Objective structured clinical examination (OSCE)

20 Objective structured clinical examination (OSCE)


This mode of assessment is frequently used in exams to test clinical skills, including history-taking, examination, explanation and advice, and prescribing. It usually involves a 5–10 min ‘station’ with a single examiner. The aim is to create a standardised test that is the same for all candidates. For each OSCE station, marks are allocated to each component of the assessment that is considered important. Although this may lead to a ‘tick-box’ mentality, the key to performing well is to have a clear and systematic approach to each case. Chronic conditions with clear physical signs dominate this environment, as examiners need to be certain of what students should find. Some typical examples are provided to illustrate the process, although clearly a wide range of additional topics may appear. The mark schemes will vary depending on the level of the exam, with greater emphasis on correct diagnosis in addition to competent technique in more senior assessments.



A. CARDIOVASCULAR EXAMINATION




CASE 1: AORTIC STENOSIS


Instruction: This 65-yr-old woman has been admitted, complaining of chest tightness and faintness on exertion. Examine her cardiovascular system.



Key positive findings



• Pulse: sinus rhythm, slow rising major pulse (carotid), narrow pulse pressure on BP measurement.

• JVP: not elevated until late stage of disease when heart failure develops.

• Apex beat: not displaced (dilatation, not concentric hypertrophy, displaces apex) but has sustained quality.

• Heart sounds: S1 normal; S2 normal or quiet, and often a single sound; S4 may occur.

• Murmur: harsh ejection systolic murmur separated from both S1 and S2, loudest over aortic area and left sternal edge. Usually radiates to both carotid arteries.


Example mark scheme (10 marks)










































1. Introduces self to patient, explains what he/she is about to do
 1 mark

2. Assesses pulse and BP
 ½ mark

3. Comments on narrow pulse pressure/slow rising pulse
 1 mark

4. Assesses JVP
 1 mark

5. Determines position of apex beat
 ½ mark

6. Accurately comments on character of apex beat
 ½ mark

7. Auscultates in relevant areas of precordium and neck
 1 mark

8. Comments on S1 and S2; notes soft S2
 1 mark

9. Identifies ejection systolic murmur, where it is loudest and its radiation
 1 mark

10. Sits patient forward to listen for aortic regurgitation
 ½ mark

11. Gives most likely diagnosis as aortic stenosis
 1 mark

12. Suggests echocardiogram and ECG to assess
 1 mark


Additional questions which could be included



1. What are markers of severity in aortic stenosis?
a. Clinical symptoms: angina and syncope. Breathlessness may occur but cardiac failure is a late and poor prognostic sign.

b. Examination: slow rising pulse, abnormal apex beat and absence of second heart sound. Loudness of murmur misleading—murmur often quiet in severe stenosis.

c. Investigations: ECG showing evidence of left ventricular hypertrophy (LVH). Echocardiogram showing concentric LVH. Gradient estimated by Doppler from aortic jet velocity; gradient >40 mmHg considered severe.

2. How would you explain to the patient that he/she has aortic stenosis?

3. How would you explain to the patient what further investigations are required?


CASE 2: MITRAL REGURGITATION


This is a common murmur that is often secondary to other cardiovascular disease: in particular, rheumatic heart disease, ischaemic heart disease and dilated cardiomyopathy. Other causes include infective endocarditis and connective tissue diseases.


Instruction: The GP has noted that this 72-yr-old man has a murmur. Can you examine his cardiovascular system and determine the nature of the murmur?



Key positive findings



• Pulse: often irregular due to atrial fibrillation, pulse pressure usually normal.

• JVP: may be elevated.

• Apex beat: displaced with a thrusting quality.

• Heart sounds: S1 soft; S2 overlapped by murmur; S3 may be present.

• Murmur: commences immediately after a soft S1, lasts throughout systole and may obscure S2. Murmur is loudest at apex and radiates into axilla.

• Other signs of cardiac failure: may be present and include bi-basal inspiratory crackles and peripheral oedema.

• Mitral valve prolapse: has mid-systolic click followed by murmur. Associated with connective tissue diseases, including Marfan’s and Ehlers–Danlos syndrome.


