Objective Structured Clinical Examination

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Objective Structured Clinical Examination:

Objective Structured Clinical Examination


OSCE A circuit of assessment stations Range of practical clinical skills Previously determined objective marking skills “Showing how” level of Millers pyramid of knowledge Uniform marking scheme for examiners Consistent examination scenarios for students

Conventional Examination:

Conventional Examination Student variability Patient or experiment variability Examiner Variability Coefficient correlation between marks awarded by different examiners for the same candidate maybe as low as .25 Depend on Global performance and not individual competencies

Conventional Examination:

Conventional Examination Communication Problems affect outcome Attitudes not tested In clinical skills student questioned only regarding his final conclusions Ability to examine a patient not observed No significant feed back to the candidate

Components of an OSCE:

Components of an OSCE Components of clinical competence History Taking Physical Examination Simple Procedures Interpretation of Lab Results Patient management problems Communication skills Attitude


OSCE Observed Stations Response Stations

Features of OSCE:

Features of OSCE Usually 31 stations in the NBE Five are Observed stations Three are rest stations Twenty three are response stations

Observed Stations:

Observed Stations Usually Five stations Resuscitation Station History Taking Counseling Clinical Examination Procedure Clinical Examination of Newborn

Observed Stations:

Observed Stations Always introduce yourself to the patient or the simulator Try and make them comfortable In case doing an examination always remember to wash hands Always communicate clearly and in an empathetic manner Do not use your hands whilst communicating

Observed Stations:

Observed Stations What is important to understand that we must follow a certain set procedure In the clinical examination the methodology should be correct

Station 1: Resuscitation:

Station 1: Resuscitation You are resuscitating a newborn at birth. The baby is limp and blue, heart rate <100 . You have done following steps Dried, warmed & positioned Suctioned Stimulate, give bag & mask ventilation (40-60/min) Heart rate <60 and gave cardiac massage (120/min) Bag & Mask inadequate so intubated

Station 1 (contd):

Station 1 (contd) No improvement at 1 min Demonstrate what steps you would take for the resuscitation of this newborn.

Instructions To Examiners:

Instructions To Examiners Place IV or umblical line Has mother received Narcotics No, then Epinepherine IV or IT If no improvement sodabicarb 2 meq/kg No improvement check bag delivers 100% O 2 Head not overflexed ET tube in Trachea Adequate ventilation pressure Adequate cardiac Massage


STATION 2: A baby is admitted to the NICU with Persistent pulmonary hypertension (PPHN). He is on ventilator with FiO 2 100% , PIP 35 and PEEP 6 and SpO 2 85% and he has following lab values: ARTERIAL BLOOD GAS pH: 7.22 pCO2: 50 pO2: 50 ELECTROLYTES, BUN & CREATININE Na: 136 K: 4 Cl: 103


Questions Q1 Calculate Alveolar-arterial oxygen gradient. Assume Respiratory Quotient (RQ)=0.8 Q2 What are the indications for Extracorporeal Membrane Oxygenation (ECMO)?


Answers Ans 1 PAO2 = FiO2 (760- H2O) – PCO2/RQ = 1(760-47) –50/0.8 =713-62.5 =650 Oxygen Gradient =pAO2 –pAO2 = 650-50= 600 Ans 2 -Reversible respiratory failure - Predicted mortality rate with conventional therapy great enough to warrant risk of ECMO. Oxygen gradient >600 for 12 hr 94% mortality or >610 at 8 hr 79% mortality


ECG Please read following statements and mark true (T) or False (F) for each Leads II, III and aVF record changes on the inferior or diaphragmatic surface of the heart Leads I and aVL record changes from the lateral border of the heart Chest leads overlie the interventicular septum and anterior wall of the right ventricle Ventricular depolarization is the source of the changes in electrical potentials which cause the P wave T wave is due to ventricular repolarization


Answers T T F F T


STATION 4 Q 1 Please choose appropriate container/bag for the type of waste TYPE OF WASTE TYPE OF CONTAINER Sharps Blue container puncture proof Solid Infectitious Yellow plastic bag Anatomical Yellow plastic bag Solid Non-infectitious Red big plastic bucket Microbiology & Biotechnology Yellow plastic bag waste

Station 5: Drugs:

Station 5: Drugs Paracetamol What are the indications for its usage? Name the route and dose to be given. How frequently it can be given and What is the dose limit? What can be done to prevent toxicity? What is the antidote for paracetamol toxicity? What dose to be given?

Answers STATION 5: DRUG :

Answers STATION 5: DRUG Analgesic & antipyretic. Oral /rectal . Dose 10-20 mg/kg/dose 4-6 hrly. 1 gram/dose or 60-90mg/kg/day Toxicity is described with chronic usage in normal range. If chronic use consider reducing dose to lower end of the range N acetyl Cysteine. 150 mg/kg iv over 15 min followed by 50 mg/kg iv over next 4 hr then 100 mg/kg iv over next 16 hr

Station 6: Counseling session:

Station 6: Counseling session You have been called in to do genetic counseling of the parents of a child with Wiskott -Aldrich Syndrome. How would you proceed?

