clinical skills for osces - scion medical€¦ · after six years at medical school i have become...

CLINICAL SKILLS FOR OSCEsBURTON

OSCEsC L I N I C A L S K I L L S F O R

5 T H E D I T I O N

5

N E E L B U R T O N9 781907 904660

ISBN 978-1-907904-66-0

w w w . s c i o n p u b l i s h i n g . c o m

What students made of previous editions:

After six years at medical school I have become very accustomed to having at least five or six books piled on my desk for each topic… Clinical Skills for OSCEs is the first book that I have come across where I can finally clear my desk and have one book in front of me. Such a joy! The book cleverly covers everything in a clear and succinct manner.

This book is very well laid out and helpful for all clinical exams. The text is clear and concise and I would recommend it to any medical student preparing for OSCEs or other clinical exams.

This is a really helpful tool for the OCSEs. In our final OSCE exam of the year I scored 9 excellent/good out of 13 stations – and I can honestly say that I did so because of this text.

This is one of the best OSCEs books I have purchased. My only regret is that I didn’t buy it sooner. It is a comprehensive reference for anyone taking an OSCE exam.

C L I N I C A L S K I L L S F O R O S C E s 5 T H E d i t i o nN E E L B U R T O N

This full-colour fifth edition of Clinical Skills for OSCEs has been updated, revised, and extended by a dynamic team of medical students and junior doctors from all over the UK, from Aberdeen to Brighton and Cardiff to Norwich.

Medical school is hard enough without having to pull together vast amounts of incomplete and often conflicting information from maladapted and sometimes unreliable resources. The purpose of this book is to save you time and trouble by gathering all the information that you need and presenting it to you in a concise, structured, and memorable fashion, freeing you to excel at your exams and become the best doctor that you possibly can.

Co-edited by John Allen, a graduate medical student at Imperial College, and Neel Burton, a tutor at Oxford University and the winner of the BMA Young Author’s Award 2009, this new edition is bigger and better than ever before, crammed with 124 stations to cover every major clinical skill examined at medical school.

O V E R 2 0 , 0 0 0 C O P I E S S O L D

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vContentsContributors ix

Preface xi

OSCE tips xiii

I. GENERAL SKILLS

1. Hand washing 12. Scrubbing up for theatre 33. Venepuncture/phlebotomy 54. Cannulation and setting up a drip 75. Blood cultures 106. Blood transfusion 127. Intramuscular, subcutaneous, and intradermal drug injection 148. Intravenous drug injection 169. Examination of a superficial mass and of lymph nodes 18

II. CARDIOVASCULAR AND RESPIRATORY MEDICINE

10. Chest pain history 2111. Cardiovascular risk assessment 2412. Blood pressure measurement 2613. Cardiovascular examination 2814. Peripheral vascular system examination 3315. Ankle-brachial pressure index (ABPI) 3616. Breathlessness history 3817. Respiratory system examination 4118. PEFR meter explanation 4619. Inhaler explanation 4820. Drug administration via a nebuliser 50

III. GI MEDICINE AND UROLOGY

21. Abdominal pain history 5222. Abdominal examination 5523. Rectal examination 6024. Hernia examination 6225. Nasogastric intubation 6526. Urological history 6727. Male genitalia examination 6928. Male catheterisation 7129. Female catheterisation 73

Fifth edition © Neel Burton, 2015

Fifth edition published in 2015 by Scion Publishing Ltd

ISBN 978 1 907904 66 0

First edition published in 2003 by BIOS Scientific Publishers

Second edition published in 2006 by Informa Healthcare

Third edition published in 2009 by Scion Publishing Ltd

Fourth edition published in 2011 by Scion Publishing Ltd

All rights reserved. No part of this book may be reproduced or transmitted, in any form or by

any means, without permission.

A CIP catalogue record for this book is available from the British Library.

