OSCE systems: Genitourinal and Respiratory

Question 1

Respiratory system: Based on initial questions, what would shortness of breath (dyspnoea) indicate?

Answer 1

conditions such as asthma, chronic obstructive pulmonary disease (COPD) and emphysema

Question 2

Respiratory system: Based on initial questions, what would a dry (unproductive) cough indicate?

Answer 2

Maybe cardiac origin, lung neoplasm, gastroesophageal reflux disease (GORD)

Question 3

Respiratory system: Based on initial questions, what would a wet (productive) cough indicate?

Answer 3

infection, cystic fibrosis

Question 4

Respiratory system: Based on the rate of breathing, what would a slow breathing pace be termed and what might it indicate?

Answer 4

Bradypnoea could be diabetic coma, drug-induced respiratory depression increased ICP

Question 5

Respiratory system: Based on the rate of breathing, what would a rapid shallow breathing pace be termed and what might it indicate?

Answer 5

Tachypnoea could be restrictive lung disease, pleuritic chest pain, elevated diaphragm

Question 6

Respiratory system: Based on the rate of breathing, what would a rapid deep breathing pace be termed and what might it indicate?

Answer 6

Hyperpnoea could indicate recent exercise, anxiety, metabolic acidosis

Question 7

Respiratory system: Based on the rate of breathing, what would be signs of respiratory distress?

Answer 7

respiratory rate greater than 20-25 per minute;
use of accessory muscles to breathe (SCM, scalenes, nasal flaring, intercostal recession)
grunting, audible breathing, pursed lip breathing
cyanosis or pallor
tachycardia
skin colour :
cyanosis
pallor
erthema

Question 8

Respiratory system: What is central cyanosis and what is the likely cause of this?

Answer 8

Cyanosis is the abnormal discolouration of the skin and mucous membranes, caused by a deoxygenated haemoglobin level above 5g/ litre. Central cyanosis is seen in the tongue, mucous membranes of the mouth and lips and is most likely caused by diseases of the heart and lungs or abnormal haemoglobin conditions. Hands and feet are at normal temperature

Question 9

Respiratory system: What is peripheral cyanosis and what is the likely cause of this?

Answer 9

This is cyanosis of the peripheral limbs caused by decreased local circulation and increased extraction of oxygen in the peripheral tissues. this is caused by congestive heart failure, circulatory shock, exposure to cold temperatures, and abnormalities of peripheral circulation. Peripheral tissues so affected are cold to the touch.

Question 10

Respiratory system inspection: Where do you find the apices of the lungs?

Answer 10

2-4 cm above clavicles

Question 11

Respiratory system inspection: Where do you find the anterior inferior border of the lungs?

Answer 11

approximately sixth rib at mid-clavicular line

Question 12

Respiratory system inspection: Where do you find the lateral inferior border of the lungs?

Answer 12

approximately the eighth rib at the midaxillary line

Question 13

Respiratory system inspection: Where do you find the posterior inferior border of the lungs?

Answer 13

approximately level of T10 spinous process

Question 14

Respiratory system inspection: Where do you find the fissures of the lungs?

Answer 14

level with approximately T3 spinous process posteriorly and rib 6 mid clavicular line anteriorly

Question 15

Respiratory system inspection: Where do you find the tracheal bifurcation of the lungs?

Answer 15

approximately in line with T4 spinous process posteriorly and sternal angle anteriorly

Question 16

Respiratory system inspection: What would be the cause of asymmetry of the lungs?

Answer 16

pleural effusion- causes asymmetrical expansion and unilateral lagging on eth affected side caused by COPD, asthma, obstruction, cardiac failure, multiple sclerosis

Question 17

Respiratory system inspection: What would be the cause of poor inflation of the lungs (bilateral or unilateral)?

Answer 17

intercostal retraction (intercostal mm sucked in with inspiration) is something blocking/restricting upper airways…asthma, COPD, upper airway obstruction
Unilateral impairment or lagging could be due to pleural disease- asbestosis, silicosis, or phrenic nerve damage or trauma.

Question 18

Respiratory system inspection: Looking at the hands, what would be the cause of clubbing?

Answer 18

Clubbing is the thickening of the connective tissue in the distal phalanges and is common in cardiovascular and respiratory conditions, thought to be related to increased PDGF and vascular endothelial growth factor due to decreased oxygenation of distal tissues. Maybe it is genetic.

