Table of Contents
Contributors
Title page
Copyright page
Companion website
Preface
Preface to the first edition
Acknowledgements
First edition contributors
Section reviewers
Figures
Selected list of abbreviations
Part 1: Introduction
Logical approach
1 The OSCE examination
Set up
Types of station
The instructions
The marks
Preparation
2 The stable patient
History and examination: hints and tips
Differential diagnoses, problem lists and management plans: hints and tips
Investigation choices: hints and tips
3 Presenting
Guide to the book
Technique
Possible viva questions
Answering technique: hints and tips
Further resources
4 History and examination
History stations
Examination stations
Practical stations
5 Practical stations 1
Practical skills
Station 1: Subcutaneous injection
Station 2: Blood transfusion
6 Practical stations 2
Station 3: Venepuncture
Station 4: Blood culture collection
Station 5: Cannula insertion
Station 6: Administering an IV injection
7 Practical stations 3
Station 7: Arterial blood gas collection
Station 8: Arterial blood gas interpretation
Station 8a
Station 8b
Station 9: Confirming and certifying death
Station 10: Nasogastric tube insertion
8 Practical stations 4
Prescribing stations
General prescribing
Station 11: Prescribing antibiotics
Station 12: Amending a prescription
Station 13: Drug dose calculation (renal)
Station 14: Drug dose calculation
Communication stations
9 Communication stations 1
Communication skills: hints and tips
Answering ethical issues: hints and tips
Further reading
10 Communication stations 2
Station 15: Breaking bad news
Station 16: Dealing with an angry relative
Station 17: Dealing with an error
Station 18: Dealing with consent
11 Communication stations 3
Station 19: Explaining a procedure
Station 20: Resuscitation decisions
Station 21: Requesting a post-mortem
Station 22: Starting a treatment
12 Communication stations 4
Station 23: Telephone information
Station 24: Third party confidentiality
Station 25: Public safety
Station 26: Self-discharge
Emergency stations
13 Emergency stations 1
Station 27: Basic life support (BLS)
Station 28: Advanced life support (ALS) algorithm
Station 29: Defibrillation
Station 30: Airway adjuncts
Station 30a: Insertion of oropharyngeal and nasopharyngeal airways
Station 30b: Insertion of laryngeal mask airway
14 Emergency stations 2
Station 31a: Medical emergencies – Airway
Station 31b: Medical emergencies – Breathing
Station 31c: Medical emergencies – Circulation
Station 31d: Medical emergencies – Disability
Station 31e: Medical emergencies – Exposure
Part 2: Medicine
Cardiovascular
15 Cardiology stations: History
Station 32: Palpitations
Station 33: Chest pain
Station 34: Hypertension
16 Cardiology stations: Examination
Station 35: Cardiovascular examination
17 Cardiology stations: Cases 1
Station 36: Mitral stenosis
Station 37: Mitral regurgitation
Station 38: Aortic stenosis
Station 39: Aortic regurgitation
18 Cardiology stations: Cases 2
Station 40: Tricuspid regurgitation
Station 41: Prosthetic heart valves
Station 42: Cardiomyopathy
Station 43: Infective endocarditis
19 Cardiology stations: Cases 3
Station 44: Jugular venous pressure
Station 45: Cardiac failure
20 Cardiology stations: Skills
Station 46: ECG recording – explanation
Station 47: ECG recording – procedure
Station 48: ECG interpretation – summary
Station 49: Blood pressure measurement
Respiratory
21 Respiratory stations: History
Station 51: Asthma
Station 52: Primary Lung malignancy
Station 53: Pneumothorax
22 Respiratory stations: Examination
Station 54: Respiratory examination
23 Respiratory stations: Cases 1
Station 55: COPD
Station 56: Bronchiectasis
24 Respiratory stations: Cases 2
Station 57: Interstitial lung disease
Station 58: Pleural effusion
25 Respiratory stations: Cases 3
Station 59: Previous TB
Station 60: Pneumonia
26 Respiratory stations: Cases 4
Station 61: Obstructive sleep apnoea
Station 62: Pneumonectomy/lobectomy
