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UWS OSCEs

Matt

Emeritus Staff
Emeritus Staff
[h1]UWS OSCEs[/h1][h3]Year 1[/h3]

[h4]2007[/h4]

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
[h4]2008[/h4]

  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
[h4]2009[/h4]

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

[h3]Year 2[/h3]
[h4]2008[/h4]

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
[h4]2009[/h4]

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?)

[h4]2010[/h4]
(Summative, 10%):

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: we're required to distinguish between: vasovagal, cardiogenic, and epilepsy.

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. Venupuncture for FBC.

Remember to look at the actor and to keep talking to the actor.

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.



[h3]Year 3[/h3]
[h4]2009[/h4]
  1. Year 3 Summative OSCE - 30% of final year's grade
  2. 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
  3. A 57 year old women is concerned her mother is becoming increasingly forgetful. Take a history
    • Develop 3 DDx
  4. 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
  5. Perform an examination of a patient's cranial nerves
  6. Take a history from a lady presenting with recent weight gain, cold intolerance and fatigue
    • Develop 3 DDx
  7. 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
  8. 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.
  9. Take a history from a patient presenting with right flank pain
    • Develop 3 DDx
[h3]Year 4[/h3][h4]Paediatric OSCE[/h4]Year 4, Summative (60% of term)

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).

[h4]Obstetrics and Gynaecology Viva Voce Exam[/h4] Year 4 (teaching session II)

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.

[h4]Mental Health OSCE[/h4]
Year 4, Teaching Session 3

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.
 
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