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OSCE Masterclass Katherine Aiken & Hannah GardinerDisclaimer - We don’t know what is coming up - We don’t know all the answers - Our answers aren’t the ‘perfect’ answer Aim: To provide a transferable framework for approaching OSCE stations through several worked examples Types of skill assessed - History taking - Communication skills and counselling - Examination - Data interpretation - Prescribing - Emergency management Station 1 You are the FY1 on your care of the elderly rotation. Mavis Smyth is an 83 year old woman with Parkinson’s disease. Please review her chest X ray and answer the examiner’s questions.Mavis Smyth 123 456 7898 12/04/1938 28/11/2021 14:35 Before you start… This is a PA erect chest X ray of Mavis Smyth, HCN…. DOB…. taken on 28/11/2021 at 14:35. I would like to compare this to previous imaging if available. Technical quality: R I P E Before you start… This is a PA erect chest X ray of Mavis Smyth, HCN…. DOB…. taken on 28/11/2021 at 14:35. I would like to compare this to previous imaging if available. Technical quality: R rotation I inspiration P penetration E extent Systematic review A airway B breathing C cardiac D diaphragm E everything else Systematic review A airway Is the trachea deviated? B breathing Identify carina, look at hila, lung fields apex-base C cardiac Cardiac size, heart borders D diaphragm R higher than L, gastric bubble, costophrenic angles E everything else Systematic review E everything else Bones Breast shadows Extras – pacemakers, NG tube, lines NG tube placement: - Descends in midline to the diaphragm, bisecting the cadeviates to the left and the tip is clearly visible below the left hemidiaphragm, in an area corresponding to the stomach Summary To summarise, this is an erect chest X ray of Mavis Smyth which reveals no acute pathology but an NG tube is present and appears to be in the correct place. Examiners questions The nurse asks you if they can use the NG tube, what would you say? What other method exists to confirm NG tube placement? Can you explain to me how you would measure and insert an NG tube? Examiners questions The nurse asks you if they can use the NG tube, what would you say? → Yes, the NG tube is in the correct position and it is safe to use What other method exists to confirm NG tube placement? → pH of aspirate Can you explain to me how you would measure and insert an NG tube? → NEX measurement → Consent, contraindications, lubricate, coordinate with swallow, secure, confirm XR Station Top Tips 1. Who, what, when & where of the x ray 2. Technical quality 3. (The most obvious abnormality….) 4. Systematic review a. CXR:ABCDE b. AXR: ABDO X c. Joints/bones:ABCS 5. Summary Station 2 Mrs Brown is a 67 year old woman who has come to the respiratory clinic with shortness of breath. Student instructions: · Please take a history from Mrs Brown · Please interpret the investigations provided and answer the examiners questions.Approach Introduction, wash hands, consent Ask open question to begin Explore each symptom - Respiratory: cough, SOB, sputum, haemoptysis, chest pain, wheeze Enquire about systemic symptoms Drug & allergy history Past medical history Family history Social history including smoking, pets, occupationThe history... You are Mrs Brown, a 67 year old woman (06/05/1953) who was referred to the respiratory clinic by your GP and have had some investigations. You are worried about what might be wrong. You have been a bit short of breath for a long time, but it has been getting worse. Now you get short of breath walking up the stairs, or walking to the end of your driveway. You also have an annoyingdry cough but you have never smoked. No wheeze, sputum, coughing up blood or chest pain. No fevers, you tend to be tired. You’ve never been someone who puts on weight. PMHx – something with your joints, you think it is called ‘rheumatoid’. Drug history – you’re on a few different things, something for blood pressure, and to keep the joints under control – called methotrexate. No drug allergies Family history – nil Social history – only when directly asked about each thing– non smoker, small amounts of alcohol, retired (and only if asked what you used to do – teacher), only pet is a dog, no pigeonsInterpreting spirometry Check patient details Comment on results Identify patternInterpreting spirometry Check patient details Comment on results FEV1 and FVC both reduced, ratio normal Identify pattern Restrictive Examiner questions What imaging investigations would you like to request? Give a likely cause of this condition in this lady: Examiner questions What imaging investigations would you like to request? Give a likely cause of this condition in this lady What would the examination findings be on auscultation in pulmonary fibrosis? Examiner questions What imaging investigations would you like to request? CXR, high res CT chest Give a likely cause of this condition in this lady Rheumatoid arthritis Drug induced by methotrexate What would the examination findings be on auscultation in pulmonary fibrosis? Fine end inspiratory crepitations History taking stations top tips 1. Start with an open question 2. Think about the associated symptoms you need to cover 3. Remember to cover all the sub headings 4. If in doubt - systematic questioning Station 3 You are an FY2 doctor working in General Practice. Please counsel this 48 year old lady, Mrs Smith, about Hormone Replacement Therapy. Setting the scene Open the consultation Wash hands (+ don PPE) Introduce to patient – full name and role Confirm patient’s name and DOB Explain why you are here / ask why the patient is there if necessary What were you hoping we would discuss today? What way do your symptoms affect you? Ask specifically : Hot flushes, low energy, dry skin, low mood, decreased libido, oligo/amenorrhoea Clarify bleeding – any abnormal bleeding? When was last period? Eligibility: indications and contraindications Check for contraindications Before we talk further, can I just check if you have any other medical problems? Are you on any regular medication? Have you ever been told you have had A clot in leg or lung (DVT / PE) Stroke Liver disease Episodes of chest pain or told you have had a heart attack Breast or endometrial cancer? Do you still have your womb? Undiagnosed abnormal bleeding? (pregnancy!) Using ICE Ideas Have you heard of HRT? What do you know about it? Do you know why some people take it? Concerns Is there anything that would worry you about taking HRT? Expectations What do you think that HRT could do for you? Is it ok if I tell you a bit more about HRT? Is there anything specifically you want to know? Why should you take it/ how does it work? The menopause occurs when your ovaries stop producing eggs. As a result of the menopause, there are reduced levels of the hormones oestrogen and progesterone in your body. This can result in symptoms such as hot flushes, weakened bones and vaginal dryness. HRT works by replacing these female hormones with the aim of reducing the symptoms and health problems associated with menopause Short term benefits – relief of symptoms eg flushing, energy levels, mood lability Long term benefits - Reduced risk of thin bones and colorectal cancer - Risks / SE / important info •There are risks Increased “thickness" of blood, increased risk of clots Strokes and heart disease Breast cancer, endometrial cancer, ovarian cancer Risks are very small and some only last for the duration you are on the HRT •Some people also experience side effects: Breast tenderness, leg cramps, nausea, bloating If using cyclical HRT– bleeding •Important caveats: You still need to use contraception (barrier, POP, mirena) 1 year after last period if aged 50 2 years after if < 50 Practicalities and alternatives •How is it given? Tablet, patch, implant, gel – start with a tablet and see what works best for you Normally start with cyclical combined if <1 year since last period If >1 year can use continuous combined If no uterus can use oestrogen only Normally given for a few years then trial without to see if symptoms have improved •Alternatives HRT is the best treatment for the symptoms you are having Counselling stations top tips 1. Use the ‘ICE’ framework 2. Ask the patient what they want to know 3. Check you have answered their questions 4. Offer a leaflet 5. No medical jargonOSCE Top Tips 1. Take a deep breath 2. Read the blurb carefully 3. Remember your basics 4. Have a framework 5. Be nice to the patient - and listen! 6. Take a deep breathQuestions?