3rd year osce revision course -...

3rd

Year OSCE Revision Course

Notes and mock mark schemes

April 2013

Peer-Assisted Learning Initiative

Glasgow University Medical School

peerassisted.org

Johnston C, Wallace S, Arthur F, Hurley R, Airlie M, Mathai N, Ross P, Sharkey J, Lange C, Nicoll R, Simonian M, McGonigal E, Beirne E, Catterall F, Waduud A, Taylor A, Maroo R, Lum J

Contents

Completion of Kardex 1

Breast Examination 3

Fundoscopy 5

Neck Examination 7

Suicide Risk Assessment 9

Jaundice History 11

Cranial Nerves II-VII 13

Cerebellar Examination 16

Peripheral Arterial Examination 18

Otoscopy and Free Field Speech Test 20

REMS: Knee 22

A note on the contents This work was produced entirely by doctors working in the West of Scotland and final year medical

students at the University of Glasgow. The contents are in no way official documents used by the

medical school for assessment purposes.

P1

3rd

Year Mock OSCE Mark Scheme

Completion of Kardex Instructions: Write the prescriptions listed inside the room onto the patient’s Kardex (see overleaf). Time: 5 minutes

Circle: Pass / Borderline Pass / Fail Total marks: ______ / 20

TASK Marks

INTRODUCTION and CHECKS

1. Correct hospital name, date, time, sheet no, tick “no” 2

nd prescription in use, hospital

number, DOB, date of admission, consultant, ward, patient name, CHI no. 0 1

2.

Identifies allergy and writes “PENICILLIN RASH” (1 mark for ticking “Yes” and writing “PENICILLIN”, 1 mark for “→ RASH”)

0 2

DRUGS

3.

FUROSEMIDE: Once only (1/2 mark for every 3 correct items.)

Spelling / dose: 40 / units: mg / route: O / current time in HH:MM / print & sign.

0 1

4.

NOVOMIX 30: Parenteral regular (1 mark for every 3 correct items.)

Tick “before admission” / spelling / dose: “AS CHARTED” / route: SC / current date / print & sign / additional: NORMALLY 10 UNITS BEFORE BREAKFAST AND 10 UNITS BEFORE TEA / time: 0700-0900, 1600-1800 / written in correct page.

0 3

5.

SIMVASTATIN: Oral & other regular (1 mark for every 3 correct items.)

Tick “before admission” / spelling / dose: 40 / units: mg / route: O / current date / print & sign / Withhold for 7 days, i.e. (9) in boxes + state reason in comments / time: 2200-2400 / written in correct page.

0 3

6.

CLARITHROMYCIN: Oral & other regular (1 mark for every 3 correct items.)

Tick “new medication” / spelling / dose: 500 / units: mg / route: O / current date / print & sign / additional: 7 DAYS COURSE + start date / times: 0700-0900, 2200-2400 / written in correct page.

0 3

7.

CO-CODAMOL 30/500: As required (1 mark for every 3 correct items.)

Tick “new medication” / spelling / dose: 2 TABLETS / route: O / indication: PAIN / print & sign / max freq: QDS / current date / written in correct page.

0 3

8.

PROPHYLACTIC LMWH: Clexane + TEDS (1/2 mark for every 3 correct items)

Tick “new medication” / spelling / dose: 40mg + 1 PAIR / route: SC + TOP / print & sign/ times: 1200-1600 + throughout

0 1

CONCLUSION

9. Writes in BLOCK CAPITALS. 0 1

10. Legible. 0 1

11. Mark of Excellence. 0 1

P2

3rd

Year OSCE Revision Course Notes

Completion of Kardex Written in January 2013 by Philip Chan. Edited April 2013 by Calum Johnston. Scenario:

Tim Riggins is a 65-year-old gentleman who has been admitted today into Glasgow Royal Infirmary Ward 66 with a presumed chest infection. Your consultant, Dr. Taylor, has instructed you to write up his Kardex and to prescribe thromboprophylaxis, a week’s course of 500mg oral clarithromycin BD and a once off 40mg dose of oral furosemide, as he thinks he may have been overloaded with overly enthusiastic fluid therapy in A&E. His details are below:

Name: Tim Riggins

Hospital Number: 33123433L

CHI: 1603473333

DOB: 16/03/47

Drug history: NovoMix 30 10 units SC before breakfast, 10 units SC before tea

Simvastatin 40mg PO nocte

Co-codamol 30/500 2 tabs PO as required for pain, max four times daily

Allergy: Penicillin Rash

Notes: a. Break down of each element

1. TICK: “Before admission” for drugs in the patient’s drug history and “new medication” for newly

prescribed drugs during admission. 2. DRUG: Correct spelling and in BLOCK CAPITALS. No abbreviations, e.g. ISOSORBIDE

MONONITRATE cannot be written as ISMN. 3. DOSE: Correct dose/units. See Kardex back page for accepted unit abbreviations. There are special

cases. a. Some drugs, e.g. insulin or warfarin, are prescribed on a second chart as well as the Kardex.

For these you should write “AS CHARTED”. b. Some drugs, e.g. compound preparations or inhalers, are more elegantly prescribed by stating

the number of tablets or puffs to take, i.e. “2 TABLETS” or “2 PUFFS”. For these drugs, ensure the strength of tablet or puff is indicated in the DRUG section. Never use the old fashioned T, TT, TTT notation.

