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10 things you need to know to Master OSCE Clinical Exam Technique (part 2)

Earlier in the week we posted the first 5 of our 10 most important things you need to focus on for your medical examination OSCE technique. Here are the final 5.

To recap, here is our 36-year old’s patient history and findings:

“I’ve been getting hot for the last 6 weeks, on and off and have been off my dinner, pretty much all the time. I’ve been generally not right, tired and that. I’ve started to get a bit breathless too, not coughing and the like, but still having problems when I’m out. Bad like. Gets worse when I have a fever. Like I’ve had a friend who had the same thing about 3 years ago and he had really bad lung fibrosis, because of infections during his childhood. Not like me and that I’ve always been well. I have still got problems injecting the drugs and that, but like my key worker, she says that me methodone will help me deal with that kind of problem, so from that side I’m pretty happy.”

• Hands Normal.
• Pulse 80.
• No Signs in the face.
• BP 182/92 Pan systolic murmur left sternal edge.
• Otherwise NAD.

Tip 6. Group your thoughts logically every time

a) By the most likely causes
“The differential includes the following:…”

b) By the problem that’s causing the issue:
“Based on the limited information from the history the differential would include infections (viral: T cell disorder seroconversion illness) Bacterial (bacterial endocarditis, bronchopneumonia, abscess etc), fungal (less likely but consider underlying immunosupression), malignancy…”

Tip 7. Let the examiners know you are finished every time

Once you’ve finished or exhausted all the possible causes, let your examiner know! “Causes of a pan systolic murmur include… they are the main causes that I know.” This is vital and stops you looking stupid standing around.

Tip 8. Acknowledge what you don’t know

If you’re asked a question you don’t know the answer to, be prepared to tell the examiner in a clear way i.e. “I cant recall that at this time, I don’t know the answer to that question”. This saves valuable time, and is refreshing for examiners to get clear, honest responses, which is what they require from junior doctors.

Tip 9. Have a set way of presenting examination findings every time

Practice this, it is the same every time. For the above case here would be our example:

“No stigmata of cardiovascular disease in the hands, pulse 80 and regular in terms of rate and volume, hypertensive with a blood pressure of 182/92. No stigmata of CVSD disease in the face. Apex beat palpable 5th intercostal space, mid clavicular line, normal character. The first heart sound is normal. The second heart sound is normal. There is a pan systolic murmur, best heard with the diaphragm, at the left sternal edge that is non-radiating. JVP not elevated, no peripheral oedema.”

If you do this the same every time it will stop you making mistakes.

Tip 10. Thank and ‘look after’ your exam patient (and the examiners).

This is vital. Your duty is first to the patient. When you have finished examining, show the patient the dignity and respect they deserve, cover up exposed areas, and express thanks. The patient has volunteered most likely to do the exam! Thanking both is important, and professional.

We hope this has helped, remember there are over a thousand questions, dozens of videos and downloads to help you with your exams in the student login area.

The 10 things you need to know to Master OSCE Clinical Exam Technique

One topic that continually crops up in medical student questions is exam technique, and issues that can revolve around it. For this reason we have produced a list of the most important things you need to know.

This is based on common errors in exam/ OSCE techniques that crop up in medical examinations from our experience.

Here are the first 5 tips for preparing for your verbal examinations, the next follow soon.

Let’s consider the following features and clinical examination…

A 36 year old male gives the following history:

“I’ve been getting hot for the last 6 weeks, on and off and have been off my dinner, pretty much all the time. I’ve been generally not right, tired and that. I’ve started to get a bit breathless too, not coughing and the like, but still having problems when I’m out. Bad like. Gets worse when I have a fever. Like I’ve had a friend who had the same thing about 3 years ago and he had really bad lung fibrosis, because of infections during his childhood. Not like me and that I’ve always been well. I have still got problems injecting the drugs and that, but like my key worker, she says that me methodone will help me deal with that kind of problem, so form that side I’m pretty happy.

Your Examination Findings are:

• Hands Normal.
• Pulse 80.
• No Signs in the face.
• BP 182/92 Pan systolic murmur left sternal edge.
• Otherwise NAD.

Tip 1. Look professional

Dress smartly and conservatively, in accordance with the accepted policy for dress and infection control. We think this means, white shirts (ironed!), smart black shoes, trousers or dress.

Tip 2. Organise your presenting posture to minimise nerves

This is it. Hands behind your back. Head up. Speak clearly and decisively. By organising your posture fidgeting with your hands (common in stressful situations) will not be possible. Standing with an open posture (feet apart, slightly out turned) is a common technique used in business, and will help you present in an organised fashion.

Tip 3. Structure your presentation of medical terminology

This needs to be structured in the same was that you elicited the history. PC, HPC PMHx, for example:

Mr X is a 36 year old male with a background of intravenous substance use, who presents with a 6 week history of malaise, retired office worker presents with a three week history malaise, night sweats, dyspnoea and anorexia…

Note the use of medical terminology to describe symptoms. This is not the same as describing clinical signs in the history, which you should not do!

