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detailed first and second year OSCE stations

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detailed first and second year OSCE stations

  1. 1. Clinical Skills Resuscitation station  Assess danger of situation. Approach.  “Rouse”. Assessment of consciousness. Gently shake shoulders. Use pain e.g squeeze trapezius  Shout for help, ask someone to stay  Open airway: head tilt chin lift. Check for obstructions in mouth: false teeth etc.  If vomit in the mouth, turn the patient towards you to try to expel as much as possible  Assess breathing by looking, hearing, listening. Take 10 secs maximum. If breathing:  ask onlooker to call ambulance. Put into the recovery position. If no apparent breathing:  Send onlooker for help. If in hospital, ask them to call 2222 and bring the trolley  Start chest compression, and continue with cycles of 30 compressions to 2 rescue breaths. - Compressions should be about 100/minute. - Breaths. Do head tilt and chin lift. Pinch nose closed. Breath in. Mouth to mouth seal. Blow steadily into mouth, watch for chest to rise. Take mouth away, watch for chest to fall. - Using a bag-valve-mask: position tightly over the nose and mouth, cover with hands while holding the airway open. The person doing compressions should squeeze the bag. Peripheral pulses  Wash hands.  Introduce yourself, and ask permission to feel the peripheral pulses.  Feel one radial pulse, and time it for 15 or 20 secs. - Report the rate, regularity, volume, symmetry (eg 68 per minute, basically regular with slight sinus arrhythmia) - Check it is symmetrical  coarctation of the aorta There is no need to time any other pulses.  Feel both brachial pulses, separately or together, whichever is easier.  Feel both carotid pulses: not at the same time. They are between the larynx/trachea and the sterno-cleido-mastoid muscle.  Feel the dorsalis pedis arteries on both sides.  Feel the posterior tibial pulses on both sides. They are posterior to the medial malleolus. With the patient lying down that means under the medial malleolus. They may be easier to feel if you dorsiflex the foot slightly to stretch the artery. Thank the patient and leave them comfortable. Wash hands at end Blood pressure  Wash hands.  Introduce yourself. Seek permission to take blood pressure. Explain briefly that it involves inflating a cuff around the arm, and that it won’t hurt.  Locate the radial and brachial pulses.  Choose cuff. Use the standard size cuff, even on petite adults. Paediatric cuffs are smaller and adult thigh cuffs are larger. Choose the standard one if there is a choice.  Put cuff on correctly: The tubes should be pointing down the arm. The soft velcro should be on the inside, facing out. The hard velcro should be on the outside, facing in.
  2. 2.  There is an arrow, which you can align with the brachial artery, but it is not vital.  Feel the radial pulse, while you pump up the cuff. Note the pressure when the pulse disappears. This is roughly the systolic pressure.  Now either: - let down the cuff, get your stethoscope in your ears, apply the diaphragm to the antecubital fossa where you felt the brachial pulse, - inflate the cuff about 20 mm above your estimate of the systolic, then start listening. - Deflate the cuff slowly. The Korotkoff sounds should start as you are deflating: a single sound per pulse. They are not heart sounds: don’t call them heart sounds. - As you deflate further, they will change character, and then disappear. - As you deflate, the appearance of the sounds indicates the systolic blood pressure, and the disappearance corresponds to the diastolic blood pressure. Or, if you are slick, after pumping up the cuff and feeling the radial pulse disappear, don’t deflate, but immediately apply your stethoscope to the antecubital fossa, and start listening.  You should be able to state what you think the blood pressure is.  You should be able to state what the sounds you hear correspond to: ie the appearance and disappearance of the sounds as you deflate the cuff correspond to the systolic and diastolic blood pressure.  Thank the patient and leave them comfortable.  Wash hands at end Cardiovascular system: general examination  Wash hands  Introduce yourself, and ask permission to “feel your pulse and listen to your heart” etc  patient should be exposed from the waist up and positioned at 45 degrees if possible  Assess the patient from the end of the bed: - conscious state, - general appearance,:  scars (old or recent) – check the back  pacemaker  colour and temp  ulcers on the feet  peripheral oedema  ascites  obvious breathing discomfort? - equipment:  drips,/cannulae  ventilators,  tablets,  GTN spray,  oxygen mask,  catheter - machine showing HR / BP / O2 sats, respiration rate, urine output 1. General exam: EYES and FACE:  look in eye mucosae  pallor: anaemia  Xanthelasma: collection of cholesterol under the skin around the eyes  high cholesterol  Corneal arcus: greyish opacity around the cornea  lipid infiltration, hyperlipidaemia  Mitral facies: pinky/purply flush on the nose and cheeks  mitral valve disease
