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OSCE List of skills: 

Hand washing

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Basic life support and first aid

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Cardiovascular history taking

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Examination of pulses

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Blood pressure

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Examination of praecordium

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Examination of the jugular venous pulse

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Respiratory history taking

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Respiratory examination

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Peak expiratory flow rate (PEFR) measurement

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Urinary history taking

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Urinalysis

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Examination of lymph nodes

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Assessment of a lump

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Assessment of vital signs and early warning scores

Things to remember 

Name badge/student card clearly visible

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Hair tied back

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Nails clean and cut

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Bare below the elbow (no watch)

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Professional dress

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Appropriate sharps disposal

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Always wash hands and clean equipment e.g. stethoscope

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Compare sides/examine both sides if appropriate e.g. check pulses on both sides of body

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Identify self and patient

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Explanation and consent

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Adequate closure with thanks and ensure patient is covered up before leaving the station

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Don’t move on too quickly from history of presenting complaint

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Ensure respiratory examination done properly including chest expansion

History Taking

Structuring a clinical history 

Greet patient, develop rapport, introduce yourself – full name and role, identify patient – full name and date of birth, and gain informed consent

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Presenting complaint – ask what brought them in and summarize your understanding of the problems to the patient.

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Ask about ideas, concerns and expectations o Have you any thoughts on what might be the cause of the problem o Do you have an particular worries about what could be wrong o What were you hoping for from your visit today

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History of presenting complaint o Onset and duration of each problem o Sequence or pattern of events o Do the symptoms relate to a specific system o Is there a pattern to the symptoms o Is there a link between the symptoms o What other associated symptoms would be important to ask the patient 

Cardiovascular & respiratory: 

Dyspnea – how far can you go before getting breathless, climbing stairs, normal walking or at rest?

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paroxysmal nocturnal dyspnea – wake suddenly during night,

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orthopnea – do you need to be propped up with pillows to sleep at night,

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palpitations – are they fast, irregular/regular, skipped beats, how long do they last for,

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ankle swelling,

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intermittent claudication – cramping/pain in calves when walking or even at rest

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syncope – under what circumstances did this occur,

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wheezing – whistling on exhaling, timing?

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cough – o sputum: color and volume, blood stained?, o duration of cough, character of cough – dry/mucus etc., is it worse at night

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Genito-urinary system 

Pain, frequency or difficulty in micturition, hematuria, regularity and duration of menstruation

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Hesitancy, is there difficulty initiating a flow of urine

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Poor stream (stops and starts)

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Feeling that you can’t fully empty

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Dripping after finishing

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Urgency

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Frequency

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Nocturia

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Incontinence and urge incontinence

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Loin/back pain

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Fever

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Blood in urine, cloudy urine, malodorous urine

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Increase/decrease in urine production

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STI

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Renal colic o Associated vomiting o Residual ache o Recurrent pattern o Cloudy/blood/stone/grit passed

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Urinary infection o Loin/back pain o Fever/rigors(chills)/sweating

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Renal failure o Tiredness/itch

o Pain: 

Pain severity (scale 1-10)

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Onset and duration

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Periodicity or constancy – if it comes and goes what is the pattern, and is there background pain, how long does the pain last each time

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Has anything changed over the time you have had this pain? (eg. lasting longer, increasingly frequent, getting more severe)

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Site – where do you feel it?

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Radiation

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Type/character – what does the pain feel like?

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Relieving factors

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Aggravating factors – does anything bring the pain on?

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Associated symptoms – e.g. nausea or sweating when you have the pain

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The pain of angina may be described as a heavy feeling, chest tightness or pressure, a dull aching or indigestion. The pain often radiates to the neck, or commonly the left arm. It characteristically occurs during exertion, when coronary blood flow becomes insufficient to meet the metabolic demands of the heart. Other situations which may precipitate angina include cold weather and exercise following meals. The pain of acute pericarditis is not related to exertion but is commonly exacerbated by deep inspiration. The pain is often described as sharp, and the patient may localise the pain to the sternum, unlike the diffuse discomfort of angina. The pain is often eased by sitting forward. The differential diagnosis of angina includes gastrointestinal disorders such as reflux oesophagitis, gastritis and peptic ulceration and musculoskeletal causes. Pleuritic pain characteristically occurs in the lateral chest wall but may be central in location. As in pericardial pain, it is often exacerbated by inspiration.

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Past medical history o “How would you rate your general health” o Have you had any serious illness in the past o Have you had any operations o Have you ever been in hospital or do you attend the hospital o Targeted 

Related illnesses

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Important illnesses

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Risk factors if appropriate

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Cardiovascular: 

Have you ever had any heart problems

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Have you ever been told you have high blood pressure, high cholesterol or diabetes, angina, stroke, heart attack, heart disease, hyperlipidaemia

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Respiratory 

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Asthma, bronchitis, chest surgery, TB, pneumonia, cystic fibrosis

Genito urinary 

Neurological diseases may cause abnormal bladder function, e.g. multiple sclerosis or cerebrovascular disease. Any history hypertension or diabetes may also be relevant. Previous surgery, e.g. for urinary incontinence in women or prostatic hypertrophy in men. Ureteric injury may occur in abdominal or gynecological operations.

