MRCEM OSCE-Travel History Station

This station tests your ability to:

Take a focused history that is relevant to the presenting complaint.

Recognise red flags for serious imported illnesses (e.g., malaria, dengue, viral haemorrhagic fevers).

Demonstrate a systematic approach to risk stratification based on travel.

Show safe and appropriate initial management and disposition.

Communicate effectively with the patient and the examiner.

Phase 1: Before Entering the Station (1 minute)

Read the scenario carefully: Note the patient’s age, presenting complaint, and any initial observations (e.g., “febrile,” “looks unwell”).

Formulate your opening: Plan how you will introduce yourself and open the conversation.

Anticipate the differentials: If the complaint is fever, think “Malaria, Dengue, Typhoid, COVID-19, Hepatitis, AMEBIC liver abscess” or other relevant mnemonics.

Phase 2: The Structured Approach Inside the Station (8 minutes)

Use the SIT DOWN mnemonic as a framework to ensure you cover all critical aspects without missing key details.

S – Symptoms & Systems Review

Start with the classic ODIPARA for the main symptom (e.g., fever, diarrhoea, rash).

Conduct a quick systems review focusing on imported diseases:

Fever: Rigors, night sweats, pattern (continuous, intermittent, quotidian)?

GI: Diarrhoea (bloody?), vomiting, abdominal pain, jaundice.

Respiratory: Cough, shortness of breath, haemoptysis.

Neurological: Headache (severe?), confusion, seizures, neck stiffness.

Skin: Rash (distribution, type: maculopapular, petechial, eschar), itching.

Musculoskeletal: Myalgia, arthralgia.

I – Itinerary (The Core of the History)

This is the most important part. Be precise.

“Which countries did you visit?” (List them all).

“Where exactly did you go within those countries?” (Urban vs. rural is critical. Malaria risk is often higher in rural areas).

“When did you travel? (Dates of departure and return).”

“When did your symptoms start in relation to your return?” (This helps establish the incubation period).

T – Transfusion, Trauma, Treatments (Other Exposures)

Activities: What did you do? (Trekking, swimming in freshwater, safari, caving, animal contact).

Accommodation: Where did you stay? (Air-conditioned hotel vs. rustic camping).

Food/Water: What did you eat and drink? (Street food, untreated water, unpasteurised dairy).

Insect bites: Noticed any mosquito/ticks/sandfly bites? (Ask about prophylactic measures).

Sexual history: Any new or unprotected sexual contacts? (Relevant for HIV, hepatitis B).

Medical care: Any tattoos, piercings, medical/dental procedures abroad? Blood transfusions?

D – Drugs (Prophylaxis and Vaccinations)

Malaria prophylaxis: “Did you take any medication to prevent malaria?”

Which drug? (e.g., Doxycycline, Malarone, Mefloquine)

Dose? (e.g., once daily?)

Compliance? (“Did you take it every day without missing a dose? Did you start before, continue during, and continue after your trip?”)

Vaccinations: “Were you vaccinated before you travelled?”

Which ones? (Yellow Fever, Typhoid, Hepatitis A, Tetanus, COVID-19).

Other medications: Any other medications taken during or since the trip?

O – Other History

Past Medical History: Especially conditions that cause immunosuppression (e.g., HIV, diabetes, on steroids/asplenia).

Medications: Regular medications.

Allergies.

Social History: Travel companions – are they also unwell?

W – Work and Wonders (Occupational & Specific Risks)

Occupation: Could this be relevant? (e.g., healthcare worker, aid worker, military).

“Is there anything else about your trip you think I should know?” (An open-ended question to catch anything unusual).

N – Next Steps (Examination & Initial Management)

State to the examiner: “Based on this history, my priority is to clinically assess the patient. I would:”

Perform a full set of observations (vitals signs) including temperature.

Conduct a focused physical examination looking for:

Rash, jaundice, lymphadenopathy.

Hepatosplenomegaly.

Signs of dehydration.

Neurological status.

State to the examiner: “I would also initiate initial investigations:”

Bedside: ECG, Blood Glucose, Urinalysis.

Bloods: FBC (look for thrombocytopenia, atypical lymphocytes), U&E, LFTs, CRP, Lactate (if septic), Coagulation.

Microbiology:

Malaria rapid diagnostic test (RDT) and thick & thin blood films (state you would request three films over 24-48 hours if high suspicion and initial negative).

Blood Cultures (x2 sets).

Consider PCR/serology for other diseases based on itinerary (e.g., Dengue NS1, Salmonella serology).

Phase 3: Management and Disposition (Final 1-2 minutes)

Initial Management: “I would ensure IV access, take bloods, and give a fluid challenge if the patient is tachycardic or hypotensive. I would not give empiric antibiotics for a fever without a clear source until I have discussed with microbiology/infectious diseases, as it can mask diagnoses like typhoid.”

Infection Control: CRUCIAL POINT. “If the patient is febrile and has travelled from a high-risk area, I would place them in a side room and discuss with the infection control team immediately. I would consider viral haemorrhagic fevers (VHF) in my differential until proven otherwise, especially with a haemorrhagic rash or concerning features.”

Seek Senior & Specialist Advice: “I would present the case to my senior emergency medicine clinician and contact microbiology or infectious diseases for further advice on investigation and management.”

Disposition: “This patient likely requires admission to a medical ward for further investigation and management. If they are systemically unwell, they may require HDU/ICU review.”

Common Pitfalls to Avoid

Forgetting the dates of travel and the incubation period.

Not asking about rural vs. urban travel.

Not asking about compliance with malaria prophylaxis (just asking “did you take it?” is not enough).

Jumping to a common diagnosis (e.g., UTI) without considering travel-related causes.

Failing to mention infection control and isolation precautions.

Not stating the need for senior and specialist input.

Example Opening & Flow

You: “Hello, my name is Dr. Smith, one of the emergency doctors. I understand you’ve been feeling unwell since returning from your travels. Could you tell me what’s been going on?”

Patient: “I’ve had a high fever and a terrible headache for the past two days.”

You: “I’m sorry to hear that. Let’s start by talking about your trip, as that might help us figure this out. First, which countries did you visit, and when did you get back?”

By following this structured SIT DOWN approach, you will demonstrate a comprehensive, safe, and efficient method for tackling any travel history station in the MRCEM OSCE.