INTERNAL MEDICINE (OSCE)

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INTERNAL MEDICINE
(OSCE)

Dr. Philopateer Adel Mikhail Fahmy

AIN SHAMS UNIVERSITY – FACULTY OF MEDICINE
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1- Endocrine………………………..…. 2

2- Geriatrics………………………..….. 7

3- Physical Medicine…………….…... 13

4- Rheumatology…………………….. 16

5- Nephrology………………………… 23

6- Neurology…………………………... 27

7- Abdominal Examination............... 34

8- History.............................................. 37

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Endocrine

“8 MARKS”

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ACROMEGALY (11 ITEMS)

1- Greet the patient + Explain + Rt side of the patient.
2- Face (6 items enough) → *BIG 3 + 2 FOLDS + 3 MOUTH + VOICE*
• Coarse features (big nose, ear, lips) → “BIG 3”
• Forehead thick supraorbital ridge and skin fold
• Prominent nasolabial fold
• Infraorbital puffiness
• Oily sweat
• Mandibular prognathism and overbite occlusion
• Widely separated teeth
• Macroglossia
• Field of vision (confrontation test)
• Deep voice

3- Neck Examination (Skin tags or Goiter) / BP

measurement / Abdominal Examination
Organomegaly (1 item only)

4- Hands Exam: (3 items enough) → *2 SHAPES + SKIN + WASTING*

• Large hands (spade shaped)
• Thick skin
• Thick fingers (sausage-shaped)
• Wasting of thenar muscles (carpal tunnel syndrome)
• Peripheral neuritis (sensory exam using toothpick)
• Proximal myopathy (power by comparing D and P)

5- Feet Examination: (1 item enough)

• Osteoarthritis (check for crepitus)
• Peripheral neuritis (sensory exam using toothpick)
• Proximal myopathy (power by comparing D and P)

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CUSHING (VD + 7 ITEMS)

1- Greeted the patient + Explain + Rt side of the patient.

2- Vital data (BP ↑ [due to salt and water retention] OR

Temp. [Recurrent infection])

3- Face: (2 items enough)

• Moon face (ear lobules not seen) VS Round face (ear lobules
seen)
• Plethora (red face) [due to polycythemia !!!]
• Hirsutism and acne vulgaris in *FEMALES*

4- Skin: (2 items enough)

• Thinning over the limbs (visible veins and cigarette paper sign)
• Bruises
• Hyperpigmentation [ due to ACTH ↑ ]
• Striae rubra (stretch marks)

5- Body fat distribution: (2 items enough)

• Supraclavicular pad of fat
• Truncal obesity + thin limbs (APPLE SHAPED OBESITY)
• Interscapular and dorsocervical fat (BUFFALO HUMP)

6- Musculoskeletal & Neurological Examination: (1 item

enough)
• Short stature (measure height and compare on chart)
• Osteoporosis (tender spine while palpating it)
• Proximal myopathy (power by comparing D and P)
• Peripheral neuropathy (sensory exam using toothpick)

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Thyroid Gland
1- Greeted the patient + Explain + Rt side of the patient.
2- Inspection
• The patient is either sitting or standing, looking forwards with
relaxed neck muscles and a slightly extended neck.
• Ask the patient to swallow, protrude the tongue.
[DD: thyroglossal cyst vs goiter]
COMMENT: Size, Shape, Jerky carotids, overlying skin

3- Palpation
• Stand behind the patient who should be sitting.
• Fix the Lt lobe with the Lt hand, palpate the Rt lobe with the Rt
hand by rolling technique. Then repeat for the other side
• Identify and palpate the lower border & ask the patient to
swallow [Retrosternal Goiter]
• Palpate the isthmus by the anterior approach
• Pinch overlying skin and check for infiltration of sternomastoid
• Examine the cervical LNs on both sides.
• Examine the carotid pulsations on both sides. (one side at the
time to avoid syncope)
COMMENT: [TTT + size + ESC + MRD]
• Temperature, Tenderness, Thrill + Size
• Edge (well defined/not well defined)
• Surface (smooth/nodular)
• Consistency (Firm)
• Mobility (freely mobile & moves ↑ & ↓ with deglutition/fixed)
• Relation to Surrounding Structures (skin, sternomastoid & carotids)
• Draining LNs

4- Percussion: Direct percussion on the sternum (RETROSTERNAL

DULLNESS → Retrosternal Goiter)
5- Auscultation: Both lobes of the thyroid (BRUIT)

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Diabetes Mellitus
1- Greeted the patient + Explain + Rt side of the patient.
2- Vital data: Blood pressure erect and supine
3- General: (2 items enough)
Consciousness, Built (weight – height – BMI – waist – W/H ratio)
Air hunger (deep breathing) & acetone smell → DKA

4- Eye: (2 items enough)

Squint / ptosis & Ophthalmoplegia → CN III, IV, VI affection!

Cataract - Arcus senelis – xanthelasma [Due to hyperglycemia
and hyperlipidemia]

5- Skin (Acanthosis nigricans, Skin & Soft tissue infections,

Vitiligo, Insulin injection site) Or Neck (Carotid pulse and

bruit, Goiter) (1 items enough)

6- Upper Limbs: (3 items enough)

Dupuytren contracture [see picture], trigger finger,

wasting of small muscles of the hand [Guttering]
skin color, temperature gradient, trophic changes or ulcers,
interdigital fungal infection, glove hypoesthesia, monofilament
test, sense of vibration

7- Lower Limbs: (3 items enough)

Charcot joints [joint dislocations, pathologic

fractures, debilitating deformities]
Edema [due to nephropathy or HF]
Peripheral pulsation [Dorsalis Pedis]
Skin Color, Temperature Gradient, Trophic Changes or Ulcers,
Interdigital Fungal Infection, Glove & Stock Hypoesthesia,
Monofilament Test [see picture], Sense of Vibration [SAME AS UL !!!]
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GERIATRICS

