Clinical phase OSCE Flashcards
Cardiovascular Examination
Wash hands and don PPE as appropriate
Introduce self
Confirm patient’s details
Explain examination and obtain patient consent
Offer chaperone as appropriate, expose patient and position bed to 45 degrees
Check patient comfort/pain
General Inspection
Inspect the environment and equipment around patient (oxygen device, ECG leads, GTN spray)
Inspect patient for signs of pathology (chest pain, work of breathing, pallor, oedema)
Hands/Arms
Inspect hands (osler’s nodes, Janeway lesions, splinter haemorrhages, tar staining, capillary refill time, clubbing, pale palmar creases, tendon xanthomata)
Assess radial pulse (rate, rhythm, character)
Assess for radio-radial delay
Offer to perform radio-femoral delay
Assess for collapsing pulse
Ask for blood pressure
Face
Inspect face (corneal arcus, xanthelasma)
Inspect eyes (pallor)
Inspect mouth (dentition, redness, mucous membranes)
Neck
Assess jugular venous pressure
Auscultate for carotid bruits
Palpate carotid pulse
Chest
Inspect chest (deformity, scars, pacemakers/implantable cardiac defibrillators)
Palpate for apex beat
Palpate for heaves and thrills
Auscultate over mitral area with bell with patient in left lateral lie (mitral stenosis)
Auscultate over mitral area with diaphragm radiation into axilla (mitral regurgitation)
Ausculate over tricuspid area and pulmonary area
Auscultate over Aortic area with diaphragm radiation to carotids(aortic stenosis)
Sit patient forward, deep expiration, auscultate over 3rd ICS left sternal edge (Erb’s point) with diaphragm (aortic regurgitation)
Back
Inspect back
Auscultate lung bases
Palpate for sacral oedema
Legs
Inspect legs for scars (saphenous vein harvest for CABG)
Assess for peripheral oedema
Completing the Examination
Thank patient
Ensure patient comfortable and redressed
Dispose PPE and wash hands
Summarise findings to examiner
Suggest further assessment (history, peripheral vascular examination, ECG, urine dip, funduscopy, bloods, imaging e.g. ECHO)
Respiratory Examination
Wash hands and don PPE as appropriate
Introduce self
Confirm patients details
Explain examination and obtain patient consent
Offer chaperone as appropriate, expose patient and position bed to 45 degrees
Check patient comfort/pain
General Inspection
Inspect the environment and equipment around patient (oxygen device, sputum pot, nebulizers, inhalers, medications, walking aids)
Inspect patient for signs of pathology (work of breathing, cyanosis, pallor, cough, wheeze, stridor, cachexia, oedema)
Hands/Arms
Inspect hands (cyanosis, tar staining, clubbing, small muscle wasting, joint deformities…)
Assess for fine tremor and asterixis
Assess radial pulse (rate, rhythm, character), respiratory rate and blood pressure
Face
Inspect face (plethora, swelling)
Inspect eyes (pallor, ptosis, miosis)
Inspect mouth (central cyanosis, redness, mucous membranes)
Neck
Assess jugular venous pressure
Palpate trachea position
Lymph Nodes
Palpate for cervical lymph nodes
Anterior Chest
Inspect chest (deformity, scars, breathing pattern)
Palpate for apex beat and right ventricular heave
Assess chest expansion (upper zone for AP expansion and lower zone for lateral expansion)
Percuss chest (lung apices, upper, middle, lower zones, axilla)
Auscultate chest (lung apices, upper, middle, lower zones, axilla)
Assess either vocal resonance or tactile fremitus (especially if area of dullness elicited)
Posterior Chest
Inspect chest (deformity, scars, breathing pattern)
Assess chest expansion (lower zone for lateral expansion)
Percuss chest (upper, middle, lower zones)
Auscultate chest (upper, middle, lower zones)
Assess either vocal resonance or tactile fremitus (especially if area of dullness elicited)
Palpate for sacral oedema
Legs
Inspect for skin changes (e.g. erythema nodosum) and signs of DVT
Palpate calves (tenderness, peripheral oedema)
Completing the Examination
Thank patient
Ensure patient comfortable and redressed
Dispose PPE and wash hands
Summarise findings to examiner
Suggest further assessment (history, cardiac examination, obs, peak flow, bloods, imaging)
Abdominal Examination
