YEAR III OSCE
1. Low Back Pain
History:
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Pattern, intensity, and duration of the current episode of low back pain
Any congenital spinal problems
Any type of arthritis in your spine.
Previous episodes of low back pain and treatment.
Previous accidents or injuries involving the back.
Family history of low back pain.
Work history.
Sports and other leisure activities.
History of cancer and other illnesses, such as abdominal disease, pelvic
disease, or osteoporosis.
Recent fever or unexplained weight loss.
Corticosteroid use.
Smoking history.
Depresssion questions to see how the pain is affecting the patient’s life. Ask
them to rate their job satisfaction, support system at home and work.
Physical:
During the physical exam, do a series of movements to elicit/reproduce the pain: standing,
sitting, lying down. This makes it possible to assess muscular and sensory problems
contributing to the low back pain. The physical exam will also include:
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Observation and measurements.
Palpation, feel for tenderness and joint alignment and check pulses in legs.
Deep tendon reflex tests.
Sensation tests. Muscle strength tests can detect true muscle weakness, which
is one sign of pressure on a nerve root. (Sometimes leg weakness is actually
due to pain, not pressure on a nerve.) Most people who have herniated discs
that cause symptoms also have some nerve root compression.
Since specific muscles receive impulses from specific nerves, finding out which muscles are
weak show where nerve roots are being compressed.
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Muscle strength
1. Hip flexion. Pt. Sits on the edge of the table with legs hanging down.
Push down near the patient’s knee as they lift their thigh. If one painful
leg is weaker than the other leg, there may be a nerve root compression at
the higher part of the lower back, in the area of the last thoracic and the
first, second, and third lumbar vertebrae (T12, L1, L2, L3 region).
2. Knee extension. Patient in the sitting position, straightens out knee
while you push down on the leg near the ankle. If one leg is weaker than
the other leg, nerve root compression at the third and fourth lumbar
vertebrae (L3 or L4 region).
3. Ankle dorsiflexion. Patient sitting, push down on the ankle while they
pull their ankle upward. Weakness is a sign of possible nerve root
compression the level of the fifth lumbar vertebra (L4 or L5 region).
4. Great toe extension. Patient sitting, push down on big toe while patient
tries to extend. Nerve root compression at L5 region.
5. Plantar flexion power. “Push on the gas pedal”. Possible S1 nerve
root compression.
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Sensory testing
Tell patient to close their eyes – use a cotton ball or sharp object.
Area of skin
Nerve level
The front of thigh
L1, L2, L3
The inside of lower leg, from the knee to the inner ankle and arch
L4
The top of foot and toes
L5
The outside of ankle and foot
S1
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Deep tendon reflexes
Movement tests.
1. Walking.
2. Flexion – have them touch their toes, watch for muscle sensitivity/spasm
3. Extension. Hyperextend back by bending backward and bending from
side to side at the waist.
4. Rotation. Rotate back by keeping your hips still and turn upper body from
side to side.
5. Side bending. Bend to one side, then the other, keeping hips level and not
letting body rotate.
In general, increased pain on bending forward (flexion) suggests a disc problem. Pain that
increases when bending backward (extending the spine) suggests degenerative changes,
spinal stenosis, or spondylolisthesis. Side bending and rotation – look for assymetry.
Spasms of the muscles next to the spine can create pain with any of these tests.
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Straight leg test.
Muscle strength tests (neurologic testing).
General abdominal, pelvic, rectal, and leg exams.
Normal
History does not reveal an obvious cause of the low back pain.
A physical exam does not cause the same type of pain, muscle weakness, or nerve-related
symptoms that you have been having.
Your doctor may recommend:
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Nonsurgical treatment (rest, pain relievers, ice, exercise).
More tests and exams to determine whether some other medical problem is
causing your low back pain.
Abnormal
The medical history and physical exam are likely to distinguish between a low back problem
related to a muscle strain or overuse and one that is caused by pressure on a nerve or
another more unusual problem.
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If your back pain seems to be related to muscle strain or overuse, or if your
nerve-related symptoms are not severe, your doctor will likely recommend
conservative treatment (rest, pain relievers, ice, exercise) for a period of time
to see whether your symptoms improve.
If your nerve-related symptoms are more serious or if your doctor suspects
that there is a more serious problem, he or she may recommend more tests,
such as X-ray, magnetic resonance imaging (MRI), computed tomography
(CT), or blood tests.
