Professional Documents
Culture Documents
Instructions
The
patient
in
the
next
room
is
Carol
who
is
68
years
old.
She
has
presented
because
she
is
experiencing
increasing
pain
in
her
hands.
You
have
eight
(8)
minutes
to
discuss
with
the
examiner
three
(3)
differential
diagnoses,
these
should
be
the
most
likely
diagnoses.
You
should
include
at
least
two
(2)
positive
and
two
(2)
negative
features
of
this
history,
other
than
those
listed
above,
which
support
or
refute
your
diagnoses.
You
should
expect
the
examiner
to
ask
questions
around
your
reasoning.
TASKS
Differential
diagnoses
with
reasoning
8
minutes
History
of
Presenting
Complaint
Carol
-
a
68
year
old
female.
Occupation
Housewife
Social
Hx
Lives
with
husband
and
eldest
son
on
a
pineapple
farm
in
a
small
town
3
hrs
North-West
of
Brisbane.
She
has
2
other
adult
children,
both
married
and
living
in
Brisbane.
They
all
keep
in
touch
but
dont
see
each
other
often.
Drug/alcohol
non-smoker.
Drinks
the
occasional
glass
of
wine
with
dinner.
Presenting
complaint
Increasing
pain
in
both
hands
over
the
past
6
months.
Story
Carol
reports
that
she
is
generally
well
and
active.
She
works
in
the
house
every
day
and
helps
out
in
the
packing
sheds
at
any
particularly
busy
times
on
the
farm.
Whenever
she
has
time,
she
enjoys
her
crafts
particularly
quilt
making
and
knitting.
This
winter
she
has
really
been
feeling
the
cold
in
the
mornings
-
her
hands
are
quite
stiff
till
she
warms
up
and
gets
going.
On
questioning
she
reports
her
knees
and
hands
have
been
a
little
stiff
when
she
first
gets
out
of
bed
in
the
mornings
for
several
years
but
is
much
worse
recently.
She
remembers
that
some
evenings
after
a
busy
day,
her
hands
ache
so
badly
she
needs
Panadol
to
ease
the
pain
so
she
can
sleep.
At
the
moment
she
says
her
hands
are
aching
a
little
a
dull,
mild
pain,
3/10.
Both
parents
are
deceased,
mother
died
of
breast
cancer
at
age
72
and
father
of
lung
cancer
at
65
(he
was
a
heavy
smoker)
She
has
one
brother
who
is
in
good
health
at
age
70.
General
Health
Carol
feels
her
general
health
is
good.
She
rarely
gets
sick
and
has
only
been
diagnosed
with
mildly
raised
cholesterol
and
with
osteoporosis
in
the
past.
She
loves
her
life
on
the
farm
and
has
a
circle
of
neighbours
and
friends
that
she
shares
her
many
interests
with.
She
has
no
surgical
history
of
note.
She
takes
Lipitor
(and
Fish
oil)
daily
for
her
cholesterol
and
Actonel
for
her
bones.
Year
2
OSCE
Practice
2011
Set
4,
Clinical
Reasoning
Station
Inspection Generally well looking elderly female, slightly overweight. She has had no recent infections. You measure her height and weight and calculate her BMI as 26. On Examination Carol is afebrile, wll-hydrated No tender areas in any other muscles and joints. Carol has no other tender, swollen joints than those shown in her hands. Her nails and skin are normal. Power, reflexes and co-ordination are all NAD. Her hands are shown in the photograph.
Past Medical History: 2000: Hypercholesterolemia 2009: Osteoporosis (on BMD) Obstetric History G3P3 all SVD Past Surgical History: Appendicectomy aged 8 yrs old Immunizations : Fluvax annually
Family History: Both parents deceased: Mother age 72 Breast ca Father age 65 lung cancer.
Lifestyle Non-smoker Alcohol -light and occasional Diet normal Exercise good Hobbies handicrafts Pets 1 dog
Demographics Occupation Housewife - farming Living arrangements lives at home on pineapple farm with husband and son Family 3 adult children, 2 of whom are married 1 older brother.
Year
2
OSCE
Practice
2011
Set
4,
Clinical
Reasoning
Station
Instructions
to
Examiners
The
patient
in
the
next
room
is
Carol,
who
is
68
years
old.
She
has
presented
complaining
of
increasing
pain
in
her
hands
back
over
the
past
six
months.
The
candidate
has
been
given
this
patients
history.
The
candidate
has
8
minutes
to
discuss
3
differential
diagnoses,
including
positive
and
negative
features
of
this
history
which
support
or
refute
their
diagnoses.
