Author: Tim Milligan

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

Case 1 – Acute Abdominal Pain

Tim Milligan Gastroenterology

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

Case 4 – Syncope

Tim Milligan Cardiovascular

You are seeing Mrs. Diaz, a 68 year old female, who is in your office because she says she has recurrent episodes of ‘fainting.’ Take a focused history of her complaint.

History

Syncope

  • Onset of syncope
  • Timing of syncope
  • Frequency
  • Duration of syncopal episodes
  • Activity surrounding syncope
  • Changes in position before syncope
  • Distinguishes if true syncope, i.e. full loss of consciousness

Pre-syncopal signs and symptoms

  • Distinguishes syncope from dizziness and vertigo
  • Chest pain before syncope
  • Shortness of breath
  • Palpitations
  • Focal neurologic deficits (vision, numbness, weakness)
  • Systemic neurologic deficits

Post-syncopal signs and symptoms

  • Post-ictal confusion
  • Incontinence
  • Weakness
  • Personal history of heart disease
  • Personal history of seizure
  • Cardiac risk factors
  • Family history of heart disease, seizure disorders

Case 3 – Volume Status

Tim Milligan Cardiovascular

Please assess the volume status of Mr. Kennedy, a 61 year old male, and comment on your findings.

Physical Examination

Vitals

  • Assesses heart rate by palpating the radial pulse
  • Measures blood pressure while supine
  • Assesses orthostatic changes by measuring blood pressure and heart rate with patient standing
  • Comments on vital signs findings of a patient who is hypovolemic

JVP

  • Observes JVP with correct patient position (30 degrees head-up-tilt); adjusts patient accordingly if JVP is not initially evident
  • Confirms JVP by changing angle of head of bed
  • Occludes JVP to confirm location
  • Comments on the multiple waveforms of the JVP
  • Comments on the JVP height

Peripheral Vasculature

  • Comments on capillary refill
  • Comments on skin turgor, mottling
  • Comments on mucus membranes
  • Examines for peripheral edema
  • Comments on peripheral temperature

Case 2 – Chest Pain

Tim Milligan Cardiovascular

You are seeing Mr. Alexander, a 55 year old male, in the ER for a one week history of worsening and debilitating chest pain. Take a focused history of his complaint.

History

  • Onset and duration of chest pain
  • Location of pain
  • Severity of pain
  • Alleviating factors
  • Aggravating factors, especially activity
  • Frequency of chest pain
  • Radiation of pain
  • Association with shortness of breath
  • Diaphoresis
  • Palpitations
  • Nausea/vomiting
  • Symptoms of syncope
  • Personal history of coronary artery disease and myocardial infarction
  • TIA/Stroke
  • Diabetes
  • Dyslipidemia
  • Hypertension
  • Smoking history (quantity in pack-years)
  • Family history of heart disease
  • Effect on daily activities/occupation
  • Patient’s concern as to the cause of the pain

Physical Examination

Inspection/Palpation

  • Inspects precordium for scars, pulsations
  • Palpates for the presence of thrills, heaves
  • Palpates PMI and comments on size, amplitude, duration, and location

Carotid/JVP

  • Examines JVP and comments on its estimated height
  • Palpates the carotid arteries bilaterally
  • Auscultates the carotid arteries for bruits

Auscultation

  • Auscultates in all 4 areas of precordium with bell and diaphragm
  • Comments on presence of murmurs, extra heart sounds
  • Auscultates the lungs