“5 MARKS”

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‫‪1-ORIENTATION OF TIME & PLACE‬‬

‫‪Greet the Patient:‬‬
‫صباح الخير أنا ‪ ....‬طالب فى سنة خامسة ممكن اسأل حضرتك شوية أسئلة؟‬
‫(مننساش نقف على يمين العيان !!!!) – (مش بنغشش العيان االجابة !!!!!)‬
‫‪Time (score out of 5):‬‬
‫]‪[Year – Month – Season – Day in Month – Day in Week‬‬
‫تقدر حضرتك تقولى احنا فى سنة كام؟‬ ‫•‬
‫طب تقدر تقولى اجنا فى شهر ايه او كام؟‬ ‫•‬
‫طب احنا فصل ايه؟ يعنى شتاء وال صيف؟‬ ‫•‬
‫احنا النهاردة كام فى الشهر؟‬ ‫•‬
‫طب يوم ايه فى أيام االسبوع؟‬ ‫•‬
‫‪Place (score out of 5):‬‬
‫]‪[Place – Floor – City – Government – Country‬‬
‫حضرتك عارف احنا فين دلوقتى؟‬ ‫•‬
‫طب احنا فى الدور الكام؟‬ ‫•‬
‫تعرف احنا فى حى ايه؟‬ ‫•‬
‫محافظة ايه؟‬ ‫•‬
‫واحنا فى انهى بلد؟‬ ‫•‬

‫مننساش نديه ‪!!!!!! score‬‬

‫مش بنلخبط أسئلة الوقت والمكان فى بعض !!!!!‬

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‫‪2-MINI-COG‬‬
‫‪Greet the Patient:‬‬
‫صباح الخير أنا ‪ ....‬طالب فى سنة خامسة ممكن نعمل بس اختبار بسيط كده بشوية‬
‫حاجات هطلبها منك دلوقتى؟‬
‫(مننساش نقف على يمين العيان !!!!) – (مش بنغشش العيان االجابة !!!!!)‬
‫‪Education:‬‬ ‫الزم نسأل هل العيان هل هو‪/‬هى متعلم‪/‬متعلمة؟؟ طب لمدة قد اية؟؟‬
‫الزم عشان نكمل ال‪ test‬يكون العيان متعلم على األقل ‪ 4‬سنوات أو اكتر‬
‫‪Recall Test:‬‬ ‫هقول لحضرتك ‪ 3‬كلمات وعايزك تكررهم ورايا‬
‫(كورة – شجرة – كرسى) حلو اوى! افتكرهم عشان هسألك عليهم بعدين بقى‬
‫دلوقتى هديك ورقة وقلم‪ .‬عايزك ترسملى ساعة ‪Clock Drawing Test (CDT):‬‬
‫تكون واضحة بس تكون عاملها على الساعة ‪ 11‬و ‪ 10‬دقايق‬

‫فاكر بقى ال‪ 3‬كلمات القولناهم؟؟ تقدر تقولهم؟؟‬

‫نعمل ‪↓↓ SCORE‬‬

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‫‪3-CALCULATION‬‬
‫‪Greet the Patient:‬‬
‫صباح الخير أنا ‪ ....‬طالب فى سنة خامسة ممكن نعمل بس اختبار بسيط كده بشوية‬
‫حاجات هطلبها منك دلوقتى؟‬
‫(مننساش نقف على يمين العيان !!!!) – (مش بنغشش العيان االجابة !!!!!)‬
‫‪Education:‬‬ ‫الزم نسأل هل العيان هل هو‪/‬هى متعلم‪/‬متعلمة؟؟ طب لمدة قد اية؟؟‬

‫‪Education ≥ 5y‬‬ ‫‪Education < 5y‬‬ ‫‪No Education‬‬

‫يطرح ‪ 7‬من ‪ 100‬ثم يكرر الطرح‬ ‫يطرح ‪ 3‬من ‪ 20‬ثم يكرر الطرح‬ ‫يقول ايام االسبوع بالعكس (الجمعة‬
‫‪ 5‬مرات‬ ‫‪ -‬الخميس – األربعاء وهكذا)‬
‫‪ 5‬مرات‬

‫]‪Score: [out of 5‬‬

‫‪4-PAST Hx OF HEALTH PROMOTION MEASURES‬‬

‫‪Greet the Patient:‬‬

‫صباح الخير أنا ‪ ....‬طالب فى سنة خامسة ممكن اسأل حضرتك شوية أسئلة؟‬
‫(مننساش نقف على يمين العيان !!!!)‬
‫بتعمل كشف دوري علي صحتك؟ ]‪[Regular Clinic Visits‬‬ ‫•‬
‫بتتبع وسائل الكشف المبكر لالمراض؟ (بتعمل اي تحاليل او اشعات الكتشاف ادا‬ ‫•‬
‫كنت تعاني من اي مرض او اورام ال قدر هلل) ]‪[Screening‬‬
‫بتاخد اي تطعيمات؟ ]‪[Vaccination‬‬ ‫•‬
‫بتتبع نظام غدائي و بتمارس الرياضه باستمرار؟ ]‪[Life Style‬‬ ‫•‬
‫هل بتاخد أى مكمالت غذائية زى ‪ Calcium‬أو ‪ Vit D‬أو ‪Omega-3‬‬ ‫•‬
‫]‪[Chemoprophylaxis‬‬
‫?‪What does the patient need‬‬ ‫مننساش نقول العيان محتاج ايه!!!‬

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‫)‪5-ACTIVITIES OF DAILY LIVING (ADL‬‬

‫‪Greet the Patient:‬‬

‫صباح الخير أنا ‪ ....‬طالب فى سنة خامسة ممكن اسأل حضرتك شوية أسئلة؟‬
‫(مننساش نقف على يمين العيان !!!!)‬
‫(حياتنا اليومية!!) ‪6 Questions:‬‬
‫]بنصحى نقوم نخش الحمام وتاخد شاور حلو كده تطلع تلبس لبسك الحلو يا حلو وتروح تفطر بعدها‬
‫وتشرب قهوتك[‬

