1. OBJECTIVE STRUCTURED CLINICAL EXAMINATION “OSCE” Hassan Nasrat Professor of Obstetrics & Gynecology King Abdulaziz University Hospital

2. OSCE O : OBJECTIVE S : STRUCTURED C : CLINICAL E : EXAMINATION

3. WHAT DOES IT TEST ? 1. HISTORY TAKING. 2.FACTUAL KNOWLEDGE. 3. INTERPRETATION OF LABORATORY RESULTS AND CLINICAL DATA. 4.ABILITY TO FORMULATE DD. 5 COUNSELING SKILLS. 6. CLINICAL PROBLEM SOLVING.

4. Why OSCE?

5.  Why OSCE?  WHAT DOES IT TEST ?  HOW TO RUN IT? OSCE

6. AntenatalLaborPostnatalNewbornGynecology HistoryObstetric H/R Diagnosis of labour History of Gynecology PhysicalObstetric Maneuvers Progress in labour Post natal evaluation ( normal and CS) Delivery relevant complicatio ns Tests/investi gations/proc edures BPP Routine AN tests CTG Instruments Tests in complicatio ns Resuscitatio n of Newborn Instruments Specific investigatio ns Data interpretati on CTG GTT PET PartogramPostnatal tests: Rubella. RH HSG Semen test Hormone profile Communica tion and education Nutrition Exercise Breast feeding Contracepti on

7. This station is to test your ability to take relevant history §Mrs. Fatma is 38 weeks pregnant lady complaining of headache

8. Total Grade GradeFailureBorder linePass Marks00.250.5 1. Age of patient 2. Duration of symptoms 3. Location of headache 4. Respond to simple analgesics ( pain killers) 5. Nausea or vomiting 6. Blurred vision 7. Swelling of hands, feet and face 8. Pain in upper abdomen ( epigastric) 9. Previous pregnancies (i.e. obstetric history) 10. Relevant Past medical history

9. Data interpretation §A 38 years old patient, Gravida 8 para 6+1. Her previous delivery ended by cesarean section due to failure to progress. §She is now around 28 weeks §Her family doctor have ordered a GTT and she brought the result for you for advise

10. Instruction for the Simulated Patient (Examiner) §Doctor can you tell me is my GTT result normal or not? § Is there any danger (complications) for me from this condition? §Is there any risk for my baby?

11. ItemMark WellAverageND Interpretation of test (Positive for GDM)21 Risks to the patient Increased risk of high BP (PET)1½ Increased rate of infection (urinary/vaginal)1½ Risks to the fetus Polyhydramnios1½ Macrosomia1½ Operative / Difficult delivery1½ RDS1½ Neonatal Jaundice1½ Other metabolic disorders1½ Total

12. ItemMark WellAverageND Interpretation of test (Positive for GDM)21 Risks to the patient Increased risk of high BP (PET)1½ Increased rate of infection (urinary/vaginal)1½ Risks to the fetus Polyhydramnios1½ Macrosomia1½ Operative / Difficult delivery1½ RDS1½ Neonatal Jaundice1½ Other metabolic disorders1½ Total

13. ItemMark WellAverageND Interpretation of test (Positive for GDM)21 Risks to the patient Increased risk of high BP (PET)1½ Increased rate of infection (urinary/vaginal)1½ Risks to the fetus Polyhydramnios1½ Macrosomia1½ Operative / Difficult delivery1½ RDS1½ Neonatal Jaundice1½ Other metabolic disorders1½ Total

14. Data Interpretation §28 years old Gravida 10 Para 9+0, at 13 weeks of gestation came to the clinic complaining of: Palpitation and shortness of breath. §A complete blood count (CBC) test was performed. §You are require to interpret the result of the CBC

15. ItemMark WellAverageND What does the result of this test shows? (Examiner to show CBC form) Low hemoglobin (anemia)11/2 What type of anemia Hypochromic microcytic21 Can it be confused with other type of anemia? Thalassanemia and11/2 Sickle cell anemia11/2 How would you confirm? Hemoglobin electrophoresis1½ Sickle cell test1½ What do you think of this result? (Examiner to show the result of the electrophoresis) Confirm Iron deficiency anemia32 Total

16. Postnatal Examination §You are the house officer in the ward and in the morning round you came across this patient who had delivered 24 hours ago. §How would you assess her?

17. ItemMark WellAverageND Initial approach to the patient (introduce him/her self, explain what he/she will be doing) 1½ Mode of delivery1½ Delivery outcome (the baby)1½ Lochia / Bleeding1½ Bladder function1½ Perineum/excessive pain (episiotomy)1½ Check vital signs1½ Breast feeding1½ What important investigations you would like to review before discharge CBC1/21/4 Blood Group (RH factor)1/21/4 Rubella test1/21/4 Hepatitis test1/21/4 Total:

18. ItemMark WellAverageND Initial approach to the patient (introduce him/her self, explain what he/she will be doing) 1½ Mode of delivery1½ Delivery outcome (the baby)1½ Lochia / Bleeding1½ Bladder function1½ Perineum/excessive pain (episiotomy)1½ Check vital signs1½ Breast feeding1½ What important investigations you would like to review before discharge CBC1/21/4 Blood Group (RH factor)1/21/4 Rubella test1/21/4 Hepatitis test1/21/4 Total:

