CAMC OSCE REVIEW STATIONS

CARIBBEAN COLLEGE OF FAMILY PHYSICIANS CAMC/OSCE REVIEW NOVEMBER 21, 2018 Venue: The Alhambra Inn, 1 Tucker Avenue, KGN. 6 Abstract Your personal copy containing Stations and Scenarios of OSCE/CAMC compiled by CCFP

Caribbean College of Family Physicians ccfp@cwjamaica.com

INFORMATION FOR CANDIDATES PREPARING FOR OSCE History taking, physical examination, communication and interpersonal behavior are all skills that can be tested during the OSCE. GENERAL COMMENTS Greet the patient and state you name Elicit or confirm the patient’s name Never attempt to communicate with the patient other than as a physician to patient Feel free to take notes during the encounter (blank paper will be provided) Concentrate on the case on which you are working Notify administrators or elevators of any problems HISTORY TAKING Begin with broad questions and then focus your inquiries Don’t rush the patient’s answers Don’t cut the patient’s answers off with another question Repeat your questions in different terms, if necessary Ask follow-up questions PHYSICAL EXAM Wash your hands between patients, preferably before touching the patient or beginning the physical examination Tell the patient when you are going to begin the physical exam Describe the manoeuvres either before or as you do them Always use patient gowns and drapes appropriately to maintain patient modesty and comfort Maintain the patient’s modesty but never examine through the gown Do a focused examination based on the patient’s compliant, symptom and history Look for physical findings Note the time warning for 2 minutes remaining in the encounter Close the encounter when the “End of Encounter” signal is given Tell the patient your initial impressions and your plan for the diagnostic work-up Ask for and answer any additional questions Do not perform rectal, pelvic/genital or female breast exams If you ask a patient to get off the examination table offer to assist him/her COMMUNICATION SKILLS Make eye contact Ask clear questions If you use medical terms, explain yourself Be direct and honest but also be sensitive If you don’t know the answer to an SP’s question, say so Acknowledge the patient’s concerns and worries

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INTRODUCTION We are using standardized patients (SPs) or real patients to assess physician skills.

SPs are individuals who have been taught to present history and physical examination findings of a particular illness or injury in an accurate, standardized and reproducible manner. The SPs will be used to assess your history-taking, physical examination, information-processing, teaching and communication skills.

DOORWAY INFORMATION Posted on the door of each examination room will be some basic information regarding the patient you are about to see. Please read this carefully before seeing the patient because it will tell you his or her name, gender, age, presenting compliant and task(s) your are to complete. [Most OSCE stations will have the same types of tasks listed but some may include specific, unique tasks].

SAMPLE: 1. Opening Scenario Pauline Williams, a 54 year-old woman, comes to your office complaining of low back pain.

2. Examine Tasks will include at least one (1) of the following: i) Obtain a focused history ii) Perform a relevant physical examination iii) (Do not perform rectal, pelvic/genital or female breast examinations) iv) Discuss your initial diagnostic impression and your workup plan with the patient. v) After leaving the room, complete the evaluation form placed outside the room.

Time Allotted: 10 minutes.

Footnote: 1. The content for this material was obtained from the Kessler Medical Rehabilitation Research and Education Corporation.

2. The materials used in this booklet have been modified from 1998 CSA Booklet issued by ECFMG materials used ABIM recertification program. 3

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DESCRIPTION OF THE OSCE OSCE PROTOTYPE Before you enter each examination room, you will have a few moments to review information that will be posted on the examination room door. This information gives you specific instructions, tells you the patient’s name, age, gender and reason for visiting the doctor and pertinent tasks you are required to complete.

Upon entering each room you will encounter an SP. Introduce yourself as you would to any patient.

By asking this patient the appropriate questions and/or performance of a relevant physical examination, you will be able to get enough information to perform the requested task(s). Please wash your hands before beginning any physical examination.

You will also be expected to communicate orally in an empathetic manner. You are to answer any questions they have, tell them what diagnoses you are considering and advise them on your follow-up plans.

The types of problems that your patients will be portraying are those you would commonly encounter in a clinic or a doctor’s office in your practice. All patients are adults, although some individuals could be present with problems relating to their spouses or family members.

Each case will require a specific task such as taking a focused history, examining a specific area or organ system, recommending a particular treatment regime or diagnostic work-up and giving medical advice.

The key to interacting with the SPs is to relate to them exactly as you would to any patients who you may see with similar problems. The only exception is that certain parts of the physical exam must not be done: rectal, pelvic/genital or female breast examinations. If you fell these are indicated, you may suggest them in your proposed diagnostic work-up.

The time you have with each patient will vary. You are responsible for pacing your time with the patient. Time allotments are written on the doorway information sheet. An announcement will tell you when to begin the encounter, when there are two minutes remaining, and when the allotted time has elapsed. Do not enter the examination room until your designated time. In some cases, you may complete the encounter in less than the allotted time. If so, you may leave the examination room early but are not permitted to re-enter. Be certain that you have gotten all the necessary information before leaving the examination room.

It is important to understand that some cases are designed to present more than one diagnostic possibility. Based on the patient’s presenting complaint and the additional information you obtain as you begin taking the history, you should keep your mind open to all possible diagnoses and explore the relevant ones as time permits.

Perform physical examination manoeuvres correctly and expect that there will be some positive physical findings. Some may be simulated but you should accept them as real and factor them into your evolving differential diagnosis.

Be considerate of the patients and always keep them comfortable and properly draped as you perform the physical examination.

