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7/29/2019 Clincal Reasoning - OA.pdf
1/9
Year2OSCEPractice2011
Set4,ClinicalReasoningStation
CandidateInstructions
The patient in the next room is Carol who is 68 years old. She has presented because she is
experiencingincreasingpaininherhands.
Youhaveeight(8)minutestodiscusswiththeexaminerthree(3)differentialdiagnoses,theseshould
bethemostlikelydiagnoses.
Youshouldincludeatleasttwo(2)positiveandtwo(2)negativefeaturesofthishistory,otherthan
thoselistedabove,whichsupportorrefuteyourdiagnoses.
Youshouldexpecttheexaminertoaskquestionsaroundyourreasoning.
TASKS
Differentialdiagnoseswithreasoning8minutes
7/29/2019 Clincal Reasoning - OA.pdf
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Year2OSCEPractice2011
Set4,ClinicalReasoningStation
HistoryofPresentingComplaint
Carol-a68yearoldfemale.
OccupationHousewife
SocialHxLiveswithhusbandandeldestsononapineapplefarminasmalltown3hrsNorth-West
ofBrisbane.Shehas2otheradultchildren,bothmarriedandlivinginBrisbane.Theyallkeepintouch
butdontseeeachotheroften.
Drug/alcoholnon-smoker.Drinkstheoccasionalglassofwinewithdinner.
PresentingcomplaintIncreasingpaininbothhandsoverthepast6months.
Story
Carolreportsthatsheisgenerallywellandactive.
Sheworksinthehouseeverydayandhelpsoutinthepackingshedsatanyparticularlybusytimeson
thefarm.
Whenevershehastime,sheenjoyshercraftsparticularlyquiltmakingandknitting.
Thiswintershehasreallybeenfeelingthecoldinthemornings-herhandsarequitestifftillshe
warmsupandgetsgoing.
Onquestioningshereportsherkneesandhandshavebeenalittlestiffwhenshefirstgetsoutofbed
inthemorningsforseveralyearsbutismuchworserecently.
Sheremembersthatsomeeveningsafterabusyday,herhandsachesobadlysheneedsPanadolto
easethepainsoshecansleep.
Atthemomentshesaysherhandsareachingalittleadull,mildpain,3/10.
Bothparentsaredeceased,motherdiedofbreastcanceratage72andfatheroflungcancerat65(he
wasaheavysmoker)
Shehasonebrotherwhoisingoodhealthatage70.
GeneralHealth
Carolfeelshergeneralhealthisgood.Sherarelygetssickandhasonlybeendiagnosedwithmildly
raisedcholesterolandwithosteoporosisinthepast.
She lovesherlifeonthe farmandhasa circleofneighboursandfriendsthatsheshareshermany
interestswith.
Shehasnosurgicalhistoryofnote.
ShetakesLipitor(andFishoil)dailyforhercholesterolandActonelforherbones.
7/29/2019 Clincal Reasoning - OA.pdf
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Year2OSCEPractice2011
Set4,ClinicalReasoningStation
Inspection
Generallywelllookingelderlyfemale,slightlyoverweight.
Shehashadnorecentinfections.
YoumeasureherheightandweightandcalculateherBMIas26.
OnExamination
Carolisafebrile,wll-hydratedNotenderareasinanyothermusclesandjoints.
Carolhasnoothertender,swollenjointsthanthoseshowninherhands.
Hernailsandskinarenormal.
Power,reflexesandco-ordinationareallNAD.
Herhandsareshowninthephotograph.
7/29/2019 Clincal Reasoning - OA.pdf
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Year2OSCEPractice2011
Set4,ClinicalReasoningStation
PastMedicalHistory:
2000:Hypercholesterolemia
2009:Osteoporosis(onBMD)
ObstetricHistory
G3P3allSVD
Meds
Lipitor20mgnocte
Actonel35mgweekly
Allergies/ADRs
Nilknown
PastSurgicalHistory:
Appendicectomyaged8yrsold
Immunizations:
Fluvaxannually
FamilyHistory:
Bothparentsdeceased:
Motherage72Breastca
Fatherage65lungcancer.
Lifestyle
Non-smoker
Alcohol-lightandoccasional
Dietnormal
Exercisegood
Hobbieshandicrafts
Pets1dog
Demographics
Occupation
Housewife-farming
Livingarrangements
livesathomeonpineapplefarmwithhusbandandson
Family
3adultchildren,2ofwhomaremarried
1olderbrother.
