TL;DR. Every MRCEM OSCE system examination station — cardiovascular, respiratory, abdominal, neurological, peripheral vascular, thyroid, cranial nerves — runs on the same skeleton: introduction and consent, focused history, general inspection (patient + environment), peripheral signs from the hands, neck and face, then the target system using inspection, palpation, percussion, auscultation (with neurology substituting tone, power, sensation, reflexes, coordination). Each station is 8 minutes long with 1 minute of reading time, examiners mark against domains shown as a pie chart on the candidate brief, and the three most commonly seen system stations in real ED practice — and therefore most commonly tested — are cardiovascular, respiratory and abdominal. Drive the examination from a differential, summarise out loud at the end, and offer the bedside tests you would use to complete it.
You have passed the MRCEM SBA. The Royal College of Emergency Medicine has emailed you a date for the OSCE in Chennai, Mumbai, Doha or London, and a system examination station is going to land in front of you. You will not know which system until the bell rings and you read the candidate brief.
This article walks through the shared skeleton that every system station hangs on, gives you per-system tables for the four cores (CVS, respiratory, abdominal, neurological), and surfaces the pitfalls that bin candidates who actually know the medicine. It is built from the RCEM OSCE Exams & FAQs page, the St Emlyn’s FRCEM Revision Guide Chapter 6 (which the RCEM curriculum committee has historically cited as a fair representation of OSCE expectations), Geeky Medics OSCE checklists, and Reddit threads from candidates who sat OSCEs in the last three diets.
For more on this, see our guide to OSCE history-taking framework.
flowchart LR
A[Introduce + consent
Position and expose] --> B[General inspection
End of bed]
B --> C[Peripheral exam
Hands, face, neck]
C --> D[Focused system exam
Inspect, palpate, percuss, auscultate]
D --> E[Closing
Thank patient, summarise, next steps]
What is the MRCEM OSCE actually testing in a system examination station?
RCEM frames every OSCE station around scenarios that reflect real life practice and could be seen in any Emergency Department in the UK. The station brief is one page. It tells you the scenario, the task, the role of the examiner, and — critically — the marking domains as a pie chart. That pie chart is the single most useful piece of information in the room. If the pie says 70% practical examination and 10% history, do not burn three minutes taking a SOCRATES.
For the MRCEM OSCE the Specialist Learning Outcomes assessed are SLO 1 (Complex Stable Patient), SLO 2 (Answer Questions), SLO 3 (Resus), SLO 4 (Injured Patient), SLO 5 (PEM), SLO 6 (Procedural Skills), SLO 7 (Complex Challenging Situations) and SLO 9 (Supervise & Teach). A system examination station typically maps to SLO 1 — you are examining a complex stable patient and feeding back a differential — though it can be folded into SLO 5 (paediatric chest examination), SLO 9 (teach a junior how to examine the abdomen) or any combination.
Station logistics: 8 minutes per station with 1 minute reading time outside the door, no double stations, two rest stations in the MRCEM circuit, an analogue clock on the wall (no visible timer), iPad-based marking with paper backup. You will not need to bring your stethoscope — RCEM provides everything required.
What is the shared skeleton for every system examination?
Examiners are scoring you against domains, and one of those domains is invariably structure. The same opening and closing applies whether you are examining a chest or a thyroid. Burn this into muscle memory so the first 45 seconds and the last 45 seconds run on autopilot — that buys you the cognitive bandwidth for the actual clinical findings.
| Phase | What it looks like |
|---|---|
| Introduction | Name, grade, role; wash hands or gel; PPE if scenario implies it; confirm patient name and DOB; explain examination in lay terms; consent; offer chaperone; ask about pain. |
| Focused history | One line: “Can you tell me briefly why you came to hospital?” Do not derail into a full clerking. |
| Position & expose | Bed at 45° for CVS/respiratory, flat for abdo, sitting for cranial nerves; expose appropriately while preserving dignity. |
| General inspection | Patient (comfort, distress, habitus, obvious signs) and environment (oxygen, GTN, inhalers, walking aids, drains). |
| Peripheral exam | Hands → pulse → observations → face → neck. Verbalise what you are looking for at each step. |
| System core | Inspect → Palpate → Percuss → Auscultate (omit percussion for the precordium; substitute Tone → Power → Sensation → Reflexes → Coordination for neurology). |
| Additional manoeuvres | Sit forward to listen to lung bases (CVS), check sacral and ankle oedema, hepato-jugular reflex, Buerger’s test — driven by your differential. |
| Close & summarise | “Thank you, that is the end of the examination. In summary, my positive findings are X, negative findings are Y, my working differential is … To complete my examination I would like to …” |
The phrase “to complete my examination I would like to” is gold dust. It buys you credit for the bedside tests you did not have time to do — ECG, urinalysis, lying and standing BP, capillary glucose, PR exam, fundoscopy — and it signals to the examiner that you understand the limits of what you have just done.