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There are 15 OSCE Stations ( 4 rest, 4 unmanned, 7 with examiners), 10 minutes per station and 2 minutes between each station Covers family medicine, Obstetrics & Gynaecology, Surgery, Pediatrics, and medicine. Screening and health promotion. Care of NCCDs important Skills tested are history-taking, physical exam, communication and counseling skills, Sample OSCE stations 1. Examination of painful shoulder; Examine the thyroid 2. Abdominal pain for history and/ or examination 3. Diabetic patient for foot examination, Motor exam of a stroke patient 4. Cardiac or respiratory examination 5. Communication skills: Death notification, test result with significant diagnosis 6. Consent for blood transfusion 7. Child wellness visit 8. Counsel recently diagnosed HIV patient 9. History-taking station e.g. chest pain, pain in abdomen, back pain 10. Do a mental status examination Abdominal pain Female with RLQ abdominal pain for 7 hours; perform history and physical, list differentials; outline management based on test results Checklist: 1. History of presenting complaint Identifies patient’s chief complaint as abdominal pain Asks age Asks duration of pain, Location of pain, quality, timing, radiation, severity using pain scale, exacerbating factors, alleviating factors 2. Review of systems Asks about fever/ chills, nausea, vomits, anorexia, weight loss, Bowel habits (diarrhea or constipation), blood in stools (hematochezia or melaena), vaginal bleeding, dysuria 3. Past medical, surgical, family & social Current medication 4. Physical Exam Washes hands prior to exam Examines mucosa, ascertains vital signs, Auscultates lungs, heart Abdomen: Inspects, palpates, percusses, auscultates (hepatosplenomegaly, Rovsings sign, iliopsoas sign, obturator sign) Request rectal exam, pelvic exam

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Counselling of HIV positive patient Checklist: Establish rapport with patient Explains to patient about confidentiality Advises pt of need to do confirmatory test, need to do CD4 count, STI screen (VDRL, Hepatitis B) Asks pt about his knowledge of HIV, about sexual orientation, sexual practices, high risk behavior (number of partners, use of illicit drugs) Explains difference between HIV and AIDS Explains about modes of spread; dispels myths; telling partner(s); enquires about confidendante or emotional support Counsels about safe sexual practices, use of condoms Advises need for antiretrovirals History-taking station Please elicit a relevant history of this patient’s complaints. Then you will be asked to present your conclusions to the examiner and discuss their implications.

Checklist: Enquires about site of pain, duration of pain, characteristics of pain, precipitating factors, aggravating factors, relieving factors, associated symptoms (Respiratory symptoms, cardiac symptoms, GI symptoms, urinary symptoms), General or constitutional symptoms: fever, chills, weight loss, anorexia etc.

Give summary of positive and negative findings which lead to provisional diagnosis; suggest investigations needed to arrive at definitive diagnosis; suggest first steps of treatment.

Complete a mental status examination of this patient, then report your findings, your diagnosis and treatment plan Checklist: Introduces self, establishes purpose of interview, appropriate use of question styles, develops rapport Asks about mood, Hallucinations (auditory, visual, tactile, olfactory, gustatory), illusions; Reports on patient’s attire, posture, body movements, level of eye contact, facial expression, mood, affect Thoughts (sad, persecutory, grandiose), flight of thoughts, repetition, etc Diagnosis, treatment Communication skills:-giving information on diagnosis, bad news Check-list: Determines the purpose of the visit, Breaks news gently, Explains the meaning of the test, Gives patient time to absorb information and significance, Elicits patients concerns and fears, elicits patient’s own knowledge, elaborates on implications of result, Advises pt of next steps and purpose of further investigations; Identifies patient support system (financial and emotional); Checks pt understanding of implications and next steps Summarizes information, schedules appropriate follow-up O&G Determine gestational age, Take an obstetric history, Diagnosis of risk of current pregnancy, Antenatal investigations, expected visits to antenatal clinic.

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IMPACT OF ILLNESS UWI FAMILY MEDICINE POSTGRADUATE PROGRAMME SAMPLE MATERIAL FOR OSCE\OSPE EXAMINATION (2005) TOPIC: SKILLS TO BE TESTED:

Impact of Illness on Family Interviewing Skills\ability to summarize

DOORWAY INFORMATION This 35 year old lady visits your private office complaining of being “stressed”. Take a social and family history from her to determine her stressors.

You will be required to tell the examiner the factors contributing to her stress in the last two minutes of the station.

Time Allotted: 10 minutes N.B. PLEASE REMEMBER TO HAND YOUR IDENTITY LABEL TO YOUR EXAMINER

CHECKLIST Item to be assessed

Initiation of encounter Greets patient appropriately

Not done or inadequately done 0 --------------------

Adequately done 1 -----------------

Establishes rapport Demonstration of ---------------------- ----------------Interviewing Techniques --------------------- - ---------------Confirms with patient reason for consultation Appropriate use of open ended questions Appropriate use of close ended questions Asks specifically about stress related to husband Asks specifically about stress related to children Asks about job related stresses Asks about support system 6

Item to be assessed

Enquires about other stressors or concerns Displays empathy Summary of interview Logical sequence Identifies at least three contributory stressors (Give 2 marks if well done) • Illness of Husband • Additional responsibilities due to husbands illness • No lessening of usual responsibilities • Inadequate support system • Worry about husband’s illness and prognosis

Not done or inadequately done 0

Adequately done 1

---------------------

----------------

EXAMINER’S GLOBAL RATING 5 Very good

4 Good

3 Average

2 Below Average

1 Poor

TOTAL MARKS GAINED TOTAL MARKS POSSIBLE MINIMUM COMPETENCE LEVEL COMMENTS

18 12

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PATIENT INFORMATION Thirty-five year old Mrs. Green has been married for ten years and has three children –a 9year old boy, a 7 year old girl and a 3 year old boy.

She works as an executive secretary in a private sector business with overseas connections.

Her boss, the CEO, depends on her heavily to ensure the smooth running of the organization; her job is therefore very stressful.

Her husband is forty years old and works as a computer engineer for a fast food chain. His job involves long hours but is flexible enough for him to transport the children to and from school on most days. He also makes an effort work from home in the evenings so he can give support at this time.

He had a long history of “indigestion” and had been taking medication intermittently for several years. One week ago he had an episode of vomiting up blood. He has been hospitalized since then and no firm diagnosis has yet been made. He is scheduled to do a number of investigations over the next few days.

The children all go to the same school and are there from 8 a.m. to 2 p.m. There is a helper who comes from 7 a.m. to 5 p.m. Monday to Friday and 9 a.m. to 2 p.m. on a Saturday but is unable to stay overnight due to her own home commitments.

The extended family – parents, brothers and sisters- are willing to help but are all working so are only really available on weekends.

INSTRUCTIONS TO SIMULATED PATIENT Answer questions based on the following scenario.

Do not volunteer information unless asked.

If asked general questions e.g. what is stressing you?

-give general answers like – everything, I don’t know where to start If doctor still not asking specific questions – you can say – maybe if you ask me about a specific area I will be able to tell you PERSONAL INFORMATION • • •

You are Beatrice Green a 35 year old executive secretary married for ten to a 40 year old computer engineer With 3 children -. a 9 year old boy, a 7 year old girl and a 3 year old boy.

