OSCE Book- History and examination Flashcards
Please take a history from this fit and healthy 40 year old lady who has been suffering from facial pain.
What features of the pain would lead you to suspect she was suffering from atypical facial pain?
- Introduce yourself to the patient
- Chief complaint - you need to determine the patients chief complaint, so start by asking them what the problem is or why they came to see you today. Record their complaint in their own words.
- History of presenting complaint. SOCRATES.
You are a CT in OMFS department. This patient has been referred with pain and clicking in the TMJ. Please examine the patients masticatory systemand carry out an E/O examination.
- Introduce yourself politely to the patient.
- Start with the extra-oral examination.
- Check facial symmetry, lip competence, any gross facial/ developmental abnormalities. - Palpate the neck nodes.
- Palpate the left and right TMJs to determine if there is pain or tenderness to touch. The TMJs should be palpated while the patient opens their mouth slowly. This can be done by placing your fingers over the joints or in the patient’s ears.
- Any noises from the joints should be noted.
- Watch the path traced by the tip of one of the lower central incisors throughout the opening and closing cycle.
- Any association between a change in direction of movement and a noise from the joint should also be noted.
- The TMjs should now be palpated throughout lateral and protrusive excursions.
- Measure the maximum opening between the incisor tips (normal is around 45 mm).
- Measure the lateral and protrusive excursions (normal is around 10 mm). - Palpate the muscles of mastication. The masseter and temporalis are palpated extra-orally. The lateral pterygoid can be evaluated by asking the patient to try to open their mouth while you try to restrict the movement by placing your hand under the chin.
- I/O exam.
i) Soft tissue exam, look for any evidence of wear. Linea alba of the buccal mucosa etc
ii) Note teeth present and their condition
iii) Note any pattern of tooth wear
iv) Examine the ICP and RCP
v) Examine GP and Canine guidance in later and protrusive movements
vi) note any displacements
Joint noises
- A click implies that there is a displaced disc that reduces to a normal position.
- Crepitus or grating noises imply degenerative changes within the joint
Mandibular movements
- Obstruction of movements within the joint will cause the mandible to deviate on opening and closing.
You are a career development post trainee in an oral and maxillofacial unit. A 44 year old lady has been referred in as she is complaining of weakness on one side of her face. Please examine the patients cranial nerves.
Introduce yourself politely to the patient.
Examine the cranial nerves.
There are 12 cranial nerves:
1 - Olfactory nerve: sense of smell.
CHAPTER 1
Answers
Ask the patient if their smell is altered.
* Test with aromatic substances.
II - Optic nerve: sight.
Ask the patient about their sight.
* Check visual acuity (see station 1.5)
III - Oculomotor nerve: motor to the extraocular muscle except superior oblique and lateral rectus.
IV - Trochlear nerve: motor to the superior oblique muscle.
VI - Abducens nerve: motor to lateral rectus.
* III-VI - Test the eye movements in all directions.
V - Trigeminal nerve: sensory to facial skin and oral mucosa, motor to the muscles of mastication.
Check all three divisions: ophthalmic, maxillary and mandibular.
Is the sensation of the skin of the face normal over all these divisions?
Does the patient have a corneal reflex? Tell the examiner you would check for corneal reflex but do NOT perform unless asked to do so by the examiner as it is unpleasant for the patient (especially if done repeatedly as in an examination).
Can the patient clench her jaw muscles?
VII - Facial nerve: motor to the muscles of facial expression, sensory to the external auditory meatus, taste sensation to the tongue, branch to the stapedius.
. Can the patient pout, whistle, smile, wrinkle her forehead or raise her eyebrows, screw up her eyes, or blow out her cheeks?
*NB: Nerve supply to the forehead is bilateral so forehead movements are not affected in upper motor neurone lesions.
VIII - Vestibulocochlear nerve: hearing and balance.
* Can the patient hear normally?
Block one ear by pressing on the tragus and whisper a number (eg 99) and get the patient to repeat the number. Repeat the test blocking the other ear.
