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2nd

Year OSCE

Notes and mock mark schemes

April 2014

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.

Contents

Cardiovascular Examination P1

Blood Pressure P4

Respiratory Examination P6

CNS – Upper Limb P8

Digital Rectal Exam P10

Gastrointestinal Examination P12

Urinalysis P14

History Taking Skills P16

CNS – Lower Limb P19

REMS Knee P21

REMS Hip P23

A note on the contents

This work was produced entirely by fourth year MBChB undergraduates at Glasgow

University Medical School in April 2012 (updated April 2014). The contents are in no way

official documents used by the medical school for assessment purposes.

P1 2

nd 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 0 1

HANDS, FACE, PULSES AND NECK

5. Inspect hands 0 1

6. Inspect face with special emphasis on central cyanosis 0 1

7. Assessment of radial pulse (rate, rhythm, volume character) 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 (5

th 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 0 1

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

P2

2

nd 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 secs. 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 2

nd 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 2

nd 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 5

th 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 2

nd 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 2

nd intercostal space. From here, count down the spaces to find the 5

th

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 2


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


P5 2


Blood Pressure Written by Joe Sharkey and Jamie Tomlinson. (April 2012) 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. 4

th edition. 2008

Artery Cuff Pressure Sounds Kortokoff

Completely occluded

> Systolic Pressure

No sounds

n/a

Just opens

Systolic Pressure

1

st 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

P6

2


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 0 1

6. Nails – clubbing, tar staining 0 1

7. Hands – asterixis, palmar creases, tar staining 0 1

8. Face – conjunctiva, tongue, pursed lip breathing 0 1

9. Chest – shape, scars, respiratory rate, symmetry 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 0 1

17. Vocal resonance 0 1

18. Compares both sides 0 1

19. Summary 0 1

20. Mark for Excellence 0 1


P7 2


Respiratory Examination Written April 2012 by Gary Rodgers and Donncha Mullin. 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

Red – Palmar erythema

White – Pallor of palmar creases

Blue – Peripheral cyanosis

Yellow – tar staining

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 lymph nodes of the neck, be systematic and comment: “no evidence of lymphadenopathy”

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. Ask patient to fully inspire then fully expire before putting hands on

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

Percussion:

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 (and it will be) 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:

“In summary this is patient has a normal respiratory examination”. Thank patient, wash hands.

P8

2


Neurological - Upper Limb Instructions: Describe what candidates have to do Time: 5 minutes.

TASK Marks

INTRODUCTION

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

2. Washes hands before and after examination 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 pronator drift 0 1

TONE

7. 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) 0 1

CO-ORDINATION

17. Finger to nose 0 1

18. Test for dysdiadochokinesis 0 1

19. Summarises key findings 0 1

20. Mark for excellence 0 1


P9

2nd

Year Mock OSCE Notes

Neurological - Upper Limb 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. The important feature 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) Conditions which lead to upper motor neuron lesion include:

Stroke

Traumatic brain injury

Cerebral palsy 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. Name 5 features of a LMN 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 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)

P10

2nd

Year Mock OSCE Mark Scheme

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

2. Explains procedure and gains consent 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 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 0 1



P11 2


Digital Rectal Examination 21

st April 2012 by Zoe Jacob and Allana Cappiello

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. 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 and examine the rectum in a logical sequence feeling for irregularities, start with the right lateral wall.

