Workshop Shortstations

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OSCE-Aid Revision Course April 2014
Short Station Scenarios
CONTENTS:

Communication skills and SBAR, Dr Giles Hockridge

Page 2

Communication and Explaining, Dr Kevin Clarkson

Page 9

Fluid balance assessment, Dr Zahra Haider

Page 18

History taking, Dr Adam Monsell

Page 23

Cranial nerve examination, Dr Clara Belessiotis

Page 29

DR ABC, Dr Kiran Patel

Page 38

Edited by: Dr Celine Lakra

Please note: these resources are copyright of the authors and OSCE-Aid. Please refer to our
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contact the team at: [email protected]

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OSCE Short Station: Communication Skills and SBAR
Overview:
This is a role-play exercise based on an OSCE communication station related to SBAR. In a typical
scenario, the students will be asked to read the station and then carry out the scenario.
Format of the exercise:







5 minutes Discussion
o Discuss SBAR with the group first – what it is and why it is important (notes provided
in Appendix 1)
10 minutes Carrying out the scenario
o Ask for one student volunteer. The examiner will act as the colleague at the end of
the phone. The student should be informed they have 10 minutes to read the
information (Appendix 2) and take appropriate action i.e. calling for appropriate help
and discussing the patient with the registrar.
o Ask the student to read the headline instructions to the group before beginning.
o When the student first uses the phone, ask them who they would like to call.
o Prompt the student where appropriate e.g.: ask for results required
o The examiner will be provided with a mark scheme and a model answer script
(Appendix 3)
5-10 minutes Feedback
o Gather feedback. Start with the student then open it up to the group. Finally, provide
your own feedback to the student. Think of the following:
 Structure: did they cover all the main areas (see Appendix 1)?
 Content: did they deliver the most important points and express the urgency
of the situation at hand?
 Style. Comment on speech (rate and tone) and professionalism
 Safety: did they call the right person and give the relevant information? Did
they understand the urgency of the scenario?
10 minutes Discussion
o If time to spare (likely), discussion of related topics (notes provided in Appendix 4).

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APPENDIX 1: Notes on SBAR
What is it and how can it help me?
SBAR is an easy to remember mechanism that you can use to frame conversations, especially critical
ones, requiring a clinician's immediate attention and action. It enables you to clarify what information
should be communicated between members of the team, and how.
The tool consists of standardised prompt questions within four sections, to ensure that staff share
concise and focused information. It allows staff to communicate assertively and effectively, reducing
the need for repetition.
The tool helps staff anticipate the information needed by colleagues and encourages assessment
skills. Using SBAR prompts staff to formulate information with the right level of detail. A description of
the steps involved:
S Situation:




Identify yourself the site/unit you are calling from
Identify the patient by name and the reason for your report
Describe your concern

Firstly, describe the specific situation about which you are calling, including the patient's name,
consultant, patient location, code status, and vital signs.
B Background:



Give the patient's reason for admission
Explain significant medical history

You then inform the consultant of the patient's background: admitting diagnosis, date of admission,
prior procedures, current medications, allergies, pertinent laboratory results and other relevant
diagnostic results, in addition to your examination findings. You need to have collected information
from the patient's chart, flow sheets and progress notes.
An Assessment:


Clinical impressions, concerns

You need to think critically when informing the doctor of your assessment of the situation. This means
that you have considered what might be the underlying reason for your patient's condition. Not only
have you reviewed your findings from your assessment, you have also consolidated these with other
objective indicators, such as laboratory results.
R Recommendation:




Explain what you need - be specific about request and time frame
Make suggestions
Clarify expectations

Finally, what is your recommendation? That is, what would you like to happen by the end of the
conversation with the physician? Any order that is given on the phone needs to be repeated back to
ensure accuracy.

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APPENDIX 2: Scenario to be read by the student
You are an FY1 doctor covering the medical wards on-call. You have been asked to review a patient
on Olive ward complaining of abdominal pain. Imagine that you have assessed the patient, written
your patient notes (as below) and now feel that you need senior support. Please read the notes and
call an appropriate senior for support on the phone provided. You are being assessed on your
communication skills. You have 10 minutes to complete the station.
You have been provided with:
1.
2.
3.
4.
5.

Patient notes
Observation chart
Fluid balance chart
Drug chart
List of numbers to call

Patient notes
Patient details:
Mrs Cathy Groves, DOB 17/02/1954, Hospital Number 01234567
History of admission:
Patient has known Ulcerative Colitis and has been admitted 3 days ago with a flare of her disease.
Her normal bowel habit is 4 times a day but for the previous week she had been passing 10+ bloody
type 7 stools each day. She is being treated with systemic steroids and Mesalazine. She is also being
supported with IV fluids. She is fit for full escalation of treatment.
PMH:
UC, HTN, High cholesterol
DHx:
Mesalazine, Prednisolone, NKDA
SHx:
Retired teacher, Ex-smoker, 20 pack year history, 4 units EtOH / week
On examination:
General – looks unwell, IV fluids running slowly
Observations – RR 30 breaths min, Sats 92% on room air, PR 120 bpm, BP 90 / 47, Temp 36.5.
CVS –
Capillary refill 4 seconds
Pulse -120 bpm regular
Normal heart sounds, no pulmonary/peripheral oedema
RS –
RR 30 breaths / min
Auscultation – normal
GIS –
Abdomen distended
On palpation abdomen is rigid and extremely tender throughout, no masses palpable
Bowel sounds are absent
Neurology - GCS 13/15 (eyes open to voice, disorientated), moving all 4 limbs

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Staff contact numbers:
Medical SHO on-call
Medical SpR on-call
Medical Consultant on-call
Surgical SHO on-call
Surgical SpR on-call
Surgical Consultant on-call
Anaesthetist on-call

2700
2701
2702
3700
3701
3702
4701

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APPENDIX 3: Mark Scheme and Model answer script:
SITUATION:
Introduces self and role
Location
Patient info: NAME / DOB / HOSPITAL NUMBER
RESUS status of patient
Appropriate HEADLINE of situation
Vital signs explained clearly

☐
☐
☐
☐
☐
☐

BACKGROUND
Patient admitted on…
PC and admission diagnosis
HPC
PMH
DHx
Examination findings

☐
☐
☐
☐
☐
☐

ASSESSMENT
I think the problem is: PERFORATION
If they do not know what the problem is – states patient is UNWELL
Identifies patient is in SHOCK
Identifies patient needs immediate SpR review

☐
☐
☐
☐

RECOMMENDATION
Urgent SpR review
2 x large bore cannula
Bloods:
- FBC – Hb for blood loss, WCC for sepsis
- U&Es – electrolytes disturbance, dehydration
- CRP – sepsis
- INR – assess bleeding risk
- Group and Save – prep for surgical intervention / transfusion
- ABG / VBG – Raised lactate suggestive of bowel ischaemia
IV Fluids
Catheter – monitor fluid balance
CXR erect
AXR
Call ITU / Surgical SpR
Contact NOK

☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐

RESPONSE
Is there anything you would like me to do?

☐

PROFESSIONALISM
COMMUNICATION SKILLS

☐☐
☐☐

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Situation
"This is …..The Medical House Officer on-call, calling from Olive Ward. The reason I'm calling is that a
patient Mrs Cathy Groves (Give DOB, Hospital number) has become very unwell. She is for full
escalation and has no DNAR in place. She is tachypnoeic with a respiratory rate of 30, her blood
pressure is 90 / 47, her pulse is 120 bpm and her sats are 92% on room air. She has also passed
only 30mls of urine in the past 6 hours. She is currently afebrile.”
Background
"Mrs. Groves is a 60-year-old woman who was admitted three days ago with a flare of her Ulcerative
Colitis. Her past medical history also includes hypertension and high cholesterol. She was started on
steroid and mesalazine treatment and is being supported with intravenous fluids. This morning her
observations were stable with her BP 120 / 80, HR 85 bpm and her RR 16. She has steadily got
worse with her blood pressure falling and her heart and RR increasing despite receiving 2L of IV
fluids. Her urine output has dropped in this time. On examination she looks generally unwell with a
GCS of 13/15. Her capillary refill time is prolonged at 4s, her heart sounds are normal and her chest
sounds clear. Abdominal examination revealed a distended, rigid abdomen that was extremely tender
throughout. Bowel sounds were absent.”
Assessment
"I think she may have perforated her bowel.'"
"This patient is in shock and I am worried."
Recommendation
"I recommend an urgent surgical SpR review. In the meantime I suggest commencing oxygen
therapy, inserting 2 large bore cannulae and sending bloods including FBC, U&Es, CRP, Clotting,
Group and Save. I also recommend running an arterial blood gas. I suggest giving a 500ml fluid
challenge and inserting a catheter to closely monitor the fluid balance. I would also like to order an
urgent AXR and erect CXR. Following these things I would like to contact the next of kin and inform
them of the situation.”
“Is there anything else you would like me to do? “
"When are you going to be able to get here?”