19. During the morning round you came across a 28 years old who has delivered 24 hours ago. She was found to run a temperature of 39 0 c. How would you approach her §Mode of Labour:Spontaneous §Mode of Delivery:Spontaneous §Outcome:3 Kg baby Boy §How is the baby:Well in the nursery §Duration of labour: 12 hours §Any history of SRM: Loss of fluid for 3 days §Symptoms of upper or lower respiratory tract infection §Symptoms of UTI (upper or lower) §Amount, and nature of Lochia

20. You were urgently called to the labour room by the obstetric nurse. A patient who just had her episiotomy sutured by your colleague has suddenly became pale and drowsy with rather heavy vaginal bleeding §What is the differential diagnosis of post-partum hemorrhage (mention 4)? §What are the immediate measures that should be taken in this case? §What is the most likely cause of this patient collapse? §How would you confirm This diagnosis

21. What is the differential diagnosis of post-partum hemorrhage (mention 4) §Uterine Atony §Lacerations of the Genital tract §Uterine Inversion §DIC

22. What are the immediate measures that should be taken in this case? §(A) Air Way §(B) Breathing §(C) Maintain Circulation IV infusion

23.  What is the most likely cause of this patient collapse? §How would you confirm This diagnosis? Uterine Atony Abdominal Palpation for Uterine fundal height and consistency

24. An 18 years old primigravida presented to the emergency room in labour §What important informations you want to know about this case? §How would you confirm the patient diagnosis?

25. What important informations you want to know about this case? §Is she booked or not §How many weeks is she now ( LMP) §Is there any known medical problem? Yes 38 weeks No

26. How would you confirm the patient diagnosis? §Symptoms: oCharacter of the pain: regular in pattern, increase in frequency and intensity. §Signs: oShow. oCervical Changes: effacement and dilatation oLoss of fluid per vaginum

27. Other Areas can be testes: §Fetal Monitoring: §Routine tests in ANC booking clinic §GCT and GTT §PET profile §Anemia §Postpartum complications: e.g. DVT, Fever, Hemorrhage

28. OSCE Gynecology

29. This station is to test your skill in doing abdominal examination and building differential diagnosis §38 years old, P1 + 0 was referred to Gynecology clinic because of recurrent lower abdominal pain Do systematic abdominal examination What is the differential diagnosis

30. GradeFailureBorder linePass Marks050% of MarkFull Mark 1. Introduce him/hers self & ask patient name0.5 2. Position patient properly for examination0.5 3. Describe systemic general examination (not to do)0.5 Inspection 4. Scars0.5 5. Hernia0.5 6.Hair distribution0.5 7. Movement of Abdomen0.5 Palpation 8. Ask about pain and start away from site of pain0.5 9. Superficial palpation : start away from pain0.5 10. Deep palpation0.5 11. Feel for renal angles0.5 Describe Mass 12. Site0.5 13. Size0.5 14. Surface0.5 15. Mobility0.5 16. Tenderness0.5 Differential Diagnosis 17. Ovarian mass0.5 18. Fibroid0.5 19. Pregnancy0.5 20. Bladder0.5 FailureBorderlinePass

31. This Lady has been married for 10 years. Has had one child who is 8 years old. No pregnancy since then. She would like your advise and help §What other relevant informations you would like to know. §How would you investigate such case? §With the data you have been given, what is the most likely diagnosis?

32. What other relevant informations you would like to know. §Age. §Duration of trial for pregnancy (Use of contraception) §Mode of delivery §Relevant surgical history: i.e. pelvic surgery §The menstrual cycle: §Previous tests or investigations for the wife §Investigations for the husband and results

33. Cause of infertility §Tubal: suggested if ch pelvic pain, pelvic surgery, infection..etc §Ovulatory: oligomenorrhea, features of PCO (obesity, hirsutism) §Peritoneal: (i.e. endometriosis) dysmenorrhea §Male factor: semen test § Others: thyroid, hyperprolactinemia §Unexplained: no obvious cause

34. A 21 year old gravida 2 presented to the ER with lower abdominal pain of acute onset, with slight vaginal bleeding §How would you assess this case. §What is the differential diagnosis §What investigations would you like to order

35. How would you assess this case. §Important points in the history: §Is she pregnant §When was the LMP §Is she using any contraception §What was the outcome of the first pregnancy §Is there any history of pelvic surgery or infection Do not Know 6 weeks ago Not regularly Baby boy Appendectomy

36. §Important points in the examination: Vital signs: Abdomen examination: Site of pain, tenderness, rigidity Pelvic Examination: Amount of bleeding: Condition of the cervix: Positive sign of cervical excitation:

37. What is the differential diagnosis §Ectopic. §Intrauterine pregnancy §Corpus luteum cyst §Surgical pelvic conditions §Cystitis The scenario of the case could take you to any of the aforementioned conditions

38. What investigations would you like to order? §Pelvic U/S §Pregnancy test (BHCG titre) §COC: WBC and Hemoglobin §Blood group (ABO) and Rh type

39. Interpretation of Investigations §HSG: §Hormonal profile for: l PCO. l Secondary amenorrhea due to hyperprolactinemia  Karyotype of Turner syndrome