OSCE for med school third year 83 slides.pptx

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1. OSCE (Objective Structured Clinical Examination ) Beckley, WV September 7-9, 2018

2. Welcome Fourth OSCE program in Beckley, West Virginia in association with Avalon Medical School Our goals are to : #1 Prepare YOU to be a GOOD physician & community leader #2 PASS the exam

3. Ayne Amjad, M.D. MPH Internal Medicine/Private Practice I want to dedicate this course to my father, Dr. Hassan Amjad and my mother, Lolita , who helped me prepare this course “Being a doctor is not enough, you have to be a part of your community. Be involved.” ---Hassan Amjad, M.D.

4. Let’s Get Started! Introductions Where in your studies/testing are each of you? HAVE YOU REGISTERED FOR THE EXAM YET? IF NOT? I WANT TO KNOW WHY AND WHEN YOU PLAN ON TAKING IT ?

5. What To Expect 12 patient encounters Total exam lasts approximately 8 hours There is a total of 50 minute break time 10 minute break after the 3 rd encounter 30 minute break which includes lunch after the 6 th encounter 10 minute break after the 9 th encounter

6. Day of Exam Bring your scheduling permit that you received after registration Your confirmation notice letter Government issued ID with photograph --with name EXACTLY how it appears on our registration ( Bring two IDs-just in case) Arrive on time as listed on the Confirmation Notice Most hotels have shuttle buses ready to take students to the testing site. Make sure you figure out how you will get to the test the NIGHT before.

7. Day of Exam There is a small locker to put your personal belongings. You cannot wear any watches. You cannot store luggage at the testing center—leave it at the hotel. Wear your white coat and bring your stethoscope—that is all the equipment you will need. DO NOT bring light pens, tuning forks, etc. Bring your favorite pen. DO NOT CHEW GUM/HAVE CANDY IN YOUR POCKETS/MOUTH Put few tissues in your pocket, in case you need it.

8. Day of Exam Before the first patient encounter, you will be given blank paper, clipboard and pen. DO NOT WRITE ON THE PAPER BEFORE THE ANNOUNCEMENT THAT THE ENCOUNTER HAS BEGUN. Patient information will be on the doorway. Take this time to jot down your notes on your clipboard.

9. Patient Encounter You have 15 minutes for each patient encounter Announcement made when to begin, when 5 minutes remain, and when encounter is completed.

10. Telephone Encounter Sit at the desk, do not dial any numbers. Hit the ‘yellow’ speaker button. Do not touch any other buttons on the phone or the call will end. When you are ready to end the call-then hit the ‘yellow’ button. You will not be allowed to call back after you end the call-that will end the encounter.

11. How To Prepare Know the purpose of the exam Know what you are being evaluated on

12. Evaluation Based On Integrated Clinic Encounter (ICE) Communication and Interpersonal Skills (CIS) Spoken English Proficiency (SEP)

13. Integrated Clinical Encounter (ICE) Two Main Components Data Gathering & Data Interpretation Can you collect pertinent information during the H&P? Can you clearly document these findings in your note-in a concise and logical manner? Are you able to summarize all the information and order the appropriate diagnostic tests?

14. Communication and Interpersonal Skills (CIS) Introducing yourself and establishing a rapport with the patient Listening-Listening-Listening Asking relevant questions Showing empathy and concern for the patient Maintaining professionalism

15. Spoken English Proficiency (SEP) Clarity of spoken English during the encounter Listening effort to the patient and having patience Minimizing repeating your questions—this can be avoided by listening . Do not write down and look at your clip board while a patient is speaking with you. Maintain eye contact during encounter Using basic words, not medical words (example angina v/s chest pain) Speak, slow, loud and clear

16. Basic tips that may seem like common sense …

17. Be calm on test day. Be professional. Introduce yourself and address the patient by name and shake their hand. Speak slowly and clearly. Sit down and talk with the patient-maintain eye contact. Ask open ended questions-one question at a time. Always be sensitive and aware of the patient’s behavior-this is part of the exam. Always tell the patient when you are about to perform the physical exam or touch them.

18. Show empathy during conversation. Do not bluntly ask patients questions ( Do you drink? do you have HIV?)-find a way to bring it into the conversation appropriately—you can say – ” I have to ask you some questions to obtain a good history”. Remember the patient will be scoring your communication skills. After the encounter is complete, sit down and tell the patient what you think is going on and what tests will be ordered. Always ask at the end—”Do you have any questions?