IX - Glossopharyngeal nerve: supplies the stylopharyngeus muscle and taste in the posterior third of tongue (injury
leads to absence of gag reflex, absence or diminished).
* Ask the patient to say ‘aahh’ and look for deviation of the uvula and movements of the soft palate.
X - Vagus nerve: supplies structures in neck, thorax and abdomen.
Ask the patient to say ‘aahh’ and look for deviation of
the uvula.
Tell the examiner that you will test the gag reflex,
although this is not reliable, and is unpleasant for the patient.
XI - Accessory nerve: innervates sternomastoid muscle and
trapezius.
* Can the patient shrug her shoulders?
XII - Hypoglossal nerve: motor to tongue muscles.
Ask patient to protrude her tongue. Is the tongue symmetrical in movement and bulk?
Tongue deviates to the side of the lesion.
Please examine the swelling in the front of the neck of a 30 year old women.
- Intorduce yourself politely to the patient
- The neck of a seated patient is observed from the front
- Ask the patient to swallow (offer a glass of water to the patient)
- Stand behind the patient and palpate the thyroid gland
- Percuss the manubrium for retrosternal extension
- Auscultate for bruit
- Palpate the triangles of the neck and supraclavicular fossae for lymph nodes
Lumps in the neck can be divided into benign and malignant. Alternatively they can be classified by their location. After you have examined the patient it is important that you are able to answer the following questions.
- Is there a single lump or are there multiple lumps? Multiple lumps usually indicate lymph nodes.
- where is the lump
- Is the lump solid or cystic ?
- Does it move with swallowing or on protrusion of the tongue?
Malignant lumps
- These can be primary, eg thyroid, or secondary (metastatic) ie lymph nodes
Benign lumps
- Congenital; lymphangiomas, dermoid cyst, thyroglossal duct cyst, branchial fistulae
- Acquired. ranulae, laryngoceles, pharyngeal pouches
- Infective bacteria or viral
- Neurogenous tumours neurofibromas, cartoid body tumours, glomus jugulare tumors.
Please examine visual acuity and other eye signs in this 21 year old man who was involved in a fight. He sustained injuries to his face and there is significant swelling of the left eye. A Snellen chart is provided.
Introduce yourself politely to the patient.
Demonstrate visual acuity (6/6 normal) of each eye using the
Snellen chart.
Assess for pupillary reaction to light - direct and consensual.
Assess for diplopia in the nine cardinal positions - stand at least 1 m away from the patient and use a pin or your finger.
Inform the examiner that you would examine for vertical displacement of the globe (hypoglobus), enophthalmos and exopthalmus (proptosis).
Comment
Central vision is tested by using the set of letters on a Snellen chart. Vision is expressed as a fraction of normal (normal is 6/6).
The patient is positioned 6 m from the card. Ask the patient to cover each eye in turn and tell you which is the smallest line of print that they can read comfortably. If the patient is only able to read down to the 12 m line, their visual acuity is 6/12. These figures are written on each line of the chart.
(See Snellen chart overleaf.)
Pupillary reaction to light: direct constriction is mediated by the oculomotor nerve (efferent pathway) whereas indirect constriction is mediated via the optic nerve (afferent pathway).
You are a dentist in a dental practice seeing a new patient who has come in for a check up. Please take a medical history from the patient.
Introduce yourself to the patient and use the MH form. If this is not available then go through a systematic way of taking a MH.
Allergies
Bleeding disorders
CVS and respiratory
Drugs
Endocrine
Fits and faints
Gastointestinal
Hopsital admissions
Infection
Jaundice and liver disease
Kidneys
Likely hood of pregnancy
Mental illness
Neurological
Good practise to ask alcohol and smoking frequency and amount.
Also ask who there GP is and if there is anything they think the dentist should know before starting treatment.
A fit and healthy 24 year old male patient has suffered from a punch to the side of the lower jaw at a party on saturday. It is now monday morning and he is attending the ED. You are a DFY2 in MAFS unit. Please take a detailed history from the patient regarding the injury.
