OSCE 2 Quick Checklists

Skin Changes
Red Flag Questions
Key Question Areas

Evolution of the lesion

History of cancer
Fx hx cancer
Whats your occupation (think sun exposure or chemical burns)
Trauma
Most skin cancers m/c in older white men with light or red hair
Allergies (contact dermatitis or hives from other allergies)

Malignant melanoma
Cellulitis
Psoriasis
Eczema
Tinea
HSV

General appearance
assess for borders, symmetry, colour, discharge, size and evolution

DDx

PE

Earache
Red Flag Questions
Key Question Areas

Acute infection?
Environmental conditions?
Systemic?
Pain?
Discharge or itching?
History of trauma or injury?
Hearing loss?

Cholesteatoma
Mastoiditis
Otitis externa
Otitis media acute, chronic, serous
Foreign body
Cerumen impaction
Barotraumas
Trauma
Cervical lymphadenitis
Referred pain from cervical or cranial nerves
TMJ disorder

Inspect external ear lesions

Palpate external ear pain
Inspect ear canals cerumen, lesions
Inspect tympanic membrane otitis media, cholesteoma
Pneumatic otoscopy - fluid
Whisper test hearing loss

Weber and Rinne if whisper fails

Conjunctivae - infection
Nose red, swollen
Palpate sinuses - pain
Intraotic manipulation - TMJ
Cranial nerve V, VII, and IX lesions

DDx

PE

Sore Throat
Red Flag Questions

Have you been drooling

Have you been unable to swallow
Have you been unable to lie down
Have you been restless, unable to stay still
Have you been unable to talk

Key Question Areas

Infectious?

Presence of fever?
Upper respiratory tract symptoms?
Systemic symptoms?
Risk factors?

Epiglottitis (key clinical difference between epiglottitis and PTA is severe pain in the absence of erythema)
Peritonsillar abscess
Mononucleosis
Viral pharyngitis
Streptoccocal pharyngitis
Thyroiditis

General appearance sick/uncomfortable

Inspect mouth (gums, teeth, palate, pharynx, tonsils, tongue) - infection
Raising of the soft palate epiglottits or abscess
Observe swallowing epiglottits or abscess
Palpate cervicofacial lymph nodes - infection
Inspect nasal mucosa - infection
Inspect conjunctivae - infection
Inspect tympanic membrane otitis media
Palpate thyroid acute thyroiditis
Auscultate the lungs pneumoniae
Palpate the abdomen spleen
Inspect skin lesions

DDx

PE

Nasal Symptoms and Sinus Congestion

Red Flag Questions

Do you have any changes in vision?

Do you have pain that came on suddenly?
Have you had any changes in consciousness?
Are you experiencing a new headache thats severe?
Do you have any nausea or vomiting?

Key Question Areas

Is anyone else around you experiencing similar sx?

Do you smoke?
Has this happened before? Does it happen around a certain time of year?
Have you taken any medication or used nasal sprays for relief?
Do you have any other sx e.g. sore throat, fever?

Allergic rhinitis
Infectious rhinitis
Sinusitis
Severe fulminant sinusitis (fungal sinusitis that occurs pretty much only in immunocompromised people- ex diabetes, HIV)
Mastoiditis
Rebound nasal congestion (from medication)
Nasal polyps

General appearance
Inspect eyes (edema, swelling, erythema, discharge, etc)
Test central and peripheral visual acuity
H test
Palpate lymph nodes
Inspect nasal cavity (polyps, erythema, discharge, septum, etc)
Inspect oral cavity
Inspect ear
Palpate mastoid
Palpate and transilluminate sinuses

DDx

PE

Vision Change
Red Flag Questions

sudden?
one or both eyes
pain?
flash of light
momentary or persistent

Key Question Areas

what can you see? can you see light?

blurry?
trauma
fmx of vision loss or eye problems
do you have a chronic disease

DDx

occlusion of central artery (if sudden - this until proven otherwise (daines))
acute angle glaucomoa
strabismus
refractive errors - myopia, hyperopia
astigmatism
cataracts
optic neuritis
injury
retinoblastoma
retinopathy
glaucoma
retinal detachment
macular degeneration
diabetic retinopathy
uveitis
optic nerve glioma

visual acuity
visual fields
inspect lid, lid margins, periorbital tisues and orbital tissues
check for nystagmus
pupillary response
corneal light reflex
cover/uncover test
amsler grid
inspect conjuctiva
inspect sclera
examine cornea, iris, pupil, lens
opthalmoscopy
test extraocular movements - H test
palpate lid/lacrimal puncta
examine tympanic membranes
check lymph nodes