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Pregnancy

Family history o Do any illnesses run in the family – and age of death or relevant illness o Targeted 

Cardiovascular 

Does anyone in your family suffer from heart problems, high blood pressure, stroke or diabetes?

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Genito – urinary 

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Kidney disease

Social history o does the problem affect their lifestyle 

effects on daily life, work, relationships

o who lives with you – married/any children? o Type of accommodation (e.g. do you find it hard to walk up stairs) o Pets and exposure to animals e.g. birds o Support – family, friends, carers o Diet and exercise o past and present employment o exposure to occupational hazards o Alcohol 

Do you drink

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How has your drinking changed over weeks/years

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Quantify in units the amount consumed per week – pint beer 2 units, small glass of wine or standard measure spirit 1 unit

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What do you drink/how many nights a week do you drink/what would you drink when you go out?

o Smoking

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Do you smoke/have you ever smoked?

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Duration and amount

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Pack years = cigs a day/20 x years smoked

Drug history o Allergies to any medications – what type of reaction they had o Prescribed medication o Over the counter medication o Complementary medication – e.g. herbal, acupuncture o Illicit drugs o Allergies o Inhalers – can you use, nebulizers, administration of medicine, dosage and frequency

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Systematic questions

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Summary o To verify your own understanding of what the patient has said o Invite the patient to correct you/add further information, “is this correct, do you have anything else you’d like to add”

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Closure

Basic life support

Order of events 

Safety – make sure you, victim and bystanders are safe

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Response – is victim conscious, gently shake shoulders and ask loudly are you alright

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Airway – open the airway, turn victim on back, place hand on forehead and tilt head back, fingertips under chin and lift the chin to open airway. Look, listen and feel for normal breathing for no more than 10 seconds o In the first few minutes after cardiac arrest, a victim may be barely breathing, or taking infrequent, slow and noisy gasps. Do not confuse this with normal breathing. If you have any doubt whether breathing is normal, act as if it is they are not breathing normally and prepare to start CPR

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Call 999 and send for an AED, do not leave victim alone, start CPR

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CPR o Start chest compressions o Kneel by the side of the victim o Place the heel of one hand in the center of the victim’s chest; (which is the lower half of the victim’s breastbone (sternum)) o Place the heel of your other hand on top of the first hand o Interlock the fingers of your hands and ensure that pressure is not applied over the victim's ribs o Keep your arms straight o Do not apply any pressure over the upper abdomen or the bottom end of the bony sternum (breastbone) o Position your shoulders vertically above the victim's chest and press down on the sternum to a depth of 5–6 cm o After each compression, release all the pressure on the chest without losing contact between your hands and the sternum; o

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Repeat at a rate of 100–120 min-1

Rescue breaths o After 30 compressions open the airway again using head tilt and chin lift and give 2 rescue breaths o Pinch the soft part of the nose closed, using the index finger and thumb of your hand on the forehead

o Allow the mouth to open, but maintain chin lift o Take a normal breath and place your lips around his mouth, making sure that you have a good seal o Blow steadily into the mouth while watching for the chest to rise, taking about 1 second as in normal breathing; this is an effective rescue breath o Maintaining head tilt and chin lift, take your mouth away from the victim and watch for the chest to fall as air comes out o Take another normal breath and blow into the victim’s mouth once more to achieve a total of two effective rescue breaths. Do not interrupt compressions by more than 10 seconds to deliver two breaths. Then return your hands without delay to the correct position on the sternum and give a further 30 chest compressions o Continue with chest compressions and rescue breaths in a ratio of 30:2 o If you are untrained or unable to do rescue breaths, give chest compression only CPR (i.e. continuous compressions at a rate of at least 100–120 min-1) 

If an AED arrives o Switch on the AED o Attach the electrode pads on the victim’s bare chest o If more than one rescuer is present, CPR should be continued while electrode pads are being attached to the chest o Follow the spoken/visual directions o Ensure that nobody is touching the victim while the AED is analysing the rhythm o If a shock is indicated, deliver shock o Ensure that nobody is touching the victim o Push shock button as directed (fully automatic AEDs will deliver the shock automatically) o Immediately restart CPR at a ratio of 30:2 o Continue as directed by the voice/visual prompts o If no shock is indicated, continue CPR o Immediately resume CPR o Continue as directed by the voice/visual prompts

