see Assignment Instruction
Watch the following videos, then complete the required assignment. Review the document in Course Resources for instructions on accessing the videos.
Lab 1
OSCE Clinical Skills
Sore throat
15:08
Upon completion of watching the video write up the scenario into a SOAP format. Is there anything you would do differently on your plan?
Lab 2
OSCE Clinical Skills
Cough
16:29
Upon completion of watching the video write up the scenario into a SOAP format. Is there anything you would do differently on your plan?
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BATES’ VISUAL GUIDE TO PHYSICAL EXAMINATION
OSCE 3: Sore Throat
This video format is designed to help you prepare for objective structured clinical examinations, or
OSCEs.
You are going to observe and participate in the clinical encounter of a 17‐year‐old patient who comes to
the office with a complaint of a sore throat.
As you observe the encounter, you will be asked to answer questions while the image on the screen
freezes. These questions will allow you to practice history taking and physical examination skills as well
your clinical reasoning as you develop your assessment or differential diagnosis, and your plan—that is,
an appropriate diagnostic workup.
You will have time to record your findings and receive feedback.
Health History
Tell me your special concerns today.
I have had a sore throat for the past week. I feel achy and tired and I don’t feel like going to softball
practice.
What are your diagnostic considerations at this point in this age group?
Strep throat.
Viral pharyngitis.
Infectious mononucleosis.
Have you had any fever or chills?
My mom checked my temperature yesterday, it was 100°F, but I haven’t felt any chills.
Okay, how about swallowing?
Yeah, it’s been pretty hard to swallow. I can get down food but…drinking is a lot easier.
Any swollen glands?
The glands in my neck have felt pretty swollen for the past few days.
Okay, is anyone sick at home or at school?
Um…yeah my friend on my team, she had the same thing. She felt really tired for a couple of weeks.
About two months ago my sister had a sore throat for a while and she felt really tired.
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What about earache or your sinuses?
My ears and sinuses are okay, I have a slight headache right in the front of my head.
How about cough?
No, I don’t really have a cough. Mostly my throat just hurts and um…I feel really tired.
Okay, any changes in your weight or your appetite?
I’m not really hungry but my weight seems about the same.
Have you tried anything to get yourself better?
Well, to be honest, I took some amoxicillin from our medicine cabinet for the past few days. My sister
thought it would help, but I still feel the same.
Okay, how much amoxicillin did you take?
It was about two or three times a day.
Physical Examination
With the patient’s concerns and health history in mind, and after good hand hygiene, you are ready for
the physical examination.
What areas of physical examination are important in this patient?
Head and neck, especially pharynx, upper palate, and lymph nodes.
The abdomen, especially the spleen.
I see that your temperature is 100.1°F. Now, your blood pressure is okay at 118 over 80 and your heart
rate is 90, which is a little up. But your breathing is about 18 per minute, which is normal. I’ll go ahead
and check your head and throat now.
Palpate the patient’s head and sinuses.
Does this hurt?
No.
Okay. How about now?
No.
Now I’m going to look at your eyes.
Check the patient’s pupillary response and inspects sclerae.
Check the patient’s ears.
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Check the patient’s pharynx.
Say, “ah.”
Ahhhhh…
I do seem some white patches on your tonsils in the back of your throat.
Check the patient’s upper palate.
I do see some spots on the roof of your mouth as well.
Palpate the patient’s anterior cervical lymph nodes.
Any tenderness here?
Not really.
Palpate the patient’s posterior cervical lymph nodes.
These lymph nodes feel enlarged. How about tenderness here?
Yeah, they’re pretty tender.
Check the patient’s heart and lungs.
Your heart and lungs are fine. I am going to check your stomach area now.
Perform a careful abdominal exam, listening in all four quadrants.
Perform light palpation…and deep palpation of the abdomen.
Palpate and percuss the patient’s liver.
With the patient supine, palpate the patient’s spleen.
Okay, take a deep breath in…and let it all the way out. Does that feel tender?
Yeah, that does feel a little tender.
Now just to be sure, I am going to check your spleen with you lying on your right side.
With the patient on the right side, palpate the patient’s spleen diagonally toward the shoulder, starting
at about the umbilical area up to the left costal margin.
Take a deep breath in…and let it all out. Any tenderness here?
Yeah, that does feel a little tender.
Check the patient’s lower extremities for petechiae or edema.
Diagnostic Considerations
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List your diagnostic considerations in order of importance and explain your rationale.
Press pause and list your answers. Resume when you are ready to receive feedback.