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APPENDIX 4: Notes for killing time
Differentials for the acute abdomen – draw abdomen – arrange differentials by site.

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OSCE Short Station: Communication and Explanation
Overview:
This is a role-play exercise based on a typical OSCE communication and explanation station. In a
typical scenario, the students will be asked to take a brief history then explain a new diagnosis or a
procedure. Two example scenarios have been provided – rheumatoid arthritis and a total knee
replacement – although there is likely to be time only for one scenario during the session.
Format of the exercise:







Ask one student to be the actor and one to be the OSCE finalist. Provide the actor with their
brief and the student with the scenario instructions (both overleaf).
Ask the student to read the instructions to the group. Check for questions.
The student should proceed to manage the actor – allow 10 minutes only.
Any questions should be directed towards the actor. The examiner should only volunteer
answers to specific questions as detailed below and should provide examination and
investigation findings when specifically asked by the student.
Afterwards, gather feedback. Start with the student then open it up to the group.
Finally, provide your own feedback to the student. Try not to focus on the clinical information
they’ve provided (except to point out whole sections they might have missed out). Instead,
think of the following:
– Structure: did they cover all the main areas (see model answer)? Did they jump back
and forth between topics or was there a coherent ‘flow’? Too much information or not
enough? Too much of one topic at the expense of another?
– Patient focus: did they allow the patient to shape the content by eliciting and
responding to concerns? Was there space for the patient to confirm they understood
and ask questions?
– Style. Comment on speech (rate and tone), empathy and body language.

Extending the session:
If there’s time available, you may want to initiate some group work after the scenario:


A generic outline suitable for most explaining stations has been provided (below) together
with model answers for each scenario. If there is time after the feedback session, you can
brainstorm a model answer of another scenario with the group, focusing on the structure they
want to use and the information they think is important. Remember the structure should
accommodate both conditions (like RA, Crohn’s etc.) and procedures (TKR, cholecystectomy
etc.). You can then re-run the scenario with the format you’ve brainstormed – write it on the
board and let them to refer to it as they go along – and ask the group to comment on any
differences second time around.

Key learning points for the students






Have a format. This ensures you touch on all the main ‘point scoring’ areas within the topic.
Keep it simple. You don’t have to provide a comprehensive list of treatments, side-effects etc.
Just a few examples will get you the points.
Respond to the cues you’re given. Acknowledge questions and concerns (verbally, if
possible) and shape you’re information based on the patient’s agenda.
‘Chunk and check’ really works, but don’t go overboard. Practice wrapping up each sub topic
with a question: Does that sound OK? Do you think that’s clear? Is there anything you want to
ask me about diagnosis/treatment/management?
Deploy open questions wisely. Their cost you time but are vital for eliciting patient ideas and
concerns.

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Scenario 1: Explaining Rheumatoid Arthritis
Student instructions
To be read out loud by the student to the group
A 58 year old clerical assistant has come to the GP to discuss the results of blood tests and x-rays
which were ordered after s/he presented with pain and swelling in the wrists and the small joints of the
hand. You are an FY2 on a General Practice rotation. Please take a brief history to confirm your
diagnosis before discussing the results. Answer any questions they may have on their condition.
Results:
Rheumatoid factor
Anti-cyclic citrullinated peptide (anti-CCP)
X ray, both hands

Negative
Strongly positive
Right: Widespread juxta-articular osteopaenia
nd
rd
th
with bony erosions in 2 , 3 and 4 DIP.
th
Evidence of active soft tissue swelling in the 4
th
and 5 DIP.
Left: A similar degree of osteopaenia is evident
in the left hand with less prominent soft tissue
swelling. There is marked loss of joint space in
nd
rd
the 2 , 3 and 4th DIP.

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Scenario 1: Explaining Rheumatoid Arthritis
Actor’s brief
You are a 58 year old part time clerical assistant and have come to the GP for the results of a blood
test. You’ve been experiencing episodes of pain and swelling in both wrists and in the small joints of
your hands for two years. More recently, you’ve begun to notice reduced manual dexterity, most
obvious when typing. You’ve not noticed any problems in the larger joints, have no nodules and no
breathlessness. You use ibuprofen to control pain during a flare. If questioned directly, you have been
experiencing dry, itchy eyes for around 6 months but put it down to ‘allergies’. You have hypertension,
for which you take amlodipine, but no other medical problems. Your mood is generally good.
Your mother had rheumatoid arthritis and you are very worried that you will end up like her – with
severely deformed joints, loss of mobility and chronic pain. You would like to know if this could
happen to you too. You also want to know if it will affect your work.
Only volunteer specific information about symptoms, concerns and your past medical history when
asked the relevant and specific questions by the student. If any questions cannot be answered with
the above information, please answer “no” or “don’t know”.

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Scenario 1: Explaining Rheumatoid Arthritis
Model answer
The prompts below (in bold) can be applied to just about any conditions or procedures you’re asked to
explain. The examples in italics describe rheumatoid arthritis.
1. Introduce yourself and gain consent. It’s often helpful to paraphrase the task from the brief.
Hello. My name is Dr Clarkson. May I ask your name please? I understand you’ve had some tests
recently, and I’d like go through the results with you. Are you happy for us to do that today?
2. Give the patient the opportunity to influence the agenda.
Is there anything else you were hoping to cover today?... OK – I’ll make sure we discuss that, but
please do ask questions as we go along especially if anything’s unclear.
3. Briefly summarise their issue. If you’ve been asked to take a history, now is the time to expand
on what you’ve already been told. It shouldn’t be exhaustive – this isn’t a history station but you will
have to follow up on any positives. Ask a few questions and move on.
I understand you’ve had problems with pain and swelling in your hands. Is that right?’ Do you every
have (i) pain or stiffness in other joints, (ii) dry or painful eyes, or blurred vision (iii) breathlessness or
(iv) chest pain. How has this affected you at home/at work? Anyone in the family had the same?
4. Establish their ideas and concerns pre-diagnosis/procedure. This is a chance for the patient to
air any preconceived ideas about their condition and its causes.
Do you have any ideas about what might be causing these symptoms? Have you thought about what
the test results will tell us?
5. Warning shot! Give them time after the ‘shot’ to collect their thoughts before you carry on. In some
OSCE scenarios the patient will already be aware of their diagnosis or the need for a procedure in
which case you can skip this.
I’ve reviewed the results and I’m concerned that they include some bad news <pause>.
6. Name the condition/procedure and find out what they know
Together with the symptoms you describe, your test results show that you have a condition called
Rheumatoid Arthritis. Is this something you’ve heard of before? Can you tell me what you understand
about the condition?
7. Describe the condition (WHAT and WHY): Fill in the gaps from what they’ve told you already but
keep it simple and focussed on the patient. Tell them WHAT the disease will do to them and WHY it’s
happening to them.
WHAT: Rheumatoid Arthritis a disease of the joints that presents with many of the symptoms you’ve
described – episodes of stiffness and swelling, often of the hands and feet, but sometimes larger
joints. If not managed early, these episodes can lead over time to permanent damage. It’s a disease
that can affect many parts of the body, including the heart, lungs and nervous system. Although
there’s no cure, many people have very good control over the disease, living normal lives.
WHY: We’re not sure exactly what causes it, but we know there’s a family link and some genes have
been identified as increasing your risk. There may be an infectious component, but the evidence is
limited and research is still ongoing.
8. Describe the goals of treatment: Is it curative or is long-term management the goal?
There is no curative treatment but there are things WE can do, and things YOU can do to control the
disease. The goals of treatment are to control the symptoms, prevent the damage caused by flare ups
of the disease and monitor you closely to catch any complications early.
9. Management (WE and YOU): For most conditions/procedures you’ll be expected to cover what the
medical profession can do (WE) and what the patient can do (YOU). Chunk and check’ as you go.
WHAT WE DO: Medical/General, Pharmacological and Surgical interventions
- MEDICAL: I will arrange early referral to a Rheumatologist - a specialist in conditions like this. They
will co-ordinate a team of people looking after your care, including nurse specialists, occupational
therapists, podiatrists, psychologists and social services. All with the goal of reducing the impact of
the disease on your day-to-day life.
- PHARMACOLOGICAL: There are many effective medicines used to treat the condition. We use
anti-inflammatory drugs to treat the symptoms of pain and swelling. These include non-steroidal
anti-inflammatory drugs as well as short courses of steroid medications. Other drug can be used to
modify the course of the disease, not just treat the symptoms, and may be started after discussion
with your rheumatologist. These are powerful medications that can be very effective but need careful
monitoring as they have side effects that may harm the immune system or affect organs like your liver
or kidneys. This is one of the reasons we monitor you closely, particularly at the early stages of
treatment.