4. ROUTE: See back of Kardex for accepted route abbreviations. 5. DATE: Today’s date in dd/mm/yy. 6. PRESCRIBER (PRINT & SIGN): Sign your name then print it legibly as well. 7. ADDITIONAL INSTRUCTIONS / COMMENTS / PHARMACY: Some drugs need additional information.

a. Antibiotics: state course length and start date. b. Insulin or warfarin: state regular doses. c. If a drug is being withheld or discontinued then state the reason.

8. TIMES: Tick or circle the correct boxes.

b. General points

1. Do not over think this station. The above example would be considered tricky. 2. Write in BLOCK CAPITALS except for units. 3. If you are not given a piece of information, e.g. height or weight, then just omit it. 4. Write down the details of drug allergies if you have the information available. 5. Accepted units, drug route abbreviations and non-administration codes are at the back of the Kardex. 6. Mark for excellence: Carry the task out confidently. If you make a mistake then cross out the entire

prescription with diagonal lines, initial, date and record the reason. Do not scribble anything out. 7. Watch out for drug interactions and withhold appropriately. Don’t forget to withhold simvastatin if giving

clarithromycin! You should (9) simvastatin for the entire course of clarithromycin and write a note in the comments.

P3

3rd


Breast Examination Instructions: Perform a full breast examination on this breast model/patient Time: 5 minutes


TASK Marks

INTRODUCTION

1. Introduce self, check patient identity (name and D.O.B) 0 1

2. Explanation of procedure, gain consent and wash hands before and after the examination 0 1

3. Offers Chaperone 0 1

INSPECTION

4. Performs general inspection (e.g. cachexia, distress) 0 1

5 Inspects breasts with patient’s arms by their sides 0 1

6. Inspects breasts and axillae with hands on hips 0 1

7. Inspects breasts with patient’s hands behind head and comments on any dimpling 0 1

8. Inspects breasts with patient pushing down on bed or hips and comments on any dimpling 0 1

9.

Comments on:

Symmetry

Skin Changes (e.g. Peau d’Orange)

Lumps

Scars

Nipple Changes (e.g. Inversion, Paget’s Disease)

Nipple Discharge ½ mark for each

0 3

PALPATION

10. Positions patient lying flat with hands behind head and asks about any tenderness 0 1

11. Palpates four quadrants of both breasts (if tender: leaves tender area to last) 0 1

12. Palpates axillary tail 0 1

13. Palpates lymph nodes (axillary, supraclavicular +/- head and neck) 0 1

14.

Describes any lumps found by:

Site

Size

Shape

Edge

Consistency

Temperature

Mobility

Attachments

Tenderness Up to 3 Marks Available

0 3

SUMMARY

15. Accurately summarises clinical findings 0 1

16. Mark for Excellence 0 1

P4

3rd

Year Revision Course Notes

Breast Examination

Written August 2012 by Kate Chapman. Adapted from 2011 version by Andrew Boyle and Alistair Tindell. Anatomy:

Breast extends from clavicle to 6th rib, from midline to posterior axillary fold (anterior border of latissimus dorsi)

Breasts overlie pectoralis major

4 Quadrants: Lower Outer, Lower Inner, Upper Inner and Upper Outer

Upper outer quadrant extends into axillary tail Describing a Lump:

Site (by quadrant or ‘O’ Clock position’, distance from nipple)

Overlying Skin

Size

Shape

Consistency

Edges (craggy/smooth)

Temperature

Tenderness

Mobility

Tethering to skin

Transillumination Malignant Lump:

Overlying skin changes – tethering, Peau d’Orange

Nipple inversion/discharge

Non-tender, firm

Non-fluctuant, no transillumination

Irregular, craggy

Attached to deep tissues ± skin Triple Assessment:

This is frequently asked about for the mark of excellence in OSCEs situations and consists of: 1. History and examination. 2. Imaging - Ultrasound (+ mammography if >35yrs). 3. Fine needle aspiration (faster, only shows cells) or core biopsy (shows structure). For distant disease, further investigations are needed to detect metastases (e.g. LFTs, CT, skeletal survey). Positioning for Examination:

P5

3rd


Fundoscopy Instructions: Examine this patientʼs fundus. Time: 5 minutes


TASK Marks

INTRODUCTION

1. Introduction, checks identity. 0 1

2. Washes hands before examination 0 1

3. Explains procedure and gains consent. Warns about bright light, that it might be uncomfortable and that you will turn off the lights.

0 1

4. Explains that ideally, would have instilled dilating drops 10-15 minutes beforehand. 0 1

INSPECTION

5. Turns off room light and sets ophthalmoscope to 0. 0 1

6. Correctly holds ophthalmoscope (same eye as patient, and same hand). 0 1

7. Checks for red reflex in correct position (30cm away). 0 1

8. Comments on external appearance of eye: scars, discharge, swelling, redness. 0 1

EXAMINATION

9. Explains to patient to focus on a spot in the distance and warns about coming in close to them.

0 1

10. Alters power until the fundus is in focus. 0 1

11. Comments on optic disc: cup-disc ratio, colour of disc, margins, neovascularisation. 0 1

12. Follows the four blood vessel arcades, and comments on appearance: tortuosity, microaneurysms, A-V nipping.

0 1

13. Comments on appearance of periphery of fundus (nasal + temporal to disc): haemorrhages, exudates, new vessels, photocoagulation scars, cotton wool spots.