7/29/2019 Clincal Reasoning - OA.pdf
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Year2OSCEPractice2011
Set4,ClinicalReasoningStation
InstructionstoExaminers
ThepatientinthenextroomisCarol,whois68yearsold.Shehaspresentedcomplainingof
increasingpaininherhandsbackoverthepastsixmonths.
Thecandidatehasbeengiventhispatientshistory.
Thecandidatehas8minutestodiscuss3differentialdiagnoses,includingpositiveandnegative
featuresofthishistorywhichsupportorrefutetheirdiagnoses.
Conductofthisstation
Ensurethecandidateunderstandsthetaskshe/shehastodo. Thecandidateisexpectedtodiscuss3possibledifferentialdiagnoses-citingatleasttwo(2)
positiveandtwo(2)negativepointsinthepatientshistory,otherthanthoselistedabove,
thatsupportorrefutetheirchoices.
Theyareexpectedtohaveabalancedreasoning,andhaveprioritisedthemostlikelydiagnoses.
Theyshouldbeabletojustifytheirreasoningwithquestions,ifrequired-theyareexpectingsomequestioningfromtheexaminers.
Ifthecandidatesappeartohavechosenanunlikelydiagnosis-pleaseaskthemtojustifytheirchoice.
Promptingthecandidateforanotherdiagnosisispermittedtoallowthemopportunitytodiscussa
morelikelydiagnosis.
TASKS
Differentialdiagnoseswithreasoning8minutes
7/29/2019 Clincal Reasoning - OA.pdf
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Year2OSCEPractice2011
Set4,ClinicalReasoningStation
DifferentialDiagnoses
1. OsteoarthritisPositive
Morningstiffnesswhicheaseswithmildactivity Discomfortreturnswithexcessactivity
Heberdensnodesondistalinter-phalangealjoint Age>60 Hxofcontinuoususeofthehandsinworkandhobbies BMIof26increasesthewearandtearontheknees
Negative
PaincontrolledwithoccasionalPanadolonly HxofosteoporosisthispaincouldbeduetoOP
2.Rheumatoidarthritis
Positive
Painandstiffnessinthehandswithsomedeformity Morningstiffnesswhicheaseswithmildactivity Hxofosteoporosis(couldhavebeenasideeffectofsteroidsgiventoCarolinthepastasatreatmentforRA)
Symptomspresentforsometimeandthiscouldbeaflareofinflammation.
Negative
Noulnardeviation Thejointsarenotred,swollenortender Ageofonset>60 Notemperature,fatigueorweakness DistalIPJinvolved,notproximal
3. BursitisPositive
Jointpainwithswelling Presentinjointsthatareusedrepetitively Followsthepatternofremissionandflare
Negative
Swellingandrednessareminimal Patientisafebrile Smalljointsofthehandsarelesscommonlyaffectedbybursitisthan
knees,elbows,shouldersorhips.
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7/29/2019 Clincal Reasoning - OA.pdf
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7/29/2019 Clincal Reasoning - OA.pdf
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Year2OSCEPractice2011
Set4,ClinicalReasoningStation
GlobalScore.Thismarkdoesnotformpartofthestudentsoverallmark.Thescoreshouldreflectthe
studentsempathyandoverallperformance,andisfromtheexaminersperspectiveonly.
PassMark=15/20 Pass/Fail(Circleasappropriate)
Comments(essentialifthecandidatehasfailedthestation)
GlobalImpression-fromexaminersonly-score0-4
Feature Comment Score(pleasecircle)
General
Organisedsummariesofdiagnoses
Appropriatediagnoseschosen
Prioritisesdiagnoses
Clearcommunicationforpresentation
0 1 2 3 4
DifferentialdiagnosisONE 0 1 2 3 4
Mostlikelyandreasonablediagnosis
Appropriatesupportivepoints
Appropriatenegativepoints
DifferentialdiagnosisTWO 0 1 2 3 4
Reasonablediagnosis
Appropriatesupportivepoints
Appropriatenegativepoints
DifferentialdiagnosisTHREE 0 1 2 3 4
Reasonablediagnosis
Appropriatesupportivepoints
Appropriatenegativepoints
AdequateReasoning
0 1 2 3 4
Balancedreasoning
Showsunderstandingofdiagnostic
signswithquestioning