Ballet Class OSCE by Luke Jeremijenko

 
You have 3 minutes reading time. This OSCE will run for a maximum of 7 minutes.

Scenario:

15 year old BOY presents to your mixed tertiary ED. His mother has been able to convince him to come up (again!) after he fainted on school parade this afternoon. She is most concerned about his head and is demanding a CT scan.. "she seems is a bit type A".

Last time he was seen in the department he was discharged by a registrar before being reviewed by the paediatric registrar -

This time, your registrar has assessed him and wants to know what to do.

Your tasks are to:
- Take a focused history
- Guide Investigations and Management

Instructions for the candidate

Domains being examined

  • Medical Expertise
  • Prioritisation And Decision Making
  • Communication
 
The candidate has 3 minutes reading time. This OSCE is expected to run for a maximum of 7 minutes.

For the actor

You name is John and you a thorough registrar but have never dealt with male anorexia nervosa before. You passed your primaries 2 years ago and are completing the logbook for your paediatric component.

Start with a line akin to "I have just reviewed a 15 year old boy named Tom. His mother did most of the talking. He looks skinny but think that this might be a growth spurt'

He did faint at school, but that was because they had him standing out in the hot sun for friday parade. He missed lunch as he was in the library finishing of his Maths C (or whatever the hard maths is in your state / country). He made a full recovery, no tongue biting etc and just wants to go home.

His maximum weight was 60kg, and that was 6 months ago. If asked his height is 178 and weight 55kg today ~ BMI 17

All - nil, Meds - nil, Last ate - 8 hours ago

SH
Going to an elite private boys school (insert city - you all know the ones!). "Doesn't fit in with the rugby union / league / AFL crowd". He does Ballet class and is trying out for the (respect state / country) ballet. His training has increased to 5 times per week in the lead up to the state competition. Really smart - A+ student but his grades have slipped this semester - now A-

Nil alcohol, nil smoking, nil drugs

Has had a girlfriend from ballet class but "didn't work"
If pushed by the consultant "he admits he might like boys as well but is uncertain at this stage"
Has never had anal or vaginal intercourse

Nil depression, nil suicidality.

If pushed "Does not purge, no laxatives, restrictive type eating pattern"

Other stuff if asked previous notes - You did review the old ED notes they were brief and stated " ?if meets criteria for admission - await paeds review". 3 hours later - "patient did not waited - stated would see GP"

FH - nothing medical but if you feeling generous "mother was a high level ballerina" "dad is a wealthy executive"

On Exam
T 36.1
P 52 reg
BP 90/60, no postural drop
HS 1+2+nil
Chest clear
nil infective foci
no focal neuro

Investigations
Bedside - If asked for the BSL 3.5
if asked - urine - NAD

If asked for Bloods:
Hb 118 WCC 9
Sodium = 138 mmol/L
Potassium = 2.9 mmol/L
Urea = 3.3 mmol/L
Creatinine = 48 umol/L
Albumin = 29 g/L
Bili = 11 umol/L
ALP = 83 IU/L
ALT = 134 IU/L
Magnesium = 0.71 mmol/L
Phosphate = 0.62 mmol/L

If asked - CXR - NAD

If asked - 12 Lead ECG - Sinus bradycardia HR 50, no hypokalaemic changes

For the examiner

Not uncommon presentation in women 14-18 but recently increasing problem with young boys. D

 

Diagnostic Criteria for AN

• Refusal to maintain body weight at or above a minimally normal weight for age and height (< 85% IBW)

• Intense fear of gaining weight

• Disturbed perception of body shape and/or size

• Amenorrhea (absence of at least 3 consecutive periods)

 

• Restricting Type: Accomplishes weight loss through dieting, fasting, or excessive exercise.

• Binge-Eating/Purging Type: Regularly engages in binge-eating or purging behavior

 

Female athlete triad - but for boys

Domains Assessment Objectives

Medical Expertise
Thorough history - specifically asks BMI, specifically asks about depression and suicidality
Tease out thorough obs, Temp, Pulse, RR, BP (including postural drop)
Specific about investigations - bedside - BSL. Bloods - anaemia, electrolyte abnromalities, albumin
Disposition - Can't go home - hypokalaemic and hypophosphatemic.
Slow IV fluids (can get heart failure)
Slow NG refeeding
Start thiamine, micronutrients (Zn, Fe, Sc), Fat sol vitamins ADEK, need to be reviewed by nutritionist on the ward
Think about bone mineral density - consider Ca supplementation
Neuro obs q4h, if develops neuro - let ICU know
Regular bloods - watching for hypophosphataemia etc...

Prioritisation And Decision Making
Refer to paediatrician with special interest in eating disorder
Ask for and consent for NGT in ED! Yes - mandatory. Check your local guideline but this is now very common for any child with electrolyte abnormalities - stops bargaining / behavioural issues on the ward

Communication
Start open ended questions with your registrar
Explain yes "it could just be moderate eating disorder and they might be fine going home, but do mind if we just exclude some other things first?"
Drill down focused history - excluding DDX - no depression, no suicidality
Good Social history for these touchy feely stations - HEADSS mnemonic for adolescent psych
Detailed examination - need the obs, need postural drop
Then last 2 minutes - really smash out the management - show your Decision making and medical expertise
Last 30 seconds - Questions from the registrar
Last 10 seconds - Extra marks for teaching and "lets do a teaching session on AN for next registrar meeting, here are some references.."

Other Assessment Notes


You must be logged in to add a comment

Comments:

There are no comments on this OSCE