TrewLink's OSCE examination series provides a guide to how students may approach specific OSCE stations, and how they may be evaluated by an OSCE examiner.
In this OSCE on Differential Diagnosis student, Dr. Dany, assesses a 45 y/o gentleman patient who presents with headaches.
Student Information
You are an FY2 doctor in general practice.
Your next patient is Mr John Jones who is a 45-year-old gentleman who has attended to discuss his headaches.
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Patient Assessment
Doctor: Good morning, my name is Dr. Dany and I am a Foundation year 2 Doctor working at the practice. Can I please confirm your name and date of birth?
Patient: Hi Dr Dany, I am John Jones and my DOB is 12/1/1983.
Doctor: Thank you. Can you please tell me what brings you to the clinic today?
Patient: I've been struggling with my headaches recently
Doctor: I see. Can you tell me a bit more about your headaches?
Patient: I have suffered with migraines for many years, since childhood, but over the past day or two they have become much worse.
Doctor: How have they become worse? Can you give me a bit more detail?
Patient: Yes, normally they occur over just above my right eye but over the past few days the pain has been at the back of my head. Usually I get around 1 migraine per month, and I tend to be able to sleep it off or if I take painkillers early on, then I am able to control the pain. With this new pain however, my usual painkillers are not working.
Doctor: Does the pain move anywhere?
Patient: No, usually, when I have my normal migraines the pain stays over my right eye/forehead. In that way, the new pain is similar to my usual migraines in that the pain does not move from the back of my head. It is more severe however.
Doctor: Have you experienced any other symptoms such as vomiting or visual disturbances?
Patient: Normally when I get my usual migraines, I see a funny wavy sensation for around 15 minutes or so but since my headaches have changed, I have been seeing double at times. I have also vomited a few times today which is unusual for me. My bowels are fine so I didnt think it would be gastroenteritis or anything.
Doctor: Can I ask if your headaches have been waking you up at night and have you had any injuries or falls recently?
Patient: Yes, I have woken up over the past few days with a headache, there have been no falls or injuries.
Doctor: Can you describe the character of the pain, and does anything help?
Patient: The headaches are like a really dull ache at the back of my head.
Doctor: Where would you rate the pain out of 10, with 10 being the worst pain you have ever experienced and 1 being no pain at all?
Patient: I would say my usual headaches are around 5 out of 10 which settle with paracetamol and my sumatriptan tablets, but this new headache is around 9 or 10 out of 10. Nothing really helps. It almost feels like some has hit me at the back of my head.
Doctor: I am sorry to hear you have been having such difficulty with your symptoms, it must be very difficult for you.
Patient: Yes, it is. I just cannot get comfortable to try and remove the pain.
Doctor: Does anything make the pain worse such as sneezing or coughing?
Patient: Not that I have noticed, no
Doctor: We will certainly try and help to get to the bottom of things and try and improve your symptoms.
Doctor: Can you tell me about your medical history – do you have any medical conditions?
Patient: Other than migraines, no. I am usually fit and well.
Doctor: Have you ever had any surgical procedures?
Patient: Yes, I had my gallbladder removed 10 years ago.
Doctor: Do you take any regular medication and do you have any allergies?
Patient: I only take paracetamol and occasional sumatriptan tablets when I get my usual migraines. I do not have any allergies.
Doctor: Do you have any family history of medical conditions?
Patient: Unfortunately, I don't know as I'm adopted.
Doctor: Can you tell me a little bit about your lifestyle and social circumstances?
Patient: I do not smoke or drink alcohol. I work as an IT support worker. I live by myself.
Doctor: I see. Before we conclude, is there anything else that concerns you, or do you have any expectations regarding your condition?
Patient: Primarily, I think a bad migraine, and I think I need stronger painkillers. However, I am also worried about my vision, I was thinking about seeing an optician.
Doctor: I understand. Is there anything else you think I should know?
Patient: No, that’s everything, doctor.
