OSCE Exam Write Up Flashcards
Head, Neck, Lymph
Head is normocephalic and atraumatic.
Scalp with no masses, normal hair distribution.
Frontal and maxillary sinuses non-tender.
No lymphadenopathy. Thyroid is smooth without nodules or goister. Cartoid pulses 2+, no thrills or bruits. Jaw with no clicks, full ROM.
Eyes
Bilateral eyes with equal hair distribution, no lesions, no ptosis, no edema.
Sclera white, conjunctive pink. EOM intact bilaterally. Peripheral vision intact. Pupils equal, round, reactive to light bilaterally. Convergence is intact. Red reflex bilaterally and symmetrical. The fundoscopic exam reveals sharp disc margins, no hemorrhages. Bilateral vision 20/20.
Ears
Ears symmetrical bilaterally. External canals without inflammation, redness, or pain with palpation. Tympanic membranes pearly grey, with positive light reflexes ( 5 o’clock on the right and 7 o’clock on the left). Weber test equal in both ears. Rinne test AC>BC. Acuity intact to spoken and whispered voices.
Nose, Mouth, & Throat
Nares are patent, no deviated septum. Nasal muscosa pink. No discharge. Sense of smell intact. Gums are pink, all teeth present. Oropharynx pink, no exudate. Muccal mucosa moist. Tongue and uvula are symmetrical and midline. Tonsils grade 1. No ulcers, lesions noted.
Thorax/Lungs
Chest is symmetrical. RR 20. Lung sounds clear to auscultation without wheezes, crackles, or cough. Normal fremitus, symmetrical bilaterally. Chest resonant to percussion; no dullness. No egophony, bronchophony, or pectoriloquy.
CV
Regular rate and rhythm. No pain on palpation, PMI non-displaced. S1 and S2 present; no murmurs, rubs, or gallops. Pulses 2+ and equal bilaterally in upper and lower extremities. No cartoid, aortic, femoral, iliac, or renal bruits. JVD 2cm. Capillary refill <3 seconds. No peripheral edema
PV
Pulses 2+ and equal bilaterally in upper and lower extremities.
Cap refill <3
Positive Allen’s test- color returns in >10 seconds.
Beurger’s sign negative.
Negative homan’s sign.
Abdomen
Soft, flat without scars, lesions, visible pulsations, or masses. Skin is warm and dry. BS present and normoative in all quadrants. No tenderness to light or deep palpation. Tympanic throughout all four quadrants. Liver is 7 cm at the MCL and 1 cm below the right costal margin. Spleen and bilateral kidneys are not palpable. NO CV tenderness.
MS
Bilateral upper extremities without muscle atrophy or joint deformity. Bilateral upper extremities have full ROM of shoulder, elbow, wrist, and fingers. No evidence of swollen joints or signs of infection.
Bilateral lower extremities without muscle atrophy or joint deformities. Full ROM of bilateral hips, knees, and ankles. No evidence of swollen joints or signs of infection.
. Flexion, extension, lateral bending, and rotation of the spine with reduced ROM - pain and difficulty. Bilateral upper extremity strength equal and 5/5 in neck, shoulders, elbows, wrists, hands. Bilateral lower extremity strength equal and 5/5 in hip flexors, knees, and ankles.
Neuro
Good posture, dressed appropriately. Calm and cooperative. Good hygiene. Speech clear and
Sense of smell intact and symmetric. Left eye vision: 20/20. Right eye vision: 20/40. Fundoscopic exam reveals sharp disc margins, no hemorrhages. Pupils equal, round, and reactive to light bilaterally. Extraocular movements intact bilaterally. Normal convergence. Facial sensation intact; facial features and symmetric. Hearing intact bilaterally. Gag reflex intact. Ability to shrug shoulders symmetric; 5 strength against resistance. Neck with full range of motion against resistance; 5 strength against resistance. Tongue symmetric with no abnormal findings. Bilateral upper and lower extremity DTRs equal and 2+ bilaterally. Point-to-point movements smooth and accurate for finger-to-nose and heel-to-shin. Rapid alternating movements of the upper extremities intact bilaterally. Gait steady with continuous, symmetric steps. Sensation intact to bilateral upper and lower extremities; sense of extremity position intact. Stereognosis and graphesthesia intact bilaterally.
