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 on Differential Diagnosis student, Dr. Dany, assesses a 63 y/o gentleman patient who presents with difficulty swallowing and presents a differential diagnosis.
Student Information
You are an FY2 doctor in general practice.
Please take a history from this 63 y/o gentleman, provide a short differential diagnosis and explain your management plan. This patient presents with difficulty swallowing.
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Patient Assessment
Doctor: Good morning, my name is Dr. Dany and I am a junior doctor. Can I please confirm your name and date of birth?
Patient: Hi Dr Dany, I am John Smith and my DOB is 12/5/1960.
Doctor: Thank you. Can you please tell me what brings you to the clinic today?
Patient: I've been having difficulty swallowing food and water for the past 12 months.
Doctor: I see. Can you tell me more about this difficulty swallowing? What happens exactly?
Patient: It feels like the food is sticking on the way down. I think it is getting worse, last year it was only really occurring with solids, but now it appears to also happen when I have liquids.
Doctor: And does this happen every time you swallow food or water?
Patient: Yes, it happens consistently.
Doctor: Have you noticed any other symptoms along with the difficulty swallowing?
Patient: Yes, in the last month, I have been vomiting after eating. But there's no blood in the vomit. I also have an intermittent dull ache in my stomach.
Doctor: Have you experienced any changes in your bowel movements?
Patient: No, my bowel movements are normal.
Doctor: I see. Have you noticed any changes in your appetite or weight?
Patient: Yes, I have lost two stones of weight over three months. Also, my appetite is decreasing because I simply don’t want to eat.
Doctor: Thank you for that. Can you tell me more about your past medical history?
Patient: I have had hypertension and heartburn for more than 10 years. Also, I had gallstones in the past.
Doctor: Do you currently take any medication?
Patient: Yes, I take Gaviscon four times a day to try to help and I take amlodipine 10mg once daily for hypertension.
Doctor: I see. Have you had any surgeries in the past?
Patient: Yes, I had my gallbladder removed about 10 years ago.
Doctor: Do you have any family history of medical conditions?
Patient: Unfortunately, I don't know as I'm adopted.
Doctor: Can you tell me a little bit about your lifestyle and social circumstances?
Patient: I smoke 20 cigarettes per day and have been for the past 35 years. I don't drink alcohol. I work as a hospital porter, and recently I have been feeling more fatigued at work. I have had to reduce my shifts and work part-time as I am feeling. I am divorced and live alone.
Doctor: I see. Before we conclude, is there anything else that concerns you, or do you have any expectations regarding your condition?
Patient: Primarily, I think it's bad heartburn, and I need better medication. However, I am also worried that it may be more serious and would like any dangerous diagnoses to be ruled out.
Doctor: I understand. Is there anything else you think I should know?
Patient: No, that’s everything, doctor.
Doctor: Mr. Smith, based on your symptoms of difficulty swallowing and the other information you have provided, I would like to proceed with some further tests to determine the cause of your symptoms. These tests will include blood tests as well as a camera test which will help us to identify any abnormalities in your oesophagus. We will also take biopsies during the camera test to help with diagnosis and exclude any dangerous causes.
We will discuss what happens next once we have the results of the tests and have made a diagnosis.
In the meantime, try to avoid large meals, eat slowly, and chew your food thoroughly.
If you experience any worsening of your symptoms or develop new symptoms, such as chest pain or difficulty breathing, please go directly to the hospital. Do you have any questions or concerns about the management plan?
Patient: No, all understood.
Student Summary
“Mr. Smith is a 63-year-old male presenting with consistent and progressive dysphagia over the past 12 months with difficulty swallowing both solids and liquids. Of concern, the patient has also lost two stones of weight over three months and has a dull ache in the epigastric region. Mr. Smith has a long history of heartburn and hypertension for which he is taking regular gaviscon and amlodipine. He also had a cholecystectomy ten years ago. He has no known family history of medical conditions. He is a smoker with a 35-pack-year history and is struggling to perform at work due to fatigue.
Mr. Smith is concerned that it may be more serious than just heartburn, and he would like dangerous diagnoses to be ruled out.
My differential diagnosis is:
Oesophageal carcinoma.
Oesophageal stricture
Achalasia or other dysmotility disorder
To further investigate I would like to perform a physical examination and order the following investigations:
Blood tests: Full blood count, urea and electrolytes, hba1c, LFTs, amylase.
Invasive tests: Endoscopy.
The most important test, in this case, is endoscopy and I would arrange this urgently to exclude cancer. Further tests such as barium swallow and manometry can be considered following a clear endoscopy."
Examiner Summary
Example Mark Scheme: Dysphagia.
The candidate will be assessed on the three following domains and be given a mark for each ranging from 1 - 4 (1 = fail and 4 = excellent).
Data gathering technical and assessment skills:
History taking:
Elicits red flags of progressive dysphagia and weight loss
Takes appropriate full history and elicits risk factors such as smoking
Physical Examination:
General examination: Cachexia/Jaundice. Vital signs. Weight/BMI.
System-specific examination: Abdominal
Investigations:
Provides an appropriate investigation plan.
Blood tests: Full blood count, urea and electrolytes, hba1c, LFTs, amylase
Radiology: Barium swallow
Invasive procedures: OGD (urgent referral), manometry.
Clinical Management Skills:
Differential Diagnosis:
Gives 2 or more differential diagnoses.
Oesophageal carcinoma is present in the differential.
Communicating with patient:
Able to explain the need for referral to exclude cancer.
Formulating a management plan:
Arranges 2ww or urgent referral / discusses with senior colleague.
Recognises urgency and need for referral / urgent discussion with a senior colleague.
Interpersonal Skills:
Communication Skills:
Establishes and maintains rapport with the patient
Initially uses open questions and progressively uses closed questions when appropriate to pull out specific/important information that is pertinent to the presenting complaint.
Elicits ICE effectively
Able to explain sensitively the need for urgent referral to exclude cancer.
Discussion:
This case of progressive dysphagia highlights some of the crucial principles being tested in PLAB2.
Safety - The candidate was able to correctly identify the concerning symptoms of progressive dysphagia with constitutional symptoms of malignancy (weight loss) as well as a significant risk factor (smoking). In this case, oesophageal carcinoma is the most dangerous diagnosis and steps were taken to urgently rule it out.
Communication skills - The candidate communicated clearly with the patient and was able to explain the management plan in a simple-to-understand manner whilst also ‘safety-netting’ the patient.
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