MD How to do better on clinical reasoning for osce?

[taeyeonlover]

I did not perform too well on my school’s osce so the faculty wants me to do it again. It looks like I did well on interviewing and physical exams but I came up with wrong diagnoses/differentials based on what I have learned from my standardized patients during the interview.

Are there any good resources out there that teach you how diseases typically present in patients?
(ex : tuberculosis : hemoptysis, weight loss, night sweats, cough
heart failure : exertional dyspnea, peripheral edema etc.)


This is my biggest weakness and is holding me back so I would love some advice.

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[mrbreakfast]

Buy an old copy of first aide for step 2 CS (not CK) and go through that. A decent portion of CS was coming up with differentials on the spot.

You can also map out differentials for different symptoms/symptom combinations to make sure you're hitting the big ones consistently - e.g. to use your example, a patient with hemoptysis, weight loss, and cough might have TB, but that's probably going to be the wrong answer on the OSCE.

Other than that, consider how you study in general. Many people rely on Anki-style apps for instant associations - X is treated with Y, W shows Z on histology, etc - but you need to also be prepared to answer open-ended questions (mentally or literally) like "tell me everything you know about pancreatitis." If your study method isn't getting you there, you might switch things up.

 

[operaman]

You’re basically asking about the very crux of clinical medicine. It’s expected that you’re not quite up to speed yet - it takes years to get really good at this.

My guess is that you’re looking at it backwards. Trying to memorize how every condition presents and then matching that up to your patient’s story is a fool’s errand and not how any doc thinks.

Instead, practice building a differential based on the story. You can Google mnemonics for building a ddx and just pick whichever one works for you. So for your hemoptysis, fevers, night sweats example-

TB is certainly on the list. So are plenty of other infections.
Various cancers are on the list (lung, H&N, lymphoma, etc)
Autoimmune stuff like PAN, GPA
EtOH withdrawal could do it
Etc
Etc

Based on the story you can usually rank them in order of likelihood. Practice building ddx based on common symptoms. Nobody is giving med students true head scratchers, so practice the obvious ones like chest pain, SOB, DOE, belly pain, back pain, blood in stool/urine, altered mental status, fever, etc. For any of those you should be able to rattle off a nice long list. Then you refine the list based on the history and your exam.

Ideally you should already have a sense of the diagnosis before you even open the door. The cc alone should clue you in on what to expect and that’s usually given to you on the chart. I never walk in a clinic room now without knowing what I’m probably going to find and you shouldn’t either.


The step 2 CS book suggestion above is gold btw. There really are a finite number of ways that patients present on exams. They can dress things up all they want but they can’t change what’s fundamentally true.