The

Medical School

CLINICAL EXAMINATION HANDBOOK (12th edition)

Clinical Examination Handbook (12th edition)

Dear Student,

Welcome to the tenth edition of the Clinical Examination Handbook.

The first edition of this handbook was introduced during 2009 to give Sheffield Medical Students guidance on how to take a clinical history and perform examinations of the major organ systems. Its content has been approved by the Clinical Leads in the relevant specialties and is intended to provide guidance for the Phase 2b Basic Clinical Competence and Phase 4 Advanced Clinical Competence Examinations.

Since its introduction, the content has been modified in response to clinician and student feedback and additional sections have been added.

This handbook is not intended to be fully comprehensive and is not substitute for your own self-directed learning. It is intended to be used in conjunction with Macleod’s Clinical Examination, 13th edition (published by Churchill Livingstone).

The materials in this handbook are intended to support the teaching provided at the University of Sheffield. You will find that different clinicians teach the same examination techniques in slightly different ways. However, the methods of physical examination outlined in this handbook are closely aligned with the mark schemes and should therefore be used in your undergraduate summative examinations.

Only the basics of history-taking are covered within this handbook and the history-taking sections are primarily aimed at Phase 2b students. You will gain proficiency by observing experienced clinicians at work and by engaging in regular history-taking practice yourself with real patients. In the End-of-Phase examinations, Phase 2b students should be prepared to take a history from a patient simulating any of the conditions listed in the Phase 2a Medical Sciences Syllabus (see Module Handbook). Phase 4 students should be prepared to take a history from a patient simulating any of the medical conditions encountered in the MBChB curriculum, including women’s health, child health (from a simulated adolescent or parent of a child) and psychiatry. The latter specialties lie outside of the scope of this handbook and you should refer to your Phase 3a course materials during your exam preparation.

All the physical examinations in this handbook may occur in the Phase 2b examination, and combinations of these examinations may also be used within an individual OSCE station (e.g. GALS and shoulder; upper limb neurological examination and selected cranial nerves). Frequent repetition is the key to learning physical examination. In the early stages, you may find it useful to have the checklist in front of you to refer to when needed. You may also find it helpful to recite the routine to yourself whilst practising; for example, whilst examining the nails, think “clubbing, pitting, leukonychia, koilonychia….” and whilst examining a lump, think “position, size, shape, surface….” Always adhere to the traditional schemes of “inspection, palpation, percussion and auscultation” when examining organ systems and “look, feel, move” when examining joints.

Avoid becoming lulled into a false sense of security by over-reliance on performing the steps within the checklist. It is essential that you ask experienced colleagues to critique your technique so that you learn to perform each aspect of the examination competently.

[1]

In the same way that a learner driver stops thinking “mirror, signal, manoeuvre” and starts concentrating on the road ahead, eventually the next step in the examination sequence will become subconscious and you will learn to concentrate on the physical signs that you are detecting. Remember that time spent examining normal subjects is never wasted and being familiar with the variations of what is normal will make the abnormal stand out much more clearly.

Finally, always practice presenting your findings at the end of the examination. The ability to communicate your findings concisely and accurately, describing the key positive and negative findings, in a logical sequence, requires repeated practice. This is an essential skill that you will need, not just in professional examinations, but also when discussing clinical cases with colleagues throughout your career.

We hope that you find this material useful and wish you the best of luck with your studies.

Dr Amir Burney Co-Director Phase 2b and Academic Lead for Clinical skills April 2020.

[2]

Contents

General history taking 4

General considerations when performing physical examination 10

Constructing a differential diagnosis 11

Examination of a swelling (lump) 14

Examination of an ulcer 15

Respiratory history and examination 16

Cardiac history and examination 20

Neurological history and examination 25

Mental State Examination 32

Gastrointestinal history and examination 40

Examination of the groin for hernias 48

Examination of scrotal swellings 49

Urological history 50

Musculoskeletal history 52

GALS screening examination 54

Examination of the hip 56

Examination of the knee 58

Examination of the ankle and foot 61

Examination of the spine 62

Examination of the shoulder 65

Examination of the elbow 68

Examination of the hand 69

Peripheral vascular system history and examination 72

Thyroid gland history and examination 77

Breast examination 80

Examination of the feet of a diabetic patient 81

[3]

History-taking

Introduction • Wash your hands • Introduce yourself (using your full name and status e.g. Sarah Smith, third year medical student) • Obtain consent to take the patients history • Establish the patients identity (ask their name and date of birth, check this on their wristband if they are wearing one) • Establish rapport: Smile, shake hands, sit at the patient’s level, establish eye contact • Ask the patient their occupation – this provides vital information for the diagnosis of occupational illnesses, the likely effect of any illness on the patient’s work, on their socioeconomic status and inquire about the level of education of the patient, all of which are relevant when formulating a differential diagnosis and management plan. • Find out who sent the patient into hospital e.g. General Practitioner, Emergency Department

Presenting Complaint (abbreviated to PC) Identify the patient’s main problem in their own words e.g. ask, “Can you tell me what the problem is?” In the OSCE, always start with an open question even when you have already been given some information about the patients concern e.g. “I understand that you have been suffering from headaches – could you tell me what is troubling you?” Listen fully to the response and then follow with a further open question e.g. “Can you tell me anything more about this problem?” before asking more detailed closed questions. It is important to summarise back to the patient, so you can check that you have captured their concern accurately and they have been given ample opportunity to advise you of all their concerns. Then you can move on to a more detailed exploration of the main complaint or concern.

History of Presenting Complaint (HPC) Obtain a detailed chronological description of the problem. If the patient complains of pain, obtain a full description of this. You may find the SOCRATES mnemonic helpful: Site, Onset, Character, Radiation, associated symptoms, Timing, Exacerbating and relieving factors, Severity. As you start to obtain information about the presenting complaint, you will need to develop your differential diagnosis (see page 11 – differential diagnosis). Think about what the most likely diagnoses are and ask questions to establish whether the patient is likely to be suffering from one of these conditions. Obtain full descriptions of any other symptoms that the patient has. Ensure that you have taken a full history relating to the relevant body system (e.g. the cardiovascular system in relation to a patient with cardiac chest pain). Enquire about specific risk factors, where relevant (e.g. risk factors for atherosclerosis) Ask about any treatment the patient has already had and their response to this treatment.

When you have completed each aspect of the history, explain to the patient what you are going to do next. For example, “I don’t have any further questions at this stage about your main problem, so I am now going to ask you about your background health and about your

[4]

family history. This can help us work out what is causing the problem”. Linking statements such as this are very helpful to the patient and improve their experience during the consultation.

Previous/Past Medical History (PMH) Obtain a detailed health record: Ask about significant illnesses. Ask about previous operations and other procedures e.g. angioplasty, stenting. Ask about mental health. When you first learn to take a history, you may also find it helpful to run through a screening checklist of illnesses with the patient e.g. the mnemonic MJ THREADS (myocardial infarction, jaundice, tuberculosis, hypertension & heart disease, rheumatic fever, epilepsy, asthma & COPD, diabetes, stroke & transient ischaemic attack). However, you should remember to adapt this according to the patient you are taking the history from.

Drug History Obtain a detailed record of prescribed, over-the-counter (OTC) and/or complementary therapies. Ask about responses to these. Is the patient compliant?

Allergies Allergies to drugs, food, elastoplast, latex etc. What reaction does the patient have: itch, rash, swelling, anaphylaxis or just a normal side effect?

Family history Ask about first degree relatives, their age, their state of health or cause of death. Ask whether any diseases run in the family. Ask about specific diseases relevant to the presenting complaint (e.g. eczema, asthma and hayfever in the relatives of a patient with symptoms of asthma; common autoimmune diseases such as Type 1 diabetes, vitiligo, pernicious anaemia and coeliac disease in the relatives of a patient presenting with symptoms of coeliac disease).

Social History (You will need to adapt this according to the age of the patient and their medical problem). Ask whether the patient lives with anyone and if so, whom? Do they have any dependents e.g. young children, carer for their spouse / parent? What sort of accommodation do they live in e.g. house, bungalow, tenth-floor flat? Do they go out at all? Are they able to carry out their activities of daily living (ADLs) e.g. who does their cooking, cleaning, shopping, personal hygiene? Do they have social services support? Are they working? What jobs have they had in the past? Have they been exposed to any occupational risks e.g. asbestos, coal dust? Have they had any recent overseas travel? What are their hobbies? Do they have any pets?

[5]

Do they drink alcohol? If so, how much and how often? How many units a week? If you suspect problem drinking, perform a CAGE questionnaire. Do they smoke / have they ever smoked / when did they stop? Calculate the no. of pack years (20 cigarettes = 1 pack; 1 pack per day for 1 year = 1 pack year). Ask about diet and recreational drugs if relevant.

At this stage, you should summarise the patient’s history back to the patient and ask them if anything has been left out.

Review of systems (This section is not examined in the End-of-Phase examinations due to time constraints but should be included whenever you take a history in clinical practice.) Ask a series of screening questions for each of the main body systems. A table of suggested questions is provided overleaf, and you will need to adapt these for relevance according to the patient’s age and medical complaint. You should not repeat the information that you have already gained in the History of Presenting Complaint (HPC). If the patient describes a symptom, you will then need to explore this in greater depth. All symptoms relevant to the presenting complaint should be written in the HPC, rather than the systematic enquiry. At the end of your review ask, “Is there anything else you think I should know?”

[6]

Review of systems

Cardiovascular Respiratory Chest pain Cough Shortness of breath, at rest or on exertion Sputum Breathlessness on lying flat and how many Shortness of breath, wheeze pillows they use Fever Breathlessness at night Night sweats Palpitations Recent chest X-ray? Ankle swelling Poor circulation in the hands or feet Pain in the calves on walking Gastrointestinal Neurological Change in appetite and/or weight Headaches Problems swallowing visual disturbance, hearing, speech Indigestion/acid reflux/hiatus hernia difficulties Peptic ulcer disease, gallstones, pancreatitis, Dizziness, vertigo jaundice, hepatitis Faints, fits, blackouts Change in bowel habit Weakness, numbness Constipation, diarrhoea Sleep disturbances Blood/mucus/slime per rectum Unsteadiness, tremors Incontinence Concentration, memory Genitourinary Endocrine Incontinence Heat or cold intolerance Frequency, dysuria, nocturia Sweating Hesitancy, dribbling Fatigue Change in quantity, colour Tremor Blood in urine Neck swelling Genital rashes, lumps Weight gain or loss Menstrual cycle, possibility of pregnancy Polydipsia and polyuria Skin Haematological Itch, rash Bruise easily Bruising Bleed excessively Swellings, lumps, ulcers Lumps in axillae, neck, groins Pigmentation changes Previous thromboses, pulmonary embolism Fever, night sweats, weight loss Musculoskeletal Mental Health Joint pain, stiffness, swelling Anxiety, preoccupations, Dry mouth Mood, Self-harm & Suicidality, Sore eyes Unusual beliefs, delusions and hallucinations Skin rash Memory problems, cognitive impairments Back or neck pain Learning difficulties

[7]

Ideas, concerns and expectations (Must be included in the OSCE) You should then establish the patient’s “ideas, concerns and expectations”, as follows: Many patients will already have an idea about what is causing their symptoms. They may have spoken with family and friends or may have looked up their symptoms on the internet. Often, they would like to share their ideas with you. You should therefore establish the patient’s “ideas, concerns and expectations”, as follows: Ideas: Ask the patient “What do you think might be happening?” or “Do you have any ideas about it yourself?” Concerns: Many patients have an underlying fear that they have cancer, or that their condition is terminal. They probably will not volunteer this information to you unless you ask. You could ask “What are you concerned that it might be?” or even “What was the worst thing you were thinking it might be?” Expectations: A patient will enter a medical consultation with an expectation about the outcome. This may be a referral to a specialist, a series of diagnostic tests, a prescription or even an operation. You should find out what the patient’s expectation is by asking “What were you hoping we might be able to do for this?” and then discuss with them whether this is an appropriate course of action.

Conclusion Thank the patient. Wash your hands. Document and report your findings.

After taking the patient’s history, always challenge yourself to write a differential diagnosis. After doing so, compare your own differential diagnosis with that written by the patient’s doctors.

During your early clinical training, when taking a history of the patient’s presenting complaint you are likely to rely on memorised lists of questions to ask, and we have provided examples of these in the subsequent chapters of this book. For example, when taking a gastrointestinal history, you will enquire about: • Pain • Abdominal distension • Nausea and vomiting • Dysphagia (difficulty swallowing) • Dyspepsia (indigestion / heartburn), hiatus hernia and peptic ulceration • History of gallstones or previous pancreatitis • Jaundice • Altered bowel habit (diarrhoea, constipation or alternating diarrhoea and constipation) • Blood loss (haematemesis or rectal bleeding) • Mucus in stools or per rectum • Appetite • Weight change • Continence

[8]

If a patient has one of these symptoms, you will then bring a further checklist into action. For example, with a patient complaining of altered bowel habit, you should ask: • How has the habit altered? Diarrhoea, constipation or both? • Frequency of stools? • Any associated abdominal discomfort or urgency? • Incontinence? • Appearance of stool? Consistency (formed or unformed)? Does it float in the pan? • Associated blood, pus or mucus (slime)? Is the blood mixed with the stool, or separate from it? Is it fresh blood or dark, altered blood? • Associated vomiting? • Foreign travel? • Medications, including over-the-counter remedies?

These checklists are an essential component of your early clinical practice and usually ensure that you gather all the information that you need. However, you should not become over-reliant on checklists in your history-taking as patients will sometimes present with symptoms for which you cannot have a pre-prepared list. Also, the use of a regimented checklist approach can turn a history-taking interaction into something closer to an interrogation! Your questions should focus as much as possible around the patient’s response to your previous question rather than moving on to the next item on your checklist e.g. “You mentioned that the pain has been less severe recently – have you made any changes that you think may have helped?” For cases with less routine presentations, you need to be able to work out the information that you need from first principles, based on your knowledge of the basic medical sciences and your understanding of the pathophysiology of disease. As you gain experience, you will find yourself thinking less about checklists and frameworks themselves, as these become subconscious and automatic, and more about the most likely diagnosis (see page 11 – differential diagnosis). You will begin to rely much more on pattern recognition and will ask questions to determine whether the patient’s symptoms fit or refute the diagnosis you have in mind (hypothetico-deductive reasoning). Some patients, however, will present with a cluster of symptoms that do not fit any recognisable pattern and you will need to revert to the basic model outlined above and take a fully-comprehensive history, including a systematic enquiry, to determine the likely basis of the patient’s problem and your next course of action.

[9]

General considerations when performing physical examination

You must always wash your hands thoroughly before and after seeing a patient. Gloves must be worn during all patient-care activities that may involve exposure to blood and other body fluids including contact with mucous membranes and non-intact skin. Gloves do not provide complete protection against hand contamination, so you must always wash your hands before applying your gloves and after removing them.

You should also always ensure that a chaperone is present during an intimate examination. This applies regardless of whether you are the same gender as the patient. The chaperone does not need to be medically qualified but should be respectful of the patient’s dignity and confidentiality and should be familiar with the procedures involved in a routine intimate examination. In most cases, you will approach another medical student, a doctor, a member of the nursing staff or a healthcare assistant to act as a chaperone.

Before you examine a patient, you must obtain informed consent. If you are examining a patient for your own educational purposes, it is essential that you explain this to them beforehand. Most patients are very happy to participate in student education and it is thankfully, quite rare for a patient to refuse. However, you should select your patients carefully and if you wish to see a patient from a different clinical firm to your own, you should ask a member of the nursing or medical staff if it is appropriate for you to examine them.

You must ensure that you do not cause excessive discomfort to the patient during your examination. However, it is also essential that you gain experience examining acutely unwell patients, particularly during the latter Phases of the course. It is often helpful if you accompany a junior doctor when they see an acute admission and if the patient has clinical signs (e.g. a rigid abdomen suggestive of peritonitis), you should ask the doctor to demonstrate the signs to you and should then try to elicit them yourself. Soon you will be the doctor, so you do need to gain these skills whilst you are a student.

Whenever you examine a patient, you should always practise presenting your findings. It may not always be appropriate for you to do this at the patient’s bedside for several reasons (e.g. using terminology that the patient may not understand, discussing clinical findings that you are uncertain of, discussing clinical findings that the patient may be unaware of). However, when you do present your findings, it is essential that confidentiality is maintained and that you are not disclosing sensitive information where it may be overheard. Most wards have seminar rooms where you can close the door and practise presenting cases to your peers.

Finally, you must never take patient-identifiable information out of the hospital and any case write-ups must not contain the patient’s name, date-of-birth or address or the date or ward on which the patient was seen.

[10]

Constructing a differential diagnosis

Whilst taking the patient’s clinical history and performing a physical examination, you will need to generate a competing set of diagnostic hypotheses – the differential diagnosis. In your End- of-Phase OSCE, you will be asked for the most likely diagnosis after taking each clinical history, and in some stations after performing a physical examination.

The experienced clinician usually thinks in terms of ‘clinical patterns’ (i.e. the typical symptoms and signs of each disease), weighing in such factors as the patient’s age, the incidence of various diseases within the population and the time-course of the patient’s illness. At any one time, most clinicians entertain approximately three working hypotheses which are subsequently narrowed down as more information is gathered, to give the single most likely diagnosis. This process requires a large amount of knowledge and experience and is often performed rapidly and subconsciously. At the start of your medical career, you are likely to lack sufficient clinical experience to work in this way, although with time you will develop these skills. You may therefore initially find one of the following methods helpful to enable you to think systematically when constructing your differential diagnoses.

