• Introduce yourself : “I am Dr._______, your attending physician and I’ll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.”
• Wash/Sanitize hands
• Explain to the patient what you are about to do and gain informed consent.
• Look for medical equipment/therapies (e.g. drains, colostomy/ileostomy bags).
• Verbalize the steps of the examination and your findings.
• Use proper draping techniques.
2. Inspection
• General inspection of the patient : Is patient comfortable at rest? Do they appear to be tachypnoeic?
• Examine the patient’s hands for presence of koilonhychia (iron deficiency), leukonychia (hypoalbuminemia), clubbing (IBD, coeliac disease, cirrhosis), palmar erythema, tar staining or Dupuytren’s contracture.
• Ask the patient to hold their hands out in front of them looking for a any tremor and then get them to extend their wrists up towards the ceiling keeping the fingers extended and look for flapping (asterixis in hepatic encephalopathy).
• Examine the face, check the conjunctiva for pallor. Also check the sclera for jaundice. Look at the buccal mucosa for any obvious ulcers which could be a sign of Crohn’s disease, B12 or iron deficiency. Also look at the tongue. If it is red and fat it could be another sign of anaemia, as could angular stomatitis. Check state of dentition - pigmentation of oral mucosa (Peutz-Jegher’s syndrome), telangectasia, candidiasis.
• Examine the neck for an enlarged left supraclavicular lymph node. A palpable enlarged supraclavicular (Virchow’s) node is known as Troisier’s Sign, may be a sign of malignancy. Virchow’s node drains the thoracic duct and receives lymphatic drainage from the entire abdomen as well as the left thorax.
Therefore, enlargement of this node may suggest metastatic deposits from a malignancy in any of these areas.
• Examine the chest, in particular look for gynaecomastia in men and the presence of 5 or more spider naevi. These are both stigma of liver pathology.
• Inspect the abdomen and comment on any obvious abnormalities such as scars, masses and pulsations.
Also note if there is any abdominal dis tension/ascites. Look for distended veins, striae, Cullen’s/Grey- Turner’s signs (pancreatitis), Sister Mary Joseph's nodule (widespread abdominal cancer)
64 NAC OSCE | A Comprehensive Review 3. Auscultation
• Listen with the diaphragm next to the umbilicus for up to 30 seconds.
• Listen for bowel sounds - absent (e.g. Ileus, peritonitis), tinkling (bowel obstruction) 4. Palpation
• Palpation of the abdomen should be performed in a systematic way using the 9 named segments of the abdomen: right and left hypochondrium, right and left flank, right and left iliac fossa, the umbilical area, the hypochondrium and the suprapubic region.
• If a patient has pain in one particular area you should start as far from that area as possible. The tender area should be examined last as they may start guarding making the examination very difficult.
• Initial examination should be superficial using one hand.Once you have examined all 9 areas superficially, you should examine deeper. This is performed with two hands, one on top of the other.
• Feel for organomegaly, particularly of the liver, spleen and kidneys. Palpation for the liver and spleen is similar, both starting in the right iliac fossa. For the liver, press upwards towards the right hypochondrium.
You should try to time the palpation with the patient's breathing as this presses down on the liver. If the liver is distended, its distance from the costal margin should be noted.
• Palpating for the spleen is as for the liver but in the direction of the left hypochondrium. The edge of the spleen which may be felt if distended is more nodular than the liver.
• To feel for the kidneys you should place one hand under the patient in the flank region and the other hand on top. You should then try to ballot the kidney between the two hands.
5. Percussion
Percussion over the abdomen is usually resonant, over a distended liver it will be dull. Percussion can also be used to check for 'shifting dullness' - a sign of ascites. With the patient lying flat, start percussing from the midline away from you. If the percussion note changes, hold you finger in that position and ask the patient to roll towards you. Again percuss over this area and if the note has changed then it suggests presence of fluid such as in ascites. It is also appropriate at this time to check for pedal edema.
6. You should mention to the examiner at this point that you would like to finish the examination with an examination of the hernial orifices, the external genitalia and also a rectal examination.
1
/l\
I
HYPO* / : ' HYPO CHONORWl/ ; CHOMORIAL EPKÎWWmW LUMBAf
t ILIAC UMBi(JCAL OASTRJUM
\
Clinical Examination 65 Cardiovascular Examination
1. Steps before beginning examination
• Introduce yourself : “I am Dr.________, your attending physician and I'll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.”
