CLINICAL SKILLS for Osces NEEL BURTON

Home , Abdominal examination, IPPA, Knee examination

55 EDITION TH 5 NEEL BURTON NEEL CLINICAL SKILLS FOR SKILLS CLINICAL OSCEs

CLINICAL SKILLS FOR OSCEs 5 BURTON Edition 781907 904660 ISBN 978-1-907904-66-0 9 TH 5

s NEEL BURTON NEEL OVER 20,000 COPIES SOLD www.scionpublishing.com www.scionpublishing.com is the first book that I have come across where I can finally clear my clear finally can I where across come have I that first book the is This is one of the best OSCEs books I have purchased. My only regret is that that is regret only My purchased. best books I have OSCEs the of one is This an taking anyone for reference a comprehensive is It sooner. it buy I didn’t exam. OSCE This is a really helpful tool for the OCSEs. In our final OSCE exam of the year the of exam OSCE final our OCSEs. In the for tool helpful a really is This I that say honestly I can – and stations 13 of out 9 excellent/good I scored text. this of so because did This book is very well laid out and helpful for all clinical exams. The text is is text The exams. clinical all for helpful and out laid very well book is This preparing student medical any to it recommend I would and concise and clear exams. clinical or other OSCEs for desk and have one book in front of me. Such a joy! The book cleverly covers covers book cleverly The a joy! Such me. of front book in one have and desk manner. succinct and a clear in everything After six years at medical school I have become very accustomed to having having to very accustomed become I have school medical at years six After for Skills Clinical topic… for each desk my on piled books six or five least at OSCEs CLINICAL SKILLS FOR OSCE What students made of previous editions: has been updated, revised, revised, updated, been has OSCEs for Skills of Clinical edition fifth full-colour This all from doctors junior and students medical of team a dynamic by extended and Norwich. to Cardiff and Brighton to Aberdeen from UK, the over of amounts vast together pull to having without enough hard is school Medical sometimes and maladapted from information conflicting often and incomplete by trouble and time you save to book is this of purpose The resources. unreliable a concise, in you to it presenting and need you that information the all gathering become and exams your at excel to you freeing fashion, memorable and structured, can. possibly you that best doctor the Neel and College, Imperial at student medical a graduate Allen, John by Co-edited Author’s Young BMA the of winner the and University Oxford at a tutor Burton, with crammed before, ever than better and bigger is edition new this 2009, Award school. medical at examined skill clinical major every cover to stations 124 Contents v

Contributors ix Fifth edition © Neel Burton, 2015 Preface xi Fifth edition published in 2015 by Scion Publishing Ltd OSCE tips xiii ISBN 978 1 907904 66 0 First edition published in 2003 by BIOS Scientific Publishers Second edition published in 2006 by Informa Healthcare Third edition published in 2009 by Scion Publishing Ltd I. GENERAL SKILLS Fourth edition published in 2011 by Scion Publishing Ltd 1. Hand washing 1 2. Scrubbing up for theatre 3 All rights reserved. No part of this book may be reproduced or transmitted, in any form or by 3. Venepuncture/phlebotomy 5 any means, without permission. 4. Cannulation and setting up a drip 7 A CIP catalogue record for this book is available from the British Library. 5. Blood cultures 10 6. Blood transfusion 12 7. Intramuscular, subcutaneous, and intradermal drug injection 14 Scion Publishing Limited 8. Intravenous drug injection 16 The Old Hayloft, Vantage Business Park, Bloxham Rd, Banbury OX16 9UX, UK 9. Examination of a superficial mass and of lymph nodes 18 www.scionpublishing.com II. CARDIOVASCULAR AND RESPIRATORY MEDICINE Important Note from the Publisher The information contained within this book was obtained by Scion Publishing Ltd from sources 10. Chest pain history 21 believed by us to be reliable. However, while every effort has been made to ensure its accuracy, 11. Cardiovascular risk assessment 24 no responsibility for loss or injury whatsoever incurred from acting or refraining from action as 12. Blood pressure measurement 26 a result of the information contained herein can be accepted by the authors or publishers. 13. Cardiovascular examination 28 14. Peripheral vascular system examination 33

15. Ankle-brachial pressure index (ABPI) 36 Readers are reminded that medicine is a constantly evolving science and while the authors 16. Breathlessness history 38 and publishers have ensured that all dosages, applications, and procedures are based on 17. Respiratory system examination 41 current best practice, there may be specific practices which differ between communities. You 18. PEFR meter explanation 46 should always follow the guidelines laid down by the manufacturers of specific products and 19. Inhaler explanation 48 20. Drug administration via a nebuliser 50 the relevant authorities in the region or country in which you are practising.

