Abdominal Examination OSCE Guide PDF

geekymedics.com http://geekymedics.com/abdominal-examination/ Abdominal examination – OSCE Guide Lewis Potter The abdominal examination frequently appears in OSCEs and this guide demonstrates how to perform the examination in a sys...

geekymedics.com http://geekymedics.com/abdominal-examination/ Abdominal examination – OSCE Guide Lewis Potter The abdominal examination frequently appears in OSCEs and this guide demonstrates how to perform the examination in a systematic manner, with an included video guide. Introduction Wash hands Introduce yourself Confirm patient details – name / DOB Explain the examination Gain consent Expose patient’s chest & abdomen Position patient – on the bed, sat upright for the first part of the examination Ask if patient has any pain General inspection Look around bedside for treatments or adjuncts – feeding tubes /stoma bags /drains Patient’s appearance – in pain? / agitated? / confused? Body habitus – obese/ low BMI / cachectic Scars – midline scars (laparotomy) / RIF (appendectomy) / right subcostal (cholecystectomy) Jaundice – cirrhosis / hepatitis Anaemia – obvious pallor suggests significant anaemia – e.g. GI bleeding Abdominal distention – ascites / bowel distension / large masses Masses – may suggest malignancy / organomegaly Dressings – may be covering wound sites – infection / bleeding Needle track marks – Hepatitis / HIV Excoriations – pruritus – cholestasis 1  General inspection < > Inspection Hands Clubbing – inflammatory bowel disease / cirrhosis / coeliac disease Koilonychia – spooning of the nails – chronic iron deficiency Leukonychia – whitened nail bed – hypoalbuminemia – liver failure / enteropathy Palmar erythema – reddening of palms – liver disease / pregnancy Dupuytren’s contracture: Thickening of palmar fascia Associated with alcohol excess / family history Hepatic flap: Ask patient to stretch out arms, with hands dorsiflexed & fingers outstretched Ask them to hold their hands in that position for 15 seconds The hands will flap (flex/extend at the wrist) in an irregular fashion if positive Causes include – hepatic encephalopathy / uraemia / CO2 retention 2 Inspect hands Inspect hands 3  Inspect for nail clubbing Assess for hepatic flap < > Arms Bruising – may suggest abnormal coagulation (↑PT) due to liver failure Petechiae – low platelets Excoriations – cholestasis Track marks – intravenous drug use – Hepatitis / HIV 4 Axillae Lymphadenopathy – malignancy / infection Hair loss – malnourishment / iron deficiency anaemia Acanthosis nigricans (darkened pigmentation) – GI adenocarcinomas / obesity Eyes Ask patient to lower one of their eyelids with their finger. Inspect for the signs below. Jaundice – noted in the sclera – haemolysis / hepatitis / cirrhosis, biliary obstruction Conjunctival pallor – suggests significant anaemia Xanthelasma – raised yellow deposits surrounding eyes – PBC/ hyperlipidaemia Mouth Angular stomatitis – inflamed red areas at the corners of the mouth – iron/B12 deficiency Oral candidiasis – white slough on oral mucous membranes – iron deficiency / immunodeficiency Mouth ulcers – Crohn’s disease / coeliac disease Tongue (glossitis) – smooth swelling of the tongue with associated erythema – iron/B12/folate deficiency Neck Cervical lymph nodes – lymphadenopathy may indicate infection / metastatic malignancy Virchow’s node – left supraclavicular fossa – suggestive of gastric malignancy Chest Spider naevi – central red spot with reddish extensions (>5 significant) – chronic liver disease Gynaecomastia – overdevelopment of male mammary glands (pseudofeminisation) – liver cirrhosis / digoxin/ spironolactone Hair loss – pseudofeminisation/ malnourishment / iron deficiency anaemia 5 Inspect axilla Inspect sclera 6 Inspect conjunctiva Inspect mouth & tongue 7 Palpate lymph nodes Palpate Virchow's node 8  Closely inspect the chest 1. 1 2. 2 3. 3 4. 4 5. 5 6. 6 7. 7 < > Detailed abdominal inspection Position the patient supine, with their arms by their side & legs uncrossed. Scars – midline scars (laparotomy) / RIF (appendectomy) / right subcostal (cholecystectomy) Masses – assess (size, position, consistency, mobility) – organomegaly / malignancy Pulsation – a central pulsatile & expansile mass may indicate an abdominal aortic aneurysm (AAA) Cullen’s sign – bruising surrounding umbilicus – retroperitoneal bleed (pancreatitis/ruptured AAA) Grey-Turner’s sign – bruising in the flanks – retroperitoneal bleed (pancreatitis/ruptured AAA) Abdominal distension – fluid (ascites) / fat (obesity) / faeces (constipation) / flatus / fetus (pregnancy) Striae – reddish/pink (new) or white/silverish (chronic) – abdominal distension Caput medusae – engorged paraumbilical veins – portal hypertension Stomas – Colostomy (LIF) / Ileostomy (RIF) / Urostomy (RIF & contains urine) 9  Inspect the abdomen Inspect for distension / masses 1. 1 2. 2 < > Palpation Ask about any areas of pain & examine these last. Kneel so that you are level with the patient. Observe the patient’s face throughout for signs of discomfort. 10 Light palpation Palpate each of the 9 abdominal regions, assessing for any of the below. Tenderness – note the areas involved and the severity of the pain Rebound tenderness – pain is worsened on releasing the pressure – peritonitis Guarding – involuntary tension in the abdominal muscles – localised or generalised? Masses – large / superficial masses may be noted on light palpation Deep palpation Assess each of the 9 regions again, but with greater pressure applied during palpation. If any masses are identified then assess: Location – which region? Size Shape Consistency – smooth / soft / hard / irregular Mobility – is it attached to superficial / underlying tissues? Pulsatility – a pulsatile mass suggests vascular aetiology Light palpation 11  Deep palpation 1. 1 2. 2 < > Liver 1. Start palpation in the right iliac fossa 2. Press your right hand into the abdomen as you ask the patient to take a deep breath 3. Feel for a step, as the liver edge passess below your hand 4. If you don’t feel anything, repeat the process with your hand 1-2 cm higher If you feel the liver edge, note the following: Degree of extension below the costal margin Consistency of the liver edge (smooth/irregular) Tenderness – suggestive of hepatitis Pulsatility – a pulsatile enlarged liver can be caused by tricuspid regurgitation 12  Liver palpation < > Gallbladder The gallbladder is not usually palpable. An enlarged gallbladder suggests obstruction to biliary flow / infection (cholecystitis). Perform palpation at the right costal margin, mid-clavicular line (9th rib tip) If enlarged, a round mass moving with respiration may be palpated – note any tenderness Murphy’s sign: Place your hand in the area noted above Ask the patient to take a deep breath As the gallbladder is pushed down into your hand the patient may suddenly develop pain & stop inspiring This is a positive Murphy’s sign, which is suggestive of cholecystitis Spleen The spleen only becomes palpable when it’s at least 3x its normal size! 1. Start in right iliac fossa – massive splenomegaly can extend this far! 13 2. Align your fingers in the same direction as the left costal margin 3. Press your right hand into the abdomen as you ask the patient to take a deep breath 4. Feel for a step, as the splenic edge passess under your hand (a notch may be noted) 5. If you don’t feel anything, repeat process with your hand 1-2 cm closer to the left hypochondrium Palpate the spleen < > Kidneys 1. Place your left hand behind the patient’s back, at the right flank 2. Place your right hand just below the right costal margin in the right flank 3. Press your right hand’s fingers deep into the abdomen 4. At the same time press upwards with your left hand 5. Ask the patient to take a deep breath 6. You may feel the lower pole of the kidney moving inferiorly during inspiration 7. Repeat this process on the opposite side to assess the left kidney 14  Ballot the kidneys < > Aorta 1. Palpate using fingers from both hands 2. Palpate just above the umbilicus at the border of the aortic pulsation 3. Note the movement of your fingers: Upward movement = pulsatile Outward movement = expansile (suggestive of AAA) 15  Palpate aorta < > Bladder An empty bladder will not be palpable (pelvic). However an enlarged full bladder can be felt arising from behind the pubic symphysis. This may suggest a diagnosis of urinary retention. Percussion Abdominal organs Liver – percuss up from RIF then down from right side of chest to determine the size of the liver Spleen – percuss up from RIF moving towards the left hypochondrium to assess for splenomegaly Bladder – percuss suprapubic region – differentiating suprapubic masses (bladder (dull) / bowel (resonant)) 16 Percuss out liver borders Percuss spleen 17  Percuss bladder 1. 1 2. 2 3. 3 < > Shifting dullness 1. Percuss from the centre of the abdomen to the flank until dullness is noted 2. Keep your finger on the spot at which the percussion note became dull 3. Ask patient to roll onto the opposite side to which you have detected the dullness 4. Keep the patient on their side for 30 seconds 5. Repeat your percussion in the same spot 6. If fluid was present ( ascites) then the area that was previously dull should now be resonant 7. If the flank is now resonant, percuss back to the midline, which if ascites is present, will now be dull ( i.e. the dullness has shifted) 18  Percuss from the midline outwards until dull Repeat percussion 1. 1 2. 2 < > Auscultation Bowel sounds Normal – gurgling 19 Abnormal – e.g. “tinkling” (bowel obstruction) Absent – ileus / peritonitis Bruits Aortic bruits – auscultate just above the umbilicus – AAA Renal bruits – auscultate just above the umbilicus, slightly lateral to the midline Auscultate for bowel sounds Auscultate for aortic bruits 20  Auscultate for renal bruits 1. 1 2. 2 3. 3 < > To complete the examination Thank patient Wash hands Summarise findings Suggest further assessments & investigations Check hernial orifices – e.g. if there’s signs of obstruction Perform a digital rectal examination (PR) – e.g. if there’s a suggestion of an upper GI bleed Perform an examination of the external genitalia – if appropriate “I would examine the hernial orifices, perform a PR and examine the external genitalia if appropriate” CONTENT REVIEWED BY Dr Ally Speight – SpR in Gastroenterology.. 