For more on this, see our guide to common OSCE station fails.
For more on this, see our guide to musculoskeletal station structure.
How do you structure the cardiovascular system examination station?
CVS is the highest-yield system station because cardiac chest pain is the bread and butter of ED practice. Expect a patient with a murmur, signs of heart failure, an irregular pulse, or an obvious sternotomy scar. Bed at 45°, patient stripped to the waist (offer a blanket).
| Step | What you say and do |
|---|---|
| General inspection | Comfort, respiratory distress, sternotomy scar, pacemaker bulge, oxygen, GTN spray on bedside table. |
| Hands | Warmth, clamminess, clubbing, tar staining, peripheral cyanosis, splinter haemorrhages, Janeway lesions, Osler nodes, capillary refill. |
| Pulse | Rate, rhythm, character; offer radio-radial and radio-femoral delay; request BP in both arms. |
| Face | Corneal arcus, xanthelasma, conjunctival pallor, central cyanosis (under tongue), malar flush. |
| Neck | JVP at 45°; carotid pulse character (one side at a time, never both). |
| Precordium — inspect | Scars, visible apex, chest wall deformity. |
| Precordium — palpate | Apex beat (5th IC space, MCL), heaves at left sternal edge, thrills at each valve area. |
| Precordium — auscultate | All four valve areas with diaphragm then bell; carotids for bruit or aortic radiation; axilla for mitral radiation; manoeuvres if you hear something (left lateral for mitral stenosis, leaning forward in expiration for aortic regurgitation). |
| Complete | Sit forward — lung bases for crackles, sacral oedema; lie flat — hepatomegaly; ankle oedema. Offer ECG, CXR, urinalysis, lying/standing BP. |
Differential-driven additions: if you suspect endocarditis, name the bedside tests for it (urine dip for haematuria, request blood cultures × 3, echocardiogram). If you suspect heart failure, comment on the absent and present features and offer BNP plus echo. The examiner is listening for clinical reasoning, not just a recitation.
How do you structure the respiratory system examination station?
The classic respiratory OSCE patient is a COPD exacerbation, pneumonia, pleural effusion, or post-pneumothorax with a chest drain scar. Same opening as CVS, same 45° positioning. The discriminating step is chest expansion + percussion + auscultation + vocal resonance done both anteriorly and posteriorly — candidates who skip the back routinely fail.
| Step | What you say and do |
|---|---|
| General inspection | Respiratory distress, accessory muscle use, pursed-lip breathing, audible wheeze/stridor, chest drain scars, chest wall deformity (barrel chest, pectus); environment for inhalers, nebuliser, sputum pot, oxygen. |
| Hands | Clubbing, tar staining, peripheral cyanosis, CO2 retention flap (arms extended, wrists cocked back), wasting (Pancoast). |
| Pulse & observations | Rate, rhythm, bounding character (CO2 retention); request RR, SpO2, temperature. |
| Face | Horner’s (ptosis, miosis, anhidrosis — Pancoast tumour), central cyanosis under tongue, nasal patency. |
| Neck | Tracheal position (deviated towards collapse, away from large effusion/tension pneumothorax), cervical lymphadenopathy, JVP. |
| Chest — anterior | Inspect; palpate expansion (upper, lower); percuss (apex, infraclavicular, mid-zone, axillary); auscultate; vocal resonance. |
| Chest — posterior | Same sequence; lean patient forward (arms crossed); compare side to side, never top to bottom of same side. |
| Complete | Sacral and ankle oedema (cor pulmonale); peak flow, ABG, sputum sample, CXR, blood tests. |
St Emlyn’s reminds candidates to do either tactile or vocal fremitus, not both — they give the same information and doing both wastes 30 seconds you do not have.
How do you structure the abdominal examination station?
