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Medicine I: OSCE I and II | Reporting Positive and Negative Findings

Region/Area Assessed Positive Finding Report (Abnormal) Negative Finding Report (Normal)
Patient is acutely ill/ Patient is chronically ill.
Patient is well.
Patient is jaundiced/there is presence of pallor or patient appears sallow or
Patient appears healthy with no obvious skin lesions present.
cyanotic.
Patient has normal facies.
Patient presents with characteristic facies of (name of disease such as
Cushing’s or hyperthyroidism)
Patient is comfortable, speaks clearly and continuously and assumes no
compensatory positions.
Patient is distressed, speaks in phrases, assumes tripod position or 2-3
pillow orthopnea, squatting, etc.
Patient is conscious
- If you speak to patient and ask appropriate questions, you can say
Patient is confused, lethargic, somnolent, obtunded, stuporous or comatose
that the patient is awake, alert and oriented
(use of Glasgow coma scale)
- If patient has not spoken or responded to questions, you cannot
speak to their orientation or responsiveness.
Patient can ambulate with assistance, is wheelchair borne, stretcher-borne
or bedridden
Patient is ambulatory: only speak to this if you have seen the patient walk
Patient is rigid, tense, restless, pacing, dragging one foot, limping, shuffling
Patient has normal gait, is relaxed and moves with ease. All movements are
gait, involuntary movement or immobile part.
smooth.
Body habitus: hyposthenic, sthenic or hypersthenic
Body habitus: hyposthenic, sthenic or hypersthenic
General Survey Patient’s body is asymmetrical, there is abnormal distribution of normal
Patient’s body has symmetrical appearance, no abnormal distribution of
tissues like fat, muscles, subcutaneous tissue or bone
normal tissues.
Patient is unkempt, does not appear to be well-groomed and is inappropriate
Patient is well-groomed, kempt, meticulous and is appropriate for the
for the situation
situation.
Patient has characteristic odor in body and breath (like alcohol, acetone
Patient has no characteristic odor of breath or body.
breath in DKA or ammoniacal fish breath in kidney failure)
Patient is cooperative and responsive, predominant mood is neutral, happy
Patient is uncooperative, guarded, suspicious, evasive, hostile and
or upbeat with normal affect.
seductive. Predominant mood is ancious, fearful, europhic, irritable, etc.
Has broad, restricted or labile affect that can also be blunted or flat. Is
Patient reacts appropriately to situation.
appropriate to situation.
Patient speaks clearly and no abnormalities noted in voice.
Patient has slurred speech, inappropriate words, hoarse voice, high or low
pitch.
No abnormal movements.
Patient responds with stream of thought, paranoia, delusions, obsessions,
Patient responds to questions clearly and coherently with clear and logical
compulsions, phobias, illusions, hallucination, depersonalization or
pattern of thought.
derealization.
Patient is oriented to time, place and person and has intact immediate,
Patient is not oriented to time, place and person and memory (immediate,
recent and long-term memory.
recent, remote) is not intact.

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Region/Area Assessed Positive Finding Report (Abnormal) Negative Finding Report (Normal)

Palpatory BP: Palpatory BP:

Patient’s palpatory blood pressure is ____mmHg. Patient’s palpatory blood pressure is ____mmHg.

Blood Pressure Auscultatory BP: Auscultatory BP:

Patient’s blood pressure is ____/____mmHg. Patient’s blood pressure is ____/____mmHg.

Blood pressure is not within normal range. Blood pressure is within normal range.

State where you are taking the pulse (radial, etc)

State where you are taking the pulse (radial, etc)
Pulse is ___ beats per minute.
Pulse is ___ beats per minute.
Pulse Pulse is irregular.
Pulse is regular.
Pulse is 1+, 3+ or 0.
Pulse is 2+.
Pulse is not within normal limits.
Pulse is within normal limits.

Respiration is ___ respirations per minute. Respiration is ___ respirations per minute.
Respirations are have an abnormal pattern (Cheyne-Stokes, Patient is breathing normally and without distress or use of
Respiration tachynpnea, bradypnea, etc.). Use of accessory muscles (if present). accessory muscles.

Respiration is not within normal limits. Respiration is within normal limits.

Temperature Temperature is ___oC and is not within normal limits. Temperature is ___oC and is within normal limits.

Height N/A Patient’s height is ___ cm/convert height to meters to state.

Weight N/A Patient weighs ___ kg.

Skin is cool to touch. Skin is moist/dry. Skin turgor is decreased and

mobility is increased/decreased. Texture is
Skin is warm and dry. Smooth to the touch and with normal turgor
scaly/flaky/dry/wet/moist.
and mobility.
Skin
Visible lesions are present (describe the lesions are primary or
No visible lesions are present. Patient has not does not note any
secondary and then describe size, shape, location, configuration,
lesions or abnormalities.
color, blanching, texture, elevation or depression, exudates, patterns,
grouping, odor or symmetry).

