2nd Year OSCE - peerassisted.orgpeerassisted.org/wp-content/uploads/2014/09/2nd-Year-PALI-Notes...also test for a collapsing pulse, but there probably will not be a mark for this in

2nd Year OSCE Notes and mock mark schemes

May 2016

Peer-Assisted Learning Initiative

Glasgow University Medical School

www.peerassisted.org

Chan N, Wallace S, Johnston C, Arthur F, Skipsy D, Murnane P, Sharkey J, Tomlinson J, Rodgers G, Mullin D, Lee WC, O’Carrol D, Saleh P, Jacob Z, Cappiello AM, Khader A, Watt K, Dockery M, Mathai N, Garrity K, Vincent S, Connolly V, Murchison L, Anderson R, Aitken T, Thomas B, Young A, McCarrison S, Smart A.

Contents

Cardiovascular Examination P1

Blood Pressure P4

Respiratory Examination P6

CNS – Upper Limb P8

Digital Rectal Exam P10

Gastrointestinal Examination P12

CPR P14

CNS – Lower Limb P16

REMS Knee P19

REMS Hip P21

Urinalysis P24

History Taking Skills P26

A note on the contents This work was produced entirely by fourth year MBChB undergraduates at Glasgow

University Medical School. The contents are in no way official documents used by the medical

school for assessment purposes.

P1 2nd Year Mock OSCE Mark Scheme

The Cardiovascular Examination Instructions: Perform a full examination of this patients cardiovascular system. Time: 5 minutes.

Circle: Pass / Borderline Pass / Fail Total marks: ______ / 20

TASK Marks

INTRODUCTION

1. Introduce self, check patient identity (name and D.O.B) and position patient at a 45 degree angle 0 1

2. Explanation of procedure and gain consent 0 1

3. Wash hands before and after the examination 0 1

4. General inspection – patient + environment (O2 therapy, GTN, pulse oximiter, cigarettes etc.) 0 1

HANDS, FACE, PULSES AND NECK

5. Inspect hands – palmar crease pallor, peripheral cyanosis, splinter haemorrhages, xanthomata, tar staining 0 1

6. Inspect face with special emphasis on central cyanosis; bonus if conjunctival pallor, corneal arcus etc. 0 1

7. Assessment of radial pulse (rate, rhythm, volume character (collapsing)) 0 1

8. Assessment of jugular venous pressure including hepato-jugular reflux 0 1

PRAECORDIUM

9. Inspect praecordium (scars, pacemakers, visible pulsations) 0 1

10. Locate apex beat with right hand 0 1

11. Correct position of apex beat (5th intercostals space in the mid-clavicular line - count down ribs) 0 1

12. Left parasternal heave and thrills 0 1

13.

Auscultate praecordium in 4 areas with bell and diaphragm: 1 mark per correctly named area • Mitral • Tricuspid • Pulmonary • Aortic

0 4

14. Offer manoeuvres to accentuate murmurs:

• Turn patient on to left side and auscultate in the mitral area (mitral stenosis) • Sit patient forward and auscultate over the lower left sternal edge in expiration

0 2

15. Auscultate carotids – listen for murmur radiation and bruits 0 1

16. Mention other key areas, appropriate summary and conclusion 0 1

P2 2nd Year OSCE Revision Course Notes

The Cardiovascular Examination Written in 2012, updated April 2014 by Alistair Skea, Sam Norman and Ross Scott. Easy OSCE Marks: Before every clinical station in the OSCE ensure you wash your hands, introduce yourself, establish the patient’s name and DOB, explain the procedure and gain consent. General Inspection: This is crucial and can give a general idea of what may be going on with the patient. Does the patient look well/unwell? Do they have a fast respiratory rate? Any medical aids such as oxygen/drip? Also, remember to correctly position the patient at 45 degrees on the bed, and check they are comfortable at rest. Hands: Feel if the hands are cold or warm. Look for peripheral cyanosis, with a blue tinge to the fingers. Capillary refill time should be less than 2 seconds, having pushed down on the nail bed for 5 seconds. Finger clubbing may be seen in endocarditis, cyanotic congenital heart disease or atrial myxoma (heart cancer). Splinter haemorrhages (tiny blood clots running vertically under the nail) are a sign of infective endocarditis. Look for tar staining as well as smoking is a risk factor for some heart disease. Radial Pulse: In general, there are 4 things to comment on with a pulse; rate, rhythm, volume and character. The radial pulse will help you establish the rate (feel for 15 secs, then multiply by 4 for heart rate) and rhythm (regular or irregular). You may also test for a collapsing pulse, but there probably will not be a mark for this in the 2nd year OSCE. The carotid pulse may also be assessed after you have examined the patient’s chest, as this is better for establishing the character and volume but, again, this will probably not be expected of you at this stage. Face: Again, you are looking for any clues that may help your diagnosis. Check the eyes for conjuctival pallor, a sign of anaemia. Hyperlipidaemia can manifest as corneal arcus (creamy discoloration at around the edge of the iris) or xanthelasma (yellowish cholesterol plaques around the eye). A purple-red discolouration of the face may suggest malar flush, which is classically associated with mitral stenosis. Be sure to check the lips and tongue for any central cyanosis but do not labour the inspection of the hands and face - in 2nd year it is best to remember a list of 4 or 5 things to look for in and say what you are doing as you quickly assess each. Jugular Venous Pressure (JVP): This is the easiest way to see if the venous pressure is raised in a patient. Ensure the patient is lying at a 45 degree angle, with their head tilted slightly up and to the left. The JVP is viewed as a double pulsation, and lies between the heads of the sternocleidomastoid muscle and the angle of the jaw. You cannot see it in everybody, particularly if they are healthy! It is said to be raised if it is >4cm vertically from sternal angle. Right sided heart failure and fluid overload are the most common cardiac reasons for a raised JVP. The hepato-jugular reflux can exaggerate a raised JVP, and is performed by pressing in the right upper quadrant of the abdomen. Praecordium: Inspect the praecordium for scars, abnormal shape/contour, visible pulsations or devices in situ (Pacemaker/Implantable cardiac defibrillator). Palpate the apex beat with your right hand and check its position - it should be in the 5th intercostal space in the mid-clavicular line. It is a good idea to palpate out this position to show an examiner that you know where this is:

First, feel the ends of the clavicle at the sterno-clavicular and acromio-clavicular joints, and estimate the ½ way point between these two anatomical landmarks. Next, palpate the sternal angle (where the 2nd rib meets the sternum) and feel along the 2nd rib until you reach the mid-clavicular line, before heading inferiorly to the intercostal space below - this is the 2nd intercostal space. From here, count down the spaces to find the 5th intercostal space.

You should comment on whether the apex beat is displaced or not, and describe the character. Forceful, sustained heaving suggests ventricular hypertrophy; a tapping beat is indicative of mitral stenosis; and a thrusting apex beat may suggest volume overload. You must also feel for heaves and thrills. A heave is the same thing as a left parasternal impulse and is present where there is an abnormally strong cardiac impulse e.g. due to right ventricular hypertrophy. To assess, you place your entire outstretched hand on the chest parallel to the sternum on the left side with your fingers pointing towards the patient’s neck. If there is a heave present, the heel of your hand will be raised with each heartbeat. A good tip is to look at the heel of your hand but also at your elbow where the abnormal movement may be more apparent. A thrill is a palpable murmur caused by turbulent blood flow through a heart valve and feels like a gentle vibration against your hand. Feel systematically around the chest but in particular feel at the apex, upper praecordium and sternal notch.

P3

Auscultate for the heart sounds in the 4 areas.

