OSCE Flashcards
1
Q
Things not to forget in resp exam
A
- chaperone & pain
- fine tremor
- asterixis
- temperature
- resp rate
- lymph nodes
- JVP hepatojugular reflex
- trachial position and cricoid distance
- palpate apex beat
- chest expansion
2
Q
to complete resp exam
A
sputum sample
chest x ray
o2 sats
peak flow
ABG cardio exam
3
Q
resp history questions 11 things
A
- breathlessness
- cough
- sputum production
- haemoptysis
- chest pain
- wheeze
- fever, night sweats and weight loss
- recent infections
- loss of appetitite
- orthopnoea
- PND
- how far can walk on flat without having to stop
4
Q
things not to forget in cardio
A
- cap refill
- radio-radio delay
- carotid pulse
- JVP - hepatojugular reflex
- carotid at same time as auscultating
- 4 valves with diaphragm
- 4 valves with bell
- roll onto left side
- mitral area with diaphragm - mitral regurge
- axilla with diaphragm - mitral regurge radiation
- sit up and forwards
- aortic area with diaphragm in expiration - aortic regurge
- auscultate carotid with diaphragm - aortic stenosis radiation
- roll onto left side
- inspect back
- listen to lung bases
- palpate sacrum
- palpate calves for oedema AND DVT
5
Q
to complete a cardio exam
A
full peripheral vascular examination
12 lead ecg
urine dip
bedside glucose
opthalmoscopy
lying and standing blood pressure
6
Q
cardiac symptoms to ask about in osce
A
- chest pain
- SOB
- orthopnoea
- PND
- palpitations
- cough, sputum, haemoptysis
- syncope/pre-syncope
- dizziness
- nausea and sweating
- oedema
- leg pain
- how far can walk on flat
- circulation
- fatigue, weight loss, night sweats, anorexia and fever
- cardiovascular risk factors
7
Q
Upper Limb things not to forget
A
- SWIFT
- scars
- wasting
- involuntary movements
- fasciculations
- tremor
- pronator drift - UMN lesion
- break the circle for finger strength
- ‘can you feel this’ with cotton wool
- 128hz fork for vibration
- coordination
- dysdiadochokinesia
- finger nose
8
Q
things not to forget in lower limb neuro
A
- gait
- tandem
- walk on heels
- rombergs
- inspection
- swift
- vibration
- proprioception
- babinski’s
- clonus
9
Q
CNI
A
- Olfactory
- ask about smell
- test with bedside items using each nostril seperately
10
Q
CNII
A
- optic nerve
- pupils
- size, shape and symmetry of pupils
- direct pupillary reflex
- consensual pupillary reflex
- swinging light test
- accommodation reflex
- visual inattention
- visual fields
- visual acuity with a snellen chart
- 6m away and the smallest line they can read
- the acuity is 6(for metres) / number they can read that’s the smallest letters on chart
- numbers get smaller as it goes down so 6/9 is better than 6/12
- if they can’t read lowest line at 6 metres record what they can read at 6 and let them move to 3 metres
- if they can’t read the smallest line at 3 get them to move to 1 metre
- colour vision with an ishihara chart
- fundoscopy
- pupils
11
Q
fundoscopy
A
- give mydriatic eye drops
- advise not to drive until vision normal again
- sit opposite them in chair
- make sure not in pain
- inspect outer eye
- assess fundal reflex (red reflex)
- one arms length flash light into eye looking for reflection
- right eye right hand
- 10-15 degree angle come in while maintaining red reflex
- find optic disc by following blood vessel
- assess contour, colour, cup of optic disk
- look at retina - 4 quadrants
- get patient to look directly into light to view macula
- repeat for other eye
12
Q
CNIII, IV and VI
A
- Oculomotor, trochlear and abducens
- check for ptosis
- eye movements with an H
- cover test for strabismus
13
Q
CN V
A
- Sensory
- Opthalmic branch - above eyebrow
- Maxillary branch - on cheekbone
- mandibular - jaw
- do light touch and offer with pinprick
- Motor
- clench teeth and feel bulk of masseter
- clench teeth and feel bulk of temporalis
- open mouth against force
- Reflex
- jaw jerk - only offer
- corneal reflex - only offer
14
Q
CN VII
A
- Facial nerve
- inspect for symmetry
- facial movements
- eyebrows up
- scrunch eyes tight and don’t let me open them
- big smile
- puff out your cheeks and don’t let me push them in
- inspect external auditory meatus
- any hearing changes?
- any changes to taste?
