OSCE & OSPE in Primary Care Posting MBBS

Communication Skills

1.
2.
3.
4.

Skills required in any patient encounter

The angry/difficult patient & family
Dealing with a serious diagnosis
Dealing with death

Picture

1. Pharyngitis
2. Measles/scabies
Procedure

1.
2.
3.
4.
5.

Use of Asthma Inhaler

Peak flow meter / isometry
Insulin Injection (novopen)
Echocardiogram
Pap Smear

Others (Prof Dr Chan)

1. Writing prescriptions
2. Writing a referral letter
3. Good or bad attitudes using case scenarios
STATION : PROCEDURE
1. MDI Technique
- Beclomethasone 2 puffs BD
How to Use a Metered-Dose Inhaler "Puffer"
A metered-dose inhaler, called an MDI for short, is a pressurized inhaler that delivers
medication by using a propellant spray.

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Using an MDI with a valved holding chamber

1.
2.
3.
4.
5.
6.

Remove the cap from the MDI and chamber.

Shake well for 5 seconds.
Insert the MDI into the open end of the chamber (opposite the mouthpiece).
Breathe out all the way.
Keep your chin up.
Place the mouthpiece of the chamber between your teeth and seal your lips tightly
around it.
7.
Press the canister once.
8.
Breathe in slowly through your mouth to completely fill your lungs. If you hear a
"horn-like" sound, you are breathing too quickly and need to slow down.
9.
Hold your breath for 10 seconds (count to 10 slowly) to allow the medication to reach
the airways of the lung.
10.
Repeat steps 2-8 for each puff ordered by your doctor. Wait about 1 minute in
between puffs.
11.
Replace the cap on your MDI when finished.
12.
If you are using a corticosteroid MDI, rinse your mouth and gargle using water or
mouthwash after each use. You should always use a chamber with a steroid MDI.

Using an MDI without a chamber

1.
2.
3.
4.

Remove the cap from the MDI and shake well for 5 seconds.
Breathe out all the way.
Keep your chin up.
Place the mouthpiece of the inhaler between your teeth and seal your lips tightly
around it.
5.
As you start to breathe in slowly, press down on the canister one time.
6.
Keep breathing in slowly to completely fill your lungs. (It should take about 5 to 7
seconds for you to completely breathe in.)
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7.

Hold your breath for 10 seconds (count to 10 slowly) to allow the medication to reach
the airways of the lung.
8.
Repeat the above steps for each puff ordered by your doctor. Wait about 1 minute
between puffs.
9.
Replace the cap on the MDI when finished.
10.
If you are using a corticosteroid MDI, you should use a valved holding chamber as
described above.
* If you need a second puff, wait 30 seconds, shake your inhaler again, and repeat steps 36. After you've used your MDI, rinse out your mouth and record the number of doses taken.
Store all puffers at room temperature
Cleaning Your MDI
To clean your MDI, follow the instructions that came with it. In most cases, they will advise
you to:
1. Remove the metal canister by pulling it out.
2. Clean the plastic parts of the device using mild soap and water. (Never wash the
metal canister or put it in water.)
3. Let the plastic parts dry in the air (for example, leave them out overnight).
4. Put the MDI back together.
5. Test the MDI by releasing a puff into the air.
Important Reminders About MDIs
Always follow the instructions that come with your MDI.
As well:

Keep your reliever MDI somewhere where you can get it quickly if you need it, but
out of children's reach.

Show your doctor, pharmacist or asthma educator how you're using your metereddose inhaler.

Store your MDI at room temperature. If it gets cold, warm it using only your hands.

Never puncture or break the canister, or try to warm it using anything except your
hands.

When you begin using an MDI, write the start date on the canister.

Check the expiry date on the MDI before you use it.

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If you're having trouble using your MDI, ask your doctor for tips or to recommend
another device.

Many doctors recommend the use of a spacer, or a holding device to be used with
the MDI.

Do not float the canister in water.

