OSCE Flashcards
Cardio exam
Say hello say who I am and ask for name and DOB
Explain examination and attain consent
Check hands for any abnormalities etc
Check mouth and eyes for cyanosis etc
Check pulse and ask for other vitals
Assess the JVP
Palpate the heart to accurately identify the apex prior to auscultation.
Palpate for thrills over the heart valves
Auscultate the heart
* Listen for the pansystolic murmur of mitral regurgitation.
* Ask the patient to place the left hand behind the head thus exposing the left axilla and move the diaphragm of the stethoscope in 2-3 steps towards the left axilla until the murmur is no longer heard
* Listen for the diastolic murmur of mitral stenosis
* Ask the patient to roll slightly to the left, to exhale completely and to hold the breath out.
* Listen to the Tricuspid valve by placing the diaphragm of the stethoscope over the left lower
sternal edge (Mitral regurgitation and added heart sounds may also be heard here).
* Listen to the Pulmonary valve over the left 2nd intercostal space.
* Listen to the Aortic valve over the right 2nd intercostal space.
* Assess radiation of the mid systolic murmur of aortic stenosis by
* moving the diaphragm of the stethoscope in 2-3 steps over the right and left sides of the neck until the murmur is no longer heard.
* Listen for the end systolic murmur of aortic regurgitation by
* Asking the patient to sit up and lean forward and to breathe all the way out, placing the diaphragm of the stethoscope over the left sternal edge and listening for the murmur in early diastole
Check for pitting oedema
Listen to the lower lobes of each lung for the inspiratory crepitations of pulmonary oedema and moving the stethoscope successively upwards on each side until the crepitations are no longer heard.
Resp exam
Say hello and ask for age and DOB
Explain examination and attain consent
Check hands for any abnormalities etc
Check pulse and ask for other vitals
Check mouth and eyes for cyanosis etc
Palpate trachea
Ask for patient to sit up and turn to one side exposing their back
Check lymph nodes
Chest expansion checks
Percuss
Tactile vocal fremitus
Auscultate
Ask patient to lie down again
Chest expansion checks
Percuss
Tactile vocal fremitus
Auscultate
Thank yo
Cervical spine examination
Say hello and ask for age and DOB
Explain examination and attain consent
Check pulse and ask for other vitals
Asking the patient to stand and expose neck and upper thorax
Inspect the neck from each angle for abnormal posture, muscle wasting, asymmetry, scarring
Palpate the neck midline from occiput to T1
Palpate paraspinal muscles from occiput to T1
Palpate supraclavicular fossa
Palpate anterior neck structures
Ask patient to flex, extend, laterally flex and laterally rotate – passively move if any pain
Perform symptomatic shoulder abduction test; relief = +ve
Test Lhermitte’s sign – passively flex cervical spine forwards; electric shock = +ve
Thank you
Present
Shoulder examination
Say hello and ask for age and DOB
Explain examination and attain consent
Check pulse and ask for other vitals
Observe from the front, the side and behind; checking for symmetry, muscle wasting, swelling, scarring, winging of the scapula.