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- SURGICAL: If describing a procedure, take a BEFORE, DURING and AFTER approach.
Occasionally, specialist surgeons can offer procedures to correct joint defects or minimise pain,
however this has become less frequent over time as medical management has improved.
WHAT YOU DO:
There are things you can do to keep your joints and your heart healthy, for example controlling your
weight, taking regular exercise and eating a Mediterranean diet (unsaturated fats, vegetables and oily
fish). It’s important to take the medication you’re given as prescribed and to report any symptoms
early so we can help.
10 Take a breather
This must be a lot to take in. Is there’s anything you’d like to ask, or anything I can make more clear?
11. Flush out their worries if they’ve not voiced them already. They almost certainly have a secret
worry you need to illicit and sometime you have to ask directly.
Is there anything in particular your worried or concerned about?
12. Recap
Just to recap, I’ve explained that you have rheumatoid arthritis, that it’s treatable with medication and
support. You’ve told me you’re worried about the impact of the disease long-term, but I hope I can
reassure you that there are many treatments available and that most people live normal lives with this
condition.
13. What happens next Discuss follow up, referral and other sources of information.
We’re coming to the end of our session, but I’m sure you’ll think of lots more questions later. Why not
talk this over with family or friends then make a follow up appointment to discuss it further. You’d be
welcome to bring someone with you if you’d like. In the meantime, with your permission I’d like to
make a referral to a rheumatologist at the hospital, who will invite you to an outpatient clinic in a few
weeks. If you’d like, I can leave some reading material at the reception desk for you to collect before
you leave. If you’re looking for information online, I’d recommend you search for Rheumatoid Arthritis
on www.nhs.uk as it’s always up to date.
14. Wrap up
Thank you for taking the time to go through your results today. I hope you feel the information has
been useful. Please do arrange another appointment if you’d like to talk more. Thanks.

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Scenario 2: Explaining a Total Knee Replacement
Student instructions
To be read out loud by the student to the group
A 67 year old retired social worker with osteoarthritis has been advised to consider a total knee
replacement (right knee) by your consultant, and has come back to the outpatient orthopaedic clinic to
discuss the matter further before deciding whether to proceed. You are an FY1 doctor on a Trauma
and Orthopaedics rotation and have been asked by your consultant to explain the procedure. Please
take a brief history to confirm the diagnosis before discussing management. You are not expected to
gain signed consent today.
Results:
X ray: Both knees, AP and Lateral

Right knee: marked loss of joint space with
widespread sclerosis. Large left lateral subchondral cyst on tibia. Prominent osteophytes.
Left knee: moderate sclerosis. Joint space
diminished but preserved medially. Lateral
osteophyte noted.

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Scenario 2: Explaining a Total Knee Replacement
Actor’s brief
You are a 67 year old retired social worker and have been experiencing slowly worsening pain in both
knees over the last 10 years. In the last two years the pain in your right knee and right hip have been
significant and disabling, and you now walk with a stick. You are otherwise in good health. You take
amlodipine for hypertension (which is well controlled) and paracetamol with ibuprofen gel regularly for
joint pain. You had a fall recently while playing with your grandchildren and you worry that you are not
safe to look after them alone.
You are eager for surgery and frustrated that it has taken two months to get an appointment. You
want to know about what the procedure entails, the expected recovery time and the common
complications. You would like your right hip and right knee replaced in a single procedure as you
believe that this will be more efficient. You will pressure the doctor to agree to this and provide you
with a consent form to sign today but will back down once the process is adequately explained.
Only volunteer specific information about symptoms, concerns and your past medical history when
asked the relevant and specific questions by the student. If any questions cannot be answered with
the above information, please answer “no” or “don’t know”.

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Scenario 2: Explaining a Total Knee Replacement
Model answer
The prompts below (in bold) can be applied to just about any conditions or procedures you’re asked to
explain. The examples in italics describe a total knee replacement
1. Introduce yourself and gain consent. It’s often helpful to paraphrase the task from the brief.
Hello. My name is Dr Clarkson. May I ask your name please? I understand you’re considering knee
replacement surgery on you right knee – is that right? I’ve been asked to explain the procedure and
answer any questions you might have. Are you happy for us to do that today?
2. Give the patient the opportunity to influence the agenda.
Is there anything else you were hoping to cover today?... OK – I’ll make sure we discuss that, but
please do ask questions as we go along especially if anything’s unclear.
3. Briefly summarise their issue. If you’ve been asked to take a history, now is the time to expand
on what you’ve already been told. It shouldn’t be exhaustive – this isn’t a history station but you will
have to follow up on any positives. Ask a few questions and move on.
I understand you’ve had pain in your right knee for some time. Is that right?’ Do you every have (i)
pain or stiffness in other joints, (ii) problems with mobility or falls. How has this affected you at
home/in your daily activities/socially?
4. Establish their ideas and concerns pre-diagnosis/procedure. This is a chance for the patient to
air any preconceived ideas about their condition and its causes.
How do you feel about surgery? What are your expectations regarding the recovery period? What are
you hoping for from the procedure in the longer term?
5. Warning shot! Give them time after the ‘shot’ to collect their thoughts before you carry on. In some
OSCE scenarios the patient will already be aware of their diagnosis or the need for a procedure in
which case you can skip this.
Not required in this scenario.
6. Name the condition/procedure and find out what they know
Together with the symptoms you describe, your test results show that the osteoarthritis in your right
knee is advanced. My consultant believes you would benefit from a total knee replacement.
7. Describe the condition (WHAT and WHY): Fill in the gaps from what they’ve told you already but
keep it simple and focussed on the patient. Tell them WHAT the disease will do to them and WHY it’s
happening to them.
WHAT: Osteoarthritis is the process of gradual damage to the joints over time. Loss of cartilage – the
material that protects the bones that form the joints – results in bony erosion and deformity of the
joints, causing pain and stiffness.
WHY: The disease is very common and affects many people as they age. We know that genetics play
a part, but other factors, for example your occupation, your weight, your sex or a previous injury to the
joint, can all increase your risk of developing osteoarthritis.
8. Describe the goals of treatment: Is it curative or is long-term management the goal?
There is no curative treatment but there are things WE can do, and things YOU can do to control the
disease. Initially, the goals of treatment are to manage the symptoms and reduce the rate of damage.
In the later stages, we focus on replacing the joint altogether.
9. Management (WE and YOU): For most conditions/procedures you’ll be expected to cover what the
medical profession can do (WE) and what the patient can do (YOU). Chunk and check’ as you go.
WHAT WE DO: Medical/General, Pharmacological and Surgical interventions
- SURGICAL: If describing a procedure, take a BEFORE, DURING and AFTER approach. ‘
As you know, we can offer a complete joint replacement. Before the procedure we invite you to preassessment clinic where we carry out basic tests to be sure you’re fit for surgery. This includes giving
you advice on any changes to medications pre-op, and suggesting practical things you may need to
arrange during the recovery period – for example help with the shopping while you’re off your feet.
You’ll come to hospital on the day of your surgery after fasting overnight and will be reviewed by the
anaesthetist and consultant before the procedure. At that stage we’ll ask you to sign a consent form.
All surgery carries risks. Rarely, patients have experienced damage to the nerves resulting in loss of
sensation or muscle weakness, loosening or stiffening of the joint over time, leading to instability or
pain. However, for the vast majority of people, the results represent a significant improvement. Do you
have any questions before I move on? During the procedure you may be asleep, or we may numb
you from the waist down. You can discuss this with your anaesthetist. The surgeon will remove the
old worn joint and a new prosthetic joint will be fitted. You’ll wake with a neat vertical scar across the
knee joint. After the procedure, you’ll wake up in the recovery room, feeling a bit groggy. We will keep

