mbbs2 osce revision lecture

MSA Medical Students’ Association

MBBS2 OSCE Revision

Advice for students from GKT MSA

All you need to know


The Format of the Evening •  History Taking – Theo Willison-Parry, MBBS 4 •  Clinical Skills – Andrew Baigey, MBBS 3 •  Anatomy – Sandeep Nayar, MBBS 4 •  Exploring and Explaining (and then some) –

Yaseen Serry, iBSc

•  Finally, we have two students who sat their Year 2 OSCEs just last year who will give an overview of their experiences.


Introduction •  How this evening will work

•  Example of an OSCE format –  Run through of OSCE stations

•  Experiences

•  Notices

•  Feedback


The OSCE •  19 stations in total •  14 active stations – 8 minutes each •  5 rest stations – 8 minutes each •  All the candidates for a session will be briefed and

allocated to a starting station and circuit. •  Your OSCE circuit will proceed in numerical order;

when you have finished station 19 you will proceed to station 1.


Example of the OSCE Format •  Blood pressure •  Urine dipstick •  Ethics •  REST •  Subcutaneous injection •  Anatomy of the heart •  CPR •  Deaf patient drug history •  REST

•  Exploring •  Explaining •  Short History •  Surface anatomy •  Choking •  REST •  Peak flow •  Anatomy of pelvis


The OSCE contd.


History Taking

Theo Willison-Parry


What is expected

“A focused history taking (FHT) will take 8 minutes and will require you to take a history of the presenting condition, explore the impact of the conditions affect on the patient’s quality of life and explore the context of the current condition including past medical history (PMH), family history (FH), drugs & allergy and smoking & alcohol.”

- KCLGKTSoME OSCE Website


Introduction •  Hello, my name is <FIRST NAME> <LAST

NAME> and I’m a second year medical student. •  Hand gel •  Can I ask you your name and date of birth? •  Address the patient as Mr./Mrs./Miss <LAST

NAME> - if in doubt, ask! –  “Is it Mrs. Smith?” – They will tell you if it’s too formal!


Confidentiality

•  What have you been told?


Presenting Complaint

•  What they have come in with •  Easy •  Open questions •  This should not take long


History of Presenting Complaint

•  Delve into the problem that the patient has presented with – you want to elicit two things: – A detailed description of the presenting complaint – How the presenting complaint is impacting on their

life

•  What questions could you ask?


History of Presenting Complaint •  When did the problem start? •  Is it a new or old problem? •  What does it feel like? •  How often does it occur? •  What starts it off? •  How long does it last? •  What makes it worse? •  What makes it better? •  Does anything else happen to you at the same time, before or after? •  What medicines have you tried? (prescribed or over-the-counter) •  What effect have they had?


History of Pain SOCRATES: •  Site - Where is the pain? •  Onset - When did the pain start, and was it sudden or gradual? •  Character - What is the pain like? An ache? Stabbing? •  Radiation - Does the pain radiate anywhere? •  Associations - Any other symptoms associated with the pain? •  Time course - Does the pain follow any pattern? Is it getting better or

worse? •  Exacerbating/Relieving factors •  Severity (on a scale of 1-10)


How is the Presenting Complaint affecting their life?

•  Ugh •  But… •  It’s in your KUMEC handbook which suggests

you do it here


Systemic Review

•  Figure out a way of doing this quickly and efficiently.

•  Head •  Chest •  Abdomen •  Bowels and bladder •  Musculoskeletal •  Constitutional


Past Medical History

•  Have you ever had any operations? •  Have you ever been in hospital? •  Do you have any long-term conditions? •  Direct questions – have you ever had diabetes/

heart disease/hypertension/asthma etc. – ask if relevant to the presenting complaint – e.g. Ask about hypertension, diabetes, high BMI in a

patient with chest pain


Family History •  Family history is important •  A history of heart disease in the patient’s father is

important. •  A history of mild chest pain after walking for thirty

miles in the patient’s third cousin, twice removed is not important.

•  Ask relevant direct questions – you must ask for a family history of diabetes and hypertension in a history of chest pain.


Drug History •  Need all drugs and doses (if possible) •  Side effects •  Remember that inhalers are drugs as well

ALLERGIES •  Remember, the Year 2 OSCE is an exercise in your

information collecting abilities not your diagnostic ability.


Social History •  Smoking – quantify •  Drinking – quantify •  Recreational drugs – in everybody (even if they’re

85) •  Home life – are they well supported at home? •  Occupation (if you didn’t ask it during the

introduction) – if they have a hacking cough with haemoptysis and they’ve worked in a shipyard/asbestos disposal company for 50 years, they are giving you a small hint…


Social History

•  You can also use this to assess impact on the patient’s normal life. Can they still: – Take part in hobbies? – See friends? – Have sex? – Continue a relationship? – Go shopping?

