FM OSCE

25m - 1.5H

OSCE

Table of Contents

• Examination
  • What is expected from candidate in diabetic foot examination?
    • Summary:
  • What is expected from candidate in knee examination?
    • Summary:
  • What is expected from the candidate in contraception case?
  • What is expected from the candidate in ANC case?
  • What is expected from the candidate in DM case?
    • Summary
  • What is expected from the candidate in hypertension case?
    • Health education
  • What is expected from the candidate in a case of arthritis?
    • Investigation:
    • Management:
  • What is expected from the candidate in dyslipidemia case?
  • What is expected from the candidate in a case of abdominal pain (IBS)?
    • Explain the non-pharmacological treatment, give him a diary, tell him that’s no serious and the symptoms could decrease with age.
  • What is expected from the candidate in a case of headache?
    • Treatment
• Education
  • What is expected from candidate in education of patient about inhaler use?
  • What is expected from candidate in education about peak flow meter?

OSCE

Lina Serhan

Diabetic foot Exam

Examination

What is expected from candidate in diabetic foot examination?

• Establishes rapport properly and uses appropriate communication skills.
• Takes permission to conduct foot examination.
• Properly explains to the patient and informs him about the steps and responses expected from him.
• Hand wash (alcohol rub) before and after foot examination.
• Inspects foot for dermatological and musculoskeletal problems.
• Asks the patient to walk and examines shoes.
• Palpates both feet for temperature, callosities (if present), edema of lower limb.
• Assesses peripheral arteries of both feet (dorsalis pedis, if not felt, posterior tibial and popliteal).
• Tests movement of joints (test of proprioception).
• Assesses pressure sensation of both feet by 10 g monofilament.
• Assesses pain sensation of both feet by pinprick sensation tests.
• Assesses vibration sensation of both feet by 128-HZ tuning fork testing.
• Performs ankle jerk reflex testing.
• Shares patient/assessor outcome of examination.
• Thanks the patient and asks if he has any questions and informs him about date of next follow-up visit.

Summary:

1. Today I examine an age - name - age.
   • There’s no any abnormality and we had a normal gait…
2. I will complete my exam by vascular/neurological examination - Advise on foot care - blood glucose…
3. And if there’s any pathology suspected I would like to ask for more investigations…

Knee Exam

What is expected from candidate in knee examination?

• Candidate demonstrates fluency in using communication skills.
• Candidate takes permission to perform examination, explains procedure and inquire about any background on it and asks patient to undress from the waist downwards.
• Candidate washes hands/uses Alcohol rub before and after knee examination.
• Candidate inspects patient’s gait and knee position.
• Candidate inspects knees with patient in supine position and measures quadriceps circumference.
• Candidate asks if patient is in any pain, assesses skin temperature, palpates joint line and surrounding structures.
• Candidate carries out patellar tap test for large effusions.
• Candidate examines active and passive flexion and extension.
• Candidate assesses collateral ligament tears.
• Candidate assesses cruciate ligament tears (Anterior & posterior drawer tests).
• Candidate examines popliteal fossa.
• Candidate performs knee reflex test.
• Candidate shares patient/assessor outcome of examination.
• Candidate thanks the patient and asks if he has any questions.

Summary:

Today I examine an age… name… PT there’s no abnormalities and he had a normal gait…
I will complete my exam by vascular examination, and if there’s any… probably suspected I would like to ask for more investigations.

History

Brief guidelines for all cases:

• Hello I’m Lina Serhan medical student can I ask you some questions?
• Personal history: I want to check your Name, age, job, married?
• Chief complaint: What brings you today? When, associated symptoms, aggravating factors..
• If he came for follow up: So you came for follow up of your — right? Ask him about medication if he takes it regularly and if he noticed any SE. and if it’s controlled or not

1. Risk factors: diet, smoking, physical activity, depression (low mood, anhedonia). If female, ask about menstrual cycle and if she takes any contraceptives.
2. Complication/ 3-exclude red flags 4-secondary causes: الأسئلة التي تخص كل مرض
3. Past medical history: chronic conditions, surgery, use and drugs Family history: any of your family has similar symptoms?
4. ICE: Any concerns?
5. *Ask him if he did any investigations before to select what are going to do more.
6. SUMMARY: Anything you want to add?
7. Any idea about what you have? Give the diagnosis: Explain the disease, in what way can I help you?
8. -10 questions?

