In 2003-2004, MUSC Family Medicine introduced an OSLE into the Family Medicine/Rural Clerkship to provide students with an OSCE-like learning experience (no grade - purely a learning experience to help prepare students for the OSCE).

OSLE

• THIRD DAY OF ROTATION

Two or three students enter a Standardized Patient's room with a Family Medicine faculty member.  Students interact with the Standardized Patient based on scenarios listed below.  Students are evaluated on their ability to gather information, perform a physical exam, respond to emotion, and negotiate a mutually agreeable assessment plan with the patient.  MUSC Family Medicine faculty members give students immediate feedback.  Students have expressed great satisfaction with the OSLE and consider it excellent preparation for the OSCE at the end of the rotation.

The Family Medicine Rural Clerkship OSLE currently has 8 stations - click on the following links for a synopsis of each station:

2 Physical Exam stations each:

                 Musculoskeletal (usually low back pain, ankle or knee)

                 Patient with shortness of breath/dizziness (Daniel Roberts)

1 Interview station each:         

                  Patient with chronic cough / smoking cessation (Dana Jones)

                 Woman with Gonorrhea / breaking bad news (Beth Henson)

                 Ongoing care of patient with DM / motivational interviewing (Morgan Sullivan)

                 Patient with hypertension / cultural competency  (Mr. Walker)

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MUSCULOSKELETAL PHYSICAL EXAMINATIONS

Low Back Pain  -  Ankle  -  Knee  -  Shoulder  -  Neck

Two examinations are presented in the OSLE, and the others are presented in an Academic Day Workshop.

LOW BACK PAIN (synopsis - as presented in the OSLE)

To include the following:

p. 597 figure 37.3 from the required textbook.

Nerve Root	L4	L5<	S1
Pain	Lat to ant thigh, anterior lower leg, great toe	Lat to post thigh, lateral lower leg, dorsum foot	Posterior thigh, posterior lower leg, lateral foot
Numbness	Medial thigh	Anterior lower leg	Posterior calf
Motor weakness	Extension of quadriceps	Dorsiflexion of great toe and foot	Plantar flexion of great toe and foot
Screening exam	Squat and rise	Heel-walking	Walking on toes
Reflexes	Knee jerk diminished	None reliable	Ankle jerk diminished

Straight Leg Raise (SLR) = pt lying on his/her back, and examiner lifts leg fully extended at the knee.  The textbook says that a positive test is defined as pain occurring at 90 degrees, but the Art and Science of Bedside Diagnosis and Bates both agree that a positive test is defined as pain radiating at least to the buttock at an angle of 30 to 60 degrees.

Synopsis of Musculoskeletal Physical Examinations in an Academic Day Workshop each rotation (if not covered in OSLE) - presented by MUSC faculty member:

Ankle

Patient Scenarios INSPECTION PALPATION -  Ottawa Rules 1.  Tender over the posterior edge or tip of either malleolus 2.  Tender over the navicular bone (medial mid-foot area) 3.  Tender at the base of the 5th metatarsal 4.  Unable to bear weight immediately and in the E.D. (or office practice) MANEUVERS - Stress Testing 1.  Positive anterior drawer sign (tests anterior talofibular ligament) 2.  Talar tilt test (tests the anterior talofibular and calcaneofibular ligaments) 3.  Squeeze test - compress tibia and fibula together, above midpoint of the calf.  Pain indicates a syndesmosis sprain. 4.  Gastrocnemius and soleus compression - normal = foot plantar flexes, abnormal--suggests Achilles tendon rupture

Knee

Patient Scenarios INSPECTION PALPATION MANEUVERS 1.  Lachamn test (ACL tear).  Knee flexed 20-30 degrees.  Anterior and slightly outward pressure applied to the proximal tibia.  (check posterior laxity at 90 degrees first to check integrity of the PCL) 2.  Medial and lateral collateral ligament testing 3.  Meniscus tear

Other musculoskeletal examinations may include Shoulder and Neck

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OSLE PRESENTING SITUATION and INSTRUCTIONS TO THE STUDENT

Daniel Roberts

Daniel Roberts is a 45 year-old patient who has had shortness of breath, worsening over the past 3 months and dizziness.  The difficulty breathing has been noticeable throughout the day, sometimes worse during activity but occurs at rest too.  The dizziness is mostly a spinning sensation and is made worse by sudden movement of his head or turning of his head.