Although every effort has been made to ensure that all owners of copyright material have III. GI MEDICINE AND UROLOGY been acknowledged in this publication, we would be pleased to acknowledge in subsequent reprints or editions any omissions brought to our attention. 21. Abdominal pain history 52 22. Abdominal examination 55 23. Rectal examination 60 Registered names, trademarks, etc. used in this book, even when not marked as such, are not 24. Hernia examination 62 to be considered unprotected by law. 25. Nasogastric intubation 65 Cover design by Andrew Magee Design Limited 26. Urological history 67 27. Male genitalia examination 69 28. Male catheterisation 71 29. Female catheterisation 73

Typeset by Phoenix Photosetting, Chatham, Kent, UK Printed in the UK

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IV. NEUROLOGY

30. History of headaches 75 31. History of ‘funny turns’ 78 32. Cranial nerve examination 81 33. Motor system of the upper limbs examination 86 34. Sensory system of the upper limbs examination 89 35. Motor system of the lower limbs examination 91 36. Sensory system of the lower limbs examination 95 37. Gait, co-ordination, and cerebellar function examination 97 38. Speech assessment 100

V. PSYCHIATRY

39. General psychiatric history 103 40. Mental state examination 106 41. Cognitive testing 111 42. Dementia diagnosis 113 43. Depression history 116 44. Suicide risk assessment 118 45. Alcohol history 120 46. Eating disorders history 123 47. Weight loss history 125 48. Assessing capacity (the Mental Capacity Act) 127 49. Common law and the Mental Health Act 130

VI. OPHTHALMOLOGY, ENT AND DERMATOLOGY

50. Ophthalmic history 134 51. Vision and the eye examination (including fundoscopy) 136 52. Hearing and the ear examination 140 53. Smell and the nose examination 145 54. Lump in the neck and thyroid examination 147 55. Dermatological history 151 56. Dermatological examination 153 57. Advice on sun protection 156

VII. PAEDIATRICS AND GERIATRICS

58. Paediatric history 157 59. Developmental assessment 159 60. Neonatal examination 162 61. The six-week surveillance review 166 62. Paediatric examination: cardiovascular system 169 63. Paediatric examination: respiratory system 173 64. Paediatric examination: abdomen 176 65. Paediatric examination: gait and neurological function 179 66. Infant and child Basic Life Support 181 67. Child immunisation programme 184 68. Geriatric history 186 69. Geriatric physical examination 188

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VIII. OBSTETRICS, GYNAECOLOGY, AND SEXUAL HEALTH

70. Obstetric history 189 71. Obstetric examination 192 72. Gynaecological history 195 73. Gynaecological (bimanual) examination 198 74. Speculum examination and liquid based cytology test 200 75. Breast history 203 76. Breast examination 207 77. Sexual history 210 78. HIV risk assessment 214 79. Condom explanation 215 80. Combined oral contraceptive pill (COCP) explanation 217 81. Pessaries and suppositories explanation 220

IX. ORTHOPAEDICS AND RHEUMATOLOGY

82. Rheumatological history 222 83. The GALS screening examination 226 84. Hand and wrist examination 229 85. Elbow examination 232 86. Shoulder examination 233 87. Spinal examination 236 88. Hip examination 239 89. Knee examination 242 90. Ankle and foot examination 245

X. EMERGENCY MEDICINE AND ANAESTHESIOLOGY

91. Adult Basic Life Support 247 92. Choking 250 93. In-hospital resuscitation 252 94. Advanced Life Support 255 95. The primary and secondary surveys 258 96. Management of medical emergencies 260 – acute asthma 260 – acute pulmonary oedema 260 – acute myocardial infarction 261 – massive pulmonary embolism 262 – status epilepticus 262 – diabetic ketoacidosis 262 – acute poisoning 263 97. Bag-valve mask (BVM/’Ambu bag’) ventilation 266 98. Laryngeal mask airway (LMA) insertion 267 99. Pre-operative assessment 269 100. Syringe driver operation 273 101. Patient-Controlled Analgesia (PCA) explanation 275 102. Epidural analgesia explanation 276 103. Wound suturing 278

