Candidate

Instructions

The patient in the next room is Earl, who is 66 years old. He has presented reluctantly to your practice
after pressure from his wife who thinks she has noticed a change in one of the moles on his back over
the past few months. You have been given this patients past medical history. You are not expected
to ask any further history from this patient

You have 8 minutes to discuss with the examiner three (3) differential diagnoses, these should be the
most likely diagnoses.

You should include at least two (2) positive and two (2) negative features of this history, other than
those listed above, which support or refute your diagnoses.

You should expect the examiner to ask questions around your reasoning.

TASKS

Differential diagnoses with reasoning 8 minutes










Year 2 OSCE Practice 2011
Set 2, Clinical Reasoning Station

History of Presenting Complaint

Earl - a 66 year old male.
Occupation Dairy farmer.
Social Hx Lives with wife on farm in small town 3 hrs West of Toowoomba. 2 sons and 1 daughter,
all adults and living several hours away, good relationship frequently visit.
Drug/alcohol smoker 40 pack year Hx. Drinks carton of beer every 2 weeks. Nil recreational drugs
Presenting complaint Wife noticed change in mole on back over past 2-3/12.
Story
Always had lot of moles since childhood.
Several weeks ago wife mentioned possible change in mole on back.
Not sure if mole was long standing or new, had never noticed before.
Felt mole was getting darker and possibly bigger.
Earl has not noticed anything, resistant to go see Dr.
States I have dozens of the things Doc, had them for years, I dont think this is any different
Has not noticed any pain or itching of mole.
Has had no recent temperatures or sweats.
As not complained of any weight loss.
Very active and busy on farm, some concerns with getting more tired and finding the work harder,
puts this down to getting old.
Has had several skin lesions excised in the past, most have come back as solar elastoses and IEC. 2
lesions returned as low grade SCC and one BCC.
Had a course of Efudex (5-fluorouracil) cream for Rx of sun damage on face ~10 years ago
completed course but did not like it due to pain and discomfort.
Has worked on dairy farm entire life except 2 years of National Service at age 20 where he was sent to
Vietnam.
Rarely, if ever, wears sunscreen though usually wears hat outdoors.
He completed high school education to Grade 10 before beginning work on the farm.
He is still very active on the farm and gets a lot of physical activity though his work.
He feels his diet is good, his wife usually cooks and he claims to get his 5 vegetables and 2 fruit/ day.
He has had his vaccinations from his national service, and a tetanus booster after a dirty cut ~ 15
years ago.
He has not been overseas except for his national service and a visit to family in England ~10 years ago.
Both parents are deceased, mother died of breast cancer at age 70 and father of lung metastases
from an unknown primary at age 69.
Has one brother who is in good health at age 70.

Year 2 OSCE Practice 2011
Set 2, Clinical Reasoning Station

General Health
He feels his general health is good, he is active and not often sick.
Inspection
Generally well looking elderly male in o obvious distress.
Pale skin with multiple naevi distributed across face, arms and torso.
Extensive solar skin damage over face and arms.
Lesion
Pigmented, papular lesion, firm to palpation.
Diameter = 6x10mm

Year 2 OSCE Practice 2011

Set 2, Clinical Reasoning Station

Past Medical History:

Meds

Telmesartan

Multiple skin lesions excised: solar elastoses, SCC

and BCC.

Allergies /ADRs
Nil known

HTN - 2001

Obstetric History
N/A
Past Surgical History:

Family History:

Appendicectomy aged 8 yrs old

Both parents deceased:

Mother age 70 Breast ca

Immunizations :

Father age 69 lung mets, unknown primary.

From national service

Tetanus booster - 1996
Lifestyle

Demographics

Smoking 20/day 40 pack year Hx

Occupation

Alcohol carton full strength beer/2 weeks

Dairy farmer

Diet normal

Living arrangements

Exercise good

lives at home on rural farm with wife

Hobbies fishing

Family

Pets 2 dogs, lots of cattle

3 adult children, 1 older brother.

Year 2 OSCE Practice 2011
Set 2, Clinical Reasoning Station

 Instructions to Examiners

The patient in the next room is Earl, who is 66 years old. He has presented reluctantly to your practice
after pressure from his wife who thinks she has noticed a change in one of the moles on his back over
the past few months. The candidate has been given this patients history.

The candidate has 8 minutes to discuss 3 differential diagnoses, including positive and negative
features of this history which support or refute their diagnoses.

