Year 3 OSCE April 2015
Station 1 – Cardiovascular examination
– If you said “I’d like to do a blood pressure”, examiner gave a BP reading which I think looking back had a narrow pulse pressure.
– You were stopped from trying to listen for crackles of pulmonary oedema at the back, for some reason.
– None of the SPs has any CVS signs, but one of them did have an obvious tremor (which I noticed during testing for finger clubbing).
– What are the signs of aortic stenosis?
Station 2 – Urinalysis
– The Scenario we were given at the door was a patient who had come in because she thought she had an UTI. You were told to do an urine dipstick and analyse it, as well as explain the results to the patient and any further tests they would need. Though I can’t remember what exactly it was, there was something in the way the scenario was worded that made it obvious (to most people anyway) that there would be something else that was ‘unexpected’.
– Pt. said they had polyuria and thought it was a urine infection as she gets recurrent ones due to having a hysterectomy previously.
– Urine dip showed high glucose present, everything else normal
– On questioning pt also had polydipsia and tiredness
– So had to explain that they would need further blood tests to check if she had diabetes (fasting glucose etc.) If you mentioned blood test for glucose, she asked whether she had to do anything ‘in preparation’ for it (i.e.fast etc).
– Patient said she had a friend who was a nurse and asked you if you could specifically name the tests as she wanted to write them down to speak to her friend
– Remember to wear gloves!
– Use paper towels (they were not laid out for you, you had to get them from the wall).
No questions asked by the examiner
Station 3 – Triadic interview
– 70 year old female with low mood, memory loss e.g. forgetting glasses
– Had come to see the GP with her son
– Her husband had passed away recently, she was barely leaving house, sleeping all the time, had some suicidal thoughts (son/family = protective factor)
– What is the most likely diagnosis and why? (depression?)
Station 4 – Paediatric history with growth chart interpretation
– Mother was told by her midwife to see GP bc her child seemed to be losing weight – mother hadn’t noticed a problem but bought her red book with her
– Weight had dropped on chart by 2 centiles = failure to thrive
– When asked if she understood the growth chart, she said yes, so no need to explain that to her
– No symptoms except recently stool had a green tinge (though this was inconsistently mentioned, apparently)
– Asked about diarrhoea, vomiting, if baby passed meconium (CF), about feed frequency and amount (baby was breastfed)
– There was a FH of cows milk allergy
– What is the diagnosis and why – unsure if cows milk allergy or underfeeding. Think you specifically had to say failure to thrive as well and demonstrate that you knew weight had dropped by 2 centiles.
Station 5 – Drug history
– Task was to take a targeted drug history of a man who had been diagnosed with angina 2 weeks ago and so had been started on some medications (aspirin, bisoprolol, GTN, simvastatin). Since starting them, he had been experiencing dizziness and abdo pain
– Symptoms only began at the time the medication was started
– Also was taking ibuprofen and cod liver oil for arthritis
– Further questioning showed he had been taking Gaviscon OTC for the epigastric pain he had been having
– Remember to ask about drug allergies
– I think no alcohol or recr drugs or smoking
– Dizziness was on standing from sitting (postural hypo) and pain was in epigastric area
– Patient said he was concerned that all the medications he was on were interacting with one another – think the statin and cod liver oil interact?
– There was a BNF in the station so I tried to look up some of the drugs to see if any could interact but didn’t get very far
– Asked which medications are causing the symptoms and why
– I think answer was bisoprol –> postural hypotension, and the aspirin + NSAID combo –> peptic ulcer
– Had to explain your reasoning
Station 6 – GI examination
– 35 year old man with RUQ pain which came and went over past 3 months, and worse after eating fish and chips
– Had to lower bed yourself
– What is the likely diagnosis and why (biliary colic / cholecystitis / cholangitis)
– What other diagnoses would you consider?
Station 1 – Ocular nerve exam
– Remember to inspect the areas around the eyes first (for ptosis etc). One SP had glasses on – remember to ask patient to keep glasses on for relevant parts.
– Snellen chart given (but was very discreetly located in the corner of the room) with tape on the floor to mark 6m. Though the Snellen chart was apparently ‘hidden’, the examiner did point it out to you if you said you would test visual acuity and asked directly.
– Magazines provided for testing near vision
– Peripheral fields
– There was no hat pin so had to do blind spot with red neurotip lid on white neurotip – some people were told just to test one side’s blind spot
There was no Ishihara test plate for colour vision (as expected)
– H test
– Pupillary reflexes etc.
– Mention corneal reflex, but told not to perform
– Had to do fundoscopy as well, need to turn light off! (remember to also leave until last – I ended up doing it before Snellen as hadn’t spotted the Snellen chart at this stage) – some of us were not expecting this, and we had so little opportunity to practice fundoscopy on the wards! I doubt they were looking for much in this area.
Station 2 – ABG
– ABG procedure
– Simulated patient with fake arm
– Some people were stopped and told not to do allens test
– Patient did not want a local anaesthetic (ask before getting equipment as the anaesthetic equipment was laid out)
– Remember to say sharp scratch, apparently someone didn’t say it and the patient screamed out
– What would u do with the blood now? (take to gas analyser? If greater than 10mins put in ice and send via transport?)
– What 3 things do you need to know? (temp, FiO2, pt identifiers)
Station 3 – Alcohol History
– Children thought she was drinking too much (she didn’t think so)
– Children no longer letting her look after her grandkids)
– Said she drank 3 glasses a wine in an evening (had previously been 3 small, now 3 large)
– Had to push further to get her to say she was also taking vodka shots some nights
– Had to do CAGE, ask Qs about alcohol dependence etc
– Think she had started drinking after her husband’s death if I remember rightly and she hadn’t been leaving the house much
– Asked what is the most likely diagnosis? Think the answer was alcohol misuse (not dependence), I also said depression could be a differential and that could be the cause of her drinking
Station 4 – Respiratory Exam
– Were not stopped when got to the back so expected to do whole exam – hard to finish in time!
– What signs would you expect to find in someone with a lower left lobe pneumonia
Station 5 – GI History
– 50 year old male patient had bloody diarrhoea and weight loss, diarrhoea was water with bits of formed stool in it, no abdo pain/vomiting/other symptoms, ?tenesmus
– No PMH, no DH
– FH of uncle with a stoma but not sure why he had it, and a cousin with “bowel disease” who takes steroids for it
– Patient was a self employed plumber so finding it embarrassing and having to turn down work as he is worried about using their toilet
– Asked most likely diagnosis and why
– There was debate between us whether it was more likely to be colorectal caner or IBD. Colorectal cancer was actually the most likely diagnosis (due to the patient’s age, as IBD usually presents younger, though you didn’t loose much by saying IBD).
Station 6 – Paeds History
– 5month child had a few weeks of cough and breathlessness then went unconscious and stopped breathing and was bought to A&E
– Preceded by coryzal symptoms, no other symptoms like fever etc
– Pregnancy and childbirth all fine
– Mother had another 2yo child who also had a cough but not as bad
– Mother didn’t believe in immunisations
– Had to ask the character of the cough, had to be very specific to make her say yes it sounded like a “whoop”
– Most likely diagnosis and why? it was whooping cough (DDx: maybe bronchiolitis/pneumonia?)
– Then shown a chart and asked to interpret the results – it had baby’s RR, HR, temp (normal ranges not given), WCC, platelet, neutrophil and lymphocyte counts (normal ranges provided)
– Think RR, HR & temp were normal (Remember to learn the normal ranges for different ages!!)
– Raised WCC and platelets
– Neuts normal, raised lymphocytes