OSCE Flashcards
Outline a cardio history
Hi, my name is Lois I am a third year medical student working with the team caring for you, is it alright I I ask you some questions about why you came in today ?
Perfect can I check your name and DOB please
And how would you like me to dress you?
Perfect is it alright to take a seat
So before I begin asking questions I just want to reassure you that you will still see the doctor and that everything you say is confidential and will only be shared with the medical team caring for you.
Presentations:
chest pain: SOCRATES
loss of consciousness: what were you doing before, how were you feeling before, did anyone witness the attack, how long were you unconscious for, after how did you feel- any confusion or headache.
palpitations
SOB : any changes in your breathing
low bp
SYSTEMS:
cardio: chest pain, SOB, palpitations, syncope, dizziness, ankle swelling, nausea or vomiting
resp: SOB, cough, haemoptysis, fever, pain on inspiration/expiration
Gastro: worse after meals or lying down
General: tiredness, weight loss or appetite change, fevers, night sweats or rashes
Present a cardio history
In summary, today I preformed a cardiovascular examination on x year old x. On inspection, there was no peripheral stigmata of disease such as any visible palpations, scars or medical paraphernalia.
On inspection of the hands there were no tendon xanthomas, Osler nodes or laneway lesions. Pulse rate was 72bpm and regular, respiratory rate of 16 breaths per min. When inspecting the face there was no xanthelasma or conceal arcus, as well as no central cyanosis or high arched palette
On palpation, there was an undisplayed apex beat with no heave or thrills
On auscultation S1 and S2 were heard clearly with no additional sounds
This was a normal cardiovascular examination
To complete my examination, I would like to obtain a full history, perform an abdominal examination to check for AAA, check BP and ECG
Perform a cardiovascular examination
WASH HANDS
Hi my name is Lois Burrows im a third year medical student from Imperial.
Can I check your name and DOB please.
Perfect, today Ive been asked to perform a cardiovascular examination on you. This will involve me having a look at your hands, head and neck and then examining your chest by having a look feel and listen. You’ll need to be exposed from the waist upwards and laying on the couch at a 45 degree angle.
Would you like a chaperone?
Before I begin are you in any pain at all? Please let me know if you are in pain at any point during the examination.
do you have any questions?
Ill just begin by having a look from the end of the bed, is it alright if I lower your gown.
Thankyou, you can put it back on as I take a look at your hands.
If you could just put your hands out infront of you please. And if you could turn them over. And bring two fingers together like this
Bring arms out again, just going to assess the temperature, and im going to press on your finger for a few seconds
Now like to feel the pulse in your wrist (radial TIME and do resp rate at same time)
Id also check the radio-femoral pulse and take their blood pressure at this point.
Now going to assess what’s called a collapsing pulse, ill need to feel your pulse and raise your arm quite briskly, do you have any pain in your shoulder at all?
Going to now look at your face, if you could look straight ahead for me, close your eyes, If you could pull down your lower eyelid for me and look up.
And if you could open your mouth, stick your tongue out, and finally lift your tongue to the roof of your mouth.
If you lie back on the couch fully for me now. Im going to listen and then feel the pulses in your neck.
JVP : turn head to left, any pain in your tummy. Im just going to press down it may feel uncomfortable but shouldn’t hurt.
Carotids : Listen, take a deep breath in out and hold
and breathe normally, now im going to feel your neck pulse
Now im going to examine your chest, is it okay if you remove your gown and place your hands on your hips so I can see the sides of your chest.
Palpation;
apex (move superiomedially) and check location
heaves (apical and left sternal)
thrills over all four
Auscultation: FFEL THE CAROTIDS WHILST AUSCULTATING
mitral regurgitation (use bell and ask to turn to left lateral decubitus, breath in, out and hold)
mitral stenosis (diaphragm over mitral valve and then listen at axilla)
tricuspid pulmonary
aortic stenosis (over aortic valve then switch to bell and listen to neck)
aortic regurgitation (sit forward, lower left sternal edge with diaphragm, breath in out and hold)
listen to the back take deep breaths in and out
Sacral oedema: just going to feel your lower back do you have any pain there, feel 5 seconds and watch)
Lay back down and cover patient/gown back on
WASH UR HANDS
To complete my examination:id like to
- take a full history
- perform an abdominal examination to check for AAA, and organomegaly
Bedside: full set of observations, 12 lead ECG, urine dipstick, fundoscopy, bloods including FBC, U+E, LFTs, CRP and troponin
Exam: Chest X Ray
Abdo history
Abdo pain history: SOCRATES question format. Site, Onset, Character, Radiation, Associated/Alleviating factors, Timing, Exacerbating factors, Severity score /10.
