How to formulate management plans in OSCEs

A brief guide to answer the question 'What would you like to do next?' or 'What is your management plan?' in exams, but also a good checklist to go through when coming up with plans for an actual patient.

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Always start off by saying you would take a full history or perform a physical examination if this is not a combined station (i.e. you already did the examination yourself), followed by investigations and treatment. If you are doing an A-E assessment, some of these should be done as you detect the problem, e.g. administer O2 if hypoxic, IV fluid bolus if hypotensive and always mention you would return later to re-assess.

Investigations

Bloods

• FBC, U&Es, CRP, LFT for everyone

• Usually no need to justify these, but if they specifically ask, generally applicable reason would be: FBC and CRP to look for signs of infection (can cause problems in any organ system), U&E and LFT in case you may need to alter drug doses

• Sometimes particular aspects of these routine bloods may be important, in which case you should mention your reasoning

• E.g. platelet count in bleeding, potassium in AKI, ALP in biliary diseases

• Bone profile (which includes ALP, calcium, and phosphate levels)

• For back pain e.g. multiple myeloma (hypercalcaemia)

• Part of confusion screen (hypercalcemia)

• Refeeding syndrome (hypophosphatemia)

• Magnesium

• Part of confusion screen (hypomagnesaemia)

• Refeeding syndrome (hypomagnesaemia)

• Coagulation screen (includes PT, aPTT and INR)

• For any bleeding conditions

• For conditions potentially requiring surgery (e.g. appendicitis)

• Before commencing LMWH (need baseline in case of heparin induced thrombocytopenia)

• Group and save

• For any bleeding conditions (crossmatch if decompensating/major haemorrhage)

• For conditions potentially requiring surgery

• Troponin (depends on local guidance and assay used, but will require serial measurements)

• For any chest pain

• Amylase

• For any abdominal pain particularly upper abdomen

• Thyroid function tests

• Part of confusion screen (hyper/hypothyroidism)

• Change in bowel habit, weight changes, menstrual changes

• Blood cultures

• For any presentation which shows infective symptoms or signs

• Blood gas for quick results

• VBG is useful for most conditions and is part of sepsis 6- mainly looking at lactate and acid-base balance

• ABG for any acute respiratory condition- mainly looking at degree of hypoxia, and whether CO2 is retained

• Vit B12 and folate

• Part of confusion screen

• Macrocytic anaemia

• Specialised bloods (non-exhaustive list, tailor to specific presentations)

• Autoantibodies e.g. for rheumatoid arthritis

• Iron studies prior to transfusions and for iron overload/deficiency

• D-dimer for DVT/PE with low pre-test probability (to rule out a clot)

• Prolactin for menstrual changes

• LDH for haemolysis or to calculate Glasgow-Imrie score for pancreatitis

Imaging

• CXR

• Any cardiorespiratory complaint

• Erect film for pneumoperitoneum

• Confusion screen

• AXR (rarely useful, think twice!)

• ?obstruction

• ?swallowed foreign object

• CT head

• Head injury (specific guidance here)

• Suspected stroke (to exclude haemorrhage)

• Suspected space occupying lesion

• Consider for confusion screen

• CTPA

• PE if high pre-test probability, or raised D-dimer on testing

• Venous doppler

• DVT if high pre-test probability, or raised D-dimer on testing

• USS

• Gallbladder -good first-line test for gallstones and cholecystitis, can reveal dilated CBD but often not the location/size/number of calculi- will need MRCP

• Appendicitis- may be able to diagnose appendicitis, but not exclude it, useful for younger patients

• Trans-abdominal and trans-vaginal for PV bleed or suspected gynae issues

• Kidneys- can look for hydronephrosis

• FAST scan

• Trauma cases in A&E – looking for pericardial/peritoneal fluid

• AAA

• CT abdomen/pelvis

• Any abdominal pathology if unable to diagnose clinically or from USS

• If diagnosis is confirmed but can help plan surgery (e.g. identifying site of perforation even if pneumoperitoneum already confirmed on erect CXR)

• CT KUB

• Gold standard for kidney stones

• CT angiograms

• Aorta- aortic dissection/AAA

• Limb- acute ischaemic limb

• Echocardiograms

• Valvular disorders

• Infective endocarditis (trans-oesophageal)

• Heart failure

Misc. tests

• Urine dip +/- culture (always send for culture in >65yo, dip alone is unreliable)

• Any abdo pain (+hCG if female)

• Part of confusion/septic screen

• ECG

• Any cardiorespiratory conditions

• Epigastric pain especially if hx inconsistent with GI/urinary pathology, think inferior MI!

• LOC/syncope- consider need for 24-hour monitor

• Lying/standing BP

• Falls

• Dizziness/LOC/syncope

• Capillary glucose

• Part of A-E (hence any acute presentation, but specifically important in LOC/seizures)

• Capillary/urinary ketones

• Hyperglycaemia

• For severe vomiting

Treatment

• Analgesia for any pain

• Anti-emetic for any nausea or vomiting

• O2 for any hypoxia/SOB

• IV fluid for

• Low BP/sepsis- as bolus

• Maintenance- Vomiting/to be kept NBM

• Specific regimes (need a lot more)- DKA/HHS/pancreatitis

• Antibiotics (according to local guidance)

• IV for most acute infective conditions

• Examples of specific treatment (non-exhaustive list)

• ACS- MONAC (morphine, oxygen, nitrates, aspirin, clopidogrel) +- fondaparinux +- thrombolysis +- PCI

• Asthma- O2, back to back neb bronchodilators (SABA and SAMA), IV hydrocortisone, IV magnesium ->escalate to ITU for theophylline and intubation

• Heart failure- POD MAN- position upright, oxygen, diuretics, morphine, anti-emetic, nitrates

• DKA- fixed rate insulin infusion, serial BMs, VBG and ketones, IV fluids

Examples

You have just taken a history of patient with cardiac sounding chest pain, likely ACS.

“My working diagnosis is acute coronary syndrome. I would like to perform a physical examination of the patient, especially the cardiorespiratory system. I would like to obtain a full set of observations. I would order routine bloods, FBC, U&Es, LFTs and CRP, and also include serial troponins to confirm diagnosis and monitor trend of rise, and coagulation screen as a baseline prior to commencing anticoagulation medications, and request an ECG and CXR. As the patient is outside the window for PCI, I would prescribe morphine for the pain, and commence treatment with nitrates and dual antiplatelets. Oxygen will be started if the patient is hypoxic. I would then refer the patient to the acute medical/cardiology team for further management.”

You have just examined a patient with abdominal pain with RIF tenderness and guarding, likely appendicitis.

“My working diagnosis is acute appendicitis. I would like to take a full history from the patient and obtain a full set of observations. I would order routine bloods, FBC, U&Es, LFTs and CRP, amylase to exclude pancreatitis and also include a group and save and coagulation screen as the patient will potentially require surgery. I would also like to perform a urine dip for UTI (note: sometimes blood and leukocytes may be positive in appendicitis as it irritates the ureter, but nitrites would still be negative in most cases). Given the patient is relatively young, I would request an ultrasound scan of the abdomen and pelvis and consider a CT abdomen/pelvis depending on the results. I would prescribe analgesia, anti-emetics and IV fluids and antibiotics, keep the patient nil by mouth and refer the patient to the surgical team for further management.”

Useful resources

1. The Easy Guide to Focused History Taking for OSCEs by David Mccollum (good set of focused questions categorized by presenting complaint)

2. The OSCE Revision Guide for Medical Students by Christopher Mansbridge (especially the acute management section)