Scion Publishing Limited

The Old Hayloft, Vantage Business Park, Bloxham Rd, Banbury OX16 9UX, UK

www.scionpublishing.com

Important Note from the Publisher

The information contained within this book was obtained by Scion Publishing Ltd from sources

believed by us to be reliable. However, while every effort has been made to ensure its accuracy,

no responsibility for loss or injury whatsoever incurred from acting or refraining from action as

a result of the information contained herein can be accepted by the authors or publishers.

Readers are reminded that medicine is a constantly evolving science and while the authors

and publishers have ensured that all dosages, applications, and procedures are based on

current best practice, there may be specific practices which differ between communities. You

should always follow the guidelines laid down by the manufacturers of specific products and

the relevant authorities in the region or country in which you are practising.

Although every effort has been made to ensure that all owners of copyright material have

been acknowledged in this publication, we would be pleased to acknowledge in subsequent

reprints or editions any omissions brought to our attention.

Registered names, trademarks, etc. used in this book, even when not marked as such, are not

to be considered unprotected by law.

Cover design by Andrew Magee Design Limited

Typeset by Phoenix Photosetting, Chatham, Kent, UK

Printed in the UK

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vi Contents

IV. NEUROLOGY

30. History of headaches 7531. History of ‘funny turns’ 7832. Cranial nerve examination 8133. Motor system of the upper limbs examination 8634. Sensory system of the upper limbs examination 8935. Motor system of the lower limbs examination 9136. Sensory system of the lower limbs examination 9537. Gait, co-ordination, and cerebellar function examination 9738. Speech assessment 100

V. PSYCHIATRY

39. General psychiatric history 10340. Mental state examination 10641. Cognitive testing 11142. Dementia diagnosis 11343. Depression history 11644. Suicide risk assessment 11845. Alcohol history 12046. Eating disorders history 12347. Weight loss history 12548. Assessing capacity (the Mental Capacity Act) 12749. Common law and the Mental Health Act 130

VI. OPHTHALMOLOGY, ENT AND DERMATOLOGY

50. Ophthalmic history 13451. Vision and the eye examination (including fundoscopy) 13652. Hearing and the ear examination 14053. Smell and the nose examination 14554. Lump in the neck and thyroid examination 14755. Dermatological history 15156. Dermatological examination 15357. Advice on sun protection 156

VII. PAEDIATRICS AND GERIATRICS

58. Paediatric history 15759. Developmental assessment 15960. Neonatal examination 16261. The six-week surveillance review 16662. Paediatric examination: cardiovascular system 16963. Paediatric examination: respiratory system 17364. Paediatric examination: abdomen 17665. Paediatric examination: gait and neurological function 17966. Infant and child Basic Life Support 18167. Child immunisation programme 18468. Geriatric history 18669. Geriatric physical examination 188

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viiContents

VIII. OBSTETRICS, GYNAECOLOGY, AND SEXUAL HEALTH

70. Obstetric history 18971. Obstetric examination 19272. Gynaecological history 19573. Gynaecological (bimanual) examination 19874. Speculum examination and liquid based cytology test 20075. Breast history 20376. Breast examination 20777. Sexual history 21078. HIV risk assessment 21479. Condom explanation 21580. Combined oral contraceptive pill (COCP) explanation 21781. Pessaries and suppositories explanation 220

IX. ORTHOPAEDICS AND RHEUMATOLOGY

82. Rheumatological history 22283. The GALS screening examination 22684. Hand and wrist examination 22985. Elbow examination 23286. Shoulder examination 23387. Spinal examination 23688. Hip examination 23989. Knee examination 24290. Ankle and foot examination 245

X. EMERGENCY MEDICINE AND ANAESTHESIOLOGY

91. Adult Basic Life Support 24792. Choking 25093. In-hospital resuscitation 25294. Advanced Life Support 25595. The primary and secondary surveys 25896. Management of medical emergencies 260

– acute asthma 260– acute pulmonary oedema 260– acute myocardial infarction 261– massive pulmonary embolism 262– status epilepticus 262– diabetic ketoacidosis 262– acute poisoning 263