PE

Red Eye
Red Flag Questions

halos
swelling
limitation of eye movement - orbital cellulitis

Key Question Areas

recent sinusitis? - cellulitis

contact lenses
unilateral (trauma/infection)
bilateral (allergy, systemic)
vision changes
discharge
photophobia (iritis, uveitis)
cough or fever

chemical burn
orbital cellulitis
trauma
acute glaucoma
conjunctivitis - viral (clear liquid, URTI), bacterial (no fever, thick yellow/green discharge), allergic (bilateral, itching)
irits
sty
chalazion
foreign body
corneal abrasion/ulcer
scleritis
retinal tear

visual acuity
visual fields
inspect lid, lid margins, periorbital tisues and orbital tissues
evert lid - foreign body
inspect conjuctiva
inspect sclera
examine cornea, iris, pupil, lens
opthalmoscopy
test extraocular movements

DDx

PE

palpate lid/lacrimal puncta

examine tympanic membranes
check lymph nodes

Cough
Red Flag Questions

Are you experiencing any SOB?

Do you have a history of heart failure or asthma?
Have you had any weight loss? Night sweats?
Are there any obstructions? (Choking risk)

Key Question Areas

Is the cough getting worse or consistent?

What time of day is the worse?
Have you noticed any triggers e.g. exercise, eating, etc?
Are you exposed to environmental irritants at work, school or home?
Do you feel like something is dripping on the back of your throat?
Are you taking any medication (i.e. an ACE inhibitor)?
Is there any sputum with your cough?
Does lying down make it worse?
Is anyone else at home or work ill?
Do you have HIV, Heart disease, HTN?
Ever exposed to TB?

GERD
Asthma
Common cold
COPD
Viral URTI
Pneumonia
Bronchitis
Postnasal drainage syndrome
Carcinoma
ACE inhibitor cough
Cystic fibrosis
TB
Heart failure
Post viral cough

General appearance
Check for central and peripheral cyanosis
Visualize use of accessory muscles, nasal flaring
Visual chest expansion
Listen for audible breath sounds and type of cough - ENSURE TO ACTUALLY COMMENT ON THEM FOR OSCE (and in real life you

DDx

PE

would chart them)

Oral Cavity: tonsils, hard and soft palate, gums, teeth, mucosa, uvula

Nasal cavity

Palpate anterior and posterior chest

Auscultate heart

Auscultate lungs - if you heard adventitious sounds, do they clear when the patient coughs?

Tactile fremitus

Consolidation - egophony, bronchophony or whispered petriloquy

Percuss lungs

Check for edema

Dyspnea
Red Flag Questions

acute onset
trouble swallowing
drooling
trauma/strenuous activity

Key Question Areas

cough or recent cold?

hx and fmhx of asthma
trauma
surgery, confined to bed, OCP, smoke, meds, feel anxious or scared, fracture?
sense of impending doom? - PE
past hx of disease
did your kid eat honey

Pulmonary Embolism
aspiration of foreign body

DDx

obstruction
epiglottitis
anaphylaxis
pneumonia
asthma attack (status asthmaticus)
Pneumothorax
anemia
poor physical conditioning
astha
COPD
croup
atelectasis
CHF
L ventricular dysfunction
anxiety/panic disorder

General appearance
Assess swallowing
inspect symmetry and shape of chest
look for retraction/ use of accessory muscles
listen for stridor and audible wheezes and voice changes
Diaphragmatic excursion
inspect oral cavity
inspect nasal cavity
LNs
palpate neck
Position of trachea
examine skin and extremities (including edema and nails)
palpate, percuss, auscultate chest
assess tactile fremitus
auscultate heart

PE

Chest Pain
Red Flag Questions

Character of pain - tearing, gripping, stabbing

Onset - sudden is more urgent
Duration - acute is more emergent
Associated sx - n/v, sweating, dyspnea, syncope, hemoptysis

Key Question Areas

Risk factors for coronary artery disease

How is pain affected by position change and activity
Is this gastrointestinal in origin
Is this from a systemic cause
Family history
Emotional state of the patient

