Pulmonary OSCE — Focused Encounter Run-Sheet

01 Opening & Preparation

Every station opens the same way. The chief complaint and vital signs are given to you on a separate form — read them before you enter.

• 1Reviews the chief complaint and vital signs on the form before entering the room
• 2Knocks, enters, and introduces self by name and role"Hello, I am [name], a physician assistant student. I will be taking care of you today."
• 3Confirms the patient's identityPatient identifying data is the one thing the “patient” will answer directly. Everything else comes from the facilitator.
• 4Performs hand hygiene
• 5States the purpose of the visit and obtains permission to proceed"I am going to ask you some questions about what brought you in, and then examine you. Is that all right?"
• 6Ensures patient comfort and privacy before beginning
• 7Interprets the vital signs out loudDo not just read them back. Say whether each is normal and what an abnormal one would mean for a respiratory complaint.

02 Focused History of Present Illness

Shortness of breath and cough are the commonest stems. Pin down the timeline before anything else.

The seven attributes, applied to the chief complaint

• 8Onset — when it began, and what the patient was doing
• 9Location — where it is, and whether the patient can point to it
• 10Duration — constant or intermittent, and how long each episode lasts
• 11Character — what it feels like, in the patient's own words
• 12Alleviating and aggravating factors — what makes it better, what makes it worse
• 13Radiation — whether it moves anywhere
• 14Severity — on a scale of one to tenAnchor the scale. The number is meaningless until you ask what a ten is for this patient.
• 15Temporal pattern — better or worse at any time of day, or with any activity

Associated symptoms — Respiratory

• 16Cough — dry or productive, and how long it has been present
• 17Sputum — color, amount, and any change
• 18Hemoptysis
• 19Dyspnea — at rest or on exertion, and how much exertion it takes
• 20Wheeze
• 21Chest pain, and whether it is worse on inspirationPleuritic versus not is the branch point.
• 22Fever, chills or night sweats
• 23Weight loss
• 24Orthopnea and paroxysmal nocturnal dyspneaAsking these is how you keep heart failure on a respiratory differential.
• 25Leg swelling or calf painThis is the pulmonary embolism question. Ask it explicitly.
• 26Recent travel, immobility or surgery
• 27Sick contacts and known exposures

03 Focused Review of Systems, Past Medical, Social & Family History

All of these are FOCUSED, not comprehensive. Ask what bears on this complaint and on your differential — that selection is itself part of what is being graded.

Focused review of systems

• 28Constitutional — fever, night sweats, weight loss, fatigue
• 29Cardiovascular — chest pain, palpitations, edema
• 30Ear, nose and throat — congestion, sore throat, post-nasal drip
• 31Gastrointestinal — refluxReflux, post-nasal drip and asthma are the three commonest causes of a chronic cough.
• 32Denies symptoms outside the focused set, and says so out loud

Focused past medical history

• 33Prior episodes of the same problem, and what was done about them
• 34Chronic medical conditions
• 35Previous surgeries or procedures
• 36Hospitalizations

Medications and allergies

• 37Prescription medications, with dose and how long they have been taken
• 38Over-the-counter medications, supplements and herbal productsEasy to skip and easy to lose a point on. Ask it explicitly.
• 39Allergies, and the reaction to each“No known drug allergies” is an answer; “allergies?” with no follow-up is not.

Focused social history

• 40Tobacco use — current or past, and how much
• 41Alcohol and recreational drug use
• 42Occupation and relevant exposures
• 43Living situation and who is at home

Focused family history

• 44Conditions in first-degree relatives that bear on this complaint

Close the history

• 45Summarizes the history back to the patient and asks whether anything was missed"Let me make sure I have this right — [summary]. Is there anything else I should know?"
• 46Signals the transition to the examination and obtains permission"I would like to examine you now. Is that all right?"

04 Vital Signs, Exposures & General Survey

Oxygen saturation and respiratory rate are the two that change the plan. Interpret them out loud rather than reading them back.

Vital signs

• 47Restates the vital signs and interprets each one
• 48Comments specifically on respiratory rate and oxygen saturation
• 49Comments on fever if present, and what it adds to the differential

Exposures and risk

• 50Tobacco use — current or past, and pack-years
• 51Occupational and environmental exposures
• 52Known asthma, chronic obstructive pulmonary disease or other lung disease
• 53Immunization status
• 54Prior tuberculosis exposure or testing

General survey

• 55Comments on distress, ability to speak in full sentences, positioning and color

05 Focused Physical Examination — Thorax & Lungs

Maneuvers from the PD1 Lungs and Thorax lab checksheet. Performed with the patient seated. Work through inspection, palpation, percussion and auscultation in that order and do not let the sequence break.