• Mitral Area = 5th intercostal space in the mid-clavicular line • Tricuspid Area = 4th intercostal space at the left sternal edge • Pulmonary Area = 2nd intercostal space at the left sternal edge • Aortic Area = 2nd intercostal space at the right sternal edge

N.B. It is important to know these areas and where they are. However, it is not necessary to palpate these out as with the apex beat. There are various mnemonics out there to help you easily remember these areas.

Have a system for auscultation- e.g. start in the mitral area → tricuspid → pulmonary → aortic regions. Work through the four areas with the diaphragm of the stethoscope and then use the bell to listen in the mitral area. Make sure the stethoscope is the right way round with the ear pieces angled away from you (apologies but people get it wrong). The diaphragm is better for listening to high pitched sounds while the bell is better for listening to low pitched rumbling sounds. Ensure you apply firm pressure when using the diaphragm of the stethoscope.

When auscultating at first, palpate the carotid or radial pulse in order to help you distinguish between the first and second heart sound. When people refer to “lub-dub”, they are referring to the heart sounds with “lub” being the first heart sound and “dub” being the second. The first heart sound is the result of the mitral and tricuspid valves closing at the end of diastole and marks the start of systole. The second heart sound is due to the aortic and pulmonary valves closing at the end of systole and marks the start of diastole.

It is important to distinguish between the heart sounds in order to decide if there are any added sounds and be able to work out which period of time is systole and which is diastole. If a murmur is heard you can then decide whether it is a systolic or diastolic murmur which in turn helps you decide which valve may be affected. The most common murmurs (in order of commonest to least) are aortic stenosis, mitral regurgitation, aortic regurgitation and mitral stenosis.

You also need to offer and carry out specific manoeuvres which can exaggerate a murmur:

1) Ask the patient to roll onto their left hand side and listen in the mitral area with the bell for mitral stenosis. 2) Ask the patient to sit forwards and hold their breath in expiration. Listen at the lower left sternal edge with the

diaphragm for aortic regurgitation. Also use the diaphragm to auscultate over the carotids, with the patient holding their breath, for radiation of aortic stenosis. Other Areas to Mention: Depends on the exact OSCE station. However, always mention that you would measure the blood pressure. Others investigations include abdominal examination (particularly for hepatomegaly), inspect the legs and feel for pulses, check for signs of heart failure (ankle oedema, sacral oedema and pulmonary oedema), ophthalmic examination, urine dipstick and observation charts. There are not always marks for stating this in the OSCE, but it is good practice for later years and may help you get the mark for excellence. Summary: Finish by saying that you have completed a cardiovascular examination of the patient which is normal with no signs of disease then thank the patient and wash your hands. Alternatively, you can go through the exam and summarize in a longer way by saying that you have completed a cardiovascular examination of the patient and that on inspection there were no signs of disease, the pulse was 60 BPM and regular with normal character and volume, the JVP was not raised, the apex beat was not displaced and there were no heaves or thrills. Heart sounds 1 and 2 were heard with no added heart sounds or murmurs. Conclude by stating that these findings are consistent with a normal CV examination. Advice:

• Practice lots on each other and make it look slick • Talk out loud to show the examiner that you know what you are doing • Do the easy things well (wash hands, introduction etc) as they give you lots of marks • If you get stuck, calm down, take a breath and break it down to basics - general inspection, hands, face, neck,

pulses, palpation and auscultation. Try and make it systematic. • Do not let auscultation phase you. It will be normal in your 2nd year. Make sure you are able to go through

your practised routine and confidently say that you can identify the first and second heart sounds with nothing added.

• Read the scenario carefully as it may give you some clues as to the marks available. Adapt your exam appropriately. For example you may be asked to examine the cardiovascular system excluding the hands and face.

BIBLIOGRAPHY AND FURTHER READING: 1. Douglas G, Nicol F, Robertson C, editors. Macleod’s clinical examination, 12th ed. London; Churchill

Livingston: 2009. 2. Cox N, Roper TA, editors. Clinical Skills, 1st ed. Oxford; Oxford University Press: 2005

P4

2nd Year Mock OSCE Mark Scheme

Blood Pressure Instructions: Assess the blood pressure in this patient/model and report your findings to the examiner. Time: 5 minutes.

TASK Marks INTRODUCTION

1. Introduces self and checks patient’s name and date of birth 0 1

2. Explains procedure and gains consent 0 1

3. Washes hands before and after examination 0 2

PROCEDURE

4. Ensures patient is sitting comfortably with arm supported 0 1

5. Palpates brachial artery 0 1

6. Chooses appropriate cuff size 0 1

7. Applies cuff correctly (arrow over brachial artery, cuff level with the heart) 0 1

8. Palpates radial artery 0 1

9. Inflates cuff for estimated systolic blood pressure 0 1

10. Places diaphragm/bell of stethoscope over brachial artery 0 1

11. Correctly identifies Korotkoff sound 1 (K1) 0 1

12. Correctly identifies Korotkoff sound 5 (K5) 0 1

SUMMARY

13.

States blood pressure: (1 mark for each of the following) o Accurately (i.e. no approximation) o Whether hypotensive/normotensive/hypertensive o With source (e.g. R arm) o With patient position (e.g. sitting, standing)

0 1

0 1

0 1

0 1

14. States would measure BP again until attained 2 reproducible results 0 1

15. States would measure BP again with patient standing (for postural hypotension) 0 1

16. Mark for excellence 0 1



Blood Pressure Written in April 2012 by Joe Sharkey and Jamie Tomlinson. Non-Invasive Blood Pressure (NIBP): Blood pressure (BP) is the force exerted by circulating blood on the walls of blood vessels, especially arteries. Systolic BP is the pressure exerted during ventricular systole. Diastolic BP is the pressure maintained by the elasticity of the arterial walls during ventricular relaxation. If performed correctly, NIBP is a reliable and accurate method of recording blood pressure. The Korotkoff Sounds: Systolic and diastolic blood pressure is determined by auscultation of the Korotkoff sounds. While Kortokoff IV corresponds most closely to true diastole, Kortokoff V is used to clinically define diastolic blood pressure. If phase V goes to 0mmHg, then phase IV can be used as the diastolic blood pressure. Defining Hypertension:

Category of Hypertension

Clinic Systolic Pressure (mmHg)

Clinic Diastolic Pressure (mmHg)

Grade 1 (mild)

≥ 140

≥ 90

Grade 2 (moderate)

≥ 160

≥ 100

Grade 3 (severe)

≥ 180

≥ 110

High blood pressure is usually asymptomatic unless ‘severe’. Hypertension is one of the leading causes of cardiac disease and stroke in the UK. Ambulatory BP Monitoring (ABPM) or Home Blood Pressure Monitoring (HBPM) is normally carried out to exclude ‘white-coat’ hypertension and confirm the diagnosis of hypertension. Defining Hypotension: Hypotension is less well defined and is below the normal expected for an individual in a given environment. For the purposes of shock, it is defined as a Systolic BP of <90mmHg. BIBILIOGRAPHY AND FURTHER READING

1. British Hypertension Society: www.bhsoc.org 2. Epstein et al. Clinical Examination. Mosby Elsevier. 4th edition. 2008 3.

Artery Cuff Pressure Sounds Kortokoff

Completely occluded

> Systolic Pressure

No sounds

n/a

Just opens

Systolic Pressure

1st audible ‘tapping’ noise

I

Open for more of the

systolic phase

Between systolic/diastolic

Regular tapping noises.

Louder and ringing in character

II/III

Open for almost all of

the systolic phase

Diastolic pressure

Muffled

IV

Open all the time

< Diastolic pressure

Disappears

V


Respiratory Examination Instructions: Complete a full respiratory examination of this patient (front and back). Time: 5 minutes.

