OSCE Flow

Benjamin Ooi

CVS Examination Flow 1) Obtain consent. Exposure and wash hand. 2) Stand right to the patient who is lying 45 degrees. 3) General appearance a) General health state b) Built c) Dyspnea d) Fatigue e) Cachexia f) Does the patient appear to be in pain or distress? g) Any congenital abnormalities eg. Marfan, Turner, Down h) Overweight, obese, cachexic 4) Hand a) Peripheral cyanosis b) Janeway lesions c) Oslers nodes d) Splinter haemorrhages e) Tendon xanthomata f) Capillary return 5) Arterial pulses (report as beats/min regular/irregular) a) Radial pulse, measure heart rate b) Radio-radio delay c) Brachial arteries d) Femoral artery, check for radio femoral delay (skip) e) Popliteal artery f) Posterior tibial artery g) Dorsalis pedis h) Collapsing artery 6) Blood pressure 7) Face a) Eye look down jaundice b) Eye look up pallor (anaemia) c) Malar flush d) Xanthelasma e) Arcus lipidus f) Mouth and tongue i) Central cyanosis ii) High arched palate 8) Neck a) Palpate for carotid artery (between the larynx and anterior border of the sternocleidomastoid muscle b) JVP i) Look for two heads of sternocleidomastoid ii) If JVP pulsation is more than 3cm from the sternal angle then JVP is raised

OSCE Flow

Benjamin Ooi

9) The praecordium a) Inspection i) Breathing rate ii) Position of the apex beat (5th ICS, mid-clavicular line) iii) Scars iv) Rashes v) Skeletal abnormalities (excavatum, wasting of muscles) vi) Pacemaker boxes vii) Feel for sacral oedema b) Palpation i) Palpate for apex beat then count the ribs ii) Left parasternal border for parasternal heave iii) Feel for thrill by palpating over the four heart sound areas c) Auscultation i) Mitral area near the apex of the heart with a bell followed with the diaphragm ii) Tricuspid area left sternal border, 5th ICS with diaphragm iii) Pulmonary area left sternal border, 2nd left ICS with diaphragm iv) Aortic area right sternal border, 2nd right ICS with diaphragm v) Positioning (1) Rolling patient to left side for mitral valve sounds (2) Sitting patient forward for aortic and pulmonary valve sounds vi) Changing the blood flow (1) Expiration squeezes the blood from the pulmonary bed into the left heart and amplify mitral and aortic murmurs (2) Inspiration amplify the tricuspid and pulmonary murmurs vii) Phases of the respiratory cycle (1) Expiration lung thickness is reduced and the distance between the heart and stethoscope is less 10) Lower Limbs a) Examine femoral, popliteal, posterior tibial and dorsalis pedis b) Ankle oedema c) Toe clubbing d) Archilles tendon xanthomata e) Examine femoral, popliteal, posterior tibial and dorsalis pedis f) Ankle oedema g) Toe clubbing h) Archilles tendon xanthomata i) Peripheral cyanosis j) Reduced capillary return and coolness k) Pallor and absence of hair