• Wash/Sanitize hands
• Explain to the patient what you are about to do and gain informed consent.
• Look for medical equipment/therapies (e.g. GTN spray, ECG pads, oxygen)
• Verbalize the steps of the examination and your findings.
2. Inspection
• Start by observing the patient from the end of the bed. You should note whether the patient looks comfortable. Are they cyanosed or flushed?
• Respiratory rate, rhythm and effort of breathing.
• Chest shape, chest movements with respration (symmetrical/assymetrical), skin (scars/nevi)
• Inspect the nails for clubbing, splinter hemorrhages (infective endocarditis), koilonychia (iron deficiency anemia).
• Inspect fingers for capillary refill time, peripheral cyanosis, osier's nodes (infective endocarditis) and nicotine staining.
• Inspect palms for palmar erythema,Janeway lesions and xanthomas.
• Take the radial pulse, assess the rate and rhythm.At this point you should also check for a collapsing pulse - a sign of aortic incompetence. Locate the radial pulse and place your palm over it, then raise the arm above the patient’s head. A collapsing pulse will present as a knocking on your palm.
At this point you should say to the examiner that you would like to take the blood pressure. They will usually tell you not to and give you the value.
• Inspect the sclera for any signs of jaundice, anaemia and corneal arcus. You should also look for any evidence of xanthelasma.
• Whilst looking at the face, check for any malar facies, look in the mouth for any signs of anaemia such as glossitis, check the colour of the tongue for any cyanosis, and around the mouth for any angular stomatitis - another sign of anaemia.
• Assess jugular venous pressure ( JVP), ask patient to turn their head to look away from you. Look across the neck between the two heads of sternocleidomastoid for a pulsation then measure the JVP.
• Examine the chest, or praecordium for any obvious pulsations, abnormalities or scars, remembering to check the axillae as well.
66 NAC OSCE | A Comprehensive Review 3. Palpation
• Palpate praecordium trying to locate the apex beat and describe its location anatomically. The normal location is in the 5th intercostals space in the mid-clavicular line.
• Palpate for any heaves or thrills. A thrill is a palpable murmur whereas a heave is a sign of left ventricular hypertrophy. Feel for these all over the praecordium.
4. Auscultation
• Mitral valve - where the apex beat was felt.
• Tricuspid valve - on the left edge of the sternum in the 4th intercostal space.
• Pulmonary valve - on the left edge of the sternum in the 2nd intercostal space.
• Aortic valve - on the right edge of the sternum in the 2nd intercostal space.
How many heart sounds are heard? Are the heart sounds normal in character? Any abnormal heart sounds? If you hear any abnormal sounds you should describe them by when they occur and the type of sound they are producing. Are there any murmurs? Can you hear any rub? Feeling the radial pulse at the same time can give good indication as to when the sound occurs - the pulse occurs at systole.
Furthermore, if you suspect a murmur, check if it radiates. Mitral murmurs typically radiate to the left axilla whereas aortic murmurs are heard over the left carotid artery.
• To further check for mitral stenosis you can lay the patient on their left side, ask them to breathe in, then out and hold it out and listen over the apex and axilla with the bell of the stethoscope.
• Aortic incompetence can be assessed in a similar way but ask the patient to sit forward, repeat the breathe in, out and hold exercise and listen over the aortic area with the diaphragm.
5. With patient sitting up percuss back for pleural effusion (cardiac failure) 6. Finally assess for any pedal & sacral oedema.
7. Finish by thanking the patient and ensuring they are comfortable and well covered.
Clinical Examination 67
Peripheral Vascular Examination 1. Steps before beginning examination
• Introduce yourself : “I am Dr._______, your attending physician and I’ll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.”
• Wash/Sanitize hands
• Explain to the patient what you are about to do and gain informed consent.
• Look for medical equipment/therapies (e.g. GTN spray, ECG pads, oxygen)
• Verbalize the steps of the examination and your findings.
2. Inspection
• General observation of the patient, arms from the finger tips to the shoulder and legs from the groin and buttocks to the toes. Comment on the general appearance of the arms and legs, size, swelling, symmetry, skin color, hair, scars, pigmentation including any obvious muscle wasting. Note colour and texture of nails.
• Any signs of gangrene or pre-gangrene such as missing toes or blackening of the extremities.
• The presence of any ulcers - ensure you check all around the feet including behind the ankle. These may be venous or arterial - one defining factor is that venous ulcers tend to be painless whereas arterial are painful.
