Clincal Reasoning - OA.pdf

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


2/9



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.


3/9



Inspection

Generallywelllookingelderlyfemale,slightlyoverweight.

Shehashadnorecentinfections.

YoumeasureherheightandweightandcalculateherBMIas26.

OnExamination

Carolisafebrile,wll-hydratedNotenderareasinanyothermusclesandjoints.

Carolhasnoothertender,swollenjointsthanthoseshowninherhands.

Hernailsandskinarenormal.

Power,reflexesandco-ordinationareallNAD.

Herhandsareshowninthephotograph.


4/9



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.


5/9



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


6/9



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.


7/9


8/9


9/9



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



DifferentialdiagnosisTHREE 0 1 2 3 4

Reasonablediagnosis



AdequateReasoning

0 1 2 3 4

Balancedreasoning

Showsunderstandingofdiagnostic

signswithquestioning

Documents

Clincal Reasoning - OA.pdf