You are to:

► Perform an appropriate physical exam to address both complaints of shortness of breath AND dizziness.

●  DO NOT take a history from the patient.

●  DO NOT check blood pressure - the nurse has already checked orthostatic vital signs and they are normal.

 

Students have 15 minutes as a group to perform the above tasks.  It is suggested each student conducts the physical exam by him/herself.  (A bell will ring 13 minutes into the encounter and again at the end of the encounter.)

 

Teaching Checklist

 Physical Examination                                                                                                                                                

The student:	YES	NO
Cardiovascular Exam
1.  Inspected.
2.  Palpated.
3.  Listened RUSB, learning forward, full expiration on skin.
4.  Listened laying down, diaphragm and bell, all areas on skin.
5.  Listened in left lateral position on skin.
6.  Checked for peripheral edema.
7.  Checked for increased JVD.
8.  Listened to carotid arteries on skin.
Lung Exam
9.  Inspected.
10.  Percussed on the skin.
11.  Auscultated.
NEURO EXAM
12.  Hallpike-Dix Maneuver
13.  Cranial nerve exam.
14.  Motor exam.
15.  Sensation to pinprick or light touch.
16.  Checked gait.
17.  Checked Romberg.
18.  Rapid alternating movements.
19.  Washed his/her hands.

Communication:                                                                                            

The student:	YES	NO
Introduced him/herself to me.

 

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OSLE PRESENTING SITUATION and INSTRUCTIONS TO THE STUDENT

 
Dana Jones

 
Dana Jones is a 52 year-old patient who has had a chief complaint of chronic cough for 3 months.  You and your preceptor have determined that the cause of the cough is bronchitis that is aggravated by smoking.  Your preceptor prescribed an Albuterol inhaler for the patient. Your preceptor has asked you to address smoking cessation with the patient.

 

You are to: ► Discuss smoking cessation counseling with the patient ► Use the 5 A's of smoking cessation. ► Identify the stage of change that your patient is      demonstrating. ► Use your motivational interviewing skills to help your      patient get to the next stage of change.      ●  You will NOT have time to conclude your           counseling with this patient. ► Conclude the session in a timely fashion. ► Include plans for your next visit that will occur during the OSCES final in several weeks.

5 A's of Smoking Cessation 1.        Ask the patient if he or she uses tobacco 2.        Advise him or her to quit 3.        Assess willingness to make a quit attempt 4.        Assist those willing to quit 5.        Arrange for follow-up contact to prevent relapse

 

Students have 15 minutes as a group to perform the above tasks.  It is suggested each student conduct a separate part of the interview within this time period.  (A bell will ring 13 minutes into the encounter and again at the end of the encounter.)

 

Teaching Checklist

 History                                                                       

The student asked:	YES	NO
1.  Age of onset smoking.
2.  Number of packs per day.
3.  About attempts to quit.
4.  Length of abstinence.
5.  Reason relapsed.

 
Communication:                                                                                            

The student:	YES	NO
6.    Introduced him/herself to me.
7.   Advises smoking cessation.
8.   Assesses willingness to quit.
9.   Appears to correctly identify stage of change.
10.  Discusses relevance of smoking cessation to patient's current problem.
11.  Identifies appropriate risks.
12.  Asks or discusses rewards of not smoking.
13.  Asks or discusses roadblocks to quitting.
14.  Acknowledges difficulty to stop smoking.
16.  Avoids argument.
17.  Asks permission to continue discussion on next visit.