  3. 3. MOUTH  “stick your tongue out” central cyanosis, sore tongue or sore corners of mouth (angular stomatitis)  anaemia, HANDS  Temperature, colour  peripheral cyanosis  Capillary refill  Clubbing of the fingers  heart disease  Splinter haemorrhage  assoc. with endocarditis  Tendon xanthoma  lipid deposition around tendons  Tar stains  Osler’s nodes: painful red lesions on the palms and soles  infective endocarditis  Janeway lesions: non-tender, small erythematous or haemorrhagic lesions of the palms and soles PULSE and BP  Feel the radial pulse, time it, report rate and rhythm.  Report the character at a central pulse - Slow rising: pulse is slow to rise and is flat  aortic stenosis - Collapsing pulse:  aortic regurgitation. The incompetent valve allows the diastolic pressure to fall dramatically. Felt more if the arm is raised over the head (radial pulse) - Pulsus bigminus: two groups of heartbeats followed by a longer pause (second weaker than the first) - Pulsus paradoxus: an exaggeration of the normal variation in the pulse during the inspiratory phase of respiration, in which the pulse becomes faster as one inhales and slower as one exhales  cardiac tamponade, constrictive pericarditis, severe asthma and COPD.  Feel both radial pulses at once for symmetry.  You need not feel all the peripheral pulses.  You will be given the blood pressure.  check for bruits: auscultate for turbulent flow in the carotids. 2. Jugular Venous Pressure.  patient should be a 45 degrees if possible  head/chin tilted across to the left slightly  area needs good light  look for a venous pulsation of the internal jugular vein (double flicker). The IJV runs between the two heads of sternocleidomastoid about 10 degrees from vertical. Normally just above the clavicle.  Measure the jugular venous pulse: - find the highest point of the flicker - measure outwards from this position - find the angle of louis/sternal angle. - Measure the vertical distance from this angle and the tangent fro the flicker, - Quoted as e.g. +5cm, or elevated 5cm.
  4. 4. *** make sure its not an arterial flicker: - should be a double flicker, not a single - not palpable - will change with the position of the patient (A will not) 3. Apex beat  Palpate the chest for the apex beat (5th intercostal space in midclavicular line).  When you have located it, check its position by counting down the ribs, and see if it is in the midclavicular line, anterior axillary line, etc. 4. Heaves and thrills  Palpate with a flat hand  Thrill: palpable murmur. Feels like a vibration  Heave: abnormally strong beating of the heart. Sign of ventricular hypertrophy  To time heart sounds, murmurs, thrills and bruits - use your nondominant fingers or thumb to palpate the patient’s right carotid pulse whilst palpating or auscultating.  Sounds or thrills that occur with the pulse are SYSTOLIC. Before or after the pulse are Diastolic. 5. Auscultation of the valves  Mitral – 5th L ICS, mid-clav line  Tricuspid – 4th L ICS, lower left sternal edge  Pulmonary – 2nd L ICS, sternal edge  Aortic – 2nd R ICS, sternal edge  You should hear the 2 hears sounds in each place. You may hear murmurs in one or more of these places.  In one of these places, you should correlate the heart sounds with the pulse (carotid or radial).  Feel the ankles for oedema. General Rules of cardiac examination 1. STENOSIS – The valve should be OPEN i.e. stenosis is the lesion of an open valve. 2. REGURGITATION – The valve should be CLOSED i.e. regurgitation is the lesion of a closed valve 3. Left sided valvular (Mitral and Aortic stenosis) initially leads to LV Hypertrophy (LVH); LVH leads to an undisplaced, forceful, hyperdynamic apex beat 4. Left sided valvular regurgitation leads to LV Dilatation; Dilatation leads to a (often grossly) displaced, diffuse apex beat 5. LEFT sided murmurs (M/A) get louder with EXPIRATION; RIGHT sided murmurs (T/P) in INSPIRATION Thank the patient and leave them comfortable. Wash hands at end ECG lead placement  P wave : atrial depolarisation.  QRS complex: ventricular depolarisation.  T wave: ventricular repolarisation.  An upward or positive movement means depolarisation travelling in the direction of the positive terminal of the lead, or repolarisation travelling away from the positive terminal of the lead.
