YEAR III OSCE

1. Low Back Pain

History:

  • 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:

  • 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.

  • 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.

  • 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
  • Deep tendon reflexes
  • Movement tests.
  • Walking.
  • Flexion – have them touch their toes, watch for muscle sensitivity/spasm
  • Extension. Hyperextend back by bending backward and bending from side to side at the waist.
  • Rotation. Rotate back by keeping your hips still and turn upper body from side to side.
  • 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.

  • 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:

  • 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.

  • 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.

  1. 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.
  1. Acute Abdomen
  2. History
  3. 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).
  4. GI and systemic symptoms (e.g. anorexia, nausea/emesis); ask about constipation, bloody diarrhea or hematochezia.
  5. Hematuria (GU disorders), STD risk factors (PID is a common cause of abdominal pain), fever/chills
  6. 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).
  7. Physical
  8. Low BP and high HR are signs of shock or impending shock. High fever in the presence of abdominal pain is a concern.
  9. Abdominal distention suggests a surgical abdomen.
  10. Manipulate the lower extremity to elicit pain (suggestive of appendicitis) and check for CVA tenderness (pylo)
  11. Differential
  12. Abrupt, excrutiating pain
  13. Biliary colic
  14. Utereral colic
  15. MI
  16. Perforated ulcer
  17. Ruptured aneurysm
  18. Rapid onset of severe, constant pain
  19. Acute pancreatitis
  20. Mesenteric thrombosis, strangulated bowel
  21. Ecgtopic pregnancy
  22. Gradual, steady pain
  23. Acute cholecystitis, acute cholangitis, acute hepatitis
  24. Appendicitis, acute salpingitis
  25. Diverticulitis
  26. Intermittent, colickypain, crescendo with free intervals
  27. Early pancreatitis(rare)
  28. SBO
  29. IBD
  30. Evaluation
  31. CBC/lytes, amylase, ABG if pt hypoxic or unstable, lactate, LFTs, PT/PTT, UA/Cx, and stoll guiac.
  32. All women of childbrearing age need B-HCG
  33. Abdominal plain X-ray followed by studies based onclinical suspicion.
  34. Contrast studeies are often performed – NO barium if a lower bowel obstruction is suspected
  35. If RUQ pain do US/HIDA scan for cholecystitis.
  36. Paracentesis if there is acites
  37. Treatment
  38. Emergency surgery
  39. D/C oral feeds, insert NG tube if obstruction
  40. Provide analgesia and supportive care
  41. Type and Cross all
  42. Asthma education
  43. Triggers: dust, animal hair, odors, URIs cold air, exertion and stress
  44. History
  45. 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.
  46. Physical Exam
  47. Tachypnea, tachycardia, prolonged expiratory duration , decreased O2 sat (late sigh), decreased breath sounds, wheezing, hyperresonance, accessory muscle use, and possibly pulsus parasoxus.
  48. Differential
  49. Kids: aspiration, broncholitis, bronchopulmonary dysplasia, CF, GERD, vascular rings, pneumonia
  50. Adults: CHF, COPD, GERD, PE, foreign body, tumor, sleep apnea, anaphylaxis
  51. Treatment
  52. ABGs reveal mild hypoxia and respiratory alkalosis
  53. Normalizing in pCO2 in acute exacerbation warrents close observation , indicates impending failure
  54. Peak flow is diminished – spirometry demonstrates decreased FEV1.
  55. CBC may show eosinophilia
  56. CXR may show hyperinflation
  57. Definitive dx with bronchial hyperresponsiveness test with a methacholine challenge.
  58. Treatment
  59. Acute: oxygen, bronchodilators, steroids
  60. Chronic: regularly inhaled bronchodilator and/or steroids, systemic steroids, cromolyn, or theophylline.
  61. Avoid allergins/triggers
  62. Child rash/fever
  63. 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.
  64. CHF
  65. Cardiac output is unable to meet systemic demand.
  66. 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.
  67. History
  68. DOE (or at rest if severe)
  69. Fatigue, lower extremity edema, orthopnea, paroxysmal nocturnal dyspnea, nocturia, and/or abdominal fullness
  70. Physical exam:
  71. Sinus tachycardia and laterally displaced PMI
  72. Right failure may have elevated JVD, hepatomegaly, hepatojugular reflex and bipedal edema
  73. Left sided failure may have bilateral basilar rales and S3 or S4 gallop.
  74. Differential
  75. MI, angina, pericarditis, nephritic syndrome/renal failure, cirrhosis, pneumonia
  76. Evaluation
  77. EKG, CXR (look for cardiomegaly, cephalization of pulmonary vessels, pleural effusions, vascular indistinctness and prominent hila) and ECHO
  78. Dx is based on clinical picture and ECHO sowing impaired cardiac function(hypertrophic or dilated cardiomyopathy )
  79. R/O MI with troponins, BNP
  80. If amyloid or vial myocarditis biopsy may be informed
  81. A-fib is common in CHF and eincreases embolization
  82. Treatment
  83. Correct treatable causes
  84. 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.
  85. 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.
  86. Low dose spironolactone shown to decrease risk of mortality when given with ACEik digoxin and diuretics in patients with left systolic dysfunction.
  87. Intractable CHF unresponsive to maximal medical therapy may require mnechanical ventricular assist devises and cardiac transplantation.
  88. GAD
  89. Commonly co-exists with other mental disorders. Women affected twice as common as men.
  90. History / PE:
  91. Usually come to clinical attention in their 20’s
  92. Excessive anxiety or worry occurring more days than not for > 6months about a variety of activities or eents, causing significant impairment or distress
  93. Accompaneied by restlessness, fatigue, difficulty concentrating, irritability, muscle tension or sleep disturbance.
  94. Differential
  95. Medical disorders – hyperthyroidism
  96. Substance abuse, OCD, specific phobias, panic disorder, major depressive disorder, dysthymic disorder, hypochondriasis
  97. Treatment
  98. Pasychotherapy and/or meds (tricyclics, benzos, or SSRI
  99. 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.
  100. Headache
  101. Nothing special, just a thorough personal and family history.
  102. Headache with drinking problem (self-medicating)
  103. CAGE questionnaire
  104. You’ll have to fish for the drinking….she may not admit to it at first.
  105. Dysmenorrhea
  106. Ask about sexual history, STD’s in the past, deliveries and any complications.
  107. Ask is she feels safe at home and how her relationship is with her significant other.