OSCE Exam Steps Flashcards
Cardio Exam Steps
End of bed inspection - pallor, pain, pillows, oedema, equipment etc.
Examine hands - colour, temp, tar, clubbing, nodules, nails etc.
Check CRT and if < 2 seconds check central RT
Examine face, eyes and mouth - pallor, oral health, jaundice, xanthelasma, Horner’s, Marfan’s etc.
Check radial pulse for rate, rhythm, character and check both sides for synchrony
Ask RE shoulder pain and check collapsing pulse
Feel carotid pulse and listen for bruit
Check JVP and mention hepatojugular reflex test
Ask for BP, RR, O2, Temp
Expose and visually examine chest and back
Palpate apex beat, palpate left sternal edge with side of hand for heave, palpate all valves with flat of hand for thrills
Auscultate mitral valve (a) with diaphragm (b) rolled onto side during expiration and (c) with the bell, rolled on side, during expiration
Auscultate tricuspid valve with diaphragm with patient inspiring
Auscultate pulmonary valve with diaphragm with patient inspiring
Auscultate aortic valve (a) with diaphragm (b) with diaphragm and sitting forward during expiration
Auscultate lung bases
Inspect and palpate for sacral oedema
Inspect and palpate for ankle oedema
Inspect for varicose veins or vein harvesting
Further assessment - ECG, echo
Abdominal Exam Steps
End of bed inspection - age, confusion, distension, jaundice, hernias, stomas, equipment etc.
Inspect hands - colour, temp, clubbing, spooning, palmar etythema etc.
Check for flap
Inspect arms for excoriations, bruising, IV drug use etc.
Inspect eyes for jaundice, pallor, inflammation etc.
Inspect mouth for candida, ulcers, angular stomatitis, glossitis etc.
Palpate supraclavicular nodes including Virchow’s node.
Inspect chest for gynaecomastia, spider naevi and hair loss
Inspect abdomen for scars, stomas, distension, caput medusae, striae, hernias, Cullen’s, Grey-Turner’s
Palpate the 9 regions of the abdomen lightly and then again but firmer
If an area is tender, see if it is more tender on pressing in or rebound
Palpate liver, spleen and kidneys
Percuss liver and spleen
Palpate abdominal aorta
Listen for bowel sounds, aortic bruit and renal bruit
Inspect and palpate ankles for oedema
Further tests - shifting dullness, hernia exam, PR exam, external genital exam
Respiratory Exam Steps
End of bed inspection - age, cyanosis, SOB, wheeze, pallor, oedema, equipment etc.
Inspect hands - temp, colour, tar, clubbing, tremor etc.
Test for flap
Check radial pulse rate, rhythm and character
Check respiratory rate whilst taking pulse
Inspect face, eyes and mouth - cyanosis, pallor, Horner’s, candida
Check the JVP and mention hepatojugular reflex
Palpate supraclavicular nodes
Inspect the chest for deformities and scars
Check trachea position
Test chest expansion on front and back
Percuss chest in multiple areas
Auscultate chest in multiple areas
Further exam - vocal resonance with 99 whilst auscultating, tactile vocal fremitus, whispered pectoriloquy, sputum, peak flow
Breast Exam Steps
Have a chaperone and have patient undress from waist up
If patient has a lump, palpate the ‘normal’ breast first
Visually inspect breasts - scars, lumps skin puckering, nipple discharge, inversion, asymmetry etc.
Ask patients to hold their arms above their head and inspect again
Ask patient to push their hands into their hips and inspect again
Palpate all 4 quadrants of the breast
Palpate all 5 areas of the axilla
Palpate infra and supraclavicular lymph nodes
Palpate liver, listen to lung bases and palpate spine for mets
Further investigation - mammogram and/or US, biopsy, drainage, removal of lump
DRE Exam Steps
Ask patient to undress from waist down and lie on side with knees to their chest
Inspect the perineum
Encourage patient to relax and explain what you’re going to do
Insert lubricated finger into the rectum
360 sweep + palpate prostate in males
Ask patient to clench to assess tone
Remove finger and inspect for blood, faeces etc.
