Level Four OSCE PDF

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LEVEL FOUR OSCE4 stationsM Clinical Examination Clinical Scenario Responding to a SymptomM Chemotherapy CounsellingClinical ExaminationBegin by introducing yourselfTask 1: Read informationTask 2: Relay information to the examiner i. list all parts of the system which you will be examiningTask 3:...

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Rafchana Khanam

LEVEL FOUR OSCE 4 stations M13  Clinical Examination  Clinical Scenario  Responding to a Symptom M07  Chemotherapy Counselling

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Rafchana Khanam

Clinical Examination Begin by introducing yourself Task 1: Read information Task 2: Relay information to the examiner i.e. list all parts of the system which you will be examining Task 3: Demonstrate components of the system Task 4: Read findings, diagnose patient and discuss treatment/referral pathway

1. 2. 3. 4.

Cardiovascular System Respiratory MSK CNS

ALWAYS WASH HANDS UPON ENTERING THE STATION

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Rafchana Khanam CARDIOVASCULAR SYSTEM Task 1 and 2: 1. General inspection 2. Inspection of the hands 3. Pulses 4. Full set of observations (vital signs) 5. Inspection of the eyes 6. Inspection of the mouth 7. Jugular Venous Pressure 8. Inspection of the chest 9. Palpation of the chest 10. Auscultation of the heart 11. Auscultation of the lungs Task 3: Section General inspection

Hands

Pulses

Aspect Obvious Pain Colour

Reason Pale (anaemia) Cold Clammy

Weight

Healthy Overweight Obese

Medical devices e.g. oxygen tank, GTN spray, etc.

Indicates medical condition

Temperature

Cold (poor perfusion) Hot (infection)

Clubbing/Shamrock’s window

Infective endocarditis or chronic disease

Splinter haemorrhage

Infective endocarditis

Capillary refill

Longer than two seconds indicated poor perfusion

Pale palmar creases

Anaemia

Tar staining

Heavy smoker

Radial (wrist for 30 seconds then multiply by

Do both and compare rate and rhythm. 3

Rafchana Khanam 2)

Any radial-radial delay? Collapsing pulse?

Brachial (elbow crease)

Any brachial delay? Normal volume and character?

Collapsing pulse (lift arm)

Rate, rhythm and volume Sign of regurgitation

Carotid (not together) Dorsalis pedal (top of foot) Posterior tibial (side of foot)

Check for peripheral oedema at this point

Full set of observations

Respiratory rate Blood pressure Oxygen saturation

Normal: 12-20 Normal: 120/80 Normal: 95-100%

Eyes

Pale conjunctiva (pull down the eye lid)

Anaemia

Yellowing of eyes

Jaundice

Xanthelasma

High cholesterol

Corneal arcus (white halo)

High cholesterol

Tongue

Central cyanosis

Mouth and teeth

Infective endocarditis

Jugular Venous Pressure

Have patient at 45 degrees, turn head left and identify where JVP would be, if raised

If JVP raid, measure the height from the sternal edge. Raised JVP indicates heart failure.

Inspection of the chest

Expose chest (front and back) and observe for: Obvious deformities

Mouth

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Rafchana Khanam

Palpation of the chest

Auscultation of the heart

Scars

Surgery e.g. pacemaker

Bruising

Indicates trauma

Visible heaves

Enlargement of the heart

Apex beat (5th intercostal space, mid clavicular line) Heaves

Enlarged cardiac muscle

Thrills

Palpable murmur

Aortic area

Right sternal edge, second IC space

Pulmonary area

Left sternal edge, second IC space

Tricuspid area

Left sternal edge, fourth IC space

Mitral

5th IC space, mid clavicular line

Using diaphragm (large side): Aortic Pulmonary Tricuspid Mitral

Should hear S1 and S2 (lub dub) Should not hear S3 and S4 (extra sounds/murmurs)

Using bell side:

Auscultation of the lungs

Aortic Pulmonary Tricuspid Mitral

Listen to values for any regurgitation or stenosis

Listen to sacrum base of lungs

Crackles and crepitus could indicate pulmonary oedema in HF

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Rafchana Khanam Additional Checks

Palpate ankles and legs

Fluid/pitting could indicate HF

Task 4: Angina

Diagnosis

Findings Pain on exertion, disappears on rest

Myocardial infarction

ST segment elevation on ECG

Infective endocarditis

Clubbing/Shamrock’s window, splinter haemorrhages, heart murmur

Heart failure

Oedema Shortness of breath Added heart sounds

Peripheral vascular disease

Weak pulse in leg, low BP in ankle, leg ulcers

RESPIRATORY SYSTEM Task 1 and 2: 1. General inspection 6

Rafchana Khanam 2. 3. 4. 5. 6.