OSCE Flow

Benjamin Ooi

PNS Upper Limb Flow 1) Introduce yourself, explain procedure, consent. 2) Wash hands and ask the patient to expose his clothing 3) General inspection a) Ask patient to relax their arms on the lap b) Inspect for posture, muscle bulk, abnormal movements, fasciculation and skin changes c) Hold out arms in front and close eyes (vestibular and proprioception senses) d) Muscle wasting (compare both hands and with yourself) e) Abnormal movements tremor (hold out their hands with the fingers spread out) f) Parkinsonian tremors (intentional tremors cerebellar disorders) g) Athetosis, chorea, hemiballismus h) Fasciculation (anterior horn cell disease) 4) Motor a) Tone i) Shake hands with patient, cannot relax grip (myotonia) ii) Passively flex and extend the wrist iii) Passively flex and extend the elbow iv) Comment on lead-pipe rigidity and cog wheel rigidity b) Power (comment on power and nerve root) i) Shoulder abduction (C5,C6) Shoulder Adduction (C6,C7,C8) ii) External Rotation (C5,C6) iii) Elbow flexion (C5,C6) Elbow extension (C7,C8) iv) Wrist flexion (C6,C7) Wrist extension (C7,C8) v) Finger flexion (C7,C8) Finger extension (C7,C8) vi) Finger abduction (C8,T1) Finger adduction (C8,T1) c) Reflex i) Biceps (C5,C6) ii) Triceps (C7,C8) iii) Brachioradialis (C5,C6) iv) Finger (C8) d) Coordination i) Finger nose test (intentional tremor, dysmetria, dyssnergia and proprioception is intact) ii) Rapidly alternating movements (cerebellar disease, pyramidal/extra-pyramidal lesions) iii) Ballistic tracking 5) Sensation a) Pain b) Temperature c) Vibration 128Hz start at DIP then ulnar head, olecranon and shoulder d) Proprioception e) Light touch f) Two point discrimination hand 3 cm, fingertips 0.6cm g) Stereognosis h) C3 above clavicle C4 below clavicle C6 thumb & index C7 middle finger C8 pinky T1 medial forearm T2 medial arm

OSCE Flow

Benjamin Ooi

6) Examination of peripheral nerves a) Radial nerve (C5-C8) check sensory at dorsum of hand and extend hand b) Median nerve (C6 T1) i) At wrist weakness of abductor pollicis brevis (pen touching test) ii) At cubital fossa loss of function of flexor digitorum sublimus (Oschners clasping test) iii) Sensory lateral 3.5 digits c) Ulnar nerve (C8 T1) i) Motor Froments sign (loss of adductor pollicis) ii) Sensory little finger 7) Carpal tunnel syndrome a) Tinels test b) Phalens test

OSCE Flow

Benjamin Ooi

Flow of Lower Limb Peripheral Nervous System Examination 1) 2) 3) 4) 5) Introducing yourself *ask if the patient is currently in pain* Ask the patient to expose appropriate clothing Wash hands General inspection built, muscle bulk, abnormal movements, fasciculation, posture, skin colour Look a) Gait i) Normal gait (no abnormal gaits) ii) On heels (L4,L5) intact iii) Tip-toe (S1,S2 intact) iv) Heel to toe (Cerebellar lesion) v) Squat rise (Proximal muscles) vi) Trendelenburg test (Gluteus medius and minimus) vii) Romberg (patients vestibular and proprioceptive senses) viii) Pull test (Cerebellar lesion) Tone move twice, once fast (spasticity), once slow (basal ganglia abnormalities) a) Thigh place a hand under the knee and pull the knee causing flexion b) Knee support the thigh and flex and extend the knee at increasing speeds for resistance c) Spasm, fasciculation (tap for fasciculation) Clonus a) Knee sudden stretch of the quadriceps b) Ankle knee needs to be bent, thigh externally rotated, sharply dorsiflex foot (UMN lesion) c) Patellar knee extended, patella held between thumb and index finger and sharply move patella downward Power (movement + nerve roots) a) Hip Abduction (L4,L5,S1) Hip Adduction (L2,L3,L4) b) Hip Flexion (L2,L3) Hip Extension (L5,S1,S2) c) Knee Extension (L3,L4) Knee Flexion (L5,S1) d) Ankle Plantar Flexion (S1,S2) Ankle Dorsiflexion (L4,L5) e) Ankle Eversion (L5,S1) Ankle Inversion (L5,S1) Reflexes a) Knee jerk (L3,L4) b) Calcaneal (S1,S2) c) Babinski (L5,S1,S2) Coordination a) Heel shin test b) Toe finger test c) Feet tapping test Sensation a) Light touch b) Pain c) Vibration d) Proprioception