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you comfortable and provide medication for pain and nausea, and fluids if you’re dehydrated. We’ll
have you on your feet within the first 2 days, and home usually within 5 days depending on progress.
You’ll have to avoid driving for 6 weeks, and carry a medical alert card to help you through airport
security! We’ll remove your stitches around day 10 post-surgery, and your GP will look after you until
we see you again at your 6-week follow up appointment. Does this sound like what you were
expecting?
- PHARMACOLOGICAL: We’ll ensure you have adequate pain control before you leave hospital and
on discharge.
- MEDICAL: The key to recovery is physiotherapy, both in hospital and after discharge. You will be
seen by the physiotherapists as an outpatient, and given exercises to help strengthen your new joint.
Also, remember that your GP is there to help if your pain is not well controlled or if you need advice.
WHAT YOU DO:
There are things you can do to keep your joints healthy, for example controlling your weight and
taking regular exercise. It’s important to take the medication you’re given as prescribed to control pain
and help to keep you mobile, and that you follow the exercise plan you’ll be given by your
physiotherapist.
10 Take a breather
This must be a lot to take in. Is there’s anything you’d like to ask, or anything I can make more clear?
11. Flush out their worries if they’ve not voiced them already. They almost certainly have a secret
worry you need to illicit and sometime you have to ask directly.
Is there anything in particular your worried or concerned about?
12. Recap
Just to recap, I’ve explained that you have osteoarthritis and that a total knee replacement is the best
option for managing your pain and mobility problems. You’ve told me that you’re keen to have the
surgery but that you’re also worried about your hip. My advice is to focus on the knee surgery as the
hip may improve once your knee is realigned. I can also get a second opinion for you regarding this. I
won’t be able to consent you today but my surgical colleagues will take care of this after pre-op clinic.
13. What happens next Discuss follow up, referral and other sources of information.
We’re coming to the end of our session, but I’m sure you’ll think of lots more questions later. Why not
talk this over with family or friends then make a follow up appointment with your GP to discuss it
further. Remember you’ll be able to ask questions at the pre-op assessment. You’d be welcome to
bring someone with you if you’d like. In the meantime, with your permission I’d like to schedule your
surgery and arrange the pre-op assessment. If you’d like, I can leave some reading material at the
reception desk for you to collect before you leave. If you’re looking for information online, I’d
recommend you search for Total Knee Replacement on www.nhs.uk as it’s always up to date.
14. Wrap up
Thank you for taking the time to go through this today. I hope the information has been useful, but do
contact your GP if you’d like to talk more, or talk to us at pre-assessment clinic. Thanks.

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OSCE Short Station: Assessment of Fluid Balance
Overview:
This is a role-play exercise based on a typical short OSCE examination station. In this scenario, the
students will be given ten minutes to examine a patient’s fluid status.

Format of the exercise:







Ask one student to be the patient and one to be the OSCE finalist.
Provide the student with the scenario instructions (both overleaf).
Ask the student to read the instructions to the group. Check for questions.
The student should proceed to manage the actor – allow 8 minutes for examination and 2
minutes to summarise/ask questions below
The examiner should only volunteer answers to specific questions as detailed below and
should provide examination and investigation findings when specifically asked by the student.
Afterwards, gather feedback. Start with the student then open it up to the group. Then provide
your own feedback to the student.
Finally, discuss key learning points. Suggestions for questions to ask the group, a
recommended ‘model answer’ and key discussion points re: fluids are included overleaf.

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Student instructions
To be read out loud by the student to the group
Mr Smith is an 82 year old man who had a Hartmann’s surgical procedure 5 days ago. Please assess
his fluid balance status, request appropriate further bedside investigations/tests and prescribe
appropriate fluids on the chart provided. You have ten minutes to complete this station.
Please talk through your examination.

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Mark Scheme and Model answer script:
Introduction

Appropriate introduction
Washes hands
Consent

☐
☐
☐

Examination

Observes from end of the bed – around the patient and at
the patient as a whole
Assessment of GCS

☐

Hands:

Capillary refill
Skin turgor
Warm, well perfused hands?

☐
☐
☐

Arm:

BP – lying and standing
Pulse – rate, character
Assesses mucous membranes

☐
☐
☐

Chest:

Assess mouth
JVP
Carotid pulse
Skin turgor

☐
☐
☐
☐

Abdomen:

Auscultates lungs
Listens to heart sounds
Assesses for ascites

☐
☐
☐

Back
Legs
General:

Sacral oedema
pedal oedema
Catheter in place?
Stoma bag? Output?

☐
☐
☐
☐

Observations:

Assesses:

Temperature
BP (110/60)
HR (115)
RR
Sats
Urine output

☐

To complete:

I would look at the input output chart
I would want to see the drug chart
Ask the nurses to put a catheter in

Prescribes fluids:

Fluids at an appropriate rate (e.g.: 4 hours, or a fluid challenge) ☐
With 40 mmol of KCl correctly prescribed if not giving challenge ☐

Face:
Neck:

☐

☐

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Questions/answers for group:
1. What else would you like to see at the patient’s bed side?
 Fluid balance sheet
 Daily weights
2. What is the patient’s fluid status?
 Patient is clinically dehydrated
3. What would you instruct the nurses to do?
 Request they put up the fluids
 Recommend regular observations
 To call you if any concerns or changes in patient’s clinical state
 Monitor urine output hourly
4. Any blood tests the candidate would like to see? Show them these results
Blood results: U&E’s:
Sodium
Potassium
Creatinine
Urea
FBC normal
CRP 6



132
3.0
199
11.2

Urea and electrolytes – in particular with focus on urea and sodium
Full blood count/CRP – any reasons for dehydration – concurrent infection

5. Blood tests: Ask the candidate to interpret the results above
 The patient is dehydrated. He needs urgent fluid resuscitation
 He is also hypokalaemic with a mild hyponatraemia
 I would also want to prescribe potassium with the fluids
6. Would this change their management plan in any way?
 Patient is hypokalemic – an ECG needs to be done urgently
 ECG changes in hypokalemia:(Show them ECG)
o Small or inverted T wave
o Prominent U waves (after T wave)
o A long PR interval
o Depressed ST segments
 Daily U&E’s and strict monitoring of fluid input/output
 Investigation of the cause of the hypokalaemia (e.g.: drugs, diarrhoea)

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Key learning points on fluids:


5% Dextrose
o Isotonic fluid
o Contains a small amount of glucose (50g/L)
o Liver metabolises all the glucose, so only water is left
o This equilibrates through all fluid compartments
o Good for maintaining hydration



0.9% Saline
o Has the same Na content as plasma – therefore isotonic with plasma
o 0.9% Saline will equilibrate rapidly through the extracellular compartment only and
take longer to reach the intracellular compartment
o Appropriate for resuscitation and maintenance



Colloids e.g.: Gelofusin
o Has high osmotic content similar to that of plasma and therefore will remain in the
intravascular space for longer than other fluids
o Appropriate for resuscitation but not for general hydration
o Small risk of anaphylactoid/anaphylactic reactions



Hartmann’s
o Meant to be similar to blood constitution of electrolytes
o Appropriate for resuscitation and maintenance

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OSCE Short Station: History taking
Overview:
This is a role-play exercise based on a typical OSCE history taking station. In this typical scenario, the
students will be given 10 minutes to take a short history from the patient, suggest a management plan
and be questioned on key points in the scenario. This scenario focuses on a patient who is tired all
the time – a common presentation seen in exams.
Format of the exercise:






10 minutes Carrying out scenario
o Ask the student to read the instructions to the group. Check for questions.
o Teacher as actor or alternatively you can pick a student as the actor – go by brief
overleaf: 8 minutes
o After 6 minutes of history taking, prompt the student to discuss the initial
investigations/management with the patient
o After 7 minutes of history taking, ask the student to summarise and present his/her
history: 1 minute
o Last minute: Teacher to press the student on an aspect of the history that they
elicited – i.e.:
 If thyroid tests were mentioned;
 What pattern of results you would expect?
 What treatment regimen you might want to try in a hypothyroid
patient?
 How can hypothyroidism mimic many other illnesses/carry similar
signs/symptoms?
 If a mood disorder is focussed on (as it will be from the brief), press them on:
 What they would do next. (i.e.: would you start them on an
antidepressant/refer them for other help?).
 What would you do if a patient was frankly suicidal
(sectioning/informal admission to a psych unit/crisis team
input/community support)? What other things are important to
consider here (drug/alcohol abuse, risk to others and safeguarding).
5 minutes Feedback
o Provision of feedback to the student via teacher and the group: particularly focus on
feedback of the student’s history taking/communication skills
 Pick one student to list 3 things they did well
 Pick one student to provide 3 things that could have gone better
 Pick one student to provide a “champagne moment” for the history –
something standout; i.e. eliciting a difficult component to the history, or
picking up on a clue dropped by the historian.
o Questions for the student (2-3) – you could recommend questions they could ask in a
future history
10 minutes Discussion
 Discussion of the material covered in “key learning points” (overleaf)
 This would benefit from a big flipchart and a pen – get the students to brainstorm the
areas you would like to see covered in the history.

