Case 3: Physical examination station
Jason Feldman, a 62-year-old construction worker, who presents to your office with right leg pain.
IN THE NEXT 10 MINUTES:
- OBTAIN A FOCUSED AND RELEVANT HISTORY OF THE PRESENTING PROBLEM.
- CONDUCT A FOCUSED AND RELEVANT PHYSICAL EXAMINATION.
The 7-minute warning signal will indicate you have 3 minutes remaining with the patient. There are NO examiner oral questions in this station.
GIVE ONE (1) LABEL TO THE EXAMINER.
Candidate voiceover: Right leg pain, and both history and physical. I’ll really have to make sure I don’t waste time. I wonder if him being a construction worker is important. He is 62…in my differential I have to think of different possibilities: Is it related to trauma? Arthritis? Maybe it’s a vascular issue? I need to make sure to ask about pain, location, relation to weight-bearing, if he’s had previous injuries, how long….
Candidate: Hi Mr. Feldman. How are you today?
Patient: Not so good.
Narrator voiceover: The candidate has decided, from the information they have elicited from the patient, that a vascular problem is the most likely cause of the leg pain. That has taken about 4 minutes. She will now do a focused examination based on her assessment of the problem. Watch how the candidate manages talking to patient while simultaneously letting the examiner know what she is doing and why throughout the physical exam.
Candidate: OK, Mr. Feldman, I’d like to take a look at your leg now, if you don’t mind.
Candidate: I’d like you to lie down, if you would, please.
Based on what you’ve told me so far, I suspect you have a problem with the circulation in your leg and that the arterial blood flow might not be as good as it could be. And so, I’d like to proceed to do an arterial circulation examination.
(To the examiner)
I suspect the patient suffers from peripheral vascular disease and so I would like to do an arterial circulation examination, beginning with the femoral pulse.
As candidate approaches the patient, examiner states (uses case prompt): Femoral pulses are normal bilaterally, no bruits heard. Please move on.
Candidate (to patient, as he bends leg): Mr. Feldman, I’d now like to take a look at the pulse behind your knee. I just need to bend your knee a little bit, and you’re going to feel me pushing behind it, just like this, as I look for the pulse. This one can be hard to find sometimes.
So, with the knee in a slightly flexed position, I am assessing for popliteal pulse intensity, bilaterally.
Popliteal pulses are equal and normal, bilaterally. I’d now like to proceed to do more an evaluation of the peripheral circulation, and I will compare both sides. (Straightens leg and feels for posterior tibial.)
So, with your leg nice and straight, I am assessing for the posterior tibial pulse, on both sides, as well as the dorsalis pedis.
I feel both pulses present, equal, and bilateral.
I’d now like to move on and do another examination, looking for some of physical signs of vascular insufficiency. And this would include looking for changes in the skin, hair on his feet, his nails, as well as looking at dependent rubor and pallor on elevation.
So, Mr. Feldman, I’m just taking a look at your feet. I see that your skin looks normal…you have some hair, which is normal. You have a good capillary refill (candidate squeezes toenail), which means that the circulation in the very small vessels of your feet is good.
Now I’d like to proceed to special maneuvers. And this would include looking at pallor on elevation, as well as dependent rubor.
Mr. Feldman, I’m just going to lift you’re leg a little bit. You don’t have to do anything. Just relax. (Lifts leg, and may place it on candidate’s shoulder for support).
At this point, we hear the buzzer/signal is indicating X minute(s) are left.
So normally I would maintain the leg in the air like this for about two minutes, and be looking at the foot for pallor. A little bit of pallor is normal, but…
Examiner: Noted. You may move on.
And now, if I could have you sit up, Mr. Feldman, and just have your feet hang over the side of the bed for me. There you go. All right. (Candidate adjusts draping as needed.)
Again, I would suspect this would take a couple of minutes before I would see any redness.
Signal heard indicating the end of the station.
Candidate leaves the room.
This candidate has used her time effectively. She gave roughly half of the allotted time to the history, and half to the physical. She needed to be strategic in gathering information given the patient’s complaint. Note that the candidate instructions for this case did not specify what kind of physical exam to conduct. As in a real-life situation, that would depend on the information the candidate gathers.
These are some other things to learn from this example about physical examination stations:
- Although the candidate asks permission of the patient for the physical exam and each manoeuvre in the exam, it is not necessary. You may save time by not asking for permission.
- The patient needs to know what they must do during the manoeuvres and it’s ideal to explain what you are doing as you go
The candidate’s primary attention is on the patient, but she speaks to the examiner when she feels a more clinical explanation is necessary in the exam context. When you address the examiner, explain what you are doing, what you are looking for, and your findings – positive or negative.
- This candidate does all of this smoothly, and with no loss of time
- The candidate drapes the patient appropriately throughout the examination, which is important
- The candidate conducts the exam rather than just saying what she would do. The examiner gives a standardized prompt when the manoeuvre is not required due to time constraints or because it is considered physically invasive for the SP.
Remember that the examiner is assessing whether the physical exam techniques are conducted satisfactorily. Never invent a finding because you expect it might be there. In this example, the exam is normal, but in some stations, there may be real or simulated findings.
In terms of time management:
- The candidate does not panic when she hears the signal indicating 3 minutes left in the station. When you hear the warning signal, do not begin to quickly list what you would do or ask. You will not gain credit for doing so.
- The examiner used a standardized prompt to indicate that the full time for leg elevation need not be done. This is because the candidate has satisfactorily done the manoeuvre, and it is a time-sensitive simulation.
When the final signal sounds, the candidate simply leaves. In an OSCE, there is no need for polite or social statements that you would normally use in your office. However, if the patient requires re-draping, that should be done as you leave.
This candidate is organized, confident, and competent, and that requires practice. It cannot be achieved just by thinking about the procedure. The same is true of patient interviews. If a candidate hesitates, has to stop to think about what to ask next, or must retrace or revisit parts of the encounter, that shows a lack of competence in that station.
While it is very important to practice the types of cases you might encounter in an OSCE, you must also pay attention to the information you receive from the SP. As in real-life clinical situations, it is not possible to apply a rehearsed, mechanical approach to an OSCE station. In fact, that can be counterproductive to understanding the patient’s clinical situation and performing well in an OSCE station.