Full set of observations Inspection of the hands Inspection of the face Inspection of the chest (anterior and posterior) Palpation of the chest (including lymph nodes, trachea and the anterior and posterior) 7. Percussion of the chest 8. Auscultation of the lungs 9. Additional checks

Task 3: Section General inspection

Aspect Obvious Pain Colour

Effort of breathing

Reason Grimacing Cyanosis Pallor e.g. pink and well perfused Symmetrical movement

Use of accessory muscles i.e. chest, shoulders, neck Medical devices e.g. oxygen tank, inhalers, walking frame, etc. Ashtray (home visit)

Indicative of COPD

Full set of observations

Respiratory rate Blood pressure Oxygen saturation Pulse

Normal: 12-20 Normal: 120/80 Normal: 95-100% Normal: 60-100

Hands

Temperature (place back Cold (poor perfusion) of my hand against theirs) Hot (infection)

Overflown? Heavy smoker?

Clubbing/Shamrock’s window

Pulmonary fibrosis or chronic disease

CO2 flap (extend hands out vertically)

CO2 retention

Fine tremor (extend hands out horizontally)

Overuse of beta 2 agonist

Capillary refill

Longer than two seconds indicated poor perfusion

Tar staining

Heavy smoker 7

Rafchana Khanam

Face

Inspection of the chest

Radial pulses (count pulse for 30 seconds and multiply by 2)

Compare both for rate and rhythm

Lips and ears

Cyanosis

Pallor

Pink puffer Blue bloater

Nasal flaring

Excessive when breathing in COPD

Pale conjunctiva (pull down eyelid)

Anaemia

Yellowing of the eye

Jaundice

Horner’s sign (droopy eyelid, pinpoint pupil)

Apical lung tumour

Tongue (stick out)

If blue and dry, sign of central cyanosis

Pursed lip breathing

Indicative of COPD

Anterior: Respiratory rate

Normal: 12-20

Deformity/scars

Previous trauma Operations

Symmetry of chest wall and symmetry of breathing

Unequal movement could indicate fracture

Bruising/rash/wounds

Injury to the chest wall

Posterior: Deformity/scars

Previous trauma Operations

Symmetry of chest wall and symmetry of breathing

Unequal movement could indicate fracture

Bruising/rash/wounds

Injury to the chest wall 8

Rafchana Khanam

Palpation of the chest

Lymph nodes: Cervical (under jaw to chin) Supraclavicular (clavicle) Axilla (armpit) Trachea: Position of trachea (check If deviated, could be an sides to ensure indication of: symmetrical) Haemothorax Pneumothorax Tumour Chest (anterior and posterior): Palpate for tenderness (ask patient) Chest expansion (thumbs together, breath in and out)

Percussion of the chest

Vocal fremitus (‘99’ over all lung areas)

Changes in vibration indicate chest infection

Tap middle finger with middle finger, in between ribs, from side to side

Identify areas of tympany and dullness:

10 points for both anterior and posterior

Drum sound: pneumothorax Dull sound: haemathorax

Auscultation of the lungs

Listen for normal/abnormal breath sounds and causes with diaphragm

Vesicular: normal breathing sounds (inspiration is 2/3 times expiration)

8 points anterior 4 points side 10 points posterior

Bronchial: harsher, indicates chronic lung disease/fibrosis (inspiration = expiration)

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Rafchana Khanam Crepitation/crackles: popping sounds made by secretions Wheeze: restricted/constricted airway Pleural rub: visceral and parietal pleura rubbing due to inflammation, infection, fibrosis or trauma Vocal resonance (say ’99’) 8 points anterior 4 points side 10 points posterior

Additional checks

Sacral oedema

Indicates heart failure

Calf pain Leg swelling (compare) Palpate calves for tenderness

Indicates DVT

Palpate temperature of legs

Indicates infection

Inspect for rash/inflammation

Task 4: Diagnosis Chest infection

Findings Green sputum 10

Rafchana Khanam Pneumonia

Asthma

COPD (non-infective exacerbation)

Pulmonary embolism

Gold/brown sputum High fever (above 39) Systemically unstable therefore refer Persistent night time cough Difficulty breathing Shortness of breath Wheezing Productive cough – more mucus than usual (but not purulent) Haemoptysis Shortness of breath Chest pain

MUSCULOSKELETAL SYSTEM Task 1 and 2: 1. Examination (expose and examine above and below the joint) 11

Rafchana Khanam 2. 3. 4. 5. 6. 7.