  5. 5. Chest lead positioning  V1: right 4th ICS  V2: Left 4TH ics  V3: halfway between V2 and V4  V4: left 5th ICS, mid-clavicular line  V5: horizontal to V4, anterior axillary line  V6: horizontal to v5, mid-axillary line You should be able to read the axis and understand all this in terms of an axis diagram. The leads:  Lead AVL: positive terminal on L arm, negative terminal on R arm and leg. Axis –30.  Lead I: positive terminal on L arm, negative terminal on R arm, axis 0  Lead AVR: positive terminal on R arm, negative terminal L arm and leg, axis –150  Lead II Positive terminal on leg, negative terminal on R arm, axis + 60  Lead AVF: positive terminal on leg, negative terminal on L and R arms, Axis +90  Lead III: positive terminal on leg, negative terminal on L arm, axis + 120.  Rate: you should be able to calculate the heart rate from an ECG.  Paper is 25mm/sec  Rhythm: if you are given an ECG you should be able to distinguish various rhythms, including: - Normal sinus rhythm, 1st, 2nd, 3rd degree ht. block, flutter, and atrial fibrillation, atrial or ventricular - premature beats (ectopics), ventricular defibrillation.
  6. 6. Respiratory system: general examination  Wash hands. Introduce yourself, and ask permission to “listen to your breathing” or some such non-specialist phrase.  Assess the patient from the end of the bed: o Conscious state, o General appearance (strained breathing, colour, bloated etc?) o presence of drips, ventilators, tablets, sputum pots, oxygen mask, GTN spray etc. 1. General exam:  Look in eye mucosae  pallor, anaemia  Look in the mouth – o “Stick your tongue out”  central cyanosis, sore smooth tongue (B12 deficiency), sore corners of mouth (iron deficiency),  Look at hands o Clubbing (pus in the chest, malignancy), o Tobacco stains o Colour, temperature of hands  Look for flapping tremor of CO2 retention. o Ask patient to hold wrists extended (demonstrate) o Look for coarse, irregular flapping tremor on sustained muscle contraction o  Sign of co2 retention  Observe for chest scars 2. Respiratory assessment  Feel the pulse: a strong “bounding” pulse is characteristic of CO2 retention.  Assess the respiratory rate and the use of accessory muscles of respiration. You will not have to count it for a five-minute station.  Observe chest: one deep breath in and out. Symmetrical?  Palpate to see if the trachea is central  Chest expansion from front and back. 3. Percussion:  The sound should be dull over the rib, and more resonant over the intercostal space. If there is fluid in the lung, the sound will be dull, and will be hyper-resonant in the presence of emphysema or pneumothorax, where there is increased airspace. 4. Tactile vocal fremitus  At 3 or 4 levels anterior and posterior  Place ulnar aspects of hands flat over the chest  Ask patient to say ‘99’  Feel for resonance and dullness 5. Auscultation for breath sounds:  Same places at percussion.  Check for symmetrical breathing sounds  Are there additional sounds e.g. wheezing, crackling or sternal friction rub?  Normal sounds may be: - Vesicular: where lung tissue is nearer to the stethoscope than main airways. Heard over peripheral areas of the chest. - Bronchical: where the main airways are nearer to the stethoscope than lung tissue (over trachea etc). Thank the patient and leave them comfortable. Wash hands at end
  7. 7. Peak flow  Wash hands.  Introduce yourself, ask permission, and explain the purpose of the investigation.  Either demonstrate on the meter or “act out” the forceful expiration necessary to obtain a peak flow reading. If you demonstrate it, you can fit a clean tube onto the apparatus yourself, and then dispose of it afterwards.  Then ask the patient to do it him/herself. It is best to ask them to fit the tube themselves, and then make sure it is disposed of afterwards.  Get them to do three expirations. Reset the meter to 0 each time. Take the best of three readings. Get them to fit the nose clip if it is provided. Standing up is the standard position.  Interpretation. The normal range depends on the age, height, and sex of the subject. The reading is usually interpreted with the aid of a nomogram. Typical conditions causing reduced peak flow are bronchial asthma, chronic obstructive airways disease. Thank the patient and leave them comfortable. Vitalograph  Wash hands. Introduction. Permission. Explanation.  This is more sophisticated than peak flow. You will not be able to demonstrate it on the apparatus, as the programming takes too long. You can “act out” what you want: a full inspiration, breath out as fast as possible, until the lungs are as empty as possible.  