21  geekymedics.com http://geekymedics.com/ankle-and-foot-examination/ Ankle and Foot examination Lewis Potter Ankle and foot examination can occasionally appear in OSCEs, so it’s important you’re familiar with it. Introduction Wash hands Introduce yourself – state your name & role Confirm patient details – name & DOB Explain examination: “I’d like to examine your ankles and feet. This will involve having a look and feel of these joints, in addition to assessing the joints’ movement” Gain consent – “Do you understand everything I’ve said?” “Are you happy to go ahead with the exam?” Gain adequate exposure – both legs should be exposed from the knee down Position patient – ask patient to stand up straight with their feet aligned facing forwards Look Gait Is the patient demonstrating a normal heel strike / toe off gait? Is each step of normal height? – increased stepping height is noted in foot drop Is the gait smooth & symmetrical? 22 Front Symmetry of feet / ankles Toe alignment – hallux valgus of the big toe may be noted Bunions – located at the 1st MTP joint Toe clawing? Scars – suggestive of previous injury / surgery Calluses – may indicate foot / gait deformity or poorly fitting footwear Swelling / erythema of the foot or ankle – may suggest injury / inflammatory arthritis / infection Examine the patient’s shoes – evidence of asymmetrical wearing may indicate abnormal gait Side Foot arches – observe for evidence of flat feet (pes planus) or high arched feet (pes cavus) If patient has flat feet ask to stand on tip toes – supple flat feet will correct / rigid flat feet will not Back Foot / Ankle symmetry – heel alignment – valgus or varus deformity? Achilles tendon – any obvious deformity / discontinuity / erythema? Feel Ask the patient to lay on a bed. Assess temperature & compare between legs – ↑ temperature may indicate inflammatory pathology Assess pulses in both feet – posterior tibial & dorsalis pedis Palpate the achilles tendon – assess for thickening or swelling Palpate the joints / bones Work distal to proximal – assess for tenderness / swelling / irregularity 23  Squeeze MTP joints – observe patient’s face for discomfort Tarsal joint Ankle joint Subtalar joint Medial / lateral malleoli Proximal fibula Move Assess each of the following movements actively & passively (feeling for crepitus). Foot plantarflexion – “push your feet downwards, like pushing a car pedal” – 30-40 º Foot dorsiflexion – “point your feet towards your head” – 12-18 º Foot inversion – grasp ankle with one hand & heel with the other – turn sole towards midline – passive assessment only Foot eversion – grasp ankle with one hand & heel with the other – turn sole away from midline – passive assessment only Midtarsal joints – hold ankle with one hand whilst moving the tarsus up/down then & side to side – passive assessment only Toe flexion – “curl up your toes” Toe extension – “point your toes towards your head” Toe adduction – “hold this paper between your toes & don’t let me pull it away” Toe abduction – “spread out your toes as far as you can” Special tests Simmonds’ test Simmonds’ test is used to assess for rupture of the achilles tendon 1. Ask patient to kneel on a chair with their feet hanging off the edge. 2. Squeeze each calve in turn. 3. Normally the foot should plantarflex. 4. If the achilles tendon is ruptured there will be no movement of the foot. To complete the examination 24 Thank patient Wash hands Suggest further assessments & investigations Examine the knee & hip joint Full neurovascular examination of the lower limbs Further imaging of the relevant joints if indicated (Xray / CT / MRI) 25  geekymedics.com http://geekymedics.com/cardiovascular-examination-2/ Cardiovascular examination – OSCE Guide Lewis Potter Cardiovascular examination frequently appears in OSCEs. You’ll be expected to pick up the relevant clinical signs using your examination skills. This cardiovascular examination OSCE guide provides a clear concise, step by step approach, to examining the cardiovascular system, with an included video demonstration. Introduction Wash hands Introduce yourself Confirm patient details – name / DOB Explain the examination Gain consent Position the patient at 45° with their chest exposed Ask if the patient has any pain anywhere before you begin! General inspection Bedside – treatments or adjuncts? – GTN spray / O 2 / medication / mobility aids Comfortable at rest? – does the patient look in pain? Shortness of breath at rest? Malar flush – plum red discolouration of cheeks – may suggest mitral stenosis Inspect chest – scars or visible pulsations? Inspect legs – harvest site scars / peripheral oedema / missing limbs or toes 26  General inspection < > Hands Hands out with palms facing downwards Splinter haemorrhages – reddish / brown streaks on the nail bed – bacterial endocarditis Finger clubbing: Ask the patient to place the nails of their index fingers back to back In a healthy individual you should be able to observe a small diamond shaped window (Schamroth’s window) When finger clubbing is present this window is lost Finger clubbing has a number of causes including infective endocarditis and cyanotic congenital heart disease Hands out with palms facing upwards Colour – dusky bluish discolouration (cyanosis) suggests hypoxia Temperature – cool peripheries may suggest poor cardiac output / hypovolaemia Sweaty/Clammy– can be associated with acute coronary syndromes Janeway lesions – non-tender maculopapular erythematous palm pulp lesions – bacterial endocarditis Osler’s nodes – tender red nodules on finger pulps / thenar eminence – infective endocarditis Tar staining – smoker – risk factor for cardiovascular disease Xanthomata – raised yellow lesions – often noted on tendons of wrist – caused by hyperlipidaemia 27 Capillary refill – normal is Pulses Radial pulse – assess rate & rhythm 29 Radio-radial delay: Palpate both radial pulses simultaneously They should occur at the same time in a healthy adult A delay may suggest aortic coarctation Collapsing pulse – associated with aortic regurgitation First ensure the patient has no shoulder pain Palpate the radial pulse with your hand wrapped around the wrist Raise the arm above the head briskly Feel for a tapping impulse through the muscle bulk of the arm as blood empties from the arm very quickly in diastole, resulting in the palpable sensation. This is a Waterhammer pulse and can occur in normal physiological states (fever/pregnancy), or in cardiac lesions (e.g AR / PDA) or high output states (e.g anaemia / AV fistula / thyrotoxicosis ) Brachial pulse – assess volume & character Blood pressure: Measure blood pressure & note any abnormalities – hypertension / hypotension Narrow pulse pressure is associated with Aortic Stenosis Wide pulse pressure is associated with Aortic Regurgitation Often you won’t be expected to actually carry this out ( due to time restraints) but make sure to mention that you’d ideally like to measure blood pressure in both arms. Carotid pulse: Assess character & volume – e.g. slow rising character in aortic stenosis It’s often advised to auscultate the carotid artery for a bruit before palpating as theoretically palpation might dislodge a plaque which could lead to a stroke. 30 Palpate radial pulse Radial-radial delay 31 Palpate brachial pulse Collapsing pulse 32  Measure BP Palpate carotid pulse 1. 1 2. 2 3. 3 4. 4 5. 5 6. 6 < > Jugular venous pressure 33 1. Ensure the patient is positioned at 45° 2. Ask patient to turn their head away from you 3. Observe the neck for the JVP – located inline with the sternocleidomastoid 4. Measure the JVP – number of cm from sternal angle to the upper border of pulsation Raised JVP may indicate – Fluid overload / Right ventricular failure / Tricuspid regurgitation Hepatojugular reflux: Apply pressure to the liver Observe the JVP for a rise In healthy individuals this should last no longer than 1-2 cardiac cycles (it should then fall) If the rise in JVP is sustained & equal to or greater than 4cm this is a positive result A positive hepatojugular reflux sign is suggestive of right sided heart failure / tricuspid regurgitation Observe for a raised JVP 34  Assess for hepatojugular reflux 1. 1 2. 2 < > Face Eyes Conjunctival pallor – anaemia – ask patient to gently pull down lower eyelid Corneal arcus – yellowish/grey ring surrounding the iris – hypercholesterolaemia Xanthelasma – yellow raised lesions around the eyes – hypercholesterolaemia Mouth Central cyanosis – bluish discolouration of lips / underneath tongue Angular stomatitis – inflammation of corners of the mouth – iron deficiency High arched palate – suggestive of Marfans – ↑ risk of aortic aneurysm/dissection Dental hygiene – important if considering sources for infective endocarditis 35 Inspect eyes Inspect conjunctiva 36  Inspect mouth Inspect for central cyanosis 1. 1 2. 2 3. 3 4. 4 < > Close inspection of the chest Scars: 37  Thoracotomy – minimally invasive valve surgery Sternotomy – CABG / valve surgery Clavicular – Pacemaker Chest wall deformities – pectus excavatum / pectus carinatum Visible pulsations – forceful apex beat may be visible – hypertension/ventricular hypertrophy Inspect chest for scars Inspect chest for deformities 1. 1 2. 2 < > 38 Palpation Heaves- left sternal edge – LVH & RVH Thrills – palpable murmurs felt over aortic valve & apex beat Apex beat: 5th intercostal space / Midclavicular line Lateral displacement suggests cardiomegaly Once located, count out the intercostal spaces to make it clear to the examiner you have located it Palpate apex beat Feel for thrills 39  Feel for heaves 1. 1 2. 2 3. 3 < > Auscultation Auscultate the 4 valves Palpate the carotid pulse to determine the 1st heart sound Auscultate using the diaphragm of the stethoscope Aortic valve – 2nd intercostal space – right sternal edge Pulmonary valve – 2nd intercostal space – left sternal edge Tricuspid valve – 5th intercostal space – lower left sternal edge Mitral valve – 5th intercostal space – midclavicular line (apex beat) Repeat auscultation across the 4 valves with the bell of the stethoscope 40 Auscultate aortic valve Auscultate pulmonary valve 41 Auscultate tricuspid valve Auscultate mitral valve 42  Repeat auscultation with bell 1. 1 2. 2 3. 3 4. 4 5. 5 < > Radiation of the murmur Carotid arteries (with breath held) – radiation of aortic stenosis murmur Axilla – radiation of heart murmur into the left axilla – mitral regurgitation Left sternal edge – Aortic regurgitation 43  Auscultate carotid arteries Auscultate axilla 1. 1 2. 