Differentials
| What might it be? | What might I find? | |
|
Acute Coronary Syndrome |
RF: known IHD/angina, diabetes, HTN, obesity, smoking, hyperlipidaemia, ↑age, male, family hx.
Central constricting chest pain lasting >15 minutes with onset at rest; associated with nausea, vomiting, sweating, SOB, pain radiation to neck/jaw/arms, palpitations, feelings of doom. ECG changes including ST elevation, new LBBB, T-wave inversion, ST depression, path Q-waves. |
|
|
Acute Pulmonary Oedema |
RF: known chronic heart failure, aggressive IV fluids, MI, arrhythmias, sepsis, acute hypertension.
Acute onset shortness of breath, patient feels very unwell, acute cough w/frothy pink/white sputum. Tachypnoea, tachycardia, hypoxia, ↑ work of breathing, bilateral basal crackles, 3rd heart sound. CXR changes: upper lobe diversion, fluid in septal lines & interlobar fissures, pleural effusion(s). |
|
|
Unstable SVT |
Triggers: stress, positional change, alcohol, caffeine, smoking, recreational drug use, medications.
Palpitations, symptoms of unstable SVT e.g., syncope, chest pain, heart failure, haemodynamic compromise |
|
|
Cardiac Arrest |
Reversible causes: thrombus, tension pneumothorax, toxin, tamponade, hypoxia, hypovolaemia, hypothermia, hyper-/hypo- kalaemia, natraemia, glycaemia (and other metabolic upset).
Lack of response to stimulus, lack of normal breathing pattern, lack of pulse. |
|
|
Acute Asthma Exacerbation |
RF: poor control, NSAID/Beta Blocker, infection, trigger exposure e.g., dust, cold, allergen, emotion.
Acute onset progressively worsening shortness of breath, wheeze, ↑work of breathing, tachypnoea. Acute severe: peak flow 33-50% best, respiratory rate >25, pulse >110, unable to speak sentences. Life threatening: peak flow <33% best, SpO2 <92%, PaO2 <8 kPa, tiring, confusion, silent chest. ABG: initial resp. alkalosis (tachypnoea ↓CO2); progression to normal pCO2 & ↓pO2 is concerning. |
|
|
Acute COPD Exacerbation |
RF: poor control, ongoing smoking, trigger exposure e.g., infection.
Acute onset cough, wheeze, shortness of breath, purulent sputum production. Tachypnoea, ↑work of breathing, unable to complete sentences, pyrexia (if infective). ABG typically respiratory acidosis & type 2 respiratory failure, CXR may show underlying infection. |
|
|
Pneumothorax |
RF: tall, thin, young male, chest trauma, procedure e.g., lung biopsy, underlying asthma/COPD.
Sudden onset pleuritic chest pain and shortness of breath. CXR: area between lung & chest wall w/ no lung markings; tracheal deviation towards ptx (if tension). |
|
|
Pulmonary Embolism |
RF: immobility, recent surgery, pregnancy, long-haul travel, oestrogen-containing hormone therapy, cancer, obesity, smoking, SLE, polycythaemia, thrombophilia, previous DVT or PE.
Sudden onset shortness of breath, pleuritic chest pain, haemoptysis, DVT signs e.g., leg swelling. Tachypnoea, tachycardia, hypoxia, hypotension (if significant haemodynamic instability). |
|
|
Acute CO2Retention |
RF: COPD, sleep apnoea, obesity, neuromuscular disorder, sedation.
Acute onset confusion, reduced GCS, reduced respiratory rate, tachycardia, flapping tremor, flush. ABG: type 2 respiratory failure – pCO2 > 6 kPa & pO2 <8 kPa. |
|
|
Acute Abdomen |
Acute onset significant abdominal pain +/- peritonism. Presentation depends on underlying cause. Causes include: acute cholecystitis, acute appendicitis, ruptured ectopic pregnancy, peptic ulcer, pancreatitis, ruptured AAA, bowel obstruction, ischaemic colitis, diverticulitis, renal colic, pyelonephritis, acute urinary retention, pelvic inflammatory disease.
Peritonism: guarding, rigidity, rebound tenderness, percussion tenderness; may be local/generalised. |
|
|
Upper GI Bleed |
RF: peptic ulcer disease, NSAID use, smoking, stress, persistent vomiting, mallory Weiss tear, alcohol related liver disease, oesophageal varices, upper GI malignancy.
Haematemesis, coffee ground vomiting, malaena, haemodynamic instability. |
|
|
Hypoglycaemia |
RF: insulin, hypoglycaemia inducing oral medication e.g., gliclazide, intercurrent illness, ↓ oral intake.