Example mark scheme (10 marks)

































1. Introduces self to patient, explains what he/she is about to do
 1 mark

2. Determines presence of irregular pulse/atrial fibrillation
 1 mark

3. Assesses that JVP is elevated
 1 mark

4. Determines position and character of apex beat
 1 mark

5. Comments on S1 and S2; notes soft/absent S1
 1 mark

6. Identifies systolic murmur, where it is loudest and its radiation
 1 mark

7. Gives most likely diagnosis as mitral regurgitation
 2 marks

8. Able to give two possible causes (e.g. LV dilatation in ischaemic heart disease, rheumatic valvular disease)
 1 mark

9. Suggests echo/Doppler as most valuable investigation
 1 mark

N.B.: Compared to case 1, this mark scheme gives more points for correctly identifying abnormalities rather than correct procedure.



B. RESPIRATORY EXAMINATION




CASE 1: IDIOPATHIC PULMONARY FIBROSIS


Instruction: This 56-yr-old man has presented with a 3-mth history of worsening breathlessness on exertion and a non-productive cough. Examine his respiratory system to identify a possible cause. At the end of your examination, please tell me your diagnosis and what further tests you would like to carry out.



Key positive findings



• Finger clubbing.

• Central cyanosis.

• Elevated respiratory rate: at rest.

• Signs of pulmonary hypertension: may be present, with elevated JVP and v-wave of tricuspid regurgitation.

• Chest expansion: may be reduced but symmetrical.

• Vesicular breath sounds: with fine inspiratory crackles.


Example mark scheme (12 marks)













































1. Appropriate introduction and explanation
 1 mark

2. Examines for presence of flapping tremor
 ½ mark

3. Identifies finger clubbing
 1 mark

4. Identifies central cyanosis
 ½ mark

5. Examines trachea to check for deviation and cricosternal distance
 1 mark

6. Assesses for cervical lymphadenopathy
 ½ mark

7. Inspects for respiratory rate and chest wall movement
 ½ mark

8. Assesses chest expansion
 ½ mark

9. Percusses chest wall
 1 mark

10. Auscultates all areas of chest wall
 ½ mark

11. Identifies vesicular breath sounds with fine inspiratory crackles
 1 mark

12. Gives most likely diagnosis as idiopathic pulmonary fibrosis
 2 marks

13. Additional investigations and likely results
a. ABGs—type 1 respiratory failure

b. CXR—small lungs, bi-basal reticular interstitial shadowing

c. Pulmonary function tests—restrictive defect

d. High-resolution CT—honeycomb basal fibrosis
 2 marks

N.B.: Complete respiratory examination within 10 mins is challenging. Often examiners will direct candidates to the front or back of the chest. Follow a strict routine (inspection/palpation/percussion/auscultation) to avoid missing signs.



CASE 2: PLEURAL EFFUSION


This is a common clinical problem with a wide range of causes. The main distinction is between a transudate (e.g. cardiac failure, nephrotic syndrome, liver disease) and an exudate (e.g. infection, malignancy, pulmonary embolus and autoimmune disease). Distinguishing these conditions may not be obvious clinically.


Instruction: This 65-yr-old man presented with a 1-mth history of cough, breathlessness and left-sided chest pain. Can you examine his chest and tell me your findings?



Key positive findings



• Peripheral clues: may be provided by presence of finger clubbing (malignancy), elevated JVP (states of fluid overload) or lymphadenopathy (malignancy).

• Trachea: usually central (rarely, deviated away from side of effusion if this is very large).

• Expansion: reduced on side of effusion (can be subtle).

• Percussion note: stony dull on side of effusion (usually obvious).

• Breath sounds: reduced or absent over effusion. Often there is area of bronchial breathing ± crackles at upper edge of effusion.


Example mark scheme (10 marks)


























1. Appropriate introduction and explanation
 1 mark

2. Checks for finger clubbing
 ½ mark

3. Inspects respiratory rate and chest wall movement
 1 mark

4. Checks trachea central
 ½ mark

5. Assesses chest expansion
 ½ mark

6. Identifies reduced expansion of left lung
 ½ mark

7. Correctly percusses chest wall

Related posts:

  1. Critical care and emergency medicine
  2. Infectious diseases
  3. Gastrointestinal and nutritional disorders
  4. Respiratory disease

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Apr 3, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Objective structured clinical examination (OSCE)

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