Get them to fit the tube themselves, and make sure it is disposed of afterwards.  To reprogram the vitalograph after the last test: - Switch off and on again using the “on” switch. - On the little display, select “test” using the up and down arrow keys. - Press enter - Select “auto” on the display using the arrow keys - Press “enter”. - Fill in personal details using up and down arrow keys, pressing “enter” after each. - Select FVC with up and down arrow keys. - Press “enter” for test. - Patient blows in as instructed: as hard and long as possible. - Press up arrow for another test. - Press down arrow for results.  You get Vital Capacity and FEV1 (forced expiratory volume in 1 second as a % of the vital capacity as well as the peak flow.  The FEV1 and peak flow are reduced in a bronchial asthma attack. Vital capacity more or less normal.  Vital capacity is reduced with more or less normal FEV1 in pulmonary fibrosis, lobar pneumonia, pleural effusion, pneumothorax.  Chronic obstructive airway disease reduces both. Thank the patient and leave them comfortable. Abdominal examination  Wash hands. Introduce yourself, ask permission to “examine your abdomen” or some such phrase.  Assess the patient from the end of the bed: o conscious state, o general appearance (obvious discomfort, guarding) o drips, nasogastric tube, tablets, special diet etc.  In most “examination OSCE” stations you are not expected to take any history, but in “abdo” you can ask if the patient is in any pain.  Lie the patient flat if possible, exposed form the xiphoid to the pubis
  8. 8. 1. General examination:  Eyes: look for pallor and jaundice. Xanthalasma.  Mouth: sore tongue, sore corners of mouth - may indicate B12 or Fe deficiency respectively,  Hands:  Clubbing  assoc. with vascular disease  palmar erythema,  portal hypertension  leukonychia: white discolouration of the nails  hypoalbuminaemia, cirrhosis  Dupuytren’s contracture  cirrhosis  Liver flap (coarse tremor)  Skin in general:  spider naevi.  Dehydration gives low turgor.  Lymph nodes.  Ideally do all LN, but a 5 min station leaves you short of time.  Do supraclavicular: Virchow’s node.  Abdo: inspect for striae, distension, prominent veins round umbilicus, bruising, asymmetry, visible peristalsis.  Ask if in pain, ask the patient to give a little cough, and ask if it hurts
  9. 9. 2. Sit down to do abdominal exam.  Two sets of palpations – superficial, then deeper  If the patient is in pain, palpate the opposite side first  Press with a flat hand, feel for any obvious masses  Gently palpate the nine areas in turn 3. Liver  Start in the right iliac fossa  Ask patient to take a deep breath in and out, sweep the hand upwards to meet the descension of the liver (lower margin)  Percuss down from the fifth ICS til the sounds become duller (to find the top margin) and upwards from the groin to find the lower margin 4. spleen  Begin in the right iliac fossa, palpate upwards in a diagonal direction towards the left hypochondrium  Ask the patient to take deep breaths in and out  Place on hand on the costal margin, and sweep with the other  Spleen needs to be 2-3 times enlarged before it can be palpated 5. kidneys  Place one hand underneath the loin (around T12/L1), and the other hand on top  Feel between the hands (“ballot”) for any enlargment 6. Auscultation  Listen in one area for approx 15seconds (OSCE) for bowel sounds  Note any hyperactivity, absence or tinkling 7. Percussion  For ascites (shifting dullness).  Percuss up the abdomen until dullness felt.  Roll the patient towards you. If there is ascites, a bubble should form (area of resonance) where there was previously dullness Thank the patient and leave them comfortable. Wash hands at end
  10. 10. PNS exam – motor function wash hands, introduction, consent and explanation – “I’d like to examine your arms and legs” 1. Observation:  Check for any obvious signs, scarring around the joints etc  Ask if any pain or stiffness in muscles or joints etc. 2. Bulk:  check for wasting by comparing bulk on both sides e.g. arms, thighs, neck, shoulder, calf etc.  can be a sign of disuse atrophy (dennervation), malnutrition, motor-neuron disease or lesion (UMN/LMN). 3. Tone:  test tone across the major joints: - upper limb: shake hands - lower limb: straight leg, shake knee (look for movement in the foot) - pick up and drop knee, heel should stay on the bed.  Hypertonia: increased tone, may be due to UMN lesion.  Hypotonia: reduced tone, may be due to LMN lesion.