TASK Marks

INTRODUCTION

1. Washes hands before and after 0 1

2. Introduces oneself, checks patients name and age, obtains consent, explains 0 1

3. Adequately exposes patient, positions semi-recumbent (45 degrees) 0 1

INSPECTION

4. Environment – O2 therapy, inhalers, sputum pots, cigarettes 0 1

5. General – breathless/distressed; listen for wheezes / stridor; identify cachexia, gross oedema 0 1

6. Nails – clubbing, tar staining 0 1

7. Hands – asterixis, cyanosis, palmar creases, tar staining, small muscle wasting 0 1

8. Face – conjunctiva, tongue, pursed lip breathing, SVC obstruction, Horner’s 0 1

9. Chest – shape, scars, respiratory rate, symmetry, pectus carinatum / excavatum 0 1

PALPATION

10. Checks trachea 0 1

11. Lymph nodes of neck 0 1

12. Expansion – correct technique (2 positions anteriorly, 3 posteriorly) 0 1

13. Tactile vocal fremitus 0 1

PERCUSSION

14. Over apices, chest and axillae 0 1

AUSCULTATION

15. Breath sounds – vesicular (normal) or bronchial 0 1

16. Added sounds – wheexe, crackles (course or fine), pleural rub 0 1

17. Vocal resonance 0 1

18. Compares both sides 0 1

19. Summary 0 1

20. Mark for Excellence 0 1



Respiratory Examination Written April 2012 by Gary Rodgers and Donncha Mullin, updated May 2016 by David Birrell. Inspection: General

• From the end of the bed, observe the patient’s general appearance • Look for signs around the bed : sputum pots, O2 masks, inhalers, intercostal drains • Count respiratory rate throughout, then comment e.g. “pt. has a RR of 16 bpm which is

within the normal range”. Hands

• Take patient’s hand in your and comment on temperature • Nails – clubbing (Ca, ILD, CF, Bronchiectasis) • Red – Palmar erythema (Hyper-dynamic circulation) • White – Pallor of palmar creases (Anaemia - cause of SOB) • Blue – Peripheral cyanosis (PVD, Raynaud's, CCF) • Yellow – tar staining (Smoking) • Asterixis – the flapping tremor of CO2 retention • Pulse – rate, rhythm, volume and character – is it the bounding pulse of CO2 retention?

Face • Eyes: look for anaemia in the conjunctiva • Mouth: central (tongue) and peripheral (lips) cyanosis

Chest

• Deformities (barrel chest, pectus excavatum, pectus carinatum) or scars (e.g. thoracotomy) • Asymmetry of chest expansion • Accessory muscles used? Tripoding?

Carry out all subsequent steps on the front of the chest and then all again on the back. Remember the apices and the axilla when examining both the front and the back – important if OSCE station asks you to do only one or the other. Palpation:

• Palpate the cervical, supraclavicular and axillary lymph nodes, naming them as you go. Be systematic and comment: “no evidence of lymphadenopathy”. Lymphadenopathy may indicate infection or a metastatic spread from a lung malignancy.

• Tracheal deviation: warn patient it may be uncomfortable, place fingers either side of the trachea and comment that it is “central, non-deviated”.

• Chest expansion – 2 at front, 3 at back. Use both hands, making sure your thumbs are not touching the chest. Unusual expansion may be due to a pneumothorax (this will not be present in your OSCE) or a pneumonectomy.

• Tactile fremitus – place the edge of the hands on the chest and ask the patient to say (ninety-nine).

Percussion: • Percussion attempts to examine changes in lung density. Examples of alterations in density

include pleural effusion (dull) and pneumothorax (hyper-resonant). • At front - start at clavicles to assess apices, move down chest comparing each side; remember

axilla. • At back – work between scapula and move out underneath them. • If normal state that chest is “resonant and equal on both sides”.

Auscultation:

• Ask patient to breathe through open mouth – listen down chest wall with diaphragm (compare sides)

• Comment: “vesicular breathe sounds, equal bilaterally, no crackles, wheeze or pleural rub” • Vocal resonance – ask the patient to say “ninety nine” and auscultate chest

Summarise:

• Summarise your findings for the examiner. For the second year OSCE, this will be normal. Thank patient, wash hands.

NB: If you want to impress the examiner check for sacral and ankle oedema to rule out RHF (cor pulmonale) which can be a cause of respiratory distress.


Neurological - Upper Limb Instructions: Assess the neurological function of this patient’s upper limbs. Time: 5 minutes.

TASK Marks

INTRODUCTION

1. Introduction, correctly identifies patient and gains consent 0 1


INSPECTION

3. General inspection: comfortable at rest, walking aids, posture, obvious deformity, gait 0 1

4. Closer neurological inspection commenting on: symmetry, position of limbs (spastic / flaccid), abnormal movements, tremor (resting/intention/pill-rolling), muscle wasting / hypertrophy

0 1

5. Elicits fasciculations 0 1

6. Assesses for pronator drift (upper motor neuron lesion) 0 1

TONE

7. Ask about pain; Correctly assesses tone (wrist clonus / spastic catch manoeuvre) 0 1

POWER

8. Shoulder abduction / adduction 0 1

9. Elbow flexion / extension 0 1

10. Wrist flexion / extension 0 1

11. Finger flexion / extension, finger abduction / adduction, thumb abduction 0 1

12. Uses MRC scale to grade power 0 1

REFLEXES

13. Biceps (Nerve root C5,6) 0 1

14. Triceps (C7,8) 0 1

15. Supinator (C5,6) 0 1

16. Uses reinforcement technique (clenching teeth) + grades 0 1

CO-ORDINATION

17. Finger to nose 0 1

18. Test for dysdiadochokinesis 0 1

19. Summarises key findings 0 1




Neurological - Upper Limb Written in April 2012, updated May 2016 by Kelvin Cheng. Upper Motor Neurone The pyramidal system is one of the motor control systems which enables purposive, skilled, intricate, strong and organized movements. The pathway originates in the motor cortex of the brain, travels through the internal capsule and crosses in the medulla (decussation of the pyramids). Here the neurones pass to the contralateral side of the spinal cord. Disease of this pathway causes upper motor neurone lesions. Features of an upper motor neurone lesion: “Everything goes up” 1. INCREASED TONE 2. INCREASED REFLEXES 3. UPGOING PLANTARS 4. GENERALLY RETAINED MUSCLE BULK 5. CLONUS (sign of increased tone) 6. PRONATOR DRIFT Conditions which lead to upper motor neuron lesion include:

• Stroke • Traumatic brain injury • Cerebral palsy • Multiple sclerosis

Lower Motor Neurone The lower motor neurone is the pathway originating in the anterior horn cell of the spinal cord via a peripheral nerve to muscle motor endplates. The lower motor neurone receives information from the upper motor neurone in the anterior horn of the spinal cord. Diseases of this pathway cause lower motor neurone lesions. Features of a lower motor neurone lesion: “Everything is lowered” 1. DECREASED TONE 2. DEPRESSED REFLEXES 3. DOWN GOING PLANTARS 4. DECREASED MUSCLE BULK 5. FASCICULATIONS Conditions which lead to a lower motor neurone lesion include:

• Cranial nerve palsy e.g. Bell’s palsy • Cervical or lumbar disc protrusion • Peripheral or cranial nerve trauma or entrapment • Guillain-Barre syndrome

The main reflexes tested in a neurological examination and their roots: 1. Triceps = C7 and C8 2. Biceps = C5 and C6 3. Supinator = C5 and C6

3. Knee = L3 and L4 4. Ankle = S1 and S2 5. Plantar = L5, S1 and S2

MRC scale (Medical Research Council) for assessment of muscle power 0. NO POWER 1. Flicker of contraction 2. Some active movement but cannot overcome gravity 3. Can overcome gravity but NO more 4. Active power against resistance – but not normal 5. Full power (allowing for age)


Digital Examination Instructions: Perform a digital rectal examination on this patient and comment appropriately. Time: 5 minutes.

