OSCE – General Review

Read the orientation file:

http://publications.mcc.ca/qeii-candidate-orientation/

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History

Key Questions:

Adult:

1. OPQRSTAAA: Onset, Position/Location, Quality, Radiation, Severity, Timing, Aggravating factors, Alleviating/ Relieving factors, Associated symptoms
   • Why is that a worry to you?
   • What can’t you do now that you can do before?
   • How has it affected your ability to work?
   • Do you have this before?
2. PMH, PSH, Medications, Family Hx
3. Social Hx: Tobacco/EtOH/Drugs, occupation, living / finance
   1. CAGE: Cut down, Annoyed, Guilty, Eye-opener / EtOH to steady nerves in AM
      • ask all 4 if any suspicious of EtOH abuse
4. Psychosocial – eg. home situation
5. Review of Systems

Child:

• Prenatal & Delivery – vacuum/forceps, resuscitation, GBS/Abx use
• Prenatal – APGARS; onset of respirations; birthweight

Score	0	1	2
Appearance	Blue / pale all over	Blue at extremities, body pink	no cyanosis
Pulse	Absent	<100bpm	>100bpm
Grimace	no response to stimulation	Grimace on suction or stimulation	Cry on stimulation
Activity	none	some flexion	flexed arms and legs that resist extension
Respiration	absent	Weak, irregular, gasping	Strong, lusty cry

• Feeding Hx – BF / Formula, vitD and iron supplements; solids
• Developmental milestones (see below)
• Sleep, toileting
• HEADSS for teenagers
• Immunizations

Selected Developmental Milestones
Speech	6 months 12 months 24 months 2-3 years	initiates sounds, eye contact 2 words beyond mama and dada 2-3 word phrases short sentences
Gross motor	6 months 9 months 12 months 15 months	roll over stand cruise walk
Fine motor	12 months 24 months	pincer grasp turns pages in a book
Social	6 months 9 months 2 years 5 years	stranger anxiety separation anxiety says “no” prints name

Abuse:

1. Many women tell me that someone at home is hurting or abusing them. How is it for you? Did somebody hit you?
2. Most parents get upset when their child cries or has been naughty? How do you feel? What do you do to discipline? Are you afraid you may hurt your child?

Sex:

1. Any problems or concerns with your sexual function?
2. Maintained interest/appetite for sex? Setting?
3. Erection (eg. morning erections)? Ejaculation?   Masturbation?
4. Changes in relationship or life situation?
5. General health (eg. smoking, peripheral vascular disease, meds, ETOH, depression)

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Symptoms & Approaches

GI

1. Abdo pain: assoc. w/ antacids, alcohol, eating, medications, defecation, urination & menstruation
2. Bowel function: nocturnal diarrhea
3. Nausea/vomiting
4. Weight & Appetite
5. Jaundice: color of urine/stools; pruritus: hepatitis risks (blood transfusions, IVDU, sexual contacts, etc.)

Urinary Tract

1. Voiding: urgency, frequency, dysuria, hesitancy, straining, weaker stream, dribbling, nocturia, polyuria, incontinence; polydipsia

2. Hematuria: beets, medications

OBSGYNE:

1. Gravida Preterm Term Abortion Living
2. Parity
3. Menarche; Menopause
4. Periods: regularity, duration, onset, amount, premenstrual symptoms (mood, weight, mastodynia, headaches)
5. menstrual discomfort
6. Amenorrhea: r/o pregnancy (frequency, N/V, fatigue)
7. Abdominal or pelvic procedures
8. Infections; Vaginal discharge; Sores or Lumps; Pruritus
9. Partners: number; multiple; high-risk, same-sex
10. Contraceptive Hx
11. PAP smear
12. Menopausal symptoms: hot flushes, dyspareunia, incontinence, depression

Musculoskeletal:

1. Joints: pain, swelling, redness, heat, stiffness, location, symmetrical, migration, limitation of motion
2. Activities: ADLs; climbing stairs; sitting; standing up from chair; pinch; writing
3. Generalized symptoms: fever, anorexia, weight loss
4. Rashes, Nails, Conjunctivitis, GI, Urethritis, Preceding sore throat

Nervous

1. Weakness: onset, progression, location, distal vs. proximal (eg. tripping for distal leg weakness)
2. Seizure disorders; Head injuries

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Differential Low Back Pain/Leg Pain

1. Common Low Back Pain

• pain relieved by rest, aggravated by moving, lifting or twisting motions
• lumbosacral area to posterior thighs but not below knee

2. Sciatica

• shooting pain to below knee in dermatomal distribution (L5, S1)
• paresthesia and possible local weakness
• pain on straight leg raising, decreased reflexes esp. ankle jerks

3. Lumbar stenosis

• worse with walking and improves with flexion of spine (eg sitting)
• Claudication relieves with rest and don’t require flexion or spine

4. Nocturnal Back Pain – r/o malignancy
5. Referred Pain – eg. pancreas, aortic aneurysm, peptic ulcer
6. Vascular

• CHECK DISTAL PULSES
• claudication: improves with rest not position, skin trophic changes
• in arteriosclerosis obliterans, relief with legs dependant
• in venous insufficiency, may have pigmentation and ulceration; relief with leg elevation

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 Seizures

1. Partial – unilateral or focal

• Simple – Motor (Jacksonian); Sensory; Autonomic (eg. epigastric discomfort, pallor or flushing);
• Psychic (flashback or hallucinations)

2. Complex – consciousness impaired; automatism may develop, aura
3. General – bilateral, consciousness impaired, no aura

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PHYSICAL EXAM:   Inspection – Palpation – Percussion – Auscultation

Eye

• a) Pupils – anisocoria (pupil inequality
• b) Narrow-angle glaucoma – crescentic shadow cast
• c) Inspect reflection in corneas for symmetry – strabismus (esotropia vs exotropia)
• d) Afferent pupillary defect (Marcus Gunn) – swinging flashlight test
• e) Argyll Robertson – do not react to light but reacts to near effort = CNS syphilis
• f) Diabetic retinopathy – microaneurysms, neovascularization, dot/blot hemorrhages
• g) Hypertension – cotton wool, hard exudates, copper wire arteries

Ears

1. Normal range 300 to 3000 Hz
2. Weber test (lateralization)
   • in conductive hearing loss, sound is heard in impaired ear.
   • in sensorineural hearing loss, sound is heard in good ear
3. Rinne test – AC>BC in sensorineural hearing loss

Respiratory

1. lower border: anterior (6th) and posterior (10th) at inspiration
2. check for cyanosis and clubbing
3. tactile fremitus – decreased with pleural effusion & pneumothorax; increased with pneumonia
4.  normal diaphragmatic excursion = 5-6 cm
5. bronchial breath sounds – loud and long expiratory phase with high pitch
6. egophony, whispered pectoriliquy = consolidation

Cardiovascular

1. JVP – axvy (atrial contraction-relaxation-filling-emptying); 4 cm ASA
   • a waves increase with tricuspid stenosis and disappear w/ a.fib.
2. S3 (ventricular gallop) – ventricular overloading (heart failure); S4 (atrial gallop) – increased ventricular stiffness (eg. hypertensive cardiomyopathy)
3. Splitting physiological increases with inspiration; paradoxical split in LBB and widened split in pulmonic stenosis
4. BP -in both arms (differential should not be >10 mm); check for postural hypotension (systolic drop > 20)
   • cuff: length equal to 80% and width equal to 40% of limb circumference
   • pulsus paradoxus – drop of >10 in systolic indicates tamponade, constrictive