  11. 11. 4. Motor/Power: Movement Roots tested Patient action Examiner action Upper limb Shoulder Abduction C4, C5 Make wings out Push medially Adduction C6, C7 Make wings at side Push laterally Elbow Extension C7, C8 Slightly bent extended arm Try to force flexion Flexion C5, C6 Elbows flexed Try to force extension Wrist Dorsiflexion C7, C8 Flat hand Try to push down Palmarflexion C7, C8 Flat hand Try to push up Fingers Abduction T1 Spread fingers Try to force close Adduction T1 Hold card/paper between fingers Try to pull card/paper out Thumb Opposition T1 Make an “O” with fingers and thumb Try to pull apart Abduction T1 Flat hand, palm up, thumb pointing superiorly Try to push down Lower limb Hip Flexion L1, L2 Hold knees up to the chest Try to pull back Extension L4, L5 Flex the knee Try to push knees to the chest Knee Flexion L5, S1 Slightly flex the knee Try to extend the knee Extension L2, L3 Slightly flex the knee Try to force flexion Ankle Dorsiflexion L4, L5 Point foot to the sky Try to push foot downwards Plantarflexion S1, S2 Point toes to the floor Try to push anterior part of the foot superiorly Foot Inversion - Try to touch soles of feet together Try to push lateral part of the foot laterally Eversion - Examiner puts into a slightly everted position Try to push lateral part of the foot medially 5. Co-ordination: Upper limb – finger-nose test  Ask patient to touch your finger held out in front of the so that they have to fully extend, and then to touch the tip of the nose  Ask then to repeat several times as quickly as possible Lower limb – Heel-shin test  Show the patient how to complete the movement of running the back of the heel up/down the shin, lift up and then repeat.  Repeat as quickly as possible. 6. Reflexes Reflex Roots tested method Desired result Upper limb Biceps C5. C6 Finger placed on the tendon at the cubital fossa, and struck with a patellar hammer Activation of stretch receptors, slight flexion of the elbow Triceps C7, C8 Arm relaxed at a right angle, tendon tapped above the olecranon fossa. Activation of stretch receptors, slight extension of the elbow Supinator C5, C6 Strike the lower end of the radius just above the wrist Flexion of the elbow. May cause finger flicker.
  12. 12. Lower limb Patellar L3, L4 Use a patellar hammer to tap the patellar tendon to initiate the reflex. Can be done sitting on the edge of the bed or lying down with one arm supporting a slightly flexed knee from underneath. Knee jerk. Achillies S1, S2 Tap the calconeal tendon with a patellar hammer while the foot is dorsiflexed Jerking of the foot (plantarflexion) Babinski (plantar) Run the lower end of a patella hammer (or similar) up the lateral side of the sole of the foot and across the ball medially. The smaller toes will flare upwards, the great toe will initially flex, then extend. Reflexes alone. The station will state which ones.  Wash hands. Introduce and explain, ask permission.  Inspect for wasting, fasciculation, assymmetry. Tell the examiner as you do it.  The full possible number of reflexes is biceps, triceps, supinator, quadriceps (patellar tendon), and ankle jerk (achilles tendon). You will not be asked to do the Babinski.  Do each reflex twice, and proceed symmetrically: do one biceps, then the other, do one triceps, then the other. Etc. - Biceps reflexes: feel for biceps tendon with your finger, hit your finger with hammer. Patient should be relaxed, with elbow flexed. Feel tendon tighten under your finger, see muscle contract. - Triceps reflex: hold the patient’s hand, supporting the weight of the flexed arm. Hit the triceps tendon directly with the hammer. Feel forearm move as elbow extends, see triceps muscle contract - Supinator: Hold the patient’s hand, hit over radius, about 1/3 way up forearm from wrist. Feel arm move, see muscle contract. - Quadriceps: feel between patella and tibial tuberosity, hit tendon directly - Ankle jerk: Hold foot in neutral position. Hit Achilles tendon with hammer. Feel and see foot plantiflexes.  People differ in how easy these reflexes are to elicit. Symmetry is important in deciding if anything is wrong.  Wash hands at end Cranial Nerve Exam I Olfactory Some Smell – asked II Optic Say Vision – accommodation, consensual pupillary reflex, visual fields III Occulomotor Money Most muscles moving the eye, except lateral rectus and superior oblique IV Trochlear Matters Superior oblique V Trigeminal But Assessed using the mandibular branch – muscles of mastication VI Abducens My Lateral rectus VII Facial Boyfriend Muscles of facial expression VIII Vestibulocochlear Says Not assessed in this document IX Glossopharyngeal Big Gag reflex - Not assessed X Vagus Boobs Palatal elevation XI Accessory Matter Strength of sternocleidomastoid and trapezius XII Hypoglossal More Tongue symmetry and movement