‫هل تستطيع االنتقال من والى السرير او الكرسى‬ ‫•‬

‫هل تستطيع التبول والتبرز‬ ‫•‬
‫هل تستطيع التحكم فى التبول والتبرز‬ ‫•‬
‫هل تستطيع االستحمام‬ ‫•‬
‫هل تستطيع ارتداء مالبسك وخلعها‬ ‫•‬
‫هل تستطيع تناول الطعام والشراب‬ ‫•‬
‫‪Scoring: IF < 3 → DEPENDENT‬‬

‫‪6-INSTRUMENTAL ACTIVITIES OF DAILY LIVING‬‬

‫)‪(IADL‬‬
‫‪Greet the Patient:‬‬
‫صباح الخير أنا ‪ ....‬طالب فى سنة خامسة ممكن اسأل حضرتك شوية أسئلة؟‬
‫(مننساش نقف على يمين العيان !!!!)‬
‫(حياتنا اليومية بردو بس أمك دعية عليك!!) ‪8 Questions:‬‬
‫]تصحى على ‪ Alarm‬تليفونك وتقفله وتكمل نوم تصحى تالقى نفسك متأخر على المحاضرة فتبقى‬
‫محتار بقى تحضر أكلك وال تبقى تجيب حاجة من هناك وتروح ب‪ taxi‬عشان تلحق وال فلوسك‬
‫يدوبك فنروح مترو تنزل جرى بعد ما اكتشفت انك كحيان فروحت بالمترو وعشان حضرتك مستعجل‬
‫فاتكعبلت ووقعت لبسك اتقطع وبقى مش نضيف فعندك حلين يا اما تشترى لبس أو لما تروح تبقى‬
‫تغسلهم فتقرر تروح البيت بعد يوم طويل تغسله بس لقيت انك محتاج تاخد مسكن أو اى دواء عشان‬
‫حالتك طين بس وكل ده عشان منظفتش األودة بتاعتك وامك مش راضية عنك‪[.‬‬
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7-GERIATRIC DEPRESSION SCALE (GDS-5)

Greet the Patient:
‫ طالب فى سنة خامسة ممكن اسأل حضرتك شوية أسئلة؟‬.... ‫صباح الخير أنا‬
)!!!! ‫(مننساش نقف على يمين العيان‬
5 Questions:
‫هل غالبا بتحس أنك متضايق؟‬ •
‫هل أنت راضى عن حياتك ؟‬ •
‫هل فى الغالب بتحس أنك قليل الحيلة كده ومش عارف أو مش عايز تعمل حاجة؟‬ •
‫هل بتحب أنك تبقى فى البيت وال تخرج وتتفسح وتعمل حاجة جديدة؟‬ •
‫هل بتحس أنك ماتستحقش الطريقة اللى انت عايش بيها دلوقتى؟‬ •
Score:
0 – 1 → NOT DEPRESSED ≥ 2 → DEPRESSED

8-TIMED UP & GO TEST (TUGT)

Greet the Patient:
‫ طالب فى سنة خامسة هنعمل بس اختبار بسيط كده بشوية حاجات هطلبها منك‬.... ‫صباح الخير أنا‬
‫دلوقتى؟ (مننساش نقف على يمين العيان !!!!) – (اشرح للعيان هنعمل ايه بالظبط !!!!) – (هتحتاج‬
)‫ و كرسى‬measuring tape ‫ و‬stopwatch
- Identify a line 3 meters & put a mark
- “On the word GO stand up, walk to the
line on the floor, turn around, walk back
to the chair & sit down.” [Walk at your
regular pace]
- Subject should be given a non-timed trial before testing. (Said)
- Subject wears their regular footwear, may use any gait aid that
they normally use during ambulation, but may not be assisted
by another person. There is no time limit. They may stop and rest
(but not sit down) if they need to.

Score: ≥ 14 sec = HIGH RISK OF FALLS

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Physical Medicine
“5 MARKS”

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LUMBAR SPINE EXAMINATION

Greet the Patient:
‫ طالب فى سنة خامسة ممكن افحص ظهر حضرتك؟‬.... ‫صباح الخير أنا‬
)!!!! ‫(مننساش نقف على يمين العيان‬
• INSPECTION: (3) [from behind & side while standing]
Skin (Scars / erythema / pigmentations)
Gait (Trendelenburg’s gait / Waddling Gait / Gait Cycle)
Alignment (Kyphosis / Scoliosis / Lordosis / Normal)
• PALPATION: tenderness (4)

Spinous processes
Paraspinal muscles
Iliac crest
Sacroiliac joint

• RANGE OF MOTION (ROM): (4)

Lumbar flexion - Lumbar extension [10° - 20°] - Lateral
lumbar flexion - Rotation [10° – 20°] (while patient is sitting
down to fix the pelvis and while doing the pharaoh move
like in picture)

COMMENT:
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KNEE JOINT EXAMINATION

Greet the Patient:

‫ طالب فى سنة خامسة ممكن افحص ركب حضرتك؟‬.... ‫صباح الخير أنا‬
)!!!! ‫(مننساش نقف على يمين العيان !!!!) – (مننساش نفحص الناحيتين ونقارن‬
• INSPECTION: while standing & supine
Redness - Muscle wasting – Swelling - Deformity
• PALPATION:
Temperature – Tenderness – Crepitus
• ROM: Active & Passive (if patient
can’t do active)
Flexion – Extension – Internal & External Rotation (ask if you
must do Valgus & Varus stress tests and Anterior &
Posterior Drawer tests for Ligaments, if so, do them)
• EXAMINE FOR KNEE EFFUSION
a- Patellar tap test

b- Bulge test (massage test)

