OSCE Flashcards
check basic ability for a neuro exam
ask where they are, what time of day is it, how did they get there etc.
general observation neuro
Look at skin /head for neurofribomatosis – skin tumours and nodules on their nerves and associated with seizures –
Look for tea stains on the face indication of disease
Look for cochlear nerve implants
Look for ptosis
Exopthalmos
Examine the 1st cranial nerve
Ask if changes in sense of smell – (loss of smell= anosmia- often due to upper respiratory tract infection, smoking, or old age)
If he’s noted a change in smell, ask him to close his eyes, ask him to smell coffee – or oranges – one nostril at a time – ask him if there is any difference in the smells
examine the 2nd cranial nerve
Ask him if he has any problems seeing
Ask him to look at clock on the wall “can you see that?”
If he cannot read the clock, check visual acuity with a snelling test
*ask to take glasses off for this Test* every ‘quadrant’ of his eye (temporal upper/lower, nasal upper/lower)– cover your eye the same for comparison – test his field of vision in comparison to your own – test “tell me when you can see them, tell me when they start moving, tell me when they stop moving” *note that when you are testing the other side of his visual field and you switch hands covering your eye, you should tell the patient “I am going to switch hands, but I want you to keep your hand exactly where it is ok?”
Test Color vision
Look in their eye for Fundoscopy
test the 3rd, 4th and 6th cranial nerve
Pupil – check direct and consensual reaction to light – put hand as wall between two eyes to prevent light spillover (Make sure to make it very obvious that you’re looking in the other eye)
i.Marcus gun pupil? – you get a paradoxical dilated pupil when light is presented back and forth between eyes
Test Accomodation reflex= ask patient to look into the distance and then tell them that you’ll be putting your finger in front of their face- when you tell them to look, as them to look at your finger
Eye movements – do H shape
i. Ask if they observed any double vision – if they did it’s an indication that there is an issue with one of the nerves
ii. Mention to the observer if you saw any nystagmus
Observe any obvious ptosis or partial ptosis
Look for nystagmus – follow eyes out as far as they can go and then if it’s pathological it will start twitching back and forth (test horizontal and vertical)
test the 5th cranial nerve
Look for wasting of the temporal and masseter muscles
Ask patient to clench their teeth and palpate for masseter muscle
Open mouth and hold open when examiner tries to close their mouth – testing pterygoids
Test each section of the face for sensory – soft touch and sharp touch – make sure to ask the patient to say “sharp” or soft – be sure to test on their sternum first
Jaw jerk reflex – don’t do in practice - but put thumb over chin and malate the thumb - jaw should close – it would be much faster/hyperreflexia if upper motor neuron lesion
Corneal reflex – don’t do in practice – but if she asks you come in from the side so they don’t blink, then light touch the cornea over their colored part of eye
test the 7th cranial nerve
Inspect for facial asymmetry “There doesn’t appear to be any obvious facial asymmetry”
Ask patient to raise eyebrows and you should see wrinkling of the forehead – try to push their forehead muscle down
Ask patient to close eyes hard and try to open them
Ask them to push cheeks out and try to push them in
Ask them to show teeth
when you talk to them say “blow your cheeks out and don’t let me push them back in
change in sense of hearing?
Change in taste?
test the 8th cranial nerve
Ask them if they’ve noticed any changes in their hearing lately
Whisper – 100 for low frequency and 68 for high frequency in both ears ask them to repeat the number
Rinne’s test – put tuning fork at mastoid process and then just outside of ear- he should be able to hear air conduction better than by bone conduction – wait until mastoid hearing is gone before you place outside of their ear
Weber’s test – put on forehead and ask “can you hear it better in one ear”? – if you heard it better in one ear, that’s the ear that is effected
Test vestibular nerve with rombergs test- tell them to stand and close their eyes and try to balance
test the 9th, 10th and 12th cranial nerve
Look at uvula and if it’s deviated ask the patient to say “ah” to properly see any deviance
Ask patient to speak to assess hoarseness – and recurrent laryngeal nerve
Ask patient to cough
Ask patient to stick out their tongue and move it from side to side – it will deviate towards the weaker side if there is a unilateral lower motor lesion -note any fasciculation or wasting
test the 11th cranial nerve
Note whether there is any muscle wasting or fasciculation
Test trapezius – try to push down against it
Test sternocleidomastoid muscle- ask them to put chin to their shoulder – try to push against chin
General inspection - respiratory
Equipment
Surrounding the bed - O2delivery, chest drain, IV access, ECG monitor, and catheter bag
On bedside table – inhalers/nebulisers, physiotherapy devices, sputum pot, nutritional supplements
Mobility – walking frame, wheelchair
Patient
Is the patient comfortable?
