OSCE in Orthopedics S Kumaravel
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Basics of OSCEChapter 1

OSCE is objective structured clinical examination. The OSCE stations can be manned or unmanned. There can be real or simulated patients, i.e. volunteers, who can be used to tell symptoms like “I have knee pain for 10 months” etc
“The success of the result of the examination is in systematic method, concentrating on the process rather than the result.”
In an ideal OSCE, the answer should be unambiguous and all students must see the same case. For critics of OSCE if one wants to differentiate an average student from a good performer, a specifically tough OSCE is the method. Lets us start with finding how an OSCE is formed with few examples. Rest of the book is a collection of OSCE based questions that can be from the cases seen in operation theaters, in ward rounds.
Instructions shall be given to the Candidate, Examiner and the Simulated patient
Example-1 -OSCE problem
35-year-old unconscious road accident victim brought to the casualty with his left lower limb splinted. What will a doctor receiving this patient do in the first 5 minutes?
Instructions shall be given to the Candidate
35-year-old unconscious road accident victim brought to the casualty. With his left lower limb splinted. You are the doctor receiving this patient what you will do in the first 5 minutes? What investigations you will order?
Instructions shall be given to the Simulated Patient
You are a 35-year-old unconscious road accident victim brought to the casualty with your left lower limb splinted. When the doctor examines and ask for anything don't respond by words or movement. You may be painted red with dye to simulate bleeding. Please cooperate.
Instructions shall be given to the Examiner
35-year-old unconscious road accident victim brought to the casualty. With his left lower limb splinted. The candidate is asked on receiving this patient, what will he do in the first 5 minutes? What investigations he will order?
2Watch if the candidate looks for
  1. Airway, breathing and circulation, cervical spine, pulses and BP.
  2. Asks for suction airway oxygen IV fluids.
  3. Assess Glasgow coma scale.
  4. Looks for the limb injury.
  5. Asks for whole body CT screening, X-rays of the leg and cervical spine lateral. blood grouping and electrolytes, sugar levels.
Example 2: Example of an OSCE
A hip problem patient can be given with malunited trochanteric fracture.
Instructions to the Candidate
This is a 45-year-old male presented after a fall and indigenous massage.
Patient has a limp. He has pain in his left groin. Measure if he has a limb length discrepancy and in what segment?
Instructions shall be given to the Examiner
Please see if the candidate
Marks
1.
Sees for the levels of anterior superior iliac spine
2
2.
If left side is higher–squares the pelvis by carrying both the lower limbs together
2
3.
Marks the bony landmarks of anterior superior iliac spine (ASIS), greater trochanter (GT), KJL, (knee joint line, medial malleolus (MM)
1
4.
Measures from ASIS to KJL, KJL to MM
2
5.
Draws Bryant's triangle
2
6.
Measures the base of the Bryant's triangle
1
The same duration of time for all cases. There can be two stations based on the idea from linked and parallel stations. There need to be spare examiners and simulated patients. When one candidate is absent, in that slot the examiner fills that the candidate does not enter the station.
How will you measure the ability of a candidate? What is sampling grid?
A sampling grid is a measure of ability of a candidate. It is about what part of the candidate's ability is being examined. Sometimes, there can be an overlap of two ability in one test or station.
Marks weighting is done by competency for example
30=not demonstrated, ½= poorly demonstrated, 1= well demonstrated
Expected outcome from candidate
Clinical skills
Demonstrating a clinical sign
Greets the patient
Explains the test and gets permission
Practical procedures
Operations,
Plaster applications
Pin tractions
Lists
1. The indications
2. Requirements to perform the procedure
3. Tells what are the important precautions or structures to avoid
Investigations
Reading clinical report and X-ray
Tells the inference normal or wants further investigation
Patient management
Treatment
Tells the prognosis/says non- controversial answers.
Health promotion
Analyses the cause of the diseases and advises accordingly
In a case of genu valgum—rickets-the need for increased vitamin intake in siblings, to look for predisposing obstructive conditions.
In a gastric carcinoma with bone secondaries advises siblings to undergo endoscopy
Communication
Delivering news of cancer, AIDS or death of a relative to the attenders
Make them sit
Uses plain language, reinforces information
Asks patient's concern ?
Explain regarding nature of the disease
The need to be positive in 1 and 2
And the tells about the amount of care given to the patient and in spite of all these the patient expired
Information handling
Data from a previous case record?
lists out the vital events of previous admission or out-patient treatment
List outs the investigations that need to be repeated or not, etc
Basic clinical and social science
Analyses the strata of society that the patient comes from. The daily demand on his body especially joints
For a laborer he needs a stable hip.
For a sedentary worker aggressive surgeries on the lateral ligament of ankle is not needed
Attitude and ethics
In case of a stage when the patient be preferably left alone uninvaded—it is better to leave him alone
Already established gastric carcinoma from gastric biopsy. If there is a bone secondaries, then no bone biopsy, is needed
Clinical judgment
On 4th day of an antibiotic, no response in infection. Wound has a greenish yellow discharge
You have to know it is due to Pseudomonas and start gram- negative bacteria specific antibiotics
4Thus clinical skills, practical procedures, investigations, patient management, health promotion, communication, information handling, basic clinical and social skills, attitude and ethics, clinical judgment can be evaluated for any specific case.