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XI. DATA INTERPRETATION

104. Blood glucose measurement 280 105. Urine sample testing/urinalysis 282 106. Blood test interpretation 284 107. Arterial blood gas (ABG) sampling 290 108. ECG recording and interpretation 294 109. Chest X-ray interpretation 306 110. Abdominal X-ray interpretation 311

XII. PRESCRIBING AND ADMINISTRATIVE SKILLS

111. Requesting investigations 315 112. Drug and controlled drug prescription 318 113. Oxygen prescription 323 114. Death confirmation 325 115. Death certificate completion 326

XIII. COMMUNICATION SKILLS

116. Explaining skills 330 117. Imaging tests explanation 333 118. Endoscopies explanation 337 119. Obtaining consent 339 120. Breaking bad news 340 121. The angry patient or relative 341 122. The anxious or upset patient or relative 342 123. Cross-cultural communication 343 124. Discharge planning and negotiation 344

00-OCSEs-Prelims_5e ccp.indd 8 19/03/2015 12:12 01-OCSEs-General_Skills_5e ccp.indd 18 18 Clinical Skills for OSCEs After examiningthelump The examination(IPPA:Inspection,Palpation,Percussion,Auscultation) Before starting nodes Examination ofasuperficialmassandlymph Station 9 • • • • • • • • • • • • • • • • • • • • • • • Examine thedraininglymphnodes(seebelow),orindicatethat youwoulddoso. with theother. A brightredglowindicatesfluidwhereas a dullorabsent glowsuggestsasolid mass. Transilluminate thelumpbyholdingitbetweenfingersofone handandshiningapentorchtoit Auscultate thelumpforbruitsorbowelsounds. Percuss thelumpfordullnessorresonance. Ask thepatient ultrasound, CT. If appropriate, suggest further investigations, e.g. fine needle aspirate cytology (FNAc), biopsy, Summarise yourfindingsandoffer adifferentialdiagnosis. Wash yourhands. Thank him. Ask himifhehasanyquestions orconcerns. Ensure thatthepatientiscomfortable. – – – – – – – – – – Palpate thelumpwithpadsofyourfingers;ifpossible,frombehindpatient.Consider: Assess thetemperatureoflumpwithbackyourhand. Wash andwarmyourhands. tion orisitamoreconstantpain? inflamma Inspect thelumpandnoteitssite,colour,anychangestooverlyingskinsuchas Inspect thepatientfromendofbed,lookingforotherlumpsandanysigns. Position himappropriatelyandensurethatheiscomfortable. Ask the patient to expose the lump completely; for example, by undoing the top button of his shirt. Consider theneedforachaperone. Explain theexaminationandobtainconsent. If allowed,takeabriefhistoryfromhim,forexample,onset,course,effectoneverydaylife. Confirm hisnameanddateofbirth. Introduce yourselftothepatient. – – – – – – – – – – reappears, itiscompressible;ifonlyreappearsuponstanding or coughing,itisreducible compressibility andreducibility:pressfirmlyonthelumptoseeif itdisappears;ifimmediately and theunderlyingmuscle mobility the lumpispulsatile pulsatility: restafingerofeachhandoneithersidethelump:ifyourfingersaredisplaced, the indexfingerofyourrighthand:iflefthandfingersaredisplaced,lumpisfluctuant fluctuance: resttwofingersofyourlefthandoneithersidethelumpandpresswith consistency: soft,firm,hard,rubbery surface: smoothorirregular edge: wellorpoorlydefined shape: spherical,ovoid,irregular,other size: estimatelength,width,andheight,orusearulermeasuringtape number: solitaryormultiple tion ortethering.Notealsothepresenceabsenceofapunctum. or fixation: consider the mobilityof the lump in relation both to theoverlying skin if the lump is painfulbefore you palpate it. Is the pain only brought on by palpa-

18/03/2015 13:18 01-OCSEs-General_Skills_5e ccp.indd 19 Upper body Figure 3. The Head andneck Lymph nodeexamination the and

submental, patient posterior Palpate • Expose • With • Now • With • your – – – – with Preauricular