0 1

14. Asks patient to look directly at light to examine macula. 0 1

15. Comments on appearance of macula: exudates, abnormal pigmentation 0 1

16. Expresses wish to examine other eye. 0 1

CONCLUSION

17. Summarises findings. 0 1

18. Offers correct diagnosis. 0 1

19. Washes hands after examination. 0 1

20. Mark of Excellence 0 1

P6

3rd


Fundoscopy Written in April 2013 by Namratha Mathai and Paddy Ross

Using the direct ophthalmoscope:

1. Look at the external appearance of the patient’s eyes and ask for/check if the pupils have been dilated with drops. Once happy that they are, dim the lights (warn the patient!).

2. Use the same eye and hand as the patient’s eye you’re examining, i.e. to examine the patient’s right eye, hold the ophthalmoscope in your right hand and look through it using your right eye. Use the other hand to stabilise your head and lift the patient’s lid if needed.

3. Look through the ophthalmoscope at the patient’s eye from a distance of approx. 30cm (arm’s length) to identify the red reflex.

4. Move in closer (again warn the patient!) while still looking at the red reflex. 5. Adjust the power of the lens to minus (myopic) direction until you can see the blood vessels clearly

– follow these back towards the optic disc. Reporting your findings: Comment on:

External appearance: discharge, swelling, redness, scars, ptosis

Red reflex: if there are any shadows/opacities consider e.g. cataracts, retinoblastoma (children)

Optic disc: o Margin: if indistinct, consider papilloedema o Colour: if pale/white, consider optic atrophy o Cup to disc ratio: if >0.5, consider glaucoma [0.3-0.5 = normal]

Vessel arcades: abnormalities include tortuosity, microaneurysms, AV nipping (kinking of the vessels where an atherosclerotic and hard artery crosses a compressible vein)

Fundus: abnormalities include haemorrhage, exudate, photocoagulation scars

Macula: abnormalities include drusen, exudates, neovascularisation Interpreting your findings: Common pathology you are likely to encounter include:

Optic disc Blood vessels Fundus Macula

Hypertensive retinopathy

Swelling/ Blurred margins

A-V nipping Copper wiring Microaneurysms

Blot and flame haemorrhages Hard exudates Cotton wool spots

Diabetic retinopathy

Non-proliferative

Microaneurysms Dot/blot haemorrhages Hard exudates Cotton wool spots (soft exudates)

Proliferative

Neovascularization – may be present at optic disc

All of the above + Flame haemorrhages Photocoagulation scars (if treated)

Macular degeneration

Dry

Drusen Areas of hypo/hyper-pigmentation Loss of foveal reflex

Wet/Proliferative Neovascularization- near macula

Haemorrhages All of the above + haemorrhages

Thrombotic disease

Central retinal artery occlusion

Pale (late) Visible emboli - seen acutely Thin arterioles

Pale Cherry red spot

Central retinal vein occlusion

Blurred margins Haemorrhages Loss of foveal reflex (oedema)

Disc disease

Optic atrophy Pale

Papilloedema Blurred margins

Glaucoma Increased cup:disc ratio

P7

3rd

Year OSCE Mock Mark Scheme

Neck Examination Instructions: Examine this patientʼs neck. Time: 5 minutes


TASK Marks

INTRODUCTION

1. Introduces self and checks identity. 0 1

2. Explains procedure and gains consent. 0 1

INSPECTION

3. Inspects for scars, JVP, distended neck veins, skin lesions. 0 1

4. Inspects for lymph nodes, swelling, goitre. 0 1

5. Asks patient to protrude tongue and comments on movement. 0 1

6. Inspects and palpates the mass when patient is sipping water. 0 1

7. Examine ears, mouth, scalp for source of primary infection. 0 1

PALPATION

8. Palpates trachea. (Ask about pain before palpation.) 0 1

9.

Palpates lymph nodes: cervical, submental, submandibular, parotid, preauricular, anterior chain, supralavicular, posterior chain, postauricular, occipital.

(Up to 3 marks available.)

0 3

10. Identifies thyroid on palpation. 0 1

PERCUSSION

11. Percusses sternum to locate lower limit of thyroid. 0 1

AUSCULTATION

12. Auscultates thyroid for bruits, after asking patient to hold their breath. 0 1

CONCLUSION

13. Describes lump (site, size, shape, colour, skin changes) (Up to 2 marks available.)

0 2

14. Transilluminates lump (or offers to do it). 0 1

15. Reports findings, suggests differential diagnosis and most likely diagnosis. 0 1

16. Washes hands at start and end. 0 1


P8

3rd


Neck Examination Written in April 2011 by Caroline Little and Rebecca Sadler. Edited April 2013 By Susan Wallace and Michael Airlie

Lymph Node Levels

(1) Neck Lumps (2)

Midline:

1. Thyroglossal cyst – painless cystic lump, transilluminates, moves on tongue protrusion. 2. Midline Dermoid cyst – mobile, cutaneous.

Anterior Triangle:

1. Thyroid Swellings – Hyperthyroidism (Graves, toxic nodular goitre).

Hypothyroidism (Hashimotos, Iodine deficiency, drugs).

Euthyroid (physiological goitre, multi-nodular goitre, thyroid adenoma). 2. Branchial Cyst – smooth rubbery swelling. 3. Pharyngeal Pouch – can compress. 4. Salivary Glands – stones, tumour, inflammation. 5. Cervical Lymph Nodes. 6. Carotid body tumour – high up in anterior triangle, painless. 7. Cervical Rib – supraclavicular fossa.

