OSCE Year 2

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A paper given to students of batch 2011 to organize the rotations between stations.

Stations[edit]

Antenatal Care (ANC), Intrauterine Device (IUD), and Implant Insertion[edit]

Leopold maneuvers

ANC involves:

  • Leopold maneuvers I, II, III, and IV. Report the result of each to the patient.
  • Measuring of the fundal height using measuring tape (twice), making sure to keep the centimeters on the underside of the tape.
  • Using fetoscope to listen to fetal heartbeat for a full 60 seconds while facing the patient's feet and holding her wrist to compare the fetus' heartrate with the mother's. Normal fetal heartrate is 120-160 per minute.
  • Estimating fetal weight and gestational age using fundal height.
  • Estimating date of delivery using date of the first day of the last menstrual period (known as "HPMT" in Indonesian).
  • Educate the patient by asking her to return in:
    • 1 month if gestation age is < 28 weeks.
    • 2 weeks if gestation age is 28 to 36 weeks.
    • 1 week if gestation age is > 36 weeks.
  • Educate the patient to go get a USG to get a more accurate estimated date of delivery.
  • Educate the patient to have sex because it releases oxytocin which is good for contractions.
  • Educate the patient to do safe exercise such as walking, swimming, or yoga for pregnant women.

Baby Delivery[edit]

See Also[edit]

Breast Exam or Education for Breast Self-Exam (BSE)[edit]

Either of these will be tested:

Education for Breast Self Exam (BSE)[edit]

  • During the OSCE, the BSE education can be done simply by talking to the patient. There is no need to inspect or touch the patient.
  • Ask the patient to perform the BSE on the same day of the month every month. So, BSE should be done monthly.
  • Patient should first stand in front of the mirror, topless. Inspect the breasts from the front and also from side-to-side.
  • BSE on Youtube.

Breast Exam[edit]

  • Anamnesis:
    1. Age is important to know whether the woman should be referred to USG (under age 45) or mammography (over age 45). The reason for this is because younger women have more dense breast tissue and detection using mammography is difficult. USG, however, can detect lumps in denser tissue.
    2. Last menstruation date? This will also answer whether the woman has had menopause already.
    3. Menarche: first menstruation at what age?
    4. Recent breast-feeding history? You can ask if she has been pregnant lately or had kids lately. (Breast-feeding gives some protection against cancer).
    5. Ask about nipple discharge.
    6. If there's a mass in the breast that the patient is complaining about ("benjolan"):
      1. When did it first appear?
      2. Where is it located? Right or left breast? Is there just one?
      3. Is it painful? Does the pain get worse or better over a menstrual cycle?
      4. Does it appear and disappear or constantly there?
      5. Personal history: has this happened before?
      6. Family history of breast lumps, breast cancer, or any other cancer?
      7. Ask about related diseases.
      8. Ask whether the patient does monthly breast-self examinations. Have they noticed color, shape, or size differences? (It is normal for breasts to get firmer and larger at certains parts of each menstrual cycle).
  • Informed consent. Explain what clothing you'll ask the patient to remove, how you'll perform the exam, what you'll be searching for, and ask if they understand the procedure and that they're comfortable with it before you continue.
  • Exam:
    1. Ask the patient to remove their shirt and bra.
    2. Wash your hands.
    3. Have the patient raise their hands up in the air. Observe from the front and sides. (The patient can be seated on the edge of the bed for this step).
    4. Then ask the patient to criss-cross their fingers and apply pressure by keeping their hands in front of them. This will flex the pectoral muscles.
    5. Ask the patient to lie down with the ipsilateral arm of the breast you're examining behind their head. So, if the patient complains about the left breast, start with the right breast, ask the patient to put their right hand behind their head.
    6. Use one of the breast palpation techniques using the pads of fingers. Know the borders of the breast: sternum, clavicle, and posterior axillary line.
    7. Try to get nipple discharge by vertically squeezing the breast.
    8. Palpate both breasts.
    9. When you feel the mass, describe it: is it moveable? is it well defined? how big is it? is it painful for the patient? where exactly is it?
    10. Tell the patient the exam is complete. Ask her to dress and return to her seat.
    11. Wash your hands.
  • Education:
    1. Calm the patient. A lump in the breast does not necessarily mean it is cancer.
    2. Refer the patient, depending on her age, to either USG (under age 45) or mammography (over age 45).
    3. Tell the patient to perform monthly breast self exams.

