OSCE shoulder examination

Sunday, May 08, 2011

5:12 PM

Before starting
 Introduce yourself
 Confirm the patients identity
 Explain the examination to the patient and ask for consent
 Ask patient to undress
 Make sure patient is comfortable

The examination

Inspection Observe shoulder movements while undressing. Symmetry of left and right
side. Position of the arms. Prominence of the acromion, coracoid, ACJ and
SCJ. Assess for erythema, swelling, deformity, scars. Atrophy of deltoid,
supraspinatus and infraspinatus. Look out for Popeye sign indicating
rupture of biceps tendon.

Palpation Does patient have any shoulder pain. Palpate for temperature, deformities,
and tenderness. Also identify the maximum point of tenderness. Palpate
landmarks such as acromion, coracoid, ACJ, SCJ, biceps tendon.

Movement Active motion of abduction, adduction, internal rotation, external rotation,

flexion and extension. Note any crepitus and abnormal mobility. If any one
movement is limited passive motion is tested. Test anterior serratous
muscle by asking patient to put hands against wall and push, observing
scapula for winging or asymmetry.

Muscle MRC power grading.

strength

Special tests Neer impingement test for rotator cuff tendinopathy: a rm is flexed at 90°
with shoulder secured with one hand. The arm is forcefully flexed beyond 90°
narrowing the subacromial space and illiciting pain if +ve.

Speeds test for bicipital tendonitis: elbow is extended and forearm in suppination.
Resist flexion of elbow and palpate biceps tendon. Localised pain in bicipital groove
is +ve test.

After examination
 Done with shoulder examination
 I would like to conclude with neurologic and vascular examination
 Thank patient
OSCE hip examination
Sunday, May 08, 2011
8:31 PM

Before starting
 Introduce yourself
 Confirm the patients identity
 Explain the examination to the patient and ask for consent
 Ask patient to undress
 Make sure patient is comfortable

The examination

Inspection Inspect posture, symmetry of legs and pelvis, deformity, muscle

wasting, scars, erythema. Observe gait from front and back
looking for antlagic gait, shortleg gait, Trendelenburg gait.
Measure true leg length from the anterior superior iliac spine to
the medial malleolus and the apparent leg length from the
umbilicus to the medial malleolus. Measure the quadriceps
circumference at fixed point to check for wasting.

Palpation Does the patient have hip pain. Palpate for temperature,
deformities, and tenderness. Also identify the maximum point of
tenderness.

Movement Active motion of abduction, adduction, internal rotation, external

rotation, flexion and extension. Note any crepitus and abnormal
mobility. If any one movement is limited passive motion is tested.

Muscle MRC power grading.

strength

Special tests Trendelenburg sign: Ask patient to lift one leg up. Positive when pelvis
tilts towards ipsilateral hip and looses balance. Suggests weakness of hip
abductors.

Thomas sign: With patient supine. Flex the hip towards the trunk until
the lumbar lordosis is obliterated. If the contralateral hip flexes its
positive. Suggests hip flexor contracture.

Ober test: Patient lies on side of unaffected limb. Examiner lifts the
affected leg, extends it and adducts it behind the other leg. Positive if
patient cannot adduct leg beyond examination table. Tests contracture of
the iliotibial tract.

After examination
 Done with hip examination
 I would like to conclude with neurologic and vascular examination
 Thank patient

OSCE knee examination

Sunday, May 08, 2011
9:04 PM

Before starting
 Introduce yourself
 Confirm the patients identity
 Explain the examination to the patient and ask for consent
 Ask patient to undress
 Make sure patient is comfortable

The examination

Inspection Inspect for symmetry, muscle wasting, scars, erythema, swelling.

Inspect position: neutral, varus, valgus, fixed flexion or
hyperextension. Assess patellar alignment. Measure the
quadriceps circumference at fixed point to check for wasting.

Palpation Does the patient have hip pain. Palpate for temperature,
deformities, and tenderness. Also identify the maximum point of
tenderness. Flex knee at 90 degrees and palpate for tenderness
along the joint line which may indicate meniscus pathology.
Patellar tap test for effusion. Palpate the tibial tuberosity, medial
and lateral ligaments, femoral condyles.

Movement Assess active and passive flexion and extension. Note any crepitus,
abnormal mobility or clicking sound.

Muscle strength MRC power grading.

Special tests Collateral ligaments: apply varus stress to assess fibular collateral
ligament and valgus stress to assess tibial collateral ligament.

Anterior and posterior drawers test: sit on patients foot and pull
the tibia back and forth to assess the cruciate ligaments.

Lachmans test: flex the knee 30 degrees and try to make joint
surfaces slide over each other to assess anterior cruciate ligament.

Mcmurray's test: for medial meniscus palpate the posteromedial

margin of joint, rotate the knee externally and extend the knee.
For lateral meniscus palpate the posterolateral margin of joint,
rotate the knee internally and extend the knee. Positive test elicits
pain, resistance or click.

Popliteal fossa: ask patient to lie prone. Inspect and palpate for
Baker's cyst.

