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We have offerings here on the content for the Year 6 OSCEs in 2003 and 2004. Many thanks to Chan Cheah for his notes from 2003. Examination
Format The 6th Year OSCE consists of 8 double
stations (16 in total). There is one
examiner at each point. A whistle is
blown half way through at 7 minutes, then again at 14 minutes, and then there is
a one minute change over between stations. There
are generally no rest stations. Generally
the exam is set up as the first part being history or examination, and
interpretation of investigations, management or procedures as the 2nd
half. OSCE 2004 Surgery 1. 32 year old lady with a 5 week history of diarrhoea. a) Take a history from the patient Patient
gave a history of blood and mucous in the stools.
4 weeks previous had been in b) What are the 3 most likely differentials Wanted Ulcerative Colitis/Crohns, pseudomembranous colitis, infection (Giardia) c) What tests would you do? Wanted standard stuff like FBC, U+E, Faecal specimen for MCS and O+P, rigid sigmoidoscopy Second part of the station was talking about the management of Ulcerative Colitis. Patient has been given the diagnosis, and has had medical treatment but has been refractory to this (20+ motions/day) and the disease spreads to the ileo-caecal valve. d) What management would you offer? Needed to talk about total colectomy and what you would do with this. Most people knew that an end ileostomy and bag was an option. They also prompted for ileal J-pouch and anastomosis to the anus. Patient asked you to draw a diagram e) Patient also wanted to know about whether or not she could have children. This was felt to be a very tough station. It was really specialist team territory in the 2nd half, and unless you’d been on a colorectal team in medical school you would have been hard pressed to come up with the answer. 2. Mr Dead pig is pinned in the middle of the table You are the intern assisting the surgical registrar on an elective inguinal hernia repair. You’re registrar descrubs and leaves you to close the 6 cm incision a) Suture the wound closed The pig skin was incredibly thick and tough. There were 3 types of 3-0 thickness suture. You had to pick the appropriate type of suture material for the closure you wanted to do. Apparently it didn’t matter whether you used interrupted sutures of subcuticular sutures. The station was excellent for those who had the chance to practice during the year. While you were suturing you were asked questions about types of needle (tapered or cutting), types of suture (absorbable/non absorbable, mono- and poly-filament) etc. Was a pretty pleasant station. Medicine 1. Renal failure This station was very similar to a previous written question 60sish woman who came in with vomiting, oliguria and dehydration. Take a history from the consultant and talk about examination findings (you had the chart of vital signs). What things are you looking for during the examination? What do you think of the medication chart (patient was on enalapril, naproxen and another nephrotoxic drug that escapes my mind). How would you manage her? What investigations do you need to order? Part Two of this station Patient remains oliguric despite appropriate medical management. You are called to review her for increasing confusion and dyspnoea. On examination she is tachypnoeic, with a grossly elevated JVP, bibasal crackles and oedema. a) What is happening now? Talk about the patient being in congestive cardiac failure and ongoing renal failure b) What are you going to do? Need to think about the complications of renal failure (fluid overload, hyperkalaemia, acidosis). So talk about examination and looking at the notes etc. Take bloods (FBC, UEC, blood gases). Catheterise (exclude postrenal obstruction). Do an ECG (K+ is 7.6), describe ECG. What now? Medical emergency, call reg responsible for patient, call HDU/ICU, needs haemofiltration The crux of this station was recognising a sick patient and knowing what to about it. 2.