Circumcision[edit]

Indications[edit]

  1. Religion
  2. Phimosis: when the foreskin cannot fully retract.
  3. Paraphimosis
  4. Balanitis: swelling of the glans penis.

Contraindications[edit]

  1. Hypospadia: a birth defect where the opening of the penis is wrongly placed.
  2. Epispadia: a birth defect where the urethral tube doesn't fully develop causing urine to exit the penis abnormally.
  3. Chordee: the head of the penis curves upwards or downwards.
  4. Hemophillic patient
  5. Micropenis

Links[edit]

ENT Exam[edit]

Either ear or oral cavity. Cases may include runny nose, tonsillitis, and sinusitis.

  • Turn on lamp.
  • Palpate the areas that hurt. Ask if they hurt when palpating.

Eye Exam[edit]

Snellen chart

Cases may include glaucoma or cataract.

  1. Smoking?
  2. High blood pressure?
  3. Diabetes?
  4. Family history?
  5. Ask the patient to cover one eye while you test the other.

Involves:

  • Snellen chart, finger counting, and hand waving. Tell the patient the result by using: 6 / (the smallest line they managed to read).
  • For intraocular pressure (IOP): Ask patient to look up. Palpate, using both index fingers, their eyeball through the eyelid from the bottom. One eye at a time.
  • For intraocular pressure (IOP): Ask the patient to look down. Palpate their eyeball through the eyelid from the top. One eye at a time.
  • Shine flashlight into the eye from the front and then from the side. Inspect eye along with pupillary reflex. Pull down their lower eyelid to inspect their conjunctiva. One eye at a time.

Integrated Patient Management (IPM)[edit]

