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Home / Station 20: Severely agitated patient

NAC OSCE preparation

Station 20: Severely agitated patient

Complete the task in 11 minutes. Reveal the full standardized-patient script, examiner prompts and structured debrief only after your attempt.

Station time

11:00

Ready for an 11-minute attempt.

Candidate instructions

Severely agitated patient

11 minutes

Discipline: Psychiatry
Station type: De-escalation + emergency plan
Setting: Emergency department

Your task

Demonstrate verbal de-escalation, then state assessment and management. Do not approach physically.

Information available at entry

DiaphoreticHR 132/minBP 172/98 mm HgT 38.0°CGlucose 5.9 mmol/L

Coach prompt: Protect safety, search medical causes and use least restrictive intervention.

In Exam Mode, coaching cues are hidden. Ask a partner to use the standardized-patient script after you start the timer.

Finished your attempt?Reveal the full station only after completing or stopping the timer.

Complete station package

Standardized-patient script and structured debrief

Station 20 of 30

Standardized-patient profile

NameMr. Marcus Hill

Age38

Pronounshe/him

RolePatient

Demeanour: Pacing, shouting and clenching fists.

Opening statement: “Stay away from me! You poisoned me and I'm leaving.”

History and standardized-patient responses

When rapport improves

Candidate explores	Standardized-patient response
Substance	Methamphetamine earlier today; heavy alcohol use, last drink this morning.
Symptoms	Formication and persecutory belief.
Medical	Chest tightness and severe anxiety.
Risk	Threatens to punch anyone blocking door.

Collateral

Candidate explores	Standardized-patient response
Paramedics	Found running in traffic; escalating agitation.
Medication/allergy	Unknown.

Physical findings

No hands-on exam until safe.
Clear movable hazards; trained team nearby without crowding.

Examiner prompts

First action?

Environmental/team safety, trained assistance, distance and exit route, reduced stimulation and one calm communicator.

Causes?

Stimulant intoxication, alcohol withdrawal, delirium/medical illness, psychosis, mania, hypoxia, hypoglycemia or head injury.

Restraint?

Only for imminent danger when less restrictive measures fail/impossible, with trained staff, monitoring and shortest duration.

Differential diagnosis

Stimulant intoxication
Alcohol withdrawal
Delirium
Primary psychosis
Mania
Head injury/metabolic emergency

Investigations

Glucose, oxygen saturation and temperature
ECG/cardiac assessment
CBC, electrolytes, renal function, CK and toxicology as indicated
Trauma/infection evaluation

Management

Environmental/verbal de-escalation
Treat underlying toxic/medical cause
Medication by protocol if severe danger
Restraint only if imminent danger with monitoring
Hydration, temperature and rhabdomyolysis care

Communication behaviours

Do not argue about poisoning
Use short phrases and personal space
Offer two safe choices

Critical safety actions

Never interview violent agitation alone
Sedation/restraint require airway monitoring
Agitation may be medical

Model closing summary

I would secure the environment, maintain distance and an exit route, call trained assistance and use one calm communicator. I would validate that he feels unsafe, offer simple choices and set limits on threats. His stimulant use, fever, tachycardia and chest tightness need urgent medical evaluation. If imminent violence persists despite de-escalation, I would use the least restrictive medication or restraint under protocol with continuous monitoring and repeated reassessment.

Common pitfalls

Blocking exit
Multiple staff shouting
Threatening restraint
Sedation without monitoring

Reference starting points

Verify current recommendations and local protocols before clinical use.

Continue practising

Choose another complete 11-minute station

1. Chest pain in a 58-year-old 2. Acute dyspnea with wheeze 3. Palpitations followed by syncope 4. Upper gastrointestinal bleeding 5. Sudden focal weakness 6. Fever with hypotension 7. Acute right-lower-quadrant abdominal pain 8. Fever on postoperative day five 9. Severe leg pain after tibial fracture 10. Consent for lumbar puncture 11. First-trimester pain and bleeding 12. Postpartum low mood and unusual beliefs 13. Contraception counselling 14. Fever in an eight-week-old infant 15. Child with severe wheeze and respiratory distress 16. Two-year-old with language delay 17. Adolescent confidentiality and sexual health 18. Depression with suicidal thoughts 19. First-episode psychosis 20. Severely agitated patient 21. Older adult with acute confusion 22. Recurrent falls and dizziness 23. Driving safety in early dementia 24. Breaking a new colorectal cancer diagnosis 25. Disclosure of an insulin medication error 26. Refusal of blood transfusion 27. Cardiovascular examination in heart failure 28. Respiratory examination with pleural effusion 29. Focused neurologic examination for stroke 30. Painful swollen knee