OSCE Stations

Case 3 – Tired Teenager

Tim Milligan Pediatrics

You are seeing Haley Schilling, a 15 year old female, who’s coming to your office today at the behest of her mother. She has recently become more tired and her mom is concerned that she has ‘low blood.’ Take a focused history from Haley.

History

  • Determines chief complaint is fatigue
  • Inquires about onset and duration of fatigue
  • Asks patient what she believes is causing her fatigue
  • Inquires about patient’s mood (“I often feel low”)
  • Inquires about association with other systemic symptoms – fever, chills, nausea (none)
  • Symptoms suggestive of thyroid disease (cold intolerance, skin/hair changes)
  • Excessive sleep (yes)
  • Increasing weight, increasing appetite (yes)
  • Feelings of worthlessness/guilt/isolation
  • Pre-occupation with self image
  • Poor concentration
  • Psychomotor activation or retardation (activation)
  • Suicidal ideation
  • Suicide attempts
  • History of self-harm behavior
  • Symptoms of mania
  • Symptoms of anxiety
  • Symptoms of psychosis
  • Establishes social context of child’s home-life and relationship with family
  • Inquires about how the patient is adapting in school
  • Relationship/sexual history
  • Activities outside of school
  • Past medical history
  • Past history of depression and other psychiatric illnesses
  • Current medications
  • Alcohol, smoking, and drug history
  • Legal history
  • Current social supports
  • Family history of psychiatric illnesses

Case 2 – Infant Diarrhea

Tim Milligan Pediatrics

You are seeing Mrs. Bosco, a 25 year old female who recently gave birth to a baby named Michael six weeks ago. Today, she presents to your office because she is concerned about the baby’s health. Take a focused history of Mrs. Bosco’s complaint.

History

  • Determines chief complaint is diarrhea
  • Volume of diarrhea (i.e. frequency of diaper change)
  • Appearance of diarrhea (appears brown, with no blood)
  • Associated nausea/vomiting
  • Lethargy
  • Child’s level of activity
  • Fever and peak temperature
  • Changes in urination, including odor
  • New rashes
  • Symptoms of URTI
  • Recent weight loss
  • Volume of oral intake
  • Infectious contacts
  • Past medical history (none)
  • Asks about developmental milestones appropriate for child’s age
  • Pregnancy history (normal)
  • Vaccinations to date
  • Allergies (none)
  • Current medications (none)
  • Inquires about mother’s stress, caregiver burden
  • Inquires about mother’s support for the care of the infant
  • Inquires about post-partum depression
  • Inquires about mother’s other concerns related to raising her infant

Case 2 – Sore Throat

Tim Milligan Ophthalmology and Otolaryngology

You are seeing Tom, a 10 year old boy, in your outpatient clinic today for a sore throat. Take a focused history of his complaint and perform the relevant physical examination.

History

  • Onset of sore throat
  • Severity
  • Alleviating factors
  • Aggravating factors
  • Change in voice
  • Presence of fever
  • Odynophagia
  • Associated cough, sputum production
  • Shortness of breath
  • Neck tenderness and swelling
  • Otalgia
  • Recent upper respiratory illness
  • Personal history of throat infections
  • Infectious contacts
  • Allergies to medication
  • Vaccination history
  • Development history

Physical Examination

Oropharynx

  • Uses tongue depressor and light to examine oropharynx
  • Comments on the presence of erythema and exudates in oropharynx
  • Comments on other findings in the oropharynx e.g. enlarged tonsils, lesions, deviated uvula

Node Examination

  • Palpates the lymph nodes of the head and neck
  • Names the nodal regions which are being palpated
  • Comments on the size, texture, mobility, and location of nodes that are identified
  • Asks patient about tenderness during examination

Respiratory

  • Auscultates in all lung fields
  • Comments on findings

Case 5 – Dizziness

Tim Milligan Ophthalmology and Otolaryngology

You are seeing Mr. Rodriguez, a 31 year old man, because he often feels dizzy. Take a focused history and perform the Dix-Hall Pike maneuver.

