Clinical Examination 8 Abdominal Examination 1. Steps before beginning examination Inteoduce 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'l 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 tachypocic? 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 lapping (asterixis in hepatic encephalopathy). Examine the face, check the conjunetiva 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. Ift 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 supractaviculae (Virchow's) node is known as Troisier's Sign, may be a sign of malignancy. Virchow’s node drains the thoracie 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 distension/ascites. Look for distended veins, striae, Cullen'yGrey- ‘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. Hleus, peritonitis), tinkling (bowel obstruction) 4, Palpation + Palpation of the abdomen should be performed in a iets of X | est systematic way using the 9 named segments of the abdomen: right and left hypochondrium, right and left via [fread] TN flank, right and left iliac fossa, the umbilical area, the Lien hypochondrium and the suprapubic region. + Tfa patient has pain in one particular area you should nes cL ae start as far from that area as possible.’The tender area eee ~inbo. wey should be examined last as they may start guarding oR making the examination very difficult, + Initial examination should be superficial using one hhand.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 lives, 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. Ifthe 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, Ifthe percussion note changes, hokl 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. Iris 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.Clinical Examination 65 Cardiovascular Examination 1. Steps before beginning examination + Introduce yourself : “Lam 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'l 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, chythm 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, osler's nodes (infective endocarditis) and nicotine staining, + Inspect palms for palmar erythema, Janeway lesions and xanthomas. + Take the radial pulse asse 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’ head. A collapsing pulse will present as a knocking on your palm. the rate Ac 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 anaemi * Assess jugular venous pressure (JVP), ask patient to turn their head to look away from you. Look ure the JVP. ‘+ Examine the chest, or praccordium for any obvious pulsations, abnormalities or scars, remembering to check the axillae as well mia. across the neck between the two heads of sternocleidomastoid for a pulsation then me:66 NAC OSCE | A Comprehensive Review 3. Palpation + Palpate praccordium trying to locate the apex beat and deseribe its location anatomically. The normal location is in the Sth intercostals space in the mid-clavicular line, + Palpate for any heaves or thrills. A thrill is a palpable murmur whereas a heave isa 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? Ace 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? Reeling 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 arca 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 T'll stop the examination sight 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 10 45°, In the presence of poor arterial supply, pallor rapidlly 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.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 plice your fingets 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. Ocelude the radial and ulnar arteries with firm pressure. The hand is then opened. It should appear blanched (pallor ean be “observed at the finger nails). Release either the Ulnar or radial artery pressure and the color should return in 7 seconds, Ifthe palm does not redden immediately, this suggests arterial insufficiency. Straight Leg Raise and Refill Test (Buerger's'Test) : Raise the log 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 : Ack 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 ley, 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. Ifthe 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, tests * 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Clinical Examination 69 Respiratory Examination 1. Steps before beginning examination nd I'l be examining you today. At jot me know and I'l stop the examination our attending ph omfortable, ple Tatroduce yourself: “Tam Dr, any point of the examination you feel ur 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 tachypnocic? 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 cof clubbing, cyanosis, hypertrophic pulmonary ostcoartheopathy, dupytren’s contacrure and nicotine staining. Assess for carbon dioxide retention flap/salbutamol tremor. ‘Take the patient’s pulse, After you have taken the pulse itis 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 sycrome (Pancoast tumour), plethora (polyeythemia). Look for any use of accessory muscles such as the sternocleidomastoid muscle. Also palpate for the left supraclavicular node (Virchow's Node) 2s an enlarged node (Toisier'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 chumbs 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 ason the back.70 4. Percussion NAC OSCE | A Comprehensive Review + Percussion should be performed on both sides, comparing similar areas on both sides, Start by tapping oon the clavicle which gives an indication of the resonance in the apex.’ Then percuss normaly for the entire hung fields. Hyper-resonance may suggest @ collapsed ung where as hypo-resonance or dullness suggests consolidation such as in infection or a turnout. 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 pati “99, Do this with your hand in the upper, middle and lower arcas of both lungs. 6. Auscultation it to say + 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 oF thonehi. ull Hyper-resonant 7. Finish by examining the lymph nodes Towards lesion Central Dull Resonant (normal) Bronchial Absent Decreased Decreasedif, severe Bronchial sounds +/- egophony at edge | Occasional crackles Nil Late inspiratory crackles 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 cervieal chain and onto the supraclavicular nodes.Clinical Examination n Central Nervous System Examination ion 1. Steps before beginning exami + Introduce yourself :*T 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'l 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 1) is simply tested by offering something familiar for the patient to smell and identify — for example coffee o vinegar. 