Infectious mononucleosis. The patient has sore throat and fatigue with mild fever and occasional
headache. Her sister had similar symptoms about 2 months earlier. The physical examination shows a
temperature of 100.1°F, pharyngeal exudates, palatal petechiae, posterior adenopathy, and tenderness
on palpation of the spleen, although splenic enlargement is not noted. Fever, pharyngeal exudates, and
posterior lymphadenopathy are the classic triad of symptoms and signs of infectious mononucleosis,
which is most common in adolescents and young adults.
Typical physical examination findings are diffuse exudates on the tonsils and enlargement of the
posterior cervical lymph nodes (typically more enlarged than in a bacterial infection). Palatal petechiae
and enlargement of the spleen may also be present.
Streptococcal pharyngitis. The patient has fever, sore throat, tonsillar exudates, and no cough. Cervical
adenopathy is anterior, unlike this patient, and palatal petechiae and splenic involvement are not seen,
although co‐infection with both Group A streptococcus and mononucleosis is not uncommon. Group A
beta hemolytic streptococcus accounts for roughly 10% of adult cases of pharyngitis and 10‐30% of
cases in children.
The modified Centor criteria are widely used to predict the likelihood of streptococcal infection and the
need for antibiotic therapy. These criteria assign one point each for fever, tonsillar exudates, anterior
cervical adenopathy, absence of cough, and age less than 15.
For 0‐1 points: no throat culture or antibiotics are necessary. For 2‐3 points: the risk is about 30%, so
you should consider a culture and possible antibiotics. At 4‐5 points, antibiotic treatment is warranted,
but a culture is not needed since the risk over 50%.
Viral pharyngitis. Most cases of viral pharyngitis are self‐limiting. Common symptoms include
conjunctivitis, prominent rhinorrhea, sinus congestion, cough, hoarseness, or diarrhea.
If cough is present, consider postnasal drip and occasionally gastro‐esophageal reflux or GERD. Viral
causes including rhinovirus, adenovirus, and coronavirus, are less likely in this patient.
Influenza typically presents with abrupt onset of fever, cough, sore throat, runny or stuffy nose,
myalgias, headache, marked fatigue, and possible vomiting and diarrhea, which is more likely in
children. It is caused by influenza viruses infecting the nose, throat, and lungs and spread by droplets
from sneezing or cough and less commonly from touching infected surfaces. Transmission lasts from 1
day before symptoms appear to 5‐7 days after infection.
However, in this patient the presence of splenic tenderness, tonsillar exudates (as opposed to
pharyngeal erythema), and lack of cough decreases the likelihood of this diagnosis.
Retropharyngeal abscess is often diagnosed late and requires a high suspicion for diagnosis and
treatment. It is most common in children under 5 but can occur at any age. Typical symptoms are fever,
sore throat, neck pain or stiff neck, and difficulty swallowing. Stridor and respiratory distress are rare.
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On physical examination there may be limitation of neck movement, especially neck extension.
Posterior pharyngeal edema or mass may be present.
Another subtle but serious diagnostic consideration is epiglottitis, which also initially presents with fever
and difficulty swallowing, but negative throat findings since the epiglottis is not visible.
Also the patient is not having difficulty swallowing or breathing and is not sitting in a “tripod” position
from neck hyperextension, which is common in epiglottitis.
This diagnosis of retropharyngeal abscess is unlikely due to the clinical presentation in this patient, but
should be considered if more serious symptoms are present.
Diagnostic Workup
List 5 next steps in your diagnostic workup.
Press pause and list your answers. Resume when you are ready to receive feedback.
Monospot test. This test is a form of the heterophile antibody test, a rapid test for infectious
mononucleosis due to Epstein–Barr virus.
It is 70%‐90% sensitive.
If this test is negative further EBV serologic testing can be obtained if needed. This test is highly specific,
so if the test is positive, infectious mononucleosis is likely to be present.
Complete Blood Count with differential. In infectious mononucleosis the total number of lymphocytes is
elevated and atypical lymphocytes are typically greater than 10%. The peripheral smear is an important
initial test if other blood disorders are suspected.
Rapid strep test. This test is 85% sensitive for streptococcal pharyngitis and can be done quickly in the
office. If positive, antibiotic therapy is warranted and throat culture can be deferred. If negative,
consider throat culture if indicated by the modified Centor criteria and clinical risk factors such as
exposure to infected contacts.
Throat culture is indicated according to the modified Centor criteria and confirms the presence or
absence of streptococcal pharyngitis.
Lateral neck films or neck CT scan. Consider these tests if there is a need to rule out or confirm
retropharyngeal abscess or epiglottis.
