March Onsite OSCE Assessment Flashcards
Introduction
Introduce self, review expectations for visit
COLDCARTS and PAMFROSTI
Establish reason for visit (OLDCARTS for any symptoms)
Past Medical History (childhood/adult/surgical/hospitalizations/accidents)
Allergies/sensitivities/intolerances & Alternative Health
Medications (including OTC/herbal)
Family History (specific to the system)
Neuro: seizure disorder, cerebral palsy, muscular dystrophy, cerebral aneurysm or stroke?
MSK: Inflammatory arthritis or OA, osteoporosis, collagen disorders?
Cardio-Resp: Rheumatic fever, CAD, sudden death at a young age, diabetes, HTN, obesity? Tuberculosis, allergies, asthma, or COPD?
ROS (specific to the system - see below)
Occupation
Social Hx (Diet, Smoking, Drugs, Alcohol, Caffeine, Exercise, Social Supports, Satety concerns, Spiritual and cultural practices)
Travel & Sick contacts (if relevant)
Immunizations and Health Screening (PAP/Mammography/FIT)
MSK ROS
General: weight (usual/change), fatigue, fever, night sweats, sleep patterns, insomnia
Skin: rashes, itching, dryness, scales, color change (erythema), warmth, swelling
MSK: Muscle or joint pains, stiffness, arthritis, gout, backache. If present, describe location of affected joints or muscles, any swelling, redness, pain, tenderness, stiffness, weakness, limitation of motion or activity, timing of symptoms (AM or PM), and any history of fractures, joint tears or injuries. Neck or low back pain, if yes does pain radiate? Location of radicular pain.
Neurologic: Changes in mood, attention or speech; changes in orientation, memory, insight or judgment; headache, dizziness, vertigo; fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or pins and needles, tremors or other involuntary movements, seizures
Consider Psychiatric (chronic pain): Nervousness, tension, mood changes, including sadness, irritability, anger, or depression, anxiety, any suicidal/homicidal ideation (plan associated with thoughts), changes in memory/concentration, difficulty getting to sleep or staying asleep
Card-Resp ROS
General: weight (usual/change), fatigue, fever, night sweats, sleep patterns, insomnia
Skin: Rashes, lumps, sores, itching, dryness, color change, changes in hair or nails, changes in color or size of moles
Ears: Hearing acuity, tinnitus, vertigo, earaches, infections, discharge, last hearing exam, use of hearing aids
Nose & Sinuses Frequent colds, nasal stuffiness, discharge, itching, hay fever, nosebleeds, sinus trouble
Mouth & throat: Condition of teeth and gums, bleeding gums, last dental examination, dentures and how do they fit, dry mouth, sore tongue, frequent sore throats, hoarseness
Neck: Lumps in the neck, swollen glands, goiter, pain or stiffness in neck
Resp: Cough, sputum (color, quantity), hemoptysis, wheezing, dyspnea, asthma, bronchitis, emphysema, pneumonia, TB, pleurisy, last CXR
Cardiac: History of heart trouble, hypertension, rheumatic fever, heart murmurs, chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, date and results of past ECG or other heart tests
PVS: Intermittent claudication, leg cramps, varicose veins, past clots in veins, swelling in calves, legs or feet, color changes in fingertips or does during cold weather, swelling with redness or tenderness
GI: N/V
GU: nocturia
+- hematologic (anticoags)
Neuro ROS
General: weight (usual/change), fatigue, fever, night sweats, sleep patterns, insomnia
Neurologic: Changes in mood, attention or speech; changes in orientation, memory, insight or judgment; headache, dizziness, vertigo; fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or pins and needles, tremors or other involuntary movements, seizures
Psychiatric: Nervousness, tension, mood changes, including sadness, irritability, anger, or depression, anxiety, any suicidal/homicidal ideation (plan associated with thoughts), changes in memory/concentration, difficulty getting to sleep or staying asleep
