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Candidate

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

Year 2 OSCE Practice 2011 Set 4, Clinical Reasoning Station

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.

Year 2 OSCE Practice 2011 Set 4, Clinical Reasoning Station

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

Meds Lipitor 20 mg nocte Actonel 35 mg weekly Allergies /ADRs Nil known

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.

Year 2 OSCE Practice 2011 Set 4, Clinical Reasoning Station

4. Pseudogout

Positive Intermittent flares of arthritic pain Joint swelling

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

Year 2 OSCE Practice 2011 Set 4, Clinical Reasoning Station

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.

1 = Marginal fail: 2 = Borderline pass: 3 = Clear pass: 4 = High pass:

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.

Year 2 OSCE Practice 2011 Set 4, Clinical Reasoning Station

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

Score (please circle) 0 1 2 3 4

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

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