Posterior Triangle:

1. Lymphadenopathy. 2. Cystic Hygroma – collection of dilated lymphatics.

Posterior Triangle:

1. Ultrasound ± Fine Needle Aspiration. 2. CT/MRI.

BIBLIOGRAPHY AND FURTHER READING:

1. http://www.droid.cuhk.edu.hk/web/specials/lymph_nodes/lymph_nodes.htm 2. http://www.firstinmedicine.com/summarysheets_files/ent.html

1. Submental.

2. Submandibular.

3. Parotid.

4. Upper cervical, above the level of hyoid bone, and along the internal jugular chain.

5.

Middle cervical, between the level of hyoid bone and cricoid cartilage, and along the internal jugular chain.

6. Lower cervical, below the level of cricoid cartilage, and along the internal jugular chain.

7. Supraclavicular fossa.

8. Posterior triangle (also known as accessory chain).

P9

3rd


Suicide Risk Assessment

Instructions: You are an FY2 working in a busy A&E department. Your next patient has arrived after a failed suicide attempt. Take a history and assess this patient’s current suicide risk. Time: 5 minutes.

TASK Marks

INTRODUCTION

1. Introduces self and identifies patient. 0 1

MEANS

2. What method was used? (how violent, when, where?) 0 1

3. Were they intoxicated? (alcohol) 0 1

4. What precipitated this event? 0 1

INTENT

5. Was it planned? 0 1

6. Any final acts? (leaving a note, changing a will) 0 1

7. What did they think would happen? (i.e. did they believe the attempt would be fatal?) 0 1

8. Did they take precautions to being found? 0 1

9. Did they seek help after event? 0 1

10. Do they regret that the attempt wasn’t successful? 0 1

11. Do they still have ongoing ideation to suicide? 0 1

12. What would stop them from attempting this again? (protective factors) 0 1

PAST PSYCHIATRIC HISTORY

13. Any previous history of attempted suicide/self-harm? 0 1

14. Any known psychiatric history? (depression, schizophrenia, substance misuse) 0 1

15. Any past medical history? 0 1

16. Drug history? 0 1

17. Family history? (including psychiatric) 0 1

18. Social history? 0 1

QUESTIONS FROM EXAMINER

19. How would you manage this patient? 0 1

20. Marks for excellence 0 1


P10

3rd


Suicide Risk Assessment Written by Joe Sharkey and Colette Lange (April 2013) Self-harm, suicidal thoughts and attempted suicide are common presentations to both A&E and psychiatric units, and as such it is important to be able to accurately assess a patient’s suicide risk. Risk Factors

There are several key characteristics that make an individual more likely to attempt suicide. The SADPERSONS scale

1 is a quick screening tool that can be used to stratify the risk of suicide:

Feature Score Results

Sex (male) Age (<45 or >65) Depression Previous attempt Ethanol abuse Rational thinking loss Social support lacking Organized plan No spouse Sickness

1 1 1 1 1 1 1 1 1 1

Score <4 = low risk Score 5-8 = moderate risk Score >9 = high risk *other factors to consider include employment status (unemployed, medical profession), housing (homeless), urban living, recent life events (bereavement), prisoners, recently discharged psychiatric patients and mothers with post-partum psychosis

Assessing Suicide Risk There are two key things that need to be established in any suicide risk assessment:

Means – how did the patient attempt to harm themselves?

o What did they do? Where/when did they do it? o Violence of act – attempted hanging, drowning, electrocution etc. are immediate red flags o Were any other substances taken? (alcohol, illicit drugs) o Were there any triggers for this event? (bereavement, relationship troubles etc.)

Intent – how serious was this attempt? If the patient were to be discharged, how likely would they be to try and attempt suicide again? Red flags include:

o Planning – non-impulsive, calculated action (such as hoarding medications) o Final acts – a goodbye note was left, or a will was recently updated o Perceived lethality – patient genuinely thought their attempt would kill them o Precautions to being found – timing the act when alone, locking doors etc. o Not seeking help – being found unexpectedly by someone else o Regret – that the attempt wasn’t successful o Ongoing ideation to suicide – probably the most important thing to ask! o Lack of protective factors – support network, children, pets, religious beliefs, hope

Management

Low risk: discharge with advice, links to other services (Lifelink, Samaritans), refer to crisis team

management in the community and bring back for later psychiatric outpatient review

Moderate risk: admit informally for psych assessment

High risk: detain under the Mental Health Act (1983, 2007) o Section 2: Assessment order (detain for 28 days to Ix and Tx) o Section 3: Treatment order (detain for 6 months for Tx) o Section 4: Emergency order (detain for 72 hours, Ix only)

BIBILIOGRAPHY AND FURTHER READING P338 Oxford Handbook of Clinical Specialties / P319 Core Psychiatry (2

nd Edition, 2005) ,P. Wright, Elsevier Saunders

1 Predicting suicide attempts with the SADPERSON scale, JM Bolton, J Clin Psychiatry, 2012 Jun; 73 (6):e735-41

P11

3rd


Jaundice History

Instructions: Take a history from this 50-year old patient who presents with jaundice. Time: 5 minutes.