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Student instructions
To be read out loud by the student to the group

You are a GP on your second foundation year placement. Ms Hardwick has presented to you stating
that she is tired all of the time. Please take a history focussing on relevant details and discuss the
initial investigations you would like to perform with her. You have eight minutes to do this in total. You
will have two minutes to discuss the case with the examiner.

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Actor’s brief
Mr Hardwick – a somewhat gruff character, who might like to read a Haynes manual in his spare time.
Work-focussed, and alone after his divorce of 6 months ago. Considers himself a ‘coper’, and capable
of overcoming any task if he sets his mind to it, but willing to entertain idea that he has had a stressful
time if approached with proviso that he remains a capable person.
I promised my daughter that I would see the doctor – she made the appointment for me – and the
least I could do for her was to come along.
Background medical history:
High blood pressure (on amlodipine 5mg).
BMI of 40
Previous cholecystectomy (laparoscopic).
Family history
Father died of MI 79
Mother – bowel ca. 82
Brother has type 2 diabetes.
Recent life stressors –
Divorce of 6 months ago (she left for unknown reason – very little contact since). Re-applying for job
at work – and recently taken out new mortgage to cover cost of new extension to house.
I am a 57 year old man, and I work for an engineering firm. For the past 3 months I’ve been having
trouble getting going and I’ve felt generally rubbish. I’ve been struggling to motivate myself to get
going at work. This is particularly frustrating, as we’re going through a re-structure and everyone is
having to re-apply for their jobs. It’s very stressful. I’m falling behind, and I think colleagues are
noticing that I’m not my old self. My concentration is all off, and that’s what’s really concerning me – I
never used to be like that.
I’ve not been able to get to sleep at night, and when I do, I wake up really early (about 4 o’clock, if
asked). I tend to get up and try to plan for things at work over a cigarette, but I never get very far. I
suppose I don’t enjoy things like I used to anymore; but I think this is probably because I’m focussed
on work. My appetite is pretty unchanged. I haven’t noticed much weight loss, but I know I should lose
quite a bit – my daughter keeps on telling me. I haven’t really been in the mood for sex, if asked, but
then I’m an old bloke carrying a bit of weight and presume no one would really want to look at me if I
did. I’m having a bit more to drink than I used to – probably three or four scotches (singles) to get to
bed at night, but no more than that.
I’ve noticed my hair thinning recently, and my voice has been a little croaky over the last few days – I
thought it was just age, and smoking a bit more, respectively. I haven’t noticed feeling cold, but then
my house is sensibly insulated.
I have been peeing more recently – I’m getting up about twice a night and going 6-8 times a day, but I
haven’t been extra thirsty – if asked more about this, I’ve been experiencing urgency, finding it difficult
to work up a stream and get post mictural dribbling. My brother has type II diabetes.
I’ve not been getting particularly breathless – at night or during the day. I do snore (my wife always
used to complain), but I wouldn’t be able to tell you if I’ve ever stopped breathing at night. I don’t drop
off at work, but do feel a bit sleepy after a meal. I would probably fall asleep if you put me in the
passenger seat of a car, but not in the driving seat (at a red light).
If approached correctly (i.e. acknowledgement that I’ve been through some stresses recently that
would impact anyone), I will accept the offer of seeing someone in the community, and will think about
starting an antidepressant if offered. I’m not suicidal – only broad thoughts about it being easier if I
wasn’t around. I’ve got my daughter and my job to live for, and I have plans to retire to the
countryside.

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Key learning points:
Lethargy is a feature of many disorders, so a ‘tired all the time’’ history will mostly be about showing
an examiner that you can structure your history to time in order to fit the main ones in, then tailor it to
fit others pertinent to the patient you are presented with.
Main ground to cover – these should be covered with any patient presenting to you:
1. Thyroid disorder
2. Anaemia
3. Diabetes
4. Mood disorders/life stressors
Then go on to consider the following, depending on the patient you are presented with, and their risk
factors:
1. Cardiac dysfunction (AF/failure)
2. Respiratory disorder (OSA/SHS)
3. Renal dysfunction (nephrotic/nephritic syndromes)
4. Infective (glandular fever, post viral fatigue syndrome)
5. Drugs (i.e. those of abuse, especially stimulants, and those prescribed by doctors/OTC)
Questions pertaining to the main risk factors/signs/symptoms for the aspects you’ve focussed on will
show the examiner that you are thinking about the main causes.
Then spend the last minute coming up with a series of investigations you’d like to perform and agree
this with the patient. This will probably run along the lines of “I’d like to do some blood tests to check
your thyroid status, your blood sugars, your kidney function and the levels of haemoglobin in the first
instance, then we might want to do some more tests of your heart and lungs if all of these are
normal.” If the patient’s presentation seems to be more life-stressor/mood-orientated, you can state
that you would still like to do the tests to rule out an organic cause, but then plan to explore their
coping strategies and most importantly, risk, with them.
As with all GP consultations; remember to safety net “if you have any more concerns, or if x gets
worse, you can make an appointment to come and see me again…” Or if you are concerned about
their risk levels, a referral to community mental health services (IAPS, or more acutely a crisis team)
may be appropriate.
NB: Chronic fatigue syndrome is a possible diagnosis in a ‘tired all the time’ history, but perhaps not
one to plump for in a short case. Show the examiner that you can exclude all of the other diagnoses
first. If you like you could raise the possibility of chronic fatigue if all tests are negative, but state you
would like to carry out tests of the more common causes first.
Thyroid disorder: Hypothyroidism
Risk factors:
Women (6:1 F:M), over 40 years old, other autoimmune diseases such as viteligo, primary biliary
cirrhosis (primary atrophic hypothyroidism/Hashimotos thyroiditis – high antibody titres). Remember
amiodarone therapy (amiodarone is iodine-rich and looks like T4; thus can suppress TSH; actual T4 is
not released.
Presenting symptoms/signs:
Lethargy, low mood, cold intolerance, constipation, hoarse voice, impaired thinking, myalgia,
constipation, weakness, eventually dementia, weight gain, thinning of hair, loss of outer third of
eyebrows (most sensitive sign), goitre (less common than in hyperthyroid)
Investigations:
High TSH and low T4, OR low TSH and low T4 (in secondary; very rare). Cholesterol and triglycerides
also raised.
(NB: Tx: levothyroxine – low dose in elderly (25 microgram intervals), start at 100mcg in younger.
Recheck TSH 12 weeks, recheck every 6 weeks to normal state and then yearly).