After examination
 Done with knee examination
 I would like to conclude with neurologic and vascular examination
 Thank patient
OSCE neurologic examination
Sunday, May 08, 2011
9:32 PM

Before starting
 Introduce yourself
 Confirm the patients identity
 Explain the examination to the patient and ask for consent
 Ask patient to undress
 Make sure patient is comfortable

The examination

Inspection Inspect for symmetry, atrophy, deformity, fasiculations, gait and

position of limbs. Gait look out for shuffling gait of Parkinson's,
wide stepping gait of cerebellar disease, high stepping gait of foot
drop.

Palpation Palpate for muscle bulk, tone and power. Note lead pipe and cog
wheel rigidity in Parkinson's disease. Note hypertonia in UMN
lesions and hypotonia in LMN lesions. Measure muscle
circumference of biceps and quadriceps and calf muscles.

Coordination Finger nose test, heel shin test, tandem gait, Romberg sign and
pronator drift. All assess cerebellar function.

Motor reflexes Ankle (S1, S2)

Knee (L3, L4)
Biceps (C5, C6)
Brachioradialis (C5, C6)
Triceps (C7, C8)
Superficial reflexes: cremasteric, abdominal reflex, Barbinski

Sensory Pain and temperature assess the spinothalamic tract. Vibration and
position sense assess the posterior column. Start peripherally.

After examination
 Done with neurologic examination
 Thank patient

OSCE cardiac examination

Sunday, May 08, 2011
11:21 PM

Before starting
 Introduce yourself
 Confirm the patients identity
 Explain the examination to the patient and ask for consent
 Ask patient to undress
  Make sure patient is comfortable

Positioning
 Adjust bed to 45 degrees for cardiac position

The examination

Inspection Patient comfortable or distressed? Inspect the hands for clubbing, splinter
hemorrhages, Osler nodes, Janeway lesions. Also peripheral cyanosis, nicotine
staining, pale palmar creases and tendon xanthomata. Cushing's moon face, central
obesity, buffalo hump. Malar flush in mitral regurgitation. Eyes for pale conjunctiva,
xanthelasma and corneal arcus. Central cyanosis, high arched palate in Marfans
syndrome. Neck vein distention. Chest for surgical scars, pacemaker mass, dilated
veins and precordial activity.

Palpation Palpate the pulses rhythm, character, symmetry and radiofemoral delay. Slow rising
in AV stenosis, collapsing in AV regurgitation and bounding pulse in hypercapnia.
Palpate precordium for point of maximum intensity; its position, amplitude and
diameter. Assess for heaves and thrills. Palpate abdomen for pulsatile mass in
aortic aneurysm, and liver for tender hepatomegaly seen in RHF and pulse in TV
regurgitation. Palpate the ankles and sacrum for pitting edema seen in RHF.

Percussion Percuss lung bases for pulmonary edema seen in LHF.

Auscultation Auscultate the aortic, pulmonic, mitral and tricuspid valve. inspiration attenuates
right sided sounds and expiration attenuates left sided sounds. Leaning forward
attenuates AV regurgitation and lying on left side attenuates mitral stenosis.
Auscultate the lung bases to appreciate crackles in pulmonary edema and bruits in
carotid, femoral and renal arteries.

After examination
 Done with cardiac examination.
 I would like to conclude examination by obtaining vital signs: BP, temperature.
 Fundoscopy: papiledema, retinal hemorrhages
 Thank patient

OSCE respiratory examination

Monday, May 09, 2011
7:41 AM

Before starting
 Introduce yourself
 Confirm the patients identity
 Explain the examination to the patient and ask for consent
 Ask patient to undress
 Make sure patient is comfortable

Positioning
 Adjust bed to 45 degrees for cardiac position
 The examination

Inspection Patient comfortable or distressed? Is the patient breathless or cyanosed? Does he

have to sit up to breathe? Is his breathing audible? Is he coughing? Note the rate
and depth of breathing. Look for deformities such as pectus excavatum, pectus
carinatum or kyphosis. Observe symmetry of chest expansion, use of accessory
muscles of respiration, recesses, nasal flaring. Operative scars. Inspect the hands
for clubbing, nicotine staining and test for flapping tremor of hypercapnia. Inspect
the hand and mucus membranes for cyanosis and neck for jugular venous pressure.

Palpation Palpate the radial pulse and assess the rate, rhythm and character. Is it bounding as
in hypercapnia or shock. Palpate the cervical, supraclavicular and infraclavicular
lymph nodes. Palpate for tracheal deviation and the position and diameter of the
apex beat. Palpate for equal chest expansion. Test for tactile fremitus: is increased
(consolidation) or decreased (pleural effusion, lung collapse).

Percussion Percuss the chest: is resonance increased (emphysema, pneumothorax) or dullness

(consolidation, fibrosis, pleural effusion).

Auscultation Auscultate anterior and posterior chest with patient breathing through the mouth
comparing both sides. Vesicular or bronchial breath sounds? Wheezes or crackles?

After examination
 Done with respiratory examination.
 I would like to conclude examination by getting sputum collection, measuring PEFR and maybe a CXR.
 Thank patient

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