OSCE Stations – Toronto Notes

Case 1 – Acute Abdominal Pain

History

Onset and duration of abdominal pain
Location of pain
Alleviating factors
Aggravating factors
Progression of pain
Quality of pain
Radiation of pain
Severity of pain
Associated nausea and vomiting
Fever
Changes in bowel habit
Blood in stools
Menstruation history
Urinary symptoms
Sexual history and use of contraception
Previous pregnancies
Previous abdominal surgery
Recent changes in diet
Travel history
Infectious contacts

Physical Examination

Inspection/Auscultation

Comments on patient’s position on the examination table and drapes patient appropriately
Inspects the abdomen for masses, scars
Auscultates in all four quadrants of the abdomen

Percussion/Palpation

Uses light and deep palpation to examine for tenderness
Monitors patient’s reaction to palpation, comments on guarding
Assesses for rebound tenderness in the right lower quadrant
Notes tenderness at McBurney’s point
States that they would perform a digital rectal examination as part of the abdominal examination

Special Maneuvers

Assesses for Murphy’s Sign
Assesses for Rosving’s sign
Assesses for Psoas sign

You are seeing Ms. Richards, a 75 year old female, in the ER. She is distraught because she is presenting with a two hour history of complete left leg paralysis. Please perform a focused history and physical examination.

History

Onset and duration of paralysis
Associated sensory loss
History of trauma to leg
Leg swelling
Pain in leg
Parasthesias in leg
Numbness in leg
Shortness of breath
Chest pain
Head trauma
Weakness elsewhere in the body
Sensory loss elsewhere in the body
Vision or speech changes
Personal history of myocardial infarction and stroke
Peripheral vascular disease
Diabetes
Dyslipidemia
Hypertension
Smoking history (quantity in pack-years)
Medications/Allergies
Family history of cardiac or cerebrovascular events

Physical Examination

Inspection

Comments on color of affected limb (pale)
Inspects for hair loss/lack of oil on affected limb
Inspects for arterial and diabetic ulcers on feet bilaterally (small ulcer on bottom of 1st toe)
Inspects for leg swelling

Palpation

Palpates affected limb for tenderness
Compares temperature in lower limbs
Assesses sensation in both lower limbs
Assesses power in both lower limbs
Assesses capillary refill in affected limb

Auscultation

Auscultates bilaterally for femoral and popliteal bruits
Auscultates abdomen for aortic aneurysm

Case 1 – Blurry Vision

You are seeing Mrs. Woods, a 74 year old woman, in your ambulatory clinic today. She states that her vision has become blurry. Take a focused history of this complaint and perform the relevant physical examination.

History

Onset and duration of blurry vision
Progression of blurry vision
Foreign body sensation, or history of foreign body in affected eye
Awareness of a red eye (none)
Visual field defects
Change in acuity
Double vision
Eye pain
Pain with eye movement
Presence of flashes and floaters
Photophobia
Excessive or poor lacrimation
Association with any extra-ocular symptoms: rashes, arthritis, urethritis
Change in colour vision
Distinguish between blurred vision vs. metamorphopsia (distorted vision)
Use of corrective lenses
Exposure to environmental irritants
History of diabetes, hypertension, cardiac disease, and stroke (risk factors for CRVO, CRAO)
History of cataract removal
Past ocular disease, including trauma
Smoking and alcohol history
Medications and allergies
Family history of eye diseases, e.g. glaucoma, retinal detachment
Inquires if patient is driving since onset of vision changes
Effect on daily living

Physical Examination

Inspection

Comments on absence of ptosis
Comments on appearance of lid, eyelashes, lacrimal glands
Comments on appearance of conjunctiva and sclera

CN II

Asks patient about prescription for corrective lenses before beginning examination
Checks visual acuity using Snellen Chart at 14 inches or 20 feet
Assesses pupillary response to light
Assesses pupillary accommodation
Assesses for RAPD/Marcus Gunn pupils
Assesses visual fields by confrontation
Performs fundoscopy and comments on findings, specifically the disc-to-cup ratio
States that color vision testing should be performed
States that a slit lamp examination should be performed

CN III, IV, & VI

Comments on absence of nystagmus
Assesses all six cardinal movements of the extraocular muscles
Asks patients about diplopia in all directions of gaze

Case 1 – Breast Mass

You are seeing Mrs. Thompson, a 56 year old woman, in your outpatient clinic today. She is worried about a left breast mass, and would like your reassurance that it isn’t cancer. Take a focused history of her complaint and perform a focused physical exam.

