Trial OSCE exam: '3' by Jayapiriya
You have 3 minutes reading time. This OSCE will run for a maximum of 7 minutes.
A 12 year old boy presents with severe RIF pain. He presented yesterday but was sent home.
Instructions for the candidate
You are required to take a history and examine the patient and then explain the likely diagnosis to the mother.
You are then required to manage the scenario as it unfolds.
Domains being examined
- Medical Expertise
For the actor
12 year old boy.
Presented yesterday with severe abdominal pain, initially central migrated to RIF and became severe.
Vomited twice, slight fever.
Feeling generally unwell, don’t feel like eating.
No pain on urination
Not ever sexually active
Pain increasing today, constant, severe, but worse with movement/walking.
When the candidate examines your abdomen it is not sore, same as yesterday. When he asks to examine your scrotum he will be given a photo showing the problem. He will not actually examine your scrotum.
History as above, immunisation up to date, no allergies, no usual medications, no asthma, no diabetes etc.
When the candidate is given the photo you should become reasonable angry that he was sent home yestaerday and now might lose one of his testicles (very likely).
Now needs urgent surgery, but the surgery will probably not make any difference. It would have done yesterday.
When the candidate requests yesterday’s notes they are available and are given to him. If he does not ask for them then the examiner will give them anyway. The candidate should have a look at the notes, which suggest “appendicitis unlikely” (which is true) but there is no record of examination of the scrotum. You are sure that the testicle was not examined. (You would have remembered that!)
Now you want to know what can be done to save the testicle? Will he have decreased fertility?
For the examiner
The child has severe right iliac fossa pain but the abdomen is soft and non tender. The child has a fever of 37.8 degrees.
They are in obvious pain which is worse with movement. The patient has a warm tender scrotum. When the candidate asks to examine the scrotum you are to give them the photo provided, which shows an acute testiculat torsion.
If the candidate does not examine the scrotum they should not be prompted.
When they make the diagnosis of torsion the mother will become quite angry that her son was seen and sent home yesterday. At that point the candidate can be given the notes from yesterday (provided) which show an assessment of “appendicitis unlikely” on the basis of soft abdomen with not RIF tenderness/rebound or guarding. There is no note of testicular examination at all.
The candidate is then required to discuss this with the mother and make a management plan including immediate referral to Urology as well as specifically addressing the issue of possibly poor assessment the day before.
Domains Assessment Objectives
- Medical Expertise
- Must make the connection between severe RIF pain, normal abdo exam and then move on to examine the scrotum. Must understand that the testicle is probably not salvagable but should make an urgent surgical referral.
- Must take a good history from the patient and mother. Must also deal with the situation when the mother is (very reasonably) upset over the missed diagnosis.
- Should be able to deal with a potentially quite difficult situation calmly and professionally.