General Inspection
Inspect the environment and equipment around patient (vomit bowls, feeding tube, stoma bags)
Inspect patient for signs of pathology (nutritional status, alertness)
Hands/Arms
Inspect hands (koilonychia, leukonychia, clubbing, dupuytren’s contracture, palmar erythema)
Assess for asterixis
Assess radial pulse (rhythm, character)
Face
Inspect face (plethora)
Inspect eyes (pallor, jaundice, corneal arcus, Kayser-Fleischer rings)
Inspect mouth (aphthous ulcers, candidiasis, angular stomatitis)
Neck
Assess jugular venous pressure
Lymph Nodes
Palpate for cervical lymph nodes with close attention to left supraclavicular lymph node
Inspect back and then reposition patient to lie flat
Chest
Inspect chest (spider naevi, gynaecomastia)
Abdomen
Inspect abdomen (distension, mass, scars, striae, visible peristalsis)
Light palpation of 9 areas of abdomen (tenderness, guarding)
Deep palpation of 9 areas of abdomen (masses)
Palpate and percuss for liver
Palpate and percuss for spleen
Palpate for kidneys
Palpate for abdominal aorta
Perform shifting dullness test
Auscultate for bowel sounds
Lower Limbs
Inspect for skin changes (e.g. erythema nodosum)
Palpate calves (tenderness)
Completing the Examination
Thank patient
Ensure patient comfortable and redressed
Dispose PPE and wash hands
Summarise findings to examiner
Suggest further assessment (history, examine hernial orifices and external genitalia, urine dipstick, consider digital rectal examination, bloods, imaging)
Cranial Nerve Examination
General Inspection
Inspect the environment and equipment around patient (mobility aids, feeding tubes)
Inspect patient for signs of pathology (facial asymmetry, muscle wasting, scars, ptosis, anisocoria, squint/strabismus)
Cranial Nerve I (Olfactory Nerve)
Check for any change in sense of smell
Cranial Nerve II (Optic Nerve)
Inspect pupil size and shape
Acuity: Check visual acuity
Offer to test colour vision (Ishihara plates)
Fields: Test visual fields
Check for visual inattention (neglect)
Reflexes: Pupil and pupillary light reflexes (swinging light test for RAPD)
Accommodation Reflex
Ophthalmoscopy: Offer to perform
Cranial Nerve III, IV, VI (Occulomotor, Trochlear and Abducens Nerves)
Inspect for ptosis (complete – oculomotor, partial – Horner’s syndrome)
Check for gaze palsy using ‘H test’ including sustained vertical gaze
Cranial Nerve V (Trigeminal Nerve)
Test light touch sensation over the three divisions of the trigeminal nerve (V1, V2, ¬V3)
Test pin-prick sensation over the three divisions of the trigeminal nerve (V1, V2, ¬V3)
Check muscle bulk of muscles of mastication
Offer to perform corneal reflex (V1) and jaw jerk (V3)
Cranial Nerve VII (Facial Nerve)
Assess muscles of facial expression (frontalis, orbicularis oculi, orbicularis oris, buccinator)
Check for any change in taste (anterior two-thirds of the tongue)
Cranial Nerve VIII (Vestibulocochlear Nerve)
Perform ‘whisper test’ to assess hearing
Offer to perform Weber’s and Rinne’s tests
Cranial Nerve IX, X (Glossopharyngeal and Vagus Nerves)
Check for any change in taste (posterior third of tongue)
Assess for palatal symmetry and uvula deviation
Ask patient to cough
Offer to assess patient swallow and speech assessment
Offer to test gag reflex
CN XI (Accessory Nerve)
Ask patient to turn head against resistance (sternocleidomastoid)
Ask patient to shrug shoulders against resistance (trapezius)
CN XII (Hypoglossal Nerve)
Inspect tongue (muscle wasting, fasciculations, scars) and check for deviation
Assess power of tongue
Completing the Examination
Thank patient
Ensure patient comfortable
Dispose PPE and wash hands
Summarise findings to examiner
Suggest further assessment (history, perform peripheral neurological examination (upper and lower limbs) including gait assessment, bloods, imaging and any special tests e.g. lumbar puncture, nerve conduction studies)
Peripheral Neurological (Upper Limb) Examination
General Inspection
Inspect the environment and equipment around patient (mobility aids)
Inspect patient for signs of pathology ((SWIFT-P) – Scars, Wasting, Involuntary movements, Fasciculations, Tremors, Postural instability)