1. Systems-based method. The first method you may use is to construct a ‘systems-based differential’. For example, when determining the possible causes of abdominal pain, you could divide these into upper gastrointestinal; lower gastrointestinal; liver, pancreas and biliary tract; kidneys and urinary tract; reproductive organs; cardiovascular; respiratory etc. Each category would then be populated with possible diagnoses and you would narrow these down based on the information you gather from your history and physical examination. Judicious use of closed questions whilst taking a history (see subsequent sections of this handbook) will assist you in this process. A variation of this anatomically-based method is particularly useful for considering the causes of failure of specific organs (e.g. jaundice (pre-hepatic, hepatic, post-hepatic), renal failure (pre-renal, renal, post-renal)) and enables you to structure your thoughts in a logical manner.

2. The surgical sieve. Rather than developing your differential diagnosis based on anatomical organs, the surgical sieve encourages you to think about the cause of the patient’s symptoms. It can be used for medical conditions as well as surgical conditions. There are many variations on this theme, all of which are based on mnemonics to assist recall). However, a commonly used surgical sieve is shown in Box A (overleaf), which has been populated with some causes of abdominal pain. The disadvantage of such approaches is the lack of reference to the symptoms and signs of the individual case. Hence, they should be used to ensure possible causes have not been overlooked rather than as a structure for presenting the differential diagnosis.

[11]

Congenital: hypertrophic pyloric stenosis, Meckel’s diverticulum Acquired (VITAMIN DEF): • Vascular: mesenteric ischaemia, ruptured abdominal aortic aneurysm, aortic dissection, sickle cell crisis, testicular torsion, myocardial infarction, pulmonary embolism • Infective: (bacterial, viral, fungal, protozoa, worms) e.g. viral mesenteric adenitis, gastroenteritis, cholecystitis, appendicitis, hepatitis. Inflammatory: Ulcerative colitis, Crohn’s disease, chemical

gastritis • Traumatic: blunt or penetrating abdominal trauma • Autoimmune: coeliac disease, SLE

• Metabolic and endocrine: hypercalcaemia, diabetic ketoacidosis, porphyria Mechanical obstruction: Intussusception • Idiopathic or iatrogenic: Drug side-effects • Neoplastic: primary or secondary intra-abdominal

malignancies; vertebral metastases • Degenerative: Osteoarthritis of the spine • Environmental: Heavy metal poisoning • Functional: Irritable bowel syndrome

Box A: An example of a surgical sieve used to develop a differential diagnosis for abdominal pain. (This list is illustrative and therefore is not intended to be exhaustive.)

Once you have developed your initial differential diagnosis, you will need to weigh in additional factors including:

• patient’s age • onset and progression of the illness • geographic location (including recent foreign travel) • incidence / prevalence of disease in the local population • past medical history • family history (especially relevant for diseases with familial bias) • occupation • social history etc.

After you have concluded taking the patient’s history and performing your physical examination, and have considered the additional factors listed above, you are likely to be left with just a small number of viable differentials. Judicious use of investigations such as x-rays and blood tests will often enable you to establish or refute each of these diagnoses. In your End-of-Phase examinations, particularly in Phase 4 (but also sometimes in Phase 2), you will

[12]

frequently be asked which tests you need to order. It is essential that you request each investigation with a specific question in mind and that you avoid a scatter-gun approach.

As you gain experience, the process of constructing a differential diagnosis will become subconscious and pattern recognition will begin to dominate your thinking. However, even experienced clinicians will be faced on occasion with problems with which they are unfamiliar and will need to revert to a systematic approach to reach a diagnosis. You should therefore ensure that these basic skills are learned thoroughly at this early stage in your training.

[13]

Examination of a swelling (lump)

The process of examining any lump is divided into ‘look, feel, move, specific tests and examination of the regional lymphatic drainage’. The following scheme will help you to examine a lump and to describe your findings in a logical and well-structured manner.

1. Look (inspection) • Location / position, measured from a landmark • Contour (if visible by inspection): regular or irregular • Colour of the overlying skin e.g. erythematous, pigmented • Abnormalities in the overlying skin e.g. peau d’orange • Abnormal vessels / telangiectasia

2. Feel (palpation) • Surface e.g. smooth, rough, irregular • Shape • Size: use a tape measure • Tenderness • Temperature – palpate with the back of your hand • Cough impulse? • Consistency (Soft, firm, hard, rubbery, uniform, varied, lobulated) • Compressible? • Fluctuant? • Pulsatile (high blood flow) or expansile (aneurysmal)? Is there a palpable thrill?

3. Move • Skin tethering - attempt to pick up a fold of skin over the swelling and compare the degree of tethering with the other side • Tethering to deeper structures - attempt to move the swelling in different planes relative to the surrounding tissues. • Tethering to muscles and tendons - palpate the swelling whilst asking the patient to use the relevant muscle.

4. Specific Tests • Transillumination - if you suspect the mass is filled with clear fluid (e.g. a hydrocoele), you should attempt to shine a pen torch through it. • Auscultation for bruits or bowel sounds

5. Regional Lymph Nodes • You must be aware of the main routes of lymphatic drainage and examine the relevant regional lymph nodes.

[14]

Examination of an ulcer

When describing an ulcer, the same scheme of look, feel, move, special tests and examination of the regional lymphatic drainage should be applied. 1. Look (inspection) • Number of lesions: single or multiple. Multiple ulcers are commonly seen in arterial disease. • Site. For example, varicose ulcers are typically vertically oval and are located over the medial malleolus. • Size. Use a tape measure to measure the ulcer. Estimate the depth in millimetres. • Shape. This may be important diagnostically. For example, varicose ulcers are typically vertically oval and are located over the medial malleolus. Malignant ulcers are typically irregular in shape. • Margin. The junction between normal and abnormal skin. • Edge. The tissue between the margin and the floor of the ulcer e.g. sloping, punched out, undermined, raised, rolled, everted. Note whether the marginal epithelium is attempting to grow over the surface. • Floor. The ulcer floor may comprise healthy or unhealthy granulation tissue, slough, scab, fat, muscle, tendon, periosteum or bone. • Discharge. Assess the quantity, consistency, colour, composition, and odour. For example, wound discharge may be serous (watery), sanguineous (bloodstained), purulent or green (which usually indicates Pseudomonas colonization / infection). • Surrounding Skin. Look for hyperpigmentation, oedema, erythema, stretch marks, and wrinkling (which may indicate resolving inflammation) • Whole Limb. Look for signs of venous and arterial insufficiency and neurological disease. Muscle wasting may be present. 2. Feel (palpation) • Check for tenderness. • Palpate the temperature of the ulcer and the surrounding skin using the back of the hand. • Palpate the edge of the ulcer for induration, which is a feature of chronic benign ulcers and of malignant ulcers. • Determine whether the ulcer bleeds on gentle touch or not. This is often a feature of malignancy. 3. Move • Gently attempt to move the base of the ulcer using your thumb and forefinger. Fixation to deeper structures may be suggestive of malignancy. 4. Examine the regional lymphatic drainage. 5. Special tests. • Palpate the peripheral pulses • Examine light-touch and pressure sensation. • If there is evidence of bony involvement, you will need to examine the nearby joints.

[15]

Respiratory system history

History of presenting complaint (HPC):

The following are examples of the level of detail that you should be eliciting for each respiratory symptom:

Breathlessness

• How is the patient normally? (Is this acute / chronic / acute on chronic?) • Onset, timing, duration, variability, diurnal variation • Exacerbating factors e.g. allergic triggers, exertion, cold air • Relieving factors e.g. rest, medication • Associated symptoms e.g. cough, sputum, haemoptysis, pain, wheeze, night sweats, weight loss, oedema • Severity e.g. at rest? Only on exertion? Limiting ADLs?

Cough

• Onset, timing, duration (less than 2 months = acute, more than 2 months = chronic), variation (e.g. recent change in a chronic cough), diurnal variation. • Productive / unproductive?

Sputum

• Onset, timing, duration, variation, diurnal variation • Colour (e.g. rusty sputum suggests pneumococcal pneumonia; frothy pink may indicate pulmonary oedema). Any haemoptysis? • Consistency (viscous (fluid), mucous, purulent, frothy) • Quantity (teaspoon, cupful etc.) • Odour (fetid suggests bronchiectasis or a lung abscess)

Haemoptysis

• Origin (differentiate haemoptysis from haematemesis, was it coughed up?) • Onset, timing, duration, variation • Quantity • Colour (fresh blood or dark altered blood) • Consistency (liquid, clots, mixed with sputum) • Sputum • Chest pain • Recent trauma to chest or elsewhere? • Recent / current DVT? • Weight loss, fever, night sweats? • Breathlessness? • Bleeding or bruising elsewhere?

[16]

Pain

• Site • Onset • Character • Radiation • Associated symptoms • Timing • Exacerbating and relieving factors • Severity

Completing the respiratory HPC:

Your history of presenting complaint should also include:

• Previous respiratory problems o Pneumonia can lead to bronchiectasis or pulmonary fibrosis o Tuberculosis can reactivate o Severe measles or whooping cough can lead to bronchiectasis o Asthma • Recent surgery: o Dental surgery can lead to aspiration of purulent material or fragments of tooth o Abdominal, pelvic or orthopaedic surgery are risk factors for DVT and possible pulmonary embolus • Cardiac disease may lead to pulmonary oedema – ask specifically about angina, orthopnoea, paroxysmal nocturnal dyspnoea • Immunocompromised (e.g. HIV, immunosuppression post-transplant surgery) may predispose to atypical infections

Drug history and allergies

Inhalers, steroids, antibiotics, ACE inhibitors (may cause cough), amiodarone (pulmonary fibrosis), beta-blockers (may worsen airways obstruction), NSAIDS, oxygen therapy

Social history

• Occupation (industrial hazards e.g. dusts, asbestos) • Smoking (pack years e.g. 10/day for 30 years = half a pack x 30 = 15 pack years) • Pets (can transmit infection or cause hypersensitivity reactions) • Overseas travel • Living conditions e.g. damp • Alcohol • Exercise, activities of daily living, independence

Family history

• Infections may be transmitted between family members • There is a genetic predisposition to allergic conditions (e.g. asthma) • Alpha1-antitrypsin deficiency is a genetic cause of emphysema

[17]

Respiratory System Examination

• Wash your hands • Introduction, identification and consent • General inspection of the bed area e.g. inhalers, nebuliser, oxygen mask, sputum pot • General observation of the patient (colour, breathing, comfort, position, purse-lipped breathing in COPD, nutritional state (obesity may suggest obstructive sleep apnoea, Pickwickianism))

Inspection

• Inspect the hands for clubbing, tar staining and wasting of the intrinsic muscles (T1 nerve invasion by an apical lung cancer) • Look for tremor (flapping asterixis in respiratory failure, fine with beta-agonists e.g. salbutamol) • Assess pulse rate, rhythm and character (e.g. bounding in CO2 retention) whilst simultaneously assessing respiratory rate, rhythm, pattern and effort. • Note the presence of pulsus paradoxus (an exaggeration of the normal decrease in blood pressure during inspiration). The ‘paradox’ is that you can detect beats on auscultation of the heart during inspiration that cannot be palpated at the radial artery due to a fall in blood pressure. Pulsus paradoxus is seen in severe obstructive airways disease and cardiac tamponade. • Check the blood pressure. • Check for raised JVP, suggesting cor pulmonale. A raised non-pulsatile JVP may be seen in superior vena cava (SVC) obstruction due to a lung cancer, in which case there will be oedema of the face and neck. • Look for respiratory disease in the eyes: o Horner’s syndrome o Chemosis (conjunctival oedema may be seen with hypercapnia 2° to COPD) • Look for respiratory disease in the face and mouth: o Facial swelling is seen in SVC obstruction o Dental caries (may cause lung abscess by inhalation of debris) o Central cyanosis • Expose the chest and inspect for: o Shape § Barrel chest (hyper inflated in emphysema) § Severe kyphoscoliosis § Severe pectus excavatum (funnel chest) § Pectus carinatum (pigeon chest) +/- Harrison’s sulci o Symmetry o Scars o Muscle wasting o Chest versus abdominal (diaphragmatic) breathing o Use of accessory muscles o Recession (more common in children, but can be seen in adults with partial laryngeal/tracheal obstruction)

[18]

Palpation

• Check trachea and apex beat for deviation. Deviation occurs toward the side of the pathology with pulmonary fibrosis or collapse, but away from the pathology with a tension pneumothorax or massive effusion. • Assess chest expansion (normal = 3-5cm; abnormal <2cm). Remember to ask the patient to exhale fully before assessing expansion. • Assess tactile vocal fremitus (“say ninety-nine”). (Transmission of vibrations is increased in consolidation as sound travels quicker through solid than air. Transmission is decreased with an effusion or pneumothorax as the lung tissue becomes separated from the chest wall).

Percussion

• Starting at the apices, percuss from side to side anteriorly. Consider the surface marking of the lungs and their fissures whilst percussing. Ensure that you have percussed every lobe (including the right middle lobe).

Auscultation

• Starting at the apices, auscultate from side to side anteriorly and laterally with open mouthed breathing (clavicle to 6th rib, mid-clavicular line; Axilla to 8th rib, mid-axillary line). Again, recall the surface markings of the lungs and their lobes whilst auscultating. Note the presence of: o Vesicular (normal) breath sounds o Bronchial breathing o Rhonchi (wheezes) o Crackles / crepitations o Pleural rub o Assess for any change in these sounds after coughing (crepitations due to secretions will alter after coughing whereas those in fibrotic conditions won’t) • Assess vocal resonance (say “ninety-nine” whilst auscultating with the stethoscope). (This technique allows discrimination between dullness to percussion from pleural effusion and that from consolidation. Voice sounds, which are created in the larynx, are transmitted more effectively across an area of consolidation. Transmission is reduced across a pleural effusion or pneumothorax.) • If you suspect an area of consolidation, perform whispering pectoriloquy (whisper “two- two-two”). (Whispers are transmitted more loudly across an area of consolidation.)

Repeat inspection, palpation, percussion, and auscultation (spine of scapula to 11th rib) on the back with the patient sitting forward

• Palpate the cervical lymph nodes. • Palpate the ankles for oedema. • Check sputum pot (volume, consistency, colour, odour, any haemoptysis) • Assess peak flow (state that you would do this in the OSCE) • Thank the patient and request them to redress. • Wash your hands

[19]

Cardiac history

Symptoms of cardiovascular disease include:

• Chest pain • Dyspnoea (shortness of breath) • Orthopnoea (SOB on lying flat that is relieved by sitting upright) • Paroxysmal nocturnal dyspnoea (acute dyspnoea that wakes the patient from sleep) • Ankle oedema • Cough, sputum & haemoptysis • Dizziness • Light-headedness • Presyncope & syncope • Palpitations • Nausea & sweating • Claudication • Systemic symptoms e.g. fatigue, weight loss, anorexia, fever Ischaemic heart disease risk factors:

• Male sex • Age • Smoking • Hypertension • Diabetes mellitus • Family history of IHD • Hypercholesterolaemia • Physical inactivity and obesity

Examples of presenting complaints:

Chest pain

Site: Central substernal, across mid-thorax anteriorly, in both arms/shoulders, in the neck/cheeks/teeth, in the forearms/ fingers, in the interscapular region Onset: Acute Character: Crushing, tight, constricting, squeezing, burning, ‘heaviness’ Radiation: Neck, jaw, left arm Associated symptoms: Sweating, nausea, shortness of breath, palpitations Timing: On exertion? At rest? Exacerbating factors: Exercise, excitement, stress, cold weather, after meals, smoking, lying flat (decubitus angina 2° to left heart failure) Alleviating factors: Rest, medication, oxygen Severity: Pain scale (1 – 10)

[20]

Factors against cardiac ischaemia as the cause of pain:

• Character of pain: ‘knife-like’, sharp, stabbing, aggravated by respiration • Location of pain: left submammary area, left hemithorax • Exacerbating factors: pain after completion of exercise, specific body motion

Shortness of breath (dyspnoea)

Onset: Acute, chronic, acute-on-chronic Associated symptoms: Sweating, nausea (due to hepatic/gastric congestion), pain, cough, sputum (watery/frothy? Blood-tinged?), swollen ankles, palpitations, nocturnal micturition, rapid weight gain (could be due to oedema) Timing: On exertion? At rest? Constant? At night (paroxysmal nocturnal dyspnoea)? Exacerbating factors: Position (number of pillows – orthopnoea)? Alleviating factors: Rest, medication, oxygen, sitting up straight Severity: How debilitating? Effect on activities of daily life? Exercise tolerance (see below) Remember to ask about respiratory diseases as well.

Questions about exercise tolerance:

• ‘How far can you walk on the flat before you need to stop and rest?’ • ‘What is it that limits how far you can walk?’ • ‘Do you feel short of breath when you walk, such as walking up hills or stairs?’ • ‘Do you have any discomfort or tightness in your chest when you walk?’ • ‘How long ago did you notice a problem when you are walking…did it get worse suddenly or gradually…. how far were you able to walk a year/month ago?’

Palpitations

• ‘Have you had any palpitations or awareness of your heart racing?’ • ‘Does anything seem to provoke this?’ • ‘Does it start suddenly or build up gradually?’ ‘Does it stop suddenly or gradually?’ ‘How long does it last?’ • ‘Do you have any other symptoms with the palpitations?’ • ‘Can you can tap the rhythm?’ (Is it regular, irregular or regularly irregular? Is it fast or slow?)