19. IF the patient does not have any questions … .shaker their hand and tell them goodbye --address them by their name. Go to your computer and write only the pertinent information and your plan. Put the most common diagnosis first—remember horses not zebras.

20. How to gather data When outside the room, pay attention to the AGE and VITAL SIGNS On your paper, write that information down along with your basic H&P? Example of doorway information: Mrs. Smith is a 35 year old woman who comes to the office with severe abdominal pain. T: 100.8. P:110. BP 110/80 RR: 20 98% RA

21. What stands out to you? What are you going to write down on your paper for your H& P? What is your differential diagnosis so far?

22. This should be what you are thinking … . Fever Tachycardia Young woman You should be wanting to rule out pregnancy, infection, urgency of situation Start to think what are the important/pertinent questions and physical exam findings you will be performing---jot in down if you need to

23. COMMON CASES TO REVIEW

24. Case Topics Fatigue, Cough, and Chest pain Back Pan & Fever Bloody stools Chest pain Irregular Periods Sore throat Weakness

25. Case Topics Hearing Loss “Somethings Wrong with my dad” Severe Headache Severe abdominal pain Chronic Diarrhea Abdominal Pain and Yellow Skin Cough and Fever Blood in Urine

26. Case Topics Pediatric Diarrhea Dizziness Difficulty swallowing Shortness of Breath Adult nosebleed Adolescent weight loss Pediatric vomiting and diarrhea

27. Case Topics Lack of Energy Knee and Great toe pain Confusion, blurry vision and shortness of breath Life Insurance request Pre employment physical Medication Refill Breaking bad news

28. How do I Study ALL these topics? There is a reason why it is called the “PRACTICE OF MEDICINE’ YOU HAVE TO PRACTICE THINKING AND LISTENING IF YOU CAN “KNOW” ALL THOSE TOPICS & PERFORM THE CIS COMPONENT WELL-—YOU WILL PASS THE EXAM----PROMISE

29. BASIC SCIENCE & CLINICAL MEDICINE REVIEW System based learning is key to understanding medicine

30. Basic Science & Clinical Review

31. Cardiovascular Disease Coronary Artery Disease Hypertension Atrial Fibrillation Aortic Aneurysm Hyperlipidemia

32. GI Issues Colon cancer Ulcerative Colitis/Crohn’s disease Hepatitis Hepatic Encephalopathy IBS Dysphagia Cholecystitis Pancreatitis

33. Neurology CVA TIA Neuropathy Parkinson’s Disease Alzheimer’s Disease

34. Pulmonary COPD Asthma Lung Cancer Pulmonary Embolus Tuberculosis

35. Musculoskeletal Osteoarthritis Rheumatoid Arthritis Fibromyalgia Back Pain/chronic and acute

36. Infectious Disease Topics Viral v/s Bacterial Lung disease Meningitis UTIs Diarrhea

37. Any Questions ???

38. The Physical Exam Vital Signs General HEENT Cardiovascular Respiratory Abdominal Musculoskeletal Neurological

39. HISTORY AND PHYSICAL EXAM CHIEF COMPLAINT – THIS IS THE INFORMATION ON THE DOORWAY—IT IS ALREADY PROVIDED FOR YOU HISTORY OF PRESENT ILLNESS (HPI)-THIS IS THE PATIENTS’ DESCRIPTION OF WHAT IS GOING ON—THIS IS THE PATIENTS’ NARRATIVE-NOT YOURS PHYSICAL EXAMINATION-PERTINENT POSITIVE AND NEGATIVVE INFORMATION ONLY ON THIS EXAM

40. H& P continued … ASSESSMENT AND PLAN—ON THIS EXAM IT IS REFERRED TO AS “DATA INTERPRETATION” THIS IS WHERE YOU LIST YOUR DIFFERENTIAL DIAGNSOSIS HERE YOU HAVE TO LIST A HISTORY FINDING AND PHYSICAL EXAM FINDING THAT CORRELATE TOGETHER-TO SUPPORT YOUR DIAGNOSIS ON THIS EXAM-AREA TO ORDER DIAGNOSTIC STUDIES

41. Time to practice !

42. CASE ONE Mr. Jones is a 55 year old man who comes to the office with fatigue and cough for the past 6 months, and chest pain for the past 2 days. T: 100.9. BP: 140/90. P: 80. RR: 22. Pulse Ox on RA : 91% Obtain a focused history, perform relevant exam, Do not perform any pelvic, or rectal, or corneal exam. Discuss initial diagnostic plan and workup with the patient After leaving the room, complete your Patient Note

43. Time to think … . Write down on your note pad what you think is important Make your outline of your questions Write down 3-4 differential diagnoses that you can start thinking about so far … .

