OSCEs Flashcards
Describe cardio exam.
Summary:
- Usual intro, general inspection, 45°
- Inspect hands (1,2,3)
- 1- front (Janeway lesion, osler)
- back (splinter haemorrhage…2- xanthoma, tar staining)
- 3- cap refill, temperature….clubbing
- Arms
- Pulse, radio-radio delay, collapsing pulse
- BP, brachial pulse
- Neck (Carotid pulse, JVP, hepatojugular reflex)
- Face
- eye (pallor, xanthelesma)
- mouth (central cyanosis, angular stomatitis, dentition, high arched palate)
- Chest Inspection (deformity, scars,.. pacemaker, ICD,.. visible pulsation)
- Palpation (apex, heaves thrills)
- Auscultate
- heart (4 regions + lean forward and roll left)
- carotid
- lung bases
- Edema (sacral, pedal edema)
- Further assessment (Peripheral vascular, ECG, …glucose level,urine dipsticks, fundoscopy)
Describe peripheral vascular exam
Summary:
- Usual intro, general inspection
- Upper body (same as cardio):
- Inspect hands (1,2,3)
- 1- front (Janeway lesion, osler)
- back (splinter haemorrhage…2- xanthoma, tar staining)
- 3- cap refill, temperature….clubbing
- Arms
- Pulse, radio-radio delay, collapsing pulse
- BP, brachial pulse
- Neck (Carotid pulse)
- Abdomen (see abdo exam)
- Inspect (visible pulsation)
- Palpation (expansion of aorta)
- Auscultation (aortic bruit)
- Lower limb
- inspection
(cap refill, pallor, temp, muscle wasting, hair loss, ..ulcers, discolouration,
scars, edema, varicose veins, missing toes) - palpation (femoral, popliteal (auscultate), post tib, dorsalis (lateral to EHL))
- motor (wiggle toes)
- sensation (distally to proximally)
- Buerger’s test (2-3mins, angle <20 degress = severe ischemia, reactive hyperaemia)
- Further exam (CV exam, ABI, lower limb neuro)
Describe resp exam.
Summary:
- Usual intro, 45°,
- general inspection (O2, SOB/accessory muscles, cough/stridor/wheezing, scars/deformities)
- Hands (peripheral cyanosis, clubbing, tar staining,
rheumatological changes, temperature
- Arms
- Asterixis (metabolic encephalopathy, in hypercapnia, CCF, liver failure, renal failure)
- Pulse, resp rate
- Head and neck (JVP, central cyanosis, Horners) (miosis, ptosis, anhidrosis (decreased sweating), with or without enophthalmos (inset eyeball)
Chest (anterior and posterior) - Inspection (scars (chest drains), chest deformities, asymmetery) - Palpation (trachea, lung expansion) - Percussion - Auscultation (lungs, vocal fremitus) Additional - Neck LN (CA) - Sacral and pedal edema
Describe abdo exam.