Station 63: Pulmonary hypertension
27 Respiratory stations: Skills
Station 64: Peak flow measurement
Station 65: Inhaler technique
Station 66: Oxygen therapy
28 Respiratory stations: Data 1
Station 67: Chest radiograph interpretation – normal chest
29 Respiratory stations: Data 2
Station 68: Chest radiograph interpretation – pleural effusion
Station 69: Chest radiograph interpretation – pneumothorax
Station 70: Chest radiograph interpretation – atelectasis
Station 71: Chest radiograph interpretation – lung metastases
Station 72: Chest radiograph interpretation – critical care patient
Station 73: Chest radiograph interpretation – pulmonary oedema
Abdominal
30 Abdominal stations: History 1
Station 74: Weight loss
Station 75: Diarrhoea
31 Abdominal stations: History 2
Station 76: Dysphagia
Station 77: Dyspepsia
32 Abdominal stations: Examination
Station 78: Abdominal examination
33 Abdominal stations: Cases 1
Station 79: Chronic liver disease
Station 80: Splenomegaly/ hepatosplenomegaly
34 Abdominal stations: Cases 2
Station 81: Hepatomegaly
Station 82: Ascites
Station 83: Jaundice
35 Abdominal stations: Cases 3
Station 84: Inflammatory bowel disease
Station 85: Polycystic kidney disease
Station 86: Chronic kidney disease
Neurology
36 Neurology stations: History
Station 87: Transient ischaemic attack
Station 88: Acute confusion
37 Neurology stations: Examination 1
Station 89: Upper limb motor examination
Station 90: Lower limb motor examination
38 Neurology stations: Examination 2
Station 91: Sensory examination
Station 92: Gait
39 Neurology stations: Examination 3
Station 93: Cranial nerve examination
40 Neurology stations: Examination 4
Station 94: Speech
41 Neurology stations: Cases 1
Station 95: Upper motor neurone lesion
Station 96: Lower motor neurone lesion
42 Neurology stations: Cases 2
Station 97: Cerebrovascular disease
Station 98: Glasgow Coma Scale assessment
Station 99: Multiple sclerosis
43 Neurology stations: Cases 3
Station 100: Parkinsonism
Station 101: Cerebellar syndrome
44 Neurology stations: Cases 4
Station 102: Myotonic dystrophy
Station 103: Motor neurone disease
Station 104: Myasthenia gravis
45 Neurology stations: Cases 5
Station 105: Facial nerve palsy
Station 106: Horner’s syndrome
Station 107: Cervical myelopathy
46 Neurology stations: Cases 6
Station 108: Visual field defect
Station 109: Ocular palsy
Endocrine
47 Endocrine stations: History
Station 110: Diabetes
Station 111: Hypercalcaemia
Station 112: Hypothyroidism
48 Endocrine stations: Examination
Station 113: Assessing thyroid status
Station 114: Assessing complications of diabetes
49 Endocrine stations: Cases 1
Station 115: Hypothyroidism
Station 116: Hyperthyroidism
50 Endocrine stations: Cases 2
Station 117: Type 1 diabetes mellitus
Station 118: Type 2 diabetes mellitus
Station 119: Diabetic eye disease
Station 120: Diabetic foot
51 Endocrine stations: Cases 3
Station 121: Cushing’s syndrome
Station 122: Hypoadrenalism/Addison’s disease
52 Endocrine stations: Cases 4
Station 123: Acromegaly
Station 124: Gynaecomastia
Station 125: Hyperlipidaemia
Part 3: Surgery
General surgery
53 Surgical history
Station 126: Acute abdominal pain
Station 127: Colorectal cancer
Station 128: Rectal bleeding
54 Surgical abdominal examination
Station 129: Surgical abdominal examination
Station 130: Digital rectal examination
55 Surgery cases 1: Abdomen
Station 131: Abdominal stoma
Station 132: Abdominal mass
Station 133: Renal transplant
56 Surgery cases 2: Groin
Stations 134 and 135: Groin examination and groin swellings
57 Surgery cases 3: Neck
Station 136: Neck examination
Station 137: Neck lumps
58 Surgery cases 4: Breast
Station 138: Breast history
Station 139: Breast examination
59 Surgery cases 5: Lumps and bumps
Station 141: Lipoma
Station 142: Epidermoid cyst
60 Surgical skills
Station 143: Preoperative assessment
61 Surgical data interpretation
Station 144: Abdominal X-ray interpretation