Summary
In sum, this is a 17‐year‐old high school student with sore throat, fatigue, and low‐grade fever for the
past week. She can swallow liquids but has some difficulty swallowing food. A fellow student has similar
symptoms and her sister had sore throat and fatigue several weeks earlier. On physical examination she
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has a temperature of 100.1°F, tonsillar exudates, palatal petechiae, and posterior cervical adenopathy.
Her spleen is slightly tender but not enlarged.
Diagnostic considerations include infectious mononucleosis, streptococcal pharyngitis, viral pharyngitis,
influenza, and retropharyngeal abscess.
Infectious mononucleosis is most likely due to the classic symptoms of sore throat, fatigue, fever, and
swollen glands…and her signs on physical examination of fever, tonsillar exudates, palatal petechiae,
posterior cervical lymphadenopathy, and splenic tenderness.
There is no rash, which is sometimes seen in patients with mononucleosis who have taken amoxicillin.
Patients with infectious mononucleosis and splenic enlargement, not present here, should avoid contact
sports until the spleen returns to normal size to reduce risk of splenic rupture.
Retropharyngeal abscess is unlikely, but airway obstruction should always be considered in patients with
difficulty swallowing.
Diagnostic workup includes the monospot test, CBCd, rapid strep test, throat culture if indicated by the
modified Center criteria for streptococcal pharyngitis, and lateral neck films or neck CT if more severe
conditions are present.
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BATES’ VISUAL GUIDE TO PHYSICAL EXAMINATION
OSCE 5: Cough
This video format is designed to help you prepare for objective structured clinical examinations, or
OSCEs.
So Ms. Chen, tell me what is your average weight that you keep.
You are going to observe and participate in a clinical encounter of a 45‐year‐old woman who comes to
the office with a complaint of a cough. As you observe the encounter, you will be asked to answer
questions while the image on the screen freezes. These questions will allow you to practice the skills of
history taking and physical examination skills as well clinical reasoning as you develop your assessment
or differential diagnosis, and plan—that is, an appropriate next diagnostic workup.
You will have time to record your findings and receive feedback.
Health History
Ms. Chen, tell me your special concerns.
I have been coughing for a week and just can’t seem to stop. I can hardly sleep at night.
Have you been bringing up any phlegm or sputum?
I’ve been coughing up a yellow‐green mucus, sometimes with pink streaks that seem to be blood.
What diagnoses are you considering at this time?
Pneumonia.
Bronchitis.
Sinus infection.
Tuberculosis.
How much pink streaking are you seeing at any one time?
Just a tinge, but maybe 3 or 4 times a day.
Have you had any fevers or chills?
Yes, I checked my temperature yesterday and it was 101°F.
What about shortness of breath?
I do feel shortness of breath when I’m working outside, but not when I’m working at my desk.
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Have you noticed any wheezing?
Just once in a while when I’m going up the stairs fast, or when I’m doing heavy work in the yard.
Have you had any of these symptoms before, or had any asthma?
No, not since I was a kid. I did have some mild asthma when I was in elementary school but luckily I
never had to go the hospital.
Any pain in your chest when you take a deep breath?
No, no pain when I breathe in or out.
You mentioned that you’re coughing a lot at night. Are you using any extra pillows?
Well, the last few nights I have been using two pillows instead of one. It seems to help me clear my
head.
Have you had any acid taste, or reflux?
No, not really.
How about any recent colds?
Well, actually last week I came down with a runny nose and a sore throat, but then my symptoms got
worse.
Have you had any sinus congestion?
Well, my sinuses do feel full a lot. Um…I first feel a drip in the back of my throat, um…but now the worst
thing is the cough.
What about allergies when you’re outside?
Pollen and golden rod get me every spring and fall. Right now my spring allergies are almost over.
And what do you do for those?
Antihistamines usually help. Um…I do try to cut down on my smoking, but right now my symptoms now
are much worse than usual, especially with the bad cough and phlegm.
Do you have pets at home?
Yes, we have two cats. I’ll admit right now that they sleep in our bedroom.
Well, animal fur picks up allergens, you may want to consider having them sleep in a different part of
the house, or even outside.
Can you tell me if you still smoke cigarettes?
I’ve smoked two packs a day for the last 10 years. I’ve tried to stop but I work as a dispute mediator.
With all that stress I just can’t seem to quit.
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Have you had any weight loss or night sweats?
No, my weight is fine, and no night sweats.
Has anyone around you been ill? Or have you been exposed to tuberculosis?
My family and co‐workers are fine. When I was a kid though, my grandmother told me she had
tuberculosis in her 20s.
