Stanford University Geriatric Education Resource Center  

HBV30: Geriatrics Objective Structured Clinical Exercises (GOSCEs)


Overview of Objective Structured Clinical Examination (OSCE) format

Table of Contents.

To the Educator 4
What does a GOSCE do?
How is the GOSCE program structured?
How have residents and faculty responded to the GOSCE program?
How will the GOSCE program add value to your graduate medical curriculum?

GOSCE STATIONS

I. Urinary Incontinence
Overview: Epidemiology and Treatment Interventions I-1
Patient Assessment
Instructions to the Preceptor I-3
Setting
Patient
Clinical Objectives
Timing
How to Proceed
Physical Examination
Laboratory Testing
Assessment and Treatment Recommendations
Table 1: Causes of Transient Urinary Incontinence
(DIAPERS Mnemonic)
I-7
Table 2: Behavioral Interventions I-8
Table 3: Preceptor's Checklist I-9
Instructions to the Resident I-11
Setting
Patient
Objective
Timing
Instructions to the Patient/Actor I-12
Case Description
Improvisational Tips
Selected Research Findings I-14

II. Falls
Overview: Epidemiology and Treatment Interventions II-1
Physical Examination
Instructions to the Preceptor II-3
Setting
Patient
Clinical Objectives
Timing
How to Proceed
Physical Examination
Laboratory Testing
Assessment and Treatment Recommendations
Table 1: Guide to Clinical Assessment of the Patient Who Falls II-7
Table 2: Summary of Tests and Procedures II-8
Table 3: On-line Problem and Medication List II-9
Table 4: Preceptor's Checklist II-10
Instructions to the Resident II-11
Setting
Patient
Objective
Timing
Instructions to the Patient/Actor II-12
Case Description
Improvisational Tip
Selected Research Findings II-14

III. Delirium/Dementia
Overview: Epidemiology and Treatment Interventions III-1
Delirium and Dementia
Diagnostic Steps
Psychoactive Drug Treatment
Instructions to the Preceptor III-4
Setting
Patient
Clinical Objectives
Timing
How to Proceed
Physical Examination
Laboratory Testing
Assessment and Treatment Recommendations
Table 1: Contributing Factors for Delirium III-8
Table 2: Differential Diagnosis of Delirium and Dementia III-9
Table 3: The Confusion Assessment Method III-10
Table 4: Principles of Psychoactive Drug Therapy III-11
Table 5: Preceptor's Checklist III-12
Instructions to the Resident III-14
Setting
Patient
Objective
Timing
Instructions to the Patient/Actor III-15
Case Description
Improvisational Tips for the Patient
Improvisational Tips for the Daughter
Selected Research Findings III-17

IV. Advance Directives
Overview: The Legal Context IV-1
Health Care Proxies and Durable Powers
Instructions to the Preceptor IV-4
Setting
Patient
Clinical Objectives
Timing
How to Proceed
Physical Examination
Laboratory Testing
Assessment and Treatment Recommendations
Table 1: The Advance Directives Process IV-8
Table 2: Preceptor's Checklist IV-9
Instructions to the Resident IV-10
Setting
Patient
Objective
Timing
Instructions to the Patient/Actor II-12
Case Description
Improvisational Tips
Selected Research Findings IV-13

Overview:
Epidemiology and Treatment Interventions


Urinary incontinence (UI) is generally recognized as one of the major causes of institutionalization of the elderly, affecting over 50 percent of the more than 1.5 million nursing home residents in the US Correlates to UI among institutionalized elders include substantial cognitive impairment, limitations in mobility, and infection.

For non-institutionalized elders as well, UI is highly correlated to various health conditions. In both males and females, physical mobility problems, specific neurological symptoms, lower urinary tract problems, bowel problems, respiratory problems and history of urological/pelvic surgery are more prevalent among those who are incontinent than those who are continent.

While a few of the causes of UI are associated with serious underlying disease, the majority are due to persistent abnormalities of the structure or function of the lower urinary tract. These manifest in four ways:

Patient Assessment
For a thorough assessment of the problem, the following four-step approach is generally recommended: Medications, when used alone, rarely control incontinence. In fact, incontinent patients are more likely to be improved by adjustment or discontinuation of a medication than by addition of a new one. Nevertheless, once all issue areas have been addressed and appropriate behavioral interventions have been initiated, medications (e.g., bladder relaxants, estrogen) may be useful.

Catheterization is generally indicated when other measures fail to adequately control incontinence, or when precise knowledge of urinary output is crucial, or when a pressure ulcer will not heal in the presence of urine, or when comfort measures require it in a terminally ill patient.

Instructions to the Preceptor

Setting
The setting is the resident's primary care clinic.