TASK Marks

INTRODUCTION

1. Introduces self and checks patient identity 0 1


3. Asks for a chaperone 0 1

4. Washes hands 0 1

PRE-EXAMINATION

5. Prepares equipment 0 1

6. Puts on gloves 0 1

7. Positions patient correctly:

• Left lateral position with hips and knees flexed • Ask patient to strain to detect any prolapse

0 0

½ ½

8. Inspects peri-anal region 0 1

9. Lubricates right index finger 0 1

10. Warns patient that they are about to insert the index finger and informs patient they may have the sensation of needing to open their bowels 0 1

EXAMINATION

11.

Ask patient to close anal sphincters against finger to check for anal tone Ask patient to cough and comment there are no external haemorrhoids/rectal prolapse Examines the rectum in a logical sequence:

• Right lateral wall • Posterior Wall • Left Lateral Wall • Anterior Wall

0 0 0 0

1 1 1 1

15. Withdraws finger and examines gloved finger 0 1

16. Cleans the peri-anal area 0 1

17. Covers the patient to maintain modesty and informs the patient the examination is complete 0 1

18. Disposes of waste in the clinical waste bin 0 1

19. Washes hands, summarises findings and states: further investigations may include a PSA and rectal USS, full GI history and examination and colonoscopy 0 1




Digital Rectal Examination Written in April 2012 by Zoe Jacob and Allana Cappiello, updated in May 2016 by Hirushi Jayasekera and Effie Evans. Introduction:

1. Introduce yourself and obtain the patients name and DOB.

2. Many patients may not know what PR examination is so explain clearly that you will be examining the patients back passage with a gloved index finger and lubrication. Explain this is done to examine the bowel and prostate/cervix. Reassure them that it may be uncomfortable but not painful.

3. A chaperone is required for the patients comfort and as a witness against any false allegations of inappropriate behaviour.

4. Always wash your hands before a procedure.

Pre-Examination:

5. Organise a pair of gloves, lubrication and tissues.

6. Ensure the patient is lying on their left side with their knees brought up towards the chin. ‘Hug your knees’ is a good instruction to get the patient to understand the position you want them to lie in. Maintain the patients modesty while you organise yourself.

7. Put on the gloves.

8. Inspect the peri-anal region for erythema, discolouration, skin lesions, fissures, fistulae, external haemorrhoids, leakage of faeces, blood or mucus.

9. Adequately lubricate the right index finger.

10. Inform the patient when you are about to insert your finger. Ask them to try and relax and warn them that it may feel cold and slightly uncomfortable and that they may experience the need to open their bowels but that this will not happen.

Examination:

11. Note the anal sphincter tone by asking the patient to ‘squeeze’ the finger. Examine the rectum in a logical sequence feeling for irregularities, starting with the right lateral wall. Comment on any masses on the anal/rectal wall and describe them.

12. Posterior wall.

13. Left lateral wall.

14. Anterior wall – feeling for the prostate in males and cervix in females. When feeling the prostate, comment on the consistency (smooth/irregular) of the right and left lateral lobes and the central sulcus.

15. Withdraw finger and examine the gloved finger for faecal colour, blood or mucus.

16. Clean the peri-anal with tissues.

17. Cover the patient and inform them that the examination is complete.

18. Dispose of gloves and tissues in the clinical waste bin.

19. Wash hands.

BIBLIOGRAPHY AND FURTHER READING

1. MacLeod’s Clinical Examination 12th Edition page 207.

2. Cox and Roper Clinical Skills Chapter 12 (has good illustrations)


Gastrointestinal Examination Instructions: Perform a gastrointestinal examination on this patient. Time: 5 minutes.

TASK Marks

INTRODUCTION

1. Introduces self and checks identity by asking full name and date of birth 0 1


3. Positions patient and exposes patient’s chest and abdomen 0 1


INSPECTION

5. General Inspection – distressed, abdominal rising (does not occur in peritonitis) 0 1

6. Inspects hands (clubbing, leuconychia, koilonychias, asterexis, Dupuytren’s contracture, palmar erythema), face (scleral jaundice, angular stomatitis), chest and axilla

0 1

7. Inspects abdomen – gynaecomastia, surgical scars, striae, spider naevi, distension 0 1

PALPATION

8. Supraclavicular lymph nodes (inc. Virchow’s node) 0 1

9. Asks if tender and ask to point to any area of pain 0 1

10. Superficial + deep palpation of all 9 areas – look for guarding, rebound tenderness, abnormal masses, AAA, distended bladder 0 1

11. Palpates liver 0 1

12. Palpates spleen 0 1

13. Ballots kidneys 0 1

PERCUSSION

14. Percusses for liver 0 1

15. Percusses for spleen 0 1

16. Checks for ascites (shifting dullness) 0 1

AUSCULTATION

17. Auscultates for bowel sounds (+/- arterial bruit) 0 1

CONCLUSION

18. Thanks patient, washes hands and summarises findings 0 1

19. Offers to examine hernial orifices, perform PR and examine the external genitalia if appropriate 0 1

20. Mark for Excellence 0 1


P13

2nd Year OSCE Revision Course Notes

Gastrointestinal Examination Written in April 2012 by Kelsey Watt and Amani Khader, updated in May 2016 by Sarah McCarrison. Inspection: General:

• Stand back (at foot of bed) and initially look for evidence of pain or discomfort, pallor, jaundice, muscle wasting, distension of abdomen. Note the patient’s body habitus (obese/low BMI/cachectic) and look at the bedside for medical adjuncts (NG tube, stoma bags, sick bowls, drains).

Hands: • Signs of liver disease (clubbing, palmar erythema and Dupuytren’s contracture) • Inspect nails for kolionychia (spooning of the nails – IDA) and leukonychia (whitening of the nail

bed – hypoalbuminaemia) • Hepatic flap: Ask the patient to stretch out their arms, with their hands dorsiflexed and hold this

position for 15 seconds. If positive, the hands will flap in an irregular fashion (hepatic encephalopathy, uraemia)

• Inspect arms for bruising (low clotting factors secondary to liver disease), excoriations (cholestasis) and track marks (IVDU – increased risk of hepatitis).

Face and Chest: • Eyes: xanthelasma, jaundice or pallor (anaemia) • Mouth: any odours; lips, tongue, teeth and gums for any telangiectasia, stomatitis or glossitis

(iron/B12 deficiency), ulcers or central cyanosis. • Inspect chest for spider naevi and gynaecomastia (liver disease).

Abdomen: With imaginary lines, divide the abdomen visually into 9 regions to assist with any description. Look for:

• The “five F’s of abdominal distension”: fluid, flatus, fat, foetus and faeces

• Normal movement of abdomen with respiration • Scars and striae (stretch marks) • Distended veins • Abdominal masses • Abnormal pulsations

Regions of the abdomen: RH, right hypochondrium; RF, right flank or lumbar region;

RIF, right iliac fossa; E, epigastrium; UR, umbilical region; H,

hypogastrium or suprapubic region; LH, left hypochondrium;

LF, left flank or lumbar region; LIF, left iliac fossa.