• Any skin changes such as pallor, change in colour (eg purple/black from haemostasis or brown from haemosiderin deposition), varicose eczema or sites of previous ulcers, atrophic changes and hair loss.
• Presence of any varicose veins - often seen best with the patient standing.
3. Palpation
• Assess the skin temperature. Starting distally, feel with the back of your hand and compare each limb to the other noting any difference.
• Check capillary return by compressing the nail bed and then releasing it. Normal colour should return within 2 seconds. If this is abnormal, perform Buerger’s Test. This involves raising the patient’s feet to 45°.
In the presence of poor arterial supply, pallor rapidly develops. Following this, place the feet over the side of the bed, cyanosis may then develop.
• Any varicosities which you noted in the observation should now be palpated. If these are hard to the touch, or painful when touched, it may suggest thrombophlebitis.
• Palpate peripheral pulses. These are:
Carotid - only palpate one carotid at a time Radial - use the pad of three fingers Brachial - may use thumb to palpate
Femoral - feel over the medial aspect of the inguinal ligament.
68 NAC OSCE | A Comprehensive Review
Popliteal - ask the patient to flex their knee to roughly 60° keeping their foot on the bed, place both hands on the front of the knee and place your fingers in the popliteal space.
Posterior tibial - felt posterior to the medial malleolus of the tibia.
Dorsalis pedis -feel on the dorsum of the foot, lateral to the extensor tendon of the great toe. You should compare these on both sides and comment on their strength.
• Check for radio-femoral delay. Palpate both the radial and femoral pulses on one side of the body. The pulsation should occur at the same time. Any delay may suggest coarctation of the aorta.
4. Auscultation : listen for femoral and abdominal aortic bruits 5. Special Tests
• Allen Test : Ask the patient to make a tight fist and elevate the hand. Occlude the radial and ulnar
arteries with firm pressure. The hand is then opened. It should appear blanched (pallor can be observed at the finger nails). Release either the Ulnar or radial artery pressure and the color should return in 7 seconds.
If the palm does not redden immediately, this suggests arterial insufficiency.
• Straight Leg Raise and Refill Test (Buerger's Test) : Raise the leg 45° to 60° for 30 seconds until pallor of the feet develops and observe empty veins. Sit the patient upright and observe the feet. In normal
patients, the feet quickly turn pink (within 10-15 seconds). If, pallor persists for more than 10- 15s or there is development of a dusky cyanosis (rubor), this suggests of arterial insufficiency.
• Test for incompetent Saphenous Vein : Ask the patient to stand and note the dilated varicose veins.
Compress the vein proximally with one hand and place the other hand 10-15 cm distally. Briskly compress and decompress the distal site. Normally, the hand at the proximal site should feel no impulse, however with varicose veins a transmitted pulse may be felt.
• Trendelenburg Maneuver (Retrograde filling) : Ask the patient to lie down. Elevate the leg, and empty the veins by massaging distal to proximal. Using a tourniquet, occlude the superficial veins in the upper thigh.
Ask the patient to stand. If the tourniquet prevents the veins from re-filling rapidly, the site of the incompetent valve must be above this level i.e. at the sapheno-femoral junction. If the veins re-fill, the communication must be lower down.
Observing the same protocol, proceed down the leg until the tourniquet controls re-filling. As necessary, test:
• above the knee - to assess the mid-thigh perforator
• below the knee - to assess competence between the short saphenous vein and popliteal vein If re-filling cannot be controlled, the communication is probably by one or more distal perforating veins.
Clinical Examination 69 Respiratory Examination
1. Steps before beginning examination
• Introduce yourself : “I am Dr.________, your attending physician and I'll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.”
• Wash/Sanitize hands
• Explain to the patient what you are about to do and gain informed consent.
• Look for medical equipment/therapies (e.g. inhalers, oxygen).
• Verbalize the steps of the examination and your findings.
2. Inspection
• General look of the patient. Check whether they are comfortable at rest, is patient tachypnoeic? Are they using accessory muscles? Are there any obvious abnormalities of the chest? Check for any clues around the bed such as inhalers, oxygen masks or cigarettes.
• Inspect the hands, hot, pink peripheries may be a sign of carbon dioxide retention. Look for any signs of clubbing, cyanosis, hypertrophic pulmonary osteoarthropathy, dupytren's contacture and nicotine staining.
Assess for carbon dioxide retention flap/salbutamol tremor.