Tone
Check tone at shoulder, elbow and wrist joints
Test for pronator drift
Power
Test power in following areas:
* Shoulder adduction and abduction
* Elbow flexion and extension
* Wrist flexion and extension
* Finger extension
* Thumb abduction
Reflexes
Test reflexes in following areas:
* Biceps brachii reflex (C5, C6)
* Brachioradialis (Supinator) reflex (C5, C6)
* Triceps reflex (C6, C7)
Coordination
Perform finger-to-nose test
Perform alternating-hand test
Sensation
Test light touch sensation in a dermatomal distribution (C5-T1)
Test pin-prick sensation in a dermatomal distribution (C5-T1)
Test vibrioception over distal bony prominence (e.g. interphalangeal joint of thumb)
Test proprioception of distal joint (e.g. interphalangeal joint of thumb)
Completing the Examination
Thank patient
Ensure patient comfortable and redressed
Dispose PPE and wash hands
Summarise findings to examiner
Suggest further assessment (history, perform peripheral neurological (lower limbs) including gait assessment and cranial nerve exam, bloods, imaging and any special tests, e.g. lumbar puncture, nerve conduction studies)
Peripheral Neurological (Lower Limbs) Examination
General Inspection
Inspect the environment and equipment around patient (mobility aids, orthoses)
Inspect patient for signs of pathology ((SWIFT-P) – Scars, Wasting, Involuntary movements, Fasciculations, Tremors, Postural instability)
Gait
Perform Romberg’s test
Assess gait, tandem gait, tip-toe gait
Tone
Check tone at hip (leg roll), knee (lifting lower leg) and ankle joints
Test for clonus
Power
Test power in following areas:
* Hip flexion and extension
* Knee extension and flexion
* Dorsiflexion and plantarflexion of ankle
* Extension of hallux
Reflexes
Test reflexes in following areas:
* Patellar reflex (L2, L3, L4)
* Achilles reflex (S1, S2)
* Plantar reflex (Babinski sign) (S1)
Coordination
Perform heel-to-shin test
Sensation
Test light touch sensation in a dermatomal distribution (L2-S1)
Test pin-prick sensation in a dermatomal distribution (L2-S1)
Test vibrioception over distal bony prominence (e.g. interphalangeal joint of hallux)
Test proprioception of distal joint (e.g. interphalangeal joint of hallux)
Ensure patient comfortable and redressed
Summarise findings to examiner
Suggest further assessment (history, perform peripheral neurological (upper limbs) and cranial nerve exam, bloods, imaging and any special tests, e.g. lumbar puncture, nerve conduction studies)
Thyroid Examination
General Inspection
Inspect the environment and equipment around patient (medications, extra clothes, mobility aids)
Inspect patient for signs of pathology (body habitus, dressed appropriately for weather, sweating or shivering, anxious or settled)
Hands/Arms
Inspect hands (thyroid acropachy and onycholysis (Grave’s); palmar erythema (hyperthyroid), dry skin (hypothyroid), temperature, capillary refill time)
Assess radial pulse (rate, rhythm, character)
Assess for fine tremor, ideally with piece of paper (hyperthyroid)
Face
Inspect face (coarse facies, thinning of hair, loss of outer thirds of eyebrows (hypothyroid), flushed)
Inspect eyes from in front, sides and from behind for exophthalmos (Grave’s)
Check for oedema around eyes (chemosis) and lid retraction (Grave’s)
Check for gaze palsy using ‘H test’ (ophthalmoplegia in Grave’s)
Test for lid lag (Grave’s)
Neck
Inspect the neck for swelling (e.g. goitre) and scars
Ask patient to swallow (if safe to do so) and inspect neck (thyroid and thyroglossal cysts move with swallowing)
Ask patient to protrude tongue (thyroglossal cyst will move)
Palpate for tracheal deviation
Palpate thyroid gland including while patient swallows and protrudes tongue
Assess for cervical lymphadenopathy
Percuss over sternum for retrosternal goitre
Auscultate for thyroid bruits
Others
Assess reflexes
Assess for pre-tibial myxoedema (Grave’s)
Assess for proximal myopathy (pt to stand from seated with arms crossed)
Completing the Examination
Thank patient
Ensure patient comfortable and redressed
Dispose PPE and wash hands
Summarise findings to examiner
Suggest further assessment (history, cardiovascular examination, BP, ECG, bloods, imaging e.g. Thyroid US)
