Articles

Case 1 – Knee Injury

Tim Milligan Musculoskeletal

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 4 – Diabetes

Tim Milligan Geriatrics

You are seeing Mrs. Rajwal, a 69 year old woman, who feels concerned about her health. She heard that her sister was recently diagnosed with diabetes and wonders if she is at risk of developing the disease as well. Take a focused history, addressing Mrs. Thompson’s concern.

History

  • Addresses patient’s concerns about diabetes
  • Establishes patient’s ethnicity
  • Polydipsia, polyuria
  • Nocturia
  • Fatigue
  • Blurry Vision
  • Parasthesias/numbness in peripheries
  • Lower extremity ulceration or infection
  • Skin darkening
  • Weight history: gain/loss
  • Asks about diet history
  • Current medications/Allergies
  • Personal history of gestational diabetes
  • Personal history of myocardial infarction and stroke
  • Personal history of renal disease
  • Peripheral vascular disease (patient has intermittent claudication)
  • Dyslipidemia
  • Hypertension
  • Smoking history (quantity in pack-years)
  • Family history of Type II diabetes mellitus
  • Family history of cardiac or cerebrovascular events

Case 3 – Sleep Problems

Tim Milligan Geriatrics

You are seeing Mr. Le, an 83 year old man, because of recent sleep problems. He says he hasn’t had a full night’s sleep in over a week. He currently lives alone. Please take a focused history.

History

  • Onset and duration of insomnia
  • Amount of sleep per night
  • Quality of sleep
  • Activating medications
  • Activities before sleep: coffee, alcohol, exercise, smoking
  • Disturbances during sleep: night terror, orthopnea, nocturia, restless leg, obstructive sleep apnea
  • Smoking and alcohol history
  • Thought content during periods of insomnia
  • Establishes social context (wife has recently been admitted to hospital for ‘failure to cope’)
  • Effect on daily activities
  • Day time somnolence
  • Inquires about what patient believes the insomnia is due to
  • Asks about guilt
  • Asks about low mood
  • Poor concentration
  • Poor appetite
  • Psychomotor retardation
  • Asks about life stresses, e.g. care-giver stress
  • Homicidal/suicidal ideation
  • Psychotic symptoms
  • Symptoms of anxiety
  • Past history of depression
  • Past history of psychiatric illness

Case 2 – Uncontrolled Blood Pressure and Elder Abuse

Tim Milligan Geriatrics

You are seeing Mr. Sampson, a 71 year old man, for the first time in 3 years. He says he hasn’t had his blood pressure checked recently and would like you to assess it today. He wanted to come sooner but says he couldn’t. Please take a focused history.

History

  • Inquires about patient’s well being since last visit
  • Establishes social context – patient lives alone with son
  • Establishes sons’ social context (has recently lost his job, divorced)
  • Inquires about independence regarding finance, health, transportation
  • Inquires about aggression from son
  • Establishes past history of injuries and abusive behavior by son
  • Extent of medical attention sought/needed for past injuries
  • Inquires if son was verbally abusive
  • If son has used weapons to harm patient, or has access to weapons
  • Substance abuse by the son and quantity (abuses alcohol weekly)
  • Assesses patient’s access to health care/medication
  • Asks if patient feels safe at home
  • Whether friends/family are aware of the abuse
  • Emergency plans to escape in the event of further abuse
  • Asks if he has access to financial resources
  • Asks if he would like help from a counselor
  • Asks if he would like support from community resources
  • Asks if he would like legal counseling
  • Addresses patient’s concern about loss of independence and lack of power

Case 1 – Feeling Slow

Tim Milligan Geriatrics

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)

General OSCE Tips

Tim Milligan General OSCE Tips

History Tips

The following are essential for a complete history:

  • All the features of the chief complaint (onset, duration, alleviating and aggravating factors, frequency, etc.)
  • Past medical history
  • Smoking/Alcohol use, as well as illicit drug use
  • Allergies
  • Current medications, including over the counter medications, herbs, and supplements
  • Family history relevant to the presenting complaint
  • How the present complaint is affecting the patient’s life
  • What the patient thinks is accounting for their symptoms

Physical Examination Tips

The student should always do the following during the exam:

  • Introduce the physical examination and ask the patient for permission to examine them
  • Always wash hands or use alcohol solution before examining the patient
  • Position the patient appropriately
  • Drape the patient appropriately, especially when sensitive parts of the body are being examined
  • Comment, out loud, about what you are examining for
  • Comment to the examiner about your findings
  • For exams that require examination of both sides of the body, complete the exam on one side and ask the examiner if he/she would like the student to examine the opposite side

Case 5 – Jaundice

Tim Milligan Gastroenterology

You are seeing Mr. Jamison, a 45 year old known alcoholic, in the ER because he states that his skin color has recently changed. Please perform a focused physical examination.

Physical Examination

Inspection

  • Comments on overall appearance
  • Comments on proximal and temporal muscle wasting
  • Examines sclera, frenulum, and skin for icterus
  • Examines upper thorax, neck, and head for spider nevi
  • Examines abdomen for caput medusa
  • Examines for asterixis

Examination of the hands

  • Examines for nail changes
  • Examines for flexion contractures
  • Comments on palmar erythema
  • Examines for thenar muscle wasting

Examination of the Abdomen

  • Estimates liver span using palpation and percussion
  • Comments on size and texture of the liver
  • Palpates for splenomegaly
  • Percusses in Traube’s Space
  • Percusses for Castell’s Sign

Examination for Ascites

  • Comments on presence of bulging flanks from the foot of the bed
  • Percusses abdomen for presence of ascites
  • Examines for Shifting Dullness (positive)
  • Performs Fluid Wave Test (positive)

Case 4 – Recurrent Abdominal Pain

Tim Milligan Gastroenterology

You are seeing Mrs. Park, a 62 year old female, in the ER for recurring abdominal pain that has recently worsened. She would like to know what’s been causing this pain and comes to you for investigations. Please take a focused history and perform a focused physical examination.

