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PCM > OSCE #2 > Flashcards

OSCE #2 Flashcards

1
Q

Identify and locate the apex and base of the heart.

A

The apex of the heart is the tip of the left ventricle. It is found in the midclavicular line near the 5th intercostal space.

The base of the heart is the junction between the heart and the great vessels. It is found just below the sternal angle.

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2
Q

Identify and locate the aortic area.

A

The aortic area is found in the right 2nd intercostal space.

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3
Q

Identify and locate the pulmonic area.

A

The pulmonic area is found in the left 2nd intercostal space.

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4
Q

Identify and locate the surface projection on the precordium of the right atrium

A

The precordium of the right atrium is the right heart border and is found from the right 2nd intercostal space to the 3rd-4th right intercostal space.

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5
Q

Identify and locate the surface projection on the precordium of the right vetricle.

A

The precordium of the right ventricle occupies most of the anterior cardiac surface. It is a wedge-like structure behind and to the left of the sternum. The inferior border is just below the junction of the sternum and xiphoid process. It narrows superiorly and meets the pulmonary artery at the left 3rd intercostal space near the sternum.

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6
Q

Identify and locate the surface projection on the precordium of the left ventricle.

A

The left ventricle is the left lateral border of the anterior cardiac surface.

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7
Q

Locate, count, and describe the patient’s radial pulse and respiratory rate.

A

Utilize the finger pads and describe beats/min and rhythm.

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8
Q

Locate, count, and describe the patient’s carotid pulse.

A

Check for ONE carotid pulse; place the fingertips in the lower half to lower third of the neck, medial to SCM, about the level of the cricoid cartilage.

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9
Q

How do you determine the correct BP cuff size for the patient? Demonstrate this.

A

The width of the blood pressure cuff should be about 40% of the circumference of the patient’s arm. The length of the bladder (not the entire cuff) should be about 80% of the circumference of the patient’s arm.

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10
Q

What happens to BP if one uses a BP cuff that is too small for a patient?

A

BP reading is falsely elevated when the cuff is too small.

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11
Q

Describe the technique and correctly measure the patient’s BP by palpation in one arm.

A

Place the cuff on the skin about 2-3 cm above the antecubital fossa. Find the radial pulse, then blow up the cuff until the pulse disappears + 20 mmHg. Slowly release the air in the cuff (about 3 mmHg/s). When the pulse returns, this is the estimate of the systolic blood pressure.

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12
Q

Correctly measure (auscultate) BP in one extremity.

A

The patient’s arm should be relaxed with the brachial artery elevated to about heart level. Find the radial pulse, then blow up the cuff to 20-30 mmHg above the systolic BP from palpation. Air should be released from the cuff slowly. When the pulse returns, this is the estimate of the systolic blood pressure. When the pulse disappears again, this is the diastolic pressure.

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13
Q

Describe what the maximal height of the internal jugular vein represents.

A

The maximal height of the internal jugular vein indicates right atrial pressure, which reflects hydration or volume status.

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14
Q

Identify the point of maximal height of the internal jugular vein on the patient and measure the JVP.

A

From the patient’s right side, have the patient lay back (adjust table to 30-45 degrees). Point out the height of the right internal jugular neck vein by having the patient turn their head slightly to the left. Place a ruler on the sternal angle and use a horizontal surface from the point of maximal height of the right internal jugular vein. Add 5 cm to this measurement to get the patient’s JVP.

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15
Q

Palpate the precordium in 4 areas and identify the PMI (apical impulse).

A

This examination is done on the skin with the patient lying flat. You may ask the patient to roll 45 degrees to the left, exhale fully, and hold breath to find the PMI. Use the palmar surface of the hand (ball of the hand) to palpate. The 4 locations are the apex (PMI), left parasternal area (left 3rd-5th intercostal space), pulmonic area (left 2nd intercostal space), and aortic area (right 2nd intercostal space).

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16
Q

Correctly auscultate the heart in 4 locations.