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What is expected from the candidate in contraception case?

• Candidate establishes rapport and introduces himself to the client.
• Candidate uses effective communication skills.
• Candidate assesses the current situation of the client (regarding postnatal, breastfeeding, last intercourse).
• Candidate assesses current and previous medical history (chronic disease, conditions, cancers, STDs).
• Candidate enquires about previous contraceptive and menstrual history.
• Candidate assesses past gynecological history.
• Candidate offers all suitable contraceptives for the client showing pros and cons.
• Candidate helps the client to choose and encourages the patient to take her own decision.
• Candidate responds to client concerns and illustrates usage of the chosen contraception.
• Candidate asks the client to return for follow-up.

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What is expected from the candidate in ANC case?

• Candidate establishes rapport with the patient.

• Candidate assesses personal and social histories:

  • age (both couple)
  • address
  • occupation (both couple)
  • duration of marriage
  • consanguinity
  • special habits

• Candidate assesses menstrual history:

  • asks about first day of last menstrual period (LMP) and calculate the expected date of delivery (EDD) and inform the pregnant.

• Candidate assesses current obstetric history:

  • symptoms of pregnancy (low back pain, heartburn)
  • enquires about dangerous signs (hypertension, severe persistent headache, vomiting, loss of feeling fetal movement, escape of liquid amniotic, vaginal bleeding, and swelling of face and extremities)

• Candidate assesses current medications, supplementations, and investigations:

  • (lab tests & ultrasound (US))

• Candidate assesses past obstetric history:

  • Pregnancy (history of gestational diabetes, labor (date and mode of delivery), and puerperium of previous pregnancy, history of previous abortion, birth weight (approximately), mode of infant feeding and family planning methods used, if any.)

• Candidate assesses the emotional and psychological situation of the patient:

  • (elicits concerns and expectations of the client)

• Candidate assesses the past medical, surgical, and other histories:

  • e.g. diseases e.g. diabetes mellitus (DM), hypertension (HTN), chest diseases, tuberculosis (TB), heart diseases, epilepsy, urinary tract infections (UTIs) or renal diseases, viral infection (Rubella), and sexually transmitted diseases (STD).
  • obstetric and gynecological operations, and other surgical operations e.g. hernia, tonsillectomy etc.
  • use of drugs, sensitivities and allergies, previous blood transfusion, X-ray exposure, and Rh incompatibility.

• Candidate assesses family history:

  • DM, HTN, multiple pregnancy, and congenital anomalies.

• Candidate asks about tetanus vaccination history:

  • (doses)

• Candidate performs what is required in the station.

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What is expected from the candidate in DM case?

• Establishes rapport properly and uses communication skills appropriately.
• Enquires about eating pattern, physical activity, smoking, and psychological stress (assesses risk factors).
• Enquires about medication compliance, intolerance, or side effects.
• Enquires about glucose monitoring.
• Assesses hypoglycemic episodes: timing, awareness, frequency, and causes.
• Enquires about target organ damage: severe headache, blurring of vision, chest pain, palpitations, history of stroke, anuria, cold extremities, intermittent claudication, pain-free walking distance, pain at rest, peripheral revascularization.
• Assesses past history of hypertension, CVD, stroke, renal disease, hospitalization, surgery, and history of drug allergy.
• Elicits the ICE of the patient and effect on daily life.
• Orders laboratory investigations: HbA1c, lipid profile, liver enzymes, albumin/creatinine ratio, GFR, and fundus examination if not ordered previously.
• Responds appropriately to candidate directions.
• Closure of the session, time management, and follow-up.

Summary

• Check understanding.
• Health education:
  • Do you have any idea about what you want? Explain the disease then give advice.
  • Try to lose some weight, stop smoking.
  • Follow DAAD site.
  • If he has very high BMI > 35, give him metformin & GLP.
  • Kidney disease SGLT.

10. Any questions?

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What is expected from the candidate in hypertension case?