Conduct of this station

Ensure the candidate understands the tasks he/she has to do.

The candidate is expected to discuss 3 possible differential diagnoses- citing at least two (2)
positive and two (2) negative points in the patients history, other than those listed above,
that support or refute their choices.

They are expected to have a balanced reasoning, and have prioritised the most likely
diagnoses.

They should be able to justify their reasoning with questions, if required- they are expecting
some questioning from the examiners.

If the candidates appear to have chosen an unlikely diagnosis- please ask them to justify their choice.

Prompting the candidate for another diagnosis is permitted to allow them opportunity to discuss a
more likely diagnosis.

TASKS
Differential diagnoses with reasoning 8 minutes

Year 2 OSCE Practice 2011

Set 2, Clinical Reasoning Station

Differential Diagnoses
1. Superficial Spreading Melanoma
Positive

Change in pigmented lesion

Hx of fair skin and multiple naevi

Hx of extensive sun exposure/damage and minimal protection

Hx of previous skin cancers

Possible family Hx in father.

Lesion asymmetry, irregular border, variegated colour, diameter > 6mm.

Negative

Unsure if lesion new or long standing

Has not noticed change himself

No pain/itching or systemic symptoms

2. Nodular Melanoma
Positive

As above.

Negative

As above.

Non-nodular pattern of growth

3. Dysplastic Naevi
Positive

As above

No systemic symptoms.

Negative

As above

No other dysplastic naevi

Potential family Hx of melanoma.

Year 2 OSCE Practice 2011

Set 2, Clinical Reasoning Station

4. Seborrheic keratosis
Positive

Rapid growth over past 2-3 months.

Change in pigmented lesion

Negative

No itching

Has not noticed change himself

Lesion does not appear hyperkeratinised

5. Pigmented Basal Cell Carcinoma

Positive

Change in pigmented lesion

Hx of solar damage and previous BCC

Negative

Significant atypical appearance

Lack of typical BCC architecture

Rapid growth/change.

6. Traumatised naevus
Positive

Hx of multiple naevi

Atypical appearance darkening (haemorrhage into lesion)

Negative

Painless lesion

No Hx of trauma to naevus given.

Suspicious of melanoma.

Year 2 OSCE Practice 2011

Set 2, Clinical Reasoning Station

MARKING


Examiners are asked to grade students performance on a scale of 0 - 4 in the areas on the mark sheet
in capitals. The standards for awarding these grades are;

0 = Unequivocal fail:

Student was unable to demonstrate history or examination skills

without significant prompting, OR displayed unethical or unprofessional
behaviour.

1 = Marginal fail:

Student lacked a comprehensive approach, and/or needed considerable

prompting to complete the task.

2 = Borderline pass:

Student performed a systematic examination or history but did not

complete some components in a number of areas of the marking guide.

3 = Clear pass:

Student had a systematic approach, required little or no prompting, was

confident and completed most components of the marking guide.

4 = High pass:

Student had a high level of proficiency, well above what would be

expected of a student in Year 2.

Examiners are required to make an overall judgement about the students performance in each area
on the marking sheet. The specific items listed are there to remind examiners about issues which
might be considered. It is not intended that these items should rigidly translate into a score.
It would be helpful, particularly when feedback is being given to poorly performing students, if there
is some notation in the comments column. Also examiners may find it helpful, when considering what
grade to award, to have indicated in the comments column when items were omitted or when
prompting was required.
Global Score. This mark does not form part of the students overall mark. The score should reflect the
students empathy and overall performance, and is from the examiners perspective only.
Year 2 OSCE Practice 2011
Set 2, Clinical Reasoning Station

Feature
General

Comment

Score (please circle)

Organised summaries of diagnoses

Appropriate diagnoses chosen
Prioritises diagnoses
Clear communication for presentation
Differential diagnosis ONE
Most likely and reasonable diagnosis

Appropriate supportive points

Appropriate negative points
Differential diagnosis TWO

Reasonable diagnosis

Appropriate supportive points

Appropriate negative points
Differential diagnosis THREE

Reasonable diagnosis
Appropriate supportive points
Appropriate negative points
Adequate Reasoning
Balanced reasoning

Shows understanding of diagnostic

signs with questioning

Pass Mark = 15/20




Pass/ Fail (Circle as appropriate)

Comments (essential if the candidate has failed the station)





Global Impression- from examiners only- score 0-4

Year 2 OSCE Practice 2011

Set 2, Clinical Reasoning Station