aye. yeh, it's probably the 'formative' factor. anatomy test, here we go
Yeah despite that, not all the clinical teaching staff have the same view on some of the components. I think the curriculum committee is discussing some of the osce, cEx, etc issues this thursday.I think it was a pretty well done OSCE. This is the benefit of OSCEs and mulitiple-mini interviews, you get a much more well-rounded assessment.
Year 2 OSCE (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
E: Movements involving the lower back
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.
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
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.
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.
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.
Station 2: Didn't have a real patient here.Year 1 Formative OSCE:
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.
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.'
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.
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.
Actually I asked that, alongside "Do you have any other medical conditions?" and the answer was still no. I wonder if my volunteer made a mistake. I only found out about hypertensives from other people.Same with station 3. I asked about medications too, but I did not ask what medications she may be taking for any other conditions, which is I think what the money question was.