Cranial Nerves I - VI Exam Steps
Sit patient on chair about an arms length away facing you
Note their speech for any slurring or other abnormalities
Inspect head and neck for any obvious deformity of eyes, eyelids, mouth, limbs etc and check for any equipment
Test CN I (olfactory, sensory) - ask RE any changes in taste or smell, mention Pennsylvania smell test
Test CN II (optic, sensory)
- Test visual fields by each covering same eye (e.g. you cover left, they cover left) and seeing if patient can see your fingers
- Test inattention with patient focusing on nose whilst you wiggle fingers
- Test acuity with snellen chart at 6m, if vision is poor can go to 3m, then fingers, then hand movement, then light
- Assess optic disc with fundoscope
Test CN III (oculomotor)
- Assess size, shape and symmetry of pupils
- Test direct and consensual reflexes
- Test accommodation reflex with patient looking at back and forth between your finger and a distance object
Test CN III, CN IV (trochlear) and CN VI (abducens)
- Test eye movements with H pattern
- Ask about diplopia
- Inspect eyelid movement and position
Test CN V (trigeminal, sensory and motor)
- Assess facial areas with neurotic for pin prick sensation then cotton wisps for light touch
- Test corneal reflex with cotton wisp
- Test muscles of mastication by clenching jaw and have patient try and open mouth as you push on chin
Cranial Nerves VII - XII Exam Steps
Test CN VII (facial, sensory and motor)
- Ask about loss of taste and noise sensitivity
- Inspect face for symmetry
- Patient to raise eyebrows to test frontalsis
- Patient scrunch eyes shut and resist opening to test orbicular oculi
- Patient to blow out cheeks and resist to test orbicular oris
- Smile to test levator anguli and zygomaticus
- Purse lips to test orbicular oris and buccinator
Test CN VIII (vestibulocochlear, sensory)
- Whisper phrase in one ear whilst blocking the other and ask to repeat back
- Rhinne’s test with tuning fork on mastoid process and in front of ear
- Weber’s test with tuning fork on forehead
- March on spot with eyes closed
Test CN IX (glossopharyngeal) and CN X (vagus)
- Ask about problems with cough, swallow or voice
- Inspect soft palpate and have patient say ahhh to see uvula elevation
- Ask patient to cough
- Mention stimulating gag reflex
Test CN XI (accessory, motor)
- Assess neck rotation and shrugging against resistance
Test CN XII (hypoglossal, motor)
- Inspect tongue for wasting, fasticulations, deviation
Male Genital Exam Steps
Inspect penis, groin and abdomen visually
Inspect scrotum and perineum visually
Palpate penis and retract foreskin if present
Palpate testes starting with ‘normal’ side - looking for shape, size, location, consistency, fluctuance, transillumination
If any masses are present ask patient to cough asnd see if you can palpate above it to check if it’s a hernia
Cremastatic reflex for testicular torsion
Inspect scrotus with patient standing
Peripheral Vascular Exam Steps
End of bed inspection with legs exposed for scars, missing limbs, walking aids, equipment etc.
Inspect and compare upper limbs for cyanosis, pallor, temperature, gangrene, xantholasma, tar staining etc.
Feel the temperature of the hands and check CRT
Take radial pulse and check rate, rhythm and character
Check for radial-radial delay
Palpate brachial pulse
Measure blood pressure
Palpate carotid pulse and auscultate for bruits
Palpate the abdominal aorta and listen for abdominal and renal bruits
Inspect and compare the lower limbs for cyanosis, pallor, temperature, ulcers, gangrene, muscle wasting, hair loss
Ask patient to wiggle toes to check for paralysis
Feel temperature of the hands and check CRT
Feel for dorsal pedis, posterior tibial, popliteal and femoral pulses
Bergers test - hold patients legs at 45 degrees for 1-2 mins and see if pallor changes which suggests poor perfusion
If pallor is present then have patient swing legs off side of bed, an ischaemic limb will go blue and then red
Further tests - CVS exam, peripheral nerve exam, ABPI
Hernia Exam Steps
Chaperone and expose patients abdomen and femoral area
End of bed inspection - pain, scars, swellings, distension, cachexia, pallor, visible hernias, stomas, equipment etc.