Examiners List:

Examiners List Introduces himself and tries to make the parents comfortable Diagnosis - based on history, physical examination, investigations Risk in next child – male Genetic basis describes X linked recessive Curable with BMT if donor available otherwise may live up to 15 yr

Station 7: Nutrition:

Station 7: Nutrition Write Total Parental Nutrition Order for a 3 yr old boy with weight of 10 kg who is getting all his drugs and infusions in 200ml of 5% dextrose.


Answer Fluids 100ml/kg = 1000 ml 200ml 5% dextrose = Calories =10x3.4 = 34 Total calories needed = 1000 Protein 2g/kg = 20gm Fat 3g/kg = 30g x 10 = 300cal 20% fat 150ml 110 ml 20% amino acids = 100ml= 80cal 1000-430 = 590 cal in 600ml 25% dextrose 600ml = 150 x 3.4 = 510cal

STATION 8: Growth & Development:

STATION 8: Growth & Development Please write TANNER STAGE of the following patients Girl BREAST - breast and papilla elevated as small mound; areolar diameter increased “bud” stage PUBIC HAIR - sparse, lightly pigmented, straight, medial border of labia Boy PUBIC HAIR – Hair spreads sparsely, darker, coarser PENIS – elongates TESTES - 10-15 ml volume Q2. Define Adolescence. Name sub stages of adolescence with age range.

STATION 8: Answers:

STATION 8: Answers STAGE 2 girl, STAGE 3 BOY It is a time of physical, psychological and emotional transition from childhood to adulthood. Sub stages – early 10-14 yr Mid 14-17 yr Late 17-20 yr

STATION 9: National Programs:

STATION 9: National Programs Define `Problem Village` AS DESCRIBED UNDER National water supply and sanitation program . Name four components of Minimum Needs Program (8 components) Name technique invented by Environmental Engineering Research Institute Nagpur for defluoridation of Water .

STATION 9: Answers:

STATION 9: Answers Answer 1 Problem village is one where no source of safe water is available within distance of 1.6 km / where water is available at depth more than 15 mtr / or water source has excess of salinity, toxic elements or water is exposed to risk of Cholera Answer 2 Rural health / Rural Water supply / Rural Electrification/ Elementry education / Adult education / Nutrition/ Environmental improvement of urban slums / Houses of landless labourers Answer 3 Nalgonda Technique


STATION 10: HISTORY TAKING A 9 yr old child presents to you in OPD with anemia and recurrent pain abdomen. There are no worm infestations. How would you take the environmental history?


Answers: Introduces himself and tries to make parents comfortable Enquiry into present & past home location-industrial area/river Age of house & condition of home for lead exposure Enquires into following environmental areas: School, Work, Play & Home


STATION 12: What vaccination schedule would you offer a new born baby born to a HbsAg+ve mother and when? Which vaccine would you advice a Thallasemic patient who is undergoing a splenectomy? What is the minimum duration advised between vaccination and splenectomy? Write the vaccination schedule for a person who has been bitten by a dog 3 hours back. The patient had been bitten by the same animal 1 year back and has received a full course of vaccinations at that time.

STATION 12: Answers:

STATION 12: Answers HBIG and Hep B vaccine to be given within 24 hours of birth at different sites, followed by Hep B vaccination at 1 and 6 months. (IAP Recommendation- not 0,1,2 ,12) HIB, Pneumococcal, Meningococcal, Typhoid 2 weeks 2 doses of the vaccine are recommended on Day 0 and 7 only

STATION 13: Statistics:

STATION 13: Statistics In a hospital 1in 5000 patients on average is finally diagnosed as a case of abdominal tuberculosis (D). Further that the complaints of pain in abdomen, vomiting and constipation (C) of long duration are seen in 70% of cases of abdominal tuberculosis. If a survey of records of that hospital also shows that these complaints are reported by nearly 1 in 1000 patients with all diseases. What is the chance that a random patient reporting in that hospital with above complaints (C) is a case of abdominal tuberculosis (D)?

Slide 35:

Hint – Apply Bayes’ rule P (C n D) = P (Dn C) P (C/D) = P (C n D) / P (D) P (D/C) = P (D n C) / P (C) P (D/C) = P (C/D) P(D) / P(C) Answer 14% C D C&D

Station 14: Emergencies:

Station 14: Emergencies What is the age of peak incidence of appendicitis? In what percentage of children, less than two years of age, with appendicitis has the appendix already perforated at presentation? What is the classic triad for intussusception? What laboratory tests are satisfactory as an initial screen in patients with abdominal pain? What is the treatment of choice for intussusception? Name three causes of abdominal pain arising from a gonad in a young girl. What is the classic finding on appendicitis? How do you test for peritoneal irritation?