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Anaemia:
Risk factors:
This depends on the cause of anaemia – common ones to think about: occult blood loss in older
patients (leading to 2 week suspected cancer referral), menorrhagia in younger women, true
nutritional causes (iron deficiency/B12 or folate def. in vegans or alcoholics), myelodisplastic
disorders, thalassemia/sickle cell, and renal dysfunction.
Presenting symptoms/signs:
Lethargy, dizziness Pallor (conjunctival, or skin).
If more severe tachycardia/palpitations, chest pains, breathlessness.
IDA: koilonychia, angular stomatitis, glossitis, think about pica – and especially craving ice
(pagophagia)
Investigations:
FBC (microcytic, macrocytic, normocytic?), Iron studies (serum iron, TIBC, Ferritin)

Iron def
Anaemia of CD
Haemolysis
Haemochromatosis

Iron
+
+

TIBC
+
-/N

Ferritin
+
+
+

Other investigations if patient is anaemic: LDH, reticulocytes, blood film, B 12, folate TFTs
Diabetes
Risk factors:
Type 1: family history, younger age, other autoimmune conditions
Type 2: obesity, age, ethnicity, male gender, poor diet and lack of exercise (though correlates more
with simple obesity), FH (MODY)
Presenting symptoms/signs:
Lethargy, polyuria/nocturia, polydipsia.
Increased risk of infections – especially skin infections/thrush.
Consider the more long-term risks present from diabetes: i.e. eye signs (cataracts, diabetic
retinopathy), peripheral neuropathy (ulcers, skin infections), and kidney dysfunction.
Can also present as DKA (type 1) or HONK (type 2)
Investigations:
Urine dip glucose +++ (can be protein too…)
Random blood glucose of over 11.1 (one with symptoms, two without)
HbA1C of over 6.5% (or 48mmol/mol in new money).
IGT: fasting plasma glucose of less than 7, but between 7.8-11.1 on OGTT
Also IFG – fasting plasma glucose between 6.1-7.
Mood disorders
Risk factors:
Life-stressors (The Holmes and Rahe stress scale – this lists potential life stressors in order; you
could check for the major ones), concurrent or past mental disorder (most likely depression), chronic
physical health conditions, social isolation, age.
Presenting symptoms/signs:
Core symptomatic features: anhedonia, anergia, low mood – most of the day, every day for 2 weeks
or more.
Core biological features: lack of sleep (plus early morning waking; though can be hypersomlenence in
c.10%), lack of appetite/weight loss (though appetite can also be increased in c.10%), low libido most
of the day, every day for 2 weeks or more.
Remember that low mood may have been preceded, or can be followed by manic episodes: check for
a history of bipolar.

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Investigations:
As with all psychiatric disorders, you must first state that you would like to rule out an organic cause
(i.e. by ordering the tests discussed above).
Assessing for risk is the most important thing to do when you’ve established depression as most
likely cause. Ask about suicidal intent.
Others
Cardiac:
Likely to be older patients with a background of hypertension/MI/hypercholesterolemia/other cardiac
risk factors
AF/flutter –ECG to diagnose.
Failures – R vs. left vs. congestive: breathlessness, swelling, exercise tolerance (MRC is a useful
scale), chest pain. (then take a brief SOCRATES history to determine if cardiac in nature).
Will always want to do an echo – with potential for further tests thereafter e.g. MPS, angiography etc.
if indicated.
Respiratory:
Main one to exclude is OSA/SHS. Obese people, unless central apnoea (rare).
Do they snore (ask a partner – or ask if a partner often sleeps in another room)
Often witnessed episodes of apnoea (by family etc.).
Tend to fall asleep during the day, and will awake feeling tired/unrested.
Epworth Sleepiness Scale.
ABG/VBG may show high bicarbonate/type 2 respiratory failure.
Infective:
Glandular fever: young people starting school/university for first time: ESR, C-reactive protein and
monospot test. Atypical mononuclear cells on blood film.
Post viral syndrome: recent infection; can take weeks to recover.
Drugs:
Started any new medication? Have a look at side effects of most prescription/OTC medication –
lethargy will be one of the main SE listed.
Think about alcohol misuse: sleep pattern interruption.
Amphetamines: cocaine and ecstasy/MDMA overuse
Renal dysfunction
Do a urine dip looking for protein. U+Es will tell you creatinine levels (important to know baseline).
This may suggest chronic kidney disease.

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OSCE Short Station: Cranial Nerve Examination
Overview:
This is a role-play exercise based on a typical short OSCE examination station. In this scenario, the
student will be given ten minutes to examine a patient’s cranial nerves. In any OSCE, a student may
be asked to examine all or part of the cranial nerves I – XII in this time.
Format of the exercise:







Ask one student to be the actor and one to be the OSCE finalist.
Provide the actor with their brief and the student with the scenario instructions (both overleaf).
Ask the student to read the instructions to the group. Check for questions.
The student should proceed to manage the actor – allow 8 minutes for examination and 2
minutes to summarise/ask questions below
The examiner should only volunteer answers to specific questions as detailed below and
should provide examination and investigation findings when specifically asked by the student.
Afterwards, gather feedback. Start with the student then open it up to the group. Then provide
your own feedback to the student.
Finally, discuss key learning points. Suggestions for questions to ask the group, a
recommended ‘model answer’ and key discussion points are included overleaf.

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Student instructions
To be read out loud by the student to the group
Please examine this patient’s cranial nerves. Do not take a history. Offer to do all aspects of the
examination; the examiner will tell you to move on if not needed and answer your questions with
findings.
You have 9 minutes to examine the patient and 1 minute to discuss with the examiner at the end.

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Actor’s brief
On examination: there are no abnormalities.
Only volunteer specific information about symptoms and your past medical history when asked the
relevant and specific questions by the student. If any questions cannot be answered with the above
information, please answer “no” or “don’t know”.

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Model examination/instructions for examiner
•
•
•
•
•

Wash your hands
Introduce yourself
Tell the patient that you would like to examine the nerves in their head and neck
Ask if they are happy to do this
Reposition the patient sitting down

I – Olfactory – offer to do this, move student on
II – Optic
•
•
•
•

Visual acuity – offer to do this, move student on
Colour recognition – offer to do this, move student on
Fundoscopy – offer to do this, move student on
Pupillary reflexes –
A) LIGHT
- check for pupil symmetry
- check for ipsilateral (same side) and contralateral (opposite side) pupil constriction
- Test for relative afferent pupillary defect (RAPD)
B) ACCOMODATION
- ask the patient to focus on a distant spot, then change focus to your finger (15cm in
front of their face). Their pupil should constrict to focus.
• Convergence - "look at a distant object, now look at my finger"
• Visual fields:
A) Visual neglect: ask the patient to keep both eyes open. Hold your hands at the periphery
of their vision and wave each hand in turn each time asking the patient to state which
hand is waving. Then wave both hands. 

B) Cover one of your own eyes and ask the patient to cover the mirror eye and fix their gaze
on your nose, keeping their head still. Hold one of your fingers in the upper outer
quadrant of their visual field and move it towards the centre asking the patient to identify
the point at which they first see the finger/pin. Repeat this for the other 3 quadrants and
then repeat with the other eye. 

C) Offer to assess blind spot – move on
III – Oculomotor/ IV – Trochlear/ VI - Abducens



Test all three nerves together: move finger in a large 'H' shape across the patient's field of
vision and ask patient to follow finger whilst keeping their head still. Ask if patient can see
double or if vision is blurred at any point during the test
Test for nystagmus: ask the patient to focus on the tip of your finger. Hold your finger at the
left lateral edge of their visual field, and move it rapidly to the right lateral edge of their visual
field and hold it there. 2-3 beats is acceptable; more than this indicates pathology. Carry out
the reverse (right to left) movement.

V – Trigeminal
• Sensation:
Test sensation on the sternum with cotton wool first
Press (don't rub) the cotton wool in the distribution of the ophthalmic (forehead), maxillary
(cheek) and mandibular (jaw) divisions
Test like for like bilaterally and ask them if it feels the same on both sides
• Motor:
- Corneal reflex - offer to do this, move student on
- Jaw jerk reflex - offer to do this, move student on
- Ask patient to clench their jaw - feel temporalis and masseter muscles for contraction
- Open jaw to resistance (try to push their jaw up).

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VII – Facial
-

Inspect: comment on facial symmetry/appearance
Assess taste - move student on
Raise their eyebrows
Close their eyes tightly
Hold their lips together and blow out their cheeks

VIII – Vestibulocochlear
-

Rub fingers together by one ear, and whisper a two-digit number (e.g. 72) by the other
Offer to carry out specific tests Weber's Test and Rinne's Test - move student on

IX – Glossopharyngeal/ X - Vagus
-

Ask the patient to open their mouth and say 'ahh' - look at uvula
Examine the gag reflex (with an orange stick) – offer to do this, move student on
Assess the patient's swallow - offer to do this, move student on

XI – Accessory
-

Ask the patient to shrug their shoulders + resist your attempts to push their shoulders down
Put your flat palm on one side of the patient's face and ask them to turn their head against
your hand. Feel for sternocleidomastoid strength

XII – Hypoglossal
-

Inspect the tongue for fasciculations at rest
Ask the patient to stick out their tongue straight and check for deviation
Ask the patient to move their tongue from side to side

Questions to ask student
1. Please summarise your findings - normal findings
2. How would you complete your examination? – assess speech, swallow, take a full history, full
neurological examination, fundoscopy
3. What investigations/tests you would you like to order – consider CT head or MRI brain, bloods

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Key learning points for students on cranial nerve palsies:
Group discussion around common cranial nerve pathologies (this should be useful for osces but also
for writtens) – images on pages below
Questions for group:
CRN 3 PALSY – show students PICTURE A
1.
2.
3.
4.
5.

