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OSCE FINAL
General Overview & Skin Color appropriate for ethnicity Texture, smooth, firm, even surface Warm, dry, intact Inspect head for symmetry, midline position Inspect and palpate head and scalp for: hair distribution, color, texture, lesions, masses, tenderness, infestations. Palpate temporal arteries for tenderness. Palpate and percuss frontal and maxillary sinuses Palpate TMJ for clicking Head and Face Cranial nerve 5- Trigeminal -Motor: palpate over masseter muscle as patient clenches jaw. -Sensory: light touch and pinprick sensation to forehead, cheeks, chin and nose. -Corneal reflex: lightly touch sclera with tissue or q tip Cranial nerve 7-Facial -Motor: inspect for facial symmetry with smile, frown, raise eyebrows, puff cheeks, pucker lips. -Test ocular strength by trying to open closed eyes Sensory: verbalize where taste is located on tongue*** Eyes Inspect lids, lashes, brows, palpebral fissures for alignment and position, hair distribution, symmetry, discharge, swelling, lesions, and nodules. Inspect sclera and conjunctiva for color, lesions, discharge. Cranial Nerve 2- optic nerve
-Assess gross visual acuity peripheral/central vision with the following:
- Acuity: Snellen or Rosenbaum
- Snellen: Have patient stand 20 feet away from chart, cover one eye, read lines all the way down. Last line the patient can read correctly is their visual acuity
- Explain what 20/60 means: A patient can see at 20 feet what a person with normal vision sees at 60 feet. The person has visual impairment and needs corrective lenses or contacts. The patient will stand 20 feet away from the chart they will be asked to read from. The patient will leave glasses or contacts on, cover one eye and read from the chart to the smallest line or letter possible. The numerator is the amount of distance the person is standing from the chart. The denominator is the distance at which a normal eye can read the chart.
- Visual Fields-Confrontation: Eye level of patient about 2 ft away, cover one eye and look straight ahead at you. Hold finger midline and advance in periphery in several directions (down, up, temporally, nasally). Ask pt to say “now” when the finger tip is first seen. Cranial Nerve 3-Oculomotor -Test for direct/consensual pupillary response to light: PERLA - Test for conjugate gaze with EOM (CN 3,4,6): Hold head steady, follow movement of finger. Hold position momentarily then move back to center. Example, left upper, nose, left lower, nose, left mid, nose. -Ophthalmic exam: describe red reflex, fundus, vessels, optic disc.
- red reflex: light reflecting off the back inner surface of eye
- Fundus: Darken room, tell patient to look at an object in the room, using ophthalmoscope, assess pupils for dilation and vessels. No lesions obstructing vision. Ears Inspect outer ears for shape and position. Inspect auricles and mastoid area for alignment, symmetry, size and shape. Inspect auditory canals for tenderness, color, cerumen, and lesions.
Palpate and auscultate carotid arteries Palpate nodes of head and neck noting size, consistency, mobility Test cervical ROM- flexion, hyperextension, lateral, flexion, rotation CN 11 Accessory: shrug shoulders against resistance, turn head against Resistance Posterior Chest Inspect skin A:P Diameter: 1: No s/s of respiratory distress. Rate and rhythm of breathing are regular and even. No s/s of respiratory distress. No tripod positioning, no nasal flaring, no retractions, no cyanosis, no tachypnea, no retractions noted. No sputum noted No obvious deformities of posterior chest
Palpate for symmetrical chest expansion. Hands on both sides of posterior chest while pt breathes in and out. Inspect for obvious chest deformities Palpate tactile fremitus: Place one hand, starting on apices, and have the patient say “ninety nine”. Move from side to side. Vibrations should feel the same. Extra palpation on R lung b/c of extra lobe. Percuss over posterior lung fields in intercoastal spaces. Identify locations of bronchial, bronchovesicular, and vesicular breath sounds
Anterior Chest Inspect skin Note any deformities and symmetry Palpate chest and tactile fremitus anteriorly Auscultate lung fields Cardiovascular Auscultate heart sounds with bell and diaphragm with patient sitting. Aortic, pulmonic, erb’s point, tricuspid, mitral Note rate, rhythm, pitch, murmurs, extra heart sounds Locate and palpate PMI Auscultate apical pulse for 1 full minute and report findings—rate and rhythm Have patient lie down Inspect for heaves and lifts
Palpate for thrills over each auscultation point Repeat cardiac auscultation with bell and diaphragm with patient supine. Assess for JVD and jugular pulsation with HOB at 30-45 degrees. Abdomen Inspect skin Inspect abdomen for contour, symmetry, musculature, umbilicus, pulsations, peristalsis, and for presence of Cullen sign (should be negative Cullen sign) Auscultate for bruits: aorta, renal, iliac, and femoral Auscultate for bowel sounds in all 4 quadrants Percuss all 4 quadrants for tympany, dullness, flatness. Tympany should be in all 4 quadrants, dullness at liver. Percuss liver and spleen- identify normal range spans and locate boarders.