A

This examination is done on the skin with the patient supine or at most 30 degrees. Use the diaphragm first; then use the bell. The 4 locations are the apex (PMI), left parasternal area (left 3rd-5th intercostal space) pulmonic area (left 2nd intercostal space), and aortic area (right 2nd intercostal space).

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17
Q

Locate and identify the area on the precordium where splitting of S2 is best auscultated.

A

Splitting of S2 is best auscultated over the pulmonic area (left 2nd intercostal space)

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18
Q

Inspect nails, palms, skin, and joints of each hand.

A

Look for nail changes, cyanosis, rashes or skin lesions, bony or muscular abnormalities, joint swelling, or erythema.

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19
Q

Demonstrate the passive and active range of motion of the following joints of the hand: distal interphalangeal, pxorimal interphalangeal, metacarpophalangeal.

A
  • Flexion/Extension

- Abduction/Adduction

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20
Q

Demonstrate the passive and active range of motion of the following joints: wrist.

A
  • Flexion/Extension
  • Radial/Ulnar deviation
  • Supination/Pronation
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21
Q

Locate, inspect, and palpate the anatomical snuff box.

A

The anatomical snuff box is the hollowed depression just distal to the radial styloid process formed by the abductor pollicis longus and extensor pollicus longus of the thumb where the scaphoid bone may be palpable.

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22
Q

Locate, inspect, and palpate the extensor carpi ulnaris tendon.

A

The extensor carpi ulnaris tendon is felt best just distal to the ulnar styloid with the wrist in ulnar deviation.

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23
Q

Demonstrate the passive and active range of motion of the elbow.

A
  • Flexion/Extension

- Pronation/Supination

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24
Q

Locate, inspect, and palpate the medial and lateral epicondyles.

A

The medial and lateral epicondyles are the bony protuberances located on the distal aspect of the humerus. The lateral epicondyle is the common extensor origin; the medial epicondyle is the common flexor origin.

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25
Q

Demonstrate the passive and active range of the motion of the shoulder (glenohumeral joint).

A
  • Flexion
  • Abduction
  • Internal Rotation (thumbs up the back)
  • External Rotation (grab the back of your neck)
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26
Q

Locate, inspect, and palpate the sternoclavicular joint

A

The sternoclavicular joint is the junction of the clavicle with the sternum.

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27
Q

Locate, inspect, and palpate the acromioclavicular joint.

A

The AC joint is located on the superior aspect of the shoulder as a small depression where the clavicle meets the acromion.

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28
Q

Locate, inspect, and palpate the spine of the scapula.

A

The spine of the scapula is a bony landmark palpated on the back of the scapula.

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29
Q

Locate, inspect, and palpate the coracoid process.

A

The coracoid process is palpated inferior to the AC joint on the anterior aspect of the shoulder; often tender to palpation.

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30
Q

Locate, inspect, and palpate the greater tuberosity and biceps tendon.

A

The greater tuberosity and biceps tendon is palpated at the proximal aspect of the humerus anteriorly.

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31
Q

Inspect and demonstrate the range of motion of the cervical spine.

A
  • Flexion (chin to chest)
  • Extension (look up at the ceiling)
  • Lateral Rotation (turn chin towards shoulder)
  • Side bending (tilt ear to shoulder)
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32
Q

Locate the spinous process of C7.

A

C7 moves with lateral rotation of the neck.

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33
Q

Inspect and demonstrate the range of motion of the thoracic and lumbar spine.

A
  • Flexion/Extension
  • Rotation
  • Side Bending
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34
Q

Demonstrate the range of motion of the hip (femoracetabular) joint.

A
  • Flexion
  • Extension
  • Abduction/Adduction (check supine with hip flexed/extended, seated, and prone)
  • Internal Rotation/External Rotation (follow the knee)
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35
Q

Locate, inspect, and palpate the greater trochanter of the femur and trochanteric bursa.