Station 145: Small bowel obstruction
Station 146: Large bowel obstruction
Station 147: Sigmoid volvulus
Station 148: Barium enema
Station 149: Erect chest radiograph
Vascular
62 Vascular history
Station 150: Intermittent claudication
Station 151: Acute pulseless leg
Station 152: Abdominal aortic aneurysm
63 Peripheral vascular examination
Station 153: Peripheral vascular examination
Station 154: Ankle brachial pressure index measurement
Station 155: Abdominal aortic aneurysm
Station 156: Amputations
64 Vascular cases
Station 157: Varicose veins
Station 158: Leg ulcers
Urology
65 Urological history
Station 159: Haematuria
Station 160: Benign prostatic hypertrophy
Station 161: Renal calculi
66 Urology examination and skills
Station 162: Examination of the man external genitalia/scrotal swellings
Station 163: Urinalysis
Station 164: Urethral catheterisation
Musculoskeletal
67 Musculoskeletal stations: History
Station 165: Swollen knee
Station 166: Gout
Station 167: Rheumatoid arthritis
68 Musculoskeletal stations: Examination 1
Station 168: Musculoskeletal examination
Station 169: GALS screen
Station 170: Spine examination
69 Musculoskeletal stations: Examination 2
Station 171: Hip examination
Station 172: Knee examination
70 Musculoskeletal stations: Examination 3
Station 173: Hand examination
Station 174: Carpal tunnel syndrome (CTS)
Station 175: Shoulder examination
71 Musculoskeletal stations: Cases 1
Station 176: Osteoarthritis of the hip
Station 177: Ruptured anterior cruciate ligament
72 Musculoskeletal stations: Cases 2
Station 178: Ankylosing spondylitis
Station 179: Rheumatoid knee
73 Musculoskeletal stations: Cases 3
Station 180: Painful shoulder
Station 181: Hallux valgus
Station 182: Charcot joints
74 Musculoskeletal stations: Cases 4
Station 183: Upper limb nerve injuries: general
Root injuries
Station 184: Radial nerve lesion
Station 185: Median nerve lesion
Station 186: Ulnar nerve lesion
Station 187: Long thoracic nerve lesion
75 Musculoskeletal stations: Cases 5
Station 188: Management of major injuries
76 Musculoskeletal stations: Data
Musculoskeletal (MSK) imaging
Station 189: MSK imaging interpretation – hips and pelvis
Station 190: MSK imaging interpretation – knee
Station 191: MSK imaging interpretation – hands
Station 192: MSK imaging interpretation – wrist
Station 193: MSK imaging interpretation – hip
Station 194: MSK imaging interpretation – pelvis
Part 4: Specialties
Paediatrics
77 Paediatric stations: History
Station 195: Paediatric history
Station 196: Bronchiolitis
Station 197: Failure to thrive
78 Paediatric stations: Cardiology
Station 199: Congenital heart disease (CHD)
Station 200: Cardiac failure
Station 201: Rheumatic heart disease
79 Paediatric stations: Respiratory
Station 203: Stridor
Station 204: Cystic fibrosis
Station 205: Chesty child
80 Paediatric stations: Gastrointestinal
Station 207: Constipation
Station 208: Vomiting
Station 209: Abdominal pain
Station 210: Lumps and bumps
81 Paediatric stations: Infectious diseases 1
General hints and tips
Station 211: Infectious diseases with rashes
Station 212: Meningitis
82 Paediatric stations: Infectious diseases 2
Station 213: Immunisations
Station 214: Childhood infections
Station 215: Skin lesions
83 Paediatric stations: Neonatology
Station 216: Newborn baby check
Station 217: Neonatal resuscitation
84 Paediatric stations: Child development
Station 218: Developmental assessment
Station 219: Growth
Obstetrics and gynaecology
85 Obstetrics and gynaecology stations: History and examination 1
Station 220: Obstetric history
Station 221: Obstetric examination
Station 222: Bimanual pelvic examination
86 Obstetrics and gynaecology stations: History and examination 2
Station 223: Gynaecological history – pelvic pain
Station 224: Gynaecological examination
Station 225: Speculum examination
87 Obstetrics and gynaecology stations: Cases 1
Station 226: Spontaneous miscarriage
Station 227: Recurrent miscarriage