Patient
The patient is a postmenopausal older female who presents with urinary incontinence. She is a first-time patient at the clinic. Her history suggests strong detrusor contractions and some degree of urinary stress incontinence since giving birth to her children.

Clinical Objectives
The salient questions are:

The resident will need to consider the causes of new onset urinary incontinence in a postmenopausal woman. Physical examination will suggest that atropic vaginitis may be a significant component. History will suggest detrusor hyperactivity.

The resident should also be able to recommend an appropriate initial course of treatment - i.e., use of estrogen - as well as consider the possible use of oxybutynin.

Timing
This GOSCE station will take about 20 minutes. In the first 10 minutes, the resident will meet with the patient and take a history. In the second 10 minutes, you will ask the resident about his/her targeted approach to the physical examination, recommendations for laboratory testing, and assessment and treatment plans based on available information.

How to Proceed
In the first 10 minutes of the GOSCE station, you will:

In the second 10 minutes of this GOSCE station, you will: More details on the physical examination, laboratory testing, and assessment and treatment plans are given in the following sections.

Physical Examination
You should ask the resident about his/her plan for a targeted physical examination. Targeted portions would include emphasis on the abdominal, pelvic, and rectal areas.

The resident's plan for a physical examination should include a test for stress incontinence (Valsalva's maneuver). With the patient standing over a cloth, ask her to cough. Resultant immediate leakage of urine is a diagnostic for stress incontinence.

When the resident asks you for the results of the physical examination, or you volunteer them, tell him/her that the patient is healthy, with normal vital signs, clear lungs, and normal heart tones without a murmur or gallop. Breasts are without masses. Abdominal examination reveals normal bowel sounds, no organomegaly, no masses, and no evidence of a distended bladder. Rectal examination is normal, with a small amount of guaiac negative stool. Pelvic examination reveals shiny atrophic vaginal mucosa with some telangiectasis and minimal friability. The impression from the physical examination is atrophic vaginitis.

The resident may also wish to obtain a post-void residual. Tell him/her that the post-void residual is 20 cc of clear urine.

Laboratory Testing
You should ask the resident for his her specific recommendations for laboratory testing. Appropriate, parsimonious testing would include a blood glucose test and a urinalysis with culture.

When the resident asks you for the results of the laboratory testing, or you volunteer them, tell him/her that glucose is normal and urinalysis is negative for protein, blood, and sugar, with a microscopic showing of a few epithelial cells, no white cells, and no red cells. If the resident wishes to know the results of a Pap test, say that it returned with atrophic cells.

Assessment and Treatment Recommendations
Ideally, the resident will

  1. recognize that this is a case of new onset urinary incontinence - most likely, detrusor hyperactivity with atrophic vaginitis and underlying long-term stress incontinence;
  2. understand this case to be an example of urinary incontinence occurring in part as a consequence of a condition not directly related to the urinary tract - i.e.. atrophic vaginitis; and
  3. make appropriate treatment recommendations.

The resident would also be wise to seek additional data by asking the patient to keep a voiding diary, which would cover a one- to two-day period and document the times the patient urinates, the approximate amount, and the times she finds herself incontinent. Analysis of the information in the voiding diary should precede any recommendation of prophylactic voiding at scheduled (e.g., 2 hour) intervals.

Though data from the voiding diary are not available at this point, the resident should nevertheless begin to outline treatment plans based on information that is already known. Appropriate initial treatment might consist of either topical vaginal estrogen (cream or suppositories) or a small dose of oral estrogen (e.g., 0.3 mg or 0.6 mg per day for one to three months). The resident should inquire about hormonally sensitive tumors before beginning the estrogen and, ideally, obtain a mammogram. Some residents might consider using oxybutynin (Ditropan) in this case. This is not necessarily wrong, but the drug might not be effective unless combined with estrogen. The preferred treatment is for a trial of estrogen for about a month, with a repeat visit to see how the patient is doing.

If the patient continues to have trouble with incontinence, a trial of oxybutynin would then be reasonable, beginning at a low dose (e.g., 2.5 mg or 5.0 mg, initially b.i.d., increasing to t.i.d.). If oxybutynin is used, the issue of checking for a post-void residual becomes important, as a common side effect of the drug is urinary retention and overflow.

It would be easy to convert the patient to overflow incontinence, especially if she already has a big, baggy bladder with strong but ineffective contractions.

Thus, a good follow-up question for the preceptor, if the resident suggests use of oxybutynin, is to ask what the resident would think if the patient complained of worsening urinary incontinence following administration of the drug.

User Comments

I liked the geriatrics content that would be incorporated into the resident's geriatrics curriculum. I also liked the preceptor's checklist - it helps to instruct the preceptor in evaluation of the resident.

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