Osce Stations Lecture Note

OSCE Stations • • • • • • • • • • • • • • Anaesthetics Abdomen Cardiovascular Respiratory Neuro o Upper Limb o Lower Limb o Cranial Nerves o Cerebellum o Speech o Higher cognitive function Vascular o AAA o Arterial o Venous o Ulcers Head & Neck Thyroid Breast Lump in groin MSK o Gals o Spine o Shoulder o Elbow o Hand o Hip o Knee o Foot Disability & Rehab Ethics Radiology 2 4 6 8 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 Anaesthetics/Resus Station Notes for this station: It is important to call for help early. There will almost certainly be an observation chart to look at at some point. Know about sats monitors, non-invasive BP monitoring, CVP lines, etc. Resus Drugs Adrenaline Amiodarone Mg Sulphate Atropine Cardiac arrest Refractory VF/VT Refractory VF/VT With hypo-Mg PEA 1mg iv/io every 3-5 mins (10ml 1:10,000 iv) 300mg iv 2g bolus iv 3mg iv once only Anaphylaxis Drugs Adrenaline 0.5ml 1:1,000 im Then chlorpheniramine and hydrocortisone (don’t need these doses). Salbutamol for wheeze MI Drugs Aspirin Morphine GTN Atenolol 300mg chewed 5-10mg iv titrate to effect + metoclopramide 10mg iv 2 puffs / 1 tablet as required 5mg iv (unless asthma/LVF) Acute Asthma Drugs Salbutamol Ipratropium Prednisolone MgSO4 5mg nebulised with O2 (every 15 mins if necessary) PLUS 0.5mg neb with O2 30mg po or hydrocortisone 100mg iv 1.2-2mg iv if still unwell Status Epilepticus Oxygen, thiamine, glucose unless known to be normal Lorazepam 4mg slow iv bolus (step 1) Painkillers Paracetamol Ibuprofen Diclofenac Tramadol Oramorph Morphine 1g/4hrs SE: few 400mg/8hrs 50mg/8hrs CI: Bleeding, Asthma, Renal impairment, Stomach SE: GI upset, hypertension, gastric erosion 50-100mg/8hrs 10mg/2-4hrs 1mg/ml solution iv, give 2ml bolus, wait 2mins, then titrate to effect Caution: head injury, ↑ICP, alcohol, respiratory depression SE: N+V, drowsiness, constipation, hypotension Basic Life Support DR ABC D R A B C NB Check for danger Check response Head tilt chin lift Look and listen for airway obstruction Look, listen feel for breathing 30 chest compressions 2 rescue breaths NO → Shout for help NO → Get help In hospital fetch resus team and trolley before starting chest compressions Continue until pt better, told to stop or exhausted LMA: attempt continuous chest compressions ETT: continuous chest compressions Primary Survey Airway Management and Oxygen Therapy Head tilt chin lift or jaw thrust Look and listen for signs of airway obstruction Cyanosis, see-saw breathing Silent, stridor, snoring, gurgling Consider Yankauer sucker, oropharyngeal tube, nasopharyngeal tube Give oxygen Non-rebreather mask + 15L/min O2 Or if COPD and not life-threatening Venturi 28% titrate to ABGs: PaO2>8, ↑PaCO2<1.5 Cervical Spine Immobilisation / Spinal Board Breathing SATS MONITOR Respiratory rate Trachea Chest inspection and palpation Chest expansion Percussion Auscultation Look specifically for tension/open pneumo, massive haemo, flail chest, tamponade Consider bag/valve/mask or intubation and ventilation Circulation and Fluid Management Work up the arm Colour, temp, cap refill, condition of veins Pulse, BP Hypovolaemia ↓conscious level, ↓urine OP (if already has catheter) Haemorrhage Floor, internal (including pelvic spring), external Interventions 2x wide bore cannulae Take bloods (check TEMP – cultures if febrile) Fluid challenge with Hartmann’s or N saline (!HF, liver failure) Normovolaemia 500mL Hypovolaemia 1L Known HF 250mL Reassess pulse, RR BP at 5mins ↓Pulse pressure earliest sign shock at Stage II (15-30% blood loss) Disability Ensure pupils, GCS and glucose (if not done before) + temp (if you forgot earlier) Exposure Ensuring dignity & avoiding hypothermia. Check for rash, bruising, bleeding, etc Abdomen OSCE Station Prelude Introduction and consent Patient name, age and reason for admission Position (start sitting up) & exposure (nipples to knees but preserve dignity!) General Patient Bedside Jaundice, Cachexia, abdo distension NG tube, stomas, catheter, feeds Peripheral (check both sides!) Nails Leuconychia - Hypoalbuminaemia – usually due to cirrhosis Koilonychias - iron def anaemia, fungal nail infection or Raynauds Clubbing - GI causes are IBD (esp crohns), cirrhosis, GI lymphoma & malabsorption Cap refill – always good practice! Hands Scratch marks – assoc with cholestatic jaundice Bruising – sign of poor clotting Dupuytren’s contractures – thickening of palmar aponeurosis. Assoc with liver dis. Palmar erythema – due to excess oestrogens. Assoc with liver failure Arms Pulse, RR, BP – good practice Asterixis - coarse flap seen on extension of the wrists due to hepatic encephalopathy Face Jaundice Mucous membrane pallor - anaemia Xanthelasma – cholesterol depositis under skin around eyes. Assoc with high cholesterol, primary biliary cirrhosis & DM Angular cheilitis & Glossitis – assoc with B12 & iron deficiency Dentition – indication of nutrition Ulcers – assoc with Crohn’s disease Lie patient at 45° Neck JVP – enlarged liver with raised JVP = right heart failure Virchow’s node – palpable supraclavicular LN (usually LHS) – sign of visceral malignancy Chest Spider Naevi (spider angiomas) – dilated capillaries over distribution of SVC. Assoc with cirrhosis. Allowed 3 before classified as significant Gynaecomastia – due to excess oestrogens – Assoc with liver failure Scratch marks & bruising – see earlier Lie patient flat Abdomen Inspection Scars, stomas – prev surgery. Location & style indicates nature of stoma Down on the level - AAA, visible perstalsis Distension – ascites, due to portal hypertension / hypoalbuminaemia / both! Caput Medusae – varicose veins radiating from the umbilicus Cullen’s sign – Periumbilical bruising – assoc with intraperitoneal haemorrhage – esp pancreatitis and ectopic pregnancy Grey Turner’s sign – retroperitoneal haemorrhage. Assoc with leaking AAA and pancreatitis Palpation Any pain? Shallow fb deep palpation. Always WATCH THE FACE! For specific organs – liver, kidneys, spleen, AAA Percussion - Quadrants, liver, spleen, shifting dullness, bimanual palp spleen Auscultation - Bowel sounds, renal/mesenteric bruits Specific tests / points – McBurney’s – tenderness at 2/3 between umbilicus & ASIS = Appendicitis Courvoisier's law - Enlargement of the gallbladder with jaundice is likely to result from carcinoma of the head of the pancreas and not from a stone in the common duct, because in the latter the gallbladder is usually scarred from infection and does not distend. Murphy’s sign – pain & arrest of deep inspiration with 2 fingers laid over RUQ (with –ve on LUQ) Suspicion of peritonitis → ask patient to blow tummy in and out To complete the examination Examine the hernial orifices, external genitalia, do a PR, urinalysis & look at the charts Cardiovascular OSCE Station Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (start sitting up) General Patient Comfort at rest, congenital conditions (downs, marfans), valve clicks, signs of Graves (can cause AF), Oxygen, nitrates, ECG Bedside Peripheral Nails Cap refill – should be < 2 sec Clubbing – congenital cyanotic heart disease & endocarditis Splinter haemorrhages & nail fold infarcts – infective endocarditis / other vasculitis Hands Osler’s nodes – tender nodules in finger pulps = endocarditis Janeway lesions – red macules on palms = endocarditis Xanothmata – hyperlipidaemia (depositis alog tendons) Arachnodactyly – marfans Polydactyly – assoc with ASD Pulse Rate – Tachy > 100, Brady < 60 Rhythm - regular, irregular (2o heart block / ventricular bigeminy), irregularly irregular (AF / multiple ectopics) Character - collapsing (aka waterhammer - check using radial, ALWAYS ask about shoulder pain = aortic incompetence / PDA), slow-rising (aka anacrotic = aortic stenosis) Volume – low (aortic stenosis, shock, pericardial effusion), med (normal), high / bounding (CO2 retention, liver failure & sepsis) Delay - radio-radial (aortic arch aneurysm), radio-femoral (coarctation of the aorta), RR, BP lying and standing Face Eyes: Xanthelasma - lipid around eyes Corneal arcus - grey/yellow ring around cornea due to hyperlipidaemia Pallor / Cyanosis of mucous membranes Skin: Malar flush (mitral stenosis) Mouth: Central cyanosis, dentition, high arched palate Lie patient at 45°if not already Neck JVP: NB. Raised if > 4cm over manubriosternal angle. Pressing on liver should cause transient increase. If perists over 15 sec = +ve hepatojugular reflux sign = right ventricular failure due to inability to eject increased venous return Raised JVP – fluid overload / right heart failure / SVC obstruction (absent wave form) Carotid pulses – symmetry and character Central Trachea – MUST DO!. If displaced can affect Apex etc Chest Inspection: Scars (median sternotomy can be CABG, valve or congenital repair. Check legs for vein harvesting), pacemaker Palpation: Apex beat Apex heave = outflow obstruction (e.g. aortic stenosis / systemic HT) Left Parasternal heave = RV enlargement (e.g. pulmonary stenosis, cor pulmonale) Thrills = transmitted murmurs Auscultation Palpate carotid pulse whilst listening – 4 areas – Mitral - Apex Tricuspid - 5th IC left sternal edge Pulmonary - 2nd IC left sternal edge Aortic - 2nd IC right sternal edge + carotids for radiation of Aortic stenosis + L axilla for radiation of mitral regurg Listen for: HS - volume, splitting Added sounds - sys and diastole Murmurs - sys and diastole; radiation to axilla/carotids Volume - Expiration increases venous return à louder right sided murmers. Inspiration has opposite effect Aortic Regurg: sit up, held expiration, listen at left sternal edge Mitral stenosis: roll to left side, held expiration, listen at apex Then allow patient to relax to normal sitting Back – while sat forward for aortic regurg Lung bases - thinking time + crackles = pulmonary oedema = LEFT cardiac failure Sacral oedema – RIGHT cardiac failure Legs Ankle pitting oedema, signs of peripheral vascular disease To complete the examination Look at the charts, BP, full peripheral pulses, Fundoscopy, 12 lead ECG Ejection systolic = peaks mid systolic (when flow is highest) – e.g. Aortic stenosis, pulmonary stenosis, common & innocent in children & tachycardia / pregnancy S1 S2 S1 Pansystolic = uniform & merges with S2 – e.g. mitral / tricuspid regurg or VSD S1 S2 S1 Early diastolic = high pitched, easy to miss - E.g. Aortic & pulmonary (rare) regurg S1 S2 S1 Mid diastolic = low pitched, rumbling – e.g. mitral stenosis, RF aortic regurg S1 S2 S1 Opening snap Respiratory OSCE Station Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (START AT 45°) General Patient Comfort at rest LOOK at their breathing (accessory muscles etc), LISTEN to their breathing Kussmalls = Rapid deep resp Cheyne Stokes = apnoea alternating with hyperpnoea Cough Bedside Oxygen, nebulisers, steroids, sputum pot Peripheral Nails Cap refill Rothman’s sign – tobacco staining of fingers Clubbing – Bronchial cell Ca, Chronic lung suppuration (empyema, abscess, bronchiectasis, CF), Fibrosing alveolitis, mesothelioma Hands Steroid skin Wasting of intrinsic hand mm = T1 lesion (pancoast tumour) Arms Pulse, RR, BP CO2 retention flap (asterixis) – hold hands extended to 90o, should flap together Wrist tenderness - HPOA (hypertrophic