88 Obstetrics and gynaecology stations: Cases 2
Station 228: Contraception
Station 228a: Missed pill
Station 228b: Antibiotics and the pill
Station 228c: Emergency contraception
Station 229: Sterilisation
89 Obstetrics and gynaecology stations: Cases 3
Station 230: Ectopic pregnancy
Station 231: Termination of pregnancy
Station 232: Antepartum haemorrhage
90 Obstetrics and gynaecology stations: Cases 4
Station 234: Preconception care
Station 235: Booking visit
Station 236: Prenatal diagnostic tests
Station 237: Hypertension in pregnancy
91 Obstetrics and gynaecology stations: Cases 5
Station 238: Dysmenorrhoea/pelvic pain
Station 239: Abnormal vaginal bleeding
92 Obstetrics and gynaecology stations: Cases 6
Station 240: Cervical dysplasia
Station 241: Cervical smear
Station 242: Endometrial hyperplasia/neoplasia
93 Obstetrics and gynaecology stations: Cases 7
Station 243: Amenorrhoea
Station 244: Polycystic ovarian syndrome
94 Obstetrics and gynaecology stations: Cases 8
Station 245: Subfertility
Further reading
Station 246: Endometriosis
95 Obstetrics and gynaecology stations: Cases 9
Station 247: Preterm labour
Station 248: Preterm, prelabour rupture of the membranes
96 Obstetrics and gynaecology stations: Skills 1
Station 249: Normal labour
Station 250: Normal delivery
97 Obstetrics and gynaecology stations: Skills 2
Station 251: Instrumental vaginal delivery
Station 252: Caesarean section
Station 253: Postpartum haemorrhage
98 Obstetrics and gynaecology stations: Data
Station 254: Fetal heart rate monitoring
Dermatology
99 Dermatology stations: History
Station 256: Pruritus/Rash
Station 257: Dermatological lesion
100 Dermatology stations: Examination
Station 258: Dermatology examination
Station 259: Pigmented lesion
Station 260: Rash
101 Dermatology stations: Cases 1
Station 261: Eczema
Station 262: Psoriasis
102 Dermatology stations: Cases 2
Station 263: Bacterial infections
Station 264: Viral infections
Station 265: Fungal infections
103 Dermatology stations: Cases 3
Station 266: Malignant melanoma
Station 267: Basal cell carcinoma
Station 268: Squamous cell carcinoma
104 Dermatology stations: Cases 4
Station 269: Acne
Station 270: Urticaria
105 Dermatology stations: Cases 5
Station 271: Lichen planus
Station 272: Pityriasis versicolor
Station 274: Bullous pemphigoid
Station 277: Erythema nodosum
106 Dermatology stations: Skills and data
Station 279: Skin punch biopsy
Station 280: Curettage
Station 281: Excision biopsy
Station 282: Incisional biopsy
Station 283: Wood’s light
Station 284: Viral cultures/Tzanck test
Station 285: Microscopy
Ophthalmology
107 Ophthalmology stations: History and examination
Ophthalmology example stations
Station 287: Vision and driving
Station 288: Eye examination
108 Ophthalmology stations: Cases 1
Station 289: Glaucoma
Station 290: Uveitis
109 Ophthalmology stations: Cases 2
Station 291: Diabetic retinopathy
Station 292: Hypertensive retinopathy
Station 293: Cataract
Station 294: Age-related macular degeneration (ARMD)
110 Ophthalmology stations: Cases 3
Station 295: Refractive errors
Station 296: The red eye
Station 297: Optic nerve disease
111 Ophthalmology stations: Skills
Station 298: Direct ophthalmoscopy
Station 299: Instilling eye drops
Station 300: Visual acuity assessment
ENT
112 ENT stations: History and examination 1
Station 301: Ear history
Station 302: Ear examination
113 ENT stations: History and examination 2
Station 303: Nose history
Station 304: Nose examination
114 ENT stations: History and examination 3
Station 305: Throat history
Station 306: Throat examination
115 ENT stations: Cases
Station 307: Ear cases
Station 307a: Squamous cell carcinoma of the pinna
Station 307b: Perforation of the ear drum
Station 307c: Otitis externa
Station 307d: Myringosclerosis
Station 307e: Otitis media
Station 308: Nose cases
Station 308a: Nasal polyps
Station 308b: Epistaxis
Station 308c: Sinusitis
116 ENT stations: Skills and data
Station 309: Hearing tests