History

Onset of awareness of mass
Size of the mass and change in size
How mass was identified
Mastalgia
Associated discharge, including pus and blood (none)
Size/tenderness association with menstrual cycle
Nipple changes
Skin changes (on affected breast)
Systemic symptoms – weight loss, low energy, anorexia
Associated shortness of breath or chest pain
Changes in personality – suggestive of brain metastases
Bone pain – suggestive of bone metastases
Inquires about date of menopause
Pregnancy history
Breastfeeding history
History of chest radiation
Age of menarche
Alcohol history
Smoking history (quantity in pack-years)
Past and current use of hormone replacement and oral contraceptive pills
Family history of breast, ovarian, or colon cancer
Past history of breast masses
Past mammography results
Addresses patient’s concerns regarding the mass

Physical Examination

Inspection

Drapes patient appropriately
Inspects breast skin for discoloration, retraction, peau d’orange, or bruising
Comments on presence of asymmetry
Examines nipples, commenting on absence of discharge, irregularities, or retraction
Examines areolas (no abnormalities)

Palpation

Uses radial or strip method to palpate both breasts,
Comments on texture, size, firmness, and mobility of any palpated masses
Palpates axillary nodes bilaterally
Palpates infraclavicular and supraclavicular nodes

Case 1 – Cranial Nerve Examination

You are seeing Mr. Grimson, a 39 year old man, for numbness of the face as well as a right facial droop. Please examine cranial nerves V and VII

Physical Examination

CN V

Examines for light touch in all three nerve distributions (forehead, cheek, chin)
Examines for pain/temperature in all three nerve distributions (forehead, cheek, chin)
Palpates masseter and temporalis muscles and comments on bulk
Tests masseter muscle power by opposing jaw opening
Tests right and left pterygoids muscle power by opposing lateral movements of the jaw
Tests the jaw reflex using reflex hammer
States that the corneal reflex (afferent V, efferent VII) should be tested and explains the procedure

CN VII
Motor:

Comments on the presence/absence of facial asymmetry/droop
Tests frontalis by asking patient to raise eyebrows
Tests orbicularis oculi by asking patient to tightly shut eyes (and tries to open them)
Tests orbicularis oris by asking patient to tightly close lips (and tries to open them)
Shows upper and lower teeth
Puffs cheeks (and tries to deflate them)
Shows the lower teeth only (platysmus)
States that the corneal reflex should be tested and explains the procedure (efferent limb)
States that lacrimation and salivation should also be tested

Sensory:

States that taste on the anterior 2/3 of the tongue should be tested, and describes how this examination could be performed

Case 1 – Dysuria

You are seeing Mrs. Singh, a 72 year old female, in your outpatient clinic today. She tells you that she has discomfort during urination and has difficulty controlling her urine. Take a focused history of his complaint.

History

Clarifies symptom of dysuria
Onset of dysuria
Urinary frequency
Change in urine color (cloudiness, darkening)
Presence of hematuria (none)
Nocturia
Urgency
Overflow Incontinence
Incomplete voiding
Flank/back pain
Abdominal discomfort/fullness/pain
Nausea and vomiting
Fever
Gastrointestinal symptoms such as pain, diarrhea, blood in stool
Pregnancy history
Current medications (particularly anti-cholinergic medication, estrogen creams)
Past history of urinary tract infections
Past history of urinary incontinence and treatments
Exposure to pool/lake/ocean water
Recent antibiotic use
Effect on daily life

Case 1 – Feeling Slow

You are seeing Mrs. Rostov, a 61 year old woman, because she feels slow. Take a focused history, and perform a physical exam pertinent to her complaint.

History

Clarifies patient’s recent symptoms of fatigue
Onset and duration of symptoms
Asks about sleep habits
Cold intolerance
Dry skin
Weight gain
Hair loss
Abnormal vaginal bleeding
Muscle cramping
Exercise intolerance
Constipation
Mood changes
Poor focus
Smoking and alcohol history
Personal history of thyroid disorders
Radiation to Head and Neck
Family history of thyroid disorders
Family history of auto-immune disorders (Type I Diabetes, Celiac Disease, Addison’s Disease, Rheumatoid Arthritis)
Current medications
Effect on daily activities

Physical Examination

Vitals

Comments on bradycardia
Assesses for orthostatic changes in vitals
States that temperature should be measured, and it may show hypothermia

Inspection

Comments on hair changes (thin)
Assesses for skin changes, including dryness, and pretibial myxedema
Edema (face and lower extremities)
Comments on nail changes (brittle nails)
Hair loss
Assesses swallowing
Proximal muscle wasting

Thyroid Examination

Inspects for enlarged thyroid
Observes thyroid while swallowing
Palpates both thyroid lobes
Comments on size, texture, and nodularity
Palpates anterior cervical nodes for abnormality

Neurological Examination

Reflexes (may be hyporeflexive)
Proximal muscle power (may be decreased)

Case 1 – Knee Injury

You are seeing Sarah Tseng, a 21 year old female in the Emergency Department. She comes in complaining of severe left knee pain after she fell while running. Perform a focused physical examination.

