Cardiovascular Exam
Inspection Colour, Breathlessness, Distress, Marfan’s, BMI,Breathlessness,
Sweating
Hands Clubbing, Co...
Respiratory Exam
Inspection Cough, BMI, Fever, Distress, Drugs
Hands Clubbing, colour, cap. Refill, asterixis, thenar wast...
Upper Peripheral Neuro
Appearance Pronator drift
Tremor, wasting, fasciculation
Tone Shake hands while supporting elbow:
P...
Groin
Exposure Move trousers below curvature of bottom
Inspection Scars, hernia
Cough & watch
Palpate 1) ASIS,/pubic-tuber...
myodema) pulsatility, spread (LNs)
Checkreflexes Hypothyroidism
GALS
ScreenQs Pain, stairs, dressing / buttons, gout/arthr...
Patient to resist dr pushing in
Teresminor Shoulder & elbow at 90o (hands pointing to ceiling)
Dr pushes wrists forward& p...
Measurementofleg
length
True length = ASIS to medial malleolus (Perthe’s disease,
avascularnecrosis,OA,RA, hip dislocation...
Upcoming SlideShare
Loading in …5
×

Stage 1 OSCE clinical exams steps breakdown - University of ...

916 views

Published on

  • Be the first to comment

Stage 1 OSCE clinical exams steps breakdown - University of ...