Station 310: Impedance audiometry
Station 311: Pure tone audiometry
Psychiatry
117 Psychiatry stations: History
Station 312: Psychiatric history
Station 313: Risk assessment
118 Psychiatry stations: Examination
Station 314: Mental state examination
119 Psychiatry stations: Cases 1
Station 315: History taking in depression and anxiety
Station 316: History taking in attention deficit hyperactivity disorder (ADHD)
Station 317: Mental state examination in autism spectrum disorder (ASD)
120 Psychiatry stations: Cases 2
Station 318: Assessment of mood disorders
Station 319: Biological management of mood disorders
Station 320: Psychosocial management of mood disorders
121 Psychiatry stations: Cases 3
Station 321: Assessment of anxiety disorders
Station 322: Psychological management of anxiety disorders
Station 323: Biological management of anxiety disorders
122 Psychiatry stations: Cases 4
Station 324: Assessment of psychosis
Station 325: Biological management of psychosis
Station 326: Psychosocial management of psychosis
Index of OSCE stations
The OSCE remains the most common type of clinical examination at medical school and continues to increase in popularity and versatility. We have fully revised this second edition and taken into consideration the feedback received following the first edition. The emphasis remains on the stations being realistic OSCE scenarios that a student will encounter. We have added 31 new stations and attempted to set out the book in an even more logical way. The other addition is that of a website companion that has example mark sheets to accompany many of the stations – we hope you feel these are a useful addition. As always, good luck with your studies.
Clinical examinations put fear into the hearts of many medical students. During a written exam, the mistakes can be ‘private’ whereas for clinical assessments there is always the danger of the hypothetical ‘hole’ being dug by the nervous student. Knowledge itself is only one requisite for becoming a competent doctor and, although important for clinical examinations, it is also essential to demonstrate the adequate skills and attitudes appropriate for a future doctor. There is still a tendency for students to focus too much of their work in the library rather than utilising the plethora of clinical signs and medical histories available on the wards. Facts alone will not permit success in clinical examinations and there is no substitute for perfecting your communication, history, examination and practical skills with a wide range of patients.
There are multiple OSCE books available but many substitute ‘written’ questions for true OSCE clinical stations. The other potential drawback is that many of them only cover one subject. This text presents potential OSCE stations from all the clinical subjects taught at medical school. We have used a case by case approach with the idea that the student should try to picture him/herself as they enter the station and are presented with the instruction and introduced to the patient or task. Each station consists of an example instruction with appropriate history or examination hints relevant to the case. Examiner questions are incorporated as discussion points. Where possible the answers to these viva topics have been given but, as a revision aid, this text needs to be used in combination with more comprehensive texts in each of the subjects. In addition to standard text books, useful information can be found on the websites of the National Institute for Health and Clinical Excellence and also the Royal College websites where multiple guidelines are written for use in clinical practice.
After our own personal experience of sitting OSCE style assessments, preparing students for them, and also as examiners, we feel this book uses a realistic approach to the OSCE exam and will help prepare students for the clinical exams throughout their medical school life.
Good luck.