Summary: - Usual intro, supine, - General inspection (comfortable, scars, masses jaundice obvious pallor abdominal distantion)
Hands Inspection
- Clubbing – inflammatory bowel disease / cirrhosis / coeliac disease
- Koilonychia – spooning of the nails – chronic iron deficiency
- Leukonychia – whitened nail bed – hypoalbuminemia (liver failure / enteropathy)
- Palmar erythema – reddening of palms – liver disease / pregnancy
- Dupuytren’s contracture: (Thickening of the palmar fascia, Associated with alcohol excess / family history)
- Hepatic flap (asterixis)
Arms
- Bruising, Petechiae
- Scratch marks (skin scraped off because of cholestatic pruritis)
- Track marks
- Palpate for axillary lymphadenopathy – malignancy / infection
Eyes
- Xanthelasma, Conjunctival pallor, Jaundice
Mouth
- Angular stomatitis – inflamed red areas at the corners of the mouth – iron/B12 deficiency
- Oral candidiasis – white slough on oral mucous membranes – iron deficiency / immunodeficiency
- Mouth ulcers – Crohn’s disease / coeliac disease
- Tongue (glossitis) – smooth swelling of the tongue with associated erythema – iron/B12/folate deficiency
Neck
- Cervical lymph nodes
- Virchow’s node – left supraclavicular fossa – suggestive of gastric malignancy
Chest
- Spider naevi – central red spot with reddish extensions (>5 significant) – chronic liver disease
Gynaecomastia – liver cirrhosis / digoxin/ spironolactone
Detailed abdominal inspection:
- Scars, Masses, Pulsation (AAA), stomas, striae, Abdominal distension
- Caput medusae – engorged paraumbilical veins – portal hypertension
- Cullen’s sign – bruising surrounding umbilicus – retroperitoneal bleed (pancreatitis/ruptured AAA)
- Grey-Turner’s sign – bruising in the flanks – retroperitoneal bleed (pancreatitis/ruptured AAA)
- Palpation (9 quadrants,
liver, spleen,
Murphy’s sign, urinary bladder,
aorta, kidneys) - Percussion (9 quadrants, liver span, spleen, shifting dullness)
- Auscultation (bowel sounds, renal bruit, aortic bruits)
- Further exam (PR, hernia orifice, genitourinary)
Normal liver span 6-12cm
Describe cranial nerve exam
Exam Summary:
Positioning/Exposure
- Sitting opposite in a chair, face and neck exposed
General Observation
- Patient is comfortable, alert and awake
- Any walking aids, ask for reading glasses/contacts
Inspection (Face, eyes, scars)
- Face: drooping, asymmetery, facial wasting, fasciculations
- Eyes – ptosis, proptosis, pupillary inequality, deviation of eyes
- Scalp for craniotomy scars
CNI – Olfactory
- Ask for changes in smell/taste (can also be CN VII and IX)
- Can test using strong smelling substances (coffee beans, vanilla, isopropyl alcohol wipes)
– don’t use pungent substances (CNV)
CNII – Optic (3) - Visual acuity – make sure to ask patient to wear reading glasses if present
- Visual fields – remove reading glasses (COVER 1 EYE)
- Visuospatial Neglect
CNII/III – Optic and Oculomotor (3)
- Light reflexes (direct and consensual)
- Test for afferent pupillary defect (shine light from one pupil into the other, look for relaxation – reduced acuity -> reduced direct reflex)
- Accommodation (constriction of both pupils)
CN III/IV/VI – (1) Oculomotor, Trochlear and Abducens - Eye movements (III – superior/inferior/medial rectus, inferior oblique, IV – superior oblique, VI – lateral rectus) – look for nystagmus, ask for double vision
- Check for saccadic movement
- Difficulty holding upward position at midline – myasthenia gravis
CN V – Trigeminal (Ophthalmic, Maxillary and Mandibular divisions) (3+3)
- Light touch sensation in each sensory division (can you feel it? Same on both sides?)
- Pin prick
- Corneal reflex (cotton wool brought in to the side of the cornea)
- Test muscles of mastication (masseters and temporalis muscle – clench jaw)
- Test pterygoids (open mouth, don’t let me close)
- Test the jaw jerk reflex (let your mouth fall, tap with tendon hammer over finger)
CN VII – Facial (4 branches +2)
- Frontalis muscle power (raise eyebrows “don’t let me push down”), Frown (temporal branch)
- Obicularis oculi muscle power (shut your eyes and don’t let me pull them open) (zygomatic branch)
- Obicularis oris (puff out your cheeks) (Buccal)
- Smile showing teeth , Purse lips (whistle) (mandibular)
- Notice any change in taste (ant 2/3 tongue)
- Hearing sounds louder than usual (stapedius paralysis)
CN VIII – Vestibulocochlear
- Hearing screening test
- Webers test – tuning fork 512 in midline on forehead “is it louder in 1 ear)
- Rinne’s test – tuning fork on mastoid, when bone conduction is lost test air conduction (positive Rinne’s test is normal)
CN IX/X – Glossopharyngeal and Vagus (4+)
- Open mouth and inspect the palate and uvula, Say “ahhhh” – check for symmetrical rise of the uvula (will deviate to normal side if abnormal)
- Ask the patient to cough
- Test for ability to swallow
- (optional)Test for gag reflex (sensory IX, motor X) or touch the back of the pharynx w/ a tongue depressor
CN XI – Accessory (2)
- Shrug shoulders, “don’t let me push it down” (trapezius)
- Sternocleidomastoid muscle power – turn head into hand (turn your head to your right and don’t let me stop you)
CN XII – Hypoglossal
- Examine tongue at rest (wasting and fasciculations)
- Protrude the tongue and look for deviation (will deviate towards lesion as tongue muscles push)
Offer - All other neurological examinations
Describe lower limb neuro exam.