• Candidate establishes rapport properly and uses communication skills appropriately.
• Candidate enquires about previous 3 readings of blood pressure measurement (if included in the station).
• Candidate enquires about risk factors of HTN (age, smoking, physical inactivity, special habits, stress).
• Candidate enquires about complications of HTN (polyuria, polydipsia, hematuria, leg pain during walking, edema, vomiting, blurring vision, syncope, sensory or motor deficit, chest pain or shortness of breath, palpitation).
• Candidate enquires about history of (sleep problem, thyroid disease, renal disease, endocrinal disorders) suggesting secondary hypertension.
• Candidate enquires about past history of similar complaint and chronic illnesses.
• Candidate enquires about medication history and family history of premature death.
• Candidate elicits idea, concern, and expectation of patient.
• Candidate asks for Bl/p measurement and general examination.
• Candidate shares the diagnosis with the patient and explains the nature of the problem.
• Candidate asks the patient if he/she has any questions and informs the patient about the next follow-up session.
• Candidate orders the needed investigation for the patient (HB, FBS, HbA1C, Lipid profile, S potassium, S sodium, S uric acid, GFR, Liver function test, and urine analysis, ECG) if ordered in the station.

Health education

Do you have any idea about what you have? Tell the patient that it’s a common disease and silent killer so you have to take your drugs even if you don’t feel anything, advise him to decrease salt and do exercise and lose weight.

Any Questions?

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What is expected from the candidate in a case of arthritis?

• Candidate establishes rapport and doctor-patient relationship and uses communication skills fluently with the patient.
• Candidate assesses patient complaint (onset, course, duration, aggravating and relieving factors).
• Candidate asks about previous trauma or surgical intervention.
• Candidate enquires about involvement of other joints and signs of inflammation.

1. Candidate enquires about systemic symptoms (skin, chest, abdominal, urinary symptoms).
2. Candidate asks about history of chronic diseases or drug use.
3. Candidate enquires about past medical and surgical history.
4. Candidate assesses psychosocial history ICE and effect of his condition.
5. Candidate interprets examination form properly.
6. Candidate responds well to candidate instructions.

Investigation:

• XR → OA
• Synovial Fluid → 5000-50000 → Gout
• Autoimmune: RF, anti-CCP, FBE, CRP → RA
• ANA → negative → SLE

Management:

• Gout:
  • Acute (Colchicine & Corticosteroids)
  • Chronic (Allopurinol)
• SLE/RA:
  • Acute (Steroids)
  • Chronic (Methotrexate, Hydroxychloroquine)
• OA → start by disc. weight + John Killer
• Septic arthritis → Aspiration, Gram stain, IV antibiotics, and Ciprofloxacin

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What is expected from the candidate in dyslipidemia case?

• Candidate establishes rapport and doctor-patient relationship and uses communication skills fluently with the patient.
• Candidate asks about atherosclerotic cardiovascular disease (ASCVD), e.g.,
  • acute coronary syndrome (ACS)
  • stable or unstable angina
  • coronary or other arterial revascularization
  • stroke
  • transient ischemic attack (TIA)
  • peripheral arterial disease (PAD).
• Candidate asks about the major risk factors for atherosclerotic cardiovascular diseases (ASCVD) as smoking, hypertension, DM, sedentary life, and family history of early CHD in first-degree relatives if male less than 55 years & if female less than 65 years.
• Candidate asks about any secondary causes for dyslipidemia as hypothyroidism, DM, chronic kidney or liver diseases.
• Candidate assesses drug history e.g., chronic drug use and drug allergy.
• Candidate explains and discusses the results of investigations with the patient.
• Candidate assesses psychosocial history ICE and effect of his condition and screening for depression.
• Candidate provides to the patient the suitable health education for his condition (lifestyle modification) including healthy diet, weight management, physical activity.
• Candidate prescribes the suitable drugs for the patient; Atorvastatin 40 -80 mg or Rosuvastatin 20-40 mg once / day after dinner.
• Candidate informs the patient about the date of follow-up (after 1 month).

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What is expected from the candidate in a case of abdominal pain (IBS)?

