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 28 y/o gentleman patient who presents with abdominal pain.
Student Information
You are an FY2 doctor working within the Emergency Department.
Your next patient is Mr. Adam Smith, a 28-year-old gentleman who has attended to discuss his abdominal symptoms.
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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, I'm Adam Smith, and my DOB is 6/12/1995.
Doctor: How can I help you today?
Patient: Hi, I have been experiencing severe pain in my lower right abdomen for the past day, along with nausea and vomiting.
Doctor: I see; can you describe the pain for me?
Patient: It's a sharp pain that started near my belly button, and then moved to my lower right abdomen. It hurts more when I move or cough.
Doctor: Have you noticed any fever or chills?
Patient: Yes, I have been feeling feverish, and I also have the chills.
Doctor: Alright, have you experienced any changes in your appetite or bowel movements?
Patient: I don't feel like eating anything, and I haven't been able to pass stool since yesterday.
Doctor: Have you noticed any blood in your stool or any other unusual symptoms?
Patient: No, I haven't noticed anything like that.
Doctor: Where exactly is the pain located? Can you point to the area?
Patient: (patient points to the lower right side of his abdomen)
Doctor: Okay, have you had any surgical procedures in the past?
Patient: No, I haven't had any surgeries.
Doctor: Do you take any regular medication, and do you have any allergies?
Patient: I take paracetamol occasionally, and I'm not allergic to any medications.
Doctor: Do you have any family history of medical conditions?
Patient: No, there isn't any significant medical history in my family.
Doctor: Can you tell me a little bit about your lifestyle and social circumstances?
Patient: I don't smoke, but I drink occasionally. I work as an accountant and I live with my girlfriend.
Doctor: Thanks. I wanted to ask what your thoughts are as to what might be going on?
Patient: I’m not sure, I thought maybe it’s something I ate perhaps that didn’t agree with me but I haven’t eaten out or changed my diet or anything.
Doctor: Did you have any thoughts as to how we could help you today?
Patient: Ideally just to get to the bottom of what’s causing the pain. It’s not been nice at all.
Doctor: Of course, you’re in the best place. Can I get you anything for the pain?
Patient: No I’m ok for now Doctor.
Doctor: Alright, in order to work out what is going on then I'd like to perform a physical examination to check for any signs of tenderness or swelling in your abdomen. I’d also like to check your temperature. Heart rate, oxygen saturations, and urine. Would that be okay?
Patient: Yes, please go ahead.
On examination:
Doctor performs a physical examination, checking for tenderness and swelling in the patient's abdomen. Doctor also checks for rebound tenderness, guarding, and rigidity. Doctor also checks blood pressure, oxygen saturations, temperature, heart rate and random blood sugar. Urine dip is also checked.
Result = Rebound tenderness in the lower right quadrant. Bowel sounds present.
BP 103/78, HR 106/min, Temp 37.4 deg C, oxygen saturations 99% (air). Urine dip normal. Random glucose 4.3 (normal).
Doctor: Based on my examination, I suspect that you may be experiencing appendicitis. This is an emergency condition that requires urgent medical attention. The appendix is a small organ that is attached to the large intestine, and when it becomes inflamed, it can cause severe pain, nausea, vomiting, and fever.
You need to be admitted into the hospital immediately for further evaluation and management. It’s likely you will require a CT scan or an ultrasound to confirm the diagnosis. In most cases, appendicitis requires surgical removal of the appendix, which is called an appendicectomy. This is done under general anaesthesia. The surgical team will go through this in more detail if appendicitis is confirmed.
In the meantime, I will arrange for some blood tests, including a full blood count, inflammatory markers (CRP and ESR), as well as liver function tests, urea and electrolytes as well as random glucose. This will help us monitor your condition and guide your treatment.
Please do not eat or drink anything until you are seen by the surgical team. Do you have any questions or concerns?
Patient: No, I understand. Thank you for your help, Doctor
Student Summary
"Mr Smith is a 28-year-old gentleman who presented to the emergency department with right lower abdominal pain that started a day ago. She reports that the pain is sharp and constant and has worsened since it first started. She also reports nausea and decreased appetite. He has no history of similar symptoms. He has no known medical conditions, takes no regular medications, and has no known allergies. He works as an accountant. Physical examination reveals tenderness and guarding in the right lower quadrant of her abdomen. His temperature is 37.4°C, he is slightly tachycardic at 106/min with the rest of his observations within normal range. I suspect he has appendicitis and would need admission under the surgical team for further investigations, likely consisting of an USS or CT abdomen."
Examiner Summary
Data Gathering and Technical and Assessment Skills:
• Candidate elicits a focused history of the patient's presenting complaint.
• Candidate asks about the onset, duration, and nature of the patient's pain.
• Candidate asks about associated symptoms, such as nausea and appetite changes.
• Candidate performs a thorough physical examination, including palpation of the abdomen.
Mark: A (excellent), B, C, D, or E (fail)
Clinical Management Skills:
• Candidate recognizes the possibility of acute appendicitis and orders appropriate investigations, such as blood tests and imaging.
• Candidate discusses the need for urgent surgical consultation and treatment.
• Candidate provides appropriate pain relief and monitors the patient's vital signs.
Mark: A (excellent), B, C, D, or E (fail)
Interpersonal Skills:
• Candidate shows empathy and concern for the patient's symptoms.
• Candidate explains the need for urgent intervention clearly and calmly.
• Candidate maintains professional boundaries and ensures patient dignity and privacy.
Mark: A (excellent), B, C, D, or E (fail)
Overall Mark:
• A (excellent) if the candidate demonstrates competence in all areas.
• Fail if the candidate does not accurately identify the potential diagnosis, fails to order appropriate investigations or provide appropriate management options, or lacks professionalism or empathy.
Discussion:
• This case highlights the importance of prompt recognition and management of acute appendicitis, a common surgical emergency.
• The candidate should be able to elicit a focused history and perform a thorough physical examination to aid in diagnosis.
• Timely referral for surgical consultation and appropriate pain management are crucial for the patient's well-being.
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