  13. 13. Wash hands, obtain consent, explain procedure. 1. Observe  for asymmetry in the face, drooping eyes (ptosis) weakness on one side of the face. 2. Olfaction (I):  Ask if they have noticed any loss/reduction in sense of smell or taste recently? 3. Vision (II):  Test acuity using a snellen chart (with any corrective glasses/lenses)  Confrontation: Compare the patient’s visual fields with your own, using the ‘wiggling finger’ method  Direct and consensual pupillary light reflexes  Convergence: look at distant point, then finger at closer proximity  Size and symmetry of pupils: o Dilated: mydriasis o Constricted: miosis  Fundoscopy  Test colour vision using an Ishihara chart 4. Extra-occular movements (III, IV, VI):  Draw an H in the air, ask patient to follow with eyes. Ask if any double vision.  Check for drooping, unopposed down and/or outward looking (3rd nerve palsy)  Check for nystagmus  ABducens Abducts (lateral rectus) 5. Muscles of mastication (V):  Ask to tightly close jaw, and try to open at the chin  Ask to open the jaw, does it open evenly?  ‘Jaw jerk’ – half open mouth, tap chin. Lesions may show exaggerated reflex. 6. Facial expression (VII):  Observe face for symmetry  Ask to smile with teeth  Blow cheeks out and push gently  Shut eyes tightly, gently try to open  Look to the ceiling, look for brow symmetry (UMN/LMN palsy) **Rinnie’s and Weber’s tests for vestibulocochlear function are absent from this document** 7. Palatal elevation (X):  Say ‘g, g, g’ and ‘ck, ck, ck’  Say ‘ahhh’, and observe soft palate. Should move upwards sharply and symmetrically. Will move away from a lesion. 8. Sternocleidomastoid and trapezius (XI):  Hold hand up, ask to press side of face into the hand  If lying down, put hand on forehead, ask to push head against hand.  Ask to shrug shoulders, look for weakness, then try to push down. 9. Motor to the tongue (XII):  Observe the tongue in the mouth, look for wasting and fasciulations  Stick tongue out, tongue will move towards the lesioned side  Ask to move tongue in both directions  Push tongue against cheek  Push tongue against cheek against finger.
  14. 14. Thyroid exam Wash hands and obtain consent “may I examine you to see how your thyroid is working?” Grave’s triad:  Acropachy:  Exophthalmos  Pretibia myxoedema Signs of hyper and hypo: Hyperthyroidism Hypothyroidism High BMR Low BMR Weight loss Tiredness/lethargy Increased appetitie Weight gain Irritability Cold intolerance High freq tremor Goitre Heat intolerance Mental slowness Tachycardia Dry, thin hair and skin Warm, vasodilated peripheries bradycardia Exopthalmos depression goitre Anxiety, agitation 1. Hands  Acropachy: clubbing of the fingers and toes with soft tissue swelling occurring in patients with thyrotoxicosis  Fine tremor: spread fingers, or use piece of paper  Turn hands over: o Dry/cool: hypo o Hot/sweaty: hyper  Palmar erythema: thyrotoxicosis  Onycholysis: painless separation of the finger nail from the nailbed: hypert 2. Face/eyes  Hypo: puffy, dry Hyper: thin, maybe sweaty  Lid lag: look at finger as it moves up and down. Lid will lag behind eye movement  Exophthalmos: look from above, may be subtle.  May be a cranial nerve palsy (medial and lateral rectus) – H test  Hair: dry and brittle in hyper; may be hair loss in hypo Other  ASK: has there been any unexplained weight loss or gain recently?  Is the patient appropriately dressed for the environment?  Proximal myopathy: resisted arm abduction and ‘cross arms, then stand’ manoeuvre
