Final OSLER script

Question 2

First 3 steps of abdominal PE

Answer 2

1) Pt is showing no signs of distress.
2) Make sure all of abdomen is visible:
○ Abdomen is flat and not protuberant with no discoloration or cellulitis
○ No masses or pulsations of the aorta, no surgical scars
3) Listen in all 4 quadrants with stethoscope
○ Bowel sounds are present in all 4 quadrants and not hypo or hyperactive

Question 3

Steps 3-5 of an abdominal PE

Answer 3

3) Listen to bruits with the bell at:
○ the aorta beneath xiphoid process (midline).
○ just laterally and inferior to this for renal arteries (bilaterally).
○ just lateral and inferior to umbilicus for iliac arteries (bilaterally).
○ groin for femoral arteries
○ No evidence of bruits
4) Percuss all 4 quadrants
○ Percussion is consistent with no excessive dullness
5) Percuss organs; bladder, spleen (left), liver (right)
○ No increased dullness

Question 4

Steps 6-8 of an abdominal PE

Answer 4

6) Have pt lay down supine and bend knees. Begin light palpation and ask if any tenderness.
○ No masses, induration, rigidity, or tenderness or pain to palpation.
7) Feel for spleen (left rib, ask pt to hold breath), liver (right rib), kidneys bilaterally (posterior pressure) bladder
○ No palpation of the spleen.
* Palpate down midline
○ No large midline pulsatile mass
8) Check CVA tenderness bilaterally; tap on each side of middle lower back
○ No tenderness to palpation

Question 5

How do you perform McBurney’s point for appendicitis? What do you verbalize?

Answer 5

Draw a line from the ASIS to umbilicus, find the midpoint, go two inches inferior to this, palpate McBurney Point for local tenderness. Any pain?
No tenderness with palpation

Question 6

How do you perform Rovsing sign for appendicitis? What do you verbalize?

Answer 6

Palpate deeply and evenly in the LLQ and quickly let go
Any pain here? point to right lower quadrant
No tenderness in RLQ or referred rebound pain, Rovsing sign is absent

Question 7

How do you perform Psoas sign for appendicitis? What do you verbalize?

Answer 7

Have patient flex Right hip against your resistance on the R thigh
Psoas sign is absent

Question 8

How do you perform Obturator sign for appendicitis? What do you verbalize?

Answer 8

Flex patient’s right leg at hip and with knee bent, rotate leg internally
-Right hypogastric pain is + obturator sign secondary to inflamed muscle
§ Ask if any right hypogastric pain (point)
§ Obturator sign for appendicitis is absent.

Question 9

How do you perform Murphy’s sign for cholecystitis? What do you verbalize?

Answer 9

Palpate under R costal margin as the patient inspires, ask if any tenderness with inspiration
No arrested breathing or increased tenderness with inspiration, Murphy’s sign for cholecystitis is absent.

Question 10

List the first 4 steps of the active ROM part of the MSK exam

Answer 10

1) Flex, extend, rotate, and laterally bend neck to each side
-Look down, up, look left to right, bend neck left and right
2) Flex and extend shoulder, externally and internally rotate shoulder, abduct and adduct shoulder.
-Move arm forward and back, away from body and toward body, put arms up like a goal post and then put behind back like a soldier.
3) Supinate and pronate and flex and extend elbow
-Palm up, palm down, pretend to do bicep curl
4) Flex, extend, abduct, and adduct wrist
-Bend wrist in and out, move wrist toward body and away from body when down by side

Question 11

List steps 5-7 of the active ROM part of the MSK exam

Answer 11

5) Flex, extend, abduct, and adduct fingers, flex against resistance (lock fingers)
-Make a fist, uncurl fist, put fingers together, spread fingers out
6) Flex, extend, abduct, and adduct thumbs
-In AP: Thumb away from hand (abd), thumb toward hand (add), put thumb on top of palm (flex) and then move back (ext)
7) Flex, extend, rotate, and laterally bend spine to each side
-Lean forward and backward, rotate left and right, lean left and right

Question 12

List steps 8-11 of the active ROM part of the MSK exam

Answer 12

8) Flex, extend, abduct, adduct, and externally and internally rotate hips
-Move leg forward and back, away from midline and toward midline, point foot in and out
9) Flex and extend knee
-Touch foot to butt when standing, then put foot back down
10) Plantar flexion, dorsiflexion, inversion and eversion of foot.
11) Hip: observe gait

Question 13

List the next step of the MSK exam after active ROM

Answer 13

Shoulder:
1) Palpate acromion (on top), greater tubercle
2) Palpate clavicle from SC joint to AC joint
3) Passive ROM: grab their arm and move it forward (flexion) and abduction (out)

Question 14

List how to do a standing elbow exam

Answer 14

1) Palpate epicondyles and space bt epicondyles and olecranon.
2) Resisted/ strength: flexion/ extension (have them try to open and close arm against yours)

Question 15

What should you do after the standing elbow portion of the MSK exam?