– – – – Lymph nodesintheheadandneck. Occipital the the the the cervical Posterior auricular Posterior

should

your right expose your your

cervical nodes posterior anterior apical

the submandibular, the

left left right hand.

right be supraclavicular

the of

hand.

hand, nodes sitting

hand, the

left axilla

medial

palpate axilla and

palpate by

parotid,

and

the lifting

aspect and

the

examined occipital lifting

the

infraclavicular

and following and

lymph of

and

abducting the pre-

nodes.

from

abducting

humerus node

and Station 9

lymph

behind.

post-auricular

nodes

groups, the

node

the Examination ofasuperficialmassandlymphnodes arm

on With

as left

groups:

and either

listed

the arm

supporting nodes.

fingers side

and above.

of supporting Next

the of Anterior cervical Anterior Submental Submandibular Parotid

both palpate

at clavicle.

the

hands,

wrist

the at

the

anterior palpate with

wrist

18/03/2015 13:18 19 General skills 01-OCSEs-General_Skills_5e ccp.indd 20 20 Clinical Skills for OSCEs Station 9 Epidermoid (sebaceous)cyst: Conditions mostlikelytocomeupinalumpexaminationstation Palpate Lower body Figure 4. and Lipoma: Results • May • Attached • Spherical, • May • Common • Spherical, • Skin-coloured • Not • group Posterior group Apical group Anterior

near underlying cottage mobile

the Examination ofasuperficialmassandlymphnodes

attached the be have Lymph nodesoftheupperbody.

superficial

and from

red,

cheese great

and a smooth. soft

muscle.

punctum ‘slippery’. hot, the

obstruction

benign and saphenous and

discharge.

skin

the and

inguinal

painless. sometimes

skin

but

tender.

which soft

and not of

vein tissue

nodes

sebaceous

may

to therefore

fluctuant. respectively,

the

tumour.

exude (horizontal

gland.

then

and Fibroma: Skin abscess:

the vertical), Common • Can • Skin-coloured • Situated • Collection • Very • May •

‘soft’. underlying popliteal

be likely

which

sessile indurated.

and node

of to

the structures.

lie

pus be

benign and or

skin below in

groups and infraclavicular Supraclavicular

red,

pedunculated, in

the

painless.

and the

hot,

fibrous popliteal the

skin. so

and

inguinal

unattached

tissue tender.

fossa.

‘hard’

ligament

tumour.

18/03/2015 13:18 02-OCSEs-Cardio_&_Resp_Med_5e ccp.indd 28 28 Clinical Skills for OSCEs Inspection andexaminationofthehands General inspection The examination(IPPA) Before starting Cardiovascular examination Station 13 As • Simultaneously • Indicate • Raise • Determine • Inspect • Wash • Observe • Ensure • Position • Explain • Confirm • Take • From • Introduce • Indicate coagulant, regurgitation). is endocarditis. atrial rhythm ment, sternotomy or – – oxygen – nutritional – – Does – – – – – – – – –

typically

any any any replacement any nail colour, temperature: you

both

fibrillation he

the your the

presence presence presence presence bed

that

move the suggests

mask,

the

that

that his him have the the

patient’s

in end yourself

hands

seen status, hands.

and capillary

the

examination he

name scar

chest particular

you repair patient’s at

you

up the

ECG

Ask

is of

45 rate, for

take

in feel or of of of

could

comfortable. the would noting: second

would

the malar

and

the

aortic degrees, for to

electrodes, multiple koilonychia splinter Osler clubbing the arm evidence of

refill

the with

rhythm, arm,

the

a couch,

mitral

surroundings, any the any date indicate patient

congenital above like

flush

pulse

also

nodes and

regurgitation;

time: degree patient. the

look

blue

other scars haemorrhages

and of ectopics. to

(endocarditis,

valve.

exclude of

obtain back observe of

volume,

birth. and

record

whether press his

or for coronary and of

intravenous

ask mitral

both and obvious heart

‘spoon

peripheral

head

of bruising, IV Do defect.