COMMENT:
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Rheumatology

“4 MARKS”
Before every checklist: Greet the Patient & Explain
‫ حضرتك؟‬...... ‫ طالب فى سنة خامسة ممكن افحص مفاصل‬.... ‫صباح الخير أنا‬
)!!!! ‫(مننساش نقف على يمين العيان‬
N.B:
• if active is not limited, then there is no need to do passive!!!
• Check for CREPITUS in all joints!!!!
• Don’t forget to compare both sides and comment at the end!!
• If there is any SWELLING, don’t forget to describe it!!!
Inspection (site, size, shape, surface, skin overlying, skin
surrounding, edge) [6S + E]
Palpation (edge, surface, consistency, mobility, relation to
surroundings) [ESC + MR]

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JOINTS OF HANDS & WRIST

• INSPECTION: [SM SD]
Skin & Nail abnormality (Scars, Erythema, Ulcers)
Muscle wasting (Thenar, Hypothenar, Guttering)
Swelling (Effusion, Bony or SC nodules)
Deformity: [2 “VS” + Thumb + 3 Fingers]
▪ Ulnar VS Radial Deviation (Wrist)
▪ Swan Neck VS Boutonniere (PIP and DIP)
▪ Z-shaped thumb (MP Flexion + IP Extension)
▪ Trigger Finger (Flexion of DIP & PIP)
▪ Fusiform Finger (Swelling of PIP)
▪ Mallet Finger (injury of tendon that straightens PIP)
• PERFORM METACARPAL SQUEEZE TEST → for Tenderness!
• PALPATION: (wrist, MP, PIP & DIP joints) [3 T + 2 S + C]
Tender, synovial Thickening, Temp., Sweating, Swelling, Crepitus
• MOVEMENT: [Active & Passive] + [3 Tests]
Fingers → Abduction – Adduction – Flexion – Extension – Opponens
Wrist → Flexion - Extension
1) POWER GRIP: open & spread fingers then close fingers
2) PRECISION PINCH: pinch index fingertip and thumb feel its
power
3) Ask patient to put his hands together in the position of prayer &
then to lower the hands keeping the palms together.
4) Ask patient to place the back of his hands together and to
raise arms upwards.

(1) (2) (3) (4)

Hand Grip Precision Pinch Phalen’s Test
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ELBOW JOINT

• INSPECTION: [SM SD]

Skin abnormality (Scars, Erythema, Ulcers, Sinuses), Muscle wasting
Swelling in Posterior between 2 Epicondyles & Olecranon (Effusion,
Bony or SC nodules), Deformity (Flexion deformity)
• PALPATION: [3Ts + SC]
Temp. – Tenderness – synovial Thickening – Swelling - Crepitus
• MOVEMENT: [Active & Passive]
Flexion – Extension – Pronation & Supination (done while elbow is
flexed 90° and shoulder adducted)

SHOULDER JOINT
• INSPECTION: [SM SD]
Skin & Nail abnormality (Scars, Erythema, Ulcers), Muscle wasting
Swelling (Effusion, Bony/SC nodules), Deformity (Flexion deformity)
• PALPATION: [3Ts + SC] → as before!!
1)Sternoclavicular joint 6)Deltoid muscle

2)Clavicle 7)Scapula Spine

3)Acromio-clavicular 8)Supraspinatus

4) Humeral head 9)Infraspinatus

5) Coracoid process 10)Trapezius

• MOVEMENT: [Active & Passive]

Ask patient to put both hands behind the head (flexion,
abduction, external rotation) then to put the arms down & reach
up behind the back (extension, adduction, full internal rotation).

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HIP JOINT
• GAIT
• INSPECTION: [SM SD]
1) Patient standing from front, side and back.
2) Patient lying flat and face up: Groin & thigh.
Skin Abnormality (Color change “Erythema” / Scars / Sinuses /
Ulcers) – Muscle Wasting – Swelling – Deformity (Flexion Deformity /
abnormal leg lengths)
• PALPATION: iliac crest, ASIS, greater trochanter [2 Ts + SC]
Tenderness, Temperature, Swelling, Crepitus
• MOVEMENT: [Active & Passive]
Flexion & Extension
Adduction & Abduction
Internal & External rotation

ANKLE & FOOT JOINTS

• GAIT
• INSPECTION: (standing & supine) [SM SD]
[longitudinal medial arch, ankle, midfoot, forefoot, dorsum & soles of the foot]

Skin & nails (Redness, ulcers, sinuses, scars) - Muscle wasting –

Swelling (effusion or bony / SC nodules)
Deformity (Hallux Valgus / Hammer Toe / Talipes Equines)
• PALPATION: [2Ts + SC]
Achilles tendon, tibiotalar joint anteriorly, Perform Metatarsal
squeeze test whilst observing the patient’s facial expression, if
positive examine each joint (MTP, IP) separately.
Temperature – Tenderness – Swelling - Crepitus
• ROM: [Active & Passive]
inversion, eversion, dorsiflexion & planter flexion

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KNEE JOINT obliteration of

medial and lateral
• GAIT dimples
• INSPECTION: (standing & supine) [SM SD]
Skin (Redness, ulcers, sinuses, scars) - Muscle wasting – Swelling
- Baker's cyst: bursa enlargement in the popliteal fossa
- Housemaid's knee: enlarged prepatellar bursa
- Any effusion or synovial hypertrophy
Deformity (Genu Varus/Valgus/Recurvatum – Flexion deformity)
• PALPATION: [2Ts + SC]
Temperature – Tenderness – Swelling - Crepitus
• ROM: [Active & Passive]
Flexion – Extension – Internal & External Rotation
• EXAMINE FOR KNEE EFFUSION:
1. Bulge test (massage test) → MILD EFFUSION!!!

