Physical examination

** Please note, the information below was written before the OSCE was modified due to COVID.

I have chosen not to replace the entire page as much of it is still relevant. However, you must familiarise yourself with the changes to the Physical Exam stations, as outlined in this ACEM document (Oct 2020).

The conduct of a clinical physical examination is a core emergency medicine skill and as such you should expect this to be assessed in the OSCE.

This is a summary of the ACEM document “OSCE Physical Examination Station Guidelines” (August 2019). The full document is available on the ACEM website and is essential reading.

Aim of the Physical Exam station

The station assesses your ability to competently perform a physical examination to:

  • Establish/clarify the most likely diagnosis from several differentials

  • Establish the severity of a condition/ injury

  • Confirm or exclude potential complications e.g. of an injury

Format of the Physical Exam station

  • You will usually be asked to demonstrate a relevant and focused physical examination on a ‘normal’ role-player with no signs or symptoms.

The role-player does not ‘act’ any pathology, or answer questions about, or describe abnormal findings when they are examined.

  • You should explain every step as you do it, throughout the examination so the examiner knows what you are doing.

Your explanation should include:

- What you are examining for

- What the different potential findings might be/might look like

- What the different potential findings would mean in terms of differential or provisional diagnosis

  • You should perform a focused physical examination as you would ‘at work’.

  • It is important to recognise that both your examination technique and the explanation you give as you go along will contribute to your score in the assessed domains.

  • After you have completed, or as you are performing, the physical examination, the lead examiner will present the ‘Examination Findings’ to you either verbally and/or in a printed handout at a pre-determined stage of the station. This is to assess your ability to synthesise examination findings to produce a provisional or differential diagnosis and to justify your conclusions.

  • Clinical findings may be provided in real time as you are performing the examination, in order to reflect examination findings in the ED. Use these findings to determine your further examination choices.

  • You should not expect to be given findings for something you have not covered in your examination.

  • You may be asked further scripted questions, for example your plans for further investigation or management.

  • You may be asked by the lead examiner to outline your ‘differentials’ before you perform the physical examination. Then you may be asked to ‘Examine the patient to clarify your differential’ or later in the station, asked ‘How would you now examine for your other differentials?’

  • As an alternative, you may be asked to discuss physical exam findings with a registrar, or teach an examination technique. In such stations, there would be no role-player present. You would explain and demonstrate to the confederate the important elements of a relevant focused physical exam, as well as the expected or important findings you are looking for in that clinical situation.

Example physical exam topics from last few ACEM exams:

  • Describe the physical examination technique you would use in the case of an 80 year old male patient with a fractured right humerus.

  • Demonstrate/explain an examination to differentiate between different causes of heart failure.

  • Provide advice to a junior registrar (role player) about the examination of a patient with facial weakness.

  • Lower back pain - immunosuppressed patient

  • Trauma - Cervical spine clearance

  • Acute vision loss

  • Vertigo

  • Facial weakness

  • Shoulder pain and weakness

  • Unsteady gait

Typical tasks

  • Describe how you would perform a relevant and focused examination

  • Outline your provisional diagnosis and a plan for further investigations

  • Outline your general approach to this patient’s assessment

  • Describe a focused examination of the (e.g. right upper limb) including an explanation of what physical findings are being sought

  • Answer further questions from the examiner.

  • Outline to the examiner the focused history you would obtain in order to clinically clear the cervical spine, then demonstrate and explain the focused examination you would perform in response to further clinical information provided.

  • Explain to the examiners what you are doing/looking for as the examination proceeds

  • Outline how other assessment information available in the ED might support a diagnosis.

  • Outline how to clinically diagnose ...(e.g. causes of facial weakness).

  • Discuss with the registrar how to investigate and manage such patients.