Observe the posture of the neck and ask about pain
Palpate the Sternoclavicular joint, Clavicle, Acromioclavicular joint, Acromion process, Greater tuberosity and surgical neck of humerus, Subacromial space, Upper humeral shaft and head via the axilla, Outline of scapula and spine of scapula
Stand behind the patient palpate for crepitus on Abduction, Adduction, Forward flexion, Backwards extension, External rotation
Apley Scratch Test; over opposite shoulder, behind the neck, from below
Drop arm test
Yergason’s test; resist supination
Resist ad/ab- duction (supraspinatus), internal (subscapularis) and external rotation (infraspinatus, teres minor)
Thank you
Present
Hip examination
Say hello and ask for age and DOB
Explain examination and attain consent
Check pulse and ask for other vitals
Ask patient to walk around
Observe spine alignment
Observe the hips checking for symmetry, muscle wasting, swelling, scarring
Ask patient to lie down
Palpate and look for any pain at the Iliac crest, Anterior superior iliac spine, Greater trochanter of the femur, Femur: place fingers over the head of the femur below the inguinal ligament and lateral to the femoral artery, Shaft of the femur
Place your left hand behind the patient’s sacrum and test:
* Hip flexion
* Abduction
* Adduction
Test internal and external rotation:
* With the legs in extension
* Flex the hip to 900 and the knee to 900
Test hip extension by
* Asking the patient to lie prone
* Lifting each leg in turn
Conduct Thomas test
Measure for any limb shortening
Conduct Trendelenburg test
Thank you
Present
Thoracolumbar exam
Say hello and ask for age and DOB
Explain examination and attain consent
Check pulse and ask for other vitals
Asking the patient to stand and expose their back
Observe and comment on patient general appearance and movements
Inspect the back from the back for deformities, scarring, muscle wasting, asymmetry, shoulder, and iliac crest level
Inspect from the side for lumbar lordosis and thoracic kyphosis
Palpate the spinous processes from T1 to L5, commenting on T1, T3 (scapular spine), T7 (inferior angle of scapula), L4/5 (posterior iliac crest)
Palpate paraspinal muscles from T1 to L5
Percuss as well
Ask patient to, whilst sitting, to turn left and right as far as possible with crossed arms
Ask patient to stand and bend forward, lean backwards, and run one hand and then the other down the side of their leg.
Conduct straight leg raises; dorsiflexion of foot and toe may exacerbate pain
If the straight leg raise is positive, test bowstring sign; slightly flex the knee and apply pressure to the tibial nerve in the popliteal fossa. Compression of the nerve reproduces the pain.
Perform femoral stretch test: In prone position, place a hand in the popliteal fossa on knee flexion.
Test the following reflexes as a minimum:
* Biceps (C5/6)
* Triceps (C6/7)
* Supinator (C5/6)
* Patellar (L3/4)
* Ankle (S1/2)
* Plantar (S1/2)
Thank you
Present
Hand examination
Say hello and ask for age and DOB
Explain examination and attain consent
Check pulse and ask for other vitals
Observe for any signs of systemic joint or CT disease
OBSERVE the hand and wrist and describe apparent abnormalities
PALPATE the hand and wrist and describe apparent abnormalities
Locate the radial and ulnar pulse
Test movement of every joint
Assess hand function, checking:
* Finger (superficialis and profundus) and thumb movement
* Fine pinch
* Grip strength
* Median nerve sensory (and motor function (thenar muscles and first two lumbricle)
* Ulnar nerve sensory and motor function (all other hand muscles)
* Radial nerve sensory and motor function (posterior arm)
* Integration of practical tasks (e.g., undo a button, use a pen)
Carpal compression test
Phalen’s test
Reverse Phalen’s
Tinel’s test
Thank you
Present
Ankle exam
Introduce yourself and check the patient’s name
Wash your hands
Explain the purpose of the examination and obtain the patient’s consent
Examine the patient’s gait
Examine the footwear for any signs of abnormal wear
With the patient lying on the couch observe both ankles for:
• Medial and lateral longitudinal arches of the midfoot
• Ankle swelling
• Scars
• Bruising
• Calluses caused by pressure points
Ask the patient if there is any pain felt
Palpate the ankle and related structures for tenderness and in particular:
• Medial and lateral malleoli
• The proximal and distal fibula
The medial and lateral ankle ligaments
• The Achilles tendon
• The base of the 5th metatarsal
Ask the patient to move the foot (active movement): 1. Downwards(plantarflexion)
2. Upwards(dorsiflexion)
3. Inwards(inversion)
4. Outwards(eversion)
Test each of the above movements yourself (passive movement)
If dorsiflexion appears restricted, then assess the movement with the knee both flexed and extended
Explain your findings and proposed plan of management to the patient
Wash your hands
Record your findings and plan of management in the patient’s records
Knee exam
Hello
Name and dob
Explain and consent
With the patient lying on the couch observe both knees for:
• Obvious malalignment including valgus and varus deformity
• Wasting of the quadriceps muscles
• Swelling
• Scars
• Erythema
• External enlargement of the distal femur and proximal tibia
• Flexion deformity (squat down and look for the space under the knees)
Ask the patient if there is any pain felt
With the patient standing, observe the front and back of the knee for the above and also for swelling of a Baker’s cyst in the popliteal fossa
Observe the patient’s knees as they walk towards and then away from you. Look at the stance and the swing of the leg for evidence of pain, stiffness and abnormality of the gait.