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Recovery position: if the patient is breathing normally but still is unresponsive place in recovery position o Remove the victim’s glasses, if worn

o Kneel beside the victim and make sure that both his legs are straight o Place the arm nearest to you out at right angles to his body, elbow bent with the hand palmup o Bring the far arm across the chest, and hold the back of the hand against the victim’s cheek nearest to you o With your other hand, grasp the far leg just above the knee and pull it up, keeping the foot on the ground o Keeping his hand pressed against his cheek, pull on the far leg to roll the victim towards you on to his side o Adjust the upper leg so that both the hip and knee are bent at right angles o Tilt the head back to make sure that the airway remains open o If necessary, adjust the hand under the cheek to keep the head tilted and facing downwards to allow liquid material to drain from the mouth o Check breathing regularly o

Be prepared to restart CPR immediately if the victim deteriorates or stops breathing normally

Hand hygiene

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Hands should be washed: o Before and after patient contact o After removing protective gloves

General observations/vital signs

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Measure levels of consciousness, respiratory rate, heart rate, blood pressure, body temperature and oxygen saturations

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Be able to assess a patient using the national early warning score (NEWS)

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NEWS o Respiratory rate o Oxygen saturation o Temperature o Systolic blood pressure o Pulse rate o Level of consciousness

Level of consciousness 

Alert

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Responds to voice

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Responds to pain – pain response tested by nail bed pressure or interdigital pressure (squeezing pen between two fingers)

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Unresponsive

Respiratory and heart rate 

Measure while measuring pulse

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Measure over 15 to 30 seconds

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Normal 60-100 bpm and 12-20 bpm

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Pulse

o Pulse volume o Rhythm o Character o Rate o And peripheral temperature o Radial pulse – rate, rhythm and volume o Carotid pulse – pulse character o Radial/femoral pulse for pulse symmetry Blood pressure 

Intro and consent o Patient should be sitting and relaxed o Ask of they’ve ever had it before o Indicate that there may be some discomfort from inflation of the blood pressure cuff

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Arm at heart level, no tight clothing

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Palpate to find brachial artery, usually quite medial

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Assess estimated systolic blood pressure – palpate radial pulse and inflate until it disappears, this is estimated systolic, pump 20/30 above this for real calculations

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Clean stethoscope

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Place stethoscope over brachial artery, pump up and slowly release

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Reduce at 2-3mmHg/seconds

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When you first hear sound, systolic pressure

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When sound disappears, diastolic pressure

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Remove cuff, and thank patient

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Record findings – date, patient and DOB, right/left arm and seated, pressure in mmHg, sign Med student

Temperature 

Axilla, orally, rectum or ear canal, 36-37.5 normal

Oxygen saturation 

Normally greater than 93%

Examination of pulses 

Radial pulse (thumb side of wrist, can measure both at same time to check symmetry)

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Brachial pulse (medial aspect antecubital fossa)

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Carotid (medial border of sternocleidomastoid muscle – don’t measure both at same time)

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Popliteal pulse (behind the knee, have the patient flex their knees, then place your thumbs on both sides of the patella and fingertips deep into the popliteal fossa)

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Dorsalis pedis (palpated against the tarsal bones on the dorsum of the foot)

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Posterior tibial (usually 1cm behind the medial malleolus, on the inside of ankles)

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Always examine pulses on both sides of the body

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When assessing pulse you should note – rate, rhythm, volume, character, symmetry, presence of bruits, character of vessel wall. Radial pulse used to assess rate, rhythm and volume, carotid pulse for pulse character and radial/femoral pulse for pulse symmetry

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Bradycardia, low pulse, tachycardia, high pulse

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Regular pulse: normal rhythm, sinus arrhythmia is also normal

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Regularly irregular pulse: commonly caused by abnormal rhythms of the heart, e.g. second degree heart block

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Irregularly irregular pulse: atrial fibrillation can cause irregularly irregular pulse

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Pulse character- best assessed at the carotid

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Radial pulse collapsing test – water hammer pulse

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This is demonstrated by feeling the pulse with the palmer aspect of the fingers, while elevating the patient's arm. In a slow rising pulse, the pulse rises slowly to a peak then falls slowly. It is of a small volume and usually indicates aortic stenosis - a condition where there is restricted flow at the aortic valve/outlet.

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Radioradial delay: is the delay of the left radial pulse compared with the right; this may be due to coarctation of the aorta proximal to the left subclavian artery, or usually due to large arterial occlusion e.g. aortic aneurysm.

Examination of Praecordium 

Inspection

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Palpation for the apex beat, thrills and heaves

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Auscultation of heart

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Prior to examination of praecordium – general observation, hands, pulses, blood pressure, JVP, and the face and mouth

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Introduction, patient identification and consent, wash hands and clean stethoscope

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Expose patient at angle of 45 degrees

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General examination o Check for chest wall deformities – pectus excavatum o Check for scars – median sternotomy scar, and thoracotomy scar

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JVP pulse o Place patient 45 degrees, patients head against pillow with neck slightly flexed looking slightly to the left. Inspect the right side of the neck for JVP

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Palpate for apex beat o Fifth intercostal space at midclavicular line o To count intercostal spaces (ICS...