97. Bag-valve mask (BVM/’Ambu bag’) ventilation 26698. Laryngeal mask airway (LMA) insertion 26799. Pre-operative assessment 269100. Syringe driver operation 273101. Patient-Controlled Analgesia (PCA) explanation 275102. Epidural analgesia explanation 276103. Wound suturing 278


viii Contents

XI. DATA INTERPRETATION

104. Blood glucose measurement 280105. Urine sample testing/urinalysis 282106. Blood test interpretation 284107. Arterial blood gas (ABG) sampling 290108. ECG recording and interpretation 294109. Chest X-ray interpretation 306110. Abdominal X-ray interpretation 311

XII. PRESCRIBING AND ADMINISTRATIVE SKILLS

111. Requesting investigations 315112. Drug and controlled drug prescription 318113. Oxygen prescription 323114. Death confirmation 325115. Death certificate completion 326

XIII. COMMUNICATION SKILLS

116. Explaining skills 330117. Imaging tests explanation 333118. Endoscopies explanation 337119. Obtaining consent 339120. Breaking bad news 340121. The angry patient or relative 341122. The anxious or upset patient or relative 342123. Cross-cultural communication 343124. Discharge planning and negotiation 344


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18 Station 9

Examination of a superficial mass and of lymph nodesBefore starting

• Introduce yourself to the patient. • Confirm his name and date of birth.• If allowed, take a brief history from him, for example, onset, course, effect on everyday life.• Explain the examination and obtain consent.• Consider the need for a chaperone.• Ask the patient to expose the lump completely; for example, by undoing the top button of his shirt.• Position him appropriately and ensure that he is comfortable.

The examination (IPPA: Inspection, Palpation, Percussion, Auscultation)• Inspect the patient from the end of the bed, looking for other lumps and any other signs.• Inspect the lump and note its site, colour, and any changes to the overlying skin such as

inflamma tion or tethering. Note also the presence or absence of a punctum. • Ask the patient if the lump is painful before you palpate it. Is the pain only brought on by palpa-

tion or is it a more constant pain? • Wash and warm your hands.• Assess the temperature of the lump with the back of your hand.• Palpate the lump with the pads of your fingers; if possible, from behind the patient. Consider:

– number: solitary or multiple – size: estimate length, width, and height, or use a ruler or measuring tape – shape: spherical, ovoid, irregular, other – edge: well or poorly defined – surface: smooth or irregular – consistency: soft, firm, hard, rubbery – fluctuance: rest two fingers of your left hand on either side of the lump and press on the lump with

the index finger of your right hand: if your left hand fingers are displaced, the lump is fluctuant – pulsatility: rest a finger of each hand on either side of the lump: if your fingers are displaced,

the lump is pulsatile – mobility or fixation: consider the mobility of the lump in relation both to the overlying skin

and the underlying muscle – compressibility and reducibility: press firmly on the lump to see if it disappears; if it immediately

reappears, it is compressible; if it only reappears upon standing or coughing, it is reducible• Percuss the lump for dullness or resonance.• Auscultate the lump for bruits or bowel sounds.• Transilluminate the lump by holding it between the fingers of one hand and shining a pen torch to it

with the other. A bright red glow indicates fluid whereas a dull or absent glow suggests a solid mass.• Examine the draining lymph nodes (see below), or indicate that you would do so.

After examining the lump• Ensure that the patient is comfortable.• Ask him if he has any questions or concerns.• Thank him.• Wash your hands.• Summarise your findings and offer a differential diagnosis.• If appropriate, suggest further investigations, e.g. fine needle aspirate cytology (FNAc), biopsy,

ultrasound, CT.

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19Station 9 Examination of a superficial mass and of lymph nodes

Lymph node examination

Head and neck

Thepatientshouldbesittingupandexaminedfrombehind.Withthefingersofbothhands,palpatethesubmental,submandibular,parotid,andpre-andpost-auricularnodes.Nextpalpatetheanteriorandposteriorcervicalnodesandtheoccipitalnodes.