•

You work as an executive secretary in a private sector business with overseas connections.

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• •

Your boss is the CEO and depends on you to ensure the smooth running of the organisation ; Your job is therefore very stressful.

HUSBAND • • • •

Michael Green is forty years old works as a computer engineer for a fast food chain job involves long hours but is flexible enough for him to transport the children to and from school on most days He tries to work from home in the evenings so he can give support at this time.

HUSBAND’S ILLNESS • long history of “indigestion” • taking medication intermittently for several years • One week ago he had an episode of vomiting up blood.

• He has been hospitalized since then and no firm diagnosis has yet been made • He is scheduled to do a number of investigations over the next few days.

SUPPORT SYSTEM • The children all go to the same school and are there from 8 a.m. to 2 p.m.

• You have a reliable helper who comes from 7 a.m. to 5 p.m. Monday to Friday and 9 a.m. to 2 p.m. on a Saturday but is unable to stay overnight due to her own home commitments.

• The extended family – parents, brothers and sisters- are willing to help but are all working so are only really available on weekends.

YOUR CONCERNS\STRESSORS • That your husband’s illness be severe- even life threatening • You are unable to take leave due to commitments at work although your boss is understanding and is allowing you some flexibility in your working hours • You are totally responsible for child care – transportation to school, homework etc- even if other are willing to help you still have to coordinate • You have to deal with the children’s questions about what is happening to their father • Depending on the diagnosis you are worried about the financial implications

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OSCE: FINAL M.Sc. FAMILY MEDICINE INSTRUCTIONS TO CANDIDATE Mr. Mark Dubois is a 31 years old Computer Engineer and has been your patient for the last several years. He came to you 6 weeks ago requesting an HIV-test. At that time, he confessed that he had unprotected sexual intercourse with a prostitute on 2 occasions about 6months ago when he was on a business trip. He has been married for the last 5 years and his wife Lisa is also a patient of yours. Mr. Dubois’s HIV- test and the confirmatory test are both positive.

You are to inform Mr. Dubois of his test results and deal with his concerns.

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INSTRUCTIONS TO SP You are 31 year old Mark Dubois. You are a successful Computer Engineer and have been married to Lisa, who is your high school sweetheart, for the last 5 years. You have no children, but are now both settled enough professionally to think of starting a family.

You have been feeling both guilty and scared since indulging in unprotected sexual intercourse with a prostitute on 2 occasions 6 months ago, when you were away at a business trip in Florida. You are very sorry for those acts, as you are not someone who takes his marriage lightly, and it was stress and pressure from colleagues at the time which led you astray!

You have been very worried about contracting ‘AIDS” since that time and finally mustered up enough courage to go and see your family physician to request an HIV test.

Physically, you have been feeling quite well and have not experienced any symptoms of ‘AIDS’ that the doctor might ask you about (e.g. diarrhea. weight loss, night sweats, skin rashes, etc.). Because you have been feeling so well, you are hoping for the best.

Therefore, you are very shocked when you are informed that your test is positive. You are scared that you have AIDS and will die shortly. You feel there is no hope for life for you and will lose all that is important in your life: your job, career, status, etc. You know there is no cure for this disease, and you feel there is not a lot the doctors can help you with anymore!

When your doctor suggests that you tell your wife, you downright refuse to do so. You feel your wife will leave you the minute she hears this, and in no way are you going to survive if she leaves you!! Also, you don’t want to hurt her and blow her life apart. You promise you will use condoms for every single sexual act with her! You want your doctor to assure you of confidentiality on this matter and in no way disclose this result to your wife, who is also his patient!!

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SP PROMPTS PROMPT 1: (immediately) “So what were the results?”

“Are you positive?”….Incredulous!

PROMPT 2: (1-2 MINS) “So I have AIDS and I’m going to die!”…..Panic and terror!

“I know there is not much any doctor can do for me any more! I know there is no cure!”

PROMPT 3: (4-5 MINS) “Does my wife have to know? Why does she have to know?”

“Isn’t this supposed to be confidential between us?”…Challenging!

PROMPT 4: (7-8 MINS) “What will you do if I don’t tell her?”…….Sad!

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CHECKLIST ITEMS 1.

2.

3.

4.

5.

Greets patient and establishes rapport.

Gives positive result and assures confidentiality.

Gives patient time to absorb impact of results.

Determines patient’s feelings about test results.

Discusses what seropositive status means and assures patient positive test does not imply presence of AIDS. 6. Discusses medical follow up: CD4 testing, HepB testing 7. Comforts: availability of anti-retrovirals, multivits, etc. to improve prognosis and quality of life.

8. Discusses social follow up: CHARES, other social organizations e.g.

JAS 9. Advises risk reduction: condom use, decreasing drug use, multiple partners, other STDs, avoiding crowds, not donating blood.

10.States wife should be told (has right to know) and should be tested.

11.Encourages patient to tell wife.

12.Advises patient that wife will find out through contact tracing.

13.Offers any help patient may require.

14.Organizes follow up visit.

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Case Scenario: Doorway Information

Michelle Ennis is a 25 year old mother of her first baby who is now 1 year old. The baby girl was found on neonatal screening to have Sickle Cell Disease. She has had a repeat blood test for hemoglobin electrophoresis which has confirmed the diagnosis of homozygous (SS) sickle cell disease. Your contact tracing officer has brought her in to you for advice.

Your task is to provide her with some information on the disease itself and to develop a management plan for the baby.

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SP Information You are 25 year old Michelle Ennis who has a 1 year old daughter. This is your first child. You are very happy as you have been married to your very loving husband for the last 4 years and have been enjoying raising your daughter. You are a high school teacher and you teach Biology.

You had been contacted by an officer from the Ministry of Health a few weeks ago when he had brought your baby’s results from tests they had done for sickle cell disease at birth. He had been unable to find you earlier as you had moved and it took some time for him to locate you. At that time, you had vague recollections of being told that this test was going to be done on your baby’s umbilical cord at the time of birth. The officer had informed you that your baby may have Sickle Cell Disease. The test had been repeated and the same officer has brought you results again confirming the earlier results. He has advised you to come to see a doctor in the Ministry.