DDx

Unstable angina

MI

Stable angina

GERD

Costochondritis

Pleuritis

PE

General appearance
Vitals - especially note respiratory patterns
Inspect skin - cyanosis, rash of herpes zoster
JVD/JVP
Palpate trachea and chest - atelectasis/pneumothorax, trauma
Percuss the chest
Auscultate breath sounds
Auscultate heart sounds
Abdomen - palpation - consider GB involvement
Extremities - nails, edema - heart failure
Peripheral pulses - atherosclerotic vessel disease or dissecting aortic aneurysm

Hypertension
Red Flag Questions

Palpitations, sweating or dizziness

Abdominal or back pain
Vision changes
Trouble urinating
Pain - tearing, gripping, sharp, radiating

Key Question Areas

Duration of hypertension
Current treatment for HTN
Current stress
FHx specifically of CVD
Chronic illness - diabetes
Other risk factors for CAD - dyslipidemia

HTN urgency/emergency (>210/120mmHg w/o or w/ sx angina, MI, papillidema, mental status change, acute LV failure)
Coarctation of the aorta
Pheochromocytoma
Polycystic Kidney Disease
Acute stress
Ateriosclerosis
Cushings syndrome
Sleep apnea
Pregnancy
Renal artery stenosis
Primary aldosteronism
Pancreatitis

General appearance
BMI and waist circumferance
Fundoscopy
JVD/JVP
Thyroid
Bruits - carotid, abdominal
Heart - auscultate, PMI
Lungs
Abdomen - kidneys, aortic pulsations
Palpate kidneys
Peripheral pulses, edema
Neurological exam
General skin

DDx

PE

Weight Loss
Red Flag Questions

Key Question Areas

DDx

Cancer
Hyperthyroidism
Depression
Diabetes mellitus
IBD
Celiac
Anorexia
TB

Thyroid test
Abdominal palpation
Lung auscultation
Inspect eye (exophalmous)
Diabetes monofilament/reflex

PE

Abdominal Pain
Red Flag Questions

LODRFICCARA covers most red flags

key is onset, evolution/change, intensity, radiation

Key Question Areas

When was your last bowel movement?

Describe your stool: colour, odour, consistency, floating or not, amount, etc
Have you travelled anywhere recently?
female - pregnant? miscarriages? menses? endometriosis? bleeding?
vomiting?

pain with vomitting? (pain before = appendicitis; pain after = gastroenteritis)

happens around certain foods?
worst lying down after meals?
depression? interest or hopelessness?

AAA
MI
Cholecystitis/cholelithiasis
Appendicitis
peptic ulcer perforation
peritonitis
acute pancreatitis
PID
peptic ulcer
gastroenteritis
gastritis
Bowel obstruction
IBD
IBS
Ectopic pregnancy
UTI
ileus
diverticulitis
uterine fibroids
dysmenorrhea
ovarian cysts
hernia
intussusception

General appearance (i.e. diaphoresis, toxic appearance, clutching abdomen in pain, etc)
Abdomen skin inspection
note abdominal distention
Auscultation of bowel sounds
look for guarding and rigid ab muscles
Auscultation of bruits
Superficial and deep palpation of abdomen
Percuss and palpate LV and SP
Palpate GB (Murphys Sign)
Appendicitis tests: McBurneys, Psoas, Obturator, Rovsings (test for peritoneal irritation)
palpate for hernias
CVA tenderness
pelvic exam - female
male genital and prostate exam
check peripheral pulses
Regional lymph nodes

DDx

PE

Diarrhea
Red Flag Questions

Risk for dehydration - urination in past 24 hours, are you thirsty, dry mouth or dry eyes

Key Question Areas

What do they mean by diarrhea - frequency, volume, formed/liquid, intervals

Acute or chronic
Blood - GI bleed or inflammation
Colour of stool - food related, malabsorption, upper GI bleed, iron supplement
Pain associated
Fever, vomiting D before V = bacterial likely
Contaminated food or exposure to others who are sick
Exposure to animals
Exposure to contaminated water
Sexual activities - shigella or proctitis
Immune problem - is immune system weak/other illness
surgery, medication or diet related
food preparation problems

Viral gastroenteritis
Food poisoning
Antibiotic induced
pseudomembranous colitis - C.Diff
Heptatitis
IBS

