Trial OSCE exam: 'micks osce exam paper' by Michael Devlin

You are taking part in a trial exam created by Michael Devlin. There are 18 OSCEs in this exam including 1 double stations (190 minutes).
 

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

Scenario:

A 65 year old man has arrived vomiting blood. Prior to seeing the patient, you look through the medical record and find the following information from an unrelated visit several months ago:

Allergies: none

Medications:
Apixiban
Metoprolol

PMH:
Hepatitis C
Atrial Fibrillation
Hypertension

Today, his vital signs are:
T 37 BP 85/40 P 100 RR 12 O2 sat (room air) 94%


The nurse hands you a venous blood gas showing:

pH 7.29
pCO2 40
PO2 36
Hgb 70
Na 135
K 4.2
Lactate 3.2


Instructions for the candidate

Please take a history only (you are not expected to examine the patient) and discuss with the patient your anticipated further investigation/management steps.

Domains being examined

  • Medical Expertise
  • Communication
  • Health Advocacy
 
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 65 year old man who called the paramedics because you started vomiting blood this morning. You’ve never had this happen before. You vomited a large amount of blood this morning before breakfast – it made a mess all over the kitchen.

If asked, you’ve had normal bowel motions without any obvious blood or other unusual feature. You have no abdominal pain and have felt quite healthy recently.

You’ve had atrial fibrillation in the past and were started on apixiban and metoprolol by your GP last year to help treat this. You found out several years ago that you had Hepatitis C, are not sure where you got it from, and haven’t been told that you’ve had any problems with this.

You are a Jehovah’s Witness and your religion mandates that you refuse to have any blood transfusions (other treatment are acceptable). Even if the candidate provides good reasons for you receiving blood, you will still refuse transfusion (even if you are told you will die).

You are concerned and scared about the bleeding.

Some questions to ask (if not already addressed by the candidate):

“Is this a stomach ulcer?”

“Are there any other treatments?”

“Do I need to call my partner?”

“Am I doing to die?”

For the examiner

Domains Assessment Objectives

Medical Expertise
-Adequate history
-Explanation of appropriate differentials (must mention liver disease/varicies)
-Explanation of further medical treatments (should mention tranexamic acid, octreotride and/or terlipressin)
-Recognition of role of NOAC and lack of utility for fresh frozen plasma/clotting factors
-Referral to ICU and gastroenterologist (or anyone who can do emergent endoscopy)

Communication
-Introduction to patient
-Verbal clarity, conciseness, specificity – at level for patient to understand
-Explanation of findings, further treatment, and prognosis

Health Advocacy
-Recognition of patient’s religious beliefs and creating a treatment plan to take that into consideration (early endoscopy, avoid blood transfusion, more aggressive use of medications)

Other Assessment Notes