ACEM example: Low back pain OSCE added anonymously 

You have 3 minutes reading time. This OSCE will run for a maximum of 7 minutes.


55 year old man presents with four week history of low back pain. He has come to the emergency department today because the pain is not getting better. He has a GP but could not get an appointment.
Please take a history from the patient

Instructions for the candidate

You are required to take a history from tha patient. You will not be required to examine the patient. Having taken the history you should explain to the patient your differential diagnosis and what investigations will be required as well as your anticipated disposition.

Domains being examined

  • Medical Expertise
  • Prioritisation And Decision Making
  • Communication
  • Professionalism
The candidate has 3 minutes reading time. This OSCE is expected to run for a maximum of 7 minutes.

For the actor

You are a 55 year old teacher (maths). You live with your wife. You have one son who is no longer at home. He is studying economics at university. You have had a bowel resection five years ago for bowel cancer, but on review last year you were given the “all clear”. You have had surgery but no other treatment. You had your colostomy closed two years ago.
You are otherwise well, non smoker, no allergies, no family history, no other illnesses.

The pain came on after minor exercise, working in the garden and cutting down a tree 4 weeks ago.
You have not had a fall or any other trauma.
It has been a dull ache but keeping you awake at night. The pain is localised to the lower back in the mid-line and does not radiate. In particular it does not go down you legs.
The pain has been gradually getting worse. It is now severe enough that you are having trouble sleeping. You have been taking regular Nurofen which worked initially but is no longer effective.
You have had no urinary or bowel symptoms.
You have had no fevers and have not felt “unwell”.
You have no pain or numbness in your legs, although you have been noticing an increasing dull ache in your buttocks.
You are worried about the possibility of cancer recurrence but have been not wanting to face this possibility.
You have been reluctant to come to the hospital about this for fear of the potential bad outcome.
Answer questions as asked by the candidate, but do not volunteer information unless it is specifically asked for.

For the examiner

The candidate should take a history and then discuss his differential diagnosis with the patient. They should in particular enquire about “red flags” such as fever, weight loss, trauma, malignancy.
You are to observe only. There should be no interaction between you and the candidate.
If the candidate is not permorming the required task they should be prompted to “re-read the task description” which will be available in the room.

Domains Assessment Objectives

Medical Expertise
Need to enquire about all “red flags” in particular should ask about cancer history. Should recognize that the pain is getting progressively worse.
Should recognize that the main concern is for metastatic cancer and that specific imaging is needed.
May suggest plain film today.
CT today, possible MRI later. Blood tests today -
U&E’s FBC, Ca, Mg, PO4
ESR, CRP (Maybe)

Prioritisation And Decision Making
Should decide that this is a potentially serious presentation which warrants urgent imaging.

Should take a thorough history and then present the findings in a logical clear way to the patient.
They should make it clear that there is a need for further investigations as it is possible that the cause of the pain is cancer recurrence. They should ensure that the patient has clearly understood.

The candidate should provide the information to the patient in a caring compassionate respectful way.

Other Assessment Notes

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