Question 19

Respiratory system inspection: Looking at the hands, what would be the cause of atrophy of thenar eminence?

Answer 19

can occur in apical lung cancer (Pancoast) due to pressure on the brachial plexus.
peripheral neuropathy

Question 20

Respiratory system inspection: Looking at the hands and forearms, what would be the cause of asterixis?

Answer 20

asterixis is the inability to hold elbows and wrists extended (a tremor) as a reaction to hyperextension… like a clonus. Due to metabolic encephalopathy (chronic renal failure, severe congestive heart failure, acute respiratory failure, and commonly decompensated liver failure )
Due to high CO2 retention.

Question 21

Respiratory system inspection: Looking at the hands and nails, squeeze the top of the nail and release. what are you looking for?

Answer 21

finger should blanch with pressure and colour should return within 1-2 seconds.

Question 22

Respiratory system inspection: Looking at the eyes. what are you looking for?

Answer 22

conjunctival pallor
Horner’s syndrome
ptosis (drooping eyelid)
miosis (constricted pupil)
anhydrosis (lack of sweating on the affected side)
This could be due to a Pancoast tumour affecting the sympathetic chain.

Question 23

Respiratory system inspection: Looking at the nose. What are you looking for?

Answer 23

any observable septal asymmetry or obstruction. inspect turbinates for swelling, polyps, obstruction, and ulcers.

Question 24

Respiratory system inspection: Looking at the nasal mucosa. What are you looking for?

Answer 24

color, discharge, bleeding.
the nasal mucosa could show signs of viral rhinitis (mucosa reddened, swollen)or allergic rhinitis (pale blueish or red)

Question 25

Respiratory system inspection: Looking at the throat. What are you looking for?

Answer 25

inspect palatine tonsil for swelling or discharge. posterior wall of oropharynx for discharge
erythema, vascularisation,
tongue and lips for cyanosis
under tongue for carcinoma (ulceration) varicose veins, leukoplakia
ulcers
Streptococcus infection- spotty white exudate
Thrush (candidiasis) fungal infection- thick white plaques somewhat adherent to underlying mucosa on the roof of the mouth
Red Pharynx indicating infection.

Question 26

Respiratory system inspection: palpating cervical lymph nodes. What are you looking for?

Answer 26

tenderness (inflammation) or hardness (suggests malignancy)

Question 27

Respiratory system inspection: palpating the trachea. What are you looking for?

Answer 27

space between the trachea and SCM should be equal on both sides.
looking for masses that might affect breathing passage. This can indicate mediastinal mass, large pneumothorax, atelectasis (only part of the lung has collapsed)

Question 28

Respiratory system inspection: inspecting the ears. What are you looking for?

Answer 28

discharge and swelling
examine canal for foreign bodies and colour
cerumen (wax- yellow-brown, sticky, hard)
discharge
redness pain swelling
exostoses (nodular swelling covered by normal skin)

Question 29

Respiratory system inspection: inspecting the ears. looking at the ear drum. What are you looking for?

Answer 29

red bulging drum - acute purulent otitis media bacterial URT infections
amber drum- serous effusion (pale yellow, benign) of viral URT infections /sudden changes in barometric pressure
Perforation - usually from purulent infections of the middle ear often heals over
tympan sclerosis chalky white patches of hyaline material after otitis media

Question 30

Respiratory system inspection: inspecting the chest. What are you looking for?

Answer 30

Asymmetry. shape, movement. abnormal retraction interspaces in the lower chest.
impaired movement caused by chronic fibrosis, (lung or pleura) pleural effusion
lobar pneumonia
pleural pain-splinting
unilateral bronchial obstruction.

Question 31

Respiratory system inspection: Percussing the chest. What does a resonant loud low-pitched sound indicate?

Answer 31

simple chronic bronchitis

Question 32

Respiratory system inspection: Percussing the chest. What does a hyper-resonant very loud, lower-pitch sound indicate?

Answer 32

COPD, pneumothorax

Question 33

Respiratory system inspection: Percussing the chest. What does a tympanic, loud, high-pitched sound indicate?

Answer 33

large pneumothorax

Question 34

Respiratory: If a patient presents reporting coughing up blood, what is the most common cause?

