How can I create an Objective Structured Clinical Examination (OSCE) about Gastroesophageal Reflux Disease (GERD)?

OSCE Examination for Gastroesophageal Reflux Disease (GERD)

Station 1: History Taking (10 minutes, 20 points)

Candidate Instructions: Take a focused history from this patient presenting with chest discomfort.

Examiner Checklist:

Opening and Rapport (2 points)

• Introduces self and confirms patient identity 1
• Explains purpose of consultation 1

Symptom Characterization (8 points)

• Typical GERD symptoms (highest specificity for diagnosis) 2:

  • Asks specifically about heartburn (burning sensation behind sternum) 2
  • Inquires about regurgitation of gastric contents 2
  • Timing relative to meals and lying down 3
  • Duration and frequency of symptoms 4

• Atypical/extraesophageal symptoms 2:

  • Chronic cough 2
  • Hoarseness or laryngitis 2
  • Dysphagia 4
  • Chest pain (non-cardiac) 2

Red Flag Symptoms (5 points) - Critical for passing

Must ask about at least 4 of the following warning signs 4:

• Dysphagia (difficulty swallowing) 4
• Odynophagia (painful swallowing) 4
• GI bleeding (hematemesis or melena) 4
• Unintentional weight loss 4
• Persistent vomiting 4
• Anemia 4

Risk Factors and Comorbidities (3 points)

• Obesity status 3
• NSAID use 5
• Smoking and alcohol consumption 3
• Previous esophageal surgery or hiatal hernia 4

Closing (2 points)

• Summarizes findings back to patient 1
• Asks if patient has questions 1

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Station 2: Physical Examination (8 minutes, 15 points)

Candidate Instructions: Perform a focused physical examination on this patient with suspected GERD.

Examiner Checklist:

General Assessment (3 points)

• Assesses general appearance and distress level 4
• Measures vital signs (particularly weight/BMI for obesity assessment) 3

Abdominal Examination (8 points)

• Inspects abdomen for distension 4
• Auscultates for bowel sounds 4
• Palpates all four quadrants systematically 4
• Specifically checks for epigastric tenderness 4
• Assesses for hepatosplenomegaly (warning sign) 4
• Checks for abdominal masses 4

Exclusion of Warning Signs (4 points)

• Examines for signs of GI bleeding (pallor, conjunctival pallor) 4
• Checks for lymphadenopathy (supraclavicular nodes) 4

Automatic Failure Criteria:

• Does not wash hands before examination 1
• Causes unnecessary patient discomfort 1

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Station 3: Diagnostic Workup and Management (10 minutes, 25 points)

Scenario: A 45-year-old presents with 3 months of heartburn and regurgitation, no alarm features. Vital signs normal, BMI 32, epigastric tenderness on exam.

Candidate Instructions: Discuss your diagnostic approach and initial management plan with the examiner.

Initial Diagnostic Approach (8 points)

For typical symptoms without alarm features 2:

• States that history and physical examination are sufficient for diagnosis 4
• Explains diagnostic testing is NOT necessary initially 4
• Recommends empiric PPI trial as first-line diagnostic/therapeutic approach 2
• Specifies 4-8 week trial duration 3, 2

Must state: "Endoscopy is NOT indicated at this time because there are no alarm symptoms" 2 (2 points - critical)

Initial Management Plan (10 points)

Pharmacologic therapy 3, 2:

• Prescribes standard-dose PPI once daily before meals 3
• Specific examples: omeprazole 20mg or lansoprazole 30mg 5, 6
• States to take 30-60 minutes before first meal of day 5, 6
• Plans reassessment in 4-8 weeks 3

Lifestyle modifications (must mention at least 3) 3:

• Weight loss for overweight patients 3
• Elevate head of bed 6-8 inches 3
• Avoid late evening meals (within 3 hours of bedtime) 3
• Eliminate dietary triggers (caffeine, alcohol, spicy foods, chocolate) 3
• Smoking cessation 3