15
Q
CN VIII
A
- Vestibulocochlear
- Gross hearing test covering each ear in turn and whispering 15 cm from patient
- if they can do that then go arms length
- Webber’s
- Rinne’s
- March on spot with arms outstretched
- if they turn they will turn to the side of the lesion
- Head thrust test
- for loss of vestibular function
- Dix Hallpike manouvre
- Gross hearing test covering each ear in turn and whispering 15 cm from patient
16
Q
IX, X
A
- Glossopharyngeal and vagus
- inspect soft palate and uvula at rest
- say aaah and inspect
- Ask them to cough
- bovine cough - damage to GP or Vagus
- Ask them to swallow
- Say you would do gag reflex
17
Q
CN XI
A
- Trapezius and SCM strength
18
Q
XII
A
- Hypoglossal
- tongue out
- deviation to affected side
- assess power with pushing into side of cheek
- tongue out
19
Q
Cerebellar exam
A
- Inspection
- Romberg’s
- Gait
- Tandem walking
- DANISHH
- Dysdiadokinesia
- Ataxia (tested above)
- Nystagmus
- Intention tremor and past pointing
- Slurred staccato speech
- Baby hippopotamus
- British constitution
- Hypotonia
- Heel to shin
- Rebound phenomenon with closed eyes
20
Q
Neurology symptoms to ask about in a history
A
- Headaches
- Blurred vision
- Ptosis
- Slurred speech
- Weakness, numbness or tingling
- Unsteady/loss of balance
- LOC
- Seizures
- Back pain
- Leg pain
- Tremor
- Dizziness/vertigo
- Sleep disturbance
- Memory, concentration/personality change
21
Q
things not to forget in a gastro exam
A
- asterixis
- lymph nodes
- expecially virchow’s
- sacral oedema
- percuss down bladder
- shifting dullness
- auscultate renal arteries
- legs
- oedema
- DVT
22
Q
Gastro history questions not to miss
A
- dysphagia
- odynophagia
- GORD symptoms
- nausea
- vomiting
- haematemesis
- change in bowel habit
- flatulence
- rectal bleeding
- mucus PR
- incontinence
- weight gain/loss
- anorexia
- jaundice
- pruritis
- abdo pain
- bloating
23
Q
dyspepsia symptoms
A
- epigastric pain
- early satiety
- post prandial fullness
- belching
- bloating
- nausea
24
Q
haematemesis differentials
A
- VINTAGE
- Varices
- Inflammation (oesophagitis/PUD)
- Neoplasia
- Trauma (mallory weiss tear)
- Angiodysplasia and other vascular abnormalities
- Generalised bleeding problems
- Epistaxis (i.e. have swallowed blood)
25
Q
key steps for peripheral arterial examination
A
- pain and chaperone
- general inspection
- inspect hands
- cap refill
- temperature
- upper body pulses
- radial
- rado-radial delay
- ulnar pulse
- allens test
- brachial pulse
- waterhammer pulse
- listen first then carotid pulse
- inspect eyes lips and tongue
- inspect abdomen
- inspect feet legs and toes
- wiggle toes
- check temp between legs
- cap refill on toes
- lower body pulses
- femoral pulse
- radio-femoral delay
- popliteal
- posterior tibeal
- dorsalis pedis
- Assess light touch sensations starting distally
- if intact distally don’t keep going
- Auscultate
- carotids
- subclavian
- aorta
- femoral arteries
- Special teste
- Buerger’s test
- stand at bottom of bed and raise legs for 2-3 mins
- observe for pallor
- buerger’s angle is the level at which pallor develops
- if buerger’s angle less than 20 degrees then you have severe limb ischaema
- then put legs over side of bed
- observe for reactive hyperaemia
- white → normal pink → red
- time it takes for limb to become pink is buerger’s time
- Buerger’s test
- Ankle brachial pressure index
- ABPI <0.8 = significant peripheral arterial disease
- to complete
- cardiovascular
26
Q
Things to remember in thyroid exam
A
- tremor temperature
- inspect forearm for wasting
- eye movements and lid lag
- swallow and stick tongue out while palpating AND observing
- look for lingual thyroid
- palpate for tracheal deviation
- percuss for retrosternal thyroid
- auscultate thyroid
- proximal muscle weakness
- pre-tibial myxoedema
- reflexes
- to complete
- tfts
- ecg
- US thyroid
- fundoscopy
27
Q
4 important thoracic scars in the cardio exam and what they mean
A
- Median sternotomy scar: located in the midline of the thorax. This surgical approach is used for cardiac valve replacement and coronary artery bypass grafts (CABG).
- Anterolateral thoracotomy scar: located between the lateral border of the sternum and the mid-axillary line at the 4th or 5th intercostal space. This surgical approach is used for minimally invasive cardiac valve surgery.
