Examination of Subcutaneous Nodule or Swelling an OSCE guide

Elicit History

Duration, mode of onset, progression, assoeiutcd pain and

treatment—history.

Inspection

Number, site, shape, colour, surface, edge, pulsation.

Impulse on coughing and skin over the swelling.

Palpation

a. Local rise of temperature, tenderness, size, shape, surface, edge or margin, consistency.

b. Fluctuation, translucency. reducibility.

c. Impulse on coughing, mobility, anatomical plane and fixity, pulsation and thrills.

Percussion or Auscultation

In relevant cases.

Regional Examination

For lymph nodes, muscle wasting, bony erosion, sensory deficits and absence of pulse.

Comment on—probable diagnosis/aetiology.

These steps are very important for students preparing for USMLE and MRCP

How to elicit the signs of liver cell failure an OSCE guide

Following are the major signs of liver cell failure

1.Spider naevus

2.Asterixis or flapping tremor

3.Constructional Apraxia

4.Gynaecomastla

Presence of a Button-like' breast tissue on palpation below the areola In a male suggests early gynaecomastla.

5.Testicular Atrophy

If the testis is less than 3.5 cm in length, and feels soft or

Flabby on  palpation, it suggests testicular atrophy.

6.Loss of Axillary and Pubic Hairs

They become sparse initially and are totally absent in later stages.

This is very important for those students preparing for USMLE and MRCP

How to elicit Asterlxis or Liver Flap an OSCE guide

Asterixis is also called as  Flapping Tremor

1. Explain procedure to the patient.

2. Ask the patient to fully extend his/her arms and dorsiflex his/her wrists.

3. His/her fingers are held widely separated.

4. Holds In the same position for a few seconds.

5. Comment as asterlxis present or not.

Alternate Method for elicitation of flapping tremor

Asterlxis can also be elicited in the legs, head and the trunk.

Note the following

• The patient is elaborately positioned because the flap is best demonstrated in that position.
• Asterlxis Is said to be present if the wrist and fingers Involuntarily flex abruptly and irregularly: fhe patient compensates by extending the wrist but the correction is only partial, tlcxion and partial extension occur alternately so that In the end the wrist comes to a flexed position.
• Asterixis occurs because of non-rhythmic, transient loss of posture In the arms.

This sign is very important for those students who are preparing for USMLE and MRCP

How to examine an erythematous lesions the OSCE guide

1. Expose the skin adequately.

2. Use natural lighting.

3. Examine lor blanching on compression with a glass slide.

4. Comment on site, number, size and blanching on compression.

5. Tell the probable diagnosis.

Note

1. Blanching on compression occurs in erythema, telangiectasia, spider naevi and partially in senile

angiomas. Blanching does not occur in purpura.

2. Purpura is a term used for collection of blood in the skin.

• Petechiae are pin-point haemorrhages in the dermis.
• Ecchymosis is a large subcutaneous collection of blood.
• Haematoma is deeper and forms a palpable swelling.

These steps are very important for students preparing for USMLE and MRCP

How to examine the breast -OSCE guide

1. Explain procedure and seek cooperation.

2. Patient is undressed upto the waist.

3. Use adequate lighting.

4. Ask patient to sit on a chair initially opposite the examiner.

5. Examine and compare both sides.

Inspection

1. Look for asymmetry of the nipple, areola or the breast in all the following positions:

• The patient s hands should rest on her thighs.
• The hands are firmly pressed onto the hips.
• The arms are raised up and both the palms are placed behind the head.
• The patient leans forwards.
• Finally make the patient lie down on a couch with a pillow below her chest.

2. Comments

• Nipple and areola: Position, size, shape, surface and any discharge.
• Breast: Size, shape, displacement, engorged veins,
• skin abnormalities, swelling (quadrantie location, size, shape, surface ) or ulcer (number, position, size, shape. Iloor. edge, discharge).
• Surrounding structures: Arm-oedema, etc.

3.Lymph Nodes

Axillary, supraclavicular, scalene nodes

4.General Examination

As relevant to the case.

Note

1. Avoid offending an unduly modest patient, but this should never prevent a complete examination.

2. In all the five positions, the patient should be symmetrically positioned. Otherwise, apparent differences in the breast will result.

3. The nipple, areola and all four quadrants must be examined In sequence in all the positions.

4. Examine in many positions to detect early changes

The pectoral muscles are relaxed in position (a)  contracted in position (b) and stretched along with the skin in position (c). The breasts are made pendulus In (d). A pillow under the back in (e) makes the breast more prominent.

5. Since the breast is a frequent site of carcinoma, a general examination is incomplete unless both the breasts have been Included.

These steps are very important for students preparing for USMLE and MRCP

How to examine exanthematous (rash) lesions-OSCE guide

Examination of exanthematous (rash) lesions

Elicit History

a. Duration of prodromal symptoms (including fever).

b. Onset and progression.

c. History of an epidemic in the locality.

Inspection and Palpation

1. Expose the patient adequately.

2. Ensure good lighting.

3. Observe and note down:

• Involvement of oral mucosa, conjunctiva and external genitalia.
• Distribution: centripetal, centrifugal, segmental.
• Stage of the lesions: macule, papule, vesicle, pustule, scabs, combined or crops.
• Regional lymphadenopathy.

Comment on:

Probable diagnosis.

Specific test to confirm diagnosis.

These steps are very imporatant for students who prepare for USMLE and  MRCP examinations

OSCE guide for Hess test (tourniquet test)

1. Expose one upper limb adequately.

2.Use adequate lighting.

3.Tie the sphygmomanometer ruff around the arm.

4.Mark out a circle of 3 cm diameter on the forearm about I cm below the cubital fossa (where there are no petechiae).

5. Raise the cuff pressure to midway between systole and diastole.

6. Maintain pressure for 5 to 7 minutes.

7. Deflate the cuff and wait for 2 to 3 minutes (for congestion to disappear).

8. Count the number of petechiae in the marked out area

Note

1.The diameter of an old one rupee coin is about 3 cms and it can be conveniently used to draw the circle

2. Normally, upto 10 petechlae can occur in the mentioned area. More than 20 arc definitely abnormal. Note that petechiac can vary in size from pin point to pin head or larger.

3.. The tourniquet test is positive in most cases of thrombocytopenia and in increased capillary fragility. It is anessential part of examination in any patient with bleeding disorder.

These steps are very important for those students who are preparing for USMLE and MRCP

OSCE guide for examination of thoracic outlet syndrome

OSCE steps for examination of thoracic outlet

1. Expose the- neck and upper torso well.

2. Palpate the supraclavicular fossae for tender spots,masses, muscle spasm and vascular thrill.

3. Perform Adson manoeuvre

• Patient sits with forearms supine and resting on the thighs.
• Palpate the radial pulse on the right side.
• Ask the patient to look up. turn the chin to the right and breathe deeply.
• Note transient disappearance of the radial pulse during deep inspiration.
• Repeat the lest on the left side.

4. Observe and note any small muscle wasting or sensory loss of C8segment.

5. Ask the patient to abduct and externally rotate the shoulder, and note Intensification of sensory symptoms and signs

This examinations steps are very important for those students preparing for USMLE and MRCP clinical examination

Hypertrichosis -clinical significance

Hypertrichosis is a condition where there is excessive growth of hair in generalized or localized pattern but this is not of male pattern of distribution.

Congenital hypertrichosis is seen in porphyria cutanea tarda, 

Hurler's syndrome, 

Giant pigmented naevus also called as [bathing suit naevus]

Acquired hypertrichosis is seen in the following conditions

• Malignancy-bronchogenic carcinoma
• Drugs-phenytoin, steroids,minoxidil, diazoxide, streptomycin.
• Endocrine causes
• Sexual precocity
• Hypothyroidism
• Adrenal hyperplasia or neoplasm

What is hypertelorism?

Hypertelorism means the presence of wide spaced eyes. This is diagnosed when the inter inner canthal distance between the two eyes is more than half of the inter pupillary distance
Causes of hypertelorism
Hypertelorism is a feature that can have many underlying etiology

• This may be due to a mass pushing the two orbits apart
• A cleft in the bone between the eyes 
• As part of a syndrome.

What is Rocker Bottom Feet ?

This is a severe type of flat foot with a protuberant heel.

It is characterised by a prominent calcaneus/heel and a convex rounded sole.
It has Persian slipper appearance

• Calcaneus in fixed equinus
• Achilles tendon is very tight
• The hindfoot is in valgus
• The head of the talus is found medially in the sole
• The forefoot is abducted and dorsiflexed.

It is also known as a congenital vertical talus
What is the pathology of Rocker bottom feet?
It occur from a dorsal and lateral dislocation of the talonavicular joint.
Seen in the following conditions
Aneuploidic syndromic

• Trisomy 13- Patau syndrome
• Trisomy 18 also called Edward's syndrome, which may be associated with PDA
• 18q deletion syndrome

Non-aneuploidicsyndrome

• Spina bifida
• Arthrogryposis

What are the differential diagnosis ?
In the antenatal/neonatal period clubfoot is an important differential diagnosis
In the adult period differentail diagnosis considered is acquired rocker bottom deformity occurring secondary to:
Underlying neuromuscular disorder

diabetic foot (Charcot joint)

Markers of Rheumatic fever

Markers of Rheumatic fever

• Poly arthritis - major joints
• Erythema marginatum - in 10%, evanescent ringed lesion wiith raised red margin.
• Subcutaneous nodule-in 10-15%. Firm painless felt over bone and tendons - extensor aspect of elbow, knee, margin of scapula and occipital region.
• Erythema nodosum - non specific lesion,erythematous tender lesion over the shin.

Markers of Coronary Heart Disease

• Arcus senilis
• Xanthelasma, xanthomas
• Earlobe creases
• Nicotine stains on fingers and teeth
• Obesity.

Stigmata of marfan's syndrome

Stigmata of marfan's syndrome are the following
Findings in Hand

• Positive wrist sign,
• Positive hand sign
• Arachnodactyly

Anthropometry

• Upper segment/lower segment ratio < 0.8
• Arm span—height > 5 cm

Findings in Face

• High arched palate
• Dislocated lens

Findings in Chest

• Pectus excavatum
• Pectus carmatum
• Kyphoscoliosis

Locomotor system and cardiac involvement

Locomotor system examination is done for evidence of

• Rheumatic fever - valvular heart disease
• Rheumatoid arthritis -Aortitis - Aortic regurgitation(AR)
• Ankylosing spondylitis - Aortitis - AR
• Psoriatic arthritis - Aortitis - AR
• Reiter's syndrome --Aortitis - AR.

Markers of heart disease

In congenital heart disease look for

• Somatic markers of congenital heart disease link
• Features of marfan syndrome link

In acquired heart disease look for:

• Markers of Rheumatic Fever link
• Markers of Infective Endocarditis link
• Markers of Coronary Heart Disease link

Markers of infective endocarditis

Findings in Hands

• Clubbing
• Osler's nodes are reddish purple tender nodule in distal pad of finger and toe
• Janeway lesions  are coalesced non-tender hemorrhagic lesion of palm and sole.
• Splinter haemorrhages  are linear subungual hemorrhage - distal third of nail.

Findings in Eyes

• Pallor and Roth spots

Splenomegaly
Arthritis.

Xanthomas

• Xanthomas are subcutaneous  nodule-Xanthoma tuberosum
• Tendon - xanthoma tendinosum
• Palm and sole - eruptive xanthoma
• Dyslipidemia  lead to CAD

Somatic abnormalities in congenital heart disease

• Polydactyly and syndactyly  is seen in VSD
• Arachnodactyly - Long thin fingers is seen in ASD
• Atrio digital anomaly-  fingerisation of thumb and ASD is called Holt oram syndrome
• Hypertelorism is an increased  interpupillary distance observed in  Pulmonary stenosis
• Mongolism is associated with endocardial cushion defect/ VSD

Turner syndrome
It is associated with

• Dwarfism
• Primary amenorrhoca 
• Coarctation of aorta.

Noonan syndrome
 It is characterised by

• Triangular facies
• Somatic features of Turner 
• Pulmonary stenosis

Ellis-Van-Creveld syndrome
It is characterised by

• Dwarfism
• Chondroectodermal dysplasia  
• VSD

Williams syndrome 
It is characterised by

• Elfin facies 
• Mental retardation
• Hypercalcemia 
• Supravalvular AS

Pierre-Robin syndrome 

• Micrognathia,
• Glossoptosis 
• Coarctation of aorta

Marfan syndrome

• Dissecting aneurysm,
• ASD
• MVP
• AR

TAR syndrome 

• Thrombocytopenia
• Absent radius
• ASD.

Markers of congenital heart disease

In congenital heart disease look for:

Abnormalities in height

• Upper segment/Lower segment inequality 
• Dwarfism
• Gigantism

Hands and arms examination

• Clubbing
• Cyanosis
• Syndactyly
• Polydactyly
• Arachnodactyly
• Absent radius
• Absent thumb
• Cubitus valgus

Eye examination

• Suffused conjunctiva of polycythemia

Face examination

• Hypertelorism
• Low set ears
• High arched palate
• Webbed neck

Chest examination

• Pectus excavatum
•  Scoliosis
• Shield chest

Abnormalities of abdomen

• Abdominal hernia
•  Cryptorchidism