2. Explanation on Insulin Injection (Novopen)

Procedure
-

introduce, self greet, explain intention

wash hand
remove pen cap
check catridge expired date
roll insulin box 10x
swab catridge top with alcohol swab
remove paper cover
attach/remove needle
insert insulin (clockwise screw until clicking sound)
test 4 units and push
select insulin dose e.g : 8 units
advise on site of injection (arm, stomach, thigh, buttock/ around umbilicus = finger
breadth either sideways/lateral or above
pinch skin
inject perpendicularly 90o
wait till 10 seconds
tell patient to always rotate side, if not it will become painful , swollen and infected
remove needle
dispose in sharp bins
advise time of injection ( before bedtime eg 8 units)
advise on monitoring sign/symptoms of hypoglycemia
[sweating, palpitation, tremor, giddiness, feeling fainting always carry sweets in your
pocket/ car and take immediately once u experience hypo]

Mixing Insulin (using syringe)

Careful. It is a 1ml syringe. DONT interchange between units and mL. Use units all
the time because the insulin dosage is in units, not mL.
Fatal action (Things NOT to do, if you do this, theyll fail u):
o Recaping (so, after removing the needle cap, straight away throw the cap)
o Throwing clinical waste into the sharp bins (sharp bin is ONLY for the needle
n syringe!)

3. PEFR & spirometry chart

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a. Expected : highest PEFR

b. Percentage :

c. List how to differentiate

d. What is hers?
Limitation of activities
e. What is the cause?
Allergen (pets, carpets), pollution, cold weather
-

f. How to monitor?
Peak Expiratory Flow Rate
Home monitoring (plot asthma table)
g. Which curve?

4. PEFR

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28y/o, factory worker, recently diagnosed with bronchial asthma. He is taking -2 agonist
almost every day. Has night symptoms >2x/week. Height: 170cm.

a. What is his PEFR?

Take the highest from the 3 readings given
b. Determine predicted value of his PEFR from chart given according to his height and
age.

c. Percentage of his current PEFR to his predicted?

d. What factors to look for to classify his asthma control?

Daytime symptoms
Night time symptoms
Use of reliever
Activity limitations
PEFR
e. 4 possible causes for his uncontrolled asthma?
Exposure to dusty environment
Improper inhaler technique
Non-compliance
Occupational factor
Wrong dosage
f.

Managment?
R: Explain what asthma is. Reassure it can be controlled/improve
A: Advice to avoid trigger factors. Correct inhaler technique
P: Add MDI corticosteroids
R:
I: PEFR
O: Follow up next month
P: Quit smoking

1) MIXING & INJECTING INSULIN USING A SYRINGE AND NEEDLE

Lee SL

Introduce self & greet patient

Explain intention of session
Advise patient to wash hands prior to the procedure each time
Check equipment
Check name &expiry date on both insulin vials. Advise patient to
discard expired insulin.
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Roll cloudy insulin between hands/gently invert vial, 10x-20x to mix

the insulin properly.
Swab top of both insulin vials with alcohol swab
Remove cap from needle, discard cap immediately to avoid
recapping later
Draw air into the syringe, equivalent to the amount of required
cloudy insulin. Push the air into the cloudy insulin vial then pull out
the needle without drawing any insulin.
Draw air into the syringe, equivalent to the amount of required
clear insulin. Push the air into the clear insulin vial. Turn the vial
upside down with the syringe still in place. Ensure that needle is
submerged in insulin before you pull the plungerto draw up the
required amount of clear insulin.
If you see air bubbles:

- Tap the syringe firmly with your fingertip to move the bubbles to the
top of the syringe - Push the plunger up a few units until the air
bubbles go back into the insulin bottle.