Doctor: Mr. Smith, based on your symptoms I would like to examine you. I am going to check your blood pressure, heart rate, temperature, as well as the main nerves from your brain as well as some tests on your arms and legs.
On examination:
Blood pressure: 230/124
Temperature: 37.1
Pulse rate 95
Oxygen saturations 98% (air)
Cranial nerves 2-12 grossly intact
Fundoscopy – few small haemorrhages
Upper limb and lower limb neurological examination normal
Doctor: Thanks. Having examined you Mr Smith, and based on your symptoms of a severe headache with visual disturbance, the headaches waking you from your sleep, and that your blood pressure is very high, I am concerned there may be something more serious going on that might be more than your usual migraines
Patient: What do you think it is Doctor, and what are the next steps?
Doctor: With your symptoms there is a possibility of a possible bleed at the back of your head, called a subarachnoid haemorrhage. I think it is very important to investigate what is causing your symptoms, and in order to do that, we will need to admit you to hospital today via ambulance. You may go on to have a head scan and possibly some further tests. Is this ok and do you gave any questions?
Patient: Yes Doctor, thank you, no further questions.
Student Summary
“Mr. Jones is a 45-year-old male presenting with a 2-day history of persisting occipital headache described as a dull ache, with associated diplopia, vomiting and hypertension. He rates his pain as 9-10/10 in severity with no exacerbating or relieving features. He has a background of chronic migraines, which are usually controlled with analgesia and of frequency of once a month. The headache he has presented with is different in character and presentation when compared to his previous migraines.
He takes occasional sumatriptan or paracetamol at the onset of his usual migraines. He has had a previous cholecystectomy 10 years ago with no other medical conditions other than longstanding migraines. He does not have any allergies. He is an IT support worker and lives alone.
Mr. Smith is concerned that it may be a more pronounced migraine, but given the red flag features of diplopia, change in character of his headache, the headaches waking him from his sleep, pain score, vomiting, significantly raised blood pressure and fundoscopy findings on examination, I am concerned about a possible sub arachnoid haemorrhage. I would like to admit Mr Jones to hospital via ambulance for consideration of CT/MRI head as well as consideration of a lumbar puncture and blood tests.
Examiner Summary
Example Mark Scheme: Headache
The candidate will be assessed on the three following domains and be given a mark for each ranging from 1 - 4 (1 = fail and 4 = excellent).
Data gathering technical and assessment skills:
History taking:
Elicits red flags of vomiting, change in nature of headache compared to usual migraines, characterises pain to that typical of SAH.
Takes appropriate full history
Physical Examination:
General examination: Blood pressure, pulse rate, neurological examination, temperature, oxygen saturations, fundoscopy
Investigations:
Provides an appropriate investigation plan. Recognises acute admission via ambulance required.
Blood tests: Full blood count, urea and electrolytes, hba1c, LFTs, amylase
Radiology: CT head/MRI
Invasive procedures: Lumbar puncture possibly required
Clinical Management Skills
Differential Diagnosis:
Aware subarachnoid haemorrhage needs to be excluded and admission to hospital required to do this.
Communicating with patient:
Able to explain the need acute admission.
Formulating a management plan:
Arranges urgent admission to the Emergency Department
Interpersonal Skills
Communication Skills:
Establishes and maintains rapport with the patient
Initially uses open questions and progressively uses closed questions when appropriate to pull out specific/important information that is pertinent to the presenting complaint.
Elicits ICE effectively
Able to explain sensitively the need for urgent admission.
Discussion:
This case of an acute change in headache presentation in the background of chronic migraines, highlights some of the crucial skills that would be required by a Doctor at FY2 level.
Safety - The candidate was able to correctly identify the concerning symptoms of diplopia, waking with headaches, high pain scoring as well as vomiting and the acute nature of the pain. The candidate was aware of abnormal clinical examination findings. In this case, a SAH is the acute diagnosis that needs to be investigated, and steps were taken to urgently rule it out via admission to hospital.
Communication skills - The candidate communicated clearly with the patient and was able to explain the management plan in a simple-to-understand manner.
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