2) The Optic nerve (CN ID i 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 directly 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 fingess at the same time and checking the patient identities thi + 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 fandoscopy should be performed on both eyes, 3) Eyemovements: Oculomotor nerve (III), Trochlear nerve (IV) and Abducent nerve (V1) are involved in movements of the eye. Asking the patient to keep their head perfectly still directly in front of you, you should draw two large joining Hs in front of them using your finger and ask them to follow your finger with their eyes. It is important the patient does not move their head. Always ask if the patient experiences any double vision and if so when is it worse. Also look for ptosis and assess saccadic eye movements, 4) The Trigeminal nerve (CN V) is involved in sensory supply to the face and motor supply to the muscles of mastication. Initially test the sensory branches by lightly touching the face with a piece of cotton wool and then with a biunt pin in three places on each side ~ around the jawline, on the check and on the forchead. The corneal reflex should also be examined as the sensory supply to the comea is from this nerve. This is done by lightly touching the cornea with the cotton wool. This should cause the patient to shut their eyelids, For the motor supply, ask the patient to clench their teeth together, observing and feeling the bulk of the masseter and temporalis muscles. Then ask them to open their mouth against resistance. Finally perform the jaw jerk on the patient by placing your left index finger on their chin and striking it with aa tendon hammer. This should cause slight protrusion of the jaw.72 NAC OSCE | A Comprehensive Review 5) ‘The Facial nerve (CN VID) supplies motor branches to the muscles of facial expression. Therefore, this nerve is tested by asking the patient to crease up their forchead (raise their eyebrows), close their eyes and keep them closed against resistance, puff out their cheeks and show you their teeth. 6) The Vestibulocochlear nerve (CN VIII) provides innervation to the hearing apparatus of the car and ‘can be used to differentiate conductive and sensori-neural hearing loss using the Rinne and Weber tests. For the Rinne test, place a sounding tuning fork on the patient’s mastoid process and then next to their ear and ask which is louder, a normal patient will find the second position louder. For Weber's test, place the tuning fork base down in the centre of the patient's forehead and ask ifit is louder in cither ear. Normally it should be heard equally in both ears. 7). The Glossopharyngeal nerve (CN IX) provides sensory supply to the palate. Tecan be tested with the gag reflex of by touching the arches of the pharynx. 8) The Vagus nerve (CN X) provides motor supply to the pharynx. Asking the patient to speak gives a good indication to the efficacy of the muscles. You should also observe the uvula before and during the patient saying ‘aah’. Check that it lies centrally and does not deviate on movement. 9) ‘The Accessory nerve (CN X1) gives motor supply to the stemnocleidomastoid and trapezius muscles ‘To test it, ask the patient to shrug their shoulders and turn their head against resistance, 10) ‘The Hypoglossal nerve (CN X11) provides motor supply to the muscles of the tongue. Observe the tongue for any signs of wasting or fasciculations. Then ask the patient to stick their tongue out. If the tongue deviates to cither side, it suggests a weakening of the muscles on that side, 3. Cerebellar Examination + Ask the patient to stand up. Observe the patient's posture and whether they are steady on their feet. + Ask the patient to walk, e.g. to the other side of the room, and back, Ifthe patient normally uses a walking aid, allow them to do s + Observe the different yait components (hee! strike, toe liftoff). Is the gait shuffling / waddling / scissoring / swinging? + Observe the patients arm swing and take note how the patient turns around as this involves good balance and co-ordination. + Ask the patient to walk heel-to-toe to assess balance. + Perform Romberg’ test by asking the patient to stand u sways or loses balance this testis positive. Stand near the p ided with his eyes closed. If the patient ent in case he falls. ordination: + Look for a resting tremor in the hands. + Test tone in the arms (shoulder, elbow, wrist) + Test for dysdiadochokinesis by showing the patient to clap by alternating the palmar and dorsal surfaces of the hand. Ask to do this as fist as possible and repeat the rest with the other hand. + Perform the finger-to-nose test by placing your index finger about two fect from the patients face, Ask him to touch the tip of his nose with his index finger then the tip of your finger. Ask him to do this as, fast as possible while you slowly move your finger. Repeat the test with the other hand. + Perform the heel-to-shin test. Have the patient lying down for this and get him to run the heel of one foot down the shin of the other leg and then to bring the heel back up to the knee and start again Repeat the test with the other leg.Clinical Examination B Upper Limb Neurological 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'l stop the examination right there.” ‘Washy/Sanitize hands Explain to the patient what you are about to do and gain informed consent. Use proper draping techniques, verbalize the steps of the examination and your findings. 2. Inspection General inspection of patient: general comfort, abnormal posture/movements, muscle wasting. "The upper body should be exposed for this examination. Observe the patient's arms, look for any muscle wasting, fasciculations or asyenmetry. Examine the tone of the muscles, Start proximally atthe shoulder, feeling how easy the joint isto move passively. Then move down to the elbow, wrist and hand joints again assessing each one’s tone in tun, Assess for spastic catch, clasp-knife rigidity, led-pipe or cog-wheel rigidity. 