44. Questions you would ask?

45. CASE ONE information Cough has been worse over last few months, small amounts of blood in sputum. Has low grade fevers with fatigue. 30 pound weight loss of the last 4 months. No appetite. Reports episodes of pneumonia. Been treated with multiple medications and still no relief. He is sexually active with men and HIV status is unknown. He smokes and has been recently in prison.

46. CASE ONE Does your differential change? What would be your ideas now?’ Diagnostic studies to order to support your differential?

47. CASE TWO Samantha is 18 year old female who presents with a sore throat for 2 days T: 101.3. BP: 120/80 P: 90 RR 20, 98% RA Obtain a focused history, perform relevant exam, Do not perform any pelvic, or rectal, or corneal exam. Discuss initial diagnostic plan and workup with the patient After leaving the room, complete your Patient Note

48. Time to think … . Write down on your note pad what you think is important Make your outline of your questions Write down 3-4 differential diagnoses that you can start thinking about so far … .

49. CASE TWO Pain in throat is 8/10, felt tired lately during soccer practice. Some teammates have been ill. Pain does not radiate, some chills, no diarrhea.

50. CASE TWO Does your differential change? What would be your ideas now?’ Diagnostic studies to order to support your differential?

51. CASE THREE—telephone call Misty is on the telephone, her 78 year old dad, Mr. Pearl is your patient. You have known him for over 5 years in your practice. She tells you “something is wrong with my dad”. Doorway has NO vital signs Obtain a history, a physical exam cannot be performed, after completing interview, finish your note, LEAVE THE PHYSICAL NOTE section BLANK

52. Time to think … . Write down on your note pad what you think is important Make your outline of your questions Write down 3-4 differential diagnoses that you can start thinking about so far … .

53. Questions you would ask?

54. CASE THREE Mr. Pearl has slurred speech for 20 minutes. Sudden onset this afternoon. He cannot use his left hand. Also c/o headache. His wife noticed a left facial droop. NO bladder incontinence or tremors. Symptoms resolved on its own

55. CASE THREE Does your differential change? What would be your ideas now?’ Diagnostic studies to order to support your differential?

56. CASE FOUR Aileen Brooks is a 45 year old female who presents to the ER if severe headache for 4 hours. T: 100.1. P: 101 BP : 170/90. RR 18, 97 % on RA Obtain a focused history, perform relevant exam, Do not perform any pelvic, or rectal, or corneal exam. Discuss initial diagnostic plan and workup with the patient After leaving the room, complete your Patient Note

57. Time to think … . Write down on your note pad what you think is important Make your outline of your questions Write down 3-4 differential diagnoses that you can start thinking about so far … .

58. Questions you would ask?

59. CASE FOUR Headache is sharp 10/10. Radiates down his neck and spine and aggravated with movement. Took OTC medications with no relief/. Described as “the worst headache of my life”. Denies vomiting, loss of consciousness, admits to cocaine on some weekends.

60. CASE FOUR Does your differential change? What would be your ideas now?’ Diagnostic studies to order to support your differential?

61. Any Questions ???

62. CASE FIVE Betty Boop Is a 32 year old female with complaints of severe abdominal pain for the past 6 hours. T: 101.4. BP: 105/60. P: 110. RR 22. 96%RA Obtain a focused history, perform relevant exam, Do not perform any pelvic, or rectal, or corneal exam. Discuss initial diagnostic plan and workup with the patient After leaving the room, complete your Patient Note

63. Time to think … . Write down on your note pad what you think is important Make your outline of your questions Write down 3-4 differential diagnoses that you can start thinking about so far … .

64. Questions you would ask?

65. CASE FIVE Sudden onset for the last 6 hours. Severity 10/10, constant and dull. LUQ and RUQ radiating to the back. Advil has not given relief. Leaning forward alleviates the pain and laying supine exacerbates t=it. 4 episodes of non-bloody, non-bilious emesis. No fever, chills, cough, chest pain, or sick contacts

66. CASE FIVE Does your differential change? What would be your ideas now?’ Diagnostic studies to order to support your differential?

