OSCE CASES

1. IRON DEFICIENCY ANEMIA

The patient is a 33-year-old woman, who is seen in the clinic. Her chief complaints include
weakness, dizziness, and epigastric pain. She has a 5-year history of peptic ulcer disease, a
10-year history of heavy menstrual bleeding, and a 15-year history of chronic headaches. She has
two children who are 1 and 3 years of age. She is currently taking
● minocycline 100 mg BID for acne
● ibuprofen 400 mg as needed for headaches
● esomeprazole 40 mg daily.
A review of her systems is positive for decreased exercise tolerance. Physical examination
reveals a pale, lethargic, white woman appearing older than her stated age. Her vital signs are
within normal limits; her heart rate is regular at 100 beats/minute. Her examination is
notable for pale nail beds and splenomegaly.

Significant laboratory results include the following:

● Hgb 8 g/dL
● Hct 26%
● Platelet count 500,000/μL
● Reticulocyte count 0.2%
● MCV 75 fL,
● MCH 23 pg/cell
● MCHC 300 g/L
● Serum iron 40 μg/dL
● Serum ferritin 9 ng/mL
● Total iron-binding capacity (TIBC) 450 g/dL
● 4+ stool guaiac.
2. LOW BACK PAIN
The patient is a 53-year-old man who presents with low back and leg pain. He has had chronic
back pain for several years, which has progressively gotten worse during the last several months.
He reports an aching pain that is localized to his lumbosacral spine with some radiation into his
buttocks and hips. He also describes burning pain into his right leg. He rates his pain as 7 of 10
on the numeric pain scale. On good days his pain is 5 of 10. He recently did some yard work and
had an acute exacerbation of his pain. He reports this felt like 10 of 10 on the numeric pain scale,
and he was in bed for the following 2 days because of pain. He is usually able to do some
chores around the house, but activity makes his pain worse. He sleeps poorly (only about
4–5 hours/night), and he does not go out or socialize very often because he is afraid this
will exacerbate his pain. He used to golf and play softball but is not able to participate
in these hobbies any more as a result of pain. He smokes two packs of cigarettes daily and drinks
about a six-pack of beer each week. He was previously a plumber but had to quit his job earlier
this year because of health problems.
On physical examination he reports pain with forward flexion of his spine and spine rotation to
the left. No pain is elicited with isolated manipulation of his hips and tailbone, and he has
minimal discomfort with straight leg raise. His reflexes are intact, and he has full strength in his
lower extremities. He has pain with palpation along his lumbar paraspinal muscles and marked
tenderness at the level of L4 to L5. He denies any lower extremity weakness and also denies loss
of bowel or bladder control. He has not found anything that really helps his pain except rest and
acetaminophen/codeine that his sister gave him. His past medical history includes hypertension,
hyperlipidemia, depression, and morbid obesity.

His current medications are:

● lisinopril for hypertension
● simvastatin for hyperlipidemia
● a baby aspirin
● acetaminophen/codeine.

He also takes three tablets of over-the-counter strength (200 mg/tablet) ibuprofen and three
tablets of extra-strength (500 mg/tablet) acetaminophen about four times daily with minimal
relief of his pain.
His reflexes are intact, and he has full strength in his lower extremities. The remainder of his
physical examination is unremarkable except that general deconditioning is noted. There are no
laboratory tests or imaging studies available. He reports that his blood pressure is usually around
150/80 mm Hg with a pulse around 75 beats/minute.
3. OSTEOARTHRITIS
The patient is a 75-year-old man seeking pharmacist consultation on OTC arthritis pain
medications . He is a retired mechanic who likes to build vintage automobiles as a hobby. He has
experienced bilateral knee pain for more than 10 years as a result of lifting heavy parts and
squatting on the knees to make automobile repairs. During the past year, the pain has become
worse on the inner part of the right knee. He complains of general stiffness in both knees early in
the morning, but his right knee will continue to have a “grinding” sensation with movement. The
pain can get so bad that his right knee “sometimes will give out.” His primary-care physician
started him on oxycodone 5 mg combined with acetaminophen 325 mg which works for a while,
but the relief does not last very long. He uses ibuprofen occasionally and
Aspercreme to a knee joint when the pain gets bad. In addition to pain, he also has hypertension.
He states that other than knee pain he feels well and has no complaints. He denies social habits
of smoking and frequent use of alcohol. His current pharmacy profile contains prescriptions for
metoprolol ER 100 mg orally once daily for blood pressure and oxycodone 5 mg/acetaminophen
325 mg with one tablet PO BID for pain.