You are quite nervous and scared as you have heard that children who have this disease die very early in life. You don’t remember anyone in your family having this disease and think it must be your husband’s family where she has got it from! You do remember your obstetrician telling you that you had the ‘sickle cell trait’ and advising your husband to get tested as well. But as you had always been a very healthy young woman, you had quite forgotten about it. Other than that you do not know anything else about this disease and are very feeling very apprehensive about the consultation. You wonder what your baby will have to face and what kind of life she will have. She has been quite well till now and has had no illnesses. You wonder now if she is going to die

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very young. You wonder if there is any cure for this disease. You wonder if your other children will also have this disease (do not volunteer).

SP Prompts

Prompt 1: (On hearing confirmation of the diagnosis of sickle cell disease) “How did she get it?”

“But no one in my family has this disease!”

Prompt 2: (2-3 mins) “So is my baby going to die very young?”

“I hear most people don’t live to become adults!!”…..sad and anxious

Prompt 3: (5-6 mins) “What kind of problems can she have?”

“What can I do?”

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CHECKLIST ITEMS

1. Greets patient warmly and introduces self.

2. Confirms results of her 1 year old daughter as having sickle cell disease (SS genotype).

3. Determines patient’s feelings about test results.

4. Discusses inheritance: • Disease inherited from both sides of family • Mendelian inheritance (uses paper to draw) • Relative clinical insignificance of the ‘sickle trait’ in causing any symptoms • Risk of other offspring having disease 5. Describes important, common problems associated: • Increased risk of infections: esp. lungs (acute chest syndrome/ pneumonia), brain (meningitis), urine (UTIs) • Presence of bone pains •

acute anaemic episodes especially due to splenic sequestration

• Lethargy, weakness and poor appetite (stroke) 6. Discusses important management issues: • Starting 4 weekly (monthly) Penicillin prophylaxis: either 4weekly Penadur injections or twice daily oral Penicillin.

• Timely routine immunizations (also pneumococcal vaccine) • Proper diet and fluids with inclusion of fruits and vegetables • Splenic palpation especially during ill events

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• Urgent attention to managing fever and pains (see physician early if symptoms persist; increase fluids, panadol /advil).

7.

Encourages patient to discuss with husband, and offers consultation

with both together.

8. Advises husband should also get tested.

9. Organizes follow up visit.

Max: 26

Min: 15

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DOORWAY INFORMATION 45 year old Paul Williams presents to your office for the first time with recurrent upper abdominal pains.

EXAMINEE TASK Take a focused history, discuss possible diagnoses, and suggest a management plan with your patient.

ALLOTTED TIME: 10 MINS.

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PATIENT SCENARIO You are 45 year old Paul Williams. You are a successful business executive with a stressful but fulfilling job. You are also happily married with 2 children.

You have been having intermittent upper abdominal pains for the last 2 months. Of note, you have had a history of peptic ulcer disease 15 years ago which was treated with Zantac at the time. No investigations were done at the time.

You have been having these similar pains for last few months but they are more regular and more severe for the last 2 months. It is in the upper central part of our abdomen, and feel ‘gnawing’ or ‘burning’ in nature. They do not move anywhere else and on a pain scale of 1-10, they are usually at about a 4.

You notice they are worse with alcohol (which you take socially with your busied usually on weekends….you may consume 4-5 beers at each night of the weekend), stress, not eating regularly (you often miss meals or eat at odd hours). You also smoke about ½ pack of cigarettes since the last 20 years. You do also notice that the pains settle most times with eating and taking antacids such as Maalox or Federgel. You have not used any painkillers such as Brufen, Voltaren or aspirin recently….you usually take panadols for headaches. You are on no other regular medications and know of no other chronic illnesses.

You have no associated symptoms like nausea, vomiting or loss of appetite.

You have experienced no weight loss and your bowel movements are reasonably regular. When asked, you do agree that you had one episode of sticky, black looking stools 2 weeks ago….but subsequent stools have been normal.

You are really just annoyed about these recurrent pains and think you just need some Zantac again to settle it again for the next few years.

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CHECKLIST 1.

2.

3.

4.

5.

6.

7.

Greets patient and elicits complaint.

Asks about the onset of pain Asks about the location of pain Asks about the quality/ character of pain Asks about radiation of pain Asks about severity of pain using pain scale Asks about aggravating factors (any 3 of following) • Alcohol use • Smoking • Poor eating habits/ caffeine use • Drugs: NSAIDs, ASA • Stress 8. Asks about alleviating factors: both food/ antacids 9. Elicits association with nausea/ vomiting 10.Elicits change in bowel habits 11.Elicits presence of black, tarry stools or blood in stools 12.Elicits history of weight loss 13.Discusses differential diagnoses: (any 2) • Peptic ulcer disease • Gastritis • Gastric CA 14.Discusses management plan: • Investigations: i. Blood tests: CBC, Electrolyte, bleeding function ii. Barium Meal iii. Endoscopy iv. H. Pylori testing • Treatment: i. Life style advice: Any 3 of avoiding alcohol, stress, smoking; and need for regular diet and exercise/ yoga. ii. Medications: Discusses at least 3 of H2 Blockers, PPIs, Triple therapy, and antispasmodics.

Overall rating: 1. Properly organizes interview.

2. Uses counseling and communication skills expertly.

3. Demonstrates knowledge of the subject matter.

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STATION 8 DOORWAY INFORMATION Scenario: A man comes to your office asking to receive a report for pre-retirement leave due to medical disability. He recently had a complete physical examination and executive blood profile, which was excellent. He works at a factory.

Examinee Task Respond to this situation.

Allotted Time: 10 minutes

NB. PLEASE REMEMBER TO HAND YOUR IDENTITY LABEL TO EXAMINER

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STATION 8 – CHECKLIST PHYSICIAN RATING SCALE Good (2)

Doctor

Adequate (1)

Inadequate (0)

Cannot Evaluate (0)

Background ▪ Asks about general happenings Affect ▪ Asks about patient’s feelings about work Trouble ▪ Asks what troubles him the most / determines the real agenda Handling ▪ Asks how he is handling the problems/ confronts patient that insomnia is not the real issue ▪ Discusses ethical requirements for medical disability ▪ Suggests/Asks patient about alternative responses to the situation ▪ Expresses empathy ▪ Schedules next appointment Global performance ▪ Accuracy of Information ▪ Organization of consultation ▪ Rapport with patient

Distinction 3

Honours 2

Pass 1

Fail 0

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Patient Scenario 8

You are Michael Walker, a factory worker. You have not slept well for over a year. You never get more that two (2) hours sleep. Your job is contributing to your lack of sleep and nerves problems. There is a lot of noise at the factory and it is affecting your nerves. The work is very boring and you have worked there for a very long time.