The requirements of a particular station needs to be asked.
Venue
Osce 2013
Date
Station
Description
Manned/Unmanned
Examiner
Patient/Simulated patient
Equipment needed
Marking sheet
1
Examination of an unconscious patient
In first five minutes
Manned
Needed
Simulated patient
Personnel hall supervisor
Nurse
Timekeeper
Answer sheets Cot, Two chairs
Thomas splint
Torch light
BP apparatus
Stethoscope
Pulse-oximeter
ECG monitor
Itemized checklist.
Instructions to examiners
To observe how the candidate is going about to evaluate an unconscious patient:
No need to greet
  1. Candidate must be able to assess GCS
    The following must be evaluated:
    Able to tell EMV—Able to explain sub classification of EMV
  2. Assessment of the ABCC
  3. Looks for chest and abdominal injuries
  4. Looks for the limb injury
    • Investigation, he needs to order
    • Trauma series X-rays -Skull, cervical spine, chest and pelvis
    • Whole body CT scan
    • Steps in management
    • Management of head injury,
    • Management of intra-abdominal or thoracic injury
    • Management of limb injury
    • Inform immediate supervisor or consultant.
Instructions to the simulated patient
You are Mr. X; you are supposed to be an RTA victim who is unconscious with a fracture in your right leg. Do not respond to any verbal commands and any painful stimuli just sleep. Your right leg will be splinted.
5Instructions to the candidate
At this station you will be asked to answer the following question
  • You are a resident on call
  • You get a 30-year-old unconscious patient with a closed tibial fracture on a splint
    Sampling Grid
    Out Come
    Clinical skills
    Practical procedures
    Investigations
    Patient management
    Health promotion
    Communication
    Information handling
    Basic clinical and social science
    Attitude and ethics
    Clinical judgement
    Manned
    +
    +
    +
    +
    +
    +
    Un manned
  • 6You are required to explain what you are doing as you do
  • Assess his unconsciousness?
  • What will you assess next?
  • What are the imaging you will perform?
  • What is the sequential step of management?
  • After evaluation and resuscitating what will be your next step.
Examiners checklist
You are about to discharge a patient who had a hemiarthroplasty for a fractured neck of femur. Patient with a dressing is done in the hip region.
What are the points you will tell the patient?.
Marks
1.
Greeting the patient.
1
2.
Tells about the type of the hip cemented or uncemented.
1
3.
Advises to keep the leg abducted with a knee brace.
1
4.
Advises walking with a walker.
1
5.
Advises not to take bath and keep the dressing dry till next visit.
1
6.
Not to keep the legs cross.
1
7.
Advises to move the ankle and do static quadriceps setting exercises.
1
8.
Report any ooze and bleeding from the dressing.
1
9.
Report any swelling of the calf.
1
10.
Continue anti-clotting medication and pain relief medications as advised.
1
We shall see a few other examples.
Problem 1. Instruction to the Candidate
  • Identify the lesion—a picture of wrist drop is displayed
  • Write the structures involved in the pathogenesis of this condition?
  • Write the commonest site of lesion.
  • Write all the branches of the structure at that level.
Instruction to the Examiner
Marks
If candidate tells
Wrist drop
1
Radial nerve
1
Spiral groove
1
2 muscular branches–N to medial head of triceps, N to lateral head of triceps
½ + ½
2 cutaneous branches- posterior cutaneous nerve of forearm and lower lateral cutaneous nerve of arm
½ + ½
Problem 2. Intramedullary reamer for ILN:
  • Identify the instrument
  • What are the indications and contraindications?
7Problem 3. A histopathology slide is given ?
Pain over the sternum.
  • What is the diagnosis? Further investigations. What is the drug of choice? What other organ it affects?
  • Slide of plasma cell tumor.
  • Whole body Tc 99 scan
  • Melphalan.
  • Kidneys.
Problem 4. An X-ray of heel.
Pain over the heel. More in the morning and reduced. What is the diagnosis? Further investigations.
  • Plantar fasciitis
  • X-ray of both heels lateral view
  • Uric acid
  • Blood sugar.
Problem 5. A 12 year old boy had a fracture elbow with severe swelling of forearm. Finger movements are reduced and painful. What is the diagnosis?
  • Compartment-syndrome.
  • How will you objectively assess this condition?
  • By measuring compartment pressure.
Problem 6. Bone cement.
What is this ampoule and sachet?
Bone cement.
1
What are its components? Polymer and monomer
1
Indications of its use.
Fixing an implant, augmenting a fixation and filling a cavity after curettage of benign bone lesion, Vertebra plasty.
½ each.
Side effects of this?
Spillage into surroundings
½ each.
Hypotension.
Problem 7.