•  You can also assess the patient’s diet


That’s everything, right?

•  REVIEW •  Summarize the case back to the patient – “Can I

check that I’ve got this right? You came in today because…”


Let’s Go Home •  Hang on a minute…

ICE


Timing •  Two minutes to read the vignette •  Eight minutes to do the station – this is more than

enough time for everything •  “Long history” – I don’t know whether you will

have the double station this year •  Psychiatric history – very very very unlikely to have

a psychiatric patient – from your point of view do exactly the same thing as we have discussed


Ethics

Theodore A. Willison-Parry BSc. (Hons)


The Ethics Station

•  The ethics in the ethics station is easy. •  The ethics station is not about you making an

ethical judgment. •  The ethics station is about understanding the

ethical issue surrounding a case with an understanding of clinical and legal requirements.


End of Life Care •  A patient is on a ventilator. The patient is dying. •  The doctor tells the family around the bedside that they

can do no more for her. •  The patient’s daughter would like the patient’s son to be

able to see the patient before she dies, but he is unable to attend for two days.

•  She wants you to keep the patient alive until then. •  What are the ethical issues involved?


Questions •  You will be asked questions to explore the issues •  For example, can the patient’s daughter demand you keep

her alive? •  Who should make the decision about removing the

ventilator? Who ultimately can make the decision? •  The patient is suffering from terminal cancer; there is a

drug that costs £10,000 which may keep her alive until the son arrives. Can the patient’s family demand it?


Driving with Epilepsy

•  You will take the role of a doctor who has seen a patient after a seizure

•  His occupation is a taxi driver •  You have advised him he should not drive home,

but you see out of your window he is getting into the driver’s side of the car

•  What are the ethical issues involved?


Advice for the Ethics Station

•  In past years, this has taken the form of a structured interview with an examiner.

•  Do not splurge – this is not a station where you gain marks by saying everything that comes into your head.

•  Keep your ethical principles intact – there are no marks for ‘wrong’ solutions to problems.


Practical Skills

Andrew Baigey


List of stations •  Infection Control •  Resuscitation •  Subcutaneous Injection •  BMI Measurement •  Asthma •  Growth Chart •  Urine Dipstick •  Blood Pressure •  Movement disorder


Infection Control (Hand Washing)


•  What other precautionary measures do the medical team take to prevent the spread of infection? –  Ties, watches, tie hair back, gloves, apron, bare below elbows,

alcohol gel •  What are the main bacteria and viruses found in hospital?

– C.difficile, Norovirus, Klebsiella, MRSA, E.coli, HIV, Hep B.

•  What hospital organisms are not appropriately dealt with with alcohol hand gel? – C.Difficile, Klebsiella, Norovirus

Example Questions


•  Danger •  Response •  HELP! •  Airway •  Breathing

If patient is not breathing: •  Dial 999/2222 •  Perform 30 chest compressions – rate of 120/min •  Give 2 rescue breaths – check for breathing after each breath •  Continue CPR (30:2)

Basic Life Support


1.  Cleanse hands! 2.  Introduction 3.  Check patient’s name, D.O.B. and hospital number – cross

reference with drug chart 4.  Explain procedure and obtain consent 5.  Check notes for any allergies/drug reactions and confirm with

patient 6.  Consult prescription for time, drug, dose, route of

administration and signature of doctor 7.  Select and prepare appropriate equipment

–  Syringe (choose size), Needles (green and yellow), Alcohol swab, Dressing/Gauze, Tape

•  Check medication – correct drug, strength, expiry date –  Confirm with a senior member of staff

Subcutaneous Injection


9.  Clean hands with alcohol gel and use gloves 10.  Assemble equipment, and draw up correct volume of drug (in units

for insulin, or ml for others) 11.  Replace needle with SC administration needle 12.  Clean site of injection using swab, pinch skin and inject at

appropriate speed. 13.  Dispose of sharps in sharps bin, and non-sharp waste in clinical

waste bin 14.  Ensure patient is comfortable – questions/concerns 15.  Clean hands with alcohol gel 16.  Record drug administration on drug chart

Subcutaneous Injection Cont.