  15. 15. 3. Pulse/BP  Tachy/Bradycardia  High/low bp 4. Neck exam A. anterior assessment  Auscultate for a bruit over the goitre (increased vascularity)  Is there a mass?  Are there any scars from neck surgery?  Ask the patient to take a sip of water, hold it in the mouth, then swallow. The mass should rise and fall with the larynx.  Ask the patient to stick out their tongue: if it is a thyroglossal cyst, the mass will move upwards with the tongue protrusion B. Posterior assessment  Palpate from behind: define the shape, size, borders, smoothness of surface, symmetry  Repeat the water test while palpating  Can you palpate below it? If not, percuss the upper sternum for dullness (retro-sternal goitre)  Palpate the local cervical lymph nodes Lymph nodes of the neck
  16. 16. Axillary lymph nodes Shoulder joint exam Rotator cuff muscles  Supraspinatus: abducts the arm the first 15 degrees  Infraspinatsus: external rotation  Teres minor: external rotation  Subscapularis: internal rotation 1. Questioning  Ask if there is any pain in the joint or muscles  Ask if there are any particular movements they find painful/uncomfortable/impossible  Has the patient ever had surgery/fracture/dislocation? 2. LOOK  Patient should be in the anatomical position where possible  Are there any obvious deformities? o Dislocated shoulder: dropped arm, loss of rounded contour of the shoulder o Winged scapula: Ask the patient to hold their arms out in front of them hands together. Or, get them to push against a wall  Muscle wasting/asymmetry  Presence of scars  Signs of inflammation: swelling, redness
  17. 17. 3. FEEL  Feel along the clavicle, comparing sides (SCJ  ACJ) and acromion  Feel along the spine of the scapula  Feel for swelling, warmth, tenderness, bulk 4. MOVE  Active movement o external rotation: Hands behind the head o Internal rotation: Hands up and behind back o Flexion/Extension: Arms up then down o Abduction/adduction: Arms crossed, then out laterally  Passive movement o Carry out the above movements for the patient o Feel the joint for crepitus while moving it  Resisted movement External rotation Copeland test Internal rotation 5. SPECIAL TESTS  Frozen shoulder: o Thickening and contracting of the capsule o Pain on external rotation with abduction?  Supraspinatus Subacromial impingement: o Empty can/Copeland’s test: Internal rotation when abducted = pain. Relieved when the arm is externally rotated  AC joint: o Scarf test: This test is positive when it revives the acromioclavicular pain.  Painful arc o Pain in ~80 degree abduction, not pain above or below this. ***test the joint above and below*** Scarf test
  18. 18. Hip joint exam 1. Questioning  Ask if there is any pain in the joint or muscles  Ask if there are any particular movements they find painful/uncomfortable/impossible  Has the patient ever had surgery/fracture/dislocation? 2. LOOK  Observe the gait (is it antalgic?)  Signs of inflammation  Scars  Symmetry of position, alignment and muscle bulk  Fractured hip: External rotation and leg shortening  Dislocated hip: Internal rotation and leg shortening 3. FEEL  Patient should lie flat if possible  Feel for the greater trochanter – is there pain? May be an avulsion fracture  Measure the leg length o True leg length: ASIS to the medial malleolus o Apparent leg length: umbilicus to the medial malleolus 4. MOVE Test passive, active and resisted movement  Internal rotation - with knee and hip both flexed at 90 degrees the ankle is abducted.  External rotation - with knee and hip both flexed at 90 degrees the ankle is adducted.  Flexion  Extension - done with the patient on their side.  Abduction - assessed whilst palpating the contralateral ASIS.  Adduction - assessed whilst palpating the ipsilateral ASIS. 5. SPECIAL TESTS  Thomas’ test for a hidden flexion contracture o Place a hand behind the lumbar spine o Getting the patient to fully flex the contralateral hip until the lumbar spine is flat o If the other leg starts to lift as well = fixed flexion deformity  Trendelenberg’s: o Tests the abductors of the hip (gluteal muscles and nerves) o Ask the patient to stand and lift (flex) one leg o The pelvis should stay balanced. If there is a tip to one side, then the abductors of the contralateral hip are weak. *** test joint above and below***

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