TASK Marks

INTRODUCTION

1. Introduces self and identifies patient. 0 1

HISTORY OF PRESENTING COMPLAINT

2. Onset – acute or chronic? Who noticed? 0 1

3. Pruritus? 0 1

4. Pain? (SOCRATES) 0 1

5. Obstructive symptoms: pale stools, dark urine? 0 1

6. GI workup: nausea, vomiting? 0 1

7. Systemic: fever, anorexia, weight loss? 0 1

PAST MEDICAL HISTORY

8. Gallstones, liver disease, ulcerative colitis? 0 1

9. Recent blood transfusion? 0 1

DRUG HISTORY

10. Recent antibiotics? Allergies? 0 1

FAMILY HISTORY

11. Family history? 0 1

SOCIAL HISTORY

12. Alcohol intake? 0 1

13. IVDU – needle sharing? 0 1

14. Tattoos/piercings? 0 1

15. Recent travel history? 0 1

16. Occupation – sewage, farmers, windsurfer? 0 1

17. Sexual history – jaundiced contacts, multiple partners, UPSI, previous STIs? 0 1

SUMMARY

18. Summarise 0 1

19. Examiner: give a differential for this patient’s jaundice 0 1

20. Mark for excellence 0 1


P12

3rd


Jaundice History Written by Joe Sharkey and Colette Lange (April 2013) Jaundice is due to an excess production of bilirubin, and becomes clinically detectible at bilirubin levels >40mmol/L (normal range 3-17mmol/L) Bilirubin Metabolism

RBC breakdown produces unconjungated bilirubin (water insoluble)

Unconjugated bilirubin binds to albumin and is transported to the liver

Hepatocytes conjugate bilirubin via glucouronyl transferase -> bilirubin diglucuronate (water soluble)

Conjugated bilirubin secreted into biliary tree and ultimately duodenum

Metabolised via GI bacteria to stercobilinogen (stercobilin, stool) and urobilinogen (urobilin, urine) Jaundice Differential Type Cause Examples

Pre-hepatic ↑ bilirubin, ↓ glucuronyl transferase ↑ unconjugated bilirubin + splenomegaly

Haemolytic anaemias Congenital hyperbilirubinaemias (Gilbert’s) Drugs: rifampicin, anti-malarials

Hepatic ↓ bilirubin metabolism by hepatocytes ↑ unconjugated bilirubin ↑ conjugated bilirubin Hepatic LFT picture: ↑ AST, ↑ ALT

Congenital (haemochromatosis, wilson’s, α1AT deficiency) Hepatitis (autoimmune, alcoholic, infectious) Hepatocellular carcinoma Non-alcoholic fatty liver disease (pregnancy) Drugs: paracetamol, tetracycline, rifampicin, isoniazid, steroids, methotrexate, amiodarone, azathioprine, halothane

Post-hepatic Obstruction of biliary tree ↑ conjugated bilirubin Obstructive LFT picture: ↑ γGT, ↑ ALP Dark urine, pale stools

Intra-hepatic Primary biliary cirrhosis (PBC) Primary sclerosing cholangitis (PSC) Cholangiocarcinoma Drugs: co-amoxiclav, erythromycin, COCP Extra-hepatic Gallstones Pancreatic carcinoma

Investigations Type Test

Bloods FBC – ↓ RBCs, ↑ reticulocyte indicates high RBC turnover LFTs – bilirubin confirms jaundice, ↑AST/ALT gives hepatic picture, ↑ γGT/ALP gives obstructive picture Liver screen – viral markers, autoantibodies, α1-antitrypsin, iron/copper studies Serum amylase – pancreatic pathology

Urine Urine bilirubin – obstructive picture

Imaging USS pancreas, biliary tree – gallstones USS liver – hepatitis, hepatocellular ca CT abdomen MRCP/ERCP – gallstones

Biopsy Liver biopsy – intra-hepatic diagnosis

BIBILIOGRAPHY AND FURTHER READING P250 Oxford Handbook of Clinical Medicine

P13

3th Year Mock OSCE Mark Scheme

Cranial Nerves II-VII Examination Instructions: Examine the III-VII cranial nerves in this patient Time: 5 minutes.


TASK Marks

INTRODUCTION

1. Introduce self, check patient identity (name and D.O.B) 0 1

2. Explanation of procedure, gain consent and wash hands before and after the examination 0 1

CN III, IV, VI

3. Inspects for ptosis, squint and pupillary size, shape & regularity 0 1

4.

Tests light reflex

Direct and consensual

Swinging flashlight test

0 1

5 Tests pupillary response to accommodation (convergence and pupillary constriction) 0 1

6. Asks patient to say if they experience diplopia with eye movement

0 1

7. Tests eye movements (H pattern of movement)

0 1

8. Looks at extreme of eye movement for nystagmus

0 1

CN V - SENSORY

9.

Tests light touch sensation in 3 areas, comparing left and right

Ophthalmic branch.

Maxillary branch.

Mandibular branch.

0 1

CN V - MOTOR

10. Palpates masseter and temporalis bulk with teeth clenched 0 1

11. Asks patient to open mouth and move jaw side to side

0 1

12. Offers to perform jaw jerk 0 1

13. Offers to perform corneal reflex 0 1

CN VII – MOTOR

14. Inspects for facial asymmetry 0 1

15. Asks patient to wrinkle up forehead 0 1

16. Asks patient to shut eyes tightly against resistance 0 1

17. Asks patient to puff out cheeks 0 1

18. Asks patient to show their teeth 0 1

SUMMARY

16. Student accurately summarises their findings and gives differential diagnosis 0 1

18. Mark of Excellence 0 1

P14

3rd


Cranial Nerves II-VII Examination Written April 2013 by Ruairidh Nicoll and Lisa Pascoe

III, IV & VI: Oculomotor, Trochlear & Abducens Inspection:

Look for abnormal eye position, ptosis, abnormal pupils, nystagmus and involuntary movements Pupillary Responses: The optic nerve (II) provides the afferent component of the pupillary reflex whilst the oculomotor (III) nerve provides the efferent limb.