Syncope

• Sudden and brief loss of consciousness associated with a deficit of postural tone, from which recovery is spontaneous (not requiring electrical or chemical cardioversion) • Usually results from sudden transient hypotension, which results in impairment of cerebral perfusion • Presyncope – the feeling of imminent loss of consciousness but not progressing to loss of consciousness e.g. faintness

[21]

Medical history

Specific cardiac questions include:

• Similar episodes, previous diagnoses, treatments and responses to treatment. • Previous cardiac surgery • Hypertension • Hypercholesterolaemia • Anaemia • Diabetes • Angina • Myocardial infarction • Cerebrovascular accident / Transient ischaemic attack • Peripheral vascular disease e.g. intermittent claudication • Cardiac failure • Rheumatic fever

Drug history and allergies

Particularly relevant drugs include: Antihypertensive drugs All cardiac drugs Other drugs with cardiac side effects e.g. corticosteroids (hypertension and fluid retention), and drugs that can cause sinus tachycardia (e.g. salbutamol, theophylline, nifedipine, thyroxine) Over-the-counter drugs e.g. aspirin, NSAIDs

Social history

Occupation, smoking (number of pack years), alcohol (can cause atrial fibrillation, cardiomyopathy, hypertension and tachycardia), diet, stress

Family history

Family history of ischaemic heart disease or cerebrovascular accident before the age of 65.

[22]

Cardiac examination The ‘full cardiac examination’ involves a specific examination of the precordium and a more general examination of the patient to detect the peripheral signs of cardiac disease. The scheme to be employed is as follows:

• Wash your hands • Introduction, identification and consent • Inspect the around the bed space for clues e.g. GTN spray • Inspect the general appearance of the patient (colour, breathing, comfort, position, build) • Inspect the patient’s hands for cardiac signs: o Tar staining o Vasodilatation/constriction, temperature o Sweating (suggests increased sympathetic drive) o Pallor of palmar creases o Peripheral cyanosis o Clubbing o Splinter haemorrhages o Osler’s nodes and Janeway lesions o Tendon xanthomas • Check the presence of both radial pulses simultaneously. Assess rate and rhythm in one radial pulse (usually the right). • Assess the character and volume of the brachial pulse (normal, slow rising, collapsing). Ask the patient if they have pain in their arm before checking for collapsing/waterhammer pulse (aortic regurgitation) • Assess the character and volume of the carotid pulse (one side at a time) • Look for cardiac signs in the eyes: o Subconjunctival pallor o Corneal arcus o Xanthelasmata • Look for cardiac signs in the face: o Malar flush (mitral stenosis) • Look for cardiac signs in the mouth/lips: o Central cyanosis (under tongue or on mucous membranes inside lips) o High-arched palate (Marfan’s) o Dental caries (may predispose to infective endocarditis) • Position the patient at 45° and check for raised JVP (normal = 2 - 4cm above sternal angle). Check for low JVP using hepatojugular reflux by compressing the liver and observing the JVP (will rise). Check for high JVP by sitting patient upright and looking near the ear lobes for venous pulsation. Identify the two main waves by palpating the carotid. • Expose the patient’s chest and inspect the precordium o sternotomy scar o severe pectus excavatum o severe kyphoscoliosis o visible cardiac pulsation

[23]

• Palpate for the apex beat and parasternal heaves (outward displacement of the palpating hand by cardiac contraction e.g. in left ventricular hypertrophy) and thrills (palpable murmurs) • Auscultate aortic, pulmonary, tricuspid and mitral valve areas. If extra sounds are heard, palpate the carotid pulse to time them with the first and second heart sounds. The start of the carotid pulsation will be synchronous with the first heart sound. • Auscultate left axilla for mitral incompetence • Switch to the bell and auscultate the apex with the patient rolled 45° to the left (for mitral stenosis). • Switch back to the diaphragm, sit the patient forward and auscultate at the 4th/5th intercostal space to the left of the sternum on held expiration (aortic regurgitation) • Auscultate lung bases, assess for sacral oedema. If coarctation is suspected, auscultate to the left of the spine in the 3rd/4th intercostal space • Sit the patient back and auscultate the carotids for bruits or a transmitted systolic murmur. • Lay the patient flat, if they can tolerate it, and palpate for hepatomegaly. If the liver is enlarged, feel for pulsation (tricuspid regurgitation). • If you suspect ascites, test for shifting dullness (percuss from the centre toward the left flank. If a dull note is heard, keep the finger in position and roll the patient onto their right side. Wait a few seconds for the fluid to redistribute. If the note becomes resonant, percuss back towards the umbilicus until the note becomes dull i.e. shifting dullness). • Check the femoral pulses. Check synchrony with the radial pulse (radiofemoral delay in coarctation). (In the OSCE, you should state that you would do this). • Check for pitting oedema at the ankles. If this is present, you should always also check for ascites (see test for shifting dullness above). • Check the blood pressure in both arms and lying and standing in one arm. (In the OSCE, you should state that you would do this). • Perform ophthalmoscopy for hypertensive retinopathy (In the OSCE, you should state that you would do this). • Obtain a 12-lead ECG (In the OSCE, you should state that you would do this). • Thank the patient and request them to redress • Wash your hands.

[24]

Neurological History

History of presenting complaint:

The following are examples of the level of detail that you should be eliciting for each neurological symptom:

Headache

Site: Ask the patient to point. Unilateral/bilateral? Onset: Sudden or gradual? Thunderclap? Character: Throbbing? Like a tight band? Radiation: Does the pain radiate? Associated symptoms: Nausea/vomiting, altered conscious level, rash, pyrexia, neck stiffness, photophobia, visual loss, blurred vision, aura, tender scalp, malaise, rhinorrhoea/lacrimation? Timing: Constant/intermittent? Single/recurrent? Duration of episodes. Worse at certain times of day/month/year? Exacerbating factors: noise, stress, bending, standing up, coughing, sneezing, blowing nose, eating, combing hair, bright or flashing lights, certain foods/drugs, dehydration? Relieving factors: analgesia, dark environment, lying down, rest Severity: Scale (1-10)

Altered consciousness Ask the patient to describe the episode in their own words. Pay attention to: Onset (gradual/sudden?), Time of the day What they were doing at the time? Any pain, injections hot crowded rooms, emotional stress, prolonged standing, How they felt before the episode Associated symptoms: Dizziness, nausea, vertigo, aura, tachycardia, sweating, weakness, paraesthesia, slurred speech, headache, tongue biting or incontinence, stiffening\jerking of limbs, awareness and responsiveness during the episode, eyes-open or closed? Groans, crying? How long did it take to recover? Any amnesia, aggression, crying or weakness after the episode? Feeling sad and crying after the episode Previous episodes? If so whether they are like the current one? Was the episode witnessed? If so what did the witness say? Can we contact them to get a description?

[25]

Any other Neurological Symptoms

With other neurological symptoms, it is important to note the course: is it sudden in onset, how long did it take to reach the peak of the symptoms- Minutes, Hours, days, weeks or months? Getting better or worse? Static/progressive/relapsing and remitting?

Also note the results of any previous attempts to diagnose the condition and responses to any previous therapeutic interventions.

[26]

Past medical history

Specific risk factors include: Head/spinal trauma Metabolic/endocrine disorders e.g. diabetes Cancer (metastases?) Epilepsy Hypertension Atrial Fibrillation Heart diseases

Drug history and allergies

Anticonvulsants Drugs that interact with anticonvulsants / lower the seizure threshold Anticoagulants and anti-platelet drugs Analgesics Antihypertensives Antidepressants Insulin Recreational drugs

Social history

Alcohol consumption Smoking Recreational drugs Occupation Social activities/hobbies Home circumstances, level of independence

Family history Diabetes Cerebral haemorrhage Cerebrovascular disease / stroke Ischaemic heart disease Migraine Epilepsy

[27]

Neurological examination

Neurological examination follows the sequence inspection, tone, power, reflexes, co- ordination and sensory examination. In clinical practice you will commonly need to perform a full neurological examination, including an assessment of the patient’s cranial nerves. However, in the OSCE situation, due to time constraints, you will be asked to examine either the upper or lower limbs separately (possibly with the addition of a few cranial nerves, depending on the case and timing of the station).

You should always ask the patient if they have any pain before you commence your examination. If so, you will need to adapt your examination and your interpretation of the results accordingly. For example, muscle power often appears diminished around a stiff or painful joint and you should not mistakenly interpret this as a primary neurological problem. You will need to check for signs of Meningeal irritation like neck stiffness and Kerning sign need to be checked. You should check against the Glasgow Coma Scale and conduct a bed side cognitive test like AMT only if there are concerns about cognition. You should also test the patient’s speech.

[28]

Neurological examination of the upper limbs

Ask if the patient has any pain (including neck pain) before commencing this examination.

Ask: Is the patient right or left handed? Patients often perform slightly better with the dominant hand/limb Inspection: Posture, wasting, tremor, fasciculations, involuntary movements.

Tone Passively move each joint Is there normal, even uneven resistance? Spasticity is velocity dependent- faster you move more the resistance. Rigidity is same irrespective of the speed of the movement. Hypertonia (spasticity or rigidity?) Hypotonia Power (against resistance) Pronator drift (UMN lesion) – see below Use the MRC grading system (see Shoulders: Flexion, extension, abduction, below) adduction Elbows: Flexion, extension, pronation, Learn the muscle groups being tested, supination their nerve roots (myotomes) and their Wrists: Flexion, extension peripheral nerve supply Fingers: flexion, extension, abduction Thumb: palmar abduction (median), adduction (ulnar) and opposition (median) Reflexes Biceps Triceps Supinator / brachioradialis Use reinforcement if needed (clench teeth) Co-ordination Finger to examiners finger then to own nose repeatedly Finger to own nose with eyes closed Fine movements e.g. piano-playing or touch thumb to each fingertip on same hand rapidly Dysdiadochokinesis Sensation Soft touch Pain / pinprick (OSCE: describe only) Learn the dermatomes being tested and Temperature (OSCE: describe only) the sensory distribution of the peripheral Proprioception nerves Vibration (128Hz tuning fork) Cortical localisation: Stereognosis (identify coin/key placed in patient’s hand with eyes closed); 2-point discrimination; graphaesthesia.

[29]

Neurological examination of the lower limbs

Ask if the patient has any pain (including back pain) before commencing this examination. You will need to perform Romberg’s test and assess the patient’s gait, either at the beginning or end of this examination (see below)

Inspection: Posture, wasting, tremor, fasciculations, involuntary movements.

Tone Passively move each joint Is there normal, even resistance? Hypertonia (spasticity or rigidity?) Hypotonia Check for ankle clonus (UMN lesion) Power (against resistance) Hip: abduction, adduction, flexion and Use the MRC grading system (see extension below) Knee: flexion and extension Ankle: dorsiflexion, plantarflexion, Learn the muscle groups being tested, Big toe: plantarflexion and dorsiflexion their nerve roots (myotomes) and their peripheral nerve supply Reflexes Knee Ankle Use reinforcement if needed (clench fingers) Plantar reflex (Babinski response) Ankle Clonus Co-ordination Heel-shin test Sensation Soft touch Pain / pinprick (OSCE: describe only) Learn the dermatomes being tested and Temperature (OSCE: describe only) the sensory distribution of the peripheral Proprioception nerves Vibration (128Hz tuning fork) Check the trunk for the sensory level if indicated.

Romberg’s Test (modified) The patient stands with feet together, arms outstretched in front of them and hands supinated. If they cannot do this with the eyes open, it suggests a cerebellar lesion. If the patient can maintain the position with the eyes open but loses balance when the eyes are closed, this suggests loss of proprioception.

Assessment of gait Assess the patient’s gait both walking normally and walking heel-to-toe. Assess their balance, posture, stride length and arm swing. Learn to recognise: • Hemiplegic gait: Arm adducted at the shoulder, flexed elbow and wrist, leg extended and adducted at the hip, knee extended, and ankle plantar-flexed The patient lurches his upper body toward the unparalysed side to elevate the pelvis and swing the paralysed leg round. The plantar-flexed foot scrapes along the ground.

[30]

• Apraxic gait: The gait is slow and shuffling. The stride length is markedly decreased. Can lose balance while turning. Gait in Parkinson’s disease: In addition to above, there is loss of arm swinging on walking. The patient takes increasingly rapid steps forward to maintain an upright posture (Festinant gait).

• Steppage gait: Paralysis of the dorsiflexors of the ankle results in a “drop-foot”. The patient flexes the knee and lifts the foot high to clear the toes from the ground. As it is returned to the ground, there is a loud slapping noise. Unilateral drop-foot suggests a common peroneal nerve palsy or spinal lesion. Bilateral suggests generalised polyneuropathy. Ataxic gait- This is a wide based gait. The feet are planted wide apart and patient sways to one or both sides while walking. Attempting to walk heel-to-toe makes ataxic gait more pronounced.

MRC grading of motor power

• 5/5 = movement against gravity with full power against resistance • 4/5 = movement against gravity with reduced power against resistance. Grades 4-, 4 and 4+ indicate reduced power but the presence of movement against slight, moderate and strong resistance respectively. • 3/5 = movement against gravity only without applied resistance • 2/5 = muscle contraction with active movement only when gravity is eliminated • 1/5 = flicker of muscle contraction seen, no movement • 0/5 =no muscle contraction

Completion

• Thank the patient • Request them to redress • Wash your hands

[31]

Mental State Examination

Mental state examination (MSE) is an important part of the clinical assessment in psychiatry and its main purpose is to obtain a comprehensive, structured, cross-sectional description of a patient’s mental state which allows the doctor to make an accurate diagnosis and formulation. It has the equivalent status to a physical examination and a psychiatric assessment is not complete without it.

To undertake a MSE you will need to:

• Use observational skills to notice aspects of the patient’s presentation.

• Consider appropriate language to describe findings (beware not to be judgmental or stigmatising).

• Practice using the right language and tone to build rapport and thus ask personal/sensitive questions. Such as:

o “That sounds difficult, do you mind if I check out what you mean by that?”

o “You look unhappy to me – is that how you feel?”

o Is it alright that I ask a little more detail about that?

1. Appearance and Behaviour A person's appearance can provide useful information into their quality of self-care, lifestyle and daily living skills.

• Build and distinctive features • Clothing – unkempt clothing might indicate depression/paranoid schizophrenia.

• Hygiene – might indicate self-neglect or depression or raw hands – might indicate frequent washing as in OCD. • Gait and posture: o Psychomotor activity and movement e.g. hyperactivity (mania) or hypoactivity (depression) o Facial expression, body language and gestures o Eye contact and rapport – lack might indicate depression o Unusual features e.g. tremors, slowed movements, stereotyped movements (purposeless movements) or mannerisms (quasi-purposeful movements). o Level of arousal – agitated, calm, provocative, abrupt?

2. Speech This is the production of speech rather than the content (which comes under “Thoughts”).

• Rate e.g. rapid/ pressured (mania) • Rhyme: words linked e.g. hair and bear or punning: 2 words have the same sound e.g. male and mail (seen in mania) • Tone e.g. monotonous (depression) • Volume e.g. loud, normal, soft

[32]

3. Mood and affect Affect refers to immediate observed or objective emotion while mood refers to a more subjective emotion over a prolonged period of time. Affect tends to be what you observe whereas you need to ask about mood.

• Mood: described using the patient’s own words.

• Nature e.g. high, depressed, anxious, angry or low. • Variability e.g. continuous, relentless, changeable • Severity e.g. out of range of normal for their personality or within the range of how they generally feel.

• Affect: described by how they convey their emotion and non-verbal cues picked up by interviewer.

• Quality e.g. sad, angry, hostile • Range e.g. restricted, expansive or labile • Intensity e.g. blunted, flat, elevated • Affect may be described as “congruent” (where affect reflects mood) or “incongruent” (where the emotion is inappropriate to the content of the speech)

4. Thoughts

You should think about the stream, the content and the form of the patient’s thoughts as gleaned from what you hear of their speech and your supposition or analysis of their thought processes.

• Stream: abnormality of the amount and speed of thought • Pressure: unusually rapid, abundant and varied. Occurs in mania. • Poverty: unusually slowed, few and unvaried. Occurs in severe depression. • Thought blocking: the mind becomes suddenly empty of thoughts. Occurs in paranoid schizophrenia. (Often gleaned from a sudden ceasation of speech and can be confirmed by asking the patient what has happened.) • Form: abnormality in the way thoughts are linked. A distinct disorganisation of thought process is known as “formal thought disorder.” • Flight of ideas: thoughts are moving so quickly that one train of thought is not completed before the next one starts thus the topic might be difficult to follow. Occurs in mania. • Loosening of associations: lack of logical connection between a sequence of thoughts – can be called “Knight’s move thinking.” Occurs in schizophrenia. • Perseveration: persistent and inappropriate repetition of the same thought – via speech or actions. (Can be associated with frontal lobe dysfunction.) • Delusions: a false, unshakeable idea or belief that is firmly held despite evidence to the contrary that is not consistent with the person's educational, cultural and social background. • Persecutory: people or organisations are trying to inflict harm

[33]

• Delusions of reference: objects, events or people have special significance e.g. a comment on the TV is directed to them alone. • Grandiose: beliefs of exaggerated self-importance, e.g. that they have special powers or influence. • Guilt or worthlessness: beliefs that the person has done something shameful based on an innocent error. Occurs in psychotic depression. • Delusions of control: beliefs that actions, impulses and thoughts are controlled by an outside agency. • Delusions concerning the possession of thoughts: • Thought insertion: thoughts have been implanted by an external agency • Thought withdrawal: thoughts have been taken away • Thought broadcast: thoughts are known to others via telepathy or the media. • These symptoms are examples of the so-called “ Schneiderian first rank symptoms of schizophrenia” • Over-valued ideas: an isolated, pre-occupying and strongly held belief that dominates a person’s life or actions. • Obsessive: recurrent and persistent thoughts, images or impulses that occur despite efforts to exclude them. They are their own thoughts and usually cause distress. (These may be associated with the compulsion to act out certain behaviors such as checking in obsessive compulsive disorder).