pericarditis or obstructive airway disease

1. Apical impulse – increase duration w/ hypertension; displacement with enlargement
2. Murmurs:
   • Sit up and lean forward to auscultate aortic murmurs; innocent murmurs usually disappear on sitting or leaning
   • Grade 5 – steth partly off chest; 6 – entirely off chest
   • Pansystolic murmurs – regurg. across AV valves
   • Early diastolic – regurg. across semiluminar or aortic
   • Midsystolic – aortic stenosis & innocent murmurs
   • Presystolic & middiastolic – AV valve stenosis
   •  Continous – PDA
   • Increased stroke volume (eg. squatting, no Vasalva) increases intensity of aortic stenosis but decreases hypertrophic cardiomyopathy
3. Pulsus alternans – LVF; Large bounding pulse – aortic regurg.

Abdomen

• a) Check inguinal and femoral areas
• b) Listen for bruits (aorta, iliac, renal, femoral)
• c) Check upper and lower borders of liver (normal span – 6-7 cm)
• d) Spleen in Traube’s space (should remain tympanic even on inspiration)
• e) Mention DRE
• f) Kidneys, Aorta (normal width no more than 3 cm)
• g) Psoas sign – raise thigh against hand; Obturator sign – internal rotation of hip
• h) Intrabdominal mass obscured by contraction vs mass in wall

Genital

• a) retroverted vs retroflexed uterus
• b) thelarche: 8-13 yrs   menarche: 10-16 yrs

Pregnancy

• a) fundus at: pubic symphysis (12 w), umbilicus (20 w)
• b) softening of isthmus (Hegar’s),   engorged bluish cervix (Chadwick)
• c) breast tenderness, nausea/vomiting, urinary frequency, no menses
• d) Naegele = minus 3 months and add 7 days
• e) Lie, Position & Presentation

Peripheral Vascular

1. size, symmetry & swelling
2. venous pattern & engorgement
3. pigmentations, rashes, ulcers; gangrene – medial malleolus for venous insufficiency
4. colour, distribution of hair; trophic changes
5. check pulses & lymph nodes; temperature; cap refill; pitting edema
6. r/o DVT for leg swelling or pai
7. Trendelenburg – pt supine; elevate leg & occlude saphenous vein; ask pt to stand
   • normally, vein fills from below (35 sec)
   • release compression (normally, no additional filling)
8. Allen’s test
9. Marked pallor on elevation suggests arterial insufficiency with unusual rubor on depenency; cyanosis on dependency suggest venous insuffiency

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Muskuloskeletal

General approach:

• Inspection – swelling, redness of jts; deformities; surrounding tissues (eg. atrophy)
• Palpation – bony landmarks; heat; tenderness; crepitus; CHECK PULSES
• Range of Motion
• Strength

Hands & Wrist

• make a fist
• flex & extend, ulnar & radial deviation
• Heberden’s nodule – OA of DIP; snuff box for scaphoid fracture

Elbows

• carrying angle
• flex/extension; pronation/supination
• lateral epiconylitis (tennis elbow) with pain on extension

Shoulders

• landmarks: acromion, coracoid, clavicle, greater tubercle of humerus, scapula
• Inspection, palpation along all the bony landmarks and joints, ROM + special tests
• External rotation – test for Infraspinatus and Teres minor (elbow flexed to 90o)

TEST	MANEUVER	DIAGNOSIS SUGGESTED BY POSITIVE RESULT
Empty Can	elevate the arms against resistance while the elbows are extended, the arms are abducted and the thumbs are pointing downward.	Supraspinatus
Neer’s sign	Arm in full flexion while fully pronated	Subacromial impingement
Hawkins’ test	Forward flexion of the shoulder to 90 degrees and internal rotation	Supraspinatus tendon impingement
Drop-arm test	Arm lowered slowly to waist	Rotator cuff tear
Cross-arm test	Forward elevation to 90 degrees and active adduction	Acromioclavicular joint arthritis
Spurling’s test	Spine extended with head rotated to affected shoulder while axially loaded	Cervical nerve root disorder
Apprehension test	Anterior pressure on the humerus with external rotation	Anterior glenohumeral instability
Relocation test	Posterior force on humerus while externally rotating the arm	Anterior glenohumeral instability
Sulcus sign	Pulling downward on elbow or wrist	Inferior glenohumeral instability
Yergason test	Elbow flexed to 90 degrees with forearm pronated – pt supinate the arm against resistance	Biceps tendon instability or tendonitis
Push-off test	Internal rotated arm, pushing off the back against resistance	Subscapularis

