OSCE APIE Scenario: Subdural Haematoma

The subdural scenario is the neurological observations exam. The bleed itself is invisible from the bedside; what you can see is the trend, and the station tests whether your technique is good enough for the trend to mean anything.

Assessment. The GCS, done to standard: eye opening (4 to 1), verbal (5 to 1), motor (6 to 1), scored on best response, with proper stimuli in proper order: voice before pain, and both sides watched for the motor response. Record components and total: E4 V4 M6 tells the next nurse where the loss is; a bare 14 doesn’t. Pupils: size, equality, reaction, each eye. Limb power, all four. Vital signs alongside. And the history that frames everything: a fall (even a trivial, weeks-old one), anticoagulants, alcohol, increasing confusion or drowsiness noticed by family: subdurals in older patients creep, and the forgotten bump is the classic backstory.

Planning. Observation frequency per head-injury policy and the clinical picture, with escalation criteria written explicitly into the plan: a GCS fall of 2 or more (or any motor drop), a new pupil abnormality, repeated vomiting, severe headache, seizure, new weakness. Safety planning around the confusion itself: falls precautions for a patient whose balance and judgement may be failing.

Implementation. Serial observations done identically each time so the trend is real: same technique, same stimuli, honestly scored even when the patient is irritable at being woken, because “obs declined, patient asleep” is the entry that precedes disasters. Family used as instruments: they hold the baseline, and “he’s just not himself” at GCS 15 is a soft sign that raises vigilance and gets documented, not dismissed. Positioning per the team (head of bed as directed), analgesia balanced against the need to assess consciousness, and antiemetics as prescribed with vomiting counted, not just treated.

Evaluation. The trend read aloud at every set: stable, improving, or moving, and moving means the emergency call with an SBAR that leads with the change: “GCS has fallen from 14 to 12 in the last hour, motor score dropping, right pupil now sluggish”. Documentation is the chart itself: complete columns, exact times, components every time; in neuro deterioration the record is the diagnosis’s paper trail, and the station marks it that way.

Five questions below. That closes the 12 scenarios; Part C finishes the course with the silent written stations and the honest chapter on why candidates fail.