2. Patellar tap test → MODERATE EFFUSION!!!

3. Cross Fluctuation Test → TENSE EFFUSION!!!

Place hand 2 Alternately

cm above & apply pressure
below patella and feel with
the other

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CERVICAL & THORACIC SPINE

• INSPECTION: (Patient standing from back & side) [SM SD]
Skin Abnormality (Color change “Erythema” / Scars / Sinuses /
Ulcers) – Muscle Wasting – Swelling
Deformity: Kyphosis / Scoliosis / Lordosis
• PALPATION: [2 Ts + S]
Tenderness or muscle spasm, Temperature, Swelling
• MOVEMENT: [Active & Passive]
*Cervical ROM* → Flexion + Extension + Lateral Rotation

[Chest-to-chin – backward & look up - look Rt then Lt - try to touch the

shoulder by ipsilateral ear, without moving the shoulders]

*Thoracic ROM* → Chest Expansion [by hand/tape meter]

[Ask patient to sit down, with arms crossed across chest and ask
to turn side to side]

LUMBAR SPINE
• INSPECTION & PALPATION [as above!!!]
• MOVEMENT: [Active & Passive]
Flexion (finger-to-floor), Extension (leaning Backwards), Lateral Flexion (Tilting)

SCHOBER’S TEST [next page] ↓↓↓↓↓↓↓↓↓↓↓↓↓↓

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Firstly identify the Dimples of Venus (2) Now in

the midline, use a tape measure and pen to
mark a point 10 cm superior (1), and another
mark 5 cm inferior (3) to this line
*15 cm*

Ask the patient to attempt to "touch their

toes" (Flexing their lumbar spine). The
distance between these two marks should be measured when the
patient's spine is flexed maximally.

INTERPRETATION!!! → Less than 5cm increase in length (≥ 20 cm in

total length) with forward flexion means decreased lumbar spine
range of motion [e.g. ankylosing spondylitis]

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NEPHROLOGY
“4 MARKS”

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RENAL DISEASE (SIGNS OF UREMIA)

[VD + Colors + 4 Regions + 4 Systems]
Greet the Patient:
)‫ طالب فى سنة خامسة ممكن افحص حضرتك؟ (مننساش نقف على يمين العيان‬.... ‫صباح الخير أنا‬
A) VITAL DATA: Blood Pressure – Pulse – Respiratory Rate – Temp.
B) COMPLEXION: Pallor [mucus membranes] – Jaundice –
Cyanosis
(1) item of these
C) 4 REGIONS:
FACE NECK UL (2) LL
A-V Shunt (Thrill + Bruit)
Earthy look Lindsey Nails
Edema
Uremic Frost Neck Veins Hyperpigmentation
Ulcers
Uremic Breath (JVP & CVP) Ecchymoses
Skin abnormalities
Xerosis
Tremors
D) 4 SYSTEMS:
CARDIO (2) CHEST (2) ABDOMEN (2) NEURO (1)
Fullness of the
upper
Venous
INSPECTION - abdomen
collaterals
Abdominal
striae
Tenderness in
Lumbar areas +
PALPATION - -
costovertebral
Myoclonic Jerk
angle
Bilateral shifting
Peripheral
dullness
Neuropathy
Dullness [Ascites]
PERCUSSION -
[Effusion] Suprapubic
Myopathy
mass
[Retention]
Slurred Speech
Distant HS
[Mitral Area] lateralizing bruit
Disturbed LOC
Fine BBC in the
Pericardial epigastrium or
Rub Diminished the flank
AUSCULTATION [Bare Area] air entry [midway
between
Hemic Pleural midaxillary line
murmur at friction rub & umbilicus]
base of heart RAS
[Base]

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ABDOMEN OF RENAL DISEASE + 3 GENERAL SIGNS OF

UREMIA
Greet the Patient:
)‫ طالب فى سنة خامسة ممكن افحص حضرتك؟ (مننساش نقف على يمين العيان‬.... ‫صباح الخير أنا‬
Proper patient positioning (supine + head & knees supported with
small pillows for comfort & to relax abdominal wall musculature)
INSPECTION:
Fullness of the upper abdomen - Abdominal striae – scratching
marks [mainly due to ↑ phosphorus]
PALPATION:
Tenderness in Lumbar areas + costovertebral
angle + BALLOTTEMENT:
[Place the Rt hand anteriorly in lumbar region
(flank) while the Lt hand posteriorly in loin. Ask
patient to take a deep breath in, press the left
hand forward and the right hand backward,
upward, and inward.]
PERCUSSION:
Bilateral shifting dullness [Ascites] - Suprapubic mass [Retention]
AUSCULTATION:
lateralizing bruit in the epigastrium or the flank (midway between
midaxillary line & umbilicus) [RAS]
SIGNS OF UREMIA:
Mention any (3) ITEMS as mentioned before!!!!!!!!
Uremic frost, Lindsay nail, congested neck veins, LL edema

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EDEMA & DISTAL PULSE OF THE LEG

PULSE
Dorsalis pedis A. Posterior tibial A.
lateral to the groove midway
extensor hallucis Compare both sides! between the
longus tendon medial malleolus
and proximal to ↓ Comment ↓ and the heel
the 1st metatarsal Rate, Rhythm, Volume,
space against the Equality, Special CCC
navicular bone

EDEMA
Press using thumb for several seconds (15 – 30 seconds) & release
behind medial malleolus & chin of tibia, while at thigh use
pinching of medial aspect

Comment:
Cardiac, Bilateral VS unilateral DVT,
Renal, cellulitis,
Hepatic, Pitting VS Non-Pitting lymphedema,
Nutritional myxedema,
Not Painful VS Painful angioneurotic

Color change
Level
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NEUROLOGY
“8 MARKS”

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STATE & TONE

Greet the Patient:
)‫ طالب فى سنة خامسة ممكن افحص حضرتك؟ (مننساش نقف على يمين العيان‬.... ‫صباح الخير أنا‬
I. STATE:
Assesses muscles of UL & LL for atrophy or hypertrophy and
compare to other side by inspection, palpation and measurement
Inspects for spontaneous fasciculations and taps on proximal limb
muscles to elicit them
II. TONE:
UL:
Passive movement and shaking test of the wrist
Passive flexion and extension of elbow
Circumduction of shoulder )‫(جدف→لجوه مش بره‬
LL:
Passive movement and shaking test of feet
Passive flexion and extension of the knee
Circumduction and/or rolling test )‫(لجوه مش بره‬
Conclude findings

