Short OSCE part 3

Short OSCE part 3

9.Patient,Para 3,known case of adenomyosis,will be undergone hysterectomy.Assess the patient risk factor for the operation and counsel the patient on hysterectomy.
-We are expected to do the pre-op assessment for the patient,look for any comorbids such as heart disease,DM,smoker etc.
-In our case,patient has low hb,signs and symptoms of anemia.Otherwise,she has no other co-morbids.
-For counselling,explain the indication,process that are going to be done-BEFORE,DURING and AFTER the operation,and complications,also the needs for alternatives if something goes wrong.
-Patient asked can the ovary be removed,in this case,the answer is YES.This is because the patient has completed family and to prevent further similiar problem to reoccur again.
-Patient asked will you give any pills for her.Yes,we need to give hormonal replacement therapy for her if necessary,and we will follow up the patient to monitor the side effects of HRT.

10. Patient is a known case of hemolytic anemia.Perform a focused abdominal examination and examiner will ask you a few questions.
-Diagnosis:Thalasemia
-Look for scars,subcutaneous injection mark of iron chelation therapy,pallor,jaundice and feel for hepatosplenomegaly (patient has all of them)
-Examiner will ask what is the diagnosis why do you say so.

Thats all! I personally feel that short OSCE is more challenging as you have to walk fast,think fast,talk fast.

One word of advise,which our lecturer always tell us,and its sometimes easier to be said than done but it is very true.


"If you did badly in one station,MOVE ON,dont drag it to the following stations,what it is done is done."

and It makes me think of this

Short OSCE Part 2

Now I'm going to continue from my previous post-Short OSCE

4. Patient came in with shoulder pain.Examine the shoulder
-Basically i think the examiner just want to see how do you perform the examination,put more attention on the special test. Exp: Frozen shoulder you will have global reduce range of movement,For rotator cuff injury,you will need to perform Lift off Test,Napoleon test,etc.For Impingement you need to perform Neer test,Hawkin Test and painful arch.For instability you need to do appehension and drawer test.Not to forget the Winging of Scapula!
-Management for frozen shoulder

5.Patient had a haematemesis and banding was done on him.Perform a general examination on this patient and do a ruuning commentary.Examiner will ask you a few questions after that,
-We are expected to look for stigmata of chronic liver disease,such as palmar erthema,dupunture contracture,pallor,perpura,echymosis,icterus on sclera,hepatic flap,fetor hepaticus,gynaecomastia,spider naevi,parotid gland enlargement,absent of axillary hair,so on and so forth.
-Basically it is a quite a easy station.I personally regretted for not remember all the findings,if not you will score in this station.But for my patient,he didnt really has jaundice but lecturer insisted that there was jaundice seen.
-Examiner will ask what is the diagnosis-oesophageal varices secondary to liver cirrhosis evidenced by (the findings that you have found)

6.Patient came in with hearing loss for the past 6 months.Take a focused history and examined the patient.
-Diagnosis-Chronic suppurative otitis media,tubo-tympanic type.
-We are expected to ask on any recent trauma,infections and risk factors that are causing chronic otitis media.
-We need to examine using the otoscope.Well,you need to start with inspection,palpation(tragus tenderness),and use the otoscope to comment the external auditory canal and tympanic membrane.
-Management of tubo-tympanic type of CSOM-it is a safe type,so just manage it conservatively.

7.Elderly patient who is a known case of hypertension,under hydrochlorothiazide, came in with a results.It showed hypokalaemia and low chloride with hyperuricaemia.Explain to the patient regarding the renal profile and cousel and take history if needed.
-Basically you need to change the medication from diuretics to CALCIUM CHANNEL BLOCKER-nifedipine.This is because patient does not has any other co-morbids except hypertension.
-Counsel the patient to come back for follow up and any complication that might arise from calcium channel blocker and diuretics.Ask for any signs and symptoms of gout.
-Patient ask does he needs to get allopurinol.The answer is NO,you just need to change the medication and follow up the patient first.

More to come...

Short OSCE

Now here comes the Short OSCE for our batch.We have 10 stations for it,5 minutes for each station (which is quite short and we have to rush!)

1.Patient just had a bowel surgery.Perform a focused abdominal examination and examiner will ask you a few questions.
-Basically this is a Stoma bag examination station.
-Patient has a end colosotomy
-We are expected to assess the stoma bag content,its complication (parastoma hearnia-ask patient to cough!)and the scars
-We are expected to look for scars in perineum
-Examiner will ask what surgery has been done-Should be abdomino perineal resection-Because it is a permanent end colostomy
-What the indication of it/causes to make a stoma bag

2.Patient has a valve replacement done.Examine the precodium of the patient.
-Patient has a prosthetic click heard (Very obvious) on first heard sound,therefore it should be Mitral valve replacement done
-What is the ideal INR for the patient?Since it is a prosthetic valve replacement,the range should be 2.5-3.5
-We are expected to perform all the maneuvers that can accentuate the murmuer (ask the patient to left lateral,hold breath,ask patient to lean forward

3.Patient has blurring of vision.Perform a confrontation test on this patient and examiner will ask you a few question
-Patient has homonymous hemianopia
-Remember to explain properly what you are going to do! (Test patient vision by moving pen in front of him first,then explain to him(fix the head,look at your eyes)).
-What other test you can do to confirm your diagnosis (Use the red tip pen to perform the same test again)
-Examiner ask you the diagnosis and where is the lesion (occipital lobe and optic radial nerve)

3 questions for now,will be continued..