Neurology a. Lower limb examination. All students got patients with good going cerebellar signs. Same as the 4th year examination type patients, just less time to do it in. b. Biochemical investigations Students were given 4 sets of investigations. Was usually describe the first investigation, give the diagnosis or differential, say what test you would do next and interpret that. The two I remember getting were SIADH in an elderly would, and multiple myeloma in a 50ish male. Emergency Along with the first surgery station, this was panned as being the worst station on the examination. My apologies, as I can’t remember much of it. It was my first station and it was a train wreck for me. Section 1. Oldish fellow with chest pain. How do you manage him on arrival at the ED? Demonstrate putting in an IV line. This was crap, not enough time to do both in 7 minutes. By the afternoon the exam had changed to talking the examiner through all the preparations you would do, then just putting the cannula straight in. Section 2. He has an arrest on the ward. Talk about management Describe the ECG (AF- hard to read as the reproduction wasn’t great- got prompted in the end) There were CXRs that I didn’t get to in this station. Psychiatry Woman in her late 20s who presents to ED. You are shown a video of the “patient” being interviewed by the registrar, keeping in mind that you have to talk about differential diagnoses, immediate management and long term problems. Rural GP Part one: Look at the photo (young child with ecchymoses over legs and buttocks), give the diagnosis (HSP), take a history and talk about management with the mother. Part two: Xray and slings. Describe the XR (left humerus, transverse diaphysial fracture). Demonstrate the appropriate sling (collar and cuff), tell the patient about any problems they may have with the sling. WACH Another video station. 8 month old baby who was unwell with bronchiolitis (45 second video), lots of barn door signs for respiratory distress. The trick I used was to watch the video once, then play it back describing as I went. Take a history from the mother:
Second part was talking with the mother about follow up in the future. Unfortunately my memory is not as good as Chan’s was for 2003. I really hated this exam as I started on Emergency (which was a really unpleasant place to start). Most people were a bit anxious afterwards but not too bad. That being said I have passed comfortably, so it wasn’t as bad as I though. Good luck for your last exam as an undergraduate! Tim Clay 14th November 2004
OSCE
2003 Surgery 1. Mrs. Jones, a 65yo woman, has been diagnosed with extensive DCIS in her left breast. Her surgeon has recommended a simple mastectomy for her and you are the intern clerking her in for admission. a. please obtain informed consent for a simple mastectomy. b. Mrs. Jones then tells you she has been asked to go in a clinical trial for prophylactic IV antibiotics to reduce the risk of wound infection (which is approximately 10% for breast surgery). It is a placebo controlled randomized control trial, but she says that she wants the real treatment, not the placebo. You’re supposed to explain the point of having placebo controls, randomization and levels of evidence or something. We thought this was pretty stupid. 2. Mr. Green a 65yo previous fit and healthy man presents to ED with a 6 hour history of left loin pain radiating to the LIF. HR 110 BP 130/80 RR 18 T37.3 a. what are your differential diagnoses? i. they prompted for renal colic, pyelonephritis, testicular torsion and shingles. I also said diverticular disease, incarcerated hernia. b. what would you do immediately for this man? c. what investigations would you order and why? i. the FBC shows a WCC of 13.8, U+E are normal. U/A shows +++ blood. ii. describe the KUB you ordered (stone in left ureter and phleboliths in bladder – don’t call them stones too) iii. what investigation would you do next? d. describe this IVP (stone in left ureter causing proximal dilatation, hydronephrosis) e. who do you call about this patient? (examiner then pretends to be urology reg and you have to present the findings so far) Medicine 1.
Cardiovascular exam a. My apparently patient had MR, AS and TR. How we were supposed to pick 3 different systolic murmurs I’m not sure. Look at the marking guide under Clinical Skills 602 on Flying Fish to see what you should do to get marks. b. ECGs i. slap in the face obvious anterior STEMI, describe management (in about 30sec) ii. broad complex tachycardia in a 60yo man with a PMH of IHD who has collapsed and is BIBA. obviously VT until proven otherwise, describe management, again in 10 secs. 2.
Respiratory exam a.