Exam Summary: Look, Tone, Power, Reflexes, Light Touch, Pain, Vibration, Proprioception, Coordination
Positioning/Exposure
- supine, legs and thighs entirely exposed
General Observation
- …
Inspection
- SWIFT (Scars, Wasting of muscle, Involuntary movement, Fasiculations, Tremor)
- Posture (UMN hemiplegia – lower limb extension)
Tone
- Test in the knees and ankles, flex and extend the knee at varying speeds
- Test for clonus in the ankles, move the ankle around to ensure relaxation and then sharply dorsiflex
Power
- Test hip flexion/extension/abduction/adduction,
- knee flexion/extension,
- ankle dorsi/plantar flexion
- Toe up and down
Reflexes
- Knee jerk
- Ankle jerk
- Plantar reflex
Light Touch (L2-S1) - Test individual dermatomes, compare left and right and ask if they are the same
Pain
- Offer to do pain (sharp dull differentiation) in all dermatomes
Vibration
- Test on the MTP head or more proximally if there is loss of vibration sense distally
Proprioception
- Test using the big toe, knees and hips if necessary
Coordination
- Heel-shin test
- Foot-tapping – tap foot against your hand as fast as they can- dysdiadochokinesis
Gait
Heel 2 toe
Heel (L5)
Toe (S1)
Squat and stand
Rombergs
- Examine stance and posture – asymmetry
- Ask to walk a few steps and turn around – foot drop, circumduction, symmetry of hips, shuffling/Parkinsonian gait, wide based cerebellar gait , antalgic gait (spending most time on 1 foot in stance phase)
- Tandem gait (heel to toe) – cerebellar ataxia
- Walking on the toes - S1 lesion
- Walking on heels L4/5 lesion causing footdrop
- Squat and stand (proximal myopathy (L3/4)
- Romberg’s
Offer - All other neurological examinations
- MSK lower limb examinations (knee, hip)
Describe hand and wrist exam.
Exam Summary: Look, Feel, Move
Positioning/Exposure
- Sitting opposite, expose the joint above (elbow) and below (N/A), remove all jewellery
General Observation
- Observe posture deformities
Inspection
- Examine the joint from all angles
- Nail changes –discolouration, pitting and ridging (psoriatic arthritis), vasculitic rash near nails (rheumatoid arthritis), splinter haemorrhages (infective endocarditis or systemic lupus erythematosus)
- Joint deformity – ulnar deviation, Z thumb, swan neck, Boutonniere’s deformities (rheumatoid arthritis), Bouchard’s nodes on PIP, Heberden’s nodes on DIP (osteoarthritis)
- Joint changes – swelling, erythema
- Wrists and elbows – rheumatoid nodules and gouty tophi (palpate for changes aswell)
- Skin changes – erythema, atrophy, scars, rashes (psoriatic rash – scaly erythematous plaques on extensor surfaces)
- Muscle wasting – thenar eminence, hypothenar eminence (carpel tunnel syndrome)
Palpation
- Ask for tenderness
- Check temperature of joints
- Palpate wrists, anatomical snuffbox, MCP, PIP and DIP feeling for swelling, sublaxation and checking for tenderness, LF Bony swelling (hard and immobile – osteoarthritis), boggy swelling (soft and spongy – synovitis), fluctuant swelling (effusion)
- Squuze MCPs
- Test for wrist crepitus
Move + Special test: 3 + Passive
- Test active movements first – gross screening tests of hand, wrist and arm movements
- Finger flex/ext, abd/add, grip, pincer grip, Thumb abduction (palms and thumb pointing ceiling), dexterity (undo button, write name, take off/put on watch)
- Prayer position (wrist extension), Reverse prayer (wrist flexion + carpal tunnel syndrome)
- pronate hands, form a fist (finger flexion), release fist quickly (finger extension + trigger finger),
- If there is time, check all passive movements, if no time, only do passive movements if a problem was found on active movement
Offer
- Elbow and Shoulder examinations
- UL neurological examinations
Describe shoulder exam.