• Thoughts of self-harm or suicide: these need to be asked about in more detail if present. It is helpful to think about a hierarchy of questions e.g. • It sounds as if you were quite desperate, do you ever wonder if it’s worth going on? • Have you ever thought about hurting or harming yourself? • Have you ever done anything about these thoughts? • What stops you from acting on these thoughts? (protective factors) • Have you tried to end your life? • Did you intend to hurt yourself or kill yourself? • What did you do to ensure that you were not found? • What did you put in place for those left behind? (Final acts) • What has stopped you from doing this again? (regrets/ hopelessness) • How do you feel about the fact that you did not die?

5. Perception • Dissociative symptoms:

• De-realisation - feeling that the world is not real • De-personalisation - feeling detached from yourself

• Illusions: misinterpretation of real stimulus in the context of emotional state, e.g. misperceiving a shadow on the wall as an intruder

[34]

• Hallucinations: these are perceptions without an external stimulus o Auditory: can be voices, noises or music § 2nd person auditory hallucinations – which voices talk to the patient “You are all-powerful, they can’t hurt you” More common in affective psychosis and personality disorder. § 3rd person auditory hallucinations – voices talking about the patient. Which may occur in a form of a running commentary – “Now jack is walking across the room. He looks scared. He is heading to the window.” Occurs in paranoid Schizophrenia. § Command hallucinations - voices telling the person to do something “Mary, you must tell the authorities about this or it will all go wrong” o Visual: can be images or flashes o Tactile: superficial sensations of being touched. o Gustatory and olfactory: usually an unpleasant taste or smell.

6. Cognition This refers to a person's current capacity to process information.

• Level of consciousness • Orientation to time and place • Memory functioning - including immediate or short-term memory, and memory for recent and remote information or events • Literacy and arithmetic skills • Visuospatial processing e.g. copying a diagram • Attention and concentration e.g. observations about level of distractibility, or performance on a mentally effortful task - e.g. counting backwards by 7's from 100 • Language e.g. naming objects, following instructions The Mini Mental State Examination (MMSE) is one way of assessing this. It should however, be considered a screening test only as it is not a comprehensive test of all cognitive functioning, for example, it does not contain any assessment of frontal or executive function.

7. Insight Insight is the patient’s awareness and understanding of their mental illness, treatment options, ability to comply with these treatment options and ability to identify symptoms. It can be explored at different levels rather than “present” or “absent”. For example, a patient might recognise the need to see a doctor and be in hospital, but not recognise that the symptoms are related to a mental illness and be unwilling to accept treatment.

[35]

Cranial nerve examination

Firstly, you should perform a general inspection of the patient’s head and neck, commenting on scars, neurofibromas, facial asymmetry, ptosis, proptosis, skew deviation of the eyes or inequality of the pupils.

The twelve cranial nerves should then be examined in order, as follows:

Olfactory nerve (I) This is only usually tested if the patient reports an alteration in their sense of smell. If required, you should either use olfactory testing bottles or easily-recognised scents such as soap and coffee. Test each nostril separately, occluding the contralateral nostril by compressing it with your finger. Do not use noxious substances as these can stimulate the pain fibres in the trigeminal nerve.

Optic nerve (II) o Test visual acuity in each eye separately. If a Snellen chart is unavailable, a basic assessment can be made by asking the patient to cover one eye and to state how many fingers you are holding up in front of them. Asking patient to read different font sizes from a newspaper or a magazine can also assess the visual acuity at bedside. If they usually wear spectacles, they should continue to do so during this examination. o Test visual fields by confrontation. Sit directly opposite the patient with your eyes at the same level and a gap of approximately one metre between your chairs. Cover one of your own eyes and ask the patient to cover the eye directly opposite this. Ask the patient to keep staring straight into your other eye. Bring a test object (e.g. a large pin or, if this is unavailable, your index finger), in gradually from a point outside of your own visual field, assuming this is normal, diagonally toward the centre of your visual field. Ask the patient to signal to you when they first see the object. You should repeat this in all four quadrants for each eye. This is a basic test and is not very accurate, but it will detect significant discrepancies between your own visual fields and those of the patient. o Test for inattention / visual extinction. Hold your hands up in the periphery of the patient’s visual field, one on each side. Move the tip of your index finger up and down on one side at a time and then on both sides together. Ask the patient to report which side is moving. If there is visual inattention / extinction the patient will be able to detect movement on both sides individually but will ignore one side when both stimuli are presented simultaneously. o Test direct and consensual light reflexes. Ask the patient to look straight ahead and bring the light source in from the side so that the patient does not focus on it and accommodate. Shine the light into the eye and look for constriction of that pupil (the direct light reflex) and the contralateral pupil (the consensual reflex). o Test accommodation. Ask the patient to focus on a distant point and then to focus on your finger, held approximately 30cm in front of their nose. A normal accommodation response will involve constriction of both pupils. Ophthalmoscopy, testing colour vision and assessing the size of the blind spot are omitted in the OSCE. However, you should be able to perform these techniques by the end of Phase 4.

[36]

Oculomotor (III), trochlear (IV) and abducens (VI) nerves. Ask the patient to keep their head still and to follow your finger with their eyes. Slowly trace a large H shape and a central I shape with your finger, taking the patients eyes to the limit of their gaze as you do so. Ask the patient if they experience any diplopia. Observe for dysconjugate eye movements and for nystagmus.

Trigeminal nerve (V) o Test sensation in the skin supplied by the ophthalmic, maxillary and mandibular nerves. Initially, demonstrate the stimulus (cotton wool) to the patient on their sternum with their eyes open and check that they can feel it. Ask the patient to close their eyes and apply the stimulus to each of the dermatomes of the trigeminal nerve. Ask the patient to indicate when they can feel the stimulus and whether they notice a difference in the strength of the sensation between the two sides of their body. o Test the motor component of the trigeminal nerve by asking the patient to clench their teeth and palpate the contraction of the masseter and temporalis muscles. Next, ask the patient to open their mouth against resistance. Look for jaw deviation, which occurs toward the side of the paralysed pterygoid. o Jaw jerk- ask the patient to half open the mouth (as if surprised). Keep your index finger vertically over the midline on the lower jaw. Gently tap on your index finger with tendon hammer. A sudden brisk closure is suggestive of an upper motor neuron lesion above pons. o The corneal reflexes are not routinely performed.

Facial nerve (VII) This is the motor supply to the muscles of facial expression. Ask the patient to screw up their eyes and not let them be opened by you, puff out their cheeks, raise their eyebrows, purse their lips and show you their teeth. Remember that muscles of the upper face (frontalis, orbicularis oculi) receive a bilateral upper motor neuron (UMN) supply and therefore may be spared in UMN lesions (e.g. cerebrovascular accident), whereas the muscles of the lower face have a unilateral UMN supply and will be weakened. The glabellar reflex and taste sensation do not need to be routinely tested.

Vestibulocochlear nerve (VIII) Cover the opposite ear with your hand and whisper a number to the patient. Ask them to repeat it. If an abnormality is suspected, perform Rinnes and Weber’s tests to determine whether this is a sensory or conductive deficit (see below). Dizziness is again a common symptom. Basic vestibular tests like vestibule ocular reflex /Hall pike and Unterberg are handy to know.

Glossopharyngeal (IX) and vagus (X) nerves. Ask the patient to open their mouth wide and assess whether the uvula is in the midline at rest. Ask the patient to say ‘aah’ and note any asymmetry of movement. The uvula will deviate away from the side of a glossopharyngeal nerve palsy. Ask whether the patient has any difficulty swallowing. The gag reflex is unpleasant and does not need to be performed routinely. Ask the patient to cough. A bovine (non-explosive) cough suggests a vagal palsy. Note any hoarseness of the voice.

[37]

Accessory nerve (XI) Test trapezius by asking the patient to shrug their shoulders against resistance. Test the power in the sternomastoids by asking the patient to turn their head again resistance. Palpate the body of the sternomastoid muscle with your free hand whilst doing so.

Hypoglossal nerve (XII) Ask the patient to open their mouth and observe their tongue at rest for fasciculation. Ask them to protrude their tongue and note any deviation. Deviation will occur toward the side of a hypoglossal nerve lesion. Ask the patient to push their tongue into their cheek again the resistance of your finger and assess the power in their tongue.

Special tests:

The following tests should be carried out to differentiate between conductive and sensorineural hearing loss. If you are required to perform these tests in an OSCE, they will be specified in the instruction sheet for the station.

Rinne’s test: The vibrating tuning fork (512Hz) is held on the mastoid until the sound is no longer heard. It is then held near the external acoustic meatus and the sound should continue to be heard. In conductive hearing loss, bone conduction is better than air conduction and the sound is not heard at the external acoustic meatus. In sensorineural hearing loss, both air and bone conduction are decreased by a similar amount.

Rinne's test (alternative method): The vibrating tuning fork is held on the mastoid then immediately moved to the external acoustic meatus, whence, if conduction is normal it should sound louder at the external acoustic meatus. If the sound is louder when the tuning fork is on the mastoid, this indicates conductive hearing loss. In sensorineural hearing loss, both air and bone conduction are decreased by a similar amount.

Weber’s test: A vibrating tuning fork (512Hz) is held against the forehead in the midline. The vibrations are normally perceived equally in both ears because bone conduction is equal. In conductive hearing loss, the sound is louder in the abnormal ear than in the normal ear. In sensorineural hearing loss, the sound appears louder in the normal ear. The sensitivity of the test can be increased by having the patient block their external ear canals with their index fingers.

[38]

Examination for signs of cerebellar dysfunction

If you are asked to examine a patient for evidence of cerebellar dysfunction, you should look for the following neurological signs:

• Speech – assess for dysarthria by asking the patient to say repeating letters e.g. “C,C,C,C” or “L,L,L,L” or tongue twisters e.g. “British Constitution” or “Baby Hippopotamus”.

• Intention tremor and dysmetria (past-pointing = pointing beyond the examiners finger in the finger-nose test)

• Nystagmus - coarse and slow; most noticeable on looking toward the side of the lesion

• Dysdiadochokinesis = difficulty controlling the rate, rhythm and force of movement. The patient is abnormally slow and uncoordinated when attempting rapid hand movements, e.g. alternately tapping the palm and dorsum of the right hand onto the back of the left hand quickly and vice versa

• Ataxia (Lesions of the vermis cause truncal ataxia, lesions of the cerebellar hemispheres cause ipsilateral limb ataxia)

• Stance: Wide based stance- Stand with feet wide apart.

• Gait- Inability to do heel to toe test

[39]

Gastrointestinal history

History of presenting complaint (HPC): When taking a gastrointestinal history, you should always enquire about: • Pain • Abdominal distension • Nausea and vomiting • Dysphagia (difficulty swallowing) • Dyspepsia (indigestion / heartburn), hiatus hernia and peptic ulceration • History of gallstones or previous pancreatitis • Jaundice • Altered bowel habit, diarrhoea, constipation or alternating diarrhoea and constipation • Blood loss (haematemesis or rectal bleeding) • Mucus or slime per rectum • Appetite • Weight change • Continence

Pain Pain from unpaired structures is usually central.

These are some classic presentations of common gastrointestinal conditions to indicate how a careful history can point to the diagnosis:

Peptic ulcer: Site: Epigastric Onset: Acute or gradual. Remissions for weeks or months. Character: Gnawing Radiation: Into the back Associated symptoms: Can lead to GI haemorrhage, peritonitis if perforates Timing: Lasts 0.5 – 3 hours. Exacerbating factors: Irregular meals (hunger), smoking, alcohol, aspirin and NSAIDs Alleviating factors: Food, antacids, vomiting Severity: Mild to moderate

[40]

Acute cholecystitis: Site: Epigastric or right hypochondriacal Onset: Constant. Unpredictable frequency or periodicity. Character: Stabbing, piercing Radiation: Right scapula or tip of right shoulder Associated symptoms: Vomiting, fever, rigors Timing: 3 – 24 hours Exacerbating factors: Sometimes food. Alleviating factors: Pain relief by medication? Severity: Severe

Acute pancreatitis: Site: Epigastric Onset: Sudden or gradual Character: Piercing, stabbing, burning Radiation: Into the back. May develop generalised peritonitis with widespread pain. Associated symptoms: Nausea, vomiting, abdominal distension, shock Timing: Lasts more than 24 hours. Exacerbating factors: Eating Alleviating factors: Sitting upright Severity: Very severe

Vomiting: Vomiting can be triggered by a wide variety of local and systemic disorders e.g. • Nervous system: motion sickness, labyrinthine disorders, migraine, meningitis, intracranial tumour • Severe pain e.g. renal colic, myocardial infarction • Systemic conditions e.g. pregnancy, renal failure, diabetic ketoacidosis, hyperparathyroidism • Drugs by central action or local gastric irritation However, it is also a common symptom of gastrointestinal disorders e.g. gastric outlet obstruction, acute gastritis, acute cholecystitis, acute pancreatitis, hepatitis. Ask: • How frequent is the vomiting? • What time of day does it occur? • Taste, colour, smell and quantity? • Is there any blood in the vomit (haematemesis)? Is it fresh blood altered blood (like coffee grounds)?

If the patient is in the hospital, then try to inspect the vomit yourself whenever possible.

[41]

Dysphagia: Causes: • Painful lesion in mouth or throat • Neurological disorder e.g. pseudobulbar palsy • Neuromuscular disorder e.g. myasthenia gravis • Obstruction in the post-cricoid area e.g. pharyngeal pouch, tumour, stricture • Obstruction at the lower end of the oesophagus e.g. tumour, achalasia of the cardia, stricture Ask: • Is it continuous or intermittent? • How long does it last for? • Where does the food stick? • Is it solids, liquids or both? • Does it occur between meals (may suggest globus hystericus, a psychogenic condition)? • Do you suffer from acid reflux or dyspepsia? • Nocturnal coughing or dyspnoea (2° to regurgitation and aspiration)? • Enquire about the risk factors for oesophageal carcinoma: smoking, alcohol, obesity and diet lacking in fruit and vegetables.

Jaundice: • Colour of urine and stools (differentiate haemolytic from obstructive jaundice) • History of gallstones? • Pain (pain of Ca pancreas is traditionally felt in the back and made worse on recumbency)? • Fever and rigors? • Itching? • Social history o Alcohol o Drugs o Foreign travel, including transfusions and tattooing abroad o Unprotected sex

Altered bowel habit: Normal bowel habit varies widely between individuals. Changes in bowel habit are significant. • How has the habit altered? Diarrhoea, constipation or both? • Frequency of stools? • Any associated abdominal discomfort or urgency? • Incontinence? • Appearance of stool? Consistency (formed or unformed)? Does it float in the pan? Associated blood, pus or mucus (slime)? • Associated vomiting? • Foreign travel? • Medications, including over-the-counter remedies?

[42]

Rectal bleeding: Causes include • Haemorrhoids (fresh red, clearly separate from the stool and may be seen only on the paper. Bleeding from haemorrhoids may splash into the pan after a motion and is generally painless) • carcinoma of the colon or rectum (may be associated with mucus) • inflammatory bowel disease (may be mixed with pus or mucus; stool may be unformed) • diverticular disease • anal fissures (fresh red, associated with severe anal pain during and after defaecation) • melena (severe bleeding from the upper GI tract tends to be dark in colour (“altered”) and may contain clots – the patient may be in shock; smaller degrees of bleeding may result in dark stools)

Abdominal distension: Increasing girth is usually due to adiposity. Increasing girth in a patient who is otherwise becoming thinner suggests intra-abdominal disease e.g. subacute bowel obstruction, ascites, ovarian cyst, undiscovered pregnancy, chronic constipation.

Loss of weight and loss of appetite: • How much weight loss and over how long? • Associated with loss of appetite or due to deliberate reduction in intake? Weight loss without reduction in food intake may be due to diabetes mellitus, hyperthyroidism or malabsorption syndrome. Loss of appetite may have a non-GI cause e.g. depression.

Completing the gastrointestinal HPC: In addition to your general survey, specifically include: • Previous gastrointestinal problems, diagnoses and effectiveness of any treatments • Previous gastrointestinal or abdominal surgery • Gynaecological problems (pelvis communicates with abdomen) • History of jaundice, anaemia, diabetes.

Drug history and allergies: Many drugs have gastrointestinal side effects, especially iron tablets, opiates, NSAIDs, antibiotics, anticoagulants and SSRI’s.

Social History: Alcohol, smoking, occupation and diet. Recent foreign travel.

Family history: There is a familial element to some carcinomas, Crohn’s disease and ulcerative colitis, malabsorption syndromes and Gilbert’s syndrome (inherited unconjugated hyperbilirubinaemia).