Palpation Technique: This is usually best done kneeling so that you are level with the patient. Begin by asking about any areas of pain. Then using the pulps of your fingers palpate lightly, keep contact with the abdomen and look at the patient’s face for any evidence of tenderness or pain. Deep palpation should be repeated with deep/firmer (or bimanual palpation) in the 9 regions, assessing for any abnormal masses found earlier.

• Liver: Start in the RIF and move towards the costal margin asking patient to take deep breaths in and out. Move your hand up with expiration (NB. on inspiration the liver moves down in the abdomen, and this may assist you in feeling the liver edge in an enlarged liver).

• Spleen: Stand up to examine the spleen. Start in the RIF and move toward the left costal margin.

• Kidneys: Using a bimanual technique in the flanks, ballot for kidneys bilaterally. Percussion Note Examples: Gas filled structures (bowel) → Resonant

Solid organs → Dull Distension (flatus) → Tympanic Fluid (ascites) → Dull in flanks and shifts when roll


1. Macleod’s Clinical Examination (12th ed): The gastrointestinal examination. p197-209. 2. Oxford Handbook of Clinical Medicine (8th ed): The gastrointestinal examination. p60-64.


Cardiopulmonary Resuscitation Instructions: You are a junior doctor heading to the hospital cafeteria for lunch when you see

somebody collapse a few metres away. It has been a quiet weekend and there is no one else in sight at that point in time. Take appropriate action immediately.

Time: 5 minutes.


TASK Marks

INTRODUCTION

1. Checks for danger 0 1

2. Assesses for response in the patient with the AVPU scale 0 1

3. Shouts for help immediately when no patient response is elicited 0 1

4. Gives clear instructions, requesting for an automated external defibrillator (AED) and bag-valve-mask 0 1

5. Rolls patient onto back 0 1

AIRWAY

6. Opens airway with airway manoeuvre e.g. head-tilt chin-lift or jaw thrust 0 1

7. Checks for airway patency 0 1

BREATHING & CIRCULATION

8. Looks, listens and feels for respiratory effort for 10 seconds 0 1

9. Maintains airway manoeuvre during assessment of breathing 0 1

10. Palpates for the carotid pulse at the same time 0 1

11. Shouts for help to call for the cardiac arrest team at ‘2222’, noting location of incident 0 1

CHEST COMPRESSIONS

12. Starts 30 chest compressions promptly 0 1

13. Uses appropriate technique:

1) Rate of 100-120 per minute 0 1

2) Depresses sternum by about 5cm 0 1

14.

Delivers 2 rescue breaths promptly after 30 compressions 0 2

- Chest expansion with mouth-to-mouth technique 0 1

- Chest expansion with formation of adequately tight seal with the bag-valve-mask 0 1

15. Continues chest compressions and rescue breathing in a 30:2 ratio 0 1

16. Verbalise intention for colleague to take over compressions & minimal interruption to chest compressions when swapping places with assistant to do compressions 0 1

OTHERS

17. Mark of Excellence 0 1


Cardiopulmonary Resuscitation Written in May 2016 by Shou Kee Ng and Gursheel Kalsi. Arriving at the scene (non-hospital setting): It is very important to first assess for potential danger at the site of patient collapse so that first responders themselves do not expose themselves to additional harm and injury. This would be assessed from the point-of-view of the larger environment (e.g. traffic junction or train station versus an empty street or corridor) and immediate environment (e.g. large water puddles, metallic objects, wires/cables). In the former, this would help you determine how readily help is available, and if there is a need to clear the scene to facilitate the arrival of emergency services and placement of medical equipment. In the former, this would help protect medical staff from electrical shocks during the use of the automated external defibrillator (AED). Medical leadership is very important in such cases as time is of the essence when resuscitating an unconscious non-breathing patient. Hence it is imperative as the first responder on scene that all steps of the Basic Life Support (BLS) protocol are carried out without any delay. In the process, it is also important to make yourself easily heard and understood when dispensing instructions to a bystander who may be inexperienced in medical work. The order of what has to be done is extremely important as well – More information can be perused on the UK resuscitation council website at https://www.resus.org.uk/resuscitation-guidelines/. During resuscitation: When opening a patient’s airway, the ‘head-tilt chin-lift’ manoeuvre is most commonly performed. In cases where a cervical spine injury (a.k.a. C-spine) is suspected, a jaw thrust would be performed instead to minimise movement of the neck. It is important to remember not to move the patient’s neck and head unnecessarily when performing these airway manoeuvres – adjust your body position based on the patient’s position and not the other way round. When making a cardiac arrest call in clinical practice, please remember to provide details of your location and reason for call in a manner such as ‘Cardiac arrest, ABC Hospital, [Location of incident]’ as some switchboards might not be located in your hospital! To do effective chest compressions, you have to first ensure the position of yourself and the patient is correct. The patient should be lying flat on his/her back with you standing or kneeling at an appropriate height that allows your shoulders to be directly above the patient. With you elbows fully stretched out and fingers interlocked, aim for the sternum at the level of the nipples when you do chest compressions. Health authorities and community first aiders like to use Bee Gee’s ‘Stayin’ Alive’ as the classic method of keeping to the optimal rate of 100-120 compressions a minute, but in clinical practice, it is usually fine if you are not too hasty and ensure optimal depth of compression (about 5cm). When to stop CPR (good to know!):

- Patient starts breathing normally. - Qualified help (e.g. cardiac arrest team) arrives. - If first responder is exhausted. - When AED is assessing heart rhythm, or if AED is discharging.


Neurological - Lower Limb

Instructions: Assess the neurological function of this patient’s lower limbs then report your findings Time: 5 minutes.


TASK Marks

INTRODUCTION

1. Introduction, correctly identifies patient and gains consent 0 1


INSPECTION

3. General inspection: comfortable at rest, walking aids, posture, obvious deformity, gait 0 1

4. Closer neurological inspection commenting on: symmetry, position of limbs (spastic/flaccid), abnormal movements, tremor (resting/intention), muscle wasting/hypertrophy

0 1

5. Elicits fasciculation 0 1

TONE

6.

Correctly assesses tone through passive movement of the joints: - Hip → roll leg from side to side - Knee → briskly lifts knee into flexed position while watching heel - Ankle → flexes and dorsiflexes the foot

0 2

7. Checks for ankle clonus → suddenly dorsiflexes/partially everts foot) 0 1

POWER

8. Hip →flexion and extension 0 1

9. Knee → flexion and extension 0 1

10. Ankle → dorsiflexion / plantarflexion 0 1

11. Uses MRC scale to grade power 0 1

REFLEXES

13. Knee Jerk (Nerve root L3-4) 0 1

14. Ankle Jerk (S1) 0 1

15. Plantar (S1-S2) 0 1

16. Uses reinforcement technique (clasping hands – Jendrassik’s Manoeuvre) 0 1

CO-ORDINATION

17. Heel-shin test 0 1

18. Heel-toe walk 0 1




Neurological – Lower Limb Written in April 2014 by Josephine Campbell. With neurological examination you should always bear in mind the five key principles:

INSPECTION, TONE, POWER, REFLEXES, COORDINATION Remember your patient has TWO legs! At each stage of the examination, compare your findings on both sides. This will help you to further determine whether your findings are normal or abnormal. General inspection from the end of the bed: Look to see if the patient is comfortable at rest, comment on their posture and any obvious deformities. Also look around the bed for walking aids. At this point you could ask the patient to walk a few metres and you can comment on their gait. Inspection: Look for and comment on the presence/absence of: Hypertrophy (Increased muscle bulk). Muscle Wasting - usually indicative of a lower motor neuron lesion. Tremors (Oscillatory movements about a joint/group of joints resulting from alternating contraction and relaxation of skeletal muscles) and involuntary movements. Fasciculations - it is important to watch the belly of the muscle for spontaneous contraction. Fasiculations can be elicited by flicking the muscle. They are abnormal can be caused by motor neuron disease, motor root compression, peripheral neuropathy and thryotoxicosis Tone: When assessing tone it is important that the legs are completely relaxed. The tone may feel increased or decreased. These movements are all done passively by the examiner. Hip: Roll leg from side to side. Knee: Briskly lift knee into flexed position, watch the heel. Ankle - flex and dorsiflex the foot Often included shortly after assessment of tone is assessment for clonus in the ankle. This can be elicited by first ensuring the ankle is relaxed, supporting the patient’s leg by holding with one hand. With the other hand plantar flex the foot then quickly dorsiflex and hold. If the foot plantar flexes more than 5 times this is sustained clonus and is abnormal. Clonus is due to hypotonia from an upper motor lesion. Power: Assess power at the hip, knee and ankle by opposing joint movements. Remember to isolate the joint you are testing. Try to encourage patient as much as possible so you can assess their maximum power. Assess both legs comparing each side as you go. Hip: Flexion: ‘Lift your leg off the bed and don’t let me push it down’

Extension: ‘Push leg into bed and don’t let me lift it up’ Knee: Flexion, extension: ‘Bend your knee and bring your heel to your bottom, don’t let me

pull it away’ and then ‘push me away‘ Ankle: Dorsiflexion: ‘Point foot and toes up to the ceiling and don’t let me push it down’ Plantar flexion: ‘Point foot and toes towards the floor, pushing my hand away’ Toe: Extension (i.e. dorsiflexion): ‘Point your big toe to the ceiling and don’t let me push it

down’ Once you have assessed the power grade it out of 5 using the MRC scale.

P18 Reflexes: Again with reflexes it is important that the patient is fully relaxed. Brisk/exaggerated reflexes are indicative of UMN lesions, whereas diminished/absent reflexes denote LMN lesions. To exaggerate reflexes or if no response is obtained, perform Jendrassik’s manoeuvre - ask patient to link hands and pull as you simultaneously try to elicit reflexes. Co-ordination: At first guide patient through the sequence step by step (Heel to knee, run heel down shin, lift heel off ankle, repeat). The heel to toe walk also tests co-ordination. Watch for any difficulty in carrying out this sequence of movements. BIBLIOGRAPHY AND FURTHER READING 1. Pentland P, Davenport R, Cowie R. The Nervous System. In: McLeod’s Clinical Examination. 12th ed. Edinburgh: Churchill Livingstone; 2009:269–305. 2. Gelb D J. Introduction to Clinical Neurology. 4th ed. Oxford: Oxford University Press; 2011

P19

2nd Year Mock OSCE Mark Scheme

REMS Knee Examination Instructions: Perform a full REMS examination of this patient’s knee. Time: 5 minutes.


TASK Marks

INTRODUCTION

1. Introduces self, checks identity (name and D.O.B.) 0 1


3. Wash hands before and after examination 0 1

4. Positions patient correctly with hands by patients side and asks if tender anywhere 0 1

INSPECTION

5.

General inspection comparing one knee with the other: • Muscle wasting • Scars • Colour changes • Joint swelling • Skin rash • Valgus / varus deformity

0 0 0 0 0 0

½ ½ ½ ½ ½ ½

PALPATION

8. Feels for temperature from mid-thigh to knee using back of hand, comparing one knee with the other 0 1

9. Palpate for tenderness along the joint line with the knee flexed at 90o 0 1

10. Feel behind the knee for a baker’s cyst 0 1

11. Assess for effusion by performing a patellar tap 0 1

12. Assess for effusion by cross fluctuation 0 1

MOVEMENT

13. Assess flexion and extension passively, then actively with hand over knee feeling for crepitus 0 2

15. Position the knee at 90o and look for posterior sag 0 1

16. Performs anterior draw test 0 1

17. Assess medial and lateral collateral ligament stability by flexing the knee at 15o and alternatively stressing the joint line on each side 0 1

FUNCTION

18. Ask patient to stand to further assess any varus/valgus deformity and to walk to assess gait 0 1


20. Mark of excellence 0 1

P20 2nd Year OSCE Revision Notes

REMS Knee Written in April 2013 by Rona Anderson, updated April 2015. Swollen Knee – Acute

1. Trauma: Blood (haemarthrosis) or Synovial fluid (effusion)

Main investigations: MRI –soft tissue injury, X-ray for bony injury

• Penetrating: Haemarthrosis • ACL tear: Common twisting injury, may have a popping

sensation with formation of an effusion, increased laxity on anterior draw test, highly vascular ± haemarthrosis.

• PCL tear: High energy trauma, posterior tibial sag with knee in flexion.

• Intra-articular fracture (e.g. Patella); Increases future risk of osteoarthritis.

• Lateral meniscal tear: Twisting injury, knee may lock/give way, tender, positive McMurray’s test.

• Collateral ligament tears: varus/valgus laxity, effusion, tenderness.

2. Non-Traumatic

Main investigations: Joint aspiration.

• Crystal arthritis: Gout –Urate crystals commonly big toe but can affect other joints. Pseudogout - calcium pyrophosphate.

• Septic arthritis: Hot, painful, swollen joint. Most commonly caused by Staph. aureus. Orthopaedic emergency.

• Reactive arthritis: Post-infectious inflammatory arthritis. Commonly follows infection with Chlamydia, Salmonella and Campylobacter.

Swollen Knee -Chronic

1. Rheumatoid arthritis: Chronic systemic inflammatory disease. Symmetrical pattern, polyarthritis, extra-articular manifestations.

2. Osteoarthritis (reactive synovitis): Commonest joint disease, crepitus, pain on movement ± knee swelling.

3. Neoplasms: Malignant e.g. Osteosarcoma, Benign e.g. Osteochondroma. Gait Types

Gait Description Cause Antalgic Painful gait, limping, short weight-bearing on painful side Mechanical injury, sciatica

Apraxic Unable to lift legs despite normal power, magnetic steps/stuck to floor Hydrocephalis, frontal lesions

Ataxic Uncoordinated, wide-based, unsteady (as if drunk), worse with eyes shut if sensory

Cerebellar, sensory

Festinating A shuffling gait with accelerating steps Parkinson’s

Hemiparetic Knee extended, hip circumducts and drags leg, elbow may be flexed up Hemiplegia e.g. CVA

Myopathic Waddling, leaning back, abdomen sticking out Proximal myopathy

Shuffling Short, shuffled steps, stooped, no arm swing Parkinson’s Spastic Restricted knee and hip movements, slow, shuffling “wading through

water” Pyramidal tract lesion e.g. MS

Steppage High steps with foot slapping Peripheral neuropathy


REMS Hip Examination Instructions: Perform a full REMS examination of this patient’s hip Time: 5 minutes


TASK Marks

INTRODUCTION

1. Introduces self, checks patient identity (name and D.O.B) Washes hands before and after examination 0 1

2. Explains procedure to patient and gains consent 0 1

3. Positions patient correctly (supine) with hands by their side, and asks if tender anywhere 0 1

INSPECTION

4.

