had a very loud murmur (characterise this). I could not palpate pts pulse and spent WAY too long trying, ran out of time and did not complete exam.
      QUESTION: CHARACTERISE THE MURMUR, and what could cause it. (all pts had murmurs, as far as I know, all pts has very loud, easily localised systolic murmurs).

    • Ran out of time to examiner asked what else would you do. Just listed everything I could think of.

    6. X-Ray interpret

    • A abdominal supine erect and chest erect
    • Has a weird ring object in pelvic region (an IUD? I didn’t see it, oops)
    • Dilated loops of bowel. ?Haustra (multiple fluid levels, nothing below obstruction)
    • Learn some system for abdominal as well as chest X-rays.
    • The examiner didn't want to know too much from the chest X-ray. Unfortunately this was the only one we had practised doing systematically. Lots of students focussed on CXR - examiner moved you on if you went on too long. Focused more on abdominal which was where the pathology was.
    • Q1. Pt (the examiner) is back with results. Tell them what results are, and what they should do now. (this pt needs to go to hospital now)
    • Q2. Call the admitting officer at the hospital, what do you say to them. (I had 30 seconds at this point, but ISBAR and 1 sentence Hx)

    7. Lower limb neuro, motor only (ie don't do sensation) (AGAIN - we had it in second year)

    • Some students got a question (upper vs lower lesion). I guess they don’t always interrupt you to ask a question if you aren’t finished the exam (quite a lot of us were doing babinski when the timer range, and did not get a question)
    • Don't do sensation
    • All pts had signs (mostly UMN, I think)

      COMMENTS &TIPS
      - We were not happy campers after this (it's ever so, isn't it?); with the exception of cardio exam, most of these stations were not things we'd focused our study on, and we were thrown by variation from previous structures. Most students found most stations hard to complete on time, and were flustered by multiple questions or tasks in the time frame.
      - I was not the only person in my session who couldn't palpate the pts pulse, and was utterly flumoxed by this. A wiser student would have said "the pulse is difficult to palpate" and moved on quickly. Moral: if you get stuck on something, MOVE ON QUICKLY.
      - Examinations on pt with signs (or simply frail aged volunteers) take WAY longer than exams on healthy medical student buddies (especially assessing gait, and also positioning pts comfortably). Bear this in mind when practicing.



     

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