OSCE examinations Flashcards
Hip exam structure
Start with patient lying down:
- Look
- Feel
- Move
- Special test (Thomas)
Patient standing up:
- Look
- Function (gait)
- Special test (Trendelenburg)
If time: neurovascular integrity
- Dorsal and sole of foot sensation
- Dorsalis pedis, posterior tibial, CRT
Hip exam: Thomas test
- Pt lying supine
- Hand in hollow of lumbar spine
- Passively flex hip
- Feel for flatting of lumbar spine (pushing down into your hand)
Positive = non-flexed thigh lifts up off bed = fixed flexion deformity
Hip exam: Trendelenburg test
- Sit on chair with patient stood in front of you
- Ask pt to hold onto your shoulders
- Hands on hips, thumbs over ASIS
- Ask pt to stand on one leg at a time (good leg first)
Normal = pelvis tilts UP on unsupported side
Positive (abnormal) = pelvis DROPS on unsupported side
Positive = aBductor instability
Knee examination structure
Start with patient lying down:
- Look (including measure thigh circumference)
- Feel (including patellar tap + sweep test)
- Move
- Special tests
With patient stood up:
- Look
- Function (gait)
If time, neurovascular integrity:
- Dorsalis pedis, posterior tibialis, CRT
- Sensation on dorsal and sole of foot
Knee exam: anterior and posterior drawer test
- With pt supine, flex knee to 90º
- Start by looking for posterior sag from side (PCL injury)
- Sit on foot, forearm on tibia
- Hands behind knee, thumbs on tibial tuberosity
- Pull tibia forward
- Push tibia backwards
Positive anterior drawer = ACL injury
Positive posterior drawer = PCL injury
Knee exam: McMurray’s
- Flex knee and hip to 90º
- Hold foot, internally rotate foot
- Hold knee with thumb+index finger on each side of joint line
- Straighten knee (still internally rotated) - FINDING
- Repeat with foot externally rotated, and on other side
Positive test = popping/clicking/pain = meniscal tear
Knee exam: collateral ligament stress test
- Flex knee to 15º
- Hold foot with one hand, support knee with other
- Apply pressure to each side of knee
Positive = laxity = MCL/LCL weakness
What special tests do you do for a knee exam?
- Anterior and posterior drawer (ACL, PCL)
- Lachman’s (alternative to anterior drawer) (ACL)
- Collateral ligament stress test (MCL, LCL)
4 McMurray’s (meniscus)
GALS: screening questions
- Do you have any pain or stiffness in your joints, muscles or back?
- Can you dress yourself completely without any difficulty?
- Can you walk up and down stairs without difficulty?
GALS exam: spine
Cervical spine ROM:
- lateral flexion
- flexion
- extension
- rotation
Lumbar spine:
- flexion
- confirm flexion by placing fingers on vertebrae and watching for separation
GALS exam: arms
Shoulders:
- “Put both hands behind your head” = aBduction, external rotation, elbow flexion
Hands:
- Squeeze MCP joints
- Pronation and supination
- Power grip (“squeeze my fingers”)
- Fine pincer grip (“touch your thumb to each finger”)
GALS exam: legs
Hips and knees:
- Patellar tap
- Active flexion (“bring your knee to your chest”)
- Passive internal rotation
Feet:
- Squeeze MTP joints
Foot and ankle exam: general structure
Patient sat on bed at 45º:
- Look
- Feel (temperature, squeeze all joints + Achilles tendon)
- Move (active + passive)
- Special tests (Simmonds’)
Patient standing:
- Look
- Function (gait)
If time, neurovascular integrity:
- Sensation on plantar surface of hallux, MTPs + heel
- Sensory level if suspected neuropathy
- Ankle jerk
- Dorsalis pedis, posterior tibialis, CRT
Foot and ankle: Simmonds’ test
- Pt prone with foot hanging off edge of bed
- Squeeze calf muscle and observe ankle plantarflexion
Absence of plantarflexion = Achilles tendon rupture
Shoulder exam: test for previous dislocation
Apprehension:
- pt lying supine
- elbow flexed to 90º, shoulder abducted to 90º, fingers pointing towards head
- force external rotation
Apprehension = previous dislocation
Shoulder exam: teres minor injury
Hornblower’s test:
- elbow flexed, shoulder abducted, forearm horizontal
- active external rotation against resistance
Weakness = TMi injury
Shoulder exam: Hawkin’s test
- elbow flexed, shoulder abducted
- force internal resistance
Pain = impingement syndrome (subacromial)
Shoulder exam: supraspinatus test
Jobe’s (empty can) test:
- arm straight, abducted to 90º, 45º angle from body
- “hold a can of coke, and empty it”
- force adduction
Pain/difficulty = supraspinatus injury
Shoulder exam: subscapularis test
Gerber’s lift off test:
- back of hand on lumbar spine
- isolate arm at wrist
- “push against me”
Pain/difficulty = subscapularis injury
Shoulder exam: teres minor and infraspinatus injury
Resisted external rotation:
- external rotation position
- “push against me” - apply inward pressure
Pain/difficulty = teres minor or infraspinatus injury
Hornblower’s will detect teres minor injury, so if Hornblower’s is negative but this is positive = infraspinatus injury