• Take the patient’s pulse. After you have taken the pulse it is advisable to keep your hands in the same position and subtly count the patient’s respiration rate.
• Inspect the face, ask the patient to stick out their tongue and note its colour - checking for cyanosis.
- Horner's sydrome (Pancoast tumour), plethora (polycythemia).
• Look for any use of accessory muscles such as the sternocleidomastoid muscle. Also palpate for the left supraclavicular node (Virchow's Node) as an enlarged node (Troisier's Sign) may suggest metastatic lung cancer.
• Examine the chest and back. Observe the chest for any deformities (barrel chest, kyphoscoliosis, pectus excavatum, pectus carinatum), symmetry of expansion, dilated veins, intercostal recession.
3. Palpation
• Palpate the chest. Feel between the heads of the two clavicles for the trachea, see if it is deviated.
• Feel for chest expansion. Place your hands firmly on the chest wall with your thumbs meeting in the midline. Ask the patient to take a deep breath in and note the distance your thumbs move apart. Normally this should be at least 5 centimetres. Measure this at the top and bottom of the lungs as well as on the back.
70 NAC OSCE | A Comprehensive Review 4. Percussion
• Percussion should be performed on both sides, comparing similar areas on both sides. Start by tapping on the clavicle which gives an indication of the resonance in the apex. Then percuss normally for the entire lung fields. Hyper-resonance may suggest a collapsed lung where as hypo-resonance or dullness suggests consolidation such as in infection or a tumour. Be sure to perform this on the back as well.
5. Vocal Fremitus
Check for tactile vocal fremitus. Place the medial edge of your hand on the chest and ask the patient to say
‘99\ Do this with your hand in the upper, middle and lower areas of both lungs.
6. Auscultation
• Do this in all areas of both lungs and on front and back comparing the sides to each other. Listen for any reduced breath sounds, or added sounds such as crackles, wheezes or rhonchi.
Tracheal Percussion
Tactile Vocal Fremitus Breath Sounds
OtherSounds Effusion Away Dull Decreased Decreased
Bronchial sounds +/- egophony at edge ComoMatton
Central DullIncreased Bronchial
Occasional crackles Pneumothorax Away
Hyper-resonant Decreased Absent NilAtelectasis Towards lesion Dull
Increased Decreased Nil
Fibrosis Central
Resonant (normal) Normal
Decreased if severe Late inspiratory crackles
7. Finish by examining the lymph nodes in the head and neck. Start under the chin with the submental nodes, move along to the submandibular then to the back of the head at the occipital nodes. Next palpate the pre and post auricular nodes. Move down the cervical chain and onto the supraclavicular nodes.
Clinical Examination 71
Central Nervous System Examination 1. Steps before beginning examination
• Introduce yourself : “I am Dr._______, your attending physician and I’ll be examining you today. At any point of the examination you feel uncomfortable, please let me know and I'll stop the examination right there.”
• Wash/Sanitize hands
• Explain to the patient what you are about to do and gain informed consent.
• Look for medical equipment/therapies (e.g. walking aids).
• Verbalize the steps of the examination and your findings.
2. Cranial Nerve Examination
1) The Olfactory nerve (CN I) is simply tested by offering something familiar for the patient to smell and identify - for example coffee or vinegar.
2) The Optic nerve (CN II) is tested in five ways:
• The acuity is easily tested with Snellen charts. This should be assessed both with the patient wearing any glasses or contact lenses they usually wear and without them.
• Colour vision is tested using Ishara plates, these identify patients who are colour blind.
• Visual fields are tested by asking the patient to look direcdy at you and wiggling one of your fingers in each of the four quadrants. Ask the patient to identify which finger is moving. Visual inattention can be tested by moving both fingers at the same time and checking the patient identifies this.
• Visual reflexes comprise direct and concentric reflexes. Place one hand vertically along the nose to block any light from entering the eye not being tested. Shine a pen torch into one eye and check that the pupils on both sides constrict. This should be tested on both sides.
• Finally fundoscopy should be performed on both eyes.
3) Eye movements: Oculomotor nerve (III), Trochlear nerve (IV) and Abducent nerve (VI) are involved in movements of the eye. Asking the patient to keep their head perfecdy still direcdy in front of you, you
3) Eye movements: Oculomotor nerve (III), Trochlear nerve (IV) and Abducent nerve (VI) are involved in movements of the eye. Asking the patient to keep their head perfecdy still direcdy in front of you, you