67. Get the Idea? Continue to Review Cases

68. CASE SIX Cathy is a 30 year old woman who presents with complaints of recurrent diarrhea for the past year. T: 100.2. BP: 128/92. P: 80. RR 16 97%RA Diarrhea for past 1 year, has some blood and mucus. As many as 10-20 BMs per day. Crampy abdominal pain in lower quadrants without radiation. Some joint pains. ROS + fevers, 20 ound weight loss. NO rash or visual changes.

69. CASE SEVEN George is a 60 year old man who comes in the office for worsening abdominal pain and ‘yellowish’ skin for the past 2 weeks. T: 98.8 BP: 120.89 P:97 RR 18 94% RA Worsening abdominal pain and yellow skin for over 2 weeks. Pain in RUQ area, 6/10, dull, constant, non radiating. Associated symptoms: tea colored urine, and light colored stools. Lost 25 pounds in 2 months. Anorexia, fatigue. NO fevers or diarrhea. Heavy drinker for over 30 years. Has arthritis and takes Tylenol daily.

70. CASE EIGHT Peter is a 68 year old man who presents to the ER with cough and fever. T: 101.0. P: 110. BP: 150/90. RR: 28. 90% RA PMH of COPD with chronic bronchitis. Worsening productive cough and fever for 3 days. Some sputum is blood tinged. Low grade fevers. Had been using inhalers. 30 pound weight loss over the last year. 40 pack year history. Denies sick contacts or recent travel.

71. CASE NINE Mark us a 60 year man who comes to the clinic with complaints of intermittent blood in his urine over the last month. T: 98.9. P:67. BP:150/80. RR 18. 95%RA Gross hematuria x 3 episodes over the past 1 month. Painless. Seen throughout micturition. ROS + increased frequency, nocturia , weak stream, incomplete voiding for the past 4 months. Had a sore throat 6 wks ago and lost some weight. Denies chills, fever, edema, uncontrolled HTN. 60 pack year smoking history but quit 10 years ago. NO known toxic work exposures.

72. CASE TEN Amy is a 55 year old female who presents to your office with complaints of difficulty swallowing. T: 99.2. BP: 148/90. P:80. RR: 18, 96% RA Difficulty swallowing solid foods, not liquids or semisolid foods for past 2 months. Feels like ‘food getting stuck in my chest”. Sometimes regurgitates food. Lost 10 pounds. No nausea, vomiting, diarrhea, fevers, chills. History of GERD and 30 year smoking history. Drinks 4 beers at night.

73. CASE ELEVEN Mark is a 67 year old man who presents to the ER with acute onset shortness of breath. T: 99.0 P: 96. BP: 170/90. RR 24, 90% RA Dyspnea on exertion that is getting worse over the last 2 months. Trouble walking up one flight of stairs. Has orthopnea and has to sleep in a recliner. 10 pound weight gain and swelling of lower extremities. No fever, chest pain, nausea. Smoker for 40 years and uses cocaine.

74. CASE TWELVE Mr. Tyler is a 57year old man who comes to your office with 1 hour of severe chest pain. T: 98.9 P:110. BP:130/90. RR: 18, 95% RA Pain is sharp, 7/10, radiates to left arm. Started while mowing the lawn. Had just finished dinner of chicken wings. Under a lot of stress due to work. No prior episodes of chest pain. Short of breath and nausea. He did not take any medications, came to see you in the clinic.

75. Any Questions ???

76. Cases from previous test takers

77. Cases of a recent test taker Case One HIV-a young guy with vague symptoms, not much information given at the doorway. After asking about sexual history-he mentioned multiple partners

78. Cases of a recent test taker Case Two Dysphagia-patient complained of painful swallowing—need to have three differential diagnosis with a plan for each.

79. Cases of a recent test taker Case Three Right upper quadrant pain-have three differential diagnoses prepared

80. Cases of a recent test taker Case Four PTSD-Patient was crying in the room, needed comforting and she mentioned history of sexual abuse

81. Cases of a recent test taker Case Five Shoulder pain—three differential and exam for shoulder pain—example: AC joint separation, rotator cuff tear, fracture

82. Cases of a recent test taker Case Six Older patient with history of smoking, weight loss, cough and hemoptysis.

83. THANK YOU ! Good Luck & Study Hard !