4. ACUTE BRONCHITIS
The patient is a 32-year-old woman presenting with a chief complaint of cough. Her
symptoms have persisted for 10 days, and she now produces yellow sputum with each cough.
She has had no recent illnesses; however, her 2-year-old daughter in daycare has
experienced recent colds. She denies nausea, vomiting, emesis or fever, and chills.
A review of the systems reveals fatigue and difficulty sleeping because of the cough.
Past medical history includes ulcerative colitis managed with mesalamine and generalized
anxiety disorder for which she takes sertraline.
Vital signs review indicates a temperature of 37.1◦C, heart rate of 70 beats/minute, blood
pressure of 130/70 mm Hg, and respiratory rate of 18 breaths/minute with accompanying oxygen
saturations of 98% on room air. Her physical examination is positive for coarse breath sounds
that clear with coughing but
is otherwise normal.
5. BACTERIAL MENINGITIS
The patient, a 6-year-old boy, is brought to the ED by his mother, who says her son has a
temperature of 39◦C, is irritable and lethargic, and has a rash. The patient was in his usual state
of good health until last night when he awoke crying. When she went to investigate, her son
began to stiffen up and rock back and forth in his bed. Because he was not arousable, the
patient’s mother rushed him to the hospital. The patient’s medical history is noncontributory
except for an allergy to amoxicillin described as a skin rash. The patient, his mother, father, and
his 7-year-old brother recently moved to the United States. The patient’s vaccination history
currently is unknown. The patient and his brother currently attend a community daycare
center. On physical examination, the patient was in marked distress, with a temperature of 40◦C,
blood pressure of 90/60 mm Hg, and a respiratory rate of 32 breaths/minute. His weight
on admission was 20 kg.
Neurologic examination showed evidence of nuchal rigidity; he was lethargic and difficult
to arouse. Brudzinski and Kernig signs were positive. On head, eyes, ears, nose, and throat
examination, the patient demonstrated photophobia (he squinted severely when the examiner
shone a light in his eyes), but no evidence was noted of papilledema. A petechial rash was visible
on his extremities. The remainder of the patient’s examination was essentially normal.

Blood drawn for laboratory tests revealed the following results:

● Sodium 128 mEq/L
● Potassium, 3.2 mEq/L
● Chloride 100 mEq/L
● Bicarbonate 25 mEq/L
● Blood urea nitrogen 16 mg/dL
● Serum creatinine 0.6 mg/dL
● Serum glucose 80 mg/dL
● WBC count was 18,000 cells/μL
● with 95% polymorphonuclear cells
● The hemoglobin, hematocrit, and platelet count all were within normal limits.

The resident in the ED performs a lumbar puncture, which yielded the following:
● Opening pressure, 300 mm CSF (normal, <20)
● CSF glucose20 mg/dL (normal, 60% of plasma glucose)
● Protein250 mg/dL (normal, <50 mg/dL)
● WBC count, 1,200 cells/μL, with 90% PMN, 4% mono histiocytes, and 6% lymphocytes
● The CSF red blood cell (RBC) count was 50/μL.
A stat Gram stain of CSF revealed numerous WBCs but no organisms. CSF, blood, and urine
cultures are pending. A detailed medication and vaccination history reveal that the patient
and his brother appropriately received vaccination for Hib when they were 2 months of age.
Twenty-four hours after admission, the patient’s culture results from his blood and CSF
samples are available. The CSF culture is growing in N. meningitidis (penicillin MIC, 0.06
mg/L), and N. meningitidis is also growing in the two collected blood cultures. An abdominal
ultrasound reveals sludge in the gallbladder. The patient is ready to be discharged home.

