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Home / Station 4: Upper gastrointestinal bleeding

NAC OSCE preparation

Station 4: Upper gastrointestinal bleeding

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

Upper gastrointestinal bleeding

11 minutes

Discipline: Internal Medicine
Station type: Emergency assessment
Setting: Emergency department resuscitation area

Your task

Take a focused history while explaining stabilization. State likely source, investigations and disposition.

Information available at entry

HR 124/minBP 88/56 mm HgRR 24/minSpO₂ 95%T 36.5°C

Coach prompt: Recognize hemorrhagic shock and prioritize resuscitation and source control.

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 4 of 30

Standardized-patient profile

NameMs. Patricia Wong

Age67

Pronounsshe/her

RolePatient

Demeanour: Pale, dizzy and frightened.

Opening statement: “I vomited a large amount of dark red blood and nearly fainted.”

History and standardized-patient responses

Bleeding

Candidate explores	Standardized-patient response
Hematemsis	Two large episodes of dark red blood with clots.
Stool	Black tarry stool since yesterday.
Severity	Dizziness and near-syncope.
Pain	Burning epigastric discomfort; no sudden severe pain.

Cause/risk

Candidate explores	Standardized-patient response
NSAID	Daily naproxen.
Liver disease	No known cirrhosis or heavy alcohol use.
History	Peptic ulcer eight years ago.
Anticoagulant	Apixaban for atrial fibrillation; last dose this morning.

Other

Candidate explores	Standardized-patient response
Allergy	None.
Goals	Wants full treatment; spouse is contact.

Physical findings

Pale, cool, delayed capillary refill.
Mild epigastric tenderness without peritonitis.
Melena when rectal examination is clinically appropriate.

Examiner prompts

First priority?

Major upper GI hemorrhage with shock: call for help, ABCs, monitoring, large-bore IVs, blood work/crossmatch, resuscitation and urgent gastroenterology.

Likely source?

NSAID-associated peptic ulcer; varices remain an alternative if liver features emerge.

Apixaban?

Hold it and assess urgent reversal according to severity, timing, renal function and protocol.

Differential diagnosis

Bleeding peptic ulcer
Erosive disease
Varices
Mallory-Weiss tear
Upper GI malignancy
Aortoenteric fistula in relevant history

Investigations

CBC and serial hemoglobin
Electrolytes, urea/creatinine and liver tests
Coagulation studies
Type and crossmatch
Lactate/blood gas if shocked
Urgent endoscopy after stabilization

Management

Immediate resuscitation
Hold NSAID and anticoagulant; consider reversal
IV acid suppression for suspected non-variceal bleed
Urgent endoscopy
Variceal-specific pathway if indicated
Critical-care/interventional/surgical escalation if ongoing instability

Communication behaviours

Use direct language about dangerous bleeding
Continue reassurance without slowing care
Confirm emergency contact when feasible

Critical safety actions

Do not wait for hemoglobin before treating shock
Address anticoagulation
Arrange urgent source control

Model closing summary

This patient has a major upper GI bleed with hemorrhagic shock, likely NSAID-associated peptic ulcer bleeding worsened by apixaban. I would call for immediate help, stabilize ABCs, obtain large-bore IV access and monitoring, send CBC, chemistry, coagulation and crossmatch, begin resuscitation, hold and assess reversal of anticoagulation, start acid suppression and arrange urgent endoscopy with critical-care support.

Common pitfalls

Long history while hypotensive
Normal initial hemoglobin falsely reassuring
No crossmatch/reversal plan
Delayed specialist involvement

Reference starting points

Verify current recommendations and local protocols before clinical use.

Continue practising

Choose another complete 11-minute station

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