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Region/Area Assessed Positive Finding Report (Abnormal)
Color: asymmetrical
Quantity: sparse, absent in some areas
Distribution: no consistent distribution, lacking in some areas,
Hair
greater presence of hair in some areas
Texture: brittle, coarse
Infestation: present.
Color/Pigmentation: cyanotic, red, pale
Shape: concave (spoon) or convex (clubbing)
Length: asymmetrical, nails can appear ripped or torn if short
Symmetry: not symmetrical appearance when compared to each
Nails
other.
Patient has prominent ridging, beading, peeling or redness and
swelling or tenderness.
There is presence of abnormal growths such as cysts, tumors and
wart-like growths.
There is observed titling or abnormal head movement (nodding,
jerking or bobbing).
Patient presents with characteristic facies.
Patient presents with abnormal facial movements.
Head
Patient’s skull size is small/large.
Patient’s head is asymmetrical in appearance.
Hair loss pattern is apparent.
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Negative Finding Report (Normal)
Color: normal throughout, consistent throughout
Quantity: covers all normal areas as expected with appropriate
amount of hair
Distribution: consistently distributed throughout normal areas
Texture: normal texture of hair, can also be fine, curly, straight, etc.
Infestation: absent.
Color: Patient has normal color of the nails, the pigmentation of the
beds is pinkish with normal return of color (capillary reflex)
Shape: patient’s nails have normal shape and no abnormal
curvature.
Length: patient’s nails are of equal length.
Symmetry: patient’s nails are symmetrical when compared to
opposite hand.
Patient has normal ridging. No beading, peeling, redness, swelling
or tenderness.
No presence of abnormal growths.
Patient holds head midline with no abnormal movement noted.
No characteristic facies.
No presence of abnormal patient movements.
Patient’s skull is of normal size and is symmetrical in appearance.
Hair distribution is normal and no apparent pattern of hair loss is
noted.
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Region/Area Assessed Positive Finding Report (Abnormal) Negative Finding Report (Normal)

Palpation reveals tenderness, soft tissue swelling, bony prominences Palpation reveals no tenderness, swelling, bony prominences or
or depression (in areas where it is not normal). depression.

Head Patient’s hair is coarse, not distributed consistently and brittle on Patient’s hair is normal, smooth, symmetrically distributed and not
palpation. brittle on palpation.

Thickening, hardness and tenderness in the temporal artery. There is no tenderness, hardness, thickening in the temporal artery.

Left and right ears do not have equal size and shape.
Left and right ears are of equal size and shape.
There are presence of skin lesions and/or mass on the external ear.
No presence of skin lesions and/or masses noted.
Patient’s ears are low-set or high-set.
Patient’s ears are in normal position, touching or hardly crossing the
Tenderness is elicited when ear is palpated both at the auricle and at imaginary line drawn from outer canthus to occiput.
the mastoid.
Ear No tenderness is elicited on palpation.
Tenderness is palpated when pressing the tragus inward.
Patient’s external auditory canal is clear of obstruction, speculum is
Patient’s external auditory canal is obstructed by ear wax, discharge, inserted easily.
foreign bodies, redness and/or swelling.
Tympanic membrane is flat or concave with no bulging. The cone of
Tympanic membrane is bulging, flat or concave, no presence of light is easily seen. Movement of membrane occurs when patient is
cone of light, no movement of the membrane upon Valsalva asked to perform the Valsalva maneuver.
maneuver.

Voice/Whisper Test: Patient is unable to repeat more than fifty

percent of the words back accurately.
Voice/Whisper Test: Patient is able to repeat more than 50% of
Stopwatch/Tick Test: Patient is unable to discern ticking of the whispered words back accurately.
watch at __ distance.
Stopwatch/Tick Test: Patient is able to discern ticking of the watch
Weber Test: Lateralization of sound is present to the ____ ear. This at all distances.
Hearing Acuity
indicates sensorineural hearing loss (if lateralized to good ear) or
conductive hearing loss (if lateralized to bad ear). Weber Test: There is no lateralization of sound. Normal findings.

Rinne Test: Patient’s air conduction is less than bone conduction, Rinne Test: Patient’s air conduction is greater than bone conduction.
which signifies conductive hearing loss. Patient’s air conduction is This is a normal finding.
greater than bone conduction, which could mean sensorineural
hearing loss.