4. Power Next assess the power of each of the muscle groups. = Shoulder abduction (C5) & Shoulder adduction (C5/C6/C7) = Elbow flexion (C5/C6) & Elbow extension (C7) = Wrist flexion (C8) & Wrist extension (C8) = Finger flexion (C8), Finger abduction (11), Finger adduction (1) = Thumb abduction (C8) 5. Reflexes ‘There ate throe reflexes in the upper limb ~ the biceps, triceps and supinator reflexes, ‘The biceps reflex (C5/C6) is tested by supporting the patient's arm, with it flexed at roughly 60°, placing your thumb over the biveps tendon and hitting your thumb with the tendon hammer. It is vital to get your patient to relax as much as possible and for you to take the entire weight of their arm. ‘The triceps reflex (C6/C7) is elicited by resting the patient's arm across their chest and hitting the triceps tendon just proximal to the elbow. Finally, with theie arm rested on their abdomen, locate the supinator tendon (C5/C6) as it crosses the radius, place three fingers on it and hit the fingers. This should give the supinator reflex. If you struggle with any of these reflexes, asking the patient to clench their teeth should exaggerate the reflex.74 NAC OSCE | A Comprehensive Review 6. Sensation ‘This is tested in a number of ways. You should test light touch, pin prick, vibration and joint position sense and proprioception. ‘Ask the patient to place their arms by their sides with their palms facing forwards. Lightly touch the patient's sternum with a piece of cotton woo! so that they know how it feels. Then, with the patient's eyes shut, lightly touch their arm with the cotton wool. The places to touch them should test each of the dermatomes. Tell the patient to say yes every time they feel the cotton wool as it felt before. Then repeat this using a light pin prick. “To assess vibration you should use a sounding tuning fork. Place the fork on the patient's sternurn to show them how it should feel. Then place it on the bony prominence at the base of their thumb and ask them if it feels the same. It does, there is no need to check any higher. fit fees different you should move to the radial stylus and then to the olecranon until it feels normal. Finally, proprioception, Hold the distal phalanx of the thumb on either side so that you ean flex the interphalangeal joint, Show the patient that when you hold the joint extended, that represents "Up! whereas when you hold it flexed that represents 'Down’. Ask the patient to close their eyes and, having moved the joint a few times hold it in one position - up or down. Ask the patient which position the join 7. Coordination Pronator drift — Ask patient to extend arms in front of them in supination and to close their eyes. A positive result occurs when the arm fills downwards and pronates (cerebral damage), in cerebellar lesions the arms may rise. “Assess for dysdiadochokinesia ‘Assess for finger to nose coordination and intentional tremor. Function is a very important part of any neurological examination as this is the area which will affect people's day to day lives the most. For upper limb you should ask people to touch their head with both hands and then ask them to pick up a small object such as a coin which each hand, Finish by thanking the patient and ensuring they are comfortable and well covered.Clinical Examination _1s Lower Limb Neurological Examination 1. Steps before beginning examination + Introduce yourself : “Tam 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'l stop the examination + Explain to the patient what you are about to do and gain informed consent, + Verbalize the steps of the examination and your findings + Make sure patient is adequately exposed, use proper draping techniques 2 Inspection * Observe the patient's legs, look for any muscle wasting, fasciculations or asymmetry. + Start by examining the tone of the muscles. Rell the leg on the bed to see if it moves easily and pull up on the knee to check its tone. Also check for ankle clonus by placing the patients leg turned outwards on the bed, moving the ankle joint a few times to relax it and then sharply dorsiflexing it. Any farther movement of the joint may suggest clonus. 4. Power + Next assess the power of each of the muscle groups. Hip flexion (1.1/1.2) & Hip extension (L5/S1) ip abduction (12/13) & Hip adduction (L2/13) = Knee flexion (15/51) & Knee extension (L3/L4) = Ankle dorsiflexion (L4/L5) & Ankle plantar flexion (S1/S2) = _ Big toe flexion (81/82) 5. Reflexes + Test the patient's reflexes. There are three reflexes in the lower limb - the knee reflex, the ankle jerk and the plantar reflex - elicited by stroking up the lateral aspect of the plantar surface. + The knee reflex (1.3/4) is tested by placing the patient's leg flexed at roughly 60°, taking the entire ‘weight of their leg with your arm and hitting the patellar tendon with the tendon hammer. It is vital to get your patient to relax as much as possible and for you to take the entire weight of their leg. + The ankle jerk (S1/S2) is elicited by resting the patient's leg on the bed with their hip laterally rotated. Pall the foot into dorsiflexion and hit the calcaneal tendon. + Finally, with their leg out straight and resting on the bed, run the end of the handle of the tendon hammer along the outside of the foot. This gives the plantar reflex (S1). An abnormal reflex would see the great toc extending. IF you struggle with any of these reflexes, asking the patient to clench their teeth should exaggerate the reflex.76 NAC OSCE | A Comprehensive Review 6. Sensation te ce ‘The final test is sensation, However, this is tested in a number) of ways. Yu should test ight touch, pin prick, bration and [4 = joint position sense and proprioception ‘Ask the patient to place their legs out straight on the bed. Lightly touch the patient's sternum with a piece of cotton wool |, so that they know how it feels."Then, with the patient's eyes shut, lightly touch their leg with the cotton wool. The places to touch them should test each of the dermatomes - make sure | // | you know these! Tell the patient to say yes every time they feel } the cotton wool as it felt before. Then repeat this using alight jo pin prick, To assess vibration you should use a sounding tuning fork. ~~ Place the fork on the patient's sternum to show them how it |." should feel. Then place it on their medial malleolus and ask them if it feels the same. If it does, there is no need to check any higher. fit fels different you should move to the epicondyle and then to the greater trochanter until it feels normal. j Finally, proprioception. Hold the distal phalanx of the great toe {2 patente: on either side so that you can flex the interphalangeal joint. 4**eF0" ° posterior Show the patient that when you hold the joint extended, that represents ‘Up’ whereas when you hold it flexed that represents ‘Down’ Ask the patient to close their eyes and, having moved the joint a few times hold it in one position - up or down, Ask the patient which position the joint is in. Function is a very important part of any neurological examination as this is the area which will affect people's day to day lives the most. For the lower limb you should assess the patient's walking, Observe their gait and check for any abnormalities. Whilst they are standing you should perform Romberg’s test. Ask the patient to stand with their feet apart and then close their eyes. Stand next to the patient in case he falls. Any swaying may be suggestive of « posterior column pathology. Finish by thanking the patient and ensuring they are comfortable and well covered.Clinical Examination 7 Musculo-skeletal system : Spine/Back 1. Steps before beginning examination + Introduce yourself “Tam Dr.___, our attending physician and I'l 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. + Ensure patient is adequately exposed. + Look for medical equipment/therapies + Show empathy. + Verbalize the steps of the examination and your findings. 