Summary of Common Findings Seen in OSCEs
- Chronic liver disease
- Hepatomegaly
- Splenomegaly
- Nephrectomy scar/features of end-stage renal failure (ESRF)
- Enlarged kidneys
- Transplanted kidneys
- Ascites
- Hernia
- Stoma
- Surgical scars
Summary of Common Conditions Seen in OSCEs
Common Conditions Leading to Chronic Liver Disease
To make things easier, we have summarised here the key clinical features and investigations of chronic liver disease that you can use in the viva/questions part at the end of the OSCE generically, regardless of what the cause of the liver disease is. Table 3.1 outlines common conditions leading to chronic liver disease – the most common ones are marked with an asterisk. This will be especially useful for students aiming for a merit or distinction, as it helps to diagnose not only chronic liver disease, but also the underlying cause.
Table 3.1 Common conditions leading to chronic liver disease
Hints and Tips for the Exam
Hepatomegaly and Splenomegaly
Hepatomegaly and splenomegaly are also very common findings at this station in finals. We have discussed various key tips below to help you in both the diagnosis and the discussion.
Examining Large Livers and Spleens
- Start low in the right iliac fossa, so that you do not miss giant organomegaly.
- Use the radial aspect of your index finger – but if that doesn’t work, use your finger with your hands pointing up towards the patient’s head.
- Keep your fingers absolutely still as the patient breathes in and out.
- Make sure that you move your hand upwards superiorly by no more than 2 cm as the patient breathes in and out. If you leave too large a distance as you move up, there is a risk that you may miss the edge of the liver or spleen.
- For the liver, percussion is almost as discriminatory as palpation. It is also useful to differentiate between lung hyperinflation pushing the liver down, and true hepatomegaly. The superior aspect of the liver usually lies between the 4th and 6th ribs, and continues down to the last rib at the inferior border of the rib cage; hence, there should be dullness in all of this area. Hyperinflation pushing down the liver is confirmed if percussion is resonant significantly below the 6th rib.
- For the spleen, use your left hand to stabilise the left ribs in order to prevent them from being pushed towards the left as you palpate the spleen with your right hand. If you still have difficulty, roll the patient on to the right side and repeat this.
- When you do find an enlarged liver or spleen, estimate the size of hepatomegaly in centimeters rather than ‘finger breadths’, which vary from person to person (depending on how big their fingers are!).
- Avoid the business of trying to identify the liver characteristics (e.g. whether it ‘firm’, ‘hard’ or ‘soft’, or pulsatile, or nodular or smooth). Doing this in an exam will make the patient uncomfortable and use up your valuable time without achieving very much. Once a large liver or spleen has been identified, the most logical way of defining its characteristics would be to carry out some sort of imaging – usually an ultrasound of the abdomen.
Systematic Differentiation of the Underlying Causes of Hepatomegaly and Splenomegaly
- A large liver and/or spleen is a very common finding at finals OSCE stations. Make sure that you have a generic system for categorising the causes, so that you can reel off a list of differential diagnoses quickly, confidently and systematically.
- Always try to use all the signs to help you devise a differential diagnosis. However, if you find an enlarged spleen or liver and have no clue what the cause is, go for conditions that can cause hepatomegaly and splenomegaly either individually or together – the first column of Table 3.2 summarises these.
- Don’t be too pedantic when distinguishing between gigantic, moderate and mild splenomegaly. Identifying splenomegaly and giving a reasonable list of differential diagnoses and investigations will usually be enough to score a decent pass. Distinguishing between mild/moderate and gigantic splenomegaly will help to get you into the merit/distinction range. Remember that the spleen has to be at least double or triple its normal size to be palpable.
- Remember to piece the other parts of your examination together to complete the diagnostic jigsaw. All the conditions that cause hepatomegaly or splenomegaly have several peripheral signs so look out for these and use them to support your differential diagnosis.
Table 3.2 Causes of hepatomegaly and splenomegaly
Figure 3.1 Scar from splenectomy after a road traffic accident, also showing the drain insertion site
Renal Cases
Although students often worry about getting a ‘renal case’ in finals, it can often be a blessing in disguise. The differential diagnosis is relatively straightforward, and the signs are easy to elicit.
Fundamentally, there are only two findings in renal cases – those of ESRF, and ballotable enlarged kidneys.
End-Stage Renal Failure
There are potentially three findings that are all attributable to ESRF:
- Nephrectomy scar (Figure 3.2): Inspect carefully for this, making sure that you look all the way around the lumbar/flank regions through to the back. Finding a nephrectomy scar is alone sufficient to devise a full list of differential diagnoses and a management plan.
- Palpable transplanted kidney: This is usually near the groin/iliac fossa with a small scar at the site.
- Signs of dialysis use (arteriovenous fistula, right internal jugular vein line, CAPD scars; Figure 3.3): A slicker way of describing this is ‘renal replacement therapy’, which covers them all – and also sounds more impressive!