2 < > Accentuation maneuvers These maneuvers cause particular murmurs to become louder DURING expiration Roll onto left side & listen to mitral area with bell during expiration – mitral murmurs (stenosis & regurgitation) Lean forward & listen over aortic area during expiration – aortic murmurs are louder (stenosis & regurgitation) 44  Auscultate left sternal edge Auscultate at heart apex using bell 1. 1 2. 2 < > To complete the examination Auscultate lung bases – crackles may suggest pulmonary oedema – left ventricular failure Sacral oedema / Pedal oedema – may indicate right ventricular failure 45 Auscultate lung bases Check for sacral oedema 46  Check for pedal oedema 1. 1 2. 2 3. 3 < > Thank patient Wash hands Summarise findings Suggest further assessments and investigations: Full peripheral vascular examination Record a 12-lead ECG – arrhythmias / myocardial ischaemia Dipstick urine – proteinuria / haematuria – hypertension Bedside capillary blood glucose – diabetes Perform fundoscopy – malignant hypertension – papilloedema CONTENT REVIEWED BY Dr Matthew Jackson – Interventional Cardiology SpR.. 47  geekymedics.com http://geekymedics.com/cranial-nerve-exam/ Cranial nerve examination – OSCE Guide David Bargiela The cranial nerve examination is often considered one of the most difficult OSCE stations, but with plenty of practice and some helpful acronyms along the way, you’ll be fine. The important thing to remember is that in an OSCE you’ll rarely be required to complete an entire cranial nerve exam in one station. Introduction Wash hands Introduce yourself Confirm patient details – name / DOB Explain the examination – “I’m going to be testing the nerves that supply your face” Gain consent Position patient on a chair at eye level – approximately 1 arms length away Ask if the patient currently has any pain. Gather equipment Pen torch Snellen chart Ishihara plates Ophthalmoscope Cotton wool Neuro-tip Tuning fork (512hz) Glass of water Mydriatic eye drops (if necessary) 48 General inspection General appearance – comfortable at rest? Obvious facial asymmetries? Position of eyes – normal alignment / strabismus Ptosis – is this unilateral or bilateral? Abnormality of speech or voice? – dysarthria Signs around the bed – e.g. hearing aid / glasses I – Olfactory nerve Any change in sense of smell? – “What was the last thing you remember smelling?” With eyes closed, ask patient to identify various scents – e.g. coffee / vinegar II – Optic nerve Pupils Size – normal size is approximately 2-4mm in diameter (bright light) Position – assess pupil alignment – misalignment noted in strabismus Inspect pupils. < > 49 Visual acuity 1. Stand the patient at 6 metres from the Snellen chart. 2. If patient normally uses distance glasses, ensure they wear them for the assessment. 3. Ask the patient to cover one eye & read to the lowest line they can manage. 4. Visual acuity is recorded as chart distance (numerator) over number of lowest line read (denominator). 5. Record the lowest line the patient was able to read (e.g. 6/6 which is equivalent to 20/20). 6. You can have the patient read through a pinhole to see if this improves vision. 7. Repeat above steps with the other eye. If patient is unable to read top line at 6 metres (even with pinhole): 1. Reduce the distance to 3 metres from the Snellen chart. 2. Reduce the distance to 1 metre from the Snellen chart. 3. Assess if they can count the number of fingers you’re holding up. 4. Assess if they can see gross hand movement. 5. Assess if they can detect light from a pen torch shone into each each. If the patient is unable to perceive light, this suggests they are blind. Assess visual acuity. < > Pupillary reflexes Direct reflex– shine torch into eye – look for pupillary constriction in that eye Consensual reflex – shine torch into eye – look for pupillary constriction in opposite eye Swinging light test– move light in from side of each eye rapidly – relative afferent pupillary defect (RAPD) 50 Accommodation reflex: 1. Ask patient to focus on a distant point (clock on a wall / light switch). 2. Place your finger/object approximately 15cm in front of the eyes. 3. Ask the patient to switch from looking at the distant object to the nearby finger / object. 4. Observe the pupils, you should see constriction & convergence bilaterally. Assess direct & consensual pupillary reflexes. Swinging light test. 51  Swinging light test. 1. 1 2. 2 3. 3 4. 4 < > Colour vision 52 Assess colour vision using Ishihara charts (unlikely to do this in an OSCE setting) Visual fields Sit directly facing the patient, approximately 1 metre away. Visual inattention (visual neglect) 1. Ask patient to focus on your face & not move their head or eyes during the assessment. 2. Hold both arms out, with one hand in the upper right and the other in the upper left quadrant of your visual field. 3. Remind the patient to keep their head still & their eyes fixed on your face. 4. Move one of your fingers (on only one hand) and ask the patient to point at the hand on which the finger is moving. 5. Move the finger on the left and right hand individually in whichever order you prefer. 6. Then move the finger of both hands simultaneously. 7. If patient only reports a finger on one of the hands moving (whilst both are moving simultaneously), it suggests the presence of visual neglect. 8. Repeat the process with your hands in the lower quadrants of vision... Visual fields 1. Ask the patient to cover their left eye with their left hand. 2. You should cover your left eye and be staring directly at the patient (mirror the patient). 3. Ask patient to focus on your face & not move their head or eyes during the assessment. 4. Ask the patient to tell you when they can see your fingertip wiggling. 5. Outstretch your arms, ensuring they are situated at equal distance between yourself & the patient. 6. Position your fingertip at the outer border of one of the quadrants of your visual field. 7. Slowly bring your fingertip inwards, towards the centre of your visual field until the patient sees it. 8. Repeat this process for each quadrant – at 10 o’clock /2 o’clock / 4 o’clock / 8 o’clock. 53 9. If you are able to see your fingertip but the patient cannot, this would suggest a reduced visual field. 10. Map out any visual field defects you detect. 11. Repeat the same assessment process on the other eye. Assess visual inattention. Assess visual fields. 1. 1 2. 2 < > Fundoscopy 54 Preparation 1. Darken the room. 2. The patient should have their pupils dilated with short-acting mydriatic eye drops. 3. Ask the patient to fixate on a distant object. Assess for red reflex 1. Position yourself at a distance of around 30cm from the patient’s eyes. 2. Looking through the ophthalmoscope observe for a reddish / orange reflection in the pupil. An absent red reflex may indicate the presence of cataract, or in rare circumstances neuroblastoma. Move in closer & examine the eye with the fundoscope Begin medially & assess the optic disc – colour / contour / cupping Assess the retinal vessels – cotton wool spots / AV nipping / neovascularization Finally assess the macula – ask to look directly into the light – drusen noted in macular degeneration III, IV, VI – Oculomotor, Trochlear & Abducens nerves Ptosis Note any evidence of ptosis – oculomotor nerve pathology Eye movements 1. Ask the patient to keep their head still & follow your finger with their eyes. 2. Move your finger through the various axis of eye movement (“H” shape). 3. Ask the patient to report any double vision. 4. Observe for restriction of eye movement & note any nystagmus. Cover test 1. Ask patient to focus on a target ( e.g. your pen top). 2. Cover one of the patient’s eyes. 55 3. Observe the uncovered eye for movement: No movement = normal response Eye moves temporally = convergent squint Eye moves nasally = divergent squint 4. Repeat the cover test on the other eye. Assess eye movements using "H" test. Observe for nystagmus. 1. 1 2. 2 < > 56 V – Trigeminal nerve Sensory Assess light touch and pinprick sensation: Forehead – ophthalmic branch (V1) Cheek – maxillary branch (V2) Jaw – mandibular branch (V3) Compare left to right for each branch. Demonstrate sensation on patient’s sternum first, to ensure they understand what it should feel like. Motor 1. Ask patient to clench their teeth whilst you feel the bulk of masseter & temporalis bilaterally. 2. Ask patient to open their mouth whilst you apply resistance under the jaw – note any deviation (jaw will deviate to side of lesion). Reflexes Jaw jerk: Ask patient to open mouth loosely Place your finger horizontally across the chin Tap your finger with a tendon hammer Normal = slight closure of the jaw Abnormal = brisk complete closure of the jaw – UMN lesion Corneal reflex: Explain procedure & gain consent Depress lower eyelid Ask patient to look upwards Touch edge of cornea using a wisp of cotton wool Normal response = Direct & consensual blinking 57 Not usually required in an OSCE setting Assess light touch sensation - Ophthalmic branch (V1) Assess light touch sensation - Maxillary branch (V2) 58 Assess light touch sensation - Mandibular branch (V3) Assess pinprick sensation across V1/V2/V3 using a neuro-tip 59 Assess temporalis muscle bulk. Assess masseter muscle bulk. 60 Ask patient to open their mouth against resistance. Assess Jaw Jerk reflex. 61  Assess corneal reflex 1. 1 2. 2 3. 3 4. 4 5. 5 6. 6 7. 7 8. 8 9. 9 < > VII – Facial nerve Inspect the patient’s face at rest for asymmetry: Forehead wrinkles Nasolabial folds Angles of the mouth Ask the patient to perform specific facial movements 62 Raised eyebrows – “raise your eyebrows as if you’re surprised” – note asymmetry Closed eyes – “scrunch up your eyes & don’t let me open them” – assess power Blown out cheeks – “blow out your cheeks & don’t let me deflate them” – assess power Smiling – “can you do a big smile for me?” – note asymmetry Pursed lips – “can you attempt to whistle for me?” – note asymmetry Raise eyebrows. Close eyes & resist opening. 63 Blow out cheeks. Purse lips. 64  Smile. 1. 1 2. 2 3. 3 4. 4 5. 5 < > Other things to check… Inspect external auditory meatus – herpes zoster lesions – Bell’s Palsy Any hearing changes? – facial nerve supplies stapedius – paralysis results in hyperacusis Any taste changes? – supplies taste sensation to the anterior 2/3 of the tongue 65  Inspect external auditory meatus. < > VIII – Vestibulocochlear nerve Gross hearing testing Ask the patient if they have noticed a change in their hearing recently. Assess each ear individually, standing behind the patient. 