You feel it is more than time for you to retire with compensation as you have been employed with the factory for 26 years. You now dislike this work. You now want to retire and farm your piece of land in the country. You ask doctor to help you get a medical disability report. You are 49 years old.

This job is really making you sick because there is a lot of loud noise and the machines jerk you about a lot.

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STATION 14

DOORWAY INFORMATION Scenario: 39-year-old patient visits you for problems with her periods.

TASK: Take a focused history with view to suggesting likely diagnoses, then initiate investigations and management. Do not examine this patient. You have 10 minutes for this station.

ALLOTTED TIME: 10 MINUTES

NB. PLEASE REMEMBER TO HAND YOUR IDENTITY LABEL TO EXAMINER

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STATION 14

Doctor:

Good (2)

Adequate (1)

Inadequat e (0)

Cannot Evaluate (0)

Elicits the following aspects of patient’s key complaints • The patient’s complaints - bleeding - heavy flow - prolonged (10 days) - presence of clots (1 inadequate, 2 adequate, 3-4 good) ▪ Timing of complaints ▪ Takes menstrual history for past three months ▪ Evolution of each complaint – getting worse ▪ Factors modifying complaints - pain ▪ Follow-up questions related to key complaints ▪ Covers treatment of current problem by patient – taking Centrum ▪ Relevant system review Asks routine screening questions unrelated to key complaints ▪ Past history of disease and hospitalization (including morbidity data on parents and siblings) ▪ Medication – for stomach Initiation of Treatment ▪ Reassures patient ▪ Suggests likely diagnosis: - Fibroids - Tumours of uterus or ovaries - DUB (1 adequate, 2 or more good) ▪ Requests investigations - CBC - Pelvic ultrasound (1 adequate, 2 or more good) ▪ Initiates treatment (choose any of the following): - Oestrogen 0.625mg daily or 1.25 mg daily or 1.25mg twice daily for 21 days and Progesterone (Colprone or Provera 10 mg daily) from day 15 till day 21 - One pack combination OCP e.g. Ovral or low dose perl (any correct option – 2 marks)

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Continued care - Iron supplement or continue Centrum - Schedules follow-up within a month - Gives contingency plan if bleeding worsens e.g. return for premarin injection or go to hospital Global Performance ▪ Communication Skills: (i) Open-ended questions (ii) Elicits patient’s views (iii) Checks patient’s understanding of information given ▪ Accuracy of information: (i) None or few minor mistakes - good (ii) Some mistakes – not critical – adequate (iii) Many or critical mistakes - 0 ▪ Organization of interview: (i) Well organized – good (ii) Somewhat organized – adequate (iii) Poorly organized - 0

Distinction 3

Honours 2

Pass 1

Fail 0

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PATIENT SCENARIO 14 You are 39-year-old Peaches Broomfield. You have come to doctor because of heavy menses from last week – eight days. Tell the doctor “Sometimes I feel like a pipe turn on in mi vagina - mi a bleed so much.” Also you pass big clots at times (size of 10 dollars). You were feeling weak, which is why you have come to doctor, but you don’t feel too bad now.

But you can’t take “it” (the heavy bleeding) anymore. You want doctor to stop it.

This has been happening for the past four months. Each period has been heavy and longer than the usual (was 5 days now 8 – 12 days). Menses come with pain but it is not severe.

Pain lasts for first two days only. Once menses has stopped there is no bleeding between periods. Period is not as regular as before. Sometimes it skips a month.

First period ever

Age 12

Last period was

Dec 28 and you are still bleeding

Previous Period

Nov 12 lasted 10 days

No period in Oct Had one in middle of Sept – don’t remember the date You have two children (sons) ages 18 and 13 (normal delivery). You lost a pregnancy at 3 months, eight years ago. You had a tubal ligation that same year.

Other Problems you have You have bad stomach – doctors says it’s an ulcer Only surgery you have had is the tubal ligation.

You take medications for your stomach and Centrum tablets you got from the pharmacist a month ago. You take one Centrum daily.

You work as a nurse assistant in a nursing home. You live with your common-law husband (a truck driver) and your 2 sons in your own home.

Family history: Your father died of a stroke. Your Mother is healthy. She never had problems with her menses. Your sister had heavy bleeding due to fibroids and her uterus was taken out. You are wondering if this is true for you too.

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SURGERY CAMC REVIEW SESSION 1. Introduction 2. OSCE scenarios: a. Introduce yourself b. Thyroid c. Hernia d. Lower limb diseases (arterial, venous) e. Breast pathology

3. Instruments a. X Rays b. Surgical devices

Dr. Hugh Anthony Roberts

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OSCE CAMC REVIEW - PHYSICAL EXAMINATION Prepared by Dr Christopher Wilks, MBBS (Hons) UWI [Updated November 2012] General Notes Be Confident, calm, introduce yourself to your patient and ask for their permission to examine them Always expose the area of examination completely Always examine from the right side of the bed Always place patient in the anatomical position (except thyroid and cranial nerve exams) Ascertain whether the patient can lay flat and if they can, have them lie flat Go in this order as much as it is possible: INSEPECTION, PALPATION, PERCUSSION, AUSCULTATION Always state the position (lying flat vs propped up) and condition (well nourished vs wasted, distressed vs no distress) of the patient, as well as obvious appendages like oxygen mask, nasal cannula, IV lines etc.