[43]

Examination of the Gastrointestinal System

• Wash your hands • Introduction, identification and consent • General inspection of the bed area for clues • General inspection of the patient e.g. colour (jaundice? anaemia?), perspiration, build (wasting? obesity?), discomfort, breathing (rate, diaphragmatic or chest wall breathing?), conscious level • Examine the hands for: o Colour § Pallor of the palmar creases suggests anaemia § Palmar erythema (2° to increased circulating oestrogens in liver disease) o Temperature o Clubbing (GI causes include hepatic cirrhosis, ulcerative colitis, Crohn’s disease and Coeliac disease) o Leukonychia. Leukonychia partialis: small isolated white patches or striae are often seen in the nail plates of normal persons in response to minor trauma to the germinal matrix. However, striae affecting all of the nail beds can occur following a course of chemotherapy, for example. Terry’s nails or leukonychia totalis: Whitening of the entire nail occurs with hypoalbuminaemia (e.g. nephrotic syndrome, liver failure, protein malabsorption and protein-losing enteropathies). o Koilonychia (spoon-shaped nails, suggesting chronic iron-deficiency) o Spider naevi (single central arteriole with radiating dilated capillaries). Occur in 15-20% of healthy individuals but multiple spider naevi suggest underlying liver disease with increased circulating oestrogens. 99% occur on the upper trunk, head, neck and arms. Only 1% occur below the umbilicus. o Dupuytren’s contracture (fibrosis and shortening of the palmar aponeurosis). Usually idiopathic or familial but there is a possible unproven association with trauma, diabetes, epilepsy, alcoholism and liver disease. o Asterixis (liver flap). Ask the patient to hyperextend their wrists and maintain the position for 15 seconds (5 seconds will suffice in the OSCE). A coarse flapping tremor suggests liver failure with failure of ammonia metabolism to urea. However, asterixis can also be seen in renal failure and in respiratory

failure with CO2 retention. • Check the patients pulse and blood pressure. • Examine the forearms for muscle wasting and for scratches suggestive of pruritis (itching). • Examine the eyes for: o Jaundice o Anaemia (subconjunctival pallor) o Xanthelasma o Corneal Arcus

[44]

o Kayser-Fleischer rings (Wilson’s disease). These are brown rings that encircle the iris, resulting from copper deposition. In the early stages they are best seen with a slit lamp, but later they can be seen with the naked eye. • Examine the face for telangiectasia (Hereditary Haemorrhagic Telangiectasia (HHT / Osler-Weber-Rendu syndrome) affects the face, oral mucosa, GI tract, lungs, liver and brain, resulting in recurrent haemorrhage) • Examine the mouth for: o Telangiectasia (HHT – see above) o Pigmentation (Peutz-Jegher syndrome, associated with small bowel hamartomas) o Angular stomatitis (sore corners of mouth), which may be caused by deficiency of Vitamin B6, B12, folate or iron. o Glossitis, an abnormal smooth red appearance of the tongue. Painful glossitis is seen in Vitamin B12 or folate deficiency whereas glossitis due to iron- deficiency tends to be painless. o Dehydration o Halitosis (bad breath) o Dental caries o Ulcers (can be associated with Vitamin B12 deficiency, iron-deficiency, Crohn’s disease, Coeliac disease) • Examine the chest wall for: o Spider naevi o Gynaecomastia (male breast development) – may be due to increased circulating oestrogens in liver failure. • Palpate the lymph nodes in the neck and supraclavicular fossae. (N.B. Troisier’s sign is an enlarged left supraclavicular lymph node (Virchow’s node) due to a metastasis from an intra-abdominal malignancy). • Ask the patient to sit forward so that you can inspect the skin of their posterior abdominal wall for scars, swellings or any other clinical findings. • Ask the patient to lie flat with one pillow, if tolerated, arms by their sides. • Inspect the abdomen for: o Scars. Skin – sudden weight loss will result in loose folds of skin, sudden weight gain may cause striae (stretch marks). Note any skin lesions. o Shape and symmetry o Movement during breathing (diaphragmatic ventilation usually ceases with acute peritonitis and ventilation is then via movement of the chest wall) o Visible swellings and masses o Visible peristalsis o Visible aortic pulsation o Distended veins (may indicate inferior vena cava obstruction or portal hypertension) o Think about the 5 F’s of abdominal distension: § Fluid (ascites) § Faeces (constipation) § Flatus (subacute intestinal obstruction) § Foetus (pregnancy) § Fat (obesity)

[45]

• Palpate the nine regions of the abdominal wall gently and systematically, whilst observing the patients face. Assess for areas of tenderness, guarding, rigidity etc. • Repeat, using deeper palpation. Visualise the underlying anatomy whilst you are palpating. Assess for any masses. Determine whether masses are intra-abdominal by asking the patient to raise their head and shoulders off the pillow. Masses within the abdominal wall become more prominent when the recti are contracted, whereas intra- abdominal masses become less prominent. Assess size, surface, shape, edge, consistency, tenderness of any masses. o If the stomach appears distended, perform a succussion splash (shake the stomach briskly from side to side whilst listening for a sloshing sound) • Proceed to palpation of specific organs: o Liver. Palpation for the liver should commence in the right iliac fossa. The patient should be asked to take a deep breath whilst the examining hand palpates deeply to feel the descending edge of the liver being pushed down by the diaphragm. Whilst the patient breathes out, the examining hand should be withdrawn and repositioned slightly nearer the costal margin, whereupon the process should be repeated. The liver can normally be palpated up to 1cm below the right costal margin on deep inspiration. The gallbladder is not usually palpable unless enlarged. (N.B. Courvoisier’s Law states that in the presence of a palpable gallbladder, jaundice is not likely to be due to gallstones). o Spleen. This is not normally palpable unless enlarged. Palpation should begin in the right iliac fossa and advance toward the left costal margin, whilst the patient takes deep breaths. As you advance toward the left costal margin using your right hand to palpate for splenomegaly, place your left hand posteriorly and roll the patient slightly toward you. This may bring the tip of a moderately enlarged spleen closer to your palpating fingers and increase the chance of detection. Splenomegaly only becomes palpable once the spleen has enlarged to 2-3 times its normal size. o Kidneys - should be examined by ballottement. The anterior hand should press deeply, lateral to the margin of the rectus muscle in the upper quadrant of the abdomen. The posterior hand should be placed in the costovertebral (renal) angle and should be used to lift the kidney up against the anterior hand repeatedly. An enlarged kidney should be detectable by the anterior examining hand. The lower pole of the right kidney may be palpable in thin normal people. The left kidney is rarely palpable. To distinguish a palpable kidney from a spleen, you should attempt to insert your hand between the upper pole of the kidney and the costal margin, which can be done if the mass is renal but not if it is the spleen. Also, the spleen has a notch which may be palpable; and the spleen is not ballotteable. o Full bladder. Palpate the suprapubic region for a full bladder. If the bladder is full, it will be impossible to feel the lower border of the mass behind the pubis and pressure on the bladder will make the patient want to urinate. o Aorta and femoral pulses. The normal aortic pulsation may be felt, especially in a thin person. However, if the aorta is expansile, this suggests aneurysmal dilatation.

[46]

• Check for Murphy’s sign by asking the patient to breathe out and then gently placing the hand below the right costal margin in the mid-clavicular line (the approximate location of the gallbladder). If inspiration is prevented by the inflamed gallbladder coming into contact with the examiners fingers, the test is considered positive. A positive test also requires no pain on performing the manoeuvre on the patient's left hand side. This test is done when suspecting acute cholecystitis in a patient. • Palpate the inguinal nodes ( Not required in OSCE Examinations) • Percuss the abdomen: o Liver (percuss from resonant to dull, from below and above). When percussing, consider the normal surface markings of the superior border of the liver (6th rib in mid-inspiration). This can be displaced downwards in respiratory diseases such as emphysema giving a false impression of hepatomegaly. o Spleen. Castell’s method: With the patient in full inspiration and then full expiration, percuss the area of the lowest intercostal space (eighth or ninth) in the left anterior axillary line. If the note changes from resonant on full expiration to dull on full inspiration, the sign is regarded as positive. The resonant note heard upon full expiration is likely to be due to the air-filled stomach or splenic flexure of the colon. When the patient inspires, the spleen moves inferiorly along the posterolateral abdominal wall. If the spleen is enlarged and the inferior pole reaches the eighth or ninth intercostal space, a dull percussion note will be heard, indicating splenomegaly. o Bladder – dull percussion note if enlarged. o If you suspect ascites, test for shifting dullness (percuss from the centre toward the left flank. If a dull note is heard, keep the finger in position and roll the patient onto their right side. Wait 10 seconds for the fluid to redistribute. If the note becomes resonant, percuss back towards the umbilicus until the note becomes dull i.e. shifting dullness) • Auscultation of the abdomen o Are bowel sounds present and normal, present but abnormal (e.g. tinkling in small intestinal obstruction), or absent (paralytic ileus e.g. in peritonitis)? o Listen for aortic and femoral bruits • The end-pieces are recalled by the mnemonic ISHRUG. In the OSCE, you should omit these but should state a list to the examiner, without prompting, at the conclusion of your physical examination. o Inguinal lymph nodes o Stools – examine the stools if clinically indicated o Hernial orifices (femoral and inguinal) o Rectal examination (always with a chaperone) o Urine – obtain urinalysis o Genitalia (examine the male external genitalia). A vaginal examination may be indicated in parous or sexually active females (only when clinically indicated and always with a chaperone) • Thank the patient and request them to redress • Wash your hands

[47]

Examination of the groin for hernias

• Wash your hands • Introduction, identification and consent • Apply gloves • Ask the patient if they have any pain • With the patient standing, inspect for a swelling in the groin. Ask the patient to cough (this may make an occult hernia visible) • If you see a swelling, ask the patient to repeat the cough whilst palpating the swelling. Feel for a cough impulse. Always examine the hernia standing on the same side of the patient as the swelling and using your left hand for left-sided hernias and your right hand for right-sided hernias. • Examine the scrotum (See scrotal swellings below). You cannot ‘get above’ an inguinal hernia, whereas you can palpate the upper extent of lumps originating in the scrotum. • Ask the patient to lie flat. • Identify the pubic tubercle. Identify its relationship to the neck of the hernial sac. Inguinal hernias enter the scrotum via the superficial inguinal ring, above and medial to the pubic tubercle. Femoral hernias pass under the inguinal ligament to enter the thigh, below and lateral to the pubic tubercle. • Attempt to reduce the hernia by gentle sustained pressure (or ask the patient to do this – many patients can reduce their own hernia). Once reduced, an indirect inguinal hernia can be controlled by finger-pressure over the deep inguinal ring at the mid-point of the inguinal ligament, midway between the pubic tubercle and the anterior superior iliac spine (ASIS). A direct hernia will bulge through the abdominal wall medial to this and cannot be controlled by pressure on the deep ring. (You should be aware that distinguishing clinically between direct and indirect inguinal hernias by this technique is notoriously unreliable and often the correct diagnosis is only established during surgery.) (N.B. the inferior epigastric artery passes medial to an indirect inguinal hernia and lateral to a direct inguinal hernia and forms an important anatomical landmark. It leaves the external iliac artery at the midinguinal point, halfway between the pubic symphysis and the ASIS).

Completion • Thank the patient • Request them to redress • Wash your hands

[48]

Examination of scrotal swellings

To determine the nature of a scrotal swelling four aspects need to be assessed.

• Can you get above the swelling? • Can the testis and epididymis be identified separately? • Does the swelling transilluminate? • Is the swelling tender?

It is first necessary to confirm that the swelling originates within the scrotum and is not an inguinoscrotal hernia. A hernia may be reducible, may have a cough impulse and the testis should be palpable. On palpation, you cannot ‘get above’ a hernia.

You also cannot get above an infantile hydrocoele, which is due to a patent processus vaginalis. However, this is irreducible, has no cough impulse and the testis is impalpable.

The differential diagnosis of lumps arising within the scrotum can then be predicted by listing the structures within the scrotum:

• Testicles: o testicular tumours (testis and epididymis definable, lump within testis, testis non- tender) o orchitis (testis and epididymis definable, testis tender) o torsion of the testis (typically adolescent boys, presents with acute scrotal pain, occasionally with abdominal pain) o torsion of the testicular appendix (hydatid of Morgagni) (presents with acute but less severe scrotal pain, tender spot at upper pole of testis, hydrocoele often present) • Processus vaginalis remnants: o Hydrocoele – a fluid-filled sac that surrounds the testis anteriorly. Note that a hydrocoele can obscure a testicular tumour. (Testis and epididymis non- palpable, transilluminates brightly) o haematocoele – as with a hydrocoele but containing blood, e.g. after testicular trauma or haemorrhage from a testicular tumour (Testis and epididymis non- palpable, does not transilluminate) • Epididymis: o epididymal cyst (testis and epididymis definable, lump separate from testis, testis and epididymis non tender, lump may transilluminate) o epididymitis (testis and epididymis definable, lump separate from testis, epididymis tender) • Pampiniform venous plexus o varicocoele (varicose enlargement of the venous plexus)

[49]

Urological history

History of presenting complaint:

Pain Use the SOCRATES mnemonic. The pain of a ureteric calculus is felt in the renal angle and radiates to the hypochondrium, groin or genitalia. It is associated with nausea and/or vomiting. Intermittent pain is seen with polycystic kidney disease when it accompanies bleeding into, or rupture of, a cyst.

Lower urinary tract symptoms: Filling: urgency, frequency, nocturia Voiding: dysuria (pain), hesitancy, poor flow, incomplete emptying, dribbling (terminal/post- micturition), straining to urinate, spraying of urine Incontinence: stress, urge, overflow, continuous, enuresis (nocturnal bedwetting)

Haematuria: Ask about: Duration, Timing within the stream (initial/continual/terminal), Presence of clots Pain (painful haematuria may suggest a renal calculus or infection; painless haematuria, may suggest a carcinoma of the kidney or bladder, or prostatic bleeding) Fever and rigors Trauma / exercise

Symptoms of urinary tract infection: Dysuria Frequency Urgency Strangury - Painful passage of small quantities of urine which are expelled slowly by straining with severe urgency; it is usually accompanied with the sensation of incomplete micturition. Fever Acute confusion (especially in the elderly)

Symptoms of chronic renal failure: Oliguria Nocturia Polyuria (increased volume of urine production secondary to the urea solute load) Anorexia Insomnia Metallic taste in the mouth Vomiting Anaemia (due to erythropoietin deficiency) Fatigue Pruritis Oedema Bruising and bleeding due to abnormal platelet function Sallow complexion (yellow-grey tinge) Uraemic fetor

[50]

Completing the urological HPC: Specifically enquire about past episodes (recurrent UTIs, renal calculi etc.), and their onset and duration. If appropriate, enquire about the patient’s sexual history (STDs), and obstetric history Is the patient diabetic?

Drug history and allergies Certain medication can affect the colour of the urine (e.g. rifampicin). Enquire about allergies to iodine if contrast is to be used for investigations

Social history Smoking, alcohol, travel, occupation (full history as certain industries e.g. rubber and dyes may lead to renal and/or bladder cancer), sexual history. Enquire about diet. Does the patient eat excessive beetroot as it can colour the urine red.

Family history As any medical history however do focus on any familial renal or urological condition for example Polycystic kidney disease is familial.

[51]

Musculoskeletal History History of presenting complaint:

Site What is the pattern of joint involvement? i.e. Which joints are affected? Small or large joints? One or more than one joint? What was the speed of onset like? Is the condition bilateral? If so, is it symmetrical or asymmetrical? Onset When did it start? What was the onset like? (Acute e.g. gout; Subacute e.g. septic arthritis, rheumatoid arthritis (RA); Chronic e.g. osteoarthritis (OA)) Has it been constant since the onset? If episodic, what are the frequency, regularity and duration of the episodes? Character e.g. ache, sharp pain, throbbing Radiation e.g. neck pain to upper limb; lower back pain (LBP) to buttocks/ lower limb; hip pain to knee Associated symptoms Stiffness and/or swelling, crepitus (grating of surfaces against each other) Erythema, increased local temperature Fatigue, malaise, depression Systemic temperature (e.g. gout, sepsis) Rashes/skin conditions (e.g. psoriasis, erythema nodosum) Nodules (e.g. rheumatoid nodules, gouty tophi) Fever, abdominal pain, weight loss (e.g. systemic symptoms of vasculitis/connective tissue disease or symptoms suggestive of associated inflammatory bowel disease) Dry mouth and gritty eyes Timing Is there a relationship with the time of day? Ask: ‘What do your joints feel like on rising; How do you feel at the end of the day? How do you sleep?’ e.g. RA – significant early morning stiffness (>60 mins usually) & joints stiffen up again after period of rest/ in evening OA – minimal to moderate early morning stiffness (<30 mins usually) & joints made worse by activity. Also stiffen up in evening. Exacerbating factors Exercise in mechanical/ degenerative conditions; Rest in inflammatory conditions. Alleviating Factors NSAIDs. Exercise / Rest as above. Severity Very severe – acute gout +/- sepsis Slightly less severe – RA/ OA (usually) Any movements that are particularly painful? Is function limited by pain?

[52]

Completing the musculoskeletal HPC:

• Has the patient had anything similar previously? What tests, diagnoses and treatments have they had and how did they respond to those treatments? Previous medication. Did it work? Any side effects? Why was it changed? • Is there a history of trauma? • Has the patient had any recent infective episodes? Including dental or pharyngeal infection (risk of joint sepsis) • Does the patient have diabetes (predisposing them to infection e.g. septic arthritis)? • Does the patient have psoriasis, inflammatory bowel disease or coeliac disease? • Have they had tuberculosis? • Do they have any auto-immune conditions (e.g. thyroid disease)? (This increases their risk of developing an additional auto-immune disease such as RA/ SLE). • Do they have risk factors for gout (alcohol intake, renal disease, low dose aspirin, diuretics, metabolic syndrome [hypertension / obesity / diabetes / vascular disease])?

Drug history and allergies

• Current medication for the presenting condition • Other current medication • Over the counter medications? Do they work?

