Station Title: Physical Examination of Secondary Hypertension
Time Allowed: 10 minutes (2 minutes reading time + 8 minutes performance)
Assessment Focus: Physical Examination Skills, Clinical Reasoning, and Patient Communication.
Learning Objectives
- Perform a systematic cardiovascular examination with a focus on hypertensive complications.
- Integrate specific screening maneuvers for secondary causes of hypertension (The “TRACKPADS” approach).
- Communicate clinical findings and a provisional diagnosis to a young patient using lay language.
- Demonstrate strategic time management within an OSCE setting.
Patient Profile
- Name: Mr. Liam O’Connor
- Age: 25 years old
- Ethnicity: Caucasian
- Occupation: Software Developer
- Social History: Non-smoker, drinks 1–2 standard drinks on weekends. Occasional gym use.
Presenting Complaint
Liam was referred by a GP after a blood donation screening revealed a blood pressure of 160/100 mmHg. He is asymptomatic but concerned about the “high number” at his age.
Contextual Information
- History of Presenting Complaint (HPC): No headaches, visual changes, palpitations, or snoring. No history of daytime somnolence.
- Past Medical History (PMH): Nil significant. No history of childhood renal issues.
- Medications: Occasional Ibuprofen for tension headaches. No herbal supplements or illicit drug use.
- Family History: Father has “mild” high blood pressure (managed by diet); no history of early stroke or kidney disease.
Candidate Instructions
Setting: General Practice Clinic
Task: 1. Perform a focused physical examination to identify potential end-organ damage and screen for secondary causes of hypertension.
2. Briefly explain your findings and provisional diagnosis to Liam.
3. Note: You do not need to take a full history. An examiner may “skip” certain parts of your exam to save time; follow their instructions if they do.
Standardised Patient (SP) Instructions
- Demeanour: You are slightly anxious because you feel “perfectly healthy” and don’t understand why your BP is high.
- Physical Findings (Simulated): * You are fit and do not have a “moon face” or “neck hump.”
- When the candidate checks your mouth, open wide (Mallampati Score is low/normal).
- If they ask to feel your pulses or listen to your abdomen, cooperate fully.
- Key Question: If the candidate finishes, ask: “Doctor, does this mean I’ll be on tablets for the rest of my life, or is there a reason this is happening?”
Key Clinical Findings (For Examiner)
- Vitals: BP 160/100 mmHg (confirmed), Pulse 72 bpm (regular).
- General: No Cushingoid features, no striae.
- Pulses: No radio-radial or radio-femoral delay.
- Eyes: No AV-nicking or papilledema (Grade 0 Retinopathy).
- Neck: JVP not raised; no carotid bruits.
- Heart/Lungs: Apex beat non-displaced; no heaves/thrills. S1, S2 heard; no murmurs. Lungs clear.
- Abdomen: No renal bruits; kidneys not palpable.
- Limbs: No peripheral edema.
Assessment & Marking Guide (Examiner Checklist)
| Assessment Domain | Critical Steps / Competencies |
| Preparation | Washed hands, introduced self, positioned patient at 45°, gained consent. |
| General Inspection | Specifically looked for Cushingoid features (moon face, neck hump, abdominal striae). |
| Vascular Assessment | Checked for Radio-Radial delay (Coarctation screen) and Carotid bruits. |
| End-Organ Screen | Performed/offered Fundoscopy (Retinopathy) and checked JVP/Lung bases (Heart failure). |
| Abdominal Exam | Correctly auscultated for Renal Bruits and attempted to palpate for Polycystic Kidneys. |
| Special Tests | Assessed Mallampati score (OSA screen) and mentioned Thyroid exam at the end. |
| Communication | Avoided jargon (e.g., used “stretch marks” instead of “striae”). Explained “Essential Hypertension.” |
| Time Management | Prioritized core CV exam; did not get bogged down in the Thyroid exam. |
Communication Triggers & Sample Answers
1. The “TRACKPADS” Diagnostic Reasoning
A high-performing candidate should use the mnemonic to ensure they haven’t missed a secondary cause:
- T – Thyroid (checked at end)
- R – Renal Artery Stenosis (bruits)
- A – Aortic Coarctation (radio-radial delay)
- C – Cushing’s (inspection)
- K – Kidney disease (palpation)
- P – Pheochromocytoma (offered via history)
- A – Aldosteronism (Conn’s)
- D – Drugs (NSAIDs)
- S – Sleep Apnea (Mallampati)
2. Explaining the Provisional Diagnosis
Candidate: “Liam, based on my examination today, your heart and lungs sound healthy, and I didn’t find any signs of underlying issues like kidney problems or narrowing of your blood vessels. This suggests you likely have what we call ‘Essential Hypertension.’ This means that while your blood pressure is high, we haven’t found a specific ‘organic’ or single cause for it today. It is common, but at your age, we will still run some blood and urine tests just to be 100% sure.”
3. Handling Patient Concern
Patient: “Am I too young for this?”
Candidate: “It is less common at 25, which is why I did such a thorough check today. We focus on lifestyle first—looking at things like salt intake and stress—before we jump to long-term medication.”
Model Performance Summary
The candidate begins with WIPE. They perform a fluid CV exam but pause to check for radio-radial delay and abdominal bruits. They inspect the mouth for airway crowding (Sleep Apnea). When the examiner says, “The fundoscopy is normal,” the candidate moves immediately to the abdomen. They save the thyroid exam for the final 30 seconds. They conclude by summarizing that since no secondary signs (like bruits or striae) were found, “Essential Hypertension” is the working diagnosis, while remaining empathetic to the patient’s age and concerns.