Have you been checked for tuberculosis, with a skin test like a tine test or PPD?
I did have one of those PPDs about 10 years ago when I started my current job, and it was negative.
Have you had a chest x‐ray?
No, I’ve never had a chest x‐ray.
What about any recent travel? Have you been out of the country?
Well, I did go to Shanghai a few months ago to visit my cousins…um, however this cough is much more
recent. No other travel.
I’d like to go back to the pink streaks in your sputum that you mentioned. Are you taking any
medications right now, such as aspirin or ibuprofen?
Right now I’m taking a decongestant over the counter and some ibuprofen maybe twice a day or so. I’m
not on any regular medication.
Okay, let’s talk about your general health. Do you drink alcohol?
Well, a glass of wine, 3 times a week.
Have you ever used any oral, nasal, or injection drugs such as marijuana, cocaine, amphetamines, or
heroin?
No, never, even though I know people who do.
To be thorough, given your cough, I need to ask about your sexual activity. What is your sexual
preference, men, women, or both?
Men.
Now, just a few questions about your past health…I see you are 45. Have you ever had any problems
with your heart or lungs?
No, I’m still able to work out even with the smoking. I just had that asthma a few times when I was in
grade school.
How about any surgery?
No, no surgery. I’ve never even been to the hospital.
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Okay, is there anything else that you would like me to know?
No, I think you’ve covered everything.
Okay, let’s start your physical examination.
Physical Examination
With the patient’s health history in mind, and after good hand hygiene, you are ready for the physical
examination.
Okay, your temperature is up a little at 101.5°F. Your blood pressure is 130 over 88. Your heart rate is
100 and you’re breathing at about 22 breaths a minute, which is higher than normal.
What regions of the physical examination are important in this patient?
Head and neck, heart and lungs, extremities.
Okay, first I’d like to check your head and neck.
Examine the ears.
Palpate the sinuses.
Examine the throat and mouth.
Palpate the anterior and posterior cervical lymph nodes.
Okay, your ears look fine but your throat is a little red, otherwise it’s okay. Now I’d like to check your
lungs.
Percuss the lungs.
There is some dullness here over the base of your left lung. Can you say “99” for me a few times?
Palpate for tactile fremitus.
Auscultate the lungs.
[RALES AND RHONCHI SOUNDS]
Can you say “99” for me a few times?
99…99…99…
Listen for bronchophony, or louder transmitted voice sounds, which are abnormal.
Good, now can you whisper the number “99”?
[WHISPERING] 99…99…99…
Listen for whispered pectoriloquy, or louder whispered sounds, which are abnormal.
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Okay. Can you say the letter “E” for me 2 or 3 times?
Eeeee…Eeeee…
Listen for egophony, or “E to A” changes, which are abnormal.
Okay, you can stop.
How am I doing?
I’m hearing some changes from consolidation in your left lower lung. Let’s continue the examination and
then we can talk more. Can you lie back for me?
Auscultate the anterior chest.
Check the neck veins for jugular venous pressure.
Palpate the carotid upstroke…
…and listen for bruits.
Listen to the heart in the six positions.
Listen to the abdomen.
Palpate the abdomen.
Inspect and palpate the calves and ankles for tenderness and swelling.
Diagnostic Considerations
List your diagnostic considerations in order of importance and explain your rationale.
Press pause and list your answers. Resume when you are ready to receive feedback.
Community acquired pneumonia: This 45‐year old smoker has a productive cough, mild shortness of
breath, and fever. On physical examination she has an elevated temperature and a mildly elevated
respiratory rate and dullness, increased tactile fremitus, rhonchi, and E to A changes in the left lower
lobe of her lungs, all features suspicious for the lung consolidation of community‐acquired pneumonia.
Rapid onset of symptoms and pleuritic chest pain are also characteristic, and 25‐50% of patients have an
accompanying pleural effusion. Risk factors include COPD, cardiovascular disease, diabetes, and
smoking.
Atypical community‐acquired pneumonia: Atypical pneumonia frequently presents with a persisting
non‐productive “dry hacking cough,” low‐grade fever, and absence of pleuritic chest pain. Lung
examination findings are variable, but may be normal. Clinical features do not clearly distinguish atypical
from typical pneumonias. This patient’s symptoms, especially fever, productive cough, and positive lung
findings, make this diagnosis less likely.
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Bronchitis: In acute bronchitis, which is usually self‐limiting, cough typically follows an upper respiratory
infection and persists for more than 5 days. Sputum production is variable and may be blood‐tinged.