Social history

• Occupation. Does the problem affect their employment? • Sports and hobbies • Home circumstances (type of dwelling e.g. house, bungalow; dependents, carers, social support) • Ability to carry out activities of daily living – a detailed history is likely to be needed here. For example, a patient with osteoarthritis of the hip may have difficulty getting in and out of a car or bath, picking up objects from the floor, putting on their shoes and socks, cutting their toenails etc. • Smoking • Alcohol consumption

Family history

• Is there a family history of RA, OA, psoriasis, gout, Ulcerative Colitis, Crohn’s disease, connective tissue disease or any other autoimmune disease?

[53]

Gait, Arms, Legs and Spine (GALS)

GALS involves assessment of the first, most commonly affected movement of a joint in rheumatic disease. It is NOT a diagnostic examination. Instead, it is a rapid, efficient screening procedure, designed to detect abnormalities in the musculoskeletal system that require further assessment.

Whilst performing the GALS screening test, you should compare the range of movement with the norm. As the patient performs a movement, ask if it is painful.

Initial Questions • Do you have any pain or stiffness in your muscles, joints or back? • Are you able to completely dress and undress yourself without any difficulty? • Are you able to climb up and down stairs without any difficulty?

Inspection • From the front: Observe abnormalities in the shoulders, elbows, wrists, hands, chest, hips, thighs, knees and feet. • From the side: Check for the presence of the normal spinal curvatures: Cervical lordosis, thoracic kyphosis and lumbar lordosis. Identify any hip and knee flexion deformity, or knee hyperextension. • From the back: Observe any abnormalities in the shoulders, spine and paraspinal muscles, the level of the iliac crests, the gluteal regions, popliteal fossae, calves, Achilles tendons and hind-feet.

Gait Ask the patient to walk a few steps, turn, and walk back. Comment on arm swing, pelvic tilt, stride length, ability to turn quickly and any antalgic (painful) gait on walking. Ask whether walking is painful/painless.

Spine • Assess flexion of the lumbar spine. Place your fingers on two adjacent lumbar vertebrae. Ask the patient to bend forward to touch their toes. Observe your fingers moving apart as the patient bends forward, and then coming together as the patient bends back. • Assess lateral flexion of the neck. Ask the patient to tilt their head sideways so that their ear touches their shoulder. Comment on the ROM on both sides and ask if it is painful.

Arms Shoulders • Ask the patient to put their hands behind their head and push their elbows back. Observe abnormalities in the ROM of shoulder abduction and external rotation & elbow flexion. You must ensure that the shoulders are pushed back as far as possible.

[54]

Wrists and Hands • Look: Ask the patient to put their hands out in front of them, palms down. Then ask them to turn their hands over, palm up. Observe any joint swelling, deformity, loss of contours, muscle wasting, skin/nail changes and nodules in the wrists and hands. Observe their ability to supinate and pronate at the elbow as they turn their hands over. Observe their ability to fully straighten their elbow. • Feel: Assess for tenderness by performing a lateral squeeze of the metacarpophalangeal joints (MCP’s). You should apply enough pressure so that your own fingernails start to blanch, not the patients! • Move: o Check the patient’s ability to make a full fist covering the nails. o Ask the patient to squeeze your fingers to assess grip strength o Ask the patient to bring each finger in turn to meet the thumb (test fine precision)

Legs Ask the patient to lie on the couch with their legs out in front of them. Hips and Knees • Ask the patient to fully flex and extend their knee. Place your hand over their knee to assess for crepitus as they do so. • Bend the knee and hip both to 900. Hold the knee and use the ankle to move the leg so that you assess internal and external rotation of the hip. ('Internal rotation in flexion' is usually the first movement to be lost in any hip pathology). • Perform a patellar tap: slide one of your hands down from mid-thigh so that any fluid in the suprapatellar pouch is pushed into the knee joint. When your hand reaches the upper pole of the patella, leave it there and maintain pressure. With your other hand, use 2 or 3 fingers to push down firmly on the patella. If the patella bounces and makes a “tap” sound, it indicates the presence of a joint effusion. • An alternative test is the bulge test (slide your hand up the medial side of the joint, then down the lateral side. Any fluid present will cause a visible bulge in the medial suprapatellar fossa when you slide your hand down over the lateral joint margin)

Feet • From the end of the couch, inspect the soles of the feet for swelling, deformity, callosities • Squeeze across the MTP joints to check for tenderness (suggests inflammatory joint disease). Watch the patient’s face for signs of discomfort.

Completion

• Thank the patient • Request them to redress • Wash your hands

[55]

Examination of the hip

Examination of the joints follows the sequence of ‘look, feel, move and special tests’. You should always examine the contralateral joint for comparison. You should also examine the joint above and below that indicated by the patient in case the pain experienced by the patient originates in a neighbouring joint, or the patient is putting undue stress on the painful joint to compensate for a deformity in a neighbouring joint.

When examining the hip, the patient should be wearing their underpants but should remove their trousers, socks and shoes.

• Wash your hands • Introduction, identification and consent

Inspection (Look) • With the patient standing, inspect the patient from the front for pelvic tilt, joint deformities (e.g. fixed flexion) and wasting of the quadriceps muscles; inspect from the side for an exaggerated lumbar lordosis, which may suggest a fixed flexion deformity of the hip; and inspect from behind for wasting of the gluteal muscles and for scoliosis, which may be primary or may be secondary to a pelvic tilt. Look at the patient’s stance. • Position the patient supine on the couch with their hips and knees extended. Inspect for scars in the groin, anterior and lateral thighs. If possible, roll the patient onto each side to inspect the gluteal regions. • Assess symmetry. Is there a leg length discrepancy? o To measure apparent leg length, use a tape-measure and measure from the xiphisternum to the medial malleolus of each leg. (This is ‘apparent’ length as it will be influenced by pelvic tilt as well as the true length of the legs) o To measure true leg length, measure from the anterior superior iliac spine (ASIS) to the medial malleolus o If there is a true leg length discrepancy, assess whether this originates in the tibia or the femur, as follows: § Position the patient with their knees bent up to a right angle and their heels flat on the bed. § Inspect from the side. § Place your hand across both tibial tuberosities. If there is femoral shortening, your hand will dip down towards the shortened side. § Place your hand across both suprapatellar regions. If there is tibial shortening, your hand will dip down towards the shortened side. Palpation (Feel) • Ask the patient whether they have any pain or tenderness in their hips • Assess the temperature using the dorsum of your hand in the upper thigh and the greater trochanter. Compare both sides. • Palpate the greater trochanter for trochanteric bursitis

[56]

Assess range of motion (Move) • Check the active range of motion (ROM) of flexion, abduction and adduction of each hip. The normal ranges are flexion 115-125°, abduction 40-50°, adduction 15-25°. • Check the passive ROM of flexion, abduction and adduction at each hip. • Check the passive ROM of internal and external rotation at each hip. First check with the lower limb fully extended at the hip and knee. This is referred to as 'internal and external rotation in extension'. Then check with the hip and knee both flexed at 90°. This is referred to as 'internal and external rotation in flexion'. (Normal ranges are internal rotation in extension = 30-40°; external rotation in extension = 40-50°; internal rotation in flexion = 25-40°, external rotation in flexion = 25-50°.) • In a young patient assess the active ROM of extension with the patient lying prone. Normal range is 10-30°.

Special tests • Thomas’s test. Assess for a fixed flexion deformity of the contralateral hip by flexing the ipsilateral hip fully. Place your hand between the patient’s lumbar spine and the bed to check for full correction of the lumbar lordosis then observe the contralateral hip. This manoeuvre will cause the patient with a fixed flexion deformity of the contralateral hip to raise their leg off the bed. • Assess the patient’s gait. A waddling gait may be associated with hip pain or proximal muscle weakness. An antalgic gait reflects pain on weight-bearing. Note: Gait may be assessed at the beginning of the examination along with stance • Trendelenburg’s test. Ask the patient to stand on one leg to assess the abductor muscle strength of that hip. In a negative (normal) test, the pelvis remains level or even rises on the contralateral side as the patient contracts their abductors (gluteus medius, gluteus minimus, tensor fascia latae and sartorius). In a positive test, the pelvis will dip on the contralateral side.

Completion • Examine the patient’s lumbar spine and the ipsilateral knee joint. • Perform a neurological and vascular examination of the patient’s lower limb. (In the OSCE, unless you are given specific instructions to perform this assessment, you should simply state to the examiner that you would do so). • Thank the patient • Request them to redress • Wash your hands

[57]

Examination of the knee This is a basic knee examination to which other specific tests can be added depending on the nature of the patient’s complaint.

When examining the knee, the patient should be wearing their underpants/shorts but should remove their trousers, socks and shoes. Ensure that upper thigh is exposed so that you can examine the quadriceps

• Wash your hands • Introduction, identification and consent

Inspection (Look) • With the patient standing, inspect from the front, side and behind for: o Valgus deformity (knock-knees) o Varus deformity (bow-legs) o Genu recurvatum (knee hyperextension) o Flexion deformity o Swellings in the popliteal fossa e.g. Baker’s cyst o Comment on the patient’s stance

• Position the patient supine on the couch with their hips and knees extended. Inspect for: o Symmetry o Valgus and varus deformity o Rashes e.g. psoriasis o Scars o Swelling, particularly in the medial fossa (the depression medial to the patella) o Muscle wasting, particularly in the medial quadriceps (vastus medialis) o Displacement of the patella o Fixed-flexion deformity

Palpation (Feel) • Assess the temperature using the dorsum of your hand in the mid-thigh, over the patella and over the upper tibia. Normally the patellar region feels cooler than the surrounding tissues. Compare both sides. • Palpate around the borders of the patella for tenderness • Palpate behind the knee for popliteal swellings or cysts • Assess for an effusion by performing: o The bulge test (cross-fluctuation). This test is particularly sensitive in picking up a small effusion. Sweep the hand firmly up the medial fossa, over the suprapatellar pouch and down the lateral fossa. The medial fossa may refill, producing a bulge of fluid; and/or o The patellar tap. With one hand, compress the suprapatellar pouch to empty it. Use 2 or 3 fingers of the other hand to ‘bounce’ the patella against the femur. • Flex the knee up to 90° to open the joint line. Palpate the joint line and patellar tendon insertion (tibial tuberosity) for tenderness.

[58]

Assess range of motion (Move) • Ask the patient to actively flex and extend his knee (normal range of flexion = 135°, normal range of extension = 0°). • Assess passive movement by placing one hand on the patient’s knee and flexing the knee as far as possible with your other hand. • Palpate for crepitus during passive flexion and extension.

Special Tests • Posterior Sag test. Position the patient with the knee flexed to 90° and the foot flat on the bed. Inspect from the side. A posterior sag of the upper tibia, with a ‘step’ visible below the patellar, is suggestive of posterior cruciate ligament (PCL) damage. • Anterior draw test. Position the patient with the knee flexed to 90° and the foot flat on the bed. Stabilise the leg using your own forearm – for infection control reasons you should not sit on the patient’s bed. With the fingers of both hands behind the knee and the patients hamstrings relaxed, place your thumbs over the tibial tuberosity and apply a forward pull. Significant movement indicates a positive draw test and suggests anterior cruciate ligament (ACL) damage. • Lateral collateral ligament test. Flex the knee to 20°. Grasp the patient's heel with one hand while exerting pressure against the inside of the knee with the other hand. The varus stress applied will cause lateral gaping in the laterally unstable knee. A small amount of lateral joint gaping is physiological and is the asymmetry of the gaping that constitutes the abnormal finding. • Medial collateral ligament test. As above but apply a valgus stress against the lateral aspect of the knee and assess for medial gaping.

Function • Ask the patient to walk. Observe the toeing angle. (This is the angle between the orientation of the foot and the direction the patient is walking. Normally the axis will be seen to point in a slightly lateral direction by 10-15°) • Is there an antalgic (painful) gait? Is there any other abnormality? Note: If you prefer, gait may be assessed at the beginning of the examination along with stance

Completion • Examine the ipsilateral hip and ankle. When examining the ankle, you should use the schema ‘look, feel, move’. • Assess the neurological and vascular status of the limb (In the OSCE, unless you are given specific instructions to perform this assessment, you should simply state to the examiner that you would do so). • Thank the patient and request them to redress • Wash your hands

[59]

Other tests to be considered: • Lachman’s test. This test has higher sensitivity and specificity than the anterior draw test for detecting ACL laxity. However, the REMS national curriculum specifies that the anterior draw should be taught to medical students (1). Many orthopaedic surgeons will ask you to perform the Lachman’s test instead and in the OSCE, you may perform either test, depending on your personal preference. Flex the knee to 20°. Place one hand behind the tibia with your thumb on the tibial tuberosity. Grasp the patient’s thigh with your other hand and pull anteriorly on the tibia. You should feel a firm end-point as the anterior cruciate ligament (ACL) prevents forward translocation of the tibia on the femur. A soft end-point suggests ACL damage. If the patient’s thigh is too large, or your hand is too small, to stabilise the limb adequately, you may perform Lachman’s test with the patient’s thigh supported by the edge of the examination couch. • McMurray’s test. The test is designed to trap or catch a torn meniscus between the femoral condyle and the tibial plateau and should only be performed if the patient’s history is suggestive of a torn meniscus (In the OSCE, if you need to perform this test, you will be instructed to do so). Flex the patient’s hip to 90° and maximally flex the knee. Externally rotate the knee and, maintaining this rotation, move the knee gradually from the fully flexed position to the fully extended position. The test is repeated using internal rotation. A palpable, audible, or painful click over the medial or lateral joint line indicates a meniscal tear. The test is useful when positive but is unreliable when negative. It is difficult to perform on an acutely painful knee.

[60]

Examination of the ankle and foot

The basic examination of the ankle includes an assessment of the foot and follows the basic structure ‘look, feel, move’. Before commencing, ask the patient if they have any pain in their ankles or feet. Both legs should be exposed from the knee down to the feet. Inspection (Look) • Inspect the patient’s shoes for uneven wear and the presence of orthoses. • Inspect the patient’s feet and ankles whilst they are standing. Inspect from the front, side and behind. Valgus or varus deformities of the ankle can be detected by looking at the alignment of the toes relative to those of the contralateral foot. Inspect the arches of the feet for pes cavus (high-arched feet) or pes planus (flat feet). Swelling of the ankle joint can be most easily seen around the malleoli. Check for scars, bunions (1st MTP joint) and calluses. • Whilst the patient is standing, ask the patient to stand on their toes. • Ask the patient to walk and observe for a normal heel strike and toe-off gait. Palpation (Feel) • Whilst the patient is standing, palpate the Achilles tendon for thickening. • Ask the patient to lie on the couch and inspect the nails and skin. Remember to inspect between the toes, the sole of the foot and lift the foot to look at the heel. Check the alignment of the toes and note the presence of calluses, clawing and joint swelling. • Using the dorsum of your hands, compare the temperature of both ankles and feet, moving from proximal to distal. • Palpate the shafts of the tibia and fibula for tenderness, including the medial and lateral malleoli. To palpate the talus, palpate anterior to the malleoli whilst everting and inverting the foot. Palpate the ligamentous attachments of the ankle joint and the muscle tendons that cross the ankle joint. Perform a lateral squeeze test on the metatarsophalangeal joints. Assess range of motion (Move) • Assess the active range of motion (ROM) of dorsiflexion, plantar flexion, inversion, and eversion of the foot. Test active dorsiflexion and plantarflexion of the great toe. • Assess the passive ROM with the patient’s lower leg supported on the examination couch and their foot unsupported. Stabilize the lower leg against the couch with one hand and use your other hand to assess joint mobility. The normal ranges are passive dorsiflexion 10-15°, plantar flexion 50-70°, inversion 40° and eversion 10°. • Fix the position of the ankle joint with one hand and using your other hand, assess passive inversion and eversion at sub talar joint. • Test passive dorsiflexion and plantarflexion of the great toe

Completion • Examine the ipsilateral knee • Assess the neurological and vascular status of the limb (In the OSCE, unless you are given specific instructions to perform this assessment, you should simply state to the examiner that you would do so). • Thank the patient and request them to redress. • Wash your hands

[61]

Examination of the spine

• Wash your hands • Introduction, identification and consent • Before commencing, ask the patient whether they have any pain in their neck or back.

Inspection (Look) Inspect the patient from in front, from the side and from behind. Adequate exposure of the spine is essential, and the patient should therefore be dressed in their bra and pants. • Inspect the patient’s skin, looking for café-au-lait spots, which may suggest neurofibromatosis, a sacral dimple, naevus or hairy patch suggestive of spina bifida occulta, or scarring suggestive of a previous thoracotomy or spinal surgery. • Inspect the cervical spine for deformity (e.g. cervical spondylosis, acute torticollis). An abnormal head posture may be due to disease in the cervical spine or neck, but you should also consider other causes e.g. extraocular muscle palsy. Look for asymmetry of the clavicles, scapulae and shoulders. • Inspect the thoracolumbar spine for kyphosis or scoliosis. Palpation (Feel) Palpate for tenderness over the spine and soft tissues. • Palpate the cervical spine and neck posteriorly in the midline, laterally, and anteriorly, Examine the supraclavicular fossae for any masses (e.g. cervical rib, lymph glands, tumours) and the paraspinal muscles for tenderness. • Palpate the thoracolumbar spine and sacrum for tenderness. Tenderness between the spines of the lumbar vertebrae, at the lumbosacral junction and over the lumbar muscles may occur with a prolapsed intervertebral disc and with mechanical back pain. • A palpable step at the lumbosacral junction may indicate spondylolisthesis. • Palpate for tenderness over the sacroiliac joints (e.g. ankylosing spondylitis). Assessing range of motion (Move) Assess the active ROM of the cervical spine. o Flexion: normal range 80°, chin able to touch sternoclavicular joint. o Extension: normal range 50° (note: flexion and extension primarily involve the atlanto-axial and atlanto-occipital joints). o Lateral flexion: normal range 45° from midline. Restriction of lateral flexion is common in cervical spondylosis. o Lateral rotation: normal range 80° to both sides. Rotation is restricted and painful in cervical spondylosis. Please note: If there is restriction of any active cervical spine movement then cautiously check passive range of motion to identify if there is any further increase in the range of motion. Ask the patient to perform the active movement and then cautiously, with one hand on the neck to feel for crepitus and the other hand on the top of the head to create the movement, slowly and gently attempt to passively move the cervical spine beyond the active range. • Assess the movement in the thoracic and lumbar spine • Flexion is due to a combination of thoracic, lumbar and hip movements. The composite movement may be recorded as the distance between the patient’s fingers and the ground (normally < 7cm) or the lowest level that the person can reach (e.g. mid-tibia).

