2018 M4 Mock OSCE Station 4

Instruction to Candidates
You are a Year 4 medical student attached to the Children’s Emergency Department. Mrs.
Lee has brought Javier, her 3 year old son, to the Children’s Emergency for fever.
1. Please take a history and address the mother’s concerns. (8 mins)
2. Present the case to the examiner with your differential diagnoses, along with
justification. (2 mins)
SP Script

Mdm Lee
Mother of Javier Lee Xiao Ming (T0101014D)
3 Year Old Boy

No known drug allergies

Not G6PD deficient

Presenting complaint: Fever with highest temperature of 38.5, measured by oral

thermometer
Stays between T38-38.5, does not fluctuate much
Currently Day 5 of fever
Other symptoms:
- Runny nose (day 6): came gradually
- Sneezing (day 6)
- Sore throat (day 4): came after runny nose and sneezing
- Productive cough with whitish phlegm but no blood (day 4)

No neck stiffness, photophobia / phonophobia → unlikely meningitis

No wheeze, difficulty breathing or cyanosis (change in colour) → unlikely pneumonia
No ear pain, no ear discharge → unlikely ear infection
Urine is not foul smelling, urine output seems normal, nothing abnormal observed,
mother is also not around most of time to check too (students to be prompted to explore
further) → unlikely urine infection
No diarrhoea, abdominal pain or nausea and vomiting → unlikely gastroenteritis

Has a rash over his body (mother will show this picture to candidate if candidate ask for rash/photo;
please refer to printout)

Mainly over trunk and limbs of body → important for candidate to rule out measles by asking for
spread (measles tend to start from face and spread downwards to other parts of the body)
No involvement of face
Started all at one go
No involvement of palms (hands) and sole (feet) → unlikely hand foot mouth disease (but
mother will be extremely concerned about it)

Sick contact: one other boy in the childcare has a similar fever and rash
No recent travel
No other babies at home
Unlikely Kawasaki Disease (but must have it as a differential):
- Lips not red
- Eyes not red
- Tongue seems a lot redder these days (if prompted, to show photograph of strawberry tongue;
please refer to printout):

- Hands not swollen or redder than usual

Slightly less active, but still able to play with other children
Eating about 70% of normal food amount
Urine output normal

Immunisations all up to date, but mother takes this opportunity to raise concerns about his past
vaccinations and future vaccinations due to reports and news on social media she has been reading
recently
- believes vaccines don’t work “every year my office forces me to take flu jab, but I still get flu!”
- if vaccines are so good and there is ‘herd immunity’, why must my child still be vaccinated?
Especially when there are so many heavy chemicals in the vaccination??

→ the good candidate will try to address this concern and correct the misconception

Full term delivery, 1st baby

No complications during pregnancy
No complications during neonatal period of life
No medical conditions from birth until now

Developmental milestones are all met, no concerns highlighted by mother

Social history (hidden agenda that candidate should tease out):

- Mother is very concerned that it is hand foot and mouth disease / life-threatening issue
- Divorced mother, working as an accountant, cannot take care of child often enough, dad is not
involved in taking care of child
- feels guilty about bringing child in only on Day 5 of illness therefore exceptionally worried and uptight
Station 4 (Paediatrics): Marking Rubrics

Name of Candidate: _____________________ TBL Team: _________

OSCE DOMAIN GRADE (A-E)

General Approach to SP

Introduces self, explains role, establishes patient’s identity, asks how patient would like to be
addressed, ensures patient is comfortable, ensures privacy if needed, offers pain relief if appropriate

Demonstrates all the above and is warm, confident & fluent A

Demonstrates most or all the above and is respectful B

Demonstrates some or most of the above and appears rehearsed C

Demonstrates some of the above and is stiff, awkward and uncomfortable D

Demonstrates almost none of the above and is curt, abrupt or rude E

Information Gathering/History Taking: Clinical Content

● Elicits presenting complaint (5-day fever in 3yo child)

● Explores presence or absence of important associated symptoms (e.g. URTI symptoms,

rash with distribution & time course, wheeze/difficulty breathing, cyanosis, neck stiffness,
photophobia, diarrhoea, N&V, abdominal pain, foul smelling urine, ear discharge)

● Looks for features of Kawasaki disease in a 5-day fever (non-purulent conjunctivitis, rash,
erythema/edema of palms & soles, cervical adenopathy, mucosal involvement)

● Assesses severity/red flag features: activity level, adequate oral intake, urine output

● Immunisation history

● Drug history especially G6PD

● Sick contacts & travel history

● Social history

● Birth history

● Developmental history

Elicits almost all or all the above including all the key points A

Elicits most of above including all the key points B

Elicits some or most of the above but misses some of the key points C

Elicits some of the above and/or misses many of the key points D

Elicits almost none of the above and/or misses the key points E

Information Gathering/History Taking: Communication

● Shows interest, respect & concern for the patient

● Uses appropriate verbal & non-verbal communication

● Begins by allowing mother to describe the problem in his/her own words

 ● Explores history in a logical & systematic way, is thorough without repetition

● Uses open & closed questions appropriately

● Builds rapport with SP and explores her concerns. Provides reassurance where appropriate
without giving false hope/over-promising. Puts SP at ease, avoids over-familiarisation, is
empathic and non-judgmental