Submental

Anterior cervical

Submandibular

Parotid

Preauricular

PosteriorauricularOccipital

Posteriorcervical

Figure 3. Lymph nodes in the head and neck.

Upper body

• Palpatethesupraclavicularandinfraclavicularnodesoneithersideoftheclavicle.

• Exposetherightaxillabyliftingandabductingthearmandsupportingitatthewristwithyourrighthand.

• Withyourlefthand,palpatethefollowinglymphnodegroups:

– theapical

– theanterior

– theposterior

– thenodesofthemedialaspectofthehumerus

• Nowexposetheleftaxillabyliftingandabductingtheleftarmandsupportingitatthewristwithyourlefthand.

• Withyourrighthand,palpatethelymphnodegroups,aslistedabove.


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20 Station 9 Examination of a superficial mass and of lymph nodes

Anteriorgroup

Apicalgroup

Posteriorgroup

Supraclavicularand infraclaviculargroups

Figure 4. Lymph nodes of the upper body.

Lower body

Palpatethesuperficialinguinalnodes(horizontalandvertical),whichliebelowtheinguinalligamentandnearthegreatsaphenousveinrespectively,thenthepoplitealnodeinthepoplitealfossa.

Conditions most likely to come up in a lump examination station

Epidermoid (sebaceous) cyst: • Resultsfromobstructionofsebaceousgland.• Maybered,hot,andtender.• Spherical,smooth.• Attachedtotheskinbutnottothe

underlyingmuscle.• Mayhaveapunctumwhichmayexudea

cottagecheesedischarge.

Fibroma:• Commonandbenignfibroustissuetumour.• Skin-colouredandpainless.• Canbesessileorpedunculated,‘hard’or

‘soft’.• Situatedintheskinandsounattachedto

underlyingstructures.

Lipoma:• Commonandbenignsofttissuetumour.• Skin-colouredandpainless.• Spherical,softandsometimesfluctuant.• Notattachedtotheskinandtherefore

mobileand‘slippery’.

Skin abscess:• Collectionofpusintheskin.• Verylikelytobered,hot,andtender.• Maybeindurated.


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28 Station 13

Cardiovascular examination

Before starting• Introduceyourselftothepatient.• Confirmhisnameanddateofbirth.• Explaintheexaminationandobtainhisconsent.• Positionhimat45degrees,andaskhimtoremovehistop(s).• Ensurethatheiscomfortable.• Washyourhands.

The examination (IPPA)General inspection

• From the end of the couch, observe the patient’s general appearance (age, state of health,nutritionalstatus,andanyotherobvioussigns).Ishebreathlessorcyanosed?Ishecoughing?Doeshehavethemalarflushofmitralstenosis?

• Observethepatient’ssurroundings, lookinginparticularfor itemssuchasanitratespray,anoxygenmask,ECGelectrodes,andIVlinesandinfusions.

• Inspect the chest for any scars and the precordium for any abnormal pulsation. A mediansternotomyscarcouldindicatecoronaryarterybypassgrafting(CABG),valverepairorreplace-ment,ortherepairofacongenitaldefect.Aleftsubmammaryscarmostlikelyindicatesrepairorreplacementofthemitralvalve.Donotmissapacemakerifitisthere!

Inspection and examination of the hands• Takebothhandsnoting:

– temperature:feelwiththebackofyourhand– colour,inparticulartheblueofperipheralcyanosisandtheorangeofnicotinestains– nailbedcapillaryrefilltime:pressthenailfor5seconds;itshouldrefillwithin2seconds– anypresenceofclubbing(endocarditis,cyanoticcongenitalheartdisease)– anypresenceofOslernodesandJanewaylesions(subacuteinfectiveendocarditis)– anypresenceofsplinterhaemorrhages(subacuteinfectiveendocarditis)– anypresenceofkoilonychiaor‘spoonnails’(irondeficiency)

• Determine the rate, rhythm, volume, and character of the radial pulse. A regularly irregularrhythmsuggestsseconddegreeheartblock,whereasanirregularlyirregularrhythmsuggestsatrialfibrillationormultipleectopics.

