Faculty Guide for Virtual OSCE: Claire – Fatigue and Vomiting

Case Overview

Patient Name: Claire
Age: 20 years old
Presenting Complaint: Vomiting and Fatigue
Setting: Emergency Department
Key Clinical Concern: Adrenal Insufficiency (Adrenal Crisis)

🔹 Faculty Role in the Virtual OSCE

The facilitator’s primary role is to observe, assess, and guide the student’s clinical reasoning while allowing them to work through the case independently. Faculty should:
✅ Encourage active learning by prompting students when needed, without giving away answers.
✅ Ensure students systematically gather data through history-taking and physical examination.
✅ Provide feedback based on student performance, identifying strong areas and improvement points.
✅ Moderate the debriefing session to reinforce key learning objectives.

🔹 Learning Objectives

By the end of this OSCE, students should be able to:

1. Perform a focused history for vomiting and dehydration.
2. Conduct a systematic physical exam, prioritizing hydration status and orthostatic vital signs.
3. Generate a well-reasoned differential diagnosis, with emphasis on endocrine causes.
4. Select appropriate investigations to confirm the diagnosis.
5. Synthesize findings into a concise problem representation.

🔹 Faculty Preparation

1. Review the case details

   • Understand the timeline of Claire’s symptoms (vomiting for 5 days, worsening).
   • Recognize the red flag symptoms (orthostatic hypotension, dehydration, persistent vomiting).
   • Note her past medical history (hypothyroidism, potential autoimmune link).

2. Familiarize yourself with the expected flow of the OSCE:

   • Step 1: Focused History
   • Step 2: Student-Directed Physical Exam
   • Step 3: Problem Representation
   • Step 4: Differential Diagnosis
   • Step 5: Investigation Selection
   • Step 6: Case Conclusion & Debriefing

3. Prepare Faculty Notes to guide discussion and feedback.

🔹 Step-by-Step Faculty Guide

Step 1: History-Taking

📢 System Prompt: “Begin by taking a focused history.”

📝 Key Information the Student Should Elicit:
✅ Vomiting history: >10x/day, unable to tolerate fluids, bright red blood streaks.
✅ Dehydration symptoms: Lightheadedness, dizziness, fatigue.
✅ No abdominal pain, no diarrhea.
✅ Recent sick contact (roommate with stomach bug).
✅ Medication history (levothyroxine for hypothyroidism, but sometimes forgets doses).

👀 Common Student Pitfalls:
❌ Focusing only on gastroenteritis and missing dehydration.
❌ Forgetting to ask about medication adherence.
❌ Not inquiring about autoimmune conditions (hypothyroidism could be linked to adrenal insufficiency).

👩‍🏫 Faculty Guidance:

• If the student misses medication history, ask:
  📢 “What conditions could affect Claire’s ability to regulate fluids and blood pressure?”
• If the student focuses only on gastroenteritis, guide them toward endocrine causes:
  📢 “What conditions other than infections can cause persistent vomiting and hypotension?”

Step 2: Physical Examination (Student-Directed)

📢 System Prompt: “Select the physical exam components you’d like to perform.”

🩺 Expected Exam Findings (Only Given If Requested):

• Vitals (Automatically Provided): BP 90/60 mmHg (drops to 80/50 standing), HR 115 bpm, RR 16, Temp 36.8°C
• General Appearance: Fatigued, dry mucous membranes, slightly delayed capillary refill.
• Abdominal Exam: Soft, mild epigastric tenderness, no guarding, no rebound.
• Neurological Exam: Alert, oriented, normal motor/sensory function.
• Cardiovascular Exam: Tachycardic but regular, delayed capillary refill.
• Skin Exam (If Requested): No hyperpigmentation or rash.

👀 Common Student Pitfalls:
❌ Not requesting capillary refill or mucous membrane check → leads to missing dehydration signs.
❌ Skipping the abdominal exam → could overlook GI-related differential diagnoses.

👩‍🏫 Faculty Guidance:

• If a student misses dehydration clues, ask:
  📢 “How would you assess Claire’s hydration status clinically?”

Step 3: Problem Representation

📢 System Prompt: “Summarize the key clinical findings in 1-2 sentences.”

✅ Strong Example:
📌 "Claire is a 20-year-old female with persistent vomiting for 5 days, dehydration, orthostatic hypotension, and fatigue. She has a history of hypothyroidism and has not been fully adherent to her medication."

❌ Weak Example:
📌 "Young woman with vomiting and tiredness." (Too vague!)

👩‍🏫 Faculty Feedback:

• If the student misses orthostatic hypotension, ask:
  📢 “How does her blood pressure change when standing influence your differential?”

Step 4: Differential Diagnosis

📢 System Prompt: “List at least three differential diagnoses and justify them.”

✅ Expected Responses:

1. Adrenal Insufficiency (Adrenal Crisis) – Persistent vomiting, dehydration, orthostatic hypotension, and history of hypothyroidism (potential autoimmune link).
2. Acute Gastroenteritis – Recent sick contact, but prolonged symptoms and severe dehydration make it less likely.
3. Peptic Ulcer or Mallory-Weiss Tear – Vomiting with streaks of blood suggests mucosal injury.

👀 Common Pitfalls:
❌ Not considering adrenal insufficiency at all.
❌ Focusing only on infection (gastroenteritis).

👩‍🏫 Faculty Guidance:

• If adrenal insufficiency is missed, ask:
  📢 “What endocrine conditions could cause severe vomiting and hypotension?”

Step 5: Investigation Selection

📢 System Prompt: “Select the most appropriate initial investigations.”

✅ Key Tests:
✔️ Serum Electrolytes (BMP/CMP) – Check for sodium/potassium abnormalities.
✔️ Serum Cortisol & ACTH – Diagnose adrenal insufficiency.
✔️ TSH, Free T4 – Assess thyroid function.
✔️ Serum Glucose & Ketones – Rule out DKA.
✔️ CBC – Assess anemia and infection.

👀 Common Pitfalls:
❌ Not ordering serum cortisol.

👩‍🏫 Faculty Guidance:

• If cortisol is not selected, ask:
  📢 “How would you confirm adrenal insufficiency in a patient like Claire?”

Step 6: Case Conclusion & Faculty-Led Debriefing

📢 System Prompt: “What is the most likely diagnosis?”

✅ Correct Answer: Adrenal Insufficiency (Adrenal Crisis)

📢 Faculty Discussion Points:

• Why was adrenal insufficiency the correct diagnosis?
• What key signs indicated severe dehydration?
• What could have happened if this diagnosis was missed?

🔹 Final Faculty Takeaways

✅ This OSCE encourages active clinical reasoning.
✅ Student-directed exams ensure realistic decision-making.
✅ The debriefing session solidifies key learning objectives.