Tip 4. Interpret as you go

Don’t be afraid to explain your interpretations as you assess the situation. For example with history: “The history importantly raises concerns: substance misuse (introducing a blood borne infection, other viral infections and T cell Disorders transmitted by IV drug use), symptoms that suggest a systemic illness/ infection (fevers, malaise, anorexia) that would have a wide differential based on this information that would include….”

Tip 5. Learn to summarise in one sentence

Floundering, being vague, or summarising in a small essay just won’t do. Be clear and to the point – for example “36 year old male, current problem of intravenous substance misuse with 6 weeks of symptoms that include anorexia night sweats and general malaise.”

We hope this helps some of you student doctors in preparing for your OSCEs…. view the final 5 tips here!

Question of the day: OSCE revision on the wards- what should be done next?

A medical student is practising for her OSCE exams on the ward…

She examines a 19 year old female patient admitted with asthma on the medical assessment ward for revision purposes.

The patient has a past medical history she has the occasional migraine, and eczema.
The observations are as follows.

BP 128/70

Pulse  98 regular

Fingerprick blood glucose 8.3

Oxygen Sats 97% on Air

She performs a cardiovascular and opthalmological examination.

Cardiovascular examination: Split S2 (second heart sound) on deep inspiration.

Ophthalmology examination: Normal Eye movements. Pupils 6mm and reactive to light. Eye movements normal. Visual fields normal. No scotoma. Fundoscopy examination of one eye is shown below…

Do you get this good a view when performing fundoscopy? Of course not, this is a digital retinal photograph-remember when you are using a hand held opthalmoscope you only get to view a bit of this at a time, which is why its important you should know which eye this is!

Why not have a go at the questions below? We’ll put up the answers in a couple of days…

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Answer to question of the day: Neurological exam

We had some great input and debate from students on this question of the day from a nero exam. Congrats to those of you who correctly guessed it as Guillain Barre Syndrome.

Now check your hypothesis against the clinical signs:

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Question of the day: Neurological exam

A 44 year old builder presents with weakness over the past 48 hours

A neurological exam reveals the following (N=normal):

Which of the following is the most likely diagnosis?

a. Polio
b. Motor Neurone disease
c. Myasthenia gravis
d. Stroke
e. Multiple sclerosis
f. Creutzfeldt Jacob disease
g. Guillain Barre Syndrome

Leave a comment with your answer… we will let you know the correct answer soon!

Try over 1000 questions like this here.

Podcast: patient history and differential diagnosis – mild cough

Listen to this patient’s symptoms, that will encompass different clinical features. Then try and provide a differential diagnosis. Let Medical Educator guide you through the process to reach a conclusion of what is wrong with this patient.

 

 Give a differential diagnosis - mild cough: Play Now | Play in Popup

Remember you can listen to more podcasts, get MCQs and EMQs, watch clinical skills videos, and download ‘one minute’ revision guides in the medical finals login area of the site.

Answer to question (EMQ) of the day – a history of weakness and fatigue

Thanks for all of your great responses to our question of the day – some good analyses and discussion.

So here we go with the likely pathology …

• Symmetrical findings make a central lesion less likely (they would localise).
• The reflexes and sensation are intact, making a cord or peripheral nerve lesion unlikely.
• The absence of fatigability makes a neuromuscular junction lesion less likely (myasthenia etc).
• This sounds like a myopathy: the rash therefore suggests polymyositis (the rash is a heliotropic rash named after the purple heliotrope flower). The CK is likely to be very high (in the thousands, NR <150 iu/l).
• The dysuria and cough are intended as distracters.

Look out for our next question of the day coming soon, and remember there are thousands more in the login area!

Question (EMQ) of the day – a history of weakness and fatigue

A 64 year old man presents with a history of weakness and fatigue. He has lost 3 stone in weight. On systemic enquiry, he has no other clinical symptoms, other than a mild dry cough which he has had for 3 days and some occasional dysuria, present intermittently for 6 months. His examination findings are as follows:

• No Jaundice , anaemia, cyanosis, jaundice or lymphadenopathy
• noted rash under both eyelids.
• BP 134/66
• Pulse 78 regular
• Sats 98% air
• BM 4.5 mmol/l  RR 16
• Normal Cardiovascular Respiratory Gastrointestinal examination.

Neurology as follows:

• Grade 4 power upper and lower limbs symmetrically.
• Normal sensory examination.
• Normal reflexes.
• No clonus
• No fatigability

Where is the likely pathology?

Central Brain Lesion
Brainstem Lesion
Cord Lesion
Peripheral Nerve
Neuromuscular Junction
Acetylcholimesterase enzyme problem
Muscle lesion
None of the above

Let us know what you think, answer to follow soon. Remember: more questions like these can be found in the free trial area.