Many people have assisted in the development of this book. We are extremely grateful that they found time during their busy schedules to read various sections at various stages in order to make suggestions and corrections. While we have attempted to acknowledge those individuals as listed, there is one large group that also deserves a special mention – all the medical students and junior doctors in Nottingham, Oxford, London and Sydney that we have had the pleasure of teaching over the last few years and whose enthusiasm and ideas have helped form this revision guide.
We would also like to thank the following individuals: Naomi Bullen, Ashleigh Chalder and Asheeta Patel for their assistance with the setting up of the photographs; Pete Thurley for supplying some of the radiology images; Nicola Sherrington for the development of some of the mnemonics; and to the various development and production editors at Wiley-Blackwell for their support throughout the project.
Our final thanks go to our friends and family and in particular to Emma and Ruth who despite the arrival of Sophie and Martha and the tendency to being author widows continue to support and encourage our crazy ideas – no more books; we promise.
Thanks to the following colleagues who contributed to the first edition.
We are indebted to the medical students and specialists who reviewed material during the early stages of the development of this book. We are also extremely grateful to the specialists listed below who have reviewed the manuscript at varying stages and have given valuable advice and feedback: Jonathon Bhargava, Consultant Ophthalmologist, Chester; Julian Boullin, Consultant Cardiologist, Norwich; Nick Clifton, Consultant in Otolaryngology, Bedford; Stuart Cohen, Consultant Dermatologist, Nottingham; Patrick Davies, Consultant Paediatrician, Nottingham; Tasso Gazis, Consultant Endocrinologist, Nottingham; Chris Gilmore, Consultant Neurologist, Nottingham; Chris Love, Pharmacist, Nottingham; Zudin Puthucheary, Senior Research Fellow & SpR Respiratory and ITU Medicine, London; Emma Sawyer, GP, Nottingham.
Some figures in this book are taken from: Bull, P. & Clarke, R. (2007) Lecture Notes: Diseases of the Ear, Nose and Throat, 10th edition; Davey, P. (2006) Medicine at a Glance, 2nd edition; Grace, P & Borley, N. (2006) Surgery at a Glance, 3rd edition; Graham-Brown, R. & Burns, T. (2006) Lecture Notes: Dermatology, 9th edition; Impey, L. (2004) Obstetrics and Gynaecology, 2nd edition; James, B. et al. (2007) Lecture Notes: Ophthalmology, 10th edition; Miall, L., Rudolf, M. & Levene, M. (2007) Paediatrics at a Glance, 2; Norwitz, E. & Schorge, J. (2006) Obstetrics and Gynaecology at a Glance, 2nd edition; Olver, J. & Cassidy, L. (2005) Ophthalmology at a Glance; Ryder, R.E.J. et al. (2003) An Aid to the MRCP Paces, 3rd edition; Ward, J.P.T. et al. (2006) The Respiratory System at a Glance, 2nd edition; Weller, R. (2008) Clinical Dermatology, 4th edition; all Blackwell Publishing, Oxford and Buxton, P.K. (2003) ABC of Dermatology, 3rd edition. BMJ Publishing Group, London. Figure 14: Advanced life support algorithm is reproduced by permission of the Resuscitation Council UK. Figure 15: Hypertension: management of hypertension in adults in primary care is reproduced with permission by National Institute for Health and Clinical Excellence (NICE) (2006) CG034 London: NICE. Available from www.nice.org.uk/GG034. Figure 90: Screening timeline is reproduced by permission of the National Screening Committee.
The OSCE has been increasingly used over the last 15 years, although one of the first descriptions was way back in 1979 by Harden and Gleeson [1]. This form of examination is now used extensively in medical schools in the UK. The main advantage is that it can be used to examine many different clinical skills with all students performing the same tasks, marked against explicit criteria by the same examiners.
An OSCE consists of a series of timed stations that each student rotates through. Each station involves a candidate carrying out a well-defined task. The time allocated for each station will vary with the required task, but in general each station lasts 5–10 minutes. The majority of stations have an examiner (or pair of examiners) who will assess the candidate’s performance using a structured marking sheet. If the station is purely data interpretation, then it is not always necessary to have an examiner present and the candidate will be required to complete a written task.