May be unaware, if aware patients feel unwell, sweaty, shaky, dizzy. Confusion and LOC if severe. Capillary blood glucose <4.0. |
|
|
Diabetic Ketoacidosis |
RF: undiagnosed T1 diabetes, poor adherence to insulin, intercurrent illness e.g., infection.
Polyuria, polydipsia, thirst, nausea, vomiting, dehydration, abdominal pain, weight loss, confusion. Capillary blood glucose raised or un-recordable, blood ketones > 3, pH < 7.3. |
|
|
Acute Stroke |
RF: previous stroke, AF, HTN, diabetes, hyperlipidaemia, carotid artery stenosis, smoking, obesity.
Sudden onset asymmetrical neurological symptoms are typical e.g., limb weakness, facial weakness, plus slurred speech, vision changes, sensory change, unsteadiness, loss of co-ordination, vertigo. |
|
|
Seizure |
RF: known epilepsy, brain or head injury, post-stroke, brain tumour, medication change, alcohol withdrawal, trigger exposure e.g., infection, flashing lights, sleep disturbance.
Generalised tonic-clonic (limb jerking, tongue biting, incontinence); focal/partial (speech, memory, emotion, behaviour); myoclonic seizures (sudden, brief muscle contraction); tonic seizures (sudden increase in muscle tone); atonic seizures (sudden loss of muscle tone); absence seizures (episodes of blank staring not responding to stimuli or surroundings). |
|
|
Intracranial Bleed |
RF: risk of falls, head injury, anticoagulation, bleeding disorder, aneurysm, ischaemic stroke, HTN.
Acute onset headache, seizure, vomiting, reduced GCS, focal neurology e.g., limb weakness. |
|
|
Anaphylaxis |
RF: known allergies, previous anaphylaxis, atopy.
Allergic reaction signs (urticaria, itch, angio-oedema) with life-threatening compromise to airway, breathing, circulation e.g., shortness of breath, wheeze, stridor, tachycardia, hypotension, pre-syncope or syncope. |
|
|
Sepsis |
RF: immunocompromise e.g., age < 1 or > 75, diabetes, chemotherapy, steroids, pregnancy, post-op.
Signs of infection e.g., cough, cellulitis, LUTS plus derangement of heart rate, respiratory rate, temperature blood pressure oxygen saturations and conscious level, urine output. Septic shock: mean arterial pressure < 65 mmHg, serum lactate > 2. |
|
|
Opiate Toxicity |
RF: iatrogenic, opiate dependence, intentional overdose.
Reduced GCS, airway compromise e.g., snoring, low respiratory rate, hypoxia, pinpoint pupils. |
|
Checklist
| Preparation | Wash – Name – Explain | |
| Position patient appropriately for examination | ||
| Request most recent observations and patient documents | ||
| Focused History | Brief history of presenting complaint | |
| Collateral history (if appropriate) | ||
| Past medical history | ||
| Drug history | ||
| Known allergies | ||
| What management has been tried so far? | ||
| Airway | Airway patency – ability to speak | |
| Stridor | ||
| Lip/tongue swelling | ||
| Evidence of airway obstruction | ||
| Breathing | Colour | |
| Ability to complete sentences | ||
| Respiratory rate | ||
| Respiratory effort | ||
| Oxygen saturations | ||
| Tracheal position | ||
| Chest wall inspection | ||
| Chest expansion | ||
| Chest percussion | ||
| Chest auscultation | ||
| Circulation | Colour | |
| Pulse – rate, rhythm, volume | ||
| Peripheral skin temperature | ||
| Capillary refill time | ||
| Blood pressure | ||
| Heart auscultation | ||
| JVP | ||
| Fluid status | ||
| Disability | GCS | |
| Pupil size & reactivity | ||
| Capillary glucose | ||
| Focal neurological exam of cranial nerves/limbs | ||
| Pain | ||
| Exposure | Temperature | |
| Abdominal palpation | ||
| Skin, rashes, bruising | ||
| Pedal oedema | ||
| Calves for signs of VTE | ||
| Clues in bed space | ||
| Reassess | Re-assess as appropriate after intervention | |
| Finishing | Re-cover patient | |
| Wash hands |
Explanation
Preparation
Wash, name, explain:
- Wash your hands
- Introduce yourself by name and role
- Check the patient’s name and date of birth
- Explain the task and get consent
“Hello, I’m one of the doctors. I’m going to ask you a couple of questions and briefly examine you to understand what’s going on. Would that be okay?”