1. Explain to the patient that you’re going to say a word or number and you’d like them to repeat it back to you. 2. With your mouth approximately 15cm from the ear, whisper a number or word. 3. Mask the ear not being tested by rubbing the tragus. 4. Ask the patient to repeat the number or word back to you. 5. If the patient repeats the correct word or number, repeat the test at an arms length from the ear (normal hearing allows whispers to be perceived at 60cm). 6. Assess the other ear in the same way. 66  Assess hearing at approximately 15cm If patient is able to hear at 15cm, repeat at 60cm. 1. 1 2. 2 < > Rinne’s test 1. Tap a 512HZ tuning fork & place at the external auditory meatus & ask the patient if they are able to hear it (air conduction) 67 2. Now move the tuning fork (whilst still vibrating), placing its base onto the mastoid process (bone conduction) 3. Ask the patient if the sound is louder in front of the ear (EAM) or behind it (mastoid process) Normal = Air conduction > Bone conduction (Rinne’s positive) Neural deafness = Air conduction > Bone conduction (both air & bone conduction reduced equally) Conductive deafness = Bone conduction > Air conduction (Rinne’s negative) Place tuning fork on the mastoid process. Place tuning fork at the external auditory meatus. 1. 1 2. 2 < 68  > Weber’s test 1. Tap a 512HZ tuning fork & place in the midline of the forehead. 2. Ask the patient where they can hear the sound: Normal = sound is heard equally in both ears Neural deafness = sound is heard louder on the side of the intact ear Conductive deafness = sound is heard louder on the side of the affected ear Place tuning fork in the midline of the forehead. < > Vestibular testing – “turning test” Ask patient to march on the spot with arms outstretched & eyes closed: Normal – patient remains in the same position Vestibular lesion – patient will turn toward the side of the lesion 69  Turning test - assessing for a vestibular lesion. < > IX & X – Glossopharyngeal & Vagus nerves Assess soft palate & uvula: Symmetry – note any obvious deviation of the uvula Ask patient to say “ahhhh” – observe uvula moving upwards – any deviation? Gag reflex – you won’t do this in the OSCE, but just make sure you mention it Ask patient to cough– damage to nerves IX & X can result in a bovine cough Swallow – ask patient to take a sip of water – note any coughing / delayed swallow Assess soft palate and uvula. 70 Ask the patient to cough. Assess patient's swallow. 71  Assess Gag reflex (not usually required in an OSCE) 1. 1 2. 2 3. 3 4. 4 < > XI – Accessory nerve Ask patient to shrug shoulders & resist you pushing down – trapezius Ask patient to turn head to one side & resist you pushing it to the other – sternocleidomastoid Note any weakness. 72  Assess Trapezius strength. Assess Sternocleidomastoid strength. 1. 1 2. 2 < > XII – Hypoglossal nerve 1. Inspect tongue for wasting & fasciculation at rest. 2. Ask patient to protrude tongue – any deviation? 3. Place your finger on the patient’s cheek & ask to push their tongue against it – assess power 73 Inspect tongue at rest for fasciculations. Ask patient to protrude their tongue and look for deviation. 74  Assess the power of the tongue. 1. 1 2. 2 3. 3 < > To complete the examination Thank patient Wash hands Summarise findings. Say you would… Perform further testing of any nerves that had abnormal results. Carry out a full neurological examination of the upper & lower limbs. 75  geekymedics.com http://geekymedics.com/diabetic-foot-examination-osce-guide/ Diabetic foot examination – OSCE Guide Lewis Potter Diabetic foot examination frequently appears in OSCEs. You’ll be expected to pick up the relevant clinical signs using your examination skills. This diabetic foot examination OSCE guide provides a clear, concise, step by step approach to examining diabetic feet. Introduction Wash hands Introduce yourself Confirm patient details – name / DOB Explain the examination Gain consent Position patient on bed at 45° Expose patient’s lower legs & feet Gather equipment Monofilament Tuning fork (128hz) Tendon hammer Inspection Inspect legs & feet thoroughly, lifting legs up to see underneath & ensuring to look between toes. Colour – pallor / cyanosis /erythema (e.g. cellulitis / ischaemia) Skin: 76  Dry / shiny / hair loss – peripheral vascular disease Eczema / haemosiderin staining – venous disease Ulcers – inspect between toes / heels / underneath legs Venous ulcers – moderate to no pain – larger /shallow – associated with venous insufficiency / varicose veins Arterial ulcers – very painful – deep punched out appearance – associated with diabetes mellitus / peripheral vascular disease Swelling: Oedema – – e.g. venous insufficiency / heart failure Deep vein thrombosis – tender on palpation Calluses – may indicate incorrectly fitting shoes Venous filling – guttering of veins / reduced visibility suggests PVD Deformity caused by neuropathy (e.g. Charcot arthropathy) Inspect legs for hair loss / skin changes 77 Inspect limb colour Inspect between toes for ulcers 78  Inspect behind legs for ulcers 1. 1 2. 2 3. 3 4. 4 < > Palpation Temperature – cool (e.g. PVD) / hot (e.g. cellulitis) Capillary refill – normal = < 2 seconds – prolongation suggests PVD Pulses: Dorsalis pedis artery – lateral to EHL tendon Posterior tibial artery – posterior & inferior to medial malleolus Absent peripheral pulses is suggestive of peripheral vascular disease. 79 Assess & compare leg temperature Check capillary refill time 80 Palpate dorsalis pedis pulses Palpate posterior tibial pulses 81  Palpate popliteal pulses 1. 1 2. 2 3. 3 4. 4 5. 5 < > Sensation Monofilament 1. Provide an example of monofilament sensation on the patient’s arm / sternum 2. With the patient’s eyes closed, place monofilament on the hallux & metatarsal heads (1/2/3/5) 3. Press firmly so that the filament bends 4. Hold the monofilament against the skin for 1-2 seconds – ask patient to say when they feel it Avoid calluses / scars, as the patient will have reduced sensation in these areas. 82 Locations to place monofilament Apply pressure until monofilament bends 83  Compare between feet 1. 1 2. 2 3. 3 < > Vibration sensation 1. Ask patient to close their eyes 2. Tap a 128hz tuning fork 3. Place onto patient’s sternum & confirm patient can feel it buzzing 4. Ask patient to tell you when they can feel it on their foot & to tell you when it stops buzzing 5. Place onto the distal phalanx of the great toe on each leg in turn 6. If sensation is impaired, continue to assess more proximally – e.g. proximal phalanx 84  Assess vibration sensation < > Gait Observe the patient walking whilst assessing: Symmetry / balance Turning – quick / slow / staggered Abnormalities – broad based gait / foot drop / antalgia Examine footwear: Note pattern of wear on soles – asymmetrical wearing – gait abnormality Ensure the shoes are the correct size for the patient Note holes / material inside the shoes that could cause foot injury 85  Assess GAIT Inspect footwear 1. 1 2. 2 < > Other tests to consider If abnormalities in monofilament or vibration sensation are identified, consider carrying out further tests shown below. 86 Proprioception 1. Hold the distal phalanx of the great toe by its sides 2. Demonstrate movement of the toe “upwards” & “downwards” to the patient (whilst they watch) 3. Then ask patient to close their eyes & state if you are moving the toe up or down 4. If the patient is unable to correctly identify direction of movement, move to a more proximal joint ( ankle > knee > hip) Assess proprioception < > Ankle jerk reflex 1. Dorsiflex the foot 2. Tap tendon hammer over the achilles tendon 3. Observe the calf for contraction – normal reflex Ankle jerk reflex may be absent in advanced peripheral neuropathy. 87  Assess ankle jerk reflex < > To complete the examination Thank patient Wash hands Suggest further assessments & investigations Full neurovascular assessment of the lower limbs Bedside capillary blood glucose Advice on good foot care CONTENT REVIEWED BY Dr Simon Ashwell – Consultant endocrinologist 88  geekymedics.com http://geekymedics.com/elbow-examination/ Elbow examination – OSCE Guide Lewis Potter Elbow examination can occasionally appear in OSCEs, so it’s important you’re familiar with it. You should feel confident diagnosing local joint issues such as bursitis, but also be able to identify stigmata of systemic diseases such as psoriasis (plaques) and rheumatoid arthritis (nodules). Introduction Wash hands Introduce yourself – state your name & role Confirm patient details – name & DOB Explain examination: “I’d like to examine your elbow. This will involve having a look and feel of the joint, in addition to assessing the joint’s movement” Gain consent – “Do you understand everything I’ve said?” “Are you happy to go ahead with the exam?” Gain adequate exposure- ideally you should be able to see the entire limb Position patient – palms facing forwards with arms by their side (anatomical position) Look Front Scars – suggestive of previous injury / surgery Swelling / erythema of the joint – may suggest acute injury / inflammatory arthritis / infection 89 Carrying angle – 5-15 degrees – females tend to have more significant carrying angles than males Side Fixed flexion deformity – often post traumatic Olecranon bursitis – the swelling overlying the olecranon is often most noticeable from this angle Scars / Swelling / Erythema Back Rheumatoid nodules – firm lumps on the elbow / olecranon – indicate systemic rheumatoid disease Psoriatic plaques – well defined pink / red elevated lesions with silvery scale Feel Temperature – a hot joint may indicate inflammatory arthritis or infection Palpate the joint lines – including the epicondyles & olecranon for any localised tenderness Move Assess each of the movements of the elbow joint actively & passively: Elbow flexion – 145º Elbow extension – 0º Pronation – 70º Supination – 85º When moving the joint passively assess for crepitus. Special tests Medial epicondylitis – a.k.a. “Golfers Elbow” Ask the patient to actively flex the wrist whilst the elbow is flexed. Localised pain over the medial epicondyle suggests a diagnosis of medial epicondylitis. 