Lee SL

Ensure that there are no air bubbles and that the correct amount of
insulin is drawn up before you remove the needle.
Now insert the needle into the cloudy insulin vial. Ensure that the
needle is submerged in insulin before you pull the plunger to draw
up the required amount of cloudy insulin. The final amount of
insulin in the syringe should be a total of the prescribed
clear & cloudy insulin.
If the total amount of insulin drawn is incorrect, discard the syringe
& start all over again.
Explain to patient the different injection sitesand how to select an
injection site.
Stress to patient the need to rotate sites to avoid scarring of the
fatty tissue(lipodystrophy) as it will affect the absorption of insulin.
Demonstrate injection technique on dummy. You may swab the
injection site with an alcohol swab but please allow it to dry before
you inject the insulin. Pinch & hold the skin with one hand.Hold the
syringe like a dart with the other hand. Inject quickly at a 90 degree
angle.Push the plunger down until all the insulin is in. You may relax
the pinch but leave the needle in for at least 6 seconds before
removing the needle to ensure that no insulin leaks out.Advise
patientnotto massage the area after injection.
Dispose needle & syringe into sharps bin/disposable puncture proof
container which has a lid.
Check patient understands & allow clarification.
Advisepatient regarding home blood glucose monitoring,
hypoglycaemic symptoms & how to manage hypoglycaemia at
home, storage of insulin.

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2) INSULIN PEN
Greet patient & introduce self
Explain intention of session
Advise patient to wash their hands prior to the procedure each time
Check equipment
Remove the insulin pen cap
Check name & expiry date of insulin
Load insulin into cartridge
If insulins cloudy, gently roll/invert pen 10x-20x until insulin is
mixed properly
Wipe the tip of the pen where the needle will be attached with an
alcohol swab
Remove paper tab from pen needle & screw needle firmly onto pen
Remove outer cover/large cap from pen needle &put it aside
Remove inner cover/small cap from pen needle &discard it
Explain need to prime needle & demonstrate it to patient. Dial 2
units. Hold pen with needle facing upwards & press the injection
button to release the insulin. Check that dial goes back to 0 after
priming. Repeat these steps until a stream of insulin is released.
Now dial the required amount of insulin
Explain the different injection sites & stress on the need to rotate
sites
Demonstrate how insulin is injected on a dummy. Please refer to
technique explained above.
Put the outer cover/large cap back on needle then unscrew the
needle
Discard needle in sharps bin/puncture proof container with a lid
Check patient understands & allow clarification
Advise patient regarding home blood glucose monitoring,
hypoglycaemic symptoms & how to manage hypoglycaemia at
home, storage of insulin.

Tip: This can be an interactive OSCE station. Please show what you are doing to
the patient & explain whatever youre doing, out loud. Please remember to use
layman terms.
STATION : COMMUNICATION SKILLS
Dealing with Serious Diagnosis
Colorectal Cancer
Patient is an end stage colorectal CA with metastasis to the liver. Her oncologist said she
has 1 year left to live. Consult her as her GP.

Questions to ask patient:

o How is she coping with this news?

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o Can she sleep well?

o Any bowel problem?
When she asked about the time left for her to live
o Ask her whether the oncologist has told her anything.
o Say that according to her oncologist, youre sorry that she only has a year to
live.
o However, anything is possible.
o What is more important is that she has to spend her time well and live life to
the fullest
When she asked what care can she expect at this stage
o Pain management
o Palliative care at the ward
o You can refer her to palliative care society
o If she has any health related problem, she can always come to you
When she asked whether she can die at home
o Yes. Say that you understand her, and that she can always asked for that
from any doctors treating her.
When she offers you money as a sign of gratitude
o Dont take it! Explain that it is against your ethics as a doctor. And that you are
satisfied enough if you are able to help her in any sort of way.
When she blamed our colleague for her miscarriage 25 years ago
o Say that you cannot comment on this. You dont know what exactly happened
back then.
When she asked how is it like to die?
o Dying is a natural process and that everyone dies eventually. Assure her that
you are going to help her undergo this without any pain.
Then, offer her for follow up.
Summarize everything before ending the session.