pulmonary osteoarthropathy) = symmetrical arthritis, severe clubbing, gynaecomastia. Assoc with Lung Ca Face Cushingoid facies Eyes: Horner’s – ptosis + constricted pupil. Assoc with pancoast tumour Conjunctival h’hage – assoc with raised thoracic pressure – e.g. chronic cough Pallor of membranes – are resp symptoms due to anaemia Sarcoid - conjunctivitis, uveitis, dry eye, facial palsy Nose: Polyps – assoc with asthma & CF Mouth: Central cyanosis Candida - steroids Neck Lymph nodes – with patient sat forward, examine from behind Central trachea – if deviated pathology likely to be in upper lobes JVP - for cor pulmonale Chest Inspection Chest expansion, symmetry, deformity, scars Respiratory effort: accessory muscles, recession, tracheal tug Mode of breathing: thoracic or abdominal Palpation Chest expansion (3-5cm normal) – at least 3 levels front (& Back) Apex beat, RV heave Tactile vocal fremitus – 99 while palpating with ulnar aspect of hand. Increased shows consolidation. Can do if percussion etc à suspicion Percussion Apex to costal margin. DON’T FORGET AXILLAE Dullness – collapse, consolidation, fibrosis, pleural thickening / effusion Liver dullness should be upto 5th rib mid clavic. If below = hyperinflation Hyperresonant – Pneumothorax or hyperinflation (COPD) Auscultation Breath sounds: Bronchial (tissue is firm / solid) e.g. consolidation, fibrosis. Decreased if pleural effusions, pleural thickening, Pneumothorax, asthma, COPD Added sounds: Wheeze (monophonic / polyphonic) – narrowed airways Crackles (fine / coarse, clear on cough?) – reopening of collapsed airways Rub – pneumonia, pulmonary infarction Note which phase of respiration (early / late) sounds occur Whispering pectoriloquy if Area dullness to percuss / reduced sounds ↑sounds (bleating) in consolidation ↓sounds in pleural effusion Back Inspection, percussion, auscultation Peripheral Legs Peripheral oedema To complete the examination Peak flow, sputum inspection, O2 sats and temperature Upper limb Neuro OSCE station Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (start sitting up) Ask about pain in joints / muscles UMNL ↑tone, clonus,↑reflexes, +ve Hoffmans, weakness LMNL ↓tone, ↓reflexes, fasciculations, wasting, weakness General Patient - Posture, involuntary movements Bedside - Aids Inspection - UMNL/LMNL signs, contractures, scars, tremor MRC scale: 3+ constitutes useful power Pronator drift – palms towards the ceiling (arms outstretched) and eyes shut. Drift indicates general weakness, UMNL, cerebellar, ↓proprioception. And indicates the abnormal side 0 1 2 3 4 5 No movement Flicker Movement, but not against gravity Movement against gravity Movement against light resistance Full power Tone – Be careful with the shoulder in the elderly. Mainly check wrist and elbow tone Power – first ask the patient to take the position = grade 3, then test resistance Position Chicken wings Elbows to side Elbows bent (don’t let me straighten) Straighten elbow (don’t let me bend) Cock wrists up (don’t let me move) Flex wrists (don’t let me straighten) Power grip Finger spread Palm up, thumb to ceiling Muscle group Deltoid Pectoralis Major Biceps Nerve Axillary Medial pectoral Musculocutaneous Root C 5, 6 C 7, 8 C 5, 6 Triceps Radial C 7, 8 Wrist extensors Radial C 7, 8 Wrist flexors Median C8, T1 FDP, FDS Extensor digitorum Interossei Abductor pollicis Median, ulnar Radial, ulnar C8 T1 Median (post carpal tunnel) C8, T1 Reflexes Biceps (C5,6), Triceps (C7,8), Supinator (C5,6) Hoffman’s reflex (UMN sign) Sensory Cotton wool (dorsal column) and pinprick (spinothalamic) Vibration and proprioception Offer temperature testing Assess for sensory neglect Coordination Finger-nose pointing, buttons, writing Lower Limb Neuro OSCE Station Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (start sitting up) General Patient - Posture, involuntary movements Bedside – walking aids Inspection - UMNL/LMNL signs, contractures, scars, tremor UMNL ↑tone, clonus,↑reflexes, +ve Babinski, weakness LMNL ↓tone, ↓reflexes, fasciculations, wasting, weakness MRC scale: 3+ constitutes useful power 0 1 2 3 4 5 No movement Flicker Movement, but not against gravity Movement against gravity Movement against light resistance Full power Motor - Tone & clonus at the ankle (3 or less beats normal) Power (MRC grade 0-5) Position Hip flexion Knee flexion Knee extension Foot dorsiflexion Foot plantarflexion Big toe extension Muscle group Iliopsoas Hamstrings Quadriceps Tibialis anterior Gastrocnemius Nerve Lumbar sacral plexus Scaitic N Femoral N Deep fibular N Tibial N Root L 2, 3 L 5, S1 L 3, 4 L 4, 5 S 1, 2 Extensor hallucis longus Deep fibular N L5 Reflexes: Patellar (L3,4), Ankle (S1,2), Babinski (plantar) Sensory Cotton wool (dorsal column) and pinprick (spinothalamic) Vibration and proprioception Offer temperature testing Assess for sensory neglect Coordination Ankle-shin slide Walk if possible L4,5 L2,3 L5, S1 S1,2 L3,4 L4,5 Cranial Nerves OSCE Station Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (start sitting up) General Patient - Posture, involuntary movements Bedside – Aids, glasses, hearing aids, food thickener Cranial Nerves CN I (Olfactory) CN II (Optic) Ask the patient Visual acuity, visual fields to confrontation Pupils to light (and accommodation, CN III) Offer Fundoscopy CN III, IV, VI Eye movement: ask re: diplopia. Nystagmus 2 or less normal Oculomotor III Ptosis, miosis, pupil down and out Trochlear IV Diplopia on looking down and in Abducens VI Diplopia on looking laterally CN V (Trigeminal) Sensation on the face - Assess for sensory neglect Motor: open jaw – deviates TOWARD lesion CN VII (Facial)Movements: wrinkle forehead, close eyes, blow out cheeks, show teeth Forehead sparing in UMNL Ask re: altered taste CN VIII (Vestib.cochlear) Hearing, Rinne, Weber’s Ask re: problems with balance, vertigo. Offer Rhomberg’s test CN IX (Glossopharyng). Say “ahhh”, uvula moves AWAY from lesion Offer gag reflex CN X (Vagus) Assess dysphonia CN XI (Accesory) Shrug shoulders, turn head opposite side CN XII (Hypoglossal) Tongue side to side; moves TOWARD lesion, test power in cheek Extras Offer formal visual field and hearing tests Cerebellum OSCE Station Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (start sitting up) General Patient Bedside Posture, including truncal ataxia, involuntary movements Signs of stroke disease, CN lesions Aids Cerebellum D A N I S H Dysdiadochokinesia Ataxia (truncal) Nystagmus Intention tremor (Finger-nose testing/heel-shin) Staccato / scanning speech Hypotonia/hyporeflexia Sequence to test in: Ask about problems with balance and coordination (speech) Slow, Deliberate production of syllables Prosody (monotonous speech due to equal stress) Scanning: slurred, monotonous speech Staccato: each syllable pronounce individually due to unintentional pauses Observe eyes, then test eye movements (nystagmus) Dysdiadochokinesia – start slow, building speed: both sides Finger-nose pointing (intention tremor): both sides OFFER TO TEST FOR HYPOTONIA, HYPOREFLEXIA Legs Heel-shin test (on couch if possible) Walk the patient Heel – toe test (walk the tightrope) Speech OSCE Station Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (start sitting up) General Patient - Stroke disease, CN lesions, other neuro disease (obvious other neuro) Screening test: tell me your name and address Receptive aphasia/dysphasia 1 stage command: close your eyes 2 stage command: touch your ear with your little finger Expressive aphasia/dysphasia Tell me your name and address Word finding “what is this?” Watch / pen / chair, etc. Speech fluency and inappropriate words “tell me what you had for breakfast” Dysarthria Say P-P-P for me facial / lip movement Say C-C-C for me palatal movement Say T-T-T for me tongue movement Repeat after me: West Register St, British Constitution, baby hippopotamus Comment on presence or absence of dysphonia Cough (vocal cord dysfunction) Cranial Nerves – assess CN 9-12 as all essential for fully functional speech Extras Sheffield screening test Assess reading and writing MAKE SURE you keep your hands still throughout the test and don’t mime any of the actions. Keep nodding and other non-verbal gestures to a minimum. Try not to correct the patient as this can cause distress. Higher Cognitive Function Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (start sitting up) General Patient Bedside GCS 1 2 3 4 5 6 Signs of neuro disease Carer, catheter bag Eyes Verbal Motor No response Open to pain Open to voice Open spontaneously No response Sounds Inappropriate words Disorientated Appropriate conversation No response Extensor response Flexor response Withdraws to pain Localises pain Obeys commands Abbreviated mental state 1. Tell patient an address (32 South St) and ask them to recall it at the end 2. Recognise two people (e.g. doctor, nurse) 3. Name of hospital / institution 4. Age 5. Date of Birth 6. Time (to nearest hour) 7. Year 8. Dates second world war 9. Name current monarch 10. Count backwards from 20 to 1 1. (recall) Ask patient to recall address Score out of 10 Extras GCS: serial testing more important than one score Mini-mental state test Vascular Station AAAs Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (start sitting up) General Patient Comfortable at rest, visible mass in the abdomen Wheelchair Peripheral Hands Shock: colour, temperature, cap refill Rothman’s sign, signs of chronic upper limb ischaemia Arms Pulse (rate, rhythm, character), RR, BP Face Xanthelasma, arcus senilis Lie patient at 45° Neck Chest JVP Carotid pulse; bruits Spiders, scratch marks, bruising, gynaecomastia Lie patient flat Abdomen Inspection Palpation Down on the level: AAA, scars Any pain? Shallow, deep AAA: pulsatile / expansile; transverse diameter Auscultation Bruits: aorta, renal, femoral arteries Legs Femoral pulses Extras Examine for cardiovascular and peripheral vascular disease Serial US to assess size Peripheral arterial Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (start STANDING if possible without trousers / socks) General Patient Comfortable at rest, wheelchair Signs of CV disease, diabetes, smoking Bedside Peripheral Hands Arms Pallor, polycythaemia, cyanosis Rothman’s sign BP both arms Legs Inspection With patient standing, inspect legs FRONT AND BACK Ask patient to lie on the couch Colour, muscle bulk, tissue defects / loss, esp. ulcers, scars, e.g. bypass op Oedema, hair distribution Note any venous disease Palpation Temperature AAA Pulses: femoral, popliteal, post. Tibial, dorsalis pedis, toe cap refill Auscultation Bruits abdominal aorta → popliteal OFFER BUERGER’S TEST Raise leg v. slowly to 90° watching for onset of pallor Pallor at 25° critical ischaemia Pallor at 50° severe ischaemia Place leg in dependent position and watch for reactive hyperaemia Extras ABPI 0.9 – 1.2 0.6 – 0.9 0.3 – 0.6 < 0.3 CV examination Normal Claudicating Rest pain Critical ischaemia Peripheral venous Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (start STANDING if possible without trousers / socks) General Patient Comfortable at rest, wheelchair / bandaged legs CV disease, diabetes, smoking Bedside Legs Inspection FRONT AND BACK, particularly the gaiter area Long and short saphenous veins, subcutaneous veins for: Tortuousity, dilation, scars, oedema, venous eczema, haemosiderin, lipdermatosclerosis, atrophie blanche, ulceration, thrombophlebitis Venous landmarks Long saphenous vein Short saphenous vein Saphenofemoral junction Saphena varix Medial lower limb Posterior calf 1cm medial to femoral pulse 5cm below and medial to femoral pulse Palpation Saphena varix Palpate, cough impulse Tap test: tap proximally , feel thrill distally Saphena varix: feel below the knee (incompetence beneath SV) Varicose veins Auscultation Listen over varicosities for bruits to exclude AV fistulae Trendelenburg / tourniquet test Raise the patient’s leg and rest it on shoulder Stroke blood out of veins Place hand or tourniquet 2/3 way from knee to groin Ask patient to stand If veins fill above→ SFJ incompetent If veins fill below → perforators incompetent Point out can be done at different levels to find incompetence Doppler test Indications: Detect venous reflux in LSV, SSV, calf communicators Method: Put jelly over the SFJ, Squeeze calf, and let go. WHOOSH-WOP = competent. WHOOSH-WHOOP = incompetent. Repeat with perforators as required. Part 2: Put tourniquet around thigh & repeat. If WHOOSH-WOP competent deep / WHOOSH-WHOOP incompetent deep – because the superficial system occluded by tourniquet Extras Duplex doppler of deep venous system Peripheral neuro if suspicion of diabetic ulceration Abdomen and pr exam to exclude obstructing pelvic mass Ulcers Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (start STANDING if possible without trousers / socks) General Patient Bedside Comfortable at rest, wheelchair / bandaged legs CV disease, diabetes, smoking Bandaging, dressings, mattresses, cushions Ulcer Is the ulcer painful? Yes→ Arterial, some venous, infective No→ Neuropathic, venous in diabetics Sloughy, stinky sores defy elegance, broadly speaking Site Size Shape Depth Edges Venous (gaiter area) Neuropathic (site trauma – side foot / heel) Arterial (periphery of limb – toes / pressure area) relate to surrounding structure – superficial, full thickness, down to bone Flat, sloping - usually healing ulcer (e.g. healing venous ulcer) Punched out - typical of ischaemic / Neuropathic ulcer Undermined - when infection affects subcutaneous tissues more than skin (e.g. pressure sore / T.B. in past) Rolled - slow growth tissue in edge ulcer (BCC) Everted / heaped - quickly growing periphery (carcinoma) Base Healthy granulation - sloping edge, margin healing tissue Sloughy - +/- infected areas associated.Swab the discharge! dress to dissolve, lift off slough. Necrotic - grey / black tissue. must go before healing can occur – slough off, lift off Surrounding skin (“the surrounding tissues show evidence of…”) Feel foot pulses (arterial disease) Look for signs of venous disease Check sensation (neuropathic ulcer) Extras Offer to swab only if signs of spreading infection Offer full peripheral arterial / venous / neuro exam Head and Neck Station A lump in the neck Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (start sitting up) History of the lump Duration of lump Symptoms Pain (triggers), bleeding, interference with breathing, swallowing Malaise, fever, weight loss Changes Size, pain, feel Movement Does it disappear or move? Do you have any other lumps? OFFER PERIPHERAL THYROID EXAMINATION (see below) Lump from the Front General Body habitus (thyroid disease) Lump site Which triangle? What structures is it associated with? Lumps deep to a muscle will disappear on muscle contraction. Descriptive Position, Colour, Translucency Movement on swallowing, on tongue protrusion GO TO THE BACK TO EXAMINE FURTHER Lump from the Back Palpation: Temperature, Tenderness, Tethered?, Shape, Size, Surface, Edge Relations to local LNs Auscultates over the lump Extras Other lymph nodes ENT examination Differential - Lumps In the Neck Midline Thyroid Thyroglossal cyst Anterior triangle Lymph node Lipoma Branchial cyst Salivary gland tumour Carotid body tumour Posterior Triangle Lymph node Lipoma Cystic hygroma Cervical rib Thyroid Examination Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (start sitting up) General Patient Thyroid from end of the bed Body habitus, hair, skin, sweatiness Bedside Peripheral Nails Hands Arms Eyes* Thyroid acropachy* Palmar erythema, sweatiness Tremor Pulse (AF, tachy, brady), BP Inspection - Chemosis (oedema around eye) Lid retraction - <1/2 iris hidden beneath upper lid Exophthalmos - sclera visible below iris Lid lag - Overactivity of levator palpebrae superioris Eye movements - Ophthalmoplegia Neck Inspection Site, size, shape, of lump; scars Puckered overlying skin Distended neck veins GO TO THE BACK TO EXAMINE FURTHER Palpation Tilt head forwards to relax ant. Muscles Check lump is thyroidal: ask pt to swallow and stick out tongue Lymph nodes Trachea Percussion Define lower extent Auscultation Bruit Legs - Pretibial myxoedema Extras - Lymph nodes, ENT, Ophthalmic examinations Single nodule Multinodular Diffusely enlarged Cyst, adenoma, carcinoma Only palpable nodule of multinodular goitre Multinodular goitre, anaplastic carcinoma Graves, thyroiditis, hyperplastic thyroid, multifocal Ca Breast Station Prelude Introduction and consent Patient name, age, reason for admission ?Chaperone Position and exposure (start sitting up) General Patient Cachexia, mastectomy/reconstruction/scars Mets: jaundice, SOB, neuro, ortho Breast Inspection Asymmetry, tethering, dimpling, colour changes Pt sitting up pressing hands to the hips Pt sitting up arms in the air Pt sitting up pressing hands to the head Nipple: inversion, discharge, eczema Ask patient to lie at 45°, tilted away from examining side. Arm examining side lifted, head relaxed Palpation Palpate quadrants and axillary tail Palpate areola Does the patient complain of discharge? Which duct? Dipstick it (if not obviously bloodstained) Smear on cytology slide Palpate axillary and supraclavicular nodes Extras - Examination for distant mets: liver, lung, brain, bone Groin and Scrotum Station Prelude Introduction and consent Patient name, age, reason for admission ?Chaperone Position and exposure (start STANDING up – lie down if patient tires) Scrotum Inspection Palpation Anterior then posterior aspect (pull the skin) Colour, scars, symmetry, swelling and lumps Both testes palpable? NO → cryptorchidism Any size difference? Lumps: Can I get above it? Can I feel testis/epididymis? Transillumination Tenderness Landmarks Deep ring Superficial ring Inf. Epigastric A Femoral A pulse 2cm above mid ASIS --> tubercle Over pubic tubercle Just medial to deep ring Midpoint ASIS to pubic tubercle Epidymis swelling Spermatic cord swelling, varicocoele Penis Ask pt to retract foreskin. Don’t forget to lift and look at the dorsum. Groin Cough impulse - Compress lump with the Points of reduction hand, ask pt turn head away and cough Direct – Above the pubic tubercle Reduction medial to the inferior epigastric Stroke hernia up through superficial / artery deep ring Indirect – Above the pubic tubercle Cough with pressure over deep ring and lateral to the inferior Cough without pressure, watch where epigastric artery it bulges Femoral – below and lateral to the pubic tubercle Groin lump Stand at side of standing patient Define landmarks 1 hand in small of pt. back for support, fingers parallel to inguinal ligt. Palpate lump (5S, 4C, 3Ts) Site Colour Tenderness Size Consistency Temperature Shape Compressibility Transillumination Surface Cough / reduction Surroundings Auscultate (bowel → resonant and audible BS) Feel the other side, cough while feeling (? Weak cough impulse) Extras Cover patient Ask to wash hands Pr exam Consider abdo, respiratory (chronic cough), CV (fitness) Lump in the groin differential Lumps Hernia, cryptorchidism, psoas bursa/abscess Vascular Saphena varix, femoral A aneurysm, lymph node Cord Hydrocoele / lipoma of cord GALS Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (start STANDING) General Patient Symmetry, attitude, orthoses, Walking aids Do have any pain or stiffness in your muscles, joints or back? Can you walk and downstairs without any difficulty? Can you dress yourself completely without any difficulty? 1. 2. Walk Inspect from the back – look for A straight spine (no scoliosis/rib-cage asymmetry) Iliac crests at equal height. Normal muscle bulk/symmetry, especially of paraspinal, shoulder, and gluteal muscles. Popliteal swelling. Swelling/asymmetry around the Achilles tendons. Hindfoot deformity (valgus/varus) ACTION: trapezius roll & midpoint of each supraspinatus 3. Inspect from the sides – look for Loss of normal cervical and lumbar lordosis, and alteration of normal mild thoracic kyphosis. Knee deformity (fixed flexion, genu recurvatum, posterior tibial subluxation). ACTION: touch toes (fingers on lumbar spine) 4. Inspect from the front - look for Swelling, abnormal position, skin change over SC and AC joints. Equal shoulder height. Muscle wasting/asymmetry, especially of deltoids and quadriceps. Inability to fully extend elbows. Deformity (particularly varus, valgus) of knee. Deformity (particularly of hallux, MTPJs) of forefoot and alteration of foot arches (especially flat feet) 5. Neck lateral flexion 6. Jaw side to side 7. Shoulder tight pack position 8. Inspect arms – look for Inspect for abnormalities (particularly swelling, deformity, attitude, and skin changes) at distal radioulnar joint, wrists, MCPJs, and IPJs. Look for extensor tenosynovitis Turn the hands over (supination) Inspect the palmar aspects (particularly for wasting, skin changes, and flexor tenosynovitis swelling) 8. Grip: power and pincer 9. Metacarpal squeeze LIE ON THE COUCH 10. Flex each hip and knee while holding the knee whilst feeling for crepitus 11. Passively internally rotate each hip with the hip still flexed 12. Press on each patella and palpate for a balloon sign 13. Foot: Inspect the soles and metatarsal squeeze Spine Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (start STANDING) General Patient Symmetry, attitude, orthoses Bedside Walking aids, orthoses 1. Walk 2. Inspect from the front, side and back – look for Loss of normal curves (cervical and lumbar lordosis, thoracic kyphosis) Scoliosis (apex determines level, convex side determines direction) Reduced chest movement (from intrathoracic disease or arthropathy) Paraspinal muscle spasm (muscles look as though they are bulging out) Skin changes (Moles, vascular malformations, and hairy tufts may indicate the site of underlying congenital abnormalities of vertebral bodies. Note any scars or nodules (most common over the bony prominences). Asymmetry, restriction, or pain on movement 3. Lumbar spine Flexion / extension (2 fingers on vertebral spines), lateral flexion Ask patient to sit, crossing arms over chest 4. Thoracic spine 5. Cervical spine Rotation Flexion / extension, lateral flexion, rotation Ask patient to lie prone on the couch 6. Palpate Temperature, swelling Spinous processes, interspinous ligaments, paraspinal muscles Fibromyalgia tender points Ask patient to lie supine on the couch 7. Straight leg raise 8. SI joint stress test 9. Neurological examination L4-S1 L4 L5 S1 Motor Foot dorsiflexion Big toe extension Plantarflexion Sensory Medial calf Big toe Sole of foot OFFER TO EXAMINE JOINTS ABOVE AND BELOW Extras Full neurological examination Reflex Patellar Ankle jerk Shoulder Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (start STANDING) General Patient Symmetry, attitude, orthoses Bedside Walking aids, orthoses Look Feel Move Test Front, sides and back Symmetry, scars, swelling, deformity, skin, attitude, wasting, orthoses Temperature, joint line tenserness, swelling and crepitus SC joint (shrug), clavicle, AC joint Glenohumoral joint, biceps tendon Painful arc Tight pack and hands behind back Active then passive in turn: Flexion / extension Abduction / adduction Internal / external rotation Rotator cuff: active resisted Abduction: Ext. rotation: Int. rotation: Hand behind back & push away: OFFER TO EXAMINE JOINT ABOVE AND BELOW Assess neurology & vascular status supraspinatus infraspinatus subscapularis teres minor Elbow Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (start STANDING) General Patient Symmetry, attitude, orthoses Bedside Walking aids, orthoses Look Feel Front, sides and back Symmetry, scars, swelling, deformity, skin, attitude, wasting, orthoses Joint line: temperature, swelling, tenderness, crepitus Lat. and med. epicondyles, olecranon process Triangle sign Tennis elbow - tenderness over the common extensor origin at the lateral epicondyle. Resisted active wrist extension reproduces the pain. Golfer's elbow - tenderness over the medial epicondyle at the insertion of the wrist flexor/pronator group. Resisted active wrist flexion with the hand supinated reproduces the pain Move Active then passive in turn: Flexion / extension Pronation / supination Tests Tinel's sign – light percussion over ulnar nerve in medial para-olecranon groove produces tingling Elbow flexion test - elbow in full flexion for 5 min. Tingling in an ulnar distribution again suggests a cubital tunnel syndrome OFFER TO EXAMINE JOINT ABOVE AND BELOW Assess neurology & vascular status Hand and Wrist Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (start sitting with hands on pillow) General Patient Symmetry, attitude, orthoses Bedside Walking aids, orthoses Look Feel Move Nails, dorsum, palmar aspect, lateral raise Function power, pincer, write/do button Hand temperature, metatarsal squeeze, soft tissues Wrist piano key sign, snuff box Fingers 2 thumb palpation of each joint Active then passive in turn Inf. Radioulnar joint pronation / supination Wrist flex / extend, lateral movement MCPs flex / extend IPs flex / extend Thumb adduction / abduction, flex / extend, opposition Assess grip, finger opposition Test Sensation Specials median, ulnar, radial Tinel’s, Phalen’s, Finklestein’s De Quervain's tenosynovitis Localised area of tenderness may be detected in a line along the lateral border of the distal radius (+/- increased temperature and linear softtissue swelling) Finkelstein's test - ask the patient to grasp the thumb in the palm while the examiner cautiously performs passively lateral flexion to the ulnar side. This manoeuvre can be uncomfortable in normal individuals but in de Quervain's tenosynovitis it causes marked pain Carpal tunnel syndrome The patient's symptoms may be reproduced (1) by percussion over the anterior wrist distal to the proximal skin crease (Tinel's sign), or (2) by asking the patient to sustain forced flexion of the wrist for at least 1 min (Phalen's test) The median supplies the lateral two lumbricals, opponens pollicis, abductor pollicis brevis and flexor pollicis brevis ('LOAF'). For thenar weakness test abductor pollicis brevis – restisted active abduction (vertical from palm) OFFER TO EXAMINE JOINT ABOVE Assess neurology & vascular status Hip Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (start STANDING) General Patient Bedside Symmetry, attitude, orthoses Walking aids, orthoses Joint Walk Look Inspect front, side and back Trendelenburg test Ask patient to lie on couch Leg length: measure ASIS to medial malleolus or rule of thumbs Feel Greater trochanter Move Active then passive Flexion (hand under spine) Passive Int / ext rotation (roly poly) Active then passive - Abduction / adduction (hand on opposite pelvis) Test Thomas’ test → fixed flexion deformity Place hand under lumbar spine Flex good hip maximally As lordosis straightens, bad leg may rise from the table OFFER TO EXAMINE JOINT ABOVE AND BELOW Assess neurology & vascular status Knee Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (start STANDING) General Patient Bedside Symmetry, attitude, orthoses Walking aids, orthoses Joint Walk Look Front, sides, back Genu varus (bow legs). Genu valgus (knock knees). Genu recurvatum. Posterior tibial subluxation. Fixed flexion. Ask patient to lie on couch Feel Temperature Bulge sign (flick fluid from side to side) Balloon sign – fingers move lateral on palpation Patella tap – “clonks” onto femur Bend knee while feeling for crepitus Tenderness: joint line, anterior line, ligament insertions and popliteal fossa Move Active then passive in turn Extension / flexion Stability Collateral ligaments – knee 'unlocked' in mild flexion Medial knee pain, particularly at the inferior insertion of the ligament, suggesting collateral ligament enthesopathy (this manoeuvre is basically a stress test for the medial collateral ligament). Cruciate ligaments - These are examined with the knee flexed to 90° and the hip to 45° Before testing for excess movement: Palpate the hamstrings to ensure they are relaxed Observe the rounded contour of the knee from the side to ensure the tibia is not starting in a posteriorly subluxed position OFFER TO EXAMINE JOINT ABOVE AND BELOW Assess neurology & vascular status Ankle and Foot Prelude Introduction and consent Patient name, age and reason for admission Position and exposure (start STANDING) General Patient Bedside Symmetry, attitude, orthoses Shoes, walking aids, orthoses Joint Walk Look Inspect front, side and back Arches. Hallux valgus, Hammertoe deformity, Mallet toe, Calcaneovalgus (eversion), Calcaneovarus (inversion), Fixed plantar flexion (talipes equinus) Congenital clubfoot (talipes) Ask patient to lie on couch Feel Move Test Inspect soles, toenails & footware Temperature, metatarsal squeeze Lat. malleolus, med. malleolus, joint line, Achilles tendon, plantar ligs Feel each ray in turn using 2 thumb technique for toes With hand over the ankle to feel crepitus: Active then passive flexion / extension Subtalar joint Midtarsal joints Active then passive toe flexion / extension Pedal pulses Sensory: stocking distribution, L4-S1 OFFER TO EXAMINE JOINT ABOVE Assess neurology & vascular status Disability/Rehab Station ICF Recognise activities : opening a door, making a cup of tea PERSON: mpairment, Activity, Participation Recognise barriers in the environment ENVIRONMENT: People, Policy, Physical environment (all aspects) PAPER Pathology/Impairment Activity Participation Environment Risk People, Policy, Physical environment Aids to mobility Available through physios Patient requirements, e.g. indoor/outdoor use Types of aid Walking frames Consider safety of use, ability to carry things or sit on aid Wheelchair, powered/unpowered Consider chair sizing, ability to self-propel Avoid pressure sores Cars Specialist driving centres assess ability & provide adaptations Aids & adaptations to the home and garden Electronic aids & adaptations Telecare / Telemedicine Control of curtains, door entry, telephone Fall detector, intruder alert, flood alert, CO monitor Remote physiological monitoring Impairment: pain, spasticity, skin lesions, contractures Activity: difficulty with mobility, swallowing, reading, writing, eating, speaking Participation: social engagement, stigma, communication, mobility and access Background information Disability Discrimination Act (1995 and 2005) - Businesses and public organisations must take reasonable steps to ensure access to toilets, education, goods, facilities and services, inc buying/renting land/property Human Rights Act (1998) Obligation on public authorities to act compatibly with Convention rights Right to life, liberty & security, respect for private and family life Freedom of conscience, thought, religion; freedom of expression Freedom of assembly and association Right to marry, found a family; education Prohibition of discrimination Who does what Social Services adapt the home environment OT helps people adapt and learn, new skills, home adaptations, help with instrumental ADLs e.g. learning, driving Physios provide most mobility aids Orthotists provide most orthoses PPD/Ethics Station Framework for answering questions Identify the important clinical decisions Define the ethical problems Identify the stakeholders and demonstrate an empathic understanding of the view of each Identify factors from the reflective grid Ethical principles Autonomy Beneficience Non-maleficience Justice Philosophy (capacity, consent, data protection) (medical competence, governance, NICE) (negligence, minimising iatrogenic harm) (distributive, rights based, legal) (utilitarianism, deontology, principles, values) Legal/statutory requirements Clinical evidence Political policy/local priorities Professional conduct/personal feelings Religious and cultural beliefs/social norms Give arguments for and against Resolve with compromise/solution/strategies Justify your answer (Discuss feelings evoked by the scenario) Framework Dilemmas (are) Easily Solved (by) Running Away Rapidly Decisions Ethical framework Stakeholders Reflective Grid Arguments Resolution Reflective Grid P Philosophy (utilitarianism/deontolog) E Ethical principles P Professional/personal feelings P Politics/local priorities E Evidence base R Religion/cultural S Statutory/legal Notes and Hints Each scenario will contain at least 4 issues 6 mins to read scenario (rest station) 6 mins to present Use a structure, don’t waffle Radiology Station Chest X-ray Patient name, age, date of investigation This is a (PA, AP, frontal) CXR Adequacy Iatrogenic Central Lung fields Bones&tissues Vertebrae visible thro’ heart, no rotation Costodiaphragmatic recesses, full chest width inc. soft tissues Adequate inflation, hyperinflation Lines, tubes & pacemakers Trachea, great vessels, hilar region, heart Diaphragms (gas underneath), costodiaphragmatic angles Search all parts of lung field, inc. apices and behind heart Turn film sideways to check for pneumothorax Follow each rib in turn Abdominal X-ray Patient name, age, date of investigation This is an erect / supine / decubitus AXR Technical Whole field of view: diaphragm to pubic rami SB/LB Obstruction, pseudoobstruction Pneumatosis intestinalis (impending obstruction) Perforation: Rigler’s sign, falciform ligt seen, triangles/angular shapes Tissues Liver, biliary tree, spleen, pancreas Psoas shadow Kidneys, ureters, bladder Bones Calcifications May or may not be pathological e.g. phleboliths MSK X-ray A B C S Adequacy, alignment Rule of 2s: 2 views, 2 joints Bones Follow cortex then check cancellous bone Cartilage (joints) Soft tissues Cervical spine A Must see C7 / T1 border Alignment: anterior, posterior vertebral lines, posterior margin spinal canal B Vertebral bodies and spines C Vertebral discs S Prevertebral soft tissue stripe Urological investigation IVU ALWAYS ask to see the control film