Look (compare left and right) Feel Move (actively and passively) Function (against resistance) Full set of observations Any additional/special tests

Task 3: LOOK (compare with unaffected side)

Hand and Wrist Examination Inspect dorsal and palmar aspect of both hands for: Scars/wounds Swelling/erythema Redness/inflammation Rash Any obvious deformities at the wrist and metacarpal joints Atrophy (muscle wasting)

FEEL

Please let me know if you feel any pain. Palpate across radius (thumb side) and ulnar (little finger side), front and back, for: Temperature (infection/poor circulation) Tenderness Swelling Crepitus (grating between either bone and bone or bone and cartilage) Bony enlargement Now, I will do the same at the wrist (carpal bones): Same as above Now I will feel down the metacarpal bones and down each proximal interphalangeal joint (fingers), medially and laterally.

MOVE

Wrist (actively and passively): Flex Extend Ulnar deviation (towards little finger) Radial deviation (towards thumb) Hand (actively and passively (for first two)): Flex (make a fist) Extend (straighten fingers) Thumb opposition (touch each finger) 12

Rafchana Khanam Abduction (spread fingers FUNCTION

LOOK (compare with unaffected side)

FEEL

Can you do the following against resistance: Flex Extend Ulan deviation Radial deviation Can you resist against me spreading your fingers? Can you grip my two fingers? Ankle Examination Inspect ankle and foot, including the base, for: Scars/wounds Swelling/erythema Redness/inflammation Rash Any obvious differences in size Atrophy (muscle wasting) Palpate medial and lateral malleolus and navicular (whole ankle and up 5cm) for bony tenderness Refer for x-ray if any tenderness present Palpate whole foot, including metatarsals, for: Temperature (infection/poor circulation) Tenderness (mention 5th metatarsal base i.e. side of foot – if tenderness present, refer) Swelling Crepitus (grating between either bone and bone or bone and cartilage) Bony enlargement

MOVE

FUNCTION

Ankle and toes (actively and passively): Flex Invert Evert Rotate Can you do the following against resistance: Flex Invert Evert Rotate Can you walk four steps for me? 13

Rafchana Khanam If unable to, they are Ottawa positive. N.B. Ankle Ottawa Rules – refer for x-ray if:    

Tenderness at lateral or medial malleolus Tenderness at navicular Tenderness at base of 5th metatarsal Inability to weight bear i.e. walk four steps

LOOK (compare with unaffected side)

Knee Examination Inspect knee, including behind in the popliteal fossa, for: Scars/wounds Swelling/erythema Redness/inflammation Rash Any obvious differences in size Atrophy (muscle wasting)

FEEL

Palpate patella (knee cap), tibia (inner) and fibula (outer) as well as collateral ligaments and menisci for bony tenderness Refer for x-ray if any tenderness present Palpate against leg for: Temperature (infection/poor circulation) Tenderness (mention patella and head of fibula (below knew cap) – if tenderness present, refer) Swelling Crepitus (grating between either bone and bone or bone and cartilage) Bony enlargement

MOVE

Knee (actively and passively): Flex (bend to 90 degrees) Extend (straighten leg out) Anterior/posterior (crucial ligaments) lag test: Bend knee (sit on foot) then pull up and push dosh; any excessive movement means damage Lateral and medial stress (collateral ligaments) test: Hold leg up, ankle under my arm, other hand holding above the knee; move side to side looking for excess movement on either side. 14

Rafchana Khanam FUNCTION

Sit on the side of the bed and do the following against resistance: Push straight up against my hands Pull back against by hands Push out sideways Push in sideways Can you walk four steps for me? If unable to, they are Ottawa positive.

N.B. Knee Ottawa Rules – refer for x-ray if:     

Over 55 Tenderness at patella Tenderness at head of fibula Inability to flex 90 degrees Inability to weight bare (limping is weight bearing)

LOOK (compare with unaffected side)

Shoulder Examination Inspect whole shoulder, anteriorly and laterally, for: Scars/wounds Swelling/erythema Redness/inflammation Rash Any obvious differences in size Atrophy (muscle wasting) Shoulder position (dropped indicates joint injury)

FEEL

Palpate clavicle (collar bone), AC joint (between collar bone and shoulder blade), humorous (above elbow) and scapula (shoulder bone) for bony tenderness Refer for x-ray if any tenderness present Palpate generally for: Temperature (infection/poor circulation) Tenderness Swelling Crepitus (grating between either bone and bone or bone and cartilage) Bony enlargement

