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  • Writer's pictureDeniz Eroglu

PLAB 2 OSCE Practice Series - History Taking (Confusion)



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 (history taking - confusion) student doctor Dr. Ayşe takes history from a 79-year-old confused patient in front of the examiner. The examiner Dr. Ahmed notes that the candidate may improve on targeted history taking skills and should remember to abide by infection prevention and control actions (eg. washing hands). The candidate was successful at requesting investigations and diagnosing.





Student Information


You are a junior doctor working on the medical assessment unit (MAU). A 79-year-old woman was admitted yesterday following a fall, and has deteriorated. A nurse reports she has become increasingly confused and complains of nausea. You are asked to take a history and answer any further questions by the examiner.



To make the PLAB 2 journey easier, the TrewLink Academy has launched its very own PLAB 2 Online and Face-to-Face courses that includes high-quality lectures, SimMan, Mocks, and recordings of each PLAB chapter taught by UK doctors and ex-OSCE examiners. This is an intensive instructor-led coaching programme, covering the highest yield topics and scenarios seen in PLAB 2. History taking, diagnosis, management, communication and counselling stations are all dealt with as well as practical skills. You can now prepare for PLAB 2 at your own pace and in the comfort of your own home, as well as attend our location in Manchester.



Patient Assessment


Opening the Consultation


Doctor - Hello, I am Ayşe a junior doctor working in this unit. Can you please confirm your name and date of birth for me?


Patient- Hi doctor, my name is Sophie Wallace. I was born in 28.08.1943


Doctor - Thank you Mrs. Wallace, today I will be asking you some questions to take your medical history. Is that alright with you?


Patient - Yes, I will try to answer them as best as I can, doctor.



Presenting Complaint


Doctor - How have you been since you came in?


Patient - I’m not sure, I think I feel nauseous.


Doctor - Can you tell me more about what is bothering you?


Patient - I know I had a fall, but everything’s been so muddled the last few hours!



History of Presenting Complaints


Doctor - Can you tell me where we are right now?


Patient - I’m not sure where I am anymore.


Doctor - Can you tell me what day it is?


Patient - What day is it? It’s Tuesday, isn’t it? No, wait, Monday? Or is it Thursday? Oh, I’m usually so good with dates.


Doctor - It’s okay Mrs. Wallace. Can you tell me a bit more about you vomiting?


Patient - I’ve been feeling queasy since last night and I brought up my breakfast this morning. That’s the only time I’ve been sick.


Doctor - What did the vomit look like?


Patient - It was just normal vomit. It didn't have blood in it or anything like that.


Doctor - Let’s talk about the fall. Can you walk me through how it happened?


Patient - I think the floor was a bit wet and I just slipped back and landed on the tiles.


Doctor - When was this?


Patient - Must have been the day before yesterday, I think.


Doctor - What happened after the fall? Did you hurt anywhere?


Patient - Unfortunately the doctors say I broke my left wrist. It hurts when I move it.


Doctor - I’m sorry about that, Mrs. Wallace. Did you hit your head or lost consciousness after the fall?


Patient - Luckily, I didn't bang my head on the way down. I didn’t pass out either.


Doctor - So how did you get to the hospital?


Patient - I was there for a while, but luckily my son found me lying on the floor the next morning.


Doctor - I see you had been lying there for a long time. Do you remember how much urine you passed these last couple of days?


Patient - I hadn't thought about it, but I don't think I’ve really passed much water since my accident.


Doctor - Were you able to walk to the toilet and try to pass urine?


Patient - I know I can ask the nursing team to go to the bathroom but, it's just not much comes out when I do go.


Doctor - What colour is your urine?


Patient - It's really dark, almost dark red.


Doctor - Are your bowel movements normal?


Patient - I last passed stool this morning with no issues.



Past Medical and Surgical History


Doctor - I would like to ask you about your past now Mrs. Wallace. Do you have any known diseases?


Patient - My GP said I have brittle bones since going through menopause.


Doctor - Okay, any other?


Patient - My doctor says I have heart failure. I had a jelly scan for the heart and they said it’s not contracting efficiently.


Doctor - Have you ever had problems with your memory or cognition?


Patient - I’m usually very good with managing my finances and I always remember birthdays.


Doctor - Have you ever had a fall before?


Patient - No, so it came as quite the shock!


Doctor - Do you have any issues with your kidneys?


Patient - Nothing apart from the odd waterworks infections throughout the years.



Drug History


Doctor - Do you take any medications regularly?


Patient - Yes doctor, I have a list.

Shows list ( Risedronate 5 mg OD, Bisoprolol 5 mg OD, Ramipril 1.25 mg OD.)


Doctor - Do you have any known allergies?


Patient - Alendronate gave me oesophagitis so my doctor changed it to risedronate.



Social History


Doctor - Now I will ask you some general questions about your life. Where do you live?


Patient - I live in a bungalow with my cat. I’d just like to get back to her. She must be starving!


Doctor - Do you live with anyone else?


Patient - Not since my husband passed away 7 years ago.


Doctor - I’m sorry for your loss. Can I ask what your occupation is?


Patient - I am a retired teacher.


Doctor - Do you smoke?


Patient - I only smoke 5 a day. I’d say it’s been like that for around 40 years.


Doctor - Do you drink alcohol?


Patient - I drink the odd sherry, but only on a blue moon.


Doctor - Do you need any help mobilising in your life?


Patient - I get around fine usually with my stick.



Family History


Doctor - Does anyone in your family have any significant diseases that come to your mind?


Patient - I can't think of anyone having any medical conditions. My niece has asthma I suppose.