6. INFECTIVE ENDOCARDITIS
The patient, a 59-year-old, 60-kg man with chief complaints of fatigue, a persistent low-grade
fever, night sweats, arthralgias, and a 7-kg unintentional weight loss, is admitted to the hospital
for evaluation. Visual inspection reveals a cachectic, ill-appearing man in no acute distress.
Physical examination is significant for a grade III/IV diastolic murmur with mitral regurgitation
(insufficiency) increased from pre-existing murmur, a temperature of 100.5◦F, petechial skin
lesions, subungual splinter hemorrhages, and Janeway lesions on the soles of both feet.
Nail clubbing, Roth spots, or Osler’s nodes are not evident.
The remainder of his physical examination is unremarkable. The patient’s medical history is
significant for mitral valve prolapse and, more recently, a dental procedure involving the
extraction of four wisdom teeth. The history of his present illness is noteworthy for the
development of symptoms 2 weeks after the dental procedure (about 2 months before
admission). His only current medication is ibuprofen 600 mg
four times a day (QID). Relevant laboratory results include the following: Hemoglobin 11.4
g/dL, Hematocrit 34%, Reticulocyte count 0.5%, White blood cell 85,000/μL with 65% polys
and 1% bands, BUN 21 mg/dL, Serum creatinine 1.8 mg/dL. A urinalysis reveals 2+ proteinuria
and 10 to 20 red blood cells per high-power field. The ESR is elevated at 66 mm/hour, and the
RF is positive. Results from a transthoracic echocardiogram were unrevealing. Three blood
cultures were obtained during 24 hours, and all cultures obtained on day 1 are growing α
-hemolytic streptococci. While confirmation and speciation of the organism are being
performed, the patient is started on penicillin G, 2 million units IV every 4 hours (12 million
units/day), and gentamicin, 120 mg (loading dose) followed by 60 mg every 12 hours.
Antimicrobial susceptibility results are pending.
7. COMMUNITY-ACQUIRED PNEUMONIA
A patient is a 35-year-old man presenting to the ED with fevers, chills, and chest pain. His
symptoms have persisted for 3 days, and he has a productive cough with rusty-colored sputum
and dyspnea with exertion. He has had no recent illnesses and no known sick contacts, but he
was recently released from a 2-year period of incarceration. He has tried ibuprofen to alleviate
his fever and chest pain. His past medical history is positive for asthma, for which he is
prescribed fluticasone and albuterol, and depression, for which he takes sertraline. Vital signs
reveal a temperature of 40.1◦C, heart rate of 128 beats/minute, blood pressure of 130/76 mm Hg,
and respiratory rate of 32 breaths/minute with accompanying oxygen saturations of 85% on 5 L
of oxygen by nasal cannula. The remainder of the physical examination is notable for orientation
to person but not place or time and for diffuse crackles bilaterally, which are most apparent on
the right side.

Laboratory results include the following: WBC count 15,500 cells/μL, Hematocrit 29.3%,
Sodium 133 mmol/L, Potassium 3.8 mmol/L, BUN 23 mg/dL, SC 0.8 mg/dL, Glucose 148
mg/dL, pH 7.42, PO2 61 mm Hg, PCO2 46 mm Hg, HCO3 28 mEq/L. A test for human
immunodeficiency virus is negative. A chest radiograph reveals a right lower lobe infiltrate.