  • Hypocalcemic tetany
  • 30-year-lady underwent neck surgery has developed the following features the next day of surgery.
Instruction to Candidate
  • What is the diagnosis? What is the etiology?
Instruction to Examiner
  • Look if the candidate examines the limbs
  • Whether gives the answer as hypocalcemia
  • Hysterical respiratory acidosis.
8
Instruction to Simulated Patient
To keep the limb in a position of carpopedal spasm.
Marks
If the candidate tells Acouchier's hand.
Carpopedal spasm
3
Two causes
Hypocalcemia
1
Hysterical respiratory acidosis
1
Problem 8
1.5-year-old male child brought to the casualty with not using his left upper limb since afternoon.
  • There is no gross swelling of the arm elbow or forearm. X-rays are normal.
  • Management of the case.
  • Investigations required for the patients.
  • What are the questions you will ask? The candidate ask for who looks after the child?
  • What violence will you ask? Pulling by an older child or house maid.
Problem 9
35-year-old female patient with multinodular goiter with toxic features fell and had a tibial fracture.
Instructions to Candidate.
  • Name three important peroperative advice/instructions to the patient/history you will ask?
Instructions to Examiner
  • Ask if candidate asks.
  1. Antithyroid drugs,
  2. Post operative voice change,
  3. Symptoms of hypocalcaemia.
  • Name one examination which will mark the control of the disease?
  • Sleeping pulse rate.
  • What is the problem in operating on this lady?
  • The operation may get delayed for control of the toxicity.
Problem 10
55-year-gentleman has LBA with dysuria.
  • What are the questions you will ask?
  • Asks duration of symptoms and gives probable system diagnosis.
  • What are the investigations you will order?
  • Basic investigations what to look for.
  • Special investigations based on basic investigation and clinical conclusions.
Instructions to Simulated Patient
  • You are Mr. X with LBA for 4 months and difficult in micturition for 1 year. You have weakness of both lower limbs for 1 month. Thanks for your cooperation.
9Instructions to Candidate
  • Ask about the symptoms.
  • Ask about the patient regarding relevant additional questions.
  • Prostrate swelling- any irritation during voiding, any incomplete emptying.
  • Weaknessà find it difficult to walkwithout support.
  • Secondaries—diffuse pain in the back.
Problem 11
60-year-old lady who fell down and had a fracture of upper humerus. She had a small contusion over the left temporal region. Her CT scan of brain is given. (Showed multiple altered intensities in the occipital lobes and on right lung field adjacent to her right shoulder). She was operated for cancer right breast 11 months back.
  • Identification of abnormal lesions 2 ½
  • What is the possible diagnosis?
  • Secondaries in lungs and brain
  • Differential diagnosis. 2 ½
Problem 12
Unmanned Station
26-year-old Mr. K presented to the hospital with diffuse crush injury to his right leg. One week before he had fever and vomiting for 3 days.
  • O/E Febrile, vitals stable, r/e crepitations right leg region, X-rays are displayed.
Instructions to Candidate
  • What is the clinical diagnosis?
  • Gas gangrene.
  • Differential diagnosis.
  • Cellulitis.
  • X - ray findings.
  • Gas in the soft tissue.
  • Differential diagnosis.
  • Final diagnosis.
  • How will you manage?
  • Debridement, Amputation.
  • Anti gas gangrene serum.
Problem 13
Rickets
Instructions to Candidate
  • What is this disease?
  • Is it prevalent in India?
  • How does it happen?
  • How can this disease be prevented?
10Problem 14
Unmanned Station
A 45-year man came with a swelling and pain over the right greattoe.
  • There is no other site of pain.
  • What is the possible diagnosis?
  • What history of diet will you like to ask?
  • What are the foodstuffs you need to avoid?
  • What is the biochemical investigation you will order?
Problem 15
A 39-year-old male presented with stiff back with severe stiffness in the morning. Had redness of the eye and photo phobia.
  • What is the possible diagnosis?
  • Ankylosing spondylitis.
  • What blood investigations apart from ESR are useful in pinning the diagnosis?
  • HLA-B27.
  • Name one region you will order an X-ray for diagnosing the lesion. X-ray lumbosacrum.
  • What possibly happened to his eyes?
  • Iridocyclitis.
SUGGESTED READING
  1. Collins JP, Harden RM AMEE Medical Education GN13, real patients, simulated patients and simulators in clinical examinations. Medical Teacher. 1998;20(6): 508-21
  1. Harden RM, Stevenson M, Downie WW, Wilson GM. Assessment of clinical competence by objective structured examinations. BMJ. 1975;447-51
  1. Instructional course lectures by Prof John Dent, In Dr MGR Medical University, Chennai on 3rd and 4th December 2010.
  1. Objective clinical structured examination(OSCE) revisited. J Posgrad Med Education, Training and Research 6 2009;1-10
  1. Selby C, Osman L, Davis M, Lee M. Setup and run an objective structured clinical exam, . BMJ. 1995;310:1187-90.