General

• 56Performs hand hygiene before touching the patient
• 57Positions the patient seated, with the back exposed
• 58Performs a general survey — distress, ability to speak in full sentences, audible wheeze

Inspection

• 59Inspects the shape and movement of the thorax, and any unilateral lag
• 60Inspects the rate, rhythm and effort of respiration
• 61Inspects for deformities, asymmetry, retractions, lesions and ecchymosis
• 62Inspects for use of accessory muscles
• 63Inspects the lips for cyanosis
• 64Inspects the nail beds for cyanosis and clubbing
• 65Inspects the anterior-posterior diameterAn increased anterior-posterior diameter is the barrel chest — say what it suggests.

Palpation

• 66Palpates the posterior chest wall for tenderness or deformity
• 67Palpates the lateral chest wall for tenderness or deformity
• 68Palpates the anterior chest wall for tenderness or deformity
• 69Palpates thoracic expansion for symmetry of respiratory effort — posteriorly
• 70Palpates tactile fremitus bilaterally — posteriorly, laterally and anteriorly
• 71States what increased and decreased fremitus would each suggestConsolidation increases it; effusion and pneumothorax decrease it. Fremitus and percussion should agree — when they do, that is your answer.

Percussion

• 72Percusses the posterior chest wall, alternating sides
• 73Percusses the lateral chest wall, alternating sides
• 74Percusses the upper lobes, anterior chest wall, alternating sides
• 75Measures diaphragmatic excursion in centimetersFour to six centimeters is normal — the distance between the level of dullness on full expiration and on full inspiration.
• 76States what dullness and hyperresonance would each suggest

Auscultation

• 77Asks the patient to breathe through the mouth
• 78Asks the patient to cross their arms for the posterior examination
• 79Verbalizes and demonstrates one full cycle of inhalation and expiration at each point
• 80Auscultates the posterior chest wall bilaterally in a ladder pattern
• 81Auscultates the lateral chest wall bilaterally in a ladder pattern
• 82Auscultates the upper lobes, anterior chest wall, bilaterally in a ladder pattern
• 83Verbalizes whether breath sounds are appropriate for the area — vesicular, bronchovesicular, bronchial, tracheal
• 84Verbalizes listening for crackles, rhonchi, wheezes and pleural rubs
• 85Verbalizes the follow-up if adventitious sounds are present"I will perform one of three tests: egophony, bronchophony, and/or whispered pectoriloquy."
• 86States which of those three would be performed and what a positive result would mean

Related

• 87Inspects the anterior neck and palpates tracheal positionTracheal deviation is the finding that turns a pulmonary station into an emergency.
• 88Palpates for cervical and supraclavicular lymphadenopathy
• 89Assesses the lower extremities for edema

06 Differentials, Studies & Diagnosis

Spoken, not performed. This is the part that separates a strong station from a complete one, and it is where the small groups have been training you: every request needs a reason attached.

Differential diagnosis

• 90States a differential diagnosis out loudKeep cardiac and pulmonary embolism causes on the differential rather than confining it to the lungs.
• 91Includes the worst-case diagnosis that must be excluded, even if it is unlikely“What must be examined to rule out the worst-case scenario?” is one of the two questions that decide the scope of a focused encounter.
• 92Justifies each differential against a specific finding from the history or examination"[Diagnosis] is on my differential because of [finding], and against it is [finding]."

Laboratory and imaging studies

• 93States which studies would be ordered
• 94Justifies each one — why it is needed and what it would tell you about the patientThis is the exact standard the small groups apply: a facilitator will not release information until the justification is given.
• 95States which differential each study would rule in or rule out

Diagnosis

• 96States the working diagnosis
• 97States the evidence from this encounter that supports it

07 Treatment Plan & Patient Education

The plan is a graded component in its own right, and patient education is named explicitly in the station's component list — it is not optional garnish.

Treatment plan

• 98States immediate management if the patient is hypoxic or in distress
• 99States whether oxygen, bronchodilators or antimicrobials are indicated, and why
• 100Addresses smoking cessation where relevant
• 101States what would prompt admission rather than discharge
• 102States red flags that would bring the patient back or send them to the emergency department

Patient education

• 103Explains the diagnosis in plain language, without medical jargonAdapting style and content to the patient is a graded professional behavior.
• 104Explains what the treatment is and why it is being recommended
• 105States return precautions — what would bring the patient back sooner
• 106Confirms understanding and invites questions"What questions do you have for me?"

Closure

• 107States the follow-up interval
• 108Thanks the patient and closes the encounter
• 109Performs hand hygiene on the way out

08 One-Minute Case Presentation

Delivered at the end of the station. A well-organized vignette that describes the patient and the clinical problem — not the note read aloud.

• 110Opens with the past medical history and the chief complaint"This is a [age]-year-old [patient] with a history of [past medical history] presenting with [chief complaint]."
• 111Gives the pertinent positives from the history
• 112Gives the pertinent negatives from the historyNegatives carry as much weight as positives. They are how the listener sees what you ruled out.
• 113Gives the pertinent positives and negatives from the respiratory examination
• 114Presents mostly in the order the history was obtained and the examination performed
• 115States the differential
• 116States the studies and the diagnosis
• 117States the plan
• 118Delivers it without reading from notesReading works directly against helping the listener visualize the patient.
• 119Keeps it to about one minute