Positioning/Exposure - Standing with top exposed
General Observation - Observe for aids – arm sling
- Observe patient removing clothing – check for pain and limitation in movement
- Any obvious deformities/malalignments
Inspection
- Skin changes – erythema, rash, scarring)
- Muscle changes – wasting/disuse atrophy
- Alignment – symmetry (shoulder and scapula)
- Joint – swelling
Palpation
- Ask for tenderness
- temperature
- sternoclavicular joint , acromioclavicular joint, coracoid process, humerus
- border of the scapula
Move, (6 movments + scapular during abduction+
Passive)
- flexion, extension, abduction, adduction,
- external rotation and internal rotation (hands up back)
- Assess scapular movement during abduction (abduct while hand on scapula)
- Passive movement
Special Tests(5)
- Anterior Apprehension test
- Supraspinatus – abduct arm at side against resistance at 0 degrees
- Supraspinatus – painful arc assessment – raise patients arm and ask them to lower slowly (pain between 60-120O suggest impingement)
- Infraspinatus and teres minor – arm forward and elbow flexed, externally rotate against resistance
- Subscapularis – hand behind back palm outwards, push out against resistance
Offer - Neck and elbow examinations
Describe knee exam.
Positioning/Exposure
- Lying supine, exposed from the joint above (hip) to the joint below (ankle)
General Observation
- Observe for aids – mobility aids
- Observe for any obvious deformities/malalignments
Inspection
- Skin changes - erythema, rash, scars
- Muscle wasting
- Swelling, deformities (valgus/varus)
Palpation
- Ask for tenderness
- Palpate quadriceps for wasting
- joint temperature
- Patellar tap
- bulge test (sweep medial side upward, then lateral side downward to see a bulge)
- Raise knee to 90O and palpate along the patella, tibial tuberosity, head of the fibula and along the joint line (tenderness and bony swelling)
- Palpate the popliteal fossa – Bakers cyst
- MEASURE quadriceps bulk (20cm above tibial tuberosity)
Move
- Active movements first – knee flexion/extension
- Passive movements – flexion (feel for crepitus), extension
Special Tests
- Anterior/posterior drawer test (ACL/PCL)
- Medial and lateral collateral ligaments
- McMurray’s test (medial and lat menisci)
Gait - Can be done at the start
- Stand the patient and reinspect for deformities
- Speed/symmetry
- Heel strike/toe off
- Abnormal gaits – antalgic, leg length discrepancy
Offer - Neurological exam, exam hip and feet
Describe hip exam.
Positioning/Exposure
- Exposure of the pelvis and hips (underwear appropriate)
- Standing initially for inspection and gait, supine for the rest of the exam
General Observation - ..
Inspection -
Skin changes – erythema, rash, scars
- Muscle wasting ( quadriceps, gluteal wasting)
- Alignment – asymmetry, pelvic tilt, leg length discrepancy, scoliosis
- Joint changes – swelling , popliteal swelling
Gait
- Speed/symmetry
- Heel strike/toe off
- Abnormal gaits – antalgic, leg length discrepancy
- Trendelenburg’s sign
Palpation
- Ask the patient to lie supine
- Measure leg length (true leg length ASIS medial malleolus, apparent leg length umbilicus medial malleolus)
- Ask for tenderness
- Assess temperature
- Palpate ASIS, greater trochanter
Move
- Active movement – hip flexion
- Passive movement – hip flexion, internal/external rotation, abduction/adduction
- Ask patient to lie prone – active and passive hip extension (keep hand on the sacroiliac joint)
Special Tests
- Thomas’s test (can be done during hip flexion) – one hand on patient’s back (ensure lordosis is gone), bring both legs up to chest, and relax one leg (inability to fully extend =fixed flexed deformity)
Offer - Neurological examination of the lower limb, examine the spine and the knee
Describe neck and back exam.