The chest examination is normal. In chronic bronchitis look for chronic cough with sputum, often seen in
smokers. Unlike this patient, chronic cough lasts for more than 8 weeks. Note that symptoms and
findings suggesting sinus infection or GERD are minimal.
Pulmonary tuberculosis: This patient’s blood‐tinged sputum raises the possibility of pulmonary
tuberculosis from Mycobacterium tuberculosis; however, in tuberculosis cough is usually present for
more than 2 to 3 weeks and hemoptysis is usually a late symptom reflecting cavitation. Actual sputum
may not be present. Initially patients are often asymptomatic then progress to constitutional symptoms
such as weight loss, anorexia, fatigue, fever, chills, night sweats, and cough. The lung examination may
be normal except for crackles, or rales.
Lung cancer: Lung cancer is unlikely in this patient due to the acute onset of cough with productive
sputum, fever, and confirming lung examination findings. However, the possibility arises since this
patient is a smoker with a cough and blood‐tinged sputum though not hemoptysis. Lung cancer
symptoms usually appear late, including cough, hemoptysis, chest pain, and dyspnea but symptoms also
arise from metastatic spread. Cigarette smoking causes roughly 90% of lung cancers.
Diagnostic Workup
List 5 next steps in your diagnostic workup.
Press pause and list your answers. Resume when you are ready to receive feedback.
O2 saturation: In an office setting, pulse oximetry helps identify hypoxia when the oxygen saturation
falls below 90%, particularly in smokers and patients with COPD or known lung disease. It is important to
note that the oxygen saturation can be high even when the more important indicator of oxygenation,
the pO2, is considerably lower due to the S‐shape of the oxyhemoglobin dissociation curve. In more
seriously ill patients an arterial blood gas is indicated.
Chest x‐ray: Chest x‐ ray is the gold standard for diagnosis of pneumonia. Although it does not identify
the causative pathogen, focal infiltrates with pleural effusion suggest bacterial infection. Interstitial
infiltrates are common in mycoplasma, chlamydia, and viral infection. Cavitation with air‐fluid levels is
suspicious for abscesses from staphylococci, anaerobes, or gram negative bacilli. Cavities without air‐
fluid levels are seen in tuberculosis and fungal infection. Chest x‐ray also helps identify cough related to
heart failure, COPD, and malignancy
Complete blood count with differential and metabolic profile: These standard tests identify the rise in
white blood cell count and neutrophils, elevation of CO2, anemia, and renal and liver disease that
influence antibiotic therapy.
Sputum culture and gram stain: Collecting a sputum culture and gram stain before starting therapy is
controversial, but can help guide therapy in severely ill patients.
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Blood cultures: Blood cultures and urine testing for legionella and pneumococcal antigens are
recommended for patients with severe pneumonia.
Summary
In sum, the patient is a 45‐year‐old dispute mediator with cough productive of yellow‐green and
occasional blood‐tinged sputum for a week, fever, mild shortness of breath and occasional wheezing,
and a 10‐year history of smoking 2 packs of cigarettes a day. There is a remote history of travel and TB
exposure, which do not contribute to the current clinical presentation. On examination her temperature
is 101.5°F; blood pressure, 130 over 88; heart rate, 100; and respiratory rate, 22. She has dullness,
decreased breath sounds, and egophony in the left lower lobe.
Diagnostic considerations include Community‐acquired pneumonia, which is most likely, atypical
community‐acquired pneumonia, acute bronchitis, pulmonary tuberculosis, and lung cancer.
The diagnostic workup includes O2 saturation, chest x‐ray, CBCd and metabolic profile, sputum culture
and gram stain, and blood cultures.
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>Lab rubric
and ) into yellow cells only in column F.
Average 2 4 0
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The entry is on topic and includes content to support the unit Learning Objectives.
Submission does not relate to the topic.
Answers some question/topics with some content linked to only one unit Learning Objective.
Answers all questions with some content linked to at least two unit Learning Objectives.
Answers all questions with opinions/ideas creatively, clearly, and completely with obvious support of all unit Learning Objectives.
60%
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Answers some question/topics with some clearly stated opinions. No example is provided.
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20
The entry meets length stated in assignment requirements.
Submission did not meet stated length.
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Grammar/ Formatting/ MechanicsSignificant errors in spelling and/or grammar. Major flaws in writing mechanics and formatting.
Poor spelling and grammar are apparent. Does not use APA style formatting when needed.
Uses Standard English with rare errors and misspellings. Minor errors in APA style formatting.
Consistently uses Standard English with rare misspellings. Appropriate mechanics and APA style formatting.
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