MOVE

Move the shoulder (actively and passively): Flex (arm up) Extend (arm back) 15

Rafchana Khanam Abduct (lift sideways, away from body) Adduct (lift across body) Rotate externally (arm at right angle and move outwards) Rotate internally (put arm behind your back) FUNCTION

LOOK (compare with unaffected side)

FEEL

Repeat the above against resistance i.e. as I hold the bicep

Elbow Examination Inspect whole elbow, anteriorly and laterally, for: Scars/wounds Swelling/erythema Redness/inflammation Rash Any obvious differences in size Atrophy (muscle wasting) Palpate generally for: Temperature (infection/poor circulation) Tenderness Swelling Crepitus (grating between either bone and bone or bone and cartilage) Bony enlargement

MOVE

FUNCTION

Keeping elbows tucked in, can you (actively and passively): Flex (raise arms from neutral) Extend (lower arms from neutral) Pronation (elbows tucked in, palms up and rotate) Repeat the above against resistance i.e. hold elbow so patient cannot use their shoulders

Task 4: Diagnosis Soft tissue injury

Findings PRICE: - Protect weakened tissue and support new fibres - Rest for approx. two days 16

Rafchana Khanam -

Ice (crushed and wrapped in towel) twenty minutes off and on for first few hours Compression (aids venous return) Elevation reverse swelling (do not combine with compression)

HARM: avoid the following for 72 hours - Heat - Alcohol - Running - Massaging Take analgesia e.g. paracetamol and/or topical NSAIDs (no oral NSAIDs for first 72 hours) Try to keep mobilised but no excessive movement Return if problem continues Suspected fracture

Patient is Ottawa positive therefore need referring for an x-ray Can give advice on analgesia in the meantime i.e. paracetamol Do NOT give PRICE/HARM advice

CENTRAL NERVOUS SYSTEM Task 1 and 2: 1. FAST TEST (perform on every patient)  Face – can you smile (symmetrical)? Is the mouth or eye drooped?  Arm – can you raise both arms? 17

Rafchana Khanam  Speech – can you say A, E, I, O, U? Slurred or jumbled?  Time – note the time of onset 2. Full set of observations 3. General inspection 4. Full set of nerves Task 3: Observe

Examination of Trigeminal Nerve (VI) i.e. Headache Any abnormalities/asymmetry of the jaw muscle

Assess sensory function

Ask patient to close eyes and use cotton wool to touch six separate areas of the face. Ask patient to confirm sensation

Assess corneal reflex (just mention you would do this)

Touch cornea with cotton wool and observe whether patient flinches (no movement is normal)

Open jaw (actively and against resistance)

Patient open and closes jaw Patient lowers jaw and I try to close it

Assess jaw jerk reflex

Observe

Let lower jaw hang loosely and tap above the chin (normal to have absent or minimal response)

Examination of Facial Nerve (VII) i.e. Bell’s Palsy Asymmetry of the face e.g. - Any muscle wastage - Paralysis - Ptosis (drooping eyelid) - Can’t blink (drying of eye, can damage eye)

Assess power of the upper limbs

Ask patient to raise arms

Assess face

Ask patient to: - Frown (equal eyebrows) - Raise eye brows (equal) - Open and close eyes tightly (tone) - Close eyelid against resistance (I keep eyelid open) - Smile and show teeth (symmetrical) - Push cheeks out; place gentle pressure on cheeks to assess 18

Rafchana Khanam resistance Assess taste

Check they can taste e.g. peppermint, coffee, oranges, etc. ‘This would be done in practice’

Task 4: Diagnosis Tension headache

Findings Widespread, constant ache affecting both sides of the head Paracetamol 1g QDS PRN Ibuprofen 400MG TDS PRN PC Lifestyle advice e.g. regular sleep, reducing stress, hydration If no improvement in 48 hours, see GP If headache worsens during the day (i.e. due to visual problems), refer.

Migraine

Localised, severe, throbbing pain at the front or side of head; usually last a couple of hours Other symptoms: - Photosensitivity - Sensitivity to noise - N&V - Fatigue Relieving factors – remain in bed OTC analgesia; if this does not help, refer to GP.

Stroke

Asymterical face, reduced muscle tone i.e. cannot lift arms, slurred speech – immediate referral

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Rafchana Khanam

CLINICAL SCENARIO In this station, you are addressing another healthcare professional. Begin by introducing yourself, confirming their identity and stating why you have contacted them i.e. which patient your query is regarding.

Scenario Patient...