•  Remove heavy clothing [& shoes!] and items from pockets •  Explain the procedure and consent •  Measure their weight (in kg) and height (in metres) •  Plot the patient’s weight/height on the BMI graph -  Reasons for being overweight:

-  well built, hypothyroidism, overeating/lack of excercise, Cushing’s -  Reasons for being underweight:

-  anorexia, malnourishment, chronic disease, cancer, hyperthyroidism

BMI Measurement


Peak flow meter & Inhaler Technique •  Introduction •  Check patient’s understanding •  Explain importance of PEFR:

‒  Importance of using PEFR ‒  Importance of using it correctly

•  Get your equipment ready, attach clean mouthpiece •  Stand up to blow into meter •  Hold it horizontal keeping fingers from marker •  Take deep breath & firm seal •  Repeat 3 times and highest reading recorded •  Check patients understanding but getting them to demonstrate •  Illicit concerns / expectations


•  Shake the inhaler and take the cap off the mouthpiece •  Sit up straight or stand with chin slightly lifted •  Hold inhaler between index finger and thumb, place inhaler upright in

front of your mouth •  Blow out and take a few deep breaths in •  Place the mouthpiece in your mouth and seal lips around the

mouthpiece •  Press down the inhaler canister to release one dose of medication &

breathe in •  Hold your breath for 10 seconds and then breathe out •  Ask the patient to demonstrate the procedure and ask if they have any

questions or concerns.

Inhaler Technique


•  They can repeat the procedure after 30 seconds for a second dose or if relief is insufficient

•  Patient needs to stand up for increased lung filling •  Use whenever they’re breathless or feel an attack coming

on

•  Provide written information

Advice


Urine Dipstick

Procedure: •  Use EtOH gel/wash hands •  Check pt details [ask examiner]

-  Patient’s Name/DOB/Hospital number -  Sample fresh? MSU?

•  Gloves & apron •  Comment on Colour & Cloudiness •  DO NOT “WAFT” •  Check dipstick container check expiry date; take one and close •  Dip and check at appropriate times •  Wash hands/ use gel


Urine Dipstick Results


Introduction: •  Introduction & Consent •  Wash hands •  Check patient’s name, DOB & occupation Explain: •  Procedure [may be uncomfortable] Confirm: •  Rested for >5 mins •  Caffeine/Smoking prior?

Blood Pressure


•  Pillow under patients arm, horizontal & extended •  Legs uncrossed •  Palpate brachial pulse and place cuff around arm with the

arterial point over the brachial artery •  Measure approximate systolic level by palpating brachial/

radial artery, then deflate cuff •  Stethoscope over brachial artery & inflate to 20mmHg

above estimate •  First sound: SBP •  Second Sound: DBP

Taking the Blood Pressure


•  Report BP to examiner and patient •  Check any symptoms which are appropriate •  Encourage questions •  Thank patient

>140/90 = HTN

BP Results


Anatomy

Sandeep Nayar


Anatomy Stations

•  Skeletal •  Living •  Organ •  Histology


Skeletal Anatomy

•  Female pelvis •  Male pelvis •  Limb anatomy •  Skull


Difference between a male and female pelvis?


Learn your bones of the skull!

“What passes through superior orbital fissure?”

Luscious French Tarts Sit Naked In Anticipation Of Sex Lacrimal nerve Frontal nerve Trochlear nerve Superior branch of oculomotor nerve Nasociliary nerve Inferior branch of oculomotor nerve Abducent nerve Ophthalmic veins Sympathe5c nerves


Living Anatomy

•  Back •  Chest & Neck •  Limbs


•  REMEMBER TO WASH YOUR HANDS

•  Know your muscle attachments and key landmarks!

e.g. “Where is C7?” “Where is the anterior superior iliac spine?” “Where does trapezius attach?” “What is the origin and insertion of biceps femoris?”


Practice on your friends!


Organ Anatomy

•  Lung •  Heart •  Renal tract •  Female pelvis


“If a peanut gets into airways, which bronchus is it likely more likely to go down?” Le$ lung – 2 lobes Right lung – 3 lobes


Learn the structure of the heart! “What are the branches of the aorta?” “Where is the sulcus terminalis?” “Where is the ligamentum arteriousus?”


Retrograde uterus = where uterus tipped backwards à abnormal


Histology

•  Common slides covered in years 1 and 2 – e.g. respiratory epithelium, bone slides, ovaries

•  Shotgun Histology videos (e.g. https://www.youtube.com/watch?v=2TIHFAKm0N8)

•  Leeds Histology Guide (http://histology.leeds.ac.uk)


“What does a graffian, primordial and primary follicle look like?” “What does the follicle secrete as it’s growing?” (oestrogen)


Communication Skills

Yaseen Serry


Communication skills (Yas)

•  Exploring – Angry patient

•  Explaining •  Sensory awareness

– Deaf – Blind (+/- BMI)


Exploring •  Start it professionally and in the same manner as

you would a Hx •  Confidentiality •  Rapport •  Elicit the patient’s Ideas, Concerns and Expectations •  Listen and show empathy •  No set criteria of what your input should be, but be

fluid in your approach •  Body language


Exploring contd.

