OSCE

Question 1

Splinter haemorrhage -CVS

Answer 1

Dark red/brown vertical lines seen at the top of the nail. They are small emboli lodged in the nail capillaries damaging vessel walls and causing localised haemorrhage. Causes include trauma, sub-acute bacterial endocarditis, scleroderma, and other autoimmune conditions.

Question 2

Osler’s nodes CVS

Answer 2

These painful, small, red lesions appear on the fingers. They are the result of immune complex deposition from bacterial endocarditis.

Question 3

Janeway lesions

Answer 3

Painless red spots appearing on the palms. Patients with bacterial endocarditis may develop these lesions from septic emboli causing microhaemorrhage.

Question 4

Fingertip pallor

Answer 4

Fingers appear white and waxy as a result of vasoconstriction or vascular obstruction. Conditions associated with this include peripheral vascular disease, Raynaud’s, Buerger’s disease and CREST syndrome.

Question 5

Clubbing different causes

Answer 5

Causes
Respiratory:

Cystic fibrosis
Tuberculosis
Pulmonary fibrosis
Bronchiectasis
Bronchial carcinoma

Cardiac:

Atrial myxoma
Cyanotic heart disease
Endocarditis
Pericarditis

Gastrointestinal:

Malabsorption
Inflammatory bowel disease
Liver cirrhosis

Question 6

Asterixis: Carbon dioxide retention flap

Answer 6

Asterixis is a coarse tremor best seen with the patient’s wrists extended. It can be caused by hypercapnia, typically in conditions such as chronic obstructive pulmonary disease (COPD) and hypoventilation secondary to reduced consciousness level. Asterixis can also be caused by hyperammonaemia and uraemia.

It can be a sign of hepatic encephalopathy, usually related to long-term alcohol excess, and indicates high levels of ammonia in the blood sufficient to impact on the motor centres of the brain. Other causes include hypercapnia (as discussed previously) and uraemia.

Question 7

Tendon/tuberous xanthomata

-Hepatology

Answer 7

Yellow nodules typically noted over the dorsal aspects of the hands. Lipid-laden macrophages are deposited as the result of hypercholesteraemia.

Question 8

Leukonychia

Answer 8

These white, horizontal bands across the nails are the result of low albumin levels in the blood. This can be the result of either decreased albumin synthesis, as seen in liver disease, or the result of increased albumin loss, usually the result of kidney malfunction (nephrotic syndrome). Leukonychia may also be the result of chemotherapy treatment.

Question 9

Palmar erythema

Answer 9

Reddening of the palms from vasodilation. Associated pathology includes liver disease and resultant oestrogen excess, and hyperthyroidism.

Question 10

Koilonychia

Answer 10

Classically described as ‘spoon-shaped’, these nails appear hollowed out or concave. They are associated with low levels of iron; this could be severe iron-deficiency anaemia, haemochromatosis, fungal infection, acromegaly, hypothyroidism or malnutrition.

Question 11

Nail pitting

Answer 11

Small indentions of the nail. Pathophysiology is unclear but this pitting is most commonly seen in patients with psoriasis.

Question 12

Dupuytren’s contracture

Answer 12

The 4th digit (or ring finger) is in a fixed-flexed position, with the tendon raised and visible on the palmar surface. This appearance is the result of thickening and shortening of the palmar fascia, possibly due to local hypoxia. Associations include smoking, alcohol use, diabetes, manual labour and trauma.

Question 13

Uvula deviation:

Answer 13

may be caused by a peritonsillar abscess, with the uvula deviating away from the abscess. A glossopharyngeal nerve lesion can also cause uvula deviation away from the side of the lesion. If there are no other symptoms or signs, uvula deviation is likely a normal finding.