A

The greater trochanter of the femur is the bony prominence on the lateral aspect of the proximal femur. The trochanteric bursa lies on top.

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36
Q

Inspect and evaluate the knee and leg for deformities.

A

Evaluate for varus (bow-legged) and valgus (knock-kneed) alignment.

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37
Q

Demonstrate the range of motion of the knee (tibiofemoral joint).

A

Flexion/Extension

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38
Q

Locate, inspect, and palpate the quadriceps tendon.

A

The quadriceps tendon is palpated from the superior aspect of the patella to the quadriceps muscle.

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39
Q

Locate, inspect, and palpate the patellar tendon.

A

The patellar tendon is palpated from the inferior aspect of the patella to the tibial tuberosity.

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40
Q

Locate, inspect, and palpate the tibial tubercle.

A

The tibial tubercle is the bony prominence on the tibia directly inferior to the patella where the patellar tendon attaches.

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41
Q

Locate, inspect, and palpate the medial collateral ligament (MCL).

A

The MCL is located on the inside of the knee connecting the femur to the tibia.

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42
Q

Locate, inspect, and palpate the lateral collateral ligament (LCL).

A

The LCL is located on the outside of the knee, connecting the femur to the fibula. It is best palpated in the “figure four” position.

43
Q

Locate, inspect, and palpate the iliotibial band.

A

The iliotibial band is a distal tendon felt in the lateral knee.

44
Q

Locate, inspect, and palpate the medial and lateral femoral condyles.

A

The medial and lateral femoral condyles are the most distal bony prominences palpated on the medial and lateral aspects of the femur.

45
Q

Locate, inspect, and palpate the tibia.

A

Palpate the tibial plateau, proximal medial tibia (pes anserine bursa) as well as the tibia shaft.

46
Q

Locate, inspect, and palpate the fibula.

A

Palpate the fibular head (biceps femoris tendon attachment) and fibular shaft.

47
Q

Locate, inspect, and palpate the joint line.

A

Palpate the soft area just medial and lateral to the patellar tendon between the tibia and femur and proceed posteriorly.

48
Q

Demonstrate the passive and active range of motion of the ankle (talocrural) joint.

A

Dorsiflexion/Plantarflexion (occurs in the sagittal plane)

49
Q

Demonstrate the passive and active range of motion of the talocalcaneal (subtalar) joint.

A

Grasp the distal lower leg with one hand, grasp the heel with the other, and abduct and adduct the calcaneus (talar tilt, occurs in coronal/frontal plane)

50
Q

Locate, inspect, and palpate the achilles tendon.

A

Large tendinous band palpated as it inserts at the calcaneus at the posterior aspect of the ankle.

51
Q

Locate, inspect, and palpate the medial and lateral malleoli.

A

The medial and lateral malleoli are the bony prominences at the medial and lateral aspects of the ankl.e

52
Q

Locate, inspect, and palpate the plantar fascia.

A

Broad ligament on the plantar asepct of the foot that originates at the medial calcaneus.

53
Q

Locate, inspect, and palpate the plantar fascia.

A

Broad ligament on the plantar asepct of the foot that originates at the medial calcaneus.

54
Q

Locate and identify the parotid glands.

A

The parotid glands are located behind and superficial to the mandible, below the zygomatic arch and in front of the ear.

55
Q

Locate and identify the submandibular salivary glands.

A

The submandibular salivary glands are located deep to or at the inner surface of the mandible.

56
Q

Locate and identify the papillae of the ducts of the submandibular glands.

A

This is known as Wharton’s duct. It is located in the mouth at the base of the tongue on both sides of the midline lingual frenulum. Ask the patient to curl up their tonngue.

57
Q

Locate and identify the opening of the parotid glands.

A

This is known as Stenson’s duct. It is located in the mouth at the 2nd upper molar on the buccal mucosa.

58
Q

Locate and examine the trapezius muscles.

A

This tests CN XI. Place hands on the patient’s trapezius muscles and ask the patient to shrug both shoulders upward against the hands.