•  Angry patient – Neighbour – Contraceptive/daughter

•  Concerned patient – Student – Parent – Friend


Explaining •  A medical condition •  Associated monitoring/treatment

•  What do they already know? •  What do they WANT to know? (ICE) •  Confidentiality and Rapport •  NO JARGON •  Check understanding


Explaining contd.

•  Diabetes – Type I – Type II

•  Parkinson’s Disease •  Hypertension •  Asthma (link to PFE/inhaler) •  HIV •  TB


Sensory Awareness

1.  Deaf patient –  Touch –  Introduction –  Lighting –  ICE –  Check understanding Ø  I had a drug history so there was a pen/paper there ‒  Summarise/Present


Sensory Awareness contd.

2. Blind patient –  Touch –  Introduction –  Check consent to be led/follow –  ICE Ø  Could be a BMI station so you will have to do the

same tasks (follow/lead) but in a different context ‒  Summarise/Present


Miscellaneous Stations

Yaseen Serry


Blood Film Examination

•  Look over lecture 4 in Scenario 35 •  Similar format as histology and anatomy i.e.

MCQ •  For each slide - Know what it is and what causes

it •  You must be able to use a microscope in order to

do so •  Go over it now! Don’t wait till 13th April


Movement Disorders Movement Disorder Library •  http://virtualcampus.kcl.ac.uk/olive/movement_library/index.html

•  Describe what you see and explain what the signs may indicate. For example:

•  Parkinson’s Disease: Resting tremor, no tremor when performing an action, bradykinesia, rigidity and freezing

•  EXTRA: Impress the examiners by addressing treatment plans for the diagnosis


Information retrieval •  Use internet •  Cochrane review, Medline, PubMed •  NOT google •  2 screens:

1. Given paper and extract PICO –  Population –  Intervention –  Comparison –  Outcome

2. Organise papers by reliability


Experiences

Vikram Vignaraja Yaseen Serry


Experiences

BEFORE •  Can be a very daunting time, lots of people

giving you lots of different advice •  PRACTICE, PRACTICE, PRACTICE •  Do a full practice osce in a group…with all the

actual timings.


Experiences

ON THE DAY •  EAT BEFOREHAND •  Read the vignette outside each station calmly and at

least twice •  If you are going to touch or do anything to a patient,

ask for their permission first (esp in surface anatomy) •  If you’re presented with something you don’t know, do

not panic…breathe and just like you would in another exam, think of a different approach you could take.


Experiences contd.

•  In histories/anything with a patient….the formats of questions etc that you MUST ask are just guidelines!

•  If a station goes badly…remember that doesn’t mean you’ve failed

•  If you remember at the end when you’re waiting for the station to end that you forgot something, say so and say how you would have done something differently. Matters that you’ve recognized this.


Experiences contd.

AFTER •  Have a break and do something fun afterwards •  Forget about it and focus on revision for exams •  Don’t feel like you have to talk about it after if

you don’t want to!


Experiences

3 MAIN PIECES OF ADVICE •  Run a full practice osce with friends •  Don’t get caught up in rumours, just stay calm,

be pleasant and don’t panic about minutia •  Once its done just forget about it!


Experiences

•  “I actually quite enjoyed it, it went faster than I thought” – Julian, Regenerative Medicine iBSc

•  “My leg was shaking SO hard, so I had to lean on it with my arm to stop it” – Mark, Medical Imaging iBSc

•  “Preparation is key. The OSCEs need to be like second nature” – Babak, MBBS3

•  “I don’t even remember my second year OSCE” – Sophie, Anatomy iBSc

•  “I thought it went well. But I failed” – Anonymous, iBSc

been there, done that


Everything else OSCE

•  The School: OSCE talk, 13th April, 16:00, GT

•  MSA OSCE Q&A: 17th April, 18:00, Harris LT


Useful Resources

•  Each other •  Older years •  Other societies

– Sports – EMDPsoc – MERJsoc


Useful Resources - Links •  OSCE skills maps:

https://virtualcampus.kcl.ac.uk/vc/medicine/assessment/osce/skillsmap/default.aspx

•  OLiVe: http://virtualcampus.kcl.ac.uk/olive/ •  Clinical Skills guides:

https://virtualcampus.kcl.ac.uk/vc/medicine/clinicalskills/skillsguides.aspx

•  E-Learning: https://virtualcampus.kcl.ac.uk/vc/tel/medicine/


Questions?

•  Thank You For listening!! •  Please don’t hesitate to get in contact:

[email protected] [email protected]

•  Follow us on Facebook & Twitter: @gktmsa •  www.gktmsa.co.uk


GOOD LUCK!!!!!


A brief reminder…

•  As you may be aware, the MSA Elections are underway. More information is available at kclsu.org/studentelections

•  Feedback – your feedback helps us to make these events better. Please leave very short feedback at:

bit.ly/oscetalk

mbbs2 osce revision lecture

Documents