Nausea/Vomiting: onset, relation to food, quantity, colour (food/bile/blood)
Diarrhoea/Constipation: onset/time course, dietary changes, associated features (fever, weight loss), stool colour (bloody/black), tenesmus, steatorrhoea, urgency/incontinence, previous investigations
Dysphagia: onset/time course, solids/liquids, level of obstruction, associated features (heartburn, weight loss, vomiting), previous investigations
Jaundice: Onset/time course, urine/stool colour, alcohol use, risk factors for hepatitis/HIV (e.g. IVDU), associated features (abdo pain, fever, weight loss, ascites, itchiness, fatigue)
Abdominal swelling: fat, fluid, fetus, flatus, faeces
PERFORM AN ABDOMINAL EXAMINATION
WASH HAND
hello, my name is Lois Burrows im a third year med student from imperial
can I check your name and DOB
nice to meet you, today Ive been asked to preform an abdominal examination which will involve me having a feel look and listen to your tummy as well as feeling the pulses in your hands and neck. You’ll have to be exposed from the waist up and from the knees down and half way through ill lower the bed and ask you to lay flat, is that okay?
Inspect: drains, catheter, IV fluids, medical paraphenaelia , obvious distention
Do you have any tattoos or bruises anywhere?
Hands:
Fine tremor: get to hold hands out
take a look at hands: koilonychia, leukonychia, dupturyns (feel the hypothenar eminence), petechiae, palmar erythema.
CO2 retention
Radial pulse
BP
Face:
- Eyes: scleral icterus, kaiser Fleischer rings, conjunctival pallor ask to pull eyelid down
- Mouth: ulcers (crohns), oral candidiasis, hydration, apthous ulcers, angular stomatitis, atrophic glossitis
Neck:
JVP and press
Closer inspection of chest: spider naevi, gynaecomastiae and abdnormal hair distribution in men, acanthosis nigracans under armpit. Ask to sit forward and look for spider nave on back. Whilst sitting up
Lymph node examination
NOW LAY FLAT and expose
Abdominal inspection: caput medusae, Cullens + Grey turners, striae,
ask to life head of bed and look at their feet: look at their stomach whilst they do this
ask them to cough and look at stomach as they do this (hernias, peritonitis)
PALPATION AND PERCUSSION
light palpation
deep palpation
Organomegaly
- liver: as breathe out place hand tell them to breathe in, as they breathe out move hand up without removing hand from abdomen, continue until the left costal margin is met, then percuss this area too, then percuss from chest down
- spleen: palpate same way from LIF to right costal margin, then percuss
- kidneys: roll slightly up, put hand underneath, other hand on abdominal and ballot
AAA
Shifting dullness
Auscultate:
Bruits: using bell listen to aortic midline, renal is either side of this then RUQ for hepatic bruits
Bowel sounds: below and left of the bellybutton
GET DRESSED AND SIT BACK UP
Legs:
erythema nodusum and pyoderma gangrenosum (IBD)
vasculitis rashes
Ankle oedema
WASH HANDS
thank patient, check if comfortable say you’re going to present your findings to examiner
To complete my examination id like to:
- take a full history
- inspect the external genitalia
- palpate hernial orfices
- DRE
- urine dip, stool culture for microscopy and culture, pregnancy test
Abdominal Ultrasound or X ray
Summarise
In summary today I performed an abdominal examination on x a x year old female/male.
On general inspection there was no peripheral stigmata of any gastrointestinal disease such as any anaemia, jaundice or medical paraphernalia.
When inspecting the hands there were no signs of any clubbing, palmar erythema or leukonychia
Their pulse was 72 beats per minute and regular.
When inspecting the face there were no signs of any octal scleras or conjunctival pallor as well as no apthous ulcers or angular stomatitis
When closely inspecting the chest there was no acanthosis nigrcans, scars or spider naevi
When closely inspecting the abdomen there were no Cullen or grey turners sign and no caput medusae
On palpation, the abdomen was soft and non tender with no masses or organomegaly.