DDx

IBD - Crohns or UC
CHO or fat malabsorption
HIV or diabetes enteropathy

general appearance
assess hydration - tissue turgor, mucous membranes
abdominal contour
auscultate abdomen - bowel sounds, bruits
Percuss abdomen
palpate abdomen
Liver, spleen if indicated
Test for ascites
Lymph nodes
Inspect skin
Inspect umbilicus
Inspect peristaltic waves/pulsations

PE

Pelvic Pain
DDx

PID
Pregnancy
Ectopic pregnancy
Endometriosis
PCOS
Diverticulitis
UTI
Fibroids

PE

Dysuria
Red Flag Questions

fevers, chills malaise? - pyelonephritis

Key Question Areas

sexual history
hx cancer
fhx prostate cancer
blood in urine
recurrent
discharge
reactive arthritis (cant pee/see/dance)
contraceptive use
smoker
occupational - exposure to chemicals (bladder cancer)
immunocompromised
catheter
voiding or storage sx
diabetic?

PID
pyelonephritis
renal failure
nephrolithiasis
UTI
urethritis/STI
interstitial cystitis
Acute bacterial prostatitis (more systemic symptoms vs cystitis)
benign prostate hyperplasis (no systemic symptoms)
urethral stricture

Kidney palpation
CVA
inspection of genitals
DRE
abdo exam
edema - glomerulonephritis

DDx

PE

Low Back Pain

Red Flag Questions

Trauma to spine or back

Fever
Treated for cancer
Do you have trouble with urination (i.e. incontinence)
Do you have loss of sensation in the genitourinary region (cauda equina syndrome)
Do you have any abdominal pain (i.e. referred pain from a AAA or rupture)

Key Question Areas

how does activity effect it

radiation
signs of neurological damage

stumbling

ataxia

numbness of tingling
Systemic disease - have you been sick recently

spine fracture
sprain
strain
herniated disc
cauda equina syndrome
spondylolisthesis, ankylosing spondylitis
sciatica
pyelonephritis
gallstones
pleuritis
pelvic inflammatory disease

general appearance
observe gait
spinal alignment and symmetry - then adams forward bend
inspect skin
palpate back, spine and SI joint

perform FABER to rule out SI

CVA tenderness
AROM of spine, hips
Straight leg raise and well leg raise
lower limb myotomes (RROM)
lower limb dermatomes
palpate abdomen

DDx

PE

Leg Pain
Red Flag Questions

Recent injury - if yes describe it

any other symptoms such as fatigue, fever, swollen joints
severity of pain, and does it occur with exercise

Key Question Areas

sprain or strain? - cracking/ripping during injury, use after injury

overuse, daily activities, other illnesses (CAD - claudication)
how has pain affected weight bearing/activity
is there a sense of giving away
position of leg during the injury
Swelling

immediate = serious

after 24 hours = inflammatory response

acute or chronic
systemic disease - medication, night pain
lyme disease - wooded areas, skin rash

tendinitis
osteomyelitis
osteoarthritis
rheumatoid arthritis
septic arthritis
gout
fracture
viral infection
psychogenic
acute leukemia
lyme disease
systemic lupus erythematosus
peroneal nerve compression

DDx

PE

General appearance
gait, and getting into seated position
have patient locate the pain
note deformities around the painful area
inspect skin and nails
leg length - unequal may be related to scoliosis
Effusion

bulge sign

balloon sign

Ballotting patella
Valgus/varus stress test - collateral ligaments
Drawer test - cruciate ligaments
McMurray test - medial meniscus
palpate, passive and active range of motion (hip, knee, maybe ankle)
muscle strength
neurological assessment - dermatomes, vibration, two point discrimination, pain

Joint Pain
Red Flag Questions
Key Question Areas

Reiters Syndrome - dysuria, red eye, arthritis

onset and related activity

DDx

Reiters syndrome

RA

OA

Trauma

Septic arthritis

Gout

PE
Headache
Red Flag Questions

worst headache of life?

syncope?
wake up with pain in morning or wake up from sleep?
worst w/ change in position
headache like this before?
thunderclap headache?
change in vision
fever + stiff neck?