(you are not expected to take a full MH and SH at this time as wont have enough time)
Any history taken from a patient follows the same routine, ie patient’s complaint, history of present complaint, medical history, social history and dental history. With patients who have suffered trauma there are a few other points to consider.
Introduce yourself politely to the patient.
Patient’s complaint - You need to ascertain their chief complaint and write it in the notes in their own words.
History of present complaint - Gain as much information as possible about the injury. Therefore, you need to know about:
Exactly how was the patient injured?
What was he hit with?
How many times was he hit?
What direction the blow(s) came from?
Did he lose consciousness, if so for how long and how has this been dealt with?
(f) Was the alleged assault witnessed and if so by whom?
(g) Are the police involved?
(h) Was any treatment sought initially?
(i) Was the patient under the influence of any substances when the injury occurred (eg alcohol or drugs)?
4 You need to find out about the symptoms that the patient is experiencing now with respect to:
Pain - SOCRATES
Loss of or altered function related to:
* The mandible - movement, occlusion, speech, swallowing
* Nerve injury - paraesthesia/anaesthesia of the trigeminal nerve?
Bleeding from ears.
You also need to find out whether the patient has shown any signs of a head injury since the time the injury occurred (although in this case the patient has been cleared by the ED staff).
After taking a comprehensive history from the fit and healthy 24- year old patient. You suspect that he has a fractured mandible. The doctors in the ED have performed a general examination and the patient does not have a head injury or any other injuries that need examining. Please examine the patient with regard to his suspected fractured mandible only. What radiographs would you ask to be taken to demonstate his injury.
Examination of all patients follows the same standard pattern. You start by doing a general examination and then move to the specific problem. The general part of the examination starts as soon as the patient moves into the room, as you are observing them. The history and the degree of trauma sustained will determine whether a whole body examination is warranted. In this question, a whole body examination has not been asked for; in fact the question asks you to concentrate on the mandibular injury alone. This is slightly artificial, as in normal practice you would be examining the whole of the facial skeleton to discount other injuries.
Introduce yourself politely to the patient.
Explain to him what you are trying to do.
Extra-oral
Look at the patient from directly in front and from the same level as the patient and note any asymmetry.
Look for any swelling, bruising, lacerations and remember to look behind the ears for bruising and for any evidence of bleeding or CSF leaking from the ears.
Check whether the patient has any sensory disturbance of the skin of the lower lip - this indicates damage to the inferior dental herve.
Palpate the mandible gently (remember it will be uncomfortable for the patient) from the condyle to the symphysis on both sides. This will allow you to feel any step defects in the continuity of the bone and also any swelling or discomfort in a particular region(s).
Ask the patient to carry out mandibular movements and watch the degree of mouth opening and deviation of the mandible. Palpate the condyles while the patient is trying to carry out the mandibular movments
Intra-oral
8 Check for any bruising or swelling within the mouth, especially in the buccal sulci and sublingually.
* Check for any lacerations within the mouth, especially gingival tears.
If there are any empty sockets, the missing teeth must be I scounted for as there is always the possibility that a patient has inhaled a tooth that has been avulsed following trauma.
Check for any loose or fractured teeth, or fractured dentures.
Check the occlusal plane for any step(s).
Check the occlusion - presence of certain malocclusions will give you a clue about where the fracture in the mandible is, eg an anterior open bite is seen with bilateral fractured condyles.
Ask the patient to carry out a full range of mandibular movements and note where discomfort is felt if movement is limited.
It is possible to hold the mandible with two hands and check for movement across a suspected fracture. However, only do this when there is no other way to determine whether the area is fractured and only gently, as it will cause the patient pain and may turn an undisplaced fracture into a displaced fracture.
Comment
Radiographs that are commonly taken to show fractured mandibles are the dental panoramic tomogram and posterior-anterior mandibular radiographs. However, if a fractured condyle is suspected it may be visualised in a reverse Towne’s view.
Some anterior mandibular fractures may be visualised in a lower anterior occlusal view. Cone beam CTs or medical CTs may also be taken to visualise fractured mandibles.