90 Lateral epicondylitis – a.k.a. “Tennis Elbow” Ask the patient to actively extend the wrist whilst the elbow is flexed. Localised pain over the lateral epicondyle suggests a diagnosis of lateral epicondylitis. To complete the examination… Thank patient Wash hands Summarise findings Suggest further assessments & investigations Examine the joint above & below (shoulder / wrist) Full neurovascular examination of the upper limbs Further imaging of the joint if indicated – X Ray / CT / MRI 91  geekymedics.com http://geekymedics.com/hand-examination/ Hand examination – OSCE Guide Lewis Potter Hand examination frequently appears in OSCEs, often involving patients with osteoarthritis or rheumatoid arthritis. You’ll be expected to pick up the relevant clinical signs using your examination skills. This hand examination OSCE guide provides a clear concise, step by step approach to examining the hand, with an included video demonstration. Introduction Wash hands Introduce yourself Confirm patient details – name / DOB Explain examination Gain consent Expose patient’s hands, wrists and elbows Position patient with hands on a pillow Ask if patient currently has any pain Look Dorsum Scars Deformity – Bouchard’s nodes (PIP) / Heberden’s nodes (DIP) – OA Skin changes – psoriatic plaques Muscle wasting Nails – pitting & onycholysis – psoriasis Swan neck deformity – DIP hyperflexion with PIP hyperextension – RA Z-thumb – hyperextension of the IP joint, fixed flexion & subluxation of MCP joint – OA Boutonnières deformity – PIP flexion with DIP hyperextension – RA Palm 92 Scars – e.g. carpal tunnel release surgery Swelling Skin colour – erythema / necrosis Deformity – Dupuytren’s contracture Thenar/ hypothenar wasting – e.g. carpal tunnel syndrome Elbows – psoriatic plaques or rheumatoid nodules Inspect dorsum of hands Inspect nails 93  Inspect palms Inspect elbows 1. 1 2. 2 3. 3 4. 4 < > Feel Elbows 94 Palpate elbow & arm for nodules / tenderness Palm Thenar/ hypothenar bulk – wasting is noted in ulnar/median nerve lesions Temperature – wrist & MCP joint lines – warm joints in inflammatory / septic arthritis Tenderness Palmar thickening – Dupuytren’s contracture – familial / alcohol excess Radial & ulnar pulse – palpate to ensure adequate arterial supply to the hand Palpate elbow Assess temperature 95  Palpate thenar / hypothenar eminences Palpate radial pulse 1. 1 2. 2 3. 3 4. 4 < > Dorsum Palpate joints of the hand & wrist – Assess for tenderness / irregularities / warmth 96  Wrist MCP joint (metatarsophalangeal joint) PIP joint (proximal interphalangeal joint) DIP joint (distal interphalangeal joint) MCP squeeze – often tender in RA / other inflammatory arthropathies Anatomical snuffbox – tenderness may suggest scaphoid fracture Palpate wrist Palpate MCP 97 Palpate MCP Palpate IPJ 98 Palpate DIPJ Palpate anatomical snuffbox 99  MCP squeeze 1. 1 2. 2 3. 3 4. 4 5. 5 6. 6 7. 7 < > Sensation: Median nerve – thenar eminence Ulnar nerve – hypothenar eminence Radial nerve – first dorsal web space 100 Assess median nerve sensation Assess ulnar nerve sensation 101  Assess radial nerve sensation 1. 1 2. 2 3. 3 < > Move Assess each of the following movements passively first, feeling for crepitus & noting any pain. Then carry out active movements (patient does the movements independently). Wrist extension – “put palms of your hands together & extend wrists fully” – ROM 90º Wrist flexion – “put backs of your hands together & flex wrists fully” – ROM 90º Finger flexion – “make a fist” Finger extension – “open your fist & splay your fingers” 102 Wrist extension Wrist flexion 103 Passive wrist flexion / extension Finger flexion 104  Finger extension 1. 1 2. 2 3. 3 4. 4 5. 5 < > Motor assessment Ask the patient to carry out the following movements against resistance. This is a screening test to quickly assess the 3 major nerves of hand. Wrist / finger extension (against resistance) – radial nerve Finger abduction (against resistance) – index finger – ulnar nerve Thumb abduction (against resistance) – median nerve 105 Finger extension Finger abduction 106  Thumb abduction 1. 1 2. 2 3. 3 < > Function Power grip – “squeeze my fingers with your hands” Pincer grip – “place your thumb & index finger together & don’t let me separate them” Pick up small object – “can you pick up this small coin?” 107 Power grip Pincer grip 108  Dexterity 1. 1 2. 2 3. 3 < > To complete the examination Thank patient Wash hands Summarise findings Suggest further assessments & investigations Perform a full neurovascular examination of upper limbs Examine the elbow joint Perform Tinel’s test – tap over carpal tunnel to elicit tingling – median nerve compression. 109  geekymedics.com http://geekymedics.com/hearing-ear-examination-osce-guide/ Hearing / Ear examination – OSCE guide Lewis Potter Hearing / Ear examination frequently appears in OSCEs. You’ll be expected to pick up the relevant clinical signs using your examination skills. Technique is very important in this station, so ensure you’ve practiced how to hold and use an otoscope before your exam. This hearing / ear examination OSCE guide provides a clear concise, step by step approach to the station. Introduction Wash hands Introduce yourself Confirm patient details – name / DOB Explain examination “Today I’d like to examine your ears, this will involve me having a look inside your ears using a special piece of equipment known as an otoscope. In addition I’ll also be assessing your hearing using a number of different tests“ Gain consent “Does everything I’ve said make sense? “ “Are you happy for me to go ahead? “ Gross hearing assessment Ask the patient if they have noticed any change in their hearing recently. Explain that you’re going to say a word or number and you’d like them to repeat it back to you. 1. With your mouth approx 15cm from the ear, whisper a number or word 2. Mask the ear not being tested by rubbing the tragus 3. Ask the patient to repeat the number or word back to you 4. If the patient repeats the correct word or number, repeat the test at an arm’s length from the ear (normal hearing allows whispers to be perceived at 60cm) 110 5. Assess the other ear in the same way Weber’s test 1. Tap a 512HZ tuning fork & place in the midline of the forehead 2. Ask the patient “Where do you hear the sound?“ Normal = sound is heard equally in both ears Neural deafness = sound is heard louder on the side of the intact ear Conductive deafness = sound is heard louder on the side of the affected ear Rinne’s test 1. Tap a 512HZ tuning fork & place at the external auditory meatus & ask the patient if they are able to hear it (air conduction) 2. Now move the tuning fork (whilst still vibrating), placing its base onto the mastoid process (bone conduction) 3. Ask the patient if the sound is louder in front of the ear (EAM) or behind it (mastoid process) Normal = Air conduction > Bone conduction (Rinne’s positive) Neural deafness = Air conduction > Bone conduction (both air & bone conduction ↓ equally) Conductive deafness = Bone conduction > Air conduction (Rinne’s negative) Otoscopy Ask patient if they have any ear discomfort (if so, examine the non-painful side first). Pinnae Inspect the pinnae – note any deformity / ear piercings Inspect behind the pinnae – skin changes / erythema Ear canal / tympanic membrane Ensure the light is working on the otoscope & apply a sterile speculum (the largest that will comfortably fit in the external auditory meatus). 1. Pull the pinna upwards & backwards – to straighten the external auditory meatus 2. Position otoscope at the external auditory meatus: Otoscope should be held in your right hand for the patient’s right ear and vice versa 111  Hold the otoscope like a pencil and rest your hand against the patient’s cheek for stability 3. Advance the otoscope under direct vision 4. Look for any wax, swelling, erythema, discharge or foreign bodies 5. Examine the tympanic membrane: Colour – pearly grey & translucent (normal) / erythematous ( inflammation) Erythema or bulging of the membrane? – inspect for a fluid level e.g. otitis media Perforation of the membrane? – note the size of the perforation Light reflex present? – absence / distortion may indicate ↑ inner ear pressure e.g. otitis media Scarring of the membrane? – tympanosclerosis – can result in significant hearing loss 6. Withdraw the otoscope carefully 7. Discard the otoscope speculum into a clinical waste bin To complete the examination Thank patient Wash hands Summarise findings Suggest further assessments & investigations Cranial nerve examination Audiometry 112  geekymedics.com http://geekymedics.com/inhaler-technique-osce-guide/ Inhaler technique – OSCE guide Kitty Chu Inhaler technique is a frequently used topic in information giving OSCE scenarios. This guide demonstrates a structured approach to explaining inhaler technique in an OSCE setting. Introduction Introduce yourself Wash hands Confirm patient details – name / DOB Check patient’s understanding of their inhaler – allowing you to tailor your explanation to the patient’s level of knowledge. Explanation Explain what the inhaler device is… “You have been started on ….(name of inhaler)…for your asthma/COPD “ – Show the patient the inhaler device. Explain when the inhaler device should be used… Preventer (e.g. beclomethasone inhaler) “(Name of inhaler) is a preventer – it helps to reduce the swelling in the airways and stops them from being so sensitive. You use this to lower the risk of severe attacks. I would like you to inhale …(x puff(s))…(x time(s) a day)…everyday. It’s really important that you don’t miss doses, as regular use is key to keeping your asthma/COPD under control” – Remind the patient to rinse mouth after use if the inhaler contains a steroid due to risk of oral candidiasis. Reliever (e.g salbutamol inhaler) “(Name of inhaler) is a reliever. This is useful to help relieve immediate wheezing/asthma attacks. It works by relaxing 113 the airways so that you can breathe more easily. You shouldn’t need this more than 3 times a week if your asthma is well controlled. Ask your GP for a review if you are using this more frequently. I would like you to inhale (x puff(s)) when you feel short of breath.” If prescribing SMART (Symbicort Maintenance and Reliever Therapy) regime “Symbicort is used as both a preventer and a reliever. You need to use this regularly …(x puff(s))…twice a day to prevent symptoms and …(x puff(s))…each time you have an attack.” – Remind the patient to rinse mouth after use due to risk of oral candidiasis. Show patient the dose counter on the inhaler where applicable. Ask the patient to summarise the key points back to you, to demonstrate understanding. Demonstration Explain the steps below as you demonstrate 1. Prepare the inhaler – Take off the lid / Shake if MDI / Insert capsule if handihaler 2. Load the dose – press button to puncture capsule if handihaler/press lever once if accuhaler/twist bottom if turbohaler 3. Breathe out gently as far as is comfortable. 