OSCE documentation

Head:

1. facial symmetry: eyebrowns and palpebral fissures

2. temporal arteries; +2 bilateral, nontender

3. TMJ: has full ROM and free of creptus and pain

4. CN V and VII: normal function

Eye:

1. Visual acuity: 20/20 vision in left eye assessed by Snellen E test

2. EOMs: cardinal gaze normal and PERRLA and 3mm

Ear:

1. hearing acuity: Weber test: bilateral equal hearing; Rinne: Ac is twice as long as BC

Nose:

1. Nasal patency (+)

Mouth:

1. CN X: uvula and palate rise when pt says “aah”

2. tongue control bilaterally

Neck:

1. thyroid is palpable with no swelling or abnormality both with and without swallowing

2. lymphatic nodes: pre auricle, post auricle, occipital, tonsillar, submandibular, submental, anterior cervical, posterior cervical, supraclavicular free of abnormal masses and tenderness

3. carotid arteries free of bruits and palpable bilaterally +3

Heart:

1. aortic, pulmonary, erb’s point, triscupid, and mitral points free of abnormal sounds

2. apical pulse is # with regular rhythm

3. radial, dorsalis pedis, posterior tibular pulse +2 bilaterally

4. capillary refill less than 3 seconds

Thorax:

• chest expansion rise and fall bilaterally, and symmetrically

Lungs:

1. posterior, anterior, and lateral lung fields auscultated bilaraly. Wheezes present upon auscultation

2. tactile fremitus, (whisper pectoctoly, bronchophony, egophony) normal equal bilaterally

Abdominal:

1. no distention, swelling, redness upon inpection.

2. Ascultation performed in all 4 quadrants: BM (+)

   1. ascultated abdominal aorta, and renal, iliac, femoral arteries bilaterally +3, free of bruits and other adventious sounds,

3. Percussion performed in all 4 quadrants and tympany was present.

4. light and deep palpation performed in all 4 quadrents: free of tenderness, distention, normal results

   1. palpated abdominal aorta: no bulge or pulsation

   2. liver, spleen, left kidney palpated. No abnormal findings

5. CVA percussed (-)

6. Pain: pt stated pain is 6/10 in the numeric pain scale. Pt stated it is a sharp, stabbing pain in the abdomin. Aggrevating factors: movement like walking. Relieving factors: resting and laying down. Pt stated this pain started yesterday morning and it comes and goes.

Neuro:

1. aoox4

2. CN XI intact

3. stereognosis and graphesthesia present

4. upper and lower extremity fine motor and coordination present

5. DTR (+) for both lower (patellar and Achilles) and upper extremities

6. (-) Babinski reflex

7. great toe sentation and vibration preception (+)

8. Romberg (-)

9. normal gait and coordination