Your preparation approach will vary depending on the patient’s stability, assessed from the end of the bed. For example, if the patient is sitting up and talking, it may be appropriate to use a phrase similar to the above. However, if you have significant immediate concerns from the end of the bed such as the patient being unconscious or showing signs of airway compromise, you may need to adapt your approach and prioritise urgent intervention.
In an OSCE scenario, remember to introduce yourself to the examiner. In real-life emergencies, always state your name and role to ensure the team knows who you are. For example, “Hello, I’m Dr Smith, FY1. How can I help?”.
Make sure to ask for and review the patient’s hospital records, including recent observations and documents such as the drug chart, admission clerking, most recent ward round entries, and escalation status/ceiling of care. In an emergency, it can be tempting to overlook this step and dive straight into assessing the patient. However, by doing so, you may miss some crucial pieces of information:
- Have the patient’s observations and Early Warning Score changed significantly?
- Has medication given or omitted today contributed to this acute illness?
- Was there a plan made on admission or during the ward round by the patient’s parent team for what to do if the patient deteriorates?
- Is there a ceiling of care for this patient, e.g., are they for escalation to HDU/ICU, or are they for CPR?
Focused History
A focused history in an acute OSCE station needs to be brief, concise, and informative. You are asking questions that will determine what you do next in this station and guide your examination and management of this patient. Really think about whether the answer to a question fits that criteria before you ask it, as you don’t have time for a full history.
If the patient is unable to give you a history, e.g., they are confused or unconscious, it is useful to gather a focused collateral history from someone who was present when the event happened, e.g., a relative, ward staff, etc.
You need to know:
- What has happened?
- When did it start?
- Has it happened before?
- What has been tried so far, and has it worked?
Take a focused past medical history e.g., “do you have any health problems?” as well as a brief drug history, e.g., “do you take any regular medications?” and “do you have any allergies to any medications?”. You can also find this information in the patient’s documentation.
Include a small amount of focused social history if applicable e.g., if assessing an elderly or frail patient. This is an important part of managing an acute scenario for your seniors, as it will help to establish the ceiling of care, the appropriateness of escalation to intensive care, and discussions surrounding resuscitation (CPR).
Airway
Assessing an acutely unwell patient’s airway is the first and most critical step of an A-E assessment. If an issue is found with the airway, e.g., visible obstruction or snoring; intervention is required, e.g., use of an airway adjunct. The patient should then be reassessed following the intervention. You should not move on to the next part of your A-E assessment until you are satisfied that the patient’s airway is clear or has been secured.
The quickest and simplest way to assess a patient’s airway is by observing the patient speaking. Asking the patient “Are you alright?” Or “Can you tell me what has happened?” will prompt them to answer your question. If the patient is able to speak, you can be reassured that their airway is patent and clear, and you can move on to the next part of your assessment.
Signs of possible compromise to the airway on assessment include:
- Stridor – a harsh whistling inspiratory sound caused by air being forced through an obstruction of the upper airway
- Snoring – gurgling sounds associated with partial airway obstruction
- Angioedema – lip or tongue swelling often associated with allergy or anaphylaxis
- Visible airway obstruction – look inside the mouth to check for obstruction, e.g., vomit, a foreign body
Airway compromise is a medical emergency and will likely require senior medical and anaesthetic support. If you are concerned about a patient’s airway, call for senior help early.
Intervention may include:
- Removing visible airway obstruction (only if safe and easy to do so – do not attempt if this would push the obstruction further into the airway), e.g., with suction or a gloved finger
- Performing airway manoeuvres e.g., head tilt, chin lift
- Inserting an airway adjunct e.g., nasopharyngeal airway or iGel
Breathing
Once the airway has been assessed as patent or has been secured, you will move on to assess the patient’s breathing.
Check the patient’s latest observations or review any continuous monitoring:
- Respiratory rate – normal range is 12-20 breaths per minute. Tachypnoea (fast respiratory rate) may be a sign of respiratory distress, sepsis, hypoxia or hypercapnia (high blood CO₂). Bradypnoea (slow respiratory rate) may indicate toxicity, e.g., opiate overdose, or a neurological issue.
- Oxygen saturation – normal range is 95-100%. Oxygen saturation <94% indicates hypoxia and requires management with supplemental oxygen titrated to maintain saturations >95%.
Of note, some patients with conditions such as COPD may have chronically low oxygen levels. Target oxygen saturations in these patients are set at 88-92% but this decision should be made by a senior clinician. If in doubt, always treat a hypoxic patient with oxygen in an emergency and escalate to a senior clinician for review.