my patient has a wheeze and a mucky cough and
crackles but no clubbing. I said he had b. CXRs i. history: 35yo man with acute onset SOB and pleuritic chest pain. obviously pneumothorax, but they’ll give you an inspiratory film. try to find it (mine was small and in the apices) but if you can’t ask for an end expiratory film. Then briefly talk about management – say needle thoracostomy and chest tube for full marks. ii. most florid case of left heart failure I’ve ever seen. huge heart, bat’s wings, small pleural effusions, the works. I even said there were Kerley’s B lines which I immediately regretted but it’s hard for the examiner to argue with you over a little squiggle when you know what the diagnosis is. Talk about management. Emergency 65yo electrician at the hospital falls off a ladder into some power plant and suffers high voltage electrical burns, his clothes catch on fire and he requires CPR from workmates at the scene of the accident. You are the intern in ED who receives the phone call notifying you of his imminent arrival. a. what preparations do you make for his arrival? He is unconscious on arrival, and EAR is being performed as he is rushed in. b. describe your immediate assessment of this patient. c. demonstrate what you would do next. i. put in a Guedel, and commence bag and mask ventilation ii. what would you do if you were struggling to ventilate with a bag and mask? (1) get someone to help you (two hands to seal mask) (2) make sure the mask fits (3) intubate iii. (if you mention cricothyroidotomy) what are the indications for this? He airway is intact and you have him on high flow oxygen, but his BP is crashing (80/50). d. What do you do now? i. volume resuscitation, eg 2L Hartmann’s via 2 14G cannulae His BP starts to stabilise. e. What further assessment would you make now? What investigations would you order? i. if you asked for an ECG or a CXR you will be shown them. (moral of the story: always ask for an ECG or CXR, you can usually justify it and it’s unlikely you’ll lose marks for asking) ii. interpret the ECG and CXR in light of this patients clinical history (1) ECG showed inferior ST depression and RBBB but not much else à maybe suggesting some myocardial damage due to the electrical current? (2) I ran out of time with the CXR but from the glance I got I couldn’t really see much wrong with it. There may have been more to this station but I didn’t get any farther. Psychiatry Mr. Black, 50yo man who underwent CABG surgery after a heart attack. That was 6 months ago, and his Cardiologist is happy with progress but patient isn’t so sure. He has continued to experience intermittent chest pain. He previously ran his own business with great enthusiasm but has been disinterested since his surgery. His wife is worried that he isn’t a sharp as he used to be and “hasn’t been himself since the operation.”
It was obviously most likely to be depression, but my examiner didn’t say, “assuming it is depression, what is the management?” So it’s probably worth checking before you launch into your explanation what exactly the diagnosis is. Rural GP You are a country GP and you come across the scene of a accident. First station is triage (so pay attention when you go on the farm visit after lunch when you do the OSCEs, because one of them is guaranteed to come up). You have a fairly comprehensive medical kit in your car. (Bag + mask, ETT + laryngoscope/other airway stuff and IV fluids even) Person A is one of the drivers. 23yo male, not wearing seat belt and thrown out of car onto bitumen. GCS 8, severe facial injuries, suspected broken arm. HR 80 BP 120/80 Person B 25yo female passenger is screaming, complaining of chest and abdo pain. On examination you find pelvic crepitus. HR 120 BP 90/60 Person C, 45yo man retrieved from under car. Responding poorly to your questions, breath sounds decreased on the left and c/o abdo pain. HR 100 BP 120/80 RR 24. Person D is a 26yo woman hysterical and suffering abrasions to right arm and contusions from seat belt over abdomen. She is in active labour.
Part two:
slings. Perform a collar and cuff and a WACH You have treated David for asthma since he was 4 years old. He is now 15 and here to see you with his mother because his asthma has been getting worse recently. He has had 3 admissions to PMH with moderately severe asthma in the last year. You suspect that he may have been smoking with his friends and that this may be contributing. Please explore the reasons why his asthma may have gotten worse recently.
 like most people, the examiner
kept interrupting and trying to get me back onto whatever track it was they
wanted | it turned out you had to kick mum
out before the kid would say anything | they seemed to want you to talk
about adolescent issues too, peer pressure and dealing with chronic illness
in adolescence etc | then I was prompted to write an
action plan for him. I stupidly didn’t realise that it was sitting in
front of me til the very end. He
didn’t know what a peak flow meter was so I don’t know how we were
supposed to do a management plan without one. | most of us found it to be a
pretty annoying and unclear station and left with a bad taste in our mouths.
obviously they wanted some very specific things from us and i think the
question was far too ambiguous. | That’s pretty much all I can remember. Some of the details may be a little bit off but the general picture of each station is pretty much right. Disclaimer: believe my answers at your own risk, but I think most of it isn’t too far off the mark. Haven’t got my results at the time of typing though so who knows? The questions are correct to the best of my knowledge, anyway. My miscellaneous advice would be:
Good luck. Chan Cheah, 8th November 2003 |
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