Key Question Areas

onset
associated symptoms
length of time
pattern

Cancer
Giant cell Arteritis/Temporal Arteritis
Stroke
Subarachnoid hemorrhage
meningitis
migraine
tension
cluster
eye strain

eye exam - fundoscopy, reaction to light, acuity, visual field

palpate skull and temple (warmth and tender w/ GCA) and sinuses
asculates skull and temple for bruits
look for beading on temples w/ GCA
muscle tone - shoulders and back of neck
Kernig and Brudzinski - meningitis
CNs I-XII

DDx

PE

10

Fatigue
Red Flag Questions

Have you recently lost weight?

Do you have night sweats, fever?

Key Question Areas

Are you on medication? (antidepressants, chemotherapy etc, - cause of fatigue)

Did you have surgery recently? (3 month for recover from surgery)
Do exercise/physical activity bring you fatigue? (Ddx CFS/FM and depression - in depression pt feel better after exercise)
Do you start things without difficulty but get weak as you go on? (FM/CFS)
Do you feel that your energy level is not restored by sleep?
Do you have chronic medical conditions?
How is your stool look like? (Malabsorption)
How you tolerate cold? (cold intolerance in hypothyroidism)
Do you have hx of mononucleosis?
Can you trace back the onset of your fatigue sx to some viral or flu like disease? (CFS, Lime dz)
Do you have chronic pain in multiple locations which may migrate? (FM/CFS)
Loss of interest/pleasure, feelings of hopelessness (depression) if yes to either, then SIGECAPS
Did you see reddish or bruise-like discolorations which persisted for several weeks? (Lime dz)

Hepatitis
Cancer (i.e. Lymphoma)
TB
HIV
mental dz: depression, anxiety etc
Hypothyroidism, thyrotoxicosis
Malabsorption
Mononucleosis
Anemia
Congenial heart failure (CHF)
CFS&FM
Lyme dz
Diabetes Mellitus
COPD, lung dz

Liver: percuss/palpate, skin color, conjunctiva (jaundice) - in hepatitis

LN (test for lymphadenopathy) - lymphoma, CA, mono, CFS/FM, HIV
Percuss/palpate spleen (CA, lymphoma, mono, Lime dz)
thyroid palpation
speech (hypothyroid speech - slow rate, deep, hyponasal, word slurring etc)
ankle reflex - slow in hypothyroidism
H test - lid lag (thyrotoxicosis), exopthalmus
skin inspection - dry, coarse - in hypothyroidism, moist,/warm - thyrotoxicosis
pharynx, tonsils, palatal petechiae, posterior cervical LN, + fever (in mono)
conjunctival rim, mucous membranes (pallor in anemia)
JVP, Heart sounds (S3), PMI displacement (cardiomegaly), edema - in heart failure
Postural hypotension (check BP when lie down and standing - see the drop in BP), also low BP, tachy/bradycardia, poor capillary refill - in

DDx

PE

FM/CFS/ME

eye examination - red conjunctiva, dry eyes, + mild conductive hearing loss, absent light reflex, red nasal mucosa, nasal polyps, chronic

sore throat (red crescent on soft palate), consistent cervical lymphadenopathy - in FM/CFS

CNS - hyper/hyporeflexia - (test deep tendon reflexes), balance disturbance, difficulty to find words/complete sentence -FM/CFS, thyroid

Mini-mental status - for depression, CFS/FM

Lung examination - COPD, CHF

Insomnia
Red Flag Questions

Key Question Areas

Nature of the problem

to sleep, waking up, daytime sleepiness

is this a sleep disorder
is this secondary to a medical condition

GERD, COPD, CHF (all may have paroxysmal nocturnal dyspnea)

psychological cause
Related to sleep hygiene
related to lifestyle - travel, shift worker, etc
Related to age
Conditioned insomnia - routines, psychosocial stressors
Somnambulism (sleep walking)

Obstructive sleep apnea

Congestive heart failure
Asthma

DDx

11

COPD
Somnambulism (sleep walking)
Sleep refusal, night terrors, nightmares
Menopause - hot flashes and night sweats promote arousal from sleep

General appearance
Growth parameters/BMI - FTT with children, sleep apnea with obese men
Inspect ears
Inspect nose
Mouth/throat - enlarged tonsils?
Neck - thick neck risk for OSA
Auscultate lung and heart - asthma, CHF
Palpate the abdomen - GERD may elicit pain

PE

12