Dengue fever: skin patches
Typhoid fever: rose spots
Spleen palpation
Spleen percussion
  • Uses a pediatric patient (aged 5 to 13) to test the student's communication skills with a child and their parent. The child may be a mannequin. Again, the most important aspect of IPM is communication and most of the marks according to the checklist are awarded for good communication and anamnesis skills.
  • May involve a clinical case such as dengue, typhoid, tuberculosis, hepatitis, diarrhea, flu, pneumonia, acute respiratory infection, or malaria.
  • It is important to know the disease progression for commonly tested diseases: know the fever pattern, fever intensity, symptoms, and physical signs.
  • Know commonly tested diseases' supporting lab exams and also the management including the medications and their dosage.
  • Communication is the most important skill being tested during IPM and the student needs to make sure the patient understands everything: the procedure for any physical examination, why they are being diagnosed of a disease (due to which symptoms or physical exam results?), what medications/treatment they must take, whether it will make their symptoms go away, and what they should do if their situation gets worse specifically. Reconfirm with the patient each point to ensure they understand it. It is important to communicate with both the child and the accompanying adult during the entire IPM station.
  • Anamnesis needs to be complete and relevant based on your study about the commonly tested diseases. Keep the differential diagnosis in your mind and narrow the list down by asking more and more questions. Communicate with both the child and the adult. Use the patient's name (both the child's and the parent's) and be respectful. Take notes on the provided medical record sheet, it will help summarize later on. Use open questions first and closed questions next. Allow the patient to talk, never interrupt them.
    1. Introduction:
      1. Start the anamnesis by introduction: give your name and ask for both the parent and the child's name ("Selamat pagi, saya dr Widiyanto, dengan siapa, pak? Dan, ini siapa?")
      2. Ask who the patient is. You can say something like, ("Jadi, hari ini pasiennya siapa? Bapak Mur atau adik Nungki?")
      3. Ask for the patient's age. ("Nungki, umurnya berapa?") At this point, you may also ask where the patient lives? ("Tinggal di mana, pak?")
      4. Ask how you can help to discover the chief complaint. ("Apa yang bisa saya bantu?")
      5. At this point, write down the patient and parent's name and patient's age on the medical record. Allow the patient/parent to speak as they may also answer the next question. Write down the chief complaint clearly at the top followed by "OLCART" vertically.
    2. Now (chief complaint):
      1. Onset: When did the chief complaint start? ("Mulai sejak kapan?")
      2. Location: If there is pain: where is the pain? Is there headache/stomach-ache? (Open-ended: "Sakitnya di mana?", open-ended: "Ada nyeri badan ga?", closed-ended: "Ada sakit kepala/perut?")
      3. Characteristics: What is the characteristic of the chief complaint? If fever, are there chills? Does the fever appear and disappear? When does the temperature decrease? Morning or night? ("Damamnya naik-turun?", "Ada keringat malam?", "Ada rasa dingin? Menggigil?") If pain, is the pain localized or diffuse? ("Sakitnya terpusat atau ga?") Is the pain constant or not? ("Sakitnya hilang-muncul atau terus-terusan?") How many times a day does the patient defecate? ("Berapa kali BAB sehari?")
      4. Aggravating: When does stomach-ache get worse? ("Kapan sakit perut makin parah?")
      5. Relieving: When does the fever disappear? Morning or night? ("Kapan damamnya turun? Pagi atau malam?")
      6. Treatment: What has the patient done to treat the problem so far? ("Sudah diobati?")
    3. Now (other complaints):
      1. Patients will rarely have just one complaint. It is important to ask if they have other complaints ("Ada keluhan lain?").
      2. Explore common symptoms as well. Ask about vomiting, nausea, stomach ache, diarrhea, constipation, weakness, arthralgia/myalgia, and headache, as necessary depending on whether they're related to the chief complaint.
      3. Does the disease disturb day-to-day activities? Can the child go to school? How is the patient's appetite? ("Mengganggu aktivitas seharian, ga?", "Selera makan nya gimana?")
      4. How are the eating habits of the patient? ("Pemakanan gimana? Suka makan jejan? Suka makan buah dan sayur?")
    4. Before:
      1. Ask if the patient has experienced this before. ("Sudah pernah mengalami seperti ini?")
      2. Recent illness? ("Sebelum ini, ada sakit lain ga?") For example, has the patient experienced fever in the past few days? In some diseases fever has a pattern of appearing and disappearing. The patient may not have fever at the time and may not even mention it, but it is important to know about recent fevers.
    5. Family: Ask whether neighbors or family members have experienced the same symptoms. ("Apakah ada orang di dalam rumah atau lingkungan mengalami hal yang sama?")
    6. Other:
      1. Does the child have a complete immunization history? ("Imunisasi langkap atau ga?")
      2. Allergies? ("Ada alergi? Alergi obat atau makanan?")
    7. Summary: Summarize at the end by repeating everything you've written down on the medical record sheet. Start with ("Jadi... "). Confirm if everything is correct ("Benar?") and ask if there's any additional information the patient wants to add ("ada tambahan?").
  • Informed Consent: After the anamnesis, explain to the patient that you need to examine their body to determine the disease they're suffering from. Verbal informed consent is necessary to proceed. ("Adik, nanti saya mau melakukan beberapa pemeriksaan pake alat ini. Juga, saya akan menekan dan mengetuk dada/perut adik. Pemeriksaan ini tidak berbahaya. Mungkin adik merasa kurang nyaman, tapi saya akan coba sebaik mungkin. Ok? Ada pertanyaan? Bisa lanjutkan?")
  • Physical Examination:
    • Remember to wash your hands before and after touching the patient. Make it a habit to wash or spray alcohol on your hands when asking the patient to go to or return from the examination bed.
    • Do the physical examination as quickly as possible because it takes a long time but is worth only a few marks on the checklist.
    • The physical exam in OSCE Year II is quite similar to the one in Year I, but you must have a logical/clinical reason for doing each exam.
    • Feel free to ask any questions you may have missed during the anamnesis.
    • The doctor will most likely interupt and give you the results of various physical exams you're doing. For example, while percussing the spleen, the doctor will say, "schuffner I", and while percussing liver, the doctor may say, "two centimeters below the costal margin".
  • After the physical examination, (and after getting the lab results from the doctor), tell the patient what disease you think they have. Tell them you are prescribing medicine and explain what each medicine does. For example, point at the prescription and say, "this is paracetamol 120 mg/5 mL in syrup form. Take two teaspoons every 8 hours. It is for the fever." ("obat ini untuk menurunkan demam")
  • Patients will often ask about the prognosis. Study the prognosis of commonly tested diseases. Know the length of the treatment and any complications in treated patients.
  • Ensure the patient understands what you're saying. Ask the patient if they understand when educating the patient or asking informed consent. Ask if the patient has questions several times ("Ada pertanyaan?") during the IPM station.
  • Chances are that in OSCE Year 2 you won't be able to make a definite diagnosis without supporting lab exams. After the physical exam, you can tell the doctor you'd like to order a chest x-ray, CBC, or other exam. The doctor will verbally reply with the result, e.g. "patient has low neutrophil count and low thrombocytes". After this, you have to immediately be able to diagnose the patient and prescribe the correct treatment and education. In OSCE Year 2, it is not very important to accurately diagnose the patient and know the management, however it is very important to give education, and to give accurate education it helps to have a good diagnosis and at least some knowledge of management.
  • If you still have time, give general education about eating healthy (fruits, vegetables, and eating regularly), giving attention to hygiene, and regular exercise.
  • If not referring patient to a specialist, ask the patient to return if they do not get well. ("Kalau tidak sembuh tiga hari kemudian, datang lagi").
  • Finally, ask again if the patient has any questions. ("Ada pertanyaan, pak?")
  • End the session by wishing the patient gets well soon. ("Semoga cepat sembuh").