Conduct
of
this
station
Ensure
the
candidate
understands
the
tasks
he/she
has
to
do.
The
candidate
is
expected
to
discuss
3
possible
differential
diagnoses-
citing
at
least
two
(2)
positive
and
two
(2)
negative
points
in
the
patients
history,
other
than
those
listed
above,
that
support
or
refute
their
choices.
They
are
expected
to
have
a
balanced
reasoning,
and
have
prioritised
the
most
likely
diagnoses.
They
should
be
able
to
justify
their
reasoning
with
questions,
if
required-
they
are
expecting
some
questioning
from
the
examiners.
If
the
candidates
appear
to
have
chosen
an
unlikely
diagnosis-
please
ask
them
to
justify
their
choice.
Prompting
the
candidate
for
another
diagnosis
is
permitted
to
allow
them
opportunity
to
discuss
a
more
likely
diagnosis.
TASKS
Differential
diagnoses
with
reasoning
8
minutes
Year
2
OSCE
Practice
2011
Set
4,
Clinical
Reasoning
Station
Differential Diagnoses
1. Osteoarthritis Positive Morning stiffness which eases with mild activity Discomfort returns with excess activity Heberdens nodes on distal inter-phalangeal joint Age >60 Hx of continuous use of the hands in work and hobbies BMI of 26 increases the wear and tear on the knees Negative Pain controlled with occasional Panadol only Hx of osteoporosis this pain could be due to OP 2. Rheumatoid arthritis Positive Pain and stiffness in the hands with some deformity Morning stiffness which eases with mild activity Hx of osteoporosis (could have been a side effect of steroids given to Carol in the past as a treatment for RA) Symptoms present for some time and this could be a flare of inflammation. Negative No ulnar deviation The joints are not red, swollen or tender Age of onset >60 No temperature, fatigue or weakness Distal IPJ involved, not proximal 3. Bursitis Positive Negative
Joint pain with swelling Present in joints that are used repetitively Follows the pattern of remission and flare Swelling and redness are minimal Patient is afebrile Small joints of the hands are less commonly affected by bursitis than knees, elbows, shoulders or hips.
4. Pseudogout
Negative Patient is not completely painfree between flares Skin over swollen joints is not warm or particularly tender Patient is well hydrated Usually mono-articular
5. Fibromyalgia Positive Negative Pain is localized, not widespread No systemic Sx such as fatigue or mood disorder Pain is dull, aching Musculoskeletal pain which disturbs sleep Gradual worsening of pain with no apparent triggering event
MARKING
Examiners are asked to grade students performance on a scale of 0 - 4 in the areas on the mark sheet in capitals. The standards for awarding these grades are; 0 = Unequivocal fail: Student was unable to demonstrate history or examination skills without significant prompting, OR displayed unethical or unprofessional behaviour. Student lacked a comprehensive approach, and/or needed considerable prompting to complete the task.
Student performed a systematic examination or history but did not complete some components in a number of areas of the marking guide. Student had a systematic approach, required little or no prompting, was confident and completed most components of the marking guide.
Student had a high level of proficiency, well above what would be expected of a student in Year 2.
Examiners are required to make an overall judgement about the students performance in each area on the marking sheet. The specific items listed are there to remind examiners about issues which might be considered. It is not intended that these items should rigidly translate into a score. It would be helpful, particularly when feedback is being given to poorly performing students, if there is some notation in the comments column. Also examiners may find it helpful, when considering what grade to award, to have indicated in the comments column when items were omitted or when prompting was required.
Feature General Organised summaries of diagnoses Appropriate diagnoses chosen Prioritises diagnoses Clear communication for presentation Differential diagnosis ONE Most likely and reasonable diagnosis Appropriate supportive points Appropriate negative points Differential diagnosis TWO Reasonable diagnosis Appropriate supportive points Appropriate negative points Differential diagnosis THREE Reasonable diagnosis Appropriate supportive points Appropriate negative points Adequate Reasoning Balanced reasoning
Comment
Shows
understanding
of
diagnostic
signs
with
questioning
Global
Score.
This
mark
does
not
form
part
of
the
students
overall
mark.
The
score
should
reflect
the
students
empathy
and
overall
performance,
and
is
from
the
examiners
perspective
only.
Pass
Mark
=
15/20
Pass/
Fail
(Circle
as
appropriate)
Comments
(essential
if
the
candidate
has
failed
the
station)
Global
Impression-
from
examiners
only-
score
0-4
Year
2
OSCE
Practice
2011
Set
4,
Clinical
Reasoning
Station