- Infraclavicular scar: located in the infraclavicular region (on either side). This surgical approach is used for pacemaker insertion.
- Left mid-axillary scar: this surgical approach is used for the insertion of a subcutaneous implantable cardioverter-defibrillator (ICD).
28
Q
how do you palpate the chest
A
- Apex beat
- In healthy individuals, it is typically located in the 5th intercostal space in the midclavicular line. Ask the patient to lift their breast to allow palpation of the appropriate area if relevant.
- Heaves
- Place the heel of your hand parallel to the left sternal edge (fingers vertical) to palpate for heaves.
- If heaves are present you should feel the heel of your hand being lifted with each systole.
- Parasternal heaves are typically associated with right ventricular hypertrophy.
- Thrills
- A thrill is a palpable vibration caused by turbulent blood flow through a heart valve (a thrill is a palpable murmur).
- You should assess for a thrill across each of the heart valves in turn (see valve locations below).
- To do this place your hand horizontally across the chest wall, with the flats of your fingers and palm over the valve to be assessed.
29
Q
how do you complete your examination at the end of a cardio exam
30
Q
A
- which eye
- trauma
- visual disturbance
- far or near
- colour
- flashes/floaters
- double vision
- red eye
- discharge
- watering
- grittiness
- dryness
- itching
- swelling
- photophobia
- driving
- glasses or contact lenses
- conditions associated with opthalmic conditions
- diabetes
- hypertension
- autoimmune disease
31
Q
to complete this respiratory examination i would life to
A
- Check oxygen saturation (SpO2) and provide supplemental oxygen if indicated.
- Check other vital signs including temperature and blood pressure.
- Take a sputum sample.
- Perform peak flow assessment if relevant (e.g. asthma)
- Request a chest X-ray (if abnormalities were noted on examination)
- Take an arterial blood gas if indicated
- Perform a full cardiovascular examination if indicated (e.g. cor pulmonale)
32
Q
what is cranial nerve 5 an show do you assess it
A
- trigeminal
- has sensory (V1, V2 and V3) and motor (V3) components
- sensory
- check they can feel cotton wool on sternum
- check sensation on:
- forehead (V1 opthalmic)
- cheek (V2 maxillary)
- chin (V3 mandibular)
- ask if same on both sides
- ask if they want you to do pinprick
- motor (V3 mandibular)
- palpate masseter bilaterally as they clench teeth
- ask to open mouth against pressure
- sensory
- offer jaw jerk reflex
- would be exaggerated in an UMN lesion
- offer corneal reflex
- absense of blinking would mean trigeminal or facial lesion
- has sensory (V1, V2 and V3) and motor (V3) components
33
Q
what is th 7th cranial nerve and how do you assess it
A
- facial
- sensory to anterior two thirds of tongue
- “any change to your sense of taste?”
- motor to muscles of facial expression
- inspect face for symetry
- movements
- “Raise your eyebrows as if you’re surprised.”
- “Scrunch up your eyes and don’t let me open them.”
- “Blow out your cheeks and don’t let me deflate them.”
- “Can you do a big smile for me?”
- “Can you purse your lips like you’re trying to whistle?”
- sensory to anterior two thirds of tongue
34
Q
what is the 8th cranial nerve and how do you assess it?
A
- vestibulocochlear
- “any change to your sense of hearing?”
- gross hearing assessment
- occlude ear from behind
- whisper three numbers from an arms length
- if can’t hear use conversational volume
- if can’t hear then use loud volume
- if still can’t hear move 15cm from ear
- use whisper and conversational - don’t shout
- repeat for other ear
- Rinne’s with 512 tuning fork
- Weber’s with 512 tuning fork
- Ask the patient to march on the spot with their arms outstretched and their eyes closed:
- Vestibular lesion: the patient will turn towards the side of the lesion
- head thrust test - ask if they have neck pain before doing it
35
Q
what is cranial nerve 9 and how do you assess it
A
Glossopharyngeal
it is assessed together with cranial nerve 10
36
Q
what is cranial nerve 10 and how do you assess it
A
vagus
it is assessed together with cranial nerve 9
37
Q
how do you assess cranial nerves 9 and 10
A
- ask
- any problems swallowing
- any changes to voice
- any cough
- inspect soft palate and uvula
- uvula deviates towards the side of the vagus nerve lesion
- say aaah
- cough
- vagus nerve lesions cause a weak bovine cough
- ask to take sip of water
- ineffective swallow can be caused by either vagus or glossopharyngeal nerve lesion
- say you would try to elicit a gag reflex
- ineffective gag reflex can be caused by either vagus or glossopharyngeal nerve lesion
38
Q
what does cranial nerve 9 do
A
The glossopharyngeal nerve transmits motor information to the stylopharyngeus muscle which elevates the pharynx during swallowing and speech.