Positioning/Exposure - Start standing and exposed to underpants (just top off may be acceptable)
General Observation - Walking/mobility aids
Inspection
(Spine curvature, Shoulder, neck and hip symmetry) - Inspect the spine from every angle
- Anterior – shoulder and neck symmetry, hip symmetry
- Lateral – normal cervical lordosis, thoracic kyphosis and lumbar lordosis (loss of any of these)
- Posterior – scars, wasting, scoliosis (bend to assess functional or anatomical)
Palpation
- Palpate spinous processes – alignment and pain
- Palpate sacroiliac joints – tenderness
- Palpate paraspinal muscles – spasm/tenderness
Move
- Cervical spine movements – flexion, extension, rotation, lateral flexion
- Lumbar spine movements – touch toes, lean back, lumbar lateral flexion
- Thoracic spine movements – rotation (must be done while sitting, arms crossed and hips stabilised by hands)
Special Tests
- Schober’s test – mark 5cm below and 10cm above the PSIS level, bend and measure (normal >20 cm)
- Sciatic nerve stretch tests – strait leg raise and dorsiflex the foot, “any pain?”
- Femoral nerve stretch test – lying on tummy, raise leg, bend knee, “any pain?”
Offer - Neurological assessment on upper and lower limbs
Describe haem exam.
Exam Summary:
(Hands, arms, head and neck
Spine and chest
Abdomen, legs)
Positioning/Exposure
- Sitting initially, and then lying supine, will require to take top and bottoms off (expose as you go)
General Observation:
- surroundings, not in respiratory distress,
- pallor
- bruising (petechiae, purpura, ecchymoses)
- jaundice (hemolysis)
- scratch marks (in some lymphoma and MPNs)
- rashes (lymphoma)
Nails: - koilonychia (dry, brittle spoon nails, Fe deficiency/fungal infection) - ??digital infarcts, - ??splinter haemorrhages Hands: - palmar crease pallor (anaemia) - wasting - arthropathy (tophi, RA)
Arms: - bruising, scratch marks - pulse (tachycardia in anemia) - epitrochlear nodes (flex elbow to 90 degree and palpate just anterior and proximal to the medial epicondyle) (infection, NHL or rarely syphilis) - axillary lymph nodes . pectoral . subscapularis . lateral (brachial) . central . apical (subclavicular)
Face: - eye: conjunctival pallor, jaundice Mouth: - gum bleeding - ulceration, infection and haemorrhage of buccal and pharyngeal mucosa - palatine tonsils - artophic glossitis (anemia) - angular stomatitis (may be affected in non-Hodgkin’s)
Head and Neck LNs
- submantle, submandibular
- pre-/post-auricular, occipital
- jugular chain (ant. SCM)
- posterior triangle nodes
- supraclavicular (shrug)
Spine and Chest
- spine tenderness: fist percussion
(one palm on spine, other hand fist percuss)
- sternum and clavicles; with heel of hand
- shoulders: push together
Abdomen (supine):
- hepatomegaly
- splenomegaly
. Traube space percussion (arms abducted slightly, precuss medial to lateral at a couple of levels)
. Castell spot (lowest ICS, MCL, full inspiration!)
- inguinal lymph nodes (along the inguinal ligament: drains pelvic, and along femoral vessels: drains lower limb)
Legs:
- bruising, scratch mark
- leg ulcers (hemolytic anemia, thrombotic thrombocytopenic purpura, Felty’s syndrome)
Additional:
- lower limb neurological exam (B12 deficiency)
- fundoscopy (engorged retinal vessels and papilledema) (increased blood viscosity from macroglobulinemia, MPN or chronic granulocytic leukaemia)
- urinanalysis (hematuria, bile)
- rectal and pelvic exam (blood loss)
Describe the thyroid exam.