Janeway him

his the

looking

your radio-femoral lines the

the arms

the not

and stenosis? block,

he consent.

to nail

artery narrow

nails’ blood signs).

precordium

(subacute hand and

miss A patient’s

cyanotic has assess remove to character

which drug

for left

cyanosis lesions

in whereas exclude

(iron

any infusions.

bypass

a pressure particular

Is submammary pulse

pacemaker seconds; for use,

may

shoulder

his

delay congenital deficiency)

general

(subacute

infective

breathless

radio-radial

and

which pressure top(s). for graft

collapsing/water

indicate

the (see

(coarctation

irregularly

for any the

it ing

pain

appearance

radial

if should

Station 12

is items

endocarditis)

orange

infective heart abnormal scar

(CABG), a in

that is

first. risk

delay

aortic

there!

pulse.

cyanosed? most

such

refill irregular

disease)

the

factor of of

valve

(aortic

endocarditis)

stenosis.

nicotine

the A hammer

(age, likely patient within as pulsation. A

wide

for a regularly aorta).

repair

rhythm

nitrate

arch Is

state indicates

acute

pulse

stains

pulse seconds

aneurysm). on

coughing? A

spray,

suggests

infective pressure

irregular

replace an

median

health,

(aortic repair

anti

an -

18/03/2015 13:21 02-OCSEs-Cardio_&_Resp_Med_5e ccp.indd 29 Palpation oftheheart Inspection andexaminationoftheheadneck Place • Gently • Palpate • Determine • Inspect • Assess • Ask • – murmurs. – dental hyperlipidaemia. – – of costal Heaves clavicular Ask thepatientifhehasanychestpain. the simultaneously. is ask no or – – – –

indicative

aortic ‘tapping’, heaving, displaced, impalpable:

tricuspid

greater

the vertical the

the

space

hygiene the retract

patient the result the

patient stenosis,

flat head

jugular

than

the

eyes, suggesting

carotid valve height

of suggesting

suggesting

of an from

anaemia. obesity,

the location (subacute to

of 45° your to 4

eyelid looking

disease.

turn venous cm:

sternocleidomastoid.

mid open of artery collapsing right

hands

the

his clavicular dextrocardia,

and pressure

and mitral

volume for his

ventricular

bacterial and

jugular pressure is head

ask

over character peri-orbital greater mouth,

assess

pulse stenosis

the

slightly

overload

line.

overload either distension

endocarditis), (see patient

of than

its and hypertrophy situs

The

of aortic

volume Figure 6

side

to xanthelasma

Assuming

the 4 cm look

and apex inversus…

(mitral one to

cm,

from

apex regurgitation. look

left

for

side, the

) may this and

and, (sternal angle) (sternal Angle ofLouis venous distention Height ofjugular and

signs up. ( ventricular the

beat.

cor pulmonale) sternum

that

suggests character. and be: aortic

a if

and

Inspect

angle

high possible,

the It look

corneal

is regurgitation) central

Never

arched

and patient normally

right the at hypertrophy Station 13

Louis

the the slow-rising feel

conjunctivus

arcus, palpate

and cyanosis,

heart palate

internal jugular

for

(sternal

located

reclining thrills pressure. the jugularvenous Figure 6.

Cardiovascular examination

both any failure,

(Marfan’s

both (aortic

venous

pulse

dehydration, vein heaves

from

of angle) in

for

carotid

which fluid at the

Assessing

medial

stenosis) is pallor,

45 transmitted

syndrome). pulse

suggestive

and fifth should

overload,

degrees, indicate

arteries

which thrills.

inter form:

poor

the

be 18/03/2015 13:21 -

29 Cardiovascular and respiratory medicine 02-OCSEs-Cardio_&_Resp_Med_5e ccp.indd 30 30 Clinical Skills for OSCEs throughout) For palpating of in Auscultation oftheheart Station 13

Table 5 I

to any Manoeuvres • Listen •

VI – – – – – – – – scope’s

according – – – – – – – – murmur, .