59
Q

Locate and examine the SCM

A

This tests CN XI. Ask the patient to turn head to each side against a hand. The SCM opposite the direction of the head turn contracts.

60
Q

Locate and identify the borders of the anterior triangles.

A

Mandible, SCM, midline of neck

61
Q

Locate and identify the external jugular vein by performing a Valsalva maneuver.

A

The external jugular vein is found behind the clavicular head of SCM or roughly about the middle third of the clavicle and then passes diagonally over the surface of SCM and up behind the angle of the mandible. A Valsalva maneuver is a forced expiration against a closed glottis. Ask the patient to bear down. The patient may need to be supine or at 30-45 degrees.

62
Q

Locate and identify the location of the thyroid gland.

A

Ask the patient to take a sip of water. Place finger pads of both hands so that the index fingers are just below the cricoid cartilage and slightly lateral to the midline. Ask the patient to swallow and feel the thyroid rising under their fingerpads. The thyroid has 2 lateral lobes and a midline isthmus; it is usually located between C5 and T1.

63
Q

Locate and identify the structures that make up the external ear.

A

Auricle/pinna: cartilaginous ear
Helix: outermost rim
Antihelix: internal to the helix
Tragus: in front of external auditory meatus

64
Q

Locate and examine the tympanic membrane with an otoscope.

A

Use an ear speculum. Stand close to the patient and pull the ear up, out, and back to straighten the canal.

65
Q

Locate and identify the pre- and post-auricular lymph nodes.

A

Pre-auricular: parotid lymph nodes infront of ear

Post-auricular: behind ear, superficial to mastoid process

66
Q

Locate and identify the occipital lymph nodes.

A

Located at the base of the skull, posterioly

67
Q

Locate and identify the submental lymph nodes.

A

Located behind the tip of the mandible (chin)

68
Q

Locate and identify the superficial cervical lymph nodes.

A

Located superficial to the surface of the SCM

69
Q

Locate and identify the posterior cervical lymph nodes.

A

Located along the anterior border of the trapezius muscles.

70
Q

Locate and identify the supraclavicular lymph nodes.

A

Located in the angle formed by the clavicle and clavicular head of SCM.

71
Q

Locate and identify the sternal angle of Louis.

A

The sternal angle of Louis is the bony ridge joining the manubrium to the body of the sternum. The second costal cartilages are adjacent to the sternal angle.

72
Q

Locate and identify the second intercostal spaces.

A

Located inferior to the second costal cargilage, which is lateral to the sternal notch.

73
Q

Locate and identify the midsternal line.

A

Vertical line that runs through the middle of the sternum and xiphoid process

74
Q

Locate and identify the midclavicular line

A

Vertical line that runs through the midpoint of the clavicle and inferiorly

75
Q

Locate and identify the anterior axillary line.

A

Vertical line running inferiorly from the anterior axillary muscle fold

76
Q

Locate and identify the posterior axillary line.

A

Vertical line running inferiorly from the posterior axillary muscle fold.

77
Q

Locate and identify the surface markings of the lungs, fissures, and lobes.

A
  1. Anteriorly, the apex of the lung rises 2-4 cm above the inner third of the clavicle. The lower border crosses the 6th rib at the midclavicular line.
  2. Laterally, the lower lung border crosses the 8th rib at the midaxillary line.
  3. Posteriorly, the lower border of the lung lies at T10. During normal breathing, the lower border may descend 5-6 cm as the diaphragm contracts.
  4. Each lung is divided in half by an oblique major fissure. This can approximated by a line from T3 posteriorly that runs obliquely down and around the chest to the 6th rib in the midclavicular line. Posteriorly above this line are the upper lobes and blow is the lower lobe.
  5. The right lung is also divided by a horizontal minor fissure. Anteriorly, this runs from the 4th rib horizontally around the chest wall to the 5th rib in the midaxillary line. Above this fissure is RUL and below is RML.