2. Inspection © Ask for patient's vitals + Observe patient : Is patient sitting comfortably? Gait? Position of comfort. + Observe the patient from behind = Pelvieand shoulder symmetry = Scoliosis ~ Gibius (dorsal spines abnormally prominent) + Observe patient fom side = = Kyphosis — Increased lumbar lordosis + Check the spine for SEADS : S: Swelling, B: Erythema, eechymosis, A: Atrophy/asymmetry (musele bulk), D: Deformity, 8: Skin changes/scars/bruising ralpate the pelvic brim to check for symmetry. 3. Range of Motion + Flexion : In the standing position by asking the patient to touch the toes. Normal - 90° ‘The normal spine should lengthen more than 5 cm in the thoracic area and more than 7.5 cm in the lumbar area on forward flexion + Extension : Stabilize the patient, ask the patient to bend backwards. Normal ~ 30°. + Lateral flexion : ask the patient to slide their hand straight down the thigh, first on the right and then oon the left, keeping the hips straight + Observe for restricted movement and loss of symmetry * ‘Test for facet joint disease : Ask patient to extend their back as far as possible and to rotate (pain suggests facet joint pathology). 4. Palpation. + Examine the back and palpate for areas of muscle spasm and tendemess (paraspinal muscles). + Palpate spinous processes with thumb for tenderness + Sacroiliac joints, sacto iliac dimples, ask for tenderness.78 NAC OSCE | A Comprehensive Review 5. Ankylosing spondylitis tests Chest expansion: Measure with a tape measure (should be »5em) Schober's Test : Draw a horizontal line 1em above and one Sem below the dimples of Venus (the: distance between these lines should increase to >20em during tumbar flexion = in ankylosing, spondylitis the distance will not increase to >20cm) Distance of tragus to wall when patient is standing with their back to the wall (useful for monitoring). 6. Cervical and thoracic movements (patient sitting on edge of bed) Cervical movements — Flexion (ask patient to touch chin to chest) — Extension (ask patient to look to the ceiling as far back as possible) — Lateral flexion (ask patient to touch their ear to the shoulder keeping the shoulder still) = Spurling Maneuver : Extend head back & bring ear towards shoulder. Give gentle axial pressure ‘on the head. If patient complains of pain radiating from head to ipsilateral arm ~ diagnosis of Radiculopathy is made. — _ Rotation (ask patient to look over the left and right shoulder) Perform these movements passively if active movements are restricted. kc patient to fold their arms and twist around. ‘Thoracic rotation 7.'Tests with patient lying on their back Straight leg raising test: ask the patient to lie with the spine on the table and to relax completely. With the knee filly extended, first one leg and then the other is slowly lifted and flexed at the hip. This produces stretch on the sciatic nerve, at which point sciatic pain is produced. If this maneuver produces pain in the hip or low back with radiation in the sciatic area, the test is considered positive for nerve 100t irritation. The angle of elevation of the log from the table at the point where pain is produced should be recorded. FABER (Flexion Abduction External Rotation) : Ask the patient to lie supine on the exam table Place the foot of the affected side on the opposite knee. Pain in the groin area indicates « problem with the hip and not the spine. Press down gently but firmly on the flexed knee and the opposite anterior superior iliac crest. Pain in the sacroiliac arca indicates a problem with the stctoiliac joints, Bowstring test: Once the level of pain has been reached, flex the knee slightly and apply firm pressure ‘with the thumb in the popliteal fossa over the stretched tibial nerve. Radiating pain and paraesthesiae suggest nerve root irritation. 8. Tests with patient lying on their abdomen th the patient supine and hip flexed, dorsiflexion of the ankle causes pain or muscle nerve irritation, Lasegue's sign: spasm in the posterior thigh if there is lumbar root or sc Femoral stretch test: With the patient prone and the anterior thigh fixed to the couch, flex each knee in turn. This causes pain in the appropriate distributions by stretching the femoral nerve roots in L2- LA. The pain produced is normally aggravated by extension of the hip.'The testis positive if pain is felt in the anterior compartment of thighClinical Examination 79 Hip Examination 1. Steps before beginning examination + Introduce yourself :*I am Dr. , your attending physician and I'll be examining you today. At y point of the examination you fecl uncomfortable, please let me know and T'l stop the examination ight there.” + Wash/Sanitize hands + Explain to the patient what you are about to do and gain informed consent + Ensure patient is adequately exposed. * Look for medical equipment/therapies + Ask which hip is painful, show empathy. + Verbalize the steps of the examination and your findings. 2. Inspection of hip (with patient standing up) * While the patient is standing, check the hip for SEADS : S: Swelling, B: Erythema, eechymosis, ‘A: Atrophy/asymmetry (muscle bulk), D: Deformity, $: Skin changes (crythema/scars/abscess/sinuses) + Log length discrepancy + Whilst the patient is still standing, perform the ‘Trendelenberg test. This is done by asking the patient to alternately stand on one leg. Stand behind the patient and feel the pelvis. It should remain at level ightly If the pelvis drops markedly on the side of the raised leg, then it suggests abduetor muscle weakness on the leg the pati standing on. orrises 3. Gait - ask patient to walk across the floor. Look for any abnormalities, aoe inonaca hip, knee, foot movements length of stride. Tendsenberg © wesines _ ofhip sdductors | Festinating - Parkinson's ds. High stepping - Polio, MS 3. Inspection & Palpation of hip (with patient lying down) Sekeior etic coretual aly + Tnspection for hip and groin swellings (hernia, lymphadenopathy, Stomping - Friedreich's saphenous vatix,effsion) ato, tabes dosalls + Tnspect for obvious fixed flexion wae. cole | + Palpace anterior hip for humps and tenderness. + Palpate the greater trochanter for any tenderness which might suggest trochanteric bursitis. 