The Final Hurdle

As part of  my final year exam at University of Melbourne, I had OSCE and one long case in the last two weeks.

OSCE stands for Objective Structured Clinical Examination. It means that you spend roughly 9 minutes either taking history from an actor or performing a brief but concise physical examination in front of an examiner or interpreting radiological images such as chest x-ray and answering several questions.

Long case means that you are given one hour with a patient in the hospital. In that one hour, you need to know why the patient is in the hospital and to perform relevant physical examination and at the same time, think of appropriate management plan for that patient. You then present your history and examination findings to two examiners. The examiners will be either a general surgeon, physician or a general practitioner. The examiners will asks several questions relevant to the patient and test the depth of your knowledge based on your answer.


OSCE
I had two OSCE at two different location for two days. The first day OSCE was held at the medical faculty and the second OSCE was held at the hospital.

Medical Faculty

1. Patient presented to you with dizzy spell. It was benign paroxysmal positional vertigo. I was not sure what else to ask in this station and was asking weird and random questions towards the end of the station.
2. Interview patient who was referred from Emergency Department to Neurology Outpatient. The ED doctors felt that her epilepsy is not fully controlled. Again, I was not sure how should I approach this station. I have to read the question several times and in the end, running out of time to answer the questions from the examiner.
   
3. Pregnant women who is vomiting. Take history and discuss the differential diagnosis and the relevant investigation. Hyperemesis gravidarum is the keyword for this station. I totally forgot about the intravenous fluid therapy.
   
4. Interpret peak flow chart and teach good inhaler technique to asthmatic patient. Was running out of time in this station.
   
5. Radiology station. CT Brain: Haemorrhagic Stroke. Chest X-ray: Tension Pneumothorax. Interpret lab result: Nephrotic syndrome. I don't have enough time in this station.
   

Clinical School

1. Interview a patient who is feeling unwell. He had malaria. I think I did pretty alright in this station.
   
2. Interview a patient who had recurrent abdominal pain. It turned out the patient had acute pancreatitis. Need to know the differential diagnosis and the relevant investigation. Despite memorising all the causes of acute pancreatitis before the exam, I forgot all the causes due to anxiety attack.
   
3. Procedural skill station. Need to perform airway management and CPR. 
4. Perform cardiovascular examination on a patient who had a murmur. I think the murmur was mitral regurgitation. Not really sure about the murmur since I was pretty nervous thinking the differential diagnosis for both diastolic and systolic murmurs.
5. Perform relevant examination for patient who had right hip pain. Need to do gait, Trendenlenburg test and hip joint examination. After that, need to interpret the hip X-Ray (Osteoarthritis) and discuss the appropriate management of osteoarthritis.

Long Case

I had the opportunity to interview a patient who came in to the hospital with acute asthma attack in the background of nephrotic syndrome (I already had nephrotic syndrome as part of my OSCE).

I don't think I did well in my presentation and the examiners does not ask me any particular question related to asthma management. Instead they opt to ask me questions related to nephrotic syndrome. It was quite difficult since I haven't learned in detail about nephrotic syndrome. When they asked the type of glomerulonephritis causing nephrotic syndrome, I stumbled a bit and just said maybe diabetic nephropathy and rapidly proggressive GN. When they asked me to explain the mechanisms of hypercoagulability state in nephrotic syndrome, I guess this must be my limit. I'm not sure which clotting factors or proteins that will explain the symptoms. I mentioned several clotting factors, protein C and S and antithrombin. I don't know the real mechanism to explain those symptom.

Anyway, up to this point, they haven't asked me anything about asthma. If they were to ask me about asthma, I guess I could do a bit better in my long case.

Hopefully all my friends and I could pass the final year exam and able to graduate together on 5th December 2009.