• Raisethepatient’sarmabovehisheadtoassessforacollapsing/waterhammerpulse(aorticregurgitation).Askthepatientwhetherhehasanyshoulderpainfirst.

• Simultaneouslytakethepulseinbotharmstoexcluderadio-radialdelay(aorticarchaneurysm).Indicatethatyouwouldalsoexcluderadio-femoraldelay(coarctationoftheaorta).

• Asyoumoveupthearm,lookforbruising,whichmayindicatethatthepatientisonananti-coagulant,andforevidenceof intravenousdruguse,whichisariskfactorforacuteinfectiveendocarditis.

• Indicatethatyouwouldliketorecordthebloodpressure(seeStation 12).Awidepulsepressureistypicallyseeninaorticregurgitation;anarrowpulsepressureinaorticstenosis.

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29Station 13 Cardiovascular examination

Inspection and examination of the head and neck• Inspecttheeyes,lookingforperi-orbitalxanthelasmaandcornealarcus,bothofwhichindicate

hyperlipidaemia.• Gentlyretractaneyelidandaskthepatienttolookup.Inspecttheconjunctivusforpallor,which

isindicativeofanaemia.• Ask thepatient toopenhismouth,and look forsignsofcentralcyanosis,dehydration,poor

dentalhygiene(subacutebacterialendocarditis),andahigharchedpalate(Marfan’ssyndrome).• Palpatethecarotidarteryandassessitsvolumeandcharacter.Aslow-risingpulseissuggestive

ofaorticstenosis,acollapsingpulseofaorticregurgitation.Neverpalpatebothcarotidarteriessimultaneously.

• Assessthejugularvenouspressure(seeFigure 6)and,ifpossible,thejugularvenouspulseform:askthepatienttoturnhisheadslightlytooneside,andlookattheinternalveinmedialtotheclavicularheadof sternocleidomastoid.Assuming that thepatient is recliningat45degrees,theverticalheightofthejugulardistensionfromtheangleofLouis(sternalangle)shouldbenogreaterthan4cm:ifitisgreaterthan4cm,thissuggestsrightheartfailure,fluidoverload,ortricuspidvalvedisease.

Palpation of the heart

Ask the patient if he has any chest pain.

• Determinethelocationandcharacteroftheapexbeat.Itisnormallylocatedinthefifthinter-costalspaceatthemidclavicularline.Theapexmaybe:– impalpable:obesity,dextrocardia,situsinversus…– displaced,suggestingvolumeoverload(mitraloraorticregurgitation)– heaving,suggestingpressureoverloadandleftventricularhypertrophy(aorticstenosis)– ‘tapping’,suggestingmitralstenosis

• Placetheflatofyourhandsovereithersideofthesternumandfeelforanyheavesandthrills.Heavesresult fromrightventricularhypertrophy(cor pulmonale)andthrills fromtransmittedmurmurs.

45°

Height of jugularvenous distention

Angle of Louis(sternal angle)

4 cm

Figure 6. Assessing the jugular venous pressure.


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30 Station 13 Cardiovascular examination

Auscultation of the heart• Listen for heart sounds, additional sounds,murmurs, and pericardial rub. Using the stetho-

scope’sdiaphragm,listeninthe: – aortic area rightsecondintercostalspacenearthesternum

– pulmonary area leftsecondintercostalspacenearthesternum

– tricuspid area leftthird,fourth,andfifthintercostalspacesnearthesternum

– mitral area (use the stethoscope’s bell) leftfifthintercostalspaceinthemid-clavicularline

• Manoeuvresandpointstoremember:– askthepatienttobend forwardandtoholdhisbreathatend-expiration.Usingthestetho-scope’sdiaphragm,listenattheleftsternaledgeinthefourthintercostalspaceforthemid-diastolicmurmurofaorticregurgitation