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OSCE Flow

Benjamin Ooi

MSK examination of the lower limb flow HIP 1) General inspection posture, any walking aids, comfort, body build 2) Gait look for a) Pain b) Joint immobility c) Muscle weakness d) Abnormal limb control e) Shortening and posture of leg 3) Tredelenburg test 4) Ask the patient to lie down and look for scars, rash and muscle bulk 5) Feel locate joint tenderness at the midpoint of the inguinal ligament a) Bony landmarks i) Iliac crest ii) Iliac tubercle iii) ASIS iv) Greater trochanter v) Pubic symphysis vi) PSIS vii) Ischial tuberosity and sacroiliac joint 6) Move a) Flexion lying on the back, flex the hip and knee by moving the thigh close to the chest (pelvis must be on the bed) b) Rotation test with hip and knee flexed, move the foot medially for external rotation and move the foot laterally for internal rotation (45 degrees is normal) c) Abduction hold the heel of the foot and secure the iliac crest and abduct the leg (normal 50 degrees) d) Adduction adduction is the opposite with the limb crossed in front of the other limb (normal 45 degrees) e) Extension roll on the stomach, one hand stabilizes the sacroiliac joint and elevate the leg (possible 30 degrees) 7) Measure a) True length ASIS to medial malleolus b) Apparent length Umbilicus to medial malleolus 8) Special test a) Thomas test place hand under the lumbar spine and ask patient to flex the hip fully (lordosis of the lumbar spine will be eliminated) and then check the other hip and check if it lifts off the couch (fixed flexion deformity)

OSCE Flow

Benjamin Ooi

KNEE 1) General inspection posture, any walking aids, comfort, body build 2) Gait look for a) Pain b) Joint immobility c) Muscle weakness d) Abnormal limb control e) Shortening and posture of leg 3) Focus on the knee: a) Quadriceps wasting b) Swelling and deformity c) Skin changes d) Genu valgum e) Genu varum f) Popliteal fossa for Bakers cyst g) Hyperextension of the knee at a lateral standpoint 4) Feel a) Temperature b) Muscle wasting c) boggy feeling of synovial swelling d) Surface landmarks i) Joint line ii) Popliteal pulse iii) Tibial tuberosity iv) Borders of patella v) Insertion of hamstring vi) Border of the quadriceps vii) Femoral condyles viii) Fibula head 5) Test for joint effusion a) Patella tap milk the synovial fuild from the suprapatellar notch, three fingers to push the patella inwards b) Bulge sign milk the medial side and stroke the lateral side for a smaller synovial effusion c) Test for stability by siding the patella sideways on the femoral condyles 6) Patellar apprehension test side patella laterally and flex the knee 7) Move a) Flexion (135 degrees) b) Extension (5 degrees) c) Lateral and medial collateral ligaments i) Valgus and varus stress test flex the knee slightly and apply adduction and abduction to the leg (>5-10degrees is abnormal) d) Cruciate ligaments i) Drawer test anterior and posterior (more than 5-10 degrees suggest ligament laxity) ii) Lachmans test

OSCE Flow

Benjamin Ooi

e) Meniscus i) McMurrays test (1) Lying down and bend the knee to 90 degrees (2) Grip the heel with right hand (3) Hold the knee to press on the medial and lateral cartilage (4) Internally rotate and extend the knee (lateral) (5) Externally rotate and extend the knee (medial) (6) Watch the face for pain, feel for clunking and locking of the knee.

OSCE Flow

Benjamin Ooi

ANKLE JOINT 1) Look a) Calf wasting, swelling, deformity, skin and nail changes b) Clawing and crowding of the toes (RA) 2) Feel i) Margins of the ankle joint, heel, metatarsophalangeal and interphalangeal joints and Archilles tendon b) Medial malleolus c) Lateral malleolus d) Calcaneus 3) Move a) Dorsiflexion (20 degrees) b) Plantar flexion (50 degrees) c) Eversion and inversion (5 degrees) 4) Tests a) Archilles tendon b) Squeeze the muscles midcalf c) Foot plantar flexion