Test for a direct and consensual response to light in each eye

Perform the swinging torch test to look for a Relative Afferent Pupillary Defect (RAPD)

Test accommodation by asking the patient to focus in the distance and then on your finger whilst held in

front of their face. When focusing on a nearby object the eyes should converge the pupils should

constrict.

PEARL (“Pupils are Equal, And Reactive to Light”)

Eye Movements: Ensure that your face is at the same level as the patient’s face and clearly explain that they should keep their head still and follow your finger with their eyes only.

With the patient’s eyes in the primary position ask the patient if they have double vision (diplopia) and to

let you know if they experience any during the examination.

With your finger 50cm from the patient’s face move slowly in an H shape (this tests all of the extraocular

eye muscles adequately in one smooth movement)

Look for ophthalmoplegia and nystagmus at the extremes of eye movement.

If diplopia is identified at any time establish whether it is vertical or horizontal, and whether it is unilateral

by asking the patient to close one of their eyes.

V: Trigeminal Facial Sensation:

Use a cotton wool ball to test light touch

Ask the patient to close their eyes and say when they can feel their face being touched. Remember to

compare facial sensation with a reference point such as over the sternum.

Test sensation on their forehead, cheek and chin on each side so all 3 branches are tested.

Ask if it feels the same on both side

Muscles of Mastication:

Ask the patient to clench their teeth and then relax

Palpate the masseter and temporalis

Ask the patient to open their mouth and move their jaw from side to side

N.B. Offer to perform jaw jerk and corneal reflex though be aware that these are not routinely tested.

VII: Facial Inspection: Look for facial asymmetry Ask the patient to do the following movements (demonstrating the movements then asking them to copy you is often helpful)

Raise eyebrows/ Wrinkle their forehead

Close eyes tightly and resist you opening them

Puff out cheeks and resist you pushing them in

Show you their teeth

P15

Additional Notes: CN III, IV and VI 3rd


Nerve Innervation Features of Lesion Cause of Lesion

III (Occulomotor)

Superior, Inferior and Medial Rectus

Inferior Oblique

Sphincter Pupillae

Levator Palpebrae Superioris

Eye sits facing down and out (unopposed IV and VI)

Diplopia

Dilated pupil unreactive to light

Ptosis

Diabetes

PCA Aneurysm

Raised ICP + Tentorial Herniation

IV (Trochlear)

Superior Oblique (‘SO4’ – Superior Oblique, 4

th nerve)

Diplopia on looking down + in

Compensatory head tilt towards opposite side

Rare

Orbit trauma

VI (Abducens)

Lateral Rectus (LR6 – Lateral rectus, 6

th nerve)

Horizontal diplopia

Loss of abduction

MS

Wernicke’s Encephalopathy

Raised ICP

Cranial Nerve Function Pathology

V: Trigeminal Nerve

a. Sensory:

Sensation to face

Afferent pathway of corneal reflex b. Motor:

Muscles of mastication

Jaw jerk

a. Unilateral Loss of Sensation:

Direct injury

Malignant invasion

Herpes Zoster b. Brisk jaw jerk:

UMN lesion above level of pons

VII: Facial Nerve

a. Sensory:

Taste to anterior 2/3 of tongue

b. Motor:

Muscles of facial expression

Stapedius muscle (middle ear)

a. Facial Asymmetry:

Bell’s Palsy (idiopathic facial palsy)

Ramsay-Hunt Syndrome (herpes zoster reactivation in geniculate ganglion)

b. Hyperacusis:

Damage to the nerve impairs Stapedius muscle function

c. UMN Lesion Note:

UMN facial weakness typically spares the forehead due to dual innervation from both sides of brain

Nose

P16

3rd

Year OSCE Mock Mark Sheet

Cerebellar Examination Instructions: Please assess this patient for signs of cerebellar dysfunction. Time: 5 minutes


TASK Marks

INTRODUCTION

1. Introduces self, identifies patient (name & date of birth), explains procedure and gains consent.

0 1

2. Washes hands before and after examination. 0 1

GENERAL

3. General inspection, commenting on abnormal posturing or movements if present, signs of alcoholism, e.g. unkempt appearance, spider naevi.

0 1

EYES

4. Test for nystagmus. 0 1

SPEECH

5. Asks patient to say, “baby hippopotamus”/”British constitution”/”West Registry Street, Edinburgh” – testing for dysarthria.

0 1

UPPER LIMBS

6. Tests tone of upper limbs. 0 1

7. Tests reflexes of upper limbs 0 1

8. Tests for dysdiadochokinesis of hands 0 1

9. Tests for intention tremor/past pointing/dysmetria with finger-to-nose test. 0 1

10. Asks patient to stretch out arms then observes for postural tremor. (Pronator drift in Stroke.)

0 1

11. Tests for rebound phenomenon on outstretched arms. 0 1

LOWER LIMBS

12. Tests tone of lower limbs. 0 1

13. Tests reflexes of lower limbs. 0 1

14. Tests for dysdiadochokinesis of feet by asking patient to tap on the floor quickly. 0 1

15. Tests for dysmetria with heel-to-shin test. 0 1

TRUNK

16. Asks patient to sit on edge of the bed with their arms crossed to their shoulders then observes for unsteadiness of truncal ataxia.

