OSCE for IMG

A 58-year-old man presents complaining of tiredness for the past 6 months.
Background information (available if asked)
Occupation: Taxi driver
Symptoms are gradually worsening
No acute illness today
Past medical history
Hypertension
No known diabetes
No previous malignancy
Medications
Amlodipine
Family history
Father: Prostate cancer (diagnosed in his 70s)
Mother: Hypertension
No family history of diabetes or thyroid disease
Social history
Non-smoker
Occasional alcohol
Lives with wife
BMI
Your tasks
Take a focused history related to his tiredness
Ask for relevant investigations / pathology
Outline your initial management plan

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🩺 OSCE Case 46: Newly Diagnosed Type 2 Diabetes Mellitus

Stem:
A 50-year-old man presents to the GP clinic. He has recently been diagnosed with type 2 diabetes. He also has hypertension and is obese. The examiner asks: “Take a history, order relevant laboratory tests, and outline your management.”

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1. Focused History 🟩

☑ Diabetes symptoms

Polyuria, polydipsia, weight changes

Blurred vision, recurrent infections (skin, UTI, thrush)

Fatigue

☑ Complications (micro & macrovascular)

Neuropathy: tingling, numbness, burning in feet

Nephropathy: swelling, frothy urine

Retinopathy: vision changes

Cardiovascular: chest pain, claudication, stroke/TIA history

☑ Past medical history

Hypertension, hyperlipidemia, cardiovascular disease

Medications (antihypertensives, statins)

Family history of diabetes, heart disease

☑ Social history

Diet, exercise

Smoking, alcohol use

Occupation and impact on lifestyle

Weight history

☑ Psychological

Mood, depression, coping with diagnosis

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2. Examination 🟩

☑ General: BMI, waist circumference, BP
☑ Fundoscopy (if trained, otherwise refer)
☑ Cardiovascular exam (pulses, murmurs, BP in both arms)
☑ Feet exam: neuropathy (monofilament test), pulses, ulcers
☑ Signs of metabolic syndrome (acanthosis nigricans, central obesity)

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3. Investigations 🟩

☑ Bloods

HbA1c (diagnosis & monitoring)

Fasting glucose (if needed)

Lipid profile

Renal function (U&E, eGFR)

LFTs (before statin)

☑ Urine

Albumin:creatinine ratio (microalbuminuria)

☑ Others

ECG (baseline CV assessment)

Retinal photography (annual screening)

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4. Differential Diagnosis 🟩

☑ Type 2 diabetes mellitus (confirmed)
☑ Type 1 diabetes (less likely at age 50, but check if atypical)
☑ Secondary diabetes (steroids, pancreatic disease)

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5. Management Plan 🟦

☑ Lifestyle modification (first-line)

Diet: reduce refined carbs, increase fiber, fruits/vegetables, portion control

Exercise: 150 min/week aerobic + resistance training

Weight loss program (BMI >30 → dietitian referral, consider bariatric surgery if severe)

Smoking cessation, reduce alcohol

☑ Pharmacological

Metformin (first-line, unless contraindicated: renal impairment, severe GI issues)

If not controlled: add sulfonylurea (gliclazide), DPP-4 inhibitor, SGLT2 inhibitor, or GLP-1 agonist (esp. if obese/heart failure risk)

Hypertension: target

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