What abnormality on the left of the page?
Where is the site of the lesion? Partial or total? Consider using clip board for this
Causes for 3rd nerve palsy?
rd
This is a partial nerve palsy - would you expect this finding in all causes of 3 nerve palsy?
What questions would you want to ask patient? Tell student that patient is a type 1 diabetic –
what other neurological findings would you expect?

VISUAL FIELD DEFECTS – show students PICTURE C
1. Where are the sites of lesions?
2. Revision of optic pathway
3. Causes of lesions along pathway (see below) – encourage students to write in causes as go
through handout and sites of lesions
BELL’S PALSY – show students PICTURE B
1. What is this?
2. How do you distinguish between this and an UMN lesion?
BULBAR PALSY
1. What is this?
2. How do you distinguish between this and an UMN (pseudobulbar) lesion?
Answers for group/general points:
Questions to consider in cranial nerves examination:
1. Single cranial nerve or groups of cranial nerves?
2. Where is the site of the lesion? In brainstem or outside brainstem?
Common pathologies: Please review with above questions
1. Crn 3 palsy:
Findings:
1. Partial or full ptosis
2. Eye down and out
3. Pupils may be equal and reactive to light or fixed and dilated one affected side
4. Convergence will be impaired
Causes:
1. ‘Medical’ causes: diabetes, atherosclerosis, inflammation, infection,
rd
demyelinating disease egg multiple sclerosis  usually partial 3 nerve palsy
2. ‘Surgical’ causes: aneurysms egg posterior communicating artery, SOLs/tumours,
rd
trauma, cavernous sinus thrombosis  usually total 3 nerve palsy
Other neurological findings if patient was a type 1 diabetic:
1. Diabetic feet e.g.: peripheral neuropathy, charcot joint, ulcers
2. Diabetic gastroparesis/other autonomic neuropathy
3. Fundoscopy – proliferative or non-proliferative diabetic retinopathy

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Causes of ptosis:
 Bilateral: myasthenia gravis, myotonic dystrophy
rd
 Unilateral: 3 nerve palsy, horner’s syndrome
2. Visual field defects:
a. Bitemporal hemianopia – loss of temporal fields bilaterally, all other fields intact.
Causes: compression at optic chiasm e.g.: pituitary adenoma, craniopharyngioma,
internal carotid artery aneurysm
b. Monocular blindness – lesion at eye or optic nerve. Causes: eye pathology, MS, GCA
c. Homonymous hemianopia or quadrantanopia – loss of L or R-sided fields or
quadrants contralateral to lesion in each eye. Lesion beyond optic chiasm, at level of
tracts, radiation, or occipital cortex. Causes: stroke, SOL, abscess, inflammatory
process e.g.: abscess
3. Facial nerve palsy:
a. LMN: unilateral flaccid facial weakness, unable to raise eyebrows. Causes: Bell’s
palsy, skull fracture, CPA tumours, Lyme disease, Ramsay Hunt syndrome,
sarcoidosis, diabetes
b. UMN: spares forehead, able to raise eyebrows. Causes: stroke, tumour
4. Lower cranial nerve findings:
a. Bulbar palsy: diseases of nuclei of cranial nerves IX-XII in medulla - LMN.
i. Signs: flaccid, fasciculating tongue, jaw jerk absent, speech is
quiet/hoarse/nasal.
ii. Causes: MND, GBS, polio, myasthenia gravis, syringobulbia, brainstem
tumours, central pontine myelinolysis
b. Pseudobulbar palsy: UMN lesion due to lesions of corticobulbar tracts
i. Signs: slow tongue movements, slow speech, hyperreflexic jaw jerk,
emotional lability
ii. Causes: MS, MND, stroke, central pontine myelinolysis
5. Groupings of cranial nerves:
a. V, VI, VIII, IX, X: CPA lesions/tumours egg acoustic neuroma
b. V, VI: lesion at apex of petrous temporal bone egg complication of otitis media
c. III, IV, VI: stroke, tumours, Wernicke’s encephalopathy, aneurysms, MS
d. III, IV, Va, VI: cavernous sinus thrombosis, superior orbital fissure lesions
e. IX, X, XI: jugular foramen lesion

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PICTURE A

PICTURE B

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PICTURE C

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OSCE Short Station: DR ABCDE
Overview:
This is a role-play exercise based on the DR ABCDE OSCE station. In a typical scenario, a student
will be asked manage an acutely unwell patient using this format and will then be asked questions
regarding the case. The scenario should take 10 minutes.
Format of the exercise:







Ask one student to be the actor and one to be the OSCE finalist. Provide the actor with their
brief and the student with the scenario instructions (both overleaf).
Ask the student to read the instructions to the group. Check for questions.
The student should proceed to manage the actor – allow 10 minutes only.
The examiner should only volunteer answers to specific questions as detailed below and
should provide examination and investigation findings when specifically prompted by the
student. An ECG has been provided and can be shown to the student on request.
Afterward the scenario is finished, gather feedback. Start with the student then open it up to
the group. Please ensure feedback is constructive. Then provide your own feedback to the
student.
Finally, discuss key learning points. Suggestions for questions to ask the group, a
recommended ‘model answer’ and key discussion points are included overleaf.

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Student brief
To be read out loud by the student to the group
A 66 year old retired lorry driver has been brought in by ambulance to the Accident and Emergency
with acute chest pain. You are the FY1 doctor on call and have been bleeped by the nurses to see the
patient urgently as they are concerned that he is unwell. Please assess the patient and instigate
appropriate management.

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Actor brief
You are a 66 year old man retired lorry driver who has been admitted to Accident and Emergency with
chest pain. You have had sudden onset chest pain, in the middle of your chest and some numbness
in the left arm and jaw. You feel sweaty, nauseous, breathless, and are worried about what is
happening to you. You look uncomfortable.
In terms of your background, you have high blood pressure, high cholesterol, type 2 diabetes, take
little exercise and smoke 30 cigarettes/day. You take amlodipine for your high blood pressure,
simvastatin for high cholesterol and metformin for diabetes. You have a family history of your dad’s
dad dying from a heart attack in his 80’s.
Only volunteer specific information about symptoms and your past medical history when asked the
relevant and specific questions by the student. If any questions cannot be answered with the above
information, please answer “no” or “don’t know”.

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Model answer and scenario results
Danger Safe to approach, no need for gloves or apron, no danger
Response
Initial assessment of patient response
Inspection:
Patient looks pale, sweaty, clammy, in distress, breathless
A

Look, listen, feel: airway patent, talking full sentences but looks uncomfortable and
short of breath, no oral obstruction, no central cyanosis, no medications etc around
the bedside
Act: apply high flow oxygen 15 L via a non-rebreather mask, aiming saturations of
94-98%
Look, listen, feel: RR 25, breathless, talking full sentences
No wheeze/stridor/gargling/cyanosis/gasping/pursed lips/tracheal tug or
deviation/asymmetrical chest movements
On auscultation: clear lung fields, no creps or wheeze
Pulse oximetry: sats 91%
Act: request chest x ray and ABG (results not available yet), continue high flow
oxygen
Look, listen, feel: HR 110bpm, BP 98/63, pale, sweaty
No blood loss or oedema, not cyanotic, JVP normal, sweaty but warm peripheries,
CRT 2 s, auscultation: HS I +II + 0, T: 36.7, UO pending
Act: Request ECG, insert 2 wide bore cannulae into both ante-cubital fossae,
suggest fluid challenge (250mL gelofusin stat or equivalent) and request blood tests
(FBC, U+E, LFT, glc, Trop, blood cultures, VBG)
Results of investigations return as:
1. Bloods: Trop 512 (high), all other results normal.
2. ECG: see below. Ask student to present the ECG (T wave inversion V5-V6
with ST depression V4-6 (main +ve findings))
3. Chest x ray (requested in B) reported as normal
AVPU alert, talking, responding to voice, GCS15/15
Pupils equal and reactive
Glucose: 5.6
Student should offer to fully expose the patient. There are no signs of haemorrhage,
bruising, injury, no gross neurological deficit

B

C

D

E

The focus of assessment and teaching should be on adequate and safe assessment using ABCDE
approach. The student should regularly reassess the patient during this scenario. Results should
improve when compared to their original if you feel the student has initiated the correct management.
During the assessment the student should be able to identify ACS/NSTEMI as the diagnosis. The
ACS protocol should be instigated at appropriate stages as student progresses through initial ABCDE
assessment with regular review to the beginning and seeking help from senior, as outlined below.
1.
2.
3.
4.
5.
6.
7.
8.