Assess the groin - a hernia will be single, expand on cough unless incarcerated, soft, reducible unless incarcerated, painless unless incarcerated, unable to be palpated above
Examine the scrotum in male patients
Further exams - external genitalia, abdominal exam, DRE
Upper Peripheral Nerve Exam Steps
Tone, Power, Reflexes, Coordination, Sensation
Visually inspect for wasting, fasciculations, scars, lesions, symmetry, abnormal movements etc
TONE
Look for clonus, cog wheeling etc. by supporting limb with one hand and moving it with the other
- Circle shoulder
- Move forearm towards upper arm and back down
- Circle wrist
POWER
- Shoulder abduction (C5, axillary): patient crosses arms and tries to push up against resistance
- Elbow flexion (C5/6, musculocutaneous): arm flex and try to pull in against resistance
- Elbox extension (C7/8, radial): arm flex and try to push out against resistance
- Wrist extension (C6/7, radial): make a fist and push up and down against resistance
- Finger ab/adduction (T1, ulnar): paper test and push fingers out against resistance
Thumb opposition (T1, median): make O
Hand grip (C8/T1, median and ulnar): pull on your thumbs
REFLEXES
- Biceps (C5/6)
- Triceps C7/C8) – patient crosses arm to opposite shoulder
- Supinator reflex (C5/C6) – radial side of arm
- Can be reinforced by clenching teeth
COORDINATION
- Hand flipping over
- Finger from nose to your finger
SENSATION
- Start distally and move inwards
- Look for stocking and glove
A-E Assesment
Airway
Check air way by talking to patient Look inside mouth Head tilt, jaw thrust Tracheal access Call aesthetics if airway compromised
Breathing
Resp rate, SpO2 100% O2 if required with trauma mask Check chest expansion Tracheal position Listen to lungs Percuss lungs Salbutamol if wheeze Nebulisers if asthma/COPD Catheter for tension pneumothorax - 2nd ICS mi clavicular or 4th/5th ICS mid axilla Portable CXR request
Circulation
HR, BP, Temp, CRT, UO if possible
2 wide bore cannulars
Take VBG, cultures, G&S, FBC, U&E’s, LFT’s, CRP and then depending on cause consider troponin, TFT’s, Ca2+, Mg+, paracetamol level, D-dimer, ABG
Fluid resuscitation of hypotensive - give 500ml bolus over 15 minutes (less if CCF, overload, renal failure, frail) and then reassess blood pressure, can be repeated 4 times
Listen to lungs before giving any more fluid to check for overload
ECG may help
Disability
Assess consciousness via AVPU - Alert, Verbal, Pain, Unresponsive
GCS if more detail needed
Pupil size, shape, symmetry and reflexes
Blood sugars
CT head if required
Exposure
Lower Peripheral Nerve Exam Steps
Tone, Power, Reflexes, Coordination, Sensation
Visually inspect for wasting, fasciculations, scars, lesions, symmetry, abnormal movements etc
Ask patient to walk if they are able and assess their gait
TONE
- Pastry roll each leg
- Lift leg by knee and move ankle up and down
- Quickly dorsiflex foot to check for ankle clonus
POWER
- Hip Flexion (L1/2, lumbar plexus): tries to lift leg against your resistance
- Hip extension (L5/S1, inferior gluteal): pushes leg down against resistance
- Knee flexion (L5/S1, sciatic): tries to pull foot to bum against resistance
- Knee extension (L3/4, femoral): bent knee and tries to kick against resistance
- Ankle dorsiflexion (L4/5, deep peroneal): try to pull foot against resistance
Ankle plantar flexion (S1/2, posterior tibial): try to push foot down against resistance
Dorsi and plantar flexion of big toe
REFLEXES
- Knee (L3/4)
- Ankle (L1/2)
- Plantar (L5-S2)/Babinski - stroke sole of foot, UMN
- Can be reinforced by patient hooking their fingers together and pulling apart
COORDINATION
- Bring foot to opposite knee then run down shin several times
- Romberg’s - feet together, eyes closed
SENSATION
- Start distally and move inwards
- Look for stocking and glove
