Articles

Case 3 – Arm Pain Spousal Abuse

Tim Milligan Musculoskeletal

You are seeing Mrs. McNeil, a 31 year old female in your general practice clinic. She states that she recently injured her arm while cleaning her home. Take a focused history of her complaint.

History

  • Inquires about circumstances in which injury occurred
  • Timing of injury
  • Mechanism (patient eventually discloses that she had been physically abused by her husband)
  • Other recent injuries
  • Visits to hospital for other reasons
  • Asks about any medication use
  • Alcohol/drug history
  • Determining social context at home (lives with husband, two young children)
  • Inquires if husband was verbally abusive
  • Inquires if husband was sexually abusive
  • Whether husband has used weapons to harm patient, or has access to weapons
  • Extent of injury in the past
  • Asks if the children have been abused
  • Asks if the children have witnessed spousal abuse
  • Asks if the husband has a substance abuse problem
  • Asks if patient feels safe at home
  • Asks if friends/family are aware of the abuse
  • Inquires about emergency plans to escape in the event of further abuse
  • Asks if she has access to financial resources
  • Asks if she would like help from a counselor
  • Asks if she would like support from community resources
  • Asks if she would like legal counseling

Case 2 – Hip Pain

Tim Milligan Musculoskeletal

You are seeing Mrs. Goldberg, a 76 year old female from a nursing home who has been well until today. She presents to the Emergency Department after being found on the floor of her room in her nursing home. She was alert and oriented when she was found, and has felt well in recent days. Take a focused history and perform all the relevant physical examination maneuvers.

History
Physical Examination

Inspection

  • Examines both hips joints for SEADS (swelling, erythema, muscle atrophy, deformity, skin changes)
  • Assesses all active range of motion for both hips (flexion/extension, abduction/adduction, rotation)
  • Assesses patient’s gait (patient refuses due to pain)
  • States that the lower back and knees should be examined as well

Palpation

  • Palpates hips, PSIS, and ASIS for tenderness
  • Determines real and apparent leg lengths (notes that there is a significant difference)
  • Assesses peripheral pulses
  • Assesses neurologic status of effected limb
  • Tests all passive range of motion for effected hip

Special Tests

  • Performs Trendelenburg’s Test assessing for hip abductor strength
  • Assesses for flexion contracture of effected hip while eliminating lumbar lordosis

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 (OSCE Station)

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 (OSCE Station)

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