Elbow exam special tests: Golfer’s elbow test
Resisted wrist flexion:
- extend elbow + supinate forearm (“hold straight arm out, palm up”)
- support elbow, palpate medial epicondyle
- passively extend wrist
- ask pt to FLEX wrist against resistance
Golfer’s elbow = pain over medial epicondyle
Elbow exam special tests: Tennis elbow
Cozen’s test (resisted wrist extension):
- extend elbow, pronate forearm, + make a fist (superman pose)
- support elbow, palpate lateral epicondyle
- “cock your wrist back and hold it there”
- apply force to wrist to force flexion
Tennis elbow = pain over lateral epicondyle
Hand exam structure (assume MSK + neuro)
- Look
2a. Feel (palpate joints + palms, temperature, CRT, pulses)
2b. Sensation (“feel” for neuro exam)
3a. Move (for ROM)
3b. Motor (for nerves) - Function
- Special tests
Hand exam: sensation
- outside of little finger (ulnar)
- outside of index finger (median)
- first dorsal web space (radial)
Hand exam: movements
Do all of these movements actively, then repeat passively if limited ROM
Fingers:
- flexion + extension (can also assess trigger finger here)
- abduction + adduction
Thumb:
- adduction + abduction
- opposition
Wrist:
- flexion + extension (prayer and reverse prayer)
- ulnar and radial deviation
Elbow:
- pronation + supination
Hand exam: motor assessment
Radial:
- wrist extension against resistance
- finger extension against resistance (fingers together + straight, try to bend them at the MCPs)
Ulnar:
- finger abduction against resistance (splay fingers, push against index + little finger)
Medial:
- thumb abduction against resistance
Hand exam: function
- Power grip (“squeeze my fingers tightly”)
- Pincer grip (“squeeze my finger with your thumb+index fingers)
- Pick up a small object
Hand exam: special tests
Tinel’s test (for carpal tunnel)
- tap over carpal tunnel
- tingling in medial distribution = positive test
Phalen’s test (carpal tunnel)
- maximum forced wrist extension for 60s (reverse prayer sign)
- reproduction of carpal tunnel sx = positive test
Froment’s sign (ulnar pathology)
- ask pt to hold a piece of paper between their thumb and index finger
- pull paper away and observe thumb shape
- thumb DIP flexion = positive Froment’s sign
Allen’s (arterial insufficiency)
- palpate radial pulse
- palpate ulnar pulse
- occlude both pulses
- ask pt to make a tight fist for 10 seconds, then open it (palm should be white)
- release one pulse at a time to see if blood returns
- repeat, releasing the other pulse first
Cerebellar exam: head
Nystagmus (present):
- move finger in + direction quickly
Speech (slurred, staccato):
- “british constitution”
- “baby hippopotamus”
Cerebellar exam: upper limbs
Tone (hypotonic):
- as per UL neuro exam
Power (may confound co-ordination findings):
- as per UL neuro exam
Co-ordination:
- rebound test (arms out, palms down, eyes closed, push each arm down and assess for overshoot - arm bouncing back past starting point)
- finger-nose test (past pointing/dysmetria, intention tremor)
- dysdiadochokinesia (slowness, difficulty)
Cerebellar exam: lower limbs
Only assess tone and power if not done in ULs
Co-ordination:
- heel-shin test (dysmetria, intention tremor)
Cerebellar exam: posture/gait
Stability when sitting:
- sit pt on side of bed with arms crossed over chest
- observe for truncal ataxia
Stability when standing (only if stable sitting)
Romberg’s test (only if stable standing):
- hands around pt to reassure them that they won’t fall
- ask pt to close eyes
- observe for sensory ataxia
Gait:
- ataxic gait = wide-based, unsteady with lateral veering, irregular steps
- heel-toe walk (almost impossible if cerebellar lesion)
Parkinson’s exam: TRAP structure
Tremor (resting):
- ask pt to hold arms out in front of them (tremor should stop)
Rigidity (cogwheel):
- assess tone as in UL neuro exam
- ask pt to tap knee with other hand to reinforce hypertonia
Akinesia (more accurately, bradykinesia):
- thumb to each finger quickly
- pretend to play piano
Postural instability:
- assess gait
- features of Parkinson’s: hesitancy, shuffling, festination (speeding up inadvertently), loss of arm swing, retropulsion (falling backwards as feet rush ahead in festination)
Parkinson’s exam: other tests
Glabellar tap:
- ask pt to fix eyes onto wall
- tap forehead and observe blinking
- normal = blinking stops after 2-3 taps
- Parkinson’s = blinking continues
Speech (slow, monotonous):
- assessed initially, but can ask pt to repeat name and DOB
Writing (micrographia)
Function:
- undo a button
- handle some coins
Diabetic foot exam: vascular
- Temperature
- Dorsalis pedis, posterior tibialis
- Popliteal if above are absent
- CRT of hallux
Diabetic foot exam: neurological
Reflexes: ankle jerk
Sensation:
- light touch
- pressure (10g monofilament)
- say you would do pin prick and temperature
Proprioception
Vibration:
- 128Hz tuning fork
- 1st MTPJ, move proximally if absent