12. Posterior wall.

13. Left lateral wall.

14. Anterior wall – feeling for the prostate in males and cervix in females.

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)

P12

2nd


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 patiently and exposes them correctly 0 1


INSPECTION

5. General Inspection of appearance 0 1

6. Inspects hands, face, chest and axilla 0 1

7. Inspects abdomen 0 1

PALPATION

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

9. Superficial palpation of all 9 areas 0 1

10. Deep palpation 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 0 1

CONCLUSION

18. Offers to examine groin and offers to perform PR 0 1

19. Appropriate conclusion with summary 0 1

20. Mark for Excellence 0 1


P13 2


Gastrointestinal Examination

Written in April 2012 by Kelsey Watt and Amani Khader Inspection: General:

Stand back (at foot of bed) and initially look for evidence of pain or discomfort, pallor, colour, muscle wasting, distension of abdomen

Hands:

Signs of liver disease (clubbing, palmar erythema and Dupuytren’s contracture)

Peripheral cyanosis Face:

Eyes: xanthelasma, jaundice or pallor (anaemia)

Mouth: any odours; lips, tongue, teeth and gums for any telangiectasia, stomatitis, glossitis, ulcers or central cyanosis

Abdomen:

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

Look for the “five F’s”: Fluid, flatus, fat, foetus and faeces

Symmetry

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: Using the pulps of your fingers, 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 (Note that 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

BIBLIOGRAPHY AND FURTHER READING

1. Macleod’s Clinical Examination (12th

ed): The gastrointestinal examination. p197-209. 2. Oxford Handbook of Clinical Medicine (8

th ed): The gastrointestinal examination. p60-64.

P14 2


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



P15 2


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

INS

PE

CT

ION

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

ST

ICK

RE

SU

LT

S

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

P16 2


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

20. Mark of Excellence 0 1

P17

2nd


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) 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?

P18

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? 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.

2. Brain J. Crash Course: History and Examination. 3rd

ed. Mosby; 2008: 214 – 217

P19

2nd


Neurological - Lower Limb

Instructions: Asses 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



P20

2nd

Year Mock OSCE Mark Schemes

Neurological – Lower Limb

Written 29/04/12 by Kevin Garrity and Sarah Vincent

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.

As with any examination, you should have a general inspection to make sure they look well and are

comfortable. It is also useful to inspect around the patient’s bed for clues the patient may have disability

or impairment e.g. walking aids etc.

Inspection:

Look for and comment on the presence/absence of:

Hypertrophy: (Increased muscle bulk)

Atrophy/Wasting (Decreased muscle bulk) - 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 but flicking

muscle may induce this.

Tone:

When assessing tone it is important that the legs are completely relaxed. The tone may feel increased or decreased. 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 with both the knee and the ankle resting in 90˙ flexion, then briskly dorsiflexing the foot and sustaining the pressure. 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 e.g. “Push as hard as you can” Hip: Flexion, extension

Knee: Flexion, extension.

Ankle: Dorsiflexion, plantarflexion

Large Toe: Extension (i.e. dorsiflexion) 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, 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). Watch for any difficulty in carrying out this sequence of movements. BIBLIOGRAPHY AND FURTHER READING


Edinburgh: Churchill Livingstone; 2009:269–305.

2. Gelb D J. Introduction to Clinical Neurology. 4th ed.Oxford: Oxford University Press; 2011

P21 2


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

Swelling

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 15

o 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

P22

2

nd Year OSCE Revision Notes

REMS Knee Written in April 2013 by Rona Anderson

Swelling in the knee may be:

Blood:

Penetrating trauma

ACL tear (most likely, highly vascular)

PCL tear

Intra-articular fracture (e.g. patella)

Tear of the lateral meniscus (periphery

has a reasonable blood supply)

Synovial fluid

Tearing of the medial meniscus results in an effusion of synovial fluid as the

central area is not very vascular)

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

P23 2


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

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 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


20. Mark of Excellence 0 1

P24

2


REMS Hip Examination Written in April 2014 by Tom Aitken

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 medial malleolus

True Leg Length – measured from the anterior superior iliac spine 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).

Function:

Ask the patient to walk across the room to check for any abnormalities of their gait. BIBLIOGRAPHY AND FURTHER READING


Edinburgh: Churchill Livingstone; 2009:386–388.

4. Brain J. Crash Course: History and Examination. 3rd

ed. Mosby; 2008: 214 – 217

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