S.P.I.K.E.S. PROTOCOL
1) Greet
2) Eye contact, body language
3) Open question
4) Patients perception when you got that chest pain, what you think is going on? Do u think
it is serious?
5) Invitation Are you sort of person who like to know the details? / How would you like me to
handle the information about your results?
6) Knowledge : giving information regarding the information. Are you understand?
7) Explore emotion
8) Summary and suggestion/strategy for future
Rheumatoid Arthritis
Hi, Brandon. How are you doing?
Thanks for coming today. Are you coming by yourself or with somebody else?
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First of thing first, would you tell me what you know so far?
Yes , youre right. We did send off the test and we jus received about results. So, im sorry to
say that the result has shown that you have Gout Arthritis.

I know this is very hard for you, Brandon since it may disturb your hobbies.

Would you like me to tell more about it?

So it is an inflammation of your joint and i have to say with time, it may get worst.

Fortunately, there are plenty of medication or alternative that we can get for you. There are
also other forms of helps and support group taht can help you and hopefully it can help
people with this condition.

If he tells his worries about other people, reply No... dont think or worried about it just yet
okey?

Are you worried? .... Its not something you need to worry yet, Brandon. Because we will help
you with other alternatives okey?

Thank you for coming today, Brandon.

Breast cancer
The patient just done her mammogram. Unfortunately the result was abnormal. Your task is
to inform the patient regarding the abnormal result of her mammogram.
1. Introduction
Let me talk to you about your mammogram. Mammogram is a test we used to detect
presence of breast cancer

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2. Truth
So we did gather the results of the mammogram, unfortunately this time it shows
that there is something in your breast. In medical, there is a mass in your breast. So,
I want to be frank with you, the reading actually does not look good. From the
radiologist mammogram report, they put that there is high probability it is a cancer
3. Are you sure about the mammogram?
Yes, i do think the reading should be right
4. I would like to suggest you to do other investigation in order to reconfirm about the
mass.
5. Do you have any health insurance ? (help them by referring them to social insurancehospital social service department)
A 41 years old male patient, heavy smoker was diagnosed with Bronchogenic Carcinoma
1.
2.
3.
4.
5.

Advanced preparation
Build therapeutic environment
Communicate well
Deal with patient reaction (denial state)
Encourage validate emotion (follow up)

Communication skills Breaking news - patient with 2cm (same as previous examination) of
adenocarcinoma in her left breast
It may go something like this: You do have cancer and it is a serious illness but it is not
necessarily a death sentence, especially these days. You will need a major operation
followed by some treatment that will make you feel very unwell but you can get through
it. You are in good hands and you have lots of people around who care about you. If the
worst does come to the worst we can control pain without knocking you out and without
loss of dignity. You have a fight on and we can win. One of the most important features is
your attitude. Remember that if you have any problems or want to discuss anything we
are here for you.

HIV

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1. introduce, address pt by name, comfort the patient

2. how much do you know about HIV?
3. Open question
4. You should discuss with your wife
5. There is 25% chance if mother is infected can spread to child
6. There is medication to give to the mother to reduce the risk
7. Ask to bring his wife to check, assure we can treat her. Do not delay anymore.
8. Health authority will tell your wife within 24h if you are still dont tell your wife
9. Tell his dentist (honesty, how pts feel, ICE)
10. Good family support
11. Good financial support check understandin, give realistic hope
12. Conclude
13. Safety net
14. Thank you
Dealing with Angry Patient

1) You look really upset.

2) Tell me about it.
3) Im so sorry this is happening to you.
4) What would you like me to do to help you?
5) Heres what Id like us to do next.
6) Thank you so much for sharing your feelings me with, its really important
that we understand each other completely, thank you.

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Dealing with Death

Hi, good morning.

I dont like it. I know you dont.
What happen before you came to the hospital?
So I would like to ask you, what do we expect to happen after you leave the hospital?
Im not sure if i can get him back to Maine (their plan after discharged).
It is a process, and i think you know it si very hard to come to the realization thet hes
dying.

Anybody has talk to you about hospice or having hospice nurses to take care?

Lee SL

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