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Region/Area Assessed Positive Finding Report (Abnormal)
Patient’s nose is deviated, there is deformity, it is asymmetrical,
inflamed or there is presence of alar flaring.
Patient’s nostril (right or left) is not patent.
Nose Patient’s septum is deviated or there is perforation.
Nasal mucosa appears dry, color is different or inconsistent, there is
presence of foreign organisms, patches, etc.
Inferior and middle turbinates appear red, swollen, etc.
Tenderness is elicited on palpation of the frontal and/or maxillary
Sinuses
sinuses.
Patient complains of tenderness when TMJ is palpated.
There is crepitus, locking or popping noted on palpation of the TMJ.
Malocclusion is noted when patient exposes his/her teeth or when
the mouth is open and shut.
Patient has difficulty moving jaw from side to side.
There is enlargement or asymmetry of the salivary glands.
- Tenderness is elicited on palpation.
- The glands are not symmetrical.
Mouth/Oropharynx - The glands are fixed/moveable.
Buccal mucosa is dry/cyanotic/jaundice, etc.
Gums and lips are dry/moist/hypertrophic/swollen with apparent
lesions noted.
Tongue is rough/scaly/red/enlarged etc. Asymmetrical when
protruded and deviates to the LEFT OR RIGHT.
Uvula ad soft palate do not rise symmetrically when patient says
“Ah” and are not symmetrical in appearance.
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Negative Finding Report (Normal)
Patient’s nose is midline with no abnormalities noted and no
presence of alar flaring.
Both nostrils are patent and patient has no complaints of difficulty
breathing.
No septal deviation or perforation upon examination.
Nasal mucosa appears pink and moist.
Inferior and middle turbinates appear normal in color.
There is no tenderness elicited upon palpation of the frontal and
maxillary sinuses.
No complaints of tenderness when TMJ is palpated.
No crepitus, locking or popping noted on palpation of the TMJ,
No malocclusion noted when patient exposes his/her teeth and
mouth is open and shut.
Patient has no difficulty moving jaw from side to side.
No enlargement, asymmetry or tenderness elicited upon palpation of
the salivary glands.
The glands are symmetrical and are fixed/moveable.
Buccal mucosa is pink, moist with no abnormalities noted.
Lips are normally colored, moist/dry with no apparent lesions noted.
Tongue has smooth edges, is symmetrical in appearance when it is
protruded and does not deviate to the left or right when exiting the
oral cavity.
Soft palate rises symmetrically when patient says “ah”
Uvula is symmetrical in appearance and in movement when the
patient says “ah”
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Region/Area Assessed Positive Finding Report (Abnormal) Negative Finding Report (Normal)

Oral mucosa and tonsils appear pale, reddened.

There are growths apparent on the tonsillar surfaces. There is

presence of pseudomembrane present. Oral mucosa and tonsils are normal, pink and moist.

Oral mucosa appears dry and color is inconsistent or is cyanotic, Tonsils are normal in size.
jaundiced, etc.
Mouth/Oropharynx
Gag reflex is present and of normal strength when elicited.
Tonsils appear to be large in size/swelling.
Hard palate and oral mucosa are free of any masses. No pain,
Gag reflex is not elicited when stimulated. tenderness or discomfort noted upon palpation.

Hard palate and oral mucosa: there can be a mass palpated in the
hard palate or oral mucosa, or tenderness elicited on palpation.

There is deviation or bulging of the trachea or esophagus or neck Musculature appears normal. There is no bulging of the trachea or
Neck
muscles present. esophagus and no deviation is apparent.

Thyroid gland is large.

Thyroid gland is of normal size on palpation.
Nodules are present (describe according to number, size, shape,
No nodules are present upon palpation.
contour, mobility, etc).
No pain or tenderness is elicited on palpation.
Thyroid Gland Pain or tenderness upon palpation.
No bruit or thrill noted on auscultation.
Bruit or thrill upon auscultation.
Thyroid gland is symmetrical, both lobes appear to be of equal size
Asymmetrical presentation of thyroid gland on inspection,
on inspection and palpation.
palpation.

Palpable lymph nodes are present in ______ (name of region).

Lymphatics of Neck No palpable lymph nodes present.
Describe the mass as to size, shape, character, borders, etc.

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Region/Area Assessed Positive Finding Report (Abnormal) Negative Finding Report (Normal)
Eyebrows: normal eyebrows with normal distribution and no
seborrhea.
Eyebrows: hair loss is present in eyebrows, there is seborrhea
Eyelashes are normal, do not cause discomfort to patient and there is
Eyelashes show matting, loss of hair
appropriate amount of hair present.
Eyelids are asymmetrical, there is crusting, redness or swelling
Eyelids are symmetrical when they open and close and movement is
present. Lid lag/drooping can be present.
also symmetrical.
Conjunctiva are swollen, the color is different (jaundiced, pale, etc),
Conjunctiva are white and no swelling or increased vasculature is
there is increased vascularity and/or swelling.
noted.
Eyes
Orbits and eyes are not symmetrical, position and alignment are not
Orbits and eyes have symmetrical appearance, position and
symmetrical, size and shape are too large/too small, not spherical,
alignment are normal and size and shape are also normal. Eyeballs
etc.
appear to be situated well within the orbit and there is no protrusion.
Eyeballs are also not deeply-set.
Cornea shows opacities.
Cornea is clear without opacities or obscurities.
Iris color is inconsistent, there is irregularity in its borders or
contour, there is a difference in size and shape between the two
Iris color is consistent in both eyes, round and well-defined. Same
irises, there are unknown markings. Opacity in the pupil is present
size and shape and no opacity in the pupil is present.
on inspection.