History

  • Onset and duration of pain
  • Location of pain (right upper quadrant)
  • Alleviating and aggravating factors
  • Quality of pain
  • Radiation of pain
  • Frequency of pain
  • Association of pain with specific food (worse with greasy/fatty foods)
  • Associated nausea/vomiting and fever
  • Change in appearance of stools (pale)
  • Presence of blood in stools
  • Change in bowel habit
  • Recent weight loss
  • Change in urine color (tea colored)
  • Decreased appetite
  • Previous abdominal surgery
  • Past history of similar symptoms
  • Personal history of gastrointestinal disease
  • Alcohol history
  • Effect on daily activities

Physical Examination

Inspection

  • Inspects abdomen for masses, scars
  • Comments on presence of scleral icterus
  • Comments on absence of extra-hepatic stigmata of liver disease
  • Percussion/Palpation/Auscultation
  • Percusses abdomen and estimates liver span by percussion
  • Palpates for tenderness (patient has tenderness in right upper quadrant)
  • Monitors patient’s reaction to palpation, commenting on guarding
  • Assesses for rebound tenderness
  • Palpates for splenomegaly
  • States that they would perform a digital rectal examination as part of the abdominal examination
  • Assesses for Murphy’s Sign (positive)
  • Auscultates in all four quadrants of the abdomen

You are seeing Mrs. Park, a 62 year old female, in the ER for recurring abdominal pain that has recently worsened. She would like to know what’s been causing this pain and comes to you for investigations. Please take a focused history and perform a focused physical examination.

History

  • Onset and duration of pain
  • Location of pain (right upper quadrant)
  • Alleviating and aggravating factors
  • Quality of pain
  • Radiation of pain
  • Frequency of pain
  • Association of pain with specific food (worse with greasy/fatty foods)
  • Associated nausea/vomiting and fever
  • Change in appearance of stools (pale)
  • Presence of blood in stools
  • Change in bowel habit
  • Recent weight loss
  • Change in urine color (tea colored)
  • Decreased appetite
  • Previous abdominal surgery
  • Past history of similar symptoms
  • Personal history of gastrointestinal disease
  • Alcohol history
  • Effect on daily activities

Physical Examination

Inspection

  • Inspects abdomen for masses, scars
  • Comments on presence of scleral icterus
  • Comments on absence of extra-hepatic stigmata of liver disease
  • Percussion/Palpation/Auscultation
  • Percusses abdomen and estimates liver span by percussion
  • Palpates for tenderness (patient has tenderness in right upper quadrant)
  • Monitors patient’s reaction to palpation, commenting on guarding
  • Assesses for rebound tenderness
  • Palpates for splenomegaly
  • States that they would perform a digital rectal examination as part of the abdominal examination
  • Assesses for Murphy’s Sign (positive)
  • Auscultates in all four quadrants of the abdomen

Case 3 – Vomiting

Tim Milligan Gastroenterology

You are seeing Frank, a 27 year old homeless male, who was brought into the ER by police because he was found vomiting in a nearby alleyway. Take a history of his complaint. Then, perform a focused physical examination.

History

  • Onset of vomiting
  • Contents/ appearance of vomitus
  • Blood in vomit
  • Recent alcohol intake
  • Change in bowel habit
  • Association with abdominal pain
  • Severity of abdominal pain
  • Radiation of abdominal pain
  • Association of abdominal pain with position (worse when supine)
  • Fever
  • Relevant social history, including current housing state
  • Alcohol history
  • Assessment for alcohol abuse (CAGE)
  • Drug history
  • Hepatitis status, past vaccination

Physical examination

Inspection/Auscultation

  • Comments on patient’s overall appearance, including jaundice and muscle wasting
  • Notes any stigmata of chronic liver disease
  • Inspects for masses and bulging flanks
  • Inspects for Cullen’s and Grey Turner’s signs
  • 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 in epigastrum, commenting on guarding
  • Assesses for peritoneal findings, including rebound and shake tenderness
  • Estimates liver span using percussion
  • Palpates for splenomegaly
  • States that they would perform digital rectal examination as part of the abdominal examination

Special Maneuvers

  • Assesses if pain varies with position (comments that pain associated with pancreatitis is somewhat alleviated when patient leans forward)
  • Assesses for asterixis and ascites

Case 2 – GI Bleeding

Tim Milligan Gastroenterology

You are seeing Mr. Martin, a 58 year old male, in the ER for a one-week history of dark stools. Take a focused history of his complaint.

History

  • Onset of symptom
  • Change in bowel habit
  • Appearance of stool – distinguishes melena from bright red blood per rectum
  • Association with bowel movements
  • Tenesmus
  • Incomplete voiding
  • Pain on defecation
  • Abdominal pain
  • Dyspepsia
  • Symptoms of reflux
  • Nausea and vomiting
  • Systemic symptoms, especially weight loss
  • Personal history of constipation and/or hemorrhoids
  • Personal history of gastrointestinal ulcers
  • Country of origin (risk factor for H. Pylori infection)
  • NSAID use
  • Smoking history (quantity in pack-years)
  • Alcohol use
  • Hepatitis status
  • Past colonoscopy and upper endoscopy
  • Family history of gastrointestinal cancers