8. INFLUENZA
A patient is a 37-year-old man presenting to the ED with complaints of fever, chills, nausea, and
vomiting for the last 7 days, and more recently, shortness of breath with productive cough with
white sputum for the past 4 days. He presents to the ED one day after visiting an urgent care
center. Initial assessment reveals the patient to be alert and oriented times three, but falling
asleep during the assessment, pulses present with a brisk capillary refill, decreased lung sounds
bilateral, and no peripheral edema. His medical history is significant for hypertension and
diabetes mellitus. The patient has a penicillin allergy, with a reported reaction of rash.
Medications at home include aspirin 81 mg daily, hydrochlorothiazide 25 mg daily, lisinopril 20
mg daily, and atorvastatin 40 mg daily. Social history is significant for 1 pack of cigarettes per
week.
In the ED, he had a temperature of 38.9◦C, heart rate of 112 beats/minute, respiratory rate of 22
breaths/minute, blood pressure of 126/80 mm Hg, and oxygen saturation of 93% on 2 L.
Laboratory results include the following: WBC count 2,900 cells/μL, Hematocrit 47.1%,
Platelets 129,000 cells/μL, Sodium 127 mmol/L, Potassium 4.6 mmol/L, BUN 7 mg/dL, SCr
0.73 mg/dL, Glucose 117 mg/dL. Chest radiograph showed bilateral interstitial infiltrates, and
RT-PCR was positive for influenza A.
9. VIRAL GASTROENTERITIS
A patient is a 75-year-old man presenting to his physician with a diarrheal illness of 1 day’s
duration. His illness began with vomiting and was followed by abdominal pain, nausea, and
watery, but non-bloody, diarrhea. Despite not feeling well, he can drink fruit juices.
The patient’s history of present illness is significant for eating raw oysters at the local seafood
restaurant 2 nights ago. He has since learned that other patrons are experiencing a similar
illness. He has no significant medical history. He denies recent hospitalization, contact with
small children, recent travel, or recent use of antimicrobials. On physical examination, he is alert
and oriented, is not “toxic” appearing, is afebrile, and has stable vital
signs. The remainder of his examination is significant for decreased skin turgor and dry
mucous membranes. The patient’s stool is negative for WBCs and RBCs. With the patient’s
history of dining and other patrons having a similar illness, the physician calls the Board of
Health to find out whether persons with a similar illness have been identified. The physician is
informed that an outbreak of norovirus (previously called Norwalk-like virus) gastroenteritis was
confirmed at the restaurant where the patient had dined.

10. PRIMARY PREVENTION TO REDUCE THE RISK OF STROKE

The patient is a 63-year-old, 5 feet 6 inches tall, an 85-kg woman concerned about a stroke. Her
father died of a stroke, and her 85-year-old mother has had several episodes diagnosed as TIAs.
The patient's blood pressure is 140 to 150/90 to 100 mm Hg, and she was recently diagnosed
with diabetes mellitus. She does not have a history of TIA or stroke. Additionally, she smoked
for 25 years but has not used tobacco for the past 10 years. Her current medications include
lisinopril, metformin, conjugated estrogen/medroxyprogesterone, and acetaminophen. She
approaches her pharmacist because of concerns about having a stroke and being “like her
parents.”

11. SECONDARY PREVENTION AND TIA

The patient is a 58-year-old, 5 feet 11 inches tall, 120- kg man, who experienced a rapidly
progressive paralysis of his right arm and slurred speech yesterday. These symptoms lasted for
15 to 20 minutes and resolved rapidly. His neurologic examination is entirely normal, and he
denies any feeling of weakness. He smokes two packs of cigarettes daily and drinks three to six
cans of beer each evening. His physical examination is entirely normal except for a left carotid
bruit, which was first noted 2 years ago. His blood pressure is 165/100 mm Hg, and he has a long
history of hypertension. His hemoglobin is 16.5 g/dL, his hematocrit is 51% and his total serum
cholesterol concentration is 275 mg/dL. A Doppler examination of his carotid arteries shows a
90% stenosis on the left and a 40% stenosis on the right. The physician decides to begin the
patient on aspirin 81 mg/day.
12. SURGICAL PROPHYLAXIS
The patient is a 28-year-old woman admitted to the obstetrics unit at term with her first
pregnancy. She is scheduled for a cesarean section because the baby is in a breech presentation.
Cefazolin 1 g IV is to be administered after the cord is clamped and every 8 hours for 24 hours is
ordered. The patient is discharged on the fifth hospital day and instructed to observe her incision
site carefully for signs of infection.