Here comes the shame OSCE by Michael

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

Scenario:

A 23yo female presents to your ED requesting the morning after pill.

Instructions for the candidate

You are the consultant on in your urban ED's "minors" area on a Sunday morning. You are to take a history, provide a management plan and answer any questions she may have.

Domains being examined

  • Medical Expertise
  • Communication
  • Health Advocacy
  • Professionalism
 
The candidate has 3 minutes reading time. This OSCE is expected to run for a maximum of 7 minutes.

For the actor

You are a 23-year-old admin assistant. You have a history of mild asthma requiring Ventolin only occasionally, no other medications. You are not on the oral or other contraceptive. No allergies. You smoke cigarettes when out with friends. You drink alcohol to excess once or twice a week - you regard this to be normal behaviour. When out with friends you will drink at least 10 standard drinks and occasionally use ecstasy.

Friday night was one of these nights. It ended with you going home with a man you met that night and you had unprotected consensual vaginal sex (~36 hours ago). You know nothing about this person, but he appeared to be a well-kempt professional, and had no markers of being a IV drug user. If asked, there was no suggestion of drink spiking or sexual assault.

You went out again with your friends last night and they have encouraged you to get emergency contraception. Your last period was 2 weeks ago. You have regular menses. You do not wish to fall pregnant.

You have no known STIs. You had not considered STI risk from this encounter, but are willing to consider antibiotics and swabs as required if the candidate explains the issue clearly. After STI risk is raised, you can ask about your risk of contracting HIV or hepatitis and whether you should receive prophylactic treatment for these.

You do not consider your behaviour to be abnormal or especially risky. You are willing to take on board other opinions if presented in a non-threatening and professional manner.

For the examiner

None.

Domains Assessment Objectives

Medical Expertise
Knowledge of emergency contraception
Knowledge of STI investigation and management (including HIV/hep C)

Communication
Establish rapport, take effective history
Clearly explain investigation and management

Health Advocacy
Address issues of risky behaviour and substance misuse

Professionalism
Maintain professional manner and approach

Other Assessment Notes

- emergency contraception
-- levonorgestrel 0.75mg stat and 12 hours later. Antiemetics, although lower incidence than older regimen
-- efficacy up to 84% in first 72 hours
-- will delay next period

- STI prophylaxis
-- IV or IM ceftriaxone 500mg, azithro 1g PO

- HIV/Hep C screening and discuss PEP
-- Unless known HIV/Hep C then limited value in PEP, but should have testing for 3 months
-- Excellent PEP summary from ASHM: http://www.ashm.org.au/pep-guidelines

- Risky behaviour - unprotected promiscuity, alcohol and drug abuse
-- Counselling technique

Bonus points:
- Forensic issues (drink spiking, possible sexual assault)
- What would you do if this patient were a minor?


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