• Builds rapport and uses appropriate communication skills.
• Enquires about IBS symptoms (altered bowel habit, abdominal pain and distension and analysis of these IBS symptoms (onset, course, radiation of pain, relieving and aggravating factors)).
• Enquires about additional symptoms consistent with IBS (clear or white mucorrhea of a noninflammatory etiology dyspepsia, heartburn, nausea, vomiting, sexual dysfunction (including dyspareunia and poor libido), urinary frequency and urgency, worsening of symptoms in the perimenstrual period and stressor-related symptoms).
• Excludes red flags (iron deficiency anemia, rectal bleeding, weight loss, or abdominal masses, family history of certain organic GI illnesses (inflammatory bowel disease, celiac sprue, colorectal cancer)).
• Enquires about recurrent fever, chronic severe diarrhea or painless diarrhea, steatorrhea, gluten intolerance, travel to areas with parasitic infestation.
• Assesses past history and enquires about family history of IBS.
• Elicits ICE and effect on function.
• Shares the diagnosis with the patient and responds to patient concerns.
• Checks patient’s understanding regarding the diagnosis.
• Emphasizes follow-up.

Explain the non-pharmacological treatment, give him a diary, tell him that’s no serious and the symptoms could decrease with age.

• Ttt:
  • Pain + constipation: Mebeverine 125mg/twice daily 20min before meal.
  • Diarrhea: Loperamide.

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What is expected from the candidate in a case of headache?

• Candidate properly builds rapport and uses communication skills.
• Candidate asks relevant questions to recognize nature and quality of pain, site, spread of pain, frequency, duration, and severity of headaches.
• Candidate enquires about any associated symptoms.
• Candidate asks for the predisposing and triggers factors.
• Candidate enquires about red flags for headaches.
• Candidate excludes secondary causes of headaches.
• Candidate assesses family history and past history and medical treatment for previous headaches.
• Candidate elicits idea, concern, expectation of patient effect of headache on her activity (function) and state of health between attacks.
• Candidate explains the nature of the problem and appropriately responds to patient concerns.
• Candidate reassures and informs the patient about the next follow-up session.

Treatment

Tension

• Acute: OTC (aspirin- ibuprofen)
• Prophylactic: Antidepressant (amitriptyline)

Migraine

• Acute (sumatriptan) - make sure it’s not contraindicated ex CAD of ASCAVD risk - if contraindicated use paracetamol
• Prophylactic: propranolol

Cluster

• Acute: sumatriptan- oxygen inhalation
• Prophylactic: Verapamil - corticosteroids - lithium - methysergide

Advices: Have a good sleep - drink water don’t forget to give him a diary.

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Education

What is expected from candidate in education of patient about inhaler use?

• Establishes rapport properly and uses communication skills appropriately.
• Checks her/his understanding of the inhaler and explains to him that an inhaler device delivers aerosolized bronchodilator medication for inhalation.
• Demonstrates standing up straight.
• Demonstrates shaking the inhaler.
• Demonstrates removing the cap from the mouthpiece.
• Demonstrates holding the inhaler between index finger and thumb.
• Demonstrates placing inhaler upright about 3-5 cm in front of mouth.
• Demonstrates breathing out completely.
• Demonstrates putting the mouthpiece in your mouth, breathe in deeply /activate inhaler simultaneously.
• Demonstrates closing her/his mouth and holding her/his breath for 10 seconds and then breathe out.
• Demonstrates repeating the procedure after 1 minute if relief is insufficient.
• Demonstrates checking the patient understands by asking her/him to carry out the procedure in front of the candidate.
• Asks if she has any questions.
• Informs her of the date of the next visit.
  • Follow up after 2 weeks.

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What is expected from candidate in education about peak flow meter?

• Wash hands, introduce yourself and establish rapport.
• Elicit patient’s understanding of asthma and peak flow measurement.
• Explain in clear and simple terms what the peak flow is measuring.
• Ensure that the patient is standing for the test or sitting upright.
• Take the peak flow device and reset the pointer to zero and place a fresh mouthpiece into the peak flow meter.
• Advise the patient to inhale fully filling their lungs with air.
• Hold the meter correctly with fingers not interfering with the pointer and make a tight seal around the mouthpiece.
• Demonstrate to the patient how to blow as hard and as fast as possible through the peak flow meter in a single blow.
• Instruct the patient to perform on waking, during the day, and before sleep and to repeat the test three times taking the highest reading.
• Check whether the patient understood the process and ask him to demonstrate.
• Compare value with reference chart taking into account the age, sex, and height of the patient.
• Mention the need for follow-up to review symptoms.

After 2 weeks:

• Normal range 400 - 700 l/m.
• If he was less than 80 → Asthmatic.