4, Leg-length difference + Make an approximate judgment by aligning the medial malleoli and looking for discrepancy. + Measure true and apparent leg-length if appropriate. Truc leg length discrepancy is found by wc spine to the medial malleolus. Apparent leg length isto the medial malleoly measuring from the anterior superior i discrepancy is measured from the umbili80 NAC OSCE | A Comprehensive Review 5, Active and passive movements + Assess active flexion, extension, abduction and adduction, — Flexion : Flex the knee to 90 degrees and passively flex the hip by pushing the knee towards the chest. — Extension : is performed by placing your hand under the patient's ankle and asking them to push your hand into the bed ‘+ Passively assess internal and external rotation of the hip (with hips at 90° flexion) — Internal rotation : performed with the knee flexed and by everting the knee for internal rotation — External rotation : performed with the knee flexed and inverting it for external rotation, 6. Special tests + ‘Thomas test : Place your hand under the patient's lumbar spine to stop any lumbar movements and fully flex one of the hips. Observe the other hip, if it lifts off the couch then it suggests a fixed flexion deformity of that hip. + FABER (Flexion Abduction External Rotation) : Ask the patient to lie supine on the exam table. Place the foot of the affected side on the opposite knee. Pain in the groin area indicates a problem with the hip and not the spine. Press down gently but firmly on the flexed knee and the opposite anterior superior iliac crest. Pain in the sacroiliac area indicates a problem with the sacroiliac joints.Clinical Examination 81 Knee Examination 1. Steps before beginning examination + Introduce yourself: am Dr. , your attending physician and I'l be examining you today. At any point of the examination you fect uncomfortable, please let me know and I'l stop the examination right there.” + Wash/Sanitize hands + Explain co the patient what you are about to do and gain informed consent. + Ensure patient is adequately exposed (up to above knees). + Look for medical equipment/therapies + Askabout knee locking, giving way and pain, show empathy. + Verbalize the steps of the examination and your findings. 2 Inspection + Gait: Ask the patient to walk for you. Observe any limp or obvious deformities such as scars or muscle wasting. Check if the patient has a varus (bow-legged) or valgus (knock-knees) deformity. Abo observe from behind to see if there are any obvious popliteal swellings such as a Baker's cyst. ‘+ While the patient is lying on the bed, make a general observation. Look for symmetry, redness, muscle wasting, scars, ashes or fixed flexion deformities. 3. Palpation * Check the temperature using the backs of your hands, comparing it with other parts of the leg. + Palpate the border of the patella for any tenderness, behind the knee for any swellings, along all of the joint lines for tenderness and at the point of insertion of the patellar tendon. Finally, tap the patella to see if there is any effusion deep to the patella, + Landmarks of the knee :Tibial tuberosity, patellar tendon, quadriceps tendon, medial and lateral femoral condyles. + Pesipatellar area : push patella medially and rub right underneath the medial facet of patella and look for tenderness ( Patellar~ fi + Joint line tenderness : bend the knee 90°, pal + Patella apprehension test ~ Move patella around and observe patients face for pain. ‘medial and lateral joint line 4, Range of Motion + Active flexion and extension of knee ~ Observe for restricted movement and for displacement of patella, + Passive flexion and extension of knee ~ feel for erepitus + Straight leg raise ~ assessment of extensor apparatus,82 NAC OSCE | A Comprehensive Review 5. Special tests ‘Tests to Deteet Arthritis: + Crepitus: Crepitus is the sensation that is felt when rough cartilage or exposed bone is rubbing as the knee is bent, The examiner will feel, and may hear, this grinding. as the knee is bent back and forth. + Deformity: As the knee cartilage is worn away, the knees may become progressively knock-kneed or bow-legged. + Limited Motion:'Vhe range of motion of the knee typically becomes limited if arthei and swelling prevents normal mobility bone spurs, ‘Tests to Detect a Torn Meniscu! + Joint Line Tenderness Joint line tenderness is a very non-specific test for'a meniscus tear, The arca of the meniscus is felt, and a positive test is considered when there is pain in this area, + McMurray's Test ‘McMurray's testis performed with the patient lying flat on his back and the examiner bending the knee. A click is felt over the meniscus tear as the knee is brought from full flexion to full extension. ‘Tests to Detect an ACL Tear: + Lachman Test ‘The Lachman testis the best test to diagnose an ACI. tear. With the knee slightly bent, the examiner stabilizes the thigh while pulling the shin forward. A tom ACL allows the shin to shift too far forward, + Anterior Drawer Test ‘This testis also performed with the patient lying flat on his back, The knee is bent 90 degrees and the shin is pulled forward to check the stability of the ACL. Tests to Detect Other Ligament Injuries: + Posterior Drawer Test ‘The posterior drawer is performed similarly to the anterior drawer test. This test detects injury to the PCL. By pushing the shin backward, the function of the PCL is tested, + Collateral Ligament Stability Side-to-side stability of the knee detects problems of the collateral ligaments, the MCL and LCL. With the patient Iying flat, and the knee held slightly bent, the shin is shifted to each side. Damage to the LCL or MCL will allow the knee to "open up" excessively, a problem called varus (ICL) or valgus (MCL) instability. ‘Tests to Detect Kneecap Problems: + Patellar Grind “The patient lies supine with the leg extended. The examiner reproduces the patient's knee pain by pushing the kneceap down and asking the patient to flex his thigh muscles. Damaged cartilage can cause a grinding sensation called crepitus. + Patellar Tenderness ‘The examiner can slightly lift up the kneecap and place direct pressure on the under surface of the kneecap. By doing so, the examiner is looking for sensitive regions of cartilage. + Patellar Apprebension ‘This is a sign of an unstable kneecap. While the examiner places pressure on the kneecap, the patient may complain of the sensation that the kneecap is going to ‘pop out’ of its groove,Clinical Examination 83 Foot and Ankle Examination 1. Steps before beginning examination your attending physician and T'l be examining you today. At uncomfortable, please let me know and I'll stop the examination Introduce yourself: “Iam Dr any point of the examination you right there.” ‘Wash/Sanitize hands Explain to the patient what you are about to do and gain informed consent. Ensure patient is adequately exposed (up to above knees). Look for medical equipment/therapies Askif patient is able to bear weight, show empathy. Verbalize the steps of the examination and your findings, 2. Inspection Gait : watch che pationt walk, observing for a normal heel strike, toe-off gait. Also look at the alignment of the toes for any valgus or varus deformities. Assess ability to weight-bear on affected side, While patient is standing check the foot arches checking for pes cavus (high arches) or