STATION 14: Answers:

STATION 14: Answers Teenage and young adult years Most Severe episodic pain "Currant jelly' stool Transverse tubular abdominal mass CBC U/A, BUN, Creatinine, electrolytes, blood sugar Serum amylase, lipase, aminotransferase, Examination of stool, Chest x-ray Flat and upright film of abdomen Hydrostatic reduction Ovarian tumor, Torsion of an ovary, Ruptured ovarian cyst RLQ tenderness Rebound tenderness

Station 15: Genetics:

Station 15: Genetics

Slide 39:

Identify the type of inheritance What is the risk of recurrence in each pregnancy? Which of these disorders consistent with this inheritance pattern – hemophilia, Gaucher disease, diabetes mellitus, achondroplasia? If the parents had been consanguineous, how would you indicate it on the pedigree chart? How will you show an affected alive boy versus an affected deceased boy?

STATION 15 Answer ::

STATION 15 Answer : Autosomal recessive 25% Gaucher disease By drawing a double line between the parents Affected alive affected deceased

STATION 16: Case Scenario:

STATION 16: Case Scenario 3 year old male child presented with loose motions for 3 days 5 days back. On 2nd day of loose motions patient passed blood along with stool which he continued to pass till loose motion subsided .On 4th day of illness loose motions stopped but also developed oliguria. Patient became irritable, not passed urine for past 24 hours. Patient also had one episode of abnormal movement 1 hour back which subsided within 1 hour .Parents were giving ORS for past 3 days. Weaning was started 3 months back On examination – Pallor ++, petechiae, hepatomegaly, tachypnoea, oedematous, BP – 100/60 Mild acidosis on ABG.

Slide 42:

Name two differential diagnosis Name surgical condition which can be associated with above clinical picture Name 3 electrolyte disturbances can be associated with it. Management plan Name common agent causing it

STATION 16: Answers:

STATION 16: Answers a) HUS b) AGN c) Dyselectrolytemia d) Intussception Intussception Hyponatremia / Hypenatremia / Hyperkalemia IVF (ARF regime), PD E Coli – 0157: H7

STATION 17: Case Scenario:

STATION 17: Case Scenario A 2 yr old child presents with cough ,cold ,fever and touching his left ear. How would you examine this child ?

Slide 45:

Introduces himself and establishes rapport with patient Takes permission to examine Asks mother to hold child with one hand and head with other Starts careful examination of pinna & surrounding scalp Examines external meatus

Slide 46:

Otoscope used or not with good lighting Pulls pinna horizontal & backwards Otoscope held like pen with ulnar palm touching head of child Normal membrane greyish translucent

STATION 18: Questions on Case Scenario:

STATION 18: Questions on Case Scenario What is CSOM? What are the differences between safe and unsafe CSOM? Give three How would you treat safe and unsafe CSOM?

STATION 18: Answers:

STATION 18: Answers Chronic suppurative otitis media Safe - tubotympanic disease, residual of ASOM, central perforation, copious discharge, granulation absent, conductive loss, sclerotic changes on x-ray Unsafe - atticoantral, perfoartion in attic, Granulation common, cholesteatoma formed with destruction of mastoid bone, scanty discharge, mixed hearing loss Tympanoplasty (safe), Mastoidectomy (unsafe)

Station 19: Case Scenarios:

Station 19: Case Scenarios CLINICAL PHOTOGRAPH OF A 2 YR OLD BOY WHO PRESENTED WITH ABDOMINAL LUMP Likely Diagnosis How to treat? What is the prognosis ?

STATION 19: Answers:

STATION 19: Answers Neuroblastoma stage IV Chemotherapy, local surgery + radiotherapy, Autologous BMT, Cis retinoic Acid Poor prognosis. <30% chance of cure

Slide 51:

Describe this peripheral smear. What investigation would you like to do next?


STATION 22 A 13 year old boy presented with ataxia. How would you examine his gait?

Examiner Check List:

Examiner Check List Introduces himself and establishes rapport with patient Takes permission to examine Undresses the child before examination No need to take history just examine Can patient walk at all Does he walk in straight line etc.


STATION 23 How would you distinguish between gray and white matter diseases of brain? At least 8 points

Slide 55:

Gray matter Dementia Early Seizures Early prominent Disturbed tone, gait, reflexes - Uncommon late Basal ganglia signs symptoms - Present Retinitis pigmentosa - May be present MRI - Cortical atrophy, basal ganglia disease ERG - May be abnormal VER/BERA - Normal White matter Late Late Most prominent feature Absent Absent Good yield for white matter disease Normal Abnormal

Station 25: Chest PA:

Station 25: Chest PA


STATION 26: Answer Following questions based on Xray seen on STATION 25 Describe Findings of the Chest X ray. Likely diagnosis


ANSWERS STATION 26 Left pleural effusion, chest tube in situ left side, mediastinal widening T cell Lymphoma or Tuberculosis

Slide 59:

This child presented with pain abdomen and fever off & on for 1 month.

STATION 30: Questions:

STATION 30: Questions Please answer questions on basis of CT Abdomen shown on station 29. Describe the findings on this CT scan. What is the likely diagnosis? What is the next step in the management?

ANSWERS Station 30.:

ANSWERS Station 30. Right sided abdominal mass involving gut Abdominal Lymphoma CBC and Bone Marrow for staging. Surgical biopsy / resection if possible.

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