Answer 34

Bronchitis

Question 35

Respiratory: What are two findings suggesting someone is in respiratory distress?

Answer 35

RR>20/minute; accessory mm activation, (SCM, scalenes, nasal flaring, intercostal recession- sudden lifting with breath), grunting, breathing through pursed lips, cyanosis

Question 36

Respiratory: if someone is blue around the lips, fingertips, and tongue, evidence of what condition, might this suggest?

Answer 36

Central cyanosis

Question 37

Respiratory: If a patient presents with finger clubbing and nicotine-stained fingers, what condition would you suspect?

Answer 37

Lung cancer

Question 38

Respiratory: when auscultating the chest, what condition is indicated by the finding of a friction rub?

Answer 38

pleurisy, pneumonia, pulmonary embolism

Question 39

Genitourinary system inspection: initial questions. What does a painful urination indicate?

Answer 39

painful urination can be a symptom of a urinary tract infection, kidney stones, or bladder infection.

Question 40

Genitourinary system inspection: initial questions. What does a change in the frequency of urination indicate?

Answer 40

prostate health. urinary tract infection, diabetes mellitus.

Question 41

Genitourinary system inspection: initial questions. What do lumps in the groin indicate?

Answer 41

enlarged lymph nodes, or hernias in the inguinal, scrotal or femoral region.

Question 42

Genitourinary system inspection: kidneys. What is “balloting” the kidney?

Answer 42

A form of palpation where the kidney is “sandwiched” between the abdominal hand pressing down and the lumbar hand pushing up.

Question 43

Genitourinary system inspection: kidneys. when percussing the kidneys, if the area is tender or painful what could this indicate?

Answer 43

pyelonephritis which is a UTI caused by bacterial infection

Question 44

Genitourinary system inspection: kidneys. what is pyelonephritis and what are its complications?

Answer 44

Acute pyelonephritis can cause a variety of problems, including the formation of renal or perinephric abscesses, sepsis, renal vein thrombosis, papillary necrosis, or acute renal failure, with emphysematous pyelonephritis being one of the more significant complications

Question 45

Genitourinary system inspection: hernia. what is a direct hernia? How does it happen?

Answer 45

A direct inguinal hernia means that the intestines penetrate directly through the wall of the inguinal canal. This weak area of the abdominal wall is called the Hesselbach triangle. This type of hernia occurs in adults over time, from a combination of weakening abdominal muscles and chronic pressure on the muscle wall.
The testicle begins above the lower abdominal wall and descends through your inguinal canal into the scrotum. The place where the testicle passes through is more susceptible to a hernia because it’s a preexisting opening, which is more easily reopened. And, sometimes, it doesn’t close all the way during development in the first place.

Question 46

Genitourinary system inspection: hernia. what are the symptoms?

Answer 46

groin pain
a bulge that comes and goes
burning or aching sensation in the groin
heavy or dragging sensation in the groin, especially at the end of a day or after prolonged activity
swollen or enlarged scrotum in boys and men

Question 47

Genitourinary system inspection: hernia. how is it palpated?

Answer 47

Explanation
draping to expose the inguinal region
Place left hand flat on the skin of the inguinal area and ask the patient to lift their head and bear down - look for swelling.
Reposition the hand over the inguinal ligament with the middle finger lying along the ligament 4th finger over the external ring and 2nd finger inferior to the inguinal ligament
Ask the patient to cough
and observe if 4th finger rises… middle and second fingers shouldn’t rise.
hernia will show as a rising of the fourth finger above inguinal ligament

Question 48

Genitourinary system inspection: hernia. what is an indirect hernia? How does it happen?

Answer 48

An indirect hernia occurs when abdominal contents protrude through the deep internal inguinal ring and into the inguinal canal protruding out through the superficial inguinal ring. This occurs lateral to the inferior epigastric vessels. The hernia contents may extend into the scrotum.
This is usually a birth defect.

Question 49

Genitourinary system inspection: hernia. what is a femoral hernia? How does it happen?

Answer 49

A femoral hernia occurs when the bowel
contents protrude through a weakening
in the abdominal wall below the
inguinal ligament into the femoral
canal. More likely to occur in females.

Question 50

Genitourinary system inspection: hernia. what is the cause of a femoral hernia?