MSK: Muscle or joint pains, stiffness, arthritis, gout, backache. If present, describe location of affected joints or muscles, any swelling, redness, pain, tenderness, stiffness, weakness, limitation of motion or activity, timing of symptoms (AM or PM), and any history of fractures, joint tears or injuries. Neck or low back pain, if yes does pain radiate? Location of radicular pain. Joint pain with systemic features e.g. fever, chills, rash, anorexia, wt loss or weakness
Skin: Rashes, lumps, sores, itching, dryness, color change, changes in hair or nails, changes in color or size of moles
Head: Headaches, head injury, dizziness, light-headedness
Eyes: Vision, glasses, contact lenses (daily or disposable), last eye exam, pain, redness, excessive tearing, double
or blurred vision, spots, specks, flashing lights, glaucoma, cataracts
Ears: Hearing acuity, tinnitus, vertigo, earaches, infections, discharge, last hearing exam, use of hearing aids
Urinary: nocturia, incontinence, retention
GI: Trouble swallowing, changes in appetite, nausea, vomiting. Bowel changes (incontinence/constipation)
CVS/Resp Physical Exam
IPPA
General survey: appearance, behaviour mannerisms
Inspection skin, face, upper and lower extremities
Inspect neck and position of trachea
Anterior thorax: Inspection: Shape of chest and movement of chest wall Resp rate, rhythm, effort AP/lateral diameter ratio 1:2
Ausc: 6 locations comparing right to left, moving from apex to base
Posterior thorax: percussion and auscultation apex to base ‘ladder’ & 2 special tests (egophony “eee”, bronchophony “99”, tactile fremitus)
Auscultation of heart: aortic, pulmonic, Erb’s point, tricuspid, mitral, PMI (bell).
*Verbalize rate, rhythm, characteristics of heart sounds (S1-S2, indications of S3, S4)
S3: may be physiologic in children and young adults (< 40). Other causes: HF (often first sign), other volume overload mitral/aortic/tricuspid regurgitation, or high cardiac output such as pregnancy/anemia/hyperthyroidism. Best heard left lateral. Early diastole (passive filling). Occurs after S2.
S4: may be physiologic in adults over 40 or 50, especially after exercise. Occurs with decreased compliance, CAD, cardiomyopathy, and increased after load (aortic stenosis, systemic HTN). Best heard left lateral position. Late diastole (atrial kick). Occurs before S1.
JVP (verbalize normal: 0-4cm)
Auscultation for bruits (bell):
- carotids
- aortic
- renal
- iliac
- femoral
Assessment of PVS: palpation of pulses and verbalize findings
- carotids (auscultate first! exhale and hold, turn head to the left)
- radial
- brachial
- femoral
- popliteal
- dorsalis pedis
- posterior tibial
MSK Physical Exam
INSPECT, PALPATE, ROM
SEADS/WETCJ/ROM
General survey: appearance, behaviour, mannerisms
Inspection and Palpation: symmetry, atrophy, deformities
Verbalize: erythema, swelling, warmth, tenderness, crepitus
Neck: Inspect anterior & posterior ROM: Flexion: 90 Extension: 70 Rotation: 90 Lateral bending: 45
Shoulder: Inspect anterior & posterior, atrophy, erythema, deformities, abnormal positioning. Palpates muscles/tendons, joints, sternoclavicular joint, AC joint, supraspinatus, infraspinatus, subscapularis, subacromial bursa, lumps, swelling... ROM: Flexion: 180 Extension: 60 ER: 90 IR: 70 Abduction: 180 Adduction: 50 ONE special test: Drop test, Empty Can, Painful arc
Elbow: contours, identifies media & lateral epicondyles and olecranon process
palpates olecranon process and epicondyles for warmth, erythema, swelling, tenderness.
ROM: Flexion: 160 Extension: 0 Supination: 90 Pronation: 90
Wrists/Hands:
Inspect the palmar and dorsal surfaces for erythema, warmth, deformity and swelling of joints
Palpate:
- Distal radius and ulnar lateral and medial surfaces.
- Radial styloid and anatomical snuff box
- 8 carpal bones, metacarpals and proximal middle and distal phalanges
- MCP, DIP & PIP joints
ROM:
Wrist:
Flexion: 80
Extension: 70
Radial deviation: 20
Ulnar deviation: 30
Fingers and thumb: clench fist, abduct/adduct.
