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:

Clinical Scenario Stem:

You are the consultant coming on for your morning handover at your regional ED. The number of presentations overnight was no more than usual, and there is no access block.
Your hospital has a single registrar on overnight (Leila), and she seems a little flustered. She has already handed over the rest of the department to your colleague. It is now time for her to hand over the 6 bed short-stay unit to you.

The department/nursing running sheet shows the following:

bed 1: 70 yo female abdo pain and tenderness normal FBE UEC LFT. ongoing pain.

bed 2: 22 yo male open fracture middle finger, for theatre (plastics) on 2pm emergency list

bed 3: 30 yo female, Left ileac fossa and flank pain, blood and WBC in urine, for IV gentamicin

bed 4: 90 yo female, fall at home, some confusion. UEC FBE ECG CTB normal. Med reg said no.

bed 5: empty

bed 6: empty

Your task is to
- take the handover from the registrar
- make suggestions or changes if and where appropriate.


7 mins station with 3 mins pre reading

Instructions for the candidate

[ nb. many similar practice o.s.c.e s available at: http://www.edcentral.com.au/education/fellowship-exam-resources/osce-administration ]

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

You are Leila. (3rd year reg if the topic comes up, immediately post primary exam)

You have had a frustrating shift, in that you have tried to make a few referrals with multiple phone calls. both bed 1 & 4 have been bounced as below… later on when the candidate changes the patient plans and/or directs that most of the patients should be admitted, appear somewhat dispirited. if the candidate explores this, voice something to the extent that you can’t win &/or you are still struggling to work out what is appropriate for short stay….

but first- give the handover, ideally fairly succinctly as time is an issue in this station

1/ 70 yo lady with PHx of NIDDM and PVD. abdo pain from about 6 pm, presented at midnight with pain and significant tenderness. no vomiting, BNO 2 days. she had a UEC FBE LFT Lipase all with normal results at time of presentation and CRP 25. You had referred her to registrar at 2am but he said with “normal” bloods and CRP “not that hight” unlikely to be any issue, likely constipation. Has been treated with lactulose and movicol and kept in SSU overnight. bowels since opened, but still has abdo pain only transiently improving with morphine.
{if asked - surg reg not seen pt}

(if asked, not in AF. “maybe” rebound. nothing focal. nothing urinary. no past surg hx)

2/ 22 yo with open fracture right (dominant) middle finger from power tool injury doing DIY home renovation. washed out, abc given, tetanus given, splinted, and referred to plastics. they will do in theatre on PM list , asked he be kept on SSU and fasted after EMB then they will call for him after midday.

3/ 30 yo female seen by one of your residents. no past history. presented with 1-2 days of left ileac fossa pain and flank pain. FBE UEC “normal”. has 2+ blood and 2+ leuk on urine FWT. admitted for Rx with IV gentamicin, and plan for renal US if not improving. (leave your handover there)
if asked about PV bleeding / bHCG / LMP / fever etc you have no idea, you just accepted the resident impression.

4/ 90 yo female, brought by ambulance after a fall at home, had been unable to get up. daughter thinks she might be a bit confused / not her normal self. UEC FBE BSL CMP CT brain normal. only on aspirin and irbesartan.
had referred to med registrar for inpatient admission, but they said with normal bloods and now mobilising well so for social work/outreach review in the AM then home with extra support.
{again if asked, med reg not seen pt but did check all results on computer}
{if asked about urine MCS or focal features or whatever - make it up or be vague, i don’t really care, it’s not the point}

try to move though these with some eye to time unless you are interrupted on the go by candidate. It is hoped there is time at the end for some sort of overall teaching moment regarding the ideal use of SSU and/or graded assertiveness with inpatient registrars overnight.

For the examiner

Domains Assessment Objectives

Medical Expertise
appropriate corrections to patient management:
1 - CTAP, ECG for AF, surgical admission, +/- blood gas
2 - should be admitted
3 - needs bHCG and reevaluation of diagnosis
4 - needs more extensive inpatient workup

Prioritisation And Decision Making
Efficiency of changes in management as above/below

Scholarship and Teaching
Several learning points for each case that would be relevant for future patients
Ideally the candidate creates some time at the end for education on the general principles behind a short stay/obsefvation unit and its best use, AND/OR graded assertiveness techniques with inpatient referrals, perhaps as well as making a future time to go over it and/or future reg education on the topic and/or undertake to make clearer departmental guidelines for admission categories.
- it’s perhaps not realistic to expect all 3 of these in detail in the timeframe but if one is done in depth that could substitute for covering all 3.

Other Assessment Notes