The abdominal aorta was pulsation and non expansile.
On auscultation he had normal bowel sounds and no bruits.
This was a normal abdominal examination.
To complete the examination, I would like to obtain a full history from the patient, inspect the external genetalia, perform a digital rectal examination as well as urine dipstick and a stool sample for microscopy and culture.
Respiratory history key points
Shortness of breath: at rest/on exertion, exercise limitation, orthopnoea, paroxysmal nocturnal dyspnoea, leg oedema
Cough: productive/non-productive, quantity, colour, mucus plugs, timing
Chest pain: ?pleuritic
Wheeze
Weight loss, fever, lethargy
In a respiratory history it is also important to ask questions about atopy, past exposure to TB, recent medication changes and an extensive social history. Occupation, household pets, smoking and travel history are all part of a comprehensive respiratory social history.
Respiratory examination
wash hands
name, role, patient name DOB
look at hands, face and neck as well as a look feel and listen to your chest.
At points you Weill need to be exposed from the waist upwards and from the knees down is that okay?
Do you need a chaperone
Any pain, any questions?
Start by looking from the end of the bed : sputum pot, sump oxygen, inhalers, chest drains
look at patient for pursed lip breathing, accessory breathing,
Hands: hands out take a look, cap refill, over, hands out and hold look for fine tremor. Co2 retention flap
Radial pulse and rest rate
offer BP
Face: inspect eyes, one eyelid down
Mouth: open, raise tongue to roof
Neck:
head to side and JVP , Hepatojugular reflex
TRACHEAL DEVIATION
Inspect Chest closer
Palpation: apex beat, heaves and chest expansion
Percussion: 3 areas including above clavicle and then axilla. SIDE TO SIDE PERCUSSION
Auscultation: bell at apices then same percussion areas, deep breaths in and out of mouth. SIDE TO SIDE
repeat on back
palpate for chest expansion at three levels
Percuss at 4 levels
Auscultate at 4 levels
Vocal Fremitus: say 111 every time I place my stethoscope at 4 levels
Nodal examination, check for sacral oedema
Look for DVT, feel up the bottom of calf checking face asking if there was any pain
Peripheral edema
Neurological history- cranial upper and lower
‘Fits, faints or funny turns’: seizures, loss of consciousness. Any evidence of pre-warning / preceding symptoms, any witnesses to the event, what the recovery period was like after regaining consciousness. It is also important to note if the patient has an occupation / hobby where a sudden syncopal episode would be especially dangerous e.g. diving / swimming / driving
Sensory changes: hearing, taste, smell, numbness, tingling, vision (including diplopia), weakness, balance
Speech and swallowing problems
Cognition and mood
Bladder and bowel changes
Headache: it is important to recognise red flags. These include - abrupt severe onset (“thunderclap”), age of onset > 50, progressive severity / worsening frequency, significant change in pattern of headache, worsening of symptoms with posture or straining / coughing, neurological symptoms or focal neurological signs, confusion, reduced consciousness, meningism, previous or family history of malignancy
As well as the above, it is important to enquire as to any risk factors for developing neurological symptoms: Immunocompromise, head injury / recent trauma, drug and alcohol use, anticoagulation, pregnancy, previous history of cancer.
Respiratory summary
In summary, I performed a respiratory examination on x.
On general inspection there were no stigmata of disease such as any accessory muscle usage or medical parephinallia.
When inspecting the hands there was no sign of any tar staining or clubbing, with a cap refill under 2 seconds.
Their pulse was regular at 72 beats per minute and rest rate within normal ranges at 16 breaths per minute
When inspecting the eye there were no signs of Horners syndrome which is ptosis, mitosis and anhydrous, and no conjunctival pallor. The mouth was hydrated with no central cyanosis
Trachea was midline without any deviation
On closer inspection of the chest there were no scars or signs of pacts excavatum or carinatum.
On palpation chest expansion was symmetrical and there were no enlarged lymph nodes around the neck
On percussion all lung fields were resonant without.
On auscultation vesicular breathing was heard throughout the lung fields and vocal fremitus was equal on both sides.