Cardiovascular examination listen stethoscope’s stenosis listen ask diastolic ask the left mitral area(usethestethoscope’sbell) scope’s left tricuspid area left pulmonary area right aortic area

and

the the fifth third, second carotid for Auscultation points

diaphragm,

second

in over

patient patient

heart

diaphragm, timing

the intercostal determine to murmur

fourth, AP C C and

its or intercostal

the left

intercostal

sounds,

intensity brachial bell points

to to

(diastolic, carotid axilla T

and

listen

of , turn ontohisleftside bend

listen

Mid-clavicular

space

its listen aortic

fifth to

for

additional space

artery

(see in location

line arteries

forward remember: space

in the

M the: in

at intercostal systolic) regurgitation

the

Table 4

the

near radiation to

near mitral

determine mid-clavicular left for and

and

sounds, the Ax

in the

any sternal Common

spaces

radiation, area to sternum

relation of

sternum

hold

bruits the and

murmurs, for

the

edge

Figure 7. near

murmur

his to

the conditions

line start

to and

and hold

breath

in the

mid-diastolic the

the

and its

sternum his Auscultation points. of

systole. cardiac

fourth

duration mitral radiation

breath associated pericardial

end-expiration.

intercostal Grade

regurgitation murmur cycle.

(early, end-expiration. of

with

rub. the the This

mid, murmur murmurs space Using

murmur

Using mitral is

best late,

for

the the stenosis

Using

are done of the ‘pan’

stetho stetho a

aortic

listed

scale mid-

the

by or - -

18/03/2015 13:21 02-OCSEs-Cardio_&_Resp_Med_5e ccp.indd 31 Chest examination Examination oftheanklesandlegs Abdominal examination I II III IV V VI Aortic stenosis Mitral regurgitation Aortic regurgitation Mitral valveprolapse RILE: R Table 4. Table 5. loudest Assess • Palpate • Ballot • Check • Inspect • Palpate • Percuss • both on extend pulmonary ight-sided

Barely Soft Murmur Murmur As As

Common conditionsassociatedwithmurmurs Grading murmurs the

above, above, feet.

xpiration

the

for

and

the

all

patient’s the the for and

audible

the kidneys

the

of of murmurs

localised temperature

oedema the legs

abdomen

murmur murmur auscultate

moderate loud

presence way

‘pitting’

for murmur legs. Slow-rising heard Displaced mitral Collapsing lower Mid-systolic

intensity and up

scars

murmur and are

audible audible

to If listen

intensity of left

the in oedema area heard

oedema pleural the exclude that

an the

the

with sternal thrusting chest,

pulse,

sacrum and for with even pulse, aortic

might click, aortic loudest

feet,

any

effusions. a

that of

radiating

ascites

only

is palpable as

especially

edge

thrusting

late-systolic

heaving cardiac aneurysm.

present, area

and renal be

stethoscope is cardiac

on stethoscope

immediately even indicative

and/or check and I

nspiration

artery to

thrill failure:

cardiac

the apex, at the assess radiating

the murmur

the

hepatomegaly.

bruits. torso

axilla, is

pan-systolic

check

rim lifted posterior

apex,

bases

apex, audible

how whereas vein

(‘anasarca’). to on patient

best

from

for ejection/early-systolic the

harvesting

far diastolic chest of

pain heard the it carotids L tibial

Station 13

chest eft-sided

may murmur extends.

wall

lungs.

and

murmur

and in be

wall

for

the and

then

dorsalis best

murmurs Heart

a Cardiovascular examination

atrial

mitral

cardiac CABG.

best some press

heard

failure fibrillation

murmur

area heard pedis

are apex for cases,

heard 5 the can

pulses at

seconds

best

the

cause

may

in 18/03/2015 13:21

31 Cardiovascular and respiratory medicine 02-OCSEs-Cardio_&_Resp_Med_5e ccp.indd 32 32 Clinical Skills for OSCEs After theexamination Station 13 Murmurs • Conditions mostlikelytocomeupinacardiovascularexaminationstation Median • Heart • Pacemaker. • Indicate • Summarise • Thank • Cover • endocarditis), with diogram.

failure. Cardiovascular examination

sternotomy

(see

the the

ophthalmoscope that

Table 5 patient patient.

your

you and,

scar,

findings ).

up would

with appropriate, and

look

and ensure (for or

without

hypertensive offer at

the that

order

scar differential observation

some is on

comfortable.

changes

the

key

lower diagnosis.

chart,

investigations,

and

leg

dipstick

the

(vein

Roth’s

harvesting).

the

e.g.

spots

urine,

FBC,

examine ECG,

subacute

CXR,

the

echocar infective

retina -

18/03/2015 13:21