Palpate peripheral pulses: radial, brachial, dorsalis pedis, posterior tibial Neck: flexion, extension, lateral bending, rotation (can be done with head and neck exam). Do with and without resistance Shoulder: adduction, abduction, internal rotation, external rotation, flexion, extension, hyperextension, circumduction. With and without resistance Apley scratch test: Use your left arm, try to touch your right shoulder, vice versa. From top and bottom. Interlock fingers behind head on right and left sides in between shoulder blades. Elbow: flexion, extension, supination, pronation. With and without resistance Wrist: Flexion, extension, hyperextension, ulnar deviation, radial deviation, rotation. Fingers: Flexion, extension, adduction, abduction Grip strength Identify snuff box Hip-internal rotation, external rotation, flexion, extension, adduction, abduction, hyperextension. With and without resistance Knee-flexion, extension Ankle-plantar flexion, dorsiflexion, inversion, eversion, rotation. With and without resistance Spine: bend backward, touch your toes, rotation (turn side to side at waist), lateral bending Assess for scoliosis: Inspect and note whether the spine is straight by following and imaginary vertical line from the head through the spinous process and down through the gluteal cleft and by noting horizontal positions for the shoulders, scapula, iliac crests and gluteal folds and equal spaces between the arms and lateral thorax on the two sides. If you’re concerned about scoliosis and it is difficult to assess you can draw small dots on the pt’s spine and see if they align when they person stands up straight. SLR: have pt lying flat on back, lift each leg one at a time to assess for pain in lower back that could be indicative of sciatica. Ballottement: Reliable when large amounts of fluid are present. Use L hand to compress the suprapatellar pouch to move any fluid into the knee joint. With your R hand push the patella sharply against the femur. Palpate the
infrapatellar fat pad and the patella. Check for crepitus by holding your hand on the patella as the knee is flexed and extended. Anterior/Posterior Drawer test: Anterior Drawer Test of the Knee - Physiopedia (physio-pedia.com), Posterior Drawer Test | Posterior Cruciate Ligament (PCL) Injury Knee (youtube.com) Varus/Valgus: Knee Valgus and Varus Stress Tests - YouTube Arm drop: Drop Arm Sign – Shoulder Rotator Cuff Special Test (youtube.com) Empty can: Empty & Full Can Tests - ThePainSource.com (youtube.com) Tinel: Direct percussion of the median nerve at the wrist produces no symptoms in the normal hand (pg. 595). Phalen: Ask pt to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrists for 60 seconds produces no symptoms in the normal hands. Neuro Cognition (memory) Mood and affect Judgement and abstraction Upper extremity DTRs: biceps, triceps, brachioradialis Lower extremity DTRS: patellar, achilles, Babinski, clonus Position sense and sensation: light touch, sharp vs dull, vibrations on UE and LE. Stereognosis: With the person’s eye closed, place a familiar object (paper clip, key, cotton ball) and ask the person to identify object. Graphesthesia: The ability to “read” a number by having it traced on the skin. With the person’s eyes closed, use a blunt instrument to trace a single digit number or letter on the palm. Ask pt to tell you what it is you drew. 2 point discrimination: use pointy object that has 2 ends. Have pt tell you when you are touching with 1 point or 2. Serial finger opposition: nose to finger alternating rapid hand response. Pronator Drift: have patient sit, close eyes and hold arms up with palms facing up for 20-30 seconds. No position change should be noted. Heel to shin: Test lower extremity coordination by asking the pt to lay supine and place the heel on the opposite knee and run it down the shin from the