Speak loudly and say what it is you are doing as you go along Maintain rapport with the patient throughout the exam, stating what you are doing and what you want them to do Always summarize relevant findings and try to give a diagnosis Always thank the patient for allowing you to examine them PRACTICE, PRACTICE, PRACTICE ON EVERYBODY! Cardiovascular Inspection Get down to patient’s level an look for scars, visible apex beat, precordial bulge, parasternal heave, appendages Palpation (You may do the chest first then peripheries, or vice versa, whichever you prefer) Check hands for clubbing, oslers nodes, Janeway lesions, splinter hemorrhages, wasting, capillary refill, pallor and cyanosis, digital pulsations

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Check pulse for 5 things: rate, rhythm, volume, synchronicity, whether collapsing or not Say you would like to do the blood pressure Check mucous membranes for central cyanosis, pallor and jaundice Check mouth for caries Do the JVP, checking for hepato-jugular reflux if necessary Palpate the precordium in a Z pattern checking for the apex beat (two hands) and then for thrills, then for a palpable P2, and for a parasternal heave THERE IS NO PERCUSSION OF THE HEART Auscultation With one hand on the carotid pulse, listen over the respective valvular areas for the heart sounds, using firstly the diaphragm then the bell Listen for murmurs; If heard, describe their 5 characteristics: Diastolic/Systolic, position, grade, radiation and changes with positioning Describe what you hear Listen to the lung bases for decreased breath sounds or crepitations Check for sacral edema (a sign of anasacra i.e. generalized edema) Palpate abdomen for hepatomegaly, whether pulsatile or not Check the legs and feet for edema (going up from just above the medial malleoli to the shin if necessary), pulses and clubbing Respiratory NB. Do all maneuvers on anterior chest before moving on to posterior chest Inspection Get down to patients level and check for scars, obvious deformities (eg pectus excavatum, kyphoscoliosis) chest movement, respiratory rate, type of breathing (thoracic, thoraco-abdominal, abdominal) dilated veins, appendages State whether the patient is in any distress and to what degree, mild, mod., or severe Palpation Check hands for clubbing, cyanosis Check mucous membranes for cyanosis Palpate the chest. A useful pneumonic is TACT T-Trachea. Check for deviation 31

A-Apex Beat. Check with both hands and identify its position. In your mind, you should see how it relates to the tracheal position and what its position means C-Chest expansion. Check at three levels: above nipples/upper chest, just blow nipples, and lower chest T-Tactile vocal fremitus. Check whether normal, increased or decreased Percussion Percuss all areas including the apices and clavicles checking if normal, increased or decreased. Check bases for stony dullness, a sign of pleural effusion Auscultation Do vocal resonance +/- whispering pectoriloquy in all areas, checkinig if normal, increased or decreased Listen to the breath sounds in all areas. At each point carefully listen for inspiration and expiration Check for quality of breath sounds, volume of breath sounds, and for any added sounds e.g.crepitatioins, wheezing, pleural rubs etc NB. Remember to complete all the examination steps on anterior chest, then posterior chest Complete the general exam by checking for cervical and supraclavicular lymph nodes and leg edema Abdomen Inspection Get down to the patients level and check for scars, stomas, abdominal state (obese, flat or scaphoid), any masses, flank distension (?ascites), dilated veins, obvious peristalsis, gynecomastia, type of hair distribution (male vs female) and any appendages Palpation and Percussion Ask patient if they are having abdominal pain and where. If yes, palpate that area LAST Do light palpation of all abdominal regions checking for tenderness Do deep palpation of all regions. If any mass is noted complete its examination determining its position, size, shape, consistency (smooth, globular, rough, soft, firm, hard) and whether tender or not and whether pulsatile or not.

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Examine the liver doing both palpation and percussion to determine its size and consistency Examine the spleen doing both palpation and percussion to determine its size Check if the kidneys are ballotable Palpate and percuss for the urinary bladder or any pelvic mass Palpate for a pulsatile expansile abdominal mass Percuss for shifting dullness Auscultation Auscultate all masses or organomegaly identified Check for bowel sounds, and for renal artery and aortic bruits Check for hernias and state that you would like to do a Digital Rectal Examination (DRE) and check the genitals. Also do a general exam checking for jaundice, lymphadenopathy, flapping tremor and leg edema Motor Examination When doing motor exam, examine similar areas on both sides before moving on to another area Inspection Check for abnormal position of limbs, wasting, uncontrolled movements, obvious fasciculation, condition of pt (eg if in diapers) and any appendages Palpation Try to induce fasciculation, flicking all the major muscle groups Check for bulk Check tone at joints using passive movement Check for Power, comparing similar muscle groups on each side of the body.

Assess patient’s power passively first (without your help) i.e. pronator drift for upper limbs and leg lift for lower limbs). Check from proximal to distal. State level of power found (range is 0-5) Check reflexes: Biceps, Triceps, Supinator, Finger, Hoffman, Knee, Ankle Check for Clonus Check Plantar reflex

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Do finger-nose, rapid alternating hand movement, heel shin test and heel to toe test (cerebellar function’) Do Romberg’s test (in a cerebellar lesion patient unable to maintain balance even with eyes open) THERE IS NORMALLY NO PERCUSSION OR AUSCULTATION IN THE MOTOR EXAM Sensory NB All sensory modalities cannot be tested in the short time given for examination. It is advised to focus on Touch, Pin prick, Vibration sense and propiception and state that if time allowed you would also do temperature and two point discrimination. Also always test similar areas bilaterally before moving on to another area Inspection Check for abnormal position of limbs, wasting, uncontrolled movements, obvious fasciculation, condition of pt (eg if in diapers) and any appendages Palpation Ask patient to close their eyes and always compare the area being tested to the way it feels at the sternum Light touch- using the twisted end of a cotton ball, test the dermatomes for light touch Using a pointed instrument (eg the end of a broken tongue depressor) test all the dermatomes for pin prick If any areas of abnormal sensation are found, map it out going from abnormal back to an area of normality Check for vibration sense: always use a bony prominence (IP joint of big toe or interphalangeal joint of forefinger), and start at the most distal point. Once the most distal point is normal, THERE IS NO NEED TO MIGRATE PROXIMALLY. If

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abnormal, move on to the next most distant prominence (mp joint, malleoli, shin then knees I lower limbs; mp joint, wrist, elbow in upper limbs) Check for Propioception (joint position sense). Start at the most distal joint (distal MP joint of the hallux or forefinger) then move proximally. Once the most distal point is normal, THERE IS NO NEED TO MIGRATE PROXIMALLY. If abnormal, move to the next most distal joint Do Romberg’s test (in a dorsal column lesion patient is able to maintain balance with eyes open but unable to maintain balance with eyes closed) THERE IS NORMALLY NO PERCUSSION OR AUSCULTATION IN THE SENSORY EXAM Cranial Nerves CNI – Check nasal passages if clear, test sense of smell in each by occluding one nostril and asking patient, with their eyes closed, to identify different smell. NB cranial nerve one is NOT usually tested CNII – Test 5 things: Visual acuity (mini eye chart), pupils (direct consensual and accommodation reflexes), colour vision (using Ischihara charts), visual fields, and fundoscopy CNIII, IV, VI (tested together) – Test extraocular movements. Remember LR6SO4O3 CN V – Test light touch and pin prick for all three sensory parts of the nerve.