The Long OSCE

Well,I have just passed my second part of my first professional exams.
Here are some question being asked:

Long Osce (1+14mins)
1. Patient came in with Left lower limb pain.Take a focus history and perform relevant examination. Examiner will ask you a few question
-Patient came in with intermittent claudication for 6 months.Diagnosis: Chronic Limb Ischaemia.
-We are expected to assess the risk factors,current status,differential diagnosis and complication of the patient.
-We were asked to perform ankle brachial pressure index and interpret the results.
-Management of the patient.

2.Patient came in with unstable gait.Examine the patient gait and perform relevant examination.
-Diagnosis:Parkinson Disease
-Patient has shuffling gait,stupor position,forward pulsion,festination and turned en block.
-Patient also has thalidomy scar and deep brain stimulator (as well as the scars)
-We are expected to look for other signs of parkinsonism,e.g micrographia,glabella tap,barbinski,cerebellar signs  (to rule out parkinson plus syndrome) and others
-We are expected to assess the functional status of the patient,e.g buttoning,open the door etc
-Management of Parkinson disease.Remember to start with dopamine agonist and its examples.

3. Patient came in with multiple swollen joint pain.Take a focused history and perform relevant examination and patient will ask you a few questions
-Diagnosis: Gouty arthritis
-We are expected to ask for presenting complain,risk factor,firrential diagnosis,current status and complications of gouty arthiritis
-Perform GALS screening and look for tophi.(Quite obvious in our case)
-Assess the functional status,e.g buttoning,use the key etc
-Counsel the patient on what is gouty arthritis,is it curable,how to start the medicaiton and their side effect.Remember start with NSAID's first,if failed proceed to colcicine.Allopurinol only can be initiated after 4 weeks of acute attack and patient has more than 2 attacks in a year.

4.Patient,Para 1,just given birth 4 weeks ago, came in complained of 4 weeks of lethargic and loss of appetite.Take a focused history and assess the risk factor of the patient.Examiner will ask you a few questions.
-Diagnosis:Post-partum depression
-Assess the risk factor,differential diagnosis,and criteria of post-partum depression.Patient has poor support,previous history of depression
-Advise the patient on contraception.-Well,you are not suppose to prescribe OCP to them as it will cause further depression on these patients.

5.Patient is a 32 weeks primigravida lady with uterine contraction.Take a focused history and perform abdominal examination.Examiner will ask you a few questions.
-Diagnosis:False labour
-History:to rule out other causes of preterm labor.
-Abdominal examination:The usual obstetrics antenatal examination,SFH,leopolds maneuver.
-If it is preterm contraction,management for it.Give tocolytic,MgSO4 and dexamethasone.Call for NICU team.
-Investigation: Look for PPROM-pooling of fluid over posterior fornix,GBS swab.

6.Patient is a 10 years old child presented with fever and joint pain for 4 days.Take a focused history from mother.
-Diagnosis:Rheumatic fever
-History: Asked about the presenting complain and mother will tell you it is a migratory polyarthritis.Further history will reveal that has sore throat3 weeks prior to that and they live in a crowded house with low social economic status.Ask relevant questions to rule out other differentials,such as septic arthritis,kawasaki,dengue,JIA,HSP.
-Examiner will ask about jones criteria and how to diagnose rheumatic fever based on the criterias given.

That's all for long OSCE now. I will write on short OSCE's and others if I'm free.Overall,the long OSCE was quite easy to score if you have a clear set of mind to think within that 15mins.You will have more than enough time to ask questions and do PE.Our batch has more physical examinations and history stations compared to previous groups,most probably all of the counselling questions were asked in MEQ.

Something to ponder upon

Sometimes I just wonder,why is the medical school recruit so many medical students in a batch,when they know that it is better to teach them in a smaller group.

I believe that when you teach in a smaller group,the lecturer will pay more attention to each and every student's daily learning progression,and can rectify their mistakes if there is any mistakes were made.Also,Students will tend to be more proactive in the discussion session,at least for me.They will also have more hands on experience when learning in the ward. With that,more quality doctors can be produced in the country. I remember there is one saying by William Osler, "you have to use all of your 5 senses to treat a patient'.I couldn't agree more than that,but how on earth can we learn when there are so many 'space occupying lesions' in the ward trying to examine on one Poor patient or following the ward round where the specialist is so far away that you need to learn lips movement language in order to know what is happening?

Unfortunately,it is happening in the medical schools these days,at least in my batch.There are 97 of us,and sometimes we can have 15 person in one case presentation and discussion session.This means that there are 15 people will try to examine on a poor patient in order to learn to identify the clinical findings.Seriously,this is not only affecting the learning process,but also the patient himself will get disturbed with all these.Imagine you are the one who being palpated for 10 times by 10 different people,or there are 7 stethoscopes being put on your chest at a same time.Sound ridiculous isn't it?

I have seen one Young female patient,diagnosed to have stroke secondary to valvular heart disease,was shivering in cold but yet still need to let bunch of the medical student to be examined on her chest one by one,and yet she cannot voice out as she has global aphasia.

Every time I have his kind of situation,I feel upset and I choose to walk away even though the patient exhibits very good clinical signs to learn from.(Of course I will come back to examine the patient later on if it's really a good sign :P).

Is this kind of scenario happening
In your clinical setting as well?