4. Tightly seal lips around the mouthpiece. 5. Breathe in: Dry powder inhalers (DPI) need to be breathed in quick and deep Metered dose inhalers (MDI) need to be breathed in slow and deep Soft mist inhalers (SMI) need to be breathed in slow and deep 6. Remove inhaler from mouth, hold breath for as long as is comfortable. 7. Repeat procedure as directed. Assess inhaler technique Ask the patient to carry out the procedure themselves whilst you observe. Most patients’ techniques will require tweaking. Point out the positives …“You are doing X&Y very well“… then introduce room for improvement …” but doing A&B may help your inhalers work more effectively for you“ DEMONSTRATE > OBSERVE > FINE TUNE > REPEAT AS NECESSARY Spacer devices Spacers are used to improve drug deposition to the lungs in patients who cannot master their aerosol inhaler technique. They are useful in reducing side effects of high dose inhaled corticosteroids by reducing the amount of drug deposited in the mouth. Commonly used spacers are Volumatic and AeroChamber. 1. Prepare inhaler (shake aerosol inhaler) 114 2. Attach inhaler mouthpiece to the spacer device 3. Breathe out gently as far as is comfortable 4. Seal lips around the spacer mouthpiece 5. Release 1 dose into the spacer device 6. Breathe in and out through the spacer mouthpiece several times 7. Administer second dose if needed and finish The spacer device should be washed with detergent (washing up liquid is fine) once a month and left to air-dry. It should never be wiped dry as this can cause static within the device and drug particles will stick to sides of the spacer as a result. Spacers should be replaced at least once a year. To close the consultation Ask if the patient has any questions or concerns. Provide information leaflet if available. Advise the patient to get in touch should they have any more questions or concerns. Thank patient. Wash hands. Commonly used inhalers 115  geekymedics.com http://geekymedics.com/knee-examination/ Knee examination – OSCE Guide Lewis Potter Knee examination frequently appears in OSCEs. You’ll be expected to pick up the relevant clinical signs using your examination skills. This knee examination OSCE guide provides a clear concise, step by step approach to examining the knee, with an included video demonstration. Introduction Wash hands Introduce yourself Confirm patient details – name / DOB Explain examination: “Today I need to examine your knee joint, this will involve looking, feeling and moving the joint.” Check understanding & gain consent: “Does everything I’ve said make sense? Are you happy for me to examine your knee joint?” Expose patient’s legs – ideally the patient should be wearing shorts Position the patient standing upright Ask if patient currently has any pain Look Inspect for mobility aids & adaptations – walking stick / wheelchair Gait Is the patient demonstrating a normal heel strike / toe off gait? Is each step of normal height? – increased stepping height is noted in foot drop Is the gait smooth and symmetrical? 116 Any obvious abnormalities? – antalgia / waddling / broad based Assess GAIT < > Inspect the knees Anteriorly Scars – previous surgery / trauma Swellings – effusions / inflammatory arthropathy / septic arthritis / gout Asymmetry / leg length discrepancy Valgus or varus deformity Quadriceps wasting – suggests chronic inflammation / reduced mobility Posteriorly Scars Asymmetry Popliteal swellings – Baker’s cyst / Popliteal aneurysm 117 Inspect Knee Joint Anteriorly Inspect Knee Joint Laterally 118  Inspect popliteal fossa (Baker's cysts / Popliteal artery aneurysm) 1. 1 2. 2 3. 3 < > Feel Ask the patient to lay on the bed. Assess temperature – ↑ temperature may suggest inflammation / infection Palpate the quadriceps tendon – whilst leg extended – synovitis Palpate the knee joint Palpate the following with the knee flexed at 90°: Patella – palpate the borders for tenderness / effusion Tibial tuberosity – tenderness may suggest Osgood Schlatter disease Head of the fibula – irregularities / tenderness Tibial & Femoral joint lines – irregularities / tenderness Collateral ligaments – both the medial and lateral Popliteal fossa – feel for any obvious collection of fluid (e.g. a Baker’s cyst) Measure quadriceps circumference & compare – 20cm above tibial tuberosity 119 Assess & compare knee joint temperature. Increased warmth may suggest septic arthritis or inflammatory arthritis. Palpate the borders of the patella. 120 Palpate the tibial tuberosity for tenderness. Palpate the head of the fibula. 121 Palpate the joint lines for tenderness or irregularities. Palpate the popliteal fossa for masses. 122  Measure & compare quadriceps circumference (20cm above the tibial tuberosity). Wasting may indicate local joint pathology. 1. 1 2. 2 3. 3 4. 4 5. 5 6. 6 7. 7 < > Patellar tap (can detect larger effusions) 1. Empty the suprapatellar pouch by sliding your left hand down the thigh to the patella. 2. Keep your left hand in position and use your right hand to press downwards on the patella with your fingertips. 3. If fluid is present you will feel a distinct tap as the patella bumps against the femur. 123  Feel for a patella tap (indicates a large joint effusion). < > Sweep test (useful for detecting small effusions) 1. Empty the suprapatellar pouch with one hand whilst also emptying the medial side of the joint using an upwards wiping motion. 2. Now release your hands and do a similar wiping motion downwards on the lateral side of the joint. 3. Watch for a bulge or ripple on the medial side of the joint. 4. The appearance of a bulge or ripple on the medial side of the joint suggests the presence of an effusion. 124 Empty the suprapatellar pouch and then sweep fluid from the medial side of the joint across to the lateral side of the joint. Sweep around the patella moving to the lateral side of the joint. 125  Sweep against the lateral side of the joint, whilst observing the medial side. If an effusion is present a bulge or ripple will occur on the medial side of the joint as fluid moves back across to that side. 1. 1 2. 2 3. 3 < > Move Active This involves the patient performing the movement. Ensure you observe for restricted range of movement and signs of discomfort. Knee flexion – normal ROM 0-140º – “Move your heel as close to your bottom as you can manage” Knee extension – “Straighten your leg out as best as you are able to.” Passive This involves the patient relaxing and allowing you to move the joint freely. It’s important to feel for crepitus as you move the joint and observe any restriction of movement. Knee flexion & extension Hyperextension – elevate both legs by the heels – note any hyperextension (10 degrees). 1. 1 2. 2 3. 3 4. 4 5. 5 < > Special tests Anterior/Posterior drawer test 1. Flex the patient’s knee to 90º. 2. Inspect for evidence of posterior sag as this can give a false positive anterior drawer sign. 3. Wrap your hands around the proximal tibia with your fingers around the back of the knee. 4. Rest your forearm down the patient’s lower leg to fix its position. 5. Position your thumbs over the tibial tuberosity. 6. Ask the patient to keep their legs as relaxed as possible (tense hamstrings can mask pathology). 7. Pull the tibia anteriorly – significant movement suggests anterior cruciate laxity /rupture 8. Push the tibia posteriorly – significant movement suggests posterior cruciate laxity /rupture With healthy cruciate ligaments there should be little or no movement noted. 129  Anterior drawer test. Posterior drawer test. 1. 1 2. 2 < > Collateral ligaments Lateral collateral ligament (LCL) 1. Extend the patient’s knee fully. 2. Hold the patient’s ankle between your elbow and side. 130 3. Place your right hand along the medial aspect of the knee. 4. Place your left hand on the lower limb (e.g. calf or ankle). 5. Push steadily outward with your right hand whilst supplying an opposite force with the left. 6. If the LCL is damaged your hand should detect the lateral aspect of the joint opening up. Medial collateral ligament (MCL) 1. Extend the patient’s knee fully. 2. Hold the patient’s ankle between your elbow and side. 3. Place your right hand along the lateral aspect of the knee. 4. Place your left hand on the lower limb (e.g. calf or ankle). 5. Push steadily inward with your right hand whilst supplying an opposite force with the left. 6. If the MCL is damaged your hand should detect the medial aspect of the joint opening up. If after this assessment the knee appears stable you can further assess the collateral ligaments by repeating this test with the knee flexed at 30°. At this position the cruciate ligament are not taught so minor collateral ligament laxity can be more easily detected. With healthy collateral ligaments there should be no abduction or adduction possible. If abduction/adduction is possible, it suggests laxity / rupture of the corresponding collateral ligament. Assess medial collateral ligament with leg fully extended. 131 Assess lateral collateral ligament with leg fully extended. If the medial collateral ligament (MCL) appeared stable with the leg fully extended, you can assess MCL again with the leg flexed at 30 degrees. This loosens the ACL & PCL to allow more subtle collateral ligament laxity to be detected. 132  If the lateral collateral ligament (LCL) appeared stable with the leg fully extended, you can assess the LCL again with the leg flexed at 30 degrees. This loosens the ACL & PCL to allow more subtle collateral ligament laxity to be detected. 1. 1 2. 2 3. 3 4. 4 < > To complete the examination Thank the patient Wash your hands Summarise your findings Suggest further assessments & investigations Neurovascular examination of both lower limbs. Examination of the joint above and below – ankle & hip Further imaging if indicated – X-ray / MRI 133  geekymedics.com http://geekymedics.com/peak-expiratory-flow-rate-pefr/ Peak expiratory flow rate (PEFR) measurement Lewis Potter Peak expiratory flow rate (PEFR) measurement often appears in OSCEs and involves a combination of both information giving (explaining the procedure) and the practical clinical skill of performing PEFR measurement. The communication skills aspect of this station is where most of the marks lie, so ensure you provide a clear explanation of the procedure to the patient, checking understanding and summarising as you go along. Introduction Wash hands Introduce yourself – state your name & role Confirm patient details – name & DOB Explain the purpose of the procedure: “I’d like to assess your breathing” “This involves measuring how well the air can flow out of the lungs” “It’s an important test, as it gives an indication of how well your asthma is controlled” Gain consent – “Do you understand everything I’ve said?” “Are you happy to go ahead with this?” Measuring PEFR Ensure you clearly explain & demonstrate each step of the procedure below to the patient. 