Note that the right middle lobe does not have a posterior projection. In addition, to examine the RML, you need to auscultate/percuss in the lateral and anterior chest.

78
Q

Test for respiratory expansion.

A

First, inspect the chest wall for symmetric expansion. Then, place hands on the lower posterior chest wall with thumbs at the level of the 10th rib. Grasp the lower chest wall and slide thumbs medially to raise a vertical skin fold. Ask the patient to take a deep breath.

79
Q

Test for tactile fremitus.

A

The goal of tactile fremitus is to detect palpable vibrations transmitted through the broncho-pulmonary tree. A normal patient will have normal and equal vibrations.

First, ask the patient to grab their opposite shoulder with their hands. This must be done on the skin. Place the ulnar surface of the hands on the posterior chest beginning at the top of the chest. Ask the patient to repeat the phrase “ninety-nine.” Examine in the upper, middle, and lower chest wall, and one area laterally.

80
Q

Demonstrate the technique of percussion.

A

The goal of percussion is to determine if the tissues 5-7cm deep to the percussed site are air filled (normal), fluid filled (pleural effusion), or solid (tumor/mass).

First, as the patient to grab their opposite shoulders. This must be done on the skin. Place the end of the index or middle finger firmly against the posterior chest in an intercostal space. Use the other index and/or middle finger to percuss. Flex from the wrist. Start at the top of the lungs and compare right side to left. Examine the upper, middle, and lower posterior chest wall, the lateral chest wall, and 3 areas anteriorly.

81
Q

State the five percussion notes and an example of each.

A
  1. Flat - thigh
  2. Dull - liver
  3. Resonant - normal lung
  4. Hyper-resonant - none normally
  5. Tympanic - gastric air bubble
82
Q

Describe two types of normal breath sounds.

A
  1. Tracheal - over trachea
  2. Bronchial - over manubrium
  3. Bronchovesicular - between scapula
  4. Vesicular - heard throughout the rest of the lungs
83
Q

Test for the technique of auscultation.

A

First, ask the patient to grab their shoulders. This must be done on the skin. Listen with the diaphragm of the stethoscope, compare right to left at each level. Ask patient to breathe through their mouth for a full respiratory cycle. Auscultate upper, mid, lower, and lateral lung fields, and 2-3 areas anteriorly

84
Q

Explain how to test for vocal fremitus and give one example.

A

While auscultating, ask the patient to repeat/whisper “ninety-nine” or say “EEEE.” In bronchophony, ninety-nine is heard louder and clearer. In egophony, “EEEE” is heard as a nasal “ayy.” In whispered pectoriloquy, whispered “ninety-nine” is heard louder and clearer.

85
Q

Explain how to test for vocal fremitus and give one example.

A

While auscultating, ask the patient to repeat/whisper “ninety-nine” or say “EEEE.” In bronchophony, ninety-nine is heard louder and clearer. In egophony, “EEEE” is heard as a nasal “ayy.” In whispered pectoriloquy, whispered “ninety-nine” is heard louder and clearer.

86
Q

Prepare for the abdomen examination.

A
  1. Patient should be supine.
  2. Pull out ledge for patient’s legs.
  3. Ensure the patient is appropriately draped.
87
Q

Locate and identify the rectus abdominis muscle.

A

Ask the patient to raise their head and shoulders from the supine position. These muscles run about 7-10 cm lateral to and parallel to the linea alba. The lateral border is the linea semilunaris. The rectus abdominis muscle arises from the pubic crest and inserts onto the anterior surface of ribs 5-7 and the xiphoid process.

88
Q

Locate and identify the umbilicus.

A

L3-L5

89
Q

Locate and identify the inguinal ligament.

A

The inguinal ligament extends from the pubic tubercle to the ASIS. The inguinal ligament separates the abdomen above from the thigh below.

90
Q

Locate and identify the surface markings of the four abdominal quadrants.

A

RUQ, LUQ, RLG, LLG; defined by a vertical line running through umbilicus and a horizontal line running through umbilicus.