Oxygen: aim sats >94%, avoid sats >98%
airway/breathing
Analgesia: morphine 5-10mg iv
circulation
Antiemetic: metoclopramide 10mg iv
circulation
Nitrates: sublingual GTN spray 2 puffs
circulation
Antiplatelet: aspirin 300mg PO stat
circulation
Antiplatelet: clopidogrel 300mg PO stat
circulation
Antithrombin: fondaparinux 2.5mg s/c stat
circulation
Call for help/consider early referral to the cardiologists

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Questions to ask student for viva if time in the scenario/group for discussion:
1. What tests would you request for a patient with ACS (acute and non-acute)?
Bloods: FBC, U+E, glucose, lipids, troponin;
ECG;
CXR;
Echocardiogram – may reveal regional wall motion abnormalities
Consider exercise tolerance tests in those with stable angina and 24 hour tapes for
arrhythmia.
2. What is the medical management for ACS?
As above and see explanations below.
3. What is the definitive treatment for STEMI ACS?
Primary percutaneous coronary intervention.
4. How do you determine the offending coronary artery/branch from the ECG?
Right coronary artery – inferior MI – II, III, aVF; arrhythmia common (supplies SAN)
Left coronary artery – circumflex – posterior infarct (R waves, ST dep in V1-2)
Left coronary artery – LADA – anteroseptal – V1-V2-V3-V4
Left coronary artery – lateral – V4-V5-V6
Combinations of the above also likely
5. What is the long term medical management post-ACS?
Please see explanations below.
6. What are the common side effects of these drugs?
ACE-I: hyperkalaemia, dry cough due to build up of bradykinin (kininogen system)
Aspirin/clopidogrel: gastritis, peptic ulcer disease, GI bleeding; use with PPI
Beta-blockers: bradycardia, avoid with CCBs (bradycardia) and thiazides (increased risk of
diabetes), associated with depression, caution in Raynaud’s syndrome/peripheral vascular
disease
Statins: muscles aches/pains, rhabdomyolysis, beware interactions e.g. clarithromycin
7. What other (lifestyle) advice or referrals would you suggest to the patient?
See explanations below; secondary prevention.

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Additional key ACS learning points for students:
Assessment of risk
Assess risk of future adverse cardiovascular events using an established risk scoring system that
predicts 6-month mortality (Global Registry of Acute Cardiac Events – GRACE) Use GRACE score to
risk stratify for 6 month risk of adverse cardiovascular events
o 1.5% risk or lower: treat conservatively
o

1.5%-3% risk: 300mg clopidogrel, 75mg clopidogrel od for 12 months
Coronary angiography if recurrent ischaemia, whether at rest or provoked
Stress test if no recurrent ischaemia. If ischaemia is induced, arrange coronary
angiography

o

Intermediate (>3.0-6.0%), high (>6-9%) or highest (>9%) risk
300mg clopidogrel, 75mg clopidogrel od for 12 months
Consider tirofiban or eptifibatide (GPIIb/IIIa inhibitors) – need to balance risk of
bleedings vs reduction in ischaemic risk
Coronary angiography+PCI within 96 hours of first admission
Consider abciximab as adjunct to PCI for these groups who are not already receiving
GPIIb/IIIa inhibitors
Coronary angiogram: ASAP if clinically unstable/high risk
Discuss with senior and cardiologist
PCI: single vessel disease (not LCA mainstem)
CABG: multivessel disease
Discuss with surgeon whether to stop clopidogrel 5 days prior to CABG depending on
risk of adverse cardiovascular events

Advanced management
Consider intravenous eptifibatide or tirofiban (GPIb/IIIa inhibitors in early management for patient with
intermediate or higher risk of adverse cardiovascular events in the next 6 months ie GRACE score of
3.0% or more)
Also consider GP IIb/IIIA inhibitors for those who are scheduled to undergo angiography within 96
hours of hospital admission.
Offer coronary angiography, with PCI if indicated, within 96 hours of admission if there is intermediate
or higher risk (predicted 6-month mortality above 3.0%) if they have no contraindications to
angiography (ie active bleeding or co morbidity)
Angiography should be performed as soon as possible for those who are clinically unstable or high
ischaemic risk
Discuss the case with seniors and interventional cardiologist as soon as possible involving the patient
at every step.
If angiography is not performed consider objectively quantifying ischaemia before discharge e.g.
stress test and echocardiogram. If there is evidence of ischaemia, coronary angiogram + PCI should
be arranged.
Patients should be offered advice on diagnosis, secondary prevention, cardiac rehabilitation,
management of lifestyle factors (see below).
Secondary prevention following ACS
Lifestyle advice

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1. Do not take supplements containing beta-carotene or antioxidant supplements (vitamin E
and/or C) or folic acid to reduce cardiovascular risk
2. Consume at least 7 g of omega 3 fatty acids per week from two to four portions of oily fish
If not possible e.g. vegetarians, consider at least 1 g daily of omega-3-acid ethyl esters
treatment licensed for secondary prevention post MI for up to 4 years for patients who have
had a MI within 3 months. Do not routinely initiate omega-3-acid ethyl esters supplements for
patients who have had an MI more than 3 months ago.
3. Encourage patients to eat a Mediterranean-style diet.
4. Offer individual consultation to discuss diet, including their current eating habits, and advice
on improving their diet
5. Advise no more than 21 units of consumption alcohol per week for men or 14 units per week
for women and to avoid binge drinking
6. Encourage regular physical activity to increase exercise capacity, aiming to be physically
active for 20–30 minutes a day to the point of slight breathlessness
If this is not possible, advise to increase activity step-by-step way, gradually increasing
exercise capacity, starting at a comfortable level and increasing duration and intensity as they
gain fitness.
7. Advise to stop smoking, and offer assistance from a smoking cessation service
8. Offer weight loss advice to those who are overweight and obese

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Pharmacotherapy:
ACE-I








Start low, go slow
Start with ACE-I, switching to ARB if ACE-I is not tolerated
Continue indefinitely
Do not use combination of ACE-I and ARB without specialist instruction
Assess LV function in all patients who have had a MI
Measure renal function, U+E and blood pressure before starting ACE-I/ARB and again 1-2
weeks after initiating therapy
Monitor whenever dose is adjusted

Antiplatelets
 Offer aspirin and continue indefinitely (75 mg od)
 Aspirin and clopidogrel should only be continued together for 12 months after NSTEMI unless
instructed by expert other indication for dual antiplatelet
 Aspirin and clopidogrel should only be continued together for 4 weeks after STEMI unless
instructed by expert or other indication for dual antiplatelet
 Aspirin 75mg should continue indefinitely for all STEMI and NSTEMI patients
 Consider PPI if there is a history of dyspepsia
 Risk of MI or death in NSTEMI is determined by signs and symptoms, ongoing ischaemia and
raised biomarkers e.g. troponin I
Beta blockers
 Start as soon as stable, start low go slow
 Continue treatment indefinitely
 If there is known heart failure or LVSD, the beta blocker already prescribed may continue to
be used
 CCBs are not routinely used for secondary prevention, but verapamil or diltiazem may be
considered in those who do not tolerate beta blockers
Statin








Start as soon as stable
For patients intolerant of statins, other lipid lowering agents should be considered
Reduce or stop the dose of statins if there are drug or food interactions or metabolic
disturbances
Discontinue the statin and seek specialist advice if patients develop peripheral neuropathy
due to statins
Measure baseline LFTs before initiating therapy
Do not routinely exclude patients who have raised LFTs from statin treatment
Routine measurement of CK in asymptomatic patients is not recommended unless the patient
develop muscle symptoms

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