Management of Treatment Failure (5 points)

If inadequate response after 4-8 weeks 2:

• Increase to twice-daily PPI dosing 3
• If still no response, proceed to upper endoscopy 2
• Consider esophageal pH monitoring if endoscopy normal 2

Long-term Management (2 points)

• After symptom control, taper to lowest effective dose 3
• Mentions potential for on-demand therapy 3

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Station 4: Patient Counseling on PPI Therapy (8 minutes, 20 points)

Scenario: You are prescribing omeprazole 20mg daily. Counsel the patient on proper use and potential risks.

Examiner Checklist:

Proper Administration (6 points)

• Take once daily before first meal 5, 6
• Swallow capsule whole, do not crush or chew 5, 6
• If difficulty swallowing, can open capsule and mix with applesauce 5
• Take at lowest effective dose for shortest duration needed 5, 6

Expected Benefits and Timeline (3 points)

• Symptom improvement expected within 4-8 weeks 3
• May help acid-related symptoms but doesn't address underlying reflux 5, 6
• Not a cure; lifestyle modifications still essential 3

Serious Side Effects to Report (8 points) - Must mention at least 5

From FDA labeling 5, 6:

• Kidney problems: decreased urination or blood in urine 5, 6
• Severe diarrhea: watery stools, stomach pain, fever (C. difficile infection) 5, 6, 7
• Bone fractures: increased risk with long-term use (>1 year) 5, 6, 7
• Lupus-like symptoms: new joint pain, rash on cheeks/arms worsening in sun 5, 6
• Low magnesium: if taking for >3 months 5, 6

Follow-up Plan (3 points)

• Return in 4-8 weeks to assess response 3
• Contact sooner if alarm symptoms develop 4
• Discusses plan to taper medication once controlled 3

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Station 5: Interpretation of Investigations (8 minutes, 20 points)

Candidate Instructions: Review these investigation results and formulate a management plan.

Case A (10 points): 35-year-old with typical GERD symptoms, failed 8-week PPI trial. Upper endoscopy shows Los Angeles Grade C erosive esophagitis.

Expected Response:

• Confirms GERD diagnosis with objective evidence 8
• Continues PPI therapy (now with documented disease) 8
• May need additional 8 weeks of therapy 5
• Discusses need for maintenance therapy 5
• Mentions risk of Barrett's esophagus with chronic erosive disease 5, 7

Case B (10 points): 8-year-old with cerebral palsy, recurrent pneumonia, poor weight gain. Parents report frequent vomiting after feeds.

Expected Response:

• Recognizes high-risk population (neurologic impairment) 4
• States upper endoscopy with biopsy is preferred diagnostic test 8
• Explains pH monitoring has limited role in this presentation 8
• Mentions up to 75% prevalence of GERD in cerebral palsy patients 8
• Considers combined bronchoscopy to evaluate for aspiration 8
• Critical: Does NOT recommend empiric PPI trial as diagnostic test (poor sensitivity/specificity 71-78%/41-54%) 8

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Global Assessment Criteria (Applies to All Stations)

Communication Skills

• Maintains appropriate eye contact 1
• Uses clear, jargon-free language 1
• Demonstrates empathy and active listening 1
• Does not rush patient or ask about their score 1

Professionalism

• Maintains patient dignity and privacy 1
• Demonstrates respect throughout encounter 1
• Manages time appropriately without appearing rushed 1

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Scoring Summary

• Station 1 (History): 20 points
• Station 2 (Physical Exam): 15 points
• Station 3 (Diagnostic/Management): 25 points
• Station 4 (Patient Counseling): 20 points
• Station 5 (Investigation Interpretation): 20 points
• Total: 100 points

Pass Mark: 60/100 (60%)

Borderline Performance Indicators: Candidates scoring 55-64% should undergo remediation focusing on recognition of alarm symptoms and appropriate use of diagnostic testing 9, 10.