Palpate the quadriceps muscles to assess wasting. You should consider also measuring the circumference of the thigh at a fixed point (e.g., 20 cm above the tibial tuberosity)
Palpate each knee to assess warmth
Milk the thigh and knee towards both medial and lateral area.
Identify the following anatomical landmarks:
• The tibial tuberosity (Figure 1)
• The quadriceps tendon
• The inferior pole of the patella
• The medial and lateral joint lines (Figure 2)
• With the tibia in medial rotation palpate the medial joint line
o Identify the broad medial collateral ligament (Figure 3)
With the tibia in external rotation palpate the lateral joint line
Identify the cord-like lateral collateral ligament
Palpate into the popliteal fossa identifying, The tendons of semimembranosus, semitendinosus and biceps femoris
Any evidence of popliteal swelling such as a Baker’s cyst
Palpate the edges of the patella for irregularity, swelling of the prepatellar bursa.
Gently move the patella to and from to elicit retropatellar crepitus
Ask the patient to bend the knee. Observe:
• The range of movement
• The tracking of the patella over the femoral condyles
Place one hand on the patella to assess for the presence of crepitus as the knee is flexed through its full range
Test for hyper-extension of the knees by lifting both legs by the feet. Up to 10 degrees if
extension is normal
Check for the presence of an extensor lag by asking the patient to lift the leg keeping the knee straight
Ask the patient about the presence of pain before you start
Test the medial and collateral ligaments of the knee with joint in both full extension and at 20 degrees of flexion. In the latter position, the cruciate ligaments are not in tension
With both knees flexed to 90 degrees look for the posterior sag suggestive of a posterior cruciate ligament injury
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CS 4.6.1 Examination of the Lower Limb
Anterior Drawer test
The patient flexes the hip to 45 degrees and the knee to 90 degrees with the foot fixed on the couch. Place your hands with the fingers in the popliteal fossa and the thumbs placed anteriorly on the tibial plateau. Ensure the patient’s hamstrings are relaxed and pull the tibia forward. Increased forward displacement of the tibia compared with the other side suggests an anterior cruciate ligament tear. (Remember in patients with a posterior sag, this test may produce a false positive result)
Posterior Drawer test
The patient is positioned as for the anterior drawer test above. Place your hands in the same position again this time applying backward pressure to the proximal tibia. Increased posterior displacement of the tibia on the femur compared to the opposite knee suggests partial or complete tear of the posterior cruciate ligament
Lachman test
The patient should be lying down. Flex the knee to between 0 and 15 degrees. Stabilise the femur with one hand and apply firm pressure posteriorly to the proximal tibia attempting to move it anteriorly on the femur. Increased anterior movement of the tibia with a ‘soft’ endpoint rather than the normal abrupt stop suggests anterior cruciate injury
Patellar apprehension test
The knee is flexed to 30 degrees. Press on the medial border of the patella with both thumbs to exert lateral pressure. Patients with a history of patellar subluxation or dislocation become apprehensive and attempt to pull the knee back into extension
With the patient lying flat, flex the knee fully and rotate the tibia on the femur. Gradually bring the knee from full flexion to a right angle (90 degrees) first with the foot in internal rotation and then in external rotation. In the case of a meniscal injury, a ‘click’ is elicited
Hernia examination
1 Explain to the patient the purpose of the examination and obtain consent
2 Offer the patient a chaperone
3 Wash your hands and put on gloves
4 Expose the groin to allow inspection of the area between the anterior superior iliac spine and the pubic tubercle
5 Start the examination with the patient standing
6 Inspect the inguinal and femoral canals (and the scrotum)
7 Ask the patient to cough and look for an impulse
8 Identify the anatomical relationships between any observed bulge and the pubic tubercle to distinguish a femoral from an inguinal hernia