pes planus (at feet), Inspection of the foot with patient sitting and feet overhanging = Check the foot and ankle for SEADS : 8: Swelling, B: Erythema, ecchymosis, A: Atrophy/asymmetry (muscle bulk), D: Deformity, S: Skin changes/scars/bruising. = Check the symmetry, nails (psoriasis), skin, toe alignment, look for toe clawing, joint swelling and plantar and dorsal calluses. Finally you should look at the patient's shoes, note any uneven wear on either sole and the presence of any insoles 3.Palpation of anlde/foot Feel each foor for temperature, comparing it to the temperature of the rest of the leg. Feel for distal pulses. Squeeze over the metatarsophalangeal joints observing the patient's face for any pain. Palpate over the midfoot, ankle and subtalar joint lines for any tenderness, Feel the Achilles tendon for any thickening or swelling, Palpate medial and lateral mallcoli for any tenderness.84 NAC OSCE | A Comprehensive Review 4. Range of Motion + Assess all active and passive movements of the foot. These movements are inversion, eversion, dorsiflexion and plantarflexion. = Subralar joint ~ inversion and eversion = Ankle joint ~ dorsiflexion and plantar flexion = Big toc— dorsiflexion and plantar flexion = Mid-tarsal joints - which are tested by fixing the ankle with one foot and inverting and everting the forefoot with the other, 5. Special tests + Ankle Anterior Drawer’Test - assesses for lateral ankle sprain Patient is seated, stabilize the tibia with one hand while grasping heel and pulling it anteriorly the other. Greater than 3 mm anterior movement may be significant. 1 em is significant and indicates anterior talofibular ligament rupture. Positive Test - laxity in the ligament with exaggerated anterior translation + TalarTile Test ~ assesses integrity of the deltoid ligament/lateral ankle sprain the leg and foot while adducting and inverting the calcaneus apply a varus Patient is seated, stabil force.’The calcaneus is then abducted and everted applying a valgus force. Positive Test - pain or laxity in the ligament + Thompson's Test - assesses for Achilles’ tendon rupture Patient is prone, squeeze the gastrocnemius and soleus muscles while noting any movement at the ankle and foot Positive Test - no movement ot plantarflexion at all indicates a 3rd degree strain of the Achilles’ tendon + Plantar Fascitis Test ~ assesses for inflammation of the plantar fascia Patient is supine, dorsflex the ankle and extends all toes then press in the medial border of the plantar fascia Positive Test - pain is consistent with plantar fascitis Ottawa Ankle rules For taking ankle series x-rays(AP and lateral ankle) + Xcray if there is pain over the malleolar zone AND tendemess on palpation of the medial/lateral 1malleolar tip and posterior aspect of medial/lateral malleolus OR + Patient unable to bear weight immediately and in ER, For foot series (AP and Lateral foot) ‘+ X-ray if there is pain in midfoot zone AND bony tenderness over the navicular or base of 5" metatarsal OR + Unable to bear weight immediately and in ERClinical Examination 85 Shoulder Examination 1. Steps before beginning examination . Your attending physician and I'll be examining you today. At + Introduce yourself: “Tam De + Wash/Sanitize hands ‘+ Explain to the patient what you are about to do and gain informed consent. + Look for medical equipment/therapics, ensure patient is adequately exposed. + Ask which shoulder is painful. Verbalize the steps of the examination and your findings. 2. Inspection + Start by exposing the joint and observe the shoulder joint looking from the back, se and front for any sears, deformities or muscle wasting (SEADS). Also compare both sides for symmetry. + With the patient standing, ask the patient to place their hands behind their head and behind their back and observe for and deformities. 3. Palpation + Feel over the joint and its surrounding areas for the temperature of the joint as raised temperature may suggest inflammation or infection in the joint. + Systematically feel along both sides of the bony shoulder girdle, Start at the sternoclavicular joint, work along the clavicle to the acromioclavicular joint + Feel the acromion and then around the spine of the scapula. + Feel the anterior and posterior joint lines of the glenohumeral joint and finally the muscles around the joint for any tenderness. 4, Range of Motion + ‘The movements of the joint should start being performed actively. + Ask the patient to bring their arm forward (flexion), bend their arm at the elbow and push backwards (extension), + Bring their arm out to the side and up above their head (abduction), When testing adduction perform the scarf test (The scarf testis performed with the elbow flexed to 90 degrees, placing the patient's hand on their opposite shoulder and pushing back, agin look for any discomfort. ) + Rotation = Internal rotation : Ask the patient to place hands in the small of their back, and slide them up the back as far as possible. = External rotation : Ask patient to rotate their arms outwards, keeping the the side of the body. + Once all of these movements have heen performed actively, you should perform them passively and feel for any crepitus whilst moving the joints, bows flexed and by86 NAC OSCE | A Comprehensive Review 5. Special Tests Tests for Rotator Cuff i. Supraspinatus + Empty Can Test ( tests integrity of Supraspinatus) : The patient stands with arms extended at the elbows and abducted in the scapular plane and with thumbs pointed to the floor. The examiner applies downward pressure to the arms and the patient attempts to resist. Positive test: Pain, muscle weakness or both. + Apley's Scratch Test- Reach over shoulder to "scratch" between scapula. Measure to which vertebrae thumb can rea ii, Infraspinatus + External Rotation Lag Sign :'The elbow is passively flexed to 90 degrees, and the shoulder is held at 20 degrees abcuction (in the scapular plane) and near maximal external rotation by the examiner. The patient is then asked to actively maintain the position of external rotation in abduction as the examiner releases the wrist while maintaining support of the limb at the elbow. The sign is positive ‘when a lag, or angular drop occurs. The magnitude of the lag is recorded to the nearest 5 degrees, iii, Subscapularis ‘+ Gerber Lift-Off Test : With the patient's hand on the small of the back, the arm is extended and internally rotated. The examiner then passively lifts the hand off the small of the back, placing, the arm in maximal internal rotation. ‘The examiner then releases the hand. If the hand falls onto the back because the subscapularis is unable to maintain internal rotation, the test result is positive. Patients with subscapularis tears have an inerease in passive external rotation and a weakened ability to resist internal