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Phase 2B Medicine > Hand OSCE Exam > Flashcards

Hand OSCE Exam Flashcards

1
Q

What are the first 5 things you should do in any examination?

A 
Wash hands
Introduce yourself
Confirm pt details
Explain examination
Gain consent
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2
Q

How would you position a pt for a hand examination?

A

Expose pt’s hands, wrists & elbows.

Position pt with hands on a pillow.

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3
Q

What crucial question should you ask before you begin?

A

Ask if the pt currently has any pain.

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4
Q

What routine would be good to adopt in a hand examination?

A

Look
Feel
Move

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5
Q

What are the 2 positions in which you’d like to examine the hands?

A

Dorm (palms down)

Palms up

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6
Q

When the hands are dorsum (palms down), what 7 things are you looking for?

A
  1. Inspect hand posture (asymmetry/abnormalities)
  2. Scars or swelling
  3. Skin colour
  4. Deformities
  5. Skin changes
  6. Muscle wasting
  7. Nail changes
    * note if any of the above changes are symmetrical or asymmetrical.
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7
Q

When the hands are in the dorsal position, what 2 things are you looking for with regards to skin colour?

A

Erythema eg. cellulitis (erythema) / palmar erythema

Pallor eg. peripheral vascular disease / anaemia

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8
Q

When the hands are in the dorsal position, what 4 deformities are you looking for?

A
  • Bouchard’s nodes (PIP) / Heberden’s nodes (DIP) - OA
  • Swan neck deformity (DIP) joint hyperflecion with PIP joint hyperextension - RA
  • Z-thumb: hyperextension of the interphalangeal joint, in addition to fixed flexion and subluxation of the MCP joint - RA
  • Boutonniere’s deformity - PIP flexion with DIP hyperextension - RA
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9
Q

What 2 skin changes are you looking for when the hands are in the dorsal position?

A

Skin thinning or bruising - long term steroid use

Rashes - eg. psoriatic plaques

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10
Q

You find muscle wasting on examination of the hands in the dorsal position. What might this indicate?

A

Chronic joint pathology OR motor neurone lesions

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11
Q

What 2 nail changes should you look for when the hands are in the dorsal position?

A
  • Nailfold vasculitis: small areas of infarction

- Pitting and onycholysis: associated with psoriasis

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12
Q

With the pt’s palms facing upwards, what 7 things are you looking at / assessing?

A
  1. Inspect hand posture: asymmetry / abnormalities (eg. clawed hand)
  2. Scars: carpal tunnel release surgery
  3. Swelling
  4. Skin colour
  5. Deformity
  6. Thenar / hypothenar wasting
  7. Elbows
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13
Q

With the pt’s palms facing upwards, what are you looking for with regards to skin colour?

A

Erythema: eg. cellulitis (erythema) / palmar erythema

Pallor: eg. peripheral vascular disease / anaemia

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14
Q

What deformity are you looking for when pt’s palms are facing upwards?

A

Dupuytren’s contracture

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15
Q

What does thenar / hypothenar wasting suggest?

A

Isolate wasting of the thenar eminence is suggestive of carpal tunnel syndrome.

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16
Q

What are you looking for on the elbows?

A

Psoriatic plaques OR rheumatoid nodules.

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17
Q

Patient’s palms are facing upwards. What 4 things should you feel for?

A
  1. Temperature: wrist & MCP joint lines (warm joints in inflammatory / septic arthritis)
  2. Radial & ulnar pulse: ensure adequate arterial supply to the hand
  3. Thenar / hypothenar eminence bulk: wasting is noted in ulnar/median nerve lesions
  4. Palmar thickening: Dupuytren’s contracture (familial / age related)
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18
Q

How would you assess median nerve sensation?

A

Touch the thenar eminence / index finger

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19
Q

How would you assess the ulnar nerve?

A

Touch the hypothenar eminence / little finger

20
Q

The pt’s palms are facing downwards. How would you assess radial nerve sensation?

A

Touch the 1st dorsal webspace.