0 1

GAIT

17. Observes patientʼ s gait (including transfer from sitting to standing and vice-versa). 0 1

18. Asks patient to perform tandem walking.

CONCLUSION

19. Summarises key findings and offers differential diagnosis. 0 1


P17

3rd


Cerebellar Examination Written in April 2011 by Kristyn Dyer and Lauren Connelly. Edited April 2013 by Calum Johnston

Introduction

The cerebellum is the largest part of the hindbrain and is mainly responsible for functional movement. This means co-ordination of motor to effect precise and accurately timed movement. The cerebellum does this by integrating sensory information from the cerebral cortex, basal ganglia, vestibular apparatus and spinal cord, to fine tune motor output.

Lesions can affect the cerebellum itself, input pathways from other parts of the brain and inner ear, or output pathways from the cerebellum.

A patient with cerebellar dysfunction will typically present with difficulties with motor function, including weakness, loss of power, and a new or worsening tremor. Other symptoms may include dizziness (exclude inner ear pathology), and changes in speech.

Common Pathologies causing Cerebellar Dysfunction:

Stroke (Ischaemic and Haemorrhagic).

Tumours.

Alcohol.

Trauma.

Migraine.

Cerebellar signs

Gait Broad-based, unsteady gait.

Eyes Nystagmus.

Speech Slow, slurring staccato speech.

Upper limbs Hypotonia, hyporeflexia, dysmetria (pass pointing), dysdiadochokinesis,

rebound on pushing down outstretched arms.

Lower limbs Hypotonia, hyporeflexia, dysmetria (heel to shin difficulty), dysdiadochokinesis (difficulty with tapping foot on floor).

Body Truncal ataxia (difficulty sitting or standing unsupported).

Romberg’s test

Romberg’s test is positive in sensory ataxia and negative in cerebellar ataxia. It is not a test of cerebellar function, as patients with cerebellar ataxia tend to have difficulty standing steady even with their eyes open. It can be used to exclude sensory ataxia in a cerebellar examination.

To perform Romberg’s test, ask the patient to stand with feet together and eyes closed, then observe for 1 minute. Be prepared to catch them. The test is positive if the patient starts swaying.

Before you panic… Remember:

D Dysdiadochokinesis: unable to perform rapid, alternating movements.

A Ataxia: usually truncal, patient may fall on the same side.

S Scanning/Staccato speech.

H Hypotonia.

I Intention tremor.

N Nystagmus.

G Gait Abnormalities.

BIBLIOGRAPHY AND FURTHER READING:

1. Essential Neurology, Wilkinson IMS, 1993, 2nd

edition, Blackwell Scientific Publications, p. 114. 2. Macleod’s Clinical Examination. 3. Oxford Handbook of Clinical Examination and Practical Skills.

P18

3rd


Peripheral Arterial Examination Instructions: Please examine this patients peripheral arterial system Time: 5 minutes


TASK Marks

INTRODUCTION

1. Introduces self 0 1

2. Checks patient details 0 1

3. Explains examination 0 1

4. Gains consent 0 1

5. Washes hands before and after examination. 0 1

INSPECTION

6. Inspects legs commenting on colour, scars, trophic skin changes and tissue loss (ulceration/gangrene)

0 1

7. Inspects between toes and under heels 0 1

PALPATION

8. Feels temperature of both feet and legs using back of hand 0 1

9. Measures capillary refill time on both feet 0 1

10. Palpates Dorsalis Pedis pulses 0 1

11. Palpates Posterior Tibial pulses 0 1

12. Palpates Popliteal pulses 0 1

13. Palpates Femoral pulses 0 1

14. Feels for abdominal aortic aneurysm 0 1

ADDITIONAL TEST

15. Performs/expresses need to perform Buerger’s test 0 1

16. Auscultates for femoral bruit 0 1

CONCLUSION

17. Compares both sides 0 1

18. Presents findings accurately 0 1

19. Suggests appropriate investigations e.g. Duplex Doppler USS, MR Angiogram, ABPI 0 1


P19

3rd


Peripheral Arterial Examination Written April 2011 by Claire Adams and Kerri Devine. Edited April 2013 by Calum Johnston. Abdominal Aortic Aneurysm: This is detected as a pulsatile and expansile mass found above the level of the umbilicus (the aorta bifurcates here). To identify an AA, place one hand on either side of the pulsation – if it is expansile, your hands will be seen to move apart in time with the patient’s pulse. A mass that is pulsatile but not expansile (i.e. your hands only move up and down slightly rather than up and apart) may simply be due to the normal abdominal aortic pulse beneath your hands. Typically, it is only normal to feel this pulse in thin patients. Anatomical Landmarks for Lower Limb Pulses: 1. Dorsalis Pedis:

- Lateral to extensor hallucis longus tendon on the dorsum of foot - A common mistake is to aim too low on the foot - Be sure to palpate gently as you may occlude a weak pulse by pressing too firmly

2. Posterior Tibialis: - In the groove between the Achilles’ Tendon and Medial Malleolus 3. Popliteal:

- Located in the popliteal fossa between the heads of the gastrocnemius - Palpate bimanually with patientʼs leg relaxed and slightly flexed at knee - This can be very difficult to feel - Consider a popliteal aneurysm if easily felt - If you can’t locate it but have already felt the DP and/or PT, its most likely fine