Spine:
Inspect posture, cervical concavity, thoracic convexity and lumbar concavity. Palpate spinous process for tenderness.
ROM: Lumbar Flexion: 40-60 Extension: 20-35 Lateral: 15-20 Rotation: 3-18
Thoracic: Flexion: 20-45 Extension: 25-45 Lateral bending: 20-40 Rotation: 35-50
Hips: Inspect for symmetry and atrophy, observe gait, stance and swing. Palpate iliac crest ROM: Flexion: 120 Extension: 30 ER: 45 IR: 45 Abduction: 45 Adduction: 30
Knees: Inspects for erythema, warmth, deformity and swelling of joints, as well as for alignment and contours of knees. Observe gait, and atrophy of quads Palpate medially and laterally ROM: Flexion 135 Extension: 0 ONE special test: Lachman, Mcmurray, or Anterior/posterior drawer test
Ankles/Feet: Inspects for deformities, nodules, swelling, erythema, warmth, calluses. Palpate ankle, achilles, tendon, medial and lateral malleolus, navicular bone, talus bone. ROM: Plantar Flexion: 50 Dorsiflexion: 20 Inversion: 35 Eversion: 15
Neuro Exam
General CN MSE Motor Sensory DTR Cerebellar/coordination
(George Craves Monthly S’Mores and Dirty Candy)
General: appearance, behaviour, mannerisms
MSE: orientation (person, place, time), thought process and content, mood/affect, speech, perception, insight and judgement. ** ask how they would like us to demonstrate thought process/insight/judgement?
**meumonic ORAL (orientation, registration - 5 min recall, attention - WORLD backward, language - naming, 3 step command)… or whatever tests they tell us?!
CN:
I - olfactory - ask about smell
II - optic - visual acuity/visual fields (confrontation test), assess pupils
III/IV/VI - oculomotor/trochlear/abducens - EOMs, pupillary light response, nystagmus
V - trigeminal - sensation in 3 areas (forehead, cheeks, chin); clench teeth
VII - facial - Raise eyebrows, frown, close eyes, show teeth, smile puff cheeks
VIII - acoustic/vestibular/cochlear - whisper/Rinne/Weber, nystagmus (if not done)
IX/X - glossopharyngeal/vagus - movement of soft palate and uvula, “Ga”, “Ka”
XI - spinal accessory - strength of shoulder rise, resistance of head against hand (SCM strength)
XII - hypoglossal - assess tongue for atrophy, lateral deviation, fascinations, stick out tongue.
Motor:
Body position, movement, muscle tone, bulk
ROM (see MSK) ** Do we perform full ROM in OSCE?
Strength (isometric - resistance to movement):
Forearm Flexion (C5, C6, biceps)
Forearm extension. (C6, C7, C8, triceps)
Wrist extension (C7, C8, radial nerve)
Wrist flexion (C6, C7, C8, T1, median nerve)
Grip (C7, C8, T1)
Finger abduction (C8, T1, ulnar)
Opposition of thumb (C7, C8, median nerve)
Flexion of hip (L1, L2, L3, L4, iliopsoas)
Adduction (L2, L3, L4, adductors)
Abduction (L4, L5, S1, gluteus medium and minimus)
Flexion of knee (L5, S1, S2, hamstring)
Extension of knee (L2, L3, L4, quads)
Dorsiflexion of foot (L4, L5, tibialis anterior)
Plantar flexion and inversion of foot (L4, L5, tibias posterior)
Plantar flexion and eversion of foot (L5, S1, branch of sciatic)
Great toe extension (L5, S1, extensor halluces longs)
Coordination: cerebellar
Fine motor: RAM (pronate/supinate hands, touch thumb to each finger)
Gross motor: finger to nose, slide heel down the opposite shin
Gait: walk across room, heel to toe, walk on toes, walk on heels (assessing for coordination)
Stance: Romberg and pronator drift (20 sec)
Sensory:
Upper and lower extremities: light touch (soft and sharp-tests spinothalamic and posterior columns). Medial and lateral.
DTR: biceps triceps brachioradialis patellar achilles
