OSCE

Patient Note
NAME: Presley Sylvester-Omorodion

Please keep in mind, that for the OSCE final AND for the STEP 2 CS, you have a maximum character
count of 950 (this includes spaces), there is also a 15 line limit.

These criteria apply for BOTH the History and Physical sections.

HISTORY: Describe the history you just obtained from this patient. Include only information (pertinent
positives and negatives) relevant to the patient's problem(s).

Leia Skywalker is a 63 yo female that came in today complaining of hoarseness for 3 months with an ongoing
dry cough. There is no alleviating or aggravating that the patient states. She describes difficulty swallowing and a
feeling of a “lump” in her throat. She also complains of heartburn with a decrease in her appetite. She states that
she unintentionally lost 10 lbs. Patient is a smoker, with a 30-pack year history. Patient also is a drinks 3-4
glasses of wine per day.

PMHx: None
Allergy: NKA
Meds: None
FHx: Mother diagnosed with a thyroid pathology; Father diagnosed with lung cancer
OB/Gyn: None
SHx: 30 pack year smoking; EtOH 3-4 glasses/day CAGE: 0/4; Married, not sexually active; Retired with
previous job as a speaker
Surgical: None

ROS: No chest pain, wheezing, abdominal pain, headache

PHYSICAL EXAMINATION: Describe any positive and negative findings relevant to the patient's
problem(s). Be careful to include only those parts of examination you performed in this encounter.

Vitals: BP: 115/75 mmHg, Temp: 99.9 F, HR: 74 bpm, RR: 16

General: Patient is alert and lucid; looks her age; well-nourished women in subtle distress while talking
HEENT: Pharynx was without erythema; No conjunctiva pallor present
Neck: Non-tender right sided Anterior cervical lymphadenopathy; Thyroid gland normal and not enlargement
Resp: Normal lung sound heard
Cardio: Normal heart sound heard, S1 and S2 heard
Abdominal: Normal bowel movement heard

DATA INTERPRETATION: Based on what you have learned from the history and the physical examination,
list up to 3 diagnoses that might explain this patient's complaint(s). List your diagnoses from most to least
likely. For some cases, fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings
 OSCE
Patient Note
from the history and the physical examination (if present) that SUPPORT each diagnosis. Lastly, list initial
diagnostic students (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers,
laboratory tests, imaging, ECG, etc.).

DIAGNOSIS #1 Laryngeal Cancer

History Findings Physical Findings
Smoking and EtOH history Temperature of 99.9 F
Worsening Hoarseness Non-tender right anterior cervical lymphadenopathy
Family History of Cancer
Unintentional weight loss, low-grade fever

DIAGNOSIS #2 Laryngitis
History Findings Physical Findings
History of GERD Difficulty speaking upon generation inspection
Worsening Hoarseness Temperature of 99.9 F
Persistent dry cough

DIAGNOSIS #3
History Findings Physical Findings

Diagnostic Studies
Laryngoscopy
CBC with differentials, ESR
CT scan of the Chest and Neck