21
Q

You need to assess & compare the temperature of the pt’s joints. How are you going to do this?

A

Use the back of your hand.

Assess the pt’s forearm, wrist & MCP joints

22
Q

You gently squeeze across the metacarpophalangeal (MCP) joints. What are you looking for?

A

Non-verbal signs of discomfort.

Tenderness may indicate inflammatory arthropathy.

23
Q

You bimanually palpate the joints of the hand.

Which joints are you feeling?

A

MCP: Metacarpophalangeal joint
PIP: Proximal interphalangeal joint
DIP: Distal interphalangeal joint
CMC: Carpometacarpal joint of the thumb (squaring of the joint is associated with OA).

24
Q

You bimanually palpate the joints of the hand. What are you assessing & comparing?

A

Assess & compare for:

  • tenderness
  • irregularities
  • warmth
25
Q

You palpate the anatomical snuffbox & find tenderness. What does this suggest?

A

Scaphoid fracture

26
Q

What else must you bimanually palpate?

A

The pt’s wrists

27
Q

Describe how you would palpate the pt’s arm & elbow.

A

Palpate the pt’s arm along the ulnar border to the elbow.

Note any rheumatoid nodules or psoriatic plaques (extensor surface).

28
Q

How should finger / hand / wrist movements be assessed?

A 
Actively first (pt does the movements independently).
Then assess movements passively, feeling for crepitus & noting any pain.
29
Q

What 4 movements should you instruct your patient to carry out?

A
  1. Finger extension: “Open your fist & splay your fingers”
  2. Finger flexion: “Make a fist.”
  3. Wrist extension: “Put palms of your hands together & extend wrists fully” (ROM = 90o)
  4. Wrist flexion: “Put the backs of your hands together & flex wrists fully” - ROM = 90o
30
Q

What are the 3 major nerves of the hand?

A

Radial nerve
Ulnar nerve
Median nerve

31
Q

What is the purpose of the Motor assessment?

A

To quickly assess the 3 major nerves of the hand.

32
Q

How would you assess the radial nerve?

A

Wrist / finger extension (against resistance)

33
Q

How would you assess the ulnar nerve?

A

(Index) Finger abduction (against resistance)

34
Q

How would you assess the median nerve?

A

Thumb abduction (against resistance)

35
Q

What 3 tests assess ‘function’?

A

Power grip
Pincer grip
Pick up small object / undo shirt button

36
Q

How would you assess ‘Power grip’?

A

“Squeeze my fingers with your hands”

37
Q

How would you assess ‘Pincer grip’?

A

“Place your thumb & index finger together & don’t let me separate them”.

38
Q

What are the 2 ‘special tests’ required to assess the hand?

A

Tinel’s test

Phalen’s test

39
Q

What is Tinel’s test used to identify?

A

Used to identify nerve irritation. Can be useful in the diagnosis of carpal tunnel syndrome.

40
Q

How would you conduct a Tinel’s test?

A
  • Tap over the carpal tunnel
  • If the pt develops tingling in the thumb and radial two and a half fingers, this is suggestive of median nerve irritation & compression.
41
Q

What is Phalen’s test used for?

A

If Hx or examination findings are suggestive of carpal tunnel syndrome, this test may be used to further support the diagnosis.

42
Q

How would you conduct a Phalen’s test?

A
  • Ask the pt to hold their wrist in complete & forced flexion (pushing the dorsal surfaces of both hands together) for 60secs.
  • If pt’s symptoms of carpal tunnel syndrome are reproduced, then the test is positive
43
Q

What symptoms (of carpal tunnel syndrome) might be elicited on conducting Phalen’s test?

A

Burning, tingling or numb sensation over the thumb, index, middle & ring fingers

44
Q

What 3 things are you going to do to complete the examination?

A

Thank pt
Wash hands
Summarise findings

45
Q

What further assessments & investigations might be appropriate?

A
  • Perform a full neurovascular examination of the upper limbs
  • Examine the elbow joint

Phase 2B Medicine (10 decks)

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