Inspect and test the bulk of the muscles of mastication. Test the corneal and jaw reflexes CNVII – Look for asymmetry, abnormal movements, drooling and ptosis. Ask patient to raise eyebrows, close eyes tightly against resistance, smile, and puff out cheeks against resistance. Say you would test for taste and do Schirmer’s test CNVIII – Test hearing bilaterally. Perform Weber’s and Rinne’s Test (remember Air conduction is usually better than bone conduction) CNIX and X – Listen to the patient speak. Look at the palate and uvula by asking patient to say “aah”. Check gag reflex 35

CNXI – Inspect trapezius and sternocleidomastoid muscles, and test their bulk by asking patient to shrug shoulders and turn their neck against resistance (respectively) CNXII – observe the tongue lying inside the mouth for fasciculation. Ask the patient to say ‘la-la-la’. Ask them to protrude tongue and observe for deviation Thyroid Inspection Look for condition of patient (nervous, sweating, lightly/heavily clothed), obvious neck mass, eye abnormalities Ask the patient to swallow some water (water is usually provided) and protrude their tongue. Remember the thyroid moves on swallowing but not with tongue protrusion Palpation Palpate for the thyroid from behind with neck slightly flexed to relax muscles Describe enlargements of lobes and/or isthmus Ask patient to swallow and check if thyroid moves on swallowing Look at eyes from above and behind head for exophthalmoses Return to the front of the patient Check for cervical supraclavicular lymph nodes Percussion Percuss from mid-sternum up for reto-sternal extension Percuss from lateral clavicles in for lateral extension Auscultate Listen over the thyroid for bruits and over closed eyelids if exophthalmos present Complete the thyroid exam by checking the….

Eyes: For lid lag, impaired extra ocular movements Hands: For sweating, tremors, pulse rate Limbs: for proximal muscle weakness Legs: for pretibial myxedema Reflexes: for hyperreflexia or clasp-knife tendon movement 36

Child Health Practice Questions 2018 - Dr Christine Hammond Gabbadon MBBS; DCH; DM Paeds; MPH Case Histories • Elements of the Paediatric History • Child is behind in immunizations-presents with Immunization card • Child with asthma • Child presents with delayed development. Approach to history, examination and management.

• Mother presents for counselling with child recently diagnosed sickle cell disease (or other chronic illness) • Child with a fever- approach to management Paediatric vs. Adult History Content Differences A. Prenatal and birth history B. Developmental history C. Social history of family - environmental risks D. Immunization history

Elements of Paediatric history • • • • • • • • •

Chief complaint History of present illness Past medical history (hosp., allergy etc) Pregnancy and birth history Developmental history Feeding history Review of systems Family/social history Immunization history

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Case #1 • A child is brought to the health centre for his 6 month visit. You ask the mother to show you his immunization card. He has received a BCG vaccine at birth and a DPT/Pentavalent vaccine at 6 weeks.

• Take an immunization history and advise the mother on the current immunization schedule Immunizations • Immunizations are useful preventive measures available to infants, children, and adults.

• All individuals should be immunized as recommended by individual country guidelines and WHO recommendations

Immunization-minimum recommended(Optional/high risk vaccines marked X) (See Appendix attached) Other vaccine recommendations • Td/Tdap - every 10 years • Hep B - Influenza yearly • Optional: rotavirus, varicella (chicken pox), pneumococcal, meningitis C Current OPV recommendations • Global Polio Eradication initiative • Removal of all oral polio vaccines (OPVs) in the long term. This will eliminate the rare risks of vaccine-associated paralytic polio (VAPP) and circulating vaccine-derived poliovirus (cVDPV).

• Switch from trivalent OPV (tOPV) to bivalent OPV (bOPV), removing the type 2 component (April 2016 switch day).

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• Introduction of at least one dose of inactivated polio vaccine (IPV) into routine immunization programmes in all countries (age 6 weeks).

Case #2 A 14 year old with a history of bronchial asthma (diagnosed at age 4) presents today with a history of increasing night time cough over the last 2 weeks. He is not wheezing and is not distressed at present. Discuss your management of this patient What is known about asthma?

• Asthma is a common and potentially serious chronic disease that can be controlled but not cured • Asthma causes symptoms such as wheezing, shortness of breath, chest tightness and cough that vary over time in their occurrence, frequency and intensity • Symptoms are associated with variable expiratory airflow, i.e. difficulty breathing air out of the lungs due to • Bronchoconstriction (airway narrowing) • Airway wall thickening • Increased mucus • Symptoms may be triggered or worsened by factors such as viral infections, allergens, tobacco smoke, exercise and stress

What is known about asthma?

• Asthma can be effectively treated o When asthma is well-controlled, patients can: • Avoid troublesome symptoms during the day and night • Need little or no reliever medication • Have productive, physically active lives • Have normal or near-normal lung function • Avoid serious asthma flare-ups (also called exacerbations, or severe attacks)

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Assessment of asthma • Asthma control - two domains • Assess symptom control over the last 4 weeks • Assess risk factors for poor outcomes, including low lung function Treatment issues • • • •

Check inhaler technique and adherence Ask about side-effects Does the patient have a written asthma action plan?

What are the patient’s attitudes and goals for their asthma?

Comorbidities • Think of rhinosinusitis, GERD, obesity, obstructive sleep apnea, depression, anxiety • These may contribute to symptoms and poor quality of life

Management of asthma-GINA guidelines • History: presenting complaint- night time cough, hospitalizations, triggers (exercise, allergens, URTI), asthma meds (rescue, maintenance) • Examination: General, RR, distress, recessions, flaring etc. Presence of clinical broncho-spasm Lung Function (PEFR) • PEFR: Compare with standard for height, Improvement of 20% after bronchodilator

Levels of asthma control • • • • • •

Assess current clinical control: Controlled Partly Controlled Uncontrolled Assess future risk (exacerbations etc) Eg. Frequent exacerbations in past year, admission frequency, high dose meds, cigarette smoke

