The general practice clinical cases
Clinical case sections Section A Section A describes the information available to candidates relating to the case. In the exam, this information will be available outside the station. You will have three minutes reading time and may take notes before entering the room. Section B Section B provides information for the patient role-player/examiner and provides details about what information may be given to the candidate throughout the case as it is requested or elicited through history taking or by requesting examination findings, surgery test results and investigation results from the examiner. In the exam, examination findings, surgery test results and investigation results will be provided on a separate sheet of paper that will be handed to the candidate on request. Section C Section C provides information for examiners about what key issues need to be covered in the case. The idea is, that when practising cases in your study group, one person takes on the role of the candidate, another the role-player and a third, the examiner. This way you can experience the process from all three vantage points. We recommend that you use this format and write your own cases for use in your study group and try to cover important areas.
IV
Clinical case rating descriptions In the RACGP OSCE, in addition to being assessed on the key issues in each case, candidates are assessed according to the clinical case rating descriptions outlined below.1 Not all will be appropriate to each case, and examiners are directed to particular areas for particular cases. When you are practising case scenarios and you are acting as the examiner, it may be helpful to make an assessment of the role-player according to these headings. Communication and rapport Rate the candidate on their ability to establish rapport and communicate effectively with the patient in a pleasant, clear and logical manner using appropriate communication skills and language. Inter-professional communication skills Rate the candidate on their ability to communicate effectively at an interprofessional level. History and physical examination Rate the candidate on their ability to take a relevant and organised history, following appropriate cues and eliciting details important to the assessment and management of the patient. Rate the candidate on their ability to perform an appropriate and systematic examination that is focused and not overly inclusive. Specific positive and negative findings relevant to the case should be elicited. Physical examination technique Rate the candidate’s physical examination technique. Systematic and appropriate examination techniques should be employed and explained to the patient. Respect for the patient and concern for the patient’s safety, comfort and modesty should be demonstrated and hands should be washed at the end of the examination.
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The general practice clinical cases
Physical examination findings Rate the candidate on their ability to detect physical examination findings accurately and interpret them correctly. Investigations Rate the candidate on their ability to select relevant, cost-effective investigations in an appropriate sequence, displaying consideration for the safety and comfort of the patient. Diagnosis Rate the candidate on their ability to make an accurate diagnosis based on interpretation of the history, physical examination and investigations. Problem definition Rate the candidate on their ability to identify, define and prioritise the physical, psychological and social issues involved for the patient, the family and the community. Medical knowledge Rate the candidate on their medical knowledge of the physical, psychological and social issues involved in this case. Public health issues Rate the candidate’s awareness of, and the ability to deal with, the public health and social issues raised by this case. Management Rate the candidate on their ability to demonstrate responsibility for the immediate and ongoing management of the patient. Candidates should offer effective explanations, education and choices to patients, and involve the patient, family and relevant community resources in management plans.
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The general practice clinical cases
Information only to be given with appropriate enquiry from the candidate: • The symptoms started about three hours after starting the higher dose of glimepiride, which you took with breakfast this morning. You had black tea with sugar, and toast with butter and Vegemite. You have not eaten since. You have had no bumps or blows to the head or any recent falls • You are conscientious about taking your medication, except you stopped taking the statin when your prescription ran out, and did not get it renewed because you thought you were taking too many tablets • You take very little exercise apart from occasional work in the garden. You do not like cooking, and tend to buy convenience food such as frozen pies and chips. You are not particularly concerned about your weight. Notes to examiners Additional and specific patient concerns or specific patient inquiries may be used where candidates require assistance. Suggested cues/prompts: • The possibility of hypoglycaemia in an older patient taking a sulphonylurea should be considered and checked immediately. Additional history As above.
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The general practice clinical cases
Information only to be given with appropriate enquiry from the candidate: • The symptoms started about three hours after starting the higher dose of glimepiride, which you took with breakfast this morning. You had black tea with sugar, and toast with butter and Vegemite. You have not eaten since. You have had no bumps or blows to the head or any recent falls • You are conscientious about taking your medication, except you stopped taking the statin when your prescription ran out, and did not get it renewed because you thought you were taking too many tablets • You take very little exercise apart from occasional work in the garden. You do not like cooking, and tend to buy convenience food such as frozen pies and chips. You are not particularly concerned about your weight. Notes to examiners Additional and specific patient concerns or specific patient inquiries may be used where candidates require assistance. Suggested cues/prompts: • The possibility of hypoglycaemia in an older patient taking a sulphonylurea should be considered and checked immediately. Additional history As above.