  1. 1. Cardiovascular Exam Inspection Colour, Breathlessness, Distress, Marfan’s, BMI,Breathlessness, Sweating Hands Clubbing, Colour, Cap. Refill, Splinter Haemorrhages, Temp., Tremor, xanthelasma, osler’s nodes, Janeway lesions. Wrist Radial Pulse (rate, rhythm, character), radial-radial/femoral delays. Elbow Brachial Pulse, Waterhammer Pulse. Ask for BP Eyes Pallor, arcus, Kaiser flescher rings, xanthelasma, retinopathy Tongue Central cyanosis and tooth decay. Neck Carotid pulse, bruits (aortic stenosis), JVP Chestlook Deformity,Scars Chest/ Heart Feel Apex beat, Heaves, Thrills, Auscultate 4 valvepositions (mitral, tricuspid, pulmonary, aortic). Lean Pt on Left Auscultate apex and axilla formitral regurge Sit pt forward Auscultate (diaphragm) for aortic stenosis Auscultate lung bases (pul. oedema) Abdo AAA Legs Femoral / popliteal / post tibial / dorsalis pedis pulses Ulcers, Ankle oedema Extras Fundoscopy,BP, urine dipstick, Temp. Peripheral Vascular Exam Exposure Abdo down, blanket for upper/lower when not examining Inspect arms Scars, colour,skin, digits, tar staining Palpatearms Temperature (backof hands), cap refill, tendon xanthelasma Radial pulses (together) Rate, rhythm, radio-radial delay Brachial pulses Radial, brachial pulses AskforBP Ask for both arms if suspect different pulses Face Arcus, xanthelasma Carotids Pulse (not together), auscultate forbruit Inspect chest& abdomen Scars, pulsations, AAA Femoral pulse Mid-inguinal point, femoro-femoraldelay (common iliac obstruction), radio-femoral delay Auscultate forbruits (anteromedial thigh, middle 1/3) Inspect legs Scars, colour,skin, digits, pressure points, xanthomata on Achilles tendon Palpatelegs Temperature (using backs of hands), cap refill (toes) Popliteal pulse Posteiortibial pulse Medial malleolus Dorsalispedis Auscultate pulses(carotid  popliteal) Buerger’stest 1) Raise both legs (straight & slowly) to 45o or angle where they become pale (Buerger’s angle) 2) Put legs overedge of bed or get pt to stand Ischaemia = 20-30o forBuerger’s angle, slow re-perfusion and then reactive hyperaemia for(2) Extras Doppler ABPI.
  2. 2. Respiratory Exam Inspection Cough, BMI, Fever, Distress, Drugs Hands Clubbing, colour, cap. Refill, asterixis, thenar wastage, tobaccostaining, tremor Wrist Radial Pulse (rate, rhythm, character) Respiratory rate Ask for BP,mention pulsus paradoxus Eyes Pallor, Horner’s Synd. Tongue Central cyanosis Neck JVP,Lymphadenopathy, Accessory muscle use Tracheal deviation& tug Deviates to side of collapse, away from tension pneumothorax ChestScars Surgery? Deformity Pectus excavatum? Barrel chest? (AP = lateral) Expansion Equal R/L?  = PE,consolidation, fibrosis, pneumothorax or collapse Percussion  in pneumothorax,  in all else TVF  TVF = consolidation, fibrosis, top of effusion Auscultation Crackleoedema or fibrosis (fine) or bronchiectasis/pneumonia (coarse). Rub pleura infarct/ inflammation (pneumonia) Wheeze  obstruction. Bronchial Breathing consolidation, fibrosis, top of effusion. Breathing sound  = consolidation, obesity, overPleural Effusion, pneumothorax. Ankle Oedema Extras Peak flow,O2 sats, spirometry, Temp., sputum pot Abdominal Exam Inspection Drugs, regimen, hydration, musculature, fever,SOB, jaundice, distress Hands Clubbing, koilonychia( Fe2+ anaemia),leukonychia,palmar erythema, Dupuytren’s contracture,asterixis, Spider naevi (allelse is Liver failure) Face Spider naevi, Jaundice, parotid swelling (ETOH) Eye Jaundice, pallor Mouth Angular stomatitis (thrush, Fe2+),glossitis ( Fe/folate/B12),ulcers (Crohn’s),thrush. Neck Lymphadenopathy – remember Virchow’s! Chestinsp. Spider naevi, gynecomastia, Caput medusae Abdo insp. Scars, distension Palpation Check forpain 1st 6 areas - Superficial & deep. Liver, spleen (hameolyticanaemias,infection), kidneys balloting (UTI),bladder. Auscultation Bowelsounds, aortic and renal artery bruits. Percussion Inc. ascites Groin Hernia, lymph nodes Leg Oedema, gangrene Extra PR exam, Inguinal orifice, ext. Genitalia, urinalysis Review jaundice, anaemia, cyanosis, clubbing, lymphadenopathy.