Each station will have an accompanying instruction for the candidate to follow. The instructions can be presented in different ways:
OSCEs can be used at any stage during medical school. The exams in the earlier years concentrate on assessing the basic clinical skills and the emphasis is on the demonstration of correct technique, rather than interpreting the signs. This usually involves simulation-based cases rather than ‘real’ patient contact.
The possibilities for individual OSCE stations are huge but generally they are divided into clinical, practical and data interpretation:
These usually involve interaction with a patient who may be real or simulated (e.g. a student/actor/the examiner). The simulated patients rarely have abnormal clinical signs.
Mannequins or anatomical models are often substituted for the patient.
The student may be required to explain and perform the procedure, gain consent or act on a result.
With the advent of improved information technology facilities, this type of knowledge can be adequately assessed during written exams, although some medical schools still include them in OSCEs.
Marking sheets will vary depending on the type of station and skill being assessed, but each task will be marked against explicit criteria. This will be in the format of a checklist of actions the student needs to perform. Patients may be asked their opinion of the candidate and it would be taken very seriously if the patient felt the student was rude or rough. Students may be examined by an individual or pair of examiners (who should mark independently). Once the station is completed an individual mark can be scored following agreement by the examiners and a statement as to the student’s global performance is often included.
There is increasing emphasis from the General Medical Council (GMC) that the clinical competence of medical students needs to be assessed and recorded. OSCE-type stations, using either ‘real’ or simulated patients, are ideal for this purpose. Clinical competence is a combination of three domains – knowledge, skills and attitudes.
There are several documents published by the GMC that describe the attitudes and behaviour expected of future doctors; these behaviours need to be developed during university along with clinical competence and will be assessed in the OSCE examinations [2–4]. Students often underestimate the need to practise their clinical skills and bury their heads in the books until nearing the practical assessment, when there is a mad rush to the clinical skills laboratory to run through examination routines and a mad dash to the wards to see as many patients as possible. This behaviour remains common despite repeatedly reminding students of the practical nature of being a doctor and one of the main recommendations of Tomorrow’s Doctors 2003 stating ‘factual information must be kept to the essential minimum that students need at this stage of medical education’ [2]. Start practising your clinical skills as early as possible, preferably with an ‘OSCE buddy’ or even ‘OSCE group’. The skills tested in the OSCE and also the skills necessary to embark on life as a Foundation doctor are best learnt in the clinical environment and not the library.
Patients seen in medical student exams are not acutely unwell and so can be assessed in a logical manner in order to determine a diagnosis and management plan. The approach is summarised opposite. This system helps a clinician make a diagnosis no matter what the presenting problem might be. This approach is also utilised in real life on the wards, although the process is dynamic, and the different areas can overlap, for example practical procedures can be performed while taking parts of the history.
See Chapter 4.
When assessing a patient, try and formulate a list of differential diagnoses (ΔΔ). Next organise your thoughts into a problem list, taking into account other aspects of the history and examination rather than just the presenting complaint (e.g. non-urgent referrals, possible future investigations, impact of the illness on the patient and relatives, social problems, patient education). From the problem list it will be possible to determine a management plan (Mx). The main aspects of a management plan are described opposite.
A 72-year-old female patient (weight 48 kg) with a known history of chronic obstructive pulmonary disease (COPD) is admitted to hospital with increasing shortness of breath (SOB) and a productive cough. Her blood tests have shown a ↑ white cell count and her chest radiograph shows consolidation in the right lower lobe. She has been on long-term steroids which cannot be weaned. She has had six admissions in the last 4 months but continues to smoke five cigarettes a day. She has rheumatoid arthritis which in addition to her COPD means she is limited in performing her activities of daily living. Her husband is fit and can help her but is due to be admitted for a hip replacement in 2 weeks’ time. On previous admissions the doctors have felt that she might benefit from home oxygen therapy.