What To Think About
Pain can be related to both physical and emotional causes. When you're stressed, for
example, muscle tightness or spasm can set into your back, causing or worsening pain.
Similarly, troubling emotions can worsen pain. If you or your doctor have a sense that your
pain is being caused or made worse by stress, anger, or other difficult emotions, be sure to
plan for specialized treatment. Cognitive-behavioral counseling and biofeedback are two
types of treatment that can give you tools for managing your pain.
2. Testicular Exam
Just as women need to check their breasts monthly for any changes, men need to do the
same with their testicles. The exam aids in early detection of cancerous growths. Caught
in the early stages, the disease is almost always treatable. Testicular cancer can affect
young men as early as 15 years of age!
Difficulty: Average
Time Required: 10 minutes
Here's How:
1. Stand naked in front of a full length mirror. Look for any swelling on the skin of
the scrotum.
2. Carefully examine each testicle with both hands. Using your thumb and fingers,
roll each testicle around. Feel for any lumps. They can be as small as a pea.
3. Next, find the cordlike structure on the top and back of the testicles. This is called
the epididymis. This is not to be confused with a lump.
4. Finally, check for any lumps on the side and front of each testicle.
Tips:
1. Perform the exam after a warm bath or shower. This allows the scrotum to relax,
making it easier to find lumps or masses.
2. Be sure to perform the exam every month.
3. Always report any abnormal findings to your doctor. Lumps may be painless, but
still require medical examination.
4. Considering testicular cancer occurs in men as young as 15 years old, teach your
sons about testicle health and how to perform a self exam.
3. Acute Abdomen
a. History
i. Character of pain: sharp implies peritoneal pain; dull, diffucse
pain is commonly visceral pain. Note location , shifting, radiation,
onset, severity, exacerbating and ameliorating factors, temporal
nature (constant v. colicky).
ii. GI and systemic symptoms (e.g. anorexia, nausea/emesis); ask
about constipation, bloody diarrhea or hematochezia.
iii. Hematuria (GU disorders), STD risk factors (PID is a common
cause of abdominal pain), fever/chills
iv. Note the patient’s menstral history, family history (acute
intermittent porphyria, familial Mediterranean fever), and past
medical and surgical history (vasculitis, SLE, sickle cell disease).
b. Physical
i. Low BP and high HR are signs of shock or impending shock.
High fever in the presence of abdominal pain is a concern.
ii. Abdominal distention suggests a surgical abdomen.
iii. Manipulate the lower extremity to elicit pain (suggestive of
appendicitis) and check for CVA tenderness (pylo)
c. Differential
i. Abrupt, excrutiating pain
1. Biliary colic
2. Utereral colic
3. MI
4. Perforated ulcer
5. Ruptured aneurysm
ii. Rapid onset of severe, constant pain
1. Acute pancreatitis
2. Mesenteric thrombosis, strangulated bowel
3. Ecgtopic pregnancy
iii. Gradual, steady pain
1. Acute cholecystitis, acute cholangitis, acute hepatitis
2. Appendicitis, acute salpingitis
3. Diverticulitis
iv. Intermittent, colickypain, crescendo with free intervals
1. Early pancreatitis(rare)
2. SBO
3. IBD
d. Evaluation
i. CBC/lytes, amylase, ABG if pt hypoxic or unstable, lactate, LFTs,
PT/PTT, UA/Cx, and stoll guiac.
ii. All women of childbrearing age need B-HCG
iii. Abdominal plain X-ray followed by studies based onclinical
suspicion.
iv. Contrast studeies are often performed – NO barium if a lower
bowel obstruction is suspected
v. If RUQ pain do US/HIDA scan for cholecystitis.
vi. Paracentesis if there is acites
e. Treatment
i. Emergency surgery
ii. D/C oral feeds, insert NG tube if obstruction
iii. Provide analgesia and supportive care
iv. Type and Cross all
4. Asthma education
a. Triggers: dust, animal hair, odors, URIs cold air, exertion and stress
b. History
i. Cough, dyspnea, episodic wheezing, and /or chest tightness.