Breast examination
Explain the need for a chaperone and gain consent to proceed with the examination
Position the patient sitting upright on the side of the bed
Ask if the patient has any pain before proceeding
Comment on Scars, asymmetry, masses, nipple abnormalities, skin changes,
Inspect the breasts with the patient’s arms by their sides
Inspect the breasts with the patient’s hands on their hips for tethering to pec major
Inspect the breasts with the patient’s arms above their head whilst leaning forward
Palpate each breast systematically
Palpate each axillary tail
Palpate the nipple-areolar complex checking for discharge
Palpate the axillary lymph nodes
Palpate the cervical, supraclavicular, infraclavicular and parasternal lymph nodes
Suggest further assessments and investigations (e.g. biopsy, mammography, ultrasound)
Testicular examination
Confirm the patient’s name and date of birth
Explain the need for a chaperone
Ask the patient if they have any pain before proceeding with the clinical examination
Inspect the patient’s penis, groin and abdomen for relevant clinical signs
Inspect the scrotum and perineum for relevant clinical signs
(Skin changes, scars, masses, swelling, bruising, necrotic tissue)
Examine the penis (foreskin, glans, urethral meatus)
Palpate each testicle and assess any scrotal masses
Palpate the epididymis
Palpate the spermatic cord
Perform Prehn’s test
Assess the cremasteric reflex
Assessment of the scrotum whilst the patient is standing
Inspect and palpate the posterior scrotum for evidence of varicocele or hernia
Suggest further assessments and investigations (e.g. full abdominal examination, ultrasound scan of the testicles)
Hernial orifice examination
Adjust the head of the bed to a 45° angle and ask the patient to lay on the bed. Offer a sheet to allow exposure only when required.
Ask the patient if they have any pain before proceeding with the clinical examination
Inspect the patient from the end of the bed whilst at rest, looking for clinical signs suggestive of underlying pathology (pain, scars, distension, pallor, cachexia, hernias) (stoma bags, surgical drains, mobility aids)
Assess the characteristics of the lump (number of lumps, cough impulse, consistency, ability to get above the lump, tenderness, bowel sounds, bruit, transillumination)
Assess the anatomical relationship of the hernia in relation to the pubic tubercle
Assess the reducibility of the hernia
Cough impulse test
Scrotal examination
Perform scrotal examination if appropriate
Suggest further assessments and investigations (e.g. testicular examination, abdominal examination, inguinal lymph node assessment, further imaging)
Peripheral Vascular examination
Adjust the head of the bed to a 45° angle
Adequately expose the patient
Ask if the patient has any pain before proceeding
General inspection
Inspect for clinical signs suggestive of underlying pathology (e.g. scars, missing limb or digits)
Look for objects or equipment on or around the patient (e.g. walking aids, medical equipment)
Inspect and compare the upper limbs (cyanosis, pallor, tar staining, gangrene)
Assess and compare the temperature of the upper limbs
Assess the capillary refill time of the upper limbs
Palpate the radial pulse
Assess for radio-radial delay
Palpate the brachial pulse
Offer to measure the patient’s blood pressure
Auscultate the carotid artery
Palpate the carotid pulse
Abdomen
Inspect the abdomen for visible pulsations
Palpate the aorta
Auscultate the aorta and renal arteries
Inspect and compare the lower limbs (Cyanosis, pallor, ulcers, missing digits, scars, hair loss, muscle wasting, paralysis)
Assess and compare the temperature of the lower limbs
Assess the capillary refill time of the lower limbs
Palpate the femoral pulse
Assess for radio-femoral delay
Auscultate over the femoral pulse
Palpate the popliteal pulse
Palpate the posterior tibial pulse
Palpate the dorsalis pedis pulse
Assess gross peripheral sensation
Buerger’s test
With the patient positioned supine, stand at the bottom of the bed and raise both of the patient’s feet to 45º for 1-2 minutes