Abdominal is the trickiest of the three to time correctly because there is so much surface area to cover. Patient lies flat on one pillow, exposed nipples-to-knees (towel over groin). Stand on the patient’s right at their level — examiners watch for this.
| Step | What you say and do |
|---|---|
| General inspection | Jaundice, cachexia, distension, scars (don’t miss the left flank for nephrectomy), spider naevi, gynaecomastia, caput medusae, stomas, drains. |
| Hands | Clubbing, leuconychia, palmar erythema, Dupuytren’s, asterixis (liver flap). |
| Face & neck | Conjunctival pallor, scleral icterus, angular stomatitis, oral ulcers, glossitis, Virchow’s node (left supraclavicular). |
| Chest | Spider naevi, gynaecomastia, lost body hair. |
| Abdomen — inspect | Closer look; ask patient to cough (hernias, peritonism); look for visible peristalsis or pulsation. |
| Abdomen — palpate | Light all nine regions watching the face; deep all nine regions; liver, spleen, kidneys (ballot), bladder, aorta. Start away from any reported pain. |
| Abdomen — percuss | Liver span, splenic dullness, bladder; shifting dullness for ascites. |
| Abdomen — auscultate | Bowel sounds (at least 30 seconds before declaring absent); aortic and renal bruits. |
| Complete | Hernial orifices, external genitalia, PR, urinalysis, observation chart, blood tests, USS/CT. |
How do you structure the neurological examination station?
Neurology can land as upper limb, lower limb, cranial nerves or cerebellar. The skeleton changes from IPPA to Inspection → Tone → Power → Reflexes → Sensation → Coordination (often remembered as “In The Park Run Some Circuits”). Examiners are watching for whether you can localise the lesion — UMN vs LMN, peripheral vs central, dermatome vs nerve.
| Step | Upper limb | Lower limb |
|---|---|---|
| Inspect | Wasting, fasciculation, posturing, scars, tremor at rest. | Wasting, fasciculation, gait (broad-based, antalgic, shuffling, high-stepping), use of aids, Romberg’s. |
| Tone | Flexion/extension at elbow, pronation/supination, wrist circumduction. | Roll the leg, briskly lift the knee, ankle clonus (>5 beats abnormal). |
| Power (MRC 0–5) | Shoulder abduction C5; elbow flexion C6, extension C7; wrist flex/ext C6/C7; finger flex C8, ext C7, abduction T1. | Hip flexion L2/3, extension L4/5; knee flex L5/S1, ext L3/4; ankle dorsiflexion L4/5, plantarflexion S1/2; big toe ext L5. |
| Reflexes | Biceps C5/6, brachioradialis C6, triceps C7/8 (re-enforce with teeth clench if absent). | Knee L3/4, ankle S1/2, plantar response (Babinski). |
| Sensation | Light touch, pin-prick, vibration 128 Hz, proprioception, temperature in all dermatomes C5–T1; demonstrate on chest first. | Same modalities L1–S2 dermatomes. |
| Coordination | Finger-nose, pronator drift, dysdiadochokinesia. | Heel-shin. |
| Complete | Cranial nerves, cerebellar exam, peripheral vascular. | Cranial nerves, cerebellar exam, peripheral vascular, hip examination. |
For cranial nerves the trick is to offer the formal tests rather than waste time doing them — say “I would formally assess olfaction with smelling bottles, would you like me to do that?” Most examiners will tell you to move on. Visual acuity with a Snellen at six metres, visual fields by confrontation, pupils (direct, consensual, swinging light for RAPD), eye movements in an H, trigeminal sensory in three divisions and motor at masseter, facial in upper and lower halves, whisper test for VIII (Rinne and Weber if asked), uvula deviation for IX/X, shoulder shrug and head turn for XI, tongue protrusion for XII.
How do you drive the examination from the differential?
Examiners separate average from strong candidates on this single behaviour. A weak candidate examines in a fixed sequence regardless of what they find. A strong candidate adapts in real time: hearing an ejection systolic murmur prompts them to feel for slow-rising pulse and ask the patient to lean forward in expiration; finding stony dullness in the right base prompts them to check tactile fremitus and trachea position; a dropped foot on lower-limb power prompts them to test L4, L5 and S1 sensation specifically and check the ankle reflex.
Practise this by running each system station three times: once on a healthy volunteer, once with a hypothetical “left-sided pneumonia” in your head, and once with “mitral regurgitation” in your head. Force yourself to verbalise the differential mid-examination, not just at the end.
What are the common pitfalls that fail candidates in system stations?
- Burning time on history. The pie chart said 10% history. You took five minutes.
- Forgetting to look at the back of the chest. Both expansion and auscultation. This is a fixable, repeatable failure.
- Listening through clothes. Auscultation through a gown is a flag for inadequate examination technique even if you heard the murmur.
- Standing on the wrong side for the abdomen. Examiners notice.
- Not warning the patient before each step. “I’m going to press on your tummy, tell me if it’s sore.” Builds rapport, demonstrates safety domain marks.