● Handles sensitive questions/information respectfully (e.g. financial issues)

Demonstrates all the above and is warm, confident, fluent and organised A

Demonstrates most or all the above and is respectful and organised B

Demonstrates some/most of the above, appears rehearsed & is largely organised C

Demonstrates some of the above & is stiff, awkward, uncomfortable & D

disorganised

Demonstrates almost none of the above and is curt, abrupt or rude E

Presentation of Findings to Examiner

● 5-day fever in a 3yo child, a/w URTI symptoms and rash mainly over the chest, trunk and
limbs (describes rash if SP had been prompted to show picture), ‘strawberry tongue’

● Significant positives: sick contact at childcare

● Significant negatives: no wheeze/SOB, no cyanosis, no eye involvement, no palmar

erythema/swelling, no recent travel, immunisations up to date except MMR

● Hydration & activity: eating 70% shares, urine output at baseline, still actively playing

● Previously well child: normal pregnancy, developmental milestones all met

Presents almost all or all of above and is confident, fluent and organised A

Presents most or all the above and is respectful and organised B

Presents some or most of the above, appears rehearsed & is largely organised C

Presents some of the above and is stiff, awkward, uncomfortable & disorganised D

Presents almost none of above and is curt, abrupt or rude, or dumbstruck E

Diagnosis & Justification to Examiner

● Scarlet fever TRO Kawasaki disease

● Reasonable differential diagnoses: measles (not immunised), dengue fever (less likely ,
HFMD (unlikely due to distribution of rash)

Identifies the topmost likely/important diagnosis correctly, considers & rules out A
all/almost all differential diagnoses with sound clinical reasoning

Identifies the topmost likely/important diagnosis correctly, considers & rules out B
some of the differential diagnoses with sound clinical reasoning

Identifies the topmost likely/important diagnosis correctly, considers and rules out C
some of the differential diagnoses but clinical reasoning is suboptimal

Unable to identify the topmost likely/important diagnosis correctly, considers and D

rules out one of the differential diagnoses but clinical reasoning is suboptimal
 Unable to identify the topmost likely/important diagnosis correctly and unable to E
present any differential diagnoses

SP’s Rating

● Commencing the encounter: appropriate greeting, introduction, asks how I would like to be
addressed, shows interest & respect

● Gathering information: uses open questions initially and moves towards closed ones as
appropriate, identifies my ideas, concerns & expectations, listens actively (verbally & non-
verbally), picks up on my verbal/non-verbal cues, acknowledges & validates my feelings, is
empathetic, makes interim summaries, signposts or transition statements

● Closing the encounter: provides a closing summary, checks for further information or
questions, checks if I have any outstanding worries or concerns

Demonstrates all the above and is warm, confident and fluent A

Demonstrates most or all the above and is respectful B

Demonstrates some or most of the above and appears rehearsed C

Demonstrates some of the above and is stiff, awkward and uncomfortable D

Demonstrates almost none of the above and is curt, abrupt or rude E

Examiner’s Global Score

Excellent Outstanding demonstration of technical & non-technical aspects of skill with

no/almost no omission or error. Completed the station confidently & fluently.

Good Majority of the technical & non-technical aspects of the skill demonstrated. Few
minor and non-essential omissions/errors. Examiner more than satisfied with
candidate’s performance.

Adequate Despite omissions/errors demonstrated in performance of skill, candidate is safe to

progress. At times can be formulaic in approach e.g. not quite contextualised to
patient’s unique characteristics. Examiner is satisfied with candidate’s performance.

Borderline Demonstrated some aspects of the skill but some omissions and inaccuracies are
concerning. Often formulaic in approach and unable to contextualise to patient’s
unique characteristics. Struggled with performing the skill and/or completing the
station. Examiner undecided whether to pass or fail the candidate.

Fail Appeared disorganised, unpractised and unfamiliar with the clinical encounter.
Unsafe and unsuitable to progress.
LEARNING POINTS

● NICE guidelines for fever in child <5yo (see below)

● Consider Kawasaki disease vs. Scarlet fever for a child with D5 fever + strawberry tongue
● Recall “CRASH and BURN” features of Kawasaki Disease – Conjunctivitis, Rashes,
Adenopathy, Strawberry Tongue, Hands (Palmar erythema or swelling) + Burn (Fever)
● To rule out red flags and occult sites of infection in children – ear, urine, abdominal,
pneumonia, meningitis
● For any rash, clarify where did it start, how long did it progress and spread, triggers, etc.
● Be comprehensive for paediatric history: “AEIOU BD”
o Activity
o Eating (at least 50%)
o Immunisations
o OU – “urine output”: no. of times child passes urine, amount, pain during urination,
foul smelling urine
o Birth history
o Developmental milestones

NICE GUIDELINES SUMMARY

● For feverish illness in children <5yo

● Evidence-based traffic light system: assess risk of serious illness → direct
management
● Clinical Assessment
1. Identify life-threatening features: ABCD. If present --> refer to E-Med Care
2. Assess risk of serious illness: traffic light system
3. Identify focus of infection/features of specific serious conditions

Traffic light system (CARHO): colour, activity, respiration, hydration, others