:OSCE ( Objective Structural Clinical Examination )

General survey : conscious , coherent. Afebrile, ambulatory with the ff. vs : BP= ? mm Hg ; CR
= ? / min RR== ? / min Temp = ? oC ; WC = ? inches ; Ht = ? meters ; Weight = ? kg ; BMI
=?
HEENT : pinkish palpebral conjunctivae ; anicteric sclerae ; (-) circus senilis ; (-) xanthelasma
; (-) alopecia ; (-) Tonsillopharyngeal congestion ;
Neck: supple ; JVP = 5 cm at 45 degrees ; (-) thyromegaly ; (-) cervical lymphadenopathy ; (-)
carotid bruit
Chest/ Lungs : symmetrical ; (-) retractions ;(-) lag; (-) spider angiomas; equal vocal and tactile
fremiti ; equally resonant on both lung fields; equal breath sounds ; (-)rales ; (-) wheezes
Heart : Adynamic precordium ; Apex beat at the 4th or 5th intercostal space left midclavicular line ;
(-) thrills/ heaves ; (-)loud and palpable P2 ; normally split S2 ; S1 > S2 at apex ; S2 > S1 base ; (-
) S3 ; (-) S4 ; normal rate regular rhythm ; (-) murmurs
Abdomen : Abdominal girth = cm ; flat ; (-) caput medusae ; normoactive bowel sounds ; soft;
nontender ; tymphanitic ; (-) splenomegaly ; liver span = __ cm at the midclavicular line ; liver
edge non palpable ( if palpable cms below the ribs ; smooth/nodular edge ; nodular / smooth
surface of the liver )
Extremities : (-) deformities ; ( -) clubbing ; (-) cyanosis ; with the ff. pulses :
DP PT P F B R
R ++ ++ ++ ++ ++ ++
L ++ ++ ++ ++ ++ ++
Rectal exam : ( -) anal tags ‘ good sphincteric tone ;rectal vault not collapse ;(-)
hemorrhoids nor mass noted; brownish stools in the tactating finger
Neurologic exam :
• Cerebrum : conscious ; oriented to 3 spheres
• Cerebellum : (-) nystagmus ; can do heel to shin test ; intact Romberg’s test ; can do rapid
alternating movements ; can do finger to nose test
• Cranial nerves :
• I – can smell coffee
• II, III – pupils equally reactive to light
• III, IV, VI – intact extraoccular muscles
• V – intact corneal reflex , bilateral ; intact masseter muscle contraction
• VII – (-) facial asymmetry
• VIII – can hear, bilateral
• IX, X – intact gag reflex
• XI – can shrug shoulders , bilateral
• XII - tongue midline on protrusion
• (-) Babinski ; (-) nuchal rigidity ( -) Brudzinski (-) Kernig’s sign
• Dermatomaltest : equal and intact on all levels
• Motor Sensory DTR
REVIEW OF SYSTEM

Constitutional :fatigue; weakness; weight loss. No fever ; chills

Neurologic :No headache ;No syncope ; no seizures ; no areas of focal

weakness ; no sensory problems / numbness ; “tingling” or “ pins and needles ;
“no history of seizures ; no dizziness; no scotoma ; no vertigo ; no tremors or
other involuntary movements

Eyes: No significant visual difficulties; blurred vision ; No diplopia ; no eye pain

ENT :No problems in hearing; no sore throat no sinus drainage ; no epistaxis ; no

tinnitus

Cardiovascular / PVS:no chest pain or discomfort ; no PND, no orthopnea ; no

palpitation ;Rheumatic fever manifestations ( sore throat , fever and joint pains);
no claudication ; pedal edema; no leg cramps

Respiratory :no cough ; no difficulty of breathing ; no hemoptysis ; ( GINA

guidelines if asthma)

Gastroenterology: Dysphagia ; odynophagia ; change in appetite ; celching or

bloatedness; flatulence ; burping No nausea ; no vomiting ; no abdominal pain ;
no diarrhea/ constipation ; no change in bowel movement ; no melena ; no
hematochezia

GUT :dysuria or burning pain on urination ; incontinence ; hematuria; nocturia ;

frequency ; polyuria/ oliguria ; urgency ; hesitation; dribbling ; loss of parabolic
curve

Musculoskeletal :No joint pain ; swelling or redness ; no decreased range of

motion ; no myalgia

Endocrine :No diabetes ( 3 P’s ) ; no thyroid disease ( heat or cold intolerance ;

Wayne’s index ) or hormone replacement ; no hot flashes or night sweats

Immunologic /Hematologic :no easy bruising or bleeding ; No urticarial/ allergy

Psychiatric :No insomnia ; depression ; mania or mood swings ; no psychotropic

drugs

* All types of pain = LPPQRST( location, provocative and palliative factors , quality ,
radiation ; severity and timing or temporal profile )