– askthepatienttoturn onto his left sideandtoholdhisbreathatend-expiration.Usingthestethoscope’sbell,listeninthemitralareaforthemid-diastolicmurmurofmitralstenosis

– listen over the carotid arteries for any bruits and the radiation of the murmur of aorticstenosis

– listenintheleftaxillafortheradiationofthemurmurofmitralregurgitation

For any murmur, determine its location and radiation, and its duration (early, mid, late, ‘pan’ orthroughout) and timing (diastolic, systolic) in relation to the cardiac cycle. This is best done bypalpatingthecarotidorbrachialarterytodeterminethestartofsystole.GradethemurmuronascaleofItoVIaccordingtoitsintensity(seeTable 4).CommonconditionsassociatedwithmurmursarelistedinTable 5.

A P

TM

Mid-clavicularline

Auscultation points

C C

Ax

Figure 7. Auscultation points.


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31Station 13 Cardiovascular examination

Table 4. Grading murmurs

I Barelyaudiblemurmur

II Softandlocalisedmurmur

III Murmurofmoderateintensitythatisimmediatelyaudible

IV Murmurofloudintensitywithapalpablethrill

V Asabove,murmuraudiblewithonlystethoscoperimonchestwall

VI Asabove,murmuraudibleevenasstethoscopeisliftedfromchestwall

Table 5. Common conditions associated with murmurs

Aortic stenosis Slow-risingpulse,heavingcardiacapex,ejection/early-systolicmurmurbestheardintheaorticareaandradiatingtothecarotidsandcardiacapex

Mitral regurgitation Displacedthrustingcardiacapex,pan-systolicmurmurbestheardinthemitralareaandradiatingtotheaxilla,patientmaybeinatrialfibrillation

Aortic regurgitation Collapsingpulse,thrustingcardiacapex,diastolicmurmurbestheardatthelowerleftsternaledge

Mitral valve prolapse Mid-systolicclick,late-systolicmurmurbestheardinthemitralarea

RILE: Right-sidedmurmursareheardloudestonInspirationwhereasLeft-sidedmurmursareheardloudestonExpiration

Chest examination• Percussandauscultatethechest,especiallyatthebasesofthelungs.Heartfailurecancause

pulmonaryoedemaandpleuraleffusions.

Abdominal examination• Palpatetheabdomentoexcludeascitesand/orhepatomegaly.• Checkforthepresenceofanaorticaneurysm.• Ballotthekidneysandlistenforanyrenalarterybruits.

Examination of the ankles and legs• InspectthelegsforscarsthatmightbeindicativeofveinharvestingforaCABG.• Palpateforthe‘pitting’oedemaofcardiacfailure:checkforpainandthenpressfor5seconds

on the patient’s legs. If oedema is present, assess how far it extends. In some cases, itmayextendallthewayuptothesacrumoreventhetorso(‘anasarca’).

• Assessthetemperatureofthefeet,andchecktheposteriortibialanddorsalispedispulsesinbothfeet.


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32 Station 13 Cardiovascular examination

After the examination• Indicate thatyouwould lookat theobservationchart,dipstick theurine,examinethe retina

withanophthalmoscope(forhypertensivechangesandtheRoth’sspotsofsubacuteinfectiveendocarditis),and,ifappropriate,ordersomekeyinvestigations,e.g.FBC,ECG,CXR,echocar-diogram.

• Coverthepatientupandensurethatheiscomfortable.• Thankthepatient.• Summariseyourfindingsandofferadifferentialdiagnosis.

Conditions most likely to come up in a cardiovascular examination station

• Murmurs(seeTable 5).

• Heartfailure.

• Mediansternotomyscar,withorwithoutscaronthelowerleg(veinharvesting).

• Pacemaker.


clinical skills for osces - scion medical€¦ · after six years at medical school i have become...

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