Ankle & Feet

• dorsi/planter flexion (tibiotalar jt); eversion/inversion at two levels (talocalcaneal and transverse talar jts)
• drawer sign & Thompson sign
• hallux & tallus valgus/varus; pes planus

Knees

• bulge sign; balloon sign; ballotment test – effusion
• Patellar apprehension test; Patella-Femoral grinding test (chondromalacia);
  • McMurray test (external rotation & valgus stress) & Appley stress test;
  • Anterior Drawer test & Lachmann & Sag test; Collateral ligaments; Jt line tenderness

Hip

• leg length – ACIS to medial malleolus; flex knees
• Trendelenburg – test gluteus medius
• Thomas test – flexion deformity
• FABER test – SI joint (+ in sacroilitis of ankylosing spondylitis pt)

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Nervous System

• Corticospinal tracts cross over at medulla;
• spinothalamic (pain/temp) + crude touch cross over at level of cord;
• posterior columns (fine touch + vibration) cross over at medulla

PE:

• Body position; involuntary movements; muscle bulk / dystrophy
• Coordination – alternate movements (tap hand w/ ball of foot), point-to-point
• Tone (rigidity, spasticity, clonus), Strength (1- flicker; 2 -gravity eliminated)
• Gait – heel-to-toe (tandem), walk on toes & heels; shallow knee bend, rise from sitting
• Romberg (close eyes for 20 sec) with feet together
• Pronator drift – pronation or downward drift suggests contralateral lesion of corticospinal; upward or sideways suggest loss of proprioreception
  • tap arms downwards: weak arms easily displaced and remains so; may not correct if loss of proprioreption
• C5 – T1 sensory, motor, and reflex (expose biceps and brachial radialis to observe  the contractions)

• “Ok sign” Opposition of thumb – median;
• “spread your fingers” finger abduction – ulnar ;
• wrist dorsiflexion “stop a bus” – radial

Nerve Root	Motor	Sensory	Reflex
L2/3	Hip flexion, hip adduction	Thigh
L4/5	Hip extension, Hip abduction, ankle dorsiflexion	L4 – Knee, medial foreleg L5 – 1st interspace
L3/4	Knee extension		Patellar reflex
L5/S1	Knee flexion	S1 – Heel, lateral foot	Babinski’s – corticospinal
L5	Great Toe extension
S1/S2	Ankle plantarflexion		Achilles

• Start distal when testing sensation
  • Trigeminal nerve – facial sensation; jaw clench
  • C3 – back of neck; T4 – nipple; T10 – umbilicus;
  • L1- inguinal; L3- knee; L4- lateral cutaneous; L5- first dorsal interspace (superficial peroneal); S5 – peroneal
• Testing sensory cortex – stereognosis; graphesthesia, two-point discrimination
• Tinel & Phalens for carpal tunnel
• Babinski’s response (abnormal) – dorsiflexion of big toe
• Clonus- sharply dorsiflex foot and maintain; asterixis (hepatic encephalopathy)
• Brudzinki’s – flex neck causes flexion of hips & knees; Kernig’s – bilateral pain on knee extension
• LMN – ipsilateral upper/lower face paralysis; UMN – contralateral lower face

