Introduction

Introduce yourself Explain what you would like to examine Gain consent Place patient at 45 with chest exposed Ask if patient has any pain anywhere before you begin!

General Inspection
Bedside for treatments or adjuncts GTN spray, O , Tablets, Wheelchair, Warfarin Comfortable at rest? SOB Malar Flush Chest for scars & visible pulsations Legs for harvest site scars and peripheral oedema ..
2

Hands
Temperature - poor peripheral vasculature Capillary refill should be <2 seconds Colour cyanosis Clubbing Splinter haemorrhages, Jane-way lesions, Oslers Nodes infective endocarditis Palmar Erythema hyperthyroidism, pregnancy, polycythaemia Nicotine Staining smoker

Pulses
Radial Pulse rate & rhythm Radial-Radial Delay aortic coarctation Collapsing Pulse aortic regurgitation BP narrow pulse pressure = Aortic Stenosis | wide pulse pressure = Aortic Regurgitation Carotid character & volume JVP measure and also possibly carry out hepatojugular reflex

Face
Eyes conjunctival pallor, jaundice, corneal arcus, xanthelasma Mouth central cyanosis, angular stomatitis

Dental hygiene infective endocarditis

Close Inspection Of Chest

Scars - lateral thoracotomy (mitral valve), midline sternotomy (CABG), clavicular (pacemaker) Apex beat visible in aortic regurgitation and thyrotoxicosis Chest wall deformities pectus excavatum, pectus carniatum

Palpation
Apex beat 5th intercostal space, mid clavicular Heaves- left sternal edge seen in left & right ventricular hypertrophy Thrills Palpatable murmurs over aortic valve & apex

Auscultation
Listen over 4 valves - ensure palpation of carotid pulse to determine first heart sound Roll onto left side & listen in mitral area mitral stenosis Lean forward & listen over aortic area- aortic regurgitation Carotids - radiation of aortic stenosis murmurs & bruits Lung bases pulmonary oedema Sacral Oedema & Pedal Oedema

To complete the examination

Thank Patient Wash hands Summarise Findings

Say you would Assess peripheral pulses Carry out an ECG Dipstick urine Bedside Blood Glucose Fundoscopy

Introduction
Introduce yourself Explain what you would like to examine Gain Consent Expose chest Position at 45 Ask patient if they have pain anywhere before you begin!

General Inspection
General appearance Any treatments or adjuncts around bed - o2, inhalers, nebulisers, sputum pots Does patient look SOB? - nasal flaring, pursed lips, accessory muscles Scars Cyanosis Chest Wall - abnormalities or asymmetry - barrel chest (COPD) Cachexia Cough or Wheeze ask to cough & assess nature (productive or dry)

Hands Check temperature Clubbing Nicotine Staining Wasting of the dorsal interossi (pancoast tumour) Fine tremor b2 agonist use Flapping tremor - CO2 retention Pulse rate & rhythm Pulse Paradoxus - pulse volume decreases with inspiration Respiratory rate

Head & Neck Conjunctival pallor - anaemia Horners syndrome - ptosis, small pupil, enopthalmos (sunken eye) & loss of sweating Central cyanosis JVP - elevated in cor-pulmonale & severe bronchitis

Close inspection of thorax

Scars - lateral (thoracotomy) Asymmetry - seen in lung removal Deformities - barrel chest, pectus excavatum & carniatum

Palpation
Crico-sternal distance Tracheal posistion Apex beat Chest Expansion

Percussion
Compare side to side Supraclavicular Infraclavicular Chest Axilla

Auscultate
Compare side to side Assess volume & quality - vesicular or bronchial Vocal resonance . Repeat Inspection, Chest Expansion, Percussion & Auscultation

To complete my examination
Thank patient Wash hands Summarise Findings

Say you would; Do a full cardiovascular examination if indicated

Introduction
Introduce yourself Explain what you would like to examine Gain consent Expose chest & abdomen (waist band down to level of the iliac crests for full view of abdomen) Position patient flat with arms by side, legs uncrossed and head on pillow Ask if patient has any pain anywhere before you begin!

General Inspection
Look around bedside for treatments or adjuncts - sick bowls, feeding tubes, stoma bags, drains Scars Abdominal Distention ascities Jaundice Masses Dressings - biopsies (liver) Tattoos or Needle Track Marks Hepatitis Excoriations pruritis

Inspection
Hands
Clubbing Koilonychia & Leukonychia Palmar erythema Duputrons contracture. Flapping Tremor

Arms
Bruising Petechiae Muscle wasting Excoriations

Axillae
Lymphadenopathy Hair loss Acanthosis nigricans (darkened pigmentation)- can be a sign of malignancy in the GI tract

Eyes
Jaundice look down Anemia - look up Xanthelasma seen in Chronic Liver Disease

Mouth
Angular Stomatitis Oral candidiasis Mouth ulcers Tongue glossitis

Neck
Cervical Lymph Nodes Virchows node - left supraclavicular fossa gastric malignancy

Chest
Spider naevi increased oestrogen in CLD more than 3 significant Gynacomastia Hair loss ..

Close inspection of abdomen

Scars Masses Abdominal distention ascites Striae chronic Liver Disease Caput Medusa portal hypertension Stomas

Palpation
Ask about tenderness Look at patients face Start palpation furthest from sites of pain Light palpation - tenderness, guarding, rebound, obvious masses Deep Palpation detailed description of mass, Liver start in right iliac fossa Spleen start in right iliac fossa

Kidneys ballot both kidneys between your hands Aorta press either side midway between xiphisternum and umbilicus

Percussion
Liver - up from right iliac fossa then down from right side of chest Spleen start in right iliac fossa Shifting Dullness ascites

Auscultation
Bowel sounds Renal & Aortic Bruits

To complete the examination

Thank Patient Wash hands Summarise Findings . Say you would Check Hernial Orifices Perform a Digital Rectal examination Perform an examination of the External Genitalia

Introduction
Introduce yourself Explain what you would like to examine - Im going to be testing the nerves that supply your face Gain consent Position patient on chair at eye level with you approximately one arm length away Ask if patient has any pain anywhere before you begin!

General Inspection
General appearance well/unwell Facial asymmetries? Abnormal position of eyes or head? Abnormality of speech or voice? Signs around bed - hearing aid, glasses

I Olfactory Nerve
Ask if there has been any change in sense of smell? - last thing you remember smelling? Tell the patient to close their eyes & ask them to identify different smells - coffee, vinegar etc

II Optic Nerve
Pupils
Size Position Ptosis? ..

Visual Acuity
Snellen chart at 6m Ask patient to cover one eye and read down from top of chart Record the lowest line read correctly ..

Pupillary Reflexes
Direct- shine torch into eye from the side look for pupillary constriction in that eye Consensual - shine torch into eye from side look for pupillary constriction in opposite eye Swinging Light Test- move light in from side of each eye rapidly relative afferent pupillary defect

Accommodation focus on distant point then focus on finger constriction & convergence ..

Colour Vision
Say you would use Ishihara chart (usually dont have to actually carry this out, just offer)

Visual Fields
Visual Neglect 1. Ask patient to focus on your nose 2. Wiggle finger either side of patients head 3. Can patient identify both fingers moving simultaneously? .. Detailed Visual Fields 1. Ask patient to cover right eye, whilst you cover your left 2. Tell them to focus on your nose and to say when your finger comes into their view 3. Test temporal & nasal visual fields 4. Repeat on the opposite eye and note any defects .. Fundoscopy Mention but usually not required in OSCE

III, IV, VI Occulomotor, Trochlear & Abducens Nerves

Eye movements
1. Draw a H in the air with your finger 2. Ask patient to follow your finger with their eyes (keeping head still) 3. Look for asymmetries and enquire about any double vision..

Nystagmus
1. Put your finger at the upper-outer extreme of a patients view 2. Ask them to follow your finger with their eyes (head still) 3. Move finger to lower-inner extreme then back to starting posisition 4. Look for nystagmus (one beat is normal)

Cover Test
Mention you would do this Dont usually have to carry it out

V Trigeminal Nerve
Sensory
Test light touch & pin prick sensation Test face comparing side to side in 3 regions Opthalmic (forehead), Maxillary (cheek) and Mandibular (jaw) Ask if each side feels the same or different to the other ..

Motor
Masseter muscle ask to clench teeth and palpate muscle bulk Ask patient to open mouth & not let you close it ..

Reflexes
Jaw jerk - ask patient to open mouth a little bit and tap your finger which is placed over their chin Corneal reflex - touch cornea using a wisp of cotton wool (Not in OSCE! Just mention it)

VII Facial Nerve

Inspect patients face at rest for asymmetry

Ask patient to Raise eyebrows Scrunch eyes - scrunch up your eyes and dont let me open them Blow out cheeks blow out your cheeks and dont let me deflate them Bare teeth can you do a big smile for me Purse Lips Inspect external auditory meatus for any signs of herpes zoster can cause Bells Palsy Any hearing changes? - facial nerve supplies stapedius results in Hyperacusis Any taste changes? - supplies taste sensation to the anterior 2/3 of the tongue (via chorda tympani)

VIII Vestibulocochear Nerve

Gross hearing testing

Ask patient to close eyes Whisper a number into each of the patients ears Ask them to repeat ..

Rinnes Test
Use 512HZ tuning fork Place in front of ear air conduction Then place on mastoid process - bone conduction Ask which is louder -air should be louder than bone ..

Webers Test
Place 512HZ tuning fork in centre of forehead Ask patient where they hear the sound The normal result is for the patient to hear the sound in the middle (equally in both ears) If the patient hears the sound on a particular side it may indicate a lesion on the opposite side ..

Vestibular Testing turning test

Ask patient to march on spot with arms out and eyes closed Patient should remain in same position normally If they start to turn in a particular direction it may indicate a lesion on that side

IX & X Glossopharyngeal & Vagus Nerves

Symmetry of soft palate & uvula can use tongue depressor and ask patient to say ahhh Gag reflex you wont do this in the OSCE, but just make sure you mention it! Ask patient to cough - damage to nerves IX & X can result in a bovine cough Swallow can ask patient to take a drink of water (rarely done, just mention you could)

XI Accessory Nerve
Ask patient to shrug shoulders & resist you pushing down trapezius Ask patient to turn head to 1 side & resist you pushing it to the other - sternocleidomastoid

XII Hypoglossal Nerve

Inspect tongue for Wasting & Fasciculations at rest Ask patient to protrude tongue any deviation? Ask patient to push tongue against inside of cheek and resist you pushing from the outside

To complete the examination

Thank patient Wash hands Summarise findings . Say you would Do further testing of any nerves that had abnormal results MRI if indicated

Lower limb exam

Introduction
Wash hands Introduce yourself Explain what you would like to examine Gain consent Expose legs Ask if patient has any pain anywhere before you begin!

Inspection
Signs around bed - walking stick, wheelchair, catheter General Appearance well/unwell Muscle Wasting - lower motor neurone lesion Fasciculations lower motor neurone lesion Tremor parkinsons, benign essential tremor Abnormal posture

Tone
Leg roll - roll the patients leg & watch the foot, it should flop independently of the leg Leg lift briskly lift leg off the bed at the knee joint, heel should remain in contact with the bed

Clonus rapidly dorsiflex the ankle & look at the calf for rhythmical contractions (>3 is abnormal)

Power
Test muscle power in the following groups using the MRC scale (1-5) Hip
Flexion - raise your leg off the bed and stop me from pushing it down Extension stop me from lifting your leg off the bed

Leg
Flexion - move your heel towards your bottom and dont let me stop you Extend knee dont let me push your heel towards your bottom

Ankle
Dorsi-flexion point your toes towards your head and dont let me push them down Planter-flexion- press down on my hand with the sole of your foot.

Big Toe
Flexion- push down on my hand with your big toe Extension- dont let me push your big toe down

Reflexes
Knee Jerk (L3,L4) Ankle (L5,S1) Plantar (S1)

Sensation
Soft touch cover various dermatomes comparing leg to leg Sharp cover various dermatomes comparing leg to leg Vibration 128hz tuning fork on base of big toe Proprioception use the big toe

Co-ordination
Heel to shin test -run your heel down the other leg from the knee & repeat in a smooth motion

Gait
Ask patient to walk to the end of the room and back Comment on speed, smoothness, spacing of feet and any unsteadiness

To complete the exam..

Thank patient Wash Hands Summarise Findings . Say you would Perform a full neurovascular exam of all limbs Test Cerebellar Function

Upper limb exam

Introduction
Wash hands Introduce yourself Explain what you would like to examine Gain consent Expose arms & trunk Ask if patient has any pain anywhere before you begin!

Inspection
Signs around bed - wheelchair, walking stick, splints General appearance well/unwell Muscle wasting - lower motor neurone lesion Fasciculation - upper motor neurone lesion (i.e Multiple Sclerosis) Tremor parkinsons, benign essential tremor Abnormal posture

Tone
Support the patients arm by holding their hand & elbow

Tell the patient to relax and allow you to fully control their arm Move the arms muscle groups through their full range of movements Is the motion smooth or is there some resistance (i.e led pipe rigidity)

Power
Shoulders (deltoids)
Abduction Dont let me push your shoulders down Adduction Dont let me push your shoulders up

Arms (biceps & triceps)

Flexion Dont let me pull your arm away from you Extension - Dont let me push your arm towards you

Wrist
Extension - Cock your wrists back & dont let me pull them down Flexion - Point your wrists downwards & dont let me pull them up .

Fingers
Finger Extension Put your fingers out straight & dont let me push them down Finger Flexion Put your fingers out straight & dont let me push them up Finger Abduction Splay your fingers & dont let me push them together Finger Adduction Hold this paper between your fingers & dont let me pull it out Thumbs - Point your thumbs to the ceiling and dont let me push them down

Pincer Grip
Get the patient to place there thumb & index finger together Attempt to pull them apart

Power Grip
Get the patient to grip your fingers tightly Attempt to remove your fingers from their grasp If your fingers can easily escape it suggests an abnormally weak grip

Reflexes

Biceps (c5, c6) hyperreflexia, hyporeflexia? Triceps (c7) - hyperreflexia, hyporeflexia? Supinator (c6) - hyperreflexia, hyporeflexia?

Sensation
Soft touch (cotton wool) cover the dermatomes & compare side to side Sharp & Dull touch (neurotip) - cover the dermatomes & compare side to side Vibration (128HZ) test over bony prominence at base of the thumb Proprioception ask patient to close eyes move finger- ask patient if its up or down

Co-ordination
Pronator Drift close eyes & put your arms outstretched in front of you, palms facing up Finger to Nose touch your nose then my finger as fast as you can repeatedly Dysdiadokinesia - ask patient to rapidly pronate & supinate one hand on the back of the other

To complete the exam

Thank patient Wash Hands Summarise Findings . Say you would Perform a full neurovascular examination of the upper limbs Perform a full neurological examination if indicated