History

  • Clarifies symptoms are descriptive of vertigo (‘the room spinning around’)
  • Duration of dizziness
  • Frequency
  • Associated activity, especially head turning
  • Other precipitants
  • Aural fullness (none)
  • Decreased hearing from one ear
  • Tinnitus (none)
  • Otalgia (none)
  • Syncopal episodes
  • Chest pain or shortness of breath
  • Nausea or vomiting
  • Vision changes
  • Sensory deficits (none)
  • Motor deficits (none)
  • Trauma to either ear
  • Previous episodes of otitis media
  • Smoking and alcohol history
  • Effect on daily activities

Dix-Hallpike Maneuver

  • Explains procedure to patient, and what they might expect
  • Asks patient to lie down and tilts head back and towards one side
  • Repeats maneuver on opposite side
  • Comments that they are looking for geotropic nystagmus towards affected ear
  • Comments on reversal when leaning toward non-affected ear

Case 4 – Neck Mass

Tim Milligan Ophthalmology and Otolaryngology

You are seeing Mrs. Nguyen, a 52 year old woman, because she noticed a large swelling on her neck. Take a focused history and perform a focused head and neck examination.

History

  • Clarifies location of mass (patient thinks it’s on the her right side of her neck)
  • Onset of mass
  • Progression in size
  • Pain
  • Dysphagia
  • Odynophagia
  • Change in voice
  • Symptoms suggestive of hyperthyroidism
  • Symptoms suggestive of hypothyroidism
  • Systemic symptoms – weight loss, night sweats, anorexia
  • Infectious symptoms – nausea/vomiting, fever, diarrhea
  • Past medical history
  • Personal history of malignancy
  • Exposure to head and neck irradiation
  • Exposure to tobacco, smoking, alcohol, and betel nuts
  • Asks patient about ethnic origin (South East Asia)
  • Personal history of thyroid disease
  • Family history of thyroid disease
  • Family history of head and neck cancer

Physical Examination

Inspection

  • Comments on location of mass and any neck asymmetry
  • Comments on stigmata of hyperthyroidism in head and neck (exophthalmos, lid lag, etc.)
  • Comments on stigmata of hypothyroidism in head and neck (skin and hair changes)
  • Comments on size of thyroid and observes thyroid as patient swallows

Palpation

  • Comments on quality, size, and mobility of mass (mass is hard, irregular, and tethered)
  • Comments on size of mass (~2 cm in diameter)
  • Palpates all lymph node regions of the head and neck
  • Names the regions which are being palpated
  • Comments on the size, texture, mobility, and location of nodes that are identified
  • Asks patient if palpation is tender
  • Palpates both lobes of the thyroid; comments on size and nodularity
  • Auscultates thyroid and comments on absence of bruits

Case 3 – Hearing Difficulty

Tim Milligan Ophthalmology and Otolaryngology

You are seeing Mr. Syed, a 73 year old man, in your outpatient clinic. He says that his family members have told him that they have a difficult time communicating with him because he has poor hearing. Take a focused history, and perform the pertinent physical examination maneuvers.

History

  • Inquires whether patient is aware of hearing loss (he agrees)
  • Onset of hearing difficulty
  • Settings in which difficulty is worst (noisy crowds)
  • Whether hearing difficulty is worse with specific frequency (patient unsure)
  • Otalgia
  • Exudation from ear, including pus and blood (none)
  • Phonophobia
  • Tinnitus
  • Vertigo
  • Associated neurologic deficits elsewhere in the body
  • Vision loss
  • Headache
  • Use of ear plugs
  • Trauma to the ear, including digital
  • Past history of cerumen
  • Use of any hearing aids
  • Past history of hearing difficulty
  • Past exposure to noise (including occupational history)

Physical Examination

Inspection

  • Comments on the gross appearance of both ears
  • Uses otoscope to examine the auditory canal, commenting on its appearance
  • Examines tympanic membrane and comments on its appearance

Special Tests

  • Performs the Rinne Test bilaterally
  • Performs the Weber Test
  • Interprets the results of these two tests
  • Performs whisper test bilaterally

Case 1 – Blurry Vision

Tim Milligan Ophthalmology and Otolaryngology

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 5 – Worsening Tremor

Tim Milligan Neurology

You are seeing Ms. Wilmington, a 63 year old woman, in your outpatient clinic. She tells you that her old tremor is getting worse. Take a focused history of her complaint and perform a focused physical exam.