General Inspection comparing one hip with the other for any: • Scars • Flexion deformities • Swelling • Gluteal Muscle Wasting

Stands at the end of the bed and notes any: • Asymmetry • Leg length discrepancies (lengthening/ shortening)

Maximum of two marks for inspection

0 0 0 0

0 0

½ ½ ½ ½ ½ ½

6. Measures leg lengths using tape measure provided:

• True leg length • Apparent Leg Length

0 0

1 1

PALPATION

8. Feels for temperature and any tenderness over hip joint, comparing one hip with the other 0 1

9. Palpates over greater trochanter + for temperature 0 1

MOVEMENT

10. Passively bends the knee to 90° and assesses full hip flexion 0 1

11. Assesses external rotation by flexing the hip and knee to 90°. One hand stabilises the thigh whilst other hand takes hold of the ankle. The foot is moved medially. 0 1

12. Assesses internal rotation – knee and hip positioned as above but foot moved laterally 0 1

13. Assesses adduction and abduction of both hip joints 0 1

14. Offers to assess hip extension with patient face down on the couch 0 1

15. Observes patients face throughout movements to assess for any sign of discomfort/ pain 0 1

SPECIAL TESTS

16. Performs Thomas’s test: with patient lying supine, one hand placed under lumbar spine and corresponding knee is flexed 0 1

17. Performs Trendelenberg’s test: Asks patient to stand on one leg and observes patient’s pelvis 0 1

FUNCTION

18. Asks patient to walk across room and inspects patient’s gait 0 1




REMS Hip Examination Written in April 2014 by Tom Aitken, updated April 2015. Inspection: General: It is always important to look at the patient as a whole before concentrating on the hip joint itself. Is the patient in any obvious discomfort? Do they have a walking aid at the side of the bed? Are there any other clues to suggest an underlying problem/ diagnosis? Inspection of the Hip: Ensure the hip joint is adequately exposed and check for any:

• Scars: indicative of previous surgery or trauma to the joint and surrounding tissue • Deformities: Long-standing arthritis may result in a fixed flexion deformity • Erythema: inflammatory arthropathy • Gluteal Muscle Wasting: due to muscle paralysis (polio) or disuse secondary to arthritis

Leg Lengths: A tape measure can usually be found at the side of the bed and this indicates to check for any leg length discrepancies. If a tape measure has not been provided, you should still offer to measure leg lengths. The patient should lie supine with their knees straight.

• Apparent Leg Length – measured from the xiphoid sternum à medial malleolus • True Leg Length – measured from the anterior superior iliac spine à medial malleolus

Compare both sides and comment on any leg length discrepancies. Fracture of the neck of femur is common following minor trauma in post-menopausal women (due to osteoporosis). Classically the leg is shortened and externally rotated. Palpation: Palpate over the greater trochanter for trochanter bursitis. Check for any temperature changes or tenderness over the hip joint which may suggest an acute synovitis. Compare both sides and observe the patient’s face for any sign of discomfort or pain. Movement: Observe the patient’s face throughout movement to detect any evidence of pain or discomfort.

• Flexion: passively bend the knee to 90° and assess full hip flexion. Normal range: up to 120° • Internal and External Rotation: Passively bend the knee to 90° and place one hand on the knee

with the other taking hold of the foot. Move the foot laterally for internal rotation, and medially for external rotation. Normal range up to 30° for internal rotation and up to 60° for external rotation.

• Abduction and Adduction: To assess abduction (=away) place one hand on the opposite iliac crest and grasp the ankle with the other. Move the leg laterally until the pelvis tilt detected – normal range: up to 45°. Adduction is assess by moving the leg medially with the pelvis fixed on the same side. Normal range of movement: up to 25°.

• Extension: The patient lie face down on the couch. Lift each leg in turn. Normal range: up to 20° Special Tests: Offer to perform special tests:

• Thomas’s Test: With the patient lying supine, place one hand under their spine to eliminate the lumbar lordosis. Passively flex one hip and watch for any movement in the contra-lateral hip. If the other hip rises off of the couch then this is suggestive of a fixed flexion deformity.

• Trendelenberg’s Test: Assesses the strength of the hip and the gluteal muscles. With the pelvis exposed, ask the patient to stand on one leg. Observe the pelvis from behind the patient. Normally the pelvis should remain level or rise on the non-weight bearing side. A positive trandelenberg test is when the pelvis drops below the horizontal on the non-weight bearing side. It is seen in gluteal muscle weakness or in an unstable hip joint (dislocation or femoral neck fractures).

P23

Function: • Ask the patient to walk across the room to check for any abnormalities of their gait.

Differential Diagnosis of a Swollen Hip:

• Acute swelling – septic arthritis, gout, psuedogout, fracture, trochanteric bursitis • Morning swelling- rheumatoid arthritis • Swelling at rest/after activity- osteoarthritis

Investigations:

• Plain X-ray both signs (look for cardinal signs) – AP and Lateral (2 views) cardinal signs (x-ray)

1. Loss of joint space. 2. Osteophytes (incr. SA) 3. Cysts 4. Subchondral sclerosis

• Bloods- inflammatory markers, Rh Factor Anti CCP

• MRI soft tissue injury

Fracture Neck of Femur:

• The affected leg may be shortened, adducted and externally rotated. Non weight bearing

• Occasionally presents with knee pain • Almost always for surgery- internal fixation/hemi-arthroplasty/total arthroplasty

Risk Factors- osteoporosis, F gender, age, dementia, delirium BIBLIOGRAPHY AND FURTHER READING

1. Pentland P, Davenport R, Cowie R. The Nervous System. In: McLeod’s Clinical Examination. 12th ed. Edinburgh: Churchill Livingstone; 2009:386–388.

2. Brain J. Crash Course: History and Examination. 3rd ed. Mosby; 2008: 214 – 217


Urinalysis Instructions: Demonstrate basic bed-side urine testing Time: 5 minutes.

TASK Marks

INTRODUCTION

1. Introduce self and checks patient identity 0 1

2. Explain purpose of procedure and gain consent 0 1

3.

Describes correct technique for sample collection a. Midstream urine collection b. Preventing contamination: cleaning skin, avoiding touching inside of bottle c. Fresh sample: <2 hours

0

1

0 1

0 1

PRE-URINALYSIS

4.

Safety checks: a. Washes hands and dons apron and gloves b. Checks label on sample bottle c. Checks expiry date of test strips

0

1

0 1

0 1

5.

Inspection: Comments on a. Colour: dark, red, orange b. Clarity: cloudy, frothy, debris c. Odour: ammonia, fishy, pear drops

0

1

0 1

0 1

URINALYSIS

6. Dips urine: 2 seconds, taps off excess 0 1

7.

Interpretation: a. Holds dipstick correctly b. Checks results at appropriate time (30 seconds – 2 minutes) c. Comments on positive and negative findings

0

1

0 1

0 1

8. Summarizes and explains findings of urinalysis 0 1

9. Reassures patient or explains need for further tests 0 1

10. Disposes of clinical waste and washes hands 0 1

11. Records results in patient notes 0 1




Urinalysis Written April 2012 by Namratha Mathai. Introduction: Urinalysis refers to the examination of urine by observation, dipstick testing and microscopy. For the purposes of the OSCE, you will only be required to demonstrate the first two skills (“bedside tests”).

Explanation of the Procedure: Should include a description of the test and why it is being done

• E.g. “a simple test involving looking at a sample of your urine and testing it with a dipstick to see if there are any abnormal substances in it”

• The OSCE instructions may give you the clinical indication for urinalysis (e.g. suspected diabetes mellitus, UTI, nephrotic syndrome) – factor this into your explanation.

Technique: The key thing to remember while demonstrating the use of a dipstick is time maintenance. Make sure you have a watch ready and visible:

• 0 seconds = start timer, as soon as the test strip has been removed from the sample • 30 seconds = first reading available. Use this waiting time to make sure you are holding

the strip against the colour chart correctly: - The strip should be parallel to the ENDS of the bottle, not the length - The first square to be read is the one closest to your hand while holding the strip - The first reading is usually glucose (but may vary with test strip manufacturer)

• 2 minutes = last reading available [square furthest away from your hand]. The timings of all the readings in between will be listed on the colour chart and refer to time from 0, NOT from the last reading.