Look at the patient to assess:
- Colour – cyanosis (blue discolouration of the skin), either centrally at the lips/tongue or peripherally at the fingertips, indicates hypoxia.
- Ability to complete sentences – inability to speak in full sentences indicates respiratory distress.
- Respiratory effort – is the patient working hard to breathe e.g., using accessory muscles, sitting forward, pursed lip breathing? Increased work of breathing is another indicator of respiratory distress.
Assess the tracheal position by applying gentle pressure between the clavicles. A central trachea is normal; deviation may occur towards a collapse or away from an effusion or tension pneumothorax.
Expose the patient’s chest. Inspect the chest wall for the following: subcostal or intercostal recession (increased work of breathing), flail segment (rib fractures), bruising (trauma/rib fracture), or asymmetrical chest movement (pneumothorax, pleural effusion, pneumonia, rib fracture).
Examine chest expansion feeling for symmetry of movement on both sides of the chest. Ask the patient to breathe out, then place your hands palms-down on patient’s chest with thumbs touching in the midline. Ask the patient to take a deep breath in and observe your hands; thumbs should move apart symmetrically. Asymmetrical movement is pathological, as outlined above.
Percuss the front and back of the chest, starting at the apices, comparing right and left sides. Continue percussing at intervals down to the level of the axilla. Percussion notes indicate the following:
- Resonant – normal
- Dull – consolidation, collapse, mass
- Stony dull – effusion
- Hyper–resonant – pneumothorax
Auscultate the front and back of the chest from the apices to the axilla, in the same areas as you percussed, comparing right and left sides before moving on. Assess the following:
- Presence of breath sounds – absence indicates pneumothorax
- Character of breath sounds – vesicular (normal) or bronchial (consolidation)
- Presence of added sounds – wheeze, crackles, stridor, pleural rub
- Pattern of added sounds – inspiratory or expiratory
Intervention may include:
- Correcting hypoxia by giving supplemental oxygen
- Correcting bronchospasm by giving bronchodilators (e.g., salbutamol)
Circulation
Check the patient’s latest observations or review any continuous monitoring:
- Pulse – a normal pulse rate is 60-100 beats per minute. Tachycardia (fast pulse rate) can be a sign of sepsis, dehydration, arrhythmia, pain, or pulmonary embolism; bradycardia (slow pulse rate) may be caused by medication (e.g., beta blockers), or conduction problems (e.g., heart block).
- Blood pressure – normal blood pressure will vary for an individual but is generally considered to be between 90/60 mmHg and 120/80 mmHg. Hypertension (high blood pressure) in an acute setting may be caused by pain or stress but may also be a cause of the acute condition, e.g., ACS, acute stroke. Hypotension (low blood pressure) is an indicator of shock (septic, hypovolaemic, cardiogenic, neurogenic).
Assess the rate, rhythm and volume of the radial pulse (carotid can be used instead). Is the pulse regular (normal) or irregular? If irregular, is the patient known to have a condition such as atrial fibrillation, or is this a new, acute arrhythmia? Is there a good volume to the pulse or is it weak and thready (hypovolaemia)?
Assess the hands for peripheral skin temperature and appearance. Cool, mottled, or blue–tinged peripheries are a sign of poor perfusion and possible hypovolaemia. Assess capillary refill time at the fingertip by pressing down on the skin for 5 seconds and checking how long the tissue takes to re–perfuse (>2 seconds is prolonged and indicates hypovolaemia).
Auscultate the patient’s heart to assess for murmurs or added sounds. A new murmur in an acutely unwell, febrile patient may indicate infective endocarditis, whereas a 3rd heart sound in a breathless patient may indicate cardiac failure.
Assess the volume status of the patient; are they dry or overloaded? A hypovolaemic patient may be tachycardic and hypotensive, with dry mucous membranes, increased capillary refill time, and reduced skin turgor. A fluid–overloaded patient may be tachypnoeic, with pedal oedema, a raised JVP, and bibasal crackles on chest auscultation.
Intervention may include:
- Correcting hypovolaemia with an IV fluid challenge (caution in elderly/frail/history of cardiac failure)
- Correcting fluid overload with IV furosemide
- Correcting any new arrhythmia will likely require senior support; so call for help early
Disability
Assess the patient’s level of consciousness using either the AVPU score (A – alert, V – responding to verbal stimulus, P – responding to painful stimulus, U – unresponsive) or the Glasgow Coma Scale (GCS). The GCS is assessed as follows, with a best possible total score of 15/15. The best response in each category is recorded:
- Eye opening (E) – spontaneous (4), to verbal stimulus (3), to painful stimulus (2), no response (1)
- Verbal response (V) – orientated (5), confused (4), inappropriate words (3), incomprehensible sounds (2), nil (1)
- Motor response (M) – obeying instructions (6), localises to pain (5), withdraws from pain (4), flexion to pain (3), extension to pain (2), no response (1)
Assess the patient’s pupils for size, symmetry and reactivity. A normal pupil size is 2-4 mm in bright light, and the size should be symmetrical. Shine a light into each eye in turn and observe the patient’s direct (pupil constriction in the eye light is being shone into) and consensual (pupil constriction in the opposite eye in response to light) pupillary reactions.