Closing The Consultation


Doctor - To sum up, you had a fall and a long lie before getting to the hospital. You had a broken wrist. You now experience nausea & vomiting and also have a diminished amount of urine. Lastly, you feel confused. Do you feel anything has been missed?


Patient - No doctor that is pretty much it.


Doctor - Thank you for your time, we will plan out a course of action and do some tests to check your kidneys.


Patient - Okay doctor but I think I just need to get my wrist fixed and I’ll be ready to head home soon.


Doctor - We will do our best to get you better.


Patient - I’d really like to go home today if that’s possible.



Candidate Summary


"Today I took history from 79-year-old Mrs. Wallace. She had acute onset confusion and was disoriented to place and time but not self. She was nauseous for 1 day and vomited once. She slipped in the bathroom and fell backwards onto a hard surface 2 days ago. She had a long lie. She had trauma to left wrist with an associated fracture causing sharp pain that's worse on movement. She has passed very little urine since the fall and urine is dark coloured. She didn't have head trauma. She has a history of osteoporosis and congestive heart failure but no known kidney diseases or cognitive impairment. She was independent and mobilised with a stick. She has a 10-pack-year history of smoking. Her family history is unremarkable."


Further clinical examinations/assessments:

  • Abdominal examination with a focus on the kidneys and bladder (e.g. check for urinary retention)

  • Urine dip

  • Bloods: U&Es, creatinine kinase, and FBC

  • Bladder ultrasound



Differential diagnosis for this patient are:

  • AKI secondary to rhabdomyolysis due to a fall with a long lie (most likely)

  • AKI secondary to other causes (e.g. the patient’s ramipril)

  • UTI


Initial management for this patient:

  • Intravenous fluid rehydration

  • Stop nephrotoxic drugs

  • Correct electrolyte abnormalities (e.g. hyperkalaemia)

  • Monitor renal function closely

  • Septic screen



Examiner Summary


Opening the consultation

Candidate did not:


  • Wash hands and don PPE


Candidate did the following well:


  • Introduced themselves to the patient including name and role

  • Confirmed the patient's name and date of birth

  • Explained that they’d like to take a history from the patient

  • Gained consent to proceed with taking a history


Presenting complaint

Candidate did the following well:


  • Used open questioning to explore the patient’s nausea and confusion. Ideally, at least 2 open questions, for example: (”How have you been since you came in?” - ”Can you tell me more about that?”)

  • Identified patient’s oliguria


History of presenting complaint

Candidate did the following well:


  • Asked about the mechanism of fall and identifies the cause as mechanical

  • Determined how the patient fell and any associated trauma

  • Identified that the patient had a long lie after the fall

  • Enquired about pain

  • Explores the history of confusion, nausea, and vomiting

  • Determines the timeline of the confusion, nausea, and vomiting

  • Determines that the oliguria history is acute


Candidate did not:


  • Explore the pain history using SOCRATES (The SOCRATES acronym stands for: Site, Onset, Character, Radiation, Associated symptoms, Timing, Exacerbating and relieving factors, Severity)


Systems review

Candidate did not:


  • Screen for relevant symptoms in other body systems (e.g. weight gain/loss, fever)


Past medical history

Candidate did the following well:


  • Asked about other conditions

  • Enquired about known kidney disease


Drug history

Candidate did the following well:


  • Asked about prescribed and over the counter medications

  • Asked about allergies


Social history

  • Asked about smoking

  • Asked about alcohol

  • Enquired into at-home life/mobility/independence


Closing the consultation


Candidate did the following well:

  • Summarised the salient points of the history back to the patient and asks if they feel anything has been missed

  • Thanked the patient for their time


Candidate did not:

  • Dispose of PPE appropriately and wash their hands


Key communication skills


Candidate did the following well:


  • Active listening - body language (leaning forward, nodding)

  • Summarising

  • Signposting


What further clinical examinations/assessments would you like to perform?


Candidate asked for:

  • Abdominal examination with a focus on the kidneys and bladder (e.g. check for urinary retention) ~ appears clinically dehydrated, abdomen soft non-tender, no palpable bladder. Passing small volumes of urine, appears dark and red in colour


Candidate did not ask for:

  • Excellent students may suggest a delirium screening test (e.g. 4AT)


Describe some appropriate further investigations


Candidate did the following well:

  • Urine dip

  • Bloods: U&Es, creatinine kinase, and FBC

  • Bladder ultrasound

What is your differential diagnosis?


Candidate did the following well:

  • AKI secondary to rhabdomyolysis due to a fall with a long lie

  • AKI secondary to other causes (e.g. the patient’s ramipril)

  • UTI


What is the most likely diagnosis?


Candidate did the following well:

  • AKI secondary to rhabdomyolysis due to a fall with a long lie


Describe the INITIAL management of this patient


Candidate did the following well:

  • Intravenous fluid rehydration

  • Stop nephrotoxic drugs

  • Correct electrolyte abnormalities (e.g. hyperkalaemia)

  • Monitor renal function closely

  • Septic screen



Blueprint Based Assessment

Domain.1 Knowledge, Skills and Performance:


The candidate had good targeted history taking skills. May improve on asking more questions.


The candidate was able to request relevant investigations.


The candidate was successful at diagnosis.


Domain.3 Communication, Partnership and Teamwork


The candidate had good communication skills with the patient.



Good luck!


If you have any questions about PLAB 2, I would be happy to answer them at trewlink.com.


For more Mock scenarios join our PLAB 2 academy and attend our monthly live sessions as well as watch previous recordings.


Source: Geeky Medics https://geekyquiz.com/





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