SNELLEN: Patient’s visual acuity is ___/___ using a Snellen chart

which means that the patient can read at ___ feet what a normal
person can read at (20, 40, 200, etc) feet.
Note that the patient has a correction (glasses or contacts) or without
Visual Acuity correction.
SNELLEN: Patient’s visual acuity is 20/20 using a Snellen chart
which means that the patient can read at twenty feet what a normal
individual can read at twenty feet.

In case of LOW VISION: No corrective lenses.

- Counting Fingers if patient cannot read at 5/200.
- Hand movements if patient cannot count fingers
- Light perception if patient cannot see hand movements.

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Region/Area Assessed Positive Finding Report (Abnormal) Negative Finding Report (Normal)

Patient is unable to see how many fingers are seen in _____

quadrant(s).
- Nasal superior Patient is able to correctly determine the number of
Peripheral Visual Acuity
- Nasal inferior fingers/movement of fingers in all quadrants.
- Temporal superior
- Temporal inferior

There is over or under action of extraocular muscles.

The patient is able to follow with their gaze through the six cardinal
Extra-Ocular Movements
There is abnormal movement in the following positions (specify positions without any abnormal movement or difficulty.
which of the six cardinal positions of gaze).

There is positive direct light reflex in the _____ eye (this is in the
eye that you shine the light into).

There is negative direct light reflex.
There is negative consensual light reflex.
Pupillary Testing
There is negative accommodation.
There is positive consensual light reflex in the ______ eye (the eye
that you are not shining the light directly into).
There is positive accommodation (the pupils constrict as you bring
your finger closer).

There is negative convergence. There is positive convergence (part of the accommodation reflex as
you bring your finger closer together, doesn’t always have to be
stated but good to know).

Positive red reflex. No opacities present.

Negative for red reflex. Opacities are present.
Optic disc is visualized. It is whitish to pink with sharply defined
Optic disc is not present.
borders.
Retinal vessels appear to be edematous, there is hemorrhage
Retinal vessels appear normal, there is no hemorrhage present also
presence of cotton-wool spots, etc.
Opthalmoscopic no abnormalities noted in the retinal or macular areas.
Disc margin is blurred.
Disc margin is clear.
Cup/disk ratio is greater than 0.5.
Cup/disk ratio is less than or equal to 0.5.
Exudates present.
No exudates are present.

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A:V ratio is greater than 2:3 or 4:5
AV nicking present.
Opthalmoscopic
Retina is opaque, the red-orange color of choroid does not show
through.
Breasts are not symmetrical in size, shape, skin color, texture,
vascular pattern, or there are lumps or lesions present.
Breast size and symmetry do not remain the same when patient is
moving.
Areola is not symmetrical and there is abnormality of color, size and
shape, surface characteristics or direction and asymmetry of nipples.
Breast There is nipple retraction or discharge.
There are vascular patterns that are not symmetrical and are not
diffuse.
There is dimpling when patient raises the arms or places hands on
hips or when the patient is leaning over, sitting or standing.
Mass present on palpation (note size, location, borders, motile/non-
motile, shape, etc).
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No copper wiring present.
A:V ratio is 2:3 or 4:5.
AV nicking is not present and there is no narrowing of the
arterioles.
Veins have no light reflex and get progressively smaller in diameter
away from the disc.
Physiologic cup is slightly depressed and lighter in color than
remainder of disc. Occupies half of the total disc diameter.
Macula is surrounded by temporal arcades and is darker than
surrounding fundus.
Breasts are symmetrical in size, shape, skin color, texture, vascular
pattern. There are no lumps or lesions present.
Breast size and symmetry remain the same when the patient is
moving.
Areola are symmetrical and there is no abnormality of color, size,
shape, surface characteristics. The direction and symmetry of
nipples is also noted.
No nipple retraction or discharge.
No abnormal vascular patterns. The vascular patterns are
symmetrical and diffuse.
There is no dimpling when patient raises arms or places hands on
hips or when the patient is leaning over, sitting or standing.
No masses noted on palpation.
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