Positioning/Exposure
- Sitting opposite, expose the neck and upper chest (unbutton top few buttons)
General Observation
- Environment – medications (thyroxine, amiodarone)
- Clothes appropriate for weather
- Agitated/anxious hyperthyroidism
- Generalised myxoedematous swelling (hypothyroidism)
Hands
- Tremor – test by placing arms out and put a piece of paper over (hyperthyroidism)
- Nail signs –clubbing – Grave’s disease, onycholysis (hyperthyroidism – sympathetic overactivity)
- Sweatiness (hyperthyroidism)
- Temperature – increased (hyperthyroidism)
- Palmar erythema (hyperthyroidism), or pallor/clammy hands w/ peripheral cyanosis (hypothyroidism)
- Hyperkeratinaemia (carrot skin – hypothyroidism, reduced heaptic metabolism, cant break down carotene)
Arms
- Pulse – increased (sinus tachycardia, atrial fibrillation if severe, hyperthyroidism), sinus bradycardia (hypothyroidism)
Eyes
- Lid retraction (sclera visible above iris)
- lid lag (hyperthyroidism) (finger horizontal, up then move down) (Lid lag is the static situation in which the upper eyelid is higher than normal with the globe in downgaze)
- Exopthalmos (Grave’s disease) – look from the side/above
- H test
Mouth
- Exclude oropharyngeal cancer
- Tongue swelling (hypothyroidism)
Neck - Inspection
- Neck swelling
- Scarring
- Discolouration
- Redness
- Dilated veins
- Swallow (thyroid moves up during swallowing)
- Poke tongue (thyroid does not move, thyroglossal cysts moves)
Neck – Palpation
- Palpate from behind, swallow again
- Surface anatomy (quite low in the neck – thyroid cartilage, cricoid cartilage, isthmus is under the cricoid cartilage)
- Size
- Shape
- Consistency – soft (normal), firm (simple goitre), rubbery firm (Hashimoto’s), stony hard (cancer, calcification, cyst)
- Tenderness (thyroiditis)
- Mobility – carcinoma may tether the gland
- Palpate all the head and neck lymph nodes +supraclavicular
- Tracheal deviation – if one lobe is enlarged
- Percuss clavicle sternum (retrosternal extension)
Neck – Auscultation
- Bruits (increased blood supply, hyperthyroidism) -> Ddx carotid bruit, venous hum (can obliterate)
Special Tests
- Reflex tests (biceps) (hyperT—hyperreflexia)
- Look for Pretibial myxoedema (Grave’s)
- Stand up with arms crossed (proximal weakness in hyperT)
Describe the UG exam.
Positioning/Exposure
- Start the patient sitting at 45O on the bed if possible, will eventually expose abdomen and legs
General Observation
- Hyperventilation (metabolic acidosis)
- Signs of uraemia – hiccuping, sallow complexion, uraemic fetor
- Asterixis – terminal chronic renal failure
Hands
- Nail changes – leukonychia (hypoalbuminaemia – nephrotic syndrome)
- Palmar crease pallor
Arms
- Skin changes – bruising, scratch marks
- AV fistula – palpate for a thrill
- Blood pressure
Face
- Eye signs – conjunctival pallor and scleral icterus (rare)
- Skin changes – rash (SLE)
- Mouth – fetor, ulcers
Neck
- JVP
- Previous vascath for haemodialysis
Abdomen
- Inspect for catheter
- Scars – nephrectomy posteriorly, transplantation anteriorly
- Palpate for enlarged kidneys – palpate and balloting, make sure to check L/R iliac fossa for transplanted kidney
- Percuss for ascites
- Auscultation for renal bruits
Legs -
Skin changes – bruising
- Peripheral oedema
Offer
- Cardiac and respiratory exams (signs of CCF and pulmonary oedema in kidney failure)
- Per rectal exam for prostatism
- Urinalysis
Describe cerebellar exam
Cerebellar exam - Nystagmus - Speech - Intention tremor - Past pointing - Rebound dysmetria - Dysdiadochokinesis - Heel shin - Toe pointing - Pendular reflexes - Hypotonia - Posture/balance (Rhomberg) - Gait (Tandem)