rotation, "Tests for Shoulder Instability + Apprchension Sign for Anterior Instability : The test is performed by abducting the shoulder to 90 degrees, and then slowly externally rotating the shoulder toward 90 degrees. A patient with anterios~ inferior instability will usually become "apprehensive" either verbally or with distressing facial expressions. "Tests for Subacromial Impingement + Neer Impingement Sign : Place one hand on the posterior aspect of the scapula to stabilize the shoulder girdle, and, with the other hand, take the patient's internally corared arm by the wrist, and place it in full forward flexion.If there is impingement, the patient will report pain in the range of 70 degrees to 120 dogrees of forward flexion as the rotator cuff comes into contact with the rigid ccoracoacromial arch, + Hawkins Impingement Sign : The examiner places the patient's arm in 90 degrees of forward Hexion and forcefully internally rotates the arm, bringing the greater tuberosity in contact with the lateral acromion, A positive result is indicated if pain is reproduced during the forced internal rotation. Tests for Long Head of the Biceps + Speed's Maneuver :’The patient's elbow is flexed 20 degrees to 30 degrees with the forearm in supination and the arm in about 60 degrees of flexion. ‘The examiner resists forward flexion of the arm while palpating the patient's biceps tendon over the anterior aspect of the shoulder. + Yergason test : The patient's elbow is flexed to 90 degrees with the thumb up. Forearm is in neutral. ‘The examiner grasps the wrist, resisting attempts by the patient to actively supimate the forearm and flex the clhow. Pain suggests biceps tendonitis.Clinical Examination 87 Elbow Examination 1. Steps before beginning examination + Introduce yourself “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'l stop the examination sight there.” + Wash/Sanitize hands + Explain to the patient what you are about to do and gain informed consent. + Look for medical equipment/therapies, ensure patient is adequately exposed. + Verbalize the steps of the examination and your findings, 2. Inspection + SEADS : $: Swelling, E: Erythema, ecchymosis, A: Atrophy/asymmetry (muscle bulk), D: Deformity, S: Skin changes/scars/brui k fora fixed flexion deformity. Look at the underside of the elbows to check for any psoriatic plaques, cysts or rheumatoid nodules. 3. Palpation + Feel the elbow, assessing the joint temperature relative to the rest of the arm. + Palpate the olecranon process as well as the lateral and medial epicondyles for tenderness (medial for olier’s elbow and lateral for tennis elbow), and cubital fossa for tenderness. + Palpate joint line with elbow flexed to 90° for tenderness and swelling, 4, Range of Motion + The movements at the elbow joint are all fairly easy to deseribe and assess. These are flexion, extension, pronation and supination, Once these have been assessed actively they should be checked passively checking for power and erepitus. + Test for varus / valgus instability. 5, Neurological Examination of hand Motor Sensory ~ Median nerve (thumb abduction) ~ Median nerve (pulp of index finger) ~ Radial nerve (wrist extension) ~ Radial nerve (1" dorsal interosseous space) ~ Ulnar nerve (finger abduction) - Ulnar nerve (pulp of 5" finger) 6, Special Tests + Tennis Elbow : Tennis elbow localises pain over the lateral epicondyle, particularly on active extension cof the wrist with the elbow bent, + Golfer's Elbow : Golfer's elbow pain localises over the medial epicondyle and is made worse by flexing the wristNAC OSCE | A Comprehensive Review Hand and Wrist Examination 1. Steps before beginning examination Tntroduce yourself: “Tam 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 Verbalize the steps of the examination and your findings, 2. Inspection Inspect hands : = Skin (rashes, Gottron’s patches, nodules, Raynaud's phenomenon, sclerodactyly, scars, skin atrophy) = Nails (pitting, onycholysis, splinter haemorrhages, clubbing) = Muscles (swelling, wasting) = _ Joints (swellings, subhrsation / deviation of wrist, swan neck / Boutonicre's deformity, Heberden's/Bouchard’s nodes, Z. deformity of thumb) = _ Inspect palm (palmar erythema, pallor, cyanosis), muscle wasting. Inspect efbows = Pooriatic skin lesions = Rheumatoid nodules = Scars 3. Palpation ‘Assess the temperature over the joint areas and compare these with the temperature of the forearm, Start proximally and work towards the fingers, feeling the radial pulses and the wrist joints. Then feel the muscle bulk in the thenar and hypothenar eminences. In the palms, feel for any tendon thickening and assess the sensation over the relevant areas supplied by the radial, ulnar and median nerves. ‘Squeeze over the row of metacarpophalangeal joints whilst watching the patient's face for any discomfort. Bi-manually palpate MCP and interphalangeal joints.Clinical Examination 89 4. Range of Motion + Ask the patient to perform the following movements in the sequence mentioned below and observe for range of movement : = Make a fist ~ Pronate wrist — Extend little finger (extensor digiti minim is usually the first tendon to rupture in rheuatoid arthritis) Extend all fingers + Assess function = Pinch grip = Opposition (touch thumb to each finger) Power grip (ask patient to squeeze your fingers) Froment's test (for ulnar nerve palsy). In this test the patient attempts to grip a paper with thumb and index finger while the examiner tries to pull the paper out of the patient's grip. — Ask patient to write something / undo a button, + Assess power = Wrist extension (radial nerve) = Thumb abduetion (median nerve) — Finger abduction (ulnar nerve) 5, Neurovascular Examination : Sensation ‘Motor (Newe Median Lateral portions ofthe pulp ofthe _| Resisted palmar abduction of the index and middie fingers thumb Ulnar Lateral pulp areas ofthe litie finger | Abduction of the fingers against resistance Radial Web space between the thumb and | Wrist extension “Index finger (anatomical sur box) 6. Special Tests + Phalen's test: Forced flexion of the wrist, either against the other hand or by the examiner for 60 seconds will reereate the symptoms of carpal tunnel syndrome. + Finkelstein’s testis used to diagnose DeQuervain’s tenosynovitis, Patient is told to flex the thumb and clench the fist over the thumb followed by ulnar deviation. If there is an increased pain in the radial styloid process and along the length of the extensor pollicis brevis and abductor pollicis longus tendons, then the testis positive for De Quervain’s syndrome. + Tinel’s sign : Use the index finger to tap over the carpal tunel at the wrist. A positive test results when the tapping causes tingling or paresthesia in the area of the median nerve distribution, which includes the thumb, index finges, and middle and lateral half