1. Ensure the PEFR meter is set to zero 2. Sit up straight or stand 3. Take a deep breath (as deep as you can possibly manage) 134 4. Place your mouth around the mouthpiece of the PEFR meter, ensuring a tight seal with your lips 5. Exhale as forcefully as you possibly can manage 6. Note the PEFR reading 7. Repeat this process a further 2 times 8. The highest reading of the 3 should be taken as the overall result Insert mouthpiece Explain correct technique 135 Set dial to zero Demonstrate technique 136 Observe patients technique 137  Record reading & repeat twice more. 1. 1 2. 2 3. 3 4. 4 5. 5 6. 6 7. 7 < > To complete the procedure… Observe patient performing PEFR measurement to ensure good technique. Ask if the patient has any questions regarding PEFR management. Thank patient Wash hands 138  geekymedics.com http://geekymedics.com/respiratory-examination-2/ Respiratory examination – OSCE Guide Lewis Potter Respiratory examination frequently appears in OSCEs. You’ll be expected to pick up the relevant clinical signs using your examination skills. This respiratory examination OSCE guide provides a clear concise, step by step approach to examining the respiratory system, with an included video demonstration. Introduction Wash hands Introduce yourself Confirm patient details – name / DOB Explain the examination Gain consent Expose the patient’s chest Position patient at 45° Ask if the patient has any pain General inspection Treatments or adjuncts around bed – O2 / inhalers /nebulisers /sputum pots Does patient look SOB? – nasal flaring / pursed lips / use of accessory muscles Able to speak in full sentences? Scars – mid axillary (e.g. chest drains) / posterior chest (e.g. lobectomy) Cyanosis – bluish/purple discolouration – ( Hands Temperature – ↓ temp – peripheral vasoconstriction / poor perfusion Tar staining – smoker – increased risk of COPD / lung cancer Peripheral cyanosis – bluish discolouration of nails – O2 saturations Head & Neck 143 Conjunctival pallor – ask patient to lower an eyelid to allow inspection – anaemia Horner’s syndrome – ptosis / constricted pupil (miosis) /anhidrosis on affected side / enophthalmos Central cyanosis – bluish discolouration of the lips / inferior aspect of tongue Jugular Venous Pressure – a raised JVP may indicate pulmonary hypertension / fluid overload Ensure the patient is positioned at 45° Ask patient to turn their head away from you Observe the neck for the JVP – located inline with the sternocleidomastoid Measure the JVP – number of cm from sternal angle to the upper border of pulsation Inspect for central cyanosis Inspect conjunctiva 144  Observe for a raised JVP 1. 1 2. 2 3. 3 < > Close inspection of thorax Scars – mid axillary (e.g. chest drains) / posterior chest (e.g. lobectomy) Skin changes – may indicate recent or previous radiotherapy – erythema / thickened skin Asymmetry – major surgery – e.g. pneumonectomy / thoracoplasty Deformities – barrel chest (COPD) / pectus excavatum & carinatum 145  Inspect chest wall Inspect for scars 1. 1 2. 2 < > Palpation Tracheal position: Ensure patient’s neck musculature is relaxed – chin slightly downwards Dip index finger into the thorax beside the trachea 146  Then gently apply side pressure to locate the trachea Compare this space to the other side of trachea using the same process A difference in the amount of space between the sides suggests deviation Palpation of the trachea can be uncomfortable, so ensure to warn the patient and have a gentle technique Cricosternal distance: Measure the distance between the suprasternal notch & cricoid cartilage using your fingers In normal healthy individuals the distance should be 3-4 fingers If the distance is Percussion 149 Technique is very important! 1. Place your non-dominant hand on the chest wall 2. Your middle finger should overlie the area you want to percuss ( between ribs) 3. With your dominant hand’s middle finger, strike middle phalanx of your non-dominant hand’s middle finger 4. The striking finger should be removed quickly, otherwise you may muffle resulting percussion note Percuss the following areas, comparing side to side: Supraclavicular – lung apices Infraclavicular Chest wall Axilla Types of percussion note Resonant – this is a normal finding Dullness – this suggests increased tissue density – consolidation / fluid / tumour / collapse Stony dullness – this suggests the presence of a pleural effusion Hyper-resonance – the opposite of dullness, suggestive of decreased tissue density – e.g. pneumothorax Supraclavicular percussion 150  Percussion 1. 1 2. 2 < > Auscultation Ask patient to take deep breaths in and out through their mouth. Assess quality – Vesicular (normal) / Bronchial (harsh sounding) – consolidation Assess volume – quiet breath sounds suggest reduced air entry – consolidation / collapse / fluid Added sounds: Wheeze – asthma / COPD Coarse crackles – pneumonia / fluid Fine crackles – pulmonary fibrosis Vocal resonance: Ask patient to say “99” repeatedly & auscultate the chest again Increased volume over an area suggests increased tissue density – consolidation/fluid/tumour 151  Auscultate the chest Assess vocal resonance 1. 1 2. 2 < > Ask patient to sit forwards Lymph nodes Palpate the anterior & posterior triangles, supraclavicular and axillary nodes. 152 Lymphadenopathy may indicate infective/malignant pathology – TB / Lung ca Palpate lymph nodes < > Assess the posterior chest Repeat inspection, chest expansion, percussion & auscultation on the back of the chest. Posterior chest expansion 153 Posterior chest percussion Posterior auscultation of the chest 154  Posterior assessment of vocal resonance 1. 1 2. 2 3. 3 4. 4 < > To complete the examination… Thank patient Wash hands Summarise findings Suggest further assessments & investigations Check oxygen saturations Provide supplementary oxygen if indicated Perform peak flow assessment (if asthmatic) Request a CXR – if abnormalities were noted on examination Take an arterial blood gas if indicated Perform a full cardiovascular examination if indicated 155  geekymedics.com http://geekymedics.com/shoulder-examination/ Shoulder examination – OSCE Guide Lewis Potter Shoulder examination frequently appears in OSCEs. You’ll be expected to pick up the relevant clinical signs using your examination skills. This shoulder examination OSCE guide provides a clear and concise step by step approach to examining the shoulder, with an included video demonstration. Introduction Wash hands Introduce yourself Confirm patient details – name / DOB Explain examination: “Today I need to examine your shoulder joint, this will involve looking, feeling and moving the joint.” Check understanding & gain consent: “Does everything I’ve said make sense? Are you happy for me to examine your shoulder joint?” Expose patient’s upper body appropriately Position the patient standing Ask if the patient currently has any pain Look Look around bed for aids & adaptations – e.g. a sling Inspect the patient Anterior Scars – previous surgery / trauma Asymmetry of the shoulder girdle – scoliosis / arthritis / trauma Swelling – inflammatory joint disease / effusion Muscle wasting – deltoids – axillary nerve injury / chronic joint disease 156 Lateral Scars – previous surgery / trauma Muscle wasting – deltoid Alignment of shoulder girdle – misalignment – dislocation / scoliosis Posterior Scars – previous surgery / trauma Trapezius – assess symmetry / wasting Para-vertebral muscles – note any swelling / wasting Scapula – assess symmetry – e.g. winged scapula (long thoracic nerve injury) Inspect the patient from the front. Inspect the patient from the side. 157  Inspect the patient from the back. 1. 1 2. 2 3. 3 < > Feel Assess temperature of shoulder joints – warmth may suggest inflammatory arthropathy/infection Palpate the various components of the shoulder girdle (note any swelling / tenderness) Sterno-clavicular joint Clavicle Acromio-clavicular joint Coracoid process – 2cm inferior & medial to the clavicular tip Head of humerus Greater tuberosity of humerus Spine of scapula 158 Assess & compare joint temperature. Palpate the sterno-clavicular joint. 159 Palpate the clavicle. Palpate the acromio-clavicular joint. 160 Palpate the coracoid process. Palpate the humerus. 161  Palpate the spine of the scapula. Palpate the borders of the scapula. 1. 1 2. 2 3. 3 4. 4 5. 5 6. 6 7. 7 8. 8 < > 162 Move Active movement Ask the patient to perform each of the following movements. Compound movements (screening) Compound movements are often used as a rapid screening tool for shoulder joint pathology as they test a number of the rotator cuff muscles in one go. If the patient experiences pain or is unable to perform these movements you would then proceed to perform a more detailed examination of the shoulder joint as shown in the “Full shoulder examination” section below. Put your hands behind your head – external rotation + abduction Put your hands as far up your back as your can – internal rotation + adduction Internal rotation & Adduction. 163  External rotation & Abduction. 1. 1 2. 2 < > Full shoulder examination Flexion – ask the patient to raise their arms forwards until they points upwards – 150°-170° Extension – ask patient to keep their arms straight and extend them behind them – 40° Abduction – ask the patient to lift their arms away from their sides as far as possible – 160°-180° Adduction – ask the patient to bring their arms across their trunk to the opposite sides – 30°-40° External rotation – ask patient to hold their elbows to their body flexed at 90° and then move their forearms outwards in an arc-like motion – 70° Internal rotation – with the patient’s elbow flexed at 90° (arm by their side) ask them to place their hand behind their back and reach as far up the spine as they can manage – Average = T5 Assess the movement of the Scapula: Ask the patient to abduct their shoulder Simultaneously palpate the inferior pole of the scapula Assess the degree and smoothness of movement of the scapula Normally 50-70% of movement occurs at the glenohumeral joint If the glenohumeral joints movement is reduced due to injury / inflammation then the majority of abduction will occur via increased scapula movement over the chest wall. 164 Active shoulder flexion. Active shoulder extension. 