POWER
Greet the Patient:
)‫ طالب فى سنة خامسة ممكن افحص حضرتك؟ (مننساش نقف على يمين العيان‬.... ‫صباح الخير أنا‬
1- UL:
Small muscles of hand: opposition + finger adduction & abduction
Forearm or Wrist: flexion, extension. ulnar & radial flexion
Elbow: Flexors and extensors
Shoulder: flexors, extensors, abductors, adductors

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2- LL:
Big toe: Flexors and extensors
All toes: Flexors and extensors
Ankle: Flexors, extensors, investors, evertors
Knee: Flexors and extensors
Hip: Flexors, extensors, adductors, and abductors

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REFLEXES
Greet the Patient:
)‫ طالب فى سنة خامسة ممكن افحص حضرتك؟ (مننساش نقف على يمين العيان‬.... ‫صباح الخير أنا‬
) ‫ وحياة ابوك يا شيخ‬reflex‫ مش ال‬muscle‫ وبص على ال‬Hammer ‫(هات معاك‬
• Upper limbs deep tendon reflexes: [3]
- Biceps (120° + Use Index finger over tendon)
- Brachioradialis (120° + Direct 3 cm above styloid process)
- Triceps (90° + Direct)
• Lower limbs deep tendon reflexes: [3]
- Knee (hip slightly flexed + knee flexed and supported)
- Patellar (bring patella downwards using index finger then tap it)
- Adductor (tap on index finger placed above adductor tubercle)
- Ankle (thigh abducted & externally rotated + knee flexed 90° +
ankle dorsiflexed & everted)
!!!‫بقولك ايه!!! خلى العيان يحط رجل على رجل ورجله دى متبصلكش انت ضاكتووووور‬
• Ankle, patellar and wrist clonus [3]
• Superficial Reflexes: [2]
- Abdominal reflex - Plantar response (Babinski Sign)

Conclude Findings

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SUPERFICIAL SENSATIONS
Greet the Patient:
)‫ طالب فى سنة خامسة ممكن افحص حضرتك؟ (مننساش نقف على يمين العيان‬.... ‫صباح الخير أنا‬
↓) ‫ وابقى اشرح للعيان وحياة ابوك يا شيخ تانى‬tissue‫ و‬toothpick ‫(هات معاك‬
!‫دلوقتى انا هشكك شكات بسيطة بخلة االسنان وانت مغمض عينك وعايزك تبقى تقولى حاسس وال أل‬
I. Toothpick → fine touch [posterior column]
II. Tissue → crude touch [anterior spinothalamic tract]
- Set a reference point on the head
- Compare difference in UL & LL ipsilaterally &
contralaterally
)4( ‫) زى هنا‬3( ‫ حاسس هنا‬، )2( ‫) زى هنا‬1( ‫حاسس هنا‬
)8( ‫) زى هنا‬7( ‫ حاسس هنا‬، )6( ‫) زى هنا‬5( ‫حاسس هنا‬
)7( ‫) زى هنا‬5( ‫) زى هنا‬3( ‫) زى هنا‬1( ‫حاسس هنا‬
)8( ‫) زى هنا‬6( ‫) زى هنا‬4( ‫) زى هنا‬2( ‫حاسس هنا‬

- Assess for peripheral superficial sensory loss (glove &

stocking) → “Proximal VS Distal”

UL ← )2( ‫) زى هنا‬1( ‫حاسس هنا‬

LL ← )4( ‫) زى هنا‬3( ‫حاسس هنا‬

If proximal is better, do next steps to determine level

dermatomal
Superficial
sensory loss
sensory level
level
(Circumfrere
ntial
- Palpate ulnar & common
peroneal nerves →

Conclude Findings:

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OPTIC & OCULAR CNs (EXCEPT FUNDUS & FIELD)

Greet the Patient:
)‫ طالب فى سنة خامسة ممكن افحص حضرتك؟ (مننساش نقف على يمين العيان‬.... ‫صباح الخير أنا‬
- Visual acuity by finger counting:
Start at 6 m and keep getting closer. If at 30 cm patient fails → use
hand movements. If fails → test for perception of light using torch.
If fails → PATIENT IS BLIND!!!!!
- Color vision: by red and white objects (Ishihara plates)
- Pupillary light reflex (direct & consensual)
Separate eyes by your hand, move the torch
from lateral to medial. look for miosis in same
eye [DIRECT] & other eye [CONSENSUAL]
- Accommodation reflex
Ask patient to follow your finger by his
eyes while moving it towards his nose.
Normal response: Convergence -
Miosis - accommodation
- Pursuit & saccadic conjugate eye movement (horizontal and
vertical) and observe for nystagmus
Ask patient to fix his eyes looking at you finger on the Rt & Lt sides
then observe any oscillatory movements
- Individual eye movements (FIX HEAD + LOOK WITH EYE ONLY!!)

