Year 4 OSCE June 2019

Day 1

Station 1 – Schizophrenia

– Complete an MSE on a patient who had been admitted as an inpatient on a psychiatric ward
– Take a history at the same time
– Asked: diagnosis and mx
– Hard station, alot to get through
– Pt presented more manic than schizophrenia in some stations and was very difficult and aggitated


Station 2 – PID Swabs

– Take triple swabs
– Asked: Where did you take each swab from and what organisms are you looking for on each swab?
– Asked: Diagnosis and how would you treat (PID and usual abx tx)


Station 3 – CV Examination

– Real patient – scenario: c/o SOB
– Perform CV exam
– Present findings (briefly)
– Asked: What is the diagnosis and why, what investigations would you do (ECG, echo, remember CXR as pt SOB, specific bloods etc)
– My patient was MR although other circuits had AS


Station 4 – Pre-op Assessment Counselling

– Setting is pre-op assessment for hip replacement
– Take history from patient (brief), including drug history, allergies, PMH, FH, social etc – don’t miss anything!
– Go through drugs and tell patient if need to stop/change etc before surgery
– My patient was on warfarin for 2x previous DVT – asked LOTS of questions on stopping, bridging with LMWH, when to restart treatment, when to start Dalteparin injections after surgery, TED stockings etc
– Also had FHx of clotting disorders (don’t forget to take FHx) – asked the relevance of this – pt would need further investigation due to personal hx of unprovoked DVT


Station 5 – Childhood Asthma

– Setting: Primary care
– Asked to take history from Dad whilst child is with nurse having peak flow done
– Recent admission for chest infection, wheezing/coughing at night, using salbutamol ++, takes steroid inhaler daily
– Don’t forget to go through asthma triggers – family smoking, pets, exercise etc
– Asked: is child’s asthma well controlled in your opinion? (No)
– How would you manage this? Add next stage drug tx, regular peak flows, regular reviews, counsel on family triggers if any
**Guidelines for asthma management were on table (didn’t see this until the end) but according to others they were the old BTS guidelines, not the updated version (!) so this year they didn’t mind if you said the next stage up treatment from either old or new guidelines**


Station 6 – Hand Examination

– My pt had obvious RA as soon as you walked in the room – real patients! Some were less obvious
– Perform hand examination
– Asked how you would manage: analgesia, steroids for flares, DMARDs, urgent referal to Rheumatology, refer also to physio and OT for help around the house – DO NOT FORGET THIS, examiner quizzed me on what sort of things are available from OT to help and what sort of ADLs the patient might struggle with at home


Station 7 – Placenta Praevia

– Pt presenting at 36/7 weeks after an USS and has been told she has placenta praevia already
– You are asked to chat to the patient, find out what she knows and counsel her on the condition
– Don’t forget safety netting – bleeding come to hospital straight away, no sex, must have someone at home etc
– Had to be careful as pt was already close to full term and therefore sending her away and rescanning in a few weeks is not an option – must tell her she needs a CS, no choice at all. Pt didn’t like this, wanted vaginal delivery, upset but came around if you discussed reasons why


Station 8 – Back Pain History

– Pt presenting with lumbar back pain
– On questioning, revealed also getting cauda equina symptoms
– PMH of breast cancer in the past **RED FLAG for bone mets**
-Asked: what are your differentials, what investigations (specifically imaging) would you do and why (MRI gold standard), when would you do this (admit immediately due to cauda equina symptoms)


Day 2:

Station 1 – Dysphagia History

– Pt struggling to swallow, started solids now liquids too
– Scenario asked to explain to pt the mangement plan – not asked by examiner
– Tell pt sending on 2ww, explain re endoscopy procedure
– Pt very insistent on being told what you were looking for – must say oesophageal cancer in empathetic way and reassure/answer any questions she has
– No questions from examiner


Station 2 – 12 Lead ECG

– Perform ECG on a pt with palpitations
– Print off ECG from machine – ours broke on the day but didn’t seem to matter!
– Examiner gives you another ECG, asked to interpret and give diagnosis, some thought sinus tachycardia, others thought SVT


Station 3 – Paeds GI Examination

– Scenario: Child with history of constipation in for r/v
– Perform GI exam
– Asked: Symptoms on history and signs you’d expect to find on examination for constipation, what rare cause is there for paeds constipation (Hirschsprungs) and what signs would you find on examination for this (include finger into rectum causes explosive release of stools)


Station 4 – Ectopic Pregnancy

– Odd station! Very vague scenario – at GP surgery, pt wants to speak to you
– Walk into station, set up as telephone consultation
– Pt c/o LIF pain, nil else given away unless asked specific questions
– Take history – must ask gynae questions, then pt reveals late for period, no shoulder tip pain or bleeding, pt well currently, no urinary symptoms
– Must safety net
– Examiner asked: what is your diagnosis (ectopic), how would you manage (must admit pt for tests), what tests would you like to do (PT, serum bHCG, USS, blood tests), salpingectomy if confirmed ectopic

**Alot of people didn’t ask gynae questions and therefore never got the diagnosis, must ask any women of repro age with abdo pain**


Station 5 – T2DM Counselling

– Pt already been told she has T2DM and has been advised lifestyle changes, in to see you for r/v
– Take history, find out what she has tried and how successful
– Given latest HbA1c – still high despite lifestyle
– Counsel on starting metformin (side effects, dose, how to take etc), start statin, discuss BP checks and management, continue lifestyle changes
– On questioning, pt knew bits about DM but not much so explained further, discussed LT consequences if not managed adequately, advised on annual eye and foot checks, talked about diabetic nurse specialist for advice if needed, smoking cessation
– Advise to come back in 3/12 for recheck of HbA1c or sooner if SEs


Station 6 – A-E SOB

– Nurse has called you to look at pt as concerned re his breathing
– Perform A-E assessment, remember glucose (not expected to do but must say) and expose legs to look for signs of DVT in this case
– Equipment available in room for BP, temp, sats etc
– Examiner then gave us a sheet of paper with results of A-E on
– Interpret results, give differentials (PE most likely), asked further investigations and mx


Station 7 – Breast Exam

– Pt presents worried, no specific lump but think friend had recently had breast cancer and pt didn’t know what was normal
– Perform breast exam, reassure patient, do a bit of counselling re self-examination, attend mammograms etc
– Asked: present findings, diagnosis (normal breast exam), what would you do if you found a lump (triple assessment)


Station 8 – PTSD History

– Take history from pt
– Asked: diagnosis (PTSD), why this over other conditions