Trial OSCE exam: 'samir' by memememo

You are taking part in a trial exam created by memememo. There are 9 OSCEs in this exam (90 minutes).
 

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

Scenario:

You are approached by a medical student who has been seeing a 57yo man with chest pain that has now resolved. They have asked you to teach them how to do an ECG.

The attached files are for use during the scenario - do not look at them in advance.

View attached:   Attachment 1   Attachment 2

Instructions for the candidate

You are to teach the student how to perform an ECG and interpret the result.

Domains being examined

  • Medical Expertise
  • Scholarship and Teaching
 
The candidate has 3 minutes reading time. This OSCE is expected to run for a maximum of 7 minutes.

For the actor

Patient:
May be mannequin. If you're a real person, you are 57 and had about 1 hour of low central chest pain with radiation to the jaw. You have never had this before, and have no cardiac history. The pain fully resolved after you were given medications by the ambulance (aspirin and GTN).

Student:
If the candidate dwells on history/exam/management, state that you have discussed this patient with another consultant, and really just need help with the ECG.
You are a capable student in the last years of med school. You have not done an ECG in the last 2 years. You interpretation of this ECG is limited to recognising a sinus rhythm and no obvious changes.

Questions to ask:
- "I've noted nearly everyone in ED gets an ECG. What are the indications for this?"
- "What are the landmarks for electrode placement?"
- "I've seen nurses put the electrodes on the torso / distal limbs (whatever the candidate does not do) for the limb leads - does this make a difference?"
- "How do you tell which lead goes where?"

After first ECG:
- if candidate recognises possible posterior involvement
-- "Is there a way to better show posterior involvement on the ECG?"

- if candidate does not recognise posterior involvement
-- "I once saw someone doing an ECG with electrodes on the back - what does that show us?"

If there is time:
- "Can you explain to me how to calculate axis?"

For the examiner

Requirements: ECG machine and adhesive electrodes. Mannequin (caution using some adhesive electrodes on these) or patient willing to have many electrodes placed and removed.

The focus in on the procedure and ECG interpretation, with progression to posterior leads. The candidate should not dwell on the history or examination.

The first ECG can be revealed with the first ECG, the second, showing posterior leads, if this is performed

Domains Assessment Objectives

Medical Expertise
Procedure and interpretation of ECG
Recognition of posterior MI and use of posterior leads

Scholarship and Teaching
Clear teaching approach

Other Assessment Notes

1. ECG acquisition
- ECG settings (speed, amplitude)
- explanation to patient & student
- electrode placement (limb leads distally preferable (handy mnemonic to remember colours? Less sensitive if proximal placement), V1 & V2 in 4th ICS parasternal, V3 btween V2 and V4, V4 5th ICS mid-clavicular, V5 & V6 on same plane as V4 in anterior axillary and mid-axillary lines respectively)
-- leave electrodes in place for future recordings
- patient data entry
- print ECG

2. ECG interpretation
- NSR, normal axis
- Dominant R wave, ST depression V2-V4, upright Ts
- 1mm ST elevation III, aVF
- acute Ts laterally
- consider posterior MI

3. Posterior leads
- V7-9 placement
-- V8 at tip scapula, V9 midway to paraspinal muscles at same level, V7 posterior axillary line same level
- criteria for ST elevation less (0.5mm)

4. Teaching
- establish rapport and experience
- allow questions
- set learning objectives and follow up

Bonus
- explanation of axis
- ensure patient adequately treated, mention cath lab as appropriate option

The ECGs for this case come from http://lifeinthefastlane.com/ecg-library/pmi/