Historical features suggesting sever asthma include a history of
frequent ER visits, intubations and PO steroid use. Symptoms
often worse at night or early morning.
c. Physical Exam
i. Tachypnea, tachycardia, prolonged expiratory duration , decreased
O2 sat (late sigh), decreased breath sounds, wheezing,
hyperresonance, accessory muscle use, and possibly pulsus
parasoxus.
d. Differential
i. Kids: aspiration, broncholitis, bronchopulmonary dysplasia, CF,
GERD, vascular rings, pneumonia
ii. Adults: CHF, COPD, GERD, PE, foreign body, tumor, sleep
apnea, anaphylaxis
e. Treatment
i. ABGs reveal mild hypoxia and respiratory alkalosis
ii. Normalizing in pCO2 in acute exacerbation warrents close
observation , indicates impending failure
iii. Peak flow is diminished – spirometry demonstrates decreased
FEV1.
iv. CBC may show eosinophilia
v. CXR may show hyperinflation
vi. Definitive dx with bronchial hyperresponsiveness test with a
methacholine challenge.
f. Treatment
i. Acute: oxygen, bronchodilators, steroids
ii. Chronic: regularly inhaled bronchodilator and/or steroids,
systemic steroids, cromolyn, or theophylline.
iii. Avoid allergins/triggers
5. Child rash/fever
a. You’re asked to take a phone call from a frantic mother who
wants you to give her kid medication over the phone. Get the
entire history but tell her you still need to see the child. Be
persistant in the fact that you can’t call in a script and to either
make an appointment or take to the ER if necessary.
6. CHF
a. Cardiac output is unable to meet systemic demand.
b. Risk factors: CAD, family historyof hypertropic cardiomypoathy, HTN,
vascular heart disease, drug toxicity, alcohol abuse, and myocarditis.
Most common cause of right-ided heart failure is left sided failure.
c. History
i. DOE (or at rest if severe)
ii. Fatigue, lower extremity edema, orthopnea, paroxysmal nocturnal
dyspnea, nocturia, and/or abdominal fullness
d. Physical exam:
i. Sinus tachycardia and laterally displaced PMI
ii. Right failure may have elevated JVD, hepatomegaly, hepatojugular
reflex and bipedal edema
iii. Left sided failure may have bilateral basilar rales and S3 or S4
gallop.
e. Differential
i. MI, angina, pericarditis, nephritic syndrome/renal failure, cirrhosis,
pneumonia
f. Evaluation
i. EKG, CXR (look for cardiomegaly, cephalization of pulmonary
vessels, pleural effusions, vascular indistinctness and prominent
hila) and ECHO
ii. Dx is based on clinical picture and ECHO sowing impaired cardiac
function(hypertrophic or dilated cardiomyopathy )
iii. R/O MI with troponins, BNP
iv. If amyloid or vial myocarditis biopsy may be informed
v. A-fib is common in CHF and eincreases embolization
g. Treatment
i. Correct treatable causes
ii. Acute: worsening dyspnea or other symptoms diurese with loop
diuretic (furosemide) and non-loop agent. ACEi for all who
tolerate and don’t have underlying kidney issues. May require
hospital admission or intubation.
iii. Chronic: use ACEi/ARB, diuretics (furosemide). Treat
arrhythmias as they arise; limit dietary sodium and fluid intake.
Use beta-blockers if tolerated. Consider warfarin for sever dilated
cardiomyopathy, a-fib, or previous embolic episodes.
iv. Low dose spironolactone shown to decrease risk of mortality when
given with ACEik digoxin and diuretics in patients with left
systolic dysfunction.
v. Intractable CHF unresponsive to maximal medical therapy may
require mnechanical ventricular assist devises and cardiac
transplantation.
7. GAD
a. Commonly co-exists with other mental disorders. Women affected twice
as common as men.
b. History / PE:
i. Usually come to clinical attention in their 20’s
ii. Excessive anxiety or worry occurring more days than not for >
6months about a variety of activities or eents, causing significant
impairment or distress
iii. Accompaneied by restlessness, fatigue, difficulty concentrating,
irritability, muscle tension or sleep disturbance.
c. Differential
i. Medical disorders – hyperthyroidism
ii. Substance abuse, OCD, specific phobias, panic disorder, major
depressive disorder, dysthymic disorder, hypochondriasis
d. Treatment
i. Pasychotherapy and/or meds (tricyclics, benzos, or SSRI
ii. Buspirone has also been shown to be effective and may be
preferable to benzos owing to a drecreased risk of additction and
absence of withdrawl effects.
8. Headache
a. Nothing special, just a thorough personal and family history.
9. Headache with drinking problem (self-medicating)
a. CAGE questionnaire
b. You’ll have to fish for the drinking….she may not admit to it at
first.
10. Dysmenorrhea
a. Ask about sexual history, STD’s in the past, deliveries and any
complications.
b. Ask is she feels safe at home and how her relationship is with
her significant other.