4. Femoral: - The femoral pulse is located at the “mid-inguinal point” - This point is halfway between the anterior superior iliac spine and the pubic symphysis - It is good exam practice to identify these landmarks in order to pinpoint the femoral pulse

Ulcers:

Remember to look between the patientʼs toes for ulceration and necrosis, and lift their heels off the bed to perform a thorough inspection. A venous ulcer is typically in the “gaiter area” over the medial malleolus. There may also be other signs of high venous pressure (usually due to varicose veins or previous DVT). These include haemosiderin deposition (a reddish brown stain to the legs), oedema, lipodermatosclerosis, and varicose veins. An arterial ulcer has typically a ʻpunched outʼ appearance with some areas of necrosis and is more likely to be painful. A neuropathic ulcer is a painless ulcer occurring on pressure areas, e.g. the heel – they are often surrounded by callous. Diabetic patients can present with neuropathic ulcers, although in practice may be a mixed aetiology (arterial and neuropathic). Buergerʼs Test:

With patient lying supine, elevate both legs at the same time to approximately 45°. Observe for onset of pallor in thesoles of the feet. The smaller the angle raised at which this occurs, the more severe the ischaemia (the angle at which pallor occurs is termed “Buergerʼs angle”). Then swing the patientʼs legs round so they are hanging off the side of the bed and observe for reactive hyperaemia (the foot turns purplish). “Pallor on elevation” followed by “rubor on dependency” is a positive Buergerʼs test.

P20

3rd


Otoscopy and Free Field Voice Test Instructions: Please examine this patient for signs hearing loss and ear pathology Time: 5 minutes


TASK Marks

INTRODUCTION

1. Introduces self, identifies patient (name & date of birth), explains procedure and gains consent and washes hands before and after examination

0 1

INSPECTION

2. Inspects external ear for scars, skin tags, tophi, sinuses, discharge, erythema, swelling 0 1

EXAMINATION

3. Selects otoscope and appropriate speculum 0 1

4. Uses appropriate technique: gently pulls pinna up and back, holds otoscope like a pen with correct hand for ear i.e. right hand for right ear and vice versa

0 1

5. Uses appropriate technique: Ulnar border of hand resting gently against patient’s face 0 1

6. Comments on external auditory canal 0 1

7. Identifies tympanic membrane 0 1

8. Assesses for ‘cone of light’ reflex 0 1

9. Comments on tympanic membrane: Colour, Translucency, Position, Integrity 0 1

10. Identifies any abnormality and accurately reports clinical findings 0 1

11. Gently withdraws otoscope 0 1

FREE-FIELD VOICE TEST

12. Explains free-field voice test to patient 0 1

13. Selects ear to test and reaches hand behind patients head to block other ear. Rubs tragus to create noise during test.

0 1

14. Begins with whisper at arm’s length then, if necessary, moves to 6 inches beside patient, arm’s length at normal volume then 6 inches at normal volume.

0 2

15. Repeats free-field voice test on other ear 0 2

CONCLUSION

16. Reports findings accurately and offers differential diagnosis 0 1

17. Safely disposes of speculum 0 1

18. Mark for excellence 0 1

P21

3rd


Otoscopy and Free-Field Voice Test Written in April 2011 by Andrew Kidd and Innes Hynd. Edited April 2013 by Calum Johnston. Anatomy of the Ear:

The pinna (or auricle) is the outer projecting portion of the ear. It is composed of elastic cartilage covered with skin. The external ear canal is about 2-5cm long in adults and extends from the external auditory meatus to the tympanic membrane. The tympanic membrane consists of the pars tensa and the pars flaccida. The malleus handle lies in the middle layer of the pars tensa. The most medial structure in the drum is the lateral process of the malleus. The tip of the handle is called the umbo, and a cone of light can usually be seen extending anteroinferiorly from the umbo. Otoscopy Equipment and Technique: The otoscope consists of a handle and a head. The head contains a light and magnifying lens. The front end of the otoscope has an attachment for disposable plastic ear specula. The speculum size should be appropriate for the patient's canals. Hold the otoscope in a pencil grip with the hand of the same side as the ear you are about to examine. The pencil grip allows the side of your hand to rest on the side of the patient's face, reducing the risk of trauma if the patient’s head suddenly moves. Free-Field Voice Testing: This is a useful test of hearing where each of the patient’s ears are tested in turn. The examiner should stand to the side of the patient and reach their hand behind the patient’s head to rub the tragus of the ear that is not being examined. This way the noise created prevents the patient hearing through this ear. The examiner should begin at arm’s length by whispering a combination of 3 numbers (e.g. 5, 8, 1) that the patient should repeat. If the patient does not hear this then move to 6 inches beside the patient’s ear and use another random whispered combination. If the patient’s responses have not yet been accurate, then the process is repeated, again starting at arm’s length but this time with a conversational normal voice, not whisper. If this is still not heard then use a conversational normal voice at 6 inches. N.B. The whisper should be a “loud” whisper. Please note that the Rinne and Weber tuning fork tests may be relevant in a cranial nerve examination, but they do not test quality of hearing in patients and are not discussed here or recommended in an ENT examination. Pure tone audiometry is the most accurate way of formally assessing a patient’s hearing.

P22

3nd


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

2. Explains procedure and gains consent 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

19. Summarises findings and offers differential diagnosis 0 1

20. Mark of excellence 0 1

P23

3

rd 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

3rd year osce revision course -...

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