9 Palpate the external (superficial) inguinal ring and the posterior wall of the inguinal canal for muscle defects. Ask the patient to cough
10 Ask the patient to lie down and see if the hernia reduces spontaneously
11 Place the fingers over the internal (deep) inguinal ring at the mid-point of the inguinal ligament. The internal ring lies approximately 1cm above and medial to this point. Ask the patient to cough or stand up to see if the hernia reappears. If it does not this may suggest the hernia is indirect
12 Examine the opposite side as hernias are often bilateral
Male external genitalia examination
1 Introduce yourself to the patient and explain the purpose of the examination and what it will involve
2 Offer a chaperone
3 Obtain the patient’s consent
4 Wash your hands and put on gloves
5 Ask the patient to lie down on the couch with the external genitalia and upper thighs exposed
6 Observe the area for herniae, redness, swelling or ulcers
7 Look at the shaft of the penis and check the position of the urethral opening
8 Retract the foreskin to check for phimosis and adhesions
9 Note any rashes, abnormal curvature, nodules, ulcers, or discharge
10 Remember to draw the foreskin forward after examination to avoid paraphimosis
11 Look at the scrotum for redness, swelling and ulcers – do not forget the posterior surface
12 Ask the patient about pain
13 Palpate the scrotum gently using both hands; check that both testes are present in the scrotum
14 With the fingers behind the testis, palpate firmly but gently over the anterior surface using the thumb (Fig. 1)
15 Check the size and consistency of the testis noting any nodules and irregularities. Repeat on the opposite side
16 Normally you should barely be able to feel the epididymis. Note any enlargement or tenderness (Fig. 2)
17 Palpate the spermatic cord; the vas deferens feels like a thick piece of string within it (Fig. 3)
18 If there is a mass within the scrotum, transilluminate it using a pen torch. A fluid-filled mass (e.g., hydrocele) will allow transmission of light; a solid tumour will not
19 Decide whether any swelling originates from within the scrotum in which case you should be able to get above it or from the inguinal canal in which case not
20 Ask the patient to stand to look for a varicocele
21 Explain your findings to the patient and outline your future management
22 Thank the patient and close the examination
23 Dispose of your gloves in a clinical waste bag and wash your hands
Female genitalia examination - speculum and bimanual
1 Consider the possibility of pregnancy prior to the examination. Ask the patient. Perform a pregnancy test with the patient’s consent.
2 Introduce yourself and check the patient’s name, date of birth, and confirm their age
3 Explain the reason and purpose of the examination, what it will involve and obtain consent (11)
4 Ask the patient to empty the bladder if necessary
5 Offer a chaperone and document if declined. Record the name of a chaperone if present. All students are advised never to perform this examination unsupervised. Male students and doctors are advised never to perform
this examination without a chaperone present.
6 Vital signs
7 Avoid making any unnecessary or irrelevant personal comments throughout the examination
8 Invite the patient to get undressed in private behind a curtain or screen
9 Wash your hands using the 8-stage technique and put on gloves
10 General observation – ensure there is adequate lighting. Are there signs of:
* Hirsutism
* Polycystic ovary syndrome (PCOS)
* Anaemia
* Raised body-mass index (BMI)
* Consider conditions associated with menstrual dysfunction:
o Cushing’s
o PCOS
o Anorexia nervosa
o Thyrotoxicosis
11 Observe the abdomen for:
* Scars (e.g., caesarean section, laparoscopy)
* Swelling
* Distended abdomen
12 Palpate the abdomen to ensure the is no swelling or mass present. If there is a mass or swelling, can you get below it? If you cannot get below a mass, it may be arising from the pelvis (e.g., pregnant uterus, fibroids, ovarian mass)
13 Explain to the patient how to position themselves for the examination: lie flat,
head support by a pillow, heels together, knees apart.