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Case 1. Alan Chew
Physical examination These findings are available on a separate sheet that is to be handed to candidates when they ask for any physical examination findings. All other physical findings are normal. Candidates are to ask for specific examination findings. General appearance Restless and agitated, sweating profusely Weight 98 kg
Height 175 cm
BMI 32 kg/m2
BP 128/80 mmHg
Investigations Candidates are to ask for specific investigations. Surgery test results Finger-prick random blood glucose
3.1 mmol/L
Investigation results Lipids
LDL-cholesterol: 2.9 mmol/L HDL-cholesterol: 0.9 mmol/L Triglycerides: 2.6 mmol/L
Other
Other test results within normal range
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The general practice clinical cases
Section C. Information for examiners Listed below are the key issues to be covered in this case. (The examiner can ‘tick’ these as covered during the consult.) Specific question the candidate should ask: • Candidates should consider the possibility of hypoglycaemia in an older patient taking glimepiride, and take a finger-prick glucose test in the surgery. Diagnosis Hypoglycaemia. Appropriate management and explanation As the patient appears to have symptomatic hypoglycaemia, it is important to manage this now. There are differing protocols for management of hypoglycaemia in an awake and alert patient. An appropriate one in this case is the ‘rule of 15’: • Provide 15 g of quick acting carbohydrate (eg. 3 teaspoons of sugar or 6–7 jelly beans or half a glass of fruit juice) • Wait 15 minutes and repeat blood sugar level (BSL) check. If BSL not increasing, then repeat 15 g quick acting carbohydrate) • If next meal is due in more than 15 minutes, have some longer acting carbohydrate (eg. a piece of fruit, a sandwich or a glass of milk) • Blood glucose should be rechecked in 2–4 hours. As the sulfonylurea is the likely cause of hypoglycaemia, alternative hypoglycaemic therapy should be initiated, taking into account: • the patient’s lipid profile and cardiovascular risk factors • desirability of establishing glycaemic control • avoiding the risk of repeat hypoglycaemia. This is particularly desirable as the patient lives alone.
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Case 1. Alan Chew
It may be that on the day of the hypoglycaemia the sulphonylurea is ceased for a period of time or the previous dose (1 g/day) resumed with follow up within one week to review medications and look at starting something else. However, for the purposes of the station, the candidate should be able to discuss what they would consider. Suitable oral options that minimise the risk of hypoglycaemia and weight gain include: • gliptins (DPP-4 inhibitors) • sodium-glucose co-transporter-2 (SGLT2) inhibitors. Thiazolidinediones are associated with weight gain, which is an issue for Alan. Acarbose could be an option but given the gastrointestinal side effects (and he is already having gastrointestinal side effects with metformin) this may be an issue. If he was open to injections, then exenatide (GLP-1 receptor agonist) could be an option. Insulin could also be considered, as although it has a risk of hypoglycaemia and weight gain, it does have evidence of reducing microvascular complications. It may also be that PBS subsidisation is an issue in what is selected. A candidate could make many reasonable suggestions about medication management in this situation. The patient could also be told that metformin alone (or with the previously tolerated sulfonylurea dose) may be sufficient for glycaemic control if he loses weight and adheres to a suitable diet and exercise regimen. This may be an additional incentive for him to lose weight. Alan should be re-educated about the symptoms of hypoglycaemia and what to do if they occur. He should also be informed about the benefits of taking his medication (and also the possible adverse events associated with his medication). Alan’s diet and exercise should also be discussed and suggestions made to improve his diet.
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The general practice clinical cases
Arrange appropriate follow up • Alan should be monitored closely when the new hypoglycaemic therapy regimen is started • As Alan lives alone, it is appropriate to assess his support network. A personal alarm may be appropriate to alert friends or neighbours in case he suffers a severe hypoglycaemic episode • A health professional could be enlisted to help Alan improve his diet, with weight loss a priority • Alan has stopped taking his statin. It is important to stress the need to control blood lipids and a statin should be restarted. Given the slightly low HDL-C it might be appropriate to prescribe rosuvastatin as this has been shown to increase HDL levels. However, current guidelines recommend a statin rather than a specific statin, hence a candidate could suggest any statin. Taking the medication and the lifestyle changes are more important than the specific drug within the class. The triglyceride level is slightly high and should be addressed in the first instance with dietary advice • Encouraging an increase in exercise might help to increase his HDL-C • Changing to a sustained release form of metformin may help to reduce the gastrointestinal side effects.
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Case 1. Alan Chew
References and study notes National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk. 2012. Available at strokefoundation.com. au/site/media/AbsoluteCVD_GL_webready.pdf NPS News: Type 2 diabetes. August 2012. Available at nps.org.au/publications/ health-professional/nps-news/2012/nps-news-type-2-diabetes#What Therapeutic Guidelines: Endocrinology. Revised October 2013. Therapeutic Guidelines Ltd (etg43 November 2014) RACGP/Diabetes Australia. General practice management of type 2 diabetes. 2014–2015. Available at racgp.org.au/your-practice/guidelines/diabetes/
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