Miosis (constricted pupils) can be a sign of opiate toxicity. Mydriasis (dilated pupils) may indicate drug toxicity if symmetrical, or brain injury, stroke or infection If unilateral and fixed.
Check the patient’s capillary blood glucose (CBG). This is a key test that is often overlooked and is especially vital if the patient is confused, drowsy, or has any neurological deficit as hypoglycaemia can mimic acute stroke. Hypoglycaemia (<4 mmol/L) can be caused by infection, dehydration or medication (e.g., insulin). Hyperglycaemia (varies by individual but usually >7 mmol/L fasted or >11 mmol/L random) may be a sign of infection, DKA, or HHS.
Perform a brief, focal neurological examination of the patient’s cranial nerves, upper limbs, and lower limbs. The purpose of this is examination is to find any focal neurological deficit, e.g., weakness or sensory loss, which may indicate acute neurological pathology (e.g., acute stroke).
Assess whether the patient is in any pain, e.g., acute abdominal pain, chest pain or pleuritic pain. Intervention to manage pain may correct other parameters (eg. tachycardia).
Intervention may include:
- Correcting hypoglycaemia with PO/IV glucose and long-acting carbohydrate
- Correcting any suspected toxicity, e.g., opiate toxicity with the available antidote (e.g., naloxone)
- If a patient is GCS <8, this is a good indicator that anaesthetic support will be required, so escalate early to a senior
Exposure
Lastly, exposure (or everything else!). Ensure you have examined every part of the patient that may provide useful information to help diagnose and manage their acute illness, including skin, abdomen, legs, back, indwelling lines or devices, and any clues in and around the bed space.
Check the patient’s temperature – a normal temperature is 36.5-37.5°C. Hyperthermia (high temperature) may be caused by infection, heat exposure, or inflammation; hypothermia (low temperature) may be caused by cold exposure or sepsis.
Examine the patient’s abdomen for any distension (is pregnancy a possibility?), swelling, wounds, bruising, pulsation (AAA?), or masses. Palpate the abdomen, feeling for pain or masses as well as for signs of an acute abdomen, including peritonism, guarding, rigidity, rebound tenderness or percussion tenderness. Listen for bowel sounds: are they present (normal), absent, or tinkling (obstruction).
Look at the patient’s skin for any rashes (blanching, non-blanching), cellulitis, bruising, or wounds. Inspect any wounds for signs of infection or dehiscence.
Look at any indwelling lines or devices (e.g., catheters, stomas, cannulas, tunnelled lines, drains). Are they draining as they should be? Is there any surrounding redness or pus indicating infection at the site? Are any infusions running that need to be stopped (e.g., IV fluids, drugs, blood, insulin pump)?
Examine the patient’s legs for any pitting oedema (indicative of fluid overload/cardiac failure), cellulitic skin, signs of VTE (unilateral red, hot, swollen calf).
Look for any other clues in the bed space (e.g., vomit bowls, medication packets, walking aids, cigarettes, alcohol bottles).
Intervention may include:
- Correction of hyperthermia by removing clothing/blankets, giving paracetamol or NSAIDs
- Correction of hypothermia by adding blankets, or giving warmed IV fluids
- Managing any infection (e.g., cellulitis, cloudy purulent catheter urine) with IV antibiotics
- Manage suspected VTE by giving anticoagulation
- Removing any infected lines, unblocking any blocked devices (e.g., catheter)
- Stop any offending infusions
Reassess
It is vital to reassess after any intervention to determine whether the abnormal parameter or finding has normalised. If there has been no improvement despite intervention, calling for senior support is recommended.
Finishing
Thank the patient and allow them to cover themselves. Wash your hands.
Depending on the examination findings, you may wish to organise investigations such as blood gases, blood tests, take samples for culture, ECG, x-ray, ultrasound, or CT scan. If you have not already done so, call for senior help.
Last updated Jan 2025
Head to members.zerotofinals.com for practice OSCE stations, including an interactive checklist, specific cases and clinical findings.
How to Learn Medicine Course