• ALWAYS comment on: glucose, blood, leukocytes, proteins and nitrates.

Interpretation of Results: The 2nd year OSCE usually involves normal specimens – you will not be expected to recognize abnormal patterns of results and make diagnoses. This information is therefore additional at this point, but may be useful for the written examination (or an excellence point, depending on your examiner)

Colour Clarity Odour

INSP

ECTI

ON

Normal

Straw-yellow

Clear

Varied

Variant

• Dark yellow → dehydration • Orange/Brown → jaundice/some drugs

(e.g. rifampcicin) • Red → haematuria, beetroot ingestion • Green → asparagus consumption,

pseudomonas infection

• Cloudy → infection (may be normal) • Frothy → proteinuria • Debris → renal stones

• Ketones (nail-polish remover) → DKA,

phenylketonuria, post-starvation • Sweet Smell → Diabetes Mellitus • Foul Smell → infection, colovesicular fistula • Strong Ammonia Smell → old sample

Glucose Blood Leukocytes Proteins Nitrates Other

DIP

STIC

K R

ESU

LTS

Diabetes mellitus

(Rare – renal glycosuria)

Contamination from menstrual bleeding

Trauma (renal/urethra)

Nephritic syndrome

Ureteric stones/infection

UTI

Nephritic syndrome

Nephrotic/ nephritic syndrome

Renovascular disease

Pre-eclampsia

Myeloma

Prolonged vertical posture (benign)

UTI

(produced by coliform bacteria)

Ketones: DKA, pregnancy, starvation, phenylketonuria

Bilirubin: intra-hepatic or post hepatic jaundice

Specific gravity: solute concentration


History: Shortness of breath Instructions: Take a focussed history of a 60-year-old patient who has presented with

breathlessness. Time: 5 minutes


TASK Marks

1. Introduction, checks identity and gains consent 0 1

2. Establishes timing of onset 0 1

3. Establishes level of activity patient can manage 0 1

4. Exacerbating and alleviating factors 0 1

5. Cough 0 1

6. Sputum 0 1

7. Chest pain 0 1

8. Haemoptysis 0 1

9. Wheeze 0 1

10. Fever 0 1

11. Symptoms of malignancy: weight loss, night sweats, anorexia, sleep disturbance 0 1

12. Orthopnoea, paroxysmal nocturnal dyspnoea (PND), ankle swelling 0 1

13. Asks about past medical and surgical history (eczema, hayfever etc) 0 1

14. Asks about drug and allergy history 0 1

15. Asks about family history 0 1

16.

Asks about risk factors and social history:

1. Smoking 2. Dinking 3. Occupation and past exposure of asbestos 4. Pets 5. Recent travel 6. Home circumstances

0

1

0

1

0 1

19. Summarises and welcomes questions 0 1


P27

2nd Year OSCE Revision Course Notes

History Taking Skills Written by Tom Aitken in April 2014. The basic structure to history taking is as follows:

- Presenting complaint - History of presenting complaint - Past medical history - Drug history - Family history - Social history - Review/ Summary

Asking open questions is important when taking any history. However in the OSCE setting, actors/ patients may not be so open and you will be expected to ask specific, detailed questions in order to get the marks. Cardiovascular System: Common scenarios include chest pain (angina), breathlessness (heart failure), leg pain (peripheral vascular disease) etc.

1. Angina: use the SOCRATES acronym. Typical features include retrosternal chest pain on exertion which is relieved by rest. The pain typically radiates to the arm and jaw and lasts usually between 2-10 minutes.

2. Breathlessness: always think of cardiac cause in a patient presenting with breathlessness (pulmonary oedema secondary to heart failure)!! Do you become more breathless when lying flat? – (orthopnoea) How many pillows do you sleep on at night? Do you ever wake up suddenly during the night short of breath? – (paroxysmal nocturnal dyspnoea – PND, due to gradual accumulation of alveolar fluid during sleep) Patients with heart failure may also produce frothy, bloodstained sputum.

3. Palpitations: Do you ever experience your heart racing? (Other phrases to use include:

“fluttering”, “skipping a beat”, “thumping” etc). Clarify: onset and termination (abrupt or gradual); precipitating factors (alcohol, exercise, caffeine); frequency and duration of episodes; character of the rhythm.

4. Syncope and dizziness: there are four main causes: postural hypotension, neurocardiogenic

syncope, arrhythmias, mechanical obstruction to cardiac output. Respiratory System: Common scenarios include breathlessness (asthma), increased sputum production (chest infection, cancer) etc.Think about the common symptoms associated with respiratory disease:

- Are you short of breath? If so did this occur suddenly or did it gradually progress over a number of days?

- Do you have a cough? How long for? (acute cough is less than 3 wks, chronic cough is more than 8 wks) Do you find yourself coughing at night (nocturnal cough – asthma)?

- Are you coughing up sputum? If so, how much? What colour? - Are you coughing up any blood? (Haemoptysis a red flag!!) - Do you have a wheeze? (def: a high-pitched whistling sound produced by air passing through

narrowed small airways, typically on expiration. Common feature of COPD/ asthma) - Are you experiencing any chest pain? Use of SOCRATES. Pleuritic chest pain is a sharp,

stabbing pain intensified by inspiration (PE, pneumonia, pneumothorax) - Do you have a fever? (?chest infection).

P28 Gastro-intestinal system: Common scenarios include difficult swallowing (oesophageal cancer), change in bowel habits (rectal bleeding, coeliac disease) etc. When taking a gastro-intestinal history, work down the GI tract:

- Any nausea or vomiting? Any blood in your vomit? What colour? (bright red blood/ coffee ground vomit)

- Any acid reflux/ heartburn? - Any difficulty swallowing? What sort of foods? How has this progressed? - Any abdominal pain? - Any change to your bowel habits? Have you noticed any blood in your stools? What colour (bright

red blood/ cherry coloured blood)? How much? Red Flag Questions: These questions should be included for any system and demonstrate to the examiner you are checking for red flags – cancer etc.

- Have you noticed any change in your weight? How much weight have you lost? Over what period of time? Some patients don’t regularly check their weight – have you noticed that your clothes have become more loose and not as tight flitting?

- Have you been experiencing any breathlessness? (anaemia secondary to cancer). SOCRATES acronym for pain history: S – site: where exactly is the pain? O – onset: when did the pain start? Did it come on suddenly or was it gradual? C – character: what is the pain like? E.g. sharp, burning tight? R – radiation: does the pain go anywhere?

A – associated symptoms: are there any symptoms associated with the pain? Sweating, vomiting, breathlessness etc

T – timing (duration, course, pattern): does the pain follow any time pattern, how long did it last? E – exacerbating/ relieving factors: does anything make the pain better/ worse?

S – severity: on a scale of 1 – 10, 1 being little or no pain and 10 being the worse pain you could imagine, how severe is the pain?


3. Pentland P, Davenport R, Cowie R. The Nervous System. In: McLeod’s Clinical Examination. 12th ed. Edinburgh: Churchill Livingstone; 2009.

4. Brain J. Crash Course: History and Examination. 3rd ed. Mosby; 2008: 214 – 217

Documents

2nd Year OSCE - peerassisted.orgpeerassisted.org/wp-content/uploads/2014/09/2nd-Year-PALI-Notes...also test for a collapsing pulse, but there probably will not be a mark for this in