14 Explain the examination may feel uncomfortable and can be stopped if requested by the patient
15 Communicate with the patient throughout the examination
16 Observe the perineum
* Vulval skin changes (e.g., lichen sclerosis, genital warts, vulvitis,
ulceration,)
* Herpetic ulcers
* Scars (e.g., episiotomy)
* Discharge (e.g., bleeding, vaginal discharge)
* Hydradenitis suppuritiva
17 Palpation of the vulva
* Part the labia with left hand.
* Observe the opening of the external urethral meatus
* Palpate any swellings (e.g., cysts, Bartholin’s glands,
18 Speculum examination
* Open pack. Use gel to lubricate unless you are doing a smear.
* Explain you are about to insert the speculum and ask patient to tell you if in pain or if they want you to stop at any point.
* Turn speculum so blades are vertical, slowly insert into vagina as far as possible.
* Rotate 90 degrees so blades are horizontal
* Check patient is ready for you to open speculum.
* Look up vagina as you slowly open the speculum and see the cervix
between the blades.
* Tighten the thumb screw.
* Note the state of the cervix, the os, presence of any polyps, cervical ectropium
* If difficulty observing the cervix reinsert speculum, consider posterior cervix and change patient position (patient hands under pelvis).
* Consider different size of speculum.
* Take swabs/ smear if required
* Explain you are about to remove speculum, loosen the thumb screw and slowly withdraw closing the speculum after you have come past the cervix.
* Dispose of speculum appropriately.
19 Bimanual vaginal examination
* Explain to the patient what you are doing and ensure you have consent
* Lubricate your gloved right index and middle fingers
* Part the labia with you left hand
* Slowly insert your fingers to the top of the vagina.
* Feel the firm, rounded and smooth cervix (the uterus may retroverted
or anteverted).
* Check for tenderness, excitation of cervix.
* Place left hand on the lower abdomen (usually initially in the suprapubic
area) and press down.
* Palpate the uterus, anterior and posterior fornices, by pressing up with
your right hand inside the vagina and down with your left hand on the
lower abdominal wall moving the uterus between the two hands.
* Palpate from above the uterus with your left hand and behind the uterus (anterior and posterior fornices) with your right-hand index and middle fingers.
* Assess the uterine size, consistency, masses, and tenderness
* Feel in both the adnexae for masses and tenderness with your right hand inside the vagina and your left hand pressing on the right lateral lower abdomen and then left lateral lower abdomen moving the right hand to the patients right vaginal wall and then left vaginal wall to coordinate the movements.
* Tell the patient you are going to remove your fingers and then slowly remove your fingers from the cervix.
* Check the glove for blood and discharge.
* Dispose of gloves appropriately.
20 A rectal examination is indicated also if there are symptoms of bowel disease.
20 Invite the patient to get dressed. The patient may need to use tissues/ wipes and to dispose of these. They may also need a sanitary towel. Ensure there is equipment for them to wash their hands
21 Wash your own hands
22 Once the patient is dressed and sitting comfortably, explain your findings to them and discuss the options for further management of the patient’s symptoms
23 Ensure you record your findings, proposed management, and the patient’s preferences for treatment in the patient’s medical record.
24 Invite questions from the patient at all stages of the examination
Breast examination
1 Carefully explain the purpose of the examination and obtain the patient’s consent
2 Offer the patient a chaperone
3 Wash your hands
4 Ask the patient to sit upright on the couch, undressed to the waist with the hands resting on the thighs
5 Facing the patient, look at the breasts for symmetry, local swelling and changes to the skin or nipples. Ask the patient to press the hands on the hips and repeat the inspection
6 Inspect again with the patient raising the arms above the head to stretch the skin over the breasts. Look for tethering of the skin, relative shift in the position of the nipples, and any change in the contour of the skin over the breasts and axillae.