[62]

• A modified Schober's test should be used to provide a quantitative evaluation of flexion of the lumbar spine. Mark a 15cm length of the lumbar spine with the patient in the erect position), measuring 10cm above and 5cm below the posterior superior iliac spines (Dimples of Venus). Instruct the patient to flex his or her spine maximally. Re-measure the distance between the marks. Normal flexion increases the distance by at least 5 cm. o Extension. Ask the patient to arch their back (normal range = thoracic 25°, lumbar 35°). Pain and restricted extension are particularly common in prolapsed intervertebral disc and spondylolysis. • Lateral flexion. Ask the patient to stand erect with hands at their sides and feet 30cm apart. Measure the distance from the finger tips to the floor. Ask the patient to flex maximally to the side and re-measure the distance from the finger tips to floor. The difference between the two measurements is recorded as the amount of lateral flexion (normal >10cm). The contributions of the thoracic and lumbar spine to lateral flexion are usually equal. • Rotation. The patient should be seated, asked to fold their arms across their chest then asked and to twist round to each side. The normal range of rotation is 40° and is almost entirely thoracic. The lumbar contribution is <5°. • Ask the patient to bend forward and lightly percuss the spine from the root of the neck to the sacrum. Significant percussion tenderness is a feature of infection, fractures and neoplasia. • Assess the patient’s gait.

Completion • Perform a full neurological examination of the patients upper and lower limbs, looking for fasciculation, wasting, and abnormalities in tone, power, reflexes and sensation. Remember that cervical spinal cord compression may lead to bladder and bowel disturbance, lower limb neurological dysfunction and abnormal gait. • In a patient presenting with lower back pain, perform an abdominal examination to identify any masses, and consider a rectal examination (omit in the OSCE) to check for loss of anal tone and perianal sensation (cauda equina syndrome). • Examine the peripheral pulses as vascular claudication in the upper and lower limbs may mimic the symptoms of radiculopathy or canal stenosis. • In patients presenting with neck pain, you should also examine the shoulder joints. In patients presenting with lower back pain you should examine the hip joints. Osteoarthritis of the hip may present with predominantly back and buttock pain as well as with pain in the groin.

Special tests: The following special tests should be performed, as an addition to the basic examination above, when indicated by the clinical history:

Suspected prolapsed intervertebral disc: • Straight leg raise. Ask the patient to lie flat on the couch. Passively flex their thigh with their leg extended. If the patient complains of back or leg pain the test is positive (hamstring tightness is not relevant). Paraesthesiae or pain in a nerve root distribution

[63]

indicates nerve root irritation. Back pain suggests, but is not indicative of, a central disc prolapse, and leg pain suggests a lateral protrusion. Lower the leg gradually until the pain disappears then dorsiflex the foot. This increases tension on the nerve roots, aggravating any pain or paraesthesiae (Lasegue’s sign). • Bowstring test. Perform a straight leg raise. If the patient experiences pain, flex the knee slightly then apply firm pressure with the thumb in the popliteal fossa to stretch the tibial nerve. Radiating pain and paraesthesiae suggest nerve root irritation. • Femoral stretch test. With the patient prone and the anterior thigh fixed to the couch, flex each knee in turn. This causes pain in the skin overlying the anterior compartment of the thigh by stretching the femoral nerve roots in L2-L4. The pain produced is normally aggravated by extension of the hip.

Suspected ankylosing spondylitis • Assess chest expansion at the level of the fourth intercostal space (normal = 3-5cm). This may be reduced in ankylosing spondylitis.

Completion • Thank the patient • Request them to redress • Wash your hands

[64]

Examination of the Shoulder

This the basic shoulder examination to which other specific tests may be added depending upon the nature of the patient’s complaint

• Wash your hands • Introduction, identification and consent • Ask the patient whether they have any pain in the arm, shoulder or neck • Fully expose the patient’s shoulders, neck and chest (female patients should retain their bra).

Inspection (Look) Ask the patient to stand, if this is not possible then the patient may sit on a chair or on the side of the couch/bed.

With the shoulder fully exposed, inspect from the o Front o Side o Back

From the front compare the two shoulders looking for • Symmetry • Posture (observe how the patient is positioning the upper limb) • Swelling (joint effusion?) • Deformity • Bony prominence (sternoclavicular joint; acromioclavicular joint) • Muscle wasting (Deltoid) • Scars • Any other skin changes (e.g. erythema)

From behind inspect • Muscle bulk (supraspinatus – above scapula wing, infraspinatus – below scapula wing; trapezius, rhomboids) • Any abnormalities in the scapula • Any scars or skin changes

Palpation (Feel) • Using the back of your hand, assess the temperature over the shoulder area • Begin palpating from the front, work from medial to lateral. Palpate for increased temperature, joint line tenderness, swelling and crepitus o Sternoclavicular joint (SCJ) o Clavicle o Acromioclavicular joint (ACJ) o Acromion process o Glenohumeral joint (anterior and posterior joint line) o Spine of the scapula o Scapula • Palpate the muscle bulk of o Deltoid o Supraspinatus o Infraspinatus o Trapezius

[65]

Assess range of motion (Move) • Screening examination o Ask the patient to put their hands behind their head and push their elbows back as far as they can (external rotation, abduction) o Ask the patient to put their hands behind their back (internal rotation, abduction) Look for any difficulty, limitation or pain on movement. Describe how far they can reach up the back.

• Assess active range of motion o External rotation: Flex the elbow to 90° and tuck it into the patient’s side- then ask the patient to rotate the arm outwards. (This is usually the first movement lost in a frozen shoulder) o Internal rotation: Flex the elbow to 90° and tuck it into the patient’s side- then ask the patient to rotate the arm inwards. o Flexion & Extension: Ask the patient to raise their arms in front and behind them. o Abduction: Check Painful Arc § Ask the patient to raise their arm to the side, palm downwards, and then lower. Normal movement is up to 180°. Observe from both the front and behind for symmetry of scapula movement & pain. Assess glenohumeral movement and scapulothoracic movement. § If the patient has rotator cuff pathology, there is often pain from 60-120°, which may be alleviated by repeating with palm facing upwards. Pain only occurring at the end of the movement (120-180°) may indicate acromioclavicular joint (ACJ) arthritis.

Assess passive range of motion o After testing active movement, passively test the range of external rotation, internal rotation, flexion, extension and abduction, palpating the shoulder joint for crepitus whilst doing so. Function • Ask the patient if they o can dress themselves without difficulty o can wash their own hair

Specific tests (To be used if indicated by the patient’s history – you be given instructions as to whether these are to be included in an OSCE station) • Testing the Rotator cuff o Resisted active abduction (supraspinatus) initiates abduction - first 15 degrees, deltoid abducts up to 90 degrees; trapezius and serratus anterior cause scapular rotation for abduction beyond 90 degrees). o Resisted active external rotation (infraspinatus, teres minor) o Resisted active internal rotation – “lift off” test (subscapularis). Ask the patient to place their hand behind their back with the dorsum of their hand resting over their mid-lumbar spine. The dorsum of the hand is then raised off the back by maintaining or increasing internal rotation of the humerus and extension at the shoulder. To perform this test the patient must have full passive internal rotation so that it is physically possible to place the arm in the desired position and pain cannot be a limiting factor during the manoeuvre. The ability to actively lift the dorsum of the hand off the back constitutes a normal lift-off test. Inability to move the dorsum off the back constitutes an abnormal lift-off test and indicates subscapularis rupture or dysfunction.

[66]

• Acromio-clavicular joint pathology o Place the arm into forced adduction across the body at 90° of flexion at the shoulder = “scarf test”. Note any pain or tenderness over the ACJ.

Completion • Examine the cervical spine and elbow. When examining the elbow, you should use the schema ‘look, feel, move’. • Assess the neurological and vascular status of the limb (In the OSCE, unless you are given specific instructions to perform this assessment, you should simply state to the examiner that you would do so). • Thank the patient and request them to redress • Wash your hands

[67]

Examination of the elbow

• Wash your hands • Introduction, identification and consent • Before commencing the examination, ask the patient if they have any pain in the shoulder, elbow or wrist. The patient’s arms should be exposed fully, including their shoulders.

Inspection (Look) • Ask the patient to stand with their arms loosely by their sides. Inspect the position of the elbows at rest and note the carrying angle and the presence of a fixed flexion deformity. Inspect the arms, elbows and forearms closely for scars, swellings, rashes, psoriatic plaques, rheumatoid nodules and muscle wasting, remembering to inspect the lateral and medial aspects of the elbow joint, the antecubital fossa and the skin over the extensor surface of the joint.

Palpation (Feel) • Using the dorsum of your hands, assess the temperature of the skin, moving from proximal to distal and comparing both sides. • With the elbow flexed to 90°, palpate the radial head, medial and lateral epicondyles and the olecranon process for tenderness.

Assess range of motion (Move) • Assess the active ROM of flexion, extension, pronation and supination. Repeat passively, whilst feeling for crepitus.

Assess Function • Can the patient move their hand to their mouth or nose – check both sides

Special Tests • Assess for medial epicondylitis (golfer’s elbow). In the supinated position, ask the patient to make a fist and flex their wrist against resistance. Pain will be felt at the medial epicondyle. • Assess for lateral epicondylitis (tennis elbow). In the pronated position, ask the patient to extend their wrist against resistance. This will re-produce pain at the origin of the extensor muscles (lateral epicondyle).

Completion • Assess the neurological and vascular status of the upper limb (In the OSCE, unless you are given specific instructions to perform this assessment, you should simply state to the examiner that you would do so). • Examine the ipsilateral shoulder and wrist/hand. • Thank the patient and request them to redress • Wash your hands

[68]

Hand examination The following is a basic hand examination, to which specific tests are added in clinical practice depending on the nature of the patient’s complaint. • Wash your hands • Introduction, identification and consent • Position the patient seated with their hands supinated and supported on a pillow • Ask the patient of they have any pain or numbness/tingling. Take care not to cause the patient excessive discomfort during your examination.

Inspection (LOOK) • Nails: LOCAL Problems o Pitting and/or nail ridges (seen in psoriasis) o Onycholysis (separation of the nail from the nailbed e.g. psoriasis, fungal infection, hyperthyroidism) o Onychogryphosis (hypertrophic nails that resemble horns or claws: may be post-traumatic or due to peripheral vascular disease) SIGNS OF DISEASE ELSEWHERE o Splinter haemorrhages, nail fold infarcts e.g. connective tissue disease/ vasculitis o Clubbing • DORSUM – 4 THINGS o SKIN - Colour (pink/white/blue?) - Raynaud’s phenomenon? § Changes - sclerodactyly -thickening and tethering of skin - Ulceration due to neuropathies or severe Raynaud’s o psoriasis o SCARS o MUSCLE WASTING – 1st Dorsal interossei and guttering (ulnar nerve) o DEFORMITY § Fusiform or focal swelling e.g. dactylitis (“sausage digit”) of psoriatic arthritis and the arthropathies associated with Ankylosing Spondylitis (AS) or Inflammatory Bowel Disease (IBD) § Nodular deformities of the interphalangeal joints (IPJs): • Bouchard’s nodes at PIPJs in osteoarthritis (OA) • Heberden’s nodes at DIPJs in OA § Swan neck and Boutonniere deformities of IPJs in rheumatoid (RA) § Squaring of the hand at the 1st carpometacarpal joint (CMCJ) in OA § Windswept deformity (ulnar deviation at MCPJ in RA) § Clawing - abnormal posture of peripheral nerve lesion (e.g. ulnar claw) § Wrist swelling – synovitis or ganglion • PALMER SURFACE o SKIN o SCARS o MUSCLE WASTING - thenar (median nerve) & hypothenar muscles (ulnar nerve) o DEFORMITY - Dupuytren’s contracture

• Elbow: Inspect the elbows for rheumatoid nodules and psoriatic plaques.

[69]

Palpation (FEEL) – 4 THINGS – remember to ask where is painful 1. TEMPERATURE - Assess using the dorsum of your hands over areas of redness or joints. Do they feel warm or cold? 2. PALPATE – for tenderness, swelling or bony deformities. Start at the wrist and palpate volar, dorsal, radial and ulnar aspects. • Perform a squeeze test of the MCPJs (as per the GALS examination) • If the squeeze test is painful, localise the disease by palpating each MCPJ individually. Place both of your thumbs just distal to the MCPJ on the dorsum of the finger overlying the extensor tendon. Your fingertips should be overlying the head of the metacarpal in the palm. • Palpate along the dorsal and volar aspect of metacarpals and phalanges (squeeze gently using your thumb on the palmar surface and index finger on the dorsum). • Palpate the radial and ulnar aspects of the phalanges. 3. NEURO Check sensation in the dermatomes (C6,7,8) and peripheral nerve (median, ulnar, radial) distributions

4. VASCULAR o Check ulnar and radial pulses o Perform an Allen’s test

Assess range of motion (MOVE) – 4 MOVEMENTS IN EACH AREA Test active movement first. If a limited range of movement exists, you will need to repeat the movement passively. Take care not to cause the patient excessive discomfort. • Fingers o Flexion/Extension - Ask the patient to ‘make a full fist’ then straighten fingers. If this is not possible examine flexion of MCPJ, PIPJ and DIPJ separately. o Abduction/adduction - Ask the patient to ‘extend and spread their fingers’ and then back to normal. • Thumb - flexion, extension, palmar abduction, adduction and opposition. You will need to demonstrate to the patient what you are asking them to do e.g. “With your hand flat, point your thumb up to the ceiling like this….” • Wrist - Ask the patient to perform the prayer and reverse prayer signs to test the range of dorsiflexion and palmar flexion of their wrists. You will need to demonstrate to the patient what you are asking them to do. Then radial and ulnar deviation with elbows by their side.

Test function • Assess grip strength o Assess power grip by asking the patient to hold a pen in their clenched fist and stop you pulling it out. (If not available, ask them to grip your fingers). o Assess lateral pinch grip (key grip) by asking the patient to hold a key or a pen normally. o Assess precision. Can the patient undo and do up buttons?

Special tests

[70]

The following are specific tests for peripheral nerve problems: each nerve has a sensory, motor and provocation test. In the OSCE, you will be instructed as to whether you need to include these tests. • Carpal tunnel syndrome (Median nerve) o Sensory - Test light touch in the median nerve distribution.

o Motor - Test palmar abduction against resistance (with the patient’s palm supinated and held out flat, ask them to point their thumb vertically up to the ceiling. Apply resistance by pushing the thumb back towards the palm with your own thumb).

o Provocation – • Tinel’s test - tap strongly over the median nerve as it goes through the carpal tunnel. Reproduction of pain, numbness or tingling in the cutaneous distribution of the median nerve is a positive test. • Phalen’s test – ask the patient to hold both wrists in palmar flexion for one minute. Reproduction of pain, numbness or tingling in the cutaneous distribution of the median nerve is a positive test. • Compression test – direct pressure over the carpal tunnel may also reproduce symptoms • Ulnar nerve: o Sensory - Test sensation in the ulnar nerve distribution o Motor – • Ask the patient to cross their index and middle fingers • to grip a piece of paper between their thumb and index finger without flexing their thumb IP joint (Froment’s sign). You will need to demonstrate to the patient what you are asking them to do. • To abduct their fingers against resistance • Radial nerve: o Sensory - Test sensation in the anatomical snuffbox o Motor - Test wrist and finger dorsiflexion against resistance.

• If the patient has pain or restricted movement at the wrist joint, you should also fully examine the ipsilateral elbow. (In the OSCE, unless you are given specific instructions to perform this assessment, you should simply state to the examiner that you would do so). • Thank the patient and wash your hands.

[71]

Peripheral Vascular System history Peripheral Arterial Disease

History of presenting complaint:

Intermittent claudication: A reproducible discomfort of a defined group of muscles that is induced by exercise and relieved with rest. This disorder results from an imbalance between supply and demand of blood flow that fails to satisfy ongoing metabolic requirements.

Site Depends on the site of arterial occlusion, e.g. occlusion of the superficial femoral artery often causes pain in the calf muscles Onset Acute e.g. after acute thrombosis Chronic e.g. atherosclerotic stenosis/occlusion Character Gripping, cramping, burning, tightness Radiation - Associated symptoms (For example, chest pain) May suggest atherosclerotic vascular disease elsewhere e.g. ischaemic heart disease, cerebrovascular disease, erectile dysfunction Timing Intermittent?

Exacerbating factors Exercise (“How far can you walk?”, “Does the pain limit your walking, or something else e.g. shortness of breath?”) Rest (“How long before the pain subsides?”) – Usually minutes Severity Pain scale (1-10).