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GINA assessment of asthma control Achieve control • Step up Rx until control achieved • Step down if control maintained at least 3 months • Follow up after 1 month then every 3 months Steps to control • Step 1: as needed rapid acting B2 agonist • Step 2: add Controller: Low dose inhaled glucocorticoids (ICS)or Leukotriene modifier (montelucast) • Step 3: Choice of low/ med/ high dose ICS +/-long acting B agonist/ leukotriene modifier/ sustained theophiline • Step 4: add long acting agonist to med or high dose ICS • Step 5: add oral glucocorticoid (lowest dose , Anti IgE Rx • Stepwise approach to control asthma symptoms and reduce risk Asthma education, Environment control Asthma Control plan • Teach how to use Peak Flow meter • Teach how to use MDI (spacer) • Asthma control test You tube demos: • https://www.youtube.com/watch?v=Rdb3p9RZoR4 • https://www.youtube.com/watch?v=ma_cmlU9DxU • https://www.youtube.com/watch?v=6oKupWgDu80

Case # 3 • A young mother comes to see you with her 2 year old son. She is concerned about his development • Take a focused history to address the mother’s concerns and discuss a plan of action

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Focused history • Touch briefly on the elements of the paediatric history, but focus more on the presenting complaint and developmental history • Management includes the history, examination, investigations and treatment

PHYSICAL DEVELOPMENTFIRST YEAR • Most babies double their birth weight by 6 mths gaining an average of 0.5oz to 1oz every day for the first 6 months of life.

• Birth weight usually triples sometime between 9 and 12 months of age.

COGNITIVE DEVELOPMENT • This is the process by which babies develop the abilities to learn and remember.

• Babies begin to recognize and interact with loved ones and start to understand that people and objects still exist even when they are out of sight (object permanence).

EMOTIONAL AND SOCIAL DEVELOPMENT. • In the first month, newborns express emotion mainly by crying and grimacing or displaying an alert and bright face.

• By about 4 months, they learn to smile, coo, and move their arms around when excited.

• By 5 months, babies show a clear preference for a loved one. In the following months, "separation protest" and "stranger anxiety" are two of the ways babies show this growing attachment.

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LANGUAGE DEVELOPMENT. • By about 3 to 6 weeks, babies develop a different crying sound to show a specific need (such as hunger or discomfort).

• By around 2 months of age, they begin to interact with caregivers by cooing and smiling, which proceeds to babbling and chuckling within about 6 months.

• Also by 6 months, most babies have learned all of the basic and distinct sounds of their native language.

• By the first year most babies can say a few words, like "mama" or "dada," and can understand many more.

SOME KEY MILESTONES FOR PRESCHOOLERS 24+ MONTHS • • • • • • •

Runs easily Climbs well Imitates adults and playmates Learns to use potty follows a 2-3-step command Able to say name, age, gender Tells stories Learns how to treat others by how he/she is treated

GROWTH AND DEVELOPMENTAGES 2 TO 5 YEARS • Physical development. stronger and starts to look longer and leaner.

• Physical growth is slower than in the first 2 years of life, but the outward changes can be dramatic.

• Cognitive development. Able to think and reason. Learn their letters, counting, and colors. Their play becomes more creative as they learn to imagine.

• Emotional and social development. Gradually learn how to manage their feelings. They begin to feel ashamed or guilty when they do something wrong. By age 5, friends become important.

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GROWTH AND DEVELOPMENTAGES 2 TO 5 YEARS • Language. The ability to use words grows quickly in these years. By age 2, most children can say at least 50 words. By age 5, a child may know thousands of words and be able to carry on conversations and tell stories.

• Sensory and motor development. By age 2, most children can walk up stairs one at a time, kick a ball, and draw simple strokes with a pencil. By age 5, most can dress and undress themselves; draw a person with a head, body, arms, and legs; and write some small and capital letters.

Case # 4 • A 25 year old mother brings her first baby who was found to have Sickle Cell Disease on neonatal screening. The repeat test for Hb electrophoresis confirms Hb SS disease.

• Provide information on the disease itself and develop a management plan for the baby

Sickle Cell Disease Some Forms of Sickle Cell Disease • • • • • •

Hemoglobin SS Hemoglobin SC Hemoglobin Sβ0 thalassemia Hemoglobin Sβ+ thalassemia Hemoglobin SD Hemoglobin SE

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Sickle Cell Anaemia • Sickle cell anemia is an inherited blood disorder (includes Homozygous SS and SB0 thalassemia).

It causes: • • • • •

Chronic destruction of red blood cells, causing severe anemia Episodes of int1`ense pain Vulnerability to infections Organ damage In some cases, early death- this has been improving

Sickle Cell Anaemia • People who have SCD inherit two abnormal hemoglobin genes, one from each parent.

• In all forms of SCD, at least one of the two abnormal genes causes a person’s body to make hemoglobin S. • When a person has two hemoglobin S genes, Hemoglobin SS, the disease is called sickle cell anemia. This is the most common and often most severe kind of SCD. Sickle SS inheritance.

Symptoms • • • • • • • • •

Fatigue, shortness of breath, pale skin and fingernails due to anemia Recurrent bouts of pain in the abdomen, chest, back, arms or legs A yellowing of the skin and whites of the eyes Slowed growth and delayed puberty in children Frequent infections Eye problems, including blindness Leg ulcers (adults) Priapism (males) Stroke

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Prevention of infections-SCD Additional immunizations: • • • •

4th Hib Prevnar 13 Pneumococcus 23 (Pneumovax)(age 4) Penicillin prophylaxis age 4 months to 4 years

Advice to parent • Keep regular appointments and follow recommended immunizations and penicillin prophylaxis • Keep warm. Avoid chills (eg beach/ exposure to elements) • Nutrition: balanced diet including fruits and vegetables, plenty water • Keep analgesics at home. Extra fluids with painful crisis • Ensure regular school attendance

Case # 5 • A one year old infant is brought to you with a 2 day history of fever and irritability • Take a focused history and outline your management plan

Child with fever • Essentials-history, examination, investigations, management/referral • Look for neck stiffness, evidence of UTI, source of infection (eg RTI), ear infection (otitis media) • Investigations- CBC, blood culture, urine culture, CSF culture (spinal tap) • Appropriate treatment when source of infection identified • Referral to hospital for ill child and if meningitis or pneumonia etc suspected

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References • http://www.patienteducationcenter.org/articles/sickle-cell-anemia/ • http://ginasthma.org/ • http://ehlt.flinders.edu.au/education/DLiT/2000/Motor%20Dev/stages.htm

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