91
Q

Locate and identify the surface markings of the colon.

A

The colon is 5 feet in length. It begins in RLG as the cecum, turns into ascending colon as it ascends to the hepatic flexure at about the 9th intercostal space. The transverse colon is the longest part; it runs from the hepatic flexure in the RUQ to the splenic flexure in the LUQ. It then turns into the descneding colon and becomes the sigmoid colon at the pelvic brim. It terminates in the rectum and anus.

92
Q

Locate and identify the surface markings of the spleen.

A

The normal spleen is located just inferior to the diaphragm in the LUQ at the level of the 9th-11th ribs, posterior to the left midaxillary line.

93
Q

Locate and identify the surface markings of the kidneys.

A

The kidneys are bean-shaped, about 11 cm long, 5-6 cm wide, 3 cm thick, and 4-5 cm from the midline at the level of T12 through L1. The kidneys are posterior/retroperitoneal. Their upper poles are protected by the 11th and 12 ribs posteriorly. The inferior poles may be 3-4 cm above the iliac crests. The right kidney is slightly lower than the left.

94
Q

Locate and identify the abdominal aorta.

A

The abdominal aorta begins as a direct continuation of the thoracic aorta at the level of T12-L1 where the thoracic aorta passes through the diaphragm at the aortic hiatus in themidline. It descendings in front of the bodies of the first four lumbar vertebrae in the midline. At L4, it bifurcates into the common iliac arteries. The total length is about 10 cm and normally its diameter is about 2.5 cm.

95
Q

Locate and identify the femoral arteries.

A

The femoral artery is a continuation of the external iliac artery as it runs posterior to th einguinal ligament at about the midpoint of the inguinal ligament.

96
Q

Auscultate the abdomen in four quadrants.

A

Place the diaphragm of the stethoscope on the abdominal wall. There are normally 5-34 bowel sounds per minute.

97
Q

Palpate for horizontal and vertical superficial inguinal lymph nodes.

A

The horizontal nodes are inferior to the inguinal ligament. The vertical nodes cluster near the upper part of the saphenous vein. Palpate medial and parallel to the femoral artery below the inguinal ligament.

98
Q

Palpate the abdomen superficially.

A

Place a flat hand on the abdomen and use gentle dipping motions to palpate in all four quadrants.

99
Q

Palpate the abdomen deeply.

A

Use two hands to palpate all four quadrants deeply.

100
Q

Palpate for the liver edge and spleen.

A

Place the right hand at the level of the umbilicus and lateral to the rectus abdominus muscle. Press gently up and in while asking the patient to take a deep breath. Repeat this, repositioning the hand closer to the costal margin. The liver edge should pass beneath the fingers as the patient takes a deep breath. Place the left hand behind the lower ribs and lift to assist.

Repeat this process for the spleen on the left side. A spleen tip is not normally felt.

101
Q

Percuss for the liver span.

A

Start at the level of the umbilicus and percuss up toward the liver (on the skin). Then, start above the liver in the lung area and percuss down toward the liver. A normal adult liver span is 6-12 cm in the right midclavicular line.

102
Q

Palpate for the kidneys.

A

In most normal adults, the kidneys are not palpable. Try to trap the lower pole of the right kidney as the patient takes a deep breath. Plate the right hand below the costal margin in the RUQ, lateral and parallel to rectus abdominus. Place the left hand below and parallel to the 12th rib. While the left hand is lifting up, ask the patient to take a deep breath. At the peak of inspiration, press deeply into the RUQ just below the costal margin. The same technique is used for the left kidney, though it is rarely felt as it is higher than the right kidney.

103
Q

With the patient in right lateral decubitus position, palpate for the spleen.

A

A spleen tip is not normally felt. Ask the patient to lay on their right side. Repeat the palpation process described previously.

104
Q

What should always be done before and after the examination?

A

WASH YOUR HANDS.

PCM (3 decks)

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