Rest pain Site Foot/toes Onset Usually progresses from intermittent Claudication to rest pain Character Sharp, burning, usually severe Radiation - Associated symptoms (For example, chest pain) May suggest atherosclerotic vascular disease elsewhere e.g. ischaemic heart disease, cerebrovascular disease, erectile dysfunction Timing At rest (Worse at night) Exacerbating factors Elevation of leg

Relieving Factors Lowering legs

Signs and symptoms of acute ischaemia Remember the 6 P’s: • Pain • Pallor • Pulselessness • Paralysis (loss of function) • Paraesthesia (loss of sensation) • Perishing cold

[72]

Abdominal Aortic Aneurysm (AAA)

Presentation Asymptomatic – majority of AAA’s are identified incidentally Symptomatic – In this situation patients may complain of back pain Ruptured – These present as an emergency with back pain and collapse

Deep venous thrombosis (Wells Score) Can be asymptomatic but signs and symptoms include: • Pain, aching • Tenderness • Swelling • Increased warmth to touch • Altered skin colour

The factors predisposing to venous thrombosis are Virchow’s triad: • Stasis e.g. prolonged immobility, post-operative state, intra-abdominal/ pelvic mass compressing the venous system • Hypercoagulability e.g. high-dose oestrogens, malignancy, sepsis, thrombophilia’s • Intimal damage – trauma

Completing the vascular HPC: Ask specifically about: • Previous vascular problems • Previous vascular surgery/intervention • Diseases caused by atheroma elsewhere e.g. coronary artery atheroma (angina and myocardial infarction), carotid artery atheroma (stroke, transient ischaemic attack, amaurosis fugax) • Major Risk factors: o Smoking o Hypercholesterolaemia o Diabetes mellitus o Hypertension

Drug history and allergies Drugs of relevance include anticoagulants, antiplatelet agents, lipid/cholesterol lowering drugs, cardiac medication, anti-hypertensives, oral contraceptive.

Social history Occupation, smoking (number of pack years), alcohol, diet, exercise, recent travel etc.

Family history Some prothrombotic conditions are hereditary e.g. Factor V Leiden mutation Family history is also a risk factor for atherosclerosis.

[73]

Peripheral Vascular Examination In your End-of-Phase examinations, you may be asked to perform a ‘full examination of the patient’s arterial system’ (arms and legs), or to examine the arterial system of either the upper or lower limbs (including the aorta) separately, or to examine the lower limbs for varicose veins and chronic venous insufficiency. Alternatively, you may be asked to examine both the arterial and venous systems of the patient’s lower limbs. The instructions will be very clear, but you should be prepared for all these scenarios. In the OSCE, you will not be asked to use a hand-held Doppler due to the noise emitted, but you should still ensure that you are competent in using one prior to graduation.

Examination of the arterial system of the upper and lower limbs

• Wash your hands • Introduction, identification and consent. • General inspection of the bed area for clues • Inspection of the patient (colour, build, comfort, position etc.) • Inspect the hands for: o Colour (pallor of the palmar creases; peripheral cyanosis) o Capillary refill o Nicotine staining • Check and compare radial pulses (rate, rhythm, volume, radio-radial delay?) • Palpate the ulnar (volume) and brachial (volume and character) pulses • Perform Allen’s test (Compress the ulnar and radial arteries at the wrist. Ask the patient to make a tight fist then release it. Release one of the arteries and observe blood flow back into the hand. Repeat but release the other artery. Check that both arteries perfuse the hand fully i.e. that the palmar arches are intact) • Check the blood pressure in both arms • Palpate the carotid pulses (one at a time). Assess character and volume. • Examine the eyes for: o Subconjunctival pallor (anaemia) o Corneal arcus (hyperlipidaemia • Assess the lips and tongue for: o Dehydration o Central cyanosis • Inspect the abdomen for scars, visible masses and visible pulsations • Inspect the legs, feet and toes for: o Symmetry o Colour o Scars o Oedema o Trophic changes § Loss of hair § Shiny skin § Wasting of subcutaneous tissues o Ulceration (describe site, depth, size, margins, ulcer bed, exudate, odour etc.)

[74]

• Palpate the o Aorta o Femoral pulses o Popliteal pulses o Dorsalis pedis and posterior tibial pulses • Check light-touch sensation and capillary refill in the toes • Assess power in the foot/leg • Auscultate: o Carotids o Subclavian arteries o Aorta (a bruit can be heard in thin healthy patients) o Femoral arteries (Note that there is no bruit over an occluded vessel and severe stenosis can be present without an audible bruit.) • Perform Buerger’s test (this assesses critical ischaemia) o With the patient supine, elevate both legs to an angle of 45° and hold for one to two minutes. Pallor of the feet indicates ischemia. The poorer the arterial supply, the less the angle to which the legs have to be raised for them to become pale (Buerger’s Angle) o Then sit the patient up and ask them to hang their legs down over the side of the bed at an angle of 90°. Gravity aids blood flow and colour returns in the ischemic leg. The skin at first becomes blue, as blood is deoxygenated in its passage through the ischemic tissue, and then red, due to reactive hyperaemia from post-hypoxic vasodilatation. Both legs should be examined simultaneously as the changes are most obvious when one leg has a normal circulation, (the time it takes to become pink/red relates to the severity or ischemia – Buerger’s time) • Calculate the ankle-brachial pressure index (ABPI) by dividing the highest systolic blood pressure in the arteries at the ankle by the higher of the two systolic blood pressures in the arms. Significant arterial disease is indicated by an ABPI of <0.8. • Thank the patient and request them to redress. • Wash your hands.

[75]

Examination of the lower limbs for varicose veins and chronic venous insufficiency • Wash your hands • Introduction, identification and consent • Ask the patient to stand up and remove their trousers. • Inspect the legs for: o Varicosities, particularly in the distribution of the long saphenous vein (medial thigh and leg) and short saphenous vein (back of leg) o Venous eczema o Oedema due to venous stasis o Lipodermatosclerosis (scarring of the skin and fat) o Haemosiderin deposition o Venous ulceration (usually in the gaiter area above the medial malleolus) o Scars (indicating previous surgery or healed ulceration) • Identify the saphenofemoral junction (SFJ). This is located 4cm lateral and 4cm inferior to the pubic tubercle. o Inspect for a saphenovarix (varicosities at the SFJ) • Perform the Cough test by putting your finger on the SFJ and asking the patient to cough. Palpate for thrills at the SFJ. • Perform the Tap test by putting your finger on the SFJ and putting a finger of your other hand on any varicosities in the long saphenous vein distribution. Tap on the SFJ and if it is incompetent, you will feel the transmitted percussion wave in the varicosities further down the leg. • Perform the Trendelenburg test (tourniquet test). Ask the patient to lie flat. Raise the leg and keep it raised for a few minutes to exsanguinate as much blood as possible. Apply a tourniquet high around the thigh. Ask the patient to stand up and inspect to see whether the varicose veins refill. If not, the problem originates at the SFJ. If the veins do refill, repeat the test at the mid-thigh perforators, the saphenopopliteal junction and the mid-calf perforators. (not required for OSCE). • Perform Perthe’s test to assess the patency of the deep veins. Ask the patient to lie down. Without exsanguinating the leg, apply a tourniquet around the thigh. Ask the patient to stand and rock up and down onto his tiptoes ten times. If the superficial veins empty, the deep veins must be patent. (not required for OSCE). • Perform auscultation using a Doppler probe on the SFJ. Squeeze the calf/ thigh. You should hear a single “whoosh” as the blood is squeezed from the long saphenous vein into the femoral vein. A second “whoosh” indicates incompetence of the SFJ as the blood falls back into the long saphenous vein past the incompetent valve. • Repeat the Doppler probe auscultation at the saphenopopliteal junction in the popliteal fossa. To enable you to squeeze the calf, the patient will need to relax their calf muscles by transferring most of their weight onto the other limb. • Examine the abdomen to exclude an abdominal or pelvic cause of raised venous pressure. • Thank the patient and request them to redress. • Wash your hands.

[76]

Thyroid history

Symptom Hyperthyroidism Hypothyroidism (overactive) (underactive) Change in body weight Decrease despite increased Increase appetite (although 10% will gain weight) Change in appetite Increase Decrease (Enquire about associated dysphagia) Change in voice Hoarseness Change in bowel habit Increased frequency of Constipation defaecation or diarrhoea Change in energy level Can increase or decrease Decrease Muscle weakness Somnolent Slower movements and muscle weakness Change in mood Anxious, irritable, emotionally Lethargy, depression labile Change in concentration Decrease Decrease Change in heat tolerance Prefers a cool environment, Prefers a warm environment, wears fewer clothes wears extra clothes Change in skin, nails and hair Increased sweating. Dry flaky skin Fine hair and hair loss Coarse thinning hair Clubbing (thyroid acropachy) Brittle nails Onycholysis (separation of the nail from the nailbed) Change in heart rate / rhythm Tachycardia, palpitations, Bradycardia atrial fibrillation Change in menstrual cycle Infrequent menses. Heavy, prolonged or irregular (exclude current or recent Fertility problems. menses. pregnancy) Fertility problems and increased risk of miscarriage

Remember to enquire about the onset and duration of symptoms and any associated pain or discomfort. Enquire about previous thyroid disease, surgery or treatment (N.B. Previously hyperthyroid patients may become hypothyroid after treatment)

Drug history and allergies Specifically enquire about use of thyroxine, lithium, amiodarone and glucocorticoids

Social history Smoking, alcohol, diet (sufficient iodine?) and effect on activities of daily living

Family history Thyroid disease can be familial.

[77]

Examination of the Thyroid Gland

Equipment: Glass of water, tendon hammer, stethoscope, sheet of paper

• Wash your hands • Introduction, identification and consent (whilst checking the patients identity, listen to their voice – a low-pitched or hoarse voice may indicate hypothyroidism) • Seat the patient comfortably in a chair that you can walk around on all sides.

Inspection • Inspect the general appearance of the patient (build, inappropriate clothing, restlessness, confusion, quality of skin and hair) • Inspect the hands for thyroid signs: o Temperature o Sweating o Palmar erythema o Clubbing (thyroid acropachy) o Brittle nails o Onycholysis • Check for a tremor by asking the patient to hold their hands outstretched and pronated (palms downward). Place a piece of paper on the dorsum of the outstretched hands. This will amplify a fine tremor. • Check the patients pulse. Note the presence of bradycardia, tachycardia or atrial fibrillation. • Inspect the forearm for muscle wasting • Inspect the eyes for thyroid signs: o Inspect for exophthalmos. This is proptosis (forward displacement of the eye) in association with Graves` disease o Exophthalmos may lead to inability to close the lids properly. This may cause sight-threatening exposure keratopathy. o Inspect for chemosis (conjunctval oedema), conjunctival injection (“bloodshot” eyes), and periorbital/lid oedema. o Inspect for lid retraction, which allows the sclera to be seen above the cornea (sign of all types of hyperthyroidism) o Inspect for lid lag by asking the patient to look up then down. Delayed downward movement of the eyelids on downgaze indicates lid lag (sign of all types of hyperthyroidism). o Check eye movements in all directions of gaze. There may be a myopathy of the extraocular muscles. Also, diplopia can result from restricted ocular mobility, initially involving the inferior rectus muscles o Check visual acuity and perform fundoscopy. Proptosis may stretch the optic nerve. The optic disc often appears normal but may be atrophic in long-standing cases with irreversible loss of vision. • Inspect the neck for masses. • Ask the patient to take some water in their mouth then observe the neck while they swallow it. Does the mass move? If so, this indicates a thyroid mass.

[78]

• Ask the patient to protrude their tongue (“Stick your tongue out”). Observe the neck. If the mass moves upwards on tongue protrusion this indicates a thyroglossal cyst. • Inspect the back of the tongue for a lingual thyroid.

Palpation • Palpate the trachea. Is it central? • From behind, palpate the anterior neck. If there is a mass: o Determine the size and site. o Is it diffusely enlarged? o Is the mass hard or soft on palpation? o Is the surface smooth or nodular? Is there a single nodule or multiple nodules? o Are the surrounding tissues mobile over the mass or is the mass fixed to the surrounding tissues? o Can you feel above the mass? o Can you feel below the mass in the suprasternal notch? If not, it may be a retrosternal goitre. o Ask the patient to take some water in their mouth then swallow it, whilst you are palpating. Does it move on swallowing? o Ask the patient to protrude their tongue? Does the mass move? • Palpate the cervical lymph nodes for metastatic spread.

Percussion • Percuss the upper sternum for retrosternal extension of the goitre. (Not obligatory as not useful clinically)

Auscultation • Ask the patient to hold their breath. Auscultate with the bell of the stethoscope over the lobes of the thyroid gland for bruits (due to increased blood flow) • Check for proximal muscle weakness. Ask patient to rise from sitting on a chair whilst folding arms on chest • Check the ankle reflexes. There may be normally brisk ankle reflexes which are slow to return to the resting state (delayed relaxation) in hypothyroidism. • Inspect for pretibial myxoedema. • Thank the patient • Wash your hands

[79]

Breast examination • Wash your hands • Introduction, identification and consent • Arrange for a chaperone to be present • Expose the patient adequately (no clothing above the waist) • Ask the patient whether they have any pain

Inspection • Position the patient so that they are seated comfortably on the edge of the couch and with their arms by their sides • Inspect for symmetry, not of size or shape between the two breasts as asymmetry is common, but instead look for abnormalities in the contours of each breast e.g. tethering or dimpling of the skin • Inspect for visible masses • Inspect for erythema of the skin +/- abnormal scaling (hyperkeratosis and desquamation) of the nipple and areolar skin • Inspect for nipple retraction (enquire about its duration as this may be normal) • Ask the patient to raise both arms, put their hands behind their head and push their shoulders back. Inspect the breast tissue whilst the patient performs this manoeuvre. Look for the appearance or accentuation of skin tethering. • Ask the patient to put their hands on their hip and push inwards. This fixes the pectoralis major and may accentuate lumps tethered to it.

Palpation • Ask the patient to lie comfortably at 45 degrees. Examination of a large-breasted woman may be easier if their arm is placed above their head. • Mentally divide the breast into four quadrants (upper outer, upper inner, lower outer and lower inner), plus the axillary tail and nipple. • Palpate each quadrant, the axillary tail and nipple using the pads of your index, middle and ring fingers (not your fingertips). Make small circular movements as if you were rolling a marble. Increase the level of pressure so that you examine the subcutaneous tissue, mid-level tissue and tissue adjacent to the underlying chest wall. • Palpate the axillary lymph nodes whilst supporting the patients arm with your free hand (this relaxes the muscles forming the anterior and posterior walls of the axilla and permits easier palpation). Palpate using a rolling action (as above) against the posterior, medial, anterior and apical boundaries of the axilla. If you identify a lump describe its size, (measure with a ruler or calliper if available), consistency, shape and the mobility of the surrounding tissues (is it fixed or mobile?). Also, is it tender on palpation and does it feel hot (inflammatory)? • Palpate the nipple and inspect for nipple discharge. It is not necessary to attempt to ‘milk’ the nipple to determine whether any discharge is present. • Examine the supraclavicular fossa for lymphadenopathy. • If you suspect malignancy, or the patient has a history of malignant breast disease, you should palpate and percuss the abdomen for hepatomegaly (possible liver metastases); and percuss the vertebral spinous processes posteriorly for tenderness (possible vertebral metastases). (In the OSCE, unless you are given specific instructions to perform this assessment, you should simply state to the examiner that you would do so). • Thank the patient and cover their chest with a gown / request them to get dressed. • Wash your hands

[80]

Examination of the feet of a diabetic patient

• Wash your hands • Introduction, identification and consent • Before commencing, ask the patient if they have any pain in their ankles or feet. Both legs should be exposed from the knee down to the feet.

Inspection • Inspect the patient’s gait • Inspect the patient’s shoes for signs of uneven wear, presence of foreign objects • Inspect the skin of the patient’s feet for: • trophic changes - hairlessness, pallor, decreased sweating (autonomic dysfunction), dry cracked skin • rubor at pressure points • skin ulceration • diabetic dermopathy (brown macules) over shins • infection: cellulitis (erythema, swelling), gangrene • webspaces: cracked, infected, ulcers, maceration • toe nails: dystrophic, in-growing toenails, paronychia, onychomycosis • Inspect the feet for deformities, intrinsic muscle wasting (clawed, hammer toes), pes planus (flat foot) or pes cavus (high arch)

Palpation • Palpate the bones and joints of the ankle and foot for swelling and tenderness. Watch the patients face throughout and ask them to let you know if they experience any discomfort.

Vascular examination • Temperature. Use the back of your hand, compare shins to feet bilaterally. Note: temperature should decrease slightly as you move distally • Pulses • femoral (omit in the OSCE) • popliteal (if foot pulses absent) • posterior tibial • dorsalis pedis • Capillary refill

Neurological examination • Reflexes • ankle jerk • Sensation • Light touch (with cotton wool). • Pressure. Apply a 10g monofilament on the patient’s hand or sternum so the patient knows what to expect. Ask the patient to close their eyes and apply the monofilament to the pulp of the hallux and to the 1st, 3rd and 5th metatarsal heads. Apply the monofilament perpendicular to the skin surface and apply

[81]

sufficient force to cause the filament to bend or buckle. Do not allow the filament to slide across the skin or make repetitive contact at the test site. The total duration of the approach, skin contact, and removal of the filament should be approximately 2 seconds. • pin prick (omit in the OSCE) • temperature (omit in the OSCE) • proprioception • vibration (1st modality to lose, 128 Hz tuning fork), if absent at 1st MTPJ, move more proximally • Thank the patient and request them to redress • Wash your hands

[82]