7 Ask the patient to lie with the head supported on a pillow and to place the hand on the side to be examined behind the head
8 The total area to be palpated lies between the clavicle and the inframammary fold and then the sternum and the mix-axillary line
9 Using the middle three fingers, and with the fingers slightly flexed, firmly palpate in each quadrant of the breast, pressing the tissue firmly against the chest wall. Begin at the outer limit of each quadrant and move up and down the quadrant in vertical lines towards the areola. Palpate in small circles applying light, medium and deep pressure as you do so (Fig. 1)
10 Compare equivalent areas on each side
11 Palpation is more difficult if an implant is present. Examine the patient lying flat with the arm by the side (3)
12 Define the characteristics of any mass found – size, tenderness, mobility, consistency
13 Examine the axillary tail using the finger and thumb
14 Only if the patient has given a history of nipple discharge, ask the patient to express any discharge from the nipple.
15 Ask the patient to sit on the edge of the couch facing you
16 After explaining the reason, ask the patient to place her forearm on yours to relax the muscles around the axilla. Palpate the medial, lateral, posterior, anterior walls, and apex of the axilla to assess for the presence of enlarged lymph nodes. You may see clinicians do this with the patient
in either a lying or sitting position (Fig. 2 and Fig. 3)
17 Palpate the supraclavicular nodes and examine the patient’s cervical nodes
18 Auscultate the chest
19 Palpate the liver as per the checklist from the abdominal examination
sessions (Module 5)
20 Palpate the spine for signs of tenderness
21 Explain your findings to the patient and outline further
management
22 Thank the patient
23 Wash your hands
24 Record your findings in the patient’s medical records
Prostate examination
1 Explain to the patient the purpose of the examination and obtain consent
2 Offer the patient a chaperone
3 Wash your hands and put on gloves
4 Ask the patient to lie on the couch in the left lateral position with the buttocks at the edge of the couch, the knees drawn up towards the chest and the knees clear of the perineum - observe for fissures, haemorrhoids, rashes etc.
5 Lubricate the index finger of your right hand with gel. Place the pulp of
your finger onto the anal margin with the palm facing posteriorly
6 With gentle pressure, pass your finger through the anal sphincter and into
the anal canal. It may help to ask the patient to breathe out and relax
7 Rotate the examining finger anteriorly and find the median sulcus of the
prostate gland. Is it definitely present?
8 Feel over each lobe of the prostate. Assess the size and consistency of
each lobe. Is there any tenderness? Are there any nodules?
9 Withdraw your finger slowly
10 Dispose of your gloves in a clinical waste bag and wash your hands
11 Explain your findings to the patient and outline further management plans
12 Thank the patient and close the examination
Renal examination (fluid balance)
Hello
Name and dob
Explain and consent
Make general observations:
Pallor (anaemia of chronic disease)
Shortness of breath
Reduced skin hydration (turgor)
Bruising
Patient is itching, evidence of scratching (excoriation)
Check hands:
Hands
Nail pigmentation
Beau’s lines - malnutrition
Splinter haemorrhages - infective endocarditis
Check arms:
Pulse and blood pressure
Arteriovenous fistulae
Evidence of carpal tunnel syndrome
Check head and neck region:
Yellow complexion
Pallor (anaemia)
Raised JVP
Dry tongue and uraemic foetor
Gingival hyperplasia
Check Eyes
Hypertensive retinopathy
Diabetic retinopathy
Band keratopathy
Listen to lower lobes of lungs:
Inspiratory crepitations in fluid overload
Hyperventilation (acidaemia)
Listen to heart sounds:
Extra heart sounds
3rd and 4th between mitral and tricuspid
Pericardial friction rub where aortic regurg is heard (Uraemia may cause inflammation of the pericardium)
Examine abdo:
Inspection for scars
Palpation for kidneys, bladder, sacral oedema
Auscultation for renal artery bruits
Rectal examination for prostatic enlargement
Check legs for:
Oedema (hypoproteinaemia, fluid overload)
Peripheral neuropathy
Measure: Weight
Say you would conduct urinalysis, MC&S, Rectal exam, Fundoscopy