To complete my examination I would like to take a full history, perform a cardiovascular examination, collect a sputum sample and measure peak flow
Venepuncture
hand gel and intro
have u had before
involve me placing a needle in your arm to take some blood, you will feel a sharp scratch but it shouldn’t be overly painful is the okay
confirm name, check hospital wrist band, how would you like to be addressed, what’s your date of birth
allergies to latex
recent surgery
any fistula on any arm
blood thinning medication
steroid medication
are you feeling generally well, how are you with needles?
any questions, would you like me to repeat anything
clean inside out
check expiry date ‘all of the equipment I have is in date)
which arm would you like me to take blood from and could you roll up your sleeve on that arm
tourniquet then find vein and release
wash hands and put gloves
open the equipment and attach the barrel to the needle
wrap tourniquet again, clean: I would wait 30 seconds to dry)
sharp scratch, flash back
hold need le to skin with one hand and put container in, fill up
tourniquet release, gauze for needle site, please hold, take out
needle in sharps bin, apply pressure and tape down gauze, take off gloves and apron.
finished taking you blood, let doctors know if any burning, changes in skin colour, pus or fevers
Results may be ready in a week, your GP will contact you
We may need another blood test if the sample is unsuitable or we wish to do more tests, in that case you’ll get a call
As you aren’t on any blood thinning medication, you can take the dressing off after 3o mins to an hour
any questions
Clean equipment, label blood bottle with patients name
I would ideally label the tubes and ill in a laboratory form which id send in a clear specimen bag
Document: purpose of blood test, amount of attempts, samples taken, name and date
Thank patient and examiner, wash hands, throw everything in bing, wipe tray
Cannulation
wash hands
name, check patient name DOB and hospital wrist band
today ive been asked to insert a cannula into your arm today. Have you had this done before.
It will involve me inserting a small plastic tube into you vein so we can give you medication during your stay in hospital, it will be a little uncomfortable but hopefully not too painful. Is that okay
few questions before we start
can u tell me why you’re in hospital
how are you with needles
allergic to latex
any recent surgery
any blood thinning medication
any steroids
any fistula
generally feeling well today, any questions or want me to repeat anything
Collect equipment
all the equipment is in date
open everything but keep in pack
tourniquet and find vein
wash hands, put gloves
prep flush, put plaster strips on corner
tourniquet and clean- wait 30 seconds
get cannula and put index and middle finger at top, thumb at bottom
sharp scratch
cannula in, first flashback, withdraw needle slightly, advance tube
undo tourniquet
gauze under
get octopus and ready to remove needle
secure cannula
flush as for pain
close ports
apply dressing
label with date
thyroid summary
today I performed a thyroid examination on x an x year old f/m.
On general inspection there were no signs of any thyroid disease such as hyperactivity.
On inspection of the hands and face there was no dryness or excessive sweating
Their pulse was 72bpm and regular
When inspecting the eyes specifically there was no exophthalmus or lid retraction. Eye movements were normal
When inspecting the neck there were no scars or any palpable masses
Percussion was resonant from the neck to the sternal notch
On auscultation there were no thyroid bruits
To complete my examination I would like to obtain a full history from the patient and use blood tests to check for T3 and T4
Opthalmoscopy summary
Today I performed ophthalmoscopy on
Thepatient presented with
On inspection there were no scars, erythema or discharge
On ophthalmoscopy:
- red reflex (presen/absent both eyes) (absent-glaucoma, retinal detachment, retinoblastoma)
- optic disk: COLOUR (pale=glaucoma, optic neuritis), MARGIN, CONTOUR, CUP:DISK RATIO (over 0.5 glaucoma, 0 high ICP)
- Retina Vessels (1narrow 2 nicking 3exudative 4 papilloedema OR BR micro aneurysm PREP blot, exudate, haemorrhage PRO neovascularisation DIABETIC hard exudate on macula)
This patient had suspected
To complete my examination I would like to perform
cranial nerve exam- stroke
capillary glucose: diabetic
blood pressure: hypertensive
retinal photography (glaucoma)
a+E (papilloedema)
Summary of otoscopy
The patient presented with
On general inspection there was erythema, discharge, scars
On palpation of the tragus there was (no) pain
Otoscopy of the ear showed ear wax within the canal, a bulging/retracted/perforated tympanic membrane and a clear/absent light reflex
These findings are consistent with :
To complete my examination I would like to perform a full neurological examination as well as a Rinne and Webers
From top and round clockwise
Pars flaccida
Lateral process of malleolus
Handle of the malleolus
Light reflex
Pars tensa