Malaria[edit]

  • Flu-like symptoms (fever, headache, malaise, fatigue, and muscle ache) and splenomegaly. Also, shaking chills and night sweats every 48 to 72 hours. There may also be jaundice.
  • Paroxysm of fever (sudden, high fever).
  • Thrombocytopenia, elevated lactate dehydrogenase (LDH) levels, and atypical lymphocytes.
  • Treatment: Antimalarials such as chloroquine phosphate.

Typhoid Fever[edit]

  • Fever pattern: Rising daily but drops in the morning.
  • Diffuse abdominal pain and tenderness. Colicky pain in the right-upper quadrant of the abdomen.
  • Dry cough, dull frontal headache, malaise, and constipation.
  • Second week of illness: the first week symptoms progress, plus splenomegaly, bradycardia, and rose spots on the skin.
  • Widal test and Typhidot test are positive if there is presence of Salmonella Typhi.
  • Treatment: wide spectrum antibiotics such as chloramphenicol, amoxicillin, or ciprofloxacin. Also, corticosteroids such as dexamethasone.

Dengue Fever[edit]

Dengue fever: disease progression

Recognition of Dengue fever:

  1. Sudden onset of high fever
  2. Severe headache (mostly in the forehead)
  3. Pain behind the eyes which worsens with eye movement
  4. Body aches and joint pains
  5. Nausea or vomiting

Recognition of Dengue Haemorrhagic Fever (DHF): Symptoms similar to dengue fever plus, any one of the following:

  1. Severe and continuous pain in abdomen
  2. Bleeding from the nose, mouth and gums or skin bruising
  3. Frequent vomiting with or without blood
  4. Black stools, like coal tar
  5. Excessive thirst (dry mouth)
  6. Pale, cold skin
  7. Restlessness, or sleepiness

Dengue shock syndrome is defined as dengue hemorrhagic fever plus:

  1. Weak rapid pulse
  2. Narrow pulse pressure (less than 20 mm Hg)
  3. Cold, clammy skin and restlessness.


Risk factors:

  1. Usually, travel within the last 2 weeks to endemic areas is a risk factor but Yogyakarta is already an endemic area. This question is not necessary in the anamnesis.


Physical Exam:

  1. Tourniquet test: after you remove the blood pressure cuff, inspect the skin there for ruptured blood vessels. Ask the doctor if there are any petechiae. You may say something like, "I inspect the skin under the blood pressure cuff for any petechiae" during the OSCE. The doctor may respond, "yes, there are petechiae".
  2. Ask the doctor if the patient has any skin rash or spots.
  3. After checking the body temperature on the simulated patient during OSCE, the result may be normal, but sometimes the doctor will simply interject and say something like, "the temperature is 39 degrees celsius".

Supporting Exams:

  1. Blood coagulation test to check for prolongation of APTT and PT.
  2. CBC to check for leukopenia, neutropenia, thrombocytopenia, and increased hematocrit.