CN III [oculomotor] CN IV [Trochlear] CN VI [Abducent]

MR → ‫عينك لجوه‬ SO → ‫عينك على كتفك‬ LR → ‫عينك بره‬
SR + IR → ‫عينك فوق وتحت‬

- Ptosis and proptosis

- Conclude Findings

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COORDINATION WITHOUT GAIT

Greet the Patient:
)‫ طالب فى سنة خامسة ممكن افحص حضرتك؟ (مننساش نقف على يمين العيان‬.... ‫صباح الخير أنا‬
- Speech for cerebellar dysfunction (ask name, age, residency)
- Eye movement for horizontal nystagmus:
Ask patient to fix his eyes looking at you finger on the Rt & Lt sides
then observe any oscillatory movements
- UL ataxia by finger to nose test ± finger to
doctor’s finger test
- Tests for UL dysdiadochokinesia by rapid
alternating supination-pronation of the
extended arms ± rapid alternating
repeated tapping of dorsum of the
hand
- Tests for rebound (overshooting) by arm
pulling test and/or arm displacement
test
Ask the patient to close their eyes and
position their arms outstretched in front of them.
Explain to patient that you are going to apply some downward
resistance on each arm & that they should try to maintain current
position of their arms as you apply that resistance.
Push downwards on one of the patient’s forearms and then
immediately remove the resistance.
- Hypotonia in extremities → Shaking – flexion & extension -
circumduction.
- LLs ataxia by heel to knee test

- Conclude Findings

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Abdominal
Examination

“7 MARKS”

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ABDOMEN INSPECTION + LIVER PALPATION

Greet the Patient:
)‫ طالب فى سنة خامسة ممكن افحص حضرتك؟ (مننساش نقف على يمين العيان‬.... ‫صباح الخير أنا‬
Inspection of Abdomen: Exposure is from
FROM END OF BED: nipple line to
• Movement with respiration mid-thigh
• Contour (normally slightly scaphoid) / Localized
Bulge / Diffuse Bulge
FROM SIDE OF BED: [ask patient to hold his/her breath]
• Epigastric pulsations + Visible peristalsis
FROM ABOVE AND GOING DOWNWARDS: [SD + U w/4 Ss & CD + 2H + 2S]
• Subcostal angle (Normally = 90° - 110°)
• Divarication of recti (‫)هم براسك‬
• Umbilicus → Site – Shape – Swelling – Skin lesions – Color - Discharge
• Hernial Orifices + Cough

• Hair Distribution → (Normally: ▲ in ♂ & ▼ in ♀) [imp for ♂ in LCF]

• Scars + Skin (Pigmentations + Dilated Veins + Stria alba ± Linea nigra)
Liver Palpation: flex hips & knees of patient to relax abdominal muscles!
[2Ss + T + ESC + MRP]
Start at RIF in MCL resting transversely parallel to costal margin.
Ask Patient to take a deep breath. Ask the patient to expire, slide the hand a
little nearer to RT costal margin till lower border of Rt lobe palpated.
Repeat the above steps till the lower border of the Lt lobe is palpated
• Size (Patient’s hand: 1 finger ≈ 2 cm) + Site (Rt. Hypochondrium)
• Tenderness
• Edge (Sharp) + Surface (Smooth/Nodular) + Consistency (Firm NOT
HARD!)
• Movement (Movement with respiration)
• Relation to skin, muscle, OR defect (‫ → )هم براسك‬swelling disappears as
it’s deep to the muscle
• Pulsations: One hand Posteriorly & the other Posteriorly. Ask patient to
hold his breath
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SPLEEN PALPATION + ASCITES PERCUSSION

Greet the Patient:
)‫ طالب فى سنة خامسة ممكن افحص حضرتك؟ (مننساش نقف على يمين العيان‬.... ‫صباح الخير أنا‬
Spleen Palpation: flex hips & knees of patient to relax abdominal
muscles! [2Ss + T + ESC + MR + 2Ps + N]
Classic: Start at RIF with tips of hand directed towards LT axilla, move toward
the Lt hypochondrium until spleen is felt.
Bimanual: Start at RIF with tips of hand directed towards LT axilla + Place LT
hand over lateral aspect of Lt costal margin, exerting compression & move
toward Lt hypochondrium until spleen is felt.
Right lateral position: Ask patient to turn on right side, Insinuate the hand
below the costal margin then ask patient to take a deep breath Press till the
lower edge of the spleen is felt
Hooking method: Stand on left side of patient’s head & place fingers of both
hands over the costal margin. Instruct the patient to take deep breath
• Size (1 finger ≈ 2 cm) + Site (Lt. Hypochondrium) + Tenderness
• Edge (well-defined) + Surface (Smooth/Nodular) + Consistency (Firm)
• Movement (Movement with respiration) + Relation
• Pulsations: One hand Ant. & other Post. Ask patient to hold his breath
• Pitting Sign + Notch
Ascites Percussion:
TENSE (≥3 L) → Transmitted Thrill: Patient’s hand is placed in mid-abdomen
with sufficient pressure applied to dampen any wave that pass through AAW.
Place one hand on flank & the other hand briskly tap the other flank.
Positive test: a shock wave be felt with palpating hand.
MODERATE (1.5 – 3 L) → Shifting Dullness: Start below xiphisternum with hand
placed transversely then start percussion downwards in the midline until
change of tone is noted (resonant → Dull !!)
Change your hand position where the tips are pointing towards the
xiphisternum then start percussion laterally until change of tone is noted.
WHILE KEEPING THE HAND ON SITE OF DULLNESS ask patient to turn to the
opposite side to move fluid by gravity then percuss again
Repeat on the other side (U-SHAPED DULLNESS)
MILD (≤1.5 L) → Knee elbow position: (If shifting dullness is -ve) OBSOLETE!!!