Answer 50

childbirth
chronic constipation
heavy lifting
being overweight
difficult urination due to an enlarged prostate
chronic coughing

Question 51

Genitourinary system inspection: lymph nodes. explain to client: what are lymph nodes, and why should they be palpated?

Answer 51

Lymph nodes are small, oval-shaped glands that produce disease-fighting cells. They also act as filters for your lymph vessels. Your lymph vessels are a network of thin tubes that collect lymph fluid and circulate it throughout your body.
In your upper inner thighs, you have about 10 superficial inguinal lymph nodes. Superficial means close to the surface of your skin. These lymph nodes drain into your deep inguinal lymph nodes. Deep inguinal lymph nodes are deep within the connective tissue of your upper thighs. Then the lymph fluid drains into other lymph nodes in your pelvic region.
Swollen Inguinal lymph nodes generally mean your body is working to fight an infection or illness. Rarely, swollen inguinal lymph nodes indicate cancer

Question 52

Genitourinary system inspection: lymph nodes. where are the inguinal lymph nodes?

Answer 52

Superficial Group
▪ Horizontal group – a chain running below the inguinal ligament (drains lower abdomen, buttock, external genitalia (but not testes), anal/perianal area, and lower vagina.
▪ Vertical group – clusters around the great saphenous vein (drains
the corresponding area of the leg)
o Deep Group (non-palpable)
▪ Inferior and medial to the vessels (deep to vertical superficial group)

Question 53

Genitourinary system inspection: the uterus. how is this palpated externally?

Answer 53

Have the patient supine with the hips and knees flexed (a pillow or bolster under the knees)
- Locate the pubic symphysis and pubic tubercle
- Press into the region immediately superior and lateral to the pubic tubercle and apply a posterior-medial force.
o Palpate for resistance, masses, tenderness, enlargement
- Compare on the other side

Question 54

Genitourinary system inspection: the ovaries. How is this palpated externally?

Answer 54

Begin ¾ of the distance from the ASIS to the pubic tubercle along the inguinal ligament
- Slide superiorly into the region of the ovarian fossa
- Apply a posterior pressure into the abdomen and palpate for an (approximately) almond-sized structure.
o Inability to palpate the ovary is not unusual and is not a cause for concern.
o Note any masses, excessive tenderness, abnormal texture (compared to surrounding
visceral tissues)

Question 55

Genitourinary system inspection: the axillary lymph nodes. How is this palpated?

Answer 55

ave the patient seated or supine and the upper limb elevated to expose the axilla
- Using the pads of the fingers press into the supero-lateral axilla at the distal arm, rolling the fingers as you apply pressure to examine the texture, mobility, and structure of the tissue
underneath.
- Move in a systematic manner superiorly-inferiorly or medially-laterally as you thoroughly examine these regions
- Note any tenderness, firmness, enlarged nodules, rash, pigmentation, or signs of infection or inflammation

Question 56

Genitourinary system inspection: the axillary lymph nodes. Where are they and what do they drain?

Answer 56

Pectoral group:
o These nodes are located in the upper portion of the axilla, near the chest wall. They receive lymphatic drainage from the breast, chest wall, and upper arm.
- Subscapular group:
o These nodes are located in the lower portion of the axilla, near the scapula. They receive lymphatic drainage from the upper back, shoulder, and upper arm.
- Apical group:
o These nodes are located near the top of the axilla, close to the clavicle. They receive lymphatic drainage from the arm, shoulder, and upper chest.
- Central axillary group:
o These nodes are located in the central portion of the axilla. They receive lymphatic drainage from the entire upper limb, as well as the breast and chest wall.
- Humeral group:
o These nodes are located along the humerus bone and receive lymphatic drainage from the arm and shoulder

Question 57

Genitourinary system inspection: the lymph nodes. What are the characteristics of abnormal lymph nodes?

Answer 57

hard, fixed, irregular surface, enlarged (>1cm)

Question 58

Genitourinary system inspection: what defines menopause?

Answer 58

1 year past the last period

Question 59

Genitourinary system inspection: at what anatomical landmark in the inguinal area do we find the femoral vessels and nerve?

Answer 59

Mid-inguinal point (Not the midpoint of the inguinal ligament which is the location of the inguinal ring)

Question 60

Genitourinary system inspection: name two of the symptoms of testicular cancer.

Answer 60

change in size; swelling; lumps; dull ache in groin or abdomen; heaviness