of the ring finger. A positive Tine!’s sign at the wrist indicates carpal tunnel syndrome,90 NAC OSCE | A Comprehensive Review Breast 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 Tet me know and I'll stop the examination right ther Wash/Sanitize hands Explain to the patient what you are about to do and gain informed consent. Verbalize the steps of the examination and your findings. Ask which side the problem is. ‘Make sure patient is adequately exposed, use proper draping techniques 1. General Inspection (with patient sitting on side of bed) Inspect with, = Patient's arm by their sides. — Patient's arms behind their head (tenses skin) — Patient's hands on their hips (tenses pectoralis major) “These manoeuvers test for'T4 disease ~ invasion of chest wall / skin. Inspect for : = Obvious masses = Scars = Radiotherapy tattoos = Skin changes = Peau d'orange = Dimpling = Nipple retraction — Paget's disease 2. Inspection (with patient lying down) ~ Breasts size, symmetry and contour. Arcola pigmentation, nipple pigmentation, shape, ulceration and discharge. = _ Skin color, thckening, venous pattern and edema. = Palpate normal breast followed by abnormal breast. = Palpate all quadrants, nipple and axillary tall of each breast. — Describe any masses : position, size shape, mobility, number, tenderness, consistenc = Palpate axillary, supraclavicular and infracavicular lymph nodes. 4. Auseultate lungs.1 Thyroid Examination 1. Steps before beginning examination Introduce yourself: “I am Dr. your attending physician and I'l be examining you today. At any point of the examination you fecl uncomfortable, please let me know and T'll stop the examination right there.” Wash/Sanitize hands Explain to the patient what you are about to do and gain informed consent. Ensure paticnt is adequately exposed. Look for medical equipment/therapies Show empathy. Verbalize the steps of the examination and your findings. 2. Inspection Ask for patients vitals. Observe patient : Is patient anxious? Weight gain/loss? Note hoarseness of woice. Feel pulse — rate/rhythm/volume Face: Facial expression ( dull in hypothyroidism) Periorbital myxedema Loss of 1/3rd of eyebrows Hair — texture/alopecia Exophthalmos (look from behind patient), lid lag Ophthalmoplegia (ask patient to follow your finger then ask for diptopia) Chemosis (redness and watering of eyes) Hands : Temperature, moist palms, texture, color. Assess for fine tremors, palmar eythema Pemberton's sign - is the development of facial flushing, distended neck and head superficial ‘veins, inspiratory stridor and elevation of the jugular venous pressure (JVP) upon saising of the patient's both arms above his/her head simultaneously. (Thoracic inlet obstruction ag. due to goitre) Carpal Tunnel Syndrome (‘Tinel's and Phalen’s Test) ~ associated with hypothyroidism. ‘Arm reflexes — brisk in hyperthyroidism. Neck: Stand in front of the patient, inspect for neck swellings/goitre uses, dilated vessels92 NAC OSCE | A Comprehensive Review 3. Examination of the Thyroid ghand and cervical lymph nodes. + Swallow rests ~ Ask patient to swallow water and observe for movement of any masses. + Tongue protrusion ~"Thyroglossal cyst moves on tongue protrusion. + Stand behind the patient and palpate. Assess size, texture, smoothness, margins and mobility of the thyroid gland (including when swallowing). Note the temperature over gland and adjacent skin, + Palpate cervical lymph nodes. + Pescuss over sternum ~ Retrostemal goitre. + Auscultate for thyroid bruit ~ Grave's disease, 4. Examination of legs. + Pretibial myxoedema + Peripheral edema due to congestive cardiac failure: + Delayed relaxation of ankle reflex in hypothyroidism. 5. Thank the patient after the examination.Clinical Examination Can you also tell me the name of the location we are in? (Hospital/cinic) JL IMMEDIATE RECALL Mini Mental State Examination |. ORIENTATION What is today's date? Whats the year? What isthe month? What isthe day today? Can you tell me what season itis? What floor are we on? What city are wein? What country are we in? What state are we in? [Ask the patient if you may test his/her memory. Say the words “ball”, “flag” , tree” clearly and slowly. Then ask the patient to repeat the words. Check for each Correct response. The frst repetition determines the score. Ifthe patient does not repeat all three correctly, keep saying them up tosix tries until the patient can repeat them. IML ATTENTION AND. CALCULATION ‘A.Counting Backwards Test Ask the patient to begin with 100, ‘and count backwards by 7.Record ‘each response. Check one box at right for each correct response. The score isthe number of correct subtractions. B. Spelling Backwards Test ‘Ask the patient to spell the word "WORLD" backwards. Record each response. Use the instructions to determine which are correct responses, and check one boxat right for each correct response. Ball Flag Tree Record each response 93 86 9 n 6 Number of Trials: ‘Maximum score: 1 f 1 1 93NAC OSCE | A Comprehensive Review C.Final Score Compare the scores of the Counting Backwards and Spelling Backwards Final Score: __ tests. Write the greater of the two (Max of 5 or Greater of| scores in the box labeled FINAL the two scores) ‘SCORE at right, and use it in deriving the TOTAL SCORE. IV. RECALL Maximum scor ‘Ask the patient to recall the three Ball 1 ‘words you previously asked him/her o = ‘to remember. Check the Box at right a ee for each correct response. Tree 1 V, LANGUAGE Naming ‘Watch Show the patient a wrist watch and ask | Pencil 1 him/her what its. Repeat for a pencil. Repetition | ‘Askthe patient to repeat “Noifs,ands, or | Correct repetition 1 buts” ‘Three ~ Stage Command Establish the patient's dominant hand. Give Takes paper in hand 1 the patient a sheet of blank paper and say, “Take the paperin yourrightlet hand, fold Folds paper in half u in half and put it on the floor: Puts paper on the floor | Reading Hold up the card that reads, “Close your | eyes.” So the patient can see it clearly. Ask him/her to read itand dowhatit says. _| Closes eyes 1 Check the box at right only ifhe/she actually loses his/her eyes. Writing | Give the patient a sheet of blank paper and ask himyher to writea sentence. Itisto be written spontaneously. Ifthe sentence | Writes sentence 1 Contains a patient and a verb, andis sensible, check the box at right. Correct ‘grammar and punctuation are not necessary. Copying Show the patient the drawing of the intersecting pentagons. Ask him/her to ‘draw the pentagons about one inch each | Copies pentagons 1 side) on the paper provided. If ten angles ‘are present and two intersect, check the box at right. Ignore tremor and rotainical Examination 95 DERIVING THE TOTAL SCORE ‘Add the number of correct responses, The maximus is 30. [ 23-30 _—_ Normal 23-19 Borderline Less than 19) Impaired,