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Cranial Nerve Exam

• CN1 Olfactory – Smell
• CN 2 Optic – Visual acuity, Visual Fields, fundoscopy
• CN 2/3 – Pupillary light reflex, accommodation, swinging flashlight
  • (2 – afferent – Marcus Gunn pupil with releative afferent papillary defect)
• CN 3 (Oculomotor), 4 (Trochlear), 6 (abducens) – Pursuit “H” pattern (SO4LR6) + saccadic movement
• CN 5 Trigeminal
  • Motor – mastication (masseters + temporalis) – deviates jaw side to side, clench teeth & open mouth
  • Sensory – V1 forehead, V2 upper lip & cheek, V3 chin (ask pt to close his eyes)
• Corneal reflex (V1 – CN7) – bilateral blink
  • Jaw jerk (V2 – afferent to V3 – efferent) – increase response in pseudobulbar palsy
• CN 7 Facial
  • sensory – ant 2/3 of tongue taste
  • Motor – raise eyebrows (frontali), close eyes (orbicularis oculi), show teeth (buccinator), puff cheeks (orbicularis oris), tense neck muscle (platysma)
• CN8 Vestibulocochlear- Screen by whispering
• CN9 glossopharyngeal:
  • Sensory – posterior 1/3 tongue taste
  • Motor – palate elevation
• CN 10 Vagus: (sensory and motor) swallowing, phonation
  • Says Ah (uvula deviates away from lesion and palate falls towards lesion), Ka, Go (palatal speech)
• CN 9/10: Gag reflex
• CN11 spinal accessory: shrug shoulder & turn head
• CN 12 hypoglossal: tongue motor – fasciculations, atrophy, midline shift
  • Stick out tongue, push tongue to cheek, say Ma, Ka, La

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Unconcious Patient (ATLS)

• ABC and stabilize C-spine
• OMIP
  • O2 through non-breather mask, connect to the wall, and set to flush
  • BP monitor – cycle as fast as it can & ECG leads
  • 2 x 16G IV to anterior cubetal fosa
  • Pulse oximetry and ask for the O2 saturation
• D: pupils (light rxn often intact in metabolic) & GCS
• Exposure: Look for bleeding, Medical Alert & DNR status
• CXR, ECG, recheck vitals (constant reassessment)
• Secondary Survey
  • Ocular movements (gaze preference towards structural lesions and away from irritative lesions)
  • check for unusuall odors, look for needle marks or head trauma, skin color
  • Head to toe exam, DRE – check anal tone
• Foley, NG

Glasgow Coma Scale
Eye Opening	(E)	Verbal Response	(V)	Best Motor Response	(M)
Spontaneous To speech To Pain never	4 3 2 1	Oriented and converses Confused conversation Inappropriate words Incomprehensible sounds None	5 4 3 2 1	Obeys commands Localizes pain Withdrawal to pain Abnormal flexion (decorticate) Abnormal extension (decerebrate) Nil	6 5 4 3 2 1

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HIV Infection (signs)

• Skin – Kaposi’s sarcoma
• Oral – hairy leukoplakia (EBV)
• LN – non-Hodgkin’s lymphoma
• GI: HepatoSplenoMegaly

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Dermatology Nomenclature

Primary Lesions

• =<1cm
  • discoloration = macule
  • Palpable = papule
  • Palpable and deep = nodule
  • Vesicle = filled with fluid
• >1cm
  • macule –> patch
  • Papule –> Plaque
  • nodule –> tumor
  • Vesicle –> bullae
  • Others: burrow, Wheal, telangiectasia

Secondary lesions

• Scale – flakes
• Crust – drying of exudate
• Atrophy – thinning of epidermis / subcutaneous fat
• Lichenification – thickening (chronic rubbing / scratching)
• Erosions – slightly depressed area – part or all epidermis has been lost
• Excoriation – abraded skin (scratching / rubbing)
• Fissure – linear cleavage extends into the dermis
• Ulceration – necrosis of the epidermis & dermis
• Scar – permanent fibrotic changes
• Eschar – hard, darkend, plaque cover an ulcer
• Keloids – exaggerated connective tissue
• Petechaie < purpura < ecchymosis – don’t not blanch