The glossopharyngeal nerve also transmits sensory information that conveys taste from the posterior third of the tongue.
Visceral sensory fibres of CN IX also mediate the afferent limb of the gag reflex.
39
Q
what is cranial nerve 11 and how do you assess it?
A
- accessory nerve
- inspect and palpate for sternocleidomastoid/trapezius wasting
- raise shoulders and resist me pushing them down
- turn hear and resist me turning it back
- do both sides
40
Q
what is the 12th cranial nerve and how do you assess it?
A
- Hypoglossal
- open mouth and inspect for wasting/fasciculations
- protrude tongue and observe for deviation
- occurs towards lesion
- push tongue against finger on cheek
- weakness on side of lesion
41
Q
what would you like to do to complete the cranial nerve examination
A
- Full neurological examination including the upper and lower limbs.
- Neuroimaging (e.g. MRI head): if there are concerns about space-occupying lesions or demyelination.
- Formal hearing assessment (including pure tone audiometry): if there are concerns about vestibulocochlear nerve function.
42
Q
what should you communicate about cervical screening
A
- offered to all women between the ages of 25-64 years
- 25-49 years: 3-yearly screening
- 50-64 years: 5-yearly screening
- in pregnancy is delayed until 3 months post partum
- process
- speculum inserted to visualise cervix
- small brush used to collect cells from around the opening of the cervix
- shouldn’t be painful
- small amount of bleeding afterwards
- results
- HPV first system
- if negative return to normal recall
- if positive then the cytology is examined
- if cytology abnormal → colposcopy
- if cytology normal then test repeated at 12 months
- if HPV now negative at 12 months then normal recall
- if HPV still positive at 12 months then return in another 12 months
- if HPV positive at 24 months then colposcopy
- HPV first system
- if sample inadequate then repeat in 3 months
- if two inadequate samples then colposcopy
43
Q
what is the treatment for CIN
A
- Large loop excision of transformation zone (LLETZ) is the most common treatment for cervical intraepithelial neoplasia.
- LLETZ may sometimes be done during the initial colposcopy visit or at a later date depending on the individual clinic.
- once treated for CIN1, CIN2, or CIN3 they should have a cervical sample in the community 6 months after treatment for a test of cure
44
Q
what are the contraindications to management of menopause with HRT
A
- Current or past breast cancer
- Any oestrogen-sensitive cancer
- Undiagnosed vaginal bleeding
- Untreated endometrial hyperplasia
45
Q
how long to advise women that the symptoms of HRT last
A
Women should be advised that the symptoms of menopause typically last for 2-5 years
46
Q
risks to advise women of with HRT
A
- Venous thromboembolism:
- A slight increase in risk with all forms of oral HRT.
- No increased risk with transdermal HRT.
- Stroke:
- Slightly increased risk with oral oestrogen HRT.
- Coronary heart disease:
- Combined HRT may be associated with a slight increase in risk.
- Breast cancer:
- Increased risk with all HRT although the risk of dying from breast cancer is not raised.
- Ovarian cancer:
- Increased risk with all HRT.
47
Q
management for menopause symptoms with lifestyle
A
- Hot flushes
- regular exercise, weight loss and reduce stress
- Sleep disturbance
- avoiding late evening exercise and maintaining good sleep hygiene
- Mood
- sleep, regular exercise and relaxation
- Cognitive symptoms
- regular exercise and good sleep hygiene
48
Q
non-HRT management of menopause symptoms
A
- Vasomotor symptoms
- fluoxetine, citalopram or venlafaxine
- Vaginal dryness
- vaginal lubricant or moisturiser
- Psychological symptoms
- self-help groups, cognitive behaviour therapy or antidepressants
- Urogenital symptoms
- if suffering from urogenital atrophy vaginal oestrogen can be prescribed. This is appropriate if they are taking HRT or not
- vaginal dryness can be treated with moisturisers and lubricants. These can be offered alongside vaginal oestrogens if required.
49
Q
methotrexate counselling
A
- methotrexate is the most widely used DMARD.
- Monitoring needs to be done before starting, weekly until treatment has stabilised and then every three months after that
- FBCs → risk of myelosuppression
- LFTs → risk of liver cirrhosis.
- U&E
- Other important side-effects include pneumonitis
- not safe until 6 months following pregnancy
- even men need to use contraception until 6 months after taking it
- taken weekly
- folic acid once weekly co-prescribed (taken 24hrs after methotrexate)
- interactions
- high dose aspirin increases risk of methotrexate toxicity
- avoid co-prescribing trimethoprim or co-trimoxazole
