Summary of Common Conditions Seen in OSCEs
Summary of Relevant Investigations and Management
- Proctoscopy (to visualise anus)
- Sigmoidoscopy ( to visualise rectum)
- Colonoscopy (to visualise colon)
- Haemoglobin and iron studies (to check if the patient has iron deficiency anaemia)
- Tumour markers (carcinoembryonic antigen for bowel cancer)
- Prostate-specific antigen (if prostate is enlarged)
- MRI of the spine (if cauda equina suspected)
Hints and Tips for the Exam
This is a relatively easy OSCE station. You may get opportunities to practise on actual patients during colorectal surgery and gastroenterology outpatient clinics. However, it is highly likely that you will be asked to perform the examination on a manikin in the OSCE. Therefore it is important to go to the clinical skills centre at your medical school and practise this examination before the OSCE. There are several important things to remember for this station.
Do NOT Forget to Request a Chaperone
This is vitally important for any intimate examination, and could easily make the difference between a fail and a pass.
Cauda Equina Syndrome
This is exceedingly rare, but is an acute neurosurgical emergency that requires immediate neurosurgical intervention. The spinal cord ends at L1/L2, below which the spinal cord branches into smaller roots – similar to how a horsetail roots out into smaller branches at the end; these branches are called the ‘cauda equina’ (cauda meaning tail, equina relating to horse). Anything that causes compression of these roots will result in cauda equina syndrome. Symptoms can very quickly become irreversible, resulting in permanent disability, which necessitates urgent neurosurgical intervention and decompression.
Communicate Clearly When Explaining How the Examination Will Be Carried Out
One suggestion is to say something like:
Hello Mr Jones. I’m —, one of the junior doctors. I understand you have recently noticed some bleeding from your back passage so is it OK if I examine your back passage to try and find out what may be causing the bleeding? You will need to undress down to your knees and lie down on your left side on the couch with your knees tucked in to your chest. I will examine your back passage with a gloved, lubricated index finger. It may be slightly uncomfortable, but if it hurts don’t hesitate to stop me. It should take no more than 5 minutes. If you are happy with my explanation, do you give consent for me to examine you?
Although this may take up a few seconds of your precious time in the exam, it is extremely important to demonstrate clear communication before performing any intimate examination. There are certain to be a sizeable proportion of marks for good communication in this station.
Ask If the Patient Is in Any Pain
This is specifically important in the PR station because anal fissures (which can be simulated on the manikin) are exquisitely painful.
Tell the Patient before You Insert or Remove Your Finger from the Back Passage, and Say What You Are Doing as You Proceed Through the Examination
This is important because the examiner will not be able to see what you are doing when your finger is in the rectum. There are five important things to comment on:
- External abnormalities around the anus
- Abnormalities palpated on the walls of the anal canal
- Prostate (size, symmetry, sulcus, texture/hardness)
- Anal tone
- Presence of blood, melaena or mucus on the glove
Inform the Patient Clearly When the Examination Is Complete
This is an intimate examination, and often a very uncomfortable one, especially if there is a significant pathological abnormality. Therefore it is very important that you tell the patient when you have finished.
Potential Variations at This Station
- Examine the abdomen (on an actor patient) and perform a PR examination (on a manikin) (5–10 minutes)
- Examine this patient’s rectum and then explain to the patient what you have found. Answer the patient’s questions regarding further management (10 minutes). This is perhaps the most difficult possible variation at this station. Remember to stick to your generic management template. For example, if the examination reveals benign prostatic hypertrophy, talk about conservative measures (e.g. avoiding anticholinergic drugs), medical measures (e.g. alpha-blockers) and surgery as the last line (TURP).
Questions You Could Be Asked
Q. How many hours does it take for cauda equina symptoms to become irreversible?
A. Potentially within 4–6 hours.
Q. Above which point in the gastrointestinal tract does bleeding cause melaena (as opposed to fresh red bleeding)?
A. Although there is no specific point immediately after which fresh red blood suddenly becomes melaena, generally speaking bleeding from an area proximal to the terminal ileum is more likely to be melaena, as there is scope for significant ‘digestion’ in that part of the gastrointestinal tract.
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