  • Demonstrate the key components of a further examination of such a patient, using a normal subject

Domains that have been tested in recent OSCEs

Medical Expertise: Assessment and differential diagnosis

  • Identifies the elements that must be sought on initial assessment to formulate an initial management plan

  • Seeks evidence of time critical diagnoses when performing assessment

  • Generates a relevant list of differential diagnoses after synthesising clinical information found on initial assessment

  • Formulates a provisional diagnosis to match the immediate issues

Medical Expertise: History

  • Elicits a focused, relevant history de novo

  • Identifies important historical details (red flags) diagnostic of an important condition

Medical Expertise - Physical examination

  • Performs a focused structured and relevant physical examination

  • Performs a proficient examination technique to elicit physical signs

  • Describes expected physical signs for a diagnosis

  • Differentiates expected physical signs for different conditions

  • Recognises signs on physical examination that indicate the patient is or at risk of imminent deterioration

Medical Expertise: Investigation and management

  • Creates a focused investigation plan that confirms or excludes time critical diagnoses

  • Explains the reasons for selecting those tests in that investigation plan

  • Initiates treatments specific to identified pathologies

  • Adapts and initiates standard therapies to that patient and creates a safe and clear discharge plan for a patient

Prioritisation and Decision Making - Prioritising patient assessment and management

  • Highlights high-risk features identified during initial patient assessment

  • Explains the rationale for prioritising a particular diagnosis over others

  • Prioritises a differential diagnosis list to determine the most likely diagnoses in a patient

  • Justifies investigation selection by linking the pre-test probability, risk-benefit ratio and availability within a hospital of that investigation to the patient’s need for that investigation

  • Prioritises chosen treatment options to create an appropriate escalating treatment plan

  • Provides a rationale to explain and justify decisions about ongoing assessment/treatment

  • Links clinical information and evidence-based practice to explain decisions made

Scholarship and Teaching

Uses a range of adult teaching strategies from the ACEM Curriculum Framework, including:

  • Checks for level of prior knowledge/ understanding

  • Demonstrates a structured approach to the topic

  • Demonstrates well-paced communication

  • Invites questions and clarifies any areas of uncertainty

ACEM OSCE report feedback

Common themes for candidates who performed well:

  • structured comprehensive answers

  • highlighted the features of their examination that would help distinguish between the key differentials

  • well-structured overview and approach to examination.

  • organised physical examination

  • able to summarise the differentiation between diagnoses and then structure a well flowing examination, pointing out the potential features of each diagnosis

Common themes for candidates who did not perform well:

  • missed high-risk features in the history

  • poor justification of imaging

  • lack of a structured approach

  • not relating the findings to a diagnosis.

  • lack of knowledge and poor organisation.

  • could not adequately explain the rationale behind examination features (e.g. HINTS exam)

  • failed to mention important ‘supportive care’ or did not have a clear, safe discharge and follow up plan.


Remember the key things the examiners are looking for:

  • Your examination must be competent. I.e. you must demonstrate an examination technique which would be expected to reliably detect relevant examination findings.

  • A focused yet thorough ED relevant exam. The examination standard expected is that which a competent FACEM would perform in the workplace, faced with a similar presentation. Candidates are not expected to perform a complete ‘short-case’ type exam. They are assessed on the focused examination they chose to perform to answer the clinical question provided.

  • You must provide an adequate explanation. ‘Did the candidate know what examination findings they were looking for, what these would mean and why they were relevant?’

  • An opening statement is often useful to summarise your differential and provide a structure/objectives for your examination. For example, with information provided in Candidate information, you may open with:

- "In this patient, my differential diagnoses at this stage are…", or "I am concerned about…."

- The aims of my examination are to:

          • Clarify a diagnosis

          • Establish the severity

          • Check for any precipitant eg asthma, heart failure

          • Assess/confirm/exclude the potential complication “blah blah”

  • Maintain dignity and comfort of the patient. Address any pain/ offer analgesia.

  • Consider hand hygiene and PPE

  • There is often a lot to cover in the seven minutes. The lead examiner will manage the flow of the station, moving you along as needed to assist you to complete all stages of the station. Listen carefully to the prompts and instructions. If they attempt to change your direction with a prompt such as ‘What else would you like to examine?’ you should take this as your cue to move on. The examiner will be trying to ensure you have the opportunity to cover all the required areas of assessment.

  • Summarise your findings

  • You will still need to study from Talley and O’Connor for this section of the exam. However, the examination will be a focused one, so you need to adapt the Talley and O’Connor method to one that is practical for the ED. This will mean your physical examination will cross disciplines e.g. a limb exam that involves assessment of neurology, as well as musculo-skeletal & vascular elements. And you need to practise your examinations A LOT so they are slick and you can do them on auto-pilot under stress. Practise on patients, each other, anyone at home. Ask a FACEM to watch you and critique you when you are at work. You probably have not done a formal clinical exam for some time, and probably have some bad habits.