  3. 3. Upper Peripheral Neuro Appearance Pronator drift Tremor, wasting, fasciculation Tone Shake hands while supporting elbow: Power Pt birdwings  push down Support elbow:“stop me pulling/pushing your hand” Pt fist and Support forearm: “stop me pushing up/down/ sides” Ask pt to turn palms up, thumbs up  try to push thumbs down Paper snatch Co-ordination Finger (moving) to nose, piano, dysdiadochokinesis Reflexes Biceps (indirect), triceps (direct), Supinator (indirect) Sensation Cotton wooland neurotip (tosternum first forreference) Vibration fork thumb carpal/metacarpal Proprioception: hold digit at sides and moveup/down Lower Peripheral Neuro Appearance Gait, Romberg’s test, tremor, wasting, fasciculation Tone Roll legs: assess ankle tone Lift knee quickly  heel lifts of bed? Ankle clonus (>5 = pathology) Power Pt liftleg  stop me pressing down Pt bend knee “stop me pulling your footaway / pushing toward” Support shins, Pt cocksfeetback  “stop me pushing yourfeet up / down / sideways” Co-ordination Heel slide on shins Reflexes Knee on lift, achilles on stretch Babinski checkusing orange stick (=,normal = ) Sensation Cotton wooland neurotip (tosternum first forreference) Vibration fork ball of foot Proprioception: hold digit at sides and moveup/down Cranial Nerves 1, Olfactory “Have younoticed any change in your sense of smell?” 2, Optic Acuity (colourvision - Ishihara) Fields Reflexes (light direct/consensual and accommodation) Ophthalmoscope (red reflex, colour,contour, cupping) 3, 4, 6 Oculomotor, trochlear,abducent Eyemovements (nystagmus), ptosis, pupillary size & shape Ask for double vision 5 Trigeminal Motor – “clenchteeth” & feel masseter/temporalis Sensory – sharp/soft on both sides in all 3 CN5 areas Mention reflexes: corneal and jaw jerk 7, Facial “Screw your eyes up, show me yourteeth, blow out your cheeks” Mention: taste ant 2/3 tongue, hyperacusis 8, Vestibulocochlear Hearing – Whisper test, auroscopy, Weber, Rhinnes 9, 10, Glossopharyngeal/vagus Gag reflex, “say ahhh” uvular deviation Ask about swallowing,hoarse voice 11, Accessory Shrug shoulders & turn head against resistance (palpate opposite SCM) 12, Hypoglossal Stick tongue out, wiggle it around
  4. 4. Groin Exposure Move trousers below curvature of bottom Inspection Scars, hernia Cough & watch Palpate 1) ASIS,/pubic-tubercle-midpoint, 1 finger on deep ring, 1 on inguinal ligament (superficial ring) – patient to cough 2) Same position but with pressure on deep ring – patient to cough again 3) Feel for superficial inguinal lymph nodes 4) Femoral pulse 5) Femoral canal – patient to cough again 6) Listen to femoral artery (aneurysm) Stand patient up & re-examine for hernia/ext genitalia Varicocele, contralateral hernia Breast Inspection Asymmetry, skin change Raisearms & watch Asymmetry of movement Palpate(lyingflat) Examine normal first Use flats of fingers, 4 quadrants + nipple, then axillary tail (withhand behind head) Palpateaxilla Lift patient’s arm & move backdown after in axilla Supra/infraclavicular fossapalpation Handsonhips to test mass movementif located Thyroid Inspection(fromfront) BMI estimate, scars, lumps, tremor/restless/agitated, eyes, hair & eyebrows, stand fromchair withouthands Palpatethyroid (Find thyroid notch, movedown to just below cricoid, then lateral) Ask to stick out tongue (thyroglossal cyst) Ask to swallow (thyroid) Uniformlyenlarged,solitaryormultinodular? Percussuppersternum Mediastinal extension Auscforthyroidbruit Graves disease Lymph nodes (explainprocess) Ant cervical,supraclavicular,post cervical, submandibular, submental, pre-auricular, post-auricular, occipital[Hard = malignant,tender= infection,rubbery= lymphoma] Eyes(in Graves’) Exophthalmos, lid retraction, lid lag, opthalmoplegia, chemosis (conjunctivaloedema) Palpateparotid Plus lookin mouth & examine facialnerve if lump, plus ask pt to open jaw to assess if attached Hands Temperature, palmar erythema, thyroidacropachy, tremor, pulse (AF, tachy),vitiligo Palpateother lumps (e.g. shins–pretibial Describe: site, size, shape, consistency, fluctuance, transilluminance, temperature, tenderness, tethering,
  5. 5. myodema) pulsatility, spread (LNs) Checkreflexes Hypothyroidism GALS ScreenQs Pain, stairs, dressing / buttons, gout/arthritis Gait Smoothness, speed, stride, symmetry, swing, turn Spine(back) Assess shoulders, paraspinals, glutes. Scoliosis, Baker’s cysts, ankle deviation Palpate supraspinatus  fibromyalgia? Spine(side) Lordosis, kyphosis Fingers on spinous processes  bend over slowly Spine(front) Assess musculature Ear  shoulder: normal lateral cervicalflexion? Arms (pronated) Out Straighten, then elbows bent at side. Wrist / finger deformity (Heberden’s=distal interphalangeal, Bouchard’s=proximal) Thenar wastage Pitted nails  psoriasis Metacarpal squeeze: pain? = Synovitis Arms (supinated) Painful /abnormal supination? Fist strength? Pincer co-ordinationand strength Wrists Elbowsout and fingers pointed up (extension), then down (flexion) Shoulder Hands behind head (elbowsout), then up behind back Legs Asymmetry of muscles. Scars, swelling, Knee effusion – patellar tap. Activethen passive (feelfor crepitus) flexion and extension Hips Check rotation on knee flexion Feet Metatarsal squeeze, callous check. Shoulder Inspection Front, side, back (including