Observe the colour of the limbs
Sit the patient up and ask them to hang their legs down over the side of the bed
Summarise your findings
Suggest further assessments and investigations (e.g. blood pressure measurement, cardiovascular examination, ABPI, neurological examination)
Diabetic foot examination
Ask the patient if they have any pain before proceeding with the clinical examination
Gather Monofilament, Tuning fork (128 Hz), Tendon hammer
Inspect the lower limbs for relevant pathology, making sure to look at the posterior aspect of each leg and between each of the toes for hidden ulcers (scars, hair loss, calluses, venous guttering, ulcers, charcots)
Place the dorsal aspect of your hand onto the patient’s lower limbs to assess and compare temperature
Palpate the posterior tibial pulse
Palpate the dorsalis pedis pulse
Provide an example of the monofilament sensation on the patient’s arm or sternum
With the patient’s eyes closed, apply the monofilament to the The pulp of the hallux.
The pulp of the third digit.
Metatarsophalangeal joints 1, 3 and 5.
Palpate the popliteal pulse
Gait
Ask the patient to walk to the end of the examination room and then turn and walk back whilst you observe their gait
Inspect the patient’s footwear
Other assessments to consider
Assess vibration sensation
Assess proprioception
Assess the ankle-jerk reflex
Summarise your findings
Suggest further assessments and investigations (e.g. bedside capillary blood glucose, serum HbA1c, lower limb neurological examination, peripheral arterial examination, foot care advice, diabetic foot risk assessment)
Digital rectal examination
Offer chaperone
Take vital signs
Ask patient to lean onto their left hand side and bring knees to their chest
Observe the area for fissures, haemorrhoids, prolapse etc.
Ask patient to breathe out and relax and enter finger into anal canal
Examine posterior wall then prostate
Withdraw and examine finger
Knee examination
Ask if the patient has any pain before proceeding
Perform a brief general inspection of the patient, looking for clinical signs suggestive of underlying pathology (body habitus, scars, muscle wasting)(walking aids)
Inspect both lower limbs with the patient standing (anterior/lateral/posterior)
Inspect the knee (scars, bruising, swelling, valgus/varus, patellar position)
Assess the patient’s gait
Ask the patient to lay on the bed and repeat inspection of the lower limbs
Assess and compare knee joint temperature
Measure and compare quadriceps muscle bulk
Palpate the knee structures whilst extended
Mention apprehension test
Perform patellar tap test
Perform sweep test
Repeat palpation of the knee whilst flexed at 90° including the popliteal fossa, tibial tuberosity and the head of the fibula
Assess active knee flexion and extension
Assess passive knee flexion and extension
Inspect for the posterior sag sign
Perform anterior drawer test
Perform collateral ligament assessment
Mention meniscal assessment
Summarise your findings
Suggest further assessments and investigations (e.g. neurovascular examination of both lower limbs, examination of the joint above and below and further imaging)
Hip examination
Ask if the patient has any pain before proceeding
Gather equipment
Perform a brief general inspection of the patient, looking for clinical signs suggestive of underlying pathology (body habitus, scars, wasting, walking aids)
Inspect both lower limbs with the patient standing (anterior/lateral/posterior)
Assess the patient’s gait
Ask the patient to lay on the bed and repeat inspection of the lower limbs
Assess and compare hip joint temperature
Palpate the greater trochanter
Assess apparent and true leg length
Assess active hip flexion and extension
Assess passive hip flexion
Assess passive internal and external rotation of the hip
Assess passive abduction and adduction of the hip
Assess passive hip extension with the patient lying prone
Perform Thomas’s test
Perform Trendelenburg’s test
Summarise your findings
Suggest further assessments and investigations (e.g. neurovascular examination of both lower limbs, examination of the joint above and below and further imaging)