Education:

  1. Avoid mosquito bites. Use a mosquito net at home and mosquito repellents when going outside.

Further reading:

Lab Exam[edit]

Either blood-grouping, microbiology, or parasitology will be tested.

Blood Grouping[edit]

Microbiology[edit]

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Thick and thin blood films
  1. Describe the bacteria based on microscopic examination.
    1. Stain: Gram positive/negative? (Red/pink=gram negative, purple=gram positive).
    2. Shape: Diplococci? Strep? Staph? Round/coccus? Rod/bacilli?
    3. Other cells: neutrophils? other pmn cells? bacteria inside leukocytes?
  2. Know the treatment for infections from that bacteria. You can mention a broad-spectrum antibiotic when asked.
  3. Know about the antibiotic susceptibility test, which is used to determine which antibiotic to give to the patient.

Parasitology[edit]

  1. Blood film analysis and preparation using thick and thin method.
  2. Describe the parasites using microscopic examination.
    1. What stage is the malarial infection in?
    2. Is it infective?
  3. Describe the stain and fixing methods used.
  4. A thick blood smear is a drop of blood on a glass slide. Thick blood smears are most useful for detecting the presence of parasites, because they examine a larger sample of blood. Thick blood smears are more sensitive.
  5. A thin blood smear is a drop of blood that is spread across a large area of the slide. Thin blood smears helps doctors discover what species of malaria is causing the infection.

Neonatal Resuscitation[edit]

Neonatal resuscitation flow chart
  1. Sign your name.
  2. Anemnesis with the mother, specifically ask about risk factors and diseases that may cause fetal complications which require neonatal resuscitation, e.g. diabetes mellitus and preeclampsia.
  3. Ask for the mother's permission to handle her baby after it is born.
  4. Turn on radiant warmer.
  5. Set oxygen tank flow to 5L/min.
  6. Check the remaining instruments.
  7. Scrub in: Wash hands. Wear apron. Wear gloves.
  8. Prepare three linens: one rolled up to serve as a pillow (which will be positioned underneath the baby's neck), above that a linen spread out diagonally (so that the shoulder support is underneath one corner of this linen, and a third linen that will be used to accept the baby and then wipe it dry later.
  9. Tell the doctor, "I am ready to accept the baby". The doctor will place the baby on the linen that you're holding in your arms.
  10. 4 vital questions: Full term? Crying? Meconium? Muscle tone?
  11. WADS: Warmth, airway, dry, and stimulation.
    1. Warmth: Place the baby underneath the radiant warmer.
    2. Airway: Use bulb-syringe to clear nose and mouth.
    3. Dry: Use the linen that the baby is on to dry. Then, discard that linen.
    4. Stimulation: Rub the legs of the baby and tap the feet with your hands.
  12. Use the umbilical cord to check heartrate for 6 seconds.
  13. If the heartrate is < 100 per minute, give PPV (positive pressure ventilation) for 5 minutes and then check heartrate again.
  14. If the heartrate is > 100 per minute, check for cyanosis and breathing.
  15. If there is cyanosis, give free-flow oxygen for 5 minutes and then evaluate again by checking heartrate, cyanosis, and breathing.
  16. If skin is pink, heartrate is > 100 per minute, and the baby is breathing, then you are done.

Neurology Exam[edit]

Kernig's sign

Either of these may be tested:

  • Pathological reflexes: Babinski, Hoffman, and Tromner; or,
  • Pathological reflexes: Brudzinski and Kernig; or,
  • Nerves III, IV, and VI. Test these by asking patient to follow an H shape with their eyes without moving their head while checking for nystagmus, ptosis, and strabismus. Check pupillary reflex.

Pap Smear and STD[edit]

Either of these will be tested:

  • STD, i.e. sexually transmitted disease/infection exam using urethral discharge and skin of the genitalia; or,
    • Acetowhite Lesion: A whitish patch on the uterine cervix when it is ‘painted’ with 5% acetic acid (vinegar); the whiter the lesion, the greater the hyperkeratosis.
    • STD skills lab (PDF)
  • Pap smear

Videos[edit]

Checklist[edit]

Links[edit]