Physical Examination

Inspection

Examines both knee joints for SEADS (swelling, erythema, muscle atrophy, deformity, skin changes)
Comments on presence of valgus/varus deformity
States that the hips and ankles should be examined as well

Palpation

Palpates knees for crepitus, warmth, and effusion.
Palpates along left joint-line for tenderness
Palpates for Baker’s cysts
Tests passive range of motion for effected knee

Tests for Effusion

Examines for Bulge Sign
Uses fluctuation to assess for effusion
Tests for ballottement

Range of Motion/Gait

Assesses patient’s gait
Assesses active range of motion for both knees

Stability

Assesses for LCL and MCL damage
Assesses for ACL damage using Anterior Drawer Sign
Assesses for PCL damage using Posterior Drawer Sign

Special Tests

Assesses for meniscal tears using McMurray Test

Case 1 – Productive Cough

You are seeing Mr. Smith, a 60 year old man, in your outpatient clinic today for a worsening productive cough. Take a focused history of his complaint.

History

Onset of cough
Worsening cough
Sputum production and volume
Change in sputum color
Presence of blood in sputum
Associated shortness of breath
Fever
Chest pain
Recent respiratory illnesses
Smoking history (quantity in pack-years)
Other drug use
Personal history of lung disease
Occupational history to airborne toxins/irritants
Infectious contacts
Exposure to environmental allergens
Recent travel
TB exposure history

Physical

Inspection

Comments on presence of central/peripheral cyanosis (frenulum, lips, fingernails)
Comments on respiratory status – tachypnea /intercostal indrawing/accessory muscle use, etc.
Examines for thoracic deformities

Percussion/Palpation

Percusses all anterior and posterior fields and comments on findings
Uses percussion to estimate diaphragmatic excursion on the posterior chest
Assesses fremitus in all anterior and posterior fields and comments on findings
Evaluates chest expansion using palpation

Auscultation

Instructs patient to breathe while auscultating; listens for at least one full breath at each location of auscultation
Auscultates both lung fields in at least 5 different locations
Auscultates posterior fields, and asks patient to cross arms in order to shift scapulae away from the lung fields
Comments on of breath sounds and presence of adventitious sounds, e.g. crackles and wheezes

Case 1 – Shortness of Breath

You are seeing Mrs. Chan, an 81 year old female, in the ER for a one week history of progressive shortness of breath. Take a focused history of her complaint.

History

Onset and duration of shortness of breath
Progression of shortness of breath
Alleviating factors
Orthopnea
Asks about nighttime symptoms and paroxysmal nocturnal dyspnea
Association with cough
Chest pain
Palpitations
Leg swelling
Nocturia
Abdominal distension
Syncope, pre-syncope
Presence of fever, chills, and other systemic symptoms
Adherence to medications, diet
Personal history of CHF, CAD, MI, and CVA
Smoking history (quantity in pack-years)
Occupational history
Diabetes
Dyslipidemia
Hypertension
Current medications
Family history of heart disease
Effect on daily activities

Physical Examination

Inspection

Inspects patient, comments on respiratory status
States that weight should be measured for BMI/fluid overload status
Volume Status
Examines lower extremities for pitting edema
Examines JVP and comments on its estimated height
Measures pulse, comments on rate and rhythm
Evaluates patient’s orthostatic vitals
Examines the abdomen for ascites and a pulsatile liver, indicating right heart failure

Pre-cordium/Carotid

Palpates for the presence of thrills, heaves
Palpates PMI and comments on size, amplitude, duration, and location
Auscultates in all 4 areas of precordium with bell and diaphragm
Comments on presence of murmurs, extra heart sounds
Examines carotid arteries for bruits

Respiratory

Percusses posterior chest, comments on dullness
Auscultates all lung fields, commenting on presence of crackles, wheezes or other adventitious breath sounds