Trial OSCE exam: 'Victory' by Soe Naing

You are taking part in a trial exam created by Soe Naing. 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:

ECG and History Station:

The participants are the candidate, and a junior registrar. The candidate has received instructions that they are a consultant and will be approached by the registrar to discuss a patient.
As part of this they will interpret an ECG (that is provided outside the room). They are to describe and interpret the ECG whilst teaching the registrar about paediatric ECGs, obtain a history of the child, formulate a management plan.

View attached:   Attachment 1

Instructions for the candidate

You are the duty consultant

A junior registrar will approach you with an ECG (provided outside room) of a 4 year old child they have seen.

TASKS :
Describe and interpret the ECG and educate the registrar on paediatric ECGs
Obtain history and examination findings of the patient
Formulate a management plan

Domains being examined

  • Medical Expertise
  • Prioritisation And Decision Making
  • 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

INSTRUCTIONS FOR “JUNIOR REG”

You have just seen 4 year old Sally. You have limited paediatric experience.

The nurses took an ECG for you but you are unsure how to interpret paediatric ECGs and have only very basic ECG knowledge

History / Examination you have obtained so far :

4 yr old, immunised
Lives with parents and younger sister (18 months old) in close proximity to ED
Bronchiolitis at 1 year old

Sally has been unwell for 24 hours with fever. Her little sister has recently had an URTI.
Currently she has no localising Sx (you have done a very thorough Hx, anything your consultant asks about the answer is negative).

She has been disinterested in food and is drinking a bit less but still passing usual amount of urine.

Behaviour : grumpy and irritable and running around less. Seems to brighten up after paracetamol for a few hours then fever returns.

Examination : looks well, all vitals in normal range except febrile 38.2 and HR 135
No localising findings. Normal behaviour.

If asked by consultant specifically - urinalysis is clear (clean catch)

For the examiner

Domains Assessment Objectives

Medical Expertise

Prioritisation And Decision Making

Scholarship and Teaching

Other Assessment Notes

ECG INTERPRETATION :
Rate 135-160, 
Rhythm sinus, 
Normal axis, 
Mention intervals (PR, QRS, QT), TWI V1-3 and lead III and ST depression V4-6

Interpret: Sinus tachycardia even for a 4 year old. Anterior TWI (maybe normal for age)

NORMAL PAEDIATRIC ECG : mentions at least 4 features to pass
- Heart rate >100 beats/min
- Rightward QRS axis > +90°
- T wave inversions in V1-3 (“juvenile T-wave pattern”)
- Dominant R wave in V1
- RSR’ pattern in V1
- Marked sinus arrhythmia
- Short PR interval (< 120ms) and QRS duration (<80ms)
- Slightly peaked P waves (< 3mm in height is normal if ≤ 6 months)
- Slightly long QTc (≤ 490ms in infants ≤ 6 months)
- Q waves in the inferior and left precordial leads.

Risk stratification of febrile child :

FEATURES TO BE SOUGHT ON HISTORY :
◦ Localising symptoms
◦ Travel history
◦ Sick contacts
◦ Immunisation hx
◦ PHx
◦ Social Hx / parental coping and understanding

FEATURES TO BE SOUGHT ON EXAMINATION:
◦ General behaviour and appearance
◦ Well vs unwell (should specifically seek signs suggestive of an unwell child: lethargic, poor interaction, inconsolability, tachycardia, poor peripheral perfusion, tachypnoea, cyanosis)
◦ Localising signs: ENT exam, neck stiffness, work of breathing, abdominal tenderness / masses, rash, swollen joints

ESTABLISH THAT :
Child has no clear source but is well despite fever and tachycardia, maybe a little dehydrated. Potentially developing URTI (sister unwell with URTI)
Parents are sensible and live near ED
Advise urine mcs -> already collected and is negative on dipstick

PLAN : Plan for discharge with GP review within 24 hour and clear ED representation criteria provided to parents