- Not washing or gelling at the start. Hand hygiene is a marking domain in itself.
- Skipping the “to complete my examination I would like to…” close. You lose easy marks for naming bedside tests.
- Failing to verbalise inspection. The examiner cannot mark what they cannot hear you noticing.
- Ignoring the environment. An asthma inhaler on the bedside table is a free differential point.
- Mismatching pace. Rushing through the first half then running out of time before percussing the chest.
- Not asking about pain before palpating. Causing pain — even mock pain to an actor — is a domain failure for professionalism.
- Failing to summarise out loud. The summary is where you crystallise positive and negative findings, give a differential, and earn the synthesis marks.
How should you practise system examinations in the run-up to the OSCE?
Reddit threads from recent MRCEM OSCE diets converge on four habits: run timed 8-minute stations with a study partner (not 10, not “until you finish”); record yourself on a phone and watch it back; verbalise everything because that is what the examiner is scoring; and get feedback from a consultant or senior trainee who has examined OSCEs. Use the St Emlyn’s FRCEM Revision Guide Chapter 6 as your script and pair it with Geeky Medics OSCE checklists for the granular peripheral signs.
Frequently asked questions
How long is each MRCEM OSCE system examination station?
Eight minutes inside the room, with one minute of reading time outside the door beforehand. There is no visible countdown timer — an analogue clock is on the wall — so time management is on you.
Do I need to bring my own stethoscope to the MRCEM OSCE?
No. RCEM provides every piece of equipment a station requires, including stethoscopes, tendon hammers, neurotips, tuning forks and ophthalmoscopes. You may bring your own stethoscope if you prefer it.
Which system examinations come up most often in the MRCEM OSCE?
Stations sample broadly across the curriculum, but cardiovascular, respiratory and abdominal are the three that map most directly to common ED presentations and therefore appear most frequently. Neurology — particularly cranial nerves and lower limb — appears regularly too.
Do I have to do percussion in every system examination?
No. Percussion is integral to respiratory and abdominal examinations and is used selectively in thyroid (retrosternal goitre) and CVS-related lung base checks. It is not part of the precordial examination itself.
Should I take a full history at the start of a system examination station?
No. A focused one-line history (“Can you briefly tell me why you came to hospital today?”) is sufficient unless the candidate brief specifies otherwise. The pie chart on the brief shows how the domain weighting is split — if history is a small slice, do not labour it.
What do I say at the end of the station?
Thank the patient, offer help getting dressed, then summarise to the examiner: positive findings, relevant negatives, working differential, and what you would do to complete your examination (bedside tests, further examination of related systems, basic investigations).
How do I demonstrate the “complete examination” component if I run out of time?
State it explicitly. “To complete my examination I would like to perform a peripheral vascular examination, request an ECG and chest X-ray, urinalysis, lying and standing blood pressure, and capillary blood glucose.” You get credit for naming the tests even if you did not perform them.
What if I cause the patient (actor) discomfort during the examination?
Stop, apologise, ask whether they would like a break, and document that you have done so. Causing pain without acknowledging it is a flag against the professionalism domain. Causing pain, apologising and adapting is acceptable behaviour.
Can I ask the examiner questions during the station?
For some tasks, yes. You can offer to do certain manoeuvres (formal smell testing, gag reflex, fundoscopy, slit lamp) and ask “would you like me to do that?”. The examiner will usually tell you to move on. You cannot ask for clinical hints or for clarification beyond the station brief.
What happens if I fail one system examination station — do I fail the whole MRCEM OSCE?
No. The MRCEM OSCE uses an overall pass mark across the circuit; you do not need to pass every station to pass the exam. Note this differs from the FRCEM OSCE, where you must pass at least one of the three resuscitation stations regardless of total score.
Should I use the same examination structure for paediatric system stations?
The skeleton is the same, but the rapport-building, language, and parental involvement matter as much as the technique. Greet the parent, name the child, offer the parent a role (“Would you mind holding her while I listen?”), and adjust your verbal explanations to the child’s developmental level.
Facts last verified . RCEM OSCE structure, station logistics, SLO mapping and equipment rules are taken from the current RCEM OSCE Exams & FAQs page. Examination skeletons are consistent with the St Emlyn’s FRCEM Revision Guide Chapter 6 and Geeky Medics OSCE checklists.
Next step. Build the muscle memory under timed conditions. Browse the EM Final Exams MRCEM OSCE course library to drill system stations with structured marksheets, recorded walk-throughs, and feedback from FRCEM-trained examiners.
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