165 Active shoulder abduction. Active shoulder adduction. 166 Active shoulder external rotation. Active shoulder internal rotation. 167  Assess movement of scapula during abduction (degree of movement & smoothness of motion) 1. 1 2. 2 3. 3 4. 4 5. 5 6. 6 7. 7 < > Passive movement Ask the patient to fully relax and allow you to move their arm for them. Warn them that should they experience any pain to let you know immediately. Repeat the above movements passively – feel for any crepitus during movement of the joint 168 Passive shoulder flexion. Passive shoulder extension. 169 Passive shoulder abduction. Passive shoulder adduction. 170  Passive internal rotation of the shoulder. Passive external rotation of the shoulder. 1. 1 2. 2 3. 3 4. 4 5. 5 6. 6 < > Special tests 171 Supraspinatus assessment This clinical test assesses the function of supraspinatus. 1. Ask the patient to abduct their shoulder from the neutral position against resistance. 2. Loss of power suggests a supraspinatus tear. Pain in early abduction suggests tendonitis. Assess Supraspinatus - early abduction against resistance < > The Painful Arc (Impingement syndrome) This clinical test assesses for impingement of supraspinatus. 1. Passively abduct the patient’s arm to its maximum point of abduction. 2. Ask the patient to lower their arm slowly back to a neutral position. 3. Impingement / supraspinatus tendonitis typically causes pain between 60-120° of abduction. 172  Passively abduct the patient's arm. Ask them to slowly lower their arm. Pain felt between 60-120 degrees of abduction suggests impingement. 1. 1 2. 2 < > External rotation against resistance This clinical test assesses the function of infraspinatus & teres minor. 173 1. Position the patient’s arm with the elbow flexed at 90° and the shoulder flexed at 30° (reducing contribution of deltoid). 2. Ask the patient to externally rotate their shoulder whilst you apply light resistance. Pain on resisted external rotation suggests infraspinatus / teres minor tendonitis. Loss of power suggests a torn infraspinatus / teres minor ligament. External rotation against resistance. < > Internal rotation against resistance (“Gerber lift off test”) This clinical test assesses the function of the subscapularis muscle. 1. Ask the patient to place the dorsum of their hand on their lower back. 2. Apply light resistance to the hand ( pressing it towards their back). 3. Ask the patient to move their hand off their back. 4. An inability to do this ( loss of power) indicates damage to subscapularis (e.g. ligamentous tear). 174  Internal rotation against resistance (Gerber's "Lift off" test). < > To complete the examination Thank patient Wash hands Summarise findings Suggest further assessments & investigations Full neurovascular examination of the upper limbs Examine the spine and elbow joint (joint above & below) Perform further imaging if indicated – e.g. X-ray / MRI 175  geekymedics.com http://geekymedics.com/spine-examination/ Spine examination – OSCE Guide Lewis Potter Spine examination frequently appears in OSCEs. You’ll be expected to pick up the relevant clinical signs using your examination skills. This spine examination OSCE guide provides a clear concise, step by step approach to examining the spine, with an included video demonstration. Introduction Wash hands Introduce yourself Confirm patient details – name / DOB Explain examination Gain consent Expose patient’s upper body Position patient standing Ask if the patient currently has any pain Look Look for aids & adaptations – walking stick / wheelchair Inspect patient from all angles Front Posture of head and neck – symmetry / abnormal position Symmetry of shoulders – note any misalignment Side Cervical lordosis – assess for hyper-lordosis – spondylolisthesis / osteoporosis / discitis Thoracic kyphosis – normal is 20-45º – hyperkyphosis (>45º) – vertebral # 176 Lumbar lordosis – assess for hyperlordosis – obesity / tight lower back muscles Behind Scars – can provide clues as to previous surgery / trauma Wasting – paraspinal muscles / back muscles – may suggest chronic immobility Scoliosis – lateral curvature of the spine – resembles an “S” shape Abnormal hair growth – spina bifida Inspect from the front. Inspect the curvature of the cervical spine. 177 Inspect the curvature of the thoracic spine. Inspect the curvature of the lumbar spine. 178  Inspect the spine posteriorly for evidence of scoliosis. 1. 1 2. 2 3. 3 4. 4 5. 5 < > Feel Palpate spinal processes & sacroiliac joints – assess for tenderness & alignment Palpate paraspinal muscles – note any tenderness or muscle spasms Observe the patient’s face as you perform the above, looking for signs of pain. 179 Palpate the spinal processes to assess alignment and detect any tenderness. Palpate the spinal processes to assess alignment and detect any tenderness. 180 Palpate the spinal processes to assess alignment and detect any tenderness. Palpate the sacroiliac joints for tenderness. 181  Palpate the paraspinal muscles for evidence of spasm or tenderness. 1. 1 2. 2 3. 3 4. 4 5. 5 < > Move Cervical spine Assess active movements: Flexion – “touch your chin to your chest” – normal ROM 0-80º Extension – “look up at the ceiling” – normal ROM 0-50º Lateral flexion – “touch your ear to your shoulder” – normal ROM 0-45º Rotation – “turn your head to the left & then to the right” – normal ROM 0-80º Perform passive movements if reduced ROM on active movement. Assess if pain/stiffness/muscle spasm is the restricting factor. 182 Assess Cervical flexion. Assess Cervical extension. 183  Assess Cervical rotation. Assess Lateral Flexion of the Cervical Spine. 1. 1 2. 2 3. 3 4. 4 < >.. Lumbar spine 184 Assess active movements: Flexion – “touch your toes, keeping your legs straight” Extension -“lean backwards as far as possible” – normal ROM 10-20 º Lateral flexion – “slide your left hand down the outer aspect of your left leg as far as possible, keeping your legs straight” – repeat the test using the right hand/leg Assess Lumbar Flexion. Assess Lumbar Extension. 185  Assess Lateral Lumbar Flexion. 1. 1 2. 2 3. 3 < >. Thoracic spine Rotation– sit the patient down, with arms crossed across chest & ask to turn side to side 186  Assess Thoracic Rotation. < > Special tests Schober’s test – tests the range of motion in lumbar spine 1. Identify position of the posterior superior iliac spine (PSIS) – “dimples of Venus” 2. Mark the skin in the midline 5cm below PSIS 3. Mark the skin in the midline 10cm above PSIS 4. Ask the patient to touch their toes – full lumbar flexion 5. Measure the distance between the two lines (started at 15cm) Normally the distance between the two marks should increase to >20cm. Reduced range of motion can indicate conditions such as ankylosing spondylitis. 187 Mark the midline at the level of the posterior superior iliac spines. Draw 2 further marks, 10cm above and 5cm below. 188  Ask patient to keep their legs straight and touch their toes. Measure the distance between the most superior and inferior marks. It should normally increase from 15cm to more than 20cm. 1. 1 2. 2 3. 3 4. 4 < >.. Sciatic stretch test – (Straight leg raise) 189 1. Position the patient supine on the bed. 2. Holding the ankle, raise the leg (passively flexing the hip) – keeping the knee straight 3. Normal ROM is approximately 80-90º of passive hip flexion. 4. Once the hip is flexed as far as the patient is able, dorsiflex the foot. 5. The test is positive if the patient experiences pain in the posterior thigh / buttock. If this causes pain in lower back /thigh/ buttocks, it suggests sciatic nerve root impingement. Raise the straight leg upwards as far is the patient is able to. Passively dorsiflex the foot. Pain in the posterior thigh / buttock would be considered a positive test result. 1. 1 2. 2 190  < >.. Femoral nerve stretch test 1. Position patient prone 2. Flex knee 3. Extend hip 4. Plantar-flex foot Positive test = pain felt in thigh/ inguinal region. With the patient prone elevate the thigh with the knee flexed. Pain in the anterior thigh / inguinal region is considered a positive test. < > To complete the examination Thank patient Wash hands Summarise findings. Suggest further assessments & investigations Full neurovascular examination of all 4 limbs Perform further imaging if indicated – X-ray / MRI / CT.. 191 192  geekymedics.com http://geekymedics.com/thyroid-status-examination/ Thyroid status examination – OSCE Guide Lewis Potter Thyroid status examination frequently appears in OSCEs. You’ll be expected to pick up the relevant clinical signs using your examination skills. This thyroid status examination OSCE guide provides a clear concise, step by step approach to examining thyroid status. Introduction Wash hands Introduce yourself Confirm patient details – name / DOB Explain the examination Gain consent Position the patient – sitting on a chair Gather equipment Stethoscope Glass of water Tendon hammer Piece of paper Inspection Behaviour Does the patient appear hyperactive? – agitation / anxiety / fidgety (hyperthyroidism) 193  General inspection < > Hands Inspect the patients hands for… Dry skin (hypothyroid) Increased sweating (hyperthyroid) Thyroid acropachy – phalangeal bone overgrowth – Graves’ disease Palmar erythema – reddening of the palms at the thenar / hypothenar eminences – hyperthyroidism Peripheral tremor 1. Ask the patient to place their arms straight out in front of them 2. Place a piece of paper across the backs of their hands 3. Observe for a tremor (the paper will quiver) Peripheral tremor can be a sign of hyperthyroidism. 194 Inspect hands Inspect palms 195  Inspect for peripheral tremor 1. 1 2. 2 3. 3 < > Pulse Assess the radial pulse for… Rate: Tachycardia (hyperthyroidism) Bradycardia (hypothyroidism) Rhythm – irregular (AF) – thyrotoxicosis 196  Assess pulse < > Face Inspect the face for… Dry skin – hypothyroidism Sweating – hyperthyroidism Eyebrows– loss of the outer third – hypothyroidism (rare) 197  Inspect face < >. Eyes Exophthalmos (anterior displacement of the eye out of the orbit) Inspect from the front, side and above Note if the sclera is visible above the iris (lid retraction) – seen in Graves’ disease