History

  • Onset of tremor
  • Onset of worsening of the tremor
  • Clarifies if tremor occurs during rest or activity (rest)
  • Difficulty performing specific tasks due to tremor (writing)
  • Change in gait – slowing, fewer steps, less arm swing
  • Stability of gait
  • Need for assistive devices for ambulation
  • Difficulty with fine motor skills
  • Posture changes
  • Difficulty initiating movement
  • Psychomotor retardation
  • Change in affect
  • Difficulty with short term memory
  • Change in voice
  • Effect on ADLs
  • Effect on IADLs
  • Personal history of a psychotic disorder
  • Family history of Parkinson’s and/or essential tremour
  • Current medications
  • Addresses patient’s concerns as to what is causing these symptoms
  • Inquires about symptoms of depression
  • Patient’s concerns about independence

Physical Examination

Vitals/Inspection

  • Measures orthostatic changes – comments on hypotension
  • Inspects for masked face (none)
  • Comments on stooped posture
  • Comments on presence of resting tremor
  • Comments on altered speech

Motor Examination

  • Tests tone in upper extremities – comments on presence of cogwheeling
  • Tests for essential tremor, likely not present
  • Tests for intent tremor, likely not present

Sensory Examination

  • Tests reflexes (normal)
  • Tests for primitive reflexes associated with Dementia – palmomental and glabellar
  • States that a sensory examination should be performed, though it would be normal

Gait Examination

  • Evaluates patient getting up from chair, comments on bradykinesia
  • Comments on shuffling gait
  • Comments on stability of gait
  • Comments on festinating gait and lack of arm swing
  • Performs retropulsion test (positive)

Case 4 – Headache

Tim Milligan Neurology

You are seeing Ms. Davis, a 32 year old woman, in your ambulatory clinic today. She states that she has had a worsening headache over the last week. Take a focused history of this complaint. Then, examine all cranial nerves except for I, II, & VIII.

History

  • Onset and duration of headache
  • Location of headache, unilateral vs. bilateral (entire head, bilateral)
  • Severity
  • Frequency
  • Radiation
  • Quality of headache (dull, diffuse)
  • Alleviating factors
  • Triggers for the headache/aggravating factors
  • Temporal association (headache not worse in mornings)
  • Association with nausea/vomiting
  • Vision changes before or during headache
  • New sensory symptoms: weakness, numbness, tingling in upper or lower extremities
  • Photophobia/phonophobia
  • Association with menstrual cycle
  • Systemic symptoms – weight loss, low energy, anorexia
  • Fever and neck stiffness
  • Personal history of head trauma
  • Personal history of migraines
  • Family history of migraines
  • Effect on daily activities
  • Use of oral contraceptive pills
  • Caffeine intake
  • Smoking and alcohol history

Physical Examination

CN III, IV, & VI

  • Assesses all six cardinal movements of the extra ocular muscles
  • Asks patients about diplopia in all directions of gaze
  • Comments on absence of nystagmus
  • Comments on absence of ptosis

CN V

  • Examines for light touch in all three nerve divisions (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 jaw movement
  • States that the corneal reflex should be tested and explains the procedure

CN VII

  • Raise eyebrows
  • Tightly clench eyes (and tries to open them)
  • Puff cheeks (and tries to deflate them)
  • Show the lower teeth only
  • Comments on the presence/absence of facial asymmetry/droop

CN IX & X

  • Assesses palatal elevation
  • Assesses gag reflex with tongue depressor
  • Asks patient to swallow
  • Tests phonation
  • States that taste on the posterior 1/3 of the tongue should be tested, and describes how

CN XI

  • Assesses power of both sternoclediomastoid muscles
  • Assesses power of both trapezius muscles

CN XII

  • Examines the tongue for fasciculations
  • Asks patient to protrude tongue, examines for deviation
  • Assesses power of tongue in lateral plane

Case 3 – Seizure

Tim Milligan Neurology

You are seeing Oleg Markov, a 15 year old male, in your ambulatory clinic today. He states that he has recently experienced moments during the day where he loses awareness for minutes at a time but soon fully recovers. Take a focused history of this complaint.

History

  • Onset and duration of awareness deficit
  • Frequency
  • Factors which precipitate these episodes
  • Injury sustained as a result of the seizure
  • Post-ictal symptoms: confusion
  • Associated sensory deficits
  • Associated motor deficits
  • Associated cognitive deficits
  • Muscle spasms
  • Anatomical progression of motor involvement (e.g. Jacksonian March)
  • Symptoms suggesting aura
  • Associated incontinence
  • Tongue biting and salivation
  • Automatisms associated with these episodes
  • Personal history of head trauma
  • Congenital neurological disorder
  • Perinatal infection
  • Medications
  • Drug history
  • Personal history of seizure disorder
  • Family history of seizure disorders
  • Effect on daily activities