neck) Muscle wasting, scars, swelling Palpatejointsformuscle bulk& tenderness Sternoclavicular Acromioclavicular Glenohumeral Palpateback ofneck in midline Flexionofjoint Stand behind patient & ask to raise arms Active& passive (if activenot complete) Abduction Stand behind pt & guide raising of arms Abduct arms at about 30o (active& passive) External rotation Stand behind & position joints: Elbowstight to sides (elbow joint at 90o facing forward) Guide patients arms to externally rotate as far as poss Internal rotation Either: Shoulder & elbow at 90o, hands pointing towards ceiling Ask to move wrists forward (internal rotation) as far as possible Or: If unable to lift arm to position above, ask to put thumb behind their backand see how high they can get it Compare each side Special tests: Supraspinatus Arms abducted to 90o, wrist internally rotated Patient to resist pushing down Subscapularis Hand overumbilicus Patient to try to slap their tummy against resistance Infraspinatus Elbowsat sides at 90o (hands pointing forwards)
  6. 6. Patient to resist dr pushing in Teresminor Shoulder & elbow at 90o (hands pointing to ceiling) Dr pushes wrists forward& patient to resist Dislocationtests Apprehensiontest: Shoulder & elbow at 90o (hand pointing up) Dr pushes humeral head from behind & pt becomes very apprehensive & tense (positivetest) Relocationtest: Patient on bed in same position as above Joint pushed posteriorly & patient is more comfortable Hands Ask about pain and use pillow, don’t shake hand Ask about manual dexterity – buttons? Nails Observe and feel Fingers Psoriatic pitting, Swelling of MCP/PIP (RA  synovitis, feels soft), swan neck/boutonnieres deformities (?), thumb z deformity (?), Passive flexion  Trigger Finger (Stenosing tendovaginitis – nodes on tendon). IP Osteophytes: Proximal= Bouchard’s, Distal=Heberden’s (both OA) Ulnar deviation, Tophus (gout) Pincer grip Coordination and power MCP Squeeze and feel for crepitus on flexion, lost inter MCP gap (RA swelling) Pt makes fist and hide nails Follow finger tendons Nodules Palm Erythema (RA), thenar wastage (carpal TS), Wrist RA swelling and all movement axes Prayer and inverse prayer movements Normally 90 both ways Elbow RA nodules and gout tophi Hip Gait Tredelenburg (pelvic side drops on raised foot),Antalgic (OA shortened stance phase) Smoothness, speed, stride, swing, symmetry, turn Askto lieflat Also reposition bed to suitable height Inspect fromend ofbed Deformities, scars, muscle wasting/fasciculations, pigmentation, creases, swelling, limb rotation Circulationcheck Dorsalis pedis Posterior tibial Popliteal (if none of above found) Palpategroin,greater trochanter,iliaccrest Painful greater trochanter (trochanteric bursitis) Abduction&adduction Fixate opposite ASIS & move legs passively ab & adduction Rotation(45 each direction) Flex knee & hip & move footaround Thomas’ test Get patient to hold knees into chest & feel obliteration of lumbar lordosis curvature  extend each leg Fixed flexion deformity? TurnPt over Extension to 20
  7. 7. Measurementofleg length True length = ASIS to medial malleolus (Perthe’s disease, avascularnecrosis,OA,RA, hip dislocationall shortening) Apparent length = xiphisternum to medial malleolus (fixed hip adductiondeformityviaOA/RA) Knee Get patient to stand& walkup & down Gait abnormality, leg alignment (valgus = knock knee, varus = bow leg), recurvatum/hyperextension Askpt to siton couch(45o ok) Feel knee Temp. Inspect quads 10cmabove patella(insertion) Wastage, fasciculation Effusion (and RAnodes,psoriatic plaques) Patellar tap Milk medial gutter inferiorly Milk lateral gutter superiorly Watchfor accumulation of fluid medial to patella RequestActiveflexion To see range of painless movement PassiveFlexto 90o & feel for jointlinetenderness Feel for crepitus during flexion RequestPatellar apprehensiontest Flex knee and press patella laterally: dislocation  instability  pain Extendknee fully Check range of extension Medial &lateral collaterals Hold ankle underarm, hand on either side of knee. Performinitially on straight leg, then 30 Medial Meniscus Flex knee, externally rotate footand abduct thigh  varus stress Lateral Meniscus Flex knee, internally rotate footand adduct thigh Flexionrange 130-140o normal Lookat profileofflexedknee Sagging of tibia (Posteriorcruciateinjury) Anteriordrawtest Anteriorcruciate rupture Lackman’stest (more sensitive) 20 flexed knee, one hand supporting lower thigh, other proximal leg. Draw leg anterior (Anterior cruciate rupture) Clark’stest Patellofemoralligament, gentle pressure Peripheral pulses Posterior tibial, dorsalis pedis Extras Also state you wouldperform hip and ankle exams. FBC, ESR/CRP, Xrays

×