Examiners will frequently ask about investigation (Ix) choices. Choose the simple ones first (unless asked for a definitive investigation), e.g. a patient who is admitted to hospital with a bleeding gastric ulcer may well need a gastroscopy at some point, but this is not the first test that would be carried out. Put yourself in your future shoes as the FY1 doctor and think what investigations you will be requesting. Remember the examiners are assessing your ability to become a safe foundation doctor; they are not assessing your ability to become a consultant.
An algorithm for investigation choices is summarised opposite. The heading ‘imaging’ is used instead of radiology to avoid missing out procedures carried out in other departments, e.g. echocardiogram.
State your investigations in the actual order you would request them, e.g. blood tests would nearly always come before imaging. It is also essential to understand the difference between an investigation and a routine part of the examination, e.g. think of blood pressure measurement as part of the cardiovascular examination, peak flow measurement part of the respiratory examination and urinalysis as part of the abdominal examination.
The only time not to start with the simple investigations is if the examiner asks for the definitive investigation, e.g. to confirm a patient has had a stroke, they need a computerised tomography (CT) scan of the head.
This book can be used alone or equally well (if not better) with two or three friends. Take it in turns being the candidate, the patient and the examiner. Example student instructions for each station have been given and where possible the patient information has also been included, although for some stations improvisation will be necessary. Part of the skill is to realise the importance of inspection and piecing together the information obtained to come to a diagnosis. The diagnosis is often apparent from the end of the bed. The chapters in this book will act as aide-memoires. Remember to consider the patient ‘as a whole’ rather than focusing on one system or organ.
The hints and tips checklists are based on the areas for each case where marks will be awarded. In addition to these, there are also marking guides available for some of the stations on line. The discussion points are example questions that could be asked around each case.
Technique does play a part in passing an OSCE. It is obvious which candidates have not practised their clinical skills sufficiently or who may have rehearsed routines on friends but have seen few abnormal physical signs. Emphasis is also on appropriate communication skills, which are essential for all OSCE stations, not just the history and communication ones. This can be especially difficult if English is not a candidate’s first language. Make sure that you have plenty of practice in ‘presenting patients’ before the exam day so you are used to hearing your own voice. When asked questions, try to present the answers in a logical order rather than blurting out the first (and often the most obscure) answer. Try to avoid suggesting senior help immediately – the examiners want to know you are a safe clinician but you should be able to initially offer some sensible discussion. This book will introduce methods of being logical when presenting and answering questions. Remember, the more you are talking the less time the examiners will have to ask tricky questions; you must, however, be talking sensibly!
Many of the OSCE stations will involve some form of discussion around the problem presented. Most of the types of question will be centred on the following checklist:
Keep to a logical structure. Start broad and become more specific (e.g. ‘the causes of a pleural effusion can be initially divided into exudates and transudates; exudates include …’). Use some form of classification in your answer rather than blurting answers out wildly. The best method to use is a systems-based approach but another one commonly in use is the surgical sieve (although the problem with mnemonics is remembering them!).
Remember to give examples in each category.
If unsure of the aetiology of a diagnosis then remember the mnemonic VITAMINS CDEFGH
It is impossible in a textbook covering so many topics to provide detailed knowledge on each of the subject areas. Each of the main sections has a companion At a Glance publication which will have further detail on each of the subject areas.
National Institute for Health and Clinical Excellence (NICE) guidelines available at www.nice.org.uk
Scottish Intercollegiate Guidelines Network (SIGN) guidelines available at www.sign.ac.uk
British/European/US specialist society websites, e.g. British Thoracic Society available at www.brit-thoracic.org.uk
Taking a comprehensive history in an OSCE can only be expected if the station is of sufficient duration. A candidate would not be expected to do this in 5 minutes. In the shorter stations it is essential to listen carefully to the instruction, which will often guide a student towards appropriate questioning. Remain focused on the facts and relevant issues. A logical approach is essential, as is the skill of realising the pertinent questions to ask given a particular history, e.g. the importance of occupa-tional history in someone with haemoptysis.
Each history station in this book has a list of hints and tips suggesting the information a candidate should be gathering. In general terms: