A site for medical students - Practical,Theory,Osce Notes

Showing posts with label usmle. Show all posts
Showing posts with label usmle. Show all posts

How to examine for Collapsing Pulse an OSCE guide

The term collapsing pulse is used to describe a pulse with a rapid upstroke and descent, and is characteristically described in aortic regurgitation.
Other  names of the collapsing pulse
  • Watson's water hammer pulse
  • Cannonball pulse 
  • Pulsus celer.
How to elicit collapsing pulse?
To elicit the collapsing pulse you have to palpate the carotids or the radial pulse.
For the radial pulse:
  • Ask the patient to fully pronate his forearm.
  • Place your right hand on the radial pulse.
  • Grasp the patient's forearm with left hand (with your palm on the flexor aspect of patient's forearm).
  • Raise the hand above the level of the patient's head
  • Repeat the manoeuvre to note the accentuation of the collapse in the elevated position.

How to examine for radiofemoral delay.an OSCE guide

Radiofemoral delay is an important clinical sign that help to detect the coarctation of aorta
How to elicit radiofemoral delay?
To detect the radiofemoral delay you have to palpate the radial and femoral artery simultaneously.Normally the time taken for the pulse wave to reach the radial artery after the cardiac systole is 80 milliseconds and for the femoral artery it is 75milleseconds.If the femoral pulse is delayed compared to radial pulse it is called as radiofemoral delay.
Causes of radiofemoral delay
Coarctation ol aorta
Atherosclerosis of aorta.
Thrombosis or embolism of aorta

How to examine for Femoral pulse:an OSCE guide

The femoral pulse is palpated over the ventral thigh between the pubic symphysis and anterior superior iliac spine with the middle and index fingers.
How to examine for femoral pulse?
  • Ask the patient to lie supine,
  • Make the leg partially flexed: abduct and externally rotate the hip,
  • Feel the pulse below the midinguinal point.
Comment on the following
  • Rate, rhythm, character, volume.
  • Character of the vessel wall.
  • Palpability of all vessels.
  • Radio-femoral delay.
Clinical significance
Examination of peripheral pulse is imporatant for detection of radiofemoral delay

This is very important for students preparing for USMLE and MRCP

How to examine for carotid artery an OSCE guide

The common carotid artery is palpated on the neck below the jaw and lateral to the larynx/trachea (that is mid-point between your earlobe and chin) using the middle and index fingers.
It can be felt between the anterior border of the sternocleidomastoid muscle, above the hyoid bone and lateral to the thyroid cartilage
Precaution on palpating the carotid artery
  • The carotid artery should be palpated gently 
  • The patient should be in  sitting or lying down posture. 
  • Stimulating its baroreceptors with low palpitation can result in  severe bradycardia or even stop the heart in some sensitive persons. 
  • Two carotid arteries of a person should not be palpated at the same time. as it may limit the flow of blood to the head, possibly leading to fainting or brain ischemia.
How to examine for carotid pulse?
  • Ask the patient to look straight ahead
  • Use your thumb and press it backwards
  • The pulse is felt at the level of the medial border of the sternomastoid muscle and lateral to the thyroid cartilage.
Comment on the following
Rate, rhythm, character, volume.
Character of the vessel wall.
Palpability of all vessels,

This is very important for students preparing for USMLE and MRCP

How to examine for Brachial pulse:an OSCE guide

Brachial artery pulse is located on the inside of the upper arm near the elbow
The brachial artery is palpated on the anterior aspect of the elbow by gently pressing the artery against the underlying bone with the middle and index fingers. 
Clinical significance 
This pulse is commonly used to measure blood pressure with a stethoscope and sphygmomanometer
How to examine for brachial artery pulse?
  • Partially flex the elbow,
  • Feel the pulse over the elbow with thumb or fingers
Comment on the following
Rate, rhythm, character, volume.
Character of the vessel wall.
Palpability of all vessels,

How to examine for Radial pulse:an OSCE guide

Radial artery pulse is located on the lateral of the wrist , it can also be found in the anatomical snuff box
The radial pulse is palpated immediately above the wrist joint near the base of the thumb (i.e., common site), or in the anatomical snuff box (i.e., alternative site), by gently pressing the radial artery against the underlying bone with the middle and index fingers.
Clinical significance
The examination of radial pulse is very useful in the following condition
Radioradial delay-seen in thoracic inlet syndrome and takayasu disease
Radiofemoaral delay in Coarctation of aorta
How examine for radial pulse
  • Semipronate the forearm,
  • Flex the wrist
  • Feel the pulse near the wrist,
Comment on the following
Rate, rhythm, character, volume.
Character of the vessel wall.
Palpability of all vessels,
Radio-femoral delay.

This is very important for students preparing for USMLE and MRCP

Examination of skin lesions an OSCE guide

1. Use good lighting: preferably natural lighting.
2. Patient is adequately exposed.
3. Comment on:              
  • Type of the lesion—primary and sequential: colour.
  • Shape of the lesions.
  • Arrangement of two or more lesions.
  • Distribution of the lesions—examine specifically the hair, nails and mucous membranes.
4. Do palpation to confirm findings.
5 Tell the probable diagnosis.
6. Do or tell one specific test to clinch the diagnosis.
1. Primary lesions They could lie
  • Flat (in the plane of the skin): Macule.
  • Elevated (above the plane of the skin): Papule, plaque, vesicle, bullae, pustule, cyst, wheal.
  • Depressed (below the plane of the skin): Ulcer, erosion.
2. Sequential lesions (occur over a primary lesion) Scaling, dry or wet exudation or llchenification.
3. Shape Round, oval, annular, iris, serpiginous, umbillicated. polygonal or polycyclic.
4. Arrangement herpctiform. zosteriform. reticular, linear or serpiginous.             '
5. Distribution Symmetrical or asymmetrical, exposed areas, intertriginous areas, sites of pressure, local or generalised.
6. Specific tests Include microscopic examination of the scales, crusts or exudate. Tzanck test. Auspltz sign. Nikolsky's sign. Koebner's phenomenon, patch test. etc.
7. The manifestations of a few common diseases are:
  • Iris lesion or target lesion: Erythema multlforme.
  • Annular lesions with scaling: Dermatophytosts. psoriasis and pityriasis rosea.
  • Annular lesions without scaling: SLE. Secondary syphilis.
  • Bilateral symmetrical eruptions: Drug or endogenous  hypersensitivity
  • On exposed areas: Pellagra, photosensitivity.
  • On interlriginous areas: Candidiasis.
  • On sites of pressure: Psoriasis.
  • Velvety brown pigmentation of the axilla and groins: Acanthosis nigricans.

This is very important for students preparing for USMLE and MRCP

Examination of a joint an OSCE guide

  1. Expose the Joint and the muscles acting on It.
  2. Observe and note any deformity, swelling or muscle atrophy.
  3. Palpate the Joint for synovial thickening, warmth, points of tenderness and any abnormal masses.
  4. Elicit fluid thrill if swelling is present.
  5.  Assess passive and active range of Joint movement.
  6. Palpate during movement to elicit Joint crepitus.
  7. Test the ligaments that stabilise the Joint.
  8. Compare the two sides.
Fluid thrill indicates effusion while a 'boggy feel" without a fluid thrill indicates synovial thickening. At times both may be present.

This is important for those students preparing for USMLE and MRCP

Examination of Subcutaneous Nodule or Swelling an OSCE guide

Elicit History
Duration, mode of onset, progression, assoeiutcd pain and
Number, site, shape, colour, surface, edge, pulsation.
Impulse on coughing and skin over the swelling.
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 conduct thyroid examination an OSCE guide

Local Examination
1. Expose the neck adequately.
2. Ensure adequate lighting.
Comment on position, size, shape, surface, pulsations.
overlying skin and movement on deglutition and protrusion of the tongue.
Neck Measurements
Measure the circumference of the neck at the most prominent part of the swelling.
  • Patient's neck is slightly flexed (to relax muscles).
  • Examine from the front or from behind the patient.
  • Otto's method: Place the thumb and fingers on the thyroid. Palpate the thyroid when the patient swallows.
  • Lahey's method -Push the thyroid to one side Palpate the lobe on the side which becomes prominent.
Comment on position, size. shape, surface, consistency (uniform, variable, cystic, solid, firm. hard), mobility (Hortzontal and vertical), tenderness and on the рутаmidal lobe If present
For thyroid bruit
1. Carotid pulse. Present or absent on each side.
2. Horner's syndrome.
3. Kocher's test: Press the lateral lobes of the thyroid (stridor occurs In compressed trachea).
4. Lymph nodes for secondaries.
 General Examination
1. Relevant examination to elicit-symptoms and signs of hyper or hypothyroidism.
Additional examination
a. Tongue: For any lingual thyroid.
b. Pemberton's sign: flic patient raises both his/her arms until they touch the ears. Hold up for some
time. Congestion of the face, cyanosis and distress occur In a retrosternal goitre.

How to elicit the eye signs of thyroid disease an OSCE guide

Following are the important eye sign in thyroid disease.
1.Exophthalmos: Unilateral or bilateral.
Comment on the widened palpebral fissure, visibility of the sclera above and below the limbus.
3. Stellwag's sign Observe for retraction of upper eyelid and Infrequent blinking.
5.Moebles sign: Look for Inability to converge the eyes.

How to elicit Pemberton's sign:an OSCE guide

Pempertons sign is seen in retrosternal goitre
  • The  patient raises both his/her arms until they touch the ears. 
  • Hold up for sometime. 
  • Look for congestion of the face, cyanosis and distress in a retrosternal goitre.

This sign demonstrate the presence of latent pressure in the thoracic inlet
Pemberton's sign was named after Dr. Hugh Pemberton
A positive Pemberton's sign is seen in  superior vena cava syndrome (SVC), as  a result of a mass in the mediastinum. the sign is most commonly described in patients with substernal goiters where the goiter “corks off” the thoracic inlet.this maneuver is very  useful in any patient with adenopathy, tumor, or fibrosis involving the mediastinum

How to elicit Joffroy's sign an OSCE guide

In Joffroy's sign there is a lack of wrinkling of the forehead when a patient looks up with the head bent forwards

Joffroys sign is a sign of hyperthyroidism.It is elicited as follows
  • Patient's face is inclined downwards.
  • Patient attempts to look up.
  • Look  for absence of wrinkles on the forehead.

How to elicit Von Graefe's sign:an OSCE guide

Von Graefes sign is an important eye sign in hyperthyroidism.It is elicited as follows
  • The patient looks straight ahead.
  • Ask the patient to look down.
  • Look for a lag of the upper eyelid.
It is the lagging of the upper eyelid on downward rotation of the eye and indicate  underlying  Graves' Disease
The terms lid lag and von Graefe's sign have been used interchangeably in the past; but, they are distinct signs of downgaze-related upper eyelid static position and dynamic movement, respectively.

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

Following are the major signs of liver cell failure
3.Constructional Apraxia
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 for Spider Naevus an OSCE guide

Spider Naevus is a sign of liver cell failure.Sometime seen in healthy Individuals also.
1. Ask the patient to adequately expose.
2. Examine the- face. neck, arms and chest above the nipples
3. Blanch the spider naevus using the head of a pin or a glass slide.          
4. Release pressure to look for flushing.
5. Comment as present or not.
If present, significant or not significant.
Note the following
  • Count the naevi above the level of the nipples i.e. in the drainage area of the superior vena cava.
  • Less than 7 spider naevi are normal in young persons
  • More than 7 occur in liver cell failure pregnancy  or in persons on oral contraceptive
  • Spider naevus occurs because of the dilatation of a central arteriole (the body of the spider) which feeds the vessels radiating from it (the legs of the spider). If a red naevus does not blanch, it is purpura. Blanching occurs fully in erythema also and partially in telanglectasias.

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

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.
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.
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.
  • 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.
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