Dyspnoea at rest
Tachypnoea- rapid respiratory rate, count respiratory rate - [Should not exceed 14 breaths/min @ rest]
Are accessory muscles of respiration being used?
hand examination - respiratory
- Tar staining
- peripheral cyanosis
- clubbing - fluctuation
- wasting of thenar/hypothenar eminence
- flapping tremor
- pulse
- blood pressure
what are the respiratory causes of clubbing?
bronchial carcinoma
lung absess
cystic fibrosis
pulmonary fibrosis
asbestosis
what can cause asterixis?
CO2 retention -
liver disease
acute renal failure
Take a blood pressure
examine the face from a respiratory perspective
Eyes
Examine conjunctiva for pallor (anaemia)
Look for Horner’s Syndrome -Ptosis, miosis, anhydrosis and enophthalmos.
Central cyanosis – examine tongue
peripheral cyanosis - lips
JVP
Upper Respiratory tract infection
Reddened pharynx
Enlarged tonsils
Tooth Decay
Examine for Tracheal Deviation
Is the trachea central or is it deviated from the midline? Explain to the patient that you are going to press gently on their neck and that it may be a little uncomfortable.
Use the forefinger of the right hand to palpate for the position of the trachea above and backwards from the suprasternal notch.
If displacement of trachea is present its edge rather than its middle will be palpated and a larger space will be present on one side than the other.
what can cause a tracheal deviation ?
Causes of tracheal deviation
Towards the lesion
- Upper lobe fibrosis
- Upper lobe collapse
- Pneumonectomy
Away from the lesion
- Tension pneumothorax
- Massive pleural effusion
examine the chest from a respiratory perspective
- general inspection
Inspection
Chest wall abnormalities
Pectus Excavatum- Depression of lower end of sternum. A developmental defect. In severe cases lung capacity may be restricted.
Barrel-shaped -
Kyphoscoliosis- Severe kyphoscoliosis may reduce lung capacity and increase the work of breathing.
Scars From previous thoracic operations.
Chest drains.
Thoracotomy scars.
Traumatic scars.
Look for asymmetry of chest wall movement anteriorly and posteriorly.
Unilateral reduction in chest wall movement may be due to consolidation/pleural effusion/pneumothorax.
Bilateral reduction of chest wall movement indicates a diffuse abnormality such as COAD/diffuse pulmonary fibrosis. A large effusion, pneumothorax, area of collapse etc in one lung can cause asymmetrical movement.
examine the chest from the respiratory perspective
- palpate
Find Apex Beat
Chest expansion
Tactile Fremitus - palpate while saying ‘ninety-nine’
percuss the chest
don’t forget to percuss supraclavicular area and directly onto the clavicle
sound should be resonant throughout the lungs
ascultate the breath sounds
use bell to listen to lung apices
and listen down where you percussed
palpate the posterior chest wall
- chest wall expansion - ask them to ‘hug a pillow’
- vocal fremitis - ask them to say ‘ninety nine’ with edge of palm on their back
percuss their posterior chest don’t forget the lateral aspects
auscultate the posterior back
auscultate using diaphragm all the way down the back
general inpection from foot of bed of patient from Cardiovascular perspective
Comment on general appearance, weight loss, chest symmetry(or lack thereof) or pulsations, and the presence of any scars.
Comment on the presence of any equipment around the bed like oxygentanks, IVdrips, medications, or walking aids.
examine the hands of patient from cardiovascular perspective
- tar staining
- peripheral cyanosis
- clubbing (fluctuance)
- splinter haemorrhages
- palmar crease pallor
oslers nodes
janeway lesions
xanthomata
examine the arms from a cardiovascular perspective
look for scars, rashes, or bruises
- take a pulse of both wrist for 15 seconds
- comment on the rate/rhythm of the pulse
- take blood pressure
examine the face from a cardiovascular perspective
eyes: zanthelasma, yellow sclera, corneal carcus (hyperlipidemia)
mouth: high arched palate (marfan’s syndrome), tooth decay, peripheral and central cyanosis
examine the neck of the patient from the cardiovascular perspective
- palpate the carotid pulse by placing hand medial to the SCM muscle
- examine the JVP - ask them to turn their neck so you can see the two heads of SCM, you should see a small pulsation in between the two SCM heads - visible but not palpable. If it is distended, ablate it and see if it fills from the top, you can do the hepatojugular reflux technique as well
examine the chest from a cardiovascular perspective
look for sternotomy scars (sternum) or thoracotomy scars (side of sternum) or pacemaker scars - comment on any rashes
palpate the chest from the cardiovascular perspective
find the apex beat
test for thrills - murmers
test for heaves - hypertrophy
auscultate the heart valves
use the bell AND The diaphragm for all of the valves
- listen to all four valves and also as the patient to lean forward and completely exhale - listen to the lower left sternal border to test for aortic regurg.
- also you can listen to the carotid artery with the diaphragm to check for aortic stenosis