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HISTORY

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‫”‪NEPHROLOGY SHEET “4 marks‬‬

‫‪Greet the Patient:‬‬
‫صباح الخير أنا ‪ ....‬طالب فى سنة خامسة ممكن أسأل حضرتك شوية أسئلة؟ (مننساش نقف على يمين العيان)‬
‫‪Personal History: Name – Age – Marital status – Occupation – Sex – Residency‬‬
‫‪– Menstrual – Special Habits‬‬
‫‪Complaint: Patient’s words + duration‬‬ ‫ايه الجابك المستشفى النهارده؟ بقالك قد ايه تعبان؟‬
‫)‪HPI: (in organized, chronological order‬‬
‫‪UREMIC SYMPTOMS: [Fatigue, Anorexia, Bony aches] + [Edema in the‬‬
‫‪face & legs] + [Dyspnea, Orthopnea] + [Nausea, Vomiting] + [Pruritus] +‬‬
‫‪4 symptoms enough‬‬

‫]‪[Restless legs, Myoclonic jerks, Seizures‬‬

‫ساعات بتحس ان جسمك وجعك؟؟ او انك مهمد ومش قادر تعمل حاجة؟؟‬

‫هل وزنك زاد الفترة األخيرة؟؟ هل وشك او رجلك ورموا؟؟ )‪(2 Edema‬‬

‫كان بيجيلك كرشة نفس؟؟ بتعرف تنام من غير مخدات؟؟ لو شلت المخدات مش هتتعب؟؟ )‪(2 Respiratory‬‬

‫هل كان بيجيلك احساس بالغثيان أو كنت بترجع؟؟‬

‫هل كان بيجيلك تشنجات أو يدك تتنفض مرة واحدة كده؟؟‬

‫‪NEPHROTIC / NEPHRITIC $: (Weight gain, Edema in the face and legs,‬‬

‫)‪Foamy urine, Oliguria, Hematuria, Hypertension, Malaise‬‬
‫‪2 symptoms enough‬‬

‫هل وزنك زاد الفترة األخيرة؟؟ هل وشك او رجلك ورموا؟؟ )‪(2 Edema‬‬

‫هل البول كان كميته كويسة الفترة الفاتت؟ طب لونه؟؟ كان بيكون رغاوى؟؟ )‪(3 Urine‬‬

‫هل ضغتك كان كويس؟؟ طب قيسته اخر مرة امتى وكان كام؟؟‬

‫)‪NEPHROTIC $ CCC: (VTE, Poor nutrition, Infections‬‬

‫طب بعد الشر جالك جلطات فى اى حتة فجسمك أو حسيت بتنميل فأطراف رجلك او يدك؟؟‬
‫كنت بتاكل كويس الفترة الفاتت؟؟ جالك اى التهابات؟؟‬
‫‪2 symptoms enough‬‬

‫)‪OBSTRUCTIVE SYMPTOMS (Urgency, Hesitancy, Dribbling, Nocturia‬‬

‫هل بيجيلك احساس قوى فجأة انك عياز تخش الحمام؟؟ طب لما بتروح بيبقى فى صعوبة فالبداية؟؟ طب هل ساعات‬
‫بتالقى بول نزل وانت مش حاسس بعد ما بتكون خلصت؟؟ هل بتقوم بليل تخش الحمام؟؟‬

‫)‪VOIDING SYMPTOMS (Urinary incontinence, Urinary retention, Polyuria‬‬

‫هل البول بيسبقك قبل ما تروح الحمام؟؟ هل لما بتروح الحمام بتحس انك مافضتش كويس؟؟ هل كمية البول كتيرة؟؟‬

‫‪Past Hx + Drug Hx + Family Hx‬‬

‫‪Provisional diagnosis‬‬

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RHEUMATOLOGY SHEET
Greet the Patient:
)‫ طالب فى سنة خامسة ممكن أسأل حضرتك شوية أسئلة؟ (مننساش نقف على يمين العيان‬.... ‫صباح الخير أنا‬
Personal History: Name – Age – Marital status – Occupation – Sex – Residency
– Menstrual – Special Habits
Complaint: Patient’s words + duration ‫ايه الجابك المستشفى النهارده؟ بقالك قد ايه تعبان؟‬
HPI: [GENERAL – ARTICULAR – EXTRA-ARTICULAR]
First started by this screening questions:
• Have you any pain, stiffness in your joint, muscle, back?
• Can you dress yourself without any difficulty?
proximal muscle weakness
• Can you walk up & down stairs easily?
GENERAL → Prodromal manifestation: (Fever - Headache – Malaise -
anorexia - Weight loss)
ARTICULAR
1- Pain → restricted range of movement + better or worse with activity
(inflammatory vs degenerative) ‫هل فى ألم فى مفاصلك؟؟ طب األلم بيزيد وال بيقل مع الحركة؟‬
)articular vs extra-articular( ‫بتقدر تحرك مفصلك وال بتحتاج مساعدة تحركه وال مش بتقدر تحركه خالص؟‬
2- Swelling → signs of inflammation (Red, Hot, Tender) + Onset & duration
of arthritis + No. of joints involved at beginning, sequence & distribution
‫هل مفاصلك ورمت؟؟ انهى واحد؟؟ طب هل مستمر وال بيروح ويجى؟؟ انهى مفصل ورم األول وورم فجأة وال‬
‫بالتدريج؟؟ لما مفاصلك بتورم بتبقى محمرة وسخنة وفيها ألم؟؟‬
3- Stiffness → morning stiffness + duration
‫هل مفاصلك بتبقى مخشبة الصبح أول ما تصحى؟ بتقعد قد ايه عمال ما تفك؟؟‬
4- Deformity + Disability → ‫هل حصل تشوهات فى اى مفصل؟؟ هل أثرت على شغلك؟؟‬
EXTRA-ARTICULAR MANIFESTATIONS:
Skin & Nail: Alopecia – Rashes - Urogenital ulcers – Urticaria – Pigmentation -
Cold peripheries (Raynaud's).
Eye: Dry, red eyes, Pain, Photophobia Hematological: L.N Swelling/anemia
CNS: Convulsion - P.N. – pain – Weakness - Muscle pain - Stroke.
Cardiopulmonary: Palpitation (AR) - Pain (pericarditis / pleurisy / effusion) -
VTE - Cough - Dyspnea (IPF)
GIT: Dysphagia - Abdominal pain Renal: L.L edema - urine changes
Past Hx + Drug Hx + Family Hx + Provisional diagnosis

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INTERNAL MEDICINE (OSCE)
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GOOD LUCK IN YOUR EXAMS !!!!

‫ركز وبالش نضيع درجات عبيطة وحياة ابوك‬

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