Answer 15

Wrist:
1) Palpate distal radius and ulna, carpals, phalanges, and anatomic snuff box
2) Flex and extend wrist against resistance.

Question 16

How do you perform a standing hip/ spine exam?

Answer 16

1) Look at spine and palpate the entire spine (spinous processes), ask if tender.
2) Palpate iliac crest, ASIS, greater trochanter, SI joint, posterior ilium, and sacrum
○ No tenderness of spinous processes or paravertebral muscles. No spasm of paravertebral muscles.
○ Curvature of cervical, thoracic, and lumbar spines are appropriate
○ Shoulders and iliac crests are appropriately aligned.

Question 17

What are the first 2 things you should do once you have the pt laying down in an MSK exam?

Answer 17

1) Passive ROM hip (lift their leg up and down with knee straight)
2) Resisted hip: have pt try to lift their leg up (flex) against your arm stopping them

Question 18

What are the last 3 steps of the laying down portion of an MSK exam?

Answer 18

1) Palpate knee: quads, patella, patellar tendon/ infrapatellar spaces, anterior tibial joint line
2) Passive ROM knee: bend and straighten their knee (flexion/ extension)
3) Palpate anterior joint lines, Achilles tendon, heel, malleoli (med and lat), tarsals, metatarsals, phalanges.

Question 19

After you have the pt move from laying to sitting, what should you do?

Answer 19

Resisted flexion/ extension of knee (kick and pull leg back against u)

Question 20

What 4 things should you say after you’ve finished your MSK exam?

Answer 20

1) No swelling, crepitus, bony deformity, or asymmetry and alignment is appropriate.
2) No redness, warmth, swelling, or pain (inflammation).
3) No skin changes, atrophy, or systemic illness.
4) ROM of all joints is appropriate.

Question 21

What 8 dermatomes should you test

Answer 21

(already did CNV)
C3: from lower neck over clavicles to shoulders
T4: side boob
T10: sides of stomach
C6: radial/ lateral side of lower arm
C8: ulnar/ medial side of lower arm
L1: inguinal region (defer)
L4: outer thigh to inner thigh inferiorly
L5: outer calf to inner calf inferiorly

Question 22

Steps 2-3 of a nervous exam

Answer 22

2) Vibration: use big tuning fork, ask if pt can feel on hand and foot
a. Sensation is intact
3) Strength: ask pt to grip two of your fingers in each hand as hard as they can
a. Grip strength is appropriate

Question 23

Steps 4-5 of a nervous system exam

Answer 23

4) Have pt close eyes, tell them this is what one point feels like and this is what two feels like. Then ask them if it’s one or two on both hands and feet.
5) Ask pt to identify 2 numbers you draw on their palms
a. Discriminative sensation is intact

Question 24

Step 6 of a nervous system PE

Answer 24

6) Reflexes:
a. Biceps: C5, C6
b. Triceps: C6, C7 (hold pt’s arm)
c. Brachioradialis: C5, C6
d. Quadriceps: L2-4
e. Achilles: S1
Reflexes are all intact and a 2 bilaterally

Question 25

Step 7/7 of a nervous system PE

Answer 25

7) Ask pt to touch their finger to their nose, then to your finger, with each hand. Then ask pt to touch their heels to their shins.
a. Cerebellar function is intact

Question 26

First step of a peripheral vascular exam

Answer 26

1) Look at pt and touch and poke calf and arm: The extremities are symmetric in size w no edema or erythema, no varicose veins or DVT symptoms, no ulcers, and temperature is appropriate.

Question 27

List the last step of a peripheral vascular exam

Answer 27

4) PT pulse (posterior medial malleolus) and DP pulse (lateral to big toe tendon) bilaterally, carotid, brachial, popliteal.
a. Pulses are 2+ bilaterally and femoral pulse is deferred